1. Hedge Funds 2/28/04 POLICIES TO REDUCE DISPARITIES IN CHILD HEALTH CARE Anne C. Beal, MD, MPH President Aetna Foundation, Inc.

2. 2 HEALTH CARE EQUITY 2 2 Disparities in Child Health Status and Healthcare Are Real African American infant mortality rate 2.5 times higher than whites African American children 3 times more likely to be hospitalized for asthma When hospitalized, African American are one third less likely to be discharged with prescriptions for routine meds to prevent future asthma-related hospitalizations (7% vs 21%) African-American and Hispanic children represented more than 80 percent of pediatric AIDS cases in 2000 Death rates for African American children are 40% higher than the national average

3. 3 HEALTH CARE EQUITY 3 3 Disparities Are Here in Westchester

4. 4 HEALTH CARE EQUITY 4 4 Black Infants are Four Times More Likely to Die than White Infants in Westchester Deaths per 1,000 Live Births, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf

5. 5 HEALTH CARE EQUITY 5 5 Black Children Are Three Times More Likely to Die Than White Children in Westchester Deaths per 1,000 Population, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf

6. 6 HEALTH CARE EQUITY 6 6 Average Length of Stay for Pediatric Hospitalization By Race, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf

7. 7 HEALTH CARE EQUITY 7 7 Health Outcomes Life Expectancy Health Status Asthma Rates Diabetes Rates Non-Medical Health Behaviors Living and Working Conditions Income Stress Healthcare Acceptability Access Effectiveness Safety Financing WHICH HEALTH DISPARITIES

8. 8 HEALTH CARE EQUITY 8 8 Health Outcomes Life Expectancy Health Status Asthma Rates Diabetes Rates Non-Medical Health Behaviors Living and Working Conditions Income Stress Healthcare Acceptability Access Effectiveness Safety Financing WHICH HEALTH DISPARITIES Source: Arah OA, Westert GP. Correlates of health and healthcare performance: applying the Canadian Health Indicators Framework at the provincial-territorial level. BMC Health Services Research. 5:76. 40%-67% 44%-57%

9. 9 HEALTH CARE EQUITY 9 9 Source: Arah OA, Westert GP. Correlates of health and healthcare performance: applying the Canadian Health Indicators Framework at the provincial-territorial level. BMC Health Services Research. 5:76. AsthmaDiabetesLife Expectancy Life Stress+0.652 Per Capita Health Expenditure -0.727-0.814 Unemployment+0.836 Physicians+0.872 Income+0.821 Heavy Drinking-0.783 What Causes Disparities?

10. 10 HEALTH CARE EQUITY 10 What Causes Disparities? Co-Morbid Conditions Access To Care/Coverage Quality of Healthcare Patient Adherence Genetic Predisposition Community Factors Environmental Factors Cultural Factors Economic Factors Physiologic Response to Meds Ease of Lifestyle Changes

11. 11 HEALTH CARE EQUITY 11 Genetic Predisposition Environmental Factors Economic Factors Cultural Factors Community Factors Access To Care/Coverage Quality of Healthcare Co-Morbid Conditions Patient Adherence Ease of Lifestyle Changes Physiologic Response to Meds Disparities WHAT CAUSES DISPARITIES?

12. 12 HEALTH CARE EQUITY 12 Genetic Predisposition Environmental Factors Economic Factors Cultural Factors Community Factors Access To Care/Coverage Quality of Healthcare Co-Morbid Conditions Patient Adherence Ease of Lifestyle Changes Physiologic Response to Meds Disparities WHAT CAUSES DISPARITIES?

13. 13 HEALTH CARE EQUITY 13 Is This About Race/Ethnicity or About Coverage?

14. 14 HEALTH CARE EQUITY 14 Minority Children are More Likely to Lack Insurance Coverage 23 20 23 37 Percent of Children Ages 0-18 Uninsured All or Part Year, 2000 Source: Adapted from Doty, MM. Insurance, Access, and Quality of Care Among Hispanic Populations. 2003 Chartpack. The Commonwealth Fund and Columbia University analysis of MEPS 2000.

