Health maintenance organizations vs indemnity insurance for children with chronic illness. Trading gaps in coverage
S. M. Horwitz and R. E. Stein
Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn 06510.
There has been increasing discussion about the potential of health
maintenance organizations to provide improved access to and coordination of
care for children with complex conditions. This study compares benefits for
a sample of health maintenance organizations and traditional indemnity
insurers in Connecticut. We conclude that in Connecticut neither health
maintenance organizations nor traditional indemnity insurers currently
offer comprehensive systems of care to these children. Health maintenance
organizations offer preventive care and are easier systems to access.
However, for children with chronic conditions, health maintenance
organizations have some problematic restrictions, including a lag between
start of employment and activation of health care benefits. Both health
maintenance organizations and traditional indemnity insurers tend to have
restrictions for specific services needed by children with chronic
illnesses, such as medical equipment and mental health services. Case
managers in both systems tend to control expenditures rather than to
coordinate care. Representatives of both systems predict additional
restrictions in the future. Our data suggest the need for more extensive
evaluation of the generalizability of these findings.
