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RESEARCH AND PRACTICE |
The authors are with the Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY.
Correspondence: Requests for reprints should be sent to Jing Fang, MD, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461 (e-mail: fang{at}aecom.yu.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We sought to determine whether supplemental private insurance coverage among Medicare recipients alters patterns of health care or outcomes associated with acute myocardial infarction.
Methods. Medicare patients hospitalized after a myocardial infarction were identified from New York City hospitalization records. Patients who had only Medicare coverage were compared with those who had supplemental private or public insurance coverage.
Results. Patients with supplemental private insurance exhibited increased rates of revascularization and decreased rates of in-hospital mortality relative to patients with either Medicare only or Medicare and public insurance. Moreover, Blacks and women were less likely to undergo revascularization and exhibited higher in-hospital mortality rates.
Conclusions. Despite Medicare, private insurance coverage appears to influence the likelihood of coronary revascularization among older patients hospitalized for acute myocardial infarction.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Measuring and monitoring access to health care is a central concern of public health and health service researchers, and it has been of great interest to the federal government since the establishment of Medicare and Medicaid benefits in 1966.7,8 Because Medicare provides nearly universal hospital insurance coverage after the age of 65 years, we hypothesized that differences in revascularization prominently associated with insurance status among younger persons9 might be ameliorated or disappear after age 65. Since some Medicare beneficiaries also have supplemental insurance coverage, we wondered whether this additional coverage influenced medical services or survival.
To address this issue, we examined data from the New York State Department of Health’s Statewide Planning and Research Cooperative System (SPARCS). We found, as reported subsequently, that race and gender continue to influence revascularization use and in-hospital mortality among Medicare recipients hospitalized for acute myocardial infarction. However, supplemental private insurance coverage favorably affects both in-hospital care and hospital survival.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Diagnostic coding was based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM).11 Myocardial infarction was defined according to its appearance as the principal diagnosis code (ICD-9 codes 410.0–410.9). Other diagnostic codes identified comorbid conditions and complications. Patients’ disposition signified their vital status at discharge.
In this study, the outcomes of interest were revascularization procedure use and in-hospital mortality. Revascularization was coded as percutaneous transluminal coronary angioplasty (PTCA) (ICD-9 codes 36.01, 36.02, and 36.05) or coronary artery bypass grafting (CABG) (ICD-9 codes 36.10–36.19). Discharge status was used in determining in-hospital mortality.
A priori risk factors selected for this study included general risk factors (e.g., age, gender, race, length of hospital stay, and admission status), comorbid conditions (e.g., diabetes [ICD-9 code 250], hypertension [ICD-9 codes 401–405]), and complications of myocardial infarction, including congestive heart failure (ICD-9 code 428). We established whether patients had experienced a previous myocardial infarction by reviewing their medical records for mention of such an event (ICD-9 code 412). The location of the myocardial infarction was categorized as anterior (ICD-9 codes 410.0–410.1), lateral/inferior (ICD-9 codes 410.2–410.6), or subendocardial (ICD-9 code 410.7).
Insurance status was based on primary and secondary coverage. Patients were categorized in the following groups: (1) Medicare only; (2) Medicare with supplemental private insurance, including both Medicare and any comprehensive private insurance plan; and (3) Medicare with other public insurance, including both Medicare and Medicaid coverage.
Study patients were limited to those older than 65 years who reported having Medicare insurance coverage (88% of all patients 65 years or older reported having such coverage) and who were discharged from the hospital with a principal diagnosis of acute myocardial infarction. Because 93% of the patients were non-Hispanic Whites, non-Hispanic Blacks, or Hispanics, patients in other race/ethnicity groups were eliminated. Length of hospital stay categories were less than 3 days, 3 to 7 days, and more than 7 days. Admission status was categorized as emergency, urgent, or elective. Patients who were discharged from the hospital alive and who had been in the hospital fewer than 3 days were eliminated from our analyses because acute myocardial infarction was likely to have been ruled out among these patients.
