Study shows Medicaid patients travel disproportionately farther for revision TJA
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Key takeaways:
- Patients travelled a farther median distance for revision TJA compared with primary TJA.
- Patients with Medicaid who had revision TJA travelled farther than patients with either Medicare or commercial insurance.
Results published in the Journal of Arthroplasty showed surgeons may be disproportionately referring Medicaid patients to non-local care centers for revision total hip and revision total knee arthroplasties.
Christopher F. Deans, MD, and colleagues retrospectively reviewed data on 317 revision THAs (rTHA) and 431 revision TKAs (rTKA) performed between Sept. 1, 2010, and Dec. 31, 2020. Researchers used home and hospital ZIP codes to compare driving distances between patients with Medicaid, Medicare and commercial health insurance.
Overall, patients who underwent rTHA drove a median of 18.2 miles farther than patients who underwent primary THA, while patients who underwent rTKA drove a median of 11 miles farther than patients who underwent primary TKA.
Researchers found patients with Medicaid who underwent rTHA travelled a median of 98.4 miles, while patients with Medicare and patients with commercial insurance who underwent rTHA travelled a median of 67.2 miles and 35.6 miles, respectively. Similarly, patients with Medicaid who underwent rTKA travelled a median of 85 miles, while patients with Medicare and patients with commercial insurance who underwent rTKA travelled a median of 43.5 miles and 42.2 miles, respectively.
According to the study, type of insurance coverage had no effect on driving distance for patients who underwent primary THA or TKA.
“In addition to patient burden, these migration patterns potentially present a financial burden to facilities accepting rTJA referrals and transfers,” the researchers wrote in the study. “Investigation of strategies to improve equitable access to revision TJA, while maintaining the highest and most economical standards of care for patients, providers and hospitals are encouraged,” they wrote.
Perspective
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The study by Christopher F. Deans, MD, and colleagues has two important findings: There was significantly greater travel burden for patients requiring revision procedures compared to patients undergoing primary hip or knee procedures, and patients requiring revision hip and knee procedures with Medicaid insurance traveled farther for surgery than non-Medicaid revision hip and knee patients.
We all know that complications are more common in revision arthroplasty cases than in primary ones and several studies have shown that cases done on patients with Medicaid have higher complication rates. While the current study did not indicate greater comorbidity status (age and American Society of Anesthesiologists score) in Medicaid patients, it did not specifically look at case complexity from an orthopedic perspective. It is possible, therefore, that patients with Medicaid, who have had less access to care over time, have more complicated orthopedic problems that require more complex revisions. This could potentially explain why these patients had to travel farther to one of the two academic centers where this study was undertaken. Patients’ travel patterns likely differ by state due in part to differences in percentage of patients and surgeons enrolled in Medicaid, as well as differences in densities of tertiary care centers and (private) joint replacement surgeons that feel comfortable doing revision surgeries. As such, it is unclear if the findings from this study can be generalized to all states. Clearly, as my research team has shown in the past, patient selection (aka “cherry picking”) does occur in certain instances, and while centers that take care of more complex patients tend to be associated with more efficient resource utilization, these centers (and the surgeons who work there) should not be penalized.
This important study sheds more light on the importance of risk-adjustment, payment reform, access to care and equitable distribution of care to patients with Medicaid.
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