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Book: Handbook of Multicultural Competencies Sage Publications, Thousand Oaks, CA Section IV: Practice Chapter: Multicultural Competencies in Managed Health Care Jean Lau Chin, Ed.D., ABPP CEO Services, Newton, MA Multicultural Competencies and Managed Care 1

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Page 1: Multicultural Competencies and Managed Health Care

Book: Handbook of Multicultural Competencies

Sage Publications, Thousand Oaks, CA

Section IV: Practice

Chapter: Multicultural Competencies in Managed Health Care

Jean Lau Chin, Ed.D., ABPP

CEO Services, Newton, MA

Multicultural Competencies and Managed Care 1

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Multicultural Competencies in Managed Health Care

Jean Lau Chin, Ed.D., ABPP

CEO Services, Newton, MA

The push for multicultural competencies arose out of ethnic and racial awareness during the early 70s in response to the Civil Rights Act of 1964. It made the integration of culture in clinical practice a matter of ethical practice, and expanded cultural awareness and cultural knowledge in clinical practice toward skill-based, culture-centered clinical practice. Most importantly, it moved the discussion of cultural sensitivity to one of skills i.e., the competencies providers must have to work cross-culturally and with diverse racial/ethnic populations. With multicultural competencies, we recognize that cultural considerations influence all levels of the client-provider encounter including the communication process, health care practices and beliefs, treatment efficacy, utilization, cultural histories, and language.

In discussing multicultural competencies in managed health care, it is important, firstly, to use a systems viewpoint, and secondly, to consider the parallel concept of cultural competence as inclusive of system, clinical, and provider competencies. Two questions inform this consideration. What competencies do providers need to work with diverse racial/ethnic groups within managed care contexts? What do managed care organizations need to do to ensure that its system of care and providers are culturally competent? This chapter will distinguish between cultural competence and multicultural competencies. It will address multicultural competencies as a standard of care, and what this means within a managed health care system. In effect, how do we view multicultural competencies as core to quality of care within a system of care.

Cultural Competence vs. Multicultural Competencies

There are some differences between cultural competence and. multicultural competencies that are worthy of note. The former came out of a systems perspective to assess the quality of mental health service delivery systems for children from racial/ethnic minority groups (Cross, et al 19891). The latter arose out an awareness within the professions that psychologists and other mental health professionals need to move beyond monocultural, Eurocentric, and ethnocentric frameworks to provide quality care to persons from diverse and minority racial/ethnic groups (Sue, Bernier, Durran,

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Feinberg, Pedersen, Smith, & Vasquez-Nuttall, 19822; Sue, Arredondo, & McDavis, 19923). Both concepts presume that there are skills necessary for psychologists, clinicians and providers to practice competently with diverse groups as well as those skills necessary to work with specific racial/ethnic groups, that diversity training and cultural competence training are necessary for the acquisition of these competencies, and that such training be ongoing process rather than a one-time workshop.

Evolution of multicultural competencies proceeded to delineate those provider skills and explicit competencies for ethical practice, and professional standards of care. Currently, professional guidelines are being proposed for adoption by the American Psychological Association to influence the practice and training of psychologists. Evolution of cultural competence, on the other hand, has proceeded toward developing performance based indicators to assess and monitor both service delivery systems and providers. Common to both is the emphasis on accountability and standards of care.

Standards of Care

Justification for both multicultural competencies and cultural competence began with moral imperatives for ethical practice, and concerns for social justice and equity. As advocates became increasingly disenchanted with the slowness of change and met resistance to making cultural issues a priority, there has grown a push toward defining multicultural competencies as standards of care, i.e., competencies by which all must abide. With the growing diversity of the U.S. population, advocates for multicultural competencies focus on the ethical and legal risks of psychologists practicing with little knowledge or integration a client’s culture. Advocates for cultural competence, on the other hand, have pushed not only to define provider competencies, but also for regulatory mandates for managed care organizations and service delivery systems, i.e., hospitals, state mental health systems, agencies, to become more culturally competent (Chin, in press)4.

Standards can address quality of care either for providers or for systems. Provider standards include those defined by the profession, i.e., American Psychological Association, its ethical code, or credentialing standards used by managed care organizations or service delivery systems. System standards, on the other hand, include National Committee for Quality Assurance (NCQA) used to govern managed care organizations or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) used to govern service delivery systems.

Standards for Service Delivery Systems

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 5 standards address an organization's level of performance in specific areas, i.e., what organizations are actually doing. JCAHO standards set maximum achievable performance expectations for activities that affect the quality of patient care. The standards detail important functions relating to patient care and the management of health care organizations, framed as performance objectives that are unlikely to change substantially over time. Because the standards aim to improve outcomes, they place little emphasis on how to achieve these objectives. Networks and provider organizations can be flexible in meeting the expectations of the standards, and can identify their own

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priorities and develop performance improvement activities that best meet their unique needs and those of their members. The Joint Commission develops all its standards in consultation with health care experts, providers, measurement experts, purchasers, and consumers. Standards are generally updated every two years and change only to improve clarity or reduce duplication (JCAHO).

During an accreditation survey, JCAHO evaluates a network's performance by using a set of standards that cross eight functional areas:

1. Rights, Responsibilities and Ethics

2. Continuum of Care

3. Education and Communication

4. Health Promotion and Disease Prevention

5. Leadership

6. Management of Human Resources

7. Management of Information

8. Improving Network Performance

JCAHO accreditation has become the gold standard for an organization or network’s standing in the health care market. While its standards address quality of care, there is little or no reference in the standards to cultural competence or multicultural competencies.

