Dr. Sarah Lyon and colleagues of the University of Pennsylvania published a study Monday comparing the experiences of insured versus uninsured patients in intensive care units across the state of Pennsylvania. What they found is just more evidence that lacking health insurance can mean worse health outcomes. Obviously the mechanism by which being uninsured leads to poorer health would have to do with differences in health care utilization between the insured and the uninsured, but how much of that difference is driven by the patients and how much is driven by the providers isn’t entirely clear.
The study was based on nearly 167,000 non-elderly patients admitted to an ICU in Pennsylvania from 2005 to 2006. Dr. Lyon’s group found that uninsured ICU patients were 21 percent more likely to die within 30-days post-admission than their insured counterparts. Of course, it’s possible that the uninsured arrive at the ICU in worse condition than the insured–the result of persistent financial barriers to care–or that the uninsured differ from the insured in other important ways. The study isn’t able to control for every conceivable factor.
What’s more concerning, though, is that health care providers may go about treating uninsured patients differently than they treat insured patients. You might hope that such things wouldn’t happen, but we have ample evidence that physicians who deny having any racial prejudices do demonstrate different courses of treatment based on the patient’s race. So, it’s plausible that physicians might pursue different treatments for the two groups. This would also help to explain why the disparity in mortality was observed within the same hospital. In other words, it isn’t because the uninsured get sent to the worst hospitals while the insured get sent to the best hospitals. On the contrary, the difference seems to be taking place either before the patient gets to the hospital or after they’re admitted. The authors carefully couch their discussion to avoid placing blame on providers by using the standard academic conclusion “more research is needed.” But, if I had to guess, I think it’s probably a combination of both patient and provider factors. Uninsured patients probably have more comorbid conditions than insured patients, and providers probably treat insured patients more aggressively because they and the hospital know that they will be paid for those services. I suppose everything really does have a price.