SLU Research: Access to Care for Minority Medicare Patients Worse Than That of Non-Minority Patients

08/17/2021

Saint Louis University research has found that Medicare patients who belong to racial or ethnic minority groups (Black, Hispanic, Asian/Pacific Islander, or Native American) experience worse access to and quality of ambulatory or out-patient medical care than Medicare patients who are White or multiracial, regardless of whether they may be enrolled in Medicare Advantage or traditional Medicare.

The research also found that minority Medicare patients enrolled in the Medicare Advantage program, which increased access to healthcare overall, experience better out-patient care access and quality than minority patients enrolled in the traditional Medicare program. Those patients still have less access than White or multiracial patients. 

Health inequities are disproportionally concentrated within racial and ethnic communities in the United States. One of the key signs of this is reduced access to ambulatory care. The individuals who lack access to such care are more likely to experience preventable complications of health conditions, leading to higher rates of hospitalization and death.

The study was led Kenton J. Johnston, Ph.D., an associate professor of health management and policy at SLU’s College for Public Health and Social Justice, and published online Aug. 17 in the Journal of the American Medical Association (JAMA).

In this exploratory study of Medicare beneficiaries from 2015-18, enrollment in Medicare Advantage compared with traditional Medicare was significantly associated with better outcomes on one of three access (primary care) and three of three quality (flu shots, pneumonia vaccinations, and colon cancer screening) measures for minority beneficiaries; however, minority beneficiaries were also significantly more likely to experience worse outcomes for two of three access (primary care and specialist visits) and two of three quality (flu shots and pneumonia vaccination) metrics compared with other beneficiaries in both Medicare programs.

The research, “Association of Race and Ethnicity and Medicare Program Type with Ambulatory Care Access and Quality Measures,” was an observational cohort study of a nationally representative sample of 26,887 people in the Medicare Current Beneficiary Survey from 2015-18.

The study looked at differences in program enrollment and measures of access and quality by race and ethnicity.

The research team compared Black, Hispanic, Native American and Asian/Pacific Islander to white or multi-racial patients enrolled in Medicare Advantage versus traditional Medicare.

The study focused on four questions:

• Does enrollment in Medicare Advantage vary by race and ethnicity?
• How do ambulatory care access and quality for racial and ethnic minority beneficiaries compare in both programs?
• How do differences in access and quality by race and ethnicity compare in Medicare Advantage versus traditional Medicare?
• Are ambulatory care access and quality better for racial and ethnic minorities enrolled in Medicare Advantage?

“Although prior studies have shown lower rates of access and quality for minority patients in both Medicare programs, it was unknown whether there were differences in care quality or access for racial and ethnic minority beneficiaries between the Medicare Advantage and traditional Medicare programs,” Johnston said. “In addition, as more minority patients have enrolled in Medicare Advantage in recent years, it was unknown whether they experienced better access to and quality of ambulatory care in that program more recently.”

The research team looked at six patient-reported measures of ambulatory care access and quality: usual source of care, usual source of care is primary care, specialist visit, influenza vaccination, pneumonia vaccination and colon cancer screening.

The study found Medicare Advantage enrollment rates have grown substantially and as quality measures have been implemented in both Medicare Advantage and traditional Medicare over the past decade these patterns persist.

Limitations on the study include the fact that Hispanic and Asian/Pacific Islander patient populations couldn’t be further disaggregated; diagnosis upcoding in Medicare Advantage can make beneficiaries appear sicker than they are; Medicare Advantage plans selectively enter local markets; and both Medicare Advantage and traditional Medicare are heterogeneous programs.

The researchers conclude that direct measurement and incentivization of equity may be required to meaningfully close gaps in access and quality between minority and non-minority patients in both programs.

In addition, Johnston said, private Medicare Advantage plans may want to begin doing this immediately as a way of improving care for a growing racial and ethnic minority customer base.

Co-authors include Gmerice Hammond, M.D., Washington University School of Medicine; David J. Meyers, Ph.D., Department of Health Services, Policy and Practice at Brown University; and Karen E. Joynt Maddox, M.D., Co-Director of the Center for Health Economics and Policy at Washington University in St. Louis.

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The Saint Louis University College for Public Health and Social Justice is the only academic unit of its kind, studying social, environmental and physical influences that together determine the health and well-being of people and communities. It also is the only accredited school or college of public health among nearly 250 Catholic institutions of higher education in the United States.

Guided by a mission of social justice and focus on finding innovative and collaborative solutions for complex health problems, the College offers nationally recognized programs in public health, social work, health administration, applied behavior analysis, and criminology and criminal justice.