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Salazar DH, Dy CJ, Choate WS, Place HM. Disparities in Access to Musculoskeletal Care: Narrowing the Gap: AOA Critical Issues Symposium. J Bone Joint Surg Am 2019; 101:e121. [PMID: 31764373 PMCID: PMC7406150 DOI: 10.2106/jbjs.18.01106] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The current health-care system in the United States has numerous barriers to quality, accessible, and affordable musculoskeletal care for multiple subgroups of our population. These hurdles include complex cultural, educational, and socioeconomic factors. Tertiary referral centers provide a disproportionately large amount of the care for the uninsured and underinsured members of our society. These gaps in access to care for certain subgroups lead to inappropriate emergency room usage, lengthy hospitalizations, increased administrative load, lost productivity, and avoidable complications and/or deaths, which all represent a needless burden on our health-care system. Through advocacy, policy changes, workforce diversification, and practice changes, orthopaedic surgeons have a responsibility to seek solutions to improve access to quality and affordable musculoskeletal care for the communities that they serve.
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Affiliation(s)
- Dane H Salazar
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, Hines, Illinois
| | | | | | - Howard M Place
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri
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Narang GL, Wiener LE, Penniston KL, Antonelli JA, Averch TD, Sivalingam S, Chew BH, Bird VG, Pais VM, Sur RL, Chi T, Streeper NM, Nakada SY, Koch GG, Viprakasit DP. The effect of travel distance on health-related quality of life for patients with nephrolithiasis. Can Urol Assoc J 2019; 14:99-104. [PMID: 31702546 DOI: 10.5489/cuaj.6090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Urolithiasis causes a significant impact on health-related quality of life (HRQOL). Patients with kidney stones have high levels of stress and anxiety. Symptom resolution often requires treatment. Travel distance is a barrier to care but little is known about its effects on HRQOL. We hypothesize that increased distance to treatment site is associated with decreased HRQOL. METHODS Patients with a history of stones were enrolled at 11 tertiary centers as part of the QOL Stone Consortium of North America. HRQOL data were obtained using the Wisconsin Stone Quality of Life questionnaire (WISQOL). We calculated distance between patient and treatment site using national ZIP codes. We used linear models to evaluate the effect of distance on HRQOL, while also considering demographics data, stones/symptom status, and distance. RESULTS Of the 1676 enrolled patients, 52% were male, 86% non-Latino White, and the mean age was 53 years. Mean distance to treatment site was 63.3 km (range 0-3774), with 74% reporting current stones and 45% current symptoms. WISQOL score and distance were negatively correlated for patients reporting current stones and symptoms (p=0.0010). Linear modelling revealed decreased WISQOL scores for patients with symptoms as distance increased from treatment site (p=0.0001), with a 4.7-point decrease for every 100 km traveled. CONCLUSIONS Stone disease imposes significant burden on patients' HRQOL due to a variety of factors. Patients with active stone symptoms report worse HRQOL with increased distance to their treatment site. Possible etiologies include travel burden, increased disease burden, decreased healthcare use, and delays in care.
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Affiliation(s)
- Gopal L Narang
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Laura E Wiener
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, United States
| | - Kristina L Penniston
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Jodi A Antonelli
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | | | - Sri Sivalingam
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Ben H Chew
- University of British Columbia, Vancouver, BC, Canada
| | - Vincent G Bird
- University of Florida College of Medicine, Gainesville, FL, United States
| | - Vernon M Pais
- Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Roger L Sur
- University of California San Diego School of Medicine, San Diego, CA, United States
| | - Thomas Chi
- University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Necole M Streeper
- Penn State Health Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Stephen Y Nakada
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Gary G Koch
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, United States
| | - Davis P Viprakasit
- University of North Carolina School of Medicine, Chapel Hill, NC, United States
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Daly CA, Cho BH, Desale S, Aliu O, Mete M, Giladi AM. The Effects of Medicaid Expansion on Triage and Regional Transfer After Upper-Extremity Trauma. J Hand Surg Am 2019; 44:720-727. [PMID: 31311682 DOI: 10.1016/j.jhsa.2019.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 04/01/2019] [Accepted: 05/31/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE Underinsured hand trauma patients are more likely to be transferred to quaternary care centers, which burdens these patients and centers. By increasing insurance coverage, care for less severe upper-extremity injuries may be available closer to patients' homes. We evaluated whether the 2014 expansion of Medicaid in Maryland under the Affordable Care Act decreased the number of uninsured upper-extremity trauma patients and the volume of unnecessary emergency trauma visits at our hand center. METHODS We identified all upper-extremity trauma patients between 2010 and 2017 at our hand trauma referral center. Injury severity was classified based on the need for subspecialty care. Bivariate relations between insurance status and demographic covariates, including injury type and distance, both before and after Medicaid expansion were evaluated. We used patient-level and multinomial logistic regression models to evaluate changes in payer and transfer appropriateness. RESULTS We studied 12,009 acute upper-extremity trauma patients. With Medicaid expansion, the percentage of trauma patients with Medicaid coverage increased from 15% to 24%, with a decrease in uninsured from 31% to 24%. After Medicaid expansion, non-transfer patient appropriateness decreased and appropriateness of transfers remained consistent across all payers. The average distance patients traveled for care remained similar before and after expansion. CONCLUSIONS Medicaid expansion significantly decreased the proportion of uninsured upper-extremity trauma patients. We identified no significant changes in the distances these patients traveled for specialized care. In addition, the appropriateness of transferred patients did not change significantly after expansion, whereas appropriateness of nontransferred patients actually declined after Medicaid expansion. CLINICAL RELEVANCE This study indicates no notable change in adherence to transfer guidelines after expansion, and a possible increase in use of emergency services by newly insured patients.
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Affiliation(s)
| | | | | | - Oluseyi Aliu
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore
| | - Mihriye Mete
- MedStar Health Research Institute, Hyattsville, MD
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Dy CJ, Tipping AD, Nickel KB, Jiang W, O’Keefe RJ, Olsen MA. Variation in the Delivery of Inpatient Orthopaedic Care to Medicaid Beneficiaries within a Single Metropolitan Region. J Bone Joint Surg Am 2019; 101:1451-1459. [PMID: 31436652 PMCID: PMC7406144 DOI: 10.2106/jbjs.18.01198] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is variability in access to and utilization of orthopaedic care, particularly for those with Medicaid insurance. One potential contributor is perceived unwillingness of surgeons and hospitals to accept underinsured patients. We used administrative data to examine the payer mix for select inpatient orthopaedic surgical procedures at all hospitals within a single region, hypothesizing that the delivery of orthopaedic surgery to Medicaid beneficiaries varies highly at the hospital level. METHODS Using administrative data, we analyzed inpatient hospitalizations for elective cases (total knee or hip arthroplasty; spinal decompression or fusion) and trauma cases (hip hemiarthroplasty; femoral or tibial and fibular fracture repair) among 22 hospitals in a single region from 2011 to 2016 for patients who were 18 to 64 years of age. The primary outcome was the percentage of each hospital's caseload with Medicaid listed as the primary payer. The secondary outcome measured each hospital's Medicaid percentage against the percentage of Medicaid-insured individuals within 10 miles of the hospital (Medicaid share ratio), using a ratio of 1 as a benchmark. To quantify variation, we calculated a weighted coefficient of variation of the Medicaid share ratio for all cases combined, elective cases only, and trauma cases only. RESULTS For all cases (n = 19,204), the mean percentage of Medicaid-funded surgical procedures was 7.6% (range, 0.2% to 57.3%). The mean Medicaid share ratio was 1.0 (range, 0.05 to 4.20). Across 22 hospitals, the weighted coefficient of variation for Medicaid share was 69, indicating very high variation. For elective cases alone, the mean percentage of Medicaid-funded surgical procedures was 5.5% (range, 0.2% to 64.6%). The mean Medicaid share ratio was 0.71 (range, 0.05 to 4.73), and the weighted coefficient of variation was 93. For trauma cases alone, Medicaid-funded surgical procedures were 14.7% (range, 0.0% to 35.7%). The mean Medicaid share ratio was 2.0 (range, 0 to 3.93), and the weighted coefficient of variation was 34. CONCLUSIONS Delivery of care was highly variable when benchmarking against the insurance composition of each hospital's surrounding community. Although generalizability to other regions is limited, our findings support previously asserted notions that delivery of orthopaedic care may differ on the basis of socioeconomic markers (such as insurance status). If not addressed, these inequities may exacerbate existing racially and socioeconomically based disparities in care.
