Popescu Ioana, Heslin Kevin C, Coffey Rosanna M, Washington Raynard E, Barrett Marguerite L, Karnell Lucy H, Escarce José J
*Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles †RAND Corporation, Santa Monica, CA ‡Agency for Healthcare Quality and Research, Rockville, MD §Truven Health Analytics, Bethesda, MD ∥ML Barrett, Inc., Del Mar, CA.
Med Care. 2017 Feb;55(2):148-154. doi: 10.1097/MLR.0000000000000633.
Research suggests that individuals with Medicaid or no insurance receive fewer evidence-based treatments and have worse outcomes than those with private insurance for a broad range of conditions. These differences may be due to patients' receiving care in hospitals of different quality.
We used the Healthcare Cost and Utilization Project State Inpatient Databases 2009-2010 data to identify patients aged 18-64 years with private insurance, Medicaid, or no insurance who were hospitalized with acute myocardial infarction, heart failure, pneumonia, stroke, or gastrointestinal hemorrhage. Multinomial logit regressions estimated the probability of admissions to hospitals classified as high, medium, or low quality on the basis of risk-adjusted, in-hospital mortality.
Compared with patients who have private insurance, those with Medicaid or no insurance were more likely to be minorities and to reside in areas with low-socioeconomic status. The probability of admission to high-quality hospitals was similar for patients with Medicaid (23.3%) and private insurance (23.0%) but was significantly lower for patients without insurance (19.8%, P<0.01) compared with the other 2 insurance groups. Accounting for demographic, socioeconomic, and clinical characteristics did not influence the results.
Previously noted disparities in hospital quality of care for Medicaid recipients are not explained by differences in the quality of hospitals they use. Patients without insurance have lower use of high-quality hospitals, a finding that needs exploration with data after 2013 in light of the Affordable Care Act, which is designed to improve access to medical care for patients without insurance.
研究表明，与拥有私人保险的人群相比，参加医疗补助计划（Medicaid）或没有保险的人在多种疾病的治疗中接受循证治疗的次数较少，且治疗效果更差。这些差异可能是由于患者在不同质量的医院接受治疗所致。
我们使用了2009 - 2010年医疗成本和利用项目州住院数据库的数据，以确定年龄在18 - 64岁之间、患有急性心肌梗死、心力衰竭、肺炎、中风或胃肠道出血且分别拥有私人保险、参加医疗补助计划或没有保险的住院患者。多项逻辑回归分析根据风险调整后的院内死亡率，估算了入住被分类为高、中、低质量医院的概率。
与拥有私人保险的患者相比，参加医疗补助计划或没有保险的患者更有可能是少数族裔，且居住在社会经济地位较低的地区。参加医疗补助计划的患者（23.3%）和拥有私人保险的患者（23.0%）入住高质量医院的概率相似，但与其他两组保险患者相比，没有保险的患者入住高质量医院的概率显著较低（19.8%，P<0.01）。考虑人口统计学、社会经济和临床特征并未影响结果。
先前指出的医疗补助计划受益人的医院护理质量差异，并不能通过他们所使用医院的质量差异来解释。没有保险的患者对高质量医院的利用率较低，鉴于旨在改善没有保险患者获得医疗服务机会的《平价医疗法案》（Affordable Care Act），这一发现需要利用2013年以后的数据进行探究。
