Health Maintenance Organization impact on minorities in New York, New Jersey, Connecticut, and Chicago

HEALTH MAINTENANCE ORGANIZATION IMPACT ON THE MINORITIES COMMUNITY: HISPANICS, African-American AND LATINOS

The focus of this research study is the health maintenance organization impact on the minorities' community and specifically the communities of Hispanics, African-American and Latinos in the locations of New York City, New Jersey, Connecticut and Chicago. In recent years it has become increasingly clear that the U.S. .healthcare system is failing in making the same quality of care provision for ethnic minority populations as are made for the majority white population and the racial and ethnic disparities in accessing quality healthcare have been documented in research studies. It is reported that African-Americans experience the highest rates of mortality from heart disease, cancer, cerebrovascular disease and HIV / AIDS than any other U.S. racial or ethnic group." (Department of Health and Human Services and Institute of Medicine, 2003) In addition, Hispanic-Americans are reported to be "twice as likely as non-Hispanic whites to die from diabetes." (Department of Health and Human Services and Institute of Medicine, 2003) The reasons that these disparities in healthcare exist are stated to be "complex and poorly understood" yet reflected is socioeconomic differences, differences in health-related risk factors, environmental degradation and direct and indirect consequences of discrimination." (Department of Health and Human Services and Institute of Medicine, 2003) The purpose of this study is to examine the Health Maintenance Organization' impact on the Minorities Community: Hispanics, African-American and Latinos in the United States.

HEALTH MAINTENANCE ORGANIZATION IMPACT ON THE MINORITIES COMMUNITY: HISPANICS, African-American AND LATINOS

I. DESCRIPTION OF THE PROJECT

The focus of this research study is the health maintenance organization impact on the minorities' community and specifically the communities of Hispanics, African-American and Latinos in the locations of New York City, New Jersey, Connecticut and Chicago.

II. PROBLEM STATEMENT

In recent years it has become increasingly clear that the U.S. .healthcare system is failing in making the same quality of care provision for ethnic minority populations as are made for the majority white population and the racial and ethnic disparities in accessing quality healthcare have been documented in research studies. The Institute of Medicine reports that despite improvement at a steady pace in the overall health of the population in the U.S. "racial and ethnic minorities with few exceptions, experience higher rates of morbidity and mortality than non-minorities." (Agency for Healthcare Research and Policy, 2004)

It is reported that African-Americans experience the highest rates of mortality from heart disease, cancer, cerebrovascular disease and HIV / AIDS than any other U.S. racial or ethnic group." (Department of Health and Human Services and Institute of Medicine, 2003) In addition, Hispanic-Americans are reported to be "twice as likely as non-Hispanic whites to die from diabetes." (Department of Health and Human Services and Institute of Medicine, 2003) The reasons that these disparities in healthcare exist are stated to be "complex and poorly understood" yet reflected is socioeconomic differences, differences in health-related risk factors, environmental degradation and direct and indirect consequences of discrimination." (Department of Health and Human Services and Institute of Medicine, 2003)

III. PURPOSE OF THE PROJECT

The purpose of this study is to examine the Health Maintenance Organization Impact on the Minorities Community: Hispanics, African-American and Latinos in the States of New York, New Jersey, Connecticut.

IV. HISTORY AND BACKGROUND OF THE PROBLEM

African-Americans, Hispanics and Latinos have historically and traditionally failed to receive the same quality provision of healthcare that has been long afforded to white individuals. African-Americans and Hispanics are stated as less likely in receiving peritoneal dialysis and kidney transplantation and African-American and Hispanic patients with bone fracture seen in hospital emergency departments are less likely than whites to receive analgesia." (Department of Health and Human Services and Institute of Medicine, 2003) Racial and ethnic diversity in the United States increases constantly due to immigration and shifts in population making delivery of adequate health care to minorities difficult at best.

The work of Hilda L. Solis (2004) entitled: "Health Disparities: A Growing challenge in the Latino Community" states that an "alarming one in three Latinos is uninsured" and this is stated to be a higher percentage than any other racial or ethnic group." (Solis, 2004) It was reported in one study that more than 50% of all Latinos and nearly two out of five African-Americans had no insurance between 2001 and 2002 when compared to white individuals who were reported to be 25% without insurance. Solis (2004) states that as it would be expected "…being uninsured has serious consequences. Lack of insurance compromises the health of the uninsured because individuals receive less preventive care, are diagnosed at more advanced disease stages, and once diagnosed, tend to receive less therapeutic care and have higher mortality rates than individuals with health insurance. Uninsured individuals are less able to afford prescription drugs or follow through with recommended treatment. Predictably, the health status of the Latino population in the United States is greatly influenced by a lack of access to medical services." (Solis, 2004)

There are stated to be several diseases that "disproportionately impact Latinos" and these include:

(1) diabetes;

(2) HIV / AIDS;

(3) obesity;

(4) cardiovascular disease;

(5) cancer;

(6) asthma; and (7) others. (Solis, 2004) Obesity rates among Latinos in the U.S. are stated to have "more than doubled in 10 years…" (Solis, 2004)

Solis (2004) notes that the minority health disparities are complex and rooted in historical and contemporary inequities."

