Racial and ethnic disparities in care for health system‐affiliated physician organizations and non‐affiliated physician organizations

Abstract

Objective: To assess racial and ethnic disparities in care for Medicare fee-for-service (FFS) beneficiaries and whether disparities differ between health system-affiliated physician organizations (POs) and nonaffiliated POs. Data Sources: We used Medicare Data on Provider Practice and Specialty (MD-PPAS), Medicare Provider Enrollment, Chain, and Ownership System (PECOS), IRS Form 990, 100% Medicare FFS claims, and race/ethnicity estimated using the Medicare Bayesian Improved Surname Geocoding 2.0 algorithm. Study Design: Using a sample of 16 007 POs providing primary care in 2015, we assessed racial/ethnic disparities on 12 measures derived from claims (2 cancer screenings; diabetic eye examinations; continuity of care; two medication adherence measures; three measures of follow-up visits after acute care; all-cause emergency department (ED) visits, all-cause readmissions, and ambulatory care-sensitive admissions). We decomposed these "total" disparities into within-PO and between-PO components using models with PO random effects. We then pair-matched 1853 of these POs that were affiliated with health systems to similar nonaffiliated POs. We examined differences in within-PO disparities by affiliation status by interacting each nonwhite race/ethnicity with an affiliation indicator. Data Collection/Extraction methods: Medicare Data on Provider Practice and Specialty identified POs billing Medicare; PECOS and IRS Form 990 identified health system affiliations. Beneficiaries age 18 and older were attributed to POs using a plurality visit rule. Principal Findings: We observed total disparities in 12 of 36 comparisons between white and nonwhite beneficiaries; nonwhites received worse care in 10. Within-PO disparities exceeded between-PO disparities and were substantively important (>=5 percentage points or>=0.2 standardized differences) in nine of the 12 comparisons. Among these 12, nonaffiliated POs had smaller disparities than affiliated POs in two comparisons (P < .05): 1.6 percentage points smaller black-white disparities in TIMBIE ET al. within their own health care organizations using evidence-based interventions. Public reporting of health equity composite measures 55 at the level of POs or health systems could provide greater accountability for providers to take action to reduce these disparities.

The promise and peril of health systems

“…Riskadjusted total cost of care, for patients attributed to physicians in a system, is a commonly used measure. 5,8,9 However, with the notable exception in this volume of analysis of data from four states with All Payer Claims Data bases, most of the research analyzing total cost of care is limited to analysis of Medicare beneficiaries. 9 To the extent that we are concerned that large health systems are able to increase prices, analysis of data on privately insured patients is needed.…”

“…Development of valid and reliable measures of health system performance has been more challenging, reflecting the challenges of measuring performance in health care more generally. Risk‐adjusted total cost of care, for patients attributed to physicians in a system, is a commonly used measure 5,8,9 . However, with the notable exception in this volume of analysis of data from four states with All Payer Claims Data bases, most of the research analyzing total cost of care is limited to analysis of Medicare beneficiaries 9 .…”

“…Measurement of health system performance in improving quality and outcomes has relied primarily on measures developed for measuring performance of hospitals and physician groups. For example, the strong contribution in this volume analyzing whether disparities in care are any smaller for patients of physician organizations affiliated with health systems than for patients of nonaffiliated physicians provides a useful list of measures, reflecting the state of the art 8 . This paper analyzes a set of process measures, such as breast and colon cancer screening; medication adherence measures; care coordination measures; and utilization measures for sentinel events, such as emergency department visits for ambulatory care sensitive admissions.…”

Making integration work

“…2 Only one of the papers addresses equity of care, finding no dramatic effects. 3 None address effects on institutional racism. There are a number of possible reasons for this disappointing result.…”

“…Despite glimmers of hope, integration is not yielding significant improvements in documentable quality and cost of care 2 . Only one of the papers addresses equity of care, finding no dramatic effects 3 . None address effects on institutional racism.…”