RESUMO
Introduction Obstetrical research confirms that earlier onset prenatal care significantly improves pregnancy and birth outcomes. Initiating care in the second trimester or having less than 50% of recommended visits has been associated with an increased risk of prematurity, stillbirth, neonatal, and infant death. Studies have shown that women on public health insurance plans initiate prenatal care substantially later into pregnancy than those on private plans. The purpose of this study is to assess whether public health insurance limits Florida patients' access to obstetric care. Methods A cross-sectional study was conducted by collecting data on the four most populated zip codes for Medicaid in South Florida using HealthGrades.com. The following search parameters were used: "obstetric care", "four stars and up" and "10-mile distance". Each obstetrician was called three times to assess appointment availability for fictional nulliparous women at eight weeks of gestation requesting prenatal care. Accepted insurance types (Medicaid, Cigna, and United Health Group (UHG)), time to an appointment in business days, and self-pay rates were recorded. Practices with invalid contact information and retired obstetricians were excluded. Summary statistics, chi-squared analysis, and a two-way t-test were conducted for the primary outcome. Results Seventy-one out of 178 obstetricians were successfully contacted, of which 31 physicians accepted all three insurances, and 40 physicians did not accept at least one insurance. Of those, 97.2% accepted UnitedHealthcare, 98.6% accepted Cigna, and 45.1% accepted Medicaid. There was a statistically significant difference when comparing acceptance rates between UHC and Medicaid as well as Cigna and Medicaid (p<0.001). There was no statistically significant difference in acceptance rates in the direct comparison of the two private insurances, Cigna and UnitedHealthcare (p=0.559). The average number of days until the next available appointment was 12.7 (SD= 7.2) for UnitedHealthcare, 20.0 (SD=6.7) for Cigna, and 17.0 (SD=8.6) for Medicaid. There was a statistically significant trend between the type of insurance and the time to the earliest appointment (p=0.002). Conclusion This study demonstrated patients enrolled in Medicaid in South Florida have significantly less access to prenatal care than those with private insurance. This evidence shows that decreased access to care from Medicaid plans can possibly increase the risk of adverse outcomes associated with inadequate prenatal care. This information should be considered by policymakers when considering future Medicaid expansion.
RESUMO
A previously healthy 28-year-old woman was admitted to the hospital with respiratory failure and was found to have significant lymphadenopathy on her CT scan. A lymph node biopsy was performed; the pathology was consistent with a diagnosis of Hodgkin's lymphoma and the patient was noted to have multiple, wrinkled, nonscaly, oval-shaped papules that were easily compressible (Figure 1) and were present on the upper and lower extremities, abdomen, chest, and back. The lesions were entirely asymptomatic and had first developed 1 year prior to presentation. Since their initial development, the wrinkled papules had continued to crop up. Some of the lesions began as brownish-red papules and subsequently turned skin-colored.Punch biopsies of the lesional and unaffected skin were performed. A Verhoeff-Van Gieson (VVG) stain showed loss of dermal elastic tissue in the lesional skin, compared to that of the unaffected skin. The clinical and histologic examinations were consistent with the diagnosis of anetoderma.
