1. Medicare Managed Care and Primary Care Quality: Examining Racial/Ethnic Effects across States Jayasree Basu, Ph.D. AHRQ 2009 Annual Conference

2. Background Medicare Modernization Act of 2003 sparked renewed interest in Medicare managed care (MMC) Medicare Modernization Act of 2003 sparked renewed interest in Medicare managed care (MMC) Medicare spends more each year on beneficiaries enrolled in Medicare Advantage (MA) plans —little evidence to suggest added value worth the extra investment Medicare spends more each year on beneficiaries enrolled in Medicare Advantage (MA) plans —little evidence to suggest added value worth the extra investment Understudied topic: program’s effectiveness in reducing racial and ethnic disparities in quality of health care delivery and access Understudied topic: program’s effectiveness in reducing racial and ethnic disparities in quality of health care delivery and access

3. Study Objective To assess the role of MA plans in providing quality primary care compared to Fee For Service (FFS) Medicare in three states (NY, CA, FL) across three racial ethnic groups (White, African American, and Hispanic) To assess the role of MA plans in providing quality primary care compared to Fee For Service (FFS) Medicare in three states (NY, CA, FL) across three racial ethnic groups (White, African American, and Hispanic) The performance will be measured in terms of providing better quality primary care, defined as lowering the risk of preventable (or Ambulatory Care Sensitive) hospital admissions The performance will be measured in terms of providing better quality primary care, defined as lowering the risk of preventable (or Ambulatory Care Sensitive) hospital admissions

4. Hypotheses Managed care plans reduce preventable hospitalizations (PH) through care coordination and provision of preventive care Managed care plans reduce preventable hospitalizations (PH) through care coordination and provision of preventive care Relative to FFS, improved care coordination in HMO plans reduce PH for minorities more than whites Relative to FFS, improved care coordination in HMO plans reduce PH for minorities more than whites H 1 : PH MA < PH FFS H 1 : PH MA < PH FFS H 2 : PH MA(Minorities|Whites) < PH FFS(Minorities|Whites) H 2 : PH MA(Minorities|Whites) < PH FFS(Minorities|Whites)

5. Patient Selection States : NY, CA, FL, Year: 2004 States : NY, CA, FL, Year: 2004 Hospitalized Medicare FFS and Medicare advantage (MA) plan enrollees (Age 65 and over) Hospitalized Medicare FFS and Medicare advantage (MA) plan enrollees (Age 65 and over) Patient level data on MA versus FFS enrollment as recorded in the confidential files of discharge database of the three states Patient level data on MA versus FFS enrollment as recorded in the confidential files of discharge database of the three states

6. MMC penetration by State and US All three states had higher penetration than US average in 1994, increasing further by 2000. CA reached 54% penetration rate By 2000. State source: InterStudy

7. Data Hospital discharge data (HCUP-SID, AHRQ) for elderly Medicare (age 65+), 2004 Hospital discharge data (HCUP-SID, AHRQ) for elderly Medicare (age 65+), 2004 Medicare managed care plans available in 2004 were predominately HMO types (96-99%) Medicare managed care plans available in 2004 were predominately HMO types (96-99%) Inpatient discharge data linked to area resource files, US Census, AHA, Interstudy, HRSA Inpatient discharge data linked to area resource files, US Census, AHA, Interstudy, HRSA Multivariate cross sectional framework with patient-level data for each State Multivariate cross sectional framework with patient-level data for each State NY FL CA

8. Variables Individual patient characteristics: Individual patient characteristics: – Three Racial ethnic groups Whites Whites African Americans (AA) African Americans (AA) Hispanics Hispanics – Type of insurer, age groups, gender, severity of illness, indirect severity indicators, severity*HMO, race*HMO Contextual data: socio-demographic conditions and provider characteristics in each Primary Care Service area (PCSA) where patients live Contextual data: socio-demographic conditions and provider characteristics in each Primary Care Service area (PCSA) where patients live

9. PCSA PCSA is the smallest geographic area validated as a discrete service area for primary care. PCSA is the smallest geographic area validated as a discrete service area for primary care. Defined on FFS Medicare patient flows to physician offices, updated frequently by HRSA. Defined on FFS Medicare patient flows to physician offices, updated frequently by HRSA. Since managed care is expected to improve outcomes through better availability of primary and preventive care in the community, an area denominator which more accurately reflects a primary care market is appropriate Since managed care is expected to improve outcomes through better availability of primary and preventive care in the community, an area denominator which more accurately reflects a primary care market is appropriate

10. Design PH admissions compared with admissions for “marker conditions” in each Racial group PH admissions compared with admissions for “marker conditions” for each State in each Racial groupPHMarker Urgent, insensitive to primary care Appendicitis with appendectomy, acute MI, gastrointestinal obstruction, fracture of hip/femur Appendicitis with appendectomy, acute MI, gastrointestinal obstruction, fracture of hip/femur Sensitive to primary care Sensitive to primary care Ex: Severe ENT infections, UTI, Ex: Severe ENT infections, UTI, COPD, Tuberculosis, Hypertension etc.,

