Evolving Trends in Insurance Coverage of Vascular Surgery Patients in Academic Practice

Accepted Manuscript Evolving Trends in Insurance Coverage of Vascular Surgery Patients in Academic Practice Anahita Dua, MD MS MBA, Kara Rothenberg, Gunjan Srivastava, MD, Kellie Brown, MD, Brian Lewis, MD, Peter Rossi, MD, Gary Seabrook, MD, Michael Malinowski, MD, Max Wohlauer, MD, Cheong J. Lee, MD PII:

S0890-5096(18)30890-2

DOI:

https://doi.org/10.1016/j.avsg.2018.09.011

Reference:

AVSG 4128

To appear in:

Annals of Vascular Surgery

Received Date: 14 February 2018 Revised Date:

23 May 2018

Accepted Date: 20 September 2018

Please cite this article as: Dua A, Rothenberg K, Srivastava G, Brown K, Lewis B, Rossi P, Seabrook G, Malinowski M, Wohlauer M, Lee CJ, Evolving Trends in Insurance Coverage of Vascular Surgery Patients in Academic Practice, Annals of Vascular Surgery (2018), doi: https://doi.org/10.1016/ j.avsg.2018.09.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Evolving Trends in Insurance Coverage of Vascular Surgery Patients in Academic

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Practice

3 Anahita Dua MD MS MBA1,2, Kara Rothenberg1, Gunjan Srivastava MD2, Kellie Brown

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MD2, Brian Lewis MD2, Peter Rossi MD2, Gary Seabrook MD2, Michael Malinowski

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MD2, Max Wohlauer MD2, Cheong J. Lee MD2.

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Division of Vascular Surgery, Stanford Health Care, Stanford, CA, USA

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Medical College of Wisconsin, Brookfield, WI, USA.

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Presented at the Midwestern Vascular Surgical Society Chicago, IL September 2017

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13 No disclosures or conflicts of interest

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Cheong J Lee MD

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Department of Surgery

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Medical College of Wisconsin

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8701 Watertown Plank Road

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Milwaukee, WI 53045

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[email protected]

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ABSTRACT

25 Objectives: Insurance coverage of vascular surgery patients may differ from patients with

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less chronic surgical pathologies. The goal of this study is to identify trends in insurance

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status of vascular surgery patients over the last 10 years at a busy academic center.

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Methods: All consecutive patient visits for a vascular procedure from 2006 to 2016 were

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retrospectively reviewed from a prospectively collected institutional database. Data

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points included insurance status, procedures performed, and date of admission. Insurance

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status was categorized as Medicare, Medicaid, and uninsured. Samples were divided

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between 2006-2009 and 2011-2016 for comparison. Unpaired t-test, Chi-square and

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regression analysis were used to determine significant trends over the study period.

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Results: From 2006-2016, 6007 vascular surgery procedures were performed. Procedure

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volume increased significantly from 1309 to 4698 between the two timeframes (p<0.05),

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while the percentage of Medicaid and Medicare patients trended upward but did not

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achieve significance. There was a significant decrease in the percentage of uninsured

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patients between the cohorts (5.65% vs. 2.96%, p<0.05). In 2012, 10.14% of patients

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were uninsured, compared to 2.56% in 2016 (p<.05).

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Conclusions: Insurance status affects access to care and subsequent outcomes. In our

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busy academic center, insurance coverage for vascular surgery has significantly increased

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over the past decade. The number of Medicaid and Medicare patients has slowly

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increased, but a significant and continuing decline in uninsured patients was observed.

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Implementation of the Affordable Care Act during this time period may have played a

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role in providing coverage for patient needing vascular surgery.

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50 INTRODUCTION

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Health insurance status influences access to care from primary preventative interventions

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to high-acuity surgery. In vascular surgery, uninsured status has been associated with

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increased operative mortality rates for elective and emergent abdominal aortic aneurysm

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repair [1, 2], increased acuity in thoracic aortic intervention[3], and higher rates of post-

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revascularization amputation [4]. The Affordable Care Act (ACA) is associated with

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increased utilization of elective surgery across all fields [5], but its impact on vascular

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surgery patients is less well described.

