Health maintenance organizations and children with special health needs. A suitable match?
H. B. Fox, L. B. Wicks and P. W. Newacheck
Fox Health Policy Consultants, Washington, DC 20036.
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. DESIGN--A cross-sectional survey.
MEASUREMENTS/MAIN 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. PARTICIPANTS--Individual HMO plans. SELECTION PROCEDURE--A
sample of 95 geographically representative HMOs were selected; 59 (62%)
responded. INTERVENTIONS--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.
