Association of Dual Medicare and Medicaid Eligibility With Outcomes and Spending for Cancer Surgery in High-Quality Hospitals

Taylor, Kristin; Díaz, Adrián; Nuliyalu, Usha; Ibrahim, Andrew M.; Nathan, Hari

doi:10.1001/jamasurg.2021.7586

Cited by 12 publications

(12 citation statements)

References 35 publications

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“…5 Low socioeconomic status (SES) populations are associated with greater risk of morbidity, 6 mortality, 5 and poor health status. 6 Current risk adjustment models do not include frailty [7][8][9] and social risk factors [10][11][12] which significantly impact patient outcomes. [11][12][13][14][15] With the higher costs of care for low-SES populations, in addition to lower reimbursements, SNH are further penalized by current value-based programs.…”

Section: Introductionmentioning

confidence: 99%

“…6 Current risk adjustment models do not include frailty [7][8][9] and social risk factors [10][11][12] which significantly impact patient outcomes. [11][12][13][14][15] With the higher costs of care for low-SES populations, in addition to lower reimbursements, SNH are further penalized by current value-based programs. 16,17 The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based program used as a quality measure and to decrease healthcare spending.…”

Section: Introductionmentioning

confidence: 99%

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Association of Cumulative Colorectal Surgery Hospital Costs, Readmissions, and Emergency Department/Observation Stays with Insurance Type

Jacobs

Tetley

Kim

et al. 2023

Journal of Gastrointestinal Surgery

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Background/Purpose Medicare’s Hospital Readmission Reduction Program disproportionately penalizes safety-net hospitals (SNH) caring for vulnerable populations. This study assessed the association of insurance type with 30-day emergency department visits/observation stays (EDOS), readmissions, and cumulative costs in colorectal surgery patients. Methods Retrospective inpatient cohort study using the National Surgical Quality Improvement Program (2013–2019) with cost data in a SNH. The odds of EDOS and readmissions and cumulative variable (index hospitalization and all 30-day EDOS and readmissions) costs were modeled adjusting for frailty, case status, presence of a stoma, and open versus laparoscopic surgery. Results The cohort had 245 private, 195 Medicare, and 590 Medicaid/uninsured cases, with a mean age 55.0 years (SD = 13.3) and 52.9% of the cases were performed on male patients. Most cases were open surgeries (58.7%). Complication rates were 41.8%, EDOS 12.0%, and readmissions 20.1%. Medicaid/uninsured had increased odds of urgent/emergent surgeries (aOR = 2.15, CI = 1.56–2.98, p < 0.001) and complications (aOR = 1.43, CI = 1.02–2.03, p = 0.042) versus private patients. Medicaid/uninsured versus private patients had higher EDOS (16.6% versus 4.1%) and readmissions (22.9% versus 14.3%) rates and higher odds of EDOS (aOR = 4.81, CI = 2.57–10.06, p < 0.001), and readmissions (aOR = 1.62, CI = 1.07–2.50, p = 0.025), while Medicare patients had similar odds versus private. Cumulative variable cost %change was increased for Medicare and Medicaid/uninsured, but Medicaid/uninsured was similar to private after adjusting for urgent/emergent cases. Conclusions Increased urgent/emergent cases in Medicaid/uninsured populations drive increased complications odds and higher costs compared to private patients, suggesting lack of access to outpatient care. SNH care for higher cost populations, receive lower reimbursements, and are penalized by value-based programs. Increasing healthcare access for Medicaid/uninsured patients could reduce urgent/emergent surgeries, resulting in fewer complications, EDOS/readmissions, and costs.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Association of Cumulative Colorectal Surgery Hospital Costs, Readmissions, and Emergency Department/Observation Stays with Insurance Type

Jacobs

Tetley

Kim

et al. 2023

Journal of Gastrointestinal Surgery

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“…Unfortunately, after cancer surgery, DE patients often have worse outcomes, including increased complication rates and readmission. 1,2 Within this context, we commend Taylor et al 2 for further characterizing surgical disparities among DE patients and studying a potential intervention that may help mitigate these disparities. In their study, they identify DE patients as a highrisk group that may benefit from treatment at high-quality hospitals, as defined by the authors.…”

mentioning

confidence: 99%

“…Patients often have multiple chronic conditions or reside in long-term care, and a diagnosis such as cancer adds complexity in care coordination to already challenging circumstances. Unfortunately, after cancer surgery, DE patients often have worse outcomes, including increased complication rates and readmission …”

