Medicare, Medicaid, and uninsured patients less likely to receive drug-eluting stents than the privately insuredDrug-eluting stents (DES) were introduced in 2003 as an improvement on bare-metal stents (BMS) often inserted during coronary angioplasty to keep open arteries that had been unblocked. DES rates for both Medicaid and uninsured patients were significantly lower than rates for the privately insured from April 2003 to December 2008 even when comparing patients treated at the same hospitals, according to a new study. DES rates for Medicare patients were also below rates for privately insured patients. Most patients receiving coronary stents have either Medicare (52.2 percent) or private insurance (38.5 percent). Only a small percentage have Medicaid (4.9 percent) or no insurance (4.4 percent).
Differences in DES rates by payer varied over time. For example, after large gaps initially, the difference with privately insured patients narrowed to roughly 1 to 2 points for Medicaid, uninsured, and Medicare patients by the fourth quarter of 2004. But by the end of 2008, the deficit was 9.4 points for Medicaid patients and 16.5 points for uninsured patients. Differences in DES rates by payer within hospitals were much greater than those between hospitals.
The authors suggest that their findings on payer differences in DES use are consistent with evidence that hospitals seem to treat cardiovascular patients differently depending on the generosity of their insurance coverage. Also, hospital acquisition prices for DES have been much higher than for BMS, resulting in lower or even negative hospital profit margins for DES for all payer types. Because the margins for DES were even lower relative to BMS for Medicaid and uninsured patients, hospitals may have effectively encouraged cardiologists to concentrate on DES use among higher-paying patients, particularly during the early supply shortages. This study was supported in part by the Agency for Healthcare Research and Quality (HS18403).
See "Variations in the use of an innovative technology by payer. The case of drug-eluting stents," by Andrew J. Epstein, PhD, Jonathan D. Ketcham, PhD, Saif S. Rathore, M.P.H., and Peter W. Groeneveld, M.D., in the January 2012 Medical Care 50(1), pp. 1-9.
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