Universal Health Care Coverage for Children: Impact on Pediatric Health Care Providers
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622 Universal health care for children
Universal Health Care Coverage for Children:
Impact on Pediatric Health Care Providers
Lisa J. Chamberlain, MD, MPH
Dana C. Hughes, DrPH
Janine S. Bishop, MPH
Donald H. Matsuda, BS
Lauren Sassoubre, BA
Abstract: A Northern California county expanded health coverage to cover nearly all
children in the state through a new insurance program. In two years, 75,500 children
entered a health care system near capacity. We hypothesized that the influx of thousands of
previously uninsured children into the health system would affect providers in many ways.
This cross-sectional study sought to investigate how this influx affected provider practices,
job satisfaction, access to specialists, and overarching views about the program. Qualitative
analyses of expert interviews were performed. Providers reported improved access to health
care, specialists, and medications for patients. They cited increased job satisfaction for
providers due to fewer limits on care, improved referral process, and decreased patient family
financial stress. Providers noted the persistence of long appointment wait times for specialist
care. After moving to near universal coverage, safety net providers described increased job
satisfaction. Because this study examined safety-net providers, future research requires a
more representative sample of providers.
Key words: Children’s insurance, universal coverage, provider satisfaction.
S ignificant federal and state efforts over the past 20 years have expanded low-
income children’s access to health insurance through Medicaid expansions and
creation of the State Children’s Health Insurance program (SCHIP). California’s
Medicaid (Medi-Cal) and SCHIP (Healthy Families) programs cover many of the
state’s low-income children, yet one in seven (1,308,000 children or 14.3%) were
uninsured for some time during 2001. Two-thirds of these children were eligible
but not enrolled in Medicaid or SCHIP, leaving one third ineligible due to income
level or immigration status.1
LISA CHAMBERLAIN is a Clinical Instructor in the Division of General Pediatrics at Stanford University
School of Medicine and can be reached at lisa.chamberlain@medcenter.stanford.edu. DANA HUGHES
is an Associate Professor at the University of California San Francisco (UCSF) Dept. of Family and
Community Medicine, Institute for Health Policy Studies, where LAUREN SASSOUBRE is a Research
Assistant. JANINE BISHOP is a Community Advocacy Liaison in the Division of General Pediatrics at
Stanford University School of Medicine, where DONALD MATSUDA is a medical student.
Journal of Health Care for the Poor and Underserved 16 (2005): 622–633.
16.4chamberlain.indd 622 11/7/05 8:21:13 AMChamberlain, Hughes, Bishop, Matsuda, and Sassoubre 623
In 2001, 71,000 children (15% of 450,000 children) 18 years old and younger were
uninsured in Santa Clara County in northern California.2 In response, the county
launched the Children’s Health Initiative (CHI), an attempt to provide near universal
health coverage to children through 1) a new insurance product called Healthy Kids
and 2) the promotion of Medicaid and SCHIP enrollment. (See Figure 1.) Healthy
Kids is modeled after California’s SCHIP program and covers children previously
ineligible for Medicaid and SCHIP due to family income cut-offs or immigration
status. The Santa Clara CHI has been overwhelmingly successful, enrolling a total
of over 75,500 children in Medicaid, SCHIP, and Healthy Kids3 between 2001 and
2002. Currently, over 13,000 children are enrolled in the Healthy Kids program.
As more counties in California and in states across the country move toward
insuring all children, the impact on already strained pediatric safety net providers
will be critical.4, 5 The literature has many articles that illustrate the importance of
insurance status as it bears on child health,6–8 while less is known about how providers
respond to changes in population coverage. Thus, we sought to explore the impact
on Santa Clara County’s safety net pediatric providers as a previously fragmented
health care system moved to near universal health coverage. Studies examining
the physician perspective on care of uninsured patients show that physicians are
frustrated with their patients’ inability to access medical services, medications,9, 10 and
specialty care.9, 11 Other analyses reveal that physicians are increasingly dissatisfied
with their practice and medical careers,12–15 and their lack of ability to maintain
continuing patient relationships.16 Of further concern is that clinician dissatisfaction
may adversely affect patient satisfaction17 and compliance.18
We hypothesized that three years after the implementation of the CHI and Healthy
Kids program, the influx of tens of thousands of previously uninsured children into
a county health system already near capacity would affect providers in many ways.
