Racial Disparities Widespread in Range of Health Plans

Numerous studies show that black Americans receive worse quality of care than white Americans across a broad array of medical conditions—disparities that can significantly harm patients or reduce quality of life. A new study from HMS shows that such disparities in care cannot simply be attributed to low-performing health plans. The research, published in the Oct. 25 Journal of the American Medical Association, shows that for four key health measures in Medicare patient cases, high-performing and low-performing health plans had comparable levels of disparity.

Adapted by David Temelini

Uneven care. Within- and between-plan racial disparities in four outcome measures were greatest in the control of low-density lipoprotein cholesterol (LDL-C) after a coronary event. (*Changed to 9.0 percent in 2003.)

“Across Medicare health plans, better overall quality is not consistently associated with smaller racial disparities on four key outcome measures for enrollees with diabetes, hypertension, or heart disease,” said John Ayanian, HMS associate professor of health care policy and of medicine at Brigham and Women’s Hospital.

Ayanian, Amal Trivedi, formerly in the Department of Health Care Policy at HMS and now at Brown Medical School, and colleagues found only one health plan in a sample of 151 that had both high overall quality and low racial disparity on more than one of the four outcome measures examined.

Since 1997, all health plans participating in Medicare have been mandated to report on quality of care using Health Plan Employer Data and Information Set (HEDIS) performance measures developed by the National Committee for Quality Assurance. The authors obtained HEDIS data for Medicare managed care plans, consisting of more than 431,000 observations from enrollees in 151 health plans.

For the four HEDIS outcome measures the authors examined, clinical performance was approximately 7 to 14 percent lower for black enrollees than white enrollees. More than 70 percent of the racial disparity on each measure was attributable to different outcomes within the same health plans for white and black enrollees, not a disproportionate enrollment of blacks in lower-performing plans.

“This study indicates that most health plans have substantial opportunities to improve their outcomes for African-American enrollees on these measures,” said Trivedi.

The authors examined data for individuals eligible for at least one of four HEDIS outcome indicators: control of blood sugar and of cholesterol among enrollees with diabetes, blood pressure control among enrollees with hypertension, and cholesterol control among enrollees following a heart attack or heart surgery. Although a few plans did not have significant disparity, some plans had racial differences of more than 20 percent.

“This shows that racial disparities in these important outcome measures are widespread and not limited to any one region or subset of poorly performing health plans,” said Ayanian.

—Leah Gourley

Nutritional Disorders Diverge by Socioeconomic Status

Obesity and malnutrition tend to prey on different socioeconomic groups within the same country, according to a study in the September American Journal of Clinical Nutrition. S.V. Subramanian, HSPH assistant professor of society, human development, and health, compared body mass index to socioeconomic status for approximately 77,000 women of childbearing age in India. He found that while affluent women were more likely to be overweight, poorer subjects suffered a higher incidence of malnutrition.

Although previous studies had shown a positive correlation between wealth and obesity throughout developing countries, Subramanian’s study is the first to examine obesity and malnutrition simultaneously, within a single country. Researchers hope that an understanding of this relationship will lead to an effective mitigation strategy for both epidemics.

Data came from the Indian National Family Health Survey of 1998–1999. Because the year marked the end of roughly a decade of market liberalization for India, the time point provided a glimpse into the impact this shift in economic policy had on individual health.

“I think we can truly say that there’s an overconsumption happening,” Subramanian said. “There’s been a huge explosion in their incomes—they can consume more, so they do.”

But that income explosion has not been uniform. For women of lower socioeconomic groups, the probability of being underweight was even higher in wealthier states. This suggests that income inequality has kept pace with economic growth. 

Within more affluent groups, the trend toward obesity was surprisingly robust. Younger women, for example, were just as likely to be obese as older women in the same region. This similarity may be directly related to diet. Higher income groups obtained almost twice as much of their energy from fat as lower-income groups.

 “Right now is the best time to intervene,” Subramanian said. He hopes that having one nutrition-based epidemic concentrated among the wealthy will force policymakers to pay attention to nutritional health. In a trickle-down fashion, this link could also benefit those suffering from malnutrition.

Subramanian also looked at macroeconomic indicators of wealth for individual states. Earlier studies had suggested that at a certain level of economic development, the burden of obesity within a given country would shift to the lower classes. This explains why in developed countries obesity is more prevalent among the poor. Although India as a whole has not reached the purported crossover point, some of its states have. When Subramanian looked at those states, however, he found no evidence of change. These findings suggest that the picture may be more complex at the state level and that more work needs to be done to clarify the factors influencing the socioeconomic distribution of nutritional health.

—Jeneen Interlandi

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