Health Policy Journal Club

Health Policy Journal Club: Access to Specialists Worse with Medicaid

Orthopedic appointment availability 5 times higher for uninsured than for Medicaid

Increase outpatient services and thereby decrease expensive emergency department visits, or so the popular axiom goes. This only works, however, if there are enough outpatient visits to be had. This study by Medford-Davis et al.  examines the availability of outpatient orthopedic ankle appointments by insurance status.

Privately insured patients had an 85% chance of success in securing appointments. Interestingly, the uninsured had the same odds as the privately insured in getting an appointment. Both the insured and uninsured had much higher odds of receiving an appointment than a patient with Medicaid.

To make matters worse, most clinics were unable to offer Medicaid patients any resources on where they could get care. When the authors checked the Medicaid list of orthopedists accepting this insurance, 15 stated they didn't accept Medicaid, 11 did not treat ankle injuries, 9 did not have working telephone numbers, and only 3 were able to schedule an appointment.

Regarding the uninsured, just because appointments were available does not necessarily mean they were affordable. On average, uninsured patients were asked to pay $353.74, with only 2 patients able to secure appointments for less than $100. A quarter of clinics offered discounts for those paying in cash and 8% allowed patients to pay for their visit via a payment plan. Clinics were compensated by privately insured patients at an average rate of $236 for a clinic visit and $36 for an x-ray, or about $77 less than the average charge to uninsured. Medicaid, on the other hand, compensated clinics at a rate of $55 to $101 for the office visit and $26.73 for the x-ray. All in all, only 1 in 7 Medicaid patients were able to secure outpatient appointments. Uninsured patients, while better able to schedule appointments, encountered prohibitively high costs.

I am sure I am not alone in looking at patient complaints in the EMR and wondering why patients were coming to the ER with problems that could clearly be treated in the outpatient setting. After reading this article and considering the amount of time the researchers must have spent attempting to schedule these appointments I am no longer surprised. When balancing real-life responsibilities such as work and childcare, who has the time to call multiple different clinics during business hours to schedule an appointment? If we as a healthcare system truly believe that reducing ED visits and hospitalizations is the way to reduce healthcare costs, then we must ensure that systems are in place to facilitate accessible and affordable outpatient care.



Abstract: Medford-Davis LM, Lin F, Greenstein A, Rhodes KV. "I Broke My Ankle": Access to Orthopedic Follow-up Care by Insurance Status. Acad Emerg Med. 2017;24(1):98-105.

OBJECTIVE: While the Affordable Care Act seeks to reduce emergency department (ED) visits for outpatient-treatable conditions, it remains unclear whether Medicaid patients or the uninsured have adequate access to follow-up care. The goal of this study was to determine the availability of follow-up orthopedic care by insurance status.

METHODS: Using simulated patient methodology, all 102 eligible general orthopedic practices in Dallas-Fort Worth, Texas, were contacted twice by a caller requesting follow-up for an ankle fracture diagnosed in a local ED using a standardized script that differed by insurance status. Practices were randomly assigned to paired private and uninsured or Medicaid and uninsured scenarios.

RESULTS: We completed 204 calls: 59 private, 43 Medicaid, and 102 uninsured. Appointment success rate was 83.1% for privately insured (95% confidence interval [CI] = 73.2% to 92.9%), 81.4% for uninsured (95% CI = 73.7% to 89.1%), and 14.0% for Medicaid callers (95% CI = 3.2% to 24.7%). Controlling for paired calls to the same practice, an uninsured caller had 5.7 times higher odds (95% CI = 2.74 to 11.71) of receiving an appointment than a Medicaid caller (p < 0.001), but the same odds as a privately insured caller (odds ratio = 1.0, 95% CI = 0.19 to 5.37, p = 1.0). Uninsured patients had to bring a median of $350 (interquartile range = $250 to $400) to their appointment to be seen, and only two uninsured patients were able to obtain an appointment for $100 or less up front. In comparison, typical total payments collected for privately insured patients were $236 and for Medicaid patients $128. When asked where else they could go, 49 (48%) uninsured callers and one Medicaid caller (2%) were directed to local public hospital EDs as alternative sources of care. Of the practices that appeared on Medicaid's published list of orthopedic providers accepting new patients, 15 told callers that they did not accept Medicaid, 11 did not treat ankles, nine listed nonworking phone numbers, and only three actually scheduled an appointment for the Medicaid caller.

CONCLUSIONS: Fewer than 1 in 7 Medicaid patients could obtain orthopedic follow-up after an ED visit for a fracture, and prices quoted to the uninsured were 30% higher than typical negotiated rates paid by the privately insured. High up-front costs for uninsured patients and low appointment availability for Medicaid patients may leave these patients with no other option than the ED for necessary care. PMID: 27442786


EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems.

As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula.

This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.