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Objective

Although private insurance typically covers many health care costs, the challenges faced by families caring for a sick child are substantial. These challenges may be more severe for CSHCN with mental illnesses than for other special needs children. Our objective is to determine whether families of privately insured children needing mental health care face different burdens than other families in caring for their children.

Patients and Methods

We use the 2005–2006 National Survey of Children with Special Health Care Needs (NS-CSHCN) to study privately insured children ages 6–17. We compare CSHCN with mental health care needs (N=4,918) to three groups: children with no SHCN (N=2,346), CSHCN with no mental health care needs (N=16,250), and CSHCN with no mental health care need but a need for other specialty services (N=7,902). The latter group is a subset of CSHCN with no mental health care need. We use weighted logistic regression and study outcomes across four domains: financial burden, health plan experiences, labor market and time effects, and parent experience with services.

Results

We find that families of children with mental health care needs face significantly greater financial barriers, have more negative health plan experiences, and are more likely to reduce their labor market participation to care for their child than other families.

Conclusions

Families of privately insured CSHCN needing mental health care face a higher burden than other families in caring for their children. Policies are needed to aid these families in obtaining affordable, high quality care for their children.

Objective

To examine the role of insurance coverage in protecting families of children with special health care needs (CSHCN) from the financial burden associated with care.

Methods

Data from the 2001 National Survey of Children with Special Health Care Needs were analyzed. We built two multivariate regression models using “work loss/cut back” and “experiencing financial problems” as the dependent variables and insurance status as the primary independent variable of interest while adjusting for income, race/ethnicity, functional limitation/severity, and other sociodemographic predictors.

Results

Approximately 29.9 % of CSHCN live in families where their condition led parents to report cutting back on work or stopping work completely. Families of 20.9 % of CSHCN reported experiencing financial difficulties due to the child’s condition. Insurance coverage significantly reduced the likelihood of families experiencing financial problems at every income level. The proportion of families experiencing financial problems was reduced from 35.7 to 23.0 % for the poor and 44.9 to 24.5 % for low-income families with continuous insurance coverage (p<0.01 for both comparisons). Similarly, the proportion of parents having to cut back or stop work was reduced from 42.8 to 35.9 % for the poor (p<0.05) and 43.5 to 33.9 % for low-income families (p<0.01).

Conclusions

Continuous health insurance coverage provides protection from financial burden and hardship for families of CSHCN in all income groups. This evidence is supportive of policies designed to promote universal coverage for CSHCN. However, many poor and low-income families continue to experience work loss and financial problems despite insurance coverage. Hence, health insurance should not be viewed as a solution in itself, but instead as one element of a comprehensive strategy to provide financial safety for families with CSHCN.

Objective

To profile and compare the health and health services characteristics for children with special health care needs (CSHCN) with and without disabilities, and to determine factors associated with unmet need.

Methods

Secondary data analysis of the 2005-06 National Survey of Children with Special Health Care Needs was conducted. The socio-demographics, health, and health services of CSHCN with and without disabilities were compared. Multivariable logistic regression was employed to examine factors associated with unmet need for health services.

Results

Children from minority racial and ethnic groups and children living in or near poverty were overrepresented among CSHCN with disabilities compared to other CSHCN. Statistically higher percentages of CSHCN with disabilities had behavioral problems (39.6% vs. 25.2%), anxiety/depressed mood (46.1% vs. 24.0%) and trouble making/keeping friends (38.1% vs. 15.6%) compared to other CSHCN. 32% of CSHCN with disabilities received care in a medical home compared to 51% of other CSHCN. CSHCN with disabilities had higher rates of need and unmet need than other CSHCN for specialty care, therapy services, mental health services, home health, assistive devices, medical supplies and durable medical equipment. The adjusted odds of unmet need for CSHCN with disabilities were 71% higher than for other CSHCN.

Conclusion

CSHCN with disabilities had more severe health conditions and more health services need, but they less commonly received care within a medical home and had more unmet need. These health care inequities should be amenable to policy and health service delivery interventions to improve outcomes for CSHCN with disabilities.

What’s New

CSHCN with disabilities are identified as a distinct group of CSHCN because of their sociodemographic, health and health services characteristics. CSHCN with disabilities had more psychosocial problems and health service needs than other CSHCN. We also document inequities in health services by highlighting the rates of unmet need and low percentages of care within a medical home for CSHCN with disabilities.

