"Reducing Racial and Ethnic Disparities in Medicare,"by Ellen O'Brien September/October 2005 issue of Poverty & Race
Medicare’s federal entitlement offers a set of defined health benefits to more than 40 million elderly individuals and persons with disabilities. By virtue of their access to a social insurance program with uniform benefits that cuts across socioeconomic, class, and racial and ethnic groups, Medicare beneficiaries are, in principle, assured access to mainstream healthcare. Hospitals, nursing homes and other medical providers who receive Medicare funds—with the notable exception of physicians—are required by Title VI of the Civil Rights Act to provide care on a nondiscriminatory basis. Medicare’s conditions of participation also mandate that care of equal quality be provided to patients regardless of their race and ethnicity.
Despite the promise of access to care that national benefits provide, not all populations fare equally well in Medicare. Numerous studies document that diverse racial and ethnic groups (African Americans, Hispanics/Latinos, Asian and Pacific Islanders, and others) experience greater difficulties than whites accessing care; are more likely to receive inferior care when they are diagnosed with an illness; and suffer worse health outcomes as a result. Elderly black Medicare beneficiaries are seen less often by specialists and receive less appropriate preventive care, lower quality hospital care and fewer expensive technological procedures. These disparities exist across a wide variety of clinical conditions (acute and chronic, and physical and mental illnesses), across healthcare settings (physician offices, hospitals, nursing homes and other healthcare facilities) and services (preventive, diagnostic, rehabilitative, therapeutic). Disparities exist in both fee-for-service (original) Medicare and Medicare-managed care.
Sources of Disparities in Medicare
Although the implementation of Medicare dramatically narrowed income- and race-related disparities in access to care and quality of care, financial access did not guarantee equity in access to and availability of services to all of Medicare’s populations. In Medicare, and in the healthcare system generally, there are several recognized sources of disparities that persist even when beneficiaries have the same insurance coverage:
Poor Neighborhoods: Racial and ethnic disparities in the amount and quality of care that beneficiaries receive arise in part because culturally diverse beneficiaries live in poor and racially segregated neighborhoods. Beneficiaries who are culturally and physically separated from the mainstream may not be willing or able to access the same hospitals and providers as high-income, white beneficiaries. The urban poor are more likely to receive care at public hospitals and other urban safety-net hospitals. Culturally diverse beneficiaries are also more likely than whites to receive care in clinics, hospital outpatient departments and emergency rooms, and have more difficulty getting care from a usual provider at a consistent location. People in poor neighborhoods receive care in segregated and resource-constrained systems, receive less continuous care from a given provider, have more limited access to specialists and are referred less often for intensive procedures. Recent surveys of the physicians who treat culturally diverse patients in Medicare reveal that primary care physicians treating black and Hispanic/Latino patients have greater difficulty obtaining access for their patients to high-quality sub-specialists, high quality diagnostic imaging and non-emergency admission to the hospital.
Poor People: Racial and ethnic disparities in Medicare persist, in part, because African-American, Hispanic/Latino and other racial and ethnic groups tend to have lower incomes than whites and greater difficulty affording Medicare’s required beneficiary cost-sharing. Minority beneficiaries in Medicare have lower incomes on average than white beneficiaries, and are less likely to have private supplemental (Medigap) coverage. They also are more likely to rely on Medicaid as a supplement to Medicare. Although studies of the impact of race and ethnicity generally “control” for income and supplemental coverage, they often do this crudely without accurately accounting for variations in the level of insurance coverage.
Part of the affordability problem can be attributed to financial and non-financial barriers, to barriers to enrollment in Part B (and Part A for certain eligibles), and to the design and implementation of the programs intended to assist poor and low-income beneficiaries with Medicare’s cost-sharing responsibilities. Medicaid provides assistance with Medicare’s premiums and cost-sharing for certain poor and low-income beneficiaries, but research on enrollment in the Medicare Savings Programs has identified many general barriers to enrollment, including a lack of information about how to enroll, complicated enrollment forms, asset tests, and a lack of one-on-one assistance from a trusted source to help eligible individuals through the enrollment process.
