Who You Are, Where You Live Affects Medical Treatment

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Who You Are, Where You Live Affects Medical Treatment, Dartmouth Atlas Study Finds

 

 

An interview with Katherine Baicker, Ph.D., and Amitabh Chandra, Ph.D., assistant professors of economics at Dartmouth College, Hanover, N.H., and Research Fellows at the National Bureau of Economic Research posted on the Robert Wood Johnson Foundation Website

 

The existence of racial and ethnic disparities in U.S. health care is well documented. To date, though, most of the knowledge of health care disparities draws from studies giving us a national average snapshot or results from a specific area or institution. Researchers Baicker and Chandra, joined by Jon Skinner and Jack Wennberg, used Medicare claims data from 1998 to 2001 to document the wide variations of disparities across regions and types of care. Their work is part of the Dartmouth Atlas of Health Care, a research project that examines geographical differences in health care resources, use and spending across the United States. The study, funded in part by the Robert Wood Johnson Foundation, was published in the Oct. 7, 2004 issue of Health Affairs.

 

Q: What role does geography play in why some people get inferior health care as compared to others?

 

A: People in different parts of the country get dramatically different quality and quantity of medical care, even after taking into account differences in their age and underlying health status. These geographic differences in the delivery of health care contribute to the existence of racial disparities in health care for two reasons. First, blacks and whites live in very different parts of the county, and within any given place, like in the city of Philadelphia, they tend to live in very different parts of that city. Secondly, the hospitals near the places that African Americans live in tend generally to have lower quality care. For example, they have higher mortality after heart attacks and are more likely to be staffed by physicians who are not board certified. Differences in care between regions of the country are just as important a contributor to overall racial disparities as ones within any given area.

 

Q: What are the factors that drive disparities in different regions, and do they affect all communities?

 

A: The pattern of disparities varies widely across communities and across different conditions – a given community may have large disparities in the use of one procedure but not in another. Some communities have virtually no disparities in treatment for certain conditions, although most communities have at least some disparities in some conditions. Areas where there is a large racial disparity in mammography (where blacks get fewer mammograms than whites) are not necessarily areas where there is a large racial disparity in the treatment of diabetes, for example. An analysis of disparities at the national level or an examination of just one area or just one treatment might give you a very misleading picture of the overall pattern of disparities.

 

Q: What types of procedures did your study examine? What were some of your findings?

 

A: We examined medical and surgical procedures, as well as overall spending. The medical procedures included eye exams and blood monitoring for diabetics and mammograms. The surgical procedures included hip replacement, back surgery, carotid endarterectomy – surgery to remove plaque from the carotid arteries, which carry blood to the brain – and several heart procedures. We looked at several measures of the care patients received in their last six months of life, including number of days they spent in the hospital, whether they were admitted to the ICU, and how much money was spent on them in those last six months. Last, we examined overall Medicare spending per beneficiary.

 

We found that some kinds of high-value, highly effective care (such as eye exams for people with diabetes) were underutilized by all racial and ethnic groups in most areas of the country. Other kinds of care, such as many surgeries, showed a much wider range of disparities. The pattern of disparities in different kinds of care was not consistent from region to region – regions that had equal care for some procedures had wide disparities in others.

 

Q: Does that mean minorities living in regions with a small racial disparities gap are getting quality care?

 

A: Regions with small racial disparities aren’t necessarily providing higher quality care. In fact, blacks may get better care in regions with greater disparities. This is true for two reasons. First, disparities could be caused by either higher treatment rates for whites, or lower treatment rates for blacks. Therefore, areas where disparities are large because white treatment rates are higher may still provide better care for blacks than areas where disparities are small. Second, blacks tend to live in areas with lower quality treatment for both black and white patients overall – so that eliminating disparities within a region would still leave black patients with lower quality of care than white patients, on average across the nation. Policies that focus on bringing up the quality of care in regions that lag behind national standards also would have the advantage of bringing the quality of care for black patients closer to that of white patients.

 

 

Q: Your paper also shows that higher-than-average surgical rates by white patients drive racial disparities for surgery. Can you explain that?

A: There are not well-established guidelines for many surgical procedures. For these procedures, factors such as physician practice style and the availability of facilities seem to drive a great deal of variation across different areas. For example, some communities perform heart bypass surgery four times as often as others do, even taking into account differences in the ages of the populations. In such regions, whites tend to get the procedure much more often than the national average, but blacks don’t get the procedure less often than the national average.

 

Q: What kind of care do blacks seem to get often?

 

A: Much of the money spent on blacks is on expensive “end-of-life†care of questionable value to the recipients. Evidence suggests that increased end-of-life spending does not improve the quantity or quality of life of those patients. Thus, while just as much money is spent on black Medicare beneficiaries as white beneficiaries, they are less likely to receive all sorts of care – both the highly effective, high-value care that all patients should receive and the more subjective, variable care that should depend on patient and physician choices. We could improve overall quality of care without increasing spending if we reallocated some of the funds devoted to end-of-life care to other uses.

 

Q: How could policy-makers reduce racial and ethnic disparities in the context of geography?

 

A: Our paper highlights the extent to which racial disparities in health care are complex phenomena, with complex answers. Therefore, well intentioned but naïve public policies that ignore the complexity of the problem are unlikely to reduce disparities. Disparities in different types of care need to be addressed with different policies. For the highly effective, high-value care that all patients should receive, policies should focus not on making sure that white and black patients receive the same care, but on increasing the quality of care in regions that lag behind the rest of the country, so that all patients have access to high quality care. For other procedures (such as back surgery) where patients’ preferences should affect their treatment, policies should focus on ensuring equal access to care. Funds that are spent on expensive end-of-life care could perhaps be devoted to more efficient uses.