Higher Death Rate for AIDS Medicaid Patients

Less than half as likely to undergo medical test to diagnose pneumonia

CHICAGO -- Medicaid patients treated for AIDS-related Pneumocystis carinii pneumonia (PCP) are 75 percent more likely to die than those with private insurance. That's the major finding of the largest quality of care study of AIDS patients ever conducted, reported by researchers at Northwestern University Medical School, Duke University Medical School, the RAND Corporation and the Department of Veterans Affairs. The study, published in November by the American Lung Association, determined that variations in health insurance status caused dramatic differences in death rates and when diagnostic bronchoscopy for PCP was performed. Patients' health insurance status was categorized as self-pay, Medicaid or private insurance carrier. In addition to their high mortality rate, Medicaid patients with AIDS-related PCP were found to be less than half as likely to undergo bronchoscopy or to have their diagnosis of PCP confirmed. Those who did undergo bronchoscopy received it later in their hospital stay than privately insured patients.

Low Medicaid reimbursement for test may be an important factor affecting outcome

According to Charles L. Bennett, M.D., associate professor of medicine at Northwestern, who headed the study, low Medicaid reimbursement for bronchoscopy may be an important factor affecting outcome and death rates. In California, physicians receive about $150 for a bronchoscopy performed on a MediCal patient, while private insurance carriers reimburse around $550 for the same procedure. In New York, Medicaid reimburses $70 for performing a bronchoscopy, while private carriers reimburse $700. "Research has shown that bronchoscopy is associated with a lower risk for death and that it can provide a definitive and timely assessment of a diagnosis of PCP as well as other serious pulmonary infections and malignancies," Bennett said. "Failure to confirm the cause of pneumonia in patients with HIV infection may be associated with high mortality rates due to treatment with a particular set of medications when different or additional antimicrobial agents or other therapies would be indicated," he said. The researchers studied the records of 890 patients from 56 private, public and community hospitals in Chicago, Los Angeles and Miami. Los Angeles has the second-largest number of reported AIDS cases in the United States; Miami ranks fifth, and Chicago eighth. According to Bennett, Medicaid patients were younger and more likely to be African-American and injection drug users than those with private insurance. Self-pay patients were intermediate between privately insured patients in terms of race and ethnicity distribution. Self-pay patients also were most likely, and Medicaid patients least likely, to be homosexual males. The study also showed that: Almost 60 percent of the Medicaid patients were admitted to a county or state hospital, while approximately 75 percent of the privately insured patients were admitted to religious affiliated or voluntary hospitals. Medicaid patients were more likely to be treated at hospitals with medical school affiliations. Medicaid patients also were more likely to be admitted to hospitals that provide care to large numbers of patients with AIDS. Miami had the highest number of Medicaid patients, and Los Angeles had the largest proportion of patients with private insurance. Severity of illness on admission was also strongly associated with insurance status. A significantly higher proportion of Medicaid patients had more severe illness at admission than those with private insurance. Significantly fewer Medicaid patients had confirmed PCP; rather, they were presumed to have PCP and were treated without confirmation of the diagnosis.

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