Medicaid and CHIP: Most Physicians Serve Covered Children but Have Difficulty Referring Them for Specialty Care
Published: 2011-06-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Medicaid and the Children's Health Insurance Program (CHIP)--two joint federal-state health care programs for certain low-income individuals--play a critical role in addressing the health care needs of children. The Children's Health Insurance Program Reauthorization Act of 2009 required GAO to study children's access to care under Medicaid and CHIP, including information on physicians' willingness to serve children covered by Medicaid and CHIP. GAO assessed (1) the extent to which physicians are enrolled and serving children in Medicaid and CHIP and accepting these and other children as new patients, and (2) the extent to which physicians experience difficulty referring children in Medicaid and CHIP for specialty care, as compared to privately insured children. GAO conducted a national survey of nonfederal primary and specialty care physicians who serve children, and asked about their enrollment in state Medicaid and CHIP programs, whether they served and accepted Medicaid and CHIP and privately insured children, and the extent to which they experienced difficulty referring children in Medicaid and CHIP and privately insured children to specialty care. GAO also interviewed officials with the Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS) that oversees Medicaid and CHIP.
section_title: What GAO Found
paragraphs: Most physicians are enrolled in Medicaid and CHIP and serving children covered by these programs. On the basis of its 2010 national survey of physicians, GAO estimates that more than three-quarters of primary and specialty care physicians are enrolled as Medicaid and CHIP providers and serving children in those programs. A larger share of primary care physicians (83 percent) are participating in the programs--enrolled as a provider and serving Medicaid and CHIP children--than specialty physicians (71 percent). Further, a larger share of rural primary care physicians (94 percent) is participating in the programs than urban primary care physicians (81 percent). Nationwide, physicians participating in Medicaid and CHIP are generally more willing to accept privately insured children as new patients than Medicaid and CHIP children. For example, about 79 percent are accepting all privately insured children as new patients, compared to about 47 percent for children in Medicaid and CHIP. Nonparticipating physicians--those not enrolled or not serving Medicaid and CHIP children--most commonly cite administrative issues such as low and delayed reimbursement and provider enrollment requirements as limiting their willingness to serve children in these programs. Physicians experience much greater difficulty referring children in Medicaid and CHIP to specialty care, compared to privately insured children. On the basis of the physician survey, more than three times as many participating physicians--84 percent--experience difficulty referring Medicaid and CHIP children to specialty care as experience difficulty referring privately insured children--26 percent. For all children, physicians most frequently cited difficulty with specialty referrals for mental health, dermatology, and neurology. In its comments on a draft of this report, HHS stated that CMS is committed to improving physician participation and that this report will be of value as CMS works with the states to ensure beneficiary access to care.

section_title: Letter
paragraphs: Medicaid and the Children’s Health Insurance Program (CHIP)—two joint  federal-state health care programs for certain low-income individuals— play a critical role in addressing the health care needs of children. In 2010,  more than 42 million children received health care coverage through  Medicaid or CHIP, and this number is expected to increase. But simply  having coverage does not ensure that a beneficiary can access physicians  and needed services. Access to health care for children in Medicaid and  CHIP is affected, in part, by the number of physicians who are  participating—that is, who are not only enrolled in state Medicaid and  CHIP programs, but also providing services to these children.
The Centers for Medicare & Medicaid Services (CMS), an agency within  the Department of Health and Human Services (HHS), oversees state  Medicaid and CHIP programs at the federal level, including monitoring  children’s access to primary care and specialty care. Under broad federal  requirements, states administer the day-to-day operations of their  programs, including enrolling physicians, establishing provider payment  rates, and paying for services provided to program beneficiaries. States  generally provide Medicaid and CHIP services through two service  delivery and financing models—fee-for-service and managed care. While  physicians and other providers must enroll with states as Medicaid and  CHIP providers to receive payment for services provided under these  programs, enrollment does not require physicians to serve a specific  number of program beneficiaries or accept all program beneficiaries  seeking care.
The Children’s Health Insurance Program Reauthorization Act of 2009  (CHIPRA) required that we study Medicaid- and CHIP-covered children’s  access to primary and specialty care, including information on providers’  willingness to serve these children. In this report, we address  1.  the extent to which physicians are enrolled as Medicaid and CHIP  providers and serving children in these programs, and the extent to  which physicians are accepting these and other children as new  patients; and 2.  the extent to which physicians experience difficulty referring children  in Medicaid and CHIP for specialty care, as compared to privately  insured children.
