Musculoskeletal Urgent Care Centers in Connecticut Restrict Patients with Medicaid Insurance Based on Policy and Location

Achieving Health Equity: Combatting the Disparities in American Access to Musculoskeletal Care : Disparities Exist in Every Aspect of Orthopaedic Care in the United States - Access to Outpatient Visits, Discretionary and Unplanned Surgical Care, and Postoperative Outcomes. What Can We Do?

PURPOSE OF REVIEW

Healthcare disparities influence multiple dimensions of orthopaedic care including access, burden and incidence of disease, and outcome in varying populations. These disparities impact healthcare at both the micro and macro scale of the healthcare experience from individual patient-physician relationships to reimbursement rates across the United States. This article provides a review of how healthcare disparities contribute to the landscape of orthopaedic care and specifically highlights how disparities affect outpatient visits, discretionary and unplanned surgical care, and postoperative outcomes.

RECENT FINDINGS

Current research demonstrates the widespread presence of healthcare disparities in the field of orthopaedics and gives both objective and subjective evidence confirming disparities' measurable influence. The disparities most highlighted by our review include differences in orthopaedic care based on insurance type and race. Currently disparities in orthopaedic care are deeply connected to patient insurance status and race. In the outpatient setting insurance significantly impacts access to care, travel burden, and utilization of services. The emergent setting is similarly influenced with measurable differences in lack of access to acute care, rates of inappropriate triage, and timeliness of care based on insurance status and race. Additionally, the postoperative period is not immune to disparities with likelihood of follow up, experience of catastrophic medical expenses, and postoperative outcomes also being affected. Addressing these disparities is a pressing need and may include solutions like wider expansion and acceptance of publicly funded insurance and the development of readily available and easily measurable metrics for healthcare equity and quality in vulnerable populations.

National trends in musculoskeletal urgent care centers: Improved Medicaid access from 2019 to 2023

Musculoskeletal urgent care centers (MUCCs) are an increasingly common alternative to emergency departments for patients with orthopedic injuries. As there is a lack of longitudinal data regarding MUCCs' impact on the emergency health care system, our study seeks to understand recent trends in MUCC growth and their acceptance of Medicaid insurance. Over the last 6 years, at 2-year intervals (2019, 2021, and 2023), we performed a search to identify all MUCCs in the United States. We determined the affiliation and Medicaid acceptance status of all MUCCs, including those that closed/opened between 2019, 2021, and 2023, to analyze trends in MUCC availability and Medicaid acceptance. In 2019, there were 558 MUCCs, which increased to 596 MUCCs in 2021 and then decreased to 555 MUCCs in 2023, representing a growth and then decline of approximately 7%. Overall, since June 2019, 90 MUCCs have opened and 95 MUCCs have closed. Medicaid acceptance increased nationally between 2019 and 2023, from 58% to 71%. Medicaid acceptance increased for both nonaffiliated and privately affiliated MUCCs. Medicaid acceptance has increased nationally from 2019 to 2023, while MUCC availability has gone through a period of growth and then reversion to 2019 levels. As MUCCs have demonstrated limited Medicaid acceptance previously, it is promising that Medicaid acceptance has improved and MUCCs are providing patients with an additional avenue to access orthopedic care.

Do Children With Medicaid Insurance Have Increased Revision Rates 5 Years After Posterior Spinal Fusions?

BACKGROUND

Socioeconomic disparities in musculoskeletal care are increasingly recognized, however, no studies to date have investigated the role of the insurance carrier on outcomes after posterior spinal fusion (PSF) with segmental spinal instrumentation for adolescent idiopathic scoliosis (AIS).

METHODS

A US insurance dataset was queried using the PearlDiver Mariner software for all patients aged 10 to 18 undergoing PSF for a primary diagnosis of AIS between 2010 and 2020. Age, sex, geographic region, number of levels fused, and baseline medical comorbidities were queried. Complications occurring within 90 days of the index surgery were queried using the International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes. Revision surgery was also queried up to 5 years after the index PSF. Categorical variables were compared using the Fisher χ 2 tests and continuous variables were compared using independent t tests. All-cause revision within 5 years was compared using the Kaplan-Meier analysis and a log-rank test. Significance was set at P -value <0.05.

