Ethnic Disparities in Place of Service
Among
Medicaid Beneficiaries with Mental Illnesses
Presenter
Mihail.Samnaliev@umassmed.edu, PhD
Funded by:
RWJ Foundation Substance Abuse
Policy Research Program
Grant:
“Medicaid Beneficiaries with Cooccurring Disorders”, PI: Robin Clark, PhD
Center for Health Policy & Research (chpr)
University of Massachusetts Medical School 1
Rationale
Accumulating evidence indicates that ambulatory care
received by Afrc Amer and Hispanics with mental illness (MI)
lags behind that received by White Americans with MI
•
African American and Hispanics receive poorer access and
quality of care (Miranda et al 2002); poorer preventive care
and rely on hospitals more heavily than White Americans
(MEPS, AHRQ)
•
People with mental illness (MI) face barriers to receipt of
care (Druss & Rosenheck 1998), are underdiagnosed
(Kessler et al 2005), have greater rates of chronic comorbidities (Felkeret al 1996); higher cost (Wolf et al 2002)
•
Why Medicaid:
- Very few national studies of Medicaid beneficiaries with MI
2
- Medicaid MH expenditures = $24 billion in 2001 (DHHS 2005)
Study objectives
Compare frequency of ambulatory care visits, for mental or comorbid disorders, received by African, Hispanic and White
Medicaid beneficiaries with MI, and if it affects health outcomes
1. Identify 12-month diagnosed prevalence of MI and ambulatory
care sensitive (ACS) comorbidities among those with MI
- Any MI; focus on 16 ACS conditions (e.g., asthma)
2. For each ethnic group, explore rates of physician office visits
with a primary diagnosis of MI or ACS condition (e.g., a primary
Dx of asthma means an office visit to seek care for asthma)
3. How does 2 relate to ACS (preventable) hospitalizations across
States (Effects of state Medicaid Programs)
______
Ethnic/racial categories as defined in the Medicaid claims datasets for 1999
3
Methods and data
•Quasi-experimental design: 6 states were selected from different
regions of the U.S.
• Logit models -> probability of office visits and hospitalization with
(i) MI
(among beneficiaries diagnosed with MI), or
(ii) ACSC
(among those diagnosed with MI + ACSC), or
(iii) any diagnosis (among beneficiaries diagnosed with MI)
Example:
• How often did a Hispanic beneficiary, diagnosed with depression
and asthma in 1999, receive care for asthma in (a) physician’s
office vs. (b) hospital? Are (a) and (b) correlated ;does it vary by
State? Why?
4
RESULTS
• A total of 4 million beneficiaries, including: 55% White, 30%
African American, 6% Hispanic
• Of which 350,000 (9%) diagnosed with MI (12-month
prevalence)
• Of which 176,000 (47%) diagnosed with one or more ACSC
For example:
5% had MI and asthma
12% had MI and COPD
14% had MI and diabetes
23% had MI and hypertension
5
RESULTS (cont)
• African Americans and Hispanics diagnosed with MI received
care in office 2 times less often than White beneficiaries
- including office visits with a diagnosis of MI, ACS or any Dx
- suggests poorer preventive care for mental and co-morbid
illness
• Higher rates of hosp. for ACS or any diagnosis, but not for MI.
- especially Afrc Amer with MI and ACSC
- suggests worse health outcomes which may be caused by a
lack of ambulatory preventive care
_________
Aside: All results above apply to people diagnosed with MI, but it seems that rates of
diagnosis are themselves affected by the lower rates of outpatient visits: African and
Hispanic beneficiaries had up to 3 times lower diagnosed MI prevalence, quite
different from the NCS, and the ECA which report similar rates across ethnic/racial
groups
6
RESULTS (cont)
• There was significant interstate variations in rates of office visits
and hospitalizations:
- Pr(office visits) 0.4 to 0.9
- Pr(hospitalization) as much as 1.8
- In 5 states, Hispanic and African American had lower rates of
office visits and non-significant or higher ACS hospitalization
rates, particularly among Afrc Amer with MI & ACS
- One state: equal ACSC office, and hospitalization were found
between African and White Americans.
7
Summary
Rates of ACS comorbidities ~ 50% for all ethnic groups
Afrc Amer and Hispanics with MI were less likely to receive care
in office-based settings, and more likely to be hospitalized
In one state: equal rates of office-based care among the 3 ethnic
groups and nonsignificant differences in rates of hospitalizations
among the 3 ethnic groups
Conclusion and Implications
State Medicaid programs may be able to improve primary care
and health outcomes for Afr Amer and Hispanics with MI by
enhancing accessibility/use of care in office-based settings.
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Appendix I: Odds Ratios1: office visits and hospitalization
African American vs. White
Pr (office visit)
Principal Dx:
Any
MI
Pr (hospitalization)
Principal Dx:
ACSC Any
MI
ACSC
0.4***
0.4***
0.7***
1.2***
ns
1.2***
AR
0.9**
ns
Ns
0.9*
ns
Ns
CO
0.4***
0.5***
0.5***
1.3**
ns
1.5*
GA
0.4***
0.4***
0.7***
0.9***
0.8***
Ns
IN
0.5***
0.6***
0.8***
1.2***
0.9***
1.1*
NJ
0.6***
0.4***
0.7***
1.5***
0.9***
1.5***
WA
0.5***
0.5***
0.6***
1.3***
ns
1.8***
All states
1Controlling
for age, gender, disability status *** p < 0.001 ** p< 0.05 * p<0.1
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Appendix I (cont) Odds Ratios1
Hispanic vs. White
All
Pr (office visit)
Pr (hospitalization)
Principal Dx:
Any
MI
ACSC
0.6*** 0.7*** 0.9***
Principal Dx:
Any Dx MI Dx ACSC
1.2***
ns
ns
AR
ns
ns
1.4*
ns
ns
ns
CO
0.9*
0.8***
ns
1.2***
ns
ns
GA
0.6***
0.7*
ns
1.4***
ns
ns
IN
0.8*
ns
ns
1.2*
ns
1.4**
NJ
0.8***
0.7***
1.2***
1.1***
ns
ns
WA
ns
0.8***
1.2***
1.3***
ns
ns
1Controlling
for age, gender, disability status *** p < 0.001 ** p< 0.05 * p<0.1
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Appendix II: 12-month diagnosed prevalence with MI
All States
AR
CO
GA
IN
NJ
WA
White
202,958
(11.6%)
15.7%
12.7%
11.4%
18.1%
14.1%
7.3%
Hispanic
22,739
(4.5%)
11.9%
5.8%
2.5%
5.7%
5.6%
2.8%
Afr.Amer
109,848
(9.1%)
15.4%
8.1%
8.1%
10.2%
8.4%
5.6%
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