Through expert interviews with pediatric providers in various practice settings,
we sought to investigate how the CHI and Healthy Kids program have affected
provider practices and job satisfaction, patient access to specialty care, and providers’
overarching views about the program.
Methods
A confidential cross-sectional observational study of pediatric provider perceptions
was conducted using in-depth individual expert interviews with Healthy Kids
pediatric providers (physicians, physician assistants, and nurse practitioners).
This method of qualitative data collection was selected 1) to provide an initial
and comprehensive exploration of this topic, allowing for the generation of new
hypotheses to inform future studies;19 and 2) to increase the scope and depth of
provider responses through use of open-ended questions, allowing respondents the
opportunity to express opinions in their own words.20
Sampling and study recruitment. In fall 2003, a list of the 189 Healthy Kids
providers serving 12,932 Healthy Kids members was obtained from the Santa Clara
Family Health Plan (SCFHP), which exclusively administers the Healthy Kids
program. The practices seeing the greatest number of Healthy Kids members were
contacted. Private practice physicians were oversampled despite seeing negligible
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Figure 1. Santa Clara County CHI outreach and enrollment structure.
numbers of Healthy Kids members. To be included in the study, providers had to
have provided care to Healthy Kids members since the implementation of the CHI
and Healthy Kids program.
Providers were contacted up to five times via telephone and/or email to request
study participation. The study protocol was approved by the Institutional Review
Board of Stanford University and informed consent was obtained from each provider
prior to the interview. Participants were informed that participation was voluntary
and confidential, without financial or other incentives for participation.
Forty pediatric providers were contacted; 30 agreed to participate while the
remaining 10 were excluded due to not providing care to Healthy Kids patients
before 2001 (n=3) or declining participation (n=3), or because they referred us to
another provider due to lack of Healthy Kids patients seen (n=4). We interviewed
26 physicians, 1 physician assistant, and 3 nurse practitioners from county clinics
(n=17), community-based clinics (n=9), and private practices (n=4).
Interview methods and study questions. Two research assistants were trained
to conduct in-person or telephone interviews, using a standard interview script of
22 open-ended questions. The confidential interviews lasted 15–20 minutes and
were conducted between September and October 2003. Interviews examined three
domains: 1) impact of CHI on pediatric health care providers, 2) impact of CHI on
patient access to specialty care, and 3) overall impressions of the CHI and Healthy
Kids program. Interview questions were refined following a pilot study in 2001 with
12 Santa Clara County pediatric providers.
Qualitative analysis. Each provider interview was audiotaped and transcribed.
The transcripts were reviewed by each study interviewer to ensure accuracy of
the transcription prior to data analysis. Two methods of qualitative analysis were
performed. Transcript-based analysis was performed to provide a preliminary
exploration of the data.21, 22 This method included independent highlighting and
16.4chamberlain.indd 624 10/7/05 2:36:59 PMChamberlain, Hughes, Bishop, Matsuda, and Sassoubre 625
margin coding of relevant themes for each open-ended interview question by all
study authors. Thematic coding and analysis was completed in a process where
authors met to discuss themes for each question response and resolve differences
by consensus. A taxonomy of themes was created to reflect the range of responses
for each question. Further analysis was performed using ATLAS.ti® v.4.2 qualitative
computer software23 to validate transcript based analysis. This software allowed
researchers to code responses within the text and analyze responses to identify
themes. All the responses for a particular code were examined and recoded if other
themes were revealed.
