Okay, good morning, Saturday morning after the hand club events. Always a lively time slot, but the fact that you are here means that you truly want to learn about this. And I am personally very excited to learn from our great panel. So this morning we're going to be discussing disparities in hand surgery, do they exist and how we can address them. Our first speaker is Eric Sears from the University of Michigan. All right, good morning, everyone. All right, well, it's an honor to be here amongst the other speakers on the panel. And so thank you, Chris, for putting it together and for inviting us to speak about this important topic. I am charged with discussing race and gender-based disparities in hand surgery and do they exist. So first a few definitions. Health disparity is preventable differences in the burden of disease, injury, violence or opportunities to achieve optimal health that are experienced by socially disadvantaged populations, whereas health equity is the opportunity for everyone to be as healthy as possible. And so with that understanding of health disparity being preventable, a show of hands, race and gender-based disparities in hand surgery, do you think they exist? All right, okay, you guys didn't want to talk, great. How about in your hospital or clinic, do they exist? Okay, how about in your practice, do they exist? Okay, well, I think we're ahead of the curve in terms of, I guess, where we've been or where surgery has been. So I'll just share some interesting data. In 2016, survey of American College of Surgeon members, they were general surgeons, but randomly selected a little over 500 members, 172 completed the survey, and at the time, this was taken a few, or the survey was given a few years before this came out in 2016, 37% felt that disparities exist in healthcare in general, 12% in their hospital or clinics, and 5% in their practice. So it seems that we have made some progress, although I'm sure we are having some selection bias here with our audience, but still, I think that there is an increased recognition that disparities do exist, even in our own practices. And so strictly as it relates to ethnicity, race, ethnicity, and gender is the question here that I will discuss, and so the answer is yes, probably. But it's very complicated. You're going to have other speakers who are going to come up and talk about social determinants of health, insurance, other factors. So it's often difficult to tease strictly race, ethnicity, and gender when you factor these other factors in, but I'll try and let you know what's in the landscape of hand surgery. And so the reason it's challenging is that there are, like I said, systemic patient provider factors that are difficult to tease out that are also going to influence differences that we see in access and outcomes. And so there's a relatively small body of disparities research that's specific to hand surgery, and even more, very little that really focuses on difference in outcomes in hand surgery as it relates to race, ethnicity, and gender. And the limited research largely focuses on a few select operations, and over time, not just in hand surgery, but in the disparities literature in general, race and ethnicity are categorized with heterogeneity. Sometimes it's very challenging if you do a non-white comparison to identify disparities, or even other subgroups that are just lumped together and categorized, and sometimes even very small and hard to even study. And then controlling for other social determinants of health within studies over time has varied. Early on, very little recognition was done or paid to social determinants of health, but it has become more common in recent times, thankfully. So just to see where we've been just with surgery in general, or actually hand surgery in general, this is a systematic review that was published in 2014 to look at disparities research in orthopedics looking at race and ethnicity with outcomes of complications and mortality. And so even though hand surgery was a search term that they used in this systematic review, there were no hand surgery studies at that time that met the inclusion criteria. So they had 33 studies that were included, largely spine and joint replacement disparities work, and two-thirds of those showed at least one significant disparity outcome based on race and ethnicity. And half of the studies that reported on mortality outcomes identified a disparity based on race and ethnicity. And so the difference that I mentioned in terms of recognizing the importance of other social determinants of health, only three articles or studies that were included in this systematic review controlled for both income and insurance factors. So fast forward to last year, 2001 study from Baxter and Chung, looking at disparities research in plastic surgery. And so not that they were all in plastic surgery journals, but just subspecialties related to plastic surgery. And this review demonstrated that there is some now hand surgery disparities work. 17 studies met the inclusion criteria, and they looked more broadly at different types of disparities, race and ethnicity, gender, insurance, religion, et cetera. They were more inclusive with their inclusion. 17 out of the 147 studies that were included were hand surgery studies, but largely in the plastic surgery literature, it's dealing with breast reconstruction. But 80% of those studies did look at differences based on race and ethnicity. And so they concluded that the results of the 17 hand surgery studies indicated that health disparities are pervasive in the specialty. And I will get at the individual studies that dealt with race and ethnicity specifically. But the interesting thing is, as it's not surprising that we've heard more about disparities research that there has been some exponential growth over time. But a lot of the research really still focuses on detecting disparities. So half of the research is just, does a disparity exist? With about 40% trying to understand those other systems, patient and provider factors, and very little, about 10% in the plastic surgery literature. And more recent over time is devoted to studying implementation and interventions to reduce disparities. And so specific to race and ethnicity and gender in terms of the specific procedures I mentioned, and where work has been done in hand surgery, carpal tunnel release, this is a study of over 90,000 patients looking at the New York statewide database. And they found a lower probability of receiving carpal tunnel release among women, Asians, African Americans, and patients with Hispanic ethnicity as compared to white patients and men. And I will say, I'm doing some work in the VA right now where we've essentially found something very similar to this in terms of patients receiving carpal tunnel release. But then also wanted to look at their referral to surgery to see if there's a barrier. And there's also a decreased referral, odds of referral amongst these groups as well. And so replantation in children, a previous study has shown in about 1,300 patients using a nationwide pediatric database that black patients, Hispanic ethnicity, were less likely to receive attempted replantation in adjusted analyses, where they also control for income and payer status. And contrary to what we saw with carpal tunnel release, female patients were more likely to receive attempted replantation. And then there's also been disparities work done on trigger finger, also using the New York statewide database, which also demonstrated a decreased odds of receiving surgery among black, Asian, Hispanic patients, but more likely to receive it in women. And so this, again, as I mentioned, a lot of the work in hand surgery, not dealing with social determinants of health, but strictly race, ethnicity, and gender has really been focused on sort of one-off procedures. And does this disparity exist? So what can we do to take advantage of some low-hanging fruit as individuals? Clearly, we