Making Medicare color-blind: How groups are striving for equality in care Racial health inequities are well-documented in Medicare, but peer review organizations are working to even the score. By Geri Aston, AMNews staff. Dec. 3, 2001. Additional information Every year researchers uncover more bad news to add to the growing body of evidence that racial disparities in health care continue to plague Medicare. Most recently, it was that influenza vaccination rates are 21.6% lower among black beneficiaries compared with white ones. In years past, it was that black heart attack patients were less likely than white ones to undergo potentially life-saving cardiac catheterization, or that black Medicare beneficiaries with pneumonia were much less likely than white counterparts to get antibiotics in an appropriate time frame. But a group of Medicare contractors has taken that bad news to heart and is working at the community level to reverse the trend. The effort started in 1999 when the Centers for Medicare & Medicaid Services began requiring the peer review organizations it contracts with to launch quality initiatives designed to lessen the inequities in their states. CMS' action was inspired by the Healthy People 2010 goal to eliminate racial or ethnic health disparities. "As a country, we should be appalled that there are these health care disparities," said Dawn Fitzgerald, vice president and director of the Disadvantaged Area Support Peer Review Organization, which provides all the other PROs with help on their disparity projects. The reasons given for the differences in treatment are many. They include distrust among some minorities of the health care system, cultural barriers to care, low education levels, financial obstacles, language barriers between doctors and patients, and subconscious stereotypes among physicians about patients of certain races that find their way into treatment recommendations. Medicare patients who are black are less likely to get flu shots than white patients. "It's like a diamond -- it's a multifaceted problem," said John H. Hebb Jr., PhD, CMS government task leader for reducing health disparities. The PROs' tasks are to discover the causes of the disparity in their states and to develop interventions. The agency required the projects to target quality indicators for which the inequity between the minority group and all Medicare beneficiaries was at least 7%. PROs chose the minority population and the clinical topic on which they would focus. The resulting programs are community oriented. "They are getting to beneficiaries where they are, in the places where they meet," Dr. Hebb said. The PRO programs are "52 different labs," he said. Each is fighting different levels of disparity, grappling with a variety of causes, and reaching out to make practicing physicians aware of racial health inequities and to get them involved. Fanning out against diabetes In Florida, 29% of African Americans 65 and older have diabetes, compared with only 16% of Caucasians. But far fewer black Medicare beneficiaries get regular tests and exams necessary for good diabetes care. So FMQAI, the state's PRO, selected black Medicare beneficiaries as the target population for its disparities project and diabetes as the disease topic. The goal of the program is to increase rates of hemoglobin A1c tests, eye exams and lipid profiles among black beneficiaries and to improve health outcomes by reducing rates of blindness, amputation and kidney disease. Churches are increasingly becoming advocates and providers of health education. "A quality indicator is just a quality indicator," said Ferdinand Richards, MD, the foundation's medical director. "We want to make sure people are receiving good care for diabetes. We're proposing good care but measuring it indirectly through quality indicators." To accomplish that goal, the foundation is taking a two-pronged approach aimed at educating patients and physicians about good diabetes care. Some of the cultural forces the project is fighting are the high-fat, high-sugar diet common among some black beneficiaries and an acceptance by some African-Americans of elderly people "having a bit of the sugar," Dr. Richards said. The goal is to educate beneficiaries about proper diet, the importance of treating diabetes before serious complications develop and the need for regular blood sugar screenings, he said. Much of the patient education portion of the program is carried out in churches. "The churches have a hand on more African-American individuals than anyone," said James Brookins, MD, president of the Florida State Medical Assn., which is working with the foundation on the disparity project. Many majority black churches there have health ministries with nurses and physicians who offer education and conduct health screenings, he said. Plus, churches are "stabilizing institutions in the community" that black beneficiaries trust, said Diadra Wright, DPM, clinical coordinator for the diabetes project. So the foundation has developed paper fans, bookmarks and other materials with an Afrocentric look and diabetes prevention messages and is disseminating them to black churches throughout the state. But the foundation is doing more than working with churches. It's also trying to get physicians involved. Using data gleaned from Medicare claims data and the program's physician registry, the organization is focusing on physicians who practice in areas with high numbers of diabetic black beneficiaries. One hope for the education campaign is that it will help address any preconceived notions physicians might have about minority patients. "We are aware that health care is being practiced disparately based on the patient population," Dr. Richard said. Because of subconscious biases, some physicians might order a test for one patient but not for another, he said. The perception is that some patients won't be able to manage their disease well anyway, he said. When physicians are told of diabetes disparities, the information is often "met with disbelief," Dr. Richards said. To spread the word, Dr. Wright is meeting with physicians across the state and delivering information about diabetes care. The message she takes to physicians is that disparity in diabetes exists and that the program has materials to help them reduce it. Included in the offerings are printed diabetes education materials and telescoping mirrors that physicians can give to patients to help them inspect their feet. "We hope