Activities to Reduce Health Disparities under Massachusetts Health Care Reform Joel S. Weissman, PhD Assoc Prof of Health Policy, Harvard Medical School Former Senior Health Policy Advisor to the Secretary Hofstra University, New Directions in America Healthcare Conference March 12, 2010
Outline of the Talk Background Collection of Race, Ethnicity and Language by Health Plans in Massachusetts MassHealth Hospital Pay for Performance (P4P) Initiative The Massachusetts Council for the Elimination of Racial and Ethnic Disparities 2
Will universal coverage lead to reductions in disparities? Medicare coverage is associated with reductions in racial, ethnic, and socioeconomic health disparities in adults with diabetes and heart disease* universal coverage [is] a possible means of reducing these types of health disparities in the general population. Commonwealth Fund Press Release for this study * J. Michael McWilliams, et al, 2009 3
Uninsurance Rates by Race/Ethnicity, All Ages Uninsurance 14% 12% Uninsured 2007 Uninsured 2008 10% 10.2 8% 7.9 7.2 6% 4% 2% 5.7 2.6 4.6 2.2 3.2 4.5 1.0 5.4 4.2 0% Total Population White, Non- Hispanic Black, non- Hispanic Asian, non- Hispanic Other race, non-hispanic Hispanic Sources: UMass CSR 2007; Urban Inst 2008; Note: Differences in methodology may be responsible for larger, or smaller, true difference. Massachusetts Division of Health Care Finance and 4 Policy
Despite Health Care Reform, Health Disparities Still Exist Disparities are apparent in premature or excessive death rates for cancer, HIV, diabetes and asthma and in higher hospitalizations rates for many diseases and conditions Disparities also exist in access to services 5 John Auerbach, DPH Commsr, 2009
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Prevalence of Diabetes in Massachusetts Varies Significantly by Race/Ethnicity 225 200 Age adjusted rate per 1000 175 150 125 100 75 50 32 123 121 54 64 25 0 2005 Asian Hispanic Black (NH) White Total 7 Source: MDPH, Bureau of Health Information, Statistics, Research and Evaluation, Health Survey Program
What Can States Do? Three Strategies Collect data (and make providers do the same) Incent reductions in disparities Report on progress (or lack thereof) 8
(1) Collection of Race, Ethnicity and Language by Health Plans in Massachusetts 9
Massachusetts already requires collection of R/E from hospitals The Division of Health Care Finance and Policy requires Race and Ethnicity reporting by Hospital Inpatient Discharge Data But insurance companies have data that hospitals do not 10
Clinical Performance on HEDIS Outcome Measures, by Race 100 90 80 70 60 50 40 30 80.2 72.2 72.2 62.9 60.2 53.4 71.6 57.2 20 10 0 A1c Control LDL Control (Diabetes) White Rate Blood Pressure Control Black 11 Rate LDL Control (Coronary Event) Trivedi, JAMA, 2006
R/E/L data collection by health plans is inconsistent Most health plans do not routinely capture information on race/ethnicity of their members and do not assess quality of care stratified by race and ethnicity Nerenz, et al. 2002 12
The HCQCC The Massachusetts Health Care Quality and Cost Council (HCQCC) was charged with directing health plans to collect and report race/ethnicity data for the all-payer claims database per regulations promulgated in 129 CMR 2.00 Uniform Reporting System For Health Care Claims Data Sets The question is: How and how much? 13
Thank God! A panel of experts! 14
HCQCC R/E/L Regulatory Motions (all unanimously accepted) 1. Requires health plans to submit selfreported R/E data 2. Includes preferred spoken language and written language 3. Specified thresholds beginning July 1, 2010. 15
Proposed Thresholds for Reporting Race, Ethnicity, and/or Language Date Threshold (assuming no transfer of information from hospitals) Threshold (with transfer of information from hospitals, DHCFP, or sponsors) July 1, 2009 0% 0% July 1, 2010 2% 2% July 1, 2011 3% 5% July 1, 2012 5% 10% 16
Meanwhile, while we wait for good R/E/L data to be reported What is indirect estimation? Indirect Estimation methodologies use an individual's name and address to estimate the probability that the person is white, the probability that the person is black, Hispanic, Asian, and so on. It does NOT assign a specific category to any individual. Approximately 90% of enrolled individuals have enough information to estimate their race-ethnicity. 17
