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PEDIATRICS Vol. 111 No. 3 March 2003, pp. 456-460

Does Gatekeeping Control Costs for Privately Insured Children? Findings From the 1996 Medical Expenditure Panel Survey

Susmita Pati, MD*,{ddagger}, Steven Shea, MD{ddagger},¶, Daniel Rabinowitz, PhD§ and Olveen Carrasquillo, MD, MPH{ddagger},||

* Departments of Pediatrics
{ddagger} Medicine, Columbia University College of Physicians and Surgeons, New York, New York
§ Department of Statistics, Columbia University, New York, New York
|| Departments of Health Policy and Management
Epidemiology, Mailman School of Public Health, Columbia University, New York, New York

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   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Objective. Gatekeeping requirements were widely adopted by health insurers in an attempt to control costs in the mid-1990s, but empirical evidence demonstrating decreased health expenditures for children enrolled in such plans is lacking.

Methods. We analyzed data from 3254 children with private health insurance sampled in the 1996 Medical Expenditure Panel Survey (MEPS) to compare total per capita health expenditures among gatekeeping versus indemnity plan enrollees. This sample represents 40.4 million privately insured American children. Total expenditures were defined as payments from all sources, including third-party and out-of-pocket payments, but excluding administrative costs. MEPS data are based on information provided by patients, health care providers, and hospitals. Gatekeeping plans included all children enrolled in health maintenance organizations or other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees.

Results. Mean total per capita annual expenditures for children in gatekeeping versus indemnity plans differed by <1% ($887 vs $881, respectively). Third-party payments by gatekeeping plans on behalf of their beneficiaries were $636 versus $595 by indemnity plans. Out-of-pocket payments were on average $62 less for gatekeeping enrollees than for indemnity enrollees. After multivariate adjustment, mean per capita expenditures were approximately 4% lower for gatekeeping enrollees than for indemnity enrollees.

Conclusion. In 1996, total per capita annual health expenditures for children in gatekeeping plans were approximately $8 less than for those in indemnity plans. These data indicate that gatekeeping is not an effective cost-containment method for children.

Key Words: child health expenditures • gatekeeping • managed care

Abbreviations: HMO, health maintenance organization • AHRQ, Agency for Health care Research and Quality • MEPS, Medical Expenditure Panel Survey • SE, standard error


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Gatekeeping arrangements have been used for decades by some health maintenance organizations (HMOs) in the United States to facilitate the provision of integrated health care.1–3 This system requires a designated primary care provider to authorize subspecialist referrals. On the basis of preliminary evidence that this model could reduce costs and inappropriate utilization of subspecialists,4,5 primary care gatekeeping emerged as a major mode of health care delivery in the 1990s and as the hallmark of managed care. As dependents of working-age people with employment-based insurance plans, children were disproportionately overrepresented among beneficiaries enrolled in managed care plans in the private sector.6,7 Even before the introduction of gatekeeping requirements, the vast majority of children obtained health care coordinated by a pediatrician.8 Formal gatekeeping requirements may have introduced additional administrative requirements for children without improving the delivery of care or reducing overuse of subspecialty services.

Empirical evidence that gatekeeping requirements have controlled health expenditures for children is scarce. The lull in health care inflation from 1994 to 1997, which coincided with peak enrollment in gatekeeping plans, is often cited as evidence that gatekeeping requirements effectively controlled costs.1,2,9–11 However, recent upward trends in private health insurance premiums have raised doubts about the ability of such strategies to control expenditures.9,12,13 Previous studies that examined this issue used data that predated the managed care expansion of the 1990s5,14,15; have limited generalizability16; or, as recently reviewed,8 have focused on children with chronic illnesses, on service utilization outcomes, or on Medicaid managed care enrollees. One recent study of children in a Massachusetts managed care organization found that expenditures decreased more for privately insured children who switched to a gatekeeping plan than for those who did not, but as the authors acknowledged, these findings are limited for a variety of reasons.16

