Date of Award

January 2021

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Kevin M. Schuster

Abstract

Introduction: Medicaid patients are known for having reduced access to care when compared to privately insured patients. Characterization and quantification of this disparity within general surgery remains limited, particularly in the context of rapid national changes over the last decade including the Affordable Care Act and rise of urgent care centers.

Aims: 1. To measure the effect of insurance type on access to inguinal hernia repair in the non-acute surgeon practice setting, under the Affordable Care Act. 2. To determine how insurance type affects access to emergency inguinal hernia care in the acute urgent care center setting, and to characterize how urgent care centers deliver care to patients based on insurance type.

Methods: In two separate studies, investigators used a secret shopper approach to pose as either a simulated Medicaid or privately insured patient seeking care at 1) surgeon practices for a non-acute inguinal hernia repair and 2) urgent care centers for an acute presentation of an incarcerated inguinal hernia. All practice settings were contacted using a standardized script on separate occasions. For the first study, insurance acceptance and appointment waiting times were recorded to determine access to care. For the second study, insurance acceptance was recorded to determine access to care, while triage and referral rates were measured to characterize delivery of surgical care. Descriptive analyses, chi-square tests, and multivariable regression were performed for both studies.

Results: In the first study, of 240 surgical practices contacted, 75.4% scheduled appointments for Medicaid patients, compared to 98.8% for Medicare patients and 98.3% for those with private insurance. In states that expanded Medicaid, fewer offices accepted Medicaid patients compared to those in nonexpanded states. No differences in wait times between expanded and nonexpanded states were observed. Surgeons in either solo practices or urban settings were less likely to accept Medicaid patients than those in either group practices or non-urban offices. In the second study, of 1,245 urgent care centers contacted, 98.2% of UCCs accepted private insurance and 78.8% accepted Medicaid. At the 78.0% UCCs that accepted both insurance types, direct-to-ED referral rates for private and Medicaid patients were 27.9% and 33.8%, respectively. Medicaid patients were significantly more likely than private patients to be referred to the ED (OR 1.32, 95% CI 1.09–1.60). Private patients who were triaged by a clinician compared to nonclinician staff were over 6 times more likely to be referred to the ED (OR 6.46, 95% CI 4.63–9.01). Medicaid patients were nearly 9 times more likely to have an ED referral when triaged by a clinician (OR 8.72, 95% CI 6.19–12.29).

Conclusion: Medicaid patients experienced significantly reduced access to care at surgeon practices and urgent care centers when seeking general surgical care. However, nuances in access to and delivery of care to Medicaid patients exist based on legislation and practice setting.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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