JOURNAL OF ADOLESCENT HEALTH 1998;22:271–277

SOCIETY FOR ADOLESCENT MEDICINE

Meeting the Health Care Needs of Adolescents in Managed Care

A Position Paper of the Society for Adolescent Medicine

Adolescents have health care needs that are specific to dollars are spent each year on the medical treatment of their age and developmental status. Many of the adolescent health problems related to potentially pre- sources of mortality and morbidity in this age group ventable causes of illness (4). are related directly or indirectly to risk behaviors that Delivering timely, effective, developmentally ap- have their onset during adolescence. All of the major propriate health care services to adolescents is in the causes of mortality in this age group (motor vehicle best interest of all involved: managed care organiza- accidents, homicide, and suicide) and many of the tions, insurers, public and private purchasers of primary causes of morbidity (pregnancy, sexually health care and insurance coverage, health care pro- transmitted infections, and substance abuse) are poten- viders, consumers, and policy makers, as well as tially preventable (1–4). At the same time, many ado- adolescents. To ensure that this occurs, the Society lescents are willing to seek care for these concerns only for Adolescent Medicine identifies four key goals for if they are able to do so on a confidential basis (5,6). adolescents in managed care: Addressing adolescent health concerns in an effective 1. Adolescents should have access to comprehen- manner requires attention to their unique developmen- sive, coordinated care on a continuous basis. tal characteristics and complex needs. 2. Managed care systems should be structured to A rapid shift is occurring in both the private and ensure access to age-appropriate, adolescent- public sectors from traditional fee-for-service reim- focused services. bursement to prepaid managed care arrangements as 3. Financing mechanisms should be adequate to the dominant method of health care financing and support provision of necessary services. service delivery (7–10). This transformation is occur- 4. Quality goals and indicators that are adolescent- ring at a time when many adolescents are uninsured specific should be implemented for monitoring (11–13) and funding is precarious for many of the managed care arrangements. health care providers and sites they use (14). Increas- ing numbers of adolescents are able to receive health See related review article, pp. 278–292. care, if at all, only through managed care arrange- ments. Position As the shift to managed care takes place, the partic- ular health care needs of adolescents must be ad- To achieve these goals, the Society for Adolescent dressed. In addition to the possibility of avoiding Medicine endorses the following positions: human suffering and disability when appropriate pre- 1. Adolescents enrolled in managed care arrange- vention and treatment services are provided, analyses ments should have access to comprehensive co- of costs and benefits favor comprehensive medical care ordinated care on a continuous basis. In order to for adolescents. By conservative estimates, billions of achieve this it will be necessary to maximize insurance coverage, establish a comprehensive benefit package, coordinate services, offer antici- Address reprint requests to: Society for Adolescent Medicine, 1916 patory guidance, and provide support services to NW Copper Oaks Drive, Blue Springs, MO 64015. facilitate access.

© Society for Adolescent Medicine, 1998 1054–139X/98/$19.50 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010 PII S1054–139X(98)00007-X 272 ENGLISH JOURNAL OF ADOLESCENT HEALTH Vol. 22, No. 4