Statistical Analysis
Associations between insurance status and sociodemographic characteristics, revascularization use, and hospital outcome were established. Multiple logistic regression models were used to estimate odds ratios and 95% confidence intervals for factors related to revascularization, as well as in-hospital mortality, controlling for other characteristics that differed significantly in the univariate analysis. Logistic regression models also were used in examining subgroups established through stratification according to race/ethnicity.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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In comparison with patients who had Medicare coverage only, patients with supplemental private insurance were more likely to be White and male and to have had a previous myocardial infarction. Those with Medicare and other public insurance coverage were more likely to be female, Black, or Hispanic and more likely to have hypertension, diabetes, and congestive heart failure. Blacks and Hispanics were more likely than Whites to have Medicare in combination with other public insurance coverage and to have only Medicare coverage. Other characteristics, including length of hospital stay and admission status, differed significantly among the 3 insurance groups as well (Table 1
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). Among Blacks and Hispanics, those with supplemental private insurance exhibited the highest frequency of PTCA, while there were no differences between those with Medicare coverage only and those with Medicare and supplemental public insurance coverage. This was also the case for overall rates of CABG use, as well as race/ethnicity- and gender-specific rates (Table 2). Altogether, revascularization was most frequent among Hispanics and least frequent among Blacks, and this was particularly true in the case of PTCA.
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).
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). Overall, both gender and race were significantly associated with procedure use and in-hospital mortality; Whites and men were more likely to undergo procedures than Blacks and women. However, there was no difference between Whites and Hispanics, although univariate analyses showed that Hispanics had higher revascularization rates and lower in-hospital mortality rates.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Previous studies have repeatedly shown that use of medical care in the United States is related to health insurance status.13,14 In the case of the elderly, Medicare provides a basic level of access to health care. Still, one study showed that individuals who have Medicare and supplemental public insurance coverage and individuals who have Medicare coverage only are twice as likely as those who have supplemental private insurance to have unmet medical needs (including needs related to immunization, dental care, prescription medicine, eyeglasses, and mental health).15 However, this investigation did not address in-hospital service.
The present study showed that Medicare cannot universally provide the health care needed by hospitalized myocardial infarction patients. Therefore, our initial hypothesis—that Medicare coverage supplemented by private insurance would not result in improvements in regard to either revascularization or in-hospital mortality rates among patients hospitalized after a myocardial infarction—was not confirmed. Moreover, the fact that the groups who, for the most part, lacked private supplemental insurance coverage were Blacks, Hispanics, and women suggests that other sociodemographic differences existed among patients with private insurance coverage.
Previous research on treatment of myocardial infarction has shown that patients with private insurance are more likely to undergo revascularization than those with Medicare, Medicaid, or no insurance.13,16 Such analyses are often confounded by age because, by definition, Medicare beneficiaries are older than 65 years. It has been reported that older patients are less likely to be reperfused than younger patients.17 A report of the National Registry of Myocardial Infarction showed that Medicare/Medicaid patients, in comparison with privately insured patients, undergo fewer reperfusion procedures, undergo fewer invasive cardiac procedures, and have longer hospitalizations. However, in this comparison, which included all age groups, Medicare patients were older and of more advanced clinical status.18
The fact that differences in PTCA and CABG rates use between Whites and Blacks persisted in each insurance group and among both men and women suggests that even with universal medical insurance in place, individuals who are socioeconomically disadvantaged are less likely to receive the services they need. In fact, the differences in revascularization use among White and Black patients observed here were generally similar to those reported in a previous study involving the overall adult population (i.e., individuals 35 years or older); in that study, White/Black ratios in regard to PTCA and CABG use were 1.63 and 1.55, respectively.19
The finding that patients with Medicare-only coverage were more likely than patients in the other insurance groups to remain in the hospital more than 7 days was consistent with an earlier report indicating that, in comparison with patients with good access to health care, those with poor access exhibit significantly longer hospital stays and poorer health outcomes in regard to the condition requiring hospitalization.20 Moreover, Medicare patients with supplemental private insurance were more likely than patients with Medicare only and those with supplemental public insurance to have had a previous myocardial infarction, suggesting in turn that these patients were more likely to survive the first event. Overall, women underwent fewer revascularization procedures than men, and Blacks underwent fewer procedures than White or Hispanic patients, regardless of insurance status. These associations persisted after adjustment for sociodemographic characteristics, comorbid conditions, complications, length of hospital stay, previous myocardial infarction, admission status, and location of myocardial infarction.
While in-hospital mortality rates were highest among Whites and lowest among Hispanics, adjustment for other characteristics revealed that Whites and Hispanics exhibited similar in-hospital mortality, and the rates for both of these groups were lower than those among Blacks. However, gender-specific mortality differences persisted after adjustment for other characteristics.
The strengths of SPARCS are its large size, standardized data collection methodology, and individualized database. However, this study was limited to the administrative database, which provides minimal clinical details and does not include diagnostic study results or information on use of thrombolytic therapy or particular medications. No long-term follow-up information is available. Also, our study included only patients admitted to New York City hospitals, limiting extrapolation to the overall US population. In addition, federal, military, Department of Veterans Affairs, and institutional hospitals were not included. Therefore, our results cannot be generalized to all hospitals in the United States.
