The Dynamics of Rationing Outpatient Subspecialty Care for Children Covered by Medicaid 9_29_11


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The Dynamics of Rationing Outpatient Subspecialty Care for Children Covered by Medicaid 9_29_11

  1. 1. The Dynamics of Rationing Outpatient Subspecialty Care for Children Covered by Medicaid Joanna Bisgaier, MSW, PhD & Karin V. Rhodes, MD, MS Table 1: Semi-structured Questions Used on Interview Guides Table 2: Selected provider quotations regarding appointment assignment decisions <ul><li>Six categories of institutional strategies were identified in the allocation of limited outpatient appointment slots for subspecialty services to Medicaid-insured children: </li></ul><ul><ul><li>Severity of patient’s health condition </li></ul></ul><ul><ul><li>Taking responsibility for patients who lack alternatives </li></ul></ul><ul><ul><li>Geographic proximity of patient’s home address or referring PCP’s location </li></ul></ul><ul><ul><li>Hospital affiliation of PCP </li></ul></ul><ul><ul><li>Personal connection or professional courtesy with PCP </li></ul></ul><ul><ul><li>Informal exchange arrangements with PCP </li></ul></ul>Results <ul><li>According to physician interviewees in one urban area with a high concentration of medical specialists, subtle methods of institutional rationing of subspecialty care for publicly-insured children are currently employed in appointment making practices. </li></ul>Conclusions <ul><li>Overall, our findings support the predominate view that rationing of specialty care by insurance status is happening. Productive debates moving forward must focus on how current institutional rationing mechanisms can be improved to maximize efficiency and equity. </li></ul><ul><li>Respondents indicated a willingness to accept responsibility for Medicaid-enrolled children who live in close proximity or receive primary care within some informal or formal organizational network. These findings illuminate how health care reform’s provision for accountable care organizations (ACOs) might work in practice to improve access for publicly-insured children. </li></ul>Policy Implications <ul><li>As we move toward covering all Americans, there is need to understand the nuances of barriers to access faced by patients enrolled in Medicaid programs. </li></ul><ul><li>Individual practices may limit the number of appointments for patients with Medicaid coverage, while still accepting some Medicaid-enrolled patients. </li></ul><ul><li>However, little is known about institutional strategies used to restrict/provide access to subspecialty services. </li></ul>Background The purpose of this study was to understand strategies currently in use to ration outpatient appointment slots for pediatric subspecialty care by insurance status. Objective <ul><li>Between April-September 2009, we conducted in-depth confidential interviews (30-90 mins) with a purposeful sample of physicians working in a large metropolitan area, Cook County , IL with a high proportion of specialists 218/100,000 population. We interviewed : </li></ul><ul><ul><li>14 primary care providers (PCPs) </li></ul></ul><ul><ul><li>30 subspecialty providers </li></ul></ul><ul><li>Open-ended interviews (in-person or by telephone) using interview guides (Table 1) were focused on children’s access to subspecialty care and conducted until theme saturation was reached. </li></ul><ul><li>Notes from non-taped interviews (n=2) and transcripts from taped interviews (n=42) were entered into Atlas-TI software and coded to identify themes and patterns within the responses. </li></ul>Methods [Orthopedic surgeon] “I do get a decent percentage of [Medicaid-enrolled] patients who have been refused care at other facilities…because they just can’t find another doctor, so then I’m happy to see them.” [Developmental pediatrician] “…And we prioritize kids based on geography. That is, if they live across the street from our outpatient activities at [street], they come to [street].” [Adolescent medicine (PCP)] “I personally need to call. And it has to be me and not a nurse or a resident; it needs to be attending to attending, so it takes a huge amount of time to get some of these specialists to see the patients. And it’s almost a favor to me that they’re doing it….” [Neurologist] “I think the hospital made a policy of providing slots… - for physicians [PCPs] that were on a preferred list if you will. I mean that were affiliated with the hospital.”