Racial disparities in the use of health services have been documented, but much less is known about racial disparities in the quality of care. Authors Eric C. Schneider, M.D., Alan M. Zaslavsky, and Arnold M. Epstein, M.D., are the first to use the Health Plan Employer Data and Information Set (HEDIS) to assess racial disparities in quality of care among Medicare managed care enrollees nationwide. "Racial Disparities in the Quality of Care for Enrollees in Medicare Managed Care," sponsored by The Commonwealth Fund, is also the first to use HEDIS to examine racial disparities in the quality of mental health care.
After drawing data from among nearly 4 million eligible managed care enrolled beneficiaries who were over age 65, 7.7 percent were included in at least one of four HEDIS measures: breast cancer screening, use of beta blocker medication after myocardial infarction, diabetic eye exams, and follow-up after hospitalization for mental illness. The total number of enrollees assessed for each HEDIS measure ranged from 161,179 for diabetic eye exams to 3,590 for mental illness follow-up.
Analysis of HEDIS scores revealed that African Americans were less likely than whites to receive breast cancer screening (62.9% vs. 70.2%), diabetic eye exams (43.6% vs. 50.4%), beta blockers (64.1% vs. 73.8%), and mental illness follow-up (33.2% vs. 54.0%). After adjusting for age, sex, Medicaid insurance, income, education, rural residence, and heath plan, racial disparities were still significant for diabetic eye exams, beta blocker use, and mental illness follow-up measures, but not for the breast cancer screening measure.
Results offer three clues about the nature and causes of racial disparities in the clinical quality of care. First, the magnitude of racial disparity varies among quality measures. The disparity is smallest for breast cancer screening and largest for mental illness follow-up. In the case of breast cancer screening, literature suggests that health plans and clinicians may effectively intervene to reduce the extent of racial disparity through increased communication with patients about the importance of screening, stages of diagnosis, and mortality for breast cancer. In contrast, the authors found no literature suggesting why African Americans are less likely to receive follow up after hospitalization for mental illness. The magnitude of the previously unrecognized disparity is formidable.
Second, results suggest that individual socioeconomic characteristics explain differing proportions of the observed racial disparity across quality measures. Comparing the adjusted and unadjusted disparities, more than half the disparity in breast cancer screening may be explained by socioeconomic factors, while less than one-tenth of the racial disparity in mental illness followup is explained by these factors.
Third, part of the racial disparities in clinical quality is explained by disproportionate enrollments of African Americans in lower-performing health plans. After accounting for individual characteristics, about half the remaining racial disparity appears to occur between plans, rather than within plans (with the exception of mental illness follow-up). For breast cancer screening, the racial disparity is no longer statistically significant after controlling for individual and health plan effects. In contrast, a substantial part of the racial disparity in the other three measures is explained by different quality of care for African Americans and whites within health plans.
Racial disparities for the clinical services studied could be associated with adverse outcomes that have been noted previously among minority patients. Lower rates of breast cancer screening among African American women may contribute to later-stage cancer diagnoses and higher mortality rates. Low rates of eye exams for African Americans with diabetes contribute to their high rate of established retinal disease at the time of first exam. Racial disparity in use of beta blockers is consistent with prior research, implying that African Americans are less likely to receive other therapies for coronary artery disease.
Other implications include:
- Medicare HEDIS data collection offers an unprecedented opportunity to assess racial and socioeconomic disparities in quality of care and to address them. Reports to health plans about disparities could be a powerful lever for change if health plans were able to use this information to target interventions that improve performance for minority enrollees.
- Health plans could intervene to improve quality of care for racial minorities by ensuring that a primary care physician is involved in care. African Americans in managed care were more likely to report a usual source of care than African Americans with other forms of insurance.
- Health plans could increase the level of service delivery to minority and nonminority populations. In a study of influenza vaccination of Medicare beneficiaries, African Americans enrolled in health plans were more likely to receive the vaccination than those with fee-for-service insurance.
The analysis demonstrates the importance of the Centers for Medicare and Medicaid Services' efforts to collect HEDIS data and their potential as a resource for tracking racial disparities in the quality of care. This monitoring program should be expanded and extended to other types of government insurance.
Study results should also motivate research that addresses reasons behind disparities and within and among health plans. Identifying plans that succeed at narrowing disparities in the quality or care could lead to effective programs to reduce and even eliminate such disparities.
Facts and Figures
- For the clinical effectiveness measures, 90.3 percent to 96.6 percent of health plans that reported data were in compliance with HEDIS technical specifications.
- For breast cancer screening, health plans in the lowest third of African American enrollment had rates of 76 percent for whites and 74 percent for African Americans, while health plans in the highest third of African American enrollment had rates of 60 percent for whites and 58 percent for African Americans.
- A study of patients of family practitioners found no disparity in preventive service use as long as patients had access to primary care.