Insurance plan affects access to and timeliness of surgery for patients with cervical degenerative conditions

Amit Jain

Insurance type has a significant impact on incidence and time-to-occurrence of surgery for patients with cervical degenerative conditions, according to new research—published in the journal Spine by Amit Jain (Johns Hopkins University, Baltimore, USA) et al—which also indicated that patients with high-deductible health plans (HDHP) may experience higher costs, thus potentially limiting their access to care.

The researchers note that prior literature “has demonstrated that disparities exist in healthcare access and outcomes by insurance status, and patients with commercial plans fare better than those with Medicaid. However, variation may exist within commercial plans which may impact care access”.

The study sought to determine the association between commercial health insurance plan type and access/time-to-surgery among patients with degenerative cervical conditions.

The MarketScan database (IBM Watson Health) was used to identify the first instance of ICD-10-CM diagnosis codes for cervical myelopathy and radiculopathy. Patients under the age of 65 and enrolled from 2015-2020 with a minimum of two years of continuous enrolment were included.

Surgery for myelopathy included anterior cervical discectomy and fusion (ACDF), posterior cervical laminectomy and fusion (PCLF), and laminoplasty, while surgery for radiculopathy included ACDF, cervical disc arthroplasty (CDA), and foraminotomy.

The time between first diagnosis and surgery was determined. Insurance plan type was categorised as non-capitated, non-high-deductible health plan (NC), health maintenance organisation (HMO)-type partially or fully capitated plans (CAP), or HDHP. Proportional hazards regression was utilised to compare time-to-incidence of surgery by plan type, adjusting for age and sex.

A total of 55,954 patients with cervical myelopathy and 705,117 patients with cervical radiculopathy were included in the study. The mean follow-up was 537 days and 657 days for myelopathy and radiculopathy, respectively.

At two years post-diagnosis, 22.6% of myelopathy and 5.6% of radiculopathy patients were managed surgically. ACDF was the most common surgery for both myelopathy (85.7% of surgically managed patients) and radiculopathy (80.6%).

The mean time to surgery for myelopathy was 101 days, and 196 days for radiculopathy. The most common plan type was NC for both myelopathy (81.5%, n= 44,832) and radiculopathy (80.6%, n= 559,109). Time-to-occurrence of surgery was significantly higher among both myelopathy and radiculopathy patients with CAP and HDHP versus NC plans, but the impact was significantly greater among those with radiculopathy than myelopathy (all p<0.05).

Speaking to Spinal News International, Jain said: “As we usher into the era of value-based care, it is important to understand the impact of patient insurance on access and equity in musculoskeletal care. In this work, we demonstrate that there are large clinical variations in access to surgery among commercial insurance plans. Preferred Provider Organisation (PPO) plans generally allow greater access, and HMO plans limit access. These data are important for patients, clinicians and policy makers.”


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