(2) MassHealth Hospital Pay for Performance (P4P) to Reduce Disparities 18
Pay-for-Performance, defined Pay-for-Performance (of P4P) is the practice of rewarding providers to meet quality goals and to improve outcomes of care, rather than paying for the volume of services they provide. 19
Health Disparities Measurement & Incentive Strategy Overall Approach Strategy RFA08 (Yr.1) HD-1 Structural Measure Reward Hospitals to improve organizational factors that reduce racial/ethnic health disparities. RFA09 (Yr. 2) HD-2 Clinical Measures Reward Hospitals to report data by Race/Ethnicity & reduce disparities in clinical quality measures Performance Measure Performance Assessment Method Require Hospitals to implement CLAS standards regardless of patient R/E/L mix served. CLAS Validation Rate CLAS Best Practice Rating CLAS Measure Score Clinical Quality Measures: Maternity/Newborn indicators Pediatric Asthma indicators Pneumonia indicators Surgical Infxn Prevention indicators Data Validation Rate (RY09) Clinical Disparity Measure Score (RY2010) Bonus Payment Approach Earn payments for meeting performance thresholds on organizational factors (implementing CLAS). 20 Earn payments for meeting performance thresholds on clinical disparities measures
RY08 CLAS Measure Rate Results Hospital Measure Rate 100% 80% 60% 40% 20% 0% 79% 74% HD1- Governance Practices RY07 Ave 73% HD1-Admin/Mgt Practices RY08 Ave 79% 82% 86% HD1-Service Practices 70% 76% HD1-Cust Reltn Practices 76% 81% HD-1 Total Measure Rate Hospital Practices Implemented by Organizational Core Function 21
P4P Challenges Implementation problems with the CLAS measure: Does the measure used for implementing CLAS standards for high stakes purposes need to be different than the one used previously just for reporting? Should clinical measures be based on Medicaid patients only, or all patients? Do Massachusetts hospitals have sufficient numbers of minority cases for stratification purposes? Are there large enough disparities? How to address the between problem? 22
(3) The Massachusetts Council for the Elimination of Racial and Ethnic Disparities 23
Council s Statutory Responsibilities Mandate: To develop recommendations for reducing and eliminating racial and ethnic disparities in health care access and outcomes within the Commonwealth Leadership Rep. Rushing and Sen. Fargo, Co-Chairs Secretary of EOHHS Judyanne Bigby, MD is a member 24
Why a Disparities Report Card? report cards provide transparent public information and a clear incentive for improved performance. Trivedi, et al, on creating State Minority Report Cards, 25
Framework for Addressing Health Disparities Access to Health Care Societal/policy Factors Community Factors Individual Factors Institutional Transformation Extent and Quality of Health Care and Outcomes Personal Health Behaviors 26 Version 2/ 2-20-09
Nonfatal Gunshot Injuries by Race/Ethnicity Boston, 2003-2005 Combined Black Bostonians are 24% of total population and 74% of victims of gunshots Other/Unknown 6.0% Latino, 12.9% White, 4.5% Asian/Pac Isl, 1.0% Cape Verdean, 2.2% Black, 73.5% DATA SOURCE: Weapon-related injuries, Massachusetts Department 27 of Public Health, Weapon-Related Injury Surveillance System DATA ANALYSIS: Boston Public Health Commission Research Office
Disparities Report Card for Massachusetts -- Outline Health Status Indicators Health utilization, access, and quality indicators Personal health practices/ Individual factors Social determinants Basic Needs and Social Well-Being Community attributes Laws and Social Policies affecting health that may disproportionately affect racial-ethnic minorities 28
SUMMARY The effect of Massachusetts HCR on disparities is still unknown The QCC is poised to make Massachusetts the first state in the nation to stratify HEDIS-type quality measures by race-ethnicity MassHealth is implementing financial incentives to reduce racial-ethnic disparities in hospitals The Massachusetts Health Disparities Council is creating a Disparities Report Card 29
Questions??? Joel S. Weissman, PhD Jweissman@partners.org 30