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While not all adults enroll in ACA coverage, the ACA could be particularly beneficial for

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vascular surgery patients. Since vascular pathophysiology is a chronic, progressive

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disease, more vascular patients are eligible for insurance coverage under the ACA as

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limitations on pre-existing conditions are lifted. This increased coverage may influence

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vascular surgery outcomes as patients obtain access to preventative services.

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In order to better investigate the influence of insurance expansion policies in vascular

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surgery, we must first determine whether or not vascular surgery patients are indeed

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utilizing the ACA. We therefore designed this retrospective review of the vascular

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surgery patients at our academic center to identify trends in insurance status over the past

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10 years.

72 METHODS

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Patient charts were retrospectively reviewed for all consecutive visits, both inpatient and

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ambulatory, in patients > 18 years old who underwent a vascular procedure from 2006 to

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2016. All trauma patients were excluded. The charts were identified from a prospectively

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collected institutional database at the Medical College of Wisconsin, a tertiary referral

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center for vascular care. These were consecutive patient visits and if a patient had

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multiple procedures performed the index procedure was counted towards this study.

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Data points included insurance status, procedures performed, and date of admission.

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Insurance status was categorized as Medicare, Medicaid, and Uninsured. Private payer

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patients were excluded. Data points were then divided between 2006-2009 and 2011 to

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2016 for comparison. The year 2010 was excluded given that this was the year the ACA

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was rolled out nationally and not all centers had adopted it. The pre-ACA and post-ACA

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cohorts were compared to determine trends in insurance coverage and the association

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with the volume of vascular patients seen.

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Unpaired t-test, chi-square testing and regression analysis was performed to determine

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significant trends over the study period. This study was reviewed and approved by the

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institutional review board (IRB)

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RESULTS

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From 2006-2016, 6007 vascular surgery procedures were performed. Procedure volume

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increased significantly from 1309 to 4698 between the two timeframes (p<0.05), while

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the percentage of Medicaid and Medicare patients did appear to be increase it did not

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achieve significance. There was a significant decrease in the percentage of uninsured

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patients between the cohorts (5.65% vs. 2.96%, p<0.05). In 2012, 10.14% of patients

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were uninsured, compared to 2.56% in 2016 (p<.05) (figure 1). There was a 20% increase

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in RVUs for the vascular service in this time period after the ACA.

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In our analysis of vascular surgery patients at a single institution in the Midwest, a trend

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toward fewer uninsured patients from 2006 to 2016 was noted. 10.14% of patients

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undergoing vascular surgery procedures were uninsured in 2012, while significantly

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fewer (2.56%, p<0.05) were uninsured in 2016. The implementation of the Affordable

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Care Act in 2010 may have played a role in reducing the percentage of uninsured

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patients. It is also notable that the percentage of Medicaid and Medicare patients

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increased, but did not achieve statistical significance during this time period.

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Additionally, procedural volume increased significantly between the divided cohorts,

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from 2006-2009 to 2011-2016 (1309 vs 4968, p<0.05) which is attributable to the

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addition of surgeons to the practice and likely the increase in patient volume from the

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addition of patients with ACA implementation. As such, a decrease in uninsured patient

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status between these time periods may reflect increased insurance enrollment, but can

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also be skewed by a disproportionate increase in utilization by insured patients.

118 Uninsured status has been associated with increased in-hospital mortality across all fields

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[6], while public payer status has been associated with increased rates of adverse events

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in vascular surgery [7]. In a study of 10,557 patients from the Nationwide Inpatient

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Sample database between 2001 and 2005, Murphy and colleagues found ethnicity and

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public payer status to be associated with increased mortality and complications such as

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pneumonia, myocardial infarction, and spinal cord ischemia following open thoracic

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aortic aneurysm repair [8]. Mell and colleagues analyzed nationwide Medicare claims for

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patients undergoing aortic aneurysm repair from 2006 to 2009, and determined that

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Medicaid-eligible men were more likely to present with ruptured abdominal aortic

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aneurysms than men who did not qualify for Medicaid [9]. Given the importance of

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medical management of risk factors in preventing the progression of vascular disease, it

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is unsurprising that lack of insurance, and thus reduced access to care, influences

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preprocedural acuity and postprocedural complications.

