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Barriers to pediatric referral in managed care systems
1Division of Research on Health Policy, American Academy of Pediatrics, Elk Grove Village, IL 60009.
Insights
Managed care systems may create referral barriers, limiting children's access to pediatric subspecialty and inpatient care. Pediatricians reported fewer referrals and denied care within these systems.
Area of Science:
- Pediatric Healthcare Access
- Managed Care Systems
- Referral Barriers
Background:
- Anecdotal evidence suggests managed care systems impede children's access to pediatric subspecialty and inpatient care.
- Referral barriers within these systems may impact the healthcare delivery process.
Purpose of the Study:
- To identify specific referral barriers imposed by managed care systems.
- To determine how these barriers affect the referral process for pediatric subspecialty and inpatient care.
Main Methods:
- A survey was distributed to a sample of 1598 American Academy of Pediatrics Fellows.
- A response rate of 79.1% (n=1264) was achieved.
- Data were analyzed from 956 pediatricians in direct patient care, 71.4% of whom participated in managed care plans.
Main Results:
- Pediatricians referred patients in managed care systems less frequently to subspecialists (8.7%) and inpatient care (6.9%) compared to traditional systems.
- Over 20% of pediatricians with managed care patients experienced denied subspecialist referrals, and over 10% experienced denied inpatient referrals in the prior year.
- Referral barriers were more prevalent in preferred provider organizations than health maintenance organizations.
Conclusions:
- Utilization management programs within managed care systems may restrict necessary access to pediatric subspecialty and inpatient services.
- These findings highlight potential systemic issues affecting timely and appropriate pediatric care.
- Further investigation into optimizing referral pathways within managed care is warranted.
Abstract:
Anecdotal evidence suggests that children's access to pediatric subspecialty and inpatient care is hampered by referral barriers imposed by managed care systems. To identify such barriers and determine how they affect the referral process, a sample of American Academy of Pediatrics Fellows (n = 1598) was surveyed. The response rate was 79.1% (n = 1264). Of those pediatricians in direct patient care (n = 956), 71.4% participated in a managed care plan. Pediatricians referred patients in managed care systems somewhat less frequently than in traditional pay systems: 8.7% and 6.9% referred managed care patients to subspecialists and inpatient care, respectively, less often. More than 20% and 10% of pediatricians with patients in managed care systems had at least one referral to subspecialist care and inpatient care, respectively, denied in the previous year. Pediatricians experienced more barriers in preferred provider organizations than in health maintenance organizations. These data suggest that utilization management programs, such as those used in managed care systems, may limit necessary access to pediatric subspecialty and inpatient care.