RESULTS

A total of 10,794 patients were identified with 9006 (83.4%) patients with private insurance and 1788 (16.6%) patients insured by Medicaid. The mean follow-up in the database was 5.36±3 years for patients with private insurance and 4.78±2.9 years for patients with Medicaid insurance ( P <0.001). Children with AIS and Medicaid insurance had a significantly higher prevalence of asthma, hypertension, and obesity. A larger percentage of children with Medicaid insurance (41.3%) underwent a ≥13-level PSF compared with privately insured children (34.5%) ( P <0.001). Medicaid patients did not experience higher odds of postoperative complications; in addition, revision surgeries occurred in 1.1% and 1.8% of patients with private insurance and Medicaid insurance, respectively at 5 years postoperatively ( P =0.223).

CONCLUSION

Despite worse baseline comorbidities and longer fusion constructs, AIS patients insured with Medicaid did not have higher rates of complications or revisions at 5-year follow-up versus privately insured patients.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

Operative management of rotator cuff tears: identifying disparities in access on a national level

BACKGROUND

The purpose of this study was to identify nationwide disparities in the rates of operative management of rotator cuff tears based on race, ethnicity, insurance type, and socioeconomic status.

METHODS

Patients diagnosed with a full or partial rotator cuff tear from 2006 to 2014 were identified in the Healthcare Cost and Utilization Project's National Inpatient Sample database using International Classification of Diseases, Ninth Revision diagnosis codes. Bivariate analysis using chi-square tests and adjusted, multivariable logistic regression models were used to evaluate differences in the rates of operative vs. nonoperative management for rotator cuff tears.

RESULTS

This study included 46,167 patients. When compared with white patients, adjusted analysis showed that minority race and ethnicity were associated with lower rates of operative management for Black (adjusted odds ratio [AOR]: 0.31, 95% confidence interval [CI]: 0.29-0.33; P < .001), Hispanic (AOR: 0.49, 95% CI: 0.45-0.52; P < .001), Asian or Pacific Islander (AOR: 0.72, 95% CI: 0.61-0.84; P < .001), and Native American patients (AOR: 0.65, 95% CI: 0.50-0.86; P = .002). In comparison to privately insured patients, our analysis also found that self-payers (AOR: 0.08, 95% CI: 0.07-0.10; P < .001), Medicare beneficiaries (AOR: 0.76, 95% CI: 0.72-0.81; P < .001), and Medicaid beneficiaries (AOR: 0.33, 95% CI: 0.30-0.36; P < .001) had lower odds of receiving surgical intervention. Additionally, relative to those in the bottom income quartile, patients in all other quartiles experienced nominally higher rates of operative repair; these differences were statistically significant for the second quartile (AOR: 1.09, 95% CI: 1.03-1.16; P = .004).

CONCLUSION

There are significant nationwide disparities in the likelihood of receiving operative management for rotator cuff tear patients of differing race/ethnicity, payer status, and socioeconomic status. Further investigation is needed to fully understand and address causes of these discrepancies to optimize care pathways.

Racial/ethnic and income-based differences in the use of surgery for cervical and lumbar disorders in New York State: a retrospective analysis

BACKGROUND CONTEXT

The extent to which use of spine surgeries for patients with cervical and lumbar disorders varies by their race/ethnicity and income is currently unknown.

PURPOSE

To assess racial/ethnic and income-based differences in use of spine surgery in New York State (NYS) from 2016 to 2019.

STUDY DESIGN

Retrospective observational analysis using 2016 to 2019 New York Statewide Planning and Research Cooperative System (SPARCS) data, direct standardization, and multivariable mixed-effects linear regression models.

METHODS

A dataset of patients who underwent surgery for cervical and spinal disorders in NYS in the period 2016 to 2019 was used to determine county-level age- and sex-standardized annual cervical and lumbar surgery rates expressed as number of surgeries per 10,000 individuals. Further sub-analysis was performed with the key independent variables being the combination of individual-level race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic individuals) and income (low-/high-income residing in zip codes below/above state median income); and year. We estimated multivariable mixed-effects linear regression models which controlled county-level variables to determine the adjusted rates of spine surgeries for patients belonging to various race/ethnicity and income group combinations.

RESULTS

The study included 29,650 and 42,498 patients in the cervical and lumbar cohorts, respectively. In 2019, the county-level mean cervical and lumbar surgery rates were 3.88 and 5.19 surgeries per 10,000 individuals, respectively. There was a five-fold rate variation across NYS. In 2019, the adjusted cervical rates were 4.59 (White low-income), 4.96 (White high-income), 7.20 (Black low-income), 3.01 (Black high-income), 4.37 (Hispanic low-income), and 1.17 (Hispanic high-income). The adjusted lumbar rates were 5.49 (White low-income), 6.31 (White high-income), 9.43 (Black low-income), 2.47 (Black high-income), 4.22 (Hispanic low-income), and 2.02 (Hispanic high-income). The rates for low-income Black or Hispanic patients were significantly higher than their high-income counterparts. Low-income Black patients had the highest rates. Over the study period, the gap/difference increased significantly between high-income Hispanic and White individuals by 2.19 (95% confidence interval [CI]: -4.27, -0.10, p=.04) for cervical surgery; and between low-income Black and White individuals by 2.82 (2.82, 95% CI: 0.59, 5.06, p=.01) for lumbar surgery.

