Publications by authors named "Pooja U Neiman"

6 Publications

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Threats to the Affordable Care Act and surgical care: What has been gained, and what could be lost.

Surgery 2021 Feb 27. Epub 2021 Feb 27.

Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, MI; Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI. Electronic address: https://twitter.com/jzayanian.

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http://dx.doi.org/10.1016/j.surg.2021.01.031DOI Listing
February 2021

The ACA at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future.

J Surg Res 2021 Feb 25;263:102-109. Epub 2021 Feb 25.

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.
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http://dx.doi.org/10.1016/j.jss.2020.12.056DOI Listing
February 2021

Impact of Affordable Care Act-related insurance expansion policies on mortality and access to post-discharge care for trauma patients: an analysis of the National Trauma Data Bank.

J Trauma Acute Care Surg 2019 02;86(2):196-205

From the Department of Surgery (J.W.S.), Harborview Medical Center, University of Washington, Seattle, WA; Department of Surgery (P.U.N., A.S., A.H.H), Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Department of Surgery (T.U.-L., A.S., A.H.H.), Brigham and Women's Hospital, Boston, MA; Harvard Medical School (K.W.S.), Boston, MA; Yale School of Medicine (C.K.Z.), New Haven, CT; and Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery (A.S., A.H.H.), Brigham and Women's Hospital, Boston, MA.

Background: Uninsured trauma patients have worse outcomes and worse access to post-discharge care that is critically important for recovery after injury. Little is known regarding the impact of the insurance coverage expansion policies of the Affordable Care Act (ACA), most notably state-level Medicaid expansion, on trauma patients. In this study, we examine the national impact of these policies on payer mix, inpatient mortality, and access to post-acute care for trauma patients.

Methods: We used the 2011-2016 National Trauma Data Bank to evaluate for changes in insurance coverage among trauma patients 18-64 years old. Our pre-/post-expansion models defined 2011-2013 as the pre-policy period, 2015-2016 as the post-policy period, and 2014 as a washout year. To evaluate for policy-associated changes in inpatient mortality and discharge disposition among the policy-eligible sample, we leveraged multivariable linear regression techniques to adjust for year-to-year variation in patient demographics, injury characteristics, and facility traits. We then examined the relationship between the magnitude of facility-level reductions in uninsured patients and access to post-acute care after policy implementation.

Results: We identified 1,656,469 patients meeting inclusion criteria between 2011 and 2016. The pre-policy uninsured rate of 23.4% fell by 5.9 percentage-points after coverage expansion (p < 0.001), with a corresponding 7.5 percentage-point increase in Medicaid coverage (p < 0.001). After policy implementation, there were no significant changes in inpatient mortality. However, there was a >30% relative increase in discharge to a post-acute care facility and a similar increase in discharge with home health services (p < 0.001 for both). The greatest gains in access to post-acute services were seen among facilities with the greatest reductions in their uninsured rate (p = 0.003).

Conclusion: ACA-related coverage expansion policies, most notably Medicaid expansion, were associated with a >25% reduction in the uninsured rate among non-elderly adult trauma patients. Although no immediate impact on inpatient mortality was seen, insurance coverage expansion was associated with a higher proportion of patients receiving critically important post-discharge care.

Level Of Evidence: Epidemiological, level III.
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http://dx.doi.org/10.1097/TA.0000000000002117DOI Listing
February 2019

The Future of Emergency General Surgery.

Ann Surg 2019 08;270(2):221-222

Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI.

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http://dx.doi.org/10.1097/SLA.0000000000003183DOI Listing
August 2019

Lower emergency general surgery (EGS) mortality among hospitals with higher-quality trauma care.

J Trauma Acute Care Surg 2018 03;84(3):433-440

From the Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (J.W.S., T.C.T., P.U.N.); Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (J.W.S., A.H.H., A.S., J.M.H.); Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, UC Davis Health System, Sacramento, California (G.J.J., G.H.U.); and Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts (A.H.H., A.S., J.M.H.).

Background: Patients undergoing emergency general surgery (EGS) procedures are up to eight times more likely to die than patients undergoing the same procedures electively. This excess mortality is often attributed to nonmodifiable patient factors including comorbidities and physiologic derangements at presentation, leaving few targets for quality improvement. Although the hospital-level traits that contribute to EGS outcomes are not well understood, we hypothesized that facilities with lower trauma mortality would have lower EGS mortality.

