Disparities in Long-Term Care: Disparities in Long-Term Care:

Building Equity into PolicyBuilding Equity into Policy

R. Tamara Konetzka, PhDR. Tamara Konetzka, PhDUniversity of ChicagoUniversity of Chicago

Co-author: Rachel M. Werner, MD, PhDCo-author: Rachel M. Werner, MD, PhDPhiladelphia VA and University of PennsylvaniaPhiladelphia VA and University of Pennsylvania

Building Bridges in LTC Colloquium 2008Building Bridges in LTC Colloquium 2008

Reducing Disparities is a Reducing Disparities is a National Health PriorityNational Health Priority

In 2002 Institute of Medicine In 2002 Institute of Medicine released “Unequal Treatment: released “Unequal Treatment: Confronting Racial and Ethnic Confronting Racial and Ethnic Disparities in Health Care”Disparities in Health Care”

Sustained interest by researchers, Sustained interest by researchers, policy makers, funding organizations, policy makers, funding organizations, practitioners, and the publicpractitioners, and the public

Not much has changed.Not much has changed.

LTC Disparities Overshadowed LTC Disparities Overshadowed by Access and Quality by Access and Quality

ConcernsConcerns Growing body of evidence points to Growing body of evidence points to

prevalent disparities in LTCprevalent disparities in LTC But overall policy and access concerns But overall policy and access concerns

have taken precedencehave taken precedence Early policies focused on Early policies focused on

reimbursement incentives to increase reimbursement incentives to increase access for Medicaidaccess for Medicaid

Last few decades focus on quality Last few decades focus on quality improvement and expanding HCBCimprovement and expanding HCBC

Use of Market-Based Use of Market-Based IncentivesIncentives

Poor quality of LTC often attributed to lack of Poor quality of LTC often attributed to lack of information on the part of consumers and information on the part of consumers and lack of competition on the part of providerslack of competition on the part of providers

Increasingly, policies aimed at quality Increasingly, policies aimed at quality improvement attempt to make health care improvement attempt to make health care more like other goodsmore like other goods– Enable consumers to shop on qualityEnable consumers to shop on quality– Providers compete to attract quality-savvy Providers compete to attract quality-savvy

consumersconsumers– Remove features of the market that may distort Remove features of the market that may distort

efficient choicesefficient choices

GoalsGoals

Review and synthesize the evidence Review and synthesize the evidence on:on:– Disparities in use of LTCDisparities in use of LTC– Disparities in qualityDisparities in quality (conditional on use)(conditional on use)

Analyze market-based quality Analyze market-based quality improvement initiatives in terms of improvement initiatives in terms of potential to affect disparitiespotential to affect disparities

Suggest potential policy modificationsSuggest potential policy modifications

What is a Disparity?What is a Disparity?

IOM definition:IOM definition:

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

Non

-Min

orit

y

Min

orit

yDifference

Clinical Appropriateness and Need

Patient Preferences

The Operation of Healthcare Systems and the Legal and Regulatory Climate

Discrimination: Biases andPrejudice, Stereotyping, andUncertainty

Disparity

Qua

li ty

o f H

e al th

Car

eIOM: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care

Populations with Equal Access to Health Care

Conceptual ApproachConceptual Approach

Modified IOM approachModified IOM approach Include differences in use/access as Include differences in use/access as

potential disparitiespotential disparities Race, ethnicity, and socioeconomic status Race, ethnicity, and socioeconomic status

form overlapping but not redundant risk form overlapping but not redundant risk pools for being underserved in the health pools for being underserved in the health systemsystem– Consider all pathwaysConsider all pathways– Disentangle to the extent possibleDisentangle to the extent possible

Conceptualize LTC as independent of settingConceptualize LTC as independent of setting

Methods for ReviewMethods for Review

Searched PubMed, Web of Science, Searched PubMed, Web of Science, and reference lists for papers related and reference lists for papers related to:to:– Disparities in use of LTCDisparities in use of LTC– Disparities in quality of LTC conditional Disparities in quality of LTC conditional

on useon use Any empirical research design Any empirical research design

(qualitative or quantitative)(qualitative or quantitative) 54 papers included54 papers included

Disparities in Use of Disparities in Use of LTCLTC

Use of Nursing Homes by Use of Nursing Homes by RaceRace

1980s and early 1990s: 1980s and early 1990s: – blacks much less likely than whites to blacks much less likely than whites to

use nursing homesuse nursing homes– blacks more disabled by the time they blacks more disabled by the time they

used nursing homesused nursing homes Research focused on whether this Research focused on whether this

was a difference or disparity...was a difference or disparity...

