- Email: [email protected]
Medicaid Patients Experience Longer Wait Times at Academic Urology Clinics Compared to Patients with Medicare
Author's Accepted Manuscript Medicaid patients experience longer wait times at academic urology clinics compared to patients with Medicare Wai Lee, MD, Andrew Chen, MD, Ramsey Kalil, BA, Tal Cohen, BA, William T. Berg, MD, Wayne C. Waltzer, MD, Jason Kim, MD, Howard L. Adler, MD
PII: DOI: Reference:
S2352-0779(17)30191-7 10.1016/j.urpr.2017.09.001 URPR 313
To appear in: Urology Practice Accepted Date: 1 September 2017 Please cite this article as: Lee W, Chen A, Kalil R, Cohen T, Berg WT, Waltzer WC, Kim J, Adler HL, Medicaid patients experience longer wait times at academic urology clinics compared to patients with Medicare, Urology Practice (2017), doi: 10.1016/j.urpr.2017.09.001. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed 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. All press releases and the articles they feature are under strict embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date.
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[email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]
Corresponding author: Wai Lee 101 Nicolls Road, HSC Level 9-040 Stony Brook, NY 11794
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(917) 295-1939
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Department of Urology, Stony Brook Medicine
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Wai Lee MD Andrew Chen MD Ramsey Kalil BA Tal Cohen BA William T Berg MD Wayne C Waltzer MD Jason Kim MD Howard L Adler MD
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Medicaid patients experience longer wait times at academic urology clinics compared to patients with Medicare
[email protected]
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Manuscipt word count: 2490
Key Words: Health disparities, Medicaid, Medicare, access to care, wait times
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Abstract
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Purpose: It has been established that Medicaid patients face unequal access to healthcare. There is a paucity of literature comparing wait times for Medicaid patients with patients with other types of insurance. Our objective was to determine if Medicaid patients experience longer wait times at academic urology clinics compared to patients with Medicare.
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Materials and Methods: A prospective cross-sectional telephone survey was conducted in October 2016. The study involves collection of data from multiple academic centers with phone interviews conducted from a single institution. Calls were made to all accredited urology residency programs (N=131). Earliest appointment times were established for fictional patients with Medicaid and then Medicare. The main outcome was the difference in wait times for a new patient appointment in a urology clinic for Medicaid and Medicare. The wait time in days was the difference between the date of the appointment made from the date the phone call was made.
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Results: There were 108 academic urology clinics that accepted both Medicaid and Medicare patients in our final analysis (82.4% participation rate). Two-tailed t-test was performed with unequal variances for the wait times between Medicaid versus Medicare groups. There was a significant difference (p<0.001) between the mean wait times for a patient with Medicare (23 days, STD 20.8, 95% CI [19.0, 26.9]) versus Medicaid (35 days, STD 27.5, 95% CI [30.0, 40.3]).
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Conclusions: Our data suggests that Medicaid patients experience longer wait times for their initial outpatient urological evaluation. These findings may be used for future health policy considerations.
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INTRODUCTION
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As of October 2016, there were over 74 million Americans enrolled in Medicaid.1 Despite expansion of Medicaid, patients with Medicaid face unequal access to healthcare. A telephone survey of 1399 metropolitan offices demonstrated that as few as 45.7% of healthcare providers accepted Medicaid, whereas 76% accepted Medicare.2 Another survey of 54 California pediatric urology offices found that only 41% accepted Medicaid new patient visits whereas 96% accepted private insurance.3
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Medicaid patients may also face longer wait times to see specialty providers, although limited data exists on Medicaid wait times for urologists.4-5 With the number of urologists expected to decline 29% by the year 2025, Medicaid patients will face a growing barrier to prompt urological care.6 However, there is a paucity of urologic literature evaluating if discrepancies in wait times for Medicaid patients currently exist. We sought to evaluate wait time disparities in academic urology programs for Medicaid compared to Medicare patients.
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MATERIALS AND METHODS Study Population
Survey Instrument
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The cohort was identified from the online listing of all Accreditation Council for Graduate Medical Education (ACGME) accredited allopathic urology residency programs.7 The site was accessed in October of 2016. All listed institutions were included in our preliminary cohort. Contact information for each program, including address and telephone number, was extracted from the listing. Programs were contacted and queried for their clinical appointment lines. Exclusion criteria were academic urology programs that did not accept Medicaid and programs located outside the contiguous United States, Hawaii or Alaska.
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A standardized script was used by 3 separate callers. The first call established if the academic urology program had a clinic or provider that saw patients with Medicaid. The telephone number for that clinic was recorded as well as if the clinic was a faculty-supervised resident clinic or an academic urologist whom accepted Medicaid. A second call was then made to the appointment line with the following script: “Hello, could I have an appointment to see a urologist? My insurance is Medicaid.” If the practice accepted Medicaid, the date of the earliest appointment with the first available provider was documented. If a reason for the visit was requested, the scripted reply was “I see blood in the urine”. At the end of the call, the receptionist was informed that the inquiry was for a research study and the appointment was not made. The option to decline participation in the study was given. A third call that same day was then made by a separate caller with the following script: “Hello, could I have an appointment to see a urologist? My insurance is Medicare.” The date of the earliest appointment with the first available provider was documented. If a reason for the visit was requested, the scripted reply was “I see blood in the urine”. At the end of the call, the receptionist was informed that the inquiry was for a research study and the appointment was not made. The option to decline participation in the study was also given. The study protocol was reviewed by our institution’s human subjects committee and considered
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exempt from formal institutional review board approval. Outcome Measure
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The main outcome was the wait time for a new patient appointment in days. This was established as the difference between the appointment time from the date of the phone call. All appointments were made on the same day to minimize bias. The secondary outcomes were the wait times by American Urological Association (AUA) section and if the Medicaid appointment was for a resident-based clinic or a standard provider clinic. For the final analysis, the shortest possible wait time was used for programs that had both resident clinics and standard provider clinics.
