Segregated Patterns of Racial and Socioeconomic Inclusivity of Access to Hospital Care Among the Medicare Population

Abstract

AbstractBackgroundA hospital-level metric of inclusion is defined, which measures disparities in hospitalizations by race and socioeconomic status. This measure can help frame research agendas around inequities in health care and guide policy.The primary objective was to quantify, for each US hospital in our sample, the difference in the patient population and the surrounding area measured by income level, education level, and racial groups. The secondary objective was to assess the associations of these inclusivity metrics with hospital characteristics.MethodsCross sectional observational study using MEDPAR claims data for calendar year 2018 involving inpatient admissions to non-specialty, non-federal hospitals of Medicare fee-for-service beneficiaries over the age of 65 years. A community area radius was calculated for each hospital based on their patient counts from surrounding zip codes. The main outcome was a difference metric between the patient demographics and the demographics of the zip codes in the community area. Hospital characteristics associated with the lowest and highest scores were reported using quantile regressions.ResultsThere were 4,230,080 patients included in the sample at 3,548 hospitals. The median community area (CA) radius was 24.7 miles, contributing 90.1% of a hospital’s total number of patients. Estimated median incomes for hospital patients’ zip codes ranged from $26,805 less than their CA zip codes to $29,041 more. Education differences varied by approximately one level of attainment in each direction. The widest percentage differences in racialized groups between hospital patient zip codes and CA codes were for Black and African American populations, which varied from 39.2% greater than the CA to 30.6% less than the CA. Metro areas, larger hospitals and major teaching hospitals were more likely to be found in the highest inclusivity scores and also in the lowest. Some Hospital Referral Regions had wide differences in inclusivity scores, indicating patterns of localized segregation in hospital utilization among Medicare beneficiaries. Safety net hospitals consistently were more inclusive.Conclusions and RelevanceRace and class inclusivity of US hospitals varies widely, with larger metro areas and teaching hospitals showing the widest patterns of segregation. Safety net hospitals overperform in both urban and rural settings, providing an essential social service of socioeconomic inclusivity.