Barriers to pediatric referral in managed care 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.