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AUA sections comprise of eight geographic regions that serve the total area of North and Central America. These include: Northeastern, New England, New York, Mid-Atlantic, North Central, Southeastern, South Central, and Western sections. Each section is chartered by the AUA as a separate entity governed by its own board and section administrator with the goal of achieving proportional representation among the sections.8
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Statistical Analysis
RESULTS
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All statistical analysis was performed using SPSS v24.0. Two-tailed t-test was performed with unequal variances for the wait times between Medicaid versus Medicare groups. Analysis of variance was performed to compare wait times between Medicaid versus Medicare patients by AUA section. Pearson correlation coefficient was performed to compare state Medicaid enrollees per one million people with Medicaid mean wait times.
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131 ACGME accredited academic urology programs were surveyed. Of these, 10 (7.6%) did not accept new patients with Medicaid insurance. 13 institutions (9.92%) declined to participate in our study or required a full profile to be completed. There were 108 academic urology clinics that accepted both Medicaid and Medicare patients in our final analysis (82.4% participation rate). Of these, 59% (n=64) had longer wait times for Medicaid patients and 26% (n=28) had equal wait times between Medicaid and Medicare patients. Overall, there was a significant difference (p<0.001) between the mean wait times for a new patient visit with Medicare (23 days, STD 20.8, 95% CI [19.0, 26.9]) versus Medicaid (35 days, STD 27.5, 95% CI [30.0, 40.3]). For Medicaid appointments, 73.1% (n=79) were scheduled in resident clinics and 26.9% (n=29) were scheduled in faculty clinics. While resident clinics had longer average wait times (38 days, STD 31.5, 95% CI [31.3, 44.5]) when compared to urology providers whom accepted Medicaid (30 days, STD 26.8, 95% CI [19.9, 39.4]), this was not found to be significant (p=0.175). When stratified by AUA section, academic urology programs in each section had overall longer average wait times for Medicaid patients when compared to Medicare patients. However, only the New York (n=16, 26.8 versus 10.1 days, p=0.022) and Southeastern (n=23, 41.8 versus 26.8 days, p=0.050) sections had significantly longer wait times (Table 1). Despite having a significant discrepancy in wait times between Medicaid and Medicare patients, the New York section academic urology clinics had the shortest average wait time for both Medicaid and Medicare patients when compared to other AUA
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sections.
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The academic urology programs in our study were located in 42 different states. 45% (n=19) of the states had only one academic urology program that met inclusion criteria. For these states, the average wait times for Medicaid patients (36.2 days, STD 22.7, 95% CI [26.0, 46.3]) were longer than Medicare patients (28.4 days, STD 15.3, 95% CI [21.5, 35.3]), but this was not found to be significant (p=0.223). 55% (n=23) of the states had 2 or more academic urology programs (range 2-17). For states with 2 or more academic urology programs, the average wait time was significantly longer (p<0.001) for Medicaid patients (34.9 days, STD 28.6, 95% CI [23.3, 46.6]) when compared to Medicare patients (21.8 days, STD 21.6, 95% CI [12.9, 30.6]). Both groups had similar mean wait times for Medicaid patients (p=0.840) (Table 2).
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Based on United States Census and Medicaid data, there was no significant difference in the mean number of Medicaid enrollees per million people (p=0.234) between states with only one academic urology program (215,578 Medicaid enrollees per one million people) and states with multiple academic urology programs in our study (239,833 Medicaid enrollees per one million people) (Table 2). The number of Medicaid enrollees per million people by state also did not correlate with the mean Medicaid wait times by state (ρ = 0.358).9-10
DISCUSSION
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We performed a cross-sectional study using a prospective telephone survey to determine if Medicaid patients faced longer wait times for new patient urology visits. In our cohort, we demonstrated that patients with Medicaid experienced greater delays to outpatient urological evaluation. This disparity existed in most (59%), but not all academic urology clinics. The difference in overall mean wait time was significant and observed most in the New York and Southeastern AUA sections. However, the New York section was noted to have the shortest wait times for both Medicaid and Medicare patients compared to all other AUA sections. One explanation for this could be that New York State has the second highest urologist to population ratio and as an AUA section comprises 8.2% of the total number of practicing urologist in the U.S.11
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In states with multiple academic urology programs, we observed a significant difference in average wait times between Medicaid and Medicare patients. This could possibly be due to the slightly higher population density of Medicaid patients in these states compared to states with only one academic program, but this was not statistically significant. Another factor could be the state-by-state geographic distributions of Medicaid patients and academic urology programs. We hope to investigate this further in future studies. Prior studies have established that patients with Medicaid may experience limited access to urological care. Overholser et al demonstrated in a telephone survey of 650 randomly selected urologists that 41.7% did not accept any Medicaid.5 Hwang et al found 59% of randomly selected pediatric urology offices in California (n=46) did not accept Medicaid.3 Other studies have shown higher acceptance rates. Based on the National Ambulatory Medical Care Survey from 2011-2012, Decker reported 84.9% of urologists accepted new Medicaid patients. Urologists represented approximately 2% of this study’s cohort of 8,158 doctors.12
