Hispanic Medicare Beneficiaries Research Articles

Racial/ethnic disparities in cost-related barriers to care among near-poor beneficiaries in Medicare Advantage vs traditional Medicare.

To compare racial and ethnic disparities in cost-related medical care and dental care barriers and use of vision care among near-poor Medicare beneficiaries in Medicare Advantage (MA) vs traditional Medicare (TM) overall and stratified by supplemental insurance enrollment. Cross-sectional analysis of 2015-2019 data from the nationally representative Medicare Current Beneficiary Survey. Propensity score-weighted difference-in-disparities analyses comparing Black-White and Hispanic-White disparities in MA vs TM among near-poor Medicare beneficiaries with incomes between 101% and 250% of the federal poverty level. We assessed differences in cost-related medical care barriers and cost-related dental care barriers as well as receipt of annual eye exams in MA vs TM. For cost-related barriers to medical care, Hispanic-White disparities were narrower by 8.8 (95% CI, -14.0 to -3.6) percentage points in MA relative to TM but differences in Black-White disparities were not statistically significant. MA was not associated with narrower differences in Hispanic-White or Black-White disparities in dental care access. Higher proportions of Black and Hispanic beneficiaries in MA received an annual eye exam vs White beneficiaries in both MA and TM. MA was associated with narrower racial disparities primarily compared with TM without supplemental insurance. Among near-poor Black and Hispanic Medicare beneficiaries, MA was associated with greater use of vision care and narrowing of some disparities in cost-related access barriers vs TM. However, MA did not uniformly narrow racial/ethnic disparities in access and use. These findings highlight the importance of maintaining and enhancing features of Medicare coverage that may promote equitable access to care, including additional benefits and lower cost sharing.

Understanding the home hospice experience of Puerto Rican caregivers.

Hospice use among Hispanic Medicare beneficiaries has declined in the last few years, and Hispanic caregivers have reported insufficient support around the emotional and spiritual aspects of care. Understanding the home hospice experience of Puerto Rican (PR) caregivers can yield insight into ways to improve hospice participation and quality of care for the Hispanic population. This exploratory study utilizes qualitative methods to identify PR caregivers' experience in the setting of home hospice care. Data from interviews with eight (n=8) bereaved PR caregivers of patients who received home hospice care were qualitatively analyzed. Participants were mostly well-educated (n=6/8) female caregivers caring for their parent (n=7/8) with mean age of 57 [standard deviation (SD) =13] years. Emerging domains from the study included (I) symptom management; (II) cultural and religious values; and (III) interaction with hospice providers. Caregivers found managing patients' loss of appetite, pain, anxiety, and confusion to be challenging. They identified family-centered values and religious support as culturally important, which manifested as the need for frequent communication from hospice providers and increased support and education at the end-of-life. Culturally tailored interventions that focus on managing symptoms, tailoring care to support family-centered values, integrating religious officials representative of the patient's beliefs into the hospice team, and communicating effectively with providers may reduce the burden experienced by PR caregivers in home hospice and improve outcomes for patients and caregivers. Additional research will aid in the development of evidence-based intervention and policies urging healthcare providers to offer culturally appropriate hospice care and resources to this population.

Association of race and ethnicity with opioid prescribing for Medicare beneficiaries following total joint replacements.

Profound racial and ethnic disparities exist in the use and outcomes of total hip/knee replacements (total joint replacements [TJR]). Whether similar disparities extend to post-TJR pain management remains unknown. Our objective is to examine the association of race and ethnicity with opioid fills following elective TJRs for White, Black, and Hispanic Medicare beneficiaries. We used the 2019 national Medicare data to identify beneficiaries who underwent total hip/knee replacements. Primary outcomes were at least one opioid fill in the period from discharge to 30 days post-discharge, and 31-90 days following discharge. Secondary outcomes were morphine milligram equivalent per day and number of opioid fills. Key independent variable was patient race-ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic). We estimated multivariable hierarchical logistic regressions and two-part models with state-level clustering. Among 67,550 patients, 93.36% were White, 3.69% were Black, and 2.95% were Hispanic. Compared to White patients, more Black patients and fewer Hispanic patients filled an opioid script (84.10% [Black] and 80.11% [Hispanic] vs. 80.33% [White], p < 0.001) in the 30-day period. On multivariable analysis, Black patients had 18% higher odds of filling an opioid script in the 30-day period (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.05-1.33, p = 0.004), and 39% higher odds in the 31-90-day period (OR: 1.39, 95% CI: 1.26-1.54, p < 0.001). There were no significant differences in the endpoints between Hispanic and White patients in the 30-day period. However, Hispanic patients had 20% higher odds of filling an opioid script in the 31- to 90-day period (OR: 1.20, 95% CI: 1.07-1.34, p = 0.002). Important race- and ethnicity-based differences exist in post-TJR pain management with opioids. The mechanisms leading to the higher use of opioids by racial/ethnic minority patients need to be carefully examined.

