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Original Investigation
August 17, 2021

Association of Race and Ethnicity and Medicare Program Type With Ambulatory Care Access and Quality Measures

Author Affiliations
  • 1Department of Health Management and Policy, Saint Louis University, St Louis, Missouri
  • 2Washington University School of Medicine, St Louis, Missouri
  • 3Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
JAMA. 2021;326(7):628-636. doi:10.1001/jama.2021.10413
Key Points

Question  Do individuals from racial and ethnic minority groups receive lower rates of ambulatory care access and quality than individuals of other races and ethnicities in Medicare Advantage and/or traditional Medicare, and how do the 2 programs compare on these measures for minority beneficiaries?

Findings  In this exploratory study of a nationally representative sample of 26 887 Medicare beneficiaries in 2015-2018, enrollment in Medicare Advantage compared with traditional Medicare was significantly associated with better outcomes on 1 of 3 access measures and 3 of 3 quality measures for minority beneficiaries; however, minority beneficiaries were also significantly more likely to experience worse outcomes for most access and quality metrics compared with other beneficiaries within both programs.

Meaning  Medicare Advantage, compared with traditional Medicare, was significantly associated with better outcomes for ambulatory care access and quality among minority beneficiaries, but minority beneficiaries nonetheless experienced worse outcomes for most of these measures compared with other beneficiaries within both Medicare programs.

Abstract

Importance  There are racial inequities in health care access and quality in the United States. It is unknown whether such differences for racial and ethnic minority beneficiaries differ between Medicare Advantage and traditional Medicare or whether access and quality are better for minority beneficiaries in 1 of the 2 programs.

Objective  To compare differences in rates of enrollment, ambulatory care access, and ambulatory care quality by race and ethnicity in Medicare Advantage vs traditional Medicare.

Design, Setting, and Participants  Exploratory observational cohort study of a nationally representative sample of 45 833 person-years (26 887 persons) in the Medicare Current Beneficiary Survey from 2015 to 2018, comparing differences in program enrollment and measures of access and quality by race and ethnicity.

Exposures  Minority race and ethnicity (Black, Hispanic, Native American, or Asian/Pacific Islander) vs White or multiracial; Medicare Advantage vs traditional Medicare enrollment.

Main Outcomes and Measures  Six patient-reported measures of ambulatory care access (whether a beneficiary had a usual source of care in the past year, had a primary care clinician usual source of care, or had a specialist visit) and quality (influenza vaccination, pneumonia vaccination, and colon cancer screening).

Results  The final sample included 6023 persons (mean age, 68.9 [SD, 12.6] years; 57.3% women) from minority groups and 20 864 persons (mean age, 71.9 [SD, 10.8] years; 54.9% women) from White or multiracial groups, who accounted for 9816 and 36 017 person-years, respectively. Comparing Medicare Advantage vs traditional Medicare among minority beneficiaries, those in Medicare Advantage had significantly better rates of access to a primary care clinician usual source of care (79.1% vs 72.5%; adjusted marginal difference, 4.0%; 95% CI, 1.0%-6.9%), influenza vaccinations (67.3% vs 63.0%; adjusted marginal difference, 5.2%; 95% CI, 1.9%-8.5%), pneumonia vaccinations (70.7% vs 64.6%; adjusted marginal difference, 6.1%; 95% CI, 2.7%-9.4%), and colon cancer screenings (69.4% vs 61.1%; adjusted marginal difference, 7.1%; 95% CI, 3.8%-10.3%). Comparing minority vs White or multiracial beneficiaries across both programs, minority beneficiaries had significantly lower rates of access to a primary care clinician usual source of care (adjusted marginal difference, 4.7%; 95% CI, 2.5%-6.8%), specialist visits (adjusted marginal difference, 10.8%; 95% CI, 8.3%-13.3%), influenza vaccinations (adjusted marginal difference, 4.3%; 95% CI, 1.2%-7.4%), and pneumonia vaccinations (adjusted marginal difference, 6.4%; 95% CI, 3.9%-9.0%). The interaction of race and ethnicity with insurance type was not statistically significant for any of the 6 outcome measures.

Conclusions and Relevance  In this exploratory study of Medicare beneficiaries in 2015-2018, enrollment in Medicare Advantage vs traditional Medicare was significantly associated with better outcomes for access and quality among minority beneficiaries; however, minority beneficiaries were significantly more likely to experience worse outcomes for most access and quality measures than White or multiracial beneficiaries in both programs.

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