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With limited providers accepting new patients with Medicaid, we hypothesized that wait times for appointments would be longer due to limited supply. We were not able to find any studies specific to urology demonstrating this disparity, but other specialty fields have found compelling data. Resneck et al surveyed 631 dermatologists in selected communities about Medicaid patient wait times. The study found Medicaid patients experienced longer wait times (50 days) than patients with Medicare and private insurance (37 days). The study also found that only 32% of dermatologists accepted new Medicaid patients compared to over 85% of them accepting Medicare or private insurance (p<0.001).4 Another study surveying orthopedic offices found that patients with Medicaid were less likely to be offered an appointment within 2 weeks compared to private insurance (36% versus 89%, p < 0.001). However, the calls for an appointment time for private insurance were made one month after the initial call for a Medicaid appointment.13
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While our data suggests significantly longer wait times for Medicaid patients seeking urological care, the consequences of this disparity are not conclusive. Stec et al demonstrated that surgical waiting time from initial consultation to surgery for renal cell carcinoma did not affect overall and disease specific survival.14 However, Liedberg et al found that shorter diagnostic delays (less than 6 months) from presentation of symptom to diagnosis of T1 bladder cancer led to a better prognosis.15 Also, Friedlander et al found that patients with longer time intervals (>45 days) between diagnosis and treatment of nephrolithiasis were associated with increased morbidity and unplanned emergency room visits.16
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Whether increased wait times for Medicaid patients to see a urologist leads to more unplanned emergency room visits is not known. It has been demonstrated that the absence of a relationship with a regular physician independently correlated with presentation for a non-urgent emergency department visit.17 Delayed access to primary care is suggested by Tang et al as a possible explanation for a rise in emergency room visits for Medicaid patients between 1997 and 2007. Interestingly, during that same period visits from private insurance, Medicare and uninsured patients actually stayed the same or decreased.18 Another interesting finding was that the expansion of Medicaid in Oregon in 2008 actually led to more emergency room visits from the 25,000 new recipients of Medicaid via lottery.19
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Our study found that patients encountered considerable average wait times for an outpatient urological appointment. Patients with Medicare had an average wait time of 23 days whereas patients with Medicaid had an average wait time of 35 days. When compared to other specialties, our cohort had comparable wait times. A 2017 survey of 1,414 medical offices in 15 large metropolitan markets found that the average wait times for family care, dermatology, cardiology, orthopedic surgery, and obstetrics/gynecology appointments were 29.0, 32.0, 21.0, 11.4 and 26.4 days respectively (ranges 0365 days). However, wait times were not stratified by insurance type.20 Our study findings may be interpreted as being critical of health policy addressing the uninsured population through expansion of Medicaid. However, the underlying issue is that providing patients with access to care may not offer them access to timely or even quality care. Another area of criticism may be of the providers who choose not to accept Medicaid or whether Medicaid offers competitive enough reimbursements to encourage broad acceptance21. There may also be an inadequate geographic distribution of academic urologists within each state to meet local demand. For instance, in New York State, the 17 academic urology programs had Medicaid wait times ranging from 0 to 118 days. We
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believe further studies on this subject matter are needed to better understand this very complex and controversial subject.
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We only evaluated access to urological care in academic urology hospitals. This was designed to adequately survey urology practices that accepted both Medicaid and Medicare. We hypothesized that academic urology clinics had a higher likelihood of accepting Medicaid compared to private practice thus minimizing sampling error. However, we were surprised to find 7.6% of the academic urology clinics did not accept new patient appointments for Medicaid.
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A limitation of our study was that we did not adequately sample all urology providers that accepted Medicaid. This was a major source of sampling bias, although we were able to obtain data from 82.4% (108/131) of all academic urology programs accredited by the ACGME and recognized by the AUA.7 Another limitation was that we did not perform a sub-analysis on the different types of Medicaid accepted by each state or their reimbursement rates. Analysis of state-by-state Medicaid reimbursement rates and how they correlate with wait times may provide useful information for future research. We also only evaluated wait times for patients with Medicaid and Medicare and did not attempt to query if differences existed for private insurance carriers.
CONCLUSIONS
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Another limitation of our protocol was that we did not query data regarding the specific urology provider for whom the appointment was made. Analysis of wait times for more recent hires or part-time faculty would have strengthened the study and ascertained if this could be another source of bias. This may have also explained the high variability in average wait times for both Medicare (STD = 20.8 days) and Medicaid patients (STD = 27.5 days). We also only provided a complaint when prompted and did not perform an analysis to see if discrepancies existed for visits scheduled with or without a complaint. Future studies could evaluate variations in appointment times based on the emergent nature of the caller’s chief complaint.
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Our data suggests that patients with Medicaid experience longer wait times for their initial urological evaluation. Barriers to timely clinical evaluation have been cited as a reason for emergency room visitation. Awareness of such disparities in urologic care is an early step toward improving the quality of healthcare for all individuals. Our results may be useful for shaping future health policy.
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ACNKOWLEDGEMENTS
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This study had no source of funding. Wai Lee has a spouse working on research on overactive bladder funded by a Medtronic research grant. Howard Adler has stock ownership in Pfizer and is a shareholder in Allied Metro Litho and Theralogix. Andrew Chen, Ramsey Kalil, Tal Cohen, Wayne Waltzer and Jason Kim have no financial disclosures to make.
