1. Efforts to Reduce Disparities in Care for Medicare Beneficiaries Peter B. Bach, MD, MAPP Senior Adviser, Office of the Administrator Centers for Medicare & Medicaid Services

2. Today The Agency philosophy regarding health disparities Programmatic initiatives in health disparities Specific health disparities initiatives Trying to move forward –What should we do? –What can we do?

3. Agency Philosophy All quality initiatives should be evaluated in light of their potential impact on the health of minority populations –Will adequate groups be included in ‘demonstrations’? –Will methodology or risk selection adversely affect minorities? –Are appropriate suites of measures being chosen to drive improvements in minority health?

4. Agency Philosophy cont’d Specific quality initiatives should focus on directly addressing identified mechanisms Should be assessed based on impact on patients, including satisfaction with care and outcomes

5. Mechanisms underlying disparities Communication and comprehension barriers Differences in access Differences in coverage To better define mechanisms: –Projects, interventions, demonstrations and research

6. Communication National Medicare Education Program (NMEP) – 1997 BBA Includes: –1-800-Medicare –www.medicare.govwww.medicare.gov –Medicare & You Handbook –HORIZONS –Other

7. HORIZONS ( Health Outreach Initiative Zeroing in On Needs) Formed to identify strategies to reach “hard to reach” populations Toolkits created for outreach to: –African Americans; Asian American/Pacific Islander; Hispanic American Include: –Handbooks, print brochures, media scripts

8. REACH Regional Education About Choices in Health Care Implemented by CMS Regional Offices to increase access to Medicare information Targets: -Low Income -Location -Language -Literacy -Culture

9. State Health Insurance Assistance Programs (SHIP’s) Funded by CMS to provide counseling to Medicare beneficiaries –Specifically about issues related to Medigap and drug coverage Counselors community based, often volunteers Present in all 50 states + D.C. Mandated to target underserved populations (usually defined by income) CMS has developed training materials (English and Spanish) in counseling and cultural competency

10. Access Specific concerns about lack of proper healthcare facilities locally available to minority populations Health Care Infrastructure Improvement Program – Sec 1016 of MMA –Large loans to facilities to build-out cancer care infrastructure –Specifically targeted at geographic regions where there are large populations of Native Americans Tremendous amount of infrastructure work focused on geographic availability of drug benefit and DME

11. Coverage differences Not all beneficiaries have the same coverage –Part B coverage requires co-pays and has a deductible Minorities more likely to have Medicaid –32% of blacks; 9% of whites Minorities more likely to have no coverage –20% of blacks, 14% of whites

12. Coverage differences Important preventive services no longer need co- pay and do not affect deductible –Vaccines – influenza, pneumococcal, Hep B –Cancer screening – mammograms, PSA test, FOBT Change in Part B drug reimbursement to ASP –Effect should be that physicians payments more similar when treating patients with Medicare and Medicaid than previously

13. Specific programs and interventions

14. Utilization and Access to Care Health Disparities: Measuring Health Care Use and Access for Racial/Ethnic Populations –Analyzes health care access trends –Assesses validity of race/ethnicity data in the Medicare enrollment database

15. READII Racial and Ethnic Adult Disparities in Immunization Initiative –CMS collaborates with CDC to improve flu and pneumococcal immunization rates Focuses on African Americans and Hispanics Five locations: –Chicago, IL –Bexar County (San Antonio vicinity), Texas –Milwaukee, WI –Monroe County (Rochester vicinity), NY –Selected Counties, rural MS

16. QIOs Quality Improvement Organizations Established by legislation in 1982 to improve quality of care Present in all 50 states and U.S. territories Undertake special efforts in health care, including specific diseases and disparities in minority populations QIO’s are “on the ground”, working with providers, beneficiaries, and networks

17. QIO Disparity Projects 1999-200251 projects 2002-2005 52 projects Include global measures on diabetes, mammography screening, immunization, and heart failure Two tasks in next scope –Work with providers who treat underserved to use IT more effectively (DOQ-IT) –Promote provider and practice system changes to achieve CLAS (culture and language) standards and cultural competency

18. Medicare Advantage Plans Ensure that all services are accessible to all QIO’s charged with improving care in these plans The QAPI project requires plans also to improve cultural competence, either as manifest by reducing a clinical health disparity or by developing cultural initiatives

19. HBCU Grant Program Historically Black Colleges and Universities Health Services Research Grant Program Small applied projects awarded to: –Remove barriers and improve health –Increase efficient utilization –Improve quality –Reduce health care costs –Improve HIV and AIDS outcomes

20. CMS Demonstrations Physician Group Practice Demonstration Medicare Health Support (CCIP) Cancer prevention and treatment

21. Physician Group Practice Demonstration Awardees are 10 large physician group practices Focuses on the quality of preventive care and ultimately on the outcomes of beneficiaries treated by the groups Incentives for practices – better efficiency and outcomes will result in bonus payments

22. Medicare Health Support Formerly the Chronic Care Improvement Program (CCIP) Beneficiaries with specific conditions – congestive heart failure and diabetes – who reside in target regions Regions (10) chosen for high prevalence –Chicago, DC, Georgia, Mississippi, Brooklyn/Queens Randomized study where enrollees can receive additional care management Objective is to enhance existing physician-patient relationships

23. Cancer Screening & Treatment Cancer Prevention and Treatment Demonstration for Ethnic and Racial Minorities Defined racial and ethnic minority groups Sites (rural and inner city) will facilitate cancer screening, diagnosis and treatment Charged with funding 9 sites

24. Screening and Treatment Randomized designs Invited participants: Care management organizations, health insurers, group practices, academic health centers, minority serving institutions Two promising strategies addressed –Risk assessment assistance –Patient navigation/community health workers

25. Cancer Screening Demo Status Solicitation was published in the Federal Register on 12/23/04 Proposals were due 3/23/05 Award is expected mid-2005 Full-scale implementation in Fall 2005

26. Other Initiatives HHS “Closing the Health Gap” campaign –Take a Loved One to the Doctor Day initiative –Broadcasts on ABC Radio Networks Celebra La Vida Con Salud initiative –Celebrate a Healthy Life

27. Summary In addressing this problem, CMS: Recognizes the magnitude of the problem Recognizes it has a special responsibility to address the problem Leverages all Agency resources Seeks ideas, suggestions, and support from ALL!

28. 1-800-MEDICARE www.medicare.gov www.cms.hhs.gov FOR MORE INFORMATION