Standards for Managed Care Organizations

The National Committee for Quality Assurance (NCQA)6 works with health plans, employers and unions to develop standards that effectively evaluate the medical and quality management systems of managed care organizations. The NCQA review process examines an HMO's performance and commitment to continuous improvement in several important areas:

1. Quality improvement

2. Utilization management

3. Physician credentialing

4. Members' rights and responsibilities

5. Preventive health services

6. Medical records

Specific measures used include: The Health Plan Employer Data and Information Set (HEDIS), a standardized, comprehensive set of indicators used to measure the performance of a health plan, i.e., a report card for managed care plans. HEDIS measures was developed by representatives from consumer groups, employers, health plans, and

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NCQA; the measures address a variety of issues including effectiveness of care, access/availability of care, member satisfaction, health plan stability, use of services and cost of care. However, there are no measures on cultural competence; there is one on access/availability of care, but it does not require MCOs to report this by race/ethnicity of its members.

Provider Standards

Professional licensing standards defined by state statute govern psychologists and their license to practice. In addition, a credentialing process may also be required for reimbursement by MCOs or employment at hospitals and networks. This process involves verifying state licensure, hospital privileges, board certification, and malpractice insurance with primary sources. The licensing exam does require knowledge of social and multicultural bases of behavior, including the role that race, ethnicity, gender, sexual orientation, disability, and their cultural differences play in the psychosocial, political, and economic development of individuals/groups; effects of culture on school motivation.

Most licensing standards do not have criteria for providers to be culturally competent; nor are there definitions of multicultural competencies. Massachusetts is one of the few states that require demonstration of competence on racial/ethnic bases of behavior with a focus on people of color defined as a minimum of three graduate semester hours in courses such as: cross-cultural psychology, psychology and social oppression, racism and psychology.

Consumer Advocacy

With the increased emphasis on a consumer-centric approach and encouraging market forces and consumer satisfaction to drive the system, the Agency for Health Care Research and Quality (AHRQ) began a new initiative in October 1995 that involved building an integrated set of carefully tested and standardized questionnaires and reporting formats that could be used to collect and report meaningful and reliable information about the experiences of consumers enrolled in health plans. This resulted in the development of CAHPS® (Consumer Assessment of Health Plans) as an easy-to-use kit of survey and report tools that provides reliable and valid information to help consumers and purchasers assess and choose among health plans. The kit contains a set of questionnaires to ask consumers about their experience with their health plans, sample formats for reporting results to consumers, and a handbook to help implement the surveys and produce the reports. While not a standard, these consumer satisfaction surveys or report cards are another way to monitor the system of care.

Multicultural Competencies as a Standard of Care

A policy brief summarizes the movement of cultural competence, a concept that developed out of a systems perspective on service delivery systems (Chin, 1999)7. It addresses the question of mandating cultural competence, developing standards, and emphasizing outcomes and indicators as means towards accountability and quality improvement. Multicultural competencies are increasingly emphasizing standards of care, and the competencies needed to ensure high quality services within a system of

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care; Appendix A diagrams these relationships of the competencies needed to ensure a consumer-centric, culturally competent quality system of care. It includes 3 levels of competencies, i.e., systems, clinical, and provider competencies, based on the standards developed the Center for Mental Health Services (SAMHSA, CMHS, 1998)8 for managed care organizations. It also includes who defines, regulates and monitors the standards of the service delivery system, MCO, and providers. We cannot look at multicultural competencies in managed health care without looking at systems issues, and without considering the constraints influencing the development of standards. This raises several controversial issues.

Standards vs. Guidelines

While there is a push for standards among advocates for multicultural competencies, the profession of psychology is increasingly moving away from standards of care as too prescriptive toward guidelines as suggestive in a risk management environment. Guidelines are a set of practices and implicitly recognized principles of conduct that evolve over the history of a profession. They are aspirational in nature and suggestive or recommend specific professional behavior. In contrast, standards of a profession are mandatory and may be accompanied by an enforcement mechanism (American Psychological Association, 1993)9. Advocates for multicultural competencies are finding greater resistance to multicultural competency standards as leaving psychologists liable for lawsuits. In considering risk management issues and contracting with MCOs, providers are often cautioned to avoid contracts that expose providers to a higher standard of care than what is normally required, or standards with which the provider is unfamiliar (US DHHS, SAMHSA, 1998)10.

Standards for Whom? System vs. Provider

A second issue is for whom are these standards intended? Are they generic competencies intended for all providers or are we talking of specialization only for those choosing to practice with diverse populations. Many have argued against making multicultural competence a specialization since it would result in the adverse consequence of limiting the number of providers able and willing to practice cross-culturally while penalizing those who already practice with diverse and racial/ethnic groups.

Many regulations in managed care focus on service delivery systems rather than individual providers. They define what hospitals, agencies, and staff model HMOs must do to monitor the competencies of its providers. There have been different MCO models; e.g., Tufts Health Plan developed its network of providers based on independent practitioners and group practices while Harvard Pilgrim Health Care began with a staff model in which it employed its own network of providers and limited members to choosing someone from within the staff. Provider networks formed from mergers between hospitals such as Massachusetts General Hospital and Brigham and Women Hospital enabling greater leverage to negotiate fees for its network of providers as they command a significant market share. The standards must be specific to the organizational entities in which providers practice.

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As managed care shifts from a staff model and capitated payments toward a network model and fee for service arrangement, MCOs have less control over the providers with whom they contract. Standards for how individual providers practice in networks or group practices now shift from the MCO to the network. As service delivery systems increasingly use Fee-For-Service clinicians who are paid only for the units of service delivered, cost begins to outweigh factors monitoring quality of care.

Performance Based Outcomes

While service delivery systems frequently will include aspirational statements of cultural competence in their goals or mission statements, few have operationalized these into competencies, measurable objectives, or performance indicators (Chin, in press).11 Moreover, one must also influence the payers or managed care organizations reimbursing the services. Collection of race/ethnicity data is typically not required; some will argue that this will result in racial profiling and adverse consequences. Consequently, it has not been possible to hold systems and providers accountable, or to evaluate disparities in outcomes or utilization among racial/ethnic groups.

