Hedge Funds 2/28/04

1. Hedge Funds 2/28/04 POLICIES TO REDUCE DISPARITIES IN CHILD HEALTH CARE Anne C. Beal, MD, MPHPresidentAetna Foundation, Inc.

2. 2 Disparities in Child Health Status and Healthcare Are Real • African American infant mortality rate 2.5 times higher than whites • African American children 3 times more likely to be hospitalized for asthma • When hospitalized, African American are one third less likely to be discharged with prescriptions for routine meds to prevent future asthma-related hospitalizations (7% vs 21%) • African-American and Hispanic children represented more than 80 percent of pediatric AIDS cases in 2000 • Death rates for African American children are 40% higher than the national average

3. 3 Disparities Are Here in Westchester

4. 4 Black Infants are Four Times More Likely to Die than White Infants in Westchester Deaths per 1,000 Live Births, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf

5. 5 Black Children Are Three Times More Likely to Die Than White Children in Westchester Deaths per 1,000 Population, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf

6. 6 Average Length of Stay for Pediatric Hospitalization By Race, 2004 Source: 2005 Annual Data Book. http://www.westchestergov.com/health/ADB/AnnualDataBook2005_2006.pdf

7. 7 Non-Medical • Health Behaviors • Living and Working Conditions • Income • Stress Health Outcomes • Life Expectancy • Health Status • Asthma Rates • Diabetes Rates Healthcare • Acceptability • Access • Effectiveness • Safety • Financing WHICH HEALTH DISPARITIES

8. 8 Non-Medical • Health Behaviors • Living and Working Conditions • Income • Stress Health Outcomes • Life Expectancy • Health Status • Asthma Rates • Diabetes Rates Healthcare • Acceptability • Access • Effectiveness • Safety • Financing WHICH HEALTH DISPARITIES 40%-67% 44%-57% Source: Arah OA, Westert GP. Correlates of health and healthcare performance: applying the Canadian Health Indicators Framework at the provincial-territorial level. BMC Health Services Research. 5:76.

9. 9 What Causes Disparities? Source: Arah OA, Westert GP. Correlates of health and healthcare performance: applying the Canadian Health Indicators Framework at the provincial-territorial level. BMC Health Services Research. 5:76.

10. 10 What Causes Disparities? Co-Morbid Conditions Community Factors Quality of Healthcare Physiologic Response to Meds Cultural Factors Environmental Factors Patient Adherence Access To Care/Coverage Economic Factors Genetic Predisposition Ease of Lifestyle Changes

11. 11 Genetic Predisposition Environmental Factors Economic Factors Cultural Factors Community Factors Disparities Access To Care/Coverage Quality of Healthcare Co-Morbid Conditions Physiologic Response to Meds Ease of Lifestyle Changes Patient Adherence WHAT CAUSES DISPARITIES?

12. 12 Genetic Predisposition Environmental Factors Economic Factors Cultural Factors Community Factors Disparities Access To Care/Coverage Quality of Healthcare Co-Morbid Conditions Physiologic Response to Meds Ease of Lifestyle Changes Patient Adherence WHAT CAUSES DISPARITIES?

13. 13 Is This About Race/Ethnicity or About Coverage?

14. 14 Minority Children are More Likely to Lack Insurance Coverage Percent of Children Ages 0-18 Uninsured All or Part Year, 2000 37 23 23 20 Source: Adapted from Doty, MM. Insurance, Access, and Quality of Care Among Hispanic Populations. 2003 Chartpack. The Commonwealth Fund and Columbia University analysis of MEPS 2000.

15. 15 Racial Disparities in Clinical Quality Occur Among the Insured Percent of Medicare managed care beneficiaries receiving service Source: Eric C. SchneiderM.D., Alan M. Zaslavsky, Arnold M. Epstein, M.D. “Racial Disparities in Quality of Care for Enrollees in Medicare Managed Care.” Journal of the American Medical Association, vol. 287, no. 10

16. 16 What Does it Really Take to Improve Care and Reduce Health Disparities? • Health care system comprised of purchasers, providers, regulators, researchers, educators, and others. • Need a multifaceted approach that affects the different sectors of the health system

17. 17 Health Care Coverage

18. 18 State Children’s Health Insurance Program (SCHIP) • Designed to provide coverage to low income children not eligible for Medicaid • Estimated that fewer than half of all eligible children are enrolled • If every child who was eligible for either Medicaid or SCHIP was enrolled • 6.7 million • 76%

19. 19 Expand SCHIP Eligibility • Universal Health Care • Uniform requirements for SCHIP eligibility • from 133% to 400% FPL • 39 states have caps of at least 200% * • Raise SCHIP eligibility cap to 300% FPL • 7.9 million • 90.3% of uninsured children *$41,300 for a family of four in 2007

20. 20 Health Care Costs $2.3 trillion in 2008 $6 Billion Over 5 Years

21. 21 Monitor the Quality of Care Stratified by Race/Ethnicity

22. 22 Disparities in Healthcare and Quality of Care • Measures of healthcare disparities are essentially quality measures. • Disparities in health is not a marginal or special interest issue. • There is a larger quality movement; use their tools, language and techniques. • Calls upon quality movement to address quality for vulnerable patients.

23. 23 COLLECTING RATE/ETHNICITY DATA:The First Step for Achieving Equity • Barriers, is it legal? • How to collect race/ethnicity data • What categories? • How long does it take? • Who should ask? • How do patients react? What Do You Do With the Data?

24. 24 Quality Improvement Reduces Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 87 84 Adequate Hemodialysis Dose, % 46 36 Source: Adapted from Sehgal: JAMA, Volume 289(8). February 26, 2003. 996-1000.

