Medicare Beneficiaries Don’t Always Get Necessary Care

Some Medicare beneficiaries are receiving necessary medical care less than two-thirds of the time, according to a study in today's Journal of the American Medical Association. In an effort to gauge underuse of care among elderly patients, researchers assembled a seven-member, multi-specialty panel of physicians to evaluate indicators for a list of chronic, acute and surgical medical conditions that are prevalent among the elderly, such as acute myocardial infarction, breast cancer, chronic obstructive pulmonary disease and diabetes. The expert panel came up with a total of 47 indicators, 41 of which were based on necessary care and six of which were based on avoidable outcomes. In applying the indicators to Medicare claims data, the researchers randomly analyzed information culled from a selected 1% sample of Medicare beneficiaries ages 65 years or older from January 1992 through December 1993, and from July 1994 through June 1996. For each indicator, the researchers studied only the recipients with relative diagnoses who were enrolled in traditional Medicare fee-for-service for an adequate number of months to have received necessary medical care. For 14 of the necessary care indicators, the selected data show that less than two-thirds of Medicare beneficiaries with the evaluated conditions were treated with care that the expert panel deemed a "minimum quality standard." The overall results show that vulnerable populations were less likely to receive necessary and preventive care and were more likely to have higher rates of avoidable outcome indicators. African Americans scored significantly worse on 16 of 46 indicators -- 10 of the non-preventive necessary care indicators, all three of the preventive care indicators, and three of the six avoidable outcomes. Furthermore, African Americans had lower follow-up rates after hospitalization and fewer necessary blood tests and eye examinations; beneficiaries who were poor or who resided in areas lacking an adequate number of health care professionals showed similar patterns. Conclusions The study's authors conclude that their model for measuring the underuse of necessary care has several advantages: For example, by combining inpatient and outpatient claims data, they contend that the system can provide a "more complete assessment" of underuse. In addition, measures based on claims data can be calculated in a "timely fashion, thus facilitating the repeated evaluations crucial to identifying trends and analyzing programmatic success" (Asch et al, 11/8). Meanwhile, in an accompanying editorial, a physician from the State University of New York offers praise for the researchers' efforts, but notes that the underuse of necessary care is "so pervasive and persistent" among minorities and the poor that any systems that aim to address and correct such problems "may not suffice" (Hannan, 11/8). To read the study, go to http://jama.ama-assn.org/issues/current/rfull/joc00215.html.