Racial, Ethnic, And Gender Disparities In Health Care In .

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April 2019Racial, Ethnic, andGender Disparitiesin Health Care inMedicare AdvantageOffice of Minority Healthin collaboration with the RAND Corporation

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ContentsExecutive Summary .ivPatient Experience Measures . viiiRacial and Ethnic Disparities in Care: All Patient Experience Measures.ixRacial and Ethnic Disparities in Care: All Clinical Care Measures .xGender Disparities in Care: All Patient Experience and Clinical Care Measures.xiRacial and Ethnic Disparities in Care by Gender: All Patient Experience Measures . xiiRacial and Ethnic Disparities in Care by Gender: All Clinical Care Measures. xiiiBackground. 1Section I: Racial and Ethnic Disparities in Health Care in Medicare Advantage . 5Disparities in Care: All Patient Experience Measures . 6Patient Experience. 8Disparities in Care: All Clinical Care Measures. 15Clinical Care . 18Section II: Gender Disparities in Health Care in Medicare Advantage. 51Disparities in Care: All Patient Experience and Clinical Care Measures. 52Patient Experience. 54Clinical Care . 61Section III: Racial and Ethnic Disparities by Gender in Health Care in Medicare Advantage. 90Disparities in Care: All Patient Experience Measures . 91Patient Experience. 93Disparities in Care: All Clinical Care Measures. 100Clinical Care . 104Appendix: Data Sources and Methods . 135References . 137iii

Executive SummaryRacial, Ethnic, andGender Disparities in Health Carein Medicare Advantage

This report describes quality of health care received in 2017 by Medicare beneficiaries enrolled inMedicare Advantage (MA) plans nationwide (30.6 percent of all Medicare beneficiaries). The reporthighlights racial and ethnic differences in health care experiences and clinical care, compares quality ofcare for women and men, and looks at racial and ethnic differences in quality of care among women andmen separately.The report is based on an analysis of two sources of information. The first source is the MedicareConsumer Assessment of Healthcare Providers and Systems (CAHPS) Survey, which is conductedannually by the Centers for Medicare & Medicaid Services (CMS) and focuses on experiences with thehealth and drug plans (e.g., ease of getting needed care, how well providers communicate, and gettingneeded prescription drugs) of Medicare beneficiaries across the nation. The second source ofinformation is the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS collects informationfrom medical records and administrative data on the technical quality of care that Medicarebeneficiaries receive for a variety of medical issues, including diabetes, cardiovascular disease, andchronic lung disease. A comprehensive list of measures included in this report appears on p. viii. Scoreson CAHPS measures are case-mix adjusted, as described in the appendix. HEDIS measures are not casemix adjusted.Distribution of Race, Ethnicity, and Gender Among Medicare Advantage BeneficiariesIn 2017, an estimated 69.5 percent of all MA beneficiaries were White, 13.8 percent were Hispanic, 9.9percent were Black, 4.3 percent were Asians or Pacific Islanders (API), 2.1 percent were multiracial (notincluded in this report), and 0.4 percent were American Indians or Alaska Natives (AI/AN), comparedwith 76.1 percent, 8.5 percent, 8.9 percent, 3.6 percent, 2.3 percent, and 0.6 percent, respectively, inthe general Medicare population. An estimated 56.3 percent of all Medicare Advantage beneficiarieswere female and 43.7 percent were male, compared with 54.1 percent and 45.9 percent, respectively, inthe general Medicare population.Racial and Ethnic Disparities in Health Care in Medicare AdvantageWith just one exception, MA beneficiaries in racial and ethnic minority groups reported experienceswith care that were either worse than or similar to the experiences reported by White beneficiaries (seefigure on p. ix). Compared with White beneficiaries, AI/AN beneficiaries reported worse1 experiences on1 measure and similar experiences on the other 6 measures. API beneficiaries reported worseexperiences than Whites on 6 measures and better experiences on 1 measure. Black beneficiariesreported worse experiences than Whites on 2 measures and similar experiences on the other 5measures. Likewise, Hispanic beneficiaries reported worse experiences than Whites on 2 measures andsimilar experiences on the other 5 measures.Racial and ethnic disparities were more variable for the clinical care measures than for the patientexperience measures (see figure on p. x). API beneficiaries received worse clinical care than Whites for 3measures but received care of similar quality for 16 measures and better quality for 14 measures. Blackbeneficiaries received worse clinical care than Whites for 14 measures but received care of similarquality for 16 measures and better quality for 3 measures. Hispanic beneficiaries received worse clinicalHere, “worse” and “better” are used to characterize differences that are statistically significant and exceed amagnitude threshold, as described in the appendix. “Similar” is used to characterize differences that are notstatistically significant, fall below a magnitude threshold, or both.1v

