Loading...
HomeMy WebLinkAboutMINUTES - 03191996 - C44 J ` I M 5 C.43, C.44,C.45 and C.46 THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Adopted this Order on March 19, 1996 , by the following vote: AYES: Supervisors Rogers, Bishop, DeSaulnier, Torlakson and Smith NOES: None ABSENT: None ABSTAIN: None SUBJECT: Correspondence C.43 LETTER dated February 29, 1996, from Skip Thomson, Chairman, Board of Supervisors, Solano County, 580 Texas Street, Fairfield, CA 94533, requesting confirmation that Solano County officials will be notified in the event of a hazardous materials release or any potential release which will impact Solano County residents. ****REFERRED TO OFFICE OF EMERGENCY SERVICES, DIRECTOR AND HEALTH SERVICES, DIRECTOR C.44 LETTER dated February 28, 1995, from Guillermo Rodriquez, Jr., Executive Director, and Alicia Lara, Director, Latino Issues Forum, 785 Market Street, Third Floor, San Francisco, CA 94103, transmitting a copy of "Medi-Cal Managed Care: A Discussion about Health Care Options and Consumer Principles", and requesting the Board's support of same. ****REFERRED TO HEALTH SERVICES DIRECTOR C.45 LETTER dated March 4, 1996, from Wayman Yee, M.B.A., Management Auditor, Audit Services Unit, State of California, Health and Welfare Agency, Department of Community Services and Development, 700 North 10th Street, Room 258, Sacramento, CA 95814, advising of the result of a desk review of an audit report on contracts administered by the Community Services Department. ****REFERRED TO COMMUNITY SERVICES DEPARTMENT, DIRECTOR AND COUNTY ADMINISTRATOR C.46 LETTER dated February 27, 1996, from Diana Patrick, P.O. Box 1086, Martinez, CA 94553, on issues pertinent to Shell Refinery. ****REFERRED TO COMMUNITY DEVELOPMENT DIRECTOR IT IS BY THE BOARD ORDERED that the recommendations as noted (****1 are approved. I hereby ccrtity th4t this is a true andcorrectcopyof an action takcn enj entered on the minutes of the c.c. Office of Emergency Services, Director Board of Sup roisors on the da sho n. ATTESTED: Health Services, Director PHIL BATCHELOR,Clerk of the Boa Community Services, Director of Supervisors d County Administrator County Administrator B>r ,Deputy Community Development, Director Correspondents LATINO ISSUES FORUM A Public Policy and Advocacy Institute February 28, 1995 1.BOARD =IE17EIVED OF DIRECTORS: JIMThe Honorable Jeff Smith M.D.Leo AvilaPresident of the Board Ben Benavidez tySupervisorsSUPERVISOR Contra Costa County Board of WITH Cecilia P.CamaBurrillo ga 652 Pine Street, Room 108-A Lydia Camarillo Martinez, CA. 94553 Castulo de to Rocha Wilma L. Espinoza Dear Supervisor Smith: Leo Estrada Rose Del Castillo Guilbault Latino Issues Forum and the California Pan Ethnic Health Network Roberto P. Haro (CPEHN) are actively involved in monitoring your county's transition of Ortensio Lopez the Medi-Cal program from"fee for service"to managed care. Frank Quevedo Cruz Reynosa Last November, we hosted a meeting of statewide health care advocates to Elisa Maria Sanchez assess the development of your county's Health Care Options (HCO) Helen Romero Shaw program, the vehicle the State will use to educate Medi-Cal consumers Louis Velasquez about the changes to their health care delivery system. Lea Yborra The meeting's main objective was to raise community awareness about PRESIDENT consumer education and to address the significance of a well developed, OF THE BOARD: and executed HCO program. It is our fear that without a well designed and Ralph Santiago Aboscal coordinated program, the success of this mammoth transition remains questionable. EXECUTIVE DIRECTOR: Guillermo Rodriguez, Jr. Enclosed you will find a copy of the proceedings of our session. We challenge you to support the Consumer HCO Principles and ask that you urge your Local Initiative Governing Board to adopt them. Thank you for your attention and should you need extra copies of the enclosed report or additional information, please contact Alfredo Gonzalez, Latino Issues Forum's Health Policy Analyst, directly at (415) 284-7226 Sincerely, Guillermo Rodriguez Jr. Alicia Lara Executive Director Director Latino Issues Forum CPEHN 14 Ca 785 Market Street, Third Floor • San Francisco • California • 94103-2003 Phone(415) 284-7220 0 Facsimile (415) 284-7222 ✓ C . MEDI-CAL MANAGED CARE: A DISCUSSION ABOUT HEALTH CARE OPTIONS AND CONSUMER PRINCIPLES . Latino Issues Forum d California Pan-Ethnic Health Network February 1996 MEDI-CAL MANAGED CARE: A DISCUSSION ABOUT HEALTH CARE OPTIONS AND CONSUMER PRINCIPLES Introduction: On November 17, 1995, Latino Issues Forum and the California