Trends in Health Care Trends in Health Care Disparities in Disparities in

Medicare Managed Medicare Managed CareCare

Trends in Health Care Trends in Health Care Disparities in Disparities in

Medicare Managed Medicare Managed CareCare

Sarah Hudson Scholle, MPH, DrPHSarah Hudson Scholle, MPH, DrPHAcademyHealthAcademyHealthJune 27, 2005June 27, 2005

Sarah Hudson Scholle, MPH, DrPHSarah Hudson Scholle, MPH, DrPHAcademyHealthAcademyHealthJune 27, 2005June 27, 2005

AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements

• Research Team– Sarah Hudson Scholle, DrPH, NCQA– Beth Virnig, PhD, University of Minnesota– Ann Chou, PhD, NCQA– Sarah Shih, MPH, NCQA– Russ Mardon, PhD, NCQA– Rich Mierzejewski, MA, NCQA

• Funded by the California Endowment

BackgroundBackgroundBackgroundBackground

• IOM: “ care should be safe, effective, patient-centered, timely, efficient, equitable”.

• Numerous reports of disparities in health care and health outcomes, including previous studies found disparities in Medicare managed care

• Quality has improved over time in Medicare managed care: what about the disparities?

• The purpose of this study is to examine trends in quality of care for blacks and whites in Medicare managed care

Data SourcesData SourcesData SourcesData Sources

• Medicare HEDIS data– Health plans report member-level HEDIS data to NCQA

separately from plan-level data– 1998 to 2003 measurement years– Excluded plans where rates calculated from member-level

data did not agree with audited plan-level rates

• CMS enrollment file– Age, sex, race/ethnicity, zip code, eligibility– Race/ethnicity assigned at enrollment in Social Security– Linked to HEDIS data using unique identifier (> 90% match)

• U.S. Census data– Zip code matched to obtain median household income for

persons age 75-84

Medicare HEDISMedicare HEDIS®® Measures MeasuresMedicare HEDISMedicare HEDIS®® Measures Measures

• Breast Cancer Screening (hybrid)• Comprehensive Diabetes Care (hybrid)

– HgbA1c screening, Poor control of HgbA1c, Eye exam, Nephropathy, Lipid screening, Lipid Control

• Cholesterol Management After Acute Cardiovascular Event (hybrid)– Lipid screening, Lipid Control

• Controlling High Blood Pressure (hybrid)• Beta Blocker After Heart Attack (hybrid)• Antidepressant Med Mgmt (admin only)

– Optimal Contacts, Acute Phase Treatment, Continuation Phase Treatment

• Follow-up After Mental Health Hospitalization within 7 or 30 days (admin)

Study Group, 2003Study Group, 2003Study Group, 2003Study Group, 2003

Plans

Eligible Members

Measure White Black

Breast Cancer Screening 146 181,595 18,732

Comprehensive Diabetes Care 148 83,269 12,938

Cholesterol Management 145 24,454 2,060

Controlling High Blood Press. 141 46,292 7,237

Beta Blocker After Heart Attack 141 13,766 1,302

Antidepressant Med Mgmt 122 27,235 1,439

Follow-Up After MH Hosp 139 7,425 883

Analytic Approach: Trends over TimeAnalytic Approach: Trends over TimeAnalytic Approach: Trends over TimeAnalytic Approach: Trends over Time

• Research questions: – Does performance differ by race? – Does performance change over time? – Does the rate of change in performance differ between

whites and blacks?

• Approach:– Logistic regression analyses modeling each quality indicator

(met/not met) – Controlling for patient age, sex, household income, region,

plan size – Used a continuous variable to test for temporal correlation

53.7%

82.4%

58.9%

70.9%

46.6%

69.5%

47.0%

31.4%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1998 1999 2000 2001 2002 2003

White

Black

Cholesterol Control

Cholesterol Screening

Cholesterol Screening and Control – Cholesterol Screening and Control – Acute Cardiac EventsAcute Cardiac Events

Cholesterol Screening and Control – Cholesterol Screening and Control – Acute Cardiac EventsAcute Cardiac Events

Adjusted OR Screening Control Race: 0.638*** 0.575***Time: 1.439*** 1.420***Race*Time: 0.975 1.001

