Wait times for RA hand surgery rose for rural patients, fell for urban patients post-ACA
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Key takeaways:
- After passage of the ACA, hand surgery wait times grew for non-urban patients and decreased for urban patients.
- Per capita cost of diagnosis and treatment fell, but mostly for insurer costs.
After the passage of the Affordable Care Act, wait times for hand surgery increased among patients with rheumatoid arthritis in rural areas and fell for patients in urban areas, according to data published in JAMA Surgery.
“Data on the effects of major health policy measures, like the Affordable Care Act, on hand surgery access are lacking,” Shashank S. Dwivedi, MD, of the University of Michigan Medical School, told Healio. “We wanted to study one common and important medical issue, namely rheumatoid arthritis of the hands, and see how the ACA has affected access to surgical care for the disease.”
Dwivedi and colleagues conducted a cross-sectional study of insurance data from 2009 through 2020 using the IBM MarketScan Research Databases. Their analysis included 3,643 adult patients (83.6% women; mean [standard deviation] age, 57.6 [12.3] years) who underwent hand surgery for RA.
The researchers examined the time to hand surgery, incidence of hand surgery and overall cost of treatment directed at RA of the hand before and after passage of the ACA, defined as 2014 onward. Multivariable linear regression was used to analyze patients by urban vs. non-urban residence and sociodemographic factors, weighed through the Social Deprivation Index (SDI) and other scores.
For patients in urban areas, time to hand surgery decreased by 70.5 days (95% CI, –112.6 to –28.3; P < .001) after the ACA, but increased by 6.7 days (95% CI, –93.5-106.6) for patients in non-urban areas (P = .89). Prior to the ACA, wait times had been greater for urban residents than non-urban residents (41.5 days; 95% CI, –4.1 to 87.2).
The greatest decline in time to surgery after the ACA — 188.8 days — was seen among the least socially disadvantaged patients, as determined by their SDI decile. The average incidence of all RA hand surgeries decreased by 83.4% in the post-ACA period, but this effect was greater among non-urban residents, who saw an 86.3% decrease vs. 82.8% among urban residents (P = .001).
Post-ACA, the per capita total cost of diagnosis and treatment decreased by an average of $20,805 (95% CI, –$51,889-$10,279). Within this overall decrease, insurer-paid costs decreased to a greater magnitude than out-of-pocket costs, the researchers wrote.
“This is surprising because the cost savings realized through the measures of the ACA are clearly not being passed down to patients themselves, at least in this limited arena,” Dwivedi told Healio.
Dwivedi and colleagues concluded that their study “supports increasing access to surgical hand specialists, especially for non-urban patients, and insurance policy reforms to pass decreased costs on to patients.”
“Further studies should evaluate whether this discrepancy in access to surgery for RA is correlated with any differences in outcomes of surgery between patients from urban and non-urban backgrounds,” Dwivedi said.
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