Insurance Status Linked to Quality of Care During Hospitalization for Primary Spinal Neoplasms

Syed K. Mehdi, BS, and Ali A. Baaj, MD, Discuss

Peer Reviewed

Insurance status was a significant predictor of experiencing adverse quality events during hospitalizations for primary spinal neoplasms in a recent retrospective cohort study in the February issue of the The Spine Journal. Patients who paid for services using Medicaid or self-pay had a significantly greater likelihood of adverse health-care quality during inpatient stay.

“This is an important study that highlights the fact that patients are not just diagnoses and ‘interesting cases,’” commented Ali A. Baaj, MD, Spinal Neurosurgeon and Assistant Professor of Neurological Surgery Weill Cornell Medical College, Cornell University, New York, NY. “Patients’ overall health status, psychosocial background, and preparedness to cope with invasive spinal procedures affect outcomes. Insurance status does not increase risk of complications but rather may be a reflection of lack of adequate access to preoperative medical optimization for ensuring successful surgical outcomes,” said Dr. Baaj, who also is a member of the SpineUniverse Editorial Board.
Business man with stethoscope."Insurance status does not increase risk of complications but rather may be a reflection of lack of adequate access to preoperative medical optimization for ensuring successful surgical outcomes”. Photo Source:

Findings Based on Nationwide Database

The findings were based on data from the National Inpatient Sample and included all patients (N=5,880) ages 18 years and older who were hospitalized for primary spine neoplasms from 1998 to 2011.

Using logistic regression models that adjusted for patient demographics and hospital characteristics, Medicaid or self-pay patients had a significantly greater likelihood of experiencing one or more patient safety indicators (odds ratio [OR] 1.81) compared to privately insured patients. Patient safety indicators are used to measure the incidence of adverse quality events, such as postsurgical hematoma or iatrogenic pneumothorax, during an inpatient stay, the study investigators explained.

Clear Disparity in Care Found

“There are two major clinical implications of this study,” said lead author Syed K. Mehdi, BS, of Case Western Reserve University School of Medicine, and the Center for Spine Health, Cleveland Clinic, Cleveland, Ohio.

“First, this study was the first to demonstrate an association between insurance status and the quality of care patients who are hospitalized for a primary spinal neoplasm receive,” Mr. Mehdi said. “It is clinically important as it demonstrates a clear disparity in the care received relative to insurance status. Those with no insurance were more likely to suffer an adverse inpatient event compared to their privately insured counterparts. While the reason is not completely known, insurance status played a role, when all cofounders were accounted for, in the incidence of adverse events,” said Mr. Mehdi.

“The second implication relates to physician and hospital system reimbursements,” Mr. Mehdi told SpineUniverse. “Current health insurance programs have begun to link reimbursement with quantifiable quality metrics. Those hospital systems that have a higher score on these metrics receive benefits from the Centers for Medicare and Medicaid Services. As a result, it is vital to find areas of healthcare where patient quality of care is unequal. Once those inequalities are found, we can work to find the cause, eliminate it, and provide optimal care for all patients,” Mr. Mehdi explained. 

“Spine surgeons need to better identify and manage the involved risks that may be inherent to this subgroup of vulnerable patients,” Dr. Baaj said. “This includes identifying and addressing delayed diagnosis, comorbidities, and potential lack of access to healthcare services before and after procedures are undertaken. This is critical for counseling patients and ensuring their safety,” said Dr. Baaj

Possible Causes of Disparity

Mr. Mehdi speculated that self-pay and Medicaid patients may be at greater risk for an adverse event because they may be less likely to present early in the disease course.

“By the time they see a physician, patients’ disease course may have progressed to a more complicated stage, making the incidence of an adverse event or complication during hospitalization more likely,” Mr. Mehdi said.

“Second, previous studies have shown that physicians alter how they order imaging tests when they are aware of their patients’ insurance status,” Mr. Mehdi added. “As a result, uninsured patients may not receive proper imaging early in the disease course, and by the time they do, the disease has progressed to a more complicated stage.”

An interesting followup study would be to observe patient care among spine professionals who were unaware of their patients’ insurance status, Mr. Mehdi suggested.

Steps to Counteract Difference in Care

To counteract these disparities in care, spine professionals must acknowledge these differences in order to make a more concerted effort to eliminate the disparities in care, Mr. Mehdi said. 

“Most importantly, physicians should make an extra effort to insure that this vulnerable patient population receives the same standard of care as their privately insured counterparts,” Mr. Mehdi noted. “This can done by ordering the indicated and necessary tests, even if that may financially burden their patient.”

Overall, he suggested that physicians and staff should “be more vigilant of these patients’ postoperative care in the hospital, and be cognizant of the fact that their financial/social status may have an impact on their overall health and adherence to postoperative care.”

Updated on: 08/01/19
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Ali A. Baaj, MD
Associate Professor of Neurological Surgery
Weill Cornell Medical College
Cornell University

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