Compensating differentials?Compensating differentials?

Blacks and Hispanics more likely to Blacks and Hispanics more likely to use home health care than whitesuse home health care than whites– But difference not large enough to explain But difference not large enough to explain

lower nursing home uselower nursing home use Blacks more likely to use informal careBlacks more likely to use informal care Blacks also more likely to report Blacks also more likely to report

unmet needunmet needDifference in nursing home use was likely Difference in nursing home use was likely

due (at least in part) to differential access due (at least in part) to differential access to careto care

Different Different attitudes/preferences?attitudes/preferences?

Blacks express greater intent to use Blacks express greater intent to use informal care and greater willingness informal care and greater willingness to rely on informal networks of careto rely on informal networks of care

But actual size of informal care But actual size of informal care networks found not to vary by racenetworks found not to vary by race

And the intent/preference/norm may And the intent/preference/norm may be endogenousbe endogenous

More recent evidenceMore recent evidence

Black/white gap in nursing home use has Black/white gap in nursing home use has narrowednarrowed

Whether it has disappeared completely or Whether it has disappeared completely or even reversed depends on perspectiveeven reversed depends on perspective– Controlling for health status and other factors, Controlling for health status and other factors,

blacks still less likely to use NHblacks still less likely to use NH– But as percent of population, blacks’ rate of But as percent of population, blacks’ rate of

use is higheruse is higher One main driver of shift: whites’ use of One main driver of shift: whites’ use of

assisted livingassisted living

Use of hospiceUse of hospice

In early 1990s, blacks substantially In early 1990s, blacks substantially less likely to use hospice than whitesless likely to use hospice than whites

Rates of use equalized during 1990sRates of use equalized during 1990s But, Asians and Pacific Islanders still But, Asians and Pacific Islanders still

much less likely to enroll in hospicemuch less likely to enroll in hospice Blacks less likely than whites to re-Blacks less likely than whites to re-

enroll after initial dischargeenroll after initial discharge

Disparities in Use by SESDisparities in Use by SES

Evidence drawn largely from studies of Evidence drawn largely from studies of Medicaid accessMedicaid access

Nursing homes:Nursing homes:– In 1980s and 1990s C.O.N. laws led to “excess In 1980s and 1990s C.O.N. laws led to “excess

demand” situation in which Medicaid recipients demand” situation in which Medicaid recipients faced restricted accessfaced restricted access

– Market has become much more competitive; Market has become much more competitive; eased access in many areaseased access in many areas

HCBC: HCBC: – ““dual eligibles” exhibit reduced and less dual eligibles” exhibit reduced and less

appropriate utilization than Medicare-onlyappropriate utilization than Medicare-only

Disparities in Quality Disparities in Quality of LTCof LTC

Clinical Studies in Nursing Clinical Studies in Nursing HomesHomes

Compared with non-Hispanic whites...Compared with non-Hispanic whites...– black and Hispanic diabetic residents black and Hispanic diabetic residents

significantly less likely to receive anti-diabetic significantly less likely to receive anti-diabetic medicationsmedications

– Asian/Pacific Islanders, blacks, and Hispanics at Asian/Pacific Islanders, blacks, and Hispanics at risk for secondary stroke received anti-risk for secondary stroke received anti-coagulants less often coagulants less often

– black nursing home residents on antipsychotic black nursing home residents on antipsychotic drugs were less likely to take a second-drugs were less likely to take a second-generation antipsychotic generation antipsychotic

– black residents were less likely to be diagnosed black residents were less likely to be diagnosed with and to receive treatment for depressionwith and to receive treatment for depression

– black residents had higher rates of pressure black residents had higher rates of pressure soressores

But which pathway?But which pathway?

