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Foot & Ankle Trauma Practice Management

The Effect of Insurance Type on Patient Access to Ankle Fracture Care Under the Affordable Care Act

Authors:
Author Affiliation | Disclosures

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

Dr. Wiznia is an Assistant Professor of Orthopaedic Surgery, Department of Orthopaedics and Rehabilitation; Mr. Wang is a medical student; and Dr. Leslie is an Associate Professor of Orthopaedics and Rehabilitation, Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut. Dr. Kim is an Orthopedic Surgery Resident, University Hospitals Cleveland Medical Center, Cleveland, Ohio. Dr. Wiznia was a resident at the time the article was written.

Address correspondence to: Daniel H. Wiznia, MD, Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, 47 College Street, New Haven, Connecticut 06510 (tel, 203-737-6358; email, daniel.wiznia@yale.edu).

Am J Orthop. 2018;47(9). Copyright Frontline Medical Communications Inc. 2018. All rights reserved.

Abstract

The purpose of this study is to assess the effect of insurance type (Medicaid, Medicare, private insurance) on the ability for patients with operative ankle fractures to access orthopedic traumatologists. The research team called 245 board-certified orthopedic surgeons specializing in orthopedic trauma within 8 representative states. The caller requested an appointment for their fictitious mother in order to be evaluated for an ankle fracture which was previously evaluated by her primary care physician and believed to require surgery. Each office was called 3 times to assess the response for each insurance type. For each call, information was documented regarding whether the patient was able to receive an appointment and the barriers the patient confronted to receive an appointment. Overall, 35.7% of offices scheduled an appointment for a patient with Medicaid, in comparison to 81.4%and 88.6% for Medicare and BlueCross, respectively (P < .0001). Medicaid patients confronted more barriers for receiving appointments. There was no statistically significant difference in access for Medicaid patients in states that had expanded Medicaid eligibility vs states that had not expanded Medicaid. Medicaid reimbursement for open reduction and internal fixation of an ankle fracture did not significantly correlate with appointment success rates or wait times. Despite the passage of the Affordable Care Act, patients with Medicaid have reduced access to orthopedic surgeons and more complex barriers to receiving appointments. A more robust strategy for increasing care-access for patients with Medicaid would be more equitable.




Take-Home Points

  • One method in which the PPACA increased the number of individuals with health insurance coverage was by expanding Medicaid eligibility requirements.
  • Despite this, Medicaid patients confronted more barriers to accessing care.
  • The overall rate of successfully being offered an appointment with Medicaid was 35.7%, 81.4% for Medicare, and 88.6% for BlueCross. Patients with Medicaid also confronted longer appointment wait times.
  • The disparity in access for this operative trauma scenario suggests that patients with Medicaid are likely to be excluded from the practice of their choice and may need to make considerably more effort to secure an appointment.
  • Ultimately, Medicaid patients may have access to care through federally funded community health centers and public and non-profit safety net hospitals, which generally care for more uninsured and Medicaid patient populations.

In 2010, the Patient Protection and Affordable Care Act (PPACA) expanded the eligibility criteria for Medicaid to all individuals with an income up to 138% of the poverty level.1 A Supreme Court ruling stated that the decision to expand Medicaid was to be decided by individual states.2 Currently, 31 states have chosen to expand Medicaid eligibility to their residents.2 This expansion has allowed an additional 11.7 million people to enroll in Medicaid and the Children’s Health Insurance Program by May 2015.3-5

Even with the passage of the PPACA, Medicaid patients seeking specialty orthopedic care have experienced more barriers to accessing care than Medicare or commercially-insured patients.2,6-10 One major cited reason is Medicaid’s low reimbursement, which may discourage physicians from open panel participation in Medicaid.11,12  

A common fundamental teaching for orthopedic traumatologists is the notion that they should be available to treat all injuries regardless of the patient’s ability to pay.13 This has resulted in both trauma centers and trauma surgeons becoming financially challenged due to the higher proportion of Medicaid and uninsured trauma patients and lower Medicaid reimbursement levels.14,15

This study focuses on the effect of different types of insurance (Medicaid, Medicare, or commercial insurance) on the ability of patients to obtain care for operative ankle fractures. The purpose of this study is to evaluate, in the context of the PPACA, patient access to orthopedic surgeons for operative ankle fractures based on insurance-type. We hypothesized that patients with Medicaid would face a greater volume of obstacles when seeking appointments for an ankle fracture, even after the PPACA.

