PEDIATRICS Vol. 116 No. 5 November 2005, pp. 1148-1154 (doi:10.1542/peds.2004-2584)
Medicaid Acceptance and Availability of Timely Follow-up for Newborns With Medicaid
,
,||,¶,#,
* Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts
Department of Preventive Care and Center for Health Studies, Group Health Cooperative, Seattle, Washington
Health Services
|| Pediatrics
¶ Epidemiology
# Robert Wood Johnson Clinical Scholars Program
** Department of Biostatistics
Child Health Institute, University of Washington, Seattle, Washington
Children's Hospital and Regional Medical Center, Seattle, Washington
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Objective. Decreased physician participation in Medicaid has been shown to affect adversely timeliness of adult acute care and pediatric specialty care, but it is not clear whether this is the case for newborn follow-up. The objectives of this study were to determine whether there is a difference within clinics in the timeliness of follow-up appointments that are given to newborns with Medicaid compared with newborns with private insurance and to determine whether there is a difference between clinics that do and do not accept Medicaid in the timeliness of appointments that are given for newborn follow-up.
Methods. A randomized crossover study was conducted among general pediatric clinics and practices that were identified from the yellow pages and Internet searches of hospitals and health departments in 8 metropolitan areas from September 2003 to March 2004. A simulated parent telephoned clinics to find the earliest available appointment for a 1-day-old infant who needed routine follow-up after discharge that day. Clinics were randomly assigned to receive a first call from a patient with either Medicaid or private insurance; each clinic received the same call at least 3 weeks later with the patient's insurance status reversed. The main outcome measure was whether the appointment was timely (
2 days from the day of the call).
Results. Of 401 participating clinics, 22% did not accept Medicaid. Among clinics that accepted Medicaid, availability of a timely appointment for a newborn with Medicaid was similar to that for a newborn with private insurance (87% vs 90%, respectively). Appointments that were provided to privately insured newborns were as likely to be timely in clinics that accept Medicaid as in clinics that do not accept Medicaid (89.5% vs 93.4%, respectively). However, providing timely appointments was significantly less likely in clinics that were in high-poverty locations compared with clinics that were not (86.1% vs 92.7%, respectively).
Conclusions. Although newborns with Medicaid did not have access to >20% of clinics because of their insurance, among clinics that did accept Medicaid, timeliness of available follow-up was similar for newborns with Medicaid compared with newborns with private insurance and similar between clinics that did and did not accept Medicaid. However, to the extent that care for newborns with Medicaid is concentrated in clinics in high-poverty areas, some newborns with Medicaid may not be able to receive timely appointments.
Key Words: access to health care • insurance • Medicaid • newborn
Abbreviations: AAP, American Academy of Pediatrics • CI, confidence interval
Children who are covered by Medicaid have decreased access to care compared with those with private insurance,1–3 and only 67% of pediatricians report that they accept all patients with Medicaid who contact them.4 The Omnibus Budget Reconciliation Act of 1989 stipulated that Medicaid provider reimbursement be sufficient to attract enough providers such that services for Medicaid enrollees are available at least to the extent that they are available to the general population, but this provision has not been enforced.5 Studies have shown that decreased physician participation in Medicaid has affected access to timely appointments for acute care and dermatology for adults6,7 and orthopedic follow-up for children.8 It is not known if limited provider participation affects timely access to pediatric primary care.
