Coverage & Access
Call for Papers
The Uninsured
Chair: Kenneth Thorpe, Ph.D.
Sunday, June 6 • 11:30 a.m.-1:00 p.m.
• Case Management of Uninsured Emergency Department
Patients: Results from an Economic Analysis of a
Randomized Controlled Trial
Susan Busch, Ph.D., Sarah Horwitz, Ph.D., Katie Balestracci,
Ph.D., Jim Rawlings, M.P.H.
Presented by: Susan Busch, Ph.D., Assistant Professor,
Health Policy, Yale Medical School, 60 College Street, New
Haven, CT 06520; Tel: 203.785.2927; Fax: 203.785.6287; E-mail:
susan.busch@yale.edu
Research Objective: To determine the economic costs and
benefits of an intensive case management intervention.
Study Design: Data comes from a randomized controlled trial
which recruited patients visiting the Yale-New Haven Hospital
ED during the period 4/22/02 to 7/21/02. Two hundred thirty
six patients (123 intervention, 113 comparison) were enrolled.
On intervention shifts all patients > 18 years who had no
insurance and no primary care provider were recruited into the
study. The patient was assisted in choosing one of 4 health
care providers and the patient’s contact information was faxed
to the case manager at the selected site. The case managers
attempted to contact intervention patients within 72 hours.
On comparison shifts care as usual took place. All
comparison patients left the ED with a physician’s
recommendation for follow up and an appropriate number to
call.
Population Studied: Uninsured Patients visiting the Yale-New
Haven Hospital Emergency Department
Principal Findings: In the six months post intervention, the
intervention group had more primary care contacts, fewer
inpatient admissions, but similar numbers of ED visits
(Horwitz et al, 2003). Examining the economic implications
of these changes we find that although total ED costs were
similar in two groups, the net cost per ED visit was lower in
the intervention group compared to the comparison group
($245 versus $312), suggesting these visits involved less
intense care. Further, examining the per person net hospital
costs for both groups, the intervention group was less
expensive ($63 versus $242, p=.09). Although hospital costs
were reduced, case management costs were substantial ($233
per intervention subject).
Conclusions: An ED referral/intensive case management
intervention can result in reduced patient care costs.
Although the number of subsequent ED visits is similar in
both groups, the intensity of these visits is less for the
intervention subjects. Net inpatient costs were substantially
reduced in the intervention group. Thus, this intervention has
the potential to reduce health care costs. The short and long
term effects on health have yet to be analyzed, but may be
substantial.
Implications for Policy, Delivery or Practice: Increases in
the number of uninsured in the US coupled with the shrinking
number of safety net providers have combined to make
Emergency Departments (EDs) the care provider for
increasing numbers of adults. ED care is expensive, often
overly invasive and rarely able to attend to prevention. The
economic benefits of case management interventions
designed to establish medical homes for uninsured
individuals visiting the ED have not been rigorously evaluated.
This study provides evidence that hospitals and others can
use to assess the feasibility of these programs.
Primary Funding Source: HRSA
• The Pent-up Demand for Health Care of the Uninsured
Near Elderly When They Are Approaching Age 65
Li-Wu Chen, Ph.D., Wanqing Zhang, M.Ed., Phani Tej Adidam,
Ph.D., Louis Pol, Ph.D., Keith Mueller, Ph.D., Dennis Shea,
Ph.D.
Presented by: Li-Wu Chen, Ph.D., Assistant Professor,
Preventive and Societal Medicine, University of Nebraska
Medical Center, 984350 Nebraska Medical Center, Omaha, NE
68198-4350; Tel: 402.559.7113; Fax: 402.559.7259; E-mail:
liwuchen@unmc.edu
Research Objective: To examine whether the pent-up
demand for health care utilization exists for the uninsured
near elderly who are approaching age 65, at which they will be
eligible for Medicare enrollment.
Study Design: Using a difference-in-difference model and
logistic regression approach, we estimated and compared the
likelihood of increasing physician visits and hospital inpatient
stay from pre-Medicare period (i.e.,ages 63-65)to postMedicare period (i.e.,ages 65-67) between the uninsured near
elderly and the insured near elderly. In addition, to address the
possible self-selection bias related to the purchase of
insurance, we tested whether the endogeneity of insurance
coverage may exist for the observed insurance status variable
at age 63.
