Patient insurance status and do-not-resuscitate orders: survival of the richest?

Journal of Sociology and Social Welfare, March, 2006 by Gigi Nordquist

This study investigated the effect of patient insurance status upon physicians' decisions to write do-not-resuscitate orders (DNRs). Ninety-four physicians completed a questionnaire consisting of demographic data and a case vignette. In addition to the main research question, the study explored the effect of religious affiliation on writing DNRs and performing "slow codes." Results indicate that insurance status has a significant effect upon the likelihood of writing a DNR, with physicians more likely to write DNRs for patients covered by public (i.e., government-funded, as compared to private) insurance. Religious affiliation was also significant, with greater church attendance associated with a lesser likelihood of writing a DNR. Results should be interpreted with caution; however, findings from this study support related research, and warrant further exploration.

Keywords: health care, do-not-resuscitate, uninsured

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Health care resources are limited, and demand far exceeds supply. The United States spends in excess of one trillion dollars a year on health care (Callahan, 1998; Nesmith, 2004); still, estimates of the number of uninsured persons in this country range from 41 to 44 million (Mills, 2002; Beauregard, Drilea & Vistnes, 1997), and the number of underinsured has been estimated at an additional 56 million (Friedman, 1991).

There are three major sources of health insurance in the United States: private, employment-related coverage; publicly-funded, governmental programs (e.g., Medicaid); and individually-purchased private policies (Long, 1987). According to Cutler (1996), approximately 60% of the population was covered by employer-based insurance in the mid-1990s, 20% was covered by public health insurance, and 7% by private policies. Unfortunately, spiraling unemployment, enduring economic recession, and decreasing sales revenues have severely limited state and local resources in recent years, and consequent fiscal cutbacks have led to severe restrictions or closures in many public programs which traditionally provided last-resort health care. Also, because the unemployed are less likely to have health insurance (Mills, 2002), record highs in unemployment levels mean increasing numbers of individuals are uninsured.

Those groups most likely to be uninsured are the poor, minorities, and young adults (Mills, 2002). When analyzed by ethnicity, it was found that 10% of non-hispanic whites had no insurance, compared with 19% of blacks, 18.2% of Asians/Pacific Islanders, and 33.2 % of hispanics. Analyses by gender and age revealed that men were slightly more likely to be uninsured than women, and 18 to 24 year olds were the age group most likely to be uninsured. While almost all of the elderly are covered by Medicare, 8.5 million children had no insurance (Mills, 2002).

Insurance Status and Health Care

According to Kilner (1990), the uninsured use health services only about half as much as the insured, and have higher mortality rates as a result. In a retrospective analysis of hospital discharge data from a 1987 national sample of over half a million patients, it was found that uninsured patients were less likely to receive specialized services, and more likely to die during hospitalization (Hadley, Steinberg, and Feder, 1991). Even after controlling for poor health status on admission, the in-hospital death rate was 1.2 to 3.2 times higher for uninsured patients than patients with private insurance.

The poor are sometimes not told about treatments that are available to them (Kilner, 1990), and are less likely to receive costly or discretionary procedures (Hadley et al., 1991). In a retrospective study using data from the 1996-1999 Medical Expenditure Panel Survey, Thorpe and Howard (2003) found that uninsured cancer patients received less health care than insured patients, despite paying over twice as much in "out of pocket" expenses.

Additionally, "dumping" of poor or uninsured patients (i.e., refusing admission or rapidly transferring to another hospital) has been common (Taira & Taira, 1991). In a study published one year after the enactment of the 1986 federal patient anti-dumping law, Ansell & Schiff (1987) found that approximately one-quarter million patients were dumped from hospital emergency rooms each year, causing delayed treatment and additional pain and suffering. Studies using various methodologies performed at five public hospitals across the country found that economic concerns were the predominant reason for patient transfers (Taira & Taira, 1991). In one of these investigations, a prospective study of 467 patients conducted at Cook County Hospital in Chicago, lack of insurance was the reason for 87 percent of all transfers for which information was available (Schiff, Ansell, Schlosser, Idris, Morrison, & Whitman, 1986). Of the patients transferred, 89 percent were black or Hispanic, and the average delay in obtaining treatment was 5.1 hours.

Social Value in the Medical Setting

All human societies consider certain classes of individuals to be more important or valuable than others (Crane, 1975). By interviewing and surveying physicians, Crane found that patients who were employed in high status occupations received more vigorous treatment than persons holding low status jobs. Pearlman and Jonsen (1985) reported that physician prejudices could "strongly affect" treatment plans for patients who failed to exhibit certain highly-valued social attributes. Similarly, Birdwell, Herbers, and Kroenke (1993) found that patient "presentation style" (i.e., being either "businesslike" or "emotional") affected physicians' treatment decisions. In field research conducted in the emergency room of a large county hospital in California, it was found that physicians were more likely to provide heroic life-saving efforts to persons who were perceived as contributing more to society (Sudnow, 1967). Persons who were seen as less valuable, for example the aged or 'deviant' (alcoholics, drug addicts, prostitutes, etc.), received less rigorous life-saving efforts, and less attention overall.