Auditing Access to Outpatient Rehabilitation Services for Children With Traumatic Brain Injury and Public Insurance in Washington State

Accepted Manuscript Auditing access to outpatient rehabilitation services for children with traumatic brain injury and public insurance in Washington State Molly M. Fuentes, MD, MS, Leah Thompson, BA, D. Alex Quistberg, PhD, Wren L. Haaland, MPH, Karin Rhodes, MD, MS, Deborah Kartin, PhD, PT, Cheryl Kerfeld, PhD, PT, Susan Apkon, MD, Ali Rowhani-Rahbar, MD, PhD, Frederick P. Rivara, MD, MPH PII:

S0003-9993(17)30015-1

DOI:

10.1016/j.apmr.2016.12.013

Reference:

YAPMR 56772

To appear in:

ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 1 August 2016 Revised Date:

14 December 2016

Accepted Date: 19 December 2016

Please cite this article as: Fuentes MM, Thompson L, Quistberg DA, Haaland WL, Rhodes K, Kartin D, Kerfeld C, Apkon S, Rowhani-Rahbar A, Rivara FP, Auditing access to outpatient rehabilitation services for children with traumatic brain injury and public insurance in Washington State, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2017), doi: 10.1016/j.apmr.2016.12.013. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Insurance and outpatient rehabilitation Auditing access to outpatient rehabilitation services for children with traumatic brain injury and public insurance in Washington State

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Molly M. Fuentes, MD, MS1,2,3; Leah Thompson BA2; D. Alex Quistberg, PhD3; Wren L. Haaland, MPH2; Karin Rhodes, MD, MS4; Deborah Kartin, PhD, PT1; Cheryl Kerfeld, PhD, PT1; Susan Apkon, MD1; Ali Rowhani-Rahbar, MD, PhD3,5; Frederick P. Rivara,

University of Washington School of Medicine, Department of Rehabilitation Medicine,

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MD, MPH2,3,5,6

Seattle WA; 2 Seattle Children’s Research Institute, Seattle WA; 3 Harborview Injury Prevention and Research Center, Seattle WA; 4 Hofstra Northwell School of Medicine, Office of Population Health, Great Neck, NY; 5 University of Washington School of

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Public Health, Department of Epidemiology, Seattle WA; 6 University of Washington School of Medicine, Department of Pediatrics, Seattle WA

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Acknowledgement of Presentation: This material was presented in poster format at the American Congress of Rehabilitation Medicine Annual Meeting in Chicago, Illinois on

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November 3, 2016.

Acknowledgement of Funding Support: This work was supported by the Seattle Sports Concussion Research Collaborative; the Satterberg Foundation; the National Institute of Child Health and Human Development (grant number 5T32HD057822-05); and the National Center For Advancing

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Translational Sciences of the National Institutes of Health (grant number UL1TR000423). The funding agencies had no involvement in any phase of study

represent the official views of the National Institutes of Health.

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conduct. The content is solely the responsibility of the authors and does not necessarily

Other Acknowledgements: We would like to thank Lauren Balsalmo, Marni Levy and

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Deana Rich for their assistance with data collection.

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Conflicts of Interest: None of the authors have financial conflict of interest to report.

Corresponding Author: Molly Fuentes, Seattle Children’s Research Institute, PO Box 5371, M/S CW8, Seattle WA 98145-5005. Telephone (206) 884-8203. Email:

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[email protected]

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Insurance and outpatient rehabilitation

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Auditing access to outpatient rehabilitation services for children with traumatic brain

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injury and public insurance in Washington State

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Abstract

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Objective: Identify insurance-based disparities in access to outpatient pediatric

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neurorehabilitation services.

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Design: Audit study, with paired calls where callers posed as a mother seeking services for a

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simulated child with history of severe traumatic brain injury (TBI) and public or private

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insurance.

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Setting: Outpatient rehabilitation clinics in Washington State

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Participants: 195 physical therapy clinics (PTc), 109 occupational therapy clinics (OTc), 102

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speech therapy clinics (STc) and 11 rehabilitation medicine clinics

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Interventions: None

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Main outcome measures: Acceptance of public insurance, business days until the next available

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appointment.

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Results: Therapy clinics were more likely to accept private versus public insurance (relative risk

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(RR) for PTc 1.33 (95% confidence interval (CI) 1.22-1.44), OTc 1.40 (95% CI 1.24-1.57), and

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STc 1.42 (95% CI 1.25-1.62), with no significant difference for rehabilitation medicine (RR

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1.10, 95% CI 0.90-1.34). The difference in median wait time between clinics that accepted

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public versus only private insurance was 4 business days for PTc and 15 days for STc (p ≤ .001)

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but not significantly different for OTc or rehabilitation medicine. When adjusting for urban and

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multidisciplinary clinic status, the wait at clinics accepting public insurance was 59% longer for

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PT (95% CI 39-81%), 18% longer for OT (95% CI 7-30%) and 107% longer for ST (95% CI 87-

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130%) than at clinics accepting only private insurance. Distance to clinics varied by discipline

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and area within the state.

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Conclusion: Therapy clinics were less likely to accept public versus private insurance. Therapy

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clinics accepting public insurance had longer wait times than clinics that accepted only private

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insurance. Rehabilitation professionals should attempt to implement policy and practice changes

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to promote equitable access to care.

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Keywords: Rehabilitation; Children with Disabilities; Health Services for Persons with

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Disabilities; Health Equity; Health Services Accessibility

Abbreviations:

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CBG Census Block Group

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CHIP Children’s Health Insurance Program

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CI

Confidence Interval

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CR

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IQR

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OTc

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PTc

Physical Therapy Clinics

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STc

Speech Therapy Clinics

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TBI

Traumatic Brain Injury

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Count Ratio

Interquartile Range

Occupational Therapy Clinics

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Traumatic brain injury (TBI) is a leading cause of acquired pediatric disability.1 A study of children hospitalized for TBI found 70% reported cognitive dysfunction and 56% physical

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dysfunction 12 months after injury.2 Nationally, 34% of children hospitalized for TBI have

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publicly funded insurance,3 and children with public insurance were more likely than those with

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private insurance to have unmet rehabilitation needs one year post-injury.2

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A systematic review found children with public insurance (Medicaid or Children’s Health Insurance Program (CHIP)), are less likely to receive specialty medical care and have difficulty

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finding physicians that accept public insurance.4 In one study, pediatric specialty appointments

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were denied to 66% of callers with public insurance versus only 11% with private (employer-

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based or privately purchased) insurance, and children with public insurance waited 22 days

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longer for an appointment than children with private insurance.5 Other studies also found access

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disparities based on insurance type.6-8

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Insurance-based disparities around outpatient neurorehabilitation services have been

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demonstrated. Claims analysis showed adults with TBI and Medicaid insurance were less likely

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than those with private insurance to receive outpatient rehabilitation services.9 A study of

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pediatric TBI services in Washington State found most providers were located in urban areas and

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70% of physical therapy/occupational therapy clinics and 80% of speech therapy/cognitive

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therapy clinics self-reported acceptance of public insurance.10 The relationship between

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insurance type and wait times for outpatient rehabilitation in the United States has not been

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examined.

