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Providing Care to Diverse Populations

Promoting Cultural Competency

States' Role as Health Care Purchaser: Medicaid and CHIP Cultural Competency Issues and Strategies


David Clark, M.B.A., Senior Adviser, Health Care Financing Administration, Baltimore, MD.

Esta-Lee Stone, M.S., OTR/L, Director of Clinical Projects, Massachusetts Department of Medical Assistance, Office of Clinical Affairs, Boston, MA.

Melba Hinajosa, M.A., R.N., Health Plan Advisor, Medical Managed Care Division, California Department of Health Services, Sacramento, CA.

One of the most important ways in which States can promote the provision of culturally competent care to low-income populations is through the requirements that are established under Medicaid and Children's Health Insurance Program (CHIP) managed care contracts. This session:

  • Identified Federal requirements in this area.
  • Focused on the experiences of several States that have taken different approaches to the development of contract requirements.
  • Discussed the issues and challenges States face in the design and enforcement of such provisions.

David Clark, Senior Advisor for the Health Care Financing Administration (HCFA), presented HCFA's strategies for promoting cultural competence. As one of the largest purchasers in the marketplace, HCFA has the unique opportunity to move the cultural-competency initiative forward. HCFA's goal is to integrate cultural-competence standards into its overall purchasing strategy, thereby improving quality of care and reducing costs.

HCFA is also working on the development of the Quality Improvement System for Managed Care, which is a set of common standards for Medicare and Medicaid that seek to advance quality improvement by using HCFA's power as a regulator and a purchaser to set up quality standards that include cultural competence.

Esta-Lee Stone, Director of Clinical Projects with the Massachusetts Department of Medical Assistance, presented information on Massachusetts' experience in the development of their cultural competence initiative. Given the changing characteristics in the MassHealth (Massachusetts Medicaid) population, the Division of Medical Assistance supported a series of studies to collect data that identified the racial/ethnic distribution of beneficiaries, determined language and translation capacity of providers, and evaluated racial and ethnic health disparities throughout the State.

As a result of the data collected, Massachusetts now has the ability to effectively match the needs of patients with provider capabilities. The Department of Medical Assistance has been able to make significant strides in the area of cultural competence because of a strong commitment from the leadership, valuable partnerships, and a solid conceptual model for a culturally competent system of care.

Melba Hinajosa, from the California Medicaid (Medi-Cal) Program Medical Managed Care Division, explained that the Medi-Cal program has incorporated cultural and linguistic requirements into one of their three managed care arrangements. This plan includes nine cultural and linguistic requirements and operates in the States' most populous regions. Community advocates, State officials, and health plan representatives were instrumental in the development of these requirements.

California faces several key challenges including:

  • Tensions between health care needs and health plan desires.
  • Varied stages of the three public plans in California. Two of the three plans have yet to include cultural-competence requirements in their contracting language.
  • Lack of understanding of the cultural-competence issues within the State health care system.


Kinder G, Leicher ES. Promoting Culture in Clinical Services: Models and Trends in Patient Education, Provider Training, and Medicaid Policy. MassHealth Access Program Reports, Division of Medical Assistance of the Commonwealth of Massachusetts. University of Massachusetts, 1998.

Coye M, Alvarea D. Medicaid Managed Care and Cultural Diversity. Published by the Lewin Group. The Commonwealth Fund, March 1999.

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