Insurance status impacts complication rates after shoulder replacement surgery



Patients undergoing shoulder replacement surgery who have Medicaid, Medicare or no health insurance, had higher complication rates as compared to patients who had private insurance.


The findings, which appear in the Journal of Shoulder and Elbow Surgery, demonstrate disparities in acute postoperative outcomes for shoulder replacement surgery based on insurance status.


Shoulder replacements (arthroplasties) are recommended for patients suffering from various conditions, including shoulder arthritis, irreparable rotator cuff tears and fractures. The primary goal of the procedure is pain relief, with a secondary benefit of restoring motion, strength, function and returning patients to an activity level as near to normal as possible.


Using a large, national administrative database (The Healthcare Cost and Utilization Project Nationwide Inpatient Sample), the researchers analyzed more than 100,000 cases (68,578 Medicare; 27,159 private insurance; 3,544 Medicaid/uninsured and 4,009 other) of patients undergoing shoulder arthroplasty (partial or hemi, total, and reverse) procedures. Overall, the perioperative medical and surgical complication rate was 17.2 percent and the mortality rate was 0.20 percent. However, they found that there was a significantly higher rate of medical, surgical and overall complications among Medicare (20.3 percent) and Medicaid/uninsured (16.9 percent) patients compared with privately insured (10.5 percent) patients. When the data was matched and analyzed, the researchers found no differences in the complication rates between Medicaid/uninsured and Medicare patients. However, both the Medicaid/Uninsured and Medicare patients had significantly more medical and surgical complications when compared to the privately insured patients.


According to the researchers, this discrepancy in the complication rates may be the result of a lack of access to both preoperative and postoperative care due to poor socioeconomic status or education level for patients that have government sponsored insurance. Additionally, patients with Medicaid or no insurance may lack access to high volume shoulder surgeons, which may also contribute to the higher complication rates. The authors also found that patients with private insurance are likely to go to higher volume hospitals to have their elective shoulder replacement surgery done.


“Studies in the literature have shown that patients with Medicaid or no insurance have a higher mortality rate after penetrating trauma compared to private insured patients. Patients with Medicaid also have higher medical complication rates after spine surgery. We report similar findings that patients with government-sponsored insurance are more likely to have medical and surgical complications compared to privately insured patients after shoulder replacement surgery. Thus, insurance status should be considered an independent risk factor for medical and surgical complications in patients undergoing shoulder replacement surgery.” said corresponding and first author Xinning Li, MD, assistant professor of orthopaedic surgery at Boston University School of Medicine.


Li believes future research should focus on both clinical and socioeconomic factors to determine the reason for possible differences in the postoperative complications and outcomes in patients after shoulder replacement surgery between government sponsored and private insurance.


“Understanding that disparities in patient care exist is an important first step. Patients with no insurance or Medicaid/Medicare insurance do not have the same access to care compared to someone with private insurance. The next logical question to ask is why these disparities exist, and subsequently, what can be done to eliminate its occurrence to improve patient care while minimizing postoperative complication,” added Li, an orthopedic surgeon that specializes in sports medicine and shoulder reconstructive surgery at Boston Medical Center.


This study was done in collaboration with researchers from the University of Wisconsin School of Medicine (Dr. Paul Yi), University of California San Francisco School of Medicine (David Sing, B.S.), New England Baptist Hospital (Dr. Andrew Jawa), Medical University of South Carolina (Dr. Josef Eichinger), and the University of Michigan School of Medicine (Dr. Joel Gagnier and Dr. Asheesh Bedi). David Veltre, M.D. is a resident in Orthopaedic Surgery and Antonio Cusano, B.S. is a medical student at the Boston University School of Medicine.


Article: Insurance status affects postoperative morbidity and complication rate after shoulder arthroplasty, Xinning Li, MD, David R. Veltre, MD, Antonio Cusano, BS, Paul Yi, MD, David Sing, BS, Joel J. Gagnier, ND, MSc, PhD, Josef K. Eichinger, MD, Andrew Jawa, MD, Asheesh Bedi, MD, Journal of Shoulder and Elbow Surgery, doi: 10.1016/j.jse.2016.12.071, published online 10 February 2017.



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This entry was posted on February 15, 2017, in Main.

Examining different accountable care organization payment models



Two new studies published online by JAMA Internal Medicine take a look at different accountable care organization (ACO) payment models.


The first study by J. Michael McWilliams, M.D., Ph.D., of Harvard Medical School, Boston, and coauthors used a sample of fee-for-service Medicare claims to examine changes in postacute care spending and the use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program. The 20 percent sample of beneficiaries included more than 8.3 million hospital admissions and more than 1.5 million stays in skilled nursing facilities (SNFs).


Excessive use of postacute SNF care is thought to be a major source of wasteful spending and a target for health care professionals who participate in new payment models, such as Medicare ACO programs.


