Musculoskeletal Urgent Care Centers in Connecticut Restrict Patients with Medicaid Insurance Based on Policy and Location

Abstract

Background

Musculoskeletal urgent care centers are a new development in the urgent care landscape. Anecdotally, these centers are known to screen patients based on their insurance status, denying care to those with Medicaid insurance. It is important to know whether the practice of denying musculoskeletal urgent care to patients with Medicaid insurance is widespread because this policy could exacerbate existing musculoskeletal healthcare disparities.

Questions/purposes

(1) Do musculoskeletal urgent care centers in Connecticut provide access for patients with Medicaid insurance? (2) Do musculoskeletal urgent care centers have the same Medicaid policies as the entities that own them? (3) Are musculoskeletal urgent care centers more likely to be located in affluent neighborhoods?

Methods

An online search was conducted to create a list of musculoskeletal urgent care centers in Connecticut. Each center was interviewed over the telephone using a standardized list of questions to determine ownership and Medicaid policy. Next, the entities that owned these musculoskeletal centers were called and asked the same questions about their Medicaid policy. Medicaid policy was compared between musculoskeletal urgent care centers and the practices that owned them. The median household income for each ZIP code containing a musculoskeletal urgent care center was compared with the median household income for Connecticut. The median household income was also compared between the ZIP codes of musculoskeletal urgent care centers that accepted or denied patients with Medicaid insurance.

Results

Of the 29 musculoskeletal urgent care centers in Connecticut, only four (13%) accepted patients regardless of their insurance type, 19 (66%) did not accept any form of Medicaid insurance, and six (21%) required that certain requisites and stipulations be met for patients with Medicaid insurance to receive access, such as only permitting a patient for an initial visit and then referring them to a local hospital system for all future encounters, or only permitting patients with Medicaid insurance who lived in the same town as the clinic. All 29 musculoskeletal urgent care centers were owned by private practice groups and nine of 14 of these groups had the same policy towards patients with Medicaid insurance as their respective musculoskeletal urgent care centers. All 29 musculoskeletal urgent care centers were co-located in a private practice clinic office. Musculoskeletal urgent care centers were located in areas with greater median household incomes than the Connecticut state median (95% CI, USD 112,322 to USD 84,613 versus the state median of USD 73,781; p = 0.001).

Conclusions

Most musculoskeletal urgent care centers in Connecticut do not accept patients with Medicaid insurance and have similar or stricter Medicaid policies as the groups that own them. Additionally, musculoskeletal urgent care centers were located in affluent neighborhoods. These findings are important because they suggest private practices are using musculoskeletal urgent care centers to capture patients with more favorable insurance. This is likely a result of the relatively low Medicaid reimbursement rates in Connecticut and reflects a need for an increase in either reimbursement or incentives to treat patients with Medicaid insurance. The financial impact of capturing well-insured patients from public and academic medical centers and directing Medicaid patients to these urgent care centers is not known. Additionally, although most of these 29 musculoskeletal urgent care clinics denied care to patients with Medicaid, the specific healthcare disparities caused by decreased access to care must be further studied.

Introduction

Musculoskeletal urgent care centers are designed to provide immediate orthopaedic care in an acute setting. They provide triage, workup, and a fast-track referral to an orthopaedic surgery subspecialist [2]. They are considered low-cost treatment centers because there is no facility fee or emergency department-level evaluation and management fee [2]. They presumably attract patients who would have otherwise presented to an emergency room, but offer shorter patient wait times and potentially increase patient satisfaction [2, 3, 15]. Preliminary evidence suggests these centers do not provide access for patients with all types of insurance, and they may deny care to patients with Medicaid [10].

If musculoskeletal urgent care centers are excluding patients with Medicaid, refusal of care may potentiate healthcare disparities by limiting access to care, causing delays in treatment that can lead to further harm [8, 12, 13]. Healthcare disparities may also arise from restricting patients from receiving more cost-effective, specialized care associated with lower costs for the patient and healthcare system [2]. The degree to which musculoskeletal urgent care centers decline to provide care to patients with Medicaid insurance has not been characterized. We were interested in evaluating access to care at these musculoskeletal urgent care centers specifically in the state of Connecticut because this state has expanded Medicaid under the Affordable Care Act and has low Medicaid reimbursement rates compared with other states [7, 16]. A single-state assessment controls for the variations in Medicaid reimbursement, Medicaid expansion, varying Medicaid populations, and unique economic situations that exist between states.

