title: A regional assessment of medicaid access to outpatient orthopaedic care: the influence of population density and proximity to academic medical centers on patient access.
abstract: BACKGROUND
  Access to care is limited for patients with Medicaid with many conditions, but data investigating this relationship in the orthopaedic literature are limited. The purpose of this study was to investigate the relationship between health insurance status and access to care for a diverse group of adult orthopaedic patients, specifically if access to orthopaedic care is influenced by population density or distance from academic teaching hospitals.
  
  
  METHODS
  Two hundred and three orthopaedic practices within the state of North Carolina were randomly selected and were contacted on two different occasions separated by three weeks. An appointment was requested for a fictitious adult orthopaedic patient with a potential surgical problem. Injury scenarios included patients with acute rotator cuff tears, zone-II flexor tendon lacerations, and acute lumbar disc herniations. Insurance status was reported as Medicaid at the time of the first request and private insurance at the time of the second request. County population density and the distance from each practice to the nearest academic hospital were recorded.
  
  
  RESULTS
  Of the 203 practices, 119 (59%) offered the patient with Medicaid an appointment within two weeks, and 160 (79%) offered the patient with private insurance an appointment within this time period (p < 0.001). Practices in rural counties were more likely to offer patients with Medicaid an appointment as compared with practices in urban counties (odds ratio, 2.25 [95% confidence interval, 1.16 to 4.34]; p = 0.016). Practices more than sixty miles from academic hospitals were more likely to accept patients with Medicaid than practices closer to academic hospitals (odds ratio, 3.35 [95% confidence interval, 1.44 to 7.83]; p = 0.005).
  
  
  CONCLUSIONS
  Access to orthopaedic care was significantly decreased for patients with Medicaid. Practices in less populous areas were more likely to offer an appointment to patients with Medicaid than practices in more populous areas. Practices that were farther from academic hospitals were more likely to offer an appointment to patients with Medicaid than practices closer to academic hospitals.
  
  
  CONCLUSIONS
  This study illustrates the barriers to timely outpatient orthopaedic care that patients with Medicaid face. The findings from our study imply that patients with Medicaid in more populous areas and in areas closer to academic medical centers are less likely to obtain an outpatient orthopaedic appointment than patients with Medicaid in less populous areas and in areas more distant from academic medical centers. A shift in policy to enhance access to orthopaedic care for patients with Medicaid, especially those in urban areas and areas close to academic medical centers, will become increasingly important as more patients become eligible for Medicaid through the Patient Protection and Affordable Care Act of 2010.
authors.affiliation: UNC School of Medicine, 130 Mason Farm Road, 3147 Bioinformatics Building, Chapel Hill, NC 27599-7055. E-mail address for R.W. Draeger: reid.draeger@gmail.com.
authors.forename: Brendan M
authors.initials: BM
authors.lastname: Patterson
authors.affiliation: UNC School of Medicine, 130 Mason Farm Road, 3147 Bioinformatics Building, Chapel Hill, NC 27599-7055. E-mail address for R.W. Draeger: reid.draeger@gmail.com.
authors.forename: Reid W
authors.initials: RW
authors.lastname: Draeger
authors.affiliation: UNC School of Medicine, 130 Mason Farm Road, 3147 Bioinformatics Building, Chapel Hill, NC 27599-7055. E-mail address for R.W. Draeger: reid.draeger@gmail.com.
authors.forename: Erik C
authors.initials: EC
authors.lastname: Olsson
authors.affiliation: UNC School of Medicine, 130 Mason Farm Road, 3147 Bioinformatics Building, Chapel Hill, NC 27599-7055. E-mail address for R.W. Draeger: reid.draeger@gmail.com.
authors.forename: Jeffrey T
authors.initials: JT
authors.lastname: Spang
authors.affiliation: The North Carolina Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, 160 North Medical Drive, Brinkhous-Bullitt Building, 2nd Floor, Campus Box CB# 7064, Chapel Hill, NC 27599.
authors.forename: Feng-Chang
authors.initials: FC
authors.lastname: Lin
authors.affiliation: UNC School of Medicine, 130 Mason Farm Road, 3147 Bioinformatics Building, Chapel Hill, NC 27599-7055. E-mail address for R.W. Draeger: reid.draeger@gmail.com.
authors.forename: Ganesh V
authors.initials: GV
authors.lastname: Kamath
mesh_terms: D000328:Adult; D000556:Ambulatory Surgical Procedures / Q000706:statistics & numerical data; D001071:Appointments and Schedules; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D019458:Insurance Coverage / Q000706:statistics & numerical data; D007348:Insurance, Health / Q000706:statistics & numerical data; D007405:Intervertebral Disc Displacement / Q000601:surgery; D008484:Medicaid / Q000706:statistics & numerical data*; D009657:North Carolina; D019637:Orthopedic Procedures / Q000706:statistics & numerical data; D011156:Population Density; D012111:Residence Characteristics / Q000706:statistics & numerical data; D000070636:Rotator Cuff Injuries; D012421:Rupture / Q000601:surgery; D013708:Tendon Injuries / Q000601:surgery; D061665:Time-to-Treatment; D014481:United States