Medicare Managed Care and Primary Medicare Managed Care and Primary Care Quality: Examining Care Quality: Examining

Racial/Ethnic Effects across StatesRacial/Ethnic Effects across States

Jayasree Basu, Ph.D. Jayasree Basu, Ph.D.

AHRQ 2009 Annual ConferenceAHRQ 2009 Annual Conference

BackgroundBackground

Medicare Modernization Act of 2003 sparked renewed Medicare Modernization Act of 2003 sparked renewed interest in Medicare managed care (MMC) interest in Medicare managed care (MMC)

Medicare spends more each year on beneficiaries Medicare spends more each year on beneficiaries enrolled in Medicare Advantage (MA) plans —little enrolled in Medicare Advantage (MA) plans —little evidence to suggest added value worth the extra evidence to suggest added value worth the extra investmentinvestment

Understudied topic: program’s effectiveness in reducing Understudied topic: program’s effectiveness in reducing racial and ethnic disparities in quality of health care racial and ethnic disparities in quality of health care delivery and accessdelivery and access

Study ObjectiveStudy Objective

To assess the role of MA plans in providing To assess the role of MA plans in providing quality primary care compared to Fee For quality primary care compared to Fee For Service (FFS) Medicare in three states (NY, CA, Service (FFS) Medicare in three states (NY, CA, FL) across three racial ethnic groups (White, FL) across three racial ethnic groups (White, African American, and Hispanic)African American, and Hispanic)

The performance will be measured in terms of The performance will be measured in terms of providing better quality primary care, defined providing better quality primary care, defined as lowering the risk of preventable (or as lowering the risk of preventable (or Ambulatory Care Sensitive) hospital Ambulatory Care Sensitive) hospital admissionsadmissions

HypothesesHypotheses

Managed care plans reduce preventable Managed care plans reduce preventable hospitalizations (PH) through care coordination hospitalizations (PH) through care coordination and provision of preventive care and provision of preventive care

Relative to FFS, improved care coordination in Relative to FFS, improved care coordination in HMO plans reduce PH for minorities more than HMO plans reduce PH for minorities more than whiteswhites

HH11: PH: PHMAMA < PH < PH FFSFFS

HH22: PH: PHMA(Minorities|Whites)MA(Minorities|Whites) < PH < PH FFS(Minorities|Whites)FFS(Minorities|Whites)

Patient SelectionPatient Selection

States : States : NY, CA, FLNY, CA, FL, Year:, Year: 2004 2004

Hospitalized Medicare FFS and Medicare advantage Hospitalized Medicare FFS and Medicare advantage (MA) plan enrollees (Age 65 and over)(MA) plan enrollees (Age 65 and over)

Patient level data on MA versus FFS enrollment as Patient level data on MA versus FFS enrollment as recorded in the confidential files of discharge database recorded in the confidential files of discharge database of the three states of the three states

MMC penetration by State and US

0% 20% 40% 60%

1994

1996

1998

2000

CA

NY

FL

US

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

State source: InterStudyState source: InterStudy

Data Data

Hospital discharge data (HCUP-SID, AHRQ) for Hospital discharge data (HCUP-SID, AHRQ) for elderly Medicare (age 65+), 2004elderly Medicare (age 65+), 2004

Medicare managed care plans available in 2004 Medicare managed care plans available in 2004 were predominately HMO types (96-99%)were predominately HMO types (96-99%)

Inpatient discharge data linked to area resource Inpatient discharge data linked to area resource files, US Census, AHA, Interstudy, HRSA files, US Census, AHA, Interstudy, HRSA

Multivariate cross sectional framework with Multivariate cross sectional framework with patient-level data for each Statepatient-level data for each State

NYNY FLFLCACA

Variables

Individual patient characteristics: Individual patient characteristics: – Three Racial ethnic groupsThree Racial ethnic groups

Whites Whites African Americans (AA)African Americans (AA) HispanicsHispanics

– Type of insurer, age groups, gender, severity of Type of insurer, age groups, gender, severity of illness, indirect severity indicators, severity*HMO, illness, indirect severity indicators, severity*HMO, race*HMOrace*HMO

Contextual data: socio-demographic conditions Contextual data: socio-demographic conditions and provider characteristics in each Primary and provider characteristics in each Primary Care Service area (PCSA) where patients liveCare Service area (PCSA) where patients live

PCSAPCSA

PCSA is the smallest geographic area validated as a PCSA is the smallest geographic area validated as a discrete service area for primary care.discrete service area for primary care.

Defined on FFS Medicare patient flows to physician Defined on FFS Medicare patient flows to physician offices, updated frequently by HRSA.offices, updated frequently by HRSA.

Since managed care is expected to improve outcomes Since managed care is expected to improve outcomes through better availability of primary and preventive through better availability of primary and preventive care in the community, an area denominator which care in the community, an area denominator which more accurately reflects a primary care market is more accurately reflects a primary care market is appropriateappropriate

DesignDesign

PH admissions compared with admissions for PH admissions compared with admissions for “marker conditions” “marker conditions” for each State in in each Racial each Racial groupgroup

PHPH MarkerMarker

• Urgent, insensitive Urgent, insensitive to primary careto primary care

• Appendicitis with Appendicitis with appendectomy, appendectomy, acute MI, acute MI, gastrointestinal gastrointestinal obstruction, fracture obstruction, fracture of hip/femurof hip/femur

