Factors associated with increased specialty care access in an urban area: the roles of local workforce capacity and practice location.

This article explores how a specialty type's local workforce capacity and a specialty practice's location relate to the likelihood of denying care to children covered by Medicaid and the Children's Health Insurance Program (CHIP) while accepting private insurance. Data on discriminatory denials of care to children with public insurance came from an audit study involving 273 practices across seven medical specialties serving children in Cook County, Illinois. These data were linked to physician workforce data and neighborhood poverty data to test for associations with discriminatory denials of public insurance, after adjusting for control variables. In a large metropolitan county, discriminatory denials of specialty care access for publicly insured children were attenuated for specialty types with greater local workforce capacity (odds ratio [OR]: 0.74, 95 percent; confidence interval [CI]: 0.57-0.98) and for practices located in higher-poverty neighborhoods (OR: 0.95, 95 percent; CI: 0.93-0.98). Although limited as a single-site study, our findings support the widespread consensus that payment rates are the strongest driver of decisions to serve patients enrolled in public insurance programs. At a time when state and federal budgets are under strain, ensuring access equity for children covered by Medicaid and CHIP may require policies focused on economic levers tailored based on practice location.

"Patients who can't get an appointment go to the ER": access to specialty care for publicly insured children.

STUDY OBJECTIVE: Emergency departments (EDs) frequently refer patients for needed outpatient specialty care, but little is known about the dynamics of these referrals when patients are publicly insured. Hence, we explored factors, including the role of ED referrals, associated with specialists' willingness to accept patients covered by Medicaid and the Children's Health Insurance Program (CHIP). METHODS: We conducted semistructured qualitative interviews with a purposive sample of 26 specialists and 14 primary care physicians in Cook County, Illinois, from April to September 2009, until theme saturation was reached. Transcripts and notes were entered into ATLAS.ti and analyzed using an iterative coding process to identify patterns of responses, ensure reliability, examine discrepancies, and achieve consensus through content analysis. RESULTS: Themes that emerged indicate that primary care physicians face considerable barriers getting publicly insured patients into outpatient specialty care and use the ED to facilitate this process. Specialty physicians reported that decisions to refuse or limit the number of patients with Medicaid/CHIP are due to economic strain or direct pressure from their institutions. Factors associated with specialist acceptance of patients with Medicaid/CHIP included high acuity or complexity, personal request from or an informal economic relationship with the primary care physician, geography, and patient hardship. Referral through the ED was a common and expected mechanism for publicly insured patients to access specialty care. CONCLUSION: These exploratory findings suggest that specialists are willing to see children with Medicaid/CHIP if they are referred from an ED. As health systems restructure, EDs have the potential to play a role in improving care coordination and access to outpatient specialty care.

"He only takes those type of patients on certain days": specialty care access for children with special health care needs.

BACKGROUND: Expansions to public and private coverage opportunities under the Affordable Care Act and the Children's Health Insurance Program are meant to provide greater access to medical services, particularly for the 10 million US children with special health care needs (CSHCN). OBJECTIVE/HYPOTHESIS: We used qualitative methods to explore the nuanced processes of obtaining access to specialty care for publicly and privately insured CSHCN. METHODS: From May 2009 to February 2010, 30 in-depth qualitative interviews (60-90 minutes in length) were conducted with English-speaking family caregivers of CSHCN covered by public insurance (n = 15), private insurance (n = 6), or both (n = 9) in Cook County, IL. We used purposive quota sampling techniques to recruit parents from a group of 102 respondents from a related telephone survey who agreed to follow-up contact. All audio transcriptions and field notes were entered into Atlas-Ti software and analyzed by the authors through a thematic coding scheme. RESULTS: Respondents varied in their success in obtaining requested specialty care. Several themes emerged that shape access to specialty care for CSHCN in this study: marked differences based upon insurance type, the acuity of a child's health condition, and the presence of language and cultural barriers in scheduling and attending appointments. CONCLUSIONS: Qualitative interviews with families illuminated current perceptions of inequities in access to outpatient specialty care for CSHCN. Such findings generate questions and concerns about parity across public and private coverage systems for vulnerable children and suggest areas for future research and policy consideration for ensuring access to both primary and specialty care.