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Affiliation(s)
- Christopher J. Dy
- Department of Orthopaedic Surgery (C.J.D., W.J., and R.J.O.), Center for Administrative Data Research, Division of Infectious Diseases, Department of Medicine (A.D.T., K.B.N., and M.A.O.), and Division of Public Health Sciences, Department of Surgery (C.J.D. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Andrew D. Tipping
- Department of Orthopaedic Surgery (C.J.D., W.J., and R.J.O.), Center for Administrative Data Research, Division of Infectious Diseases, Department of Medicine (A.D.T., K.B.N., and M.A.O.), and Division of Public Health Sciences, Department of Surgery (C.J.D. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Katelin B. Nickel
- Department of Orthopaedic Surgery (C.J.D., W.J., and R.J.O.), Center for Administrative Data Research, Division of Infectious Diseases, Department of Medicine (A.D.T., K.B.N., and M.A.O.), and Division of Public Health Sciences, Department of Surgery (C.J.D. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Winston Jiang
- Department of Orthopaedic Surgery (C.J.D., W.J., and R.J.O.), Center for Administrative Data Research, Division of Infectious Diseases, Department of Medicine (A.D.T., K.B.N., and M.A.O.), and Division of Public Health Sciences, Department of Surgery (C.J.D. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Regis J. O’Keefe
- Department of Orthopaedic Surgery (C.J.D., W.J., and R.J.O.), Center for Administrative Data Research, Division of Infectious Diseases, Department of Medicine (A.D.T., K.B.N., and M.A.O.), and Division of Public Health Sciences, Department of Surgery (C.J.D. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Margaret A. Olsen
- Department of Orthopaedic Surgery (C.J.D., W.J., and R.J.O.), Center for Administrative Data Research, Division of Infectious Diseases, Department of Medicine (A.D.T., K.B.N., and M.A.O.), and Division of Public Health Sciences, Department of Surgery (C.J.D. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
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Gittings DJ, Mendenhall SD, Levin LS. A Decade of Progress Toward Establishing Regional Hand Trauma Centers in the United States. Hand Clin 2019; 35:103-108. [PMID: 30928043 DOI: 10.1016/j.hcl.2018.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Although upper extremity amputations have become less common in the workplace because of improvements in safety and equipment, the American health system's ability to provide emergent microvascular care for these injuries remains highly fragmented, inconsistent, overburdened, and at times unavailable. Over the past decade, hand surgeons have worked to improve this disparity within health systems. This article discusses the need for emergent microsurgical treatment, barriers encountered in improving access to care, and a description of current and future efforts of developing a sustainable network of highly specialized regional hand trauma centers.
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Affiliation(s)
- Daniel J Gittings
- University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - Shaun D Mendenhall
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, UT 84132, USA
| | - L Scott Levin
- University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA.
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Dy CJ, Brown D, Maryam H, Keller M, Olsen MA. Two-State Comparison of Total Joint Arthroplasty Utilization Following Medicaid Expansion. J Arthroplasty 2019; 34:619-625.e1. [PMID: 30642704 PMCID: PMC6430692 DOI: 10.1016/j.arth.2018.12.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although Medicaid expansion has improved access to primary care services, its impact on surgical specialty utilization remains unclear. The aim of this study is to determine whether Medicaid expansion is associated with increased utilization rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Illinois (which expanded Medicaid) relative to Missouri (which did not expand Medicaid). METHODS Using administrative data sources, we analyzed 374,877 total hospitalizations (236,333 in Illinois and 138,544 in Missouri) for THA/TKA from 2011 to 2016 (Illinois' Medicaid expansion date: January 1, 2014). RESULTS The percentage of THA/TKA funded by Medicaid in Illinois was 2.4% in 2013 and 3.9% in 2016 (Missouri 2013: 2.7%; 2016: 2.6%). A difference-in-difference analysis (adjusted for patient age and gender, county-level Area Deprivation Index, and number of orthopedic surgeons) demonstrated a statistically significant increase in Medicaid-funded THA/TKA in Illinois in 2016 compared to 2013 (P = .012). CONCLUSION Our study demonstrates that Medicaid expansion in Illinois was associated with increased utilization of THA and TKA. Further study is needed to understand the impact of Medicaid expansion in other states and for other procedures.
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Affiliation(s)
- Christopher J. Dy
- Department of Orthopaedic Surgery, Division of Hand and Microsurgery; Washington University School of Medicine - St. Louis, MO,Department of Surgery, Division of Public Health Sciences; Washington University School of Medicine - St. Louis, MO,Corresponding Author: Christopher J. Dy, MD MPH, Assistant Professor, Department of Orthopaedic surgery, 660 S. Euclid, Campus Box 8233, St. Louis, MO 63110, Washington University School of Medicine, Phone number: 314-747-2535,
| | - Derek Brown
- George Warren Brown School of Social Work; Washington University - St. Louis, MO
| | - Hera Maryam
- Department of Orthopaedic Surgery, Division of Hand and Microsurgery; Washington University School of Medicine - St. Louis, MO
| | - Matthew Keller
- Department of Medicine, Division of Infectious Diseases; Center for Administrative Data Research; Washington University School of Medicine - St. Louis, MO
| | - Margaret A. Olsen
- Department of Surgery, Division of Public Health Sciences; Washington University School of Medicine - St. Louis, MO,Department of Medicine, Division of Infectious Diseases; Center for Administrative Data Research; Washington University School of Medicine - St. Louis, MO
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Access to Orthopedic Care post Medicaid Expansion Through the Affordable Care Act. J Natl Med Assoc 2019; 111:148-152. [DOI: 10.1016/j.jnma.2018.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/12/2018] [Accepted: 07/12/2018] [Indexed: 11/19/2022]
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Variations in Utilization of Carpal Tunnel Release Among Medicaid Beneficiaries. J Hand Surg Am 2019; 44:192-200. [PMID: 30579689 DOI: 10.1016/j.jhsa.2018.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/12/2018] [Accepted: 11/02/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the null hypothesis that Medicaid patients receive carpal tunnel release (CTR) at the same time interval from diagnosis as do patients with Medicare Advantage or private insurance. METHODS We conducted a retrospective review using a database containing claims records from 2007 to 2016. The cohort consisted of patient records with a diagnosis code of carpal tunnel syndrome (CTS) and a procedural code for CTR within 3 years of diagnosis. We stratified patients into 3 groups by insurance type (Medicaid managed care, Medicare Advantage, and private) for an analysis of the time from diagnosis until surgery and use of preoperative electrodiagnostic testing. RESULTS Of all patients who received CTR within 3 years of diagnosis, Medicaid patients experienced longer intervals from CTS diagnosis to CTR compared with Medicare Advantage and privately insured patients (median, 99 days vs 65 and 62 days, respectively). The Medicaid cohort was significantly less likely to receive CTR within 1 year of diagnosis compared with the Medicare Advantage cohort (adjusted odds ratio [OR] = 0.54) or within 6 months of diagnosis compared with the privately insured cohort (adjusted OR = 0.61). Those in the Medicaid cohort were less likely to receive electromyography and nerve conduction studies within 9 months before surgery compared with their Medicare Advantage (adjusted OR = 0.43) and privately insured (adjusted OR = 0.41) counterparts. These effects were statistically significant after accounting for age, sex, region, and Charlson comorbidity index. CONCLUSIONS Medicaid managed care patients experience longer times from diagnosis to surgery compared with Medicare Advantage or privately insured patients in this large administrative claims database. Similar variation exists in the use of electrodiagnostic testing based on insurance type. CLINICAL RELEVANCE Medicaid patients may experience barriers to CTS care, such as delays from diagnosis to surgery and reduced use of electrodiagnostic testing.