This paper grew out of a project reviewing progress in children's oral health since the Surgeon General's Report (SGR) on Oral Health. It includes a summary of advances in national surveillance of children with special health care needs (CSHCN), and presents more recent data on unmet dental care need among CSHCN. To that end, we used the 2006-National Survey of CSHCN to determine the prevalence of unmet dental care need among CSHCN and to compare this within subgroups of CSHCN, as well as to children without special health care needs, and to results from the previous iteration of this survey.

We found that dental care remains the most frequently cited unmet health need for CSHCN. More CSHCN had unmet need for non-preventive than preventive dental care. CSHCN who are teens, poorer, uninsured, had insurance lapses, or more severely affected by their condition had higher adjusted odds of unmet dental care needs. CSHCN who were both low-income and severely affected had 13.4 times the adjusted odds of unmet dental care need.

In summary, CSHCN are more likely to be insured and to receive preventive dental care at equal or higher rates than children without SHCN. Nevertheless, CSHCN, particularly lower income and severely affected, are more likely to report unmet dental care need compared to unaffected children. Despite advances in knowledge about dental care among CSHCN, unanswered questions remain. We provide recommendations towards obtaining additional data and facilitating dental care access for this vulnerable population.

Objective

To examine the impact of full-year versus intermittent public and private health insurance coverage on the immunization status of children aged 19–35 months.

Data Source

2001 State and Local Area Integrated Telephone Survey's National Survey of Children with Special Health Care Needs (NS-CSHCN) and the 2000–2002 National Immunization Survey (NIS).

Study Design

Linked health insurance data from 2001 NS-CSHCN with verified immunization status from the 2000–2002 NIS for a nationally representative sample of 8,861 nonspecial health care needs children. Estimated adjusted rates of up-to-date (UTD) immunization status using multivariate logistic regressions for seven recommended immunizations and three series.

Principal Findings

Children with public full-year coverage were significantly more likely to be UTD for two series of recommended vaccines, (4:3:1:3) and (4:3:1:3:3), compared with children with private full-year coverage. For three out of 10 immunizations and series tested, children with private part-year coverage were significantly less likely to be UTD than children with private full-year coverage.

Conclusions

Our findings raise concerns about access to needed immunizations for children with gaps in private health insurance coverage and challenge the prevailing belief that private health insurance represents the gold standard with regard to UTD status for young children.

Objective

To test the feasibility of using the National Health Interview Survey (NHIS) to identify children with chronic illness through a noncategorical approach, as exemplified by the Children with Special Health Care Needs (CSHCN) screener. The ability to use the NHIS to identify CSHCN will permit analyses of the effects of welfare reform and public insurance eligibility expansions during the late 1990s on CSHCN.

Data Sources

The NHIS from 1997, 1999, and 2000. The NHIS is an ongoing household survey representative of the civilian, noninstitutionalized population of the United States.

Study Design

Survey items were selected from the NHIS and thresholds designated to replicate the content and logic of the CSHCN screener. The screener asks explicit questions concerning an elevated need for, or use of health care services, and about limitations in activity, both caused by a chronic health condition. The algorithm created was applied to the pooled 1999–2000 NHIS to generate national prevalence estimates. Multivariate logistic regression was estimated to determine the effect of having particular demographic characteristics on the likelihood of being identified as CSHCN. Log odds ratios were compared to those from earlier NHIS-based estimates and from a pretest of the CSHCN screener.

Principal Findings

An estimated 12 percent of noninstitutionalized children aged 0 through 17 have a chronic condition that results in elevated service use or limitations in normal activity. This estimate is sensitive to inclusion of children with a broader array of less serious or shorter-term conditions. The estimated effects of child characteristics on the likelihood of being identified as having special health needs are similar but not identical to other algorithms that have been used to identify CSHCN.

Conclusions

It is feasible to use existing questions in the NHIS to identify a population of CSHCN that is substantially similar to children identified through other algorithms or through use of a screening instrument imbedded in a household survey. The availability of this algorithm will permit use of the NHIS for important analyses of the effects of welfare reform and public insurance expansions on children with special health care needs.

Objective

To study the financial impact of state parity laws on families of children in need of mental health services.

Data Source

Privately insured families in the 2000 State and Local Area Integrated Telephone Survey National Survey of Children with Special Health Care Needs (CSHCN) (N=38,856).

Study Design

We examine whether state parity laws reduce the financial burden on families of children with mental health conditions. We use instrumental variable estimation controlling for detailed information on a child's health and functional impairment. We compare those in parity and nonparity states and those needing mental health care with other CSHCN.

