# Presentation: 802060

## 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**

## 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?

## 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?

## 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

## Mechanisms underlying disparities

- Communication and comprehension barriers
- Differences in access
- Differences in coverage
- To better define mechanisms:
- Projects, interventions, demonstrations and research

## Communication

- National Medicare Education Program  (NMEP) – 1997 BBA
- Includes:
- 1-800-Medicare
- _[www.medicare.gov](http://www.medicare.gov/)_
*Medicare & You* Handbook
- HORIZONS
- Other

## 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

## REACH 

- _R_egional _E_ducation _A_bout _C_hoices in _H_ealth Care
- Implemented by CMS Regional Offices to increase access to Medicare information
- Targets:
- 		-Low Income
- 			-Location
- 				-Language
- 					-Literacy
- 						-Culture

## 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

## 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

## 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

## 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

## Specific programs and interventions

## 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

## READII

- _R_acial and _E_thnic _A_dult _D_isparities in _I_mmunization _I_nitiative
- 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

## QIOs

- QIOs

- _Q_uality _I_mprovement _O_rganizations
- 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 diseasesand disparities inminority populations
- QIO’s are “on the ground”, working with providers, beneficiaries, and networks

## QIO Disparity Projects

- 1999-2002	51 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

## 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

## 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

## CMS Demonstrations 

- Physician Group Practice Demonstration
- Medicare Health Support (CCIP)
- Cancer prevention and treatment

## 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

## 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

## 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

## 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

## 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

## 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*

## 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!

## 1-800-MEDICARE
www.medicare.gov
www.cms.hhs.gov

***www.medicare.gov***
- _[www.cms.hhs.gov](http://www.cms.hhs.gov/)_

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