Background
Methods
Search Protocol
Eligibility Criteria
Definitions
Literature Synthesis
Results
Specialty
| Number | Percent |
---|---|---|
All/Not specific | 20 | 67 |
Asthma specialist | 6 | 20 |
Juvenile rheumatoid arthritis specialist | 1 | 3 |
Cardiology | 1 | 3 |
Urology | 1 | 3 |
Otolaryngology | 1 | 3 |
Sample Location
| ||
Local/Other | 12 | 40 |
State | 12 | 40 |
National | 6 | 20 |
Access Measure
| ||
Utilization | 17 | 57 |
Referral rate | 3 | 10 |
Referral type | 1 | 3 |
Satisfaction with availability of specialists | 1 | 3 |
Unmet need | 5 | 17 |
Time to referral | 1 | 3 |
Appointment availability | 2 | 7 |
Study Population
| 0 | |
Patients | 26 | 87 |
Physicians | 3 | 10 |
Both | 1 | 3 |
Uninsured
Author | Year | Sample Size | Data Source | Study Design | Access Measure | Statistic |
Comparison
| Findings |
Endogeneity/Selection
|
---|---|---|---|---|---|---|---|---|---|
Kane et al. [12] | 2005 | 700 | National Survey of CSHCN, single state | Cross-sectional | Unmet needs | Logistic regression; likelihood of unmet need |
Ever uninsured vs. insured all year
| OR = 8.6, p < 0.001 |
No consideration of selection into insurance
|
Mayer et al. [13] | 2003 | 38,866 | National Survey of CSHCN | Cross-sectional | Unmet need | Logistic regression; likelihood of unmet need for specialty care |
Private insurance vs. uninsured
| OR = 4.29, p < 0.01 |
No consideration of selection into coverage type
|
Park et al. [14] | 2002 | 1,985 | National Health Interview Survey | Cross-sectional | Utilization | Proportion having seen a specialist (exact values not reported) |
Uninsured vs. any insurance type
| Less likely vs. any insurance |
No consideration of selection into coverage type
|
Perlstein et al. [15] | 1997 | 544 | Regional cardiac registry | Retrospective cohort | Time to referral | t-test; mean age at referral |
Uninsured vs. "commercial"
| 251 days vs. 80 days, p < 0.05 |
No consideration of selection into coverage type
|
Szilagyi, et al. [16] | 2000 | 2,126 | Single SCHIP | Quasi-experimental | Utilization | t-test, difference in number of specialist visits (pre- and post-enrollment) |
Uninsured vs. following SCHIP enrollment
| Fivefold increase in utilization after SCHIP enrollment |
No consideration of selection in program
|
Public insurance
Author | Year | Sample Size | Data Source | Study Design | Access Measure | Statistic |
Comparison
| Findings |
Endogeneity/Selection
|
---|---|---|---|---|---|---|---|---|---|
Cabana et al. [21] | 2002 | 3,163 | Single MCO | Cross-sectional | Utilization | Logistic regression; likelihood of specialty care |
Medicaid vs. non-Medicaid insured
| Private with copay: OR = 2.52, p < 0.05 Private w/o copay: OR = 3.40, p = NS |
Single MCO with Medicaid and private; patients do not choose
|
Damiano et al. [22] | 2003 | 463 | State SCHIP | Prospective cohort | Unmet need | McNemar; unmet need pre- vs. post-enrollment |
SCHIP vs. prior coverage
| 40% vs. 13%; p < 0.05 |
No consideration of selection into program
|
Davidoff et al. [23] | 2005 | 3413 | National Health Interview Survey | Quasi-experimental | Utilization | Change in proportion with any visit |
SCHIP ineligible vs. SCHIP eligible
| +3.8, p = NS |
Groups compared on eligibility, not enrollment
|
Forrest et al. [24] | 1999 | 27,104 | National practice-based research network | Prospective | Referral rates | t-test, percent referred; logistic regression, likelihood of referral to specialty |
Medicaid vs. Private
| 4.46% vs. 2.61%, p < 0.001 |
No consideration of selection into coverage type
|
Holl et al [25] | 2000 | 1,730 | Single SCHIP | Quasi-experimental | Utilization | Change in proportion with any specialist visit |
Prior to SCHIP enrollment vs. after enrollment
| Age < 1 year: 15.5% vs. 16.1%, p = NS; Age 1–5 years: 19.7% vs. 19.4%, p = NS |
No consideration of selection into program
|
