Medicaid: Equal yet Unequal

Time spent and interventions conducted for Medicaid and private patients are similar; yet outcomes are not.

Critics of , particularly state leaders who have chosen not to expand Medicaid, argue that Medicaid provides a lower quality of care through a broken system in which it is not worth investing or expanding. Brian Bruen and colleagues at George Washington University have tried to objectively address this claim by determining whether patients insured privately receive a different standard of care than those who are either or uninsured.

The authors chose two markers of quality of care: (1) length of time physicians spent with patients and (2) the number of interventions the physician did for the patient during the visit (e.g. diagnoses, procedures, counseling, etc.). The data come from the National Ambulatory Medical Care Surveys (NAMCS). Physicians nationwide completed surveys about each patient’s office visit describing the care provided. The authors limited data to visits to primary care physicians and patients younger than 65 for a total of 31,825 visits over 5 years (2006-2010). Medicaid patients accounted for 19% of visits and the uninsured were responsible for 6%. Four percent of visits occurred in a community health center.

Physicians spent an average of 18.5 minutes with patients and provided 6.8 interventions, only 0.82 of which were preventative counseling.

Multivariate regression modeling found no significant difference in time spent or number of interventions offered between the different insurance groups. Not surprisingly, new patients took longer than established patients (p<0.001) as did older patients (p=0.005). Chronic care, such as diabetes management, and prevention took longer than acute care (e.g. runny nose, cough, etc.) (p<0.001). The authors postulated that the near identical time spent with patients, regardless of insurance status, was due to the trend among physicians in scheduling visits into 15-minute blocks.

Commentary

is defined by factors beyond the length of the visit or the number of services rendered. Many observational studies show worse outcomes for Medicaid patients, including number of hospitalizations, measures of disease control (HgbA1c for diabetes, blood pressure), number of heart attacks or strokes, and premature death. These outcomes are much more meaningful than the length of an office visit. Medicaid patients have more complex medical problems than privately insured patients, likely due to the interactions between poverty, high-risk lifestyle (poor diet, obesity, smoking), and disease. Thus, office visits of equal length may actually show inadequate time spent with a Medicaid patient to fully discuss more complex medical and social problems.

The fact that this study finds no difference between insurance groups should not reassure us that the quality of care is equal, but rather should cause us to question why meaningful clinical outcomes remain unequal despite seemingly equal treatment during each primary care visit. How much difference can doctors make on complex health problems within the limits of an 18.5 minute visit? This study asks the wrong questions about the health of Medicaid patients.

Bruen, BK, et al. Health Affairs. 2013; 32 (9): 1624-1630.

by

Laura Medford-Davis, MD

Laura Medford-Davis is Chief Resident in Emergency Medicine at Baylor College of Medicine. Dr. Medford-Davis earned her medical degree at Harvard Medical School and undergraduate degrees in Spanish and Psychology at the University of Oklahoma. She has worked for the World Health Organization and as a consultant for McKinsey&Company. After residency, she will begin the Robert Wood Johnson Clinical Scholar Program at University of Pennsylvania. Her interests include access to health care for vulnerable populations, health care delivery systems, health care financing, and coordination of care between emergency and outpatient settings to prevent emergency recidivism.

Editor’s Note:

The link in the commentary  about observational studies and Medicaid health outcomes will direct you to the Incidental Economist blog which purports that such observations are biased due to methodological flaws. That author, Austin Frakt claims “there is no credible evidence that Medicaid is worse for health than being uninsured.” I highly recommend that you also read the opposing viewpoint by Avik Roy suggesting that Medicaid is worse than having no insurance at all, available at the Forbes Website. Each analyst looks at the same studies, with different conclusions. I encourage you to make up your own mind as to the clinical benefit of Medicaid. (CD)