Principle Findings

Multivariate regression results indicate that living in a parity state significantly reduced the financial burden on families of children with mental health care needs. Specifically, the likelihood of a child's annual out-of-pocket (OOP) health care spending exceeding $1,000 was significantly lower among families of children needing mental health care living in parity states compared with those in nonparity states. Families with children needing mental health care in parity states were also more likely to view OOP spending as reasonable compared with those in nonparity states. Likewise, living in a parity state significantly lowered the likelihood of a family reporting that a child's health needs caused financial problems. The likelihood of reports that additional income was needed to finance a child's care was also lower among families with mentally ill children living in parity states. However, we detect no significant difference among residents of parity and nonparity states in receipt of needed mental health care.

Conclusion

These results indicate that state parity laws are providing important economic benefits to families of mentally ill children undetected in prior research.

Objective

To determine the association between Medicaid managed care pediatric behavioral health programs and unmet need for mental health care among children with special health care needs (CSHCN).

Data Source

The National Survey of CSHCN (2000–2002), using subsets of 4,400 CSHCN with Medicaid and 1,856 CSHCN with Medicaid and emotional problems. Additional state-level sources were used.

Study Design

Multilevel models investigated the association between managed care program type (carve-out, integrated) or fee-for-service (FFS) and reported unmet mental health care need.

Data Collection/Extraction Methods

The National Survey of CSHCN conducted telephone interviews with a sample representative at both the national and state levels.

Principal Findings

In multivariable models, among CSHCN with only Medicaid, living in states with Medicaid managed care (odds ratio [OR]=1.81; 95 percent confidence interval: 1.04–3.15) or carve-out programs (OR=1.93; 1.01–3.69) were associated with greater reported unmet mental health care need compared with FFS programs. Among CSHCN on Medicaid with emotional problems, the association between managed care and unmet need was stronger (OR=2.48; 1.38–4.45).

Conclusions

State Medicaid pediatric behavioral health managed care programs were associated with greater reported unmet mental health care need than FFS programs among CSHCN insured by Medicaid, particularly for those with emotional problems.

Background

In the United States, primary and secondary online schools are institutions that deliver online curricula for children enrolled in kindergarten through 12th grade (K-12). These institutions commonly provide opportunities for online instruction in conjunction with local schools for students who may need remediation, have advanced needs, encounter unqualified local instructors, or experience scheduling conflicts. Internet-based online schooling may potentially help children from populations known to have educational and health disadvantages, such as those from certain racial or ethnic backgrounds, those of low socioeconomic status, and children with special health care needs (CSHCN).

Objective

To describe the basic and applied demographics of US online-school users and to compare student achievement in traditional versus online schooling environments.

Methods

We performed a brief parental survey in three states examining basic demographics and educational history of the child and parents, the child’s health status as measured by the CSHCN Screener, and their experiences and educational achievement with online schools and class(es). Results were compared with state public-school demographics and statistical analyses controlled for state-specific independence.

Results

We analyzed responses from 1971 parents with a response rate of 14.7% (1971/13,384). Parents of online-school participants were more likely to report having a bachelor’s degree or higher than were parents of students statewide in traditional schools, and more of their children were white and female. Most notably, the prevalence of CSHCN was high (476/1971, 24.6%) in online schooling. Children who were male, black, or had special health care needs reported significantly lower grades in both traditional and online schools. However, when we controlled for age, gender, race, and parental education, parents of CSHCN or black children reported significantly lower grades in online than in traditional schooling (adjusted odds ratio [aOR] 1.45, 95% confidence interval [CI] 1.29–1.62 for CSHCN, P < .001; aOR 2.73, 95% CI 2.11–3.53 for black children, P < .001.) In contrast, parents with a bachelor’s degree or higher reported significantly higher online-school grades than traditional-school grades for their children (aOR 1.45, 95% CI 1.15–1.82, P < .001).

Conclusions

The demographics of children attending online schools do not mirror those of the state-specific school populations. CSHCN seem to opt into online schools at a higher rate. While parents report equivalent educational achievement in online and traditional classrooms, controlling for known achievement risks suggests that CSHCN and black children have lower performance in online than in traditional schools. Given the millions of students now in online schools, future studies must test whether direct assistance in online schools, such as taking individualized education plans into consideration, will narrow known disparities in educational success. Only then can online schools emerge as a true educational alternative for at-risk populations.

CONTEXT

Previous studies have demonstrated a strong association between minority race, low socioeconomic status (SES), and lack of potential access to care (e.g., no insurance coverage and no regular source of care) and poor receipt of health care services. Most studies have examined the independent effects of these risk factors for poor access, but more practical models are needed to account for the clustering of multiple risks.

