*Patient’s name has been changed
Magda* was 70 years old when she suffered a mild stroke. She was taken to a hospital, where the emergency department and critical care unit ran the appropriate tests and sent her home with medicine and a monitor for irregular heartbeats.
Practice guidelines for stroke follow-up advise providers to evaluate stroke cause, which includes, for patients like Magda, noninvasive cervical carotid imaging to evaluate any stenosis. If present, cervical artery stenosis must be addressed. This would include revascularization when appropriate, or medication and lifestyle modification. Magda was not told this. If not for a knowledgeable family member who categorically requested the necessary imaging, she may have gone untreated.
The oversight was almost catastrophic. She had severe stenosis. It could have taken her life.
There are many possible reasons why the attending physician decided not to proceed with imaging tests. Perhaps they felt it was clinically unnecessary. But then why, once it was requested, did they perform the test without any objections? Magda suspects it happened because of her insurance: she is covered by Medicare.
Unfortunately, Magda’s experience is not unique. Private insurance generally pays healthcare providers more than federally funded programs like Medicare or Medicaid. Public insurance beneficiaries report they feel that they don’t have the same level of access to high-quality care as privately insured patients. This apprehension is not imaginary.
Patients must be able to determine not only whether a provider accepts Medicaid/Medicare, but also if that provider treats patients who have publicly funded insurance with the same level of care. One part of the solution could be transparent and easily accessible information about patient demographics (information that includes data by patient insurance type).
A Medicare or Medicaid patient’s first challenge is in finding a healthcare provider that will take their insurance. Many providers do not accept federally funded insurance coverage, although some get certified because, despite the lower revenue, they expect more consistency in payments. (Unfortunately, claim denials and billing problems often stymie these expectations.)
However, even once a Medicare or Medicaid patient finds a provider that accepts their insurance, their care may be delayed or superficial. No regulations prevent providers that serve patients insured by Medicare or Medicaid from offering preferential treatment to privately insured individuals. In fact, bigger providers, like hospitals and clinics, can openly declare their partiality for patients with private insurance to maximize their profit — or even stay solvent. A few years back, the Mayo Clinic declared that unless it took up this practice to increase their revenue, it would have to close its doors.
While this may seem cruel, it is almost preferable in comparison to providers who discriminate without letting their patients know. Research suggests that Medicare bundling, which pays per-illness rather than per-treatment and requires providers to only do “necessary” tests, may result in underuse of services. As in the case of stroke victims like Magda, this could prove fatal. Unfair treatment by a Medicaid/Medicare-certified provider can be addressed by a formal complaint. But some patients may not recognize that they’ve been treated unfairly. Others, like Magda, may be unable to prove it.
In the absence of rules to prevent disparate care for those with publicly funded insurance, we need to arm patients with as much information as possible. Evidence suggests that transparency policies, such as publicly releasing performance data, improve the quality of care. In New York state, for example, after the Department of Health mandated transparent reporting of outcomes from heart surgery and coronary artery procedures, the state saw a drop in mortality. This was, in part, because providers were incentivized to adopt improvements to their care models.
Transparency on outcomes based on insurance type could provide similar benefits.
Information about insurance coverage, treatment, and outcomes needs to be intelligible and easily accessible. CMS already collects and tracks quality measures for participating providers, but those measures do not include the percentage of Medicare and Medicaid patients served by a provider or if they treat those patients differently.
One model for achieving transparency for patients without adding to providers’ already heavy workload is to expand non-profit organization efforts. For example, the Lown Institute created a Hospital Index, which ranks providers based on social responsibility metrics including outcomes, value, and equity. While this ranking does include public insurance coverage in its equity metric, it doesn’t offer as clear information as stand alone measures would. Another example is the Leapfrog group, which gives providers a safety grade based on national performance measures but does not break down data by patient insurance type. While not perfect, both efforts give patients and their advocates information to help choose a provider that would best suit their needs.
It is no secret that socioeconomic status affects healthcare outcomes. Federally funded insurance coverage seeks to help alleviate some of the burden, but when patients are getting less than optimal care due to that coverage, it may hurt beneficiaries. Patients have the right to know about their provider’s history when it comes to who they treat and how well they do.
Rosa Mino, PhD, is a professor of biology at Huston-Tillotson University and a public voices fellow at the Op-Ed project and UT Austin. Amanda Masino, PhD, is a professor of biology and Natural Sciences Department chair at Huston-Tillotson University.
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