• Sensitive to Sensitive to primary careprimary care

• Ex: Severe ENT Ex: Severe ENT infections, UTI,infections, UTI,COPD, Tuberculosis,COPD, Tuberculosis,Hypertension etc., Hypertension etc.,

severe ENT infections bacterial pneumoniasevere ENT infections bacterial pneumoniachronic obstructivechronic obstructive tuberculosis tuberculosispulmonary diseasepulmonary disease hypertension hypertension diabetesdiabetes cellulitis cellulitisconvulsions convulsions gastroenteritis requiring gastroenteritis requiringhypoglycemia hypoglycemia hospitalization hospitalizationkidney infection kidney infection urinary tract infection urinary tract infectionasthmaasthma dehydration dehydrationangina angina pelvic inflammatory pelvic inflammatory disease congestive heart failure nutritional disease congestive heart failure nutritional deficienciesdeficiencies

certain dental conditionscertain dental conditions

PH Admissions

Marker Admissions: Marker Admissions: The Comparison GroupThe Comparison Group

Diagnoses for which provision of timely and Diagnoses for which provision of timely and effective outpatient care is likely to have little effective outpatient care is likely to have little impact on the need for hospital admissionimpact on the need for hospital admission

Agreement among practitioners on clinical criteria Agreement among practitioners on clinical criteria for admission:for admission:

appendicitis with appendectomyappendicitis with appendectomy acute myocardial infarctionacute myocardial infarction gastrointestinal obstructiongastrointestinal obstruction fracture of hip/femurfracture of hip/femur

AnalysisAnalysis

Unit of analysis = patientsUnit of analysis = patients

Logistic regression models with odds of PH admission Logistic regression models with odds of PH admission compared to marker admission for MA versus FFS enrolleescompared to marker admission for MA versus FFS enrollees

Logistic models by each Racial group and Pooled Logistic models by each Racial group and Pooled modelsmodels

Multivariate logistic models with multilevel data, Multivariate logistic models with multilevel data, adjusting for area-level clustering, by stateadjusting for area-level clustering, by state

RESULTSRESULTS Odds Ratios of PH Admissions (relative to Odds Ratios of PH Admissions (relative to

Marker): MA VS. FFS enrolleesMarker): MA VS. FFS enrollees

WhiteWhite AAAA

0.820.82

0.930.93

0.89 0.89

0.70 0.70

N.S.N.S.

0.820.82

NYNY

FLFL

CACA

Hispanic

0.71 0.71

0.850.85

0.750.75

0.400.500.600.700.800.901.001.101.201.30

CA FL NY

White

AA

Hispanic

PH versus marker

Odds Ratios

----------------------------------------------------------

(PH/marker) MA = (PH/marker) FFS

0.8

20

.70

0.7

1

0.8

90

.82

0.7

5

0.9

3

0.8

5

ResultsOdds ratios <1 in all racial groups in each state, and lower for minorities than whites

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

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

WhiteWhite AAAA

-18-18

-7-7

-11 -11

-30 -30

N.S.N.S.

-18-18

NYNY

FLFL

CACA

Hispanic

-29 -29

-15-15

-25-25

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

AA / WhiteAA / White Hispanic / WhiteHispanic / White

0.83 (p=.000)*0.83 (p=.000)*

N.S.N.S.

0.90 (p=.153)0.90 (p=.153)

0.87 (p=.012)*0.87 (p=.012)*

N.S.N.S.

0.81 (p=.000)*0.81 (p=.000)*

NYNY

FLFL

CACA

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

Summary

In all racial groups, MA enrollment was associated In all racial groups, MA enrollment was associated with lower risks of PH admissions (versus marker with lower risks of PH admissions (versus marker admissions) than FFS enrollmentadmissions) than FFS enrollment

Minority MA enrollees had lower risks of PH Minority MA enrollees had lower risks of PH admissions (versus marker admissions) than white admissions (versus marker admissions) than white MA enrollees, relative to their FFS counterpartsMA enrollees, relative to their FFS counterparts

CA and FL: Interaction effect in pooled model shows CA and FL: Interaction effect in pooled model shows statistically significant reductions in PH rates among statistically significant reductions in PH rates among minority relative to white MA enrolleesminority relative to white MA enrollees

Conclusion

MA plans were associated with beneficial impacts MA plans were associated with beneficial impacts in all three states by improving quality primary in all three states by improving quality primary care and reducing preventable hospitalizationscare and reducing preventable hospitalizations

The benefit also spilled over to different racial and The benefit also spilled over to different racial and ethnic subgroupsethnic subgroups

In CA and FL, MA enrollment was associated with In CA and FL, MA enrollment was associated with significant reductions in racial and ethnic significant reductions in racial and ethnic differences in preventable hospitalization ratesdifferences in preventable hospitalization rates

Implications

MA plans (HMO) added value to the quality of primary care to the MA plans (HMO) added value to the quality of primary care to the elderly by racial groups.elderly by racial groups.

Greater reduction of PH rates among minority subgroups indicates Greater reduction of PH rates among minority subgroups indicates favorable role of MA plans in achieving racial/ethnic equalities.favorable role of MA plans in achieving racial/ethnic equalities.

Care management provided in Medicare HMOs may have implications Care management provided in Medicare HMOs may have implications for future strategies to reduce racial ethnic gaps and improve quality for future strategies to reduce racial ethnic gaps and improve quality of primary care.of primary care.

The findings may have implications for greater use of preventive care The findings may have implications for greater use of preventive care advocated for health reform. advocated for health reform.

Future research should evaluate the MMC programs by other plan Future research should evaluate the MMC programs by other plan types using more recent data. types using more recent data.