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Effect of Managed Care on Children's Relationships With Their Primary Care Physicians
Differences by Race
Gregory D. Stevens, PhD;
Leiyu Shi, DrPH, MPA, MBA
Arch Pediatr Adolesc Med. 2002;156:369-377.
ABSTRACT
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Context Racial and ethnic disparities in the quality of the patient-provider
relationship have been documented previously, but only among adults. Few studies
have examined this aspect of primary care quality for children, and none has
examined the role of managed care in mediating disparities.
Objective To explore variations in the associations among 3 managed care policies
and the sustained patient-provider relationship for children by racial and
ethnic group.
Design, Setting, and Participants Telephone survey of parents of a random sample of 413 children attending
elementary school in a large school district spanning 3 cities in southern
California. Self-reported managed care information was validated through contact
with health plan representatives.
Main Outcome Measure Parent reporting of the strength of affiliation and interpersonal relationships
among the child, the family, and the health care provider.
Results Parents of Hispanic and black children reported significantly lower
strength of affiliation than whites did (mean, 3.19 and 3.27 vs 3.57; P<.05 and P<.01, respectively). Asians and Hispanics
reported significantly poorer interpersonal relationships with providers than
whites did (mean, 3.35 and 3.38 vs 3.53; P<.05 for both).
Managed care policies requiring patients to (1) sign up with a particular
provider, (2) seek a referral for specialty care, and (3) stay within a network
were associated with reductions in the interpersonal relationship. All minority
groups, but not whites, reported significantly poorer relationships when managed
care policies were present. Asian children were most sensitive to the managed
care policies.
Conclusions Our data suggest that racial and ethnic minority children experience
poorer patient-provider relationships compared with white children, even controlling
for socioeconomic status and health system factors. Minority children are
particularly sensitive to managed care policies that restrict patient freedom
in choosing where to seek care. Implementing less restrictive policies may
enhance the development of the patient-provider relationship.
INTRODUCTION
THE INSTITUTE of Medicine defines primary care as "the provision of
integrated, accessible health care services by clinicians who are accountable
for addressing a large majority of personal health care needs, developing
a sustained partnership with patients, and practicing in the context of family
and community.1(p31) A sustained relationship
between a patient and a health care provider, also called longitudinality,
is the foundation for the delivery of high-quality primary care.1-3
For children, the patient-provider relationship involves the physician building
mutual trust, conducting coparticipatory communication with parent and child,
giving support and empathy, and accumulating knowledge about the patient and
family. Without a sustained relationship, physicians may not have sufficient
patient familiarity to accurately recognize and diagnose children's health
needs. This may lead to poor delivery of preventive services,3-5
increased patient reliance on emergency departments,6-8
and, ultimately, the patient switching providers.9
Health plans, particularly the myriad variants of managed care, have
become intermediaries in the development and maintenance of these relationships
for children. Early managed care organizations (MCOs) showed promise for promoting
sustained relationships because they linked children with primary care providers
(PCPs) instead of emergency departments and assumed responsibility for the
well-being of their enrollees.4-7
To curb rising costs, however, insurers implemented a variety of policies
and restrictions that limit patient freedom in seeking care and that intercede
in and potentially undermine the patient-provider relationship.8-10
Common policies include gatekeeping patients' access to specialists and limiting
choices to a network of providers.
Previous studies examining the effects of managed care on the patient-provider
relationship for adults show that those in fee-for-service plans report better
continuity and communication with their PCP than those in MCOs.11-13
Other studies reveal lower patient trust and confidence in PCPs in managed
care settings, characterized by limited patient choice and reduced provider
autonomy.14-17
There is little concomitant research evaluating the effects of managed
care on the sustained relationship for children. Starfield et al,18 conducting the only study of this type for children,
reported that reduced physician autonomy (ie, limiting the ability of the
physician to refer patients to specialists without utilization management
by a health plan) was associated with slight increases in the strength of
affiliation between families and doctors. Children are increasingly being
enrolled in MCOs, and the increase is directly attributable to the number
of children who are enrolled in programs such as Medicaid and the State Children's
Health Insurance Program, which rely heavily on managed care.19
The unique set of financing, organization, and delivery systems for children
makes studies of adults not readily applicable to children.20
In addition, children have different health care needs; thus, parents are
likely to have different expectations and needs when seeking care for their
children as opposed to seeking care for themselves.
Managed care may be particularly troublesome for racial and ethnic minority
children. Minorities may be more susceptible to the effects of MCO policies
because of language barriers, difficulty finding PCPs of the same racial background
in a network, and cultural differences in seeking care.21-22
Indeed, recent research among adults shows that ethnic minority patients experience
less partnership with physicians, lower levels of satisfaction, and less trust
in physicians.23-27
However, none of these studies directly examines the role of managed care
in these racial disparities.