CONCLUSION

There are differences in the rates of spine surgery in New York State, among identifiable groups. Black individuals from poorer zip codes experience relatively higher spine surgery rates. Understanding the drivers of surgical rate variation is key to improving the equitable delivery of spine care. A better understanding of such rate variations could inform health policy.

Characterizing the lack of diversity in musculoskeletal urgent care website content

BACKGROUND

Musculoskeletal urgent care centers (MUCCs) are becoming an alternative to emergency departments for non-emergent orthopedic injuries as they can provide direct access to orthopedic specialty care. However, they tend to be located in more affluent geographies and are less likely to accept Medicaid insurance than general urgent care centers. MUCCs utilize websites to drive patients to their centers, and the content may influence patients' consumer behaviors and perceptions of the quality and accessibility of the MUCCs. Given that some MUCCs target insured patient populations, we evaluated the racial, gender, and body type diversity of website content for MUCCs.

METHODS

Our group conducted an online search to create a list of MUCCs in the United States. For each MUCC, we analyzed the content featured prominently on the website (above the fold). For each website, we analyzed the race, gender, and body type of the featured model(s). MUCCs were classified according to their affiliation (i.e. academic versus private) and region (i.e. Northeast versus South). We performed chi-squared and univariate logistic regression to investigate trends in MUCC website content.

RESULTS

We found that 14% (32/235) of website graphics featured individuals from multiple racial groups, 57% (135/235) of graphics featured women, and 2% (5/235) of graphics featured overweight or obese individuals. Multiracial presence in website graphics was associated with the presence of women on the websites and Medicaid acceptance.

CONCLUSION

MUCC website content has the potential to impact patients' perceptions of medical providers and the medical care they receive. Most MUCC websites lack diversity based on race and body type. The lack of diversity in website content at MUCCs may introduce further disparities in access to orthopedic care.

Are Neighborhood Conditions Associated With Surgical Delays and Meniscus Tears in Children and Adolescents Undergoing ACL Reconstruction?

BACKGROUND

Markers of a patient's social determinants of health, including healthcare insurance and median household income based on ZIP Code, have been associated with the interval between injury and ACL reconstruction (ACLR) as well as the presence of concomitant meniscus tears in children and adolescents. However, the aforementioned surrogate indicators of a patient's social determinants of health may not reflect all socioeconomic and healthcare resources affecting the care of ACL injuries in children and adolescents. The use of multivariate indices such as the Child Opportunity Index (COI) may help to better identify patients at risk for increased risk for delay between ACL injury and surgery, as well as the incidence of meniscus tears at the time of surgery. The COI is a summative measure of 29 indicators that reflect neighborhood opportunities across three domains: education, health and environment, and social and economic factors. COI scores range from 0 to 100 (100 being the highest possible score), as well as five categorical scores (very low, low, moderate, high, and very high) based on quintile rankings.

QUESTIONS/PURPOSES

To investigate the relationship between neighborhood conditions and the treatment of ACL injuries in children and adolescents via the COI, we asked: (1) Is a lower COI score associated with a longer delay between ACL injury and surgery? (2) Does a higher proportion of patients with lower COI scores have meniscus tears at the time of ACLR?

