The Impact of Payment Reform on Utilization of Reconstructive Surgery
Bibliographic record
Abstract
PURPOSE: Medicaid beneficiaries systematically face challenges in accessing healthcare, especially with regard to specialty services such as reconstructive surgery. In January 2014, the Affordable Care Act (ACA) took effect, allowing states to expand Medicaid eligibility. Concurrently, Maryland also launched statewide global budgeting of hospitals, intended to control healthcare costs.1 However, the impact of such reform on utilization of reconstructive procedures has not been characterized. This study evaluated the impact of Medicaid expansion and global hospital budgeting on utilization of 3 common reconstructive procedures (reconstructive breast surgery, maxillofacial surgery, and hand surgery) by marginalized populations (Medicaid/uninsured patients). MATERIALS AND METHODS: Adults in New Jersey (Medicaid expansion state), Maryland (expansion state with global hospital budgeting), and Florida (non-expansion state) undergoing the selected reconstructive procedures between 2012-2016 were tabulated using Healthcare Costs and Utilization Project State Ambulatory Surgery and Services and State Inpatient Databases. Interrupted time-series analyses were used to evaluate the impact of policy reform on reconstructive surgery utilization by marginalized patients. RESULTS: During the study period, 96,662 Medicaid/uninsured patients underwent the selected reconstructive procedures in the 3 states. The likelihood of Medicaid being listed as the primary payer for patients undergoing reconstructive surgery significantly increased in expansion states (Maryland absolute policy effect: 0.02% per quarter, 95% confidence interval: 0.01% to 0.02% per quarter; New Jersey absolute policy effect: 0.04% per quarter, 95% confidence interval 0.02%–0.05%) when compared to Florida (non-expansion state). There was also an immediate policy effect: within 1 year of ACA implementation, there was a significant increase in the proportion of Medicaid beneficiaries undergoing the reconstructive procedures (Maryland, 0.03%, 95% CI, 0.01%–0.05%; New Jersey, 0.01%, 95% CI, 0.01%–0.02%), whereas there was a significant decline in the proportion of uninsured patients (Maryland, −0.01%, 95% CI, −0.01% to 0.0%; New Jersey, −0.008%, 95% CI, −0.01% to −0.006%). Trends in Maryland versus New Jersey were compared with understand the impact of global hospital budgeting. Global budgeting did not significantly impact overall utilization of reconstructive procedures amongst Medicaid beneficiaries, though there was an increase in utilization of emergent/urgent reconstructive procedures that reached borderline significance (0.03% per quarter; 95% CI, 0.0%–0.05%). CONCLUSIONS: Medicaid beneficiaries experienced an increased utilization of reconstructive surgery post-ACA in expansion states when compared with nonexpansion states, mirroring trends in other areas of healthcare. Increased utilization by Medicare beneficiaries was not completely offset by decreases in utilization by uninsured patients, suggesting that the ACA expanded access to reconstructive surgery. It was encouraging that global hospital budgeting did not limit utilization of reconstructive procedures by Medicaid beneficiaries. In fact, utilization of emergent/urgent procedures among marginalized patients in globally budgeted hospitals increased, perhaps as a result of greater incentives for hospitals to connect vulnerable/high-risk patients to the care they need under this system. REFERENCE: 1. Rajkumar R, Patel A, Murphy K, et al. Maryland’s all-payer approach to delivery-system reform. N Engl J Med. 2014;370:493.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.004 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.000 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.000 | 0.001 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.001 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".