“I broke my ankle”: Access to orthopedic follow-up care by insurance status

Abstract

Objectives

While the Affordable Care Act seeks to reduce emergency department 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 emergency department 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% CI 73.2%-92.9%), 81.4% for uninsured (95% CI 73.7%-89.1%), and 14.0% for Medicaid callers (95% CI 3.2%-24.7%). Controlling for paired calls to the same practice, an uninsured caller had 5.7 times higher odds (95% CI 2.74-11.71) of receiving an appointment than a Medicaid caller (p<0.001), but the same odds as a privately insured caller (OR=1.0, 95% CI 0.19-5.37, p=1.0). Uninsured patients had to bring a median of $350 (IQR $250-$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 are $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 emergency departments as alternative sources of care. Of the practices that appeared on Medicaid's published list of orthopedic providers accepting new patients, 15 told callers they did not accept Medicaid, 11 did not treat ankles, 9 listed non-working phone numbers, and only 3 actually scheduled an appointment for the Medicaid caller

Conclusions

Less 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 emergency department for necessary care.

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