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REFERENCES
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1. Total monthly Medicaid and CHIP enrollment. The Henry J. Kaiser Family Foundation. Available at http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment . Accessed January 6, 2017. 2. Merritt Hawkins: Physician appointment wait times and Medicaid and Medicare acceptance rates: 2014 survey. Available at https://www.merritthawkins.com/2014survey/patientwaittime.aspx . Accessed January 6, 2017. 3. Hwang AH, Hwang MM, Xie HW et al. Access to urologic care for children in California: Medicaid versus private insurance. Urology; 66: 170-173. 2005. 4. Resneck J, Pletcher MJ and Lozano N. Medicare, Medicaid, and access to dermatologists: the effect of patient insurance on appointment access and wait times. J Am Acad Dermatol; 50: 8592. 2004. 5. Overholser S, Thompson I, Sosland R et al. Medicaid patient access to urological care in the era of the Patient Protection and Affordable Care Act: A baseline to measure policy effectiveness. Urology Practice; 3: 276-282. 2016. 6. Pruthi RS, Neuwahl S, Nielsen ME et al. Recent trends in the urology workforce in the United States. Urology; 82: 987-994. 2013. 7. American Urological Association: Accredited listing of U.S. urology residency programs. Available at https://www.auanet.org/education/residency-programs/. Accessed October 13, 2016. 8. American Urological Association, Inc. Bylaws. 2017. Available at http://www.auanet.org/ about-us/aua-governance/aua-bylaws. Accessed July 5, 2017. 9. State Medicaid & CHIP Profiles. Available at https://www.medicaid.gov/medicaid/by-state/bystate.html. Accessed August 24, 2017 10. United States Census Bureau State Population Total Tables: 2010-2016. Available at https://census.gov/data/tables/2016/demo/popest/state-total.html. Accessed August 25, 2017. 11. The State of the Urology Workforce and Practice in the United States. AUA Census Report. 2016. Available at http://www.auanet.org/research/data-services/aua-census/census-results. Accessed July 7, 2017. 12. Decker SL. Two-thirds of primary care physicians accepted new Medicaid patients in 2011-2012: a baseline to measure future acceptance rates. Health Aff; 32: 1183-1187. 2013. 13. Labrum JT, Paziuk T, Rihn TC et al. Does Medicaid Insurance Confer Adequate Access to Adult Orthopaedic Care in the Era of the Patient Protection and Affordable Care Act? Clinical Orthopaedics and Related Research; 475(6):1527-1536. 2017. 14. Stec AA, Coons BJ, Chang SS et al. Waiting time from initial urological consultation to nephrectomy for renal cell carcinoma – does it affect survival? J Urol; 179: 2152-2157. 2008. 15. Liedberg F, Anderson H, Mansson A et al. Diagnostic delay and prognosis in invasive bladder cancer. Scand J Urol Nephrol; 37: 396-400. 2003. 16. Friedlander J, Kavoussi N, De S et al. The consequences of delaying stone treatment. J Urol; 193: e953. 2015. 17. Petersen LA, Burstin HR, O’Neil AC et al. Nonurgent emergency department visits – the effect of having a regular doctor. Medical Care; 36: 1249-1255. 1998. 18. Tang N, Stein J, Hsia RY et al. Trends and characteristics of US emergency department visits, 1997-2007. JAMA; 304: 664-670. 2010. 19. Taubman SL, Allen HL, Wright BJ et al. Medicaid increases emergency department use: evidence from Oregon’s health insurance experiment. Science; 343: 263-268. 2014.
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20. Merritt Hawkins: 2017 Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance Rates. Available at https://www.merritthawkins.com/2017survey/patientwaittime.aspx . Accessed June 10, 2017. 21. Sommers, Benjamin D., and Richard Kronick. Measuring Medicaid Physician Participation Rates and Implications for Policy. Journal of Health Politics, Policy and Law; 41.2: 211-24 2014.
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Table 1. Wait time for outpatient urological evaluation at academic urology programs Medicaid
Medicare
# of programs
Mean (days)
STD (days)
Range (days)
CI 95%
Mean (days)
Northeastern
4
45.5
49.6
8 – 118
[-3.08, 94.1]
10.3
New England
11
33.2
21.1
8 – 63
[20.7, 45.7]
30.8
New York
16
26.8
25.8
0 – 83
[14.2, 39.5]
Mid-Atlantic
18
32.9
25.9
1 – 98
[21.0, 44.9]
North Central
24
29.5
30.8
1 – 100
[17.2, 41.8]
Southeastern
23
41.8
24.2
1 – 98
South Central
17
45.0
33.3
3 – 115
Western
18
35.7
14 - 60
Range (days)
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p
9.0
1 – 21
[1.43, 19.1]
0.251
21.4
7 – 55
[18.1, 43.5]
0.804
0 – 41
[5.19, 15.1]
0.022
25.5
20.4
5 – 92
[16.1, 34.9]
0.380
25.0
27.1
1 – 100
[14.1, 35.8]
0.623
[31.9, 51.7]
26.8
18.2
1 – 56
[19.3, 34.2]
0.050
[29.2, 60.8]
24.8
23.8
3 – 98
[13.5, 36.1]
0.077
[27.5, 44.0]
23.5
17.3
1 - 54
[15.6, 31.5]
0.120
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Table 1: Wait times for Medicaid and Medicare patients stratified by the AUA section.
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CI 95%
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STD (days)
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AUA Section
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Table 2. Characteristics of states with a single academic urology program versus states with multiple programs
Medicaid wait times
Medicare wait times
%
N
STD
Range
Mean (days)
STD (days)
Range (days)
Mean (days)
STD (days)
Range (days)
p
States with only one academic urology program
19
45
215,578
61,264
100,322 – 375,510
36.2
22.7
1 - 91
28.4
15.3
1 - 54
0.224
States with multiple academic urology programs
23
55
239,833
68,797
118,404 – 402,132
34.9
28.6
21.6
0100
<0.001
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# of programs
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Average # Medicaid patients per million population
0118
21.8
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Table 2: Characteristics of states with a single academic urology program compared to states with multiple academic urology programs. Data based on academic urology programs that met inclusion criteria for the study and their respective states.
