Abstract
It is becoming increasingly apparent that some disparities in health outcomes for vulnerable populations relate to performance of providers. Based on analysis of Medicaid claims records, large differences in performance among primary care providers are documented for New York City patients, suggesting the need for better evidence in making management decisions.
Over the last several decades, an enormous amount of data has been assembled documenting dramatic disparities in health outcomes based on race/ethnicity, income, and insurance status. Black males have a life expectancy in the United States that is 6 years less than white males; black females have a life expectancy 5 years shorter than white females.1 Hispanic populations are less likely to receive coronary angiography, coronary artery bypass surgery, and angioplasty even after controlling for age, comorbidity, income, and insurance status.2 Uninsured patients are less likely than privately insured patients to have a usual source of care (24% vs. 8%), and uninsured mothers have been found to begin prenatal care later and to have fewer total visits than privately insured mothers,3 and uninsured newborns have been shown to have more adverse outcomes than babies with insurance.4 Uninsured women have also been found to present with later-stage breast cancer than privately insured patients and have lower survival rates.5
Typical of these findings was work analyzing hospitalization rates for preventable or avoidable conditions where timely and effective ambulatory care can help reduce the risk of hospitalization (ambulatory care sensitive or "ACS" conditions). In 1988, residents of low-income areas in New York City were found to have hospitalization rates for ACS conditions that were more than three times higher than high-income areas, with some low-income zip codes having rates that were as much as 15 times higher than adjacent more affluent zip codes.6 See Figure 1.
The response to this research has largely involved a combination of hand-wringing calls for universal health coverage in the United States and efforts to expand primary care capacity in many communities. While the impetus for Clinton Health Plan may have been stimulated in part by middle-class concerns about the impact of losing health insurance coverage revealed in the Pennsylvania senate campaign of 1991, the huge disparities in health outcomes have been at the center of rallying cries for supporters of some form of national health insurance. A typical response at the state and local level was the New York's Primary Care Initiative in the early 1990s, involving a new fund to support new primary care capacity, or New York City's Primary Care Development Corporation (PCDC), an innovative initiative to use tax-exempt bonds to provide capital for new primary care delivery sites. The latest example is the Bush administration's proposal to increase funding for community health centers, to permit a large expansion of sites and capacity, and to provide primary care services to those most in need. While the proposed budget for this expansion of capacity has shrunk dramatically since the concept was introduced by candidate Bush during the 2000 presidential campaign sweepstakes (in part to rebut Democratic calls for expanded health coverage), it reflects a consensus that a large part of the problem for the nation's vulnerable populations is a lack of health care system capacity available to provide care to those in need.
Of course, these responses presuppose that we understand the causes of the disparities that this growing body of research has so carefully assembled. Shorter life expectancy for blacks: what they need is an insurance card. No usual source of care for uninsured: if we cannot afford to buy coverage, let us expand capacity of community health centers. High ACS rates: that is easy-more primary care doctors.
However, what is becoming increasingly apparent is that we do not fully understand the nature and extent of factors that contribute to these differences in health outcomes. For example, in New York City, the rates of admission for ACS conditions for adults have remained relatively stable since 1998, with the huge differences between low-income and high-income areas virtually unchanged. See Figure 2. For children, however, there has been a dramatic change. In 1988, low-income areas had rates that were 150 percent higher than more affluent areas; but by 2000, the difference in rates was only 50 percent. See Figures 3-5.
While the data indicate that this dramatic improvement was the result of a drop in ACS rates among low-income areas, what is not clear are the reasons. Broader insurance coverage for children resulting from Child Health Plus (New York's SCHIP program)? Perhaps, but the drop in rates preceded big expansions of the program and the rates remained relatively stable (or even increased slightly) in the early nineties during the dramatic expansion of Medicaid coverage for children. More primary care capacity resulting from the Primary Care Initiative or the efforts of the PCDC? Greater willingness of the traditional middle-class-oriented providers to serve Medicaid patients as Medicaid reimbursement rates appear increasingly attractive in an era of growing competition and budget constraints? Maybe. Expanded capacity has been targeted largely at families and children. There has been an erosion of Medicaid market share among traditional safety net providers, with loss of patients to "middle-class" providers. Better performance by safety net providers? Possibly-PCDC has shifted its emphasis from "capacity expansion" to "performance improvement." Safety net providers, facing competition for their patients and pressures of Medicaid-managed care, have begun to reexamine operations to make services more responsive to patients. A change in the composition of low-income populations? True-recent immigration has brought a wave of Mexican, Central/South American, Asian, and eastern European immigrants to New York City. Hispanic populations in New York City now exceed the black population-more than 50 percent of births in New York City were to foreign-born mothers in 2000.7
However, the bottom line is that we simply do not have a clear explanation for this improvement. Each of these factors, as well as a litany of others, undoubtedly played a role. However, given the state of the current knowledge, it is difficult to give policy-makers and planners much direction based on existing evidence. This situation is comparable with the state of research related to the causes of racial, ethnic, and economic, health care disparities. They are large. They are persistent. They permeate virtually every aspect of the health care delivery system. However, what we do not have is a complete understanding of the causes. How important is the lack of insurance? What is the impact of provider performance? Capacity? Lifestyle/personal behavior? Confidence/motivation? Attitudes toward health or the health care delivery system?
In the material that follows, a model for thinking about these disparities is described, and then one component of the model, the impact of provider performance, is explored to examine some evidence that performance contributes to disparities in outcomes. In conclusion, some of the barriers to developing an effective management research agenda are explored, and suggestions for managers and policy-makers are offered to help overcome these barriers and facilitate efforts to help make the health care delivery system more responsive to patient concerns.