Children who are insured by Medicaid are less likely to see a specialist for their care than kids receiving private insurance. This is unfair, in my view, because Medicaid kids are poorer and often sicker than kids covered by private insurance. But it hasn't been clear why this happens. Part of the problem could be the parents. The parents may, for example, have been less likely to complete appointments than parents holding private insurance. But it's also possible that specialists are less likely to offer care to parents covered by Medicaid.
Joanna Bisgaier and Karin V. Rhodes decided to test whether specialists treat Medicaid and non-Medicaid kids in an even-handed way by doing an elegant experiment, published today in the New England Journal of Medicine.
research assistants posing as mothers made paired calls to the same clinic and attempted to schedule an appointment for a child needing specialty care. The calls were separated by 1 month and varied only by insurance status (private vs. Medicaid–CHIP insurance).
What the researchers found was that,
Of the 546 calls to clinics, 297 (54%) involved a request for information about the child's insurance type before the caller was told whether an appointment could be scheduled. For 153 (52%) of these 297 calls, the type of insurance coverage was the first question asked.
The results are in the Figure, where the blue bars are the percentages of visits to specialists that were scheduled when the caller said the child had private insurance, and the red bars were when the child was said to have Medicaid–CHIP insurance. The leftmost pair of bars summarizes the overall responses: 89% got visits in the private insurance condition, versus 34% in the Medicaid-CHIP condition.
When calls to the same clinic were analyzed as matched pairs, there were 5 discordant pairs (2%) in which children with Medicaid–CHIP obtained an appointment but those with private insurance did not, and 155 discordant pairs (57%) in which the clinic accepted privately insured children but not Medicaid–CHIP enrollees (odds ratio for appointment denial with public insurance, 31.0; 95% CI, 13.0 to 96.8).
This is a huge effect, the epidemiologists rule of thumb is that an odds ratio bigger than 2.0 is important. But even when a Medicaid-CHIP kid got a visit, they had to wait longer to be seen:
Among the 89 specialty clinics that scheduled appointments for both Medicaid–CHIP enrollees and privately insured children, children with Medicaid–CHIP had greater delays in obtaining needed specialty care... On average, children with public insurance waited 42 days for an appointment with a specialist, whereas privately insured children waited 20 days (mean difference, 22.1 days; 95% CI, 6.8 to 37.5; P=0.005).
In summary, when medical specialist practices were approached twice by parents calling about identical children that differed only in whether the child was covered by private insurance or Medicaid, the Medicaid child was far less likely to receive care. What do we think of these striking results?
As a matter of law, a physician is not obligated to treat someone with whom he or she does not have a prior relationship. So is there an ethical obligation? Let's stipulate that Medicaid pays less for care than private insurers. I have great sympathy with those specialists who preferentially care for patients who pay better, after all, quite a few of them have boat mortgages to pay. It is interesting that physicians are, according to the AMA, obligated to supply care during disasters:
National, regional, and local responses to epidemics, terrorist attacks, and other disasters require extensive involvement of physicians. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life.
Perhaps we could discuss why physicians have an obligation to put their lives at risk in emergencies, but are not obligated to accept public insurance in return for care of the poor?
Shaming these people won't change specialists' behavior. It may work better, perhaps, to point to heroes like Paul Farmer, Medicins Sans Frontieres, or the many denominational medical missionary groups. The authors suggest that the compensation for services offered by Medicaid should be made equal to that provided by private insurers; and in a sense that is the more serious way to approach policies that could change physician, at least in the short run. The problem is that increasing what Medicaid pays is, shall we say, not realistic in the current "fiscal environment."
The quotes are meant to indicate that "fiscal environment" is a euphemistic way to refer to the values and voting behavior of Americans holding private insurance: not enough of them support decent care for the poor. This is far more understandable for the median American, who makes far less than the median specialist. The road to equity requires that we bend the cost curve.
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