Whether a woman is covered by Medicare or by commercial insurance appears to influence the type of treatment she will likely undergo for uterine fibroids, researchers have reported.
A team led by Pratik Shukla, MD, of Rutgers New Jersey Medical School, Newark, NJ, found that women covered by Medicaid are 38% more likely to undergo uterine artery embolization (UAE) for fibroids than those with commercial insurance — but that if they undergo hysterectomy or myomectomy they are 20% less likely to receive the less invasive, laparoscopic versions of these procedures.
The findings suggest that reimbursement incentives may impact whether gynecologists refer patients to interventional radiologists for UAE or perform surgical procedures themselves, study coauthor Eric Christensen, PhD, of the Neiman Health Policy Institute in Reston, VA, said in a statement released by the institute.
“On the surface, these results may appear conflicting; however, both are consistent with how reimbursement may influence gynecologists’ treatment decisions — both the treat-or-refer decision, and for those they choose to treat, the decision to treat with an open or laparoscopic procedure,” Christensen said. “The higher UAE rate among Medicaid patients is consistent with reimbursement incentives that are associated with gynecologists being more likely to refer Medicaid versus commercial patients. Likewise, the lower laparoscopic rate among Medicaid patients treated by gynecologists is also consistent with the notion that reimbursement incentives influence treatment patterns, given payment differences between laparoscopic open surgical procedures and between Medicaid and commercial patients.”
Seventy percent to 80% of women develop uterine fibroids by the age of 50, the team explained. The condition can be treated in a variety of ways, including hysterectomy and myomectomy (which can be open surgery or laparoscopic), and less invasive alternatives such as UAE, percutaneous radiofrequency ablation, and MRI-guided focused ultrasound. Women seeking treatment for fibroids first see their gynecologist — who can perform a hysterectomy or myomectomy or refer them to an interventional radiologist for UAE. UAE is considered as effective as hysterectomy or myomectomy, is less invasive, and is cost-effective. But hysterectomy is the most common treatment for fibroids, at 75%.
“Patients seeking treatment for uterine fibroids typically see a gynecologist for evaluation and treatment of symptoms,” Shukla said in the statement. “When medical management does not suffice, gynecologists could perform a hysterectomy or myomectomy or refer patients to an interventional radiologist to perform a UAE. Accordingly, gynecologists face a treat-or-refer decision, which ideally would not be influenced by the reimbursement the gynecologist would receive when choosing to treat rather than refer the patient.”
Prior research has suggested that reimbursement influences referrals and that Medicaid and uninsured patients receive “less or different care than commercial patients for an array of conditions,” the authors wrote. They sought to investigate the association of insurance type with type of fibroid treatment via a study of women between the ages of 30 and 59 who underwent either hysterectomy, myomectomy, or UAE for uterine fibroids between October 2015 and September 2023, culling this information from the Inovalon Insights dataset, which indicates whether individuals are covered by Medicaid or commercial insurance. The final study sample consisted of 579,153 procedures.
The team found the following:
- Women covered by Medicaid compared to those with commercial insurance had 38% higher odds of undergoing of UAE (odd ratio [OR], 1.38, with 1 as reference).
- States with higher Medicaid reimbursement for hysterectomy were associated with lower odds for UAE (OR, 0.95).
- For women who had a hysterectomy or myomectomy, those with Medicaid had 20% lower odds (OR, 0.8) of receiving it laparoscopically compared to their commercially insured counterparts.
The research underscores a need for collaboration across specialties, according to the authors.
“Collaboration between [gynecologists and interventional radiologists improves] perception of their management of fibroid patients, their relationships with collaborating colleagues, and work satisfaction,” they concluded. “[Other partnerships like this] have demonstrated increased patient satisfaction and understanding of their disease process and treatment options through the establishment of multidisciplinary clinics.”
The complete study can be found here.