WASHINGTON, Nov. 21 (UPI) -- Compared to patients with private insurance, Medicaid patients with coronary conditions receive inferior care across the spectrum of services, placing their health in jeopardy, a new study says, but the reason for the disparity is still not clear.
"When you look at everything together -- drugs, procedures, discharge instructions -- we see that systematically (Medicaid patients) are always under," said James Calvin, director of cardiology at Rush University Medical Center and lead author of the study appearing in the Tuesday volume of the Annals of Internal Medicine.
The study of 96,000 coronary patients at 521 hospitals across the country found that patients insured by Medicaid, the joint federal-state program for low-income families and disabled people, were less likely than members of HMOs and private insurance to receive critical basic care recommended by the American College of Cardiology and American Heart Association to prevent heart attacks.
That care includes recommended medications within the first 24 hours, medications and dietary advice to control cholesterol levels, counseling to stop smoking, and cardiac rehabilitation programs.
As a result, the in-hospital mortality rate for Medicaid patients was 2.9 percent -- more than twice the rate for the privately insured population, the study found, even after the researchers took into account hospital type and geographic region.
"These things start to add up and suddenly there's a big difference," Calvin told United Press International. "The effect on the individual patient could be quite profound."
The precise workings of the relationship between insurance type and the decreased care are not known, however, Calvin said.
Medicare, the federal insurance program for seniors, had outcomes similar to private insurance in the study, indicating that government involvement may have little to do with the discrepancy.
The problem is also unlikely to be doctors consciously giving better care to privately insured patients, or doctors staying away from care they feel low-income patients cannot afford, Calvin said. "On the surface people may conclude that doctors have a bias against poor people. However, it doesn't cost a thing to tell someone to watch the salt in their diet or to quit smoking, which is really good advice to reduce heart problems."
One possible cause, not measured in the study, is patient attitudes, he said. Lower-income patients may be less likely to be assertive in seeking care and less thorough in carrying out doctors' instructions.
Another possible cause is the fact that Medicaid patients tend to be concentrated among hospitals, doctors and community clinics. Since the program pays less for services than Medicare and private insurance, such providers may have less to invest in quality improvement than those with a higher proportion of privately insured patients.
"It takes investment to really improve in quality," Calvin said.
In the end, he said, more research is needed to find systemic explanations for what appears to be a very widespread phenomenon.
"We need to make the quality of care universal," Calvin added. "More research will give us clarity as we go forward to try to make care better."
A good place to start looking for possible explanations is the socio-economic status of the patients, said Spencer King, director of interventional cardiology at Piedmont Hospital in Atlanta and spokesman for the American College of Cardiology.
"A great deal about care is influenced by the patient," King told UPI. More well-to-do patients are "more likely to go to successful hospitals, advocate for up-to-date care and comply with the medications suggested."
Low-income patients are also more likely to have other conditions that contribute to poor outcomes, he said.
Pay for doctors in hospitals is often not very closely linked to the type of patients' insurance, making it an unlikely cause of the difference, King agreed.
"To get access to care equality will require a lot more than changing who's reimbursing and what the rates are," King said. "It's a social and economic problem."
