AJC: Will universal access to care improve outcomes?
Patients with no insurance or government-held insurance have worse one-year outcomes after PCI compared with those who have private insurance; however, providing universal healthcare to all may not improve outcomes, Ron Waksman, MD, told Cardiovascular Business News.

To assess whether or not there were differences between types of insurances—Medicare/Medicaid, privately-held insurance or no insurance—Waksman and colleagues of the Washington Hospital Center in Washington, D.C, performed a retrospective observational study of 13,573 patients who underwent PCI between June 2000 and June 2009.

They published their results online Dec. 24, 2010, in the American Journal of Cardiology.

Within the patient cohort, 49 percent held private insurance, 45.3 percent held Medicare, 3.6 percent held Medicaid and 2.1 percent were uninsured at hospital discharge post-PCI. The researchers noted that patients with Medicare were sicker and had more comorbidities—hypertension, chronic renal insufficiency and hyperlipidemia, among others—compared with the others. However, those with Medicaid were more likely to have diabetes mellitus and be smokers.

Of the 13,573 patients, 51.9 percent were less than 65 years old and of those patients, 81.7 percent held private insurance, 8.7 percent had Medicare, 5.8 percent had Medicaid and 3.8 percent were uninsured.

The results showed that patients with Medicaid, Medicare or no insurance were more likely to die in-hospital compared with patients who held private insurance, 6.2, 4.5, 5.1 and 1.5 percent, respectively. The trends for 30-day major adverse cardiovascular events (MACE) were similar: 9.7 percent for those with Medicaid, 5.5 percent for those with Medicare, 8.1 percent for those without insurance and 2.2 percent for patients who held private insurance.

“Patients who had private insurance did better in terms of late outcomes and there were no differences between those who were not insured and those who were insured by the government,” Waksman said.

“Patients who were uninsured or even government insured were sicker than those who held private insurance, which may tell us that maybe patients who are privately insured are more aware of their health and are taking care of risk factors,” he said.

“What was surprising was to find out that there is sometimes no difference in the outcome whether you are insured or uninsured,” Waksman noted. “This tells us that insurance does not guarantee good procedural outcomes and that you always have to invest in your healthcare in terms of watching risk factors and taking medications.

"Just having insurance is not sufficient. There are other factors that impact the outcome of the patient,” he said.

In terms of healthcare reform, Waksman said that providing free insurance to all may not work. He said that educating patients on how to get good use of insurance and the best care will be the key to improving outcomes.

“I think that it is nice to have access to care for everyone, but that doesn’t guarantee people will use it,” he noted. “Patients must be aware that they have conditions like hypertension or diabetes, for example, and having access to free care doesn’t necessarily bring them to the level of healthcare that we all want to see.”

The better health of those with privately held insurance may be due to their higher socioeconomic level and better awareness about preventive care, he said.

The key issue is focusing on getting patients optimal care and outcomes, rather than access to healthcare for free. He noted that while the healthcare reform bill is attempting to provide access to care for everyone, it may not translate into better patient outcomes.

“Patients who do pay for their healthcare are probably more motivated to take care of the problems they have and services they recieve. My concern is that by just providing free care without having the motivation and education of the patients, will not make many differences on outcomes,” he concluded.