Materials and Methods

The study population included board-certified orthopedic surgeons who belonged to the Orthopaedic Trauma Association (OTA) from 8 representative states; 4 states with expanded Medicaid eligibility (California, Massachusetts, New York, Ohio) and 4 states without expanded Medicaid eligibility (Florida, North Carolina, Georgia, Texas). These states were selected due to their ability to represent diverse healthcare marketplaces throughout the country. Using the OTA website’s “Find a Surgeon” search tool,16 we created a list of surgeons for each state and matched each surgeon with a random number. The list of surgeons was ordered according to the value of the surgeon’s associated random number, and surgeons were called in ascending order. We excluded disconnected or inaccurate numbers from the calling list. Surgeons who did not manage ankle fractures were removed from the dataset. Approximately 30 orthopedic trauma surgeons per state were contacted.

Each office was called to make an appointment for the caller’s mother. Every surgeon’s office was specifically asked if the surgeon would accept the patient to be evaluated for an ankle fracture that occurred out-of-state. The caller had a standardized protocol to limit intra- and inter-office variations (Appendix). The scenario involved a request to be evaluated for an unstable ankle fracture, with the patient having Medicaid, Medicare, or BlueCross insurance. The scenario required 3 separate calls to the same surgeon in order to obtain data regarding each insurance-type. The calls were separated by at least 1 week to avoid caller recognition by the surgeon’s office.

The date of each phone call and date of appointment, if provided, were recorded. If the office did not give an appointment, we asked for reasons why. If an appointment was denied for a patient with Medicaid, we asked for a referral to another office that accepted Medicaid. We considered barriers to obtaining an initial appointment, such as requiring a referral from a primary care physician (PCP), as an unsuccessful attempt at making an appointment. We determined the waiting period for an appointment by calculating the time between the date of the call and the date of the appointment. Appointments were not scheduled to ensure that actual patients were not disadvantaged. For both appointment success rates and waiting periods, we stratified the data into 2 groups: states with expanded Medicaid eligibility (California, Massachusetts, New York, Ohio) and states without expanded Medicaid eligibility (Florida, North Carolina, Georgia, Texas).

We obtained Medicaid reimbursement rates for open reduction and internal fixation of an ankle fracture by querying each state’s reimbursement rate using Current Procedural Terminology code 27822.

Chi-square test or Fisher’s exact test was used to analyze acceptance rate differences based on the patient’s type of insurance. To compare the waiting periods for an appointment, we used an independent samples t-test after applying natural log-transformation, as the data was not normally distributed. We performed logistic regression analysis to detect whether reimbursement was a significant predictor of successfully making an appointment for patients, and a linear regression analysis was used to evaluate whether reimbursement predicted waiting periods. Unless otherwise stated, all statistical testing was performed two-tailed at an alpha-level of 0.05.

This study was approved by the Institutional Review Board of Yale University School of Medicine (HIC No. 1363).

Results

In total, 350 offices were contacted across 8 states (4 states with and 4 states without expanded Medicaid eligibility) of which we identified 245 orthopedic surgeons who would surgically treat ankle fractures. The 245 surgeons’ offices were called 3 times for each separate insurance-type.

The overall rate of successfully being offered an appointment with Medicaid was 35.7%, 81.4% for Medicare, and 88.6% for BlueCross (Table 1). For states with expanded Medicaid eligibility, the success rate for obtaining an appointment was 39.6%, 83.5%, and 89.2% for Medicaid, Medicare, and BlueCross, respectively. For states without expanded Medicaid eligibility, the success rate for obtaining an appointment was 31.9% for Medicaid, 79.4% for Medicare, and 87.9% for BlueCross. In all cases, the success rate for obtaining an appointment was significantly lower for Medicaid, compared to Medicare (P < .0001) or BlueCross (P < .0001). Medicaid appointment success rate was 39.6% in expanded states vs 31.9% in non-expanded states, however, the difference was not statistically significant (Table 2).