Pan-Ethnic Health Network (CPEHN) hosted a day long workshop with consumer and health care advocates from Medi-Cal Managed Care Fast Track Coun- ties.l The goal of the meeting was to bring together consumer, community and health care advocates to dis- cuss how each "fast track" county is progressing in its respective effort to transition their Medi-Cal beneficiary population from fee-for-service to managed care. Special attention was given to the design and implementation of the Health Care Options Program (HCO).2 Further, a set of Consumer Principles were developed to be used as a foundation or blueprint for all transition counties to use in developing an effective HCO program. For Medi-Cal managed care to work successfully, it is dependent on a well educated Medi-Cal population. However, the state's HCO program, as currently de- signed,is scattered,uncoordinated and insufficient. The goal of this report is to increase public awareness about 1 currently,there are five Medi- Medi-Cal's transition to managed care and to underscore Cal managed care transition the importance of the HCO program. After all nothing counties that have been dubbed i "fast track" because they are less than the health of millions of California's most vul- nearest to actually implement- ing Medi-Cal managed care's nerable is at stake. Unless greater attention is given to Two Plan model. Those coup ties are Alameda,San Joaquin, HCO,millions of low income women,children,disabled, Kern,Tulare, a contra costa. Other countiess also present at ang d the ed will be left in the dark about how their own the meeting were Los Angeles, health care has changed. Fresno,and San Francisco. z Health Care Options(HCO)is the program created by the De- partment of Health Services (DHS)to educate Medi-Calcon- sumers about the impending GU2IIeYmO Rodriguez,Jr., Alicia Lara transition from fee-for-service to Executive Director Director,California managed care. In other words, HCO is the State's main vehicle Latino Issues Forum Pan-Ethnic Health Network to ensure, through education, that Medi-Cal consumers under- stand managed care changes. LATINO ISSUES FORUM 1 Background: California's Medi-Cal program,which provides health care cover- age to more than 5 million women,children,elderly,and disabled, is undergoing a major transition as never before experienced. California policy makers have approved a plan to place nearly half of all Medi-Cal recipients into managed care arrangements by 1996. Under the Medi-Cal Managed Care expansion plan, 3.4 million Medi-Cal recipients in thirteen of California's largest coup- ties3 will be faced with complex and difficult choices regarding their health care. California's new managed care initiative,known as the Two Plan Model, is based on competing plans and consumer choice. Medi- Cal consumers in each of the designated counties will be required to choose between the "Mainstream plan" or the "Local Initia- tive." Within the Two Plan Model, each county's Local Initiative and Mainstream plan have the option to sub-contract their services out to as many other agencies as needed. Although Medi-Cal consumers will choose between two plans, they may deal with several health care providers within the plan they choose. The Local Initiative is designed and managed by the county and the Mainstream or commercial plan is a single for-profit HMO se- lected by the Department of Health Services (DHS). Once the two plans are fully operational, fee-for-service will be eliminated as an option. At that point,Medi-Cal consumers will be asked to choose between the competing managed care plans provided in their county. Recipients will then receive Medi-Cal services under their chosen plan; with the state paying the plan directly for each recipient whom they have enrolled,regardless of whether the beneficiaries actually sought services or not. 3 California's Two Plan Model New Medi-Cal consumers will be notified by mail and referred to expansion of managed care will affect twelve ofthe state's an HCO presentation to alert them of the provider choice that they largest counties, they are: Alameda, Contra Costa, must make. Once the Medi-Cal consumer receives notification or Fresno, Kern, Los Angeles, Riverside, San Bernardino, attends a presentation,the recipient will have thirty days to enroll San Francisco, San Joaquin, In a plan.. If they do not choose a plan, then they will be assigned Santa Clara, Stanislaus, Tulare. Note that San Diego a plan—this is known as "the default function." Once recipients County will subscribe to the GMC plan which Sacramento are enrolled in a plan, they are