Racial Disparities High In Medicare Plans

Armen Hareyan's picture

Race and Medicare Insurance Plans

Numerous studies show the African-Americans receive worse quality of care relative to white Americans across a broad array of medical conditions - disparities that can significantly harm patients or reduce quality of life. A new study from Harvard Medical School and Brown Medical School shows that such disparities in care cannot simply be attributed to low-performing health insurance plans. The research, published in the Oct. 25 Journal of the American Medical Association, shows that high-performing health insurance plans and low-performing health plans, based on four key health measures, have comparable levels of disparities in these measures while serving Medicare patients.

"Across Medicare health plans, better overall quality is not consistently associated with smaller racial disparities on four key outcome measures for enrollees with diabetes, hypertension, or heart disease," says John Ayanian, MD, MPP, associate professor of health care policy and of medicine at Harvard Medical School (HMS) and Brigham and Women's Hospital.

Ayanian, Amal Trivedi, MD, MPH, formerly of the Department of Health Care Policy at HMS and now an assistant professor of community health at Brown Medical School, and colleagues found only one health insurance plan in a sample of 151 that had both high overall quality and low racial disparity on more than one of four outcome measures examined.

Since 1997, all health insurance plans participating in Medicare have been mandated to report on quality of care using Health Plan Employer and Data Information Set (HEDIS) performance measures developed by the National Committee for Quality Assurance. The authors obtained HEDIS data for Medicare managed care plans, containing more than 431,000 observations from enrollees in 151 health insurance plans.

For the four HEDIS outcome measures the authors examined, clinical performance was approximately 7 to 14 percent lower for black enrollees than white enrollees. More than 70 percent of the racial disparity on each measure was attributable to different outcomes within the same health plans for white and black enrollees, not a disproportionate enrollment of blacks in lower-performing plans.

"This study indicates that most health plans have substantial opportunities to improve their outcomes for African-American enrollees on these measures," says Trivedi.


The authors examined data for individuals eligible for at least one of four HEDIS outcome indicators: control of blood sugar and cholesterol among enrollees with diabetes, blood pressure control among enrollees with hypertension, and cholesterol control among enrollees following a heart attack or heart surgery.

For all measures, the difference between the top and bottom ranked health plan in overall quality ranged from 35 (for blood pressure control of hypertension) to 70 percent (for blood sugar control of diabetes). Although a few plans did not have significant disparity, some plans had racial differences of more than 20 percent.

"This shows that racial disparities in these important outcome measures are widespread and not limited to any one region or subset of poorly performing health plans," says Ayanian.

Achieving equity may be more difficult for outcome measures, which often require sustained access and adherence to drug therapy, an ongoing relationship with a health care provider, lifestyle modifications, and attention to social determinants of health, than for measures of processes of care that require simpler actions, such as a single annual blood test.

"Our findings suggest that nearly all Medicare health plans will need to develop specific programs to improve equity on at least three of the four clinical outcome measures we studied," says Trivedi. "The federal government requires health plans to measure and report overall quality on these clinical indicators. We recommend that health insurance plans assess disparities in clinical performance measures as part of a broad strategy to eliminate racial and ethnic disparities in quality of care."

Many health insurance plans do not collect data on the race or ethnicity of enrollees, but without such data, health care organizations will be unable to detect systematic racial or ethnic disparities among patients or develop and evaluate interventions to eliminate disparities.

This work was supported by an institutional National Research Service Award and grant from the Agency for Healthcare Research and Quality; an institutional National Research Service Award from the Health Resources and Services Administration; the Primary Care Research Fund at Brigham and Women's Hospital; and a Bridge Award from Harvard Medial School.