V. ORGANIZATIONAL CONTEXT/SCOPE OF THE PROBLEM

Disparities in health care as it relates to racial or ethnic minorities will be examined in this study which will be conducted through a qualitative process of reviewing literature in this area of study in order to better inform this study of the particulars of ethnic and racial healthcare disparities. This study will specifically examine the health organization impact on African-American, Latino and Hispanic communities and specifically in the states of New Jersey, Connecticut, New York.

VI. DEFINITION OF TERMS

(1) Health disparities - Differences in health across individuals in the population.

(2) Health Maintenance Organization - (HMO) A type of managed care organization that provides comprehensive medical care for a predetermined annual fee per enrollee.

(3) AAFP -- American Academy of Family Physicians

(4) CCOP -- Community Clinical Oncology Program

VII. SIGNIFICANCE OF THE PROJECT'

The significance of the research contained herein is the information and knowledge that will be added to the already existing knowledge base o research.

VIII. LITERATURE REVIEW

A. Disparities in Healthcare Provision

The Department of Health and Human Services and Institute of Medicine (2003)reports that some racial and ethnic minorities "experience higher rates of chronic and disabling illnesses, infectious diseases and mortality than white Americans." (Department of Health and Human Services and Institute of Medicine, 2003) In addition, Americans of racial and ethnic minorities are "significantly less likely than white Americans to possess health insurance. The problem is particularly acute among the working poor and individuals who have no employment-based insurance, and among whom minorities, particularly Hispanic-Americans are over-represented." (Department of Health and Human Services and Institute of Medicine, 2003)

The greatest barrier to care is posed by lack of private or employment-based health insurance and in fact it is held that insurance status is more likely than any other demographic or economic factor to determine the "timeliness and quality of healthcare, if it is received at all." (Department of Health and Human Services and Institute of Medicine, 2003) The work of the Department of Health and Human Services and the National Institutes of Health report entitled: "Minority-Based Community Clinical Oncology Program" (2004) states that when the African-American population is compared to the general population that African-Americans have "…an increased incidence of a number of malignancies and worse overall survival rates." (Department of Health and Human Services and the National Institutes of Health, 2004)

The report goes on to state that there is a need for "greater involvement in clinical trials research by Black, Hispanic, Asian-American, American Indian and other racial/ethnic minority patients…needed if the advances in clinical research are to be extended to all groups, and if the results of clinical trails are to be generalizable to the entire population. In general, there has been limited participation in clinical trials research by minority cancer patients." (Department of Health and Human Services and the National Institutes of Health, 2004)

The work of the AAFP entitled: "Principles for Improving Cultural Proficiency and Care to Minority and Medically-Underserved Communities" states that the managed care/health plan organization includes both public and private Health Maintenance Organizations (HMOs) should work in cohesion with physician and other health professional organizations "to ensure the development, evaluation, and diffusion of curricula, training, and education programs that address cultural proficiency, medically underserved communities, and health disparities." (AAFP, nd)

Health Maintenance Organizations are in need of cultural proficiency and the provision of high quality and easily accessible language services in order to enable access to and quality of services. In addition it is stated that "Both public and private HMOs and health plans should be asked to take explicit responsibility for paying and arranging for interpreter services as a covered benefit for members with the caveat that such services are the responsibility of the primary financial entity (HMO or purchaser) and are not to be born by fiscal intermediaries such as local medical groups or physicians and other health professionals, unless they have explicitly contracted for the provision of such interpreter services." (AAFP, nd)

The Health Maintenance Organization further should "…negotiate with both public and private payers for adequate reimbursement or direct payment to cover the expenses of interpreter services so that they can establish services without burdening physicians…" and the private industry should be "…engaged by medical organizations, including the AAFP, and patient advocacy groups to consider innovative ways to provide interpreter services to both employees and the medically underserved." (AAFP, nd)

One example of the community healthcare organization is the CCOP model is reported as a community cancer screening center model and is stated to be an effective mechanism for facilitating the linkage of investigators and their institutions with the clinical trials network. It is reported that the minority-based CCOP was approved initially by the NCI, Division of Cancer Prevention Board of Scientific Counselors in January 1989. The implementation began in the fall of 1990 and the program was experiencing success by 1992. Success meant that the minority populations were made provisions of access to clinical trails and it is reported that in 2003, there were a total of eleven programs in eight U.S. states, the District of Columbia and Puerto Rico involving approximately forty hospitals and more than four hundred physicians, including over 100 minority investigators.

