Length of Stay in Skilled Nursing Facilities Following Total Joint Arthroplasty

Medicare skilled nursing facilities' occupancy and payer source: The moderating role of financial performance

Objectives

While extensive research has focused on patient outcomes in skilled nursing facilities, a critical gap remains in understanding factors influencing their managerial performance, particularly occupancy rates. This study examines the occupancy rates of skilled nursing facilities and assesses the significance of two important drivers of managerial performance that have not received sufficient attention-the influence of payer mix and total profit margin. Specifically, we focused on the role played by a nursing home's financial performance (as assessed by profit margin) in influencing the relationship between payer mix and occupancy rate among skilled nursing facilities.

Methods

Data were extracted from the 2019 to 2020 Joint Annual Report of Nursing Homes for a sample of 612 skilled nursing facilities in Tennessee, USA. Regression analysis was performed by fitting a generalized estimating equation of occupancy rate.

Results

Compared to skilled nursing facilities in the lowest quartile of profit margin, for example, those in the highest quartile had approximately 18 percentage points higher occupancy rates per unit increase in resident days of care covered by traditional Medicare (β = 0.18, p = 0.0028). Similarly, skilled nursing facilities in the second highest quartile of profit margin had a higher occupancy rate by approximately 23 percentage points per unit increase in Medicare Advantage (β = 0.23, p = 0.0375) when compared to those in the lowest quartile of profit margin.

Conclusions

Skilled nursing facilities with stronger financial performance generally have higher occupancy rates, particularly notable in relation to an upswing in payer sources such as traditional Medicare and Medicare Advantage, when compared to skilled nursing facilities with weaker profitability. Given the increasingly larger role of Medicare in long-term care funding, policymakers and nursing home managers may find it useful to consider our findings when evaluating opportunities to enhance managerial performance of skilled nursing facilities.

Lost in the Shuffle: Low Health Literacy in Geriatric Fracture Patients and Families Regarding Post-Acute Care-A Prospective Study

INTRODUCTION

This study aims to evaluate health literacy (HL) in geriatric orthopaedic trauma patients and their families as it relates to their post-acute care (PAC) in skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs).

METHODS

This nonrandomized controlled clinical trial included patients aged 65 years and older treated for acute fracture at a Level 1 trauma center and discharged to either IRF or SNF. First 106 patients enrolled served as the control group and received standard discharge instructions. The second 101 patients were given a set of oral and written instructions regarding PAC detailing important questions to ask upon arrival to their facility.

RESULTS

The mean HL score for all patients/families was 2.4 out of 5. No significant difference was noted in HL scores (2.4 versus 2.3) or median LOS (22 versus 28 days) between the control and intervention groups. Family involvement (68%) slightly improved HL scores (2.6 versus 1.9, P < 0.001). Patients discharged to IRF had better HL scores (3.4 versus 2.3, P < 0.001), shorter LOS (median 15 vs 30 days, P < 0.001), and trended toward improved knowledge of discharge goals (48.1% versus 35.6%) than those in SNF.

CONCLUSION

System-wide solutions are necessary to improve geriatric HL and optimize outcomes in orthopaedic trauma.

Use of The Risk Assessment and Prediction Tool to Predict Same-day Discharge After Primary Hip and Knee Arthroplasty

INTRODUCTION

The Risk Assessment and Prediction Tool (RAPT) is a preoperative screening tool developed to predict discharge disposition after total hip arthroplasty (THA) and total knee arthroplasty (TKA), but its predictive value for same-day discharge (SDD) has not been investigated. The aims of this study were (1) to assess RAPT's ability to predict SDD after primary THA and TKA and (2) to determine a cutoff RAPT score that may recognize patients appropriate for SDD.

METHODS

Data were retrospectively collected from patients undergoing primary THA and TKA at a single tertiary care center between February 2020 and May 2021. A receiver operating characteristic curve was generated to choose a cutoff value to screen for SDD. Logistic regression analysis was done to identify factors including age, BMI, or RAPT score that may be associated with SDD.

RESULTS

Three hundred sixty-one patients with preoperative RAPT scores were included in the analysis of whom 147 (42.6%) underwent SDD. A cutoff of ≥9 was identified for TKA and ≥11 for THA. RAPT had a predictive accuracy of only 66.7% for SDD, whereas the discharge plan documented in the preoperative note was 91.7% accurate.

