Need to travel for urologic care: The impact of insurance.
396 Background: We sought to examine the impact of the Affordable Care Act on access to subspecialty services, such as urologic care, through evaluating the need to travel by insurance status for index urologic procedures. Methods: We accessed the Comprehensive Hospital Abstract Reporting System from 2011-2012. Patients were identified using billing claims and ICD-9 codes. Procedures analyzed were: radical cystectomy (RC), radical prostatectomy (RP), transurethral prostate resection, shockwave lithotripsy, nephrectomy, percutaneous nephrolithotomy (PCNL), retroperitoneal lymph node dissection (RPLND), and pyeloplasty. Patients were categorized as Medicaid, Medicare, private/Health Maintenance Organization, or other (i.e. charity care). Hospital service areas (HSAs, where the majority of local patients were hospitalized), and hospital referral regions (HRR, where most patients received tertiary care) were identified. Chi squared analysis and multivariate logistic regression were performed. Results: We identified 600 patients with Medicaid, 3,806 patients with Medicare, 4,998 patients with private insurance, and 554 with other. 13.3% of Medicaid patients undergoing RC left their HRR versus 29.9% for Medicare and 39.8% for private insurance (Chi squared p < 0.05). We found similar trends for RP (10.8% of Medicaid traveled outside of their HRR vs. 19.5% for Medicare and 24.6% for private, p < 0.05) and PCNL (21.9% of patients with private insurance traveled outside of HRR vs. 12% with Medicare and 17.2% with Medicaid, p < 0.05). On multivariate analysis, (adjusting for race, age, and comorbidity) private insurance had higher odds of leaving their HRR (OR = 1.4, CI 1.1 – 1.8, p< 0.002). Non-white patients (OR = 0.66, 0.54 – 0.81, p <0.001), those with increased comorbidities (OR = 0.95, CI 0.91 - .99, p<0.04), and older patients (p < 0.001) are less likely to travel outside of their HRR. Conclusions: Patients undergoing complex urologic procedures like RC, RP, and PCNL are more likely to travel outside of their HRR if they have private insurance, potentially reflecting increased capacity to access healthcare resources based on income. Patients of older age and with greater comorbidities may be less likely to travel outside of their HRR to obtain urologic care.