The minority-based CCOP initiative is stated to have a design which: (1) brings the advantages of state-of-the-art cancer treatment and prevention and control research to minority individuals in their own communities by having practicing physicians and their patients/participants enroll in NCI-approved cancer treatment and prevention and control clinical trials; (2) provides a basis for involving a wider segment of the community in cancer prevention and control research and investigates the impact of cancer therapy and control advances community medical practices; (3) increases the involvement of primary health care providers and other specialists with the minority-based CCOP investigators in cancer treatment and prevention and control research providing an opportunity for education and exchange of information; (4) facilitates wider community participation among racial/ethnic minorities, women and other populations through acceleration of the transfer of newly designed cancer prevention, detection, treatment, patient management, rehabilitation, and continuing care technology to widespread community application; and (5) examination of selected issues in Minority-based CCOP performance. (Department of Health and Human Services and the National Institutes of Health, 2004)

C. Hispanic-Americans Demographics and Other Vital Information

The work of Talamantes and Linderman (nd) entitled: "Health and Health Care of Hispanics: states that "The diverse use of the terms "Hispanic and Latino" in the literature can be attributed to the diversity of the subgroups of Mexican-American, Cuban American and Puerto Rican populations within a broader context. State and/or Regional differences in the use of terms are frequently noted in the Southwest. For example, in Texas where there is a large Mexican-American population, the identifiers Hispanic or Mexican-American are primarily used. New Mexicans usually self-identify as Hispanic or Hispanos. In California, Latino or Latina is typically the favored term. The term "Latino" emphasizes Latin American origin." According to the U.S. Bureau of the Census the term 'Hispanic' is used as an ethnicity category that refers to individuals who trace their origin or descent to Mexico Puerto Rico, Cuba, Central or South America, or Spain. Since 1980, according to the Census Bureau, Hispanics can be of any race." (Talamantes and Linderman, 2003)

Talamantes and Linderman additionally report that there is "substantial heterogeneity among the various Hispanic/Latino elder groups. They carry a unique historical and sociopolitical reality, which impacts who they are today. The subgroups vary by their patterns of geographic distribution in the United States. The Mexican-American population tends to reside in the Southwestern states of California, Arizona, Colorado, and Texas; the Hispanic population resides in New Mexico. The Cuban population predominantly resides in Florida, and the Puerto Rican population lives mostly in the Northeast with growing concentrations in New York, New Jersey and in major Midwestern cities such as Chicago." (Talamantes and Linderman, 2003)

Individuals in the United States who identify themselves as Hispanic or Latino is stated to equal 5.6% of all older Americans with an estimated 1,938,000 elders in this category in 2000. The population of Hispanic/Latino elderly is projected to grow 3.9% per year from 1990 to 2050. By 2020 they are expected to be 9% of all people 65 and older in the U.S., and by 2050 they will increase to 16.4%." (Talamantes and Linderman, ) The fact is that it is expected that the older Hispanic/Latino population will grow faster than any other ethnic minority group by 2028 even surpassing the non-Hispanic Black population in the elder aged category. The following figure is a chart that shows the ethnic distribution of Hispanic/Latino elderly in the United States.

Figure 1

Ethnic Distribution of Hispanic/Latino Elderly

Source: Talamantes and Linderman

The following figure is a chart showing the percent of population aged 65 and older by Ethnic group for Hispanic/Latinos in the United States.

Source: Talamantes and Linderman

The Hispanic origin population by gender, age and ethnicity in the United States is shown in the following table labeled Figure 3 in this study.

Figure 3

Hispanic Origin Population by Gender, Age and Ethnicity

Gender and Age

Total Hispanic

Hispanic Origin Type

Female

Number

Mexican-American

Puerto Rican

Cuban

Central/South American

55-64

12,250

8.7

4.5

7.2

9.7

7.5

65-74

9,747

7.0

3.3

4.9

12.3

4.0

75-84

6,889

4.9

1.4

2.3

9.6

1.4

85 +

2,099

1.5

0.3

1.7

Male

55-64

11,137

8.3

4.1

7.1

11.5

0.5

65-74

8,049

6.0

2.3

3.1

12.1

75-84

4,796

3.6

1.1

1.6

4.5

85 +

1,041

0.8

1.7

0.2

0.2

Source: Talamantes and Linderman

One of the most commonly shared Hispanic/Latino characteristic among elders is their "affinity for the retention and use of the Spanish language. Limited proficiency in English is stated to been a "barrier to accessing medical care and social services. (Mutchler & Brallier, 1999 cited in: Talamantes and Linderman, 2003)

Case Study on Health Maintenance Organizations

The work of Darrell J. Gaskin (1997) entitled: "The Impact of Health Maintenance Organizational Penetration on the Use of Hospitals that Serve Minority Communities" published in the Medical Care journal reports a study with the objectives of the examination of the penetration that health maintenance organization has made in making hospital markets more price competitive. Specifically stated is that "Hospitals in minority communities may be at a competitive disadvantage because they serve patients who are, on average, sicker and more likely to be uninsured or underinsured. This study estimated the impact of HMO penetration on the use of hospitals in minority communities during 1987 to 1992." (Gaskin, 1997)

The method of the study reported by Gaskin used a sample of 1,413 short-term general hospitals from the 85 largest metropolitan statistical areas" and it is reported that "…the determinants of hospitals' patient volumes were estimated. Hospitals located in predominately nonwhite neighborhoods were designated minority hospitals, and other hospitals were designated nonminority hospitals. Using regression analysis, the impact of HMO penetration and concentration on hospitals' patient volumes were estimated. Through interaction the HMO penetration and concentration variables with a minority hospital indicator variable, HMOs' impact on minority hospitals was calculated." (Gaskin, 1997) Results of the study report that health maintenance organization penetration was correlated with lower patient volumes in minority hospitals and higher patient volumes in nonminority hospitals." (Gaskin, 1997)

