Relationship between quality of care and racial disparities in Medicare health plans

JAMA. 2006 Oct 25;296(16):1998-2004. doi: 10.1001/jama.296.16.1998.


Context: Overall quality of care and racial disparities in quality are important and related problems in health care, but their relationship has not been well studied. In the Medicare managed care program, broad improvements in quality have been accompanied by reduced racial gaps in processes of care, but substantial disparities in outcomes have persisted.

Objectives: To assess variations among Medicare health plans in overall quality and racial disparity in 4 Health Plan Employer and Data Information Set (HEDIS) outcome measures, to determine whether high-performing plans exhibit smaller racial disparities, and to identify plans with high quality and low disparity.

Design, setting, and patients: We assessed the relationship between quality and racial disparity using multilevel multivariable regression models. The study sample included 431,573 individual-level observations in 151 Medicare health plans from 2002 to 2004.

Main outcome measures: Hemoglobin A(1c) of less than 9.5% or less than 9.0% for enrollees with diabetes; low-density lipoprotein cholesterol level of less than 130 mg/dL for enrollees with diabetes or after a coronary event; and blood pressure of less than 140/90 mm Hg for enrollees with hypertension.

Results: Clinical performance on HEDIS outcome measures was 6.8% to 14.4% lower for black enrollees than for white enrollees (P<.001 for all). For each measure, more than 70% of this disparity was due to different outcomes for black and white individuals enrolled in the same health plan rather than selection of black enrollees into lower-performing plans. Health plans varied substantially in both overall quality and racial disparity on each of the 4 outcome measures. Adjusted correlations between overall quality and racial disparity were small and not statistically significant, ranging from 0.01 (blood pressure control) to -0.21 (cholesterol control in diabetes). Only 1 health plan achieved both high quality and low disparity on more than 1 measure.

Conclusions: In Medicare health plans, disparities vary widely and are only weakly correlated with the overall quality of care. Therefore, plan-specific performance reports of racial disparities on outcome measures would provide useful information not currently conveyed by standard HEDIS reports.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • African Americans
  • Bayes Theorem
  • Blood Pressure
  • Cholesterol, LDL / blood
  • Ethnic Groups*
  • European Continental Ancestry Group
  • Glycated Hemoglobin A / metabolism
  • Health Benefit Plans, Employee / standards
  • Health Services Accessibility*
  • Humans
  • Managed Care Programs / standards*
  • Managed Care Programs / statistics & numerical data
  • Medicare / organization & administration
  • Medicare / standards*
  • Minority Groups
  • Outcome and Process Assessment, Health Care
  • Quality of Health Care*
  • Regression Analysis
  • Socioeconomic Factors
  • United States


  • Cholesterol, LDL
  • Glycated Hemoglobin A