Medicaid Patients Have Less Access, Longer Waits for Dermatologists

By Lisa Rapaport

January 25, 2021

(Reuters Health) - Patients covered by Medicaid have a much harder time scheduling appointments with a dermatologist and significantly longer wait times when they do manage to get on the schedule, a U.S. study suggests.

The study was designed to examine differences in access at dermatology clinics with or without private-equity (PE) ownership, but researchers found no difference in wait times based on the type of ownership. They did find, however, that patients with Medicaid had significantly longer wait times and less success obtaining appointments than patients with Medicare or private health insurance.

"While we did not study this specifically in our study, there is substantial evidence that the compensation provided for Medicaid patients is substantially lower than that offered by Medicare or private insurance," said senior author Dr. Arash Mostaghimi, an assistant professor of dermatology at Harvard Medical School and director of the inpatient consultation service for dermatology at Brigham and Women's Hospital in Boston.

"In some places, these payments may not cover the costs of treatments, leading practices to not accept or to substantially limit appointment slots for patients on Medicaid," Dr. Mostaghimi said by email.

For the study, researchers made a total of 1,833 calls to 204 randomly selected PE-owned dermatology clinics and 407 control clinics without PE ownership. Callers posed as patients with a new and changing mole who were seeking appointments with coverage from either Medicaid, Medicare, or a private Blue Cross Blue Shield (BCBS) preferred provider organization (PPO) plan.

Overall, it was significantly easier for callers to get appointments with BCBS (96%) and Medicare (94%) than with Medicaid (17%). The proportion of Medicaid patients who received appointments was slightly higher at PE-owned clinics (20.2%) than at control clinics (15.5%).

Median wait times for appointments were also shorter with BCBS and Medicare (7 days with both types of coverage) than with Medicaid (13 days). Medicaid median wait times were longer with PE ownership (20 days) than without it (11 days) but this difference wasn't statistically significant.

Next-day appointment availability was higher at PE-owned clinics (30%) than at control clinics without PE ownership (21%). However, more PE-owned clinics (80%) than control clinics (63%) made these appointments available with non-physician providers.

"It is generally thought that PE clinics attempt to have more non-physician providers," said Dr. Lawrence Casalino, chief of the division of health policy and economics in the Department of Population Health Sciences at Weill Cornell Medical College in New York City.

"This could be a good thing - cost-effective, possibly faster access - or a bad thing, depending on how they are used," Dr. Casalino, who wasn't involved in the study, said by email.

The study didn't examine how non-physician providers were used in patient care. They may provide appropriate care that expands access and helps contain costs if they're used only for relatively simple diagnoses, treatments or procedures, Dr. Casalino said.

One limitation of the study is that the results may not be nationally representative of all dermatology clinics, the researchers note in JAMA Dermatology. Ownership data was also based on voluntarily reported financial records, and it's possible that ownership of some clinics was misclassified.

It's also possible that results would look different for urgent, same-day appointments, or that Medicaid patients might seek care at academic medical centers or other settings other than dermatology clinics, said Dr. Jane Zhu, an assistant professor of medicine and a health services researcher at Oregon Health and Science University in Portland.

However, the study still adds to a large body of evidence documenting reduced access to primary and specialty care for Medicaid patients, Dr. Zhu, who wasn't involved in the study, said by email.

"The reality is that clinics and hospitals respond to incentive, and the current structure of reimbursement is to incentivize patients with higher-paying insurance," Dr. Zhu said.

SOURCE: JAMA Dermatology, online January 13, 2021.