Bruce E Landon1,2, Jukka-Pekka Onnela3, Laurie Meneades1, A James O'Malley4,5, Nancy L Keating1,6. 1. Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts. 2. Division of General Internal Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts. 3. Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts. 4. The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. 5. Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. 6. Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Abstract
Importance: Disparities in quality of care according to patient race and socioeconomic status persist in the US. Differential referral patterns to specialist physicians might be associated with observed disparities. Objective: To examine whether differences exist between Black and White Medicare beneficiaries in the observed patterns of patient sharing between primary care physicians (PCPs) and physicians in the 6 specialties to which patients were most frequently referred. Design, Setting, and Participants: This cross-sectional observational study of Black and White Medicare beneficiaries used claims data from 2009 to 2010 on 100% of traditional Medicare beneficiaries who were seen by PCPs and selected high-volume specialists in 12 health care markets with at least 10% of the population being Black. Statistical analyses were conducted from December 20, 2017, to September 30, 2020. Exposures: Differences in patterns of patient sharing among Black and White patients. Main Outcomes and Measures: Primary care physician and specialist degree (the number of other PCPs or specialists to whom each physician is connected) and strength (the number of shared patients per connection, overall, for Black patients and White patients and after equalizing the numbers of Black and White patients per PCP), as well as distance between PCP and patient and specialist zip code centroids. Results: The 12 selected markets ranged in size from Manhattan, New York (187 054 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 9794 total physicians), to Tallahassee, Florida (44 644 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 847 total physicians). The percentage of Black beneficiaries ranged from 11.5% (Huntsville, Alabama) to 46.8% (Chicago, Illinois). The mean PCP-specialist degree (number of specialists with whom a PCP shares patients) was lower for Black patients than for White patients. For instance, the mean PCP-cardiologist degree across all markets for White patients was 17.5 compared with 8.8 for Black patients. After sampling White patients to equalize the numbers of patients seen, the degree differences narrowed but were still not equivalent in many markets (eg, for all specialties in Baton Rouge, Louisiana: 4.5 for Black patients vs 5.7 for White patients). Specialist networks among White patients were much larger than those constructed based just on Black patients (eg, for cardiology across all markets: 135 for Black patients vs 330 for White patients), even after equalizing the numbers of patients seen per PCP (123 for Black patients vs 211 for White patients). The overall test for differences in referral patterns was statistically significant for all 6 specialties examined in 7 of the 12 markets and in 5 specialties for another 3. Conclusions and Relevance: This study suggests that differences exist in specialist referral patterns by race among Medicare beneficiaries. This is an observational study, and thus some differences might have resulted from patient-initiated visits to specialists.
Importance: Disparities in quality of care according to patient race and socioeconomic status persist in the US. Differential referral patterns to specialist physicians might be associated with observed disparities. Objective: To examine whether differences exist between Black and White Medicare beneficiaries in the observed patterns of patient sharing between primary care physicians (PCPs) and physicians in the 6 specialties to which patients were most frequently referred. Design, Setting, and Participants: This cross-sectional observational study of Black and White Medicare beneficiaries used claims data from 2009 to 2010 on 100% of traditional Medicare beneficiaries who were seen by PCPs and selected high-volume specialists in 12 health care markets with at least 10% of the population being Black. Statistical analyses were conducted from December 20, 2017, to September 30, 2020. Exposures: Differences in patterns of patient sharing among Black and White patients. Main Outcomes and Measures: Primary care physician and specialist degree (the number of other PCPs or specialists to whom each physician is connected) and strength (the number of shared patients per connection, overall, for Black patients and White patients and after equalizing the numbers of Black and White patients per PCP), as well as distance between PCP and patient and specialist zip code centroids. Results: The 12 selected markets ranged in size from Manhattan, New York (187 054 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 9794 total physicians), to Tallahassee, Florida (44 644 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 847 total physicians). The percentage of Black beneficiaries ranged from 11.5% (Huntsville, Alabama) to 46.8% (Chicago, Illinois). The mean PCP-specialist degree (number of specialists with whom a PCP shares patients) was lower for Black patients than for White patients. For instance, the mean PCP-cardiologist degree across all markets for White patients was 17.5 compared with 8.8 for Black patients. After sampling White patients to equalize the numbers of patients seen, the degree differences narrowed but were still not equivalent in many markets (eg, for all specialties in Baton Rouge, Louisiana: 4.5 for Black patients vs 5.7 for White patients). Specialist networks among White patients were much larger than those constructed based just on Black patients (eg, for cardiology across all markets: 135 for Black patients vs 330 for White patients), even after equalizing the numbers of patients seen per PCP (123 for Black patients vs 211 for White patients). The overall test for differences in referral patterns was statistically significant for all 6 specialties examined in 7 of the 12 markets and in 5 specialties for another 3. Conclusions and Relevance: This study suggests that differences exist in specialist referral patterns by race among Medicare beneficiaries. This is an observational study, and thus some differences might have resulted from patient-initiated visits to specialists.
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