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Pediatrician Participation in Medicaid and CHIP: National and State Reports

By AAP Department of Practice
See the Pediatrician Participation Survey Reports by State.

Behind the Conventional Measure of a Longstanding Issue
While insuring 42 million (54%) of US children (2010 CMS report), Medicaid and CHIP pay physicians poorly, at 72% of average Medicare payment and only 64% of average private insurance fees. Still, most physicians see some Medicaid and CHIP-covered children, although many of them limit their public caseloads. 

The extent to which physicians participate in Medicaid has frequently been examined as a proxy measure of access. Initially reported simply in terms of participants (those with any Medicaid patients) vs. non-participants, a more thoughtful dimension of full vs. limited participants (participants taking all new Medicaid patients, vs. those accepting some or none) later became the conventional yardstick for gauging physician participation in public programs. A recent (June 2011) GAO report, for example, found that 47% of physicians who saw Medicaid and CHIP-covered children accepted all new Medicaid and CHIP patients. 44% accepted only some, while 9% did not accept any, compared to 79%, 18% and 3%, respectively, for new privately insured patients.

One limitation of the conventional measure is that, conceived at a time when managed care penetration was relatively non-significant, it omits selective managed care plan participation as a way for physicians to limit participation. With 60% of Medicaid children and a vast majority of CHIP children currently enrolled in managed care (HMO) plans(FFY2009 CMS/MSIS2082), however, ignoring selective managed care plan participation now may have resulted in over-estimation of full public program participants, a bias potentially reflected in the recent GAO report and other previous studies of physician participation.

New AAP Survey Data
To correct the potential bias and obtain state-level data, the Academy mailed a survey to a state-stratified random sample totaling 20,133 of its members with a new set of questions to capture pediatrician participation in public and private insurance at both the plan selection and new patient acceptance levels.  After 4 mailings of the survey, data collection was concluded in March this year with 10,138 returns from FAAPs, at a final response rate of 50.4%.

New AAP data suggests, based on the conventional measure alone, that pediatricians participate in public insurance at higher levels than all physicians on average as was reported by the GAO. It found a lower proportion of non-Medicaid participants (15%, compared to 22% reported in the GAO report for all physicians) and higher proportions of Medicaid and CHIP participants who reported accepting all new Medicaid or CHIP patients (Figure 1). 

Compared to data collected by the AAP on the same topic in 2010, however, pediatrician participation had dropped for both public and private insurance.  (Figure 2)

Nuanced Picture of Medicaid Participation 
When Medicaid plan-level participation data is brought into the picture, however, the AAP study found that only a third of all Medicaid participants accepted all new Medicaid patients while also participated in all Medicaid plans, including state-administered and any Medicaid HMO/ managed care plans, available in their geographic area. That is because some of the presumed “full Medicaid program participants” by the conventional measure (i.e., those who reported accepting all new Medicaid patients) also declined participation in some of the Medicaid plans providing services to children in their geographic area, and thus effectively closed their practice off to certain publicly-insured populations in their community.  

In sum, after all 3 factors of patient load, health plan participation and new patient acceptance are accounted for, only 27% of surveyed pediatricians would be “full Medicaid participants” who not only accept all new Medicaid patients who contact their office for appointment but also participate in all Medicaid plans serving children in their area. 58% either decline participation in at least some Medicaid plan(s) and/or refuse at least some Medicaid patient(s). Within this group of “limited” Medicaid participants, about 5 in 9 are “receptive” in the sense that they accept new Medicaid patients at least to the same extent as new privately-insured patients. 4 in 9 would be “restrictive” participants, who are more likely to accept new privately-insured patients than Medicaid. 15% of all respondents are non-participants. (Figure 3) 

As such, fewer than 3 out of 10 surveyed pediatricians fully participate in Medicaid, whereas fully 4 out of 10 either restricts new Medicaid patients more so than private patients, or do not see any Medicaid patients at all. On the contrary, although only 2 of 10 respondents reported participating in all private plans while accepting all new private patients, almost 7 in 10 are “receptive” participants who accept private patients as least as much as Medicaid, and only 1 in 10 either restrict new private patients more so than Medicaid patients, or do not see any private patients at all. As expected, Medicaid participation rate varies widely by state, with lowest participation in the most populous states of New Jersey, Illinois, California and Texas. (Figure 4)


Medicaid Participation Barriers    
While a number of factors had been found to deter or discourage physician participation in Medicaid, low physician payment has consistently been found to be the top participation barrier. In the new survey, 74% of respondents rated “low provider payment” “very important” as a participation barrier, compared to 44% for “referral difficulties”, 42% for “burdensome paperwork”, and 10% for “language barrier”. (Figure 5)


Widening Gap between Pediatrician’s Medicaid/CHIP caseload and Public Program Enrollment of the Pediatric Population
Although Medicaid and CHIP enrollment reached 54% of the total US infant and child population in 2010 (up from 32% in 2000 according to CMS data), pediatricians’ combined Medicaid and CHIP caseload increased merely 3 percentage points to an average of 36% over the last decade according to the new AAP survey and a similar study conducted in 2000. (Figure 6)


As such, the increase in pediatricians’ public caseload has fallen behind much faster growth in Medicaid and CHIP enrollment. While the widening gap may in part be explained by the fact that Medicaid and CHIP eligibility expansions include disproportionately adolescents and older children who are more likely than younger children to see adult specialty physicians, new survey data suggests that low payment and other participation barriers likely contributed significantly to the gap between the representation of publicly insured children in the pediatrician’s office and their presence in the general child population.

Reprinted with permission of AAP News, September, 2012
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