Children on public insurance are being denied treatment by doctors at much higher rates than those with private coverage, according to an undercover study that had researchers pose as parents of sick kids seeking an appointment with a specialist.

Snubbed even by specialists whose offices supposedly accept public insurance patients, these kids also had to wait much longer to see a doctor. Low Medicaid reimbursements are the likely reason, the study authors said.

The study was done in Cook County, Ill., the nation's second-most populous county which includes Chicago, but the researchers and others say the results likely reflect practices around the country.

"People should be very concerned," said Dr. Karin Rhodes, the lead author and an emergency medicine specialist at the University of Pennsylvania.

The study results suggest many of the 40 million publicly insured U.S. children are not getting recommended timely treatment for dangerous conditions including asthma, diabetes and depression, she said.

"I work in an emergency room ... where you see the long-term consequences of people who did not get the care they needed," Rhodes said.

The study appears in Thursday's New England Journal of Medicine.

The study is "simple and elegant" and bolsters previous research while presenting a more accurate real-world picture of disparities facing public aid patients, said Dr. Steve Wegner, former head of the American Academy of Pediatrics' child health financing committee.

To test whether type of insurance influences doctors' willingness to schedule appointments, the researchers posed as parents of fictitious sick children referred to specialists by primary-care doctors or emergency room physicians. Seven scenarios were created, including a 9-month-old with a severe skin rash, a 7-year-old with diabetes, a 12-year-old with a suspected broken arm and a 13-year-old with symptoms of severe depression.

The researchers phoned 273 specialty clinics twice, a month apart, seeking an appointment with doctors including dermatologists, allergists, psychiatrists and bone specialists. In one call, the children were said to have private insurance; in the other, they were insured through Illinois' Medicaid program.

Overall, specialists refused to grant appointments for 66 percent of the Medicaid children, versus only 11 percent of privately insured youngsters.

Among 89 clinics that accepted both insurance types, Medicaid children had to wait an average of 42 days for an appointment, versus 20 days for private coverage.

In about half the calls, clinics asked about insurance before telling callers whether an appointment was available. In other cases, callers volunteered their insurance information — and were often told that Medicaid was the reason the appointment request was denied, the researchers said.
Orthopedic (bone) doctors were among specialists most likely to deny appointments for public kids; psychiatrists were among the least likely. Rhodes said an analysis of the reasons offices gave has not been completed.

In about 20 percent of the denials, callers were told they could seek treatment at the county public hospital or at an emergency room.

Rhodes said information is not available on how many of the doctors involved accept Medicaid patients, but that most specialists are affiliated with hospitals, which generally require them to enroll in Medicaid.

All appointments made were canceled at the end of the call. Many specialists told about the study afterward said they wanted to see any kids "who need to see me" but that they worked within health systems or hospitals that for financial reasons discouraged them from treating too many patients on public aid, Rhodes said.

In Illinois, Medicaid pays doctors about $100 for office visits like those sought in the study, versus an average of $160 from private insurers, the researchers said.

Other factors against Medicaid patients include "delays in payment and hassles of payment procedures," the researchers said.

Wegner, a Medicaid consultant and chairman of Community Care of North Carolina, a managed care group that includes most primary care doctors in his state, said accountable care organizations to be set up starting next year would help address the disparities. The groups were part of President Barack Obama's health care law.

These networks of hospitals, doctors and other health care providers would include organizations focused on the pediatric Medicaid population, he said. The idea is for providers to work together to streamline care, prevent medical errors, and focus on keeping patients healthier and out of the emergency room.

In a study published last month in Pediatrics, the same researchers used similar undercover methods to examine access to emergency dental care for children on Medicaid in Cook County — and found similar disparities.

The Illinois Department of Healthcare and Family Services paid for both studies as part of a 2005 consent decree stemming from a class-action lawsuit alleging Medicaid children in Cook County weren't getting equal access to primary care.

Department spokesman Mike Claffey said both studies "provide data that highlights an issue that has been and continues to be an area of focus" for his agency and Medicaid programs in all states.