Cultural Competency as It Intersects With Racial/Ethnic, Linguistic, and Class Disparities in Managed Healthcare Organizations

Culture in and of itself is not the most central variable in the patient-provider encounter. The effect of culture is most pronounced when it intersects with low education, low literacy skills, limited proficiency in English, culture-specific values regarding the authority of the physician, and poor assertiveness skills. These dimensions require attention in Medicaid managed care settings. However, the promise of better-coordinated and higher quality care for low-income and working-poor racial/ethnic populations— at a lower cost to government—has yet to be fully realized. This paper identifies strategies to reduce disparities in access to healthcare that call for partnerships across government agencies and between federal and state governments, provider institutions, and community organizations. Lessons learned from successful precedents must drive the development of new programs in Medicaid managed care organizations (MCOs) to reduce disparities. Collection of population-based data and analyses by race, ethnicity, education level, and patient's primary language are critical steps for MCOs to better understand their patients' healthcare status and improve their care. Research and experience have shown that by acknowledging the unique healthcare conditions of lowincome racial and ethnic minority populations and by recruiting and hiring primary care providers who have a commitment to treat underserved populations, costs are reduced and patients are more satisfied with the quality of care.

(Am J Manag Care. 2004;10:SP37-SP44)

Minority populations–Hispanics, African Americans, Asian Americans, and other people of color–currently comprise 28% of the population of the United States, and this figure is projected to increase to 40% by 2030.¹ Racial and ethnic minorities, especially those with low incomes and limited English proficiency (LEP), experience multiple barriers to healthcare, encounter lower access to and availability of healthcare, and experience less favorable health outcomes.^2-9 Multiple barriers to healthcare access exist –such as language, economics, geography, and cultural familiarity–even when minorities are insured at the same level as nonminorities.^10,11 The emerging awareness in the United States over the past 3 decades of what is termed "disparity" has presented innumerable challenges, partly because of the lack of scholarship that examines the intersections of socioeconomic, racial, and ethnic statuses. Questions remain regarding how to improve access and quality of care for economically disadvantaged and culturally distinct groups.

This paper examines the definitions of cultural competence within the context of access to care and identifies Medicaid managed care experiences in select states to describe the experiences of underrepresented low-income racial/ethnic minorities within managed care systems. Building on extant empirical literature, we propose strategies to enhance competent and high-quality care for racial and ethnic groups in managed care systems. A computerized literature search was conducted for the years 1999-2003 using the following keywords: Medicaid managed care, disparities; access to services; health services accessibility; access to primary and preventive care, co-payments; cost sharing; low-income, minority, Latino/Hispanic, African American/Black; quality of care, and Medicaid managed care policy. The databases searched included MEDLINE, Social Science Citation Index, and Science Citation Index. In addition, government and Kaiser and Commonwealth Foundation reports were reviewed. A version of this paper was presented at the Conference on Diversity and Communication in Health Care: Addressing Race/Ethnicity, Language, and Social Class in Health Care Disparities convened in February 2000 by the Office of Minority Health of the US Department of Health and Human Services in Washington, DC.

Cultural Competence: Past and Emerging Definitions

In the past, cultural competence has been called cultural sensitivity, cultural responsiveness, or cultural appropriateness; the name "cultural competence" is recent.¹² Cultural competence is defined as a "set of congruent behaviors, attitudes, and policies that come together in a system, agency or profession that enables that system, agency or profession to work effectively in cross-cultural situations."^2,13 Cultural competence, as originally conceived, emerged as an issue because of public health efforts to make healthcare services more responsive to underserved populations in both rural and urban areas. As the number of patients of diverse racial, ethnic, cultural, and linguistic backgrounds increased in the United States, the need to produce culturally competent providers who incorporate patients' world view into management decisions also grew.

Unequal Treatment

The release of the national standards for culturally and linguistically appropriate services in 2001 drew attention to the need for culturally and linguistically competent healthcare services for diverse populations and attracted the attention of policymakers, medical schools, public health systems, and healthcare providers.^12,14 The Institute of Medicine's report concluded that ethnic and racial gaps in care beyond access-related factors were attributable to a range of patient-level factors (patient preference, treatment refusal, clinical appropriateness of care), provider-level factors (bias, stereotyping, uncertainty), and system-level factors (lack of interpreters, geography, managed care system).¹⁵

