Abstract
Background:
Comprehensive craniomaxillofacial trauma care includes correcting functional deficits, addressing acquired deformities and appearance, and providing psychosocial support. The aim of this study was to characterize insurance coverage of surgical, medical, and psychosocial services indicated for longitudinal facial trauma care and highlight national discrepancies in policy.
Methods:
A cross-sectional analysis of insurance coverage was performed for treatment of common functional, appearance, and psychosocial facial trauma sequelae. Policies were scored for coverage (3), case-by-case coverage (2), no mention (1), and exclusion (0). The sum of points determined coverage scores for functional sequelae, acquired-appearance sequelae, and psychosocial sequelae, the sum of which generated a Comprehensive Coverage Score.
Results:
Medicaid earned lower comprehensive coverage scores and lower coverage scores for psychosocial sequelae than did private insurance (P = 0.02, P = 0.02). Medicaid CCSs were lowest in Oklahoma, Arkansas, and Missouri. Private insurance CCSs and psychosocial sequelae were highest in Colorado and Delaware, and lowest in Wisconsin. Coverage scores for functional sequelae and for acquired-appearance sequelae were similar for Medicaid and private policies. Medicaid coverage scores were higher in states that opted into Medicaid expansion (P = 0.04), states with Democrat governors (P = 0.02), states with mandated paid leave (P = 0.01), and states with >40% total population living >400% above federal poverty (P = 0.03). Medicaid comprehensive coverage scores and coverage scores for psychosocial sequelae were lower in southeastern states. Private insurance coverage scores for functional sequelae and for ASCSs were lower in the Midwest.
Conclusions:
Insurance disparities in comprehensive craniomaxillofacial care coverage exist, particularly for psychosocial services. The disparities correlate with current state-level geopolitics. There is a uniform need to address national and state-specific differences in coverage from both Medicaid and private insurance policies.
INTRODUCTION
Insurance-related disparities in accessible coverage and healthcare quality have been described in many medical and surgical populations. For patients with traumatic injury, Medicaid enrollment has been associated with less surgery, poorer outcomes, and longer hospitals stays compared with private insurance.1,2 These differences have contributed to inadequate mechanisms for delivering needed trauma care and unsustainable financial consequences to healthcare systems as a whole. With nearly a quarter of Level-I trauma presentations involving the face, and due to their steep resource needs, craniomaxillofacial (CMF) trauma patients are particularly subject to disparities in care.3–11
Traditional paradigms have considered CMF trauma reconstruction as an acute disease process that is often deprioritized because of perceptions of an undesirable patient population, undesirable financial incentives, lack of specialist interest, and the lifestyle unpredictability associated with its specialization.12,13 On the contrary, modern paradigms recognize CMF trauma as a chronic disease of acute onset in terms of facial deformity, functional disability, and psychosocial issues. Thus, as with other disease processes, wholistic interdisciplinary management potentiates patient care.14 The concept of a comprehensive CMF trauma program is to combine acute trauma care with secondary management of established facial deformities, address functional issues, and to unite patients with social and psychiatric care services.
The aim of this study was to characterize insurance coverage of surgical and medical services indicated to treat common functional, appearance-related, and psychosocial sequelae of major CMF trauma, and highlight discrepancies in coverage.
METHODS
Medicaid and private insurance policies were cross-sectionally reviewed in April 2020 to assess coverage of comprehensive CMF trauma care for nondisabled adults in all 50 US states and the District of Columbia (D.C.). Only private policies available on the Affordable Care Act (ACA) Marketplace as silver options—the most commonly enrolled ACA marketplace option—were considered.15 Policies offered by each state’s largest insurer (FY2018 market-cap) were included. Certificates of coverage were reviewed for all policies along with insurance company medical policies. To define comprehensive care, 3 classes of common injury sequelae were created: 1. Functional deficits (acquired malocclusion, nasal airway obstruction, facial paralysis/paresthesia, excessive tearing/dry eyes, difficulty closing eyes, pain with mastication, trouble breathing); 2. Acquired appearance-related (orbital dystopia, nasal deformity, scar needing revision, asymmetry/contour irregularity); 3. Psychosocial support (employment services/assistance, occupational/physical/speech therapy, psychiatric care, social services).
Surgical treatments for functional and appearance-related sequelae classes were individually scrutinized for coverage. The same was done for the defined psychosocial services. Policies were uniquely classified as clear coverage, case-by-case coverage, lack of mention, or explicit exclusion. Policies indicating clear coverage were given 3 points, case-by-case coverage 2 points, no mention (silent) 1 point, and explicit exclusion of coverage 0 points. The sum of all points was determined for each class of sequela to yield functional sequelae coverage scores (FSCS), acquired-appearance sequelae coverage scores (ASCS), and psychosocial service coverage scores (PSCS).
