Date of Award

2025

Degree Name

Healthcare Administration

College

College of Business

Type of Degree

M.S.

Document Type

Research Paper

First Advisor

Alberto Coustasse, Dr.PH. MD, MBA, MPH

Abstract

Introduction: Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) have provided health coverage for over 135 million Americans, with Medicaid playing a significant role in financing pediatric healthcare. Medicaid covers a wide range of services for children, particularly those from low-income families or with special healthcare needs, including preventive care, immunizations, vision and dental services, and mental health treatments. However, Medicaid reimbursement rates are lower compared to Medicare and private insurance, in some cases 30.6% lower, and have often been insufficient to cover the full cost of care, contributing to financial losses for children's hospitals. Despite these challenges, nearly 50% of children in the U.S. rely on Medicaid and CHIP for healthcare coverage, making adequate reimbursement rates essential for the viability of pediatric practices and children’s hospitals.

Purpose of the Study: The purpose of this research was to evaluate how lower Medicaid reimbursement rates for pediatric care, compared to adult Medicaid reimbursement and commercial payer rates, have affected pediatric healthcare delivery. Specifically, the study examined the impact on access to care, utilization of pediatric specialty services, health outcomes and sustainability of the pediatric workforce.

Methodology: This study used a qualitative literature review and semi-structured interview to test the hypothesis, utilizing databases such as PubMed, ProQuest, and Google Scholar, as well as the Google search engine. The research was limited to the English language and published between the years 2015-2025.

Results: Pediatric provider availability, inpatient units, and beds have declined, with a 13% drop in providers from 2022–2023 and a 19.1% decrease in units from 2008–2018. Four in ten children on Medicaid/CHIP faced access barriers like transportation, and those living over 90 minutes from referral centers were more likely to be treated by adult-trained subspecialists. The percentage of uninsured children who did not have a usual source of health care increased from 13% in 2020 to 21% in 2021. Pediatric lab services lack age-specific technologies and rely on adult testing standards, resulting in inaccurate results and suboptimal care. Broader pediatric research also lags, with only 12% of trials addressing high-burden pediatric conditions and less industry funding, leading to off-label drug use in up to 80% of hospitalized children. Pediatricians earn 25% less than adult physicians—about $1.2 million less over a career—with Medicaid’s lower reimbursement rates contributing to burnout, reduced participation. Declining interest in pediatric careers resulted in only 48% of pediatric residency positions filled in 2024 and nearly 30% of programs going unmatched.

Discussion/Conclusion: This study highlights the critical role that Medicaid reimbursement plays in shaping pediatric healthcare delivery. The findings suggest that lower reimbursement rates for pediatric services contribute to reduced access and utilization of pediatric specialty services, and diminished workforce sustainability. Addressing these disparities through policy reform is essential for ensuring the long-term viability of pediatric care and improving health outcomes for children.

Subject(s)

Health services administration.

Health facilities -- Business management.

Health insurance -- United States.

Pediatrics.

Medicaid.

Medicare.

Children's Health Insurance Program (U.S.)

Health services accessibility -- Children.

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