Frank Diamond
MANAGED CARE April 2009. ©MediMedia USA

Insurers will be judged on how well they find and serve groups whose health outcomes have historically lagged

Insurers will need to do a better job of finding and serving minorities under a new standard that’s on track to be added to the National Committee for Quality Assurance’s health plan accreditation program.

“Our current standards do address identifying what the special needs of your population are,” says Patricia Barrett, the NCQA’s vice president for product development. “So if that means if you have a large Hispanic population among your membership, then your programs should already be addressing their needs. However, the new standard places a little additional weight on this effort and identifies that there should be a very comprehensive look at both the membership and the capacity of your delivery system to service members who have special cultural or language needs.”

To do this, NCQA encourages plans to infer race and/or ethnicity from a person’s home address and surname. Research has shown that working with home addresses works best in the black community, while surname analysis is usually used when trying to locate and service Hispanic patients, though the NCQA publicly states that it doesn’t prescribe specific methods for specific populations.

“Health plans match their members’ addresses to census data,” says Sarah Scholle, the NCQA’s assistant vice president for research and analysis. “Then they are able to see that this person lives in a census tract that is mostly black. Using surname analysis, they can do the same thing to identify people who have Hispanic backgrounds or Chinese or other. There are well-respected, well-tested ways of doing this. They can try to match it to the information they have from their claims data and their other administrative data to see where they might have disparities in the quality of care.”

For instance, churches are often the mainstays of black communities. One of the ways a health plan could fulfill its outreach obligation is by holding a breast cancer awareness workshop in a church auditorium.

“That’s exactly what we were looking at,” says Scholle. “Health plans can use the information to develop programs. Sometimes it is a disease management type of program where they are reaching out to people, specifically offering culturally tailored materials and support.”

The new standard states, “The organization must establish a method for determining whether gaps exist. Where gaps in the network exist (e.g., limited numbers of African-American primary care physicians in a predominantly African-American neighborhood or insufficient practitioners who speak a prevalent language), the organization develops and implements a plan to meet the needs of its members.”

Public comment on the new standard was closed April 1. The standard is scheduled to be made final in July, though it will not have to be implemented until 2011. Still, many health plans long ago took on this challenge. “Kaiser Permanente developed a training program for its bilingual staff to first assess whether the bilingual staff had sufficient skills in the second language to really be able to provide clinical care in that second language versus simply receptionist skills,” says Scholle. “That’s important because we know that people with language needs are more likely to have inappropriate care if they are being treated in English when they don’t understand English.”


Of course, when Scholle and Barrett were asked whether there were enough bilingual clinicians to go around, they laughed. “That can be a challenge,” admits Barrett.

The new standard also states, “NCQA recognizes that, in an environment in which there is a shortage of primary care practitioners, it is not practical to address gaps solely by recruiting additional practitioners with specific racial/ethnic or linguistic backgrounds. Organizations will need to consider a variety of innovative approaches to meeting member needs. These may include use of community partnerships, such as faith communities, public health agencies, or other community based organizations, or other avenues such as social networking approaches.”

Motivation matters

It is all about motivation, says NCQA President Margaret E. O’Kane. “Health plans that deliver the highest level of care design programs that speak to and motivate their members to be active in maintaining their own health. To do this, plans need an understanding of who their members are and what their members need.”

The NCQA recognizes that serving nonwhite or Hispanic members can be challenging, says Patricia Barrett, VP for product development.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.