Financial (FY2018), socioeconomic, and political data were collected from the Kaiser Family Foundation Fund (KFF) State Health Facts to investigate underlying associations with calculated coverage scores. The Kaiser Family Foundation Fund State Health Facts provides free, up-to-date health data for all states and DC.16 Financial data included Gross State Product ($), state spending per capita ($), total state tax collection ($), total state Medicaid spending ($), state decision regarding the ACA Medicaid Expansion (opt-in/out), and federal: state contribution ratio to the state’s Medicaid budget. Socioeconomic data included total Medicaid utilizers (as % of state population), populations making <100% and >400% of the federal poverty level (as % of state population), non-citizen population (as % of state population), and state mandated paid leave (sick or family). Political data included voter population (as % of state’s registered voters) and majority political affiliations of state governors, senates, and houses (Democrat/Republican). Bivariate correlation and one-way ANOVA were performed using Kaiser Family Foundation Fund financial, socioeconomic, and political data as independent variables and calculated coverage scores (CCS, FSCS, ASCS, PSCS) as dependent variables. Continuous independent variables were nominally transformed using cutoffs ± 2 standard deviations (sds.). All statistical analyses were performed using IBM SPSS Statistics for Mac OS, version 25 (IBM Corp., Armonk, N.Y.). Significance was defined as P < 0.05.
RESULTS
A total of 102 policies were analyzed, half from Medicaid (n = 51) and half from private insurance (n = 51). Coverage of individual CMF-trauma related injuries are shown in Table 1. The majority of functional injuries were explicitly covered. Acquired malocclusion was covered by 82.3% (n = 42) of private policies and 84.3% (n = 43) of Medicaid policies. Pain with mastication, nasal airway obstruction, and excessive tearing were covered by 94.1% (n = 48) of Medicaid policies. Pain with mastication, difficulty breathing, excessive tearing/dry eyes, and difficulty closing eyes were covered by 82.3% (n = 42) of private policies. Nasal airway obstruction was covered by 80.4% (n = 41) of private policies. Breathing difficulty and difficulty closing eyes were explicitly covered by 96.1% (n = 49) of Medicaid policies. Facial paralysis/paresthesia was covered by 84.5% (n = 38) of private policies and 72.5% (n = 37) Medicaid policies; 25.5% (n = 13) of private policies, and 27.5% (n = 14) of private policies provided case-by-case coverage of facial paralysis/paresthesia. Coverage of acquired-appearance injuries was heterogenous across policies. Nasal deformity was explicitly not covered by 25.5% (n = 13) of private policies and 29.4% (n = 15) of Medicaid policies. The majority of private policies (47.1%, n = 24) and Medicaid policies (45.1%, n = 23) provided case-by-case coverage of nasal deformity. Scar revision was similarly covered, with 47.1% (n = 24) of private policies and 43.1% (n = 22) of Medicaid policies providing case-by-case coverage. An estimated 31.4% (n = 16) and 27.4% (n = 14) of Medicaid and private policies, respectively, explicitly did not cover scar revision without functional consequence. Facial asymmetry or contour irregularity were covered on a case-by-case basis in 47.1% (n = 24) private and Medicaid policies. The range (n) of Medicaid and private policies providing explicit coverage for any acquired-appearance injury was 13–14 (25.5%–27.4%). Employment services were explicitly not covered by 98% (n = 50) of Medicaid policies. Private insurance policies nearly half the time excluded coverage (49%, n = 25) or did not mention coverage (47%, n = 24). The majority of private (n = 46, 90.2%) and Medicaid policies (n = 46, 90.2%) provided rehabilitative occupational, physical, and speech therapies. Psychiatric/psychology services were covered by 92.1% (n = 47) of private policies and 88.2% (n = 45) of Medicaid policies.
Table 1.
