It is no secret that patients with Medicaid (both adults and children) have difficulty making appointments for both elective and trauma-related orthopaedic care. They also travel further for care compared to privately insured patients. Conversely, Medicaid reimbursement rates for orthopaedic surgeries are substantially lower than those from Medicare and commercial insurers. Patients with Medicaid also tend to be more socially complex and have higher no-show rates for clinic appointments and surgery.
Consequently, as recently as 2011, only 40% of US orthopaedic surgeons were accepting new patients with Medicaid. This “bottleneck” effect may only get worse as reimbursement plans shift towards “pay-for-performance” and value-based payment, prompting surgeons and hospitals to become increasingly concerned about optimizing patient selection.
In a 2012 JBJS study, my colleague Ryan Calfee and co-authors demonstrated that patients with Medicaid were traveling to our institution (Washington University/Barnes Jewish Hospital in St. Louis) not only for complex cases, but also for simple and moderate-complexity hand surgery issues. These patients were bypassing hand surgeons closer to home partly because the local hand surgeons did not accept Medicaid.
With those findings in mind, we decided to more closely examine Medicaid care delivery in our region. Ideally, the insurance mix of the area surrounding a hospital should match the payer mix of the hospital. Most of us who currently work or have trained in large academic centers know that this is often not the case. Anecdotally, there are hospitals in every region that “cherry pick” the best-insured patients and transfer out the financially less desirable cases to a nearby teaching hospital. In our paper, published in the August 21, 2019 issue of JBJS, the concept of “Medicaid share ratio” is intended to reflect whether the hospital payer mix matches the insurance mix of the community. A value of 1 indicates a perfect balance.
We examined the Medicaid share ratios of the 22 hospitals in our region to see if the hospitals were “pulling their weight.” The Medicaid share ratios for elective orthopaedic care such as total joint arthroplasty ranged from 0.05 to 4.73, demonstrating massive imbalances on both ends of the spectrum. We also found very high variability in the delivery of elective orthopaedic care (coefficient of variation = 93, where values >60 are considered “very high”) and moderate variability in trauma care (coefficient of variation = 34).
Our findings were sobering, but not unexpected. The fact that some hospitals bear the brunt of care for the underinsured and uninsured is not new, and the federal government currently includes Disproportionate Share Hospital (DSH) payments to offset these losses. However, DSH payments are scheduled to decrease substantially in coming years as part of the original intent of the Affordable Care Act. If the continuing (and possibly worsening) burden of undercompensated care becomes financially suffocating to teaching and safety-net hospitals, they may seek to curb those losses in ways that could further limit access to underinsured patients and/or drive costs up for patients with other types of insurance.
At the surgeon level, we should address surgeon hesitation to accept Medicaid patients through engagement with specialty societies and policy reform. Our research team is currently working to learn more about what surgeons and patients think are potential solutions for these disparities in our region. As surgeons and researchers, we must work toward a more complete understanding of what drives these disparities in orthopaedic care. Otherwise, it will be impossible to figure out how to fix them.
Christopher Dy, MD, MPH is a hand and peripheral nerve surgeon, an assistant professor at Washington University Orthopaedics, and a member of the JBJS Social Media Advisory Board.
Healthcare spending in 2013 grew at the slowest rate since 1960, according to a recent article in Modern Healthcare. According to federal data, the nation spent $2.9 trillion on healthcare last year, which was an increase of 3.6% from the prior year—and the weakest spending growth since 1960. Reasons cited for the slowdown include aftermath from the Great Recession, changes in health benefits, and federal healthcare spending rollbacks triggered by the Affordable Care Act. For example, Medicare spending increased in 2013 by 3.4%, down from 4% growth in 2012. Spending on technology and construction to upgrade or expand healthcare services dropped during the recession and still has not rebounded. Most analysts don’t expect this growth slowdown to carry into 2014, although quarterly national estimates for 2014 suggest spending growth below 4%. While some of the slowdown in healthcare spending growth may be attributed to doctors and other healthcare professionals running more efficient practices, health spending in 2013 still consumed 17.4% of the US gross domestic product.
2013 has been a year filled with news impacting the world of orthopaedics. Terry Canale, MD, Editor-in-Chief of AAOS Now, has compiled a top ten list:
- The Affordable Care Act
- No Fiscal Cliff or Sustainable Growth Rate (SGR) Fix
- The Value of Orthopaedics
- Operation Walk USA
- Concussion and Chronic Traumatic Encephalopathy (CTE)
- Orthopaedic medications
- Yale Open Data Access (YODA) results
- Boston Marathon bombings
- AAOS initiatives
Almost everyone will be affected by the Affordable Care Act in one way or another. For many, it will mean an abundance of new patients because as of Jan. 1, 2014, twenty-two states and the District of Columbia expanded access to Medicaid to children and adults with individual or family incomes less than 133% of the federal poverty levels. Additionally, Jan. 1st means the beginning of Stage 2 requirements of the CMS meaningful use program for EHRs. February 28 is also the reporting deadline for physicians to submit performance data that qualifies for a bonus through the Physician Quality Reporting System. To see more important dates and deadlines for physicians and healthcare providers, see Medscape’s slideshow (login required).
