Incentives drive care patterns. This is equally true in health maintenance organizations, commercial fee-for-service systems, structures that care for past and present military personnel and their dependents, and centralized programs like Medicare or Medicaid. This should come as no surprise—incentives drive behavior in all spheres, and the stronger the incentives, the more influence they carry.
And few incentives are stronger than those influencing one's ability to earn a living.
Proponents of the Patient Protection and Affordable Care Act (PPACA, or “Obamacare”) were enthusiastic about the broad increases it provided in basic healthcare coverage. The enthusiasm seemed reasonable; PPACA provided insurance to millions of individuals who previously had none. But critics feared that the low levels of reimbursement provided by Medicaid expansion under Obamacare might provide insufficient financial incentive to care for these newly insured patients, resulting in the mere appearance of coverage, with little or no improvements to actual health or even access.
As candidates drop-kicked this political football from Iowa to New Hampshire and beyond, and as armchair philosophers talked about it like the weather, the research group led by Jeffrey A. Rihn MD, at Thomas Jefferson University Hospital and the Rothman Institute, set out to evaluate PPACA's actual effects on access to care. They published their findings—required reading, in my estimation—in this month's issue of Clinical Orthopaedics and Related Research®.
Using a “secret shopper” approach, posing as a patient with a new ankle fracture who needed followup (and who had either commercial insurance or Medicaid), Dr. Rihn's team called both academic and private groups in four states. The simulated Medicaid patient's experience was far worse than that of the patient with commercial coverage. The researchers supplemented this experiment with a broad-based national practice survey evaluating access to care for Medicaid patients, and whether differences state-by-state reimbursement rates were associated with differential access. As reimbursement rates increased, so did Medicare access. In addition, at the same reimbursement levels, academic practices were more likely to take Medicaid patients than were private practices. Finally, states that expanded Medicaid after PPACA did not appear to provide broader orthopaedic access than states that did not expand Medicare under Obamacare.
The authors’ findings and their thoughtful analyses provide critical perspective about Obamacare's successes and shortcomings, as well as what it might take to expand coverage to the broadest-possible cross-section of the US population. Join me for the Take-5 interview that follows. It is a must-read for anyone who does surgery in the United States, or who cares about the influence of incentives on behavior.
Take Five Interview with Jeffrey A. Rihn MD, senior author of “Does Medicaid Insurance Confer Adequate Access to Adult Orthopaedic Care in the Era of the Patient Protection and Affordable Care Act?”
Seth S. Leopold MD:Congratulations on this unusual and well-conducted study. While the hypothetical patient with Medicaid in your study was turned away by about half the practices surveyed, that still meant that half were willing to care for him. Presumably, those odds would have been vastly worse if the patient had been entirely without coverage. To what degree does this validate Obamacare as a good initial step towards providing basic care to a large and diverse constituency?
Jeffrey A. Rihn MD: While Obamacare did expand Medicaid coverage to millions of adults, it is pretty clear from this study that it remains difficult for many individuals with Medicaid to obtain appointments and subsequent care. Studies that looked at this issue prior to Obamacare and Medicaid expansion had similar findings: A large portion of patients with Medicaid could not obtain an appointment for various orthopaedic problems. I think that the proportion of practices and physicians that accepted Medicaid insurance before and after Obamacare was implemented is similar. What Obamacare did, however, was to increase the number of adult patients with Medicaid that are trying to get appointments with those practices or physicians that accept Medicaid insurance. On some level, this may have actually made it harder for patients to get an appointment, since more patients are trying to get into the same number of accepting physician offices. Obamacare expanded Medicaid to more adults, but did not really do anything to improve the proportion of orthopaedic specialists that accept Medicaid insurance.
Dr. Leopold:I assume you were not surprised that a patient whose coverage reimburses the provider poorly would experience less access to care than a patient with more-remunerative coverage. What did surprise you in the course of doing this work, and how did your unexpected findings change your perspective on the subject you studied?
