Audit study: Yes medical specialists avoid Medicaid/CHIP-insured kids

Today’s New England Journal of Medicine includes a nice audit study by Joanna Bisgaier and Karin Rhodes conducted here in Cook County. Between January and May 2010, research assistants called a stratified random sample outpatient medical specialty clinics. The calls followed a standard script. Each of these clinics received two phone calls, one month apart, from the same research assistant, who would pose as the mother of a child with a rather significant medical complaint who was seeking outpatient care.

There was one key difference between the two calls. In one of them, the RA stated that her child was insured by Medicaid or CHIP. In another call, the RA stated that her child was insured through Blue Cross-Blue Shield. (The state of Illinois provided dummy Medicaid identification numbers and other help to the study, in part to comply with a consent decree stemming from a class-action suit.)

At one level, the results speak for themselves. Wallet biopsies matter. Overall, 66% of the callers reporting public insurance coverage were denied appointments, compared with only 11% of those reporting private coverage. As shown below the fold for every speciality, publicly insured kids were much more likely to be denied appointments than were otherwise comparable patients with nice private coverage.

As is also shown below the fold, many of the presenting complaints were pretty serious: a child with possible type 1 diabetes seeking to see an endocrinologist, one with a possible forearm fracture seeking care from an orthopedist, and so on. When publicly-insured could get an appointment, on average they faced a longer wait as well.

Different hypotheses might explain these access disparities are less obvious. As in the old mystery Murder on the Orient Express, there are many suspects, and I suspect they are all at least somewhat guilty. Illinois’ Medicaid reimbursement rates are below market rates–a problem compounded by the state’s reputation for delayed payment and administrative hassles. For various other reasons, Medicaid recipients themselves face discrimination from providers, in part because of real or perceived reactions to these patients among more profitable patients.

The consequences of these patterns for patients are also unclear. Bisgaier and Rhodes provide further evidence that Cook County has a segmented medical system in which publicly-insured patients face constrained access to a range of medical specialists who prefer the privately insured. Studies such as this one do not address whether Medicaid-CHIP patients receive delayed care or worse care because they rely on a more limited range of specialty providers. Audit studies leave important questions unanswered.

Still, I hope that state and federal policymakers pay attention to the stark answers such studies do provide. Governors across the country now complain about the fiscal burden Medicaid imposes. Many in official Washington speak of the “entitlement crisis” as if Medicaid and Medicare raise similar dilemmas. This is misguided. Medical specialists argue and cajole policymakers in search of higher Medicare reimbursement rates. Sometimes these higher rates are justified. Many specialists don’t even bother to argue about Medicaid. They just don’t treat patients. The same is true of many hospitals.

I wish medical specialists behaved differently. Many of these specialties are quite lucrative. They can do better. Yet the market signal could hardly be clearer. If we want low-income people to have access to good medical care, Medicaid needs to pay for it. Right now it doesn’t, with predictable results.

Comments

  1. Dan Staley says

    IOW: if they simply worked harder, stopped looking for handouts, and pulled themselves up by their bootstraps they’d have private insurance. What could be easier?

  2. FuzzyFace says

    If we want low-income people to have access to good medical care, Medicaid needs to pay for it. Right now it doesn’t, with predictable results.

    And where exactly is Medicaid supposed to get the funds to pay for it?

  3. Warren Terra says

    FuzzyFace,
    The short answer, or at least one short answer, is “with money”.
    You seem to have missed the first part of the sentence you quote:

    If we want low-income people to have access to good medical care

    Now, obviously, you don’t wan’t them to have such access. Or at least, not enough to consider making an effort to pay for it. This is about the sort of society we want to be: one that finds the money to care for its less fortunate members, or one that doesn’t.

    A different answer, one that would be much harder to implement and has no significant support from mainstream politicians, would be to look at our healthcare system. We pay something like twice as much as other wealthy countries do on health care, for outcomes that are no better, and we generally enjoy far worse access to primary care. We pay an enormous amount to the health insurance industry – middle men who provide no treatment, and whose primary responsibility is literally to seek to deny care. One reason most politicians avoided contemplating single-payer was because if implemented single-payer would wipe out major insurance companies that have huge market valuations and that employ huge numbers of people, whose jobs would have become surplus to requirements. A fundamental reform of our health care system could in theory give us the same care other countries enjoy for the same cost – but such a major transformation probably isn’t conceivable; certainly, no major politician is proposing it.

  4. FuzzyFace says

    Warren, we don’t [i]have[/i] more money. Our governments are already running massive deficits.

    And it is far from clear that other countries are getting better results for less money. I’ve seen the studies and they seem to be measuring different things: for one, other countries don’t have anything close to our levels of gun violence or low birthweight babies. The news stories keep reporting on horrendous levels of neglect in places like Britain and France – how is this better outcomes?