Results
Results are presented below with illustrative quotations from respondents found
in the Appendix.
Domain 1: Perceptions about the impact of the CHI on pediatric health care
providers. Theme 1. Improved access to health care for patients. Medical practices were
affected by the implementation of CHI and Healthy Kids program in February 2001.
Providers perceived improved access to health care for their patients, specifically
citing improved access to mental health services and prescription drugs. Providers
believed the improved access reduced stress on parents previously concerned about
the financial implications of seeking care for uninsured children. Others noted that
the Healthy Kids program is meeting an unmet need by insuring children who did
not previously have health insurance.
Theme 2. Increased patient volume. Since implementation of the CHI, safety net
providers witnessed an increased volume of pediatric patients, with some noting
a significant increase. Providers cited an increased number of physical exams and
first time visits. Those interviewed offered two related explanations for the increased
volume: the introduction of CHI and Healthy Kids program and external factors,
such as rising unemployment, which was rapid in Silicon Valley in 2000, causing
newly unemployed families to rely on safety net programs for their children’s health
care needs.
Theme 3. Mixed effect on patient flow. The interviewees were asked if their clinic
or practice experienced patient flow changes since the implementation of CHI.
Findings were mixed. Interviewees who reported a change in patient flow described
increases in patient volume, visits with new patients, vaccinations, physicals, and
appointments with older children. They explained that visits with new patients take
more time than visits with established patients, and many of the older kids being
seen for the first time had previously unmet medical care needs. Those who cited
no change stated that patient flow concerns were of long standing.
Theme 4. Minimal changes in patient profile. While providers witnessed an increased
volume of patients, most reported few changes in patient gender or ethnicity. Providers
did note seeing more school aged and adolescent children. With respect to ethnicity,
several providers noted that their patient population was already largely Spanish-
speaking Latino children and that this had not changed with the advent of CHI.
Theme 5. Increased or high level of job satisfaction. Providers described an increased
overall level of job satisfaction as a result of the CHI and Healthy Kids program.
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Providers cited greater ease in providing care without limitations. With the financial
barriers associated with a lack of insurance removed, providers believed, parents
were able to seek more efficient and frequent visits with their children’s health care
providers, which led to noticeably improved continuity of care. Job satisfaction
was also affected by decreased programmatic frustration and reduced paperwork.
A small subset of providers noted an already high level of job satisfaction that had
not changed as a result of the CHI and Healthy Kids program.
Domain 2: Perceptions about children’s access to specialty care. Theme 1. Access
to specialty care available. Providers indicated that, as a result of the CHI and Healthy
Kids program, patients could be referred to specialty care. However, providers
reported long or increased wait time to see specialists. The following specialties were
mentioned as having significant backlogs: pediatric dermatology, otolaryngology,
neurology, orthopedics, hematology and rheumatology. There was no difference
between the responses given by private practice providers, county or community
clinic providers on this theme.
Domain 3: Impressions of the CHI and Healthy Kids program. Theme 1. CHI
and Healthy Kids program is a great county asset. Among public and private providers
interviewed, the CHI and Healthy Kids program is very popular. Interviewees
described the program as “wonderful,” “great,” “unique,” “forward thinking,” and “a
great model for health care.” They noted that the program is well timed and a good
model for providing health care to the growing population of children ineligible for
health insurance as a result of family income requirements and legal documentation
status. Overall, providers felt that the CHI and Healthy Kids program is a great
county asset that not only benefits children, but their families and the communities
in which they live as well.
Theme 2. CHI programming and outreach works well. Interviewees were asked
what they think worked well about the program. Many interviewees noted the
success of outreach strategies. These included a good application process, strong
outreach strategies, and outstationed Certified Application Assistors (CAA) that help
families complete their Medicaid/Healthy Families and Healthy Kids applications.
