1
|
Tadé Y, Timperley J, Dilsaver D, McDermott J, de Rosa N, Al-Refaie WB. High-risk rural surgical patients and poor access to elective colorectal cancer surgery: insight for multilevel intervention for rural America. J Gastrointest Surg 2024:S1091-255X(24)00583-3. [PMID: 39242216 DOI: 10.1016/j.gassur.2024.08.011] [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: 05/15/2024] [Revised: 08/09/2024] [Accepted: 08/13/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Colorectal cancer (CRC) is a leading cause of death in rural America. Rural populations are large and heterogeneous, yet patient-related drivers of inequities in CRC access are understudied. This study aimed to identify vulnerable rural populations at lower odds of undergoing elective CRC surgery. METHODS Evaluation of the Policy Map and United States Census Bureau identified factors associated with poor surgical access in the most populous states (by total rural population). To assess whether these identified factors were associated with reduced access to elective CRC surgery, the 2007 to 2020 National Inpatient Sample was used to evaluate 69,212 hospitalizations of rural patients undergoing CRC surgery. Rural was defined as counties with a population of <250,000. Multivariable logistic regression models assessed predictors of elective CRC surgery. Patient- and hospital-level factor interactions were specified a priori. RESULTS More than 72% of hospitalizations of rural patients were elective. Multivariate regression analysis demonstrated that older age, multimorbidity, Black race, Latino-Hispanic ethnicity, Medicaid insurance, and rural hospitals predicted lower odds of elective CRC surgery. On interaction analyses, high-risk patients were less likely to undergo elective CRC surgery in urban facilities relative to rural. CONCLUSION In this large study of rural dwellers, ethnoracial minorities, elders, and Medicaid beneficiaries had profoundly less access to elective CRC surgery, especially when care was received in urban settings. Future studies should focus on exploring actionable social drivers of health in these rural populations. Findings underscore the need for multilevel interventions to enhance rural access to equitable and quality surgical cancer care.
Collapse
Affiliation(s)
- Yanick Tadé
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, United States; Department of Surgery, Catholic Health Initiatives Health, Omaha, NE, United States
| | - Jillian Timperley
- Department of Surgery, Catholic Health Initiatives Health, Omaha, NE, United States
| | - Danielle Dilsaver
- Department of Surgery, Catholic Health Initiatives Health, Omaha, NE, United States; Department of Clinical Research and Public Helath, Creighton University School of Medicine, Omaha, NE, United States
| | - James McDermott
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, United States
| | - Nicole de Rosa
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, United States; Department of Surgery, Catholic Health Initiatives Health, Omaha, NE, United States
| | - Waddah B Al-Refaie
- Department of Surgery, Creighton University School of Medicine, Omaha, NE, United States; Department of Surgery, Catholic Health Initiatives Health, Omaha, NE, United States.
| |
Collapse
|
2
|
Wahid N, Lee J, Rosenblatt R, Kaplan A, Tipirneni R, Fortune BE, Safford M, Brown RS. Affordable Care Act Medicaid expansion associated with increased liver transplant waitlist access without worsening mortality. Liver Transpl 2024; 30:20-29. [PMID: 37486623 DOI: 10.1097/lvt.0000000000000221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Abstract
It is unclear what impact Affordable Care Act (ACA) Medicaid expansion has had on the liver transplantation (LT) waitlist. We aimed to assess associations between ACA Medicaid expansion and LT waitlist outcomes. The United Network for Organ Sharing Standard Transplant Analysis and Research (UNOS STAR) database was queried for patients listed for LT between January 1, 2009, and December 31, 2018. Our primary outcome was waitlist mortality and our secondary outcomes included Medicaid use on the LT waitlist and transplant rate. States were divided into groups based on their expansion status and the study period was divided into 2 time intervals-pre-expansion and post-expansion. Difference-in-difference (DiD) models were created to assess the impacts of expansion on each of the outcomes and for racial/ethnic and sex groups. In total, 56,414 patients from expansion states and 32,447 patients from nonexpansion states were included. Three-year waitlist mortality decreased at a similar rate in both cohorts [DiD estimate: 0.1, (95% CI, -1.1, -1.4), p = 0.838], but Medicaid use increased [DiD estimate: +7.7, (95% CI, 6.7, 8.7), p < 0.001] to a greater degree in expansion states after expansion than nonexpansion states. Between the 2 time intervals, Medicaid use on the LT waitlist increased from 19.4% to 26.1% in expansion states but decreased from 13.4% to 12.1% in nonexpansion states. In patients on Medicaid, there was a slight increase in the 3-year transplant rate associated with Medicaid expansion [DiD estimate +5.0, (95% CI, 1.8, 8.3), p = 0.002], which may in part be explained by differences in patient characteristics. Medicaid expansion was associated with increased Medicaid use on the LT waitlist without worsening overall waitlist mortality or transplant rate, suggesting that lenient and widespread public health insurance may increase access to the LT waitlist without adversely affecting outcomes.
Collapse
Affiliation(s)
- Nabeel Wahid
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern Medicine, Chicago, Illinois
| | - Jihui Lee
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Russell Rosenblatt
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Alyson Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Renuka Tipirneni
- Department of Internal Medicine, Division of General Medicine, Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, Michigan
| | - Brett E Fortune
- Department of Medicine, Division of Hepatology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Monika Safford
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Robert S Brown
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| |
Collapse
|
3
|
Bouchard ME, Zeymo A, Desale S, Cohen B, Bayasi M, Bello BL, DeLia D, Al-Refaie WB. Persistent Disparities in Access to Elective Colorectal Cancer Surgery After Medicaid Expansion Under the Affordable Care Act: A Multistate Evaluation. Dis Colon Rectum 2023; 66:1234-1244. [PMID: 37000794 DOI: 10.1097/dcr.0000000000002560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