know that this is something even sometimes controlling for social determinants of health the best that we can that's present. And so I just wanted to highlight a few things that we can think about. Implicit bias training, it's likely something that many institutions are requiring. My institution has for recruiting for some time, if you're on a committee to be considered for hiring, and highly recommended for anyone involved in resident and fellow interviewing. And then it's now where I practice medicine in Michigan required for licensing by the state, and it is three other states require this as well. So something to also think about that, obviously, we all have biases. And so it's the recognition of that and constant awareness that's really important. Another thing to think about is how to realize the importance of having diverse teams and how that elevates the group and outcomes, and cultural competency, and the importance of trying to proactively understand cultures in which you are not a member, and how that may impact them as individuals and their health. And so I love this quote from this Harvard Business Review article on why diverse teams are smarter, because there's also a lot of data that talks about patients when they receive care from an individual with the same race and ethnicity sometimes have higher outcomes or better outcomes. And it's not that we should be segregating care. It's that when we have diverse teams, it might actually alter the behavior of a group's social majority in ways that lead to improved and more accurate group thinking. So that's the way I like to think about everybody being elevated in diverse groups. And one other thing is we also do need to promote research that explores interventions and solutions. And I just wanted to highlight that the health disparities in hand surgery is a special emphasis topic for AFSH-funded grants with a special emphasis on studies that explore interventions and solutions to improve care among underrepresented and disadvantaged groups. So anyone out here in the audience interested in disparities research know that this is highly valued by the Hand Society. Thank you. So that was a fantastic talk, Dr. Sears. Thank you. I had a question for you since you mentioned some of your own work but didn't cite it. It's not clearly. It's not published yet. Okay. So in the VA, that should theoretically take out a lot of the access to care issues, some of which Dr. Biladi will speak to. But so if it's not an access to care issue, then what is it? I think it's hard to generalize, but I think it could be both for sure. This is something that we just don't know to say with confidence with data, but it's something that definitely needs to be explored. I know one of my colleagues in the room has a, Dr. Hooper right here, has a desire to explore this further. Because I think for sure there are patients that have a distrust of the system or even just based on social needs, have an inability to have surgery and take the time off of work or have ideas about what surgery is, where they may be getting not all the accurate information to understand. So I think it's really, I'd say a wicked problem where it needs to be tackled from a lot of different angles. Thank you. Thanks. All right. Our next speaker is my partner at Washington University, Dr. Ryan Calfee, who will speak about social determinants of health. Good morning, guys, and thank you again for getting up so early. I think this talk is also going to be kind of preaching to the choir here in terms of people that are willing to be here at 6.45 a.m. to talk about this, but welcome. And so we'll talk a little bit about social determinants of health, and as Dr. Sears was up here talking, you know, it's humbling and unfortunate that most of the research I'm going to present today is about just documenting the issue as opposed to here are great answers as to what to do. My disclosure is not relevant to this. So no social determinants of health really cover a broad spectrum of things that affect us from economics to education to neighborhood environments and healthcare systems. And I'm sure this audience right here this morning knows that this matters a lot. You know, the fact that the place of birth in the U.S. is more strongly associated with life expectancy than race or genetics, or that you can have a 15-year difference in expected life expectancy, you know, when you look at people who are advantaged or disadvantaged, it's pretty humbling and sobering to look at some of this stuff. So you know, one of the questions that comes up, and I think we all know the answer in this room, but is if your social environment doesn't relate to your physical health, you know, how does that impact your function musculoskeletally with your hand? You know, we looked at our department's data, had about 7,500 patients coming in, and we looked at social deprivation by the Area Deprivation Index and looked at PROMIS scores, which are basically patient-reported health, physical and mental. And I would just put a plug in here for the University of Wisconsin developed this Area Deprivation Index, and if you want to do sort of social determinant research or social situations, this is a great tool. And they will allow you to use it for free. All you have to do is write them and say, I'm doing it for academics. So I would really highly suggest it. I have liked it a lot because it gives you a number, a percentile that is the national percentile associated with a nine-digit zip code and state decile data you can get. And instead of just saying, you know, this person's income is this or they have Medicaid instead of Blue Cross, you know, you're getting a composite score from about 17 elements of the census, putting together a lot of factors that really do give you a nice composite picture of where patients are coming from. So in our patients, when we separated people out, let's say into the people coming from neighborhoods that are sort of the least deprived quartile of the nation and the most, we saw differences that, you know, were expected. You know, the folks coming from the worst areas had, you know, worse rated physical function, more pain, and worse mental health scores. I think this gets really impressive too, is that when we break it down by quartile, there's really like a dose effect here. I mean, when we went from the least deprived quartile to the second to the third to the fourth, every one of these graphs followed right in step the way you would expect, whether it's worse function, perceiving more pain, or the mental health side. And if you break it into different thresholds like, hey, levels of anxiety that might warrant treatment on their own when you show up to the doctor, or depression levels, we see the part of the pie that's not as good on the green getting bigger and bigger as you move from the higher advantage zip codes to the worse. We've broken it down to carpal tunnel patients, and not surprisingly, basically found the exact same results with more of a granular look at comorbidities. And then this raised the question to us, which again, this audience probably knows the answer, but does it really take a lifetime to end up here? I can understand adults that have lived in these type of conditions all their life, and it's a different level of stress, and it's a different experience. But what about kids? So we looked at about 1,000 kids presenting to our hospital at our clinics with acute upper extremity fractures, so not chronic illness, not something that's going to change your whole outlook. It's, I fell and broke my arm. And so when you look at the folks, and we had a couple hundred children from the least deprived areas, most deprived areas, if you fall off at either one of these playgrounds, the same things happen. It's usually the boys, they're usually around age 12, and they get the same distribution of fractures. So they're identical in that way. But interestingly, when you look at their