Factors associated with discrimination in specialty care access for children with public insurance examined in new study

"Studies suggest that providers of children's outpatient specialty services are less likely to accept Medicaid and the Children's Health Insurance Program (CHIP) than private insurance," the authors write as background information in the article. "Identifying health care provider and system-level characteristics associated with acceptance of publicly insured children can inform the allocation of public resources."

Using audit study data from 273 specialty clinics collected from January through May 2010, Joanna Bisgaier, M.S.W., Ph.D., and colleagues with the University of Pennsylvania, Philadelphia, examined the association between a clinics' academic medical center (AMC) affiliation and equity in scheduling appointments for children with public and private insurance. Trained researcher assistants posing as mothers of children called each clinic twice, and used standard scripts to attempt to schedule appointments for children, in which only the insurance status of the child was modified (Medicaid-CHIP vs. Blue Cross Blue Shield). Of the 273 clinics in the study, approximately half (51 percent) were affiliated with AMCs.

Of the 273 paired calls to clinics, 155 (57 percent) resulted in an appointment being denied for a Medicaid-CHIP enrolled child while a privately insured child obtained an appointment at the same clinic for the same medical condition (defined as "discriminatory denial"). In this study sample, 46.8 percent of academic-affiliated clinics had a discriminatory denial compared to 67.2 percent of non-academically-affiliated clinics. An affiliation with an AMC was associated with a 45 percent lower odds of denying an appointment to a child with Medicaid-CHIP. Additionally, a specialty clinics' neighborhood poverty level increased, the likelihood of having discriminatory denials of Medicaid-CHIP decreased.

When assessing wait times, callers reporting Medicaid-CHIP coverage had wait times 22 days longer than callers reporting private insurance, even after adjusting for outside factors. Independent of insurance status, scheduling an appointment at AMC-affiliated clinics resulted in wait time for appointments that were 29 days longer than calls to nonaffiliated clinics. On average, academic clinics scheduled appointments for Medicaid-CHIP children with wait times 40 days longer than for children with private insurance.

"Compared with specialty clinics that were not affiliated with an academic medical center, clinics with AMC-affiliated health care providers were more likely to give children with Medicaid-CHIP an opportunity to see a specialist," the author conclude. "However, while they are less likely to outright deny an appointment, academically affiliated clinics were more likely to schedule children with public insurance with longer wait times than privately insured children. Research and oversight that measures and monitors outcomes related to health care access disparities, along with other quality measures, is needed as we make adjustments to our health care delivery systems."

Editorial: Ensuring Children with Public Insurance Access to Pediatric Specialty Care

In an accompanying editorial, Stephen Berman, M.D., of the University of Colorado School of Medicine, Aurora, writes, "While there are many reasons that physicians refuse to care for Medicaid-enrolled children, studies carried out over the past three decades have consistently identified low Medicaid payments as the most influential reason."

"As the proportion of children with public insurance increases, AMCs and affiliated children's hospitals struggle to maintain an appropriate 'patient mix' of private insurance- to public insurance-covered patients," Dr. Berman writes. "One method to accomplish this involves placing a monthly limit on the number of scheduled appointments for patients with public insurance in a specialty clinic...This may explain the observed difference in wait times in the current study."

"Child health policy makers at both state and national levels need to understand the need for continued Children's Hospitals Graduate Medical Education federal funding and higher Medicaid payments for pediatric services," he concludes. "The findings of the current study strongly support this view."