Abstract
Background
Few studies have evaluated whether outcome disparities between Medicaid and private insurance beneficiaries are driven by the hospital at which the patient receives care. The purpose of this study was to evaluate the effect of the hospital on surgical outcomes in Medicaid beneficiaries.
Methods
We identified 139,566 non-elderly Medicaid and private insurance beneficiaries undergoing general, vascular, or gynecological surgery between 2012 and 2017 using a statewide clinical registry in Michigan. We calculated risk-adjusted rates of complications, readmissions, emergency department (ED) visits, and post-acute care utilization using multivariable logistic regression, accounting for patient and procedural factors. We then evaluated whether, and to what extent, the hospital influenced outcome disparities between Medicaid and privately insured beneficiaries.
Results
Risk-adjusted rates for all outcomes were higher in Medicaid beneficiaries. For example, overall post-discharge ED visit rates were 14.3% (95% CI 13.7% to 14.9%) for Medicaid compared to 7.5% (95% CI 7.1% to 7.9%, P < 0.01) for private insurance beneficiaries. Hospital factors explained 3.9% of the observed difference in complication rates between Medicaid and private insurance beneficiaries. In contrast, hospital factors explained a greater proportion of the disparities in readmissions (30.6%), ED visits (33.0%), and post-acute care utilization (16.1%). Results were similar when restricting the study population to elective cases only.
Conclusions
Hospital factors account for a significant proportion of the disparities in post-discharge resource utilization between Medicaid and private insurance beneficiaries. Policies aiming to improve the quality and equity of surgical care for Medicaid beneficiaries should focus on the post-discharge period.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Armenia SJ, Pentakota SR, Merchant AM (2017) Socioeconomic factors and mortality in emergency general surgery: trends over a 20-year period. J Surg Res 212:178–186
Bradley CJ, Dahman B, Bear HD (2012) Insurance and inpatient care: differences in length of stay and costs between surgically treated cancer patients. Cancer 118:5084–5091
LaPar DJ, Bhamidipati CM, Mery CM et al (2010) Primary payer status affects mortality for major surgical operations. Ann Surg 252:544–550 (discussion 550–541)
Sabesan VJ, Petersen-Fitts G, Lombardo D et al (2017) Medicaid payer status is linked to increased rates of complications after treatment of proximal humerus fractures. J Shoulder Elbow Surg 26:948–953
Shahan CP, Bell T, Paulus E et al (2015) Emergency general surgery outcomes at safety net hospitals. J Surg Res 196:113–117
Waits SA, Reames BN, Sheetz KH et al (2014) Anticipating the effects of medicaid expansion on surgical care. JAMA Surg 149:745–747
Ayanian JZ (2013) Michigan’s approach to Medicaid expansion and reform. N Engl J Med 369:1773–1775
Birkmeyer JD, Gust C, Dimick JB et al (2012) Hospital quality and the cost of inpatient surgery in the United States. Ann Surg 255:1–5
Dimick JB, Birkmeyer NJ, Finks JF et al (2014) Composite measures for profiling hospitals on bariatric surgery performance. JAMA Surg 149:10–16
Hechenbleikner EM, Zheng C, Lawrence S et al (2017) Do hospital factors impact readmissions and mortality after colorectal resections at minority-serving hospitals? Surgery 161:846–854
Torres H, Poorman E, Tadepalli U et al (2017) Coverage and access for Americans with chronic disease under the affordable care act: a quasi-experimental study. Ann Internal Med 166:472–479
Han X, Nguyen BT, Drope J et al (2015) Health-related outcomes among the poor: medicaid expansion vs. non-expansion states. PLoS ONE 10:e0144429
Holzmacher JL, Townsend K, Seavey C, et al (2017) Association of expanded medicaid coverage with hospital length of stay after injury. JAMA Surg 152:960–966
Campbell DA Jr, Englesbe MJ, Kubus JJ et al (2010) Accelerating the pace of surgical quality improvement: the power of hospital collaboration. Arch Surg 145:985–991
Campbell DA Jr, Kubus JJ, Henke PK et al (2009) The Michigan Surgical Quality Collaborative: a legacy of Shukri Khuri. Am J Surg 198:S49–S55
Sheetz KH, Guy K, Allison JH et al (2014) Improving the care of elderly adults undergoing surgery in Michigan. J Am Geriatr Soc 62:352–357
Sheetz KH, Waits SA, Krell RW et al (2013) Improving mortality following emergent surgery in older patients requires focus on complication rescue. Ann Surg 258:614–617 (discussion 617–618)
Bynum JP, Fisher ES, Song Y et al (2010) Measuring racial disparities in the quality of ambulatory diabetes care. Med Care 48:1057–1063
Charles EJ, Johnston LE, Herbert MA et al (2017) Impact of medicaid expansion on cardiac surgery volume and outcomes. Ann Thorac Surg 104:1251–1258
Shrime MG, Alkire BC, Grimes C et al (2017) Cost-effectiveness in global surgery: pearls, pitfalls, and a checklist. World J Surg 41:1401–1413. https://doi.org/10.1007/s00268-017-3875-0
Coetzee WC, Apffelstaedt JP, Zeeman T et al (2018) Disparities in breast cancer: private patients have better outcomes than public patients. World J Surg 42:727–735. https://doi.org/10.1007/s00268-017-4187-0
Funding
Support for this manuscript from Blue Cross/Blue Shield Foundation and the Association for Academic Surgery Resident Research Grant (KHS).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors do not have any conflicts of interest to report.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Claflin, J., Dimick, J.B., Campbell, D.A. et al. Understanding Disparities in Surgical Outcomes for Medicaid Beneficiaries. World J Surg 43, 981–987 (2019). https://doi.org/10.1007/s00268-018-04891-y
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-018-04891-y