1. Quality Data Quality Improvement Equitable Health & Health Care Advancing Health Equity Through Implementation of Health Reform National Academy for State Health Policy October 5, 2011 Cheryl J. Roberts Deputy Director Programs & Operations Department of Medical Assistance Services

2. Let ’ s Go Back to the Future

4. You Are A Census Taker In 1790 The next household to survey belongs to Mr. Kevin Anderson You ask the following: 1. What is your name? Kevin Anderson 2. How many persons in your household are: a. Free white males over age 16 One b. Free white males under age 16 Two c. Free white females One d.All other persons None e.Slaves None Kevin Anderson

5. Fast Forward To 1910 Sample questions that you ask Mr. Anderson regarding race, ethnicity, primary language and disability:  Sex - Male  Color or Race - White  (Enumerators were to enter "W" for White, "B" for Black, "MU" for Mulatto, "CH" for Chinese, "JP" for Japanese, "IN" for American Indian, or "OT" for other races).  Place of birth of the person – Johannesburg, South Africa  Place of birth of the person's father - Johannesburg, South Africa  Place of birth of the person's mother - Johannesburg, South Africa  Year of immigration to the United States - 1901  Is the person naturalized or an alien?  Can the person speak English? If not, what language does the person speak? Yes  Is the person blind in both eyes? No  Is the person deaf and dumb? No

6. Present Day Census 2010 Meet Mr. Kevin Anderson:  What is Person 1's sex? Male  What is Person 1's age and Date of Birth? Age 25  Is Person 1 of Hispanic, Latino, or Spanish origin? No  What is Person 1's race? White alone Black or African American alone American Indian and Alaska Native alone Asian alone Native Hawaiian and Other Pacific Islander alone Some Other Race alone Two or More Races Since Mr. Anderson is from South Africa, would you consider him to be white, African American, or other race alone?

7. Meet the Real Mr. Anderson  Professional tennis player from South Africa  His world ranking has been as high as #33  He went to college in the United States, but continues to reside in Africa  How would we “ count ” him in the next census if he becomes a U.S. citizen?

8. What ’ s The Point?  For data on race, ethnicity, sex, primary language, and disability status to be used for reducing health and health care disparities – it must be collected:  timely  ongoing  accurately and  evaluated across all Federal and State entities in order to foster data sharing!  The point is, we have a challenge as even slight changes to race categories can reduce the ability to compare data over time and our ability to identify trends and opportunities is also limited

9. Can the Categories Really Be “ Evergreen ” ?  According to a 2007 U.S. Census Bureau report, there are 382 language categories of single languages or language families. These 382 language categories represent the most commonly spoken language other than English at home. Due to small sample counts, data tabulations are not generally available for all 382 detailed languages. Instead, the Census Bureau collapses languages into smaller sets.  How do we even begin to prioritize where to put our limited health literacy resources?  What will our census and other surveys ask 10 years from now?

10. The Current Landscape  Medicare has advantage as CMS obtains ethnicity data from the Social Security Administration records and has imputed the data for all Medicare beneficiaries  Medicaid: states are collecting the data as part of the enrollment process but only new systems are capturing information on claims data base  HHS action plan to reduce racial and ethnic health disparities noted 5 priorities in increasing the availability, quality and use of data for equities projects  NCQA ’ s Multicultural Health Care (MHC) offers distinction to organizations that engage in efforts to improve culturally and linguistically appropriate services and reduce health care disparities  Hope in the development of meaningful use in the Health Information Technology for Economic and Clinical Health (HITEC), which requires physicians to record ethnicity as part of transition to electronic health records  New England Journal of Medicine called for the development of a national infrastructure and an “ all payer data base ” that will allow transferability as well as the analysis of monitoring disparities

11. Affordable Care Act Provisions Related to Disparities Reduction and Data Collection  DHHS recently released the Action Plan to Reduce Racial and Ethnic Health Disparities  Increase the availability, quality, and use of data to improve the health of minority populations including, “ publicly display aggregately collected Medicaid and Medicare quality measurements data in new ways that call attention to racial and ethnic disparities ”  To help understand and reduce persistent health disparities, the law requires any ongoing or new Federal health program to collect and report racial, ethnic and language data  The Secretary of Health and Human Services will use this data to help identify and reduce disparities

12. Effective March, 2012  To help understand and reduce persistent health disparities, the law requires any ongoing or new Federal health program to collect and report racial, ethnic and language data.  The Secretary of Health and Human Services will use this data to help identify and reduce disparities.identify and reduce disparities

13. Ongoing Challenges  Information from vital statistics is not fully standardized throughout the nation  No single entity or insurer has the capacity to analyze disparities for every country or every state  Health plans who have limited direct contact with members are limited to member information gathered at the point of enrollment (self-report)  Some states have examined all payer databases but have not imputed race data  IOM suggested to supplement data with GEO coding and surname combinations developing probabilities that can be rolled up into estimations  Some health plans are using imputed data combinations to address disparities issues

14. Data Collection Is Not Enough  We need to link data to quality measures and target initiatives to reduce inequities  Data analysis has to be drilled down in order to have the most impact  As payers and purchasers, we want to know the causes and prevention techniques, not as a distraction, but as a means toward reducing the unfavorable health and economic impact  When disparities are identified, we need to use the data and resources to ask “ why ” and “ so, now what ” from different perspectives

15. Healthy People 2020 is Adding Value  One of the four overarching goals of the recently unveiled the Healthy People 2020 initiative is “ to achieve health equity, eliminate disparities and improve the health of all groups. ”  Throughout the next decade, the Healthy People 2020 initiative will assess health disparities in the U.S. population by tracking rates of death, chronic and acute diseases, injuries, and other health-related behaviors for sub-populations defined by race, ethnicity, gender identity, sexual orientation, disability status or special health care needs, and geographic location.

