Do patients with government insurance payors experience delayed access to surgical care for cervical spondylotic myelopathy? A Spine CORe™ analysis of QOD data

OBJECTIVE: Insurance status is known to influence access to spine surgery, but its role in cervical spondylotic myelopathy (CSM) remains underexplored. The authors hypothesized that government insurance payor status would be associated with delayed care access, evidenced by prolonged symptom duration and greater baseline symptom severity relative to those with private insurance. METHODS: This was a prospective observational cohort study of 1085 patients enrolled in the Quality Outcomes Database CSM module of the 14-site Spine CORe™ study group. Patients were included if they had complete data for insurance, symptom duration, and baseline patient-reported outcomes (PROs). Insurance status was categorized as private, Medicare, Medicaid, or Veterans Affairs (VA)/federal. Primary outcomes included surrogates of access to care, assessed by symptom duration (> 12 months) and baseline PROs, i.e., the Neck Disability Index (NDI) and EQ-5D. Associations were evaluated using multivariable logistic regression analysis. RESULTS: A total of 1085 patients with CSM who underwent surgery were enrolled, with more than 80% completing 5-year follow-up. Patients were excluded if they were uninsured or did not report baseline symptom duration, EQ-5D score, or NDI score, leaving a cohort of 977 patients for analysis. The proportion of patients reporting symptom duration > 12 months differed by insurance status (p < 0.001): highest in VA/federal (18/24, 75%), followed by Medicaid (45/70, 64%), Medicare (206/375, 55%), and private insurance (228/508, 45%). Compared to those who had private insurance, patients covered by VA/federal insurance (OR 3.85, 95% CI 1.56-10.89), Medicaid (OR 2.05, 95% CI 1.18-3.61), and Medicare (OR 1.98, 95% CI 1.39-2.82) had symptom duration > 12 months. Of patients with government insurance payors, Medicaid insurance status was independently associated with worse baseline disability (NDI: β = 7.35, 95% CI 2.35-12.35; p = 0.004) and lower quality of life (EQ-5D: β = -0.12, 95% CI -0.18 to -0.07; p < 0.001). CONCLUSIONS: Compared to patients with private insurance, patients covered by government insurance payors (VA/federal insurance, Medicare, and Medicaid) had significantly longer symptom duration before undergoing surgery. Patients with VA/federal insurance coverage had the longest symptom duration of the government payors. Of the government insurance payor types, Medicaid was the only one independently associated with significantly worse baseline disability (NDI) and quality of life (EQ-5D). After controlling for other factors, patients with government insurance coverage, and more specifically Medicaid, have difficulty accessing surgical care in a timely fashion to treat CSM compared to patients with private insurance.