Summary: The state of Michigan has been aggressive and innovative in confronting health care disparities. The state's Medicaid program has undertaken a variety of measures, including providing funds to community organizations to target health conditions within specific racial or ethnic groups, requiring managed care organizations to undertake disparities reduction initiatives, and analyzing Health Plan Employer Data and Information Set (HEDIS) data across racial categories to help identify and confront disparities at the system, community, and individual levels.
The Issue
The March 2002 Institute of Medicine report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, cited consistent research noting significant racial and ethnic disparities for medical procedures, even when insurance status, age, income, and seriousness of illness are analogous.
In Michigan, the state surgeon general's Healthy Michigan 2010: Health Status Report finds progress being made in preventing chronic disease. However, it also found that significant racial disparities exist for many chronic conditions.[1] For example, compared with whites, Hispanics are 1.75 times more likely to have diabetes and 1.5 times more likely to die of the condition. African Americans are 1.4 times more likely than whites to die from heart disease and are hospitalized for asthma at a rate five times greater than whites.[2]
According to Loretta Davis-Satterla, the director of the Division of Health, Wellness, and Disease Control at the Michigan Department of Community Health, "although overall health indicators have improved for most of the Michigan population, the same improvement in health measures has not been realized for racial and ethnic minorities."
Participants
The Health Disparities Reduction Program, part of the Michigan Department of Community Health, funds highly targeted and evidence-based prevention, health promotion, and screening services to help reduce health disparities. The state also has a Health Disparities Reduction Committee, a workgroup comprising representatives from various entities across the Department of Community Health, including Medicaid, mental health, chronic disease, HIV/AIDS and STD, epidemiology, child family health, and immunization.
Process of Change
Michigan's strategies to address disparities include: 1) providing funds to community organizations to target health conditions within specific racial or ethnic groups, 2) requiring managed care organizations (MCOs) to undertake disparities reduction initiatives, and 3) analyzing Health Plan Employer Data and Information Set (HEDIS) data across racial categories to identify and confront health disparities at the system, community, and individual levels.
Funding Community Efforts
Michigan's Medicaid administrators believe that building relationships on the ground level—that is, with and among community-based organizations (CBOs)—will lead to reductions in health disparities. Michigan's Department of Community Health funded 12 CBOs to target health conditions within particular groups. Among these are Tomorrow's Child, targeting infant mortality among African Americans in Detroit; the Arab-American & Chaldean Council, targeting cancers (breast, cervical, prostate, and colorectal) among Arabs in Dearborn and Detroit; St. Joseph Mercy Health Care, targeting asthma among African Americans in Ypsilanti; and St. John Community Health, focusing on diabetes and obesity among African Americans in Northwest and Northeast Detroit. The funding is a combination of state dollars and money from federal preventive health block grants. Davis-Satterla points out that "the funding of new, innovative, and targeted programs, especially at the community level, to reduce health disparities is critical, not only for the sake of the clients served, but also so successful programs can be duplicated in other venues."
Managed Care Initiatives
Every year, the Medicaid program brings together all the contracted Medicaid health plans in the state for a health disparities workshop, run by the Institute for Health Care Studies at Michigan State University. Health plans report on projects they are undertaking to help reduce health disparities and exchange ideas about effective strategies.
In FY 2005, the state required Medicaid managed care organizations to identify and implement a health disparities initiative. For example, the Physician's Health Plan of Southwest Michigan is hosting a cultural competency workshop for high-volume providers in Kalamazoo. M-Caid, the Medicaid health plan from M-Care, the University of Michigan's health plan, is revising its member Web site in an effort to make health information easier to understand. For the initial round, none of the initiatives was scored and measurable data were not required. According to Moran, "the next step is to review the projects, share the list with all plans, and encourage plans to take their initiative to the next step, which is a formalized performance improvement project. From the Medicaid agency perspective, the next step would be a requirement, beyond encouragement, that all plans analyze their population's racial and ethnic characteristics using HEDIS data, and initiate improvement actions accordingly."
Analyzing Data
The state has begun to analyze HEDIS data from Medicaid managed care plans in Wayne County, which includes Detroit, focusing specifically on access to care measures across racial and ethnic categories. The state, researchers from the University of Michigan and Michigan State University, and the managed care plans will evaluate the findings and develop policy recommendations to address major health disparities. Annual HEDIS data will then be collected over time to determine whether particular measures have changed.
Lessons
Moran says that obtaining data on disparities has been a challenge since "a regular and standardized method for collection of data by race and ethnicity does not exist." Also, reporting data on quality of care for racial and ethnic groups within health plans can result in relatively small sample sizes, making it difficult to draw conclusions. In addition to such issues, the state faces staffing and budgeting constraints. Even with these challenges, Moran maintains that "state Medicaid agencies are in a unique position to focus attention on health care disparities, specifically through Medicaid managed care organizations."
Anne Beal, M.D., senior program officer for the Program on Quality of Care for Underserved Populations at The Commonwealth Fund, describes Michigan's multifaceted approach as particularly noteworthy. "It appears to be a coordinated, multi-pronged effort to address disparities," Beal says. "Most work is done by individual entities, such as hospitals, health plans, and providers, but this seems to involve several players in the health care system in Michigan. That is innovative."
References
[1] Available online: http://www.michigan.gov/documents/Healthy_Michigan_2010_1_88117_7.pdf.
[2]Hispanic/Latino American and African American Fact Sheets, Michigan Department of Community Health. Available online: http://www.michigan.gov/mdch/0,1607,7-132-2940_2955_2985---,00.html.
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