CHILDREN’S INSURANCE: Delivery Is as Crucial as Access
Simply providing health insurance coverage to low-income children without developing a comprehensive delivery system may do little to alleviate problems in access to quality care, according to a study published in this month's Pediatrics. Authors Drs. Margo Rosenbach, Carol Irvin and Robert Coulam of Mathematica Policy Research, Inc., and Abt Associates Inc. studied the features of three Medicaid Extension Demonstration projects that were authorized by Congress in 1989 as part of a pilot to develop innovative ways of expanding health insurance to children. The authors conducted telephone interviews with parents of children who participated in the programs in Florida, Maine and Michigan, which all took different approaches to health care delivery. The authors also interviewed parents of children who were eligible, but not participating in the pilots. The Florida Healthy Kids program is a school-based insurance vehicle that used a capitated managed care contractor. The Maine demonstration extended the state's Medicaid program and relied on the program's own administrative mechanisms. Finally, the Michigan Caring Program for Children relied on private donations to fund health care coverage through Blue Cross Blue Shield of Michigan, which donated the administrative costs and provided care on a fee-for-service basis.
Nuts and Bolts
Compared to uninsured children, the children in Florida's managed care pilot fared the best, as they were more likely to have a "usual source" of care, improved preventive care, lower emergency department usage and lower rates of unmet health care needs. Ninety-five percent of Florida children in the study had a usual source of care, compared with 68% of uninsured children, 93% of demonstration children in Maine and 86% of demonstration children in Michigan. Participants in all three demonstration projects had a higher likelihood of having visited a physician during the past three months than uninsured children. And while demonstration children in Florida and Maine had higher rates of physician checkups than their uninsured counterparts, which the authors linked to an increase in preventive care, those in Michigan did "not experience gains in preventive use." In Florida, the HMO took pains to facilitate alternative health care sources at nights and on weekends, instructed ER physicians to refer patients to their primary care physicians and charged $25 co-pays for those ER patients without referrals. In achieving "positive access outcomes on all fronts," the Florida program "actually seems to have enhanced health care access," the authors concluded. However, in Maine and Michigan the projects lacked patient education programs or financial incentives to divert patients from over-using the ER. "Surprisingly," they found, the children enrolled in the Maine program, a "more traditional approach to expanding insurance coverage for low-income children," were more likely to experience "unmet need than low-income children with other types of insurance coverage." The findings, the authors conclude, bolster assertions that the mode of delivery significantly impacts the quality of access to health care for low-income children (Rosenbach et al., June 1999 issue).
You Get What You Pay For
Low Medicaid reimbursements for pediatricians adversely impact children's health, shuttling more children to emergency departments and making it harder for them to make appointments, the AAP Division of Health Policy Research found in a new state-by-state report that suggests Medicaid reimbursements lag behind Medicare reimbursements for the same services. According to "Medicaid Reimbursement Rates by State--1998/1999," the "[s]ervices provided under Medicaid are reimbursed at 20% to 50% less than the same services provided under Medicare." Those figures trail for more than 100 services commonly provided by pediatricians, and reflect an adverse effect on children's access to health care. Further, many states have not increased their Medicaid reimbursement rates for five years, meaning that the reimbursements are "often lower than pediatricians' practice costs." Dr. Richard Nelson, chair of the AAP Committee on Child Health Financing, said, "Medicaid is 25% of pediatricians' revenue compared to the average for all physicians of 12%" (AAP release, 6/14).