allowed to choose a primary care County is currently using. LATINO ISSUES FORUM 2 physician. Further,they are assigned,by their plan,to a provider location. Those who do not enroll with a primary care physician will be assigned one by default. SECTION I: County Status Reports The following are brief status reports on the progress of each fast track county in the implementation of their Local Initiative and HCO program: Alameda is the first county to implement the Two Plan Model. HCO presentations and enrollment activities began on December 1, 1995. According to Alameda representatives attending the meeting, Medi-Cal managed care materials were to be mailed to all new and re-determinant Medi-Cal beneficia- ries on December 1. To date, the exact logistics of Alameda's HCO program have yet to be released, and it is not definite who has received or will receive HCO information or how it will reach Alameda's Medi-Cal constituency. HCO concerns in Alameda County include, the use of untested HCO literature and materials,uncertainty as to which federal waiver the county is working under,protection of language translations including those that do not constitute a• threshold4, and locating proper sites for HCO pre- sentations. Since our initial meeting, Alameda County has started its HCO program. As of December 1, 1995, Alameda had three permanent HCO locations in county social service offices serving new and re- determinant Medi-Cal consumerS5. HCO materials have been translated into five threshold languages (English,Spanish,Vietnamese,Cantonese and Farsi) 4 A threshold language is a and are currently being used in the HCO protocol. language that is documented Because there is a consumer thirty day decision by DHS as being spoken by more than3,000Medi-Cal con- period between an HCO presentation and actual sumers in a given county,or enrollment in a plan,Alameda's Local Initiative did more than 1000 consumers in a single zip code,or more than not have any members until January 1,1996. To date, 1500 consumers within two Alameda's health plan, known as the "Alameda 52)contiguous Zip codes. Alliance for Health" has approximately 3 000 en- Due to HCFA granting Cali- pp y � fornia the Two Plan Waiver rolled members. Although the county has an HCO (1/22/96),it is now possible for Alameda County to enroll outreach plan,no Community Based Organizations Medi-Cal consumers who do (CBOs) are being used as HCO sties at this time. not belong to Two Plan aid categories. LATINO ISSUES FORUM 3 • San Joaquin is expected to be the second county to implement the Two Plan Model. Like Alameda,San Joaquin has also met with the Department of Health Services (DHS) and Health Choice, Inc.6 staff to establish an appropriate HCO protocol. HCO mate- rials have been finalized, yet individuals from San Joaquin, who attended the meeting, voiced their reservations about the HCO process in their county. Among the most important concerns they raised were the appropriateness of HCO presentation sites, the issue of language translations for those commu- nities that do not constitute a threshold,HCO mate- rial literacy level, and the hiring process and diver- sity of HCO counselors. The high level of concern regarding HCO led to the establishment of a local task force of area CBOs to work with the Local Initiative representatives and DHS on HCO. The county is slated to begin enrollment and HCO pre- sentations in February 1996. • Kern county is scheduled to begin its HCO pro- gram in June 1996. Although DHS and Health Choice, Inc. have met with county representatives, consumers of Medi-Cal have played a very limited. role in the formulation of Kern's HCO outreach plan. Representatives from Kern County suggested that the HCO process incorporate more Medi-Cal con- sumers and utilize other social services, such as Head Start in the formulation of their HCO process. •Tulare,like the prior four counties,has also met on various occasions with Health Choice,Inc.and DHS to develop a local HCO program. Tulare County health care leaders voiced similar concerns as those expressed by other"fast track"counties representa- tives (i.e., language protection, effective outreach, HCO hiring protocol etc.). The start up date for the HCO program in Tulare has not yet been deter- mined. It is important to note that many of the same issues and concerns raised by one county were true for all the other counties. Concern 6 Health Choice,Inc.is the for accurate and culturally sensitive translation of materials, col- single contractor selected by the Department of laborative outreach using CBOs, and the diversity of HCO