OBJECTIVE

To present a profile of risk factors for poor access based on income, insurance coverage, and having a regular source of care, and examine the association of the profiles with unmet health care needs due to cost. Relationships are examined by race/ethnicity.

DESIGN

Analysis of 32,374 adults from the 2000 National Health Interview Survey.

MAIN OUTCOME MEASURES

Reported unmet needs due to cost: missing/delaying needed medical care, and delaying obtaining prescriptions, mental health care, or dental care.

RESULTS

Controlling for personal demographic and community factors, individuals who were low income, uninsured, and had no regular source of care were more likely to miss or delay needed health care services due to cost. After controlling for these risk factors, whites were more likely than other racial/ethnic groups to report unmet needs. When presented as a risk profile, a clear gradient existed in the likelihood of having an unmet need according to the number of risk factors, regardless of racial/ethnic group.

CONCLUSION

Unmet health care needs due to cost increased with higher risk profiles for each racial and ethnic group. Without attention to these co-occurring risk factors for poor access, it is unlikely that substantial reductions in disparities will be made in assuring access to needed health care services among vulnerable populations.

Background

The current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Our objective was to review the literature on the effects of insurance status on children's access to specialty care.

Methods

We conducted a systematic review of original research published between January 1, 1992 and July 31, 2006. Searches were performed using Pubmed.

Results

Of 30 articles identified, the majority use number of specialty visits or referrals to measure access. Uninsured children have poorer access to specialty care than insured children. Children with public coverage have better access to specialty care than uninsured children, but poorer access compared to privately insured children. Findings on the effects of managed care are mixed.

Conclusion

Insurance coverage is clearly an important factor in children's access to specialty care. However, we cannot determine the structure of insurance that leads to the best use of appropriate, quality care by children. Research about specific characteristics of health plans and effects on health outcomes is needed to determine a structure of insurance coverage that provides optimal access to specialty care for children.

Objectives

Limited studies consider the effect of differential item functioning (DIF) on health-related quality of life (HRQOL) comparisons between ill and health children. The objective is to assess DIF and compare HRQOL between children with special health care needs (CSHCN) and children without needs.

Methods

Data were collected from 1195 families of children enrolled in Florida’s public insurance programs. HRQOL was measured using physical, emotional, social, and school functioning of the PedsQL. We identified CSHCN using the CSHCN Screener and assessed DIF related to CSHCN using a multiple group-multiple indicator-multiple cause (MG-MIMIC) method. We assessed the impact of DIF by examining expected item/test scores and item/test information function. We tested the discrepancy between underlying HRQOL scores of both groups before and after DIF calibration (allowing parameters of DIF items to be different and DIF-free items to be the same across both groups).

Results

Two (25%) and 3 items (60%) of physical and school functioning, respectively, were identified with non-uniform DIF, and two items (40%) of social functioning were identified with uniform DIF. Expected item/test scores and item/test information function suggest the impact of DIF is minimal. Before DIF calibration, HRQOL in CSHCN was more impaired than children without needs (effect size −1.04, − 0.74, −0.96, and −0.98 for physical, emotional, social and school functioning, respectively). After DIF calibration, the discrepancy was increased slightly.

Conclusions

Although 30% of items in the PedsQL were identified with DIF related to CSHCN and children without needs, the impact of DIF is minimal.

Relatively few quality-improvement efforts have been aimed at reducing differences in children’s care and outcomes across race and ethnicity, socioeconomic status, and insurance status. To inform quality-improvement efforts to reduce child health disparities, we summarize lessons learned from the adult disparities-intervention literature, identify interventions that have reduced disparities in pediatric asthma outcomes and immunization rates, and outline special considerations for child disparity interventions. Key recommendations for providers, health care organizations, and researchers include: (1) examine your performance data stratified according to insurance status, race/ethnicity, language, and socioeconomic status; (2) measure and improve childhood health-related quality of life, development, and condition-specific targets (such as asthma and immunizations); (3) measure and improve anticipatory guidance for early prevention of conditions (such as injuries, violence, substance abuse, and sexually transmitted diseases) and efforts to promote positive growth (such as readership programs to improve low literacy); (4) measure and improve structural aspects of care that affect child health outcomes and can reduce disparities, such as patient-centered medical-home elements; (5) incorporate families into interventions; (6) use multidisciplinary teams with close tracking and follow-up of patients; (7) integrate non–health care partners into quality-improvement interventions; and (8) culturally tailor quality improvement. A key recommendation for payers is to align financial incentives to reduce disparities. The National Institutes of Health and other funders should support (1) disparity-intervention studies on these recommendations that analyze clinical outcomes, intervention-implementation processes, and costs, and (2) creation of new child health services researchers who can find effective quality-improvement approaches for reducing disparities.

