A Health Equity Q&A with Cara James

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Dr. Cara James - Director of the Office of Minority Health, CMS

Cara James, Ph.D., is the Director of the Office of Minority Health at the Centers for Medicare & Medicaid Services (CMS). In that role, she is responsible for providing leadership, vision and direction to address CMS Strategic Plan goals and objectives related to improving minority health and eliminating health disparities. She also oversees the office's efforts to address the goals of the U.S. Department of Health and Human Services (HHS) Action Plan to Reduce Racial and Ethnic Disparities. Prior to that, Dr. James was the Director of the Disparities Policy Project and the Director of the Barbara Jordan Health Policy Scholars Program at the Henry J. Kaiser Family Foundation, where she was responsible for addressing a broad array of health and access-to-care issues for racial and ethnic minorities and other underserved populations. Earlier in her career, she worked at Harvard University and The Picker Institute. 

Dr. James is a member of the Institute of Medicine’s (IOM) Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities and has served on several IOM committees, including the Committee on Leading Health Indicators for Healthy People 2020. She received her Ph.D. in Health Policy and her A.B. in Psychology from Harvard University.

Q. Tell us how CMS’ Office of Minority Health has evolved under your leadership.

A. CMS’ Office of Minority Health (OMH) originated in the Patient Protection and Affordable Care Act. We have been in existence for nearly four years and have been working to lay a strong foundation for doing disparities work and integrating it into the fabric of all agency programs. Our primary goal is to ensure that all beneficiaries achieve their highest level of health and to eliminate disparities. Another goal is to expand our data collection capabilities; we are working to develop and include survey questions related to race, ethnicity, gender, sexual orientation, language and disabilities, so we can better understand challenges and barriers that minorities face.

In our first year, we kicked off our activities by trying to understand disparities related to race and ethnicity. We looked at the data and identified challenges. Last year, we began using CMS data to understand and identify individuals who represent sexual and gender minorities. This year, we have begun exploring challenges for people with disabilities. Our cross-agency collaboration has also expanded over the past few years. For instance, we have begun working with the Medicare-Medicaid Coordination Office to address dual-eligible beneficiaries, with the Center for Clinical Standards and Quality and its Quality Improvement Organization (QIO) Program, and with the Center for Medicaid and Children’s Health Insurance Program (CHIP) Services.

Q. What are a few of the biggest challenges in eliminating health disparities, and how can our nation overcome them?

A. I honestly think one of our biggest challenges is convincing people to make a firm commitment to address health disparities. As a nation, we haven’t truly made that commitment yet. We attempt to tackle it in ways like improving the quality of care for consumers across the board; however, we have a decade of research from the Agency for Healthcare Research and Quality showing that while health care quality is improving for everyone, the gaps in care between groups are remaining largely unchanged. We need to make a concerted effort to reduce these gaps and not just improve the quality of care as a whole.

Another challenge goes back to our data. We have a well-documented history of disparity information for certain minority groups, but for others we have little understanding of their challenges due to the small size of the minority group or because we have not asked the right questions. We are working across CMS to standardize the collection of race and ethnicity data on our surveys, and are testing questions to help identify other minority groups, such as sexual and gender minorities. We are also analyzing our existing data to identify disparities among our beneficiaries.

Another hurdle to eliminating disparities is that some people may feel overwhelmed by what it takes to address them because disparities are a result of a number of factors outside of the health care system, like where you live, health care access, socio-economic status, education, etc. We have to address some of these issues or take them into consideration when developing solutions. We are trying to do a better job of eliminating disparities. Within the CMS Quality Strategy, we explore the role of patient and family engagement, providing culturally/​linguistically appropriate services, health literacy and meeting consumers where they are in the programs we develop.

Q. Providing culturally and linguistically appropriate services to beneficiaries has been a long-standing priority for CMS. How is the Office of Minority Health planning to expand upon what is already in place over the coming year?

A. The number of individuals with limited English proficiency is continuing to grow. We are working to provide more resources for those individuals and thinking about how to meet their needs. However, we know that providing culturally and linguistically appropriate services is about more than translating materials. It is about understanding the cultural background and communication needs of the person and addressing those needs. Our From Coverage to Care initiative is a great example of how we are helping consumers who are new to insurance or confused by it to understand their coverage and be able to use it to get the care they need. Through the resources we’ve developed, we help consumers improve their health literacy and connect them to the primary care and preventive services they need. We also explain how to better engage with providers. Our From Coverage to Care roadmap is available in seven languages; we worked with community groups on translations that are culturally meaningful to certain populations. The CMS Tribal Affairs Group helped with resources for tribal members.

Q. Tell us about your office’s involvement in addressing diabetes-related disparities.

A. In September 2014, we launched an effort to develop a four-year strategic plan focused on eliminating disparities in quality of care involving cardiovascular health, diabetes and chronic kidney disease. We have been engaged in an environmental scan to understand what the biggest disparities are and what some effective strategies might be. In the coming months, we will be engaging with thought leaders from around the country to determine which activities can have the greatest impact. We are exploring strategies involving both consumers and providers, and we are looking at possible policy/​structural changes for moving the needle on disparities and health care equity. We look forward to hearing from the QIOs and partnering with them to address these critical issues.

Q. How does your office support the work of the CMS QIO Program?

A. One of the things we have recently started and are enthusiastic about is our support of the QIO Program. In fact, the deputy director of the CMS OMH is Madeleine Shea who previously worked with a quality improvement organization and the QIO Program’s former Disparities National Coordinating Center. She brings a wealth of expertise in engaging with Quality Innovation Network-QIOs (QIN-QIOs). Through the development of our four-year strategic plan, we also are actively gathering input from Telligen – the Quality Innovation Network-National Coordinating Center, and we will continue to engage with them. Moving forward, we will help develop tools and resources, provide technical assistance to help with data analysis, and identify potential areas of improvement for QIN-QIOs. We encourage everyone to explore the free resources that are available on our From Coverage to Care site.

Q. Anything else you’d like QIO News readers to know? 

A. We are very excited about engaging with the health care quality improvement community to reduce disparities. If you have any questions or suggestions, please contact us.