Green Clare K, Scanaliato John P, Polmear Michael M, Narimissaei Danielle S, Fitzpatrick Kelly V, Parnes Nata, Dunn John C
School of Medicine and Health Sciences, George Washington University, Washington, DC, USA.
William Beaumont Army Medical Center, El Paso, TX, USA.
J Shoulder Elbow Surg. 2021 Nov;30(11):2543-2548. doi: 10.1016/j.jse.2021.04.016. Epub 2021 Apr 28.
Medicare and Medicaid are 2 of the largest government-run health care programs in the United States. Although Medicare reimbursement is determined at the federal level by the Centers for Medicare & Medicaid Services, Medicaid reimbursement rates are set by each individual state. The purpose of this study is to compare Medicaid reimbursement rates with regional Medicare reimbursement rates for 12 orthopedic procedures performed to treat common fractures of the upper extremity.
Twelve orthopedic procedures were selected and their Medicare reimbursement rates were collected from the 2020 Medicare Physician Fee Schedule. Medicaid reimbursement rates were obtained from each state's physician fee schedule. Reimbursement rates were then compared by assessing the ratio of Medicaid to Medicare, the dollar difference in Medicaid to Medicare reimbursement, and the difference per relative value unit. The range of variation in Medicaid reimbursement and Medicare wage index-adjusted Medicaid reimbursement was calculated. Comparisons in reimbursement were calculated using coefficient of variation and Student t tests to evaluate the differences between the mean Medicaid and Medicare reimbursements. Two-sample coefficient of variation testing was used to determine whether dispersion in Medicare and Medicaid reimbursement rates differed significantly.
There was significant difference in reimbursement rates between Medicare and Medicaid for all 12 procedures, with Medicare reimbursing on average 46.5% more than Medicaid. In 40 states, Medicaid reimbursed less than Medicare for all 12 procedures. Regarding the dollar difference per relative value unit, Medicaid reimbursed on average $18.03 less per relative value unit than Medicare. The coefficient of variation for Medicaid reimbursement rates ranged from 0.26-0.33. This is in stark contrast with the significantly lower variability observed in Medicare reimbursement, which ranged from 0.06-0.07.
Our findings highlight the variation in reimbursement that exists among state Medicaid programs for 12 orthopedic procedures commonly used to treat fractures of the upper extremity. Furthermore, average Medicaid reimbursement rates were significantly lower than Medicare rates for all 12 procedures. Such discrepancies in reimbursement may act as a barrier, impeding many Medicaid patients from accessing timely orthopedic care.
医疗保险（Medicare）和医疗补助（Medicaid）是美国最大的两个政府运营的医疗保健项目。尽管医疗保险的报销金额由联邦医疗保险与医疗补助服务中心确定，但医疗补助的报销率则由各个州自行设定。本研究的目的是比较医疗补助报销率与区域医疗保险报销率，针对治疗上肢常见骨折所施行的12种骨科手术。
选取12种骨科手术，并从《2020年医疗保险医师费率表》中收集其医疗保险报销率。医疗补助报销率则从每个州的医师费率表中获取。然后通过评估医疗补助与医疗保险的比率、医疗补助与医疗保险报销的美元差值以及每个相对价值单位的差值来比较报销率。计算医疗补助报销以及经医疗保险工资指数调整后的医疗补助报销的变化范围。使用变异系数和学生t检验来计算报销方面的比较结果，以评估医疗补助和医疗保险平均报销之间的差异。采用双样本变异系数检验来确定医疗保险和医疗补助报销率的离散程度是否存在显著差异。
所有12种手术的医疗保险和医疗补助报销率存在显著差异，医疗保险的平均报销额比医疗补助高出46.5%。在40个州，医疗补助对所有12种手术的报销都低于医疗保险。就每个相对价值单位的美元差值而言，医疗补助每个相对价值单位的平均报销额比医疗保险少18.03美元。医疗补助报销率的变异系数范围为0.26 - 0.33。这与医疗保险报销中观察到的显著更低的变异性形成鲜明对比，医疗保险报销的变异系数范围为从0.06 - 0.07。
我们的研究结果凸显了各州医疗补助项目在用于治疗上肢骨折的12种骨科手术报销方面存在的差异。此外，所有12种手术的医疗补助平均报销率显著低于医疗保险率。这种报销差异可能成为障碍，阻碍许多医疗补助患者获得及时的骨科护理。