Hwang et al. [26] | 2005 | 54 | Clinics in a single state | Cross-sectional | Appointment availability | t-test, proportion offering appointment |
Private insurance vs. Medicaid
| 96% vs. 41%, p < 0.0001 |
Physician offices; no patient selection
|
Kempe et al. [27] | 2000 | 596 | Pediatric practices in a single state | Retrospective cohort | Referral rates | χ2; proportion with referral |
Private insurance vs. Medicaid
| 11% vs. 20%, p = 0.09 |
No consideration of selection into coverage type
|
Kempe et al [28] | 2005 | 480 | Single SCHIP | Prospective cohort | Utilization | Logistic regression; saw specialist when needed; any specialist visit |
Prior to enrollment vs. after enrollment
| OR = 1.96, p < 0.05; OR = 1.22, p = NS |
No consideration of selection into program
|
Mayer et al. [13] | 2004 | 38,866 | National Survey of CSHCN | Cross-sectional | Unmet need | Logistic regression; likelihood of unmet need for specialty care |
Private insurance vs. Medicaid and SCHIP
| Medicaid: OR = 1.26, p = NS; SCHIP: OR = 0.82, p = NS |
No consideration of selection into coverage type
|
Ortega et al. [29] | 2001 | 1,002 | Multiple hospitals; single geographic region | Retrospective cohort | Utilization | χ2;percent seeing an asthma specialist |
Private insurance vs. Medicaid
| 30% vs. 6%, p < 0.001 |
No consideration of selection into coverage type
|
Park et al. [14] | 2002 | 1,985 | National Health Interview Survey | Cross-sectional | Utilization | Proportion having seen a specialist |
Private insurance vs. public insurance
| Less likely vs. private insurance |
No consideration of selection into coverage type
|
Perlstein et al. [15] | 1997 | 544 | Regional cardiac registry | Retrospective cohort | Time to referral | t-test; mean age at referral |
Medicaid vs. "commercial"
| 168 days vs. 80 days, p < 0.05 |
No consideration of selection into coverage type
|
Price et al. [34] | 1999 | 94 | Single hospital | Cross-sectional | Utilization | t-test; number of specialist visits |
Medicaid vs. fee-for-service
| All: 3 vs. 6, p = NS; asthma-related: 2 vs.4, p < 0.05 |
No consideration of selection into coverage type
|
Szilagyi, et al. [31] | 2000 | 187 | Single SCHIP, children with asthma | Quasi-experimental | Utilization | χ2 and t-test; percent seeing specialist, number of visits |
Prior to SCHIP enrollment vs. after enrollment
| Any specialist: 30% vs. 40%, p = 0.02; Visits: 0.36 vs. 0.48, p = 0.02 |
No consideration of selection into program
|
Szilagyi, et al. [16] | 2000 | 2,126 | Single SCHIP | Quasi-experimental | Utilization | t-test, difference in number of specialist visits |
Prior to SCHIP enrollment vs. after enrollment
| 0.174 more visits after enrollment, p < 0.001 |
No consideration of selection into program
|
Szilagyi et al. [30] | 2004 | 2,644 | Single SCHIP | Prospective cohort | Utilization and unmet need | Logistic regression, change in unmet needs pre- and post-enrollment |
Prior to SCHIP enrollment vs. after enrollment
| 15.5 percentage point decrease after enrollment, p < 0.01 |
No consideration of selection into program
|
Wang et al. [32] | 2004 | 100 | Clinics in single state | Cross-sectional | Appointment availability | Percentage comparisons, no statistical test, percent offering an appointment |
Private PPO vs. Medicaid
| 97% vs. 27% |
Physician offices; no patient selection
|
Zwanziger, et al. [33] | 2000 | 1,910 | Single SCHIP | Quasi-experimental | Utilization | OLS, change in expenditures pre- and post-enrollment |
Prior to SCHIP enrollment vs. after enrollment
| $71.85 increase after enrollment |
No consideration of selection into program
|
Managed care
Author | Year | Sample Size | Data Source | Study Design | Access Measure | Statistic |
Comparison
| Findings |
Endogeneity/Selection
|
---|---|---|---|---|---|---|---|---|---|
Alessandrini et al. [37] | 2001 | 553 | Single hospital | Prospective cohort | Utilization | χ2; % with a specialty visit; number of visits |
