Neighborhood Opportunities and Pediatric Health Care Utilization: Implications for Medicaid Managed Care

ABSTRACT

Objectives: Disparities in health care utilization exist, particularly among children in socially disadvantaged neighborhoods. This study examined the relationship between neighborhood opportunity and health care utilization among pediatric Medicaid managed care beneficiaries, identifying key areas for interventions to address disparities and improve pediatric health outcomes.

Study Design: We conducted a retrospective cross-sectional analysis of a merged 2022 administrative claims data set with the Child Opportunity Index (COI) 3.0 database for Medicaid managed care beneficiaries younger than 21 years who were continuously enrolled for 12 months (N = 157,261).

Methods: Generalized linear models (logistic regression and zero-inflated negative binomial regression) were used to examine the association between neighborhood opportunities and health care utilization (measured by primary care physician [PCP] visits, emergency department [ED] visits, and hospitalizations) while adjusting for confounders.

Results: Compared with those in high-opportunity neighborhoods, pediatric beneficiaries in very low–, low-, and moderate-opportunity neighborhoods were 11.5 percentage points, 5.1 percentage points, and 2.2 percentage points less likely to have PCP visits, respectively, and 1.4 times, 1.2 times, and 1.1 times more likely to visit the ED. Hospitalizations were 0.5 percentage points more likely in very low–opportunity neighborhoods.

Conclusions: The results corroborate that health care utilization varies by neighborhood opportunity levels. Managed care organizations can use the COI to address disparities in pediatric beneficiaries’ health care utilization. Findings underscore the differences in health care utilization that may be a basis for researchers, policy analysts, and decision makers to further investigate underlying unmet needs that affect pediatric health care utilization in lower opportunity neighborhoods.

Am J Manag Care. 2026;32(3):154-161. https://doi.org/10.37765/ajmc.2026.89894

Takeaway Points

More than 75% of pediatric Medicaid beneficiaries are enrolled in managed care, highlighting its crucial role in improving health care utilization. This study examined neighborhood opportunity and health care use among pediatric Medicaid managed care enrollees, identifying opportunities for managed care.

• Children from the lowest-opportunity neighborhoods had fewer primary care visits but more emergency department visits and hospitalizations, indicating barriers to primary care.
• Most managed care beneficiaries resided in low-opportunity neighborhoods.
• More than two-thirds of beneficiaries from low-opportunity neighborhoods were Black or Hispanic/Latino.
• Findings emphasize the need for targeted interventions to improve access and equity in pediatric Medicaid managed care.

Although medical care is essential to health, it is a weak health determinant. Research shows that 80% to 90% of modifiable health outcomes are influenced by social and environmental factors and that 10% to 20% are influenced by medical care.¹ These findings indicate that social and economic resources are the primary drivers of health in both children and adults. Unfortunately, the inequitable distribution of these resources results in health care disparities, which are especially prominent among US children.² Children in neighborhoods with poor social, environmental, and economic opportunities are at higher risk of childhood illnesses, developmental delays, and premature deaths^3-5; these neighborhood factors are multidimensional and impact all aspects of their adult lives.⁶

Associations between neighborhood opportunities and pediatric health care utilization are well documented.^7-10 Studies show that children in low-opportunity neighborhoods have more emergency department (ED) visits^8,10 and hospitalizations^7,9 than those residing in high- opportunity neighborhoods. Pediatric primary care was also found to be associated with neighborhood opportunity.¹¹ Children in high-opportunity neighborhoods were shown to have a higher likelihood of preventive care visits compared with those in low-opportunity neighborhoods.¹¹ Studies on spatial differences in health care utilization similarly found fewer primary care services were used by those in neighborhoods with low socioeconomic status.^12,13 These studies were based on either a single health care system, multiple US pediatric hospitals, or pediatric health information systems and were focused on either ED visits or hospitalizations or primary care for the general pediatric population.^7-11

