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Core Outcome 3

All families of children with special health care needs will have adequate private and/or public insurance to pay for the services they need.

 

National Center to Address Core Outcome 3
National Center to Address Outcome 3

Cultural and linguistic competence in assuring adequacy of insurance for all children and youth with special health care needs will be demonstrated in the following ways:

  1. Insurance plans, particularly publically funded programs, utilize culturally and linguistically adapted materials and methods of recruiting families.
  2. Insurance plans provide information to families on coverage and utilization that is easy to understand and meets their individual language and literacy preferences and needs.
  3. Insurance plans proactively recruit provider networks that reflect the diversity of children, youth and families of the communities and geographic areas served.
  4. Insurance plans proactively support the development of cultural and linguistic competence in members of their provider networks.
  5. Insurance plans provide adequate reimbursement for costs associated the provision of interpretation and translation services.

The Evidence

Racial/Ethnic Disparities in Adequacy of Insurance: Recruitment, Understanding Plans

Based on responses to the 2005/2006 National Survey of Children with Special Health Care Needs, there is evidence that a third or more of all children and youth with special health care needs have families who report that they do not have adequate insurance. There is, however, a significant disparity for Hispanic children and youth—nearly half (45.8%) have families who report inadequate insurance.

Outcome #3: CSHCN whose families have adequate private and/or public insurance to pay for the services they need
Nationwide

Race/ethnicity of child
Outcome #3: CSHCN whose families have adequate private and/or public insurance to pay for the services they need
Citation format: Child and Adolescent Health Measurement Initiative. 2005/2006 National Survey of Children with Special Health Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved [06/20/09] from www.cshcndata.org

Some of this disparity is accounted for by the finding that Hispanic children and youth with special health care needs are significantly more likely to have been uninsured during the past year and significantly more likely to have experienced inconsistent insurance coverage. This disparity in coverage extends to all Hispanic children, not just those with special health care needs. While expansions in public health insurance programs between 1996 and 2005 increased health insurance coverage for Hispanic children, disparities between Hispanic and non-Hispanic White children persist (VanWie, et.al., 2008).

Major obstacles to enrollment include lack of knowledge about the application process and eligibility, language barriers, immigration issues (including fear that receiving benefits might jeopardize immigration status), family mobility, misinformation from insurance representatives about costs (for SCHIP programs) and system problems such as lost paper work and long waits. (Flores, et.al., 2005b) These same issues impact children of immigrant families from other groups as well, but since 21% of children in the United States are Hispanic, the numbers affected are the greatest. (Federal Interagency Forum on Child and Family Statistics, 2008)

Improving the rates of coverage will require an array of strategies for recruitment and enrollment for public health insurance programs that engage community partners (Flores, et. al., 2005a; Flores, et.al.,2006; Ross and Hill, 2003).

In addition, non-Hispanic black children are more likely than non-Hispanic white children to have one or more period without insurance during the past year. Again, an array of approaches to increasing enrollment is key, including, but not limited to:

  • simplifying eligibility procedures (such as one-stop applications for multiple services),
  • making application materials easier to understand, or
  • providing application assistance within the community by familiar organizations or individuals for families (Ross and Hill, 2003)
Indicator 3: CSHCN without insurance at some point during past year
Nationwide

Race/ethnicity of childIndicator 3: CSHCN without insurance at some point during past year
Citation format: Child and Adolescent Health Measurement Initiative. 2005/2006 National Survey of Children with Special Health Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved [06/20/09] from www.cshcndata.org

Even when one considers children and youth who are currently insured, the disparity in reported adequacy of coverage persists between Hispanic children and non-Hispanic white, African-American or multiracial children.

Indicator 5: Currently insured CSHCN whose insurance coverage is not adequate
Nationwide

Race/ethnicity of child
Indicator 5: Currently insured CSHCN whose insurance coverage is not adequate
Citation format: Child and Adolescent Health Measurement Initiative. 2005/2006 National Survey of Children with Special Health Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved [10/27/09] from www.cshcndata.org

Diversity and Cultural and Linguistic Competence in Provider Networks

A report for the Bureau of Health Professions indicates that diversity in the health professions has been associated with improved access, utilization, and quality of care for diverse populations ( Saha, S., & Shipman, S.,2006). Emerging studies indicate that there are positive effects on communication, partnership and respect in the patient-provider interaction when there is racial, ethnic and/or linguistic concordance between the two. (Cooper, et.al., 2002; Cooper et.al., 2003;, Cooper and Rote, 2002;,Johnson, et.al., 2004;, Cooper, et.al., 2006) Yet, despite growing diversity in the overall population, the diversity in the health and mental health care professions and in research programs does not match those of the general population. (The Sullivan Commission, 2004).

Thus, health insurance efforts to assure a diverse pool of providers in their networks are a component of addressing the adequacy of insurance. It is also important that health insurance plans address the knowledge and skills of their providers to provide quality care in cross-cultural interactions. America’s Health Insurance Plans, an organization that represents health insurance plans has itself noted the importance of assuring that providers have this knowledge and skill set. “Cross-cultural education and training for health care professionals can build a solid foundation to improve quality of care and reduce health care disparities among our nation’s growing diverse population.” (America’s Health Insurance Plans, 2008)

Language Access and Access and Quality of Care

Flores and Tomany-Korman (2008) identified disparities between children in non-English-primary-language and those whose families use English as their primary language in terms of access to care. These disparities were evident in having no usual source of medical care (38% vs 13%), had no medical (27% vs 12%) or preventive dental (14% vs 6%) in the previous year, and had problems obtaining specialty care (40% vs 23%). While there are multiple factors involved in these disparities, difficulties with language access in making appointments, getting information about health care coverage and interacting with providers can contribute to the access disparities.

