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Quality of Care and Racial Disparities in Medicare Among Potential ACOs

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Journal of General Internal Medicine Aims and scope Submit manuscript

A Capsule Commentary to this article was published on 08 July 2014

ABSTRACT

BACKGROUND

The Medicare Accountable Care Organization (ACO) programs encourage integration of providers into large groups and reward provider groups for improving quality, but not explicitly for reducing health care disparities. Larger group size and better overall quality may or may not be associated with smaller disparities.

OBJECTIVE

To examine differences in patient characteristics between provider groups sufficiently large to participate in ACO programs and smaller groups; the association between group size and racial disparities in quality; and the association between quality and disparities among larger groups.

DESIGN AND PARTICIPANTS

Using 2009 Medicare claims for 3.1 million beneficiaries with cardiovascular disease or diabetes and linked data on provider groups, we compared racial differences in quality by provider group size, adjusting for patient characteristics. Among larger groups, we used multilevel models to estimate correlations between group performance on quality measures for white beneficiaries and black–white disparities within groups.

MAIN MEASURES

Four process measures of quality, hospitalization for ambulatory care-sensitive conditions (ACSCs) related to cardiovascular disease or diabetes, and hospitalization for any ACSC.

KEY RESULTS

Beneficiaries served by larger groups were more likely to be white and live in areas with less poverty and more education. Larger group size was associated with smaller disparities in low-density lipoprotein (LDL) cholesterol testing and retinal exams, but not in other process measures or hospitalization for ACSCs. Among larger groups, better quality for white beneficiaries in one measure (hospitalization for ACSCs related to cardiovascular disease or diabetes) was correlated with smaller racial disparities (r = 0.28; P = 0.02), but quality was not correlated with disparities in other measures.

CONCLUSIONS

Larger provider group size and better performance on quality measures were not consistently associated with smaller racial disparities in care for Medicare beneficiaries with cardiovascular disease or diabetes. ACO incentives rewarding better quality for minority groups and payment arrangements supporting ACO development in disadvantaged communities may be required for ACOs to promote greater equity in care.

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REFERENCES

  1. McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES. A national strategy to put accountable care into practice. Health Aff (Millwood). 2010;29(5):982–990.

    Article  Google Scholar 

  2. Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule, 42 CFR Part 425. (2011).

  3. Lewis VA, Larson BK, McClurg AB, Boswell RG, Fisher ES. The promise and peril of accountable care for vulnerable populations: a framework for overcoming obstacles. Health Aff (Millwood). 2012;31(8):1777–1785.

    Article  Google Scholar 

  4. Pollack CE, Armstrong K. Accountable care organizations and health care disparities. JAMA. 2011;305(16):1706–1707.

    Article  CAS  PubMed  Google Scholar 

  5. Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med. 2004;351(6):575–584.

    Article  CAS  PubMed  Google Scholar 

  6. Jha AK, Orav EJ, Li Z, Epstein AM. Concentration and quality of hospitals that care for elderly black patients. Arch Intern Med. 2007;167(11):1177–1182.

    Article  PubMed  Google Scholar 

  7. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675–681.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  8. Barnato AE, Lucas FL, Staiger D, Wennberg DE, Chandra A. Hospital-level racial disparities in acute myocardial infarction treatment and outcomes. Med Care. 2005;43(4):308–319.

    Article  PubMed Central  PubMed  Google Scholar 

  9. Spertus JA, Jones PG, Masoudi FA, Rumsfeld JS, Krumholz HM. Factors associated with racial differences in myocardial infarction outcomes. Ann Intern Med. 2009;150(5):314–324.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Groeneveld PW, Laufer SB, Garber AM. Technology diffusion, hospital variation, and racial disparities among elderly Medicare beneficiaries: 1989–2000. Med Care. 2005;43(4):320–329.

    Article  PubMed  Google Scholar 

  11. Rittenhouse DR, Casalino LP, Gillies RR, Shortell SM, Lau B. Measuring the medical home infrastructure in large medical groups. Health Aff (Millwood). 2008;27(5):1246–1258.