We therefore asked, (1) Do musculoskeletal urgent care centers in Connecticut provide access for patients with Medicaid insurance? (2) Do musculoskeletal urgent care centers have the same Medicaid policies as the entities that own them? (3) Are musculoskeletal urgent care centers more likely to be located in affluent neighborhoods?

Materials and Methods

Study Design and Setting

In November 2018, an online search using multiple search engines was conducted by a single team member (DHW) in a manner by which a patient might try to identify a musculoskeletal urgent care center location. First, Google (Mountain View, CA, USA), the most heavily trafficked search engine in the United States for patients seeking medical care, was used to search the following key terms: “CT musculoskeletal urgent care,” “CT orthopedic urgent care,” and “CT MSK urgent care” to create a list of musculoskeletal urgent care centers in Connecticut. Next, the same team member performed a second and third online search using Google Maps (Mountain View, CA, USA) centered over Connecticut and Bing (Bellevue, WA, USA) with the same key terms, identifying no additional centers that were not found in the initial Google search. Each center was interviewed over the telephone using a standardized list of questions, developed and verified by the study members collectively, to determine whether the musculoskeletal urgent care center was owned by a larger healthcare group or private practice and to what extent they accepted patients with Medicaid insurance.

Next, the groups that owned these musculoskeletal urgent care centers were called and asked about their policy regarding patients with Medicaid insurance using the same set of questions. The differences in policies between the musculoskeletal urgent care centers and the groups that owned them were compared. Next, clinic and office locations were recorded from the practice websites and compared with the musculoskeletal urgent care center locations. The median household income, defined as the collective 12-month income of all individuals in a household older than 15 years, was recorded using data from the United States Census Bureau for the ZIP codes containing each musculoskeletal urgent care center. This was compared with the state median household income [18].

Statistical Analysis, Study Size

Twenty-nine musculoskeletal urgent care centers were identified and divided into two groups based on whether they accepted any form Medicaid insurance (n = 10) or did not accept any Medicaid insurance (n = 19). The 10 centers that accepted Medicaid insurance were subdivided into those four that accepted Medicaid insurance unconditionally and those six that accepted Medicaid with restrictions such as requiring the patient to live in the same town as the center or only willing to see the patient for triage and then referring all subsequent treatment to an unaffiliated public hospital or academic medical center.

To compare Medicaid policies between musculoskeletal urgent care centers and the private practices that owned them, contingency tables and a chi-square analysis were used. Medicaid acceptance and denial by all musculoskeletal urgent care centers (n = 29) and all private practices (n = 14) were compared. Then, because policy did not vary between musculoskeletal urgent care centers owned by the same practice, a second analysis was performed to compare Medicaid acceptance and denial policies for private practices (n = 14) matched to the collective policies of their respective musculoskeletal urgent care centers (n = 14).

The mean of the median ZIP code incomes of patients in the two groups (Medicaid and no Medicaid) were compared with one another using an unpaired t-test. The United States Census Bureau’s median Connecticut household income of USD 73,781 was used as a specified constant and compared with the mean of the median household incomes for all 29 ZIP codes that contained musculoskeletal urgent care centers, using a one-sample t-test [18]. The musculoskeletal urgent care centers were then subdivided into the same two groups as mentioned above (Medicaid and no Medicaid), and the mean of each group’s median household income was individually compared with the state median of USD 73,781, using a one-sample t-test. All statistical analyses were performed using GraphPad Prism (San Diego, CA, USA).

Results

Nineteen of the 29 musculoskeletal urgent care centers (65%) did not accept patients with Medicaid insurance. Of the 10 centers that accepted Medicaid insurance (35%), six had stipulations and conditions for patients with Medicaid, such as the patient was required to live in the town where the clinic was located (three of six centers) or the patient would only undergo triage at the center and then be referred to the state hospital system, which was not affiliated with the center, for follow-up (three of six centers) (Fig. 1).

Fig. 1.

This figure shows the Medicaid policy for musculoskeletal urgent care centers. Each graph represents one of 29 musculoskeletal urgent care centers in Connecticut. They are colored based on their Medicaid insurance acceptance policy.

