Factors Associated with Increased

Specialty Care Access in an Urban Area:

The Roles of Local Workforce Capacity
and Practice Location
Joanna Bisgaier
Karin V. Rhodes
Daniel Polsky
University of Pennsylvania

Abstract This article explores how a specialty type’s local workforce capacity and
a specialty practice’s location relate to the likelihood of denying care to children cov-
ered by Medicaid and the Children’s Health Insurance Program (CHIP) while accepting
private insurance. Data on discriminatory denials of care to children with public
insurance came from an audit study involving 273 practices across seven medical
specialties serving children in Cook County, Illinois. These data were linked to phy-
sician workforce data and neighborhood poverty data to test for associations with
discriminatory denials of public insurance, after adjusting for control variables. In a
large metropolitan county, discriminatory denials of specialty care access for publicly
insured children were attenuated for specialty types with greater local workforce
capacity (odds ratio [OR]: 0.74, 95 percent; confidence interval [CI]: 0.57–0.98) and for
practices located in higher-poverty neighborhoods (OR: 0.95, 95 percent; CI: 0.93–
0.98). Although limited as a single-site study, our findings support the widespread
consensus that payment rates are the strongest driver of decisions to serve patients
enrolled in public insurance programs. At a time when state and federal budgets are
under strain, ensuring access equity for children covered by Medicaid and CHIP may
require policies focused on economic levers tailored based on practice location.

We had full access to all the data in the study and take responsibility for the integrity of the data
and the accuracy of the data analysis. We thank the attorneys from Heath and Disability Advo-
cates, the Sargent Shriver National Center on Poverty Law, and Goldberg Kohn (particularly
Frederick Cohen) for generating the impetus for this study; the staff of the Illinois Department of
Healthcare and Family Services for their collaboration; Martha Van Haitsma, David Chearo, and
Theresa Anasti from the University of Chicago Survey Laboratory; and Jeffrey Draine and
members of our expert review panel for their input, as well as methodological advice.
Journal of Health Politics, Policy and Law, Vol. 39, No. 6, December 2014
DOI 10.1215/03616878-2829214  2014 by Duke University Press
1174 Journal of Health Politics, Policy and Law

Introduction
The Medical Assistance Program (Medicaid) and the Children’s Health
Insurance Program (CHIP) are designed to extend access to high-quality
medical care to all American children (Sebelius 2010a, 2010b). Children
may require care from specialty physicians for both acute and chronic
health problems when their condition requires highly technical equip-
ment or expertise (Forrest et al. 1999; Forrest 2009; Iglehart 2008). Recent
studies have drawn attention to disparities in access to specialty care that
result when specialty physicians choose not to accept patients covered by
Medicaid and CHIP (Bisgaier and Rhodes 2011; Chaudhry et al. 2013;
Sabatini et al. 2012; Pierce et al. 2012; Iobst et al. 2010). These disparities
occur even in urban areas with a higher per capita concentration of medical
specialists (Bisgaier and Rhodes 2011; Chaudhry et al. 2013). Unraveling
the factors driving specialty practices’ decisions to accept public versus
private insurance is a vital first step in constructing effective policies that
improve low-income children’s access to specialty care.
Much of the scholarly research pertaining to determinants of physician
acceptance of public versus private insurance posits that providers who
have less demand for their services in the private insurance market will be
more likely to accept less lucrative patients with Medicaid and CHIP
coverage (Sloan, Mitchell, and Cromwell 1978). Consequently, providers
with characteristics that are perceived as less appealing, such as attending a
medical school outside the United States or having fewer years of expe-
rience, will be more likely to schedule appointments for publicly insured
children. Another application of this model predicts that urban areas
with a higher physician-to-population ratio (i.e., workforce capacity) will
have higher rates of participation in Medicaid and CHIP. If patterns of
specialists’ acceptance of public versus private insurance uphold these
expectations, then policies that will decrease the likelihood of discrimi-
nation against public insurance include raising Medicaid and CHIP reim-
bursement levels, minimizing the administrative burden of processing
Medicaid and CHIP claims, and increasing the workforce capacity of
specialists (ibid.).
However, with regard to medical workforce capacity, evidence con-
tradicts what scholars and policy makers conventionally predict. Studies
using physician surveys have found that rates of self-reported provider
participation in Medicaid are actually lowest among providers located in
urban geographic areas with higher physician-to-population ratios (Adams
2001; Cunningham and Nichols 2005; Perloff, Kletke, and Fossett 1995).
 Bisgaier, Rhodes, and Polsky - Increased Specialty Care Access 1175

