As of June 2022, 82,344,149 individuals were enrolled in Medicaid (see this link); this amounts to almost one in five Americans (see this link). As pointed out by Andrea Elliott in her 2022 Pulitzer Prize winning non-fiction book, Invisible Child: Poverty, Survival & Hope in an American City, 38% of those living in New York City receive Medicaid insurance. This book is a "must read" for those of social conscience.

As physicians and surgeons, our obligation is to render care to all individuals, without concern regarding their payor status and to pay particular attention to those at risk for societal marginalization and bias in the rendering of treatment.

A recent article, Medicaid Payer Status is Associated with Increased 90-Day Morbidity and Resource Utilization Following Primary Shoulder Arthroplasty: A Propensity Score Matched Analysis, concludes that "Medicaid payer status is independently associated with increased 90-day readmission and reoperation rates, length of stay, and direct cost following primary shoulder arthroplasty. Providers may have a disincentive to treat patient populations who require increased resource utilization following surgery. Risk adjustment models accounting for Medicaid payer status will be necessary to ensure good access to care for this patient population by avoiding penalties for physicians and hospital systems."

The implication is that access to arthroplasty for the large number and large percentage of patients receiving Medicaid insurance will remain limited until "adjustments" are made for the incremental associated costs.

This study divided patients receiving primary shoulder arthroplasty in the National Readmission Database (NRD) into two groups: “Medicaid” or “non-Medicaid”. The potential biasing effect of Medicaid status on selection for arthroplasty was suggested by the fact that only 2.8% patients receiving arthroplasty were covered by Medicaid insurance (4,667 Medicaid and 161,147 non-Medicaid), a percentage far lower than the prevalence of Medicaid insurance in the population at large.

While the study used propensity score matching to control for some of the baseline differences in cohorts that could act as confounders, "including age, comorbidities, discharge status, proximal humerus fracture status, and arthroplasty type", it did not consider the economic, educational, social, and environmental disparities that have been shown to have major influence on shoulder arthroplasty outcomes as discussed in The effect of economic and educational disparities on outcomes of shoulder arthroplasty - what can be done to address it?

Even with the limited propensity matching used in this study, the "significant" associations with Medicaid payer status were surprisingly small in magnitude:

90-day all-cause readmission rates of 11.6% vs. 9.3%

90-day shoulder-related readmission rates of 3.3% vs. 2.3%

90-day reoperation rates 24 of 2.0% vs.1.3%.

risk of extended LOS >2 days (28.4% vs. 25.7%

increased direct cost (median of $17,612 vs. $16,775)

Finally, this study did not present the benefit of shoulder arthroplasty to those patients covered by Medicaid insurance - we can expect that this procedure resulted in increased comfort and function for the great majority of them. It would be indeed unfortunate if such individuals did not have access to the benefits of arthroplasty.

Comment: As surgeons, our task is to consider each patient as an individual and to optimize their management in a way that will lead to the best and safest outcome for that person. Medicaid insurance status itself cannot be considered a risk factor for adverse outcomes, but rather as a call for us to dig deeper and identify risk factors that may be modifiable or manageable.

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