Kutscher Eric J, Joshi Sucheta M, Patel Anup D, Hafeez Baria, Grinspan Zachary M
Department of Healthcare Policy & Research, Weill Cornell Medicine, New York, New York.
Department of Pediatrics and Communicable Diseases, University of Michigan Health System, Ann Arbor, Michigan.
Pediatr Neurol. 2017 Aug;73:28-35. doi: 10.1016/j.pediatrneurol.2017.04.014. Epub 2017 Apr 20.
Children with public insurance (Medicaid) have increased barriers to specialty care in the United States. For children with epilepsy, the relationship between public insurance and barriers to genetic testing is understudied.
We surveyed a sample of US child neurology clinicians. We performed quantitative and qualitative analysis of responses.
There were 302 responses (of 1982 surveyed; response rate 15%) from clinicians from 46 states, the District of Columbia, and Puerto Rico, including board-certified child neurologists (82%), resident physicians (6%), nurses (3%), and nurse practitioners (3%). Clinicians felt it was more difficult to get genetic testing for patients with Medicaid insurance compared with commercial insurance, (43% vs 12%, P < 0.05), although many felt it was about the same degree of difficulty (25%) or were not sure (20%). Increased availability of testing was associated with less complex testing (P < 0.001), in-house testing (P < 0.001), and no preauthorization requirements (P < 0.001). Qualitative responses described barriers related to cost, clinician familiarity and comfort, commercial laboratories, health care organization, payer, and patient concerns. Descriptions of facilitators included lowered cost, availability of clinical genetics expertise, clinician knowledge, commercial laboratory assistance, health care organizational changes, improved payer coverage, and increased interest by parents.
Pediatric Medicaid beneficiaries with epilepsy have barriers to genetic testing, compared with children with commercial insurance, particularly for more advanced testing. Potential strategies to improve access include broader coverage, lower co-pays, increased capacity for testing outside of specialty laboratories, fewer preauthorization requirements, improved clinician education, ongoing development and dissemination of guidelines, improved availability of clinical genetics services, and continued assistance programs from commercial laboratories.
在美国，参加公共保险（医疗补助）的儿童获得专科护理的障碍更多。对于癫痫患儿，公共保险与基因检测障碍之间的关系尚未得到充分研究。
我们对美国儿童神经科临床医生进行了抽样调查。我们对调查结果进行了定量和定性分析。
来自46个州、哥伦比亚特区和波多黎各的临床医生共给出了302份回复（共调查1982人；回复率15%），其中包括获得委员会认证的儿童神经科医生（82%）、住院医师（6%）、护士（3%）和执业护士（3%）。临床医生认为，与商业保险患者相比，医疗补助保险患者进行基因检测更加困难（43%对12%，P<0.05），不过许多人认为困难程度大致相同（25%）或不确定（20%）。检测的可及性增加与检测复杂性降低（P<0.001）、内部检测（P<0.001）以及无需预先授权（P<0.001）相关。定性回复描述了与成本、临床医生的熟悉程度和舒适度、商业实验室、医疗保健机构、付款方以及患者担忧相关的障碍。促进因素包括成本降低、临床遗传学专业知识的可及性、临床医生的知识、商业实验室的协助、医疗保健机构的变革、付款方保险范围的改善以及家长兴趣的增加。
与商业保险儿童相比，患有癫痫的儿科医疗补助受益患者在基因检测方面存在障碍，尤其是进行更高级检测时。改善可及性的潜在策略包括扩大保险范围、降低自付费用、增加专科实验室以外的检测能力、减少预先授权要求、改善临床医生教育、持续制定和传播指南、提高临床遗传学服务的可及性以及商业实验室持续提供协助项目。
