oversight

Health Care: Approaches to Address Racial and Ethnic Disparities

Published by the Government Accountability Office on 2003-07-08.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

United States General Accounting Office
Washington, DC 20548




          July 8, 2003

          The Honorable Bill Frist
          Majority Leader
          United States Senate

          Subject: Health Care: Approaches to Address Racial and Ethnic Disparities

          Dear Senator Frist:

          A recent report by the Institute of Medicine, a branch of the National Academy of
          Sciences, found that racial and ethnic minority groups tend to receive a lower quality
          of health care than nonminorities, even when access-related factors such as income
          and insurance coverage are controlled.1 It concluded that the elimination of racial and
          ethnic health care disparities is a major challenge in the United States. Racial and
          ethnic minority groups identified by the federal government—American Indians or
          Alaska Natives, Asians, Blacks or African Americans, Hispanics or Latinos, and
          Native Hawaiians or other Pacific Islanders—are expected to make up an
          increasingly large portion of the U.S. population in coming years.

          The federal government, primarily through programs under the Department of Health
          and Human Services (HHS), plays a major role in providing and financing health care
          for minority groups. HHS is also the primary federal entity involved in projects and
          research aimed at understanding and addressing disparities in health care. HHS has
          focused on racial and ethnic disparities in health access and outcomes in six areas:
          cancer screening and management, cardiovascular disease, diabetes, HIV
          infection/AIDS, immunizations, and infant mortality. HHS offices and agencies,
          researchers at philanthropic foundations, and private organizations such as
          employers and health plans have efforts under way to try to address racial and ethnic
          disparities in health care, using interventions such as disease management programs,
          disease prevention programs, health literacy and language service projects, and
          education and outreach programs. You requested that we identify approaches that
          experts view as promising to address racial and ethnic disparities in health care. The
          enclosure contains the information we provided during our July 8, 2003, briefing of
          your staff.




          1
          Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, eds., Unequal Treatment: Confronting
          Racial and Ethnic Disparities in Health Care (Washington, D.C.: National Academies Press, 2003).


                                                                        GAO-03-862R Health Care Disparities
To respond to your request, we reviewed studies, journal articles, reports, and
evaluations by the Institute of Medicine, federal agencies, researchers, and other
organizations on racial and ethnic health care disparities and on potential
interventions to reduce disparities. We also interviewed federal officials at the Office
of Personnel Management, HHS’s Office of Minority Health, and six HHS agencies—
the Agency for Healthcare Research and Quality (AHRQ), Centers for Disease Control
and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), Health
Resources and Services Administration (HRSA), Indian Health Service (IHS), and
National Institutes of Health (NIH)—to learn about their programs and initiatives. In
addition, we obtained information on relevant programs, initiatives, and promising
approaches to address disparities from health care researchers at academic
institutions and research organizations such as the Institute of Medicine,
representatives from large employers and a health plan, and officials at philanthropic
foundations and other organizations. We performed our work from April through
June 2003 in accordance with generally accepted government auditing standards.

In brief, identifying promising approaches to address racial and ethnic disparities in
health care is challenging because current efforts are in early stages of
implementation, evaluations and data are limited, and information on the
nonfinancial causes of health care disparities is incomplete. Experts identified the
following promising approaches that the federal government could pursue to address
disparities:

•    Develop new demonstration projects in federal programs using the best available
     evidence to target areas of disparities and plan promising interventions.

•    Expand current efforts in programs and demonstration projects such as CDC’s
     REACH 2010 community-based coalitions.

•    Strengthen federal leadership on disparities, including prompt dissemination of
     information on successful interventions to reduce or eliminate health care
     disparities.

•    Collect complete and accurate racial and ethnic health care data in national
     surveys to better understand and target efforts to reduce health care disparities
     through steps such as ensuring the inclusion of adequate numbers of minority
     participants.

We provided a draft of this report to officials at HHS for their technical review. We
incorporated their comments as appropriate.

