Background In the United States, black patients generally receive lower-quality health care than white patients. Black patients may receive their care from a subgroup of physicians whose qualifications or resources are inferior to those of the physicians who treat white patients. Methods We performed a cross-sectional analysis of 150,391 visits by black Medicare beneficiaries and white Medicare beneficiaries 65 years of age or older for medical “evaluation and management” who were seen by 4355 primary care physicians who participated in a biannual telephone survey, the 2000–2001 Community Tracking Study Physician Survey. Results Most visits by black patients were with a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent, P=0.02) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs. 19.3 percent, P=0.005). The physicians treating black patients also reported facing greater difficulties in obtaining access for their patients to high-quality subspecialists, high-quality diagnostic imaging, and nonemergency admission to the hospital. Conclusions Black patients and white patients are to a large extent treated by different physicians. The physicians treating black patients may be less well trained clinically and may have less access to important clinical resources than physicians treating white patients. Further research should be conducted to address the extent to which these differences may be responsible for disparities in health care.

https://www.nejm.org/doi/pdf/10.1056/NEJMsa040609

Primary care physicians who treat blacks and whites.

Context Substantial racial disparities in the use of some health services exist; however, much less is known about racial disparities in the quality of care. Objective To assess racial disparities in the quality of care for enrollees in Medicare managed care health plans. Design and Setting Observational study, using the 1998 Health Plan Employer Data and Information Set (HEDIS), which summarized performance in calendar year 1997 for 4 measures of quality of care (breast cancer screening, eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness). Participants A total of 305 574 (7.7%) beneficiaries who were enrolled in Medicare managed care health plans had data for at least 1 of the 4 HEDIS measures and were aged 65 years or older. Main Outcome Measures Rates of breast cancer screening, eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. Results Blacks were less likely than whites to receive breast cancer screening (62.9% vs 70.9%; P<.001), eye examinations for patients with diabetes (43.6% vs 50.4%; P = .02), -blocker medication after myocardial infarction (64.1% vs 73.8%; P<.005), and follow-up after hospitalization for mental illness (33.2 vs 54.0%; P<.001). After adjustment for potential confounding factors, racial disparities were still statistically significant for eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. Conclusion Among Medicare beneficiaries enrolled in managed care health plans, blacks received poorer quality of care than whites.

https://jamanetwork.com/journals/jama/articlepdf/194724/JOC11037.pdf

Racial disparities in the quality of care for enrollees in medicare managed care.

Background This randomized trial evaluated an integrated model of primary medical care for a cohort of patients with serious mental disorders. Methods A total of 120 individuals enrolled in a Veterans Affairs (VA) mental health clinic were randomized to receive primary medical care through an integrated care initiative located in the mental health clinic (n = 59) or through the VA general medicine clinic (n = 61). Veterans who obtained care in the integrated care clinic received on-site primary care and case management that emphasized preventive medical care, patient education, and close collaboration with mental health providers to improve access to and continuity of care. Analyses compared health process (use of medical services, quality of care, and satisfaction) and outcomes (health and mental health status and costs) between the groups in the year after randomization. Results Patients treated in the integrated care clinic were significantly more likely to have made a primary care visit and had a greater mean number of primary care visits than those in the usual care group. They were more likely to have received 15 of the 17 preventive measures outlined in clinical practice guidelines. Patients assigned to the integrated care clinic had a significantly greater improvement in health as measured by the physical component summary score of the 36-Item Short-Form Health Survey than patients assigned to the general medicine clinic (4.7 points vs −0.3 points, P Conclusion On-site, integrated primary care was associated with improved quality and outcomes of medical care.

https://jamanetwork.com/journals/jamapsychiatry/articlepdf/481816/yoa20292.pdf

Integrated medical care for Patients with serious psychiatric illness: A randomized trial

Objectives To examine the association between provider continuity and future hospitalization in a Medicaid population, and to determine if this association is greater for ambulatory care-sensitive conditions. Design Analysis of paid claims to the Delaware Medicaid program during a 2-year period (July 1, 1993, to June 30, 1995). Continuity with a single provider during year 1 of the study was computed for each participant. Participants A total of 13,495 continuously enrolled fee-for-service Medicaid patients aged 0 to 64 years who had made at least 3 ambulatory physician visits during the first year of the study. Main outcome measure Likelihood of hospitalization in year 2 of the study for all conditions and for ambulatory care-sensitive conditions. Results The mean continuity score was 0.50 in year 1 and 11.9% of patients were hospitalized in year 2. After controlling for demographics, number of ambulatory visits, and case mix, higher provider continuity was associated with a lower likelihood of hospitalization for any condition (odds ratio [OR] = 0.56; 95% confidence interval [CI], 0.46-0.69). For chronic ambulatory care-sensitive conditions there was a similar association between provider continuity and hospitalization (OR = 0.54; 95% CI, 0.34-0.88), but for acute ambulatory care-sensitive conditions there was no significant association (OR = 0.80; 95% CI, 0.48-1.34). Conclusions Continuity of care with a provider is associated with a decreased future likelihood of hospitalization in the Delaware Medicaid population. This suggests that policies that encourage patients to concentrate their care with a single provider may lead to lower hospitalization rates and possibly lower health care costs. This study does not support the hypothesis that a certain set of conditions are particularly ambulatory care sensitive.

