Despite relatively adequate insurance, some people do not seek or do not receive preventive or necessary care for their chronic or acute conditions and therefore are at risk for avoidable (bad) outcomes from treatable conditions. And there are risk factors for underusing health care, such as poverty and minority group status.

But in order to determine who is not receiving necessary care, health care providers must a) define what that necessary care is for specified conditions, b) be able to track utilization of such care in a low cost way, and c) identify populations with abnormally high bad outcomes -- indicating they did not receive the necessary care.

Researchers from the RAND Corporation and the Veterans Affairs Department have tested such a quality monitoring system. They compared Medicare claims data on 345,000 patients with a set of 37 indicators chosen by an expert panel for a number of chronic and acute conditions, such as diabetes, stroke, heart disease and cancer.

• For 14 of the 37 recommended procedures, they found that less than two-thirds of Medicare beneficiaries received them, including diagnostic tests and hospitalization.

• For instance, fewer than two-thirds of white breast cancer patients received annual mammograms, and fewer than half of diabetics (who are prone to eye problems) received annual vision tests.

• Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; and residents of mostly rural Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none.

An editorial on the study notes, "The findings underscore the fact that lack of insurance is not the only reason that minorities and the poor have more problems than others accessing necessary medical care."

Source: Steven M. Asch, et al., "Measuring Underuse of Necessary Care Among Elderly Medicare Beneficiaries Using Inpatient and Outpatient Claims"; Edward L. Hannan, "The Continuing Quest for Measuring and Improving Access to Necessary Care," Editorial, both Journal of the American Medical Association, November 8, 2000.

For study text http://jama.ama-assn.org/issues/current
/rfull/joc00215.html

For JAMA editorial http://jama.ama-assn.org/issues/current
/ffull/jed00077.html