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ABBREVIATIONS AND ACRONYMS ACGME = Accreditation Council for Graduate Medical Education
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AUA = American Urological Association
PII: DOI: Reference:
S2352-0779(17)30191-7 10.1016/j.urpr.2017.09.001 URPR 313
To appear in: Urology Practice Accepted Date: 1 September 2017 Please cite this article as: Lee W, Chen A, Kalil R, Cohen T, Berg WT, Waltzer WC, Kim J, Adler HL, Medicaid patients experience longer wait times at academic urology clinics compared to patients with Medicare, Urology Practice (2017), doi: 10.1016/j.urpr.2017.09.001. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed 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. All press releases and the articles they feature are under strict embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date.
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[email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected]
Corresponding author: Wai Lee 101 Nicolls Road, HSC Level 9-040 Stony Brook, NY 11794
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(917) 295-1939
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Department of Urology, Stony Brook Medicine
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Wai Lee MD Andrew Chen MD Ramsey Kalil BA Tal Cohen BA William T Berg MD Wayne C Waltzer MD Jason Kim MD Howard L Adler MD
RI PT
Medicaid patients experience longer wait times at academic urology clinics compared to patients with Medicare
[email protected]
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Manuscipt word count: 2490
Key Words: Health disparities, Medicaid, Medicare, access to care, wait times
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Abstract
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Purpose: It has been established that Medicaid patients face unequal access to healthcare. There is a paucity of literature comparing wait times for Medicaid patients with patients with other types of insurance. Our objective was to determine if Medicaid patients experience longer wait times at academic urology clinics compared to patients with Medicare.
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Materials and Methods: A prospective cross-sectional telephone survey was conducted in October 2016. The study involves collection of data from multiple academic centers with phone interviews conducted from a single institution. Calls were made to all accredited urology residency programs (N=131). Earliest appointment times were established for fictional patients with Medicaid and then Medicare. The main outcome was the difference in wait times for a new patient appointment in a urology clinic for Medicaid and Medicare. The wait time in days was the difference between the date of the appointment made from the date the phone call was made.
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Results: There were 108 academic urology clinics that accepted both Medicaid and Medicare patients in our final analysis (82.4% participation rate). Two-tailed t-test was performed with unequal variances for the wait times between Medicaid versus Medicare groups. There was a significant difference (p<0.001) between the mean wait times for a patient with Medicare (23 days, STD 20.8, 95% CI [19.0, 26.9]) versus Medicaid (35 days, STD 27.5, 95% CI [30.0, 40.3]).
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Conclusions: Our data suggests that Medicaid patients experience longer wait times for their initial outpatient urological evaluation. These findings may be used for future health policy considerations.
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INTRODUCTION
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As of October 2016, there were over 74 million Americans enrolled in Medicaid.1 Despite expansion of Medicaid, patients with Medicaid face unequal access to healthcare. A telephone survey of 1399 metropolitan offices demonstrated that as few as 45.7% of healthcare providers accepted Medicaid, whereas 76% accepted Medicare.2 Another survey of 54 California pediatric urology offices found that only 41% accepted Medicaid new patient visits whereas 96% accepted private insurance.3
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Medicaid patients may also face longer wait times to see specialty providers, although limited data exists on Medicaid wait times for urologists.4-5 With the number of urologists expected to decline 29% by the year 2025, Medicaid patients will face a growing barrier to prompt urological care.6 However, there is a paucity of urologic literature evaluating if discrepancies in wait times for Medicaid patients currently exist. We sought to evaluate wait time disparities in academic urology programs for Medicaid compared to Medicare patients.
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MATERIALS AND METHODS Study Population
Survey Instrument
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The cohort was identified from the online listing of all Accreditation Council for Graduate Medical Education (ACGME) accredited allopathic urology residency programs.7 The site was accessed in October of 2016. All listed institutions were included in our preliminary cohort. Contact information for each program, including address and telephone number, was extracted from the listing. Programs were contacted and queried for their clinical appointment lines. Exclusion criteria were academic urology programs that did not accept Medicaid and programs located outside the contiguous United States, Hawaii or Alaska.
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A standardized script was used by 3 separate callers. The first call established if the academic urology program had a clinic or provider that saw patients with Medicaid. The telephone number for that clinic was recorded as well as if the clinic was a faculty-supervised resident clinic or an academic urologist whom accepted Medicaid. A second call was then made to the appointment line with the following script: “Hello, could I have an appointment to see a urologist? My insurance is Medicaid.” If the practice accepted Medicaid, the date of the earliest appointment with the first available provider was documented. If a reason for the visit was requested, the scripted reply was “I see blood in the urine”. At the end of the call, the receptionist was informed that the inquiry was for a research study and the appointment was not made. The option to decline participation in the study was given. A third call that same day was then made by a separate caller with the following script: “Hello, could I have an appointment to see a urologist? My insurance is Medicare.” The date of the earliest appointment with the first available provider was documented. If a reason for the visit was requested, the scripted reply was “I see blood in the urine”. At the end of the call, the receptionist was informed that the inquiry was for a research study and the appointment was not made. The option to decline participation in the study was also given. The study protocol was reviewed by our institution’s human subjects committee and considered
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exempt from formal institutional review board approval. Outcome Measure
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The main outcome was the wait time for a new patient appointment in days. This was established as the difference between the appointment time from the date of the phone call. All appointments were made on the same day to minimize bias. The secondary outcomes were the wait times by American Urological Association (AUA) section and if the Medicaid appointment was for a resident-based clinic or a standard provider clinic. For the final analysis, the shortest possible wait time was used for programs that had both resident clinics and standard provider clinics.