One pediatric primary care service for which access to timely care is important is follow-up after early newborn discharge. Newborns who are discharged within 48 hours of birth are at increased risk for rehospitalization and morbidity from conditions such as jaundice that do not occur until the third or fourth day of life.9–12 The American Academy of Pediatrics (AAP) recommends that newborns receive follow-up within 48 hours of an early discharge.13 These guidelines are supported by data that suggest that early-discharged newborns who receive early follow-up have lower rates of urgent care visits and rehospitalizations than those who do not.14–16 However, early-discharged newborns with Medicaid are less likely to receive timely follow-up compared with those with private insurance,17 particularly in clinics with large proportions of Medicaid patients.18
It is not clear if limited availability of timely appointments contributes to this delayed follow-up for newborns with Medicaid. It is possible that clinics may schedule appointments differently for patients with Medicaid compared with those with private insurance.8 Also, limitations in the number of clinics that are available to patients with Medicaid may cause clinics that accept Medicaid to be overburdened and less able to provide timely appointments. Thus, our objectives in this study were to determine (1) the extent to which there is a difference within clinics in the timeliness of follow-up appointments that are given to newborns with Medicaid compared with newborns with private insurance and (2) the extent to which clinics that do and do not accept Medicaid differ in the timeliness of appointments for newborn follow-up. In other words, are newborns with Medicaid treated differently within a clinic? And, even if newborns with Medicaid do not have access to the same clinics as do newborns with private insurance, are they still able to get as timely appointments as newborns receive in clinics that do not accept Medicaid?
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METHODS |
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Design
We used a randomized crossover study design to assess the effect of insurance status on appointment timeliness within clinics. We used a cross-sectional analysis to assess appointment timeliness between clinics that did and did not accept Medicaid.
Patients
We sought to identify all general pediatric clinics in 8 metropolitan areas: Atlanta, Georgia; Baltimore, Maryland; Chicago, Illinois; Dallas, Texas; Minneapolis, Minnesota; Philadelphia, Pennsylvania; San Francisco, California; and Seattle, Washington. These sites were chosen for geographic diversity from states that have legislation that calls for early follow-up services for early-discharged newborns (S. A. Egerter, PhD, K. S. Marchi, MPH, and P. A. Braveman, MD, MPH, "State Legislation on Early Discharge," unpublished report for the federal Maternal and Child Health Bureau, April 1998).
Eligible clinics included private practices, hospital outpatient departments, community health centers, and large group practices; for simplicity, we refer to them as "clinics." The sample of clinics was drawn from the yellow pages of the most recent telephone book. We selected all clinics that were listed under the headings "Physicians-Pediatrics," "Clinics," and "Clinics-Medical." Shared addresses and telephone numbers were used to link individually listed physicians to clinics. When a listing for a clinic system did not identify individual clinics, we contacted the listed telephone number or web site to identify eligible individual clinics. We identified additional hospital-based and community clinics through web searches with the keywords "hospitals," "pediatric," and "public health department" with the name of the city (and/or county for health departments).
We excluded clinics when they did not provide general pediatric well-child care, did not employ any pediatricians, were specialty clinics, were open only to a limited population, had an invalid address or telephone number, or were not taking any new patients irrespective of insurance status. For clinics with ambiguous listings, verification of eligibility was done before data collection by calling the clinics, doing Internet searches under the clinic's name, or searching the AAP membership directory. Clinics were excluded when a receptionist could not be reached after 7 attempts or when leaving a callback number was required. Some clinics were found to be ineligible after the research assistants called (eg, the clinic was not taking any new patients), and some clinics became ineligible between the first and second calls (eg, the clinic's only pediatrician had recently left).
Telephone Call Protocol
Eligible clinics received a telephone call from a research assistant who called as the simulated mother of a 1-day-old infant who was discharged from the hospital that morning. The caller said that she was told to follow-up with a provider within a day or so and wanted to know what the earliest available appointment was at that clinic. Each clinic was randomly assigned to receive the initial call from a patient with Medicaid or with private insurance (the newborn's insurance was considered to be the same as the mother's). Each clinic was called again after an interval of at least 3 weeks (mean: 5.7 weeks; SD: 2.3) with the same scenario, except that insurance status was reversed. Randomization was done using a computer-generated randomization scheme. Calls were made in overlapping waves by city between September 2003 and March 2004 (excluding the weeks of December 25 and January 1).
