Thursday, July 27, 2017

Health care debate: turmoil, the 'skinny bill', health insurance as a risk factor

Insurance status affects postoperative morbidity and complication rate after shoulder arthroplasty

This is not a political post, although its topic has profound political and economic implications. The authors take a very small slice of the health care pie to illustrate the relation between the health care coverage that a patient can afford and the surgical risk for that patient undergoing a shoulder arthroplasty.

These authors evaluated the effect of patient insurance status on perioperative outcomes after shoulder replacement surgery using data on 103,290 having surgery between 2004 and 2011 identified in the Nationwide Inpatient Sample. The distribution of insurance coverage was 68,578 Medicare, 27,159 private insurance, 3544 Medicaid/uninsured, 4009 other. The overall complication rate was 17.2% (n = 17,810)and the mortality rate was 0.20% (n = 208). Medicare and Medicaid/uninsured patients had a significantly higher rate of medical, surgical, and overall complications compared with private insurance using the controlled match data.
Multivariate regression analysis found that having private  insurance payer status is associated with a lower risk of perioperative medical and surgical complications compared with an age- and sex-matched Medicare and Medicaid/uninsured payer status.

Comment: Insurance status can be a marker for factors affecting surgical risk, such as nutrition status, health maintenance, social support, exercise status, bone quality, compliance, mental health, and traveling distance to a quality medical facility. Insurance status can also affect risk by influencing the accessibility to pre-surgical medical care, experienced surgeons and the availability of postoperative physical therapy and other forms of support. 

This important paragraph is included in the authors' discussion: "The data also showed that the comorbidity index and age are independent risk factors for medical complications after shoulder arthroplasty, with a higher preoperative comorbidity index seen in the government-sponsored insurance groups. In addition, the increased rate of complications seen in the government-sponsored insurance groups (Medicaid and Medicare) resulted in higher hospital charges after shoulder replacement compared with the private insurance group. Furthermore, privately insured patients were more likely to go to a higher-volume hospital for their elective shoulder replacements than patients with government-sponsored insurance. This finding may reflect that ability of patients with private insurance to select their own physicians. In contrast, Medicaid patients may have difficulty finding orthopaedic surgeons that will accept their insurance type and uninsured patients may have an inability to see an orthopaedic surgeon altogether due to lack of insurance coverage and consequently, exorbitant out of pocket cost."

Ironically, increased expenditures are necessary to manage the greater risks associated with patients with less remunerative health care coverage. It seems unlikely that the interaction between surgical risk and insurance coverage identified in this study will be eliminated or even reduced by any of the health care plans under discussion.

Here is a study with a similar conclusion:

Medicaid payer status is linked to increased rates of complications after treatment of proximal humerus fractures

These authors note that low socioeconomic status and Medicaid insurance as a primary payer have been associated with major disparities in resource utilization and risk-adjusted outcomes for patients undergoing totaljoint arthroplasty.

Using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database they identified patients who were treated for proximal humeral fractures (PHFs) from 2002 to 2012.

In an effort to minimize confounding variables, each Medicaid patient was matched to a privately insured patient on the basis of gender, race, year of procedure, and age (but notably not to fracture type or type of treatment):

Of the 678,831 patients treated with PHF, 4.9% (33,263) had Medicaid as the primary payer during the 10-year period. Medicaid patients were found to have a significantly higher risk (P < .05) of postoperative in-hospital complications, including postoperative infection (odds ratio [OR], 2.00 [1.37-2.93]), wound complications (OR, 1.69 [1.04-2.75]), and acute respiratory distress syndrome (OR, 1.34 [1.15-1.59]).

They concluded that Medicaid patients have a significantly higher risk for certain postoperative hospital complications and consume more resources after treatment for PHFs.

It is apparent that our health care system is on the cusp of change with the new administration. Under most any system, however, the observation that Medicaid insurance (which provides relatively low reimbursement) can be a risk factor for an increased rate of complications and for increased per-case expense will continue to create an ethical, social and economic challenge for the providers. This is especially the case if there are penalties for the increased readmission rates that are likely to be necessary to manage the increased rate of complications. Our hope is that broad-based discussion will lead to a well-informed approach so that our patients can get the care they need.

The reader may also be interested in these posts:

Information about shoulder exercises can be found at this link.

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