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State Variations in Public Payer Reimbursement for Common Plastic Surgery Procedures. Plast Reconstr Surg 2018; 142:1653-1661. [DOI: 10.1097/prs.0000000000005013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dodds SD, Fenoglio AK, Bohl DD, Gala RJ. The Impact of Insurance Status on the Development of Nonunion following Scaphoid Fracture. J Wrist Surg 2018; 7:288-291. [PMID: 30174984 PMCID: PMC6117168 DOI: 10.1055/s-0038-1639509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 02/21/2018] [Indexed: 10/17/2022]
Abstract
Purpose Certain factors have been associated with the development of scaphoid nonunion, including delayed diagnosis, smoking, inadequate initial management, proximal location, and carpal instability. We hypothesized that insurance status would also be a risk factor for the development of scaphoid nonunion. Methods A case-control study was performed on patients who presented to a single surgeon at a tertiary referral center during 2006 to 2015. Cases were patients presenting with nonunions, controls, and patients with acute fractures. Patients were characterized as underinsured if they lacked any type of insurance or if they were on Medicaid. Results Patients (39 nonunions [cases] and 32 primary fractures [controls]) presenting with nonunions were more likely than controls to have had displaced fractures (72 vs. 41%) and fractures located at the proximal aspect of the scaphoid (18 vs. 0%), and to be underinsured (46 vs. 19%). Conclusion Patients presenting with nonunions were more likely to be underinsured than patients presenting with primary fractures. This finding suggests that underinsurance is a risk factor for the development of nonunion. Assuming delay between fracture and intervention is a known risk factor for the development of nonunion, and it is likely that the association between nonunion and underinsurance is mediated through this delay. Level of Evidence Prognostic, level III, case-control study.
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Affiliation(s)
- Seth D. Dodds
- Department of Orthopaedic Surgery and Rehabilitation, University of Miami, Miller School of Medicine, Miami, Florida
| | - Amy K. Fenoglio
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
| | - Daniel D. Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Raj J. Gala
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut
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Effects of the Affordable Care Act on Payer Mix and Physician Reimbursement in Hand Surgery. J Hand Surg Am 2018; 43:511-515. [PMID: 29602658 DOI: 10.1016/j.jhsa.2018.02.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 01/22/2018] [Accepted: 02/21/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the effect of the Affordable Care Act (ACA) on the payer distribution and reimbursement rate for hand surgery at our institution. METHODS We reviewed records of 4,257 patients who underwent hand surgery at our institution between January 2008 and June 2016; 2,601 patients underwent surgery before the implementation of the ACA, and 1,656 patients after. Type of procedure, insurance status, amount of money billed, and amount collected were recorded. RESULTS After the implementation of the ACA, we performed fewer metacarpal fracture repairs, distal radius fracture repairs, and abscess incision and drainage procedures. We performed more endoscopic carpal tunnel releases. The proportion of uninsured patients decreased significantly (15% to 6.4%), and the proportion of patients on Medicare (15.4% to 20.3%) and Medicaid (9.5% to 17.8%) increased significantly. The overall reimbursement rate did not change significantly (32.3% to 30.3%) between the 2 time periods. CONCLUSIONS After the implementation of the ACA, we observed a significant reduction in the number of uninsured patients and an increase in Medicaid and Medicare patients. However, this led to no significant change in reimbursement rates. TYPE OF STUDY/LEVEL OF EVIDENCE Economic and design analysis II.
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Abstract
INTRODUCTION As policies are implemented to encourage high-quality care, it is important to identify any persistent limitations to the uniform delivery of anatomic and reverse total shoulder arthroplasty (TSA). The study's goal was to assess current TSA use and identify predictors of geographic variability. METHODS We used data from 2012 through 2014 that was obtained from public Medicare databases to identify the case volume, locations, and names of surgeons performing >10 TSAs annually. We also recorded regional characteristics of the Medicare population, including demographic characteristics and health factors. RESULTS From 2012 through 2014, the number of surgeons performing >10 TSAs annually increased from 824 to 1,060-an increase ranging from 0.75 to 0.95 TSAs per 1,000 beneficiaries. In 2012, there were 59 hospital referral regions with no TSAs performed; the number of regions decreased to 35 by 2014 (P = 0.009). The use of TSA varied widely across regions (range, 0.1 to 6.4 per 1,000 beneficiaries). A larger proportion of white patients and a smaller proportion of patients eligible for Medicaid were independent predictors for increased use of TSA. Despite this finding, 74.4% and 96.9% of the US population resided within 50 km and 200 km, respectively, of a surgeon performing at least 20 TSAs in Medicare patients annually. DISCUSSION TSA utilization in the Medicare population is increasing across the country. Although notable geographic disparities in the use of TSA persist, increased TSA utilization has provided greater access to surgeons with high-volume TSA caseloads. CONCLUSION Substantial geographic variation in TSA use remains, largely due to socioeconomic factors.
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Lalezari RM, Pozen A, Dy CJ. State Variation in Medicaid Reimbursements for Orthopaedic Surgery. J Bone Joint Surg Am 2018; 100:236-242. [PMID: 29406345 DOI: 10.2106/jbjs.17.00279] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Medicaid reimbursements are determined by each state and are subject to variability. We sought to quantify this variation for commonly performed inpatient orthopaedic procedures. METHODS The 10 most commonly performed inpatient orthopaedic procedures, as ranked by the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample, were identified for study. Medicaid reimbursement amounts for those procedures were benchmarked to state Medicare reimbursement amounts in 3 ways: (1) ratio, (2) dollar difference, and (3) dollar difference divided by the relative value unit (RVU) amount. Variability was quantified by determining the range and coefficient of variation for those reimbursement amounts. RESULTS The range of variability of Medicaid reimbursements among states exceeded $1,500 for all 10 procedures. The coefficients of variation ranged from 0.32 (hip hemiarthroplasty) to 0.57 (posterior or posterolateral lumbar interbody arthrodesis) (a higher coefficient indicates greater variability), compared with 0.07 for Medicare reimbursements for all 10 procedures. Adjusted as a dollar difference between Medicaid and Medicare per RVU, the median values ranged from -$8/RVU (total knee arthroplasty) to -$17/RVU (open reduction and internal fixation of the femur). CONCLUSIONS Variability of Medicaid reimbursement for inpatient orthopaedic procedures among states is substantial. This variation becomes especially remarkable given recent policy shifts toward focusing reimbursements on value.
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Affiliation(s)
- Ramin M Lalezari
- Department of Orthopaedic Surgery (R.M.L. and C.J.D.) and Division of Public Health Sciences, Department of Surgery (C.J.D), Washington University School of Medicine, St. Louis, Missouri
| | - Alexis Pozen
- Department of Health Policy and Management, CUNY School of Public Health, New York, NY
| | - Christopher J Dy
- Department of Orthopaedic Surgery (R.M.L. and C.J.D.) and Division of Public Health Sciences, Department of Surgery (C.J.D), Washington University School of Medicine, St. Louis, Missouri
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Tanenbaum JE, Knapik DM, Fitzgerald SJ, Marcus RE. National Incidence of Reportable Quality Metrics in the Knee Arthroplasty Population. J Arthroplasty 2017; 32:2941-2946. [PMID: 28602536 DOI: 10.1016/j.arth.2017.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 04/13/2017] [Accepted: 05/11/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) characterizes adverse quality events in the inpatient setting as patient safety indicators (PSI). The incidence of PSI has not been quantified in the total knee arthroplasty (TKA) population. METHODS All patients in the Nationwide Inpatient Sample who underwent primary TKA during an inpatient episode in 2013 were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Disease, Ninth Revision diagnosis code algorithms used by CMS. Multivariable logistic regression was used to determine significant associations between patient level covariates (demographics, comorbidities, and hospital characteristics) and the risk of experiencing one or more PSI after TKA. RESULTS We identified 132,453 primary TKA patients in the Nationwide Inpatient Sample in 2013. We estimated the national incidence rate of experiencing one or more PSI as 0.98%. After adjusting for patient demographics and hospital characteristics, we found that relative to Medicaid/self-pay patients, neither Medicare nor privately insured patients faced significantly different risk of experiencing one or more PSI after TKA. However, alcohol abuse, deficiency anemia, congestive heart failure, coagulopathy, and electrolyte imbalance were associated with increased risk of experiencing one or more PSI after TKA. CONCLUSION The national incidence of PSI among TKA patients was lower than has been reported in other surgical populations. CMS uses the incidence of adverse quality events (measured using PSI) in part to determine hospital reimbursement. As value-based payment becomes more widely adopted in the United States, initiatives designed to eliminate and reduce PSI incidence can benefit vulnerable patient populations, physicians, and hospital systems.
