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HOS HighlightsHealth Disparities Among Older Women Enrolled in
Medicare Managed Care Arlene S. Bierman, M.D., M.S., Samuel C. Haffer, Ph.D., and Yi-Ting Hwang, Ph.D.
INTRODUCTION
The Medicare Health Outcomes Survey (HOS) provides comprehensive information about the health and functional status of Medicare beneficiaries enrolled in Medicare managed care organizations. The survey’s core instrument contains items for assessing physical and mental health status, activities of daily living, clinical case mix adjustment variables, chronic conditions, and demographic information (National Committee for Quality Assurance, 2000). The data are collected through mail administration of the survey with telephone followup. Results from the HOS will be used to guide quality improvement activity in health plans, improve CMS’s ability to monitor health plan performance, and provide comparative information to beneficiaries to use when making health plan choices (Stevic et al., 2000; Cooper et
Arlene Bierman is with the Agency for Healthcare Research and Quality (AHRQ). Samuel Haffer is with the Centers for Medicare & Medicaid Services (CMS)(formerly known as the Health Care Financing Administration), and Yi-Ting Hwang is with the Georgetown University School of Medicine. The views expressed in this article are those of the authors and do not necessarily reflect those of AHRQ, CMS, or the Georgetown University School of Medicine.
al., 2001). The following figures are based on the responses of 91,314 community-dwelling women age 65 or over enrolled in managed care who participated in the 1999 Medicare HOS Cohort 2 Baseline Survey.
Differences in income, education, and health status were noted among the five racial/ethnic groups surveyed (non-Hispanic white, non-Hispanic black/African American,1 Hispanic/Spanish, non-Hispanic Asian/Pacific Islander, and American Indian/Alaska Native). Among community- dwelling women age 65 or over, those individuals with less education and lower incomes are more likely to report fair or poor health, experience a higher burden of chronic illness, and to indicate that they felt depressed or sad much of the time in the past year.
Future research should focus on under-standing the interrelationships between socioeconomic status, race/ethnicity and health, and functional status to identify effective strategies for maximizing health and functional status among all subgroups of older women. 1 Non-Hispanic black or African American includes non-Hispanic natives of the Caribbean.
HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4 187
Figure 1
Ethnic Differences in Annual Income Among Women Age 65 or Over Enrolled in Medicare Managed Care
40
Low ($10,000-$20,000)
30
0
Non-Hispanic White
18
28
Non-Hispanic Black or
African American
Hispanic or Spanish
Non-Hispanic Asian or Pacific
Islander
American Indian or
Alaska Native
Per
cen
t R
epo
rtin
g
20
10
Poor (Less than $10,000)
29 28
17 16
29 27
37
23
Race/Ethnicity
NOTE: Non-Hispanic black or African American includes non-Hispanic natives of the Caribbean.
SOURCE: 1999 Medicare Health Outcomes Survey - Cohort 2 Baseline Measurement Data Set.
• Non-Hispanic black/African American women are more likely to report annual house-hold incomes less than $10,000.
• Over one-half of non-Hispanic Black/African American, Hispanic/Spanish, and American Indian/Alaskan Native women age 65 or over report annual household incomes less than $20,000.
• Non-Hispanic Asian/Pacific Islander women enrolled in Medicare managed care are least likely to report lower incomes.
• Nearly one-half of Non-Hispanic white women age 65 or over also report low incomes.
188 HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4
Figure 2
Ethnic Differences in Level of Education Among Women Age 65 or Over Enrolled in Medicare Managed Care
40
Less than High School
30
0
Non-Hispanic White
10
18
Non-Hispanic Black or
African American
Hispanic or Spanish
Non-Hispanic Asian or Pacific
Islander
American Indian or
Alaska Native
Race/Ethnicity
Per
cen
t R
epo
rtin
g
20
10
Less than 8th Grade37
20 19
11
23
29
24
27
NOTE: Non-Hispanic black or African American includes non-Hispanic natives of the Caribbean.
SOURCE: 1999 Medicare Health Outcomes Survey - Cohort 2 Baseline Measurement Data Set.
• Over one-half of non-Hispanic black/African American, Hispanic/Spanish, and American Indian/Alaskan Native women age 65 or over report less than a high school education.
• Over one-third of Hispanic/Spanish women age 65 or over enrolled in Medicare man-aged care report having an eighth grade education or less.
• One of every four non-Hispanic white women age 65 or over reports less than a high school education.
HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4 189
Figure 3
Ethnic Differences in the Proportion of Women Age 65 or Over Enrolled in Medicare Managed Care Reporting Fair or Poor Health
50 Fair or Poor Health
30
0
Non-Hispanic White
27
Non-Hispanic Black or
African American
Hispanic or Spanish
Non-Hispanic Asian or Pacific
Islander
American Indian or
Alaska Native
Race/Ethnicity
Per
cen
t R
epo
rtin
g
20
10
46
42
28
36 40
NOTES: Non-Hispanic black or African American includes non-Hispanic natives of the Caribbean. Results are age-adjusted.
SOURCE: 1999 Medicare Health Outcomes Survey - Cohort 2 Baseline Measurement Data Set.
• Overall slightly greater than one-quarter of all women in the survey reported being in fair or poor health.
• The proportion of women reporting fair or poor health varies significantly across the racial and ethnic groups identified in the survey.
• Non-Hispanic black/African American women are most likely to report fair or poor health.
• Non-Hispanic white and Non-Hispanic Asian/Pacific Islander women enrolled in Medicare managed care are least likely to report fair or poor health.
190 HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4
Figure 4
Proportion of Women Age 65 or Over Enrolled in Medicare Managed Care Reporting Fair or Poor Health, by Annual Income
50 Fair or Poor Health
30
0
Poor Less than $10,000
40
Low $10,000-$20,000
Middle $20,000-$30,000
Upper Middle $30,000-$50,000
High More than $50,000
Annual Household Income
Per
cen
t R
epo
rtin
g
20
10
31
24
19
15
40
NOTE: Results are age-adjusted.
SOURCE: 1999 Medicare Health Outcomes Survey - Cohort 2 Baseline Measurement Data Set.
• The proportion of women reporting that they are in fair or poor health declines with each increase in income level.
• Women reporting annual household incomes of less than $10,000 are more than twice as likely to report fair or poor health compared with women reporting annual household incomes of more than $50,000.
HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4 191
Figure 5
Proportion of Women Age 65 or Over Enrolled in Medicare Managed Care Reporting Fair or Poor Health, by Level of Education
50 Fair or Poor Health
30
0
45
35
25
15
5
Less than Eighth Grade
47
Some High School
High School or Graduate Equivalent
Degree
Some College
College Graduate
Education
Per
cen
t R
epo
rtin
g
20
10
38
26
21
16
40
NOTE: Results are age-adjusted.
SOURCE: 1999 Medicare Health Outcomes Survey - Cohort 2 Baseline Measurement Data Set.
• Nearly one-half of respondents with an eighth grade education or less report that they are in fair or poor health. These women are nearly three times most likely to report that they are in fair or poor health than women who are college graduates.
• For each increase in level of education there is a decline in the proportion of women reporting that they are in fair or poor health.
• Women who report having attended some college are more likely to report that they are in fair or poor health then those who are college graduates.
192 HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4
Figure 6
100
Arthritis
75
0
Non-Hispanic White
55 55
33
76
64
36
57 58
28
55
44
24
59 56
40
Non-Hispanic Black or
African American
Hispanic or Spanish
Non-Hispanic Asian or Pacific
Islander
American Indian or
Alaska Native
Per
cen
t R
epo
rtin
g
50
25
Hypertension
Cardiovascular Disease
Race/Ethnicity
Ethnic Differences in Self-Reported Prevalence of Common Chronic Conditions Among Women Age 65 or Over Enrolled in Medicare Managed Care
NOTES: Non-Hispanic black or African American includes non-Hispanic natives of the Caribbean. Results are age-adjusted.
SOURCE: 1999 Medicare Health Outcomes Survey - Cohort 2 Baseline Measurement Data Set.
• HOS data illustrate the high burden of chronic illness experienced by older women. • Hypertension and arthritis are the two most common chronic conditions reported by
older women in the survey. Over one-half of all women report having at least one of these conditions.
• Three of every four Non-Hispanic black/African American women report that a doctor has told them that they have high blood pressure or hypertension.
• Women of American Indian/Alaskan Native descent are most likely to report having been told by their doctor that they have cardiovascular disease.
HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4 193
Figure 7
70
40
0
60
50
30
61 60
36
59 57
34
55 55
32
51 52
31
47 51
29
Per
cen
t R
epo
rtin
g
20
10
Hypertension
Cardiovascular Disease
Poor Less than $10,000
Low $10,000-$20,000
Middle $20,000-$30,000
Upper Middle $30,000-$50,000
High More than $50,000
Annual Household Income
Self-Reported Prevalence of Chronic Conditions Among Women Age 65 or Over Enrolled in Medicare Managed Care, by Annual Income
NOTE: Results are age-adjusted.
SOURCE: 1999 Medicare Health Outcomes Survey - Cohort 2 Baseline Measurement Data Set.