Coverage of Individual Injuries within Each Sequelae Class for Medicaid Policies (n = 51) and Private Insurance Policies (n = 51)
| Functional Sequelae | Acquired-appearance Sequelae | Psychosocial Sequelae | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Acquired Malocclusion | Pain with Mastication | Nasal Airway Obstruction | Difficulty Breathing | Excessive Tearing/Dry Eyes | Difficulty Closing Eyes | Facial Paralysis/Paresthesia | Orbital Dystopia | Nasal Deformity | Scar Revision | Facial Asymmetry/Contour Irregularity | Employment Services | OT/PT/Speech Therapy | Psych Care* | ||
| Private Insurance (n = 51) | Explicit noncoverage | — | — | — | — | — | — | — | 10 (19.6%) | 13 (25.5%) | 14 (27.4%) | 10 (19.6%) | 25 (49%) | — | — |
| No mention | — | — | — | — | — | — | — | — | — | — | 4 (7.8%) | 24 (47%) | 1 (2%) | — | |
| Case-by-case | 9 (17.6%) | 9 (17.6%) | 10 (19.6%) | 9 (17.6%) | 9 (17.6%) | 9 (17.6%) | 13 (25.5%) | 27 (53%) | 24 (47.1%) | 24 (47.1%) | 24 (47.1%) | — | 4 (7.8%) | 4 (7.8%) | |
| Covered | 42 (82.3%) | 42 (82.3%) | 41 (80.4%) | 42 (82.3%) | 42 (82.3%) | 42 (82.3%) | 38 (74.5%) | 14 (27.4%) | 14 (27.4%) | 13 (25.5%) | 13 (25.5%) | 2 (3.9%) | 46 (90.2%) | 47 (92.1%) | |
| Medicaid (n = 51) | Explicit noncoverage | 2 (3.9%) | — | — | — | — | — | — | 11 (21.6%) | 15 (29.4%) | 16 (31.4%) | 15 (27.5%) | 50 (98%) | — | 2 (3.9%) |
| No mention | 1 (2%) | 1 (2%) | — | — | — | — | — | — | — | — | — | — | 1 (2%) | — | |
| Case-by-case | 5 (9.8%) | 2 (3.9%) | 3 (5.9%) | 2 (3.9%) | 3 (5.9%) | 2 (3.9%) | 14 (27.5%) | 27 (52.9%) | 23 (45.1%) | 22 (43.1%) | 24 (47.1%) | — | 4 (7.8%) | 4 (7.8%) | |
| Covered | 43 (84.3%) | 48 (94.1%) | 48 (94.1%) | 49 (96.1%) | 48 (94.1%) | 49 (96.1%) | 37 (72.5%) | 13 (25.5%) | 13 (25.5%) | 13 (25.5%) | 13 (25.5%) | 1 (2%) | 46 (90.2%) | 45 (88.2%) | |
Coverage scores were calculated by the sum of points earned for the individual conditions listed within each sequelae class: explicit exclusion from coverage garnered 0 points, no mention of coverage garnered 1 point, case-by-case coverage garnered 2 points, and clear coverage garnered 3 points.
*Outpatient services, including psychologist visits.
Comprehensive CMF Trauma Coverage: Medicaid versus Private Insurance
Comprehensive care coverage scores (CCS) were higher for private insurance than for Medicaid across all states (Fig. 1). The national mean CCS was 38 (sd. 5.8) for Medicaid versus 40.9 (sd. 6.4) for private policies (P = 0.02). The top Medicaid comprehensive care score (CCS 45) was from 7 states (California, Idaho, Kansas, Maine, Rhode Island, South Dakota, and Vermont) plus D.C., while Oklahoma, Arkansas, and Missouri Medicaid CCSs were 2 sds. below the national mean. The top private comprehensive care score (CCS 50) was calculated from policies in Colorado and Delaware. Private policy CCSs from Indiana, Iowa, South Dakota, Tennessee, and Wisconsin fell 2 sds. below the national mean, with the lowest private score (CCS 23) from Wisconsin.
Fig. 1.
National heat maps contrasting Medicaid and private insurance CCS. The national mean Medicaid CCS was significantly higher than the national mean private insurance CCS (P = 0.02). Southeastern states scored significantly lower Medicaid scores than Medicaid from other states (P = 0.01). Medicaid from states that opted into Medicaid expansion scored significantly higher than states that did not expand Medicaid (P = 0.01). Midwestern private insurance policies scored significantly lower than private insurance from non-Midwest states (P = 0.01).
