Worries About Costs, Time Off Work, and COVID-19 Kept Some Older Adults from Having Surgery

When it comes to having surgery, older adults don’t just base their decision on how much pain they’ll feel and how quickly they’ll recover, a new study finds.

Many also have serious concerns about how much they’ll have to pay out of their own pockets, how much work they’ll miss, and whether they’ll catch COVID-19 in the hospital or surgery center.

And a majority of those who called themselves very concerned about these issues ended up not having an operation that they had considered having, the study finds. The percentage who didn’t go through with surgery was much lower among those who said they’d been very concerned about pain or the recovery process.

The new data, published in JAMA Network Open by a team from the University of Michigan Institute for Healthcare Policy and Innovation, could inform policymakers, surgical teams and employers.

The findings come from a further analysis of data from the National Poll on Healthy Aging, which in 2022 showed that nearly half of older adults who had considered surgery had concerns about costs, time off from work or COVID risk. IHPI runs the poll, with funding from AARP and Michigan Medicine, U-M’s academic medical center.

Surgeon Nicholas Berlin, M.D., M.P.H., M.S., said the new findings have influenced his own interactions with patients.

“When I counsel patients in my clinic who are considering elective surgery, I now also spend a good deal of time discussing the financial and employment implications of surgery with them,” he said. “Unfortunately, I have seen a number of insured patients forego needed surgery because they are unable to afford the out-of-pocket costs or take time away from work for recovery.”

Cost considerations

The new study shows that nearly half of those who said they were very concerned about cost, and more than half of those who were very concerned about taking time off work, ended up not having an operation they had considered.

By contrast, those who said they’d been very concerned about surgery-related pain were just as likely as those with no concerns about pain to have gone ahead with the operation.

He notes that federal policymakers have tried to address this issue by requiring hospitals to make prices for operations more transparent and reduce “surprise” billing for services by providers who don’t take part in a patient’s insurance network.

But, he adds, these policies don’t address financial concerns about losing wages from employment that doesn’t come with paid time off, or costs related to the way a person’s health insurance is structured. In the past two decades, the percentage of people over 60 who work has doubled, and enrollment in Medicare Advantage plans with limited networks, and in high deductible health plans, has grown.

Berlin is a fellow in microsurgery and plastic surgery at the U-M Medical School’s Department of Surgery, and an alumnus of the National Clinician Scholars Program at IHPI.

COVID-19 considerations

The COVID-19 concerns found in the study reflect the fact that the original poll was conducted in August 2021 and asked respondents to reflect on surgery-related concerns and decisions in the previous five years.

At the time, two-thirds of those who said they were very concerned about COVID-19 exposure in the surgery and recovery process ended up not having an operation they had considered.

At the start of the pandemic in early 2020, elective operations like the ones asked about in the poll were canceled for months, and only emergency operations proceeded. That led to ripple effects on surgery scheduling after elective operations resumed.

Even today, for patients who are especially vulnerable to severe COVID-19, or cautious about it, the recent surge in COVID-19 cases and rolling back of infection-prevention requirements by hospitals and surgery centers may affect decision-making, Berlin said.

Poll director and senior author of the new paper Jeffrey Kullgren, M.D., M.S., M.P.H, say more research is needed to understand what influences a person’s decision to proceed with operations so that health care providers can best counsel their patients. Kullgren is a primary care physician at the VA Ann Arbor Healthcare System and associate professor of internal medicine at U-M, and a member of IHPI and the VA Center for Clinical Management Research.

The most common elective operations considered by poll respondents were hip or knee replacement, cataract surgery, hernia repair, gall bladder removal and hysterectomy, all of which can be medically necessary and covered by insurance. But some respondents also had considered or had cosmetic surgery, which is paid for entirely out of pocket.

“More research is needed to understand and address caregiver impacts, which were also a factor in not having surgery for some people in the study,” said Kullgren. “This includes both those who are concerned about surgery temporarily making them unable to care for someone else, and those concerned about having someone to care for them after their operation.”

The poll involved 2,110 adults between the ages of 50 and 80, of whom 32% said they had considered having an elective operation in the previous five years. Two-thirds of those who said they’d considered having an operation actually had the operation.

For more about the NPHA’s methodology, visit https://www.healthyagingpoll.org/survey-methods

In addition to Berlin and Kullgren, the study’s authors are NPHA poll team members Matthias Kirch, M.S., Dianne Singer, M.P.H., Erica Solway, Ph.D., and Preeti Malani, M.D.

Preoperative Concerns of Older Adults and Decisions About Elective Surgery, JAMA Network Open, doi:10.1001/jamanetworkopen.2023.53857