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AUA sections comprise of eight geographic regions that serve the total area of North and Central America. These include: Northeastern, New England, New York, Mid-Atlantic, North Central, Southeastern, South Central, and Western sections. Each section is chartered by the AUA as a separate entity governed by its own board and section administrator with the goal of achieving proportional representation among the sections.8
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Statistical Analysis
RESULTS
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All statistical analysis was performed using SPSS v24.0. Two-tailed t-test was performed with unequal variances for the wait times between Medicaid versus Medicare groups. Analysis of variance was performed to compare wait times between Medicaid versus Medicare patients by AUA section. Pearson correlation coefficient was performed to compare state Medicaid enrollees per one million people with Medicaid mean wait times.
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131 ACGME accredited academic urology programs were surveyed. Of these, 10 (7.6%) did not accept new patients with Medicaid insurance. 13 institutions (9.92%) declined to participate in our study or required a full profile to be completed. There were 108 academic urology clinics that accepted both Medicaid and Medicare patients in our final analysis (82.4% participation rate). Of these, 59% (n=64) had longer wait times for Medicaid patients and 26% (n=28) had equal wait times between Medicaid and Medicare patients. Overall, there was a significant difference (p<0.001) between the mean wait times for a new patient visit with Medicare (23 days, STD 20.8, 95% CI [19.0, 26.9]) versus Medicaid (35 days, STD 27.5, 95% CI [30.0, 40.3]). For Medicaid appointments, 73.1% (n=79) were scheduled in resident clinics and 26.9% (n=29) were scheduled in faculty clinics. While resident clinics had longer average wait times (38 days, STD 31.5, 95% CI [31.3, 44.5]) when compared to urology providers whom accepted Medicaid (30 days, STD 26.8, 95% CI [19.9, 39.4]), this was not found to be significant (p=0.175). When stratified by AUA section, academic urology programs in each section had overall longer average wait times for Medicaid patients when compared to Medicare patients. However, only the New York (n=16, 26.8 versus 10.1 days, p=0.022) and Southeastern (n=23, 41.8 versus 26.8 days, p=0.050) sections had significantly longer wait times (Table 1). Despite having a significant discrepancy in wait times between Medicaid and Medicare patients, the New York section academic urology clinics had the shortest average wait time for both Medicaid and Medicare patients when compared to other AUA
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sections.
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The academic urology programs in our study were located in 42 different states. 45% (n=19) of the states had only one academic urology program that met inclusion criteria. For these states, the average wait times for Medicaid patients (36.2 days, STD 22.7, 95% CI [26.0, 46.3]) were longer than Medicare patients (28.4 days, STD 15.3, 95% CI [21.5, 35.3]), but this was not found to be significant (p=0.223). 55% (n=23) of the states had 2 or more academic urology programs (range 2-17). For states with 2 or more academic urology programs, the average wait time was significantly longer (p<0.001) for Medicaid patients (34.9 days, STD 28.6, 95% CI [23.3, 46.6]) when compared to Medicare patients (21.8 days, STD 21.6, 95% CI [12.9, 30.6]). Both groups had similar mean wait times for Medicaid patients (p=0.840) (Table 2).
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Based on United States Census and Medicaid data, there was no significant difference in the mean number of Medicaid enrollees per million people (p=0.234) between states with only one academic urology program (215,578 Medicaid enrollees per one million people) and states with multiple academic urology programs in our study (239,833 Medicaid enrollees per one million people) (Table 2). The number of Medicaid enrollees per million people by state also did not correlate with the mean Medicaid wait times by state (ρ = 0.358).9-10
DISCUSSION
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We performed a cross-sectional study using a prospective telephone survey to determine if Medicaid patients faced longer wait times for new patient urology visits. In our cohort, we demonstrated that patients with Medicaid experienced greater delays to outpatient urological evaluation. This disparity existed in most (59%), but not all academic urology clinics. The difference in overall mean wait time was significant and observed most in the New York and Southeastern AUA sections. However, the New York section was noted to have the shortest wait times for both Medicaid and Medicare patients compared to all other AUA sections. One explanation for this could be that New York State has the second highest urologist to population ratio and as an AUA section comprises 8.2% of the total number of practicing urologist in the U.S.11
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In states with multiple academic urology programs, we observed a significant difference in average wait times between Medicaid and Medicare patients. This could possibly be due to the slightly higher population density of Medicaid patients in these states compared to states with only one academic program, but this was not statistically significant. Another factor could be the state-by-state geographic distributions of Medicaid patients and academic urology programs. We hope to investigate this further in future studies. Prior studies have established that patients with Medicaid may experience limited access to urological care. Overholser et al demonstrated in a telephone survey of 650 randomly selected urologists that 41.7% did not accept any Medicaid.5 Hwang et al found 59% of randomly selected pediatric urology offices in California (n=46) did not accept Medicaid.3 Other studies have shown higher acceptance rates. Based on the National Ambulatory Medical Care Survey from 2011-2012, Decker reported 84.9% of urologists accepted new Medicaid patients. Urologists represented approximately 2% of this study’s cohort of 8,158 doctors.12