    Article  Google Scholar 

  12. Rittenhouse DR, Shortell SM, Gillies RR, et al. Improving chronic illness care: findings from a national study of care management processes in large physician practices. Med Care Res Rev. 2010;67(3):301–320.

    Article  PubMed  Google Scholar 

  13. Rittenhouse DR, Casalino LP, Shortell SM, et al. Small and medium-size physician practices use few patient-centered medical home processes. Health Aff (Millwood). 2011;30(8):1575–1584.

    Article  Google Scholar 

  14. Casalino L, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA. 2003;289(4):434–441.

    Article  PubMed  Google Scholar 

  15. Friedberg MW, Safran DG, Coltin KL, Dresser M, Schneider EC. Readiness for the Patient-Centered Medical Home: structural capabilities of Massachusetts primary care practices. J Gen Intern Med. 2009;24(2):162–169.

    Article  PubMed Central  PubMed  Google Scholar 

  16. McWilliams JM, Chernew ME, Zaslavsky AM, Hamed P, Landon BE. Delivery System Integration and Health Care Spending and Quality for Medicare Beneficiaries. JAMA Intern Med. 2013;173(15):1447–1456.

    Article  PubMed Central  PubMed  Google Scholar 

  17. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: U.S. trends from 1999 to 2006 and effects of medicare coverage. Ann Intern Med. 2009;150(8):505–515.

    Article  PubMed  Google Scholar 

  18. Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Trends in the quality of care and racial disparities in Medicare managed care. N Engl J Med. 2005;353(7):692–700.

    Article  CAS  PubMed  Google Scholar 

  19. Sequist TD, Adams A, Zhang F, Ross-Degnan D, Ayanian JZ. Effect of quality improvement on racial disparities in diabetes care. Arch Intern Med. 2006;166(6):675–681.

    Article  PubMed  Google Scholar 

  20. Centers for Medicare and Medicaid Services. Chronic Condition Data Warehouse. Available at: http://www.ccwdata.org/index.htm. Accessed May 7, 2014.

  21. Zaslavsky AM, Ayanian JZ, Zaborski LB. The validity of race and ethnicity in enrollment data for Medicare beneficiaries. Health Serv Res. 2012;47(3 Pt 2):1300–1321.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Arday SL, Arday DR, Monroe S, Zhang J. HCFA’s racial and ethnic data: current accuracy and recent improvements. Health Care Financ Rev. 2000;21(4):107–116.

    CAS  PubMed  Google Scholar 

  23. Yun H, Kilgore ML, Curtis JR, et al. Identifying types of nursing facility stays using medicare claims data: an algorithm and validation. Health Serv Outcome Res Methodol. 2010;10(1):100.

    Article  Google Scholar 

  24. McWilliams JM, Chernew ME, Zaslavsky AM, Landon BE. Post-acute care and ACOs—who will be accountable? Health Serv Res. 2013;48(4):1526–1538.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Agency for Healthcare Research and Quality. Prevention Quality Indicators Overview. Available at: http://www.qualityindicators.ahrq.gov/modules/pqi_resources.aspx. Accessed May 7, 2014.

  26. Jencks SF, Cuerdon T, Burwen DR, et al. Quality of medical care delivered to Medicare beneficiaries: A profile at state and national levels. JAMA. 2000;284(13):1670–1676.

    Article  CAS  PubMed  Google Scholar 

  27. Jencks SF, Huff ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998–1999 to 2000–2001. JAMA. 2003;289(3):305–312.

    Article  PubMed  Google Scholar 

  28. U.S. Census Bureau. 2010 American Community Survey 5-year estimates. Available at: http://factfinder2.census.gov. Accessed May 7, 2014.

  29. Huber P. The Behavior of Maximum Likelihood Estimates Under Non-standard Conditions. Berkeley: University of California Press; 1967.

    Google Scholar 

  30. White H. Maximum likelihood estimation of misspecified models. Econometrica. 1982;50:1–26.

    Article  Google Scholar 

  31. Auerbach DI, Liu H, Hussey PS, Lau C, Mehrotra A. Accountable care organization formation is associated with integrated systems but not high medical spending. Health Aff (Millwood). 2013;32(10):1781–1788.

