Medicaid & surgical complictions

[101N]

Medicaid Status is Associated With Higher Complication Rates After Spine Surgery
Hacquebord, Jacques M.D.; Cizik, Amy M. M.P.H., M.S.; Malempati, S. Harsha M.D.; Konodi, Mark A. M.S.; Bransford, Richard J. M.D.; Bellabarba, Carlo M.D.; Chapman, Jens M.D.; Lee, Michael J. M.D.

Spine . POST ACCEPTANCE, 15 April 2013
doi: 10.1097/BRS.0b013e3182959b68

Abstract

Study Design. Multivariate analysis of prospectively collected registry data

Objective. To determine the affect of payor status on complication rates after spine surgery.

Summary of Background Data. Understanding the risk of perioperative complications is an essential aspect in improving patient outcomes. Previous studies have looked at complication rates after spine surgery and factors related to increased perioperative complications. In other areas of medicine, there has been a growing body of evidence gathered to evaluate the role of payor status on outcomes and complications. Several studies have found increased complication rates and inferior outcomes in the uninsured and Medicaid insured.

Methods. The XX Registry (XX-XX) is a collection of prospectively collected data on all patients who underwent spine surgery at our two institutions. Extensive demographic data, including payor status, and medical information were prospectively recorded as described previously by Mirza et al. Medical complications were defined in detail a priori and were prospectively recorded for at least 2 years after surgery. Using univariate and multivariate analysis, we determined risk of postoperative medical complications dependent on payor status.

Results. 1591 patients underwent spine surgery in 2003 and 2004 that met our criteria and were included in our analysis. With the multivariate analysis and by controlling for age, patients whose insurer was Medicaid had a 1.68 odds ratio (95% CI: 1.23, 2.29, p = 0.001) of having any adverse event when compared to the privately insured.

Conclusion. After univariate and multivariate analyses, Medicaid insurance status was found to be a risk factor for postoperative complications. This corresponds to an ever-growing body of medical literature that has shown similar trends and raises the concern of underinsurance.

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[Ligament]

Concern of underinsurance?? LOL how socialist. How about concern of being a failure at life?

 

[Ducttape]

Concern of underinsurance?? LOL how socialist. How about concern of being a failure at life?

ugh.

30% of 20 year olds do not have any health insurance. they make up 25% who have no insurance. 13 million people, people starting out on the job market. are you calling them all failures?

there is a significant portion of people out there that cant afford health insurance and are working hard. your viewpoint that not having insurance is equivalent of being a failure in life is fairly presumptuous and elitist.


(ps Medicaid goes to 8.8 million disabled people, and 11 million low income people)

 

[lobelsteve]

ugh.

30% of 20 year olds do not have any health insurance. they make up 25% who have no insurance. 13 million people, people starting out on the job market. are you calling them all failures?

there is a significant portion of people out there that cant afford health insurance and are working hard. your viewpoint that not having insurance is equivalent of being a failure in life is fairly presumptuous and elitist.


(ps Medicaid goes to 8.8 million disabled people, and 11 million low income people)

Sure more data is needed but the trend in the literature is that caid means bad outcomes in general. Our practice does not accept caid for this and the obvious other reasons.

 

[Jcm800]

Sure more data is needed but the trend in the literature is that caid means bad outcomes in general. Our practice does not accept caid for this and the obvious

I am with Steve on this. Regardless of the social implications, If a group has shown now in the literature as well as on a day to day basis to have poorer outcomes, all the social pandering around it doesn't change the bottom line. They have poorer outcomes, and we should avoid these patients.

 

[emd123]

What if Medicaid is their secondary? Do you still not accept? (ie Primary:Medicare, Secondary ins: Medicaid)

 

[lobelsteve]

What if Medicaid is their secondary? Do you still not accept? (ie Primary:Medicare, Secondary ins: Medicaid)

If secondary we will see, but we do not file and the patient is responsible for all costs up front.

 

[geauxg8rs]

Going to see less and less groups take as we increasingly get paid based on outcomes

 

[SSdoc33]

ugh.

30% of 20 year olds do not have any health insurance. they make up 25% who have no insurance. 13 million people, people starting out on the job market. are you calling them all failures?

there is a significant portion of people out there that cant afford health insurance and are working hard. your viewpoint that not having insurance is equivalent of being a failure in life is fairly presumptuous and elitist.


(ps Medicaid goes to 8.8 million disabled people, and 11 million low income people)

The working 20 year olds are not the ones getting spine surgery.

We all know that 'disabled' is in the eye of the beholder.

'Failure in Life' is definitely harsh, but not necessarily untrue.

 

[Jcm800]

The working 20 year olds are not the ones getting spine surgery.

We all know that 'disabled' is in the eye of the beholder.

'Failure in Life' is definitely harsh, but not necessarily untrue.