Health disparities are associated with factors such as patients' perceived discrimination¹⁶ and mistrust of the healthcare system,¹⁷ poor or ineffective communication between patient and physician,¹⁸ and healthcare providers' lack of cultural competence and sensitivity.^19,20 Other contributing factors to healthcare disparities are social factors such as socioeconomic status and racism, and systemic factors such as access to care and communication barriers.^21-23 To ensure quality healthcare and access for minority populations, care must be congruent with patients' cultural, linguistic, and literacy needs. A recent study of a large staff-model HMO found that interpreter services can increase delivery of healthcare to non—English-speaking patients by facilitating patient-physician understanding, which affects patient adherence and accuracy of diagnosis and treatment, while fostering trust and increased satisfaction with care.²⁴ Quality healthcare is culturally competent and patient centered.²⁵ Culturally competent care can improve the continuity of a patient's care and health outcomes by increasing the understanding between patients and providers.^18,26,27

When healthcare providers and organizations understand and effectively respond to the diverse cultural and linguistic needs of patients, the benefits of a true patient-clinician relationship are more fully realized.²⁸ Several attributes of culturally competent care are useful in examining its meaning within managed care settings:

• When culture-specific health beliefs and health behaviors, gender, race, ethnicity, age, and low socioeconomic status are part of a shared dialog between provider and patient, both communication and delivery of care are more effective.²⁹

Providers who are aware of and address potential communication difficulties, and who provide linguistically appropriate and literacy-appropriate information in the patient's native language, interact more effectively with patients.³⁰

• Culturally competent providers consider the patient's needs and preferences within the context of his or her cultural beliefs and practices, and understand the importance of these factors in the treatment plan.²⁵

Culture in and of itself is not the most central variable in the patient-provider encounter. The effect of culture is most pronounced when it intersects with low education, low literacy skills, LEP, culture-specific values regarding the authority of the physician, and poor assertiveness skills. It is precisely this intersection that has been poorly understood or ignored. Yet these dimensions require attention in Medicaid managed care settings.

Expanding the definition of cultural competency has implications for underrepresented minority groups. The ability to take into account individual and institutional factors, the known health consequences of poverty, and barriers to healthcare access could lead to new mechanisms and interventions to address health disparities. Healthcare access, health outcomes, and patient satisfaction could be improved, and long-term costs for managed care organizations (MCOs) could be reduced.

Emergence of Managed Care as a Policy Solution to Improve Access and Reduce Costs for Medicaid Programs

The trend toward managed care began in the late 1980s, when the cost of healthcare services escalated at an alarming rate, as evidenced by Medicaid costs, which were increasing by an average of 30% annually during that period.³¹ Simultaneously, the number of uninsured in the population continued to increase and presented a challenge to those concerned with providing access to healthcare services for the poor and working poor. As a result, commitments to legislate major changes in healthcare that would address the issues of cost and access to healthcare services became part of the national health agenda. Yet the failure of the healthcare reform plan and all competing proposals introduced during the 103rd Congress suggests that the primary focus of this national debate was predominantly to control the cost of healthcare and to support managed care as a viable solution.³² Managed care advocates promoted the notion that a well-run managed care system could provide quality healthcare while at the same time reducing costs.^33,34

In an effort to control rising healthcare costs and limit the utilization of services, public purchasers are increasingly relying on managed care models. By the year 2000, almost all states had begun to offer the option of managed care to their Medicaid beneficiaries, with varying degrees of success. Remaining states continue to study plans to transition and restructure state and county systems to managed care.³⁵ Managed care has continued to expand as states experience pressure to contain costs and is increasing in both Medicaid and State Children's Health Insurance Program (SCHIP) programs. The number of Medicaid clients enrolled nationwide in managed care has increased dramatically, with a 3% enrollment in 1983, a 23% enrollment in 1994, and a 58% enrollment as of December 31, 2001.³⁶

Managed care, which is based on the premise that regular use of primary and preventive care can prevent illness and reduce costs, holds great promise for delivering quality and cost-efficient healthcare to low-income families, many of whom face overwhelming barriers to care. But while more Medicaid recipients and low-income children are enrolling in managed care plans, the promise of better coordinated and higher quality care for low-income and working-poor racial/ethnic populations–at a lower cost to government–has yet to be fully realized.³⁷

Medicaid beneficiaries are more likely to have poor health status and therefore incur higher costs for healthcare services.³⁸ Further, a large majority of Medicaid patients lack transportation, live in medically underserved communities, are less likely to have continuous telephone service, and tend to use the emergency room as a regular source of care. In 30% of Aid to Families and Dependent Children households, at least 1 family member reported having a disability.⁵ More than 50% of Medicaid beneficiaries belong to racial/ethnic minorities.³⁹ In general, underrepresented racial/ethnic minority groups are poorer, have more chronic health conditions (eg, asthma, diabetes, heart disease), engage in more high-risk behavior, and have less access to providers. As a result, they are more expensive to care for. However, unfavorable health status is associated with poverty and limited access to quality health services, not with minority status. The performance of managed care systems in providing care for publicly insured populations in different states must be examined as part of any effort to reduce ethnic and racial disparities in healthcare.

