In Massachusetts, rates of discretionary surgical procedures rose, while rates of non-discretionary or emergency procedures declined in the years following the state's insurance expansion, researchers found.
As the insured population grows, hospital surgery centers should expect to perform more elective and discretionary surgical procedures, but fewer non-discretionary operations performed on an emergency basis.
That's what researchers have concluded after looking at what happened in Massachusetts in the years before and after the state's 2006 insurance expansion. Researchers compared the Massachusetts experience with concurrent surgical utilization in New Jersey and New York, states that were not undergoing coverage expansion at that time.
"Most people are saying that by 2019, when we expect 25 million more people with insurance, we'll see a huge influx of patients, and thus a huge influx of surgery," says Chandy Ellimoottil, MD, urology surgeon at the University of Michigan, Ann Arbor, and first author of a report in JAMA Surgery. "But what we find is that it doesn't affect all surgical procedures uniformly."
"This has implications for anyone looking at workforce shortages, and whether they should increase staffing," in order to meet future demand from Medicaid expansion and health insurance exchange coverage, Ellimoottil says.
In Massachusetts, rates of discretionary procedures rose, while rates of non-discretionary procedures declined compared to trends in the two other states.
Extrapolating the Massachusetts experience to a national level, Ellimoottil says, surgeons can expect to perform nearly 500,000 new discretionary procedures such as knee and hip replacements by 2017.
The research project looked at more than 800,000 inpatient procedures in the three states, comparing volumes during the period between 2003 and June 30, 2007 with volumes from July 1, 2007 to Dec. 31, 2010.
Discretionary or elective procedures examined included knee and hip replacement, which rose by 14% and 12% respectively; back surgery, which increased by 4%; transurethral resection of the prostate, which went up 6%; and inguinal hernia repair, up 38%.
Likewise non-discretionary surgeries that declined included appendectomies, which dropped by 6%, hip fracture repair, down 4%; colectomy, down 8%; and pancreatectomy, reduced by 6%.
Outpatient surgical procedures were not included in the analysis.
Ellimoottil cautions that one important limitation of the study is the inability to see potential overutilization from the data. It may be that once patients received healthcare coverage in Massachusetts, they were more likely to get a surgical procedure for a condition that evidence suggests may have been more appropriately treated with medication or physical therapy rather than surgery.
Overutilization Unknown
"We don't know whether or not someone might have undergone a procedure we described as discretionary, like knee surgery, because they had [endured] debilitating osteoarthritis that was affecting their quality of life to such a great degree, and now were able to get insurance and could get that surgery they really needed," Ellimoottil says.
"Or the other way of looking at this is that now patients had insurance, so surgeons could do more and more procedures that were unnecessary. We didn't have a way to parse that out, so whether or not there was overutilization was unclear," he says, adding, that should be the subject for further research.
Another limitation is that it was impossible to determine whether the increase in discretionary procedures might have been due to an increase in surgical staffing in Massachusetts, which might have geared up to take more patients to meet increased demand from the 2006 change in state law.
However, Ellimoottil says, the insurance expansion is "the most likely reason" for the changes in surgical volumes in the state of Massachusetts compared with New York and New Jersey.
A Surprising Finding
Ellimoottil said one surprising finding from the study was that procedures generally classified as non-discretionary or emergency, dropped. One would have expected that they would have remained the same.
One reason for the decline might be that after Massachusetts expanded coverage options, patients were diagnosed and treated for conditions before they became emergent. The study, however, did not reveal whether that was, in fact, the sole reason or a contributing factor.
"I'm a urologist, and it may be that now we're catching conditions in an outpatient setting, like a small bladder tumor, and are treating it quickly so the patient doesn't require major surgery like a cystectomy. That's a possible explanation, but we don't have strong evidence to say why these non-discretionary surgeries went down."
The study did find that reduced rates off non-discretionary or emergency procedures "was most apparent for patients from counties with high rates of low-income and newly insured individuals."
That would indicate that one purpose of expanded health coverage has produced the desired result: reducing racial disparities in access to certain surgical procedures.
The authors conclude that "Moving forward, research in this area should focus on whether greater utilization of such procedures represents a response to unmet need or changes in treatment thresholds driven by patients, providers, or some combination of the two."