Of the 342 orthopaedic practices (ie, 271 private practices, 71 academic practices) contacted for this study, 260 (76%) accepted adult patients with Medicaid, but only 233 do so without restriction (68%) (Table 3).
(2) What are the observed state Medicaid acceptance rates under Medicaid expansion?
Simulated Patient Survey
The Medicaid acceptance rates observed across states sampled in this survey were 66.6% in Pennsylvania (10/15), 21% in New Jersey (four of 19), 58.3% in Delaware (seven of 12), and 50% in Maryland (nine of 18) (p = 0.04). However, the sample size of four states used in a chi-square analysis was insufficient to elicit these specific pairwise differences (Table 4).
The Medicaid acceptance rates, by State, that were observed in this national survey varied from two of seven to seven of seven (Table 5). For the practices that limited or did not accept adult patients with Medicaid, the individual answering the phone most commonly did not know the reason why this policy was in place (78/109). The other common reasons for not accepting or limiting access of adult patients with Medicaid included emergency room patients only (three of 109), required referral (four of 109), managed care organization preference (eight of 109), case-by-case basis (eight of 109), physician preference in practice (six of 109), and children covered by Medicaid only (two of 109) (Table 6).
(3) Are Medicaid acceptance rates associated with reimbursement or practice type?
The acceptance of Medicaid becomes increasingly more likely as the associated CPT® code reimbursement rates increase. Access to orthopaedic care in the adult orthopaedic patient population also varied in accordance with orthopaedic practice setting. The OR for CPT® reimbursement rate and the acceptance of Medicaid is 1.03 (95% CI, 1.02-1.04) per dollar for 99243, 1.05 (95% CI, 1.03-1.07) per dollar for 99213, and 1.01 (95% CI, 1.00-1.01) per dollar for 28876 (p < 0.001) (99213 = established followup outpatient visit - level 3 of 5; 99243 = new outpatient consultation - level 3 of 5; and 27786 = closed treatment of distal fibular fracture - lateral malleolus - without manipulation - surgical care only) (Table 7). Moreover, the OR for private versus academic practice setting and the acceptance of Medicaid is 0.11 (95% CI, 0.04-0.33, p < 0.001) for CPT® code 99243, 0.11 (95% CI, 0.04-0.32, p < 0.001) for CPT® code 99213, and 0.12 (95% CI, 0.04-0.35, p < 0.001) for CPT® code 27786. Consequently, for a given reimbursement rate, private practices were less likely to take an adult patient with Medicaid insurance relative to an academic practice (Table 7).
Of the 260 institutions that accepted adult patients with Medicaid, 194 were considered private practice and 66 were considered academic practice. Thus, 72% (194/271) of private practices and 93% (66/71) of academic practices accepted adult patients with Medicaid (194 of 271 [72%] versus 66 of 71 [93%]; OR, 0.19; 95% CI, 0.07-0.49; p < 0.001) (Table 3). Regarding the private practices that accepted adult patients with Medicaid, 12% (23/194) imposed restrictions on the number of patients they see, leaving 63% of private orthopaedic practices using a full-access Medicaid model. Of the academic practices that accept adult patients with Medicaid, 6% (four of 66) imposed restrictions on the number of patients they see, leaving 87% of academic orthopaedic practices using a full-access Medicaid model. The difference between the number of private and academic practices that use this full-access model was noted (171 of 27 [64%] versus 62 of 71 [87%]; OR, 0.25; 95% CI, 0.12-0.52; p < 0.001) (Table 3).
(4) Do patients in Medicaid-expansion States have better access to orthopaedic care?
When we compared states that expanded Medicaid after the PPACA with those that did not, there was no difference in access to care for adult orthopaedic patients. This was true for all practice types (OR, 1.02; 95% CI, 0.62-1.70; p = 0.934), for academic practices alone (OR, 1.22; 95% CI, 0.19-7.82; p = 0.84), and for private practices alone (OR, 1.02; 95% CI, 0.59-1.76; p = 0.94) (Table 8). Thus, there was no difference, with the numbers available, in access to care for adult patients with Medicaid insurance based on whether their associated state had adopted PPACA Medicaid expansion.
Adult patients with Medicaid insurance typically have faced substantial hurdles in obtaining timely care [3, 4, 7-9, 11, 13-16, 19]. Much of the impetus for the 2009 passage of the PPACA was an effort to address this . However, there are little data regarding whether the expansion of coverage to previously uninsured groups has resulted in improved access or care. Since a majority of the almost 12 million newly insured have received their coverage through Medicaid, we sought to determine whether the new orthopaedic patients with Medicaid insurance would face fewer impediments to care. We found that inequality in access to orthopaedic care based on health insurance status likely exists in the adult patient population seeking care for an acute ankle fracture in state marketplaces with expanded Medicaid. Results from the national telephone survey study likely indicate that there is no difference in access to care for patients with Medicaid across states that have adopted Medicaid expansion versus states that have foregone Medicaid expansion. Additionally, we found that lower Medicaid reimbursement rates and the private practice setting (as opposed to academic practice) are associated with limited access to orthopaedic care in the adult population with Medicaid.
