the health disparities podcast

197: Secret Shopper research shows bias against patients with ‘worse’ insurance

The underlying causes of health disparities are many, and sometimes healthcare providers can exacerbate disparities with how they operate.

Health equity researchers have conducted “secret shopper” studies, revealing how healthcare providers limit appointments — and even treatment recommendations — to people with certain types of insurance.

“Patients with Medicaid were significantly less likely to be offered appointments compared to those with Medicare or private insurance, and in many cases, clinics told us they weren’t accepting any new Medicaid patients or that they didn’t take Medicaid at all,” says Dr. Daniel Wiznia, Associate Professor of Orthopaedics & Rehabilitation at Yale and a former member of Movement Is Life’s Steering Committee.

“But when we would call back with private insurance, suddenly they have plenty of appointments available for the private insurance patients,” he says.

Wiznia and his colleagues also found that even when Medicaid patients were offered appointments, wait times were often much longer — delays which can have serious consequences.

“So if a Medicaid patient has to wait six weeks or eight weeks for an appointment, while a private patient just waits maybe a week, that can really impact outcomes, especially for patients with chronic conditions or urgent needs,” he says.

Wiznia joined Movement Is Life’s Dr. Mary O’Connor to discuss these findings in detail. He offers advice to patients who may find themselves in a situation where they’re denied care due to their insurance status and explains how raising reimbursement rates for Medicaid could help address the problem.

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The transcript from today’s episode has been lightly edited for clarity.

Dr. Mary O’Connor: So the Medicaid patient falls, maybe they break their wrist, they fracture their ankle, they have a clear orthopedic injury that requires evaluation and treatment right now, not something that can be delayed. They go to an urgent care center. Why? Because it’s closer, more convenient. They bring their insurance cards, it says Medicaid, and they’re turned away.

Dr. Daniel Wiznia: And it’s sort of ironic, because you know, how do they know about these sites? These sites are advertised as urgent care centers. ‘Come, there’s no wait time. If you go to the emergency room, there’s got to be a long wait time.’ Rarely is there any advertising that specifically says we don’t accept Medicaid, but the patient unfortunately finds this out as they’re in this acute position.

O’Connor: You’re listening to the Health Disparities podcast from Movement Is Life. I’m Dr. Mary O’Connor, Chair of the Movement Is Life Board of Directors and CoFounder and Chief Medical Officer at Vori Health. The underlying causes of health disparities are many, and sometimes healthcare clinicians can exacerbate disparities with how they operate. Health equity researchers have conducted ‘secret shopper’ studies revealing how healthcare providers limit appointments and even treatment recommendations to people with no insurance, or what the healthcare system would call lower-insured individuals, meaning insurances that don’t pay as much, don’t reimburse as well. To learn more, I’m joined today by Dr. Daniel Wiznia, Associate Professor of Orthopaedics and Rehabilitation at Yale School of Medicine, and a former member of our Movement Is Life steering committee. So Dan, welcome to the Health Disparities podcast. And thanks for being here.

Wiznia: Thanks for having me, Mary.

O’Connor: So Dan, you’ve you’ve done a lot of research in this kind of secret shopper concept, and so that may not be familiar to a lot of our listeners. So can you just update them and give them a little bit of understanding of what that means in terms of a secret shopper research project?

Wiznia: So let me tell you a little bit about what a secret shopper methodology is. So what we’re essentially doing is we’re acting as undercover patients, and we’re trying to understand how patients are treated when they access care. So as an undercover patient, we’ll make phone calls to clinics, and we use a standardized script, and we’re trying to see if our insurance influences whether we’re able to get an appointment like so, for example, we might call a clinic once and say, you know, we have private insurance, and then we’ll call back maybe a week later and say, we have Medicaid. And this allows us to isolate how insurance status affects whether someone can get an appointment, and then we can also catalog how long they had to wait for the appointment. So it’s a powerful way to uncover hidden biases in the healthcare system.

O’Connor: Yeah, you’ve done just such amazing work in this area, excuse me so but, but before we go deeper into into your research, perhaps it would be good to share with our listeners and audience the difference between Medicare and Medicaid, especially given the recent changes that we’re hearing about eligibility for Medicaid, and you know, not, not everybody’s familiar with what the difference in the programs.

