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Identifying Opportunities to Improve Quality of Care and Functional Health Outcomes

Older women experience a high burden of chronic illness, disability, and comorbidity, and this burden is highest among socioeconomically disadvantaged and minority women. The consequences of a mismatch between the organization, delivery, and financing of health care for older women and their actual needs fall disproportionately on low-income and minority women. New sources of data, such as the Medicare Health Outcomes Survey, a new quality measure for Medicare+Choice plans, will provide valuable information to practitioners about the health and functioning of older women in general and about socioeconomically disadvantaged and minority women in particular. This information can be used to develop and implement interventions to improve the quality and outcomes of care for vulnerable subgroups of older women. There is cause for optimism that by improving the quality of clinical preventive services and the management of common chronic conditions and geriatric syndromes it will be possible to improve functional health outcomes, prevent or postpone disability, and extend active life expectancy for all older women while making progress toward eliminating health disparities among the most disadvantaged. (JAMWA. 2001;56:155-159)

Reducing disparities in health and health care associated with race, ethnicity, and socioeconomic position has emerged as a major challenge for the United States health care system. These health disparities persist into old age. Gaining access to health care does not necessarily result in equivalent treatment. Race, ethnicity, socioeconomic position, and other factors are frequently associated with differential treatment. The proportion of the population age 65 and older who are from racial or ethnic minority groups is projected to grow from 16% in the year 2000 to 36% by the year 2050 (16% Hispanic, 12% African American, 7% Asian and Pacific Islander, and 0.6% Native American). The aging of the "baby boomers" and associated challenges for Medicare make it critical that we address health care disparities among the increasingly ethnically diverse older population, the majority of whom are women. Inequality of care can no longer be viewed as the result of socioeconomic forces beyond the control of clinicians and health care organizations. The high burden of chronic illness, comorbidity, and disability among older women, coupled with a health care system inadequately organized to respond to these needs, makes addressing health disparities among older women a pressing challenge.

Efforts to assess and improve quality of care for older patients now include a specific focus on improving the management of chronic illness and functional health outcomes, which is of prime importance for older women. Previous studies have examined how individual and community characteristics, including use of services, are associated with older women's health and functional status. These studies have provided important insights into the epidemiology of functional decline among older women. Few studies have examined the direct impact of health care and policy on older women's health, and none have addressed the interaction of health care and race, ethnicity, and socioeconomic position on older women's ability to function. Evidence suggests that improving the quality of clinical preventive services and the management of chronic illness and common geriatric syndromes may have a positive impact on functional health outcomes and form the foundation for addressing disparities in health care among older Americans.

We focus here on how health care and the policies that effect health care delivery can improve health outcomes and reduce health disparities among older women. We present descriptive data illustrating health disparities in older women from the Medicare Health Outcomes Survey (MHOS), a new quality measure in HEDIS 2000, and provide selected examples of interventions that can improve quality of care and reduce health disparities.

Two Conceptual Frameworks

We present 2 complementary conceptual frameworks that clarify the relationships among the many factors that influence health outcomes and help us to identify potential opportunities to improve care. The first (Figure 1) illustrates the relationships among health policy; the organization and financing of care; clinical practice; and the biological, individual, social, and community factors that influence health outcomes. It includes a patient-centered rather than disease-specific focus, particularly relevant for older women (because many have multiple chronic conditions). Patient-centered models recognize the net effect of individual conditions and treatments on overall function in the context of pyschosocial factors and patient values. Multiple domains of functioning, including physical, emotional, cognitive, role, and social functioning, contribute to overall health outcomes. A patient's functioning is influenced by her biology (eg, genetics), individual characteristics (eg, health beliefs and behaviors), family (eg, social support), and community (eg, environmental factors, community services) as well as by her interactions with the health care system. The clinician-patient interaction is influenced by how the clinical setting is organized and by the financial incentives created by payment mechanisms, which are in turn influenced by health policy. All of the arrows in the framework are bidirectional, reflecting the multiple, complex interrelationships that influence health and function in older people.

