Reducing Disparity: Achieving Equity in Behavioral Health Services
March 13-15, 2003
Many thanks and expressions of gratitude are due to the members of the Summit Planning Committee, the other volunteers at the Summit and, of course, our speakers. Everyone volunteered their time. The Committee members were critical in planning and conducting the Summit and in reviewing this document. The Committee consisted of Richard H. Dougherty, PH.D., Chair; Neal Adams, MD, MPH; Fred Fowler, Ed.D.; Eric N. Goplerud, Ph.D.; Jerome H. Hanley, Ph.D.; Leighton Y. Huey, M.D.; Francis G. Lu, M.D.; Ken Martinez, Psy.D.; Hubert A. (Ting) Mintz III; and Josie Romero, MSW. In addition, the Committee was assisted by a number of other volunteers who, in addition to members of the Planning Committee, helped to facilitate the breakout groups at the conference. They included: Kana Enomoto, Miriam Delphin; Mareasa Isaacs; Russell Pierce; Sharon Yokote; DA Johnson; Steve Petre; Sharon Walter; Diane Valdez and Charlie Williams. Finally, our speakers (described herein) also gave considerably of their time and wisdom to the Summit attendees. Without the speakers, clearly this would not have been possible. With them, I believe that we significantly advanced the debate and understanding of the scope of change required to reduce disparities in our behavioral health system. Thanks to everyone!
The American College of Mental Health Administration Summits would not be possible without the continuing support of the Eli Lilly Company, the Substance Abuse and Mental Health Services Administration and our members. Thanks to everyone who made this possible.
Richard H. Dougherty, Ph.D.
Behavioral health services are certainly not immune to disparity, inequality and prejudice. The President’s New Freedom Commission on Mental Health outlined six broad areas for reform of the mental health system, including the goal that “disparities in mental health are eliminated”. Mental illness and addictions are enormously stigmatizing conditions by themselves; no surprise that they may also fall victim to racial prejudice and cultural stereotyping. Behavioral conditions are subject to enormous variation in diagnosis and thus more likely to be influenced by differences in the perceptions of professionals and organizational differences between providers. At the heart of our profession and industry are relationships between the caregiver and individual receiving services. As with all human relationships, behavioral health treatment services are based primarily on interpersonal communication and they fall victim to the bias and prejudice that are part of our culture. While professionals in the behavioral healthcare system pride themselves on objectivity and empathy, we often overlook the importance of the cultural and environmental causes of behavior and the impact of cultural differences on the diagnosis and treatment of behavioral conditions.
To begin to address the problems of disparity in behavioral health will require the efforts of individuals receiving services, professionals, managers, policy makers and researchers at all levels of the system. At each stage of our service system – access, treatment and outcomes – different interventions or analyses may be relevant to reduce disparity. The complexity of this type of change effort requires a long and substantial effort first by leaders in the industry and later at all levels. To meet this challenge, the American College of Mental Health Administration devoted its 2003 Santa Fe Summit to the topic of “Reducing Disparities: Achieving Equity in Behavioral Health Services”. This paper reviews the issues and challenges that were identified in that Summit and outlines an agenda for the field to begin to reduce these disparities.
Background and Scope of the Problem
From a research perspective, we have long recognized that the numbers of African American adults in state hospitals significantly exceed their ratio in the population. The reasons are unclear and though we have many hypotheses, we have not aggressively pursued answers to them. Hispanic children are under-represented in the children’s mental health system and black children are over-represented and yet we can only offer more hypotheses as to the reasons for this. Finally, we have very little information with any certainty that lets us understand the reasons for the enormous variation in practice that results in the level of geographic variation we see in the behavioral health and the overall health care system. Variation is evident in public programs across states because of the different benefits available to recipients but significant variation is also seen across counties and regions within states, where the benefits are technically the same. It is extremely difficult in public mental health systems to reallocate resources to match community need – too many providers will be negatively affected. Yet even within Medicaid programs, where any willing and qualified provider should be able to participate and individuals have a relatively high degree of choice of providers, disparate practice patterns persist. To help reduce disparity and yet remain cost neutral, imagine the irony in having to waive “freedom of choice” within Medicaid in order to reallocate resources and improve equity!
Keynote Address: King Davis, Ph.D.
“Groups of American citizens and their descendants, identifiable by color, language, culture, race, (and) ethnicity, have been and remain at greater long-term risk of co-occurring poverty, ill health, hunger, violence, impaired self-esteem, powerlessness, sub-standard housing, unemployment, (and) environmental hazards. (This) is manifested in a higher than expected frequency of unrecognized, under-diagnosed, over-diagnosed, and untreated behavioral disorders in unresponsive systems.”