The purpose of this study is to examine the influence of specific managed
care policies on the patient-provider relationship for children, and to explore
variations in the effects by race and ethnicity. We examine managed care less
by its various names than by the rules and restrictions the health plans place
on their enrollees and physicians. In this study, we explore the effects of
(1) the requirement to select a primary care physician from a provider network;
(2) the requirement to obtain a referral from a primary care provider before
seeing a specialist; and (3) restrictions on use of providers outside the
plan's network. Both self-reported and validated insurance data are used in
the analyses. This study makes a unique contribution to our understanding
of primary care delivery because it is the first to unravel racial and ethnic
disparities in the effect of managed care on the patient-provider relationship
specifically for children.
PARTICIPANTS AND METHODS
STUDY DESIGN AND SETTING
We conducted a cross-sectional, community-based survey among a random
sample of 1200 parents of elementary school–aged children in one school
district. The district spans 3 large suburban communities in San Bernardino
County, California. A school district was the setting for this study because
it provides a comprehensive list of children in a community. A community sample
avoids the biases associated with research in provider settings, which generally
includes only the most frequent users of services.
The sampling frame of children was sorted and systematically sampled
by the child's sex, grade level, and school stratum to ensure that the sample
was as representative of the community as possible. To improve the analytic
capacity of the sample, Asian and black subgroups were oversampled at 4 times
the rate for Asians (compared with whites) and 16 times the rate for blacks
to obtain approximately equal numbers of respondents across racial and ethnic
groups.
DATA COLLECTION
The Johns Hopkins University Office for Research Subjects, Baltimore,
Md, approved the survey instrument and administrative procedures. Questionnaires
were administered during structured telephone interviews between November
2000 and January 2001.
Two rounds of informational mailers were sent to parents before they
were contacted by telephone. To maintain legal privacy protections for parents,
clerks employed by the school district made the initial contact with families
to schedule appointments for interviewers to complete the telephone interview.
Letters were mailed to parents who had missed an appointment reminding them
to reschedule the interview. Interviews were conducted at a time specified
by the respondent. Mothers made up the vast majority (98%) of respondents,
and the remaining respondents were fathers or grandparents.
Of the original sample of 1200 children, 289 families had moved homes
or left the school district, disconnected their telephone numbers, or had
a telephone number that was busy or not answered on repeated ( 10) attempts;
59 families were unable to participate because of language difficulties. Interviews
were completed with the families of 413 children. After subtracting the unreachable
families from the original sampling frame, the overall response rate was 49%.
Children with no regular source of health care or insurance coverage were
excluded from the analyses in this article, leaving 377 respondents in the
analytic sample. The moderate response rate is partially a trade-off of conducting
a community-based study, where parents may be less motivated to respond than
if they were to participate in a study from which they would more directly
benefit (eg, a consumer satisfaction survey from their physician).
For all children, data on race and ethnicity, sex, grade level, and
school were available through an administrative data set assembled annually
from parent-completed enrollment forms. Analysis of nonrespondents suggests
that they were similar to respondents on all factors, except that respondents
were slightly more likely than nonrespondents (P<.05)
to have a younger child (mean age, 8.1 vs 8.4 years).
MEASUREMENT OF STUDY VARIABLES
Categories of race/ethnicity coded in the administrative data set were
white (non-Hispanic), Hispanic, black (non-Hispanic), Asian, Filipino, Pacific
Islander, and American Indian. To assure a sufficiently large sample size,
we combined Asian, Filipino, and Pacific Islander into a single category called
"Asian," and we chose to exclude American Indians from the study sample.
Independent Variables
The independent variables were the managed care policies. Questions
about health insurance were borrowed from the Community Tracking Study Household
Survey, designed and conducted by the Center for Studying Health System Change,
Washington, DC.28 Parents' responses to 3 questions
about their child's health insurance were used to construct 3 managed care
variables. Respondents were asked about (1) the requirement to select a primary
care provider from a panel of physicians; (2) the requirement to obtain a
referral from a PCP to see a specialist; and (3) financial restrictions on
seeing providers outside the provider network. Answers were recorded dichotomously
(yes/no).
For 213 respondents (approximately 57%) who reported the exact name
of their child's health insurance plan (obtained from their insurance card
in all cases), responses to the 3 insurance questions were verified through
anonymous structured interviews with health plan administrators. To avoid
overburdening families, only parents who had their child's insurance card
available at the time of the interview were asked to respond. This accounts
for the 25% overall response rate for the subsample. Both self-reported and
validated data are presented in this study because they reflect perceived
and actual health insurance experiences, and each has the potential to influence
the patient-provider relationship.
Because we were not able to validate information for the entire sample,
it is possible that the subsample could vary in some important way from the
full sample. Our analyses, however, show that there were very few differences
between the full respondent sample and the validated subset (data not shown).
