Insurance Status and Access to Urgent Primary Care Follow-up After an Emergency Department Visit in 2016

      Study objective

      We examine the availability of follow-up appointments for emergency department (ED) patients without established primary care by insurance and clinical condition.


      We used “secret shopper” methodology, employing 2 black men to telephone all 53 primary care practices in greater New Haven, posing as new patients discharged from the ED and requesting follow-up appointments. Each practice received 6 scripted calls from each caller during an 8-month period, reflecting all possible scenarios based on 3 insurance types (Medicaid, state exchange, and commercial) and 2 conditions (hypertension and back pain). Primary outcome was the proportion of calls that obtained an appointment in 7 calendar days (7-day appointment rate). Secondary outcomes included overall appointment rate and appointment wait time.


      Among the total of 604 calls completed, the 7-day appointment rate was 30.7% (95% confidence interval [CI] 22.6% to 38.8%). Compared with commercial insurance, Medicaid calls had lower 7-day rate (25.5% versus 35.7%; difference 10.2%; 95% CI 2.2% to 18.1%) and overall appointment rate (53.5% versus 77.8%; difference 24.4%; 95% CI 13.4% to 35.4%). There was no significant difference between state exchange and commercial insurance calls in 7-day rate (30.9% versus 35.7%; difference 4.8%; 95% CI –3.1% to 12.6%) or overall appointment rate (73.4% versus 77.8%; difference 4.4%; 95% CI –2.7% to 11.6%). Back pain, compared with hypertension, had lower 7-day appointment rate (27.6% versus 33.7%; difference 6.1%; 95% CI 1.0% to 11.2%), but no significant difference in overall appointment rates (67.0% versus 69.4%; difference 2.4%; 95% CI –2.7% to 7.5%).


      For patients without established primary care, obtaining timely follow-up after acute care in the ED is difficult, particularly for Medicaid beneficiaries.
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      1. National Center for Health Statistics; Centers for Disease Control and Prevention. National Hospital Ambulatory Medical Care Survey: 2013 emergency department summary tables. Available at: Accessed May 15, 2016.

        • Bradley J.S.
        • Byington C.L.
        • Shah S.S.
        • et al.
        The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.
        Clin Infect Dis. 2011; 53: e25-e76
        • Wolf S.J.
        • Lo B.
        • Shih R.D.
        • et al.
        Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure.
        Ann Emerg Med. 2013; 62: 59-68
        • Mace S.E.
        • Gemme S.R.
        • Valente J.H.
        • et al.
        Clinical policy for well-appearing infants and children younger than 2 years of age presenting to the emergency department with fever.
        Ann Emerg Med. 2016; 67: 625-639.e13
        • Hahn S.A.
        • Lavonas E.J.
        • Mace S.E.
        • et al.
        Clinical policy: critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy.
        Ann Emerg Med. 2012; 60: 381-390.e28
        • Edlow J.A.
        • Panagos P.D.
        • Godwin S.A.
        • et al.
        Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache.
        Ann Emerg Med. 2008; 52: 407-436
        • Cheung P.T.
        • Wiler J.L.
        • Lowe R.A.
        • et al.
        National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries.
        Ann Emerg Med. 2012; 60: 4-10.e2
        • Ginde A.A.
        • Lowe R.A.
        • Wiler J.L.
        Health insurance status change and emergency department use among US adults.
        Arch Intern Med. 2012; 172: 642-647
        • Weber E.J.
        • Showstack J.A.
        • Hunt K.A.
        • et al.
        Does lack of a usual source of care or health insurance increase the likelihood of an emergency department visit? results of a national population-based study.
        Ann Emerg Med. 2005; 45: 4-12
        • Rhodes K.
        Taking the mystery out of “mystery shopper” studies.
        N Engl J Med. 2011; 365: 484-486
        • Medicaid Access Study Group
        Access of Medicaid recipients to outpatient care.
        N Engl J Med. 1994; 330: 1426-1430
        • Asplin B.R.
        • Rhodes K.V.
        • Levy H.
        • et al.
        Insurance status and access to urgent ambulatory care follow-up appointments.
        JAMA. 2005; 294: 1248-1254
      2. Namrata Uberoi KF, Gee E. Health insurance coverage and the Affordable Care Act, 2010-2016. Available at: Accessed May 22, 2017.

      3. Connecticut Department of Social Services. DSS reports. Available at: Accessed April 22, 2017.

      4. Kaiser Family Foundation. Total marketplace enrollment. Available at:,%22sort%22:%22asc%22%7D. Updated March 15, 2017. Accessed April 22, 2017.

      5. Vornovitsky JCBM. Health Insurance Coverage in the United States: 2015. Washington DC: US Census Bureau; 2016. Available at: Accessed January 25, 2017.