In this study, we analyzed data from the Agency for Healthcare Research and Quality’s (AHRQ’s) 1996 Medical Expenditure Panel Survey (MEPS)17 to determine whether health expenditures in the mid-1990s were lower for privately insured children in gatekeeping plans compared with those in indemnity plans. Gatekeeping plans included all children enrolled in HMOs or other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees. In contrast to previous studies, this data source supports a more comprehensive approach by providing nationally representative data on total costs to all purchasers for all types of services. We also examined costs from the insurer’s perspective to determine whether gatekeeping decreased total third-party payments compared with indemnity plans.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The MEPS 1996 expenditure data that were released in the spring of 2001 are the third in a series of national probability surveys conducted by AHRQ on the financing and use of medical care in the United States. The MEPS is designed to provide nationally representative estimates of health care use, expenditures, sources of payment, and insurance coverage for the US civilian noninstitutionalized population.18,19 AHRQ compiled these expenditure data using information obtained from the Household Component, the Medical Provider Component, and the Insurance Component of the MEPS. In the MEPS Household Component ~23 000 individuals were interviewed in person using a computer-assisted personal instrument20 to collect detailed self-reported information on sociodemographic characteristics, health and functional status, utilization of medical care services, health insurance coverage, income, and employment.

The MEPS Medical Provider Component supplements and validates information on medical care events reported in the MEPS Household Component by contacting medical providers and pharmacies identified by household respondents. The MEPS Medical Provider Component includes expenditure data provided by hospitals, medical providers, home health agencies, and pharmacies reported in the MEPS Household Component. Expenditures in MEPS are defined as payments made or received (including out-of-pocket and third-party payments) rather than the amounts charged by providers.20 MEPS estimates of health expenditures do not include administrative costs (ie, costs not directly related to patient care).21 Data from office-based physicians in a 75% sample of Household Component households receiving care through a managed care organization, and a 25% sample of the remaining households are included in the Medical Provider Component.17 Weighted sequential hot-deck imputation is used for the remainder of the sample and any missing values (missing data are imputed from the nearest respondent preceding that person in the sequence who has similar characteristics and complete information).20 The third source of data, the MEPS Insurance Component, collects data from copies of health insurance policies obtained through employers, unions, and other sources of private health insurance and links these data back to individual MEPS Household Component respondents.

We analyzed data from the 3254 children (<18 years old) with private insurance in the 1996 MEPS. Children with publicly funded insurance including Medicaid or other government-subsidized benefits were excluded. Consistent with previous studies,10,22,23 gatekeeping plans were defined as classic staff-model HMOs or plans requiring a primary care gatekeeper based on responses from the MEPS Household Component.20 Indemnity plans were defined as traditional fee-for-service plans as well as preferred provider organization plans that reimbursed providers on a fee-for-service basis and did not have a gatekeeping requirement.10,20 Approximately 10% of hospital cases and 20% of office-based cases were reimbursed through capitation, and thus individual-level expenditure data for this group were not available.20 In these instances, AHRQ used imputation methods to estimate expenditures on the basis of discounted fee-for-service payments.20

We compared total per capita expenditures among children in gatekeeping plans versus indemnity plans. We also examined expenditures by type of service, including inpatient, ambulatory, dental, prescription medication, and home health services. Expenditures included all sources of payment (ie, out-of-pocket, private third-party payers, and other sources) but excluded administrative costs. We performed additional analyses of payments made by private third-party payers on behalf of their beneficiaries and of out-of-pocket expenses paid by beneficiaries.

Statistical Analyses
To obtain nationally representative estimates, we used 1996 person-level weights, which reflect population distributions and account for the household probability of selection, ratio adjustment to national population estimates at the household level, and adjustment for nonresponse. To obtain estimates of variability, we used a Taylor Series estimation approach.24 Variance estimation strata and primary sampling unit variables were provided with the MEPS Household Component data.19

We used {chi}2 tests to compare distributions of categorical covariates (gender, ethnicity, parent-reported health and functional status) between children in gatekeeping and indemnity plans. We used t tests to compare differences in mean per capita expenditures between these 2 groups.

We used multivariate models to examine predicted expenditures for enrollees in gatekeeping and indemnity plans as though both groups had similar distributions of baseline characteristics. Because a significant percentage of the sample had no expenditures, predictions were done using a 2-part model and smearing retransformation methods as described by Duan et al.25,26 We calculated standard errors for predicted expenditures using bootstrapping with 2000 iterations.27

Covariates in the 2-part model included age, ethnicity, gender, poverty status (percentage of federal poverty level), parental perceived health status of the child (rating their child’s ability to resist illness and comparing their child’s health to other children), and functional status (ability to perform age-appropriate social roles). We also examined whether geographic region (northeast, midwest, south, or west) was a significant predictor of expenditures. Among children, expenditures were relatively high for those younger than 2 years and homogeneous for those older than 2 years. Thus, age was modeled as a categorical variable (<1 year, 1–2 years, and >2 years). Because expenditures are increased for pregnant women, we also included a term for the interaction of gender with teenagers of childbearing age (>=15 years).

