Analysis of Medicaid and Medicare Reimbursement Variations for Common Orthopaedic Trauma Procedures

Abstract

OBJECTIVES: Medicaid (MCD) reimbursement for surgery is determined by state governments and is subject to substantial variation in comparison to Medicare (MCR), which is determined by the federal government and invariable across the United States. This mismatch in reimbursement has previously been described as a component of the disparity in access to care in orthopaedics. While this variation has been previously quantified for general orthopaedics and orthopaedic hand surgery, no such analysis has been performed for orthopaedic trauma. This study aims to quantify the variation in MCD and MCR reimbursement for common orthopaedic trauma procedures.

DESIGN: Billing data obtained from a Level I trauma center were retrospectively reviewed and the ten most commonly billed Current Procedural Terminology (CPT) codes were extracted. State and federal physician fee schedules were collected and assessed to determine MCD- and MCR-specific reimbursement rates, or relative value units (RVUs), for these ten procedures. An economic analysis was then conducted to evaluate the disparities between MCD and MCR reimbursement.

MAIN OUTCOME MEASURES: MCD and MCR RVUs for each procedure were compared using dollar difference and coefficient of variation (CV).

RESULTS: Our analysis showed considerable variance in MCD reimbursement rates between states. Additionally, we found that the majority of RVUs for MCD were higher than MCR for the evaluated trauma procedures.

CONCLUSION: The variance in MCD reimbursement values may be driven by differences in the underlying characteristics of each systems’ patient population. This variance, particularly in bordering states, could represent a barrier to healthcare access for some populations.