Maximizing insurance coverage. Only adolescents pregnancy termination, childbirth, and postpar- who have insurance coverage will potentially be able tum care, to receive any of the benefits associated with man- • screening and treatment for sexually transmitted aged care enrollment. As a group, however, adoles- infections, HIV/AIDS, and other infectious/con- cents are uninsured at high rates and dependent tagious/communicable disease (such as tubercu- coverage is decreasing in private employer-based losis), health insurance plans (11–13). To address this, pri- • appropriate immunizations, including those for vate and public purchasers of health insurance hepatitis B and varicella, should maximize the number of young people who • nutritional services, are covered throughout their adolescence. Depen- • substance abuse counseling and treatment (in- dent coverage should be included in employer-based cluding options for individual and family therapy plans at an affordable cost for families. State Medi- and a full range of treatment settings including caid programs and other publicly funded health inpatient hospitalization, day treatment programs, insurance programs for children and youth (14a), at and outpatient care), minimum, should include coverage for all adoles- • mental health screening, counseling, and treat- cents living below the poverty level or, preferably, ment (including options for individual and family up to 200% of poverty. Coverage for both privately therapy and medical therapy for co-morbid med- and publicly insured adolescents should be continu- ical problems or those which arise as a complica- ous and should extend at least through age 18 years. tion of the mental health problem; and a full range Whenever possible, coverage should continue be- of treatment settings including inpatient hospital- yond age 18 years to support young people through ization, day treatment programs, and outpatient their early twenties. care), Establish a comprehensive benefit package. Adoles- • care for acute and chronic illness and disability, cents will not receive the full benefit from enrollment including necessary medical equipment and med- in managed care, particularly the advantages of ications, receiving comprehensive preventive care (15), unless • rehabilitation services, including physical, speech, the benefit package is appropriate for their needs occupational, and respiratory therapy, and (16–19). Therefore, a comprehensive package of ben- • care coordination and case management. efits that meets the physical, psychological, and developmental health care needs of adolescents Coordinating services. While it is critically impor- should be available across all plans, both public and tant that this range of services be available to ado- private. These services should be available within a lescents, it is equally important that they be provided reasonable time once a need is identified. They in a coordinated manner, because many adolescents should not be subject to exclusions based on pre- have complex needs that require services from mul- existing conditions. The benefit package should in- tiple providers or even separate plans (18,25). Nev- clude services that reflect the developmental needs ertheless, these different services and providers are of this age group or are required to prevent and treat often needed to address a single problem. For this the consequences of adolescent high-risk behaviors. reason, and particularly to the extent that some A comprehensive benefit package appropriate to the health care services are provided to an enrolled needs of adolescents should include, but not be adolescent through separate plans (such as a behav- limited to: ioral health plan for mental health care), services must be closely coordinated between plans and • periodic preventive health screening, including among plan providers to ensure that enrolled ado- physical examinations, and other clinical preven- lescents are not denied essential care. tive services consistent with the recommendations Offering anticipatory guidance. Many of the health contained in professional guidelines such as problems experienced by adolescents are prevent- Bright Futures (20), the Guidelines for Adolescent able (1–4). A key element in the prevention effort Preventive Services (GAPS) (21), the AAP guide- is individualized, prevention-oriented counseling. lines (22), and others (23,24), Therefore, health education and anticipatory guid- • dental, vision, and hearing services, ance should be provided to all enrolled adoles- • family planning and contraceptive services and cents. supplies, Providing support services to facilitate access. Certain • pregnancy-related care, including prenatal care, groups of adolescents are unlikely to be able to April 1998 ADOLESCENTS IN MANAGED CARE: POSITION PAPER 273

access care appropriately without support services: vulnerabilities in the health care system as a result of in particular, low income and high risk adolescents, their physical or psycho-social health status, devel- and adolescents with chronic illness and disability opmental characteristics, legal status, or social cir- (18,26). Therefore, in managed care arrangements cumstances (18,26). These groups include adoles- serving these young people, covered benefits should cents with chronic illness or disability, including include support services, such as case management, HIV-related conditions; adolescents with mental ill- individualized treatment plans, medically necessary ness or developmental disability; adolescents in fos- emergency transportation and, for low income ado- ter care, state custody, or other out-of-home-place- lescents, other medically necessary transportation. ments; homeless and runaway youth; and immigrant or migrant adolescents (25,26,31). When these special 2. Managed care arrangements should be struc- populations are enrolled in their plans, managed tured so that adolescents enrolled in managed care arrangements should adopt special rules of plan care have access to age-appropriate, adolescent- administration and case management that address focused services and providers. In order to their needs (16). achieve this it will be necessary to protect adoles- Assuring access to adolescent-focused providers. Many cents’ special access concerns, recognize the needs adolescents are most likely to seek care when they of special populations of adolescents, assure ac- can do so from providers who have interest, experi- cess to adolescent-focused providers, require ad- ence, and expertise in caring for them (26). For olescent-specific proficiency among providers, certain problems, the special expertise of adolescent- implement adolescent specific practice guidelines, focused providers is important for effective care (32). and assure fairness in prior authorization and Managed care arrangements should include in their utilization review. provider networks, both as primary care providers and as specialists for referral, health care providers Protecting adolescents’ special access concerns. Due to with training, expertise, and experience in serving their age and developmental status, many adoles- adolescents. Physicians who are sub-board certified cents will only use necessary health care if they can in adolescent medicine should be allowed to serve as obtain services in adolescent-friendly sites on a con- primary care gatekeepers for enrolled adolescents in fidential basis (18,26,27). Therefore, managed care appropriate circumstances, but should also be in- arrangements should incorporate protections for ad- cluded in provider networks as specialists. To in- olescents to receive confidential care and procedures crease adolescents’ options for points of access, man- allowing adolescents to give informed consent for aged care arrangements should collaborate, and in their own care, as allowed by state and federal law some cases subcontract, with safety-net providers (2,5,6,28,29). Certain modes of operation—such as serving adolescents in the community. These safety- extended hours; accessible community based sites; net providers may include community clinics and and clinical and administrative staffs who are ap- school-based health clinics, family planning and STD proachable and aware of the unique needs of adoles- clinics, maternity care coordination programs, and cents, as well as culturally and linguistically sensi- substance abuse and mental health treatment centers. tive—are key elements in providing care that is Adolescents enrolled in managed care should be appropriate for an adolescent population (25–27) and offered maximum choice among providers (includ- managed care arrangements should adopt them. ing culturally and linguistically sensitive providers). Managed care arrangements also should make avail- Managed care arrangements should establish, and able toll-free telephone numbers that adolescents can publicize, policies to allow adolescents to select a call to obtain information about available services primary care provider different from the one serving and ways to access them. Co-payments, if required at other family members (33). all, should be minimal; co-payments should not be Requiring adolescent-specific proficiency among pro- imposed for services such as family planning, screen- viders. Appropriate care for adolescents depends on ing for sexually transmitted infections, or substance providers having certain adolescent-specific profi- abuse counseling and treatment that are related to ciencies or, at minimum, the ability to recognize adolescents’ high risk behaviors and that adolescents when such proficiency is required (15,32,34). To the are reluctant to seek other than on a confidential maximum extent possible, primary care providers basis (25,27,30). who care for adolescents enrolled in managed care Recognizing the needs of special populations of adoles- arrangements should be required to demonstrate cents. Certain groups of adolescents have special proficiency in areas essential to the care of adoles- 274 ENGLISH JOURNAL OF ADOLESCENT HEALTH Vol. 22, No. 4

