A Business Imperative and Long-Term Company Commitment
Over the past decade, Cigna has been a key advocate at the national level and actively shares best practices related to addressing health disparities and advancing equitable health care with other health plans, employer groups, and clients. Cigna also works closely with customers and health advocates in the public and private sectors to address health disparities that plague many people and communities. Our company has made a long-term commitment to improving health equity in the marketplace – deploying strategic and operational resources to improve access to affordable high-quality health care.
Where Health Disparities Often Occur
A health disparity, as defined by Healthy People 2020, is a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.
- Hispanics and African-Americans have lower colon cancer screening rates and higher mortality rates than Whites.1
- Black women have nearly double the preterm birth rate and triple the infant death rates compared to Asians.2
- Hispanics have 133% higher rate of diabetes and are 51% more likely to die from the disease.3
- Transgender people have a 1,600% higher murder rate.4
Health equity is the pursuit of the elimination of these health disparities.
The Factors That Contribute to Health Disparities
Some of the factors that contribute to health disparities are low health literacy, language barriers, cultural beliefs and practices, access to quality care, bias in the medical profession and social determinants to care such as physical environment or educational achievement. Individually and collectively these factors can present preventable health care barriers to achieving optimal health status and outcomes for certain populations. Despite significant improvement to overall health outcomes over the past decade, many subpopulations, including under-resourced communities, continue to experience substantial health disparities.
Why Addressing Health Disparities is Critical
As the United States becomes increasingly more diverse, it's no surprise that Cigna's clients reflect this diversity within their workforces. This demographic shift requires different health service models to offer culturally-responsive care. We know that to be a more effective health advocate for our customers, we need to understand cultural differences, recognize changing population demographics, and address gaps in care relative to health disparities.
Disparities can result in worsened health outcomes, added health care costs, lost work productivity, and premature death. A recent analysis estimated that disparities amount to approximately $93 billion in excess medical care costs and $42 billion in lost productivity per year as well as economic losses due to premature deaths. Many opportunities exist for the public and private sectors – including Cigna as a leading health services company – to help close the gaps between health disparity and health equity in the United States.
Cigna's Health Equity Council
Leadership is provided by Cigna's Health Equity Council, which is the governing body of our overall strategy to address health equity. The Council is comprised of more than two dozen influential leaders from across the Cigna enterprise, committed to dozens of new actions each year to improve health equity. This work is supported by the Enterprise Leadership Team. The Council's purpose is to:
- Increase awareness, share knowledge, and exchange ideas about health equity
- Integrate health equity into every business area and promote collaboration
- Establish and monitor progress on the strategy to promote health equity.
The Health Equity Council's strategic plan is based on the following five pillars: Leadership; Data, Research and Evaluation; Social Determinants of Health; Health Care Services; and Cultural and Linguistic Competence.
Each of the Council’s five pillars are the foundation of these actions to improve health equity.
Cigna established a Language Services Governance Council to oversee and improve communications for our Limited English Proficiency (LEP) customers, such as access to proficient bilingual Cigna staff members that have passed an oral proficiency assessment and, at the request of the customer, qualified professional interpreter services, and written translation, of health and benefit related documents in more than 33 languages including Braille, large print, alternative fonts, and audio.
Cigna sponsored a training event led by the Disparities Solutions Center and the Institute for Diversity and Health Equity, an affiliate of American Hospital Association (AHA). Representatives from more than a dozen state hospital associations and hospital/health care systems participated. The training curriculum included how to build the business case for addressing health equity; complete an organizational assessment; collect and utilize demographic data; address diversity and inclusion and improve the cultural competence of your workforce.
Data, research, and evaluation is used to identify and prioritize health disparities and evaluate the impact of initiatives to close gaps in care. To help us quantify and better comprehend these disparities, Cigna utilizes the Disparities Dashboard to track several quality measures by race and gender at the state and county level, as well as to pinpoint where to focus improvement efforts and inform clinical interventions. These analytics help us to move the needle from health disparity to health equity, which is one of the goals in our mission as a leading health service company to improve the health, well-being, and peace of mind of those we serve.
The Social Determinants Index (SDI) is designed to help us better understand the potential health disadvantages a community and its individuals may face based on their geographic location. A health disadvantage is the inability of people to fulfill basic human needs, which includes economic security, food, housing, safety, transportation, and education, required for full social participation and optimal health and well-being. Cigna is using the SDI to better understand the challenges in a local community that may be influencing health status, health care utilization, and outcomes. It allows us to design unique, carefully targeted interventions to help Cigna customers overcome the barriers that impact their ability to focus on their health, as well as improves our ability to evaluate the relationship between social determinants of health and health inequalities.
Social Determinants of Health is a new pillar was added to the Health Equity Council’s 2018-2020 Strategic Plan to address non-medical issues. Healthy People 2020 defines social determinants of health as conditions in the environments in which people live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Social determinants of health have a significant impact on quality of life, health conditions and health seeking behaviors. Cigna uses the Social Determinants Index to identify vulnerabilities and needs of the communities we serve at a national, regional, and local level based on publicly available data along with Cigna's claims data.
Health Matters Care Management Community Support Program
Cigna’s community support program helps identify and address barriers that can limit the ability to focus on health improvement. When medical or behavioral care managers identify a need, they refer the individual to a community resource. They can perform a behavioral health assessment and make appropriate referrals. A search engine is used to locate national and community-based resources that are confirmed every six months and includes direct service nonprofits such as: homeless services, disability services, supportive housing programs, food pantries, utility assistance, and civic programs.
