Home > Medical/Health Commentary > Paediatric subspecialists and insurance crowd-out

Paediatric subspecialists and insurance crowd-out

An op-ed in today’s New York Times by a pediatric pulmonologist seeks to draw attention to shortages of paediatric subspecialists in the US.  While most health policy nerds enthusiasts can talk about a shortage of primary care physicians (family practitioners, general outpatient internists, paediatricians) and to a lesser extent a shortage of general surgeons, the issue of paediatric subspecialists hasn’t been cause for much discussion… at least none that I’ve seen.

Dr. Rosen writes:

However, pediatrics has the opposite problem: a growing shortage of pediatric subspecialists. There are plenty of general pediatricians in the United States — about 70 per 100,000 children. But according to the American Board of Pediatrics, there are only 751 practicing pediatric pulmonologists in the country: one for every 100,000 children. In four states — Alaska, Idaho, Montana and Wyoming, where more than 941,000 children live — there are none. Even in Massachusetts, the state with the highest ratio of pediatric pulmonologists to children in the country (2.6 for every 100,000 children), the wait for an appointment is often several months.

The numbers are similar for other pediatric subspecialties, leading to a shortage of doctors trained to treat problems many children face, like asthma, digestive issues and cancer. And not only are the current subspecialists aging (the average age of pediatric pulmonologists is 52.4), but few pediatric residents are choosing to undergo subspecialty training at the end of their residencies.

There are many reasons for the declining interest in pediatric subspecialties, including longer hours and the burden of medical school debt worsened by the low salaries paid during three extra years of training.

A paediatric subspecialist I once shadowed while at university told me the three main differences between her paediatric subspecialty and its internal medicine subspecialty equivalent:  a) children are not just “little adults;” b) for various reasons, she and her colleagues tended to deal with higher acuity patients than their adult medicine counterparts; c) “stick the word ‘paediatric’ in front of a subspecialty, and you cut the pay by a third, if not more.”

I haven’t done any serious number crunching or analysis, but I get the sense that there’s a good deal of truth to her third statement.  Of course, this makes me wonder why.

One hypothetical reason that I’d love to be able to test is Medicaid and S-CHIP crowd-out of private insurance for children.  These two programs have been expanded several times during my lifetime in an attempt to ensure that all children have medical coverage of some sort.  We also know that these two programs tend to pay less, on average, than commercial insurers for the same sort of service.  Have these programs crowded out private coverage of children to any extent?  Does this mean that paediatric subspecialists could expect a different payor mix than their medical subspecialist counterparts?  If so, does this different payor mix explain a significant portion of the pay differential (again, assuming it actually exists on analysis)?

If anyone knows of existing research on this topic, I’d love to hear about it.  This question has me intrigued.


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Update (August 3):  I guess I was onto something.

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