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Affiliation(s)
- Joseph E Tanenbaum
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio; Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
| | - Derrick M Knapik
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
| | - Steven J Fitzgerald
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
| | - Randall E Marcus
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio
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Tanenbaum JE, Knapik DM, Wera GD, Fitzgerald SJ. National Incidence of Patient Safety Indicators in the Total Hip Arthroplasty Population. J Arthroplasty 2017; 32:2669-2675. [PMID: 28511946 PMCID: PMC5572751 DOI: 10.1016/j.arth.2017.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/24/2017] [Accepted: 04/03/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services use the incidence of patient safety indicators (PSIs) to determine health care value and hospital reimbursement. The national incidence of PSI has not been quantified in the total hip arthroplasty (THA) population, and it is unknown if patient insurance status is associated with PSI incidence after THA. METHODS All patients in the Nationwide Inpatient Sample (NIS) who underwent THA in 2013 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The incidence of PSI was determined using the International Classification of Diseases, Ninth Revision, diagnosis code algorithms published by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality. The association of insurance status and the incidence of PSI during the inpatient episode was determined by comparing privately insured and Medicare patients with Medicaid/self-pay patients using a logistic regression model that controlled for patient demographics, patient comorbidities, and hospital characteristics. RESULTS In 2013, the NIS included 68,644 hospitalizations with primary THA performed during the inpatient episode. During this period, 429 surgically relevant PSI were recorded in the NIS. The estimated national incidence rate of PSI after primary THA was 0.63%. In our secondary analysis, the privately insured cohort had significantly lower odds of experiencing one or more PSIs relative to the Medicaid/self-pay cohort (odds ratio, 0.47; 95% confidence interval, 0.29-0.76). CONCLUSION The national incidence of PSI among THA patients is relatively low. However, primary insurance status is associated with the incidence of one or more PSIs after THA. As value-based payment becomes more widely adopted in the United States, quality benchmarks and penalty thresholds need to account for these differences in risk-adjustment models to promote and maintain access to care in the underinsured population.
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Affiliation(s)
- Joseph E. Tanenbaum
- Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA,Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio, USA,Corresponding Author: Joseph Tanenbaum, Department of Orthopedic Surgery, University Hospital Case Medical Center, 11100 Euclid Avenue, Cleveland, Ohio 44106, Tel: 518-369-1053,
| | - Derrick M. Knapik
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio, USA
| | - Glenn D. Wera
- Department of Orthopedic Surgery, Metro Health Medical Center, Cleveland, Ohio, USA
| | - Steven J. Fitzgerald
- Department of Orthopedic Surgery, University Hospital Case Medical Center, Cleveland, Ohio, USA
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Impact of Safety Net Hospitals in the Care of the Hand-Injured Patient: A National Perspective. Plast Reconstr Surg 2017; 138:429-434. [PMID: 27465165 DOI: 10.1097/prs.0000000000002373] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
A clear disparity in the pattern and provision of surgical care exists, particularly for patients with vulnerable socioeconomic backgrounds. For hand-injured patients in particular, this discrepancy has been frequently shown in their receiving appropriate care. With the advent of the Affordable Care Act and with Medicaid expansion on the horizon, more patients will be requiring access to care. Safety net programs have been shown to provide equivalent levels of care for patients compared with non-safety net providers, and the survival of these hospitals for the disadvantaged is essential to providing quality care for this growing patient population. In this article, the authors review the factors that affect the barriers to care, the importance of safety net hospitals, the epidemiology of the hand-injured patient, and how the Affordable Care Act will impact these safety net programs.
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Tanenbaum JE, Alentado VJ, Miller JA, Lubelski D, Benzel EC, Mroz TE. Association between insurance status and patient safety in the lumbar spine fusion population. Spine J 2017; 17:338-345. [PMID: 27765713 PMCID: PMC5508741 DOI: 10.1016/j.spinee.2016.10.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 08/04/2016] [Accepted: 10/12/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar fusion is a common and costly procedure in the United States. Reimbursement for surgical procedures is increasingly tied to care quality and patient safety as part of value-based reimbursement programs. The incidence of adverse quality events among lumbar fusion patients is unknown using the definition of care quality (patient safety indicators [PSI]) used by the Centers for Medicare and Medicaid Services (CMS). The association between insurance status and the incidence of PSI is similarly unknown in lumbar fusion patients. PURPOSE This study sought to determine the incidence of PSI in patients undergoing inpatient lumbar fusion and to quantify the association between primary payer status and PSI in this population. STUDY DESIGN A retrospective cohort study was carried out. PATIENT SAMPLE The sample comprised all adult patients aged 18 years and older who were included in the Nationwide Inpatient Sample (NIS) that underwent lumbar fusion from 1998 to 2011. OUTCOME MEASURE The incidence of one or more PSI, a validated and widely used metric of inpatient health-care quality and patient safety, was the primary outcome variable. METHODS The NIS data were examined for all cases of inpatient lumbar fusion from 1998 to 2011. The incidence of adverse patient safety events (PSI) was determined using publicly available lists of the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Logistic regression models were used to determine the association between primary payer status (Medicaid and self-pay relative to private insurance) and the incidence of PSI. RESULTS A total of 539,172 adult lumbar fusion procedures were recorded in the NIS from 1998 to 2011. Patients were excluded from the secondary analysis if "other" or "missing" was listed for primary insurance status. The national incidence of PSI was calculated to be 2,445 per 100,000 patient years of observation, or approximately 2.5%. In a secondary analysis, after adjusting for patient demographics and hospital characteristics, Medicaid and self-pay patients had significantly greater odds of experiencing one or more PSI during the inpatient episode relative to privately insured patients (odds ratio 1.16, 95% confidence interval 1.07-1.27). CONCLUSIONS Among patients undergoing inpatient lumbar fusion, insurance status is associated with the adverse health-care quality events used to determine hospital reimbursement by the CMS. The source of this disparity must be studied to improve the quality of care delivered to vulnerable patient populations.
