Barriers to Subspecialty Care in Military Managed Care

摘要

The potential impact of managed care delivery systems on services for children with special health care needs (CSHCN) is of significant interest to policy makers, providers, and consumers because managed care organizations may reduce the quality of care for CSHCN and their families. Primary care providers (PCPs) within systems of managed care are often unable to accurately diagnose or treat CSHCN because their complicated disease processes are outside the scope of a general medical practice, and referral options can be limited by in-network provider contracts dictated by the managed care organization. Managed care plans may also limit services for CSHCN through benefit exclusions and restrictive medical necessity standards. As a result, these children are at risk for being medically underserved. At the same time, specialty service providers who serve these children are at risk for decreased financial viability because of low reimbursement rates and decreased referrals. The nature of chronic illness and disability demands a specialized form of health care, including visits to sub-specialists and access to family-centered care. Because managed care attempts to control costs by decreasing utilization, particularly referrals to specialists, this study proposed to analyze the content of the TRICARE provider manual and benefits package to determine if referral barriers and exclusion of benefits impede access to pediatric subspecialty care for military-dependent CSHCN in a managed care environment.