State Experiences With Low-income and Medicaid Recipients: Issues and Challenges

States can move toward managed care either by allowing voluntary enrollment or by instituting a mandatory enrollment program. In some cases, the voluntary option comes first and is used as an experimental enrollment strategy, often followed by a more structured and systematic mandatory model. The rapid expansion of Medicaid managed care was seen by the states as a way to improve the quality of care by encouraging more primary healthcare services and less emergency room utilization. In the second generation of managed care, states are moving to ensure quality of care by incorporating innovative approaches designed to guarantee that both psychosocial needs and medical needs are met.⁴⁰ The states of Oregon and Washington have taken the lead in this regard, as MCOs are mandated to develop a continuum of services that meet the needs of Medicaid populations. Most states, however, are lagging behind and have not developed the capacity to meet the comprehensive needs of low-income and underrepresented racial/ethnic minority populations.⁴¹

Medicaid managed care experience in 5 states (California, Minnesota, New York, Oregon, and Tennessee) consistently shows that Medicaid managed care confronts more challenges than commercial managed care efforts because the Medicaid population of low-income women and children, the disabled, and the elderly have unique needs that require initiatives to be tailored so that they are responsive to these populations. 41 States vary significantly in their requirements for services such as translation, outreach, and transportation. Oregon, for example, has no such requirement; and Minnesota adopted special services only after it was evident that certain supportive services were an essential and necessary part of providing access for the poor.

However, in the long term, the stability of Medicaid managed care programs is uncertain. Private HMOs have dropped out of the Medicaid market when the profit margin has declined.⁴² Although competition for Medicaid business is fierce in most states, the profitability of serving Medicaid clients may diminish if Medicaid officials try to reduce reimbursement rates whenever they conclude that a MCO is making excessive profits. If the federal contribution to Medicaid declines, there will be additional pressure to decrease HMO reimbursement rates. If Medicaid officials introduce program improvements to reduce adverse selection, the profitability of Medicaid clients will diminish even further.

Enrollment and Outreach

Addressing disparities in the recruitment and enrollment of Medicaid beneficiaries into managed care plans is critically important for the health of low-income and racial and ethnic populations. In the early wave of recruiting Medicaid clients, many MCOs engaged in recruitment and enrollment tactics that did not protect the rights, options, and choices of the client population. Both Oregon and Minnesota do not allow any direct marketing by health plans, because direct marketing by plans has been associated with abuse of rights in Medicaid managed care. Initially, the New York marketing was conducted from door to door, a practice that has since been suspended.

There is evidence that some MCOs have engaged in discriminatory practices, including refusing to provide services to entire geographic areas and populations.37,43 The Office of Civil Rights of the US Department of Health and Human Services has been called on to investigate Medicaid managed care enrollment and marketing practices.⁴⁴ Some MCOs also have been found to engage in additional "skimming" or "creaming" practices such as locating their membership office on the second floor (without access to elevators), or training their enrollment counselors to visually assess whether the enrollee would need a lot of services in order to enroll only the healthiest members.^6,44 States have found that if managed care structures are to benefit all enrollees, the states must establish marketing guidelines and prohibit these discriminatory practices. Populations with low education, low literacy, and/or LEP are particularly vulnerable in the transition to managed care. Notices informing enrollees of their rights often go unread because they are not understood or have not been translated into the appropriate languages of the population. States implementing mandatory enrollment in Medicaid managed care have found that these groups are least likely to respond to enrollment notices and are more likely to be automatically enrolled by the state.⁴⁵

Safety-net Providers

The transition from a fee-for-service system to a managed care system poses a major challenge, with significant implications for the future viability of safety-net providers that deliver healthcare to the poor and near poor.⁴⁶ Given the high proportion of uninsured persons in the US population (particularly the Latino population), safety-net providers that serve this community are doubly challenged in the managed care environment. Despite the fact that there is no competition among providers to serve uninsured patients, the transition of Medicaid recipients (another patient population traditionally served by safety-net providers) into managed care plans has produced competition for Medicaid enrollees that has implications for safety-net providers.⁴⁷ The ability of community-based organizations, public hospitals, and public clinics, the traditional safety net for the poor and medically indigent, to compete in the Medicaid managed care environment and to negotiate contracts and appropriate payment rates is uncertain.

