Paying Attention to Children in a Changing Health Care System (1996) / Chapter Skim
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4 Strategies for Assuring the Provision of Qulaity Services Through Managed Care Delivery Systems to Children with Special Health Care Needs
4 Strategies for Assuring the Provision of Qulaity Services Through Managed Care Delivery Systems to Children with Special Health Care Needs
Pages 61-74
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From page 61... ...
CHAPTER 4 Strategies for Assuring the Provision of Quality Services Through Managed Care Delivery Systems to Children with Special Health Care Needs Workshop Highlights Jo Harris-Wehling, Henry T Ireys, and Margaret Heagarty, Editors Board on Health Care Services Institute of Medicine National Academy Press Washington, D.C.
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From page 62... ...
62 PAYING ATTENTION TO CHILDREN IN A CHANGING HEALTH CARE SYSTEM CONTENTS INTRODUCTION 63 CHILDREN WITH SPECIAL HEALTH CARE NEEDS: DIMENSIONS OF THE POPULATION 64 Epidemiology, 65 Expenditures and Financing of Care, 66 QUALITY SERVICES AND MANAGED CARE PROGRAMS 67 Access to Services, 67 Gaps in Community-Based Systems of Care, 68 Monitoring and Assuring Quality of Care, 69 CONCLUDING REMARKS 71 REFERENCES 73
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From page 63... ...
As states plan and implement health care reform and the private sector pursues major restructuring in health care delivery, new issues of concern are emerging regarding whether this population of children will be given opportunities to reach their full potential as adults. Many families and health care professionals are concerned, for example, that managed care programs1 in both the public and private sectors will decrease access to certain subspecialty and supportive services and undermine recent efforts to develop community-based systems of care for these children and their families.
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From page 64... ...
Little baseline data are available, however, to assess the influence of these changes on health status and quality of life for these children and their families. A narrow focus on subspecialty medical care provided to this population ignores other essential services for quality health care; these include primary care, developmentally appropriate assistive technology, or community-based family support programs.
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From page 65... ...
produces limitations in function, activity, or social role; need for more than the usual amount of medical care; need for care at home or school; or dependency on medications, special diets, or assistive technologies.5 Such a condition-consequences definition provides the framework for identifying needed services of the population. Once a baseline is ascertained, public and private agencies are in a more informed position to discuss which services managed care providers will deliver and what critical needs of the population remain to be addressed by other sources such as the education system, parents, and public health agencies.
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From page 66... ...
Overall, studies suggest that despite the extremely high costs for a small percentage of children, the majority of children with disabilities or chronic illnesses have annual medical expenditures that are below the maximum expenditure limits of many private indemnity health insurance plans. Nevertheless, because of the potentially high and unpredictable resource consumption, all but a small number of managed care companies have been reluctant to assume the significant financial risks that are associated with enrolling children with health care needs.
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From page 67... ...
QUALITY SERVICES AND MANAGED CARE PROGRAMS A previous IOM meeting noted that, although some resources are available to guide and monitor children's care, assessing the quality of children's health care poses special challenges (National Research Council and Institute of Medicine, 1994)
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From page 68... ...
Who funds and who provides care management or care coordination is also of particular concern as managed care arrangements increasingly become the mode for delivering health care to children. Participants encouraged experimentation with a range of models, including the use of specialists as primary care providers and gatekeepers or care managers for children with certain types of conditions.
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From page 69... ...
from many Medicaid managed care plans, and they continue to receive health care services in the more traditional fee-for-service delivery systems. Other structural models are evolving, however, including managed care programs that enter into capitated subcontract arrangements with specialty managed care programs to serve selected subgroups of children (e.g., those who are disabled Supplemental Security Income recipients)
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From page 70... ...
Some participants expressed interest in moving towards state-based legislation that explicitly designates state public health agencies that administer these programs as overseer of private sector managed care plans in terms of the care they provide to these children. Others noted the importance of databases that inform providers and policy makers on the health status of the population and the critical link between good data and effective quality assurance and improvement systems.
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From page 71... ...
Additionally, tertiary care institutions make valuable contributions to quality care for children with special health care needs through both caring for patients and providing medical education and research. The specific and perhaps unique roles such institutions can and should play in an environment oriented more toward managed care and cost containment needs further exploration.
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From page 72... ...
Third, traditional measures of quality of medical care are insufficient to assess quality of health care for children with special needs and their families. State agencies managing the Programs for Children with Special Health Care Needs, managed care programs, and academic health care centers must work together to develop relevant, useful, and comprehensive indices of quality that are family-centered.
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From page 73... ...
REFERENCES Fox, H.B., and M.A. McManus 1994 Preliminary Analysis of Issues and Options in Serving Children with Chronic Conditions Through Medicaid Managed Care Plans.
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