Musculoskeletal Urgent Care Centers Restrict Access for Patients with Medicaid Insurance Based on Policy and Location

Abstract

Background As the urgent care landscape evolves, specialized musculoskeletal urgent care centers (MUCCs) are becoming more prevalent. MUCCs have been offered as a convenient, cost-effective option for timely acute orthopaedic care. However, a recent “secret-shopper” study on patient access to MUCCs in Connecticut demonstrated that patients with Medicaid had limited access to these orthopaedic-specific urgent care centers. To investigate how generalizable these regional findings are to the United States, we conducted a nationwide secret-shopper study of MUCCs to identify determinants of patient access. Questions/purposes (1) What proportion of MUCCs in the United States provide access for patients with Medicaid insurance? (2) What factors are associated with MUCCs providing access for patients with Medicaid insurance? (3) What barriers exist for patients seeking care at MUCCs? Methods An online search of all MUCCs across the United States was conducted in this cross-sectional study. Three separate search modalities were used to gather a complete list. Of the 565 identified, 558 were contacted by phone with investigators posing over the telephone as simulated patients seeking treatment for a sprained ankle. Thirty-nine percent (216 of 558) of centers were located in the South, 13% (71 of 558) in the West, 25% (138 of 558) in the Midwest, and 24% (133 of 558) in New England. This study was given an exemption waiver by our institution’s IRB. MUCCs were contacted using a standardized script to assess acceptance of Medicaid insurance and identify barriers to care. Question 1 was answered through determining the percentage of MUCCs that accepted Medicaid insurance. Question 2 considered whether there was an association between Medicaid acceptance and factors such as Medicaid physician reimbursements or MUCC center type. Question 3 sought to characterize the prevalence of any other means of limiting access for Medicaid patients, including requiring a referral for a visit and disallowing continuity of care at that MUCC. Results Of the MUCCs contacted, 58% (323 of 558) accepted Medicaid insurance. In 16 states, the proportion of MUCCs that accepted Medicaid was equal to or less than 50%. In 22 states, all MUCCs surveyed accepted Medicaid insurance. Academic-affiliated MUCCs accepted Medicaid patients at a higher proportion than centers owned by private practices (odds ratio 14 [95% CI 4.2 to 44]; p < 0.001). States with higher Medicaid physician reimbursements saw proportional increases in the percentage of MUCCs that accepted Medicaid insurance under multivariable analysis (OR 36 [95% CI 14 to 99]; p < 0.001). Barriers to care for Medicaid patients characterized included location restriction and primary care physician referral requirements. Conclusion It is clear that musculoskeletal urgent care at these centers is inaccessible to a large segment of the Medicaid-insured population. This inaccessibility seems to be related to state Medicaid physician fee schedules and a center’s affiliation with a private orthopaedic practice, indicating how underlying financial pressures influence private practice policies. Ultimately, the refusal of Medicaid by MUCCs may lead to disparities in which patients with private insurance are cared for at MUCCs, while those with Medicaid may experience delays in care. Going forward, there are three main options to tackle this issue: increasing Medicaid physician reimbursement to provide a financial incentive, establishing stricter standards for MUCCs to operate at the state level, or streamlining administration to reduce costs overall. Further research will be necessary to evaluate which policy intervention will be most effective. Level of Evidence Level II, prognostic study.

Charges for Initial Visits for Uninsured Patients at Musculoskeletal Urgent Care Centers in the US

“…The existing literature 3 , 4 indicates that MUCCs operate on a profit-driven model, having clinic policies in place that ensure a certain payer mix. Therefore, care at MUCCs may be unavailable to patients who are most in need of cost savings: the uninsured and underinsured.…”

“… 3 Multiple studies have confirmed that a high percentage of MUCCs do not accept Medicaid insurance. 3 , 4 Urgent care centers are not subject to the Emergency Medical Treatment and Active Labor Act and therefore are legally able to screen patients based on their perceived ability to pay. Our findings suggest that a practice’s policy of Medicaid acceptance, median household income per zip code, and Medicaid reimbursement for a level 3 visit are associated with visit charges at MUCCs.…”

“…MUCCs have been shown to be more likely to provide treatment to privately insured patients than to their Medicaid-insured counterparts. 3 , 4 Operating under a profit-driven model, centers that did not accept Medicaid prioritized optimizing their payer mix by limiting Medicaid-insured patients. The higher charges at MUCCs not accepting Medicaid, which accounted for 41.6% of the sample, suggest that these centers are more profit-driven than MUCCs that accept Medicaid.…”

“… 3 In a comprehensive national survey of all MUCCs in the US, half of all centers surveyed did not accept Medicaid insurance. 4 Given the large number of uninsured patients in the US, it is important to characterize the charges that patients without insurance coverage would incur if they were to seek urgent orthopedic care at these centers. Furthermore, freestanding EDs providing urgent care services have been established in areas with a more profitable payer mix.…”

Evaluating musculoskeletal urgent care center triage and transfer of emergency conditions for emergency surgical assessment and intervention

“…[ 1 ] MUCCs also increase access to specialty providers, as many MUCCs are owned and operated privately by orthopedic surgeons. [ 2 ] Accessing orthopedic specialists in the ED setting can be challenging and approximately 25% of visits to the ED are due to diseases of the musculoskeletal system or musculoskeletal injuries. [ 3 , 4 ] However, many MUCCs restrict access to patients based on insurance type which may limit care options for patients.…”