HMGT 400 Research and Data Analysis in Healthcare
DOI:10.1093/jnci/djt333 Advance Access publication December 6, 2013 © The Author 2013. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: [email protected]. Article Racial and Ethnic Differences in Use of Mammography Between Medicare Advantage and Traditional Medicare John Z. Ayanian, Bruce E. Landon, Alan M. Zaslavsky, Joseph P. Newhouse Manuscript received May 29, 2013; revised September 3, 2013; accepted October 11, 2013. Correspondence to: John Z. Ayanian, MD, MPP, Institute for Healthcare Policy and Innovation, University of Michigan, 2800 Plymouth Road, NCRC Building 16, Ann Arbor, MI 48109 (e-mail: [email protected]). Breast cancer is a leading cause of mortality for women in all racial/ethnic groups. We compared use of mammography by race/ethnicity in Medicare health maintenance organizations (HMOs), preferred provider organizations (PPOs), and traditional Medicare. Methods We matched 495 836 women in HMOs and 81 480 women in PPOs who were aged 65 to 69 years during 2009 to women enrolled in traditional Medicare by race/ethnicity, Medicaid eligibility status, and geographic area. We identified mammography use from the Healthcare Effectiveness Data and Information Set for Medicare HMOs and PPOs and from claims data for traditional Medicare with the same specifications. We then compared racial/ ethnic differences in rates of mammography in HMOs and PPOs to matched populations in traditional Medicare and estimated differences with z tests. All statistical tests were two-sided. Results Relative to matched white women, mammography rates were statistically significantly higher for black, Hispanic, and Asian/Pacific Islander women in HMOs (6.1, 5.4, and 0.9 percentage points, respectively; all P ≤ .003) and statistically significantly lower for all three groups in traditional Medicare (3.3, 7.4, and 7.7 percentage points, respectively; all P < .001). Similar improvements in mammography rates also were observed in PPOs among all minority groups relative to traditional Medicare. Conclusions Higher rates of mammography in HMOs and PPOs were associated with a reversal of racial and ethnic differences observed in traditional Medicare. These differences may be related to lower patient cost-sharing and better systems to promote preventive services in managed care plans, as well as unmeasured characteristics or beliefs of minority women who enroll in these health plans relative to those in traditional Medicare. J Natl Cancer Inst;2013;105:1891–1896 Breast cancer is a leading cause of cancer mortality for women in the United States, ranking first for Hispanic women and second behind lung cancer for black, Asian/Pacific Islander, and white women (1). To facilitate the diagnosis of breast cancer at earlier stages and reduce mortality, mammography is recommended by national guidelines in the United States for women aged 50 through 74 years, based on evidence from randomized clinical trials (2,3). At age 65 years, almost all US women become insured through the Medicare program, which began covering screening mammography biennially in 1991 and annually in 1998 (4). Since the Medicare Modernization Act in 2003, the proportion of Medicare beneficiaries enrolled in private health plans through the Medicare Advantage program has doubled from 13% in 2004 to 27% in 2012 (5), with the remainder enrolled in traditional fee-for-service Medicare. Among beneficiaries in Medicare Advantage in 2012, 65% were enrolled in health maintenance organizations (HMOs), and 28% were enrolled in preferred provider organizations (PPOs) (5). HMOs and PPOs receive capitated payments from Medicare and provide medical services through contracts with physicians and jnci.oxfordjournals.org hospitals. Whereas HMOs have been widely available in Medicare since the mid-1990s, PPOs were rare before 2006 and have fewer restrictions on beneficiaries seeking care from physicians or hospitals outside PPO provider networks. Relative to traditional Medicare, Medicare HMOs and PPOs had lower patient cost-sharing for preventive services before 2010 (6), and they may have more organized systems to promote appropriate preventive services. Medicare HMOs and PPOs are required by the Centers for Medicare and Medicaid Services (CMS) to publicly report their use of mammography each year for women aged 65 to 69 years, whereas such reporting is not required in traditional Medicare. Recently, we found that overall mammography rates were statistically significantly higher in Medicare HMOs than in traditional Medicare by 17.9% in 2003 and by 13.5% in 2009 (7). Given