Association of Insurance Type With Inpatient Surgical 30-Day Readmissions, Emergency Department Visits/Observation Stays, and Costs

Abstract

Objective: To assess the association of Private, Medicare (MC), and Medicaid/Uninsured (MU) insurance type with 30-day emergency department visits/observation stays (EDOS), readmissions, and costs in a safety-net hospital (SNH) serving diverse socioeconomic status patients. Background: MC’s hospital readmission reduction program (HRRP) disproportionately penalizes SNHs. Methods: This retrospective cohort study used inpatient National Surgical Quality Improvement Program (2013–2019) data merged with cost data. Frailty, expanded operative stress score, case status, and insurance type were used to predict odds of EDOS and readmissions, as well as index hospitalization costs. Results: The cohort had 1477 Private; 1164 MC; and 3488 MU cases with a patient mean age 52.1 years [SD = 14.7] and 46.8% of the cases were performed on male patients. MU [adjusted odds ratio (aOR) = 2.69, 95% confidence interval (CI) = 2.38–3.05, P < 0.001] and MC (aOR = 1.32, 95% CI = 1.11–1.56, P = 0.001) had increased odds of urgent/emergent surgeries and complications versus Private patients. Despite having similar frailty distributions, MU compared to Private patients had higher odds of EDOS (aOR = 1.71, 95% CI = 1.39–2.11, P < 0.001), and readmissions (aOR = 1.35, 95% CI = 1.11–1.65, P = 0.004), after adjusting for frailty, OSS, and case status, whereas MC patients had similar odds of EDOS and readmissions versus Private. Hospitalization variable cost %change was increased for MC (12.5%) and MU (5.9%), but MU was similar to Private after adjusting for urgent/emergent cases. Conclusions: Increased rates and odds of urgent/emergent cases in MU patients drive increased odds of complications and index hospitalization costs versus Private. SNHs care for higher cost populations while receiving lower reimbursements and are further penalized by the unintended consequences of HRRP. Increasing access to care, especially for MU patients, could reduce urgent/emergent surgeries resulting in fewer complications, EDOS/readmissions, and costs.

Social Determinants of Health and Surgical Desirability of Outcome Ranking in Older Veterans

“…However, alleviating these disparities requires metrics to target reducing this greater comorbidity burden. Explanation 2 requires analyzing longer-term outcomes than typically captured by surgical studies . While the discrepancy between racial disparities in 30-day mortality vs DOOR requires further investigation, we nonetheless suggest focusing resources on preventive care to reduce presentation acuity among veterans identified as Black, as acuity seems to be a key driver in outcome disparities for Black veterans.…”

“…These disparities, studied across various health care domains, are critically important in surgical care, as even minor surgery can sometimes include serious risk . Moreover, SDOH are incredibly varied: Black patients can have 1.2 to 1.5 times higher surgical mortality vs White patients, patients living in areas labeled by the US Government Home Owners Loan Corporation as historically “hazardous” neighborhoods can have 1.19 times higher mortality than those living in areas labeled the “best” neighborhoods, and insurance type (means-tested insurance like Medicaid or no insurance) drives greater urgent and emergent surgical procedures, complications, readmissions, and lengths of hospital stay . All this prior work suggests that multiple SDOH need to be evaluated simultaneously, not in isolation, because SDOH can have independent effects or be heavily confounded with each other …”

No healthcare coverage, big problem: lack of insurance for older population associated with worse emergency general surgery outcomes

“…These findings are consistent with another study from the USA that showed Medicare self-paid patients had 24% higher odds of developing complications. 42 In this regard, working toward attaining universal health coverage is imperative for reducing financial risk and ensuring the provision of essential healthcare services for all, including vulnerable populations. 39 Our results showed that the CCI score was associated with mortality in EGS patients.…”