Medicaid Participation by Private and Safety Net Pediatricians, 1993 and 2000

BACKGROUND: Eligibility expansions and managed care growth were 2 major forces shaping the Medicaid program during the 1990s. Although Medicaid managed care was introduced to contain rising costs of growing enrollment and expenditures, it also offered states an opportunity to improve enrollees' access to mainstream health care providers. By enrolling in commercial managed care plans, they could gain access to private office-based physicians, thus eliminating a 2-tiered health care system. OBJECTIVES: To investigate changes in private and safety net pediatricians' participation in Medicaid between 1993 and 2000, a period noted for eligibility expansion for children and rapid managed care growth. DESIGN: Survey data collected from private and safety net pediatricians in 1993 and 2000 were analyzed to investigate how pediatricians' Medicaid caseloads were affected by 1) their practice setting, and 2) whether they accepted all Medicaid patients. RESULTS: Pediatricians' Medicaid caseloads increased significantly between 1993 and 2000, with those in private practice settings reporting greater increases. More pediatricians accepted all Medicaid patients in 2000, but Medicaid caseloads remained twice as high for safety net pediatricians. Medicaid caseloads increased dramatically for those accepting all Medicaid patients, except in safety net settings, where pediatricians who were turning away some Medicaid patients had heavier Medicaid caseloads than those who accepted all Medicaid patients. CONCLUSIONS: Although Medicaid children were still disproportionately served in the safety net in 2000, their access to private pediatricians had improved since 1993. But a ceiling in the safety net's capacity to absorb more Medicaid patients was suggested by the finding that safety net pediatricians turned away Medicaid patients as their Medicaid caseloads increased. Combined with decreasing participation by commercial plans in the Medicaid managed care market, increasing hospital emergency department overloads, and growing Title XXI Medicaid enrollments, interventions may be needed to avert a looming pediatric provider shortage for publicly insured low-income children.