Do patient outcomes and follow-up completion rates after shoulder arthroplasty differ based on insurance payor?

Abstract

Background: Disparities associated with socioeconomic status (SES) and insurance coverage have been shown to affect outcomes in different medical conditions and surgical procedures. We hypothesized that patients insured by Medicaid will be associated with lower follow-up rates and inferior outcomes relative to those with Medicare or private insurance. Methods: Patients undergoing shoulder arthroplasty, including anatomic total shoulder arthroplasty, reverse arthroplasty, and hemiarthroplasty, were enrolled preoperatively in an institutional database. Preoperative demographics, payor (Medicaid, Medicare, or private insurance), and baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores were recorded. Postoperatively, patients completed ASES scores at multiple time points. Follow-up completion rate was calculated as the number of follow-up visits completed relative to possible visits. Continuous variables were compared between groups with 1-way analyses of variance, and chi-squared tests were used for categorical variables. Significance was defined as P < .05. Results: There were 491 shoulder replacements performed for 438 patients from 2012-2017. The mean follow-up completed percentage was significantly lower (P < .001) for Medicaid patients (62.6% AE 33.7%) relative to Medicare patients (80.2% AE 26.7%; P < .001) and private insurance patients (77.8% AE 22.1%; P ¼ .001). The ASES Composite score increased significantly for all patients from baseline to final follow-up. At each time point, including before surgery and each postoperative time point, patients with Medicaid insurance had significantly lower ASES Composite scores. The final ASES Composite score was significantly lower in the Medicaid patients (66.1 AE 28.7) relative to private insurance patients (78.3 AE 20.8; P ¼ .023). Medicaid patients had significantly lower preoperative (P < .001) and postoperative (P ¼ .018) ASES Pain subscores. In multivariate regression analysis, Medicaid insurance was associated with both inferior preoperative and postoperative ASES scores relative to patients with Medicare or private insurance. Conclusions: We observed that all patients, regardless of insurance payor, improved by similar magnitudes after shoulder arthroplasty, though patients with Medicaid insurance had significantly lower preoperative and postoperative ASES scores, primarily because of the ASES Pain subscore. Patients with Medicaid insurance also have lower follow-up rates than other payors.

Patients With Medicaid Insurance Undergoing Anterior Cruciate Ligament Reconstruction have Lower Postoperative International Knee Documentation Committee Scores and are Less Likely to Return to Sport Than Privately Insured Patients

“… 22 , 23 , 24 , 25 More specifically, recent investigations have demonstrated that in those undergoing total joint arthroplasty of the hip, knee, or shoulder, patients with Medicaid have greater resource use, greater complication rates, and poorer postoperative outcomes. 8 , 10 , 13 , 14 , 23 , 26 , 27 With the expansion of Medicaid through the Affordable Care Act in 2014, the investigation of these disparities in one of the most common orthopaedic sports medicine procedures performed, ACL reconstruction, is critical. 23 …”

“…This may be due to the greater difficulty patients with Medicaid insurance face when trying to access PT appointments. 13 For instance, a cross-sectional study conducted in a large metropolitan area within a Medicaid-expansion state found that 43% fewer PT clinics accept Medicaid and those patients with Medicaid must wait significantly longer for an initial appointment as compared with private insurance patients. 28 The PT benefits covered by Medicaid insurance in 2 different states (Illinois and Indiana) is provided in Table 5 , suggesting there is no barrier to accessing PT for patients with Medicaid insurance with regards to limitations on number of PT visits or other restrictions.…”

“…For instance, 2 separate studies found Medicaid insurance to be associated with inferior postoperative ASES scores relative to patients undergoing shoulder arthroplasty with Medicare or private insurance. 13 , 14 Similarly, in patients undergoing primary total hip or knee arthroplasty, Halawi et al. 12 found that Medicaid insurance type was associated with inferior Oxford Hip Score.…”

“…[22][23][24][25] More specifically, recent investigations have demonstrated that in those undergoing total joint arthroplasty of the hip, knee, or shoulder, patients with Medicaid have greater resource use, greater complication rates, and poorer postoperative outcomes. 8,10,13,14,23,26,27 With the expansion of Medicaid through the Affordable Care Act in 2014, the investigation of these disparities in one of the most common orthopaedic sports medicine procedures performed, ACL reconstruction, is critical. 23 When assessing our primary outcome, despite similar preoperative IKDC scores (53.65 vs 53.95; P ¼ .978) between the 2 cohorts, we found significantly lower postoperative IKDC scores (P ¼ .005) at final follow-up in patients with Medicaid insurance compared with those with private insurance (74.68 vs 90.45, respectively; P ¼ .005).…”

“… 8 , 9 , 10 , 11 , 12 For those undergoing shoulder arthroplasty procedures, patients insured through Medicaid demonstrated greater complication rates, lower follow-up rates, and inferior postoperative PROs. 13 , 14 , 15 Similarly, multiple studies reported inferior PROs in patients insured through Medicaid who underwent a variety of foot and ankle procedures. 16 , 17 Medicaid insurance status also was observed to negatively impact pain scores in patients undergoing upper-extremity orthopaedic surgeries, as well as result in more resource consumption and greater complication rates in those undergoing surgery to treat proximal humerus fractures.…”