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Assessing medicare Advantage trends in lumbar spine surgery: Balancing financial Appeal vs patient outcomes
, Muhammad Talal Ibrahimb, Hai Lea, Yashar Javidana, Frank Phillipsc, Safdar N. Khana,
⁎Corresponding author: Safdar N. Khan. safkhan@ucdavis.edu
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
To assess coverage trends and demographic characterization of patients opting for Medicare Advantage (MA) plans and its impact on 90-day complications risks in patients undergoing lumbar fusion surgery.
This study utilized the Pearldiver database, Mariner161Ortho dataset, containing de-identified patient records from 01/01/2010–10/31/2022. Patient records for primary lumbar fusion procedures in patients aged 65 and above were retrieved, and were categorized into traditional medicare (TM), MA, and other plans. Outcomes included an assessment of the trends of utilization, demographic characterization of patients and their comorbidities, and 90-day post-operative complications risks. Statistical analysis involved T-tests, chi-square tests, and multivariable regression, with significance defined as a p-value <0.05.
A total of 270,300 records were retrieved [TM (134,224 or 49.66%), MA (109,015 or 40.33%), and other plans (27,061 or 10.01%)]. MA utilization increased substantially (24.13%–47.99%), while TM cases declined (55.63%–43.26%). Demographic characterization showed that MA patients, compared to TM, were utilized by a higher percentage of men, with higher Elixhauser Comorbidity Index (ECI) scores, greater average reimbursement, and higher mean family income. Furthermore, all comorbidities were significantly more prevalent in the MA group. In terms of complications, MA plans demonstrated an increased risk of 90-day wound-related, medical, neurological, and long-term complications.
While MA plans may appear attractive for patients considering lumbar fusion surgery, spine surgeons need to thoroughly assess and discuss with patients the 90-day complication risks associated with MA coverage.
1 Introduction
The surge in popularity of Medicare Advantage (MA) plans since their introduction has significantly altered the landscape of healthcare coverage. Originally designed to privatize Medicare and provide additional benefits not offered by traditional Medicare (TM), MA plans have become increasingly favored by beneficiaries seeking to limit out-of-pocket expenses. Unlike TM, where individuals often spend a substantial portion of their income on health-related costs,1 MA plans offer an appealing alternative, crucial for those on fixed incomes facing high healthcare expenses. The allure of MA plans extends beyond financial considerations, encompassing additional benefits like dental care and gym memberships.2
In contrast to TM, which may necessitate supplemental coverage and a separate Part D prescription drug plan, MA plans provide the convenience of one-stop shopping, covering all Medicare benefits.3 This shift in insurance coverage towards MA has witnessed a remarkable increase over the past decade.4 The surge in MA utilization is not only attributable to financial advantages but is also reflected in improved healthcare outcomes, as indicated by increased preventive care visits, reduced hospital admissions, emergency department visits, and shorter hospital and skilled nursing facility stays.5 Notably, MA plans have demonstrated superiority over TM in various quality-of-care metrics.6,7
However, despite these advancements, certain domains reveal limitations in MA plans, including patient experience, readmission rates, mortality, and racial/ethnic disparities.5 Against this backdrop, the significance of MA plans in addressing spine-related pathologies, affecting over 11 % of the US population,8 cannot be overstated. Lumbar fusion surgeries, often required by older individuals,9 a demographic favoring MA plans, involve complex healthcare needs associated with spinal conditions and age-related health challenges. The rehabilitation and ongoing care required post-surgery10 align with the coverage provided by MA plans, rendering them an attractive option for individuals contemplating elective spine surgery.
Despite the evident popularity of MA plans in this context, there is currently a lack of empirical evidence regarding the insurance coverage trends and demographic composition of patients opting for spine surgery with MA plans. Furthermore, there is a dearth of evidence regarding the comparative post-operative clinical outcomes and complications between MA plans and other coverage options. Given the projected increase in MA coverage,11 it becomes imperative to provide objective data on its status and role in spine surgery outcomes.
1.1 Objective
This study aims to bridge this gap by investigating the evolving coverage trends of MA utilization over the past decade in patients undergoing primary lumbar spine surgery. Specifically, the study seeks to demographically characterize the lumbar surgery patient cohort opting for MA plans over other options. Lastly, by controlling for demographics and comorbidities, the study aims to identify the independent effects of MA plans on 90-day complications in patients undergoing primary lumbar spine surgery.
2 Methods
2.1 Study design
A retrospective database study was conducted.
