Disparities in Quality of Care among Publicly Insured Adults with Schizophrenia in Four Large U.S. States, 2002–2008

It has been a decade since the Institute of Medicine published its report Unequal Treatment on racial/ethnic disparities in health in the United States (Smedley, Stith, and Nelson 2003). Substantial effort has been devoted to documenting racial/ethnic disparities and understanding their causes. Disparities among people with schizophrenia further burden a severely ill and disabled population whose quality of care is undermined by underuse of evidence-based practices and overuse of low-value or unsupported practices (U.S. Department of Health and Human Services 2003; Horvitz-Lennon et al. 2009a). Racial/ethnic disparities in schizophrenia care have been documented, but little research exists on Latino-white disparities (Vega et al. 2007). Furthermore, most studies have focused on one or a small number of interventions (Barrio et al. 2003; Kreyenbuhl et al. 2003; Leslie and Rosenheck 2004), and although some evidence exists on longitudinal trends (e.g., Busch et al. 2009) it pertains to earlier time periods. Last, although there is evidence of variations in racial/ethnic disparities in health care across regions (Fisher, Goodman, and Chandra 2008), we are not aware of studies that have investigated geographic variations in disparities in schizophrenia care. These knowledge gaps limit our ability to guide policy and improve clinical practice and outcomes (Zaslavsky and Ayanian 2005). We examined whether a comprehensive measure of quality of mental health care differed for black, Latino, and white Medicaid beneficiaries in four large states that contribute about one-third of all Medicaid beneficiaries. We also examined whether overall quality and disparities in quality changed over time, and whether disparities in quality of care differed among the states. We focused on Medicaid beneficiaries because of the dominant role played by Medicaid as health care payer for people with schizophrenia in the United States (Frank and Glied 2006). We hypothesized that (1) racial/ethnic disparities in quality of care exist in all study states; (2) the size of the disparity varies across the study states; and (3) disparities have not improved meaningfully over time.