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Effect of managed care on children's relationships with their primary care physicians: differences by race
1Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, 624 N Broadway St, Room 661, Baltimore, MD 21205, USA. gstevens@jhsph.edu
Insights
Racial and ethnic minority children experience poorer patient-provider relationships, especially under restrictive managed care policies. Less restrictive policies may improve these relationships for all children.
Area of Science:
- Pediatric primary care quality
- Health services research
- Health equity
Background:
- Racial and ethnic disparities in patient-provider relationships are documented in adults but understudied in children.
- The role of managed care in mediating these disparities for pediatric populations is largely unknown.
Purpose of the Study:
- To examine how managed care policies influence patient-provider relationships for children across different racial and ethnic groups.
- To identify variations in these associations based on managed care structures.
Main Methods:
- A telephone survey of parents of 413 elementary school children in southern California.
- Validated self-reported managed care information through health plan contacts.
- Assessed parent-reported strength of affiliation and interpersonal relationships with healthcare providers.
Main Results:
- Hispanic and black children had lower affiliation strength compared to white children.
- Asian and Hispanic children reported poorer interpersonal relationships with providers than white children.
- Restrictive managed care policies (provider assignment, referral requirements, network limitations) were linked to poorer relationships, particularly for minority children.
Conclusions:
- Racial and ethnic minority children face worse patient-provider relationships than white children, independent of socioeconomic status.
- Minority children are especially sensitive to managed care policies that limit care choices.
- Adopting less restrictive managed care policies could improve patient-provider relationships for all children.
Context:
Racial and ethnic disparities in the quality of the patient-provider relationship have been documented previously, but only among adults. Few studies have examined this aspect of primary care quality for children, and none has examined the role of managed care in mediating disparities.
Objective:
To explore variations in the associations among 3 managed care policies and the sustained patient-provider relationship for children by racial and ethnic group.
Design, Setting, And Participants:
Telephone survey of parents of a random sample of 413 children attending elementary school in a large school district spanning 3 cities in southern California. Self-reported managed care information was validated through contact with health plan representatives.
Main Outcome Measure:
Parent reporting of the strength of affiliation and interpersonal relationships among the child, the family, and the health care provider.
Results:
Parents of Hispanic and black children reported significantly lower strength of affiliation than whites did (mean, 3.19 and 3.27 vs 3.57; P<.05 and P<.01, respectively). Asians and Hispanics reported significantly poorer interpersonal relationships with providers than whites did (mean, 3.35 and 3.38 vs 3.53; P<.05 for both). Managed care policies requiring patients to (1) sign up with a particular provider, (2) seek a referral for specialty care, and (3) stay within a network were associated with reductions in the interpersonal relationship. All minority groups, but not whites, reported significantly poorer relationships when managed care policies were present. Asian children were most sensitive to the managed care policies.
Conclusions:
Our data suggest that racial and ethnic minority children experience poorer patient-provider relationships compared with white children, even controlling for socioeconomic status and health system factors. Minority children are particularly sensitive to managed care policies that restrict patient freedom in choosing where to seek care. Implementing less restrictive policies may enhance the development of the patient-provider relationship.