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Recent legislative changes have fostered the growth of a highly competitive health care market in California. In addition to selective hospital contracting for Medicaid (Medi-Cal) services, the California Medical Assistance Commission is attempting to initiate pilot projects to capitate Medi-Cal beneficiaries in selected geographic areas throughout the state. Selective contracting with county capitated organized health systems is also underway in Santa Barbara County, with plans for other counties on the drawing boards. This paper describes these capitated programs as well as addressing problems that may arise in this transition from a fee-for-service to a capitated Medi-Cal system. Specifically considered are issues related to underutilization, quality of care, implementation, eligibility and effects on existing patterns of care.

The value of innovation must be measured against the costs, financial and political, associated with changing the current employer-based insurance system and the Medicaid, Title V, Title XXI/SCHIP, and other federal and state programs that supplement it. Although imperfect, this system still provides most children with insurance, and in the near term, it will need to continue to do so. Administrators, child advocates, and politicians understand how it works and how to make it work for many children. Yet, no close observer of the children's health "nonsystem" can escape the uneasy awareness that uninsurance, access barriers, and inadequate benefit packages and a lack of attention to developmental monitoring and services continue to constitute serious problems, particularly for lower-income children. However, many of the very trends and forces that complicate and are undermining the current children's health care system may suggest the potential shape of solutions. For example, the desire of payers to control costs and the consequent growth of large integrated managed-care organizations that focus primarily on cost control issues also has created new opportunities to improve quality. The key to quality improvement seems to be the improved measurement and evaluation techniques that more-integrated organizations can potentially bring to bear on developmental health. Another key to a more developmental approach to health is the creation of community oversight mechanisms, possibly in the form of outcomes trusts or health insurance purchasing cooperatives, that allocate funding for services based on a larger vision of developmental health outcomes. To do this, communities will first need to develop a vision of developmental health and then to begin to create the outcomes trusts that can coordinate the full range of services needed to promote developmental health. As communities develop a shared vision of developmental and contextual health promotion, the contemporary emergence of integrated managed-care organizations ...

Americans' perceptions of childhood disability have changed dramatically over the past century, as have their ideas about health and illness, medical developments, threats to children's health and development, and expectations for child functioning. Neal Halfon, Amy Houtrow, Kandyce Larson, and Paul Newacheck examine how these changes have influenced the risk of poor health and disability and how recent policies to address the needs of children with disabilities have evolved. The authors examine the prevalence in the United States of childhood disability and of the conditions responsible for impairment, as well as trends in the prevalence of chronic conditions associated with disability. They find that childhood disability is increasing and that emotional, behavioral, and neurological disabilities are now more prevalent than physical impairments. They stress the importance of, and lack of progress in, improving socioeconomic disparities in disability prevalence, as well as the need for better measures and greater harmonization of data and data sources across different child-serving agencies and levels of government. They call on policy makers to strengthen existing data systems to advance understanding of the causes of childhood disabilities and guide the formulation of more strategic, responsive, and effective policies, programs, and interventions. The authors offer a new and forward-looking definition of childhood disability that reflects emerging and developmentally responsive notions of childhood health and disability. They highlight the relationship between health, functioning, and the environment; the gap in function between a child's abilities and the norm; and how that gap limits the child's ability to engage successfully with his or her world. Their definition also recognizes the dynamic nature of disability and how the experience of disability can be modified by the child's environment.

Publicly funded categorical programs for children often differ in eligibility rules, allowable services, and criteria for provider participation, making it necessary for families to navigate through several programs to piece together care for their children. Recognizing these problems, the Robert Wood Johnson Foundation launched a national demonstration project in 1991 with the goal of decategorizing children's health services in nine communities. It was hoped that by releasing funds from categorical restrictions on their use, scarce public resources could be directed where they might have the greatest impact. However, the demonstration sites confronted a number of challenges in designing and implementing decategorization strategies: an absence of existing models and effective technical assistance; political hurdles in gaining cooperation from the multiple local agencies engaged in service provision; and difficulties in carrying out major programmatic changes when the health care system itself was rapidly being transformed. The proposition that decategorization holds promise as a tool for improving access to health care deserves further investigation.