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Geissler KH, Shieh MS, Krishnan JA, Lindenauer PK, Ash AS, Goff SL. Health Insurance Type and Outpatient Specialist Care Among Children With Asthma. JAMA Netw Open 2024; 7:e2417319. [PMID: 38884996 PMCID: PMC11184461 DOI: 10.1001/jamanetworkopen.2024.17319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/17/2024] [Indexed: 06/18/2024] Open
Abstract
Importance Although children with asthma are often successfully treated by primary care clinicians, outpatient specialist care is recommended for those with poorly controlled disease. Little is known about differences in specialist use for asthma among children with Medicaid vs private insurance. Objective To examine differences among children with asthma regarding receipt of asthma specialist care by insurance type. Design, Setting, and Participants In this cross-sectional study using data from the Massachusetts All Payer Claims Database (APCD) between 2014 to 2020, children with asthma were identified and differences in receipt of outpatient specialist care by whether their insurance was public (Medicaid and the Children's Health Insurance Program) or private were examined. Eligible participants included children with asthma in 2015 to 2020 aged 2 to 17 years. Data analysis was conducted from January 2023 to April 2024. Exposure Medicaid vs private insurance. Main Outcomes and Measures The primary outcome was receipt of specialist care (any outpatient visit with a pulmonology, allergy and immunology, or otolaryngology physician). Multivariable logistic regression models estimated differences in receipt of specialist care by insurance type accounting for child and area characteristics including demographics, health status, persistent asthma, calendar year, and zip code characteristics. Additional analyses examined if the associations of specialist care with insurance type varied by asthma persistence and severity, and whether associations varied over time. Results Among 198 101 unique children, there were 432 455 child-year observations (186 296 female [43.1%] and 246 159 male [56.9%]; 211 269 aged 5 to 11 years [48.9%]; 82 108 [19.0%] with persistent asthma) including 286 408 (66.2%) that were Medicaid insured and 146 047 (33.8%) that were privately insured. Although persistent asthma was more common among child-year observations with Medicaid vs private insurance (57 381 [20.0%] vs 24 727 [16.9%]), children with Medicaid were less likely to receive specialist care. Overall, 64 239 child-year observations (14.9%) received specialist care, with substantially lower rates for children with Medicaid vs private insurance (34 093 child-year observations [11.9%] vs 30 146 child-year observations [20.6%]). Regression-based estimates confirmed these disparities; children with Medicaid had 55% lower odds of receiving specialist care (adjusted odds ratio, 0.45; 95% CI, 0.43 to 0.47) and a regression-adjusted 9.7 percentage point (95% CI, -10.4 percentage points to -9.1 percentage points) lower rate of receipt of specialist care. Compared with children with private insurance, there was an additional 3.2 percentage point (95% CI, 2.0 percentage points to 4.4 percentage points) deficit for children with Medicaid with persistent asthma. Conclusions and Relevance In this cross-sectional study, children with Medicaid were less likely to receive specialist care, with the largest gaps among those with persistent asthma. These findings suggest that closing this care gap may be one approach to addressing ongoing disparities in asthma outcomes.
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Affiliation(s)
- Kimberley H. Geissler
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield
| | - Meng-Shiou Shieh
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield
| | - Jerry A. Krishnan
- Department of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago
- Division of Pulmonary, Critical Care, Sleep and Allergy, University of Illinois Chicago
- Office of Population Health Sciences, University of Illinois Chicago
| | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School-Baystate, Springfield
- Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester
| | - Arlene S. Ash
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester
| | - Sarah L. Goff
- Department of Health Promotion and Policy, School of Public Health & Health Sciences, University of Massachusetts Amherst
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Baum RA, Berman BD, Fussell JJ, Patel R, Roizen NJ, Voigt RG, Leslie LK. Child Health Needs and the Developmental-Behavioral Pediatrics Workforce Supply: 2020-2040. Pediatrics 2024; 153:e2023063678H. [PMID: 38300001 DOI: 10.1542/peds.2023-063678h] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
Developmental-behavioral pediatrics (DBP) subspecialists care for children with complex neurodevelopmental and behavioral health conditions; additional roles include education and training, advocacy, and research. In 2023, there were 1.0 DBP subspecialists per 100 000 US children aged 0 to 17 years (range 0.0-3.8), with wide variability in DBP subspecialist distribution. Given the prevalence of DB conditions, the current workforce is markedly inadequate to meet the needs of patients and families. The American Board of Pediatrics Foundation led a modeling project to forecast the US pediatric subspecialty workforce from 2020 to 2040 using current trends in each subspecialty. The model predicts workforce supply at baseline and across alternative scenarios and reports results in headcount (HC) and HC adjusted for percent time spent in clinical care, termed "clinical workforce equivalent." For DBP, the baseline model predicts HC growth nationally (+45%, from 669 to 958), but these extremely low numbers translate to minimal patient care impact. Adjusting for population growth over time, projected HC increases from 0.8 to 1.0 and clinical workforce equivalent from 0.5 to 0.6 DBP subspecialists per 100 000 children aged 0 to 18 years by 2040. Even in the best-case scenario (+12.5% in fellows by 2030 and +7% in time in clinical care), the overall numbers would be minimally affected. These current and forecasted trends should be used to shape much-needed solutions in education, training, practice, policy, and workforce research to increase the DBP workforce and improve overall child health.
