Can We Ensure That Children With Public Insurance Have Access to Necessary, High-quality Pediatric Specialty Care?

The article entitled “Academic Medical Centers and Equity in Specialty Care Access for Children” by Bisgaier et al¹ has special relevance for 2 current important health policy issues. The first is the need for the Department of Health and Human Services and its Centers for Medicare & Medicaid Services to issue detailed compliance standards related to ensuring equal access to health care for children with public insurance. The second is the need to continue adequate federal funding for the freestanding Children's Hospitals Graduate Medical Education (CHGME) program.

When Congress passed the enabling Medicaid legislation in 1966, legislators were concerned that children enrolled in Medicaid would not receive needed care if the payment levels determined by states were too low. Therefore, the Medicaid legislation included federal oversight of provider payments for pediatric services. The Medicaid expansion enacted in the Omnibus Budget Reconciliation Act of 1989 codified the issue of pediatric and obstetric physician payments in a provision called the equal access clause. This clause states that all Medicaid state programs must

assure that payments (provided to children and pregnant women) are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.

This provision also required state Medicaid programs to report to the federal government the participation rates of pediatric providers and the payment rates for specified services. Many states sought to comply by defining physician Medicaid participation as having accepted at least 1 Medicaid beneficiary a year because almost all pediatricians meet this criterion for participation. One of the first publications to propose an alternative approach to participation documented the influence of insurance status on being able to get an appointment for outpatient orthopedic care in California.²

This study by Bisgaier et al¹ as well as their similar prior publication³ refine the audit method used in earlier work for determining compliance with the equal access clause. This audit method documents whether children with public insurance are denied medical appointments when children with private insurance can schedule appointments. Paired mothers with standardized scripts for 7 pediatric health conditions varying only in the child's reported insurance status (Medicaid–Children's Health Insurance Program vs Blue Cross Blue Shield) tried to schedule pediatric appointments with medical subspecialists and surgical specialists (allergy-immunology, pulmonary, dermatology, endocrinology, neurology, orthopedics, otolaryngology, and psychiatry) located in Cook County, Illinois, during 2010. The investigators compared denials for requested appointments for physicians working at academic medical centers (AMCs) with private practices. When new appointments were made for children with both public and private insurance, the differences in waiting times for appointments according to insurance status were documented. More than half of the practices (57% of 155) were not willing to make an appointment for a child with public insurance. Orthopedics and dermatology private offices were the least likely to schedule an appointment with a child having public insurance. The likelihood that a child with public insurance would be denied an appointment was 45% lower if a clinic was affiliated with an AMC (odds ratio = 0.55; 95% confidence interval = 0.31-0.99). On average, children with public compared with private insurance had wait times 40 days longer for scheduled specialty appointments in AMCs. While there are many reasons that physicians refuse to care for Medicaid-enrolled children, studies carried out over the past 3 decades have consistently identified low Medicaid payments as the most influential reason.^{4 - 16} As the proportion of children with public insurance increases, AMCs and affiliated children's hospitals struggle to maintain an appropriate “patient mix” of private insurance–to public insurance–covered patients. One method to accomplish this involves placing a monthly limit on the number of scheduled appointments for patients with public insurance in a specialty clinic. This keeps timely appointments available for patients with private insurance while delaying appointments for patients with public insurance. This may explain the observed difference in wait times in the current study.

There is a precedent for using the findings from this audit method to make federal policy.¹⁷ This audit method was used in the 1980s to assess discrimination in mortgage lending. Two potential borrowers, one applicant being African American, the other white, both with a standardized script having identical educational backgrounds, employment histories, and credit ratings, applied for a home mortgage loan. Discrimination against African American applicants, documented by differences in loan acceptance rates, led to federal legislation and regulation of fair lending practices.

In the absence of Department of Health and Human Services guidelines on state compliance with the equal access clause or any realistic enforcement methods, families, pediatricians, and child advocates turned to the courts to enforce compliance and establish the legal standard for equal access. This approach has been complicated by matters of initial congressional intent, subsequent legislation, and contradictory legal opinions. Unfortunately, the Medicaid statute (unlike the Medicare legislation) does not state that people have a right to bring legal action against “unlawful state conduct.” This means that equal access suits must be based on the US Constitution's Supremacy Clause, which declares that state law in conflict with federal law is unconstitutional. Rosenbaum¹⁸ has reviewed this issue and Flint¹⁹ has summarized most of the legal cases. Efforts to promote equal access suffered a setback in 1997 from Congress. The Balanced Budget Act of 1997, while maintaining the equal access clause, repealed the state reporting requirements. The Supreme Court in 2002 placed greater restrictions on the ability of private parties to sue states in federal court for a wide range of federal issues using the Supremacy Clause (Gonzaga University v Doe). This had implications for all subsequent cases related to equal access. In 2008, the US Court of Appeals for the Ninth Circuit prevented California from making large cuts to Medicaid provider payments based in large part on the equal access clause. The State of California appealed the ruling and this case (Douglas v Independent Living Center of Southern California) is now before the Supreme Court. It will decide the legal question as to whether the Supremacy Clause confers a right to legal action based on the equal access clause. This decision will be critical for determining if Medicaid beneficiaries and pediatricians will be able to use the courts to force compliance with the equal access clause. This legal recourse is necessary when states cut Medicaid programs and physician payments since the Centers for Medicare & Medicaid Services at this time has no realistic federal enforcement methods. Regardless of the outcome of the Supreme Court case, child advocates and the American Academy of Pediatrics can use this and related studies to press the Centers for Medicare & Medicaid Services to implement an equal access framework for reporting payment rates, access to services, and enforcement measures. Since public insurance enrollees are disproportionately minority African American and Latino populations, the failure to ensure equal access is discriminatory on the basis of both race and income.

The second policy issue that relates to the findings of this current study is continued funding for CHGME. Since most freestanding children's hospitals are affiliated with AMCs, the findings of this study suggest that many children with public insurance rely on these hospitals for necessary, high-quality pediatric specialty. If federal funding for CHGME is eliminated, as was proposed in the president's budget, many of these hospitals will be less able to care for children with public insurance given current low payment rates.²⁰ This will have a detrimental impact on access to pediatric care as suggested by the findings of this study. In addition, pediatric training programs will be adversely affected. According to a letter sent to Congress from the Pediatric Public Policy Council:

While independent children's teaching hospitals account for less than one percent of all hospitals, these teaching hospitals train nearly 30 percent of all pediatricians and nearly half of all pediatric specialists. For pediatric surgery, over 65% of physicians are trained at these children's hospitals. CHGME-recipient hospitals have accounted for more than 65 percent of the growth in pediatric specialist training.

Removing or even reducing CHGME funding undermines our country's efforts to address our current critical shortage of pediatric specialty care. The $317.5 million appropriated and funded in fiscal year 2010 supports residencies, strengthens the financial stability of these hospitals, and helps the hospitals care for larger numbers of Medicaid beneficiaries than might otherwise be possible. Child health policy makers at both state and national levels need to understand the need for continued CHGME federal funding and higher Medicaid payments for pediatric services. The findings of the current study strongly support this view.