Medicaid reimbursement for common orthopedic procedures is not consistent

David S. Casper, Gregory D. Schroeder, Benjamin Zmistowski, Jeffery A. Rihn, D. Greg Anderson, Alan S. Hilibrand, Alexander R. Vaccaro, Christopher K. Kepler

Research output: Contribution to journalArticlepeer-review

12 Scopus citations

Abstract

Two major forms of physician reimbursement include Medicare (MCR; federally funded) and Medicaid (MCD; state funded). The only oversight provided to individual states for setting MCD reimbursement is that it must provide a standard payment that does not negatively affect patient care. The goals of this study were to determine the variability of MCD reimbursement for patients who require orthopedic procedures and to assess how this compares with regional MCR reimbursement. Medicaid reimbursement rates from each state were obtained for total knee arthroplasty, total hip arthroplasty, anterior cruciate ligament repair, rotator cuff repair, anterior cervical decompression and fusion, posterior lumbar decompression, carpal tunnel release, distal radius open reduction and internal fixation, proximal femur open reduction and internal fixation, and ankle open reduction and internal fixation. Discrepancy in reimbursement for these procedures and overall differences in MCD vs MCR reimbursement were determined. Average MCD reimbursement was 81.9% of MCR reimbursement. There was significant variation between states (37.7% to 147% of MCR reimbursement for all 10 procedures). Twenty and 40 states provided less than 75% and 100% of MCR reimbursements, respectively. Medicaid valued knee arthroplasty (91.4% of MCR reimbursement) over other common procedures. Conversely, carpal tunnel release (74.1% of MCR reimbursement; P=.004) had the lowest reimbursements. The most interstate variation was noted for anterior cruciate ligament reimbursement, ranging from 20.6% to 229% of local MCR reimbursement. Disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to understand the impact of these significant differences. It is likely that these discrepancies lead to suboptimal access to necessary orthopedic care.

Original languageEnglish
Pages (from-to)E193-E196
JournalOrthopedics
Volume42
Issue number2
DOIs
StatePublished - Mar 2019

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