Editor's Spotlight/Take 5: Does Medicaid Insurance Confer Adequate Access to Adult Orthopaedic Care in the Era of the Patient Protection and Affordable Care Act?

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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.
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