The costs of children with sickle cell anemia: Preparing for managed care

Purpose: To anticipate the clinical challenges and financial risks facing p hysicians and managed care organizations who care for children with chronic illnesses, such as sickle cell anemia (SCA), under capitated managed care arrangements. Patients and Methods: A cross-sectional study based on claims data from the Washington State Medicaid Program (WSMP) and the Federal Employees Health Benefits Program (FEP). Expenditure patterns were compared for children 18 years of age or younger for whom a claim with a diagnosis of SCA was submit ted and paid in the State of Washington during fiscal year 1993 (FY1993) or by the FEP during FY1992 to expenditure patterns for all children. Results: Children with SCA had mean expenditures 8.8 times the mean expendi tures for all children in WSMP. There was wide variation in the annual expe nditures among children with SCA; the most expensive 10% of children accoun ted for 56% of total expenditures. Ninety-seven percent of the expenditures were concentrated in four broad categories: 72% for inpatient care, 11% fo r outpatient care, 11% for physician payments, and 3% for prescription drug s. Examination of expenditure and utilization patterns for children with si ckle cell anemia enrolled in the FEP yielded similar results. Conclusions: Unless managed care organizations and capitated pediatricians receive payment rates that reflect the higher expected expenditures of cari ng for these children, access to and quality of care may suffer. Analyses o f practice guidelines and utilization patterns suggest that newborn screeni ng, regular access to specialty facilities, and comprehensive education pro grams are critical areas that are vulnerable to reductions under capitation .