Statistical tests were 2-tailed and performed on the weighted nationally representative population using SAS-callable (SAS Institute, Cary, NC) SUDAAN.24


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The 3254 children sampled in the MEPS were representative of 40.4 million privately insured American children in 1996. Of these, 22.7 million (58%) were enrolled in gatekeeping plans and 17.7 million (42%) were enrolled in indemnity plans. Members of racial/ethnic minorities were more likely than non-Hispanic whites to belong to gatekeeping plans (Table 1). Children in gatekeeping plans were also more likely to reside in the West or Northeast than those in indemnity plans (P < .05). Otherwise, demographic characteristics were similar in both groups. Functional status and parent-reported health status of children did not differ significantly between the 2 groups.


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  		TABLE 1. Sociodemographic and Health Status Characteristics of Privately Insured Gatekeeping and Indemnity Plan Enrollees in the United States: 1996

 
These 40.4 million privately insured children accounted for $35.7 billion in health expenditures in 1996. Mean annual total expenditures were $887 (standard error [SE]: 101) for children in gatekeeping plans compared with $881 (SE: 90) for those in indemnity plans (P = .96; Table 2). Median per capita expenditures for children in gatekeeping plans were $268 (SE: 10) versus $266 (SE: 17) for indemnity enrollees. The proportion of children with no health expenditures was slightly lower in the gatekeeping group than in the indemnity group (9.0% vs 11.2%; P = .09).


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  		TABLE 2. Mean Per Capita Expenditures for Privately Insured Children (Age <18 Years) by Type of Service: 1996*

 
To examine expenditure differences between gatekeeping and indemnity enrollees in the inpatient and outpatient settings, in Table 2 we show expenditure data by type of service. The proportions of enrollees with any inpatient expense were similar in gatekeeping and indemnity plans (1.6% and 2.4%; P = .21). This subsample was too small to make stable extrapolations about differences between the groups. The proportion of children with any ambulatory care expenditures was higher among gatekeeping plan enrollees compared with indemnity plan enrollees (78% vs 74%; P < .05). Among those with any outpatient expenditures, gatekeeping and indemnity plan enrollees had similar ambulatory expenditures ($288 [SE: 19] and $299 [SE: 20]; P = .69).

We next examined expenditures by source of payment. As shown in Table 3, enrollment in a gatekeeping plan was associated with lower out-of-pocket payments. Families of children enrolled in gatekeeping plans on average paid $62 less out-of-pocket than indemnity plan enrollees (P < .05). Lower out-of pocket payments for children in gatekeeping plans were primarily attributable to lower out-of-pocket payments for ambulatory care and prescription drugs. In contrast, third-party expenditures averaged $636 (median: $173) by gatekeeping plans versus $595 (median: $120) for indemnity enrollees (P = .74). Third-party expenditures for ambulatory services were on average $45 greater for children enrolled in gatekeeping plans compared with those in indemnity plans (P < .05). This difference was primarily attributable to the fact that children in gatekeeping plans were more likely to have ambulatory care expenditures. Analysis limited to children with any ambulatory expenditures found that third-party payers’ outpatient expenditures averaged $762 (SE: 107) for those in gatekeeping plans versus $765 (SE: 114) for those in indemnity plans (P = .99).


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  		TABLE 3. Mean Per Capita Expenditures Among Privately Insured Children, by Source of Payment: 1996

 
The final portion of our analysis used 2-part multivariate methods to model differences in mean annual total expenditures as though gatekeeping and indemnity plan enrollees had a similar distribution of sociodemographic and health status characteristics. Significant predictors of having health expenditures included in the models were age <2 years, non-Hispanic white ethnicity, nonpoor status, functional impairments, parental report of poor health status, and the interaction term for gender with childbearing age (P < .05 for each of these variables). After accounting for the probability of having any health expenditure, we found that if gatekeeping and indemnity plan enrollees had similar characteristics, then total mean per capita expenditures would have been approximately 4% lower for children in gatekeeping plans at $646 (SE: 11) versus $673 (SE: 10) for indemnity plan enrollees (Table 4).