In 2018, Cigna announced a breast cancer screening rate disparity between White and African-American customers in Tennessee had been successfully eliminated. Cigna achieved this successful result by
- Providing customers with accurate information about network screening facilities in their neighborhood, which fosters improved health care navigation, making it easy for customers to get the information they need to take action on their health.
- Creating personalized messages for customers that focus on the issues and concerns they care about most, and promotes positive health-seeking behavior and builds trust in the customer-health plan relationship.
- Collaborating with local partners, like Methodist Le Bonheur Healthcare and the Congregational Health Network, to improve access to care and leverage trusted relationships already established in the community.
By making cancer screening easier, more personalized, and local, it is possible to see measureable and impactful improvement in health disparities and improved health outcomes for populations who are experiencing disparate care. Cigna didn’t achieve these results alone – they stemmed from a collaborative, community-wide effort in Memphis and across Tennessee to address this disparity. Providers, payers, employers, community organizations, and government entities all worked collectively to bring about change. Cigna is proud of our efforts and the role we contributed to eliminating this disparity in Tennessee for our customers.
Hospital Collaborative Care Initiative
Cigna recognizes the important role hospitals and health systems play in helping to ensure that individuals of all races, ethnicities, and cultural backgrounds receive high-quality, equitable care. To accelerate these efforts, Cigna added a health equity metric into the performance standard for our Hospital Collaborative Care (HCC) program. Starting on January 1, 2018, all new or renewing hospitals in the HCC program have the opportunity to earn credit towards their overall performance score when they sign American Hospital Association’s #123forEquity pledge. Cigna is the first health plan to collaborate with American Hospital Association (AHA) and its #123forEquity pledge. The Centers for Excellence program will also include the Equity of Care pledge on the revised annual report to hospitals. Cigna hospitals can fulfill the cultural competency training goal in the pledge by encouraging their providers to take advantage of the Cultural Competency Training and Resources web page.
Cigna recognizes the importance of equipping our internal workforce, network providers, and clients, in understanding and addressing health disparities within the communities we serve. Cigna efforts aim to address gaps identified through various need assessments conducted over the past 10 years among our stakeholders.
In 2018, Cigna employees completed more than 28,400 cultural training modules. Cigna updated the Cultural Competency series tailored to Cigna job roles. Learners gain insights into delivering culturally-responsive services including identifying and countering implicit bias and establishing trust through cross-cultural communication. Being responsive to health beliefs and practices, as well as the linguistic needs of our diverse customers, is important to Cigna's mission.
A special promotion of two specific cultural competency training series was implemented in 2018 for clinical staff, behavioral staff, coaches, and personal advocates. The Hispanic-Latino series assists Cigna employees with better engaging and connecting with Hispanic-Latino customers. Each module includes specific customer simulations for the given cultural values. Diabetes among South Asians, a population-specific series, helps learners gain an appreciation for expanding clinical awareness related to culturally driven disparities. The modules include a deeper exploration into certain subpopulations, case studies, and patient education available in English, Hindi, Nepali, and Urdu.
Cigna continued to host Cross Cultural Diversity Forums for our clinical, customer-facing employees. Five working groups convened across different sites and teams, providing culturally diverse content and education to more than 1,500 Cigna employees. Topics include homelessness and poverty, mental health and poverty, transplant diversity in veterans, cultural difference with the elderly population, and more.
Cigna also promoted other training resources including the Developing Cultural Agility course in which learners develop cultural agility by examining assumptions and cultural competency best practices. This course serves as a primer for other trainings.
The resources are readily accessible through our recently (2018) redesigned Cultural Competency and Health Equity Resources website for network providers. At no cost to providers and their staff, many additional tools and resources are available, including:
- A cultural resource center providing insights on cultural communities.
- Commonly used patient forms in Spanish such as consent, refusal instruction, and treatment forms.
- Interpretation and translation services discounts are available to Cigna-contracted health care providers.
Focus Areas for 2019
In 2019, Cigna will seek to expand our efforts to address health equity by:
- Further engaging employees to be health equity leaders in their communities.
- Investing in the design of intervention strategies and generating meaningful insights to create best practices for reducing health disparities.
- Creating community-originated intervention strategies to build capacity and scale solutions for addressing the social determinants of health that result in inequitable care.
- Integrating cultural competency as a key component of Cigna's workforce personalization efforts and supporting network providers to meet the patients’ social, cultural, and linguistic needs.
1 American Cancer Society, Inc, 2017 Colorectal Cancer Facts & Figures 2017-2019 https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2017-2019.pdf.
2 CDC.Health, United States, 2015 Chartbook: Special Feature on Racial and Ethnic Health Disparities. http://www.cdc.gov/nchs/hus.htm
3 MMR Weekly. Vital Signs: Leading Causes of Death, Prevalence of Diseases and Risk Factors, and Use of Health Services Among Hispanics in the United States — 2009-2013. May 8, 2015 / 64(17);469-4784
4 Cigna. (n.d.). Health Disparities: Lesbian, gay, bisexual and transgender (LGBT). Retrieved March/April, 2018, from https://www.cigna.com/assets/docs/health-care-professionals/lgbt-health-disparities.pdf.
5 Disparities in Health and Health Care: Five Key Questions and Answers, KFF Henry J. Kaiser Family Foundation, Published: August 8, 2018
Disclaimer: The report covers calendar year 2018 and unless otherwise noted, excludes the combination with Express Scripts, which closed on December 20, 2018.