2.2 Participants
All patient records with claims for primary lumbar fusion procedures, including anterior lumbar interbody fusion (ALIF), posterolateral fusion (PLF), and transforaminal interbody lumbar fusion (TLIF) were retrieved. These records were filtered for patients aged 65 years and above. Patients included in the study were stratified into three groups including TM, MA, and other plans based on their insurance enrollment status at the time of their initial surgery, using specific insurance identifiers provided by the PearlDiver database. Patients were grouped into TM plans if they only had Medicare enrollment, and other plans if they had only commercial enrollment. The patient's records in the commercial insurance group were filtered for additional Medicare insurance plans to reflect patients with MA plans. The TM cohort was the reference group against which all analysis was conducted.
2.3 Variables
Primary outcomes included utilization of each of three insurance plans across the last 12 years. Identification of demographic characteristics of the patients included age (years), gender (male), Elixhauser Comorbidity Index or ECI score,12,13 total reimbursement on the patient record i.e., paid ($), and average family income ($ per annum). ECI score is a commonly used measure that uses administrative data to characterize a patient's comorbidity burden and is reliable in predicting in-hospital complications following lumbar fusion surgery.14
Comorbidities were identified using the in-built comorbidity buckets in the Pearldiver database and included Osteoarthritis, Rheumatoid arthritis (RA), Asthma, Hypertension, Ischemic heart disease, Pulmonary heart disease, Obesity, Diabetes, COPD, Coronary artery disease, Congestive heart disease, Chronic kidney disease, Tobacco use. Complications were identified by using in built-pearldiver database bucket if available, or ICD 9 and 10 diagnostic codes (Table 1) and included wound-related complications (wound infection, systemic infection/sepsis, seroma, hematoma, disruption of wound) medical complications (acute kidney injury, cardiac arrest, deep venous thrombosis (DVT), pneumonia, pulmonary embolism (PE), urinary tract infection (UTI), ileus), and neurological complications (sexual dysfunction, paralytic syndrome, seizures, nerve root damage). Long-term complications were evaluated using a follow-up period of 10 years and included adjacent segment disease, pseudoarthrosis, and mortality rates.
| Variable | Coding Reference |
| Lumbar Fusions | CPT-22558, CPT-22585, CPT-22612, CPT-22614, CPT-22612, CPT-22614, CPT-22630, CPT-22632, CPT-22633, CPT-22634 |
| Wound infection | ICD-10-D-G061, ICD-10-D-L0390, ICD-10-D-S31000A, ICD-10-D-T8130XA, ICD-10-D-T8131XA, ICD-10-D-T814XXA, ICD-10-D-T847XXA, ICD-9-D-3241, ICD-9-D-6829, ICD-9-D-8760, ICD-9-D-8761, ICD-9-D-99667, ICD-9-D-99830, ICD-9-D-99832, ICD-9-D-99851, ICD-9-D-99859, ICD-9-D-99883 |
| Systemic infection & sepsis | ICD-10-D-A419, ICD-10-D-1189, ICD-10-D-R5082, ICD-10-D-R509, ICD-9-D-0389, ICD-9-D-486, ICD-9-D-78060, ICD-9-D-78062, ICD-9-D-99591 |
| Seroma | ICD-10-D-M96843 |
| Adjacent segment disease | ICD-10-D-M5136 |
| Pseudoarthrosis | ICD-10-D-M960 |
| Mortality | ICD-9-D-7980, ICD-9-D-7981, ICD-9-D-7982, ICD-9-D-7989, ICD-10-D-R99 |
2.4 Data Source
This study was conducted using the Pearldiver database (PearlDiver Technologies, IN, USA), specifically utilizing the Mariner161Ortho which contains medical and prescription records dating from 01/01/2010–10/31/2022 derived from provider networks. The database includes claims billed to all payer types, including commercial insurance, Medicare, Medicaid, self-pay, and more. The provided data were deidentified and compliant with the Health Insurance Portability and Accountability Act (HIPPA) hence does not require ethical review board approval for analysis. The database is organized based on the diagnostic codes within the International Classification of Diseases (ICD)-9 and ICD-10 classifications and Current Procedural Terminology (CPT). We selected this database for analysis to ensure that a large population of patients was analyzed, thereby improving the power of the study, and reducing the risk of Type II error.
