Anticipating the impact of insurance expansion on inpatient urological surgery

Abstract

Purpose: The Affordable Care Act (ACA) is expected to provide coverage for nearly twenty-five million previously uninsured individuals. Because the potential impact of the ACA for urological care remains unknown, we estimated the impact of insurance expansion on the utilization of inpatient urological surgeries using Massachusetts (MA) healthcare reform as a natural experiment.

Methods: We identified nonelderly patients who underwent inpatient urological surgery from 2003 through 2010 using inpatient databases from MA and two control states. Using July 2007 as the transition point between pre- and post-reform periods, we performed a difference-indifferences (DID) analysis to estimate the effect of insurance expansion on overall and procedure-specific rates of inpatient urological surgery. We also performed subgroup analyses according to race, income and insurance status.

Results: We identified 1.4 million surgeries performed during the study interval. We observed no change in the overall rate of inpatient urological surgery for the MA population as a whole, but an increase in the rate of inpatient urological surgery for non-white and low income patients. Our DID analysis confirmed these results (all 1.0%, p=0.668; non-whites 9.9%, p=0.006; low income 6.6%, p=0.041). At a procedure level, insurance expansion caused increased rates of inpatient BPH procedures, but had no effect on rates of prostatectomy, cystectomy, nephrectomy, pyeloplasty or PCNL.

Conclusions: Insurance expansion in Massachusetts increased the overall rate of inpatient urological surgery only for non-whites and low income patients. These data inform key stakeholders about the potential impact of national insurance expansion for a large segment of urological care.

Figure 1. Change in inpatient urological surgery after insurance expansion in Massachusetts

Bar graphs represent percent change in the mean rate of all inpatient urological surgery from before to after Massachusetts healthcare reform (July 2007). Control states are New Jersey and New York. Net change in Massachusetts due to insurance expansion was determined using multivariable difference-in-differences analysis and represents change in rate of surgery attributed to healthcare reform.

Figure 2. Change in inpatient urological surgery after insurance expansion in Massachusetts, by subgroups

Bar graphs represent percent change in the mean rate of discretionary surgery from before to after Massachusetts healthcare reform (July 2007). Non-white population includes blacks and patients of Hispanic origin. Low Income refers to patients residing in Massachusetts counties with low median income. High Uninsured refers to patients residing in Massachusetts counties with high numbers of newly insured. Control states are New Jersey and New York. Percent change in Massachusetts due insurance expansion was determined using multivariable difference-in-differences analysis and represents the change in rate of surgery attributable to healthcare reform.