Medicaid Children Denied Medical Specialist Appointments

Medicaid Children Denied Medical Specialist Appointments

Penn Undercover Study Finds 66% Unable to Get Access

PHILADELPHIA -- An undercover research project targeting 273 specialty medical clinics in Cook County, Ill., found that 66 percent of Medicaid-covered children were unable to get an appointment for needed specialty care. Identical children with private-insurance were turned away only 10 percent of the time.

Federal law requires that Medicaid-Children's Health Insurance Program (CHIP) recipients have the same access to care as the general population in a given area.

Karin Rhodes

The study, published in the June 16 issue of the New England Journal of Medicine, was conducted by a research team at the University of Pennsylvania's Perelman School of Medicine.

'Disturbing disparities'
“We found disturbing disparities in specialty physicians’ willingness to provide outpatient care for children with public insurance, even when these children have urgent and severe health problems,” said senior author Karin V. Rhodes, MD, MS, director of Emergency Care Policy Research in the department of Emergency Medicine and senior fellow at the Leonard Davis Institute of Health Economics.

Even those Medicaid children who were scheduled for appointments faced disparities in wait times. They had to wait an average of 44 days to see a specialist. Privately-insured children's average wait was only 20 days.

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 children were able to get an appointment, as compared with 89 percent of callers reporting Blue Cross Blue Shield PPO insurance.

Insurance first
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, said Rhodes.

The scripts used by the undercover researchers were vetted by a panel of medical experts, said Rhodes. The conditions cited by the callers were common ones 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, seizures and a fracture that could affect bone growth.

Rhodes said that prior research showed that reimbursement amounts are a key factor influencing doctors’ decisions about whether to accept public insurance patients. For example, in Illinois, an office consultation for a problem of moderate severity is reimbursed at $99.86 by Medicaid–CHIP; but the average reimbursement for the same problem by a private insurer is approximately $160.

Need for policy interventions
The authors said their findings underscore the need and potential for policy interventions that target providers to end the disparity identified in their study. But questions remain: Is it better to raise reimbursement rates for specialists or do states need to reorganize the manner in which we provide specialty care?

“We can definitely solve this problem” said Rhodes. "The key question is: Are we willing to make the health of American children a national priority?"