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Generalist and subspecialist care for children with chronic conditions
James M Perrin1, Karen A Kuhlthau, Steven L Gortmaker
1Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Boston 02114, USA. perrin.james@mgh.harvard.edu
Insights
Medicaid children with chronic conditions in generalist care arrangements often have more complex health issues and higher costs. While generalist-only care shows lower spending, this may not account for all variations in child morbidity.
Area of Science:
- Pediatric Health Services Research
- Health Economics
- Chronic Disease Management
Background:
- Medicaid-enrolled children with chronic conditions require diverse healthcare services.
- Understanding patterns of care (generalist vs. subspecialist) is crucial for managing costs and outcomes.
- Previous research has not fully elucidated the relationship between care patterns, morbidity, and expenditures in this population.
Purpose of the Study:
- To examine associations between healthcare utilization patterns (generalist, subspecialist, pediatric subspecialist) and indicators of morbidity and healthcare expenditures.
- To identify how different care models impact children with chronic conditions covered by Medicaid.
Main Methods:
- Cross-sectional analysis of Medicaid claims, enrollment, and provider data from four US states.
- Inclusion of children (0-21 years) with 11 specified chronic conditions, including those with Supplemental Security Income.
- Categorization of care patterns into generalist-only, predominantly generalist, and predominantly subspecialist, with expenditure analysis using linear regression.
Main Results:
- Most children (60.7%) received generalist-only care; 28% predominantly generalist; 11% predominantly subspecialist.
- Children in predominantly generalist arrangements exhibited higher morbidity compared to other groups.
- Mean annual expenditures ranged from $1,306 (attention deficit hyperactivity disorder) to $11,633 (acquired immunodeficiency syndrome).
- Generalist-only care was associated with significantly lower expenditures for 6 of 11 conditions, adjusted for morbidity.
Conclusions:
- Medicaid children in predominantly generalist arrangements appear to manage more complex conditions, leading to higher expenditures.
- While generalist-only care shows lower costs, unmeasured variations in morbidity might influence these findings.
- Care pattern optimization is essential for managing chronic conditions in pediatric Medicaid populations.
Objective:
To determine, among Medicaid-enrolled children with chronic conditions, associations of indicators of morbidity and expenditures with different patterns of generalist, subspecialist, and pediatric subspecialist use.
Design And Setting:
Cross-sectional analysis of Medicaid claims, enrollment, and provider data from 4 states (California, Georgia, Michigan, and Tennessee).
Sample:
All children enrolled in Supplemental Security Income (aged 0-21 years) and a sample of other Medicaid-enrolled children matched for age and gender. We included 11 chronic conditions, including both uncommon conditions (eg, spina bifida, hemophilia) and common ones (eg, asthma, attention deficit hyperactivity disorder).
Main Outcome Measures:
We determined the number of visits per year to generalists and subspecialists (pediatric and other), using only subspecialists relevant to that condition. We categorized patterns of care as generalist only, predominantly generalist, or predominantly subspecialist, and examined patterns by condition and an indicator of morbidity. Among children seeing subspecialists, we also compared morbidity by pediatric and other subspecialists. We used linear regression to determine per-year total expenditures, controlling for demographic characteristics and morbidity.
Results:
Most children (60.7%) saw generalists only. Twenty-eight percent were in predominantly generalist arrangements, and 11% were in predominantly subspecialist arrangements. Children in predominantly generalist arrangements had higher morbidity than children in generalist-only or predominantly subspecialist arrangements. Among children seeing subspecialists, those seeing pediatric subspecialists had generally higher morbidity than those seeing other subspecialists. Mean yearly expenditures varied from 1306 dollars (attention deficit hyperactivity disorder) to 11,633 dollars (acquired immunodeficiency syndrome). Children who saw only generalists had significantly lower expenditures for 6 of the 11 conditions, after adjusting for morbidity.
Conclusions:
Medicaid-enrolled children in predominantly generalist arrangements appear to have more complicated conditions than children in generalist-only or predominantly subspecialist arrangements, engendering also higher expenditures. Although children who saw generalists only had lower expenditures than those seeing subspecialists, this finding may reflect unmeasured variations in morbidity.