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More than 60 percent of all Medicaid-enrolled children with chronic conditions receive generalist care only. Medicaid-insured children with chronic conditions who receive all of their care from generalists tend to have less complex conditions than those seen jointly by generalists and subspecialists. Children receiving care in generalist-only arrangements also have lower expenditures, perhaps due in part to the lower severity and complexity of their conditions, explains James M. Perrin, M.D., of MassGeneral Hospital for Children and Harvard Medical School.
In a study supported by the Agency for Healthcare Research and Quality (HS09416), Dr. Perrin and his colleagues examined 1989-1992 Medicaid data on more than 68,000 children from four States to correlate morbidity of chronic disease (complexity or severity) with patterns of generalist and subspecialist use and expenditures among Medicaid fee-for-service children. They included 11 chronic conditions, including both uncommon conditions (for example, spina bifida and hemophilia) and common ones (for example, asthma and attention deficit hyperactivity disorder, ADHD).
Most children (61 percent) saw generalists only. Twenty-eight percent were in predominantly generalist arrangements, that is, they saw specialists as well as generalists; and only 11 percent were in predominantly subspecialist arrangements, perhaps due to specialists' unwillingness to care for Medicaid-insured children. Children in predominantly generalist arrangements had more severe chronic conditions or other coexisting conditions than children in generalist-only or predominantly subspecialist arrangements. However, the small numbers of children in predominantly subspecialist arrangements limited the validity of this comparison.
Mean yearly expenditures varied by condition, from $1,306 (ADHD) to $11,633 (AIDS). Children who saw only generalists had significantly lower expenditures for 6 of the 11 conditions studied, after adjusting for morbidity. These findings do not support the notion that generalists' relative lack of experience with chronic conditions leads to greater expenditures, for example, by excessive ordering of tests. Dr. Perrin cautions, however, that the finding of lower expenditures for children in generalist-only arrangements may reflect unmeasured variations in morbidity.
See "Generalist and subspecialist care for children with chronic conditions," by Dr. Perrin, Karen A. Kuhlthau, Ph.D., Steven L. Gortmaker, Ph.D., and others, in the November 2002 Ambulatory Pediatrics 2, pp. 462-469.
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