BACKGROUND Despite their higher incidence of colorectal cancer, ethnoracial minority and low-income patients have reduced access to elective colorectal cancer surgery. Although the Affordable Care Act's Medicaid expansion increased screening of colonoscopies, its effect on disparities in elective colorectal cancer surgery remains unknown. OBJECTIVE This study assessed the effects of Medicaid expansion on elective colorectal cancer surgery rates overall and by race-ethnicity and income. DESIGN Using the 2012 to 2015 State Inpatient Databases, a retrospective cohort study was conducted. SETTINGS State Inpatient Databases from 3 expansion states (Maryland, New Jersey, and Kentucky) and 2 nonexpansion states (Florida and North Carolina) were used. PATIENTS This study examined 22,304 adult patients aged 18 to 64 years who underwent colorectal cancer surgery. MAIN OUTCOME MEASURES Using interrupted time series analysis, the effect of Medicaid expansion on the odds of elective colorectal cancer surgery was assessed. RESULTS Elective vs nonelective surgery rates remained unchanged overall (70.2% vs 70.7%, p = 0.63) and in ethnoracial minorities in expansion states (whites from 72.8% to 73.8% pre to post, p = 0.40 and non-white from 64.0% to 63.1% pre to post, p = 0.67). There was an instantaneous increase in odds of elective surgery in expansion vs nonexpansion states at policy implementation (adjusted OR 1.37; 95% CI, 1.05-1.79; p = 0.02), but it subsequently decreased (combined adjusted OR 0.95; 95% CI, 0.92-0.99; p = 0.03). Elective surgery rates were also unchanged among ethnoracial minorities (instantaneous changes in expansion states, combined effect 1.06; pre-trend 1.01 vs post-trend 0.98) and low-income persons in expansion states (pre-trend 1.03 vs post-trend 0.97) (for all, p > 0.1). LIMITATIONS The study was limited to 5 states. Although patients may have increased access to cancer screening services and surgery after expansion, the State Inpatient Databases only provide information on patients who underwent surgery. CONCLUSIONS Despite gains in screening, Medicaid expansion was not associated with reductions in known ethnoracial or income-based disparities in elective colorectal cancer surgery rates. Expanding access to colorectal cancer surgery for underserved populations likely requires attention to provider and health system factors contributing to persistent disparities. See Video Abstract at http://links.lww.com/DCR/C217 . DISPARIDADES PERSISTENTES EN EL ACCESO A LA CIRUGA ELECTIVA DEL CNCER COLORRECTAL DESPUS DE LA EXPANSIN DE MEDICAID EN VIRTUD DE LA LEY DEL CUIDADO DE SALUD A BAJO PRECIO UNA EVALUACIN MULTIESTATAL ANTECEDENTES: A pesar de su mayor incidencia de cáncer colorrectal, los pacientes de minorías etnoraciales y de bajos ingresos tienen un acceso reducido a la cirugía electiva de cáncer colorrectal. Aunque la expansión de Medicaid de la Ley del Cuidado de Salud a Bajo Precio aumentó las colonoscopias de detección, aún se desconoce su efecto sobre las disparidades en la cirugía electiva de cáncer colorrectal.OBJETIVO: Este estudio evaluó los efectos de la expansión de Medicaid en las tasas de cirugía electiva de cáncer colorrectal en general y por raza, etnia e ingresos.DISEÑO: Utilizando las bases de datos estatales de pacientes hospitalizados de 2012-2015, se realizó un estudio de cohorte retrospectivo.CONFIGURACIÓN: Se utilizaron bases de datos estatales de pacientes hospitalizados de tres estados en expansión (Maryland, Nueva Jersey, Kentucky) y dos estados sin expansión (Florida, Carolina del Norte).PACIENTES: Este estudio examinó a 22,304 pacientes adultos de 18 a 64 años que se sometieron a cirugía de cáncer colorrectal.RESULTADO PRINCIPAL: Mediante el análisis de series de tiempo interrumpido, se evaluó el efecto de la expansión de Medicaid en las probabilidades de cirugía electiva de cáncer colorrectal.RESULTADOS: Las tasas de cirugía electiva frente a no electiva permanecieron sin cambios en general (70,2% frente a 70,7%, p = 0,63) y en las minorías etnoraciales en los estados de expansión (blancos del 72,8% al 73,8 % antes y después, p = 0,40 y no blancos del 64,0% al 63,1% pre a post, p = 0,67). Hubo un aumento instantáneo en las probabilidades de cirugía electiva en los estados de expansión frente a los de no expansión en la implementación de la política (OR ajustado 1,37, IC del 95%, 1,05-1,79, p = 0,02), pero disminuyó posteriormente (OR ajustado combinado 0,95, 95% IC, 0,92-0,99, p = 0,03). Las tasas de cirugía electiva también se mantuvieron sin cambios entre las minorías etnoraciales (cambios instantáneos en los estados de expansión, efecto combinado 1,06; antes de la tendencia 1,01 frente a la postendencia 0,98) y las personas de bajos ingresos en los estados de expansión (antes de la tendencia 1,03 frente a la postendencia 0,97; para todos, p > 0,1).LIMITACIONES: El estudio se limitó a cinco estados. Si bien los pacientes pueden tener un mayor acceso a los servicios de detección de cáncer y la expansión posterior a la cirugía, la base de datos de pacientes hospitalizados del estado solo brinda información sobre los pacientes que se sometieron a cirugía.CONCLUSIONES: A pesar de los avances en la detección, la expansión de Medicaid no se asoció con reducciones en las disparidades etnoraciales o basadas en los ingresos conocidas en las tasas de cirugía electiva de cáncer colorrectal. Ampliar el acceso a la cirugía del cáncer colorrectal para las poblaciones desatendidas probablemente requiera atención a los factores del proveedor y del sistema de salud que contribuyen a las disparidades persistentes. Consulte el Video Resumen en http://links.lww.com/DCR/C217 . (Traducción-Dr. Yesenia.Rojas-Khalil ).
Collapse
Affiliation(s)
- Megan E Bouchard
- Department of Surgery, MedStar-Georgetown Surgical Outcomes Research Center, Washington, D.C
| | - Alexander Zeymo
- Department of Surgery, MedStar-Georgetown Surgical Outcomes Research Center, Washington, D.C
| | - Sameer Desale
- Department of Surgery, MedStar-Georgetown Surgical Outcomes Research Center, Washington, D.C
| | - Brian Cohen
- Department of Surgery, MedStar-Georgetown Surgical Outcomes Research Center, Washington, D.C
| | - Mohammad Bayasi
- Department of Surgery, MedStar-Georgetown Surgical Outcomes Research Center, Washington, D.C
| | - Brian L Bello
- Department of Surgery, MedStar-Georgetown Surgical Outcomes Research Center, Washington, D.C
- Georgetown University Medical Center, Washington, D.C
| | - Derek DeLia
- Department of Surgery, MedStar-Georgetown Surgical Outcomes Research Center, Washington, D.C
| | - Waddah B Al-Refaie
- Department of Surgery, MedStar-Georgetown Surgical Outcomes Research Center, Washington, D.C
| |
Collapse
|
4
|
Bouchard ME, Kwon S, Many BT, Vacek JC, Abdullah F, Ghomrawi H. Impact of the Affordable Care Act's Medicaid expansion on tertiary pediatric surgical care. J Pediatr Surg 2022; 57:502-508. [PMID: 34034883 DOI: 10.1016/j.jpedsurg.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/27/2021] [Accepted: 04/10/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many children gained insurance with the 2014 Affordable Care Act's (ACA) Medicaid Expansion (ME), yet its impact on access to pediatric tertiary surgical care remains unknown. We examined the effect of ME on rates of elective, ambulatory surgery (EAS), especially among publicly-insured and ethnoracial-minority patients. METHODS Surgical patients ≤18 years between 2012 and 2018 were identified using the Pediatric Health Information System. Interrupted time series analyses were conducted to predict the monthly proportion of publicly-insured patients and EAS rates in ME and nonexpansion states. RESULTS 3,270,842 patients were included. Nonexpansion states demonstrated a 1.10% (p<0.05) increase in the proportion of publicly-insured patients at ACA implementation, which then plateaued. No immediate change was observed in ME states, but there was an annual 1.08% (p<0.01) decrease in subsequent years. Publicly-insured EAS rates decreased by 1.09% (p<0.01) in nonexpansion states; no change was observed in ME states. A 3.36% (p<0.01) increase in EAS rates was observed in nonexpansion and ME states. The gap in EAS rates increased between private and publicly-insured patients in nonexpansion, but not ME states. CONCLUSIONS Increased coverage for children in ME states was not associated with more access to tertiary pediatric surgical care; however, while nonexpansion states saw an increase in insurance-based disparities, ME states did not. Though insurance coverage is critical to access, other factors may be contributing to persistent disparities in access to pediatric surgical care.
