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Original Investigation
January 13, 2021

Insurance Acceptance, Appointment Wait Time, and Dermatologist Access Across Practice Types in the US

Author Affiliations
  • 1Brigham and Women's Hospital, Department of Dermatology, Harvard Medical School, Boston, Massachusetts
  • 2Boston University School of Medicine, Boston, Massachusetts
  • 3Tufts University School of Medicine, Boston, Massachusetts
  • 4Harvard Medical School, Boston, Massachusetts
  • 5Ponce Health Sciences University, Ponce, Puerto Rico
  • 6Department of Public Health Sciences, Loyola University, Chicago, Illinois
  • 7Department of Dermatology, University of California School of Medicine, San Francisco
JAMA Dermatol. Published online January 13, 2021. doi:10.1001/jamadermatol.2020.5173
Key Points

Question  What are the insurance acceptance practices, wait times, and clinician availability at dermatology clinics with and without private equity (PE) ownership?

Findings  In this cross-sectional, secret-shopper study of 611 dermatology clinics, patients with Medicaid had significantly longer wait times and lower success in obtaining an appointment compared with patients with private insurance or Medicare, regardless of clinic ownership. Private equity–owned clinics had increased appointment availability with nonphysician clinicians and decreased appointment availability with dermatologists.

Meaning  Dermatology access for patients with Medicaid remains limited across PE and non-PE clinics and should be monitored as the dermatology practice landscape continues to evolve.


Importance  In the 15 years since dermatology access was last investigated on a national scale, the practice landscape has changed with the rise of private equity (PE) investment and increased use of nonphysician clinicians (NPCs).

Objective  To determine appointment success and wait times for patients with various insurance types at clinics with and without PE ownership.

Design, Setting, and Participants  In this study, PE-owned US clinics were randomly selected and matched with 2 geographically proximate clinics without PE ownership. Researchers called each clinic 3 times over a 5-day period to assess appointment/clinician availability for a fictitious patient with a new and changing mole. The 3 calls differed by insurance type specified, which were Blue Cross Blue Shield (BCBS) preferred provider organization, Medicare, or Medicaid.

Main Outcomes and Measures  Appointment success and wait times among insurance types and between PE-owned clinics and control clinics. Secondary outcomes were the provision of accurate referrals to other clinics when appointments were denied and clinician and next-day appointment availability.

Results  A total of 1833 calls were made to 204 PE-owned and 407 control clinics without PE ownership across 28 states. Overall appointment success rates for BCBS, Medicare, and Medicaid were 96%, 94%, and 17%, respectively. Acceptance of BCBS (98.5%; 95% CI, 96%-99%; P = .03) and Medicare (97.5%; 95% CI, 94%-99%; P = .02) were slightly higher at PE-owned clinics (compared with 94.6% [95% CI, 92%-96%] and 92.8% [95% CI, 90%-95%], respectively, at control clinics). Wait times (median days, interquartile range [IQR]) were similar for patients with BCBS (7 days; IQR, 2-22 days) and Medicare (7 days; IQR, 2-25 days; P > .99), whereas Medicaid patients waited significantly longer (13 days; IQR, 4-33 days; P = .002). Clinic ownership did not significantly affect wait times. Private equity–owned clinics were more likely than controls to offer a new patient appointment with an NPC (80% vs 63%; P = .001) and to not have an opening with a dermatologist (16% vs 6%; P < .001). Next-day appointment availability was greater at PE-owned clinics than controls (30% vs 21%; P = .001).

Conclusions and Relevance  Patients with Medicaid had significantly lower success in obtaining appointments and significantly longer wait times regardless of clinic ownership. Although the use of dermatologists and NPCs was similar regardless of clinic ownership, PE-owned clinics were more likely than controls to offer new patient appointments with NPCs.

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