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This study used audit methodology to define insurance-based disparities in access to

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outpatient pediatric neurorehabilitation services, with access measured by acceptance of

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insurance plan and wait time to the next available appointment. Exploratory aims based on

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anecdotal experience assessed the relationship between insurance type, access, the number of

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therapy disciplines provided by the clinic, and the urban status of the clinic. Another exploratory

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aim evaluated insurance-based variation in the distance traveled to services. The study team hypothesized that compared to private insurance, public insurance would

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be accepted less frequently by outpatient rehabilitation clinics and would be associated with

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longer wait times for services. Exploratory hypotheses were that multidisciplinary and non-urban

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status would be associated with higher rates of public insurance acceptance but longer wait

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times, and that callers with public insurance would travel further to access services.

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Methods

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Study design

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This was an audit study where researchers posed as mothers and made scripted, paired

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calls to therapy and rehabilitation medicine clinics to determine: if the clinic provided services

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for a simulated child with sequelae from a TBI; if the clinic accepted the caller’s insurance; and

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the number of business days until the next available appointment. The calls occurred between

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November 2, 2015 and March 17, 2016, with paired calls separated by three to five weeks. This

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study was conducted in Washington, a state where 41% of children are publicly insured,11 most

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by Medicaid managed care plans. In Washington State, children with family incomes up to 210%

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of the federal poverty level are eligible for Medicaid and children with family incomes up to

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312% of the federal poverty level qualify for Washington’s separate CHIP (5.5% of children

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using public insurance in the state).12,13

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Clinical scenario and protocol

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Each clinic was called twice using a script in which the caller had moved and needed to

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establish rehabilitation care for her simulated child with the following sequelae of TBI: balance

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difficulties, diminished use of the dominant arm, and cognitive-communication impairments.

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The paired calls varied by insurance status (private insurance or Medicaid-managed care plan,

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hereafter referred to as public insurance) and child’s age, gender and time since injury (eight-

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year-old girl nine months post-TBI or nine-year–old boy ten months post-TBI). The time frames

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represent a phase of injury beyond acute inpatient rehabilitation but when functional change is

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expected. The order of these characteristics was assigned using an Excel random number

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generator.14 If not asked about insurance, the caller confirmed the clinic accepted their insurance

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after obtaining the date of the next available appointment. The public insurance plan with the

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largest market share was used in this study, with the exception of calls to clinics in one county

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where the primary plan was not utilized. After completing paired calls, a team member called the

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clinics which did not accept the public insurance plan in the study to confirm they did not accept

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public insurance. No appointments were scheduled and calls were ended as soon as the outcome

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information was obtained. Responses to possible scheduling barriers were included in the scripts,

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which can be found in the supplementary materials.

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Sampling methods

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The sample of therapy clinics potentially offering pediatric neurorehabilitation services

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was generated from (1) marketing lists of licensed physical therapists, occupational therapists,

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and speech therapists; (2) lists of community therapy clinics and county-specific resources for

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children with special healthcare needs maintained by the state’s tertiary children’s hospital; (3) a

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pediatric resource list from the Brain Injury Alliance of Washington; and (4) a Google Maps15-

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based search using the terms “pediatric [physical/occupational/speech] therapy”. Clinics

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identified by the children’s hospital or Brain Injury Alliance and those with websites listing

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neurological or pediatric services were included. Therapy clinics were excluded if they provided

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only home health or specialized treatments (e.g. hand therapy), served only children under 3-

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years-old, focused on musculoskeletal or sports therapy, or did not accept any insurance.

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The sample of rehabilitation medicine clinics was generated from publicly-available

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databases from the American Board of Physical Medicine and Rehabilitation, the American

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Academy of Physical Medicine and Rehabilitation, and major healthcare systems in Washington

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State. The rehabilitation medicine sample included those providing pediatric, neurological, or

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general outpatient rehabilitation care; clinics focused on musculoskeletal rehabilitation or

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electrodiagnostic testing were excluded.

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Outcomes and covariates

This study's primary outcomes were the clinic’s acceptance of public insurance and the

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number of business days until the next available appointment. Secondary outcomes included the

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distance from each Washington State census block group (CBG) center point to the five nearest

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clinics accepting any insurance type (since those with private insurance can access clinics

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accepting both insurance types) and the distance to the five nearest clinics accepting public

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insurance. Urban and multidisciplinary statuses of the clinic were covariates. Urban status was

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derived from the county-level Urban Influence Code16 and classified as being in a large

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metropolitan (greater than one million people) or small/non-metropolitan area. Clinics were

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classified as single discipline if they offered only one discipline or multidisciplinary if two or

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more therapy services were available at the facility.

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Study oversight

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The University of Washington Human Subjects Division determined this study was not human subjects research, as clinics, not people, were studied. The study team independently

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obtained a research bioethics consultation from the University of Washington Institute of

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Translational Health Sciences, which recommended clinics be sent a letter indicating this study

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was taking place. Two clinics responded that they did not serve children with TBI and were

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removed from the sample.

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Statistical analysis

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Descriptive statistics characterized the population of clinics and insurance acceptance

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patterns. Generalized linear models (GLM), using Poisson family and log link, with a random

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effect for clinic to account for repeated measures from paired calls and robust variance

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estimations compared the proportion of clinics accepting private versus public insurance. This

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analysis was then stratified by multidisciplinary and urban status. Because baseline risk for

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insurance acceptance between callers with public and private insurance was hypothesized to be

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different, Poisson-based GLM were thought to be superior to other forms of regression.17

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Median wait time for callers with public insurance at clinics accepting public insurance was compared to the wait time at clinics accepting only private insurance using the Wilcoxon

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rank-sum on median difference test. For clinics accepting both insurance types, the intra-clinic

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difference in number of business days until the next available appointment with public versus

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private insurance was calculated. A multivariable GLM, using Poisson family and log link with

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robust variance for wait times in business days until an appointment, assessed the influence of

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insurance type acceptance and clinic’s multidisciplinary and urban status on wait time for each

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discipline. In this model, the wait time at clinics accepting public insurance was the wait time for

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callers with public insurance. The estimates from this model are interpreted as count ratios

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describing the factor by which the count of business days is greater at clinics accepting public

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insurance compared to those accepting only private insurance. Because only one rehabilitation

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medicine clinic did not accept public insurance and one STc did not accept private insurance,

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these clinics were excluded from analyses comparing wait times by types of insurance accepted.