Absence of a Population Focus

Currently, most regulatory mandates for provider or service delivery systems within managed care do not address cultural competence or multicultural competence. Managed care legislation or performance measures generally consider patients, clients, members in the aggregate as a unitary group. There lacks a multicultural perspective, or a consideration of diverse communities; there has not been a population focus in the development of regulations, standards, or guidelines. Contracts refer to the agreements between provider and service delivery system or provider and MCO. The consumer, client, or community has often been forgotten in the process.

Within a multicultural competency framework, the recognition of unique and diverse needs of clients and community, i.e., a population focus, is critical. Performance measures cannot strive to attain a uniform and normative criterion without attending to differential norms and targets for different communities and racial/ethnic groups. Health disparities and inappropriate utilization will result among minority groups when the system has failed to be culturally competent in serving all segments of a diverse population.

Multicultural Competence in Managed Health Care

Managed care imposed a radical change on the health care system. Driven by the imperative to stem increasing health care costs, managed care seeks to save money by “managing health care utilization and narrowing the choices available to health care consumers. The hardest part of this process was to formulate a set of viable guidelines that will improve the ability of a MCO to meet high quality standards in all populations and that will translated into measures of accountability (Lavizzo-Mourey, R. & Mackenzie, E. R., 1996)12. Use of a culturally competent framework is needed to address how population specific issues of health beliefs and cultural values, disease incidence and prevalence, and treatment efficacy are managed within a managed care environment.

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Economic Imperative

While a social justice perspective and moral imperative has dominated the push for multicultural competencies and cultural competence, many argue that an economic perspective will prevail as the U.S. population becomes increasingly diverse. As managed care increasingly dominates the market, many argue that market forces of changing population demographics will drive providers and systems to become culturally competent, and to develop multicultural competencies; consumers will demand the quality of care that is responsive to specific cultural needs.

At the same time, many managed care strategies raise concerns because of potential bias against racial/ethnic groups. Risk selection, i.e., selecting against the possibility of loss associated with a given population, might have adverse consequences for racial/ethnic groups where the need for interpreter services and case management services may be viewed as increasing risk.

Consumer Choice

The question of choice has been pivotal to the discussion in managed care. Critics of managed care have argued that managed care narrows the choice of providers and level of benefits such that the service delivery systems will be less competent and responsive to the diverse needs of racial/ethnic minority groups. From a multicultural perspective, the ability of clients to use race/ethnicity and cultural competence as criteria in their choice of therapists is crucial. Yet, most MCOs have not structured their provider directories to give consumers this choice in selecting a therapist by race/ethnicity. Choice is further reduced because provider networks are not always balanced to include providers from diverse racial/ethnic backgrounds mirroring the client population.

Costs vs. Quality

Managed care came about to achieve cost containment goals through managing care. Utilization review is intended to limit care to that which is medically necessary. Unfortunately, this emphasis on costs has potential adverse consequences on racial/ethnic groups. Interpretation of medical necessity criteria by reviewers who may not be culturally competent will result in a bias against racial/ethnic groups. The failure to collect or track utilization data by race/ethnicity further limits the ability of MCOs to evaluate disparities in utilization. Underutilization commonly found among racial/ethnic groups unable to access the system pit multicultural competence objectives against managed care objectives to reduce utilization or length of stays. Similarly, higher costs associated with delivering services to non-English speaking populations are often not recognized or accept within managed care. Reimbursement rates do not factor in interpreter costs; no incentives are given to bilingual providers in their reimbursement rates.

Payors and the consumer public are demanding that providers and service delivery systems be accountable for both quality and cost of services. Managed care has made a shift toward quality of care; this has resulted in an emphasis on performance outcomes and consumer satisfaction. At the same time, performance indicators specific to multicultural competencies tend to be limited to language access. Consumer

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satisfaction surveys rarely are conducted in languages other than English, or sample access, availability, and appropriateness of services differentially for diverse racial/ethnic groups.

Provider Contracts

MCOs use provider contracts to monitor and regulate care. Contracts between MCOs and providers often hold providers accountable to reasonable and commonly accepted standards of care in providing services to its members; they hold MCOs accountable for timely reimbursement when contracted services are delivered in the manner specified in the contract. From a multicultural perspective, exclusivity clauses limiting providers from participating in other networks have reduced consumer choice or limited the diversity of providers within a network. At the same time, as long as multicultural competencies are not standards of care, providers may object that they are being held to a higher standard of care than commonly accepted practice.

Medicaid

State contracts to MCOs, vendors or counties for Medicaid patients frequently include provisions for cultural competence. Medicaid is part of the continuum of care for many clients in the public mental health sector. The Medicaid-Balanced Budget Act of 1997 requires that states and managed care entities provide information and instructional materials to enrollees “in a manner and form which may be easily understood”. Health Care Financing Administration (HCFA) regulations of 1998 require states “to establish a methodology for determining the prevalent language or languages in a geographic area”, and to ensure that materials are available in those languages. Cultural groups that represent at least 5% of the Medicaid population in a particular area is recommended as the criterion. Cultural competency requires awareness of the culture of the population being serviced; network should include an adequate number of providers, commensurate with the population enrolled, who are aware of the values, beliefs, customs and parenting styles of the community.

Approximately 48% of all Medicaid beneficiaries in the United States are now enrolled in a managed care program. In a survey of cultural competence in Medicaid Managed Care Purchasing completed at Georgetown, cultural competence is a general requirement on Medicaid Purchasing in 29 of 50 states. Translated literature/interpreter assistance is reported as available in 35 of 50 states. On the other hand, only 9 of 50 states require cultural competency training for contractors and employees; only 12 states require language proficient providers; only 8 states have administration standards (Rosenblum, 1998).13

Managed Care Initiatives to promote multicultural competence

There have been managed care initiatives to promote multicultural competence; however, this has generally been limited to language accessibility to improve access for persons of limited English proficiency through translation or interpreter services. There is generally little emphasis on bilingual/bicultural providers or multicultural competencies of providers. Language translation of brochures and other educational materials, if available, are often available only in Spanish. Translations for Asian and

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other languages are often deferred to the future because of their costs and complexity. Sometimes, this is handled by providing a multilingual announcement asking members to get the notice translated because it is important. Several model initiatives where definitions are clear, measurable, with benchmarks that are responsive to racial/ethnic minorities are described below.

