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Prior approval in the pediatric emergency room
Insights
Managed care gatekeeping for pediatric emergency care was evaluated. The study found gatekeeping policies burdensome and inappropriate for after-hours visits, with most children needing urgent care.
Area of Science:
- Health Services Research
- Pediatric Emergency Medicine
- Managed Care Policy
Background:
- Managed-care plans aim to improve healthcare quality and control costs by using primary care physicians as gatekeepers.
- This study focuses on the gatekeeping prior approval element for children accessing emergency services.
Purpose of the Study:
- To evaluate the effectiveness and impact of managed care gatekeeping prior approval for pediatric emergency room visits.
- Assessing the burden and appropriateness of these policies on patients, primary care physicians, and ER staff.
Main Methods:
- Retrospective review of 385 pediatric emergency room visit records over 6 months.
- Survey of 29 primary care physicians and 19 emergency room staff regarding their experience with prior approval policies.
Main Results:
- Most pediatric ER visits (72%) occurred when primary care sites were closed.
- Only 3% of prior authorization requests for ER care were denied.
- A majority of primary care physicians and ER staff found gatekeeping policies burdensome and inappropriate, especially for after-hours care.
Conclusions:
- Existing managed care gatekeeping policies for pediatric emergency care are perceived as burdensome and inappropriate by healthcare providers.
- The current system shows limited effectiveness in controlling access to emergency services, particularly outside of regular clinic hours.
Abstract:
Managed-care plans for low-income Americans are widely promoted to improve the quality and control the cost of medical care by reducing unnecessary specialty and emergency room (ER) care through the use of primary care physicians as case managers/gatekeepers. The purpose of this study was to evaluate one element of managed care, gatekeeping prior approval, for children who use the pediatric ER of one urban public hospital. Over a 6-month period, 518 children and adolescents insured under managed-care plans that required authorization from the primary care physician to receive treatment presented to the ER. Of the 385 records reviewed for this study, the majority (87%) received their primary care at community health centers or the hospital's own outpatient clinics. Most ER visits (72%) were made when primary care sites were closed. According to nursing triage assessment, 57% presented with urgent or emergent conditions, and 26% had a history of chronic illness. Nine percent required hospitalization. Although an elaborate system for gatekeeping was established, only 13 (3%) patients' requests for ER care were denied. Of these, 3 were seen in the ER without authorization, 6 received the recommended follow-up, and 4 were not seen in follow-up. Twenty-nine participating primary care physicians (74%) and 19 ER staff (63%) responded to a survey of their experience with and attitudes toward prior approval. For a variety of reasons, the majority of primary care physicians and ER staff found the gatekeeping policies for after-hours visits burdensome and inappropriate.(ABSTRACT TRUNCATED AT 250 WORDS)