Insurance Acceptance, Appointment Wait Time, and Dermatologist Access Across Practice Types in the US

Abstract

In the 15 years since dermatology access was last investigated on a national scale, the practice landscape has changed with the rise of private equity (PE) investment and increased use of nonphysician clinicians (NPCs).OBJECTIVE To determine appointment success and wait times for patients with various insurance types at clinics with and without PE ownership. DESIGN, SETTING, AND PARTICIPANTSIn this study, PE-owned US clinics were randomly selected and matched with 2 geographically proximate clinics without PE ownership. Researchers called each clinic 3 times over a 5-day period to assess appointment/clinician availability for a fictitious patient with a new and changing mole. The 3 calls differed by insurance type specified, which were Blue Cross Blue Shield (BCBS) preferred provider organization, Medicare, or Medicaid. MAIN OUTCOMES AND MEASURESAppointment success and wait times among insurance types and between PE-owned clinics and control clinics. Secondary outcomes were the provision of accurate referrals to other clinics when appointments were denied and clinician and next-day appointment availability.RESULTS A total of 1833 calls were made to 204 PE-owned and 407 control clinics without PE ownership across 28 states. Overall appointment success rates for BCBS, Medicare, and Medicaid were 96%, 94%, and 17%, respectively. Acceptance of BCBS (98.5%; 95% CI, 96%-99%; P = .03) and Medicare (97.5%; 95% CI, 94%-99%; P = .02) were slightly higher at PE-owned clinics (compared with 94.6% [95% CI, 92%-96%] and 92.8% [95% CI, 90%-95%], respectively, at control clinics). Wait times (median days, interquartile range [IQR]) were similar for patients with BCBS (7 days; IQR, 2-22 days) and Medicare (7 days; IQR, 2-25 days; P > .99), whereas Medicaid patients waited significantly longer (13 days; IQR, 4-33 days; P = .002). Clinic ownership did not significantly affect wait times. Private equity-owned clinics were more likely than controls to offer a new patient appointment with an NPC (80% vs 63%; P = .001) and to not have an opening with a dermatologist (16% vs 6%; P < .001). Next-day appointment availability was greater at PE-owned clinics than controls (30% vs 21%; P = .001).CONCLUSIONS AND RELEVANCE Patients with Medicaid had significantly lower success in obtaining appointments and significantly longer wait times regardless of clinic ownership. Although the use of dermatologists and NPCs was similar regardless of clinic ownership, PE-owned clinics were more likely than controls to offer new patient appointments with NPCs.

Prevalence of Misrepresentation of Nonphysician Clinicians at Dermatology Clinics

“…A total of 344 unique dermatology clinics were contacted on February 27, 2020, in 25 states (Table 1 ) [ 4 ]. Phone calls at 128 clinics (37.2%) met our inclusion criterion for data collection.…”

“…Although NPCs who are appropriately supervised play an important role in the care of dermatology patients in the United States, training for NPCs is not standardized and has no guarantee to include dermatologyspecific training [2]. Statements contradicting this or attempting to convince potential patients that outcomes under both provider types will be equivalent are inaccurate and diminish the importance and necessity of the additional training required of physicians [2][3][4].…”

“…If, in response to this inquiry, the receptionist used inaccurate terminology to describe the NPCs and their qualifications, we recorded this instance along with the specific language that they used. A total of 344 unique dermatology clinics were contacted on February 27, 2020, in 25 states (Table 1) [4]. Phone calls at 128 clinics (37.2%) met our inclusion criterion for data collection.…”

“…This study is an extension of a prior secret shopper study of dermatology appointment access at clinics with and without private equity (PE) ownership that provided adult medical dermatology services [ 4 ]. Clinics were randomly selected using a specific protocol described previously and called using a standardized script to determine the first available appointment for a new patient with a new and changing mole [ 4 ]. After learning the date of the first available appointment, we inquired what the type of provider for this appointment would be.…”

“…Per protocol, if an appointment with an NPC was offered, the receptionist was next asked when the next appointment was available with a physician dermatologist instead of an NPC [ 4 ]. If, in response to this inquiry, the receptionist used inaccurate terminology to describe the NPCs and their qualifications, we recorded this instance along with the specific language that they used.…”