As we agreed with your office, unless you publicly announce the contents of this
report earlier, we plan no further distribution of it until 30 days from the date of this
letter. We will then send copies to the Secretary of HHS, the Director of the Office of
Personnel Management, and interested congressional committees and will make
copies available to others upon request. The report will also be available at no charge
on the GAO Web site at http://www.gao.gov.


2                                                       GAO-03-862R Health Care Disparities
If you have any questions or need additional information, please contact me at (202)
512-7119 or Kim Yamane at (206) 287-4772. Lisa A. Lusk and Elaine Swift made key
contributions to this report.

Sincerely yours,




Janet Heinrich
Director, Health Care—Public Health Issues

Enclosure




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Enclosure                                                                 Enclosure




            Health Care: Approaches to
            Address Racial and Ethnic
                    Disparities

             Briefing for Congressional Staff of Senator Bill Frist
                               Majority Leader
                            United States Senate




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4                                                  GAO-03-862R Health Care Disparities
Enclosure                                                                                                                                                     Enclosure




        Racial and Ethnic Health Care
        Disparities Are Serious and Pervasive

            “[D]isparities are associated with socioeconomic differences and tend to
            diminish significantly, and in a few cases, disappear altogether when
            socioeconomic factors are controlled. The majority of studies, however, find
            that racial and ethnic disparities remain even after adjustment for
            socioeconomic differences and other healthcare access-related factors.”
            (Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington, D.C.: National Academies Press, 2003)).




            “Disparities in health care are among this nation’s most serious health care
            problems. Research has extensively documented the pervasiveness of
            racial and ethnic disparities.” (Institute of Medicine, Guidance for the National Healthcare Disparities Report (Washington, D.C.:
            National Academies Press, 2002)).




                                                                                                                                                                          2




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Enclosure                                                     Enclosure




        Objective




            Identify promising ways to address racial
            and ethnic disparities in health care




                                                                             3




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Enclosure                                                                   Enclosure




        Scope and Methodology


        • Reviewed studies, journals, reports, and evaluations by the
          Institute of Medicine, federal agencies, researchers, and other
          organizations on racial and ethnic health care disparities and on
          potential interventions to address disparities


        • Interviewed federal officials at the HHS’s Office of Minority Health
          and six HHS agencies, including AHRQ, CDC, CMS, HRSA, IHS,
          and NIH as well as at the Office of Personnel Management




                                                                                           4




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Enclosure                                                                         Enclosure




        Scope and Methodology (cont.)


        • Interviewed individual health care researchers knowledgeable about
          health care disparity issues, including researchers at academic institutions,
          the Institute of Medicine, and the RAND Corporation

        • Interviewed representatives of organizations including philanthropic
          foundations such as the California Endowment, Commonwealth Fund, and
          Kaiser Family Foundation; large employers and a health plan affiliated with
          the Washington Business Group on Health; and other organizations, such
          as the American Medical Association, Community Service Society of New
          York, National Committee for Quality Assurance, National Health Law
          Program, and MacColl Institute for Healthcare Innovation



                                                                                                 5




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Enclosure                                                                Enclosure




        Background

        Racial and Ethnic Populations

        HHS identifies the following racial and ethnic minority groups:

        •   American Indian or Alaska Native
        •   Asian
        •   Black or African American
        •   Hispanic or Latino
        •   Native Hawaiian or Other Pacific Islander




                                                                                        6




9                                                 GAO-03-862R Health Care Disparities
Enclosure                                                               Enclosure




        Background

        Areas of Disparities in Health Care

        While disparities have been identified in many areas, HHS has
        focused on six areas where serious racial and ethnic disparities
        exist in health access and outcomes:

        •   Cancer screening and management
        •   Cardiovascular disease
        •   Diabetes
        •   HIV infection/AIDS
        •   Immunizations
        •   Infant mortality


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10                                               GAO-03-862R Health Care Disparities
Enclosure                                                                        Enclosure




