Disparities in receipt of recommended care among younger versus older medicare beneficiaries: a cohort study

The Healthy People 2020 initiative seeks to eliminate health disparities and improve the health of all groups in the US [1]. A distinct group that suffers multiple health disparities, yet has not been investigated thoroughly, is Medicare beneficiaries under 65 years of age. Younger Medicare beneficiaries face major social disadvantages and a disproportionately high burden of disabilities and medical morbidities. Unlike those who are eligible for Medicare solely due to being 65 years of age and older, younger enrollees must have received Social Security disability benefits for 24 months or have either amyotrophic lateral sclerosis or end-stage renal disease [2]. Younger Medicare beneficiaries are more likely to be male, non-white, economically and educationally disadvantaged, to be in fair or poor health, and to have a higher prevalence of disabilities and mental health disorders [3‐6]. In 2012, younger beneficiaries constituted 17% of the 50.8 million Medicare enrollees, but triggered 20% of total Medicare expenditures [7]. Despite these higher expenditures, they underutilized preventive health services including influenza vaccine, eye and dental exams, mammograms, and prostate exams [4].

Braveman’s health disparity framework lays the ground for our analysis of younger Medicare beneficiaries [8]. A health disparity is a population-specific, potentially avoidable difference in health or important influences on health that is systematically associated with socially disadvantaged groups [8], such as the impoverished, racial minorities and individuals with disabilities. An important way to eliminate health disparities is through equitable health care, defined as equally accessible care to all users, and greater provision of care to users who demonstrate greater need [8‐10]. In Braveman’s framework, a health disparity should be assessed by comparing groups in a social hierarchy in relation to each other [11], because such comparisons help policy makers identify vulnerable social groups, target interventions and reallocate resources to achieve greater health equity. Factors associated with health disparities include minority race [12, 13], lower income and less education [14], and disability [15‐17]. Often these vulnerabilities, as well as rural location and reduced physician supply, are also associated with poor quality of care [18‐25]. Although it is expected that younger beneficiary status is associated with health disparity due to Medicare enrollment criteria, younger beneficiaries demonstrated largely unmet health care needs.

However, younger beneficiaries are often excluded from studies of Medicare beneficiaries. The few pioneering studies comparing younger versus older beneficiaries highlighted the importance of the topic, although they tend to have several limitations [4‐6]: self-reported health service utilization is subject to recall bias; types of services are often limited to preventive care; and crude associations without risk adjustment are not particularly useful for policy planning. To better capture underuse of care in the younger population, we employed claims data, a variety of indicators and risk-adjusted models. Furthermore, three main characteristics of younger beneficiaries (greater comorbidity, disability and socioeconomic disadvantages) do not always affect quality of care in the same direction. Multimorbid patients tend to get higher quality of care [26], disability has mixed quality [24]; minority race and lower income, while also having mixed quality, tend to predict worse care [21, 27]. Comparing younger with older Medicare beneficiaries can shed light on the direction and magnitude of these relationships, and their synergies and dys-synergies as they co-occur in younger beneficiary population. The comparison is important as a policy evaluation issue: is the Medicare program failing its younger beneficiaries?

We sought to identify predictors of underuse of recommended care by applying Asch’s underuse indicator system to recent Medicare claims of health service utilization [21]. Asch’s underuse indicator system is a clinically valid, comprehensive and claim-based measurement tool, which examines highly prevalent conditions and preventive care. These indicators have been validated on both inpatient, outpatient and physician service claims data for Medicare beneficiaries 65 years of age and older [21, 24], but not younger beneficiaries. Therefore, we aimed to characterize vulnerabilities of the younger Medicare age group and then explore age group as a determinant of use of recommended care among Medicare enrollees. We assess the extent to which the earlier findings of disparities in sociodemographic and health characteristics hold in younger beneficiaries in our data. We further test our hypothesis that compared to older beneficiaries, younger beneficiaries are less likely to receive recommended care after accounting for sociodemographic characteristics, degree of comorbidity and activity limitation.

