Patients with Medicaid experience difficulty getting appointments and significantly longer wait times at dermatology practices, according to study findings published in JAMA Dermatology.

The study aimed to focus on dermatology accessibility, which has not been studied nationally in 15 years despite significant changes to the practice of dermatology including the rise in private equity (PE) clinics and the use of nonphysician clinicians (NPCs).

Investigators randomly selected PE dermatology clinics by systematically searching financial databases. They included clinic locations that provided adult medical dermatology services still operating as of February 21, 2020, and excluded academic, federal, cosmetic, surgical, and pathology clinics. They matched each PE practice with the 2 nearest non-PE clinics, which served as controls.


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Using a secret-shopper study design, researchers called the clinics 3 times from February 24 to 28, 2020, to make an appointment for a fictitious new patient with a new and changing mole. Each researcher was randomly assigned to 1 of 3 study arms – Blue Cross Blue Shield (BCBS) preferred provider organization (PPO), Medicare, or Medicaid – and used a prepared script.

Appointment success was defined as insurance acceptance and the ability to make an appointment with any provider at any time in the future. There were 611 clinics across 28 states included in the final analysis. Overall appointment success rates were 96% for BCBS patients, 94% for Medicare patients, and 17% (P <.001) for Medicaid patients.

Compared with BCBS patients, appointment success for Medicaid patients was significantly lower in both PE clinics (20.2%; 95% CI, 15-26; P <.001) and control clinics (15.5%; 95% CI, 12-19; P <.001).

Medicaid patients had significantly longer appointment wait times at all clinics, with a median of 13 days (IQR, 4-33 days; P =.002), compared with BCBS (7 days; IQR, 2-22 days) and Medicare (7 days; IQR, 2-25 days) patients.

The median time to specifically see a dermatologist (MD or DO) for Medicaid patients was 22 days (IQR, 7-43 days), compared with a 13-day wait for BCBS (IQR, 4-34 days; P =.01) and Medicare (IQR, 4-33 days) patients. There was no statistically significant difference in wait times between PE and control clinics for any insurance type.

NPCs were offered for the first available appointment in 51% (95% CI, 46-56) of PE clinics vs 39% (95% CI, 36-43; P =.01) of control clinics. NPCs were available for appointments at 80% of PE clinics (95% CI, 75-84) vs 63% of control clinics (95% CI, 59-67; P =.001).

Dermatologists were not available to see a new patient with a new and changing mole at 16% of PE clinics (95% CI, 12-20) vs 6% of control clinics (95% CI, 5-8; P <.001). Next-day appointment availability with any provider – dermatologist or NPC – was higher at PE vs control clinics (30%; 95% CI, 26-35 vs 21%; 95% CI, 19-24; P =.001).

Investigators noted that control clinics in their database could have been acquired by PE firms after they were updated on July 3, 2019, and that some of the PE clinics could have been recently acquired without allowing sufficient time for policy changes to take effect.

The lack of a significant difference in appointment wait times for PE and control clinics between insurance groups suggests that “increased availability of NPCs does not affect average appointment wait time,” the study authors wrote.

That, combined with previous studies questioning the accuracy of skin cancer diagnoses by NPCs vs dermatologists, led the authors to conclude that “it remains unknown whether and in which clinical scenarios increased access to care with NPCs outweighs tradeoffs in clinical management.”

Disclosure: One study author declared affiliations with industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Creadore A, Desai S, Li SJ, et al. Insurance acceptance, appointment wait time, and dermatologist access across practice types in the US. JAMA Dermatol. 2021;157(2):181-188. doi:10.1001/jamadermatol.2020.5173