TY - JOUR
T1 - Medicaid reimbursement for common orthopedic procedures is not consistent
AU - Casper, David S.
AU - Schroeder, Gregory D.
AU - Zmistowski, Benjamin
AU - Rihn, Jeffery A.
AU - Anderson, D. Greg
AU - Hilibrand, Alan S.
AU - Vaccaro, Alexander R.
AU - Kepler, Christopher K.
N1 - Funding Information:
Drs Casper and Zmistowski have no relevant financial relationships to disclose. Dr Schroeder is a paid consultant for Advance Medical, Zimmer, Medtronic, and Stryker and has received research support from Medtronic Sofamor Danek. Dr Rihn is a paid consultant for Globus Medical and holds stock in XTANT Medical. Dr Anderson is a paid consultant for DePuy, Integrity Medical, and K2M; receives royalties from DePuy; and holds stock in ISD and PST. Dr Hilibrand receives royalties from Amedica and Biomet and holds stock in Lifespine and Paradigm Spine. Dr Vaccaro is a paid consultant for Atlas Spine, DePuy, Gerson Lehrman Group, Globus Medical, Guidepoint Global, Innovative Surgical Design, Medtronic, Nuvasive, Or-thobullets, SpineWave, Stout Medical, and Stryker; receives royalties from Aesculap, Atlas Spine, Globus Medical, Medtronic, Stryker, and SpineWave; and holds stock in Advanced Spinal Intellectual Properties, Avaz Surgical, Bonovo Orthopaedics, Computational Biodynamics, Cytonics, Dimension Orthotics LLC, Electrocore, Flagship Surgical, FlowPharma, Franklin Bioscience, Gamma Spine, Globus Medical, Innovative Surgical Design, Insight Therapeutics, Nuvasive, Paradigm Spine, Parvizi Surgical Innovations, Prime Surgeons, Progressive Spinal Technologies, Replication Medica, Spine Medica, Spinology, Stout Medical, and Vertiflex. Dr Kepler has received research support from Biomet, Medtronic, Pfizer, and Regeneration Technologies, Inc.
Publisher Copyright:
Copyright © 2019 Slack Incorporated.
PY - 2019/3
Y1 - 2019/3
N2 - 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.
AB - 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.
UR - http://www.scopus.com/inward/record.url?scp=85063304024&partnerID=8YFLogxK
U2 - 10.3928/01477447-20181227-06
DO - 10.3928/01477447-20181227-06
M3 - Article
C2 - 30602045
AN - SCOPUS:85063304024
VL - 42
SP - E193-E196
JO - Orthopedics
JF - Orthopedics
SN - 0147-7447
IS - 2
ER -