RAND Study Finds All Socio-Demographic Groups at Risk for Poor Quality Health Care

Virtually every person in the United States is at risk of failing to receive needed care regardless of race, gender, income or insurance status, according to a RAND Corporation study published today in the New England Journal of Medicine.

The study, the third installment of the largest and most comprehensive examination ever conducted of health care quality in the United States, finds that while some disparities in care exist they are small relative to the gap between what everyone needs and what they are receiving.

Two previous landmark publications from RAND Health documented that Americans receive just half of recommended care no matter where they live. Today's report represents the most comprehensive evaluation to date of the relationship between individual socio-demographic characteristics and multiple areas of quality of care. It shows that people in all socio-demographic groups experience deficits in receiving needed care, but the relative performance varies by the aspect of care examined.

“Differences exist. But they pale in comparison to the chasm between where we are today and where we should be,” said lead study author Steven M. Asch, M.D. of RAND, the Veterans Affairs Greater Los Angeles Health Care System, and the University of California, Los Angeles. “These findings tell us that no one can afford to be complacent, and they underscore that the quality-of-care problem in this country is profound and systemic.”

According to the study, which assessed preventive services and care for 30 acute and chronic conditions that constitute the leading causes of death and disability, participants received about 55 percent of recommended care. This is despite the fact that recommended care for these conditions is widely known and accepted.

Women More Likely To Receive Recommended Preventive Care;
Younger And Wealthier Score Better For Screening

The study found that:

• Women received a higher proportion of recommended care than men (57 percent vs. 52 percent).
• Women were more likely than men to receive preventive services (58 percent vs. 50 percent) and needed chronic care (58 percent vs. 55 percent).
• Women were less likely than men to receive needed acute care (52 percent vs. 58 percent).
• Younger and wealthier participants were more likely to be screened, but less likely to receive follow-up care than older participants.
• Adults under age 31 were significantly more likely to receive preventive care than those older than 31.
• Those aged 31 to 64 received significantly better chronic care than those under 31 (57 percent vs. 51 percent).
• Those with annual family incomes over $50,000 had quality scores that were just 3.5 percentage points higher than those with incomes less than $15,000.

The authors found that insurance status had no real effect on quality. Insurance “is not sufficient to assure appropriate use of services,” write the authors. In fact, in situations where everyone has equal access, disparities in care according to race or ethnic group are often reduced or even reversed.

Blacks Fare Better Overall and With Chronic Disease Care;
Hispanics More Likely To Receive Screening

The relationship between personal characteristics and care received is highly complex and often condition-specific, according to the authors. For example, they note that other studies have demonstrated disparities in care for blacks associated with invasive and expensive procedures, such as kidney transplantation or coronary-artery bypass graft surgery. But the RAND Health study, which assessed a broader range of care including more routine care, showed that blacks had higher scores than whites on several indicators.

According to the study:

• Overall quality scores for blacks were 3.5 percentage points higher than for whites.
• Overall quality scores for Hispanics were 3.4 percentage points higher than for whites.
• Blacks had higher scores than whites for chronic care (61 percent vs. 55 percent).
• Blacks had higher scores for treatment than whites (64 percent vs. 56 percent).
• Hispanics were more likely to receive screening than whites (56 percent vs. 52 percent).

The authors noted that participants in the study had at least one encounter with the health care system in two years, indicating some minimal access to care. However, access alone was not enough to guarantee the appropriate delivery of care.

“We found that once patients get in the door they are likely to experience another set of barriers to receiving needed care,” Asch said. “Policies to improve access, while critically important, will not by themselves fix the quality problem.”

“The results of our study will be surprising to some people, but the findings make it clear that the quality problem affects all of us,” said Elizabeth McGlynn, Ph.D., associate director of RAND Health and senior author of the study. “This tells us that the U.S. health care system is unreliable and cannot guarantee that patients – rich or poor, white or black, insured or uninsured – will receive the right care at the right time. We need to fundamentally redesign the health system to ensure that no matter who you are or where you go for care you will get what you need.”

The study, funded by the Robert Wood Johnson Foundation, used a state-of-the art methodology that involved both telephone surveys and reviews of patients' medical records from all providers seen during the two-year study period. Nearly 7,000 adults in 12 nationally representative metropolitan areas participated in the study, which evaluated performance on 439 indicators of quality for 30 acute and chronic conditions such as urinary tract infections, diabetes, asthma, high blood pressure and heart disease – along with preventive care.

In addition to Asch and McGlynn, collaborators included: Eve A. Kerr, Veterans Affairs Ann Arbor Health Care System and the University of Michigan; Joan Keesey, John Adams, and Claude Setodji of RAND; and Shaista Malik of the University of California, Irvine.

RAND Health, a division of the RAND Corporation, is the nation's largest independent health policy research organization, with a broad research portfolio that focuses on health care quality, costs, and delivery, among other topics.