Academic medical centers and equity in specialty care access for children.

OBJECTIVE: To test whether specialty clinics' academic medical center (AMC) affiliation was associated with equity in scheduling appointments for children with public vs private insurance. Academic medical centers are safety-net providers of specialty medical care and it is unknown whether equitable access is afforded by AMCs across insurance conditions. DESIGN: Audit study data were linked to data describing audited clinics. SETTING: Specialty clinics serving children residing in Cook County, Illinois. PARTICIPANTS: From January-May 2010, 273 clinics were each called twice. MAIN OUTCOME MEASURES: Logistic regression was used to examine associations between AMC affiliation and discriminatory denials of Medicaid-Children's Health Insurance Program (CHIP) (ie, nonacceptance of Medicaid-CHIP when accepting commercial insurance), controlling for clinics' specialty type, practice size, neighborhood poverty level, and physicians' credentials. Among clinics that accepted both insurances, linear regression was used to examine the association between wait times (days) for appointments and insurance status, adjusting for covariates. Tests for interaction terms were performed to identify changes in wait time for academic clinics across insurance status. RESULTS: Of the 273 paired calls to clinics, 155 (57%) resulted in discriminatory denials of Medicaid-CHIP. The odds of a discriminatory denial were 45% lower if a clinic was AMC affiliated (odds ratio, 0.55; 95% CI, 0.31-0.99). On average, academic clinics scheduled Medicaid-CHIP appointments with wait times 40 days longer than private insurance (ß, 40.73; 95% CI, 5.06-76.41). CONCLUSIONS: Affiliation with an AMC was associated with fewer discriminatory denials of children with Medicaid-CHIP. However, children with Medicaid-CHIP had significantly longer wait times at AMC-affiliated clinics compared with privately insured children. Academic medical centers' propensity toward serving publicly insured patients makes them candidates for targeted resource allocation, perhaps with incentives contingent on equitable appointment acceptance and wait times.

Specialty care referral patterns for the underserved: a study of community health centers on the South Side of Chicago.

Little is known about the primary-specialty care interface for underserved patients. In order better to understand inter-physician communication patterns in urban community health centers (CHCs), we conducted a retrospective chart review of specialty care referrals for patients from four South Side Chicago CHCs. Of the 406 identified referrals, 74% (n=301) were made from CHCs that employed referral coordinators and 64% (n=258) were made to affiliated specialists. Chart documentation of whether or not the patient attended the referred specialty visit was present for 43% (n=176) of referrals, and communication from the specialist to the referring clinician was present for 31% (n=127) of referrals. Employing CHC referral coordinators was positively associated with documented specialty clinical communication (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-3.2). Use of referral coordinators to facilitate care and integrating delivery systems to increase information sharing appear to improve care coordination, but further investigation is warranted.

Limitations in access to dental and medical specialty care for publicly insured children.

Medicaid and the state-run Children's Health Insurance Program (CHIP) cover about 42 million children, many of whom would not have access to care without public insurance. Federal law requires that this access be equivalent to that of privately insured children for covered services, and many states have implemented policies to improve longstanding disparities in primary and preventive care. Reimbursement rates are up, but significant disparities remain, especially for dental and specialty services. It is important to understand the distinct effect of provider-related barriers, because they are potentially more modifiable through health policy than patient-related ones. This Issue Brief summarizes research that directly measures the willingness of dental and medical providers to see publicly-insured children, using research assistants posing as mothers calling for an urgent appointment for their child.

Cumulative adverse financial circumstances: associations with patient health status and behaviors.

