UW Shoulder and Elbow Academy: Does Medicaid enable access to shoulder care that is comparable to private insurance??

Access to outpatient care for adult rotator cuff patients with private insurance versus Medicaid in North Carolina

The authors took the 'phantom shopper' approach to assessing access to care for a rotator cuff tear in North Carolina. 71 orthopaedic surgery practices were contacted on 2 different occasions separated by 3 weeks. In the first contact, the practices were presented with an appointment request for a fictitious 42-year-old man with an acute rotator cuff tear with Medicaid insurance. In the second contact, the practices were presented with an appointment request for a fictitious 42-year-old man with an acute rotator cuff tear with private insurance. This relatively young hypothetical patient with a traumatic injury would seem to meet surgical criteria for most orthopaedic shoulder surgeons.

The results were that 51 (72%) offered the patient with Medicaid an appointment, whereas 68 (96%) offered the patient with private insurance an appointment (P < .001). The likelihood of patients with private insurance obtaining an appointment was 8.8 times higher than that of patients with Medicaid.

The reasons for declining to schedule an appointment in 20 Medicaid-insured calls were (1) the practice does not accept Medicaid (38%), (2) a physician referral would be needed (33%), the medical records from the emergency department would need to be reviewed first (29%). The reasons for declining to schedule an appointment in 2 private-insured calls were the needed to review the patient’s records from the emergency department before making an appointment.

The authors went on to evaluate the difference between Medicaid and private insurance reimbursement rates in their environment for arthroscopic rotator cuff repair CPT code 29287 in 2011 for patients with (1) Medicaid and (2) private insurance. On average, the reimbursement was $827 for Medicaid and $2125 (over 2.5 times higher) for private insurance. Another way of looking at this is that the surgeon would need to operate on 5 Medicaid patients to generate the same gross revenue as operating on 2 patients with private insurance.

The significance of this result is that with the implementation of the Affordable Care Act, the number of individuals in the U.S. covered by Medicaid may increase by over 15,000,000. In this event the practices accepting Medicaid are likely to be overwhelmed by the volume of individuals not accepted by practices rejecting Medicaid recipients. This may well tempt private practices to implement additional strategies to limit access to these relatively less well insured patients. Academic institutions generally do not restrict access by payer and may become the recipients of a disproportionate share of Medicaid-funded patients, a phenomenon that will pose an additional challenge to their sustainability.

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