Does your insurance card matter when you have a heart attack?

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Medicaid reimbursement to healthcare facilities on ST-elevation myocardial management—or STEMI, a serious form of a heart attack—is often lower when compared with the reimbursement rate of private insurance, according to a study published in the journal Circulation: Cardiovascular Quality and Outcomes. The findings were made by a team of cardiovascular researchers at the University of Alabama (UAB; Birmingham, USA).

Utilising the largest in-patient database—the National Inpatient Sample—investigators from UAB summarised the impact of the reimbursement gap between Medicaid and private insurance on management and in-hospital outcomes among patients admitted for STEMI.

Medicaid is the largest federally funded health insurance program in the United States, covering nearly 73 million people. Implementation of the Affordable Care Act and expansion of Medicaid has allowed more than 15 million previously uninsured individuals to gain healthcare coverage.

However, Medicaid reimbursement to the healthcare facilities is often lower as compared with private insurance. Researchers say that, in principle, the reimbursement rates should have no effect on healthcare outcomes, especially to those requiring immediate assistance such as with a heart attack, where there is abrupt blockage of a heart artery with changes on the electrocardiogram.

In this nationwide retrospective study from January 2012 through September 2015, researchers found that Medicaid beneficiaries with STEMI had significantly lower rates of coronary revascularisation and higher rates of in-hospital mortality compared with the privately insured.  Medicaid beneficiaries with STEMI were more likely to receive bare metal stents, while those with private insurance were more likely to receive drug eluting stents for coronary revascularisation.

Additionally, the rates of coronary angiography and utilisation of thrombolysis were also significantly lower in Medicaid beneficiaries compared with privately insured with STEMI. The rates of invasive hemodynamic support and median length of stay were similar between Medicaid beneficiaries and privately insured with STEMI. However, the cost of STEMI hospitalisation was higher among Medicaid beneficiaries compared with privately insured.

“The finding of disparities in management and in-hospital outcomes by insurance status can be explained by Medicaid’s complex payment system—base plus supplemental payments and reimbursement rates”, said senior author Pankaj Arora, an assistant professor in UAB’s Division of Cardiovascular Disease.

He continued: “Historically, Medicaid pays roughly 90 percent of the cost incurred to the hospitals, whereas private insurances typically remunerate roughly 144 per cent of the cost of the service provided by the hospital. After the execution of the Affordable Care Act, hospitals are getting a higher number of Medicaid beneficiaries, which has distorted the hospital payer mix—pooled Medicaid and private insurance payment basket.”

Additionally, Arora said mandated federal spending cuts through the Tax Cuts and Jobs Act of 2017 may further exacerbate the disparities in quality of health care for Medicaid beneficiaries. He cautioned that there can be bias, or residual confounding, in an observational study, but he said that their findings of disparities by insurance status in treatment of heart attack are intriguing and underscore the importance of additional research to identify and understand the reasons behind these disparities.

Authors emphasised the need to dedicate efforts to customise healthcare reforms by increasing transparency on policymaking decisions and the overall process, restructuring reimbursement policies for life-threating conditions and lifesaving procedures independently, increasing the supplemental payments to solidify Medicaid reimbursement, and timeliness of supplemental payments to hospitals and healthcare providers to avoid distorting the payer mix as possible solutions to improve the disparities.

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