Policy Information Center Highlights: Vol. 7, No. 1

01/01/1997

In This Issue:


TOOLS FOR MONITORING CULTURAL COMPETENCE IN HEALTH CARE

Increasingly, minority groups are expressing concerns that the growth of managed care will lead to a monolithic approach to health care, one which ignores the cultural and linguistic diversity of their communities. The California state government responded to these concerns by establishing cultural competency guidelines for Medi-Cal health plan contractors. Cultural competency, or the level of knowledge-based skills required to provide effective clinical care to patients from a particular racial or ethnic group, is distinguished from cultural sensitivity, which is a psychological propensity to adjust practice styles to the needs of different racial or ethnic groups.

This report, Tools for Monitoring Cultural Competence in Health Care, attempts to clarify the dimensions of culturally competent health care practices. Two expert panels composed of primary care physicians and other health care professionals were drawn from two minority owned and operated health maintenance organizations: the Chinese Community Health Plan (CCHP) and the Community Health Group of San Diego County (CHG), a Latino owned IPA serving 35,000 primarily Latino members. These panels focused on three health conditions as a way to determine cultural competency: asthma, diabetes, and hypertension. Each panelist evaluated the impact of cultural and linguistic factors in achieving adherence to the accepted standards of care for these conditions. A Chinese patient panel and a Latino patient panel were also convened. These focus groups were composed of 8 to 10 health plan members, each of whom was non- or limited-English speaking, suffering from hypertension, and living in neighborhoods with high concentrations of recent immigrant populations.

The surveys developed through the panel process are designed to be used in investigating several questions related to cultural competency. These include:

  • how do providers in managed care organizations meet the specific needs of non-English speaking enrollees?
  • how can a managed care organization assess its success in meeting those needs?
  • how can individual health care providers within managed care organizations evaluate the extent to which they are providing high quality, culturally competent care to limited English-speaking patients?

In order to answer these questions, the report first provides a review of the literature, noting that little attention has been devoted to the role cultural beliefs and cross cultural communication play in the delivery of medical care; even less attention has been given to these issues in the managed care context. The literature review examines health beliefs, provider-patient interactions, language barriers, the role of ethnicity in disease, acculturation and socioeconomic status, the importance of identifying patients' ethnicity, and the effects of managed care on providing culturally competent health care to minority ethnic groups.

The report also provides a discussion of the findings of the two physician panels and of the patient focus groups. The Chinese physician panel examined factors which complicate the care of Chinese patients. These include Chinese patients' customary deference to physicians' authority; the reliance on Chinese medicines, which have the potential for adverse interactions with Western medicines or the abandonment of Western treatments; the use of imperfect family interpreters; and the diversity of Chinese dialects used by patients. The physician panel made several recommendations intended to ameliorate the effects of these complicating factors, including: (1) prescribing medicines in smaller dosages or numbers of units to help physicians enforce drug regimens; (2) minimizing the number of medications given at any one time; (3) acknowledging the patient's use of Chinese medicines; (4) including all relevant family decision makers in office visits; and (5) using multiple questions to ascertain the nature of the patient's symptoms. The Chinese physician panel also noted that written patient satisfaction surveys have only limited utility for members of the Chinese community; that Health Status Inventories developed for Caucasian respondents are too culturally specific to permit their general use with Chinese patients; and that health care facilities must also exhibit cultural competence.

The Latino physician panel also examined factors complicating the clinical care of Latino patients and offered recommendations to alleviate them. The panel noted that Latino patients often use an indirect form of communication, may be overly deferential to physicians, and at the same time, may call for overt demonstrations of respect from physicians. The panel's recommendations included: (1) making sure that care for chronic conditions is culturally competent; (2) using the extended family and neighbors in order to ensure Latino patients' adherence to health prevention and treatment recommendations; (3) acknowledging the fact that patients will use traditional remedies as well as Western medicine; (4) spending more time with patients to establish communication and trust; and (5) identifying the patient's level of acculturation early in physician/patient interactions.

The report closes with a discussion of the development of two surveys, a patient satisfaction survey instrument and a provider cultural competence self-assessment. The first was tested in samples of 75 hypertension patients who had made at least three physician visits in the prior year at each HMO. The results from the pilot test of the patient satisfaction survey were used to make changes to the survey format. Nine questions were revised in order to be more relevant to respondents and to more closely meet the goals of the survey, in order to more closely correlate with the Provider Cultural Competence Self-Assessment, and in order to rectify difficulties that the telephone interviewers faced in administering the survey. The Provider Cultural Competence Self-Assessment was produced by the Latino and Chinese physician panels. It is intended to afford providers with an indication of the extent to which they could benefit from additional training in cultural competence. The self-assessment tool was pilot-tested with 54 physicians from the CCHP. Several changes were made in response to the pilot test results.

