Are Higher Medicaid Payments the Solution in Quality Care?

Researchers have expended considerable time and effort in an attempt to quantify and describe the extent, character, and effects of disparities in the quality of healthcare received by racial and ethnic minorities in the US. Part of that effort has also included attempts to identify the causes of these disparities, with report after report concluding that there are a wide variety of factors specific to patients, providers, the healthcare delivery system, socioeconomics, and other cultural and institutional factors that together are at the root of the less than desirable health outcomes experienced by minorities in this country. An interesting article by James D. Reschovsky, PhD, and Ann S. O'Malley, MD, MPH, in the April 22 Health Affairs, titled “Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care?” addressed this topic from the perspective of primary care physicians. Acknowledging the “broad consensus” surrounding the existence (if not the root causes) of widespread racial and ethnic disparities in primary healthcare, the authors reviewed data from the 2004—05 Community Tracking Study (CTS) Physician Survey and other sources for more than 3,300 practices, focusing on general internists, family or general practitioners, and general pediatricians.

The authors wanted to know whether lack of resources was a primary cause of the quality disparities in the care received by ethnic and racial minorities, specifically by exploring whether primary care physicians “whose patient panels… consist of a disproportionate percentage of minorities report more difficulties obtaining services for their patients and delivering high-quality care than those treating fewer minority patients.”

The authors reviewed data from what they label as “low-, medium-, and high-minority” practices, defined as practices with patient panels that were “less than 30 percent, 30—70 percent, and 70 percent black or Latino, respectively.” Of the practices covered by the data reviewed for the article, slightly more than half (52%) reported panels consisting of less than 30% minorities; 36% reported panels in the 30–70% range; and 12% treated patient populations that consisted of more than 70% minority patients.

Several interesting, if in some cases unsurprising, findings stand out from the article:

• 35% of “high-minority” practices reported that “patients’ inability to pay was a major problem affecting their ability to provide high-quality care, compared with 23% of those in low-minority practices.”

• Physicians treating large numbers of minority patients did report having a greater percentage of patients with whom they have a hard time communicating because they speak a different language.

• Only 35% of physicians in high-minority practices were white, non-Hispanic. Conversely, very few (3.4%) physicians in practices with less than 30 percent minority patients were African American or Hispanic themselves.

• Physicians in high-minority practices had fewer years of practice experience and were less likely to be board certified than their counterparts in low-minority practices.

• Physicians in high-minority practices across all settings reported a greater share of practice revenues from the generally low-paying Medicaid program, as compared with those serving fewer minority patients. Moreover, physicians in high-minority practices were in locations where the ratio of Medicaid to Medicare reimbursements was significantly lower than the ratios in practices with 30—70% minority patients in 2004–05. Physicians in high-minority practices were also located in areas with lower private insurance reimbursements to physicians.

• There were no significant differences in the use of health information technologies between physicians in high- and low-minority practices.

• More than a quarter of physicians in high-minority practices disagreed that it was possible to provide high-quality care to all of their patients, compared with 16% of those in low-minority practices.

• Physicians with high-minority patient panels were more likely than those treating few minorities to report difficulties obtaining specialty care for their patients.

• Physicians in high-minority practices were more likely than those in low-minority practices to report language or cultural barriers to communication with patients as a major problem affecting quality.

• Physicians in high-minority practices spent about 30 percent less time per patient seen than those in low-minority practices.

• Nearly a quarter of PCPs in high-minority practices reported that not getting timely reports from other providers was a major problem affecting their ability to provide high-quality care, compared with 11% of PCPs in low-minority practices.

Without the benefit of more detailed analysis of some of this data (how are the practices defining “quality care,” for example, and how does this affect the weight that should be given to their replies), it is difficult to argue with the authors’ conclusions that “racial and ethnic disparities in primary health care are in part systemic in nature, and the lower resources flowing to physicians treating more minority patients are a contributing factor.”

The authors do, however make one assertion that I find somewhat difficult to reconcile. They claim that if “Medicaid payments to physicians were on par with those paid by Medicare, disparities in reported difficulties between physicians whose patient panels were made up of greater versus smaller proportions of minorities would diminish, often substantially.” While there are certainly many additional layers to the authors’ contention, this solution would seem to reduce the issue of racial health disparities to a question of reimbursement: more money equals fewer disparities. With federal health dollars already scarce and likely to become even more so in the future, this does not bode well for efforts to improve the care provided to minority patients.