State Variation in Medicaid Reimbursements for Orthopaedic Surgery

Evaluating Changes in Surgical Outcomes for Patients With Inflammatory Bowel Disease Following Medicaid Expansion

BACKGROUND

Little is known about the impact of Medicaid expansion on the surgical care of inflammatory bowel disease. We sought to determine whether Medicaid expansion is associated with improved postsurgical outcomes for patients with inflammatory bowel disease undergoing a colorectal resection.

METHODS

We performed a risk-adjusted difference-in-difference study examining postsurgical outcomes for patients ages 26 to 64 with Crohn's disease or ulcerative colitis undergoing a colorectal resection across 15 states that did and did not expand Medicaid before (2012-2013) and after (2016-2018) policy reform. Primary study outcomes included 30-day readmission and postoperative complication.

RESULTS

Study population included 11 394 patients with inflammatory bowel disease that underwent a colorectal resection. States that underwent Medicaid expansion were associated with a rise in Medicaid enrollment following policy reform (11.8% pre-Medicaid expansion vs 19.7% post-Medicaid expansion). Difference-in-difference analysis revealed a statistically significant lower odds of 30-day readmission in patients undergoing a colorectal resection in expansion states following policy reform relative to patients in nonexpansion states prior to reform (odds ratio, 0.56; 95% confidence interval, 0.36-0.86). No changes in odds of postoperative complication were noted across expansion and nonexpansion states.

CONCLUSIONS

Medicaid expansion is associated with a rise in Medicaid enrollment in expansion states following policy reform. There were greater improvements in postoperative outcomes associated with patients in expansion states following policy reform relative to patients in nonexpansion states prior to reform, which may have been related to improved perioperative care and medical management.

Variability in Medicaid Reimbursement in Hand Surgery May Lead to Inequality in Access to Patient Care

BACKGROUND

Medicare (MCR) and Medicaid (MCD) remain the dominant providers of government-funded health insurance in the United States. The purpose of this study was to evaluate the variability between MCR and MCD reimbursements for common hand and wrist surgical procedures. We hypothesized that MCD reimbursement rates would have substantial variation between states, whereas MCR rates would remain relatively constant.

METHODS

Using the Medicare Physician Fee Schedule Database, the 2019 reimbursements for 7 common hand and wrist procedures were recorded via the respective Current Procedural Terminology codes. The MCD reimbursement rates were then obtained from each state's physician fee schedule database. Comparisons of reimbursement for these procedures were then calculated between states and between MCD and MCR while adjusting for cost of living using the Medicare Wage Index. Finally, the coefficients of variation were computed to compare the extent of variability between the insurance types.

RESULTS

Across all procedures, reimbursement rates for MCD ranged from 30.6% to 240% of the average MCR reimbursement, with the mean reimbursement for MCD valued at 78.3% of MCR. Endoscopic carpal tunnel release (CTR) is valued similarly by MCD compared with open CTR with an average of 77.7% and 78.2% reimbursement of MCR, respectively. The coefficients of variation for MCD reimbursements ranged from 0.25 to 0.45, whereas the value was 0.06 for all MCR procedures.

CONCLUSIONS

These findings demonstrate a wide variation in MCD payments between states. When compared with MCR, the lower average state MCD reimbursement questions the sustainability for hand surgeons to accept these patients in practice.

What Factors Affect Whether Patients Return to the Same Surgeon to Replace the Contralateral Joint? A Study of Over 200,000 Patients

BACKGROUND

Patients with hip and knee arthritis often undergo bilateral total hip arthroplasty (THA) and total knee arthroplasty (TKA) in a staged or simultaneous fashion. However, when staged, the incidence and factors associated with having both procedures performed by the same surgeon or different surgeon are not well studied.