OBJECTIVE: To examine the sociodemographic, need, risk, and insurance characteristics of persons with severe mental illness and the importance of these characteristics for predicting specialty mental health utilization among this group. DATA SOURCE: The Healthcare for Communities survey, a national study that tracks alcohol, drug, and mental health services utilization. Data come from a telephone survey of adults from 60 communities across the United States, and from a supplemental geographically dispersed sample. STUDY DESIGN: Respondents were categorized as having a severe mental disorder, other mental disorder, or no measured mental disorder. Differences among groups in sociodemographics (gender, marital status, race, education, and income), insurance coverage, need for mental health care (symptoms and perceived need), and risk indicators (suicide ideation, criminal involvement, and aggressive behavior) are examined. Measures of service use for mental health care include emergency room, inpatient, and specialty outpatient care. The importance of sociodemographics, need, insurance status, and risk indicators for specialty mental health care utilization are examined through logistic regression. PRINCIPAL FINDINGS: The severely mentally ill in this study are disproportionately African American, unmarried, male, less educated, and have lower family incomes than those with other disorders and those with no measured mental disorders. In a 12-month period almost three-fifths of persons with severe mental illness did not receive specialty mental health care. One in five persons with severe mental illness are uninsured, and Medicare or Medicaid insures 37 percent. Persons covered by these public programs are over six times more likely to have access to specialty care than the uninsured are. Involvement in the criminal justice system also increases the probability that a person will receive care by a factor of about four, independent of level of need. The average number of outpatient visits for specialty care varies little across type of disorder, and the median number of visits (ten) is equivalent for those with a severe mental illness and those with other disorders. CONCLUSIONS: Persons with severe mental illness have a high level of economic and social disadvantage. Barriers to care, including lack of insurance, are substantial and many do not receive specialty care. Public insurance programs are the major points of leverage for improving access, and policy interventions should be targeted to these programs. Problems of adequate care for the severely mentally ill may be exacerbated by the managed care trend to reductions in intensity of treatment.

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Objectives

To examine whether clinical severity is greater among children receiving ADHD care in primary care compared to those in specialty mental health clinics, and to examine how care processes and clinical outcomes vary by sector across three 6-month time intervals.

Method

Longitudinal cohort study of 530 children ages 5–11 years receiving ADHD care in primary care or specialty mental health clinics from November 2004 through September 2006 in a large, county-wide managed care Medicaid program.

Results

Clinical severity at study entry did not differ between children who received ADHD care in solely primary or specialty mental health care clinics. At three 6-month intervals, receipt of no care ranged from 34%–44% and unmet need for mental health services ranged from 13%–20%. In primary care, 80%–85% of children had at least one stimulant prescription filled and averaged 1–2 follow-up visits a year. Less than one-third of children in specialty mental health clinics received any stimulant medication, but all received psychosocial interventions averaging more than 5 visits per month. In both sectors, stimulant medication refill prescription persistence was poor (31%–49%). With few exceptions, ADHD diagnosis, impairment, academic achievement, parent distress, and parent-reported treatment satisfaction, perceived benefit, and improved family functioning did not differ between children who remained in care and those that received no care.

Conclusion

Areas for quality improvement are alignment of clinical severity with provider type, follow-up visits, stimulant use in specialty mental health, agency data infrastructure to document delivery of evidence-based psychosocial treatment, and stimulant medication refill prescription persistence.

The numbers of children with special health care needs (CSHCN) have increased in schools. This study was conducted to document mothers’ experiences of the care their CSHCN receive across health care and educational settings. Data were collected during standardized, open-ended, one-on-one interviews with 10 mothers of CSHCN in urban, suburban, and rural areas in a Midwestern state. Interviews were transcribed and content analysis revealed five themes: (a) communication, (b) educational system issues, (c) mother as a caregiver and expert, (d) navigating the system, and (e) strategies and coping. Describing and understanding experiences of mothers of CSHCN is important to developing appropriate supportive interventions.

Objective

Health care disparities remain largely unexplained and need to be better understood to be addressed. Little is known about whether resident physicians screen patients differently based on race or socioeconomic status (SES). The objective of this study was to assess whether residents' preventive screening practices are influenced by patient race or SES or by resident gender, specialty, minority status, or years of training.