DISCUSSION

Although there is a positive association between RAPT and SDD, it is not a useful screening tool given its low predictive accuracy.

Tranexamic Acid in Foot and Ankle Surgery: A Topical Review and Value Analysis

Tranexamic acid (TXA) has become a commonly used perioperative intervention in total joint arthroplasty, shoulder and knee arthroscopy, and spinal procedures in order to minimize blood loss, hematoma formation, hemarthrosis, and wound healing complications. There is a potential role for TXA use in foot and ankle procedures, with limited studies suggesting a potential benefit in minimizing postoperative wound complications and blood loss without an increased risk of thromboembolic events. In light of the profound clinical and financial impact of TXA use in other orthopaedic subspecialties and the early successes in foot and ankle surgery, we aim to provide more information about TXA and its use in foot and ankle surgery. Therefore, the purpose of this review is to perform a comprehensive literature review on the topic of TXA use in foot and ankle procedures in order to describe the pertinent available literature on the use of TXA in orthopaedic surgery and its implications specifically in foot and ankle surgery. It is our aim to identify potential benefits and shortcomings in the available evidence on TXA use for foot and ankle surgery in hopes to (1) best inform foot and ankle surgeons where beneficial and safe and (2) inspire further research on this topic as it relates to clinical management for foot and ankle patients.Levels of Evidence: Level IV.

The Spillover Effect of the Medicare Mandatory Bundled Payment Program on Joint Replacement Outcomes: Analysis of Patients with Commercial Insurance and Medicare Advantage

BACKGROUND

To improve the value and efficiency of care among traditional Medicare enrollees, the Centers for Medicare & Medicaid Services has implemented alternative payment models designed to control health-care spending and improve quality. These models may affect care beyond traditional Medicare enrollees, "spilling over" into other populations. Established in April 2016, the Medicare mandatory bundled payment program, called the Comprehensive Care for Joint Replacement (CJR) model, holds hospitals accountable for spending and quality of care for traditional Medicare joint-replacement patients during care episodes that span from the index hospitalization to 90 days post-discharge. We assessed the extent to which the CJR model was associated with outcomes for patients enrolled in commercial insurance and Medicare Advantage plans.

METHODS

With use of Health Care Cost Institute claims data from 2012 through 2017, we assessed the association of the CJR model with total expenditures, discharges to institutional post-acute care, and readmissions among commercial insurance and Medicare Advantage joint-replacement patients. The exposure variable was the implementation of the CJR model in 67 randomly selected metropolitan statistical areas compared with 103 similar areas without CJR implementation. We utilized difference-in-differences models to estimate the spillover effects of the CJR model by comparing outcomes between these areas before and after CJR implementation.

RESULTS

The study included 174,893 joint-replacement episodes of care in commercial insurance enrollees and 202,070 episodes in Medicare Advantage enrollees. Among both commercial insurance and Medicare Advantage enrollees, CJR implementation was associated with no meaningful changes in total episode expenditures, discharges to institutional post-acute care, or readmissions.

CONCLUSIONS

We found no evidence for spillover effects of the CJR model on commercial insurance and Medicare Advantage patients, suggesting that alternative payment models targeting traditional Medicare patients may have limited effects on the cost and quality of care for patients outside of the traditional Medicare system.

Rehabilitation Intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review

OBJECTIVE

Exponential increases in rehabilitation intensity in skilled nursing facilities (SNFs) motivated recent changes in Medicare reimbursement policies, which remove financial incentives for providing more minutes of physical therapy, occupational therapy, and speech therapy. Yet, there is concern that SNFs will reduce therapy provision and patients will experience worse outcomes. The purpose of this systematic review was to synthesize current evidence on the relationship between therapy intensity and patient outcomes in SNFs.

METHODS

PubMed, Medline, Scopus, Embase, CINAHL, PEDro, and COCHRANE databases were searched. English-language studies published in the United States between 1998 and February 14, 2020, examining the relationship between therapy intensity and community discharge, hospital readmission, length of stay (LOS), and functional improvement for short-stay SNF patients were considered. Data extraction and risk of bias were performed using the American Academy of Neurology Classification of Evidence scale for causation questions. American Academy of Neurology criteria were used to assess confidence in the evidence for each outcome.