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Affiliation(s)
- Joseph E Tanenbaum
- Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, USA; Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106, USA.
| | - Vincent J Alentado
- Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, USA
| | - Jacob A Miller
- Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9980 Carnegie Ave, Cleveland, OH 44195, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans St, Baltimore, MD 21287, USA
| | - Edward C Benzel
- Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA
| | - Thomas E Mroz
- Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave, S-80, Cleveland, OH 44195, USA
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Mehdi SK, Tanenbaum JE, Alentado VJ, Miller JA, Lubelski D, Benzel EC, Mroz TE. Disparities in reportable quality metrics by insurance status in the primary spine neoplasm population. Spine J 2017; 17:244-251. [PMID: 27664341 PMCID: PMC5493960 DOI: 10.1016/j.spinee.2016.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 08/22/2016] [Accepted: 09/12/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The Centers for Medicare and Medicaid Services (CMS) defines "adverse quality events" as the incidence of certain complications such as postsurgical hematoma or iatrogenic pneumothorax during an inpatient stay. Patient safety indicators (PSI) are a means to measure the incidence of these adverse events. When adverse events occur, reimbursement to the hospital decreases. The incidence of adverse quality events among patients hospitalized for primary spinal neoplasms is unknown. Similarly, it is unclear what the impact of insurance status is on adverse care quality among this patient population. PURPOSE We aimed to determine the incidence of PSI among patients admitted with primary spinal neoplasms, and to determine the association between insurance status and the incidence of PSI in this population. STUDY DESIGN This is a retrospective cohort study. PATIENT SAMPLE We included all patients, 18 years and older, in the Nationwide Inpatient Sample (NIS) who were hospitalized for primary spine neoplasms from 1998 to 2011. OUTCOME MEASURES Incidence of PSI from 1998 to 2011 served as outcome variable. METHODS The NIS was queried for all hospitalizations with a diagnosis of primary spinal neoplasm during the inpatient episode from 1998 to 2011. Incidence of PSI was determined using publicly available lists of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Logistic regression models were used to determine the effect of primary payer status on PSI incidence. All comparisons were made between privately insured patients and Medicaid or self-pay patients. RESULTS We identified 6,095 hospitalizations in which a primary spinal neoplasm was recorded during the inpatient episode. We excluded patients younger than 18 years and those with "other" or "missing" primary insurance status, leaving 5,880 patients for analysis. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more PSI (odds ratio [OR] 1.81 95% confidence interval [CI] 1.11-2.95) relative to privately insured patients. CONCLUSIONS Among patients hospitalized for primary spinal neoplasms, primary payer status predicts the incidence of PSI, an indicator of adverse health-care quality used to determine hospital reimbursement by the CMS. As reimbursement continues to be intertwined with reportable quality metrics, identifying vulnerable populations is critical to improving patient care.
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Affiliation(s)
- Syed K Mehdi
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106, USA.
| | - Joseph E Tanenbaum
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106, USA; Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Vincent J Alentado
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Case Western Reserve University School of Medicine, 10900 Euclid Ave., Cleveland, OH 44106, USA
| | - Jacob A Miller
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave., NA41, Cleveland, OH 44195, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 855 N Wolfe St, Baltimore, MD 21205, USA
| | - Edward C Benzel
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave., NA41, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Ave., S-80, Cleveland, OH 44195, USA
| | - Thomas E Mroz
- Center for Spine Health, Cleveland Clinic, 9500 Euclid Ave., S40, Cleveland, OH 44195, USA; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Ave., NA41, Cleveland, OH 44195, USA; Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave., A41, Cleveland, OH 44195, USA
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Tanenbaum JE, Miller JA, Alentado VJ, Lubelski D, Rosenbaum BP, Benzel EC, Mroz TE. Insurance status and reportable quality metrics in the cervical spine fusion population. Spine J 2017; 17:62-69. [PMID: 27497887 PMCID: PMC5493958 DOI: 10.1016/j.spinee.2016.08.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 06/14/2016] [Accepted: 08/02/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The incidence of adverse care quality events among patients undergoing cervical fusion surgery is unknown using the definition of care quality employed by the Centers for Medicare and Medicaid Services (CMS). The effect of insurance status on the incidence of these adverse quality events is also unknown. PURPOSE This study determined the incidence of hospital-acquired conditions (HAC) and patient safety indicators (PSI) in patients with cervical spine fusion and analyzed the association between primary payer status and these adverse events. STUDY DESIGN This is a retrospective cohort design. PATIENT SAMPLE All patients in the Nationwide Inpatient Sample (NIS) aged 18 and older who underwent cervical spine fusion from 1998 to 2011 were included. OUTCOME MEASURES Incidence of HAC and PSI from 1998 to 2011 served as outcome variables. METHODS We queried the NIS for all hospitalizations that included a cervical fusion during the inpatient episode from 1998 to 2011. All comparisons were made between privately insured patients and Medicaid or self-pay patients because Medicare enrollment is confounded with age. Incidence of nontraumatic HAC and PSI was determined using publicly available lists of International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. We built logistic regression models to determine the effect of primary payer status on PSI and nontraumatic HAC. RESULTS We identified 419,424 hospitalizations with cervical fusion performed during an inpatient episode. The estimated national incidences of nontraumatic HAC and PSI were 0.35% and 1.6%, respectively. After adjusting for patient demographics and hospital characteristics, Medicaid or self-pay patients had significantly greater odds of experiencing one or more HAC (odds ratio [OR] 1.51 95% conflict of interest [CI] 1.23-1.84) or PSI (OR 1.52 95% CI 1.37-1.70) than the privately insured cohort. CONCLUSIONS Among patients undergoing inpatient cervical fusion, primary payer status predicts PSI and HAC (both indicators of adverse health-care quality used to determine hospital reimbursement by CMS). As the US health-care system transitions to a value-based payment model, the cause of these disparities must be studied to improve the quality of care delivered to vulnerable patient populations.
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Affiliation(s)
- Joseph E. Tanenbaum
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA,Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, Ohio, USA,Corresponding Author: Joseph Tanenbaum, Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Avenue, S-80, Cleveland, Ohio 44195, Tel: 518-369-1053,
| | - Jacob A. Miller
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Vincent J. Alentado
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin P. Rosenbaum
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA,Anchorage Neurosurgical Associates, Inc., Anchorage, AK
| | - Edward C. Benzel
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Thomas E. Mroz
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA,Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Gornitzky AL, Milby AH, Gunderson MA, Chang B, Carrigan RB. Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center. Orthopedics 2016; 39:e333-9. [PMID: 26913765 DOI: 10.3928/01477447-20160222-06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/01/2015] [Indexed: 02/03/2023]
Abstract
Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries.
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Kim CY, Wiznia DH, Roth AS, Walls RJ, Pelker RR. Survey of Patient Insurance Status on Access to Specialty Foot and Ankle Care Under the Affordable Care Act. Foot Ankle Int 2016; 37:776-81. [PMID: 27026727 DOI: 10.1177/1071100716642015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to assess the effect of insurance type (Medicaid, Medicare, and private insurance) on access to foot and ankle surgeons for total ankle arthroplasty. METHODS We called 240 foot and ankle surgeons who performed total ankle arthroplasty in 8 representative states (California, Massachusetts, Ohio, New York, Florida, Georgia, Texas, and North Carolina). The caller requested an appointment for a fictitious patient to be evaluated for a total ankle arthroplasty. Each office was called 3 times to assess the responses for Medicaid, Medicare, and BlueCross. From each call, we recorded appointment success or failure and any barriers to an appointment, such as need for a referral. RESULTS Patients with Medicaid were less likely to receive an appointment compared to patients with Medicare (19.8% vs 92.0%, P < .0001) or BlueCross (19.8% vs 90.4%, P < .0001) and experienced more requests for referrals compared to patients with Medicare (41.9% vs 1.6%, P < .0001) or BlueCross (41.9% vs 4%, P < .0001). Waiting periods were longer for patients with Medicaid compared to those with Medicare (22.6 days vs 11.7 days, P = .004) or BlueCross (22.6 days vs 10.7 days, P = .001). Reimbursement rates did not correlate with appointment success rate or waiting period. CONCLUSION Despite the passage of the PPACA, patients with Medicaid continue to have difficulty finding a surgeon who will provide care, increased need for a primary care referral, and longer waiting periods for appointments. LEVEL OF EVIDENCE Level II, prognostic study.