  5. Warren Terra says

    FuzzyFace,
    Gun violence is not an issue. Glancing at Wikipedia, I was surprised to see that guns kill as many people as they do (it’s on par with road accidents, more or less), but most of those are suicides (who need very little medical care). In any case, it’s the lingering diseases, the high-tech cures, and the care for invalids that adds up to real money – and while I’m sure that gun violence does create victims needing such care, I would be very surprised if it’s a big enough factor to greatly affect our overall medical expenses.

    We do have rather bad infant mortality statistics, but you seem to think that’s innate rather than a problem to be addressed. Some of it is surely a problem of poor access to medical services – and so we’ve come full circle.

    If you can find me news stories about the horrible level of neglect in France, please do so. But I’m betting you can’t; even conservative commenters who will repeat the most outre of NHS stories often praise the results the French system achieves.

    The NHS is a bit more complicated – it is by far the cheapest medical system in the wealthy world, and it has at times suffered from long wait times, mostly for non-emergency procedures (some of which have huge quality-of-life consequences). But Blair’s New Labour government made big improvements in that situation (mostly by throwing money at the problem, admittedly), and polls show that Britons are by and large quite pleased with the NHS. In any case, the statistics don’t lie: in essentially every measurable category, the Canadians and the Brits fare as well as we do or slightly better, for about half the money. Some outliers would appear to indicate otherwise, but these tend to be problematic (most famously, survival time after a diagnosis of prostate cancer is much longer in the US than in Britain – but this is because we test for, diagnose, and treat asymptomatic prostate cancer that would likely never cause a problem if ignored, while they diagnose prostate cancer mostly when it has become a possible health issue).

    The other common trope, which you manage to avoid, is to claim that Canadians are seeking essential medical care in the US because they can’t get it at home – a claim that is just demonstrably false.

    As to the money: it’s a question of priorities. Do we really need to have by far the lowest taxes in the developed world? While subsidizing massively profitable oil and mining industries and agribusiness giants? While spending as much on our military as the rest of the world combined? This is not the best possible moment to consider higher taxes – but is it ever the right time to contemplate massive unfunded permanent tax cuts going mainly to the very wealthy, as Ryan and Pawlenty (separately and differently) propose?

  6. Brett Bellmore says

    “I wish medical specialists behaved differently.”

    On some level, I suppose we all wish that people who have, or can do, something we want, would agree to do it cheaply, ideally for free. What could be more ideal, after all, than a world where everyone else exists solely for your own benefit?

    Most of us, however, are adult enough not to indulge such childish feelings, let alone thing they should be the basis of government policy.

    It’s my understanding that the primary way that Obamacare was supposed to “bend the curve” was by forcing everybody into a government buying pool, so that pool could exercise monopoly power when negotiating with doctors and medical suppliers, presenting them with the classic “deal you can’t refuse”: Work for what we’re willing to pay, or find you have no customers at all.

    Nothing but a plan for how to implement that childish dream…

  7. Rob in CT says

    That childish dream, as you put it, works rather well in many other countries, Brett.

  8. says

    I want Brett and FuzzyFace to acknowledge that they are completely OK with people dying because they want lower taxes. FFS, where are the jobs to work harder at? You know, the ones that pay enough to cover health insurance? Do either of you have a stockpile of 10 million well-paying jobs? How about 1 job?

    Brett, you continue to lie bold-facedly about what you dismiss as Obamacare. FOAD. You are nothing but a sick troll.

  9. Brett Bellmore says

    John, this will doubtless shock you to the core, but people die no matter what you do. Even if we taxed people to the point of bare survival, and spent it all on medical care, nobody gets to live forever. It would probably only push the average life expectancy up a year or two, as the main driver of life expectancy is actually lifestyle.

    So, since I don’t want 100% taxation with it all going to medicine, I am, in fact, ok with people dying because they want lower taxes. No matter how much you want to demagogue it.

    Now, if you were perfectly serious in this complaint, what would you be proposing? Government funded cryonics for the terminal? A Manhattan style push for anti-aging research? What’s your damn the expense plan for making sure people never die?

    Because if you don’t have one, you are every bit as much in favor of people dying for lower taxes as I am.

  10. Brett Bellmore says

    Yes, John, I am. Since people die, 100% of them, and even raising taxes to the maximum sustainable level, and spending every cent on medical care would not change that, you are, too. In fact, all the talk I hear from liberals is that we have to spend *less* on medical care. I’m not hearing any arguments in favor of government funded cryonics, or a Manhattan style anti-aging research program.

    Demagogue it all you like, I’m not intimidated.