For families who need or prefer interpreter services because of limited English proficiency, adequate insurance must address the reimbursement of interpreter services. Without those services there is evidence that quality of care is compromised. Loeb, Chang, and Divi (2006) investigated the epidemiology of adverse events attributed to problems in communication between providers and patients with limited English proficiency. The study used retrospective and prospective data collection processes and random sampling of incident reports for English-speaking and limited-English-speaking patients.

The researchers cited significant differences between the English-speaking and limited-English-speaking patients in areas such as inaccurate or incomplete information, questionable advice or interpretation, questionable tracking and follow-up, and correct diagnosis or questionable intervention. Cohen et al. conducted a case-control study in a large, academic, regional children’s hospital in the Pacific Northwest from January 1, 1998 to December 31, 2003 and found that hospitalized pediatric patients with families with language barriers are more likely to experience serious medical errors than families without language barriers. Interpretation as a covered service in health plans is key to adequacy of insurance.

Resources

Resources on Cultural and Linguistic Competency in Achieving the Outcome of Adequate Insurance for All Children and Youth with Special Health Care Needs

OUTREACH STRATEGIES FOR MEDICAID AND SCHIP: An Overview of Effective Strategies and Activities – Report

CULTURAL COMPETENCE CALIFORNIA STYLE
Cindy Brach and Kathryn Paez and Irene Fraser
Agency for Healthcare Research and Quality Working Paper No. 06001
February 2006

CALIFORNIA INSURERS WORK TO COMPLY WITH REGULATIONS FOR INTERPRETER, TRANSLATIONS SERVICES

INFORMATION ON MEDICAID/MEDICARE COVERAGE OF LANGUAGE ACCESS SERVICES

Funding Sources for Language Access Services

Diversity and Cultural Competency in Health Plans
A set of resources for health plans from America’s Health Insurance Plans (AHIP), the national association representing nearly 1,300 member companies

References

America’s Health Insurance Plans, 2008. Diversity and Cultural Competency in Health Plans, Retrieved on May 25, 2009 from http://www.ahip.org/content/default.aspx?bc=38|10760

Child and Adolescent Health Measurement Initiative, (2005/2006). National Survey of Children with Special Health Care Needs, Data Resource Center for Child and Adolescent Health website. Retrieved 5/12/2009 from www.cshcndata.org

Cohen AL, Rivara F, Marcuse EK et al., (2005). “Are language barriers associated with serious medical events in hospitalized pediatric patients?” Pediatrics, 116(3):575-79.

Cooper, L., Beach, M., Johnson, R. and Inui, T., (2006). “Delving below the Surface,” Understanding how race and ethnicity influence relationships in health care. Journal of General Internal Medicine J21, (S1): S21–S27.

Cooper, L., Roter, D., Johnson, R., Ford, D., Steinwachs, D., & Powe, N., (2003). Patient-centered communication, ratings of care, and concordance of patient and physician race. Annals of Internal Medicine, 139(11), 907-915.

Cooper, L., & Roter, D., (2002). Patient-provider communication: The effect of race and ethnicity on process and outcomes of health care. In A. Smedley, & A. R. Nelson (Ed.), Unequal treatment: Confronting racial and ethnic disparities in health care, 306-330. Washington, D.C.: Institute of Medicine, National Academy Press.

Federal Interagency Forum on Child and Family Statistics, (2008). America’s Children in Brief: Key National Indicators of Well-Being. Federal Interagency Forum on Child and Family Statistics, Washington, DC: U.S. Government Printing Office.

Flores G, Tomany-Korman SC. The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children. Pediatrics. 2008 Jun;121(6):e1703-14. Erratum in: Pediatrics. 2009 Oct;124(4):1265.

Johnson, R., Roter, D., Powe, N., & Cooper, L., (2004). Patient race/ethnicity and quality of patient-physician communication during medical visits. American Journal of Public Health, 94(12), 2084-2090.

Lessard, G. and Ku, L., (2003). Gaps in coverage for children in immigrant families. The Future of Children, 13(1), 101-114. Retrieved May 25, 2009 from www.futureofchildren.org

Loeb JM, Chang A, and Divi C., (2005). “Understanding adverse events in patients with limited English proficiency.” Center for Patient Safety Research, Joint Commission on accreditation of Healthcare Organizations. Presentation at Academy Health’s 2005 Annual Research Meeting, Boston, Mass. Retrieved Mar. 8, 2006.

Persistent disparities in health insurance coverage: Hispanic children, 1996 to 2005 Journal of Health Care for the Poor and Underserved, 19(4), 1181-1191

Ross, D. and Hill, T., (2003). Enrolling eligible children and keeping they enrolled. The Future of Children, 3(1), 81-97. Retrieved May 25, 2009 from www.futureofchildren.org

Saha, S., & Shipman, S., (2006). The Rationale for Diversity in the Health Professions: A Review of the Evidence. Washington, DC: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions.

The Sullivan Commission, (2004). “Missing Persons: Minorities in the Health Professions.” A Report of the Sullivan Commission on Diversity in the Healthcare Workforce. www.sullivancommission.org. retrieved 12/13/2009 from http://www.aacn.nche.edu/Media/pdf/SullivanReport.pdf

Van Wie, A.,Ziegenfuss, J., Blewett, L. and Davern, M. (November, 2008)

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