Collapse
Affiliation(s)
- Megan E Bouchard
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Soyang Kwon
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Benjamin T Many
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jonathan C Vacek
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Fizan Abdullah
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Hassan Ghomrawi
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.
| |
Collapse
|
5
|
Greenberg JK, Brown DS, Olsen MA, Ray WZ. Association of Medicaid expansion under the Affordable Care Act with access to elective spine surgical care. J Neurosurg Spine 2022; 36:336-344. [PMID: 34560659 PMCID: PMC8942868 DOI: 10.3171/2021.3.spine2122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/05/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Affordable Care Act expanded Medicaid eligibility in many states, improving access to some forms of elective healthcare in the United States. Whether this effort increased access to elective spine surgical care is unknown. This study's objective was to evaluate the impact of Medicaid expansion under the Affordable Care Act on the volume and payer mix of elective spine surgery in the United States. METHODS This study evaluated elective spine surgical procedures performed from 2011 to 2016 and included in the all-payer State Inpatient Databases of 10 states that expanded Medicaid access in 2014, as well as 4 states that did not expand Medicaid access. Adult patients aged 18-64 years who underwent elective spine surgery were included. The authors used a quasi-experimental difference-in-difference design to evaluate the impact of Medicaid expansion on hospital procedure volume and payer mix, independent of time-dependent trends. Subgroup analysis was conducted that stratified results according to cervical fusion, thoracolumbar fusion, and noninstrumented surgery. RESULTS The authors identified 218,648 surgical procedures performed in 10 Medicaid expansion states and 118,693 procedures performed in 4 nonexpansion states. Medicaid expansion was associated with a 17% (95% CI 2%-35%, p = 0.03) increase in mean hospital spine surgical volume and a 23% (95% CI -0.3% to 52%, p = 0.054) increase in Medicaid volume. Privately insured surgical volumes did not change significantly (incidence rate ratio 1.13, 95% CI -5% to 34%, p = 0.18). The increase in Medicaid volume led to a shift in payer mix, with the proportion of Medicaid patients increasing by 6.0 percentage points (95% CI 4.1-7.0, p < 0.001) and the proportion of private payers decreasing by 6.7 percentage points (95% CI 4.5-8.8, p < 0.001). Although the magnitude of effects varied, these trends were similar across procedure subgroups. CONCLUSIONS Medicaid expansion under the Affordable Care Act was associated with an economically and statistically significant increase in spine surgery volume and the proportion of surgical patients with Medicaid insurance, indicating improved access to care.
Collapse
Affiliation(s)
- Jacob K. Greenberg
- Department of Neurological Surgery, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO
| | - Derek S. Brown
- Brown School, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO
| | - Margaret A. Olsen
- Department of Medicine, Washington University in St. Louis, St. Louis, MO
| | - Wilson Z. Ray
- Department of Neurological Surgery, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO
| |
Collapse
|
6
|
Beydoun HA, Huang S, Beydoun MA, Eid SM, Zonderman AB. Interrupted Time-Series Analysis of Stereotactic Radiosurgery for Brain Metastases Before and After the Affordable Care Act. Cureus 2022; 14:e21338. [PMID: 35186596 PMCID: PMC8849367 DOI: 10.7759/cureus.21338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/30/2022] Open
Abstract
The 2010 Patient Protection and Affordable Care Act was aimed at reducing healthcare costs, improving healthcare quality, and expanding health insurance coverage among uninsured individuals in the United States. We examined trends in the utilization of radiation therapies and stereotactic radiosurgery before and after its implementation among U.S. adults hospitalized with brain metastasis. Interrupted time-series analyses of data on 383,934 Nationwide Inpatient Sample hospitalizations (2005-2010 and 2011-2013) were performed, whereby yearly and quarterly cross-sectional data were evaluated and Affordable Care Act implementation was considered the main exposure variable, stratifying by patient and hospital characteristics. Overall, we observed a declining trend in radiation therapy over time, with an upward shift post-Affordable Care Act. A downward shift in radiation therapy post-Affordable Care Act was observed among Northeastern and rural hospitals, whereas an upward shift was noted among specific patient (females, 18-39 or ≥ 65 years of age, Charlson Comorbidity Index (CCI) ≥10, non-elective admissions, Medicare, self-pay, no pay or other insurance) and hospital (Midwestern, Western, non-teaching urban) subgroups. Stereotactic radiosurgery utilization among recipients of radiation therapy increased over time among Hispanics, elective admissions, and rural hospitals, whereas post-Affordable Care Act was associated with increased stereotactic radiosurgery among African-Americans and non-elective admissions and decreased stereotactic radiosurgery among elective admissions, and rural hospitals. Whereas hospitalized adults in the United States utilized less radiation therapy over the nine-year period, utilization of radiation therapy, in general, and stereotactic radiosurgery, in particular, were not consistent among distinct subgroups defined by patient and hospital characteristics, with some traditionally underserved populations more likely to receive healthcare services post-Affordable Care Act. The Affordable Care Act may be helpful at closing the gap in access to technological advances such as stereotactic radiosurgery for treating brain metastases.
Collapse
Affiliation(s)
- Hind A Beydoun
- Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, USA
| | - Shuyan Huang
- Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, USA
| | - May A Beydoun
- Intramural Research Program, National Institute on Aging, Baltimore, USA
| | - Shaker M Eid
- Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Alan B Zonderman
- Intramural Research Program, National Institute on Aging, Baltimore, USA
| |
Collapse
|
7
|
Yesantharao PS, Jenny HE, Lopez J, Chen J, Lopez CD, Aliu O, Redett RJ, Yang R, Steinberg JP. The Impact of Payment Reform on Pediatric Craniofacial Fracture Care in Maryland. Craniomaxillofac Trauma Reconstr 2021; 14:308-316. [PMID: 34707791 PMCID: PMC8543597 DOI: 10.1177/1943387520983634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective, quasi-experimental difference-in-differences investigation. OBJECTIVE Pediatric craniofacial fractures are often associated with substantial morbidity and consumption of healthcare resources. Maryland's All Payer Model (APM) represents a unique case study of the health economics surrounding pediatric craniofacial fractures. The APM implemented global hospital budgets to disincentivize low-value care and encourage preventive, community-based efforts. The objective of this study was to investigate how this reform has impacted pediatric craniofacial fracture care in Maryland. METHODS Children (≤18 years) receiving inpatient craniofacial fracture-related care in Maryland between January, 2009 through December, 2016 were investigated. New Jersey was used for comparison. Data were abstracted from the Kid's Inpatient Database (Healthcare Cost and Utilization Project). RESULTS Between 2009-2016, 3,655 pediatric patients received inpatient care for craniofacial fractures in Maryland and New Jersey. Prior to APM implementation, around 20% of Maryland patients received care outside of urban teaching hospitals. After APM implementation, less than 6% of patients received care outside of urban teaching hospitals (p = 0.003). Implementation of the APM in Maryland also resulted in fewer pediatric craniofacial fracture admissions than New Jersey, though this only reached borderline significance (adjusted difference-in-differences estimate: -1.1 fewer admissions, 95% confidence interval: -2.1 to 0.0, p = 0.05). Inpatient costs for pediatric craniofacial care and mean did not change post-APM. CONCLUSIONS Maryland's APM consolidated pediatric craniofacial fracture inpatient care at urban, teaching hospitals. Inpatient costs and lengths of stay did not change after policy implementation, but overall admission rates decreased. Such considerations are important when considering national expansion of global hospital budgeting.
