Medicaid and CHIP:

Most Physicians Serve Covered Children but Have Difficulty Referring Them for Specialty Care

GAO-11-624: Published: Jun 30, 2011. Publicly Released: Jun 30, 2011.

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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.

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.

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