Robert Weech-Maldonado

Race/ethnicity, Language, and Patients' Assessments of Care in Medicaid Managed Care

OBJECTIVE Consumer assessments of health care provide important information about how well health plans and clinicians meet the needs of the people they serve. The purpose of this study was to examine whether consumer reports and ratings of care in Medicaid managed care vary by race/ethnicity and language. DATA SOURCES Data were derived from the National CAHPS Benchmarking Database (NCBD) 3.0 and consisted of 49,327 adults enrolled in Medicaid managed care plans in 14 states in 2000. DATA COLLECTION The CAHPS data were collected by telephone and mail. Surveys were administered in Spanish and English. The response rate across plans was 38 percent. STUDY DESIGN Data were analyzed using linear regression models. The dependent variables were CAHPS 2.0 global rating items (personal doctor, specialist, health care, health plan) and multi-item reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables were race/ethnicity, language spoken at home (English, Spanish, Other), and survey language (English or Spanish). Survey respondents were assigned to one of nine racial/ethnic categories based on Hispanic ethnicity and race: White, Hispanic/Latino, Black/African American, Asian/Pacific Islanders, American Indian/Alaskan native, American Indian/White, Black/White, Other Multiracial, Other Race/Ethnicity. Whites, Asians, and Hispanics were further classified into language subgroups based on the survey language and based on the language primarily spoken at home. Covariates included gender, age, education, and self-rated health. PRINCIPAL FINDINGS Racial/ethnic and linguistic minorities tended to report worse care than did whites. Linguistic minorities reported worse care than did racial and ethnic minorities. CONCLUSIONS This study suggests that racial and ethnic minorities and persons with limited English proficiency face barriers to care, despite Medicaid-enabled financial access. Health care organizations should address the observed disparities in access to care for racial/ethnic and linguistic minorities as part of their quality improvement efforts.

Nurse Staffing Patterns and Quality of Care in Nursing Homes

Using the structure-process-outcome framework and the resource-based view of the firm, this study considers both direct and indirect effects of registered nurse staffing patterns on the quality of patient care outcomes. Consistent with theory, registered nurse staffing patterns were found to affect quality of patient care both directly and indirectly through their positive effect on the processes of delivering care.

Can Hospital Cultural Competency Reduce Disparities in Patient Experiences with Care

Background:Cultural competency has been espoused as an organizational strategy to reduce health disparities in care. Objective:To examine the relationship between hospital cultural competency and inpatient experiences with care. Research Design:The first model predicted Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores from hospital random effects, plus fixed effects for hospital cultural competency, individual race/ethnicity/language, and case-mix variables. The second model tested if the association between a hospital’s cultural competency and HCAHPS scores differed for minority and non-Hispanic white patients. Subjects:The National CAHPS Benchmarking Database’s (NCBD) HCAHPS Surveys and the Cultural Competency Assessment Tool of Hospitals Surveys for California hospitals were merged, resulting in 66 hospitals and 19,583 HCAHPS respondents in 2006. Measures:Dependent variables include 10 HCAHPS measures: 6 composites (communication with doctors, communication with nurses, staff responsiveness, pain control, communication about medications, and discharge information), 2 individual items (cleanliness and quietness of patient rooms), and 2 global items (overall hospital rating, and whether patient would recommend hospital). Results:Hospitals with greater cultural competency have better HCAHPS scores for doctor communication, hospital rating, and hospital recommendation. Furthermore, HCAHPS scores for minorities were higher at hospitals with greater cultural competency on 4 other dimensions: nurse communication, staff responsiveness, quiet room, and pain control. Conclusions:Greater hospital cultural competency may improve overall patient experiences, but may particularly benefit minorities in their interactions with nurses and hospital staff. Such effort may not only serve longstanding goals of reducing racial/ethnic disparities in inpatient experience, but may also contribute to general quality improvement.

