"I Broke My Ankle": Access to Orthopedic Follow-up Care by Insurance Status

While the Affordable Care Act seeks to reduce emergency department (ED) visits for outpatient-treatable conditions, it remains unclear whether Medicaid patients or the uninsured have adequate access to follow-up care. The goal of this study was to determine the availability of follow-up orthopedic care by insurance status.

Using simulated patient methodology, all 102 eligible general orthopedic practices in Dallas-Fort Worth, Texas, were contacted twice by a caller requesting follow-up for an ankle fracture diagnosed in a local ED using a standardized script that differed by insurance status. Practices were randomly assigned to paired private and uninsured or Medicaid and uninsured scenarios.

We completed 204 calls: 59 private, 43 Medicaid, and 102 uninsured. Appointment success rate was 83.1% for privately insured (95% confidence interval [CI] = 73.2% to 92.9%), 81.4% for uninsured (95% CI = 73.7% to 89.1%), and 14.0% for Medicaid callers (95% CI = 3.2% to 24.7%). Controlling for paired calls to the same practice, an uninsured caller had 5.7 times higher odds (95% CI = 2.74 to 11.71) of receiving an appointment than a Medicaid caller (p < 0.001), but the same odds as a privately insured caller (odds ratio = 1.0, 95% CI = 0.19 to 5.37, p = 1.0). Uninsured patients had to bring a median of $350 (interquartile range = $250 to $400) to their appointment to be seen, and only two uninsured patients were able to obtain an appointment for $100 or less up front. In comparison, typical total payments collected for privately insured patients were $236 and for Medicaid patients $128. When asked where else they could go, 49 (48%) uninsured callers and one Medicaid caller (2%) were directed to local public hospital EDs as alternative sources of care. Of the practices that appeared on Medicaid's published list of orthopedic providers accepting new patients, 15 told callers that they did not accept Medicaid, 11 did not treat ankles, nine listed nonworking phone numbers, and only three actually scheduled an appointment for the Medicaid caller.

Less than one in seven Medicaid patients could obtain orthopedic follow-up after an ED visit for a fracture, and prices quoted to the uninsured were 30% higher than typical negotiated rates paid by the privately insured. High up-front costs for uninsured patients and low appointment availability for Medicaid patients may leave these patients with no other option than the ED for necessary care.