In California, state Medicaid officials have developed a managed care model (the 2-plan model) designed to protect safety-net providers. In contrast, New York State Medicaid officials have neither designed nor implemented a safety-net protection plan. Instead, the state tasked its 57 counties to design and implement their own initiatives to protect the provider safety net.⁴³ Lipson and Naierman argue that this decentralized approach does not provide for clear universal guidelines or clear lines of accountability that would ensure the systematic strengthening and protecting of the safety-net infrastructure.⁴⁸ The potential lack of long-term MCO commitment to the Medicaid population increases the need to preserve a strong medical safety net to serve the poor and medically indigent.⁴⁹

only

Safety-net providers have historically been able to cross-subsidize care for the uninsured using Medicaid payments, but as Medicaid dollars decrease while uninsured patients increase, providers are forced to turn to grant money to subsidize their operations. Thus, few to no resources remain for public health programs and health education efforts. But in some communities, the result is even worse: public hospitals, federally qualified health centers, and health clinics are shutting their doors or drastically reducing their services.⁶ The challenge is not only to contain costs and provide quality healthcare, but more importantly, to secure the future viability of safety-net providers delivering healthcare services to the poor and uninsured. Furthermore, strengthening safety-net providers under managed care may be the way of ensuring that the poor and uninsured populations continue to be served.

Andrulis argues that the entire tradition of public-sector healthcare is threatened by managed care, as the intensity and growth of the competition might be too powerful for it to withstand.⁵⁰ He raises 2 central issues: (1) Although community healthcare centers might become attractive to MCOs as a way of gaining entry into certain neighborhoods, it still remains unclear whether MCOs would invest adequate funds to deliver effective healthcare services to low-income and working-poor populations, or whether any autonomous role would remain for community-based organizations under such partnerships. (2) Although in the past a fully vested public sector provided and financed healthcare, the emergence of a "residual public sector" or an entirely "divested public sector" is possible given the current questioning by policymakers and state and local governments regarding what role, if any, the public sector has to play in the new managed care environment.⁵⁰

A review of the nonprofit sector in managed care suggests that to ensure the survivability of the system, innovative models of joint partnership and ownership of managed care enterprises by community providers need to be explored.⁵¹ Although the healthcare reform debate addressed the need to better define expectations for the nonprofit sector as a provider of free services, it did not adequately envision the role of the nonprofit-sector providers as entrepreneurs who would assume an ownership role in the system. Unless the nonprofit sector assumes an ownership role in managed care, services for the poor will be compromised.^52,53

Community-based organizations providing safety-net healthcare services require particular attention, because they serve a disproportionate number of uninsured. The ability of community-based organizations to compete in the managed care marketplace and gain entry to Medicaid contracts will solidify their position as safety-net providers serving low-income and racial ethnic groups in their community. However, the majority of community-based organizations work within an organizational environment that has few financial and personnel resources available–which makes them less able to compete and negotiate in their environment.⁵⁴ Community-based organizations that provide healthcare services to the poor and near poor are mandated by their governance not only to provide culturally competent healthcare but also to advocate on behalf of these patients for their rights. The transition to managed care poses additional challenges for these organizations. Organizations adapting to the managed care environment generally lack the technological resources, cash reserves, and sophisticated accounting systems needed to be part of a provider network, despite the fact that they carry the heaviest burden for delivering healthcare services to the poor and underserved.⁵⁴

Managed care organizations can meet their goals of lowered costs and improved access to care by tailoring their services to the needs of the population they serve and by working closely with local community-based providers to increase access, enhance the trust of clients, and utilize existing community resources. Strategies include:

• Provide financial resources to support partnerships between local government, MCOs, and community agencies for outreach and enrollment in publicly funded programs. The involvement of community-based healthcare organizations in improving access to healthcare for low-income, racial/ethnic communities has become increasingly apparent. Many states and counties are beginning to formalize these relationships (particularly in SCHIP programs), and these efforts must be evaluated.⁴⁶

Improve government purchasing. Public purchasers need training on rate setting to establish payment rates that do not discourage MCOs from serving high-risk populations. The costs of providing culturally and linguistically competent healthcare should be included in capitation rate-setting methodologies.

• Provide federal subsidies to MCOs that serve low-income vulnerable populations to ensure the provision of supplemental services such as transportation, medical supplies, and medications.

Mandate the inclusion of minority, linguistically competent, and culturally competent providers in managed care networks.

• Conduct radio and television mass media education campaigns to help people understand their rights as MCO enrollees.

