April 2001

From University of Michigan Health System

Kids on Medicaid less likely to see specialist for asthma care, study finds

ANN ARBOR, MI - Asthmatic children insured through Medicaid are less likely to see a physician who specializes in asthma care than children who get their health insurance through other types of managed care plans, a new University of Michigan Health System study finds.

The report, which shows a dramatic three-fold difference in the odds of receiving specialty care between kids on Medicaid and non-Medicaid children even when several other factors are taken into account, seems to confirm anecdotal reports of major variations in care among children with different forms of health insurance. Children who don't see a specialist like an allergist or pulmonologist for their asthma may not receive appropriate management that can prevent emergency room visits, hospitalizations and increased health costs.

The research will be presented April 30 at the joint meeting of the Pediatric Academic Societies and the American Academy of Pediatrics in Baltimore.

"There will always be variations in health care, but this is a sizable difference based on insurance status, even controlling for the severity of a child's asthma," says Michael Cabana, M.D., MPH, who led the research team. "Now, we must work to find out the reasons behind this disparity." Cabana is an assistant professor and member of the Child Health Evaluation and Research Unit, or CHEAR, in the Division of General Pediatrics at UMHS.

The study also showed that children were more likely to see a specialist if they were relatively young, or if their condition was severe. These trends may reflect the willingness of primary care physicians and parents to seek specialty help in the hardest-to-handle cases.

But the reasons for the Medicaid disparity are less easy to discern, Cabana notes. "The difference may stem from primary care physicians' referral practices, from low rates of Medicaid acceptance by specialists, and/or from patient preference," he says.

An estimated 17 million Americans suffer from asthma, nearly 5 million of them under age 18. The most common chronic childhood disease, asthma affects more than one in every 20 children with inflamed air passages that narrow and produce wheezing and breathing problems. Asthma is already known to disproportionately affect those living in urban areas or in poverty, members of racial minorities, and those who do not get good health education or medical care.

The U-M findings come from a study of a single managed-care organization's claims from all outpatient visits for patients under 19 years of age in a 32-month period ending in 2000. Cabana and his colleagues examined the claims to determine which had been for patients with any form of asthma - a total of 886 children. Approximately 70 percent of the patients were insured through non-Medicaid managed care plans; the rest were Medicaid participants.

The researchers then looked at who had treated the children for their asthma in that time period, including primary care providers like pediatricians and pediatric subspecialists like pediatric or adult allergists, or pulmonologists.

The results showed that 21 percent of the 886 children with asthma saw a subspecialist during the studied period. But far fewer of the Medicaid-insured children visited a subspecialist.

The disparity persisted even when Cabana and his colleagues factored out patients' ages, length of time in the insurance plan, copayments for doctor visits, and asthma severity. The same was true when the researchers considered the training background of the physicians in either family practice or pediatrics.

The difference in specialty care was also independent of the physician's financial "risk" for referring patients to specialists due to arrangements between physician practices and managed care plans that place the physician practices at any financial liability for the costs of referrals to subspecialists.

The study did not assess whether subspecialists in the geographic area served by the insurance plan accepted Medicaid, nor whether patients received referrals for specialty care but did not make or keep an appointment with a specialist.

Overall, Cabana says, the study is the first step in understanding how and why care for such a common disease varies among different populations, and how to close the gap in care for certain groups.

"The spectrum of disease severity for kids with asthma has a wide range, and proper management of asthma for some kids requires occasional referral by primary care physicians to specialists with additional expertise," Cabana says.

"With the emphasis on primary care 'gatekeeping' in managed care arrangements, and the increasing specialization of medical care today, understanding the factors associated with physician referral is important," he continues. "There are implications for delivery of services, cost of care, patient satisfaction, the continuity of care that patients receive, and even the number of subspecialists and primary care doctors that medical educators need to train."

Besides Cabana, the research team included David Bruckman, M.S., research associate; Jerry Rushton, M.D., MPH, assistant professor of pediatrics; and Lee Green, M.D., MPH., an associate professor in the Department of Family Medicine.












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