2.5 Statistical method
Demographic characteristics and comorbidities were compared using T-tests and chi-square tests. 90-day postoperative complications were assessed using multivariable regression analysis controlling for age, sex, region, and ECI score keeping TM as the reference group. Significance was defined as a p-value of <0.05. Results are reported as adjusted odds ratios (aOR), along with 95 % confidence intervals (CI) and p-values. All statistical analyses were performed using PearlDiver's built-in statistical software.
3 Results
3.1 Trends
A total of 270,300 records for primary lumbar fusion procedures in patients aged 65 and above were retrieved, categorizing them into TM (134,224 or 49.66%), MA (109,015 or 40.33%), and other plans (27,061 or 10.01%). Fig. 1 illustrates the trends in payer type for lumbar spine fusion surgery cases between 2010 and 2021. In 2010, TM had the highest utilization with 13,262 cases (55.63%), followed by MA with 5760 cases (24.13 %), and O with 4108 cases (18.24 %). In 2021, the data reveals a distinct trend with a declining proportion of cases covered by TM (12,637 cases, 43.26 %), a substantial increase in cases covered by MA (14,113 cases, 47.99 %), and a relatively stable representation of O plans (2460 cases, 8.71 %).
3.2 Descriptive data
Results of the analysis revealed that compared to patients in the TM group, MA patients constitute a higher percentage of males (OR: 1.09, 95% CI: 1.04–1.15, p < 0.05), higher ECI scores (OR: 1.46, 95% CI: 1.41–1.51, p < 0.05), higher average reimbursement on their records (OR: 2.05, 95% CI: 1.97–2.14, p < 0.05), and a higher average mean family income (OR: 1.04, 95% CI: 1.01–1.06, p < 0.05) (Table 2). The results further revealed that except for RA, all comorbidities had a statistically significant higher prevalence in the MA group compared to both TM and O groups (Table 3).
| Traditional Medicare | Advantage Medicare | Other Plans | P-value | |
| Total | 134,224 (49.66 %) | 109,015 (40.33 %) | 27,061 (10.01 %) | |
| Age (Years) | 71.94 | 71.80 | 68.78 | <0.05 |
| Gender (male) | 57,841 (43.09 %) | 49,329 (45.25 %) | 13,975 (51.64 %) | <0.05 |
| ECI | 4.63 | 5.82 | 4.18 | <0.05 |
| Paid ($) | 3538.21 | 7246.56 | 6469.50 | <0.05 |
| Family income ($) | 75897.36 | 77846.23 | 79086.09 | <0.05 |
| Traditional Medicare | Advantage Medicare | Other Plans | P-value | |
| Total | 134,224 | 109,015 | 27,061 | |
| Osteoarthritis | 84,261 (63 %) | 73,683 (68 %) | 15,629 (58 %) | <0.05 |
| Rheumatoid arthritis | 9404 (7 %) | 8122 (7 %) | 1604 (6 %) | <0.05 |
| Asthma | 17,818 (13 %) | 17,219 (16 %) | 3616 (13 %) | <0.05 |
| Hypertension | 120,583 (90 %) | 100,403 (92 %) | 23,709 (87 %) | <0.05 |
| Ischemic heart disease | 45,769 (34 %) | 38,651 (36 %) | 7785 (29 %) | <0.05 |
| Pulmonary heart disease | 17,569 (13 %) | 16,187 (15 %) | 3094 (11 %) | <0.05 |
| Obesity | 48,122 (36 %) | 48,632 (45 %) | 10,400 (38 %) | <0.05 |
| Diabetes | 65,689 (49 %) | 59,126 (54 %) | 13,144 (49 %) | <0.05 |
| COPD | 50,731 (38 %) | 44,907 (41 %) | 9634 (36 %) | <0.05 |
| Coronary artery disease | 60,716 (45 %) | 51,907 (48 %) | 10,766 (40 %) | <0.05 |
| Congestive heart disease | 16,189 (12 %) | 14,491 (13 %) | 2794 (10 %) | <0.05 |
| Chronic kidney disease | 38,899 (29 %) | 36,818 (34 %) | 6807 (25 %) | <0.05 |
| Tobacco use | 52,321 (39 %) | 50,672 (46 %) | 11,294 (42 %) | <0.05 |
3.3 Outcome data
Except for AKI (OR: 1.13, 95% CI: 1.08–1.18, p < 0.05), and PE (OR: 1.07, 95% CI: 1.02–1.12, p < 0.05), all wound-related, medical, neurological, and long-term complications had an increased risk of incidence in MA plans when compared to TM plans (Table 4).