To answer our two research objectives, we conducted a national survey of  physicians who serve children. We surveyed a nationally representative  sample of physicians from each of three groups—specialty care  physicians, primary care physicians in urban areas, and primary care  physicians in rural areas—all of whom were practicing physicians in the  United States who were office- or hospital-based and age 65 or younger,  provided direct patient care to children (age 0-18), and were not federal  employees. We received responses from 932 eligible physicians, and had a  response rate of 35 percent. We performed a nonresponse bias analysis to  determine whether any bias was introduced in the results due to the  absence of responses from some members of the sample. We also  performed additional analysis of the survey data to determine whether  certain characteristics, such as age, gender, and the percentage of children  served, influenced responses to our survey questions. We found that  physicians’ willingness to serve and accept children in Medicaid and CHIP  was not influenced by these factors. Our survey methodology allowed us  to generalize our results to the total population of physicians who serve  children in the United States, and to four groups of physicians who serve  children: primary care physicians, specialty care physicians, rural primary  care physicians, and urban primary care physicians. The survey was  administered from August 5, 2010, to October 31, 2010. All estimates are  based on self-reported information from the survey respondents and have  a margin of error of plus or minus 5 percent or less at the 95 percent  confidence level, unless otherwise noted. (For more information on the  scope and methodology of our survey, see app. I.) The survey included  questions about physicians’ enrollment in state Medicaid and CHIP  programs, whether they serve and accept children (age 0-18) in Medicaid  and CHIP as new patients, the share of their child patients that are covered  by Medicaid and CHIP, whether they experience difficulty referring  children to specialists, and factors that may affect their own willingness to  participate in Medicaid and CHIP. We also reviewed related literature on  physician supply and participation in public programs, including Medicaid.  In addition, we reviewed certain provisions of the Patient Protection and  Affordable Care Act (PPACA) that may affect physicians’ participation in  the program, and interviewed officials from CMS and selected provider  associations.
We conducted this performance audit from September 2009 through June  2011 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: Medicaid and CHIP are the nation’s largest health care financing programs  for low-income children, accounting for about $79 billion in shared federal  and state expenditures in 2009, the most recent year for which data are  available. Medicaid is a federal-state program for certain categories of  low-income children, families, and individuals. In fiscal year 2010,   34.4 million children had health coverage through Medicaid. CHIP is also a  federal-state program and provides health care coverage to children 18  years of age and younger living in low-income families whose incomes  exceed the eligibility requirements for Medicaid. In fiscal year 2010,   7.7 million children had health care coverage through CHIP.
State Medicaid and CHIP programs are required to cover certain groups of  individuals and offer a minimum set of services, including services  provided by primary care and specialty care physicians, and services  provided in hospitals, clinics, and other settings. States are also  responsible for enrolling physicians as Medicaid and CHIP providers. For  Medicaid programs, federal law establishes that state Medicaid payments  to providers must be sufficient to enroll enough providers so that care and  services are available to beneficiaries at least to the extent that they are  available to the general population in the same geographic area. On May  6, 2011, CMS issued a proposed regulation regarding this requirement.  The proposed regulation is intended to promote standardized and  transparent methods for states to review and monitor Medicaid  beneficiaries’ access to covered services delivered under a fee-for-service  delivery model. Under the proposed regulation, state monitoring of  Medicaid beneficiaries’ access is anticipated to be an ongoing and evolving  process. The proposed regulation describes different approaches states  may use to assess Medicaid beneficiaries’ access to care, and identifies  different actions states may take to address access problems. In addition,  the proposed regulation includes a requirement for states to annually  assess Medicaid beneficiaries’ access to a different subset of covered  services and then make the results of these assessments available to the  public. Figure 1 illustrates how the supply of primary care physicians  varies among states and within states.
Like all children, children in Medicaid and CHIP depend on physicians and  other health care providers for regular health screenings to monitor their  health, development, and growth. In addition to primary health care needs,  these screenings are important in identifying conditions that may warrant  specialty care and services. Medicaid programs are required to provide  regular health screenings, under the benefit known as Early and Periodic  Screening, Diagnostic and Treatment (EPSDT) services, for eligible  children. We and others have reported, however, that many children in  Medicaid and CHIP are not receiving well-child checkups, all required  health screening services, or needed specialty services. For example:  In August 2009, we reported that, on the basis of parents’ reports in the  Medical Expenditure Panel Survey (MEPS), about 40 percent of  children in Medicaid and CHIP had not had a well-child checkup over a  2-year period.
In May 2010, HHS’s Office of Inspector General reported that in nine  states, three of four children in Medicaid did not receive all required  covered health screening services.
In April 2011, on the basis of MEPS, we reported that for 12 percent of  children in Medicaid and CHIP 17 years of age and younger who  needed health care services, such as tests or treatments, their families  had difficulties accessing those services. In addition, an estimated   24 percent of children in Medicaid and CHIP 17 years of age and  younger who needed specialists had problems accessing specialty  services.