Providers cited the benefit of having a CAA located at clinics, allowing parents
direct access to application assistance at the time of their visit, thus overcoming
time and transportation barriers to enrollment. One physician pointed out the CHI
and Healthy Kids program did a good job dispelling fears that participation would
threaten their ability to remain in the U.S.
Theme 3. Improved referral and formulary systems needed. Providers suggested an
improved specialist referral system, including more timely referrals, decreased wait
times, and an easier referral process. They voiced a need to increase the number of
available specialists and the process for specialist follow-up. Providers also described
frustration with the various formularies, citing difficulty in using three formularies
for one patient population.
Theme 4. Concerns about the future of the Healthy Kids program. While there is
widespread support for the CHI and Healthy Kids program, considerable concern
was voiced about the program’s future given state and local budgetary problems.
Providers expressed the need for program expansions, including removing a recently
placed enrollment cap and continuing outreach. Many worried that the program
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would lose funding, leading to children losing much needed health insurance benefits
and necessary access to health care.
Discussion
We sought to learn from a group of safety net pediatric providers (physicians,
physicians’ assistants and nurse practitioners) if and how their medical practices
changed following an influx of previously uninsured children into the local health
system and how their practices are different operating with near universal health
coverage. The impact of health insurance and/or its absence is typically studied
from the perspective of the patient. Strong evidence is available to suggest that
children’s access to health care is significantly improved when they are afforded
health insurance coverage. However, little is known about the implications of health
insurance expansions for medical care providers.
Interviews with 30 pediatric providers told an overwhelmingly positive story about
the effect of Santa Clara County’s CHI and Healthy Kids program on their practices.
Providers perceived improved access to needed medical services for their patients,
greater job satisfaction and reduced financial stress for parents. Despite busier clinics
and greater patient volume (in contrast to what is reported in the literature)15 most
providers experienced increased job satisfaction as a result of being able to provide
primary care without limitations, while voicing concerns about obtaining timely
referrals and formularies.
These findings are significant for several reasons. First, other studies have found
an association between provider dissatisfaction and high patient load in a managed
care setting.15, 24–26 Our research indicates that despite increased patient volume,
job satisfaction also increased among surveyed providers. This new finding may be
attributable to clinicians providing care with more continuity, as opposed to sporadic
acute care visits, to a large number of formerly uninsured children. In an attempt
to confirm this, we reviewed the Santa Clara Family Health Plan’s 2004 Health
Plan Employer Data and Information Set (HEDIS), which confirmed an increasing
number of well child and well baby visits, and higher immunization rates among
Medicaid and SCHIP patients, from 2002 to 2004. Healthy Kids data show similar
increases in well child visits and immunizations from 2003–2004.
Second, the CHI and Healthy Kids program reduced the frustration physicians
encounter when attempting to obtain diagnostic tests and specialty services for
uninsured patients.5, 10 The program also reduced the concern providers have about
patients deferring visits and going without prescriptions and other medical care
because of cost.9 Providers reported improved, but not perfect, access to referral
services as a result of the Healthy Kids program, which not only aids patients
but was also cited as a primary reason for increased job satisfaction. Finally, the
uniformity of coverage allows providers to treat children with one standard of care.
Regardless of increasing patient load, the ability to provide continuity of care to
patients without limitations may further contribute to high levels of satisfaction
among providers.16, 27
Our findings demonstrate overwhelming support among safety net providers for
a local county-based initiative that offers near universal health insurance coverage to
16.4chamberlain.indd 627 10/7/05 2:37:01 PM628 Universal health care for children
otherwise uninsured children. The positive impact of the CHI on this sample of safety
net providers suggests that local interventions in different regions may significantly
influence provider job satisfaction in a time of declining career satisfaction among
physicians.16 As physician satisfaction decreases, the potential for physicians to leave
patient care or to seek employment in less stressful settings increases,28 which in turn
can adversely affect the continuity of patient relationships,16, 27 patient satisfaction,17
and patient compliance.18
The generalizability of this study is limited due to the restrictions adopted for
choosing providers to interview. The study participants were primarily from county
and community health center clinics, because such providers see the majority of
underserved and previously uninsured children. These providers may not represent
other practitioners well, particularly those who do not serve uninsured or publicly
insured patients. Furthermore, while the majority of the providers approached agreed
to participate in this study, some declined, which may have led to overrepresentation
of those with positive feelings about the CHI and Healthy Kids program. Finally,
the study theme analysis was conducted by all study authors who were not blinded
to the study methods and hypothesis.