Little is known about pediatric Medicaid beneficiaries’ health care utilization across the spectrum of neighborhood opportunity levels. The Medicaid pediatric population accounted for 40% of total Medicaid beneficiaries and 42% of the projected number of children living in the US in 2023.¹⁴ Because a majority of the low-income pediatric population are enrolled in Medicaid managed care,¹⁵ it is imperative to examine pediatric Medicaid managed care beneficiaries’ distribution and health care utilization across neighborhood opportunity levels. Medicaid managed care organizations (MCOs) provide health care services through contracted arrangements with state Medicaid agencies based on a set per-beneficiary per-month payment.¹⁶ Our objectives were to examine the association between the latest multidimensional measure of child neighborhood opportunity and health care utilization for pediatric Medicaid managed care beneficiaries and to provide MCOs with evidence of disparities in pediatric beneficiaries’ health care utilization and opportunities to intervene. We hypothesized that pediatric Medicaid managed care beneficiaries residing in lower-opportunity neighborhoods may have fewer primary care physician (PCP) visits and higher rates of ED visits and hospitalizations. Our study offers a comprehensive analysis of pediatric beneficiaries’ health care services utilization across neighborhood opportunity levels, focusing on PCP visits, ED visits, and hospitalizations, and will guide policy design and targeted area-level interventions that address health care utilization differences among pediatric Medicaid managed care populations.

METHODS

Study Design, Setting, and Population

We conducted a retrospective cross-sectional analysis of secondary data obtained from an MCO located in a northeastern US state. The data set was created by combining the MCO’s 2022 administrative claims data with the enrollment files. The administrative claims data had information on beneficiaries’ chronic health conditions and health care utilization, and the enrollment files had beneficiaries’ sociodemographic information including residential census tract. The data were merged at the census tract level with the Child Opportunity Index (COI) 3.0 database.¹⁷ The analysis included Medicaid pediatric beneficiaries from newborns to individuals younger than 21 years who were continuously enrolled in the MCO from January to December 2022. Neighborhood opportunity measured by the COI quantifies community resources and conditions that matter for children’s development. The COI is a validated multidimensional measure of neighborhood-level child opportunity and is a composite index of neighborhood attributes that influence a child’s development and health.¹⁷ The latest COI (version 3.0) is made up of 44 indicators categorized into 3 domains: (1) education, (2) health and environment, and (3) social and economic. These 3 domains have 14 subdomains incorporating data from the American Community Survey and other sources to provide a composite score for all US census tracts.¹⁷ We used the COI 3.0 as a measure of neighborhood opportunity in the study. The overall sample size was 160,413. We excluded 3152 (2.0%) beneficiaries due to incomplete data on area of residence and PCP visits. The final analytical sample consisted of 157,261 beneficiaries.

Variables and Measurement

The outcome variable was pediatric beneficiaries’ health care utilization measured as PCP visits, ED visits, and hospitalizations. Beneficiaries’ PCP visits were defined as visits to one of the following specialties: pediatrics, family medicine, general internal medicine, and physician assistants or nurse practitioners working in primary care offices. ED visits were defined as any ED visit that did not include an observation stay and did not result in hospitalization. Hospitalizations were defined as hospital stays lasting 24 hours or more. PCP visits and hospitalizations were measured as dichotomous variables (yes/no), and ED visits were measured as a count variable. The predictor variable was pediatric neighborhood opportunity measured by the COI 3.0, which assigns values of 1 to 100 at the census tract level; smaller values indicate lower-opportunity neighborhoods and larger values indicate higher-opportunity neighborhoods. The values were categorized into quintiles: very low–, low-, moderate-, high-, and very high–opportunity neighborhoods. This approach has been used in other studies.^8-11,18,19