Racial and Ethnic Disparities in Health Care Use and Access Associated With Loss of Medicaid Supplemental Insurance Eligibility Above the Federal Poverty Level

Medicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program's income eligibility threshold (100% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries' ability to afford care. To examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care. This cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0% to 200% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022. Patient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data. This cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1% of beneficiaries were women, 14.8% were non-Hispanic Black, 13.6% were Hispanic, and 71.6% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95% CI, 2.0-9.4), lower outpatient use (-6.3 services per person-year; 95% CI, -10.4 to -2.2), and fewer medication fills (-6.9 fills per person-year; 95% CI, -11.4 to -2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: -6.2 services per person-year; 95% CI, -11.7 to -0.6; P = .03) and medication fills (disparity: -7.2 fills per person-year; 95% CI, -13.4 to -1.0; P = .02) among Black and Hispanic vs White beneficiaries. This cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.

Variations in Medicare Advantage Switching Rates Among African American and Hispanic Medicare Beneficiaries With Alzheimer's Disease and Related Dementias, by Sex and Dual Eligibility.

The objective of this study was to identify rates of switching to Medicare Advantage (MA) among fee-for-service (FFS) Medicare beneficiaries with Alzheimer's disease and related dementias (ADRD) by race/ethnicity and whether these rates vary by sex and dual-eligibility status for Medicare and Medicaid. Data came from the Medicare Master Beneficiary Summary File from 2017 to 2018. The outcome of interest for this study was switching from FFS to MA during any month in 2018. The primary independent variable was race/ethnicity including non-Hispanic White, non-Hispanic African American, and Hispanic beneficiaries. Two interaction terms among race/ethnicity and dual eligibility, and race/ethnicity and sex were included. The model adjusted for age, year of ADRD diagnosis, the number of chronic/disabling conditions, total health care costs, and ZIP code fixed effects. The study included 2,284,175 FFS Medicare beneficiaries with an ADRD diagnosis in 2017. Among dual-eligible beneficiaries, adjusted rates of switching were higher among African American (1.91 percentage points [p.p.], 95% confidence interval [CI]: 1.68-2.15) and Hispanic beneficiaries (1.36 p.p., 95% CI: 1.07-1.64) compared to non-Hispanic White beneficiaries. Among males, adjusted rates were higher among African American (3.28 p.p., 95% CI: 2.97-3.59) and Hispanic beneficiaries (2.14 p.p., 95% CI: 1.86-2.41) compared to non-Hispanic White beneficiaries. Among persons with ADRD, African American and Hispanic beneficiaries are more likely than White beneficiaries to switch from FFS to MA. This finding underscores the need to monitor the quality and equity of access and care for these populations.

COVID-19 Vaccine Intentions Within the Medicare Population

COVID-19 vaccine intentions by older adults reflect individual care seeking behavior and medical system trust and broader systemic cultural shifts related to vaccine hesitancy. The purpose of this paper is to examine the October wave of the rapid response panel survey fielded by the Centers for Medicare and Medicaid Services (CMS) to track and monitor the effects of the pandemic within the Medicare population. With a sample size of 9686 Medicare beneficiaries, the calculated statistics use replicate weights to adjust for the complex survey sample design and balanced repeated replication using Fay’s adjustment of 0.3 for variance estimation. When asked about the likelihood of getting the COVID-19 vaccine if one were available, 58 percent of the Medicare population definitely or probably intended to get the vaccine, 16 percent expressed they would probably or definitely not, and 26 percent were not sure. Black or Hispanic Medicare beneficiaries were significantly more likely to express they would probably not or definitely not get the vaccine than White, non-Hispanic Medicare beneficiaries. Distrust of what government says about the vaccine and concern about the safety or side effects were the most common reasons for not intending to get the vaccine. Those expressing intentions to not get the COVID-19 vaccine in the October 2020 survey wave were more likely to lack access to the internet, which is a potential systematic barrier if they changed their intentions following the FDA approvals of the COVID-19 vaccines and more information became available in the winter and spring of 2021.