Collapse
Affiliation(s)
- Pooja S. Yesantharao
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hillary E. Jenny
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph Lopez
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonlin Chen
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher D. Lopez
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Oluseyi Aliu
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J. Redett
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robin Yang
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jordan P. Steinberg
- Assistant Professor of Plastic and Reconstructive Surgery, Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
8
|
Wahid NA, Lee J, Kaplan A, Fortune BE, Safford MM, Brown RS, Rosenblatt R. Medicaid Expansion Association With End-Stage Liver Disease Mortality Depends on Leniency of Medicaid Hepatitis C Virus Coverage. Liver Transpl 2021; 27:1723-1732. [PMID: 34118120 DOI: 10.1002/lt.26209] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/20/2021] [Accepted: 06/03/2021] [Indexed: 12/12/2022]
Abstract
The Affordable Care Act expanded Medicaid around the same time that direct-acting antivirals became widely available for the treatment of hepatitis C virus (HCV). However, there is significant variation in Medicaid HCV treatment eligibility criteria between states. We explored the combined effects of Medicaid expansion and leniency of HCV coverage under Medicaid on liver outcomes. We assessed state-level end-stage liver disease (ESLD) mortality rates, listings for liver transplantation (LT), and listing-to-death ratios (LDRs) for adults aged 25 to 64 years using data from United Network for Organ Sharing and Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. States were divided into 4 nonoverlapping groups based on expansion status on January 1, 2014 (expansion versus nonexpansion) and leniency of Medicaid HCV coverage (lenient versus restrictive coverage). Joinpoint regression analysis evaluated the significant changes in slope over time (joinpoints) during the pre-expansion (2009-2013) and postexpansion (2014-2018) time periods. We found significant changes in the annual percent change for population-adjusted ESLD deaths between 2014 and 2015 in all cohorts except for the nonexpansion/restrictive cohort, in which deaths increased at the same annual percent change from 2009 to 2018 (annual percent change of +2.5%; 95% confidence interval [CI], 1.8-3.3]). In the expansion/lenient coverage cohort, deaths increased at an annual percent change of +2.6% (95% CI, 1.8-3.5) until 2014 and then tended to decrease at an annual percent change of -0.4% (95% CI, -1.5 to 0.8). LT listings tended to decrease over time for all cohorts. For LDRs, only the expansion/lenient and expansion/restrictive cohorts had statistically significant joinpoints. Improvements in ESLD mortality and LDRs were associated with both Medicaid expansion and leniency of HCV coverage under Medicaid. These findings suggest the importance of implementing more lenient and widespread public health insurance to improve liver disease outcomes, including mortality.
Collapse
Affiliation(s)
- Nabeel A Wahid
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY
| | - Jihui Lee
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Alyson Kaplan
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Brett E Fortune
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of General Internal Medicine, Weill Cornell Medicine, New York, NY
| | - Robert S Brown
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| | - Russell Rosenblatt
- Department of Medicine, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, NY.,Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
| |
Collapse
|
9
|
Cohen BD, Zeymo A, Bouchard M, McDermott J, Shara NM, Sellke FW, Sodha N, Al-Refaie WB, Ehsan A. Increased Access to Cardiac Surgery Did Not Improve Outcomes: Early Look into Medicaid Expansion. Ann Thorac Surg 2021; 114:1637-1644. [PMID: 34678282 DOI: 10.1016/j.athoracsur.2021.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 08/02/2021] [Accepted: 09/04/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac surgery utilization has increased after passage of the Affordable Care Act. This multi-state study examined whether changes in access after Medicaid Expansion (ME) have led to improved outcomes, overall and particularly among ethno-racial minorities. METHODS State Inpatient Databases were used to identify non-elderly adults (ages 18-64) who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or mitral valve repair in three expansion (Kentucky, New Jersey, Maryland) vs two non-expansion states (North Carolina, Florida) from 2012 to 2015. Linear and logistic Interrupted Time Series (ITS) were used with two-way interactions and adjusted for patient, hospital, and county-level factors to compare trends and instantaneous changes at the point of ME implementation (Q1 2014) for mortality, length of stay (LOS), and elective status. ITS models estimated expansion effect, overall and by race-ethnicity. RESULTS Analysis included 22,038 cardiac surgery patients from expansion states and 33,190 from non-expansion states. In expansion states, no significant trend changes were observed for mortality (OR 1.01, p=0.83) or LOS (β= -0.05, p=0.20), or elective surgery (OR 1.00, p=0.91). There were similar changes seen in non-expansion states. Among ethno-racial minorities, ME did not impact outcomes or elective status. CONCLUSIONS Despite an increase in cardiac surgery utilization following ME, outcomes remained unchanged in the early period after implementation, overall and among ethno-racial minorities. Future research is needed to confirm long-term trends and examine reasons behind this lack of improved outcomes.
Collapse
Affiliation(s)
- Brian D Cohen
- MedStar-Georgetown University Medical Center, Department of Surgery, Washington, DC; MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Alexander Zeymo
- MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Megan Bouchard
- MedStar-Georgetown University Medical Center, Department of Surgery, Washington, DC; MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - James McDermott
- MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Nawar M Shara
- MedStar Health Research Institute, Washington, DC; Georgetown-Howard Universities, Center for Clinical and Translational Science, Washington, DC
| | - Frank W Sellke
- Brown University Medical School/Rhode Island Hospital, Division of Cardiothoracic Surgery, Providence, RI
| | - Neel Sodha
- Brown University Medical School/Rhode Island Hospital, Division of Cardiothoracic Surgery, Providence, RI
| | - Waddah B Al-Refaie
- MedStar-Georgetown University Medical Center, Department of Surgery, Washington, DC; MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.
| | - Afshin Ehsan
- Brown University Medical School/Rhode Island Hospital, Division of Cardiothoracic Surgery, Providence, RI
| |
Collapse
|
10
|
Yesantharao PS, He W, Shetty P, Aravind P, Quan A, Fadavi D, Aliu O. The Impact of Policy Reform on Utilization of Popular Reconstructive Procedures. Ann Plast Surg 2021; 87:e40-e50. [PMID: 33346555 DOI: 10.1097/sap.0000000000002608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Medicaid beneficiaries systematically face challenges in accessing healthcare, especially with regard to specialty services like reconstructive surgery. This study evaluated the impact of 2 healthcare reform policies, Medicaid expansion and global hospital budgeting, on utilization of reconstructive surgery by Medicaid patients. METHODS Utilization of reconstructive surgery by Medicaid patients in New Jersey (Medicaid expansion/no global budget), Maryland (Medicaid expansion/with global budgets), and Florida (no Medicaid expansion/no global budget) between 2012 and 2016 was compared using quasi-experimental, interrupted time-series modeling. Subgroup analyses by procedure type and urgency were also undertaken. RESULTS During the study period, the likelihood of Medicaid patients using reconstructive surgery significantly increased in expansion states (Maryland: 0.3% [95% confidence interval = 0.17% to 0.42%] increase per quarter, P < 0.001; New Jersey: 0.4% [0.31% to 0.52%] increase per quarter, P = 0.004) when compared with Florida (nonexpansion state). Global budgeting did not significantly impact overall utilization of reconstructive procedures by Medicaid beneficiaries. Upon subgroup analyses, there was a greater increase in utilization of elective procedures than emergent procedures by Medicaid beneficiaries after Medicaid expansion (elective: 0.9% [0.8% to 1.3%] increase per quarter, P = 0.04; emergent/urgent: 0.2% [0.1% to 0.4%] increase per quarter, P = 0.02). In addition, Medicaid expansion had the greatest absolute effect on breast reconstruction (1.0% [95% confidence interval = 0.7% to 1.3%] increase per quarter) compared with other procedure types. CONCLUSIONS Medicaid expansion increased access to reconstructive surgery for Medicaid beneficiaries, especially for elective procedures. Encouragingly, although cost-constrictive, global hospital budgeting did not limit longitudinal utilization of reconstructive surgery by Medicaid patients, who are traditionally at higher risk for complications/readmissions.
