PROVIDENCE, R.I. -- Racial disparities are widespread in Medicare managed care plans – and persist even within high-performing plans – with significantly fewer blacks meeting important benchmarks for controlled cholesterol, blood pressure and blood sugar levels, according to new research from Brown Medical School and Harvard Medical School.
While other studies have measured racial disparities in the Medicare program, this study is the first to examine disparities within health plans using a nationally representative sample.
The findings, published in JAMA, are both strong and surprising: Even high-quality managed care plans produce different health outcomes for patients based on race. For each of four clinical measures – each a critical gauge of health care quality for people with hypertension, diabetes and heart disease – more than 70 percent of the gap between blacks and whites was due to different outcomes for enrollees within the same health plan.
"Racial disparity is a universal problem in the Medicare managed care system," said Amal Trivedi, M.D., lead author of the JAMA study and assistant professor in the Department of Community Health at Brown Medical School. "It's a problem virtually all plans own – not just low-performing ones."
"Our study suggests that the federal Medicare program should work closely with health plans to develop routine reports of racial disparities in quality of care," said John Ayanian, M.D., an associate professor of health care policy and of medicine at Harvard Medical School who served as senior scientist on the project. "These reports can then be used by health plans and doctors to improve treatments and health outcomes of black patients with hypertension, heart disease and diabetes."
In a landmark 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine defined quality health care by six measures. One was equity. But what is the relationship between quality and equity? Do blacks really fare better in high-performing health plans? Trivedi, whose research focuses on disparities in medical care, set out to answer the question.
Trivedi studied the Medicare managed care program, which provides medical care to more than 6 million Americans 65 and older.
Trivedi and his team chose to study the program due to the data: Medicare managed care plans are required by federal law to report on the quality of care they provide – data that is publicly available and audited by the federal Centers for Medicare and Medicaid Services. Since 1997, plans have annually reported their performance on several quality measures, developed by the National Committee for Quality Assurance, that focus on key clinical indicators, such as the number of patients who receive cancer screenings or medications for heart disease.
For his study, Trivedi focused on four of these measures. They include blood pressure for enrollees with hypertension, low-density lipoprotein cholesterol (LDL-C) control for enrollees who recently had a heart attack or heart bypass surgery, and blood sugar and LDL-C control for enrollees with diabetes. In the study, Trivedi and his team analyzed information gathered between 2002 and 2004 from a total of 334,204 black and white enrollees.
These patients were enrolled in a nationally representative sample of 151 Medicare managed care health plans that include all plan types, from health maintenance organizations to preferred provider organizations. The plans are private and non-profit, large and small, urban and rural. In total, they cover 38 states.
Using performance measures pulled from the Health Plan Employer and Data Information Set, the team calculated the performance rates for each quality measure stratified by race. The team then assigned a rating – above average, average or below average – to each plan and compared outcomes between and within plans.
The results were unequivocal: Across the board, significantly fewer blacks had their cholesterol, blood sugar and blood pressure under control.
Clinical performance for blacks was 7 percentage points lower for blood pressure control, 8 percentage points lower for blood sugar control, and 9 and 14 percentage points lower for LDL-C control for diabetics and patients with heart disease, respectively. That racial gap persisted, even after controlling for factors that might explain the differences in health outcomes, such as the age, education and income of the enrollee and the location and size of the health plan.
Moreover, the results showed that, for each measure, more than 70 percent of the racial disparity was due to different outcomes for blacks and whites enrolled in the same health plan. These disparities surfaced even if a plan earned an above average ranking. In fact, only one health plan in the study received both a high quality and low disparity ranking on more than one measure.
"These results debunk the belief that health disparities exist and persist because a majority of black Medicare enrollees are stuck in low-performing health plans. The data clearly show that even high-performing plans do not provide effective medical treatment to all people," Trivedi said. "This has serious consequences. Controlled blood pressure, cholesterol and glucose are critical if you have hypertension, diabetes or heart disease. If we improve quality and eliminate disparities, we will save lives."
One important policy implication of the study, Trivedi said, is that plans should collect and analyze clinical performance data for the racial and ethnic groups they serve. This data could be obtained if patients are asked to report their race and ethnicity on enrollment forms.
"The first step is collecting the data," Trivedi said. "You can't improve what you don't measure. Then plan administrators have to act on that data to get results."
Harvard Medical School professors Alan Zaslavsky, a professor of health care policy, and Eric Schneider, M.D., an associate professor of medicine, also conducted the research and served as authors of the JAMA study.
The Agency for Healthcare Research and Quality, the Health Resources and Services Administration, Brigham and Women's Hospital and Harvard Medical School funded the work.
Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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