The report concludes with a combined analysis of the patient satisfaction survey and the provider cultural competence self-assessment. Available data allowed the exploration of associations for two questions: the mutual understandability of the languages spoken by the patient and the physician; and physician direct contact and communication with patients' families. However, since CCHP is located in San Francisco's Chinatown, serves a primarily Asian population, and is staffed by physicians who speak their patients' language, the analysis could not explore the association between physician-patient linguistic compatibility and patient satisfaction. The analysis did show, however, that all responding physicians rated direct communication with patients' families as effective or very effective in maximizing adherence. Despite this, all but one responding patient reported that their physician never talked with family members. This gap may indicate that there are considerable differences between physicians' stated strategies and their actual practices.

This report was sponsored by the Health Resources and Services Administration (HRSA). The study project officer, Michael Millman, may be reached at 301-443-0368. Copies of the report, PIC ID No. 6352, may be obtained from the Policy Information Center.

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THE RELATIONSHIP BETWEEN FAMILY STRUCTURE AND ADOLESCENT SUBSTANCE ABUSE

Adolescent substance use is associated with many developmental problems; it increases the risk of low academic achievement, high school drop out, early sexual initiation, teenage pregnancy, troubled interpersonal relationships, and marital disruption in adulthood. At the same time, adolescents living in single-parent households also suffer from an increased risk of high school drop out, teenage pregnancy, emotional problems, and marital disruption in adulthood. The similarity of these outcomes suggests that a promising area of research would be an exploration of the effects of family structure on adolescent substance use. However, small sample sizes of previous studies have prevented a thorough investigation of the effects of family structure on the risk of adolescent substance use.

This report, The Relationship Between Family Structure and Adolescent Substance Abuse, uses National Household Survey on Drug Abuse (NHSDA) data from 1991 through 1993 to analyze the distribution of substance use among adolescents aged 12-17 according to family structure. The total number of adolescent respondents for the three years is 22, 237: this large sample allows a more thorough investigation of the effects of family structure on adolescent substance abuse than has been available in previous research.

The report finds that adolescents who live with both parents are significantly less likely to use alcohol, cigarettes, marijuana, and other illicit drugs, or to report problems associated with their use, than adolescents who do not live with two biological parents. It is important to note that these effects of family structure hold true while the effects of gender, age, family income, and race/ethnicity are controlled for in the analysis. At especially high risk are adolescents who live in families (1) that are headed by a father and a stepmother; (2) where the adolescent is married and is living with a spouse; (3) that are headed by a single father; and (4) that are headed by a mother and a nonrelative. The report also finds that, regardless of family structure, black adolescents have a lower risk of past-year substance use and dependence than either white or Hispanic adolescents, and that Hispanic adolescents are more likely to need illicit drug abuse treatment than either white or black adolescents. Finally, the report notes that the association between drug use and family structure is especially pronounced among females living with their mothers only or with their mothers and stepfathers, although the relatively small sample size makes it impossible to determine whether this effect would also hold true if the adolescent lived in a single father headed household.

The report notes that, despite its finding of consistent patterns of risk, there are several limitations to its analysis. First, although the report controls for some sociodemographic variables, there are numerous other variables that may have a more consequential effect. For example, the analysis cannot take into account the quality of relationships within the family, which may have more influence over an adolescent's substance use than the number of biological parents within the family. The second limitation inherent in the analysis is that the NHSDA is limited to only one cross-sectional observation for each adolescent. It does not record how long a family structure has existed, nor does it determine whether any recent transitions have taken place. Thus, the data cannot determine whether changes in family structure, such as divorce, separation, or remarriage, are more important causes of adolescent substance abuse than the family structure itself. Finally, the data do not show how particular adolescents came to live in particular family structures. Child custody decisions are often determined by the child's past behavior and the emotional and financial well-being of the parent. Adolescents with behavioral problems are sometimes placed with fathers because it is assumed that these parents will better control or discipline the child. Therefore, it is impossible to determine whether an adolescent's substance abuse is a cause, rather than an effect, of his or her living in a particular family situation.

