Quality of Care Differences by Insurance Status at Community Health Centers
Filed under: Community Health Centers, Medicaid, Medical Journals, Medicare, Private Insurance
by Maggie Osterberg via flickr
On the heels of President Obama’s announcement designating $155 million to establish 126 new community health centers across the country, a study recently published in the American Journal of Public Health found that these centers do not provide the same quality of care to all their patients. These centers, also known as Federally Qualified Health Centers or safety net providers, are intended to “enhance the provision of primary care services in underserved urban and rural communities.” Unfortunately, studies appear to indicate that even within the confines of the same community health centers, quality of care received by patients varies depending on insurance status — those with private insurance receiving the best quality of care and those without insurance at the opposite end of the spectrum.
In their article, Insurance Status and Quality of Diabetes Care in Community Health Centers, Zhang et al. found that uninsured patients were the least likely to satisfy specified diabetes quality of care measures and Medicaid patients’ quality of care closely resembled that of the uninsured. It might be tempting to explain away this phenomenon by pointing out that this study is limited only to diabetes care and may not be representative of quality of care overall. This assertion, however, may be at least somewhat quelled by a study published last year in Inquiry, where Bradley et al. found a similar pattern in breast cancer patients treated in a safety net setting. In that study, Differences in Breast Cancer Diagnosis and Treatment: Experiences of Insured and Uninsured Women in a Safety-Net Setting, researchers found that within the same safety net setting, “insured women with breast cancer were diagnosed with smaller tumors and at earlier disease stages, and received surgery and initiated chemotherapy considerably faster than otherwise similar uninsured women.”
So, how could quality of care disparities exist in a safety-net setting whose very goal is to “enhance” care to the underserved? Zhang et al. point to a study that suggests “physicians incorporate their patients’ health insurance status into their clinical decisionmaking and acknowledge that they frequently alter their clinical management as a result, including changes in preventive services, diagnostic evaluations, and therapeutic treatments.” Whether this explains quality of care variations in a safety-net setting, however, is open to question as a patient’s access to treatment is presumably not affected by insurance matters or ability to pay.
Bradley et al. suggest that the larger tumors found in uninsured women reflect poor access to care and cancer screenings because too few mammography providers are available or because the uninsured are not aware of low cost screening options. Reasons for differences in timeliness of treatment were less clear, but the study notes that uninsured patients were twice as likely to miss their appointments as were their insured counterparts. It is also important to note that in this study, although still part of the Virginia Commonwealth University Health Care System’s Massey Cancer Center (the safety net provider at issue in this study), women were treated in two different outpatient facilities on the basis of insurance status. Insured women were treated in a suburban facility whereas uninsured women were treated at the downtown location (also the location of inpatient care for both the insured and uninsured alike.) The study points out that the downtown outpatient facility used to treat the uninsured could have been overburdened and unable to “see patients in a timely manner,” contributing to a delay in receipt of necessary treatment.
Where problems involving quality of care to the uninsured in safety net settings are due to funding issues, i.e., “too few mammography providers,” “overburdened” facilities, and/or variations in compensation for medical service based upon insurance status– providing more money and opening more clinics could help alleviate them. If the problem is one where physicians themselves treat patients differently by virtue of their insurance status or the uninsured have obstacles in the way of their care that transcend payment issues but reflect a social system where patients’ healthcare is competing with more urgent life circumstances, merely opening more community health centers may not be the answer. Bradley et al. provide a fitting conclusion: “Our evidence suggests, therefore, that safety-net institutions — at least as they currently operate — are only a partial substitute for health insurance, and that a more comprehensive alternative for uninsured patients is needed.”