In addition it was reported that "competition in HMO markets was correlated with lower patient volumes for all hospitals. This effect was stronger for minority hospitals." (Gaskin, 1997) Conclusions of the study suggest that minority hospitals "may be at risk of losing patients as HMO penetration increases." (Gaskin, 1997) The study states that the health maintenance organization penetration was "correlated with lower patient volumes in minority hospitals and higher patient volumes in nonminority hospitals. Competition in HMO markets was correlated with lower patient volumes for all hospitals. This effect was stronger for minority hospitals." (Gaskin, 1997)

Case Study on Health Maintenance Organization Penetration and Payer Mix

The work of Kevin G.M. Volpp (2004) entitled: "The Effect of Increases in HMO Penetration and Changes in Payer Mix on In-Hospital Mortality and Treatment Patterns for Acute Myocardial Infarction" reports a study with the objective of determining whether changes in health maintenance organization (HMO) penetration or payer mix affected inhospital mortality and treatment patterns of patients with acute myocardial infarction (AMI). The study design is one in which an observational study was conducted through use of patient-level logistic regression analysis and hospital and year fixed effects of data from the Agency for Healthcare Research and Quality's Healthcare Costa and Utilization Project Nationwide Inpatient Sample, a geographically diverse sample of 20% of the hospitalized patients in the United States.

It is reported that managed care has grown and is a mechanism "to lower healthcare costs…" and is of the nature that has resulted in concerns that this may inadvertently have an adverse effect upon the quality of care. Additionally stated is that "relative reductions in payment may affect the quality of care because hospitals have fewer resources with which to provide services. The overall effect on patient care of declines in reimbursement by a specific insurer is stated to comprise two phenomena. (Volpp, 2004) Those two are listed as follows: (1) a direct effect on the care of patients with that particular insurance, who may receive fewer beneficial services, and (2) an indirect or spillover effect on other patients within the same hospital, whose care is altered because of hospital-wide resource constraints. (Volpp, 2004)

It is stated that in direct comparisons of quality of care between health maintenance organizations and fee-for-service patients have resulted in mixed findings however, it is reported that commercial HMO penetration "has been shown to have spillover effects on the cost of care among Medicare FFS patients, as lower costs among Medicare patients have been observed in areas with high commercial HMO penetration " (Volpp, 2004) Furthermore, it is reported that higher HMO and managed care penetration rates "have been shown to be associated with reduced access to care, less use of costly diagnostic testing and reductions in hospital cost growth." (Volpp, 2004)

Medication of the quality of care for HMO hospitalized patients is stated to be of the nature that could be "…mediated by several mechanisms besides reduced availability of resources. Growth in managed care could bring about changes in physician practice patterns, system-wide availability of resources and new technology, and changes in the mix of services available to favor more cost-effective technologies and services." (Volpp, 2004)

Unknown are the quality effects for non-HMO patients of the observed spillover effects of HMOs on hospital costs. Reductions in cost growth of hospitals is likely to result in less being available in the way of resources for care of patient and this includes worse outcomes. HMOs are stated to be better able to shop for providers of better quality than are individuals. It is reported that in two cross-sectional analyses that examined the link between HMO penetration and quality of care that FFS patients received using data from 1994 to 1995 on Medicare FFS patients found that in FFS patients with acute myocardial infarction (AMI) "higher HMO penetration was associated with higher use of beneficial medications such as ?-blockers and aspirin and lower rates of coronary angiography, but was not associated with AMI mortality rates." (Volpp, 2004) Also reported is a study in 1990 that examined data for Medicare patients and which states findings that there was a "…statistically significant but small reduction in 30-day mortality risk of roughly 0.15% among patients in the highest (>24.5%) HMO market penetration group relative to those in the lowest (

The study design of Heidereich and Mukamel were both cross-sectional and is stated to make inferences "about causality problematic…" in that explanations such as a tendency by HMOs to locate in higher cost markets because of greater potential for cost savings may explain the observed associations, as higher cost markets may also have better outcomes." (Volpp, 2004) Furthermore, both of the studies are stated to focus solely on the Medicare population, and the effect of managed care on patient quality may have been more significant in hospitals with greater proportions of patients younger than 65 years of age and this is stated to be particularly true "if a significant portion of patients is part of a vulnerable population group, such as the uninsured." (Volpp, 2004)

Previous study has demonstrated that HMO profits are lower in markets with more competition and that HMO penetration "was not independently associated with profit rates." (Volpp, 2004) This is stated to suggest competition between HMOs may result in a limitation of the ability to reduce prices paid to hospitals and might also reduce the degree of cost reductions and the potential effect on quality of care." (Volpp, 2004)

