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Research Letter |

Anticipating the Effects of Medicaid Expansion on Surgical Care FREE

Seth A. Waits, MD1; Bradley N. Reames, MD, MS1; Kyle H. Sheetz, MS1; Michael J. Englesbe, MD1; Darrell A. Campbell Jr, MD1
[+] Author Affiliations
1Section of General Surgery, Department of Surgery, University of Michigan, Ann Arbor
JAMA Surg. 2014;149(7):745-747. doi:10.1001/jamasurg.2014.222.
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Published online

The Affordable Care Act expanded Medicaid coverage to adults with incomes up to 133% of the federal poverty level, but a subsequent Supreme Court ruling determined Congress could give states the option to expand. In September of 2013, the state of Michigan approved expansion. Beginning in April 2014, more than 400 000 adults will be newly eligible for Medicaid enrollment in the state.1

The effect of this influx of patients on surgical care and hospital costs in Michigan is unknown. Previous national studies of Medicaid patients undergoing surgery have shown worse outcomes2 and increased costs.3 Given that the Affordable Care Act also mandates a reduction in payments to disproportionate share hospitals,4 increased Medicaid enrollment could have substantial clinical and financial implications for hospitals facing expansion. To better understand this change, using a statewide clinical registry, we examined the surgical outcomes and resource use of Medicaid patients in Michigan the year prior to implementation of the Affordable Care Act.

We retrospectively studied all nonelderly adults undergoing inpatient general surgery within the 52-hospital Michigan Surgical Quality Collaborative in the year prior to approval of Medicaid expansion (July 2012 to June 2013). Medicare patients and those 65 years of age or older were excluded. Details of prospective data collection, case sampling, and definitions of comorbidities and outcomes have been previously described.5 We calculated descriptive statistics and rates of unadjusted surgical outcomes for patients stratified by insurance status. Hospitals were ranked according to the proportion of Medicaid patients served and were divided into quintiles. For all statistical tests, P values are 2 tailed, and α is set at .05. Analyses were performed using Stata version 13.1 (StataCorp). Our study was ruled exempt by the institutional review board.

The final cohort included 13 887 patients undergoing general surgery during the study period. Data on patient demographics, surgical outcomes, and resource use of Medicaid patients and of patients with private insurance are shown in our Table. Medicaid patients were younger and more likely to be female and nonwhite than were privately insured patients. Rates of smoking (50%), chronic obstructive pulmonary disease (10%), and peripheral vascular disease (7%) among Medicaid patients were twice those seen among the privately insured. Medicaid patients underwent 21% more emergent operations, experienced 67% more serious complications, and used 50% more resources than did privately insured patients. Examination of hospitals revealed wide variability in the proportion of Medicaid patients treated (Figure, A). The highest 2 hospital quintiles accounted for 61.2% of all Medicaid patients treated (Figure, B).

Table Graphic Jump LocationTable.  Patient Demographics, Procedure Mix, Postoperative Outcomes, and Resource Use of 13 887 Patients Undergoing Surgery During the Period From July 2012 to June 2013, Stratified by Health Care Coverage
Place holder to copy figure label and caption
Figure.
Proportion of Medicaid Patients Treated by Each of Michigan’s 52 Hospitals (A) and Percentage of Total Medicaid Volume Treated Within Each Hospital Quintile (B)

Data obtained for the period from July 2012 to June 2013. Error bars indicate 95% CIs.

Graphic Jump Location

Medicaid patients undergoing surgery in Michigan represent a significant challenge to the health care system. These patients have a worse health status, experience more complications, and use more resources than privately insured patients. The proportion of Medicaid patients served varies substantially, and a small subset of hospitals cares for a large percentage of the state’s Medicaid population. Given these findings, the Affordable Care Act–mandated decrease in disproportionate share hospitals payments could place this subset of hospitals at risk for financial insolvency.

This analysis is limited by the small sample size. However, our study represents the most current data available and uses an internally validated clinical registry. Although the data are limited to a single state, there is no reason to believe that there are systematic differences between our cohort and the national Medicaid population.

To ensure high-quality care, legislators and hospitals must adapt to meet the needs of this patient population. In Michigan, the legislation to expand Medicaid also funded an advisory committee to study the cost and quality of care delivered to these patients.1 Existing regional quality collaboratives, such as the Michigan Surgical Quality Collaborative, have the infrastructure necessary to address these issues, and have been shown to improve outcomes.6 State legislatures considering expansion should partner with these organizations to ensure that increased access is met with high-value surgical care.