        Background
        Examples of Areas with Disparities in Health
        Care
        •   Cancer screening and                  • HIV infection/AIDS:
            management: procedures (e.g.,           appropriate medication (e.g.,
            diagnostic procedures, surgery)
                                                    antiretroviral drugs)
            and pain management
        •   Cardiovascular disease:
                                                  • Immunizations: on-time
            appropriate medication (e.g.,           delivery of recommended
            thrombolytics) and procedures           immunizations
            (e.g., diagnostic procedures, heart   • Infant mortality: appropriate
            surgery)                                prenatal treatment and
        •   Diabetes: disease management            prenatal procedures
            (e.g., lipid testing, measurement
            of glycosylated hemoglobin)


                                                                                                8




11                                                        GAO-03-862R Health Care Disparities
Enclosure                                                                                                                                                         Enclosure




        Background

        Examples of Disparities in Health Care

        •   African Americans, American Indians, Hawaiians, Indians and Pakistanis, Mexicans,
            South and Central Americans, and Puerto Ricans were 1.4 to 3.6 times more likely
            to present with advanced (stage IV) breast cancer than non-Hispanic whites. (C. I. Li and
            others, “Differences in Breast Cancer Stage, Treatment, and Survival by Race and Ethnicity,” Archives of Internal Medicine, vol. 163, no.1 (2003)).


        •   For early-stage lung cancer, the rates of surgery and of 5-year survival were lower
            for African Americans than whites. Survival rates for African Americans and whites
            who underwent surgery, however, were similar. This observation suggests that
            lower survival rates among African Americans may be explained by the lower rate of
            surgical treatment. (P.B. Bach and others, “Racial Differences in the Treatment of Early-Stage Lung Cancer,” New England Journal of Medicine, vol.
            341, no. 16 (1999)).



        •   Among those age 65 years and older, 69 percent of white persons received
            influenza vaccinations, compared with only 50 percent and 48 percent of older
            African American and Hispanic persons, respectively. (Based on data collected from January through September
            in the Sample Adult Core Component of the 2002 National Health Interview Survey). http://www.cdc.gov/nchs/about/major/nhis/released200303.htm
            (downloaded June 11, 2003).




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12                                                                                                                   GAO-03-862R Health Care Disparities
Enclosure                                                                Enclosure




        Background

        Factors behind Health Care Disparities
        Experts have identified many factors that contribute to
        disparities in health care. These factors include:


        • Access: physical (e.g., proximity to health care sites,
          transportation); financial (e.g., health insurance, personal
          resources); and other (e.g., ability to take time off from work,
          ability to navigate a complex health care system)


        • Provider-patient relationships: cultural barriers, language
          barriers, literacy levels, provider bias, and unequal treatment

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Enclosure                                                                         Enclosure




        Background
        The Federal Government Plays a Major Role in
        Health Care for Minority Populations
        The federal government provides or finances health care directly or jointly
        with states for large numbers of minorities. For example, of the estimated
        29 million African Americans with health care insurance in 2001:

        • Nearly 8 million were covered by Medicaid

        • Nearly 4 million were covered by Medicare


        • More than 1 million were covered by military health care, including care
          provided by the Department of Veterans Affairs and the Department of
          Defense’s TRICARE program


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Enclosure                                                                  Enclosure




        Background

        Examples of Interventions
        Some efforts by the federal government and private sector to
        address health care disparities include:

        • Disease management, such as diabetes management programs
        • Disease prevention, such as cancer screening programs for
          breast cancer
        • Health literacy and language services to ensure the
          understanding of heath information
        • Cultural competency, such as increasing cultural awareness to
          help providers serve a diverse population
        • Education and outreach, such as programs administered by
          community and faith-based groups, targeting specific populations

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Enclosure                                                               Enclosure




        Promising Approaches
        Challenges to Identifying Promising Approaches
        to Address Health Care Disparities
        • Incomplete understanding of nonfinancial causes of
          disparities
        • Targeted programs and demonstrations in early stages of
          implementation; limited evaluations on existing programs
          and interventions
        • No one overarching approach to address disparities; many
          believe that multiple approaches are needed because
          groups and subgroups experience different disparities for
          different reasons
        • Limited health care data on racial and ethnic minorities


