Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and
business strategies about Medicare Advantage plans, product design, marketing,
enrollment, market expansions, CMS audits, and countless federal initiatives in
MA and Medicaid managed care.
By James
Gutman, Managing Editor
April 21, 2016 Volume
22 Issue 8
There are significant health care
disparities, both in terms of access and results, between minority groups and
whites in Medicare Advantage plans, according to the first-ever CMS release of
data stratified by contract for race and ethnicity in MA. The data, which were
released April 19 and are slated to be issued annually, show “we have a number
of measures that we need to do a better job” on, Cara James, Ph.D., director of
the CMS Office of Minority Health, tells MAN.
But a close look at the 2013 and 2014
quality measures that CMS and its research partner RAND Corp. used for the
analysis shows there is considerable variation in which racial and ethnic
groups scored best and worst on particular items. While the minority groups
generally fared worse on the measures, for instance, blacks and Hispanics
actually scored better than whites in the doctor-communications category, and
Asians fared far better than whites in the “all clinical care measures” item as
well as in getting timely flu vaccinations. The analysis did not look into
differences in care based on gender.
Although the data CMS used for the new
analysis came from two sources — HEDIS and the Consumer Assessment of
Healthcare Providers and Systems (CAHPS) — used in the agency’s star quality
ratings for MA plans, the agency emphasized that this initiative is “entirely
separate” from the star-ratings program and will not be used “for payment
purposes of any sort.” There is a separate ongoing study HHS is conducting
under terms of the Affordable Care Act on the effect of numerous demographic
variables on Medicare payment policy as a whole, but no results from it are
expected until 2017, CMS said.
Data Show Racial, Ethnic Disparities
The agency, in its FAQs surrounding the
data release, also stressed that the data do not indicate its recent decision
to alter MA risk adjustment starting in 2017 to reflect some aspects of
socioeconomic status (MAN 4/7/16, p. 1) is inappropriate. The new data,
CMS noted, are presented “as they are scored” with no further adjustment. And
HHS research has found that “adding indicators of race/ethnicity” to HEDIS
measures used in MA star ratings “had little effect on the coefficients used”
for the new risk adjustment, the agency asserted.
CMS, though, did include with the data
release links to resources it suggested could help MA organizations (MAOs)
respond to the disparities found. One of those is the CMS Office of Minority
Health’s own “Mapping Medicare Disparities Tool.”
Speaking of the overall report, Michael
Adelberg, a former top CMS MA official who now is senior director at FaegreBD
Consulting, tells MAN, “This data seeds the ground for eventual
comparisons between Medicare Advantage and traditional Medicare in
understanding how minorities and other vulnerable populations are served in the
Medicare program.” He adds that “the dataset will, no doubt, evolve over time.
It will be interesting to see it normalized by service area.”
In its news release, CMS attempted to
summarize the MA data-analysis findings by saying “Asians and Pacific Islanders
typically received care that is similar to or better than the care received by
Whites, whereas African Americans and Hispanics typically received care that is
similar to or worse than” that of whites. “African Americans and Hispanics also
reported their health care experiences as being similar to or worse than the
experiences reported by Whites,” the agency said.
But the actual specific findings are
far more complex than that and, perhaps with this in mind, James emphasizes
“these data really are [just] a first step” in studying MA disparities. She
also notes that CMS has done the same kind of analysis on Medicare
fee-for-service and got “similar” results.
Looking at specific CAHPS measures,
which are based on patient self-reports, whites scored 87% on how easy it is
for them to access care. By contrast, Hispanics scored 85.5%, blacks 84.6% and
Asian or Pacific Islanders 80.6%. The pattern was similar, albeit with blacks
and Hispanics juxtaposed in ranking, on how quickly patients get medical
appointments and care. Blacks almost matched whites (86.3% versus 86.4%) in
self-reported responses on how well patients’ care was coordinated, but Hispanics
and Asians trailed substantially at 82.5% and 81.0%, respectively. That also
was the situation on access to needed prescription drugs, with whites at 91.1%,
blacks at 90.0%, Hispanics at 88.0% and Asians at 85.1%.
Asked by MAN whether the latter
three categories suggest that language barriers may be a reason for the scores
lagging among Hispanics and Asians, James responds that while this is possible,
there would need to be more research done to confirm it. In the interim,
though, she says, plans could examine their specific contract data to help
determine whether language barriers are hurting their scores on these measures.
The communications-related findings are
“also a reminder to MAOs to make sure their member services are meeting CMS’s
language requirements,” says Adelberg.
There was a large gap between whites
and the various minority groups on how easy it was for MA beneficiaries to get
information from their plan regarding prescription drug coverage and costs.
Whites were at 82.2% on that measure, followed by blacks at 77.7%, Hispanics at
76.8% and Asians at 72.7%.
Moving to more clinical measures based
on MA HEDIS results, CMS found that Asians actually outperformed whites — as
they also did on a CAHPS measure for getting flu vaccination — while both
blacks and Hispanics usually trailed both. Specifically, out of 27 HEDIS
clinical measures studied, Asians outperformed whites on 14, underperformed on
three and were similar on 10. The comparable figures for blacks were three, 14
and 10, respectively, while for Hispanics it was three, 15 and 9, respectively.
In MA diabetes care, the differences
were especially pronounced — and interesting — as whites and blacks
consistently underperformed Asians and Hispanics (in that order) with only one
partial exception. The measures for which this was the pattern included
blood-glucose testing, retinal eye exams for diabetics, medical attention for
nephropathy and blood pressure control. Only on the measure for hemoglobin A1c
measuring 9% or less on the most recent test did whites push past Hispanics for
second place.
Asked about these findings, James says
that diabetes research suggests the factors affecting scores on these measures
include access (and transportation) to primary care providers and copayment
levels. Also, the prevalence of diabetes is higher in blacks, she notes.
The differences between MA blacks and
the other groups in the data were especially pronounced on two of the three
heart-focused HEDIS measures studied. The share of MA blacks with a diagnosis
of hypertension whose blood pressure was adequately controlled was only 52.5%
in the CMS data, compared with 65.6% for Asians, 64.8% of whites and 62.4% for
Hispanics. Similarly, the percentage of persons who had been hospitalized for a
heart attack, cardiac bypass surgery or angioplasty or had a diagnosis of
ischemic vascular disease and whose cholesterol was “adequately managed in the
past year” was just 51.9% for blacks, compared with 75.7% for Asians, 62.9% for
whites and 58.7% for Hispanics.
What is the first thing MA plans should
do to start remedying some of the disparities found? “They should begin by
empowering providers to do a better job,” James tells MAN.
View CMS’s MA disparities report by
visiting the April 19 From the Editor entry at MAN's
subscriber-only Web page: www.aishealth.com/newsletters/
medicareadvantagenews.
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