This finding may be due to the economic and racial residential segregation
common to many US urban areas, where medical practices tend to be
located in upper-income areas that are difficult for Medicaid enrollees to
reach (Fossett and Peterson 1989). Studies of income characteristics of
medical practice communities typically use data at the zip code level and
find that as income level decreases, provider participation in Medicaid
increases (Cunningham and Nichols 2005; Perloff et al. 1997). However,
one study of specialty office–based physicians found that increased per
capita income of the clinic’s zip code slightly increased the likelihood that
the providers self-reported accepting all new Medicaid-enrolled patients
(Perloff, Kletke, and Fossett 1995).
The goal of this study was to explore how the local workforce capacity of
different specialty types within a single urban county and the poverty level
of the neighborhoods in which the specialty practices are located relate
to the likelihood of denying care to a child with Medicaid-CHIP coverage
but accepting private insurance. This study goes beyond previous studies
by leveraging data from an audit study with unique methodological rigor
that captures ‘‘real life’’ behavior (Bisgaier and Rhodes 2011). To measure
physician participation, trained and supervised research assistants posed as
parents attempting to schedule appointments for children referred by their
primary care physicians. The same research assistant called each practice
twice, varying only insurance status. Unlike much of the prior work in
this area that used physician self-reported acceptance of insurance, audit
study outcomes are designed to overcome selection, recall, and response
biases. Sofia B. Chaudhry et al. (2013) used audit study methods to measure
children’s access to dermatology appointments in thirteen metropolitan
areas and found that increased physician workforce did not correlate with
increased Medicaid acceptance. However, that study did not account for
the potential role of neighborhood economic segregation within urban
areas. This study is the first to link audit study outcomes to both physician
workforce data and neighborhood poverty data to explore trends in how
discrimination takes place across multiple specialty types in the market.

Methods
Data on discriminatory denials of care to children with public insurance
came from an audit study involving 273 specialty practices serving chil-
dren in Cook County, Illinois. From January through May 2010, each
practice was called twice by the same research assistant posing as a
mother attempting to schedule an outpatient appointment for a problem
1176 Journal of Health Politics, Policy and Law

