The Journal of Arthroplasty xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act Chang-Yeon Kim, B.S., M.S., Daniel H. Wiznia, M.D., Walter R. Hsiang, B.S., Richard R. Pelker, M.D., Ph.D. Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
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Article history: Received 31 December 2014 Accepted 15 March 2015 Available online xxxx Keywords: total knee arthroplasty knee revision patient Protection and Affordable Care Act medicaid health care access
a b s t r a c t This study evaluated access to knee arthroplasty and revision in 8 geographically representative states. Patients with Medicaid were significantly less likely to receive an appointment compared to patients with Medicare or BlueCross. However, patients with Medicaid had increased success at making an appointment in states with expanded Medicaid eligibility (37.7% vs 22.8%, P = 0.011 for replacement, 42.6% vs 26.9%, P = 0.091 for revision), although they experienced longer waiting periods (31.5 days vs 21.1 days, P = 0.054 for replacement, 45.5 days vs 22.5 days, P = 0.06 for revision). Higher Medicaid reimbursement also had a direct correlation with appointment success rate for Medicaid patients (OR = 1.232, P = 0.001 for replacement, OR = 1.314, P = 0.014 for revision). © 2015 Elsevier Inc. All rights reserved.
The Patient Protection Affordable Care Act (PPACA) has significantly expanded the eligibility for Medicaid. Previously, only individuals with low incomes (61% of federal poverty level in most states) who fell into certain categories (children, parents, pregnant women, people with disabilities, and those N65 years of age) were eligible [1]. With the passage of the PPACA, anyone with incomes up to 138% of the poverty level is qualified for Medicaid [2]. The legislation represents the largest expansion of government sponsored health insurance since the inception of the Medicaid program in 1965 [2]. A Supreme Court ruling in 2012 decided that expanding the eligibility for Medicaid was optional, and currently 28 states and the District of Columbia have decided to do so. This has created a dichotomy between states that have expanded coverage for Medicaid patients to 138% of the poverty level and states that adhere to previous guidelines, with no expanded coverage. However, all states are projected to eventually expand coverage due to financial incentives [2]. Six months after the passage of the law, 6 million new people had enrolled in Medicaid or CHIP (Children’s Health Insurance Program) [1]. At full implementation (all states participating), the PPACA is projected to lower the uninsured rate by almost 50%, reducing the number of uninsured by over 23 million [3]. Increased coverage, however, does not necessarily equate to more access to care [4]. The expansion of Medicaid is occurring at a time when the number of health care practitioners willing to accept Medicaid
is decreasing [5]. The low reimbursement rate from Medicaid has been cited as the primary reason for this trend [5–7]. While there have been provisions in the PPACA to improve Medicaid payments for primary care physicians, there are currently no such provisions for specialists, including orthopedic surgeons, to create an incentive to improve patient access to care [7]. Previous studies have shown that patients with Medicaid have difficulty accessing orthopedic surgeons for a wide range of issues [8–12]. Therefore, Medicaid patients may encounter particular difficulty with elective orthopedic procedures such as total joint arthroplasty and revision [5,12]. The rising age of the population and the decrease in fellowshiptrained arthroplasty surgeons will likely exacerbate the issue of access to total joint arthroplasty by creating a supply–demand imbalance [13]. In addition, the projected retirement of many high-volume joint arthroplasty surgeons will put additional pressures on patient access to revision surgery in the future because physicians without specialized training in this area are hesitant to perform these procedures [13]. Our study focuses on the effect of the different types of insurance (Medicaid, Medicare, or BlueCross) on the ability of patients to obtain care for joint reconstruction and revision. The purpose of this study is to determine whether, in the setting of the Patient Protection Affordable Care Act, orthopedic surgeons are more likely to accept patients with Medicaid. We hypothesize that despite the passage of the PPACA, Medicaid patients will have increased difficulty obtaining access compared to patients with other types of insurance.
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.03.015. Supplementary material available at www.arthroplastyjournal.org. Reprint requests: Richard R. Pelker, M.D., Ph.D., Yale Physicians Group, 800 Howard Avenue, 1st Floor, New Haven, CT 06510.
Materials and Methods The study population included board-certified orthopedic surgeons who belonged to the American Association of Hip and Knee Surgeons from 8 representative states: California, Massachusetts, Ohio, New
http://dx.doi.org/10.1016/j.arth.2015.03.015 0883-5403/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Kim C-Y, et al, The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.03.015
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C-Y. Kim et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
York, Florida, Pennsylvania, Texas, and North Carolina. These states were selected because they represent diverse geographic areas and health marketplaces. Alphabetized lists of orthopedic surgeons from these states were generated and each surgeon was paired with a number. The numbers were then randomized and called. If a number was disconnected or inaccurate, it was excluded from the calling list and the next number was selected. Each office was called to make an appointment for the caller’s fictitious 65-year old mother, using two scenarios. The caller had a standardized protocol to limit intra and inter-office variation (see Appendix). The first scenario was a request to be evaluated for a total knee arthroplasty, with the patient having Medicaid, Medicare, or BlueCross. The second scenario was a request to be evaluated for a knee revision surgery, again with the patient having Medicaid, Medicare, or BlueCross. The two scenarios each required three separate calls, for each insurance type. Every surgeon we called was specifically asked if he or she would accept the patient for a knee arthroplasty or revision. We recorded the following data from each attempt at making an appointment: date of phone call and date of appointment if given. If the office did not give an