In most cases, differences were no greater than 3% to 4% and did not change
the directionality or ordering of the characteristic among racial groups.
The largest difference was a moderately insignificant increase of about 6%
in Asian female children in the validated subsample.
Dependent Variables
The Pediatric Primary Care Assessment Tool, developed by the Johns Hopkins
Primary Care Policy Center for the Underserved, was used to evaluate longitudinality
of care. Longitudinality refers to the development of a sustained relationship
with a health care provider over time, regardless of the presence of disease
or injury. This relationship can be formed with a provider, a group of providers,
or a facility, but in the latter cases, particular care must be taken to coordinate
services and records across providers. Such continuity in the delivery of
health care is intended to help the patient and provider develop mutual knowledge
of and trust in each other and improve the efficiency and effectiveness of
care. A sustained relationship with a provider distinguishes primary care
from most specialty care, where the majority of patients enter into problem-specific
partnerships of limited duration.1-3
The Pediatric Primary Care Assessment Tool assesses the structural characteristics
of the facility or provider that reflect the capacity to achieve a sustained
patient-provider relationship and processes of care that indicate the achievement
of the sustained relationship in actual practice. Two subdomains of longitudinality
that cover these facets of the patient-provider relationship are strength of affiliation with the provider and the interpersonal relationship. Child, adult, and provider versions of
the instrument are available, and the reliability and validity are reported
elsewhere.27-28
The strength of affiliation subdomain assessed the extent of the child's
affiliation with a specific provider or place of care. The subdomain was scored
with an algorithm based on 3 questions. A higher value was assigned if the
provider was (1) identified as the regular source of care and was also (2)
the provider who knew the child best and (3) the provider from whom care would
be sought for a new problem. Respondents who identified a provider for only
1 question were considered to have poor strength of affiliation and were given
the minimum score of 1, as were respondents who identified different providers
for each question. Those identifying the same provider for all 3 questions
were considered to have high strength of affiliation and were given the maximum
score of 4. Respondents who identified the same provider for 2 questions were
given a score of 3 if the provider was the regular source of care and knew
the child best and a 2 for any other combination.
The interpersonal relationship subdomain was evaluated through 14 questions
asking parents to report on the interactions between the child, the family,
and the health care provider. Questions asked, for example, about 2-way communication,
knowledge of the family, and the interaction between provider and child. Four
Likert-type response choices were given including "definitely" (score = 4),
"probably," "probably not," "and definitely not" (score = 1). "Don't know"
responses were coded as the middle score (2.5) because we assumed that not
knowing about a provider's behavior signified a partial failure on the part
of the physician to convey or practice this behavior. Responses were averaged
to produce a single scale score. A complete list of the questions is included
(Figure 1).
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Complete list of survey questions on the relationships among children,
families, and primary care providers.
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Interpretation of the interpersonal relationship domain is slightly
complex because of the small range of the scale scores (1-4). Because of the
large number of items in the scale and the small scale range, even a relatively
small change in the mean score reflects a substantive difference in interpersonal
relationship experience. Though the ability of the Pediatric Primary Care
Assessment Tool to predict future outcomes has not yet been established, differences
of a single point (1.0) reflect a real change from one Likert point to another
(eg, "probably" to "definitely"). Though this may seem insignificant at first
glance, most of the scores fall in the range of 2.5 to 3.5, and, therefore,
a difference of even half a point (.50) is likely to reflect a real change
in direction from having a generally negative experience (responses averaging
"probably not") to a generally positive one (responses averaging "probably").
Covariates
We controlled for socioeconomic status (family income, maternal employment,
and maternal education), characteristics of the health care system (provider
specialty and cost sharing), and demographics (child's age and sex and public
vs private insurance coverage). Covariates were selected from previous studies
examining primary care quality, use, and satisfaction—factors inherent
to a sustained patient-provider relationship. The effects of also controlling
for health status and naming a provider vs a place as a regular source of
care are described in the "Comment" section.
ANALYSIS
The analyses tested the significance of the association among the 3
managed care policies and longitudinality scores for each of the 4 racial
and ethnic groups separately, while adjusting for study covariates. To further
explore which racial group was most affected by the managed care policies,
we then tested the difference in mean longitudinality scores across the racial
and ethnic groups for both self-reported and validated managed care characteristics.
First, frequencies of the study variables (including socioeconomic status,
health system factors, and demographic characteristics) were assessed across
racial and ethnic groups. Then, a  2 test of association was
used to assess the significance of differences across groups. The frequencies
of the self-reported and validated managed care policies were also compared
across racial and ethnic groups, again using a 2 test of association.
Mean longitudinality subdomain scores were reported across racial and ethnic
groups, and the significance was assessed using a standard t test.
