Dynamics of rationing outpatient subspecialty care for children covered by Medicaid

Background: As we move toward covering all Americans, there is need to understand the nuances of barriers to access faced by patients enrolled in Medicaid programs. Individual practices may limit the number of appointments for patients with Medicaid coverage, while still accepting some Medicaid-enrolled patients. However, little is known about institutional strategies used to restrict/provide access to subspecialty services.

Objectives: The purpose of this study was to understand strategies currently in use to ration outpatient appointment slots for pediatric subspecialty care by insurance status.

Method: Between April-September 2009, we used convenience sampling techniques to conduct in-depth confidential interviews (30-90 minutes in length) with a purposeful sample of 14 primary care providers (PCPs) and 30 subspecialty providers working in a large U.S. metropolitan area. Open-ended interviews (in-person or by telephone) were focused on children's access to subspecialty care and conducted until theme saturation was reached. Notes from non-taped interviews (n=2) and transcripts from taped interviews (n=42) were entered into Atlas-TI software and coded to identify themes and patterns within the responses.

Results: Six categories of institutional strategies were identified in the allocation of limited outpatient appointment slots for subspecialty services to Medicaid-insured children: severity of patient's health condition; taking responsibility for patients who lack alternatives; geographic proximity of patient's home address or referring PCP's location; hospital affiliation of PCP; personal connection or professional courtesy with PCP; and informal exchange arrangements with PCP.

Conclusions: Subtle methods of institutional rationing of subspecialty care for publicly-insured children are currently employed in the U.S. health system.