Primary Care Capacity in Low-income and Racial/Ethnic Communities

Primary care capacity (ie, having enough primary care practitioners to meet people's needs for healthcare) is a critical link to improving the health status of low-income, minority, and LEP populations. People who have access to convenient primary care facilities where care is available in their language receive higher quality care and are less likely to experience serious illness; for those with chronic conditions such as asthma, diabetes, and hypertension, many hospitalizations are avoidable.⁵⁵

Underrepresented racial/ethnic communities have long been plagued with a paucity of medical professionals. In New York City, for example, there are 232 physicians in office-based practice per 100 000 residents. In 9 low-income, primarily minority communities, the rate was as low as 21.6 physicians per 100 000. These communities experienced a severe shortage in primary care capacity within a city that has immense physician resources.⁵⁶ Racial/ethnic practitioners are more likely to serve minority and poorer patients, and racial/ethnic health researchers are more likely to be interested in problems relevant to minority and historically underserved populations.⁵⁷ African American physicians are more likely than others to treat patients who are African American and/or on Medicaid; Latino physicians are more likely than others to treat patients who are Latino and/or uninsured.⁵⁸ Racial/ethnic minority patients also are more likely to feel that their physicians involved them in decisions about their care when the patient and the physician are of the same sex and race.⁵⁹

Over the past several years, the number of African Americans and Latinos admitted to medical school has declined. Although racial and ethnic minority groups represented 19.4% of the US population in the 1990 US Census, they represented only 10.9% of the 1997 medical school matriculants. The shift away from a national acceptance of affirmative action is having a negative effect on the ability to recruit and retain minority students and faculty in the health professions. After Proposition 209 in California and the Hopwood decision in Texas, Louisiana, and Mississippi, applications of minorities to medical schools in these states declined 17% (2.3 times more than the national average), accepted applications of minorities declined 27% (7 times more than the national average), and minority matriculants declined 26% (6 times more than the national average).⁶⁰

At the federal level, repeatedly documented strategies have been recommended to increase the number of underrepresented minorities in the health professions through investments in pipeline programs, mentoring programs, and incentive programs for both providers and MCOs, and more scholarship funds targeting low-income, underrepresented racial and ethnic groups.^57,58 Although federal efforts are required to increase African American and Latino representation in medicine and the health professions, MCOs can enhance the number of primary care physicians and health professionals by recruiting professionals who have a commitment to practicing in underserved areas, by creating opportunities for internships and residencies in MCOs, and by providing financial incentives to underrepresented minority primary care physicians to work in underserved communities. In addition, federal and state governments can strengthen the efforts of MCOs through the following strategies:

• Increase the reimbursement rate for MCOs that serve Medicaid and SCHIP individuals, and provide incentives such as tax credits to encourage MCOs to recruit the participation of more providers in underserved areas.

Create financial incentives for MCOs to reimburse primary care providers who practice in neighborhoods with a primary care shortage at an aboveaverage rate.

• Strengthen existing efforts and create new opportunities through the Health Resources and Services Administration to support primary care improvement, especially in MCOs that are located in minority communities (eg, National Health Service Corps, Bureau of Health Professions).

Culturally Competent Practices

There is no universal understanding among providers and researchers of what culturally competent care is, how to measure or evaluate appropriate care, or how to define successful programs. There are several reasons for this: no established standards define competent care; the costs of providing appropriate care (eg, interpreter services) often are not reimbursed; many public officials, healthcare facilities, and providers are unaware of their obligations or unwilling to provide linguistic and culturally appropriate healthcare to their patients61; and institutional practices often tend to disregard the healthcare needs of those who are unable to pay, have public insurance, or are unable to negotiate the system due to low education and literacy skills, and/or access constraints. In addition, cultural competence involves a dynamic interplay among socioeconomic status, race, ethnicity, and language–an interplay that definitions and interpretations of the term do not always acknowledge.

Local clinics, health centers, and individual providers have provided leadership in bringing high-quality, culturally competent healthcare to the communities they serve. Yet many publicly financed programs continue to be uninformed about the unique characteristics of the populations they serve. This information gap is associated with provision of less effective services, particularly for those who have a low income and LEP. (See the article by Carter-Pokras et al in this issue for a complete discussion of LEP.⁶²) Several studies have shown that language is important when a person does not have health insurance, has limited education, and has a low income.^7,22 In those instances, qualified medical interpreters– who are aware not only of language appropriateness but also of literacy and culture-specific health beliefs and behaviors–are crucial in bridging the language and culture chasm between patient and physician to effectively communicate health issues.²⁴

Training for health professionals on the provision of culturally appropriate care also lacks systematic and comprehensive standards. Schools of medicine, nursing, and public health offer courses on cultural competency. But the quality and depth of these offerings varies dramatically, from a single lecture per semester to an entire course on cultural differences. To date, no clear guidelines or comprehensive standards exist on how to prepare healthcare providers to become culturally competent. When 118 US and 15 Canadian medical schools were surveyed, few schools (United States: 8%, Canada: 0%) had separate courses addressing cultural issues and only 35% of US schools addressed the cultural, economic, and insurance status issues of the largest minority groups in their particular states.^63,64 Managed care organizations can institute continuing education or required training for all healthcare professionals regarding the culture-specific health beliefs and clinical, economic, and language issues experienced by the population they serve.