The behavioral model of health care utilization, a model widely used to study health care utilization, was used to identify the confounders associated with beneficiaries’ neighborhood opportunity and health care utilization.²⁰ According to the model, pediatric beneficiaries’ health care utilization is influenced by predisposing factors, such as sociodemographic characteristics; enabling factors that facilitate or hinder access to health services; and need-related factors that motivate service use, such as illness. The predisposing factors included in the model are age, sex, and race/ethnicity. Enabling factors are primary language and area of residence, and need-related factors include medical complexity. We categorized beneficiaries’ primary language into English, Spanish, and other, and we categorized beneficiaries’ area of residence into rural and urban as per the definition from the Center for Rural Pennsylvania. An area was classified as rural if its population density was fewer than 291 people per square mile; otherwise, it was considered urban.²¹ Age was categorized into 4 groups: newborn through 3 years, 4 to 11 years, 12 to 17 years, and 18 to 21 years. We included both male and female beneficiaries in the analysis. Race and ethnicity were categorized as White, Black, Hispanic/Latino, other racial/ethnic group, and missing. The other racial/ethnic group included individuals who were Native American, Alaskan Native, Asian, and Hawaiian/Pacific Islander. Beneficiaries with missing race and ethnicity were classified as a separate category. To assess pediatric beneficiaries’ medical complexity, we used the Pediatric Medical Complexity Algorithm version 3.2, a validated measure that can be applied to large administrative claims data sets.²² We utilized the least conservative version of the algorithm to identify beneficiaries’ chronic conditions by reviewing claims from January to December 2022. Medical complexity was categorized into 3 groups: complex chronic conditions, chronic conditions, and no chronic conditions. Beneficiaries with complex chronic conditions had either 2 or more chronic conditions or a progressive or malignant health condition. Those classified under chronic conditions had a single chronic condition, such as asthma, diabetes, or autism spectrum disorder.²²

Analysis

We used descriptive statistics to summarize beneficiaries’ demographics and health conditions. The χ² test was employed to examine association between nominal and ordinal variables, and the Kruskal-Wallis test was used to examine association between ordinal and continuous variables. Associations between neighborhood opportunities and PCP visits and hospitalizations were modeled as logistic regression. Associations between neighborhood opportunities and ED visits were modeled as zero-inflated negative binomial regression. Results from logistic regression were presented as average marginal effects with SEs and P values. Results from zero-inflated negative binomial regression were presented as incidence rate ratios with 95% CIs. Data management and statistical analyses were conducted using Stata 15 (StataCorp LLC). The Allegheny Health Network Research Institute Institutional Review Board granted the study exempt status because it was a retrospective analysis of a deidentified secondary data set (FWA# 00015120).

RESULTS

Table 1 shows the descriptive characteristics of our pediatric Medicaid managed care population. Of the 157,261 pediatric managed care beneficiaries, 33%, 23%, 21%, 16%, and 7% were from very low–, low-, moderate-, high-, and very high–opportunity neighborhoods, respectively. The mean age was approximately 10 years. The plurality belonged to the group aged 4 to 11 years (41%). The very low–opportunity neighborhoods had the highest percentage of pediatric Medicaid managed care beneficiaries who identified as Black and Hispanic/Latino (69%). The Figure shows that the very low–opportunity neighborhoods had the highest percentage of Medicaid beneficiaries who did not have a PCP visit (47%) and had the highest percentage of those who had ED visits (32%). Hospitalizations were similar across very low–, low-, and moderate-opportunity neighborhoods (2%).

Results from generalized linear models indicated an association between neighborhood opportunities and the 3 health care utilization measures after adjusting for confounders. Compared with beneficiaries in very high–opportunity neighborhoods, beneficiaries residing in very low–, low-, and moderate-opportunity neighborhoods were 11.5 percentage points, 5.1 percentage points, and 2.2 percentage points less likely to have PCP visits, respectively. There were no statistically significant differences in PCP visits between those residing in high- and very high–opportunity neighborhoods (Table 2). ED visits for beneficiaries from very low–, low-, and moderate-opportunity neighborhoods were 1.4, 1.2, and 1.1 times higher, respectively, compared with beneficiaries in very high–opportunity neighborhoods. There were no statistically significant differences in ED visits between those residing in high- and very high–opportunity neighborhoods (Table 3). Compared with very high–opportunity neighborhoods, beneficiaries residing in very low–opportunity neighborhoods were 0.5 percentage points more likely to have hospitalizations. There were no statistically significant differences in hospitalizations between those residing in low-, moderate-, high-, and very high–opportunity neighborhoods (Table 4).

