Is care best in West? Racial gaps in Medicare Advantage persist across US, except in West

December 10, 2014

ANN ARBOR, Mich. -- Despite years of effort to help American seniors with high blood pressure, heart disease, or diabetes get their blood pressure, cholesterol and blood sugar under control, new research shows wide gaps between older people of different ethnic backgrounds in all three of these key health measures.

Black seniors in Medicare Advantage health plans are still much less likely than their white peers to have each of the three measures in check, according to a new study published in the December 11 issue of the New England Journal of Medicine.

If not well controlled, the three factors can substantially increase an older person's risk of health complications, from heart attacks and strokes to kidney failure and amputations.

But in a sign of hope, the researchers report that in Western states, control of these risk factors was highest -- and disparities between black and white seniors disappeared in the five-year period they studied from 2006 through 2011.

The team from the University of Michigan and Harvard University performed the study using data from representative samples of approximately 100,000 people across the U.S. in Medicare Advantage health maintenance organizations (HMOs).

"The 'disappearing disparities' in the West surprised us," says lead author John Ayanian, M.D., MPP, director of the U-M Institute for Healthcare Policy and Innovation. "It's one of a few examples in large populations where we've seen that higher quality of care can eliminate racial disparities in major risk factors," he says.

In the West, 74 percent of both blacks and whites had their blood pressure under control. The difference between the two groups was only one percentage point in both LDL cholesterol control and diabetic blood sugar control.

But in Northeast, Midwest, and South, the researchers found gaps as big as 14 percentage points between the two groups. In the Northeast, for instance, 60 percent of blacks had good blood pressure levels, and 51 percent had good cholesterol levels, compared with 71 percent and 65 percent, respectively, for whites.

Exactly why this Western effect happened, and how the success could be spread to the rest of the nation, needs further study, the authors note. But they report that seniors in Kaiser Permanente health plans in the West were more likely to have these three key risk factors under control than participants in other plans. Kaiser plans have devoted considerable effort to modifying these health risks for seniors.

Going beyond testing

The researchers linked and analyzed data from two Medicare data sources - enrollment data and HEDIS measures of quality of care. They used data from 2006 and 2011 to assess change over time, and adjusted for age and sex differences between racial and ethnic groups and regions.

The study confirms that in 2011, 90 to 95 percent of seniors with heart disease were tested for cholesterol and a similar proportion of seniors with diabetes had their blood sugar monitored. However, in regions outside the West, the test results for seniors were more likely to fall short of achieving levels that they need to reduce their long-term health risk, particularly for black seniors.

"These results show that the testing part of the puzzle has been solved, as nearly everyone is getting tested," says Ayanian. "But when we look at whether the risk factors are under control it really drops off, even for whites, despite the fact that we have multiple effective medications and lifestyle modifications for each of these risk factors." The disconnect may arise from the out-of-pocket costs of drugs and whether seniors receive or follow diet and exercise advice.

On a national level for 2011, the researchers were able to look at risk factor control rates not just for black and white seniors, but for those of Hispanic and Asian/Pacific Islander origin as well. This kind of analysis only recently became possible due to changes in the way Medicare collects racial and ethnic data for Medicare enrollees.

Hispanic seniors were somewhat less likely than whites to have good control of all three measures, though the differences much smaller than those between whites and blacks on a national scale. Asians were actually more likely than whites to have their blood pressure and cholesterol under control, and just as likely to have their blood sugar under control if they had diabetes.

Still, says Ayanian, "The fact that disparities have been eliminated in the West suggests that the racial disparities elsewhere are not mainly about biological differences between different groups. It's about treatment decisions by doctors and patients' ability to adhere to treatment, as well as the overall approach to controlling risk factors that a plan takes."

Major differences between health plans

Besides the differences between Kaiser and non-Kaiser plans in the West, the authors looked at the levels of control across all plans. They found that black Medicare Advantage enrollees were more likely to be enrolled in lower-performing health plans. In fact, this difference accounted for about half of the differences in how well their three risk factors were controlled.

Seniors can actually compare Medicare Advantage plans online to see how well their members' health risk factors are controlled, on average. The availability of such data makes it possible for seniors to get a good sense of the performance of the plans available to them.

The researchers note that their data only include seniors who were enrolled in Medicare Advantage plans, which included 30 percent of all Medicare beneficiaries in 2014. But they hope that a similar analysis will soon be possible for traditional Medicare, as more physicians join Accountable Care Organizations that collect quality data on key health risk factors.
In addition to Ayanian, the study's authors include Bruce Landon, M.D., M.B.A., Joseph Newhouse, Ph.D., and Alan Zaslavsky, Ph.D., all of Harvard. Ayanian is the Alice Hamilton Professor of Medicine in the U-M Medical School, and also serves as a professor of health management and policy in the U-M School of Public Health, and professor of public policy in U-M's Gerald R. Ford School of Public Policy. Research reported in this press release was supported by the National Institute on Aging of the National Institutes of Health under award number P01AG032952. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Reference: New England Journal of Medicine 2014;371:2288-97, DOI: 10.1056/NEJMsa1407273

University of Michigan Health System

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