It is a widespread belief that poor people get worse health care, and some studies have suggested that being uninsured or on Medicaid results in poorer quality hospital care. Other studies, however, have suggested that this is due more to the characteristics of the hospitals which treat more poorer patients than to insurance status or income. New research published in Health Affairs focuses on quality differences within the same hospital for varying classes of patients. (Health Affairs Article) Quality could vary within the same facility if lower payments led to less resource use for the patients covered by those lower payments or to less use of newer, more expensive treatments. It could also be the attending physicians for some classes of patients are less skilled and competent. And payer-specific quality improvement programs may differ among payers and may not affect the care of uninsured patients. The researchers looked at hospitalizations from 2006-2008 in eleven states. They looked at mortality rates for eight surgical procedures and seven medical conditions across Medicare, Medicaid, private insurance, self and no-pay and other, which included TriCare, workers’ compensation, etc. While overall the results suggested that Medicaid and self or no-pay patients had higher mortality, there were a number of cases in which private patients or Medicare patients actually showed worse outcomes by this limited measure, including on some of the most common medical conditions. The authors appear to have really strained to make the analysis fit their bias. It should be noted that the study has serious limitations, including sample sizes and the reliance on one limited quality measure. A better study would look more specifically at a large number of process and ultimate outcome measures and would ensure that all relevant patient and physician characteristics are accounted for before drawing any conclusions about the effect of payer type.