Certain populations face substantial barriers to enrollment in the Medicare Savings Programs—three federal programs that help people with low incomes to pay for Medicare coverage. For example, a recent research study shows that the number of eligible American Indian or Alaska Natives (in 15 states with large AI/AN populations) significantly exceeds the number enrolled in Medicare. The research suggests that federal outreach and education for AI/AN populations is inadequate, and that the Part B premium is a substantial barrier to enrollment in Part B for these populations as well. Research on Asian Americans confirms that lack of awareness of eligibility is a significant problem and suggests that Asian-American elderly also have a limited understanding of and limited willingness to enroll in health insurance plans. According to a 2001 study by the Center for Medicare Education: “Cultural background affects people’s understanding of the concept of insurance, their attitudes toward government programs, their willingness to trust information about Medicare, as well as their capacity to understand the information they receive.” Administrative barriers—a lack of linguistic and cultural competence at federal, state and county offices where enrollment takes place—are also significant.
Health System Barriers: Disparities in clinical care also arise because culturally diverse populations face unique logistical and cultural challenges dealing with healthcare providers and health systems. Complex medical bills and forms, and complicated processes for obtaining necessary care, may deter patients with low literacy or limited English proficiency from seeking care. Physician practices, medical institutions and healthcare plans may erect systems that create intentional and unintentional barriers to care for racial and ethnic groups. Hispanic/Latino beneficiaries, for example, are more likely than whites to have been uninsured before becoming eligible for Medicare. As a result, they may be less likely to have the skills needed to navigate a complex healthcare delivery and insurance system, and they may not have access to physicians willing to advocate strongly on their behalf when coverage is denied.
Marginal literacy and limited English proficiency create barriers in access to health information and health services. Recent research has shown that the elderly in Medicare with limited English proficiency are less likely to have a usual source of care, less likely to see a private physician and more likely to use a safety-net provider. In general, according to a 2004 Center on Budget and Policy Priorities paper by Leighton Ku and Glenn Flores, studies show that “LEP patients frequently defer needed medical care, have a higher risk of leaving the hospital against medical advice, are less likely to have a regular medical provider, have an increased risk of drug complications, and are more likely to miss follow-up appointments.” A significant part of the explanation for these difficulties rests with the fact that culturally diverse patients often rely on healthcare providers who are not sensitive to cultural differences and are not able to communicate effectively with patients with whom they do not share a common race or ethnicity, language or culture.
Provider Bias: Physician behavior also contributes to racial disparities. In fact, most discussions of disparities in medical care focus not on the disparities that arise because minority patients are disproportionately poorer or less well insured than whites, or disproportionately affected by geographic and other logistical barriers to access. Rather, they focus on the fundamental inequity that arises because patients of color receive different diagnoses and treatments than patients who are white. Race and ethnicity influence providers’ beliefs and expectations about patients, how they interpret patients’ symptoms and refer for diagnostic tests, procedures recommended, whether and how they provide patient education, and how they assess patients’ intelligence and willingness and ability to adhere to treatment plans. Provider prejudice, bias and stereotyping by physicians and other providers may create disparities in the quality of care provided to white and nonwhite patients.
Patient-Related Factors: Patients, too, may lack the tools they need to obtain needed care. Cultural differences may affect patients’ willingness to seek medical attention and follow medical advice, and language barriers may interfere with patient-provider communication and the ability to comprehend and follow medical advice. Racial and ethnic groups, as noted above, may have less experience navigating health systems and may be less assertive in their dealings with physicians than white patients. Although many of the patient-related barriers to receiving timely and appropriate healthcare affect patients of all races and ethnicities, some barriers—lack of time, lack of knowledge, competing demands and uncertainly about the benefits of healthcare—may affect some racial or ethnic groups more than others.
Strategies and Their Impacts
Numerous tools are available to Medicare to reduce or eliminate at least some of the disparities in access to care and quality of care for all of its populations. Recommendations for changes in Medicare tend to focus on: (1) data systems and information feedback; (2) structuring payments systems to limit provider incentives that may promote disparities or to reward providers who reduce disparities; (3) appropriate screening and preventive services and adherence to other evidence-based clinical care protocols; and (4) greater resources for interpretation services, multidisciplinary teams, community health workers and culturally appropriate patient education. Some of these activities and interventions would require legislative changes, some can be accomplished administratively and most could be adopted by innovative managed care plans.
