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Managed care for children: effect on access to care and utilization of health services
1Ambulatory Service, University of Rochester School of Medicine and Dentistry, USA.
Insights
Evidence is limited on how managed care impacts children's healthcare access and use. Factors like payment models and plan benefits significantly influence these effects, especially for Medicaid enrollees.
Area of Science:
- Pediatric Health Services Research
- Health Services Administration
- Managed Care Policy
Background:
- Children's unique healthcare needs, focusing on prevention and early intervention, differ from adults.
- Managed care enrollment for children is increasing without conclusive evidence of its impact on care access and utilization.
- Methodological challenges complicate the evaluation of managed care's effects on pediatric healthcare access and utilization.
Purpose of the Study:
- To review existing evidence on managed care's impact on pediatric healthcare access and utilization.
- To analyze findings separately for privately insured children and Medicaid enrollees.
- To identify factors influencing managed care's effects on pediatric health services.
Main Methods:
- Literature review of studies on managed care's effect on pediatric healthcare access and utilization.
- Separate consideration of findings for privately insured children and Medicaid enrollees.
- Analysis of impacts on hospital care, emergency department visits, primary care, and specialty services.
Main Results:
- Limited conclusive evidence exists regarding managed care's effect on pediatric health services access and utilization.
- Managed care's impact is contingent upon provider reimbursement (capitation vs. fee-for-service), benefit comprehensiveness, and family cost-sharing.
- For Medicaid recipients, managed care is linked to reduced emergency department use and specialty care access for chronically ill children, but potentially fewer preventive visits under capitation.
Conclusions:
- Managed care demonstrates some identifiable effects on pediatric health services, particularly for Medicaid enrollees.
- The evolving nature of health plans blurs distinctions, complicating impact analysis.
- Methodologically sound research is crucial to understand managed care's influence on pediatric healthcare delivery and outcomes as enrollment grows.
Abstract:
The rapid trend toward enrolling children in managed care has occurred largely without conclusive evidence about the effects of these arrangements on two important aspects of care: access and utilization. Although the effect of managed care on these measures has been studied more widely in the adult population, the results may not be applicable to children, who have unique health care needs centering around prevention and early treatment of acute illnesses to avoid long-term health problems. Moreover, several methodological challenges make it difficult to evaluate the impact of managed care on health care access and utilization in general. This article reviews what is known about the effect of managed care on access to health services, as well as utilization of hospital care, emergency department (ED) visits, primary care services, and specialty services for the pediatric population. In each area, findings from privately insured children and Medicaid enrollees are considered separately. There is little conclusive evidence on the effect of managed care on access to and utilization of pediatric health services. A recurring theme is that the effect of managed care is dependent on several factors, including whether providers assume financial risk through capitated reimbursements or retain fee-for-service payments; the comprehensiveness of benefits offered by health plans; and the level of cost sharing required of families. Among privately insured children, for example, managed care usually has been associated with higher primary care visit rates, though the benefit of managed care is reduced when fee-for-service plans cover preventive care and require minimal or no cost sharing for these services. Among Medicaid recipients, studies suggest that managed care is more likely to be associated with a decrease in preventive visits when provider payments are capitated. Attempts to decipher effects by health plan type are made more difficult by the rapid evolution of both managed care and fee-for-service plans, which often blurs the distinction between these two entities. Nonetheless, in some areas, managed care does appear to have an identifiable effect on pediatric health services. For Medicaid recipients, managed care has been associated with decreased emergency department use and decreased access to specialty care for chronically ill children. As enrollment of children in managed care plans increases, the need continues for methodologically sound studies evaluating the effect of these arrangements on the delivery of pediatric health services and on health outcomes.