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Affiliation(s)
- Rebecca A Baum
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill/North Carolina Children's Hospital, Chapel Hill, North Carolina
| | - Brad D Berman
- Division of Developmental-Behavioral Pediatrics, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Jill J Fussell
- University of Arkansas for Medical Sciences/Arkansas Children's Hospital, Little Rock, Arkansas
| | - Rohan Patel
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina at Chapel Hill/North Carolina Children's Hospital, Chapel Hill, North Carolina
| | - Nancy J Roizen
- Division of Developmental and Behavioral Pediatrics and Psychology, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Robert G Voigt
- Michael R. Boh Centers for Child Development, Department of Pediatrics, Ochsner Health, and University of Queensland Medical School/Ochsner Clinical School, New Orleans, Louisiana
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Patel M, Raphael JL. Pediatric subspecialty pipeline: aligning care needs with a changing pediatric health care delivery environment. Pediatr Res 2023:10.1038/s41390-023-02599-x. [PMID: 37142648 PMCID: PMC10157557 DOI: 10.1038/s41390-023-02599-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 03/18/2023] [Indexed: 05/06/2023]
Affiliation(s)
- Mona Patel
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA.
| | - Jean L Raphael
- Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, TX, USA
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McCafferty S, Pereira-Smith S, Koshy AJ, Valdez P, Nyp SS. Skipping the Line: Inequality in Access to Developmental-Behavioral Care. J Dev Behav Pediatr 2022; 43:545-547. [PMID: 36040829 DOI: 10.1097/dbp.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
CASE The mother of an 18-month-old boy contacted the developmental and behavioral pediatrics clinic to request an evaluation because of concerns that her son is not using any words and only recently began walking. The child's mother became upset when she was notified that the clinic policy requires receipt of a formal request for evaluation from the primary care physician and that the first available appointment was in 9 months. Later that day, the child's grandmother contacted the clinic and reported that she is a member of the Donor Society affiliated with the university/medical system. Membership in the Donor Society is granted to individuals who have met specific philanthropic thresholds benefiting the university. One benefit to members of the Donor Society is the ability to access subspecialty medical services for themselves and their family members, across all disciplines, within 5 business days of their request.After confirming the details of the Donor Society promise with the philanthropic department of the hospital, a small committee of professionals within the clinic gathered to discuss the implications of this promised benefit to Donor Society members. This clinic is the only source for specialized, multidisciplinary developmental-behavioral health care that accepts public insurance within a 200-mile radius. The current waitlist for evaluation is 9 to 15 months depending on the reason for referral, and approximately 75% of patients on the waitlist receive some form of public assistance and/or live in a rural or underserved area. During the discussion, it was noted that there are 2 developmental-behavioral pediatric clinicians who practice within a cash-based private practice setting in the community. The waitlist for that practice was recently reported to be 3 to 6 months depending on the reason for evaluation, but that practice also requires a referral from the primary care physician before scheduling an initial evaluation.How would you recommend that the clinicians in the developmental and behavioral pediatrics clinic respond to the request to fulfill the promises made by the university to members of the Donor Society? How does a promise such as this one made to the Donor Society affect structural inequalities within the health care system and what strategies could be used to mitigate further inequalities that may result?
