Medicaid/CHIP: The Emergency Room Gateway to Specialists

Medicaid and CHIP (Children's Health Insurance Program) are two types of public insurance for adults and children, respectively. While these insurances provide an important safety net for people, they are notorious among health care providers for extremely low levels of reimbursement compared to other types of insurance (e.g., private, no-fault, workers compensation).

These insurances are also widely known for denying coverage for overly technical reasons (e.g., not adding a decimal point in a billing code) and for bogging health care providers down in paperwork. Accepting such patients also carries the risk of a government audit, which can have serious consequences (e.g., large fine and/or jail time) if found guilty of violating the rules.  Patients with Medicaid and CHIP also tend to have high no-show rates.

As such, many private outpatient health care providers refuse to see patients with these types of insurances. Even in public health care settings (e.g., state hospitals) where it is not legal to deny evaluations patients with these insurances due to government contracts, the numbers of patients seen per day, per week, or per month with these insurance are often capped.  These problems are becoming more and more salient across the country due to increasing economic strain caused by various factors such as declining reimbursement in general, decreased government financial aide, and the impacts of health care reform. As a result, many health care providers are under increasing pressure from the institutions they work in to bring in more money. This often means seeing more patients with higher paying insurances.

All of this creates a serious problem for patients who have Medicaid or CHIP who need to be seen by outpatient specialists (e.g., neurologists, psychologists, psychiatrists, gynecologists).  It is also a problem for the primary care physicians (PCPs) who refer these patients because without input from the specialist it is much more difficult to coordinate care.

If the patients calls the specialist office themselves, one of the first questions they will be asked is “What insurance Do You Have?” If the answer is a private insurance, the patient will often be seen relatively quickly. If it is Medicaid or CHIP, there is a much greater chance of being put on a waiting list, given an appointment many months later, or told there are no appointments at this time.  The same can hold true if a staff member from a PCPs office calls the specialist’s office to make the appointment.

Due to this problem, patients with Medicaid and CHIP and their PCPs find ways to work around these obstacles. One of the most effective ways this is done is by going to the Emergency Room (ER), even though the medical situation may not be a true emergency. In an upcoming article in the Annals of Emergency Medicine, researchers explored this topic more by interviewing 26 specialists and 14 primary care physicians in Illinois.

The results of the study confirmed much of what was discussed above, including how the ER is used by PCPs and patients to access specialty care. The study also found that specialists will often take patients from the ER out of sense of obligation and because referrals from the ER often have established mechanisms in place to distribute these patients equitably so that no one provider is seeing too many low-paying patients. Referrals from PCPs, however, often do not have such equitable distribution mechanisms. Specialists are also more likely to take patients from the ER is the specialty service is affiliated with the ER in some way (e.g., located in the same hospital). For urgent situations that a patient cannot get an outpatient specialist to evaluate for many months, showing up in the ER usually means that the specialist will be paged to see him/her that day for an evaluation.

Other factors that the study found was associated with the specialist accepting a Medicaid/CHIP patient was a personal request (i.e., call) from the PCP, informal economic relationships between the specialist and PCP, patient hardship, the more urgent the case was, and geography. With regards to the latter, it appeared that providers were more willing to see Medicaid/CHIP patients who lived closer to their office (probably because it decreased the no-show risk that can result from transportation problems).

Suggested reading: Confessions of Emergency Room Doctors

Related Blog Entry: Who Uses the Emergency Room Most? The Answers May Surprise You

Reference: Rhodes KV, Bisgaier J, Lawson CC, Soglin D, Krug S, Van Haitsma M. (2013, in press). "Patients Who Can't Get an Appointment Go to the ER": Access to Specialty Care for Publicly Insured Children. Ann Emerg Med.