MedStar Investigators Evaluate the Effects of Medicaid Expansion on Trauma Triage

Recently published research from the team at the Curtis Hand Center explored whether the 2014 expansion of Medicaid in Maryland under the Affordable Care Act decreased the number of uninsured upper-extremity trauma patients and the volume of unnecessary emergency trauma visits at the hand center.

“The Effects of Medicaid Expansion on Triage and Regional Transfer After Upper-Extremity Trauma” was published in the Journal of Hand Surgery. The research team was led by Charles A. Daly, MD and included Brian H. Cho, MD; Sameer Desale, MS; Oluseyi Aliu, MD, MS; Mihriye Mete, PhD; and Aviram M. Giladi, MD, MS.

In the United States, 17% of total trauma-related costs are associated with hand and wrist injuries. In addition, care for hand trauma is often complex and time sensitive which creates a burden for patients sometimes being transferred long distances for treatment. The Affordable Care Act was passed in March 2010 with an intent of expanding health insurance coverage and health care access nationwide. Currently, only 32 states and the District of Columbia have elected to expand coverage.

The availability of trauma centers that specialize in upper-extremity care is critical to treating patients. However, there’s an overuse of referrals and transfers which creates additional financial burden for these centers. The study team hypothesized that by decreasing the number of uninsured trauma patients, Medicaid expansion would decrease unwarranted transfers because the patients may be able to find care closer to home.

This retrospective study looked at patients with isolated hand and upper-extremity trauma between 2010 and 2017 at the Curtis Hand Center. Demographic data was collected and the intensity of each patient’s injury was classified using the Hand Trauma Severity Matrix. The Severity Matrix assists with indicating the need for acute specialized hand trauma management. Patients were classified as appropriate/inappropriate, transfer/non-transfer, and pre-expansion or post Medicaid expansion in Maryland.

The research team studied 12,009 acute upper-extremity trauma patients. In total, 20% had Medicaid and 27% had no insurance. Thirty percent of patients traveled over 25 miles to obtain treatment and 25% of all patients were transferred to the hand center from other health care facilities. After Medicaid expansion, the percentage of trauma patients with Medicaid coverage increased from 15% to 24%, with a decrease in uninsured from 31% to 24%. After Medicaid expansion, non-transfer patient appropriateness decreased and appropriateness of transfers remained steady. Transfer patients were required to travel significantly farther for care than were non-transfer patients but the distance all groups traveled on average did not change significantly from before to after expansion.

The results show that Medicaid expansion significantly decreased the proportion of uninsured upper-extremity trauma patients. However, the study team did not find a significant change in the appropriateness of transferred patients after expansion, whereas appropriateness of non-transferred patients declined after Medicaid expansion. There is still a high percentage of uninsured patients that remain in the hand trauma population, which continues to place a financial burden on regional referral centers. Future research should focus on how to lessen the burden of unnecessary urgent referrals and improving resource use.

Dr. Avi Giladi recently had an interview with Dr. Brent Graham, Hand surgeon, Editor-in-Chief of the Journal of Hand Surgery (JHS) regarding “The Effects of Medicaid Expansion on Triage and Regional Transfer After Upper-Extremity Trauma” on the JHS monthly podcast. You may listen to Episode 42 here.  

 Journal of Hand Surgery, 2019. DOI: 10.1016/j.jhsa.2019.05.020