appointment, we asked for reasons why. If a denial occurred for a patient with Medicaid, we asked for a referral to another office that accepted Medicaid. We considered barriers to obtaining an initial appointment, such as requiring a referral from a PCP (primary care physician), as an unsuccessful attempt at making an appointment. The waiting period for an appointment was obtained by calculating the time between the date of call and the date of the appointment. For both appointment success rates and waiting periods, the data were stratified into two groups: states with expanded Medicaid eligibility (California, Massachusetts, New York, Ohio) and states without expanded Medicaid eligibility (Florida, North Carolina, Pennsylvania, Texas). At the time of our investigation, Pennsylvania had not expanded eligibility for Medicaid. Concurrent with the telephone survey, we also sent an electronic fax to the orthopedic offices generated from randomization. The fax asked whether the respondent was an orthopedic surgeon, secretary, or receptionist. It then asked whether the respondent would accept a patient with Medicaid, Medicare, BlueCross, or self-paid insurance. The Medicaid reimbursement rates for total knee arthroplasty and knee revision were obtained by querying each state’s reimbursement rate using Current Procedural Terminology (CPT) code 27447 (primary total knee arthroplasty) and 27847 (revision for total knee arthroplasty). Statistical analysis was performed using SPSS version 21 (SPSS, Inc, Chicago, IL). Chi-square test or Fisher’s exact test was used to analyze differences in acceptance rate based on type of insurance. To compare the time period to an appointment, a Wilcoxon rank test and Kruskal– Wallis tests were used, as the data were not normally distributed. Multiple regression analysis was performed to detect whether Medicaid reimbursement was a significant predictor for successfully making an appointment for patients with Medicaid. Unless otherwise stated, all statistical testing was performed two-tailed at an alpha-level of 0.05. The study was submitted to and approved by the Yale University Institutional Review Board office, HIC# 13637. Results Our query across the 8 selected states resulted in a randomly generated list of 250 offices (4 states with and 4 states without expanded Medicaid eligibility) to call for scenario 1 (knee arthroplasty) and 106 offices (2 states with and 2 states without expanded Medicaid eligibility) to call for scenario 2 (knee revision). For our first scenario (evaluation for a primary total knee arthroplasty), the rate across all states for successfully obtaining an appointment was 30.1% for Medicaid patients, 96% for Medicare patients, and 100% for patients with BlueCross (Table 1A). In states with expanded Medicaid eligibility, the success rate was 37.7% for Medicaid patients, 96.7% for Medicare patients, and 100% for patients with BlueCross. In states without expanded Medicaid eligibility, the success rate was
Table 1 Appointment Success Rate.
A. Knee arthroplasty All states Yes (%) No (%) P value States w/ expanded Medicaid eligibility Yes (%) No (%) P value States w/o expanded Medicaid eligibility Yes (%) No (%) P value B. Knee revision All states Yes (%) No (%) P value States w/ expanded Medicaid eligibility Yes (%) No (%) P value States w/o expanded Medicaid eligibility Yes (%) No (%) P value
Medicaid
Medicare
Private
75 (30.1) 174 (69.9)
240 (96) 10 (4) b0.0001
248 (100) 0 b0.0001
46 (37.7) 76 (62.3)
119 (96.7) 4 (3.3) b0.0001
122 (100) 0 b0.0001
29 (22.8) 98 (77.2)
121 (95.3) 6 (4.7) b0.0001
126 (100) 0 b0.0001
37 (34.9) 69 (65.1)
99 (93.4) 7 (6.6) b0.0001
103 (100) 0 b0.0001
23 (42.6) 31 (57.4)
52 (96.3) 2 (3.7) b0.0001
51 (100) 0 b0.0001
14 (26.9) 38 (73.1)
47 (90.4) 5 (9.6) b0.0001
52 (100) 0 b0.0001
⁎ P value in comparison to Medicaid.
22.8% for Medicaid patients, 95.3% for Medicare patients, and 100% for patients with BlueCross. The success rate was significantly lower for Medicaid compared to either Medicare (P b 0.0001) or BlueCross (P b 0.0001). However, patients with Medicaid were significantly more likely to obtain an appointment in states with expanded Medicaid eligibility (37.7% vs 22.8%, P = 0.011). For our second scenario (evaluation for a total knee revision), the rate across all states for successfully obtaining an appointment was 34.9% for Medicaid patients, 93.4% for Medicare patients, and 100% for patients with BlueCross (Table 1B). In states with expanded Medicaid eligibility, the success rate was 42.6% for Medicaid, 96.3% for Medicare, and 100% for BlueCross. In states without expanded Medicaid eligibility, the success rate was 26.9% for Medicaid, 90.4% for Medicare, and 100% for BlueCross. Statistical results were similar to those for a total knee arthroplasty. The success rate for Medicaid was significantly lower when compared to Medicare (P b 0.0001) and BlueCross (P b 0.0001). Patients with Medicaid were more likely to obtain an appointment in states with expanded Medicaid eligibility (42.6% vs 26.9%, P = 0.091). Barriers to an appointment differed according to insurance type. For a knee arthroplasty, not having a referral from a PCP (primary care physician) was a barrier to an appointment for patients with Medicaid in 13.8% of offices called. In contrast, lack of a PCP referral was not an obstacle for any patient with Medicare or BlueCross. For a knee revision, not having records from the previous surgery was a barrier to an appointment for patients with Medicaid in 18.8% of offices called. However, the majority of patients with Medicare and BlueCross were able to schedule an appointment even when the office required previous records. For Medicaid patients who did not get an initial appointment, 32% of offices referred the caller to another office that took Medicaid for knee arthroplasty and 26% of offices did so for knee revision. The majority of offices either could not refer the caller to an office that took Medicaid or instructed to contact the number on the patient’s Medicaid card for a list of state-generated offices that may accept Medicaid. Patients who successfully made an appointment experienced different waiting periods based on expansion of Medicaid eligibility. In states with expanded Medicaid eligibility, patients experienced significantly longer waiting periods (Table 2A) for both knee arthroplasty (27.2 days vs 22.9 days, P = 0.001) and knee revision (41.8 days vs
Please cite this article as: Kim C-Y, et al, The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.03.015
C-Y. Kim et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx Table 2 Waiting Period Until Appointment.
