Medicaid Coverage and Impact on Appointment Wait Times for Acute Gynecologic Care: A Mystery Caller Study

INTRODUCTION: Physicians receive more reimbursement on private payor insurance visits than similar visits paid with public insurance. Previous studies have illustrated increased wait times for patients with public insurance seeking obstetrics and gynecologic subspecialty care. However, no research exists showing the impact of insurance type on access to general gynecologic care. OBJECTIVE: We sought to audit mean appointment wait times for US Blue Cross Blue Shield and Medicaid patients. Additionally, we investigated the ability of clinician office staff to identify emergent concerns and advise patients accordingly. METHODS: Office phone numbers were identified from the searchable HealthGrades patient-facing database. Using a “mystery caller” study approach, each unique phone number was called twice, once by a caller with Medicaid and once with BCBS. The caller asked for the soonest appointment available for their relative, who is currently experiencing an acute gynecologic concern. One of four clinical scenarios was selected per office. Half of the scenarios described an emergent condition that warranted immediate medical intervention. The date of the soonest appointment, physician, office demographics, and whether the caller was advised to visit the emergency department were collected. RESULTS: Our sample included 1,140 calls to physician offices from 48 states, excluding North Dakota and Rhode Island. We called 567 unique physicians who accepted Blue Cross/Blue Shield, and 75.2% of obstetrics and gynecology offices accepted Medicaid. The median physician age was 53 (IQR 44–61), and almost two-thirds (63.2%) of physicians were female. When controlling for factors, a Poisson model predicted patients with recurrent or treatment-resistant vaginitis had the longest estimated wait time at 22.0 business days (95% CI 21–23), while those with acute cystitis experienced the shortest wait at 13.4 business days (95% CI 13–14); patients with a prior emergency department visit and a 6-cm tubo-ovarian abscess waited 19.2 business days (95% CI 18–20), and those with a positive pregnancy test after tubal ligation waited 17.0 business days (95% CI 16–18). Predictors of shorter wait time were female physician gender (IRR=0, 95% CI 0–0.02, p<0.01). While seeing an academic physician (p<0.01) and longer phone call hold time (IRR=5.10, 95% CI 1–24, p=0.04) are associated with longer wait times. Of the 161 patients who were told to go to the emergency department, 12.3% were in the Emergent scenario type (n=70/N=571), and 16.0% were in the Urgent scenario type (n=91/N=569). CONCLUSIONS: Significant delays in gynecologic diagnosis and treatment can harm patients. Understanding factors influencing appointment wait times is essential to mitigating harm in gynecologic care. Ours is the first nationwide audit of insurance payors on barriers to general gynecologic care. Obstetric and gynecology practices should work toward keeping wait times at a minimum, regardless of patient insurance (Figure 1).