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Geospatial analysis

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Because families likely utilize geographically accessible services, geospatial analysis was

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conducted to assess the average driving distance and wait time by CBG. Clinics were geocoded

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by latitude and longitude from street addresses using GPS Visualizer via the Bing Maps API.18,19

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Center points from the centroid of the polygon of each CBG in Washington were generated.

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Driving distance (miles) from a CBG center point to a clinic was determined by creating a road

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network dataset with the US Census and Washington public roads geodatabase, including ferry

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routes.20,21 Each clinic was assigned a single wait time, either the wait for a caller with public

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insurance at clinics accepting public insurance or the wait for a caller with private insurance at

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clinics accepting only private insurance. For each CBG, the average distance to and wait time at

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the five nearest therapy clinics and the five nearest therapy clinics accepting public insurance for

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each therapy discipline were determined, as using values for the single nearest clinic would

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reveal identifiable information about clinics. Given the small number of clinics, only distance to

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the rehabilitation medicine clinic nearest to the center point was determined for each CBG to

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avoid disclosure of individual clinic information.

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Linear mixed models with robust variance and clinics nested in CBGs for each discipline

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were used to estimate mean differences in distance from the CBG center point to the five nearest

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clinics accepting public insurance and the five nearest clinics. Area-value maps (choropleths) of

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the mean distance and wait time for each CBG were created in order to visually compare access

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to rehabilitation services across geographic locations and insurance types.

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Statistical significance was set at P<.05. ArcGIS Desktop 10.4 was used for geospatial

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analysis. Stata 12 software was used for data analysis.

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Results

Of the 427 clinics in the sample, 400 clinics were contacted and 287 indicated they could

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provide rehabilitation services for the simulated child with TBI, resulting in data from 195

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physical therapy clinics (PTc), 109 occupational therapy clinics (OTc), 102 speech therapy

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clinics (STc), and 11 rehabilitation medicine clinics (Figure 1). Most PTc were single discipline,

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while OTc and STc were predominantly multidisciplinary. The majority of STc and

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rehabilitation medicine clinics were located in large metropolitan areas with most PTc and OTc

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located in small/non-metropolitan areas. (Table 1)

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Insurance Acceptance

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Overall, 147 (75.4%) PTc, 78 (71.6%) OTc, 71 (69.6%) STc and 10 (90.9%) rehabilitation medicine clinics accepted public insurance. Therapy clinics were 33-42% more

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likely to accept private versus public insurance while there was no significant difference in

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insurance plans accepted by rehabilitation medicine clinics. Multidisciplinary clinics were more

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likely than single discipline clinics to accept public insurance. Less than half of single discipline

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OTc and STc accepted public insurance. A higher proportion of clinics in small/non-

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metropolitan areas accepted public insurance compared to those in large metropolitan areas.

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(Table 2)

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Wait Times for Rehabilitation Services

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When comparing the median wait time at clinics accepting public insurance versus only

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private insurance, there were statistically significant differences for PTc (7 versus 3 business

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days to next available appointment, p<.0001) and STc (20 versus 5 business days, p=.0006), and

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neared statistical significance for OTc (12.5 versus 5 business days, p=.0584). Stratifying by

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urban status revealed different effects on wait time for the various disciplines. The wait at STc

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accepting public insurance in large metropolitan areas was 38.5 business days compared to only

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5 business days at clinics accepting only private insurance (P=.0059). Large metropolitan OTc

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accepting public insurance had longer wait times than those accepting only private insurance

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(median 20 versus 5 business days, p=.0182) while there was no significant difference for PTc in

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large metropolitan areas (4 versus 3 business days, p=.2239). (Table 3) Rehabilitation medicine

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clinics had a median wait of 13 business days (interquartile range (IQR) 9-44, range 4-80),

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regardless of insurance type accepted.

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When examining the distribution of difference in wait times within the 147 PTc, 78 OTc and 70 STc that accepted both insurance types, most clinics had no within-clinic insurance-based

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difference in wait time (median difference of 0 business days for all disciplines, IQR 0-1).

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However, the wait when the caller to these clinics had public insurance ranged up to 50 (PTc), 55

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(OTc), and 115 (STc) business days longer than when the caller had private insurance.

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Multivariable analysis

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Adjusting for urban and multidisciplinary status, the wait until the next available

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appointment at clinics accepting public insurance was 59% longer (count ratio (CR) 1.59, 95%

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confidence interval (CI) 1.39-1.81) for PTc, 18% longer (CR 1.18, 95% CI 1.07-1.30) for OTc

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and 107% longer (CR 2.07, 95% CI 1.87-2.30) for STc compared to clinics accepting only

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private insurance. Urban status remained statistically significant for OTc and STc and

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multidisciplinary status affected wait times for PTc and STc when adjusting for other covariates.

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(Table 4)

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Geospatial Analysis

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The average distance from the CBG center point to the five nearest clinics varied by

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discipline (PTc 11.0 miles (SD 13.5); OTc 15.0 miles (SD 17.8); STc 17.4 miles (SD 21.5),

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rehabilitation medicine 60.7 miles (SD 37.5)). The difference in mean distance from the CBG

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center point to the five nearest clinics and the mean distance to the five nearest clinics accepting

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public insurance also varied by discipline, with the greatest difference among STc (mean

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difference 6.2 miles (95% CI 5.8, 6.9)). The visual representation of the average distance

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traveled and wait time for therapy services by CBG demonstrates geographic variation across the

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state (supplemental figures 1 and 2).

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Discussion

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In this study, callers posing as mothers of a simulated child with TBI covered by public

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insurance in Washington State were less likely to have their insurance accepted and had longer

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waits for therapy services than callers with private insurance. More than a quarter of therapy

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clinics sampled did not accept public insurance, a finding that corroborates previous work10 and

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suggests barriers to care following pediatric TBI in Washington State.

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Median wait times at therapy clinics accepting public insurance were 4 to 15 business

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days longer than at clinics accepting only private insurance. This represents less disparity than

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found in other insurance-based studies of access to care.5-7 These studies did not include analyses

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comparing access based on urban status. In this study, disparities in the proportion of therapy

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clinics accepting public insurance were more pronounced in large metropolitan areas. It is

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possible that the greater population density in large metropolitan areas makes it feasible for

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urban clinics to fill a practice while only accepting private insurance, reducing access options for

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those with public insurance. The geospatial analysis revealed a number of findings. As might be expected, travel

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distances were longer for rehabilitation medicine access than for any of the therapy services

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since there were only 11 such clinics in the state. While the differences in travel times by

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insurance status for different services were relatively small, the effect of insurance type on wait

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times varied by region of the state. Federally qualified health centers and other clinics which

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provide care for children with public insurance should consider adding therapy services to their

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program to increase access to rehabilitation services.

