Health maintenance organizations vs indemnity insurance for children with chronic illness. Trading gaps in coverage

Abstract

There has been increasing discussion about the potential of health maintenance organizations to provide improved access to and coordination of care for children with complex conditions. This study compares benefits for a sample of health maintenance organizations and traditional indemnity insurers in Connecticut. We conclude that in Connecticut neither health maintenance organizations nor traditional indemnity insurers currently offer comprehensive systems of care to these children. Health maintenance organizations offer preventive care and are easier systems to access. However, for children with chronic conditions, health maintenance organizations have some problematic restrictions, including a lag between start of employment and activation of health care benefits. Both health maintenance organizations and traditional indemnity insurers tend to have restrictions for specific services needed by children with chronic illnesses, such as medical equipment and mental health services. Case managers in both systems tend to control expenditures rather than to coordinate care. Representatives of both systems predict additional restrictions in the future. Our data suggest the need for more extensive evaluation of the generalizability of these findings.