Addressing Disparity in Treatment Received
Susan T. Hoggard, RN, BSNPediatric Nurse Practitioner Graduate Student
University of North Carolina
Chapel Hill, NC 27599
To the Editor.—
Certainly, as a health care professional that has practiced in a poverty-stricken area her whole career, I could understand the importance of the February 2004 Pediatrics article "Unmet Need for Routine and Specialty Care: Data From the National Survey of Children With Special Health Care Needs."1 In my past experience as an obstetrics/gynecology/newborn nursery nurse, and in my current role as a pediatric nurse practitioner in training, I have seen first-hand medically underserved women and children and how their problems are aggravated by the lack of regular medical care. More often than not, the patients we see are nonwhite, uninsured, or on some type of entitlement program. This is in stark contrast to my peers in more affluent areas, many of whom rarely, if ever, are exposed to patients who have real issues in securing adequate health care, housing, and nutrition. Raising the awareness regarding the disparity in the treatment received by poor and nonwhite children, compared with more affluent ones, is very important. It is equally as important that all of the factors that affect health care access be addressed.
Although a significant number of the children in my county, including those seen in my clinical site, are near or below national poverty levels, 2 we do have some patients from more affluent families come in for treatment. More often than not, the poor children are sicker when they come in than are the others and also lack in the routine preventive care that the more affluent children receive. A large number of the children we see are not only economically challenged but are minorities. Even when controlling for economic factors, minorities typically underutilize certain medical procedures, have higher mortality rates, and are typically less insured, when compared with whites.3 This fact, along with the patient’s lack of insurance and the low provider/population ratios mentioned by the authors, are all phenomena that I have seen while in actual practice. In my county, with a population of 24 000, there are only 2 pediatricians, 1 physician’s assistant, and 1 pediatric nurse practitioner in dedicated pediatric practice, with the nearest pediatric specialist 60 miles away. Many times, parents and caregivers will relate to us the difficulty they have in just getting to us, not to mention the hardships they have in getting their children to a pediatric specialist. In our county, something as simple as not having a ride to the doctor keeps many children from the medical care that they need.
A review of the recent literature regarding unmet patient needs in the pediatric venue reveals several issues that may contribute to the problems experienced in underserved areas. As reported by Mayer et al,1 the largest single group of children with unmet needs is the uninsured. One of the standard solutions put forth by some is to have the government provide everyone with an insurance card, rationalizing that that alone would solve the problem. In fact, the problems with accessing health care in rural areas are not that simplistic. As mentioned previously, even something as simple as transportation to the medical facility is contributory to the problem.4 There are places in this country in which there are adequate medical facilities and a relatively high level of insurance, but prospective patients cannot get to the facilities to use their insurance cards because of a lack of public transportation or the inability to provide transportation on their own. Insurance, or lack of it, is but just a part of the access problem. Many other small contributory problems exist that conspire to limit children’s access to medical care, including access to care on a 24-hour basis and the previously mentioned lack of referral resources.4
Mayer et al found that higher levels of providers, relative to the pediatric population, positively affected unmet needs for routine pediatric care. Factors in our present health care system often limit the number of providers that are available to see the uninsured patients in medically underserved areas. A prime example of this is the fact that physicians providing a disproportionate amount of care to the uninsured and to nonwhite patients have been shown to be excluded from managed care contracts at a rate much higher than the average.5 This is a significant problem, because managed care contracts have become a large part of a practice’s financial picture. Programs that encourage medical and nurse practitioner school graduates to locate in medically underserved areas need to be embraced by all participants in the health care system, not discouraged by a powerful segment of the system such as managed care through dubious policies.
Finally, many health care practitioners and politicians are advocating that all of the problems stated herein, as well as many others found within our health care system, would be solved through a single-pay, government-controlled plan. The premise is that the bureaucratic management costs associated with current managed care programs would be eliminated and saved monies could be plowed back into caring for the indigent. One need only look at the problems with welfare and some of the other entitlement programs to see that government bureaucracies are even less efficient than private ones, and trading a private bureaucracy for a government bureaucracy influenced by the same group of lobbyists may not be a good idea. Given the broad nature of the problem, simply giving away insurance is not a solution. Public awareness of all of the factors that contribute decreased access to health care by our children is necessary.