All 29 musculoskeletal urgent care centers were privately owned by 14 different orthopaedic practices. Nine of these 14 practices had the same policy regarding Medicaid as their respective musculoskeletal urgent care centers. Of the five practices that had different policies regarding Medicaid, three had more liberal Medicaid policies at the clinics than the musculoskeletal urgent care sites did. Seven of the 14 practices accepted Medicaid, two of which unconditionally accepted Medicaid, while stipulations and conditions were applied at the other five practices in order for a Medicaid patient to be seen, such as the requirement that patients live in the same town (two of five practices) or that patients would only be seen if an outside referral was placed (two of five practices); only one member of a large specialty group accepted Medicaid. In comparing private practice Medicaid policy with musculoskeletal urgent care center policy, we found that 50.0% of private practices and 34.5% of musculoskeletal urgent care centers accepted some sort of Medicaid insurance, while 14.2% of private practices and 13.8% of musculoskeletal urgent care centers unconditionally accepted Medicaid patients. There was no difference in acceptance of Medicaid insurance between musculoskeletal urgent care centers and private practices (34% versus 50%; odds ratio 0.5263; 95% confidence interval, 0.146 to 2.041; p = 0.33) (Table 1). There was also no difference between Medicaid acceptance and denial policies when multiple musculoskeletal urgent care centers with the same policy under a single private practice were pooled and compared with their respective private practices (35.7% versus 50.0%; OR 0.5556; 95% CI, 0.1058 to 2.374; p = 0.45) (Table 2).

Table 1.

Medicaid acceptance and denial by all musculoskeletal urgent care centers and private practices

Table 2.

Medicaid acceptance and denial by all private practices and their pooled musculoskeletal urgent care centers

All 29 musculoskeletal urgent care centers were co-located in a private practice clinic or office location and were in areas with greater median household incomes than the Connecticut state median (USD 73,781) (Fig. 2). The mean ± standard deviation of the median household incomes per care center ZIP code was USD 98,468 ± USD 37,103 (95% CI, USD 112,322 to USD 84,613; p = 0.001) (Table 3). When the care centers were divided into groups based on whether they accepted any Medicaid, only the subgroup that did not accept any Medicaid had musculoskeletal urgent care centers in areas with higher median household incomes than the state median. The mean ± SD of the median household incomes per care center ZIP code for clinics that did not accept any Medicaid was USD 102,837 ± USD 42,339 (95% CI, USD 123,244 to USD 82,430; p = 0.0078). The mean ± SD of the median household income per care center ZIP code for clinics that accepted Medicaid was USD 90,165 ± USD 27,087 (95% CI, USD 109,542 to USD 70,788; p = 0.0881).

Fig. 2.

This map shows musculoskeletal urgent care center locations in Connecticut as related to the township’s median income. The musculoskeletal urgent care center locations are marked by stars, overlying Connecticut townships that are color-coded based on the quartile of their median household income. The stars are also color-coded based on the extent to which the marked urgent care center accepts or does not accept Medicaid patients.

Table 3.

Household incomes and ZIP code-based musculoskeletal urgent care locations, stratified by Medicaid policy

Discussion

Musculoskeletal urgent care centers are a new addition to the urgent-care landscape and promise to deliver cost-effective, specialized care [2]. However, the extent to which musculoskeletal urgent care centers are available to patients with Medicaid insurance has not been characterized. We focused solely on Connecticut because a single-state assessment controls for variations in Medicaid expansion and reimbursement that exist between states. Connecticut decided to expand Medicaid under the Affordable Care Act and has relatively low Medicaid reimbursement rates [7, 16].

This study has several limitations. First, although our search appeared to be inclusive and complete, our catalog of orthopaedic urgent care centers in Connecticut may not be comprehensive. However, we used the most common internet search engines, in addition to lay terms similar to the terms a patient might use when searching for a center to receive treatment. No additional musculoskeletal urgent care centers were identified in the second and third searches, suggesting our search was comprehensive. In addition, we were able to interview and acquire data from all of the sites we were able to identify. Second, our catalog only represents the findings of a single state at a single point in time (Connecticut, November 2018). We decided to focus on Connecticut to control for state variations in Medicaid reimbursement and expansion. Connecticut has expanded access to Medicaid under the Affordable Care Act, has low Medicaid reimbursement rates compared with other states, permits for-profit clinics and ambulatory surgery centers, and allows for-profit and non-profit hospitals. The findings of this study may not be generalizable to states with higher Medicaid reimbursement rates because there may be more of a financial incentive in those states to treat patients with Medicaid insurance. These findings may also vary in applicability when compared with states that chose not to expand Medicaid or have different policies with respect to for-profit centers and hospitals. The quantity of musculoskeletal urgent care centers and the patients they elect to treat is a complex multifactorial decision that likely varies depending on the economic pressures of the competitive healthcare landscape in which they exist.

