Published online April 1, 2005
PEDIATRICS Vol. 115 No. 4 April 2005, pp. 833-838 (doi:10.1542/peds.2004-1510)
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Physician Reimbursement Levels and Adherence to American Academy of Pediatrics Well-Visit and Immunization Recommendations

Thomas K. McInerny, MD*, William L. Cull, PhD{ddagger} and Beth K. Yudkowsky, MPH{ddagger}

* Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
{ddagger} Division of Health Services Research, American Academy of Pediatrics, Elk Grove Village, Illinois

Background. There is concern that commercial health insurance reimbursement levels for immunizations and well-child visits may not be meeting the delivery and practice overhead costs within some areas of the country. There is also concern that insufficient physician reimbursement levels may negatively affect the quality of children’s health care.

Objective. We examined the relationships between commercial health insurance reimbursement levels to physicians for pediatric services and rates of immunization and well visits for children and adolescents.

Design. Quality of care was measured by examining state-level immunization and well-visit rates for 2002, which were obtained from the National Committee for Quality Assurance, Health Plan Employer Data and Information Set (HEDIS). Reimbursement data were obtained from the American Academy of Pediatrics Medical Cost Model. Variations in the child and adolescent HEDIS measures were examined as a function of physician reimbursement levels for pediatric services across states. HEDIS data were available for a total of 32 states. Partial correlations controlled for pediatrician concentration, as collected from the US Bureau of the Census and the American Medical Association Physician Masterfile data.

Results. Compliance with HEDIS immunization rates for all recommended vaccines was 60% for children and 24% for adolescents. By excluding the varicella vaccine, these rates increased to 70% for children and 44% for adolescents. Adherence rates for well visits were also higher for infants (60%) and children (59%) than for adolescents (34%). Physician reimbursement levels for pediatric services varied from $16.88 per member per month to $32.06 per member per month across states. Statistically significant positive correlations for reimbursement levels were found for 8 of the 16 HEDIS measures examined. Correlations with reimbursement levels were found for childhood immunizations (r = 0.42), infant well visits (r = 0.44), childhood well visits (r = 0.46), and adolescent well visits (r = 0.42). Reimbursement levels were especially strongly related to the rates of adolescent varicella vaccination (r = 0.53). When partial correlations were examined to control for pediatrician concentration, the correlations were reduced by 0.09 on average, suggesting that pediatrician supply may serve as an intermediary of the reimbursement relationship.

Conclusions. Immunization and well-visit rates for infants, children, and adolescents were positively linked with physician reimbursement rates for those services. Although methodologic limitations suggest caution when interpreting these findings, more attention should be given to physician reimbursement levels as a possible predictor of immunization and well-visit rates as measures of quality of care and to the importance of reimbursement levels for pediatrician recruitment.

Key Words: reimbursement • immunizations • health supervision • quality of care

Abbreviations: AAP, American Academy of Pediatrics • HEDIS, Health Plan Employer Data and Information Set • NCQA, National Committee for Quality Assurance • MMR, mumps-measles-rubella • VZV, varicella-zoster virus • PMPM, per member per month • AMA, American Medical Association

Accepted Aug 9, 2004.




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