self-reported PROMIS scores, and we chose kids that were eight and up, because that's the self-administered PROMIS pediatric scores as opposed to a parent proxy. So when the kid has the iPad, the kids from the worst areas are rating themselves as perceiving less function, more pain, and then peer relations is one that we give to kids as kind of a social interaction with friends at school type of thing. And they were worse on that, again, not surprising. But again, this was an acute injury. I don't think that the injury itself caused these differences. And so we wanted to follow that up, because then the next question was, well, maybe the social stresses and things just magnify the acute pain from the injury. So we followed about 300 kids through fracture healing. And this is my one little plug, as Dr. Sears mentioned, unfortunately, race and socioeconomics and social deprivation are very much linked. And in a place like St. Louis, it's pretty terrible. When we looked at our children, 107 in the study from the most deprived areas, 45% of them were black. And if you looked at the least deprived areas, only 4%. And so St. Louis is, I think, a terrible example of how things are really divided along race very explicitly. So I told you about our pretreatment differences between the kids. Post-treatment, this is the interesting thing. The fractures were healed. Kids should be better, back to school, back to play. The differences didn't go away. And so in both groups, if you look at how much they improve on function, so going up is better, each group improved about eight points. It's like a standard deviation, which you would expect because you broke your arm and now your arm is healed. But they didn't catch up. Pain got better. Peer relationship didn't change, which it shouldn't change, right? You had a fracture, it healed. But treating orthopedic problems or treating hand problems and fractures didn't help these kids catch up at all. They start behind and they stayed worse. And changing this is hard. I just present this. This was a survey in 2017 of physicians for what would benefit their patients that need extra help socially. And people realize that their patients need things like transportation, income, food, housing. These are things that we can't just snap our fingers and make happen. So it's frustrating. And that's where a lot of this research is frustrating from our standpoint. So I have my brief summary. And unfortunately, I have like little tiny tips for us today. This is it. Obviously, I think most of us understand that mental, social, and physical health are very much intertwined. And that social environments can change health perceptions, even at a very early age. And so I'd encourage you guys to do what you can. And I think we do a lot of advocating for our patients, whether I'm working trying to get social work help or trying to get vouchers for whatever. I don't always succeed. Clinic arrivals. I mention this because, for instance, in our department, there's a policy that is if you're a half hour late, your appointment gets canceled or you no longer get seen. That may work in one of our locations, but in our main hospital where I have clinic every single week, a half hour is not much time if you have to rely on our bus system to get you over there. And one bus doesn't come. And St. Louis' public transportation is terrible. So I think being flexible, realizing that, you know what, I know they were 45 minutes late. It was a big deal to get there, see them. That's been my push. Get in-office therapy instruction. I mention this because a lot of our patients with Illinois and Missouri Medicaid, they can come see me. I can offer them the surgery for the flexor tendon. The insurances don't cover therapy. They're stuck. So a lot of times we see them more often in the office. It's hard for them to come see us, but at least it's covered under the global fee and I can see them for free. And I can give them therapy instruction basically each week. Sometimes that's just how we do it. Or offering telehealth. There's been some neat research submitted recently because one thing is that we've noticed is that, you know, at least in my patients, even the ones that are the worst off still have smartphones a lot of times. And you can at the very least be sending things or, you know, whether it's handouts for some people or sending things to the phone or phone reminders, you know, you can do things without having them be able to come to a therapy office and get more instruction. And then finally, I just put listen. Sometimes it is depressing and I sit in clinic and really all I can do is listen to the story and give a hug at the end of the visit and, you know, there's not much else, but you try. So thank you very much, guys. Thank you, Dr. Fauci. I have a question for you. Okay. You've done some really interesting work with the paper that you did. I don't know what somebody here wants to study, but I will just encourage you to do it. I think, I mean, one of our things, I think Dr. Sears looks like she pulled up our new emphasis grants from the most recent iteration, I mean, we met a couple weeks ago to rewrite those for the society, and we tried to specifically write the one on disparity to say, please give us submissions for interventions, for addressing, because right now we are just a lot of documenting, so I'm hoping that encouraging things like the society to come up with ideas, otherwise, I mean, I think we're doing the small local things on a patient by patient basis, but I think the next big things, the next big investigations need to be interventions, and they can be clever interventions, they can, you know, it's just different ways to maybe at least deliver care, even if we can't change the whole social system. All right, our next speaker is Dr. Avi Gulati from the Curtis National Land Center, so Dr. Gulati. Good morning, everybody, thanks for the opportunity to be here, and I wouldn't say it's a pivot from what's been discussed, but I think when it gets to insurance, there are so many complexities to the system that this really is a much more discussion around access and how it's related rather than just the existence of the disparity or not, and how it's impacting, because what I try to focus on in this talk are sort of the ways that it splits some of the factors in the way it impacts things, because it can be a good and bad thing, whether you're talking about the financial impact versus the access and coverage impact, or the ability to see a provider impact, and those things have this really ugly Venn diagram I'm going to try to kind of run through today. Again, you know, I think Dr. Kalfi's conclusion there is maybe the best part, which is be understanding as much as you can about these issues, because they affect patients far more than any of us ever appreciate, and so as much as I can relay that to you today, that's sort of my hope. As we probably can all tell, coverage is a key barrier to healthcare in the United States. That's true within hand surgery, it's true within all surgical care, and really all medical care. But I want to frame this in the concept of the question of access, so Dr. Deef asked me to talk about access, and so I think it's important to think, this is actually a paper that just came out I think two weeks ago, one week ago, hot off the presses, this concept around domains of access, and I put it up here because I think anything in this entire slide could be impacted by insurance coverage. So they talk about travel time and delayed presentation, as you just heard from Dr. Kalfi, but quite frankly, where you have to go to see a provider that takes your insurance, that can impact you. Workforce density, so surgical deserts, providers that take your insurance, that's not exactly what they maybe meant in this specific paper, but of course we all know that that matters. Where is somebody who takes my insurance going to be, where do I find them, is there anyone even