We advise physicians and patients to be aware that most urologists are rated on at least 1 physician review website, and while most ratings and reviews are favorable, composite scores are typically based on a small number of reviews and, therefore, can be volatile.

Importance While the enthusiasm for the Affordable Care Act (ACA) revolves around its impact on access to preventive and primary care services, the effect of this reform on surgical care remains undefined. Objective Using Massachusetts (MA) healthcare reform as a natural experiment, we estimate the differential impact of insurance expansion on the utilization of discretionary versus non-discretionary inpatient surgery. Design We used the State Inpatient Databases from MA and two control states to identify nonelderly patients (19–64 years) who underwent discretionary (DS) versus non-discretionary surgery (NDS) during the years 2003–2010. We defined DS as elective, preference-sensitive procedures (e.g., joint replacement, back surgery), and NDS as imperative and potentially lifesaving procedures (e.g., cancer surgery, hip fracture repair). Using July 2007 as the transition point between pre and post-reform periods, we performed a difference-in-differences (DID) analysis to estimate the effect of insurance expansion on rates of DS vs NDS among the entire study population, and for subgroups defined by race, income and insurance status. We then extrapolated our results from MA to the entire US population. Main Outcome(s) and Measure(s) Rate of DS and NDS performed before and after the healthcare reform in Massachusetts. Results We identified a total of 836,311 surgeries during the study period. In contrast to NDS, post-reform rates of DS increased more in MA than in control states. Based on our DID analysis, insurance expansion was associated with a 9.3% increase in the use of DS in MA (p=0.021). Conversely, the rate of NDS decreased by 4.5% (p=0.009). We found similar effects for DS in all subgroups, with the greatest increase observed for non-whites (19.9%, p<0.001). Based on the findings in MA, we estimated that full implementation of national insurance expansion would yield an additional 465,934 discretionary surgeries by 2017. Conclusions and Relevance Insurance expansion in Massachusetts was associated with increased rates of discretionary surgery, and a concurrent decrease in utilization of nondiscretionary surgery. If similar changes are seen nationally, the value of insurance expansion for surgical care may depend on the relative balance between increased expenditures and potential health benefits of greater access to elective inpatient procedures.

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The Centers for Medicare & Medicaid Services (CMS) recently implemented the Comprehensive Care for Joint Replacement (CJR) model. While many stakeholders are enthusiastic that the program will reduce spending for joint replacement, others are concerned that the program will unintentionally penalize hospitals that treat medically complex patients. This concern stems from the fact that the program may not include a mechanism to sufficiently account for patient complexity (i.e., risk adjustment). Using Medicare claims, we examined this concern and found an inverse association between patient complexity and year-end bonuses (i.e., reconciliation payments). Specifically, reconciliation payments were reduced by $827 per episode for each standard deviation increase in a hospital’s patient complexity (p<0.01). Moreover, we found that risk adjustment could increase reconciliation payments to some hospitals by as much as $114,184 annually. Our findings suggest that CMS should include risk adjustment in the CJR model and future bundled payment programs.

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