Table 4.

Summary of articles addressing the effects of managed care on access to specialty care.

Author	Year	Sample Size	Data Source	Study Design	Access Measure	Statistic	Comparison	Findings	Endogeneity/Selection
Alessandrini et al. [37]	2001	553	Single hospital	Prospective cohort	Utilization	χ2; % with a specialty visit; number of visits	Managed care vs. fee-for-service	10% vs. 12%, p = 0.68; 0.2 vs. 0.2, p = 0.65	MC mandated' no patient selection
Cartland and Yudkowsky [43]	1992	1,264	American Academy of Pediatrics Fellows	Cross-sectional	Referral rates	χ2; frequency of referral of MCO patients	Managed care vs. fee-for-service	More frequent: 2.5%; less frequent, 8.7%; p < 0.05	Study is of physician behavior; no patient selection
Cuesta et al. [44]	2000	49	Single hospital	Retrospective cohort	Referral type	χ2	Initial referral is to rheumatologist vs. orthopedic surgeon	Managed care: 83% vs. 17%; "Traditional commercial": 58% vs. 42%; p = NS	Examines insurance type at initial referral, prior to diagnosis
Ferris et al. [39]	2002	59,952	Single MCO	Quasi-experimental	Utilization	t-test; number of specialist visits and proportion new specialist visits	With gatekeeping vs. without gatekeeping	Visits: 0.28 vs. 0.28, p = NS; % new visits: 30.6% vs. 34.8%; p < 0.05	Single MCO initiated removal of gatekeeping; no patient choice
Ferris et al. [45]	2001	1,839	Single insurance plan	Prospective cohort	Utilization	t-test; change in visits	Gatekeeping vs. indemnity	57% decrease vs. 31% increase; p = 0.005	Patient voluntarily selected into coverage type
Forrest et al [24]	1999	27,104	National practice-based research network	Prospective	Referral rates	t-test, percent referred; logistic regression, likelihood of referral to specialty	Gatekeeping vs. no gatekeeping	Medicaid, OR = 1.86, p < 0.001; Private, OR = 1.76, p < 0.01	No consideration of selection into type of plan
Garrett et al [38]	2003	34,280	National Health Interview Survey	Retrospective	Utilization	Probit; mandatory PCCM vs. FFS, mandatory HMO vs. FFS; likelihood of any specialist visit	Fee-for-service vs. primary care case management or HMO	PCCM = 0.003, p = NS; HMO = 0.378, p < 0.05	Mandatory enrollment into program type
Lake [46]	1999	12,383	Community Tracking Survey	Cross-sectional	Satisfaction	Logistic regression; difference in percent satisfied with choice of specialists	HMO vs. non-HMO	-8.3%, p < 0.05	No consideration of selection into coverage type
Mitchell, Khatutsky, and Swigonski [40]	2001	966	Single SCHIP	Cross-sectional	Unmet need	χ2; percent with unmet need for specialist	Managed care vs. fee-for-service	6.0% vs. 10.6%, p = NS	Patients seek managed care exemptions
Perlstein et al. [15]	1997	544	Regional cardiac registry	Retrospective cohort	Time to referral	t-test; mean age at referral	Managed care vs. "commercial"	140 days vs. 80 days, p < 0.05	No consideration of selection into coverage type
Price et al. [34]	1999	94	Single hospital	Cross-sectional	Utilization	t-test; number of specialist visits	Capitated plan vs. fee-for-service	All: 7.5 vs. 6, p = NS; asthma-related: 5 vs. 4, p,0.05	No consideration of selection into coverage type
Roberto et al. [53]	2005	935	Single Medicaid program	Quasi-experimental	Utilization	Probit; change in access to specialist	Fee-for-service vs. partially capitated managed care	b = 0.221, p < 0.05	Voluntary selection into plan type
Shenkman at al. [42]	2004	2,333	Single SCHIP	Cross-sectional	Utilization	Logistic regression; likelihood of a specialist visit	Plans with certain managed care characteristics vs. those without	Percent paid on FFS basis: 0.950, p = 0.003; Bonus for quality profile: 1.714, p = 0.0003	Mandatory enrollment into specific plan
Shields, et al. [41]	2002	6,231	Single Medicaid program	Cross-sectional	Utilization	Logistic regression; likelihood of specialist visit	HMO vs. primary care case management plan	OR = 1.80, p < 0.05	Voluntary selection into coverage type