Who you are and where you live: How race and geography affect the treatment of medicare beneficiaries

Health Affairs

Volumn 23, Issue SUPPL., 2004, Pages

  Baicker, Katherine ^a,b,c   Chandra, Amitabh ^a,b,c   Skinner, Jonathan S ^b,d   Wennberg, John E ^b  

^a Dartmouth College   (United States)

^b DARTMOUTH MEDICAL SCHOOL   (United States)

^c NATIONAL BUREAU OF ECONOMIC RESEARCH   (United States)

^d Department of Economics ^*

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CONTROLLED STUDY; ETHNOLOGY; GEOGRAPHY; HEALTH CARE; HEALTH CARE ORGANIZATION; HEALTH CARE QUALITY; HEALTH CARE UTILIZATION; HUMAN; MEDICARE; MINORITY GROUP; RACE DIFFERENCE; UNITED STATES;

EID: 8844269543     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.var.33     Document Type: Article

References (47)

1. Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington: National Academies Press, 2002); and K. Baicker, A. Chandra, and J. Skinner, "Geographic Variation and the Problem of Measuring Racial Disparities in Health Care," Perspectives in Biology and Medicine (forthcoming).
2. Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Washington: National Academies Press, 2002); and K. Baicker, A. Chandra, and J. Skinner, "Geographic Variation and the Problem of Measuring Racial Disparities in Health Care," Perspectives in Biology and Medicine (forthcoming).
3. E.D. Peterson et al., "Racial Variation in the Use of Coronary Revascularization Procedures: Are the Differences Real? Do They Matter?" New England Journal of Medicine 336, no. 7 (1997): 480-486. The trade-off is that clinical data are often more detailed at the hospital level.
4. A. Chandra and J. Skinner, "Geography and Racial Disparities in Health and Health Care," NBER Working Paper no. 9513 (Cambridge, Mass.: National Bureau of Economic Research, 2003); A. Zaslavsky, E. Schneider, and A. Epstein, "Racial Disparities in the HEDIS Measures of Health Care Quality," Proceedings of the Joint Statistical Meetings, American Statistical Association (2002): 3933-3938; and J. Skinner et al., "Racial, Ethnic, and Geographic Disparities in Knee Arthroplasty Rates among the Medicare Population," New England Journal of Medicine 349, no. 14 (2003): 1350-1359. Skinner and colleagues show, for example, that knee replacement rates for black female Medicare enrollees were equal to rates for white female enrollees in some regions but far below rates for white female enrollees in other regions. Unlike rates for women, rates for black men were consistently below those for white men.
5. A. Chandra and J. Skinner, "Geography and Racial Disparities in Health and Health Care," NBER Working Paper no. 9513 (Cambridge, Mass.: National Bureau of Economic Research, 2003); A. Zaslavsky, E. Schneider, and A. Epstein, "Racial Disparities in the HEDIS Measures of Health Care Quality," Proceedings of the Joint Statistical Meetings, American Statistical Association (2002): 3933-3938; and J. Skinner et al., "Racial, Ethnic, and Geographic Disparities in Knee Arthroplasty Rates among the Medicare Population," New England Journal of Medicine 349, no. 14 (2003): 1350-1359. Skinner and colleagues show, for example, that knee replacement rates for black female Medicare enrollees were equal to rates for white female enrollees in some regions but far below rates for white female enrollees in other regions. Unlike rates for women, rates for black men were consistently below those for white men.
6. A. Chandra and J. Skinner, "Geography and Racial Disparities in Health and Health Care," NBER Working Paper no. 9513 (Cambridge, Mass.: National Bureau of Economic Research, 2003); A. Zaslavsky, E. Schneider, and A. Epstein, "Racial Disparities in the HEDIS Measures of Health Care Quality," Proceedings of the Joint Statistical Meetings, American Statistical Association (2002): 3933-3938; and J. Skinner et al., "Racial, Ethnic, and Geographic Disparities in Knee Arthroplasty Rates among the Medicare Population," New England Journal of Medicine 349, no. 14 (2003): 1350-1359. Skinner and colleagues show, for example, that knee replacement rates for black female Medicare enrollees were equal to rates for white female enrollees in some regions but far below rates for white female enrollees in other regions. Unlike rates for women, rates for black men were consistently below those for white men.
7. As we discuss below, the data preclude a more detailed breakdown of racial and ethnic groups.
8. HRRs are not necessarily the appropriate geographical level for primary care services but are best viewed as the level where tertiary services such as cardiac surgery are received. For more details, see J.E. Wennberg and M.M. Cooper, eds., The Quality of Medical Care in the United States: A Report on the Medicare Program, The Dartmouth Atlas of Health Care 1999 (Chicago: AHA Press, 1999).