In 43.7% of occasions, patients with Medicaid did not have their insurance accepted, compared to 7.3% for Medicare and 0% for BlueCross. The majority of offices which did not accept Medicaid were not able to refer patients to another surgeon who would accept Medicaid. The requirement to have a primary care referral was the second most common reason for Medicaid patients not obtaining an appointment. No Medicare (10.4% vs 0.0%, P < .0001) or BlueCross (10.4% vs 0.0%, P < .0001) patients experienced this requirement (Table 3). There was no difference found between the percent of Medicaid patients who were required to have referrals in states with and without expanded Medicaid eligibility (Table 4).

Reimbursements for ankle fracture varied across states (Table 5). For Medicaid, Georgia paid the highest reimbursement ($1049.95) and Florida paid the lowest ($469.44). Logistic and linear regression analysis did not demonstrate a significant relationship between reimbursement and appointment success rate or waiting periods.

Waiting periods (Table 6) varied significantly by the type of insurance (7.3 days for Medicaid, 6.0 days for Medicare, and 6.0 days for BlueCross; P = .002). For states with expanded Medicaid eligibility, waiting periods varied significantly by insurance (7.7 days for Medicaid, 6.2 days for Medicare, P = .003; and 6.1 days for BlueCross, P = .01). Waiting periods did not vary significantly for states without expanded Medicaid. Additionally, waiting periods did not differ significantly when comparing between states with and without Medicaid expansion.

Discussion

This study assessed how insurance type (Medicaid, Medicare, and BlueCross) affects patient access to orthopedic trauma surgeons in 8 geographically representative states. We selected unstable ankle fractures as they are basic fractures treated by nearly all trauma surgeons and should often be surgically treated to prevent serious long-term consequences. Our hypothesis stated that despite the passage of the PPACA, patients with Medicaid would have reduced access to care. As the PPACA has changed the healthcare marketplace by increasing the number of Medicaid enrollees, it is important to ensure that patient access to care improves.

This nationwide survey of orthopedic trauma surgeons demonstrates that Medicaid patients experience added barriers to care that ultimately results in lower rates of successfully obtaining care. This is consistent with other investigations which have assessed Medicaid patient healthcare access.6,8,10,17-19 This study did not demonstrate a statistically significant difference between Medicaid patients’ ability to obtain appointments in states with expanded Medicaid eligibility vs in states without expanded Medicaid eligibility (39.6% vs 31.9%, P < .18); this has been demonstrated in the literature.6  

A barrier that was unique to Medicaid patients was the requirement to have a PCP referral (Table 3). A PCP referral was not a barrier to receiving an appointment for patients with Medicare or BlueCross. One reason to explain why Medicaid patients may be required to have PCP referrals is due to their increased medical complexity, extra documentation requirements, and low reimbursement.4 Patients who have obtained a PCP referral may be characterized as being more medically compliant.

It is important to note that the Medicaid policies for 4 states included in this study (Massachusetts, North Carolina, Texas, and New York) required a PCP referral in order to see a specialist. However, we found that many orthopedic trauma practices in these states scheduled appointments for Medicaid patients without a PCP referral, suggesting that the decision depended on individual policy. In addition, the majority of offices within these states cited that they simply did not accept Medicaid as an insurance policy, and not that they required a referral.

Our regression analysis did not find a significant relationship between being able to successfully obtain an appointment to be evaluated for an ankle fracture and reimbursement rates for Medicaid. Although studies have stressed the importance of Medicaid reimbursements on physician participation, this result is consistent with previous studies regarding carpal tunnel release and total ankle replacements.17,19 Long20 suggested that although reimbursements may help, additional strategies for promoting Medicaid acceptance may be needed, including: lowering the costs of participating in Medicaid by simplifying administrative processes, speeding up reimbursement, and reducing the costs associated with caring for those patients.

