Published online June 1, 2005
PEDIATRICS Vol. 115 No. 6 June 2005, pp. 1547-1554 (doi:10.1542/peds.2004-1496)
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Managed Care Organization Characteristics and Outpatient Specialty Care Use Among Children With Chronic Illness

Elizabeth Shenkman, PhD*,{ddagger},§, Lili Tian, PhD||, John Nackashi, MD, PhD{ddagger} and Desmond Schatz, MD{ddagger}

* Department of Epidemiology and Health Policy Research
{ddagger} Department of Pediatrics
|| Department of Biostatistics, College of Medicine
§ Institute for Child Health Policy, University of Florida, Gainesville, Florida

Background. Limited information is available about managed care organization (MCO) characteristics that influence outpatient physician specialist use among children with chronic conditions.

Objective. To examine the association between MCO characteristics and outpatient physician specialist use among children with chronic conditions who were receiving care in MCOs in which primary care providers (PCPs) served as gatekeepers for referrals and who were publicly insured.

Design and Methods. A total of 2333 children who had been diagnosed with a chronic condition and had functional limitations, an increased need for or use of health care services beyond what children normally use, and/or dependence on medications or home medical equipment were included in the study. The odds of an outpatient physician specialist visit 1 year after study entry were examined as a function of child health and sociodemographic characteristics, MCO characteristics, the child’s prior specialty care use, and provider availability in the MCO service delivery area.

Results. Children cared for in MCOs with lower percentages of PCPs paid on a fee-for-service basis (odds ratio: 0.95; 95% confidence interval: 0.92–0.98), with higher percentages of pediatricians in the PCP network (odds ratio: 1.17; 95% confidence interval: 1.07–1.29), and offering financial incentives for meeting quality of care standards (odds ratio: 1.71; 95% confidence interval: 1.28–2.29) had greater odds of outpatient physician specialist visits. Black children had odds of specialty care that were approximately one half those of white children. Children with prior physician specialist use were 52% more likely to have a physician specialist visit in the year after study entry. The children’s diagnoses and condition consequences were not related significantly to the odds of a specialty visit.

Conclusions. Specific MCO characteristics were associated with greater specialty care use among a group of low-income children with chronic conditions. Such information should be used to improve the structure of managed care arrangements for these vulnerable children.

Key Words: children • chronic conditions • pediatric specialty care use • managed care

Abbreviations: MCO, managed care organization • PCP, primary care provider • SCHIP, State Children’s Health Insurance Program • FPL, federal poverty level • ICD-9, International Classification of Diseases, Ninth Revision • ADD, attention-deficit disorder • ADHD, attention-deficit/hyperactivity disorder • QuICCC, Questionnaire for Identifying Children With Chronic Conditions

Accepted Sep 24, 2004.