Health Affairs, 23, no. 5 (2004): 77-87 doi: 10.1377/hlthaff.23.5.77 © 2004 by Project HOPE	New Online   New Issue: China & India   Obesity In China   Pay Cuts For Medicare Docs   Access To Care Woes

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Quality & Access

Access And Quality In Child Health Services: Voltage Drops

Abstract

 
Children require a health care system that promotes healthy development for all children while reaching out to the neediest. Barriers to care have been described as "voltage drops"—resistance points at which patients drop from the system like voltage from an electrical current. We examine the size and nature of these drops, ranging from insurance access to service quality, with respect to children. We find critical policy needs (such as expanded insurance opportunities, increased care coordination, and improved quality measurement) at all system levels. Comprehensive access to insurance and services does not guarantee that children will receive high-quality (safe and effective) care.

It is essential to understand where the current system succeeds and fails for children. John Eisenberg and Elaine Power adopted the term "voltage drops." Just as an electrical system loses voltage when current passes through resistance, the health care system loses people as they confront barriers in seven areas: access to insurance coverage, enrollment in available insurance plans, access to covered services/providers, choice of plans/providers, consistent access to primary care, access to referral services, and delivery of high-quality care.¹ For children, evidence is scant regarding one drop, the impact of plan/provider choice. The other six drops, however, clearly have policy implications that are the focus of this paper. How large are these drops for children, and how might they be reduced?

Voltage Drop 1: Access To Insurance Coverage

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Background. Lack of insurance is a major barrier to receipt of services. Uninsured children are half as likely as privately insured children to have well-child visits, office visits, or hospitalizations.² By contrast, uninsured children are just as likely to visit emergency departments (EDs): Lack of insurance may cause parents to shift care to EDs or wait until emergency care becomes unavoidable.

In 2002, 61 percent of children had private insurance at least part of the year (mostly through parents’ employers), 21 percent had public insurance (primarily through Medicaid or the State Children’s Health Insurance Program, SCHIP), and 6 percent had both (or switched between them).³ Although 12 percent were uninsured all year, more were uninsured at any given time. In 1999, 26 percent were uninsured at least part of the year.⁴ Reasons for being uninsured include lacking access to insurance (voltage drop 1) and not enrolling despite having access (voltage drop 2).

For most children, access to insurance depends heavily on parents’ ability to obtain employer-based insurance. In 2003, 66 percent of firms offered health benefits to at least some of their employees; 74 percent of employees were eligible for benefits.⁵ Benefits, however, were offered primarily to full-time employees in larger firms. Only 46 percent of part-time employees, 7 percent of temporary employees, and 46 percent of employees in firms with one to nine workers were offered benefits, down from 2000–2001 peaks. Many employees not offered benefits are above typical income limits for Medicaid/SCHIP; others are noncitizens whose children are often ineligible for public insurance.⁶

Even children currently eligible for public insurance are vulnerable. Although federal Medicaid/SCHIP funding remains stable in 2004, budget shortfalls have prompted thirty-four states to drop a half-million children from Medicaid/SCHIP this year through tightened eligibility.⁷ Many of these children will be unable to obtain private insurance.

Policy implications. Immediate policy needs include recouping losses in Medicaid/SCHIP eligibility and protecting against future threats. Because state budgets have proven particularly vulnerable in economic downturns, Medicaid/SCHIP funding appears inherently unstable, placing children’s eligibility in jeopardy. SCHIP reauthorization in 2007 may need to include increased federal control of both funding and eligibility standards.

