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Quality Disparities exist between Payers

Are worse outcomes for Medicare and Medicaid patients due to lower payments?

Although providing health insurance to Americans who didn’t have prior coverage sounds like a good thing; not all insurance provides equal . Disparities exist in the quality of care specifically with Medicare patients. From facing higher risk of inpatient mortality to experiencing more adverse safety events – patients with Medicaid may not see the same inpatient health benefits as others with private insurance. A recent study examined whether differences exist in rates of patient safety events within the same hospital among patients with different insurance.

Source: John Campbell (Flickr / Public Domain)

Source: John Campbell (Flickr / Public Domain)

Using discharge records from 2006 – 2008 at acute care general hospitals in 11 states,  patient safety indicators (PSI) were compiled and used as a measure of hospital quality. The 11 states were chosen because they contain 41% of the nation’s population and 38.4% of acute care discharges.  With a shift to reimbursing hospitals more for quality as opposed to quantity of care, the importance of PSI is underscored by the government’s use of PSI to adjust reimbursements to hospitals.

Medicare and Medicaid patients experienced a higher rate of adverse safety events in as many as 7 out of the 13 indicators. For example, the prevalence of pressure ulcers, death among elective surgical patients, development of post surgical pulmonary embolism, and severe post surgical infections – all were significantly higher among Medicare and Medicaid patients in comparison to patients with private insurance. As an aside, Medicaid patients did have significantly lower rates of adverse events in 2 of the 13 indicators. Although the authors were able to pinpoint areas of disparity within patients’ insurance status, they could only subtly suggest that such variability exists due to differences in reimbursement between public and private insurance.

The reduction of preventable medical events and improvement of access to health care are two priorities of the Affordable Care Act. Reducing preventable events in hospitals is a good start, mainly because approximately 44% of Medicare patient safety events were indeed preventable and cost $4.4 billion.

Quality measures and differences in reimbursement only tell a partial story for patient safety events as discriminated by payer. Often, the baseline level of health (e.g. comorbid conditions) for Medicare or Medicaid patients is worse than privately insured patients. Simply penalizing hospitals and providers for sub-par performance may make matter worse.

commentary by Nii Darko


BACKGROUND: The reduction of adverse patient safety events and the equitable treatment of patients in hospitals are clinical and policy priorities. Health services researchers have identified disparities in the quality of care provided to patients, both by demographic characteristics and insurance status. However, less is known about the extent to which disparities reflect differences in the places where patients obtain care, versus disparities in the quality of care provided to different groups of patients in the same hospital.

OBJECTIVE: In this study, we examine whether the rate of adverse patient safety events differs by the insurance status of patients within the same hospital.

METHODS: Using discharge data from hospitals in 11 states, we compared risk-adjusted rates for 13 AHRQ Patient Safety Indicators by Medicare, Medicaid, and Private payer insurance status, within the same hospitals. We used multivariate regression to assess the relationship between insurance status and rates of adverse patient safety events within hospitals.


Medicare and Medicaid patients experienced significantly more adverse safety events than private pay patients for 12 and 7 Patient Safety Indicators, respectively (at P<0.05 or better). However, Medicaid patients had significantly lower event rates than private payers on 2 Patient Safety Indicators.


Risk-adjusted Patient Safety Indicator rates varied with patients’ insurance within the same hospital. More research is needed to determine the cause of differences in care quality received by patients at the same hospital, especially if quality measures are to be used for payment. PMID: 25906014

Spencer, CS, et al. Med Care. 2015; 53 (6): 524-9.

Nii Darko, DO, MBA
About Nii Darko, DO, MBA

Dr. Darko is a board-certified general surgeon who currently practices in Pennsylvania. He began writing for Policy Prescriptions® in 2012. Contact: Facebook | Twitter | More Posts