Another Media Failure Over A Questionable Study: Medicare Associated With Increased Trauma Deaths? No Better Than NOT Having Insurance?

Did you know that Americans with Medicare health insurance have a higher adjusted mortality rate from trauma compared to persons with commercial insurance?

The Disease Management Care Blog explains.

According to numerous news outlets such as ABC News, MSNBC, the Huffington Post and Reuters, a study's been published that shows that not being insured at the time of hospitalization for trauma leads to a higher death rate. Adding to the drumbeat of liberal dismay over lives lost for lack of a public option, this research by Rosen and colleagues, published in the prestigious Archives of Surgery, shows there are 'sky high' death rates (Democratic Underground) that are 'shocking' (Daily Kos) and could be the evil consquence of 'less enthusiasm on the part of providers.... once it was realized they would not be compensated' (Physicians for a National Health Program). Of course, the luster of this scientific report was only enhanced further by the inclusion as author of superstar surgeon Atul Gawande, that (in)famous author of the New Yorker article that used the shortcomings of single outlier McAllen Texas to call the entire U.S. healthcare system to task.

Like the media, should the DMCB be impressed by a published study in a prestigious journal by rock star authors? Just take their word for it? Actually no, because the purpose of peer reviewed literature is to allow readers to assess the research findings and decide for themselves. It's called trust, but verify.

So, unlike the attention-deficit disordered denizens of the oxygen-deprived mediasphere, the DMCB responded in a novel way. It decided to pull the study and actually take the time to read it.

Here's what it found. Data from 2.7 million U.S. hospitalized patients were mined, looking for correlations between death and insurance status while mathematically neutralizing the effect of age, gender, race, the type of trauma center as well as the type of trauma. Persistent and statistically significant correlations were found between dying and a) increasing age, b) race (being black plus young) c) the severity and mechanism of the trauma (for example penetrating injury is bad), d) an increased number of comorbid illnesses and e) insurance status.

In fact, two types of insurance status had statically significant associations with a higher death rate: 1) not having any health insurance and 2) being on Medicare. If you look at the graphic from the study, you'll see that compared to commercial insurance, Medicare had a statistically significant odds ratio of a higher death at about 1.5, while no insurance was also high at 1.8. Look carefully, because the lack of an asterix means the finding is statistically significant.

The DMCB thoughts about the implications:

1) What should the 'comparator' be? We don't know. One separate study used managed care as the baseline while this other study used Medicare. Since there is no generally accepted baseline for research like this, the author's choice of using commerical insurance as the gold standard in this article made not having insurance look bad. If Medicare had been the standard, persons without health insurance probably would not have turned out to be worse. Even more ironically, managed care (accounting for the majority of U.S. commercial insurance) would have turned out looking better. Interestingly, the authors neglected tell us why they chose this approach.

2) Are the authors (and the Archives' editors) politically motivated? There is one explanation for the use of the commerical comparator: it's a ringer that makes everyone else look bad. What's more, failing to mention that Medicare insurance status was also associated with lower survival rates is either a monumental lapse or an intentional attempt to understate a finding that is also important. Knowing that policy makers, media and many readers won't get past the title ('Downwardly Mobile. The Accidental Cost of Being Uninsured'), the abstract (no mention) and some juicy interviews, only half the story is being told. The full story is that when it comes to trauma care, giving everyone Medicare-style insurance is no better than no health insurance at all. This is a great example of framing, especially since the asterix seem to call the readers' attention away from Medicare's inconvenient......

3) Are some other potential explanations? While a lack of health insurance is associated with poor health outcomes, it is also known that having poor health leads to lack of insurance. Accordingly, the mathematical 'signal' from being nominally 'uninsured' in this study may really be due to the influence of unmeasured health or other issues that were not captured in the data base. That's called systematic bias and it went completely unmentioned as a potentional shortcoming in the authors' discussion of their results. Assuming the results are real, the DMCB believes post-hospitalization care (rehab and outpatient) is generally not well covered and coordinated under Medicare, which in turn leads to problems.

4) Association is not necessarily causality. Just because not having insurance is associated with death from trauma doesn't mean giving this poverty-prone population insurance will reverse things any more than the association between white hair and more heart attacks (due to age) can be fixed by dying everyone's hair black. Likewise unmentioned by the authors.

Once again, the media has demonstrated its shortcomings. What's more, the peer reviewed process has shown how necessary it is to look at the results for yourself: you can't always count on the authors or the editors to look at all sides of the data or rise above their prejudices. Lastly, there's an old joke out there that is sometimes told by us general internists: how do you create a double blind study? Get two or more surgeons involved.

This publication was double binded.

At the time of this posting, the DMCB had an email into the author asking for feedback. None yet

An Example of How the Mainstream Media Fails When It Comes to Health Care Policy

The Disease Management Care Blog has generally shied away from commenting on the mainstream news' peculiar ability to misinform the public thanks to considerable medical illiteracy, shrilly sensationalism, political bias and a remarkably lazy ineptitude. But it cannot resist after it made a big mistake and watched the November 12 ABC’s ‘World News with Charles Gibson’ tonight. Below is slightly edited blue text taken from a segment morosely titled how “Americans Cut Back on Medical Care.” Commentary from the DMCB is in black.