RESULTS

Eight observational studies met inclusion criteria. There was moderate evidence that higher intensity therapy was associated with higher rates of community discharge and shorter LOS. One study provided very low-level evidence of associations between higher intensity therapy and lower hospital readmissions after total hip and knee replacement. There was low-level evidence indicating higher intensity therapy is associated with improvements in function.

CONCLUSIONS

This systematic review concludes with moderate confidence that higher intensity therapy in SNFs leads to higher community discharge rates and shorter LOS. Future research should improve quality of evidence on functional improvement and hospital readmissions.

IMPACT

This systematic review demonstrates that patients in SNFs may benefit from higher intensity therapy. Because new policies no longer incentivize intensive therapy, patient outcomes should be closely monitored to ensure patients in SNFs receive high-quality care.

Partnership Across Transitions to Improve Outcomes in the Lower Extremity Total Joint Population

BACKGROUND

With the urgency related to improving quality and creating efficiency in healthcare, partnership is emerging as a critical concept related to transitions of care.

PURPOSE

This quality improvement project included facilitation of hospital partnership with skilled nursing facilities to improve outcomes associated with the lower extremity total joint arthroplasty population.

METHODS

The clinical nurse specialist (CNS) utilized a standardized framework to implement partnership strategies with multidisciplinary teams. Outcomes were monitored for the 2 quarters of partnership activities.

RESULTS

All recommendations for developing a partnership model were facilitated within the project timeline. Patient experience and quality measures remained at, or improved, from baseline and met all strategic targets. Efficiency through episode payment demonstrated improvement at each interval during the study period. Analysis revealed a significant (p < .05) reduction in the mean hospital length of stay.

CONCLUSION

The CNS practice outcomes suggest that the use of structured partnership strategies between agencies improves efficiency of care and accelerates rapid spread of innovation.

Postacute Care Disposition for Total Hip and Total Knee Replacement Surgery for Asian Americans

This study explored differences in postacute disposition for total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a focus on whether Asian Americans (AS) experience joint replacement disparities observed in other racial/ethnic minorities compared with majority white patients. We used data from the Nationwide Inpatient Sample for 2009 through 2012. We looked at disposition to home health care (HHC) and transfer to another facility for postacute care (e.g., skilled nursing facility, rehabilitation facility) for each of the 4 years under study. Findings for AS were mixed. There were differences in discharge to postacute facilities other than HHC for AS compared with whites for THA for 2011 and 2012. For TKA, there were differences in disposition to HHC for Asians compared with whites for 2009 and 2012; for disposition to postacute facilities other than HHC for TKA, there were differences for 2011 and 2012 only. Differences for AS in postacute disposition to facilities other than HHC appear to increase over the 4 years of the study. Further research with additional data is warranted.

Outpatient, Home-Based Physical Therapy Promotes Decreased Length of Stay and Post-Acute Resource Utilization After Total Joint Arthroplasty

BACKGROUND

Patients and healthcare systems are increasingly focused on evaluating interventions that increase the value of care delivered. Our objective of this study is to evaluate early post-operative outcomes among those patients who underwent total joint arthroplasty with and without the participation in our piloted Outpatient Physical Therapy Home Visits (OPTHV) program.

METHODS

A retrospective analysis of patients undergoing total hip arthroplasty and total knee arthroplasty at a single institution from July 2016 to September 2017 was performed. Matched cohorts were compared according to OPTHV enrollment status.

RESULTS

In total, 1729 patients were included in this study. Two hundred ninety-three patients were enrolled in OPTHV, while 1436 patients received institutional standard care. Patients were matched by gender (56.7% vs 57.7% female, P = .751), age (67.75 vs 66.95 years, P = .167), body mass index (30.18 vs 30.12 kg/m², P = .859), and average American Society of Anesthesiologists score (2.31 vs 2.36, P = .131). OPTHV patients had a shorter length of stay (1.39 vs 1.64 days, P < .001) and were more likely to discharge to home (89.8% vs 74.7%, P < .001). Ninety-day re-admissions (2.7% vs 2.6%, P = .880) and emergency room visits (4.1% vs 4.3%, P = .864) were equivalent.