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Among the therapy disciplines, STc were least likely to accept public insurance and had

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the largest insurance-based differences in wait times. This is concerning, as a prior study found

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children 12 months after TBI had greater need for cognitive health services – such as those

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provided by STc – than physical or socioemotional services.2 This study’s findings suggest the

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rehabilitation therapy discipline in greatest demand may also have the most striking insurance-

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based access disparities.

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Study limitations

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As a single state study, these results cannot be generalized to other states, particularly

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states which did not expand Medicaid under the Affordable Care Act. The injury profile assessed

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by this study was limited to the chronic sequela of TBI; access patterns may differ for children

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with acute TBI, such as those recently discharged from hospitals or rehabilitation units. The

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sample may not include every clinic offering outpatient pediatric neurorehabilitation therapies.

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Because the analysis focused on differences by insurance type, the sampling method did not

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utilize the insurance plans' provider directories, which means avenues for accessing rehabilitation

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services may have been missed. Excluding clinics focusing on musculoskeletal impairments

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might have undercounted children’s access to rehabilitation services. However, the study team

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felt a child with TBI would be best served by clinics specializing in pediatric or neurological

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rehabilitation. Multiple callers collected this data, though all were trained by one individual

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(L.T.). The analysis did not adjust for the number of providers at a clinic, clinic’s popularity or

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reputation for quality services, or whether the clinic was hospital-based, all of which could affect

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the wait time for an appointment and likelihood of public insurance acceptance. Future studies

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should include details on clinic infrastructure, which will need to be obtained using a different

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methodology than used in this study. This analysis focused on wait times to initial evaluation

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and not ongoing treatments. While there may be different patterns of access for ongoing

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outpatient pediatric rehabilitation services, barriers to accessing initial evaluations – such as

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those described in this study – preclude opportunities for ongoing service delivery.

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Conclusions

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Further work is needed to characterize and mitigate factors influencing disparities in

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access to outpatient rehabilitation services for children with public insurance. It is not known

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whether the disparities found in this study were a result of intentional policies or implicit bias.

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Regardless, this study’s findings serve as a call to action. Along with policy makers,

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rehabilitation professionals should implement changes to promote equitable access to

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rehabilitation care.

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Acknowledgements: We would like to thank [name], [name] and [name] for their assistance with

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data collection.

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Funding: This work was supported by the [name of local research funding source]; [local

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philanthropy group]; the National Institute of Child Health and Human Development (grant

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number XX); and the National Center For Advancing Translational Sciences of the National

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Institutes of Health (grant number XX). The content is solely the responsibility of the authors

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and does not necessarily represent the official views of the National Institutes of Health.

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References

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1.

Faul M, Xu L, Wald MM, Coronado VG, National Center for Injury Prevention and Control. Traumatic brain injury in the United States: emergency department visits,

333

hospitalizations, and deaths, 2002-2006. Atlanta, GA: U.S. Dept. of Health and Human

334

Services, Centers for Disease Control and Prevention, National Center for Injury

335

Prevention and Control; 2010:

336

http://www.cdc.gov/traumaticbraininjury/pdf/blue_book.pdf.

3.

4.

access for children. Arch Pediatr Adolesc Med. 2012;166(4):304-310. 7.

Penn EB, Jr., French A, Bhushan B, Schroeder JW, Jr. Access to care for children with symptoms of sleep disordered breathing. nt J Pediatr Otorhinolaryngol. 2012;76(11):16711673.

349

351

Bisgaier J, Polsky D, Rhodes KV. Academic medical centers and equity in specialty care

EP

6.

348

350

Bisgaier J, Rhodes KV. Auditing access to specialty care for children with public insurance. New Engl J Med. 2011;364(24):2324-2333.

346 347

TE D

5.

344 345

Skinner AC, Mayer ML. Effects of insurance status on children's access to specialty care: a systematic review of the literature. BMC Health Serv Res. 2007;7:194.

342 343

Greene NH, Kernic MA, Vavilala MS, Rivara FP. Variation in pediatric traumatic brain injury outcomes in the United States. Arch Phys Med Rehabil. 2014;95(6):1148-1155.

340 341

SC

pediatric traumatic brain injury. Pediatrics. 2006;117(4):e663-674.

338 339

Slomine BS, McCarthy ML, Ding R, et al. Health care utilization and needs after

M AN U

2.

AC C

337

RI PT

332

8.

Chaudhry SB, Armbrecht ES, Shin Y, et al. Pediatric access to dermatologists: Medicaid versus private insurance. J Am Acad Dermatol. 2013;68(5):738-748.

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352

9.

Schiraldi M, Patil CG, Mukherjee D, et al. Effect of insurance and racial disparities on

353

outcomes in traumatic brain injury. J Neurol Surg A Cent Eur Neurosurg.

354

2015;76(3):224-232. 10.

Moore M, Jimenez N, Rowhani-Rahbar A, et al. Availability of Outpatient Rehabilitation

RI PT

355 356

Services for Children After Traumatic Brain Injury: Differences by Language and

357

Insurance Status. Am J Phys Med Rehabil. 2016;95(3):204-213. 11.

Kaiser Family Foundation. State Health Facts: Health Insurance Coverage of Children 0-

SC

358

18. 2016; http://kff.org/other/state-indicator/children-0-18/?state=WA. Accessed March

360

16, 2016.

361

12.

M AN U

359

Medicaid and CHIP Payment and Access Commission. Medicaid and CHIP Income Eligibility Levels as a Percentage of the FPL for Children and Pregnant Women by State,

363

July 2016. 2016; https://www.macpac.gov/wp-content/uploads/2015/01/EXHIBIT-34.-

364

Medicaid-and-CHIP-Income-Eligibility-Levels-as-a-Percentage-of-the-FPL-for-Children-

365

and-Pregnant-Women-by-State-July-2016.pdf. Accessed October 17, 2016.

366

13.

TE D

362

Medicaid and CHIP Payment and Access Commission. Child Enrollment in CHIP and Medicaid by State, FY 2015. 2015; https://www.macpac.gov/wp-

368

content/uploads/2015/01/EXHIBIT-31-Child-Enrollment-in-CHIP-Medicaid-by-state-

369

FY-2015-1.pdf. Accessed October 17, 2016.

14.

Excel (Part of Microsoft Office Professional Edition) [computer program]. Microsoft; 2010.

371 372

AC C

370

EP

367

15.

Google. Google Maps. https://www.google.com/maps/. Accessed January 11, 2016.