The Role of Provider Continuity in Preventing Hospitalizations

Objective. To identify all financial incentives that had been proposed, described, or used regardless of their initial objective and, when possible, to assess the results of these incentives on costs, process or outcomes of care. Material and methods. Systematic review of the literature. Databases searched were: Medline, Embase, Health Planning and Administration, Pascal, International Pharmaceutical Abstracts and the Cochrane Library. Search terms were: health professionals and type of practice, type of incentive, methodology, languages English or French, January 1993 to May 1999. Results. Financial incentives concerned the modalities of physician payment and financing of the health care system. Confounding factors included: age of the doctor, training, speciality, place and type of medical practice, previous sanctions for over-prescribing, type and severity of disease, type of insurance. Risks of financial incentives were: limited access to certain types of care, lack of continuity of care, conflict of interests between the physician and the patient. Any form of fund-holding or capitation decreased the total volume of prescriptions by 0–24%, and hospital days by up to 80% compared with fee-for-service. Annual cap on doctors’ incomes resulted in referrals to colleagues when target income is reached. Discussion. Financial incentives can be used to reduce the use of health care resources, improve compliance with practice guidelines or achieve a general health target. It may be effective to use incentives in combination depending on the target set for a given health care programme.

Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues.

This article reviews the existing literature on the efficacy of primary care with an emphasis on the evaluation of primary care for vulnerable populations: groups whose demographic, geographic, or economic characteristics impede or prevent their access to health care services. A significant portion of the literature derives from studies of poor and underserved populations. However, to construct a more complete evaluation of primary care services, the authors cite literature that has examined both advantaged and disadvantaged populations. Even then the literature is incomplete, at best. The article describes a definition of primary care suitable for policy analysis and formulation, reviews evidence on the efficacy of care that meets that definition, and concludes that widespread use of primary care services is likely to result in improved patient satisfaction and health status.

The efficacy of primary care for vulnerable population groups.

OBJECTIVESIndividuals without health insurance in general receive fewer health services and are more likely than insured patients to experience poor outcomes. The main goal of this research was to study whether physicians' clinical recommendations vary for insured and uninsured patients, implying th

Physician response to patient insurance status in ambulatory care clinical decision-making. Implications for quality of care.

IN THE year sinceThe Journalpublished its theme issue on "Caring for the Uninsured and Underinsured" (May 15, 1991), the debate over the need for a national health plan has intensified. The already broad interest in health care reform has been widened by a diverse group of proposals by presidential candidates, members of Congress, professional associations, and national leadership groups that can be added to the 13 proposals we reviewed. Opinion surveys show that public interest in national solutions to these problems remains intense. When asked in January 1992 what issues besides the economy and foreign For editorial comment see p 2521. affairs presidential candidates should emphasize, the public ranked health care and health insurance highest among all items mentioned. 1 Similarly, when queried about the future content of the President's State of the Union Address, 93% of Americans reported that they thought it should include a program for

Making the Critical Choices

These recent events provide the impetus for this theme issue ofThe Journal: (1) Government reports show a 24% increase in the last decade in the total number of uninsured people and a 40% increase in the number of uninsured children. 1-4 Most uninsured children are part of a family with a working adult. (2) Recent studies have found that, despite considerable amounts of uncompensated care provided by hospitals and physicians, Americans without health insurance face major barriers to the receipt of needed health services. Although they suffer from higher rates of ill health than the insured population, the uninsured report fewer hospitalizations and fewer visits to a physician, shorter hospital stays, and fewer discretionary inpatient hospital treatments and tests, at higher cost. The uninsured also experience higher mortality rates when hospitalized than persons with health insurance coverage who have similar medical diagnoses. 5-11 (3) There is evidence of growing

Caring for the Uninsured Choices for Reform

Many of the legislative proposals to address the growing problem of uninsured Americans to date have focused on improving access to health insurance for small businesses. This focus is sound for three reasons. First, the impact could be quite large–over 53 percent of the uninsured work for small businesses, and many more are dependents of someone who works for a small firm. Second, these reforms retain our current employment-based system of providing health insurance–a system that is favored by a large number of employers and employees. Third, the reforms expand access to health insurance without requiring that the federal government raise taxes. Proposals targeted at covering employees of small businesses have taken two forms. The first, reforms of the small-group insurance market, attempt to address many of the problems small businesses face in offering health insurance to employees: high costs, rising rates, policy cancellations, lack of access to a policy due to insurance policies such as “redlining” (that is, excluding) specific industries, exclusions of certain individuals or illnesses, and lack of information about rates. Such proposals retain the voluntary nature of health benefits and only attempt to regulate the sale of policies by insurance companies. The second group of proposals focuses on providing access to insurance for small businesses as part of a comprehensive program to cover all of the uninsured. Universal access proposals fall into three categories-employer mandates, “play-or-pay” proposals, and single-payer programs-and the effect of any policy on small businesses will depend on the financing levels set in the legislation. A variety of tax rates and subsidy levels are being considered.

Jennifer N. Edwards

Papers

The efficacy of primary care for vulnerable population groups.

Physician response to patient insurance status in ambulatory care clinical decision-making. Implications for quality of care.

Making the Critical Choices

Caring for the Uninsured Choices for Reform

Small business and the national health care reform debate.