Managed care and the quality of children's health services.

Managed care has changed the practice of medicine. The choice of health care providers has been narrowed, physicians are being held financially accountable for the number of services they use, and a new emphasis is being placed on the cost and quality of the care provided. The transition to managed care has occurred with little attention to its impact on access to health care services or the quality of services provided. There is an absence of information about how children fare in these new systems. What little is known indicates that children in managed care arrangements are less likely to be able to be seen by pediatric specialists, and that families and providers are less satisfied under managed care. The impact of these changes on children's health status, however, is yet to be determined. For children with special needs, the problems of coordination of care, coverage of needed services, and the choice of the appropriate pediatric subspecialists, many of which existed in traditional fee-for-service systems, persist under managed care. In spite of all of the negative anecdotes about managed health care, managed care's focus on its population of enrollees and its heightened sense of a need for health care accountability bring exciting new opportunities to measure and improve the health care children receive. A new emphasis is being placed on practicing evidence-based medicine; the focus is on closing the gap between what is known (effective, evidence-based care) and what is done (current practice). Improved health outcomes and reduced health care costs have been documented in demonstration projects in neonatal intensive care units and in pediatric offices. Applying the principles of these learning collaboratives and employing the tools of continuous quality improvement in health care are urgent challenges that deserve to be met. Health plans, physicians, health care purchasers, regulators, families, and their children must work together to assure that children receive the highest-quality care possible--care that is technically excellent and medically appropriate, and that improves the health of our children.