ACCEPTED MANUSCRIPT

373

16.

United States Department of Agriculture Economic Research Service. Urban Influence

374

Codes. 2013; http://ers.usda.gov/data-products/urban-influence-

375

codes/documentation.aspx. Accessed July 14, 2014.

Am J Epidemiol. 2004;159(7):702-706.

377 378

18.

Schneider A. GPS Visualizer Address Locator. 2016;

http://www.gpsvisualizer.com/geocoder/. Accessed 20 Jun, 2016.

379 380

Zou G. A modified poisson regression approach to prospective studies with binary data.

RI PT

17.

19.

SC

376

Bing™ Maps REST (Representational State Transfer) Services API (Application Programming Interface): Locations. Microsoft Corporation; 2016.

382

https://msdn.microsoft.com/en-us/library/ff701715.aspx. Accessed 20 Jun 2016. 20.

https://www.census.gov/geo/maps-data/data/tiger-line.html. Accessed 20 Jun 2016.

384

386

387

21.

Washington All Public Roads (WAPR). Washington State; 2014. http://www.wsdot.wa.gov/mapsdata/geodatacatalog/. Accessed 23 May 2016.

Suppliers

EP

385

TIGER/Line® Shapefiles and TIGER/Line® Files. US Department of Commerce; 2015.

TE D

383

M AN U

381

a. Esri (ArcGIS Desktop 10.4), 380 New York Street, Redlands, CA 92373-8100

389

b. StataCorp LP (Stata 12), 4905 Lakeway Drive, College Station, TX 77845-4512

390

AC C

388

391

Figure Legends

392

Figure 1: Clinics included in study sample. Abbreviations: Physical Therapy (PT), Occupational

393

Therapy (OT), Speech Therapy (ST)

ACCEPTED MANUSCRIPT

Table 1. Characteristics of outpatient rehabilitation clinics. Physical

Occupational

Speech

Medicine

Therapy

Therapy

Therapy

Clinics

Clinics

Clinics

Clinics

(N=11)

(N=195)

(N=109)

(N=102)

SC

Number of disciplines

Single discipline

11 (100.0)

Multidisciplinary

0 (0.0)

28 (25.7)

44 (43.1)

78 (40.0)

81 (74.3)

58 (56.9)

6 (54.6)

80 (41.0)

49 (45.0)

54 (52.9)

EP

115 (59.0)

60 (55.0)

48 (47.1)

Large metro area

AC C

Small metro/non-metro area

117 (60.0)

TE D

Urban location of

M AN U

in clinic

clinic

RI PT

Rehabilitation

5 (45.4)

Note. Values presented as N (column %).

ACCEPTED MANUSCRIPT Table 2. Insurance plan acceptance at outpatient rehabilitation clinics, by insurance type

Clinic accepts

Clinic accepts

Relative Risk

private insurance

public insurance

[95% CI]

All clinics

RI PT

N(%)

195 (100.0)

147 (75.4)

1.33 [1.22-1.44]

OTc (n=109)

109 (100.0)

78 (71.6)

1.40 [1.24-1.57]

STc (n=102)

101 (99.0)

71 (69.6)

Rehab Med (n=11)

11 (100.0)

10 (90.9)

SC

PTc (n=195)

1.42 [1.25-1.62]

M AN U

1.10 [0.90-1.34]

Number of Disciplines in Clinic

TE D

Single Discipline 117 (100.0)

84 (71.8)

1.39 [1.24-1.56]

OTc (n=28)

28 (100.0)

12 (42.9)

2.33 [1.51-3.61]

STc (n=44)

44 (100.0)

21 (47.8)

2.10 [1.53-2.86]

78 (100.0)

63 (80.8)

1.24 [1.11-1.38]

81 (100.0)

68 (84.0)

1.23 [1.11-1.36]

57 (98.3)

49 (84.5)

1.14 [1.02-1.27]

PTc (n=78) OTc (n=81) STc (n=58)

AC C

Multidisciplinary

EP

PTc (n=117)

Urban Location of Clinic Large metro area

ACCEPTED MANUSCRIPT PTc (n=80)

80 (100.0)

53 (66.3)

1.51 [1.29-1.77]

OTc (n=49)

49 (100.0)

26 (53.1)

1.88 [1.44-2.46]

STc (n=54)

54 (100.0)

28 (51.9)

1.93 [1.49-2.50]

Rehab Med (n=6)

6 (100.0)

5 (83.3)

1.20 [0.81-1.78]

PTc (n=115)

115 (100.0)

94 (81.7)

1.22 [1.12-1.33]

OTc (n=60)

60 (100.0)

52 (86.7)

1.15 [1.04-1.28]

STc (n=48)

47 (97.9)

43 (89.6)

Rehab Med (n=5)

5 (100.0)

5 (100.0)

RI PT

Small metro/Non-metro

SC

area

1.09 [0.98-1.22]

M AN U

--

Note: Relative risk in this generalized linear model compares proportion of clinics offering an appointment when the caller had private insurance versus public insurance. All rehabilitation medicine clinics were single disciplinary.

TE D

Abbreviations: CI, confidence interval; PTc, physical therapy clinic; OTc, occupational therapy clinic; STc,

AC C

EP

speech therapy clinic; Rehab Med, rehabilitation medicine clinic

ACCEPTED MANUSCRIPT

Table 3. Wait times in work days according to clinic acceptance of public insurance

Physical Therapy Clinics

Accepts only P-value Accepts public Accepts only P-value

(Median,

public

private

IQR)

insurance

insurance

N=147

N=48

7 (3,14)

3 (1,6.5)

insurance

private insurance

Accepts

Accepts only

public

private

insurance

insurance

N=70

N=31

20 (9,41)

5 (2,20)

N=28

N=26

38.5 (7.5, 62.5)

5 (4,20)

N=42

N=5

18.5 (9,40)

5 (2,5)

RI PT

Accepts

Speech Therapy Clinics P-value

SC

Work Days

Occupational Therapy Clinics

N=78 <.0001

5 (4,25)

N=26

N=23

4 (2,10)

3 (1,5)

.2239

N=21

9 (4,14)

3 (1,7)

<.0001

5 (3,24)

N=52

N=8

10 (5.5,20)

11 (5,43.5)

AC C

N=94

20 (10,40)

EP

Clinics in Small Metro or Non-Metro Areas

TE D

N=27

N=31

12.5 (6,30)

Clinics in Large Metro Areas N=53

M AN U

All Clinics

.0584

.0182

.9216

Notes. Wait at centers that accept both public and private insurance is the wait time in work days for a child with public insurance. Abbreviations: IQR, interquartile range

