Department of Orthopaedic Surgery (C.J.D., W.J., and R.J.O.), Center for Administrative Data Research, Division of Infectious Diseases, Department of Medicine (A.D.T., K.B.N., and M.A.O.), and Division of Public Health Sciences, Department of Surgery (C.J.D. and M.A.O.), Washington University School of Medicine, St. Louis, Missouri.
J Bone Joint Surg Am. 2019 Aug 21;101(16):1451-1459. doi: 10.2106/JBJS.18.01198.
There is variability in access to and utilization of orthopaedic care, particularly for those with Medicaid insurance. One potential contributor is perceived unwillingness of surgeons and hospitals to accept underinsured patients. We used administrative data to examine the payer mix for select inpatient orthopaedic surgical procedures at all hospitals within a single region, hypothesizing that the delivery of orthopaedic surgery to Medicaid beneficiaries varies highly at the hospital level.
Using administrative data, we analyzed inpatient hospitalizations for elective cases (total knee or hip arthroplasty; spinal decompression or fusion) and trauma cases (hip hemiarthroplasty; femoral or tibial and fibular fracture repair) among 22 hospitals in a single region from 2011 to 2016 for patients who were 18 to 64 years of age. The primary outcome was the percentage of each hospital's caseload with Medicaid listed as the primary payer. The secondary outcome measured each hospital's Medicaid percentage against the percentage of Medicaid-insured individuals within 10 miles of the hospital (Medicaid share ratio), using a ratio of 1 as a benchmark. To quantify variation, we calculated a weighted coefficient of variation of the Medicaid share ratio for all cases combined, elective cases only, and trauma cases only.
For all cases (n = 19,204), the mean percentage of Medicaid-funded surgical procedures was 7.6% (range, 0.2% to 57.3%). The mean Medicaid share ratio was 1.0 (range, 0.05 to 4.20). Across 22 hospitals, the weighted coefficient of variation for Medicaid share was 69, indicating very high variation. For elective cases alone, the mean percentage of Medicaid-funded surgical procedures was 5.5% (range, 0.2% to 64.6%). The mean Medicaid share ratio was 0.71 (range, 0.05 to 4.73), and the weighted coefficient of variation was 93. For trauma cases alone, Medicaid-funded surgical procedures were 14.7% (range, 0.0% to 35.7%). The mean Medicaid share ratio was 2.0 (range, 0 to 3.93), and the weighted coefficient of variation was 34.
Delivery of care was highly variable when benchmarking against the insurance composition of each hospital's surrounding community. Although generalizability to other regions is limited, our findings support previously asserted notions that delivery of orthopaedic care may differ on the basis of socioeconomic markers (such as insurance status). If not addressed, these inequities may exacerbate existing racially and socioeconomically based disparities in care.
在获得和利用骨科护理方面存在差异，特别是对于那些拥有医疗补助保险的人。一个潜在的原因是外科医生和医院对接受保险不足的患者的意愿。我们使用行政数据检查了一个单一地区内所有医院特定住院骨科手术的支付人组合，假设向医疗补助受益人的骨科手术在医院层面上存在高度差异。
我们使用行政数据，分析了 2011 年至 2016 年间一个单一地区的 22 家医院的择期病例（全膝关节或髋关节置换术；脊柱减压或融合术）和创伤病例（髋关节半髋关节置换术；股骨或胫骨和腓骨骨折修复术）的住院患者，年龄在 18 至 64 岁之间。主要结果是每家医院的病例中以医疗补助为主要支付人的比例。次要结果是，使用医院 10 英里范围内医疗补助保险人数的比例（医疗补助份额比）来衡量每家医院的医疗补助比例，以 1 作为基准。为了量化差异，我们计算了所有病例、择期病例和创伤病例的医疗补助份额比的加权变异系数。
对于所有病例（n = 19204），以医疗补助为资金来源的手术比例平均为 7.6%（范围，0.2%至 57.3%）。医疗补助份额比平均为 1.0（范围，0.05 至 4.20）。在 22 家医院中，医疗补助份额的加权变异系数为 69，表明差异非常大。仅择期病例中，以医疗补助为资金来源的手术比例平均为 5.5%（范围，0.2%至 64.6%）。医疗补助份额比平均为 0.71（范围，0.05 至 4.73），加权变异系数为 93。仅创伤病例中，以医疗补助为资金来源的手术比例为 14.7%（范围，0.0%至 35.7%）。医疗补助份额比平均为 2.0（范围，0 至 3.93），加权变异系数为 34。
以每家医院周边社区的保险构成作为基准时，护理的提供存在高度差异。虽然推广到其他地区的可能性有限，但我们的研究结果支持了先前的观点，即骨科护理的提供可能基于社会经济指标（如保险状况）而有所不同。如果不加以解决，这些不公平现象可能会加剧现有的基于种族和社会经济的护理差异。
