RECENT HHSOCR INITIATIVES AND THE ELIMINATION OF HEALTH DISPARITIES

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DIABETES TRANSLATION CONFERENCE

• RECENT HHS/OCR INITIATIVES AND THE ELIMINATION OF
  HEALTH DISPARITIES
• U.S. Department of Health and Human Services
• Office for Civil Rights, Region IX
• Michael F. Kruley, Regional Manager
• Michael Leoz, Deputy Regional Manager

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OCR National Initiative

• National Consortium for
• Multicultural Education for Health Professionals
• Stanford University School of Medicine
• Clarence H. Braddock III, MD, MPH
• U.S. Department of Health and Human Services
• Office for Civil Rights

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• How extensive are health disparities?

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Patient Perceptions

• Patient perceptions
• Race affects my health care
• 17 of African-American patients agree
• 3 of White patients agree
• How often do you think our health system treats
  people unfairly based on race or ethnic
  background?
• 47 of the public responded very/somewhat often
• 29 of physicians responded very/somewhat often

Agency for Healthcare Research and Quality,
HHH, National Healthcare Disparities Report,
2004 Kaiser Family Foundation, National Survey of
Physicians, 2002
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Summary of disparities literature

• White patients receive more health care services
  and achieve better outcomes than
  African-American, Latino, Native American, and
  Asian-American patients
• Cardiovascular disease myocardial infarction,
  heart attack
• Asthma
• Cancer breast, lung, colorectal
• Mental illness
• HIV/AIDS
• Screening and preventive services

Institute of Medicine, Unequal
Treatment, 2003
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Health Disparities

• Examples of racial and ethnic disparities
• Differences in rates of disease
• Prevalence of diabetes
• Differences in health outcomes
• Rates of death from stroke
• Differences in health care access
• Ease of access to prenatal care
• Differences in treatment
• Rates of flu shots

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Why do health disparities exist?
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Why do health disparities exist (continued)?

• Actual clinical differences
• Access to health care
• Lack of insurance
• Institutional barriers to health care
• Patient-physician interaction
• Differences in patient-physician communication
• Linguistic barriers
• Racial bias and discrimination

Adapted from Oddone, 2002
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How do physicians contribute to health
disparities?
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Research on provider bias

• Schulman study
• Actors portrayed patients with the same clinical
  characteristics but there were differences in
  gender and race
• Physicians viewed videotapes and made
  recommendations for managing chest pain
• The study examined
• Physician recommendations for referrals
• Assessment of personality traits attributed to
  patients
• Predictions of behavior attributed to patients

Schulman, 1999
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Patients as Portrayed by Actors in the Video
Component of the Survey
A
B
D
C
Schulman, K. A. et al. N Engl J Med
1999340618-626
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Evidence of provider bias

• Cardiac catheterization referral rates differed
• Black patients less likely to be referred than
  White patients
• Women less likely to be referred than men
• In a combined analysis, Black women fared the
  worst as compared to White males
• Attributed personality traits differed
• White women were perceived as sadder, more
  worried
• Black women were perceived as more likely to
  over-report symptoms
• White men were perceived as more likely to sue
• White women were perceived as more likely to
  comply with treatment

Schulman, 1999
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When does racial bias amount to a civil rights
violation?
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Bias and Discrimination

• Beliefs or attitudes alone are not
  discriminatory.
• If beliefs or attitudes affect the quantity or
  quality of the health care provided, then
  treatment may be discriminatory.

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Legal Implications of Bias

• Impaired trust can result in
• Suboptimal patient-physician relationship
• Poor communication
• Perception that the physician is not working in
  the best interest of the patient
• Patient/group perception of systematic bias
• Malpractice litigation
• Inequitable treatment leading to disparities may
  be actionable under the law.

Crossley, 2003
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What is the history of Title VI?
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U.S. Health CarePrior to Title VI

• Jim Crow laws imposed segregated health care
  accommodations.
• During the 1940s, African-American physicians
  were often excluded from white hospitals and as a
  result developed a separate system that included
  historically black medical schools and hospitals,
  as well as professional societies and
  organizations.

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U.S. Health CarePrior to Title VI (continued)

• President Johnson signed
• the Civil Rights Act into law on July 2, 1964,
  including Title VI and
• the Medicare and Medicaid legislation into law on
  July 30, 1965.
• The bulk of the income received by most hospitals
  and their physicians flows from the federal
  government.
• Therefore, these hospitals and their physicians
  must comply with Title VI or risk losing their
  funding.

