Impact of insurance and implant coverage on arthroscopic shoulder surgery patients: a prospective multicenter...

Advances in implant technology for arthroscopic shoulder surgery allow patients to achieve similar success rates as traditional approaches with reduced morbidity and quicker recovery. However, in the U. S. health care system, insurance coverage for these implants remains variable. Unlike commercial carriers, patients with governmental insurance typically do not have coverage for arthroscopic shoulder implants. How this disparity impacts the health care of patients with shoulder pathology remains unclear.

We performed a prospective multicenter study analyzing the effects of insurance type and implant coverage on patients undergoing arthroscopic shoulder surgery. Patients were selected upon confirmation of surgery. Each case was documented for patient age, American Society of Anesthesiologists score, body mass index, race, and sex. Each case was then categorized based on insurance carrier (traditional Medicare, managed Medicare, commercial plans, Medicaid, workers' compensation, cash, or other governmental insurance). The timing for surgery, primary surgical indication, whether a primary or revision surgery, number of anchors used, site of service (freestanding ambulatory surgery centers (ASCs) vs. hospital-based operating room), and utilization of biologic or structural grafts were all then tracked.

A total of 326 cases from 6 participating states were analyzed. In comparison to ASCs, patients having surgery in hospital settings were older (56.8 vs. 52.0 years), had a higher body mass index (31.3 vs. 29.0), had higher American Society of Anesthesiologists scores (2.4 vs. 1.9), and were more likely to be non-white (41.2% vs. 31.5%). (P < .05) After controlling for comorbidities, patients with Medicare Advantage (71%), Traditional Medicare (55%), and Medicaid/Cash (66%) were more likely to have their surgery in the hospital setting than patients with commercial plans (42%) (P < .05). Hospital patients waited significantly longer before surgery in comparison to ASC patients (45.9 days vs. 34.4 days) (P < .05). No statistically significant difference was identified between the number of anchors used and the insurance carrier (P = .58). A higher percentage of surgeries in the hospital (19.6%) included biologics vs. those in an ASC (10.4%) (P = .03).

Patients with governmental insurance plans were less likely to undergo arthroscopic shoulder surgery at an ASC than at a hospital-based facility. Patients who had their surgery at a hospital facility had a longer wait until surgery. Insurance carrier and implant coverage might influence where and when a patient receives care. Equal coverage of surgical implants for arthroscopic shoulder surgery would improve timely access and care for shoulder pathology. Legislatures should closely consider these findings when developing insurance policies.