‘We’re try­ing to build the busi­ness case for achiev­ing health equity’

Modern Healthcare - - Q & A -

Cara James, di­rec­tor of the Of­fice of Mi­nor­ity Health at the CMS, runs the agency’s pro­gram for ad­dress­ing racial health dis­par­i­ties. She pre­vi­ously di­rected the Bar­bara Jor­dan Health Pol­icy Schol­ars Pro­gram at the Henry J. Kaiser Fam­ily Foun­da­tion. Mod­ern Health­care re­porter Steven Ross John­son re­cently ex­plored the agency’s ef­forts to ad­dress health­care dis­par­i­ties. The fol­low­ing is an edited ex­cerpt.

Mod­ern Health­care: How has the Of­fice of Mi­nor­ity Health evolved since your ar­rival four years ago?

Cara James: The of­fice has evolved in a num­ber of ways. We’ve grown our staff. We also have evolved our work port­fo­lio. So we have a cou­ple of sig­na­ture ef­forts that we work on. The first that we’ve been do­ing is From Cov­er­age to Care, to help those in­di­vid­u­als who are get­ting cov­er­age through the mar­ket­place un­der­stand their cov­er­age and con­nect to health­care so that they can live a long and healthy life.

An­other ef­fort is the re­lease of the CMS Equity Plan for im­prov­ing qual­ity in Medi­care. It fo­cuses on six pri­or­ity ar­eas that our stake­hold­ers told us were re­ally key.

And our third ef­fort is im­prov­ing our CMS data to help un­der­stand where we have our gaps and where we can do bet­ter.

MH: What are some of the big­gest bar­ri­ers to re­duc­ing health­care dis­par­i­ties?

James: From a CMS per­spec­tive, one of our chal­lenges is just re­ally try­ing to touch as many places as we can. If you think about Medi­care, Med­i­caid, mar­ket­place, in­di­vid­u­als on dial­y­sis, nurs­ing homes, home health, there are a num­ber of ar­eas where we still see quite large dis­par­i­ties. It’s a chal­lenge just try­ing to be at so many ta­bles.

Even though we have im­prove­ments in health cov­er­age, we still have a num­ber of peo­ple who don’t have ac­cess. Cov­er­age doesn’t al­ways equal ac­cess. So en­sur­ing that the health­care sys­tem is able to meet the needs of pop­u­la­tions that vary from one ge­o­graphic lo­ca­tion to the next or from one com­mu­nity to the next is a chal­lenge that we con­tinue to face.

MH: What are some of the strate­gies?

James: It’s very sim­ply a USA frame­work. We’re try­ing to in­crease un­der­stand­ing and aware­ness of health dis­par­i­ties. That’s the “U.” Our “S” is to de­velop and dis­sem­i­nate so­lu­tions. And the “A” is to im­ple­ment sus­tain­able ac­tions through our­selves and our stake­hold­ers.

We de­vel­oped From Cov­er­age to Care for those in­di­vid­u­als who are com­ing into the health­care sys­tem, some for the first time ever, some for the first time in a long time. What are their needs and how do we help sup­port them to bridge that gap to care? We’re try­ing to build the busi­ness case for achiev­ing health equity.

MH: The CMS re­cently launched an in­ter­ac­tive map that helps iden­tify dis­par­i­ties and chronic con­di­tions among

Medi­care ben­e­fi­cia­ries. What was the pur­pose of cre­at­ing this tool?

James: The map­ping tool, Map­ping Medi­care Dis­par­i­ties, is re­ally the “U” part of our frame­work. It helps peo­ple un­der­stand dis­par­i­ties and their causes. In many cases, peo­ple have na­tional data but re­ally want to be able to drill down to fig­ure out what’s go­ing on in their com­mu­nity.

