Out-of-Network Care in Commercially Insured Pediatric Patients According to Medical Complexity

Area of Science:

• Health Services Research
• Pediatric Health
• Health Economics

Background:

• Commercial health plans often steer patients to in-network providers through higher cost-sharing for out-of-network (OON) care.
• The adequacy of pediatric specialist networks for children with medical complexity remains understudied.

Purpose of the Study:

• To investigate disparities in OON care utilization and associated cost-sharing for commercially insured children based on their medical complexity.
• To quantify the financial burden of OON care for children with varying degrees of chronic conditions.

Main Methods:

• A cross-sectional study utilizing a large, nationwide commercial claims database.
• Children aged 0-18 were categorized into three groups: no chronic disease, non-complex chronic diseases, and complex chronic diseases using the Pediatric Medical Complexity Algorithm.
• Key metrics included OON care rates, cost-sharing for both OON and in-network services, and OON costs as a proportion of total healthcare and cost-sharing spending.

Main Results:

• Children with non-complex chronic diseases had 6.77% higher OON care rates and $288 higher OON cost-sharing compared to those without chronic diseases.
• Children with complex chronic diseases experienced 16.08% higher OON care rates and $599 higher OON cost-sharing.
• Out-of-network care rates were particularly elevated for children seeking behavioral health services.

Conclusions:

• Commercially insured children with medical complexity are more likely to utilize OON care and incur higher cost-sharing expenses than their healthier peers.
• These findings highlight potential access barriers and financial challenges for vulnerable pediatric populations within commercial insurance networks.