Here are a few excerpts from the JBJS conversation with Dr. Jo Hannafin, President of AOSSM (American Orthopaedic Society for Sports Medicine).
JBJS: You were recently elected the first woman president of AOSSM – what significance do you see in that fact?
Dr. Jo Hannafin: My election to the AOSSM presidency reflects the breadth of membership in the AOSSM and the slowly changing face of orthopaedic surgery. Our goal as educators and surgeons is to bring the best and brightest medical students into our field and this includes men, women and individuals with diverse racial and ethnic backgrounds.
JBJS: What are your key goals for your presidency?
Dr. Jo Hannafin: My goals as president are to increase engagement of the membership in the AOSSM via volunteerism (committee involvement), attendance at specialty day and the annual meeting, and by providing continued opportunities for community education by our members via the STOP Sports Injury program started by Dr. James Andrews.
JBJS: How do you think JBJS can best address the needs of the members of AOSSM and other sub-specialty organizations?
Dr. Jo Hannafin: JBJS can address the needs of orthopaedic surgeons by partnering in webinar programs and by continuing to publish high quality manuscripts in subspecialty areas.
JBJS: What trends in orthopaedics/sports medicine are you most intrigued by?
Dr. Jo Hannafin: The identification of biomarkers with early association with trauma or sports injury has the potential to modify the development of post-traumatic arthrosis. This idea is particularly compelling in sports injuries such as the acute ACL. The frequency of this injury continues to increase, and we are seeing younger athletes sustaining this injury. The continued attention to the development and validation of injury prevention programs provides opportunity for risk modification.
The use of biologic therapy in sports medicine, such as stem cell transplantation and PRP, may have the potential to treat sports injuries, but the clinical use of these treatments needs to be carefully studied and validated.
JBJS: What at are your expectations of changes to come as a result of the Affordable Care Act (ACA)?
Dr. Jo Hannafin: The ACA is an extraordinarily complex document and quite honestly, with a few exceptions, I don’t think we know what it will bring. The ACA will provide health insurance to a large number of previously uninsured or uninsurable people (those with pre-existing conditions). The volume of patients seeking care will increase, and that has the potential to stress the existing system. Reimbursement for orthopaedic care will likely be modified and requires the careful attention of our members, hospital systems, specialty organizations, and the AAOS.
JBJS: Looking ahead to the next 20 years or so, what do you think might be three significant advances or changes in orthopaedics?
Dr. Jo Hannafin: I anticipate that scientists will be able to identify biomarkers associated with acute injury and physicians/surgeons will have the capacity to modify the response to catabolic agents, thus preventing the development of post-traumatic arthrosis. The field of biomechanical engineering will provide surgeons with improved scaffolds which when combined with biologic therapies will permit restoration of bone, cartilage, and ligaments. The field of total joint arthroplasty will benefit from continued interaction with scientists to optimize interface mechanics and prolong the lifetime of arthroplasty implants.
JBJS: You recently participated in a webinar co-sponsored by JBJS and JOSPT. Do you see benefits from greater teamwork among different types of health-care providers? If so, what are the most important benefits? What barriers remain to greater collaboration?
Dr. Jo Hannafin: Teamwork and interaction between providers of musculoskeletal care will continue to grow and will be necessary as the volume of patients treated increases. We need to define the scientific benefits of conservative and surgical treatments for musculoskeletal conditions, and this will require interactions between scientists, physicians, surgeons, and physical therapists. The questions posed during the adhesive capsulitis webinar reflected input from both surgeons and physical therapists and helped each group to understand the issues associated with treatment. The ultimate benefit of this interaction is improved patient care, which is important to all of us. The biggest barrier is time!
JBJS: You have recently overcome some serious health issues. It’s great to hear that you are doing well. Has this experience changed the way you approach your patients?
Dr. Jo Hannafin: The last two years of my life have been marked by highs and lows. My election to the presidency of the AOSSM, and the associated opportunities, has been personally and professionally fulfilling. In April 2012 I was diagnosed with early multiple myeloma, which was treated at Dana Farber Cancer Institute with chemotherapy followed by an autologous stem cell transplant. The experience was the most difficult challenge that I have faced but I received incredible support from family, friends, patients and AOSSM colleagues from across the country. I am happy to report that my health is excellent and I have been back to a normal schedule for almost one year. The experience reinforced the need for careful and thoughtful communication with our patients.
JBJS: What is your favorite thing about your profession?
Dr. Jo Hannafin: As a sports medicine specialist, I love taking care of athletes and active people of all ages. While many sports related injuries do not require surgery, it is especially gratifying as a surgeon to restore function via repair and reconstruction of injured structures, permitting return to sports or fitness activities.
JBJS: Thank you, Dr. Hannafin for sharing this time with us. We look forward to speaking with you again in the near future.