Medicaid vs Medicare vs Private Pay THA Outcome Data

Do Medicaid total hip arthroplasty (THA) patients have different post-op pain and narcotic requirements, notably opioid use, than patients with private insurance or Medicare? A team from New York University (NYU) Langone Health in New York and Beaumont Health in Royal Oak, Michigan, collected data from 5,845 patients and looked to see if there were any answers in the data.

Their study, “The Effects of Patient Point of Entry and Medicaid Status on Postoperative Opioid Consumption and Pain After Primary Total Hip Arthroplasty” appears in the July 15, 2022, edition of the Journal of the American Academy of Orthopaedic Surgeons.

Co-author Ran Schwarzkopf, M.D., an orthopedic surgeon with Langone, explained to OTW, “Low-income patients, that are represented many times by Medicaid coverage, have been shown in many studies to have lower outcomes than patients with Medicare and commercial insurance. We wanted to evaluate if patients with Medicaid differ in opioid consumption after THA.”

The team collected data for 5,845 patients who had been treated with primary THA (elective) between January 2016 and March 2019. Of that group, 326 relied on Medicaid insurance to pay for their THA (5.6%) and 5,519 patients used non-Medicaid insurance (94.4%). Of the latter group, 2,635 patients (45.08%) were private pay.

The researchers found that Medicaid patients were generally younger than the non-Medicaid group (56.09 years of age ± 13.64 versus 63.82 years of age ± 11.24) and the private pay group (57.39 years of age ± 9.05). Medicaid patients were less likely to be White (39.1% versus 78.2% in the non-Medicaid group versus 76.2% in the private insurance group) and were more likely to identify as Black (23.7% versus 10.5% versus 11.5%), Asian (4.6% versus 1.8% versus 1.84%), or “other” race (32.6% versus 9.6% versus 10.33%).

In addition, patients with Medicaid insurance were significantly more likely to be smokers than non-Medicaid patients (21.6% versus 8.8% versus 10.5%). Not only was surgical time (113 minutes versus 96 minutes versus 98 minutes) and length of stay (2.7 versus 1.7 versus 1.4 days) longer for Medicaid patients, but they were less likely to have a home discharge (86.5% versus 91.8% versus 97.2%).

Overall opioid consumption (178 morphine milligram equivalents versus 89 morphine milligram equivalents versus 82 morphine milligram equivalents) and average morphine milligram equivalents/day in the first 24 hours and 24 to 48 hours (52.3 versus 44.7 versus 44.45 and 73.8 versus 28.4 versus 29.8) were higher for those with Medicaid insurance.

“Our results showed that patients with Medicaid had a higher narcotic pain medication consumption than Medicare and commercial insured patient,” stated Dr. Schwarzkopf to OTW. “Furthermore, patients with Medicaid had a higher reported pain level and a lower post-surgery activity level.

When OTW asked how he might proceed if tasked with starting a postop counseling and optimization program with Medicaid patients, Dr. Schwarzkopf replied, “I think a multidisciplinary care team that includes a social worker, a care coordinator and nurse navigator would be the minimal team as well as a pain management specialist. Smoking was more prevalent among the Medicaid patients as well as previous narcotic usage. Patients can be better optimized and educated about the recovery period. Furthermore, their discharge expectations need to be evaluated. Patients with a history or current opioid users need to be optimized prior to surgery in order to help facilitate a decreased opioid usage after surgery.”