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confidence: 99%

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Surgical Cancer Care for Dually Eligible Beneficiaries

2022

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Medicare-Medicaid enrollees represent a group of patients with complex health needs and socioeconomic vulnerabilities. Dually eligible (DE) patients qualify for Medicare through age (65 years or older) or disability and meet state-specific income and resource criteria as qualifications for Medicaid.Patients often have multiple chronic conditions or reside in long-term care, and a diagnosis such as cancer adds complexity in care coordination to already challenging circumstances. Unfortunately, after cancer surgery, DE patients often have worse outcomes, including increased complication rates and readmission. 1,2 Within this context, we commend Taylor et al 2 for further characterizing surgical disparities among DE patients and studying a potential intervention that may help mitigate these disparities. In their study, they identify DE patients as a highrisk group that may benefit from treatment at high-quality hospitals, as defined by the authors. While DE patients still had a higher rate of complications, the disparity between DE and Medicare-only patients was lower at high-quality hospitals. Although this finding is not unique (that disparities in care can be mitigated at certain hospitals) it continues to be an important area of investigation.These findings invite 2 considerations. First, while DE patients may benefit from selective referral to high-quality hospitals, improving care at a greater number of lowerperforming hospitals may also prove effective from a health systems standpoint. For example, it is not practical to shunt patients needing colon cancer surgery to "high-quality" hospitals. Rather, identifying the underlying factors driving bet-

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Presentation Acuity and Surgical Outcomes for Patients With Health Insurance Living in Highly Deprived Neighborhoods

Schmidt,

Jacobs,

Kim

et al. 2024

JAMA Surg

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ImportanceInsurance coverage expansion has been proposed as a solution to improving health disparities, but insurance expansion alone may be insufficient to alleviate care access barriers.ObjectiveTo assess the association of Area Deprivation Index (ADI) with postsurgical textbook outcomes (TO) and presentation acuity for individuals with private insurance or Medicare.Design, Setting, and ParticipantsThis cohort study used data from the National Surgical Quality Improvement Program (2013-2019) merged with electronic health record data from 3 academic health care systems. Data were analyzed from June 2022 to August 2023.ExposureLiving in a neighborhood with an ADI greater than 85.Main Outcomes and MeasuresTO, defined as absence of unplanned reoperations, Clavien-Dindo grade 4 complications, mortality, emergency department visits/observation stays, and readmissions, and presentation acuity, defined as having preoperative acute serious conditions (PASC) and urgent or emergent cases.ResultsAmong a cohort of 29 924 patients, the mean (SD) age was 60.6 (15.6) years; 16 424 (54.9%) were female, and 13 500 (45.1) were male. A total of 14 306 patients had private insurance and 15 618 had Medicare. Patients in highly deprived neighborhoods (5536 patients [18.5%]), with an ADI greater than 85, had lower/worse odds of TO in both the private insurance group (adjusted odds ratio [aOR], 0.87; 95% CI, 0.76-0.99; P = .04) and Medicare group (aOR, 0.90; 95% CI, 0.82-1.00; P = .04) and higher odds of PASC and urgent or emergent cases. The association of ADIs greater than 85 with TO lost significance after adjusting for PASC and urgent/emergent cases. Differences in the probability of TO between the lowest-risk (ADI ≤85, no PASC, and elective surgery) and highest-risk (ADI &gt;85, PASC, and urgent/emergent surgery) scenarios stratified by frailty were highest for very frail patients (Risk Analysis Index ≥40) with differences of 40.2% and 43.1% for those with private insurance and Medicare, respectively.Conclusions and RelevanceThis study found that patients living in highly deprived neighborhoods had lower/worse odds of TO and higher presentation acuity despite having private insurance or Medicare. These findings suggest that insurance coverage expansion alone is insufficient to overcome health care disparities, possibly due to persistent barriers to preventive care and other complex causes of health inequities.

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Association of Dual Medicare and Medicaid Eligibility With Outcomes and Spending for Cancer Surgery in High-Quality Hospitals

Cited by 12 publications

References 35 publications

Association of Cumulative Colorectal Surgery Hospital Costs, Readmissions, and Emergency Department/Observation Stays with Insurance Type

Association of Cumulative Colorectal Surgery Hospital Costs, Readmissions, and Emergency Department/Observation Stays with Insurance Type

Surgical Cancer Care for Dually Eligible Beneficiaries

Presentation Acuity and Surgical Outcomes for Patients With Health Insurance Living in Highly Deprived Neighborhoods

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