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  		TABLE 4. Mean Per Capita Expenditures Among Privately Insured Children, Adjusted* and Unadjusted: 1996{dagger}

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In 1996, annual total per capita health expenditures differed by <1% for children in gatekeeping plans compared with those in indemnity plans. With 40.4 million children enrolled in gatekeeping plans, this suggests savings of approximately $35.7 million in expenditures in 1996, or an average of $6 per child. This potential saving is <1% of total annual national health expenditures for children and an insignificant amount compared with the $62.1 billion spent for child health care in 1996.28 After multivariate adjustment for differences in sociodemographic and health characteristics of enrollees in both types of plans, predicted expenditures were approximately 4% lower among gatekeeping beneficiaries compared with indemnity plan enrollees.

We also performed expenditure analyses from the insurer’s perspective. Third-party payments for health care services provided through gatekeeping plans were slightly greater than third-party payments in indemnity arrangements. This was attributable mainly to greater payments for ambulatory services resulting from higher rates of ambulatory visits by children in gatekeeping plans compared with indemnity plans. Thus, gatekeeping was not an effective cost containment strategy for insurers. Conversely, out-of-pocket health expenditures for consumers averaged $62 less for children enrolled in gatekeeping plans than in indemnity plans. This was attributable mainly to lower copayments for ambulatory visits and medications gatekeeping beneficiaries than indemnity plan enrollees.

Previous studies have produced mixed findings. Some studies16,22,29–31 have shown similar patterns of utilization for children enrolled in gatekeeping and indemnity plans. In the ambulatory setting, we found that children in gatekeeping plans were slightly more likely to have any outpatient expenditure than those in indemnity plans, but overall outpatient expenditures were similar for both groups. Other studies5,16 have shown decreased subspecialty utilization for children in gatekeeping plans, and these findings have raised concerns about the impact on the quality and accessibility of specialty care, especially for children with chronic conditions.6,8,30

Several caveats apply to our study. First, our study addressed the impact of gatekeeping only on expenditures. We did not explore the impact of gatekeeping on quality of care, including items such as improvements in access to care and coordination of care. A recent literature review30 reported some evidence that privately insured children have improved access to primary preventive health care services in managed care gatekeeping arrangements. Consistent with these findings, we found that privately insured children in gatekeeping plans were slightly more likely to have a visit within the past year compared with those in indemnity plans. As gatekeeping proponents have argued, this suggests that such plans may improve the provision of primary pediatric care in the ambulatory setting. In contrast, enrollment of low-income children in Medicaid managed care plans has led to decreased use of primary care services.30 Evaluations of the mandatory implementation of managed care enrollment for Medicaid recipients in nearly all 50 states may provide additional data on publicly insured children.32 Second, MEPS estimates do not include most administrative costs. Although insurers do not routinely publish administrative costs for each of type of health plan, some have estimated administrative costs as high as 20% of operating expenses in some HMOs and gatekeeping plans,33,34 whereas these costs are only 2% in the predominantly fee-for-service Medicare plan.35,36 Third, our study is a cross-sectional analysis that cannot address longitudinal effects of gatekeeping on health care expenditures. A recent study of health care expenditures from 1991 to 1994 among 1839 children in Massachusetts found that switching to enrollment in a gatekeeping plan was associated with a 42% reduction in expenditures compared with remaining in an indemnity plan.16 However, this study was conducted among children of hospital employees who switched plans and does not provide nationally representative data. Finally, there is substantial heterogeneity among gatekeeping plans. For example, some plans require a primary care provider referral only for the initial visit to a specialist, whereas other plans require referrals for each specialty visit. Our analysis cannot compare costs among these various gatekeeping arrangements.

For the vast majority of children, pediatricians have historically served as the de facto source of primary care. In an attempt to control costs, managed care organizations mandated systematic gatekeeping in the 1990s. Such arrangements have often created unnecessary administrative burdens and difficulties in gaining access to needed care for children with special health care needs.8,37,38 Our analysis of nationally representative 1996 data shows that such a gatekeeping requirement was not associated with lower costs compared with costs for children enrolled in nongatekeeping plans. Many analysts9,11,13,39 believe that managed care organizations priced premiums below cost in the 1990s to gain market share as part of the insurance underwriting cycle. In the last few years, employers and insurance companies have begun abandoning stringent gatekeeper requirements in favor of less restrictive preferred provider arrangements. Contributing factors to this trend may have included "managed care backlash" from patients and providers and threats of tighter governmental regulation. However, as health care costs continue to escalate, some are calling for a return of the cost-containment strategies of the early 1990s.40 Our analysis suggests that gatekeeping is not an effective cost containment method for children.