cents, such as basic gynecologic care and pelvic cluding a range of pediatric sub-specialists, and to examinations; mental health, substance abuse, and special services such as substance abuse and eating eating disorder screening; and developmentally ap- disorder treatment, mental health counseling, and propriate health education and anticipatory guid- rehabilitation services. Prior authorization proce- ance. At minimum, even if primary care providers dures should be timely and should provide for rapid who care for adolescents are not proficient in all of response in emergencies. They should also provide these areas, they should nevertheless be able to an opportunity for timely review of requests for recognize when adolescents have such problems and authorization of payment for services from providers properly refer and follow them. outside the plan network when necessary covered Implementing adolescent-specific practice guidelines. services are not available to adolescents with special- Adolescents are not simply large children or small ized needs from appropriate providers within the adults and the guidelines for their care cannot be network. Procedures also should allow for prior identical to those for the care of these younger and authorization for an adequate range of services for a older groups (20–22). Managed care arrangements sufficient length of time to permit appropriate treat- should implement practice guidelines that are ado- ment planning and provision of services in complex lescent-specific and approved by specialists in ado- cases and should protect against arbitrary reversals lescent health care and that recognize the primary of prior authorization once it has been granted. For role of the physician to make treatment decisions for cases in which services desired by adolescents or individual patients. To the extent that guidelines their families are denied, reduced, or suspended, a developed and approved by governmental bodies grievance procedure should be in place that is acces- and nationally recognized professional organizations sible to families and to adolescents themselves. specializing in the care of adolescents are available, such guidelines should be used (20–24). The guide- 3. Financing mechanisms should be adequate to lines used in managed care arrangements should support services for adolescents enrolled in include clear criteria specifying when the care of an managed care arrangements. In order to achieve adolescent with complex needs (such as multiple this it will be necessary for policymakers, public psycho-social or mental health problems, chronic and private purchasers of health care, and man- illness, post-trauma rehabilitation, or eating disor- aged care arrangements to provide for adequate ders) should be transferred from the primary care capitation rates, protect the financial viability of provider to a provider with appropriate adolescent- safety net providers, and avoid inappropriate specific expertise either within or outside the net- financial incentives. work of the managed care arrangement. Assuring fairness in prior authorization and utilization Provide for adequate capitation rates. Plans and pro- review. Optimal health care of adolescents depends viders will only be able to deliver comprehensive on their being able to receive an appropriate range of services, including preventive services, to adoles- services in an appropriate amount and in a timely cents in an appropriate manner if capitation rates are manner. To achieve this, the fairness of prior autho- established at a level that will enable them to do so rization and utilization review procedures in man- (15,16,37). It is especially important that payment aged care arrangements should be assured through methodologies (which might include risk adjustment implementation of specific protections (35). Managed or other mechanisms) be in place to ensure that care arrangements should use definitions of medical capitation rates are sufficient to allow for appropriate necessity that take into account the physical, psycho- care of special populations of adolescents with more logical, cognitive, and developmental needs of ado- intense or specialized health care needs when they lescents (36). The treating physician should retain are enrolled in managed care arrangements. These primary responsibility for determining which ser- special groups might include adolescents who have a vices are medically necessary. The personnel respon- chronic illness or disability; are HIV positive; are sible for prior authorization and utilization review in mentally ill; have an eating disorder; or are home- managed care arrangements should have some ado- less, runaway, migrant or immigrant youth. The lescent-specific experience or expertise or should be need for reinsurance and/or population- or disease- trained to develop a familiarity with the health care specific stop loss coverage should be specifically needs of adolescents. Referral procedures should considered for plans and plan subcontractors. facilitate, rather than impede, appropriate referrals Protecting the financial viability of safety net provid- to providers with adolescent-specific expertise, in- ers. Safety-net providers are a key element in the April 1998 ADOLESCENTS IN MANAGED CARE: POSITION PAPER 275