Coverage of Specific CMF Trauma Sequelae: Medicaid versus Private Insurance
FSCS (Fig. 2) and ASCS (Fig. 3) were similar across all states for Medicaid and private policies. The national mean FSCS for Medicaid was 20.2 (sd. 1.4) versus 20.7 (sd. 2.7) for private policies (P = 0.27), and the national mean ASCS for Medicaid was 6.8 (sd. 4.3) versus 8.1 (sd. 4.1) for private policies (P = 0.12). Functional coverage scores were 2 sds. less than the national mean for Medicaid policies from Colorado, New Mexico, Texas, Alaska, Tennessee, and Wisconsin. In comparison, the range of private policy functional coverage scores across all states was fewer, as all private FSCSs fell within 1 sd. of the national mean; private policies falling below the national mean were from Alabama, Indiana, Iowa, Kansas, Montana, Pennsylvania, South Dakota, Tennessee, Wisconsin. Medicaid in 11 states scored an ASCS of 0 (Connecticut, Georgia, Iowa, Ohio, Oregon, Wyoming, Arkansas, Missouri, New Mexico, Texas, Tennessee), and private policies from Indiana, Iowa, South Dakota, Tennessee, Wisconsin, Hawaii, Minnesota, Nevada, Rhode Island, Massachusetts scored an ASCS 2 sds. below the national mean. Psychosocial service coverage scores (PSCS) were higher across all states for private policies than Medicaid (Fig. 4). The national mean PSCS for Medicaid was 11 (sd. 2.9) versus 12.1 (sd. 1.6) for private policies (P = 0.02). Amongst Medicaid policies, California scored the highest in psychosocial coverage (PSCS 15), while Florida scored the lowest (PSCS 0). In addition to Florida, Alabama, Oklahoma, Arkansas, and Missouri Medicaid PSCSs fell 2 sds. below the national mean. Amongst private policies, Colorado and Delaware had the highest psychosocial coverage scores (PSCS 15) while Wisconsin had the lowest (PSCS 7).
Fig. 2.
National heat maps contrasting each state’s Medicaid and private insurance FSCS. Scores were similar for Medicaid and private insurance policies nationally. Midwestern private insurance policies scored significantly lower than private insurance from non-Midwest states (P = 0.01).
Fig. 3.
National heat maps contrasting each state’s Medicaid and private insurance ASCS. National mean scores were similar for Medicaid and private insurance policies. Midwestern private insurance policies scored significantly lower than private insurance from non-Midwest states (P = 0.04).
Fig. 4.
National heat maps contrasting each state’s Medicaid and private insurance PSCS. The national mean score for private insurance was higher than the national Medicaid mean (P = 0.02). Southeastern states scored significantly lower Medicaid scores than private insurance scores (P = 0.01). Medicaid from states that opted into Medicaid expansion scored significantly higher than states that did not expand Medicaid (P = 0.01).
Analysis by Region and Associated State Factors
Medicaid coverage scores stratified by geographic region are shown in Table 2. There were no significant differences in the scores of Medicaid policies from Northeast, Midwest, and West Coast states; however, Southeast states’ Medicaid policies earned significantly lower CCSs and PSCSs than the rest of the nation. The Southeast states’ mean CCS was 33.2 (sd. 6.6) versus 39.3 (sd. 4.9) for non-Southeast states (P = 0.01) and their mean PSCS was 8.5 (sd. 5) versus 11.7 (sd. 1.6) for non-Southeast states (P = 0.01).
Table 2.
Mean FSCS, ASCS, PSCS, and CCS by Medicaid Region
| FSCS | ASCS | PSCS* | CCS* | ||
|---|---|---|---|---|---|
| National (n = 51) | Mean (sd.) | 20.2 (1.4) | 6.8 (4.3) | 11.01 (2.9) | 38.04 (5.8) |
| Range | 7 | 12 | 15 | 22 | |
| Minimum | 14 | 0 | 0 | 23 | |
| Maximum | 21 | 12 | 15 | 45 | |
| Median | 21 | 8 | 12 | 40 | |
| Southeast (n = 9) | Mean (sd.) | 20.4 (0.7) | 5.9 (4.5) | 7.7 (5.2)* | 34 (7.0)* |
| Range | 2 | 12 | 12 | 18 | |
| Minimum | 19 | 0 | 0 | 24 | |
| Maximum | 21 | 12 | 12 | 42 | |
| Median | 21 | 8 | 12 | 36 | |
| Northeast (n =15) | Mean (sd.) | 20.1 (1.2) | 7 (4.4) | 11.9 (0.4) | 39 (5.3) |
| Range | 4 | 12 | 1 | 16 | |
| Minimum | 17 | 0 | 11 | 29 | |
| Maximum | 21 | 12 | 12 | 45 | |
| Median | 21 | 8 | 12 | 40 | |
| Midwest (n =16) | Mean (sd.) | 20.2 (1.8) | 6.3 (4.1) | 11.4 (2.2) | 37.8 (5.6) |
| Range | 7 | 12 | 9 | 22 | |
| Minimum | 14 | 0 | 3 | 23 | |
| Maximum | 21 | 12 | 12 | 45 | |
| Median | 21 | 8 | 12 | 39.5 | |
| West coast (n =11) | Mean (sd.) | 20.1 (1.6) | 8.2 (4.6) | 12.1 (1.1) | 40.4 (4.8) |
| Range | 4 | 12 | 5 | 15 | |
| Minimum | 17 | 0 | 10 | 30 | |
| Maximum | 21 | 12 | 15 | 45 | |
| Median | 21 | 8 | 12 | 41 | |
CCSs and PSCSs for southeastern states were significantly lower than the remaining states’ national average (P = 0.01).