Second, generalized linear model procedures were used separately for
each racial and ethnic group to assess differences in longitudinality across
managed care characteristics, while adjusting for covariates. Bonferroni t tests were used to test the significance of the difference
in mean scores between "yes" and "no" responses to a particular managed care
policy, while accounting for multiple comparisons. These analyses were done
separately for the self-reported and validated managed care data. Health status
and having a provider vs a place as the primary source of care were controlled
for in additional models described in the "Comment" section.
Third, we assessed differences in mean longitudinality scores across
racial and ethnic groups, adjusting for covariates. To control for the effects
of managed care, we used the same generalized linear model procedures to compare
scores across races, but only for those who reported "yes" to a managed care
policy. This was done for each policy, as well as for both self-reported and
validated insurance information, using white race as the reference group.
The mean values that are presented in the tables for across-policy comparisons
naturally differ from the mean values of across-race analyses because of the
process of adjustment. These differences do not affect the direction or overall
magnitude of the findings; therefore, only the across-policy means are presented.
RESULTS
Table 1 shows the unadjusted
demographic characteristics, socioeconomic status, and health system factors
of our analytic sample by racial and ethnic group. Because of the sampling
strategy, respondents were approximately equally divided among the 4 categories
of race and ethnicity, although slightly greater numbers of Hispanic respondents
were uninsured (n = 7) and, therefore, were excluded from these analyses.
Most of the respondents (74.3%) had family incomes greater than $36 000
per year, although a smaller proportion of black (69.0%) and Hispanic (72.6%)
families had incomes above this amount compared with Asians (83.5%) and whites
(92.2%) (P<.001). Racial and ethnic groups also
differed in maternal education and employment, with Asians reporting the highest
proportion of respondents with a high school education or greater (P<.01) and blacks reporting the highest employment among mothers
(P<.001).
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Table 1. Sociodemographic Characteristics, Managed Care Policies, and
Mean Relationship Scores of 377 Participants by Race and Ethnicity*
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With regard to health system factors, there were no significant differences
across racial and ethnic groups in the proportions of children who saw a pediatrician
as their regular source of care. Asians and whites, however, were more likely
to report a particular provider (82.4% each) rather than a place, such as
a clinic or hospital department, as their source of care (P<.01). Black respondents had the lowest proportion reporting any
cost sharing (60.0%), which is likely attributable to their 3-fold greater
participation in Medicaid (which does not require cost sharing) compared with
whites (16.0% vs 4.9%). Asians were the most likely to report cost sharing
(81.3%) (P<.01). There were no significant differences
in child's age, sex, or health status across groups.
Table 1 also compares the
frequencies of self-reported and validated managed care policies and longitudinality
scores by race and ethnicity. Hispanics were the most likely (77.4%) and whites
the least likely (55.9%) to report that their health plan required them to
sign up with a particular network provider (P<.01).
When compared with the validated data, all racial and ethnic groups overestimated
the prevalence of this policy. According to the validated data, Asians and
Hispanics were more likely to be required to sign up with a PCP (about 48%
for both), and blacks were the least likely (24.6%) (P<.05).
There were no significant differences in self-reporting of the requirement
to seek a referral for specialty care or to stay within the provider network.
Compared with the validated data, however, all racial and ethnic groups underestimated
the prevalence of the policies. The validated data suggest that Hispanics
and blacks were the racial and ethnic groups most likely to be required to
seek referrals and stay within a provider network. Hispanics had the highest
frequency of the 2 policies (88.5% and 92.3%, respectively), and Asians had
the lowest frequency (62.5% and 67.9%, respectively) (P<.01 for both).
Verification of the self-reported insurance information with the validated
data revealed that 67.1% of parents correctly reported the requirement to
select a PCP, 78.0% correctly reported that they needed a referral to see
a specialist, and 86.4% correctly reported that their health plan would pay
some portion of the expense for out-of-network care (data not shown).
The longitudinality subdomain scores also varied according to race and
ethnicity. Whites had the greatest strength of affiliation and interpersonal
relationship scores (3.57 and 3.53, respectively, on a scale of 1-4). Hispanics,
followed by blacks, reported significantly lower affiliation scores (3.19
and 3.27, respectively) than whites (P<.05). And
Asians and Hispanics had the lowest relationship scores (3.35 and 3.38, respectively
(P<.05). These scores reflect differences of about
5% to 10% across racial and ethnic groups.
More detailed analyses (not shown) reveal that racial disparities are
particularly large for 2 specific items in the interpersonal relationship
domain. Asian, black, and Hispanic respondents, compared with whites, had
shorter-duration relationships with their regular sources of care. On average,
whites had been seeing their regular provider for between 1 and 2 years, and
minorities, on average, had been seeing their regular provider for 6 to 11
months (P<.05 for Asians and Hispanics; P<.01 for blacks). Similarly, Asians and Hispanics were,
on average, leaning toward "probably" changing providers if it were easy to
do (mean scores, 2.88 and 2.86, respectively) compared with whites (mean,
3.20) who were, on average, "probably not" interested in changing providers.
