Effect of Health Insurance Type on Access to Care

Effect of Health Insurance Type on Access to Care John M. Froelich, MD; Ryan Beck, MD; Wendy M. Novicoff, PhD; K.J. Saleh, MD, MSc, FRCSC, MHCM abstract Full article available online at Healio.com/Orthopedics. Search: 20130920-19 Growing orthopedic and nonorthopedic literature illustrates the point that having health insurance does not equal having access to care. The goal of this study was to evaluate the burden placed on patients to gain access to outpatient orthopedic care. For this study, burden was quantified as the distance traveled by the patient to be seen in clinic. This study was a retrospective review of all new patient encounters at an adult orthopedic outpatient clinic in an academic tertiary referral center over 1 calendar year. All patients were stratified into 4 categories: commercial/private insurance, Medicaid, Medicare, and uninsured/private pay. The average distance traveled by each patient to the center was then calculated based on the patient s billing zip code. Patient visits were further stratified based on whether the patients were seen by 1 of 3 different categories of providers: general orthopedics/adult reconstruction, spine, and sports/upper extremity. The study group comprised 774 (31.1%) Medicaid patients, 653 (26.2%) Medicare patients, 917 (36.8%) commercial/private insurance patients, and 146 (5.9%) uninsured/private pay patients. The average 1-way distance traveled was 36.2 miles for Medicaid patients, 21.3 miles for Medicare patients, 24.1 miles for commercial/private insurance patients, and 25.3 miles for uninsured/private pay patients (P,.00). Subgroup analysis noted a statistical difference in distance traveled for the general orthopedics/adult reconstruction and sports/upper extremity groups. The study s findings suggest that having insurance does not equal access to outpatient orthopedic care at a single institution. The specific burdens that each group faces to gain access to care are unclear. The authors are from the Department of Orthopaedic Surgery (JMF), University of Colorado, Aurora, Colorado; the Division of Orthopaedic Surgery (RB, KJS), Southern Illinois University, Springfield, Illinois; and the Department of Orthopedic Surgery and Public Health Sciences (WMN), University of Virginia, Charlottesville, Virginia. Dr Froelich is an AAOS Washington Health Policy Fellow. The authors have no relevant financial relationships to disclose. Correspondence should be addressed to: John M. Froelich, MD, Department of Orthopaedic Surgery, University of Colorado, 12631 E 17h Ave, Academic Office One, Mail Stop B202, Aurora, CO 80045 (john.froelich@ucdenver.edu). doi: 10.3928/01477447-20130920-19 e1272

Effect of Health Insurance Type on Access to Care Froelich et al Previous authors have noted a second-tier treatment of patients with Medicaid insurance, requiring them to wait longer for outpatient clinic appointments compared with those patients with private insurance. 1-5 Whatever the outcome of health-care reform may be, the number of people requiring healthcare services will continue to grow, thus increasing the current clinical burden on medical providers. When a provider becomes busier, a patient s insurance status may become a screening tool for clinic access. 6 The goal of the current study was to evaluate the influence of a patient s insurance provider on his or her ability to gain access to orthopedic care as a reflection on the distance traveled by the patient to be seen in clinic. Broadly, the authors hoped to begin addressing the question of whether insurance equals access to care in outpatient orthopedic care. The authors hypothesized that Medicaid patients will travel farther than Medicare and commercially insured patients for an outpatient orthopedic clinic appointment. Materials and Methods This study was a retrospective review of all new patient encounters for an adult orthopedic outpatient clinic at an academic tertiary referral center for 1 calendar year. All patients were filtered into 4 categories based on their insurance provider: commercial/private, public aid/medicaid, Medicare, and uninsured/private pay (referred to as self-pay throughout the text). The average distance traveled for each patient to the clinic was then calculated using Google Maps (Mountain View, California) based on the patient s home billing zip code. Pediatric patients, prisoners, charity cases, students using university insurance, liability cases, and workers compensation patients were excluded from the study because they each represent unique referral and access issues that were believed to potentially bias the data. Patients were further stratified based on the county in which their reported zip code was associated using an online search through the US Census Bureau. Institutional review board approval was obtained for the study. The average 1-way distance traveled in miles was calculated for each of the 4 insurance types. The same comparison of mileage traveled per patient in comparison with insurance type was then completed for visits based on whether the patients were seen by 1 of 3 different categories of providers: general orthopedics/adult reconstruction, spine, and sports/upper extremity. The top 5 referring counties for all new patients were also tabulated. The percentage of adult Medicaid enrollees in the top 5 referring counties was then compared with the percentage of Medicaid enrollees in the county in which the clinic is based. Public 2010 data available from the State Department of Public Health and the federal census were used to tabulate the percentage of adult enrollees in each evaluated county. 