Managing acute cholecystitis among Medicaid insured in New York State: opportunities to optimize care
Identifying sources of unnecessary cost within Medicaid will help focus cost containment efforts. This study sought to identify differences in surgical management and associated costs of cholecystitis between Medicaid and privately insured in New York State.
The New York State all-payer mandatory discharge database from 2003 to 2013, had 297,635 patients with Medicaid (75,512) and privately (222,123) insurance who underwent cholecystectomy for cholecystitis. Patients were stratified by insurance. Four surgical management approaches were delineated based on cholecystectomy timing: primary, interval, emergency, and delayed cholecystectomy. Delayed cholecystectomy was defined as more than one hospital visit from diagnosis to definitive cholecystectomy. Medicaid and privately insured patients were propensity score matched. Surgical management approach and associated costs were compared between matched cohorts.
A greater proportion of Medicaid patients underwent delayed cholecystectomy compared to matched privately insured patients, 8.5 versus 4.8%; P < 0.001. Primary initial cholecystectomy was performed in fewer Medicaid compared to privately insured patients, 55.4 versus 66.0%, P < 0.001. Primary initial cholecystectomy was the cheapest surgical management approach, with the median cost of $3707, and delayed cholecystectomy was the most expensive, $12,212, P < 0.001. The median cost per Medicaid patient was $6170 versus $4804 per matched privately insured patient, P < 0.001. The annual predicted cost savings for New York State Medicaid would be $13,097,371, if the distribution of surgical management approaches were proportionally similar to private insurance.
Medicaid patients with cholecystitis were more frequently managed with delayed cholecystectomy than privately insured patients, which had substantial cost implications for the New York Medicaid Program.
KeywordsMedicaid Delayed choleycstectomy Cost
Compliance with ethical standards
Anne M. Stey, Alexander J. Greenstein, Arthur Aufses, Alan J. Moskowitz, and Natalia N. Egorova have no conflicts of interest or financial ties to disclose
- 3.Delgado MK, Yokell MA, Staudenmayer KL, Spain DA, Hernandez-Boussard T, Wang NE (2014) Factors associated with the disposition of severely injured patients initially seen at non-trauma center emergency departments: disparities by insurance status. JAMA Surg 149(5):422–430CrossRefPubMedPubMedCentralGoogle Scholar
- 4.Berman L, Rosenthal MS, Moss RL (2010) The paradoxical effect of medical insurance on delivery of surgical care for infants with congenital anomalies. J Pediatr Surg 45:38–43; discussion 44Google Scholar
- 6.Schwartz DA, Hui X, Schneider EB, Ali MT, Canner JK, Leeper WR, Efron DT, Haut E, Haut ER, Velopulos CG, Pawlik TM, Haider AH (2014) Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities? Surgery 156:345–351CrossRefPubMedGoogle Scholar
- 16.Riall TS, Zhang D, Townsend CM, Kuo YF, Goodwin JS (2010) Failure to perform cholecystectomy for acute cholecystitis in elderly patients is associated with increased morbidity, mortality, and cost. J Am Coll Surg 210:668–677, 677–669Google Scholar
- 17.Gurusamy KS, Davidson C, Gluud C, Davidson BR (2013) Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Cochrane Database Syst Rev 6:CD005440Google Scholar
- 21.Sheetz KH, Waits SA, Krell RW, Campbell DA, Englesbe MJ, Ghaferi AA (2013) Improving mortality following emergent surgery in older patients requires focus on complication rescue. Ann Surg 258:614–617; discussion 617–618Google Scholar
- 31.LaPar DJ, Bhamidipati CM, Mery CM, Stukenborg GJ, Jones DR, Schirmer BD, Kron IL, Ailawadi G (2010) Primary payer status affects mortality for major surgical operations. Ann Surg 252:544–550; discussion 550–541Google Scholar
- 32.Cohen ME, Ko CY, Bilimoria KY, Zhou L, Huffman K, Wang X, Liu Y, Kraemer K, Meng X, Merkow R, Chow W, Matel B, Richards K, Hart AJ, Dimick JB, Hall BL (2013) Optimizing ACS NSQIP modeling for evaluation of surgical quality and risk: patient risk adjustment, procedure mix adjustment, shrinkage adjustment, and surgical focus. J Am Coll Surg 217(336–346):e331Google Scholar
- 36.Bozic KJ, Grosso LM, Lin Z, Parzynski CS, Suter LG, Krumholz HM, Lieberman JR, Berry DJ, Bucholz R, Han L, Rapp MT, Bernheim S, Drye EE (2014) Variation in hospital-level risk-standardized complication rates following elective primary total hip and knee arthroplasty. J Bone Joint Surg Am 96:640–647CrossRefPubMedGoogle Scholar
- 43.Gutt CN, Encke J, Köninger J, Harnoss JC, Weigand K, Kipfmüller K, Schunter O, Götze T, Golling MT, Menges M, Klar E, Feilhauer K, Zoller WG, Ridwelski K, Ackmann S, Baron A, Schön MR, Seitz HK, Daniel D, Stremmel W, Büchler MW (2013) Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304). Ann Surg 258:385–393CrossRefPubMedGoogle Scholar
- 46.Hing E, Decker S, Jamoom E (2013) Acceptance of new patients with public and private insurance by office-based physicians: United States. NCHS Data Brief 2015:1–8Google Scholar