In Minority Health Policy, Data Drives Passion for Change

The annual meeting of leadership programs in minority health policy based at HMS gives a front-row view of many of the players and challenges driving this field.

During the May 4 practicum presentations, part of this year’s three-day event, 10 fellows described their research projects, addressing disparities, health care quality, and “safety-net” providers. These rising leaders represented the Commonwealth Fund/Harvard University Fellowship in Minority Health Policy, the California Endowment Scholars in Health Policy at Harvard University, and the Joseph L. Henry Oral Health Fellowship in Minority Health Policy. Among the luminaries to speak was David Satcher, interim president of Morehouse School of Medicine and former U.S. Surgeon General, who said that improving health and closing disparities require that Americans on multiple levels care enough to effect these changes. Urging an unflagging commitment, he said, “We need more research, but you should also understand that there are many people in this country who are not benefiting from the research that we’ve already done.”

Taking aim at health care disparities, California Endowment scholar Katherine Ruiz-Mellott studied mental health services for vulnerable populations and developed an integrated service proposal for the California Department of Mental Health’s Mental Health Services Act. Latinos, she said, have among the lowest rates of mental health–service utilization, a deficit due in part to a cultural preference for addressing certain social problems by seeking out friends, family members, or even spiritual counselors rather than mental health professionals. Yet according to U.S. figures that Ruiz-Mellott cited, mental health problems have become the most frequent diagnosis for all patients at federally approved health centers over the past six years.

To increase utilization and access among Latinos and other minorities, she proposed a primary care model that makes mental wellness a routine part of health care. In it, psychiatrists would be fully integrated into community health centers as a point of entry for behavioral health services. She calls this prevention and early intervention model the LEAD program for the functions that psychiatrists would have: to listen, educate, advocate, and deliver.

In his presentation, Commonwealth Fund fellow Jean Raphael described an approach to improve pediatric emergency services using reliability as a new quality framework. He explained that current data on the reliability of these services suggests that failure to provide adequate care in terms of expertise, equipment, and environment is not uncommon; hospitals are typically assumed to have failure rates of about 10 percent, he said. While the practical ideal would be a pediatric emergency system in which processes and structure support outcomes with only a 0.1 percent failure rate, the realistic minimum target for improvement would be performance with a 1.0 percent rate. To achieve this, a system would need specific safeguards against human error such as redundant processes, decision aids, and systematic reminders.

“Basically, what that means is limiting the options for people to make errors,” Raphael said.

Kim Rhoads, a California Endowment scholar, investigated the impact of hospital type on colorectal cancer outcomes in California. Although incidence and mortality rates have been declining across the board during the last two decades, disparities in survival persist for minorities. Rhoads wanted to know if the disparities are influenced by hospital type. She found that of the 18,000 operations done for colorectal cancer in 1998–99, only 8 percent were done in hospitals with more than 30 percent of patients on Medicaid. These “high Medicaid” hospitals had higher rates of inpatient mortality, 30-day mortality, and 1-year mortality (though the impact of hospital type on 30-day mortality was offset by adjustment for surgical volume).

Interpreting her findings, Rhoads said, “I feel that my data really support an assertion from the IOM report Unequal Treatment, which says ‘because of Medicaid’s low reimbursement rates for doctors and hospitals, its poor, disproportionately minority beneficiaries are subject to largely separate, often segregated systems of hospital and neighborhood clinics. These systems often adopt their own norms of medical practice shaped by tight resource constraints.’”

Rhoads concluded: “This is really a systems problem.”

At the start of the speaking program, Joan Reede, dean for diversity and community partnership at HMS, whose department sponsors the meeting, pointed out that 2006 marks the 10th anniversary of the Commonwealth Fund program and the fourth anniversary of the California Endowment program. This brief retrospective set the stage for the day’s forward thinking.

One of the commentators, Jim Kim, the incoming head of the HMS Department of Social Medicine, said in response to the first series of presenters and in reference to Martin Luther King’s inspiring leadership for social change, “Now that we have this data, we have these insights, we have these models, let’s not lose the passion that drove this movement in the first place.”

—Robert Neal

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