15. 15 HEALTH CARE EQUITY 15 Racial Disparities in Clinical Quality Occur Among the Insured Source: Eric C. SchneiderM.D., Alan M. Zaslavsky, Arnold M. Epstein, M.D. Racial Disparities in Quality of Care for Enrollees in Medicare Managed Care. Journal of the American Medical Association, vol. 287, no. 10 Percent of Medicare managed care beneficiaries receiving service

16. 16 HEALTH CARE EQUITY 16 What Does it Really Take to Improve Care and Reduce Health Disparities? Health care system comprised of purchasers, providers, regulators, researchers, educators, and others. Need a multifaceted approach that affects the different sectors of the health system

17. 17 HEALTH CARE EQUITY 17 Health Care Coverage

18. 18 HEALTH CARE EQUITY 18 State Childrens Health Insurance Program (SCHIP) Designed to provide coverage to low income children not eligible for Medicaid Estimated that fewer than half of all eligible children are enrolled If every child who was eligible for either Medicaid or SCHIP was enrolled –6.7 million –76%

19. 19 HEALTH CARE EQUITY 19 Expand SCHIP Eligibility Universal Health Care Uniform requirements for SCHIP eligibility –from 133% to 400% FPL –39 states have caps of at least 200% * Raise SCHIP eligibility cap to 300% FPL –7.9 million –90.3% of uninsured children *$41,300 for a family of four in 2007

20. 20 HEALTH CARE EQUITY 20 Health Care Costs $6 Billion Over 5 Years $2.3 trillion in 2008

21. 21 HEALTH CARE EQUITY 21 Monitor the Quality of Care Stratified by Race/Ethnicity

22. 22 HEALTH CARE EQUITY 22 Disparities in Healthcare and Quality of Care Measures of healthcare disparities are essentially quality measures. Disparities in health is not a marginal or special interest issue. There is a larger quality movement; use their tools, language and techniques. Calls upon quality movement to address quality for vulnerable patients.

23. 23 HEALTH CARE EQUITY 23 COLLECTING RATE/ETHNICITY DATA: The First Step for Achieving Equity Barriers, is it legal? How to collect race/ethnicity data What categories? How long does it take? Who should ask? How do patients react? What Do You Do With the Data?

24. 24 HEALTH CARE EQUITY 24 Quality Improvement Reduces Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 Source: Adapted from Sehgal: JAMA, Volume 289(8). February 26, 2003. 996-1000. 46 36 87 84 Adequate Hemodialysis Dose, %

25. 25 HEALTH CARE EQUITY 25 Quality Improvement Could Maintain Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 46 36 87 77 Adequate Hemodialysis Dose, %

26. 26 HEALTH CARE EQUITY 26 Quality Improvement Could Worsen Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 46 36 87 57 Adequate Hemodialysis Dose, %

27. 27 HEALTH CARE EQUITY 27 Health Care Is Separate and Unequal

28. 28 HEALTH CARE EQUITY 28 Percent of adults 18–64 LARGE PROPORTIONS OF MINORITY PATIENTS USE PRIVATE DOCTORS AS THEIR REGULAR SOURCE OF CARE * Compared with whites, differences remain statistically significant after adjusting for insurance or income. Source: Commonwealth Fund 2006 Health Care Quality Survey.

29. 29 HEALTH CARE EQUITY 29 CARE FOR MINORITY PATIENTS IS CONCENTRATED AMONG A FEW PROVIDERS Half of All Minority Patients Are Treated by One-Third of Primary Care Physicians Source: J. D. Reschovsky and A. S. O'Malley, Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?, Health Affairs Web Exclusive, Apr. 22, 2008, w222-w230 Not an 80:20 rule, but a 80:50 rule

30. 30 HEALTH CARE EQUITY 30 Source: David Barton Smith, Zhanlian Feng, Mary L. Fennell, Jacqueline S. Zinn, and Vincent Mor,Separate And Unequal: Racial Segregation And Disparities In Quality Across U.S. Nursing Homes, Health Affairs, Vol 26, Issue 5, 1448-1458 85% 20% CARE FOR MINORITY PATIENTS IS CONCENTRATED AMONG A FEW PROVIDERS

31. 31 HEALTH CARE EQUITY 31 PRACTICES WITH MORE MINORITY PATIENTS REPORT MORE PROBLEMS WITH QUALITY Percent Quality Problems by Proportion of Minority Patients Source: J. D. Reschovsky and A. S. O'Malley, Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?, Health Affairs Web Exclusive, Apr. 22, 2008, w222-w230

32. 32 HEALTH CARE EQUITY 32 <15% Black 15-35% Black >35% Black NE MW South West % Black Region NICU Volume >40 Infants <40 Infants Odds Ratio Source: Morales LS et al. Mortality among very low-birthweight infants in hospitals serving minority populations. American Journal of Public Health. Dec 2005. Vol 95, No. 12. Infant Mortality Is Higher in Hospitals with More Minority Patients