We also reported, in April 2011, that monitoring access to specialty care  for children in Medicaid and CHIP was important because the National  Survey of Children’s Health—which is based on responses from parents or  guardians—showed that these children had problems accessing needed  services. We also found that the required state reports submitted to CMS  regarding services provided to children in Medicaid lacked detail. For  example, the reports do not indicate whether children referred to  providers for treatment actually receive the services they need. We  recommended that the Administrator of CMS work with states to identify  additional improvements that could be made to the annual reports that  states are required to submit to CMS, including options for capturing  information on children’s receipt of the services for which they are  referred. CMS agreed with our recommendations.
section_title: Most Physicians Are Enrolled and Serving Children in Medicaid and CHIP, but Are Generally More Willing to Accept Privately Insured Children as New Patients
paragraphs: On the basis of our survey of physicians, we estimate that nationally more  than three-quarters of primary and specialty care physicians are enrolled  as Medicaid and CHIP providers and serving children covered by these  programs. These participating physicians are generally more willing to  accept privately insured children as new patients than children in  Medicaid and CHIP. In addition, the percentage of physicians accepting  children in Medicaid and CHIP is similar to the percentage of physicians  accepting uninsured children. Participating physicians do not appear to  show a preference when scheduling appointments for new patients, as the  reported wait times for new appointments are generally the same for  privately insured children and children in Medicaid and CHIP. We also  found that for most participating physicians, children in Medicaid and  CHIP represent less than 20 percent of the children they serve. Physicians  not enrolled or not serving children in these programs often cited  administrative issues related to reimbursement and provider enrollment  requirements as factors limiting their willingness to serve these children.
subsections: section_title: More Than Three-quarters of Physicians Are Enrolled and Serving Children in Medicaid and CHIP
paragraphs: On the basis of physicians’ responses to our survey, we estimate that  nationally 78 percent of physicians are enrolled as Medicaid and CHIP  providers and serving children in these programs. A larger share of  primary care physicians than specialty care physicians are participating in  Medicaid and CHIP—that is, enrolled and serving children in Medicaid and  CHIP. Among primary care physicians, participation in Medicaid and CHIP  is higher in rural areas than in urban areas. Overall, the proportion of  physicians participating in Medicaid and CHIP ranged from a low of   71 percent for specialty care physicians to a high of 94 percent for primary  care physicians in rural areas. (See table 1.)
Physicians who participate in Medicaid and CHIP do not appear to show a  preference for a particular delivery model. In areas where both managed  care and fee-for-service delivery models exist for these programs,   78 percent of participating physicians serve Medicaid and CHIP children in  both delivery models. Among participating physicians, 10 percent only  serve children under the fee-for-service model, and 8 percent only serve  children in the managed care model. (For additional data on physicians’  participation in Medicaid and CHIP, including estimates of the percentage  of participating physicians serving children in Medicaid and CHIP by  delivery model, and the lower and upper bounds of all estimates on  physician participation, see app. II, tables 5-8.)
section_title: Physicians Participating in Medicaid and CHIP Are Generally More Willing to Accept Privately Insured Children as New Patients Than Children in Medicaid and CHIP
paragraphs: Although most participating physicians are accepting children in Medicaid  and CHIP as new patients, they are generally more willing to accept  privately insured children as new patients. For example, about 8 of 10  participating physicians are accepting all privately insured children,  compared to less than 5 of 10 accepting all children enrolled in Medicaid  and CHIP. About 1 of 10 participating physicians are not accepting any  children in Medicaid and CHIP as new patients, compared to about 1 of 30  who are not accepting any privately insured children as new patients. (See  fig. 2.) Participating physicians were generally more willing to accept  privately insured children than Medicaid and CHIP children in each of the  physician types we analyzed: primary care physicians, specialty care  physicians, and primary care physicians in urban and rural areas.
Both primary care physicians and specialty care physicians are more  willing to accept privately insured children as new patients than children  in Medicaid and CHIP. (See fig. 3.) For example, for both primary care  physicians and specialty care physicians the percentage of participating  physicians who accept all privately insured children as new patients is  about 30 percent higher than the percentage who accept all children in  Medicaid and CHIP. (For additional data on acceptance of new patients  by child’s insurance and physician type, including estimates of physicians’  acceptance of uninsured children, and the lower and upper bounds of all  estimates, see app. II, tables 9 and 10.)