*P = 0.001 for comparisons of southeastern states’ PSCSs and CCSs versus non-southeastern states’ scores.
Private coverage scores stratified by state region are shown in Table 3. Midwest states had significantly lower CCSs, FSCSs, and ASCSs than non-Midwest states. The Midwest states’ mean CCS was 37.8 (sd. 7.7) versus 42.4 (sd. 5.1) for non-Midwest states (P = 0.01), mean FSCS was 19.3 (sd. 3.5) versus 21.3 (sd. 2) for non-Midwest states (P = 0.01), mean ASCS was 6.4 (sd. 4.3) versus 8.9 (sd. 3.8) for non-Midwest states (P = 0.04). States from the Southeast, Northeast, and West Coast regions all earned similar coverage scores across sequelae classes.
Table 3.
Private Policy Coverage Scores Stratified by US Regions
| Private Policy Region | FSCS* | ASCS* | PSCS | CCS* | |
|---|---|---|---|---|---|
| National (n = 51) | Mean (sd.) | 20.7 (2.7) | 8.1 (4.1) | 12.1 (1.6) | 40.9 (6.4) |
| Range | 7 | 12 | 8 | 27 | |
| Minimum | 15 | 1 | 7 | 23 | |
| Maximum | 22 | 13 | 15 | 50 | |
| Median | 22 | 9 | 12 | 43 | |
| Southeast (n = 9) | Mean (sd.) | 21.8 (.4) | 8.7 (1.4) | 11.6 (2.1) | 42 (2.6) |
| Range | 1 | 5 | 5 | 7 | |
| Minimum | 21 | 6 | 8 | 38 | |
| Maximum | 22 | 11 | 13 | 45 | |
| Median | 22 | 9 | 12 | 43 | |
| Northeast (n = 15) | Mean (sd.) | 21 (2.4) | 8.7 (4.3) | 12.7 (.8) | 42.3 (5.7) |
| Range | 7 | 12 | 3 | 21 | |
| Minimum | 15 | 1 | 12 | 29 | |
| Maximum | 22 | 13 | 15 | 50 | |
| Median | 22 | 9 | 13 | 43 | |
| Midwest (n = 16) | Mean (sd.) | 19.3 (3.5)* | 6.4 (4.3)* | 12 (1.7) | 37.8 (7.7)* |
| Range | 7 | 12 | 6 | 25 | |
| Minimum | 15 | 1 | 7 | 23 | |
| Maximum | 22 | 13 | 13 | 48 | |
| Median | 22 | 8 | 13 | 39.5 | |
| West coast (n = 11) | Mean (sd.) | 21.3 (2.1) | 9.5 (4.7) | 12.1 (1.6) | 42.8 (6.1) |
| Range | 7 | 12 | 7 | 16 | |
| Minimum | 15 | 1 | 8 | 34 | |
| Maximum | 22 | 13 | 15 | 50 | |
| Median | 22 | 12 | 12 | 46 | |
The mean scores for each region were compared individually against the mean score of all other regions combined. Midwest states earned significantly lower CCSs, FSCSs, and ASCSs than the remaining states (P = 0.01, P = 0.01, P = 0.04).
*P < 0.05 for comparisons of Midwest states’ CCSs (P = 0.01), FSCSs (P = 0.01), and ASCSs (P = 0.04) versus scores from non-Midwest states.
States that opted into Medicaid expansion (n = 36) had higher Medicaid comprehensive coverage scores (CCS) and psychosocial coverage scores (PSCS) than those that did not (n = 15); the mean Medicaid CCS for states that had opted in was 39.2 versus 25.4 for those that did not (P = 0.04), and the mean Medicaid PSCS for states that had opted in was 11.7 versus 9.4 for those that did not (P = 0.01). These scores were also higher in states with Democrat governors; the mean Medicaid CCS for Democrat governor-led states was 39.9 versus 36.3 for Republican-led states (P = 0.02), and the mean PSCS for states with Democrat governors was 12 versus 10.2 for states with Republican governors (P = 0.03). Medicaid CCSs were also higher in states that mandated paid sick/family leave (n = 36) than those that did not (n = 15); the mean CCS for states with mandated leave was 41.2 versus 36.7 for those that had no mandate (P = 0.01). Psychosocial coverage scores were higher in states with 40% or more of the total population earning >400% of the federal poverty line (FPL) (n=23); in these states the mean PSCS was 12 versus 10.2 for states with less than 40% of the total population earning >400% of the FPL (n = 28) (P = 0.03).
