EVIDENCE THAT THE QUALITY OF SPECIALTY CARE DIFFERS BETWEEN MEDICAID AND COMMERCIALLY INSURED PATIENTS SA Shipman, CB Forrest, GB Glade, AE Baker. RWJ Clinical Scholars Program, Johns Hopkins University, Baltimore, MD; Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD; Department of Pediatrics, University of Utah, Salt Lake City, UT; and Pediatric Research in Office Settings (PROS), Center for Child Health Research, American Academy of Pediatrics, Elk Grove Village, IL. Presented as a platform presentation at the 2000 Pediatric Academic Societies? Annual Meeting.

BACKGROUND: Improving access to a "medical home" has garnered much attention for children insured by Medicaid. Less emphasis has been placed on evaluating their specialty care, and the process of referrals from primary care physicians to specialists.

OBJECTIVE: To compare patterns and outcomes of specialty referrals between Medicaid and commercially insured patients.

DESIGN/METHODS: We conducted a prospective study of 58,771 visits made to 142 pediatricians across 36 states. Data were collected for all visits and referrals (N = 1854) over 20 consecutive days. Physicians completed a questionnaire when making each referral, and used patients' records to complete a three-month follow-up questionnaire. Data were analyzed by comparing visits and referrals for Medicaid patients (15% of sample) with commercially insured patients (85%).

RESULTS: Patients with Medicaid were 71% more likely to be referred than those with commercial financing (p<.001). This trend was consistent across all ages and both genders. Compared with patients with commercial financing, those with Medicaid were more likely to be referred for management of chronic disease (29% v. 19%, p<.0001). Reasons for making the referral, specialties referred to, and expectations of the specialist were similar between the two groups. Referring pediatricians were 60% more likely to schedule the specialty appointment (p<.0001) and 32% more likely to communicate with the specialist (p<.0001) for Medicaid patients versus those with commercial financing. On the other hand, specialists were less likely to send feedback to referring physicians (p<.01), and referring physicians gave lower ratings to the specialists' letters they received (p<.01) for their referred Medicaid patients. A multivariate regression analysis using the generalized estimating equation to control for the nested study design and several patient and referral covariates showed that referring physicians rated their overall satisfaction with the specialty care their Medicaid patients received as lower than that received by their commercially insured patients (p<.05).

CONCLUSION: Higher referral rates among patients with Medicaid financing compared with commercially insured patients appear to be related to a higher morbidity burden. Referring physicians are less satisfied with the specialty care their Medicaid patients receive than counterparts with commercial insurance. This finding raises concerns about the quality of specialty care provided to patients with Medicaid insurance.