Hospital mortality rates by payment source
Mortality in California Hospitals, 2006
State of California
Office of Statewide Health Planning and Development (OSHPD)
November 2008
In-hospital mortality refers to deaths that occur to patients during the time they are hospitalized.
The data sources for these analyses were the Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data for 2006, which includes death certificate data for 2006 and information for all patients who were hospitalized in California during that year.
Patients paying for care out-of-pocket were 80% more likely to die (Odds Ratio = 1.8) and patients covered by Medi-Cal were 60% more likely to die (Odds Ratio = 1.6), compared with patients covered by private insurance. (From a table in this report, the odds ratio for Medicare was 1.1.)
http://www.oshpd.ca.gov/HID/Products/Research_Briefs/Brief1_rev.pdf
Comment:
By Don McCanne, MD
Although it is tempting to say that being uninsured causes an 80 percent higher death rate for hospitalized patients, and being on Medi-Cal (California’s Medicaid) causes a 60 percent increase in deaths, these population sectors undoubtedly varied in factors other than simply the source of payment for their hospital bills.
For this study, privately insured patients were the reference source (i.e., the base of 1.0 to determine the odds ratio for those with other payment sources). Privately insured patients in California include primarily the younger and relatively healthy workforce and their healthy families, plus those able to pass underwriting standards in the individual health insurance market. It would not be unreasonable to assume that this group would have a lower in-hospital death rate than groups that include older individuals and individuals with greater medical problems.
Medi-Cal is a welfare program for low-income people, a group with other demographic factors that could put them at greater risk of facing lethal medical conditions. The Medi-Cal program is severely underfunded, and that has reduced participation by health care providers, significantly limiting access to care for this more vulnerable population. For this reason health care reform that includes a role for Medicaid is problematic. Although eliminating Medicaid would not eliminate the other negative health factors for this group, a uniform financing system for everyone at least would reduce financial barriers to access.
Of greater concern is the very high death rate in the self-pay group (uninsured). These are people under 65, 80 percent of whom have a head of household who is employed. This is the “working America” sector, but with more modest incomes on average, and in jobs without affordable employer-sponsored health plans. This is a group in which other demographic variants are not nearly as great as this one single factor of not having health insurance. The benefits of health care reform that would include this group in a uniform financing system for everyone are obvious.
The Medicare numbers are interesting. The Medicare sector includes seniors and individuals with long-term disabilities, creating the largest high-risk insurance pool in the nation. You would expect this group to have a much higher death rate than the younger, healthier privately insured sector. Yet Medicare patients have only a 10 percent higher in-hospital death rate than do those from the healthiest sector of our population. Undoubtedly privately insured patients who are hospitalized have developed significant problems, separately them from their peer group. That likely explains why they have an in-hospital death rate approaching that of the high-risk Medicare population.
The real, non-intuitive, take-home lesson is that Medicare patients have an in-hospital death rate that is much lower than the uninsured, much lower than Medi-Cal patients, and that is close to the death rate of the younger, privately insured patients.
Medicare is a program that works. With some improvements, it would serve all of us well while eliminating the waste and inequities of our dysfunctional, fragmented, multi-payer system.