AAP News Vol. 18 No. 4
April 2001, p. 143
Data raise concerns about Medicaid accessfrom the AAP Division of Health Policy ResearchMedicaid and Title XXI (SCHIP) programs have increased the number of children eligible for health insurance. But their impact on access to pediatric care and the financial viability of providers is less obvious. New AAP data show a strong correlation between payment rates and willingness to participate in Medicaid. Those pediatricians getting the lowest reimbursement rates have the lowest levels of Medicaid participation. Without pediatrician participation, the capacity of the Medicaid program to provide quality care to children is at risk. Thus, monitoring the participation of pediatricians is key to assessing the capacity of the system. Because of the Academy’s long-standing commitment to the Medicaid program and for the purpose of improving this program, we are interested in both monitoring the levels of pediatrician participation and understanding the barriers to increased pediatrician participation. To that end, the AAP Division of Health Policy Research asked more than 13,000 pediatricians about their participation in Medicaid and SCHIP, in one of the largest surveys of members ever undertaken. The survey was mailed during the winter of 2000, and more than 8,300 members responded for a response rate of 67%. The Academy conducted a similar study on Medicaid participation in 1993. According to our findings of pediatrician participation in public and private health insurance programs, more than one-third of pediatricians’ patients were enrolled in Medicaid or SCHIP in 2000, up from one-fourth enrolled in Medicaid in 1993. At the same time, participation in Medicaid by all pediatricians in direct patient care increased by 20 percentage points to 67% between 1993 and 2000. This change parallels an almost two-fold increase in Medicaid-paid visits to general pediatricians, from 9.6 million in 1993 to 18.7 million in 1998, according to the National Ambulatory Medical Care Survey conducted by the National Center for Health Statistics. Yet, despite overall higher acceptance of Medicaid patients in 2000, private office-based primary care pediatricians are significantly less likely to fully participate in Medicaid than pediatric subspecialists or primary care pediatricians in safety-net settings. Nonetheless, to achieve the goal of providing every Medicaid-eligible child with a primary care medical home, full participation by primary care pediatricians in private practice settings is key, especially when clinicians working in public safety-net settings, such as community health centers and hospital-based clinics, are already practicing over capacity. According to the 2000 AAP survey, participation by primary care pediatricians in private office-based settings is substantially lower than participation by pediatric subspecialists or primary care pediatricians in safety-net settings based on two alternative measures of participation. The first measure is the proportion of private office-based primary care pediatricians accepting all Medicaid patients who request care ("full participation"). The second measure is expressed as the ratio of providers accepting all Medicaid vs. non-Medicaid patients ("relative participation"), which has the advantage of adjusting for practices that lack the capacity to take new patients of any type.
By both measures, providers in states in the lower quartiles of Medicaid payments in terms of (1) overall payment for primary care services (Norton S. "Recent Trends in Medicaid Fees, 1993-1998." Urban Institute,1999), and (2) payments for three commonly used primary care codes (99391, 99213 and 99214) for children (American Academy of Pediatrics Medicaid Reimbursement Survey, 1998/99) have substantially lower participation rates (See
By any standard, these low rates are very likely to impact access to having a primary care provider and needed services. A multivariate regression analysis further demonstrates the interactions among payment rates, administrative concerns, capitated managed care and ratio of child health care providers in the state. In addition to low payments, higher paperwork concerns, larger share of capitated than (reduced) fee-for-service Medicaid patients and greater ratios of children per child health care physician also contributed significantly to provider unwillingness to accept Medicaid patients to the same extent they accept non-Medicaid patients. By demonstrating a clear relationship between low payment, administrative burden, capitated managed care and impeded participation by primary care pediatricians in private office-based settings, these data raise concerns about equal access to physician offices by Medicaid children and system capacity to care for an estimated 6.4 million children currently eligible to enroll in Medicaid expansion and SCHIP programs.
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