Letter to the Editor: Medicaid Payer Status Is a Predictor of Early Postoperative Pain Following Upper Extremity Procedures

We were intrigued by this recent work by Scott et al ¹ on the association between Medicaid insurance status and perioperative pain. While there is value in investigating socioeconomic disparities pertinent to upper extremity surgery, we have several concerns with the methodology and conclusions.

The authors fail to control for several important variables. The most critical information missing is disease severity, time from onset to presentation, and time to surgical intervention or management. Because patients with more severe pathology are likely to suffer from more severe pain, a longer wait time from onset to presentation is likely to result in greater pain at presentation. Unfortunately, it is the underinsured and socioeconomically disadvantaged who are most likely to suffer from such delays in care. This has been studied in orthopedics where patients who are uninsured or underinsured present with greater disease severity and worse prognosis in musculoskeletal oncology. ² Our own work has demonstrated disparities in timing of distal radius fracture surgery in more disadvantaged groups. ³ The effects of these variables may very well explain the discrepancies in pain reported by the authors.

Furthermore, the authors report significant differences in types of procedures performed by insurance type, with Medicaid and uninsured patients more commonly treated for nerve repair and fractures. Literature from the study of narcotic abuse has shown that patients undergoing different procedures are expected to have varying levels of postoperative pain. ⁴ Although preoperative narcotic use is controlled for in the current work, the differences in procedures between insurance groups suggest that the authors may be comparing different clinical populations. Finally, statistical significance versus clinical relevance should be considered when interpreting the results. Most of the significant differences reported are of a magnitude less than one point on the Visual Analog Scale.

The authors suggest that racial and ethnic differences by insurance class may contribute to their findings. The implications of making such statements without providing data or references to support have the potential to perpetuate existing stereotypes with readers who do not appreciate the methodological limitations. The authors very responsibly acknowledge that Medicaid patients may be suffering worse disease and delays in care. We suggest that the question of whether Medicaid patients report more pain after upper extremity surgery cannot be answered without controlling for these critical variables.

As stated by Seth Leopold in an editorial on the topic, “Poor health may result in poverty (or vice versa), and poverty may result in a patient being insured by Medicaid, but Medicaid itself cannot cause surgical complications.” ⁵ For all of us, our research comes with methodological limitations, and it is important that these limitations be understood and acknowledged when drawing conclusions. Proposing that Medicaid insurance status itself is independently associated with pain risks pushing surgeons and health care systems to treat these patients differently, or worse, not at all. Without this critical lens to the methodological limitations, this study may unfortunately promote, rather than eliminate, bias against those who already face great barriers to care.