Abstract
Disparities in quality of care according to patient race and socioeconomic status persist in the US. Differential referral patterns to specialist physicians might be associated with observed disparities. To examine whether differences exist between Black and White Medicare beneficiaries in the observed patterns of patient sharing between primary care physicians (PCPs) and physicians in the 6 specialties to which patients were most frequently referred. This cross-sectional observational study of Black and White Medicare beneficiaries used claims data from 2009 to 2010 on 100% of traditional Medicare beneficiaries who were seen by PCPs and selected high-volume specialists in 12 health care markets with at least 10% of the population being Black. Statistical analyses were conducted from December 20, 2017, to September 30, 2020. Differences in patterns of patient sharing among Black and White patients. Primary care physician and specialist degree (the number of other PCPs or specialists to whom each physician is connected) and strength (the number of shared patients per connection, overall, for Black patients and White patients and after equalizing the numbers of Black and White patients per PCP), as well as distance between PCP and patient and specialist zip code centroids. The 12 selected markets ranged in size from Manhattan, New York (187 054 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 9794 total physicians), to Tallahassee, Florida (44 644 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 847 total physicians). The percentage of Black beneficiaries ranged from 11.5% (Huntsville, Alabama) to 46.8% (Chicago, Illinois). The mean PCP-specialist degree (number of specialists with whom a PCP shares patients) was lower for Black patients than for White patients. For instance, the mean PCP-cardiologist degree across all markets for White patients was 17.5 compared with 8.8 for Black patients. After sampling White patients to equalize the numbers of patients seen, the degree differences narrowed but were still not equivalent in many markets (eg, for all specialties in Baton Rouge, Louisiana: 4.5 for Black patients vs 5.7 for White patients). Specialist networks among White patients were much larger than those constructed based just on Black patients (eg, for cardiology across all markets: 135 for Black patients vs 330 for White patients), even after equalizing the numbers of patients seen per PCP (123 for Black patients vs 211 for White patients). The overall test for differences in referral patterns was statistically significant for all 6 specialties examined in 7 of the 12 markets and in 5 specialties for another 3. This study suggests that differences exist in specialist referral patterns by race among Medicare beneficiaries. This is an observational study, and thus some differences might have resulted from patient-initiated visits to specialists.
Highlights
For several decades, significant problems with the quality of care and disparities in quality according to patient race and socioeconomic status have been documented in the US health care system.[1,2,3,4,5,6,7,8,9,10,11,12,13] Despite quality improvement efforts, whether general or aimed at specific underserved populations, little progress has been made in attenuating disparities
Meaning This study suggests that differences exist in specialist referral patterns by race among Medicare beneficiaries
This is an observational study, and some differences might have resulted from patient-initiated visits to specialists
Summary
Significant problems with the quality of care and disparities in quality according to patient race and socioeconomic status have been documented in the US health care system.[1,2,3,4,5,6,7,8,9,10,11,12,13] Despite quality improvement efforts, whether general or aimed at specific underserved populations, little progress has been made in attenuating disparities. The 2018 National Healthcare Quality and Disparities Report concluded that “Overall, some disparities were getting smaller from 2000 through 2016-2017, but disparities persist, especially for poor and uninsured populations in all priority areas.”13(p1). There are many factors associated with disparities in care and outcomes, including adequacy of insurance coverage,[14] neighborhood issues related to food or housing scarcity or insecurity,[15,16] and lack of resources,[17] at least some causes of disparities are mediated through health care professionals.[18,19] Fundamentally, this can happen through 2 mechanisms. Primary care visits by Black patients were concentrated with a smaller group of physicians who saw relatively few White patients.[20] These physicians were less likely to be board certified and reported more difficulty obtaining access to high-quality specialists. Neighborhoods that are poor or underserved might have more difficulty attracting the highestquality physicians, and hospitals in these neighborhoods might have relatively fewer resources because of the relatively low payment rates for Medicaid and other safety-net programs
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