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Data Highlight | Volume 11 - December 2017


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Mapping Medicare Disparities

Volume 11 - December 2017

Racial and Ethnic Disparities in Mental Health Among Diverse Groups of Medicare Advantage Beneficiaries

Judy Ng, Qian Zhang, Sarah Hudson Scholle, and Paul Guerino

Key Findings:
  • Relative to other races, American Indian and Alaska Native as well as Native Hawaiian or Other Pacific Islander (NHOPI) beneficiaries generally reported worse mental health status across multiple indicators related to depression and depression symptoms, days of activities missed because of poor physical and mental health, and mental health functioning.
  • Among all ethnicities, multiethnic Hispanic beneficiaries generally reported worse mental health status than non-Hispanic beneficiaries or those reporting a single ethnicity.
  • There were considerable variations within Asian and NHOPI race groups, with some detailed Asian and NHOPI groups reporting results notably different than the larger group. Important variations were also observed among Hispanic ethnicities.
  • Despite some exceptions, particularly among smaller racial or ethnic groups, the majority of observed differences were significant.
  • The findings suggest that viewing results for only larger race or ethnicity groups – such as all Asians, all NHOPI, or all Hispanic beneficiaries – may obscure important detailed group differences, reinforcing the importance of reporting more granular data.
smiling couple

Data Source: Medicare Health Outcomes Survey (HOS), 2014-2016 Baseline

Introduction

The U.S. Census Bureau estimates that by 2060, the racial and ethnic minority population in the U.S. is projected to rise to 56 percent of the total population, up from 38 percent in 2014.1,2 By 2050, 39 percent of the older population (65 years of age and older) is projected to be a minority, up from 21 percent in 2012.1,2 Medicare beneficiaries who are racial and ethnic minorities face persistent health disparities, including disparities in numerous patient-reported outcomes that have long been used as quality indicators – from experiences with care to functional health status.3,4,5 As racial and ethnic minorities become a greater proportion of the U.S. population, the importance of addressing these disparities in the Medicare population will only continue to grow.

Despite these important demographic changes, there are limited national-level data on how patient-reported physical and mental health functioning varies across many racial and ethnic groups, particularly smaller racial and ethnic groups. Previous studies on racial and ethnic disparities in Medicare have focused on differences between Black and White beneficiaries, and to some extent have included Hispanic beneficiaries.6 Studies do not consistently compare all three of these groups, and smaller racial and ethnic groups may be excluded entirely because of sample size limitations.6

This data highlight presents findings from the Medicare Health Outcomes Survey (HOS) using pooled data from the three most recent fielded baseline surveys: Cohorts 17, 18, and 19 (2014-2016). The collection of race and ethnicity data in the HOS makes it possible to examine both the physical and mental health outcomes of beneficiaries from many smaller racial and ethnic groups, including those who self-identify as American Indians or Alaska Natives (AI/AN), Asians, and Native Hawaiian or Other Pacific Islanders (NHOPI).

Fielded annually since 1998, the HOS collects self-reported health status information at baseline and follow-up from a nationally representative sample of Medicare Advantage (MA; i.e., Part C or Medicare Managed Care) beneficiaries. These data have been used to assess changes in the physical and mental health outcomes, and health-related quality of life, of MA beneficiaries over time. In 2013, the HOS became the first large scale Centers for Medicare & Medicaid Services (CMS) survey to collect data using the expanded, detailed race and ethnicity categories in the Department of Health and Human Services (HHS) data collection guidelines.7 The HOS also continues to gather data on a number of key indicators related to self-reported mental health status: receipt of a diagnosis of depression, reporting of a positive depression screen (based on depression symptoms), days of activities missed due to poor physical and mental health, and the Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS)—a 0-100 standardized score that reflects mental health functioning. These mental health indicators are of special salience in Medicare populations because of the under-diagnosis of depression among older adults.8,9

A prior HOS data brief examined the physical health status of Asians and NHOPI, using expanded categories of race and ethnicity.10 (For further details on the expanded categories of race and ethnicity, please refer to the “Definitions” section in the .pdf file). Building on this prior work, the current analysis uses the expanded categories to describe racial and ethnic differences in the mental health status of Medicare Advantage beneficiaries across many smaller racial and ethnic groups. For each racial and ethnic group, results are reported as percentages (for receipt of depression diagnosis and positive depression screen) or averages (for average number of days of activities missed and average VR-12 MCS). The results reflect all respondents, regardless of age and disability. For all comparisons of differences between racial and ethnic groups, a Bonferroni correction was used to interpret P values.

