Disparities in Long-Term Care: Building Equity into Policy

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Disparities in Long-Term Care Building Equity
into Policy

• R. Tamara Konetzka, PhD
• University of Chicago
• Co-author Rachel M. Werner, MD, PhD
• Philadelphia VA and University of Pennsylvania
• Building Bridges in LTC Colloquium 2008

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Reducing Disparities is a National Health Priority

• In 2002 Institute of Medicine released Unequal
  Treatment Confronting Racial and Ethnic
  Disparities in Health Care
• Sustained interest by researchers, policy makers,
  funding organizations, practitioners, and the
  public
• Not much has changed.

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LTC Disparities Overshadowed by Access and
Quality Concerns

• Growing body of evidence points to prevalent
  disparities in LTC
• But overall policy and access concerns have taken
  precedence
• Early policies focused on reimbursement
  incentives to increase access for Medicaid
• Last few decades focus on quality improvement and
  expanding HCBC

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Use of Market-Based Incentives

• Poor quality of LTC often attributed to lack of
  information on the part of consumers and lack of
  competition on the part of providers
• Increasingly, policies aimed at quality
  improvement attempt to make health care more like
  other goods
• Enable consumers to shop on quality
• Providers compete to attract quality-savvy
  consumers
• Remove features of the market that may distort
  efficient choices

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Goals

• Review and synthesize the evidence on
• Disparities in use of LTC
• Disparities in quality (conditional on use)
• Analyze market-based quality improvement
  initiatives in terms of potential to affect
  disparities
• Suggest potential policy modifications

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What is a Disparity?

• IOM definitionracial or ethnic differences in
  the quality of healthcare that are not due to
  access-related factors or clinical needs,
  preferences, and appropriateness of
  intervention.

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IOM Differences, Disparities, and
Discrimination Populations with Equal Access to
Health Care
Clinical Appropriateness and Need Patient
Preferences
Non-Minority
Difference
The Operation of Healthcare Systems and the
Legal and Regulatory Climate
Quality of Health Care
Minority
Disparity
Discrimination Biases and Prejudice,
Stereotyping, and Uncertainty
Populations with Equal Access to Health Care
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Conceptual Approach

• Modified IOM approach
• Include differences in use/access as potential
  disparities
• Race, ethnicity, and socioeconomic status form
  overlapping but not redundant risk pools for
  being underserved in the health system
• Consider all pathways
• Disentangle to the extent possible
• Conceptualize LTC as independent of setting

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Methods for Review

• Searched PubMed, Web of Science, and reference
  lists for papers related to
• Disparities in use of LTC
• Disparities in quality of LTC conditional on use
• Any empirical research design (qualitative or
  quantitative)
• 54 papers included

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Disparities in Use of LTC
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Use of Nursing Homes by Race

• 1980s and early 1990s
• blacks much less likely than whites to use
  nursing homes
• blacks more disabled by the time they used
  nursing homes
• Research focused on whether this was a difference
  or disparity...

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Compensating differentials?

• Blacks and Hispanics more likely to use home
  health care than whites
• But difference not large enough to explain lower
  nursing home use
• Blacks more likely to use informal care
• Blacks also more likely to report unmet need
• Difference in nursing home use was likely due (at
  least in part) to differential access to care

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Different attitudes/preferences?

• Blacks express greater intent to use informal
  care and greater willingness to rely on informal
  networks of care
• But actual size of informal care networks found
  not to vary by race
• And the intent/preference/norm may be endogenous

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More recent evidence

• Black/white gap in nursing home use has narrowed
• Whether it has disappeared completely or even
  reversed depends on perspective
• Controlling for health status and other factors,
  blacks still less likely to use NH
• But as percent of population, blacks rate of use
  is higher
• One main driver of shift whites use of assisted
  living

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Use of hospice

• In early 1990s, blacks substantially less likely
  to use hospice than whites
• Rates of use equalized during 1990s
• But, Asians and Pacific Islanders still much less
  likely to enroll in hospice
• Blacks less likely than whites to re-enroll after
  initial discharge

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Disparities in Use by SES

• Evidence drawn largely from studies of Medicaid
  access
• Nursing homes
• In 1980s and 1990s C.O.N. laws led to excess
  demand situation in which Medicaid recipients
  faced restricted access
• Market has become much more competitive eased
  access in many areas
• HCBC
• dual eligibles exhibit reduced and less
  appropriate utilization than Medicare-only

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Disparities in Quality of LTC
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Clinical Studies in Nursing Homes

• Compared with non-Hispanic whites...
• black and Hispanic diabetic residents
  significantly less likely to receive
  anti-diabetic medications
• Asian/Pacific Islanders, blacks, and Hispanics at
  risk for secondary stroke received
  anti-coagulants less often
• black nursing home residents on antipsychotic
  drugs were less likely to take a
  second-generation antipsychotic
• black residents were less likely to be diagnosed
  with and to receive treatment for depression
• black residents had higher rates of pressure
  sores

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But which pathway?

