Meeting the Health Care Needs of Adolescents in Managed Care: A Background Paper
1998; Elsevier BV; Volume: 22; Issue: 4 Linguagem: Inglês
10.1016/s1054-139x(98)00008-1
ISSN1879-1972
AutoresAbigail English, Cynthia J. Kapphahn, Jonathan A. Perkins, Charles J. Wibbelsman,
Tópico(s)Primary Care and Health Outcomes
ResumoManaged care is replacing traditional fee-for-service reimbursement as the dominant method of health care financing and service delivery for patients whose care is paid for by private health insurance or public programs such as Medicaid. This shift to managed care presents both opportunities and impediments as adolescent health care professionals work to meet the needs of adolescents. Adolescents present issues for managed care arrangements which are distinct from those of other age groups and populations. The needs of adolescents must be addressed as the shift to managed care occurs in both the private and public sectors. The overall goal in addressing these needs should be to improve health care access and quality of care for adolescents but, at minimum, adolescents' access must not be diminished. See related article: pp. 278–292. The shift to prepaid managed care is occurring rapidly in both the private and public sectors. The growth in managed care in the private sector has been described as "explosive": the percentage of enrollees with such employment-based coverage doubled (from 27% to 54%) between 1987 and 1991 [1Freund DA Lewit EL Managed care for children and pregnant women Promises and pitfalls.The Future of Children. 1993; 3: 92-122Crossref Google Scholar], for example, and by 1996, 77 million people were enrolled in health maintenance organizations (HMOs) [2Faulk S Market trends For-profit IPAs, big HMO chains enjoyed strong enrollment growth in 1996.BNA Managed Care Rptr. 1997; 3: 554-555Google Scholar]. Estimates of percentages range even higher when the broadest definitions of "managed care" are used [3Stains VS Impact of managed care on national health spending.Health Affairs. 1993; 12: 248-257Crossref Scopus (6) Google Scholar]. The growth of managed care in the public sector has been equally rapid. In a single year, from 1993 to 1994, enrollment of Medicaid recipients rose 63% [4Rowland D Rosenbaum S Simon L Chait E Medicaid and Managed Care. The Henry J. Kaiser Family Foundation, Menlo Park, CA1995Google Scholar], and as of mid-1996, 35% of all Medicaid beneficiaries (13 million people) were enrolled in managed care [5Press Office, US Department of Health and Human Services. Fact Sheet: Managed Care in Medicare and Medicaid, Jan 28, 1997.Google Scholar]. The term "managed care" refers to a wide variety of organizations and mechanisms for financing and delivering health care services [6Wagner ER Types of managed health care organizations.in: Kongstvedt PR Essentials of Managed Health Care. Aspen Publishers Inc, Gaithersburg, MD1995: 24-34Google Scholar]. Indeed, over the past few decades numerous different forms of managed care have been developed, such as HMOs, including staff, group, and network model HMOs as well as individual practice associations (IPAs); preferred provider organizations (PPOs) and point of service (POS) plans, which allow enrollees to use nonparticipating providers at reduced coverage; primary care case management, in which providers are paid on a fee-for-service basis with an additional fee to provide case management and gatekeeping functions; and targeted managed care, which is limited to a single service or a specific population group [6Wagner ER Types of managed health care organizations.in: Kongstvedt PR Essentials of Managed Health Care. Aspen Publishers Inc, Gaithersburg, MD1995: 24-34Google Scholar, 7Welch WP Hillman AL Pauly MV Toward new typologies for HMOs.Millbank Quarterly. 1990; 68: 221-243Crossref PubMed Scopus (51) Google Scholar, 8Gold MR HMOs and managed care.Health Affairs. 1991; 10: 189-208Crossref Scopus (18) Google Scholar]. Although the term managed care is often used to refer to a method for financing health care and controlling costs, integrated managed care organizations, such as staff model HMOs, represent not only a way of financing health care services but also an approach to health services delivery [6Wagner ER Types of managed health care organizations.in: Kongstvedt PR Essentials of Managed Health Care. Aspen Publishers Inc, Gaithersburg, MD1995: 24-34Google Scholar]. The conceptual underpinning for such organizations is that "health insurance coverage and the delivery of medical care are integrated into a single organization to facilitate access to care while at the same time removing financial incentives to provide 'extra' care to plan enrollees" [1Freund DA Lewit EL Managed care for children and pregnant women Promises and pitfalls.The Future of Children. 