Home > Medical/Health Commentary > I guess I was onto something

I guess I was onto something

Remember earlier when I speculated that crowd-out of private insurance by Medicaid and S-CHIP could be one of the main drivers of the pay differential between adult and paediatric subspecialists?  According to the first letter at this NY Times link, it’s not a completely crazy idea.

I’ll repeat my earlier bleg here:  if anyone knows of good research or data on this, let me know!  This has only increased my curiosity as to whether this conjecture is borne out in the data.


Yes, posting has been light recently.  This is what happens when you leave shopping/packing/preparation for medical school to the last minute.  There’s more content to come soon, I promise!

  1. David Keller MD
    August 12, 2010 at 20:27

    Disclosure: I’m a pediatrician.
    There actually is a fair literature on crowd-out, mostly not showing much. (For example, see E. Shenkman, et al., “Crowd-out: Evidence from the Florida Healthy Kids Program,” Pediatrics 104: 507-513 (1999); E. Feinberg, et al., “Family Income and Crowd Out Among Children Enrolled in Massachusetts Children’s Medical Security Plan,” Health Services Research, 36: 45-63 (December 2001); D. Hughes, J. Angeles, & E. Stilling, “Crowd-Out in the Healthy Families Program: Does It Exist?,” Institute for Health Policy Studies, University of California, San Francisco, (August 2002); and L. Shone, et al., “Crowd-Out in the State Children’s Health Insurance Program (SCHIP):
    Incidence, Enrollee Characteristics and Experiences, and Potential Impact on New York’s SCHIP,”
    Health Services Research, 43: 419-434 (February 2008). Georgetown Center on Children and Families reviewed the literature last year. But, even without crowd-out, 25-30% of kids in America are poor and many of those are on Medicaid and SCHIP, so you really can’t be a pediatrician (or a pediatric sub-specialist) and not take Medicaid/CHIP, and, as you correctly observe, it pays us not as a well as Medicare (which means that pediatric sub-specialist salaries are only 1.5-2 x as high as general pediatric salaries). Not enough juice to tip lots of people to do an extra three years of training.
    The editorial didn’t mention several other key differences between pediatric residents and others in training. First 80% of pediatric residents are women, many of whom want to work part-time and have families- which drives the professional to shorter training periods and less subspecialization. Second, all pediatric specialities need bigger markets to have an adequate patient base- so they tend to accumulate in academic centers more than there adult colleagues do.
    That said, there is current a major push to subspecialty training within pediatric residencies- it will be interesting to see if the market can support them when they come out of the pipeline.

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