Collapse
Affiliation(s)
- Pooja S Yesantharao
- From the Department of Plastic & Reconstructive Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD
| | | | | | | | | | | | | |
Collapse
|
11
|
Nathan NH, Bakhsheshian J, Ding L, Mack WJ, Attenello FJ. Evaluating Medicaid expansion benefits for patients with cancer: National Cancer Database analysis and systematic review. J Cancer Policy 2021; 29:100292. [PMID: 35559947 PMCID: PMC8276859 DOI: 10.1016/j.jcpo.2021.100292] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/28/2021] [Accepted: 06/03/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Insurance status modifies healthcare access and inequities. The Affordable Care Act expanded Medicaid coverage for people with low incomes in the United States. This study assessed the consequences of this policy change for cancer care after expansion in 2014. METHODS National Cancer Database (NCDB) public benchmark reports were queried for each malignancy in 2013 and 2016. Furthermore, a systematic search [PubMed, Embase, Scopus and Cochrane] was performed. Data on insurance status, access to cancer screening and treatment, and socioeconomic disparities in these metrics was collected. RESULTS Two-tailed analysis of the NCDB revealed that 14 out of 18 eligible states had a statistically significant increase in Medicaid-insured patients with cancer after expansion. The average percentage increase was 51 % (13.2-204 %). From the systematic review, 229 studies were identified, 26 met inclusion. All 21 relevant articles reported lower uninsured rates. The average increase of Medicaid-insured patients was 77 % (9.5-230 %) and the average decrease of uninsured rates was 55 % (13.4-73 %). 15 out of 21 articles reported increased access to care. 16 out of 17 articles reported reductions in inequities. CONCLUSION Medicaid expansion in 2014 increased the number of insured patients with cancer. Expansion also improved access to screening and treatment in most oncologic care, and reduced socioeconomic disparities. Further studies evaluating correlative survival outcomes are needed. POLICY SUMMARY This study informs debates on expansion of Medicaid in state governments and electorates in the United States, and on health insurance reform broadly, by providing insight into how health insurance can benefit people with cancer while revealing how less insurance coverage could harm patients with cancer before and after their diagnosis. This study also contributes to discussions of health insurance mandates, subsidized coverage for people with low incomes, and covered healthcare services determinations by public and private health insurance providers in other countries.
Collapse
Affiliation(s)
- Neal H Nathan
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA, 90033, USA.
| | - Joshua Bakhsheshian
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA.
| | - Li Ding
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, 2001 North Soto Street, Los Angeles, CA, 90032, USA.
| | - William J Mack
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA.
| | - Frank J Attenello
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA.
| |
Collapse
|
12
|
Liu B, Ornstein KA, Alpert N, Schwartz RM, Dharmarajan KV, Kelley AS, Taioli E. Trends of hospitalizations among patients with both cancer and dementia diagnoses in New York 2007-2017. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2021; 9:100565. [PMID: 34252707 PMCID: PMC8453053 DOI: 10.1016/j.hjdsi.2021.100565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/25/2021] [Accepted: 07/05/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Cancer and dementia have often been studied in isolation. We aimed to examine the spatiotemporal trend of inpatient admissions with both cancer and dementia diagnoses. METHODS Using state-wide inpatient claims data, we identified all hospital admissions for patients aged ≥50 years with both cancer and dementia diagnoses in New York State, 2007-2017. We examined the spatiotemporal trend of the admission using a novel Bayesian hierarchical model adjusting for socioeconomic factor, as measured by Yost index. RESULTS Admissions with the presence of both cancer and dementia diagnoses represented 8.5% of all admissions with a cancer diagnosis, and the proportion increased from 7.1% in 2007 to 9.7% in 2017. The median admission rate was 3.5 (interquartile range: 2.2-5.2) hospitalizations per 1000 population aged ≥50 years, which increased from 2.9 in 2007 to 3.7 in 2017. The admission rate peaked first in 2010 followed by a smaller peak in 2014, before stabilizing at a level higher than the pre-2010 period. Taking into account the spatiotemporal heterogeneity, we found that hospitalizations among those with both cancer and dementia diagnoses were associated with a higher socioeconomic status (the posterior median relative risk for Yost index = 1.046 (95% credible interval: 1.033-1.058)). CONCLUSIONS Hospitalizations of patients with both cancer and dementia increased over time. Cancer care providers and healthcare systems should be prepared to provide prevention and management strategies and engage in complex medical decision-making for this increasingly common patient population comprised of individuals with cancer and dementia.
Collapse
Affiliation(s)
- Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Katherine A Ornstein
- Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Naomi Alpert
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rebecca M Schwartz
- Department of Occupational Medicine, Epidemiology and Prevention, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Kavita V Dharmarajan
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emanuela Taioli
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
13
|
The Effects of the Affordable Care Act on Utilization of Bariatric Surgery. Obes Surg 2021; 31:4919-4925. [PMID: 34415519 DOI: 10.1007/s11695-021-05669-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/11/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The Affordable Care Act (ACA) expanded Medicaid (ME) and instituted Essential Health Benefits (EHB) that included bariatric surgery coverage on a state-by-state opt-in basis, increasing insurance coverage of bariatric surgery. MATERIALS AND METHODS Using a difference-in-differences framework, changes in bariatric surgery rates, defined as utilization in the population of people with obesity, before and after the ACA were evaluated in four states. Bariatric surgery procedure data were taken from the Healthcare Cost and Utilization Project's State In-patient Database 2012-2015. Adjusted multivariable regressions were run in the Medicaid and commercially insured populations. RESULTS We identified 36,456 bariatric surgeries across the 286 Health Service Areas and time periods, with 31,732 covered by commercial insurers and 4724 covered by Medicaid. An unadjusted increase in utilization rates was seen in the Medicaid and Commercial populations in both ME- and EHB-covered states as well as non-expansion and EHB opt-out states over time. In the Medicaid population, after adjusting for confounders, there was a significant increase of 24.77 cases per 100,000 people with obesity (95% confidence interval: 12.41, 37.13) in the expansion states relative to the control and pre-period. The commercial population experienced a nonsignificant change in the rates of bariatric surgery, decreasing by 2.89 cases per 100,000 people with obesity (95% confidence interval: - 21.59, 15.81). CONCLUSIONS There was a significant increase in bariatric surgery rates among Medicaid beneficiaries associated with Medicaid expansion, but there was no change among the commercially insured.
Collapse
|
14
|
Mishra A, DeLia D, Zeymo A, Aminpour N, McDermott J, Desale S, Al-Refaie WB. ACA Medicaid expansion reduced disparities in use of high-volume hospitals for pancreatic surgery. Surgery 2021; 170:1785-1793. [PMID: 34303545 DOI: 10.1016/j.surg.2021.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/17/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early evaluation of the Affordable Care Act's Medicaid expansion demonstrated persistent disparities among Medicaid beneficiaries in use of high-volume hospitals for pancreatic surgery. Longer-term effects of expansion remain unknown. This study evaluated the impact of expansion on the use of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. METHODS State inpatient databases (2012-2017), the American Hospital Association Annual Survey Database, and the Area Resource File from the Health Resources and Services Administration, were used to examine 8,264 non-elderly adults who underwent pancreatic surgery in nine expansion and two non-expansion states. High-volume hospitals were defined as performing 20 or more resections/year. Linear probability triple differences models measured pre- and post-Affordable Care Act utilization rates of pancreatic surgery at high-volume hospitals among Medicaid and uninsured patients versus privately insured patients in expansion versus non-expansion states. RESULTS The Affordable Care Act's expansion was associated with increased rates of utilization of high-volume hospitals for pancreatic surgery by Medicaid and uninsured patients (48% vs 55.4%, P = .047) relative to privately insured patients in expansion states (triple difference estimate +11.7%, P = .022). A pre-Affordable Care Act gap in use of high-volume hospitals among Medicaid and uninsured patients in expansion states versus non-expansion states (48% vs 77%, P < .0001) was reduced by 15.1% (P = .001) post Affordable Care Act. A pre Affordable Care Act gap between expansion versus non-expansion states was larger for Medicaid and uninsured patients relative to privately insured patients by 24.9% (P < .0001) and was reduced by 11.7% (P = .022) post Affordable Care Act. Rates among privately insured patients remained unchanged. CONCLUSION Medicaid expansion was associated with greater utilization of high-volume hospitals for pancreatic surgery among Medicaid and uninsured patients. These findings are informative to non-expansion states considering expansion. Future studies should target understanding referral mechanism post-expansion.