DISCUSSION

Our results highlight differences in health care utilization across neighborhood opportunity areas. Beneficiaries from neighborhoods with the lowest opportunities were less likely to have PCP visits and more likely to have ED visits and hospitalizations, suggesting potential barriers to accessing primary care. Additionally, our study found that more than two-thirds of Medicaid managed care beneficiaries with lower likelihood of PCP visits and higher ED visits in very low–opportunity neighborhoods were Black or Hispanic/Latino. These findings align with those of a previous cross-sectional study of electronic health records from a children’s hospital primary care network, which showed that children from low-opportunity areas were less likely to usepreventive care visits.¹¹ However, the children included in that study had coverage from all payer types and not specifically from Medicaid managed care. Pediatric Medicaid managed care beneficiaries are encouraged to select a PCP within the MCO’s provider network within 45 days of enrollment. If they do not choose a PCP within this time frame, the MCO assigns one to them, and beneficiaries have the option to change their assigned PCP.²³ Despite these policies, our study shows low PCP utilization, suggesting that barriers to accessing primary care persist and need to be addressed. Our findings of high ED utilization align with previous studies examining the association between the COI and ED utilization, which were based on a nationally representative sample of children.^8,18,24 In a 2018 study of 3 large health systems in San Francisco, California, Kersten and colleagues found that the likelihood of having 4 or more ED and urgent care visits was 44% and 33% higher in very low– and low-opportunity neighborhoods, respectively.¹⁹ Unfortunately, reliance on EDs for episodic care is not favorable for individual health, as it lacks the continuity and coordination of care that a PCP can provide.²⁵

More than 75% of the overall pediatric Medicaid beneficiaries in the US are enrolled in managed care,¹⁶ indicating the key role that Medicaid managed care can play in health care utilization and health outcomes for pediatric beneficiaries. Utilization of primary health care services is important for population health.²⁶ Health care access through health insurance alone does not guarantee primary care services utilization; therefore, it is crucial that MCOs work with community representatives, especially in socially disadvantaged areas, to address barriers to primary care utilization. In addition, studies have shown that some health system factors such as limited provider office hours, delayed availability of appointments, lack of patient-centered communication, and limited culturally competent care may influence pediatric beneficiaries’ PCP visits, especially in disadvantaged neighborhoods²⁶; therefore, MCOs should work with the health care systems and providers in their network to address these issues. Further, patients or caregivers are often unaware of the services available at PCP offices and may choose the ED for nonurgent acute health issues.²⁷ Hence, it is important for MCOs to provide clear information about PCP assignments or selection, clinic times, and available services. Successful interventions to increase PCP visits include educating families about the importance of having a PCP and assisting with scheduling appointments with a PCP of choice. The support can be provided by health professionals or other clinic staff to families who visit EDs for nonurgent health issues.^28,29

Our results also highlight MCOs’ opportunity to address beneficiaries’ health-related social needs (HRSN) and community social risks, as the majority of the pediatric managed care beneficiaries with fewer PCP visits and more ED visits and hospitalizations resided in the lowest-opportunity neighborhoods. These beneficiaries may face barriers to primary care utilization such as transportation, limited English proficiency, caregivers’ inability to take time off from work, caregivers’ mistrust of the health care system, lower health literacy of parents, and higher exposure to environmental hazards.²⁶ MCOs can address beneficiaries’ HRSN through their case management assessment and referral programs to community-based organizations and collaborate with PCP offices for assessment, referral, and claims-based documentation of HRSN. The documentation will help with designing value-based payment (VBP) models around primary care services and HRSN. Although there is a shift from fee-for-service (FFS) payment to VBP in primary care, FFS still dominates primary care. MCOs should focus their efforts to increase VBP models in primary care, which have been shown to provide more comprehensive care with improved quality and reduced cost.³⁰ Additionally, reducing preventable ED visits and improving PCP access in low-opportunity neighborhoods will require community-based interventions that focus on health promotion, preventive services, housing stability, neighborhood safety, and reducing exposure to environmental hazards.¹⁹ MCOs can partner with schools, grocery stores, transportation providers, social service agencies, health care systems, community-based organizations, and public health entities to address the social risks and needs faced by children and families in these areas. Such multisector partnerships are crucial for developing strategies that address both neighborhood- and individual-level factors.