Interventions directed at physicians include efforts to educate physicians about disparities and provide formal training on how to deliver culturally competent care. Cultural competence, in the words of a 2002 Commonwealth Fund study, describes “the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery systems to meet patients’ social, cultural, and linguistic needs.”
Interventions targeted at culturally diverse communities and patients seek to educate and inform patients by providing culturally appropriate education and outreach about healthcare risks, the role of screening and preventive services, and health risk management. Projects may also seek to reduce financial and logistical barriers to receiving care.
Initiatives targeted at health systems focus on the organization of care and may seek to improve data collection systems (beneficiary race and ethnicity, primary language preferences, data on providers who may be bilingual, bicultural, or both); address cultural and linguistic barriers by improving access to interpretation; and address beneficiaries’ ability to navigate the healthcare system through the use of community health workers or other kinds of interventions to improve patient-provider communication.
Although a range of approaches have been identified and tested in various settings, relatively little is known about the efficacy of alternative approaches to reducing disparities or about the strategies that are effective within various racial/ethnic sub-populations. Some published reviews of these interventions have assessed the evidence of their impact on disparities. These reviews conclude, for example, that physician tracking and reminder systems can be effective in improving preventive care and screening services for racial and ethnic minorities, as are initiatives that bypass the physician, and give responsibility for offering a service to a nurse or nurse practitioner (e.g., standing orders for adult immunizations). Multifaceted provider interventions may also be effective, but interventions that include only a provider education component are not generally found to be very effective in improving care or narrowing disparities.
There is very little evidence yet on the effectiveness of cultural competence training. A few studies found that trainings enhanced providers’ knowledge and skills, and attitudes improved, but only a very few studies sought to evaluate the impact on patient outcomes, and those findings were limited to changes in patient satisfaction with care. There were no findings on patient adherence or outcomes.
A recent review of interventions to narrow disparities in cancer care finds that efforts to improve screening participation and adherence are worthwhile goals. For cancers without accepted screening mechanisms, interventions need to address access to primary care. The literature review finds that there are few interventions that address racial/ethnic disparities in the timely completion of all recommended primary and secondary treatments. However, according to a 2003 study by John Capitman and Sarita Bhalotra, a key finding within this literature is that treatment management interventions that draw upon a “knowledgeable and trusted community health worker, serving as a patient navigator, has the potential to increase the share of elders of color who receive the current standard of care.”
Medicare’s central commitment to fund a consistent set of healthcare for all of the elderly has substantially reduced racial and ethnic disparities for those who would otherwise be unable to obtain affordable healthcare services. However, more can be done to assure that those eligible for Medicare and related programs are enrolled in those programs, are able to navigate them effectively, and have access to providers from whom they can receive culturally competent and continuous care, and who will be strong advocates to help them obtain the services they need.
As nearly 40 years of history demonstrates, a national program like Medicare can effectively address diverse groups by doing what it does best: It can assure that resources are distributed in a relatively equitable fashion across the nation; it can improve the quality of care for all beneficiaries; it can assure that federal outreach and education is linguistically and culturally appropriate; and that states and communities have materials and tools they can use to meet local needs.
At the same time, research and practical experience demonstrate that many of the obstacles and solutions vary by region and culture, so there probably will never be one model for care that would work in all communities. Local medical and social cultures vary dramatically across the country, as do the populations receiving care. Local understanding of cultures and barriers can be addressed by community groups and institutions with federal financial assistance. Ideally, a mid-21st century Medicare program will be better able to address the needs of its much more diverse beneficiary population.
Ellen O'Brien is Research Associate Professor, Health Policy Institute, Georgetown University. This article is adapted from a much lounger paper, "CMS Programs and Initiatives to Reduce Racial and Ethnic Disparties in Medicare," prepared for the National Academy of Social Insurance's Study Panel on Sharpening Medicare's Tools to Reduce Racial and Ethnic Disparities. Citations and references are available from Dr. O'Brien. firstname.lastname@example.org
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