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CHICAGO -- Children receiving Medicaid are finding it increasingly difficult to obtain prompt orthopedic care following a fracture, a researcher said here.

In a national survey conducted in 2006, 92% of orthopedic offices agreed to see children with private insurance, but only 38% would take a child on Medicaid, according to Christopher Iobst, MD, of Miami Children's Hospital in Florida.

Today, however, those numbers have fallen to 82% and 24%, respectively, he said at the annual meeting of the American Academy of Orthopaedic Surgeons.

Iobst and colleagues identified this decline by randomly picking five general orthopedic centers in each state, and telephoning them with this scripted request:

"My 10-year old son broke his arm while out of the country last week. He was splinted and told to see an orthopedic surgeon within 1 week. His fracture does not involve the growth plate."

The interviewer then said the child was a Medicaid recipient. If the center did not offer an appointment, the interviewer asked for a reason and requested a referral for another nearby office.

The researchers then called the same office a week later with the same request, but said that the child had private insurance.

Overall, 82% of children with private insurance were offered an appointment, compared with only 24% of children on Medicaid.

In 40% of cases where no appointment was available within a week, the reason was that the center did not accept Medicaid patients.

Of those not given an appointment, almost half also were not given a referral to another center.

"This was pretty dismal," Iobst said.

In the 10 states with the highest Medicaid reimbursement rates, private patients were offered an appointment in 82% of cases, while Medicaid patients were given appointments in 44%.

In states with the lowest Medicaid reimbursements, 88% of private patients were given an appointment, as were only 6% of Medicaid patients.

"Even more dismal," he said.

In nine states (Connecticut, Illinois, Louisiana, New Jersey, North Carolina, Oklahoma, Rhode Island, South Dakota, and Texas), all five offices turned away the Medicaid patients, but accepted the private insurance patients.

A number of factors may be contributing to this increasing inability of children, particularly those with public insurance, to receive care for fractures, including low reimbursement and excessive paperwork.

But other contributors may be a trend toward subspecialization in orthopedics, with only 24% now considering themselves general orthopedic surgeons, and limited numbers being interested in emergency department work.

There also may be concerns about malpractice, Iobst noted.

"But if there's a silver lining, it's that patients are being shifted to tertiary facilities and receiving better care, even though that can involve greater burdens on the family for travel and costs," he said.

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