Collapse
Affiliation(s)
- Ankit Mishra
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Derek DeLia
- MedStar Health Research Institute, Hyattsville, MD; Georgetown University School of Medicine, Department of Plastic and Reconstructive Surgery, Washington, DC
| | - Alexander Zeymo
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Hyattsville, MD
| | - Nathan Aminpour
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - James McDermott
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC; David Geffen School of Medicine, University of California, Los Angeles, CA. https://twitter.com/jimmymcd13
| | | | - Waddah B Al-Refaie
- MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Hyattsville, MD; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.
| |
Collapse
|
15
|
Dy CJ, Salter A, Barker A, Brown D, Keller M, Olsen MA. Increased Utilization of Total Joint Arthroplasty After Medicaid Expansion. J Bone Joint Surg Am 2021; 103:524-531. [PMID: 33475310 PMCID: PMC8186843 DOI: 10.2106/jbjs.20.00303] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The expansion of state Medicaid programs under the U.S. Affordable Care Act has led to a dramatic increase in the number of Americans with health insurance coverage. Prior analyses of a limited number of states have suggested that greater utilization of total hip arthroplasty (THA) and total knee arthroplasty (TKA) should be expected after Medicaid expansion. The purpose of our study was to examine whether increased utilization of THA and TKA occurred across a broader range of states after Medicaid expansion. METHODS We analyzed administrative data from the Healthcare Cost and Utilization Project from 9 states (Arkansas, Arizona, Colorado, Iowa, Massachusetts, Maryland, Nevada, New York, and Vermont) that expanded Medicaid in 2014 and 2 states that did not expand Medicaid (Florida and Missouri). We included patients who were 18 to 64 years of age and had a primary THA or TKA from 2012 to 2015 with Medicaid as the primary payer. Other payers (including dual-eligible Medicaid and Medicare beneficiaries) were excluded. We performed multivariable regression modeling with the number of Medicaid-insured THAs or TKAs as the dependent variable and the interaction between the state Medicaid expansion status and year as the main policy independent variable, with adjustment for community characteristics. RESULTS Among all 11 states, there were 39,452 total joint arthroplasties (42% THA and 58% TKA) funded by Medicaid from 2012 to 2015. After adjusting for community characteristics, within expansion states, compared with 2013, THA and TKA increased 15% in 2014 (p < 0.0001) and 23% in 2015 (p < 0.0001) within expansion states. Within non-expansion states, compared with 2013, there were significant utilization decreases of 18% in 2014 (p < 0.0001) and 11% in 2015 (p = 0.0002). CONCLUSIONS Medicaid expansion was associated with significant increases in Medicaid-funded THA and TKA utilization in 9 states. As additional states consider expanding Medicaid programs and as alternative health reforms that increase insurance eligibility are debated, surgeons, administrators, and policymakers should prepare for a surge in the utilization of THA and TKA.
Collapse
Affiliation(s)
- Christopher J. Dy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri,Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Amber Salter
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Abigail Barker
- Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri
| | - Derek Brown
- Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri
| | - Matthew Keller
- Division of Infectious Diseases, Department of Medicine, and Center for Administrative Data Research, Washington University School of Medicine, St. Louis, Missouri
| | - Margaret A. Olsen
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri,Division of Infectious Diseases, Department of Medicine, and Center for Administrative Data Research, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
16
|
Lin S, Brasel KJ, Chakraborty O, Glied SA. Association Between Medicaid Expansion and the Use of Outpatient General Surgical Care Among US Adults in Multiple States. JAMA Surg 2021; 155:1058-1066. [PMID: 32822464 DOI: 10.1001/jamasurg.2020.2959] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance The Affordable Care Act expanded access to Medicaid coverage in 2014 for individuals living in participating states. Whether expanded coverage was associated with increases in the use of outpatient surgical care, particularly among underserved populations, remains unknown. Objective To evaluate the association between state participation in the Affordable Care Act Medicaid expansion reform and the use of outpatient surgical care. Design, Setting, and Participants This case-control study used a quasi-experimental difference-in-differences design to compare the use of outpatient surgical care at the facility and state levels by patient demographic characteristics and payer categories (Medicaid, private insurance, and no insurance). Data from 2013 (before Medicaid expansion reform) and 2015 (after Medicaid expansion reform) were obtained from the State Ambulatory Surgery and Services Database of the Healthcare Cost and Utilization Project. The absolute and mean numbers of procedures performed at outpatient surgical centers in 2 states (Michigan and New York) that participated in Medicaid expansion (expansion states) were compared with those performed at outpatient surgical centers in 2 states (Florida and North Carolina) that did not participate in Medicaid expansion (nonexpansion states). The population-based sample included 207 176 patients aged 18 to 64 years who received 4 common outpatient procedures (laparoscopic cholecystectomy, breast lumpectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repair). Data were analyzed from May 19 to August 25, 2019. Interventions State variation in the adoption of Medicaid expansion before and after expansion reform was implemented through the Affordable Care Act. Main Outcomes and Measures Changes in the mean number of procedures performed at the facility level before and after Medicaid expansion reform in states with and without expanded Medicaid coverage. Results A total of 207 176 patients (106 395 women [51.35%] and 100 781 men [48.65%]; mean [SD] age, 45.7 [12.4] years) were included in the sample. Overall, 116 752 procedures were performed in Medicaid expansion states and 90 424 procedures in nonexpansion states. A 9.8% increase (95% CI, 0.4%-20.0%; P = .04) in cholecystectomies, a 26.1% increase (95% CI, 9.8%-44.7%; P = .001) in lumpectomies, and a 16.3% increase (95% CI, 2.9%-31.5%; P = .02) in laparoscopic inguinal hernia repairs were observed at the facility level in expansion states compared with nonexpansion states. Among patients with Medicaid coverage, the mean number of procedures performed in all 4 procedure categories increased between 60.5% (95% CI, 24.7%-106.6%; P < .001) and 79.2% (95% CI, 53.5%-109.2%; P < .001) at the facility level. The increases in the number of Medicaid patients who received treatment exceeded the reductions in the number of uninsured patients who received treatment with laparoscopic cholecystectomy, open inguinal hernia repair, and laparoscopic inguinal hernia repairs in expansion states compared with nonexpansion states. Black patients received more laparoscopic cholecystectomies, lumpectomies, and open inguinal hernia repairs in expansion states than in nonexpansion states. Conclusions and Relevance Study results suggest that Medicaid expansion was associated with increases in the use of outpatient surgical care in states that participated in Medicaid expansion. Most of this increase represented patients who were newly treated rather than patients who converted from no insurance to Medicaid coverage.
