Who cares for medicaid-enrolled children with chronic conditions?

Improved Health Care Among Children With Special Health Care Needs After Enrollment Into the State Children’s Health Insurance Program

OBJECTIVE

To assess the impact of New York's State Children's Health Insurance Program (SCHIP) on health care for children with special health care needs (CSHCN).

METHODS

Little is known about the impact of health insurance on CSHCN. Parents of a stratified random sample of new enrollees onto New York's SCHIP were interviewed by telephone at enrollment (n = 2644) and 1 year later (n = 2290, 87% response). At baseline, the cohort of CSHCN was defined by means of the standardized CSHCN screener instrument. The impact of SCHIP was assessed for CSHCN and for subgroups of CSHCN stratified by prior insurance (uninsured or insured) or type of chronic condition (physical or mental/behavioral). Access (having a usual source of care [USC], unmet medical needs); and quality (continuity of care at the USC, parent rating of quality of care or worry about child) were measured. Bivariate and multivariate analyses compared measures 1 year before SCHIP versus the year during SCHIP.

RESULTS

A total of 398 (17%) of 2290 children had special health care needs identified at baseline. Enrollment onto SCHIP was generally associated with improved access: unmet needs for prescription medications declined 3-fold for all subgroups (eg, 36% to 9% among the previously uninsured) and unmet needs for specialty care declined >4-fold among CSHCN who were previously insured (48% to 10%) or had mental/behavioral conditions (32% to 2%; all P < .05). Enrollment was associated with improved continuity with the USC, parent-reported quality of care, and worry, irrespective of prior insurance or type of chronic condition (P < .05).

CONCLUSIONS

Enrollment onto New York's SCHIP improved medical care for CSHCN.

Medical care utilization and mortality in sickle cell disease: a population-based study

The purpose of this study was to evaluate the pattern of medical care utilization and mortality in children and adults with sickle cell disease (SCD) in the state of Tennessee. Rates of hospitalization, emergency department visits, and deaths were measured in a cohort of adults and children with SCD enrolled in TennCare, Tennessee's Medicaid managed health care program, from January 1995 to December 2002. TennCare data linked to Tennessee vital records were used to define the population and identify the outcomes. For children less than 5 years of age, the mortality rate was similar to that of other black Tennessee children (P = 0.71). Among children, the death rate was highest in 10-19 years of age and was 8-fold higher than Tennessee's race- and age-specific rate. Among 20- to 49-year-old patients with SCD, mortality was significantly higher in males than in females (P < 0.001). As compared to the black population without SCD in TennCare, patients with SCD had 7-30 times higher rate of hospitalization and 2-6 times higher rates of emergency department visits (P < 0.001). The death rate in adolescents and young adults with SCD continues to be much higher than population-specific rates. Interventions to prevent morbidity and mortality related to SCD are urgently needed.

The pediatric subspecialty workforce: public policy and forces for change

Policy has not adequately addressed the unique circumstances of pediatric subspecialties, many of which are facing workforce shortages. Pediatric subspecialties, which we define to include all medical and surgical subspecialties, are discrete disciplines that differ significantly from each other and from adult medicine subspecialties. Concerns about a current shortage of pediatric subspecialists overall are driven by indicators ranging from recruitment difficulties to long wait times for appointments. The future supply of pediatric subspecialists and patient access to pediatric subspecialty care will be affected by a number of key factors or forces for change. We discuss 5 of these factors: changing physician and patient demographics; debt load and lifestyle considerations; competition among providers of subspecialty care; equitable reimbursement for subspecialty services; and policy to regulate physician supply. We also identify issues and strategies that medical and specialty societies, pediatric subspecialists, researchers, child advocates, policy makers, and others should consider in the development of subspecialty-specific workforce-policy agendas.

Association between underinsurance and access to care among children with special health care needs in the United States

OBJECTIVE

To examine the impact of underinsurance on access to care among children with special health care needs (CSHCN) in the United States.

METHODS

Interviews were conducted by telephone with the families of 38866 CSHCN who were younger than 18 years using the 2001 National Survey of Children With Special Health Care Needs. The prevalence of underinsurance and its relationship to access to care and family financial problems was examined in this cross-sectional analysis. CSHCN were classified as underinsured when coverage was deemed inadequate to meet the child's needs.

