Category: Epidemiology, Health Policy, Socioeconomics & Outcomes
Introduction & Objective : In March 2010 the Affordable Care Act (ACA) was signed into law, yet health insurance markets did not become fully operational until January 2014. We hypothesized that enactment of this legislation would alter the payer distribution for kidney stone patients undergoing ureteroscopy (URS), shockwave lithotripsy (SWL), and percutaneous nephrolithotomy (PCNL) in California (CA).
We utilized CA's Office of Statewide Health Planning and Development (OSHPD) public inpatient and ambulatory surgical databases from 2011-2016 to examine URS, SWL, and PCNL operations for nephrolithiasis. Data was obtained on an aggregate level and split into two eras: 2011-2013 (pre-implementation) and 2014-2016 (post-implementation). The proportion of patients/procedures was compared for payer type by Chi square test for independence before and after the ACA. ArcMap 10.5 Software (ERSI, Redlands, CA) was used to create the choropleth map of CA labor market regions.
A total of 86,437 procedures were performed from 2011-2013, while 95,866 were performed from 2014-2016. After 2014, the number of operations performed on Medicaid patients increased by 88% (from 8,878 to 16,717, p < .01, Figure), while operations on the uninsured dropped by 67% (from 2,887 to 1,676, p < .01, Figure) with a ratio of 6.5:1 in favor of increased Medicaid operations. When examined by CA labor market region, wide variability was noted with a range of -4% to +214% for the change in procedures on Medicaid patients (Figure). Counts for privately insured and Medicare patients increased without abrupt change after 2014.
Conclusions : Compared to before ACA implementation, the payer mix for patients undergoing surgery for urinary stone disease within California appears drastically altered, however not all geographic regions experienced the same degree of change. The ACA also may have improved access to stone surgery given that the increase in Medicaid patients was 6.5 times larger than the decrease in uninsured patients. It remains to be seen if the observed variation by geography is due to patient or system related factors.
Scott Wiener– Clinical Fellow, UCSF, San Francisco, California
David Bayne– Clinical Fellow, UCSF, San Francisco, California
David Tzou– Assistant Professor, University of Arizona, Tucson, Arizona
Thomas Chi– Associate Professor, UCSF, San Fransisco, California
Marshall Stoller– Professor, UCSF, San Francisco, California
San Francisco, California
Scott Wiener is a clincal fellow in endourology at UCSF.
San Francisco, California
David Bayne, MD, MPH
UCSF Urology Endo/Lap Fellow
BA in Biochemistry at Harvard College 2006
MD at Harvard Medical School 2012
MPH at UC Berkeley in 2017
Residency in Urology at UCSF 2018
San Fransisco, California
Thomas Chi, MD
Associate Chair for Clinical Affairs
Kutzmann Endowed Professor for Clinical Urology
UCSF Department of Urology
Dr. Thomas Chi, MD, graduated as a President's Scholar from Stanford University with a BA in Human Biology and MAs in Sociology and Music. He earned his MD from the University of California, San Francisco where he also completed urology residency and a fellowship in Endourology and Laparoscopy under the mentorship of Dr. Marshall L. Stoller.
During his fellowship, Dr. Chi was awarded grant funding from the National Institutes of Health and the American Urological Association Urology Care Foundation to research the fundamental mechanisms underlying the formation of urinary stones.
He joined the UCSF faculty of the Department of Urology in 2013 where his clinical interests include the care of patients with urinary stone disease and those in need of minimally invasive surgery. He specializes in the performance of endoscopic, laparoscopic, and percutaneous surgeries as well as HoLEP. He has established ReSKU, the Registry for Stones of the Kidneys and Ureter, the first kidney stone registry of its kind for tracking patient clinical outcomes and is an internationally recognized specialist in the use of ultrasound in the management of kidney stones to minimize patient radiation exposure.
In addition to his clinical interests, Dr. Chi supervises an NIH-funded translational science lab where he leads a cross-disciplinary research team. His research focuses on understanding the genetic and microbial environment of the kidney related to how kidney stones form and developing new medical preventative interventions. He has developed a novel model fruit fly for the study of kidney stones and has published over 80 peer-reviewed articles and book chapters spanning both basic science as well as epidemiologic approaches centered around improving the care of patients with urinary stone disease.