Quality of Care May Vary Within a Hospital by Insurance Type

Marcia Frellick

October 08, 2013

New data indicate that the quality of care patients receive in a given hospital may be linked to the type of insurance they have, and Medicare patients, researchers say, may be particularly at risk for lower-quality care.

Christine S. Spencer, ScD, an associate professor in and executive director of the School of Health and Human Services in the College of Public Affairs, University of Baltimore, Maryland, and colleagues used the Agency for Healthcare Research and Quality's Inpatient Quality Indicators and applied them to 2006-2008 State Inpatient Database records from 1601 hospitals in 11 states.

The results of the study were published in the October issue of Health Affairs.

The authors examined the risk-adjusted mortality rates for 8 surgical procedures and 7 medical conditions and then compared the rates by patients' insurance status and type of insurance. They found that privately insured patients had lower rates in 12 of the 15 procedures or conditions.

For example, for hip fractures, Medicare patients had, on average, 5.85 more deaths per 1000 patients than privately insured patients at the same hospital. Mortality rates among Medicare patients were 104% higher than that for private insurance for hip replacements and 102% higher for esophageal resection.

With stroke, congestive heart failure, and pneumonia, privately insured patients fared worse than those in other categories. In the case of stroke, for example, there were an average of 9.08 fewer deaths per 1000 patients among Medicaid patients in comparison with privately insured patients at the same hospital.

Questions raised by the researchers include why there were differences that varied by payer for patients in the same hospital undergoing the same procedure, how the differences manifest themselves in a patient's care, whether privately insured patients have more access to cutting-edge technology or more individual care from physicians, and whether coding differences could explain discrepancies. For example, hospitals may have a financial incentive to report comorbidities that existed before hospitalization.

The authors note that the Affordable Care Act has taken a big step toward insurance for all but add that these findings suggest that policymakers will need to further examine why patients' quality of care differs across payers.

The researchers encourage requiring hospitals to report outcomes by payer status on quality performance scorecards to elevate transparency and higher-quality care.

Health Aff. 2013;32:1731-1739. Abstract

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