33. 33 HEALTH CARE EQUITY 33 High Quality Care Promotes Equity

34. 34 HEALTH CARE EQUITY 34 TotalPercent by Race Indicator Estimated millionsPercentWhite African AmericanHispanic Asian American Regular doctor or source of care 1428085795784 Among those with a regular doctor or source of care... Not difficult to contact provider over telephone 1218588827684 Not difficult to get care or medical advice after hours 9265 696066 Doctors office visits are always or often well organized and running on time 936668656062 All four indicators of medical home 472728341526 Source: Commonwealth Fund 2006 Health Care Quality Survey. Hispanics Are Least Likely to Report Their Providers Have Indicators of a Medical Home

35. 35 HEALTH CARE EQUITY 35 Percent of adults 18--64 reporting always getting care when they need it *Compared to Whites, differences remain statistically significant after adjusting for income Source: 2006 Commonwealth Fund Health Care Quality Survey Hispanics And Asians Are Less Likely to Report Always Getting Medical Care When Needed

36. 36 HEALTH CARE EQUITY 36 Racial and Ethnic Differences in Getting Needed Medical Care Are Eliminated When Adults Have Medical Homes Percent of adults 18–64 reporting always getting care they need when they need it Note: Medical Home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone, or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running time. Source: 2006 Commonwealth Fund Health Care Quality Survey

37. 37 HEALTH CARE EQUITY 37 *Compared to Whites, differences remain statistically significant after adjusting for income or insurance Source: 2006 Commonwealth Fund Health Care Quality Survey Percent of adults 1864 able to get an appointment same or next day Hispanics and Asians are Less Likely To Get Rapid Access to Medical Appointments

38. 38 HEALTH CARE EQUITY 38 Minorities Who Have Medical Homes Have More Rapid Access to Medical Appointments Percent of adults 18–64 able to get an appointment same or next day * Note: Medical Home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone, or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running time. Source: 2006 Commonwealth Fund Health Care Quality Survey

39. 39 HEALTH CARE EQUITY 39 Health Care Providers

40. 40 HEALTH CARE EQUITY 40 Cultural Competency Improves Quality of Care Preventive medication underuse among children with persistent asthma Cultural Competency Score Source: Lieu TA et al., Cultural Competence Policies and other Predictors of Asthma Care Quality for Medicaid-Insured Children. Pediatrics 114, no. 1 (2003), e102-e110.

41. 41 HEALTH CARE EQUITY 41 Promoting Cultural Competency in Healthcare Raise Awareness Develop Measures of Processes and Outcomes Set Standards for Practice Incorporate into QI

42. 42 HEALTH CARE EQUITY 42 Workforce Diversity Physicians of color more likely to serve in low- income and underserved communities and care for patients of color Better results when there is doctor-patient race and language concordance 25% of US population from underrepresented minority groups; only 11% of medical students are from these groups

43. 43 HEALTH CARE EQUITY 43 People of Color Are Underrepresented in College, Medical School and as Medical Faculty Percent of Students from Underrepresented Groups Source: Manhattan Institute and AAMC Data Warehouse. Previously reported in Beal AC, Abrams M, Saul J. Healthcare Workforce Diversity: Developing Physician Leaders. The Commonwealth Fund. October 2003.

44. 44 HEALTH CARE EQUITY 44 What Does it Take to Eliminate Disparities in Care? Health Care Coverage Quality Improvement Train Health Care Providers –Cultural Competency –Workforce Diversity Disparities/Quality Oversight

45. 45 HEALTH CARE EQUITY 45 An Aetna Foundation Priority: Racial and Ethnic Equity in Health and Health Care

46. 46 HEALTH CARE EQUITY 46 LOOKING AHEAD: The Foundations National Program Areas Obesity To address the rising rate of obesity among U.S. adults and children Racial and ethnic health care equity To promote equity in health and health care for common chronic conditions and infant mortality Integrated health care To advance high-quality health care by: –Improving coordination and communications among –health care professionals –Creating informed and involved patients –Promoting cost-effective, affordable care Beginning in 2010, we will focus our grant-making on issues that lead to meaningful improvements in health and the health care system:

47. 47 HEALTH CARE EQUITY 47 CONTACT US E-mail the Aetna Foundation: AetnaFoundation@aetna.com Aetna Foundation website: www.AetnaFoundation.org Call for Proposals Was Released March 15, 2010