Third, all of the musculoskeletal urgent care centers were co-located in a private practice clinic and had similar or more restrictive policies towards patients with Medicaid insurance. This suggests that musculoskeletal urgent care centers are effectively an extension of private practice clinics and, to a degree, may further restrict access for Medicaid patients.

We found strong evidence to suggest that musculoskeletal urgent care centers in Connecticut decline to treat patients with Medicaid insurance. This corroborates the findings of other studies demonstrating that Medicaid-insured patients have more difficulty obtaining access to orthopaedic care. Many studies have demonstrated that patients with Medicaid insurance have had decreased access to care since the passage of the Affordable Care Act [1, 5, 6, 14, 19, 20]. Our findings substantiate this notion with respect to the recently developed delivery model, the musculoskeletal urgent care center. Musculoskeletal urgent care centers have been shown to decrease wait times, result in faster times to follow-up, and have lower mean charges per visit than a hospital emergency room (USD 461 versus USD 8150) [2]. These centers have great potential to reduce costs to the healthcare system, improve healthcare delivery, and reduce healthcare disparities. Unfortunately, when patients with Medicaid insurance are excluded from receiving care at musculoskeletal urgent care centers, their alternative is to present to the emergency department or a primary care provider or forego care [15]. A novel method of delivering cost-effective care is falling short of reaching disadvantaged patients who are likely to benefit the most from its use.

We surmise that Medicaid reimbursement plays a large role in determining whether a practice accepts Medicaid and whether the practice has created musculoskeletal-specific urgent care centers. Most revenue from musculoskeletal urgent centers comes from patient acquisition and relies heavily on reimbursement [2]. Further, reimbursement is a key factor in determining whether physicians will opt to treat Medicaid patients [16]. The extent to which a musculoskeletal urgent care center can be profitable and sustainable in treating a representative proportion of Medicaid patients who reflect the state population (approximately 24% in Connecticut) with low levels of reimbursement is an important question that needs be answered [11].

All 29 musculoskeletal urgent care centers identified in Connecticut were owned by private practices, and the practices and their corresponding musculoskeletal urgent care centers had similar or stricter policies for Medicaid patients. These findings suggest that all musculoskeletal urgent care centers in Connecticut function as an extension of an already existing private practice. An interesting question raised by our findings was, why is it that only private practices have developed these musculoskeletal urgent care centers in Connecticut while hospitals and non-profit institutions have not elected to do so? Musculoskeletal urgent care centers have been shown to generate substantial revenue far exceeding start up and maintenance costs [2], but there is much uncertainty about whether these centers are sustainable with an increased Medicaid insurance patient base in conjunction with low Medicaid reimbursement rates.

The 29 musculoskeletal urgent care centers in Connecticut were co-located at a private practice office in neighborhoods that had a higher income than the median for the state, and this was particularly true for centers that did not accept Medicaid. The current locations of musculoskeletal urgent care centers are a challenge for individuals who may reside in more underserved areas [9]. Patients who live in medically underserved areas have a higher odds of preventable emergency department use, and the effective placement of musculoskeletal urgent care centers may decrease orthopaedic emergency department admissions for issues that do not require admission [4]. Despite being located in more affluent areas and restricting patients with Medicaid insurance, these musculoskeletal urgent care centers provided substantial benefit to those who were able to use them and presumably provided increased access to affordable care. However, there is room for much more to be accomplished in this realm as emergency department visits rise, with the highest rates of use being among patients with Medicaid insurance, which has been observed in states that expanded Medicaid under the Affordable Care Act [17].

Conclusions

We found that 66% of musculoskeletal urgent care centers in Connecticut do not accept Medicaid insurance. In addition, all musculoskeletal urgent care centers in Connecticut were owned by private practices, were co-located in a private practice clinic, had similar or more restrictive policies towards patients with Medicaid insurance than the practice that owned them, and were in locations with a greater median household income than the state median. These novel musculoskeletal urgent care centers limit access to care to the Medicaid population via policy and clinic location. The Medicaid population would likely benefit the most from the reduced healthcare costs and improved access to care that musculoskeletal urgent care centers offer. Further investigation is needed to understand whether these centers are sustainable based on varying degrees of Medicaid volume and reimbursement.