DISCUSSION
Acute management of CMF trauma is the mainstay of care for patients with these injuries. Beyond the acuity of physical injury, appearance-related, functional, and psychosocial sequelae can persist. For many patients, CMF trauma becomes a chronic disease resulting in long-term quality of life decline.17,18 As such, optimal management of CMF trauma offers comprehensive care involving three paradigms: restoring function, correcting appearance-related deformities, and addressing psychosocial well-being.
Upon national comparison of coverage scores, our results indicated more comprehensive coverage of CMF trauma care offered by private insurance policies than Medicaid (CCS 40.9 versus CCS 38, P = 0.02). Scrutiny of this difference indicated coverage of psychosocial sequelae as the area of discrepancy. These findings mirror past reports of Medicaid enrollees receiving less care than private policy beneficiaries.19,20 For both Medicaid and private policies, however, preventative mental health and social/occupational support services were rarely covered and typically not mentioned. This is particularly consequential given the importance of social support and accessible resources for resilience and achieving post-traumatic emotional resolution.21, Across states’ Medicaid policies, we found coverage of functional and appearance related sequelae to vary minimally. The minimal heterogeneity in functional sequelae coverage is unsurprising, as Centers for Medicare & Medicaid Services have long considered loss of function an unequivocal justification for coverage. This is similar for appearance-related coverages, as it was atypical for Medicaid to offer coverage in the absence of functional deficit; for states that did offer elective surgery for non-functionally deficit presentations, it was not common for there to be limits to the number of annual elective surgeries covered, thereby limiting the number of corrective operations one may undergo for trauma-related problems.
When coverage scores were stratified by geographic region, Medicaid coverage for comprehensive care and psychosocial sequelae were lower in the southeastern states than the rest of the country. By comparison, Medicaid coverage offered by Northeast, Midwest, and West Coast states was statistically similar. The median Medicaid score for comprehensive coverage was the greatest for West Coast states (CCS 41) and the lowest for Southeast states (CCS 9). Different geographic trends were noted upon analysis of private policy coverage, where policies from Midwest states scored a significantly lower mean for coverage of comprehensive care, functional sequelae, and appearance-related sequelae. Appearance-related coverage scores from Midwest state private policies were of the same range as policies from other regions (range, 12); however, Midwest state policies had the lowest median appearance-related coverage score (median ASCS 8).
Commonly a disease of poverty and product of socioeconomic environment, CMF trauma disproportionately affects disadvantaged populations who historically lack access to social and mental health services.10,22–24 Unfortunately, CMF trauma care has become increasingly costly for medical systems over the past 3 decades.25 Today, robust CMF trauma care is limited by significant opportunity costs that are incurred when higher-reimbursed CMF procedures are forgone to render trauma care, as well as tangential costs related to iatrogenic and pathologic complications.26,27 These system-level adversities have trickled down to affect the clinical environment, with the majority of surgeons who treat CMF trauma believing inpatient care address psychosocial health inadequately.28 This highlights the need to restructure incentives of comprehensive CMF trauma care. Evidence indicates increasing insurance enrollment in surrounding populations may not only reduce barriers to care for currently uninsured patients but also improve fiscal returns of CMF trauma operations.12 One study reported mandible fracture surgery in uninsured patients having resulted in >$15 million in lost revenue.29 In facial fracture patients, Erdmann et al. discovered collection rates to be the lowest in those without insurance (10% total billing over collections) and the highest for patients with state coverage.30 Additionally, health systems benefit significantly when CMF trauma patients undergo subsequent elective procedures.31,32 This ability for additional corrective treatment is much less afforded to uninsured patients and, as such represents significant opportunity cost and lost revenue to trauma centers.33 These findings suggest that decreasing uninsured rates and eliminating coverage disparities through expanded individual access to insurance may alone have consequential improvement to the fiscal returns of CMF trauma care.
This study is limited by the inclusion of only silver policies available on the ACA marketplace (versus bronze, gold, and platinum). Additionally, coverage determination required referencing both medical policies of insurers (nonspecific to plan) and plan-specific certificates of coverage because the latter often lacked the nuanced medical descriptions needed to judge treatment context. Furthermore, judging policies that did not mention a condition required assuming that, compared with case-by-case statements of coverage, silent policies inherently translate to lesser coverage. In doing so, the considerable roles of prior authorization and peer-to-peer reviews on the determination of coverage are disregarded. Lastly, the limited number of insurance policies reviewed in this study precludes broader conclusions of all available insurance policies.