Previous studies have demonstrated that more physicians may accept Medicaid if reimbursements increased.4,12 Given the high percentage of trauma patients with Medicaid as their primary insurance or whom are emergently enrolled in Medicaid by hospital systems, it is concerning that the PPACA is reducing payments under the Medicare and Medicaid Disproportionate Share Hospital programs which provide hospitals for uncompensated care given to low-income and uninsured patients.21 Trauma centers generally operate at a deficit due to the higher proportion of Medicaid and uninsured patients.14 This is currently worsened by additional federal funding cuts for supporting trauma service’s humane mission.21

This study has several limitations. While the study evaluated access to care in 8 representative states, a thorough nationwide survey would be more representative. Some results may have become statistically significant if we had performed the study with a larger sample size. In addition, we were unable to control for many factors which could impact appointment wait times, such as physician call schedules and vacations. Socioeconomic factors can influence a patient’s ability to attend an appointment, such as transportation costs, time off from work, and childcare availability. In addition, this study did not assess access for the uninsured, who are predominantly the working poor who cannot afford health insurance, even with federal and state subsidies.

The authors apologize for inconveniencing these offices, however, data collection could not be achieved in a better manner. We hope that the value of this study compensates any inconvenience.

Conclusion

Overall, our results demonstrate that despite the ratification of the PPACA, Medicaid patients are confronted with more barriers to accessing care by comparison to patients with Medicare and BlueCross insurance. Medicaid patients have worse baseline health22 and are at an increased risk of complications. These disparities are thought to be due to decreased healthcare access,23,24 as well as socioeconomic challenges. Interventions, such as increasing Medicaid’s reimbursement levels, reducing burdensome administrative responsibilities, and establishing partnerships between trauma centers and trauma surgeons, may enable underinsured patients to be appropriately cared for.

This paper will be judged for the Resident Writer’s Award.

  • Key Info
  • Figures/Tables
  • References
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Key Info

Key Info

Figures/Tables

Table 1. Appointment Success Rate

 

Medicaid

Medicare

Private

All states

 

 

 

Yes (%)

100 (35.7)

228 (81.4)

248 (88.6)

No (%)

180 (64.3)

52 (18.60

32 (11.4)

P-valuea

 

0.0001

0.0001

States with expanded Medicaid eligibility

 

 

 

Yes (%)

55 (39.6)

116 (83.5)

124 (89.2)

No (%)

84 (60.4)

23 (16.5)

15 (10.8)

P-valuea

 

0.0001

0.0001

States without expanded Medicaid eligibility

 

 

 

Yes (%)

45 (31.9)

112 (79.4)

124 (87.9)

No (%)

96 (68.1)

29 (20.6)

17 (12.1)

P-valuea

 

0.0001

0.0001

aComparison to Medicaid.

 

Table 2. Medicaid Appointment Success Rate in Expanded Vs Non-Expanded States

 

Expanded states

Non-expanded states

P-value

Yes (%)

55 (39.6)

45 (31.9)

.181

No (%)

84 (60.4)

96 (68.1)

 

 

Table 3. Referral Rate

 

Medicaid

Medicare

Private

All states

 

 

 

Yes (%)

29 (10.4)

0 (0)

0 (0)

No (%)

251 (89.6)

280 (100)

280 (100)

P-valuea

 

0.0001

0.0001

States with expanded Medicaid eligibility

 

 

 

Yes (%)

12 (8.6)

0 (0)

0 (0)

No (%)

127 (91.4)

139 (100)

139 (100)

P-valuea

 

0.0001

0.0001

States without expanded Medicaid eligibility

 

 

 

Yes (%)

17 (12.1)

0 (0)

0 (0)

No (%)

124 (87.9)

141 (100)

141 (100)

P-valuea

 

0.0001

0.0001

aComparison to Medicaid.

