Medicaid insurance as primary payer predicts increased mortality after total hip replacement in the state inpatient databases of California, Florida and New York

Abstract

Study Objective To confirm the relationship between primary payer status as a predictor of increased perioperative risks and post-operative outcomes after total hip replacements. Design Retrospective cohort study. Setting Administrative database study using 2007 – 2011 data from California, Florida, and New York from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Patients 295,572 patients age ≥18 years old who underwent total hip replacement with non-missing insurance data were collected, using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedures code (ICD-9-CM code 81.51). Interventions Patients underwent total hip replacement. Measurements Patients were cohorted by insurance type as either Medicare, Medicaid, Uninsured, Other, and Private Insurance. Demographic characteristics and comorbidities were compared. Unadjusted rates of in-hospital mortality, postoperative complications, LOS, 30-day, and 90-day readmission status were compared. Adjusted odds ratios were calculated for our outcomes using multivariate linear and logistic regression models fitted to our data. Main Results Medicaid patients incurred a 125% increase in the odds of in-hospital mortality compared to those with Private Insurance (OR 2.25, 99% CI 1.01–5.01). Medicaid payer status was associated with the highest statistically significant adjusted odds of mortality, any complication (OR, 1.26), cardiovascular complications (OR, 1.37), and infectious complications (OR, 1.66) when compared with Private Insurance. Medicaid patients had the highest statistically significant adjusted odds of 30-day (OR, 1.63) and 90-day readmission (OR, 1.58) and the longest adjusted LOS. Conclusions We found higher unadjusted rates and risk adjusted odds ratios of postoperative mortality, morbidity, LOS, and readmissions for patients with Medicaid insurance as compared to patients with Private Insurance. Our study shows that primary payer status serves as a predictor of perioperative risks and that primary payer status should be viewed as a peri-operative risk factor.

Response to Letter to the Editor on “Medicaid Insurance Correlates With Increased Resource Utilization Following Total Hip Arthroplasty”

“…The care pathways established at this institution have been optimized, and nonetheless, Medicaid insurance status was found to be an independent predictor of increased resource utilization perioperatively. The included number of Medicaid patients in the study (3.2%) is similar to previous reports utilizing State Inpatient Databases (3.4%) [7]. In the current Medicaid study population, African Americans were a greater proportion (62.9%) compared with Medicare (17.4%) and other insurance coverage (16.8%).…”

Disparities in length of stay for hip fracture treatment between patients treated in safety-net and non-safety-net hospitals

“…These outcomes, however, are not homogenous across the population; researchers have identified differences in hip fracture treatment outcomes among racial and socioeconomic groups [12]. Disparities between groups on health care outcomes may arise from patientlevel factors [13,14] as well as from where patients receive treatment [15][16][17] and their health insurance status [13,14,18]. The primary objective of this study was to examine whether hip fracture treatment outcomes differed between patients who received care at safety-net hospitals (e.g., hospitals with a payer mix consisting of a large share of Medicaid and uninsured patients) and patients who received care at non-safety-net hospitals.…”

Medicaid payer status is associated with increased mortality and morbidity after inpatient shoulder arthroplasty: a multistate analysis, 2007–2014

“…Primary payer was classified into five categories: Medicare (including fee-for-service and managed care patients), Medicaid (including fee-for-service and managed care patients), uninsured (including self-paying patients or with no charge reported), other payer (such as worker’s compensation, military, other government insurers), and private insurance (including Blue Cross Blue Shield, commercial carriers, private Health Maintenance Organizations (HMOs), and private Preferred Provider Organizations (PPOs)) 12. In our multivariate models, we collapsed the primary payer categories of private insurance, other insurance, and Medicare into a single category (collectively referred to as “non-Medicaid”), in order to compare patients with those insurance types with populations insured by Medicaid and the uninsured, individually.…”