JACC: Insurance type impacts quality of care, outcomes

Heart failure (HF) patients who hold no insurance, or are on Medicare or Medicaid, experience worse outcomes compared with those who hold private insurance, according to a study published Sept. 27 in the Journal of the American College of Cardiology. Many with no insurance refuse care, which has led to worse outcomes. While the future of payment models remains unknown, it is crucial to attempt to close these care gaps, Marvin A. Konstam, MD, wrote in an accompanying editorial.

HF is prevalent and produces great economic strain. While mortality from HF is higher in patients with a lower socioeconomic status, it remains unknown as to why. To provide some hard evidence, John R. Kapoor, MD, PhD, of the University of Chicago Pritzker School of Medicine in Chicago, and colleagues set out to evaluate the relationship between payment source and quality of care and outcomes in HF.

To do so, Kapoor and colleagues analyzed 99,508 HF admissions from 224 sites between January 2005 and September 2009. The researchers grouped patients by type of insurance: private, no insurance, Medicare and Medicaid. Patients with privately held insurance were used as the control group.

Of the enrolled patients, 55.4 percent were on Medicare, 10.7 percent were on Medicaid and 5 percent were uninsured. While those on Medicare had more instances of coronary artery disease, cerebrovascular accident or transient ischemic attack, those on Medicaid had more instances of obstructive pulmonary disease, diabetes and hypertension. Those who held no insurance had the lowest prevalence of comorbidities.

The researchers reported that those with no insurance and those on Medicaid were less likely to receive beta-blockers, implantable cardioverter-defibrillators (ICDs) or anticoagulation therapy for atrial fibrillation (AF). Additionally, those on Medicare were less likely to receive ACE inhibitors, ARBs or beta-blockers.

Those on Medicare and Medicaid and those with no insurance experienced longer lengths of stay. Patients on Medicaid also had higher adjusted rates of in-hospital mortality, as did those with no insurance who also had reduced systolic function.

“Patients with Medicaid were also less likely to receive smoking cessation instructions, evidence-based specific beta-blockers for LVSD [left ventricular systolic dysfunction] and ICDs in eligible patients,” the authors wrote.

“These findings suggest that even among hospitals participating in a national quality improvement program, HF patients’ insurance status is still associated with the care provided and clinical outcomes in the inpatient setting.”

The authors noted that these variations of care could stem from the differences in the implementation of guideline-endorsed HF therapy. “A bias not to prescribe drugs or therapies with lifesaving benefits to certain groups can certainly perpetuate the observed increases in HF prevalence and poor outcomes,” the authors wrote. However, the reason for these decisions remains unknown.

“The reasons behind the disparities warrant further investigation to help mitigate associated poorer outcomes in patients with lower socioeconomic status,” the authors concluded. “Finally, it is unclear how the quality of healthcare and outcomes will be affected in the era of healthcare reform that is expected to expand insurance coverage to more Americans, including an expansion of Medicaid eligibility.”

In an accompanying editorial, Marvin A. Konstam, MD, of the Tufts Medical Center and the Tufts University School of Medicine in Boston, wrote that it will be important to address three healthcare challenges: variable access, disparate quality and spiraling costs. “Many uncertainties remain regarding the characteristics of the system that will evolve as we try to meet these challenges,” Konstam wrote.

Konstam said that while Kapoor and colleagues addressed disparities of care, they did not address the impacts of the various reimbursement models on quality or outcomes. Additionally, the impact of reimbursing on a fee-for-service basis vs. bundling payments for services was not addressed in the current study.

Kapoor and colleagues “have also provided a window on the potential for our evolving healthcare system to either exacerbate or mitigate healthcare disparities across socioeconomic groups,” Konstam wrote. “Although none of the choices we face will be easy, patients and providers alike will be far better off if the system allows them to share in the rewards of quality healthcare, rather than incentivizing the arbitrary withholding of proven management approaches.”

Konstam said that rather than forcing patients to settle for less expensive drugs, a financial structure should be instated which allows patients to share in the rewards of improving their own healthcare quality.