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How is Title VI enforced today?
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Title VI of the Civil RightsAct of 1964 (Title
VI)

• No person in the United States shall, on the
• ground of race, color, or national origin, be
• excluded from participation in, be denied the
• benefits of, or be subjected to discrimination
• under any program or activity receiving
• Federal financial assistance.

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Who does Title VI protect?
EVERYONE

• Title VI protects people of every race, color or
  national origin from unlawful discrimination.

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What entities are covered by Title VI?

• Recipients of Federal financial assistance
• can include
• Hospitals, nursing homes, home health agencies,
  managed care organizations
• Health research programs
• Physicians, dentists, hospital social workers
  and
• Other providers who receive funding from HHS.

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Unlawful Discriminationunder Title VI

• Recipients of Federal financial assistance
• may not on the basis of race, color, or
• national origin
• Deny or restrict an individuals enjoyment of a
  service, aid or benefit under the program
• Provide a benefit which is different or provided
  in a different manner or
• Subject an individual to segregation or separate
  treatment.
• 45 C.F.R. 80.3(b)

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Unlawful Discrimination under Title VI
(continued)

• Recipients of Federal financial assistance may
• not on the basis of race, color, or national
  origin
• Treat an individual differently in determining
  eligibility
• Deny an individual an opportunity to participate
  in the program (including as an employee) or
• Deny an individual an opportunity to participate
  on a planning or advisory board.
• 45 C.F.R. 80.3(b)

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Title VI and Limited English Proficient (LEP)
Persons

• An LEP individual is a person whose primary
  language is not English and who has a limited
  ability to read, write, speak or understand
  English.
• Title VI and the implementing regulations
  prohibit conduct that has a disproportionate
  adverse impact on the basis of national origin.
  Failure to provide LEP individuals meaningful
  access may constitute discrimination.
• Health care providers may be required to provide
  language access services at no cost if necessary
  to ensure that persons are not discriminated
  against on the basis of national origin.

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Americas Population Reflects Diverse
Communication Needs

• Approximately 28 million Americans have hearing
  loss.
• In 2000, 18 of the population (47 million
  people) spoke a language other than English at
  home.
• 63 of hospitals treat LEP patients daily or
  weekly.
• More than 15 languages are frequently encountered
  by at least 20 of hospitals.
• Sources National Institute on Deafness and
  Other Communication Disorders, Statistics about
  Hearing Disorders, Ear Infections, and Deafness
  (2007) Agency for Healthcare Research and
  Quality (AHRQ), U.S. Department of Health and
  Human Services (HHS), 2006 National Healthcare
  Disparities Report Health Research and
  Education Trust (HRET), Hospital Language
  Services for Patients with Limited English
  Proficiency Results from a National Survey 2-3
  (2006)

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Effective Communication is Critical

• Appropriate communication and understanding
  between patient and provider is essential to
  safe, quality health care. Hospitals need to
  seek ways of enhancing communication and
  understanding with diverse populations. Failing
  to do so may contribute to recognized racial and
  ethnic disparities in health care.
• Source The Joint Commission, Hospitals,
  Language, and Culture A Snapshot of the Nation
  14 (2007)
• A study of health plan members and use of
  interpreters showed that the use of interpreters
  reduced disparities for Hispanics and Asian and
  Pacific Islander members (28 and 21,
  respectively).
• Source AHRQ, 2006 National Healthcare
  Disparities Report

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Effective Communication is Critical

• Communication barriers contribute to reduced
  quality, adverse health outcomes, and health
  disparities. Solid evidence also shows that
  language barriers between a patient and provider
  may result in increased use of expensive
  diagnostic tests, increased use of emergency
  services and decreased use of primary care
  services, and poor or no patient follow-up when
  follow-up is indicated.
• Source HRET, Issue Brief (2006), citing the
  Institute for Medicine (2003)
• Inadequate communication with deaf and
  hard-of-hearing patients can lead to misdiagnosis
  and medication errors, as well as patient
  embarrassment, and fear.
• Source AHRQ, Communicating about health care
  Observations from persons who are deaf or hard of
  hearing (2004)

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The Effective Communication in Hospitals
Initiative

• A Collaborative Initiative of the Office for
  Civil Rights, U.S. Department of Health and Human
  Services (HHS), the American Hospital Association
  (AHA) and State Hospital Associations
• This initiative will continue to help hospitals
  provide quality care to all patients. Rich
  Umbdenstock, President, AHA
• This initiative will help hospitals move toward
  this critical goal ensuring that all
  individuals have an equal opportunity to access
  health care. Mike Leavitt, Secretary of Health
  and Human Services
• The Effective Communication in Hospitals
  Initiative is, and will continue to be, one of my
  highest priorities. Winston A. Wilkinson,
  Director, Office for Civil Rights, HHS