The second conceptual framework (Figure 2) illustrates how access to and quality of care mediate health outcomes and can help us identify opportunities for improving the interaction between patients and providers. Primary, secondary, and tertiary barriers to access must be addressed. Primary barriers represent the first obstacle in getting care and include such factors as lack of or inadequate health insurance, proximity of providers, and lack of transportation. Secondary barriers are structural barriers such as difficulty getting appointments, specialty referrals, or advice after hours. Tertiary access reflects the ability of providers and the health care system to understand and address the patient's needs, including the provider's communication skills, cultural competence, knowledge, and clinical skills. These barriers have a disproportionate impact on low-income and minority individuals and on older people, especially those who are functionally impaired.

Health Disparities Among Older Women

A new measure of overall functional status required for managed care plans that serve Medicare beneficiaries is of particular relevance to efforts to improve functional health outcomes and reduce health disparities among older women. The MHOS is designed to measure change in self-reported function over 2 years. Respondents are asked to provide information on symptoms, diagnoses, and sociodemographic characteristics in addition to reporting on their ability to function, assessed by the SF-36. The measure that will be reported for health plans is the casemix-adjusted proportion of enrollees whose 2-year change in function is worse compared to those whose function is the same or better. Despite limitations of the survey, the large sample size of the MHOS affords an unprecedented opportunity to understand the health and functional status of low-income and minority elderly women and to examine how race, ethnicity, income, and education affect quality and outcomes of care. These data will be used at the federal, state, and health plan levels to design and evaluate interventions aimed at improving functional health outcomes for Medicare managed care enrollees. Descriptive data from the 1999 baseline survey of 91 314 community-dwelling women age 65 and older illustrate existing health disparities.

The second conceptual framework (Figure 2) illustrates how access to and quality of care mediate health outcomes and can help us identify opportunities for improving the interaction between patients and providers. Primary, secondary, and tertiary barriers to access must be addressed. Primary barriers represent the first obstacle in getting care and include such factors as lack of or inadequate health insurance, proximity of providers, and lack of transportation. Secondary barriers are structural barriers such as difficulty getting appointments, specialty referrals, or advice after hours. Tertiary access reflects the ability of providers and the health care system to understand and address the patient's needs, including the provider's communication skills, cultural competence, knowledge, and clinical skills. These barriers have a disproportionate impact on low-income and minority individuals^[7] and on older people, especially those who are functionally impaired.

Differences in Socioeconomic Position.

There are large differences in income, education, and marital status among racial and ethnic groups of older women that can influence effective access to care (Figure 3). Twenty percent of all women age 65 and older enrolled in Medicare managed care reported annual household incomes of less than $10,000, and income varied markedly by race and ethnicity. African-American, Latina, and Native American older women were significantly more likely to be living in poverty than non-Hispanic white and Asian older women. Out-of-pocket health care costs place considerable financial strain on low-income beneficiaries. One study found that the 60% of beneficiaries with incomes below the poverty level who did not receive Medicaid spent half their incomes, on average, on out-of-pocket expenses, whether they were enrolled in Medicare managed care or in the traditional fee-for-service program.

Many women had not benefited from formal education, placing them at risk for low health literacy. Thirty-one percent of all women age 65 and older enrolled in Medicare managed care had not graduated from high school, 12% of whom had less than an eighth-grade education. At least half of all African-American, Latina, and Native American women reported less than a high school education (Figure 3). Older women are being called on to make increasingly complex decisions about Medicare coverage, to choose among a growing array of therapeutic interventions, and to become active participants in their care. Their ability to do this effectively will depend on having information communicated clearly in a manner that takes literacy level into account.

Older women were more likely than men to live alone, and when they lived with others, they were more likely to be caregivers for spouses or grandchildren. Caregiving responsibilities and resulting competing demands can result in barriers to care. Figure 3 shows racial and ethnic differences in marital status. African-American women were more likely to be unmarried; they were also more likely to live with other relatives, so that about 40% of white and African-American women lived alone. Hispanic and Asian women were least likely to live alone.