• Lower income respondents report a significantly higher illness burden than their more affluent counterparts.
• Hypertension and arthritis are the two most common chronic conditions reported by older women in the survey irrespective of income.
• Over 60 percent of women who reported an annual income of less than $10,000 indicate that a doctor has told them that they have high blood pressure or hypertension. The pro-portion of women reporting this condition declines for each increase in income category.
• A similar pattern is observed for arthritis and cardiovascular disease across income categories.
194 HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4
Figure 8
Self-Reported Prevalence of Chronic Conditions Among Women Age 65 or Over Enrolled in Medicare Managed Care, by Level of Education
70
40
0
60
50
30
62 62
35
61 58
36
56 54
31
53 54
33
47
51
30
Per
cen
t R
epo
rtin
g
20
10
Hypertension
Cardiovascular Disease
Less than Eighth Grade
Some High School
High School or Graduate Equivalent
Degree
Some College
College Graduate
Education
NOTE: Results are age-adjusted.
SOURCE: 1999 Medicare Health Outcomes Survey - Cohort 2 Baseline Measurement Data Set.
• Respondents with a lower level of education report a significantly higher illness burden than respondents with higher levels of education.
• Over 60 percent of women who reported less than a high school education indicate that a doctor has told them that they have high blood pressure or hypertension. The proportion of women reporting this condition declines for each increase in educational level.
• Sixty-two percent of women with an eighth grade education or less report having arthritis compared with 51 percent of women who have graduated from college.
• Women with less than a high school education are more likely to report having cardiovascular disease than women who have graduated from high school.
HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4 195
Figure 9
Ethnic Differences in the Self-Reported Prevalence of Depressed Mood Among Women Age 65 or Over Enrolled in Medicare Managed Care
30 Depression
20
0
25
Non-Hispanic White
13
Non-Hispanic Black or
African American
Hispanic or Spanish
Non-Hispanic Asian or Pacific
Islander
American Indian or
Alaska Native
Race/Ethnicity
Per
cen
t R
epo
rtin
g
15
10
5
20
24
14
21
25
NOTES: Non-Hispanic black or African American includes non-Hispanic natives of the Caribbean. Results are age-adjusted.
SOURCE: 1999 Medicare Health Outcomes Survey - Cohort 2 Baseline Measurement Data Set.
• One of every seven women responded yes when asked if “In the past year, have you felt depressed or sad much of the time?”
• At least one in every five non-Hispanic black/African American, Hispanic/Spanish, and American Indian/Alaskan Native women age 65 or over report feeling depressed or sad much of the time.
196 HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4
Figure 10
Prevalence of Depressed Mood Among Women Age 65 or Over Enrolled in Medicare Managed Care, by Annual Income
25 Depression
15
0
Poor Less than $10,000
21
Low $10,000-$20,000
Middle $20,000-$30,000
Upper Middle $30,000-$50,000
High More than $50,000
Annual Household Income
Per
cen
t R
epo
rtin
g
10
5
16
12
9 8
20
NOTE: Results are age-adjusted.
SOURCE: 1999 Medicare Health Outcomes Survey - Cohort 2 Baseline Measurement Data Set.
• Lower income respondents report a significantly higher prevalence of depressed mood than their more affluent counterparts.
• Of women who reported an annual income of less than $10,000, 21 percent indicate that they felt depressed or sad much of the time in the passed year compared with 8 percent of women with annual household incomes more than $50,000.
• Women with annual incomes in the lower-middle category report a greater prevalence of depressed mood than women in higher income categories, but lesser prevalence of depressed mood than women in lower income categories.
HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4 197
REFERENCES
Cooper, J.K., Kohlmann, T., Michael, J.A., Haffer, S.C., et al.: Health Outcomes. New Quality Measure for Medicare. International Journal for Quality in Health Care 13(1):9-16, February 2001. National Committee for Quality Assurance: HEDIS®2000. Specifications for the Medicare Health Outcomes Survey. National Committee for Quality Assurance. Washington, DC. 2000. Stevic, M.O., Haffer, S.C., Cooper, J.K., et al.: How Healthy Are Our Seniors? Baseline Results from the Medicare Health Outcomes Survey. Journal of Clinical Outcomes Management 7(8):39-42, August 2000.
Reprint Requests: Samuel C. Haffer, Ph.D., Centers for Medicare & Medicaid Services, Office of Clinical Standards and Quality, 7500 Security Boulevard, S3-02-01, Baltimore, MD 21244-1850. E-mail: hos@cms.hhs.gov
198 HEALTH CARE FINANCING REVIEW/Summer 2001/Volume 22, Number 4
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