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Original Contribution |

Racial Disparities in the Quality of Care for Enrollees in Medicare Managed Care FREE

Eric C. Schneider, MD, MSc; Alan M. Zaslavsky, PhD; Arnold M. Epstein, MD, MA
[+] Author Affiliations

Author Affiliations: Department of Health Policy and Management, Harvard School of Public Health (Drs Schneider and Epstein), Section on Health Policy, Division of General Medicine, Brigham and Women's Hospital (Drs Schneider and Esptein), and the Department of Health Care Policy, Harvard Medical School (Dr Zaslavsky), Boston, Mass.


JAMA. 2002;287(10):1288-1294. doi:10.1001/jama.287.10.1288.
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Context Substantial racial disparities in the use of some health services exist; however, much less is known about racial disparities in the quality of care.

Objective To assess racial disparities in the quality of care for enrollees in Medicare managed care health plans.

Design and Setting Observational study, using the 1998 Health Plan Employer Data and Information Set (HEDIS), which summarized performance in calendar year 1997 for 4 measures of quality of care (breast cancer screening, eye examinations for patients with diabetes, β-blocker use after myocardial infarction, and follow-up after hospitalization for mental illness).

Participants A total of 305 574 (7.7%) beneficiaries who were enrolled in Medicare managed care health plans had data for at least 1 of the 4 HEDIS measures and were aged 65 years or older.

Main Outcome Measures Rates of breast cancer screening, eye examinations for patients with diabetes, β-blocker use after myocardial infarction, and follow-up after hospitalization for mental illness.

Results Blacks were less likely than whites to receive breast cancer screening (62.9% vs 70.9%; P<.001), eye examinations for patients with diabetes (43.6% vs 50.4%; P = .02), β-blocker medication after myocardial infarction (64.1% vs 73.8%; P<.005), and follow-up after hospitalization for mental illness (33.2 vs 54.0%; P<.001). After adjustment for potential confounding factors, racial disparities were still statistically significant for eye examinations for patients with diabetes, β-blocker use after myocardial infarction, and follow-up after hospitalization for mental illness.

Conclusion Among Medicare beneficiaries enrolled in managed care health plans, blacks received poorer quality of care than whites.

The technology of medical care has improved dramatically in the past century, yet for some populations in the United States, care has fallen short of important goals.1,2 In particular, blacks have been less likely to receive many types of medical services and procedures.38 Blacks bear a disproportionate share of suffering related to a variety of chronic diseases. To the extent that they fail to receive quality care, they may be at risk for complications that could otherwise have been ameliorated or prevented altogether.

Enrollment in managed care has grown in the past decade, yet few studies have examined whether there are racial disparities in the quality of care within health plans.912 Some features of managed care insurance, such as mandatory enrollment with a primary care physician, targeted outreach to populations with special needs, case-management programs for patients with chronic conditions, and enhanced quality monitoring, may lessen racial disparities by differentially improving the quality of care for blacks.1315 Alternatively, managed care may fail to reduce disparities if financial competition leads health plans to curtail needed services or raise barriers to access that disproportionately affect the quality of care for blacks.9,16

Until recently, limited nationally representative data were available to assess health care quality.2 Most studies of racial disparities in care have examined differences in use that may or may not accurately represent the quality of care. However, the Balanced Budget Act of 1997 requires all health plans that enroll Medicare beneficiaries to report quality-of-care data annually using a Medicare-specific version of the Health Plan Employer Data and Information Set (HEDIS).17 Derived from measures explicitly designed to assess the quality of care, these data offer the first opportunity to examine racial disparities in the quality of care provided to Medicare enrollees in health plans nationwide.

Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States?  Milbank Q.1998;76:517-563.
Jencks SF, Cuerdon T, Burwen DR.  et al.  Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels.  JAMA.2000;284:1670-1676.
Ayanian JZ, Udvarhelyi IS, Gatsonis CA, Pashos CL, Epstein AM. Racial differences in the use of revascularization procedures after coronary angiography.  JAMA.1993;269:2642-2646.
Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer.  N Engl J Med.1993;329:326-331.
Roetzheim RG, Pal N, Tennant C.  et al.  Effects of health insurance and race on early detection of cancer.  J Natl Cancer Inst.1999;91:1409-1415.
Gornick ME, Eggers PW, Reilly TW.  et al.  Effects of race and income on mortality and use of services among Medicare beneficiaries.  N Engl J Med.1996;335:791-799.
President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry.  Quality First: Better Health Care for All Americans. Washington, DC: US Government Printing Office; 1998.
Miller B, Campbell RT, Furner S.  et al.  Use of medical care by African American and white older persons: comparative analysis of three national data sets.  J Gerontol B Psychol Sci Soc Sci.1997;52:S325-S335.
Schoen C, Neuman P, Kitchman M, Davis K, Rowland D. Medicare beneficiaries: a population at risk. In: Findings From the Kaiser/Commonwealth 1997 Survey of Medicare Beneficiaries. Menlo Park, Calif and New York, NY: The Henry J. Kaiser Family Foundation and The Commonwealth Fund; 1998:1-48.
Phillips KA, Fernyak S, Potosky AL, Schauffler HH, Egorin M. Use of preventive services by managed care enrollees: an updated perspective.  Health Aff (Millwood).2000;19:102-116.
Davis K, Collins KS, Morris C. Managed care: promise and concerns.  Health Aff (Millwood).1994;13:178-185.
Schneider EC, Cleary PD, Zaslavsky AM, Epstein AM. Racial disparity in influenza vaccination: does managed care narrow the gap between blacks and whites?  JAMA.2001;286:1455-1460.
Grumbach K, Selby JV, Schmittdiel JA, Quesenberry Jr CP. Quality of primary care practice in a large HMO according to physician specialty.  Health Serv Res.1999;34:485-502.
Blumenthal D, Mort E, Edwards J. The efficacy of primary care for vulnerable population groups.  Health Serv Res.1995;30:253-273.
Wood D, Halfon N, Donald-Sherbourne C.  et al.  Increasing immunization rates among inner-city, black children: a randomized trial of case management.  JAMA.1998;279:29-34.
Miller RH. Healthcare organizational change: implications for access to care and its measurement.  Health Serv Res.1998;33:653-680.
Epstein AM. Rolling down the runway: the challenges ahead for quality report cards.  JAMA.1998;279:1691-1696.
Health Care Financing Administration.  1997 Medicare HEDIS 3.0/1998 Data Audit Report. Baltimore, Md: HCFA; 1998.
Zaslavsky AM, Hochheimer JN, Schneider EC.  et al.  Impact of sociodemographic case mix on the HEDIS measures of health plan quality.  Med Care.2000;38:981-992.
 The Competitive Edge Database: Version 8.2.  St Paul, Minn: InterStudy Publications; 1998.
 STATA: Version 6.  College Station, Tex: Stata Corp; 1999.
 SUDAAN: Version 7.5.  Research Triangle Park, NC: Research Triangle Institute; 2001.
Yood MU, Johnson CC, Blount A.  et al.  Race and differences in breast cancer survival in a managed care population.  J Natl Cancer Inst.1999;91:1487-1491.
Hunter CP, Redmond CK, Chen VW.  et al. for the Black/White Cancer Survival Study Group.  Breast cancer: factors associated with stage at diagnosis in black and white women.  J Natl Cancer Inst.1993;85:1129-1137.
Ayanian J, Kohler B, Abe T, Epstein A. The relation between health insurance coverage and clinical outcomes among women with breast cancer.  N Engl J Med.1993;329:326-331.
Walker EA, Basch CE, Howard CJ, Zybert PA, Kromholz WN, Shamoon H. Incentives and barriers to retinopathy screening among African-Americans with diabetes.  J Diabetes Complications.1997;11:298-306.
Javitt JC, Aiello LP, Bassi LJ, Chiang YP, Canner JK.for the American Academy of Ophthalmology.  Detecting and treating retinopathy in patients with type I diabetes mellitus: savings associated with improved implementation of current guidelines.  Ophthalmology.1991;98:1565-1573.
Schulman KA, Berlin JA, Harless W.  et al.  The effect of race and sex on physicians' recommendations for cardiac catheterization.  N Engl J Med.1999;340:618-626. [published erratum appears in N Engl J Med. 1999;340:1130].
Fink R. HMO data systems in population studies of access to care.  Health Serv Res.1998;33:741-759.
Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care.  JAMA.2000;283:2579-2584.
Williams RL, Flocke SA, Stange KC. Race and preventive services delivery among black patients and white patients seen in primary care.  Med Care.2001;11:1260-1267.
Bindman A, Gold M. Measuring access to care through population-based surveys in a managed care environment. In: A Special Supplement to HSP 3. 2nd ed. Washington, DC: Health Services Research; 1998:611-766.
Grumbach K, Osmond D, Vranizan K, Jaffee D, Bindman AB. Primary care physicians' experience of financial incentives in managed-care systems.  N Engl J Med.1998;339:1516-1521.
Bindman AB, Grumbach K, Vranizan K, Jaffe D, Osmond D. Selection and exclusion of primary care physicians by managed care organizations.  JAMA.1998;279:675-679.
Komaromy M, Grumbach K, Drake M.  et al.  The role of black and Hispanic physicians in providing health care for underserved populations.  N Engl J Med.1996;334:1305-1310.
Moy E, Bartman BA. Physician race and care of minority and medically indigent patients.  JAMA.1995;273:1515-1520.
Diette GB, Wu AW, Skinner EA.  et al.  Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled beta-agonists and underuse of inhaled corticosteroids.  Arch Intern Med.1999;159:2697-2704.
Health Care Financing Administration.  Medicare Managed Care Contract (MMCC) Plans: Monthly Summary Report. Baltimore, Md: HCFA; 2001.