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16                                               GAO-03-862R Health Care Disparities
Enclosure                                                                                 Enclosure




        Promising Approaches
        Addressing Health Care Disparities

        Health care researchers, federal officials, or other sources identified several
        ways that the federal government could address health care disparities:

        •   Develop new demonstration projects in federal programs

        •   Expand current efforts to reduce disparities in demonstration projects and
            initiatives

        •   Strengthen federal leadership on disparities, including prompt dissemination of
            information

        •   Collect complete and accurate racial and ethnic health care data in national
            surveys to better understand and target efforts to reduce health care disparities
            through steps such as ensuring the inclusion of adequate numbers of minority
            participants


                                                                                                   14




17                                                                GAO-03-862R Health Care Disparities
Enclosure                                                                        Enclosure




        Promising Approaches
        Develop New Demonstration Projects

        Experts identify new demonstration projects as a promising approach to
        address disparities. Research indicates that new demonstrations
        could incorporate the following features:

        • The best available evidence to target areas of health care disparities and
          plan promising interventions

        • Data sufficient to evaluate a demonstration’s effectiveness, to allow
          comparisons to other approaches, and to facilitate possible expansion

        • A source independent of those conducting the intervention evaluating the
          intervention



                                                                                           15




18                                                        GAO-03-862R Health Care Disparities
Enclosure                                                                          Enclosure




        Promising Approaches
        Expand Current Efforts

        Experts identified several current federal efforts that offer promise and
        could be expanded. They include:

        • CDC’s REACH 2010: a multiyear demonstration project that began in 1999
          and currently supports 42 community-based coalitions across the country
          to, for example, target cardiovascular disease and diabetes in African
          American women and cervical cancer among Vietnamese women.

        • HRSA’s Community Health Center Collaboratives: a health initiative
          that involves multidisciplinary teams in community health centers and
          promotes systemic changes in health care for chronic conditions and
          prevention. For example, collaboratives provide disease management and
          education in a largely minority population for conditions such as diabetes,
          asthma, and cardiovascular disease. More than 530 of over 800 community
          health centers have participated in the collaboratives.


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19                                                          GAO-03-862R Health Care Disparities
Enclosure                                                                     Enclosure




        Promising Approaches
        Expand Current Efforts (cont.)


        • AHRQ’s EXCEED program: nine centers that bring together teams of
          researchers to address a group of projects organized around a central
          theme, such as cultural competency. For example, the centers test
          interventions such as diabetes care and cancer screening among elderly
          American Indians/Alaska Natives and assess the extent to which doctor-
          patient communications contribute to disparities in health care use.




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20                                                     GAO-03-862R Health Care Disparities
Enclosure                                                                   Enclosure




        Promising Approaches
        Strengthen Federal Leadership

        Experts suggest that HHS leadership is key to reducing and
        eliminating racial and ethnic disparities in health care. While
        HHS leadership supports activities to address this issue, experts said
        stronger direction could include steps to:

        • Initiate and facilitate the development of additional interagency
          initiatives on disparities
        • Ensure the collection and prompt dissemination of best practices
          and lessons learned on approaches to reduce or eliminate
          disparities
        • Promote the expansion of programs with demonstrated track
          records of success

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21                                                   GAO-03-862R Health Care Disparities
Enclosure                                                                      Enclosure




           Promising Approaches
           Collect Complete and Accurate Racial and
           Ethnic Health Care Data
           Experts suggest that HHS could strengthen how surveys such as
           MEPS, NHANES, NHIS, and others could contribute to understanding
           disparities and effective interventions by:

           • Ensuring and supporting the inclusion of adequate numbers of
             minority participants in national surveys or conducting smaller scale
             surveys of specific groups

           • Identifying gaps in the understanding of disparities and
             interventions and using surveys to help fill them



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