METHODS

In this retrospective, comparative study, we considered data from 565 patients, 18 years or younger, who underwent primary ACLR at an urban, tertiary children's hospital between 2011 and 2021. Of these patients, 5% (31 of 565) did not have a clearly documented date of injury, 2% (11 of 565) underwent revision reconstructions, and 1% (5 of 565) underwent intentionally delayed or staged procedures. Because we specifically sought to compare patients who had low or very low COI scores (lowest two quintiles) with those who had high or very high scores (highest two quintiles), we excluded 18% (103 of 565) of patients with moderate scores. Ultimately, 73% (415 of 565) of patients with COI scores in either the top or bottom two quintiles were included. Patient addresses at the time of surgery were used to determine the COI score. There were no differences between the groups in terms of gender. However, patients with high or very high COI scores had a lower median (IQR) age (15 years [2.6] versus 17 years [1.8]; p < 0.001) and BMI (23 kg/m 2 [6.1] versus 25 kg/m 2 [8.8]; p < 0.001), were more commonly privately insured (62% [117 of 188] versus 22% [51 of 227]; p < 0.001), and had a higher proportion of patients identifying as White (67% [126 of 188] versus 6.2% [14 of 227]; p < 0.001) compared with patients with low or very low COI scores. Medical records were reviewed for demographic, preoperative, and intraoperative data. Univariate analyses focused on the relationship of the COI and interval between injury and surgery, frequency of concomitant meniscus tears, and frequency of irreparable meniscus tears treated with partial meniscectomy. Multivariable regression analyses were used to determine factors that were independently associated with delayed surgery (longer than 60 and 90 days after injury), presence of concomitant meniscal injuries, and performance of meniscectomy. Multivariable models included insurance and race or ethnicity to determine whether COI was independently associative after accounting for these variables.

RESULTS

Patients with a high or very high COI score had surgery earlier than those with a low or very low COI score (median [IQR] 53 days [53] versus 97 days [104]; p < 0.001). After adjusting for insurance and race/ethnicity, we found that patients with a low or very low COI score were more likely than patients with a high or very high COI score to have surgery more than 60 days after injury (OR 2.1 [95% CI 1.1 to 4.0]; p = 0.02) or more than 90 days after injury (OR 1.8 [95% CI 1.1 to 3.4]; p = 0.04). Furthermore, patients with low or very low COI scores were more likely to have concomitant meniscus tears (OR 1.6 [95% CI 1.1 to 2.5]; p = 0.04) compared with patients with high or very high COI scores. After controlling for insurance, race/ethnicity, time to surgery, and other variables, there was no association between COI and meniscectomy (OR 1.6 [95% CI 0.9 to 2.8]; p = 0.12) or presence of a chondral injury (OR 1.7 [95% CI 0.7 to 3.9]; p = 0.20).

CONCLUSION

As the COI score is independently associated with a delay between ACL injury and surgery as well as the incidence of meniscus tears at the time of surgery, this score can be useful in identifying patients and communities at risk for disparate care after ACL injury. The COI score or similar metrics can be incorporated into medical records to identify at-risk patients and dedicate appropriate resources for efficient care. Additionally, neighborhoods with a low COI score may benefit from improvements in the availability of additional and/or improved resources. Future studies should focus on the relationship between the COI score and long-term patient-reported functional outcomes after ACL injury, identification of the specific timepoints in care that lead to delayed surgery for those with lower COI scores, and the impact of community-based interventions in improving health equity in children with ACL injury.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Evaluating musculoskeletal urgent care center triage and transfer of emergency conditions for emergency surgical assessment and intervention

Musculoskeletal urgent care centers (MUCCs) are an alternative to emergency departments (EDs) for patients to seek care for low acuity orthopedic injuries such as ankle sprains or joint pain, but are not equipped to manage orthopedic emergencies that require a higher level of care provided in the ED. This study aims to evaluate telephone and online triage practices as well as ED transfer procedures for MUCCs for patients presenting with an orthopedic condition requiring urgent surgical intervention. We called 595 MUCCs using a standardized script presenting as a critical patient with symptoms of lower extremity compartment syndrome. We compared direct ED referral frequency and triage frequency for MUCCs for patients insured by either Medicaid or by private insurance. We found that patients presenting with an apparent compartment syndrome were directly referred to the ED by < 1 in 5 MUCCs. Additionally, < 5% of patients were asked additional triage questions that would increase clinician suspicion for compartment syndrome and allow MUCCs to appropriately direct patients to the ED. MUCCs provide limited telephone and online triage for patients, which may result in delays of care for life or limb threatening injuries that require ED resources such as sedation, reductions, and emergency surgery. However, when MUCCs did conduct triage, it significantly increased the likelihood that patients were appropriately referred to the ED. Level of Evidence: Level II, prognostic study.

Access to telehealth services for colorectal cancer patients in the United States during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic yielded rapid telehealth deployment to improve healthcare access, including for surgical patients.

METHODS

We conducted a secret shopper study to assess telehealth availability for new patient and follow-up colorectal cancer care visits in a random national sample of Commission on Cancer accredited hospitals and investigated predictive facility-level factors.