Differences in Global Health.

Global health is highly correlated with income and education. Figure 4 shows differences in the proportion of women in the MHOS who reported fair or poor health by income, education, and ethnicity. After adjusting for age, the lower a woman's income, the more likely she was to report fair or poor health. Women reporting annual household incomes of less than $10,000 were more than twice as likely to report fair or poor health as were women reporting annual household incomes of more than $50,000. Nearly one-half of respondents with an eighth-grade education or less reported that they were in fair or poor health. These women were nearly 3 times more likely to report that they were in fair or poor health than were college graduates, highlighting the paradox that women with the fewest resources to negotiate the health care system have the highest burden of illness.

Chronic Conditions and Symptom Severity.

The proportions of women who reported chronic conditions are shown in the table. More than half of the women in the survey reported hypertension or arthritis, and one-third reported cardiovascular disease or symptoms of urinary incontinence. Fifty-two percent of women reported 3 or more chronic conditions. Women with low incomes and less education were significantly more likely to report each of these conditions. Prevalence of chronic illness varied by race and ethnicity, with African-American and Native American women reporting the highest burden of illness.

Low-income and less educated women were not only more likely to report chronic illness, but they were also more likely to report symptoms. For example, 58% of poor women reported having arthritis, and 54% of poor women with arthritis reported moderate or severe pain much of the time. Fifty-one percent of women with annual household incomes of $50,000 or more reported arthritis, 37% of whom reported having moderate or severe pain much of the time. A similar pattern by income was seen among women reporting ischemic heart disease and chest pain with exercise all or most of the time.

Differences in Depressed Mood.

The proportion of older women reporting depressed mood differed by income and race/ethnicity (Figure 5). Low-income women were much more likely to report that they felt depressed or sad much of the time in the past year than were their more affluent counterparts. Twenty-one percent of women who reported an annual income of less than $10,000 indicated that they felt depressed or sad much of the time in the past year compared to 8% of women with annual household incomes of more than $50,000. Nearly 1 in 4 Latina women reported depressed mood. African-American and Native American women were more likely to report depressed mood than were white and Asian women. Depression often goes undiagnosed, and screening for depression coupled with interventions to improve its management has been shown to improve quality of care for depression in primary care practice.

Differences in Comorbidity and Disability.

Comorbidity and disability are common problems in older women. Women who had low incomes, who had less than a high school education, or who were African American were more likely to report 3 or more chronic conditions or limitations in activities of daily living (ADLs). A prior study using the 1992 Medicare Current Beneficiary Survey found that women age 65 and older with less than a high school education were nearly twice as likely to report 3 or more chronic conditions or ADL limitations as women who had more than 12 years of education. Although it is a major concern for older patients, many doctors do not routinely assess their functional status. A survey of individuals age 80 and older in New England found that many perceived that their physicians were unaware of their marked functional impairments, including physical limitations, moderate to severe pain, and impairments due to mental health.

Targeting Critical Gaps

By systematically and strategically targeting critical gaps in the organization, delivery, and financing of care for older women, we can make progress toward eliminating the large socioeconomic and racial/ethnic disparities in health described above. These gaps can be categorized into 5 key areas: access, quality, organizational, evidence, and payment gaps. Clinicians can play a central role in improving care for older women, but cannot do it alone. Systemwide changes will be required. Below we provide examples of approaches that may be used to narrow gaps in these areas.

Access Gaps

Providers can increase access for their patients by identifying and targeting primary, secondary, and tertiary barriers within their practices. Providing patients with information about such federal programs as the Medicare Buy-In Qualified Medicare Beneficiaries can reduce financial barriers. Many states sponsor pharmacy benefit programs for the low-income elderly that can help older women purchase needed medications. Small organizational changes at the practice level, such as facilitating scheduling of urgent appointments or developing efficient mechanisms to address patient concerns by telephone, may help reduce secondary barriers. Attention to such issues as cultural competence and health literacy can serve to reduce tertiary barriers to care.