Managed care vs. fee-for-service
| 10% vs. 12%, p = 0.68; 0.2 vs. 0.2, p = 0.65 |
MC mandated' no patient selection
|
Cartland and Yudkowsky [43] | 1992 | 1,264 | American Academy of Pediatrics Fellows | Cross-sectional | Referral rates | χ2; frequency of referral of MCO patients |
Managed care vs. fee-for-service
| More frequent: 2.5%; less frequent, 8.7%; p < 0.05 |
Study is of physician behavior; no patient selection
|
Cuesta et al. [44] | 2000 | 49 | Single hospital | Retrospective cohort | Referral type | χ2
| Initial referral is to rheumatologist vs. orthopedic surgeon | Managed care: 83% vs. 17%; "Traditional commercial": 58% vs. 42%; p = NS |
Examines insurance type at initial referral, prior to diagnosis
|
Ferris et al. [39] | 2002 | 59,952 | Single MCO | Quasi-experimental | Utilization | t-test; number of specialist visits and proportion new specialist visits |
With gatekeeping vs. without gatekeeping
| Visits: 0.28 vs. 0.28, p = NS; % new visits: 30.6% vs. 34.8%; p < 0.05 |
Single MCO initiated removal of gatekeeping; no patient choice
|
Ferris et al. [45] | 2001 | 1,839 | Single insurance plan | Prospective cohort | Utilization | t-test; change in visits |
Gatekeeping vs. indemnity
| 57% decrease vs. 31% increase; p = 0.005 |
Patient voluntarily selected into coverage type
|
Forrest et al [24] | 1999 | 27,104 | National practice-based research network | Prospective | Referral rates | t-test, percent referred; logistic regression, likelihood of referral to specialty |
Gatekeeping vs. no gatekeeping
| Medicaid, OR = 1.86, p < 0.001; Private, OR = 1.76, p < 0.01 |
No consideration of selection into type of plan
|
Garrett et al [38] | 2003 | 34,280 | National Health Interview Survey | Retrospective | Utilization | Probit; mandatory PCCM vs. FFS, mandatory HMO vs. FFS; likelihood of any specialist visit |
Fee-for-service vs. primary care case management or HMO
| PCCM = 0.003, p = NS; HMO = 0.378, p < 0.05 |
Mandatory enrollment into program type
|
Lake [46] | 1999 | 12,383 | Community Tracking Survey | Cross-sectional | Satisfaction | Logistic regression; difference in percent satisfied with choice of specialists |
HMO vs. non-HMO
| -8.3%, p < 0.05 |
No consideration of selection into coverage type
|
Mitchell, Khatutsky, and Swigonski [40] | 2001 | 966 | Single SCHIP | Cross-sectional | Unmet need | χ2; percent with unmet need for specialist |
Managed care vs. fee-for-service
| 6.0% vs. 10.6%, p = NS |
Patients seek managed care exemptions
|
Perlstein et al. [15] | 1997 | 544 | Regional cardiac registry | Retrospective cohort | Time to referral | t-test; mean age at referral |
Managed care vs. "commercial"
| 140 days vs. 80 days, p < 0.05 |
No consideration of selection into coverage type
|
Price et al. [34] | 1999 | 94 | Single hospital | Cross-sectional | Utilization | t-test; number of specialist visits |
Capitated plan vs. fee-for-service
| All: 7.5 vs. 6, p = NS; asthma-related: 5 vs. 4, p,0.05 |
No consideration of selection into coverage type
|
Roberto et al. [53] | 2005 | 935 | Single Medicaid program | Quasi-experimental | Utilization | Probit; change in access to specialist |
Fee-for-service vs. partially capitated managed care
| b = 0.221, p < 0.05 |
Voluntary selection into plan type
|
Shenkman at al. [42] | 2004 | 2,333 | Single SCHIP | Cross-sectional | Utilization | Logistic regression; likelihood of a specialist visit |
Plans with certain managed care characteristics vs. those without
| Percent paid on FFS basis: 0.950, p = 0.003; Bonus for quality profile: 1.714, p = 0.0003 |
Mandatory enrollment into specific plan
|
Shields, et al. [41] | 2002 | 6,231 | Single Medicaid program | Cross-sectional | Utilization | Logistic regression; likelihood of specialist visit |
HMO vs. primary care case management plan
| OR = 1.80, p < 0.05 |
Voluntary selection into coverage type
|