This article examines associations between cumulative adverse financial circumstances and patient health in a sample of 1,506 urban emergency department (ED) patients. Study participants completed a previously validated Social Health Survey between May and October 2009. Five categories of economic deprivation were studied: food insecurity, housing concerns, employment concerns, cost-related medication nonadherence, and cost barriers to accessing physician care. Logistic regression that adjusted for the effects of demographics (age, gender, race, education) tested the association between the cumulative number of adverse financial circumstances (range: 0 to 5) and patients' health status (self-rated health, stress level, depressed mood) and health behaviors (smoking and substance abuse). Approximately 48 percent of respondents reported one or more financial concern, and 31 percent reported two or more financial concerns. A significant graded relationship was found between the number of adverse financial circumstances and patients' poor/fair self-rated health, depressed mood, high stress, smoking, and illicit drug use. Findings suggest that in today's acute health safety net, patients' concerns related to financial insecurity are very relevant to patient health.This underscores the imperative for hospital-based social workers to design models of routine social health risk screening and system interventions that address patient financial well-being in the ED.

Auditing access to specialty care for children with public insurance.

BACKGROUND: Health care reform has expanded eligibility to public insurance without fully addressing concerns about access. We measured children's access to outpatient specialty care to identify disparities in providers' acceptance of Medicaid and the Children's Health Insurance Program (CHIP) versus private insurance. METHODS: Between January and May 2010, research assistants called a stratified, random sample of clinics representing eight specialties in Cook County, Illinois, which has a high proportion of specialists. Callers posed as mothers of pediatric patients with common health conditions requiring outpatient specialty care. Two calls, separated by 1 month, were placed to each clinic by the same person with the use of a standardized clinical script that differed by insurance status. RESULTS: We completed 546 paired calls to 273 specialty clinics and found significant disparities in provider acceptance of Medicaid-CHIP versus private insurance across all tested specialties. Overall, 66% of Medicaid-CHIP callers (179 of 273) were denied an appointment as compared with 11% of privately insured callers (29 of 273) (relative risk, 6.2; 95% confidence interval [CI], 4.3 to 8.8; P<0.001). Among 89 clinics that accepted both insurance types, the average wait time for Medicaid-CHIP enrollees was 22 days longer than that for privately insured children (95% CI, 6.8 to 37.5; P=0.005). CONCLUSIONS: We found a disparity in access to outpatient specialty care between children with public insurance and those with private insurance. Policy interventions that encourage providers to accept patients with public insurance are needed to improve access to care.

Disparities in child access to emergency care for acute oral injury.

OBJECTIVE: We examined the impact of insurance status on dental practices' willingness to schedule an appointment for a child with a symptomatic fractured permanent front tooth. PATIENTS AND METHODS: Between February and May 2010, 6 research assistants posed as mothers of a 10-year-old boy seeking an urgent dental appointment. Two calls 4 weeks apart, with the same clinical scenario, were made by the same caller to a stratified random sample of dental practices, one-half of which were enrolled in the state's combined Medicaid and Children's Health Insurance Program (CHIP) dental program. The only difference in the calls was the child's insurance coverage (Medicaid/CHIP versus private Blue Cross dental coverage). We estimated differences in the log-odds probability of scheduling an appointment for a child with public versus private insurance by using exact conditional (fixed-effects) logistic regression, which accounts for paired data. RESULTS: Of 170 paired calls to 85 dental practices (41 participating in the Medicaid program), only 36.5% of Medicaid beneficiaries obtained any appointment compared with 95.4% of Blue Cross-insured children with the same oral injury. Among dental providers enrolled in the Medicaid program, children with Medicaid were still 18.2 times more likely to be denied an appointment than privately insured counterparts (95% confidence interval: 3.1 to ∞; P < .001). CONCLUSIONS: Illinois dentists, including those participating in Medicaid, are less likely to see a child for an urgent dental complaint if the child has public versus private dental coverage. These results have implications for developing policies that improve access to oral health care.

Risk for cost-related medication nonadherence among emergency department patients.

