Disparities in Pediatric HMO Enrollment Draws Care Access Concern

Hispanic and Black children are enrolled in health maintenance organizations (HMO) at higher rates than their non-Hispanic White peers, based on research published in JAMA Network Open that draws attention to the potential for access to care health disparities within managed care enrollment.

HMOs intend to promote value-based care through a closed network of providers who are reimbursed with capitated payments, however the efficacy of the model has been contested as a narrow provider network may limit access to care.

Researchers examined national data from the 2018 Medical Expenditure Panel Survey Household Component (MEPS-HC). The survey group included 5,543 HMO-enrolled and non-HMO-enrolled children, representing 57.4 million US children.

When the data was weighted to represent the national population, 3,143 children (56.7 percent) were non-Hispanic White individuals, 1,569 (28.3 percent) were Hispanic individuals, and 831 (15.0 percent) were non-Hispanic Black individuals. 

Hispanic children were enrolled in HMOs most frequently, followed by non-Hispanic Black children and non-Hispanic White children.

The weighted percentage of HMO enrollment for Hispanic children was 52.5 percent, followed by 39 percent of non-Hispanic Black children. Least often enrolled in HMOs were non-Hispanic White children (31.4 percent).

The weighted percent of Hispanic children who were enrolled in a public HMO was 59.4 percent, compared to 42.4 percent who were enrolled in commercial HMO coverage.

Approximately 35 percent of non-Hispanic Black children enrolled in an HMO had public coverage, while 43.2 percent had commercial coverage.

Among non-Hispanic White children enrolled in HMOs, 36.3 percent had public coverage and 30.1 percent had commercial coverage.

Overall, non-Hispanic Black and Hispanic children with commercial coverage, as well as Hispanic children with public coverage, were all more likely to be enrolled in HMOs than non-Hispanic White children.

The researchers found that the weighted percent of HMO enrollment for those in the West was greatest, coming in at 46.5 percent. HMO enrollment among children was 42.4 percent for those in the Northeast, 37.8 percent for children in the Midwest, and 32 percent for children in the South. 

The authors proposed that state-to-state differences in Medicaid policies that mandate HMO enrollment may explain this variation in HMO enrollment based on census region.

They also noted that further research is needed to examine which factors cause the ethnic/racial imbalance in HMO enrollment. The researchers suggested that lower rates of employer-sponsored coverage in minority communities may partially account for this enrollment disparity.

“Our results call for future inquiry to examine the degree to which the observed national imbalance in HMO enrollment results from state-specific policies, family preferences, or coverage affordability,” the research letter authors wrote.

“Absent the unequivocal benefit of HMOs, the observed national differences in enrollment raise concerns for structural racism with regard to children’s coverage, with potential implications for access to care,” they continued.

Some providers are considering the adoption of capitated payment models to promote long-term financial viability considering how COVID-19 upended usual healthcare delivery practices. Under these payment models, physicians are paid a fixed amount per patient, per unit of time, regardless of whether the individual seeks care.

In addition to concerns regarding the quality of HMO care due to restrictive provider networks, evidence has also shown high turnover amongst in-network HMO providers.

For organizations to make the alternative payment model successful, they will have to demonstrate the benefits of establishing narrow networks of high-quality, cost-efficient providers for care delivery and access to care.

Additionally, further research should be done to determine whether HMOs and other alternative payment models exacerbate racial/ethnic health disparities.