RESULTS

Of 397 hospitals, 302 (76%) offered telehealth for colorectal cancer patients (75% for follow-up, 42% for new patients). For new patients, NCI-designated Cancer Programs offered telehealth more frequently than Integrated Network (OR: 0.20, p = 0.01), Academic Comprehensive (OR: 0.18, p = 0.001), Comprehensive Community (OR: 0.10, p < 0.001), and Community (OR: 0.11, p < 0.001) Cancer Programs. For follow-up, above average timeliness of care hospitals offered telehealth more frequently than average hospitals (OR: 2.87, p = 0.04).

CONCLUSIONS

We identified access disparities and predictive factors for telehealth availability for colorectal cancer care during the COVID-19 pandemic. These factors should be considered when constructing telehealth policies.

Acceptance of Simulated Adult Patients With Medicaid Insurance Seeking Care in a Cancer Hospital for a New Cancer Diagnosis

IMPORTANCE

Although there have been significant increases in the number of US residents insured through Medicaid, the ability of patients with Medicaid to access cancer care services is less well known.

OBJECTIVE

To assess facility-level acceptance of Medicaid insurance among patients diagnosed with common cancers.

DESIGN, SETTING, AND PARTICIPANTS

This national cross-sectional secret shopper study was conducted in 2020 in a random sample of Commission on Cancer-accredited facilities in the United States using a simulated cohort of Medicaid-insured adult patients with colorectal, breast, kidney, and melanoma skin cancer.

EXPOSURES

Telephone call requesting an appointment for a patient with Medicaid with a new cancer diagnosis.

MAIN OUTCOMES AND MEASURES

Acceptance of Medicaid insurance for cancer care. Descriptive statistics, χ2 tests, and multivariable logistic regression models were used to examine factors associated with Medicaid acceptance for colorectal, breast, kidney, and skin cancer. High access hospitals were defined as those offering care across all 4 cancer types surveyed. Explanatory measures included facility-level factors from the 2016 American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services General Information database.

RESULTS

A nationally representative sample of 334 facilities was created, of which 226 (67.7%) provided high access to patients with Medicaid seeking cancer care. Medicaid acceptance differed by cancer site, with 319 facilities (95.5%) accepting Medicaid insurance for breast cancer care; 302 (90.4%), colorectal; 290 (86.8%), kidney; and 266 (79.6%), skin. Comprehensive community cancer programs (OR, 0.4; 95% CI, 0.2-0.7; P = .007) were significantly less likely to provide high access to care for patients with Medicaid. Facilities with nongovernment, nonprofit (vs for-profit: OR, 3.5; 95% CI, 1.1-10.8; P = .03) and government (vs for-profit: OR, 6.6; 95% CI, 1.6-27.2; P = .01) ownership, integrated salary models (OR, 2.6; 95% CI, 1.5-4.5; P = .001), and average (vs above-average: OR, 6.4; 95% CI, 1.4-29.6; P = .02) or below-average (vs above-average: OR, 8.4; 95% CI, 1.5-47.5; P = .02) effectiveness of care were associated with high access to Medicaid. State Medicaid expansion status was not significantly associated with high access.

CONCLUSIONS AND RELEVANCE

This study identified access disparities for patients with Medicaid insurance at centers designated for high-quality care. These findings highlight gaps in cancer care for the expanding population of patients receiving Medicaid.

Charges for Initial Visits for Uninsured Patients at Musculoskeletal Urgent Care Centers in the US

IMPORTANCE

In recent years, specialized musculoskeletal urgent care centers (MUCCs) have opened across the US. Uninsured patients may increasingly turn to these orthopedic-specific urgent care centers as a lower-cost alternative to emergency department or general urgent care center visits.

OBJECTIVE

To assess out-of-pocket costs and factors associated with these costs at MUCCs for uninsured and underinsured patients in the US.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study, a national secret shopper survey was conducted in June 2019. Clinics identified as MUCCs in 50 states were contacted by telephone by investigators using a standardized script and posing as uninsured patients seeking information on the out-of-pocket charge for a new patient visit.

EXPOSURES

State Medicaid expansion status, clinic Medicaid acceptance status, state Medicaid reimbursement rate, median income per zip code, and clinic region.

MAIN OUTCOMES AND MEASURES

The primary outcome was each clinic's out-of-pocket charge for a level 3 visit, defined as a new patient office visit requiring medical decision-making of low complexity. Linear regression was used to examine correlations of price with clinic policy against accepting Medicaid, median income per zip code, and Medicaid reimbursement for a level 3 visit.