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Table 3 Electronic Fax Responses. Knee Arthroplasty
Knee Revision
A. Waiting period (days) organized by procedure type States w/ expanded Medicaid eligibility 27.2 ± 1.4 (n = 278) States w/o expanded Medicaid eligibility 22.9 ± 1.4 (n = 276) P value 0.004 Medicaid
Medicare
41.8 ± 4.0 (n = 126) 18.6 ± 1.7 (n = 113) b0.0001 Private
B. Knee arthroplasty. Waiting period (days) organized by insurance type States w/ expanded Medicaid eligibility 31.5 ± 3.8 26.7 ± 2.2 26.2 ± 2.1 (n = 44) (n = 115) (n = 119) States w/o expanded Medicaid eligibility 21.1 ± 3.4 23.2 ± 2.2 23.1 ± 2.1 (n = 29) (n = 121) (n = 126) P value 0.054 0.081 0.138 C. Knee revision. Waiting period (days) organized by insurance type States w/ expanded Medicaid eligibility 45.5 ± 11.2 39.6 ± 5.8 42.3 ± 6.3 (n = 23) (n = 52) (n = 51) States w/o expanded Medicaid eligibility 22.5 ± 5.7 18.0 ± 2.6 18.0 ± 2.5 (n = 14) (n = 47) (n = 52) P value 0.06 b0.0001 b0.0001
18.6 days, P b 0.0001). The waiting periods were then stratified by insurance type (Table 2B, C). Regardless of insurance type, patients experienced longer waiting periods in states with expanded Medicaid eligibility. For knee arthroplasty, the waiting periods were 31.5 days vs 21.1 days (P = 0.054) for patients with Medicaid, 26.7 days vs 23.2 days (P = 0.081) for patient with Medicare, and 26.2 days vs 23.1 days (P = 0.138) for patients with BlueCross. For knee revision, the waiting periods were 45.5 days vs 22.5 days (P = 0.06) for patients with Medicaid, 39.6 days vs 18.0 days (P b 0.0001) for patient with Medicare, and 42.3 days vs 18.0 days (P b 0.0001) for patients with BlueCross. Results from our electronic fax survey confirmed the trends from the telephone study (Table 3). Patients with Medicaid had a low acceptance rate (57.1%) compared to patients with Medicare (96.9%), patients with BlueCross (93.8%), and patients with self-paid insurance (93.7%). However, the fax response rate was low, with responses from 65 out of 800 faxed offices. Medicaid reimbursements for total knee arthroplasty and revision varied across states (Table 4). Massachusetts paid the highest reimbursements for both procedures, with $1492.58 for a total knee arthroplasty and $1483.24 for knee revision. Florida paid the lowest, with $817.16 for total knee arthroplasty and $933.72 for a knee revision. Multiple regression analysis showed that for patients with Medicaid, an increase in reimbursements was a positive predictor for successfully obtaining an appointment to be evaluated for both primary (P = 0.001, OR = 1.232 for every $100 increase) and revision procedures (P = 0.014, OR = 1.314 for every $100 increase). Discussion In this study, we assessed patient access to total knee arthroplasty and revision for three different types of insurance (Medicaid, Medicare, and BlueCross) in 8 geographically representative states. To our knowledge, our work is the first to evaluate patient access for both knee arthroplasty and revision across multiple states, whereas other reports focus on access in a single state or county. Given the recent expansion of Medicaid eligibility by the PPACA, a national evaluation of the policy’s effect on insurance coverage and access to care is timely. We chose to focus the study on total knee arthroplasty because it is a common elective procedure, has a proven efficacy, and is projected to become increasingly more common in the next decade [14–17]. We hypothesized that despite the passage of the PPACA, patients with Medicaid requesting a total knee arthroplasty and revision would have relatively limited access to care.
Yes (%) No (%)
Medicaid
Medicare
BlueCross
Self-Pay
P Value
36 (57.1) 27 (42.9)
62 (96.9) 2 (3.1)
60 (93.8) 4 (6.2)
93.7 (63) 4 (6.3)
b0.0001
Our telephone survey of representative orthopedic offices across the nation demonstrated that among the three different insurance types, Medicaid patients continue to have the lowest rate of appointment success. This was true for both total knee arthroplasty and total knee revision, which was consistent with results from previous literature [5,7,18]. This outcome was further confirmed by similar results from our electronic fax survey, which included direct responses from the actual surgeon. Importantly, the patients with Medicaid were more likely to receive an appointment in states with expanded Medicaid eligibility than in states without expanded eligibility (37.7% vs 22.8%, P = 0.011 for knee arthroplasty, and 42.6% vs 26.9%, P = 0.091 for knee revision). Our analysis demonstrates that although the acceptance rate for patients with Medicaid continues to be low for joint arthroplasty, orthopedists in PPACAcompliant states may be more willing to accept Medicaid patients A common reason for denying an evaluation for knee arthroplasty to patients with Medicaid was the lack of a PCP referral. In contrast, no patient with Medicare or BlueCross was denied an appointment due to lack of a PCP referral. Similarly, not having records of the previous surgery was a barrier to obtaining an appointment for a knee revision. However, patients with Medicare or BlueCross were able to obtain appointments even when the office required previous surgical records. Four states included in our study (Massachusetts, North Carolina, Texas, and New York) required a PCP referral to see a specialist. However, a number of orthopedic practices in these states accepted Medicaid patients without a PCP referral, suggesting that the decision depended on individual policy. In addition, most orthopedic offices in these states cited that they simply do not accept Medicaid as an insurance policy, not that they required a referral, which is consistent with results from previous studies [6,7,19]. The results for Medicaid also stand in contrast with those for Medicare, which may also require a PCP referral depending on the type of Medicare. The fact that no patient with Medicare was inquired about a PCP referral suggests that Medicaid patients face unique hurdles when obtaining care. Previous studies have mentioned the difficulty of working with Medicaid patients as a secondary reason for the unpopularity of Medicaid among orthopedic surgeons [5]. Orthopedic surgeons have stated that Medicaid patients come from more socioeconomically disadvantaged backgrounds, are non-compliant with medical instructions, and pose increased regulatory hurdles for processing reimbursements. It is possible that orthopedic offices may consider patients with referrals from primary care physicians as more manageable than those without referrals. A patient also needs to be proactive in order to acquire a referral, which may be another indication that the patient will be compliant with treatment instructions.
Table 4 Medicaid Reimbursements for Total Knee Arthroplasty and Revision in 2014. State a
CA FL MAa NC NYa OHa PA TX a
Total Knee Arthroplasty (CPT 27447)
Knee Revision (CPT 27487)
$1489.20 $817.16 $1492.58 $1148.49 $890 $1228.01 $1000 $1092.38
$1428.52 $933.72 $1483.24 $1322.92 $1023.84 $1441.87 $870.50 $1350.42
States with expanded Medicaid eligibility.