The goal of this qualitative research was to gain provider perspectives regarding
one county’s experience with making the transition to near universal health care
coverage for children, and thus to generate new hypotheses regarding the benefits or
drawbacks of such expansion. We were surprised by the extent to which providers
described increased job satisfaction simultaneous with increases in patient volume.
This finding suggests that safety net provider job satisfaction may be affected by the
patient’s ability to obtain needed services. It appears that moving towards a more
comprehensive health coverage system may improve the job satisfaction of safety
net providers because it enhances their ability to provide uncompromised primary
care for all their patients.
Additionally, increased job satisfaction coupled with increased patient volume
may relate to the types of providers who elect to treat low-income, publicly insured
pediatric patients. Such providers typically do so because they have a personal
commitment to serve underserved children. Increased volume means that more
children receive comprehensive coverage, thereby helping to fulfill their personal
mission.
Determining the relationship between provider job satisfaction and increased
patient volume with more certainty will require further research with a more
representative sample of providers, including a larger sample of private practice
physicians. A transition to universal health care coverage for children may not
have the same impact on job satisfaction among private practice physicians, who
might be dissatisfied by limitations placed on their fees and practice patterns,
in contrast to county and community-based providers, who would not directly
see the reimbursement for newly insured patients. In future studies, quantitative
research methods should be used to allow for more detailed examination of job
satisfaction.
For a select group of safety net providers, implementation of a near universal
health care coverage program for children resulted in perceptions of higher patient
16.4chamberlain.indd 628 10/7/05 2:37:01 PMChamberlain, Hughes, Bishop, Matsuda, and Sassoubre 629
volume, increased job satisfaction, and increased access for patients to specialty care.
The providers’ positive job satisfaction and overall impressions of the program are
worthy of note as other counties and states across the nation move toward universal
coverage for children. Such comprehensive coverage may benefit providers as
much as their patients. Further studies examining larger groups of providers are
warranted.
Acknowledgments
We would like to express our sincere appreciation to Leona Butler and the Santa
Clara Children’s Health Initiative for their continuous support; to the Santa Clara
pediatric health care providers who generously shared their thoughts, opinions and
time; to Hanna Chiou and Natalie Pagler for their invaluable assistance; and to Drs.
David Bergman, Paul Wise and Embry Howell for their critical reviews.
This study was supported by grants from the David and Lucile Packard Foundation
and the William Randolph Hearst Foundation awarded to Dr. Chamberlain.
Conflict of interest statements: Study authors do not have any financial agreement
with any organization mentioned in the article.
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Appendix.
Representative Responses from the Three Domains Studied
DOMAIN 1. Perceptions about the impact of the CHI and Healthy Kids
program on pediatric health care providers
Theme 1. Improved access to health care for patients
“Patients don’t have to worry whether their visits are covered. It is a lot less stress
on the families financially. They come in more for their follow-up visits, where they
couldn’t afford to come in before. So, it has made a big difference.”
“[Patients] don’t delay coming in for follow-up appointments. Where before, it
may have been a decision of whether they could afford it, whether their kid was really
sick enough. I don’t think that the same equation is being made, except for maybe
those who can’t afford the co-pay, which I think most people can.”
Theme 2. Increased patient volume
“I have personally seen an incredible increase in patient volume.”
