The Mihalik Blog

Health and Health Care Disparities

We all recognize that disparities exist in both health and health care.  The term health care disparities indicates differences in the quality of health care between population groups.  Health disparities are differential burdens of disease among different populations. 

 

A Medicaid demonstration project across managed care plans in six states looked at differences in HEDIS and HEDIS-like results among different racial and ethnic groups.  Essentially the HEDIS data were coded for racial and/or ethnic group affiliation and analyzed by group.  Of the 12 plans participating in the study, 11 reported at least one disparity between groups.  And 10 of the 11 plans finding a disparity found more than one. 

 

A few of the health care disparities included more frequent Hemoglobin A1c testing for Caucasians with diabetes than African-Americans and Latinos and higher rates of glycemic control among Caucasians than among African-Americans and Latinos; higher rates of appropriate medication use among Caucasians with asthma than among African-Americans and Latinos; and more frequent prenatal care for Caucasians than African Americans and Latinos.    

 

The Centers for Disease Control, in an analysis of data from the 2003 Behavioral Risk Factor Surveillance System survey, found that approximately 37% of the survey population had two or more risk factors for heart disease and stroke.  However there were considerable differences among groups with 49% of African-Americans, 47% of American Indians/Alaska Natives; 40% of Hispanics, 35% of non-Hispanic Caucasians and 29% of Asians having two or more risk factors. 

In future blogs I’ll talk about some of the reasons for differences in health disparities and health care disparities. 

 

In the meantime, I invite you to review NCQA’s draft standards for Culturally and Linguistically Appropriate Services which are available for public comment until January 16, 2009. 

If you take a look at those draft standards, you’ll find a requirement to use data to identify disparities that looks very similar to the Medicaid HEDIS study I described.  The draft standard looks like this:

 

The organization uses race/ethnicity and language data and the following methods to determine if health care disparities exist.

1.      Stratifying one or more HEDIS or other clinical performance measures by race/ethnicity

2.      Stratifying one or more HEDIS or other clinical performance measures by language

3.      Stratifying one or more CAHPS or other member experience measures by race/ethnicity or language

4.      Comparing performance data for racial, ethnic or linguistic subgroups against a pre-defined reference group

 

The proposed scoring algorithm requires all four components for a score of 100%.

About Face: Member Initiated Exceptions Process

One of the NCQA Health Plan Accreditation standards that seems to give many health plans hiccups is MEM 4A, a standard that requires that members be able to initiate the process to consider coverage for a non-formulary drug.  I’m not exactly sure why it creates such consternation but occasionally it does. 

 

Until just recently NCQA had a loophole in the process that has just been closed.  The explanation for the element indicated that having a process to communicate directly with the dispensing pharmacist met the intent of the standard.  Essentially, a member could walk into the pharmacy with a prescription for a non-formulary drug and allow the pharmacist and health plan to communicate via the online pharmacy adjudication system thereby meeting the intent of the standard.

 

Gone!

 

The new clarification indicates that while such a system might exist, there MUST be a process for the member to initiate the process himself/herself on the web WITHOUT going through the pharmacy’s online system. 

 

For all of you health plans who keep holding out on this one, it’s time to initiate a web-based system for allowing members to request coverage for a non-formulary drug.  Remember, NCQA just says the member must be able to initiate the process.  NCQA doesn’t say you have to process the request based solely on the information supplied by the member.  You could easily contact a practitioner specified by the member to get the necessary clinical information to process the request. 

New Additions to the 100% Club

I’m really excited to say that Community Care Behavioral Health Organization in Pittsburgh as garnered another perfect score on its most recent MBHO accreditation survey.  This is the third time that Community Care has gotten a perfect score.

UPA Services, Inc of in Louisville, Kentucky also got a score of 100% on their first-ever NCQA survey under the PO standards.

I’m pleased that The Mihalik Group was able to assist these organizations achieve benchmark status! 

Contracted Services for Hospitals

When I started The Mihalik Group in 1994, I was just leaving my position as Associate Director in the Department of Standards at The Joint Commission.  Naturally, almost all of the consulting engagements were for organizations surveyed by TJC.  In addition to myself, I had a great team of other health care professionals, including physicians, nurses, hospital administrators, pharmacists, and laboratorians, among others, working with me to provide services.

 

Over the years, as I became more involved with NCQA and health plans I eased out of providing accreditation related services to organizations surveyed by TJC, although I still provide non-accreditation-related consulting, such as quality improvement training and management of root cause analyses, for these organizations.  Although the faces of the consultants who work with The Mihalik Group have changed since 1994, what remains constant is that they are a wonderful group of skilled and knowledgeable professional consultants. 

 

One of our consultants, Mike Troncone of Calvary Hospital in  New York, saw a need to assist hospitals with contracted services and approached us about his interest in writing a guide. 

I asked Mike to explain why he thought the guide was a good idea. 

 

Here is Mike’s response:

 

As a hospital administrator, there are many things that keep me awake at night.  From the covering ER physician who shows up one weekend night with no previous introduction to the window washer using an acid based cleaner in the nursery, whatever can go wrong will go wrong, and potentially harm the patients trusting us for their care. 

 

How can I be sure that the services being provided in the name of my hospital are being provided in a safe, effective manner? 

 

In fact, am I even aware of all of the contracted services being provided? 

 

From a risk management perspective, I can’t control risk or the quality of service without controlling the contracted services provided within my hospital’s walls or in the name of my hospital. 

 

The Joint Commission defines a contractual agreement as “an agreement with any organization, group, agency, or individual for services or personnel to be provided by, to, or on behalf of the organization.  Such agreements are defined in a contract or in some other form of written agreement such as a letter of agreement or memorandum of understanding (also referred to as contract, contracted services, contractual services, memorandum of understanding, letter of agreement, or written agreement).” 

 

I began to ask myself:

§         How many agreements are in effect in my organization today? 

§         Who reviewed them to ensure that all services are provided safely and effectively? 

§         Who is monitoring them on an ongoing basis? 

§         What will we do if a key contracted service terminates?

The result of one sleepless night was the plan for developing

The Management of Contracted Services: A Guide to Regulatory Compliance.  By developing a concrete approach to manage all types of contracts, I can be sure that I know who is in my facility, that they are competent to do the task they are assigned, and that the quality of the service they provide is being monitored.  If a contract terminates, or if the service does not live up to the performance level promised, a back up plan has been identified.  While there is a lot of ground work involved in inventorying and evaluating current contracted services, once a mechanism is in place to take control the ongoing the effort is minimal. 

I know that I certainly sleep the better for it!