RESULTS

An estimated 12.8% of US children experienced a special health care need in 2001. Although 95% of CSHCN had some type of insurance coverage at the time of the interview, 32% were classified as underinsured. Underinsured CSHCN were disproportionately represented in low-income families and were significantly more likely than fully insured children to have unmet health needs, and their families were more likely to report difficulty in obtaining specialty referrals, experience financial problems, and report that the child's condition caused family members to reduce or stop work. Underinsured CSHCN seemed to be somewhat better off than CSHCN with no insurance coverage on these measures.

CONCLUSIONS

Underinsured CSHCN represent an important and largely hidden underserved population.

Disease burden in the managed care population at an academic medical center: the effect of adding local partners

PURPOSE

Academic medical centers (AMCs) have traditionally cared for the most severely ill patients. AMCs' effort to meet the challenges of managed care contracts may be nullified by adverse selection unless payment mechanisms adequately consider the health risk of the AMC's managed care population. The authors compared the disease burden between the University of Michigan Health System (UMHS) and its community competitors and assessed the effect of adding local primary care partners through strategic outsourcing on these differences in disease burden.

METHOD

This is a population-based study from one managed care plan in Michigan. The study population was commercial members (n = 127, 892) enrolled in the plan for the entire 12 months of 2001. The authors derived several morbidity measures from age and sex, Adjusted Clinical Groups, and Aggregated Diagnosis Groups using administrative data.

RESULTS

Compared to community groups, the UMHS consistently had a higher disease burden, while the nonacademic groups as a whole had more young members with acute conditions. After the UMHS partnered with two local primary care practice groups in their area, this AMC-local partner group had an equal or lower disease burden than the remainder of the community groups that experienced a slightly higher proportion of members with multiple medical conditions.

CONCLUSIONS

The higher disease burden borne by AMCs is a complex phenomenon. Without local partners, the UMHS did experience higher disease burden, although the degree depends on the measurement of morbidity. Partnering with carefully selected local primary care groups may ameliorate the AMC's disproportionate disease burden.

Delayed or forgone care among children with special health care needs: an analysis of the 2001 National Survey of Children with Special Health Care Needs

OBJECTIVE

To examine the associations of sociodemographic characteristics with both the prevalence and the causes of delayed or forgone care in a nationally representative sample of children with special health care needs.

METHODS

Data were abstracted from the 2001 National Survey of Children with Special Health Care Needs. The families of children with special health care needs (CSHCN) who reported delayed or forgone care were asked about the reasons. The 12 reasons in the questionnaire were grouped into 5 categories. Bivariate and multivariate logistic regression analyses were conducted in SUDAAN to examine the relationship between sociodemographic characteristics of CSHCN and the incidence of delayed or forgone care by its reasons.

RESULTS

Nearly 10% of CSHCN had experienced delayed or forgone health care in the past 12 months in 2001. Logistic regression showed that delayed or forgone care was more likely to be reported by the families of CSHCN who were adolescents, who had more severe limitations, lived in the South or West, lacked medical insurance, and who lived in families under or near the federal poverty line. Hispanics were more likely to report "lack of medical specialty" and "had language, communication, or cultural problems with provider." Both Hispanics and non-Hispanic others were twice as likely to report "provider not accessible" as reasons for the delayed or forgone care compared with non-Hispanic whites or blacks. conclusion: CSHCN with certain socioeconomic status and sociodemographic characteristics, as well as those with severe limitations in activity, were more likely to be affected by circumstances that result in delayed or forgone care.

A national assessment of children with special health care needs: prevalence of special needs and use of health care services among children in the military health system

OBJECTIVE

Children are frequently perceived to be healthy, low-risk individuals with a majority of clinical services devoted to health maintenance and preventive clinical services. However, a subset of children have unique needs that require specialized care to achieve optimal health outcomes. The purpose of this research was to use survey tools that have been developed to identify children with special health care needs (CSHCN) to measure prevalence and resource needs of these children in the military health system (MHS).

