"The fact that there are differences in this setting shows us exactly that the groups were NOT well matched. Is it plausible that the logo on the check (Medicare, Medicaid, Blue Cross) is a medical factor? No way. While it is unquestionably true that poverty goes hand in hand with poorer health and perhaps inadequate social support (which are the real “risk factors” here) and poorer payor status, this is the very definition of a confounding variable…entirely analogous to cigarette smoking, yellow fingers, and lung cancer. The studies you’re citing here did the equivalent of controlling for older age, patient sex, perhaps hair color, but they missed the cigarette smoking and as a result claimed that yellow fingers are “independently” associated with lung cancer. In the studies you cited, there is (there has to be) a medical factor here (or, more likely, several such factors) that went undetected in the study that made that claim, since the payor itself does not cause complications. Poor health causes the patient to have that payor, and poor health results in the complications in question. We know that folks screen by payor, and that is wrong. But what I worry about here is that overstated claims like that will cause those who ACCEPT patients with Medicaid to note the increased risk (perhaps even counsel patients because of it “patients with Medicaid like you are at higher risk…”) without doing a proper search for the actual cause of the risk, which in some patients may well be modifiable."
These authors sought to identify the impact of being Medicaid-insured on in-hospital mortality, readmission, complications, and length of stay (LOS) in 89,460 patients who underwent inpatient shoulder arthroplasty.
They found that Medicaid-insured patients had greater odds than patients with private insurance, other insurance, and Medicare of inpatient mortality (OR: 4.61, 95% CI 2.18 to 9.73, p<0.001) and 30-day and 90-day readmissions (OR: 1.94, 95% CI 1.57 to 2.38, p<0.001; OR: 1.65, 95% CI 1.42 to 2.38, p<0.001, respectively). Compared with private insurance, other insurance, and Medicare patients, Medicaid patients had increased likelihood of developing infectious complications and were expected to have longer lengths of stay.
Medicaid Payer Status Is Associated with Increased 90-Day Morbidity and Resource Utilization Following Primary Total Hip Arthroplasty A Propensity-Score-Matched Analysis
These authors used the Nationwide Readmissions Database to identify patients who underwent total hip arthroplasty in 2013 as well as corresponding “Medicaid” or “non-Medicaid” payer status. A total of 5,311 Medicaid and 144,814 non-Medicaid patients managed with total hip arthroplasty were identified from the 2013 NRD.
Our response: The point of the post was not to suggest causation of poor outcomes by payer status. Rather it was to observe that (like those patients on Worker's Compensation) patients covered by Medicaid tend to have poorer outcomes, perhaps attributable to the associated risk factors that tend to come along with Medicaid status (malnutrition, poor health maintenance, less robust social support). While yellow fingers don't cause lung cancer, folks with yellow fingers are more likely to have lung cancer. All patients deserve a thorough analysis of risk factors and possible means for addressing them before considering elective surgery.
Such reports suggest that medical centers may have financial disincentives to offer joint arthroplasty to patients covered by Medicaid insurance: the reimbursement is less yet the chances are that the cost of providing the care will be greater. Furthermore, the increased readmission rates for Medicaid patients puts the medical centers at increased risk for financial penalties (penalties that were put in place to incentivize quality of care as reflected in low 90 readmission rates). These disincentives pertain to the surgeon as well: there is substantially lower per case reimbursement on one hand and increased physician work to manage the medical and social characteristics that are more prevalent among patients covered by Medicaid.
There are three implications: The first 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 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 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. In the meanwhile, it may be expected that health care systems will experience a bias to limit access of patients covered by Medicaid to joint arthroplasty.
Our hope is that such systems will consider each patient as an individual when considering the advisability and safety of joint arthroplasty - assessing medical and social risk factors independent of payer status.
Such reports suggest that medical centers may have financial disincentives to offer joint arthroplasty to patients covered by Medicaid insurance: the reimbursement is less yet the chances are that the cost of providing the care will be greater. Furthermore, the increased readmission rates for Medicaid patients puts the medical centers at increased risk for financial penalties (penalties that were put in place to incentivize quality of care as reflected in low 90 readmission rates). These disincentives pertain to the surgeon as well: there is substantially lower per case reimbursement on one hand and increased physician work to manage the medical and social characteristics that are more prevalent among patients covered by Medicaid.
There are three implications: The first 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 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 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. In the meanwhile, it may be expected that health care systems will experience a bias to limit access of patients covered by Medicaid to joint arthroplasty.
Our hope is that such systems will consider each patient as an individual when considering the advisability and safety of joint arthroplasty - assessing medical and social risk factors independent of payer status.
These authors sought to identify the impact of being Medicaid-insured on in-hospital mortality, readmission, complications, and length of stay (LOS) in 89,460 patients who underwent inpatient shoulder arthroplasty.