'Bette Corbett says it seems that every day, she gets a new medical bill for the chemotherapy treatment for ovarian cancer…. After paying for the basics, such as food and gas, the 52-year-old who lives outside Boston says she cannot seem to make ends meet. Her doctors recommend she get a CT scan to see whether her cancer is progressing, but Corbett has decided not to, at least for now….'

It is not uncommon for the media to open with a compelling anecdote to set the stage. In this instance, a heart-breaking yet highly lethal (45% survival at 5 years) and relatively uncommon (8.5 to 16 per 100,000) condition was chosen, probably less on the merits of any generalizable lessons and more on its ability grab the viewer’s attention. From the synopsis above, it sounds like the patient has gone through a first round of treatment. Accordingly, the purpose of a CT scan is to monitor for a relapse. Unfortunately for persons with relapse, cure is generally not possible. Lead time bias and the comfort of knowing what's going on aside, does forgoing a CT scan make that much of a difference, really? It does for Bette, but first dollar coverage of all high dollar imaging with questionable value makes for lousy policy.

'Even though Corbett has medical coverage through her job as a customer service agent, she says she cannot afford the rising deductibles and co-pays, and is close to meeting the cap on her insurance.'

Bette’s employer chose an insurance policy that cannot afford to fully cover the rising cost of health care services. Co-pays and deductables are a time honored approach to keeping the monthly premium down, which is not only linked to the ability of companies to maintain higher levels of employment, it is what Bette’s fellow employees would probably prefer. There are two lessons here: 1) when it comes to insurance, you get what you pay for and 2) Massachusetts’ (where Bette lives) universal coverage falls short of assuring access to care. Now onto to the bigger picture....

'According to a recent survey by the Kaiser Family Foundation, nearly half of Americans report that someone in their household skipped necessary health care in the past year because of the cost. Just over one-third said they've put off or postponed needed care, and three out of 10 said they've skipped a recommended test or treatment…. Some doctors worry that the economic crunch will cause controllable conditions to escalate into major medical problems.'

You can find the report here. It’s based on a nationally representative same of over 1200 adults. Yet, the real question is what is the prevalence of skipping and postponing care among persons with employer-based insurance? As for 'the doctors,' research has demonstrated that many, not 'some,' doctors don’t worry at all about the escalation of controllable conditions. Their inertia, not an 'economic crunch,' is the bigger problem.

'"What you think is a simple thing you can skip, becomes a disaster, a medical disaster, and the difference between life and death," said Dr. Richard Penson, the clinical director of medical gynecologic oncology at Massachusetts General Hospital.'

Medical disaster? The difference between life and death? At this point, the DMCB lost track of what simple test we were talking about. One thing is pretty clear from the peer review literature, however. While doctors disappoint when it comes to preventive medical management, we love to test. Much of the literature is devoted to helping physicians intelligently skip the testing that is one ingredient in making health care the disaster, and the difference between solvency and bankruptcy.

'Jean Mitchell, who researches health care at Georgetown University's Public Policy Institute, thinks the problem is not just people who have lost their jobs and, therefore, cannot afford treatment, but also people who are still employed and have to pay high co-pays on their insurance plans. "Even for people who have insurance, they are faced with paying an increasing share of the health insurance bill out of pocket, which makes them question whether they really need each type of health care service," said Mitchell.'

That is one credible perspective, but at the same time, Aetna has been selling a consumer directed health plan with an increased share of the bill that they say has not prompted persons with diabetes to skip services. Maybe they’re misstating the numbers outside of a peer review setting. A better analysis is this one, which showed an approximate 4% increase in the number of consumers that were forgoing care. As money gets tighter, that number will go up, but this is hardly the kind of widespread epidemic of substandard care implied in this news segment.

'On top of the cost of a doctor's visit is the expensive trip to the pharmacy. Patients taking multiple medications are plagued by higher costs.'

Whoa! Talk about a two-sentence drive by shooting. Nothing like spreading the blame to include that favorite whipping boy, big bad pharma. By the way, most health plans fund medications outside of the medical benefit, but that wasn't mentioned. The DMCB is surprised ABC didn't toss in the health consequences of global warming.

'More Americans find themselves forced to choose between short-term survival and long-term health. For Corbett, whose bills are mounting, postponing her CT scan is an unforeseen repercussion of the crumbling economy.'

Even before this news segment aired, it was pretty clear that more Americans are confronting the rising costs of health care and are being forced to make tough decisions. Now more than ever, viewers need to know just how which Americans, to what degree and in what sectors of health care. Based on the half truths and framing of this faux analysis, millions of American citizens have made no progress in understanding what we're up against. No wonder evening news viewership is declining.

Coda: Could it have gotten any worse you ask? Later on in the same broadcast, viewers were informed by ABC news about that public health menace called shopping carts.