Collapse
Affiliation(s)
- Saunders Lin
- Department of Surgery, Oregon Health and Science University, Portland.,Wagner School of Public Policy, New York University, New York
| | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland
| | | | - Sherry A Glied
- Wagner School of Public Policy, New York University, New York
| |
Collapse
|
17
|
Ko H. Moral hazard effects of supplemental private health insurance in Korea. Soc Sci Med 2020; 265:113325. [PMID: 32905966 DOI: 10.1016/j.socscimed.2020.113325] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 07/19/2020] [Accepted: 08/22/2020] [Indexed: 11/29/2022]
Abstract
Supplemental private health insurance has gained popularity despite having a mandatory social health insurance program in Korea. Private insurance supplements the social insurance program by covering co-pays and services not covered by social insurance. Using longitudinal microdata from the 2008-2014 Korea Health Panel, this study finds evidence of favorable selection into supplemental private insurance. Results show that supplemental private insurance increases outpatient and hospitalization utilization. Private health insurance generates welfare benefits especially among the elderly and low-income individuals, though the coverage rate for these groups is low.
Collapse
Affiliation(s)
- Hansoo Ko
- New York University Wagner Graduate School of Public Service, 295 Lafayette street room3034, New York, NY, 10012, USA; University of Illinois at Chicago School of Public Health, USA.
| |
Collapse
|
18
|
Goldman AL, Paasche-Orlow MK, Drake FT. Affordable Care Act Medicaid Expansion and Access to Outpatient Surgical Care. JAMA Surg 2020; 155:1066-1067. [PMID: 32822496 DOI: 10.1001/jamasurg.2020.2974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anna L Goldman
- Section of General Internal Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Frederick Thurston Drake
- Section of Surgical Oncology, Department of Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| |
Collapse
|
19
|
Unintended Consequences of Health Care Reform: Impact of Changes in Payor Mix on Patient Safety Indicators. Ann Surg 2020; 272:612-619. [PMID: 32932318 DOI: 10.1097/sla.0000000000004203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the impact of the Affordable Care Act's Medicaid expansion on patient safety metrics at the hospital level by expansion status, across varying levels of safety-net burden, and over time. SUMMARY BACKGROUND DATA Medicaid expansion has raised concerns over the influx of additional medically and socially complex populations on hospital systems. Whether increases in Medicaid and uninsured payor mix impact hospital performance metrics remains largely unknown. We sought to evaluate the effects of expansion on Centers for Medicare and Medicaid Services-endorsed Patient Safety Indicators (PSI-90). METHODS Three hundred fifty-eight hospitals were identified using State Inpatient Databases (2012-2015) from 3 expansions (KY, MD, NJ) and 2 nonexpansion (FL, NC) states. PSI-90 scores were calculated using Agency for Healthcare Research and Quality modules. Hospital Medicaid and uninsured patients were categorized into safety-net burden (SNB) quartiles. Hospital-level, multivariate linear regression was performed to measure the effects of expansion and change in SNB on PSI-90. RESULTS PSI-90 decreased (safety improved) over time across all hospitals (-5.2%), with comparable reductions in expansion versus nonexpansion states (-5.9% vs -4.7%, respectively; P = 0.441) and across high SNB hospitals within expansion versus nonexpansion states (-3.9% vs -5.2%, P = 0.639). Pre-ACA SNB quartile did not predict changes in PSI-90 post-ACA. However, when hospitals increased their SNB by 5%, they incurred significantly more safety events in expansion relative to nonexpansion states (+1.87% vs -14.0%, P = 0.013). CONCLUSIONS Despite overall improvement in patient safety, increased SNB was associated with increased safety events in expansion states. Accordingly, Centers for Medicare and Medicaid Services measures may unintentionally penalize hospitals with increased SNB following Medicaid expansion.
Collapse
|
20
|
Dy CJ, Barker AR, Brown DS, Keller M, Chang P, Yamaguchi K, Olsen MA. Unmet Need for Total Joint Arthroplasty in Medicaid Beneficiaries After Affordable Care Act Expansion. J Bone Joint Surg Am 2020; 102:1495-1500. [PMID: 32898378 PMCID: PMC8313181 DOI: 10.2106/jbjs.20.00125] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The utilization of total hip arthroplasty (THA) and total knee arthroplasty (TKA) increased after Medicaid expansion under the U.S. Affordable Care Act (ACA), suggesting a potential unmet need for THA and TKA. We examined the timing of THA and TKA in patients after obtaining Medicaid expansion insurance coverage. We hypothesized that patients with Medicaid expansion insurance would undergo a surgical procedure sooner than patients in traditional Medicaid populations. METHODS We used administrative data from a Medicaid managed care company to determine the timing of primary THA and TKA in patients who were 18 to 64 years of age in 4 states with Medicaid expansion (Illinois, Ohio, Oregon, and Washington) and 4 states without Medicaid expansion (Louisiana, Mississippi, Texas, and Wisconsin) from 2008 to 2015. The insurance types were Medicaid expansion, Medicaid plans for Supplemental Security Income (SSI), or Temporary Assistance for Needy Families (TANF). Roughly, these 3 groups correspond to relatively healthy childless adults, relatively unhealthy disabled adults, and parents of children with Medicaid insurance. The main outcome measure was time from enrollment to the surgical procedure. The primary exposure of interest was insurance type. We used a generalized linear regression model to adjust for patient age, sex, social deprivation, surgeon supply and reimbursement, and state-level Medicaid enrollment. RESULTS In the unadjusted analysis of 4,117 patients, there was a significantly shorter time from enrollment to THA and TKA for the expansion group (median, 7.5 months) relative to the SSI group (median, 16.1 months; p < 0.0001) and the TANF group (median, 12.2 months; p < 0.0001). In the adjusted analysis, the time from enrollment to THA and TKA was significantly shorter in the expansion group (β, -1.21 [95% confidence interval (CI), -1.35 to -1.07]; p < 0.001) compared with the TANF group (β, -0.27 [95% CI, -0.38 to -0.17]; p < 0.001) and the SSI group (reference). Compared with the SSI group, these coefficients are equivalent to a 70% shorter time to the surgical procedure in the expansion group and a 24% shorter time to the surgical procedure in the TANF group. CONCLUSIONS Our findings suggest an unmet need for THA and TKA among newly enrolled Medicaid expansion beneficiaries. This need should be considered by surgeons, hospitals, and policymakers in ensuring access to care. Furthermore, consideration should be given to existing insurance-based disparities in access to orthopaedic care, as these may be exacerbated by an increased demand for THA and TKA from Medicaid expansion beneficiaries.