Table 2 compares the associations
among the 2 measures of longitudinality and the 3 managed care policies for
each race and ethnicity, adjusting for socioeconomic status, health system
factors, and demographic characteristics. When data were reported by respondents,
there were no significant differences in the affiliation subdomain for any
racial and ethnic group across these policies. Although the differences were
not significant, there was a consistent overall trend of lower affiliation
scores associated with reporting "yes" to any of the restrictive policies
for all groups.
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Table 2. Adjusted Longitudinality Subdomain Means (SDs) by 377 Self-reported
and Validated MCO Policy Participants*
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According to the self-reported data, all 3 managed care policies were
correlated with interpersonal relationships among the child, the family, and
the provider. These 3 policies were particularly correlated with reductions
in the relationship scores for Asian and Hispanic children. Requiring patients
to sign up with a PCP was associated with a 0.23-lower mean affiliation score
for Asians (P<.01) and a 0.25-lower mean score
for Hispanics (P<.05). The requirement to stay
within a provider network was associated with nearly equivalent reductions
for Asians (0.21; P <.05) and Hispanics (0.29; P<.01). Asians further reported a 0.20-lower mean relationship
score when the health plan required them to see their PCP for a referral to
a specialist (P<.05). Surprisingly, both white
and black children did not experience a reduction in the relationship score
when the managed care policies were present.
With regard to data validated by health plan representatives, there
were still few significant differences in the affiliation domain (Table 2). Black children were a major exception,
reporting a 0.97 lower mean affiliation score (about 25%) when the health
plan required the child to stay within the provider network (P<.05). Though still nonsignificant for most races, the trend of
lower affiliation being associated with more restrictive policies continued
and was slightly enhanced with the validated insurance data.
According to the validated data, managed care policies are strongly
negatively associated with minority (but not white) children's interpersonal
relationships with their physicians. The specialist referral policy was associated
with reductions in relationship scores of 0.40 for Asians (P<.001), 0.36 for blacks (P<.05), and
0.49 for Hispanics (P<.01). Similarly, the requirement
to stay within a provider network was associated with deficits in relationship
scores of 0.43 for Asians (P<.001), 0.36 for blacks
(P<.01), and 0.34 for Hispanics (P = .06). In addition, black children who were required to sign up
with a PCP reported a 0.40-lower mean relationship score (P<.05). The majority of these managed care policy differences reflect
reductions of approximately 10% to 12% in interpersonal relationship scores.
Table 2 demonstrates that,
controlling for managed care policies, racial and ethnic minorities experience
poorer longitudinality of care. The self-reported insurance data show that
Hispanics and blacks report much lower strength of affiliation than whites,
regardless of the managed care policies. Hispanics, in particular, report
striking deficits in strength of affiliation of about 25% or more compared
with whites—findings that are corroborated by the validated data. Asian
and Hispanic children also experience poorer interpersonal relationships with
their primary care physicians than whites. According to both the self-reported
and validated data, Asians report the largest deficits in interpersonal relationships,
with disparities ranging from about 13% to 15%.
COMMENT
The findings of our community-based study advance the literature on
MCOs and the patient-provider relationship for children by demonstrating that
managed care policies restricting patient flexibility in seeking medical care
are negatively correlated with the parent-reported interpersonal relationship
between child and provider. Racial and ethnic minority children experienced
much larger deficits in longitudinality under these policies than white children
do, even after controlling for socioeconomic status, health system factors,
and demographic characteristics.
The policy requiring patients to seek care within a network of physicians
was associated with the largest deficits in longitudinality of care. Both
self-reported and validated insurance data revealed significant deficiencies
for minority children in the relationship scale. In addition, the affiliation
between child and physician was severely compromised for black children in
health care plans with an in-network policy (a reduction of about 25%). The
policy may affect this relationship by limiting the ability of families, and
minorities in particular, to seek and develop relationships with culturally
appropriate providers. This may be the case particularly if there are language
difficulties, or if prior relationships are disrupted by forced entry into
managed care, changing of health plans, or the frequent turnover of physicians
in MCOs.
The requirements to select a network PCP and to seek referrals for specialty
care were also associated with significant, but slightly smaller, deficits
in longitudinality of care. The policy requiring patients to select a PCP
from a network was associated with reductions in the relationship domain for
Asians and Hispanics (using self-reported data) and blacks (using validated
data). The perception of limited choice, in this case, is more negatively
correlated with a sustained relationship than the actual presence of the policy.
