Medicaid is a federal-state program for certain categories of  low-income children, families, and individuals. 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. 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. 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. 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. 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. Of further note, 34 percent of the physicians experience great difficulty for  children in Medicaid and CHIP, compared to 1 percent for privately  insured. 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 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. 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. 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. 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.
Why GAO Did This Study

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.

What GAO Found

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.