METHODS

All patients undergoing nonsimultaneous bilateral THA or TKA for osteoarthritis were abstracted from the 2010 to 2020 PearlDiver Mariner administrative database. The National Provider Identifier number was used to determine whether the same surgeon performed both surgeries. Demographics, comorbidities, and 90-day complications after the first joint replacement were assessed as possible independent predictors of utilizing a different surgeon for the contralateral joint.

RESULTS

Of 87,593 staged bilateral THAs, the same surgeon performed 40,707 (46.5%) arthroplasties. Of 147,938 staged bilateral TKAs, the same surgeon performed 77,072 (52.1%) arthroplasties. Notably, older cohorts of patients had independent, stepwise, and significantly greater odds of changing surgeons for the contralateral THA and TKA. Those patients who were insured by Medicare and Medicaid had significantly lower odds of changing surgeons. For both THA and TKA, surgical and implant-related adverse events (surgical site infection/periprosthetic joint infection, periprosthetic fracture, dislocation, manipulation) carried the greatest odds of undergoing the contralateral replacement with a different surgeon.

CONCLUSION

Patients covered by Medicaid and sicker patients were significancy less likely to switch surgeons for their contralateral THA or TKA. Additionally, patients experiencing a surgery-related adverse event within 90 days of their first THA or TKA had significantly, increased odds of switching surgeons for their subsequent TJA.

Variations in Discharge Destination Following Severe TBI across the United States

BACKGROUND

Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients.

METHODS

All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size.

RESULTS

75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF.

CONCLUSIONS

Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.

Variation in state and federal reimbursement in the United States in the treatment of upper extremity fractures

BACKGROUND

Medicare and Medicaid are 2 of the largest government-run health care programs in the United States. Although Medicare reimbursement is determined at the federal level by the Centers for Medicare & Medicaid Services, Medicaid reimbursement rates are set by each individual state. The purpose of this study is to compare Medicaid reimbursement rates with regional Medicare reimbursement rates for 12 orthopedic procedures performed to treat common fractures of the upper extremity.

METHODS

Twelve orthopedic procedures were selected and their Medicare reimbursement rates were collected from the 2020 Medicare Physician Fee Schedule. Medicaid reimbursement rates were obtained from each state's physician fee schedule. Reimbursement rates were then compared by assessing the ratio of Medicaid to Medicare, the dollar difference in Medicaid to Medicare reimbursement, and the difference per relative value unit. The range of variation in Medicaid reimbursement and Medicare wage index-adjusted Medicaid reimbursement was calculated. Comparisons in reimbursement were calculated using coefficient of variation and Student t tests to evaluate the differences between the mean Medicaid and Medicare reimbursements. Two-sample coefficient of variation testing was used to determine whether dispersion in Medicare and Medicaid reimbursement rates differed significantly.

RESULTS

There was significant difference in reimbursement rates between Medicare and Medicaid for all 12 procedures, with Medicare reimbursing on average 46.5% more than Medicaid. In 40 states, Medicaid reimbursed less than Medicare for all 12 procedures. Regarding the dollar difference per relative value unit, Medicaid reimbursed on average $18.03 less per relative value unit than Medicare. The coefficient of variation for Medicaid reimbursement rates ranged from 0.26-0.33. This is in stark contrast with the significantly lower variability observed in Medicare reimbursement, which ranged from 0.06-0.07.

CONCLUSION

Our findings highlight the variation in reimbursement that exists among state Medicaid programs for 12 orthopedic procedures commonly used to treat fractures of the upper extremity. Furthermore, average Medicaid reimbursement rates were significantly lower than Medicare rates for all 12 procedures. Such discrepancies in reimbursement may act as a barrier, impeding many Medicaid patients from accessing timely orthopedic care.

What Is the Financial Impact of Orthopaedic Sequelae of Intravenous Drug Use on Urban Tertiary-care Centers?