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Affiliation(s)
- Chang-Yeon Kim
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Daniel H Wiznia
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Alexander S Roth
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Raymond J Walls
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Richard R Pelker
- Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510, USA
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Tanenbaum JE, Lubelski D, Rosenbaum BP, Thompson NR, Benzel EC, Mroz TE. Predictors of outcomes and hospital charges following atlantoaxial fusion. Spine J 2016; 16:608-18. [PMID: 26792199 PMCID: PMC5506776 DOI: 10.1016/j.spinee.2015.12.090] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 11/27/2015] [Accepted: 12/21/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Atlantoaxial fusion is used to correct atlantoaxial instability that is often secondary to traumatic fractures, Down syndrome, or rheumatoid arthritis. The effect of age and comorbidities on outcomes following atlantoaxial fusion is unknown. PURPOSE This study aimed to better understand trends and predictors of outcomes and charges following atlantoaxial fusion and to identify confounding variables that should be included in future prospective studies. STUDY DESIGN A retrospective analysis of data from the Nationwide Inpatient Sample (NIS), a nationally representative, all-payer database of inpatient diagnoses and procedures in the United States. PATIENT SAMPLE We included all patients who underwent atlantoaxial fusion (International Classification of Disease, Ninth Revision, Clinical Modification code 81.01) between 1998 and 2011 who were 18 years or older at the time of admission. OUTCOME MEASURES Outcome measures included in-hospital charges, hospital length of stay (LOS), in-hospital mortality, and discharge disposition. METHODS Predictors of outcome following atlantoaxial fusion were assessed using a series of univariable analyses. Those predictors with a p-value of less than .2 were included in the final multivariable models. Independent predictors of outcome were those that were significant at an alpha level of 0.05 following inclusion in the final multivariable models. Logistic regression was used to determine predictors of in-hospital mortality and discharge disposition whereas linear regression was used to determine predictors of hospital charges and LOS. Discharge weights were used to produce generalizable results. RESULTS From 1998 to 2011, there were 8,914 hospitalizations recorded wherein atlantoaxial fusion was performed during the inpatient hospital stay. Of these hospitalizations, 8,189 (91.9%) met inclusion criteria. Of the study sample, 62% was white, and the majority of patients were either insured by Medicare (47.2%) or had private health insurance (35.6%). The most common comorbidity as defined by the NIS and the Elixhauser comorbidity index was hypertension (43.2%). The in-hospital mortality rate for the study population was 2.7%, and the median LOS was 6.0 days. The median total charge (inflation adjusted) per hospitalization was $73,561. Of the patients, 48.9% were discharged to home. Significant predictors of in-hospital mortality included increased age, emergent or urgent admissions, weekend admissions, congestive heart failure, coagulopathy, depression, electrolyte disorder, metastatic cancer, neurologic disorder, paralysis, and non-bleeding peptic ulcer. Many of these variables were also found to be predictors of LOS, hospital charges, and discharge disposition. CONCLUSION This study found that older patients and those with greater comorbidity burden had greater odds of postoperative mortality and were being discharged to another care facility, had longer hospital LOS, and incurred greater hospital charges following atlantoaxial fusion.
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Affiliation(s)
- Joseph E Tanenbaum
- Center for Spine Health, Cleveland Clinic, Cleveland, OH, USA; School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA; Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA.
| | - Daniel Lubelski
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA,Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Benjamin P Rosenbaum
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicolas R Thompson
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Edward C Benzel
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Thomas E Mroz
- Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA,Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Abstract
BACKGROUND Hand trauma is one of the most complex injuries treated in the emergency department. Hand trauma injuries are time sensitive and require highly specialized care. Patients may have difficulty accessing appropriate hand trauma care because of a variety of factors. The authors aimed to evaluate the state of the hand trauma system by examining articles that reported on access to hand trauma care. METHODS The authors conducted a literature review on hand trauma care using the PubMed, Ovid MEDLINE, and Embase databases. The authors included English language articles from the United States that described access to hand trauma care in the emergency health system. RESULTS Fourteen studies met the authors' inclusion criteria. Ten studies evaluated access to hand trauma care on a patient level. Of these 10 studies, five reported on access to care for transferred patients and five reported on access to care for patients with amputation injuries. The other four studies evaluated access to hand trauma care at a hospital level. CONCLUSIONS Lack of hand trauma guidelines at emergency departments and a severe shortage of on-call hand specialists at community hospitals and trauma centers have created a suboptimal system of hand emergency care in the United States. The current system of hand trauma care in the United States not only may drive up the cost of care but may also adversely affect patients' health and well-being.
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The Effect of Insurance Type on Patient Access to Carpal Tunnel Release Under the Affordable Care Act. J Hand Surg Am 2016; 41:503-509.e1. [PMID: 26908020 DOI: 10.1016/j.jhsa.2016.01.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/07/2016] [Accepted: 01/08/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the effect of insurance type (Medicaid, Medicare, and private insurance) on access to hand surgeons for carpal tunnel syndrome (CTS). METHODS The research team called 240 hand surgeons in 8 states (California, Massachusetts, Ohio, New York, Florida, Georgia, Texas, and North Carolina). The caller requested an appointment for her fictitious mother to be evaluated for CTS and possible surgical management through carpal tunnel release (CTR). Each office was called 3 times to assess the responses for Medicaid, Medicare, or Blue Cross Blue Shield. From each call, we recorded whether an appointment was given and whether there were barriers to an appointment, such as the need for a referral. RESULTS Twenty percent of offices scheduled an appointment for a patient with Medicaid, compared with 89% for Medicare and 97% for Blue Cross Blue Shield. Patients with Medicaid had an easier time scheduling appointments (28% vs 13%) and experienced fewer requests for referrals (25% vs 67%) in states with expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement for CTR was significantly correlated with the incidence of successful appointments. Although the difference in Medicaid and Medicare reimbursements for CTR was small, the appointment success incidence for Medicare was approximately 5 times higher. CONCLUSIONS Despite the passage of the Affordable Care Act, patients with Medicaid have reduced access to surgical care for CTS and more complex barriers to receiving an appointment. Although Medicaid was accepted at a higher rate in states with expanded Medicaid eligibility, a more robust strategy for increasing access to care may be helpful for patients with Medicaid. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Waljee JF, Ladd A, MacDermid JC, Rozental TD, Wolfe SW, Calfee RP, Dennison DG, Hanel DP, Herzberg G, Hotchkiss R, Jupiter JB, Kaufmann RA, Lee SK, Ozer K, Ring DC, Ross M, Stern PJ. A Unified Approach to Outcomes Assessment for Distal Radius Fractures. J Hand Surg Am 2016; 41:565-73. [PMID: 26952734 DOI: 10.1016/j.jhsa.2016.02.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 02/02/2023]
Abstract
Distal radius fractures are one of the most common upper extremity injuries. Currently, outcome assessment after treatment of these injuries varies widely with respect to the measures that are used, timing of assessment, and the end points that are considered. A more consistent approach to outcomes assessment would provide a standard by which to assess treatment options and best practices. In this summary, we review the consensus regarding outcomes assessment after distal radius fractures and propose a systematic approach that integrates performance, patient-reported outcomes, pain, complications, and radiographs.
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Affiliation(s)
- Jennifer F Waljee
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Amy Ladd
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA
| | - Joy C MacDermid
- School of Rehabilitation Sciences, University of Western Ontario, Ontario, Canada
| | - Tamara D Rozental
- Department of Orthopaedic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Scott W Wolfe
- Department of Orthopedic Surgery, Hospital for Special Surgery and Weill Medical College of Cornell University, New York, NY.