1993; 3: 92-122Crossref Google Scholar]. Integrated delivery systems may include not only staff model HMOs but also other types of organizations [9Kongstvedt PR Plocher DW Integrated health care delivery systems.in: Kongstvedt PR Essentials of Managed Health Care. Aspen Publishers Inc, Gaithersburg, MD1995Google Scholar]. Financial arrangements and management structure can differ substantially even between care sites within the same general organization category. For example, health care organizations may be for-profit or non-profit entities, and may vary significantly in the degree to which decisions are made by clinical versus administrative staff. These factors may alter the organization's priorities which may be reflected in how care is delivered to patients, including adolescents [10Hillman AL How do financial incentives affect physicians' clinical decisions and the financial performance of health maintenance organizations?.NEJM. 1989; 321: 86-92Crossref PubMed Scopus (343) Google Scholar, 11Hillman AL Managing the physician Rules versus incentives.Health Affairs. 1991; 10: 138-146Crossref PubMed Scopus (67) Google Scholar]. Whatever the specific form they take, one of the key features of most, if not all, managed care arrangements is that they control the flow of patients to both primary care providers and specialists and limit patient choice of provider. This is one of the most significant differences between managed care and fee-for-service health insurance coverage, which allows patients a free choice among providers who are willing to serve them. In Medicaid, as well as private insurance, managed care enrollment may entail limitations on provider choice [12English A, Perkins J, Teare C, Rivera L. Adolescent Health Care in Transition: Medicaid, Managed Care, and Health Care Reform. San Francisco: National Center for Youth Law (in press).Google Scholar]. However, even after recent legislation giving states more flexibility, federal law continues to provide significant protection for Medicaid beneficiaries' "freedom of choice" of provider, particularly for children and adolescents with special health care needs [12English A, Perkins J, Teare C, Rivera L. Adolescent Health Care in Transition: Medicaid, Managed Care, and Health Care Reform. San Francisco: National Center for Youth Law (in press).Google Scholar, 13Perkins J Melden M Section 1115 Medicaid Waivers. National Health Law Program, Washington, DC1994Google Scholar]. In managed care arrangements, enrollees' choice of providers is limited in at least two ways. First, they may be required to select a single primary care provider who acts as the point of entry into the health care system by functioning as the "gatekeeper," from whom a referral must be obtained prior to consulting with a specialist [14General Accounting Office. Factors to Consider in Managed Care Programs (June 29, 1992). (Statement of Janet L. Shikles, Director Human Resources Division)(GAO/T-HRD-92-43).Google Scholar]. Second, the choice of both primary care providers and specialists may be limited either to those who are members of the staff (as in staff model HMOs) or to those who are members of the managed care arrangement's network, unless express authorization is received from the managed care entity to go "out-of-plan" or "out-of-network" to obtain services or, as in point-of-service plans, unless the enrollee chooses a non-network provider and assumes a higher cost-sharing burden to do so [6Wagner ER Types of managed health care organizations.in: Kongstvedt PR Essentials of Managed Health Care. Aspen Publishers Inc, Gaithersburg, MD1995: 24-34Google Scholar]. Another key feature of many managed care arrangements is that the payment mechanism increasingly involves capitation and, thus, sharing of financial risk [15Perkins J Financing issues in Medicaid managed care.in: Medicaid Managed Care An Advocate's Guide for Protecting Children. National Association of Child Advocates, Washington, DC1996Google Scholar]. Providers receive a fixed sum of money, monthly or annually, to provide a specified set of services to each enrolled member of the managed care plan. The agreements with providers usually allocate financial risk so that it is, to some extent, shared by the providers rather than borne entirely by the managed care entity. In addition, many contracts between managed care plans and health care providers include financial incentives that are intended to discourage excessive provision of services and unnecessary referrals [10Hillman AL How do financial incentives affect physicians' clinical decisions and the financial performance of health maintenance organizations?.NEJM. 1989; 321: 86-92Crossref PubMed Scopus (343) Google Scholar, 11Hillman AL Managing the physician Rules versus incentives.Health Affairs. 