   ACKNOWLEDGMENTS
 
This study was supported by NRSA General Medicine Research Fellowship Training grant T32 PE10012-07 (to Dr Pati) and Robert Wood Johnson Generalist Physician Faculty Scholar RWJF grant 036830 (to Dr Carrasquillo).


   FOOTNOTES
 
Received for publication Apr 12, 2002; Accepted Aug 30, 2002.

Reprint requests to (O.C.) Division of General Medicine, Columbia University College of Physicians and Surgeons, PH 9 East, Rm 105, 622 West 168th St, New York, NY 10032. E-mail: oc6{at}columbia.edu


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Dudley RA, Luft HS. Managed care in transition. N Engl J Med.2001; 344 :1087 –1092[Free Full Text]
  2. Robinson JC. The end of managed care. JAMA.2001; 285 :2622 –2628[Abstract/Free Full Text]
  3. Lawrence D. Gatekeeping reconsidered. N Engl J Med.2001; 345 :1342 –1343[Free Full Text]
  4. Leibowitz A, Manning WG, Keeler EB, Duan N, Lohr KL, Newhouse JP. Effect of cost-sharing on the use of medical services by children: interim results from a randomized controlled trail. Pediatrics.1985; 75 :942 –952[Abstract/Free Full Text]
  5. Martin DP, Diehr P, Price KF, Richardson WC. Effect of a gatekeeper plan on health services use and charges: a randomized trial. Am J Public Health.1989; 79 :1628 –1632[Abstract/Free Full Text]
  6. Hughes DC, Luft HS. Managed care and children: an overview. Future Child.1998; 8 :25 –38[CrossRef][ISI][Medline]
  7. Leatherman S, McCarthy D. Opportunities and challenges for promoting children’s health in managed care organizations. In: Stein REK, ed. Health Care for Children: What’s Right, What’s Wrong, What’s Next. New York, NY: United Hospital Fund; 1997
  8. Simpson L, Fraser I. Children and managed care: what research can, can’t, and should tell us about impact. Med Care Res Rev.1999; 56(suppl 2) :13 –36[Abstract]
  9. Blumenthal D. Controlling health care expenditures. N Engl J Med.2001; 344 :766 –769[Free Full Text]
  10. Berk ML, Monheit AL. The concentration of health care expenditures, revisited. Health Aff (Millwood).2001; 20 :9 –18[Abstract/Free Full Text]
  11. Levit K, Smith C, Cowan C, Lazenby H, Martin A. Inflation spurs health spending in 2000. Health Aff.2002; 21 :172 –181[Free Full Text]
  12. Weinick RM, Cohen JW. Leveling the playing field: managed care enrollment and hospital use, 1987–1996. Health Aff.1998; 18 :178 –184
  13. Altman DE, Levitt L. The sad history of health care cost containment as told in one chart. Health Aff.2002; 21 :W83 –W84. Available at: www.healthaffairs.org
  14. Moore SH, Martin DP, Richardson WC. Does the primary-care gatekeeper control the costs of health care? Lessons from the SAFECO experience. N Engl J Med.1983; 309 :1400 –1404[ISI][Medline]
  15. Valdez RB, Ware JE, Manning WG, et al. Prepaid group practice effects on the utilization of medical services and health outcomes for children: results from a controlled trial. Pediatrics.1989; 83 :168 –180[Abstract/Free Full Text]
  16. Ferris TG, Perrin JM, Manganello JA, Chang Y, Causino N, Blumenthal D. Switching to gatekeeping: changes in expenditures and utilization for children. Pediatrics.2001; 108 :283 –290[Abstract/Free Full Text]
  17. Household Component Full Year Files. April 2001. Agency for Healthcare Research and Quality, Rockville, MD. Available at: www.meps.ahrq.gov/Data_Pub/hc_fydata96
  18. Machlin SR, Taylor AK. Design, Methods, and Field Results of the 1996 Medical Expenditure Panel Survey Medical Provider Component. Rockville, MD: Agency for Healthcare Research and Quality; 2000 (MEPS Methodology Report No. 9; AHRQ Pub. No. 00-0028)
