Brendan M. Patterson

The Influence of Patient Insurance Status on Access to Outpatient Orthopedic Care for Flexor Tendon Lacerations

PURPOSE To determine the effect of patient insurance status on access to outpatient orthopedic care for acute flexor tendon lacerations. METHODS The research team contacted 100 randomly chosen orthopedic surgery practices in North Carolina by phone on 2 different occasions separated by 3 weeks. The research team attempted to obtain an appointment for a fictitious 28-year-old man with an acute flexor tendon laceration. Insurance status was presented as Medicaid in 1 call and private insurance in the other call. Ability of an office to schedule an appointment was recorded. RESULTS Of the 100 practices, 13 were excluded because they did not perform hand surgery, which left 87 practices. The patient in the scenario with Medicaid was offered an appointment significantly less often (67%) than the patient in the scenario with private insurance (82%). The odds of the patient with private insurance obtaining an appointment were 2.2 times greater than the odds of the Medicaid patient obtaining an appointment. The Medicaid patient was more likely not to be offered an appointment owing to the lack of a hand surgeon at a practice (28% of appointment denials) than privately insured patients (13% of appointment denials). CONCLUSIONS For patients with acute flexor tendon lacerations, insurance status has an important role in the ability to obtain an orthopedic clinic appointment. We found that patients with Medicaid have more barriers to accessing care for a flexor tendon laceration than patients with private insurance. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

The impact of injury severity and transfer status on reimbursement for care of femur fractures.

BACKGROUND This study investigates the impact of injury severity, patient origin, and payer on charges and payments associated with treatment of femoral fractures at a Level I trauma center. We hypothesized that transfer patients and patients with minor injury would be underinsured, whereas reimbursement rate would be higher for patients with severe injury. METHODS Medical and financial records of 420 adult patients treated for femoral fractures at a public, urban Level I trauma center were reviewed. Facility and professional charges and payments were determined. Reimbursement rate was defined as the ratio of payment to charge. Payer groups included Medicare, Medicaid, commercial, managed care, workers’ compensation, and self-pay. Severe injury was defined by Injury Severity Score of 18 or higher. RESULTS Patients with Injury Severity Score of less than 18 were more often uninsured compared with the severe injury group (25% vs. 14%, p = 0.005). Patients with severe injury had higher facility (0.47 vs. 0.39, p = 0.005) and total reimbursement rates (0.41 vs. 0.34, p = 0.002) compared with patients with minor injury. Likewise, transfer patients trended toward higher overall reimbursement rate compared with nontransfer patients (0.42 vs. 0.37, p = 0.056). Patients with severe injury were more likely to have commercial insurance (28 vs. 20%, p = 0.06), and transferred patients were more likely to have insurance (88% vs. 79%, p = 0.034). CONCLUSION The higher proportion of self-pay in the nontransfer group may be caused by the large population of uninsured patients in the area surrounding our trauma center. Favorable payer mix and higher facility reimbursement rate for patients with severe injury may be an incentive for trauma centers to continue providing care for patients with multiple injuries. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III. Economic analysis, level IV.

A Regional Assessment of Medicaid Access to Outpatient Orthopaedic Care: The Influence of Population Density and Proximity to Academic Medical Centers on Patient Access

BACKGROUND Access to care is limited for patients with Medicaid with many conditions, but data investigating this relationship in the orthopaedic literature are limited. The purpose of this study was to investigate the relationship between health insurance status and access to care for a diverse group of adult orthopaedic patients, specifically if access to orthopaedic care is influenced by population density or distance from academic teaching hospitals. METHODS Two hundred and three orthopaedic practices within the state of North Carolina were randomly selected and were contacted on two different occasions separated by three weeks. An appointment was requested for a fictitious adult orthopaedic patient with a potential surgical problem. Injury scenarios included patients with acute rotator cuff tears, zone-II flexor tendon lacerations, and acute lumbar disc herniations. Insurance status was reported as Medicaid at the time of the first request and private insurance at the time of the second request. County population density and the distance from each practice to the nearest academic hospital were recorded. RESULTS Of the 203 practices, 119 (59%) offered the patient with Medicaid an appointment within two weeks, and 160 (79%) offered the patient with private insurance an appointment within this time period (p < 0.001). Practices in rural counties were more likely to offer patients with Medicaid an appointment as compared with practices in urban counties (odds ratio, 2.25 [95% confidence interval, 1.16 to 4.34]; p = 0.016). Practices more than sixty miles from academic hospitals were more likely to accept patients with Medicaid than practices closer to academic hospitals (odds ratio, 3.35 [95% confidence interval, 1.44 to 7.83]; p = 0.005). CONCLUSIONS Access to orthopaedic care was significantly decreased for patients with Medicaid. Practices in less populous areas were more likely to offer an appointment to patients with Medicaid than practices in more populous areas. Practices that were farther from academic hospitals were more likely to offer an appointment to patients with Medicaid than practices closer to academic hospitals. CLINICAL RELEVANCE This study illustrates the barriers to timely outpatient orthopaedic care that patients with Medicaid face. The findings from our study imply that patients with Medicaid in more populous areas and in areas closer to academic medical centers are less likely to obtain an outpatient orthopaedic appointment than patients with Medicaid in less populous areas and in areas more distant from academic medical centers. A shift in policy to enhance access to orthopaedic care for patients with Medicaid, especially those in urban areas and areas close to academic medical centers, will become increasingly important as more patients become eligible for Medicaid through the Patient Protection and Affordable Care Act of 2010.