coun- Health Services to design and implement the HCO selors were issues of concern raised by all of the "fast track" program for each county. LATINO ISSUES FORUM 4 counties. What was most startling during the status report presen- tation given by county representatives was that none of the pre- senters had met with their counterparts in other counties undergo- ing similar discussions. In other words, health care advocates working on the same issues were not collaborating with their colleagues in other counties. However, many of the representa- tives did indicate that the State and Health Choice Representatives often referred to the work of other counties when discussing the use of standard HCO educational materials. Clearly, it is important for consumer and health care advocates involved in the development of their Local Initiative to remain in contact with one another,and meet regularly as does the State and Health Choice,Inc. The participants urged DHS representatives in attendance that it should be the State's responsibility to facilitate better communication among the consumer and health care advo- cates in the transition counties. SECTION II: Questions & Related Issues for Further Discussion While the discussion at the meeting was enlightening and educa- tional for all in attendance, it, however, raised many more ques- tions and concerns that were specific to each individual county. We thought it useful to list these questions by category so that consumer and health care advocates can use them to approach their local county officials charged with the design of the Local Initiative. Health Care Options: 1. Who hires the HCO counselors and who determines the selection criteria? 2. What is Health Choice, Inc. doing to enhance the employ- ment of Medi-Cal beneficiaries, former Medi-Cal consum- ers, advocates, and CBOs staff as HCO counselors? Will HCO counselors in a given county reflect the Medi-Cal racial,ethnic,and linguistic make up? Will Health Choice, Inc.contract directly with CBOs to administer HCO presen- tations? LATINO ISSUES FORUM 5 3. What is the reading level of HCO materials to be used in this county? Why was this level chosen? How did you test the translated HCO materials for appropriate language level, cultural sensitivity and effectiveness? 4. Does DHS intend to publicly circulate all HCO materials in an appropriate and timely manner for public comment and review prior to their use? 5. Will Medi-Cal consumers receive directories of primary care providers at HCO presentations? How will they be distributed and updated? 6. Will HCO grievance materials have the names and phone numbers of local legal services offices? Will the HCO contractor or DHS post grievance,rights,and procedures at HCO sites? 7. Will HCO presentations be mandatory for Medi-Cal con- sumers? 8. What agency has the responsibility of monitoring the HCO process, and how will that agency evaluate the effective- ness of the HCO program? 9. Will Health Choice, Inc. monitor results of the presenta- tions,including the demographic characteristics of the Medi- Cal consumers who attend,and the plans they choose,etc.? 10. Will Health Choice, Inc. conduct outreach sessions for CBOs and train them on Medi-Cal managed care? 11. What will the role of the office of Multicultural Health be in the HCO process? What role will the Department of Social Services and eligibility workers play in the HCO process? General Questions & Concerns: • Will DHS suspend default enrollment until both plans are fully operational? • Will the state give priority to the Local Initiative in the default process? • Is their any intention to create provider report cards that LATINO ISSUES FORUM 6 1 will be distributed to Medi-Cal consumers prior to making their plan selection? • What kind of data collection will exist for Medi-Cal Man- aged care? • How will consumer satisfaction be measured? SECTION III: HCO Principles The following principles were collectively developed to serve as a foundation or blueprint for a successful HCO program. The principles are intended to guide the implementation of Medi-Cal managed care and should be specifically adapted to each county and population to be served. Principles to Guide the Implementation of Medi-Cal Managed Care's Health Care Options Program • Medi-Cal Consumer Participation DHS and the HCO contractor will increase the participation of Medi-Cal consumers in the development of the Health Care Op- tions program for each county. • Language Protection DHS will ensure that all threshold and non-threshold languages are protected. This includes generating HCO materials