Medicaid beneficiaries undergoing complex surgery at quality care centers: insights into the Affordable Care Act

Abstract

BACKGROUND Medicaid beneficiaries do not have equal access to high-volume centers for complex surgical procedures. We hypothesize there is a large Medicaid Gap between those receiving emergency general vs complex surgery at the same hospital. METHODS Using the Nationwide Inpatient Sample, 1998 to 2010, we identified high-volume pancreatectomy hospitals. We then compared the percentage of Medicaid patients receiving appendectomies vs pancreatectomies at these hospitals. Hospital characteristics associated with increased Medicaid Gap were evaluated using generalized estimating equation models. RESULTS A total of 602 hospital-years of data from 289 high-volume pancreatectomy hospitals were included. Median percentages of Medicaid appendectomies and pancreatectomies were 12.1% (interquartile range: 5.8% to 19.8%) and 6.7% (interquartile range: 0% to 15.4%), respectively. Hospitals that performed greater than or equal to 40 pancreatic resections per year had higher odds of having significant Medicaid Gap (odds ratio 2.3, 95% confidence interval 1.1 to 5.0). CONCLUSIONS Gaps exist between the percentages of Medicaid patients receiving emergency general surgery vs more complex surgical care at the same hospital and may be exaggerated in hospitals with very high volume of complex elective surgeries.

Acceptance of Simulated Adult Patients With Medicaid Insurance Seeking Care in a Cancer Hospital for a New Cancer Diagnosis

“…Comprehensive community cancer programs, or programs that assess 500 or more newly diagnosed cancer cases annually, were less likely to accept Medicaid . This finding is concordant with trends in literature, which show that patients with Medicaid may face significant financial and logistic barriers to care and are less likely to receive surgical care at high-volume centers . Given that patients with Medicaid typically have complex health needs, worse outcomes, and lower reimbursement rates, performance and revenue-conscious facilities with access to more favorably insured patients may continue to exercise greater selectivity and exclude patients with Medicaid .…”

“…15 This finding is concordant with trends in literature, which show that patients with Medicaid may face significant financial and logistic barriers to care and are less likely to receive surgical care at high-volume centers. 31 , 32 , 33 , 34 , 35 , 36 Given that patients with Medicaid typically have complex health needs, worse outcomes, and lower reimbursement rates, performance and revenue-conscious facilities with access to more favorably insured patients may continue to exercise greater selectivity and exclude patients with Medicaid. 24 , 33 , 37 , 38 Reduced access to high-volume centers may, in turn, generate self-fulfilling cycles of adverse outcomes for patients with Medicaid.…”

“…[31][32][33][34][35][36] Given that patients with Medicaid typically have complex health needs, worse outcomes, and lower reimbursement rates, performance and revenue-conscious facilities with access to more favorably insured patients may continue to exercise greater selectivity and exclude patients with Medicaid. 24,33,37,38 Reduced access to high-volume centers may, in turn, generate self-fulfilling cycles of adverse outcomes for patients with Medicaid. [39][40][41][42][43][44] Greater complexity may also contribute to the below-average effectiveness of care of high-access facilities.…”

Medicaid Expansion and Disparity Reduction in Surgical Cancer Care at High-Quality Hospitals

“…Using surgical cancer care as a proxy for tertiary specialty care, it has been widely documented that receiving surgery at high-quality hospitals such as high volume or low mortality is closely associated with insurance status and race (6). Specifically, the uninsured and Medicaid beneficiaries traditionally receive their surgical cancer care at low-quality hospitals and experience worse surgical outcomes (6–8). Furthermore, evidence also support that vulnerable population (e.g.…”

Toward Quantification of Geographic Disparity in Access to Surgical Care—Betwixt and Between

“…There is evidence that expansion brings improved emergency surgical care and access for elective cancer surgery at high-quality centers, but also exacerbates racial/ethnic disparities . Another study noted a Medicaid gap (a difference between the ratios of Medicaid patients undergoing appendectomy and pancreatectomy at the same hospitals), finding that hospitals with the highest volume and improved quality had higher gaps, likely in part because of differential rates of travel for complex care. In the current study, 39.1% of the population of the lowest-ranked counties was African American and 60.1% resided in a rural locale, compared with 17.4% and 32.5%, respectively, of those in the highest-ranked counties.…”