Methods: Using the Nationwide Inpatient Sample (2008-2011), we calculated hospital-level risk-adjusted trauma mortality rates for hospitals with more than 400 trauma admissions. We then calculated hospital-level risk-adjusted EGS mortality rates for hospitals with more than 200 urgent/emergent admissions for seven core EGS procedures (laparotomy, large bowel resection, small bowel resection, lysis of adhesions, operative intervention for ulcer disease, cholecystectomy, and appendectomy). We used univariable and multivariable techniques to assess for associations between hospital-level risk-adjusted EGS mortality and hospital characteristics, patient-mix traits, EGS volume, and trauma mortality quartile.

Results: Data from 303 hospitals, representing 153,544 admissions, revealed a median hospital-level EGS mortality rate of 1.21% (interquartile range, 0.86%-1.71%). After adjusting for hospital traits, hospital-level EGS mortality was significantly associated with trauma mortality quartile as well as patients' community income-level and race/ethnicity (p < 0.05 for all). Mean risk-adjusted EGS mortality was 1.09% (95% confidence interval, 0.94-1.25%) at hospitals in the lowest quartile for risk-adjusted trauma mortality, and 1.64% (95% confidence interval, 1.48-1.80%) at hospitals in the highest quartile of trauma mortality (p < 0.01). Sensitivity analyses limited to (1) high-mortality procedures and (2) high-volume facilities; both found similar trends (p < 0.01).

Conclusions: Patients at hospitals with lower risk-adjusted trauma mortality have a nearly 33% lower risk of mortality after admission for EGS procedures. The structures and processes that improve trauma mortality may also improve EGS mortality. Emergency general surgery-specific systems measures and process measures are needed to better understand drivers of variation in quality of EGS outcomes.

Level Of Evidence: Epidemiological, level III; Care management, level IV.
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http://dx.doi.org/10.1097/TA.0000000000001768DOI Listing
March 2018

Potential impact of Affordable Care Act-related insurance expansion on trauma care reimbursement.

J Trauma Acute Care Surg 2017 05;82(5):887-895

From the Department of Surgery, Center for Surgery and Public Health (J.W.S., P.N., T.C.T., A.S., A.H.H.), Brigham & Women's Hospital; Program in Global Surgery and Social Change (J.W.S., M.G.S.), Harvard Medical School, Boston; John F. Kennedy School of Government (P.U.), Harvard University, Cambridge, Massachusetts; David Geffen School of Medicine at the University of California (P.U.), Los Angeles, Los Angeles, California; Harvard Business School (P.N.); Department of Health Policy and Management (T.C.T.), Harvard T.H. Chan School of Public Health; Harvard Medical School (K.W.S.); Department Of Otolaryngology & Office of Global Surgery (M.G.S.), Massachusetts Eye & Ear Infirmary, Boston; Department of Economics (D.M.C.), Harvard University; National Bureau of Economics Research (D.M.C.); and Division of Trauma, Department of Surgery (A.S., A.H.H.), Brigham & Women's Hospital, Boston, Massachusetts.

Background: Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect.

Methods: We abstracted nonelderly adults (ages 18-64 years) admitted for trauma from the Nationwide Inpatient Sample during 2010-the last year before most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using Nationwide Inpatient Sample-supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population.

Results: There were 145,849 patients (representing 737,852 patients nationwide) included. National inpatient trauma costs for patients aged 18 years to 64 years totaled US $14.8 billion (95% confidence interval [CI], 12.5,17.1). Preexpansion reimbursements totaled US $13.7 billion (95% CI, 10.8-14.7), yielding a national margin of -7.9% (95% CI, -10.6 to -5.1). Postexpansion projected reimbursements totaled US $15.0 billion (95% CI, 12.7-17.3), increasing the margin by 9.3 absolute percentage points to +1.4% (95% CI, -0.3 to +3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using postexpansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains.

Conclusion: Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers' financial viability and their ability to provide care for their communities.

Level Of Evidence: Economic analysis, level II.
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http://dx.doi.org/10.1097/TA.0000000000001400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5468098PMC
May 2017