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Association between all-cause mortality and insurance status transition among the elderly population in a rural area in Korea: Kangwha Cohort Study. Health Policy 2015; 119:680-7. [DOI: 10.1016/j.healthpol.2014.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 10/16/2014] [Accepted: 10/16/2014] [Indexed: 11/22/2022]
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Abstract
OBJECTIVE Our purpose was to compare patients transferred from another hospital to our trauma center with those arriving directly, to identify barriers to care for similar fractures. We hypothesized that the most frequent reason for delayed definitive fixation would be interhospital transfer and that patients would be transferred primarily for 2 reasons: complex patients with more severe injuries and less complex patients without insurance. DESIGN Retrospective review. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS A total of 1549 skeletally mature patients with 1655 fractures: 379 acetabulum, 301 pelvic ring, 876 femur, and 99 spine. INTERVENTION All patients were treated surgically, with early fixation defined as <24 hours after injury. MAIN OUTCOME MEASUREMENTS Demographic and injury characteristics were recorded. Reasons for and timing of transfer were determined. RESULTS A total of 814 patients (53%) were transferred from another hospital, including 66% of acetabular and 62% of pelvic ring fractures. Transferred patients were older (39.1 vs. 36.6 years, P = 0.002), had more commercial insurance (21% vs. 17%, P = 0.10), and were less often uninsured (27% vs. 31%, P = 0.11). However, the mean Injury Severity Score of uninsured transferred patients was lower than that of the other transferred patients (22.9 vs. 25.8, P < 0.0001). Transfer was not related to weekday or time of injury. A total of 973 patients (63%) had early definitive fixation. Delayed fixation was often for surgeon preference (57%). Transferred patients were more likely to have delayed fixation (43% vs. 31% of nontransferred, P < 0.0001). CONCLUSIONS Internal barriers to definitive fracture care were noted, the most frequent of which is surgeon preference. Treatment delays due to transfer accounted for 12% of all delays. Many transferred patients appeared appropriate based on injury complexity. However, over one-fourth of those transferred had low Injury Severity Score and a significantly higher incidence of no insurance. Communication and transparency about these issues may serve to expedite care and to enhance financial stability of larger trauma centers. LEVEL OF EVIDENCE Prognostic level II.
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79
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Patterson BM, Draeger RW, Olsson EC, Spang JT, Lin FC, Kamath GV. A regional assessment of medicaid access to outpatient orthopaedic care: the influence of population density and proximity to academic medical centers on patient access. J Bone Joint Surg Am 2014; 96:e156. [PMID: 25232086 PMCID: PMC4159965 DOI: 10.2106/jbjs.m.01188] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Access to care is limited for patients with Medicaid with many conditions, but data investigating this relationship in the orthopaedic literature are limited. The purpose of this study was to investigate the relationship between health insurance status and access to care for a diverse group of adult orthopaedic patients, specifically if access to orthopaedic care is influenced by population density or distance from academic teaching hospitals. METHODS Two hundred and three orthopaedic practices within the state of North Carolina were randomly selected and were contacted on two different occasions separated by three weeks. An appointment was requested for a fictitious adult orthopaedic patient with a potential surgical problem. Injury scenarios included patients with acute rotator cuff tears, zone-II flexor tendon lacerations, and acute lumbar disc herniations. Insurance status was reported as Medicaid at the time of the first request and private insurance at the time of the second request. County population density and the distance from each practice to the nearest academic hospital were recorded. RESULTS Of the 203 practices, 119 (59%) offered the patient with Medicaid an appointment within two weeks, and 160 (79%) offered the patient with private insurance an appointment within this time period (p < 0.001). Practices in rural counties were more likely to offer patients with Medicaid an appointment as compared with practices in urban counties (odds ratio, 2.25 [95% confidence interval, 1.16 to 4.34]; p = 0.016). Practices more than sixty miles from academic hospitals were more likely to accept patients with Medicaid than practices closer to academic hospitals (odds ratio, 3.35 [95% confidence interval, 1.44 to 7.83]; p = 0.005). CONCLUSIONS Access to orthopaedic care was significantly decreased for patients with Medicaid. Practices in less populous areas were more likely to offer an appointment to patients with Medicaid than practices in more populous areas. Practices that were farther from academic hospitals were more likely to offer an appointment to patients with Medicaid than practices closer to academic hospitals. CLINICAL RELEVANCE This study illustrates the barriers to timely outpatient orthopaedic care that patients with Medicaid face. The findings from our study imply that patients with Medicaid in more populous areas and in areas closer to academic medical centers are less likely to obtain an outpatient orthopaedic appointment than patients with Medicaid in less populous areas and in areas more distant from academic medical centers. A shift in policy to enhance access to orthopaedic care for patients with Medicaid, especially those in urban areas and areas close to academic medical centers, will become increasingly important as more patients become eligible for Medicaid through the Patient Protection and Affordable Care Act of 2010.
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Affiliation(s)
- Brendan M. Patterson
- UNC School of Medicine, 130 Mason Farm Road, 3147
Bioinformatics Building, Chapel Hill, NC 27599-7055. E-mail address for R.W. Draeger:
| | - Reid W. Draeger
- UNC School of Medicine, 130 Mason Farm Road, 3147
Bioinformatics Building, Chapel Hill, NC 27599-7055. E-mail address for R.W. Draeger:
| | - Erik C. Olsson
- UNC School of Medicine, 130 Mason Farm Road, 3147
Bioinformatics Building, Chapel Hill, NC 27599-7055. E-mail address for R.W. Draeger:
| | - Jeffrey T. Spang
- UNC School of Medicine, 130 Mason Farm Road, 3147
Bioinformatics Building, Chapel Hill, NC 27599-7055. E-mail address for R.W. Draeger:
| | - Feng-Chang Lin
- The North Carolina Translational and Clinical Sciences
Institute, University of North Carolina at Chapel Hill, 160 North Medical Drive,
Brinkhous-Bullitt Building, 2nd Floor, Campus Box CB# 7064, Chapel Hill, NC
27599
| | - Ganesh V. Kamath
- UNC School of Medicine, 130 Mason Farm Road, 3147
Bioinformatics Building, Chapel Hill, NC 27599-7055. E-mail address for R.W. Draeger:
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80
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Schairer WW, Zhang AL, Feeley BT. Hospital readmissions after primary shoulder arthroplasty. J Shoulder Elbow Surg 2014; 23:1349-55. [PMID: 24618197 DOI: 10.1016/j.jse.2013.12.004] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/25/2013] [Accepted: 12/03/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although shoulder arthroplasty procedures are more frequently performed in the United States, there is insufficient information on outcome measures such as hospital readmission rates or factors for readmission after surgery. METHODS The State Inpatient Database from 7 different states was used to identify patients who underwent hemiarthroplasty, total shoulder arthroplasty (TSA), or reverse total shoulder arthroplasty (RTSA) from 2005 through 2010. The database was used to determine the 90-day readmission rate, causes of readmission, and risk factors for readmission. Multivariate modeling and a Cox proportional hazards model were used to measure factors and risk for readmission. RESULTS Included were 26,218 patients receiving shoulder arthroplasty, with an overall 90-day readmission rate of 7.3%. RTSA had the highest rate (11.2%), followed by hemiarthroplasty (8.2%) and TSA (6.0%; P < .001). Medical complications contributed to 82% of readmissions, and surgical complications contributed to 18%. Osteoarthritis was the most common medical diagnosis (11%), followed by deep venous thrombosis or pulmonary embolism (4.4%) and pneumonia (3.9%). Infection was the most common surgical cause of readmission (4.8%), followed by dislocation (4.6%). There was a stepwise increase in risk of readmission with increasing age. Patients with Medicaid insurance had more than a 50% greater risk of readmission than patients with Medicare. Procedures performed at medium-volume and high-volume hospitals showed lower risk of readmission than low-volume centers. CONCLUSIONS Patients undergoing RTSA had higher hospital readmission rates than those undergoing hemiarthroplasty or TSA, but most readmissions after shoulder arthroplasty were due to medical causes.
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Affiliation(s)
- William W Schairer
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA, USA.
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81
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Sears ED, Chung KC. Future education and practice initiatives in hand surgery: improving fulfillment of patient needs. Hand Clin 2014; 30:377-86, vii-viii. [PMID: 25066857 DOI: 10.1016/j.hcl.2014.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the current health care environment, there are several areas in the delivery of health care to patients having hand surgery that need improvement to adequately fulfill patient needs, including difficulty in maintaining adequate emergency call coverage for patients having hand surgery, decreasing trends in hand surgeons willing to perform microsurgery and replantation, and deficiencies in musculoskeletal education of non-hand surgery providers. Both educational reforms and reforms in the practice environment are needed to improve the ability of hand surgeons to fulfill patient needs in the future.
