A major new study looking at health disparities across the U.S. finds that significant gaps in managing heart disease and diabetes persist -- except in Western states, where the gap has been eliminated.
Researchers at the University of Michigan and Harvard University looked at 100,000 Medicare patients who were enrolled in HMOs, called "Medicare Advantage" plans, from 2006 to 2011. While management of blood pressure, cholesterol and blood sugar improved overall, blacks "substantially" trailed whites everywhere except the Western U.S., an area from the Rocky Mountains to the Pacific, as well as Alaska and Hawaii.
"We were certainly hoping we would see indications of progress in eliminating disparities in the country as a whole," said lead author Dr. John Ayanian, who heads the Institute for Healthcare Policy and Innovation at the University of Michigan. He said that while it was "disappointing" that disparities persisted, "it's also heartening to see that ... in the West, the disparities had been eliminated, and that was both surprising and encouraging."
The study was published in the New England Journal of Medicine and was funded by a grant from the National Institute on Aging.
Disparities in health care have long been noted in the American system. The researchers wrote that, in 2008, "life expectancy was 5.4 years shorter for black men and 3.7 years shorter for black women than for white men and white women." Heart disease and diabetes -- diseases that can be better managed by controlling blood pressure, cholesterol and blood sugar, the risk factors measured in the study -- accounted for 38 percent of the gap in mortality between black and white men, and 54 percent of the gap among women, the researchers said. That's why closing the racial gap on these measures is so critical.
"It's one of the first large studies to show that it's possible to eliminate deeply ingrained racial disparities in important risk factors," Ayanian said. He said that outcomes for Hispanics, Asians and Pacific Islanders were "also encouraging." Hispanics were 1 to 3 percent less likely than whites to have blood pressure, cholesterol or blood sugar under control. Asians and Pacific Islanders were more likely than whites to have good control of blood pressure and cholesterol. Blood sugar control was about the same.
Kaiser Health Plans Noted
Specifically, the researchers pointed to Kaiser health plans as being successful in eliminating disparities.
"Our findings in the West of nearly identical control of three major risk factors among black Medicare enrollees and white Medicare enrollees in Kaiser health plans and control of [blood sugar] in other health plans show the potential to achieve equity in these key health outcomes," the researchers wrote. Kaiser includes "nearly half" of Medicare HMO enrollees in the western region of the U.S., Ayanian said.
Kaiser representatives said they did not have any advance knowledge of the publication of the study. Dr. Joseph Young who leads Northern California Kaiser's clinical hypertension program said that Kaiser adopted a "population management approach to managing chronic conditions" in 2006. He said that Kaiser has created registries for people with various kinds of conditions, so that patients who might be missing preventive care or better management of disease can be easily identified.
In the area of blood pressure control specifically, Kaiser changed its drug formulary to allow a "combined pill" -- a single pill that includes two drugs, to make medication adherence easier for patients.
These population-based strategies across the board resulted in big improvements in overall outcome for Kaiser patients. Young said that during the 2000s, "very serious heart attacks ... fell by 62 percent, and our stroke mortality fell by 42 percent." Kaiser does have some remaining racial disparities in its non-Medicare population, and Young said they are "actively focusing" on closing those remaining gaps.
Dr. Anthony Iton leads the Healthy Communities initiative at the California Endowment. He's also past director of the Alameda County Public Health Department. In both roles, he has championed fighting disparities in health care. He called the study "very hopeful" and believes that Kaiser's approaches are replicable elsewhere. "We want clinicians to do what Kaiser is doing and take seriously to provide high quality race-blind clinical care. Kaiser is showing it can be done."
"Any other system that says it's not doable has to explain how they can justify not providing the same high-quality care to everyone that comes in the door," Iton said.
Still, Iton observed that California probably has "less of a socioeconomic spread between whites and blacks than you do in the Southeastern United States. Those are quite disparate populations. ... It's a heavier lift in the Southeast than in the West, but despite that it's clearly doable."