Please cite this article as: Kim C-Y, et al, The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.03.015
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Although no office stated that the reason for denying patient with Medicaid was due to lower Medicaid reimbursements, our regression data showed that a $100 increase in reimbursements predicted a 23.2% increase in the odds of being accepted for an appointment to be evaluated for a total knee arthroplasty, and a 31.4% increase in the odds of being accepted for an appointment to be evaluated for a total knee revision. These results are consistent with Perloff et al, who found a positive correlation between appointment success and the reimbursement for office visits [19]. Our results show a similar relationship, but between appointment success and the reimbursement for the actual operation. This suggests that despite the potential difficulty of working with Medicaid patients, an increase in reimbursements may convince more joint arthroplasty surgeons to accept Medicaid. However, the results also indicate that despite the increased coverage provided by the PPACA, patients with Medicaid may not actually obtain increased access to care if Medicaid reimbursements remain stagnant. For both knee arthroplasty and revision, patients tended to wait longer for an appointment in states with expanded Medicaid eligibility. For patients seeking a knee arthroplasty, the difference was more pronounced for Medicaid. For patients seeking a knee revision, the difference was substantial regardless of insurance type. A possible explanation is that due to the higher volume of patients eligible for coverage from Medicaid expansion, orthopedic surgeons may impose a longer wait time to accommodate for the increased patient load. In addition, orthopedic offices may restrict the number of appointments that are available at a time, especially for the more complex and technically demanding knee revision surgeries. The longer waiting periods may lead to worse outcomes, as previous studies have demonstrated that patients are likely to deteriorate further while waiting for an appointment [20,21]. One of the main objectives of the Patient Protection Affordable Care Act was to increase the number of people with health insurance in the United States. Despite one of the highest expenditures per capital for health care (17.9% of GDP in 2011), there were 46 million uninsured Americans in 2012. One of the primary objectives of the PPACA is to decrease this gap by expanding the eligibility for Medicaid. Our data show that in states that have expanded Medicaid eligibility, more orthopedic offices are accepting Medicaid patients. However, when compared to other types of insurance, the acceptance rate for Medicaid continues to be low. In addition, our data suggest that increased coverage may come at the cost of longer waiting periods. Ultimately, increasing the reimbursements for Medicaid patients may be the most effective option for facilitating access to care, although increasing the eligibility for Medicaid may help. Our study has several limitations. Importantly, we only considered 8 states. Although these states were selected from diverse regions across the nation, a full survey of all states may yield a more representative analysis. Some results, such as the differences in waiting periods for patients with Medicaid, may become statistically significant with the inclusion of additional states. Finally, factors that we could not control for, such as the day of the week called, or any inadvertent delays, such as surgeon’s availability, may have influenced our findings.
Appendix Scenario 1 1. 2. 3. 4. 5. 6.
Date of birth: 7-24-49. Total right knee arthroplasty. X-ray two months ago. No emergency room previously. No surgeries previously. Not seen previously by your clinic or hospital, she would be a new patient. 7. Asked how early she could be scheduled for an appointment. 8. Script:
“I’m calling because my primary care physician believes that my mother needs a total knee replacement. My mother has Medicaid/ Medicare/a BlueCross insurance plan. Are you taking new patients who have Medicaid/Medicare/BlueCross as insurance?” If the office responded yes, a follow-up question was asked: “What is the earliest appointment that I could schedule?” Scenario 2 1. Prior surgery 10 years ago out of state on left knee. 2. Called to inquire about earliest appointment for new patient who has loose components of that prior surgery. 3. If asked, he had X-ray two months ago. 4. No surgeries between the last 10 years and now. 5. Date of birth: 7-13-49. 6. Script: “I’m calling because my mother has been told that the components of her total knee replacement are loose, and that they need to be revised. She is in a great deal of pain when she walks. Her initial joint replacement surgery was over 10 years ago, and since she has recently moved here, she needs to find a new orthopedic surgeon. My mother has Medicaid/Medicare/a BlueCross insurance plan. Are you taking new patients who have Medicaid/Medicare/BlueCross as insurance?” If the office responded yes, a follow-up question was asked: “Are you taking new patients who have this insurance?”
References 1. Kaiser Family Foundation. Medicaid moving forward. Available at: http://kff.org/ medicaid/fact-sheet/the-medicaid-program-at-a-glance-update/. [Accessed October 10, 2014]. 2. Blumenthal D, Collins S. Health care coverage under the Affordable Care Act — a progress report. N Engl J Med 2014;371:275. 3. Kaiser Family Foundation. The uninsured: a primer — key facts about health insurance on the eve of coverage expansions. Available at: http://kff.org/uninsured/ report/the-uninsured-a-primer/. [Accessed October 10, 2014]. 4. Hahn B, Flood A. No insurance, public insurance, and private insurance: do these options contribute to differences in general health? J Health Care Poor Underserved 1995;6:41. 5. Hinman A, Bozic K. Impact of payer type on resource utilization, outcomes and access to care in total hip arthroplasty. J Arthroplasty 2008;23:9. 6. Decker S. In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help. Health Aff (Millwood) 2012;31:1673. 7. Schwarzkopf R, Phan D, Hoang M, et al. Do patients with income-based insurance have access to total joint arthroplasty? J Arthroplasty 2014;29:1083. 8. Skaggs D, Lehmann C, Rice C, et al. Access to orthopaedic care for children with Medicaid versus private insurance: results of a national survey. J Pediatr Orthop 2006;26: 400. 9. Skaggs D, Clemens S, Vitale M, et al. Access to orthopedic care for children with Medicaid versus private insurance in California. J Pediatr Orthop 2001;107:1405. 10. Pierce T. Access to care for the adolescent anterior cruciate ligament patient with Medicaid versus private insurance. J Pediatr Orthop 2012;32:245. 11. Bisgaier J, Rhodes K. Auditing access to specialty care for children with public insurance. N Engl J Med 2011;364:2324. 12. Patterson B, Draeger R, Olsson E, et al. A regional assessment of Medicaid access to outpatient orthopaedic care: The influence of population density and proximity to academic medical centers on patient access. J Bone Joint Surg Am 2014;96:1. 13. Fehring T. Joint replacement access in 2016. J Arthroplasty 2010;25:1175. 14. Cram P, Lu X, Kates S, et al. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991–2010. JAMA 2012;308:1227. 15. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780. 16. Lavernia C, Guzman J, Gachupin-Garcia A. Cost effectiveness and quality of life in knee arthroplasty. Clin Orthop Relat Res 1997;345:134. 17. Ravi B. The changing demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007. Best Pract Res Clin Rheumatol 2012;26:637. 18. Lavernia C. Access to arthroplasty in South Florida. J Arthroplasty 2012;27:1585. 19. Perloff J, Kletke P, Fossett J. Which physicians limit their Medicaid participation, and why. Health Serv Res 1995;30:7. 20. Lavernia C, D’Apuzzo M, Rossi M, et al. Is postoperative function after hip or knee arthroplasty influenced by preoperative functional levels? J Arthroplasty 2009;24: 1033. 21. Vergara I, Bilbao A, Gonzalez N, et al. Factors and consequences of waiting times for total hip arthroplasty. Clin Orthop Relat Res 2011;469:1413.