that are comprehensive and understandable in all threshold languages,as well as providing proper HCO access to all Medi-Cal managed care consumers who do not belong to a constituency large enough to constitute a threshold. • Outreach DHS and the HCO contractor in conjunction with each expansion county will develop a series of outreach sessions that explain Medi-Cal managed care to beneficiaries, advocates, health care leaders,CBO's and any other group or individuals who work with Medi-Cal managed care consumers. LATINO ISSUES FORUM 7 e #q • Testing of HCO materials Prior to the dissemination of any HCO materials,all collateral and forms for each threshold language must be tested for effectiveness with Medi-Cal managed care consumers. HCO Presentations Sites for HCO presentations will be thoroughly investigated prior to their establishment. The state will approach community based organizations for assistance in identifying the most suitable HCO sites in a given community,thereby assuring consumers access to presentations. Also,sites for presentations must be uniform across counties and should be identified early in the managed care planning process. Locations should include CBOs, legal aid of- fices, community clinics and any other entities that advocate for the Medi-Cal community. Non state agencies serving as HCO presentation sites should be compensated. • Hiring process for HCO counselors Information on the hiring process and job descriptions of HCO counselors will be open for public comment and review. More- over,the contractor will make sufficient efforts to recruit appropri- ate HCO counselors from the local community. Counties and area CBOs should be included in any recruitment process. • Strong monitoring of HCO To minimize unnecessary patient suffering and subsequent litiga- tion, DHS and the Department of Corporations will strictly and pro-actively enforce all Medi-Cal managed care regulations and impose significant fines on those providers or contracted organi- zations who violate any Medi-Cal regulations. • Minimize default enrollment DHS and the HCO contractor will rigorously strive to attain a greater than 80% rate of plan selection by Medi-Cal consumers to decrease default enrollment. LATINO ISSUES FORUM S CONCLUSION The transition of 3.4 million beneficiaries from fee-for-service to managed care is a monumental task. Thus, the HCO program is one of the most critical elements needed during this transition to ensure that Medi-Cal consumers do not face added obstacles when accessing health care services. Community leaders must become increasingly aware and involved in the development of their county's Local Initiative and Mainstream Plan. The publication of the proceedings of our first meeting is intended to serve as a catalyst for further discussion and action. We encourage you to take the initiative and use the information contained in this report to engage yourself in the deliberations in your county. Latino Issues Forum and CPEHN will continue to serve as conven- ers and disseminators of information to community leaders and advocates. However, only through increased participation at the local level will we be able to ensure that Medi-Cal consumers are not "Left Behind." LATINO ISSUES FORUM 9 STRATEGY SESSION ON HEALTH CARE OPTIONS ATTENDEES Ms.Joice Blaitout Mr.Perfecto Munoz Administrator Executive Director, Concilio/Latino Kings Winery Medical Clinic Partnership for a Healthy Tomorrow Mr.Frank Camargo Mr.Alfred Murillo Executive Director Deputy Director,Health Care Services Familias Unidas San Joaquin General Hospital Mr.Harry Foster Mr.Elizer Risco-Lozada Executive Director Research and Development Director Porterville Family Health Center United Health Center of the San Joaquin Valley Ms.Jane Garcia Executive Director Mr.Guillermo Rodriguez Jr. La Clinica de la Raza Executive Director Latino Issues Forum Mr.Alfredo B.Gonzalez Health Policy Analyst Ms. Gladys Sandlin Latino Issues Forum Executive Director Mission Neighborhood Health Center Ms. Ele Hamburger Fellow for Economic Justice Ms.Laretha Senyo-Mensah Consumers Union Health Policy Associate Alameda Health Consortium Ms. Sherry Hirota Executive Director Ms.Brenda Solorzano Asian Health Services Project Coordinator, Latino Coalition for a Healthy California Ms.Wendy J.Jameson Sr.Health Policy Specialist Ms. Shirley Stanley California Assoc. of Public Hospitals Public Policy Committee Chair Kern County Local Initiative Dr.Hwai-Tai Lam,Ph.D. Statistician REPRESENTING THE STATE& V.A.Medical Center HEALTH CHOICE,INC. Ms.Alicia Lara Mr.Jeff Baker Director Benova/Health Choice