16. Institute Of Medicine  The collection of data on race, ethnicity, and language will, in principle, have the greatest impact if it is done according to standards that allow for comparison of data across organizations, sharing of individual-level data from one to another, and combining of data from multiple sources.  The work carried out by individual physician offices and community health centers coupled with the collection and use of data on race, ethnicity, and language are key parts of the process of identifying health care needs and eliminating disparities.

17. Patient-Provider Level One purpose for defining a standard set of race, ethnicity, and language categories and methods for obtaining information is to: Improve communication by identifying and understanding the cultural beliefs and experiences of racial and ethnic groups and by the communication of health care needs and information in the language the patient best understands Source: Race, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement (Institute of Medicine, 2009)

18. Virginia ’ s Focus on Low Birth Weight  Maternity services are core to Medicaid  In Virginia Medicaid/SCHIP covers 30% of all maternities in the State  Virginia is innovative  The Department implemented TEXT4Baby program(3 free SMS text messages per week)  Worked with CDC and using the Pregnancy Risk Assessment Monitoring System (PRAMS) and database, which spans 17 years and allows analysis for a woman ’ s reproductive system  One health plan won an award for a partnership of home aids that provides assistance from pregnancy to age 6  Healthy Moms and Babies are fairly inexpensive. Most low birth weight babies can be very costly in the short and long term to the State  High Investment in early intervention, maternity programs, education and specialized health care cost  In spite of major investment there are disparities

19. Falls Church Fredericksburg Covington Roanoke City Salem Roanoke Alexandria Fairfax City Manassas Arlington Charlottesville Albemarle Williamsburg Matthews Henry Bedford Norton Pulaski Radford Lynchburg Isle of Wight Frederick Winchester Lexington Richmond Chesterfield Petersburg Col.Heights Portsmouth Newport News Norfolk Southampton Emporia Franklin Galax Bristol Martinsville Danville Rockbridge Buena Vista Staunton Waynesboro Augusta King & Queen New Kent Montgomery Prince Edward Campbell Northumberland Caroline Essex Accomack Fluvanna Northampton Wythe Franklin Sussex Wise Charles City CraigGloucester Buchanan Appomattox Virginia Beach Floyd Smyth Pittsylvania Fauquier Shenandoah Dickenson Giles Washington Lee Scott Russell Tazewell Bland Grayson Carroll Patrick Botetourt Charlotte Amherst Mecklenburg Greensville Suffolk Surry Dinwiddie Amelia Henrico Powhatan Middlesex Lancaster Richmond Hanover King William Louisa Goochland Highland Greene Stafford Page Prince William Bath Clarke Rappahannock Madison Westmoreland Nelson Chesapeake Spotsylvania Orange Warren Manassas Park Rockingham Brunswick King George Alleghany Cumberland Prince George Halifax Culpeper Loudoun York James City Lunenburg Nottoway Harrisonburg Hopewell Poquoson Hampton Fairfax MCO and Primary Care Case Mgt (PCCM) Managed Care Organizations ( MCO) Map Key Buckingham Primary Care Case Management Virginia Medicaid Delivery System Arrangements May 2011: 920,000 Medicaid/SCHIP Members 346,000 FFS and 580,000 MCO Rural Option- MCO Managed Care Organizations AMERIGROUP Community Care Anthem Health Keepers Plus CareNet – Southern Health Optima Family Care Virginia Premier

20. First Step – Quality Virginia ’ s Quality Improvement Program DATA  Virginia collects race and ethnicity data and provides to the health plans for accreditation  The Department requires all health plans to obtain National Committee for Quality Assurance (NCQA) accreditation  4 of 5 have Excellent status  All plans are required to use NCQA ’ s HEDIS measures  Achievements  4 out of the 5 Virginia Medicaid MCOs (Anthem, Optima, CareNet, and Virginia Premier) were ranked in 'America's Best Health Plans' by U.S. News and World Report  Performance Improvement  MCO Collaborative on two mandatory performance improvement projects to improve their two lowest HEDIS rates and two state wide projects  One plan won a national award on chronic care management program and another on increasing the breast feeding rate for African Americans  Virginia ’ s quality program has a large focus on prenatal care, health and birth weights

21. Virginia women who are served through Medicaid managed care when pregnant receive timely care

22. Trends in Overall Low Birth Weight Rates (LBW < 2,500 grams) At face value, Virginia Medicaid is doing ok when compared with CDC ’ s data from all births

23. Disparities In Low Birth Weight Rates By Race Of Mother Source: Virginia Medicaid 2010 Focused Study on Birth Outcomes

24. Questions? ¿tienes preguntas? (Spanish) Fragen? (German) domande? (Italian) питання? (Ukrainian) Translation source for the word Question : Babelfish.com About Babelfish - Babelfish.com is an free online translator.