To institutionalize a set of practices that ensure equal treatment for all, both federal and state legislative pol

From the Department of Women's Studies and The Consortium for Race, Gender, and Ethnicity, University of Maryland, College Park, Md (REZ); the Community Health Access Department, Community Service Society of New York, NY (CM); Management Sciences Development, Washington, DC (HBM); and the Department of Medicine and the Division of Academic Medicine, Geriatrics and Community Programs, University of Medicine and Dentistry–New Jersey Medical School, Newark, NJ (DSL).

Prepared for the Conference on Diversity and Communication in Health Care: Addressing Race/Ethnicity, Language, and Social Class in Health Care Disparities; Washington DC; February 17-18, 2000. This study was sponsored by the Office of Minority Health, US Department of Health and Human Services.

Address correspondence to: Ruth Enid Zambrana, PhD, University of Maryland, 2101 Woods Hall, College Park, MD 20742. E-mail: rzambran@umd.edu.

Racial and Ethnic Disparities: Key Findings from the National Survey of America's Families

1. Staveteig S, Wigton A. . New Federalism: National Survey of America's Families Series No. B-5. Washington, DC: The Urban Institute; February 2000. Available at: http://www.urban.org/url.cfm?ID=309308. Accessed July 16, 2004.

Cultural Competency in Health, Social, and Human Services

2. Lecca PJ, Quervalu I, Nunes JV, Gonzales HF. . New York, NY: Garland Publishing; 1998.

Pediatrics

3. Lieu TA, Lozano P, Finkelstein JA, et al. Racial/ethnic variation in asthma status and management practices among children in managed Medicaid. . 2002;109:857-865.

South Med J

4. Rubin RM, Chang C, Stolarick R. Uninsured under TennCare: a case study of public health users. . 2000;93:989-995.

J Health Soc Policy

5. Jennings DL, White-Means SI. Medical care utilization by AFDC recipients under reformed Medicaid. . 2001;13(2):21-39.

Med Care Res Rev

6. Rosenbaum S, Markus A, Darnell J. US civil rights policy and access to health care by minority Americans: implications for a changing health care system. . 2000;57:236-259.

Health Serv Res

7. Weech-Maldonado R, Morales LS, Spritzer K, Elliott M, Hays RD. Racial and ethnic differences in parents' assessments of pediatric care in Medicaid managed care. . 2001;36(3):575-594.

8. Roetzheim RG, Pal N, Gonzalez EC, Ferrante JM, Van Durme DJ, Krischer JP. Effects of health insurance and race on colorectal cancer treatments and outcomes. Am J Public Health. 2000;90:1746-1754.

Health Aff

9. Phillips KA, Mayer ML, Aday LA. Barriers to care among racial/ethnic groups under managed care.. 2000;19(4):65-75.

JAMA

10. Halfon N, Wood DL, Valdez RB, Pereyra M, Duan N. Medicaid enrollment and health services access by Latino children in inner-city Los Angeles. . 1997;277:636-641.

Pediatrics

11. Berman S, Bondy J, Lizotte D, Stone B, Byrns PJ. The influence of having an assigned medical primary care physician on utilization of otitis media-related services. . 1999;104 (5 pt 2):1192-1197.

12. US Department of Health and Human Services, Office of Minority Health. Assuring cultural competence in health care: recommendations for national standards and an outcomes-focused research agenda. 1999. Available at: http://www.omhrc.gov/clas/ds.htm. Accessed June 3, 2004.

Social Work Practice With Asian Americans

13. Chung D. Asian cultural commonalities. In: Furuto SM, Biswa R, Chung DK, Murase K, Ross-Sheriff F, eds. . Newbury, Calif: Sage; 1992:274-275.

14. US Department of Health and Human Services, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care. Final Report. Washington, DC. March 2001. Available at: http://www.omhrc.gov/clas/. Accessed July 19, 2004.

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

15. Smedley BD, Stith AY, Nelson AR, eds. . Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy, Institute of Medicine. Washington, DC: National Academies Press; 2002.