 

Table 4. Medicaid Referral Rates in Expanded Vs Non-Expanded States

 

Expanded states

Non-expanded states

P-value

Yes (%)

12 (9.7)

17 (14.0)

.35

No (%)

127 (91.4)

124 (87.9)

 

 

Table 5. Medicaid Reimbursements for Ankle Fracture Repair (CPT and HCPCS 27822) in 2014

State

Medicaid reimbursement

Californiaa

$785.55

Texas

$678.95

Florida

$469.44

Ohioa

$617.08

New Yorka

$500.02

North Carolina

$621.63

Massachusettsa

$627.94

Georgia

$1,049.95

Average

$668.82

aStates with expanded Medicaid eligibility.

Abbreviations: CPT, Current Procedural Terminology; HCPCS, Healthcare Common Procedure Coding System.

 

Table 6. Waiting Period (Days) by Insurance Type.

 

Medicaid

Medicare

Private

Comparison by Insurance Type

 

 

 

All states

 

 

 

Waiting period

7.3

6.0

6.0

P-value

 

0.002

0.002

States with expanded Medicaid eligibility

 

 

 

Waiting period

7.7

6.2

6.1

P-value

 

0.003

0.01

States without expanded Medicaid eligibility

 

 

 

Waiting period

6.9

5.9

5.9

P-value

 

0.15

0.15

Comparison by Medicaid Expansion

 

 

 

States with expanded

Medicaid eligibility

7.7

6.2

6.1

States without expanded

Medicaid eligibility

6.9

5.9

5.9

P-value

0.17

0.13

0.07

 

Appendix

Scenario

1. Date of Birth: Medicaid–2/07/55; BlueCross PPO–2/09/55; Medicare–7/31/45.

2. Ankle fracture evaluated by primary care physician 1 or 2 days ago

3. Not seen previously by your clinic or hospital, she would be a new patient

4. Asked how early she could be scheduled for an appointment

5. Script:

“I’m calling for my mother who injured her ankle a few days ago. Her family doctor took an X-ray and believes she has a fracture and needs surgery. Is Dr. X accepting new patients for evaluation and treatment of ankle fractures?” If YES

“I was wondering if you take Medicaid/Medicare/BlueCross plan?” If YES

“When is your soonest available appointment?”

References

References

1. Blumenthal D, Collins SR. Health care coverage under the affordable care act--a progress report. N Engl J Med. 2014;371(3):275-281. doi:10.1056/NEJMhpr1405667.

2. Sommers BD. Health care reform's unfinished work--remaining barriers to coverage and access. N Engl J Med. 2015;373(25):2395-2397. doi:10.1056/NEJMp1509462.

3. US Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicaid & CHIP: February 2015 monthly applications, eligibility determinations and enrollment report. https://www.medicaid.gov/medicaid/program-information/downloads/medicaid-and-chip-february-2015-application-eligibility-and-enrollment-data.pdf. Published May 1, 2015. Accessed May 2015.

4. Iglehart JK, Sommers BD. Medicaid at 50--from welfare program to nation's largest health insurer. N Engl J Med. 2015;372(22):2152-2159. doi:10.1056/NEJMhpr1500791.

5. Kaiser Family Foundation. Medicaid moving forward. http://kff.org/medicaid/fact-sheet/the-medicaid-program-at-a-glance-update/. Updated 2014. Accessed October 10, 2014.

6. Kim CY, Wiznia DH, Hsiang WR, Pelker RR. The effect of insurance type on patient access to knee arthroplasty and revision under the affordable care act. J Arthroplasty. 2015;30(9):1498-1501. doi:10.1016/j.arth.2015.03.015.

7. Draeger RW, Patterson BM, Olsson EC, Schaffer A, Patterson JM. The influence of patient insurance status on access to outpatient orthopedic care for flexor tendon lacerations. J Hand Surg Am. 2014;39(3):527-533. doi:10.1016/j.jhsa.2013.10.031.

