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Managed care, primary care, and quality for children
R J Reid1, M P Hurtado, B Starfield
1Johns Hopkins School of Hygiene and Public Health, Baltimore, MD 21205, USA.
Insights
Newer managed care plans may not improve children's primary care quality. While early models showed promise, current evidence is mixed, with potential negative impacts on access and coordination. Further research is needed.
Area of Science:
- Health Services Research
- Pediatric Healthcare
- Managed Care Policy
Background:
- Managed care organizations (MCOs) use incentives to control healthcare costs and effectiveness.
- Early MCOs (prepaid group practices) showed promise for improving children's primary care.
- Recent MCO variants' impact on pediatric primary care quality is unclear and potentially negative.
Purpose of the Study:
- To evaluate the impact of newer managed care models on the quality of primary care for children.
- To assess whether current managed care structures enhance or hinder key aspects of pediatric primary care.
Main Methods:
- Review of existing evidence on managed care's effects on pediatric primary care.
- Analysis of impacts on accessibility, continuity, comprehensiveness, coordination, and outcomes.
- Comparison of newer MCO variants with early models and traditional indemnity plans.
Main Results:
- Managed care can improve initial access and reduce emergency room use for children.
- Continuity of care is threatened by provider/enrollee instability and disrupted relationships.
- Preventive services may increase, but specialty care access can be restricted; care coordination is not guaranteed.
- Evidence for improved clinical quality in newer MCOs for children is lacking.
Conclusions:
- Newer managed care models may not deliver superior primary care for children.
- The organizational structures of current MCOs may impede, rather than facilitate, quality primary care.
- More rigorous studies are essential to determine the true effect of proliferating managed care on pediatric healthcare quality.
Abstract:
In an effort to provide medical care that is both more effective and less costly, the new variants of managed care organizations have instituted a variety of incentives and administrative controls that impact on the types and quantity of care provided to patients. Evidence suggests that the early forms of managed care, namely prepaid group practices, showed particular promise in improving the primary care delivered to children, ie, care that is accessible, person-focused in the long term, comprehensive, coordinated, and oriented toward achieving better outcomes. However, recent evidence concerning the quality of care delivered to children in the newer variants of managed care is mixed and scant; the newer organizational forms may not facilitate and may even have a negative impact on the attainment of primary care. Managed care can have a positive effect on first contact care, because it contractually defines a primary care provider and reduces use of the emergency room as a source of care. It may, however, have mixed effects on other aspects of access and use, depending on the plan's particular characteristics. Longitudinality is threatened by the disruption of prior relationships with out-of-plan providers and by the instability of both enrollees and providers in managed care plans. Children's benefits in managed care arrangements tend to include more preventive services, but access to specialty services has generally been found to be more restrictive. Coordination of care is not inherent to managed care, and many plans are no more likely to foster communication than are traditional indemnity plans. Evidence for the superior clinical quality afforded to children by new variants of managed care is lacking. Because managed care arrangements are proliferating rapidly, better studies are needed to prove or refute the contention that managed care has a significant positive effect on quality of care.