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Affiliation(s)
- Erika D Sears
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA.
| | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, The University of Michigan Health System, 2130 Taubman Center, SPC 5340, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5340, USA
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82
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Cologne KG, Hwang GS, Senagore AJ. Cost of practice in a tertiary/quaternary referral center: is it sustainable? Tech Coloproctol 2014; 18:1035-9. [PMID: 24938394 DOI: 10.1007/s10151-014-1175-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 05/30/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Third-party payers are moving toward a bundled care payment system. This means that there will need to be a warranty cost of care-where the cost of complexity and complication rates is built into the bundled payment. The theoretical benefit of this system is that providers with lower complication rates will be able to provide care with lower warranty costs and lower overall costs. This may also result in referring riskier patients to tertiary or quaternary referral centers. Unless the payment model truly covers the higher cost of managing such referred cases, the economic risk may be unsustainable for these centers. METHODS We took the last seven patients that were referred by other surgeons as "too high risk" for colectomy at other centers. A contribution margin was calculated using standard Medicare reimbursement rates at our institution and cost of care based on our administrative database. We then recalculated a contribution margin assuming a 3 % reduction in payment for a higher than average readmission rate, like that which will take effect in 2014. Finally, we took into account the cost of any readmissions. RESULTS Seven patients with diagnosis related group (DRG) 330 were reviewed with an average age of 66.8 ± 16 years, American Society of Anesthesiologists score 2.3 ± 1.0, body mass index 31.6 ± 9.8 kg/m(2) (range 22-51 kg/m(2)). There was a 57 % readmission rate, 29 % reoperation rate, 10.8 ± 7.7 day average initial length of stay with 14 ± 8.6 day average readmission length of stay. Forty-two percent were discharged to a location other than home. Seventy-one percent of these patients had Medicare insurance. The case mix index was 2.45. Average reimbursement for DRG 330 was $17,084 (based on Medicare data) for our facility in 2012, with the national average being $12,520. The total contribution margin among all cases collectively was -$19,122 ± 13,285 (average per patient -$2,731, range -$21,905-$12,029). Assuming a 3 % reimbursement reduction made the overall contribution margin -$22,122 ± 13,285 (average -$3,244). Including the cost of readmission in the variable cost made the contribution margin -$115,741 ± 16,023 (average -$16,534). CONCLUSIONS Care of high-risk patients at tertiary and quaternary referral centers is a very expensive proposition and can lead to financial ruin under the current reimbursement system.
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Affiliation(s)
- K G Cologne
- Keck School of Medicine of the University of Southern California, 1441 Eastlake Avenue, Suite 7418, Los Angeles, CA, 90033, USA,
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83
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Repeat emergency room visits for hand and wrist injuries. J Hand Surg Am 2014; 39:752-6. [PMID: 24594269 DOI: 10.1016/j.jhsa.2014.01.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 01/10/2014] [Accepted: 01/10/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To characterize patients with hand or wrist injuries presenting to our university-based emergency department (ED) after a previous evaluation by an outside ED. We hypothesized that a majority of these patients did not require emergent care, most arrived during working hours, and a disproportionate number were uninsured. METHODS We retrospectively reviewed 3,047 orthopedic hand consults from 2002 to 2010. Patients were included if our ED was the patient's second ED evaluation within 30 days for the same complaint. Demographics, diagnosis, referral instructions from the initial institution, date and time of ED visit, treatment received, and insurance status were recorded. Clinical urgency was quantified on an ordinal scale. RESULTS A total of 325 patients met the inclusion criteria. The most common diagnoses were distal radius and metacarpal fractures. There were 266 (82%) patients with nonurgent diagnoses. A junior-level orthopedic resident treated and discharged 97% of patients from the ED. Sixty-two percent of the patients were uninsured, 32% had Medicaid, and 6% had commercial insurance or Medicare. There was a disproportionate percentage of uninsured and Medicaid patients compared with the payer mix of our state, orthopedic department, and ED. Ninety percent of patients presented on weekdays, and 84% arrived between 6 am and 6 pm. CONCLUSIONS Most patients who met our inclusion criteria presented to our ED during regular business hours. Most were uninsured and did not have a condition that warranted urgent or emergent evaluation and treatment. With limited resources, it is important that an appropriate follow-up plan from the initial ED be in place so that patients do not have to present to a second ED for the same problem. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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84
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Draeger RW, Patterson BM, Olsson EC, Schaffer A, Patterson JMM. The influence of patient insurance status on access to outpatient orthopedic care for flexor tendon lacerations. J Hand Surg Am 2014; 39:527-33. [PMID: 24559630 DOI: 10.1016/j.jhsa.2013.10.031] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 10/31/2013] [Accepted: 10/31/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the effect of patient insurance status on access to outpatient orthopedic care for acute flexor tendon lacerations. METHODS The research team contacted 100 randomly chosen orthopedic surgery practices in North Carolina by phone on 2 different occasions separated by 3 weeks. The research team attempted to obtain an appointment for a fictitious 28-year-old man with an acute flexor tendon laceration. Insurance status was presented as Medicaid in 1 call and private insurance in the other call. Ability of an office to schedule an appointment was recorded. RESULTS Of the 100 practices, 13 were excluded because they did not perform hand surgery, which left 87 practices. The patient in the scenario with Medicaid was offered an appointment significantly less often (67%) than the patient in the scenario with private insurance (82%). The odds of the patient with private insurance obtaining an appointment were 2.2 times greater than the odds of the Medicaid patient obtaining an appointment. The Medicaid patient was more likely not to be offered an appointment owing to the lack of a hand surgeon at a practice (28% of appointment denials) than privately insured patients (13% of appointment denials). CONCLUSIONS For patients with acute flexor tendon lacerations, insurance status has an important role in the ability to obtain an orthopedic clinic appointment. We found that patients with Medicaid have more barriers to accessing care for a flexor tendon laceration than patients with private insurance. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
- Reid W Draeger
- Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Brendan M Patterson
- Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Erik C Olsson
- Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Alicia Schaffer
- Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - J Megan M Patterson
- Department of Orthopaedics, University of North Carolina School of Medicine, Chapel Hill, NC
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85
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Meyer FN. Commentary on "the influence of patient insurance status on access to outpatient orthopedic care for flexor tendon lacerations". J Hand Surg Am 2014; 39:534. [PMID: 24559631 DOI: 10.1016/j.jhsa.2013.11.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 11/14/2013] [Indexed: 02/02/2023]
Affiliation(s)
- Frederick N Meyer
- Department of Orthopaedic Surgery, University of South Alabama, Mobile, AL
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86
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Abstract
Growing orthopedic and nonorthopedic literature illustrates the point that having health insurance does not equal having access to care. The goal of this study was to evaluate the burden placed on patients to gain access to outpatient orthopedic care. For this study, burden was quantified as the distance traveled by the patient to be seen in clinic. This study was a retrospective review of all new patient encounters at an adult orthopedic outpatient clinic in an academic tertiary referral center over 1 calendar year. All patients were stratified into 4 categories: commercial/private insurance, Medic-aid, Medicare, and uninsured/private pay. The average distance traveled by each patient to the center was then calculated based on the patient's billing zip code. Patient visits were further stratified based on whether the patients were seen by 1 of 3 different categories of providers: general orthopedics/adult reconstruction, spine, and sports/upper extremity. The study group comprised 774 (31.1%) Medicaid patients, 653 (26.2%) Medicare patients, 917 (36.8%) commercial/private insurance patients, and 146 (5.9%) uninsured/private pay patients. The average 1-way distance traveled was 36.2 miles for Medicaid patients, 21.3 miles for Medicare patients, 24.1 miles for commercial/private insurance patients, and 25.3 miles for uninsured/private pay patients (P<.00). Subgroup analysis noted a statistical difference in distance traveled for the general orthopedics/adult reconstruction and sports/upper extremity groups. The study's findings suggest that having insurance does not equal access to outpatient orthopedic care at a single institution. The specific burdens that each group faces to gain access to care are unclear.
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