9. We choose HRRs with larger black populations both to protect confidentiality and to minimize sampling error, which would make treatment patterns appear more variable. For example, see P. Diehr et al., "Can Small Area Analysis Detect Variation in Surgery Rates? The Power of Small Area Variations Analysis," Medical Care 30, no. 6 (1992): 484-502. In practice, sampling errors are extremely small because of the use of multiple years and 100 percent or 20 percent data sources.
10. S. Arday et al., "HCFA's Racial and Ethnic Data: Current Accuracy and Recent Improvements," Health Care Financing Review 21, no. 4 (2000): 107-116.
11. Note that the Medicare claims data do not allow overlap across racial and ethnic groups, as the 2000 census did, so each Medicare enrollee is placed in just one racial or ethnic category.
12. S.F. Jencks et al., "Quality of Medical Care Delivered to Medicare Beneficiaries," Journal of the American Medical Association 284, no. 13 (2000): 1670-1676. This approach follows J.E. Wennberg, E.S. Fisher, and J.S. Skinner, "Geography and the Debate over Medicare Reform," Health Affairs, 13 February 2002, content .healthaffairs.org/cgi/content/abstract/ hlthaff.w2.96 (2 August 2004).
13. S.F. Jencks et al., "Quality of Medical Care Delivered to Medicare Beneficiaries," Journal of the American Medical Association 284, no. 13 (2000): 1670-1676. This approach follows J.E. Wennberg, E.S. Fisher, and J.S. Skinner, "Geography and the Debate over Medicare Reform," Health Affairs, 13 February 2002, content .healthaffairs.org/cgi/content/abstract/ hlthaff.w2.96 (2 August 2004).
14. Note that some of the QIO-identified interventions are preventive care measures that should be performed (at least) annually (such as HbAlc monitoring for diabetics) or biennially (such as mammograms for women), while others are interventions that should be performed at the time of an acute incident (such as the use of beta-blockers or aspirin after acute myocardial infarction). The "right" rate for the use of these procedures is thus 100 percent for the relevant population within the recommended time frame. Thus, perfect compliance with the QIO recommendations would imply that an average of 50 percent of female beneficiaries receive mammograms each year but that 100 percent of diabetics receive HbAlc monitoring each year.
15. These are sometimes referred to as "preference-sensitive" conditions because, in theory, the choice of these procedures should depend on individual preferences. In practice, rates of procedure use may depend more on providers' practice styles, whether across regions or by race. See J.Z. Ayanian et al., "The Effect of Patients' Preferences on Racial Differences in Access to Renal Transplantation," New England Journal of Medicine 341, no. 22 (1999): 1359-1368.
16. Wennberg et al., "Geography and the Debate over Medicare Reform."
17. Ibid.; E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care," Annals of Internal Medicine 138, no. 4 (2003): 283-287, and "The Implications of Regional Variations in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care," Annals of Internal Medicine 138, no. 4 (2003): 288-299; J. Skinner, E. Fisher, and J. Wennberg, "The Efficiency of Medicare," NBER Working Paper no. 8395 (Cambridge, Mass.: NBER, 2001); and K. Baicker and A. Chandra, "Medicare Spending, the Physician Workforce, and Beneficiaries' Quality of Care," Health Affairs, 7 April 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.184 (2 August 2004).
18. Ibid.; E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care," Annals of Internal Medicine 138, no. 4 (2003): 283-287, and "The Implications of Regional Variations in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care," Annals of Internal Medicine 138, no. 4 (2003): 288-299; J. Skinner, E. Fisher, and J. Wennberg, "The Efficiency of Medicare," NBER Working Paper no. 8395 (Cambridge, Mass.: NBER, 2001); and K. Baicker and A. Chandra, "Medicare Spending, the Physician Workforce, and Beneficiaries' Quality of Care," Health Affairs, 7 April 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.184 (2 August 2004).
19. Ibid.; E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care," Annals of Internal Medicine 138, no. 4 (2003): 283-287, and "The Implications of Regional Variations in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care," Annals of Internal Medicine 138, no. 4 (2003): 288-299; J. Skinner, E. Fisher, and J. Wennberg, "The Efficiency of Medicare," NBER Working Paper no. 8395 (Cambridge, Mass.: NBER, 2001); and K. Baicker and A. Chandra, "Medicare Spending, the Physician Workforce, and Beneficiaries' Quality of Care," Health Affairs, 7 April 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.184 (2 August 2004).