Private insurance access for children might be increased through market-oriented approaches, including (1) creating employer incentives to provide family coverage for part-time, temporary, and small-firm employees; (2) expanding coverage under the Consolidated Omnibus Budget Reconciliation Act (COBRA) to include these employees; (3) helping small firms establish purchasing cooperatives; and (4) regulating insurance markets to limit costs for small firms. Recent experience with these approaches, however, has been disappointing.⁸

Voltage Drop 2: Enrollment In Available Insurance Plans

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Background. Even when they have access to insurance, many parents do not enroll their children in a plan. In 2001, 20 percent of children within typical income limits for Medicaid/SCHIP were uninsured all year; 64 percent of uninsured children met income eligibility criteria for Medicaid/SCHIP but were not enrolled.⁹

Barriers to enrollment included parents’ lack of awareness of Medicaid/SCHIP and eligibility, lack of perceived value of insurance, and administrative obstacles (for example, complicated application process).¹⁰ Non-English-speaking parents enrolled at disproportionately low rates because of language issues and confusion about eligibility for children with noncitizen parents. Moreover, in states that did not automatically offer public insurance to families of eligible children, twice as many eligible children remained uninsured.¹¹ Thus, parents who have access to public insurance are more likely to obtain insurance for their children, perhaps because family coverage reduces enrollment barriers. Finally, in 2003 many states began raising barriers to discourage enrollment of eligible children (such as creating additional administrative obstacles and waiting lists, increasing cost sharing, and greatly diminishing outreach efforts).¹²

With private insurance, enrollment is hampered by the cost of family coverage premiums, which rose 19 percent in 2002 and 13 percent in 2003.¹³ Employers have absorbed only a portion of the increase.

Policy implications. The impact of recent state budget cuts suggests that Medicaid/SCHIP enrollment is fragile. Reliance on states might be reduced through federal funding and mandates to limit cost sharing, resurrect outreach efforts, and extend family coverage to all states (through programs such as the Health Insurance Flexibility and Accountability, or HIFA, demonstration initiative).

In the private sector, helping lower-income employees purchase family coverage could increase enrollment. Such efforts, however, appear to increase enrollment only modestly—investing in a strengthened safety-net system may actually reach more children.¹⁴

Voltage Drop 3: Access To Covered Services And Providers

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Background. Enrollment in an insurance plan does not guarantee access to services. First, many insured children may be "underinsured" (lacking coverage for specific services, such as prescription drugs or dental care). Private insurance plans vary widely, with few rules regarding what services to cover.¹⁵ Public insurance coverage also varies; SCHIP in particular gives states wide latitude.¹⁶

Second, even covered services often include substantial cost sharing: In 2003, deductibles and copayments rose much faster than inflation.¹⁷ Low family income strongly predicts unmet need even among insured children, which suggests that the cost of care may be a serious barrier.¹⁸

Finally, insurance plans do not provide identical access. Managed care plans, for instance, may improve access somewhat for children. Children in Medicaid health maintenance organizations (HMOs) have fewer ED visits and more well-child visits than other Medicaid-insured children.¹⁹ Fewer children are hospitalized for preventable reasons in counties with greater HMO penetration.²⁰

Policy implications. How many children are underinsured remains unknown and needs further exploration. Establishing standard packages of covered services might reduce underinsurance. Standardization, however, is most accepted when there is compelling evidence, now lacking for many child health services.

Cost sharing tends to reduce use of nonurgent services far more than urgent services; however, nonurgent well-child visits are considered among the most important services for children. Managed care’s focus on improving access to well-child care might be one reason why its effects appear more positive in children than in adults. Creating incentives for insurance plans to limit cost sharing for well-child visits might improve children’s access to basic services.

Could offering parents wider choice of plans reduce underinsurance and cost sharing? Ability to choose among plans to find the best mix of services and costs is a central tenet of market-driven health care. Benefits, however, have been mostly theoretical, in part because employers have little ability or incentive to provide choices.²¹ Most employers offer only one health plan, and most who offer multiple plans merely offer different payment structures (for example, HMO versus preferred provider organization, or PPO) for the same providers. Moreover, provider networks are often so large and overlapping that true competition rarely occurs.