References

  1. Colby, Sandra L., and Jennifer M. Ortman. (2015, March). "Projections of the Size and Composition of the U.S. Population: 2014 to 2060." Retrieved from https://www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf (accessed May 18, 2017).
  2. U.S. Census Bureau, Fueled by Aging Baby Boomers, Nation’s Older Population to Nearly Double in the Next 20 Years, Census Bureau Reports. 2014. https://www.census.gov/newsroom/press-releases/2014/cb14-84.html (accessed May 18, 2017).
  3. Agency for Healthcare Research and Quality, 2015 National Healthcare Quality and Disparities Report and 5th Anniversary Update on the National Quality Strategy. Rockville, MD, 2016, https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr15/2015nhqdr.pdf (accessed May 18, 2017).
  4. CMS Office of Minority Health in collaboration with the RAND Corporation, Racial and Ethnic Disparities in Health Care in Medicare Advantage. Baltimore, MD, 2016. https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Stratified-Reporting-2016-National-Level-Results.pdf (accessed May 18, 2017).
  5. CMS Office of Minority Health in collaboration with the RAND Corporation, Gender Disparities in Health Care in Medicare Advantage. Baltimore, MD, 2017. https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Health-Disparities-Gender-Disparities-National-Report.pdf (accessed May 18, 2017).
  6. Ng, Judy H., Arlene S. Bierman, Marc N. Elliott, Rachel L. Wilson, Chengfei Xia, and Sarah Hudson Scholle. "Beyond Black and White: Race/Ethnicity and Health Status among Older Adults." The American Journal of Managed Care 20, no. 3 (2014):239-248.
  7. Office of the Assistant Secretary for Planning and Evaluation. U.S. Department of Health & Human Services, U.S. Department of Health and Human Services Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. 2011. https://aspe.hhs.gov/basic-report/hhs-implementation-guidance-data-collection-standards-race-ethnicity-sex-primary-language-and-disability-status (accessed May 18, 2017).
  8. Luppa, M. C., Sikorski, T. Luck, L. Ehreke, A. Konnopka, B. Wiese, S. Weyerer, H.-H. König, and S.G. Riedel-Heller. "Age- and gender-specific prevalence of depression in latest-life – Systematic review and meta-analysis." Journal of Affective Disorders 136, no. 3(2012): 212-221.
  9. Centers for Disease Control and Prevention and National Association of Chronic Disease Directors. The State of Mental Health and Aging in America. Issue Brief 1: What Do the Data Tell Us? Atlanta, GA: National Association of Chronic Disease Directors, 2008. https://www.cdc.gov/aging/pdf/mental_health.pdf (accessed May 20, 2017).
  10. CMS Office of Minority Health, Medicare Health Outcomes Survey Data Brief: Asian Americans and Pacific Islanders. Baltimore, MD, 2015. http://www.hosonline.org/globalassets/hos-online/publications/omh_aapi_data_brief_2015.pdf  (accessed May 18, 2017).
  11. American Psychology Association. Patient Health Questionnaire (PHQ-9 & PHQ-2). http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health.aspx (accessed May 18, 2017).
  12. Schalet, Benjamin D., Nan E. Rothrock, Ron D. Hays, Lewis E. Kazis, Karon F. Cook, Joshua P. Rutsohn, and David Cella. "Linking physical and mental health summary scores from the Veterans RAND 12-Item Health Survey (VR-12) to the PROMIS Global Health Scale." Journal of General Internal Medicine 30 (2015): 1524-1530.
  13. Adults: United States, 2010-2014. Atlanta, GA: Centers for Disease Control and Prevention, 2016. https://www.cdc.gov/nchs/products/databriefs/db247.htm (accessed May 21, 2017).


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