America's Children Health Insurance and Access to Care (1998) / Chapter Skim
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7 Children's Health Care Needs
7 Children's Health Care Needs
Pages 120-140
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From page 120... ...
Another 10 percent about 7 million children have one or more severe chronic conditions, such as congenital heart defects, neural tube defects, juvenile diabetes mellitus, sickle cell disease, or HIV infections. Expenditures for this group account for 70 to 80 percent of all medical expenditures for children (Neff anc3 Anderson, 1995~.
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From page 121... ...
Depending on the setting for care and the availability of allied health professionals on staff, these primary care practitioners also provide health education for parents and children, refer them for specialty consultations, and coordinate their care, as appropriate. Expanded services such as behavioral counseling, nutrition education, and parenting skills training also may be provided in a primary care setting.
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From page 122... ...
12. Data are from the 1994 National Health Interview Survey.
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From page 123... ...
But a cough and a fever can be a sore throat and a viral upper respiratory infection, or it can be the beginning of a serious pneumonia or an asthma exacerbation. Julius Goepp Johns Hopkins Hospital, Baltimore, MD Public Workshop June 2, ~ 997 Chronic Conditions 123 This section describes the distinguishing features of the most prevalent chronic conditions: dental conditions, mental health and substance abuse problems, and developmental disabilities.
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From page 124... ...
Although some of these practitioners may be willing to provide appropriate care and referrals for these children, others may not have adequate training or time to JO so. A variety of sources incluc3 ing community mental health centers, the mental health anc3 substance abuse block grant, anc3 state anc3 local funding for mental health services support services for these children anc3 their families.
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From page 125... ...
Children with Developmental Disabilities The Personal Responsibility anc3 Work Opportunity Reconciliation Act of 1996 defines disability as a physical or mental condition or conditions that can be medically proven anc3 that result in marked anc3 severe functional limitations (SSA, 1997a)
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From page 126... ...
Access to these interventions clepencis in large part on the structure of the chilc3's health insurance benefit package anc3 on the availability of services anc3 providers in a community. Traditionally, more of the case manage' ment services anc3 other expanclec3 approaches have been more likely to be financed by the public sector than by private insurers anc3 health plans (IOM, 1997a)
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From page 127... ...
States may provide services for children with special health care needs uncler the Maternal anc3 Child Health Services Block Grant (Title V) of the Social Security Act.
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From page 128... ...
Supplemental Security Income In 1996, approximately 955,000 children with disabilities received SSI payments that macie them eligible for Meclicaic3 (Alliance for Health Reform, 19971. SSI benefits are used to preserve the ability of families to take care of clisablec3 children at home by providing cash assistance to help them meet some of their disability- related expenses, to help compensate for lost income, anc3 to help meet basic expenses for food, clothing, anc3 shelter (National Academy of Social Insurance, 1996~.
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From page 129... ...
These include case management, care coordination, anc3 family support services anc3 a limited number of home- visiting services, supported by the block grant. FINANCIAL BARRIERS ASSOCIATED WITH SPECIAL NEEDS Even for families with comprehensive benefits proviciec3 through traditional private health insurance, out- of- pocket expenses for copayments anc3 clecluctibles for the required medical services, occupational anc3 physical therapy, anc3 clurable medical equipment can be quite substantial (Leonard et al., 1992~.
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From page 130... ...
Charles LaVallee Western Pennsylvania Caring Foundation for Children Public Workshop June 2, ~ 997
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From page 131... ...
Although the treatment needs for each child anc3 the treatment protocols for each chronic illness differ, children with chronic conditions anc3 special health care needs typically see a wide range of practitioners. They are clinically managed by primary care pediatricians or family physicians, typically with an extensive amount of family anc3 community involvement anc3 referrals to specialists as needled.
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From page 132... ...
In many areas, children with complicated health care needs are referred to regional pediatric specialty centers even for routine care because locally available primary care providers may not be able to deliver the neeciec3 specialized care or the necessary case management anc3 care coordination may not be not available locally (Schlesinger anc3 Mechanic, 1993~. In abolition to the travel time anc3 the rearrangement of work anc3 child care schedules, out-of-pocket expenses for transportation anc3 hotel bills can be significant.
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From page 133... ...
ACCESS UNDER MANAGED CARE As of the summer of 1997, 36 states had manciatec3 managed care arrangements for at least some children with special needs (Alliance for Health Reform, 19971. Some providers anc3 researchers have expressed serious concerns about the potential for incorporating patients with chronic illnesses anc3 serious medical conditions into the typical capitatec3 managed care model (Hughes et al., 1995; Newacheck et al., 1994~.
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From page 136... ...
Because at least 36 states now have some form of manciatec3 managed care for at least some children with special needs, several strategies have been proposed to increase the likelihood that their medical needs will be met. These include ensuring that there are a significant number of local pediatric specialists in networks before contracts are negotiated (Newacheck et al., 1994~; setting up separate payment systems for children with certain medical conditions or "carving out" these groups (Neff anc3 Anderson, 19951; anc3 developing quality assurance measures that assess quality of care for children with chronic conditions, including clinical practice guidelines anc3 practice parameters, anc3 consumer protections, such as written policies concerning grievances anc3 availability of services (IOM, 1997a; Newacheck et al., 1994~.
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From page 137... ...
Broaclly speaking, traditional private insurance is primarily designed to provide time- limited coverage for acute episodes, whereas Meclicaic3 also covers treatments which may improve functioning anc3 quality of life, but are not expected to result in a cure. Healthy children, as well as children with special health needs, could benefit from the coordination anc3 management of care that are offered in managed care environments, but some in the chilciren's health community are concerned that managed care floes not yet have adequate quality assurance methods for special needs children.
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From page 138... ...
1997a. Prevalence of Selected Chronic Conditions: United States, 1990-1992.
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From page 139... ...
Apfel, Commissioner of Social Security, ore SSI Childhood Disability Reviews. thttp://www.ssa.glv/press/childhood_statement.htmll Szilagyi PG et al.
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