The report provides recommendations for further research, including: (1) a comparison of risks of adolescent substance abuse and dependence among families characterized by both their structure and the quality of their marital relations; and (2) supplementing NHSDA data with panel survey data that can provide information on developmental factors such as family background, early childhood socialization, intergenerational transmission of maladaptive behaviors, neighborhood and community context, and significant life events.

This study was sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA); the study project officer, Janet Greenblatt, may be reached at 301-443-7981. Copies of the report highlights, PIC ID No. 6232, are available from the PIC.

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THE IMPACT OF MANAGED CARE ON CLINICAL RESEARCH: A PRELIMINARY INVESTIGATION

The growing share of the health care market held by managed care organizations is likely to have significant impact on the nation's academic medical centers (AMCs). These institutions are unique in that they have a three-part mission: patient care, medical education, and research. They generally have higher costs than community hospitals, in part because of their education and research activities. AMCs are also involved in direct competition with community hospitals to provide sophisticated tertiary care services.

The report, The Impact of Managed Care on Clinical Research: A Preliminary Investigation, (March 1995), examines the impact of managed care on clinical research, and was precipitated in part by anecdotal reports from clinical investigators about increasing difficulty enrolling patients in clinical research protocols.

The report notes that one of the major difficulties of financing clinical research is the fact that any particular course of care in AMCs may include costs related to patient care, research, and medical education. While it is generally accepted that third party payers should not be responsible for costs associated with research, such as experimental drugs, extra tests, data management, and the like, there is a general consensus that payers are responsible for appropriate, non-experimental patient care services. However, the distinction between which services are experimental and which are not is often unclear, especially where an experimental therapy replaces a standard therapy or where there is no effective standard therapy for a patient's condition. The extent of the public versus private obligation to pay for research is also in dispute.

This study examines the effect of managed care organizations on clinical research in eight sites: Johns Hopkins University in Baltimore; the University of Minnesota in Minneapolis; the University of California San Francisco; Stanford University in Palo Alto; University of Pennsylvania and Fox Chase Cancer Center in Philadelphia; Oregon Health Sciences University in Portland; and the University of Washington in Seattle.

The study finds that, although managed care has had a limited impact on clinical research to date, most individual researchers expressed concern about the future funding of research and the availability of patients for clinical research. Managed care practices, such as utilization review, selective contracting, primary care gatekeeping, and payment rate negotiation, may result in several negative impacts for clinical research. These consequences include

  • denial of coverage for experimental treatments;
  • reduced lengths of stay;
  • reduced coverage of diagnostic tests;
  • reduced patient flow if the AMC is not in networks or if the primary care physician is at risk for specialty referrals; and
  • General pressure on AMC finances.

Another possible negative consequence of the increased influence of managed care on AMCs is that faculty will face increasing pressure to bring in clinical revenue, thus reducing the time available for clinical research.

The report notes that many managed care organizations are interested in clinical research, although they usually focus on outcomes and effectiveness research. They are most interested in those conditions that commonly affect their service populations, while AMCs tend to pursue more innovative research. Furthermore, even the most research oriented managed care organizations expressed reservations about increasing their participation in research funding. Some of the organizations felt that researchers were not held accountable for designing studies that address appropriate questions and yield results relevant to clinical practice or that researchers were not open about their activities and their outcomes for patients. The organizations also note that, to the extent that they are being asked to support clinical research, they should also have an increased role in setting research priorities.

The report provides a discussion of potential federal involvement in determining the effects of managed care on clinical research. It recommends that the federal government act as a mediator and facilitator of dialog between managed care organizations and academic medical centers, and that it promote clinical research in several areas.

This report was sponsored by the former Office of the Assistant Secretary for Health (OASH). Copies of the executive summary, PIC ID No. 6219, are available from the PIC.

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OREGON CONSUMER SCORECARD PROJECT: FINAL REPORT

The Oregon Consumer Scorecard Consortium was formed in order to develop a prototype consumer-oriented health plan scorecard for implementation statewide. The primary function of the scorecard is to aid consumers in choosing a health plan that best meets their individual needs and preferences for how health care services are delivered. If successful, the scorecard will serve as a comparative performance measurement tool that provides feedback to health plans, purchasers, and state policy makers about how well health plans are performing and meeting the expectations and needs of their customers.

This report, Oregon Consumer Scorecard Project: Final Report, provides information on the development of the scorecard, as well as the results of its pilot test.

The scorecard's target population was the Oregon Health Plan (OHP)-Medicaid population. Fully capitated health plans were the unit of comparison for the pilot test. Consumers must choose between health plans when they sign up for OHP, and health plans assume financial risk and clinical responsibility for enrollees; it is therefore appropriate to measure quality at the health plan level.