California’s County Cultural Competence Plans

California has an Annual Review Protocol for Consolidated Specialty Mental Health Services with implementation plan requirements, and criteria for compliance; a number of the criteria require cultural and linguistic competence. All counties are required have an approved Cultural Competence Plan (CCR, title 9, Chapter 11, Section 1810.410; DMH Information Notice No: 97-14). Plan elements include: vision and mission, policies, data, measures/analysis of data to identify targets and benchmarks, training and credentialing.

Thresholds are set for when linguistic services must be provided which state that: The contractor will provide linguistic services to a population group of mandatory Medi-Cal enrollees residing in the proposed Service Area who indicate their primary language as other than English and who meet a numeric threshold of 3000, or a population group of mandatory Medi-Cal eligibles residing in the proposed service area who indicate their primary language as other than English and who meet the concentration standards of 1000 in a single zip code or 1500 in two contiguous zip codes. Thresholds are established by counties for the languages meeting criteria which require linguistically appropriate services and translated materials. Critics have argued that this puts the onus of responsibility on enrollees; the criterion is the number of enrollees or residents in the service area.

California’s Medicaid contracting offered counties a choice to take a carve-out which could be either public managed care, i.e., or privatized. Counties all submitted implementation plans to the state. Coye & Alvarez (1999) reviewed Medicaid Managed Care and Cultural Diversity in California14. California has detailed requirements in health plan contracting to ensure effective services for diverse Medicaid population using a Cultural Index of Accessibility to Care; this is a system for rating culturally competent service requirements of HMOs when contracting for services. It includes two threshold and concentration standards for the provision of services to non-English speaking beneficiaries/populations, i.e., linguistic services must be provided in areas that meet either the threshold standard of 3000 beneficiaries per language group or they must otherwise meet concentration standard, defined as of 1000 beneficiaries in a single ZIP code or 1500 in two contiguous ZIP codes.

California contracts with one local initiative and one commercial managed care plan in each county to serve Medi-Cal beneficiaries to offer choice and competition. There are 8 core contract provisions required by the state to ensure cultural competency, five of which specifically address interpretation and translation services (Coye & Alvarez, 1999).15 These include:

Provide LEP with 24-hour access to linguistic interpreter services over phone or interpreters on site

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Provide linguistic services including: information on plan coverage, health education programs, provider orientation and training, appointment scheduling, medical advice phone lines, membership assistance, satisfaction surveys

Assess and report the linguistic capacity of interpreters employed or contracted by the plan

Establish community advisory committee to assist in developing and monitoring culturally competent services

Conduct an internal needs assessment and formulate a plan to meet the cultural and linguistic service needs of enrollees within 12 and 18 months respectively of contracting with the state

Monitor the provision of providers’ linguistic services

Develop and implement standards and performance requirements for the provision of linguistic services and monitor the performance of individuals offering such services

Implement an interpreter coordination system and set standards for coordinating appointment scheduling with interpreter services.

This has had a favorable effect in stimulating the development of culturally competent initiatives by MCOs in California; the Alameda Alliance for Health Plan, for example, pays directly for interpreter services as a reimbursable service at about $70 per encounter. In addition, they are considering a financial incentive for physicians of about $15 per encounter to compensate for the additional time required in interpreter supported services (Quan, 2001).16

Language Thresholds in Contracting

Other states have used different definitions for these threshold levels compared to California. Missouri , e.g., uses a threshold of 200 or 5% of program membership whichever is less for interpreter services. Threshold criteria clearly define the point at which MCOs and service delivery systems must provide certain services such as bilingual providers and interpreter support.

Massachusetts procurement language for state contracts includes a language threshold requirement to evaluate cultural competency of bidders: If a population reaches a threshold of 15%, then the vendor will be asked by the area office to respond to clinical vignettes related to that population in their applications. This will have the effect of developing clinically relevant criteria targeting racial/ethnic populations; evaluation tools are currently being developed. This threshold is probably too high, and would exclude too many distinct racial/ethnic groups.

Massachusetts contract language for managed care organizations ensures that multilingual providers are available for the most commonly used languages in a particular service area (as defined by the state). The MCO shall ensure non-English speaking enrollees a choice of at least 2 multilingual primary care providers. The compliance measure requires the MCO to: Provide an analysis of where enrollees who require multi-

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lingual services reside within the MCO’s service area and provide a list of all multi-lingual primary care providers by zip code in the area. It is unambiguous, offers choice, and also asks contractor to document where it cannot perform.

Washington’s Parity Initiative

Washington has a Parity Initiative used to compare services to ethnic minority populations against the population residing in the county. Parity is a contract requirement used for accountability of services to ethnic minority populations since 1989. It is a method to see who’s enrolled and being serving, comparing the general population demographics to the service population demographics based on 15 racial/ethnic categories. Differences can exist if it is demonstrated that this is appropriate to the population. Some flexibility is permitted; a county could build in a range if numbers are small, or use the smaller of a number and %, e.g., 500 or 2% at the county level, or 1000 or 5% at the Regional Service Network level. These requirements are not targets, but descriptive.

Originally, the concept of parity used percentages as contracting benchmarks (e.g., if an RSN was at 50% of parity, they needed to be at 75% in two years, 87.5% in 4 years, and 100% in 6 years). Currently, the concept of benchmark performance used states that payment to a contractor will be withheld in the amount of the lesser of $2500 or 1% of the monthly capitated payment for each biennial quarter the Contractor fails to meet the minimum compliance levels…, and will be released if the minimum compliance is met (Balderama, 2000)17. The intent of such parity initiatives is to ensure that racial/ethnic groups will served in the system; it does not ensure quality.