  11. Cranky Observer says

    > John, this will doubtless shock you to the core, but people die
    > no matter what you do. Even if we taxed people to the point of
    > bare survival, and spent it all on medical care, nobody gets to
    > live forever.

    Oddly, Germany manages to provide health care at least as good as what the average /insured/ person in the US receives, to all its citizens, for one-half the cost per person spent in the US. Providing similar care to all US citizens would require at most returning our tax rates to what they were when Ronald Reagan left office (and probably not that high), which is hardly “point of bare survival”. Yet somehow Mr. Bellmore can never bring himself to address this point.

    Cranky

  12. Brett Bellmore says

    Let me address that: If everybody in the US lived at a population density comparable to Germany, (7 times that of the US.) and thus in close proximity to hospitals, if the demographics were the same, and there were no lifestyle differences, you might have a point.

    They aren’t, and so you don’t.

    Most of the differences in ‘health care’ between developed nations are differences in lifestyle. Good luck doing something about that.

  13. Warren Terra says

    The double-post isn’t what you should apologize for here, Brett; either of those posts would thoroughly justify an apology in its own right. Both make the same reductio ad absurdum argument, if argument is the right word.

  14. Benny Lava says

    “forcing everybody into a government buying pool”

    You understanding of Obamacare is incorrect. That is the root of many of your problems.

  15. Cranky Observer says

    > Let me address that: If everybody in the US lived at a population
    > density comparable to Germany, (7 times that of the US.) and
    > thus in close proximity to hospitals, if the demographics
    > were the same, and there were no lifestyle differences,
    > you might have a point.
    >
    > They aren’t, and so you don’t.

    Do you actually believe that? Or are you aware that it is just a set of Radical Right talking points, strung together for effect? I am not sure which would make me feel sadder for you: the former or the latter.

    Cranky

  16. says

    I’ve heard many odd things from right-wingish folks during the healthcare debate, but proximity to hospitals as a marker for overall health of the population is truly the oddest I’ve heard so far.

  17. SamChevre says

    Proximity to a hospital isn’t a marker for overall health, but it has a huge impact on survival in trauma and heart-attack cases. (I’ve had one friend die who would have been fine had he been at a hospital 15 minutes after the injury that damaged his liver; by the time he got to a hospital 45 minutes away he was DoA.)

  18. Cranky Observer says

    The urban/rural split for the 2010 Census apparently hasn’t been calculated yet, but for the 2000 Census it was 80.3% urban/19.7% rural. Metro/non-metro was similar with 81% living in a metropolitan area and 19% living in a not-metro-area.

    I’m not going to try to geolocate every hospital in the US vs. population density maps, but based on a lot of driving the backroads I’ll guesstimate that 1/4 of the rural population is within reasonable driving distance of a medical facility of some type (keeping in mind that there are still hospitals and clinics out in rural areas (just not as many as there were in the 1920s), and that driving times to the closest hospital in a metro area can be quite long depending on traffic) that means that somewhere around 85% of the US population lives reasonable close to a reasonable amount of medical care. Even if you assume that all 40 million uninsured are rural (which is clearly not even close to correct), that pretty much vaporizes Mr. Bellmore’s theory of the US vs. Germany.

    Cranky

  19. SamChevre says

    Cranky,

    It’s not an insurance problem, and it’s not a “some medical care” problem–it’s a “how fast can you have a saline line running?” and “how fast can you be in surgery?” problem that I’ve seen as a problem in rural areas.

  20. Cranky Observer says

    > Cranky,
    > It’s not an insurance problem, and it’s not a “some
    > medical care” problem–it’s a “how fast can you have
    > a saline line running?” and “how fast can you be in
    > surgery?” problem that I’ve seen as a problem in rural areas.

    I fully understand the problem you are referring to; my mother’s family farms in the central Midwest and they are now up to a 1 hr drive to a nurse/practitioner (doctor at the clinic 2 days/week) and at least 2 hours to major medical care. And that’s a problem throughout the Midwest (and West too I believe): even large towns that you would expect to have at least a doctor if not a hospital just don’t anymore.

    However, Mr. Bellmore’s 10:02 addressed a specific theory; to wit, that the differences in population density between the US and Germany made the implementation of a German universal health care system impossible in the US. That’s false; it might be difficult to provide universal care in some places in the US but my information showed that that would be a marginal effect.

    Cranky

  21. says

    I live in the West (New Mexico, before that Colorado) and those vast distances we have out here can be deceiving from a total population standpoint. That is, the West is more urbanized than the East, in the sense that a larger proportion of the West’s population lives in an urban area than is the case east of the Mississippi. And anyway the contention that our country cannot provide cost-effective universal healthcare owing to our geographical particulars is just silly.