CONCLUSION

OPTHV is a novel program that facilitates discharge home and decreased length of stay after total joint arthroplasty without increasing re-admissions or emergency room visits. Utilization of OPTHV may contribute toward reducing the episode of care costs by reducing utilization of skilled nursing facility and home health services. Further prospective studies are needed to evaluate the effect of OPTHV on the total cost of care and functional outcomes.

The Relationship Between Medicaid Coverage and Outcomes Following Total Knee Arthroplasty: A Systematic Review

BACKGROUND

Access to elective total knee arthroplasty is important in the treatment of end-stage arthritis, and numerous initiatives, including Medicaid expansion, have sought to improve patients' ability to undergo this procedure. However, despite this, the role of Medicaid insurance in patient outcomes remains unclear. The purpose of this study was to perform a systematic review of the literature to explore the relationship between preoperative Medicaid insurance status and outcomes following primary total knee arthroplasty.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies examining outcomes in patients who had Medicaid and were undergoing total knee arthroplasty. Studies including complex revision operations or less common indications for total knee arthroplasty were excluded. Data on insurance status, postoperative complications, length of stay, readmissions, and subsequent revision surgical procedures were collected for each article.

RESULTS

A total of 13 studies showing 6.18 million patients undergoing total knee arthroplasty were included in the qualitative synthesis. Seven analyses described an important association between Medicaid coverage and short-term readmissions, and 2 analyses showed a relationship between Medicaid and prolonged length of stay. However, the included studies did not describe a significant association between Medicaid and postoperative mortality or revision rates.

CONCLUSIONS

Patients with Medicaid undergoing total knee arthroplasty may be more likely to experience an increased length of stay and to be readmitted postoperatively. The unique factors associated with these patients may help to inform customized perioperative surveillance and optimization to improve outcomes in this group.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Successful Implementation of an Accelerated Recovery and Outpatient Total Joint Arthroplasty Program at a County Hospital

Outpatient and accelerated recovery total joint arthroplasty (TJA) programs have become standard for private and academic practices. County hospitals traditionally serve patients with limited access to TJA and psychosocial factors which create challenges for accelerated recovery. The effectiveness of such programs at a county hospital has not been reported.

Methods

In 2017, our county hospital implemented an accelerated recovery protocol for all TJA patients. This protocol consisted of standardized, preoperative medical and psychosocial optimization, perioperative spinal anesthesia, tranexamic acid and local infiltration analgesia use, postoperative emphasis on non-narcotic analgesia, and early mobilization. LOS, complications, disposition, and cost were compared between patients treated before and after protocol implementation.

Results

In 15 months, 108 primary TJA patients were treated. Compared with the previous 108 TJA patients, LOS dropped from 3.4 to 1.6 days (P < 0.001), more patients discharged home (92% versus 72%, P < 0.001), average hospitalization and procedure-specific costs decreased 24.7% and 22.1%, respectively, and were significantly fewer complications (7% versus 21%, P = 0.007).

Conclusions

Implementation of an accelerated recovery TJA program at a County Hospital is novel. This implementation requires careful patient selection and a coordinated multidisciplinary approach and is a safe and cost-effective method of delivering high-quality care to an underserved cohort.

Spending On Postacute Care After Hospitalization In Commercial Insurance And Medicare Around Age Sixty-Five

Postacute care costs are the primary determinant of episode spending around hospitalization. Yet there is little evidence that greater spending on postacute care improves readmission rates or functional recovery. Recent Medicare payment reform evaluations have suggested that postacute care spending is responsive to episode-based incentives. However, it remains unknown whether Medicare payment policies are responsible for excess postacute care spending, compared with that of commercial payers. In a population-based, statewide collaborative of Michigan hospitals, we used regression discontinuity design among propensity-weighted, age-adjusted cohorts to compare postacute care spending between patients with commercial insurance and those with Medicare around age sixty-five. Spending was 68-230 percent greater among fee-for-service Medicare beneficiaries than among similar commercially insured people across varied medical and surgical conditions. Despite greater spending, there were no differences in readmission rates. These findings suggest that postacute care utilization is highly sensitive to payer influence, and there may be an opportunity for additional savings in Medicare without sacrificing quality.