“As a [medical] group, it [patient volume] has gone up enormously. We have
hired a lot more pediatricians, a lot more staff, a lot more clinic hours—tremendous
increase in the number of visits.”
Theme 3. Mixed impact on patient flow
“They [providers] have to do so many more physicals, which takes longer, longer
than what we normally give them for an appointment. So that has, especially initially,
and that happened all of a sudden, that has had a great impact on our patient flow.
There doesn’t seem to be any more of an issue now.”
“We’ve always had patient flow issues and they will always continue. Kind of
saturated now. The occasional new patient will come in, but not like when the
program first started.”
Theme 4. Minimal changes on patient profile
“We certainly are seeing a lot of school age children who were previously
uninsured.”
“Now, we’re seeing more of the kids from maybe age 6 to age 12 right into the
teens . . . In terms of ethnicity, it just hasn’t really changed the population that much
because we see immigrant populations with a lot of Hispanic patients anyway, and
it tends to be the same mix.”
Theme 5. Increased or already high level of job satisfaction
“I love it. It’s really great when you can see all the kids that you can. So when a
new patient needs this and that, you can send him to the dentist, to an eye doctor,
without having to wait months on a waiting list. That is really rewarding.”
“They were afraid of coming in and having to pay for the visit. Now, because of
this program, knowing that they are covered, they are taking more advantage of the
benefits . . . I see more continuity.”
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DOMAIN 2. Perceptions about children’s access to specialty care
Theme 1. Access to specialty care available
“Yes [access is available]. You know I think there are certain specialties that are
more difficult to get into. But, that doesn’t depend on the payer, but it just depends
on the wait to get into a particular specialty.”
“Yeah [access is available], they have to wait, but they eventually get there if they
follow-up with appointment. For all the specialties, the time that they wait has
increased.”
DOMAIN 3. Impressions of the CHI and Healthy Kids program
Theme 1. CHI and Healthy Kids program is a great county asset
“My perception is that it [CHI] is an incredibly insightful, proactive program, and
I am really honored to be a part of it . . . I can’t say enough good things about it.”
“It [CHI] has helped a lot of kids to have insurance, and when I started here, there
was maybe only one person in the family that happened to have insurance. It was
unusual to for the whole family to have access to health insurance. Now, we have
one child enrolled in a program, we can get the others enrolled in other programs.
The family is insured, as opposed to one kid.”
Theme 2. CHI programming and outreach works well
“The way that they have signed them up has worked well. We are able to put a CAA
right here. She had a desk right outside the window of our clinic for quite a while.
It was an immense asset to be able to . . . say you [parents and children] can just go
over to that desk and they’re going to help you get on this insurance plan. It made
it very smooth and not intimidating. Because we were saying everything will be ok.
You just have to fill out the papers, and no one will come after you. It just helped us
to get practically all of our kids signed up, and the process was smooth.”
“I think that it has, given the populations that need it, the confidence to reach
out for medical care that they didn’t have before. They were afraid of immigration
laws, and they’ve made a huge marketing push to reassure them that it is ok, and it’s
worked, its working. I think there are a lot of kids that come for care that weren’t
coming.”
Theme 3. Improved referral and formulary systems needed
“Our biggest problem is getting timely referrals . . . I don’t know, if that’s something
the program could actually do. Perhaps if they could contract with private specialists,
private consultants . . . that could speed up some of the referrals.”
“The formulary is different for each plan and I think that is really ridiculous,
because I can’t understand why the formulary has to be different for each plan.”
Theme 4. Concerns about the future of the Healthy Kids program
“It needs an injection of money from the State to be able to raise the quality of
services, the more people involved, more specialists in the network, to get better
medicines.”
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“I think it is a blessing, a wonderful asset for us in SC County. I’m afraid that they
[CHI] will run out of money and take it [Healthy Kids program] away and go right
back to where we were. Oh, there’s such a need. And the need is huge.”
Notes
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