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
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.

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

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
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

What is a Disparity?

IOM definition:
“racial or ethnic differences in the quality
of healthcare that are not due to accessrelated factors or clinical needs,
preferences, and appropriateness of
intervention.”
IOM: Differences, Disparities, and
Discrimination: Populations with Equal Access
to Health Care
Clinical Appropriateness
and Need
Patient Preferences
Minority
Non-Minority
Difference
Populations with Equal Access to Health Care
The Operation of Healthcare
Systems and the Legal and
Regulatory Climate
Disparity
Discrimination: Biases and
Prejudice, Stereotyping, and
Uncertainty
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
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

Disparities in Use of LTC
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...
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
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

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
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

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
Disparities in Quality of
LTC
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
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.

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

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
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

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-oflife care quality by race, but little
difference among hospice users.

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 fixedeffects models to determine pathway of
disparities: within or across providers?
 IV may also be helpful.

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

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

Supply

information about the quality of providers
is not useful if access to high-quality
providers close to home is restricted
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

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
Pay for Performance
Often used in conjunction with public
reporting; effects may be similar
 In addition, bonuses paid to highperforming 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
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

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
Potential Policy Modifications
1.
2.
3.
4.
5.
6.
“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
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

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.