Dr. Rihn: You are correct; the main findings of this study were not surprising to us. The study served as a means of analyzing the access to orthopaedic care for adult patients with Medicaid insurance in the era of Obamacare and Medicaid expansion, and the results were essentially what we predicted they would be. It was interesting that a national survey produced seemingly different results than the fictitious patient survey. In the national survey, we did not attempt to schedule an appointment of any kind, but rather just inquired as to whether or not the adult orthopaedic practice accepted Medicaid insurance. In this national survey, 72% of private and 93% of academic adult orthopaedic practices stated that they accept Medicaid insurance. With the fictitious patient survey, we actually tried to make an appointment for acute fracture care in an adult patient with Medicaid insurance. Only 36% of the surveyed practices offered the patient an appointment within 2 weeks. This number is reported to be as low as 20% in patients with Medicaid trying to secure and appointment for carpal tunnel release surgery . These findings suggest that a practice's overall policy of “accepting Medicaid insurance” does not necessarily translate into patients obtaining timely orthopaedic appointments. Although the exact reason for this discrepancy was not studied, there are some likely explanations, including that only some of the physicians in the group actually accept Medicaid insurance, the acceptance of Medicaid patients is limited only to those patients seen in emergency rooms, and physicians may limit the number of Medicaid-insured individuals they will see in a given week.
Dr. Leopold:It seems an odious proposition that one's financial situation should be tied so directly into one's likelihood of achieving good health. And yet there is no right to healthcare in this country as there is in so many others. What can be the philosophical justification for this, or are the reasons for the system in the United States driven entirely by practical concerns?
Dr. Rihn: I have to start with the caveat that I do not consider myself an expert in healthcare policy. The primary justification that most assert for our current system of healthcare is that we live in an individualist, capitalist society, not a socialist one. In this system, healthcare is treated as a commodity driven by the market, and the provider of services profits from those services. Healthcare is provided to those who cannot afford it by the government, but many people fall through the cracks. In contrast, in socialist societies, healthcare is a collective business shared by society as a whole and guaranteed to all. The most-lauded benefit of our system is the encouragement and fostering of innovation, which leads to cutting-edge medical advances. However, many of these innovations are only available to those who can afford them. This creates a paradox. In the land where “all men are created equal,” we have a disparity in access to quality healthcare. The PPACA greatly expanded coverage, but it did not accomplish universal healthcare coverage, and as our study found, it did not address the underlying access-to-care issues for patients with Medicaid. The United States is out of step with the majority of developed nations in terms of striving to provide “the highest attainable standard of physical and mental health” to all of its citizens, which is recognized by the International Covenant on Social, Economic, and Cultural Rights . Further, this covenant requires that “steps should be taken by the States Parties to achieve the full realization of this right …” This international treaty has been signed and ratified by 165 nations. The United States is one of only six nations that have signed but not ratified this treaty; an additional 27 nations, including Qatar, Samoa, Oman, Saint Kitts and Nevis, Saint Lucia, and Bhutan, have not signed it . The United States lags behind most developed nations in ratifying this fundamental human rights treaty and in meeting this healthcare obligation. The framework for ensuring this coverage does not have to be the same as that used by other developed nations. We live in a country known for its ability to innovate, and in an area as critical as fundamental healthcare, I am hopeful that the collective idea bank here ultimately will be successful in finding a solution that not only protects innovation and cutting-edge medical advances, but also succeeds in guaranteeing high-level, quality healthcare to all citizens.
Dr. Leopold:And on the practical side, if one accepts that it is difficult for any practice to make ends meet caring for Medicaid patients, what can or should be done to better share the burden across academic and private groups? What are some specific, reasonable next steps to increase surgeons’ participation in Medicare? To make this more interesting, assume arguendo that increasing Medicare reimbursements is not an option.
Dr. Rihn: Assuming that increasing reimbursement is not an option, the next-best way to increase meaningful access to care may be to encourage a consistent professional obligation to provide access to care for the medically underserved population. Such an “access-to-care” push would likely have to be implemented at the societal level, perhaps through the American Academy of Orthopaedic Surgeons. A program or initiative at that level to organize, recognize, and possibly even incentivize participation amongst orthopaedic surgeons might go a long way towards improving access to orthopaedic care. Such a program will not fully meet the needs of the medically underserved, but it may make this issue more visible amongst orthopaedic surgeons and it could improve the current situation.
Dr. Leopold:What topics of social interest are you exploring now? Any preliminary findings you can tease us with?
Dr. Rihn: We recently completed a statewide 33-item survey of orthopaedic surgeons addressing access to care for patients with Medicaid, Medicare, private insurance, and evaluating the effect Obamacare has had on access to orthopaedic care. This is an attempt to further understand the issues that affect access to care from the orthopaedic surgeon's standpoint and explore possible solutions. We found that 50% of practicing orthopaedic surgeons accepted Medicaid insurance and 98% accepted Medicare insurance. Sixty-one percent of those surveyed felt that privately insured patients have more substantial barriers to orthopaedic care in the Obamacare era due to various reasons, including higher deductibles and insurance denials. Only 21% of those surveyed felt as though the PPACA improved access to orthopaedic care. We are planning to administer this survey nationally.