The authors report that entrance into the Medicare Shared Savings Program (MSSP) in 2012 for ACOs was associated with a 9 percent differential reduction in postacute spending by 2014 – driven by reductions in discharges to facilities, length of facility stays and acute inpatient care. Reductions were smaller for later program entrants and similar for ACOs with and without financial ties to hospitals, according to the article.


The study’s limitations include that the MSSP is a voluntary program and ACOs likely differ from providers who don’t participate.


“Participation in the MSSP has been associated with significant reductions in postacute care spending without ostensible changes in quality, suggesting gains in the value of health care. Postacute care spending reductions were more consistent with efforts by clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs. Understanding such early successes can support regulatory policy that enhances rather than inhibits the effectiveness of payment and delivery system reform,” the article concludes.


A second study by K. John McConnell, Ph.D., of the Oregon Health & Science University, Portland, examined early performance in Medicaid ACOs in Oregon and Colorado.


With a $1.9 billion investment from the federal government, Oregon started to transform Medicaid in 2012 by moving enrollees into 16 Coordinated Care Organizations so care was managed within a global budget. In 2011, Colorado began its Medicaid Accountable Care Collaborative by creating seven regional care collaborative organizations that were funded to coordinate care and connect Medicaid enrollees with community services, according to the article.


The authors report standardized expenditures, which have common codes across states, for selected services decreased in both states from 2010 to 2014 with no difference between the states. The Oregon model also was associated with improvements in some utilization, access and quality measures.


The study notes important limitations, including that the analysis did not include prescription drug expenditures, which is a growing portion of Medicaid spending.


“These results should be considered in the context of overall promising trends in both states. Continued evaluation of Medicaid reforms and payment models can inform the most effective approaches to improving and sustaining the value of this growing public program,” the article concludes.


Articles: Changes in Postacute Care in the Medicare Shared Savings Program, J. Michael McWilliams, MD, PhD; Lauren G. Gilstrap, MD; David G. Stevenson, PhD et al., JAMA Internal Medicine, doi:10.1001/jamainternmed.2016.9115, published online 13 February 2017.


Early Performance in Medicaid Accountable Care Organizations A Comparison of Oregon and Colorado, K. John McConnell, PhD; Stephanie Renfro, MS; Benjamin K. S. Chan, MS et al., JAMA Internal Medicine, doi:10.1001/jamainternmed.2016.9098, published online 13 February 2017.



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This entry was posted on February 14, 2017, in Main.

Study shows impact of dental benefits on meeting children's dental needs



A report in The Journal of the American Dental Association (JADA) shows that dental benefits play a significant role in meeting the dental needs of children, including checkups and treatments. The study is particularly timely as February is National Children’s Dental Health Month.


The report finds U.S. children enrolled in private or public dental care plans were more likely to receive dental care than children who did not have coverage from 1997 to 2014. The study also showed that unmet dental needs of children who were enrolled in a dental care plan, private or public, steadily decreased from 2009 to 2014.


“The number of uninsured children decreased by 58 percent from 1997 to 2014 with a significant shift from private to public insurance coverage,” stated authors Maryam Amin, D.M.D., M.S.c., Ph.D., Maryam Elyasi, D.D.S., and Zhou J. Yu, B.S.c. “The shift toward use of public insurance along with a significant association between unmet needs and dental visits support the effectiveness of publicly funded programs in facilitating the use of dental services in the United States.”


The authors examined data from more than 65,000 participants collected by the National Health Interview Survey (NHIS), which is conducted by the U.S. Census Bureau.


Dental needs are met by regular visits to the dentist and adequate access to dental care. According to the study, some barriers to receiving care include socioeconomic status, beliefs about dental care, and the accessibility of providers. Some enabling factors include level of education, household income, and dental insurance.


“If an imbalance exists between barriers and enabling factors, a patient may have a higher chance of having unmet dental needs because of cost, which leads to delayed diagnosis of issues, more complex treatment, and ultimately increased burden on public health systems,” the authors stated.


Article: Associations among dental insurance, dental visits, and unmet needs of US children, Zhou J. Yu, BSc, Maryam Elyasi, DDS, Maryam Amin, DMD, MSc, PhD, The Journal of the American Dental Association, doi: 10.1016/j.adaj.2016.11.013, published February 2017.



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This entry was posted on February 8, 2017, in Main.

New survey finds many Americans want changes to ACA but few support immediate repeal



According to a new national survey on Americans’ opinions on the Affordable Care Act (ACA) conducted by The Associated Press-NORC Center for Public Affairs Research, 12 percent of Americans want the ACA kept in its current form, 40 percent say it should be preserved with improvements, 16 percent say the law should be repealed immediately, and 31 percent want a repeal to wait until a replacement is ready. While most Americans express a desire for change, few report being negatively impacted by the law, and nearly half say they haven’t been affected at all. Forty-six percent of Americans say they have not been personally affected by the law, while 27 percent say the law has improved their lives, and 26 percent say it has had a detrimental effect.