BACKGROUND

Orthopaedic sequelae such as skin and soft-tissue abscesses are frequent complications of intravenous drug use (IVDU) and comprise many of the most common indications for emergency room visits and hospitalizations within this population. Urban tertiary-care and safety-net hospitals frequently operate in challenging economic healthcare environments and are disproportionately tasked with providing care to this largely underinsured patient demographic. Although many public health initiatives have been instituted in recent years to understand the health impacts of IVDU and the spreading opioid epidemic, few efforts have been made to investigate its economic impact on healthcare systems. The inpatient treatment of orthopaedic sequelae of IVDU is a high-cost healthcare element that is critically important to understand within the current national context of inflationary healthcare costs.

QUESTIONS/PURPOSES

(1) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of extraspinal orthopaedic sequelae of IVDU? (2) What were the total healthcare costs incurred and total hospital reimbursements received in the treatment of spinal orthopaedic sequelae of IVDU? (3) How did patient insurance status effect the economic burden of orthopaedic sequelae of IVDU?

METHODS

An internal departmental record of all successive patients requiring inpatient treatment of orthopaedic sequelae of IVDU was initiated at Boston Medical Center (Boston, MA, USA) in 2012 and MetroHealth Medical Center (Cleveland, OH, USA) in 2015. A total of 412 patient admissions between 2012 to 2017 to these two safety-net hospitals (n = 236 and n = 176, respectively) for orthopaedic complications of IVDU were included in the study. These sequelae included cellulitis, cutaneous abscess, bursitis, myositis, tenosynovitis, septic arthritis, osteomyelitis, and epidural abscess. Patients were included if they were older than 18 years of age, presented to the emergency department for management of a musculoskeletal infection secondary to IVDU, and required inpatient orthopaedic treatment during their admission. Exclusion criteria included all patients presenting with a musculoskeletal infection not directly secondary to active IVDU. Patients presenting with an epidural abscess (Boston Medical Center, n = 36) were evaluated separately to explore potential differences in costs within this subgroup. A robust retrospective financial analysis was performed using internal financial databases at each institution which directly enumerated all true hospital costs associated with each patient admission, independent of billed hospital charges. All direct, indirect, variable, and fixed hospital costs were individually summed for each hospitalization, constituting a true "bottom-up" micro-costing approach. Labor-based costs were calculated through use of time-based costing; for instance, the cost of nursing labor care associated with a patient admission was determined through ascription of the median hospital cost of a registered nurse within that department (that is, compensation for salary plus benefits) to the total length of nursing time needed by that patient during their hospitalization. Primary reimbursements reflected the true monetary value received by the study institutions from insurers and were determined through the total adjusted payment for each inpatient admission. All professional fees were excluded. A secondary analysis was performed to assess the effect of patient insurance status on hospital costs and reimbursements for each patient admission.

RESULTS

The mean healthcare cost incurred for the treatment of extraspinal orthopaedic sequelae of IVDU was USD 9524 ± USD 1430 per patient admission. The mean hospital reimbursement provided for the treatment of these extraspinal sequelae was USD 7678 ± USD 1248 per patient admission. This resulted in a mean financial loss of USD 1846 ± USD 1342 per patient admission. The mean healthcare cost incurred at Boston Medical Center for the treatment of epidural abscesses secondary to IVDU was USD 44,357 ± USD 7384 per patient. Hospital reimbursements within this subgroup were highly dependent upon insurance status. The median (range) reimbursement provided for patients possessing a unique hospital-based nonprofit health plan (n = 4) was USD 103,016 (USD 9022 to USD 320,123), corresponding to a median financial gain of USD 24,904 (USD 2289 to USD 83,079). However, the mean reimbursement for all other patients presenting with epidural abscesses (n = 32) was USD 30,429 ± USD 5278, corresponding to a mean financial loss of USD 5768 ± USD 4861. A secondary analysis demonstrated that treatment of extraspinal orthopaedic sequelae of IVDU for patients possessing Medicaid insurance (n = 309) resulted in a financial loss of USD 2813 ± USD 1593 per patient admission. Conversely, treatment of extraspinal orthopaedic sequelae for patients possessing non-Medicaid insurance (n = 67) generated a mean financial gain of USD 2615 ± USD 1341 per patient admission.