Collapse
Affiliation(s)
- Christopher J. Dy
- Department of Orthopaedic Surgery (C.J.D., P.C., and K.Y.), Division of Public Health Sciences, Department of Surgery (C.J.D., A.R.B., D.S.B., and M.A.O.), and Division of Infectious Diseases, Department of Medicine (M.K. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Abigail R. Barker
- Department of Orthopaedic Surgery (C.J.D., P.C., and K.Y.), Division of Public Health Sciences, Department of Surgery (C.J.D., A.R.B., D.S.B., and M.A.O.), and Division of Infectious Diseases, Department of Medicine (M.K. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Derek S. Brown
- Department of Orthopaedic Surgery (C.J.D., P.C., and K.Y.), Division of Public Health Sciences, Department of Surgery (C.J.D., A.R.B., D.S.B., and M.A.O.), and Division of Infectious Diseases, Department of Medicine (M.K. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Matthew Keller
- Department of Orthopaedic Surgery (C.J.D., P.C., and K.Y.), Division of Public Health Sciences, Department of Surgery (C.J.D., A.R.B., D.S.B., and M.A.O.), and Division of Infectious Diseases, Department of Medicine (M.K. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Peter Chang
- Department of Orthopaedic Surgery (C.J.D., P.C., and K.Y.), Division of Public Health Sciences, Department of Surgery (C.J.D., A.R.B., D.S.B., and M.A.O.), and Division of Infectious Diseases, Department of Medicine (M.K. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Ken Yamaguchi
- Department of Orthopaedic Surgery (C.J.D., P.C., and K.Y.), Division of Public Health Sciences, Department of Surgery (C.J.D., A.R.B., D.S.B., and M.A.O.), and Division of Infectious Diseases, Department of Medicine (M.K. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| | - Margaret A. Olsen
- Department of Orthopaedic Surgery (C.J.D., P.C., and K.Y.), Division of Public Health Sciences, Department of Surgery (C.J.D., A.R.B., D.S.B., and M.A.O.), and Division of Infectious Diseases, Department of Medicine (M.K. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
21
|
Gaffney A, Woolhandler S, Himmelstein D. The Effect of Large-scale Health Coverage Expansions in Wealthy Nations on Society-Wide Healthcare Utilization. J Gen Intern Med 2020; 35:2406-2417. [PMID: 31745857 PMCID: PMC7403378 DOI: 10.1007/s11606-019-05529-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/25/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
Most analysts project that a reform like Medicare-for-All that lowers financial barriers to care would cause a surge in the utilization of services, raising costs despite stable or even reduced prices. However, the finite supply of physicians and hospital beds could constrain such utilization increases. We reviewed the effects of 13 universal coverage expansions in capitalist nations on physician and hospital utilization, beginning with New Zealand's 1938 Social Security Act up through the 2010 Affordable Care Act in the USA. Almost all coverage expansions had either a small (i.e., < 10%) or no effect on society-wide utilization. However, coverage expansions often redistributed care-increasing use among newly covered groups while producing small, offsetting reductions among those already covered. We conclude that in wealthy nations, large-scale coverage expansions need not cause overall utilization to surge if provider supply is controlled. However, such reforms could redirect care towards patients who most need it.
Collapse
Affiliation(s)
- Adam Gaffney
- Harvard Medical School, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02138 USA
| | - Steffie Woolhandler
- Harvard Medical School, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02138 USA
- City University of New York at Hunter College, New York, USA
| | - David Himmelstein
- Harvard Medical School, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02138 USA
- City University of New York at Hunter College, New York, USA
| |
Collapse
|
22
|
Medicaid Expansion and Mechanical Ventilation in Asthma, Chronic Obstructive Pulmonary Disease, and Heart Failure. Ann Am Thorac Soc 2020; 16:886-893. [PMID: 30811951 DOI: 10.1513/annalsats.201811-777oc] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Rationale: The Affordable Care Act's Medicaid expansion has led to increased access to chronic disease care among newly insured adults. Despite this, its effects on clinical outcomes, particularly for patients with asthma, chronic obstructive pulmonary disease, and heart failure, are uncertain. Objectives: To assess whether Medicaid expansion was associated with changes in mechanical ventilation rates among hospitalized patients with heart failure, asthma, and chronic obstructive pulmonary disease. Methods: Difference-in-differences analysis comparing discharge data from four states that expanded Medicaid in 2014 (Arizona, Iowa, New Jersey, and Washington) and three comparison states that did not (North Carolina, Nebraska, and Wisconsin) was performed. Models were adjusted for patient and hospital factors. Results: Mechanical ventilation rates at baseline were 7.2% in nonexpansion states and 8.8% in expansion states. Medicaid expansion was associated with a decline in mechanical ventilation rates at -0.2% per quarter (95% confidence interval [CI], -0.3% to 0.0%; P = 0.010). We did not observe a change in the rate of ICU admission (-0.4% per quarter; 95% CI, -0.8% to 0.1%; P = 0.10) or in-hospital mortality (0.1% per quarter; 95% CI, 0.0% to 0.1%; P = 0.30). In a negative control among adults aged 65 years or older, changes in mechanical ventilation rates were similar, though the CIs crossed zero (-0.1%; 95% CI, -0.2% to 0.0%; P = 0.08). Conclusions: Medicaid expansion may have been associated with a decline in mechanical ventilation rates among uninsured and Medicaid-covered patients admitted with heart failure, chronic obstructive pulmonary disease, and asthma.
Collapse
|
23
|
Bariatric surgery among vulnerable populations: The effect of the Affordable Care Act’s Medicaid expansion. Surgery 2019; 166:820-828. [DOI: 10.1016/j.surg.2019.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/27/2019] [Accepted: 05/06/2019] [Indexed: 01/27/2023]
|
24
|
Utilization of Left Ventricular Assist Devices in Vulnerable Adults Across Medicaid Expansion. J Surg Res 2019; 243:503-508. [DOI: 10.1016/j.jss.2019.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/23/2019] [Accepted: 05/08/2019] [Indexed: 11/23/2022]
|
25
|
Crocker AB, Zeymo A, McDermott J, Xiao D, Watson TJ, DeLeire T, Shara N, Chan KS, Al-Refaie WB. Expansion coverage and preferential utilization of cancer surgery among racial and ethnic minorities and low-income groups. Surgery 2019; 166:386-391. [DOI: 10.1016/j.surg.2019.04.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/08/2019] [Accepted: 04/24/2019] [Indexed: 11/30/2022]
|
26
|
Plate JF, Ryan SP, Goltz DE, Howell CB, Bolognesi MP, Seyler TM. Medicaid Insurance Correlates With Increased Resource Utilization Following Total Hip Arthroplasty. J Arthroplasty 2019; 34:255-259. [PMID: 30396744 DOI: 10.1016/j.arth.2018.10.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/29/2018] [Accepted: 10/09/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND With increased restraints and efforts to contain costs in total hip arthroplasty (THA), an emphasis has been placed on risk stratification. The purpose of this study was to determine whether Medicaid patients have increased resource utilization (including 90-day emergency department [ED] visits and readmissions) compared to Medicare or commercial insurance carriers. The study hypothesized that the Medicaid population would represent a high-risk cohort with increased resource utilization. METHODS The institutional database was retrospectively queried for primary THAs from 2013 to 2017 based on Current Procedural Terminology codes and patients undergoing revision surgery were excluded. Demographic information including age, sex, and body mass index (BMI) and medical comorbidities including American Society of Anesthesiologists (ASA) scores were evaluated. Patients were stratified by insurance type and length of stay (LOS), and 90-day ED visits and 90-day readmissions were assessed in univariable and multivariable analysis. RESULTS A total of 3674 primary THA patients were included in the analysis (including 116 with Medicaid, 1713 with Medicare, and 1845 with other insurance providers). Medicaid patients had significantly higher ASA scores (P < .001) and BMI (P < .001), with corresponding increase in procedure duration (115 vs 99 vs 105 minutes; P < .001). They had a prolonged LOS (2.5 vs 2.5 vs 1.5 days; P < .001) compared with other insurances, but similar to Medicare patients. Following discharge, in multivariable analysis controlling for age, BMI, and ASA score, Medicare patients were significantly more likely to return to the ED (odds ratio, 3.15; 95% confidence interval, 1.88-5.27; P < .001) and be readmitted (odds ratio, 2.46; 95% confidence interval, 1.26-4.81; P = .009). CONCLUSION Medicaid patients represent a higher risk cohort with increased resource utilization perioperatively, including longer LOS, and more 90-day ED visits and readmissions. This should be considered in outcome assessments and alternative expectations for the episode of care should be set for this population.
Collapse
Affiliation(s)
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University, Durham, NC
| | - Daniel E Goltz
- Department of Orthopaedic Surgery, Duke University, Durham, NC
| | - Claire B Howell
- Department of Orthopaedic Surgery, Duke University, Durham, NC
| | | | | |
Collapse
|