Taking away podiatrist visits from Arizona's poorest residents had a swift, adverse impact on diabetics, three University of Arizona researchers say.
"It is a real case of unintended consequences," said UA Medical Center researcher and podiatric surgeon Dr. David G. Armstrong. "The state was in a fiscal bind and I don't disparage them. It was a very difficult decision."
The state announced it would remove care by podiatrists from benefits covered by its Medicaid program (the Arizona Health Care Cost Containment System, or AHCCCS) in October 2009.
The result was an increase in hospital admissions and higher costs for diabetics, who are at a high risk of foot infection and amputation, Armstrong and his colleagues found.
The researchers studied inpatient data on nearly 4,700 Arizona Medicaid patients with diabetic foot infections from January 2006 through December 2010.
While the study includes only three months when the cuts were actually in effect, Armstrong said the adverse impacts began almost immediately after the state announced it would end the coverage for podiatrists. He could see no other reason the change would have occurred, he said. The cuts went into effect Oct. 1, 2010.
Armstrong co-authored the report along with UA College of Medicine professor and chief of vascular surgery Dr. Joseph L. Mills, and health economist Grant H. Skrepnek of the UA's Center for Health Outcomes and Pharmacoeconomic Research. The researchers presented their findings at a meeting of the American Diabetes Association in Chicago last week and have submitted it for publication in a peer-reviewed journal.
"We looked at what happened after 2009 and ran the analysis, and boom, it was horrible," Skrepnek said.
The authors found that for every $1 removed from the Arizona Medicaid budget, there was a $44 increase in cost of care. They also found a 50 percent increase in severe outcomes, including deaths, sepsis and surgical complications, and a 38 percent increase in hospital admissions for diabetic foot infections.
The researchers did not analyze what happened to patients in 2011, 2012 and this year, and Skrepnek said it would be impossible to speculate.
Officials with AHCCCS say there are no current plans to change coverage benefits. AHCCCS spokeswoman Monica Coury said she was not aware of the UA study but stressed that the benefits cut applied only to reimbursements to podiatrists.
"We eliminated podiatrists as a provider type, not podiatry services," she wrote in an email.
The income cap for someone to be enrolled in Medicaid is generally 100 percent or less of the federal poverty level - an annual income of $23,550 for a family of four.
Armstrong said officials reviewing the numbers may have thought about podiatric services as care for a hangnail, bunion or heel pain. But for diabetics, foot problems can be severe, particularly because they typically cannot feel the pain in their feet. As a result, sores on the feet may go undetected without medical attention and lead to massive infection and even amputation.
Armstrong, who directs a limb salvage clinic at the UA, says he's seen more patients with diabetic foot problems coming through the emergency room.
"I was hopeful that maybe our patients would be able to find good care in some other fashion, but unfortunately that hasn't happened," Armstrong said. "It's just been terrible."
As a researcher in an academic medical center, Armstrong says he has no personal interest in increasing patient volume at his clinic.
"This is not something where we are thinking about the size of a practice or anything of that nature," he said.
Contact Star medical reporter Stephanie Innes at firstname.lastname@example.org or 573-4134.