In 2011, the first of the post-World War II "baby boom"; generation will reach age 65 and become eligible for Medicare. The cost implications of the entry of baby boomers into Medicare have been widely discussed, but less attention has been paid to the implications for health care quality. This report discusses disparities in care of baby boom patients with diabetes who become eligible for Medicare. It also examines disparities related to cardiovascular conditions because of their prevalence among older adults and their association with diabetes. Specifically, this report contains 1.) an overarching conceptual model for disparities in midlife adults (45–64) vs. older adults (>65); 2.) key findings from the literature on disparities in health care quality among midlife and older adults, including disparities based on gender, race/ethnicity and socioeconomic factors; and 3.) an analysis of data from the National Medical Expenditures Panel Survey, to explore whether patterns of disparities differ between midlife and older adults, guided by specific research questions. A discussion of policy implications and recommendations for future directions for research into disparities of care, particularly among older adults, is also included. Key outcomes and findings from this project:
- A conceptual model for examining disparities in quality of care among older adults, reflecting a multilevel approach and documenting individual and system wide factors that may contribute to quality of care along domains delineated by the Institute of Medicine (IOM): safe, equitable, effective, patient-centered, timely/accessible, efficient care. A review of existing measures available from national data sources indicates that effectiveness of care measures are well established, but more measures are needed to address safety, patient-centeredness and efficiency of care domains.
- A review of the literature on disparities in care suggests that while race/ethnicity has been a major focus of most disparity studies, fewer studies have reported on potential care disparities based on factors such as gender or socioeconomic status. Furthermore, few studies have examined whether the pattern of disparity is consistent across the midlife and older age groups. This is important because both age groups have a high prevalence of chronic conditions, yet have different health insurance coverage status, which may affect care. The literature also suggests that the most striking racial/ethnic disparities occur in outcome measures such as cholesterol or blood pressure control, but these studies often did not address disparities related to IOM quality domains and did not account for insurance coverage status.
- A quantitative analysis of quality of care measures from the National Medical Expenditures Panel Survey (MEPS) was conducted to understand disparities based on individual factors beyond race/ethnicity and to assess outcomes related to quality of care domains considered important by the IOM. In particular, a better understanding of the role of health insurance coverage on disparities in quality was sought. Specific research questions that guided the analysis were:
- What are the patterns of gender, racial/ethnic and socioeconomic disparities in effectiveness of care, access to care and patient-centeredness of care among midlife and older diabetes and cardiovascular condition patients?
- What are the multivariate associations of gender and health insurance status for effectiveness of care, access to care and patient-centeredness of care?
In terms of the first research question, analysis indicates that midlife respondents ages 45–64 more often reported delays in care than Medicare-eligible respondents 65 and older, with women reporting access to care problems more often than men. Non-Hispanic Whites were more likely to report problems in access to care compared to African Americans/Blacks ("Blacks";) or Hispanics. The findings also indicate that there were racial/ethnic differences in the effectiveness of care measures that favored Whites, but there were few statistically significant gender differences in effectiveness of care measures. There were statistically significant differences in patient-centeredness measures, but the magnitude of effect was generally small and inconsistent
Findings from the analysis addressing the second research question indicate that the observed patterns related to gender generally persisted, even after controlling for key covariates in multivariate analyses. Findings also suggest that health insurance status—which differs among midlife and older adults—also plays a significant role in the quality of care, even in the presence of other individual factors. Specifically, women were significantly more likely to report access to care problems than men were. However, there were few significant gender differences for effectiveness of care or patient-centeredness measures. The midlife adult population, especially the uninsured, demonstrated more access to care issues than did the Medicare-covered older adult population, but there were few significant health insurance differences for effectiveness of care or patient-centeredness
This report highlights differences in access to care based on gender and health insurance status, and offers insight into whether the extent of disparities varies among midlife and older age groups with differing insurance coverage. Findings suggest that gender disparities persist in access to care, and that uninsured midlife women have more issues with access to care. Findings also suggest that Medicare coverage may play a role in quality of care, as it may mitigate access to care problems among diabetes and cardiovascular condition patients who age from midlife to older adults. Policymakers could consider extending health care coverage to uninsured midlife adults with chronic conditions, in order to mitigate access problems that may become exacerbated as the population becomes Medicare eligible. Future research should consider the causes of disparities in access to care, and take into account the role of health insurance coverage in mitigating disparities.