Association of Program-Specific Variation in Bariatric Surgery Volume for Medicaid Patients and Access to Care: A Tale of Inequality?

Document Type

Conference Proceeding

Publication Date

10-27-2021

Publication Title

Surg Endosc

Abstract

BACKGROUND: Requirements for bariatric surgery coverage vary considerably by insurance type which can impact utilization. To date, it is unclear if Medicaid patients who qualify for bariatric surgery experience limited access to surgery as a result of program-specific variation in volume and distribution of cases based upon insurance type. The objective of this study was to evaluate the current structure of bariatric programs to identify the distribution of patients. METHODS: Using a state-wide bariatric-specific data registry that includes 39 programs performing 97,207 cases between 2006 and 2020, bariatric programs were stratified into quartiles according to the percentage of Medicaid cases performed. Patient characteristics, postoperative outcomes and wait times were compared between programs designated as high or low volume based on percent of Medicaid patients. RESULTS: A total of 4,780 (4.9%) bariatric operations were performed for patients with Medicaid during the study period. Program-specific distribution of Medicaid cases varied between 0.69% to 22.4%. Programs in the top quartile for Medicaid patients (n = 11) performed an overall mean of 13% Medicaid with a total volume of 18,885 cases. Programs in the bottom quartile (n = 11) performed a mean 1% of Medicaid cases with a total bariatric volume of 32,447. Patients undergoing surgery at high-volume Medicaid programs were more likely to be Black (20.2% vs 13.5%, p < 0.0001) and had higher rates of diabetes (35.1% vs 29.5%, p < 0.0001), hypertension (55.1% vs 49.6%, p < 0.0001), asthma (24.9 vs 19.3%, p < 0.0001), sleep apnea (48.4 vs 42.0%, p < 0.0001), and hyperlipidemia (47.6% vs 45.2%, p < 0.0001) despite clinically similar age and preoperative body mass index (BMI). In addition, high volume Medicaid programs had higher rates of complications (8.4% vs 6.6%, < 0.0001), extended length of stay (5.6% vs 4.0%, p < 0.0001), Emergency Department visits (8.1% vs 6.5%, p < 0.0001) and readmissions (4.7% vs 3.9%, p < 0.0001). Median time from initial evaluation to surgery date was significantly longer for patients with Medicaid than with private insurance (216 days vs 136 days, p < 0.0001). CONCLUSIONS: Bariatric surgery programs vary widely in their case volume of Medicaid patients. Centers with high Medicaid case volumes include more Black and low-income patients. These centers also perform fewer operations with substantially longer wait times for Medicaid patients compared to private insurances, leading to a significant disparity in access to care. Moreover, high-volume Medicaid programs treat patients with greater disease severity and more postoperative resource utilization, which may disincentivize any efforts to improve equality in access to care.

Volume

35

Issue

1

First Page

S55

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