Acute Limb Ischemia: Medicare and Medicaid Reimbursement Gaps Threaten Sustainability of Care.

OBJECTIVE

Acute limb ischemia (ALI) is a vascular emergency associated with high morbidity and mortality, prolonged hospitalization, and substantial resource utilization. However, contemporary data evaluating the financial sustainability of ALI care across insurance types remain limited. This study aimed to evaluate hospitalization costs, reimbursement, profitability, and contribution margin for operative ALI care stratified by insurance status and revascularization strategy.

METHODS

A retrospective review of patients admitted with ALI at a quaternary medical center (2016-2024) was performed. Patients were identified using ICD-10 and CPT codes. Exclusion criteria were outpatient encounters and non-operative or non-procedural management. Hospitalization cost was defined as the sum of variable and fixed costs. Profit was reimbursement minus cost. Analyses were stratified by insurance status and treatment modality. Continuous variables were compared using nonparametric tests, with statistical significance set at p<0.05.

RESULTS

A total of 565 patients were included, of whom 60.2% were insured by Medicare, 24.2% by Medicaid, and 15.6% by commercial insurance. Median total hospitalization costs exceeded $50,000 per admission and did not differ by insurance status (Medicare $50,894 [IQR $33,496-$90,923], Medicaid $49,417 [$33,775-$83,379], commercial $56,603 [$35,823-$96,067]; p=0.577) or by revascularization strategy (open vs endovascular; p>0.05). Professional and technical cost components were similarly comparable across payer groups. Despite similar costs, reimbursement varied significantly by insurance status. Medicare and Medicaid admissions were associated with median hospital losses of -$12,673 [-$28,732 to -$1,425] and -$3,176 [-$10,035 to $3,859], respectively, while commercially insured admissions generated a median profit of $30,622 [$7,602-$50,208] (p<0.001). These differences persisted across both open and endovascular subgroups.

CONCLUSION

Operative management of ALI is associated with substantial hospitalization costs that are consistent across revascularization strategies and payer types. While commercially insured admissions generated positive contribution margins, Medicare and Medicaid reimbursements were insufficient to offset costs. Given that most patients were insured through Medicare, the reimbursement disparities translated into an overall negative financial impact for ALI care. Without reimbursement reform or payment adjustment, the long-term financial sustainability of ALI care, and equitable patient access to timely revascularization, may be jeopardized.