Research on the appropriate use of health services by younger Medicare beneficiaries remains quite limited [3]. In this nationally representative study of community dwelling Medicare beneficiaries, we found that those younger than 65 compared to those 65–74 years of age had a higher proportion of characteristics conventionally associated with social disadvantage. Such characteristics include being non-Hispanic Black, living with disabilities, lower educational achievement and non-metropolitan residency. Even after adjusting for these factors and further adjusting for dual enrollment in Medicare and Medicaid, cognitive, developmental or psychiatric disorders and vision impairment, we found substantially reduced use of recommended care by younger Medicare beneficiaries. In contrast, the older old group was slightly more likely than the younger old to receive recommended care.

Our results are consistent with previous reports on younger beneficiaries with respect to the proportion of those who were non-Hispanic black, who were eligible for Medicare and Medicaid [5, 33] and who self-reported to have cognitive, developmental or psychiatric disorders [6]. Younger beneficiaries demonstrated a higher prevalence of self- or proxy- reported dependencies in ADLs and IADLs in our study than previously reported [34]. The results suggest that activity limitations of younger Medicare beneficiaries have not improved over time, supporting need for interventions.

Although it has been reported that younger Medicare beneficiaries significantly underuse preventive care compared to older beneficiaries [4], our study was able to quantify the extent of such deficits. We found the most striking deficiencies across the three prevention indices, routine care for diabetes and post-discharge follow-up for CVA and TIA. Inadequate care, particularly for chronic conditions, suggests that the current service delivery model that centers on acute illness [35] does not meet current needs for prevention and chronic conditions. The reorientation of Medicare to the management of chronic illness and the amelioration of activity limitation could improve the care and reduce costs for chronically ill beneficiaries [36]. Appropriate use of preventive services, medication management and behavioral interventions have been proposed as promising strategies for reducing severity of chronic conditions and their complications [3].

Younger beneficiary status was an independent predictor of underuse in the adjusted model, possibly due to the operation of unknown factors influencing underuse in this population, such as infrequent contact with the health system, especially outpatient services. A post-hoc analysis revealed that among beneficiaries with a cognitive, developmental or psychiatric disorder, the three age groups made similar numbers of outpatient visits (Median = 2.2, 2.1 and 1.9 respectively); in contrast, among beneficiaries without those disorders, younger beneficiaries visited a doctor more often than the younger old and older old beneficiaries (Median = 2.1 vs. 1.0 and 1.5). The excess office visits made by younger beneficiaries were likely due to Medicare eligible conditions other than cognitive, developmental or psychiatric disorders. These findings suggest that a greater number of office visits does not necessarily translate into adequate care for younger beneficiaries. One explanation for the paradox is that specialists may not make recommendations for preventive care outside their area of specialty. We speculate that improved care coordination among mental health, primary care and specialty care providers may contribute to a better understanding of patients’ comprehensive care needs and making critical recommendations.

In contrast, older old beneficiaries had a slightly better chance to get recommended care than the younger old, all else equal. This is consistent with our post-hoc finding that on average older old beneficiaries visited their doctors more often than the younger old. We found greater comorbidity associated with greater likelihood of receiving appropriate care, similar to published reports [26, 37]. Increased use of recommended care for both groups is likely due to their frequent office visits leading to a greater chance to fulfill care requirements.