Wiznia: It can be confusing because they sound very similar, but it’s important to understand the differences, because they have a big role, actually, in how patients access healthcare. So Medicare, it’s a federal program, and this primarily serves patients over 65 or those with certain disabilities, and it’s the same across the country. So it’s a federal program, and it’s the same in every state how it’s run. Medicaid, on the other hand, is a joint federal and state. Program, and that provides health care mostly to low income individuals and families. Now, because it’s administered by each state, the rules and reimbursement rates can vary widely, so some states reimburse at a higher level for services for care than others, and that can impact whether you’re able to access care. And some states have different rules in terms of who’s eligible for Medicaid, so that can also influence access to care.

O’Connor: And so let’s start with doctors. Are doctors required to take insurance, and if they’re, if they’re, that’s the first question. And then the second question is, are they required to take insurance like Medicaid or Medicare? Again, Medicare, the federal program for seniors, and Medicaid, joint program from the federal government in the state, but administered by the state for we’ll just use the term lower income individuals and families. So are doctors forced to take those insurances if patients have them.

Wiznia: So for the most part, doctors are not required to accept any insurance. Now, usually private insurance reimburses at the highest rate. And then the Federally run Medicare program for seniors reimburse about a little bit lower than the private insurance rates, and then the Medicaid rates can be considerably lower. It depends on what state you’re in, but sometimes it can be a lot lower, to the point that some health systems actually can lose money because the reimbursement rates are so low. But there’s no requirement that a physician needs to accept any insurance at all, but usually, you know, for vast majority of clinicians are accepting private insurance and Medicare and as Medicaid has become more universal, there’s been more acceptance of Medicaid, but there’s still a significant portion of clinicians who don’t accept Medicaid, right?

O’Connor: And by private insurance, just for the podcast audience, right, you mean insurance that people typically get through their employer.

Wiznia: Correct, correct. So this might be from a health insurance company, and you know, your employer gives you a health insurance card, and that would be defined as private insurance.

O’Connor: But just Just to wrap this up on the in this insurance question, but hospitals are required to see any patient for emergency services, regardless of how they’re insured.

Wiznia: Okay, so that’s a good point. So in an emergency, even if you don’t have any insurance, the emergency room is required to care for you, and if then you need a life saving care, that hospital is required to care for you, for that care.

O’Connor: Although, of course, the individual can then be sent a bill for the services.

Wiznia: That is true, but they cannot deny life-saving care. Now that being said, if you don’t have insurance and it’s an elective reason that you’re in the hospital, so it’s not an urgent emergency, they don’t need to offer you those services.

O’Connor: Right. Okay, so I’m eager to hear about the kinds of things that you’ve learned from your secret shopper research studies. So walk us through some of the key findings when it comes to Medicaid and Medicare. We’ll focus on those two as the comparators.

Wiznia: So, you know, just to remind everyone you know, with the secret shopper research, we’re calling these medical practices trying to get appointments, acting as though we’re a real patient, either with Medicaid or Medicare or private insurance. So there are a few things that we found. First one was that patients with Medicaid were significantly less likely to be offered appointments compared to those with Medicare or private insurance, and in many cases, clinics told us they weren’t accepting any new Medicaid patients or that they didn’t take Medicaid at all, but when we would call back with private insurance, suddenly they have plenty of appointments available for the private insurance patients. We also found that even when Medicaid patients were offered appointments, the wait times are often much longer. So these delays can have serious consequences. So if a Medicaid patient has to wait six weeks or eight weeks for an appointment, while a private patient, you know, just waits maybe a week, that can really impact outcomes, especially for patients with chronic conditions or urgent needs. And we saw this, access did vary by state. So states with higher Medicaid reimbursement, they had better access, while states with lower reimbursement, they had more barriers. So your ability to get care can depend not just on your insurance, but what state you’re in, because your state determines what your Medicaid plan reimburses at.

O’Connor: So basically, and I’ll just use the term doctors to refer to the system, right if the doctor is going to be paid more to see the patient. They will tell their appointment staff, I’m making a general statement now, that they’re more willing to see the patient who’s going to pay whose insurance will pay more for the visit than the patient who has insurance that doesn’t pay the doctor very much for the visit.