Population Studied: A sample of 640 near elderly people
were obtained from Wave 1 to Wave 5 of the Health and
Retirement Study (HRS). Longitudinal information related to
health care use, insurance coverage, demographic, socioeconomic,health status, and life style of the study sample was
used in the regression analysis.
Principal Findings: Being uninsured (as opposed to being
insured) at age 63 increases the likelihood of using 200%
more or above of physician care after Medicare enrollment.
On the other hand, being uninsured at age 63 does not
increase the likelihood of using increasing hospital inpatient
care after Medicare enrollment.
Conclusions: Pent-up demand for physician care exists for the
uninsured near elderly as compared with their insured
counterparts. However, such phenomenon does not exist for
the hospital inpatient care of the near elderly. One possible
reason for this discrepancy may be that hospital inpatient
care, in nature, is more acute and urgent when it is needed,
thus reducing the chance of postponing care until the near
elderly are covered by Medicare.
Implications for Policy, Delivery or Practice: The delay in
receiving physician care of the uninsured near elderly until
they are covered by Medicare may impose a significant
financial burden on Medicare program. With the possibility of
developing a worsening health condition due to the
postponement of care, the financial burden may become even
larger in the long run when these previously uninsured
Medicare beneficiaries are aging. Therefore, providing
insurance coverage to the uninsured near elderly, especially
those underserved people, should be a critical issue to
consider when designing Medicare reform policies.
Primary Funding Source: Economic Research Initiative on
the Uninsured
• The Accessibility of Specialty Care for California's
Uninsured
Suzanne Felt-Lisk, M.P.A., Megan McHugh, M.P.P., Melissa
Thomas, M.A.
Presented by: Suzanne Felt-Lisk, M.P.A., Sr. Health
Researcher, Mathematica Policy Research, 600 Maryland
Avenue, S.W., Suite 550, Washington, DC 20024; Tel:
202.484.4519; Fax: 202.863.1763; E-mail: SfeltLisk@Mathematica-mpr.com
Research Objective: Many studies of the safety net have
identified specialty care access as a major problem, but
knowledge of the extent and nature of this problem has been
limited. The objective of this study was to better understand
the accessibility of specialty care for the uninsured in
California, where they obtain specialty care, and how and why
access varies across communities.
Study Design: (1) Survey of all 101 FQHC medical directors in
California regarding access to specialty care for uninsured
patients across different specialties and where they refer
patients for specialty care (response rate 76%); (2) survey of
hospital outpatient department directors (from hospitals
identified as referral organizations by the FQHC medical
directors) regarding hospital policies for serving uninsured
patients, wait times for appointments, and motivations for
providing charity care (response rate 48%); and (3) case
studies of four communities to identify barriers to care and
learn why some communities are better able than others to
meet the demand for specialty care from the uninsured; these
included focus groups in each community with uninsured
patients who have needed specialty care.
Population Studied: Uninsured FQHC patients in California
needing specialty care and the organizations that provide care
to those patients.
Principal Findings: Access problems for uninsured FQHC
patients extend across a wide range of specialties, and are
worse for adults than for children. Obtaining specialty care
appointments typically requires time-intensive case-by-case
efforts by primary care providers, adding cost to the safety net
system. Hospitals are the major source of specialty care for
uninsured FQHC patients; about half of those hospitals
named by FQHC medical directors as key referral destinations
focus their business on low-income populations and about
half do not. In the case study communities, weak
relationships between FQHCs and hospitals; lack of
community support; having a large, geographically dispersed
uninsured population; and having shortages of physician
specialists were identified as barriers to access. Community
efforts to address the problems include providing selected
specialty services at the FQHCs, and covering more uninsured
children through county-based programs.
Conclusions: Access to specialty care is a major problem for
uninsured Californians, particularly adults. Community efforts
to address the problems seem poised to “chip away” at them
but leave major gaps.
Implications for Policy, Delivery or Practice: If it could be
captured, the cost of time providers spend arranging specialty
care for uninsured patients now could help offset the cost of
standing formal referral arrangements or insurance coverage.
Efforts to expand insurance coverage could have the added
benefit of making it easier for the remaining uninsured to
access care since providers appear to be more willing to
provide charity care when the size of the uninsured population
is small. State and federal funding streams that support
uncompensated care are policy levers that could be fine-tuned
to better counteract lack of community support for
improvement at the local level.