In summary, the results of this study suggest that purchase of supplemental private health insurance leads to increased use of specialized medical care and hospital survival among Medicare patients hospitalized with acute myocardial infarction. In view of the marked insurance-linked disparities in services and outcomes observed among younger Americans, it seems likely that universal health insurance coverage involving Medicare alone will not reduce health disparities among older Americans. Moreover, since sociodemographic characteristics, including gender and race, continue to be associated with receipt of health services as well as overall in-hospital mortality, it is clear that equalizing insurance coverage for hospital services through Medicare does not, in itself, eliminate all health disparities.
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Acknowledgments |
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Human Participant Protection
No protocol approval was needed for this study.
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Footnotes |
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Accepted for publication June 15, 2003.
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References |
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2. Goldberg RJ, McCormick D, Gurwitz JH, Yarzebski J, Lessard D, Gore JM. Age-related trends in short- and long-term survival after acute myocardial infarction: a 20-year population-based perspective (1975–1995). Am J Cardiol. 1998;82:1311–1317.[ISI][Medline]
3. Shen JJ, Wan TT, Perlin JB. An exploration of the complex relationship of socioecologic factors in the treatment and outcomes of acute myocardial infarction in disadvantaged populations. Health Serv Res. 2001;36:711–732.[ISI][Medline]
4. Hannan EL, van Ryn M, Burke J, et al. Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery. Med Care. 1999;37:68–77.[ISI][Medline]
5. Gillum RF, Gillum BS, Francis CK. Coronary revascularization and cardiac catheterization in the United States: trends in racial differences. J Am Coll Cardiol. 1997;29:1557–1562.[Abstract]
6. Goldberg KC, Hartz AJ, Jacobsen SJ, Krakauer H, Rimm AA. Racial and community factors influencing coronary artery bypass graft surgery rates for all 1986 Medicare patients. JAMA. 1992;267:1473–1477.[Abstract]
7. Gornick M, Greenberg JN, Eggers PW, Dobson A. Twenty years of Medicare and Medicaid: covered populations, use of benefits, and program expenditures. Health Care Financing Rev. 1985(suppl):13–59.
8. Health Care Financing Review Medicare and Medicaid Statistical Supplement. Washington, DC: Health Care Financing Administration; 1995.
9. Brooks JM, McClellan M, Wong HS. The marginal benefits of invasive treatments for acute myocardial infarction: does insurance coverage matter? Inquiry. 2000;37:75–90.[ISI][Medline]
10. New York State Dept of Health. SPARCS—data quality initiatives. Available at: http://www.health.state.ny.us/nysdoh/sparcs/operations/dataqual.htm. Accessed February 12, 2004.
11. International Classification of Diseases, Ninth Revision, Clinical Modification. Hyattsville, Md: National Center for Health Statistics; 1980. DHHS publication PHS 80-1260.
12. Sada MJ, French WJ, Carlisle DM, Chandra NC, Gore JM, Rogers WJ. Influence of payor on use of invasive cardiac procedures and patient outcome after myocardial infarction in the United States: participants in the National Registry of Myocardial Infarction. J Am Coll Cardiol. 1998;31:1474–1480.
13. Hadley J, Steinberg EP, Feder J. Comparison of uninsured and privately insured hospital patients: condition on admission, resource use, and outcome. JAMA. 1991;265:374–379.[Abstract]
14. Young GJ, Cohen BB. The process and outcome of hospital care for Medicaid versus privately insured hospital patients. Inquiry. 1992;29:366–371.[ISI][Medline]
15. Cohen RA, Bloom B, Simpson G, Parsons PE. Access to health care. Part 3: older adults. Vital Health Stat 10. 1997;198:1–32.
16. Wenneker MB, Weissman JS, Epstein AM. The association of payer with utilization of cardiac procedures in Massachusetts. JAMA. 1990;264:1255–1260.[Abstract]
17. Philbin EF, McCullough PA, DiSalvo TG, Dec GW, Jenkins PL, Weaver WD. Socioeconomic status is an important determinant of the use of invasive procedures after acute myocardial infarction in New York State. Circulation. 2000;102:107–115.
18. Canto JG, Rogers WJ, French WJ, Gore JM, Chandra NC, Barron HV. Payer status and the utilization of hospital resources in acute myocardial infarction: a report from the National Registry of Myocardial Infarction 2. Arch Intern Med. 2000;160:817–823.
19. Barnhart JM, Fang J, Alderman MH. Differential use of coronary revascularization and hospital mortality following acute myocardial infarction. Arch Intern Med. 2003;163:461–466.
20. Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med. 1991;114:325–331.
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