As expected, non-Hispanic black race, less than high-school education, non-Metropolitan residence and disability independently predicted underuse of care. Although reversed racial disparity has been reported [27], likely due to selection bias of the samples [38], different sets of quality of care indicators studied, and use of claims versus self-reported data, underuse of medical care among racial minorities is more accentuated in literature [21, 39]. Improving surveillance data systems, creating a culturally-competent medical workforce and recruiting minority health professionals have emerged as strategies to address racial/ethnic differences in health and health care [40, 41]. Lower socioeconomic position [42] and rural settings [43, 44] diminish the chance to obtaining cancer prevention services. Removal of access barriers to care, especially financial barriers, was endorsed as central to create equity in health outcomes across different socioeconomic groups [45]. Availability of services, knowledge or physician recommendations of needed care and transportation are often reported factors underlying the geographic disparities in care and are points to address in interventions [43, 44] Greater use of home care in rural areas was also reported [46]. Future research may investigate population-level utilization of a wide range of health services. Disability is a known risk factor for underuse of certain care among Medicare beneficiaries excluding younger beneficiaries [24, 25]. This is also reflected in our study, which found a monotonic increase in care disparities with higher activity limitation stages (greater severity). Physical barriers, lack of professional assistance and social support, as well as experiences of distress likely influence service underuse [47, 48]. Resource reallocation targeting disabled individuals may aid their access to care and increase use of recommended care. Furthermore, since functional decline after hospitalization is fairly common [49], establishing care continuity in communities after hospital discharge can be critical for disabled persons.

We studied three Medicare age groups who likely occupy different positions in a social hierarchy and differ in their health status and utilization of health services. Such comparison is useful in identifying a disadvantaged population and its care needs, which subsequently informs resource reallocation to achieve greater equity. The study has several limitations. This study does not answer the question why younger beneficiaries underuse recommended care. The mechanism can be explained by access barriers to care, care not recommended by providers, or care recommended by providers but was not sought by the patient. For instance, some beneficiaries did not seek or comply with recommended care because of their limited health literacy or knowledge about their care plans [50, 51]. It has also been reported that providers tend to downplay the importance of healthy behaviors and disease prevention in the lives of their disabled patients [47]. Due to data limitation, we were not able to incorporate these potential causes for failure of care compliance in our analysis. We recommend in-depth observational studies that explore patient-doctor encounters to determine the causes of underuse and what types of appropriate preventions should be in place. Asch’s indicator system reflects care needs of highly prevalent conditions among the elderly population. These indicators may not reflect all care needs of younger beneficiaries, especially those experiencing cognitive, developmental or psychiatric disorders. Indicators that address the care for prevalent diseases in younger beneficiaries are highly desirable. Stratified analysis of receipt of recommended care among beneficiaries with versus without psychiatric disorders may also be considered, since persons who have been admitted for mental disorders tend to have poorer quality of care and higher mortality in somatic diseases, compared to persons who only have somatic diseases [52]. We acknowledge the likelihood of residual confounding in socioeconomic, comorbidity and to a lesser extent disability, measures. It is possible that even after controlling for all these variables, the reason of underuse among younger beneficiaries is that they are still sicker and more disadvantaged, rather than an independent effect of younger beneficiary status. Although there may be geographic variations in receipt of recommended care, MCBS is not powered to investigate state-level estimates. MCBS claims data (2002–2010) used in this study are not the most recent; however, the structure of the Medicare program eligibility for those under 65 has not changed, and the historical data matches the period when Asch’s indicators were developed. Due to incomplete claims data from beneficiaries enrolled in a managed care program, our results only apply to the fee-for-service Medicare population. Even though we combined eight beneficiary cohorts to compensate for small sample sizes associated with certain indicators, some indicators could not be addressed in the younger beneficiaries since cell sizes were still too small to report.

Our study has identified social and medical vulnerabilities of younger Medicare beneficiaries, and their lack of overall and specific type of care. Our results based on improved indicator metrics corroborated previous findings of potential influences on health service underutilization. CMS (Quality Strategy 2016) envisions care as valued-based: person-centered, cost-efficient and health-promoting [53]. It sets effective communication and coordination of care, prevention and treatment of chronic diseases, and partnership with communities to promote healthy living as among its goals, and eliminating racial and ethnic disparities and strengthening infrastructure and data systems as part of its foundational principles. Our findings provide evidence for the need of interventions that may bridge the health equity gap in the Medicare population.