Where We are Now

  • Posted In: Your Voices
  • Four years ago, when I began working at NCQA, several projects were underway to address culturally and linguistically appropriate services (CLAS) and health care disparities in racial, ethnic and linguistic minorities. With funding from The California Endowment, NCQA had just launched the Recognizing Innovation in Multicultural Health Care Award program and a quality improvement technical assistance grant program to help small primary care practices serving diverse communities. Over the next several years, members of the NCQA team presented at various conferences and attended numerous meetings to discuss health care disparities and how we could move forward to close the gaps. We were hoping not only to move the ball forward within NCQA’s programs, but also to contribute to the discussion at large, to help raise awareness of the issue, and really make an impact. We followed the lead of many great organizations active in the field and based our work on the growing research evidence of disparities and its impact on the health of our communities.

    But for years, whenever I attended a briefing on health care disparities, it felt as if we were starting all over again. Though there was already an abundance of research, it seemed as if leaders were always expressing just how astonished they were to learn that there were actually disparities in health care and promising to look into it. While advocacy organizations were working tirelessly to push for solutions, too many people didn’t even know that disparities existed. We were constantly fighting against the tide.

    Shortly after I began working there in 2006, NCQA moved to require public reporting of two existing measures of health plan membership diversity, Race/Ethnicity Diversity of Membership and Language Diversity of Membership. However, though we all wanted to move forward with measurement and more targeted disparities reduction efforts, there were several barriers. In addition to concerns about how much it would cost to measure and report on the race, ethnicity and language preferences of their members, health plans lacked leadership and best practices – there were very few health plans that were collecting this information and very little guidance on how to move forward. Categories for collection of race and ethnicity were not standardized and data that were received from state or federal agencies was unreliable and inconsistent. There remained significant concern about the feasibility of programs to measure and reduce disparities in health care organizations and about the evidence base to guide such activities.

    With all of this in mind, we embarked on several projects to add to the evidence base of successful approaches, including research on disparities and health care quality. NCQA also convened a multi-stakeholder panel and conducted key informant interviews with representatives from health plans, providers, researchers and other stakeholders to gain insight on potential strategies for addressing CLAS within health-plan evaluation programs. We continued the health plan award program to identify and recognize best practices and our work with small practices. We also continued to learn from the efforts of many other organizations doing work in this field.

    These days, it seems as if the tide has turned and momentum may finally be on our side. While there remains a significant need for education about the existence and impact of health care disparities in the United States, the environment has become much more supportive of the kind of work that so many have been doing for years. With the new administration, there is increased attention on issues of diversity and equity. Providing more than just lip-service, recent federal actions have made a concrete difference: The 2008 Medicare Improvements for Patients and Providers Act, the Children’s Health Insurance Program Reauthorization Act and the 2009 Health Information Technology and Clinical Health Act contain multiple provisions addressing the need for cultural and linguistic competence and the elimination of health care disparities. The health reform act also addresses these issues, specifically calling for the collection and analysis of race, ethnicity and language data; national strategies for quality improvement, including disparities reduction; and health workforce development for under-represented minorities.

    Work at NCQA has also moved forward quickly and with noticeably more enthusiastic external support. Based on research, best practices and lessons learned from four years of the Recognizing Innovation in Multicultural Health Care Award program, NCQA launched its Multicultural Health Care Standards program. Through this program, health care organizations such as health plans, wellness, disease management and managed behavioral health organizations can earn distinction for the work they are doing in multicultural health care. Taking examples from the numerous health plans that have worked over the years to improve CLAS and reduce disparities, we were also able to publish Implementing Multicultural Health Care Standards: Ideas and Examples, a publication offering ideas and examples to aid in the implementation of the standards and presenting the research evidence supporting the standards (also Funded by The California Endowment) and Multicultural Health Care: A Quality Improvement Guide, a guide and resource library for organizations using QI methods to improve CLAS and reduce disparities in health care (funded by Eli Lilly and Company).

    In addition, NCQA’s Committee on Performance Measurement recently voted to extend reporting of the Race/Ethnicity Diversity of Membership and Language Diversity of Membership measures to commercial health plans in addition to Medicare and Medicaid plans. Following the Institute of Medicine’s 2009 report and recommendations, NCQA will require plans to report race and ethnicity according to the Office of Management and Budget categories. Relying on the hard work of many health plans and the work of the National Health Plan Collaborative, NCQA will also allow data collection using multiple methods, including third party and indirect sources like geo-coding and surname analysis.

    This July, I left NCQA after four years. I have learned a great deal and feel fortunate to have worked at an organization dedicated to improving health care quality. And of all of the projects I have had the opportunity to work on and support in some small capacity, I am most excited to see these measures move forward. I believe that until organizations collect race, ethnicity, and language data, they cannot have an accurate picture of the communities they serve or fully understand their needs and whether they are being met. It is only with this kind of data that organizations can begin to really identify health care disparities in access or quality of care that might exist among its members and communities and act to close those gaps.  As I start my new venture, I celebrate with them these small victories.


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