1. Policies to Reduce Disparities in Child Health Care Anne Beal Senior Program Officer The Commonwealth Fund Bronx CREED, AECOM February 16, 2007

2. Minorities Are the Majority in New York City White 35% Black 25% Hispanic 27% Asian 10% 2 or more races Other races <1% Source: Health Disparities in New York City. NYC Dept of Health and Mental Hygiene.

3. Blacks and Hispanics are the Poorest in NYC Source: Health Disparities in New York City. NYC Dept of Health and Mental Hygiene.

4. Blacks and Hispanics Face Inferior Housing Conditions Percent of adults reporting mouse and rat sightings in their home Source: Health Disparities in New York City. NYC Dept of Health and Mental Hygiene.

5. Blacks and Hispanics are in Poorer Health in NYC Percent of adults reporting their health as “fair” or “poor” Source: Health Disparities in New York City. NYC Dept of Health and Mental Hygiene.

6. 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?

7. 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. 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 40%-67% 44%-57% Which Health Disparities?

8. -0.783Heavy Drinking +0.821Income +0.872Physicians +0.836 Unemployment -0.814-0.727Per Capita Health Expenditure +0.652Life Stress Life Expectancy DiabetesAsthma 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.

9. Focus on Healthcare Quality and Disparities Impacts health status Functions within a single “system” Best way to leverage limited funds Opportunity to build on general quality efforts

10. Federal Initiatives to Address Disparities

11. Minority Health and Health Disparities Research and Education Act 2000 Written by Senators Edward M. Kennedy and Bill Frist Established National Center on Minority Health and Health Disparities at NIH Funded Excellence Centers to Eliminate Ethnic/Racial Disparities (EXCEED)

12. Department of Health and Human Services Initiatives Closing the Health Gap Campaign –Youth media campaign to promote physical activity in children 9-13 Healthy People 2010 Objectives –Priority areas include 2 child health areas: immunizations and infant mortality

13. 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

14. Knowledge

15. Disparities in Disparities IOM literature review: only 5 of 103 published studies address disparities in children

16. Disparities in Disparities NHDR found examination of child health disparities limited by lack of data –Small sample sizes –Few child-specific measures of effective clinical care

17. Uninsured Top Priority for Congress According to Health Care Opinion Leaders Note: Based on a list of 17 issues. Source: The Commonwealth Fund Health Care Opinion Leaders Survey, Jan 2007. “How important do you think the following health care issues are for Congress to address in the next five years?” Top 10 issues: Percent responding “absolutely essential” or “very important” 9 9 8 7 6 5 3 3 2 1

18. Uninsured Top Priority for Congress According to Health Care Opinion Leaders Note: Based on a list of 17 issues. Source: The Commonwealth Fund Health Care Opinion Leaders Survey, Jan 2007. “How important do you think the following health care issues are for Congress to address in the next five years?” Top 10 issues: Percent responding “absolutely essential” or “very important” 9 9 8 7 6 5 3 3 2 1

19. Health Care Coverage

20. Minority Children are More Likely to Lack Insurance Coverage Percent of Children Ages 0-18 Uninsured All Year 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. http://www.childrenshealthcampaign.org/assets/pdf/Uninsured-Minority-Kids-at-Risk.pdf

21. 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.

22. State Children’s Health Insurance Program (SCHIP) Designed to provide coverage to low income children not eligible for Medicaid Estimated that fewer that half of all eligible children are enrolled If every child who was eligible for either Medicaid or SCHIP was enrolled –6.7 million –76%

23. 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

24. Quality Improvement

25. 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.

26. Disparities Are Due to WHO You Are and WHERE You Go <15% Black 15-35% Black >35% Black NE MW South West % BlackRegionNICU 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.

27. Children of Color Are More Likely to Have Public Insurance Percent of Children Ages 0-18 With Public Only Insurance, 2002 Source: Rhoades J, Cohen J. Statistical Brief #28: Health Insurance Status of Children in America: 1996-2002. November 2003. AHRQ. http://www.meps.ahrq.gov/papers/st28/stat28.htm

28. Medicaid Managed Care Plans Do Not Perform as Well as Commercial Plans Source: Thompson JW et al. Quality of Care for Children in Commercial and Medicaid Managed Care. Journal of the American Medical Association 290, no. 11 (2003):1486-1493.

29. Children of Color Get Most of Their Health Care in Private MD Offices Usual Place of Health Care for Children 0-18 With a Source of Care Source: Bloom B, Cohen RA, Vickerie JL, Wondimu EA. Summary health statistics for U.S. children: National Health Interview Survey, 2001. National Center for Health Statistics. Vital Health Stat 10(216). 2003.

30. Monitoring Disparities in Quality Child health care quality measures are not designed for measuring disparities –Collect data on patients’ race and ethnicity; –Stratify reporting of quality measures by race and ethnicity Apply QI techniques –P4P, Registries, Report Cards, Case Management

31. 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, %

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

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

34. Health Care Providers

35. 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.

36. Current Practices and Policies Liaison Committee on Medical Education requires all medical schools to include cultural competency training in curricula Accreditation Council for Graduate Medical Education includes responsiveness to diverse patient groups among its core competencies

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

38. 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

39. 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.

40. Health and Education Empowerment Zones

41. High School Dropout Rate

42. Asthma Hospitalizations, 5-14 Years

43. Late or No Prenatal Care

44. What Does it Take to Eliminate Disparities? Knowledge Health Care Coverage Quality Improvement Train Health Care Providers –Cultural Competency –Workforce Diversity Community Action Disparities Oversight Council

45. Visit the Fund at www.cmwf.org www.cmwf.org