The researchers could not be blinded to the insurance status of the fictitious patient and/or the responses of the contacted practice. There is potential bias introduced by the fictitious caller, which may artificially reduce the rate of appointment scheduling; practices might be more likely to appoint the same person if they were referred from a hospital where the practice is affiliated and provides call coverage, or if a referral came from an associated or known practice. The simulated patient survey construct was used to minimize potential researcher bias with the use of a script and identical presentation of information in preappointment screenings. The use of a fictitious patient in the simulated patient survey eliminated the potential for the office contacted to be aware of its participation in a research study, eliminating bias via the observer effect and allowing a more-accurate assessment of access to care. The sample size used in the simulated patient survey and national survey studies may be inadequate to show differences that truly exist, allowing the possibility of a Type II error. Calls were made consecutively and spaced over 4 weeks, which could have resulted in sampling bias owing to an unforeseen confounder. This was preferred over call randomization, as it was presumed that calls made to the same practice during a shorter interval may have introduced bias. The national survey study was limited by an inability to fully access participating practices’ policy on Medicaid insurance acceptance. In many cases, the person completing the survey could not and/or would not provide explanations of the practices’ Medicaid acceptance policies.
The results of our study corroborate those of previous studies, which consistently show that patients with Medicaid face increased challenges during the course of orthopaedic care; patients with Medicaid must travel farther to obtain orthopaedic care, wait a longer time before accessing care, are delayed in receiving the diagnosis of an acute orthopaedic injury, experience disruption in continuity of ambulatory care, and experience worse outcomes after surgery compared with patients with different health insurance [3, 9, 11, 19]. Pierce et al.  observed that the pediatric patients with Medicaid seeking outpatient care for an ACL tear before Medicaid expansion were 57 times less likely to receive an appointment within 2 weeks compared with a child with private insurance.
The results of the simulated patient survey study suggest that this inequality may be present to varying degrees on a state-by-state basis, as differences were observed in Medicaid acceptance rates among states surveyed. This was supported by our findings in the national survey, where access to orthopaedic care increased with increasing Medicaid reimbursement rates as well as the academic practice setting on a nationwide scale. Before the PPACA, Skaggs et al.  observed a state-by-state variation in access to care for pediatric orthopaedic patients, reporting that state-based access to care improved as state-determined physician reimbursement rates for treatment of a nondisplaced radius and ulna fracture without manipulation increased. Kim et al.  had similar findings, observing increased success in appointment scheduling for patients with Medicaid in states with a direct relationship between increased Medicaid reimbursement rates.
Our study and several others [11, 13, 16] showed that limited access to orthopaedic care for the Medicaid population is associated with low physician reimbursement rates. While individuals responding to phone surveys in both studies rarely cited low Medicaid reimbursement as a reason to limit care, this correlation suggests that financial remuneration does play a role in access to orthopaedic care. Prevention of discrepancies in access to care attributable to reimbursement disparities between the Medicaid and private insurance populations is in part why the equal access provision of the Medicaid Act was implemented in the Social Security Act . This requires physician reimbursement rates to be “sufficient to enlist enough providers so that services under the plan are available to recipients at least to the extent that those services are available to the general population” . Despite this provision, the reimbursement rate disparity between private insurance and Medicaid continues to be substantial, as does the disparity between Medicaid and Medicare rates . Additionally, for a given reimbursement rate, private practices were less likely to take an adult patient with Medicaid insurance relative to an academic practice.
Our national study found no difference in access to orthopaedic care between states that have adopted Medicaid expansion and those that have not. Lack of a prior study on access to orthopaedic care in Pennsylvania, New Jersey, Delaware, and Maryland before Medicaid expansion prevents us from quantifying the effects that Medicaid expansion has had on access to orthopaedic care in these states. The effects of Medicaid expansion on access to orthopaedic care are not fully understood. Patterson et al.  found that access to orthopaedic care was decreased in areas with high population density and areas in close proximity to an academic orthopaedic center. They posited that areas with high population density have a larger orthopaedic patient base, which may allow practices to operate with increasingly stringent patient-payer selection criteria while practices in less populous areas may lack this capability. Additionally, practices in areas of lower population density may feel uncomfortable informing patients of the need to travel long distances to seek care at an academic center . However, Kim et al.  reported that patients with Medicaid pursuing orthopaedic appointments for primary TKA witnessed successful appointment scheduling rates of 22.8% in states foregoing Medicaid expansion and 37.7% in states with expanded Medicaid (p = 0.011). Importantly, Kim et al.  also reported that patients with Medicaid seeking orthopaedic care in states with expanded Medicaid programs experienced longer waiting times for appointments obtained (p = 0.001).
Patients with Medicaid insurance face a greater barrier to accessing a timely standard of care relative to patients with commercial health insurance. Unfortunately, this trend appears to have continued despite Medicaid expansion, likely indicating that increases in Medicaid coverage availability are not sufficient to increase access to orthopaedic care for the underinsured. Current expansions in Medicaid have likely realized minimal gains for the underinsured as policy has focused only on increasing the patient pool qualified for coverage. As more and more adults obtain coverage through Medicaid expansion and “compete” for a limited number of appointments, it may become more difficult for these patients to obtain an orthopaedic appointment. Policy aimed to improve access to care for orthopaedic patients with Medicaid must encourage greater Medicaid participation by orthopaedic surgeons. Although further research is needed to clearly delineate physician-patient-payer selection criteria, Medicaid reimbursement rates may need to be increased to incentivize the care of these patients and alleviate the pervasive inequality they experience in accessing orthopaedic treatment.
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