Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Feb 18, 2019; 10(2): 81-89
Published online Feb 18, 2019. doi: 10.5312/wjo.v10.i2.81
Mandated health insurance increases rates of elective knee surgery
Daniel Kim, Woo Do, Shahein Tajmir, Brandon Mahal, Joe DeAngelis, Arun Ramappa
Daniel Kim, Brandon Mahal, Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
Woo Do, Department of Surgery, Madigan Army Medical Center, Tacoma, WA 98431, United States
Shahein Tajmir, Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
Joe DeAngelis, Arun Ramappa, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
Author contributions: Kim D, Do W, Tajmir S, Mahal B, DeAngelis J and Ramappa A substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Institutional review board statement: This certifies that the action on the research study referenced was reviewed by the Committee on Clinical Investigations (CCI), the appropriately authorized Institutional Review Board and Privacy Board appointed to review research involving human subjects. This action was reviewed via Expedited review. This study approved for continuation for a period of one year with waiver of informed consent and authorization under expedited category #8.
Conflict-of-interest statement: Nothing.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Arun Ramappa, MD, Chief Doctor, Associate Professor, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Shapiro 2, 330 Brookline Avenue, Boston, MA02215, United States. aramappa@bidmc.harvard.edu
Telephone: +1-617-6673940 Fax: +1-617-6672155
Received: December 22, 2018
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
Abstract
BACKGROUND

The recent federal ruling to against Affordable Care Act (ACA), specifically the mandate requiring people to buy insurance, has once again brought the healthcare reform debate to the spotlight. The ACA increased the number of insured Americans through the development of subsidized healthcare plans and health insurance exchanges. Insurance-based differences in the rate of upper extremity elective orthopaedic surgery have been described before and after healthcare reform in Massachusetts, where a similar mandate was put into place years before the ACA was passed. However, no comprehensive study has evaluated insurance-based differences of knee elective surgery before and after reform.

AIM

To investigate how an individual mandate to purchase health insurance affects rates of knee surgery.

METHODS

A retrospective review was performed within an orthopaedic surgery department at a tertiary-care, academic medical center in Massachusetts. The rate of elective knee surgery performed before and after the healthcare reform (2005-2006 and 2007-2010, respectively) was calculated. The patients were categorized by insurance type (Commonwealth Care, Medicare, Medicaid, private insurance, Workers’ Compensation, TriCare, and Uninsured). Using χ2 testing, differences in rates of surgery between the pre-reform and post-reform period and among insurance subgroups were calculated.

RESULTS

Rate of surgery increased in the post-reform period (pre-reform 8.07% (95%CI: 7.03%-9.11%), post-reform 9.38% (95%CI: 8.74%-10.03%) (P = 0.04) and was statistically significant. When the insurance groups and insurance types were compared, the rates of surgery are not significantly different before or after reform.

CONCLUSION

The increase in the rate of elective knee surgery in the post-reform period suggests that health care reform in Massachusetts has been successful in decreasing the uninsured population and may increase health care expenditures. This is a hypothesis generating study that suggests further avenues of study on how mandated coverage may change healthcare utilization and cost.

Keywords: Healthcare reform, Elective surgery, Lower extremity, Affordable Care Act, Orthopaedic surgery

Core tip: We examined how an individual mandate in the United States may affect rates of knee surgery. This topic is of great interest as the United States thinks about moving to a universal coverage model and to countries that already have such a system. We found that the rate of surgery increased after the implementation of mandated universal coverage. Also, we found that patients on lesser reimbursing insurance plans were not discriminated against compared to private insurance plans.