25. 25 Quality Improvement Could Maintain Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 87 Adequate Hemodialysis Dose, % 77 46 36

26. 26 Quality Improvement Could Worsen Disparities Percent Medicare Enrollees With Adequate Hemodialysis Dose, 1993- 2000 87 Adequate Hemodialysis Dose, % 46 57 36

27. 27 Health Care Is Separate and Unequal

28. 28 LARGE PROPORTIONS OF MINORITY PATIENTS USE PRIVATE DOCTORS AS THEIR REGULAR SOURCE OF CARE Percent of adults 18–64 * Compared with whites, differences remain statistically significant after adjusting for insurance or income. Source: Commonwealth Fund 2006 Health Care Quality Survey.

29. CARE FOR MINORITY PATIENTS IS CONCENTRATED AMONG A FEW PROVIDERS 29 Half of All Minority Patients Are Treated by One-Third of Primary Care Physicians Not an 80:20 rule, but a 80:50 rule Source: J. D. Reschovsky and A. S. O'Malley, Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?, Health Affairs Web Exclusive, Apr. 22, 2008, w222-w230

30. CARE FOR MINORITY PATIENTS IS CONCENTRATED AMONG A FEW PROVIDERS 30 85% 20% Source: David Barton Smith, Zhanlian Feng, Mary L. Fennell, Jacqueline S. Zinn, and Vincent Mor,Separate And Unequal: Racial Segregation And Disparities In Quality Across U.S. Nursing Homes, Health Affairs, Vol 26, Issue 5, 1448-1458

31. PRACTICES WITH MORE MINORITY PATIENTS REPORT MORE PROBLEMS WITH QUALITY 31 Percent Quality Problems by Proportion of Minority Patients Source: J. D. Reschovsky and A. S. O'Malley, Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?, Health Affairs Web Exclusive, Apr. 22, 2008, w222-w230

32. 32 Infant Mortality Is Higher in Hospitals with More Minority Patients NICU Volume % Black Region Odds Ratio NE MW South West <15% Black 15-35% Black >35% Black >40 Infants <40 Infants Source: Morales LS et al. Mortality among very low-birthweight infants in hospitals serving minority populations. American Journal of Public Health. Dec 2005. Vol 95, No. 12.

33. 33 High Quality Care Promotes Equity

34. Hispanics Are Least Likely to Report Their Providers Have Indicators of a Medical Home 34 Source: Commonwealth Fund 2006 Health Care Quality Survey.

35. Hispanics And Asians Are Less Likely to Report Always Getting Medical Care When Needed 35 Percent of adults 18--64 reporting always getting care when they need it *Compared to Whites, differences remain statistically significant after adjusting for income Source: 2006 Commonwealth Fund Health Care Quality Survey

36. 36 Racial and Ethnic Differences in Getting Needed Medical Care Are EliminatedWhen Adults Have Medical Homes Percent of adults 18–64 reporting always getting care they need when they need it Note: Medical Home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone, or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running time. Source: 2006 Commonwealth Fund Health Care Quality Survey

37. Hispanics and Asians are Less Likely To Get Rapid Access to Medical Appointments 37 Percent of adults 18—64 able to get an appointment same or next day *Compared to Whites, differences remain statistically significant after adjusting for income or insurance Source: 2006 Commonwealth Fund Health Care Quality Survey

38. 38 Minorities Who Have Medical Homes Have More Rapid Access to Medical Appointments Percent of adults 18–64 able to get an appointment same or next day * Note: Medical Home includes having a regular provider or place of care, reporting no difficulty contacting provider by phone, or getting advice and medical care on weekends or evenings, and always or often finding office visits well organized and running time. Source: 2006 Commonwealth Fund Health Care Quality Survey

39. 39 Health Care Providers

40. 40 Cultural Competency Improves Quality of Care Preventive medication underuse among children with persistent asthma Cultural Competency Score Source: Lieu TA et al., Cultural Competence Policies and other Predictors of Asthma Care Quality for Medicaid-Insured Children. Pediatrics 114, no. 1 (2003), e102-e110.

41. 41 Promoting Cultural Competencyin Healthcare Raise Awareness Set Standards for Practice Develop Measures of Processes and Outcomes Incorporate into QI

42. 42 Workforce Diversity • Physicians of color more likely to serve in low-income and underserved communities and care for patients of color • Better results when there is doctor-patient race and language concordance • 25% of US population from underrepresented minority groups; only 11% of medical students are from these groups

43. 43 People of Color Are Underrepresented in College, Medical School and as Medical Faculty Percent of Students from Underrepresented Groups Source: Manhattan Institute and AAMC Data Warehouse. Previously reported in Beal AC, Abrams M, Saul J. Healthcare Workforce Diversity: Developing Physician Leaders. The Commonwealth Fund. October 2003.

44. 44 What Does it Take to Eliminate Disparities in Care? • Health Care Coverage • Quality Improvement • Train Health Care Providers • Cultural Competency • Workforce Diversity • Disparities/Quality Oversight

45. 45 An Aetna Foundation Priority: Racial and Ethnic Equity in Health and Health Care

46. 46 LOOKING AHEAD: The Foundation’s National Program Areas Beginning in 2010, we will focus our grant-making on issues that lead to meaningful improvements in health and the health care system:  • ObesityTo address the rising rate of obesity among U.S. adults and children • Racial and ethnic health care equityTo promote equity in health and health care for common chronic conditions and infant mortality • Integrated health careTo advance high-quality health care by: • Improving coordination and communications among • health care professionals • Creating informed and involved patients • Promoting cost-effective, affordable care

47. 47 CONTACT US E-mail the Aetna Foundation: AetnaFoundation@aetna.com Aetna Foundation website: www.AetnaFoundation.org Call for Proposals Was Released March 15, 2010