They found that Medicaid-insured patients had greater odds than patients with private insurance, other insurance, and Medicare of inpatient mortality (OR: 4.61, 95% CI 2.18 to 9.73, p<0.001) and 30-day and 90-day readmissions (OR: 1.94, 95% CI 1.57 to 2.38, p<0.001; OR: 1.65, 95% CI 1.42 to 2.38, p<0.001, respectively). Compared with private insurance, other insurance, and Medicare patients, Medicaid patients had increased likelihood of developing infectious complications and were expected to have longer lengths of stay.
Comment: These findings are consistent with those reported for other joint arthroplasties as shown below.
Medicaid Payer Status Is Associated with Increased 90-Day Morbidity and Resource Utilization Following Primary Total Hip Arthroplasty A Propensity-Score-Matched Analysis
These authors used the Nationwide Readmissions Database to identify patients who underwent total hip arthroplasty in 2013 as well as corresponding “Medicaid” or “non-Medicaid” payer status. A total of 5,311 Medicaid and 144,814 non-Medicaid patients managed with total hip arthroplasty were identified from the 2013 NRD.
Medicaid versus non-Medicaid payer status yielded significant differences in overall readmission rates of 28.8% versus 21.0% and 90-day hip-specific readmission rates of 2.5% versus 1.8%. Mean length of stay was greater in the Medicaid group than in the non-Medicaid group at 4.5 versus 3.3 days (p < 0.0001), as was the mean total cost at $71,110 versus $65,309 (p < 0.0001).
These authors concluded that Medicaid payer status is independently associated with increased resource utilization, including readmission rates, length of stay, and total cost following primary total hip arthroplasty.
These authors concluded that Medicaid payer status is independently associated with increased resource utilization, including readmission rates, length of stay, and total cost following primary total hip arthroplasty.
Medicaid Payer Status Is Associated with In-Hospital Morbidity and Resource Utilization Following Primary Total Joint Arthroplasty
The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database was used to identify patients who had undergone primary hip or knee arthroplasty from 2002 through 2011. Complications, costs, and length of hospital stay for patients with Medicaid were compared with those for non-Medicaid patients. Each Medicaid patient was matched to a non-Medicaid patient according to age, sex, race, type of total joint arthroplasty, procedure year, hospital characteristics, smoking status, and all twenty-nine comorbidities defined in the NIS-modified Elixhauser comorbidity measure.
It was determined that 191,911 patients who underwent total joint arthroplasty had Medicaid payer status (2.8% of the entire total joint arthroplasty population), and 107,335 (56%) of these Medicaid patients were matched one to one to a non-Medicaid patient for all variables for the adjusted analysis. After matching, Medicaid patients were found to have a higher prevalence of postoperative in-hospital infection (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.3 to 2.1), wound dehiscence (OR, 2.2; 95% CI, 1.4 to 3.4), and hematoma or seroma (OR, 1.3; 95% CI, 1.2 to 1.4) but a lower risk of cardiac complications (OR, 0.7; CI, 0.6 to 0.9). 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 (p < 0.01).
Compared with non-Medicaid patients, Medicaid patients have a significantly higher risk for certain postoperative in-hospital complications and consume more resources following total joint arthroplasty even when the two groups have been matched for patient-related factors and comorbid conditions commonly associated with low socioeconomic status.
How you can support progress in shoulder surgery
You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
The Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database was used to identify patients who had undergone primary hip or knee arthroplasty from 2002 through 2011. Complications, costs, and length of hospital stay for patients with Medicaid were compared with those for non-Medicaid patients. Each Medicaid patient was matched to a non-Medicaid patient according to age, sex, race, type of total joint arthroplasty, procedure year, hospital characteristics, smoking status, and all twenty-nine comorbidities defined in the NIS-modified Elixhauser comorbidity measure.
It was determined that 191,911 patients who underwent total joint arthroplasty had Medicaid payer status (2.8% of the entire total joint arthroplasty population), and 107,335 (56%) of these Medicaid patients were matched one to one to a non-Medicaid patient for all variables for the adjusted analysis. After matching, Medicaid patients were found to have a higher prevalence of postoperative in-hospital infection (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.3 to 2.1), wound dehiscence (OR, 2.2; 95% CI, 1.4 to 3.4), and hematoma or seroma (OR, 1.3; 95% CI, 1.2 to 1.4) but a lower risk of cardiac complications (OR, 0.7; CI, 0.6 to 0.9). 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 (p < 0.01).
Compared with non-Medicaid patients, Medicaid patients have a significantly higher risk for certain postoperative in-hospital complications and consume more resources following total joint arthroplasty even when the two groups have been matched for patient-related factors and comorbid conditions commonly associated with low socioeconomic status.
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We have a new set of shoulder youtubes about the shoulder, check them out at this link.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
Use the "Search" box to the right to find other topics of interest to you.
We have a new set of shoulder youtubes about the shoulder, check them out at this link.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
Use the "Search" box to the right to find other topics of interest to you.
How you can support progress in shoulder surgery
You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