Requiring referral was associated with reductions in parent reporting
of the interpersonal relationship between minority children and physicians,
primarily when validated insurance data were used. Perception of the referral
policy, in this case, appears to be less detrimental than the actual policy
(and the corresponding physician behaviors it inspires) with regard to the
patient-provider relationship. Policies undermining patient autonomy in seeking
care or emphasizing the gatekeeping role of the PCP rather than the coordination
of care role may lead to distrust of the physician and a poorer overall relationship.
Interestingly, Asian parents reported the poorest interpersonal relationships
between their child and their child's physician and were the most affected
by managed care policies. Asian children experienced significant deficits
in the relationship domain across each managed care policy, regardless of
the source of insurance data. These findings are supported, in part, by previous
research documenting tenuous patient-provider relationships for Asian American
adults.24, 29 These findings are
particularly important because of the growing numbers of Asian children who,
despite higher family education and income, are at greater risk than whites
and some other ethnic groups of being in poor health, underimmunization, and
contracting preventable illnesses such as hepatitis B.30-32
Despite nearly all respondents being able to complete our interviews
in English, Asian and Hispanic families (Hispanics were the second-most affected
by managed care policies) commonly experience language barriers to seeking
adequate health care. This was initially thought to explain some of our findings,
but examination of the questions composing the scale did not fully support
this theory. Asians, but not Hispanics, were more likely to report that their
physician did not know their family well (P<.05),
did not show interest in their child as a person (P<.001),
and did not give them enough time to talk about their child's problems (P<.05). Scores on questions about 2-way communication
between the patient and provider, however, were only slightly lower for both
Asians and Hispanics and were not significant. These contradictory findings
suggest some lapse in communication, but a lapse that is not clearly attributable
solely to language difficulty.
Inclusion of health status as a covariate did not significantly affect
the correlation between race and reporting of the patient-provider relationship.
The relationship score for Hispanics self-reporting the requirement to sign
up with a PCP became slightly nonsignificant (P =
.06), but there was no change in the mean score. Further adjustment for whether
the parent reported a specific clinician or a place of care as the PCP appeared
to be overcontrolling (and was removed from the analysis) because of its colinearity
with several of the longitudinality questions. Including the provider vs place
variable reduced, but did not eliminate, the effect of provider network restrictions
on strength of affiliation for black children. This reduction is explained,
in part, by the greater reliance on clinics (vs private practitioners) among
blacks compared with other racial groups.
Our analyses suggest that racial and ethnic differences in the patient-provider
relationship are not clearly attributable to variations in socioeconomic status
or insurance coverage. Cultural factors, including the physician and patient
behaviors induced by social and cultural stereotypes or biases, are likely
to play an important role in the development of the patient-provider relationship.
The effects of these intentional and unintentional behaviors may be particularly
salient in a primary care setting because the development of the patient-provider
relationship is essential to making appropriate long-term treatment decisions,
delivering and rationing adequate primary care services, and coordinating
care.
An interesting secondary finding is that parents who reported a pediatrician
as the child's regular source of care reported significantly better interpersonal
relationships between their family and the child's physician than parents
reporting other generalist providers. However, having a pediatrician did not
provide any benefit in the strength of affiliation domain. This unique finding
may be attributable, in part, to the greater frequency of visits to pediatricians
for well-child care, thus allowing greater time for development of the relationship
between the child and family and the provider. Low family income and having
public insurance coverage were also both weakly associated with lower interpersonal
relationships, but this occurred very infrequently (ie, in only 1 or 2 analyses
across managed care policies and races/ethnicities).
Other factors that may play a role in determining primary care quality,
but were not included in this analysis, include practice arrangements, racial
concordance between the patient and provider, family mobility, and, perhaps,
provider-specific factors, such as training or years in practice. The fact
that all respondents were able to speak English suggests that disparities
exist even when language difficulty is not a factor, but this does not discount
the potential of language difficulty to enhance disparities in health care.
Further research should explore the complex role of language.
This study has several limitations. First, the cross-sectional design
and analysis allow for the demonstration of association but not causality.
Second, we examine 4 broad classifications of race and ethnicity but do not
capture within-group variations in ethnicity or culture. Measurements of race
and ethnicity are often just measures of skin color that do not fully capture
biological, cultural, socioeconomic, political, and historical aspects of
multiculturalism that are likely to produce more complex findings than are
reported here.33 However, the use of self-reported
race and ethnicity data strengthens the validity of the measure in this study.
Third, because of the moderate response rate, the respondents in this
study may not be completely representative of the population being studied.
Because the sampling frame included many unreachable families—families
that may, in fact, be more chaotic or mobile and have even more difficulty
with the medical system—we may even be underestimating the disparities
in care experienced by our population. Additionally, although respondents
and nonrespondents were similar on many demographic factors, there is the
possibility that respondents were motivated to participate because of some
factor (eg, having children in poor health or negative experiences with the
health care system) that increase or reduce susceptibility to the hypothesized
effects of managed care. The internal validity of this study is not threatened
by this effect, and the direction of bias is difficult to predict. Because
of the similarity in health status across racial and ethnic groups, any bias
would not be likely to operate differentially across racial groups.
