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.
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ABSTRACT: While recent studies have demonstrated an overall increase in psychiatric visits in the emergency department (ED), none have focused on a nationally representative pediatric population. Understanding trends in pediatric psychiatric ED visits is important because of limited outpatient availability of pediatric specialists, as well as long wait times for psychiatric appointments. The study aim was to evaluate the trends in ED psychiatric visits for children between 2001 and 2010 with comparison by sociodemographic characteristics. This was a retrospective, cross-sectional analysis of ED psychiatric visits for children < 18 years of age using the National Hospital Ambulatory Medical Care Survey (NHAMCS). Visits were identified by International Classification of Diseases, Ninth Revision (ICD-9), codes. Outcome measures included frequency of visits for children with psychiatric diagnosis codes and odds and adjusted odds of psychiatric visits controlling for temporal, demographic, and geographic factors. From 2001 to 2010, an average of 28.3 million pediatric visits to EDs occurred annually. Among those, an approximately 560,000 (2% of ED visits) were psychiatric visits each year. Pediatric psychiatric ED visits increased from an estimated 491,000 in 2001 to 619,000 in 2010 (p = 0.01). Teenagers (adjusted odds ratio [AOR] = 3.92, 95% confidence interval [CI] = 3.37 to 4.57) and publicly insured patient visits (AOR = 1.47, 95% CI = 1.25 to 1.74) had increased odds of psychiatric ED visits. Pediatric ED psychiatric visits are increasing. Teenagers and children with public insurance appear to be at increased risk. Further investigation is needed to determine what the causative factors are.Academic Emergency Medicine 01/2014; 21(1):25-30. DOI:10.1111/acem.12282 · 2.20 Impact Factor
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ABSTRACT: Background Insurance coverage alone does not guarantee access to needed health care. Few studies have explored what ¿access¿ means to low-income families, nor have they examined how elements of access are prioritized when availability, affordability, and acceptability are not all achievable. Therefore, we explored low-income parents¿ perspectives on accessing health care.Methods In-depth interviews with a purposeful sample of 29 Oregon parents who responded to a previously administered statewide survey about health insurance. Transcribed interviews were analyzed by a multidisciplinary team using a standard iterative process.ResultsParents highlighted affordability and limited availability as barriers to care; a continuous relationship with a health care provider helped them overcome these barriers. Parents also described the difficult decisions they made between affordability and acceptability in order to get the best care they could for their children. We present a new conceptual model to explain these experiences accessing care with health insurance: the Optimal Care Model. The model shows a transition from optimal care to a breaking point where affordability becomes the driving factor, but the care is perceived as unacceptable because it is with an unknown provider.Conclusions Even when covered by health insurance, low-income parents face barriers to accessing health care for their children. As the Affordable Care Act and other policies increase coverage options across the United States, many Americans may experience similar barriers and facilitators to health care access. The Optimal Care Model provides a useful construct for better understanding experiences that may be encountered when the newly insured attempt to access available, acceptable, and affordable health care services.BMC Health Services Research 11/2014; 14(1):585. DOI:10.1186/s12913-014-0585-2 · 1.66 Impact Factor
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ABSTRACT: This article explores how a specialty type's local workforce capacity and a specialty practice's location relate to the likelihood of denying care to children covered by Medicaid and the Children's Health Insurance Program (CHIP) while accepting private insurance. Data on discriminatory denials of care to children with public insurance came from an audit study involving 273 practices across seven medical specialties serving children in Cook County, Illinois. These data were linked to physician workforce data and neighborhood poverty data to test for associations with discriminatory denials of public insurance, after adjusting for control variables. In a large metropolitan county, discriminatory denials of specialty care access for publicly insured children were attenuated for specialty types with greater local workforce capacity (odds ratio [OR]: 0.74, 95 percent; confidence interval [CI]: 0.57-0.98) and for practices located in higher-poverty neighborhoods (OR: 0.95, 95 percent; CI: 0.93-0.98). Although limited as a single-site study, our findings support the widespread consensus that payment rates are the strongest driver of decisions to serve patients enrolled in public insurance programs. At a time when state and federal budgets are under strain, ensuring access equity for children covered by Medicaid and CHIP may require policies focused on economic levers tailored based on practice location.Journal of Health Politics Policy and Law 09/2014; DOI:10.1215/03616878-2829214 · 0.96 Impact Factor