Switching to Gatekeeping: Changes in Expenditures and Utilization for Children

Ferris, Timothy G.; Perrin, James M.; Manganello, Jennifer A.; Chang, Yuchiao; Causino, Nancyanne; Blumenthal, David

doi:10.1542/peds.108.2.283

Cited by 46 publications

(43 citation statements)

References 21 publications

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“…41 Managed care efforts have generally not improved the provision of appropriate services for these children. 42 The Supplemental Security Income (SSI) program, while providing important cash and Medicaid benefits for some of the most seriously affected children, does not make provisions for establishing systems of care. In addition, proposals to extend coverage for "basic care" to currently uninsured children by eliminating specialized benefits for chronically ill children can only exacerbate these financial disincentives.…”

Section: Implications For Practice and Policymentioning

confidence: 99%

The Transformation Of Child Health In The United States

Wise¹

2004

Health Affairs

109

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PROLOGUE:The health of children in the United States poses a paradox. Mortality rates have declined dramatically. Health insurance coverage has improved. Insuring the nation's children has been the focus of much policy activity ever since President Clinton's failed effort to provide universal health coverage. The notion was, if we can't cover everyone, let's at least cover the children. And on the current presidential campaign trail, insuring the children (for eight million or so are still uninsured) has been a popular political topic. Yet as author Paul Wise explores the state of child health today in a sweeping epidemiological "check-up," he finds that because of social trends and medical progress over the past three decades, the threats to children's health have changed so dramatically that many of our current health policies and systems of delivery have been rendered obsolete. Here, Wise proposes a new way of thinking about children's health in this country that could drive policy in important ways. He calls for more focused attention on the role of chronic illness in childhood, on the impact of social determinants in health, and on the striking prevalence of disparities. Policy action is needed to address reforms both in clinical care and in the public health aspects that ultimately drive the health of our children.

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Section: Implications For Practice and Policymentioning

confidence: 99%

The Transformation Of Child Health In The United States

Wise¹

2004

Health Affairs

109

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“…Researchers have demonstrated decreases in costs associated with PCCM programs (Martin et al 1989;Rask et al 1999;Ferris et al 2001a), while others have found little effect, or even cost increases (Schoenman, Evans, and Schur 1997;LoSasso et al 2000;Escarce et al 2001;Ferris et al 2001b). However, many of these studies have been limited by a small sample size, limited program duration, inability to measure the cost shifting away from inpatient and towards outpatient care that one would expect, and a lack of adequate theoretical and statistical methods.…”

Section: Discussionmentioning

confidence: 99%

A Cost Analysis of the Iowa Medicaid Primary Care Case Management Program

Momany

Flach

Nelson³

et al. 2006

Health Services Research

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Objective. To determine the cost savings attributable to the implementation and expansion of a primary care case management (PCCM) program on Medicaid costs per member in Iowa from 1989 to 1997. Data Sources. Medicaid administrative data from Iowa aggregated at the county level. Study Design. Longitudinal analysis of costs per member per month, analyzed by category of medical expense using weighted least squares. We compared the actual costs with the expected costs (in the absence of the PCCM program) to estimate cost savings attributable to the PCCM program. Principal Findings. We estimated that the PCCM program was associated with a savings of $66 million to the state of Iowa over the study period. Medicaid expenses were 3.8 percent less than what they would have been in the absence of the PCCM program. Effects of the PCCM program appeared to grow stronger over time. Use of the PCCM program was associated with increases in outpatient care and pharmaceutical expenses, but a decrease in hospital and physician expenses. Conclusions. Use of a Medicaid PCCM program was associated with substantial aggregate cost savings over an 8-year period, and this effect became stronger over time. Cost reductions appear to have been mediated by substituting outpatient care for inpatient care.

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“…This finding may be due to the restrictions placed on use in HMO systems (eg, referrals are needed) but also may reflect a selection bias of sicker children into non-HMO care. 19,20,29 When the results for privately insured children were stratified by chronic condition/disability status, only children without chronic conditions or disabilities had lower use of specialists compared with non-HMO children. These data cannot help us understand whether this reflects HMOs reducing discretionary use among the privately insured, whether HMOs are reducing needed care among the privately insured, or whether other factors (eg, selection bias) account for this finding.…”

Section: Discussionmentioning

confidence: 99%

Correlates of Use of Specialty Care

et al. 2004

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ABSTRACT.Objective. This study examines patterns of specialist use among children and adolescents by presence of a chronic condition or disability, insurance, and sociodemographic characteristics.Design. Cross-sectional analysis of national survey data, describing rates of specialist use, with logistic regressions to examine associations with having a chronic condition or disability, insurance status, and sociodemographic variables.Setting. The 1999 National Health Interview Survey, a nationally representative household survey.Participants. Children and adolescents 2 to 17 years old.Outcome. Parental/respondent reports of specialist visits based on reports of the child having seen or talked to a medical doctor who specializes in a particular medical disease or problem about the child's health during the last 12 months.Results. Thirteen percent of US children were reported as seeing a specialist in the past year. Specialistvisit rates were twice as high for children with a chronic condition or disability (26% vs 10.2%). The specialist utilization rates for children without insurance were much lower than those for insured children, but among the children who have coverage (private, Medicaid, or other), specialist-utilization rates were similar (no statistically significant difference).Results of multivariate analyses predicting the use of specialists confirm the above-mentioned findings. Additionally, they show that use of specialist care was lower among children in the middle age group, minorities, children in families between 100% and 200% of the federal poverty level, and lower parental educational levels. We found no difference in specialist-visit rates between rural-and urban-dwelling children, by family status, or by gender. Differences in specialist use by gatekeeping status are found only among subgroups.Conclusions. The results showed that, overall, 13% of children used a specialist in a year. Among the insured, a slightly greater percentage of children used such care (15%). These numbers were slightly lower than the 18% to 28% of pediatric patients referred per year in 5 US health plans, although the sources of data and definitions of specialist use differ. Our results showed that 26% of children with a chronic condition or disability who were insured by Medicaid use a specialist. Although the data are not directly comparable, this is within the range of previous findings showing annual rates by condition of use between 24% and 59%. These findings are consistent also with greater use of many different types of health care by children with special health care needs.Medicaid-utilization rates presented here were similar also to the rates found among privately insured children and children with "other" insurance. In our earlier work examining use of specialists by children insured by Medicaid, we speculated that Medicaid-insured children might face particular difficulty with access (eg, due to transportation or language barriers). The findings presented here suggest that children insured by Medicaid had no ...

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Switching to Gatekeeping: Changes in Expenditures and Utilization for Children

Cited by 46 publications

References 21 publications

The Transformation Of Child Health In The United States

The Transformation Of Child Health In The United States

A Cost Analysis of the Iowa Medicaid Primary Care Case Management Program

Correlates of Use of Specialty Care

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