HEALTH-CARE UTILIZATION BY CHILDREN WITH CHRONIC ILLNESSES - A COMPARISON OF MEDICAID AND EMPLOYER-INSURED MANAGED CARE

Objectives. This study compared utilization of health care services by children with chronic conditions who were insured by either Medicaid or an employer group in 1992 and 1993. Five chronic conditions were se lected to illustrate patterns of service use: asthma, attention defici t disorder, diabetes, epilepsy, and sickle cell anemia. Methodology. A dministrative databases were used to develop estimates of health servi ces utilization for children <18 years of age with the five selected c onditions, who had been enrolled for at least 6 continuous months. All claims for a child identified with one of these five conditions were included in the analysis, including claims for diagnoses and procedure s not directly related to the primary diagnosis. Estimates were derive d for eight services (eg, hospital admissions, emergency department (E D), home health). Data were used from two Independent Practice Associa tion model health plans in two states. Differences across the states w ere controlled by selecting one Medicaid and one employer-insured prog ram from each of the two plans in both states. Regional variation was controlled for because both health plans were located in one geographi cal region. In each case, physicians were paid on a fee-for-service ba sis, with generally open access to specialists rather than primary car e gatekeeper models of delivery: t tests were used to compare service use rates between Medicaid and employer-insured populations. Results. A total of 8668 children across all health plan groups had at least on e of the selected conditions. Because Medicaid enrolled-children tende d to be younger, analyses were adjusted for age. In both systems, a gr eater percentage of Medicaid children had these five study conditions (5%) compared with employer-insured children (3%), suggesting that the Medicaid population was sicker. Mean length of enrollment during the 2-year study was longer for children in employer-insured programs. Chi ldren with chronic conditions enrolled in Medicaid managed care genera lly used services at a higher rate compared with children with similar conditions enrolled in employer-insured managed care. The extent of t he increased use varied by condition, by service type, and by plan. Ch ildren with any of the chronic conditions studied had from 2 to almost 5 times more ED visits if they were enrolled in Medicaid than if they were enrolled in employer-based managed care, depending on the specif ic condition. In one of the two plans, Medicaid-enrolled children had more outpatient services, laboratory services, and radiography service s than their counterparts in employer-based managed care. The same pat tern of use was found for home health services (except for children wi th diabetes) and for office visits (except for children with sickle ce ll). The results show higher use of all services by children with asth ma and diabetes in Medicaid managed care compared with employer-based managed care. In contrast, the pattern is mixed for children with epil epsy and sickle cell. The sample size of children with these condition s was smaller than with the three other conditions, which may account, in part, for a varied pattern of results. The pattern of use for atte ntion deficit hyperactivity disorder (ADHD) was generally different fr om the other conditions. Children with ADHD :in employer-based managed care had more hospital admissions, hospital days, and office visits t han their counterparts in Medicaid managed care. In contrast, Medicaid -enrolled children with ADHD had more ED visits, :Laboratory services, outpatient hospital visits, and radiography services. Other than ED v isits, the differences in service use between Medicaid and employer-in sured children with ADHD were minimal. Of note, the pattern for ADHD i s the same for most services for Plans A and B (excluding home health visits). This utilization pattern may reflect service use for comorbid conditions. Part of this difference may be explained by differences i n Medicaid eligibility criteria used by the two plans. Medicaid eligib ility regarding level of poverty was more stringent in Plan A than in Plan B. Plan A showed consistently high service utilization for Medica id children compared with employer-insured children; Plan B showed les s consistency. There are several patterns of utilization common to all disease and insurance groups. The majority of care seems to be delive red in physicians' offices, rather than in other locations. When compa ring the differences by disease categories, asthma shows more statisti cally significant differences in utilization between Medicaid and comm ercially-insured children than the other conditions. Asthma is the mos t prevalent condition of these five, which increases the power to dete ct statistical significance for this defined population. These results show the importance of evaluating conditions other than asthma, becau se utilization comparisons for different services may vary depending o n the condition studied. Conclusion. This study of children with selec ted chronic health conditions indicates that: 1) a higher percentage o f children enrolled in Medicaid managed care (5%) have these condition s compared with children enrolled in employer-insured managed care pro grams (3%); 2) on average, children with chronic health conditions who are enrolled in Medicaid managed care use moreservices than children with similar conditions who are insured through employers; and 3) alth ough utilization rates are generally higher for children enrolled in M edicaid managed care than far children enrolled in employer-based mana ged care, Me differences in rates vary greatly by service, by diagnosi s, and by plan. Differences between the children enrolled in Medicaid and children enrolled in employer-based programs were more pronounced in one of the plans we studied compared with the other. Children with chronic conditions in Medicaid managed care have substantially differe nt patterns of service use compared with children with similar conditi ons in employer-based managed care. This finding has major implication s for policy development related to legislative proposals regarding re ferral practices, quality assurance, and capitation rates. Our results demonstrate;he importance of examining a broad spectrum oi chronic co nditions and services when comparing Medicaid to employer-insured chil dren with special needs. Utilization of several services, including ED , was higher for Medicaid children than for employer-insured