Unkind But Not Illegal Behavior

Jun 16 2011 Published by under [Medicine&Pharma]


From today's New England Journal of Medicine:


Auditing Access to Specialty Care for Children with Public Insurance by Joanna Bisgaier, M.S.W., and Karin V. Rhodes, M.D from University of Pennsylvania

This study examined barriers to specialty care for children with public health insurance, both Medicaid and Children's Health Insurance Program (CHIP). They studied Cook County, IL, the second most populous county in the US, and had trained graduate students posing as mothers make phone calls to clinics to schedule new specialist appointments for the following patients:

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They selected specialists that see children using the following sampling method:

We constructed an exhaustive list of providers, using state-provided physician-licensure data, cross-referenced with lists of physicians submitting specialty claims for children in Cook County and lists of specialists provided by children’s hospitals and the American Academy of Pediatrics. The final sample included all specialists for whom there was any evidence that they provided care to children (0 to 18 years of age) residing in Cook County. Because several specialists may practice at the same clinic and some specialists practice at several clinics, we did not sample providers; rather, we sampled clinics, defined by unique (unduplicated) telephone numbers used for scheduling appointments. Random samples of 40 clinics per health-condition scenario were stratified according to two key variables (provider licensure reporting acceptance vs. nonacceptance of Medicaid–CHIP and urban vs. suburban location) with the use of a computer algorithm. During the study, physicians’ licensure data regarding Medicaid–CHIP acceptance were not publicly available.

No data is reported on the nature of these clinics. Were the doctors pediatric sub-specialists, or adult specialists who were willing to see children? Were these private practice offices, or were they satellites of an academic center or children's hospital? The latter are more likely to be staffed by us pesky pediatric subspecialists. Unfortunately, the investigators did not plan or power their study to address these differences.

At any rate, the study found that children with public insurance were less likely to have an appointment scheduled (I don't believe you will have trouble figuring out which bar is which):


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Waiting times for appointments were also longer with public insurance:


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Expansion of Medicaid-CHIP programs were promoted to increase access of poor children to high-quality medical care, and they do allow these children to be seen by specialists eventually. However, choices in specialty care may be limited, and waiting times may be longer, in part because there are fewer providers taking that insurance.

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The first tweet I saw this morning regarding this article suggested that something about these practices was illegal; however, as far as I can tell, it is not.

In our capitalist healthcare system, no practice can be forced to take on every payor, especially those that reimburse at much lower rates.

The authors point out that Illinois Medicaid reimburses ~$100 for a visit for which Blue Cross Blue Shield pays $160. When my department discusses ways to increase our revenue, improving payor mix always comes up. However, for us subspecialists, the kids on Medicaid -CHIP use our services at a higher rate than their suburban counterparts. That I cannot change.

I do not believe my own nephrology group has a problem with this issue. We do ask about insurance during the intake, mostly to figure out what sort of precertification hoops must be jumped since our kids often need laboratory and imaging studies with their appointments. As the only two practitioners in our specialty for a multi-state region, we see them all; delaying appointments just would not matter in the long-run.

The authors correctly conclude that there is a discrepancy in specialty care for these children. They discuss issues to consider, but they do not address the most obvious way to eliminate these disparities, a single-payor system.

Of course not; that would be socialist, even if it would be more fair.




One response so far

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