Design

Cross-sectional survey.

Methods

Residents from 6 specialties at a large academic medical center participated in an online survey to gauge their knowledge, attitudes, and practices pertaining to primary care screening. The survey consisted of 1 of 4 clinical vignettes that varied by patient race and SES (African-American or Caucasian; high income or low income), followed by questions pertaining to 9 routine screening areas. Resident demographics and patient race and SES were compiled, and bivariate and multivariate analyses were used to assess associations between patient and/or resident characteristics and residents' reported importance of screening as well as intention to screen the vignette patient for the 9 specified health risks.

Results

Of 309 residents sent the online survey, 167 responded (response rate, 54%). Four of the 9 screening areas (sexual behavior, physical activity, depression, diet) were reported by residents as both “very important” (versus “not very important”) and “would definitely ask about during an office visit” (versus “would not definitely ask about”). In the adjusted odds models, residents showed no racial preference in intention to screen for depression, diet, physical activity, or sexual behavior. Residents were less likely to report that they would screen the high-income patient for sexual behavior compared with the low-income patient (adjusted odds ratio [OR], 0.46 [95% confidence interval {CI}, 0.21–0.99]). Female residents were more likely than male residents to report that they would screen for sexual behavior (adjusted OR, 3.79 [95% CI, 1.69–8.52]). Emergency medicine residents were less likely to screen for sexual behavior (adjusted OR, 0.36 [95% CI, 0.14–0.95]) and for physical activity (adjusted OR, 0.27 [95% CI, 0.10–0.73]) than residents from all other specialties.

Conclusion

Intention to screen for high-risk sexual behavior varied significantly by patient SES and by resident gender and specialty. Future research should examine how preventive screening is addressed in the curriculum of each residency program to ensure that patients will receive appropriate and consistent screening when evaluated by resident physicians.

Background And Objectives

To understand the association between shared decision-making (SDM) and health care expenditures and use among children with special health care needs (CSHCN).

Methods

We identified CSHCN <18 years in the 2002–2006 Medical Expenditure Panel Survey by using the CSHCN Screener. Outcomes included health care expenditures (total, out-of-pocket, office-based, inpatient, emergency department [ED], and prescription) and utilization (hospitalization, ED and office visit, and prescription rates). The main exposure was the pattern of SDM over the 2 study years (increasing, decreasing, or unchanged high or low). We assessed the impact of these patterns on the change in expenditures and utilization over the 2 study years.

Results

Among 2858 subjects representing 12 million CSHCN, 15.9% had increasing, 15.2% decreasing, 51.9% unchanged high, and 17.0% unchanged low SDM. At baseline, mean per child total expenditures were $2131. Over the 2 study years, increasing SDM was associated with a decrease of $339 (95% confidence interval: $21, $660) in total health care costs. Rates of hospitalization and ED visits declined by 4.0 (0.1, 7.9) and 11.3 (4.3, 18.3) per 100 CSHCN, and office visits by 1.2 (0.3, 2.0) per child with increasing SDM. Relative to decreasing SDM, increasing SDM was associated with significantly lower total and out-of-pocket costs, and fewer office visits.

Conclusions

We found that increasing SDM was associated with decreased utilization and expenditures for CSHCN. Prospective study is warranted to confirm if fostering SDM reduces the costs of caring for CSHCN for the health system and families.

OBJECTIVE: To identify models for caring for children with special health care needs (CSHCN) under the State Children's Health insurance Program (SCHIP) and to analyze the strengths and weaknesses of each. DATA SOURCE: Site visits in five study States conducted in late 1999. STUDY DESIGN: Approximately 12 to 15 interviews were conducted in each site with state and local-level policymakers, program administrators, providers, and families. DATA COLLECTION: Standard protocols were used across sites to explore a range of key policy variables including eligibility, enrollment , identification, and referral of CSHCN; benefits; service delivery systems; payment mechanisms; and quality assurance and monitoring strategies. PRINCIPAL FINDINGS. Each of the study States' approaches to serving CSHCN represents one of four models: a mainstream approach , a wrap-around model, a service carve out , or a specialized system of care. Special provisions designed to enhance the coverage and accessibility of services beyond those extended to children generally can help to ensure that CSHCN enrolled in SCHIP receive comprehensive, coordinated care. CONCLUSIONS: The mainstream approach , wh ile aimed at providing comprehensive care for all children , could not identify CSHCN or monitor their care. Wrap-around models, while offering rich benefits to CSHCN, rely on providers to identify eligible children , with few referrals reported to date. Service carve outs preserve long-standing specialty systems of care for CSH CN but create challenges for care coordination . Specialized systems of care present challenges for capitation but appear to offer the most promise for comprehensive, coordinated care to CSHCN.