METHODS

The US Department of Defense manages the MHS, which is one of the largest integrated health care systems in the world and provides care to almost 2,000000 children. We incorporated the CSHCN survey screener and assessment questions into the annual health care survey of beneficiaries who are eligible for benefits within the MHS. In addition, we used claims information available from inpatient and outpatient services. We used parent reports from the survey to estimate the prevalence of CSHCN. Incorporating claims data and restricting our analyses to those who were enrolled continuously in a military health maintenance organization (TRICARE Prime), we described utilization of different types of health care resources and compared CSHCN with their healthy counterparts. Finally, we examined alternative types of special needs and performed regression analyses to identify the major determinants of health needs and resource utilization to guide system management and policy development.

RESULTS

CSHCN compose 23% of the TRICARE Prime enrollees who are younger than 18 years and whose parents responded to the survey. The needs of a majority of these children consist of prescription medications and services targeting medical, mental health, and educational needs. CSHCN experience 5 times as many admissions and 10 times as many days in hospitals compared with children without special needs. CSHCN are responsible for nearly half of outpatient visits for enrolled children and more than three quarters of inpatient days. Service utilization varies dramatically by type of special need and other demographic variables.

CONCLUSION

CSHCN represent a major challenge to organized systems of care and our society. Because they represent a group of children who are particularly at risk with potential for improved health outcomes, efforts to improve quality, coordinate care, and optimize efficiency should focus on this target population.

Role of pediatric and internist rheumatologists in treating children with rheumatic diseases

OBJECTIVE

To quantify and describe the role of internist and pediatric rheumatologists in the care of children with rheumatic diseases and identify factors associated with internist rheumatologists' willingness to treat children.

METHODS

We surveyed physician members of the American College of Rheumatology who currently practice in California (n = 589). Bivariate and logit analyses were used to examine the effects of training, provider, practice, and distance to the nearest pediatric rheumatologist on the likelihood that an internist rheumatologist treated children.

RESULTS

Our effective response rate was 51%. More than one third of internist rheumatologists who practice in California reported treating pediatric patients. On average, internist rheumatologists who treated children saw 3.1 patients younger than 18 years weekly; half of these patients were 16 and 17 years of age. In logistic regression analysis, internist rheumatologists who treat pediatric patients were significantly more likely to practice in a multispecialty clinic (adjusted odds ratio: 3.5; 95% confidence interval: 1.9-9.7) and to live >50 miles from a pediatric rheumatologists (adjusted odds ratio: 6.8; 95% confidence interval: 2.1-22.7). In aggregate, we estimate that pediatric rheumatologists and internist rheumatologists provide care to 550 and 419 patients younger than 18 years per week, respectively.

CONCLUSIONS

A substantial number of California internist rheumatologists are involved in the care of children, especially adolescents. The heavy involvement of internist rheumatologists in the care of children suggests that additional pediatric rheumatologists may be needed in select areas. Our findings have important implications for the size and distribution of the pediatric rheumatology workforce, the content of fellowship training for internist rheumatologists, and future studies of the relative quality of pediatric rheumatology care offered by internist rheumatologists. Furthermore, the role of internist subspecialists in caring for children with other chronic illness should be assessed.

Correlates of use of specialty care

OBJECTIVE

This study examines patterns of specialist use among children and adolescents by presence of a chronic condition or disability, insurance, and sociodemographic characteristics.

DESIGN

Cross-sectional analysis of national survey data, describing rates of specialist use, with logistic regressions to examine associations with having a chronic condition or disability, insurance status, and sociodemographic variables.

SETTING

The 1999 National Health Interview Survey, a nationally representative household survey.

PARTICIPANTS

Children and adolescents 2 to 17 years old.

OUTCOME

Parental/respondent reports of specialist visits based on reports of the child having seen or talked to a medical doctor who specializes in a particular medical disease or problem about the child's health during the last 12 months.

RESULTS

Thirteen percent of US children were reported as seeing a specialist in the past year. Specialist-visit rates were twice as high for children with a chronic condition or disability (26% vs 10.2%). The specialist utilization rates for children without insurance were much lower than those for insured children, but among the children who have coverage (private, Medicaid, or other), specialist-utilization rates were similar (no statistically significant difference). Results of multivariate analyses predicting the use of specialists confirm the above-mentioned findings. Additionally, they show that use of specialist care was lower among children in the middle age group, minorities, children in families between 100% and 200% of the federal poverty level, and lower parental educational levels. We found no difference in specialist-visit rates between rural- and urban-dwelling children, by family status, or by gender. Differences in specialist use by gatekeeping status are found only among subgroups.

