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      Medicaid Patients Have Greater Difficulty Scheduling Health Care Appointments Compared With Private Insurance Patients: A Meta-Analysis

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          Abstract

          Medicaid patients are known to have reduced access to care compared with privately insured patients; however, quantifying this disparity with large controlled studies remains a challenge. This meta-analysis evaluates the disparity in health services accessibility of appointments between Medicaid and privately insured patients through audit studies of health care appointments and schedules. Audit studies evaluating different types of outpatient physician practices were selected. Studies were categorized based on the characteristics of the simulated patient scenario. The relative risk of appointment availability was calculated for all different types of audit scenario characteristics. As a secondary analysis, appointment availability was compared pre- versus post-Medicaid expansion. Overall, 34 audit studies were identified, which demonstrated that Medicaid insurance is associated with a 1.6-fold lower likelihood in successfully scheduling a primary care appointment and a 3.3-fold lower likelihood in successfully scheduling a specialty appointment when compared with private insurance. In this first meta-analysis comparing appointment availability between Medicaid and privately insured patients, we demonstrate Medicaid patients have greater difficulty obtaining appointments compared with privately insured patients across a variety of medical scenarios.

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          Systematic reviews in health care: Investigating and dealing with publication and other biases in meta-analysis.

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            Auditing access to specialty care for children with public insurance.

            Health care reform has expanded eligibility to public insurance without fully addressing concerns about access. We measured children's access to outpatient specialty care to identify disparities in providers' acceptance of Medicaid and the Children's Health Insurance Program (CHIP) versus private insurance. Between January and May 2010, research assistants called a stratified, random sample of clinics representing eight specialties in Cook County, Illinois, which has a high proportion of specialists. Callers posed as mothers of pediatric patients with common health conditions requiring outpatient specialty care. Two calls, separated by 1 month, were placed to each clinic by the same person with the use of a standardized clinical script that differed by insurance status. We completed 546 paired calls to 273 specialty clinics and found significant disparities in provider acceptance of Medicaid-CHIP versus private insurance across all tested specialties. Overall, 66% of Medicaid-CHIP callers (179 of 273) were denied an appointment as compared with 11% of privately insured callers (29 of 273) (relative risk, 6.2; 95% confidence interval [CI], 4.3 to 8.8; P<0.001). Among 89 clinics that accepted both insurance types, the average wait time for Medicaid-CHIP enrollees was 22 days longer than that for privately insured children (95% CI, 6.8 to 37.5; P=0.005). We found a disparity in access to outpatient specialty care between children with public insurance and those with private insurance. Policy interventions that encourage providers to accept patients with public insurance are needed to improve access to care.
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              Insurance status and access to urgent ambulatory care follow-up appointments.

              There is growing pressure to avoid hospitalizing emergency department patients who can be treated safely as outpatients, but this strategy depends on timely access to follow-up care. To determine the association between reported insurance status and access to follow-up appointments for serious conditions that are commonly identified during an emergency department visit. Eight research assistants called 499 randomly selected ambulatory clinics in 9 US cities (May 2002-February 2003) and identified themselves as new patients who had been seen in an emergency department and needed an urgent follow-up appointment (within 1 week) for 1 of 3 clinical vignettes (pneumonia, hypertension, or possible ectopic pregnancy). The same person called each clinic twice using the same clinical vignette but different insurance status. Proportion of callers who were offered an appointment within a week. Of 499 clinics contacted in the final sample, 430 completed the study protocol. Four hundred six (47.2%) of 860 total callers and 277 (64.4%) of 430 privately insured callers were offered appointments within a week. Callers who claimed to have private insurance were more likely to receive appointments than those who claimed to have Medicaid coverage (63.6% [147/231] vs 34.2% [79/231]; difference, 29.4 percentage points; 95% confidence interval, 21.2-37.6; P<.001). Callers reporting private insurance coverage had higher appointment rates than callers who reported that they were uninsured but offered to pay 20 dollars and arrange payment of the balance (65.3% [130/199] vs 25.1% [50/199]; difference, 40.2; 95% confidence interval, 31.4-49.1; P<.001). There were no differences in appointment rates between callers who claimed to have private insurance coverage and those who reportedly were uninsured but willing to pay cash for the entire visit fee (66.3% [132/199] vs 62.8% [125/199]; difference, 3.5; 95% confidence interval -3.7 to 10.8; P = .31). The median charge was 100 dollars (range, 25 dollars-600 dollars). Seventy-two percent of clinics did not attempt to determine the severity of the caller's condition. Reported insurance status is associated with access to timely follow-up ambulatory care for potentially serious conditions. Having private insurance and being willing to pay cash may not eliminate the difficulty in obtaining urgent follow-up appointments.
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                Author and article information

                Journal
                Inquiry
                Inquiry
                INQ
                spinq
                Inquiry: A Journal of Medical Care Organization, Provision and Financing
                SAGE Publications (Sage CA: Los Angeles, CA )
                0046-9580
                1945-7243
                05 April 2019
                Jan-Dec 2019
                : 56
                : 0046958019838118
                Affiliations
                [1 ]Yale School of Medicine, New Haven, CT, USA
                [2 ]University Hospitals Cleveland Medical Center, OH, USA
                [3 ]Yale School of Public Health, New Haven, CT, USA
                Author notes
                [*]Walter R. Hsiang, Department of Orthopaedics & Rehabilitation, Yale School of Medicine, 800 Howard Avenue, New Haven, CT 06519, USA. Email: walter.hsiang@ 123456yale.edu
                Author information
                https://orcid.org/0000-0002-4718-6231
                https://orcid.org/0000-0002-3542-8803
                Article
                10.1177_0046958019838118
                10.1177/0046958019838118
                6452575
                30947608
                10128172-81ae-483a-95fa-9de0b48a945b
                © The Author(s) 2019

                This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

                History
                : 10 July 2018
                : 1 February 2019
                : 21 February 2019
                Categories
                Original Research
                Custom metadata
                January-December 2019

                appointments and schedules,health services accessibility,medicaid,insurance,patient protection and affordable care act,healthcare disparities,primary health care,meta-analysis

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