8. Patterson BM, Spang JT, Draeger RW, Olsson EC, Creighton RA, Kamath GV. Access to outpatient care for adult rotator cuff patients with private insurance versus Medicaid in North Carolina. J Shoulder Elbow Surg. 2013;22(12):1623-1627. doi:10.1016/j.jse.2013.07.051.

9. Patterson BM, Draeger RW, Olsson EC, Spang JT, Lin FC, Kamath GV. A regional assessment of medicaid access to outpatient orthopaedic care: the influence of population density and proximity to academic medical centers on patient access. J Bone Joint Surg Am. 2014;96(18):e156. doi:10.2106/JBJS.M.01188.

10. Schwarzkopf R, Phan D, Hoang M, Ross S, Mukamel D. Do patients with income-based insurance have access to total joint arthroplasty? J Arthroplasty. 2014;29(6):1083-1086. doi:10.1016/j.arth.2013.11.022.

11. Decker SL. In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help. Health Aff (Millwood). 2012;31(8):1673-1679 doi:10.1377/hlthaff.2012.0294.

12. Perloff JD, Kletke P, Fossett JW. Which physicians limit their Medicaid participation, and why. Health Serv Res. 1995;30(1):7-26.

13. Althausen PL. Building a successful trauma practice in a community setting. J Orthop Trauma. 2011;25 Suppl 3:S113-S117. doi:10.1097/BOT.0b013e318237bcce.

14. Greenberg S, Mir HR, Jahangir AA, Mehta S, Sethi MK. Impacting policy change for orthopaedic trauma. J Orthop Trauma. 2014;28 Suppl 10:S14-S16. doi:10.1097/BOT.0000000000000216.

15. Wiznia DH, Averbukh L, Kim CY, Goel A, Leslie MP. Motorcycle helmets: The economic burden of an incomplete helmet law to medical care in the state of Connecticut. Conn Med. 2015;79(8):453-459.

16. Orthopaedic Trauma Association. Find a surgeon. https://online.ota.org/otassa/otacenssafindasurgeon.query_page. Updated 2015. Accessed July, 2015.

17. Kim CY, Wiznia DH, Roth AS, Walls RJ, Pelker RR. Survey of patient insurance status on access to specialty foot and ankle care under the affordable care act. Foot Ankle Int. 2016;37(7):776-781. doi:1071100716642015.

18. Patterson BM, Draeger RW, Olsson EC, Spang JT, Lin FC, Kamath GV. A regional assessment of Medicaid access to outpatient orthopaedic care: the influence of population density and proximity to academic medical centers on patient access. J Bone Joint Surg Am. 2014;96(18):e156. doi:10.2106/JBJS.M.01188.

19. Kim CY, Wiznia DH, Wang Y, et al. The effect of insurance type on patient access to carpal tunnel release under the affordable care act. J Hand Surg Am. 2016;41(4):503-509.e1. doi:S0363-5023(16)00104-0.

20. Long SK. Physicians may need more than higher reimbursements to expand Medicaid participation: findings from Washington state. Health Aff (Millwood). 2013;32(9):1560-1567. doi:10.1377/hlthaff.2012.1010.

21. Issar NM, Jahangir AA. The affordable care act and orthopaedic trauma. J Orthop Trauma. 2014;28 Suppl 10:S5-S7. doi:10.1097/BOT.0000000000000211.

22. Hahn B, Flood AB. No insurance, public insurance, and private insurance: do these options contribute to differences in general health? J Health Care Poor Underserved. 1995;6(1):41-59.

23. Hinman A, Bozic KJ. Impact of payer type on resource utilization, outcomes and access to care in total hip arthroplasty. J Arthroplasty. 2008;23(6 Suppl 1):9-14. doi:10.1016/j.arth.2008.05.010.

24. Schoenfeld AJ, Tipirneni R, Nelson JH, Carpenter JE, Iwashyna TJ. The influence of race and ethnicity on complications and mortality after orthopedic surgery: A systematic review of the literature. Med Care. 2014;52(9):842-851. doi:10.1097/MLR.0000000000000177.

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