CONCLUSIONS

Even when excluding all professional fees, the inpatient treatment of orthopaedic sequelae of IVDU resulted in substantial financial losses driven primarily by high proportions of under- and uninsured people within this patient population. These financial losses may be unsustainable for medical centers operating in challenging economic healthcare landscapes. The development of novel initiatives and support of existing programs aimed at mitigating the health-related and economic impact of IVDU must remain a principal priority of healthcare providers and policymakers in coming years. Advocacy for the expansion of Medicaid accountable care organizations and national syringe service programs (SSPs), and the development of specialized outpatient wound and abscess clinics at healthcare centers may help to substantially alleviate the economic burden of the orthopaedic sequelae of IVDU.

LEVEL OF EVIDENCE

Level, IV, economic and decision analyses.

Effect of Insurance Type on Access to Orthopedic Care for Pediatric Trigger Thumb

PURPOSE

To assess the effect of type of insurance coverage on the ability of a pediatric patient to obtain an outpatient orthopedic appointment for trigger thumb.

METHODS

A list of 200 orthopedic practices in 4 states were contacted and presented with a fictitious 3-year-old patient with trigger thumb. The patient was presented as having Blue Cross Blue Shield Insurance during the first call and Medicaid during the second call. Data regarding whether an appointment was offered or denied were recorded.

RESULTS

Of the 200 practices, 81 were excluded, 22 because they did not answer the calls, 25 needed the patient's social security number, 19 needed medical records, 5 had no hand surgeon in the practice, and 10 would not see any children at all. Of the 119 practices included in the analysis, the private insurance patient was able to get an appointment 51.3% of the time whereas the Medicaid patient was able to get an appointment in 26.9% of instances.

CONCLUSIONS

There is a significant effect of insurance status on the ability of pediatric patients with trigger thumb to obtain outpatient orthopedic appointments.

CLINICAL RELEVANCE

Pediatric patients with Medicaid face greater barriers to accessing proper care for trigger thumb than patients with private insurance.

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

BACKGROUND

Musculoskeletal urgent care centers are a new development in the urgent care landscape. Anecdotally, these centers are known to screen patients based on their insurance status, denying care to those with Medicaid insurance. It is important to know whether the practice of denying musculoskeletal urgent care to patients with Medicaid insurance is widespread because this policy could exacerbate existing musculoskeletal healthcare disparities.

QUESTIONS/PURPOSES

(1) Do musculoskeletal urgent care centers in Connecticut provide access for patients with Medicaid insurance? (2) Do musculoskeletal urgent care centers have the same Medicaid policies as the entities that own them? (3) Are musculoskeletal urgent care centers more likely to be located in affluent neighborhoods?

METHODS

An online search was conducted to create a list of musculoskeletal urgent care centers in Connecticut. Each center was interviewed over the telephone using a standardized list of questions to determine ownership and Medicaid policy. Next, the entities that owned these musculoskeletal centers were called and asked the same questions about their Medicaid policy. Medicaid policy was compared between musculoskeletal urgent care centers and the practices that owned them. The median household income for each ZIP code containing a musculoskeletal urgent care center was compared with the median household income for Connecticut. The median household income was also compared between the ZIP codes of musculoskeletal urgent care centers that accepted or denied patients with Medicaid insurance.

RESULTS

Of the 29 musculoskeletal urgent care centers in Connecticut, only four (13%) accepted patients regardless of their insurance type, 19 (66%) did not accept any form of Medicaid insurance, and six (21%) required that certain requisites and stipulations be met for patients with Medicaid insurance to receive access, such as only permitting a patient for an initial visit and then referring them to a local hospital system for all future encounters, or only permitting patients with Medicaid insurance who lived in the same town as the clinic. All 29 musculoskeletal urgent care centers were owned by private practice groups and nine of 14 of these groups had the same policy towards patients with Medicaid insurance as their respective musculoskeletal urgent care centers. All 29 musculoskeletal urgent care centers were co-located in a private practice clinic office. Musculoskeletal urgent care centers were located in areas with greater median household incomes than the Connecticut state median (95% CI, USD 112,322 to USD 84,613 versus the state median of USD 73,781; p = 0.001).

