Massachusetts Health Care Reform and Reduced Racial Disparities in Minimally Invasive Surgery

Loehrer, Andrew P.; Song, Zirui; Auchincloss, Hugh; Hutter, Matthew M.

doi:10.1001/jamasurg.2013.2750

Cited by 63 publications

(51 citation statements)

References 23 publications

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“…39 Multiple studies have suggested increased surgical referrals and decreased disparities in the receipt of certain procedures after expanded insurance coverage. [40][41][42][43][44][45] However, our data do contrast another recent study that found no change in disparities of coronary revascularization procedures after Massachusetts health care reform, although their analysis was limited by short follow-up data ending in September of 2008, only nine months after implementation of mandate requiring insurance coverage. 46 The HCUP-SID capture nearly 100% of all inpatient admissions across states but are bound by the limitations of administrative data, including the possibility of coding discrepancies and limited clinical granularity better captured in clinical datasets.…”

Section: Discussioncontrasting

confidence: 99%

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Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights from Massachusetts

Loehrer¹,

Hawkins²,

Auchincloss³

2016

Journal of Vascular Surgery

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STRUCTURED ABSTRACTObjective-To evaluate the impact of health insurance expansion on racial disparities in severity of peripheral arterial disease.Summary Background Data-Lack of insurance and non-white race are associated with increased severity, increased amputation rates, and decreased revascularization rates in patients with peripheral artery disease (PAD). Little is known about how expanded insurance coverage affects disparities in presentation with and management of PAD. The 2006 Massachusetts health reform expanded coverage to 98% of residents and provided the framework for the Affordable Care Act.Methods-We performed a retrospective cohort study of non-elderly, white and non-white patients admitted with PAD in Massachusetts (MA) and four control states. Risk-adjusted difference-in-difference models were used to evaluate changes in probability of presenting with severe disease. Multivariable linear regression models evaluated disparities in disease severity before and after the 2006 health insurance expansion.Results-Prior to the 2006 MA insurance expansion, non-white patients in both MA and control states had a 12-13 percentage-point higher probability of presenting with severe disease (P<0.001) than white patients. After the expansion, measured disparities in disease severity by patient race were no longer statistically significant in Massachusetts (+3.0 percentage-point difference, P=0.385) while disparities persisted in control states (+10.0 percentage-point difference, P<0.001). Overall, non-white patients in MA had an 11.2 percentage-point decreased probability of severe PAD (P=0.042) relative to concurrent trends in control states. Conclusions-The 2006Massachusetts insurance expansion was associated with a decreased probability of patients presenting with severe PAD and resolution of measured racial disparities in severe PAD in MA.

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Section: Discussioncontrasting

confidence: 99%

“…The designation of revascularization included all open bypass procedures as well as endovascular interventions (ICD-9-CM 00. 40 48). All amputations of bony structures from the level of hip disarticulation through toe amputation were considered an amputation (ICD-9-CM 84.10 -84.18).…”

Section: Outcome Measuresmentioning

confidence: 99%

Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights from Massachusetts

Loehrer¹,

Hawkins²,

Auchincloss³

2016

Journal of Vascular Surgery

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“…We selected these particular surgical conditions given extensive documentation of disparities in patient presentation with and subsequent care received based on insurance coverage, in addition to data suggesting an association between insurance expansion and care delivery for these conditions. [5][6][7][8][9][10][11][12][13][14] Surgery for appendicitis, cholecystitis, and diverticulitis represent the three most frequent and highest morbidity procedures in general surgery. 20 Vascular diseases, including aortic aneurysm and PAD, are increasingly prevalent in the U.S., and timely appropriate management has been shown to directly impact both mortality and major morbidity.…”

Section: Data Source and Outcomesmentioning

confidence: 99%

“…[13][14][15] However, it is unclear whether the Massachusetts experience generalizes to the ACA's Medicaid expansion.…”

Section: Introductionmentioning

confidence: 99%

Association of the Affordable Care Act Medicaid Expansion With Access to and Quality of Care for Surgical Conditions

et al. 2018

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IMPORTANCE Lack of insurance coverage has been associated with delays in seeking care, more complicated diseases at the time of diagnosis, and decreased likelihood of receiving optimal surgical care. The Patient Protection and Affordable Care Act's (ACA) Medicaid expansion has increased coverage among millions of low-income Americans, but its effect on care for common surgical conditions remains unknown. OBJECTIVE To evaluate the association of the ACA's Medicaid expansion with access to timely and recommended care for common and serious surgical conditions. DESIGN, SETTING, AND PARTICIPANTS This quasi-experimental, difference-in-differences study used hospital administrative data to compare patient-level outcomes in expansion vs nonexpansion states before (2010-2013) vs after (2014-2015) expansion. A total of 293 529 patients aged 18 to 64 years with appendicitis, cholecystitis, diverticulitis, peripheral artery disease (PAD), or aortic aneurysm admitted to an academic medical center or affiliated hospital in 27 Medicaid expansion states and 15 nonexpansion states from January 1, 2010, through September 31, 2015, were included in the study. Data analysis was performed from November 1, 2016, to March 3, 2017. EXPOSURES State adoption of Medicaid expansion.MAIN OUTCOMES AND MEASURES Presentation with early uncomplicated disease (diverticulitis without abscess, fistula, or sepsis; nonruptured aortic aneurysm at time of repair; and PAD without ulcerations or gangrene) and receipt of optimal management (cholecystectomy for acute cholecystitis, laparoscopic approach for cholecystectomy or appendectomy, and limb salvage for PAD). RESULTSOf the 293 529 study patients (128 392 [43.7%] female and 165 137 [56.3%] male), 225 572 had admissions in Medicaid expansion states and 67 957 had admissions in nonexpansion states. Medicaid expansion was associated with a 7.5-percentage point decreased probability of patients being uninsured (95% CI, −12.2 to −2.9; P = .002) and an 8.6-percentage point increased probability of having Medicaid (95% CI, 6.1-11.1; P < .001). Medicaid expansion was associated with a 1.8-percentage point increase in the probability of early uncomplicated presentation (95% CI, 0.7-2.9; P = .001) and a 2.6-percentage point increase in the probability of receiving optimal management (95% CI, 0.8-4.4; P = .006). CONCLUSIONS AND RELEVANCEThe ACA's Medicaid expansion was associated with increased insurance coverage and improved receipt of timely care for 5 common surgical conditions. Health care systems and policymakers should be aware of the influence of insurance coverage expansion (or its repeal) on presentation with and management of surgical disease.

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“…Expanded coverage was associated with increased access to MIS for racial minorities and historically underinsured patients. 52,53 This suggests that a multipronged approach including enhanced education of patients and providers, and policy changes to improve access and incentivize the use of best practices, may be needed to reduce unjustified variation.…”

Section: Discussionmentioning

confidence: 99%

Variation in the Utilization of Minimally Invasive Surgical Operations

Kuo

Murayama²,

Simmons³

et al. 2017

Annals of Surgery

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Massachusetts Health Care Reform and Reduced Racial Disparities in Minimally Invasive Surgery

Cited by 63 publications

References 23 publications

Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights from Massachusetts

Impact of Expanded Insurance Coverage on Racial Disparities in Vascular Disease: Insights from Massachusetts

Association of the Affordable Care Act Medicaid Expansion With Access to and Quality of Care for Surgical Conditions

Variation in the Utilization of Minimally Invasive Surgical Operations

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