Studies of disparities in quality are Studies of disparities in quality are dominated by nursing home studies.dominated by nursing home studies.

Clinical studies document that Clinical studies document that disparities in nursing home care exist. disparities in nursing home care exist.

But is this discrimination among But is this discrimination among residents by providers? Or do racial residents by providers? Or do racial and ethnic minorities go to low-quality and ethnic minorities go to low-quality facilities?facilities?

These studies did not differentiate.These studies did not differentiate.

SegregationSegregation

Nursing homes more segregated than Nursing homes more segregated than other health care sectorsother health care sectors

Nursing home segregation mirrors (and Nursing home segregation mirrors (and often exceeds) residential segregationoften exceeds) residential segregation

Unequal quality across homesUnequal quality across homes Evidence is markedly consistent: Evidence is markedly consistent:

Segregation– where people go for LTC-- Segregation– where people go for LTC-- is the likely pathway to disparities in is the likely pathway to disparities in qualityquality

Disparities and SegregationDisparities and Segregation

Nursing homes in poor Nursing homes in poor neighborhoods are lower quality neighborhoods are lower quality

The low-quality facilities tend to:The low-quality facilities tend to:– Be high MedicaidBe high Medicaid– Be high minorityBe high minority– Have more deficienciesHave more deficiencies– Have lower staffingHave lower staffing– Be more likely to be terminated from Be more likely to be terminated from

Medicare/MedicaidMedicare/Medicaid

Little evidence of within-Little evidence of within-provider disparitiesprovider disparities

Quality is generally a “common Quality is generally a “common good” among Medicaid and private-good” among Medicaid and private-pay residents in the same facility pay residents in the same facility

Black/white differences in mortality Black/white differences in mortality disappear when site of care is disappear when site of care is controlledcontrolled

Non-nursing-home settingsNon-nursing-home settings

Blacks fare significantly worse than Blacks fare significantly worse than whites in home health outcomes (no whites in home health outcomes (no control for agency or neighborhood).control for agency or neighborhood).

PACE study: black mortality rates not PACE study: black mortality rates not worse than white ratesworse than white rates

Mixed evidence on differences in Mixed evidence on differences in end-of-life care quality by race, but end-of-life care quality by race, but little difference among hospice users.little difference among hospice users.

Study Designs and Study Designs and MethodologyMethodology

Almost all observational, cross-sectional Almost all observational, cross-sectional studies with multivariate adjustmentstudies with multivariate adjustment

Little variation in quality of designsLittle variation in quality of designs Common weakness that causality cannot Common weakness that causality cannot

be established.be established. More studies should use provider fixed-More studies should use provider fixed-

effects models to determine pathway of effects models to determine pathway of disparities: within or across providers?disparities: within or across providers?

IV may also be helpful.IV may also be helpful.

Will information and Will information and competition help reduce competition help reduce

disparities?disparities? Market-based policies are aimed at Market-based policies are aimed at

improving overall quality of careimproving overall quality of care Concerns have been raised about the Concerns have been raised about the

potential for disparities to be potential for disparities to be exacerbatedexacerbated

We know very little about this potential We know very little about this potential empirically, especially in LTCempirically, especially in LTC

Concerns rooted in differential Concerns rooted in differential consumer and provider responseconsumer and provider response

Accessing, Processing and Accessing, Processing and Understanding InformationUnderstanding Information

information may be more accessible information may be more accessible to residents who are educated or to residents who are educated or wealthywealthy

Information may be more Information may be more understandable to those who are understandable to those who are more educated more educated

disparities in use of information disparities in use of information technology may be increasing technology may be increasing

SupplySupply

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

Provider resourcesProvider resources

Low-quality providers tend to have fewer Low-quality providers tend to have fewer resourcesresources

