Published online Feb 18, 2019. doi: 10.5312/wjo.v10.i2.81
Peer-review started: December 23, 2018
First decision: December 30, 2018
Revised: January 11, 2019
Accepted: January 26, 2019
Article in press: January 26, 2019
Published online: February 18, 2019
Our study is timely given the recent federal ruling against the Affordable Care Act (ACA), specifically the mandate requiring people to buy insurance. The ACA increased the number of insured Americans through the development of subsidized healthcare plans and health insurance exchanges. Healthcare reform was enacted in Massachusetts, where a similar mandate was put into place years before the ACA was passed. We use this opportunity to describe differences in rates of surgery before and after the implementation of the mandate to purchase insurance after healthcare reform.
We answer the key question of whether healthcare reform and the individual mandate increases the rate of knee surgery. Healthcare cost and healthcare reform are the key questions facing the medical field today. How physicians can deliver quality care without exorbitant costs is of interest to many around the world. This hypothesis generating study provides strong impetus to further examine the effects of healthcare reform on other health services.
The main objective was to determine if healthcare reform had an effect on the rate of knee surgery in the state of Massachusetts. The significance of realizing this research is a greater impetus to study healthcare reform and how it may reflect healthcare costs going forward. This is of great interest to every nation in the world.
A retrospective review was performed within the department of orthopedics at a tertiary-care, academic medical center in Massachusetts. The departmental billing database was queried to identify all International Classification of Diseases, Ninth Revision, Clinical Modification codes related to the knee. These ten diagnosis codes were then used to identify all new patients seen by three surgeons in pre-reform (2005-2006) and post-reform (2007-2010) periods (n = 10420). The rate of surgery was defined as the number of patients who underwent surgery divided by the total number of unique patients in that cohort. For each insurance type at both points in time, the rate of elective knee surgery (ROS) was calculated. The ROS was compared using a Pearson-type χ2 test with Yate’s continuity correction for the entire cohort, each group (uninsured vs government insurance vs private insurance vs Workers’ Compensation) and the seven types of insurance (uninsured vs Commonwealth Care vs Medicare vs Medicaid vs TriCare vs private insurance vs Workers’ Compensation) pre-reform and post-reform. A two-tailed p-value less than or equal to 0.05 was considered significant.
Comparing the overall rate of surgery during the pre- and post-reform periods, there was a significant increase in the ROS following mandated coverage. This finding suggests that with increased insurance coverage (near-universal), patients enjoy increased access to medical services, and, in turn, there may be a higher ROS for musculoskeletal problems. Because the ROS increased in the post-reform period, it is possible that mandated coverage in Massachusetts leads to rising costs in a time when national health care spending has leveled off for the first time in over a decade. Given the limitations of our study, a study to better examine the relationship between healthcare reform and costs should be considered.
Healthcare reform and a mandate to purchase health insurance increase the rate of knee surgery. It suggests that having a mandate to buy insurance will lead to increased healthcare costs as patients who now have insurance will utilize more care. Healthcare reform and the individual mandate lead to high rates of knee surgery. As above, healthcare reform and the individual mandate lead to high rates of knee surgery. Healthcare costs increase as more people obtain insurance. The main difference in our study was that we controlled for surgeon number. Other studies can be confounded increasing or decreasing number of providers. We were able to analyze rates of surgery across three surgeons before and after healthcare reform, keeping one of the largest confounders constant. As noted above, healthcare reform and a mandate to purchase health insurance increases the rate of knee surgery. Rates of healthcare utilization are higher in places that have a greater proportion of insured patients as they utilize more healthcare services.
Healthcare reform should be pursued carefully as policies to increase access may also increase costs which may not be desired. A study to examine how other procedures and healthcare service utilization changed with healthcare reform. A similar study can be done for other types of procedures assuming appropriate sample size and ability to collect key information such as rates of procedure done before and after healthcare reform. It would be interesting to do in Massachusetts but also on a national level.