Abstract
BackgroundProposed payment reforms in the US healthcare system would hold providers accountable for the care delivered to an assigned patient population. Annual hemoglobin A1c (HbA1c) tests are recommended for all diabetics, but some patient populations may face barriers to high quality healthcare that are beyond providers' control. The magnitude of fine-grained variations in care for diabetic Medicare beneficiaries, and their associations with local population characteristics, are unknown.MethodsHbA1c tests were recorded for 480,745 diabetic Medicare beneficiaries. Spatial analysis was used to create ZIP code-level estimated testing rates. Associations of testing rates with local population characteristics that are outside the control of providers – population density, the percent African American, with less than a high school education, or living in poverty – were assessed.ResultsIn 2009, 83.3% of diabetic Medicare beneficiaries received HbA1c tests. Estimated ZIP code-level rates ranged from 71.0% in the lowest decile to 93.1% in the highest. With each 10% increase in the percent of the population that was African American, associated HbA1c testing rates were 0.24% lower (95% CI −0.32–−0.17); for identical increases in the percent with less than a high school education or the percent living in poverty, testing rates were 0.70% lower (−0.95–−0.46) and 1.6% lower (−1.8–−1.4), respectively. Testing rates were lowest in the least and most densely populated ZIP codes. Population characteristics explained 5% of testing rate variations.ConclusionsHbA1c testing rates are associated with population characteristics, but these characteristics fail to explain the vast majority of variations. Consequently, even complete risk-adjustment may have little impact on some process of care quality measures; much of the ZIP code-related variations in testing rates likely result from provider-based differences and idiosyncratic local factors not related to poverty, education, or race.
Highlights
New payment models, including Accountable Care Organizations (ACOs), create incentives for providers to deliver high quality care to all patients attributed to them
ZIP code-level population measures included total population, overall population density, and the percent African American, as well as the percent living below 100% of the federal poverty level (FPL) and the percent with less than a high school education
Local sociodemographic characteristics are related to testing rates, as the populations of ZIP codes with lower testing rates tend to be comprised of a greater proportion of residents living in poverty, with less than a high school education, or who are African American
Summary
New payment models, including Accountable Care Organizations (ACOs), create incentives for providers to deliver high quality care to all patients attributed to them. Some patient populations may face barriers to high quality care beyond the control of healthcare providers. The local environment in which a person lives may have a strong effect on his or her ability to seek care [1,2]. If such effects are present, payment mechanisms may need to take them into account to prevent ACOs from avoiding such patients, or from being penalized with lower reimbursements [3,4], potentially worsening current disparities. Annual hemoglobin A1c (HbA1c) tests are recommended for all diabetics, but some patient populations may face barriers to high quality healthcare that are beyond providers’ control. The magnitude of fine-grained variations in care for diabetic Medicare beneficiaries, and their associations with local population characteristics, are unknown
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