The purpose of this study was to examine whether CAHPS® reports and ratings of care vary by race/ethnicity and language for adult patients in Medicaid managed care. Our findings suggest that racial/ethnic and linguistic minorities still face access to care barriers and lower quality of care, even after financial access has been assured by Medicaid. Racial/ethnic minorities had lower reports of care than white-English speakers, especially for timeliness of care and staff helpfulness. Timeliness of care addresses issues related to promptness in receiving urgent care as well routine care, while staff helpfulness deals with issues related to the courtesy and respect of the doctor's office staff. On the other hand, racial/ethnic and linguistic minorities were similar to white-English speakers in their health plan customer service scores. This pattern may be a result of Medicaid state agencies requirements to ensure that health plans have the appropriate organizational infrastructure to address the customer service needs of members of different racial/ethnicities and languages.
Our findings also suggest that language determines experiences with care among whites, Hispanics, and Asians. Among Asians, English speakers had experiences with care similar to that of whites, while non-English speakers had more negative reports and ratings of care. We also found that Asian non-English speakers had the lowest reports and ratings of care of all racial/ethnic groups. Similarly, among whites, non-English speakers had worse reports and ratings of care than did white-English speakers.
Among Hispanics, we observe a gradient effect of language whereby Spanish speakers had worse reports of care than did both bilinguals or English speakers, while bilinguals had scores in between English and Spanish speakers. However, lower reports concerning actual health care experiences did not translate into poorer ratings of care among Hispanic-Spanish speakers. A possible explanation is that reports of care are more objective and better capture differences in care, whereas ratings may be influenced by expectations and obscure these differences if Hispanic-Spanish speakers have lower expectations (Weech-Maldonado, Morales et al. 2001
This study has important policy implications. Traditionally, policymakers have focused on financial access to care as a mechanism to address disparities in care. These study findings suggest that it is necessary to go beyond financial access to address nonfinancial barriers to care (Williams and Rucker 2000
). Possible remedies to reduce health disparities in quality of care include engaging in human resources and health care delivery practices and policies aimed at: (1) recruiting, retaining, and managing a more diverse workforce; and (2) developing culturally appropriate systems of care (Weech-Maldonado et al. 2002
). Health systems should ensure adequate representation of minorities in areas of clinical practice and management. However, workforce diversity is only one mechanism to ensure culturally appropriate health care services and improve access to care. Health systems should also adopt practices and policies that reduce institutional barriers to care. Potential fruitful activities include establishing interpreter services, providing training to its workforce in cultural competency, using community health workers, developing culturally appropriate services, and addressing other nonfinancial barriers to care such as clinic locations and hours of operation (Brach and Fraser 2000
). The national standards for culturally and linguistically appropriate services (CLAS) in health care, set forth by the Department of Health and Human Services (DHHS) Office of Minority Health, provide guidelines on policies and practices aimed at developing culturally appropriate health care systems (see http://www.omhrc.gov/CLAS/finalcultural1a.htm
Health care organizations should address the observed racial/ethnic disparities in assessments of care as part of their quality improvement efforts. Our study shows wide variations across health plans in the reports and ratings of care among racial/ethnic minorities. For example, reports on getting needed care showed about a 10-point spread across health plans for Asian-other (73–82) and for Hispanic-Spanish (76–86). By engaging in quality improvement activities aimed at reducing the observed disparities in assessments of care, health plans should be able to improve their overall ratings and reports of care.
Our study also suggests the importance of identifying the patient experiences of non-English speakers. As such, health care organizations should step up their efforts to increase the availability of translated surveys and ensure the proper representation of non-English speakers in patient surveys. In addition, the National Committee on Quality Assurance should establish a policy for the CAHPS®
survey protocol requiring plans with a critical number of non-English speakers to administer surveys in languages other than English. Finally, efforts should continue to translate the CAHPS®
and other patient surveys into other languages, and to evaluate the cultural appropriateness of these instruments for non-English speakers (Morales
, Elliott et al. 2001
; Weech-Maldonado, Weidmer et al. 2001
). Producing culturally and linguistically appropriate research instruments should be viewed as a process. Ensuring an adequate translation is only the first step. The translated instrument needs to be evaluated further with qualitative (e.g., cognitive interviews) and quantitative (e.g., psychometric analysis) methods and revised accordingly to maximize its readability, reliability, and validity in measuring the health needs of English- and non–English-speakers.
Our study presents several limitations. First, participation in the NCBD is on a voluntary basis. As such, the database is neither nationally representative nor necessarily representative of Medicaid managed care organizations. Notwithstanding this limitation, state Medicaid managed care programs represented in the NCBD 3.0 data constituted 44 percent of the total number of Medicaid managed care enrollees in the United States in 2000.
Second, the observed differences in evaluations between subgroups may be due to differences in the quality of care received or to response bias. Cultural differences may influence response style in surveys and limit our ability to make comparisons between respondents of different racial/ethnic groups. For example, Hayes and Baker (1998)
compared the reliability and validity of the English and Spanish versions of a patient satisfaction survey, and found that the Spanish version of the scale was significantly less reliable and valid. They also found evidence that the response scale was not equivalent between different groups of patients, as Spanish-speakers appeared, all other things being equal, to be more likely to respond “good” than were English-speaking patients. The main objective of the Spanish CAHPS® project was to assess the cultural and linguistic appropriateness of the Spanish version of CAHPS® 2.0. This was accomplished through focus groups and cognitive interviews among Hispanic subgroups, as well as through a larger-scale field test. Results from the qualitative and quantitative analyses provide support for the cultural and linguistic appropriateness of the Spanish version of the CAHPS® 2.0 survey for most Spanish speakers, regardless of their national origin (Marshall et al. 2001
; Morales, Weidmer et al. 2001
; Weidmer, Weech-Maldonado, Hays, and Morales 2002
). The second phase of CAHPS® (CAHPS® II) aims to further assess the cultural appropriateness of the Spanish version of CAHPS® by conducting extensive psychometric analysis to evaluate the equivalence of the English and Spanish CAHPS® survey instruments (Weidmer, Weech-Maldonado, Darby, and Morales 2002
Third, the observed effects in this study reflect the overall differences in ratings and reports of care among racial/ethnic groups, which are a combination of within-plan effects and between-plan effects. The lower scores among racial/ethnic minorities may be a result of minorities being clustered in health plans that provide poor care. Future research should estimate the unique contributions of within-plan and between-plan sources of disparities in ratings and reports of care.
Finally, this study did not differentiate among managed care plans and there is great diversity among plans. Managed care organizations differ on various dimensions: methods of provider reimbursement, scope of benefit coverage, access to primary and specialty care, patient cost-sharing, and utilization management. Relatively little is known about the impact of managed care organizational characteristics on consumer assessments of care (Hellinger 1998
; Miller and Luft 1997
). Future research should examine whether health plan differences, in terms of organizational structure and practices, influence racial/ethnic differences in patients' assessments of care.