Similarly, a March 2011 report found that the percentage of primary care  physicians who were accepting all or most Medicaid patients—adults and  children—was considerably lower than the percentage accepting all or  most privately insured patients. This study also found that the relative  supply of primary care physicians did not affect physician willingness to  accept new Medicaid patients. Specifically, primary care physicians in  states with fewer primary care physicians per capita were as willing to  accept new Medicaid patients as primary care physicians in states with  more primary care physicians per capita.
subsections: section_title: Physicians in Rural and Urban Areas
paragraphs: As illustrated in figure 4, primary care physicians in urban and rural areas  are more willing to accept privately insured children as new patients than  children in Medicaid and CHIP; however, rural primary care physicians are  more willing than urban primary care physicians to accept children in  Medicaid and CHIP as new patients. In rural areas, the percentage of  participating primary care physicians who will accept all privately insured  children as new patients is about 20 percent higher than the share willing  to accept all children in Medicaid and CHIP. In urban areas, the difference  is about 30 percent. Further, the percentage of primary care physicians in  rural areas who are willing to accept all children in Medicaid and CHIP as  new patients (62 percent) is much higher than the percentage in urban  areas (43 percent). (For additional data on acceptance of new patients by  child’s insurance and primary care physician’s geographic location,  including estimates of physician acceptance of uninsured children, the  lower and upper bounds of all estimates, and information on statistically  significant differences, see app. II, table 11.)
The percentage of physicians accepting uninsured children as new  patients is similar to the percentage accepting children in Medicaid and  CHIP. For example, 55 percent of all participating physicians accept all  uninsured children as new patients, and 9 percent do not accept children  without insurance, compared to 47 percent and 9 percent, respectively, for  children in Medicaid and CHIP. (See app. II, tables 9-11.) Other research  has found that physicians’ willingness to accept patients enrolled in  Medicaid and uninsured patients is lower than willingness to accept  privately insured patients.
When accepting new Medicaid and CHIP patients, physicians who  participate in Medicaid and CHIP do not appear to show a preference for  children in a fee-for-service or managed care delivery model. In areas  where both delivery models exist for these programs, 69 percent of  participating physicians accept children in Medicaid and CHIP under both  fee-for-service and managed care. The percentage of physicians who only  accept these children under one type of delivery model is about the same  for each delivery model—7 percent only accept Medicaid and CHIP  children in a managed care delivery model, and 10 percent only accept  these children in a program with a fee-for-service delivery model. (See  app. II, table 12, for additional information regarding physician acceptance  of children in Medicaid and CHIP by delivery model.)
Participating physicians do not appear to have a preference for, or to give  priority to, privately insured children when scheduling appointments for  new patients. Nationally, physicians cited wait times for new patient  appointments as largely the same for children in Medicaid and CHIP and  privately insured children. For example, the most common wait time for a  new appointment cited was less than 48 hours for both children in  Medicaid and CHIP and privately insured children. Further, for both  groups of children, more than half of the participating physicians could  schedule a nonurgent visit in 6 days or fewer.
Wait times for children in Medicaid and CHIP and privately insured  children were similar for primary care physicians (national, urban, and  rural) and specialty care physicians. For primary care physicians overall  and those in urban and rural locations, more than half of participating  physicians indicated that wait times are less than 1 week for children  seeking new appointments, regardless of insurance coverage of the child.  For specialty care physicians, more than half of physicians indicated that  wait times for new appointments are 1 week or more for children with  private insurance, as well as for children covered by Medicaid and CHIP.  (See app. II, tables 13 through 15, for data on wait times by physician type  and geographic location of primary care physicians.) A June 2011 report  on children’s access to specialty services found that wait times in one  large urban county differed for children in Medicaid and CHIP as  compared to privately insured children. Using a methodology that entailed  researchers calling clinics in Cook County, Illinois, and posing as mothers  of children with Medicaid or CHIP coverage, and, in separate calls, as  mothers of children with private insurance, the study found that among  the clinics that accepted both Medicaid and CHIP and private insurance,  the average wait time for children covered by Medicaid and CHIP was   22 days longer than that for children with private insurance.
Children in Medicaid and CHIP represent a relatively small share of most  participating physicians’ child patients. Although the percentage of  children in Medicaid and CHIP served by participating physicians varies,  for more than half (55 percent) of all participating physicians, children in  Medicaid and CHIP represent less than 20 percent of the children they  serve. The most common physician response was that children in  Medicaid and CHIP represent less than 10 percent of the children they  serve. The second most common response was that children in Medicaid  and CHIP represent 60 percent or more of the children they serve. (See   fig. 5.)
