Primary Payer Status Affects Outcomes for Cardiac Valve Operations

Abstract

Background Disparities in healthcare have been reported among various patient populations, and the uninsured and Medicaid populations are a significant focus of current healthcare reform. The objective of this study was to examine the influence of primary payer status on outcomes following cardiac valve operations in the United States. Methods From 2003-2007, 477,932 patients undergoing cardiac valve operations were evaluated using discharge data from the Nationwide Inpatient Sample (NIS) database. Records were stratified by primary payer status: Medicare (n=57,249, age=74.0±0.02 yrs), Medicaid (n=5,868, age=41.2±0.13 yrs), Uninsured (n=2,349, age=49.7±0.15 yrs), and Private Insurance (n=31,808, age=53.3±0.04yrs). Multivariate regression models were applied to assess the independent effect of payer status on in-hospital outcomes. Results Preoperative patient risk factors were more common among Medicare and Medicaid populations. Unadjusted mortality and complication rates for Medicare (6.9%, 36.6%), Medicaid (5.7%, 31.4%) and Uninsured (5.2%, 31.4%) patient groups were higher compared to Private Insurance groups (2.9%, 29.9%, p<0.001). Moreover, mortality was lowest for patients with Private Insurance for all types of valve operations. Medicaid patients accrued the longest unadjusted hospital length of stay and highest total hospital costs compared to other payer groups (p<0.001). Importantly, after risk adjustment, Uninsured and Medicaid payer status conferred the highest odds of risk adjusted mortality and morbidity compared to Private Insurance status and were higher than those for Medicare. Conclusions Uninsured and Medicaid payer status is associated with increased risk adjusted in-hospital mortality and morbidity among patients undergoing cardiac valve operations compared to Medicare and Private Insurance. Further, Medicaid patients accrued the longest hospital stays and highest total costs. Primary payer status should be considered as an independent risk factor during preoperative risk stratification and planning.

Insurance status predicts acuity of thoracic aortic operations

“…However, after adjustment for baseline differences between patients and case status, the present study found no association between insurance status and patient outcomes. The difference between our study and the findings of LaPar and colleagues14 and 15 may be due to the single-institution design and unique differences in locoregional or hospital practices that relate to insurance status. For instance, all patients requiring thoracic aortic surgery at our hospital undergo operation by the same team of highly experienced surgeons regardless of insurance status,27 which may contribute to the normalization of operative parameters and outcomes between insured and underinsured patients in our study.…”

“…Medicaid is jointly funded by state and federal governments and is a health insurance program that provides health insurance for lower-income people, families and children, the elderly, and people with disabilities 12. Medicaid reimburses practitioners at lower rates than other forms of insurance, and patients with Medicaid are generally considered underinsured 13, 14. and 15…”

“…Prior studies by LaPar and colleagues14 and 15 reported that Medicaid and uninsured payer status confer increased risk-adjusted in-hospital mortality for heart valve and coronary artery bypass graft operations. The explanation for this disparity is unknown but may again relate to decreased postoperative resource use for patients with lesser forms of health insurance or referral to less-experienced surgeons 13.…”

Impact of Medicaid Expansion on Cardiac Surgery Volume and Outcomes

“…Patients undergoing coronary artery bypass grafting (CABG) and cardiac valve operations had longer lengths of stay and higher costs if they had Medicaid, as opposed to those with Medicare, private insurance, or no insurance. [11,12]…”

Disparities in mortality after blunt injury: Does insurance type matter?

“…While Medicaid has been associated with worse outcomes in patients with lung cancer, 25 uterine cancer, 26 in patients undergoing cardiac valve operations, 27 and even after lower-extremity injuries, 28 we found that Medicaid was associated with a relative decrease in odds of death when compared to private insurance coverage. Given the inconsistency of our results with the bulk of the literature, which has shown that private insurance is associated with lower mortality than public insurance, we conducted several sub-group analyses.…”