Please cite this article as: Kim C-Y, et al, The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.03.015
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act Chang-Yeon Kim, B.S., M.S., Daniel H. Wiznia, M.D., Walter R. Hsiang, B.S., Richard R. Pelker, M.D., Ph.D. Department of Orthopedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
a r t i c l e
i n f o
Article history: Received 31 December 2014 Accepted 15 March 2015 Available online xxxx Keywords: total knee arthroplasty knee revision patient Protection and Affordable Care Act medicaid health care access
a b s t r a c t This study evaluated access to knee arthroplasty and revision in 8 geographically representative states. Patients with Medicaid were significantly less likely to receive an appointment compared to patients with Medicare or BlueCross. However, patients with Medicaid had increased success at making an appointment in states with expanded Medicaid eligibility (37.7% vs 22.8%, P = 0.011 for replacement, 42.6% vs 26.9%, P = 0.091 for revision), although they experienced longer waiting periods (31.5 days vs 21.1 days, P = 0.054 for replacement, 45.5 days vs 22.5 days, P = 0.06 for revision). Higher Medicaid reimbursement also had a direct correlation with appointment success rate for Medicaid patients (OR = 1.232, P = 0.001 for replacement, OR = 1.314, P = 0.014 for revision). © 2015 Elsevier Inc. All rights reserved.
The Patient Protection Affordable Care Act (PPACA) has significantly expanded the eligibility for Medicaid. Previously, only individuals with low incomes (61% of federal poverty level in most states) who fell into certain categories (children, parents, pregnant women, people with disabilities, and those N65 years of age) were eligible [1]. With the passage of the PPACA, anyone with incomes up to 138% of the poverty level is qualified for Medicaid [2]. The legislation represents the largest expansion of government sponsored health insurance since the inception of the Medicaid program in 1965 [2]. A Supreme Court ruling in 2012 decided that expanding the eligibility for Medicaid was optional, and currently 28 states and the District of Columbia have decided to do so. This has created a dichotomy between states that have expanded coverage for Medicaid patients to 138% of the poverty level and states that adhere to previous guidelines, with no expanded coverage. However, all states are projected to eventually expand coverage due to financial incentives [2]. Six months after the passage of the law, 6 million new people had enrolled in Medicaid or CHIP (Children’s Health Insurance Program) [1]. At full implementation (all states participating), the PPACA is projected to lower the uninsured rate by almost 50%, reducing the number of uninsured by over 23 million [3]. Increased coverage, however, does not necessarily equate to more access to care [4]. The expansion of Medicaid is occurring at a time when the number of health care practitioners willing to accept Medicaid
is decreasing [5]. The low reimbursement rate from Medicaid has been cited as the primary reason for this trend [5–7]. While there have been provisions in the PPACA to improve Medicaid payments for primary care physicians, there are currently no such provisions for specialists, including orthopedic surgeons, to create an incentive to improve patient access to care [7]. Previous studies have shown that patients with Medicaid have difficulty accessing orthopedic surgeons for a wide range of issues [8–12]. Therefore, Medicaid patients may encounter particular difficulty with elective orthopedic procedures such as total joint arthroplasty and revision [5,12]. The rising age of the population and the decrease in fellowshiptrained arthroplasty surgeons will likely exacerbate the issue of access to total joint arthroplasty by creating a supply–demand imbalance [13]. In addition, the projected retirement of many high-volume joint arthroplasty surgeons will put additional pressures on patient access to revision surgery in the future because physicians without specialized training in this area are hesitant to perform these procedures [13]. Our study focuses on the effect of the different types of insurance (Medicaid, Medicare, or BlueCross) on the ability of patients to obtain care for joint reconstruction and revision. The purpose of this study is to determine whether, in the setting of the Patient Protection Affordable Care Act, orthopedic surgeons are more likely to accept patients with Medicaid. We hypothesize that despite the passage of the PPACA, Medicaid patients will have increased difficulty obtaining access compared to patients with other types of insurance.
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.03.015. Supplementary material available at www.arthroplastyjournal.org. Reprint requests: Richard R. Pelker, M.D., Ph.D., Yale Physicians Group, 800 Howard Avenue, 1st Floor, New Haven, CT 06510.
