The impact of managed care insurance on use of lower-mortality hospitals by children undergoing cardiac surgery in California

Context. Managed care plans aggressively seek to contain costs, but few dat a are available regarding their impact on access to high quality care for t heir members. Objective. To assess the impact of managed care health insurance on use of lower-mortality hospitals for children undergoing heart surgery in Californ ia. Design. Retrospective cohort study using state-mandated hospital discharge datasets. Setting. Pediatric cardiovascular surgical centers in California. Patients. Five thousand seventy-one children admitted for open cardiac surg ical procedures during 1992-1994. Results. Hospitals were divided into lower- and higher-mortality groups acc ording to adjusted surgical mortality. Using multivariate logistic regressi on analysis to control for medical, socioeconomic, demographic, and distanc e factors, children with managed care insurance were less likely to be admi tted to a lower-mortality hospital for surgery relative to children with in demnity insurance (odds ratio: .53; 95% confidence interval: .45,.63). Simi lar findings resulted when the analysis was stratified by race/ethnicity. I n addition, length of stay, a correlate of health care costs, was no longer for children admitted to lower-mortality centers than for those at higher- mortality centers (adjusted difference: .54 days shorter at lower-mortality centers; 95% confidence interval: -1.50,.41). Conclusions. During this study, children with managed care insurance had si gnificantly reduced use of lower- mortality hospitals for pediatric heart s urgery in California compared with children with indemnity insurance. Furth er study is necessary to determine the mechanisms of this apparent insuranc e-specific inequity.