The epidemiologic manifestations of traumatic CMF injury have been clearly borne out in national- and institution-level data, with evidence that already marginalized patients are overly affected.30,34,35 Currently, however, sparse efforts have scrutinized disparities in the post-acute, longitudinal care provided to CMF trauma patients.36 Because the pervasive effects of a traumatic CMF experience are unpredictable in the acute setting, policies of predetermined coverage boundaries that limit standard access to wide-ranging multidisciplinary follow up care preclude patients an equitable likelihood of recovery. With the current heterogeneity in coverage offered across insurance policies, it is inevitable for aspects of medically necessary care to not be afforded to the underinsured aggregate and, by failing to do so, magnify known medical biases related to race, education, and socioeconomic status. To uniformly improve outcomes of CMF trauma, public policy efforts are needed to mitigate disparities in access-to-comprehensive care and better understanding factors contributing to inequity.
CONCLUSIONS
Comprehensive CMF trauma care includes restoring function, correcting posttraumatic deformities, and psychosocial support. Disparities exist nationally between Medicaid and private policies and between state Medicaid programs. State differences in Medicaid coverage are associated with overarching state demographic conditions and geopolitical factors. Collaborative efforts between physicians, medical systems, insurers, and lawmakers are required to improve access to the longitudinal care necessary following significant traumatic CMF injury.
Footnotes
Published online 10 November 2020.
Disclosure: None of the authors has a financial interest to declare in relation to the content of this article.
REFERENCES
- 1.Englum BR, Hui X, Zogg CK, et al. Association between insurance status and hospital length of stay following trauma. Am Surg. 2016;82:281–288. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Chaudhary MA, Sharma M, Scully RE, et al. Universal insurance and an equal access healthcare system eliminate disparities for black patients after traumatic injury. Surgery. 2018;163:651–656. [DOI] [PubMed] [Google Scholar]
- 3.Osman MF, Baugh RF, Baugh AD, et al. Relative value units and payer mix analysis of facial trauma coverage at a level 1 trauma center: is the current model sustainable? Surgery. 2014;156:995–1000. [DOI] [PubMed] [Google Scholar]
- 4.Rothweiler R, Bayer J, Zwingmann J, et al. Outcome and complications after treatment of facial fractures at different times in polytrauma patients. J Craniomaxillofac Surg. 2018;46:283–287. [DOI] [PubMed] [Google Scholar]
- 5.Thorén H, Snäll J, Salo J, et al. Occurrence and types of associated injuries in patients with fractures of the facial bones. J Oral Maxillofac Surg. 2010;68:805–810. [DOI] [PubMed] [Google Scholar]
- 6.McGoldrick DM, Fragoso-Iñiguez M, Lawrence T, et al. Maxillofacial injuries in patients with major trauma. Br J Oral Maxillofac Surg. 2018;56:496–500. [DOI] [PubMed] [Google Scholar]
- 7.Derdyn C, Persing JA, Broaddus WC, et al. Craniofacial trauma: an assessment of risk related to timing of surgery. Plast Reconstr Surg. 1990;86:238–245; discussion 246. [PubMed] [Google Scholar]
- 8.Huang LK, Wang HH, Tu HF, et al. Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury. Injury. 2017;48:1417–1422. [DOI] [PubMed] [Google Scholar]
- 9.McQuistion K, Zens T, Jung HS, et al. Insurance status and race affect treatment and outcome of traumatic brain injury. J Surg Res. 2016;205:261–271. [DOI] [PubMed] [Google Scholar]
- 10.Lento J, Glynn S, Shetty V, et al. Psychologic functioning and needs of indigent patients with facial injury: a prospective controlled study. J Oral Maxillofac Surg. 2004;62:925–932. [DOI] [PubMed] [Google Scholar]
- 11.Glynn SM, Asarnow JR, Asarnow R, et al. The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg. 2003;61:785–792. [DOI] [PubMed] [Google Scholar]
- 12.Khansa I, Khansa L, Pearson GD. Surgeon reimbursements in maxillofacial trauma surgery: effect of the affordable care act in Ohio. Plast Reconstr Surg. 2016;137:613–618. [DOI] [PubMed] [Google Scholar]
- 13.Koenig WJ, Lewis VL., Jr. The physician cost of treating maxillofacial trauma. Plast Reconstr Surg. 1993;91:778–782. [DOI] [PubMed] [Google Scholar]
- 14.Zatzick D, Roy-Byrne PP. From bedside to bench: how the epidemiology of clinical practice can inform the secondary prevention of PTSD. Psychiatr Serv. 2006;57:1726–1730. [DOI] [PubMed] [Google Scholar]
- 15.HealthCare.gov. Silver Health Plan. https://www.healthcare.gov/glossary/silver-health-plan/.