Inc., California Pan-Ethnic Health Network Accounts Manager Mr.Bruce Lee Livingston Mr.Craig Miller Executive Director HCO Systems Support Unit Health Access Department of Health Services Ms.Julie Matsumoto Mr.Ruben Gonzalez Medi-Cal Consumer Advocate Chief Managed Care Expansion Branch Local Initiative,Los Angeles County Department of Health Services LATINO ISSUES FORUM 10 CEO's for Medi-Cal Managed care "Two Plan" expansion counties are: Alameda: San Francisco: Mr.David J.Kears, Ms. Shahnaz Nikpay Chief Executive Officer Chief Executive Officer Alameda Alliance for Health San Farncisco Health Authority 1850 Faiway Drive 825 Van Ness Ave. Suite 602 San Leandro,CA 94577 San Francisco,CA 94109 Tel:(510)895-4500 Fax:(510)483-6038 Tel(415)775-7515 Fax(415)202-7690 Contra Costa: San Joaquin: Mr.Milt Camhi Ms. Leona Butler Chief Executive Officer Chief Executive Officer Contra Costa Health Plan Health Plan of San Joaquin 595 Center Ave. Suite 100 1550 W.Fremont Street Martinez,CA 94553 Stockton,CA 95203-2643 Tel(510)313-6024 Fax(510)313-6002 Tel(209)939-3500 Fax(209)939-3535 Fresno: Santa Clara: Ms.Yolanda Partida Mr.Joseph A.Sidas Assit. Dir.for Ambulatory Care Chief Executive Officer Fresno County Santa Clara Co.Health Authority 445 S.Cedar Avenue 2220 Moorpark Ave.,Room 105 Fresno,CA 93702 San Jose,CA 95128 Tel(209)453-4900 Fax(209)453-3867 Tel(408)885-4040 Fax(408) 885-4050 Kern: Stanislaus: Carroll Sorrell Ms. Beverly M. Finley Chief Executive Officer Managing Director 1600 Norris Road Health Services Agency P.O.Box 81976 1030 Scenic Drive P.O.Box 3271 Bakersfield,CA 93380-1976 Modesto,CA 95353 Tel(805)391-4000 Fax(805)391-4000 Tel(209)558-5600 Fax(209)558-7262 Los Angeles: Tulare: Mr.Anthony D.Rodgers, Mr.Ronald Probasco Chief Executive Officer Chief Executive Officer Los Angeles Local Initiative Medico 633 W.5th Street,27th Floor 1062 South K Street Los Angeles,CA 90071 Tulare,CA 93274 Tel(213)240-8162 Fax(213)482-4513 Tel(209)685-2528 Fax(209)685-2643 Riverside/San Bernardino: Mr.Richard Bruno Chief Executive Officer Inland Empire Health Plan 1250 E.Cooley Drive,Suite 100 Colton,CA 92324 Tel(909)825-7414 Fax(909)825-7944 LATINO ISSUES FORUM 11 ACKNOWLEDGMENTS Publication of this report was made possible, in part,by a grant from the Public Welfare Foundation. In addition special thanks is given to Ruth Brousseau and The San Francisco Foundation for without their support and as- sistance our meeting would not have been possible. In addition, special thanks to Alicia Lara, Ele Hamburger, Luis Arteaga and Zina Markevicius who laboriously edited this report for publication. We are greatful to Julie Matsumoto,Brenda Solorzano and Perfecto Munoz who contributed to the planning and design of this event. Most importantly,we thank the participants who volun- teered their time and talents to make this possible. FOR MORE INFORMATION This report is one of several that will be periodically published by Latino Issues Forum to ensure that the needs of Latino Medi-Cal consumers are not overlooked during the Medi-Cal Managed Care transition. To obtain more information, please contact: Alfredo Gonzalez Health Policy Analyst Latino Issues Forum 785 Market Street, Third Floor San Francisco, CA 94103 Tel 415-284-7226 Fax 415-284-7210 LATINO ISSUES FORUM 12 - jq E, • r LATINO ISSUES FORUM 785 Market Street, Third Floor San Francisco • California • 94103-2003 " 415-284-7220 LATINO IssUEs FORUM (LIF) is a non-profit public policy and advocacy institute dedicated to advancing new and innovative public policy solutions for a better, more equitable and prosperous society. LIF's primary focus is on the broader issues of access to higher education, economic development, health, regional development, and telecommunication issues. LIF also serves as a clearinghouse to assist and provide the news media with accurate information and sources in the Latino community for fair and effective coverage of issues. THE CALIFORNIA PAN-ETHNIC HEALTH NETWORK (CPEHN) 2140 Shattuck Ave., Suite 404 Berkeley • California • 94704 510-704-9576 CPEHN is a statewide network of approximately 50 multicultural health care organizations, including health care providers, community based organizations and policy experts committed to working together to improve health care access to California's minority populations. The mission of CPEHN is to promote changes to health care delivery systems that improve the health status of communities of color. Through a collaborative process, CPEHN monitors, analyzes and informs health care policies, legislation, and business strategies affecting minority populations.