Cultural Competence Self-Assessment Surveys

Self-Assessment Surveys have been developed in Oregon (Mason, 1995)18, New York (Chambers, 1998)19 and New Jersey (Weiss & Minsky, 1996)20 to assess cultural competence of agencies, and are used as monitoring and compliance tools for site visits. In New Jersey, the tool is sent to agencies before the Bureau of Licensing and Inspections go out for a site visit. Items on cultural competence are also included for the Patient Services Compliance Unit when they monitor compliance. It is also used informally at staff meetings for self-assessment.

While these tools have the weight of audit tools, they are voluntary in nature, and are recommended as self-assessment tools rather than mandatory standards. Statewide training of mental health staff (hospitals and agencies) often accompanies the dissemination of the tool to promote cultural competence skills training.

Cultural Competence Standards

The US Department of Health and Human Services, Office for Minority Health developed national standards for Assuring Culturally Competent and Linguistically Appropriate Services in Health Care, (i.e., CLAS Standards) in 2000 (DHHS, OMH, 2000).21 These include 14 standards that define culturally competent care, language access, organization supports, implementation guidelines, relationship between the

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standards and existing laws, diverse and culturally competent staff, data collection, and information dissemination.

The Center for Mental Health Services developed Cultural Competence Standards for managed behavioral health services provided to racial/ethnic populations (SAMHSA, CMHS, 1998)22. These include overall System and Clinical Competencies, implementation guidelines, recommended performance indicators and outcomes or benchmarks, and Provider Competencies.

The Association for Multicultural Counseling and Development operationalized multicultural counseling competencies for providers using dimensions of personal identity and world views (Arredondo, Toporek, Brown, Jones, Locke, Sanchez, & Stadler, 1996).23

While these standards describe specific benchmarks and indicators for assessing and monitoring the cultural competence of systems and providers, none of these standards are mandated by legislation.

Cultural Competence Legislation

Several legislative mandates support the implementation of cultural competence initiatives. Title VI of the 1964 Civil Rights Act prohibits entities that receive federal financial assistance from engaging in practices that have the effect of discriminating on the basis of race or national origin. State Human Rights Laws prohibit forms of discriminatory practices that impair access by specific, identified subclasses of individuals, i.e., from racial and ethnic minority groups, and that contractors have an affirmative obligation to ensure that services are accessible and “culturally competent”. The Disadvantaged Minority Health Improvement Act of 1990 (PL 101-527) set the stage for cultural competence in health care systems with its intent to improve the health of racial/ethnic minority groups.

Several states have cultural competency standards. These include: Michigan, New York, California, Washington which are written into statute, and result in criteria that states and counties, or MCOs must implement in the form of cultural competency plans. A study out of Georgetown summarizes contracting specifications used by different states in contracting with counties or vendors for the delivery of mental health services (Rosenblum & Teitelbaum, 1999).24

The Washington parity initiative is analogous to affirmative action while the California cultural competence initiative is more analogous to standards; both are set in statute. In Massachusetts, a bill has been filed to require that MCOs have a culturally competent provider network or allow their members to go out of network to access culturally competent providers.

System Competencies

System standards domains include competencies of the system to ensure that services are accessible, available, appropriate, and adequate for all segments of the population. Components are fully described in the CMHS document.

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1. Cultural Competence Planning – Are there population assessments to identify demographic characteristics and user profiles by race/ethnicity to ensure that the needs of diverse groups are addressed? Does the needs assessment formulate a plan for meeting the cultural and linguistic needs of members using an incremental approach with concrete timelines?

2. Governance – Who is at the table when deciding on policies and protocols governing the system of care and its reimbursement? Are consumer voices and diverse voices of racial/ethnic groups represented in meaningful roles?

3. Benefit Design – Is there equitable access and comparability of benefits across populations? Is there flexibility in the plan benefits to allow for culturally specific interventions such as alternative medicine?

4. Prevention, Education, and Outreach – Are plan materials and health education materials linguistically and culturally appropriate?

5. Quality Monitoring and Improvement – What indicators, benchmarks, and targets are there that are relevant to diverse racial/ethnic groups and ensures access, availability, appropriateness, and adequacy of services? Is there a plan and the ability to monitor the MCO for its cultural competence?

6. Utilization review – Utilization review, prior authorization, and precertifications are all intended to limit coverage to those services that are medically necessary. Do reviewers have training in cultural competence to ensure unbiased reviews?

7. Decision support and Management Information Systems – Do data sources collect race/ethnicity data at all levels of care? Are racial/ethnic groups disaggregated? Can the MCO generate utilization and outcome reports by race/ethnicity with relevant indicators?

8. Human Resource Development. – Are staffing patterns diverse and mirror the client population? Can the MCO identify providers by race/ethnicity to offer consumer choice? Is staff training and development in the area of cultural competence and racial/ethnic mental health offered or required for all staff?

Clinical Competencies

Clinical standards domains include competencies of the services that are delivered to ensure that they are accessible, available, appropriate, and adequate for all segments of the population. Components are described fully in the CMHS document.

1. Access and Service Authorization – Is there linguistic access for all groups including both over the phone and on site? Are access criteria evaluated based on spiritual, social functioning, family and community supports as well as medical and mental health?

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2. Triage and Assessment – Do triage and assessment criteria take in individual, family, cultural, and community strengths?

3. Care Planning – Are care plans compatible with cultural frameworks and community environments of consumers and family members?

4. Treatment Plan – Are treatment plans relevant to culture and life experiences? Do they have input from consumer and family members?

1 Cross, T.L., Bazron, B.J., Dennis, K.W., & Isaacs, M.R. (1989). Toward a Culturally Competent System of Care. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center.

2 Sue, D. W., Bernier, J., Durran, M., Feinberg, L., Pedersen, P., Smith, E., & Vasquez-Nuttall, E. (1982). Position paper: Cross-cultural counseling competencies. The Counseling Psychologist, 10, 45-52.

3 Sue, D.W., Arredondo, P., & McDavis, R. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20(6), 64-88.

4 Chin, J. L. (in press) Assessment of Cultural Competence in Mental Health systems of Care for Asian Americans. In Kurasaki, K. S., Okazaki, S., & Sue, S. (Eds) Asian American Mental Health: Assessment Theories and Methods. The Netherlands: Kluwer Academic Publishers.

