Medicaid and Medicare Health Outcomes Survey

According to a May 2022 report released by the U.S. Department of Health and Human Services Office of Inspector General (OIG), approximately 1 in 4 Americans (25%) suffered either temporary or permanent harm during hospital stays in October 2018. These adverse health events occurred under Medicare coverage, which is one of the largest health coverage providers in America. In fact, almost 80 million Americans receive Medicare coverage.

While this newly released statistic is alarming, it shows a slight decrease in patient harm over the last decade. According to an OIG study released in 2010, approximately 27% of Medicare patients were harmed during their hospital stays in October 2008. This original study estimates that about 50% of these adverse events in community hospitals were preventable. These harmful events were also very expensive, costing Medicare health insurance about $324 million in reimbursements and deductibles. 

The goal of federal government studies like these is to improve American health care and patient safety. This is due to the alarming number of annual deaths caused by medical malpractice. In fact, a 1999 report released by the Institute of Medicine (IOM) claims that medical errors in hospitals cause up to 100,000 American deaths every year. Since the IOM released this report, the United States government, health care providers, and medical insurance companies have been working together to create fewer medical errors. For example, one of the most common and most dangerous medical errors in the U.S. involves prescription drugs. A 2019 report from the Academy of Managed Care Pharmacy (AMCP) estimates that medication errors and drug injuries in hospitals alone rack up approximately $3.5 billion every year.

Types of Harm That Medicare Patients Experienced

The OIG study included 770 patients covered by Medicare health insurance. These patients suffered two main types of harm in October 2018. 12% suffered from adverse events which resulted in permanent injury, longer hospital stays, life-saving interventions, and even death. Meanwhile, 13% experienced health events that only caused temporary harm. The temporary harm may have required some kind of medical intervention, but unlike the patients who suffered from adverse events, these patients didn’t need longer hospital stays or life-saving interventions. 

The study breaks down the specific harm events even further. It states that 43% of the hospital patients involved in this study were harmed by medication errors. Medicare prescription drug coverage had to cover the costs of all extended hospital stays and life-saving interventions. Meanwhile, 23% of the harm events were caused by a lack of proper patient care, 22% were caused by procedures and surgeries, and 11% were caused by hospital-acquired infections.

Preventability of These Harm Events

To make these statistics scarier, the OIG study also claims that 43% of these harmful events were completely preventable. This means that Americans are suffering from more medical trauma than they have to because doctors aren’t taking proper care of their patients. This study also concludes that about 56% of harmful events weren’t preventable despite medical professionals following proper protocols.

Costs of Harm Events to the Centers for Medicare/Medicaid Services (CMS)

23% of the 770 patients who suffered either preventable or nonpreventable harmful events needed more medical treatment. Naturally, this medical treatment resulted in more costs covered by Medicare benefits. While the OIG didn’t provide a specific price tag, they estimate that these harmful events cost hundreds of millions of dollars in October 2018 alone.

Recommendations to the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research Quality (AHRQ)

Even though the U.S. has some of the best health care services in the world, it’s still very flawed. And with how much the average American pays for their health plan, it’s crucial for hospitals and medical professionals everywhere to prioritize patient safety. Not only will a gradual decrease in harmful events save lives, but it will also save money too. 

That’s why the OIG concluded its study with recommendations to both the Centers for Medicare/Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ). 

Firstly, the OIG recommends that the CMS expand its list of hospital-acquired conditions. That way, the list will include more conditions that are common, preventable, and expensive. The study also suggested that the CMS expand patient safety metrics in demonstrations and develop guidance for surveyors who assess hospital compliance and track patient care.

As for recommendations created for the AHRQ, the OIG suggests that the federal government agency effectively use the Quality and Safety Review System, create an effective model that will spread information about how to improve patient safety, and create new strategies to prevent patients from suffering from common hospital-acquired conditions.

Are Medicare Patients At a Higher Risk of Malpractice?

Yes, Medicare patients are at a higher risk of medical malpractice. This is largely due to the following:

• Medicare generally covers individuals 65 and older.
• Older Medicare patients are more likely to undergo procedures, surgeries, or inpatient stays. These all increase exposure to negligent care.
• Hospitals with high numbers of Medicare patients may face staffing shortages, rushed medical care, or diagnostic delays. All of these increase malpractice risks.
• Medicare patients are frequently transferred between primary doctors, specialists, hospitals, and rehabilitation centers. This can lead to miscommunication, medication errors, misdiagnosis, and missed diagnosis.

