Wednesday, November 12, 2014

Patients on Medicaid are at greater risk for complications after arthroplasty

Medicaid Payer Status Is Associated with In-Hospital Morbidity and Resource Utilization Following Primary Total Joint Arthroplasty

The Affordable Care Act has extended health care coverage through an expansion of the Medicaid program. In order to compare outcomes of Medicaid and non-Medicaid insurees, these authors used the Nationwide Inpatient Sample database to identify patients who had undergone primary hip or knee arthroplasty from 2002 through 2011.

They found 191,911 patients who underwent total joint arthroplasty with Medicaid payer status (2.8% of the entire total joint arthroplasty population). 107,335 (56%) of these Medicaid patients were matched one to one to a non-Medicaid patient according to age, sex, race, type of total joint arthroplasty, procedure year, hospital characteristics, smoking status, and twenty-nine comorbidities.

Medicaid patients had a higher prevalence of postoperative in-hospital infection, wound dehiscence, and hematoma or seroma, but a lower risk of cardiac complications. The length of the hospital stay was longer, total cost was higher, and discharge to an inpatient facility was more frequent for patients with Medicaid status.

Comment: This study indicates that even with careful matching, Medicaid insurance status is a risk factor for complications and increase cost of care. The first implication is that such individuals deserve extraordinary preoperative medical and social evaluation as well as in depth counseling to minimize the risk and prepare for the possibilities of complications. The second implication is that medical centers and providers caring for these patients should anticipate a higher level of work and less reimbursement in caring for these individuals. The third implication is that providers and medical centers caring for a individuals on Medicaid may carry the risk that scores on quality of performance scales may be lower that with individuals on other types of health coverage. If these disincentives for providing care to Medicaid patients are to be removed, government systems need to revise the payment and readmission penalty systems currently in place. These observations are especially relevant to the bundled payment initiative. For more on bundled payments, see also here.

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