children and parents, an especially critical element of palliative and end-of-life care. Reimbursement for this time-consuming and challenging care is typically very limited and may be entirely unavailable, for example, if the child is not present during discussions with parents (Hilden et al., 2001b).
Most complaints about level of payment focus on Medicaid. In 1994, a government commission concluded that Medicaid fees were still less than 75 percent of Medicare fees and less than half of what private insurers paid (PPRC, 1994). In 2001, the federal government’s General Accounting Office reported to Congress that Medicaid fees in the states surveyed were only 29 to 61 percent of Medicare levels for the same services (U.S. GAO, 2001a). In 1997, Congress repealed Medicaid requirements that states reimburse pediatric services at rates sufficient to secure physician participation and access to care similar to that for the general population in the area (see the AAP analysis at http://www.aap.org/advocacy/schippro.htm#reim).
The variability and often low level of Medicaid payments is evident in AAP data on payments for services commonly provided by pediatricians (AAP, 1999d). For example, for a “high-complexity” evaluation and management visit for a new patient, Medicare paid $168 and Medicaid averaged $102 (AAP, 1999d). Among states, Medicaid payments for this visit category varied more than sixfold. New Jersey, Pennsylvania, and Missouri paid less than $25 for each visit, whereas Alaska, Arizona, and Connecticut paid more than $150. To cite another example, fees for newborn resuscitation (CPT 99440—see the explanation below of Current Procedural Terminology [CPT] codes) averaged $124 for all states but ranged from $29 in Maryland and $33 in Rhode Island to $243 in Idaho and $288 for Alaska (AAP, 1999d).
Some states provide higher payments for certain pediatric office and outpatient department visits than for corresponding adult visits (see, e.g., Prestowitz and Streett, 2000; Katz et al., 2001). This is consistent with Medicaid’s usually more generous coverage of services for children compared to adults.
Some physicians respond to low levels of Medicaid reimbursement by choosing not to serve Medicaid patients or by limiting the number of such patients they will see. A recent survey of members of the AAP reported that 67 percent of pediatricians in direct patient care accepted all Medicaid patients, considerably higher than the 48 percent reported in the organization’s 1993 survey (Yudowsky et al., 2000).34 The figure varied among states from 48 percent in Oklahoma to 94 percent in Massachusetts.