Materials and Methods The study population included board-certified orthopedic surgeons who belonged to the American Association of Hip and Knee Surgeons from 8 representative states: California, Massachusetts, Ohio, New
http://dx.doi.org/10.1016/j.arth.2015.03.015 0883-5403/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Kim C-Y, et al, The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.03.015
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York, Florida, Pennsylvania, Texas, and North Carolina. These states were selected because they represent diverse geographic areas and health marketplaces. Alphabetized lists of orthopedic surgeons from these states were generated and each surgeon was paired with a number. The numbers were then randomized and called. If a number was disconnected or inaccurate, it was excluded from the calling list and the next number was selected. Each office was called to make an appointment for the caller’s fictitious 65-year old mother, using two scenarios. The caller had a standardized protocol to limit intra and inter-office variation (see Appendix). The first scenario was a request to be evaluated for a total knee arthroplasty, with the patient having Medicaid, Medicare, or BlueCross. The second scenario was a request to be evaluated for a knee revision surgery, again with the patient having Medicaid, Medicare, or BlueCross. The two scenarios each required three separate calls, for each insurance type. Every surgeon we called was specifically asked if he or she would accept the patient for a knee arthroplasty or revision. We recorded the following data from each attempt at making an appointment: date of phone call and date of appointment if given. If the office did not give an appointment, we asked for reasons why. If a denial occurred for a patient with Medicaid, we asked for a referral to another office that accepted Medicaid. We considered barriers to obtaining an initial appointment, such as requiring a referral from a PCP (primary care physician), as an unsuccessful attempt at making an appointment. The waiting period for an appointment was obtained by calculating the time between the date of call and the date of the appointment. For both appointment success rates and waiting periods, the data were stratified into two groups: states with expanded Medicaid eligibility (California, Massachusetts, New York, Ohio) and states without expanded Medicaid eligibility (Florida, North Carolina, Pennsylvania, Texas). At the time of our investigation, Pennsylvania had not expanded eligibility for Medicaid. Concurrent with the telephone survey, we also sent an electronic fax to the orthopedic offices generated from randomization. The fax asked whether the respondent was an orthopedic surgeon, secretary, or receptionist. It then asked whether the respondent would accept a patient with Medicaid, Medicare, BlueCross, or self-paid insurance. The Medicaid reimbursement rates for total knee arthroplasty and knee revision were obtained by querying each state’s reimbursement rate using Current Procedural Terminology (CPT) code 27447 (primary total knee arthroplasty) and 27847 (revision for total knee arthroplasty). Statistical analysis was performed using SPSS version 21 (SPSS, Inc, Chicago, IL). Chi-square test or Fisher’s exact test was used to analyze differences in acceptance rate based on type of insurance. To compare the time period to an appointment, a Wilcoxon rank test and Kruskal– Wallis tests were used, as the data were not normally distributed. Multiple regression analysis was performed to detect whether Medicaid reimbursement was a significant predictor for successfully making an appointment for patients with Medicaid. Unless otherwise stated, all statistical testing was performed two-tailed at an alpha-level of 0.05. The study was submitted to and approved by the Yale University Institutional Review Board office, HIC# 13637. Results Our query across the 8 selected states resulted in a randomly generated list of 250 offices (4 states with and 4 states without expanded Medicaid eligibility) to call for scenario 1 (knee arthroplasty) and 106 offices (2 states with and 2 states without expanded Medicaid eligibility) to call for scenario 2 (knee revision). For our first scenario (evaluation for a primary total knee arthroplasty), the rate across all states for successfully obtaining an appointment was 30.1% for Medicaid patients, 96% for Medicare patients, and 100% for patients with BlueCross (Table 1A). In states with expanded Medicaid eligibility, the success rate was 37.7% for Medicaid patients, 96.7% for Medicare patients, and 100% for patients with BlueCross. In states without expanded Medicaid eligibility, the success rate was
Table 1 Appointment Success Rate.
A. Knee arthroplasty All states Yes (%) No (%) P value States w/ expanded Medicaid eligibility Yes (%) No (%) P value States w/o expanded Medicaid eligibility Yes (%) No (%) P value B. Knee revision All states Yes (%) No (%) P value States w/ expanded Medicaid eligibility Yes (%) No (%) P value States w/o expanded Medicaid eligibility Yes (%) No (%) P value
Medicaid
Medicare
Private
75 (30.1) 174 (69.9)
240 (96) 10 (4) b0.0001
248 (100) 0 b0.0001
46 (37.7) 76 (62.3)
119 (96.7) 4 (3.3) b0.0001
122 (100) 0 b0.0001
29 (22.8) 98 (77.2)
121 (95.3) 6 (4.7) b0.0001
126 (100) 0 b0.0001
37 (34.9) 69 (65.1)
99 (93.4) 7 (6.6) b0.0001
103 (100) 0 b0.0001
23 (42.6) 31 (57.4)
52 (96.3) 2 (3.7) b0.0001
51 (100) 0 b0.0001
14 (26.9) 38 (73.1)
47 (90.4) 5 (9.6) b0.0001
52 (100) 0 b0.0001
⁎ P value in comparison to Medicaid.
22.8% for Medicaid patients, 95.3% for Medicare patients, and 100% for patients with BlueCross. The success rate was significantly lower for Medicaid compared to either Medicare (P b 0.0001) or BlueCross (P b 0.0001). However, patients with Medicaid were significantly more likely to obtain an appointment in states with expanded Medicaid eligibility (37.7% vs 22.8%, P = 0.011). For our second scenario (evaluation for a total knee revision), the rate across all states for successfully obtaining an appointment was 34.9% for Medicaid patients, 93.4% for Medicare patients, and 100% for patients with BlueCross (Table 1B). In states with expanded Medicaid eligibility, the success rate was 42.6% for Medicaid, 96.3% for Medicare, and 100% for BlueCross. In states without expanded Medicaid eligibility, the success rate was 26.9% for Medicaid, 90.4% for Medicare, and 100% for BlueCross. Statistical results were similar to those for a total knee arthroplasty. The success rate for Medicaid was significantly lower when compared to Medicare (P b 0.0001) and BlueCross (P b 0.0001). Patients with Medicaid were more likely to obtain an appointment in states with expanded Medicaid eligibility (42.6% vs 26.9%, P = 0.091). Barriers to an appointment differed according to insurance type. For a knee arthroplasty, not having a referral from a PCP (primary care physician) was a barrier to an appointment for patients with Medicaid in 13.8% of offices called. In contrast, lack of a PCP referral was not an obstacle for any patient with Medicare or BlueCross. For a knee revision, not having records from the previous surgery was a barrier to an appointment for patients with Medicaid in 18.8% of offices called. However, the majority of patients with Medicare and BlueCross were able to schedule an appointment even when the office required previous records. For Medicaid patients who did not get an initial appointment, 32% of offices referred the caller to another office that took Medicaid for knee arthroplasty and 26% of offices did so for knee revision. The majority of offices either could not refer the caller to an office that took Medicaid or instructed to contact the number on the patient’s Medicaid card for a list of state-generated offices that may accept Medicaid. Patients who successfully made an appointment experienced different waiting periods based on expansion of Medicaid eligibility. In states with expanded Medicaid eligibility, patients experienced significantly longer waiting periods (Table 2A) for both knee arthroplasty (27.2 days vs 22.9 days, P = 0.001) and knee revision (41.8 days vs
Please cite this article as: Kim C-Y, et al, The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.03.015
C-Y. Kim et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx Table 2 Waiting Period Until Appointment.