Intraoperative complications during total hip arthroplasty

Total hip replacement is one of the most common adult reconstructive procedures performed today. Even though training in total hip replacement has become fairly common in many orthopedic residency programs, complications can still occur during surgery. Preoperative planning and close attention to detail may prevent intraoperative problems. Awareness of the potential downfalls allows the surgeon to properly prepare for surgery, avoid intraoperative complications, and manage unavoidable problems when they do arise.

Access to outpatient care for adult rotator cuff patients with private insurance versus Medicaid in North Carolina.

BACKGROUND Access to orthopaedic care for pediatric patients has been shown in previous studies to be decreased for patients with Medicaid compared with those with private insurance. The relationship between type of insurance and access to care for adult patients with acute rotator cuff tears has not yet been examined. This study aimed to determine if type of health insurance would have an impact on access to care for an adult patient with an acute rotator cuff tear. METHODS Seventy-one orthopaedic surgery practices within the state of North Carolina were randomly selected and contacted on 2 different occasions separated by 3 weeks. The practices were presented with an appointment request for a fictitious 42-year-old man with an acute rotator cuff tear. Insurance status was reported as Medicaid for the first call and as private insurance during the second call. RESULTS Of the 71 practices contacted, 51 (72%) offered the patient with Medicaid an appointment, whereas 68 (96%) offered the patient with private insurance an appointment. The difference in these rates was statistically significant (P < .001). The likelihood of patients with private insurance obtaining an appointment was 8.8 times higher than that of patients with Medicaid (95% CI: 2.5, 31.5). CONCLUSION For patients with acute rotator cuff tears, access to care is decreased for those with Medicaid compared with those with private insurance. Patients with private insurance are 8.8 times more likely than those with Medicaid to obtain an appointment. LEVEL OF EVIDENCE Basic science, survey study.

Factors affecting revenue from the management of pelvis and acetabulum fractures.

Objectives: The purpose was to define charges and reimbursement in the management of pelvis and acetabulum fractures and to identify opportunities for revenue enhancement. Design: Retrospective review. Setting: Level 1 trauma center. Patients/Participants: Four hundred sixty-five patients with 210 pelvic ring injuries and 285 acetabulum fractures. Intervention: All fractures were treated surgically. Main Outcome Measurements: Professional and facility charges and collections were determined for each patient. Costs of care and profitability were calculated for patients with isolated pelvis or acetabulum fractures. Results: Definitive fixation was ⩽24 hours of injury in 35% and >72 hours in 24%. Mean hospital length of stay (LOS) was 9.2 days, with mean 3.1 days in the intensive care unit (ICU). Mean facility charges were

Osteocutaneous Pedicle Flap Transfer for Salvage of Transtibial Amputation After Severe Lower-Extremity Injury

51,069 with collections of

Initial medical management of rotator cuff tears: a demographic analysis of surgical and nonsurgical treatment in the United States Medicare population

22,702 (44%). Mean orthopaedic professional charges were

Patient Satisfaction Is Associated With Time With Provider But Not Clinic Wait Time Among Orthopedic Patients

20,184 with collections of

Total shoulder arthroplasty in patients with a B2 glenoid addressed with corrective reaming

4629 (23%). Combined pelvis and acetabulum fractures had the highest facility collection rates (49%) with lower professional collections (21%) versus isolated fractures (25%, P = 0.03). The payer mix had significantly more commercial (27%), managed care (27%), and Bureau of Workers Compensation (10%) versus the entire hospital, despite progressively more patients with Medicaid or no insurance during the study. Uninsured patients were significantly younger with lower injury severity score. Fractures managed definitively ⩽24 hours had shorter LOS, shorter ICU stay, and fewer complications, with mean net facility revenue over costs of