Does Medicaid Broaden the Choices of Patients with Low Socioeconomic Status? An Analysis of Bypassing Behaviors in Brooklyn

Background: Many governments worldwide have committed to extending choices in public service delivery. However, the extent to which policies ensure equity is unclear. We investigated whether Medicaid programs in the United States improve hospital accessibility among patients with low socioeconomic status, compared to those with non-low socioeconomic status who are non-Medicaid recipients or uninsured.Methods: We employed a difference-in-difference-in-differences approach using a rich dataset of information on inpatients and their choice of hospitals from Statewide Planning Research and Cooperative System and information on hospitals from the American Hospital Association in Brooklyn, New York, from 2003 to 2009Results: The findings indicated that Medicaid has failed to broaden the range of the hospital choices for patients with low socioeconomic status, assessed in terms of bypassing behaviors. Conclusions: Medicaid is a public program that offers choices driven by purchasing power. The findings of this study imply that this program has some limitations in alleviating existing socioeconomic inequities in available hospital choices.

Does Medicaid Broaden the Choices of Patients with Low Socioeconomic Status? An Analysis of Bypassing Behaviors in Brooklyn

BackgroundMany governments worldwide have committed to extending choices in public service delivery. However, the extent to which policies ensure equity is unclear. We investigated whether Medicaid programs in the United States improve hospital accessibility among patients with low socioeconomic status, compared to those with non-low socioeconomic status who are non-Medicaid recipients or uninsured.MethodsWe employed a difference-in-difference-in-differences approach using a rich dataset of information on inpatients and their choice of hospitals from Statewide Planning Research and Cooperative System and information on hospitals from the American Hospital Association in Brooklyn, New York, from 2003 to 2009ResultsThe findings indicated that Medicaid has failed to broaden the range of the hospital choices for patients with low socioeconomic status, assessed in terms of bypassing behaviors. ConclusionsMedicaid is one public program that offers choices driven by purchasing power. The findings of this study imply that this program has some limitations in alleviating existing socioeconomic inequities in available hospital choices.

Can high-volume surgeons achieve optimal outcomes at low-volume hospitals? Implications for the Leapfrog Initiative and regionalization of high-risk surgical oncology procedures.

6585 Background: The Leapfrog group recently released surgeon and hospital procedure volume standards for several surgical oncology procedures. This study investigated trends in volume and whether high-volume surgeons at low-volume hospitals achieve equivalent outcomes to high-volume surgeons at high-volume hospitals. Methods: New York’s Statewide Planning and Research Cooperative System was queried for esophagectomy, lung resection, pancreatectomy, and proctectomy for cancer from 2004-2015. Mixed-effects analyses assessed the association among Leapfrog surgeon/hospital volume standards and 90-day mortality. Results: Among 55,528 cases, high-volume surgeons performed 64.7% of cases (esophagectomy = 52%; lung resection = 75.6%; pancreatectomy = 56.7%; proctectomy = 53%), and high-volume hospitals performed 59.5% of cases (esophagectomy = 55.5%; lung resection = 58.3%; pancreatectomy = 63.4%; proctectomy = 61%). After risk-adjustment, high-volume surgeons at high-volume hospitals had lower odds of 90-day mortality compared to high-volume surgeons at low-volume hospitals for each organ system except for pancreas. Despite trends toward regionalization, between 2012-2015, there were large differences in the number of hospitals and median annual case number between high-volume and low-volume centers for esophagectomy (8 vs. 56 hospitals; 31.5 vs. 3 cases), lung resection (22 vs. 89 hospitals; 69.5 vs. 7 cases), pancreatectomy (15 vs. 56 hospitals; 36 vs. 3 cases), and proctectomy (38 vs. 117 hospitals; 28 vs. 3 cases). Conclusions: This study supports the Leapfrog initiative for performance of high-risk surgical oncology procedures by high-volume surgeons at high-volume hospitals. However, it remains unclear whether full regionalization to high-volume centers is feasible. [Table: see text]

The Regionalization of Total Ankle Arthroplasties and Ankle Fusions in New York State: A 10-Year Comparative Analysis

Background. Total ankle arthroplasty (TAA) provides an alternative to ankle fusion (AF). The purpose of this study is to (1) determine the extent of TAA regionalization, as well as examine the growth of TAA performed at high-, medium-, and low-volume New York State institutions and (2) compare this regionalization and growth with AF. Methods. The New York Statewide Planning and Research Cooperative System (SPARCS) administrative data were used to identify 737 primary TAA and 7453 AF from 2005 to 2014. The volume of TAA and AF surgery in New York State was mapped according to patient and hospital 3-digit zip code. Results. The number of TAA per year grew 1500% (from 11 to 177) from 2005 to 2014, while there was a 35.6% reduction (from 895 to 576) in yearly AF procedures. TAA recipients were widely distributed throughout the state, while TAA procedures were regionalized to a few select metropolitan centers. AF procedures were performed more uniformly than TAA. The number of TAA has continued to increase at high- (15 to 91) and medium-volume (14 to 67) institutions where it has decreased at low-volume institutions (44 to 19). Conclusion. The increased utilization of TAA is attributed to relatively few high-volume centers located in major metropolitan centers. Levels of Evidence: Level IV: well-designed case-control or cohort studies