service delivery infrastructure that provides health and evaluation to be relevant for the adolescent care to the adolescent population (16,32). Therefore, population, sufficient data must be collected that are collaborative relationships and subcontracts between specific to adolescents. Therefore, managed care ar- managed care organizations and safety-net providers rangements should be required to collect and report in the community should include special payment uniform adolescent-specific data that will enable arrangements or enhancement mechanisms to ensure public and private purchasers and consumers of that safety-net providers are not placed at excessive health care to evaluate whether the goals for adoles- financial risk (37,38). Such arrangements might in- cent health care in the quality assurance plan have clude, among others, fee-for-service reimbursement been met (39). for certain services. Developing adolescent-specific indicators. An insuffi- Avoiding inappropriate financial incentives. Financial cient number of adolescent-specific indicators are incentives and disincentives can have a powerful being used to monitor and evaluate quality in man- effect on the ability and willingness of physicians aged care arrangements (40). Indicators, including and other health care professionals to provide certain measures of outcomes in terms of health status over services or to make certain referrals (37). To safe- time, should be developed to evaluate the impact of guard against the potential adverse effect of financial early identification and treatment of problems that incentives on services to the adolescent population, develop during the adolescent years. Potential sav- they should not be structured in a way that discour- ings from the use of early identification and treat- ages providing necessary services to adolescents, ment for problems during adolescence (4) should be including necessary referrals to specialists. Managed included in analyses used to determine the scope of care arrangements should be prohibited from limit- benefits that will be covered, but should not be the ing the treating provider’s ability to discuss the sole determining factor. entire range of appropriate treatment alternatives Tracking utilization and measuring satisfaction. Few with the patient. data are available concerning comparative utilization of services by adolescents within and outside of 4. Quality goals and indicators that are adolescent- managed care arrangements (25). Monitoring of the specific should be developed and implemented quality of services to adolescents in managed care for monitoring managed care arrangements. In arrangements should include tracking of service uti- order to achieve this it will be necessary to imple- lization by enrolled adolescents both within and ment adolescent-specific quality assurance, collect outside the managed care system, measurement of and report adolescent-specific data, develop ado- satisfaction on the part of both adolescents and lescent-specific indicators, track utilization, mea- adolescent health care providers who are participat- sure satisfaction, and conduct further research. ing in the plan and those who have elected to leave the plan, and peer review by health care providers Implementing adolescent-specific quality assurance. with training and experience in the care of adoles- Quality assurance plans should be established for cents. managed care arrangements in both the private and Conducting further research on quality issues. Cur- public sectors (16,39). Generally such plans have not rent data on the effects and effectiveness of managed focused specifically on the adolescent age group, care contain little information about their implica- even though information specific to this age group is tions for the adolescent population. Research should necessary to evaluate the quality of their care. For be conducted to identify those characteristics, incen- this reason, quality assurance plans should include tives, and services offered in various managed care measures that are specifically relevant to the adoles- arrangements that can best serve adolescents’ health cent age group with respect to access and availability needs. as well as performance and outcome. To the extent that such measures have already been adopted or approved by nationally recognized organizations they should be used by managed care arrangements Conclusion in both the private and public sectors. As discussed more fully in the accompanying back- Collecting and reporting adolescent-specific data. Data ground paper (41), specific attention must be focused that are collected and reported in a uniform manner on the needs of adolescents in the rapid transition across plans are essential in monitoring and evaluat- from fee-for-service to managed care as the domi- ing quality of care (25). In order for such monitoring nant method of financing and delivery of health care 276 ENGLISH JOURNAL OF ADOLESCENT HEALTH Vol. 22, No. 4

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