SAUSALITO, CA (NCP-ASSN.ORG)-- Orthopedic surgeons are much more hesitant to see kids with broken bones than they were a decade ago, suggests new research from California.

When contacted by telephone, more than half of orthopedic practices wouldn't schedule an appointment for a kid with a recently-broken arm who had private insurance. What's more, almost all refused appointments to kids covered by Medicaid, the government-run health insurance program for the poor.

"I'm not at all surprised by what happened with Medicaid," said Dr. David Skaggs, from Children's Hospital Los Angeles, one of the study's authors.

When his team did a similar study 10 years ago, most practices also wouldn't see kids on Medicaid. But all of them scheduled appointments for those with private insurance.

"The shocking finding was that half of the people don't see children anymore," Skaggs told Reuters Health.
"They come with parents who ask lots of questions, and it just takes longer and it's more energy... and you're not paid any more," he explained.

Especially outside of big cities with specialized pediatric hospitals, that may mean it's harder for injured kids to get treatment, he said.

For the new study, a researcher called 45 orthopedic practices around Los Angeles pretending to be the parent of a 10-year-old boy with a broken arm who needed an appointment with an orthopedic surgeon. The investigator called each office on two different occasions, once saying that the son was privately insured, and once telling staff he was covered by Medicaid.

Nineteen of those 45 practices offered the "parent" an appointment for a privately-insured kid within a week. That compared to 50 out of 50 offices that offered parents an appointment when Skaggs and his colleagues made the same calls ten years ago.

Only one practice set up an appointment for a kid covered by Medicaid. And when the investigator asked each office for a referral to an orthopedic surgeon who did take Medicaid, just nine could name one.

It's no secret that kids on Medicaid have a harder time getting appointments, because public insurance often doesn't reimburse doctors as much as private insurance. In California, "the orthopedic surgeons were losing money on every visit," Skaggs said.

"The evidence in the article... is consistent with other evidence that a lot of physicians just don't accept Medicaid patients, period," said Sandra Decker, a researcher from the U.S. Centers for Disease Control and Prevention who has studied kids' access to care.

"Even though these kids are 'insured,' they really don't have access to medical care," Skaggs added.

That will only change if health care reform not only increases the number of people who are insured, but also increases reimbursement rates so practices have an incentive to see those patients, he added.

Right now, Decker said, reimbursements to primary care doctors are set to increase -- but not payments to specialists like orthopedic surgeons.

When orthopedic practices won't take kids -- regardless of what type of insurance they have -- more and more families have to seek out special pediatric facilities for treatment.

Dr. James Kasser, the orthopedic surgeon-in-chief at Children's Hospital Boston, said that more youngsters getting treated at specialized centers just for kids isn't necessarily a bad thing. After all, doctors there have more experience with similar cases.

In addition, "Most of the pediatric specialized systems provide care regardless of people's ability to pay," Kasser, who was not involved in the new research, told Reuters Health.

That's as long as kid-focused care is available in a family's area, he added.

Finding a specialist isn't so much of an issue in Los Angeles, Skaggs said. But, "it does become a problem when you're outside of an urban setting -- there's the rub."

For some families, finding a kids-only orthopedic surgeon means more travel, money and time away from work and school.

General orthopedic practices, Kasser said, "just aren't taking care of kids the way they were before."



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