    Article  Google Scholar 

  32. Center for Medicare and Medicaid Innovation. Pioneer Accountable Care Organization (ACO) Model Request for Application. Washington, DC: Department of Health and Human Services and Centers for Medicare and Medicaid Services; 2011. Available at: http://innovation.cms.gov/Files/x/Pioneer-ACO-Model-Request-For-Applications-document.pdf; Accessed May 7, 2014.

    Google Scholar 

  33. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283(19):2579–2584.

    Article  CAS  PubMed  Google Scholar 

  34. Center for Medicare and Medicaid Innovation. Advance Payment ACO Model. Available at: http://innovation.cms.gov/initiatives/Advance-Payment-ACO-Model. Accessed May 7, 2014.

  35. Centers for Medicare and Medicaid Services. More partnerships between doctors and hospitals strengthen coordinated care for Medicare beneficiaries. Available at: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-12-23.html. Accessed May 7, 2014.

  36. Sequist TD, Fitzmaurice GM, Marshall R, et al. Cultural competency training and performance reports to improve diabetes care for black patients: a cluster randomized, controlled trial. Ann Intern Med. 2010;152(1):40–46.

    Article  PubMed  Google Scholar 

  37. Thorlby R, Jorgensen S, Ayanian JZ, Sequist TD. Clinicians' views of an intervention to reduce racial disparities in diabetes outcomes. J Natl Med Assoc. 2011;103(9–10):968–977.

    PubMed Central  PubMed  Google Scholar 

  38. Jones RG, Trivedi AN, Ayanian JZ. Factors influencing the effectiveness of interventions to reduce racial and ethnic disparities in health care. Soc Sci Med. 2010;70(3):337–341.

    Article  PubMed Central  PubMed  Google Scholar 

  39. Epstein AM, Jha AK, Orav EJ. The relationship between hospital admission rates and rehospitalizations. N Engl J Med. 2011;365(24):2287–2295.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

Funders: Supported by grants from the Doris Duke Charitable Foundation (Clinical Scientist Development Award #2010053), Beeson Career Development Award Program (National Institute on Aging K08 AG038354 and the American Federation for Aging Research), National Institute on Aging (P01 AG032952), the Malcolm Weiner Center at Harvard Kennedy School, the Dean’s Summer Research Fellowship at Washington University School of Medicine, St. Louis, and by the Health Disparities Research Program of Harvard Catalyst/The Harvard Clinical and Translational Science Center (NIH Award #UL1 RR 025758 and financial contributions from Harvard University and its affiliated academic health care centers).

Prior Presentations

Society of General Internal Medicine Annual Meeting, 26 April 2013 (poster presentation)

AcademyHealth Annual Research Meeting, 24 June 2013 (oral presentation)

Conflicts of Interest

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

  1. Harvard Kennedy School of Government, Cambridge, MA, USA

    Ryan E. Anderson M.D., M.P.P

  2. Washington University School of Medicine, St. Louis, MO, USA

    Ryan E. Anderson M.D., M.P.P

  3. Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave., Boston, MA, 02115, USA

    John Z. Ayanian M.D., M.P.P., Alan M. Zaslavsky Ph.D. & J. Michael McWilliams M.D., Ph.D.

  4. Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA

    John Z. Ayanian M.D., M.P.P. & J. Michael McWilliams M.D., Ph.D.

  5. Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA

    John Z. Ayanian M.D., M.P.P.

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  1. Ryan E. Anderson M.D., M.P.P
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  3. Alan M. Zaslavsky Ph.D.
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Corresponding author

Correspondence to J. Michael McWilliams M.D., Ph.D..

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Anderson, R.E., Ayanian, J.Z., Zaslavsky, A.M. et al. Quality of Care and Racial Disparities in Medicare Among Potential ACOs. J GEN INTERN MED 29, 1296–1304 (2014). https://doi.org/10.1007/s11606-014-2900-3

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  • DOI: https://doi.org/10.1007/s11606-014-2900-3

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