BACKGROUND: Social risk factors (SRFs) such as minority race-and-ethnicity or low income are associated with quality-of-care, health, and healthcare outcomes. Organizations might prioritize improving care for easier-totreat groups over those with SRFs, but measuring, reporting, and further incentivizing quality-of-care for SRF groups may improve their care. OBJECTIVE: To develop, as a proof-of-concept, a Health Equity Summary Score (HESS): a succinct, easy-tounderstand score that could be used to promote highquality care to those with SRFs in Medicare Advantage (MA) health plans, which provide care for almost twenty million older and disabled Americans and collect extensive quality measure and SRF data. DESIGN: We estimated, standardized, and combined performance scores for two sets of quality measures for enrollees in 2013-2016 MA health plans, considering both current levels of care, within-plan improvement, and nationally benchmarked improvement for those with SRFs (specifically, racial-and-ethnic minority status and dual-eligibility for Medicare and Medicaid). PARTICIPANTS: All MA plans with publicly reported quality scores and 500 or more 2016 enrollees. MAIN MEASURES: Publicly reported clinical quality and patient experience measures. KEY RESULTS: Almost 90% of plans measured for MA Star Ratings received a HESS; plans serving few patients with SRFs were excluded. The summary score was moderately positively correlated with publicly reported overall Star Ratings (r = 0.66-0.67). High-scoring plans typically had sizable enrollment of both racial-and-ethnic minorities (38-42%) and dually eligible beneficiaries (29-38%). CONCLUSIONS: We demonstrated the feasibility of developing and estimating a HESS that is intended to promote and incentivize excellent care for racial-and-ethnic minorities and dually eligible MA enrollees. The HESS measures SRF-specific performance and does not simply duplicate overall plan Star Ratings. It also identifies plans that provide excellent care to large numbers of those with SRFs. Our methodology could be extended to other SRFs, quality measures, and settings.
Study Design. We defined seven subgroup characteristics: low-income subsidy eligible, no high school degree, poor or fair self-rated health, age 85 and older, female, Hispanic, and black. We estimated disparities in CAHPS experience of care scores between each of these groups and beneficiaries without those characteristics within MA and FFS for 11 CAHPS measures and assessed differences between MA and FFS disparities in linear models. Principal Findings. The seven subgroup characteristics had significant (po.05) negative interactions with MA (larger disparities in MA) in 27 of 77 instances, with only four significant positive interactions. Conclusion. Managed care may provide less uniform care than FFS for patients; specifically there may be larger disparities in MA than FFS between beneficiaries who have low incomes, are less healthy, older, female, and who did not complete high school, compared with their counterparts. There may be potential for MA quality improvement targeted at the care provided to particular subgroups.
Objective To examine racial/ethnic differences in Medicare beneficiary experiences with Medicare Part D prescription drug (PD) coverage. Data Sources/Study Setting 2008 Consumer Assessment of Health Care Providers and Systems survey of U.S. Medicare beneficiaries. Study Design Surveys were administered by mail with phone follow-up to a nationally representative sample (61% response rate). This study examines 201,496 beneficiaries of age 65 and older with PD coverage [6% Hispanic, 7% non-Hispanic Black, 3% non-Hispanic Asian or Pacific Islander (API)]. Key variables are self-reported race/ethnicity and Consumer Assessment of Health Care Providers and Systems getting information and needed PDs measures. Data Collection/Extraction Methods We generated weighted case-mix adjusted means for 4 racial/ethnic groups and for Hispanics separately by English-language or Spanish-language preference status. We calculated within-plan disparities using a linear mixed-effect model, with fixed effects for race/ethnicity, coverage type and case-mix variables, and random effects for contract and contract by race/ethnicity interactions. Principal Findings Disparities for Hispanic, Black, and API beneficiaries on obtaining needed PDs and information regarding coverage range from −2 to −11 points (0–100 scale) relative to non-Hispanic Whites, with the greatest disparities observed for Spanish-preferring Hispanics and API beneficiaries, especially those with low income. There is wide variation in disparities across contracts, and contracts with the largest disparities for Hispanics have higher proportions of beneficiaries with lower education and income. Conclusions Quality improvement efforts may be needed to reduce racial/ethnic disparities in beneficiary experience with PD coverage. Cultural, language, and health literacy barriers in navigating Medicare's Part D program may partially explain the observed disparities.
Objectives To investigate whether health care experiences of adult Medicaid beneficiaries differ by race/ethnicity and rural/urban status. Data Sources A total of 270 243 respondents to the 2014‐2015 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems Survey. Study Design Linear regression was used to estimate case mix adjusted differences in patient experience between racial/ethnic minority and non‐Hispanic white Medicaid beneficiaries, and between beneficiaries residing in small urban areas, small towns, and rural areas vs large urban areas. Dependent measures included getting needed care, getting care quickly, doctor communication, and customer service. Principal Findings Compared with white beneficiaries, American Indian/Alaska Native (AIAN) and Asian/Pacific Islander (API) beneficiaries reported worse experiences, while black beneficiaries reported better experiences. Deficits for AIAN beneficiaries were 6‐8 points on a 0‐100 scale; deficits for API beneficiaries were 13‐22 points (P's < 0.001); advantages for black beneficiaries were 3‐5 points (P's < 0.001). Hispanic white differences were mixed. Beneficiaries in small urban areas, small towns, and isolated rural areas reported significantly better experiences (2‐3 points) than beneficiaries in large urban areas (P's < 0.05), particularly regarding access to care. Racial/ethnic differences typically did not vary by geography. Conclusions Improving experiences for racial/ethnic minorities and individuals living in large urban areas should be high priorities for policy makers exploring approaches to improve the value and delivery of care to Medicaid beneficiaries.
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