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Table 3 Electronic Fax Responses. Knee Arthroplasty
Knee Revision
A. Waiting period (days) organized by procedure type States w/ expanded Medicaid eligibility 27.2 ± 1.4 (n = 278) States w/o expanded Medicaid eligibility 22.9 ± 1.4 (n = 276) P value 0.004 Medicaid
Medicare
41.8 ± 4.0 (n = 126) 18.6 ± 1.7 (n = 113) b0.0001 Private
B. Knee arthroplasty. Waiting period (days) organized by insurance type States w/ expanded Medicaid eligibility 31.5 ± 3.8 26.7 ± 2.2 26.2 ± 2.1 (n = 44) (n = 115) (n = 119) States w/o expanded Medicaid eligibility 21.1 ± 3.4 23.2 ± 2.2 23.1 ± 2.1 (n = 29) (n = 121) (n = 126) P value 0.054 0.081 0.138 C. Knee revision. Waiting period (days) organized by insurance type States w/ expanded Medicaid eligibility 45.5 ± 11.2 39.6 ± 5.8 42.3 ± 6.3 (n = 23) (n = 52) (n = 51) States w/o expanded Medicaid eligibility 22.5 ± 5.7 18.0 ± 2.6 18.0 ± 2.5 (n = 14) (n = 47) (n = 52) P value 0.06 b0.0001 b0.0001
18.6 days, P b 0.0001). The waiting periods were then stratified by insurance type (Table 2B, C). Regardless of insurance type, patients experienced longer waiting periods in states with expanded Medicaid eligibility. For knee arthroplasty, the waiting periods were 31.5 days vs 21.1 days (P = 0.054) for patients with Medicaid, 26.7 days vs 23.2 days (P = 0.081) for patient with Medicare, and 26.2 days vs 23.1 days (P = 0.138) for patients with BlueCross. For knee revision, the waiting periods were 45.5 days vs 22.5 days (P = 0.06) for patients with Medicaid, 39.6 days vs 18.0 days (P b 0.0001) for patient with Medicare, and 42.3 days vs 18.0 days (P b 0.0001) for patients with BlueCross. Results from our electronic fax survey confirmed the trends from the telephone study (Table 3). Patients with Medicaid had a low acceptance rate (57.1%) compared to patients with Medicare (96.9%), patients with BlueCross (93.8%), and patients with self-paid insurance (93.7%). However, the fax response rate was low, with responses from 65 out of 800 faxed offices. Medicaid reimbursements for total knee arthroplasty and revision varied across states (Table 4). Massachusetts paid the highest reimbursements for both procedures, with $1492.58 for a total knee arthroplasty and $1483.24 for knee revision. Florida paid the lowest, with $817.16 for total knee arthroplasty and $933.72 for a knee revision. Multiple regression analysis showed that for patients with Medicaid, an increase in reimbursements was a positive predictor for successfully obtaining an appointment to be evaluated for both primary (P = 0.001, OR = 1.232 for every $100 increase) and revision procedures (P = 0.014, OR = 1.314 for every $100 increase). Discussion In this study, we assessed patient access to total knee arthroplasty and revision for three different types of insurance (Medicaid, Medicare, and BlueCross) in 8 geographically representative states. To our knowledge, our work is the first to evaluate patient access for both knee arthroplasty and revision across multiple states, whereas other reports focus on access in a single state or county. Given the recent expansion of Medicaid eligibility by the PPACA, a national evaluation of the policy’s effect on insurance coverage and access to care is timely. We chose to focus the study on total knee arthroplasty because it is a common elective procedure, has a proven efficacy, and is projected to become increasingly more common in the next decade [14–17]. We hypothesized that despite the passage of the PPACA, patients with Medicaid requesting a total knee arthroplasty and revision would have relatively limited access to care.
Yes (%) No (%)
Medicaid
Medicare
BlueCross
Self-Pay
P Value
36 (57.1) 27 (42.9)
62 (96.9) 2 (3.1)
60 (93.8) 4 (6.2)
93.7 (63) 4 (6.3)
b0.0001
Our telephone survey of representative orthopedic offices across the nation demonstrated that among the three different insurance types, Medicaid patients continue to have the lowest rate of appointment success. This was true for both total knee arthroplasty and total knee revision, which was consistent with results from previous literature [5,7,18]. This outcome was further confirmed by similar results from our electronic fax survey, which included direct responses from the actual surgeon. Importantly, the patients with Medicaid were more likely to receive an appointment in states with expanded Medicaid eligibility than in states without expanded eligibility (37.7% vs 22.8%, P = 0.011 for knee arthroplasty, and 42.6% vs 26.9%, P = 0.091 for knee revision). Our analysis demonstrates that although the acceptance rate for patients with Medicaid continues to be low for joint arthroplasty, orthopedists in PPACAcompliant states may be more willing to accept Medicaid patients A common reason for denying an evaluation for knee arthroplasty to patients with Medicaid was the lack of a PCP referral. In contrast, no patient with Medicare or BlueCross was denied an appointment due to lack of a PCP referral. Similarly, not having records of the previous surgery was a barrier to obtaining an appointment for a knee revision. However, patients with Medicare or BlueCross were able to obtain appointments even when the office required previous surgical records. Four states included in our study (Massachusetts, North Carolina, Texas, and New York) required a PCP referral to see a specialist. However, a number of orthopedic practices in these states accepted Medicaid patients without a PCP referral, suggesting that the decision depended on individual policy. In addition, most orthopedic offices in these states cited that they simply do not accept Medicaid as an insurance policy, not that they required a referral, which is consistent with results from previous studies [6,7,19]. The results for Medicaid also stand in contrast with those for Medicare, which may also require a PCP referral depending on the type of Medicare. The fact that no patient with Medicare was inquired about a PCP referral suggests that Medicaid patients face unique hurdles when obtaining care. Previous studies have mentioned the difficulty of working with Medicaid patients as a secondary reason for the unpopularity of Medicaid among orthopedic surgeons [5]. Orthopedic surgeons have stated that Medicaid patients come from more socioeconomically disadvantaged backgrounds, are non-compliant with medical instructions, and pose increased regulatory hurdles for processing reimbursements. It is possible that orthopedic offices may consider patients with referrals from primary care physicians as more manageable than those without referrals. A patient also needs to be proactive in order to acquire a referral, which may be another indication that the patient will be compliant with treatment instructions.