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With limited providers accepting new patients with Medicaid, we hypothesized that wait times for appointments would be longer due to limited supply. We were not able to find any studies specific to urology demonstrating this disparity, but other specialty fields have found compelling data. Resneck et al surveyed 631 dermatologists in selected communities about Medicaid patient wait times. The study found Medicaid patients experienced longer wait times (50 days) than patients with Medicare and private insurance (37 days). The study also found that only 32% of dermatologists accepted new Medicaid patients compared to over 85% of them accepting Medicare or private insurance (p<0.001).4 Another study surveying orthopedic offices found that patients with Medicaid were less likely to be offered an appointment within 2 weeks compared to private insurance (36% versus 89%, p < 0.001). However, the calls for an appointment time for private insurance were made one month after the initial call for a Medicaid appointment.13
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While our data suggests significantly longer wait times for Medicaid patients seeking urological care, the consequences of this disparity are not conclusive. Stec et al demonstrated that surgical waiting time from initial consultation to surgery for renal cell carcinoma did not affect overall and disease specific survival.14 However, Liedberg et al found that shorter diagnostic delays (less than 6 months) from presentation of symptom to diagnosis of T1 bladder cancer led to a better prognosis.15 Also, Friedlander et al found that patients with longer time intervals (>45 days) between diagnosis and treatment of nephrolithiasis were associated with increased morbidity and unplanned emergency room visits.16
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Whether increased wait times for Medicaid patients to see a urologist leads to more unplanned emergency room visits is not known. It has been demonstrated that the absence of a relationship with a regular physician independently correlated with presentation for a non-urgent emergency department visit.17 Delayed access to primary care is suggested by Tang et al as a possible explanation for a rise in emergency room visits for Medicaid patients between 1997 and 2007. Interestingly, during that same period visits from private insurance, Medicare and uninsured patients actually stayed the same or decreased.18 Another interesting finding was that the expansion of Medicaid in Oregon in 2008 actually led to more emergency room visits from the 25,000 new recipients of Medicaid via lottery.19
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Our study found that patients encountered considerable average wait times for an outpatient urological appointment. Patients with Medicare had an average wait time of 23 days whereas patients with Medicaid had an average wait time of 35 days. When compared to other specialties, our cohort had comparable wait times. A 2017 survey of 1,414 medical offices in 15 large metropolitan markets found that the average wait times for family care, dermatology, cardiology, orthopedic surgery, and obstetrics/gynecology appointments were 29.0, 32.0, 21.0, 11.4 and 26.4 days respectively (ranges 0365 days). However, wait times were not stratified by insurance type.20 Our study findings may be interpreted as being critical of health policy addressing the uninsured population through expansion of Medicaid. However, the underlying issue is that providing patients with access to care may not offer them access to timely or even quality care. Another area of criticism may be of the providers who choose not to accept Medicaid or whether Medicaid offers competitive enough reimbursements to encourage broad acceptance21. There may also be an inadequate geographic distribution of academic urologists within each state to meet local demand. For instance, in New York State, the 17 academic urology programs had Medicaid wait times ranging from 0 to 118 days. We
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believe further studies on this subject matter are needed to better understand this very complex and controversial subject.
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We only evaluated access to urological care in academic urology hospitals. This was designed to adequately survey urology practices that accepted both Medicaid and Medicare. We hypothesized that academic urology clinics had a higher likelihood of accepting Medicaid compared to private practice thus minimizing sampling error. However, we were surprised to find 7.6% of the academic urology clinics did not accept new patient appointments for Medicaid.
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A limitation of our study was that we did not adequately sample all urology providers that accepted Medicaid. This was a major source of sampling bias, although we were able to obtain data from 82.4% (108/131) of all academic urology programs accredited by the ACGME and recognized by the AUA.7 Another limitation was that we did not perform a sub-analysis on the different types of Medicaid accepted by each state or their reimbursement rates. Analysis of state-by-state Medicaid reimbursement rates and how they correlate with wait times may provide useful information for future research. We also only evaluated wait times for patients with Medicaid and Medicare and did not attempt to query if differences existed for private insurance carriers.
CONCLUSIONS
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Another limitation of our protocol was that we did not query data regarding the specific urology provider for whom the appointment was made. Analysis of wait times for more recent hires or part-time faculty would have strengthened the study and ascertained if this could be another source of bias. This may have also explained the high variability in average wait times for both Medicare (STD = 20.8 days) and Medicaid patients (STD = 27.5 days). We also only provided a complaint when prompted and did not perform an analysis to see if discrepancies existed for visits scheduled with or without a complaint. Future studies could evaluate variations in appointment times based on the emergent nature of the caller’s chief complaint.
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Our data suggests that patients with Medicaid experience longer wait times for their initial urological evaluation. Barriers to timely clinical evaluation have been cited as a reason for emergency room visitation. Awareness of such disparities in urologic care is an early step toward improving the quality of healthcare for all individuals. Our results may be useful for shaping future health policy.
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ACNKOWLEDGEMENTS
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This study had no source of funding. Wai Lee has a spouse working on research on overactive bladder funded by a Medtronic research grant. Howard Adler has stock ownership in Pfizer and is a shareholder in Allied Metro Litho and Theralogix. Andrew Chen, Ramsey Kalil, Tal Cohen, Wayne Waltzer and Jason Kim have no financial disclosures to make.