around, and how does that impact care? Certainly the infrastructure is the same thing, providers of a skill set that I need, or of willingness to see me and related to insurance coverage. The safety aspect, again, they focused on it here with perioperative mortality, but really the safety of care, if the only provider in your area that takes your insurance has not seen a flexor tenant in two years, is that going to be safe care? Not sure. But obviously that's going to impact things. And then of course affordability, and the impact not only of being able to pay for it, but the financial burden of medical care, which is something we've all at some point experienced maybe personally, or seen experienced for some of our patients or family members. So those domains of access really are impacted in every way by insurance, in one framework or another. Certainly within hand surgery care, there are a multitude of studies. Again, this is more in the does it exist category, not so much a what do we do about it category. But again, there are 40 to 99% of providers accepting Medicaid. That's a general sort of physician landscape. That's a huge range. And as we know, Medicaid is an incredibly important provider for a lot of our patients, especially in the trauma sphere, but certainly even for chronic care. Within hand surgery, Medicaid patients tend to have less outpatient access to hand specialists. So again, seeing that thought process trickle down. And then with acute hand injuries, not only is it an issue of access, but it's a harder time making appointments. This was a really interesting study where they essentially did phone calls and just called a clinic and asked, I need an appointment, here's my insurance. If you listed Medicaid, you got worse times, more delayed access, and sometimes weren't even offered an appointment. The association with insurance and financial distress is really important. And I think any time you're talking about access to care, finance has to come into it with the insurance discussion. Financial distress as a general concept is usually highest in the Medicaid patients when you look across the literature. But certainly there are now high deductible plans or other insurance plans that feel to many patients like they have adequate insurance until something real happens. And the financial impact is so substantial that it really changes care. There is a understandable association between financial distress and reported disability across many non-acute orthopedic conditions. So I think Dr. Calfee's example of the impact in a fracture where the fracture itself probably didn't create those disparities. I think when we're talking about dealing with some of these chronic conditions where in a lot of ways insurance is going to be more important to seeing multiple visits, multiple aspects of care needed, these patients are reporting challenges that we run into daily. Higher pain catastrophizing, higher average pain in the preceding week. They're just having a harder time. And I think that that makes a lot of sense, but maybe isn't so easily understood just by understanding how their care is getting paid for. I also think that where we maybe need to pay more attention is the trends in costs and care delivery in the areas where we can maybe impact things or at least be aware of things. Out-of-pocket costs are increasing. So again, there, if you have the wrong insurance plan, that can really impact you. What's interesting, and I think this is maybe the challenge in understanding insurance-based disparities is that for patients with Medicaid, in a lot of ways that's actually not as much of a problem because of the way Medicaid works. So you may have a harder time getting a physician to take care of you, but your out-of-pocket costs are going to be less. And so it puts these patients in a really tough spot between getting in versus getting the care. But as we see costs increasing and things trending up, we have to be aware of how that's impacting patients that are in the under-insured category, where they have coverage, but it's just maybe not enough to deal with what they really need. Certainly these high-deductible health plans come up a lot in a lot of lay press, but also medical literature. And site-of-service is another area where it's evolving relatively rapidly and hasn't maybe been looked at more carefully enough in the insurance component of that or the payer component of that, whether it's facility fees and associated facility fees, depending on where you get your care, or again, is someone willing to give care in an ASC based on insurance type and how that impacts access, whether it's timeliness, safety, infection rates, depending on the kind of procedure you're having, et cetera. So focusing on CMC arthritis care, you probably recognize the name of that author in the middle there. This is a really important look, again, this concept around fee-for-service and out-of-pocket costs, where the managed care, the capitated plans, just had way lower out-of-pocket expenses. And this concept, again, around which of the insurance plans you have, it may not inherently make sense, but some of them, where they have capitation or managed care, in many ways protected their patients for some of these really impactful financial burdens. But then again, if you remember a few slides earlier, a lot of these patients have harder time sometimes getting seen. And so that dichotomy, that split continues to show up, and certainly for something like CMC, where the care pathway is usually over multiple months, if not years, understanding those differences is really important. Corporal Tunnels, another one that's been studied, again, Dr. Kamal and his group at Stanford, they compared Medicaid versus Medicare Advantage or private insurance. And again here, they had delays from diagnosis to surgery, but also reduced use of electrodiagnostic testing. Whether that falls in your own care spectrum, or whether you think that that's a good or bad thing with regards to electrodiagnostics is kind of your own thing, but again, it's are they being offered it the same way. And the hard thing about insurance, and I maybe should have brought this up a little earlier, is that sometimes it even functions as a proxy for some of the other social determinant issues, obviously. So it's not just about the insurance. Often it's the patient who has that insurance, but it's easier to, in many cases, look at. And in this case, again, here you saw what is maybe even a care split, where your diagnosis is delayed, but maybe the testing need or the testing use was lower. Is that because the patients couldn't get the testing done? Is that because the patients didn't want to get the testing, or is it because it wasn't ordered? I don't know, but all those things can play into care delivery. Replantation care, trauma care. So there's a few slides coming sort of at the look of insurance impact on trauma care with replantation as the focus. Uninsured patients less likely to have replantation attempted, and if it was attempted, less likely to be successful. I think the first one maybe inherently makes sense to all of us, even if it's kind of a terrible statistic. I think the second one is really difficult to understand, and that it's a care quality issue or a willingness to do the things in the post-operative period that are required for salvage issue. Or maybe it's, I mean, there's so many different factors that can come into it. So again, insurance access is a window to this problem, not so much an answer. But it's something to really consider. I think pediatric distal radius fracture care provides some really interesting sort of conflicting examples. This gets back to what I was talking about a few slides ago, where in one study, you see that the patients with Medicaid actually had no medical debt and no uncompensated costs as part of their care. And actually, when they looked at it, PPO and HMOs were no different than the uninsured