Most QIMost QI efforts require significant financial efforts require significant financial investments investments

market-based incentives may induce market-based incentives may induce improvements only in providers that are improvements only in providers that are already well financed and of high qualityalready well financed and of high quality

Market-based incentives may also induce Market-based incentives may also induce exit of low-quality providers, raising exit of low-quality providers, raising potential access issuespotential access issues

Public Reporting of QualityPublic Reporting of Quality

Designed to provide consumers with Designed to provide consumers with a tool to choose high-quality a tool to choose high-quality providers; providers respond to providers; providers respond to increased consumer sensitivity by increased consumer sensitivity by competing on qualitycompeting on quality

But disparities could increase if:But disparities could increase if:– racial and ethnic minorities and low-SES racial and ethnic minorities and low-SES

individuals less likely to access, individuals less likely to access, understand, and use quality informationunderstand, and use quality information

– Low-resource providers less able to act Low-resource providers less able to act

Pay for PerformancePay for Performance

Often used in conjunction with public Often used in conjunction with public reporting; effects may be similarreporting; effects may be similar

In addition, bonuses paid to high-In addition, bonuses paid to high-performing providers to increase performing providers to increase incentiveincentive

But disparities could increase even more:But disparities could increase even more:– High-resource providers are more able to High-resource providers are more able to

respond to incentivesrespond to incentives– Bonuses increase the resource gap Bonuses increase the resource gap

Consumer-directed careConsumer-directed care

““Cash and Counseling” is best LTC Cash and Counseling” is best LTC exampleexample

Give consumers more control to Give consumers more control to choose/hire/fire LTC providers, formal choose/hire/fire LTC providers, formal and informal. and informal.

Designed to increase quality, Designed to increase quality, satisfaction, efficiencysatisfaction, efficiency

Consumer-directed care...Consumer-directed care...

Disparities may increase if:Disparities may increase if:– low-income groups are less able to navigate or low-income groups are less able to navigate or

access choices and search out appropriate access choices and search out appropriate caregiverscaregivers

– Low-income groups are more cost-sensitiveLow-income groups are more cost-sensitive But disparities may also decrease by:But disparities may also decrease by:

– Increasing choice among low-SESIncreasing choice among low-SES– Inducing an increase in the supply of providers Inducing an increase in the supply of providers

in neighborhoods where there was littlein neighborhoods where there was little– Creating jobs in low-income neighborhoods by Creating jobs in low-income neighborhoods by

paying informal caregivers paying informal caregivers

Potential Policy Potential Policy ModificationsModifications

1.1. ““Medical homes”Medical homes”2.2. Better ways to summarize and present Better ways to summarize and present

quality informationquality information3.3. Educational campaigns that target Educational campaigns that target

underserved, including the availability of underserved, including the availability of quality information in Spanishquality information in Spanish

4.4. P4P rewards based on improvement as P4P rewards based on improvement as well as level of performancewell as level of performance

5.5. Consider subsidizing QI efforts of low-Consider subsidizing QI efforts of low-resource providersresource providers

6.6. Continued Medicaid expansion into home- Continued Medicaid expansion into home- and community-based careand community-based care

Research PrioritiesResearch Priorities

Research that explores the source or Research that explores the source or causal pathway of existing disparities causal pathway of existing disparities

Research that tests the effect of QI Research that tests the effect of QI initiatives on disparities initiatives on disparities

Research that tests policy and practice Research that tests policy and practice modifications modifications

Research on more racial and ethnic Research on more racial and ethnic groups and on non-nursing-home groups and on non-nursing-home settings settings

Broad ConclusionsBroad Conclusions Residence and segregation may be more Residence and segregation may be more

important than differential treatment by important than differential treatment by providers in explaining disparities in LTC -- providers in explaining disparities in LTC -- presenting a more difficult policy presenting a more difficult policy challenge.challenge.

Improving overall quality and reducing Improving overall quality and reducing disparities in LTC are both important but disparities in LTC are both important but potentially competing goals. The extent to potentially competing goals. The extent to which they can be pursued simultaneously which they can be pursued simultaneously should be considered explicitly in the should be considered explicitly in the policy debate.policy debate.