• Studies of disparities in quality are dominated
  by nursing home studies.
• Clinical studies document that disparities in
  nursing home care exist.
• But is this discrimination among residents by
  providers? Or do racial and ethnic minorities go
  to low-quality facilities?
• These studies did not differentiate.

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Segregation

• Nursing homes more segregated than other health
  care sectors
• Nursing home segregation mirrors (and often
  exceeds) residential segregation
• Unequal quality across homes
• Evidence is markedly consistent Segregation
  where people go for LTC-- is the likely pathway
  to disparities in quality

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Disparities and Segregation

• Nursing homes in poor neighborhoods are lower
  quality
• The low-quality facilities tend to
• Be high Medicaid
• Be high minority
• Have more deficiencies
• Have lower staffing
• Be more likely to be terminated from
  Medicare/Medicaid

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Little evidence of within-provider disparities

• Quality is generally a common good among
  Medicaid and private-pay residents in the same
  facility
• Black/white differences in mortality disappear
  when site of care is controlled

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Non-nursing-home settings

• Blacks fare significantly worse than whites in
  home health outcomes (no control for agency or
  neighborhood).
• PACE study black mortality rates not worse than
  white rates
• Mixed evidence on differences in end-of-life care
  quality by race, but little difference among
  hospice users.

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Study Designs and Methodology

• Almost all observational, cross-sectional studies
  with multivariate adjustment
• Little variation in quality of designs
• Common weakness that causality cannot be
  established.
• More studies should use provider fixed-effects
  models to determine pathway of disparities
  within or across providers?
• IV may also be helpful.

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Will information and competition help reduce
disparities?

• Market-based policies are aimed at improving
  overall quality of care
• Concerns have been raised about the potential for
  disparities to be exacerbated
• We know very little about this potential
  empirically, especially in LTC
• Concerns rooted in differential consumer and
  provider response

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Accessing, Processing and Understanding
Information

• information may be more accessible to residents
  who are educated or wealthy
• Information may be more understandable to those
  who are more educated
• disparities in use of information technology may
  be increasing

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Supply

• information about the quality of providers is not
  useful if access to high-quality providers close
  to home is restricted

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Provider resources

• Low-quality providers tend to have fewer
  resources
• Most QI efforts require significant financial
  investments
• market-based incentives may induce improvements
  only in providers that are already well financed
  and of high quality
• Market-based incentives may also induce exit of
  low-quality providers, raising potential access
  issues

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Public Reporting of Quality

• Designed to provide consumers with a tool to
  choose high-quality providers providers respond
  to increased consumer sensitivity by competing on
  quality
• But disparities could increase if
• racial and ethnic minorities and low-SES
  individuals less likely to access, understand,
  and use quality information
• Low-resource providers less able to act

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Pay for Performance

• Often used in conjunction with public reporting
  effects may be similar
• In addition, bonuses paid to high-performing
  providers to increase incentive
• But disparities could increase even more
• High-resource providers are more able to respond
  to incentives
• Bonuses increase the resource gap

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Consumer-directed care

• Cash and Counseling is best LTC example
• Give consumers more control to choose/hire/fire
  LTC providers, formal and informal.
• Designed to increase quality, satisfaction,
  efficiency

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Consumer-directed care...

• Disparities may increase if
• low-income groups are less able to navigate or
  access choices and search out appropriate
  caregivers
• Low-income groups are more cost-sensitive
• But disparities may also decrease by
• Increasing choice among low-SES
• Inducing an increase in the supply of providers
  in neighborhoods where there was little
• Creating jobs in low-income neighborhoods by
  paying informal caregivers

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Potential Policy Modifications

• Medical homes
• Better ways to summarize and present quality
  information
• Educational campaigns that target underserved,
  including the availability of quality information
  in Spanish
• P4P rewards based on improvement as well as level
  of performance
• Consider subsidizing QI efforts of low-resource
  providers
• Continued Medicaid expansion into home- and
  community-based care

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Research Priorities

• Research that explores the source or causal
  pathway of existing disparities
• Research that tests the effect of QI initiatives
  on disparities
• Research that tests policy and practice
  modifications
• Research on more racial and ethnic groups and on
  non-nursing-home settings

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Broad Conclusions

• Residence and segregation may be more important
  than differential treatment by providers in
  explaining disparities in LTC -- presenting a
  more difficult policy challenge.
• Improving overall quality and reducing
  disparities in LTC are both important but
  potentially competing goals. The extent to which
  they can be pursued simultaneously should be
  considered explicitly in the policy debate.