20. Ibid.; E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care," Annals of Internal Medicine 138, no. 4 (2003): 283-287, and "The Implications of Regional Variations in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care," Annals of Internal Medicine 138, no. 4 (2003): 288-299; J. Skinner, E. Fisher, and J. Wennberg, "The Efficiency of Medicare," NBER Working Paper no. 8395 (Cambridge, Mass.: NBER, 2001); and K. Baicker and A. Chandra, "Medicare Spending, the Physician Workforce, and Beneficiaries' Quality of Care," Health Affairs, 7 April 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.184 (2 August 2004).
21. Ibid.; E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care," Annals of Internal Medicine 138, no. 4 (2003): 283-287, and "The Implications of Regional Variations in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care," Annals of Internal Medicine 138, no. 4 (2003): 288-299; J. Skinner, E. Fisher, and J. Wennberg, "The Efficiency of Medicare," NBER Working Paper no. 8395 (Cambridge, Mass.: NBER, 2001); and K. Baicker and A. Chandra, "Medicare Spending, the Physician Workforce, and Beneficiaries' Quality of Care," Health Affairs, 7 April 2004, content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.184 (2 August 2004).
22. To control for differences in age and sex among regions, utilization rates presented below are adjusted for differences across regions in age (in five-year increments), sex, and race using the indirect method. See the Appendix to Wennberg and Cooper, eds., The Quality of Medical Care, for further discussion of indirect adjustment.
23. This was shown at the national level by L.R. Shugarman et al., "Differences in Medicare Expenditures during the Last Three Years of life," Journal of General Internal Medicine 19, no. 2 (2004): 127-135.
24. These results are available as Exhibit Al in an online appendix, content.healthaffairs.org/cgi/content/full/hlthaff.var.33/DC2.
25. Surgical signatures refer to the persistent and dramatic differences in the rates at which certain surgical procedures are performed in adjacent regions with similar patient populations. They are the consequence of individual physicians' practice patterns and the local medical culture regarding a particular treatment. They have not been found to be correlated with patient characteristics or differences in physician supply. N.P. Roos and L.L. Roos, "High and Low Surgical Rates: Risk Factors for Area Residents," American Journal of Public Health 71, no. 6 (1981): 591-600; and J. Wennberg and A. Gittelsohn, "Health Care Delivery in Maine I: Patterns of Use of Common Surgical Procedures," Journal of the Maine Medical Association 66, no. 5 (1975): 123-130, 149.
26. Surgical signatures refer to the persistent and dramatic differences in the rates at which certain surgical procedures are performed in adjacent regions with similar patient populations. They are the consequence of individual physicians' practice patterns and the local medical culture regarding a particular treatment. They have not been found to be correlated with patient characteristics or differences in physician supply. N.P. Roos and L.L. Roos, "High and Low Surgical Rates: Risk Factors for Area Residents," American Journal of Public Health 71, no. 6 (1981): 591-600; and J. Wennberg and A. Gittelsohn, "Health Care Delivery in Maine I: Patterns of Use of Common Surgical Procedures," Journal of the Maine Medical Association 66, no. 5 (1975): 123-130, 149.
27. One study found relatively small differences in monitoring and treatment by race or ethnicity among diabetics in the general population. M.I. Harris, "Racial and Ethnic Differences in Health Care Access and Health Outcomes for Adults with Type 2 Diabetes," Diabetes Care 24, no. 3 (2001): 454-459. For related research, see D.E. Bonds et al., "Ethnic and Racial Differences in Diabetes Care: The Insulin Resistance Atherosclerosis Study," Diabetes Care 26, no. 4 (2003): 1040-1046.
28. One study found relatively small differences in monitoring and treatment by race or ethnicity among diabetics in the general population. M.I. Harris, "Racial and Ethnic Differences in Health Care Access and Health Outcomes for Adults with Type 2 Diabetes," Diabetes Care 24, no. 3 (2001): 454-459. For related research, see D.E. Bonds et al., "Ethnic and Racial Differences in Diabetes Care: The Insulin Resistance Atherosclerosis Study," Diabetes Care 26, no. 4 (2003): 1040-1046.
29. Other results are shown graphically in Exhibits A3-A8, available online at content.healthaffairs.org/cgi/content/full/hlthaff.var.33/DC2.