Good point the 20 year old medicaids I see typically are not working, do not have clean urine, and have a lawsuit pending from an accident of a sort

 

[pmrmd]

What defines a complication? The article does not say. Most of the common things I think of would not be unexpected. Also, I would not think an article needs to be published to confirm the obvious.

 

[nvrsumr]

Sure more data is needed but the trend in the literature is that caid means bad outcomes in general. Our practice does not accept caid for this and the obvious

I am with Steve on this. Regardless of the social implications, If a group has shown now in the literature as well as on a day to day basis to have poorer outcomes, all the social pandering around it doesn't change the bottom line. They have poorer outcomes, and we should avoid these patients.

Not treating wc? In some states that might be reasonable financially but comp is a good payor in co.

 

[Jcm800]

Not treating wc? In some states that might be reasonable financially but comp is a good payor in co.

Good payer or not, I avoid WC, to my financial detriment, but to my psychological benefit.

I don't turn them away, but I don't pander to get them. And I nip it in the bud when it is BS, which is mainly always.

 

[101N]

http://www.ncbi.nlm.nih.gov/pubmed/18547726

Pain. 2008 Aug 31;138(2):440-9. doi: 10.1016/j.pain.2008.04.027. Epub 2008 Jun 10.
Trends in use of opioids for non-cancer pain conditions 2000-2005 in commercial and Medicaid insurance plans: the TROUP study.
Sullivan MD, Edlund MJ, Fan MY, Devries A, Brennan Braden J, Martin BC.
Source
Department of Psychiatry and Behavioral Sciences, Division of Consultation-Liaison Psychiatry, University of Washington, Box 356560, 1959 NE Pacific Street, Seattle, WA 98195-6560, USA. [email protected]
Abstract
Opioids are widely prescribed for non-cancer pain conditions (NCPC), but there have been no large observational studies in actual clinical practice assessing patterns of opioid use over extended periods of time. The TROUP (Trends and Risks of Opioid Use for Pain) study reports on trends in opioid therapy for NCPC in two disparate populations, one national and commercially insured population (HealthCore plan data) and one state-based and publicly-insured (Arkansas Medicaid) population over a six year period (2000-2005). We track enrollees with the four most common NCPC conditions: arthritis/joint pain, back pain, neck pain, headaches, as well as HIV/AIDS. Rates of NCPC diagnosis and opioid use increased linearly during this period in both groups, with the Medicaid group starting at higher rates and the HealthCore group increasing more rapidly. The proportion of enrollees receiving NCPC diagnoses increased (HealthCore 33%, Medicaid 9%), as did the proportion of enrollees with NCPC diagnoses who received opioids (HealthCore 58%, Medicaid 29%). Cumulative yearly opioid dose (in mg. morphine equivalents) received by NCPC patients treated with opioids increased (HealthCore 38%, Medicaid 37%) due to increases in number of days supplied rather than dose per day supplied. Use of short-acting Drug Enforcement Administration Schedule II opioids increased most rapidly, both in proportion of NCPC patients treated (HealthCore 54%, Medicaid 38%) and in cumulative yearly dose (HealthCore 95%, Medicaid 191%). These trends have occurred without any significant change in the underlying population prevalence of NCPC or new evidence of the efficacy of long-term opioid therapy and thus likely represent a broad-based shift in opioid treatment philosophy.

 

[Ducttape]

Sure more data is needed but the trend in the literature is that caid means bad outcomes in general. Our practice does not accept caid for this and the obvious other reasons.

I understand the logic of not accepting Medicaid from a financial reason... But does it not seem more appropriate that patients with poorer potential outcomes be seen by specialists such as ourselves, rather than be treated only by the PCP?

Perhaps part (not all) of the problem is that some of these patients are not given access to proper care and this is what directly causes the poor outcome?

(Aldo, ED docs are now primary caregivers of a significant number of uninsured patients... Who have also as a group shown poorer outcomes.)

This is a system/societal problem that none of us will be able to rectify, even with this so-called ACA.

 

[Aether2000]

Medicaid patients are far more likely to engage in drug diversion, substance abuse, smoking, have lower education, and have lost their social and ethical compass. Their modus operandi is for passive treatment methods while continuing their self destructive behaviors. Active interventions (physical therapy and other functional restoration methods) take a back seat to watching TV. Obesity is rampant. Frequent doctor's appointment misses are common even when they have adequate transportation and there is no logical reason that can be given to miss appointments.

Medicaid for many is not simply a social insurance program: it is a lifestyle of self imposed poor health habits, doing drug deals to make the rent, and inability to plug in to the normal social mores of society.

For these reasons, they make poor choices for pain management treatment.

 

[Jcm800]

"Medicaid is a disease, and I'm the cure...."


