PEDIATRICS Vol. 114 No. 5 November 2004, pp. e584-e590 (doi:10.1542/peds.2004-0210)
ELECTRONIC ARTICLE |
Inequality of Access to Surgical Specialty Health Care: Why Children With Government-Funded Insurance Have Less Access Than Those With Private Insurance in Southern California
* Department of Otolaryngology, Keck School of Medicine, University of Southern California, Los Angeles, California
Department of Plastic and Maxillofacial Surgery, Royal Children's Hospital, Melbourne, Australia
Department of Otolaryngology, Children's Hospital, Los Angeles, California
Objective. More than 25 million children in the United States are dependent on federal and state medical insurance programs for their health care needs. In California, 3.25 million children depend on Medi-Cal for their health insurance. In Southern California alone, the figure is as high as 1.81 million. However, 9.30 million children nationally and 1.55 million in California have no health insurance. Various public policies that would increase enrollment in these programs are being discussed to address this problem. However, before their implementation, it is important to understand what impact such policies would have on the actual delivery of health care to this patient population. In California, 2 predominant health care delivery models exist for Medi-Cal: a fee-for-service (so-called regular or straight Medi-Cal) and a managed care plan. One third of the children in Medi-Cal in the state are enrolled in the fee-for-service plan with the remainder in the managed care plan, whereas in Southern California, this figure is slightly lower at 28% in the fee-for-service plan. The objective of this study was to determine the number of otolaryngologists in Southern California who would offer a new patient appointment for an evaluation for tonsillectomy for a child with commercial insurance versus government-funded (Medi-Cal) insurance through direct contact with the physician and to determine whether the surgeon would offer to perform the procedure or refer the patient to another institution and to identify the specific reason(s) for any disparity in access to health care.
Methods. A written questionnaire was sent via regular mail to 303 otolaryngologists in the Southern California area in 2003.
Results. A total of 100 fully completed questionnaires were received. Ninety-seven surgeons would offer an office appointment to a child with commercial insurance as compared with only 27 for a child with Medi-Cal. Of those 27 surgeons, 8 would then refer the child to another physician to perform the surgery, and only 19 would actually offer to perform surgery, if indicated. Reasons provided for not offering an office appointment or surgery for the child with Medi-Cal include excessive paperwork and/or administrative burdens (96%), low monetary reimbursement for the surgery (92%), and low monetary reimbursement for the office visit (87%).
Conclusions. There is a tremendous inequality of access to surgical specialty health care for children with government-funded insurance when compared with those with commercial insurance in Southern California. Physicians indicate that this disparity is related to excessive administrative burdens and low monetary reimbursement. The implications of our findings on public health care policies are discussed.
Key Words: access to health care (health care accessibility) • child health services • Medicaid • tonsillectomy • health insurance reimbursement • health insurance • medical economics
Abbreviations: DHS, Department of Health Services • SCHIP, State Children's Health Insurance Program • OSA, obstructive sleep apnea • TAR, treatment authorization request • LAO, Legislative Analyst's Office
Accepted Jun 3, 2004.
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