patients. So you'd say that's a really interesting finding, that Medicaid essentially protected the patients from some of the financial burden, whereas some of the payers or the PPOs and HMOs had an impact as if they were uninsured. Sort of shocking to see. Let me see the other side of the coin on the right side of the slide. If you have private insurance, 100% were getting treatment, whereas only 76% with Medicaid. And when they looked at the refusals, they were all because of insurance type. And so again, there you're seeing, you might not be able to get in the door. But if you do, it may not actually be as hard on your family. And so that really puts patients and the policymakers, really, I think, in a tough spot. Because if the physicians on the ground are not getting patients in, that's a huge problem. Even if the goal of those plans is to protect the patients in the end. Hospital transfers. So going back to that replantation discussion and trauma, I think hospital transfers are a big issue. The burden of transfers is something that is a big focus of whether you're being traveled the long distance, whether you're not able to get care closer to home, your family can't support you, et cetera. The likelihood of getting transferred and getting transferred at a really unfortunate hour of the day are much higher based on insurance status. And I think that's, again, something that all of us that deal with trauma certainly understand and experience. So is this getting better? Is policy changing? Is it moving the needle? So we looked at this in pre-Affordable Care Act Medicaid expansion. So this is sort of a natural experiment in New York State, where if you had trended it out with no expansion, that's what the red line is. So you would have seen this slightly progressive increase in replantation delivery for Medicaid versus the uninsured. This is not so much an access issue as it is a health system issue, where you are now seeing the insurance coverage shifting the care from an uncompensated or uninsured care to a now insured care. So the patient component of this, like we showed before, is that Medicaid in many ways protects patients when they have trauma as opposed to being uninsured. And now we're seeing that in New York State, at least when we modeled it out, that that care shifted from uninsured to Medicaid patients when expansion occurred. I don't want to steal too much of Dr. D's thunder and talk about the Affordable Care Act, because I'm sure it will be a phenomenal talk. But I do want to focus a little bit on, again, where this kind of split focus came into focus in some of my work, where we certainly saw that the Medicaid expansion in Maryland. So we studied the Curtis Hansater's trauma data. And we saw, as you might expect, a big decrease in uninsured patients, an increase in Medicaid patients with regards to trauma care and trauma delivery. What we sort of were, I don't know necessarily surprised, but I thought was an interesting issue, is that we really saw an increase in emergency department use by these newly insured patients. So the appropriateness, we looked at it from the perspective of transfers. Did expanding insurance coverage improve this transfer problem that I was talking about a few slides ago? And in fact, it actually didn't really change things at all. The transfer patient appropriateness, the challenge of the medical care, of the hand surgical care, didn't really shift at all. So we didn't get less, quote, dumps, or patients that were sent to us for no reason. What we did see was that a huge increase in maybe unnecessary self-referrals, patients coming to our ER on their own, that now had Medicaid. And you can kind of look at that and say, well, that's an overuse issue. It's a health system's overuse issue. That's a major problem. Or you can look at it and say, these patients weren't getting care before. And we might need to teach them or provide interventions on what the appropriateness for using a clinic versus an emergency department is, or provide access to a clinic rather than an emergency department to fix the ED overuse problem. But now they're getting care. I don't know which one it is, but I think that everyone in this room and certainly the people that we work with, that's the framework that we need to start thinking about these problems is that if we give access or at least open the door to coverage rather, does giving access need to look like this? Do they need to just go to an ER? Can we find ways to make it not only good ability to have your care paid for, but also get treated in the same workflow as other patients? And I think the more we can shift that, the more this entire discussion around insurance and access and disparities will get better. We also looked at the issues around site of care and changes. So this is, I think, the last slide, I mean, the last two slides. What we were trying to understand is whether trends in billing and utilization, and we used a Medicare data because CMS data drives private payers in a lot of ways. And what we saw was that, as you might expect, charges were going up. So you might say, well, charges don't really matter. Insurance companies negotiate all this stuff, it gets different. But if you don't have a good insurance company or if you are someone who has one of these sort of high deductible or underinsured plans, that's a really big problem. So this trend that we're kind of ignoring where hospitals just charge more to offset costs or whatever the excuses are, I think has a substantially outsized impact or potential impact on the underinsured population. The other issue is this shift from ambulatory surgery centers, excuse me, from acute care hospitals or inpatient settings to ambulatory care. There are a lot of payers that are now either restricting site of service, so you cannot get your surgery done in some of these more expensive locations, but that obviously pinches providers and patients. Or the opposite, where depending on the kind of insurance you have, you may not have access to the ambulatory sites. But if more and more providers are only using ambulatory sites, you can see how that might exacerbate some of these access problems. So these shifting trends, I think, are very important for us to pay attention to. And again, in your own practices, if you are finding yourself having less access to some of these more broad places, like less inpatient surgery or at least less access to hospital surgery, be thoughtful about how that can impact your patients, because it probably is depending on your payer mix, and I think it's important to think about. So insurance coverage impacts all domains of care access, and it's such a broad problem that I don't think anybody in this room is fixing it today, but I think being thoughtful about it is an incredible first step. And the impacts go in all directions, as I was highlighting with some of the, especially the financial impact issues. Being fully insured essentially is always better, and I think that understanding that may just make your conversations with patients a lot more warm and appropriate and perhaps understanding. And access may continue to get worse if the billing trends, site of service trends, and some of these other forces continue to push things into a more lean or economic model, because a lot of these plans just don't really consider that. Thank you. Thank you all. So that was fantastic, and you definitely stole a lot of my thunder, but... It's hard to do. But we're still doing it. So I know that you personally sit on our, or on the Hansen-Simon's government... So, I think there probably are a few, the one that is going to come up a lot that I maybe will take the opportunity to put on people's minds is this issue around authorization and pre-authorization, all the stuff that goes into being able to actually get care. I think if you've been reading anything, it's becoming more available in the lay press, but certainly the AOS and the ASSH have