Nov. 7, 2000 -- Health services researchers have long focused on insurance as an indicator of access to care. But does coverage by insurance necessarily mean that patients are getting the care they should?
A report in the Nov. 8 edition of the Journal of the American Medical Association suggests that many people enrolled in the federal Medicare program are not receiving necessary care, according to study author Steven M. Asch, MD, MPH, a physician researcher at the West Los Angeles VA Medical Center and the Rand Corporation.
What Asch and colleagues found were substantial shortfalls in the care patients received, compared to what medical experts believe they should have been receiving. The shortfalls were especially prominent among African-Americans and among low-income groups, Asch says.
These shortfalls were not only confined to minorities and the poor, though. They also appear to be widespread and occurred across various groups as well as across health services, Asch says.
"The take-home message is that there is plenty of under-use to go around in the Medicare program," Asch tells WebMD. "Though there are differences between racial groups and between zip codes, the differences are actually smaller than the differences between our hopeful expectations for what everyone should receive and what we see everyone receiving."
To assess the care Medicare patients were receiving, Asch and colleagues assembled a seven-member panel of medical experts to develop "indicators" of under-use likely to be associated with a poor outcome for 15 common chronic and acute medical and surgical conditions. These indicators were then compared to the actual care received by almost 350,000 randomly selected Medicare beneficiaries during the years 1994 to 1996, Asch reports.
For instance, the researchers looked at whether beneficiaries with a diagnosis of breast cancer received a mammogram at diagnosis, and whether they had follow-up visits following a mastectomy. They found that of eligible beneficiaries with a diagnosis of breast cancer, 64.6% received a mammogram at the time of diagnosis. They also found that 62.7% of eligible beneficiaries with a history of breast cancer received follow-up mammograms every year, according to the report.
Overall, for 16 of the 40 indicators, beneficiaries received the indicated care less than two-thirds of the time. African-Americans scored significantly worse than whites on 16 indicators, while residents of poverty areas scored lower than nonresidents on 17 indicators. Also, individuals residing in areas designated as "health professional shortage areas" scored lower than nonresidents on 16 of the indicators, Asch and colleagues report.
Asch refers to such shortcomings as a kind of medical "error" that can be corrected through "systems analysis," a way of improving care for individual patients by looking at overall patterns. "In order to build a system that catches errors and prevents them, we need to build a system that detects errors," Asch tells WebMD.
Elliott Fisher, MD, MPH, professor of medicine at the Dartmouth School of Medicine in Hanover, N.H., and a researcher in the Dartmouth Atlas Study Series, hails the study as comprehensive and says it underscores the fact that under-use of medical services is a significant problem, especially for the poor and for minorities. "Their findings suggest that the data works very well to document under-use, and the scope of the work and the effort to validate it across underserved populations is commendable," Fisher says.
But Fisher, who reviewed the report for WebMD, notes that many of the indicators used in the study were based on "expert opinion," not necessarily on clinical studies. And the lack of good data about what constitutes proper medical care only underscores the need for more and better health services research.
"There is an underlying assumption that under-use is the major problem facing the health care system," Fisher tells WebMD. "There clearly is under-use of services, but the article ignores the problem of overuse. We are without strong evidence for many of the basic elements of clinical practice, such as how often we should visit a physician."
Still, for consumers and patients, the research is significant, Asch says.
"My hope is that as beneficiaries who are invested in the Medicare program, patients will demand the program continue to track the quality of care they receive," Asch tells WebMD. "These findings are evidence that the this kind of tracking is absolutely necessary to develop a system that prevents errors and increases the chances that beneficiaries will get the care they need."