Health Equity Q&A with Madeline Shea

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Dr. Madeleine Shea, CMS
Dr. Madeleine Shea, CMS

Madeleine Shea is the Deputy Director of the Office of Minority Health at the Centers for Medicare & Medicaid Services (CMS). Prior to joining the Office of Minority Health at CMS, Dr. Shea was the Director of the Disparities National Coordinating Center for Medicare Quality Improvement Organizations where she led Medicare disparities analytics and the diffusion of evidence-based interventions to reduce racial and ethnic disparities in chronic disease, adverse drug events and preventive health care access. Dr. Shea directed Maryland’s State Health Improvement Process, the state’s framework for health reform, where she oversaw the development of performance measures to chart the state’s progress in meeting population health goals and coached statewide local health improvement coalitions to align action to meet local health targets. Dr. Shea has held leadership positions in Baltimore City and the state of Maryland in healthy homes, asthma, HIV/AIDS and chronic disease. She has served on numerous national and state committees, advisory groups and boards, and is a champion of performance measurement, improving social health determinants and advocacy for disadvantaged groups. Dr. Shea’s service career started in the Peace Corps in Liberia. She holds degrees in economics, management and public policy.

Q. Before joining CMS, you worked in population health for an international service organization, the Maryland state government, a city health department and a QIO. How does that range of experience impact your work for CMS’ Office of Minority Health (OMH)?

I am so fortunate to have had many opportunities to work on community health improvement, in Africa, the City of Baltimore, the State of Maryland, nationally in partnership with QIOs, and now with the CMS Office of Minority Health. These experiences have strengthened my understanding of all the opportunities for collective action to improve our health care delivery system. One example that comes to mind involves public health practitioners in states and counties across the nation who are being funded to improve social and environmental determinants of health. QIN-QIOs can find natural partners through their cardiac health and diabetes work. These partners don’t have access to all the granular Medicare data that QIN-QIOs have and would be really interested in their perspective on where there is need for improvement. We can make so much progress when we find our common ground and build strong health improvement partnerships. 

Q. What are the most recent accomplishments and plans for OMH in 2016?

In January 2016, OMH released its Guide to Preventing Readmissions Among Racially and Ethnically Diverse Medicare Beneficiaries. This is a great new tool that can be used to improve care transitions, particularly among vulnerable populations. It includes simple steps hospitals can take to understand who is at risk for readmissions; what the drivers are for preventable readmissions; and how to put a team and plan in place to make progress in driving down these numbers. In March 2016, we posted a powerful new tool enabling the examination of disparities in chronic diseases by county and state, called the Mapping Medicare Disparities tool. It allows users to easily visualize disparities in 18 specific chronic conditions. It includes measures for prevalence, cost, utilization, hospitalization, readmission and mortality. We are excited for population health specialists to start using this tool because it will enable them to select measures that relate to their own local questions to better understand their target communities. One great feature of the tool is that it lets the user look at disparities between dual eligible and non-dual eligible Medicare beneficiaries. When I led the Disparities National Coordinating Center (NCC) a few years ago, QIN-QIOs often asked for better data on dual eligibles who experienced worse outcomes on almost all of their clinical measures than non-duals.

Q. Tell us about some of the ways in which OMH presently is working with Quality Innovation Network-QIOs, Hospital Engagement Networks and any other CMS quality programs or initiatives to achieve health equity?

We have been really busy working with the QIN NCC, Hospital Engagement Networks (HENs), Partnership for Patients, the Transforming Clinical Practices Initiative and many more partners to develop and share resources to drive equity. We also are in constant dialogue with leaders and folks on the ground about how our office can continue to support their work. We are here to serve. Drop us a line at omh@​cms.​hhs.​gov to let us know how we can help you.

"We can make so much progress when we find our common ground and build strong health improvement partnerships." 

Q. End-of-life counseling and hospice care options have become increasingly popular with patients and families. Do disparities exist in these areas, and, if so, how can they be overcome?

Studies show that high-intensity treatment in the last year of life may not be associated with greater quality of care, improved satisfaction or improved outcomes. Non-Hispanic black and Hispanic patients are more likely to seek life-sustaining interventions in the last six months of life than white patients. There have been documented differences across races and ethnicities in spiritual beliefs about dying, preferences for certain types of treatment, mistrust of the health care system and language barriers. Non-Hispanic blacks, and Hispanics to a lesser extent, show a higher level of mistrust in the health care system compared with non-Hispanic whites, and report lower levels of trust and satisfaction in their providers than non-Hispanic whites. This mistrust of the health care system has its roots in historic injustices and current disparities in quality of care. Hispanics also experience greater language barriers to establishing advanced directives and receiving hospice care services.

Our office examined the existence of and the underlying reasons for racial-ethnic disparities in End of Life (EOL) care for all Medicare beneficiaries using data from the Medicare Current Beneficiary Survey. We confirmed racial-ethnic differences for Medicare beneficiaries in the likelihood of receiving intensive EOL treatment versus hospice care. We also found inadequate access to hospice care for Medicare beneficiaries with certain terminal conditions like renal failure, which disproportionately affects minority populations. Beneficiaries enrolled in Medicare Advantage Plans had fewer hospitalizations and significantly lower total cost of care at end of life. Dual-eligible persons were significantly less likely to receive hospice care and had fewer hospitalizations at end of life. Finally, we saw that a stronger physician-patient relationship expanded EOL care choices but did not explain racial-ethnic disparities in EOL care. If anyone has interest in this report, feel free to reach out to me and we can send you a copy.

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

QIO News readers should know that their efforts are really important to our making collective progress in providing better care, smarter spending and healthier people, and the CMS Office of Minority Health stands ready to support you! Thanks for your contributions to improving our health care system.