How Medicare Could Improve Chronic Care, Reduce Disparities

Article excerpt

While most attention to Medicare these days is focused on the prescription drug law, the Medicare program lies at the intersection of two front-burner issues in health policy: improving the quality of care, especially for those with chronic conditions, and reducing racial and ethnic disparities. Two expert panels convened by the nonpartisan National Academy of Social Insurance (NASl) examined these issues in depth. The Study Panel on Medicare and Chronic Care in the 21 st Century issued its report in 2003. The Study Panel on Sharpening Medicare's Tools to Reduce Racial and Ethnic Disparities completed its work recently in 2006. The reports and working papers from both of these panels are available on the NASI website at fo-url2712/info-url_show.htm?doc_id=49027.

The Institute of Medicine's 2001 report Crossing the Quality Chasm documents the uneven quality of the U.S. healthcare system and recommends focusing on chronic illness as the starting point for improvement. Congress and the public are becoming increasingly aware of systemic deficiencies in handling chronic conditions and are putting pressure on the Medicare program to improve care to beneficiaries.


Chronic conditions are prevalent among Medicare beneficiaries, and the cost of managing those conditions is substantial. Among today's beneficiaries, 87% have at least one chronic condition, such as diabetes, emphysema, heart disease, hypertension or arthritis. Twothirds have more than one chronic condition. Beneficiaries with five or more chronic conditions account for 20% of the Medicare population, but their care constitutes 66% of Medicare spending.

Few people are surprised by the prevalence of chronic conditions among Medicare beneficiaries, who must be either 65 or older or have disabilities. Most are not aware, however, of the disparities in healthcare and health status among Medicare beneficiaries of different racial and ethnic groups. After all, lack of health insurance-a factor contributing to disparities-is not a problem for Medicare beneficiaries. Medicare's hospital and outpatient care programs provide the same benefit package to all beneficiaries-rich and poor, black and white-and the vast majority of healthcare providers participate in the program.

Nonetheless, even among Medicare beneficiaries, marked disparities persist in medical treatment and health status, although they are smaller than the disparities that minority beneficiaries experience before becoming entitled to Medicare. The 2002 Institute of Medicine report Unequal Treatment found sizable racial and ethnic healthcare disparities among Medicare beneficiaries. Beneficiaries from various ethnic or racial groups also fall short of whites on many measures of health status. African Americans, for example, have shorter life expectancy at age 65 than whites, and black and Latino beneficiaries are more likely than whites to have major chronic conditions, such as hypertension and diabetes.

Improving chronic care and reducing disparities are likely to become even more important in the years to come. The prevalence of some conditions, such as hypertension and diabetes, has been increasing in the older population. As life expectancy continues to lengthen, chronic health conditions may become even more common. The proportion of ethnic or racial minorities among the aging population will also grow. By 2050, nonHispanic whites are projected to represent only 61% of elders, compared with 83% today.


Medicare can influence chronic care and disparities in care both directly and indirectly. Clearly, Medicare's policies affect the care received by its .42 million enrollees. But Medicare also shapes the entire healthcare system through its leverage as the nation's largest purchaser and regulator. Its reimbursement and coverage policies are widely imitated, and it influences the safety and quality of care through its conditions of participation and standards of accreditation. …