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

Letter

Background

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.

Most Physicians Are Enrolled and Serving Children in Medicaid and CHIP, but Are Generally More Willing to Accept Privately Insured Children as New Patients

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.

More Than Three-quarters of Physicians Are Enrolled and Serving Children in Medicaid and CHIP

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.)

Physicians Participating in Medicaid and CHIP Are Generally More Willing to Accept Privately Insured Children as New Patients Than Children in Medicaid and CHIP

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.

Physicians in Rural and Urban Areas

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.

Nonparticipating Physicians Largely Cited Administrative Issues as Limiting Their Own Willingness to Serve Children in Medicaid and CHIP

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.

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

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.

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

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.

The Specialties Cited as Difficult Referrals Were Largely the Same for Children in Medicaid and CHIP and for Privately Insured Children

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.

Concluding Observations

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.

Agency Comments and Our Evaluation

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.

Appendix I: Scope and Methodology for GAO Survey of Primary Care and Specialty Care Physicians

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.

Development of Survey Questionnaire

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.

Survey of Primary Care and Specialty Care Physicians

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.

Analysis of Physician Responses

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.

Characteristics of Survey Respondents

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).

Nonresponse and Internal Consistency of Survey Data

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.

Appendix II: 2010 Physician Survey Results

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).

Appendix III: Comments from the Department of Health and Human Services

Appendix IV: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

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.

Related GAO Products

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.