Objective

To review the literature on racial and ethnic disparities in behavioral health services and present recent data, focusing on services for substance use disorders (SUD) and comorbid mental health disorders for children and adolescents.

Method

A literature review was conducted of behavioral health services for minority youth. Papers were included if specific comparisons in receipt of SUD services for youth were made by race or ethnicity. The review was organized following the Sociocultural Framework.

Results

Compared to non-Latino Whites with SUD, Black adolescents with SUD report receiving less specialty and informal care, while Latinos with SUD report less informal services. Potential mechanisms of racial and ethnic disparities were identified in: federal and economic health care policies and regulations; the operation of the health care system and provider organization; provider level factors; the environmental context; the operation of the community system; and patient level factors. Significant disparities reductions could be achieved by adoption of certain state policies and regulations that increase eligibility in public insurance. There is also a need to study how the organization of treatment services might lead to service disparities, particularly problems in treatment completion. Institutional and family characteristics linked to better quality of care should be explored. Since treatments appear to work well independent of race/ethnicity, translational research to bring evidence based care in diverse communities can bolster their effectiveness.

Conclusions

Our review suggests promising venues to reduce ethnic and racial disparities in behavioral health services for ethnic and racial minority youth.

Background

Primary care medical homes may improve health outcomes for children with special healthcare needs (CSHCN), by improving care coordination. However, community-based primary care practices may be challenged to deliver comprehensive care coordination to complex subsets of CSHCN such as children with medical complexity (CMC). Linking a tertiary care center with the community may achieve cost effective and high quality care for CMC. The objective of this study was to evaluate the outcomes of community-based complex care clinics integrated with a tertiary care center.

Methods

A before- and after-intervention study design with mixed (quantitative/qualitative) methods was utilized. Clinics at two community hospitals distant from tertiary care were staffed by local community pediatricians with the tertiary care center nurse practitioner and linked with primary care providers. Eighty-one children with underlying chronic conditions, fragility, requirement for high intensity care and/or technology assistance, and involvement of multiple providers participated. Main outcome measures included health care utilization and expenditures, parent reports of parent- and child-quality of life [QOL (SF-36®, CPCHILD©, PedsQL™)], and family-centered care (MPOC-20®). Comparisons were made in equal (up to 1 year) pre- and post-periods supplemented by qualitative perspectives of families and pediatricians.

Results

Total health care system costs decreased from median (IQR) $244 (981) per patient per month (PPPM) pre-enrolment to $131 (355) PPPM post-enrolment (p=.007), driven primarily by fewer inpatient days in the tertiary care center (p=.006). Parents reported decreased out of pocket expenses (p<.0001). Parental QOL did not significantly change over the course of the study. Child QOL improved between baseline and 6 months in two PedsQL™ domains [Social (p=.01); Emotional (p=.003)], and between baseline and 1 year in two CPCHILD© domains [Health Standardization Section (p=.04); Comfort and Emotions (p=.03)], while total CPCHILD© score decreased between baseline and 1 year (p=.003). Parents and providers reported the ability to receive care close to home as a key benefit.

Conclusions

Complex care can be provided in community-based settings with less direct tertiary care involvement through an integrated clinic. Improvements in health care utilization and family-centeredness of care can be achieved despite minimal changes in parental perceptions of child health.

Multiple agencies at the federal and state level provide for children with special health care needs (CSHCN), with variation in eligibility criteria. Epidemiological studies show that 3.8%-32% of children could be classified as children with special health care needs, depending on the definition and method of determination used. OBJECTIVES: To determine the extent of variation between definitions used and funding by Supplemental Security Income (SSI), Title V, and Medicaid for CSHCN. METHODS: Statistics on children receiving SSI and the amount of funding were obtained from the SSI website. This was compared to information on Title V children from the Maternal and Child Health Bureau (MCHB) website and eligibility definitions published by the Institute of Child Health Policy in Gainesville, Florida. Medicaid definitions were obtained through interviews with state Medicaid agencies and confirmed with state regulations. RESULTS: The population enrolled in SSI has varied with alterations in eligibility criteria. The number of children enrolled in SSI and the amount of funding per child in each state correlate with the state poverty rate (r=0.56, p<0.0001; r=0.44, p<0.001). Enrollment in Title V does not correlate with state poverty rates (r=0.16, p=0.25). Title V definitions vary widely among states, but there was no correlation between the number of children served or amount of funding per child and the type of definition used (Z=-0.12, p=0.91; Z=-0.59, p=0.55). State Medicaid agencies rarely define CSHCN. CONCLUSIONS: There is significant variation in definitions used by agencies serving CSHCN. Agencies need to be more explicit with eligibility criteria so the definitions are logical to those making referrals for services.