Quality Gaps

In recent years much attention has been focused on the failure of our health system to consistently provide high-quality care. The Institute of Medicine's report Crossing the Quality Chasm emphasizes gaps in the quality of care for chronic conditions and describes strategies to help close these gaps. Closing the quality gap for older women will require improvement across the continuum of care, including health promotion, clinical preventive services, management of chronic illness, coordination and accountability across different sites and settings of care, and coordination between clinical and community services. Clinical interventions can reduce the risk of both acute events such as stroke and hip fractures and the progressive loss of function from such conditions as arthritis and congestive heart failure. As the population ages, it will be increasingly important for basic geriatric principles to be incorporated into practice.

Organizational Gaps

Health system redesign is needed to close organizational gaps that present obstacles to improving the care of chronic illness. Wagner et al have developed a chronic care model that provides a framework for systems change that has been used to improve the quality of care in diverse settings. This model recognizes the critical role of the patient as an active participant in her care and the value of self-management interventions. Clinical leadership is a key element needed in this model.

Evidence Gaps

Gaps exist in our knowledge of how best to organize, finance, and deliver health care services that will improve the functional status of older women; of the most cost-effective ways of achieving these improvements; and of how to implement existing knowledge of what improves function in clinical practice. Evidence on how best to take into account the impact of multiple comorbid conditions on clinical decision making is needed. Outcomes and effectiveness research can provide the evidence to close some of these gaps.

Payment Gaps

Although this paper has focused on health status, much work needs to be done to develop payment mechanisms that align financial incentives with the provision of high-quality, comprehensive, coordinated care for older women (Figure 1). Shortcomings in the reimbursement of care for chronic illness and disability present a barrier to innovations to improve the quality of care for older women. For example, traditional fee-for service Medicare rewards the acute care model and creates incentives for overuse of services, but not for prevention, and does not allow for financing of innovative models of care for chronic illness. Feedback from providers about the resources needed to improve functional health outcomes could provide valuable information to inform payment policy.

Conclusion

Enormous opportunities exist to improve the health of and health care for older women and to benefit socioeconomically disadvantaged women, who experience the highest illness burden and are disproportionately affected by the shortcomings of our health care system. Enhancing our understanding of factors that contribute to racial/ethnic and age disparities in quality of care will allow us to strategically target and eliminate them. New sources of data such as the MHOS will provide valuable information about the health and functioning of older women that can be used to develop, implement, and evaluate interventions aimed at improving quality and outcomes of care for low-income and minority women. Improving the quality of clinical preventive services and the management of common chronic conditions and geriatric syndromes will make it possible to improve functional health outcomes, prevent or postpone disability, and extend active life expectancy for all older women and to make progress toward eliminating health disparities among the most disadvantaged.

We acknowledge Samuel C. Haffer, PhD, and Yi-Ting Hwang, PhD, for their contributions to the analysis of the MHOS data.

Table 1.
Self-Reported Chronic Disease and Symptom Prevalence of Women Age 65 and Older in Medicare Managed Care,* %

Figure 1.



Policy, organization, finance, clinical practice, patient factors, and functional health outcomes.






Figure 2.



Access, quality, and health outcomes.




Figure 3.



Income, education, and marital status of wonen age 65 and older enrolled in Medicare managed care by race/ethnicity.
Source: 1999 Medicare Health Outcomes Survey Cohort 2 Baseline Data.




Figure 4.



Proportion of women age 65 and older enrolled in Medicare managed care reporting fair or poor health by income, education, and race/ethnicity.
Source: 1999 Medicare Health Outcomes Survey Cohort 2 Baseline Data.




Figure 5.



Proportion of women age 65 and older reporting depressed mood by income and race/ethnicity.
Source: 1999 Medicare Health Outcomes Survey Cohort 2 Baseline Data.