Disparities in Care Experienced by Older Hispanic Medicare Beneficiaries in Urban and Rural Areas.

Hispanic older adults face substantial health disparities compared with non-Hispanic-White (hereafter "White") older adults. To the extent that these disparities stem from cultural and language barriers faced by Hispanic people, they may be compounded by residence in rural areas. The objective of this study was to investigate possible interactions between Hispanic ethnicity and rural residence in predicting the health care experiences of older adults in the United States, and whether disparities in care for rural Hispanic older adults differ in Medicare Advantage versus Medicare Fee-for-Service. Medicare beneficiaries age 65 years and older who responded to the 2017-2018 nationally representative Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. We fit a series of linear, case-mix-adjusted models predicting Medicare CAHPS measures of patient experience (rescaled to a 0-100 scale) from ethnicity, place of residence, and Medicare coverage type. In all residential areas, Hispanic beneficiaries reported worse experiences with getting needed care (-3 points), getting care quickly (-4 points), and care coordination (-1 point) than White beneficiaries (all P's<0.001). In rural areas only, Hispanic beneficiaries reported significantly worse experiences than White beneficiaries on doctor communication and customer services (-3 and -9 points, respectively, P<0.05). Tests of a 3-way interaction between ethnicity, rural residence, and coverage type were nonsignificant. There is a need to improve access to care and care coordination for Hispanic beneficiaries overall and doctor-patient communication and customer service for rural Hispanic beneficiaries. Strategies for addressing deficits faced by rural Hispanics may involve cultural competency training and provision of language-appropriate services for beneficiaries (perhaps as telehealth services).

Bathroom modifications among community-dwelling older adults who experience falls in the United States: A cross-sectional study.

Falls impose substantial health and economic burdens on older adults. Over half of falls in older adults occur at home, with many involving bathroom areas. Limited information is available on the presence of bathroom modifications for those who experience them. Therefore, we examined factors associated with bathroom modifications among older adults with at least one fall in the United States. We analysed the nationally representative 2016 Medicare Current Beneficiary Survey Public Use File of Medicare beneficiaries aged ≥65years with ≥1 fall (n=2,404). A survey-weighted logistic model was used to examine associations between bathroom modifications and factors including socio-demographic characteristics, health-related conditions, and fear of falling. Among Medicare beneficiaries with ≥1 fall, 55.5% had bathroom modifications and 50.1% had repeated falls (≥2 falls). Approximately 40.2% of those with repeated falls had no bathroom modifications. In the adjusted model, non-Hispanic Blacks (odds ratio [OR]=0.38; p<0.001) and Hispanics (OR=0.64; p=0.039) had lower odds of having bathroom modifications than non-Hispanic Whites. Fear of falling and activities of daily living limitations had incremental impacts on having bathroom modifications. This study highlights the need to improve disparities in bathroom modifications for non-Hispanic Black and Hispanic Medicare beneficiaries, including those with repeated falls. With the aging population and growing number of older minorities in the United States, reducing these disparities is vital for fall prevention efforts and aging-in-place.

Association of Medicare Mandatory Bundled Payment Program With the Receipt of Elective Hip and Knee Replacement in White, Black, and Hispanic Beneficiaries