Voltage Drop 4: Access To A Consistent Source Of Primary Care

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Background. Once services can be accessed, actual health care delivery becomes possible. Well-child care (delivered mostly through pediatricians and family practitioners) is the cornerstone of child health services. Its goals are to prevent illness and promote health through immunizations, routine surveillance (such as developmental screening), and anticipatory guidance (such as car-seat counseling). National guidelines recommend at least twenty-six well-child visits by age twenty-one.²² Although benefits of well-child care remain underexplored, children who meet well-child-visit recommendations are half as likely as other children to visit an ED or be hospitalized and 30 percent more likely to be immunized.²³ Continuity of care (visits with the same provider) may improve these benefits. In a large HMO, children with high continuity of care received less ED and hospital care than other children.²⁴

Both frequency and continuity of well-child visits, however, vary widely. Black and Hispanic children have far fewer visits than white children.²⁵ English speakers are three times as likely as non–English speakers to have a regular source of care.²⁶ Children whose parents are not college graduates or who have incomes below 200 percent of poverty have fewer well-child visits than others.²⁷ Because these factors tend to cluster, many families who are nonwhite, non–English speaking, less educated, and poor have drastically limited access to well-child care.

Finally, some insurance plans may facilitate continuity more than others. Children in private or managed care plans are more likely than other children to have high continuity.²⁸ Moreover, 89 percent of parents who reported a usual provider for their child were allowed to choose the provider.²⁹

Children without access to well-child care often seek care in EDs. In 2002, 16 percent of children’s ED visits were nonurgent.³⁰ Despite the much higher cost of ED visits, poor children are three times as likely as other children to use EDs for nonurgent care.³¹ EDs, however, are neither intended nor prepared to deliver the preventive care that these children lack. Thus, while EDs provide an important safety net for vulnerable populations, they do so inefficiently.

Policy implications. Access to consistent primary care is threatened by both insurance discontinuities (often related to parental employment transitions) and complex social factors associated with race/ethnicity, language, education, and income. How to overcome these barriers is a question not unique to children. Because primary preventive care, however, is particularly sensitive to barriers, children’s health needs may be especially vulnerable.

Access to consistent primary care may be affected by issues such as the number of providers in underserved communities, choice of providers, availability of school-based health centers, patient outreach by community organizations, community-provider relations, and interpreter services and cultural sensitivity among providers. Providers, public and private, have generally not led development of community systems of care. Thus, local governments or community consortia may need to drive and direct coordination, treating community organizations and providers less as independent actors and more as members of a network with common goals and policies. An important research priority is to fund and analyze community pilot programs that identify the most effective coordination methods.

Voltage Drop 5: Access To Referral Services

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Background. Although access to consistent primary care is essential for children, it is often not enough. Most children need referral to other services at some point, and primary care clinicians often have no systematic ties with providers of these services (such as dental clinics, social services, or subspecialists), which makes referral, feedback, and tracking challenging.

A subgroup of children known as children with special health care needs has a particular need for referral services. These are children "who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally."³² Such services include specialty services, prescription drugs, educational and mental health services, or medical supplies and equipment. About 15 percent of U.S. children have special health care needs, with asthma and attention deficit/hyperactivity disorder (ADHD) accounting for two-fifths of them.³³

Although children with special health care needs use more services than other children, their needs often outstrip their use of services. They are more likely than other children to have insurance, to have a usual source of care, and to receive primary care. Nevertheless, they are also twice as likely to delay care because of cost and to have an unmet health need. Most such needs are for referral services.³⁴

Policy implications. Many children need access to referral services. Access might be greatly improved, especially for children with special health care needs, through widespread implementation of medical home programs.³⁵ Such programs attempt to introduce in existing practices mechanisms to consolidate primary and referral services into a seamless comprehensive care model. Children with special health care needs in practices that meet medical home standards (continuity, access to referral services, service coordination, and good family-provider communication) are half as likely as other children with such needs to delay care or have unmet medical needs.³⁶ Only 53 percent of children with special health care needs, however, belong to medical homes; nonwhite and poor children are only half as likely as others to belong. Moreover, medical homes rely heavily on states, many of which have cut funding because of budget shortfalls.