Wiznia: So you know, many of these practices, they’re small groups of clinicians working together, maybe private practice, one clinician or several. That’s primarily how medicines practice in many, many states across the country. They’re not all these large, large groups, so they’re going to focus on the patients who are going to pay more, so they’ll make more appointments available, open to patients with private insurance, compared to Medicaid.

O’Connor: So you’ve done some of this research focused on specifically Orthopedic Urgent Care Centers and musculoskeletal urgent care centers. And of course, at Movement Is Life, we’re very focused on disparities in musculoskeletal health, right? Because we know that joint pain leads to lower levels of physical activity, which then promotes obesity, and that extra weight puts more pressure on the joints, which then causes even more joint pain, and that immobility and obesity predisposed dramatically increase the risk of that individual, individual developing diabetes, heart disease, hypertension, depression and so you know, all these factors come together, which is why movement is obviously so important. So talk to us about your research that’s been focused on access to musculoskeletal care.

Wiznia: So we looked specifically at orthopedic or musculoskeletal urgent care centers. So these are sites that focus on getting patients in the same day who are suffering acutely from pain, musculoskeletal pain and what we found was that many of these centers didn’t accept Medicaid at all. Even though they advertise as walk-in clinics, they often would turn away patients based on insurance. And again, this pattern varied by state, in states with better Medicaid reimbursement, access was better, more of these urgent care centers accepted Medicaid, but in lower reimbursement states, Medicaid patients were routinely denied care. So this is really concerning, because if you have an urgent, acute issue, like a fracture or a dislocation, and you rush to one of these urgent care centers and they say, Oh, we’re not going to see you because we don’t accept your insurance well. Now your care has been delayed. Now you got to rush somewhere else for care. And you know, these urgent care centers aren’t obligated to see you like an emergency room is.

O’Connor: So, where do those patients go, Dan?

Wiznia: Many of them end up going to the hospital, to the emergency room, because that’s that, you know, that’s who will who will see them, especially in that acute, really stressful situation, when you’re you know at one of these urgent, you urgently are seeking care.

O’Connor: So the Medicaid patient falls, maybe they break their wrist, they fracture their ankle, they have a clear orthopedic injury that requires evaluation and treatment right now, not something that can be delayed. They go to an urgent care center. Why? Because it’s closer, more convenient. They bring their insurance card that says Medicaid, and they’re turned away.

Wiznia: And it’s sort of ironic, because you know, how do they know about these sites? These sites are advertised as urgent care centers, come, there’s no wait time. If you go to the emergency room, there’s got to be a long wait time. Rarely is there any advertising that specifically says we don’t accept Medicaid, but the patient, unfortunately finds this out as they’re in this acute position.

O’Connor: And where, in general, I know you’ve looked at this in your research, as well, are the urgent care centers located, physically located?

Wiznia: Many of them are located in wealthier neighborhoods. And they’re positioned in these neighborhoods because they’re trying to draw off of patients who have private insurance. So in wealthier neighborhoods, you have a patient mix where a higher percent are going to have private insurance versus Medicaid, so that’s why they’re located in those neighborhoods.

O’Connor: So take us a little bit deeper on the implications and the outcomes for how this differential treatment based on health insurance can contribute to disparities you touched on it before, but I think it would be really helpful for you to expand on that.

Wiznia: That’s a good question. So if you think about this, Medicaid patients are having a harder time accessing care, so sometimes their care is delayed, and if their care is delayed, they could have a worse outcome. We know that there are many musculoskeletal conditions that if you’re not seen within a certain window of time, then your outcome, your functional outcome, will be worse. So we know that, and also, a lot of patients with Medicaid really don’t have the resources to seek out, you know, a second, a third a fourth clinic which might accept their insurance, you know. So sometimes patients just give up. You know, they call two or three places they haven’t been able to get an appointment. So, you know, they just, they just give up. And then that orthopedic issue is neglected. It’s very unfortunate, because then these patients become more limited, more disabled, and then they can’t contribute to society.

O’Connor: So and I’m gonna, I’m gonna put up my plug in for academic medical centers here, because, in my experience, most academic medical centers like Yale, where you are right, you’re going to accept patients on Medicaid, and so you will care For those patients, regardless of whether they have lower quality insurance, and is that, would you say that that’s kind of a general statement across the country, that academic teaching centers are going to be more likely to care for patients with Medicaid?

