Study Ties Death Rate to Type of Insurance

AIDS patients hospitalized with a special form of pneumonia are nearly twice as likely to die if they are covered by Medicaid than if they have private health insurance, according to a new study by RAND Corp. in Santa Monica and the Department of Veterans Affairs.

The higher death rate occurred because the Medicaid patients were less likely to receive bronchoscopy, an expensive technique necessary to diagnose the pneumonia correctly.

In a study of 890 AIDS patients treated for pneumocystis carinii pneumonia (PCP) at 56 hospitals in Los Angeles, Miami and Chicago, the team reports today that 23.2% of the Medicaid patients died, compared to 11.7% of the privately insured patients.

Many who died received incorrect treatment because their PCP was not diagnosed properly with bronchoscopy, in which a tube is inserted into the lungs to collect fluids for analysis. It is often the only way to distinguish among PCP, tuberculosis and other types of pneumonia, all of which require different treatments.

In California, Medi-Cal reimburses hospitals $156 for a bronchoscopy, while private insurers pay about $551, but the disparity can be worse elsewhere. In New York, Medicaid pays $70 for a bronchoscopy while private insurance pays $700.

“In the past, it has been suggested that people on Medicaid had worse medical outcomes because they had trouble getting into the medical system,” said Dr. Charles L. Bennett of the Northwestern University Medical School and the Lakeside V.A. Medical Center in Chicago.

“This shows that access to medical care isn’t the only issue,” he said. “Everyone in this study was hospitalized, but depending on their insurance status, they got different care once they were in the hospital.”

The research appeared in the latest issue of the American Journal of Respiratory and Critical Care Medicine.

“It’s troubling that people who don’t have the right insurance may receive a different class of care,” wrote Dr. Jeffrey Glassroth of the Medical College of Pennsylvania in an editorial in the journal. He also expressed concern about managed care organizations because their financial incentives are generally geared toward encouraging less testing.

The report, called the largest quality of care study of AIDS patients ever conducted, also revealed that almost 60% of Medicaid patients were admitted to a county or state hospital, while 75% of privately insured patients were admitted to a religious-affiliated or voluntary hospital. Medicaid patients were also more likely to be treated at hospitals with medical school affiliations.

Severity of illness at admission was also correlated with insurance status, the group found. A significantly higher proportion of Medicaid patients had more severe illness at the time of admission than those with private insurance.

Overall, however, the process of care was similar for patients in all insurance categories. Insurance status was unrelated to length of stay, presence of “Do Not Resuscitate” orders in the patient’s medical record, use and timing of intensive care, and timing of the initiation of PCP therapy.

It was only in diagnosing PCP that significant differences occurred. In patients with private insurance, suspected PCP was confirmed by bronchoscopy before treatment began. With Medicaid patients, physicians often treated suspected PCP without confirming the diagnosis.