  22. says

    SamChevre: thing is, we’re pretty good at trauma care in the US. What we’re lousy as is things like making sure poor women have an OB/Gyn to see.

  23. Brett Bellmore says

    We’re pretty good at trauma care if you reach it in time. Nobody is very good at resurrecting bodies that are DOA.

    No single factor is going to explain all of this, and this study is a bad place to start in attempting an explanation, because they took all the detail they collected, and mashed it together into life expectancy, which means they aren’t telling us what people are dying OF, or what age they’re doing it at. Which are things you really need to know, to have the slightest clue what’s going on.

    So we’re limited to general observations, and expressing our ideological biases. Which can be fun, but isn’t very enlightening.

    So, a general observation: Lifestyle is going to explain most of this. It generally does, unless you’re comparing a third world country to a first world country, or a peaceful country to a war zone.

    That doesn’t translate into “stupidity”, so much as it does ignorance.

    It also doesn’t translate into “We’re paying doctors too much” or “We’re paying doctors too little”, or “insurance companies are evil”, or “Republicans are murderous SOBs”, or anything else but being ignorant being bad for your health.

  24. Anonymous says

    It’s not just Medicaid patients that have trouble; I know of a Medicare patient who had a stroke and had to be air-transported (at patient cost) to another state from Arizona because no neurologist in Arizona would see him.

    For those so concerned about not wanting to spend money on adequate care for kids–you do realize, I hope, that the kids will just (suffer and) get sicker and will no doubt end up in emergency rooms to ultimately receive care for illnesses that have reached a more critical stage, and where their care will cost far more (orders of magnitude more), paid for by the same people who didn’t want to pay for their earlier care. Heartless to deny them the earlier care, yes, but also penny-wise and dollar-foolish.

    Also of note are the privately-insured kids who were refused treatment–are those providers now limiting their practices to the independently wealthy? Why go into neurology if you don’t want to care for people with seizures?

    No one is being served by the present system, except the independently wealthy. Privately-insured people are treated badly too; publicly-insured people are just treated worse.

  25. says

    I think Brett is right that this is mainly ideological. Even assuming that American health care costs are going to be expensive because of lifestyle, we can also assume that we could raise taxes a reasonable amount for everyone to get the health care they need. The bottom line is that some people simply don’t want to see their – or anyone’s – taxes raised, even marginally, to do it. It is a matter of principle.

    So what’s interesting to me is how they get to that point. What are all the various assumptions about economics, human behavior, liberty, the government, etc. that go into such a position?

  26. Brett Bellmore says

    “we could raise taxes a reasonable amount for everyone to get the health care they need.”

    You have some objective basis for determining what health care everybody “needs”, that doesn’t involve highly subjective determinations of value? This ought to be interesting.

  27. Cranky Observer says

    > You have some objective basis for determining
    > what health care everybody “needs”,

    “Objective”? No. Do you have some “objective” basis that your belief that the concept of property ownership overrides all other societal structures and goals? Didn’t think so.

    So as I noted before, let’s start with the level of health care that is available to all citizens of Germany (and for reasonable fees, to all non-citizens who require care while in the country). As good or better than the average _insured_ has in the United States at half the cost. Again you seem to have a problem with that but can’t articulate any supportable reason why.

    Cranky

  28. Mark Kleiman says

    Shorter Brett: Since everyone dies eventually, it’s fine with me if poor people die now.

  29. Brett Bellmore says

    Since everybody dies eventually, there’s no magic level of health care everybody “needs”; which you couldn’t say if there were some threshold level of health care beyond which people stop dying. The point at which you decide you’re not spending more on health care is arbitrary. And anybody who says you don’t value human life because you draw a line in one place, is equally guilty if they draw a line anywhere else.

    But, really, there’s no “our” money to spend on it anyway.

  30. flicka47 says

    I wish butchers behaved differently. Many of their specialty “cuts” are quite lucrative. They can do better. After all hamburger comes from the same cow as filet mignon. Yet the market signal could hardly be clearer. If we want low-income people to have access to good cuts of meat, somebody needs to pay for it so those rich folks don’t get all the good meat. Right now nobody does, with predictable results.

    I wish auto manufacturers behaved differently. Many of their “specialty” cars are quite lucrative. They can do better. After all why should a BMW or a Prius cost more than a Taurus? Yet the market signal could hardly be clearer. If we want low-income people to have access to good transportation, somebody needs to pay for it. Right now nobody does, with predictable results. Aww, let them take the HSR which they can’t afford either!

    I wish University Professors behaved differently. Many of these specialty chairs are quite lucrative. They can do better. Maybe university professors should be made to teach at community colleges for free! Yet the market signal could hardly be clearer. If we want low-income people to have access to good education, they need to pay for it at a university. Right now they don’t, with predictable results.

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