Medicare Managed Care and Primary Care Quality: Examining Racial/Ethnic Effects Across States

Slide presentation from the AHRQ 2009 conference.

On September 16, 2009, Jayasree Basu made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (958 KB) (Plugin Software Help).


Slide 1

Slide 1. Medicare Managed Care and Primary Care Quality: Examining Racial/Ethnic Effects across States
 

Medicare Managed Care and Primary Care Quality: Examining Racial/Ethnic Effects across States

Jayasree Basu, Ph.D.

AHRQ 2009 Annual Conference

 

Slide 2

Slide 2. Background
 

Background

  • Medicare Modernization Act of 2003 sparked renewed interest in Medicare managed care (MMC)
  • Medicare spends more each year on beneficiaries enrolled in Medicare Advantage (MA) plans -little evidence to suggest added value worth the extra investment
  • Understudied topic: program's effectiveness in reducing racial and ethnic disparities in quality of health care delivery and access

 

Slide 3

Slide 3. Study Objective
 

Study Objective

  • To assess the role of MA plans in providing quality primary care compared to Fee For Service (FFS) Medicare in three states (NY, CA, FL) across three racial ethnic groups (White, African American, and Hispanic)
  • The performance will be measured in terms of providing better quality primary care, defined as lowering the risk of preventable (or Ambulatory Care Sensitive) hospital admissions

 

Slide 4

Slide 4. Hypotheses
 

Hypotheses

  • Managed care plans reduce preventable hospitalizations (PH) through care coordination and provision of preventive care
  • Relative to FFS, improved care coordination in HMO plans reduce PH for minorities more than whites
  • H1: PHMA < PH FFS
  • H2: PHMA(Minorities|Whites) < PH FFS(Minorities|Whites)

 

Slide 5

Slide 5. Patient Selection
 

Patient Selection

  • States : NY, CA, FL, Year: 2004
  • Hospitalized Medicare FFS and Medicare advantage (MA) plan enrollees (Age 65 and over)
  • Patient level data on MA versus FFS enrollment as recorded in the confidential files of discharge database of the three states

 

Slide 6

Slide 6. MMC Penetration by State and US
 

MMC penetration by State and US

All three states had higher penetration than US average in 1994, increasing further by 2000. CA reached 54% penetration rate By 2000.

MMC penetration by State and US

 1994 1996 1998 2000 
US 15% 31% 28% 29% 
FL 20% 29% 31% 31% 
NY 24% 36% 36% 36% 
CA 38% 44% 45% 54% 

State source: InterStudy

 

Slide 7

Slide 7. Data
 

Data

  • Hospital discharge data (HCUP-SID, AHRQ) for elderly Medicare (age 65+), 2004
  • Medicare managed care plans available in 2004 were predominately HMO types (96-99%)
  • Inpatient discharge data linked to area resource files, US Census, AHA, Interstudy, HRSA
  • Multivariate cross sectional framework with patient-level data for each State

 

Slide 8

Slide 8. Variables
 

Variables

  • Individual patient characteristics:
    • Three Racial ethnic groups
      • Whites
      • African Americans (AA)
      • Hispanics
    • Type of insurer, age groups, gender, severity of illness, indirect severity indicators, severity*HMO, race*HMO
  • Contextual data: socio-demographic conditions and provider characteristics in each Primary Care Service area (PCSA) where patients live

 

Slide 9

Slide 9. PCSA
 

PCSA

  • PCSA is the smallest geographic area validated as a discrete service area for primary care.
  • Defined on FFS Medicare patient flows to physician offices, updated frequently by HRSA.
  • Since managed care is expected to improve outcomes through better availability of primary and preventive care in the community, an area denominator which more accurately reflects a primary care market is appropriate

 

Slide 10

Slide 10. Design
 

Design

  • PH admissions compared with admissions for "marker conditions" for each State in each Racial group

PH

  • Sensitive to primary care
  • Ex: Severe ENT infections, UTI, COPD, Tuberculosis, Hypertension etc.,

Marker

  • Urgent, insensitive to primary care
  • Appendicitis with appendectomy, acute MI, gastrointestinal obstruction, fracture of hip/femur

 