Calls were made only on Mondays, Tuesdays, or Wednesdays so that timely follow-up would not be needed over a weekend. The callers used a WATS line, which would appear as "out of area" on caller ID. Three research assistants were trained to make the telephone calls using a standardized protocol. Except for 13% of clinics, the same research assistant made both rounds of calls to a given clinic. The caller began each call by saying, "I just had my first infant yesterday. I just got home from the hospital today, and they told me that I should have the infant checked by the doctor in the next day or so because he looked a little yellow. We just recently moved here, and I'm looking around for a pediatrician for him. I'm calling to get some information and see when the earliest is that I could get an appointment in your office." The caller requested the first available appointment, regardless of whether it was with a general pediatrician, family practitioner, or nurse practitioner. When given an appointment, the caller recorded the specific date and time, then said that she would check whether it was convenient for her husband and call back if she wanted to book the appointment. When the receptionist insisted on scheduling an appointment, the caller telephoned back later to cancel it. The research assistants were instructed to seem unsophisticated about the newborn's medical condition and not to dispute the appropriateness of a given appointment time.
The caller did not initially volunteer her insurance status. If the receptionist did not ask about insurance by the end of the call, then the caller asked if the clinic accepted the newborn's insurance type; we did this to gather data on insurance acceptance and because we did not want to count a caller as having access to an appointment if the newborn's insurance ultimately would not be accepted at the clinic. In the private insurance scenario, the caller said that she had an insurance plan through her husband's new job. For both the Medicaid and private insurance scenarios, the caller did not specify the exact name of the insurance plan or whether it was managed care or fee-for-service; the caller said that she had recently moved to town, could not remember the name of the specific plan, and could not find the insurance card. When clinics said that more insurance information was necessary to make an appointment, the caller asked for appointment availability so that she could check specific times with her husband before calling back with her insurance information to book the appointment.
Primary Outcome Variables
The primary outcome variable was the timeliness of the appointment given by the clinic for each call when the newborn's insurance was accepted. We defined a timely appointment as an appointment that was 2 calendar days from the day of call, which is concordant with the AAP guidelines. Clinics were considered not to have given timely appointments when they said that the newborn had to go elsewhere before being seen in the clinic (eg, returning to the birth hospital or emergency department for blood work or evaluation).
For the within-clinic comparison, we examined appointment timeliness for newborns with Medicaid compared with newborns with private insurance within clinics that accept both insurance types. For the between-clinic comparison, we examined appointment timeliness between clinics that did and did not accept Medicaid. Because newborns with Medicaid could not receive appointments in clinics that did not accept Medicaid, we could not compare timeliness for newborns with Medicaid in both types of clinics. Instead, to make a more analogous comparison, we looked at appointment timeliness for privately insured newborns, who were able to receive appointments in both types of clinics.
Predictor Variables
The primary predictor variable for the within-clinic comparison was the caller's insurance status (Medicaid or private insurance). The primary predictor variable for the between-clinic comparison was whether the clinic accepted Medicaid, as determined from the call. Clinics were considered to accept Medicaid when they said that they accepted at least 1 Medicaid plan. If the clinic accepted Medicaid only under limited circumstances (eg, living in a certain zip code, delivering in only 1 specific hospital, only with approval from the physician), then we considered it not to accept Medicaid.
Callers also asked the number of physicians in the clinic (categorized into 1, 2–5, 6–9, or 
10) and whether the clinic was a private practice (with "private practice" open to the interpretation of the receptionist). We created a variable to indicate whether the clinic was in a high-poverty location, presumably with a larger number of children with Medicaid. We defined this as whether the clinic zip code had >20% of families below the poverty level according to the 2000 census, which is a threshold used by the Health Resources and Services Administration to determine an area with unusually high needs for primary medical services.19 To account for temporal trends that could affect illness burden and appointment availability, we categorized calls as occurring in September/October, November/December, or January/February/March and as occurring on a Monday, Tuesday, or Wednesday.