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Affiliation(s)
- Shawna McCafferty
- Division of Developmental and Behavioral Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Silvia Pereira-Smith
- Developmental-Behavioral Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Anson J Koshy
- Meyer Center for Developmental Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Purnima Valdez
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Sarah S Nyp
- Division of Developmental and Behavioral Health, Department of Pediatrics, Children's Mercy Kansas City, UMKC School of Medicine, Kansas City, MO
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Bohnhoff JC, Babinski T, Essien UR, Ray KN. Visit characteristics associated with discharge from specialty care: Results from the National Ambulatory Medical Care Survey. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2022; 10:100656. [PMID: 36156380 DOI: 10.1016/j.hjdsi.2022.100656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/12/2022] [Accepted: 09/07/2022] [Indexed: 01/26/2023]
Affiliation(s)
- James C Bohnhoff
- Department of Pediatrics, University of Pittsburgh School of Medicine, 3414 Fifth Ave, Pittsburgh, PA, 15213, USA.
| | - Tyler Babinski
- Division of Management and Education, University of Pittsburgh at Bradford, 300 Campus Dr, Bradford, PA, 16701, USA.
| | - Utibe R Essien
- Department of Medicine, University of Pittsburgh School of Medicine, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA, 15240, USA.
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, 3414 Fifth Ave, Pittsburgh, PA, 15213, USA.
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Affiliation(s)
- Gary L Freed
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan.,Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan
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Catenaccio E, Rochlin JM, Simon HK. Association of Lifetime Earning Potential and Workforce Distribution Among Pediatric Subspecialists. JAMA Pediatr 2021; 175:1053-1059. [PMID: 34180976 PMCID: PMC8239999 DOI: 10.1001/jamapediatrics.2021.1912] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Differences in lifetime earning potential between pediatric subspecialties may contribute to shortages in the subspecialty workforce. OBJECTIVES To evaluate the association between lifetime earning potential and workforce distribution and to investigate the potential role of a pediatric subspecialist-specific loan repayment program (LRP) in workforce expansion. DESIGN, SETTING, AND PARTICIPANTS This study was performed on publicly available mean debt and compensation data from national physician surveys from 2018 to 2019 of pediatric subspecialists in academic practice. Linear regression analysis was used to evaluate the association between lifetime earning potential and measures of workforce distribution in 2019, including distance to subspecialists, percentage of hospital referral regions with a subspecialist, and ratio of subspecialists to the regional child population as well as between lifetime earning potential in 2018 to 2019 and mean subspecialty fellowship fill rates between 2014 and 2018. The association between the change in lifetime earning potential from 2007 to 2018 and the change in workforce distribution metrics from 2003 to 2019 was also examined. The potential role of a pediatric subspecialist-specific LRP was modeled. EXPOSURES Lifetime earning potential by subspecialty. MAIN OUTCOMES AND MEASURES Measures of workforce distribution and fellowship fill rates. RESULTS This study included mean compensation data representing 7539 pediatric subspecialists, workforce distribution data representing 24 375 pediatric subspecialists, and fellowship fill rates representing a mean of 1344 pediatric subspecialty fellows per year. Higher lifetime earning potential was associated with shorter distance to subspecialists (-0.59 miles/$100 000 increase in lifetime earning potential; 95% CI, -1.10 to -0.09), higher percentage of hospital referral regions with a subspecialist (+1.17%/$100 000 increase in lifetime earning potential; 95% CI, 0.34-2.00), and higher ratio of subspecialists to regional child population (+0.11 subspecialists/100 000 children/$100 000 increase in lifetime earning potential; 95% CI, 0.04-0.19). The subspecialties for which lifetime earning potential increased the least between 2007 and 2018 experienced the least growth in the ratio of subspecialists to regional child population from 2003 to 2019 (+0.11 subspecialists/100 000 children/$100 000 increase in lifetime earning potential; 95% CI, 0.07-0.16). Higher lifetime earning potential was associated with higher mean fellowship fill rates (+0.96% spots filled/$100 000 increase in lifetime earning potential; 95% CI, 0.15-1.77). Implementing a pediatric subspecialist-specific LRP could increase fellowship fill rates and improve workforce distribution. CONCLUSIONS AND RELEVANCE Lifetime earning potential based on subspecialty may contribute to imbalances in both the current and future pediatric subspecialty workforce. Pediatric subspecialist-specific LRPs, especially for underfilled subspecialties, are potential tools for policy makers to target workforce shortages.
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Affiliation(s)
- Eva Catenaccio
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan M. Rochlin
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Harold K. Simon
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia,Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
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Keller DM, Davis MM, Freed GL. Access to pediatric subspecialty care for children and youth: possible shortages and potential solutions. Pediatr Res 2020; 87:1151-1152. [PMID: 32294663 DOI: 10.1038/s41390-020-0889-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/21/2020] [Indexed: 01/21/2023]
Affiliation(s)
- David M Keller
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA.
| | - Matthew M Davis
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital and Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gary L Freed
- Susan B. Meister Child Health Evaluation and Research (CHEAR) Center, University of Michigan, Ann Arbor, MI, USA
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