put a big focus on getting that legislation moving forward around decreasing the barriers to care by changing the pre-authorization requirements. I didn't really talk about that so much. It's probably more of a Medicare problem than a Medicaid problem, and certainly more of the senior patients that get put through many more hoops to get care. But I think that that does function as a transition barrier. You can see somebody maybe getting that first appointment is easier as insurance changes, maybe Affordable Care Act and certain expansions made that better, but then getting from point A to point B has remained incredibly difficult. And so I think there's been a big focus on that, which I sort of initially felt like maybe actually wasn't the best place to put energy, but it seems like something that maybe everyone agrees should get better, and sometimes those are the best things to go after. So I think that's probably where you're going to see the most movement first. Yeah. Yeah. Okay. All right. So my name is Christopher D. I'm from Washington University in St. Louis. And the title of this talk is, Has Obamacare Helped or Worsened? And it's kind of a catchy, controversial talk title for a reason, but I think that we would all assume that this would be a good thing. But as Avi pointed out, there may be some unforeseen consequences of policy. So I do have research funding for disparities projects that is relevant to this and fortunate enough to have that in order to fund some of the work that we're doing. So the Affordable Care Act, I think to many of us, at least in the United States, this is a topic that was very controversial about 10 years ago, but it is something that expanded Medicaid throughout the United States and was encountered with a lot of challenges, but eventually got through in some form. And there isn't a ton of work about hand surgery and hand surgeons and the Affordable Care Act, but I wanted to cover the limited work that is out there. So this is a survey that was conducted out of the University of Pennsylvania, and as Lynn is the senior author. So they surveyed hand society members. So they had 974 respondents, 33% response rate, largely in private practice, but with some academic surgeons. And here are the questions they asked. Will the Affordable Care Act improve health care in the United States? Over two-thirds of the respondents either disagreed or strongly disagreed with that. So there's a little bit of a bias in how hand surgeons think about the ACA. And will the ACA decrease reimbursements for hand surgery? Many thought yes, almost four out of five. Will the ACA improve access to emergent hand surgery? 65% disagreed, said that it would not help. Will the ACA improve access for elective hand surgery? 60%, 58% said no. Disagreed, strongly disagreed. So here is how the Affordable Care Act is currently implemented, at least as of last week. So we've got some states that did not expand Medicaid, and you've got states that did. And some of them are earlier adopters or later adopters. I think the question really in thinking about this is would Medicaid expansion improve access to care? That's one. And then actual use of services. So it's one thing to have access. It's another thing to use it. Or would Medicaid expansion widen these existing gaps that we've seen shown by Dr. Sears, Dr. Calfee, Dr. Galati between Medicaid and other payers? And does it matter whether it's emergent or nondiscretionary care versus discretionary care or elective care? So Dr. Galati showed this slide from his work when he was at the University of Michigan. And New York State actually had an earlier Medicaid expansion that provided a nice natural experiment. In this work, their projections were that at least in the five years after Medicaid expanded in New York State, 12 additional replants were performed for Medicaid patients within five years, and 11 fewer replants were performed for uninsured patients within five years. Now for a huge state like New York, that doesn't sound like a lot of patients, but you can see if you took this and extrapolated it to a more common injury, for example, either a flexor tendon, some kind of fracture, you can see the implications this might have. So there is some additional data, and again, Dr. Galati scoops me on this, but from his work and Charles Daly's first author, looking at the Maryland State Upper Extremity Trauma Database over a seven-year period in which the ACA was expanded right in the middle, there were payer mixed changes. You essentially saw a shift from a large uninsured population, almost 31%, and that went down 7%, which was statistically significant. And you saw a big bump in the Medicaid patients in terms of their payer mix. The appropriateness of transfers was unchanged, and there was a similar travel distance for those patients. Single center series from Ohio State from January 2008 to June of 16, so just a couple of years after the ACA was implemented. They pulled cases for metacarpal fractures, distal radius fractures, CMC arthroplasty, and endoscopic carpal tunnel, as well as INDs. Now there were some payer mix changes during their study period, when the Affordable Care Act was implemented. So they went from 15% uninsured prior to the ACA, down to 6.4%. Their Medicaid went from 9.5 to 17.8, and then Medicare actually went up as well. Not quite sure why that would happen. But there were no significant differences in their overall reimbursement rate. So you remember that survey from Penn that was asking whether hand surgeons would see a decrease in their reimbursement rate. It really didn't matter. So here's one of the graphs from that paper. So looking at an elective or discretionary type of service, so like a thumb CMC arthroplasty, there's actually a big increase in access for those Medicaid patients. It went from 7% to 16.5%. So that's a notable increase in access to a procedure that can change quality of life, can help patients, and does rely somewhat on therapy access. So that is perceivably quite a good thing. For distal radius fractures, you saw a big decrease in the uninsured, so going from 21% to 11%, and a big increase from 5% to 14.5% for Medicaid. So presumably it's those patients that are shifting from earlier on not having access to now having some insurance. Now for the surgeon, that may not make much of a difference. It's no secret in many states, surgeons are not collecting much from Medicaid. But the hospital system sees a big difference because that's actually where a lot of the money goes for Medicaid programs is to the hospital systems. So then you look overall, not just those specific procedures, but you can see the changes in their payer mix as we showed before. And then by procedure, you can see the changes as well before and after the Affordable Care Act. So let's fast, or let's rewind to 2020 before Missouri, my home state, Ryan's home state, actually expanded Medicaid. So Medicaid expansion actually happened in Missouri earlier this year. The government is slow rolling it, so it's not really in effect, but theoretically we are a state that has now expanded Medicaid. So we would be blue on this map now. But back in 2020 when we looked at this before, Illinois had expanded, Missouri had not. So to take a more common procedure that is easier to study with administrative data, but outside of the world of hand surgery, we looked at total hip and knee arthroplasties. And you can see in the period before the Affordable Care Act expanded in Illinois, so that green line is the dividing line, things are pretty steady in terms of the payer mix being Medicaid. But then if you look after Medicaid expansion, you can see a pretty notable increase in the percentage of cases that were Medicaid during those years, as opposed to in Missouri where that stayed flat. So as Medicaid expansion continues, and maybe we'll see this live out in our home state of Missouri, and maybe you're seeing this at home for you, we don't know, is