Survey Response Style and Differential Use of CAHPS Rating Scales by Hispanics

Background:Previous Consumer Assessments Of Healthcare Providers And Systems (CAHPS) studies have shown that Hispanics report care that is similar to or less positive than for non-Hispanic whites, yet have more positive ratings of care. Objective:To examine differential use of the 0–10 rating scales in the CAHPS health plan survey by Hispanic ethnicity and insurance status (Medicaid vs. commercial managed care). Data:CAHPS 2.0H adult Medicaid and commercial data submitted to the National Committee for Quality Assurance. Measures:The dependent variables are the CAHPS 2.0 ratings of care: personal doctor or nurse, specialists, and health care received. Ratings were categorized into 4 levels: 0–4, 5–8, 9, and 10. The independent variable is a 4-level categorical variable: Hispanic Medicaid, Hispanic commercial, (non-Hispanic) white Medicaid, and (non-Hispanic) white commercial. Six potential confounders were controlled: gender, age, education, self-rated health, survey mode, and survey language. Analysis:Multinomial logistic regression was used to test for differences in extreme response styles. Results:Hispanics exhibited a greater tendency toward extreme responding in the CAHPS ratings than non-Hispanic whites—in particular, they were more likely than whites in commercial plans to endorse a “10,” and often, scores of 4 or less, relative to an omitted category of “5” to “8.” Conclusions:The observed higher Hispanic ratings may be partially attributed to differences in response style rather than superior care. This suggests caution in the use of central tendency measures and the proportion of 10 ratings when examining racial/ethnic differences in CAHPS ratings of care. It is advisable to consider pooling responses at the top end (eg, 9 and 10) and lower end (eg, 0–6) of the response scale when making racial/ethnic comparisons.

The Impact of Interpreters on Parents’ Experiences with Ambulatory Care for Their Children

Health plan members who did not need an interpreter in the past 6 months were compared with those who needed one and always, usually, sometimes, or never got one. In multivariate analyses, Hispanic and Asian/Pacific Islanders (API) members who needed interpreters and usually, sometimes, or never used one reported significantly worse (p < .05) provider and office staff communication, access to care, and health plan customer service compared with members who did not need interpreters. Hispanic and API members who needed and always used an interpreter reported similar or significantly better (p < .05) provider and office staff communication, access to care, and health plan customer service than members that did not need interpreters. Use of interpreters reduced White-Hispanic disparities in reports of care by up to 28 percent and White-API disparities by as much as 21 percent. Increasing use of interpreters could reduce racial/ethnic disparities and improve health plan performance.

The Relationship Between Quality of Care and Costs in Nursing Homes

The purpose of this study was to evaluate the impact of quality of care on costs in nursing homes. The sample consisted of 749 nursing homes in 5 states in 1996. Nursing home cost functionswere estimated using weighted 2-stage least-squares regression analysis. Costs are measured as the facilitys total patient care costs. Two outcome measures are used as quality indicators: pressure ulcers worsening and mood decline. Nonmonotonic relationships are observed between quality and costs for nursing homes in the sample. However, the pattern of the relationship is different depending onthe quality indicator. For pressure ulcers, the authors observe an inverted U-shaped curvewith increasing costs at the lower range of quality but decreasing costs associated with higher quality after a threshold. The opposite pattern is observed for mood decline, with a relatively flat curve at the lower range of quality but increasing costs after a threshold.

Patient Safety Culture and the Association with Safe Resident Care in Nursing Homes

PURPOSE OF THE STUDY Studies have shown that patient safety culture (PSC) is poorly developed in nursing homes (NHs), and, therefore, residents of NHs may be at risk of harm. Using Donabedians Structure-Process-Outcome (SPO) model, we examined the relationships among top managements ratings of NH PSC, a process of care, and safety outcomes. DESIGN AND METHODS Using top managements responses from a nationally representative sample of 3,557 NHs on the 2008 Nursing Home Survey on PSC, the Online Survey, Certification, and Reporting Database, and the Minimum Data Set, we examined the relationships among the three components of Donabedians SPO model: structure (PSC), a process of care (physical restraints), and patient safety outcomes (residents who fell). RESULTS Results from generalized estimating equations indicated that higher ratings of PSC were significantly related to lower prevalence of physical restraints (odds ratio [OR] = 0.997, 95% confidence interval [CI] = 0.995-0.999) and residents who fell (OR = 0.999, 95% CI = 0.998-0.999). Physical restraint use was related to falls after controlling for structural characteristics and PSC (OR = 1.698, 95% CI = 1.619-1.781). IMPLICATIONS These findings can contribute to the development of PSC in NHs and promote improvements in health care that can be measured by process of care and resident outcomes.

