Barriers to pediatric referral in managed care systems.
Anecdotal evidence suggests that children's access to pediatric subspecialty and inpatient care is hampered by referral barriers imposed by managed care systems. To identify such barriers and determine how they affect the referral process, a sample of American Academy of Pediatrics Fellows (n = 1598) was surveyed. The response rate was 79.1% (n = 1264). Of those pediatricians in direct patient care (n = 956), 71.4% participated in a managed care plan. Pediatricians referred patients in managed care systems somewhat less frequently than in traditional pay systems: 8.7% and 6.9% referred managed care patients to subspecialists and inpatient care, respectively, less often. More than 20% and 10% of pediatricians with patients in managed care systems had at least one referral to subspecialist care and inpatient care, respectively, denied in the previous year. Pediatricians experienced more barriers in preferred provider organizations than in health maintenance organizations. These data suggest that utilization management programs, such as those used in managed care systems, may limit necessary access to pediatric subspecialty and inpatient care.
Cartland
J D
JD
Division of Research on Health Policy, American Academy of Pediatrics, Elk Grove Village, IL 60009.
Yudkowsky
B K
BK
D002648:Child; D002662:Child Health Services / Q000706:statistics & numerical data; D006279:Health Maintenance Organizations / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007345:Insurance Claim Review; D008329:Managed Care Programs / Q000706:statistics & numerical data*; D010372:Pediatrics / Q000706:statistics & numerical data*; D011243:Preferred Provider Organizations / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D014481:United States; D014600:Utilization Review