Poorer shoulder arthroplasty outcomes in patients with Medicaid payer status



Medicaid payer status is associated with increased mortality and morbidity after inpatient shoulder arthroplasty: a multistate analysis, 2007–2014

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.



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.

Additional comment: These reports indicate that medical centers have financial disincentives to offer joint arthroplasty to patients covered by Medicaid insurance: the reimbursement is less yet the cost of providing the care is 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. 

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Poorer shoulder arthroplasty outcomes in patients with Medicaid payer status