Statistical Analysis
We used the McNemar matched pairs test for the within-clinic comparison of appointment timeliness for newborns with Medicaid versus newborns with private insurance. We used the 
2 and Fisher's exact tests for all other bivariate comparisons. To adjust for potential confounders in the comparison of timeliness between clinics, we used multivariate logistic regression, controlling for variables that were found to be significantly associated with timeliness in bivariate comparisons, with city included in the model as a fixed effect. Robust variance estimates were used to account for possible clustering within clinic system; for comparison, we also used a model that accounted for possible clustering within both clinic system and clinic zip code.20 As timely appointments were not a rare outcome, odds ratios provided an appropriate measure of association but not of relative risk. Thus, we derived the adjusted prevalence of timely appointments by clinic type by using model-based direct adjustment,21 using the entire study sample as the standard population. For categorical predictor variables with >2 categories, an overall P value was calculated using the multivariate Wald test. For the comparison between clinics that did and did not accept Medicaid, we used bootstrapping to derive a 95% confidence interval (CI) for the adjusted risk difference in frequency of timely appointments for privately insured newborns.22
Before the study, we performed sample size calculations for the between-clinic comparison, as the paired within-clinic comparison would not require as large a sample size for the same power. We calculated that a sample size of 370 clinics would give 80% power to detect a 15% difference in timeliness between clinics that did and did not accept Medicaid (2-sided 
= .05), based on estimates that 63% of clinics in study states accepted Medicaid4 and 44% of privately insured newborns had follow-up within 2 days of discharge.17 A 2-sided P < .05 was considered significant. Data were analyzed using STATA 8.0 (Stata Corp, College Station, TX).
Consent
Because clinic staff might have altered their behavior if they were aware of the real purpose of the telephone call, we did not obtain full informed consent. Instead, the medical directors of all identified clinics were sent a letter that described our study's use of a simulated patient to study appointment making; insurance was not mentioned. The letter described the study's minimal risk, consistency with usual office business, avoidance of no-show appointments, minimal time involved, and confidentiality of individual clinic data. The clinic could opt out of the study by returning a postcard. If we did not receive a refusal postcard after 6 weeks, then the research assistant began calling. The study was approved by the University of Washington Human Subjects Review Committee.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Of the 508 clinics initially identified, 495 were randomly assigned: 244 were assigned to receive the first call from a patient with Medicaid, and 251 were assigned to receive the first call from a patient with private insurance (Fig 1). Three clinics that were assigned to the Medicaid-first group and 1 clinic in the private insurance-first group erroneously received the calls in the opposite order. Data were analyzed according to the call that was actually received. Overall, 42 (8.3%) clinics refused to participate; some refusal postcards were received after randomization but before the clinic was called. Fifty-two (10.2%) clinics were ineligible, 9 (1.8%) had invalid addresses or telephone numbers or were duplicates, and 4 (0.8%) were unable to be reached; this resulted in a final study sample of 401 clinics.
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The number of clinics in each city ranged from 85 (21.2%) in Atlanta to 28 (7.0%) in San Francisco (Table 1). Most clinics had 2 to 5 physicians, and 58.0% identified themselves as a private practice. More than one quarter of the clinics were in a high-poverty location (ie, a zip code with >20% of families below the poverty level).
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After exclusion of 1 clinic with missing data on acceptance for both insurance types, 78.3% (313) of clinics accepted patients with Medicaid; this was significantly lower than the 97.5% (390) of clinics that accepted patients with private insurance (P < .001). One clinic did not accept any form of insurance, and 9 of the clinics that accepted Medicaid did not accept private insurance. There was wide variation in Medicaid acceptance by city, from 100% of clinics accepting Medicaid in Minneapolis to fewer than half in Dallas (P < .001; Table 2).
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Of the 699 calls during which the newborn was given an appointment, 88.7% were timely (ie, 2 days or less from the day of the call). There were no significant differences in insurance acceptance or appointment timeliness by whether it was the first or second call, by whether the clinic received the Medicaid call first or private insurance call first, by whether the call was made before or after noon, or by which research assistant made the call.