"I'm sorry, we do not accept your 'insurance'. No I don't know who does. I suggest you call Medicaid. No I don't know what you are going to do now, since we have never seen you befiore, No, I don't think we are required to see you because your pcp sent you here to get pain medications. Yes I understand you were in a car accident 3 years ago, and that you have 5 'bad' discs,even though you have never had an MRI. Yes I understand both your disability lawyer and your personal injury lawyer guaranteed we would see you. Yes I understand your back has been really bad since standing in line for hours for the. New iPhone..."

 

[lobelsteve]

But does it not seem more appropriate that patients with poorer potential outcomes be seen by specialists such as ourselves, rather than be treated only by the PCP?

This is a system/societal problem that none of us will be able to rectify, even with this so-called ACA.

It does not seem more appropriate. It is a waste of my time, education, experience, and training when I can see a patient that might desire to improve. I have not seen a patient on medicaid that had any desire to do anything other than get more free stuff from my tax dollars.

I do not treat because I do not think I can help because I believe they do not want help.
But I can give them your number....

I'm sure there are folks who are on MC/Mcaid that I do see because they are disabled from trauma and resultant multiple surgeries, or MS, or ALS, or cancer, or RA. Many of these folks still fail out of clinic.

 

[nvrsumr]

I can't believe I am going to stand up for mediciad patients but my experience is very different from what has been described. I find a large population of working poor willing to drive over a hundred miles to see the only pain doc in the state who takes their insurance outside of a hospital setting. Most have multiple longstanding pain complaints and are incredibly grateful to finally see a specialist. I get homemade cookies, cakes, burritos and thank you cards.

My main tool to screen out patients with major personality disorders whether Medicaid, cash pay, Wc, auto lien or private insurance is not to write for candy. It's that easy.

 

[Ligament]

ugh.

30% of 20 year olds do not have any health insurance. they make up 25% who have no insurance. 13 million people, people starting out on the job market. are you calling them all failures?

there is a significant portion of people out there that cant afford health insurance and are working hard. your viewpoint that not having insurance is equivalent of being a failure in life is fairly presumptuous and elitist.


(ps Medicaid goes to 8.8 million disabled people, and 11 million low income people)

Right. Tons of 20 year old hard working medicaid recipients getting SPINE surgery. Thanks for reminding me.

 

[powermd]

Medicaid patients are far more likely to engage in drug diversion, substance abuse, smoking, have lower education, and have lost their social and ethical compass. Their modus operandi is for passive treatment methods while continuing their self destructive behaviors. Active interventions (physical therapy and other functional restoration methods) take a back seat to watching TV. Obesity is rampant. Frequent doctor's appointment misses are common even when they have adequate transportation and there is no logical reason that can be given to miss appointments.

Medicaid for many is not simply a social insurance program: it is a lifestyle of self imposed poor health habits, doing drug deals to make the rent, and inability to plug in to the normal social mores of society.

For these reasons, they make poor choices for pain management treatment.

Wow, that was really well said.

Totally reflects my experience with Medicaid in my state. Of course, there are exceptions to the rule, and small number of my favorite patients are on Medicaid. We take Medicaid because it pays well enough here to help cover overhead, and we have lots of patient slots with 4 NPs. It would probably piss off our referring docs if we stopped taking it all together.

Last week I had an early 20s female patient with 'Caid tell one of my NPs she was just getting shots to show her PCP she was "doing something" so he might give in to her requests for narcs. He sent her back for MBBs! Surprisingly, she didn't even wince. Hopefully that will be the last we see of her.

 

[SSdoc33]

"Medicaid is a disease, and I'm the cure...."


"I'm sorry, we do not accept your 'insurance'. No I don't know who does. I suggest you call Medicaid. No I don't know what you are going to do now, since we have never seen you befiore, No, I don't think we are required to see you because your pcp sent you here to get pain medications. Yes I understand you were in a car accident 3 years ago, and that you have 5 'bad' discs,even though you have never had an MRI. Yes I understand both your disability lawyer and your personal injury lawyer guaranteed we would see you. Yes I understand your back has been really bad since standing in line for hours for the. New iPhone..."

Love it

 

[Ducttape]

It does not seem more appropriate. It is a waste of my time, education, experience, and training when I can see a patient that might desire to improve. I have not seen a patient on medicaid that had any desire to do anything other than get more free stuff from my tax dollars.

I do not treat because I do not think I can help because I believe they do not want help.
But I can give them your number....

I'm sure there are folks who are on MC/Mcaid that I do see because they are disabled from trauma and resultant multiple surgeries, or MS, or ALS, or cancer, or RA. Many of these folks still fail out of clinic.

I'm sorry, it's my fault - I forgot that I'm a specialist now.