While Medicare coverage itself doesn’t cause medical malpractice, the patient population that Medicare serves is more vulnerable to medical errors.

Are Medicaid Patients At a Higher Risk of Malpractice?

Yes, Medicaid patients are at a higher risk of malpractice for several reasons that are mostly systemic and socioeconomic:

• Many top specialists and hospitals limit or refuse Medicaid patients. They do so because of lower reimbursement rates. This results in Medicaid patients receiving medical care from less experienced providers and overburdened facilities.
• Medicaid patients are often forced to wait longer and have access to fewer preventive medical services. This increases the risk of late or missed diagnosis.
• Because of lower reimbursement rates, Medicaid patients are more likely to receive medical treatment at facilities with fewer resources, outdated medical equipment, and fewer staff.
• Medicaid serves those with lower incomes. According to the Kaiser Family Foundation, three‑quarters of non‑elderly patients enrolled in Medicaid report having at least one chronic condition. Additionally, nearly one‑third have three or more chronic conditions. These stats are significantly higher compared to patients with private insurance.

Is Medicaid Worse Than Private Insurance?

Research shows that Medicaid patients who are undergoing surgery generally are sicker beforehand, have longer hospitalizations, higher readmissions, and worse postoperative outcomes when compared to patients with private insurance. This is noted in a University of Michigan study. Additionally, the Heritage Foundation also found that Medicaid patients often experience delayed diagnoses, medical care from less skilled physicians or surgeons, and have higher mortality rates.

Is Medicaid Worse Than No Insurance?

The Oregon Health Insurance Experiment showed that Medicaid patients had more preventive visits, better monitoring for chronic conditions, and improved mental health outcomes as opposed to patients who didn’t have insurance.

Why Do Doctors Refuse Medicaid Patients?

Doctors refuse Medicaid patients for a combination of reasons. The most significant reasons doctors refuse Medicaid patients include:

• Medicaid pays doctors significantly less than private insurance or Medicare. Sometimes, the Medicaid reimbursement doesn’t even cover the cost of the medical care provided.
• Medicaid billing involves much more paperwork. This billing comes with complex rules. Additionally, Medicaid reimbursements are much slower than private insurance payments. These factors make it more difficult for providers to manage billing efficiently. Furthermore, because Medicaid is state-run, reimbursement rates and rules differ, and in some states, participation is less practical for providers.
• Medicaid patients are statistically more likely to miss appointments. Privately insured patients have insurance taken out of their paychecks and may face a higher sense of duty to show up for scheduled visits.
• According to the study referenced above, Medicaid patients are more prone to having multiple chronic conditions. This requires more time from physicians without a higher payment, resulting in financial losses for the practice.

Many doctors who limit or refuse Medicaid patients are not doing so out of disregard for those patients. Many physicians are trying to navigate a healthcare system that has serious financial and administrative constraints. Medicaid does play a crucial role in helping millions of Texans get access to healthcare. However, the structure of the Medicaid program often puts excessive pressure on smaller medical practices and specialists who already have limited resources.

In practice, this makes it harder for Medicaid patients to find quality medical care, especially in rural areas or locations that are underserved. This is not because providers don’t want to help, but because the Medicaid system doesn’t make it sustainable for them to consistently treat Medicaid patients and keep their practice open.

Via What Entry Are Medicare and Medicaid Sanctions and Malpractice History Checked?

Medicare and Medicaid sanctions and malpractice history are checked through the National Practitioner Data Bank (NPDB).

So, if a patient wants to check whether a doctor or healthcare provider has a history of Medicare or Medicaid sanctions or malpractice problems, most of that information is stored in the link above.

Hospitals, insurers, and government agencies use this to look up any serious issues related to medical malpractice claims or sanctions. They do this by submitting a Query using the provider’s name or their National Provider Identifier (NPI). The NPI is essentially an ID number for doctors.

The NPDB can show the following:

• Past malpractice payouts
• Medicare or Medicaid exclusions
• License suspensions
• Hospital discipline or privilege restrictions

For Medicare-related violations, agencies can also search the Office of Inspector General (OIG) Exclusions List to determine if someone is banned from billing federal health programs.

However, these searches aren’t available to the public with names attached. Many researchers and journalists look at the trends using the NPDB Public Use File. This shows the data without naming any providers.