So we’re pro­vid­ing the data on 18 dif­fer­ent con­di­tions, on preva­lence rates, mor­tal­ity, hos­pi­tal­iza­tions, read­mis­sions, qual­ity in­di­ca­tors, and al­low­ing for com­par­isons that can help the users iden­tify where they have par­tic­u­lar chal­lenges and where they may want to start try­ing to ad­dress is­sues. A lot of lo­cal or­ga­ni­za­tions, some even at the state, may not have the an­a­lytic ca­pac­ity to pro­duce such re­sults. We wanted to make it easy and user-friendly for them.

MH: What role do so­cial de­ter­mi­nants such as poverty, crime, hous­ing, food and se­cu­rity play in cre­at­ing health dis­par­i­ties? How can govern­ment en­ti­ties such as the CMS ad­dress those de­ter­mi­nants?

“We have de­creased the unin­sured rate among (African-Amer­i­cans and His­pan­ics) quite sig­nif­i­cantly. That’s progress.”

James: There are es­ti­mates that as much as 80% of the dis­par­i­ties come from those so­cial de­ter­mi­nants. Many com­mu­ni­ties of color have much higher rates of poverty than oth­ers and that contributes both to their in­abil­ity to af­ford cov­er­age, to af­ford hous­ing, ac­cess healthy foods, or have neigh­bor­hoods that are safe.

Re­cently, our Cen­ter for Medi­care and Med­i­caid In­no­va­tion an­nounced the launch of the Ac­count­able Health Com­mu­ni­ties Model, which is the first model within CMS to start look­ing at how we help con­nect peo­ple to those so­cial ser­vices to ad­dress some of those so­cial de­ter­mi­nants. That model fo­cuses on trans­porta­tion, hous­ing and those sorts of things that are very im­por­tant to peo­ple be­ing able to main­tain good health.

MH: How does the CMS work with health­care providers to ad­dress health­care dis­par­i­ties?

James: In 2013, the HHS Of­fice of Mi­nor­ity Health re­leased … cul­tur­ally, lin­guis­ti­cally and ap­pro­pri­ate ser­vices stan­dards to help providers un­der­stand how to ad­dress things like lan­guage, cul­ture and the com­mu­nity re­sources that are avail­able to pro­vide high-qual­ity care.

We work with providers to ed­u­cate them about re­spon­si­bil­i­ties for pro­vid­ing ser­vices for peo­ple with dis­abil­i­ties, and also how to work with med­i­cal in­ter­preters or oth­ers to pro­vide ser­vices for in­di­vid­u­als with limited English pro­fi­ciency. And we also work with providers to help them con­nect with other com­mu­nity or­ga­ni­za­tions that may be more trusted re­sources within the com­mu­nity.

MH: Is the pay­ment en­vi­ron­ment con­ducive for health­care providers to ini­ti­ate th­ese strate­gies?

James: The pay­ment en­vi­ron­ment is chang­ing. We are shift­ing much more to value-based medicine and value-based pur­chas­ing. There have been a lot more op­por­tu­ni­ties to test in­ter­est­ing mod­els that can help pro­mote pre­ven­tive ser­vices and pop­u­la­tion health ef­forts.

MH: Why has race re­mained such a large fac­tor in de­ter­min­ing whether an in­di­vid­ual re­ceives care and, ul­ti­mately, in their health out­comes?

James: Race is a very com­pli­cated fac­tor. The

U.S. has a long his­tory with race. Although the Af­ford­able Care Act is cel­e­brat­ing its sixth an­niver­sary, those prob­lems won’t go away in six years. But we are mak­ing progress. I think as you look at the dis­pro­por­tion­ate rates of unin­sur­ance among African-Amer­i­cans and His­pan­ics when the first open-en­roll­ment pe­riod started, and how we have de­creased the unin­sured rate among those pop­u­la­tions quite sig­nif­i­cantly, that’s progress.

But we still have sys­temic is­sues that we need to ad­dress.

Providers, the health­care sys­tem, have struc­tural bar­ri­ers to ad­dress­ing some of those so­cial de­ter­mi­nants. Those aren’t things that are go­ing to be fixed overnight.

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