“It is clear that very few Americans want to keep the law as it currently is,” said Trevor Tompson, director of The AP-NORC Center. “However, there are many elements of the law that appear to be popular, and there is support for retaining those provisions in any replacement legislation that might be passed.”


Key findings from the poll include:


  • Fifty-three percent disagree with the new administration and say the health care law should remain. But only 12 percent of Americans support keeping the law as it is now; 40 percent would like to see changes to make it better. Nearly half of Americans, 46 percent, agree that the law should be repealed. However, 31 percent want to wait until a replacement law is ready, while only 16 percent want to see the law repealed immediately.

  • Even a majority of those who oppose the ACA support eliminating out-of-pocket costs for some preventive health care (70 percent), allowing adult children to remain on their parents’ insurance until age 26 (65 percent), and protecting people with pre-existing medical conditions (60 percent).

  • The individual mandate that requires most Americans to be insured or pay a fine is the least popular element of the ACA, even among those who support it. Less than half (49 percent) of those who want the law to remain support the mandate, along with only 12 percent of those who want it repealed.

  • Despite provisions in the health care law that impact Americans regardless of their source of health insurance, 46 percent say they have not been personally affected by the law, and 26 percent say it has had a detrimental effect. Only 27 percent say the law has improved their lives.

  • Overall, 40 percent say the ACA has helped average Americans, 33 percent say it has hurt them, and 25 percent do not perceive any difference. Fifty-three percent say the health care law has helped low-income families, and 44 percent say it has been beneficial for women. But 41 percent say the law has hurt small businesses.

  • Fifty-six percent of Americans are extremely or very concerned that many people will lose their coverage if the health care law is repealed. And 49 percent expect the elimination of the ACA to be detrimental for most Americans; only 26 percent think it will be advantageous.

  • The idea of a government-financed single payer insurance program gets mixed support. Thirty-eight percent favor the concept, while 39 percent oppose it. Support drops to 24 percent when asked if a single payer system meant large increases in government spending.

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This entry was posted on January 31, 2017, in Main.

Most primary care doctors 'strongly endorse' key elements of the Affordable Care Act



Proponents of repealing the Affordable Care Act, including President Donald Trump’s nominee for Secretary of Health and Human Services, Tom Price, have argued that the law places an undue burden on physicians. However, according to new research, while nearly 74 percent of physicians surveyed favor making some changes to the law, only 15 percent favor repealing the legislation in its entirety. Additional results of the survey, published in the New England Journal of Medicine, show that participants almost universally support prohibiting insurance companies from denying coverage or charging higher prices on the basis of pre-existing conditions, and allowing young adults to remain on their parents’ insurance plan until 26 years of age.


“Tens of millions of people could be at risk of losing health insurance if critical elements of the Affordable Care Act are repealed. Given the central role physicians play in the health care system, their views of the legislation are important for informing the public debate,” said co-author David Grande, MD, MPA, an assistant professor of Medicine at the Perelman School of Medicine and director of Policy at Penn’s Leonard Davis Institute of Health Economics. “We don’t yet know what provisions may be repealed or modified, but we have started to see signs of what could be coming, and what has been absent in the conversation so far is how physicians feel the law has impacted their patients’ and the care they are able to deliver.”


Given the rapidly and dramatically changing political landscape, the authors conducted a survey of more than 400 physicians randomly selected from the American Medical Association’s Masterfile from December 2016 through January 2017 to gauge perspectives of the ACA and specific policy options put forth in recent public debate. Though responses varied according to the physicians’ self-reported political party affiliation (no Democrats wanted to see the ACA repealed, while 32 percent of Republicans did), among all participants, only 37.9 percent of those who reported voting for Trump wanted to repeal the ACA in its entirety.


In general, participants responded most favorably to policy changes that might increase choice for consumers, such as creating a public option resembling Medicare to compete with private plans, providing tax credits to allow people who are eligible for Medicaid to purchase private health insurance, and increasing the use of health savings accounts. Physicians responded most negatively to policies that would shift more costs to consumer through high-deductible health plans, and less than half were in favor of proposals to decrease insurance-market regulations, require states to expand Medicaid, or expand Medicare to adults 55 to 64 years of age.


“With his new executive order, President Trump has sent a message that he may try to unravel key elements of the ACA,” said lead author Craig Pollack, MD, MHS, an associate professor of General Internal Medicine at the Johns Hopkins University School of Medicine. “By and large, primary care physicians are open to modifications of the law, but believe several aspects of the ACA with its focus on increasing insurance coverage are important to patient’s health. They worry about changes that rely on high deductible health plans that require patients to shoulder more health care costs.”


Article: A View from the Front Line – Physicians’ Perspectives on ACA Repeal, Craig Evan Pollack, M.D., M.H.S., Katrina Armstrong, M.D., and David Grande, M.D., M.P.A., New England Journal of Medicine, doi: 10.1056/NEJMp1700144, published 25 January 2017.



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This entry was posted on January 28, 2017, in Main.