Medicare, Medicaid, and access to dermatologists: The effect of patient insurance on appointment access and wait times

Background. In 2002, the Centers for Medicare and Medicaid Services implemented a 5.4% cut in Medicare physician payments, and further reductions are expected in 2004. These cuts have raised concerns that beneficiaries of Medicare will face significant problems obtaining needed physician services. Although there is clear evidence of poor access to care for patients with Medicaid, data measuring access to physicians for patients with Medicare are sparse. Given current lengthy appointment wait times resulting from a relative shortage of dermatologists; we hypothesized that patients with lower-paying coverage might be more likely to experience appointment refusals, longer wait times, or both. Methods: Because the ability to obtain timely appointments is a key measure of access, we surveyed dermatologists in 12 medium- and large-sized communities to assess wait times for routine new-patient visits. Dermatologists in these areas (or their staff) received a telephone call asking about the next available appointment for a hypothetical patient with a randomly assigned insurance type (ie, Medicaid, Medicare, or fee-for-service private insurance). Results: Of 631 physicians (or staff members) contacted, 612 (97%) agreed to participate. Overall acceptance rates were similar for patients with Medicare (85%) and private insurance (87%), but were much lower for those with Medicaid (32%). Among patients whose insurance was accepted, mean wait times for patients with Medicare and private insurance were 37 days, but patients with Medicaid experienced significant queuing (50 days). There was dramatic geographic variation. In areas where Medicare payments are low relative to commercial payors, there were increases in Medicare rejection rates and wait times. In communities with relatively low Medicaid payment rates, patients with Medicaid faced higher rejection rates and longer wait times. There were also longer overall wait times for female dermatologists and in communities where the concentration of dermatologists was low. Conclusion: Although overall access to dermatologists appears comparable for patients with Medicare and private insurance, some access limitations in "hot spots" where Medicare payments are low relative to commercial insurers suggest that patients in these areas may be most sensitive to further payment reductions. Significant access problems for beneficiaries of Medicaid, particularly in areas where Medicaid payments are relatively low, may be a harbinger of the potential consequences of sustained declines in Medicare physician reimbursement.