they will help improve health and generate dialogue between patients and physicians," Dr. Wright said. Preaching a mammography message Across the country, another PRO program is working through the church community to attack a racial health disparity in Medicare. But the population being targeted and the worrisome disease are very different. The Colorado Foundation for Medical Care is trying to fight breast cancer in the Hispanic community by increasing mammography rates. In Colorado, the mammography rate for Hispanic women in Medicare is 34%, compared with 66% for all female Medicare beneficiaries. A review of literature and feedback from the community revealed that an approach involving the Catholic Church would have the greatest impact on Latina Medicare beneficiaries, said Angela Sauaia, MD, the project's clinical coordinator. "The church is a community they can trust," she said. "They feel safe there." The program has both a statewide and a local component. The foundation sent bilingual educational brochures developed by the National Cancer Institute, shower cards, and proposed church bulletin and pulpit announcements to Catholic churches throughout Colorado. About 154 churches are actively participating, Dr. Sauaia said, and have displayed the materials anywhere from their lobbies to their women's restrooms. The materials also have been made available to primary care physicians. The message -- mammograms are good for you and good for your families -- is tailored to appeal to the Latina focus on family, Dr. Sauaia said. The materials also aim to combat one reason for the disparity in mammography rates: Many low-income Hispanic women believe they cannot afford the test. The brochures let women know that Medicare covers mammograms and provide a number to call for free mammograms for women who can't afford the co-pay. "There is an incentive to do it and a way to do it," Dr. Sauaia said. "We can't just educate if they have nowhere to go." For the local component of the program, the foundation has partnered with Denver's La Clinica Tepeyac to expand its promotora -- peer educator -- program. The clinic provides a variety of health services to low-income people in its largely Hispanic neighborhood. It was established by parishioners of Our Lady of Guadalupe and is next door to the church. Foundation funding enabled the clinic to expand its program to parishes in three other largely Hispanic neighborhoods. The promotoras, whose numbers fluctuate between three and six, are female church members trained to teach others about cancer, breast health, and Medicare eligibility and enrollment. The project is fighting several cultural barriers to mammography. Many Hispanic women are shy about discussing breasts, some believe cancer is a punishment for bad deeds, and others are too busy with their families to take care of their own health, Dr. Sauaia said. "There is a whole taboo around that fact that it is breast cancer," she said. But because the promotoras are from the community and speak Spanish, they are able to overcome many women's fears, Dr. Sauaia said. The program is succeeding in getting women into the clinic -- which works with 150 volunteers, including physicians -- for mammograms, said Johanna Leyba, the facility's executive director. "It's pretty phenomenal," Leyba said. "In the spring of last year, we had to ask the promotoras to slow down because we were overbooking mammograms." Pitching in against diabetes Some PRO programs are designed to assist existing efforts to reduce racial health disparities. The South Dakota Foundation for Medical Care's project aims to supplement efforts by the Indian Health Service and individual reservations to improve diabetes care, said Gerald Tracy, MD, the organization's medical director. "We're enhancing what they do," he said. "In general, we're trying to do what we can to encourage Native Americans to get earlier and better care for diabetes." Those efforts include a new culturally sensitive diabetes brochure, public service announcements on Lakota radio stations and in Lakota newspapers, booths at health fairs, and visits to reservation health clinics and with physicians. The goal is to increase rates of hemoglobin A1c tests. The public awareness campaign is key, said AnnaMaria Bosma, RN, CNS, Aberdeen Area Indian Health Service diabetes consultant. "I can't say enough about education," she said. "Informed patients will drive improved patient care." Measuring the results Between now and spring 2002, CMS hopes to begin collecting data showing the impact of the various PRO programs as measured by the quality indicators, Dr. Hebb said. "For us, it's not just a numbers thing," he said. "One of the key elements is: What did you learn about the medically underserved and which interventions worked?" Next May, the support PRO plans to publish a compendium of PRO interventions so the organizations can learn from one another, Fitzgerald said. The goal is "to share lessons learned and successful strategies," she said. "We're all neophytes with this." Back to top.  ADDITIONAL INFORMATION: Taking on disparities A breakdown of the PRO projects by target group and number of states, including Puerto Rico and the District of Columbia: African-Americans - 27 (52%) Acute myocardial infarction - 1 Breast cancer - 8 Diabetes - 11 Immunization - 7 Hispanics - 3 (6%) Breast cancer - 2 Immunization - 1 Dual-eligibles* - 19 (37%) Breast cancer - 9 Diabetes - 6 Immunization - 3 Pneumonia - 1 American Indians** - 2 (3%) Diabetes - 1 Immunization - 1 Asian/Pacific Islanders - 1 (2%) Diabetes - 1 * Dual-eligibles are low-income individuals who qualify for both Medicaid and Medicare. ** Figures are for American Indians who are not on reservations. Source: American Health Quality Assn. Back to top. Below average Minorities often lag behind Medicare beneficiaries overall in their use of diagnostic services. National usage rates by Medicare beneficiaries of mammography and hemoglobin A1c tests: Mammo- Hemoglobin graphy A1c ------ ---------- All beneficiaries 55.8% 67.1% African-Americans 46.5% 59.6% Hispanics 45.7% 58.4% Dual-eligibles 45.9% 61.7% American Indians* 34.8% 41.5% Asian/Pacific Islanders 43.9% 65.4% * Dual-eligibles are low-income individuals who qualify for both Medicaid and Medicare. ** Figures are for American Indians who are not on reservations. Source: Disadvantaged Area Support Peer Review Organization Back to top. Copyright 2001 American Medical Association. All rights reserved.