Cost Concerns Delay Heart Attack Care

Uninsured, Underinsured Patients Seek Treatment Later, Study Finds

By Salynn Boyles
WebMD Health News

Reviewed By Elizabeth Klodas, MD, FACC

April 13, 2010 -- Patients without health insurance and even insured patients worried about paying for medical care are more likely to delay seeking treatment during a heart attack, new research confirms.

It is well recognized that uninsured and underinsured people access preventive medical care and receive treatment for chronic conditions like diabetes and asthma less often than people who are fully insured. But this study is among the first to suggest that cost concerns affect decisions about potentially lifesaving emergency medical care.

Nearly half of uninsured heart attack patients surveyed and 45% of people who considered themselves underinsured delayed seeking medical treatment for more than six hours after symptoms began, compared to 39% of patients without financial concerns.

The study appears in today's issue of the Journal of the American Medical Association.

"We have good lifesaving treatments that can prevent heart muscle damage during heart attacks," study co-author Paul S. Chan, MD, tells WebMD. "But after about six hours the benefits of many of these therapies are limited, and beyond 12 hours they are unlikely to be of any benefit at all."

70 Million Lack Adequate Coverage

About 45 million Americans have no health insurance, and 25 million have insurance with prohibitively high medical co-pays and deductibles, according to a recent analysis.

In an effort to determine how insurance status affects decisions about treatment during heart attacks, Chan and colleagues analyzed data from interviews with 3,721 patients treated at 24 U.S. hospitals between April 2005 and December 2008.

All the patients were enrolled in a heart attack registry and all were asked about their insurance status and financial concerns regarding their medical care.

Nearly 62% of the patients were insured with few financial concerns, while 20% and 18%, respectively, were uninsured or had financial concerns about seeking care.

Among insured patients who had financial concerns, 83% reported having gone without medical care because of cost, 56% said financial concerns kept them from taking prescribed medications, and 13% said they had a hard time obtaining medical services because of cost.

About a third of the patients (1,273) reported seeking medical treatment within two hours of noticing symptoms of a heart attack, while 42% (1,567) reported waiting more than six hours after symptoms began.

After adjusting for other factors that could contribute to treatment delays, uninsured and underinsured patients were 38% and 21%, respectively, more likely to delay treatment for more than six hours than fully insured patients, Chan says.

More than half of patients who considered themselves underinsured had fee-for-service medical plans or were covered by HMOs.

"This makes it clear that having insurance does not mean that care is affordable," Chan says.

Health Care Reform: Will It Change Things?

The sweeping health care reform legislation signed into law last month by President Obama is projected to extend health care coverage to 32 million previously uninsured Americans.

But Chan says it remains to be seen if medical care will be affordable for these people and for those who are insured but are seeing their out-of-pocket health care costs continue to rise.

"A decade ago, having insurance meant that most of your medical costs were covered," he says. "These days, patients may be paying 20% and even 30% out of pocket."

University of Washington researcher Andrew Wilper, MD, who studies the impact of insurance coverage on medical outcomes, agrees that rising out-of-pocket costs are a growing deterrent to medical treatment.

In a study published late last year, Wilper and colleagues from Harvard Medical School found that lack of adequate insurance is responsible for 45,000 deaths in the U.S. each year.

"I don't think anyone should be surprised that people delay seeking treatment for heart attacks and other life-threatening conditions because of concerns about paying for care," Wilper tells WebMD.

Harvard associate professor of medicine David Himmelstein, MD, tells WebMD that in the United States someone dies every 12 minutes because they are either uninsured or underinsured.

"This study makes the point in a very dramatic way," he says. "The findings are disturbing, but not really surprising."

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SOURCES: Smolderen, K.G. Journal of the American Medical Association, April 14, 2010; vol 303: pp 1392-1400.

Paul S. Chan, MD, MSc, assistant professor of internal medicine, Mid America Heart Institute, Kansas City, Mo.

Andrew Wilper, MD, University of Washington School of Medicine, Seattle.

David Himmelstein, MD, associate professor of medicine, Harvard Medical School, Boston.

News release, Journal of the American Medical Association.

Gabel, J.R. Health Affairs, July/August 2009; vol 28: pp w595-w606.

Wilper, A.P. American Journal of Public Health, December 2009; vol 99: pp 2289-2295.

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