Significantly fewer publicly-insured than privately-insured children report a medical home, using a broadly adopted composite measure of medical home in this recent, nationally representative sample. Our examination of the individual components of the medical home measure illustrates that this insurance-based disparity has less to do with basic access to primary care (usual source of care or personal doctor/nurse) than with disparities in perceptions of physician-family interactions (family-centered care).
Other studies have demonstrated medical home disparities associated with a variety of sociodemographic factors, including uninsured versus insured children.7, 10–13
In contrast, this study is the first to find an association between a composite measure of the medical home and type of insurance (public versus private) in a broad cross-section of children. These findings provide a national benchmark for state programs promoting the medical home for publicly- and privately-insured children and illustrate both successes and challenges regarding the goal of high-quality primary care for children with public insurance.
The medical home disparity identified in this study can be described as a disparity in realized access, as described by Andersen and Aday.23, 24
Most medical home research involving children with public insurance has focused instead on potential access, typically measured as a usual source of care.23–26
By that measure, nearly all children with public and private insurance in this study would have a medical home. In contrast, disparities by insurance type in this study are apparent in markers of realized access, including a process of care (getting needed referrals) and the experience of care (family-centered care).
This study is the first to show that insurance type has an independent association with perceptions of FCC in a population of primarily healthy children. Public versus private insurance has been shown to be associated with less family-centered care in one study of children with special health care needs,32
but another study found no association.33
The public-private disparity in FCC found here has several potential explanations. Cross-cultural communication likely plays a key role, including communication across racial/ethnic, socioeconomic, and language differences. Parents from racial/ethnic minorities and other disadvantaged groups report less family-centered communication with their child’s provider,33–35
and these groups are over-represented in the publicly-insured population. Also, physicians have expressed negative opinions about publicly-insured patients in some studies;17, 36, 37
these opinions may affect the quality of interpersonal interactions. Additionally, many publicly-insured patients receive care in primary care practices where resource limitations and patient volumes may limit family-centered care.18, 38
Interestingly, the public-private disparity in FCC was not attributable to any specific question but rather a trend toward lower reports by publicly-insured children for all included questions except getting help with an interpreter.
The public-private disparity in obtaining needed referrals is also concerning. However, because relatively few children needed referrals, this gap contributed little to the overall medical home disparity. Studies of specialty care utilization and access have shown inconsistent trends for publicly versus privately-insured children.39–42
The 2007 NSCH only asks if “getting referrals” was a problem; it does not include follow up questions to explore causes of problems. Thus, these findings cannot differentiate whether difficulties were related to parents not communicating concerns, primary care providers not responding to requests for referrals, specialty providers not being available, or other factors. Further work is needed to identify points of intervention to decrease problems for publicly-insured children in getting referrals.
The measure of the medical home used in this study reveals the challenges in measuring this complex concept on a population scale and proposing interventions to reduce disparities. On one hand, the full composite measure allows estimation of a single prevalence for large groups of children and can be used to make comparisons based on many different sociodemographic characteristics. On the other, the composite collapses different aspects of care into an all-or-none measure that has the potential to obscure important meaning. For example, if the public-private difference in the overall medical home composite is viewed in isolation, it could lead to the reasonable, but flawed, assumption that the disparity is indicative of differences in access to a usual source of care, given the restricted number of primary care providers that have accepted Medicaid.16–18, 21
Interventions to address a disparity in usual source of care might include adjusting primary care provider rates or providing other incentives for primary care providers to accept publicly-insured patients. However, examination of the components of the medical home in this study would contradict this assumption and show that this medical home disparity more directly reflects a difference in the report of family-centered care, likely indicating the relationship between parents and providers after a usual source of care is established. Promoting family-centered care will require interventions to enhance parent-provider interactions, such as practice resources to improve timely communication during and after office hours, provider incentives for results on patient satisfaction surveys, or continuing medical education on communication skills.
This study has several limitations. First, as in all survey research, there is the possibility of selection bias influencing estimates of a medical home. It is difficult to hypothesize the direction of this bias because the medical home questions were part of a much larger survey instrument. Second, the cross-sectional nature of the study shows associations between insurance type and the prevalence of a medical home for children and cannot determine causation. Additionally, the medical home questions reflect parent recall of the prior 12 months while the insurance type only reflects coverage at the time of survey. We attempted to adjust for this by including a variable for gaps in insurance coverage, but these data cannot indicate if the child had coverage with a different insurance type at any point during the prior 12 months. Third, the medical home composite was used as an all-or-none measure. While this is the structure most commonly used and advocated by the authors of the National Survey of Children’s Health,7, 10, 11, 27, 28, 30
other constructs of the measure have been implemented.27, 43
With the absence of strong validation of any specific medical home measure, we chose the form most commonly used in the literature. Fourth, we were unable to associate the medical home composite or its components with patterns of health care utilization or patient health outcomes. The 2007 NSCH did not include questions regarding emergency department use or hospitalization. Lastly, all data are by parent self-report. Differences in parent report may be due to complex interactions between parent expectations and specific provider behaviors, particularly for family-centered care. This study cannot determine the relative contribution of these factors to the disparities identified.