care than White beneficiaries for 13 of 33 measures but received care of similar quality for 14 measuresand better quality for 6 measures.2Gender Disparities in Health Care in Medicare AdvantageIn general, the quality of care received by women and men was similar. Women and men reportedsimilar experiences with care for all measures of patient experience (see figure on p. xi). Clinical carereceived by women and men was of similar quality for 23 of 29 measures.3 For the 6 remainingmeasures, women received worse care than men for 4 measures and better care for 2 measures.Racial and Ethnic Disparities by Gender in Health Care in Medicare AdvantagePatterns of racial and ethnic differences in patient experience among women and among men parallelthe differences that were observed among both groups combined (see figure on p. xii). Among bothwomen and men, API beneficiaries reported worse experiences than White beneficiaries with gettingneeded care, getting appointments and care quickly, customer service, doctor communication, carecoordination, and getting needed patient drugs and had higher rates of vaccination for the flu. Amongboth women and men, Black beneficiaries and Hispanic beneficiaries reported worse experiences thanWhite beneficiaries with getting appointments and care quickly and had lower rates of vaccination forthe flu. Otherwise, the experiences of Black beneficiaries and Hispanic beneficiaries were similar tothose of Whites, regardless of gender.Patterns of racial and ethnic differences in clinical care among women and men also parallel thedifferences observed among both groups combined (see figure on p. xiii). Among both women and men,API beneficiaries received worse clinical care than White beneficiaries for 4 of 31 measures; 3 of those 4measures were the same for women and men. API women received better care than White women for 9measures, whereas API men received better care than White men for 10 measures; of those 9 or 10measures, 8 were the same for women and men. Black women received worse clinical care than Whitewomen for 14 measures. Black men received worse clinical care than White men for those same 14measures plus an additional 3 measures. Among both men and women, Black beneficiaries receivedbetter clinical care than White beneficiaries for 3 measures; 2 of those 3 measures were the same forwomen and men. Among both women and men, Hispanic beneficiaries received worse clinical care thanWhite beneficiaries for 11 measures; 9 of those 11 measures were the same for women and men.Hispanic men received better clinical care than White men for 4 measures. Hispanic women receivedbetter clinical care than White women on those same 4 measures plus an additional 2 measures.ConclusionThe focus of this report is on racial, ethnic, and gender differences in quality of care that exist at thenational level. Although this analysis revealed few gender differences in care, it did reveal patterns inwhich (1) Black and Hispanic beneficiaries received worse clinical care than White beneficiaries on a2For reporting HEDIS data stratified by race and ethnicity, racial and ethnic group membership is estimated using amethodology that combines information from CMS administrative data, surname, and residential location.Estimates of membership in the AI/AN group are less accurate than for other racial and ethnic groups; thus, thisreport does not show scores for AI/AN beneficiaries on the clinical care measures.3Two clinical care measures, Breast Cancer Screening and Osteoporosis Management in Women Who Had aFracture, pertained to women only and so were not eligible for stratified reporting by gender. Two othermeasures, Statin Use for Cardiovascular Disease and Medication Adherence for Cardiovascular Disease—Statins,were defined differently for men and women and so were also not eligible for stratified reporting by gender.vi

large portion of the clinical care measures examined and (2) API beneficiaries reported worse patientexperiences than White beneficiaries on almost all measures of patient experience. The resultspresented in this report lead to a conclusion that quality improvement efforts should focus onenhancing clinical care for Black and Hispanic beneficiaries and investigating differences between APIand White beneficiaries’ patient experience. This information may be of interest to MA organizationsand Medicare Part D sponsors as they consider strategies to improve the quality of care received byracial and ethnic minorities and reduce disparities.vii