The Comprehensive Care for Joint Replacement (CJR) model was designed to reduce the cost and improve the quality of hip or knee replacement among Medicare beneficiaries. Yet whether this model may exacerbate existing racial/ethnic disparities in access to the surgery is unclear. To examine the association of the CJR model with the receipt of elective hip or knee replacement across White, Black, and Hispanic Medicare beneficiaries. Retrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic Medicare beneficiaries undergoing elective joint replacement in 65 treatment (selected for CJR participation) and 101 control metropolitan statistical areas (MSAs). Starting in April 2016, hospitals in the treatment MSAs were required to participate in the CJR model and were accountable for expenditures occurring during patients' hospitalization for hip or knee replacement and 90 days after the hospital discharge. Beneficiary-level elective hip or knee replacement receipt in a given year. Among 17 243 304 patients, 9 839 996 (57%) were women; 2 107 425 (12%) were age 85 years or older. Of the final sample, 14 632 434 (85%) were White beneficiaries, 1 518 629 (9%) were Black beneficiaries, and 1 092 241 (6%) were Hispanic beneficiaries. The CJR model was associated with an increase of 1.6 elective hip or knee replacements per 1000 beneficiary-years for Hispanic beneficiaries (95% CI, 0.06-2.05) and a decrease of 0.64 replacements for Black beneficiaries (95% CI, -1.25 to -0.02). No evidence was found for any changes for White beneficiaries per 1000 beneficiary-years (0.04 replacements, 95% CI, -0.35 to 0.42 replacements). The Black-White difference in the rate of elective hip or knee replacement per 1000 beneficiary-years further widened by 0.68 replacements (-0.68, 95% CI, -1.20 to -0.15). In this cohort study, the CJR model was associated with increased receipt of elective hip or knee replacement among Hispanic beneficiaries, decreased receipt among Black beneficiaries, and no change in receipt among White beneficiaries. The decreased receipt of elective hip or knee replacement among Black beneficiaries may suggest that value-based payment models, including the CJR model, could be monitored for unintended consequences. However, the lack of similar findings among Hispanic beneficiaries suggests that payment models may have differential impacts across racial/ethnic groups.

2009-2017 RACIAL AND ETHNIC DISPARITIES IN MEDICARE PATIENT EXPERIENCE AND INFLUENZA IMMUNIZATION

We sought to understand the extent to which racial and ethnic disparities in the immunization rates and case-mix adjusted patient experiences of access (getting needed care and getting care quickly) of Black, Hispanic, and non-Hispanic White Medicare beneficiaries have changed over time. Accordingly, we analyzed 2009-2017 CAHPS data from 2,725,614 Medicare beneficiaries. In 2009, flu immunization rates for Black and Hispanic beneficiaries were lower than non-Hispanic White beneficiaries by 17 and 14 percentage points, respectively. Over 9 years, these gaps were reduced to 12 and 8 points, respectively (p<.01 for all comparisons). In 2009, Black beneficiaries had 2-point and 5-point disparities on getting needed care and getting care quickly (on a 0-100 scale) respectively, relative to non-Hispanic Whites. For getting needed care, there was no significant change over time in the gap between Blacks and non-Hispanic Whites. For getting care quickly, the gap between Blacks and non-Hispanic Whites narrowed to 3 points in 2017. In 2009, Hispanic beneficiaries had 2-point and 5-point disparities on getting needed care and getting care quickly, respectively, compared to non-Hispanic Whites. The gap on getting needed care widened by 1 point to a 2017 disparity of 3 points. For getting care quickly, there was no significant change over time in the gap between Hispanics and non-Hispanic Whites. These findings suggest that flu immunization rates for Black and Hispanic Medicare beneficiaries have improved significantly relative to non-Hispanic Whites; however, substantial disparities remain. For the patient experience measures, the findings are more mixed.

Impact of The Affordable Care Act's Elimination of Cost-Sharing on the Guideline-Concordant Utilization of Cancer Preventive Screenings in the United States Using Medical Expenditure Panel Survey.

Currently available evidence regarding the association of the Affordable Care Act’s (ACA) elimination of cost-sharing and the utilization of cancer screenings is mixed. We determined whether the ACA’s zero cost-sharing policy affected the guideline-concordant utilization of cancer screenings, comparing adults (≥21 years) from 2009 with 2011–2014 data from the Medical Expenditure Panel Survey. Study participants were categorized as: 21–64 years with any private insurance, ≥65 years with Medicare only, and 21–64 years uninsured, with a separate sample for each type of screening test. Adjusted weighted prevalence and prevalence ratios (PR (95%CI)) were estimated. In 2014 (vs. 2009), privately-insured women reported 2% (0.98 (0.97–0.99)) and 4% (0.96 (0.93–0.99)) reduction in use of Pap tests and mammography, respectively. Privately-insured non-Hispanic Asian women had 16% (0.84 (0.74–0.97)) reduction in mammography in 2014 (vs. 2009). In 2011 (vs. 2009), privately-insured and Medicare-only men reported 9% (1.09 (1.03–1.16)) and 13% (1.13 (1.02–1.25)) increases in colorectal cancer (CRC) screenings, respectively. Privately-insured women reported a 6–7% rise in 2013–2014 (vs. 2009), and Hispanic Medicare beneficiaries also reported 40–44%, a significant rise in 2011–2014 (vs. 2009), in the utilization of CRC screenings. While the guideline-concordant utilization of Pap tests and mammography declined in the post-ACA period, the elimination of cost-sharing appeared to have positively affected CRC screenings of privately-insured males, females, and Hispanic Medicare-only beneficiaries. Greater awareness about the zero cost-sharing policy may help in increasing the uptake of cancer screenings.