Primary Funding Source: California Healthcare Foundation
• The Effect of Employment-Based Health Insurance on
Wages and Returns to Tenure: Evidence that High- and
Low-Wage Workers Differ
Patricia Ketsche, Ph.D., M.H.A., William Custer, Ph.D.
Presented by: Patricia Ketsche, Ph.D., M.H.A., Assistant
Professor, Institute of Health Administration, Georgia State
University, 33 Gilmer Street, S.E., Unit 4, (MSC 4A1473),
Atlanta, GA 30303-3084; Tel: 404.651.2993; Fax: 404.651.1230;
E-mail: pketsche@gsu.edu
Research Objective: Employment-based insurance is credited
with spreading risks but has been criticized because it limits
choice of plans for most workers and fails to cover a large
number of Americans. The extent to which risks are actually
pooled depends upon how individual wages adjust for the
costs of health insurance. These compensating differentials
could undermine risk pooling if individual workers experience
substantial wage penalties based on health risk. This paper
contributes to the limited literature by demonstrating that
adjustments to wages differ for different groups of workers.
Study Design: Data are from the March CPS combined with
the February Job Tenure and Occupation Mobility
Supplements from 1996 and 1998. These data permit analysis
of worker salary controlling for specific job tenure. Like other
researchers we estimate the effect of coverage on wages using
a dummy variable for the presence of health insurance.
However, given that demand for health insurance is heavily
dependent upon income and that low-wage workers face a
different after tax price for coverage, analysis is performed
separately for workers with wages above- and below the
median for their geographic area.
We first estimate the effect of coverage on wages and the
differential effect of coverage on returns to tenure using a
reduced form. We compare these results to a two part model
that estimates the probability of coverage among workers as a
function of worker demographic and firm characteristics. This
estimated probability is used in a wage regression that
includes variables that reflect individual productivity and firm
characteristics. Identification is achieved through inclusion of
state policy variables that are likely to have a strong effect on
the price of coverage such as community rating requirements,
guaranteed issue laws and the presence of risk pools in the
coverage equation. Finally we estimate coverage and wages
in a nonlinear OLS simultaneous equation model.
Principal Findings: In each of the models estimated, wage
adjustments for coverage and effect of coverage on returns to
tenure are different in sign for high- and low-wage earners.
Low wage workers with coverage experience increased wages
but negative returns to tenure. Among workers with wages
above the median, coverage depresses or has no effect on
wages, depending upon model specification, but increases
returns to tenure.
Conclusions: In the short run, high-income workers with
health insurance may bear a larger share of the cost of that
coverage than do low-income workers with health insurance.
However, the effect of coverage on worker retention may be
different for high- and low-wage workers, with low-wage
workers with coverage experiencing a greater degree of “joblock”.
Implications for Policy, Delivery or Practice: If high-wage
workers value coverage sufficiently to bear a greater share of
the cost in terms of wage reductions, social welfare is affected
by expanding coverage to those who otherwise might not
purchase coverage. However, low-wage workers who value
coverage may bear the cost of coverage through a reduction in
wage increases associated with tenure.
• The Demise of Oregon’s Medically Needy Program:
Effects of Losing Prescription Drug Coverage and
Pharmaceutical Company Drug Assistance Programs
Judy Zerzan, M.D., M.P.H., Tina Edlund, M.S.
Presented by: Judy Zerzan, M.D., M.P.H., Assistant Professor,
Internal Medicine, Oregon Health & Science University, 3181
S.W. Sam Jackson Park Road, OP30, Portland, OR 97239; Tel:
503.768.9106; E-mail: zerzanj@ohsu.edu
Research Objective: In January 2003, people covered by
Oregon’s Medically Needy (MN) program lost their benefits
due to financial shortfalls in the state budget. The MN
program is a federally-matched optional Medicaid program in
which states may chose to provide Medicaid coverage and/or
Medicare premium assistance to certain groups not otherwise
eligible for Medicaid with significant health care needs. This
population is not well characterized either nationally or locally.
In Oregon the MN program mainly provided a prescription
drug benefit. The primary objective was to determine how the
loss of benefits has affected this population's health.
Secondary objectives include investigating how this
population is getting their prescription medications and
changes in use of prescriptions and health care. Most
pharmaceutical manufacturers offer some of their medications
free for low-income people through drug company assistance
programs. These programs vary widely in the application
process, drugs available and amount of drug supplied. After
the loss of the MN program, many turned to drug company
programs to obtain needed medications. This survey also
provides information about use of these programs in this
population.