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Given the limited literature regarding the effects of insurance status in vascular surgery,

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the impacts of efforts to expand insurance coverage are even less known. While the

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future of the Affordable Care Act remains uncertain, the implementation of an Act

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Providing Access to Affordable, Quality, and Accountable Health Care in Massachusetts

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in 2006 has been studied as an example of modern health care reform. At inception, the

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reform law mandated a minimum level of insurance coverage for the majority of

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residents in Massachusetts, and offered free insurance to patients earning less than 150%

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of the federal poverty level [10].

141 Loehrer and colleagues performed a retrospective cohort study of patients with peripheral

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arterial disease (PAD) before and after implementation of the insurance expansion,

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compared to four control states without reform laws. While non-white patients in

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Massachusetts and control states had a higher probability of presenting with severe PAD

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prior to reform, racial disparities in disease severity were no longer statistically

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significant in Massachusetts after insurance expansion [11]. In comparison, these

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disparities persisted in the control states, where health insurance expansion policies were

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not pursued.

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Ultimately, our findings illustrate a trend of increasing insurance coverage amongst

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vascular surgery patients at an academic institution where procedural volumes continue

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to grow. Our data does support the notion that the ACA increased the number of patients

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with access to care and while a lot of elective vascular population benefits from

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Medicare, it is logical that this access to care has led to higher volume. This in turn

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increased the vascular service RVUs by 20% annually without increasing hospital days

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for standard procedures. While additional data is needed to characterize the factors

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contributing to changes in payer mix, we note a significant decrease in the percentage of

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uninsured patients after implementation of the Affordable Care Act.

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CONCLUSION

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162 Insurance status, whether insured versus uninsured or private versus public payer, has

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been shown to influence outcomes in vascular surgery. At a busy academic center in the

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Midwest, insurance coverage has increased in patients undergoing vascular surgery, with

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a non-significant increase in the percentage of Medicare and Medicaid patients.

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1.

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Payer status is related to differences in access and outcomes of abdominal aortic

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aneurysm repair in the United States. Surgery. 2003;134(2):142-5.

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insurance type on the outcome of endovascular abdominal aortic aneurysm (AAA) repair.

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Journal of vascular surgery. 2008;47(6):1172-80.

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JG, et al. Insurance status predicts acuity of thoracic aortic operations. The Journal of

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thoracic and cardiovascular surgery. 2014;148(5):2082-6.

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Insurance status predicts access to care and outcomes of vascular disease. Journal of

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vascular surgery. 2008;48(4):905-11. e1.

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utilization of inpatient surgery. JAMA surgery. 2014;149(8):829-36.

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hospital patients: condition on admission, resource use, and outcome. Jama.

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Lemaire A, Cook C, Tackett S, Mendes DM, Shortell CK. The impact of race and

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Andersen ND, Hanna JM, Ganapathi AM, Bhattacharya SD, Williams JB, Gaca

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Giacovelli JK, Egorova N, Nowygrod R, Gelijns A, Kent KC, Morrissey NJ.

Ellimoottil C, Miller S, Ayanian JZ, Miller DC. Effect of insurance expansion on

Hadley J, Steinberg EP, Feder J. Comparison of uninsured and privately insured

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Determinants of adverse events in vascular surgery. Journal of the American College of

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Surgeons. 2012;214(5):788-97.

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ethnicity and insurance type on the outcome of open thoracic aortic aneurysm repair.

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abdominal aortic aneurysms in the US Medicare population. Annals of vascular surgery.

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2014;28(6):1378-83.

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Impact of expanded insurance coverage on racial disparities in vascular disease: insights

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from Massachusetts. Annals of surgery. 2016;263(4):705.

Hernandez-Boussard T, McDonald KM, Morton JM, Dalman RL, Bech FR.

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Murphy EH, Stanley GA, Arko MZ, Davis CM, Modrall JG, Arko FR. Effect of

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Mell MW, Baker LC. Payer status, preoperative surveillance, and rupture of

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Loehrer AP, Hawkins AT, Auchincloss HG, Song Z, Hutter MM, Patel VI.

Figure legend:

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Figure 1: Percent uninsured by year

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