Evaluation of a Learning Collaborative's Process and Effectiveness to Reduce Health Care Disparities Among Minority Populations
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1. To assist in clear presentation of findings, we have taken the liberty of condensing the five evaluation questions into four, and rearranging components of the original questions into groupings that lend themselves better to summarizing the findings for purposes of this Executive Summary.
2. Specifically, the third of six areas of interest AHRQ defined for the evaluation asked the evaluator to "measure and assess whether the Collaborative has reduced or eliminated targeted health care disparities experienced by minorities in health plans participating in the Collaborative." We concluded, and AHRQ (and other sponsors and support organizations) agreed that this was unrealistic within the time frame of the Collaborative. The reframed evaluation questions eliminated this area of interest, and took into account AHRQ's desire to avoid burdening participating firms with additional requests for data (Gold et al. 2005).
3. Firms generally found our multiple requests for interviews burdensome (especially in round 2, when we requested substantially more interviews). Firms often did not distinguish between requests from the evaluation team and those of the support organizations. They cooperated but asked for fewer demands in the final round of interviews. Their concerns ultimately also will influence the shape of the Phase II evaluations.
4. The BCAP initiative encourages plans to organize rapid-cycle quality improvement work around efforts to identify a target population, stratify by risk, reach out to members, and intervene, measuring results to provide formative feedback that can guide future interventions or refinements.
6. For example, firms that have addressed quality assurance may have many ongoing initiatives. Their approach to disparities could involve building on these efforts to enhance their effectiveness in dealing with disparities.
7. One firm used its work with minorities to build grassroots support among community and church leaders. Another firm told us that an RFP issued by the National Business Group on Health in early 2005 had a section asking it to address racial and ethnic disparities as part of the firm's bid. Another firm said that it had a purchaser with a diverse workforce and therefore viewed disparities as a high-priority issue.
8. RAND has subsequently refined the method to allow the estimates to reflect uncertainty about the race/ethnicity of members residing in mixed racial/ethnic areas. RAND staff believe this change will lead to better estimates of racial/ethnic composition in heterogenous areas.
9. This firm later decided to make use of geocoding and surname analysis to supplement its own data. While these analyses are not specific enough to support member interventions, they provide a vehicle for comparing areas consistently to identify those that might need to be targeted for geographically based interventions. The firm saw this as valuable because reporting was voluntary and could vary by area, and members providing their race/ethnicity were not necessarily representative of all enrollees in an area.
10. Several reasons limited our ability to do so. First, AHRQ asked us not to request data from plans, a request most plans would not care to honor in any case because of its burden. Second, the firms are complex organizations whose initiatives do not lend themselves to easy characterization in a telephone interview without supporting documentation. Third, we went into the interviews with limited knowledge of each firm's efforts. While most firms were cooperative—and the technical staff involved in geocoding particularly so—we were covering a broad scope of inquiry and found it challenging to formulate a set of appropriate questions. Fourth, we interviewed staff who often were uncomfortable providing us much detail.
11. RAND used what is termed a "deterministic" method of assignment. Members are assigned either as African American or white/other according to whether the proportion of such residents in their census block is above or below 60 percent. "Probabilistic" assignment takes into account uncertainty about what the "true" identifier should be, given the heterogeneity of the population in the census block. RAND says they have now modified its techniques to include probabilistic assignment.
12. Though some firms desire RAND to place the tools on the Collaborative web site for their use, we understand that RAND's ability to do so is limited because the tools currently are not set up for easy user interface so doing the conversion would have costs.
13. RWJF has done work in this area independent of the Collaborative. For example, RWJF funded a policy brief on the legality of collecting and disclosing patient race and ethnicity data, which was released in June 2006 (www.rwjf.org/files/publications/other/RaceEthnicDisparitiesData06222006.pdf).
16. In addition to sharing several copies of the toolkit with each of the participating firms, GMMB has made available selected materials from the NHPC toolkit in a few other forums, such the Alliance for Health Reform briefing on racial/ethnic disparities in December 2005 and a Kaiser Family Foundation briefing on the National Healthcare Disparities Report in April 2006.
18. In addition, representatives from three firms in the Collaborative are participating in the CHCS Quality Summit on Improving Health Care for Racially and Ethnically Diverse Populations in December 2006. This summit, however, is neither an official Collaborative activity nor sponsored by the Collaborative per se.
20. In summer 2006, GMMB discussed with Collaborative members the possibility of developing several issue briefs on the Collaborative. Lacking much concrete detail to disseminate at this stage, GMMB opted to develop a summary report on the Collaborative instead.
21. The analysis was part of the second round of data collection. We originally planned to field it again at the end of the Collaborative, but dropped this plan in response to firms' concern over the burden of participating in the evaluation.