Voltage Drop 6: Delivery Of High-Quality Health Care Services

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Background. Access to services is beneficial only if the quality of those services is high. Clinical practices, however, vary widely among regions, institutions, and individuals, and evidence links practice variations with variations in quality. Professional groups sometimes attempt to reduce variations by disseminating clinical guidelines derived from evidentiary review. Adoption of guidelines, however, is generally slow and incomplete. In a survey of general pediatricians, most failed to use guidelines despite agreeing that guidelines improve outcomes.³⁷

High-quality health care should be, at a minimum, safe and effective (the Institute of Medicine [IOM] has also recommended that care be patient-centered, timely, equitable, and efficient).³⁸ Although information on the quality of child health services is limited, evidence reveals large gaps between what should occur and what actually does. We briefly review the degree to which child health services are safe and effective and identify gaps in quality and our understanding of quality.

Are services safe? In 1999 the IOM estimated that inpatient medication errors contribute to 44,000–98,000 annual deaths among people of all ages and dramatically raise inpatient costs.³⁹ These errors appear to be more common for children than adults because child dosing tends to be more complicated. In two institutions, 6 percent of pediatric inpatient medication orders contained errors, and more than 1 percent of orders contained errors that might have injured patients ("potential adverse drug events"), three times as many as for adults.⁴⁰ Potential adverse drug events were even more common among children in intensive care. Information technology is an essential part of the solution. Computerized physician order entry (CPOE) produced a 96 percent reduction in errors in a pediatric critical care unit and a 40 percent reduction in a nonintensive inpatient setting.⁴¹

Children, especially young and poor children, suffer numerous preventable inpatient injuries beyond those caused by medications.⁴² Almost 1 percent of child hospitalizations in 2000 resulted in preventable injuries, generating more than $1 billion in excess charges. We have found no published assessments of outpatient errors in children. Since almost all child health services are outpatient, the need for research in this area is critical.

Are services effective? Safety addresses whether services hurt patients; effectiveness addresses whether they help. Three types of threats to quality may limit effectiveness: inadequate delivery of services, excessive delivery, and inappropriate delivery.

First, services may be delivered in amounts inadequate to provide full benefits. For children, the primary concern has generally been inadequate delivery. Comprehensive, longitudinal services in particular defy easy reduction into short, discrete office visits and are highly susceptible to quality gaps. Often, primary care clinicians must both provide basic management and coordinate support from a haphazard patchwork of resources including office-based specialists; school or day care services; social services; and overlapping private, local, state, and federal government–sponsored referral centers. The primary clinician must act as an informational nexus throughout the course of care. Gaps in quality may occur at each point of service and throughout the coordination process. In other words, voltage drop 6 is itself often a complex network of voltage drops.

Well-child care, for instance, suffers large quality gaps. Fundamental health-promoting activities are performed irregularly. Only a minority of parents report receiving parenting advice, child developmental assessment, or family psychological or social assessment from their children’s providers.⁴³ Many parents want more information on various developmental and parenting topics.⁴⁴ Two-thirds of adolescents report at least one of five health risks (smoking, drinking, having sex, feeling depressed, or not wearing seatbelts), but few report being assessed or counseled about them.⁴⁵ In three Medicaid managed care plans, only a quarter of girls who had had sexual intercourse in the past year were screened for chlamydia, despite the recommendation to screen all such girls.⁴⁶

Care of chronic illnesses also exhibits gaps. Asthma is the most frequent inpatient diagnosis for children age one and older.⁴⁷ Managing asthma requires longitudinal coordination of primary, specialty, and emergency care to prevent attacks and limit severity. Only a quarter of adults and children with asthma, however, use anti-inflammatory medications that national guidelines say they need, and children are less likely than adults to use them.⁴⁸

Mental health disorders are also common: 7 percent of children are identified with an emotional or behavioral disorder, usually ADHD, depression, or anxiety.⁴⁹ They require early detection and vigilant management; 80 percent of children who need mental health services, however, do not receive any.⁵⁰

Although inadequate delivery has been documented for these and other services, root causes and potential solutions remain underexamined. Better understanding of them would improve our ability to provide effective care for children.