Dr. Davis continued with a detailed, and perhaps the most comprehensive review conducted to date, of the status of research on issues of racial and ethnic disparity in behavioral health care. In general, the number of high quality research studies on access to and outcomes of care by people of color in America is minimal. Research over the last two decades has increased on this topic, led in no small degree by Manderscheid and Sonnenschein and his 1985 research on admission rates by type of facility and racial and ethnic group. This study documented significantly higher admission rates to state hospital and general hospitals for African Americans and American Indians than the general population. The rate for African Americans in state hospital was more than twice the general population rate.
The Surgeon General’s groundbreaking report on culture race and ethnicity in mental health  documents key findings on mental health status by ethnic group. For instance while African Americans have overall lower rates of depression than the general population, female African American have higher rates than the general population. Poverty is strongly linked to the rate of illness and African Americans have significantly higher rates of homelessness and use of inpatient services. The report went on to document the paucity of Asian Americans and Pacific Islanders in research studies and to highlight the particular importance of culture in defining symptoms in this population. Asian Americans and Hispanics generally experience lower levels of suicide and substance abuse conditions. Incidences for Hispanics are strongly influenced by their countries of origin. Finally, American Indians have much higher rates of substance abuse, aged depression, suicide and conduct disorder.
More recent research studies help to further identify contextual issues in the general statements identified above. For example, there are significant exceptions to general statements about racial and ethnic groups when results are analyzed by age and sex. Current research is delving into issues of access to care, family roles in access and treatment, effective service models for specific populations, workforce training and medication differences. All of these will further help to identify effective service interventions to reduce disparity. In conclusion, King Davis stated:
The level of scientific knowledge, as shown in high quality epidemiological studies, of people of color and behavioral disorders is minimal. The quality of studies conducted on these populations has been minimal over the decades, with greater productivity and quality in the past decade. These populations are often left out of samples or the analysis of data does not focus on differences by culture, race or ethnicity”.
Panel Discussion: Other Perspectives on Race
Culturally Relevant Diagnosis and Assessment
It was clear to all of us that the cultural formulation should be at the heart of the overall diagnostic process, rather than being relegated to an addendum.
Examples from the Field
Josie Romero summarized the efforts to improve the cultural competency in the state of California’s mental health system, the most culturally diverse state in the country. More than ten years of work has gone into the development of a statewide effort that was initiated by legislation in 1994 as a part of California’s managed care plan. Cultural competency plans are required as a part of each County’s managed care plan and standards are embedded in all statewide program planning. The statewide Cultural Competency Advisory Committee provides guidance to state leaders and seeks to implement the following goals/principles:
The scope and persistence of the effort have transformed California’s mental health service system.Connecticut:
A different approach has been taken by the state of Connecticut over the last two or three years. Arthur Evans, Deputy Commissioner of the Connecticut Department of Mental Health and Addiction Services outlined the state’s efforts. Initial research using data from the state confirmed many long held beliefs about the extent and scope of disparities. Blacks and Hispanics were hospitalized more frequently in the state hospital than whites and blacks had less access to the newer generation of atypical medications. Similarly, whites were much more successful than other racial and ethnic groups in maintaining the continuity of care between acute detoxification services and longer term rehabilitation services.
Reflecting a somewhat different approach to cultural competency, culturally competent services may not have attributes that we can independently identify, but they can be identified by their effectiveness and their outcomes. The evidence-based definition of cultural competency is:
“Outcomes + Client Satisfaction = Cultural Competence”
Evans presented a framework for thinking about disparities that describes the factors that influence disparities at three levels in the behavioral health care system. These include:
Dr. Evans noted that the issues at a system level are responsible for a much larger degree of the variation in disparities and yet the research literature has focused most attention at the individual level of analysis. To address the need for change at a system level, Dr. Evans outlined a multi-level and multi-dimensional approach that includes: training, standard setting, changes in contracts, new data reporting and data systems, quality management approaches, clinical and systems policies, consumer and family input and evaluation. As an example of an effective statewide change effort, Evans proposed multi-method data analysis efforts that include better understanding of disparity data at a system level, case studies of programs that work and “hearing the voice of consumers and communities”. At a policy level, contracts will be modified, RFPs developed and new funding targeted to areas of highest need. Treatment needs to move beyond formal treatment methods to include non-traditional services, faith based services, traditional healers and special efforts targeted at urban areas.