Figures

Tables

References

Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States?  Milbank Q.1998;76:517-563.
Jencks SF, Cuerdon T, Burwen DR.  et al.  Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels.  JAMA.2000;284:1670-1676.
Ayanian JZ, Udvarhelyi IS, Gatsonis CA, Pashos CL, Epstein AM. Racial differences in the use of revascularization procedures after coronary angiography.  JAMA.1993;269:2642-2646.
Ayanian JZ, Kohler BA, Abe T, Epstein AM. The relation between health insurance coverage and clinical outcomes among women with breast cancer.  N Engl J Med.1993;329:326-331.
Roetzheim RG, Pal N, Tennant C.  et al.  Effects of health insurance and race on early detection of cancer.  J Natl Cancer Inst.1999;91:1409-1415.
Gornick ME, Eggers PW, Reilly TW.  et al.  Effects of race and income on mortality and use of services among Medicare beneficiaries.  N Engl J Med.1996;335:791-799.
President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry.  Quality First: Better Health Care for All Americans. Washington, DC: US Government Printing Office; 1998.
Miller B, Campbell RT, Furner S.  et al.  Use of medical care by African American and white older persons: comparative analysis of three national data sets.  J Gerontol B Psychol Sci Soc Sci.1997;52:S325-S335.
Schoen C, Neuman P, Kitchman M, Davis K, Rowland D. Medicare beneficiaries: a population at risk. In: Findings From the Kaiser/Commonwealth 1997 Survey of Medicare Beneficiaries. Menlo Park, Calif and New York, NY: The Henry J. Kaiser Family Foundation and The Commonwealth Fund; 1998:1-48.
Phillips KA, Fernyak S, Potosky AL, Schauffler HH, Egorin M. Use of preventive services by managed care enrollees: an updated perspective.  Health Aff (Millwood).2000;19:102-116.
Davis K, Collins KS, Morris C. Managed care: promise and concerns.  Health Aff (Millwood).1994;13:178-185.
Schneider EC, Cleary PD, Zaslavsky AM, Epstein AM. Racial disparity in influenza vaccination: does managed care narrow the gap between blacks and whites?  JAMA.2001;286:1455-1460.
Grumbach K, Selby JV, Schmittdiel JA, Quesenberry Jr CP. Quality of primary care practice in a large HMO according to physician specialty.  Health Serv Res.1999;34:485-502.
Blumenthal D, Mort E, Edwards J. The efficacy of primary care for vulnerable population groups.  Health Serv Res.1995;30:253-273.
Wood D, Halfon N, Donald-Sherbourne C.  et al.  Increasing immunization rates among inner-city, black children: a randomized trial of case management.  JAMA.1998;279:29-34.
Miller RH. Healthcare organizational change: implications for access to care and its measurement.  Health Serv Res.1998;33:653-680.
Epstein AM. Rolling down the runway: the challenges ahead for quality report cards.  JAMA.1998;279:1691-1696.
Health Care Financing Administration.  1997 Medicare HEDIS 3.0/1998 Data Audit Report. Baltimore, Md: HCFA; 1998.
Zaslavsky AM, Hochheimer JN, Schneider EC.  et al.  Impact of sociodemographic case mix on the HEDIS measures of health plan quality.  Med Care.2000;38:981-992.