7 The county in which the clinic is located served as a control and was not included in the calculations as one of the top 5 referral counties. Analysis of variance was used to compare the groups. Resulting P values less than.05 were considered statistically significant. Figure 1: Graph showing the average distance traveled for all adult outpatient clinic encounters based on insurance type. Results A total of 2596 new patients were evaluated during the collection period, with 106 patients ultimately excluded for the following reasons: incomplete insurance information (n516), prisoners (n514), workers compensation patients (n541), liability cases (n519), student insurance (n57), and local charity aid (n59). Therefore, a total of 2490 individual new patient encounters were evaluated for this study. The study group comprised 774 (31.1%) Medicaid patients, 653 (26.2%) Medicare patients, 917 (36.8%) commercial insurance patients, and 146 (5.9%) selfpay patients. The average 1-way distance traveled was 36.2 miles for Medicaid patients, 21.3 miles for Medicare patients, 24.1 miles for commercial insurance patients, and 25.3 miles for self-pay patients (P<.00) (Figure 1). The distance traveled was quantified into groups of 25-mile increments for a 1-way trip based on insurance type. The percentage of total patients who traveled per 25-mile increment was tabulated for each insurance type (Table 1). These findings were significant, noting that a larger percentage of Medicaid patients traveled more than 50 miles each direction compared with patients from the other insurance groups (P<.00). County-specific calculations found that the percentage of adults with Medicaid insurance in the county in which the clinic is based was 8.4%. The percentage of adult Medicaid enrollees in each of the top 5 referring counties for all new patients was also tabulated and is presented in Table 2. A 0.6% higher average adult enrollment existed based on county populations for the top 5 referring counties, which was statistically significant (P,.00). In the subgroup analysis of patients who saw general orthopedics/adult reconstruction, spine, or sports/upper extremity physicians, it was noted that Medicaid patients seen by general orthopedics/adult reconstruction and sports/upper extremity physicians traveled a significantly greater distance than did those with Medicare insurance, commercial insurance, or selfpay patients. Specifically, Medicaid pa- 1 OCTOBER 2013 Volume 36 Number 10 e1273

tients who saw general orthopedics/adult reconstruction physicians traveled an average of 39.24 miles (P,.00) vs 22.92 miles for commercial insurance patients, 21.88 miles for Medicare patients, and 24.63 miles for self-pay patients (Figure 2A). Medicaid patients who saw sports/ upper extremity physicians traveled an average of 41.01 miles (P,.00) vs 22.5 miles for commercial insurance patients, 23.42 miles for Medicare patients, and 25.33 miles for self-pay patients (Figure 2B). No statistical difference was noted in the spine subgroup (P5.24), with Medicaid patients traveling an average of 34.3 miles, commercial insurance patients traveling an average of 29.79 miles, Medicare patients traveling an average of 26.07 miles, and self-pay patients traveling an average of 27.05 miles (Figure 2C). Discussion In this study, a statistically significant difference was noted in the distance traveled by patients to access adult outpatient orthopedic care in 1 referral area depending on the patient s insurance provider. Further analysis of the data showed that the discrepancy based on distance traveled to clinic was present in the specialty subdivisions of general/adult reconstruction and sports/upper extremity. Interestingly, no statistically significant difference was found in distance traveled by patients seeing spine physicians based on insurance Table 1 Percentage of New Patients per Insurance Type Based on Distance Traveled Insurance Type <25 miles 26-50 miles >51 miles Total Medicaid 52.3 17.7 30 a 100 Medicare 71.8 14.9 13.3 100 Commercial 69.4 16.3 14.4 100 Self-pay 65.8 12.3 21.9 100 a P,.00 % provider. When all new patient encounters for 1 calendar year were considered, Medicaid patients traveled 26 more miles round-trip than did Medicare patients and 24 more miles than did commercially insured patients to see either an orthopedic physician or an