‘Striking’ Disparities in Specialty Care for Kids With Asthma on Public Insurance

Children with asthma were substantially less likely to see an outpatient specialist if they had Medicaid rather than private health insurance, a cross-sectional study revealed.

In an analysis of child-year observations in the Massachusetts All Payer Claims Database from 2014 to 2020, specialty care use was reported in 11.9% of the publicly insured observations, as compared with 20.6% of the privately insured observations (P<0.001), reported researchers led by Kimberley Geissler, PhD, of the University of Massachusetts Chan Medical School-Baystate in Springfield.

“We found striking disparities in the receipt of specialist care based on insurance type… despite children with Medicaid having higher rates of persistent asthma,” the researchers wrote in JAMA Network Open. “Contrary to expectations, disparities in specialist care by insurance type were even more striking in children with persistent asthma.”

Adjusted regression-based estimates confirmed the disparities in the study and showed that those with Medicaid had a 55% lower likelihood of specialist care (adjusted OR 0.45, 95% CI 0.43-0.47), with a regression-adjusted 9.7-percentage point (95% CI -10.4 to -9.1) lower rate versus the privately insured.

Moreover, for children with persistent asthma, there was a 3.2-percentage point (95% CI 2.0-4.4) deficit for patients enrolled to MassHealth, which includes Medicaid and the Children’s Health Insurance Program.

“Although most children with asthma are successfully treated by primary care clinicians, guidelines recommend an asthma specialist referral when there is poor control despite evidence-based management,” Geissler and colleagues wrote in their introduction.

Furthermore, they noted, Medicaid disproportionately insures kids from minority racial and ethnic groups — children already at higher risk for asthma and asthma exacerbations.

“Differences in asthma specialist care use could contribute to this disparity; however, little is known about use of specialists by children, particularly with respect to comparisons by insurance type or changes over time,” the researchers wrote.

The analysis from Geissler’s team included a total of 198,101 unique children in the Massachusetts All Payer Claims Database, amounting to 432,455 child-year observations from 2014 to 2020, 66.2% of which were covered by MassHealth (Medicaid group) and 33.8% of which were covered by private insurance.

A majority of the patient population were boys (57%), and nearly half were between the ages 5 and 11. Overall, 14.9% received specialist care and 19% had persistent asthma (20% in the Medicaid group vs 16.9% in the privately insured group). Patients with Medicaid tended to be younger, have more comorbidities, and were more likely to live in an area with higher Structural Racism Equity Index scores.

Of the 64,239 child-year observations involving specialist care, 68% were to allergy and immunology physicians, 34% to pulmonologists, and 2.5% to otolaryngologists. Visits to a specialist were more common for those with persistent asthma (32.2% vs 10.8% for those without persistent asthma).

Most of the differences in the main outcome of specialty care related to visits to allergy and immunology physicians (7.1% for Medicaid vs 15.9% for private insurance, P<0.001), but there were still statistically significant differences in visits to pulmonologists and otolaryngologists.

“Novel approaches to integrating of specialty care into primary care, such as electronic consultation, is an increasingly used innovation designed to deliver appropriate specialty care to children,” Geissler and co-authors wrote in their conclusion. “Other experiments such as primary care oriented interdisciplinary asthma clinics may improve quality of care and outcomes for children with all insurance types.”

“Ongoing attention to disparities in asthma care quality and outcomes by insurance type, and the contributions of specialist consultation, is warranted,” they added.

Limitations to the study included that the participants were only from Massachusetts, that researchers could not account for referrals to specialists, and missing information on asthma severity.

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