        • Bodenheimer T.
        • Pham H.H.
        Primary care: current problems and proposed solutions.
        Health Aff (Millwood). 2010; 29: 799-805
        • Anderson A.
        The Impact of the Affordable Care Act on the Health Care Workforce.
        Heritage Foundation, Washington, DC2014 (Available at:) (Accessed April 22, 2017)
        • Polsky D.
        • Candon M.
        • Saloner B.
        • et al.
        Changes in primary care access between 2012 and 2016 for new patients with Medicaid and private coverage.
        JAMA Intern Med. 2017; 177: 588-590
        • Polsky D.
        • Richards M.
        • Basseyn S.
        • et al.
        Appointment availability after increases in Medicaid payments for primary care.
        N Engl J Med. 2015; 372: 537-545
        • Tipirneni R.
        • Rhodes K.V.
        • Hayward R.A.
        • et al.
        Primary care appointment availability for new Medicaid patients increased after Medicaid expansion in Michigan.
        Health Aff (Millwood). 2015; 34: 1399-1406
        • Haeder S.F.
        • Weimer D.L.
        • Mukamel D.B.
        Secret shoppers find access to providers and network accuracy lacking for those in marketplace and commercial plans.
        Health Aff (Millwood). 2016; 35: 1160-1166
        • Froud R.
        • Patterson S.
        • Eldridge S.
        • et al.
        A systematic review and meta-synthesis of the impact of low back pain on people's lives.
        BMC Musculoskelet Disord. 2014; 15: 50-63
        • Slade S.C.
        • Molloy E.
        • Keating J.L.
        Stigma experienced by people with nonspecific chronic low back pain: a qualitative study.
        Pain Med. 2009; 10: 143-154
        • Coffman J.M.
        • Rhodes K.V.
        • Fix M.
        • et al.
        Testing the validity of primary care physicians' self-reported acceptance of new patients by insurance status.
        Health Serv Res. 2016; 51: 1515-1532
      6. Kolko J. “Normal America” is not a small town of white people. Available at: Accessed October 10, 2016.

        • Abraham M.
        • Buchanan M.
        Greater New Haven Community Index.
        DataHaven, New Haven, CT2016 (Available at:) (Accessed April 22, 2017)
      7. US Census Bureau. American fact finder. Available at: Accessed April 22, 2017.

      8. PCare4NHV. Primary Care for New Haven. Available at: Accessed August 26, 2015.

      9. Transitions Clinic. Transition Clinic Network. 2014. Available at: Accessed November 20, 2016.

      10. Fronstin P. Sources of health insurance and characteristics of the uninsured: analysis of the March 2013 current population survey. Available at: Accessed August 3, 2016.

        • Edlow J.A.
        Managing nontraumatic acute back pain.
        Ann Emerg Med. 2015; 66: 148-153
      11. Kaiser Family Foundation. Market share and enrollment of largest three insurers—individual market. Available at:,%22sort%22:%22asc%22%7D. Accessed October 26, 2016.

      12. Becker AL. ConnectiCare takes lead as most popular insurer on exchange. Available at: Accessed October 26, 2016.

        • Blanchard J.
        • Ogle K.
        • Thomas O.
        • et al.
        Access to appointments based on insurance status in Washington, DC.
        J Health Care Poor Underserved. 2008; 19: 687-696
        • Hochberg Y.
        A sharper Bonferroni procedure for multiple tests of significance.
        Biometrika. 1988; 75: 800-802
        • Wright S.P.
        Adjusted P-values for simultaneous inference.
        Biometrics. 1992; 48: 1005-1013
      13. Health Indicators Warehouse. Primary care providers (per 100,000). Available at: Accessed November 30, 2016.

        • Center for Workforce Studies
        2015 State Physician Workforce Data Book.
        Association of American Medical Colleges, Washington DC2015 (Available at:) (Accessed May 6, 2017)
      14. Merritt Hawkins. The physician workforce in Texas. Available at: Accessed May 1, 2017.

        • Conley J.
        • O'Brien C.W.
        • Leff B.A.
        • et al.
        Alternative strategies to inpatient hospitalization for acute medical conditions: a systematic review.
        JAMA Intern Med. 2016; 176: 1693-1702
        • Schuur J.D.
        • Baugh C.W.
        • Hess E.P.
        • et al.
        Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care.
        Acad Emerg Med. 2011; 18: e52-e63
        • Malloy D.P.
        • Bremby R.L.
        Department of Social Services Annual Report: State Fiscal Year 2015.
        Connecticut Department of Social Services, Hartford, CT2015 (Available at:) (Accessed August 3, 2016)
        • Rhodes K.V.
        • Basseyn S.
        • Friedman A.B.
        • et al.
        Access to primary care appointments following 2014 insurance expansions.
        Ann Fam Med. 2017; 15: 107-112
        • Allen H.
        • Wright B.J.
        • Harding K.
        • et al.
        The role of stigma in access to health care for the poor.
        Milbank Q. 2014; 92: 289-318
        • Han X.
        • Call K.T.
        • Pintor J.K.
        • et al.
        Reports of insurance-based discrimination in health care and its association with access to care.
        Am J Public Health. 2015; 105: S517-S525
        • Ketsche P.
        • Adams E.K.
        • Minyard K.
        • et al.
        The stigma of public programs: does a separate S-CHIP program reduce it?.
        J Policy Anal Manage. 2007; 26: 775-789
        • Cunningham P.J.
        • O'Malley A.S.
        Do reimbursement delays discourage Medicaid participation by physicians?.
        Health Aff (Millwood). 2009; 28: w17-w28
      15. Medical Group Management Association. MGMA ACA exchange implementation survey report: May 2014. Available at: Accessed August 4, 2016.

        • Blumenthal D.
        • Collins S.R.
        Health care coverage under the Affordable Care Act—a progress report.
        N Engl J Med. 2014; 371: 275-281
      16. Cox C, Claxton G, Levitt L, et al. Analysis of 2017 premium changes and insurer participation in the Affordable Care Act’s health insurance marketplaces. Available at: Accessed October 7, 2016.

        • Chou R.
        • Qaseem A.
        • Snow V.
        • et al.
        Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.
        Ann Intern Med. 2007; 147: 478-491
        • Schuur J.D.
        • Venkatesh A.K.
        The growing role of emergency departments in hospital admissions.
        N Engl J Med. 2012; 367: 391-393
        • Rhodes K.V.
        • Bisgaier J.
        • Lawson C.C.
        • et al.
        “Patients who can't get an appointment go to the ER”: access to specialty care for publicly insured children.
        Ann Emerg Med. 2013; 61: 394-403