OBJECTIVES: There has been a rapid rise in prescription drug costs over the past decade. As a result, many Americans are unable to afford their medications, especially in the current economic recession. Medication nonadherence is known to have adverse effects on health outcomes. The purpose of this study was to gain a preliminary understanding of cost-related medication nonadherence (CRMN) disclosure among screened emergency department (ED) patients and to describe the extent to which CRMN is associated with other economic and psychosocial risk factors. METHODS: This was a prospective, cross-sectional study of a convenience sample of adult patients presenting to an urban academic ED with 61,962 annual visits in 2009. Nonemergent patients received an optional self-administered Social Health Survey between May and October 2009. Results were assessed from the sample of anonymous surveys that were completed and collected. Standard statistical methods were used to determine the frequencies and relative risks (RRs) for CRMN with 95% confidence intervals (CIs). RESULTS: A total of 384 (25.5%) of the 1,506 adult patients who completed the survey either screened positive for any prior CRMN (20.7%) or disclosed concerns about affording medication (4.8%). Patients were significantly more likely to report risk for CRMN if they used tobacco (RR = 1.8, 95% CI = 1.5 to 2.2) or illicit drugs (RR = 2.0, 95% CI = 1.6 to 2.4), experienced intimate partner violence (IPV; RR = 1.8, 95% CI = 1.5 to 2.2), or reported concerns about overall financial instability (RR = 3.9, 95% CI = 3.2 to 4.7), food insufficiency (RR = 3.7, 95% CI = 3.1 to 4.3), housing problems (RR = 2.5, 95% CI = 2.1 to 2.9), and inadequate health insurance coverage (RR = 7.7, 95% CI = 6.2 to 9.5). CONCLUSIONS: Risk for medication nonadherence due to cost concerns was identified in a quarter of nonemergent urban ED patients in our sample and was more likely to be reported by patients experiencing other economic and psychosocial risks. These findings indicate a need to include discussions about medication affordability and referrals to social services as part of ED discharge planning.

Emergency care of urban women with sexually transmitted infections: time to address deficiencies.

BACKGROUND: Patient education upon diagnosis of a sexually transmitted infection (STI) may effect changes in high-risk sexual behavior. OBJECTIVE: Describe emergency department (ED) communication with urban female patients treated for STIs. METHODS: : This secondary analysis of data collected during a study of ED communication used mixed quantitative and qualitative methods. The medical records of female patients ages 18 to 35 presenting to an urban ED for low abdominal/pelvic pain, gynecological complaints, and urinary symptoms (n = 134) were reviewed for STI testing and treatment proportions. A subsample of 30 audiotaped interactions with women treated for STIs were coded for provider assessment of sexual risks and delivery of STI prevention messages. RESULTS: Audiotape analysis found sexual histories were very limited and only 17% of women received prevention messages. Provider STI treatment had an estimated overall sensitivity of 46% (95% CI, 24.4%-69.0%) and specificity of 66% (95% CI, 61.8%-70.7%). CONCLUSIONS: Urban female patients treated for an STI in the ED rarely received recommended STI prevention messages. The study raises policy issues regarding the need for quality indicators in acute STI care. Access to STI treatment in other practice settings or by alternative methods need to be strongly considered.

Characterizing emergency department discussions about depression.

BACKGROUND: The reality of emergency health care in the United States today requires new approaches to mental health in the emergency department (ED). Major depression is a disabling condition that disproportionately affects women. OBJECTIVES: To characterize ED provider-patient discussions about depression. METHODS: This was a secondary analysis of a database of audiotaped ED visits with women patients collected during a clinical trial of computer screening for domestic violence and other psychosocial risks. Nonemergent female patients, ages 18-65 years, were enrolled from two socioeconomically diverse academic EDs. All audio files with two or more relevant comments were identified as "significant depression discussions" and independently coded using a structured coding form. RESULTS: Of 871 audiorecorded ED visits, 70 (8%) included discussions containing any reference to depression and 20 (2%) constituted significant depression discussions. Qualitative analysis of the 20 significant discussions found that 16 (80%) required less than 90 seconds to complete. Ten included less than optimal provider communication characteristics. Despite the brevity or quality of the communication, 15 of the 20 yielded high patient satisfaction with their ED treatment. CONCLUSIONS: ED providers rarely addressed depression. Qualitative analysis of significant patient-provider interactions regarding depression found that screening for depression in the ED can be accomplished with minimal expenditure of provider time and effort. Attention to psychosocial risk factors has the potential to improve the quality of ED care and patient satisfaction.