Specialty Physician Attitudes and Beliefs about Medicaid Patients

Research Article

J Fam Med. 2018; 5(3): 1141.

Specialty Physician Attitudes and Beliefs about Medicaid Patients

Niess MA1*, Blair IV2, Furniss A3 and Davidson AJ4

¹Department of Medicine, Fair Haven Community Health Care, New Haven, CT and Department of Medicine, Yale School of Medicine, 374 Grand Ave, New Haven, CT 06513, USA

²Department of Psychology and Neuroscience, University of Colorado, Boulder, CO, USA

³Bureau of Program Evaluation, Mississippi Department of Education, USA

4Adult and Child Center for Health Outcomes Research and Delivery Science University of Colorado, Aurora, CO USA and Denver Public Health, Denver Health, Denver, CO, USA, and University of Colorado, School of Public Health, Aurora, CO, USA

*Corresponding author: Meredith Niess, Department of Medicine, Fair Haven Community Health Care, New Haven, CT and Department of Medicine, Yale School of Medicine, 374 Grand Ave, New Haven, CT 06513, USA

Received: April 23, 2018; Accepted: May 24, 2018; Published: May 31, 2018


Using a cross-sectional statewide survey, we described specialist attitudes and beliefs about Medicaid patients and characteristics associated with negative beliefs. 804 physician members of the Colorado Medical Society providing adult specialty care in Colorado (1600 eligible) endorsed 14 positive and negative characteristics about Medicaid patients on a Likert Scale from which we created a “favorableattitude outcome.86% of r versus “unfavorableattitude outcome.86% of r attitude outcome.86% of respondents had unfavorable attitudes towards Medicaid patients. In an adjusted model, unfavorable attitudes were associated with physician characteristics of income highly dependent on productivity (versus little/no dependence p=.01; versus some dependence, p=.07), an independent practice (versus employed by large organization, p=.03), and being in a surgical or hospital-based specialty (versus a medical specialty p=.05 and p‹.01, respectively).Given the potential for negative bias to affect access to and quality of care, more research is needed into the contributors to and effects of this bias.

Keywords: Medicaid; Access; Bias; Vulnerable Populations


ACA: Affordable Care Act; CMS: Colorado Medical Society; OBGYN: Obstetrics/Gynecology


Medicaid, the largest United States health coverage provider, insures more than 1 in 5 Americans. In states expanding Medicaid, Medicaid and Children’s Health Insurance Program enrollment increased nearly 39% under the Affordable Care Act (ACA) as of May, 2017 [1]. Colorado is among the trend leaders with only 2 states surpassing its 76% enrollment increase as of May, 2017 [2].

There is currently little understanding of how Medicaid patients are viewed by physicians. Do physicians view this patient population positively and welcome them into their practices? Or do negative beliefs predominate, with potential implications for lowered quality of care and reduced willingness to improve access? In national healthcare debates, a common critique of Medicaid centers around lower practice acceptance of Medicaid patients [3], heightening the relevance of these questions.

The importance of answering these questions is further underscored by a growing body of evidence on bias in health care, mostly with regard to racial bias [4]. These studies showed that many physicians had negative attitudes that favored whites over minority groups [5,6]. Furthermore, these attitudes were reflected in worse interactions with minority patients [7-9], and in some cases may have affected medical decision-making [10-12].

To date, most investigations of physician bias have focused on general attitudes – overall positivity or negativity without regard to underlying beliefs. Such attitudes revealed general propensities to behave more positively or negatively, but did not provide information about specific issues that may be of concern [13]. For example, a belief that a patient group is dangerous would imply different reactions than a belief that the group is lazy, although both are negative. The goal of the current study was to examine specialty physicians’ attitudes and beliefs about Medicaid patients. We further investigated practice and physician characteristics associated with negative attitudes. We focused on specialty rather than primary care because Medicaid patients experienced worse specialty care access compared to Medicare and privately insured patients [14].


Population surveyed

To obtain a wide sample across the state, we partnered with the Colorado Medical Society (CMS) for physician recruitment. CMS is the largest organization of physicians in Colorado, with over 7,500 members across all specialties and employment settings. After passage of the ACA, CMS identified access to specialty care as a strategic priority, leading to organizational support of this member survey. Physicians were excluded if retired, still in training, primarily in pediatric practice or focused on general medical care including family medicine, general internal medicine or emergency medicine. From the resulting pool of 3,266 adult specialist CMS members for recruitment, 1,800 were randomly selected to receive a solicitation letter with a $2 bill included. Of letter recipients, 200 were subsequently found to be ineligible (e.g., deceased, met exclusion criteria or invalid contact information), leaving 1600 for recruitment. Between April and June of 2014, physicians with email addresses known to CMS (70%) were sent up to 5 electronic requests to participate in the survey through a secure website, followed by a printed survey if no response. Physicians with unknown email address were mailed printed surveys twice (Figure 1). The Colorado Multiple Institutional Review Board approved the study.