Language and Regional Differences in Evaluations of Medicare Managed Care by Hispanics

OBJECTIVES This study uses the Consumer Assessments of Healthcare Providers and Systems (CAHPS((R))) survey to examine the experiences of Hispanics enrolled in Medicare managed care. Evaluations of care are examined in relationship to primary language (English or Spanish) and region of the country. DATA SOURCES CAHPS 3.0 Medicare managed care survey data collected in 2002. STUDY DESIGN The dependent variables consist of five CAHPS multi-item scales measuring timeliness of care, provider communication, office staff helpfulness, getting needed care, and health plan customer service. The main independent variables are Hispanic primary language (English or Spanish) and region (California, Florida, New York/New Jersey, and other states). Ordinary least squares regression is used to model the effect of Hispanic primary language and region on CAHPS scales, controlling for age, gender, education, and self-rated health. DATA COLLECTION/EXTRACTION METHODS The analytic sample consists of 125,369 respondents (82 percent response rate) enrolled in 181 Medicare managed care plans across the U.S. Of the 125,369 respondents, 8,463 (7 percent) were self-identified as Hispanic. The survey was made available in English and Spanish, and 1,353 Hispanics completed one in Spanish. PRINCIPAL FINDINGS Hispanic English speakers had less favorable reports of care than whites for all dimensions of care except provider communication. Hispanic Spanish speakers reported more negative experiences than whites with timeliness of care, provider communication, and office staff helpfulness, but better reports of care for getting needed care. Spanish speakers in all regions except Florida had less favorable scores than English-speaking Hispanics for provider communication and office staff helpfulness, but more positive assessments for getting needed care. There were greater regional variations in CAHPS scores among Hispanic Spanish speakers than among Hispanic English speakers. Spanish speakers in Florida had more positive experiences than Spanish speakers in other regions for most dimensions of care. CONCLUSIONS Hispanics in Medicare managed care face barriers to care; however, their experiences with care vary by language and region. Spanish speakers (except FL) have less favorable experiences with provider communication and office staff helpfulness than their English-speaking counterparts, suggesting language barriers in the clinical encounter. On the other hand, Spanish speakers reported more favorable experiences than their English-speaking counterparts with the managed care aspects of their care (getting needed care and plan customer service). Medicare managed care plans need to address the observed disparities in patient experiences among Hispanics as part of their quality improvement efforts. Plans can work with their network providers to address issues related to timeliness of care and office staff helpfulness. In addition, plans can provide incentives for language services, which have the potential to improve communication with providers and staff among Spanish speakers. Finally, health plans can reduce the access barriers faced by Hispanics, especially among English speakers.

Building partnerships with the community: lessons from the Camden Health Improvement Learning Collaborative.

This case study describes the Camden City Health Improvement Learning Collaborative (the Collaborative), a community care network initiative formed in 1993. The organization is composed of representatives from local healthcare providers, public agencies, religious organizations, and neighborhoods. The major goal of this initiative is to improve the health status of the community by involving and empowering residents in the solution of their needs. The Collaborative represents a grassroots strategic model of community inclusion in the formulation of goals and programs to improve community health status. The case study describes the dynamics of the Collaborative by examining the following: historical development; political, institutional, and social context; planning process; organization and structure; and performance evaluation. The article concludes with a discussion of the strategic and operational lessons learned from the Collaborative.

The relationship between perceived discrimination and patient experiences with health care.

Background:Prior studies have shown that racial/ethnic minorities have lower Consumer Assessments of Healthcare Providers and Systems (CAHPS) scores. Perceived discrimination may mediate the relationship between race/ethnicity and patient experiences with care. Objective:To examine the relationship between perceived discrimination based on race/ethnicity and Medicaid insurance and CAHPS reports and ratings of care. Methods:The study analyzed 2007 survey data from 1509 Florida Medicaid beneficiaries. CAHPS reports (getting needed care, timeliness of care, communication with doctor, and health plan customer service) and ratings (personal doctor, specialist care, overall health care, and health plan) of care were the primary outcome variables. Patient perceptions of discrimination based on their race/ethnicity and having Medicaid insurance were the primary independent variables. Regression analysis modeled the effect of perceptions of discrimination on CAHPS reports and ratings controlling for age, sex, education, self-rated health status, race/ethnicity, survey language, and fee-for-service enrollment. SEs were corrected for correlation within plans. Results:Medicaid beneficiaries reporting discrimination based on race/ethnicity had lower CAHPS scores, ranging from 15 points lower (on a 0–100 scale) for getting needed care to 6 points lower for specialist rating, compared with those who never experienced discrimination. Similar results were obtained for perceived discrimination based on Medicaid insurance. Conclusions:Perceptions of discrimination based on race/ethnicity and Medicaid insurance are prevalent and are associated with substantially lower CAHPS reports and ratings of care. Practices must develop and implement strategies to reduce perceived discrimination among patients.