CONCLUSIONS

The results showed that, overall, 13% of children used a specialist in a year. Among the insured, a slightly greater percentage of children used such care (15%). These numbers were slightly lower than the 18% to 28% of pediatric patients referred per year in 5 US health plans, although the sources of data and definitions of specialist use differ. Our results showed that 26% of children with a chronic condition or disability who were insured by Medicaid use a specialist. Although the data are not directly comparable, this is within the range of previous findings showing annual rates by condition of use between 24% and 59%. These findings are consistent also with greater use of many different types of health care by children with special health care needs. Medicaid-utilization rates presented here were similar also to the rates found among privately insured children and children with "other" insurance. In our earlier work examining use of specialists by children insured by Medicaid, we speculated that Medicaid-insured children might face particular difficulty with access (eg, due to transportation or language barriers). The findings presented here suggest that children insured by Medicaid had no different use of specialists than other insured children. We do not know, however, whether similar rates are appropriate. As predicted, sociodemographic differences were pronounced and followed patterns typically found for use of health services. Lower rates of specialist use by non-Hispanic blacks and Hispanics remains even, controlling for chronic condition/disability, status, insurance, and socioeconomic status. This is an important issue that not only needs to be addressed in using specialist care but also in many areas in health care. It is the near poor who seem to have difficulty accessing care (as is evidenced by lower use of specialists). In a study of access to care, similar results were found, with those between 125% and 200% of the federal poverty level being less likely to have a usual source of care. This is roughly the population targeted by the State Children's Health Insurance Programs. These findings cannot determine whether rates of use are too high or too low. Additional work on outcomes for children who do and do not use specialist care would further inform the work presented here. Extending that work to examine patterns of care including but not limited to specialists and generalists would be even better.

Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs

OBJECTIVE

To assess the prevalence of unmet needs for routine and specialty care among children with special health care needs (CSHCN) and to identify factors associated with the likelihood of having unmet need for medical care.

METHODS

Data come from the respondents for 38 866 children interviewed for the National Survey of Children With Special Health Care Needs. Bivariate analyses were used to assess differences in unmet need for medical care by various environmental, predisposing, enabling, and need factors. Logit analyses were used to determine independent effects of these variables on the likelihood of having an unmet need for medical care.

RESULTS

Nationally, 74.4% and 51.0% of CSHCN needed routine and subspecialty physician care, respectively. Of those reporting that they needed routine care, 3.2% were unable to obtain these services. Of those reporting a need for specialty care, 7.2% reported not obtaining all needed specialty care. The prevalence of unmet need for specialty care significantly exceeded the prevalence of unmet need for routine care. In logit analyses, African American children and children whose mothers had less than a high-school education faced twice the odds of having an unmet need for routine care. Compared with nonpoor children, children living below the federal poverty level were significantly more likely to have an unmet need for routine (adjusted odds ratio [aOR]: 1.97; 95% confidence interval [CI]: 1.23-3.14) and specialty (aOR: 2.50; 95% CI: 1.49-4.18) care. Near-poor children were also significantly more likely than nonpoor children to have unmet needs for routine and specialty care. Uninsured children were significantly more likely than continuously insured children to report an unmet need for routine (aOR: 7.51; 95% CI: 4.99-11.30) and specialty (aOR: 4.29; 95% CI: 2.99-6.15) care. Our findings also show that higher levels of general pediatrician supply, relative to the pediatric population, are associated with a significantly lower likelihood of having an unmet need for routine care. Likewise, a greater supply of pediatric subspecialists is associated with a decreased likelihood of having an unmet need for specialty care.

CONCLUSIONS

Compared with previous reports of the general pediatric population, CSHCN have higher levels of unmet need for medical services. Our regression results emphasize that children vulnerable because of their social circumstances (eg, poverty, etc) have significantly greater odds of having unmet need for routine and specialty physician care. Furthermore, our findings highlight the importance of insurance coverage in ensuring access to needed routine and specialty medical services.