11. severe ENT infections bacterial pneumonia chronic obstructive tuberculosis pulmonary disease hypertension diabetes cellulitis convulsions gastroenteritis requiring hypoglycemia hospitalization kidney infection urinary tract infection asthma dehydration angina pelvic inflammatory disease congestive heart failure nutritional deficiencies certain dental conditions certain dental conditions PH Admissions

12. Marker Admissions: The Comparison Group Diagnoses for which provision of timely and effective outpatient care is likely to have little impact on the need for hospital admission Diagnoses for which provision of timely and effective outpatient care is likely to have little impact on the need for hospital admission Agreement among practitioners on clinical criteria for admission: Agreement among practitioners on clinical criteria for admission: appendicitis with appendectomy appendicitis with appendectomy acute myocardial infarction acute myocardial infarction gastrointestinal obstruction gastrointestinal obstruction fracture of hip/femur fracture of hip/femur

13. Analysis Unit of analysis = patients Unit of analysis = patients Logistic regression models with odds of PH admission compared to marker admission for MA versus FFS enrollees Logistic regression models with odds of PH admission compared to marker admission for MA versus FFS enrollees Logistic models by each Racial group and Pooled models Logistic models by each Racial group and Pooled models Multivariate logistic models with multilevel data, adjusting for area-level clustering, by state Multivariate logistic models with multilevel data, adjusting for area-level clustering, by state

14. RESULTS Odds Ratios of PH Admissions (relative to Marker): MA VS. FFS enrollees WhiteAA 0.82 0.93 0.890.70 N.S. N.S.0.82 NYFL CA Hispanic 0.710.850.75

15. PH versus marker Odds Ratios ---------------------------------------------------------- (PH/marker) MA = (PH/marker) FFS 0.82 0.70 0.71 0.89 0.82 0.75 0.93 0.85 Results Odds ratios <1 in all racial groups in each state, and lower for minorities than whites

16. % Difference in Odds of PH Admissions: MA versus FFS Enrollees CA and FL had greater reductions in odds of PH among MA enrollees by racial groups, minorities in particular, relative to FFS WhiteAA -18 -18 -7 -7 -11 -11-30 N.S. N.S.-18 NYFL CA Hispanic -29-15-25

17. Odds Ratios of PH Admissions versus Marker Admissions: Race*HMO Interactions AA / White Hispanic / White 0.83 (p=.000)* 0.83 (p=.000)* N.S. 0.90 (p=.153) 0.90 (p=.153) 0.87 (p=.012)* N.S. 0.81 (p=.000)* NYFL CA *MA enrollment associated with significantly lower PH among Minorities relative to Whites

18. Summary In all racial groups, MA enrollment was associated with lower risks of PH admissions (versus marker admissions) than FFS enrollment In all racial groups, MA enrollment was associated with lower risks of PH admissions (versus marker admissions) than FFS enrollment Minority MA enrollees had lower risks of PH admissions (versus marker admissions) than white MA enrollees, relative to their FFS counterparts Minority MA enrollees had lower risks of PH admissions (versus marker admissions) than white MA enrollees, relative to their FFS counterparts CA and FL: Interaction effect in pooled model shows statistically significant reductions in PH rates among minority relative to white MA enrollees CA and FL: Interaction effect in pooled model shows statistically significant reductions in PH rates among minority relative to white MA enrollees

19. Conclusion MA plans were associated with beneficial impacts in all three states by improving quality primary care and reducing preventable hospitalizations MA plans were associated with beneficial impacts in all three states by improving quality primary care and reducing preventable hospitalizations The benefit also spilled over to different racial and ethnic subgroups The benefit also spilled over to different racial and ethnic subgroups In CA and FL, MA enrollment was associated with significant reductions in racial and ethnic differences in preventable hospitalization rates In CA and FL, MA enrollment was associated with significant reductions in racial and ethnic differences in preventable hospitalization rates

20. Implications MA plans (HMO) added value to the quality of primary care to the elderly by racial groups. MA plans (HMO) added value to the quality of primary care to the elderly by racial groups. Greater reduction of PH rates among minority subgroups indicates favorable role of MA plans in achieving racial/ethnic equalities. Greater reduction of PH rates among minority subgroups indicates favorable role of MA plans in achieving racial/ethnic equalities. Care management provided in Medicare HMOs may have implications for future strategies to reduce racial ethnic gaps and improve quality of primary care. Care management provided in Medicare HMOs may have implications for future strategies to reduce racial ethnic gaps and improve quality of primary care. The findings may have implications for greater use of preventive care advocated for health reform. The findings may have implications for greater use of preventive care advocated for health reform. Future research should evaluate the MMC programs by other plan types using more recent data. Future research should evaluate the MMC programs by other plan types using more recent data.