The share of participating physicians’ child patients that are in Medicaid  and CHIP was similar for primary care physicians, specialty care  physicians, and urban primary care physicians. For the majority of  participating physicians in each of these groups, children in Medicaid and  CHIP accounted for less than 20 percent of the children they served. In  contrast, for the majority of rural primary care physicians, these children  accounted for 20 percent or more of all the children they served. (See   app. II, tables 16 through 19, for data on the patient mix of participating  physicians.) Our findings are similar to those from recent research in  California, which found that for the majority of the physicians  participating in the state’s Medicaid program—primary care, specialty  care, and urban as well as rural physicians—adults and children enrolled  in Medicaid accounted for 20 percent or less of their patients.
section_title: Nonparticipating Physicians Largely Cited Administrative Issues as Limiting Their Own Willingness to Serve Children in Medicaid and CHIP
paragraphs: Physicians not participating in the programs—that is, those not enrolled or  not serving children in Medicaid and CHIP—often cited certain  administrative issues related to reimbursement and enrolling as a provider  as factors that limit their own willingness to serve children enrolled in  these programs. Specifically, of 13 factors that physicians could identify on  our survey as limiting their own willingness to serve children in Medicaid  and CHIP, nonparticipating physicians most frequently identified   5 factors. For physicians not participating in Medicaid and CHIP, we  estimate that nationally  1.  95 percent are influenced by low reimbursement,  2.  87 percent are influenced by burdens associated with billing,  3.  85 percent are influenced by delayed reimbursement, and  4.  85 percent are influenced by burdens associated with enrolling and  participating. 5.  78 percent are influenced by difficulty referring patients to other  providers.
In contrast, two factors were frequently cited as not limiting physicians’  own willingness to participate in Medicaid and CHIP: practice capacity  and other patients’ perceptions of Medicaid and CHIP patients.  Specifically, 64 percent of nonparticipating physicians said that practice  capacity does not limit their own willingness to serve Medicaid and CHIP  children, and 71 percent said other patients’ perceptions of Medicaid and  CHIP patients does not limit their own willingness to serve these  children. (For additional information on the degree to which certain  factors influence participation for participating and nonparticipating  physicians, see app. II, tables 20 and 21.)
Other research has suggested that although physicians often cite  administrative issues as limiting their own willingness to participate in  Medicaid and CHIP, raising reimbursement rates may not increase their  participation in these programs. For example, one study found that  physicians’ negative perceptions of the program or its beneficiaries may  cause them to be reluctant to participate. Other studies have shown that  a number of factors unrelated to reimbursement can affect physician  participation in these programs, including gender, the type of practice,  whether the physician owns or is an employee in a practice, and the  geographic area in which the physician practices.
Recent provisions have been implemented to increase Medicaid  reimbursement rates. Under PPACA, states are required to increase  Medicaid payment rates for primary care services for 2013 and 2014. For  these 2 years, states will be required to pay certain primary care  physicians an amount equal to the amount Medicare pays for primary care  services, and the federal government will pay 100 percent of the  additional costs. However, one researcher noted that for states with the  lowest levels of physician supply the increase in reimbursement rates may  not increase the supply of Medicaid primary care providers to the levels  necessary for the likely growth in the Medicaid population.
section_title: More Than Three Times as Many Participating Physicians Have Difficulty Referring Children in Medicaid and CHIP to Specialty Care as Have Difficulty Referring Privately Insured Children
paragraphs: On the basis of our national survey, most physicians participating in  Medicaid and CHIP experience difficulty referring children in these  programs to specialty care, but relatively few have difficulty referring  privately insured children to specialty care. This difference is consistent  for primary and specialty care physicians at the national level, as well as  for primary care urban and primary care rural physicians. Physicians who  responded to our survey told us that they experience difficulty referring  children in Medicaid and CHIP to specialty care for a number of reasons,  including specialty physician supply and long waiting lists for specialists  willing to accept children covered by Medicaid and CHIP. The most  frequently cited specialty types that are difficult referrals for children in  Medicaid and CHIP were nearly identical to the types most frequently  cited as difficult for privately insured children.
subsections: section_title: About 84 Percent of Participating Physicians Experience Difficulty Referring Children in Medicaid and CHIP to Specialty Care, a Rate More Than Three Times That for Privately Insured Children
paragraphs: On the basis of the results of our survey, more than three times as many  physicians experience difficulty referring children in Medicaid and CHIP  to specialty care as experience difficulty referring privately insured  children. We estimate that nationally, 84 percent of participating  physicians experience some or great difficulty referring children in  Medicaid and CHIP, compared to 26 percent for privately insured children.
Of further note, 34 percent of the physicians experience great difficulty for  children in Medicaid and CHIP, compared to 1 percent for privately  insured. At the same time, 75 percent experience no difficulty referring  privately insured children to specialty care, compared to 16 percent for  children in Medicaid and CHIP. (See fig. 6.)
