Disparities in Access to Spinal Surgery Based on Insurance Type Among Elderly Patients

Spinal surgeries are increasingly performed in the aging United States Medicare population. There has been a demonstrated increase in the utilization of multiple core spine procedures over the last two decades in the over-65 age demographic. Costs for core procedures, such as spinal fusions, have doubled for government-based insurance programs. Additional barriers to access to care may lead to increased complication rates among patients with public insurance compared to private insurance carriers. With an increasing demand for spinal operations coinciding with the aging population, we seek to examine trends in access to spinal surgery for Medicare Advantage (MA) plans compared to private insurance and Traditional Medicare (TM) programs.

In this cross-sectional study, a search of the American Academy of Orthopedic Surgeons directory was conducted for spine surgeons practicing in Florida. Once identified, offices were contacted on four occasions by four separate researchers to assess insurance acceptance and appointment availability using the "secret shopper" technique. This technique utilized a script for a fictitious elderly patient seeking spinal fusion. Insurance plans assessed included TM, Blue Cross Blue Shield (BCBS), and two MA plans (Humana Choice Preferred Provider Organization, PPO, and United Health Preferred Choice Health Maintenance Organization, HMO). Appointment availability was measured in business days. Physicians who retired, relocated, no longer performed spinal fusion surgery, or could not be contacted were excluded from the study.

Of the 120 contacted orthopedic spine surgeons, 55 surgeons met eligibility criteria and reported accepting new surgical consultations. Out of the 55 eligible surgeons, 27 (49%) confirmed in-network benefits for Humana Choice (MA-PPO), and 26 (47%) confirmed in-network benefits for United Healthcare Preferred Choice (MA-HMO). In comparison, BCBS BlueOptions and TM were in-network for 41 (74%) and 47 (85%) of eligible surgeons, respectively. Humana Choice and United Healthcare Preferred Choice were accepted at significantly lower rates than TM and BCBS BlueOptions (p < 0.01). Time to appointment did not differ based on insurance type (p = 0.575).

This study found that patients with MA plans have significantly decreased access to spine surgeons in the state of Florida compared to those with TM and private insurance. Our study highlights a trend in patients with MA plans that may put them at a disadvantage when it comes to patient care. Additional research is required to clarify the broader implications and financial impacts of variations in insurance provider accessibility.