• Some good comments on Medicaid outcomes studies

    Just in case folks don’t read comments, here are some good ones by steve and another by Jay related to my recent posts about Medicaid coverage, outcomes, and policy implications. In particular steve asks some great questions:

    I would bet almost anything that they do not look at all of the social factors that would contribute to worse outcomes for a Medicaid population. Docs dont generally look for those. If you are uninsured, how long have you been uninsured? Are you working if you are uninsured? What is the functional capability of someone on Medicaid not working vs someone uninsured who is working? Which group is more likely to have communication problems? Which group is more likely to give a better history? Which group is more likely to get family support? Which group is staff more likely to dislike?

    I look forward to some answers.

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    • I think Avik has it right with Mcaid and association with poorer outcomes, but not for the reason he states, mainly poorer payment for docs (Steve has it right with SES–too complicated to untangle). I dont have recall of the citations, but many of these types of studies I have read demonstrate poorer outcomes post-op, intrahospital, and after discharge. This attenuates some of the payment issues, and indicates a stronger predilection for poor patient substrate. I would also like to see the abstract that he cites peer reviewed and published.

      Additionally, he cites volume at hospitals as a strong indicator for quality. That has been dogma for some time, and always took it as a truism, but a NEJM 2010 study gave me pause.

      http://content.nejm.org/cgi/content/full/362/12/1110

      Looking at public vs private (proxy for Mcaid treatment), has more to do with hospital size and a “threshold.” A passage in discussion:

      “Despite this association between hospital volume and mortality, we observed heterogeneity among the hospitals. Many patients who were admitted to low-volume hospitals had excellent outcomes, whereas many other patients who were admitted to high-volume hospitals had poor outcomes. For medical conditions, volume alone does not appear to be a proxy for hospital outcome.”

      That is not to say there is no relationship, but Mcaid probably has less to do with this than other factors.

      Anyway, Medicaid has its problems–we all know–payment being one. However, probably a smaller contributor to outcomes than other variables.

      Brad