RESULTS

Of 565 MUCCs identified, 558 MUCCs were able to be contacted (98.8%); 536 of the 558 MUCCs (96.1%) disclosed a new patient visit out-of-pocket charge. Of those, 313 (58.4%) accepted Medicaid insurance and 326 (60.8%) were located in states with expanded Medicaid at the time of the survey. The mean (SD) price of a visit to an MUCC was $250 ($110). Clinic policy against accepting Medicaid (β, 22.91; 95% CI, 12.57-33.25; P < .001), higher median income per zip code (β, 0.00056; 95% CI, 0.00020-0.00092; P = .003), and increased Medicaid reimbursement for a level 3 visit (β, 0.737; 95% CI, 0.158-1.316; P = .01) were positively correlated with visit price. The overall regression was statistically significance (R2 = 0.084; P < .001).

CONCLUSIONS AND RELEVANCE

In this survey study, MUCCs charged a mean price of $250 for a new patient visit. Medicaid acceptance policy, median income per zip code, and Medicaid reimbursement for a level 3 visit were associated with differences in out-of-pocket charges. These findings suggest that accessibility to orthopedic urgent care at MUCCs may be limited for underinsured and uninsured patients.

Variation in Use of Surgical Care During the COVID-19 Pandemic by Surgical Urgency and Race and Ethnicity

Question

To what extent did the COVID-19 pandemic reduce access to surgical care, and were racial and ethnic minority groups more likely to have reduced access to surgical care?

Findings

In this cohort study of more than 13 million inpatient and outpatient surgical encounters in 767 US hospitals in a hospital administrative database, surgical use was 13% lower in 2020 compared with 2019, with the greatest decrease concentrated in elective surgical procedures. While Black and Hispanic patients experienced a reduction in surgical encounters, White patients experienced the greatest reduction in surgical encounters.

Meaning

Despite severe and persistent disruptions to health systems during the COVID-19 pandemic, racial and ethnic minority groups did not experience a disproportionate decrease in access to surgical care.

Importance

The extent of the disruption to surgical care during the COVID-19 pandemic has not been empirically characterized on a national level.

Objective

To characterize the use of surgical care across cohorts of surgical urgency during the COVID-19 pandemic, and to assess for racial and ethnic disparities.

Design, Setting, and Participants

This was a retrospective observational study using the geographically diverse, all payer data from 767 hospitals in the Premier Healthcare Database. Procedures were categorized into 4 cohorts of surgical urgency (elective, nonelective, emergency, and trauma). A generalized linear regression model with hospital-fixed effects assessed the relative monthly within-hospital reduction in surgical encounters in 2020 compared with 2019.

Main Outcomes and Measures

Outcomes were the monthly relative reduction in overall surgical encounters and across surgical urgency cohorts and race and ethnicity.

Results

The sample included 13 175 087 inpatient and outpatient surgical encounters. There was a 12.6% relative reduction in surgical use in 2020 compared to 2019. Across all surgical cohorts, the most prominent decreases in encounters occurred during Spring 2020 . For example, elective encounters began falling in March, reached a trough in April, and subsequently recovered but never to prepandemic levels (March: −26.8%; 95% CI, −29.6% to −23.9%; April: −74.6%; 95% CI, −75.5% to −73.5%; December: −13.3%; 95% CI, −16.6%, −9.8%). Across all operative surgical urgency cohorts, White patients had the largest relative reduction in encounters.

Conclusions and Relevance

As shown by this cohort study, the COVID-19 pandemic resulted in large disruptions to surgical care across all categories of operative urgency, especially elective procedures. Racial and ethnic minority groups experienced less of a disruption to surgical care than White patients. Further research is needed to explore whether the decreased surgical use among White patients was owing to patient discretion and to document whether demand for surgical care will rebound to baseline levels.

Musculoskeletal Urgent Care Centers Restrict Access for Patients with Medicaid Insurance Based on Policy and Location

BACKGROUND

As the urgent care landscape evolves, specialized musculoskeletal urgent care centers (MUCCs) are becoming more prevalent. MUCCs have been offered as a convenient, cost-effective option for timely acute orthopaedic care. However, a recent "secret-shopper" study on patient access to MUCCs in Connecticut demonstrated that patients with Medicaid had limited access to these orthopaedic-specific urgent care centers. To investigate how generalizable these regional findings are to the United States, we conducted a nationwide secret-shopper study of MUCCs to identify determinants of patient access.

QUESTIONS/PURPOSES

(1) What proportion of MUCCs in the United States provide access for patients with Medicaid insurance? (2) What factors are associated with MUCCs providing access for patients with Medicaid insurance? (3) What barriers exist for patients seeking care at MUCCs?