Physicians generally have more difficulty referring children in Medicaid  and CHIP to specialty care than privately insured children regardless of  physician type and geographic location. For each physician group— primary care physicians, specialty care physicians, and primary care urban  and primary care rural physicians—a greater percentage of physicians  experience difficulty referring children enrolled in Medicaid and CHIP to  specialty care than experience difficulty referring privately insured  children. (See figs. 7 and 8.) (For additional data on referrals to specialty  care by child’s insurance and physician specialty type and geographic  location, including estimates for uninsured children, the lower and upper  bounds of all estimates, and information on statistically significant  differences, see app. II, tables 22 through 24.) The June 2011 report  examining children’s access to specialty services in one large urban  county found disparities in provider acceptance of children in Medicaid  and CHIP as compared to privately insured children. The study found that  66 percent of the calls for children covered by Medicaid and CHIP were  denied an appointment compared to 11 percent for children with private  insurance.
The level of difficulty physicians experience in referring children in  Medicaid and CHIP to specialty care is similar to the level of difficulty they  experience in referring uninsured children. Specifically, the percentage of  participating physicians that experience some or great difficulty referring  uninsured children to specialty care (84 percent) was the same as the  percentage that experience some or great difficulty referring Medicaid and  CHIP to specialty care. These findings are consistent with the findings of  our April 2011 report that children in Medicaid and CHIP and uninsured  children were more likely to experience problems receiving needed  specialty care than privately insured children. “Few pecili in thi ll geogrphicre will ee children in the firt plce; if the  rik i high nd the reimbuement low, it getrder”
Physicians who responded to our open-ended survey question requesting  information on whether they experience difficulty referring children in  Medicaid and CHIP to specialty care cited a variety of reasons, including  the short supply of specialists in the area, long waiting lists for specialists,  specialists not accepting or limiting the number of children covered by  Medicaid and CHIP that they will accept, and low reimbursement rates and  other administrative issues associated with the programs.
section_title: The Specialties Cited as Difficult Referrals Were Largely the Same for Children in Medicaid and CHIP and for Privately Insured Children
paragraphs: The specialties cited by physicians as difficult to refer children to for  specialty care were largely the same for children in Medicaid and CHIP  and privately insured children. In our survey, we asked physicians who  indicated that they face difficulty referring children to specialists to list the  particular specialties for which making a referral is difficult. The most  frequently cited specialties for children enrolled in Medicaid and CHIP and  privately insured children were mental health specialties (such as  psychiatry and psychology), dermatology, and neurology. Shortages in  these specialty types are not unknown. For example, a 2010 survey of  physicians in Michigan found that dermatology, neurology, and pediatric  psychiatry were among the most difficult specialties for referrals.  Similarly, a 2010 study of the physician workforce in Massachusetts  classified the shortages of physicians in dermatology, neurology, and  psychiatry as severe. HHS projects that, as for many specialties, the  supply of psychiatrists, dermatologists, and neurologists will continue to  grow for the next decade or so. However, HHS noted that demand for  physician services—both primary and specialty care—is growing faster  than supply, and that the resulting shortfall could impede national health  care goals.
section_title: Concluding Observations
paragraphs: Medicaid and CHIP have a significant role in addressing the preventive and  specialty health care needs of tens of millions of children in the United  States. In April 2011, we reported that children’s access to needed  specialty care is an issue warranting closer monitoring. We recommended  to CMS—a recommendation to which CMS agreed—that the agency work  with states to identify ways to improve annual Medicaid and CHIP reports  that states submit to CMS, including ways to capture information on  children’s receipt of specialty care services for which they have been  referred by a physician or other provider. Findings of our current review,  capturing perspectives of physicians working to serve the medical needs  of Medicaid and CHIP children, further suggest the need for monitoring of  children’s receipt of needed specialty care in Medicaid and CHIP. In  particular, our finding that more than three times as many physicians  experience difficulty referring children in Medicaid and CHIP to specialty  care as experience difficulty referring privately insured children lends  importance to our April 2011 recommendation in that it gives the clearest  indication to date of the extent of the referral problem for children in  Medicaid and CHIP.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS for its review and comment.  HHS’s letter and general comments are reprinted in appendix III. HHS  commented that CMS is committed to improving physician participation  rates and that our report will be of significant value to CMS as it works  with states and providers to ensure that beneficiaries have access to  covered health care services. HHS also raised concerns about the report’s  portrayal of the percentage of physicians accepting all Medicaid and CHIP  children separately from the percentage accepting some, saying that when  the report describes half of physicians as accepting all new children, the  reader may assume the other half does not accept any new children. HHS  suggested that we combine the percentages of physicians accepting some  and all. We do not agree with HHS’s suggestion. The report consistently  depicts the extent of physicians’ willingness to serve by providing the  share accepting all, some, or no children in Medicaid and CHIP as new  patients, and combining all and some would mask the important  differences in physicians’ willingness to accept Medicaid and CHIP  children. HHS also commented that we should provide qualifying  statements about our sample of physicians, because the majority of  physicians who responded to our survey do not serve a large percentage of  children. We conducted statistical testing of the survey data to determine  whether physician characteristics—including the percentage of the  physician’s practice that is made up of children—influenced physicians’  responses. We found that the percentage of children in physicians’  practices did not affect physician responses to key questions in our survey.  We revised our report to provide information about this additional  statistical testing. HHS also provided technical comments, which we  incorporated as appropriate.