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What the Effective Communication in Hospitals
Initiative Is All About

• Through a tailored program of technical
  assistance, OCR helps state hospital associations
  and their members to
• Develop a process for assessing the communication
  needs of patients and their families
• Identify tools and strategies for developing
  training, best practices, educational materials,
  technical assistance activities and other
  resources
• Respond appropriately and efficiently to the
  communication needs of individuals who are LEP or
  deaf or hard of hearing
• Share the results of efforts to assist other
  hospitals and state associations facing similar
  communication issues and
• Identify potential resources and creative
  approaches to cover costs.

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Effective Communication in Hospitals Initiative

• 17 Hospital Associations in 16 states are part of
  the Initiative
• Collaboration on the Initiative has included
  webinar presentations and training
• The Initiative includes strategies and approaches
  that hospitals can use for effective
  communication
• OCRs dedicated web page includes a wide range of
  informational materials such as regulations,
  guidance and examples of voluntary compliance
  activities

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Determining What Language Services HHS Fund
Recipients Needs to Provide

• The four factor analysis
• Number or proportion of LEP persons eligible to
  be served or likely to be affected by the program
  or service
• Frequency of contact
• Nature and importance of the program, activity,
  or service
• Costs and resources available
• Source Executive Order 13166, Improving Access
  to Services for Persons with Limited English
  Proficiency (2000) United States Department of
  Justice (USDOJ), Guidance to Federal Financial
  Assistance Recipients Regarding Title VI
  Prohibition Against National Origin
  Discrimination Affecting Limited English
  Proficient Persons, 67 Fed. Reg. 41455 (2002)Sho

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When an Interpreter Is Needed and Reasonable

• Hospitals should ensure that a competent language
  service provider is used. A competent provider
• Is proficient and communicates accurately in
  English and the other language
• Uses appropriate mode of interpreting
• Knows specialized terms and concepts in both
  languages
• Understands and follows confidentiality and
  impartiality rules
• Understands and adheres to the role of the
  interpreter
• Hospitals should avoid planning to rely on an LEP
  persons family and friends.

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Examples of Language Access Services

• Bilingual staff
• Contract interpreters
• Telephonic interpreters or language lines
• Videoconferencing interpretation
• Translated materials
• For more information about Title VIs
  prohibition against national origin
  discrimination and health care providers
  obligations to provide language access services,
  visit OCRs webpage at http//www.hhs.gov/ocr/ci
  vilrights/resources/specialtopics/lep/index.html

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OCRs Enforcement Responsibilities

• The HHS Office for Civil Rights (OCR) enforces
• laws that prohibit discrimination on the basis of
  race, color, national origin, disability, age,
  sex, and religion by recipients of Federal
  financial assistance from HHS and
• the Privacy Rule under the Health Insurance
  Portability and Accountability Act (HIPAA) that
  protects health information from improper use and
  disclosure.

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OCRs Enforcement Responsibilities (continued)

• OCRs responsibilities include
• - investigating complaints from the public
• - conducting compliance reviews of health care
  facilities
• - securing voluntary corrective action and
• - initiating enforcement proceedings.
• OCR provides technical assistance to health care
  providers and entities to promote compliance with
  the law.
• OCR conducts public outreach to educate consumers
  about their rights.
• For more information and to contact OCR
  visit
• http//www.hhs.gov/ocr/office/about/rgn-hqadd
  resses.html

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Resources

• National Consortium for Multicultural Education
  for Health Professionals http//culturalmeded.s
  tanford.edu/
• HHS Office for Civil Rights http//www.hhs.gov/o
  cr/
• HHS Health Resources and Services Administration,
  Unified Health Communication 101 Addressing
  Health Literacy, Cultural Competency, and Limited
  English Proficiency (LEP) (on-line course)
  http//www.hrsa.gov/healthliteracy/training.htm
• HHS Office of Minority Health
  http//www.omhrc.gov/ A
  Physicians Practical Guide to Culturally
  Competent Care (on-line course) Health Care
  Language Services Implementation Guide
  (web-based interactive planning tool)
  http//www.thinkculturalhealth.org/
• Cultural Competence Online for Medical Practice
  (CCOMP), A Clinicians Guide to Reduce
  Cardiovascular Disparities (on-line course)
  http//www.c-comp.org
• Federal Interagency Working Group on LEP
  http//www.lep.gov/