| Advantage MedicareaORa [95% CIa] | P-value | Other PlansaOR [95% CI] | P-value | |
| Total | 109,015 | 27,061 | ||
| Wound-related complications | ||||
| Wound infection | 1.03 [1.01, 1.06] | <0.05 | 1.00 [0.96, 1.04] | 0.86 |
| Systematic Infection/sepsis | 1.03 [1.02, 1.05] | <0.05 | 1.06 [1.03, 1.09] | <0.05 |
| Seroma | 0.83 [0.61, 1.13] | 0.23 | 0.83 [0.49, 1.41] | 0.49 |
| Hematoma | 1.00 [0.96, 1.04] | 0.91 | 0.97 [0.91, 1.05] | 0.48 |
| Disruption of wound | 1.07 [1.02, 1.11] | <0.05 | 0.96 [0.89, 1.03] | 0.29 |
| Medical related complications | ||||
| Acute kidney injury | 0.97 [0.95, 0.99] | <0.05 | 0.97 [0.94, 1.00] | 0.09 |
| Cardiac arrest | 1.06 [1.00, 1.12] | 0.03 | 1.10 [1.00, 1.20] | 0.04 |
| DVT | 0.99 [0.95, 1.03] | 0.58 | 0.98 [0.91, 1.05] | 0.55 |
| Pneumonia | 0.98 [0.96, 1.00] | 0.07 | 0.98 [0.95, 1.01] | 0.18 |
| Pulmonary embolism | 0.88 [0.84, 0.92] | <0.05 | 1.03 [0.95, 1.12] | 0.48 |
| UTI | 1.07 [1.05, 1.09] | <0.05 | 0.98 [0.95, 1.01] | 0.21 |
| Ileus | 1.15 [1.09, 1.22] | <0.05 | 1.06 [0.96, 1.16] | 0.26 |
| Neurological complications | ||||
| Sexual dysfunction | 1.57 [1.03, 2.40] | 0.04 | 1.41 [0.76, 2.62] | 0.27 |
| Paralytic syndrome | 1.25 [1.08, 1.46] | <0.05 | 1.16 [0.89, 1.52] | 0.26 |
| Seizures | 1.22 [0.87, 1.72] | 0.24 | 1.33 [0.78, 2.29] | 0.30 |
| Nerve root damage | 1.17 [1.12, 1.23] | <0.05 | 1.09 [1.01, 1.18] | 0.03 |
| Long-term complications | ||||
| Adjacent segment disease | 1.35 [1.33, 1.37] | <0.05 | 1.01 [0.98, 1.03] | 0.67 |
| Pseudoarthrosis | 1.08 [1.03, 1.12] | <0.05 | 0.84 [0.78, 0.90] | <0.05 |
| Mortality | 1.76 [1.22, 2.56] | <0.05 | 2.09 [1.21, 3.63] | <0.05 |
4 Dicussion
4.1 Key results
The 12-year claims data analysis of over 42 million patient records reveals a growing shift towards MA plans. Patients opting for MA plans tend to be male, of older age, have higher mean family incomes, and have a greater comorbidity burden compared to patients enrolled in TM plans. In addition, when accounting for age, gender, comorbidity burden, and region, patients with MA coverage are at an increased risk of 90-day wound-related, medical, and neurological complications.
Spine-related disorders, such as low-back pain necessitating lumbar fusion surgery, are more common in patients aged 65 years and above.15 The management of these disorders often necessitates addressing chronic health conditions, repeated healthcare consultations, prescription painkillers, and a variety of conservative therapeutic modalities.16 MA plans offer the convenience of having all aspects of spine care management in a single plan, capped out-of-pocket expenditures, and additional advantages that promote physical activity such as gym memberships.2 These aspects of spine surgery management explain why MA plans have gained popularity among patients seeking lumbar fusion surgery treatment. While MA has attracted a substantial percentage of beneficiaries, it has not yet surpassed TM. The limited provider network, along with hassles like prior authorization and referral requirements, may contribute to this. Additionally, for beneficiaries with high healthcare spending, traditional Medicare with supplemental insurance, particularly popular Medigap plans, offers a potentially more cost-effective alternative. Despite attracting a similar percentage of beneficiaries, the financial incentive appears to favor the preference for MA coverage among lumbar surgery patients.
