100. Disparities in elective spine surgery for Medicaid beneficiaries: a systematic review

Abstract

<h3>BACKGROUND CONTEXT</h3> With Medicaid expansion being one of the major provisions of the Affordable Care Act, the number of patients under Medicaid is higher than ever. Nonetheless, Medicaid beneficiaries have been shown to be disadvantaged in health care access and outcomes, particularly within surgical specialties. Understanding and mitigating these inequities is critical for the ability of spine surgeons to provide better care for their patients. <h3>PURPOSE</h3> We sought to synthesize the literature investigating the disparities that Medicaid patients sustain with regard to two types of elective spine surgery: lumbar fusion (LF) and anterior cervical discectomy and fusion (ACDF). <h3>STUDY DESIGN/SETTING</h3> Systematic review. <h3>METHODS</h3> Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. We systematically searched PubMed, Embase, Scopus, CINAHL, and Web of Science databases. We included studies comparing Medicaid beneficiaries to other payer categories with regard to rates of LF and ACDF, costs/reimbursement, and health outcomes. Two independent reviewers performed title and abstract screening followed by full-text review. In both cases, a third reviewer served as an arbiter in cases of disagreement. Additionally, references cited by included articles were also screened for inclusion. The two primary reviewers utilized the methodological index for non-randomized studies (MINORS) criteria to evaluate the quality of included studies. <h3>RESULTS</h3> A total of 573 articles were assessed. Twenty-five articles were included in the analysis. All articles were relatively recent with year of publication ranging from 2016 to 2021. MINORS scores ranged from 18 to 22, indicating moderate to good quality of all studies. We found that the overwhelming majority of research detected significant disadvantages associated with Medicaid insurance. Medicaid was strongly associated with decreased access to LF and ACDF, lower reimbursement rates, and worse health outcomes compared to other insurance types. These findings were replicated in large database studies, multicenter studies, and single institution studies. Worse health outcomes included prolonged length of stay, lower satisfaction and outcome scores, higher pain scores, and higher odds of readmission, emergency department visits, surgical site infections, prolonged opioid use and reintubation. <h3>CONCLUSIONS</h3> In adult patients undergoing elective spine surgery, Medicaid insurance is associated with wide disparities with regard to access to care and health outcomes. The decreased access to health care and the lower reimbursement rates we found highlight the reluctance of health care systems to increase Medicaid coverage. Additionally, the worse health outcomes indicate the need for efforts focused on identifying causes and interventions for disparities in this vulnerable population. With the increasing importance of spine surgery for the aging population, our findings warrant close examination of the roots of inequities in spine surgery to produce interventions that can ameliorate them. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.