Article
Access to Orthopedic Care post Medicaid Expansion Through the Affordable Care Act

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Abstract

Background

As of January 2017, 32 states have decided to expand Medicaid through the Patient Protection and Affordable Care Act. The uninsured rate in the United States has decreased, but does the increased coverage translate to increased access to outpatient orthopedic care? Through a simulated patient telephone survey, this study aims to evaluate access to orthopedic surgeons for Medicaid patients in Louisiana.

Methods

A comprehensive list of potentially eligible orthopedic surgeons in the state of Louisiana was obtained from an online public database managed by the Louisiana Medicaid website (lamedicaid.com). This list represented all orthopedic surgeons that received a Medicaid payment within the six months prior to February 1st, 2017 (August 1st, 2016–January 31st, 2017). Using an internet search, we found that 309 orthopedic surgeons listed met the inclusion criteria and were practicing in 93 different clinical practices. Because several orthopedists practiced in the same group practice, and some practiced in multiple practices, we sampled unique clinical practices as opposed to individual providers. One telephone call was made to each practice in an attempt to secure an appointment for a simulated Medicaid patient. The average number of orthopedic surgeons per practice was 3.4, with the majority of practices (60%) being private practices with only one surgeon.

Results

Of the 93 practices in the study, only 17 (18.3%) offered an appointment. The 17 practices represented 41 orthopedic surgeons (13.3%) that were willing to accept new Medicaid patients. That number decreased to 22 (7.1%) if you remove the orthopedic surgeons practicing at safety-net facilities.

Conclusion

The results suggest that although Medicaid expansion has decreased the uninsured rate, access to outpatient orthopedic care for Medicaid patients in Louisiana is still significantly limited.

Introduction

The Patient Protection and Affordable Care Act, also known as the Affordable Care Act (ACA) or Obamacare, is a United States federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. It allowed expansion by individual states of Medicaid eligibility to individuals with incomes up to 138% of the federal poverty level. As of January 1, 2017, 32 states including the District of Columbia had adopted Medicaid expansion and 19 had not. While the ACA has increased coverage, it may not have increased access to specialty outpatient health services.

In California, a study evaluated access to pediatric orthopedic care by contacting 50 orthopedic offices. All 50 offered an appointment to see a child with private insurance within 7 days, whereas, only one offered an appointment to see a child with Medi-Cal (the Medicaid equivalent in California).1

Another study evaluated access to foot and ankle surgeons for total ankle arthroplasty across 8 states, 4 of which had adopted Medicaid expansion and 4 that did not. It showed patients with Medicaid were less likely to receive an appointment compared to patients with Medicare or BlueCross and experienced more requests for referrals and had longer waiting periods.2

Another study evaluated access to orthopedic care for an ankle fracture across 4 Mid-Atlantic States that had all adopted Medicaid expansion.3 It showed that orthopedic offices were less likely to accept Medicaid than commercial insurance, and patients with Medicaid were less likely to be offered an appointment within 2 weeks.

In July 2016, Louisiana became the 31st state to expand its Medicaid program. This expansion has increased the number of Medicaid enrollees in Louisiana by over 400,000 pushing its Medicaid population from approximately 20%-30% of Louisiana residents, one of the highest Medicaid populations per capita in the country.4, 5 The current literature suggests that even with increased coverage, access remains difficult for Medicaid enrollees compared to the privately insured and uninsured across geographic and diverse health marketplaces. The purpose of this study is to evaluate the access to orthopedic surgeons for Medicaid patients in Louisiana. We hypothesize that, despite the Medicaid expansion in Louisiana, a hypothetical patient with Medicaid would have significantly limited access to orthopedic care and experience delays in treatment.

Section snippets

Methods

A comprehensive list of potentially eligible orthopedic surgeons in the state of Louisiana was obtained from an online public database managed by the Louisiana Medicaid website (lamedicaid.com). The list was comprised of all orthopedists in the state of Louisiana that received a Medicaid payment within the six months prior to February 1st, 2017 (August 1st, 2016-February 1st, 2017). The list contained 330 single surgeon entries. Twenty-one surgeons from the list were excluded because the

Results

The number of orthopedic surgeons per practice ranged from one to thirty-one with an average of 3.4 surgeons per practice; 60% of the practices in the study were private practices with only one surgeon. Twenty-six of all 64 parishes in the state had an orthopedic surgeon that received a Medicaid payment within the study timeframe (Figure 1). Only 11 of those 26 parishes had practices that offered an appointment when contacted. Of the 93 practices included in the study, 17 (18.3%) offered an

Discussion

Prior data in other states suggests that Medicaid patients seeking orthopedic care in an outpatient setting face greater difficulty securing an appointment for follow up care compared to the privately insured.1, 2, 3, 6, 7, 8, 9, 10, 11, 12, 13 A large reason the ACA was signed into law was to expand coverage to previously uninsured groups to improve access to health care. However, the current data on whether the expansion accomplished the goal is limited to certain states. In this study, we

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Declarations of interest: none.

Financial disclosure: The authors have no financial or proprietary interest in the subject matter of this article.

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