Betsy Shenkman, Lili Tian, John Nackashi, and Desmond Schatz June 2005

1. Managed Care Organizational Characteristics and Outpatient Specialty Use Among Children With Chronic Conditions Betsy Shenkman, Lili Tian, John Nackashi, and Desmond Schatz June 2005 This work was funded by the Agency for Health Care Research and Quality, the American Association of Health Plans Foundation, and Health Resources and Services Administration, Maternal and Child Health Bureau, Grant #U01 HS09949-02.

2. Background • Access to specialty care particularly important for children with chronic conditions • Examine the relationship between managed care organizations’ (MCOs) characteristics and children’s outpatient specialty use in a cohort of children with chronic conditions • All children enrolled in SCHIP (Florida)and receiving care where the primary care providers (PCPs) served as gatekeepers • All MCOs required to offer the same benefit package and co-payments at the time of the visit

3. The Sample N=2,333 • Identified children enrolled in SCHIP who had a diagnosis indicative of a chronic condition (asthma, diabetes, cystic fibrosis, depression, etc) (8% of children - dx and enrolled) • Had one or more condition consequences using the Questionnaire for Identifying Children With Chronic Conditions (QuICCC) (65% of those with the dx) • Surveys conducted in 2000

4. The Sample • Eight MCOs participating in SCHIP • Conducted interviews to characterize: • Prior authorization procedures, • The availability of PCPs who are pediatricians in the networks, • PCP reimbursement (FFS, capitation, salary), and • The use of financial incentives to promote meeting pediatric quality of care standards. • No MCO withheld payments based on specialty referrals.

5. Specialty Use • Examined children’s outpatient specialty use one year after the survey using claims and encounter data supplied by the MCOs – 2001 • Variables included: • MCO characteristics • Children’s sociodemographic characteristics and number of condition consequence • Provider availability and presence of a children’s hospital or academic health center in area

6. Analyses • Examined clustering effects using GEE • Logistic regression with forward model selection to identify most significant explanatory variables • The full model not different from reduced model at .05 level

7. Children’s Sociodemographic and Health Characteristics • 12 years old on average • Enrolled an average of 15 months • Race - 76% white, 13% black, 11% other • Ethnicity - 25% Hispanic • 15% had specialty visit in year before survey • 15% had specialty visit in year after the survey

8. MCO Characteristics

9. Key Findings – MCO Characteristics • Each 10% increase in pediatricians – specialty use increased 17% • Each 10% increase in % PCPs receiving FFS, specialty use decreased 5% • Children cared for in MCOs offering financial incentives related to quality 71% more likely to have an outpatient specialty visit • Controlled for presence of children’s hospital and providers in area

10. Key Findings - Sociodemographic and Health Characteristics • Black children about one-half as likely as White children to have an outpatient specialty visit • Girls 19% less likely than boys to have a visit • Odds of a specialty visit increased with longer enrollment • 52% more likely to see a specialist in year after survey if child saw a specialist in year prior to the survey • Condition consequences and diagnoses not significant

11. Limitations • Can only partially address complex structures of MCOs • Studying groups of children with chronic conditions – no clear benchmarks • Possible unmeasured community factors related to specialist availability

12. Summary • Limited standards of care available about specialty use • Blended payments – may encourage capitated providers to see children where referral may be discretionary • Other studies show pediatricians use more resources than family practitioners • Use of financial incentives linked to quality may foster a focus on meeting children’s health care needs