Information used in the development of the scorecard pilot test was gathered through several methods. These included a review of findings from other scorecard projects, a consumer satisfaction survey, process measures from the most commonly used health plan performance measurement tool, the Medicaid Health Plan Employer Data Information System (HEDIS), descriptive information on how consumers should access care within each health plan, and focus groups.

The scorecard is designed to assist consumers in two ways: by providing comparative health information and by serving as an educational tool on health plan operations for consumers. The project provided a range of information about the gaps in current quality measurement efforts, the need to tailor information to a variety of consumer needs, and issues related to the interpretation of data. The project also collected information on health plan management issues, consumer survey information, and qualitative information through consumer focus groups.

The report finds that: (1) consumers were highly receptive to the materials presented and were eager for objective choice materials; (2) a major challenge confronting the project was how to present comparative health plan data on consumer satisfaction and performance that were meaningful, understandable, and reliable; (3) there are differences between how professionals and consumers think about quality; (4) consumers expressed a strong preference for choice information that was personally relevant and geographically sensitive; (5) uniform data specifications will help to consolidate and reduce the data burden on health plans; (6) information about severity of condition or risk adjustment is needed if consumers are to get reliable and accurate comparative information about health plans; (7) consumers prefer multiple media presentations of the scorecard; and (8) the costs of producing a scorecard are formidable.

This project was sponsored by the Agency for Health Care Policy and Research (AHCPR); its project officer, Sandra Robinson, may be contacted at 301-594-1349, ext. 1314. Copies of the executive summary, PIC ID No. 5960, are available from the Policy Information Center.

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STEPS TO SUCCESSFUL IMPLEMENTATION OF YOUTH VIOLENCE PREVENTION PROGRAMS

Violence is a major danger for many of the nation's youth: homicide is the overall leading cause of death for adolescents and young adults in the inner city, surpassing medical causes of death by 150 percent in New York City, Chicago, and Los Angeles. The youth agencies in place in these areas all too often deliver specialized or fragmented services that, while undoubtedly useful, do nothing to address or combat youthful exposure to violence. The effects of these programs are often diminished when children return to their dysfunctional families and violence-plagued neighborhoods. Community groups that seek to ameliorate the consequences of young people's exposure to violence must have access to information about successful programs in other communities, how to apply those programs close to home, and how to measure the success of interventions in their communities.

This report, Steps to Successful Implementation of Youth Violence Prevention Programs, examines and describes the factors that allow some youth violence prevention efforts to succeed where others fail in order to provide community groups and individuals begin their own prevention and intervention programs. The National Center for Injury Prevention and Control (NCIPC), within the Centers for Disease Control and Prevention (CDC) funded fifteen three-to-five year youth violence prevention programs beginning in 1994. This report uses data collected during these projects to identify key factors in their successful development and implementation.

Information was gathered for the report by way of a literature review, site visits to selected CDC-funded and privately-funded projects, and telephone interviews with all other CDC-funded projects. The report finds that there is a distinct lack of information found in the literature that specifically applies to implementation of youth violence prevention programs. Therefore, it was necessary to examine literature describing implementation of community-based programs in general. The literature review finds that there is little concrete information reported on the specific characteristics or leadership qualities associated with successful programs. It also finds that theory-based program implementation is very important: implicit theory guides every program decision, but it is necessary to make the theory explicit in order to guide implementation. The literature review also offers insights in several other key areas, such as funding, staffing and training, community development, and inter-organizational relationships.

The report finds that, in many communities, escalating rates of youth violence and grim statistical profiles of turbulent neighborhoods and communities seriously impede the ability of youth to construct a positive future for themselves. Programs addressing youth violence offer viable alternatives to such violence, especially those with a strong community base. Leadership, whether it is vested in a group or community or in the personal characteristics of an individual, is extremely important to successful implementation of youth violence prevention programs. Such leadership is democratic, indigenous to the community, and relies upon input from the community in the design of the intervention. Good leadership is also flexible and responds quickly and efficiently to crises.

The report also finds that good planning is key to success. Although planning is time-consuming by nature, the report finds that programs must resist the "quick fix," even though many are initiated in response to immediate community adversity. Primary components of good planning are community involvement in program planning and a realistic assessment of a community's needs and the goals that can be accomplished. The report notes that funding is a continually important issue, both at the outset of a program and while it is ongoing. It recommends that multiple funding sources be pursued from program inception and that the program be marketed to local businesses, organizations, and churches. Respondents note that they are particularly frustrated with the interplay between funding needs and the political process.

