Trends in Pediatric Malpractice Claims 1987-2015: Results From the Periodic Survey of Fellows.

BACKGROUND: Pediatricians are less frequently sued than other physicians. When suits are successful, however, the average payout is higher. Little is known about changes in the risk of litigation over time. We sought to characterize malpractice lawsuit trends for pediatricians over time. METHODS: The Periodic Survey is a national random sample survey of American Academy of Pediatrics members. Seven surveys between 1987 and 2015 asked questions regarding malpractice (n = 5731). Bivariate and multivariable analyses examined trends and factors associated with risk and outcome of malpractice claims and lawsuits. Descriptive analyses examined potential change in indemnity amount over time. RESULTS: In 2015, 21% of pediatricians reported ever having been the subject of any claim or lawsuit, down from a peak of 33% in 1990. Report of successful outcomes in the most-recent suit trended upward between 1987 and 2015, greatest in 2015 at 58%. Median indemnity was unchanged, averaging $128 000 in 2018 dollars. In multivariate analysis, male sex, hospital-based subspecialty (neonatology, pediatric critical care, pediatric emergency medicine, and hospital medicine), longer career, and more work hours were associated with a greater risk of malpractice claim. CONCLUSIONS: From 1987 to 2015, the proportion of pediatricians sued has decreased and median indemnity has remained unchanged. Male pediatricians and hospital-based subspecialists were more likely to have been sued. Greater knowledge of the epidemiology of malpractice claims against pediatricians is valuable because it can impact practice arrangements, advise risk-management decisions, influence quality and safety projects, and provide data to guide advocacy for appropriate tort reform and future research.

Increased Medicaid Payment and Participation by Office-Based Primary Care Pediatricians.

BACKGROUND AND OBJECTIVES: Whether the Medicaid primary care payment increase of 2013 to 2014 changed physician participation remains unanswered amid conflicting evidence. In this study, we assess national and state-level changes in Medicaid participation by office-based primary care pediatricians before and after the payment increase. METHODS: Using bivariate statistical analysis, we compared survey data collected from 2011 to 2012 and 2015 to 2016 by the American Academy of Pediatrics from state-stratified random samples of pediatrician members. RESULTS: By 4 of 5 indicators, Medicaid participation increased nationally from 2011 and 2012 to 2015 and 2016 (n = 10 395). Those accepting at least some new patients insured by Medicaid increased 3.0 percentage points (ppts) to 77.4%. Those accepting all new patients insured by Medicaid increased 5.9 ppts to 43.3%, and those accepting these patients at least as often as new privately insured patients increased 5.7 ppts to 55.6%. The average percent of patients insured by Medicaid per provider panel increased 6.0 ppts to 31.3%. Nonparticipants dropped 2.1 ppts to 14.6%. Of the 27 studied states, 16 gained in participation by 1 or more indicators, 11 gained by 2 or more, and 3 gained by all 5. CONCLUSIONS: Office-based primary care pediatricians increased their Medicaid participation after the payment increase, in large part by expanding their Medicaid panel percentage. Continued monitoring of physician participation in Medicaid at the national and state levels is vital for guiding policy to optimize timely access to appropriate health care for >37 million children insured by Medicaid.

Children in the United States with discontinuous health insurance coverage.

BACKGROUND: Estimates of the number of uninsured people in the United States usually exclude those with discontinuous coverage. The effects of gaps in insurance coverage for children on access to and use of ambulatory care are poorly understood. METHODS: We analyzed a sample of 26,955 children under 18 years of age from the 2000 and 2001 National Health Interview Surveys. Children with discontinuous health insurance coverage were compared with those who were uninsured all year and with those who had public or private full-year coverage. RESULTS: During the last 12 months before they were interviewed, 6.6 percent of children in the United States had no insurance and an additional 7.7 percent had gaps in insurance. Children who had full-year insurance coverage (private or public) had low rates of unmet health care needs and good access to care (delayed care, unmet medical care, and unfilled prescriptions were reported in <3 percent, and <5 percent had no usual place of care). Access to care was much worse for children who were uninsured for part of the year and for those who were uninsured for the full year (delayed care, 20.2 percent and 15.9 percent, respectively; unmet medical care, 13.4 percent and 12.6 percent, respectively; unfilled prescriptions, 9.9 percent and 10.0 percent, respectively; P<0.01 for all comparisons with children with full-year, private insurance coverage). In multivariate analyses adjusting for age, income, race or ethnic group, region, citizenship, family structure, parental employment, and health status, the differences in access to care persisted. As compared with the parents of children with full-year, private insurance, parents of children uninsured for the full year were far more likely to report delaying care (adjusted odds ratio, 12.65; 95 percent confidence interval, 9.45 to 16.94), as were parents of children uninsured for part of the year (adjusted odds ratio, 13.65; 95 percent confidence interval, 10.41 to 17.90). CONCLUSIONS: Children with gaps in health insurance coverage commonly do not seek medical care, including preventive visits, and do not get prescriptions filled. These findings are important for both research and policy and point to the need for more encompassing and sensitive measures of the situation of being uninsured.

