Original Research

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

Publish date: September 13, 2018

References

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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.

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-value^a		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-value^a		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-value^a		0.0001	0.0001

^aComparison to Medicaid.

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).

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)

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).

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-value^a		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-value^a		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-value^a		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)

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.

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

State	Medicaid reimbursement
California^a	$785.55
Texas	$678.95
Florida	$469.44
Ohio^a	$617.08
New York^a	$500.02
North Carolina	$621.63
Massachusetts^a	$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.

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.

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

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