Slide 11

Slide 11. PH Admissions
 

PH Admissions

severe ENT infections
chronic obstructive
pulmonary disease
diabetes
convulsions
hypoglycemia
kidney infection
asthma
angina
congestive heart failure
bacterial pneumonia
tuberculosis
hypertension
cellulitis
gastroenteritis requiring
hospitalization
urinary tract infection
dehydration
pelvic inflammatory disease
nutritional deficiencies
certain dental conditions

 

Slide 12

Slide 12. Marker Admissions: The Comparison Group
 

Marker Admissions: The Comparison Group

  • Diagnoses for which provision of timely and effective outpatient care is likely to have little impact on the need for hospital admission
  • Agreement among practitioners on clinical criteria for admission:

appendicitis with appendectomy
acute myocardial infarction
gastrointestinal obstruction
fracture of hip/femur

 

Slide 13

Slide 13. Analysis
 

Analysis

  • Unit of analysis = patients
  • Logistic regression models with odds of PH admission compared to marker admission for MA versus FFS enrollees
  • Logistic models by each Racial group and Pooled models
  • Multivariate logistic models with multilevel data, adjusting for area-level clustering, by state

 

Slide 14

Slide 14. RESULTS: Odds Ratios of PH Admissions (relative to Marker): MA VS. FFS enrollees
 

RESULTS Odds Ratios of PH Admissions (relative to Marker): MA VS. FFS enrollees

 WhiteAAHispanic
CA0.820.700.71
NY0.93N.S.0.85
FL0.890.820.75

 

Slide 15

Slide 15. RESULTS: Odds Ratios of PH Admissions (relative to .Marker): MA VS. FFS enrollees
 

RESULTS Odds Ratios of PH Admissions (relative to .Marker): MA VS. FFS enrollees

 CAFLNY
White0.820.890.93
AA0.70.82 
Hispanic0.710.750.85

 

Slide 16

Slide 16. % Difference in Odds of PH Admissions: MA versus FFS Enrollees
 

% Difference in Odds of PH Admissions: MA versus FFS Enrollees

 WhiteAAHispanic
CA-18-30-29
NY-7N.S.-15
FL-11-18-25

CA and FL had greater reductions in odds of PH among MA enrollees by racial groups, minorities in particular, relative to FFS
 

 

Slide 17

Slide 17. Odds Ratios of PH Admissions versus Marker Admissions: Race*HMO Interactions
 

Odds Ratios of PH Admissions versus Marker Admissions: Race*HMO Interactions

 AA/WhiteHispanic/White
CA0.83 (p=.000)*0.87 (p=.012)*
NYN.S.N.S.
FL0.90 (p=.153)0.81 (p=.000)*

*MA enrollment associated with significantly lower PH among
Minorities relative to Whites
 

 

Slide 18

Slide 18. Summary
 

Summary

  • In all racial groups, MA enrollment was associated with lower risks of PH admissions (versus marker admissions) than FFS enrollment
  • Minority MA enrollees had lower risks of PH admissions (versus marker admissions) than white MA enrollees, relative to their FFS counterparts
  • CA and FL: Interaction effect in pooled model shows statistically significant reductions in PH rates among minority relative to white MA enrollees

 

Slide 19

Slide 19. Conclusion
 

Conclusion

  • MA plans were associated with beneficial impacts in all three states by improving quality primary care and reducing preventable hospitalizations
  • The benefit also spilled over to different racial and ethnic subgroups
  • In CA and FL, MA enrollment was associated with significant reductions in racial and ethnic differences in preventable hospitalization rates

 

Slide 20

Slide 20. Implications
 

Implications

  • MA plans (HMO) added value to the quality of primary care to the elderly by racial groups.
  • Greater reduction of PH rates among minority subgroups indicates favorable role of MA plans in achieving racial/ethnic equalities.
  • Care management provided in Medicare HMOs may have implications for future strategies to reduce racial ethnic gaps and improve quality of primary care.
  • The findings may have implications for greater use of preventive care advocated for health reform.
  • Future research should evaluate the MMC programs by other plan types using more recent data.
Current as of December 2009
Internet Citation: Medicare Managed Care and Primary Care Quality: Examining Racial/Ethnic Effects Across States. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/basu/index.html