Skilled Nursing Facilities After Total Knee Arthroplasty: The Time for Selective Partnerships Is Now!

BACKGROUND

Bundled payment initiatives for total knee arthroplasty (TKA) patients are dramatically impacted by discharges to skilled nursing facilities (SNFs), making target prices set by the Center for Medicare and Medicaid Services difficult to achieve. However, we hypothesized that a granular examination of SNF discharges would reveal that some may disproportionately increase costs compared to others.

METHODS

The institutional database was retrospectively queried for primary TKA patients under bundled payment initiatives. The 4 most common SNFs utilized by our patient population (A, B, C, and D) were investigated for length of stay, cost of care, and whether the overall target price for the episode of care (EOC) was reached.

RESULTS

In total, 1223 TKA patients were analyzed, with 378 (30.9%) discharged to an SNF and 246 patients selecting one of the 4 most common SNFs (A: 198, B: 21, C: 15, D: 12). Each SNF represented a significant fiscal portion of the total EOC; however, SNF D had significantly longer length of stay (21 vs 13 days, P < .001) and cost of care ($11,805 vs $6015, P < .001) relative to the others, resulting in no EOC under the target price. SNF costs >24.6% of the total EOC were predictive of exceeding the target price.

CONCLUSION

Bundled payment models are significantly impacted by SNF disposition; however, select facilities disproportionately impact this system. In order to maintain free patient selection for disposition, post-acute care facilities must be held accountable for controlling cost, or a separate bundled payment provided.

Comparison of 90-Day Perioperative Outcomes in Shoulder Arthroplasty Between the Elderly and Nonelderly Patients

INTRODUCTION

As life expectancy increases, the incidence of shoulder arthroplasty continues to increase as well. There are few shoulder arthroplasty studies investigating perioperative complication, readmission, and mortality. Furthermore, with bundled payments on the horizon, the cost of shoulder arthroplasty has become a significant issue. Clarifying risk factors for the need for postdischarge acute care will be critical information due to the high cost of such care. The goal of this study was to compare discharge disposition, length of stay (LOS), perioperative complications, readmission, and mortality in elderly and nonelderly cohorts to determine whether age is a risk factor for shoulder arthroplasty.

MATERIALS AND METHODS

We retrospectively compared 89 elderly patients (80 years or older) and 86 nonelderly patients (79 years or younger) who underwent hemiarthroplasty, total shoulder arthroplasty, reverse total shoulder arthroplasty, or revision shoulder arthroplasty from 2007 to 2015. Baseline characteristics were compared between the 2 cohorts. We then compared discharge disposition, LOS, 90-day complication rate, readmission, and mortality between the 2 cohorts.

RESULTS

Average length of hospitalization and percentage of patients with greater than 2 days of hospitalization were significantly higher in the elderly cohorts. Forty-four percent of the elderly cohorts were discharged to a skilled nursing facility compared to 6% in the nonelderly cohorts (P < .0001). There were no significant differences found in 90-day major complication rate, readmission, or mortality.

DISCUSSION

Shoulder arthroplasty is a valuable surgery for various indications in the elderly population. However, the likelihood of a patient to need a prolonged hospitalization or skilled nursing facility care after surgery are important questions that need to be answered. Our study shows that age over 80 years is a risk factor for prolonged hospitalization and need for skilled nursing facility care after shoulder arthroplasty.

CONCLUSION

We conclude that elderly patients who undergo shoulder arthroplasty are significantly more likely to have extended hospitalizations and to be discharged to skilled nursing facilities compared to nonelderly patients.

Challenges and Consequences of Reduced Skilled Nursing Facility Lengths of Stay

OBJECTIVE

To identify the challenges that reductions in length of stay (LOS) pose for skilled nursing facilities (SNFs) and their postacute care (PAC) patients.

DATA SOURCES/SETTING

Seventy interviews with staff in 25 SNFs in eight U.S. cities, LOS data for patients in those SNFs.

STUDY DESIGN

Data were qualitatively analyzed, and key themes were identified. Interview data from SNFs with and without reductions in median risk-adjusted LOS were compared and contrasted.