45.8%

33.7%

93.2%

71.7%

89.4%

62.5%

71.3%

62.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1999 2000 2001 2002 2003

White

Black

Cholesterol Control

Cholesterol Screening

Cholesterol Screening and Control - Cholesterol Screening and Control - DiabeticsDiabetics

Cholesterol Screening and Control - Cholesterol Screening and Control - DiabeticsDiabetics

Adjusted OR Screening Control Race: 0.685*** 0.653***Time: 1.816*** 1.382***Race*Time: 0.993 1.031***

71.3%

89.0%

78.1%85.2%

20.8%

33.0%

44.0%

29.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1999 2000 2001 2002 2003White

Black

HbA1cScreening

HbA1cPoor Control§

Diabetes HbA1c Diabetes HbA1c Screening and ControlScreening and Control

Diabetes HbA1c Diabetes HbA1c Screening and ControlScreening and Control

Adjusted OR Screen ControlRace: 0.748*** 1.459***Time: 1.424*** 0.825***Race*Time: 1.011 0.984 § Lower is better.§ Lower is better.

46.9%

61.3%

41.4%

56.0%

93.4%

81.8%87.7%

77.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1998 1999 2000 2001 2002 2003

White

Black

Beta Blocker

HighBlood Pressure

Beta Blocker & Blood PressureBeta Blocker & Blood PressureBeta Blocker & Blood PressureBeta Blocker & Blood Pressure

Adjusted OR BBH HBP Race: 0.838** 0.782***Time: 1.626*** 1.351***Race*Time: 0.934* 1.002

12.4%12.2%

12.0%12.9%

59.5%

67.1%

46.7%

56.1%

52.3%45.9%

32.1%38.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000 2001 2002 2003 2004White

Black

Acute Phase

Optimal Contacts

ContinuationPhase

Antidepressant Medication Antidepressant Medication ManagementManagement

Antidepressant Medication Antidepressant Medication ManagementManagement

Adjusted OR Acute Continuation Contacts Race: 0.589*** 0.544*** 1.024Time: *** *** NSRace*Time: NS NS NS

58.2%55.9%

46.2%39.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1998 1999 2000 2001 2002 2003White

Black

Follow Up After Mental Health Follow Up After Mental Health Hospitalization (30 Days)Hospitalization (30 Days)

Follow Up After Mental Health Follow Up After Mental Health Hospitalization (30 Days)Hospitalization (30 Days)

Adjusted OR Race: 0.537***Time: 1.163*** Race*Time: 1.028

76.3% 76.3%

72.3% 75.1%

0.0%

10.0%

20.0%

30.0%

40.0%50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1998 1999 2000 2001 2002 2003White

Black

Breast Cancer ScreeningBreast Cancer ScreeningBreast Cancer ScreeningBreast Cancer Screening

Adjusted OR Race: 0.911***Time: 1.021*** Race*Time: 1.030***

Magnitude of Racial Disparity DiffersMagnitude of Racial Disparity DiffersMagnitude of Racial Disparity DiffersMagnitude of Racial Disparity DiffersAdjusted

Odds Ratio

B-W Diff in Adjusted

Rate

Blacks gaining or

losing

Breast Cancer Screening 0.91 1.2 +Diabetes HgbA1c screen 0.75 3.2

Diabetes LDL screen 0.69 3.8

Controlling High Blood Pressure 0.78 5.2

Beta Blocker after Heart Attack 0.84 5.7 -Diabetes LDL control <130 0.65 9.0 +Poor HgbA1c control§ 1.46 11.6

Cardiac event : Chol Screening 0.64 11.5

Cardiac event: Chol Control 0.58 15.8

Depress Med Mgmt Acute Phase 0.59 11.0

Depress Med Mgmt Cont Phase 0.54 13.8

Follow Up after MH Hosp 0.54 12.0

§ Lower is better.§ Lower is better.

ConclusionsConclusionsConclusionsConclusions

• Quality of care for Medicare managed care beneficiaries is improving

• Black/white disparities remain for most measures

• On most measures, the rate of improvement is not different for blacks and whites – the gap is not closing

• The amount of disparity varies: lower for most screening measures, higher for control and cardiac measures

ImplicationsImplicationsImplicationsImplications

• General efforts to improving quality are not enough to reduce the racial gap

• Understand root causes that contribute to disparities

• Develop and evaluate quality improvement interventions that address racial disparities specifically and within the context of general QI

• Continue to monitor quality by race and expand to include ethnicity and language