  19. Cohen SB, DiGaetano R, Goksel H. Estimation Procedures in the 1996 Medical Expenditure Panel Survey Household Component. Rockville, MD: Agency for Healthcare Research and Quality; 2000 (MEPS Methodology Report No. 5; AHCPR Pub. No. 99-0027)
  20. Monheit AC, Wilson R, Arnett RH, eds. Informing American Health Care Policy: The Dynamics of Medical Expenditure and Insurance Surveys, 1977–1996. San Francisco, CA: Jossey-Bass Publishers; 1999
  21. Cohen S. Sample Design of the 1996 Medical Expenditure Panel Survey Household Component. Rockville, MD: Agency for Health Care Policy and Research; 1997 (MEPS Methodology Report No. 2; AHCPR Pub. No. 97-0027)
  22. Miller RH, Luft HS. Managed care plan performance since 1980, a literature analysis. JAMA.1994; 271 :1512 –1519[Abstract]
  23. Newacheck PW, Hung Y, March KS, Hughes DC, Pitter C, Stoddard JJ. The impact of managed care on children’s access, satisfaction, use, and quality of care. Health Serv Res.2001; 36 :315 –334[ISI][Medline]
  24. Shah BV, Barnwell BG, Bieler GS. SUDAAN User’s Manual. Research Triangle Park, NC: Research Triangle Institute; 1997
  25. Duan N, Manning WG, Morris CN, Newhouse JP. A comparison of alternative models for the demand for medical care. J Bus Econ Stat.1983; 1 :115 –126
  26. Duan N. Smearing estimate: a nonparametric retransformation method. J Am Stat Assoc.1983; 78 :605 –610[CrossRef][ISI]
  27. Mooney CZ, Duval R. Bootstrapping: A Nonparametric Approach to Statistical Inference. Newbury Park, CA: Sage University Press; 1993
  28. McCormick MC, Weinick RM, Elixhauser A, Stagnitti MN, Thompson J, Simpson L. Annual report on access to and utilization of health care for children and youth in the United States-2000. Ambulatory Pediatr.2001; 1 :3 –15
  29. Miller RH, Luft HS. Does managed care lead to better or worse quality of care? Health Aff (Millwood).1997; 16 :7 –25[Medline]
  30. Szilagyi PG. Managed care for children: effect on access to care and utilization of health care services. Future Child.1998; 8 :39 –59[ISI][Medline]
  31. Forrest CB, Glade GB, Starfield B, Baker AE, Kang M, Reid RJ. Gatekeeping and referral of children and adolescents to specialty care. Pediatrics.1999; 104 :28 –34[Abstract/Free Full Text]
  32. Anderson GF. State regulation of managed care: the impact on children. Future Child.1998; 8 :76 –92[CrossRef][ISI][Medline]
  33. Himmelstein DU, Lewontin JP, Woolhandler S. Who administers? Who cares? Medical administrative and clinical employment in the United States and Canada. Am J Public Health.1996; 86 :172 –178[Abstract/Free Full Text]
  34. Woolhandler S, Himmelstein DU. Costs of care and administration at for-profit and other hospitals in the United States. N Engl J Med.1997; 336 :769 –774[Abstract/Free Full Text]
  35. 2000 Annual Report of the Board of Trustees of the Supplementary Medical Insurance Trust Fund. April 20, 2000. Available at: www.hcfa.gov/pubforms/tr/
  36. 2000 Annual Report of the Board of Trustees of the Federal Hospital Insurance Trust Fund. March 30, 2000. Available at: www.hcfa.gov/pubforms/tr/
  37. Byrd RS, Hoekelman RA, Auinger P. Adherence to AAP guidelines for well-child care under managed care. Pediatrics.1999; 104 :536 –540[Abstract/Free Full Text]
  38. Ireys HT, Grason HA, Guyer B. Assuring quality of care for children with special needs in managed care organizations: roles for pediatricians. Pediatrics.1996; 98 :178 –185[Abstract/Free Full Text]
  39. Ginsburg P, Gabel JR. Tracking health care costs: what’s new in 1998? Health Aff (Millwood).1998; 17 :141 –146[CrossRef][Medline]
  40. Darling H. Containing costs: corporate employers’ perspective. Health Aff.2002; 21 :W91 –W93. Available at: www.healthaffairs.org
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics



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