Int J Health Serv

16. Krieger N. Embodying inequality: a review of concepts, measures and methods for studying health consequences of discrimination. . 1999;29:295-352.

Health Care Finance Rev

17. Coleman-Miller B. A physician's perspective on minority health. . 2000;21(4):45-56.

J Clin Pharm Ther

18. Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. . 2001;26:331-342.

Can Med Assoc J

19. Geiger HJ. Racial stereotyping and medicine: the need for cultural competence. . 2001;164:1699-1701.

J Healthc Manag

20. Rutledge EO. The struggle for equality in healthcare continues. . 2001;46:313-326.

Ann Intern Med

21. Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient based approach. . 1999;130:829-834.

JAMA

22. Putsch WR. Cross-cultural communication: the special case of interpreters in health care. . 1985;254:3344-3348.

Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons

23. US Department of Health and Human Services, Office of Civil Rights. . Washington, DC. August 2003. Available at: http://www.hhs.gov/ocr/lep/revisedlep.html. Accessed July 17, 2004.

J Gen Intern Med

24. Jacobs EA, Lauderdale DS, Meltzer D, Shorey JM, Levinson W, Thisted RA. Impact of interpreter services on delivery of health care to limited-English-proficient patients. . 2001;16:468-474.

Envisioning the National Health Care Quality Report

25. Hurtado MP, Swift EK, Corrigan JM, eds. . Institute of Medicine. Washington, DC: National Academy Press; 2001.

J Pediatrics

26. Flores G. Culture and the patient-physician relationship: Achieving cultural competency in health care. . 2002;136:14-23.

Ann Intern Med

27. Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM. Patient-centered communication, ratings of care, and concordance of patient and physician race. . 2003;139:907-915.

Qual Manag Health Care

28. Brach C, Fraser I. Reducing disparities through cultural competent health care: an analysis of the business case. . 2002;10(4):15-28.

Toward a Culturally Competent System of Care

29. Cross T, Bazron B, Dennis K, Isaacs M. . Vol 1. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center; 1989.

JAMA

30. Epstein RM, Hundert EM. Defining and assessing professional competence. . 2002;287:226-235.

Medicaid: Challenges and Choices in Health Care for the Poor

31. Rowland D. . Testimony Before the Committee on Commerce, United States House of Representatives, Hearing on Perspectives on the Transformation of the Medicaid Program, Washington, DC (86-M). Prepared by the Kaiser Commission on the Future of Medicaid. Washington, DC: Henry J. Kaiser Foundation; August 1, 1995.

The New Medical Marketplace

32. Stoline AM, Weiner JP. . Baltimore, Md: The Johns Hopkins University Press; 1993.

Health Aff

33. Miller RH, Luft HS. Does managed care lead to better or worse quality of care? . 1997;16(5):7-25.

J Health Econ

34. Frank RG, Glazer J, McGuire TG. Measuring adverse selection in managed health care. . 2000;19:829-854.

35. Health Care Financing Administration. Centers for Medicare and Medicaid Services. Medicaid Managed Care State Enrollment—December 31, 1998. Available at: www.hcfa.gov/medicaid.omcpr98.htm. Accessed August 10, 2004.

36. Brown ER Wyn RM, Teleki S. Disparities in health insurance and access to care for residents across US cities (Report of the Commonwealth Fund and UCLA Center for Health Policy Research). Available at: www.cmwf.org and www.healthpolicy.ucla.edu. Accessed August 10, 2004.

Inquiry

37. Leigh W, Lillie-Blanton M, Martinez RM, Scott Collins K. Managed Care in Three States: Experiences of Low-Income African Americans and Hispanics. . Fall 1999;26:218-331.

Medicaid Managed Care: Opportunities and Challenges for Minority Americans

38. Rosenbaum S, Shin P. . Washington, DC: Joint Center for Political and Economic Studies; October 1997.

39. National Health Law Program. NHeLP's Analysis of HFCA BBA Proposed Rules on Medicaid Managed Care: Cultural Competency. National Health Law Program Web Site. November 13, 1998. Available at: http://www.healthlaw.org/pubs/BBAregs/BBAcultural.html. Accessed June 14, 2004.

Care Coordination and Medicaid Managed Care: Emerging Issues for States and Managed Care Organizations

40. Rosenbach M, Young M. . Policy Brief. Princeton, NJ: Mathematica Policy Research, Inc; 2000.

Health Aff

41. Gold M, Sparer M, Chu K. Medicaid managed care: lessons from five states. . 1996;1(3):153-166.

Health Aff

42. Lipson DJ, Naierman M. Effects of health care system changes on safety-net providers. . 1996;15(2):33-48.

Managed Care and Low-Income Population; A Case Study of Managed Care in New York

43. Sparer M, Chu K. . Kaiser/Commonwealth Low-Income Coverage and Access Project. Washington, DC: The Henry J. Kaiser Family Foundation and the Commonwealth Fund; 1996.

