- The Washington Times - Thursday, March 13, 2003

CHICAGO, March 13 (UPI) — A new study indicates patients on Medicaid and the uninsured are less likely to undergo an angiogram than patients with commercial insurance plans.

The study by Dr. Leslie Cho, assistant professor of cardiology at Loyola University Chicago Stritch School of Medicine, examined the insurance status of 6,612 people who suffered severe chest pain or other heart attack symptoms. It found those with commercial insurance were twice as likely as Medicaid patients to undergo angiograms, which measure blood flow through the arteries supplying the heart and can detect advanced coronary artery disease before it causes heart muscle damage. Those without any health insurance received the tests 69 percent of the time.

The study was published Thursday in the American Journal of Cardiology.

The Census Bureau reported in September that 41 million Americans are without health insurance and an analysis by Families USA indicated nearly 75 million people under 65 were without coverage for at least a portion of 2001 or 2002. About 36 million Americans are covered by Medicaid or the Children's Health Insurance Plan, according to the Kaiser Family Foundation.

Dr. Uwe Reinhardt, a health care economist at Princeton University, said the results are not surprising.

The study also found insurance status made a difference in the kinds of medications prescribed. Use of aspirin, beta-blockers and lipid-lowering drugs were highest among those with private insurance and lowest among Medicare beneficiaries. Use of nitrites for those with chest pains was highest among the uninsured.

"There appears to be some bias on the part of physicians when they offer treatment for patients with acute coronary syndrome based on what kind of insurance the patient has," Cho said.

Reinhardt said bias definitely is at work.

"I have said this for years: What America has to understand — we teach this to freshmen in economics — that prices, the prices we offer producer signal the value we put on them," Reinhardt said. "When a state legislator budgets $10 for a pediatric visit for a Medicaid child but same legislator is willing to budget $60 to have his own child seen, the legislator signals to pediatrician the relative value of the doctor's work if applied to the poor child and the rich child.

"The fault does not lie with the doctors or the hospitals. The fault lies on payment system. We have created a payment system that screams at doctors and hospitals to ration health care by economic class. When doctors and hospitals act on these signals, we all get in a huff and very surprised."

Overall the study found patients with unstable angina or acute myocardial infarctions with heart tissue damage not apparent on electrocardiograms who had private health insurance were more likely to receive coronary angiograms than those enrolled in managed care, Medicare, Medicaid or without any insurance.

When taking age, gender and ethnicity were taken into account, Medicare and managed care patients received coronary angiograms at about the same rate as those with private health plans.

No differences were found among patients who suffered heart attacks that showed up on electrocardiograms indicating heart muscle damage.

"Apparently the decision not to order a coronary angiogram is being made mostly in cases where the indications that the patient has suffered a heart attack are less certain," Cho said. "However, this practice is not consistent with the latest research findings, which clearly indicate that patients presenting with unstable angina benefit from cardiac catheterization."

Cho said though the study did not show a difference in survival rates after six months, that likely is because the sample was too small — 733 uninsured and 250 Medicaid patients. Previous larger studies have shown patients with unstable angina who receive coronary angiograms are more likely to survive than those who do not.

Cho said the study demonstrates a gap in medical care for the uninsured and the poor that should concern both doctors and society as a whole.

"I'm not sure how to get around it but we need to offer all patients the same high standard of medical care — not a multi-tiered system where people who don't have insurance are subjected to a lower standard of care," Cho said.

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