Within-Clinic Comparison of Appointment Timeliness
Of the 304 clinics that accepted both Medicaid and private insurance, 6 had missing data on appointment timeliness (5 for the newborn with Medicaid and 1 for the newborn with private insurance), leaving 298 clinics with data for both insurance types. Within these clinics, timely appointments were given to 87.2% of newborns with Medicaid and 89.9% of newborns with private insurance, a difference of –2.7% (95% CI: –7.9% to 2.6%).
Between-Clinic Comparison of Appointment Timeliness
After exclusion of 11 clinics with missing data on appointment timeliness for the privately insured newborn (10 of which accepted Medicaid and 1 of which did not), there were 389 clinics in the between-clinic comparison, 303 of which accepted Medicaid and 86 of which did not. In bivariate comparisons, there was no significant difference between clinics that did and did not accept Medicaid in the timeliness of appointments given to privately insured newborns (90.1% vs 90.7%, respectively; P = .87). Appointment timeliness was significantly associated with the number of physicians in the clinic, location of the clinic in a high-poverty area, the day of the week of the call, and city. Appointment timeliness was not significantly associated with the clinic's being a private practice or with the month of the call.
After accounting for clustering by clinic system and controlling for the number of physicians in the clinic, location in a high-poverty area, the day of the week of the call, and city, there was no significant difference in timeliness of appointments that were given to privately insured newborns between clinics that did and did not accept Medicaid (Table 3). Using model-based direct adjustment, the adjusted frequency of timely appointments in clinics that accepted Medicaid was 89.5%, compared with 93.4% in clinics that did not accept Medicaid (P = .26); the 95% CI around this –3.9% difference was –10.4% to 3.2%. These adjusted percentages can be considered to be the frequency of timely appointments that would have been observed in each type of clinic if the clinics had the same distribution of covariates as did the study population as a whole. The adjusted percentage of timely appointments in clinics in high-poverty locations was 86.1%, which was significantly lower than the 92.7% for clinics that were not in high-poverty locations (P = .04). In the adjusted analysis, there were no significant differences in appointment timeliness by the number of physicians in the clinic or day of the week of the call. There was significant variation in appointment timeliness by city. Results from the adjusted analysis were similar using a model that accounted for clustering within both clinic system and clinic zip code (data not shown).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study found that although >20% of clinics did not accept Medicaid, there was no significant difference in the timeliness of appointments that were given to newborns with Medicaid compared with newborns with private insurance or in the timeliness of appointments that were given to privately insured newborns in clinics that did and did not accept Medicaid. It is reassuring that within the Medicaid program in pediatric clinics, there is potential access to timely newborn follow-up appointments that is comparable to that of privately insured children. However, the existence of pediatric clinics within a city that can provide timely appointments does not necessarily mean that children with Medicaid can actually gain access to them easily. We found that clinics in high-poverty locations were less likely to give timely appointments; because care for patients with Medicaid is often concentrated in a small number of clinics in poor urban areas,23 a number of newborns with Medicaid may not actually be able to receive timely appointments. This suggests that a higher concentration of Medicaid patients in a clinic may be a more important correlate of availability of timely appointments than simply participating or not. Some have proposed increasing Medicaid reimbursement rates as a means to improve access to care for children with Medicaid24,25; our results suggest the need to investigate whether resources should be redirected toward clinics in high-poverty areas that serve large numbers of children with Medicaid. Differences in other measures of access and quality between clinics that do and do not accept Medicaid also merit additional study.
Other reasons may explain the decreased frequency of timely follow-up for newborns with Medicaid in other studies.17 Physicians do not always recommend follow-up after early discharge according to the AAP guidelines26; capitated arrangements and low Medicaid reimbursement may create a disincentive to recommend visits to newborns with Medicaid. Parents of newborns with Medicaid may delay making or miss follow-up appointments27 and may face other barriers to accessing services besides acceptance of insurance.28
Our results differed from those of similar studies that found decreased availability of timely appointments for patients with Medicaid for adult acute care and dermatology and pediatric orthopedic care.6–8 However, our findings would have been more congruent if we had used similar analyses in which nonacceptance of Medicaid was considered tantamount to not receiving a timely appointment. Done this way, our data show that 68.1% of newborns with Medicaid received a timely appointment compared with 88.0% of privately insured newborns (P < .001), a difference that is driven largely by Medicaid acceptance. It has already been shown that children with Medicaid cannot get appointments, timely or otherwise, in a substantial number of clinics that do not accept Medicaid4,29,30; instead, we wanted to determine if the limited number of clinics that are available to children with Medicaid might be less able to provide timely appointments compared with clinics that do not accept Medicaid. Differences from other studies may also be related to the greater degree of Medicaid participation for pediatricians relative to other physicians5,29 or to a heightened vigilance concerning follow-up for newborns, particularly those who might have jaundice.
