Racial differences in low value care among older adult Medicare patients in US health systems: retrospective cohort study

Principal findings

In this analysis of Medicare patients attributed to US health systems, a range of <1% to 37% of eligible patients received each the 40="40" low value services examined>

Strengths and weaknesses

This study examines racial differences in low value care use across a large number of low value services with a range of impacts on spending and patient harms,39 and examines the role of health systems in these differences. These results build on previous research that found reduced risk of low value cervical cancer screening among Black US veterans13 and Medicare patients.11 Similar to the findings of Schpero and colleagues (2006-11 data),11 we found Black patients with advanced dementia were at higher risk of receiving feeding tubes. However, unlike Schpero, we found that Black patients experienced no significant difference in vitamin D screening, lower risk of antipsychotic use in dementia, and higher risk of imaging for low back pain.

The study has several limitations. The 40 services examined represent a fraction of all low value care, and claims data lack clinical details to confirm clinician intent.47 Potential for bias exists if misclassification of low value care eligibility varies systematically by race. We also acknowledge important methodological debate in choice of model covariates.4344 Our data are from 2016 to 2018, and differences in low value care use might have changed since then. The study focuses on patients attributed to larger US health systems, therefore our results might not generalize to patients attributed to small systems or to those who are not attributed to health systems—who might receive low value care at slightly higher rates.48 However, we note that Black and White patients had similar likelihood of being attributed to the included systems (when applying our cohort criteria to Medicare patients before and after system attribution, Black patients made up 6.9% of all patients and 6.4% of all attributed patients). Similarly, our results might not generalize to the growing share of older adults enrolled in Medicare Advantage or to other populations.29

Our intention in this study was to generate hypotheses; underlying mechanisms should be explored in future research. We did not involve the public in shaping study questions and interpretation, which will be critical for future studies. Future quantitative and qualitative work might also assess low value care receipt among other racial groups, examine the role of health system characteristics in inequities, explore the association between high value and low value care, and study positive outliers in net care value to identify best practices.

Study meaning

Although the racial differences we found were heterogeneous and generally modest, they varied by low value service category in informative ways. These patterns suggest hypotheses about possible mechanisms at individual, interpersonal, and structural levels that can inform low value care reduction efforts more broadly.

Black patients were at slightly (one to twofold) greater risk of receiving several low value acute diagnostic tests. At the individual level, mistrust in the healthcare system because of historical and present day racism4950 might contribute to Black adults being more receptive to diagnostic testing when acutely ill—in this scenario, it is possible that a tangible test is more reassuring than a clinician’s words and might serve to lessen valid concerns about undertreatment. Mistrust, and structural factors such as access barriers, might also result in care seeking delays, so that Black adults are sicker when they present with acute conditions, potentially leading clinicians to order more low value tests.

At an interpersonal level, clinicians’ implicit or explicit biases51 and patient-clinician racial discordance5253 might contribute to clinician misperceptions of patient needs, less effective communication, and in turn, greater clinical uncertainty54 that prompts more testing.555657 In a similar vein, we found Black patients with advanced dementia were more likely to receive feeding tubes, mirroring evidence that patients from racial and ethnic minority groups were more likely to receive high cost, aggressive interventions at the end of life.255859 These findings may be due to patients in racial and ethnic minority groups having fewer treatment limitations in place (eg, do not resuscitate orders), more severe illness, or different end-of-life preferences.5758 At a structural level, these results might reflect decades of structural racism resulting in racially segregated neighborhoods and lower density of primary care clinics and high quality urgent care centers60 in predominantly Black neighborhoods compared with White neighborhoods. Despite our finding that Black patients had a larger share of visits with primary care or advanced practice clinicians, they are less likely to have a regular primary care clinician2861 (who might appropriately triage them away from the emergency department) and might be more likely to receive acute care from urgent care or emergency medicine clinicians who do not know them well,2762 potentially contributing to more acute diagnostic testing.63 This low value acute diagnostic testing affects recipients through direct harms (eg, radiation exposure, treatment burden, and out-of-pocket spending)64 and through downstream care cascades that can often arise from imaging tests in particular.6566