this experience generalizable? So we tried to look at this experience in nine other states, again, using primary total hips and knees because that is an easier group to study with administrative data. And we looked at expansion states, you can see all of them listed there. The no expansion states, at the time, Missouri was a no expansion state, Florida still is. And our policy variable in our model was expansion status by year. And so you can see the no expansion states are blue, and things remained steady the entire study period. But in the dotted red, that's the expansion states. And you can see, at 2014, things started to go up. So in those expansion states, compared to the year 2013, pre-expansion, in 2014, there was a 24% increase within those states. And in 2015, there was a 31% increase. And as expected, things stayed flat for the non-expansion. So this leads people to say, everybody's gonna get a hip and knee arthroplasty because now there's access. Is there a pent-up demand? We've seen in the arthroplasty literature that once you get eligible for Medicare, all of a sudden there's a big bump in people getting their hips and knees done. So maybe you've waited since you were 58 to say, okay, I'm gonna get it when I have my Medicare. Is that gonna happen now that we see a bunch of new Medicaid in release? So does it become a bit of a royal rumble to see who's actually going to get access to care? So again, staying in the world of hip and knee arthroplasty, we looked at a Medicaid managed care company based in St. Louis, Centene. We had access to their data, and we looked at some of their expansion states that they're in the market for, and some that they're not, and you can see those listed there. We looked at these various different plans, which Medicaid is a bit of a mixed bag in many ways. In looking at a smaller group of these patients compared to the earlier studies, we saw that in the expansion plans, the median time to surgery was much shorter compared to the other types of Medicaid plans in this managed care group's portfolio. So it was 70% shorter. So as Medicaid expansion continues, I would say I'd expect a surge in demand, and we don't know whether this is actually going to exacerbate the existing disparities that are present in our current care. And it's important to point out, access does not necessarily equate to quality, and I think these are the big questions that remain for those of us that are studying this. Thank you. And our final speaker is Dr. Walji from the University of Michigan, who is gonna share her work with the opioid epidemic. See, maybe yours is the one that doesn't wanna load. There we go. Thank you. Good morning. It's so nice to see everyone, and thank you, Dr. D, for the opportunity to share a little bit with you today about the intersection of healthcare disparities and the public health problem that we've certainly seen in our country. So I'm gonna talk a little bit about lessons learned from the opioid epidemic. So certainly there's been a lot of attention that's been paid to opioid-related morbidity and mortality in our country over the last couple of decades, and particularly its close association with the rise in prescription opioid marketing and dispensing. So you can see here in 2012, we saw wide variation and clear hotspots in our country with respect to opioid dispensing that have fortunately changed pretty dramatically when you fast forward to 2020 due to a multitude of efforts to create and implement opioid stewardship strategies, particularly in the management of acute and chronic pain. However, I think it's really interesting to juxtapose it against this particular graph. So if we look at drug overdose rates in the United States, those continue to rise. And in 2021, there was an estimate of 100,000 individuals who died from a drug overdose, which was up 28% from the prior year. And while the deaths attributable to prescription opioids have started to decline, as you can see there in the yellow line, the rates of mortality due to synthetic opioids have sharply risen and reflects a continued public health threat in both opioid-related mortality as well as other substance use disorders in our country. And I think most of the attention to this epidemic has focused almost entirely on white, suburban, and rural communities, and far less attention has been focused on how this affects black, Hispanic, Asian, and Native American communities who are similarly experiencing dramatic increases in opioid misuse and related overdose deaths. So let's take a look at this a little bit closer. And this is a recent study that was published in JAMA Network Open earlier this year, which looked longitudinally at CDC data to understand rates of opioid overdose deaths among individuals who are 55 and older. And they identified a higher total number of overdose deaths across populations specifically related to individuals who are black, Latinx, or American Indian and Native American communities, and a higher accelerated rate of overdose deaths, and specifically gender disparities with males having higher rates of overdose deaths than females. This is a similar study, but looking at a slightly younger population, and they also examined overdose rates in our country. And again, this is pretty recent data, so this goes up to 2021, and you can see a sharp rise in overdose deaths. And this particular study looked at the rates before and after the COVID-19 pandemic, which of course isn't complete yet, but what's concerning is that we start to see a sharp uptick in opioid-related overdose after COVID-19 for a variety of reasons that we'll unpack a little bit in the next few slides, and we can talk about afterwards. So why are these rates higher? I think there's a number of different reasons for this, and not all of them are well understood or well described, but I think one of the biggest drivers is that the rates of treatment for individuals with substance use disorder, and OUD specifically, are markedly different by race. So this is a study by Dr. Pooja Laghacetty, who's at the University of Michigan, and she observed that white individuals with private insurance, or those who paid for prescriptions out-of-pocket, were far more likely to receive medications used to treat opioid use disorder, such as methadone, buprenorphine, naltrexone. And those individuals who were paying for them either, I'm sorry, who had either Medicare or Medicaid coverage, or were in these marginalized or disadvantaged groups, had worse outcomes. And even after accounting for payment methods, sex and age, black patients had still had a statistically significant lower odds of receiving buprenorphine at their visits. So really concerning trends here. This is a study by Dr. Mark LaRochelle and others, who also found similar trends among young adults, who are arguably the most vulnerable OUD related to rates of relapse and overdose. So I think taken together, addressing the overdose, the opioid epidemic requires eliminating racial and ethnic disparities, along with the socioeconomic, gender-based, and geographic disparities that we clearly see in OUD prevention and care. This is a quote from Dr. Jerome Adams from the US Surgeon General, talking about stigma. Again, the causes of this are multifactorial, but as he highlights in this quote here, stigma is one of the most important drivers of individuals to seek and receive care. So this is his quote. The biggest killer out there is stigma. Stigma keeps people in the shadows. Stigma keeps people from coming forward and asking for help. Stigma keeps families from admitting that there's a problem. And I think so many factors in our society today compound that. When we look at the deeply entrenched structural factors that exacerbates racism and stigma in our culture and prevents treatment for marginalized groups, I think that's where we see these phenomena play out and part of the drivers and the differences in mortality that we see related to this