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Table 4 Summary of articles addressing the effects of managed care on access to specialty care.

From: Effects of insurance status on children's access to specialty care: a systematic review of the literature

Author

Year

Sample Size

Data Source

Study Design

Access Measure

Statistic

Comparison

Findings

Endogeneity/Selection

Alessandrini et al. [37]

2001

553

Single hospital

Prospective cohort

Utilization

χ2; % with a specialty visit; number of visits

Managed care vs. fee-for-service

10% vs. 12%, p = 0.68; 0.2 vs. 0.2, p = 0.65

MC mandated' no patient selection

Cartland and Yudkowsky [43]

1992

1,264

American Academy of Pediatrics Fellows

Cross-sectional

Referral rates

χ2; frequency of referral of MCO patients

Managed care vs. fee-for-service

More frequent: 2.5%; less frequent, 8.7%; p < 0.05

Study is of physician behavior; no patient selection

Cuesta et al. [44]

2000

49

Single hospital

Retrospective cohort

Referral type

χ2

Initial referral is to rheumatologist vs. orthopedic surgeon

Managed care: 83% vs. 17%; "Traditional commercial": 58% vs. 42%; p = NS

Examines insurance type at initial referral, prior to diagnosis

Ferris et al. [39]

2002

59,952

Single MCO

Quasi-experimental

Utilization

t-test; number of specialist visits and proportion new specialist visits

With gatekeeping vs. without gatekeeping

Visits: 0.28 vs. 0.28, p = NS; % new visits: 30.6% vs. 34.8%; p < 0.05

Single MCO initiated removal of gatekeeping; no patient choice

Ferris et al. [45]

2001

1,839

Single insurance plan

Prospective cohort

Utilization

t-test; change in visits

Gatekeeping vs. indemnity

57% decrease vs. 31% increase; p = 0.005

Patient voluntarily selected into coverage type

Forrest et al [24]

1999

27,104

National practice-based research network

Prospective

Referral rates

t-test, percent referred; logistic regression, likelihood of referral to specialty

Gatekeeping vs. no gatekeeping

Medicaid, OR = 1.86, p < 0.001; Private, OR = 1.76, p < 0.01

No consideration of selection into type of plan

Garrett et al [38]

2003

34,280

National Health Interview Survey

Retrospective

Utilization

Probit; mandatory PCCM vs. FFS, mandatory HMO vs. FFS; likelihood of any specialist visit

Fee-for-service vs. primary care case management or HMO

PCCM = 0.003, p = NS; HMO = 0.378, p < 0.05

Mandatory enrollment into program type

Lake [46]

1999

12,383

Community Tracking Survey

Cross-sectional

Satisfaction

Logistic regression; difference in percent satisfied with choice of specialists

HMO vs. non-HMO

-8.3%, p < 0.05

No consideration of selection into coverage type

Mitchell, Khatutsky, and Swigonski [40]

2001

966

Single SCHIP

Cross-sectional

Unmet need

χ2; percent with unmet need for specialist

Managed care vs. fee-for-service

6.0% vs. 10.6%, p = NS

Patients seek managed care exemptions

Perlstein et al. [15]

1997

544

Regional cardiac registry

Retrospective cohort

Time to referral

t-test; mean age at referral

Managed care vs. "commercial"

140 days vs. 80 days, p < 0.05

No consideration of selection into coverage type

Price et al. [34]

1999

94

Single hospital

Cross-sectional

Utilization

t-test; number of specialist visits

Capitated plan vs. fee-for-service

All: 7.5 vs. 6, p = NS; asthma-related: 5 vs. 4, p,0.05

No consideration of selection into coverage type

Roberto et al. [53]

2005

935

Single Medicaid program

Quasi-experimental

Utilization

Probit; change in access to specialist

Fee-for-service vs. partially capitated managed care

b = 0.221, p < 0.05

Voluntary selection into plan type

Shenkman at al. [42]

2004

2,333

Single SCHIP

Cross-sectional

Utilization

Logistic regression; likelihood of a specialist visit

Plans with certain managed care characteristics vs. those without

Percent paid on FFS basis: 0.950, p = 0.003; Bonus for quality profile: 1.714, p = 0.0003

Mandatory enrollment into specific plan

Shields, et al. [41]

2002

6,231

Single Medicaid program

Cross-sectional

Utilization

Logistic regression; likelihood of specialist visit

HMO vs. primary care case management plan

OR = 1.80, p < 0.05

Voluntary selection into coverage type