- AAP —
- American Academy of Pediatrics
- CI —
- confidence interval
- ppt —
- percentage point
How well does having a Medicaid card translate into getting needed care in a private-practice pediatrician’s office? For many years, families with children enrolled in Medicaid have experienced difficulties finding private-practice pediatricians and family physicians willing to accept them into their practice panels.1–6 And, for many years, private-practice pediatricians and physicians have cited reasons for limiting or not accepting children with Medicaid. Consistently, inadequate payment for services has been the dominant factor.1–6 As a result, many children were forced to use emergency departments for their primary care. In addition, children enrolled in Medicaid who needed specialty and/or subspecialty care often experienced a much longer waiting period to get an appointment than did children with commercial insurance.7,8
Pediatricians indicated their willingness to care for more children with Medicaid if payment rates were raised to reasonable levels.1–6 On the basis of data from these surveys and state early and periodic screening, diagnosis and treatment data, class action lawsuits were filed in Illinois (2003), Florida (2007), and Oklahoma (2005) alleging a failure to adhere to the equal access provision as codified in Title XIX of the Social Security Act (42 U.S.C. §1396 et seq). This section of federal statute requires states “to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.” The defendants representing the states countered that pediatricians, the American Academy of Pediatrics (AAP), and Medicaid beneficiaries did not have standing (the right) to bring these class action law suits. The US Supreme Court in the Gonzaga University v. John Doe case issued a ruling that was interpreted as barring Medicaid beneficiaries and pediatricians from using the federal courts to require states to set Medicaid payment rates at federally mandated levels.
Despite the Supreme Court ruling, these lawsuits put Medicaid payments for pediatric services on the radar of federal and state policy makers as well as child health advocates. As a result, the Patient Protection and Affordable Care Act raised Medicaid payments to Medicare levels for 2013 and 2014 in all states with federal funds. The goal was to expand physician participation in Medicaid, especially the adult clinicians needed to care for the large Medicaid expansion for adults. This increase in Medicaid payment levels provided an opportunity for the AAP to document the impact of increased payments for pediatric services on access to care by private primary care pediatricians by using data from their annual surveys. In their article in this issue of Pediatrics, Tang et al9 compared information from AAP surveys in 2011 and 2012 (before the rate increase) to surveys in 2015 and 2016 (after the increase) on 5 measures. These included the following: (1) Medicaid nonparticipants, (2) participating pediatricians who accepted at least some (or all) new Medicaid patients, (3) participating pediatricians who accepted all new patients, (4) participants who accepted new Medicaid patients as often as new privately insured patients, and (5) the percentage of Medicaid patients compared with all patients in the provider panel.
The overwhelming majority of private-practice primary care pediatricians (85.4% in 2015–2016) participated in Medicaid. Increasing Medicaid payment levels to Medicare did increase access to private-practice primary care pediatricians; open-practice participants accepting at least some new Medicaid patients increased by 3.0 percentage points (ppts) (95% confidence interval [CI]: 1.2–4.8 ppts) to 77.4%. Full participants accepting all new Medicaid increased by 5.9 ppts (95% CI: 4.2–7.7 ppts) to 43.3%, and nonrestrictive participants accepting new Medicaid at least as often as new privately insured patients increased by 5.7 ppts (95% CI: 3.8–7.5 ppts) to 55.6%. The percentage of Medicaid patients compared with all patients in the provider panel increased by 6.0 ppts (95% CI: 5.1–7 ppts) to 31.3%.
The payment increase did not significantly decrease the percent of primary care pediatricians who did not participate in Medicaid. It is likely that these pediatricians have strong philosophical or financial reasons for not participating in Medicaid and/or practice in high-income communities where there are few, if any, children with Medicaid. These findings, based on pediatrician self-report, suggest that more children with Medicaid were able to receive care from private-practice primary care pediatricians because payment rates were increased. However, we need to improve access further. Improved access may have contributed to the findings that the disparities related to race and/or ethnicity and income in access to a medical home, well-child care, and having unmet health care needs have also narrowed considerably.9
These data should encourage states to maintain Medicaid primary care payments that are equal to Medicare levels. There are several ways of targeting Medicaid payments to pediatric clinicians to increase participation and reward quality care. These include selectively raising rates for preventive care visit codes to levels that are similar to private insurance, raising vaccine administration codes so they fully cover costs, paying for developmental screening, and providing incentive payments for up-to-date immunization rates and targets for developmental and lead screenings. An administratively easy approach is to provide per-member, per-month care-coordination payments. It is also important to simplify claims filing and pay claims in a timely manner.
Although not directly addressed by this study, states should also address access to specialty and subspecialty care, especially for children with medically complex conditions. In addition to increasing payments, Medicaid systems need to better integrate primary care with specialty and subspecialty care, ancillary services, and mental health services. State Medicaid programs should be in the vanguard of efforts to transform our fragmented systems to more integrated systems that have a population-health approach.
Medicaid coverage has become the health insurance safety net for approximately half of America’s children. In 2016, 47.6% of children were at some time enrolled in Medicaid.10 If these children are to receive needed care, state policy makers will need to ensure that Medicaid payments will lead to equal access that is consistent with the law.
- Accepted September 28, 2017.
- Address correspondence to Stephen Berman, MD, FAAP, Center for Global Health, 13199 E Montview Blvd, Suite 310, A090 Aurora, CO 80045. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-2570.
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- Cartland JD,
- Flint SS
- Tang SF,
- Yudkowsky BK,
- Davis JC
- Berman S,
- Dolins J,
- Tang SF,
- Yudkowsky B
- Decker SL
- Medicaid and CHIP Payment and Access Commission
- Tang S,
- Hudak M,
- Cooley D,
- Shenkin B,
- Racine A
- Larson K,
- Cull WL,
- Racine AD,
- Olson LM
- Copyright © 2018 by the American Academy of Pediatrics