Stroke patients fare better with private insurance than with Medicaid

The uninsured and Medicaid patients were also more likely to develop a new medical condition in the hospital, according to a study published recently in the Journal of Neurosurgery. The study was the largest and most comprehensive analysis of how insurance status relates to stroke outcomes in the United States. Researchers analyzed nationwide data from more than 1.5 million hospital admissions involving stroke patients between 2002 and 2011.

The most concerning part of the findings was the statistically higher rate of patient-safety issues for those without private insurance, as well as their higher death rate, longer stays and worse outcomes, researchers said. Among Medicaid and self-pay patients, 5.1 percent of stroke victims died in the hospital, compared with 4.4 percent of those with private insurance.

That doesn't mean hospitals treat people differently based on their insurance status, said Maryam Rahman, M.D., an assistant professor in the UF College of Medicine's department of neurosurgery and the study's principal investigator. Rather, the difference in mortality rates and medical outcomes between Medicaid patients and those with private insurance may be influenced by what happens before they arrive at a hospital.

"This is most likely related to the fact that Medicaid and uninsured patients don't have access to primary preventive care the way insured patients do," Rahman said. "In general, they're going to be a sicker population with higher obesity rates and a greater rate of uncontrolled diabetes. That's going to influence how they do with any diagnosis."

Patients with Medicaid or no insurance are often in worse shape due to many factors, Rahman said. Stroke outcomes in particular are dependent on how quickly a patient gets medical attention.

"They may not be recognizing the symptoms in a timely fashion or getting to the hospital soon enough," she said.

Once hospitalized, those with Medicaid or no insurance also fared differently, the study found. Medicaid and uninsured patients were more likely to suffer from pressure ulcers, respiratory failure and infections. Still, privately insured patients weren't immune from so-called patient-safety indicators: They were more likely to have postoperative bleeding, pulmonary embolism and accidental cuts and punctures than Medicaid patients, the study found. Overall, 22.8 percent of Medicaid and self-paying patients had some type of patient-safety indicator, compared with 13.6 percent of patients with private insurance.

Stroke patients with private insurance may also have other advantages that improve their outcomes, such as better access to inpatient rehabilitation services once they leave the hospital, said Kyle Fargen, M.D., the study's lead author, an assistant professor of neurosurgery at the Medical University of South Carolina. Fargen was a resident in the UF College of Medicine's department of neurosurgery when the journal article was written.

"This really does suggest that patients without private insurance are not getting the quality of care that privately insured patients are getting," Fargen said.

The findings can be put to use in several ways, including a better understanding of the factors that put some people at higher risk for poor outcomes after a stroke, the researchers said. Hospitals that treat higher-risk Medicaid patients with more complicated medical histories shouldn't necessarily be graded the same way as hospitals with more privately insured patients, Rahman said. The study's findings should also be useful to government officials who want to know that health care money is being spent effectively, she said. Fargen said it's likely that health care quality measures will someday be tied very closely to the reimbursements that hospitals get for treating Medicaid and other patients with government-funded health care.