orthopedic physician extender. Calfee et al 8 recently reported the influence of insurance status on the distance traveled for new patients in a single tertiary center hand practice. The authors found a similar trend of increased distance traveled for patients with Medicaid insurance, as well as a disproportionate rate of Medicaid patients from greater distances that cannot be explained by the density of Medicaid patients from the region. Wolinsky et al 5 evaluated nonurgent operative management of ankle and distal radius fractures in California. The authors found that a statistically significant higher proportion of noninsured or underinsured patients initially evaluated outside of their trauma center ultimately received definitive care at their center, independent of the fracture severity or patient comorbidities compared with insured patients. 5 This recent work investigating the management of nonurgent fractures adds to the existing and growing orthopedic literature describing increased transfer rates of traumatic poorly insured orthopedic injuries, as well as access burdens for outpatient spine clinics based on insurance status. 9-12 Table 2 Percentage of Enrolled Adult Medicaid Recipients by County County Medicaid, % Home 8.4 1 8.8 2 5.5 3 9.3 4 9.3 5 9.9 Total referring counties Wolinsky et al 5 divided treatment groups by insurance reimbursement levels. Previous authors have also suggested the influence of poor reimbursement on access to care. 6,12-16 It could be hypothesized that lower financial reimbursement played a role in determining how far Medicaid patients in the current study had to travel. According to the state-specific 2010 Medicaid reimbursement schedule for Current Procedural Terminology codes 99203 (New Patient Visit Detailed/Level 3) and 99213 (Established Patient Visit Detailed/ Level 3), the current authors practice was reimbursed approximately 45% less per Medicaid visit compared with the average commercially insured patient during the data collection period. 3,17 The authors believe the discrepancy in reimbursement for services provided for Medicaid patients vs commercially insured patients contributed substantially to the study s findings, but the authors acknowledge that reimbursement rates are not the sole factors in determining patient access. 16,18 Medicaid patients often have complex social stresses that can complicate the ability to arrange and attend clinical visits and adhere to treatment protocols. Although difficult to quantify, these real and perceived complexities may also lead to physicians limiting the number of Medicaid patients evaluated and cared for in their clinics. 9 e1274

Effect of Health Insurance Type on Access to Care Froelich et al 2A 2B 2C Figure 2: Graphs showing the 1-way distance traveled by patients with different insurance types visiting general orthopedic/adult reconstruction (A), sports/ upper extremity (B), and spine (C) physicians. One potential reason for the increased distance traveled by Medicaid patients in the current study could be explained by the perceived lower economic status of rural counties more distant from the authors clinic. The authors attempted to address this potential geographic bias by evaluating the percentage of enrolled Medicaid adults in the top 5 referring counties based on publicly available 2010 enrollment data from the state Department of Public Aid and 2010 US census data (Table 2). Based on the calculations for adult enrollees, a significant difference was found in the percentage of adult Medicaid enrollees between the county in which the study was based and the combined Medicaid enrollment for the top 5 referring counties. The authors acknowledge that these findings demonstrate a statistically significant increase in the concentration of adult Medicaid patients in the surrounding referring counties, but they do not believe the numerical difference carries the same clinical significance. Based on a delta of 0.6% of total enrolled Medicaid adults and an absolute lower number of enrolled patients in the top 5 referring counties of 161,032 vs 197,465 people in the authors home county, it is difficult to explain the large disproportionate number of Medicaid patients who travel greater distances for a clinic visit vs Medicare, commercial insurance, or self-pay patients. This study has some limitations. First, the study is a single-year retrospective review. Due to the retrospective nature of the data, the authors were unable to determine the factors that led to individuals traveling large distances to be seen in clinic. The authors clinic is a tertiary referral center, and due to that distinction, it attracts patients from throughout the state. This could increase the distance traveled by patients, but one would expect this increased travel burden to be more equitable in distribution across all insurance types. One could theorize that if an individual drove farther, he or she was more likely to have been turned down by a more local orthopedic surgeon, but it is