Study Design: A 49-question survey instrument was created
to collect information about this population including
demographic information, health insurance coverage, health
conditions, access to care, prescription drug use, utilization of
health care, and use of drug company assistance programs. A
data collection contractor telephoned a sample of this
population obtaining an overall completion rate of 58%.
Medication use during the MN program was obtained from
administrative data and current medication use was obtained
from the interview. Results of this survey were compared to
the Medicare Health Outcomes Survey and the National
Health Interview Survey.
Principal Findings: The 439 people surveyed included 36%
men and 64 % women from age 21-91 with 70-75% at less
than 133% of the federal poverty level. 2/3 of respondents rate
their current health as poor or fair and compared to last year
44% rate their health as worse and 39% about the same. Only
7.5% currently have prescription coverage. In the six months
since the MN program ended 61% have skipped doses of a
medication and 64% have gone without filling a prescription.
In order to pay for medications 60% of respondents have cut
back on their food budget, 47% have borrowed money and
49% have skipped paying other bills. There was no significant
difference in ER visits and a small statistically significant
decrease in hospitalizations by self-report comparing the six
months before losing the MN program and the six months
after. Over half of respondents are aware of drug company
assistance programs and currently 45% of those surveyed use
these programs with most getting application assistance from
a doctor’s office or clinic. 55% of people report using these
programs is hard and 37% find it easy. Only 12% of
respondents are very confident they can continue to use these
programs, 27% are somewhat confident, and 52% are not at
all or not very confident. 82% of people currently using these
programs are only obtaining some of their drugs from this
source because not all of their prescribed drugs are available.
Drug use has shifted to more name brand drugs since these
programs provide newer medications. Of the 55% who are not
currently using drug company assistance programs, most
have applied before or used these programs in the past.
Conclusions: The MN program provided coverage for a lowincome, chronically ill population. Since its termination, there
have been significant changes in prescription drug use and
financial impact in their daily lives. This population is sicker
with worse perceived health status than the general
population over 65 and people eligible for both Medicare and
Medicaid. As states make program changes, the effects on
vulnerable populations must be considered. Losing
prescription coverage has immediate impact on use of
prescriptions and finances in this population. Drug company
assistance programs are one way for people to obtain needed
medications. About half of the MN population is now using
drug company prescription assistance programs, but this
does not appear to be a sustainable mechanism for obtaining
prescription medications because it can be difficult to apply
and not all medications are covered. With these programs
people are using more brand name medications instead of
generics which may have implications for shifting future
prescription use.
Primary Funding Source: Oregon Health Policy & Research
via a RWJ State Coverage Initiatives Grant
Call for Papers
Health Insurance Changes
Chair: Thomas Buchmueller, Ph.D.
Sunday, June 6 • 3:00 p.m.-4:30 p.m.
• Effects of an Economic Boom on Health Insurance
Status
Linda Blumberg, Ph.D., Lisa Dubay, Sc.M.
Presented by: Linda Blumberg, Ph.D., Senior Research
Associate, Health Policy Center, The Urban Institute, 2100 M
Street, N.W., Washington, DC 20037; Tel: 202.261.5769; Fax:
202.223.1149; E-mail: lblumber@ui.urban.org
Research Objective: This study assesses the effects of an
economic boom on the health insurance coverage of modest
income adults using the 1996 Survey of Income and Program
Participation (SIPP). Our objective is to identify whether those
whose incomes rose substantially over the period also
benefited by gaining health insurance, or whether their
coverage status was not affected significantly compared to
those whose incomes were more stable.
Study Design: Using a multivariate framework, we contrast
observed changes in coverage over the course of the panel for
adults who benefited from the economic expansion (those in
families with significant increases in income between the first
and last waves of the SIPP panel) with those for adults who
did not benefit from the expansion. The specification of the
multivariate models will take the form shown below:
Probability(coverageiL = µ | coverageiF = unins) = a1 + a2
boomi + a3 individuali + a4 familyi + a5 regioni,
where coverageiL = person i’s insurance coverage (private
coverage, SCHIP coverage, or
uninsurance) at the last
wave of the survey; coverageiL = person i’s insurance coverage
(private coverage, SCHIP coverage, or uninsurance) at the last
wave of the survey; boomi = indicator for whether the
individual is a non-elderly adult whose family income
increased significantly between the 1st and last waves of the
panel -- this is our key explanatory variable; individuali = vector
of variables describing the characteristics of the individual
(e.g., race, gender, health status , age); familyi = vector of
explanatory variables depicting characteristics of the
individual’s family (e.g., family type, number of working adults
in the unit, family income in first wave, education of the high
earner); regioni = vector of indicators for the region of
residence.