The High Coverage of Dental, Vision, and Hearing Benefits Among Medicare Advantage Enrollees.

While the traditional Medicare program does not cover dental, vision, and hearing services, Medicare Advantage (MA) plans have been given the flexibility to do so. However, it is not known how many MA enrollees are in plans that cover these services. The 2016 Medicare Current Beneficiary Survey linked to MA plan benefit data is used to examine enrollment levels in plans that cover dental, vision, and/or hearing services in MA. Medicaid beneficiaries are excluded from this analysis as coverage of supplemental benefits is largely determined by the state. The highest coverage of supplemental services is vision, followed by hearing and dental (71%, 56%, and 41%, respectively). Across all supplemental services, coverage for supplemental benefits is highest among low-income beneficiaries and those who have not completed high school. Hispanic Medicare beneficiaries had the highest enrollment in plans that offered a supplemental benefit, and white Medicare beneficiaries tended to have the lowest enrollment in these plans. Unlike in traditional Medicare, MA enrollees have access to health plans that offer supplemental benefits, including dental, vision, and/or hearing services. This analysis shows that enrollment in these plans is highest among low-income MA enrollees who may not have the means to purchase stand-alone insurance for these services in traditional Medicare. More analysis is warranted to examine the generosity of the coverage of these services in MA plans. However, for federal policy makers to consider offering supplemental coverage in traditional Medicare, the MA experience suggests this type of benefit would be valuable.

PHS81 - Impact of the Affordable Care Act (ACA)’S Elimination of Cost-Sharing Provision on the Guideline-Recommended Cancer Preventive Screenings in the United States

To determine whether the Affordable Care Act’s elimination of cost-sharing affected guideline-concordant use of cancer preventive screenings. Adults (≥21 years) from 2009 and 2011-14 Medical Expenditure Panel Survey (MEPS) were included. Participants in each year were divided into 3 groups: aged 21-64 years with any private insurance, aged ≥65 years with Medicare only and aged 21-64 years uninsured. Study sample for each type of screening was defined separately: women aged 21-65 years (cervical cancer [Pap test]), women aged ≥40 years (breast cancer [mammography]) and adults aged 50-75 years (colorectal cancer [CRC, screenings–blood stool test, sigmoidoscopy, or colonoscopy]). Receipt of screening consistent with recommended frequency was determined. Prevalence and prevalence ratios (PR[95% CI]) were multivariate-adjusted and weighted to be nationally representative. Stratified analyses by race/ethnicity (and by sex for CRC screening) were also conducted. In 2014 (vs. 2009), privately insured women had 2% (0.98[0.97, 0.99]) and 4% (0.96[0.93, 0.99]) decline in receipt of Pap test and mammography. Privately insured Non-Hispanic (NH) White and Asian women had 2% (0.98[0.96, 1.00]) and 6% (0.94[0.88, 1.00]) reduction in receipt of Pap test in 2014 (vs. 2009), respectively (all p<0.10). Privately insured NH Asian women had 16% (0.84[0.74, 0.97]) reduction in receipt of mammography in 2014 (vs. 2009). In 2011 (vs. 2009), 9% (1.09[1.03, 1.16]) and 13% (1.13[1.02, 1.25]) increases in receipt of CRC screening were found among privately and Medicare-only insured men, respectively. Privately insured women had 7-6% rise in 2013-14 (vs. 2009) and Hispanic Medicare beneficiaries also had significant rise 2011-14 (vs. 2009), in receipt of CRC screening. A stable-to-declining trend in guideline-recommended screening for cervical and breast cancers were observed in 2011-2014 compared to 2009. ACA’s elimination of cost-sharing appeared to have positively affected CRC screening of privately insured males, females and Medicare-only insured males and Hispanics.