Corresponding Author: Seth A. Waits, MD, Section of General Surgery, Department of Surgery, University of Michigan, 2800 Plymouth Rd, Bldg 16, Room 16-0123, Ann Arbor, MI 48109-2800 (waitss@umich.edu).

Published Online: May 7, 2014. doi:10.1001/jamasurg.2014.222.

Author Contributions: Drs Waits and Sheetz had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Waits, Reames, Sheetz, Englesbe, Campbell.

Acquisition, analysis, or interpretation of data: Waits, Reames, Sheetz, Englesbe.

Drafting of the manuscript: Waits, Reames, Sheetz, Englesbe.

Critical revision of the manuscript for important intellectual content: Waits, Reames, Englesbe, Campbell.

Statistical analysis: Waits, Reames, Sheetz.

Administrative, technical, or material support: Reames.

Study supervision: Waits, Englesbe, Campbell.

Conflict of Interest Disclosures: None reported.

Additional Information: Dr Campbell is program director of the Michigan Surgical Quality Collaborative.

Additional Contributions: We thank John Z. Ayanian, MD, MPP, the director of the Institute for Health Policy and Innovation and Professor of Medicine at the Department of Internal Medicine, University of Michigan, Ann Arbor, for his helpful comments. He was not compensated financially for his contributions.

Ayanian  JZ.  Michigan’s approach to Medicaid expansion and reform. N Engl J Med. 2013;369(19):1773-1775.
PubMed   |  Link to Article
LaPar  DJ, Bhamidipati  CM, Mery  CM,  et al.  Primary payer status affects mortality for major surgical operations. Ann Surg. 2010;252(3):544-550; discussion 550-541.
PubMed
Bradley  CJ, Dahman  B, Bear  HD.  Insurance and inpatient care: differences in length of stay and costs between surgically treated cancer patients. Cancer. 2012;118(20):5084-5091.
PubMed   |  Link to Article
Centers for Medicare & Medicaid Services (CMS), HHS.  Medicaid program; state disproportionate share hospital allotment reductions. Final rule. Fed Regist. 2013;78(181):57293-57313.
PubMed
Waits  SA, Sheetz  KH, Campbell  DA,  et al.  Failure to rescue and mortality following repair of abdominal aortic aneurysm. J Vasc Surg. 2014;59(4):909, e1.
PubMed   |  Link to Article
Share  DA, Campbell  DA, Birkmeyer  N,  et al.  How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care. Health Aff (Millwood). 2011;30(4):636-645.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Proportion of Medicaid Patients Treated by Each of Michigan’s 52 Hospitals (A) and Percentage of Total Medicaid Volume Treated Within Each Hospital Quintile (B)

Data obtained for the period from July 2012 to June 2013. Error bars indicate 95% CIs.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Patient Demographics, Procedure Mix, Postoperative Outcomes, and Resource Use of 13 887 Patients Undergoing Surgery During the Period From July 2012 to June 2013, Stratified by Health Care Coverage

References

Ayanian  JZ.  Michigan’s approach to Medicaid expansion and reform. N Engl J Med. 2013;369(19):1773-1775.
PubMed   |  Link to Article
LaPar  DJ, Bhamidipati  CM, Mery  CM,  et al.  Primary payer status affects mortality for major surgical operations. Ann Surg. 2010;252(3):544-550; discussion 550-541.
PubMed
Bradley  CJ, Dahman  B, Bear  HD.  Insurance and inpatient care: differences in length of stay and costs between surgically treated cancer patients. Cancer. 2012;118(20):5084-5091.
PubMed   |  Link to Article
Centers for Medicare & Medicaid Services (CMS), HHS.  Medicaid program; state disproportionate share hospital allotment reductions. Final rule. Fed Regist. 2013;78(181):57293-57313.
PubMed
Waits  SA, Sheetz  KH, Campbell  DA,  et al.  Failure to rescue and mortality following repair of abdominal aortic aneurysm. J Vasc Surg. 2014;59(4):909, e1.
PubMed   |  Link to Article
Share  DA, Campbell  DA, Birkmeyer  N,  et al.  How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care. Health Aff (Millwood). 2011;30(4):636-645.
PubMed   |  Link to Article

Correspondence

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