For example, a positive and significant coefficient on "Boom"
in a regression where last wave coverage is private, implies
that the those uninsured adults affected monetarily by the
economic boom were more likely than their counterparts who
were not directly affected to gain private insurance coverage.
In other words, the boom not only increased incomes, it also
increased private insurance coverage.
We will also identify, descriptively, the characteristics of those
with large income gains who remain uninsured. We will
assess how they differ from those whose incomes increased
but who also gained coverage. We will describe the
characteristics of those who gained coverage but whose
incomes did not increase during the period.
Population Studied: We use a sample of non-elderly adults
with first survey wave family incomes at or below 300 percent
of poverty, focusing on those adults who were uninsured at
the first interview.
Principal Findings: Analysis has not yet been completed.
Conclusions: Pending completion of the analysis.
Implications for Policy, Delivery or Practice: Studying the
effects of an economic boom not only gives us insight into
whether such economic cycles benefit particular types of
individuals, but it also assists us in understanding the
potential ramifications of the reverse situation – an economic
recession. If an economic boom significantly increases
coverage among those who benefit most directly from it, one
could also reasonably expect that a contraction of the
economy would lead to a decline in coverage for those
affected.
Primary Funding Source: RWJF, The Urban Institute
• Increasing Health Insurance Premiums and the Decline
in Insurance Coverage
Michael Chernew, Ph.D., David Cutler, Ph.D., Patricia Keenan,
M.H.S.
Presented by: Michael Chernew, Ph.D., Associate Professor,
University of Michigan School of Public Health, Department of
Health Management and Policy, 109 S. Observatory Street,
Ann Arbor, MI 48109-2029; Tel: 734.936.1193; Fax:
734.764.4338; E-mail: ggbz@umich.edu
Research Objective: This paper examines the determinants of
declining insurance coverage during the 1990s, with a focus
on the role of rising health care premiums, relative to other
explanations such as changes in employment patterns or state
policies. In contrast to substantial media coverage linking
rising premiums to declines in coverage rates, empirical
evidence quantifying the extent to which higher premiums
deter coverage is limited.
Study Design: We take advantage of wide geographic
variation in changes in premiums and coverage rates to
estimate the association between rising local health insurance
costs and the falling propensity for individuals to have any
health insurance coverage. We focus on coverage from any
source (private or public), because some individuals may
switch their source of coverage rather than become uninsured.
Using probit regression models and instrumental variable
techniques, we analyze changes in coverage between two
periods, 1989-1991 and 1998-2000, using the March Current
Population Survey (CPS). We estimate the impact of changing
health care costs, tax subsidies, Medicaid reforms, other state
regulatory reforms, a rise in spousal employment and general
economic conditions on declining coverage, controlling for
changes in population demographics. Our contributions,
relative to the existing literature, include more detailed
controls for non-premium explanations for declining coverage,
focus on any coverage (as opposed to employer sponsored
coverage), use of geographic variation in cost growth (as
opposed to national trends in cost growth that may be
confounded by other factors), a broader measure of health
care costs, and recognition of the endogeneity of cost growth.
Population Studied: The non-elderly population of the United
States residing in 64 MSAs.
Principal Findings: Over half of the decline in coverage rates
experienced over the 1990s is attributable to the increase in
health insurance premiums (1.6 percentage points of the 3.1
percentage point decline). Medicaid expansions led to a 1
percentage point increase in coverage. Changes in economic
and demographic factors had little net effect. Effects of rising
premiums on coverage declines are greater for individuals in
families with lower as opposed to higher education, and for
younger as opposed to older adults.
Conclusions: As other studies have found, changing
demographics and employment patterns explain little of the
decline in coverage. Instead, much of the decline in coverage
over the 1990s appears to be related to the rise in health care
premiums.