Patients covered with MA plans also tend to be at higher risk of 90-day complications. While data on MA performance in patients seeking spine surgery is unavailable, insights can be drawn from joint arthroplasty patients. Individuals undergoing total hip or knee arthroplasty with MA coverage were linked to higher post-acute care (PAC) facility resource utilization and costs compared to TM coverage patients.17 This elevated PAC utilization may signify an increased need to manage complications. Our study's data aligns with these findings, suggesting that MA plans may independently contribute to worse post-surgery outcomes. This may be attributed to cumbersome pre-authorizations, causing delays in care which results in greater disability.18
There could be multiple reasons why MA plans may not show superior outcomes in lumbar spine surgery patients. MA plans optimize preventative care,3 a feature less beneficial for lumbar spine surgery patients where factors predicting the need for surgery are unmodifiable such as deformity, trauma, and aging—unmodifiable risk factors. The painful nature and urgency of spinal conditions, especially myelopathies, may encounter hindrances due to MA plans' pre-authorization processes,19 impacting patient quality of life. Higher complication rates associated with MA plans pose adverse implications for hospitals, spine surgeons, and facilities, potentially affecting overall healthcare quality metrics.20 Therefore, the suitability of MA plans for patients undergoing lumbar surgery necessitates careful consideration for comprehensive healthcare delivery.
The current data in supporting MA plans in terms of quality-of-care metrics is not applicable to patients seeking lumbar fusion surgery. Patients undergoing lumbar fusion surgery have complex and multifaceted healthcare needs, which have not been evaluated when evaluating MA coverage.3 Additionally, this data fails to account for the high disenrollment rates among enrollees in poor health and those utilizing post-acute services,21 further rendering these deductions ineligible for patients seeking lumbar fusion on MA plans. Therefore, this study holds significance in providing an initial premise that addresses the lack of data regarding patients with MA coverage seeking lumbar fusion surgery.
4.2 Limitations & Strength
Several limitations characterize this retrospective study, including its inherent design constraints, which hinder the establishment of causation. Relying on the Pearldiver database introduces potential limitations, as evaluating only complications that can be extracted using ICD9 and 10 codes. Coding accuracy is contingent on the precision of diagnostic and procedural codes. The lack of patient-reported outcomes diminishes insights into subjective experiences and satisfaction. Nevertheless, the study is the first of its kind to report 90-day complication risks in patients undergoing lumbar fusion surgery with MA plans. Future researchers should consider incorporating detailed clinical data, including the socioeconomic status of patients, and expanding the evaluation of MA to emergency services, as existing studies have predominantly focused on elective care. With nearly half of Medicare-eligible patients now choosing MA, the public health significance of this data cannot be overstated, where MA plans will have a central role in public health decision-making. With high stakes, policymakers will need to depend on data comparing MA with other options, to produce the best public health decision.
5 Conclusion
In conclusion, the increasing popularity of MA plans in lumbar spine surgery beneficiaries, demands attention to the associated 90-day complication risks. While MA plans offer unique benefits, including capped out-of-pocket expenses, our study signals a call for more robust research to delineate the causes of increased complication risks. The insights gained from this study can inform policy changes aimed at optimizing patient choices and improving postoperative outcomes in lumbar spine surgery.
Ethical approval and patient Consent
Since this was a database study and the patient data included was deidentified, no ethical approval was required.
Funding disclosure
The authors received no funding for this study.
Funding
No funding was available to conduct this study.
Author contribution statement
Hania Shazad: Conception and design, Acquisition and data, Analysis and interpretation of data, Drafting of the manuscript, Critical revision of the manuscript for important intellectual content, Statistical analysis.
Muhammad Talal Ibrahim: Conception and design, Analysis and interpretation of data, Critical revision of the manuscript for important intellectual content, Statistical analysis.
Hai Le: Conception and design, Analysis and interpretation of data, Critical revision of the manuscript for important intellectual content, Statistical analysis.
Yashar Javidan: Conception and design, Analysis and interpretation of data, Critical revision of the manuscript for important intellectual content, Statistical analysis.
Frank Phillips: Conception and design, Analysis and interpretation of data, Administrative, technical or material support, Supervision.
Safdar N. Khan: Conception and design, Analysis and interpretation of data, Critical revision of the manuscript for important intellectual content.
Conflict of interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Permission to reproduce copyrighted materials
The authors hereby affirm that appropriate permissions have been obtained for the reproduction of copyrighted materials included in this publication. All necessary acknowledgments and attributions to the original sources have been duly made in accordance with the copyright holders' terms and conditions.
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