title: The influence of insurance status on access to and utilization of a tertiary hand surgery referral center.
abstract: BACKGROUND
  The purpose of this study was to systematically examine the impact of insurance status on access to and utilization of elective specialty hand surgical care. We hypothesized that patients with Medicaid insurance or those without insurance would have greater difficulty accessing care both in obtaining local surgical care and in reaching a tertiary center for appointments.
  
  
  METHODS
  This retrospective cohort study included all new patients with orthopaedic hand problems (n = 3988) at a tertiary center in a twelve-month period. Patient insurance status was categorized and clinical complexity was quantified on an ordinal scale. The relationships of insurance status, clinical complexity, and distance traveled to appointments were quantified by means of statistical analysis. An assessment of barriers to accessing care stratified with regard to insurance status was completed through a survey of primary care physicians and an analysis of both patient arrival rates and operative rates at our tertiary center.
  
  
  RESULTS
  Increasing clinical complexity significantly correlated (p < 0.001) with increasing driving distance to the appointment. Patients with Medicaid insurance were significantly less likely (p < 0.001) to present with problems of simple clinical complexity than patients with Medicare and those with private insurance. Primary care physicians reported that 62% of local surgeons accepted patients with Medicaid insurance and 100% of local surgeons accepted patients with private insurance. Forty-four percent of these primary care physicians reported that, if patients who were underinsured (i.e., patients with Medicaid insurance or no insurance) had been refused by community surgeons, they were unable to drive to our tertiary center because of limited personal resources. Patients with Medicaid insurance (26%) were significantly more likely (p < 0.001) to fail to arrive for appointments than patients with private insurance (11%), with no-show rates increasing with the greater distance required to reach the tertiary center.
  
  
  CONCLUSIONS
  Economically disadvantaged patients face barriers to accessing specialty surgical care. Among patients with Medicaid coverage or no insurance, local surgical care is less likely to be offered and yet personal resources may limit a patient's ability to reach distant centers for non-emergency care.
authors.affiliation: Division of Hand Surgery, Department of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110, USA. calfeer@wudosis.wustl.edu
authors.forename: Ryan P
authors.initials: RP
authors.lastname: Calfee
authors.forename: Chirag M
authors.initials: CM
authors.lastname: Shah
authors.forename: Colin D
authors.initials: CD
authors.lastname: Canham
authors.forename: Ambrose H W
authors.initials: AH
authors.lastname: Wong
authors.forename: Richard H
authors.initials: RH
authors.lastname: Gelberman
authors.forename: Charles A
authors.initials: CA
authors.lastname: Goldfarb
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D005260:Female; D006225:Hand / Q000601:surgery*; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000191:economics* / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000191:economics*; D006801:Humans; D019458:Insurance Coverage / Q000191:economics*; D008297:Male; D008484:Medicaid / Q000191:economics; D017057:Medically Uninsured / Q000706:statistics & numerical data; D006278:Medicare / Q000191:economics; D008875:Middle Aged; D020380:Needs Assessment; D019637:Orthopedic Procedures / Q000191:economics / Q000379:methods; D012017:Referral and Consultation / Q000191:economics* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D014481:United States