Patient Experience and Clinical Care Measures Included in This ReportPatient Experience MeasuresGetting Needed CareGetting Appointments and Care QuicklyCustomer ServiceDoctors Who Communicate WellCare CoordinationGetting Needed Prescription DrugsAnnual Flu VaccineClinical Care MeasuresColorectal Cancer ScreeningBreast Cancer Screening*Diabetes Care—Blood Sugar TestingDiabetes Care—Eye ExamDiabetes Care—Kidney Disease MonitoringDiabetes Care—Blood Pressure ControlledDiabetes Care—Blood Sugar ControlledStatin Use in Patients with DiabetesMedication Adherence for Diabetes—StatinsAdult Body Mass Index (BMI) AssessmentControlling High Blood PressureStatin Use in Patients with CardiovascularDisease†Medication Adherence for CardiovascularDisease—Statins†Persistence of Beta-Blocker TreatmentAsthma Medication Ratio in Older AdultsTesting to Confirm Chronic ObstructivePulmonary Disease (COPD)Pharmacotherapy Management of COPDExacerbation—Systemic CorticosteroidPharmacotherapy Management of COPDExacerbation—BronchodilatorRheumatoid Arthritis ManagementOsteoporosis Management in Women whoHad a Fracture*Appropriate Monitoring of Patients TakingLong-Term MedicationsAvoiding Use of High-Risk Medications in theElderlyAvoiding Potentially Harmful Drug-DiseaseInteractions in Elderly Patients with ChronicRenal FailureAvoiding Potentially Harmful Drug-DiseaseInteractions in Elderly Patients with DementiaAvoiding Potentially Harmful Drug-DiseaseInteractions in Elderly Patients with a Historyof FallsOlder Adults’ Access to Preventive/Ambulatory ServicesMedication Reconciliation After HospitalDischargeAntidepressant Medication Management—Acute Phase TreatmentAntidepressant Medication Management—Continuation Phase TreatmentFollow-Up Visit After Hospital Stay for MentalIllness (within 7 days of discharge)Follow-Up Visit After Hospital Stay for MentalIllness (within 30 days of discharge)Initiation of Alcohol or Other Drug TreatmentEngagement of Alcohol or Other DrugTreatment* These measures are specific to women and are thus not included in the set of comparisons bygender.† These measures are defined differently for men and women and thus are not included in the set ofcomparisons by gender. They are, however, included in the set of comparisons by race and ethnicitywithin gender.viii

Racial and Ethnic Disparities in Care:All Patient Experience MeasuresNumber of patient experience measures (out of 7) for which members of selected groups reportedexperiences that were worse than, similar to, or better than the experiences reported by Whites in201715522Black vs.WhiteHispanic vs.White66Better thanWhitesSimilar toWhitesWorse thanWhites1AI/AN vs.WhiteAPI vs.WhiteSOURCE: This chart summarizes data from all Medicare Advantage beneficiaries nationwide whoparticipated in the 2017 Medicare CAHPS survey.NOTES: AI/AN American Indian or Alaska Native. API Asian or Pacific Islander. Racial groups suchas Blacks and Whites are non-Hispanic. Hispanic ethnicity includes all races.ix

Racial and Ethnic Disparities in Care:All Clinical Care MeasuresNumber of clinical care measures (out of 33) for which members of selected groups experiencedcare that was worse than, similar to, or better than the care experienced by Whites in 201736141614Better thanWhitesSimilar toWhites16Worse thanWhites1413Black vs.WhiteHispanic vs.White3API vs.WhiteSOURCE: This chart summarizes clinical quality (HEDIS) data collected in 2017 from Medicarehealth plans nationwide.NOTES: API Asian or Pacific Islander. Racial groups such as Blacks and Whites are non-Hispanic.Hispanic ethnicity includes all races.x