1991; 10: 138-146Crossref PubMed Scopus (67) Google Scholar, 16Rodwin MA Conflicts in managed care.NEJM. 1995; 332: 604-607Crossref PubMed Scopus (118) Google Scholar, 17McCleary K Asobonteng P Munchus G The effect of financial incentives on physicians' behavior in health maintenance organizations.J Managed Med. 1995; 9: 8-26Google Scholar, 18Kassirer JP Managed care and the morality of the marketplace.NEJM. 1995; 333: 50-52Crossref PubMed Scopus (203) Google Scholar, 19Hillman AL Health maintenance organizations, financial incentives, and physicians' judgments.Ann Intern Med. 1990; 12: 891-893Crossref Scopus (61) Google Scholar, 20Povar G Moreno J Hippocrates and the health maintenance organization A discussion of ethical issues.Ann Intern Med. 1988; 109: 419-424Crossref PubMed Scopus (46) Google Scholar]. The managed care entity also frequently monitors the nature and extent of the referrals by each gatekeeper [21Kassirer JP Access to specialty care.NEJM. 1994; 331: 1151-1153Crossref PubMed Scopus (97) Google Scholar]. This paper focuses primarily on managed care arrangements which are risk-based, regardless of whether or not they are fully capitated. Much of the discussion, however, is broader in scope and would also be valid for any situation in which an insurance company becomes involved in limiting or "managing" care for adolescents through prior authorization and utilization review procedures. The research literature on the general effects of managed care on health care savings, access, and quality remains inconclusive [1Freund DA Lewit EL Managed care for children and pregnant women Promises and pitfalls.The Future of Children. 1993; 3: 92-122Crossref Google Scholar, 4Rowland D Rosenbaum S Simon L Chait E Medicaid and Managed Care. The Henry J. Kaiser Family Foundation, Menlo Park, CA1995Google Scholar, 22Iglehart JK. The American health care system: Managed care. NEJM 327:742–747.Google Scholar]. Even less is known about the ways in which managed care affects certain populations, particularly adolescents. Much of the research that has been done regarding managed health care has focused on adults. The few studies that have included adolescents usually did not consider them as a distinct population with unique characteristics and needs, but instead studied the effects of various insurance factors on the family unit or on children in general, including adolescents [1Freund DA Lewit EL Managed care for children and pregnant women Promises and pitfalls.The Future of Children. 1993; 3: 92-122Crossref Google Scholar, 4Rowland D Rosenbaum S Simon L Chait E Medicaid and Managed Care. The Henry J. Kaiser Family Foundation, Menlo Park, CA1995Google Scholar]. Another problem is that research in managed health care has failed to keep pace with the rapid expansion in the types of managed care that are available today. For instance, from 1971 to the mid-1980's the RAND health insurance experiment provided a rich data set from which to make inferences about the impact of a number of specific insurance factors on health care utilization and outcomes [23Newhouse JA Free for All? Harvard University Press, Cambridge1993Google Scholar]. However, these studies were done at a time when there was far less variation in the types of managed care entities available, and they focused primarily on staff-model HMOs, which represent a small and diminishing portion of the managed care marketplace today. Despite the research that has been done, there is little conclusive evidence with respect to improvement in health status, quality, or cost-savings from the use of managed care [1Freund DA Lewit EL Managed care for children and pregnant women Promises and pitfalls.The Future of Children. 1993; 3: 92-122Crossref Google Scholar, 24Miller RH Luft HS Managed care plan performance since 1980 A literature analysis.JAMA. 1994; 271: 1512-1519Crossref PubMed Scopus (603) Google Scholar]. The available research does suggest that specific features of the managed care system may have a significant effect on utilization, preventive health care delivery, and patient satisfaction [25Burns LR Wholey DR Differences in access and quality of care across HMO types.Health Services Manage Res. 1991; 4: 32-45PubMed Google Scholar]. Some factors reflect general trends that vary depending on the type of managed care arrangement involved. For instance, when free care was provided for patients in both fee-for-service and prepaid group-model HMO systems in the RAND health insurance experiment, the patients in the HMO received more preventive health visits and had lower hospitalization rates [26Manning WG Leibowitz A Goldberg GA et al.A controlled trial of the effect of a prepaid group practice on use of services.NEJM. 1984; 310: 1505-1510Crossref PubMed Scopus (414) Google Scholar]. Another study found that adult patients with depression were significantly less likely to be detected in a prepaid practice than patients in a fee-for-service system [27Wells KB Hays RD Burman A et al.Detection of