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Certain managed care organization characteristics can increase specialty care use among chronically ill low-income children

Certain characteristics of managed care organizations (MCOs) can increase specialty care use among chronically ill, low-income children, according to a study supported in part by the Agency for Healthcare Research and Quality (HS09949). After controlling for health status, children with chronic conditions cared for in MCOs that had more pediatricians in their primary care physician (PCP) network and offered financial incentives for meeting quality of care standards had 17 and 71 percent, respectively, greater odds of seeing an outpatient specialist.

MCOs using these strategies would provide better access to specialty care for these vulnerable children, suggests Elizabeth Shenkman, Ph.D., of the University of Florida. Dr. Shenkman and her colleagues examined the association between MCO characteristics (prior authorization procedures, availability of pediatricians in the networks, type of PCP reimbursement, and use of financial incentives to promote meeting of pediatric quality of care standards) and outpatient specialist use among 2,333 children with conditions such as asthma, diabetes, and cystic fibrosis. All of the children in this study were receiving care in MCOs in which PCPs served as gatekeepers and were insured through a State Children's Health Insurance Program for poor children.

Researchers found that for each 10 percent decrease in the percentage of PCPs paid on a fee-for-service basis, children had 5 percent lower odds of visiting an outpatient specialist. These findings suggest that capitated providers who are not at financial risk for making specialty referrals may be more likely to make discretionary referrals to specialists. Also, children who saw a physician specialist in the year prior to the study interview were 52 percent more likely to see a physician specialist in the subsequent year. Overall, black children were only half as likely to receive specialty care than white children.

See "Managed care organization characteristics and outpatient specialty care use among children with chronic illness," by Dr. Shenkman, Lili Tian, Ph.D., John Nackashi, M.D., Ph.D., and Desmond Schatz, M.D., in the June 2005 Pediatrics 115(6), pp. 1547-1554.

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