A second threat to quality is excessive delivery. It has gone largely unstudied, except regarding antibiotics, where evidence is compelling. Unnecessary antibiotics raise risks for harmful drug reactions and resistance to antibiotic effects. Among children, antibiotics are prescribed for 10 percent of common colds and 50 percent of bronchitis, neither of which responds to antibiotics.⁵¹ Moreover, 80 percent of these children receive broad-spectrum antibiotics ideally reserved for infections that are resistant to narrower-spectrum agents. These data actually represent recent improvements following professional and public education campaigns.⁵²

A third threat to quality is inappropriate delivery of services, which is perhaps the most difficult quality threat to study. The evidence for most medical decisions does not yet exist, and clinician judgment involves many situation-specific factors that cannot be measured or experimentally replicated. However, as evidence for clinical practices grows and standardization becomes more widespread, examination of inappropriate delivery will become increasingly common.

It is already apparent, for instance, that decisions regarding hospital admission may increase spending and morbidity through unnecessary admissions or failure to admit when necessary. In a national survey of pediatric emergency physicians regarding bronchiolitis (the most common serious respiratory infection in infants), most physicians recommended therapies for which there was little or no evidentiary support, and whether to hospitalize was influenced by nominal variations in test results.⁵³ Similar studies, and studies examining causes and solutions, are needed throughout the range of child health services.

Policy implications. Addressing quality from a policy standpoint is challenging but essential. As evidence for high-quality practices builds, quality standards must be developed and enforced, perhaps through economic incentives, quality report cards, or accreditation mechanisms. Providers must also be educated in quality improvement techniques and equipped with measurement and feedback systems.

Just as important, however, is the development of a child health services infrastructure that supports quality by simplifying and strengthening links between primary care clinicians and specialty, allied health, and social services, as well as schools, community organizations, and governments. Medical home programs may play a role in improving these linkages, but more radical and creative restructuring of the service network may need to be explored.

Larger systems must be addressed as well. The quality of child health services is intimately connected to the quality of all health services. Many child and adult services are supported by common infrastructural elements serving different, sometimes conflicting, needs. Until now, discussions of quality for adults have been largely divorced from discussions of quality for children; both may have suffered as a result.

Finally, more data are needed. Priorities for research include errors in outpatient medical services, and causes of inadequate delivery of well-child and chronic disease services, excessive delivery of services, and clinician misjudgment.

Conclusion

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We have addressed voltage drops individually, generally describing policy implications that are focused and incremental. Our approach has the advantage of establishing distinct, achievable objectives that together might greatly improve child health services. Equally importantly, our approach highlights the surprising independence between access and quality. One does not ensure the other, and without both, health care will remain trapped in a high-resistance system through which many vulnerable children will not pass.

What if, for instance, our incremental approach were eschewed in favor of comprehensive universal access, through either insurance coverage (government-sponsored, employer-based, or privately purchased) or direct provision of care? Conceivably, then, voltage drops 1–3 might greatly diminish or disappear. voltage drops 4 and 5 might also diminish, although racial/ethnic-, language-, education-, and income-related barriers would probably linger. Voltage drop 6, however, would remain problematic—although universal access might allow standardized quality assessment through more uniform medical and administrative records, it would have little direct effect on the practice variations and quality gaps that occur throughout child health services.

Thus, whether access is approached incrementally or comprehensively, children will not fully realize the benefits until quality is addressed. Access has been the focus of the health policy debate (along with cost) for several decades. Despite attention from the IOM and key stakeholders, quality is still too often overlooked. If the policy community can build and maintain a firm, enduring commitment to both access and quality, then children may eventually get the health care system they need and deserve.