CONCLUSIONS

Most musculoskeletal urgent care centers in Connecticut do not accept patients with Medicaid insurance and have similar or stricter Medicaid policies as the groups that own them. Additionally, musculoskeletal urgent care centers were located in affluent neighborhoods. These findings are important because they suggest private practices are using musculoskeletal urgent care centers to capture patients with more favorable insurance. This is likely a result of the relatively low Medicaid reimbursement rates in Connecticut and reflects a need for an increase in either reimbursement or incentives to treat patients with Medicaid insurance. The financial impact of capturing well-insured patients from public and academic medical centers and directing Medicaid patients to these urgent care centers is not known. Additionally, although most of these 29 musculoskeletal urgent care clinics denied care to patients with Medicaid, the specific healthcare disparities caused by decreased access to care must be further studied.

State variation in Medicaid and Medicare reimbursements in musculoskeletal radiology

BACKGROUND

Medicaid reimbursements for physician services are determined by each state. However, how these reimbursements vary between states, and how these reimbursements vary in comparison to Medicare reimbursements is unknown for musculoskeletal radiology studies.

OBJECTIVE

To evaluate the variability in Medicaid and Medicare physician reimbursements for musculoskeletal imaging studies between states.

METHODS

We evaluated the Medicare and Medicaid physician reimbursements for the most commonly performed musculoskeletal radiology studies (15 radiographs and 10 MRIs) based on Medicare's 2017 National Summary Data File. Medicare and Medicaid reimbursements for these studies were compared by dollar difference (difference in reimbursement in dollars between Medicare and Medicaid). State-wide variability in these reimbursements was quantified by the coefficient of variation (COV) and by the dollar difference in reimbursement amounts. Medicaid and Medicare reimbursement rates were compared using a paired t-test, since the data was paired by state.

RESULTS

The mean Medicaid reimbursement rates were lower for musculoskeletal radiographs (p < 0.05) but higher for musculoskeletal MRI studies than the Medicare rates (p < 0.05). As hypothesized, there was variation in both Medicare and Medicaid imaging reimbursements between states, however, the variation was substantially higher for Medicaid reimbursements. We found the Medicare reimbursement COV between states was 0.07 for all imaging studies, whereas the Medicaid reimbursement COV between states varied from 0.23 to 0.55 for radiographs and from 0.31 to 0.45 for MRIs.

DISCUSSION

The data show that there is mild, but constant variation across imaging studies in Medicare reimbursement for musculoskeletal imaging studies between states. However, there is more variation in the Medicaid reimbursements across imaging studies and between states. More appropriate reimbursement may increase access to care for Medicaid patients.

Medicaid Reimbursement for Common Spine Procedures: Are Compensation Rates Consistent?

STUDY DESIGN

Health Services Research.

OBJECTIVE

The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery.

SUMMARY OF BACKGROUND DATA

The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively.

METHODS

MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement.

RESULTS

The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements <50% of MCR reimbursements in the region. In total, 20 and 42 states provided <75% and 100% of MCR reimbursements, respectively. Based upon relative reimbursement, MCD appears to value microdiscectomy (84.1% of MCR; P = 0.10) over other elective spine procedures. Microdiscectomy also had the most interstate variation in MCD reimbursement: 39.0% to 207.0% of MCR.

CONCLUSION

Large disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to fully understand the effect of these significant differences. However, it is likely that these discrepancies lead to suboptimal access to necessary spine care.

LEVEL OF EVIDENCE

4.

