Do Primary Care Physicians Treating Minority Patients Report Greater Problems Delivering Quality...

Do Primary Care Physicians Treating Minority Patients Report Greater Problems Delivering Quality Care?1

A New Perspective on Racial and Ethnic Disparities

James D. Reschovsky, Ph.D.Ann S. O’Malley, M.D.

Center for Studying Health System Change

1 Results based in part on James D. Reschovsky and Ann S. O’Malley, “Do Primary Care PhysiciansTreating Minority Patients Report Problems Delivering High-Quality Care,” Health Affairs 26(3):w222–w231 (published online Apr. 22, 2008).

Summary

Racial and ethnic disparities in primary health care likely reflect the aggregate socioeconomic composition of the physician’s patient panels as much as they do differences in individual patient characteristics. Physicians in high-minority practices depend more on low-paying Medicaid, receive lower private insurance reimbursements, and have lower incomes. These resource constraints help explain greater difficulties reported by these physicians with care processes—such as coordination of care, ability to spend adequate time with patients during office visits, and ability to obtain specialty referrals. Efforts to increase resources flowing to physicians treating many low-income minority patients—for instance by raising Medicaid reimbursements—would reduce racial and ethnic healthcare disparities.

Primary care for minorities is concentrated among a small proportion of physicians.

Figure 1. 48 Percent of Physicians Treat 82 Percentof All Minority Patients1

Source HSC Community Tracking Study Physician Survey, 2004-05.

*Approximation based on the number of patient visits and percent of patients who are African American or Latino.

12

52

36

18

52

30

0%

20%

40%

60%

80%

100%

Percent of minority patients* Percent of primary care

physic ians

High minority >70% Medium minority 30-70% Low minority <30%

Personal and practice characteristics of primarycare physicians in low-, medium-, and high-minoritypractices often differ.

Figure 2. Primary Care Physician Characteristics Differfor Practices with Low, Medium, and High Proportions

of Minority Patients

20.6

89.2

16.9

56.6

28.2*

87.9

15.3*

51.7

38.8*

80.4*

14.0*

30.8*

0

20

40

60

80

100

Percent practice

owner

Y ears in

practice

Percent board-

certified in

primary

spec ialty

Percent

international

medical

graduate

Low minority <30% Medium minority 30-70% High minority >70%

Source: HSC Community Tracking Study Physician Survey, 2004–05.

*Differs from physicians in low-minority practices at p0.05.

Figure 3. Physicians with High-Minority Patient PanelsAre More Likely to Be in Community or Public Clinics

and Institutional Practices1

30.8

67.7 62.9

12.2*3.1*1.5

44.0*34.0

43.7*

0%

20%

40%

60%

80%

100%

Low (<30%) Medium (30-70%) High (>70%)

Solo and group practicesInstitutional practicesCommunity/public c linics


* Differs from physicians in low-minority practices at p0.05.

1 Institutional practice settings include hospitals, medical schools, group/staff model HMOs, free-standing clinics, integrated health systems, PHOs, MSOs, foundations, independent contractors, locum tenens, and other miscellaneous types of practice settings.

Figure 4. Physicians with More Minority PatientsHave Same Level of Health Information Technology (IT)

Adoption as Those Treating Fewer Minority Patients

4.1 4.34.0

0

1

2

3

4

5

Number of Clinically Related Functions That

Practice IT Systems Perform



* Differs from physicians in low minority practices at p0.05.

Physicians in high-minority practices treat lower-income patients and are in more resource-constrained practices.

Figure 5. High-Minority Physician Practices Are inCommunities with Lower Patient Income and More Uninsured

48,364

43,049*

35,346*

$0

$20,000

$40,000

$60,000

Median Household

Income in Practice Zip

Code

12.4

15.3*16.9*

0%

5%

10%

15%

20%

Percent Uninsured in

County



Low (<30%) Medium (30–70%) High (>70%)

Figure 6. Primary Care Practices with More MinoritiesAre More Reliant on Medicaid Revenue, Less Reliant

on Private Insurance

55.4

13.1

31.7 52.528.2*

19.3*

42.5*

33.7*

24.4*

Low Minority Medium Minority High Minority (<30%) (30–70%) (>70%)



Private Medicaid Medicare

Figure 7. Physicians in High-Minority Practices Are in Communities with Lower Private and Medicaid

Payment Rates1 to Physicians

93.2 92.6 89.2*

0

20

40

60

80

100

Private insurance

payment index

Paym

ent

Index

71.2 75.066.6*

0

20

40

60

80

100

Ratio of Medicaid to

Medicare payments

Rati

o


1 Private insurances payment index developed by GAO based on Federal Employee Health Benefits Program PPO plans; Medicaid to Medicare payment index from Menges, et al., 2001.


Low minority, <30% Medium minority, 30–70% High minority, >70%

Figure 8. Primary Care Physicians in High-Minority Practices Earn Less Income

146,031

152,807

127,708*

$100,000

$120,000

$140,000

$160,000

Net Income from Medical Practice




Primary care physicians in high-minority practices are more likely to report they are unable to provide high-quality care to all of their patients—a pattern in part reflecting lower resources flowing to their practices.