Implications for Policy, Delivery or Practice: The uninsured
population is likely to increase further if health care cost
growth continues to exceed income growth. Initiatives aimed
at reducing the number of uninsured must confront the
growing pressure on coverage rates generated by rising costs.
At the same time, while policy has traditionally focused on the
need to limit the growth of costs, this may not be desirable if
medical cost increases are buying valuable services. A careful
examination of how to encourage optimal design of insurance
policies and delivery of medical care is warranted.
Primary Funding Source: RWJF, RWJF's Economic Research
Initiative on the Uninsured, National Institute on Aging
• The Response of Small Business to Variation in the Price
of Insurance: Results from a Randomized Controlled Trial
Richard Kronick, Ph.D., Louis Olsen, Ph.D., Todd Gilmer,
Ph.D.
Presented by: Richard Kronick, Ph.D., Professor, Department
of Family and Preventive Medicine, University of California,
San Diego, UCSD School of Medicine, 9500 Gilman Drive, La
Jolla, CA 92093-0622; Tel: 858.534.4273; Fax: 858 534.4642; Email: rkronick@ucsd.edu
Research Objective: To determine what fraction of small
businesses that do not currently offer insurance would
purchase coverage when offered a 50% premium subsidy, and
how that fraction varies as the subsidy is varied between 20%
and 80% of premium.
Study Design: A randomized trial conducted in San Diego.
Businesses were sampled from a Dun&Bradstreet listing of
small businesses, and randomized into 25 treatment groups.
Each group was offered Sharp Health Plan, a San Diego-based
HMO, and the price to employers and employees was
experimentally varied. Subsidies for the difference between
the full premium and the price offered the business were
provided by the California HealthCare Foundation.
Population Studied: Small businesses and their employees in
San Diego.
Principal Findings: Subsidized coverage was offered to 345
businesses that were eligible to purchase, and 71 of these
businesses bought the product. The average subsidy was
approximately 50% of premium; thus, at a subsidy of 50% of
premium, approximately 20% of businesses purchased. As
the subsidy was varied from 20% to 80% of premium, the
percent purchasing varied from 10% to 40%.
Conclusions: Small businesses that do not currently offer
insurance are not very responsive to variations in the price of
coverage. Even at an 80% subsidy, only 40% of businesses
purchase coverage. It appears that many businesses operate
satisfactorily without offering coverage, and are unlikely to
start offering even when offered very large subsidies.
Implications for Policy, Delivery or Practice: Increasing
insurance coverage by offering subsidized coverage to small
businesses is not likely to be effective in significantly reducing
the number of uninsured.
Primary Funding Source: California HealthCare Foundation
• Uninsured Decliners of Employer Sponsored Health
Insurance: How They Changed from 1997-2003
Peter Cunningham, Ph.D., Len Nichols, Ph.D., Len Nichols,
Ph.D.
Presented by: Len Nichols, Ph.D., Vice President, , Center for
Studying Health System Change, 600 Maryland Avenue, S.W.,
Washington, DC 20024; Tel: 202.484.5269; Fax: 202.484.9258;
E-mail: lnichols@hschange.org
Research Objective: To assess if more or different people
need subsidies to purchase insurance than in the mid-1990s.
Prior work showed about 20% of the uninsured declined an
offer of employer sponsored insurance (ESI). If workers,
especially higher income workers, are increasingly likely to
decline offers, then proposals to expand coverage could
benefit from current data and analysis, especially in this
election year. The 4th round of the Community Tracking
Household Survey will be completed in January of 2004, with
weighted analysis files ready by March, in time to produce
reliable analyses by June. This survey and study can yield
nationally representative estimates of coverage, offer, take-up,
access to care, individual, family and job characteristics for
calendar 2003, as well as support a multivariate model
explaining the decision to accept or decline ESI.
Study Design: Data are based on the 1996-97 and the 2003
Community Tracking Study household surveys, both of which
are representative of the nation as well as of 60 randomly
selected sites. We initially present descriptive results
comparing 1996-97 with 2003 data to test if the likelihood of
declining ESI and remaining uninsured increased and if so, for
whom. We are able to study decisions made by workers in
families with more than one ESI offer, which is increasingly
common in a workforce dominated by two-earner couples.
Next we develop a multivariate model of ESI take-up using
both survey years to test if the likelihood of declining has
increased and if so, why and/or for whom.
Population Studied: The civilian non-elderly population of the
United States, with particular emphasis on worker decisions,
but with family members accounted for and tracked as well.