Readmission rates for Hispanic Medicare beneficiaries with heart failure and acute myocardial infarction

Hispanics are the fastest growing segment of the US population and have a higher prevalence of cardiovascular risk factors than non-Hispanic whites. However, little is known about whether elderly Hispanics have higher readmission rates for heart failure (HF) and acute myocardial infarction (AMI) than whites and whether this is due to site of care. We examined hospitalizations for Medicare patients with a primary discharge diagnosis of HF and AMI in 2006 to 2008. We categorized hospitals in the top decile of proportion of Hispanic patients as "Hispanic serving" and used logistic regression to examine the relationship between patient ethnicity, hospital Hispanic-serving status, and readmissions. Hispanic patients had higher risk-adjusted readmission rates than whites for both HF (27.9% vs 25.9%, odds ratio [OR] 1.11, 95% CI 1.07-1.14, P < .001) and AMI (23.0% vs 21.0%, OR 1.12, 95% CI 1.07-1.18, P < .001). Similarly, Hispanic-serving hospitals had higher readmission rates than non-Hispanic-serving hospitals for both HF (27.4% vs 25.8%, OR 1.09, 95% CI 1.06-1.12, P < .001) and AMI (23.0% vs 20.8%, OR 1.13, 95% CI 1.09-1.18, P < .001). In analyses considering ethnicity and site of care simultaneously, both Hispanics and whites had higher readmission rates at Hispanic-serving hospitals. Elderly Hispanic patients are more likely to be readmitted for HF and AMI than whites, partly due to the hospitals where they receive care. Our findings suggest that targeting the site of care and these high-risk patients themselves will be necessary to reduce disparities in readmissions for this growing group of patients.

Is There Disparity in Physician Service Use? A Comparison of Hispanic and White Medicare Beneficiaries

This article investigates general physician service use by a national sample of non-Hispanic white and Hispanic Medicare beneficiaries age 65 and older. Using the health behavior model as the conceptual framework, Oaxaca decomposition multivariate analyses were conducted to examine predictors for contact with a physician and the number of physician's office visits. Racial and ethnic differences were found in the predictor variables of initial contact with the physician and volume of physician service use. Besides needs factors, poverty level and having Medicaid were also significant predictors. Oaxaca decomposition analysis indicated that Hispanic beneficiaries' being less likely to make the initial physician contact could not be explained only by racial and ethnic differences. Although findings point to the equitable and nondiscriminatory treatment of Hispanic beneficiaries already using physician services, there is variance in the entry point of contact with a general physician for this minority group. Implications for social work are discussed.

Exploring racial and ethnic disparities in prescription drug spending and use among medicare beneficiaries

Background: Little is known about why minority Medicare beneficiaries spend less on and use fewer prescription drugs than white Medicare beneficiaries. Objective: We explored whether population differences in demographic characteristics, socioeconomic status, and health status were associated with observed disparities by race and ethnicity in the prescription drug spending and use of noninstitutionalized elderly Medicare beneficiaries. Methods: We used a nationally representative sample of 8101 white, 816 black, and 642 Hispanic Medicare beneficiaries from the 1999 Medicare Current Beneficiary Survey Cost and Use files. For each of these groups, we calculated total prescription drug spending, out-of-pocket spending, and number of prescriptions. We then used the Oaxaca-Blinder decomposition method to separate the impact of race and ethnicity on disparities in spending and use from the impact of differences in population characteristics across racial and ethnic groups. Results: Much of the disparity in spending between whites and blacks and some of the disparity between whites and Hispanics can be attributed to race/ethnicity. Because of race/ethnicity, total spending for whites was 8.9% more than for blacks and 5.4% more than for Hispanics. Similarly, total out-of pocket spending for whites was 28.8% more than for blacks and 10.7% more than for Hispanics. Race/ethnicity also influenced the amount of prescription drug use. Whites used 2.3 more prescriptions than blacks and 1.6 more than Hispanics. However, these differences in use were offset by the impact of differences in population characteristics. Conclusions: Differences in factors identified in the Andersen model of access to care do not fully explain observed disparities in prescription drug use and spending. The portion of the disparities due to race and ethnicity may reflect patients' skepticism about medicine and medical care in general, patients' adherence to medical advice, patient-physician communication, physicians' prescribing habits, and usual source of care. Future research should explore whether these and other unobserved factors associated with race and ethnicity are responsible for disparities in drug spending and use.

The causes of racial and ethnic differences in influenza vaccination rates among elderly Medicare beneficiaries.

