Kassam Hafiz F, Khan Adam Z, Ramirez Miguel
Department of Orthopedic Surgery, Hoag Orthopedic Institute, Irvine, CA, USA.
Department of Orthopedic Surgery, Southern California Permanente Medical Group, Panorama City, CA, USA.
J Shoulder Elbow Surg. 2025 Jan;34(1):375-383. doi: 10.1016/j.jse.2024.08.004. Epub 2024 Sep 20.
Significant discrepancy and variance exist in the United States health care system with regard to patient access to medical care based on a patient's insurance type, whether that be government-assisted or a private insurer. There are currently 3 major government-assisted insurance programs, Medicare, Medicare Advantage, and Medicaid, each of which has its own patient mix and regulatory processes that govern care delivery. The purpose of this study was to evaluate the current perceptions of shoulder and elbow surgeons surrounding practice patterns and barriers to access for patients whose primary insurance is a government-assisted payor.
This was a national, observational study that surveyed the American Shoulder and Elbow Surgeons (ASES) society membership. This 15-question survey assessed surgeon demographics, practice types, reimbursement models, as well as rates and trends of their access to patients with government-assisted insurance. Subgroup analysis between practice type and barriers to access for patients with one of these 3 government-assisted insurance were also analyzed and compared. Pearson χ test or Fisher exact test was used to test association between categorical responses and categorical/binary respondent characteristics. A P value <.05 was deemed statistically significant.
A total of 257 ASES members completed the survey. Mean years in practice for respondents was 14. For Medicare patients, the most common perceived barriers were reimbursement (49%) followed by administrative burden (33%) and then implant reimbursement at the surgeon's primary surgical facility (32%). For Medicare Advantage patients, the most common barrier to access was administrative burden (52%), reimbursement (50%), and the patient's ability to access perioperative services such as physical therapy and home health (40%). The most common barriers for Medicaid patients were relatively evenly distributed between reimbursement (62%), low patient engagement in their care (61%), and patient's ability to access perioperative services (60%).
Among members of the ASES, barriers to patient access varied by government-assisted payor. For Medicare advantage, administrative burden was the largest barrier to access. Whereas for Medicare and Medicaid, reimbursement was the most significant barrier. Further investigation and understanding of these barriers to patient access are necessary to improve availability of shoulder and elbow subspecialized care to a broader population of patients insured by government-assisted payors.
在美国医疗保健系统中，患者获得医疗服务的机会因保险类型（无论是政府资助的还是私人保险公司的）存在显著差异和变化。目前有3个主要的政府资助保险项目，即医疗保险、医疗保险优势计划和医疗补助，每个项目都有自己的患者群体和管理医疗服务提供的监管程序。本研究的目的是评估目前肩肘外科医生对主要保险为政府资助支付方的患者的执业模式和就医障碍的看法。
这是一项全国性的观察性研究，对美国肩肘外科医生（ASES）协会成员进行了调查。这份包含15个问题的调查问卷评估了外科医生的人口统计学特征、执业类型、报销模式，以及他们接诊政府资助保险患者的比例和趋势。还对执业类型与这3种政府资助保险之一的患者就医障碍之间进行了亚组分析和比较。采用Pearson χ检验或Fisher精确检验来检验分类反应与分类/二元应答者特征之间的关联。P值<0.05被认为具有统计学意义。
共有257名ASES成员完成了调查。受访者的平均执业年限为14年。对于医疗保险患者，最常见的就医障碍是报销（49%），其次是行政负担（33%），然后是外科医生主要手术机构的植入物报销（32%）。对于医疗保险优势计划患者，最常见的就医障碍是行政负担（52%）、报销（50%）以及患者获得围手术期服务（如物理治疗和家庭护理）的能力（40%）。医疗补助患者最常见的障碍在报销（62%）、患者对自身护理的参与度低（61%）和患者获得围手术期服务的能力（60%）之间相对均匀分布。
在ASES成员中，患者就医障碍因政府资助支付方而异。对于医疗保险优势计划，行政负担是最大的就医障碍。而对于医疗保险和医疗补助，报销是最主要的障碍。有必要进一步调查和了解这些患者就医障碍，以提高政府资助支付方承保的更广泛患者群体获得肩肘专科护理的机会。