Variation in the Delivery of Inpatient Orthopaedic Care to Medicaid Beneficiaries within a Single Metropolitan Region

BACKGROUND

There is variability in access to and utilization of orthopaedic care, particularly for those with Medicaid insurance. One potential contributor is perceived unwillingness of surgeons and hospitals to accept underinsured patients. We used administrative data to examine the payer mix for select inpatient orthopaedic surgical procedures at all hospitals within a single region, hypothesizing that the delivery of orthopaedic surgery to Medicaid beneficiaries varies highly at the hospital level.

METHODS

Using administrative data, we analyzed inpatient hospitalizations for elective cases (total knee or hip arthroplasty; spinal decompression or fusion) and trauma cases (hip hemiarthroplasty; femoral or tibial and fibular fracture repair) among 22 hospitals in a single region from 2011 to 2016 for patients who were 18 to 64 years of age. The primary outcome was the percentage of each hospital's caseload with Medicaid listed as the primary payer. The secondary outcome measured each hospital's Medicaid percentage against the percentage of Medicaid-insured individuals within 10 miles of the hospital (Medicaid share ratio), using a ratio of 1 as a benchmark. To quantify variation, we calculated a weighted coefficient of variation of the Medicaid share ratio for all cases combined, elective cases only, and trauma cases only.

RESULTS

For all cases (n = 19,204), the mean percentage of Medicaid-funded surgical procedures was 7.6% (range, 0.2% to 57.3%). The mean Medicaid share ratio was 1.0 (range, 0.05 to 4.20). Across 22 hospitals, the weighted coefficient of variation for Medicaid share was 69, indicating very high variation. For elective cases alone, the mean percentage of Medicaid-funded surgical procedures was 5.5% (range, 0.2% to 64.6%). The mean Medicaid share ratio was 0.71 (range, 0.05 to 4.73), and the weighted coefficient of variation was 93. For trauma cases alone, Medicaid-funded surgical procedures were 14.7% (range, 0.0% to 35.7%). The mean Medicaid share ratio was 2.0 (range, 0 to 3.93), and the weighted coefficient of variation was 34.

CONCLUSIONS

Delivery of care was highly variable when benchmarking against the insurance composition of each hospital's surrounding community. Although generalizability to other regions is limited, our findings support previously asserted notions that delivery of orthopaedic care may differ on the basis of socioeconomic markers (such as insurance status). If not addressed, these inequities may exacerbate existing racially and socioeconomically based disparities in care.

Variations in Medicaid Payment Rates for Radiation Oncology

PURPOSE

Interstate variations in Medicaid reimbursements can be significant, and patients who live in states with low Medicaid reimbursements tend to have worse access to care. This analysis describes the extent of variations in Medicaid reimbursements for radiation oncology services across the United States.

METHODS AND MATERIALS

The Current Procedural Terminology codes billed for a course of whole breast radiation were identified for this study. Publicly available fee schedules were queried for all 50 states and Washington, DC, to determine the reimbursement for each service and the total reimbursement for the entire episode of care. The degree of interstate payment variation was quantified by computing the range, mean, standard deviation, and coefficient of variation. The cost of care for the entire episode of treatment was compared to the publicly available Kaiser Family Foundation (KFF) Medicaid-to-Medicare fee index to determine if the pattern of payment variation in medical services generally is predictive of the variation seen in radiation oncology specifically.

RESULTS

Data were available for 48 states and Washington, DC. The total episode reimbursement (excluding image guidance for respiratory tracking) varied from $2945 to $15,218 (mean, $7233; standard deviation, $2248 or 31%). The correlation coefficient of the KFF index to the calculated entire episode of care for each state was 0.55.

CONCLUSIONS

There is considerable variability in coverage and payments rates for radiation oncology services under Medicaid, and these variations track modestly with broader medical fees based on the KFF index. These variations may have implications for access to radiation oncology services that warrant further study.