.0006

.0059

.0643

ACCEPTED MANUSCRIPT

Table 4. Poisson regression for work days to appointment at clinics accepting both insurance types relative to clinics accepting only private insurance, with adjustment for urban status and multidisciplinary services

Count ratio

Large Metro Area Small Metro/Non-Metro Area Single Discipline Multiple Disciplines

Count ratio

1

-ref-

1.0

1.59

1.39, 1.81

1.18

1

-ref-

1.00

0.91, 1.11

1 3.18

95% CI

Speech Therapy Clinics Count ratio

95% CI

-ref-

1.0

-ref-

1.07, 1.30

2.07

1.87, 2.30

-ref-

1.0

-ref-

1.21

1.12, 1.32

0.71

0.66, 0.77

-ref-

1.0

-ref-

1.0

-ref-

2.88, 3.51

0.96

0.87, 1.05

1.64

1.51, 1.79

SC

Accepts Both Insurances

95% CI

1.0

M AN U

Accepts Private Insurance Only

Occupational Therapy Clinics

RI PT

Physical Therapy Clinics

TE D

Note. In this model, count ratio is interpreted as the factor by which the count of work days is greater for calls with public insurance compared to private insurance. For instance, if a multidisciplinary ST clinic in a large metropolitan area that only accepted private insurance had a wait time of 5

Abbreviations: CI, confidence interval

AC C

work days.

EP

work days, the expected wait time at a multidisciplinary ST clinic in a large metropolitan area that accepted public insurance would 5 x 2.07, or 10.35

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT Supplemental Figure 1. Mean distance to nearest clinics and to nearest clinics accepting public insurance for each discipline by census block group. Mean distance is the distance using road network analysis from the census block group center point to the nearest therapy clinics that offered an appointment to the simulated child

Clinics Accepting Public Insurance

AC C

EP

TE D

M AN U

SC

RI PT

A. Physical Therapy Clinics (PTc). PTc accepting public insurance also accepted private insurance.

All Clinics

ACCEPTED MANUSCRIPT

Clinics Accepting Public Insurance

AC C

EP

TE D

M AN U

SC

RI PT

B. Occupational Therapy Clinics (OTc). OTc accepting public insurance also accepted private insurance

All Clinics

ACCEPTED MANUSCRIPT

Clinics Accepting Public Insurance

AC C

EP

TE D

M AN U

SC

RI PT

C. Speech Therapy Clinics (STc). One STc accepting public insurance did not accept private insurance.

All Clinics

ACCEPTED MANUSCRIPT

Clinics Accepting Public Insurance

AC C

EP

TE D

M AN U

SC

RI PT

D. Rehabilitation Medicine Clinics. Rehabilitation medicine clinics accepting public insurance also accepted private insurance.

All Clinics

ACCEPTED MANUSCRIPT

Clinics Accepting Public Insurance

AC C

EP

TE D

M AN U

SC

RI PT

Supplemental Figure 2. Wait time at the five clinics and at the five clinics accepting public insurance nearest the census block group center point. A. Physical Therapy Clinics

All Clinics

ACCEPTED MANUSCRIPT

Clinics Accepting Public Insurance

AC C

EP

TE D

M AN U

SC

RI PT

B. Occupational Therapy Clinics

All Clinics

ACCEPTED MANUSCRIPT

Clinics Accepting Public Insurance

AC C

EP

TE D

M AN U

SC

RI PT

C. Speech Therapy Clinics

All Clinics

ACCEPTED MANUSCRIPT Therapy Script/Work-Arounds for Profile 1: Background info Your name: Jennifer Moore Daughter: Emily Moore, 8-year-old, DOB: 4/12/2007

RI PT

See clinic spreadsheet for address

My daughter needs to see a [physical therapist/occupational therapist/speech therapist]. We’re trying to figure out the best place to take her. When is your next available appointment?

SC


SEE IF YOU CAN GET A DATE BUT DO NOT SCHEDULE. IF OFFERED SCHEDULING: • That should work...Oh, wait, I might have to be out of town then. How about I just call back later to schedule.

M AN U

IF ASKED WHAT THE APPOINTMENT IS FOR: • She had a brain injury in February [move month forward so 9 months prior to call] and still has some difficulty [with balance (PT)/using her right hand (OT)/ with her memory and keeping organized (ST)].

TE D

If ASKED ABOUT INSURANCE BEFORE BEING TOLD AVAILABLE APPOINTMENTS. • Our insurance is [see spreadsheet for type of insurance for the call]. o If asked for insurance number: [Pause to mime riffling for insurance card] Oh shoot, I left my insurance card in my other bag. I’ll bring the card to the appointment. o If asked about subscriber: Christopher Moore o If told that they cannot schedule an appointment without having insurance card: Well, can you tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling? IF THE DATE IS MORE THAN 2 WEEKS AWAY ADD: • I don’t want her to lose any of the gains she has made. Is there an appointment sooner than that?

AC C

EP

IF THEY OFFER APPOINTMENT: • I am also trying to get her set up with [other two disciplines, OT/Speech or PT/OT or PT/Speech]. Do you offer [other 2 disciplines]? • IF INSURANCE HAS NEVER BEEN DISCUSSED: Before I get everything set up, I want to make sure you take our insurance. We have [see spreadsheet for type of insurance for the call]


IF TOLD THAT YOU NEED A REFERRAL/DOCTOR ORDER TO GET AN APPOINTMENT: • I have the doctor’s order for [PT/OT/ST], I can bring it in at the time of the appointment. •

IF TOLD THAT THE OFFICE MUST SEE THE ORDER BEFORE MAKING THE APPOINTMENT: I can read what the order says, but can you just tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling? o PT: Okay it says diagnosis: personal history of traumatic brain injury (Z87.820), spastic hemiplegia affecting right dominant side (G81.11), paralytic gait abnormality (R26.1). Precautions: none. Order comments: Evaluate and treat: gait training on uneven surfaces, balance, floor recovery, endurance. Provide HEP for ROM, strength, endurance and functional mobility. See weekly with re-evaluation at 12 weeks. o

OT: it says diagnosis: personal history of traumatic brain injury (Z87.820), spastic hemiplegia affecting right dominant side (G81.11), limitation of activities due to disability

ACCEPTED MANUSCRIPT (Z73.6), other lack of coordination (R27.8). Precautions: none. Order comments: Evaluate and treat right upper extremity strength, ROM and coordination, splinting as necessary, bimanual activities, dressing/ADLs. See weekly with re-evaluation at 12 weeks. ST: Okay it says diagnosis: personal history of traumatic brain injury (Z87.820), cognitive communication deficit (R41.841). Precautions: none. Order comments: Evaluate and treat cognitive communication deficits, word retrieval skills, compensatory strategies to improve recall, attention, organization; auditory and written comprehension. See weekly with re-evaluation at 12 weeks.

