Medicaid Patients With Common “Buckle” Fractures Have Less Access to Primary Care Physicians

Limits in access to specialty orthopedic care exist for children with Medicaid, in a large part due to many practices not accepting government insurance. Although many orthopedic injuries can be safely and appropriately managed outside of the orthopedic office, a recent study in Current Orthopedic Practice found that less than half of the study’s 250 contacted pediatric primary care offices nationwide accepted Medicaid “buckle” fracture patients, and those that did were significantly less likely to schedule Medicaid patients for care of a simple fracture within 7 days compared to patients with private insurance.

“First, we wanted to study the level of comfort pediatricians had in managing a straightforward, minor orthopedic injury,” says Christopher Iobst, MD, pediatric orthopedic surgeon and director of the Center for Limb Lengthening and Reconstruction at Nationwide Children’s Hospital, who led the research during his time at Nemours Children’s Hospital in Florida. He is senior author on the recent national study and a similar Florida-specific paper published in June in Journal of Pediatric Orthopedics. “We also wanted to find out whether the disparity that exists in access to specialty orthopedic care among kids with private insurance and Medicaid extends into the world of primary care as well.”

The research team created a fictitious pediatric patient case with a simple distal radius fracture — commonly called a “buckle” fracture — and called five randomly selected pediatric care offices in each state. Each office received two calls several weeks apart, one with the sample patient covered by Medicaid and one with the patient covered by private insurance.

Buckle fractures were selected due to simplicity of the diagnosis and treatment. Julie Balch Samora, MD, PhD, hand and upper extremity surgeon and director of quality improvement in the Department of Orthopaedics at Nationwide Children’s, helped develop and disseminate a rule for simple, definitive diagnosis of this type of fracture, as well as early research demonstrating the cost-effectiveness of switching from the fracture’s prior standard of care (short- or long-term casting applied by an orthopedic specialist) to the newer practice (removable splints), which can now be done in primary care offices across the country.

“We found that pediatricians did feel very comfortable taking care of these patients on their own, without sending them to an orthopedic surgeon,” says Dr. Iobst. “They had no problem managing these patients. However, it appears that the insurance status influences the willingness to schedule these patients.”

Of the 250 contacted offices in the national study, 88% were willing to accept the new patient with private insurance, and more than 95% of those offices offered an appointment to treat the fracture within 7 days. In contrast, less than half of the offices contacted (45%) were willing to accept a new patient with Medicaid; of those that were, 84% scheduled patients within 7 days. The differences in both patient acceptance and scheduling were statistically significant.

“We established that children with Medicaid have more difficulties gaining access to care even among primary care providers,” says Dr. Iobst. “And it’s not restricted to just one geographic area. The data indicate it is a national issue.”

One of the chief reasons for these pediatric care access disparities in buckle fracture treatment is likely to be poor Medicaid reimbursement rates. In orthopedic offices, Dr. Iobst suggests reasons for care refusal likely also include the desire to avoid filling up appointment slots with uncomplicated cases that can more appropriately and affordably be treated in a general practitioner’s office.

“There are multiple studies on access to care for other orthopedic problems, such as ACL tears, braces for scoliosis, and more — all confirming the same thing: If you don’t have good insurance, you don’t have the same access to care,” says Dr. Iobst, who suspects many of these patients may end up in urgent care or emergency departments when they can’t find care elsewhere.

But the findings are not to be interpreted as an indictment of physicians.

“Certainly within the world of orthopedics, Medicaid is a losing proposition financially. For each Medicaid patient you see, you are losing money due to unreimbursed time, supplies and resources used in caring for the patient,” explains Dr. Iobst. “It’s a big problem, with no easy answer.”

Although increasing reimbursement rates to better cover clinicians’ time sounds straightforward enough, budget restrictions make such a simple solution unlikely.

“When every minute spent caring for one type of patient is a financial loss, you’re left weighing the moral benefits of what’s best for the child versus what keeps the bottom line afloat so that you can continue to help other children,” says Dr. Iobst. “The kids are getting caught in this health care system. They’re the ones that are losing.”

Citations:

1. Marchenko M, Iobst C. National access to pediatric care based on insurance type for children with buckle fractures. Current Orthopaedic Practice. 2019;30(2):133-135.
2. Potak H, Iobst CA. Influence of insurance type on the access to pediatric care for children with distal radius torus fractures. Journal of Pediatric Orthopaedics. 2019 May/Jun;39(5):237-240.