REFERENCES
- Mayer ML, Skinner AC, Slifkin RT. Unmet need for routine and specialty care: data from the national survey of children with special health care needs. Pediatrics.2004; 113(2) . Available at: www.pediatrics.org/cgi/content/full/113/2/e109
- United States Census Bureau. Summary file 4 (SF 4). Available at: www.census.gov/Press-Release/www/2003/SF4.html. Accessed February 9, 2004
- Blanchard JC, Haywood YC, Scott C. Racial and ethnic disparities in health: an emergency medicine perspective. Acad Emerg Med.2003; 10 :1289 –1295[CrossRef][Web of Science][Medline]
- Friedrich MJ. Medically underserved children need more than insurance card.
JAMA.2000; 283
:3056
–3057.
[Free Full Text] - Bindman AB, Grumbach K, Vranizan K, Jaffe D, Osmond D. Selection and exclusion of primary care providers by managed care organizations.
JAMA.1998; 279
:675
–679
[Abstract/Free Full Text]
Michelle L. Mayer, PhD, MPH
Rebecca T. Slifkin
Cecil G. Sheps Center for Health Services Research
University of North Carolina
Chapel Hill, NC 27599-7590
Asheley C. Skinner, BS
Department of Health Policy and Administration
University of North Carolina
Chapel Hill, NC 27599-7400
In Reply.—
As academic researchers, we often lack sufficient personal experience with the populations that we study. We greatly appreciate Ms Hoggard’s "front-line" perspective on the challenges that face children and their families when attempting to obtain medical care. Many of her insights echo the findings of our study; namely, that poor, uninsured, and minority children face difficulties in obtaining health care services. We agree that the underlying relationships between these sociodemographic and financial characteristics and having unmet need are likely multifactorial. For example, we found that poverty and near-poverty statuses maintain an independent relationship with unmet need despite the inclusion of statistical controls for Medicaid status. We suspect that the effects of transportation barriers, limited control over work schedules, gaps in Medicaid enrollment, and other factors may influence the relationship between economic status and likelihood of reporting an unmet need for medical care. Furthermore, the limited availability of general pediatric and pediatric subspecialty providers, especially in rural areas and under some managed care arrangements, may also impede children’s access to medical care.
Just as the causes of unmet need involve many facets, the solutions to minimizing unmet need among children with special health care needs must address a variety of issues. Lack of health insurance coverage seems to play a very important role in limiting children’s access to care. As such, increasing the availability of insurance coverage through Medicaid, State Children’s Health Insurance Programs (SCHIPs), or private sources seems appropriate. This is especially important at a time when states are limiting Medicaid and SCHIP enrollment and coverage.1,2 Despite the availability of Medicaid coverage to many low-income children, our results show that poor children are at greater risk than those in higher-income families for reporting an unmet need. Additional research may be needed to understand the factors associated with poverty that place children at specific risk for having unmet needs, such as limited availability of services, discontinuous insurance coverage, and incidental costs.3–6 Finally, the association between unmet need and provider supply needs additional research to inform physician workforce debates and policies.
Children with special health care needs represent an especially vulnerable population because of their medical challenges. When such medical challenges occur within the context of social vulnerability because of poverty, lack of insurance, or minority status, the risk for having unmet needs increases. As clinicians, policy makers, and researchers, we have a duty to minimize the role of social vulnerability in undermining access to care among children with special health care needs.
REFERENCES
- Ross D, Cox L. Out in the Cold: Enrollment Freezes in Six State Children’s Health Insurance Programs Withhold Coverage From Eligible Children. Washington DC: Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation; 2003
- Smith V, Ramesh R, Gifford K, Ellis E, Wachino V, O’Malley M. States Respond to Fiscal Pressure: A 50-State Update of State Medicaid Spending Growth and Cost Containment Actions. Washington DC: Kaiser Commission on Medicaid and the Uninsured, Kaiser Family Foundation; 2003
- Smith MW, Kreutzer RA, Goldman L, Casey-Paal A, Kizer KW. How economic demand influences access to medical care for rural Hispanic children. Med Care.1996; 34 :1135 –1148[CrossRef][Web of Science][Medline]
- Rosenbach ML, Irvin C, Coulam RF. Access for low-income children: is health insurance enough?
Pediatrics.1999; 103
:1167
–1174
[Abstract/Free Full Text] - Strickland B, McPherson M, Weissman G, van Dyck P, Huang ZJ, Newacheck P. Access to the medical home: results of the National Survey of Children With Special Health Care Needs. Pediatrics.2004; 113(5 suppl) :1485 –1492
- Sturm R, Ringel JS, Andreyeva T. Geographic disparities in children’s mental health care. Pediatrics.2003; 112(4) . Available at: www.pediatrics.org/cgi/content/full/112/4/e308
PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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