RI PT

o

If unable to just read the order to the scheduler: • I don’t have a fax machine to send the order I have. Maybe I can call the doctor’s office and ask them to fax the order to you. What’s your fax number? What will happen after you get the order, should I call you back? Can you just tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling?

M AN U

SC


IF TOLD THAT THE OFFICE MUST HAVE CLINICAL INFORMATION BEFORE MAKING THE APPOINTMENT: • I have the doctor’s note from a few weeks ago, I can read it to you, but can you just tell me what day you can give me an appointment? I’m trying to work out my schedule. o If asked to read clinic note:  What sort of information do you need? [Read that part of the “dummy clinic note Profile 1”].  Try to avoid sending the dummy note, but can email it from gmail account if needed
IF TOLD THAT SOMEONE WILL HAVE TO CALL YOU BACK TO SCHEDULE THE APPOINTMENT. • Okay, my cell number is [XXX-XXX-XXXX].

TE D


IF TOLD THAT ADDRESS SEEMS FAR AWAY: • This place is on the list of possible therapy centers that our rehab doctor gave us; we don’t mind driving to get Emily what she needs.


IF YOU ARE ASKED…/WORK-AROUNDS

Has she had therapy before? • Yes, she did inpatient rehab in Colorado and went to a therapy clinic and had therapy in school.

EP

Does she have any other medical problems? • Nothing else.

AC C

What is the name of your child’s doctor? • Dr. [Rehab Doctor]; [Dr. full name if asked for full name] Who is the primary care doctor? • She has an appointment at [nearby clinic] next week; I can’t recall the doctor’s name. AFTER THE CALL: FILL OUT POST-CALL EVALUATION

IF NO ANSWER, CALL BACK A SECOND TIME. IF NO ANSWER ON SECOND CALL, LEAVE A MESSAGE:

•

Hello, I am trying to make a therapy appointment for my 8-year-old daughter who had a brain injury. Please call me at XXX-XXX-XXXX.

ACCEPTED MANUSCRIPT Rehab Medicine Script/Work-Arounds for Profile 1: Background info Your name: Jennifer Moore Daughter: Emily Moore, 8-year-old, DOB: 4/12/2007

RI PT

See clinic spreadsheet for address

My daughter needs to see a rehab doctor to follow up on her brain injury.

SC


SEE IF YOU CAN GET A DATE BUT DO NOT SCHEDULE. IF OFFERED SCHEDULING: • That should work...Oh, wait, I might have to be out of town then. How about I just call back later to schedule.

M AN U

IF ASKED WHAT THE APPOINTMENT IS FOR: • She had a brain injury in February [move month forward so 9 months prior to call] and still has some difficulty with balance, using his right hand, with his memory and keeping organized.

TE D

If ASKED ABOUT INSURANCE BEFORE BEING TOLD AVAILABLE APPOINTMENTS. • Our insurance is [see spreadsheet for type of insurance for the call]. o If asked for insurance number: [Pause to mime riffling for insurance card] Oh shoot, I left my insurance card in my other bag. I’ll bring the card to the appointment. o If asked about subscriber: Christopher Moore o If told that they cannot schedule an appointment without having insurance card: Well, can you tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling? IF THE DATE IS MORE THAN 2 WEEKS AWAY ADD: • I’m worried about her muscle tone. Is there an appointment sooner than that?

EP

IF THEY OFFER APPOINTMENT DATE AND INSURANCE HAS NEVER BEEN DISCUSSED: Before I get everything set up, I want to make sure you take our insurance. We have [see spreadsheet for type of insurance for the call]

AC C


IF TOLD THAT YOU NEED A REFERRAL/DOCTOR ORDER TO GET AN APPOINTMENT: • Emily is seeing her new pediatrician next week, so we will ask her to send a referral. Can you tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling? •
IF TOLD THAT THE OFFICE MUST HAVE CLINICAL INFORMATION BEFORE MAKING THE APPOINTMENT: Can you tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling?


IF TOLD THAT SOMEONE WILL HAVE TO CALL YOU BACK TO SCHEDULE THE APPOINTMENT. • Okay, my cell number is [XXX-XXX-XXXX].

ACCEPTED MANUSCRIPT
IF YOU ARE ASKED…/WORK-AROUNDS Has he seen a rehab doctor before? • Yes, she did inpatient rehab in Colorado and went to the outpatient rehab clinic a few times. Does she have any other medical problems? • Eczema.

AFTER THE CALL: FILL OUT POST-CALL EVALUATION

RI PT

Who is the primary care doctor? • She has an appointment at [nearby clinic] next week; I can’t recall the doctor’s name.

IF NO ANSWER, CALL BACK A SECOND TIME. IF NO ANSWER ON SECOND CALL, LEAVE A MESSAGE:

EP

TE D

M AN U

SC

Hello, I am trying to make a Rehab appointment for my 8-year-old daughter who had a brain injury. Please call me at XXX-XXX-XXXX.

AC C

•

ACCEPTED MANUSCRIPT Therapy Script/Work-Arounds for Profile 2: Outpatient Rehabilitation Services: Background info Your name: Amy Miller Son: Ethan Miller, 9-year-old, DOB: 9/30/2006

RI PT

See clinic spreadsheet for address

SC

My son needs to see a [physical therapist/occupational therapist/speech therapist]. We’re trying to figure out the best place to take him. When is your next available appointment?

M AN U


SEE IF YOU CAN GET A DATE BUT DO NOT SCHEDULE. IF OFFERED SCHEDULING: • That should work...Oh, wait, I might have to be out of town then. How about I just call back later to schedule. IF ASKED WHAT THE APPOINTMENT IS FOR: • He had a brain injury in January [move month forward so 10 months prior to call] and still has some difficulty [walking (PT)/with coordination (OT)/ with his memory and answering questions (ST)].

TE D

If ASKED ABOUT INSURANCE. • Our insurance is [see spreadsheet for type of insurance for the call]. o If asked for insurance number: [Pause to mime riffling for insurance card] Oh shoot, I can’t find my insurance card. I’ll bring the card to the appointment. o If asked about subscriber: Michael Miller o If told that they cannot schedule an appointment without having insurance card: Well, can you tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling? IF THE DATE IS MORE THAN 2 WEEKS AWAY ADD: • I don’t want him to lose any of the gains he has made. Is there an appointment sooner than that?