- 16.KFF. State Health Facts. https://www.kff.org/state-category/health-insurance-managed-care/.
- 17.Levine E, Degutis L, Pruzinsky T, et al. Quality of life and facial trauma: psychological and body image effects. Ann Plast Surg. 2005;54:502–510. [DOI] [PubMed] [Google Scholar]
- 18.Lalloo R, Lucchesi LR, Bisignano C, et al. Epidemiology of facial fractures: incidence, prevalence and years lived with disability estimates from the global burden of disease 2017 study. Inj Prev. 2020;26(suppl):injuryprev-2019-043297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Inverso G, Mahal BA, Aizer AA, et al. Health insurance affects head and neck cancer treatment patterns and outcomes. J Oral Maxillofac Surg. 2016;74:1241–1247. [DOI] [PubMed] [Google Scholar]
- 20.Fazzalari A, Pozzi N, Alfego D, et al. Treatment of appendicitis: do Medicaid and non-Medicaid-enrolled patients receive the same care? Surgery. 2019;166:793–799. [DOI] [PubMed] [Google Scholar]
- 21.Foa EB, Riggs DS, Gershuny BS. Arousal, numbing, and intrusion: symptom structure of PTSD following assault. Am J Psychiatry. 1995;152:116–120. [DOI] [PubMed] [Google Scholar]
- 22.Esses DF, Costa FW, Sá CD, et al. Occupational group, educational level, marital status and deleterious habits among individuals with maxillofacial fractures: retrospective study. Med Oral Patol Oral Cir Bucal. 2018;23:e13–e22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Jaycox LH, Marshall GN, Schell T. Use of mental health services by men injured through community violence. Psychiatr Serv. 2004;55:415–420. [DOI] [PubMed] [Google Scholar]
- 24.Miranda J, Cooper LA. Disparities in care for depression among primary care patients. J Gen Intern Med. 2004;19:120–126. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Abubaker AO, Lynam GT. Changes in charges and costs associated with hospitalization of patients with mandibular fractures between 1991 and 1993. J Oral Maxillofac Surg. 1998;56:161–7; discussion 167. [DOI] [PubMed] [Google Scholar]
- 26.Moses H, Powers D, Keeler J, et al. Opportunity cost of surgical management of craniomaxillofacial trauma. Craniomaxillofac Trauma Reconstr. 2016;9:76–81. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Hemmila MR, Jakubus JL, Maggio PM, et al. Real money: complications and hospital costs in trauma patients. Surgery. 2008;144:307–316. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Zazzali JL, Marshall GN, Shetty V, et al. Provider perceptions of patient psychosocial needs after orofacial injury. J Oral Maxillofac Surg. 2007;65:1584–1589. [DOI] [PubMed] [Google Scholar]
- 29.Dillon JK, Christensen B, McDonald T, et al. The financial burden of mandibular trauma. J Oral Maxillofac Surg. 2012;70:2124–2134. [DOI] [PubMed] [Google Scholar]
- 30.Erdmann D, Price K, Reed S, et al. A financial analysis of operative facial fracture management. Plast Reconstr Surg. 2008;121:1323–1327. [DOI] [PubMed] [Google Scholar]
- 31.David LR, Bisseck M, Defranzo A, et al. Cost-based analysis of the treatment of mandibular fractures in a tertiary care center. J Trauma. 2003;55:514–517. [DOI] [PubMed] [Google Scholar]
- 32.Sanger C, Argenta LC, David LR. Cost-effective management of isolated facial fractures. J Craniofac Surg. 2004;15:636–41; discussion 642. [DOI] [PubMed] [Google Scholar]
- 33.Shen YC, Hsia RY, Kuzma K. Understanding the risk factors of trauma center closures: do financial pressure and community characteristics matter? Med Care. 2009;47:968–978. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.National Institutes of Health. Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities Volume I Fiscal Years 2002–2006. 2002. Available at https://www.nimhd.nih.gov/docs/2002_2006__vol1_031003ed_rev.pdf. Accessed August 5, 2020.
- 35.Nalliah RP, Allareddy V, Kim MK, et al. Economics of facial fracture reductions in the United States over 12 months. Dent Traumatol Off Publ Int Assoc Dent Traumatol. 2013;29:115–120. [DOI] [PubMed] [Google Scholar]
- 36.Fazzalari A, Alfego D, Shortsleeve JT, et al. Treatment of facial fractures at a level 1 trauma center: do Medicaid and non-Medicaid enrollees receive the same care? J Surg Res. 2020;252:183–191. [DOI] [PubMed] [Google Scholar]