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.
Concerns have arisen that the implementation of value-based, alternative payment models pegged to “bundled” episodes of care and/or patient outcomes may make it harder for a subset of patients to access the care they need. Specifically, some surgeons may be apprehensive to treat patients who have substantial medical comorbidities or socioeconomic situations that increase their risk of postsurgical complications and poor outcomes, because these alternative payment models often financially penalize physicians and hospitals for the cost of suboptimal results. The study by Shau et al. in the December 5, 2018 issue of The Journal provides data that sharpens the horns of this dilemma.
The authors used the National Readmissions Database to perform a propensity-score-matched comparison between >5,300 patients with Medicaid payer status who underwent a primary total hip arthroplasty (THA) and an equal number of patients with other types of insurance who also underwent primary THA. Shau et al. found that Medicaid-covered THA patients had significantly increased overall readmission rates (28.8% vs 21%, p <0.001, relative risk=1.37), mean length of stay (4.5 vs 3.3 days, p <0.0001), and mean total cost of care ($71,110 vs $65,309, p <0.0001), relative to the other group. These results strongly suggest that Medicaid payer status is an independent factor associated with increased resource utilization after total hip arthroplasty.
These findings can be viewed from a couple of different perspectives. First, from a preventive standpoint, surgeons and healthcare systems providing THA for Medicaid patients may need to spend more time preoperatively optimizing these patients (both physically and psychosocially) to decrease their postoperative resource burden and increase the likelihood of a good clinical outcome. Second, these results are further proof that any fair and effective alternative payment model needs to take into consideration factors such as Medicaid payer status and patient comorbidities. If they do not, such models will actually throw access barriers in front of patients in this demographic because providers may feel that caring for them increases the likelihood of being penalized financially.
Both perspectives are valid, so Medicaid payer status is a crucial factor to consider as alternative payment programs move forward. Nowadays, controlling costs is an important goal of any healthcare delivery system, but it must not lead to unintended discrimination in patient access to care. As we create further alternative payment models and refine existing ones, we must be careful not to prioritize cost cutting ahead of equitable patient access.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
When it comes to access to many things people look for, big cities offer numerous advantages over small towns. This seems to be true for consumer goods and services—and for access to health care, especially “high-tech” procedures. That is one issue that Suchman et al. touch on in their retrospective database study in the September 19, 2018 issue of The Journal.
The study evaluated almost 650,000 patients who underwent one of three meniscal procedures (meniscectomy, meniscal repair, or meniscal allograft transplantation) in New York State from 2003 to 2015. In determining which procedures were performed where, the authors found that meniscectomies and meniscal repairs—the vast majority of the procedures performed—were scattered throughout the state, but that meniscal transplants were performed almost exclusively at urban, academic hospitals. This finding is not surprising, considering the technical complexity of allograft transplantation. However, if a patient who would benefit from a meniscal allograft lived three hours from an urban, academic setting, they would either have to travel to the city to be evaluated, treated, and followed, or settle for a different procedure from a surgeon closer to home. Neither option would be optimal in terms of quality care.
At the same time, this article emphasizes that not every patient needs to go to a large hospital to receive excellent care. While a preponderance of recent data shows an association between hospital and surgeon procedure volume and patient outcomes, those data do not mean that smaller hospitals or “medium volume” surgeons should not perform certain procedures. In fact, medium volume surgeons performed the largest proportion of meniscal procedures evaluated in this study.
The fact is that the “delivery” of health care does not happen via FedEx or UPS. The burden falls on patients to transport themselves to the physician, not vice versa. And until that model drastically changes, access disparities based on geography will likely remain.
However, Suchman et al. also found that the majority of patients who underwent any meniscal procedure had private insurance—and that Medicaid patients had the lowest rates of meniscal surgery. Although disparities arising from socioeconomic/insurance status are also very difficult to address, they would seem to be more remediable than disparities related to geography.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
In the February 7, 2018 issue of The Journal, Lalezari et al. provide a detailed analysis of the variability in state-based Medicaid reimbursements to physicians for 10 common orthopaedic procedures, including hip and knee replacement and 5 spinal surgeries. The discrepancies in reimbursements between states, even bordering states in the same geographic region, are substantial and do not seem to follow any pattern. This phenomenon of reimbursement variability has been mentioned in podium presentations and some less comprehensive reports in the past. However, the authors of this study used a careful, methodological approach to accurately report these differences in a manner that is easy for readers to understand.
There is simply no way to rationalize this degree of variation in Medicaid reimbursement; the magnitude cannot be explained by differences in workload or practice costs because Lalezari et al. adjusted for cost of living and relative value units (RVUs). Nor does Medicaid-reimbursement variability seem to be related to Medicare reimbursement rates, as some states had Medicaid reimbursements that were higher than Medicare reimbursements for all procedures analyzed.
The orthopaedic community should not react directly to the reimbursement discrepancies presented in this article. Rather, orthopaedic surgeons, health system administrators, and patients alike should bring the variability of Medicaid reimbursements to the attention of state and federal policy makers.
Alas, I am not optimistic that this issue will gain a lot of traction given the long list of healthcare-related issues currently on the desks of state and federal lawmakers. Moreover, as the authors mention, these state-based reimbursement rates are likely related to many variables, and Lalezari et al. further observe that “health policy intended to improve access to specialty care should not solely focus on physician reimbursement.” However, consistent communication with elected officials to help explain the impact that these variable rates can have on patient care, accompanied by updated studies like this one every 2 to 4 years, would seem to be a rational response to these data.
Marc Swiontkowski, MD
The orthopaedic community has been aware of racial disparities in care delivery for two decades. The phenomenon has been most clearly elucidated in joint replacement surgery, but in the May 18, 2016 edition of The Journal, Dy et al. confirm that the issue is also at play in hip fracture care.
The authors analyzed the prospectively collected records of nearly 200,000 New York State residents who underwent hip fracture surgery between 1998 and 2010. After multivariable adjustment for factors such as patient characteristics and hospital/surgeon volume, Dy et al. found that black patients were at significantly greater risk for delayed surgery, a reoperation, readmission, and 1-year in-hospital mortality than white patients. The authors also found that patients covered by Medicaid (a marker for low socioeconomic status) were at increased risk for delayed hip-fracture surgery.
It is time for the orthopaedic community to develop an organized strategy to deal with this important social issue. Recruitment into the ranks of orthopaedists of underrepresented minorities, enhanced cultural-sensitivity training, and culturally relevant patient and family educational materials may begin to address the situation. Perhaps the AAOS, the AOA, and the J. Robert Gladden Orthopaedic Society could convene a meeting to develop such a strategic plan? I am confident we can begin to reduce racial and socioeconomic disparities if we put our collective minds to it.
Marc Swiontkowski, MD
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).