 The Competitive Edge Database: Version 8.2.  St Paul, Minn: InterStudy Publications; 1998.
 STATA: Version 6.  College Station, Tex: Stata Corp; 1999.
 SUDAAN: Version 7.5.  Research Triangle Park, NC: Research Triangle Institute; 2001.
Yood MU, Johnson CC, Blount A.  et al.  Race and differences in breast cancer survival in a managed care population.  J Natl Cancer Inst.1999;91:1487-1491.
Hunter CP, Redmond CK, Chen VW.  et al. for the Black/White Cancer Survival Study Group.  Breast cancer: factors associated with stage at diagnosis in black and white women.  J Natl Cancer Inst.1993;85:1129-1137.
Ayanian J, Kohler B, Abe T, Epstein A. The relation between health insurance coverage and clinical outcomes among women with breast cancer.  N Engl J Med.1993;329:326-331.
Walker EA, Basch CE, Howard CJ, Zybert PA, Kromholz WN, Shamoon H. Incentives and barriers to retinopathy screening among African-Americans with diabetes.  J Diabetes Complications.1997;11:298-306.
Javitt JC, Aiello LP, Bassi LJ, Chiang YP, Canner JK.for the American Academy of Ophthalmology.  Detecting and treating retinopathy in patients with type I diabetes mellitus: savings associated with improved implementation of current guidelines.  Ophthalmology.1991;98:1565-1573.
Schulman KA, Berlin JA, Harless W.  et al.  The effect of race and sex on physicians' recommendations for cardiac catheterization.  N Engl J Med.1999;340:618-626. [published erratum appears in N Engl J Med. 1999;340:1130].
Fink R. HMO data systems in population studies of access to care.  Health Serv Res.1998;33:741-759.
Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care.  JAMA.2000;283:2579-2584.
Williams RL, Flocke SA, Stange KC. Race and preventive services delivery among black patients and white patients seen in primary care.  Med Care.2001;11:1260-1267.
Bindman A, Gold M. Measuring access to care through population-based surveys in a managed care environment. In: A Special Supplement to HSP 3. 2nd ed. Washington, DC: Health Services Research; 1998:611-766.
Grumbach K, Osmond D, Vranizan K, Jaffee D, Bindman AB. Primary care physicians' experience of financial incentives in managed-care systems.  N Engl J Med.1998;339:1516-1521.
Bindman AB, Grumbach K, Vranizan K, Jaffe D, Osmond D. Selection and exclusion of primary care physicians by managed care organizations.  JAMA.1998;279:675-679.
Komaromy M, Grumbach K, Drake M.  et al.  The role of black and Hispanic physicians in providing health care for underserved populations.  N Engl J Med.1996;334:1305-1310.
Moy E, Bartman BA. Physician race and care of minority and medically indigent patients.  JAMA.1995;273:1515-1520.
Diette GB, Wu AW, Skinner EA.  et al.  Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled beta-agonists and underuse of inhaled corticosteroids.  Arch Intern Med.1999;159:2697-2704.
Health Care Financing Administration.  Medicare Managed Care Contract (MMCC) Plans: Monthly Summary Report. Baltimore, Md: HCFA; 2001.
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