Finally, the report examines common elements of successful programs in the areas of staffing, economic development, inter-organizational relationships, and monitoring successful implementation of programs. It discusses the use of volunteers, staff turnover, and comprehensive training and support systems for both salaried and volunteer employees. The report also stresses that not all communities are ready to be host to a youth violence intervention program. For example, a community that is concentrating on attracting or retaining an industrial enterprise might not have the time or resources available to devote to an intervention.

The report concludes that there are several factors common to all specific youth violence prevention efforts. These include: (1) a strong community and individual belief in the potential of youth; (2) community participation in examining the problems and developing solutions; (3) community representation in leadership and other staff positions; (4) adequate funding; and (5) the ability to monitor implementation and program effectiveness. These findings are intended to provide the background for a more specific manual that will help community-based organizations and individuals design and implement successful youth violence prevention efforts.

This report was sponsored by the Centers for Disease Control and Prevention (CDC). Its project officer, Dr. Jennifer Friday, may be reached at 770-488-4646. Copies of the executive summary, PIC ID No. 5920, are available from the Policy Information Center.

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THE EFFECT OF MARKET STRUCTURE ON HMO FINANCIAL PERFORMANCE: FINAL REPORT

One of the primary motivations for health care reform efforts, especially the movement for managed competition, is that some managed care organizations have lower operating costs. However, critics of managed competition maintain that the ability of this putative cost-containment method to actually reduce health care costs by establishing more HMOs and thus reduce costs through an increased supply of providers, is untested and unproven.

This report, Effect of Market Structure on HMO Financial Performance, uses data on HMO premiums from 1988 to 1991 to test the hypothesis that the expansion of HMOs has resulted in lower premiums for consumers. HMOs restructure the traditional delivery of health care by combining the functions of insurance and health care provision. Theoretically, HMOs lead to lower insurance premiums, lower payments to providers, and more efficient use of medical services.

The report examines a database consisting of all HMOs operating within the United States between 1988 and 1991. The database contained information on HMO finances and service utilization, HMO characteristics, market characteristics, and regulatory characteristics. The study methodology allows for different effects between group HMOs (HMOs that contract with multi-specialty physician groups), and IPAs (those that contract predominantly with independent physicians).

The report finds that the hypothesis that the greater the number of HMOs located in a given area, the lower the costs for premiums is borne out. Group HMOs exhibit this effect in every level of competition, but IPAs do not do so until the highest level of competition is reached. The report also shows that for-profit HMOs have lower premiums than non-profit HMOs, and that for-profit Group HMOs also have lower costs. At the same time, Blue Cross affiliation is associated with higher HMO premiums and higher IPA HMO costs. The report also finds that HMOs (particularly Group HMOs) have significant scale economies associated with both non-Medicare and Medicare enrollment, especially when this enrollment expands from a small base. Conversely, there are disadvantages of scope affecting HMOs who offer both Medicare and non-Medicare coverage. These scope diseconomies, along with the scale economies, suggest that a national strategy encouraging all HMOs to enroll a few Medicare beneficiaries may be more expensive than targeting Medicare beneficiaries to fewer HMOs.

This report was sponsored by the Health Care Financing Administration (HCFA). The study's project officer, Gerald Riley, may be reached at 410-786-6699. Copies of the executive summary, PIC ID No. 5782.1, are available from the PIC.


Recently Acquired Reports

  • Coordinated Community Responses to Domestic Violence in Six Communities: Beyond the Justice System (PIC ID No. 6154)
  • Cost Effectiveness in Health and Medicine(PIC ID No. 5619)
  • Consent for Adolescent Immunizations: Issues and Current Practices (Three Volumes) (PIC ID No. 5933)
  • Community Context Study: Minors' Access to Tobacco (PIC ID No. 6474)
  • Interdisciplinary Education Training of Professionals Caring for Persons with Disabilities: Current Approaches Implications for a Changing Health Care Systems(PIC ID No. 6052)

SERVICES AVAILABLE FROM THE PIC

The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research; and policy-oriented projects conducted by HHS as well as other federal departments and agencies. The PIC on-line database, which is updated daily, provides project descriptions of these studies. The on-line database is now accessible via the Internet on the HHS HomePage. Inquiries regarding PIC services should be directed to PIC Central Mailbox, or to (202) 690-6445

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