not known whether that is true for the current study because that information was not available in a retrospective fashion. In addition, the study data were limited and potentially biased because it is not known whether any of the patients had seen a previous orthopedic surgeon and were seeking a second opinion. Finally, the authors did not collect demographic information for associated medical comorbidities for comparison between the groups to delineate whether more medically complex patients were being referred to the tertiary care center. To the authors knowledge, this study is the largest on the travel burden placed on a patient to access outpatient adult orthopedic care based on his or her insurance provider. The study s findings demonstrate that insurance status affects the distance traveled by patients for a new patient visit. The authors acknowledge a statistically significant larger Medicaid population in the surrounding counties that could influence the study findings, but they do not believe that the data can be completely explained by this finding. Access to care has been most classically quantified in measuring clinic appointment availability or wait times. The authors suggest that another way to quantify limited access to care and a subsequent increased burden on a population group is to measure the distance a patient needs to travel to see a physician. Based on the premise that an average individual would not choose to travel farther, incur increased fuel expenses, and have more time away from work or children to receive orthopedic care independent of insurance requirements, the authors believe that the study data demonstrate that simple possession of insurance does not result in equal access to outpatient orthopedic care. A larger review of burdens placed on patients due to their insurance status is necessary to understand the full effect of the disconnect between possessing insurance and having access to care. References 1. Access of Medicaid recipients to outpatient care. N Engl J Med. 1994; 330(20):1426-1430. 2. Asplin BR, Rhodes KV, Levy H, et al. Insurance status and access to urgent ambulatory care follow-up appointments. JAMA. 2005; 294(10):1248-1254. 3. Blanchard J, Ogle K, Thomas O, Lung D, Asplin B, Lurie N. Access to appointments OCTOBER 2013 Volume 36 Number 10 e1275

based on insurance status in Washington, D.C. J Health Care Poor Underserved. 2008; 19(3):687-696. 4. Resneck J Jr, Pletcher MJ, Lozano N. Medicare, Medicaid, and access to dermatologists: the effect of patient insurance on appointment access and wait times. J Am Acad Dermatol. 2004; 50(1):85-92. 5. Wolinsky P, Kim S, Quackenbush M. Does insurance status affect continuity of care for ambulatory patients with operative fractures? J Bone Joint Surg Am. 2011; 93(7):680-685. 6. Bisgaier J, Rhodes KV. Auditing access to specialty care for children with public insurance. N Engl J Med. 2011; 364(24):2324-2333. 7. Number of persons enrolled in the medical program by county. SFY 2010. Illinois Department of Healthcare and Family Services Web site. http://www2.illinois.gov/hfs. Accessed April 1, 2011. 8. Calfee RP, Shah CM, Canham CD, Wong AH, Gelberman RH, Goldfarb CA. The influence of insurance status on access to and utilization of a tertiary hand surgery referral center. J Bone Joint Surg Am. 2012; 94(23):2177-2184. 9. Archdeacon MT, Simon PM, Wyrick JD. The influence of insurance status on the transfer of femoral fracture patients to a level-i trauma center. J Bone Joint Surg Am. 2007; 89(12):2625-2631. 10. Koval KJ, Tingey CW, Spratt KF. Are patients being transferred to level-i trauma centers for reasons other than medical necessity? J Bone Joint Surg Am. 2006; 88(10):2124-2132. 11. Decker SL. Medicaid payment levels to dentists and access to dental care among children and adolescents. JAMA. 2011; 306(2):187-193. 12. Weiner BK, Black KP, Gish J. Access to spine care for the poor and near poor. Spine J. 2009; 9(3):221-224. 13. Decker SL. Medicaid payment levels to dentists and access to dental care among children and adolescents. JAMA. 2011; 306(2):187-193. 14. Garber S, Ridgely MS, Bradley M, Chin KW. Payment under public and private insurance and access to cochlear implants. Arch Otolaryngol Head Neck Surg. 2002; 128(10):1145-1152. 15. Skaggs DL, Lehmann CL, Rice C, et al. Access to orthopaedic care for children with medicaid versus private insurance: results of a national survey. J Pediatr Orthop. 2006; 26(3):400-404. 16. Berman S, Dolins J, Tang SF, Yudkowsky B. Factors that influence the willingness of private primary care pediatricians to accept more Medicaid patients. Pediatrics. 2005; 110(2 pt 1):239-248. 17. Illinois Department of Healthcare and Family Services practitioner fee schedule. Illinois Department of Healthcare and Family Services Web site. http://www2.illinois.gov/hfs. Accessed April 1, 2011. 18. Cunningham PJ, O Malley AS. Do reimbursement delays discourage Medicaid participation by physicians? Health Aff (Millwood). 2009; 28(1):17-28. e1276