Community Based Change: The Hill District
Creating culturally competent services is a complex process in any community. CCF involves a strong neighborhood and family partnership which works with local government and managed care to provide integrated and family directed support and services, rather than just offering families what is dictated by service systems. By hiring people with a positive history in the neighborhood, and giving families and neighborhood residents an opportunity to choose who that person might be, the program has an opportunity to gain trust from local residents. Training is a key feature of the CCF initiative. However, however, some of the most important interventions according to Hanley are the neighborhood interventions. Social and recreational activities are sometimes coordinated with the efforts of other neighborhood groups such as the Resident Tenant Council or the Community Collaborative so that families are part of the larger community. Family support activities along with training, (which parents can use right in their neighborhood), increase involvement and build trust. Families are not only involved in training, but also may provide support to other families such as going with another parent to an IEP meeting. Finally, food has always been a staple in training and meetings with families. If you come to Allegheny County, the food is reflective of the culture of that neighborhood.
Engaging African American and low income families in planning, leadership, support and decision-making activities with professionals builds self-esteem and gives families an opportunity to meet and influence people within systems that they otherwise might only know through receiving service. It promotes mutual understanding and respect. "Cultural competence and family involvement go hand in hand; you can't have one without the other."
CCF has insisted that every program activity have inclusive procedures and that they are enforced. One way to keep true to this commitment is through program evaluation. Each community in CCF has family and neighborhood representatives that sit on a Community Evaluation Team. Each community also gets a bi-annual outcomes report of their progress, which is compiled and distributed by the CCF Evaluation Team.
Programmatic Change: The Bridge Program
International Perspectives on Disparity
The key issues and action items for each of the system levels are summarized below:
Families, caregivers and community members live in the fall-out of mental illness and are critical parts of an effective treatment plan, particularly for people from non-majority cultures. Consumers and family members need to be actively involved in the treatment plan and be informed about the availability and use of advance directives. They need preparation to be caregivers through educations, training and support. Access should be improved through social marketing and public health awareness campaigns designed to help people identify symptoms and understand the benefits of services and treatment. Finally though not mentioned at the Summit, consumer directed services can help to address many of these areas while raising new challenges of educating individuals so they can be knowledgeable consumers.
Participants urged that providers conduct a self-assessment to better understand how others see them. What is it like when people arrive at your offices the first time? What does it say about your culture? Providers were urged to abandon their offices and reach out to the community using a variety of outreach methods. Similarly, providers must move out of their comfort-zone and be able to answer the question of who is the service really for. Treatment must be individualized and all should commit to the treatment goals. The mix of services may need to be adjusted to reflect these goals – less reliance on office-based visits and more focus on community interventions.
Many urged providers to actively try to identify ways to link to other members of the community and other natural supports. Psychiatry that is coupled with effective natural supports may be the most effective way to achieve change. Providing a single point of access within provider organizations and delivering systems is one way to ensure that consumers are educated properly and receive information about the full range of community supports. Several of the participants acknowledged the importance of consumer directed services and how this would change the perspective of providers to be more consumer centered. Finally many felt that providers needed to develop the capacity to track individualized outcomes for the people we serve. These outcomes should have specific operational outcome measures that aim at wellness, recovery and resiliency.
To achieve equity in our behavioral health system, purchasers may have to adopt a more strategic approach to the allocation of resources to underserved communities and providers from minority racial and cultural groups. In the past, many state behavioral health systems have been opportunistic in the development of new programs, providing funding to programs that had innovative proposals. Often these agencies have been the agencies that are the most successful – “success breeds success”. Medicaid services have grown with “any willing and qualified” provider. Once again, successful providers have often been the ones that have taken the most advantage of Medicaid growth. New efforts must more directly target underserved communities and provide funds to build capacity in the providers that serve or are willing to serve these communities.
Other issues that Payers need to consider include:
Behavioral health treatment systems must increasingly develop real choice across a range of treatments, services and supports for consumers. These services must be evidence based, but more importantly must be relevant to the individuals being served. This will help to ensure that services are both culturally appropriate and desirable to consumers.