Volpp (2004) reports an analysis that utilized data form 1989 through 1996 from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS) for the express purpose of examining the association between changes in HMO penetration and changes in outcomes and treatment patterns for all AMI patients. The study used discharges from repeated cross-sectional samples of hospitals and "makes the selection bias inherent in single cross-sectional studies less problematic and allows us to control for baseline quality differences among patients in different hospital markets to examine how outcomes and treatment patterns changed over time in association with changes in HMO penetration." (Talamantes and Linderman) The study is stated to have been in contrast to previous studies in that Medicare patients and non-Medicare patients younger than 65 years of age were examined since the price and competition effects as well as the reduction in reimbursement were thought to be the most direct in this particular group." It is reported as important for Medicare and non-Medicare patients to be studied and there is also existing evidence that outcomes and treatment patterns in a specific market place may be similar for all individual patients yet the services and prices experience a wide variation. Therefore, "intertemporal changes in mortality and cardiac procedure use for all patients in the two main groups of patients, as opposed to looking at changes in these measures for patients with specific insurance types." () Additionally examined was the role of HMO market concentration for the purpose of determining whether the While it is important to study Medicare and non-Medicare patients, there is some evidence that within a given marketplace outcomes and treatment patterns may be similar for all patients, although the price being paid for similar services may vary widely. For this reason, we focus on intertemporal changes in mortality and effects observed "…are a function of the competitiveness of HMO markets." (Talamantes and Linderman, 2003) The changes in the proportion of uninsured, Medicaid and Medicare patients were adjusted for since reimbursements had been low for these payers and it is like that the proportion of these were affected in the hospital care delivery processes and outcomes.

HMO penetration and the number of HMOs within each MSA were measured by an MSA-level measure of HMO competition. The MSA-level measures was used instead of the hospital-level measures since it is held to be less likely to be endogenous since HMOs may choose to contract with hospitals of better quality but however would not be likely to make selective contracting decisions on the market level upon the basis of varying quality levels. Use of an MSA-level measures of HMO penetration further offer protection against potential hospital-level selection bias which might result from changes that are significant in the admission pattern of patients with "different-than-average AMI mortality in conjunction with increases in HMO penetration." (Talamantes and Linderman, 2003)

It is reported that each group that was discharged was grouped into one of four quartiles upon the basis of the market-level HMO penetration "between 0% and less than 9.3% (quartile 1)." () HMO penetration was stated to be at 9.3% and 14.5% (quartile 2) and HMO penetration between 14.6% and 21.4% (quartile 3) and HMO penetration greater than 21.4% (quartile 4)." (Talamantes and Linderman, 2003) It is reported that the percentage of uninsured, Medicare, and Medicaid patients were calculated in each hospital per year in the sample using the NIS data." (Talamantes and Linderman, 2003) Stated as the principal outcome measure was that of death occurring in the initial hospitalization in the case that the hospital length of stay was equal to or less than 30 days. Treatment pattern changes involved examination of cardiac cauterizations, coronary artery bypass graft procedures and coronary angioplasties or stents during the first 30 days of the initial hospitalization.

The method for adjustment of risk was developed by Elixhauser and colleagues at the Agency for Healthcare Research and Quality and is a method that has undergone testing extensively in regards to superior discrimination vs. other approaches in risk adjustment when using administrative data. Testing for spillover effects and specifically if changes in the number of patients with HMO insurance resulted in affecting the outcomes and treatment patterns of patients who had Medicare insurance. The sample was grouped into two subsamples: (1) Medicare patients; and (2) non-Medicare patients. (Talamantes and Linderman, 2003)

The hospitals in the NIS are reported to have changed from one year to the next based on the sampling criteria of the NIS and in 1989, the sample included 180 hospitals with the total sample including 457 hospitals contributing data for two years enabling the use of fixed effects for the hospital. Findings are stated as follows: "Mean HMO penetration increased from 18.8% in 1989 to 27.5% in 1996. There were no large changes in the mean number of HMOs within each MSA. The percentage of uninsured decreased from 6.0% to 4.1%. Changes in payer mix for each of the other classes of payers were small (Table 1). Overall, in-hospital mortality for AMI patients declined from 14.6% to 9.3% during this period, while cardiac catheterization, angioplasty, and CABG rates rose substantially. Hospitals in the sample in 1989 and hospitals in the sample in 1996 were not necessarily the same hospitals." (Talamantes and Linderman, 2003)

The following table list the descriptive statistics of sample population comprising 340,064 patients and 457 hospitals as reported in the work of Talamantes and Linderman (Talamantes and Linderman, 2003) .

Figure

Descriptive Statistics of Sample Population Comprising 340064 Patients and 457 Hospitals

Figure 3

Odds Ratios of Effect of Changes in payer Mix on Treatment and Outcomes among Medicare Patients

Figure 4

Listed in the following table are the patient's characteristics for hospitals with and without Interquartile Change in HMO Penetration

Source: (Talamantes and Linderman, 2003)

The following figure lists the odds ratios of effect of changes in Payer Mix on Treatment and Outcomes among Non-Medicare Patients.