In contrast to our finding that Black patients received more low value acute services, White patients received one to threefold more of most low value screenings examined. At the individual level, it is possible that White patients are more likely to request or agree to screening services if relative privilege and the racial opportunity gap augment their perceived benefit of such services compared with Black patients.67 At an interpersonal level, clinicians might be more likely to offer screening services to White patients because of implicit biases. Some racial differences could be explained by socioeconomic differences, as suggested by our finding that the greater risk of low value prostate specific antigen testing in White men compared with Black men was diminished when controlling for a poverty indicator. At a structural level, Black patients have less access to routine, timely primary care (despite our finding that Black patients had a larger share of visits with primary care doctors or advanced practice clinicians).22286168 For instance, Black Medicare patients are less likely to receive annual wellness visits2268 and use disproportionately more emergency department and inpatient care relative to ambulatory care.2769 Unfortunately, lower rates of low value screening among Black patients parallels lower rates of high value screening, such as age appropriate colorectal cancer screening.70 Most notably, higher rates of prostate cancer incidence and death among Black men71 could arguably justify higher rates of low value prostate cancer screening in this population, but Black men were instead less likely than White men to receive this service. Finally, White patients were at slightly (one to threefold) higher risk of receiving eight of 12 examined low value treatments, such as antibiotics for acute upper respiratory tract and ear infections. These findings might reflect White patients being more likely to request treatments, or clinicians being more inclined to offer them to White patients, partly because of implicit, historically rooted power differentials.7273

Our exploratory examination of race and sex interactions revealed some substantial differences in low value care receipt across sex-race groups. Hypotheses that might explain these patterns would be speculative, but we believe these findings merit further examination in future studies.

Examining the role of health systems, we found racial differences in receipt of low value care were driven less by Black and White patients receiving care in different systems, and more by differential treatment within systems (eg, through services directly provided by in-system primary care and specialist clinicians, or through referrals19), consistent with previous evidence of stronger within-system racial inequalities in care quality measures.9 The most notable exception to this was prostate specific antigen testing—health systems serving larger proportions of Black patients offered more low value prostate specific antigen tests to all of their patients, perhaps in response to higher rates of prostate cancer among Black men. However, within any given system, White patients were still more likely to get the service. Studies have revealed that hospitals or practices that predominantly serve patients from racial and ethnic minority groups provide lower care quality for all of their patients,212223 but we did not find clear evidence of this in our study.

Conclusions

Low value care is problematic, not only because of direct and cascading harms to patients,1439 but also because it diverts limited resources, contributing to underuse of effective care especially among racial and ethnic minority populations. In general, we found Black patients were at modestly greater risk of receiving low value acute diagnostic tests commonly performed in acute care settings, while White patients were at modestly greater risk of receiving low value screening services and treatments. Even small differences might be clinically important because of the direct and indirect effects of low value care, while the patterns across service categories suggest hypotheses about underlying mechanisms. We also found that these differences result almost entirely from differential care delivered within systems. Taken together, these results invite further exploration of differential access by race to routine, high value primary care, patient-clinician concordance, and trust. Our findings also highlight the need to develop and test effective interventions to reduce low value services, especially those with greatest potential impact (ie, based on numbers of people affected, direct and cascading costs, and likelihood of other harms).39 Health systems invested in reducing low value care and promoting health equity could begin by measuring low value service use internally overall, and by race and sex, in line with a recent Joint Commission mandate to report care quality data stratified by demographic categories.74 Such efforts might allow systems to identify and address underlying sources of racial differences; for example, clinician-patient interactions (bias, mistrust) or structural issues (access to high quality primary care or differential referral patterns). Granular, population stratified analyses within health systems are increasingly feasible with the use of electronic health record data, and will likely be essential to advancing equitable, high value care for all.