44. Office for Civil Rights. Complaint concerning the rights of LEP individuals in New York Medicaid Managed Care Program. Filed by the Legal Aid Society against the New York State Department of Health, December 30, 1999.

Educating Medicaid Beneficiaries About Managed Care: Approaches Used in Thirteen Cities

45. The Center for Health and Public Service Research of New York University and The Community Service Society. . New York, NY: The Commonwealth Fund; May 2000.

J Urban Health

46. Gusmano MK, Sparer MS, Brown LD, Rowe C, Gray B. The evolving role and care management approaches of safety-net Medicaid managed care plans. . December 2002;79(4):600-616.

47. Lichiello P, Madden C. Context and catalysts for change in health care markets. Health Aff. 1996;15(2):121-129.

Health Aff

48. Lipson DJ, Naierman N. Effects of health system changes on safety-net providers. . 1996;15(2):33-48.

Health Care Finance Rev

49. Gold M, Mittler J. Second generation Medicaid managed care: can it deliver? . 2000;22(2):29-47.

Health Aff

50. Andrulis DP. The public sector in health care: evolution or dissolution? Three scenarios for a changing public-sector health care system. . 1997;16(4):131-140.

J Health Polit Policy Law

51. Schlessinger M, Gray B, Bradley E. Charity and community: the role of nonprofit ownership in a managed health care system. . 1996;21(4):697-751.

Exempt Organization Tax Review

52. Boisture R. Assessing the impact of health care reform on the formation of tax-exempt health care providers and HMOs. . February 1994;9(2):271.

J Health Admin Educ

53. Sigmond R, Seay JD. In health care reform, who cares for the community? . Summer 1994;12(3):259-268.

Readiness of Latino Health Community Based Organization to Adapt to Managed Care Providership: Managerial Perceptions and Institutional Resources

54. Munoz-Baras H. [dissertation]. Washington, DC: National Catholic School of Social Services, The Catholic University of America; 2004.

No Health Insurance? It's Enough to Make You Sick—Scientific Research Linking the Lack of Health Coverage to Poor Health

55. American College of Physicians–American Society of Internal Medicine. . White Paper. Philadelphia, Pa: American College of Physicians—American Society of Internal Medicine; 1999.

The Changing Face of Primary Care in New York's Low-Income Communities

56. Soffel D. . New York, NY: The Community Service Society of New York; January 2000. Abstract available at: www.cssny.org/pubs/research/health.html. Accessed June 3, 2004.

Current Challenges to Racial/Ethnic Diversity in Medicine

57. Nickens HW. . Paper presented at: Group on Student Affairs Professional Development Conference for Admissions Officer and Registrars; June 14-17, 1997; Denver, Colo.

N Engl J Med

58. Steinbrook R. Diversity in medicine. . 1996;334:1327-1328.

JAMA

59. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. . 1999;282:583-589.

The Impact of Ending Affirmative Action of the Nation's Physician Workforce

60. Association of American Medical Colleges. . Issue Brief. Washington, DC: Association of American Medical Colleges; 1997.

Ensuring Linguistic Access in Health Care Settings: Legal Rights & Responsibilities

61. Perkins J, Youdelman M, Wong D. . August 2003. National Health Law Program Web site. Order at: www.healthlaw.org/pubs/2003.linguisticaccess.html. Accessed June 3, 2004.

Am J Manag Care

62. Carter-Pokras O, O'Neill MJF, Soleras A. Provision of linguistically appropriate services to persons with limited English proficiency: a needs and resources investigation. . 2004;10:SP29-SP36.

Acad Med

63. Flores G, Kastner B. The teaching of cultural issues in the US and Canadian medical schools. . 2000(May);75(5):451-455.

J Clin Ethics

64. Kaufert, JM, Putsch RW. Communication through interpreters in healthcare: ethical dilemmas arising from differences in class, culture, language, and power. . 1997;8(1):71-87.

J Natl Med Assoc

65. Zambrana RE, Carter-Pokras O. Improving health insurance coverage for Latino children: a review of barriers, challenges and state strategies. . 2004;96:508-523.

National Healthcare Disparities Report

66. Agency for Healthcare Research and Quality. . Rockville, Md: Agency for Healthcare Research and Quality; December 2003:7.

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