AC C

EP

IF THEY OFFER APPOINTMENT: • I am also trying to get him set up with [other two disciplines, OT/Speech or PT/OT or PT/Speech]. Do you offer [other 2 disciplines]? • IF INSURANCE HAS NEVER BEEN DISCUSSED: Before I get everything set up, I want to make sure you take our insurance. We have [see spreadsheet for type of insurance for the call].
IF TOLD THAT YOU NEED A REFERRAL/DOCTOR ORDER TO GET AN APPOINTMENT: • I have the doctor’s order for [PT/OT/ST], I can bring it in at the time of the appointment. IF TOLD THAT THE OFFICE MUST SEE THE ORDER BEFORE MAKING THE APPOINTMENT: I can read what the order says, can you just tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling? o PT: Okay it says diagnosis: personal history of traumatic brain injury (Z87.820), spastic hemiplegia affecting right dominant side (G81.11), paralytic gait abnormality (R26.1). Precautions: Fall. Order comments: Evaluate and treat: gait training on uneven surfaces, balance, floor recovery, endurance. Provide HEP for ROM, strength, endurance and functional mobility. See weekly with re-evaluation at 12 weeks. o OT: it says diagnosis: personal history of traumatic brain injury (Z87.820), spastic hemiplegia affecting right dominant side (G81.11), limitation of activities due to disability

ACCEPTED MANUSCRIPT (Z73.6), other lack of coordination (R27.8). Precautions: Fall. Order comments: Evaluate and treat right upper extremity strength, ROM and coordination, splinting as necessary, bimanual activities, dressing/ADLs. See weekly with re-evaluation at 12 weeks. ST: Okay it says diagnosis: personal history of traumatic brain injury (Z87.820), cognitive communication deficit (R41.841). Precautions: none. Order comments: Evaluate and treat cognitive communication deficits, word retrieval skills, compensatory strategies to improve recall, attention, organization; auditory and written comprehension. See weekly with re-evaluation at 12 weeks.

RI PT

o

If unable to just read the order to the scheduler: • I don’t have a fax machine to send the order I have. Maybe I can call the doctor’s office and ask them to fax the order to you. What’s your fax number? What will happen after you get the order, should I call you back? Can you just tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling?

M AN U

SC


IF TOLD THAT THE OFFICE MUST HAVE CLINICAL INFORMATION BEFORE MAKING THE APPOINTMENT: • I have the doctor’s note from a few weeks ago, I can read it to you, but can you just tell me what day you can give me an appointment? I’m trying to work out my schedule. o If asked to read clinic note:  What sort of information do you need? [Read that part of the “dummy clinic note Profile 2”].  Try to avoid sending the dummy note, but can email it from gmail account if needed
IF TOLD THAT SOMEONE WILL HAVE TO CALL YOU BACK TO SCHEDULE THE APPOINTMENT. • Okay, my cell number is [XXX-XXX-XXXX].

TE D


IF TOLD THAT ADDRESS SEEMS FAR AWAY: • This place is on the list of possible therapy centers that our rehab doctor gave us; we don’t mind driving to get Ethan what he needs.


IF YOU ARE ASKED…/WORK-AROUNDS

EP

Has he had therapy before? • Yes, he did inpatient rehab in California and then went to a therapy clinic and had therapy in school.

AC C

Does he have any other medical problems? • Only eczema.

What is the name of your child’s doctor? • Dr. [Rehab Doctor]; [Dr. full name if asked for full name] Who is the primary care doctor? • He has an appointment at [nearby clinic] next week; I can’t recall the doctor’s name. AFTER THE CALL: FILL OUT POST-CALL EVALUATION

IF NO ANSWER, CALL BACK A SECOND TIME. IF NO ANSWER ON SECOND CALL, LEAVE A MESSAGE:

•

Hello, I am trying to make a therapy appointment for my 9-year-old son who had a brain injury. Please call me at XXX-XXX-XXXX.

ACCEPTED MANUSCRIPT Rehab Medicine Script/Work-Arounds for Profile 1: Outpatient Rehabilitation Services: Background info Your name: Amy Miller Son: Ethan Miller, 9-year-old, DOB: 9/30/2006

RI PT

See clinic spreadsheet for address

My son needs to see a rehab doctor to follow up on his brain injury.

SC


SEE IF YOU CAN GET A DATE BUT DO NOT SCHEDULE. IF OFFERED SCHEDULING: • That should work...Oh, wait, I might have to be out of town then. How about I just call back later to schedule.

M AN U

IF ASKED WHAT THE APPOINTMENT IS FOR: • He had a brain injury in January [move month forward so 10 months prior to call] and still has some difficulty with balance, using his right hand, with his memory and keeping organized.

TE D

If ASKED ABOUT INSURANCE BEFORE BEING TOLD AVAILABLE APPOINTMENTS. • Our insurance is [see spreadsheet for type of insurance for the call]. o If asked for insurance number: [Pause to mime riffling for insurance card] Oh shoot, I left my insurance card in my other bag. I’ll bring the card to the appointment. o If asked about subscriber: Michael Miller o If told that they cannot schedule an appointment without having insurance card: Well, can you tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling? IF THE DATE IS MORE THAN 2 WEEKS AWAY ADD: • I’m worried about his muscle tone. Is there an appointment sooner than that?

EP

IF THEY OFFER APPOINTMENT DATE AND INSURANCE HAS NEVER BEEN DISCUSSED: Before I get everything set up, I want to make sure you take our insurance. We have [see spreadsheet for type of insurance for the call]

AC C


IF TOLD THAT YOU NEED A REFERRAL/DOCTOR ORDER TO GET AN APPOINTMENT: • Ethan is seeing his new pediatrician next week, so we will ask her to send a referral. Can you tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling? •
IF TOLD THAT THE OFFICE MUST HAVE CLINICAL INFORMATION BEFORE MAKING THE APPOINTMENT: Can you tell me when the next available appointment is, so I can have an idea of how far out you’re scheduling?


IF TOLD THAT SOMEONE WILL HAVE TO CALL YOU BACK TO SCHEDULE THE APPOINTMENT. • Okay, my cell number is [XXX-XXX-XXXX].

ACCEPTED MANUSCRIPT
IF YOU ARE ASKED…/WORK-AROUNDS Has he seen a rehab doctor before? • Yes, he did inpatient rehab in California and went to the outpatient rehab clinic a few times. Does he have any other medical problems? • Eczema.

AFTER THE CALL: FILL OUT POST-CALL EVALUATION

RI PT

Who is the primary care doctor? • He has an appointment at [nearby clinic] next week; I can’t recall the doctor’s name.

IF NO ANSWER, CALL BACK A SECOND TIME. IF NO ANSWER ON SECOND CALL, LEAVE A MESSAGE:

EP

TE D

M AN U

SC

Hello, I am trying to make a Rehab appointment for my 9-year-old son who had a brain injury. Please call me at XXX-XXX-XXXX.

AC C

•