Objectives

To determine whether family resources predict use of therapeutic and supportive services and unmet needs in medical versus educational settings.

Data Source

Children 5–17 years of age with at least one functional limitation (n = 3,434) from the 1994 to 1995 Disability Supplement to the U.S. National Health Interview Survey.

Study Design

Family resources included the child's type of health insurance, household education level, and poverty status. Therapeutic services included audiology; social work; occupational, physical, or speech therapy. Supportive services included special equipment, personal care assistance, respite care, transportation, or environmental modifications. Need was controlled by child health status and the severity and type of functional limitation(s). Age, gender, race/ethnicity, family size, and structure were covariates.

Data Analysis Methods

Logistic regression provided estimates of associations between-family resources and use of or unmet need for therapeutic and supportive services. Multinomial methods were used to determine therapeutic service outcomes in medical versus educational settings.

Principal Findings

Children with public insurance were two to three times more likely to use services than children with private or no insurance regardless of type of service. Household education and public insurance were associated with supportive and therapeutic service use, but for therapeutic services only among children receiving services beyond the school setting. Household education predicted unmet need for both types of services and therapeutic services across settings. Findings should be interpreted cautiously, given the survey's dependence on respondent report to define the need for services and the potential for overrepresentation of children with more severe needs in the public insurance category.

Conclusions

Disparities in the use of services by household education level and by type of health insurance across service settings suggests inequitable access among the U.S. policies and programs serving children with functional limitations. Family income and education appear to give families an advantage in obtaining services and in identifying a child's unmet need.

Objective

Despite the recognition by some experts that survey measures have the potential to improve capitation rates for those with chronic conditions, few studies have examined risk-adjustment models for children, and fewer still have focused on survey measures. This study evaluates the performance of risk-adjustment models for children and examines the potential of survey-based measures for improving capitation rates for children.

Data Sources

The study sample includes 8,352 Medicaid children who were followed up for 2 years by the Medical Expenditure Panel Survey in 2000–2005.

Study Methods

Children's information in 1 year was used to predict their expenditures in the next year. Five models were estimated, including one each that used demographic characteristics, subjectively rated health status, survey measures about children with special health care needs (CSHCN), prior year expenditures, and Hierarchical Condition Category (HCC), which is a diagnosis-based model. The models were tested at the individual level using multiple regression methods and at the group level using split-half validation to evaluate their impact on expenditure predictions for CSHCN.

Principal Findings

The CSHCN information explained higher proportion of the variance in annual expenditures than the subjectively rated health status, but less than HCC measures and prior expenditures. Adding the CSHCN information into demographic factors as adjusters would remarkably increase capitation rates for CSHCN.

Conclusions

Survey measures, such as the CSHCN information, can improve risk-adjustment models, and their inclusion into capitation adjustment may help provide appropriate payments to managed-care plans serving this vulnerable group of children.

OBJECTIVE: To examine the independent effects of minority status, residence, insurance status, and income on physician utilization, controlling for general health status and the presence of acute or chronic health problems. Of special interest was the question of utilization differences among rural minority populations, as compared with urban non-Latino whites. DATA SOURCE: Data from the 1992 National Health Interview Survey (NHIS). STUDY DESIGN: Multivariate analyses used multiple logistic regression methods to detect independent effects of residence and minority status on whether or not individuals used physician services. DATA COLLECTION/EXTRACTION METHODS: Data were obtained from the National Health Interview Survey, 1992. The survey included information about the race/ethnicity of the respondent, health status, utilization of services, insurance status, and socioeconomic status. PRINCIPAL FINDINGS: The most salient determinant of utilization of healthcare services is insurance status, regardless of race/ethnicity or (rural or urban) place of residence. Racial and ethnic minorities were less likely than whites to use physician services, and use was generally lower for rural residents. The most striking differences were for rural Latinos and rural Asians/other persons. CONCLUSIONS: Although the results demonstrate a need to adjust policies designed to improve utilization by accounting for particular problems faced by minority populations, they also demonstrate the primacy of addressing financial access.