Wiznia: That’s certainly the case. Usually you’ll have safety net hospitals that are very that really serve the communities around them and those patients, and really try to care for all the patients in the community. So, you know, there’s definitely going to be some health systems that put up barriers to access for patients with Medicaid. And you know, the motivation, it’s really the financial incentives.

O’Connor: Yes. So do you have any advice for patients out there who have Medicaid, meaning, you know, kind of lesser insurance on what they could try to proactively do, assuming that they they’re not in a position to get on private insurance, they’re not old enough, you know, they’re not old enough for Medicare?

Wiznia: I have a few tips so you know, it can be very frustrating, especially when you’re being treated differently than others. But one thing is, don’t give up. If one clinic turns you away, try another second. You should really speak with your primary care provider. There may be a social worker, also you have access to, who can help you navigate the system. And the other thing is, usually there is an insurance advocate that the state employees that can help the patients navigate access as well, so the patients can reach out to that insurance advocate to help them. And you know, in those emergency situations, just know that every hospital is there to treat you regardless of insurance. So you should keep that in mind that even if you don’t have insurance, if it’s an emergency, go to the hospital.

O’Connor: Absolutely. Yeah. So let’s talk or riff on solutions, which, of course, is the like, trillion dollar question in healthcare, right? If you were King of the universe and you could change the healthcare system, what would you change it to, to help address this?

Wiznia: Well, I think the easiest answer to come to is just increase Medicaid reimbursement rates so that they’re at the same level as Medicare or private insurance, then these patients won’t be treated differently because the financial incentives are the same. Unfortunately, we’re really strained financially with how Medicaid is funded through the federal and state government, so that does limit what those reimbursement rates are, and also understand that the states are trying to cover as many patients in their state as they can, but they know it’s a balancing act, because if they cover too many, then they’re not going to be able to reimburse at a rate that that the patients will be able to receive care. You know there’s another solution would be for there to be more transparency so that providers, you know, clinicians, have to openly publish which insurances they accept. Healthcare systems could openly publish how long their wait times are for all patients. And you know, potentially, you could have some incentives that would provide more equitable access in terms of outcome measures. So if your patients are doing better, regardless of insurance, the the health system gets sort of a bonus payment.

O’Connor: Great. Those are absolutely great ideas but challenging ones, right? Because there’s a finite amount of money, basically, and, and health care still remains expensive, even though, I’ll point out that the the cost, the the monies that are paid to the doctors, is actually a very, very small percentage of the total health care costs. But nonetheless, health care still remains expensive. And you know, if I was queen of the universe, right? We would make neighborhoods safer so people could walk outside. We’d eliminate food deserts, you know? We would do things that would support individuals in promoting their own wellness so they don’t get as sick as they do now, alright, but, but I’m not, Dan, so, so tell me what’s next for your research on this issue and kind of the secret shopper theme?

Wiznia: So we’ve been really exploring how insurance status affects access to care, and then what we started to tack on are social determinants of health. So one of our recent studies looked at how factors like housing, food security, transportation, how those impact whether patients can get orthopedic surgery, and we found that patients with even one social risk factor like food insecurity, they were significantly less likely to be cleared for surgery and get surgery. So these social determinants of health, they affect access to care, and then also the outcomes after you receive the care. This summer, we’ve been really focusing on a new study looking at food insecurity, and we’re also going to expand our secret shopper research to other specialties, other sub specialties within orthopedics. The goal is really to make sure that we have a microscope looking at these disparities, so that we can make certain that the system is treating everyone and everyone has access to care.

O’Connor: Dan, I’m I remain a big fan and supporter. You’ve done amazing work over the years, and I’m really looking forward to the future research that’s going to come out of your lab. So we’ll have to leave it there for this episode of the health disparities podcast. But I want to thank you, Dr. Wiznia, for joining us. You’re always welcome, and I’m sure we’ll have you back again in the future. We’ll include links to Dan’s work, Dr. Wiznia, in our show notes for today’s episode. So this brings me to the end of another episode of the Health Disparities podcast from Movement Is Life. I’m Dr. Mary O’Connor, until next time, be safe and be well.