5 JACHO website: http://www.jcaho.org/standards_frm.html

6 NCQA website: www.ncqa.org

7 Chin, J. L. (1999). Cultural Competence and Health Care in Massachusetts: Where are we? Where should we be? Issue Brief No. 5. Waltham, MA: The Massachusetts Health Policy Forum.

8 Substance Abuse, Mental Health Services Administration, Center for Mental Health Services, Center for Mental Health Services, The Western Interstate Commission for Higher Education (1998). Cultural Competence Standards in Managed Care, Mental Health Services for Four Underserved/Underrepresented Racial/Ethnic groups. Rockville, MD: SAMHSA, CMHS.

9 American Psychological Association (1993) Legal Risk Management. Washington, DC: Author.

10 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (1998). Volume Nine: A guide for providers of mental health and addictive disorder services in managed care contracting. DHHS Publication No. 98-3242. p. 16.

11 Chin, J. L. (in press) Assessment of Cultural Competence in Mental Health Systems of Care for Asian Americans. In Kurasaki, K. S., Okazaki, S., & Sue, S. (Eds) Asian American Mental Health: Assessment Theories and Methods. The Netherlands: Kluwer Academic Publishers.

12 Lavizzo-Mourey, R., & Mackenzie, E. R. (1996). Cultural Competence: Essential Measurements of Quality for Managed Care Organizations. The Annals of Internal Medicine, Volume 124(10), 919-921.

13 Rosenblum, S., (1998). Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts (2d Ed.). The George Washington University Medical Center, School of Public Health and Human Services, Center for Health Policy Research, Washington, DC.

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5. Treatment Services –Is the full array of services available, and appropriate to the consumer’s needs?

6. Discharge planning – Does discharge planning involve the consumer and family? Is it done within a culturally competent framework and communication style congruent with the consumer’s values?

7. Case Management – Are case management services consumer and family driven? Do they address specific and diverse need for consumers who are uninsured, having different cultural perspectives, or lacking in familiarity with the system of care?

8. Communication Styles and Cross-cultural Linguistic and Communication Support – Is linguistic access and cross-cultural communication supports available are all points of entry and throughout the system?

14 Coye, M., & Alvarez, D. (1999). Medicaid Managed Care and Cultural Diversity in California. CA: The Lewin Group. www.cmwf.org/programs/minority/coye_culturaldiversity_311.asp

15 Coye, M. & Alvarez, D. (1999) Medicaid Managed Care and Cultural Diversity in California. CA: The Lewin Group. www.cmwf.org/programs/minority/coye_culturaldiversity_311.asp

16 Quan, K., Chief Financial Officer and General Counsel, Alameda Alliance for Health. (May 2001), Personal communication.

17 Balderama, H., Washington Department of Mental Health. (2000) Personal communication.

18 Mason, J. (1995) The cultural competence self-assessment questionnaire: A manual for users. Portland, OR: Portland Research and Training Center.

19 Chambers, E. D. (1998). Cultural Competence Performance Measures for Managed Behavioral Healthcare Programs. NY: New York State Office of Mental Health, The Research Foundation of New York State.

20 Weiss, C. I & Minsky, S. (1996). Self-Assessment Survey Tool. Trenton, NJ: New Jersey Division of Mental Health Services, Multicultural Advisory Committee.

21Department Of Health And Human Services, Office of Minority Health. (2000) National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care. URL: http://www.omhrc.gov/clas/frclas2.htm

22 Substance Abuse, Mental Health Services Administration, Center for Mental Health Services. (1998) Cultural Competence Standards in managed care, mental health services for four underserved/underrepresented racial/ethnic groups. Rockville, MD: SAMHSA, CMHS.

23 Arredondo, P., Toporek, R., Brown, S., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996) Operationalization of the Multicultural Counseling Competencies. AMCD: The dawn of a new century; Association for Multicultural Counseling and Development, A Division of the American Counseling Association.

24 Rosenblum, S. & Teitelbaum, J. (1999) Cultural Competence in Medicaid Managed Care Purchasing: General and Behavioral Services for Persons with Mental and Addictions-Related Illnesses and Disorders. http://www.samhsa.gov/mc/managed%20care%20contracting/issubr4/Issue_Brief4.htm

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9. Self-Help – Is self-help part of the continuum of care? How does the plan address different strategies and needs of different racial/ethnic communities?

Provider Competencies

Provider Competency domains include competencies of the provider and the skills they bring to the clinical encounter. 3 documents have attempted to define these skills specifically, the Center for Mental Health Services document, the Association for Multicultural Counseling and Development, and proposed guidelines currently under review through the American Psychological Association.

1. Knowledge, understanding, skills, and attitudes – Providers must understand the cultural backgrounds of the consumers with whom they work, its implications for clinical issues, and have developed the treatment strategies that are effective and relevant for working cross-culturally and with diverse racial/ethnic groups. These include differences in symptom expression, communication styles, health beliefs and practices, psychosocial stressors and histories, and different pharmacological effects.

2. Training – Minimal baseline training for providers to be culturally competent in preparation for licensure and credentialing, and ongoing training as a continuing process is essential.

While professional associations such as the American Psychological Association has moved away from professional standards toward guidelines because of risk management concerns, advocates for multicultural competencies are moving toward professional standards to hold individuals and systems accountable. While many embrace the concept of multicultural competence, many find the definition of competencies ambiguous, or limited to cultural knowledge. Others are concerned that this is restrictive in advocating for concordance between client and provider based solely on race/ethnicity.

Definitions of provider competencies are only now being defined to include the above dimensions. Massachusetts is one of the few states to have a training requirement of 3 hours for professional licensure on racial/ethnic bases of behavior.