their higher rates of mammography, Medicare HMOs may be more effective than traditional Medicare in eliminating racial and ethnic disparities in this service. Between 1997 and 2003, disparities in use of mammography between black and white women enrolled in Medicare HMOs narrowed, but rates for black JNCI | Articles 1891 Downloaded from https://academic.oup.com/jnci/article/105/24/1891/2517738 by guest on 23 February 2024 Background women remained statistically significantly lower (8). Comparable data were not available for Hispanic or Asian/Pacific Islander women because of incomplete identification of these groups in Medicare enrollment data (9,10). Similarly, little is known about racial and ethnic disparities in Medicare PPOs, which have largely developed since 2006. Therefore, the objective of our study was to compare racial and ethnic differences in use of mammography in Medicare HMOs and PPOs relative to traditional Medicare. In addition to black and white women, we included Hispanic and Asian/Pacific Islander women using a new algorithm that identifies these latter two groups much more accurately (11). Study Cohort We studied care of Medicare beneficiaries in 2009, the most recent data available when our study was conducted. The study was approved by the CMS Privacy Board and by the Human Studies Committee of Harvard Medical School with a waiver of informed consent and in accord with an assurance filed with and approved by the US Department of Health and Human Services. The Medicare Beneficiary Summary File from CMS provides data on beneficiaries’ demographic characteristics (age, race/ethnicity, county, and state of residence), enrollment in HMOs or PPOs, dual eligibility for Medicaid, and vital status. Our study cohort included women in HMOs, PPOs, or traditional Medicare who were recorded as black, Hispanic, Asian/Pacific-Islander, or nonHispanic white using a new race/ethnicity variable developed and validated by the Research Triangle Institute to identify Hispanic and Asian/Pacific Islander beneficiaries more accurately (11). This new race/ethnicity variable uses algorithms based on lists of Hispanic and Asian/Pacific Islander surnames and given names from the US Census Bureau and on the CMS designation of Spanish as a beneficiary’s preferred language. The sensitivity of the prior Medicare race/ethnicity variable exceeded 93% for white and black beneficiaries but was substantially lower for Hispanic (30%–41%), Asian (56%–60%), and Pacific Islander (26%–39%) beneficiaries, and the prior Medicare variable disproportionately identified poorer and less healthy individuals in these latter three groups (10). Application of the new algorithm to Medicare enrollment data in 2003 increased the sensitivity for identifying Hispanic beneficiaries from 43% to 77% and for Asian/Pacific Islander beneficiaries from 54% to 79%, with essentially no change in specificity (>99%) for either group (11). As described in previous research (7), we excluded partialyear enrollees and those in HMOs and PPOs with less than 500 enrollees. Outcome Variables As specified in the Healthcare Effectiveness Data and Information Set (HEDIS) developed by the National Committee for Quality Assurance, Medicare HMOs and PPOs submit individual-level data to CMS on use of mammography among women aged 65 to 69 years. This HEDIS measure for 2009 included screening and diagnostic mammograms identified from health plan records using Current Procedure Terminology codes (codes 77055– 77057), Healthcare Common Procedure Coding System codes 1892 Articles | JNCI Statistical Analysis Racial and ethnic groups are distributed unevenly across US regions, as are Medicare HMOs and PPOs. Black, Hispanic, and Asian/Pacific Islander women are also more likely than white women to be eligible for Medicaid because of lower incomes, which may affect their use of mammography. To account for these geographic and socioeconomic differences by race/ethnicity, for women eligible for mammography in each minority group (black, Hispanic, Asian/Pacific Islander), we statistically reweighted white women in the same component of Medicare to match the distribution of the minority group cohort by age, eligibility for Medicaid, and county or state. To do so, we assigned women to cells defined by crossing these variables and weighted the white observations by the ratio of minority group to white observations in the cell. For the HMO cohort, all racial and ethnic groups were matched within county (>97%) or state (92%) and more likely to be matched within state (
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