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Article Excerpt
INTRODUCTION
Faced with persistent growth in health care costs, employers, state Medicaid programs, the State Children's Health Insurance Program, and other purchasers of care continue to study and often reconfigure managed care plans to find the most efficient strategies that provide access to quality health care while controlling costs. As the delivery and financing of health care services continue to face profound challenges, diligent and focused efforts are needed to ensure that managed care plans serve the varied health care needs of neonates, infants, children, adolescents, and young adults (hereinafter referred to as children) and their families.
The effect of managed care on children's access to services and actual health outcomes remains poorly defined. Some studies suggest no statistically significant differences in self-reported outcomes for children enrolled in managed care plans versus traditional health plans. (1) The effectiveness of managed care in linking more low-income children to a medical home is uncertain. Medicaid program shifts from fee-for-service to managed care plans have had little consistent effect on the pattern of children's health care use and satisfaction with care received. (2) The American Academy of Pediatrics (AAP) urges the use of the principles outlined in this statement in designing and implementing managed care for children. Managed care plans typically use certain cost and utilization management features. (A glossary of managed care terms is available in the AAP publication A Pediatrician's Guide to Managed Care. (3)) It is important to monitor the effects of cost-containment measures on the quality and outcome of medical services for children. The financial arrangements often include discounted charges and fee schedules, performance incentives, and, with decreasing frequency, capitation. The features of utilization management generally include precertification, concurrent review and discharge planning, care coordination, case management, preauthorization, formulary management, and physician practice profiling. These financial and utilization incentives and disincentives should be structured to preserve and, when appropriate, extend access to comprehensive and coordinated preventive, acute, and chronic care for all children. Performance incentives must improve quality of care and actual clinical outcomes and not become barriers to access to care and receipt of services. Attention should be paid to physician reimbursement as a predictor of the quality of care that children and adolescents receive. (4) By including the precepts of primary care in the delivery of services, managed care can be instrumental in increasing access to a full range of health care services and clinicians within a medical home. It is imperative that managed care plans fully support the intent and desired outcomes of a medical home. A medical home provides care that is accessible, family centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. (5)
Medically necessary health interventions are intended to prevent, diagnose, detect, treat, ameliorate, or palliate the effects of a physical, mental, genetic, or congenital condition, injury, or disability that lies outside the range of normal variation. Managed care organizations frequently use medical management guidelines to make coverage determinations, many of which are not well supported by medical evidence, are not developed with a pediatric focus, are derived from best-case actuarial data, or are proprietary. The...
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