Response rates and response bias for 50 surveys of pediatricians.

RESEARCH OBJECTIVE: To track response rates across time for surveys of pediatricians, to explore whether response bias is present for these surveys, and to examine whether response bias increases with lower response rates. DATA SOURCE/STUDY SETTING: A total of 63,473 cases were gathered from 50 different surveys of pediatricians conducted by the American Academy of Pediatrics (AAP) since 1994. Thirty-one surveys targeted active U.S. members of the AAP, six targeted pediatric residents, and the remaining 13 targeted AAP-member and nonmember pediatric subspecialists. Information for the full target samples, including nonrespondents, was collected using administrative databases of the AAP and the American Board of Pediatrics. STUDY DESIGN: To assess bias for each survey, age, gender, location, and AAP membership type were compared for respondents and the full target sample. Correlational analyses were conducted to examine whether surveys with lower response rates had increasing levels of response bias. PRINCIPAL FINDINGS: Response rates to the 50 surveys examined declined significantly across survey years (1994-2002). Response rates ranged from 52 to 81 percent with an average of 68 percent. Comparisons between respondents and the full target samples showed the respondent group to be younger, to have more females, and to have less specialty-fellow members. Response bias was not apparent for pediatricians' geographical location. The average response bias, however, was fairly small for all factors: age (0.45 years younger), gender (1.4 percentage points more females), and membership type (1.1 percentage points fewer specialty-fellow members). Gender response bias was found to be inversely associated with survey response rates (r=-0.38). Even for the surveys with the lowest response rates, amount of response bias never exceeded 5 percentage points for gender, 3 years for age, or 3 percent for membership type. CONCLUSIONS: While response biases favoring women, young physicians, and nonspecialty-fellow members were found across the 52-81 percent response rates examined in this study, the amount of bias was minimal for these factors that could be tested. At least for surveys of pediatricians, more attention should be devoted by investigators to assessments of response bias rather than relying on response rates as a proxy of response bias.

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.

Uninsured children: how we count matters.

BACKGROUND: Because children uninsured for less than a full year are often reported as insured, they receive less attention in health policy debates than do the full-year uninsured and are underrecognized as potential users of public insurance programs. OBJECTIVE: The purpose of this study is to assess the impact on estimates of how many US children are uninsured when alternatives to the full-year uninsured definition are used. METHODS: Monthly health insurance coverage data collected from children through age 18 in the 1999 Medical Expenditure Panel Survey were analyzed to estimate prevalence of health insurance gaps among children in terms of the size of part-year and full-year uninsured child population, duration of uninsured gaps, and aggregate uninsured spells. RESULTS: Although 6.6 million ([M] 8.4%) children in the United States were uninsured throughout 1999, an additional 11.4M (14.4%) were uninsured for part of the year. Part-year uninsured gaps accounted for 41.7% of a total of 130M months of missing coverage experienced by all children. CONCLUSIONS: Different definitions and measures of who are uninsured can project radically different pictures of the magnitude of the problem. As this study shows, including the part-year uninsured more than doubled the estimated uninsured child population for 1999, and increased the estimated aggregate uninsured months by 71%. As potential users of public coverage, children who have no insurance for part of the year should be included when evaluating challenges to and accomplishments by the State Children's Health Insurance Program and other public programs. Their significant numbers and the potential burden they place on the health care delivery system argue for them to be counted and for the causes and consequences of short-term uninsured spells to be better understood.