Fourth, because the data source for determining children's quality of
care was the child's parent, there is the possibility that the responses may
be biased by parents' own experiences with the medical care system. This applies
primarily to questions about parent communication with the physician (eg,
"Do you feel comfortable telling the doctor about your worries or problems?")
and not the majority of the scale.
Finally, our results suggest that relying on self-reported insurance
information may be quite inaccurate. In this study, we analyzed both validated
and self-reported information to more accurately capture the effects of managed
care. In addition, studies that rely on self-reporting to compare aspects
of quality across racial and ethnic groups may capture primarily racial group
variations in perceptions of care or standards for assessing care. In this
study, we chose to use an instrument for assessing quality of care that relies
more heavily than other instruments on factual reporting of physician behaviors,
rather than solely satisfaction or performance ratings, and, thus, our study
is less subject to these biases. Future work should explore racial and ethnic
differences in the validity of self-reported insurance information.
In conclusion, this study demonstrates a significant correlation between
specific managed care policies and reductions in the patient-provider relationship
for minority children, particularly Asians and Hispanics. A strong relationship
between family and doctor is essential to the receipt of high-quality primary
care and maintaining health. To reduce racial and ethnic disparities in health
and health care—a current national health priority—the studied
restrictions on patient care-seeking in managed care should be limited or
removed. Lack of choice is particularly detrimental to racial and ethnic minorities,
who may have difficulty locating linguistically and culturally appropriate
providers and who may be less likely to actually change providers, even if
they are dissatisfied. With so many vulnerable children moving into managed
care, health plans must substantially increase efforts to attend to the different
cultural needs of minority children. If these disparities already exist for
children, they can only widen as they become adults.
| What This Study Adds
A strong relationship between family and physician is essential to the
receipt of high-quality primary care and the ability to maintain health. However,
intensifying pressure to contain health care costs has led MCOs to develop
policies that restrict patient freedom in care-seeking. These policies threaten
the patient-provider relationship for children in primary care, and we explore
the hypothesis that these policies may be even more problematic for racial
and ethnic minority patients.
This study demonstrates a significant correlation between specific managed
care policies and reductions in the quality of the patient-provider relationship
for minority children, regardless of ability to pay, health status disparities,
or racial differences in expectations for care. To reduce racial and ethnic
disparities in health and health care—a current national health priority—the
studied restrictions on patient care-seeking in managed care should be limited
or removed.
|
|
AUTHOR INFORMATION
Accepted for publication December 21, 2001.
We thank Barbara Starfield, MD, and Lisa Cooper, MD, for their insights
and thoughtful reviews of the manuscript and Jane Lyon, RN, for her generous
support and help coordinating the study.
Corresponding author and reprints: Gregory D. Stevens, PhD, Department
of Health Policy and Management, Bloomberg School of Public Health, Johns
Hopkins University, 624 N Broadway St, Room 661, Baltimore, MD 21205 (e-mail: gstevens{at}jhsph.edu).
From the Department of Health Policy and Management, Bloomberg School
of Public Health, Johns Hopkins University, Baltimore, Md.
REFERENCES
| |
1. Donaldson M, Yordy K, Lohr K, Vanselow N. Primary Care: America's Health in a New Era. Washington, DC: National Academy Press; 1996.
2. Starfield B. Primary Care: Balancing Health Needs, Services, and
Technology. New York, NY: Oxford University Press; 1998.
3. Leopold N, Cooper J, Clancy C. Sustained partnership in primary care. J Fam Pract. 1996;42:129-137.
ISI
| PUBMED
4. Bergman D, Homer C. Managed care and the quality of children's health services. Future Child. 1998;8:60-75.
FULL TEXT
|
ISI
| PUBMED
5. Szilagyi PG. Managed care for children: effect on access to care and utilization
of health services. Future Child. 1998;8:39-59.
ISI
| PUBMED
6. Simpson L, Fraser I. Children and managed care: what research can, can't, and should tell
us about impact. Med Care Res Rev. 1999;56(suppl 2):13-36.
7. Deal LW, Shiono PH. Medicaid managed care and children: an overview. Future Child. 1998;8:93-104.
FULL TEXT
|
ISI
| PUBMED
8. Reid RJ, Hurtado MP, Starfield B. Managed care, primary care, and quality for children. Curr Opin Pediatr. 1996;8:164-170.
PUBMED
9. Hughes DC, Luft HS. Managed care and children: an overview. Future Child. 1998;8:25-38.
FULL TEXT
|
ISI
| PUBMED
10. Mechanic D, Schlesinger M. The impact of managed care on patients' trust in medical care and their
physicians. JAMA. 1996;275:1693-1697.
