Physicians have long assumed that uninsured patients have worse outcomes and are at higher risk for complications given that they tend only to seek medical care once their condition has progressed to something serious. More recently, literature has emerged demonstrating that Medicaid patients are also at increased risk of worse outcomes and complications. Dr. Hacquebord and his colleagues from Seattle wanted to determine if this was true for Medicaid spine surgery patients, so they queried their prospective database including over 1,500 patients to determine if insurance status was an independent risk factor for having a complication. In their multivariate analysis, they found that surgical invasiveness was by far the strongest predictor of suffering any adverse event, while age, heart failure, a bleeding or clotting disorder, surgery for trauma or infection, and having Medicaid were all independent risk factors for having a complication. Medicaid patients had a 68% increase in the odds of having a complication compared to private insurance patients, even after controlling for comorbidities, age, and surgical invasiveness. While Medicare patients had nearly a 3-fold increase in the odds of having a complication compared to private insurance patients in the univariate analysis, after controlling for age, comorbidities, and other risk factors, Medicare was no longer a risk factor.
The question this obviously raises, and is discussed by the authors, is “why are Medicaid patients at higher risk of complications?” The authors suggest two possibilities; the first of which is that being underinsured prevents patients from seeking medical care when needed which predisposes them to complications; the second of which is that Medicaid is simply a marker for other unmeasured characteristics that put patients at risk for complications. The first explanation suggests that being underinsured plays a causal role in suffering an adverse event, while the second suggests only a correlation between Medicaid and worse outcomes. It is likely that both explanations play a role, though the fact that uninsured patients did not have an increased risk of complication suggests that Medicaid may be more of a marker for unmeasured risk factors rather than a direct cause of complications. While only 3% of patients were uninsured, this group was actually at lower risk of adverse event than the private insurance patients, suggesting that underinsurance or lack of insurance was not a driver of complications. Now that it is clear that Medicaid patients are at increased risk of suffering an adverse event, what can be done about it? Healthcare reform leading to high quality universal healthcare would likely address the issue of underinsurance, though it unclear if this is going to occur anytime in the near future. From a practical standpoint, spine surgeons should realize that Medicaid patients are at increased risk of complications and should be more vigilant in their surveillance for complications. One area that puts these vulnerable patients at risk is care after discharge, whether they are discharged home or to rehab. Many of these patients lack a social support network to help them when they get home, and this lack of support can put them at risk of complication. Care should be taken to make sure that patients have a good discharge plan and won’t fall through the cracks after surgery. The authors also point out that in payment models that penalize institutions or providers for complications, risk adjustment models should take Medicaid status into account.
Make sure you read Dr. Hacquebord’s paper in the July 15 issue. Does this article change how you view Medicaid as a risk factor for complications following spine surgery? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor