Health maintenance organizations and children with special health needs. A suitable match?
OBJECTIVE
To address how well health maintenance organizations (HMOs) meet the needs of almost 700,000 children with disabilities due to chronic conditions enrolled in these plans.


METHODS
A cross-sectional survey.


RESULTS
Health maintenance organizations offered better protection than conventional plans against out-of-pocket expenses and were much more likely than fee-for-service plans to cover ancillary therapies, home care, outpatient mental health care, and medical case management. In addition, few HMOs maintained exclusions for preexisting conditions. Other aspects of HMO policies, however, were found to operate against the interest of families with chronically ill children. In particular, HMOs commonly made specialty services available only when significant improvement was expected within a short period. Also, HMOs typically placed limits on the amount and duration of mental health, ancillary services, and certain other services frequently needed by chronically ill children. Probably the most serious problems for chronically ill children enrolled in HMOs were the lack of choice among and access to appropriate specialty providers.


METHODS
Individual HMO plans.


METHODS
A sample of 95 geographically representative HMOs were selected; 59 (62%) responded.


METHODS
None.


CONCLUSIONS
Health maintenance organizations offer several advantages over traditional fee-for-service plans for families whose children have special health needs. However, the results also indicate that HMOs do not always operate effectively as service provision systems for these children. To a large extent, the availability and quality of services available to a child with special needs is likely to depend on the parents' ability to maneuver within the system.
Fox
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HB
Fox Health Policy Consultants, Washington, DC 20036.
Wicks
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LB
Newacheck
P W
PW
D000293:Adolescent; D002648:Child; D002662:Child Health Services / Q000191:economics*; D002675:Child, Preschool; D002908:Chronic Disease / Q000191:economics*; D003430:Cross-Sectional Studies; D004389:Durable Medical Equipment / Q000191:economics; D006279:Health Maintenance Organizations / Q000592:standards / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand; D006699:Home Care Services / Q000191:economics; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008134:Long-Term Care / Q000191:economics*; D008605:Mental Health Services / Q000191:economics; D010044:Outpatient Clinics, Hospital / Q000191:economics; D026741:Physical Therapy Modalities / Q000191:economics; D012017:Referral and Consultation; D014481:United States