Variability in Medicaid Reimbursement in Hand Surgery May Lead to Inequality in Access to Patient Care

Background: Medicare (MCR) and Medicaid (MCD) remain the dominant providers of government-funded health insurance in the United States. The purpose of this study was to evaluate the variability between MCR and MCD reimbursements for common hand and wrist surgical procedures. We hypothesized that MCD reimbursement rates would have substantial variation between states, whereas MCR rates would remain relatively constant. Methods: Using the Medicare Physician Fee Schedule Database, the 2019 reimbursements for 7 common hand and wrist procedures were recorded via the respective Current Procedural Terminology codes. The MCD reimbursement rates were then obtained from each state’s physician fee schedule database. Comparisons of reimbursement for these procedures were then calculated between states and between MCD and MCR while adjusting for cost of living using the Medicare Wage Index. Finally, the coefficients of variation were computed to compare the extent of variability between the insurance types. Results: Across all procedures, reimbursement rates for MCD ranged from 30.6% to 240% of the average MCR reimbursement, with the mean reimbursement for MCD valued at 78.3% of MCR. Endoscopic carpal tunnel release (CTR) is valued similarly by MCD compared with open CTR with an average of 77.7% and 78.2% reimbursement of MCR, respectively. The coefficients of variation for MCD reimbursements ranged from 0.25 to 0.45, whereas the value was 0.06 for all MCR procedures. Conclusions: These findings demonstrate a wide variation in MCD payments between states. When compared with MCR, the lower average state MCD reimbursement questions the sustainability for hand surgeons to accept these patients in practice.

COVID-19 and the Long-Standing Vulnerabilities of Older Adults

The COVID-19 pandemic has taken a devastating toll on the lives of older adults, intensifying long-standing challenges in the US health care system. Persistent health and mortality disparities on the basis of race and socioeconomic status, staffing shortages and insufficient financial resources at some nursing homes, and a reluctance among Americans to make formal plans for their end-of-life health care are problems of heightened magnitude in the pandemic era. Policy solutions like extending Medicare benefits to younger people, increasing Medicaid reimbursement rates, and facilitating formal conversations regarding end-of-life care may help Americans to age and die with dignity.

ADULT FOSTER HOME OWNERS' PERSPECTIVES ON REWARDS AND CHALLENGES OF OPERATING AN ADULT FOSTER HOME

Adult foster homes (AFHs) are small, residential settings providing older adults and persons with disabilities an alternative to nursing facilities and larger residential care settings. Some groups, including individuals with Alzheimer’s disease and related dementias, are well served by smaller settings. Although AFHs are common throughout the US, research on this setting is scant and dated. This study summarizes four years of qualitative data from Oregon AFH owners’ (N=726) responses to open-ended questions about the challenges and rewards of owning and operating an AFH. Content analysis of 924 comments indicate that providing resident care (42%), finding the work meaningful and “a life calling” (21%), developing a family-like connection with residents (15%), and working at home (8%) were the most commonly reported rewards. The most frequently described challenges included caring for residents with multiple chronic health conditions—including those with difficult behaviors (17%), difficulty hiring and retaining qualified caregivers (15%), low Medicaid reimbursement rates (14%), and adhering to administrative rules (14%). Results highlight AFH providers’ personal satisfaction with caring for and establishing connections with residents, and challenges associated with residents’ increasingly complex care needs, Medicaid reimbursement rates, and attitudes about state regulations. Although AFHs are licensed by states, they are subject to federal regulations, including the 2014 Centers for Medicare & Medicaid Services home and community-based services ruling. The new regulations, Oregon administrative rules, Medicaid reimbursement rates, and caregiver supply are presented to contextualize AFH owner comments and regulatory considerations.