Figure 5

odds ratios of effect of changes in Payer Mix on Treatment and Outcomes Among Non-Medicare Patients

Source: (Talamantes and Linderman, 2003)

The study concludes that the observations made with the data in this study suggest that "increases in HMO penetration within hospitals in the HCUP NIS did not affect the availability of resources to a sufficient degree to have a significant adverse effect on AMI mortality. Further work should investigate the effects of changes in payer mix and HMO competition on quality of care for other diseases, as well as in portions of the country that have experienced large increases in the percentage of HMO patients or other changes in payer mix that could cause sufficient financial stress within hospitals to affect the quality of care." (Talamantes and Linderman, 2003)

The 'Opening Doors: Reducing Sociocultural Barriers to Health Care' a program of the Robert Wood Johnson Foundation had as its aim the sharpening of the focus on factors of culture, language, race, and ethnicity on health care access. This involved 23 projects in rural and urban areas in 11 states. The funded project is reported to have fallen into two categories: (1) Service projects to reduce sociocultural barriers. The program funded several replicable models that exemplified cost-effective strategies to reduce sociocultural barriers to care; (2) Research projects to identify the sociocultural barriers to health care and strategies to reduce them. (Robert Wood Johnson Foundation,, )

This project accomplished the following: (1) (1) affected direct services in rural and urban settings in 11 states across the country by: (a) Using community outreach workers; (b) Providing interpreter services; (c) Changing policies and practices that created barriers; (d) (2) Trained health care workers through: (a) Developing cross-cultural curricula for medical students; (b) Providing community-based training opportunities for residents; (c) Offering cultural competency training for agency staff and board members; (3) Improved use patterns, such as: (a) Reducing unnecessary emergency room visits in a rural immigrant community; (b) Increasing patient enrollment in an urban, hospital-based HMO where interpreters and outreach workers were available for immigrants; (4) Developed policy recommendations regarding: (a) Cultural competency in managed care; (b) HMO compliance with state standards for access to reproductive health care; and (c) Cultural and linguistic competency in interpreter services. (, )

It is stated that the proportion of the population belonging to the four minority groups that the U.S. Census Bureau counts are: (1) American Indian; (2) Asian and Pacific Islander; (3) Black; and (4) Hispanic and that these will rise from 25% to 32% by 2010 and 48% by 2050. There are already "minority majorities" existing in New Mexico and Hawaii and some of the most populated U.S. cities including central Chicago, Detroit, Miami and New York City. Stated to be one of the biggest challenges that health care organizations face is the welcoming of immigrants and native-born members of ethnic and racial minority groups. (, )

It is stated that: (1) Disparities exist in health status, access, and quality of care for these groups compared with the majority population; (2) Many minority groups have shorter life spans and higher rates of infant mortality; (3) As of writing of this report, 31% of minority adults, ages 18 to 64, lacked health insurance, compared with only 14% of white adults in the same group; (4) Some minority groups are more likely to receive care in a hospital emergency room and are less likely to receive important preventive services; (5) Of Americans who have visited a doctor in the past year, minority adults (29%) were less likely to receive preventive care services, such as blood pressure tests, Pap smears, or cholesterol readings, compared with white adults (26%), according to the National Comparative Survey of Minority Health Care, The Commonwealth Fund, 1995. Other barriers include the following: (1) Language and communication barriers; (2) Medical practices that differ from their own beliefs and traditions; (3) Fear and mistrust of health care institutions; (4) Lack of knowledge about how to navigate the system. ()

Identified sociocultural barriers to health care are those due to patient and provider differences including those as follows: (1) Language and nonverbal communication, including nonproficiency in English, degree of formality and openness in conversation, eye contact, and the role of silence in cross-cultural encounters. For example, a Latina arrives at a primary care unit with a feverish three-year-old and an 11-year-old daughter. Because the mother speaks no English, the young girl is forced to serve as translator. The child has difficulty understanding the doctor's questions about "fever" and "pain," and does not have the English vocabulary to translate the information her mother provides; (2) Health practices and beliefs, including patients' reliance on alternative therapies and spiritual healers, differences in understanding the causes of illness, and religious beliefs that contradict Western medical practices.

For example, an Ethiopian couple, recent immigrants to the United States, bring their baby to a pediatrician in the Seattle area. The pediatrician proceeds to warn them about the dangers of exposing their newborn to second-hand smoke.

Speaking through an interpreter, the mother asks whether some smoke is okay. It takes some time before the doctor realizes that she wants to burn incense -- a traditional ritual surrounding childbirth in her culture; (3) Role of family members in decision-making, such as reliance on elders, men, or the whole family to make decisions on behalf of the patient, which may affect the informed consent process and confidentiality, and can delay time-sensitive medical procedures; (4) Two examples: a hospital nurse is perplexed when an African-American child is brought in for routine visits by different family members each time. In another example, during a check-up, the wife of a migrant worker (and mother of four girls), refuses information on family planning, explaining that her husband wants her to continue becoming pregnant until she has given him a son; (5) Patients' knowledge and expectations of the health care system, including: (a) Lack of knowledge of the value of preventive services; (b) Confusion about how and where to seek care; (c) Fear of providing personal or medical information based on experience (particularly for immigrants who are undocumented and refugees who were persecuted in their native countries). (d) Mistrust among African-Americans and other groups who believe they may unknowingly be part of a study or experiment.