We are sending copies of this report to the Administrator of CMS and  other interested parties. In addition, the report is available at no charge on  GAO’s Web site at http://www.gao.gov.
If you or your staffs have any questions or need additional information,  please contact me at (202) 512-7114 or iritanik@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs may be found  on the last page of this report. GAO staff members who made key  contributions to this report are listed in appendix IV.
section_title: Appendix I: Scope and Methodology for GAO Survey of Primary Care and Specialty Care Physicians
paragraphs: We conducted a mixed-mode survey (mail and Web-based) of primary care  and specialty care physicians to determine the extent to which nonfederal  primary care and specialty care physicians are enrolled as Medicaid and  Children’s Health Insurance Program (CHIP) providers and serve children  in these programs; the extent to which they are accepting new Medicaid  and CHIP patients; factors that may affect physicians’ own willingness to  participate in Medicaid and CHIP; and the extent to which participating  physicians experience difficulty referring children in Medicaid and CHIP  for specialty care.
subsections: section_title: Development of Survey Questionnaire
paragraphs: We developed a questionnaire for surveying primary care and specialty  care physicians. We pretested the questionnaire with a convenience  sample of primary care and specialty care physicians in four states:  Georgia, Illinois, Oregon, and Washington. On the basis of the pretest  results, we revised the questionnaire for clarity. Most questions were  closed-ended, in which physicians selected from a list of possible  responses, answered yes or no questions, or selected responses on a three- point scale, such as none, some, or all. The questionnaire also included  some open-ended questions to allow respondents to identify specific types  of specialty care physicians that were difficult to get referrals to or other  comments respondents had regarding serving children in Medicaid and  CHIP.
section_title: Survey of Primary Care and Specialty Care Physicians
paragraphs: Using the questionnaire, we surveyed a nationally representative sample of  primary care and specialty care physicians, including a representative  sample of primary care physicians in rural and urban areas. We used the  American Medical Association’s Physician Masterfile to select a random  sample. We fielded the questionnaire from August 2010 through October  2010. Our random sample included 2,642 primary care and specialty care  physicians who were eligible to participate. Eligible physicians were those  who  1.  work in an office- or hospital-based setting;  2.  provide direct patient care to children (age 0-18);  3.  have a primary specialty in one of our two groups of physicians;  4.  are age 65 or younger; and  5.  are not an employee of a federal agency.
We received complete responses from 932 eligible physicians, for an  overall response rate of 35 percent. Based on the sampling frame and the  results of our nonresponse bias analyses, we were able to generalize  results nationally to primary care and specialty care physicians who serve  children. Table 2 illustrates the response rates for each physician group  surveyed.
section_title: Analysis of Physician Responses
paragraphs: We analyzed survey results for four groups of physicians: primary care  physicians, specialty care physicians, primary care physicians in urban  areas, and primary care physicians in rural areas. We analyzed physician  responses using standard descriptive statistics. In our analysis, we project  results to the national level, and to areas where both managed care and  fee-for-service delivery systems are available. All estimates are based on  self-reported information provided by the survey respondents and have a  margin of error of plus or minus 5 percent or less at the 95 percent  confidence level, unless otherwise noted.
For the open-ended questions related to difficulties making referrals to  specialty care, we used a standard content review method to identify the  types of specialists that physicians have difficulty referring children to for  specialty care. Our coding process for these qualitative responses involved  one independent coder and an independent reviewer who verified the  coded comments.
section_title: Characteristics of Survey Respondents
paragraphs: Of the 932 eligible physicians responding to our survey, two-thirds were  male; over two-thirds worked in an office-based setting; and, for most,  child patients represented less than 20 percent of the patients they served  (see table 3 and figs. 9 and 10). On average, respondents were 50 years old,  and had graduated from medical school 23 years earlier. Ninety-three  percent provided at least 20 hours of patient care per week.
The number of physicians who employ nurse practitioners or physician  assistants was about evenly split among physicians responding to our  survey. About two-thirds of primary care rural physicians in our sample  said they employ nurse practitioners or physician assistants (see table 4).