DATA COLLECTION/EXTRACTION METHODS

We conducted 70 semistructured interviews. LOS data were derived from minimum dataset (MDS) admission records available for all patients in all U.S. SNFs from 2012 to 2014.

PRINCIPAL FINDINGS

Challenges reported regardless of reductions in LOS included frequent and more complicated re-authorization processes, patients becoming responsible for costs, and discharging patients whom staff felt were unsafe at home. Challenges related to reduced LOS included SNFs being pressured to discharge patients within certain time limits. Some SNFs reported instituting programs and processes for following up with patients after discharge. These programs helped alleviate concerns about patients, but they resulted in nonreimbursable costs for facilities.

CONCLUSIONS

The push for shorter LOS has resulted in unexpected challenges and costs for SNFs and possible unintended consequences for PAC patients.

Comparison of postarthroplasty functional outcomes in skilled nursing facilities among Medicare and Managed Care beneficiaries

Background

After home health care, the skilled nursing facility (SNF) is the most commonly used postacute care modality, among Medicare beneficiaries, after total joint arthroplasty. Prior studies demonstrated that a loss in postsurgical ambulatory gains is incurred in the interval between hospital discharge and arrival at the SNF. The aim of this present study is to determine the consequences of that loss in function, as well as compare SNF-related outcomes in patients with Medicare vs Managed Care (MC) insurance.

Methods

We conducted a retrospective analysis of 80 patients (54 Medicare and 26 MC) who attended an SNF after hospitalization for total joint arthroplasty. Outcomes from physical therapy records were abstracted from each patient's SNF file.

Results

There was an approximately 40% drop-off in gait achievements between hospital discharge and SNF admission. This decline in ambulation was significantly greater in Medicare patients (Medicare: 94.6 ± 123.2 ft, MC: 40.0 ± 48.9 ft, P = .034). Larger reductions in gait achievements between hospital discharge and SNF admission were significantly correlated with longer SNF lengths of stay and poorer gait achievements by SNF discharge. Patients with MC insurance made significant improvements in gait training at the SNF beyond that which was acquired at the hospital, whereas Medicare patients did not (P_Medicare = .28, P_MC = .003).

Conclusions

Large losses in motor function between hospital discharge and SNF admission were associated with poor functional outcomes and longer stays at the SNF. These effects were more pronounced in Medicare patients than those with MC insurance.

Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York

STUDY OBJECTIVE

To confirm the relationship between primary payer status as a predictor of increased perioperative risks and post-operative outcomes after total hip replacements.

DESIGN

Retrospective cohort study.

SETTING

Administrative database study using 2007-2011 data from California, Florida, and New York from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.

PATIENTS

295,572 patients age≥18years old who underwent total hip replacement with non-missing insurance data were collected, using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedures code (ICD-9-CM code 81.51).

INTERVENTIONS

Patients underwent total hip replacement.

MEASUREMENTS

Patients were cohorted by insurance type as either Medicare, Medicaid, Uninsured, Other, and Private Insurance. Demographic characteristics and comorbidities were compared. Unadjusted rates of in-hospital mortality, postoperative complications, LOS, 30-day, and 90-day readmission status were compared. Adjusted odds ratios were calculated for our outcomes using multivariate linear and logistic regression models fitted to our data.

MAIN RESULTS

Medicaid patients incurred a 125% increase in the odds of in-hospital mortality compared to those with Private Insurance (OR 2.25, 99% CI 1.01-5.01). Medicaid payer status was associated with the highest statistically significant adjusted odds of mortality, any complication (OR, 1.26), cardiovascular complications (OR, 1.37), and infectious complications (OR, 1.66) when compared with Private Insurance. Medicaid patients had the highest statistically significant adjusted odds of 30-day (OR, 1.63) and 90-day readmission (OR, 1.58) and the longest adjusted LOS.

CONCLUSIONS

We found higher unadjusted rates and risk adjusted odds ratios of postoperative mortality, morbidity, LOS, and readmissions for patients with Medicaid insurance as compared to patients with Private Insurance. Our study shows that primary payer status serves as a predictor of perioperative risks and that primary payer status should be viewed as a peri-operative risk factor.