depressive disorder for patients receiving prepaid or fee-for-service care.JAMA. 1989; 262: 3298-3302Crossref PubMed Scopus (355) Google Scholar]. The time physicians spend with patients during each visit also appears to vary by type of practice. In outpatient settings, prepaid physicians were found to spend less time with patients than physicians in fee-for-service practices [28Wolinsky FD Marder WD Waiting to see the doctor The impact of organizational structure on medical practice.Medical Care. 1983; 21: 531-542Crossref PubMed Scopus (12) Google Scholar]. However, physicians in staff-model HMOs spent more time with hospitalized patients than physicians in fee-for-service group practice [28Wolinsky FD Marder WD Waiting to see the doctor The impact of organizational structure on medical practice.Medical Care. 1983; 21: 531-542Crossref PubMed Scopus (12) Google Scholar]. More recent data suggest that for adult patients with chronic illness, HMOs offered a higher level of care coordination but a lower level of comprehensive care than fee-for-service systems [29Safran DG Tarlov AD Rogers WH Primary care performance in fee-for-service and prepaid health care systems Results from the Medical Outcomes Study.JAMA. 1994; 271: 1571-1586Crossref Scopus (162) Google Scholar]. Other factors influencing care may be present in a variety of different health care arrangements. For instance, in the RAND health insurance experiment, the amount of co-payment required significantly influenced outpatient health care utilization by families for preventive health care, as well as acute illness [30Leibowitz A Manning WG Keeler EB et al.Effect of cost-sharing on the use of medical services by children Interim results from a randomized controlled trial.Pediatrics. 1985; 75: 942-951PubMed Google Scholar, 31Valdez RB Ware JE Manning WG et al.Prepaid group practice effects on the utilization of medical services and health outcomes for children Results from a controlled trial.Pediatrics. 1989; 83: 168-180PubMed Google Scholar]. The size of the practice also has been found to be associated with a number of factors, from waiting times to patient satisfaction. In general, patients appear to receive more individual attention from physicians and patient satisfaction appears higher when they are seeing a solo practitioner or going to a smaller group practice [32Wolinsky FD Marder WD Spending time with patients The impact of organizational structure on medical practice.Medical Care. 1982; 20: 1051-1059Crossref PubMed Scopus (20) Google Scholar, 33Rubin HA Gandek B Rogers WH et al.Patients' ratings of outpatient visits in different practice settings.JAMA. 1993; 270: 835-840Crossref PubMed Scopus (505) Google Scholar]. For the Medicaid population generally, managed care appears to have mixed results in terms of access to care. While quality of care in managed care plans may be comparable to that in fee-for-service Medicaid plans, not all the indicators are positive [4Rowland D Rosenbaum S Simon L Chait E Medicaid and Managed Care. The Henry J. Kaiser Family Foundation, Menlo Park, CA1995Google Scholar]. Declines in the use of specialist services and emergency rooms have been observed; but the evidence is less conclusive with respect to the frequency of physician visits, the use of preventive services, and inpatient hospitalization [4Rowland D Rosenbaum S Simon L Chait E Medicaid and Managed Care. The Henry J. Kaiser Family Foundation, Menlo Park, CA1995Google Scholar]. For example, despite the frequent argument that managed care promotes the use of preventive services, access to preventive care does not appear to increase in Medicaid managed care compared with fee-for-service programs [4Rowland D Rosenbaum S Simon L Chait E Medicaid and Managed Care. The Henry J. Kaiser Family Foundation, Menlo Park, CA1995Google Scholar]. Similarly, studies have produced conflicting evidence with respect to cost savings in Medicaid managed care programs [4Rowland D Rosenbaum S Simon L Chait E Medicaid and Managed Care. The Henry J. Kaiser Family Foundation, Menlo Park, CA1995Google Scholar]. To date, however, none of the data have focused specifically on the adolescent population enrolled in Medicaid managed care. To appreciate their potential impact, research findings such as these need to be viewed within the context of adolescent health needs. For instance, the decrease in time spent during outpatient visits in staff-model HMOs, relative to fee-for-service systems, may be more important for adolescent health care than the increase in time spent with hospitalized patients, as adolescents are predominantly seen on an outpatient basis. The increase in preventive health visits in staff model HMOs may be an asset for adolescents, provided that age-appropriate anticipatory guidance and health risk screening are provided during these visits, and provided that this pattern