Children's health care use in the Healthy Kids Program.
Children's health care use in the Healthy Kids Program.
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健康儿童计划中的儿童保健用途。
DOI：
10.1542/peds.100.6.947
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发表时间：
1997
期刊：
影响因子：
8
通讯作者：
R. Bucciarelli
中科院分区：
文献类型：
--
作者：
E. Shenkman;J. Pendergast;D. Wegener;T. Hartzel;R. Naff;S. Freedman;R. Bucciarelli
背景
1990年，佛罗里达立法机构成立了佛罗里达健康儿童公司，以实施以入学为基础的儿童健康保险的概念。县学区被用作谈判健康保险政策的分组机制。佛罗里达健康儿童公司与健康维护组织（HMO）谈判合同，承担财务风险，并在每个项目地点提供医疗保健服务。1994年，有五个地点，有四个不同的保健组织参加。在与卫生组织签订合同时，评估护理质量尤为重要，因为人们认为财务和使用审查安排可能会限制登记者获得所需的卫生保健。保健质量的一个基本组成部分是，在多大程度上保健服务的使用方式符合入学儿童人口的预期使用模式。本研究的目的是比较五个不同的佛罗里达健康儿童计划网站的儿童的医疗保健使用。具体来说，我们比较了参加者的实际医疗保健使用跨HMO设置和计划网站的预期医疗保健使用的基础上参加者的情况组合。
方法
每个HMO都提供了儿童特定的医疗保健使用数据，包括医生现行程序术语代码和国际疾病分类第9版代码。我们使用门诊护理组（ACG）软件比较儿童的实际医疗保健使用的预期医疗保健使用在每个站点调整病例组合。然后采取了几个步骤，以确定这些儿童是否根据他们的诊断接受了预期数量的医疗保健访问。首先，我们将每个站点的平均遭遇次数除以所有站点的组平均数，而不调整登记者的病例组合。然后，我们将每个研究中心的平均访视次数除以基于病例组合调整的预期访视次数。值为1.00表示实际使用和预期使用相同。数值低于1表示保健服务利用不足，数值高于1表示保健服务利用过度。通过推导适当的卡方统计量，对五个研究中心的实际与预期平均医疗保健使用情况进行统计比较。
结果
在分析中包括了在每个研究中心参加佛罗里达健康儿童项目6个月或更长时间的所有儿童（N = 14688）的普查。在12个月的时间段内，所有研究中心的平均医疗保健就诊次数为2.98 +/- 4.6次。在使用ACG软件调整每个研究中心登记者的病例组合后，五个研究中心中的几个研究中心与一个研究中心的差异具有统计学意义。然而，这些统计评估必须与评估所观察到的差异的实际幅度相协调。
结论
公共和私人部门为那些没有资格享受医疗补助和父母无法购买私人保险的儿童提供保险的努力数量急剧增加。这些方案对于确保无保险儿童获得财政照顾至关重要。然而，至关重要的是，这些计划不被视为仅仅是成本控制的努力。评估儿童在多个交付环境中获得所需医疗保健服务的程度是质量保证的一个重要但具有挑战性的组成部分。一般来说，我们的分析表明，在佛罗里达健康儿童计划的儿童正在接受医疗保健的预期金额根据他们的医疗保健需求，这是一个高质量的医疗保健计划的一个组成部分。
BACKGROUND
In 1990, the Florida Legislature established the Florida Healthy Kids Corporation to implement the concept of school enrollment-based health insurance coverage for children. The county school districts are used as a grouping mechanism to negotiate health insurance policies. The Florida Healthy Kids Corporation negotiates contracts with health maintenance organizations (HMOs) to assume financial risk and to provide health care services at each program site. In 1994, there were five sites with four different participating HMOs. Assessing quality of care is particularly important when contracting with HMOs because of the perception that financial and utilization review arrangements may restrict the enrollees' access to needed health care. One essential component of health care quality is the extent to which health care services are used in a manner consistent with the expected pattern of use for the population of enrolled children. The purpose of this study is to compare children's health care use across five different Florida Healthy Kids Program sites. Specifically, we compare the enrollees' actual health care use across HMO settings and program sites to the expected health care use based on the enrollees' case-mix.
METHODS
Each HMO provided child-specific health care use data including Physician's Current Procedural Terminology codes and International Classification of Diseases, 9th Revision codes. We used the Ambulatory Care Groups (ACGs) software to compare the children's actual health care use to the expected health care use at each site adjusted for case-mix. Several steps were then taken to determine if the children were receiving the anticipated number of health care visits based on their diagnoses. First, we divided the average number of encounters at each site by the group average across all of the sites, without adjusting for the case-mix of the enrollees. We then divided the average number of visits at each site by the expected number of visits based on the case-mix adjustment. A value of 1.00 means that the actual use and the expected use are identical. Values below 1 indicate underuse and values over 1 indicate overuse of health care services. Statistical comparisons of the actual versus expected average health care use across the five sites were performed by deriving the appropriate chi2 statistics.
RESULTS
A census of all children (N = 14 688) enrolled in the Florida Healthy Kids Program at each of the sites for 6 months or longer were included in the analysis. The average number of health care encounters across all sites for a 12-month time period was 2.98 +/- 4.6 visits. After adjusting for the case-mix of the enrollees in each site using the ACG software, several of the five sites differed from one in a statistically significant way. However, these statistical assessments must be tempered with assessing the practical magnitude of the observed differences.
CONCLUSIONS
The number of public and private efforts to insure children who are not eligible for Medicaid and whose parents cannot purchase private insurance has grown dramatically. These programs are vital for ensuring financial access to care for uninsured children. However, it is essential that such programs are not viewed as merely cost containment efforts. Assessing the degree to which children receive the health care services they need across multiple delivery settings is an essential yet challenging component of quality assurance. Generally, our analysis indicates that children in the Florida Healthy Kids Program are receiving the amount of health care expected based on their health care needs; which is one component of a high-quality health care program.