Heart Failure Care Influenced by Insurance Coverage

Study found those on Medicaid, Medicare fared worse than those with private insurance

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Monday, September 19, 2011

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MONDAY, Sept. 19 (HealthDay News) -- The quality of care people with heart failure receive, along with outcomes, are significantly influenced by what type of insurance patients have, a new study finds.

Medicare and Medicaid patients and those without health insurance are less likely to be given some essential treatments and tend to be hospitalized longer, researchers report. Medicaid patients were 22 percent more likely to die in the hospital than patients with private insurance, the researchers said.

"I wish the results revealed a different story," said lead researcher Dr. John R. Kapoor, an assistant professor of medicine at the University of Chicago Pritzker School of Medicine.

The findings reveal that disparities in heart failure care do exist and are associated with worse outcomes, he added, and these unequal practices should be corrected.

"It remains medicine's major unhealed wound that care continues to be tailored to individuals based on their pocketbook, and not their condition," he said. "Quality of care for all patients --- insured and uninsured -- is priceless."

The report will be published in the Sept. 27 issue of the Journal of the American College of Cardiology.
For the study, Kapoor's team collected data on 99,508 heart failure patients seen in 244 hospitals that are part of the American Heart Association's Get with the Guidelines Heart Failure quality program.

The researchers found that, even among these hospitals, insurance coverage had an influence on how the guidelines were applied.

For example, compared with privately insured patients, patients with Medicaid or no insurance were less likely to be given blood pressure drugs called beta blockers or have an implantable cardioverter-defibrillator prescribed or placed before leaving the hospital. A cardioverter-defibrillator automatically delivers a shock to the heart if the heart starts beating irregularly, to return the heartbeat to normal.

Other drugs that are part of the guidelines for treating heart failure were also less likely to be prescribed to those with Medicaid or no insurance, Kapoor's group found.

In addition, Medicaid and Medicare patients were also less likely to receive other blood pressure medication such as angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and beta blockers, compared with privately insured patients, the researchers found.

Study co-author Dr. Gregg Fonarow, a professor of cardiology at the University of California, Los Angeles, said there are many reasons for the disparities in quality of care based on who is paying the bill.

"Inequalities in access to specialist care during hospital admissions may explain some of the differences by insurance status," Fonarow said. "There may also be a bias among certain physicians and hospitals to not prescribe medications or therapies with life-prolonging benefits to patients based on whether the patient is well-insured or not. Patient insurance status is also correlated with socioeconomic status, which may in turn also influence care and outcomes."

"These shocking and equally disturbing findings call for physicians to pause and reflect on practice behaviors," Kapoor said. "Quality care should be a priority, irrespective of financial incentives."

Dr. Marvin Konstam, director of the CardioVascular Center at Tufts Medical Center in Boston and author of an accompanying journal editorial, said there are "blatant" examples throughout the health care system in which patients don't get proven therapies because they lack adequate insurance coverage.

He cited a decision in Arizona to halt paying for several types of organ transplants for Medicaid recipients.
"That's a decision that has since been rescinded, but that's an example of how in the current system there is a very great risk of making misguided arbitrary decisions and cutting off whole segments of the population from a proven therapy," he said.

That can range from decisions made by individual doctors for a particular patient all the way up to state and federal governments making decisions on whole classes of treatments, he said.

Konstam thinks decisions on care need to take into account the cost-effectiveness of therapies, not just the cost of the therapy itself. In addition, payment for care needs to be changed to make costs similar for patients across the board.

SOURCES: John R. Kapoor, M.D., Ph.D., assistant professor, medicine, University of Chicago Pritzker School of Medicine, Chicago; Gregg Fonarow, M.D., professor, cardiology, University of California, Los Angeles; Marvin Konstam, M.D., professor, cardiology, and director, CardioVascular Center, Tufts Medical Center, Boston; Sept. 27, 2011, Journal of the American College of Cardiology

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