The impact of managed care insurance on use of lower-mortality hospitals by children undergoing cardiac surgery in California

Context. Managed care plans aggressively seek to contain costs, but few data are available regarding their impact on access to high quality care for their members. Objective. To assess the impact of managed care health insurance on use of lower-mortality hospitals for children undergoing heart surgery in California. Design. Retrospective cohort study using state-mandated hospital discharge datasets. Setting. Pediatric cardiovascular surgical centers in California. Patients. Five thousand seventy-one children admitted for open cardiac surgical procedures during 1992-1994. Results. Hospitals were divided into lower- and higher-mortality groups according to adjusted surgical mortality. Using multivariate logistic regression analysis to control for medical, socioeconomic, demographic, and distance factors, children with managed care insurance were less likely to be admitted to a lower-mortality hospital for surgery relative to children with indemnity insurance (odds ratio: .53; 95% confidence interval: .45,.63). Similar findings resulted when the analysis was stratified by race/ethnicity. In addition, length of stay, a correlate of health care costs, was no longer for children admitted to lower-mortality centers than for those at higher-mortality centers (adjusted difference: .54 days shorter at lower-mortality centers; 95% confidence interval: -1.50,.41). Conclusions. During this study, children with managed care insurance had significantly reduced use of lower- mortality hospitals for pediatric heart surgery in California compared with children with indemnity insurance. Further study is necessary to determine the mechanisms of this apparent insurance-specific inequity.