Table 4 Medicaid Reimbursements for Total Knee Arthroplasty and Revision in 2014. State a
CA FL MAa NC NYa OHa PA TX a
Total Knee Arthroplasty (CPT 27447)
Knee Revision (CPT 27487)
$1489.20 $817.16 $1492.58 $1148.49 $890 $1228.01 $1000 $1092.38
$1428.52 $933.72 $1483.24 $1322.92 $1023.84 $1441.87 $870.50 $1350.42
States with expanded Medicaid eligibility.
Please cite this article as: Kim C-Y, et al, The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.03.015
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C-Y. Kim et al. / The Journal of Arthroplasty xxx (2015) xxx–xxx
Although no office stated that the reason for denying patient with Medicaid was due to lower Medicaid reimbursements, our regression data showed that a $100 increase in reimbursements predicted a 23.2% increase in the odds of being accepted for an appointment to be evaluated for a total knee arthroplasty, and a 31.4% increase in the odds of being accepted for an appointment to be evaluated for a total knee revision. These results are consistent with Perloff et al, who found a positive correlation between appointment success and the reimbursement for office visits [19]. Our results show a similar relationship, but between appointment success and the reimbursement for the actual operation. This suggests that despite the potential difficulty of working with Medicaid patients, an increase in reimbursements may convince more joint arthroplasty surgeons to accept Medicaid. However, the results also indicate that despite the increased coverage provided by the PPACA, patients with Medicaid may not actually obtain increased access to care if Medicaid reimbursements remain stagnant. For both knee arthroplasty and revision, patients tended to wait longer for an appointment in states with expanded Medicaid eligibility. For patients seeking a knee arthroplasty, the difference was more pronounced for Medicaid. For patients seeking a knee revision, the difference was substantial regardless of insurance type. A possible explanation is that due to the higher volume of patients eligible for coverage from Medicaid expansion, orthopedic surgeons may impose a longer wait time to accommodate for the increased patient load. In addition, orthopedic offices may restrict the number of appointments that are available at a time, especially for the more complex and technically demanding knee revision surgeries. The longer waiting periods may lead to worse outcomes, as previous studies have demonstrated that patients are likely to deteriorate further while waiting for an appointment [20,21]. One of the main objectives of the Patient Protection Affordable Care Act was to increase the number of people with health insurance in the United States. Despite one of the highest expenditures per capital for health care (17.9% of GDP in 2011), there were 46 million uninsured Americans in 2012. One of the primary objectives of the PPACA is to decrease this gap by expanding the eligibility for Medicaid. Our data show that in states that have expanded Medicaid eligibility, more orthopedic offices are accepting Medicaid patients. However, when compared to other types of insurance, the acceptance rate for Medicaid continues to be low. In addition, our data suggest that increased coverage may come at the cost of longer waiting periods. Ultimately, increasing the reimbursements for Medicaid patients may be the most effective option for facilitating access to care, although increasing the eligibility for Medicaid may help. Our study has several limitations. Importantly, we only considered 8 states. Although these states were selected from diverse regions across the nation, a full survey of all states may yield a more representative analysis. Some results, such as the differences in waiting periods for patients with Medicaid, may become statistically significant with the inclusion of additional states. Finally, factors that we could not control for, such as the day of the week called, or any inadvertent delays, such as surgeon’s availability, may have influenced our findings.
Appendix Scenario 1 1. 2. 3. 4. 5. 6.
Date of birth: 7-24-49. Total right knee arthroplasty. X-ray two months ago. No emergency room previously. No surgeries previously. Not seen previously by your clinic or hospital, she would be a new patient. 7. Asked how early she could be scheduled for an appointment. 8. Script:
“I’m calling because my primary care physician believes that my mother needs a total knee replacement. My mother has Medicaid/ Medicare/a BlueCross insurance plan. Are you taking new patients who have Medicaid/Medicare/BlueCross as insurance?” If the office responded yes, a follow-up question was asked: “What is the earliest appointment that I could schedule?” Scenario 2 1. Prior surgery 10 years ago out of state on left knee. 2. Called to inquire about earliest appointment for new patient who has loose components of that prior surgery. 3. If asked, he had X-ray two months ago. 4. No surgeries between the last 10 years and now. 5. Date of birth: 7-13-49. 6. Script: “I’m calling because my mother has been told that the components of her total knee replacement are loose, and that they need to be revised. She is in a great deal of pain when she walks. Her initial joint replacement surgery was over 10 years ago, and since she has recently moved here, she needs to find a new orthopedic surgeon. My mother has Medicaid/Medicare/a BlueCross insurance plan. Are you taking new patients who have Medicaid/Medicare/BlueCross as insurance?” If the office responded yes, a follow-up question was asked: “Are you taking new patients who have this insurance?”
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Please cite this article as: Kim C-Y, et al, The Effect of Insurance Type on Patient Access to Knee Arthroplasty and Revision under the Affordable Care Act, J Arthroplasty (2015), http://dx.doi.org/10.1016/j.arth.2015.03.015