FREE FULL TEXT
11. Safran DG, Tarlov AR, Rogers WH. Primary care performance in fee-for-service and prepaid health care
systems. JAMA. 1994;271:1570-1586.
FREE FULL TEXT
12. Safran D, Rogers W, Tarlov A, et al. Organizational and financial characteristics of health plans: are they
related to primary care performance? Arch Intern Med. 2000;160:69-76.
FREE FULL TEXT
13. Shi L. Type of health insurance and the quality of primary care experience. Am J Public Health. 2000;90:1848-1855.
FREE FULL TEXT
14. Grumbach K, Selby J, Damberg C, et al. Resolving the gatekeeper conundrum: what patients value in primary
care and referrals to specialists. JAMA. 1999;282:261-266.
FREE FULL TEXT
15. Kao A, Green D, Davis N, Koplan J, Cleary P. Patients' trust in their physicians: effects of choice, continuity,
and payment method. J Gen Intern Med. 1998;13:681-686.
FULL TEXT
|
ISI
| PUBMED
16. Kao A, Green D, Zaslavsky A, Koplan J, Cleary P. The relationship between method of physician payment and patient trust. JAMA. 1998;280:1708-1714.
FREE FULL TEXT
17. Reschovsky J, Kemper P, Tu H. Does type of health insurance affect health care use and assessments
of care among the privately insured? Health Serv Res. 2000;35(pt 2):219-237.
18. Starfield B, Cassady C, Nanda J, Forrest CB, Berk R. Consumer experiences and provider perceptions of the quality of primary
care: implications for managed care. J Fam Pract. 1998;46:216-226.
ISI
| PUBMED
19. Fox H, Limb S, Chen C, Hayden M. An Analysis of States' Medicaid Managed Care Plan
Arrangements and Service Requirements Affecting Children, 1995-1999. Washington, DC: Maternal & Child Health Policy Research Center;
2000.
20. Forrest C, Simpson L, Clancy C. Child health services research: challenges and opportunities. JAMA. 1997;277:1787-1793.
FREE FULL TEXT
21. Fiscella K, Franks P, Gold M, Clancy C. Inequality in quality: addressing socioeconomic, racial, and ethnic
disparities in health care. JAMA. 2000;283:2579-2584.
FREE FULL TEXT
22. Phillips K, Mayer M, Aday L. Barriers to care among racial/ethnic groups under managed care. Health Aff (Millwood). 2000;19:65-75.
ABSTRACT
23. Cooper-Patrick L, Gallo J, Gonzales J, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583-589.
FREE FULL TEXT
24. Murray-Garcia J, Selby J, Schmittdiel J, Grumbach K, Quesenberry CJ. Racial and ethnic differences in a patient survey: patients' values,
ratings, and reports regarding physician primary care performance in a large
health maintenance organization. Med Care. 2000;38:300-310.
FULL TEXT
|
ISI
| PUBMED
25. Saha S, Komaromy M, Koepsell T, Bindman A. Patient-physician racial concordance and the perceived quality and
use of health care. Arch Intern Med. 1999;159:997-1004.
FREE FULL TEXT
26. Shi L. Experience of primary care by racial and ethnic groups in the United
States. Med Care. 1999;37:1068-1077.
FULL TEXT
|
ISI
| PUBMED
27. Doescher M, Saver B, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and
trust. Arch Fam Med. 2000;9:1156-1163.
FREE FULL TEXT
28. Kemper P, Blumenthal D, Corrigan J, et al. The design of the community tracking study: a longitudinal study of
health system change and its effects on people. Inquiry. 1996;33:195-206.
ISI
| PUBMED
29. Taira D, Safran D, Seto T, et al. Asian American patient ratings of physician primary care performance. J Gen Intern Med. 1997;12:237-242.
FULL TEXT
|
ISI
| PUBMED
30. Weigers M, Weinick R, Cohen J. Children's Health, 1996. Rockville, Md: Agency for Healthcare Research and Quality, US Dept
of Health and Human Services; 1998. AHRC publication 98-0008.
31. Centers for Disease Control and Prevention. Vaccination coverage by race/ethnicity and poverty level among children
aged 19-35 months: United States, 1997. MMWR Morb Mortal Wkly Rep. 1998;47:956-959.
PUBMED
32. Centers for Disease Control and Prevention. Hepatitis B vaccination coverage among Asian and Pacific Islander children:
United States, 1998. MMWR Morb Mortal Wkly Rep. 2000;49:616-619.
PUBMED
33. LaVeist T. Beyond dummy variables and sample selection: what health services researchers
ought to know about race as a variable. Health Serv Res. 1994;29:1-16.
ISI
| PUBMED
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