of moderate severity for a child referred for one of seven pediatric health
condition scenarios across eight specialty types: allergy-immunology/
pulmonary, dermatology, endocrinology, neurology, orthopedics, otolaryn-
gology, and psychiatry. At the time of data collection, an office consulta-
tion visit for a problem of moderate severity (Healthcare Common Pro-
cedure Coding System code 99243) was reimbursed at $99.86 by the joint
Medicaid-CHIP program in Illinois, whereas the average reimbursement
for the same code by a commercial preferred-provider organization was
approximately $160.00. The only difference between the two calls to the
same practice was the reported insurance status of the child (Medicaid-
CHIP vs. Blue Cross Blue Shield), which allowed for an isolated mea-
surement of the effect on insurance status on specialty practices’ acceptance
of new patients. Details of the audit study’s methodology, its outcomes,
and the impact of physician affiliation with academic medical centers have
been previously reported (Bisgaier and Rhodes 2011; Bisgaier, Polsky, and
Rhodes 2012).
To determine whether the variation in discriminatory denials by spe-
cialty was related to the availability of physicians to adequately meet
demand for services, we first created a measure of local workforce capacity
by specialty for Cook County. This measure was defined as the specialty-
specific physician-to-population ratio in Cook County as the numera-
tor (i.e., local supply) as a fraction of the nation’s average physician-to-
population ratio (i.e., typical demand). A higher workforce capacity rate
indicates a local oversupply of physicians relative to typical demand for the
specialty. A lower workforce capacity rate indicates a local undersupply of
physicians relative to the typical demand for the specialty. This measure
was estimated from the specialty-specific counts by county of active (i.e.,
full-time), nonfederal office-based physicians (with doctorate degrees in
either medicine or osteopathy) delivering patient care and excluded resi-
dent physicians and fellows. These counts are derived from the American
Medical Association (AMA) Masterfile and reported in the Area Resource
File (ARF) (US Bureau of Health Professions 2007). The workforce capacity
rates for each specialty type in the audit study appear in table 1.
Notably, our measurement of endocrinologist supply was limited due
to the AMA Masterfile, which categorizes endocrinology as an internal
medicine subspecialty, and because the American Board of Internal Medicine
certifies the subspecialty of ‘‘endocrinology, diabetes, and metabolism’’
(ABMS 2001; Smart 2010). Therefore, we used supply of internal medi-
cine physicians as an approximation of endocrinologist supply.
A specialty practice neighborhood poverty level was defined as the
percentage of families with children (under age eighteen years) living
 Bisgaier, Rhodes, and Polsky - Increased Specialty Care Access 1177

Table 1 Specialty Types’ Normalized Workforce Capacity Rates

in Cook County, Illinois
Cook County Nation’s Average Workforce
Physician-to- Physician-to- Capacity
Specialty Type Population Ratio Population Ratio Rate
Allergy-immunology 5.60 4.15 1.35
and pulmonary
disease
Dermatology 4.48 3.36 1.34
Internal medicine 18.12 11.67 1.55
subspecialties
(endocrinology)
Neurology 6.34 4.22 1.50
Orthopedics 8.68 7.61 1.14
Otolaryngology 3.61 3.12 1.16
Psychiatry 18.37 14.08 1.30
Source: 2007 Area Resources File (ARF) (US Bureau of Health Professions 2007)
Notes: The number of endocrinologists is approximated by 2007 ARF estimates of the number
of internal medicine subspecialists.

below the federal poverty level in the neighborhood. We considered a

‘‘neighborhood’’ to be the one-mile circular radius around each specialty
practice generated using ESRI’s ArcGIS 10.0. For all zip codes captured
within this one-mile radius, we calculated the mean percentage of families
in poverty per zip code using data from the 2000 Decennial Census,
Summary File 3 (QT-P35) (US Census Bureau 2000). On average, prac-
tices in our sample were located in neighborhoods with approximately 10.4
percent (range: 1.1–41.6 percent) of families living in poverty. The average
percentages of families living in poverty in neighborhoods of the practices
in our sample are outlined by specialty type in table 2.
We used logistic regression to investigate the association between dis-
criminatory denials of Medicaid-CHIP and each specialty type’s local
workforce capacity and neighborhood poverty level after adjusting for
a set of relevant control variables. We entered into the regression a nor-
malized version of the workforce capacity rate to make our results more
interpretable. Control variables relevant to provider acceptance of public
insurance that could be measured in the current study were the practice
size (i.e., number of physicians within the practice), practice affiliation
with an academic medical center, and the international medical graduate
status and average years of experience of physicians within the practice.
1178 Journal of Health Politics, Policy and Law

Table 2 Average Practice Neighborhood Poverty Level

by Specialty Type
Average % of Families Living in
Specialty Type Poverty in Practice Neighborhoods
Allergy-immunology and pulmonary disease 9.0
Dermatology 10.1
Endocrinology 16.1
Neurology 10.6
Orthopedics 11.4
Otolaryngology 8.6
Psychiatry 9.4
Source: 2000 Decennial Census, Summary File 3 (QT-P35) (US Census Bureau 2000)

Details describing the measurement and distribution of these variables

among the 273 practices studied have been previously reported (Bisgaier,
Polsky, and Rhodes 2012). No data were missing on any variables. All tests
were two sided, and p-values of less than 0.05 were considered statisti-
cally significant.