Principal Findings: Previous studies and preliminary analysis
of 1996-97 and 2000-01 data indicate that take-up rates
declined for the lower income population, and that lower
income, younger, and somewhat less healthy workers and
their family members are more likely to decline ESI and
remain uninsured. The 2003 CTS survey just completed will
be the first to be conducted with weaker labor markets. With
higher premiums, larger employee premium shares, and
sharply higher co-payments at the point of service in recent
years, we hypothesize and will test whether the average
income of decliners has risen since 1996-97 while controlling
for all other relevant factors, including the availability of SCHIP
coverage for any children in the household.
Conclusions: Depend on findings, to be determined.
Implications for Policy, Delivery or Practice: If declining ESI
is no more likely in 2003 than in 1996-97, then the relative
importance of income-based subsidies for private group
insurance is unchanged as well. But if indeed rising health
care costs have increased the likelihood and income levels of
decliners who remain uninsured, then policy makers may reconsider the wisdom of policy proposals that only subsidize
those without ESI offers. Our study could improve the design
and effectiveness of any coverage expansion proposal by
indicating which populations should be targeted most directly.
Primary Funding Source: RWJF
Call for Papers
Effects of Cost-Sharing & Reimbursement
Chair: Willard Manning, Ph.D.
Monday, June 6 • 8:30 a.m.-10:00 a.m.
• A Medicaid Buy-in Program’s Effects on Costs and
Earnings
Robin Clark, Ph.D., Karin Swain, M.S., William Peacock, M.S.
Presented by: Robin Clark, Ph.D., Associate Professor, Center
for Health Policy and Research, University of Massachusetts
Medical School, 222 Maple Avenue, Chang Building,
Shrewsbury, MA 01545; Tel: 508.856.4226; E-mail:
robin.clark@umassmed.edu
Research Objective: To evaluate New Hampshire’s Medicaid
for Employed Adults with Disabilities (MEAD) program, a
“buy-in” program which allows persons with disabilities to
maintain Medicaid coverage after their earnings exceed typical
maximum amounts. Almost half of all states have a Medicaid
buy-in program in place for persons with disabilities and
others are in the early stages of implementation.
Study Design: We measured changes in Medicaid payments,
disability determination costs, earnings and total income for
the 985 persons who enrolled during the first year of the
program. Changes in provider payments and other state costs
were compared to those for a similar group of 1,000 Medicaid
beneficiaries who did not enroll in the program.
Population Studied: All New Hampshire Medicaid
beneficiaries enrolled in MEAD at any time between February
1, 2001 and January 31, 2002 were included in the evaluation.
In addition, a group of persons with disabilities matched with
MEAD participants on gender, types of medical diagnoses,
age and community residence were selected for purposes of
comparison. MEAD participants averaged 43 years of age and
were equally divided by gender. More than one-third had a
severe psychiatric disorder.
Principal Findings: Average monthly income for MEAD
participants increased by $218 after enrollment. More than
84% ($184) of the gain came from additional earnings, which
increased from $292 to $476 per month. The total earnings
increase for MEAD participants from the year before to the
year following enrollment was approximately $1.4 million.
Despite higher than expected enrollment during the first year,
preliminary analyses show MEAD cost the state less than onethird of the $1,353,441 predicted in a prior fiscal impact study.
The actual net state cost of MEAD was $435,950. The
difference between actual and predicted costs was primarily
due to lower than expected Medicaid payments for
participants without prior Medicaid coverage and smaller than
expected increases in payments for beneficiaries previously
classified as medically needy. Provider payments for MEAD
participants with prior Medicaid enrollment increased at a
slightly higher rate than those for comparison group
members.
MEAD participants generated $3.28 in new earnings for each
additional state dollar invested in the program.
Conclusions: These findings suggest that many persons with
disabilities can increase earnings significantly if the fear of
losing health insurance coverage is removed. Further,
additional state costs associated with the program were
modest compared with benefits realized by participants.
Implications for Policy, Delivery or Practice: Although
further research in a variety of settings is needed to confirm
the generalizability of these findings, Medicaid buy-in
programs show significant promise as a way of increasing
employment and earnings for persons with disabilities at
relatively low cost. Many states currently have options similar
to New Hampshire’s MEAD program or are planning to
implement them. The long-term effects on participants
personal and financial health remain to be studied as do costs
for local, state and federal government. Additional work is also
necessary to understand better the characteristics of persons
who benefit most from buy-in programs and the additional
supports that may be necessary to sustain gains in
employment.