California Policy on Workforce Diversity

Los Angeles county (1995)25 has a model Policy on Diversity for its workforce addressing provider competencies on a systems level. The objective is to create a high performing, productive organization and an inclusive workplace environment in which each person is valued for his/her unique gifts and talents; to capitalize on the innovation inherent in diverse work groups; and to assure that each person is valued based on individual characteristics rather than on stereotypes or assumptions.

The policy emphasizes workforce diversity and creating a nurturing environment. Departments are expected to develop opportunities, create policies to promote an open,

25 County of Los Angeles Policy on Diversity. Adopted by Board of Supervisors, December 1995.

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flexible, responsive and responsible work environment; monitor affirmative action compliance, consider bonus pay for bilingual staff, promote diversity in recruitment, hiring, and training practices. This is reflected in the mission, vision, and strategic plan.

According to the goals of its workforce training, there is an emphasis on managing diversity viewed as achieving full use of human resources (including white males), which is differentiated from affirmative action, and valuing differences viewed as achieving representation, and promoting quality interpersonal relationships respectively. Training is conducted regularly, and all employees are required to attend diversity trainings. A bilingual bonus is offered to staff and included in policy with eligibility criteria and measures of proficiency.

Washington’s Initiative on Culturally Competent Providers

Washington defines culturally competent providers under its parity initiative. There is a contract requirement for agencies to have ethnic minority specialists, i.e., they must have 100 hours of specialty training in cultural competence; supervised for 2 years post-master, to ensure that the treatment plan must be defined with relationship to the client’s culture. The state has a 100 training program for mental health specialists, but this is no longer offered. The initiative is not tied to professional licensure but to agency licensure.

The standards for Mental Health Specialists are specific with 3 different levels, i.e., direct service provider, supervisor, and consultant with indicators to monitor compliance with these standards. Unfortunately, monitoring mechanisms for these standards remain weak. Mainstream providers often will attempt to sidetrack these standards using cost as an excuse not to do it. Currently, these regulations are poorly monitored other than through self-report. For example, agencies providing services to racial/ethnic minorities by non-specialists need to call in a consultant; however, they will only do it for an upcoming audit. Then if the consultant does not give them the report that they want, they will not call him/her back. Some mainstream agencies do not have ethnic minority staff or supervisors. To be in compliance, they may have 4 people walk into a room, and expect an outside consultant to evaluate all of them in an hour. Others will use providers qualified as a specialist signing off for clients from different racial/ethnic groups with whom they have had no experience (Focus group participant, 2001).26

Conclusions

There is a window of opportunity to promote multicultural competencies as a standard of care within managed care. Changes in managed care have led to new organizational entities, i.e., integrated service networks, giving greater leverage to service delivery systems. There is a shift in emphasis toward quality of care, performance indicators, and accountability. There is a growing disenchantment with managed care as a failed experiment to manage costs as health care premiums continue to soar.

Changing population demographics with racial/ethnic groups soon to become the majority should make both the public and the system of care re-consider consumer

26 Focus group participant (2001) Comments held January 2001 in Seattle, Washington.

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choice, economic imperatives, and accountability to prioritize cultural competence and multicultural competencies as a standard of care. Multicultural competencies have been operationalized for a managed care environment to address system, clinical and provider competencies. These competencies need to be clearly defined, measurable, with monitoring mechanisms defined by indicators, benchmarks, and timelines.

MCOs, service delivery systems, and providers have yet to implement these competencies as a standard of care. Referring to the diagram in Appendix A, this would require advocacy from consumer and professional groups, legislative change, integrated into regulations, accreditation standards, and professional licensure. Several considerations are offered to move the system toward cultural competence and providers toward multicultural competencies.

Maintain a Population Focus

Although cultural competence is increasingly included in mission statements and goals of organizations and MCOs, operationalization of these competencies within managed care has yet to occur. MCOs and service delivery systems often do not maintain a population focus as if ignoring racial/ethnic differences is unbiased and equitable.

1. Population Demographics: MCOs should define the racial/ethnic groups in their target area, and provide data on the population distribution by racial/ethnicity for planning and resource allocation.

2. Changing demographics: When specific groups in the member population has shown rapid growth by more than 10%, MCOs should demonstrate what they have done to ensure that services are appropriate and adequate to their needs. Population/cultural specific indicators should be developed when a rapid growth in the population is reported.

3. Planning: Needs assessments should include racial/ethnic groups who meet a criterion of 1500 or 3% in the member population.

4. Governance committees should mirror the racial/ethnic demographics of the member population.

Collect Race/Ethnicity Data

For managed care, there is often a disincentive to collect data by race/ethnicity since it can document managed care enrollment biases if under-service or utilization disparities exist.

1. A federal and common standard for the collection of race/ethnicity data with disaggregation of the 5 major race/ethnic groups using Census 2000 categories should be set, and set a timeline for implementation.

2. Representation of racial/ethnic groups on consumer satisfactions surveys and needs assessments should be ensured. Where disaggregation results in numbers less than 50, there should be oversampling and secondary

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analysis to enable meaningful analysis of trends and results for specific racial/ethnic groups.

3. Conduct consumer satisfaction surveys in the client’s primary language, and include non-English speaking groups to the extent that they exist in the client population.

Cultural Competence Peformance Indicators

With the growing emphasis on performance based contracting and indicators for quality assurance, cultural competence indicators need to be included in quality assurance monitoring of MCOs and service delivery systems.

1. Utilization patterns by race/ethnicity should be reported to answer how ethnic minorities are represented in covered vs. uninsured groups, if there are differentials in referrals, types of intervention, etc.

2. Disparities in utilization by service type or in penetration rates among different racial/ethnic groups to the extent that they exist within the target area should be identified with a plan for eliminating the disparity.

3. Performance indicators targeting cultural/linguistic needs of specific racial/ethnic groups should be identified.

Promoting Workforce Development

1. Provider Networks should be diverse and mirror the client population. A matrix of providers by geographic location, race/ethnicity, language, and expertise should be developed to identify the availability of culturally specific resources. These should be identified in a separate directory so as not to bias consumers in limiting racial/ethnic provider to racial/ethnic clients.