carries over to managed care models other than the staff model HMO. Findings such as the differences in detection rates for adults with depression in prepaid and fee-for-service systems may have particular significance for adolescents, as mental health problems are a common source of morbidity and mortality in this age group. In all cases, research that specifically focuses on how adolescent health is influenced by factors within the vast array of managed care systems available today is sorely needed. An extensive body of literature has documented the health status of adolescents, their health care needs, and the limitations on their access to health care [34U.S. Congress, Office of Technology Assessment. Adolescent Health—Volume I: Summary and Policy Options. Washington, DC: U.S. Government Printing Office, 1991.Google Scholar, 35US. Crosscutting Issues in the Delivery of Health and Related Services. Washington, DC: U.S. Government Printing Office, Congress, Office of Technology Assessment. Adolescent Health—Volume III1991Google Scholar, 36Dryfoos JG Adolescents at Risk. Oxford University Press, New York1990Google Scholar, 37U.S. Congress, Office of Technology Assessment. Adolescent Health—Volume II: Background and the Effectiveness of Selected Prevention and Treatment Services. Washington, DC: U.S. Government Printing Office, 1991.Google Scholar, 38The National Commission on the Role of the School and the Community in Improving Adolescent HealthCode Blue. National Association of State Boards of Education and the American Medical Association, Washington, DC1990Google Scholar]. Particular problems that characterize adolescents as a group include: a high incidence of health effects associated with the onset of risk-taking behaviors; a need to have service delivery adapted to reflect their age and their cognitive, psycho-social and developmental status; and a lack of adequate insurance coverage. Moreover, certain populations of adolescents have special health care issues that need to be addressed within the health care system, whether care is financed and delivered through managed care arrangements or other mechanisms. While the age boundaries of adolescence have been variously defined, it is the position of the Society for Adolescent Medicine that the appropriate scope of adolescent medicine includes health care and research, as well as training for health professionals and advocacy, related to persons age 10 to 25 years [39Society for Adolescent MedicineA position statement of the Society for Adolescent Medicine.J Adolesc Health. 1995; 16: 413Abstract Full Text PDF PubMed Scopus (19) Google Scholar]. The age limits for health insurance coverage for adolescents have generally been less comprehensive, frequently ending at age 18 years or younger or, in the case of privately insured dependents who continue in school, at 23 years. To meet adolescents' needs in a comprehensive way, however, health care coverage should continue for as long as possible throughout adolescence, particularly for young people who are not yet financially independent. Adolescents, as a group, need special care and attention in order to avoid preventable illness. Risk-taking behaviors are a major source of morbidity and mortality for this age group. The high cost of adolescent risk-taking, in physical and emotional impact as well as financial burden, has been well documented [34U.S. Congress, Office of Technology Assessment. Adolescent Health—Volume I: Summary and Policy Options. Washington, DC: U.S. Government Printing Office, 1991.Google Scholar, 35US. Crosscutting Issues in the Delivery of Health and Related Services. Washington, DC: U.S. Government Printing Office, Congress, Office of Technology Assessment. Adolescent Health—Volume III1991Google Scholar, 36Dryfoos JG Adolescents at Risk. 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Often a multi-disciplinary approach is most effective, drawing on the skills of care providers with special training in adolescent health care delivery. Research has indicated that teen-focused providers and comprehensive adolescent health care centers can increase adolescents' willingness to disclose sensitive information regarding their risk-taking behaviors and their level of emotional distress, so that timely intervention can occur [50Kay BJ Share DA Jones K et al.Process, costs and outcomes of community-based prenatal care for adolescents.Medical Care. 1991; 29: 531-542Crossref PubMed Scopus (12) Google Scholar, 51Borok G, Ershoff D, Ung D, et al. Evaluation of a comprehensive teen health center versus traditional primary care in an HMO. Presentation for the American Public Health Association Annual Meeting. Washington, D.C., 1992.Google Scholar], although these sites are not the only ones that can provide effective care to this age group. 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