Sixty-six percent of publicly-insured children were unable to get a doctor's appointment for medical conditions requiring outpatient specialty care including diabetes and seizures, while children with identical symptoms and private insurance were turned away only 11 percent of the time, according to an audit study of specialty physician practices in Cook County, Ill. conducted by researchers from the Perelman School of Medicine and the School of Social Policy and Practice at the University of Pennsylvania.
The findings are published in the June 16 issue of the New England Journal of Medicine.
"We found disturbing disparities in specialty physicians' willingness to provide outpatient care for children with public insurance -- even those with urgent and severe health problems," said senior author Karin V. Rhodes, MD, MS, director of Emergency Care Policy Research in Penn's department of Emergency Medicine and a senior fellow in the Leonard Davis Institute of Health Economics. "This study shows a failure to care for our most vulnerable children."
The study also found that Medicaid and Children's Health Insurance Program (CHIP)-insured children who received an appointment faced longer wait times to be seen. Their average wait to see a specialist was 44 days, while privately-insured children with similar urgent conditions waited 20 days. Federal law, however, requires that Medicaid recipients have the same access to medical care as the general population in their community.
In the study, research assistants posed as mothers of children with seven common health conditions. They made calls to a random sample of 273 clinics representing eight specialties in Cook County. Two calls, separated by one month, were placed to each clinic by the same person using a script that varied only by insurance status. Overall, only 34 percent of callers with Medicaid-insured children were able to get an appointment, as compared with 89 percent of callers reporting Blue Cross Blue Shield PPO insurance.
In more than half of the calls to clinics, the caller was asked for information about the child's insurance type before being told whether an appointment could be scheduled. In 52 percent of these calls, the type of insurance coverage was the first question asked.
The clinical conditions cited by the callers were common problems that impact large numbers of children and warrant timely specialty care. They included severe body rashes, obstructed breathing during sleep, Type 1 diabetes, uncontrolled asthma, severe depression, new onset seizures and a fracture that could affect bone growth.
Prior research has found that reimbursement amounts are a key factor influencing doctors' decisions about whether to accept patients with public insurance. However, the authors suggest that incentives and mission of the health systems in which the doctors work may play an even larger role. Their findings underscore the need to identify policy interventions that will end the disparities identified in the study.
"We studied the health system, not individual providers," Rhodes said. "To reduce disparities, we may need to restructure reimbursement strategies and reorganize the manner in which our health system provides specialty care. We can fix this problem, but it will not happen unless we are willing to make the health of American children a national priority."
- Joanna Bisgaier, Karin V. Rhodes. Auditing Access to Specialty Care for Children with Public Insurance. New England Journal of Medicine, 2011; 364 (24): 2324 DOI: 10.1056/NEJMsa1013285
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