2. Credentialling should identify the multicultural competencies providers should possess and the curriculum modules for training providers to include: the influence of culture in clinical practice, cross-cultural communication skills, culturally competent interviewing skills, as well as knowledge of clients’ cultures.

3. Provider contracting - MCOs can redesign their contracts with providers to expand cultural competence objectives, and target racial/ethnic needs. They should expand provider networks and contracted vendors to include racial/ethnic providers who are culturally competent.

4. MCOs can require cultural competency plans from service delivery systems with whom they contract, and have sufficient enforcement mechanisms and incentives to ensure their success.

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Model of Multicultural Competencies

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Consumer-Centric System of Care

PayerMCOState

Service Delivery System

Hospitals, Agencies

Provider

System CompetenciesState and federal statute

Regulations and StandardsPolicies

Clinical CompetenciesState and federal statute

Regulations and StandardsPolicies

JCAHOAccreditation

LicensingCredentialling

Provider CompetenciesProfessional GuidelinesProfessional Standards

Ethics

NCQAAccreditation

MonitoringQuality Assurance

AuditsSite Visits

Self-Assessment

AdvocacyProfessionalConsumer

Community

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Glossary

APA – American Psychological AssociationAHRQ – Agency for Health Care Research and QualityCAHPS – Consumer Assessment of Health PlansCLAS Standards – Cultural and Linguistically Appropriate Services Standards CMHS – Center for Mental Health ServicesDHHS – Department of Health and Human ServicesHCFA – Health Care Financing AdministrationHEDIS – Health Plan Employer Data and Information SetJCAHO – Joint Commission on Accreditation of Healthcare OrganizationsMCO – Managed care organizationsNCQA – National Committee for Quality AssurancePL 101-527 – Public Law 101-527RSN – Regional Service NetworkSAMHSA – Substance Abuse, Mental Health Services Administration

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ReferencesAmerican Psychological Association (1993) Legal Risk Management. Washington, DC: Author.

Arredondo, P., Toporek, R., Brown, S., Jones, J., Locke, D. C., Sanchez, J., & Stadler, H. (1996) Operationalization of the Multicultural Counseling Competencies. AMCD: The dawn of a new century; Association for Multicultural Counseling and Development, A Division of the American Counseling Association.

Balderama, H., Washington Department of Mental Health. (2000) Personal communication.

Chambers, E. D. (1998). Cultural Competence Performance Measures for Managed Behavioral Healthcare Programs. NY: New York State Office of Mental Health, The Research Foundation of New York State.

Chin, J. L. (1999). Cultural Competence and Health Care in Massachusetts: Where are we? Where should we be? Issue Brief No. 5. Waltham, MA: The Massachusetts Health Policy Forum.

Chin, J. L. (in press) Assessment of Cultural Competence in Mental Health Systems of Care for Asian Americans. In Kurasaki, K. S., Okazaki, S., & Sue, S. (Eds) Asian American Mental Health: Assessment Theories and Methods. The Netherlands: Kluwer Academic Publishers.

County of Los Angeles Policy on Diversity. Adopted by Board of Supervisors, December 1995.

Coye, M., & Alvarez, D. (1999). Medicaid Managed Care and Cultural Diversity in California. CA: The Lewin Group. www.cmwf.org/programs/minority/coye_culturaldiversity_311.asp

Cross, T.L., Bazron, B.J., Dennis, K.W., & Isaacs, M.R. (1989). Toward a Culturally Competent System of Care. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center.

Department Of Health And Human Services, Office of Minority Health. (2000) National Standards on Culturally and Linguistically Appropriate Services (CLAS) in Health Care. URL: http://www.omhrc.gov/clas/frclas2.htm

Focus group comments held January 2001 in Seattle, Washington.

Joint Commission on Accreditation of Healthcare Organizations website: http://www.jcaho.org/standards_frm.html

Lavizzo-Mourey, R., & Mackenzie, E. R. (1996). Cultural Competence: Essential Measurements of Quality for Managed Care Organizations. The Annals of Internal Medicine, Volume 124(10), 919-921.

Mason, J. (1995) The cultural competence self-assessment questionnaire: A manual for users. Portland, OR: Portland Research and Training Center.

National Committee for Quality Assurance website: www.ncqa.org

Quan, K., Chief Financial Officer and General Counsel, Alameda Alliance for Health. (May 2001), Personal communication.

Rosenblum, S. & Teitelbaum, J. (1999) Cultural Competence in Medicaid Managed Care Purchasing: General and Behavioral Services for Persons with Mental and Addictions-Related Illnesses and Disorders. http://www.samhsa.gov/mc/managed%20care%20contracting/issubr4/Issue_Brief4.htm

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Rosenblum, S., (1998). Negotiating the New Health System: A Nationwide Study of Medicaid Managed Care Contracts (2d Ed.). The George Washington University Medical Center, School of Public Health and Human Services, Center for Health Policy Research, Washington, DC.

Substance Abuse, Mental Health Services Administration, Center for Mental Health Services, Center for Mental Health Services, The Western Interstate Commission for Higher Education (1998). Cultural Competence Standards in Managed Care, Mental Health Services for Four Underserved/Underrepresented Racial/Ethnic groups. Rockville, MD: SAMHSA, CMHS.

Sue, D. W., Bernier, J., Durran, M., Feinberg, L., Pedersen, P., Smith, E., & Vasquez-Nuttall, E. (1982). Position paper: Cross-cultural counseling competencies. The Counseling Psychologist, 10, 45-52.

Sue, D.W., Arredondo, P., & McDavis, R. (1992). Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling and Development, 20(6), 64-88.

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (1998). Volume Nine: A guide for providers of mental health and addictive disorder services in managed care contracting. DHHS Publication No. 98-3242. p. 16.

Weiss, C. I & Minsky, S. (1996). Self-Assessment Survey Tool. Trenton, NJ: New Jersey Division of Mental Health Services, Multicultural Advisory Committee.

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Endnote References

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