Auditing Access to Outpatient Rehabilitation Services for Children With Traumatic Brain Injury and Public Insurance in Washington State

Published:January 23, 2017DOI:



      To identify insurance-based disparities in access to outpatient pediatric neurorehabilitation services.


      Audit study with paired calls, where callers posed as a mother seeking services for a simulated child with history of severe traumatic brain injury and public or private insurance.


      Outpatient rehabilitation clinics.


      Sample of rehabilitation clinics (N=287): 195 physical therapy (PT) clinics, 109 occupational therapy (OT) clinics, 102 speech therapy (ST) clinics, and 11 rehabilitation medicine clinics.


      Not applicable.

      Main Outcome Measures

      Acceptance of public insurance and the number of business days until the next available appointment.


      Therapy clinics were more likely to accept private insurance than public insurance (relative risk [RR] for PT clinics, 1.33; 95% confidence interval [CI], 1.22–1.44; RR for OT clinics, 1.40; 95% CI, 1.24–1.57; and RR for ST clinics, 1.42; 95% CI, 1.25–1.62), with no significant difference for rehabilitation medicine clinics (RR, 1.10; 95% CI, 0.90–1.34). The difference in median wait time between clinics that accepted public insurance and those accepting only private insurance was 4 business days for PT clinics and 15 days for ST clinics (P≤.001), but the median wait time was not significantly different for OT clinics or rehabilitation medicine clinics. When adjusting for urban and multidisciplinary clinic statuses, the wait time at clinics accepting public insurance was 59% longer for PT (95% CI, 39%–81%), 18% longer for OT (95% CI, 7%–30%), and 107% longer for ST (95% CI, 87%–130%) than that at clinics accepting only private insurance. Distance to clinics varied by discipline and area within the state.


      Therapy clinics were less likely to accept public insurance than private insurance. Therapy clinics accepting public insurance had longer wait times than did clinics that accepted only private insurance. Rehabilitation professionals should attempt to implement policy and practice changes to promote equitable access to care.


      List of abbreviations:

      CBG (census block group), CI (confidence interval), CR (count ratio), GLM (generalized linear model), OT (occupational therapy), PT (physical therapy), ST (speech therapy), TBI (traumatic brain injury)
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