The number of physicians who responded to our survey varied by region,  with the highest numbers of physicians responding from the South, and  the lowest from the Northeast (see fig. 11).
section_title: Nonresponse and Internal Consistency of Survey Data
paragraphs: We performed checks on survey responses to identify inconsistent  answers. We also reviewed survey data for missing or ambiguous  responses, and performed statistical testing to determine whether  physician characteristics (such as age, gender, or percentage of children  physicians reported serving) influenced physicians’ responses to key  survey questions. We found that physician characteristics did not  influence responses. We also conducted a nonresponse bias analysis to  determine whether any bias was introduced in the results due to the  absence of responses from some members of the sample. For the  nonresponse bias analysis, we utilized data from our survey, the American  Medical Association Physician Masterfile, and follow-up telephone  interviews with physicians who did not respond to our paper or Web- based survey. Based on the results of our nonresponse bias analysis, we  adjusted our survey analysis weights to ensure that physicians were  appropriately represented in our study.
Based on our systematic survey processes, follow-up procedures, and  nonresponse bias analysis, we determined that the questionnaire  responses were representative of the experience and perceptions of  primary care and specialty care physicians nationally, and of primary care  physicians in urban and rural areas. We determined that the data were  sufficiently reliable for our purposes.
section_title: Appendix II: 2010 Physician Survey Results
paragraphs: This appendix contains additional data we collected from our 2010  national survey of physicians who serve children. It includes the results  from the closed-ended survey questions on our questionnaire, but does not  include narrative responses that we received to the open-ended questions.  Results are generally provided for physicians participating in state  Medicaid and Children’s Health Insurance Program (CHIP) programs— that is, physicians who are enrolled in these programs and also providing  services to these children in these programs.
We report statistically significant differences only when comparing  responses by (1) the child’s type of insurance (Medicaid and CHIP  coverage and private insurance coverage); (2) physician type (all  physicians, primary care physicians, and specialty care physicians);   (3) geographic location (rural and urban) of primary care physicians; and  (4) child’s type of insurance for each type of physician. We provide  national estimates regarding the following:    physician participation—the extent to which physicians are  participating, that is, enrolled in Medicaid and CHIP and serving  children in these programs (tables 5 through 8);   acceptance of new patients—participating physicians’ acceptance of  new child patients by insurance type, physician type, delivery model,  and Medicaid and CHIP (tables 9 through 12), and the length of time  patients must wait for a new appointment, by insurance type (tables 13  through 15);   patient composition—children in Medicaid and CHIP as a share of all  children served by participating physicians (tables 16 through 19);  factors limiting Medicaid and CHIP participation—factors cited  by nonparticipating and participating physicians as limiting their own  participation in these programs (tables 20 through 21); and level of difficulty referring children for specialty care—the  extent to which participating physicians experience difficulties  referring to specialty care (tables 22 through 24).
section_title: Appendix III: Comments from the Department of Health and Human Services
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Catina Bradley, Assistant  Director; Martha Kelly, Assistant Director; Suzanne Worth, Assistant  Director; Zhi Boon; Tim Bushfield; Sean DeBlieck; Laura Henry; Roseanne  Price; Dan Ries; Hemi Tewarson; and Jennifer Whitworth.
section_title: Related GAO Products
paragraphs: Medicaid and CHIP: Reports for Monitoring Children’s Health Care  Services Need Improvement. GAO-11-293R. Washington D.C.: April 5, 2011.
Oral Health: Efforts Under Way to Improve Children’s Access to Dental  Services, but Sustained Attention Needed to Address Ongoing Concerns.  GAO-11-96. Washington, D.C.: November 30, 2010.
Health Care Delivery: Features of Integrated Systems Support Patient  Care Strategies and Access to Care, but Systems Face Challenges.  GAO-11-49. Washington, D.C.: November 16, 2010.
Medicaid Managed Care: CMS’s Oversight of States’ Rate Setting Needs  Improvement. GAO-10-810. Washington, D.C.: August 4, 2010.
Medicaid Preventive Services: Concerted Efforts Needed to Ensure  Beneficiaries Receive Services. GAO-09-578. Washington, D.C.: August 14,  2009.
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of  Children’s Dental Services. GAO-07-826T. Washington, D.C.: May 2, 2007.
Medicaid Managed Care: Access and Quality Requirements Specific to  Low-Income and Other Special Needs Enrollees. GAO-05-44R.  Washington, D.C.: December 8, 2004.
Medicaid and SCHIP: States Use Varying Approaches to Monitor  Children’s Access to Care. GAO-03-222. Washington, D.C.: January 14,  2003.
Medicaid: Stronger Efforts Needed to Ensure Children’s Access to Health  Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001.