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

September 13, 2018 | Surgery
Daniel H. Wiznia, MD ; Mike Wang, BS ; Chang-Yeon Kim, MD ; Michael P. Leslie, DO
Author and Disclosure Information

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).

Daniel H. Wiznia, MD Mike Wang, BS Chang-Yeon Kim, MD Michael P. Leslie, DO . The Effect of Insurance Type on Patient Access to Ankle Fracture Care Under the Affordable Care Act. Am J Orthop. September 13, 2018

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.

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.

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