Health Affairs, 24, no. 2 (2005): 417-420 doi: 10.1377/hlthaff.24.2.417 © 2005 by Project HOPE	New Online   Pay Cuts For Medicare Docs   Access To Care Woes   Public Coverage More Efficient   Empowering Consumers

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Insurers' Response

PERSPECTIVE

Taking On Racial And Ethnic Disparities In Health Care: The Experience At Aetna

Abstract

 
Among the nation’s health plans, Aetna is considered the industry leader in efforts to eliminate racial and ethnic disparities in health care. This Perspective describes the work of a task force led by Aetna’s chairman and CEO, charged with a number of strategic activities including cultural competency training and the identification of disparities occurring within the Aetna membership population. The cornerstone of this quality-of-care initiative is a successful and ongoing data collection enterprise. Aetna is putting the data to work in its chronic disease management, breast health, and African American Preterm Labor Prevention and Breastfeeding programs.

Aetna’s Task Force on Racial and Ethnic Disparities in Health Care, formed officially in 2002, includes representatives from throughout the company.² Each representative brought certain assumptions to the table—and none so fixed as those relating to what we believed to be the first and central opportunity: data collection. What follows is a sampling of these assumptions and the facts or experiences that emerged in the course of the initiative.

Assumptions About Collecting Race/Ethnicity Data

Top Assumptions About Collecting... Other Aetna Activities NOTES

 
Assumption 1: HIPAA violation. "Collecting race/ethnicity data on a volunteer basis from a commercially insured population constitutes a HIPAA [Health Insurance Portability and Accountability Act] violation." No, it does not. The states, exercising regulatory power over the health insurance industry, have legislation to prevent such data collection. A few states have laws or processes that inhibit voluntary data collection; the vast majority, however, have no such barriers. Aetna initiated the data collection effort with its health maintenance organization (HMO) product in thirteen states and the District of Columbia; in just two years it has expanded the effort to forty-seven states and multiple product lines.

Assumption 2: cost. "Information technology costs are too high." This is not true, either. Costs are no more or less than usual when adding additional fields.

Assumption 3: lack of acceptance. "Plan Sponsors (also known as employers or customers) will not permit it." No one could disabuse Aetna of this assumption until a year had elapsed with no customer objection or complaint. Today, interestingly, plan sponsors are actively inquiring about our efforts in this area; some are beginning to pose questions and statements of interest about disparities in their requests for proposal (RFPs).

Assumption 4: lack of investment. "Self-insured employers—in particular those that provide the industry with health plan enrollment data electronically—will not invest in the information technology required to enable electronic transfer of the data solely for Aetna’s purposes." This is true, generally—and it is one of the reasons that we expanded the opportunity for members to share their race or ethnicity with us on their "personal member portal" or Aetna Navigator. Data collection using Aetna Navigator became live in the second quarter of 2004 and triggered a sharp increase in reporting. As of this writing, close to 1.5 million Aetna members have shared their race/ ethnicity information with us, and more than half of these have come through Aetna Navigator.

Assumption 5: lack of trust. "Individuals will not trust insurers with this information." Our experience does not bear this out. Given an opportunity to inform us of their race or ethnicity, some 70–80 percent of our members have done so.

Assumption 6: not enough classifications. "Many Americans do not identify with at least one of the standard race/ethnicity classifications." We believe this to be the case. And although we would have preferred to list all prevailing possibilities, doing so would have delayed implementation. We elected therefore to proceed with one category—"other"—to represent all groups not specifically listed as options. Somewhat surprisingly, fewer than 50,000 of the almost 1.5 million members reporting race or ethnicity checked "other." There is no evidence to suggest that those opting not to report were inhibited by the absence of a preferred identity. Still, it is likely that our yield will be even greater once additional categories are introduced. We plan to expand the list to include "biracial" on Aetna Navigator in the coming year.

Assumption 7: lawsuits. "We will be sued." Perhaps. We haven’t been yet. Aetna will not violate the trust our members have placed in us, and we have taken major steps to ensure integrity and minimize risk. Through the disparities task force and its data subcommittee, we continue to monitor existing policies and procedures and routinely strengthen protections around data access and application. Independent audits are conducted annually and reported out to the task force by the Compliance division.

Assumption 8: lack of usefulness. "There is nothing useful to be done with the information." We retired this assumption early on with the understanding that having the data would allow us to more effectively target existing programmatic interventions designed for African American, Latino, and Asian populations. Today the data are enabling the Medical Services division to explore new opportunities for improvement in selected geographic areas and within our panoply of disease management programs.

Assumption 9: racial or ethnic insensitivity. "We will be labeled as racists." We haven’t been. It is generally understood that in light of the growing body of research on population and disease prevalence, Aetna’s intent is to collect data so that it can put its powerful and content-rich databases to work toward closing the gap and elevating the quality of care overall.

Other Aetna Activities

Top Assumptions About Collecting... Other Aetna Activities NOTES

 
Although perhaps the most challenging component of the initiative, data collection is but one facet of a larger body of work. Related activities, occurring in tandem with data collection, reinforce one another and contribute in synergistic ways to the overall success of the initiative. These include the following.

