Government Insurance Limits Patient Access to Orthopaedic Surgeons and Physical Therapy Services

Physical therapy plays a large role in both nonoperative and postoperative treatment of orthopaedic conditions in adult and pediatric populations. Although Medicaid expansion from the Affordable Care Act (ACA) focused on increasing healthcare access and quality by providing health insurance to individuals who cannot afford or obtain private insurance, there are still gaps in access to healthcare services for patients with government insurance (e.g., Medicaid). Due to low reimbursement rates, patients with Medicaid face challenges in finding orthopaedic surgeons who will treat them in a timely matter. This access issue may extend after surgery to finding a physical therapy facility that will accept their insurance. This article assesses the current literature and evidence regarding access and utilization of both physical therapy services and orthopaedic surgeons for patients with government insurance versus private insurance.

Physical therapy as nonoperative management
In general, access to physical therapy can be difficult for all patients, and many insurance payers, particularly the government, limit the overall number of therapy visits during a specific time period regardless of whether the visits are for the same or different issues. Some payers even combine occupational, physical, and speech therapy into a single category. This action can negatively impact individuals with complex and/or chronic medical issues who may be poor surgical candidates or who were referred to physical therapy as a component of nonoperative management.

Similarly, in the acute post-hospitalization period for patients with nonoperative orthopaedic diagnoses, it was shown that the Medicaid/Medicare patient population had a lower likelihood of receiving physical therapy services for general mobilization compared to privately insured patients. A limited number of studies have evaluated physical therapy access for nonoperative orthopaedic referrals, but several studies found Medicaid/Medicare insurance to be associated with less utilization of physical therapy and longer time to establishing a therapy appointment for diagnoses such as lumbar stenosis. Across orthopaedic specialties, many patients are routed to physical therapy through primary care referrals prior to being evaluated by surgical specialists, which may hide or underestimate the size of this care-access gap from the orthopaedic specialty’s viewpoint.

Pediatric physical therapy
Many pediatric orthopaedic conditions may not require physical therapy given the high functional capacity of healthy pediatric patients. However, some common injuries rely on pediatric physical therapy for adequate trial of nonoperative management (e.g., first-time patellar instability) and appropriate postoperative recovery after operative intervention (e.g., anterior cruciate ligament [ACL] reconstruction or shoulder labral repair). One study found that after nonoperative or operative orthopaedic treatment, pediatric patients with government insurance were three times more likely to experience a delay in starting physical therapy compared with privately insured patients. Many pediatric patients with neuromuscular or musculoskeletal developmental abnormalities who are followed in the orthopaedic clinic rely on formal physical therapy for stretching, strengthening, and modalities to optimize functional status.

One study showed that the use of physical therapy during a single year by pediatric patients with cerebral palsy was significantly reduced for those with government insurance rather than private insurance. Access to trained pediatric/adolescent physical therapy locations is paramount for optimal outcomes for these patients, given the need for certain types of therapy and age-appropriate regimens. Several studies that evaluated access to pediatric/adolescent physical therapy found reduced acceptance to clinics and associated lower functional outcomes for patients with government insurance compared with private insurance.

Surgical delays
Prior studies have demonstrated that patients with government insurance have limited access to orthopaedic surgeons compared with privately insured patients, which was thought to be related to low reimbursement rates impacting surgeons’ ability and willingness to accept Medicaid patients. Patients with ACL tears and Medicaid insurance had, on average, a 5-month delay from diagnosis to surgery and worse outcomes at 2-year follow-up compared with non-Medicaid patients.

Additionally, Medicaid or Medicare insurance has been associated with increased risk of postoperative medical and surgical complications. One possible contributing factor could be limited access to physical therapy. Additionally, patients with government insurance may have higher comorbidities or other risk factors related to lower socioeconomic status, which may increase the risk of complications.

Postoperative physical therapy limitations
Postoperative physical therapy protocols and adherence are paramount to optimal patient outcomes for various orthopaedic procedures, including but not limited to ACL reconstructions, rotator cuff repairs, shoulder arthroplasties, shoulder labral repairs, and traumatic hand injuries. Multiple studies have found worse patient-reported outcomes, functional status improvements, and postoperative pain in patients who were unable to adhere to postoperative physical therapy regimens. Insurance status—specifically Medicaid compared with private insurance—has been shown to be an independent risk factor for reduced utilization of physical therapy in the postoperative period.

Some studies have postulated that Medicaid patients’ reduced utilization of physical therapy is the result of lower acceptance by physical therapy clinics, reduced number of therapy sessions approved by insurance, and/or higher associated therapy co-pays, which limit patients’ ability to adhere to their surgeons’ recommended regimens. Cross-sectional studies in urban locations have demonstrated that physical therapy clinics were less likely to accept Medicaid patients. If clinics did accept Medicaid, there were longer times to initial appointments compared with wait times among privately insured patients. Other studies comparing rural to urban physical therapy clinic locations demonstrated higher acceptance of Medicaid-insured patients in rural locations. This finding may point to regional variations based on local insurance payer mix and competition, suggesting that financial opportunities are driving factors for clinic acceptance.

Summary
Orthopaedics is a specialty that regularly requires the involvement of high-quality physical therapy to maximize functional outcomes in both operative and nonoperative settings. The current literature discussing physical therapy access and outcomes for patients based on insurance payer is still relatively sparse, but the literature available is consistent and concerning, with findings suggesting that government insurance for adult and pediatric orthopaedic patients is associated with reduced or delayed access to both orthopaedic surgeons in general and physical therapy services. Additionally, even when this care is accessible, there are often associated delays of initiating physical therapy for patients with government insurance versus private insurance. These findings indicate significant barriers in the ability of our healthcare system to provide adequate orthopaedic care to patients unable to afford private insurance.

Lauren Swany, MD, is an orthopaedic surgery resident at the University of Michigan in Ann Arbor.

Jacqueline Kobayashi, MD, is an AAOS resident delegate and an orthopaedic surgery resident at the University of Michigan in Ann Arbor.

Miranda J. Rogers, MD, MS, is an assistant professor of orthopaedic surgery at the University of Michigan in Ann Arbor.

Xinning Li, MD, FAAOS, is a professor of orthopaedic surgery at the Boston University School of Medicine and a member of the AAOS Now Editorial Board.

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