Identification and recall of children with chronic medical conditions for influenza vaccination

OBJECTIVES

Despite long-standing recommendations to provide annual influenza vaccination to children with chronic medical conditions, immunization rates are <10% in most primary care settings. Many obstacles impede implementation of these recommendations, including the challenge of identifying targeted children and the need to immunize yearly in a short time interval. The objective of this study was to assess the accuracy of billing data for identifying children who have high-risk conditions (HRCs) and need influenza vaccination and 2) to evaluate the efficacy of reminder/recall for children with HRCs.

METHODS

The study was conducted in 4 private pediatric practices in metropolitan Denver, Colorado, that share a computerized billing system and also participate in an immunization registry. For all children aged 6 to 72 months, registry records were linked with the billing database. Patients with >or=1 encounters for an HRC in the previous 24 months were selected, with HRCs identified from International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Using medical records as the "gold standard," we reviewed 327 randomly selected records to determine the sensitivity, specificity, and accuracy of billing data for identifying HRCs. For children with an HRC, we then conducted a randomized, controlled trial of reminder/recall for influenza vaccination. The primary outcome of the recall trial was receipt of influenza vaccine.

RESULTS

Billing data had a sensitivity of 72% (95% confidence interval [CI]: 48%-95%), specificity of 95% (95% CI: 90%-100%), and overall accuracy of 90% (95% CI: 84%-96%) in determining which children had an HRC. Of the 17,273 patients aged 6 to 72 months, 2007 had >or=1 HRCs (12% overall; range: 9%-14% per practice). Asthma/reactive airways disease accounted for 87% of all HRCs. Reminder/recall significantly increased influenza immunization in children with HRCs, with a vaccination rate of 42% in those recalled, compared with 25% in control subjects. Recalled subjects were more likely to have an office visit (68% vs 60%) and less likely to have a missed opportunity to immunize (28% vs 37%) compared with control subjects.

CONCLUSIONS

Diagnosis-based billing data accurately identified children who had HRCs and needed annual influenza vaccination, and registry-driven reminder/recall significantly increased influenza immunization in targeted children.

Access to pediatric rheumatology care in the United States

OBJECTIVE

To describe rheumatology providers, depict their availability, and determine the extent to which internist rheumatologists may expand access to care for children with rheumatic diseases.

METHODS

Using data from the American College of Rheumatology and the Bureau of Health Professions Area Resource File, we generated a national map of providers' practice locations and calculated distances between each county and the nearest rheumatologist. We also performed a logit analysis to identify provider and county characteristics that were associated with internist rheumatologists' willingness to treat children.

RESULTS

Approximately 50% of the under 18 population in the United States live within 50 miles of a pediatric rheumatologist and nearly 90% live within 50 miles of a pediatric rheumatologist or an internist rheumatologist who treats children. Internist rheumatologists in private practice were 3 times as likely as those in medical schools to treat children (P < 0.001). Likewise, internist rheumatologists who live 200 or more miles from a pediatric rheumatologist were more than twice as likely to treat children as those who lived within 10 miles of a pediatric rheumatologist (P < 0.001).

CONCLUSIONS

Our analysis suggests that internist rheumatologists are more geographically diffuse than pediatric rheumatologists and act as substitutes for pediatric rheumatologists in those regions that lack such providers. Research is needed to understand the role of internist rheumatologists in caring for children with rheumatic diseases and the quality of the care that they provide to this population.

Sicker and poorer--the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income

Health services research conducted over the past 25 years makes a compelling case that having health insurance or using more medical care would improve the health of the uninsured. The literature's broad range of conditions, populations, and methods makes it difficult to derive a precise quantitative estimate of the effect of having health insurance on the uninsured's health. Some mortality studies imply that a 4% to 5% reduction in the uninsured's mortality is a lower bound; other studies suggest that the reductions could be as high as 20% to 25%. Although all of the studies reviewed suffer from methodological flaws of varying degrees, there is substantial qualitative consistency across studies of different medical conditions conducted at different times and using different data sets and statistical methods. Corroborating process studies find that the uninsured receive fewer preventive and diagnostic services, tend to be more severely ill when diagnosed, and receive less therapeutic care. Other literature suggests that improving health status from fair or poor to very good or excellent would increase both work effort and annual earnings by approximately 15% to 20%.

Comorbidity: implications for the importance of primary care in 'case' management

BACKGROUND

Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions.

METHODS

Data from claims on the nonelderly were classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions.

RESULTS

Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions.

CONCLUSIONS

In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients' overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.