METHODS

An online search of all MUCCs across the United States was conducted in this cross-sectional study. Three separate search modalities were used to gather a complete list. Of the 565 identified, 558 were contacted by phone with investigators posing over the telephone as simulated patients seeking treatment for a sprained ankle. Thirty-nine percent (216 of 558) of centers were located in the South, 13% (71 of 558) in the West, 25% (138 of 558) in the Midwest, and 24% (133 of 558) in New England. This study was given an exemption waiver by our institution's IRB. MUCCs were contacted using a standardized script to assess acceptance of Medicaid insurance and identify barriers to care. Question 1 was answered through determining the percentage of MUCCs that accepted Medicaid insurance. Question 2 considered whether there was an association between Medicaid acceptance and factors such as Medicaid physician reimbursements or MUCC center type. Question 3 sought to characterize the prevalence of any other means of limiting access for Medicaid patients, including requiring a referral for a visit and disallowing continuity of care at that MUCC.

RESULTS

Of the MUCCs contacted, 58% (323 of 558) accepted Medicaid insurance. In 16 states, the proportion of MUCCs that accepted Medicaid was equal to or less than 50%. In 22 states, all MUCCs surveyed accepted Medicaid insurance. Academic-affiliated MUCCs accepted Medicaid patients at a higher proportion than centers owned by private practices (odds ratio 14 [95% CI 4.2 to 44]; p < 0.001). States with higher Medicaid physician reimbursements saw proportional increases in the percentage of MUCCs that accepted Medicaid insurance under multivariable analysis (OR 36 [95% CI 14 to 99]; p < 0.001). Barriers to care for Medicaid patients characterized included location restriction and primary care physician referral requirements.

CONCLUSION

It is clear that musculoskeletal urgent care at these centers is inaccessible to a large segment of the Medicaid-insured population. This inaccessibility seems to be related to state Medicaid physician fee schedules and a center's affiliation with a private orthopaedic practice, indicating how underlying financial pressures influence private practice policies. Ultimately, the refusal of Medicaid by MUCCs may lead to disparities in which patients with private insurance are cared for at MUCCs, while those with Medicaid may experience delays in care. Going forward, there are three main options to tackle this issue: increasing Medicaid physician reimbursement to provide a financial incentive, establishing stricter standards for MUCCs to operate at the state level, or streamlining administration to reduce costs overall. Further research will be necessary to evaluate which policy intervention will be most effective.

LEVEL OF EVIDENCE

Level II, prognostic study.

Recent Trends in Medicare Utilization and Reimbursement for Orthopaedic Procedures Performed at Ambulatory Surgery Centers

BACKGROUND

As part of a market-driven response to the increasing costs of hospital-based surgical care, an increasing volume of orthopaedic procedures are being performed in ambulatory surgery centers (ASCs). The purpose of the present study was to identify recent trends in orthopaedic ASC procedure volume, utilization, and reimbursements in the Medicare system between 2012 and 2017.

METHODS

This cross-sectional, national study tracked annual Medicare claims and payments and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates, and reimbursement rates, and to identify demographic predictors of ASC utilization.

RESULTS

A total of 1,914,905 orthopaedic procedures were performed at ASCs in the Medicare population between 2012 and 2017, with an 8.8% increase in annual procedure volume and a 10.5% increase in average reimbursements per case. ASC orthopaedic procedure utilization, including utilization across all subspecialties, is strongly associated with metropolitan areas compared with rural areas. In addition, orthopaedic procedure utilization, including for sports and hand procedures, was found to be significantly higher in wealthier counties (measured by average household income) and in counties located in the South.

CONCLUSIONS

This study demonstrated increasing orthopaedic ASC procedure volume in recent years, driven by increases in hand procedure volume. Medicare reimbursements per case have steadily risen and outpaced the rate of inflation over the study period. However, as orthopaedic practice overhead continues to increase, other Medicare expenditures such as hospital payments and operational and implant costs also must be evaluated. These findings may provide a source of information that can be used by orthopaedic surgeons, policy makers, investors, and other stakeholders to make informed decisions regarding the costs and benefits of the use of ASCs for orthopaedic procedures.

Access to Urologic Care at Urgent Care Centers

OBJECTIVE

To evaluate Medicaid insurance access disparities for urologic care at urgent care centers (UCCs) in the United States.

