In the first 2 years since Oregon revamped its Medicaid program, the state has seen a reduction of more than one third in disparities in primary care use and access between blacks and whites, and between American Indians/Alaskan Natives and whites, a new study shows.
These early signs of success suggest Oregon’s changes could be a model for other states, the authors conclude in an article published online today in Health Affairs.
A Medicaid expert in Michigan says although any reduction in health disparities is good, the crucial test will be whether better access results in better health.
K. John McConnell, PhD, professor in the Department of Emergency Medicine and director of the Center for Health Systems Effectiveness at Oregon Health & Science University, Portland, and colleagues found a 36% relative reduction in primary care visit disparities for black enrollees compared with white enrollees, from 39.8 per 1000 member months in the preintervention period to 25.4 postintervention.
There was also an 80.3% drop in primary care visit disparities for American Indian/Alaska Native enrollees vs white enrollees. The absolute decline was similar in magnitude as that for blacks, going from 15.2 per 1000 member months to 2.9.
However, the researchers saw no change in emergency department (ED) use among black or American Indian/Alaska Native enrollees. Moreover, white-black disparities in the rate of preventable hospitalizations decreased, but the change was not significant.
McConnell and colleagues analyzed data from 601,217 Medicaid enrollees 2 years before the program and 2 after (January 2010-December 2014). They focused on black, white, and American Indian/Alaskan Natives because a prior review of data showed relatively few disparities between whites and Hispanics, Asian Americans, and Hawaiian/Pacific Islander enrollees.
Oregon targeted eliminating health disparities as a top priority for its Medicaid program. Before the effort, in 2011, more than 35% of minority women in the state had no regular provider compared with 18% of white women. Life expectancy for black or American Indian/Alaska Natives was 2 years lower than for whites, and black enrollees had significantly higher ED visit rates than whites (27% higher for overall ED visits and 31% higher for potentially avoidable ED visits).
Coordinated Care Organizations Formed
The state set up a combined strategy that included 16 coordinated care organizations (CCOs), similar to accountable care organizations for Medicaid.
CCOs weave together physical, behavioral, and oral health and social service needs. The strategy also added health equity to the measures for which health leaders would be held accountable.
Changes also included hiring new staff dedicated to achieving equity, and diversifying and training the workforce so that language and cultural needs were met.
Oregon also invested heavily in recruiting, training, and certifying more than 400 community health workers. The community health workers “provided a new source of information and outreach, using personal relationships and an understanding of their community to provide a link between the people and their local health care services,” the authors write.
Other efforts included state-supported leadership training geared toward health equity and passage of a law to improve the cultural competence of healthcare workers.
Promising, but Will Better Outcomes Follow?
Susan Goold, MD, MHSA, professor of internal medicine and health management and policy at the University of Michigan in Ann Arbor, said Oregon has often been on the cutting edge when it comes to Medicaid, but many of the changes they tested can be implemented elsewhere.
“They have been one of the most innovative and productive state laboratories for Medicaid,” she said.
Goold, part of the team evaluating Michigan’s Medicaid expansion efforts, was particularly impressed with the part of the package of interventions that deals with holding organizations accountable for narrowing disparities.
That’s something that could be modeled in hospitals in other states, with approaches tailored to each location, she said. However, reliably defining race and ethnicity can be a challenge in measuring the disparities anywhere, particularly with claims data, she notes.
The authors acknowledge the limitations of using claims data, writing that they “are limited in their ability to capture all of an enrollee’s risk factors or to provide a comprehensive assessment of the experience and quality of a care episode.”
Care coordination is already a movement spreading across many kinds of medical organizations, Goold noted.
She applauds Oregon for having a package of interventions, rather than a single approach. However, that also makes it harder to tell which part is making the most difference.
Goold said although it’s very important to equalize access to care for minority populations, the “$60 million question” is whether that then leads to better health for the people who gain ground.
“If people have safer housing, that’s not going to improve their health tomorrow,” she noted.
Whether better access equals better health is a question that will be answered only after many more years of study, she noted.
Support for all authors was provided by the National Institute on Minority Health and Health Disparities. The authors and Goold have disclosed no relevant financial relationships.
Health Aff. 2018;37:386-393. Abstract
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