To explore three potential causes of racial/ethnic differences in influenza vaccination rates in the elderly: (1) resistant attitudes and beliefs regarding vaccination by African-American and Hispanic Medicare beneficiaries, (2) poor access to care during influenza vaccination weeks, and (3) discriminatory behavior by providers. Medicare beneficiaries who responded to both the 1995 and 1996 Medicare Current Beneficiary Survey (MCBS) (n=6,746). We combined survey information from the MCBS with Medicare claims. We measured resistance to vaccination by self-reported reasons for not receiving vaccination, access to care by claims submitted during vaccination weeks, and discrimination by racial differences in vaccinations among beneficiaries who visited the same providers during vaccination weeks. White beneficiaries (66.6 percent) were more likely to self-report having received vaccination than were African Americans (43.3 percent) or Hispanics (52.5 percent). Resistance to vaccination plays a role in low vaccination rates of African-American (-11.8 percentage points), but not Hispanic beneficiaries. Unequal access accounts for <2 percent of the disparity. Minority beneficiaries remained unvaccinated despite having medical encounters with their usual providers on days when those same providers were administering vaccinations to white beneficiaries. This disparity is attributable not to provider discrimination but to a 1.6-5 x higher likelihood of white beneficiaries initiating encounters for the purpose of receiving vaccination. Disparities in access to care and provider discrimination play little role in explaining racial/ethnic disparities in influenza vaccination. Eliminating missed opportunities for vaccination in 1995 would have raised vaccination rates in three racial/ethnic groups to the Healthy People 2000 goal of 60 percent vaccination.

The Causes of Racial and Ethnic Differences in Influenza Vaccination Rates among Elderly Medicare Beneficiaries

Objective. To explore three potential causes of racial/ethnic differences in influenza vaccination rates in the elderly: (1) resistant attitudes and beliefs regarding vaccination by African‐American and Hispanic Medicare beneficiaries, (2) poor access to care during influenza vaccination weeks, and (3) discriminatory behavior by providers.Data Sources. Medicare beneficiaries who responded to both the 1995 and 1996 Medicare Current Beneficiary Survey (MCBS) (n=6,746).Study Design. We combined survey information from the MCBS with Medicare claims. We measured resistance to vaccination by self‐reported reasons for not receiving vaccination, access to care by claims submitted during vaccination weeks, and discrimination by racial differences in vaccinations among beneficiaries who visited the same providers during vaccination weeks.Principal Findings. White beneficiaries (66.6 percent) were more likely to self‐report having received vaccination than were African Americans (43.3 percent) or Hispanics (52.5 percent). Resistance to vaccination plays a role in low vaccination rates of African‐American (−11.8 percentage points), but not Hispanic beneficiaries. Unequal access accounts for &lt;2 percent of the disparity. Minority beneficiaries remained unvaccinated despite having medical encounters with their usual providers on days when those same providers were administering vaccinations to white beneficiaries. This disparity is attributable not to provider discrimination but to a 1.6−5 × higher likelihood of white beneficiaries initiating encounters for the purpose of receiving vaccination.Conclusion. Disparities in access to care and provider discrimination play little role in explaining racial/ethnic disparities in influenza vaccination. Eliminating missed opportunities for vaccination in 1995 would have raised vaccination rates in three racial/ethnic groups to the Healthy People 2000 goal of 60 percent vaccination.

Pneumococcal pneumonia and influenza vaccination: access to and use by US Hispanic Medicare beneficiaries.

This study examined differences between elderly Hispanic Medicare beneficiaries and other Medicare beneficiaries in the probability of being immunized for pneumococcal pneumonia and influenza. We used the 1992 national Medicare Current Beneficiary Survey to evaluate influenza and pneumococcal pneumonia immunization rates. Elderly Hispanic Medicare beneficiaries were less likely than non-Hispanic White Medicare beneficiaries to have received an influenza vaccine in the past year or to have ever been immunized for pneumococcal pneumonia. Speaking Spanish was statistically significantly associated with influenza vaccination but not with pneumococcal pneumonia vaccination. Supplemental insurance status, HMO enrollment, having a usual source of care, and being satisfied with access to care were positively associated with immunization. Strategies that may improve immunization rates among elderly. Hispanics include reducing the inconvenience of being immunized, decreasing out-of-pocket costs, linking beneficiaries with providers, and educating Hispanic beneficiaries in Spanish about the benefits of vaccinations.