Medicaid TKA Patients Show High Satisfaction Despite Worse Outcomes

The experience of undergoing a total knee arthroplasty (TKA) can vary significantly depending on a patient’s insurance coverage, according to data presented at the American Academy of Orthopaedic Surgeons Annual Meeting earlier this month. Even as patients on Medicaid demonstrated slightly less robust functional improvements compared to those with private insurance, they reported surprisingly high levels of satisfaction with their outcomes. This finding underscores the importance of ensuring equitable access to care for all patients, even those facing socioeconomic challenges.

Researchers retrospectively analyzed data from 260 patients – 83 with Medicaid and 177 with private insurance – all under the age of 65 who underwent primary TKA between May 2020 and May 2023. The study, led by Arthur L. Malkani, MD, FAAOS, of University of Louisville Health, focused on functional outcomes measured by the Forgotten Joint Score and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), as well as patient-reported health scores using the PROMIS-10 system. Additional factors considered included the Charlson Comorbidity Index, American Society of Anesthesiologists classification, discharge location, length of stay, diabetes status, and living arrangements.

Social Determinants and Surgical Outcomes

The analysis revealed several key differences between the two groups beyond insurance status. John E. Whitaker, MD, similarly of the University of Louisville, highlighted that patients on Medicaid were more likely to live alone, smoke, be female, and have obesity compared to those with private insurance. These factors, often referred to as social determinants of health, can significantly impact a patient’s recovery and overall well-being following surgery. The Centers for Disease Control and Prevention (CDC) defines social determinants of health as the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health outcomes, and risks.

Specifically, the study found that Medicaid patients exhibited slightly lower scores on the KOOS JR and Forgotten Joint Scores, indicating somewhat less functional improvement post-surgery. Though, this difference did not translate into lower patient satisfaction. Dr. Malkani emphasized that despite these potential challenges, these patients still experience meaningful benefits from TKA, including pain relief and improved mobility. “You are not going to see a dramatic improvement in their KOOS JR or Forgotten Joint Scores, yet they are going to be happy patients, and they are going to keep on maintaining independence,” he stated.

Beyond PROMs: Capturing the Full Picture

Dr. Whitaker suggested that standard patient-reported outcome measures (PROMs) may not fully capture the complexities faced by Medicaid patients. “There are a lot of issues that Medicaid patients suffer that are not captured in some of these PROMs that we are taking, such as living alone and having poor social support,” he explained. He noted that patients with private insurance often benefit from stronger social support networks at home, which can aid in their recovery process. Research published in BMC Public Health supports the link between social support and positive outcomes after joint replacement surgery.

The study’s findings align with a growing body of evidence highlighting the impact of social determinants on orthopedic outcomes. A 2023 study in the Journal of Bone & Joint Surgery found that patients from lower socioeconomic backgrounds were at increased risk of complications following hip and knee arthroplasty.

Implications for Care Delivery

The researchers advocate for a more holistic approach to care for patients undergoing TKA, particularly those on Medicaid. This includes recognizing and addressing the unique challenges they face, such as limited social support, housing instability, and food insecurity. Developing hospital-wide and community-wide services to provide additional resources and support is crucial.

“This is going to be an issue that affects all of us in the orthopedic field,” Dr. Whitaker said. “Not only arthroplasty surgeons, but also people in sports and in the community, everybody is doing total joints now. It is going to be something we need to gaze at as a hospital system and as individual orthopedic surgeons to make sure we are taking care of everybody.”

The Importance of Access and Equity

Dr. Malkani underscored the ethical imperative of providing access to TKA for all patients, regardless of their insurance status. “They need to walk, they want to alleviate their pain, so you cannot deny them care. Despite these comorbid conditions, you still have to operate on them,” he stated. Denying care based on insurance status would exacerbate existing health disparities and further disadvantage vulnerable populations.

Looking ahead, the researchers emphasize the need for continued investigation into the factors that influence orthopedic outcomes among Medicaid patients. Further research could explore the effectiveness of targeted interventions designed to address social determinants of health and improve patient support systems. The ultimate goal is to ensure that all patients have the opportunity to benefit from the life-changing potential of TKA, regardless of their socioeconomic circumstances.

For more information, contact David McArthur at [email protected].