Academic Medical Centers and Equity in Specialty Care Access for Children
ABSTRACT To test whether specialty clinics' academic medical center (AMC) affiliation was associated with equity in scheduling appointments for children with public vs private insurance. Academic medical centers are safety-net providers of specialty medical care and it is unknown whether equitable access is afforded by AMCs across insurance conditions.
Audit study data were linked to data describing audited clinics.
Specialty clinics serving children residing in Cook County, Illinois.
From January-May 2010, 273 clinics were each called twice.
Logistic regression was used to examine associations between AMC affiliation and discriminatory denials of Medicaid-Children's Health Insurance Program (CHIP) (ie, nonacceptance of Medicaid-CHIP when accepting commercial insurance), controlling for clinics' specialty type, practice size, neighborhood poverty level, and physicians' credentials. Among clinics that accepted both insurances, linear regression was used to examine the association between wait times (days) for appointments and insurance status, adjusting for covariates. Tests for interaction terms were performed to identify changes in wait time for academic clinics across insurance status.
Of the 273 paired calls to clinics, 155 (57%) resulted in discriminatory denials of Medicaid-CHIP. The odds of a discriminatory denial were 45% lower if a clinic was AMC affiliated (odds ratio, 0.55; 95% CI, 0.31-0.99). On average, academic clinics scheduled Medicaid-CHIP appointments with wait times 40 days longer than private insurance (β, 40.73; 95% CI, 5.06-76.41).
Affiliation with an AMC was associated with fewer discriminatory denials of children with Medicaid-CHIP. However, children with Medicaid-CHIP had significantly longer wait times at AMC-affiliated clinics compared with privately insured children. Academic medical centers' propensity toward serving publicly insured patients makes them candidates for targeted resource allocation, perhaps with incentives contingent on equitable appointment acceptance and wait times.
- JAMA Pediatrics 12/2011; 166(4):380-2. DOI:10.1001/archpediatrics.2011.1164 · 5.73 Impact Factor
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ABSTRACT: Objective: To describe the implementation and evaluation of a quality improvement intervention to increase new-patient access and decrease time-to-appointment wait for gastroenterology care. Methods: We used a new model of care for gastroenterology evaluation. For specified clinical complaints, we offered new-patient appointments that were scheduled with a general pediatrician as an alternative to a subspecialist. A nurse navigator assisted in triaging patients. We analyzed all patient encounters over an 8-month period. To verify decreased time-to-appointment wait, mystery shoppers made semimonthly calls to centralized scheduling. We surveyed parents/families after visits with the pediatrician or subspecialists regarding satisfaction. Results: The "access" pediatrician evaluated and treated ∼40% of all new patients presenting to the division during the study period. Approximately 10% of new patients evaluated by the pediatrician (4% overall) were referred on to the subspecialist; fewer patients were reevaluated by the pediatrician in follow-up. The pediatrician ordered a minimal number of procedures. Semimonthly sampling revealed that overall new-patient access improved from an average time-to-appointment wait of 25 days to <1 day. Parent/family satisfaction was high for the patients evaluated by the pediatrician. Conclusions: Embedding a general pediatrician within a subspecialty division, and navigating patients to this provider, can increase access to treatment of new low- to moderate-complexity patients. The access pediatrician can maintain patient satisfaction, provide high-quality care, and decrease need for subspecialist evaluation. The model, in the setting of a large academic medical center, may provide a solution for barriers to patient care such as lengthy time-to-appointment wait.PEDIATRICS 04/2013; 131(5). DOI:10.1542/peds.2012-2372 · 5.47 Impact Factor
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ABSTRACT: BACKGROUND:: It is unclear if socio-economic factors like type of insurance influence time to referral and developmental outcomes for pediatric epilepsy surgery patients. OBJECTIVE:: This study determined if private compared with state government insurance was associated with shorter intervals of seizure onset to surgery and better developmental quotients for pediatric epilepsy surgery patients. METHODS:: A consecutive cohort (n=420) of pediatric epilepsy surgery patients were retrospectively categorized into those with Medicaid (California Children's Services; n=91) or private (PPO, HMO, Indemnity; n=329) insurance. Intervals from seizure-onset to referral and surgery, and Vineland developmental assessments were compared by insurance type using log-rank tests. RESULTS:: Compared with private insurance, children with Medicaid had longer intervals from seizure-onset to referral for evaluation (log-rank test, p=0.034), and from seizure-onset to surgery (p=0.017). In a subset (25%) that had Vineland assessments, children with Medicaid compared with private insurance had lower Vineland scores pre- (p=0.042) and post-surgery (p=0.0029). Type of insurance was not associated with seizure severity, types of operations, etiology, postsurgical seizure-free outcomes, and complication rate. CONCLUSION:: Compared with Medicaid, children with private insurance had shorter intervals from seizure-onset to referral and to epilepsy surgery, and this was associated with lower Vineland scores before surgery. These findings may reflect delayed access for uninsured children who eventually obtained state insurance. Reasons for the delay and whether longer intervals before epilepsy surgery affect long-term cognitive and developmental outcomes warrant further prospective investigations.Neurosurgery 04/2013; 73(1). DOI:10.1227/01.neu.0000429849.99330.6e · 3.62 Impact Factor