We do not believe that the negative findings of our study are attributable to inadequate power to detect meaningful differences. Differences of >10% would fall outside the 95% CIs around the observed differences in proportions of timely appointments in both the within-clinic and between-clinic comparisons; differences in timeliness of 10% or less would not have great clinical relevance.
Our study has several notable limitations. Although we endeavored to simulate a real-life scenario, there are ways in which it was not. First, home visits may be routine in some areas for newborn follow-up, or appointments may be made by nursery staff before discharge. Second, we did not present a situation in which follow-up was needed over a weekend, which may be more difficult in community health centers that serve disproportionate numbers of children with Medicaid.3,31 Third, our study did not differentiate between types of Medicaid plans, whereas a real parent might have difficulty finding a clinic that accepts a specific Medicaid plan. Fourth, we used callers who were college educated and whose primary language was English. Some parents might face barriers to getting appointments on the basis of their race/ethnicity, language, or education level. However, our callers had no medical background and were trained to simulate actual parents via a script. Notably, the callers reported that no clinic seemed suspicious or recognized the scenario on the second round of calls. In addition, although we selected many diverse urban areas across the United States, our results may not generalize to other cities and other states or to rural areas. Variations in state Medicaid programs might differentially affect how clinics in each city handle patients with Medicaid. However, our data were too sparse to adequately assess effect modification by city. Finally, our results may not be generalizable to other populations of children in different clinical scenarios. Our description of a newborn that was "a little yellow" may have biased the clinics to give an earlier appointment as a result of concern about a potentially sick infant. However, when asked, the callers were instructed to say that they and the nursery doctors thought that the infant was doing well and seemed yellow only in the face; also, the fact that this newborn's follow-up had not been previously arranged would suggest that the level of jaundice was not concerning.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study found that although >20% of clinics did not accept Medicaid, timeliness of available follow-up was similar for newborns with Medicaid compared with newborns with private insurance and between clinics that did and did not accept Medicaid. However, our results suggest that if care for newborns with Medicaid is concentrated in clinics in high-poverty areas, then some newborns with Medicaid may not actually be able to receive timely appointments in clinics that will take them. Additional efforts should focus on strategies to improve timeliness of care that is actually received by newborns with Medicaid, particularly in high-poverty areas, and ultimately to ensure that children with Medicaid have equitable, timely access to important primary care services.
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ACKNOWLEDGMENTS |
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This work was supported by the Robert Wood Johnson Foundation through the Clinical Scholars Program (Dr Galbraith) and the Generalist Physician Scholars Program (Dr Christakis). This work was conducted while Dr Galbraith was a Robert Wood Johnson Clinical Scholar at the University of Washington.
We thank Frederick Rivara, MD, MPH, for useful comments on the manuscript; the Work in Progress Sessions of the Robert Wood Johnson Clinical Scholars Program and the Child Health Institute at the University of Washington for helpful feedback; Colin Sox, MD, for advice and support on the project; and Jeanne Allen and Krisi Dill for skillful handling of the telephone calls.
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FOOTNOTES |
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Accepted Jan 24, 2005.
Address correspondence to Alison A. Galbraith, MD, MPH, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, 133 Brookline Ave, 6th Floor, Boston, MA 02215. E-mail: alison_galbraith{at}hms.harvard.edu
The views expressed in this article are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation.
No conflict of interest declared.
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