Gender Disparities in Care:All Patient Experience and Clinical Care MeasuresNumber of patient experience measures (out of 7) and clinical care measures (out of 29) forwhich women received care that was worse than, similar to, or better than the care received bymen in 20172 of 29Women receivedbetter care than men23 ofWomen and menreceived similar careWomen receivedworse care than men7 of 74 of 29Patient experience measuresClinical care measuresSOURCES: The bar on the left (patient experience measures) summarizes data from all MedicareAdvantage beneficiaries nationwide who participated in the 2017 Medicare CAHPS survey. The bar onthe right (clinical care measures) summarizes clinical quality (HEDIS) data collected in 2017 fromMedicare health plans nationwide.xi

Racial and Ethnic Disparities in Care by Gender:All Patient Experience MeasuresNumber of patient experience measures (out of 7) for which women/men of selectedracial and ethnic minority groups reported experiences that were worse than, similar to, or betterthan the experiences reported by White women/men in 2017WomenMen1 of 71 of 75 of 75 of 66 of 72 of 71 of 6AI/AN vs.White5 of 7API vs.WhiteAI/AN vs.WhiteSimilar to Whites5 of 75 of 72 of 72 of 76 of 72 of 7Black vs. Hispanic vs.WhiteWhiteWorse than WhitesNotenoughdataAPI vs.WhiteBlack vs. Hispanic vs.WhiteWhiteBetter than WhitesSOURCE: This chart summarizes data from all Medicare Advantage beneficiaries nationwide who participatedin the 2017 Medicare CAHPS survey.NOTES: AI/AN American Indian or Alaska Native. API Asian or Pacific Islander. Racial groups such as Blacksand Whites are non-Hispanic. Hispanic ethnicity includes all races. There were not enough data from AI/ANmen to compare their patient experiences to those of White men. For one patient experience measure, therewere not enough data from AI/AN women to permit a comparison to White women.xii

Racial and Ethnic Disparities in Care by Gender:All Clinical Care MeasuresNumber of clinical care measures (out of 31) for which women/men of selected racial and ethnicminority groups experienced care that was worse than, similar to, or better than the careexperienced by White women/men in 2017Women9314Men61011141841617144API vs.White3Black vs.WhiteWorse than Whites1711Hispanic vs.White4API vs.WhiteSimilar to WhitesBlack vs.White11Hispanic vs.WhiteBetter than WhitesSOURCE: This chart summarizes clinical quality (HEDIS) data collected in 2017 from Medicare health plansnationwide.NOTES: Racial groups such as Blacks and Whites are non-Hispanic. Hispanic ethnicity includes all races. API Asian or Pacific Islander.xiii

BackgroundRacial, Ethnic, andGender Disparities in Health Carein Medicare Advantage

OverviewThis report presents summary information on the quality of health care received in 2017 by Medicarebeneficiaries enrolled in Medicare Advantage (MA) plans nationwide. In 2017, 30.6 percent of Medicarebeneficiaries were enrolled in MA. Two types of quality of care data are presented in this report:measures of patient experience, which describe how well the care patients receive meets their needs forsuch things as timely appointments, respectful care, clear communication, and access to information;and measures of clinical care, which describe the extent to which patients receive appropriate screeningand treatment for specific health conditions. The Institute of Medicine has identified the equitabledelivery of care as a hallmark of quality.4 Assessing equitability in the delivery of care requires makingcomparisons of quality by personal characteristics of patients, such as gender, race, and ethnicity. Threesets of such comparisons are presented in this report. In the first set, quality of care for racial and ethnicminority groups is compared with quality of care for Whites. In the second, quality of care for women iscompared with quality of care for men. In the third, quality of care for racial and ethnic minority groupsis compared with quality of care for Whites of the same gender. As in the 2018 report, thisinformation—which may be of interest to Medicare beneficiaries, MA organizations, and Part Dsponsors—is being presented in a single report to provide a more comprehensive understanding of theways in which care differs by race and ethnicity, gender, and the intersection of these twocharacteristics. The focus of this report is on differences that exist at the national level. Interestedreaders can find information about health care quality for specific Medicare plans athttps:

Racial and Ethnic Disparities by Gender in Health Care in Medicare Advantage Patterns of racial and ethnic differences in patient experience among women and among men parallel the differences that were observed among both groups combined (see figure on p. xii). Among both

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