More broadly, however, the participants at the AMCHA Summit felt strongly that our behavioral health service systems must explicitly adopt approaches that seek to increase the social capital of our communities. Social capital is a term used to refer to the characteristics of a social organization or community that facilitate coordination and cooperation for mutual benefit. In the case of behavioral health services, policies that improve social capital would seek to increase the level of communication and connectedness between behavioral health care organizations and other voluntary and government funded programs that serve individuals, and their families, who have mental illness and emotional disturbance. Critical services that need to be better coordinated include the different levels of behavioral health treatment services, prevention services, primary care, school based services, the criminal justice system and employment services. While this may seem like a broad mandate, it is consistent with and provides a new framework for a public health approach to behavioral health and for many efforts at developing existing community support services in both the child and adult service systems.
Many at the Summit agreed that many of our data systems already collect information on the race and ethnicity of individuals being served but these data are not often analyzed in a manner that helps to identify patterns of disparate care. In other cases, key data elements on race and ethnic status may need to be collected and stored in a manner that facilitates their use in analyzing access and utilization data. The core data elements that were recommended for inclusion were as follows:
Because of the lack of data on disparities, there was acknowledged to be little evidence on the effectiveness of cultural competency interventions in the reduction of disparity. The research agenda for the field needs to include cost-effectiveness research on cultural competency training and culturological assessments of the quality of care. As data are made more available, expected levels for different racial and ethnic groups can be estimated and actual access, utilization and quality levels should be compared to these estimates. In this way, jurisdictions that lag behind the expected levels can be held increasingly accountable for these results and for improvements.
Successful outcomes are defined by the culture and economic status of the individual served. Just as the relevance of certain Quality of Life (QOL) measures vary by economic status, so also QOL measures may vary by racial and ethnic group. The differences include the role of the family, community, religious organizations in the person’s life, and other characteristics. Western dominated outcome measures, such as employment and independence, may not be salient for people of other cultures.
We need to put the issue of disparity in the foreground of behavioral health policy. Only through the collection and dissemination of data on the nature and scope of disparities can we convince public policy makers of the need for fundamental change in our behavioral health system. Suggestions for steps to achieve this include:
The framework for our discussions produced a considerable level of discussion and recommendations for change at many levels. The principal recommendations to reduce disparities have been organized into the cells of a matrix. An example of some of the most critical elements of this framework follows:
As noted, a change agenda needs to include efforts at national, state and local levels involving consumers, providers, purchasers, oversight organizations and researchers. ACMHA is committed to advancing the field and helping the national effort to reduce disparities. Examples of potential projects include the following:
The 2003 ACMHA Summit has provided a foundation and a framework for work to proceed at all levels of the behavioral health delivery system. To accomplish meaningful change, we challenge SAMHSA, CMS and the other federal agencies to provide the leadership to develop: common and core performance measures focused on the reduction of disparities; to coordinate the research agenda, and; to facilitate the use of new information technologies to collect and review these data. This is completely consistent with the vision of federal “Leadership by example” that has been outlined by the Institute of Medicine for the implementation of the Crossing the Quality Chasm Report. We need to facilitate the efforts of states and the federal government to identify and reduce disparities and provide a forum for states to share the results of their efforts, to benchmark their performance and seek technical assistance. Over the next several years, we also expect that states will expand their efforts to implement evidence based practices. However, we urge these states to implement existing evidence based practices cautiously, especially with culturally diverse populations due to the limited representation of ethnically diverse subjects in the research evidence on current practices. We strongly recommend that data are also collected for “practice based evidence“ - where effective interventions are routinely identified from existing practice and shared with the field, particularly those practices that seem effective with minority populations.
With one effort followed by another, step-by-step, incrementally across the country, the impact of a person’s place of residence, their race, or their ethnic status on the scope and quality of health care they receive can be diminished. The American College of Mental Health Administration looks forward to working with the federal government, states, managed care plans, providers and individuals receiving services to achieve this vision.
 Richard H. Dougherty, PhD. “Reducing Geographic Disparities in Mental Health Access, Utilization and Cost: Implications for Policy and Planning” National Conference on Mental Health Statistics; Center for Mental Health Services. May 28, 2003.
 Dougherty Management Associates, Inc. “Children’s Mental Health Benchmarking Project: Year Three Report”, Lexington, MA: 2003; http://www.doughertymanagement.com/. Dougherty Management Associates, Inc. “Medicaid Managed Behavioral Healthcare Benchmarking Project”. Substance Abuse and Mental Health Services Administration, in press.
 U.S. Department of Health and Human Services. “Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General.” U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services: Rockville, MD: 2001.
 Institute of Medicine: Committee on Enhancing Federal Healthcare Quality Programs. “Leadership by Example: Coordinating Government Roles in Improving Health Care Quality”. The National Academies Press: Washington, DC: 2003