Parents of children with chronic conditions are not likely to choose an HMO plan, according to a study by Massachusetts General Hospital (MGH) researchers. The report, in the August issue of Pediatrics, suggests these parents are willing to pay higher costs for medical care in order to have direct access to specialists.
"This study adds one more piece of evidence that people with chronic conditions avoid changing health plans," says lead author Timothy G. G. Ferris, MD, a pediatrician at MGH. Although other studies have shown that adults with chronic conditions are less likely to switch plans, this study showed that a child's health status matters when parents are choosing a health plan.
From 1991 to 1994, the study followed more than 1,800 children whose parents either voluntarily switched to a "gatekeeping" HMO - one that requires that a primary care physician pre-approves visits to specialists - or remained in an indemnity plan, which provided unlimited patient access to specialist physicians. The results showed that parents of children with chronic health conditions were significantly less likely than other parents to enroll in the gatekeeping plan.
Ferris says the incentive to switch health plans is usually a lower cost to the patient, so if parents of chronically ill children want to retain their old health plans, they have to pay a higher price. Parents who are financially burdened may feel torn between getting the best plan financially versus the plan they perceive to be best for their child's health.
That perception may be valid. The current study also questions the claim that HMO gatekeeping plans lower costs while improving delivery of care. "According to this study, after switching to a gatekeeping plan, kids with chronic illness had fewer visits to both generalists and specialists in the HMO.
This is concerning since one of the goals of managed care gatekeeping is to improve contact of children with chronic conditions with primary care physicians," says Ferris. He and his colleagues expected that the primary care physicians would provide some of the care previously provided by specialists before coverage was switched to a gatekeeping plan. However, this was not the case.
Parents who made the switch had fewer visits with both specialists and primary care physicians, indicating a decreased amount of care for each child. "Gatekeeping has been touted by managed care providers as a mechanism for improving coordination of care for children with chronic illness," says Ferris. "But those children did not visit their primary care physicians more often. That runs contrary to what the managed care providers state." Ferris says although switching to gatekeeping was associated with disruption in care for children, the implications for children's health were not evaluated as part of the study and remain unclear.
Study support was provided by the Robert Wood Johnson Foundation and the Pediatric Scientist Development Program.
The Massachusetts General Hospital, established in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $300 million and major research centers in AIDS, the neurosciences, cardiovascular research, cancer, cutaneous biology, transplantation biology and photomedicine. In 1994, the MGH joined with Brigham and Women's Hospital to form Partners HealthCare System, an integrated health care delivery system comprising the two academic medical centers, specialty and community hospitals, a network of physician groups and nonacute and home health services.
Journal
PEDIATRICS