Editor's Notes

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Paul Chung (paulchung{at}mednet.ucla.edu) is an assistant professor of pediatrics at the University of California, Los Angeles (UCLA), and a research core leader at the UCLA/RAND Center for Adolescent Health Promotion. Mark Schuster (schuster{at}rand.org) is a professor of pediatrics and health services at UCLA; a senior natural scientist and codirector of maternal, child, and adolescent health research at RAND in Santa Monica, California; and director of the UCLA/RAND Center for Adolescent Health Promotion.

The authors thank Elizabeth A. McGlynn and Lisa Simpson for comments on a draft of this article, and Burton O. Cowgill, Rita R. Delgado, Deborah G. Perlman, and Bruce M. Tran for research assistance.

NOTES

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1. J.M. Eisenberg and E.J. Power, "Transforming Insurance Coverage into Quality Health Care: Voltage Drops from Potential to Delivered Quality," Journal of the American Medical Association 284, no. 16 (2000): 2100–2107.[Abstract/Free Full Text]
2. S.M. Yu et al., "Factors That Influence Receipt of Recommended Preventive Pediatric Health and Dental Care," Pediatrics 110, no. 6 (2002): e73[Abstract/Free Full Text]; and S. Dovey et al., "The Ecology of Medical Care for Children in the United States," Pediatrics 111, no. 5, Part 1 (2003): 1024–1029.[Abstract/Free Full Text]
3. R.J. Mills and S. Bhandari, Health Insurance Coverage in the United States: 2002, Current Population Reports (Washington: U.S. Census Bureau, 2003).
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13. Claxton et al., Employer Health Benefits: 2003 Annual Survey.
14. Marquis and Long, State Efforts to Insure the Uninsured.
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16. S. Rosenbaum and P. Budetti, "Low-Income Children and Health Insurance: Old News and New Realities," Pediatrics 112, no. 6, Part 2 (2003): e551.
17. Claxton et al., Employer Health Benefits: 2003 Annual Survey.
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24. D.A. Christakis et al., "Association of Lower Continuity of Care with Greater Risk of Emergency Department Use and Hospitalization in Children," Pediatrics 107, no. 3 (2001): 524–529.[Abstract/Free Full Text]
25. Yu et al., "Factors That Influence Receipt."
26. R.M. Weinick and N.A. Krauss, "Racial/Ethnic Differences in Children’s Access to Care," American Journal of Public Health 90, no. 11 (2000): 1771–1774.[Abstract/Free Full Text]
27. Yu et al., "Factors That Influence Receipt"; and Dovey et al., "The Ecology of Medical Care."
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29. Ibid.
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32. S.J. Blumberg et al., "Design and Operation of the National Survey of Children with Special Health Care Needs, 2001," Vital and Health Statistics 1, no. 41 (2003).
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34. E.J. Silver and R.E. Stein, "Access to Care, Unmet Health Needs, and Poverty Status among Children With and Without Chronic Conditions," Ambulatory Pediatrics 1, no. 6 (2001): 314–320.[CrossRef][ISI][Medline]
35. B. Strickland et al., "Access to the Medical Home: Results of the National Survey of Children with Special Health Care Needs," Pediatrics 113, no. 5 Supp. (2004): 1485–1492.[Abstract/Free Full Text]
36. Ibid.
37. G. Flores et al., "Pediatricians’ Attitudes, Beliefs, and Practices Regarding Clinical Practice Guidelines: A National Survey," Pediatrics 105, no. 3, Part 1 (2000): 496–501.[Abstract/Free Full Text]
38. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academies Press, 2001).
39. L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., To Err Is Human: Building a Safer Health System (Washington: National Academies Press, 2000).
40. R. Kaushal et al., "Medication Errors and Adverse Drug Events in Pediatric Inpatients," Journal of the American Medical Association 285, no. 16 (2001): 2114–2120.[Abstract/Free Full Text]
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