Results
Specialty types with a greater local workforce capacity and specialty
practices with higher neighborhood poverty levels were less likely to have
discriminatory denials of Medicaid-CHIP after adjusting for academic
affiliation, practice size, international medical graduate status, and years
of experience (table 3).
A 1–standard deviation increase in a specialty type’s workforce capacity
was associated with a 26 percent decrease in the odds of denying an
appointment to a child with Medicaid-CHIP (odds ratio [OR]: 0.74, 95
percent; confidence interval [CI]: 0.57–0.98). A one-unit increase in a
specialty practice neighborhood’s poverty level was associated with a 5
percent decrease in the odds of denying an appointment to a child with
Medicaid-CHIP (OR: 0.95, 95 percent; CI: 0.93–0.98).

Discussion

Overall, we found evidence that discriminatory denials of specialty med-

ical care access for children with public insurance were attenuated for
specialty types with a greater workforce capacity and for practices located
 Bisgaier, Rhodes, and Polsky - Increased Specialty Care Access 1179

Table 3 Specialty Type Local Workforce Capacity, Practice

Neighborhood Poverty Level, and the Adjusted Odds of Denying
a Child with Medicaid-CHIP While Accepting a Child
with Private Insurance (n = 273)
Variables OR 95% CI p
Workforce capacity of specialty type 0.74 0.57–0.98 0.032
Poverty level in practice neighborhood 0.95 0.93–0.98 0.000
Practice is affiliated with academic medical center 0.54 0.31–0.93 0.028
Practice size (number of specialists) 0.94 0.80–1.10 0.456
Average years of experience of specialists in practice 1.00 0.98–1.02 0.972
Practice employs any foreign medical graduates 0.61 0.34–1.09 0.094
Notes: OR = odds ratio; CI = confidence interval. Adjusted R2 for the model was 0.09.

in neighborhoods where a higher density of publicly insured children

reside. Our findings imply that economic principles of supply and demand
may drive trends of local interspecialty variation in nonacceptance of
public versus private insurance. This finding supports the widespread
consensus that payment rates are the strongest driver of decisions to serve
patients enrolled in public insurance programs (Berman et al. 2002;
Coburn, Long, and Marquis 1999; Cunningham and Nichols 2005; Decker
2007; Showalter 1997). As such, policies aimed at improving access to
care without improving reimbursement, such as managed care, should be
monitored to ensure that access indeed improves. At a time when state and
federal budgets are under strain, our findings also indicate that focusing
investments in reimbursement rates globally for all specialists may not be
as beneficial as providing targeted incentives to specialists located in low-
resource neighborhoods.
The hypothesis that specialty types with greater workforce capacity
have more equitable insurance acceptance behavior was based on the
theory that providers who have less demand for their services are more
likely to accept ‘‘less lucrative’’ patients covered by Medicaid-CHIP
(Sloan, Mitchell, and Cromwell 1978). However, previous studies using
physician surveys have found that providers located in urban geographic
areas with higher workforce capacities have the lowest rates of self-reported
Medicaid acceptance (Adams 2001; Cunningham and Nichols 2005;
Perloff, Kletke, and Fossett 1995). In addition, one audit study that did not
measure the effects of practice location found that an increased derma-
tologist workforce did not correlate with increased appointment accep-
tance of children with Medicaid (Chaudhry et al. 2013). Our study diverges
1180 Journal of Health Politics, Policy and Law