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REFERENCES
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1. Total monthly Medicaid and CHIP enrollment. The Henry J. Kaiser Family Foundation. Available at http://kff.org/health-reform/state-indicator/total-monthly-medicaid-and-chip-enrollment . Accessed January 6, 2017. 2. Merritt Hawkins: Physician appointment wait times and Medicaid and Medicare acceptance rates: 2014 survey. Available at https://www.merritthawkins.com/2014survey/patientwaittime.aspx . Accessed January 6, 2017. 3. Hwang AH, Hwang MM, Xie HW et al. Access to urologic care for children in California: Medicaid versus private insurance. Urology; 66: 170-173. 2005. 4. Resneck J, Pletcher MJ and Lozano N. Medicare, Medicaid, and access to dermatologists: the effect of patient insurance on appointment access and wait times. J Am Acad Dermatol; 50: 8592. 2004. 5. Overholser S, Thompson I, Sosland R et al. Medicaid patient access to urological care in the era of the Patient Protection and Affordable Care Act: A baseline to measure policy effectiveness. Urology Practice; 3: 276-282. 2016. 6. Pruthi RS, Neuwahl S, Nielsen ME et al. Recent trends in the urology workforce in the United States. Urology; 82: 987-994. 2013. 7. American Urological Association: Accredited listing of U.S. urology residency programs. Available at https://www.auanet.org/education/residency-programs/. Accessed October 13, 2016. 8. American Urological Association, Inc. Bylaws. 2017. Available at http://www.auanet.org/ about-us/aua-governance/aua-bylaws. Accessed July 5, 2017. 9. State Medicaid & CHIP Profiles. Available at https://www.medicaid.gov/medicaid/by-state/bystate.html. Accessed August 24, 2017 10. United States Census Bureau State Population Total Tables: 2010-2016. Available at https://census.gov/data/tables/2016/demo/popest/state-total.html. Accessed August 25, 2017. 11. The State of the Urology Workforce and Practice in the United States. AUA Census Report. 2016. Available at http://www.auanet.org/research/data-services/aua-census/census-results. Accessed July 7, 2017. 12. Decker SL. Two-thirds of primary care physicians accepted new Medicaid patients in 2011-2012: a baseline to measure future acceptance rates. Health Aff; 32: 1183-1187. 2013. 13. Labrum JT, Paziuk T, Rihn TC et al. Does Medicaid Insurance Confer Adequate Access to Adult Orthopaedic Care in the Era of the Patient Protection and Affordable Care Act? Clinical Orthopaedics and Related Research; 475(6):1527-1536. 2017. 14. Stec AA, Coons BJ, Chang SS et al. Waiting time from initial urological consultation to nephrectomy for renal cell carcinoma – does it affect survival? J Urol; 179: 2152-2157. 2008. 15. Liedberg F, Anderson H, Mansson A et al. Diagnostic delay and prognosis in invasive bladder cancer. Scand J Urol Nephrol; 37: 396-400. 2003. 16. Friedlander J, Kavoussi N, De S et al. The consequences of delaying stone treatment. J Urol; 193: e953. 2015. 17. Petersen LA, Burstin HR, O’Neil AC et al. Nonurgent emergency department visits – the effect of having a regular doctor. Medical Care; 36: 1249-1255. 1998. 18. Tang N, Stein J, Hsia RY et al. Trends and characteristics of US emergency department visits, 1997-2007. JAMA; 304: 664-670. 2010. 19. Taubman SL, Allen HL, Wright BJ et al. Medicaid increases emergency department use: evidence from Oregon’s health insurance experiment. Science; 343: 263-268. 2014.
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20. Merritt Hawkins: 2017 Survey of Physician Appointment Wait Times and Medicare and Medicaid Acceptance Rates. Available at https://www.merritthawkins.com/2017survey/patientwaittime.aspx . Accessed June 10, 2017. 21. Sommers, Benjamin D., and Richard Kronick. Measuring Medicaid Physician Participation Rates and Implications for Policy. Journal of Health Politics, Policy and Law; 41.2: 211-24 2014.
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Table 1. Wait time for outpatient urological evaluation at academic urology programs Medicaid
Medicare
# of programs
Mean (days)
STD (days)
Range (days)
CI 95%
Mean (days)
Northeastern
4
45.5
49.6
8 – 118
[-3.08, 94.1]
10.3
New England
11
33.2
21.1
8 – 63
[20.7, 45.7]
30.8
New York
16
26.8
25.8
0 – 83
[14.2, 39.5]
Mid-Atlantic
18
32.9
25.9
1 – 98
[21.0, 44.9]
North Central
24
29.5
30.8
1 – 100
[17.2, 41.8]
Southeastern
23
41.8
24.2
1 – 98
South Central
17
45.0
33.3
3 – 115
Western
18
35.7
14 - 60
Range (days)
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p
9.0
1 – 21
[1.43, 19.1]
0.251
21.4
7 – 55
[18.1, 43.5]
0.804
0 – 41
[5.19, 15.1]
0.022
25.5
20.4
5 – 92
[16.1, 34.9]
0.380
25.0
27.1
1 – 100
[14.1, 35.8]
0.623
[31.9, 51.7]
26.8
18.2
1 – 56
[19.3, 34.2]
0.050
[29.2, 60.8]
24.8
23.8
3 – 98
[13.5, 36.1]
0.077
[27.5, 44.0]
23.5
17.3
1 - 54
[15.6, 31.5]
0.120
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Table 1: Wait times for Medicaid and Medicare patients stratified by the AUA section.
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CI 95%
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STD (days)
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AUA Section
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Table 2. Characteristics of states with a single academic urology program versus states with multiple programs
Medicaid wait times
Medicare wait times
%
N
STD
Range
Mean (days)
STD (days)
Range (days)
Mean (days)
STD (days)
Range (days)
p
States with only one academic urology program
19
45
215,578
61,264
100,322 – 375,510
36.2
22.7
1 - 91
28.4
15.3
1 - 54
0.224
States with multiple academic urology programs
23
55
239,833
68,797
118,404 – 402,132
34.9
28.6
21.6
0100
<0.001
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# of programs
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Average # Medicaid patients per million population
0118
21.8
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Table 2: Characteristics of states with a single academic urology program compared to states with multiple academic urology programs. Data based on academic urology programs that met inclusion criteria for the study and their respective states.
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ABBREVIATIONS AND ACRONYMS ACGME = Accreditation Council for Graduate Medical Education
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AUA = American Urological Association