The Aetna Foundation. Since 2001, through its Regional Grant Program, the Aetna Foundation (Aetna’s independent philanthropic organization) has awarded more than $5 million to support programs addressing disparities in health. The foundation has set aside up to $2.6 million for awards in 2005.

Cultural competency training. Aetna engaged the Manhattan Cross Cultural Group in collaboration with Critical Measures to provide required cultural competency training for some 1,500 of our doctors, nurses, and clinical professionals.³ The program, titled Quality Interactions, employs case histories in a Web-based interactive e-learning environment to raise awareness and convey knowledge on cultural variations in the context of health and health care. The response has been overwhelmingly positive. The training is supplemented with quarterly e-newsletters to reinforce newly acquired skills and convey new knowledge and techniques. We are interested in working with funding agencies, our competitors (with whom we share a broad and overlapping physician and provider base), and others to expand cultural competency training to physicians and providers nationwide.

Research and consultation. One member of our task force is charged exclusively with the responsibility to keep us all abreast of academic research, news, and general developments in the field. Further, we work closely with independent experts who form an external advisory committee and who have guided us successfully in all aspects of implementation.⁴

Putting the data to work. As mentioned earlier, Aetna is already using the data to target members who are likely to benefit from its special programs and services. These include the African American Preterm Labor Prevention and Breastfeeding Program and the Breast Health Initiative, which focuses on African American and Latina women. In cooperation with Emory University, a barrier analysis study is under way involving diabetics who are Aetna members and enrolled in disease management programs (DMPs). The results will be used to strengthen outreach, personalize treatment programs, and improve quality measures overall.

Communication strategy: a health care quality initiative. Recognizing from the outset that effective communication with multiple constituencies would be essential, our communication divisions launched a coordinated and focused campaign around specific programmatic objectives. Plan sponsors, physicians, the media, Aetna employees, brokers, professional groups, policymakers, and others continue to receive information in various forms regarding Aetna’s ambitions to close the gap in quality of care. Announcement of the initiative in March 2003 earned favorable press in the Wall Street Journal, Baltimore Sun, and Hartford Courant. All communications underscore that this is a quality-of-care initiative. For Aetna, this is not about civil rights or race relations. It is about raising the bar and improving the quality of care for all.

Collaboration. Aetna is a member of the National Health Plan Learning Collaborative to Reduce Disparities and Improve Quality, a public-private partnership led by the Agency for Healthcare Research and Quality (AHRQ). The goal of the collaborative is to move beyond the research and "actively tackle racial and ethnic inequities in health care service delivery."⁵

Our work in disparities has followed on the heels of an earlier venture in genetic testing. Most recently, Aetna expanded its focus at the leadership level to the end of life by introducing the Compassionate Care program. Taken together, genetic testing, racial and ethnic disparities in health care, and Compassionate Care form an emerging suite of quality-of-care initiatives whose purpose is to contribute broadly and significantly to the improvement of health care quality overall.

Editor's Notes

 
Patricia Hassett (HassettP{at}aetna.com) is vice president and chief of staff at Aetna Inc. in Hartford, Connecticut.

The author gratefully acknowledges the Aetna Task Force and External Advisory Committee (noted below) for lending their considerable talents and expertise to this important endeavor.

NOTES

Top Assumptions About Collecting... Other Aetna Activities NOTES

 

1. B.D. Smedley, A.Y. Stith, and A.R. Nelson, eds., Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington: National Academies Press, 2002).
2. Task force members are Jack Rowe, Aetna chairman and CEO (task force chair); Lou Briskman, senior vice president and general counsel; Kathleen Campbell, Sales and Marketing; Maisha Cobb, Communications and Research; Charles Cutler, Quality Management; Marilda Gandara, Aetna Foundation; Jill Griffiths, Communications; Patricia Hassett, chief of staff (task force cochair); Raymond Arroyo, Human Resources; Dennis Oakes, Public Policy; Michael Reardon, Medical Services; Eileen Scheye, National Quality Administration; Tina Brown-Stevenson, Aetna Informatics; and Tom Strohmenger, counsel and chief compliance officer.
3. Content for this program was provided by Joseph Betancourt (president, Manhattan Cross Cultural Group, with cofounders J. Emilio Carrillo and Alexander R. Green). Delivery of the program via the Web was created by Critical Measures LLC in conjunction with the Manhattan Cross Cultural Group.
4. The advisory committee comprises Joseph Betancourt, Harvard Medical School; W. Michael Byrd, Harvard School of Public Health; Linda Clayton, Harvard School of Public Health; Arnold Epstein, Harvard Medical School; Kevin Fiscella, University of Rochester; Risa Lavizzo-Mourey, Robert Wood Johnson Foundation; and Nicole Lurie, RAND.
5. Agency for Healthcare Research and Quality, "Major Health Plans and Organizations Join AHRQ to Reduce Racial and Ethnic Disparities in Health Care," Press Release, www.ahrq.gov/news/press/pr2004/dispcalpr.htm (24 January 2005).

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