from prior work by finding that the role of workforce capacity in physi-
cian’s insurance acceptance is more consistent with what theories of sup-
ply and demand would predict. As the first to observe physicians’ ‘‘real
life’’ behavior and control for practice neighborhood poverty level, this
study shows that more work is needed to resolve this debate.
Our findings must be considered in light of several limitations. First, our
workforce capacity rate was an approximation of the extent to which supply
of physician services by specialty exceeds the demand for those services.
Idiosyncratic preferences for physician services between specialties in
Cook County that differ from the national average may exist that are
not fully reflected in our measure. As a single-site study in a state imple-
menting a primary care case management program for most Medicaid
and CHIP enrollees, this study could not examine the impact of different
state policies and Medicaid managed care systems. In addition, the scope
of this investigation did not allow us to identify the causal influence of all
potential underlying variables associated with discriminatory denials of
care to children with Medicaid-CHIP, such as physicians’ race/ethnicity,
their attitudes and beliefs, and the status of practices as self-employed.
A multisite audit study that can compare overall workforce capacity by
region (rather than be limited to comparing workforce capacity of specialty
types within the same region) is a logical next step for research in this area.
Variables of interest to measure in such a study would be the size of the
demand catchment area, the supply of specialists in the area relative to the
surrounding area, and the proportion of children in a region who are
enrolled in public insurance. A multisite study could better investigate
policy levers by comparing each site’s Medicaid and CHIP reimbursement
rates relative to private insurances, Medicaid managed care systems,
density of certain types of practice settings, and other specific character-
istics of different states’ implementation of their Medicaid programs.
In summary, our findings indicate that variation in workforce capacity
and practice location may be driving trends of local interspecialty variation
in nonacceptance of public versus private insurance. In a large metropolitan
county, we found that specialty types with greater local workforce capacity
and practices located in neighborhoods where a higher density of publicly
insured children reside were more likely to provide equitable access across
insurance types to children in need of specialty care. Changing the behavior
of specialty practices so that they grant access to more children covered by
Medicaid and CHIP may require a focus on economic levers that are tai-
lored based on practice location.
 Bisgaier, Rhodes, and Polsky - Increased Specialty Care Access 1181

n n n

Joanna Bisgaier recently received a PhD in social welfare and an MSW from the
University of Pennsylvania. Her research areas include access to health care and
evaluation of human service programs. She is the coauthor of a number of articles
published in academic journals, including the New England Journal of Medicine and
Pediatrics.

Karin V. Rhodes is the director of the Center for Emergency Care Policy Research in
the Department of Emergency Medicine at the University of Pennsylvania. A former
Robert Wood Johnson Foundation Clinical Scholar, she completed a residency in
emergency medicine along with an MS in health studies at the University of Chicago.
Her research focuses on the use of the health care visit and patient-centered health
information technology for screening, intervention, and treatment for major psy-
chosocial risks. Her interest in assuring the linkage of emergency patients to appro-
priate outpatient care resources has resulted in several high-profile simulated patient
studies assessing the impact of insurance status on access to care. Recent publica-
tions include ‘‘ ‘Patients Who Can’t Get an Appointment Go to the ER’: Strategies
for Getting Publicly Insured Children into Specialty Care’’ (2013) and ‘‘Primary Care
Access for New Patients on the Eve of Health Care Reform’’ (2014).

Daniel Polsky is the executive director of the Leonard Davis Institute of Health
Economics, a professor of medicine in the Perelman School of Medicine, and the
Robert D. Eilers Professor of Health Care Management in the Wharton School at the
University of Pennsylvania. He currently serves on the Congressional Budget Office’s
Panel of Health Advisers, and he was the senior economist on health issues at the
President’s Council of Economic Advisers in 2007–8. He received a PhD in economics
from the University of Pennsylvania in 1996 and an MPP from the University of
Michigan in 1989. His research areas include access to the health care workforce and
economic evaluation of medical and behavioral health interventions. He is a coauthor
of the book Economic Evaluation in Clinical Trials (2007).

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