Using historical data from a federal survey, this study found that blacks and Hispanics both would have a lower likelihood of being eligible for MTM than would whites according to 2006 criteria and 2010 criteria. Using 2006 data after MTM implementation, similar disparity patterns were found, although some disparity findings were not significant because of inadequate statistical power. Because the MTM eligibility criteria are predominantly based on the use of prescription drugs and health services, these study findings are consistent with previous literature that reported that minorities use fewer prescription drugs and health services than do whites (Briesacher, Limcangco, and Gaskin 2003
; Schore, Brown, and Lavin 2003
; Wang et al. 2006
Andersen's Behavioral Model of Health Services Utilization seems to be a reasonable model to use for this study. For example, in the main analysis in , the significant variables included predisposing factors (non-Hispanic blacks, Hispanics, and male), enabling factors (with Medicaid), and need factors (self-perceived good, fair, and poor health status, disability eligibility). Previous literature has reported various causes for the lower utilization of health services and pharmaceutical products among minorities than among whites. These causes can again be summarized as predisposing, enabling, and need factors (e.g., Briesacher, Limcangco, and Gaskin 2003
; Wang et al. 2006
). Regardless of the causes for the lower utilization among racial and ethnic minorities, because MTM eligibility criteria are predominantly based on utilizations, our study found that there would be a lower likelihood of meeting MTM eligibility criteria among racial and ethnic minorities than among whites. Andersen's Behavioral Model of Health Services Utilization then further reminds us that, because of the would-be lower likelihood of meeting eligibility criteria among minorities than among whites, minorities may have lower likelihood of enjoying improved patient satisfaction and improved health outcomes from the use of MTM services compared with whites. The findings of this study have wider implications than Medicare because health plans that offer MTM services also include state Medicaid programs and self-insured employers (Schommer et al. 2008
). As the government agency that administers both Medicare and Medicaid, CMS has great influence on all other payers.
MTM is one example of value-based strategies, which are typically based on economic evaluations that do not usually incorporate the distributional effects or equity concerns of the strategies. Equity-efficiency dilemma has characterized the health care systems that formally include economic evaluation in their decision-making processes (Sassi, Le Grand, and Archard 2001
). One example of these systems is the British National Health Service (NHS) (Sassi, Le Grand, and Archard 2001
). It has been reported that policies to improve economic efficiency are often in direct conflict with the equity doctrine on which the NHS was founded (Sassi, Le Grand, and Archard 2001
). There have been few studies on equity concerns of specific value-based strategies in the United States partly because value-based strategies are not common in the United States (Neumann 2005
). With the ever-increasing burden of the health care budget, the United States may need to use more value-based strategies in the future.
A health care environment conducive to equal access is pivotal for eliminating health disparities, one of the two overarching goals of Healthy People 2010
(U.S. Department of Health and Human Services 2000
). The U.S. government's commitment to eliminate racial and ethnic disparities is all the more justified because of the increasing proportion of the minority populations in the United States. According to the U.S. Census Bureau, 40 percent of the elderly population in the United States will be persons of color by 2050, while this proportion was only 20 percent in 2000 (U.S. Census Bureau 2008
According to a widely cited framework for the causes of racial and ethnic disparities, if certain systems or policies cause racial and ethnic disparities, these systems and policies are classified as institutionalized causes for disparities (Jones 2000
). Researchers previously have examined institutionalized causes for racial and ethnic disparities in health status. For example, Williams and Collins (2001)
suggested that residential segregation determines access to education and employment opportunities and, in turn, creates conditions inimical to health in the physical and social environment.
In this study, we found that, among individuals with severe health problems, blacks and Hispanics still would have a lower likelihood of meeting MTM eligibility criteria than would whites, suggesting further urgency of changing the existing eligibility criteria for MTM. Regarding the previous literature related to the disparities for needy situations, Wang et al. (2006)
found that blacks used fewer essential new medications than did whites. The researchers defined new medications as those in the market <5 years and essential drugs as those whose use can prevent worsening medical conditions, hospitalization, or mortality.
Our study findings were based on historical data, and the disparity implications of the MTM eligibility criteria were based on simulation. Therefore, future studies are warranted to confirm our findings using data after MTM implementation. Additionally, this study aimed to determine the would-be disparities in meeting eligibility criteria. Further research should examine whether the proportions of accepting the services differ across racial and ethnic groups when these services are actually offered to patients. This study examined only whether there would be disparities in meeting MTM eligibility criteria but did not determine effective measures to eliminate disparities. Strategies for eliminating disparities in meeting MTM eligibility criteria have national policy implications, so such strategies should be subject to more comprehensive tests.
The merits of this study come with several limitations. First of all, the target population for MEPS is noninstitutionalized civilians, so the study findings may not be generalizable to other populations such as individuals living in nursing homes. Additionally, MEPS data are mainly self-reported and have the potential for error during data collection, editing, and imputation. However, MEPS represents a significant improvement in the quality of pharmacy data over most other surveys, because it also collects information from pharmacy providers frequented by survey respondents, a step rarely taken in other surveys (Agency for Healthcare Research and Quality 2009
). MEPS data are frequently used in important studies and federal reports (Agency for Healthcare Research and Quality 2005
). When determining MTM eligibility, we have included all drugs rather than only Part D drugs; without a universal list of chronic conditions used by Part D plans, we used 25 medical conditions devised by Daniel and Malone (2007)
. All these strategies, although well thought through, may have caused some inaccuracy in the estimation of would-be disparities. Nonetheless, the internal validity of this study is boosted because the eligibility thresholds for the MTM criteria are clearly defined, and our findings on racial and ethnic disparities are rather robust. Additionally, this study had similar findings as a CMS report on the proportions of individuals eligible for MTM. According to the main analysis for 2006 thresholds, the proportions of eligible individuals represent approximately 10 percent for each racial and ethnic group. Although these are would-be proportions, they are consistent with the CMS report on the proportion of MTM enrollees among the Part D beneficiaries in 2006 (CMS 2008
). This consistency attests to the reliability of our findings.