By prioritizing lower-opportunity neighborhoods for interventions to optimize health care utilization and improve health outcomes, MCOs will also indirectly address the racial and ethnic disparities in pediatric health care utilization because more than two-thirds of the beneficiaries in lower-opportunity neighborhoods were Black and Hispanic/Latino. However, Medicaid MCOs should also differentiate between interventions designed to enhance quality of care for all Medicaid beneficiaries and those specifically focused on improving care for racial and ethnic minority groups.³¹ Creating culturally tailored interventions that reflect the practices, values, and beliefs of targeted communities is more likely to resonate with the targeted population. It may also help resolve minority groups’ mistrust in the health care system. In addition, implementing strategies that increase power sharing and trust building between providers and pediatric beneficiaries and their parents may enhance trust.³² Future studies should focus on whether additional resources in low-opportunity areas result in more PCP visits and reduced ED visits and hospitalizations, which is unclear at this time. There are other factors that may influence utilization even in resource-rich neighborhoods, such as care coordination, ability to self-manage chronic conditions, and behavioral health diagnosis.³³

Limitations

There are several limitations to this study. First, our results are from a single Medicaid MCO from one US state, so our results may not be generalizable to the Medicaid FFS population or other Medicaid managed care populations. Second, information on PCP availability, after-office PCP clinic hours, residence to PCP office distance, and residence to closest ED distance was not available. These provider-related factors may confound our results on health care utilization. Third, pediatric beneficiary-level information on parents’ educational status, parents’ childcare needs, and time off from work for sick care was not available. Lack of these beneficiary-level information may over- or underestimate our results. Fourth, the study had a cross-sectional design; hence, causality between neighborhood opportunity and health care utilization cannot be inferred. However, this is the first study to the best of our knowledge that examines neighborhood opportunity and pediatric Medicaid managed care beneficiaries’ health care utilization and discusses opportunities for managed care. Fifth, in our analysis, we considered the outcomes of PCP visits and hospitalizations as categorical variables. Beneficiaries who had only 1 PCP visit or hospitalization vs those who had 2 or more may differ on continuity of care with their PCP, thus underestimating beneficiaries’ primary care utilization and continuity of care. Sixth, the study team did not have access to risk scores such as the combined Chronic Illness and Disability Payment System and Medicaid Rx risk-assessment model³⁴ and the Chronic Conditions Data Warehouse algorithm,³⁵ which may provide better risk adjustment for beneficiaries’ health conditions than the Pediatric Medical Complexity Algorithm.

CONCLUSIONS

Our study findings underscore differences in health care utilization that require further investigation from researchers, policy analysts, and decision makers to assess any underlying unmet needs in lower-opportunity neighborhoods. Medicaid MCOs can use the COI to segment their populations to analyze pediatric health care utilization, address HRSN, and tackle issues related to minority health care. Our results suggest that Medicaid MCOs have unique opportunities to address health care access and utilization through targeted interventions in lower-opportunity neighborhoods. The findings provide empirical evidence identifying communities that require both policy-level and community-based health care interventions to support child health and overall well-being in the context of Medicaid managed care. Future research should explore VBP models in primary care; the impact of multistakeholder collaborations that include MCOs partnering with providers, community-based organizations, and state Medicaid agencies; and the role of financial investments in low-opportunity neighborhoods. 

Author Affiliations: Research, Development, and Analytics Department, Highmark Health (SA, AO), Pittsburgh, PA; Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham (HQ), Birmingham, AL.

Source of Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Prior Presentation: A version of the study was presented as a poster at the 2025 Medicaid Health Plans of America Annual Conference. Findings included that majority of the Medicaid managed care beneficiaries resided in low-opportunity neighborhoods and were more likely to have more emergency department visits and fewer primary care physician visits.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SA, AO); acquisition of data (SA); analysis and interpretation of data (SA, HQ); drafting of the manuscript (SA, AO, HQ); critical revision of the manuscript for important intellectual content (SA, AO, HQ); statistical analysis (SA); and administrative, technical, or logistic support (SA, AO).

Address Correspondence to: Shamly Austin, PhD, MHA, Highmark Health, 501 Penn Ave, Pittsburgh, PA 15222. Email: shamly.austin@highmark.com.

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