Schneider EC, Zaslavsky AM, Epstein AM. Racial Disparities in the Quality of Care for Enrollees in Medicare
Managed Care. JAMA. 2002;287(10):1288-1294. doi:10.1001/jama.287.10.1288
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.
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
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
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.9- 12
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.13- 15
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.