opioid epidemic. For example, here, black and Latinx individuals are more likely to be targeted by police and incarcerated for drug possession than white individuals. And OUD treatment compounds racism experienced in healthcare settings. So stigma related to both factors, which has multiplicative effects when people then go on to seek care related to OUD or in any other context. We also see lower rates, as we talked about in the previous talks of health insurance, among black, Latinx, American Indian and Alaska Native populations than among white populations. There's a dearth of community-based physicians who treat underinsured and uninsured people, particularly related to opioid use disorder. And then we've also seen underinvestment by the public sector and historically marginalized communities. They have less access to more modern tools such as digital and mobile health applications that could potentially expand the treatment options for patients with opioid use disorder. But I think one of the other big components of this epidemic were our prevention strategy. So there's been a lot of attention paid for how much opioid we prescribe, particularly in the setting of acute pain. So lots of effort, including policies to reduce the amount of opioid prescribing that we, that we, reduce the amount of opioid that we prescribe for acute pain. But does that mean that we leave individuals behind? Equitable patient-centered pain management has not occurred from marginalized and underrepresented groups. And as a signal of care quality, as this particular study looked at, it's kind of, opioid prescribing is a particularly complex phenomena. Interestingly, it's discouraged for the management of long-term, non-cancer-related pain. And clinicians have historically accepted these drugs, however, as being quite appropriate to prescribe as first-line therapy for severe acute pain. Overdose events and deaths are well-described and recognize risks related with opioids. And prescribers are then challenged to balance these risks. So let's unpack this study a little bit. This was recently published in the New England Journal of Medicine. And the authors used Medicare linked to pharmaceutical claims to understand opioid prescribing across 310 health systems. This represented over a million patients. Interestingly, the rates of opioid prescribing were fairly similar among black individuals and white individuals. However, the doses were much less. Black individuals received a 36% lower dose compared with white individuals. With pain management, this has been played out in multiple studies. And this has been in the literature for literally decades. But what I'm highlighting here are newer studies that have come out showing this is still a major problem. So this is a secondary analysis of data drawn from a PCORI study by Dr. Meisel and colleagues. And I think what is really telling about this study is if you look even for individuals who preferred to have opioids managed for acute pain, black individuals were still far less likely to receive an opioid prescription compared with white individuals. Persistent disparities have also been shown in perinatal pain management. And in this particular study published in 2019, severe pain was much more common among black and Hispanic women than among women who identified as white or Asian. This is both in the initial zero to 24 hours postpartum and also 24 to 48 hours postpartum. And again, playing out here, compared with non-Hispanic white women, Hispanic and non-Hispanic black women had a significantly greater odds of reporting a pain score of five or higher, but received significantly fewer opioids, both in inpatient setting and at discharge. So I think to avoid perpetuating the inequalities that we've seen with respect to opioid prescribing and pain management, any type of guideline development or dissemination or implementation strategy must embed health equity and patient experiences across all the stages of development and implementation. So what are some thoughts about the path forward? Well, there's certainly numerous trials that have demonstrated the efficacy of medications for opioid use disorder. But the access to these lag for many of the reasons that we've talked about over the last hour or so. These treatments are often less available to members of historically marginalized groups and to white patients. And strategies to try to expand this could include more investment in telehealth or mobile health modules that are available to low resource communities, more partnership with criminal justice systems, and addiction treatment and mental health services than what we currently see. I also think as we've heard from Dr. Kalfi and others on this panel, integration of the social determinants of health into our research frameworks has the potential to really understand the impact of opioid related harms, morbidity and mortality, but also how that directly relates to components of structural racism that are in our society, how people access food, how they're able to get education, and how they're able to get the resources that they need for their family. And then I also think that prevention strategies as we just saw in the last slide that intentionally include a focus on health equity and have a clear strategy to evaluate the intended and unintended effects of policies and guidelines. For example, the policies that reduce the, or limit the amount of opiate that can be prescribed for acute pain. It's really important to understand what the differential effects might be for vulnerable groups. And then I'll close on this. So I think that our research practices also need to include members of underrepresented groups in the development of interventions and also with respect to the individuals who are trying to study the effects of those interventions to make sure that we're really able to understand the impact of the things that we're doing to try to mitigate opioid related mortality in our country. And while most of my talk is focused on differences in race, it's also important to consider the scope and intersectionality of all of the factors that impact opioid related mortality, such as age, gender, sexuality, geographic location of residence, religious background and education. And so I think integrating equity oriented frameworks in our work that encompasses the intersection of these factors is critical. And I'll stop there. Thank you very much for having me. Thank you. One question for you. You talk about incorporating health equity into policies. How have you either in your practice or your institution's policies, how has that been incorporated? That's a great question. I think that right now when we look at legislation that has been enacted or even institutional policies, I think they've largely been quite simple, meaning like, okay, we're just gonna limit the amount of opioid that's being prescribed. In some places we've looked at patient reported outcomes, such as pain and satisfaction, but I don't know that we've specifically drilled down to understand how do those play out differently for people who may feel less heard in a healthcare system or have less access to a healthcare system. And so I think that going forward, we need to understand kind of how those play out and what the unintended consequences might be to make sure that there's some evidence out there that suggests, okay, well, we have prescribing guidelines and we have these uniform order sets, then everyone should theoretically get the same amount. But I don't know if that truly means that everyone is having their pain managed equitably. Thank you. Thank you, everybody, for attending. I hope you've learned as much as I have and please ask the faculty if you have any other questions.

disparities

hand surgery

healthcare disparities

opioid epidemic

race

ethnicity

gender

social determinants of health

insurance coverage

implicit bias training

diversity in healthcare teams

reducing disparities