For years, as a board certified internist and a practicing emergency medicine doc, I was a generalist. I find myself on the "wrong side" of the divide that separates generalists from specialists - doctors who feel that all patients should be cared for vs. those doctors who feel that there are only select patients worth a specialists attention and care

I need to reorient myself and give up on all those losers and certain insurances with let their PCP write tons of inappropriate opioids at excessive doses etc....

 

[painstop]

"Medicaid is a disease, and I'm the cure...."


"I'm sorry, we do not accept your 'insurance'. No I don't know who does. I suggest you call Medicaid. No I don't know what you are going to do now, since we have never seen you befiore, No, I don't think we are required to see you because your pcp sent you here to get pain medications. Yes I understand you were in a car accident 3 years ago, and that you have 5 'bad' discs,even though you have never had an MRI. Yes I understand both your disability lawyer and your personal injury lawyer guaranteed we would see you. Yes I understand your back has been really bad since standing in line for hours for the. New iPhone..."

Awesome!

 

[VA Hopeful Dr]

Wow, that was really well said.

Totally reflects my experience with Medicaid in my state. Of course, there are exceptions to the rule, and small number of my favorite patients are on Medicaid. We take Medicaid because it pays well enough here to help cover overhead, and we have lots of patient slots with 4 NPs. It would probably piss off our referring docs if we stopped taking it all together.

Last week I had an early 20s female patient with 'Caid tell one of my NPs she was just getting shots to show her PCP she was "doing something" so he might give in to her requests for narcs. He sent her back for MBBs! Surprisingly, she didn't even wince. Hopefully that will be the last we see of her.

As a PCP, I hope you included that quote in your note back to her PCP. That's the kind of thing I appreciate knowing.

 

[lonelobo]

Guess our Practice is an outlier here.
we accept Medicaid as well as every other type of insurance.

Is the turd quotient a little higher with medicaid pts?, ya probably.

But according to the majority on this board every medicaid pt is a drug seeker and
and a worthless piece of human flesh.

This has not been my experience, in fact some my worst pts(besides WC) have
the best insurance. These are usually the most needy with a true sense of entitlement.

We screen all our pts the same before 1st visit, and the percentage of Medicaid pts on narcotics vs medicare or other insurances is the same if not lower at our clinic.

 

[Tenesma]

we screen that population heavily since there are some patients on medicaid who truly need help and guidance...

 

[bedrock]

Medicaid patients are far more likely to engage in drug diversion, substance abuse, smoking, have lower education, and have lost their social and ethical compass. Their modus operandi is for passive treatment methods while continuing their self destructive behaviors. Active interventions (physical therapy and other functional restoration methods) take a back seat to watching TV. Obesity is rampant. Frequent doctor's appointment misses are common even when they have adequate transportation and there is no logical reason that can be given to miss appointments.

Medicaid for many is not simply a social insurance program: it is a lifestyle of self imposed poor health habits, doing drug deals to make the rent, and inability to plug in to the normal social mores of society.

For these reasons, they make poor choices for pain management treatment.

I believe that about 85% of Medicaid patients fit the description by Algos, although the number is probably 95% in deep south/midwest where disability/welfare is such a lifestyle.

Our multi-specialty practice will be dropping Medicaid in the near future. Currently they are 10% of our patients, but 80% of our problems. As Obama and other keep cutting our pay, we just can't continue charity care. The margins aren't there anymore.

The vast majority of medicaid patients are not good candidates for multi-disciplinary pain care. Most psychologist/psychiatrists don't take medicaid. Half of PTs don't take medicaid. They won't get complimentary treatments I suggest, because these are all out of pocket. And many have quite the entitled attitude and often harass my staff, which really pisses me off as my taxes are funding their care, while I lose money from the time I take to care for them.

I feel bad for the 10% of the medicaid patients I could help, but the lost revenue, headaches, wasted time from the other 90% just aren't worth it.

 

[PinchandBurn]

I believe that about 85% of Medicaid patients fit the description by Algos, although the number is probably 95% in deep south/midwest where disability/welfare is such a lifestyle.

Our multi-specialty practice will be dropping Medicaid in the near future. Currently they are 10% of our patients, but 80% of our problems. As Obama and other keep cutting our pay, we just can't continue charity care. The margins aren't there anymore.

The vast majority of medicaid patients are not good candidates for multi-disciplinary pain care. Most psychologist/psychiatrists don't take medicaid. Half of PTs don't take medicaid. They won't get complimentary treatments I suggest, because these are all out of pocket. And many have quite the entitled attitude and often harass my staff, which really pisses me off as my taxes are funding their care, while I lose money from the time I take to care for them.

I feel bad for the 10% of the medicaid patients I could help, but the lost revenue, headaches, wasted time from the other 90% just aren't worth it.

you make a good point. Most arent willing to buy into the multi disciplinary approach, but are ok with buying cigarettes and gadgets.....