Figure 9. Physicians in Higher-Minority PracticesReport Greater Difficulty Providing Quality Care to Patients,1

in Part Explained by Lower Resource Levels

21.7 23.225.9*

21.7*

16.1 16.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Low Minority,

<30%

Medium

Minority, 30-

70%

High Minority,

>70%

Unadjusted percent Adjusted percent


1 Based on disagreement with the statement, “It is possible to provide high-quality care to all my patients.”

2 Adjusted for practice resource levels (payer mix, reimbursement levels, and interactions between the two).


2

Figure 10. Disparities in Providing Quality Careto Patients1 Are Reduced with Medicaid–Medicare Physician

Payment Parity

19.722.7

25.9*

21.7*

16.1 15.6

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Low Minority,

<30%

Medium

Minority, 30-

70%

High Minority,

>70%

Unadjusted percent

Predicted if Medicaid physic ian payments raised to Medicare levels


1 Based on disagreement with the statement, “It is possible to provide high-quality care to all my patients.”

2 These simulations are based on regression models; from J. D. Reschovsky and A. S. O’Malley, “Do Primary Care Physicians Treating Minority Patients Report Problems Delivering High-Quality Care,” Health Affairs, 26(3):w222–w231 (published online Apr. 22, 2008).

* Differs from physicians in low-minority practices at p0.05. No significance tests for simulated values provided.

2

Figure 11. Physicians in Higher-Minority Practices AreMore Likely to Report Inadequate Time with Patients

During Office Visits—Explained in Part by theLower Resource Levels of High-Minority Practices

21.817.7

24.6* 26.0*

18.6

24.6*

0

5

10

15

20

25

30

Low minority,

<30%

Medium

minority, 30-

70%

High minority,

>70%





1

Figure 12. Consistent with Physician Reports of Inadequate Time with Patients, Office Visits in

Higher-Minority Practices Are Shorter

21.419.1

15.1*

0

5

10

15

20

25

Min

ute

s

Average Time Spent w ith Patients During Office Visits

Low minority, <30% Medium minority, 30-70% High minority, >70%



Figure 13. Physicians with More Minority PatientsReport Greater Difficulty Obtaining Specialty Care

42.4*

35.7*

30.8

40.135.6

31.4

0

5

10

15

20

25

30

35

40

Low minority,

<30%

Medium minority,

30-70%

High minority,

>70%





1

Figure 14. Physicians with More Minority PatientsAre More Likely to Report That the Scope of Care

They Are Expected to Treat Without Referral Is Too Broad

28.4*

22.5*

18.1

25.222.6

18.7

0%

10%

20%

30%

Low minority,

<30%

Medium minority,

30-70%

High minority,

>70%





1

Figure 15. Physicians in High-Minority Practices Face a Greater Challenge Coordinating Care1 Than Those Treating Fewer Minorities—

in Part Attributable to Lower Practice Resources

24.1*

14.5*

11.0

21.2*

14.6*

11.5

0

5

10

15

20

25

Low minority,

<30%

Medium minority,

30-70%

High minority,

>70%



1 As indicated by the percent reporting not getting timely reports from other providers is a major problem affecting quality.



2

Figure 16. Physicians in High-Minority Practices Do Not Report Greater Difficulties Maintaining Continuity of Care with Patients Than

Those Treating Fewer Minority Patients1

18.317.815.7 16.3

17.316.5

0

5

10

15

20

25

Low minority,

<30%

Medium minority,

30-70%

High minority,

>70%



1 As indicated by the percent disagreeing with the statement “It is possible to maintain the kind of continuing relationship with patients over time that promote the delivery of high quality care.”



2

High-minority practices have better access tooutpatient mental health services.

Figure 17. There Are Fewer Reports of Difficulties Obtaining Outpatient Mental Health Services in

High-Minority Practices

68.360.5*

49.3*

0%

20%

40%

60%

80%

Percent Reporting Problems Obtaining Outpatient

Mental Health Services for Patients




The percent of minority patients in a practice isnot associated with reports of difficulties accessing other types of services for patients.

Indicators of practice resources (payer mix and reimbursement levels) have little impact onthese reports.

Figure 18. There Are No Disparities with Regardto Reported Problems Obtaining Nonemergency

Hospital Admissions or Diagnostic Imaging

17.6

28.4

15.8

27.3

19.6

31.0

0%

10%

20%

30%

40%

Percent Reporting Difficulty

Obtaining Nonemergency

Hospital Admissions for

Patients

Percent Reporting Difficulty

Obtaining Diagnostic Imaging

for Patients




Conclusions

• The care of minority patients is concentrated in practices whose physicians treat many other minority patients.

• High-minority practices appear to have less adequate resources, as indicated by their payer mix, reimbursements, and incomes.

• Primary care physicians’ ability to effectively function as their patients medical homes—coordinating care, obtaining specialty referrals, spending adequate time with patients—is more difficult in higher-minority practices. For those physicians with predominantly minority patients, resource levels appear to explain some of this association.

Policy Remedies

• Increase resources for physician practices that predominantly treat low-income/high-minority populations through:

– Health insurance coverage expansions

– Greater subsidies to encourage physicians (including specialists) to serve in low-income, high-minority areas

– Increased Medicaid payments to physicians

– Practice supports for medical home functions.

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