Health care reform: pediatric elective surgery payer mix and utilization under TennCare managed competition.

UNLABELLED

Managed care decreases reimbursement for surgical referral care and may decrease access for elective procedures. This study seeks to determine the impact of Medicaid managed competition on elective pediatric otolaryngology surgery.

DESIGN AND SETTING

Payer mix was analyzed for tonsillectomy and adenoidectomy (T&A) and bilateral myringotomy with ventilation tube insertion (BM&VT) charges for an eight-year period surrounding TennCare implementation. The payer mix for hospital gross charges was analyzed for the same period as a control.

RESULTS

After TennCare implementation, hospital gross charges shifted toward increased TennCare/Medicaid and decreased commercial insurance, whereas charges for the two elective procedures shifted toward increased commercial insurance and decreased TennCare/Medicaid.

CONCLUSION

Otolaryngologists avoided impending losses under TennCare through indirect cost shifting. Numbers of T&A and BM&VT procedures performed on Tenncare/Medicaid patients remained constant, while numbers of these procedures performed on commercially-insured patients increased.