Managed care for children: effect on access to care and utilization of health services.

The rapid trend toward enrolling children in managed care has occurred largely without conclusive evidence about the effects of these arrangements on two important aspects of care: access and utilization. Although the effect of managed care on these measures has been studied more widely in the adult population, the results may not be applicable to children, who have unique health care needs centering around prevention and early treatment of acute illnesses to avoid long-term health problems. Moreover, several methodological challenges make it difficult to evaluate the impact of managed care on health care access and utilization in general. This article reviews what is known about the effect of managed care on access to health services, as well as utilization of hospital care, emergency department (ED) visits, primary care services, and specialty services for the pediatric population. In each area, findings from privately insured children and Medicaid enrollees are considered separately. There is little conclusive evidence on the effect of managed care on access to and utilization of pediatric health services. A recurring theme is that the effect of managed care is dependent on several factors, including whether providers assume financial risk through capitated reimbursements or retain fee-for-service payments; the comprehensiveness of benefits offered by health plans; and the level of cost sharing required of families. Among privately insured children, for example, managed care usually has been associated with higher primary care visit rates, though the benefit of managed care is reduced when fee-for-service plans cover preventive care and require minimal or no cost sharing for these services. Among Medicaid recipients, studies suggest that managed care is more likely to be associated with a decrease in preventive visits when provider payments are capitated. Attempts to decipher effects by health plan type are made more difficult by the rapid evolution of both managed care and fee-for-service plans, which often blurs the distinction between these two entities. Nonetheless, in some areas, managed care does appear to have an identifiable effect on pediatric health services. For Medicaid recipients, managed care has been associated with decreased emergency department use and decreased access to specialty care for chronically ill children. As enrollment of children in managed care plans increases, the need continues for methodologically sound studies evaluating the effect of these arrangements on the delivery of pediatric health services and on health outcomes.