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Table 4 Summary of articles addressing the effects of managed care on access to specialty care.

From: Effects of insurance status on children's access to specialty care: a systematic review of the literature

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