30. This graphical approach is very similar to that of Zaslavsky et al., "Racial Disparities in the HEDIS Measures of Health Care Quality." Also available online are graphs showing the white rate and the white-black disparity for the twenty-five regions with the largest numbers of elderly black residents, ordered according to the size of the racial disparity. The vertical line indicates the average black rate. See Exhibits A3-A4 and A6-A7 at content.healthaffairs.org/cgi/content/full/hlthaff.var.33/DC2.
31. See Note 19.
32. There is a strong negative association between disparities and black rates for low-intensity effective care, hip replacement, end-of-life care, and total expenditures, however, and a weak or negative relationship between these disparities and the percentage of the population that is black. The full tables are available as Exhibits A1 and A2 at content.healthaffairs.org/cgi/content/ full/hlthaff.var.33/DC2.
33. Results for end-of-life care are shown in ibid., Exhibit A8.
34. D. Card, C. Dobkin, and N. Maestas, "The Impact of Nearly Universal Insurance Coverage on Health Care Utilization and Health: Evidence from Medicare," NBER Working Paper no. 10364 (Cambridge, Mass.: NBER, 2004), find that insurance coverage jumps (although copayments may increase) and disparities in use based on race and education drop when patients become eligible for Medicare.
35. Black and white beneficiaries are enrolled in HMOs at roughly the same rate: 20.4 percent of black beneficiaries versus 19.3 percent of nonblack beneficiaries. Thus, differential enrollment in HMOs is not likely to drive the observed racial disparities in treatment of those enrolled in FFS Medicare. See also Zaslavsky et al., "Racial Disparities in the HEDIS Measures of Health Care Quality."
36. G.A. Hawker et al., "Differences between Men and Women in the Rate of Use of Hip and Knee Arthroplasty," New England Journal of Medicine 342, no. 14 (2000): 1016-1022; and R. Hirsch et al., "Radiographic Knee Osteoarthritis Prevalence in Older Adults in the United States," Arthritis and Rheumatism 44 Suppl. (2001): S225.
37. G.A. Hawker et al., "Differences between Men and Women in the Rate of Use of Hip and Knee Arthroplasty," New England Journal of Medicine 342, no. 14 (2000): 1016-1022; and R. Hirsch et al., "Radiographic Knee Osteoarthritis Prevalence in Older Adults in the United States," Arthritis and Rheumatism 44 Suppl. (2001): S225.
38. Skinner et al., "Racial, Ethnic, and Geographic Disparities"; and Card et al., "The Impact of Nearly Universal Insurance Coverage."
39. Skinner et al., "Racial, Ethnic, and Geographic Disparities"; and Card et al., "The Impact of Nearly Universal Insurance Coverage."
40. Chandra and Skinner, "Geography and Racial Disparities."
41. For the case of joint replacement, see S. Ibrahim et al., "Understanding Ethnic Differences in the Utilization of Joint Replacement for Osteoarthritis," Medical Care 40, no. 1, Supp. (2002): 144-151; and S. Ibrahim et al., "Variations in Perceptions of Treatment and Self-Care Practices in Elderly with Osteoarthritis: A Comparison between African American and White Patients," Arthritis and Rheumatism 45, no. 4 (2001): 340-345.
42. For the case of joint replacement, see S. Ibrahim et al., "Understanding Ethnic Differences in the Utilization of Joint Replacement for Osteoarthritis," Medical Care 40, no. 1, Supp. (2002): 144-151; and S. Ibrahim et al., "Variations in Perceptions of Treatment and Self-Care Practices in Elderly with Osteoarthritis: A Comparison between African American and White Patients," Arthritis and Rheumatism 45, no. 4 (2001): 340-345.
43. I b i d.
44. J.N. Katz, "Patient Preferences and Health Disparities," Journal of the American Medical Association 286, no. 12 (2001): 1506-1509.
45. A.M. O'Connor, H.A. Llewellyn-Thomas, and A.B. Flood, "Modifying Unwarranted Variations in Health Care: Shared Decision Making using Patient Decision Aids," Health Affairs, 7 October 2004, content .healthaffairs.org/cgi/content/abstract/hlthaff.var.63.
46. Growing evidence suggests that greater intensity of care in managing chronic illness or at the end of life does not result in better outcomes (or improved quality of care or satisfaction). See Fisher et al., "The Implications of Regional Variations in Medicare Spending, Parts 1 and 2"; and Baicker and Chandra, "Medicare Spending."
47. Growing evidence suggests that greater intensity of care in managing chronic illness or at the end of life does not result in better outcomes (or improved quality of care or satisfaction). See Fisher et al., "The Implications of Regional Variations in Medicare Spending, Parts 1 and 2"; and Baicker and Chandra, "Medicare Spending."