It is reported that the culture and complexity of the health care system is one that creates obstacles for patients including those as follows: (1) Complex eligibility rules; (2) Imposing health care facilities; (3) Long waits for appointments; (4) Inconvenient hours for working people; (5) history and reputation of an organization's responsiveness to minority communities; The stated example, is one involving a woman "who is a member of a managed care plan must travel from her home in Brooklyn to Manhattan for her hospital appointments, but must obtain her medications from the plan's pharmacy in Brooklyn" and the second examples given is in the setting of Chicago in which "…residents of an African-American community prefer to wait up to six hours for care at a county hospital rather than visit a clinic in their neighborhood that has a reputation for rude staff and disrespectful treatment of patients. Meanwhile, residents of an Appalachian community fear being admitted to a large medical center where other residents have died." ()

It is reported that several replicable models were funded by Opening Doors and that these models were of the nature that "exemplified cost-effective strategies to reduce sociocultural barriers to care. Stated as examples are those as follows: (1) Shared Language Services in an Ethnically Diverse Community - Asian Health Services, a community health center in Oakland's Chinatown, established an innovative project to weave interpreter services into the new landscape of managed care. The Asian Health Services Language Cooperative is a county-wide pool of interpreters and translation services in seven languages. Health providers in Alameda County could subscribe to the 24-hour service on a monthly or hourly basis. The project established an interpreter development program to recruit, train, and test potential interpreters." ( ) Results of the study report that there were 120 interpreters trained and the project additionally trained 250 practitioners to "recognize language and cultural barriers and work effectively with interpreters." () (2) Family Planning Outreach and Education Man-to-Man - The Nuestra Decision Project, sponsored by Community Health of South Dade, Inc., Florida, trained and deployed male farm workers as family planning health promoters in their communities. These individuals, following 250 hours of training: (1) visited homes; (2) led educational group sessions; (3) assisted their neighbors to gain access to community health resources

Community Health of South Dade is stated to have expanded clinic hours remaining open until 9:00 P.M. two days per week as part of the Opening Doors Project. Additionally, the evening clinics made provision of education and support groups for individuals with problems of substance abuse as well as diabetes. Medical services were also part of the clinic's offerings. The results of this project reports an increase in: (1) Women entering prenatal care in their first trimester; (2) Men accompanying their partners to these visits and bringing their children to the clinic; (3) Women seeking family planning services; (4) Men seeking health care services for themselves.

In another study in Redding, Northern California described as a rural community and home to 2,500 Southeast Asian refugees primarily from Laos it is stated that only 36% of Southeast Asian two years olds were up-to-date on their immunizations in the early 1990s. Further it is reported that members of the isolated community relied on the emergency rooms on a regular basis for nonemergency care instead of making use of the primary care services available. The approach taken by the Shasta Community Health Center was one that was affordable in nature and one that included: (1) develo9pment of a dedicated appointment and communication line in the Mien language; (2) provide patients with interpreter services; and (3) offer health education to consumers with an emphasis on preventive care. Study results state that the health center reached the population through two new part-time interpreters and a new full time outreach worker. A unique cohesion was developed between the staff at the center and the Shaman in the community (a traditional spiritual healer) It is reported that the shaman was specifically useful in treating post-traumatic stress disorder cases. The shaman was particularly helpful in treating numerous cases of post-traumatic stress disorder.

The results of this study are reported to include: (1) The immunization rate of two-year-old Southeast Asians in Redding rose to 93%; (2) The number of visits by Southeast Asians to the health center increased 30%; (3) Hospital emergency room visits by Southeast Asian families decreased 20%. In yet another study, the Seattle-based Community House Calls project at Harborview Medical Center focused on the gap in cultural practices existing between the individual providers and the institutional providers and the immigrants. It is reported that the caseworker/cultural mediators were "bilingual, biocultural members of the health care team who helped Cambodians and East Africans in accessing the health and social services systems. These individuals worked in the hospitals as interpreters and as outreach workers in assisting community families. These individuals worked with palm-top computers in maintaining records and providing information to the health care team and administrators concerning the beliefs, practices and living arrangements of patients in the study. It is reported that older community members functioned as community advisers in working with the cultural mediators. The study results state that the participating clinics in Community House Calls "…saw an increase in patient enrollment in Harborview's HMO, while HMO enrollment in other Harborview clinics leveled off or declined. To publicize what it learned, Community House Calls created an electronic database on the Internet, EthnoMed, which offered information on culture, language, health, illness, and available community resources for the diverse groups living in Seattle." (Robert Wood Johnson Foundation, 2008)

In yet another study the Homeless prenatal program hired and trained women who were formerly homeless for the purpose of reaching women who lived in the streets and in parks as well as in single room occupancy hotels and shelters in San Francisco. Located between the Tenderloin and Mission districts in San Francisco, the Homeless Prenatal Program hired and trained formerly homeless women to reach out to women living on the streets, and in parks, single-room-occupancy hotels, and shelters. Women who were referred were those in their final trimester of pregnancy and those who were post-partum to the AfterCare Project. Results of the study state that the program assisted pregnant women in coping with their pregnancies and in taking care of their babies. Also the program made provision of housing, health care, substance abuse treatment, food, immunizations, family planning and other services referral. Additionally it is stated that 90% of the babies born to women in the program were of normal birth weight. (Robert Wood Johnson Foundation, 2008, paraphrased)

Opening Doors funded several research projects that incorporated cross-cultural strategies to: (1) Obtain information on health care use in underserved communities, assess sociocultural barriers to care; (2) Measure the effectiveness of culturally and linguistically appropriate health care strategies; (3) Many replicable research models and strategies emerged that could be used to identify and reduce sociocultural barriers to health care. In yet another study that was conducted for the purpose of discovering why fifty percent of residents were traveling outside of their own community to receive health care services the Westside Health Authority, a community-based coalition of providers and organizations at the grassroots level in Chicago is reported to have "turned to the best source of information -- community members." (Robert Wood Johnson Foundation, 2008)