MATERIALS AND METHODS

We conducted a cross-sectional study using a "secret shopper" methodology. We sampled 240 UCCs across 8 states. Using a standardized script, researchers posed as a patient with either Medicaid or commercial insurance in the clinical setting of obstructing nephrolithiasis. The primary study endpoint was whether a patient's insurance (Medicaid vs commercial) was accepted. We assessed factors associated with Medicaid acceptance using logistic regression models adjusted for state-level and facility-level characteristics. Additionally, we calculated triage rates, emergency department referral rates, and the ability of a UCC to refer the patient to a specialist.

RESULTS

Of 240 UCCs contacted, 239 (99.6%) accepted commercial insurance and 159 (66.2%) accepted Medicaid. UCCs in Medicaid expansion states more frequently accepted patients with Medicaid insurance (74.2% vs 58.3%, respectively, P < .01). On multivariable logistic regression analysis, state Medicaid expansion (OR 1.84, 95% CI 1.04-3.26, P = .04) and affiliation with an institution (OR 2.97, 95% CI 1.59-5.57, P < .01) were independently associated with greater odds of accepting Medicaid. Medicaid-insured patients were significantly less likely to be triaged or referred to the emergency department compared to commercial patients.

CONCLUSION

We identified significant disparities in access to UCCs for Medicaid patients presenting with a urologic condition. Given the expanding national role of UCCs, these findings highlight potential sources of insurance disparity in the context of a urologic emergency.

Perception of Risk: A Poll of American Association of Hip and Knee Surgeons Members

BACKGROUND

Providers of total hip and knee replacements are being judged regarding quality/cost by payers using competition-based performance measures with poor medical and no socioeconomic risk adjustment. Providers might assume that other providers shed risk and the perception of added risk can influence practice. A poll was collected to examine such perceptions.

METHODS

In 2019 a poll was sent to the 2800 surgeon members of the American Association of Hip and Knee Surgeons using Survey Monkey while protecting respondent anonymity/confidentiality. The questions asked whether the perception of poorly risk-adjusted medical comorbidities and socioeconomic risk factors influence surgeons to selectively offer surgery.

RESULTS

There were 474 surgeon responses. Prior to elective total hip arthroplasty/total knee arthroplasty, 95% address modifiable risk factors; 52% require a body mass index <40, 64% smoking cessation, 96% an adequate hemoglobin A1C; 82% check nutrition; and 63% expect control of alcohol 2. Due to lack of socioeconomic risk adjustment, 83% reported feeling pressure to avoid/restrict access to patients with limited social support, specifically the following: Medicaid/underinsured, 81%; African Americans, 29%; Hispanics/ethnicities, 27%; and low socioeconomic status, 73%. Of the respondents, 93% predicted increased access to care with more appropriate risk adjustment.

CONCLUSION

Competition-based quality/cost performance measures influence surgeons to focus on medical risk factors in offering lower extremity arthroplasty. The lack of socioeconomic risk adjustment leads to perceptions of added risk from such factors as well. This leads to marginal loss of access for patients within certain medical and socioeconomic classes, contributing to existing healthcare disparities. This represents an unintended consequence of competition-based performance measures.

Urgent care center wait times increase for COVID-19 results in August 2020, with rapid testing availability limited

BACKGROUND

In a response to the pandemic, urgent care centers (UCCs) have gained a critical role as a common location for COVID-19 testing. We sought to characterize the changes in testing accessibility at UCCs between March and August 2020 on the basis of testing availability (including rapid antigen testing), wait time for test results, cost of visits, and cost of tests.

METHODS

Data were collected using a secret shopper methodology. Researchers contacted 250 UCCs in 10 states. Investigators used a standardized script to survey centers on their COVID-19 testing availability and policies. UCCs were initially contacted in March and re-called in August. T-tests and chi-square tests were conducted to identify differences between March and August data and differences by center classification.

RESULTS

Our results indicate that both polymerase chain reaction (PCR) tests to detect COVID-19 genetic material and rapid antigen COVID-19 tests have increased in availability. However, wait times for PCR test results have significantly increased to an average of 5.79 days. Additionally, a high proportion of UCCs continue to charge for tests and visits and no significant decrease was found in the proportion of UCCs that charge for COVID-19 testing from March to August. Further, no state reported a majority of UCCs with rapid testing available, indicating an overall lack of rapid testing.

CONCLUSIONS

From March to August, COVID-19 testing availability gradually improved. However, many barriers lie in access to COVID-19 testing, including testing costs, visit costs, and overall lack of availability of rapid testing in the majority of UCCs. Despite the passage of the CARES Act, these results suggest that there is room for additional policy to improve accessibility to testing, specifically rapid testing.