Who cares for Medicaid-enrolled children with chronic conditions?

Objective. To estimate generalist, pediatric subspecialist, and any subspecialist use by Medicaid-enrolled children with chronic conditions and to determine the correlates of use. Methods. We analyzed Medicaid claims data collected from 1989 to 1992 from 4 states for 57 328 children and adolescents with 11 chronic conditions. We calculated annual rates of generalist, subspecialist, and pediatric subspecialist use. We used logistic regression to determine the association of demographics, urban residence, and case-mix (Adjusted Clinical Groups) with the use of relevant pediatric and any subspecialist care. Results. Most children with chronic conditions had visits to generalists (range per condition: 78%-90% for children with Supplemental Security Income [SSI] and 85%-94% for children without SSI) during the year studied. Fewer children visited any relevant subspecialists (24%-59% for children with SSI and 13%-56% for children without SSI) or relevant pediatric subspecialists (10%-53% for children with SSI and 3%-37% for children without SSI). In general, children who were more likely to use pediatric subspecialists were younger, lived in urban areas, were white (only significant for non-SSI children), and had higher Adjusted Clinical Groups scores. Use of any subspecialists followed a similar pattern except that urban residence is statistically significant only for children with SSI and the youngest age group does not differ from the oldest age group for children without SSI. Conclusions. Children who had chronic conditions and were enrolled in Medicaid received a majority of their care from generalist physicians. For most conditions, a majority of children did not receive any relevant subspecialty care during the year and many of these children did not receive care form providers with pediatric-specific training.