It is reported that nine African-American women in the community and who were unemployed were trained by a researcher form the university in observing, documenting and analyzing the behaviors of patients as well as providers for the purpose of identifying sociocultural barriers to care in four health clinics. Findings are stated to include those as follows: (1) An "Adult Medicine" sign in the window of a new clinic was ambiguous to patients more accustomed to words like "clinic," "health," and "community." (2) In other sites, patients felt violated when staff asked them personal questions loudly enough for people in the waiting area to hear. Patients were unclear about what clinic staff members' jobs were, and felt frustrated when they could see staff members sitting idle as they waited to be seen by a clinician. (3) Some patients' children were unruly because of the lack of play areas and supervision. (4) Patients were frightened by receiving negative test results in the mail and, as a result, would not call for follow-up exams. (5) Clinic staff members were annoyed at what they perceived as the rude and demanding behavior of patients. (Robert Wood Johnson Foundation, 2008)

It is reported that based upon the findings from this study that numerous changes were undertaken in the clinic include the following:(1) The "Adult Medicine" sign now reads "Health Care for the Community." (2) Community advocates helped facilitate communication between staff and patients. (3) personnel wore nametags. (4) Play areas were established for children and were supervised. (5) Clinics telephone patients and explained lab results directly.(6) All the trained observers were able to find employment after the research project was over. (Robert Wood Johnson Foundation, 2008)

In a study conducted in New York City among African-American, Latino, and Medicaid managed care enrollees the Center for Reproductive Law and Policy, New York, under the project Focus on Access, Information, and Reproductive Rights: Health Care Reform, assessed the quality and availability of reproductive health services under Medicaid managed care in New York state. It is stated that the project consisted of: (1) seven focus groups of primarily African-American and Latina Medicaid managed care enrollees; (2) Surveyed 52 providers at 32 clinics; and (3) Reviewed member handbooks from 23 Medicaid managed-care plans. interviewed 16 leading policymakers and health care advocates in the state. (Robert Wood Johnson Foundation, 2008)

Findings reported in the study include: (1) The project discovered that many sociocultural barriers to reproductive health care for women on Medicaid may be exacerbated by inherent structural features in managed care. These include: (a) Requirements for prior approval for specialty care; (b) Primary care "gatekeepers" who manage a patient's health care; (c) Long waits for obstetrical appointments; (d) Member handbooks that are difficult to understand; (e) A lack of interpreters for non-English-speaking women; (f) The project developed a public-policy framework, including a blueprint for statutory protections, to overcome nonfinancial barriers to reproductive health care for New York state residents. (Robert Wood Johnson Foundation, 2008)

The work of Darby ( ) entitled: "Managed Care: Sacrificing Your Health Care for Insurance Industry Profits" reports that health maintenance organizations and big insurance companies "are becoming major forces in America, clamping down on which health care providers we can and cannot see -- and when we see them." ( ) The story of Joyce Ching is a related and it is stated that Joyce, a wife and mother in California "Enrolled in an HMO, Joyce repeatedly visited her primary care doctor for three months complaining of severe abdominal pain and bleeding, but was routinely denied referral to a specialist because of the costs involved. When she finally got the referral, it was too late -- she soon died of colon cancer. She was 34." (Darby, )

Darby writes that the managed cared "conglomerates [are] eyeing impoverished minority communities as untapped sources of Medicaid dollars, are now targeting minority-owned and managed health care plans for eradication. This assault on our communities and health care providers by profit-driven corporations that previously showed little interest in the medical fate of minorities is unconscionable. At a time when African-Americans are facing higher-than-average rates of mortality from cancer, heart disease and diabetes, the focus should be on improving our access to quality care, not bottom-line profit." ( )

It is reported that managed care effectively creates a conflict of interest because insurance companies "naturally keep their eye on the bottom line…" (Darby, ) The interest of the insurance company is not in making sure that individuals are in receipt of quality medical care but instead is focused on minimization of medical expenses and maximizing profit. It is stated to be a conflict of interest for the "same insurance company that is focused on profits to be deciding what is appropriate medical care There is economic pressure for the company to choose physicians that provide less medical care and fewer diagnostic tests and referrals as opposed to more quality treatment." (Darby, )

When a physicians signs on with a managed care organization the physician is paid a flat monthly fee or 'capitation' per policyholder whether the policyholder needs treatment or not. It is reported that doctors that receive larger capitation fees are required to pay referrals diagnostic tests or emergency care and the policy contains an economic incentive for the doctor to provide the patient's care without a referral to a specialist treating the patient quickly so as to refrain from losing money. Another negative aspect of managed care is that informed consent is destroyed because the doctor is not required to communicate to the patient all of the available options along with the risks allowing the patients to ultimately make the decision as to the type of treatment that is best for them. To reduce costs, the insurance industry will be inclined to decide that certain expensive procedures, such as new high-technology tests, are unnecessary." (Darby, ) This results in the individual's right to choose their own medical care being removed.