Receipt of asthma subspecialty care by children in a managed care organization

BACKGROUND

Although proper outpatient asthma management sometimes requires care from subspecialists, there is little information on factors affecting receipt of subspecialty care in a managed care setting.

OBJECTIVE

To determine factors associated with receipt of subspecialty care for children with asthma in a managed care organization.

METHODS

We conducted an analysis of the claims from 3163 children with asthma enrolled in a university-based managed care organization from January 1998 to October 2000. We used logistic regression analysis to determine factors associated with an outpatient asthma visit with an allergist or pulmonologist.

RESULTS

Of the 3163 patients, 443 (14%) had at least 1 subspecialist visit for asthma; 354 (80%) were seen by an allergist, 63 (14%) were seen by a pulmonologist, and 26 (6%) were seen by both. In multivariate analysis, patients with more severe asthma (odds ratio [OR], 3.81; 95% confidence interval [CI], 2.99-4.86) and older patients (OR, 1.04; 95% CI, 1.02-1.07) were more likely to receive care from a subspecialist. Compared with Medicaid patients, both non-Medicaid patients with copayment (OR, 2.52; 95% CI, 1.85-4.43) and non-Medicaid patients without any copayment (OR, 3.40; 95% CI, 2.35-4.93) were more likely to receive care from an asthma subspecialist.

CONCLUSIONS

Children insured by Medicaid are less likely to receive care from subspecialists for asthma. Reasons may be due to health care system-related factors, such as accessibility of subspecialists, to physician referral decisions, and/or to patient factors, such as adherence to recommendations to see a subspecialist. Our findings suggest a need to further investigate health care system barriers, physician referral, and patient acceptance and completion of subspecialty referral.

Generalist and subspecialist care for children with chronic conditions

OBJECTIVE

To determine, among Medicaid-enrolled children with chronic conditions, associations of indicators of morbidity and expenditures with different patterns of generalist, subspecialist, and pediatric subspecialist use.

DESIGN AND SETTING

Cross-sectional analysis of Medicaid claims, enrollment, and provider data from 4 states (California, Georgia, Michigan, and Tennessee).

SAMPLE

All children enrolled in Supplemental Security Income (aged 0-21 years) and a sample of other Medicaid-enrolled children matched for age and gender. We included 11 chronic conditions, including both uncommon conditions (eg, spina bifida, hemophilia) and common ones (eg, asthma, attention deficit hyperactivity disorder).

MAIN OUTCOME MEASURES

We determined the number of visits per year to generalists and subspecialists (pediatric and other), using only subspecialists relevant to that condition. We categorized patterns of care as generalist only, predominantly generalist, or predominantly subspecialist, and examined patterns by condition and an indicator of morbidity. Among children seeing subspecialists, we also compared morbidity by pediatric and other subspecialists. We used linear regression to determine per-year total expenditures, controlling for demographic characteristics and morbidity.

RESULTS

Most children (60.7%) saw generalists only. Twenty-eight percent were in predominantly generalist arrangements, and 11% were in predominantly subspecialist arrangements. Children in predominantly generalist arrangements had higher morbidity than children in generalist-only or predominantly subspecialist arrangements. Among children seeing subspecialists, those seeing pediatric subspecialists had generally higher morbidity than those seeing other subspecialists. Mean yearly expenditures varied from 1306 dollars (attention deficit hyperactivity disorder) to 11,633 dollars (acquired immunodeficiency syndrome). Children who saw only generalists had significantly lower expenditures for 6 of the 11 conditions, after adjusting for morbidity.

CONCLUSIONS

Medicaid-enrolled children in predominantly generalist arrangements appear to have more complicated conditions than children in generalist-only or predominantly subspecialist arrangements, engendering also higher expenditures. Although children who saw generalists only had lower expenditures than those seeing subspecialists, this finding may reflect unmeasured variations in morbidity.

Health services research for children with disabilities

Growing numbers of children and adolescents have long-term disabilities. Research on the epidemiology, clinical care and its improvement, organization, and financing of care for children with disabilities is very limited. Given the cost burden of the nation's chronic diseases and disabilities, the lack of investigation into necessary clinical activities seems remarkable. This article reviews recent research on health services relating to children and adolescents with disabilities and outlines a research agenda in clinical and health services for this population in these study areas.