Primary Funding Source: CMS
• The Effects of Medicaid Reimbursement on Access to
Care of Medicaid Enrollees: A Community Perspective
Peter Cunningham, Ph.D., Len Nichols, Ph.D.
Presented by: Peter Cunningham, Ph.D., Senior Health
Research, Center for Studying Health System Change, 600
Maryland Avenue, S.W., Washington, DC 20024; Tel:
202.484.4242; Fax: 202.484.9258; E-mail:
pcunningham@hschange.org
Research Objective: Previous research has found that while
higher Medicaid reimbursement levels increase physicians’
acceptance of Medicaid patients, reimbursement levels have
little direct effect on access to care as reported by Medicaid
enrollees. This research takes a community perspective, and
examines the extent to which Medicaid fee levels and other
local factors affect enrollee access indirectly by influencing the
supply of physicians in a community who are willing to accept
Medicaid patients.
Study Design: Data are based on the 2000-01 Community
Tracking Study physician and household surveys, both of
which are representative of the nation as well as for 60
randomly selected sites. The survey data are supplemented by
state-level data on Medicaid reimbursement levels. Using
multivariate analysis from the physician survey data, we first
examine the effects of varying Medicaid fee levels on whether
physicians’ practices are open to new Medicaid patients. We
then examine the effects of fee levels and the relative number
of physicians accepting Medicaid patients (measured at the
site-level) on measures of access to care for Medicaid
enrollees, using the CTS household survey. Measures of
access to care include usual source of care, use of outpatient
physician and hospital care, and self-reported difficulties in
getting needed medical care.
Population Studied: U.S. physicians involved in patient care,
and Medicaid enrollees.
Principal Findings: The relative number of physicians who
accept Medicaid patients varies considerably across
communities. Multivariate analysis shows that variation in
Medicaid reimbursement levels across states contributes to
community variations in physicians’ willingness to accept
Medicaid patients, but that many other factors are also
important. These include the mix of practice type and
specialty in a community, population characteristics, Medicaid
managed care penetration, insurance rate in the community,
and geographic area. As a consequence, Medicaid
reimbursement levels have little direct effect on access to care
as reported by Medicaid enrollees. Rather, reimbursement
levels have an indirect effect insofar as they influence (but do
not determine) the relative number of physicians in a
community that accept Medicaid patients. Findings show
that Medicaid beneficiaries in communities with a relatively
high number of physicians accepting Medicaid patients are
more likely to have a usual source of care, less likely to have
difficulty getting medical care, and have fewer hospitalizations.
Conclusions: Medicaid fee levels are just one of many factors
that determine the “supply” of physicians in a community
willing to accept Medicaid patients. For Medicaid enrollees, it
is the availability of physicians who accept Medicaid
patients—and not fee levels per se—that affect their access to
care. Therefore, the effects of Medicaid reimbursement on
enrollee access are indirect, and other market factors may
outweigh fee levels in determining access to medical
providers.
Implications for Policy, Delivery or Practice: Rapidly
escalating Medicaid costs are contributing to state budgetary
pressures and deficits, which has led most states to adopt a
variety of cost-containment strategies for their Medicaid
program, including cuts in fees to providers. The results of
this study suggest that such cuts are not as cost-free with
respect to enrollee access as previous research implies.
However, modest provider payment cuts may be less harmful
to beneficiary access than other cost-containment strategies,
such as a reduction in eligibility or benefits.
Primary Funding Source: RWJF
populations: one with commercial and one with Medicare
insurance. We compared the relative rates of deaths using
Cox-regression and hospitalizations, ICU admissions, and ED
visits using a poisson mixed-effects model applied to monthly
utilization counts, while adjusting for covariates. For subjects
with commercial insurance, we classified ED copayments into
five categories: free care or no copayment, $1–9, $10–19, $20–
35, and $50–100 per ED visit. For Medicare subjects, we
classified ED copayments into three categories: free care or no
copayment, $1-15, and $20-50 per ED visit.
Population Studied: There were 2,257,445 subjects with
commercial insurance and 261,091 subjects with Medicare
insurance at the beginning of the study. At baseline, 23.4% of
commercial subjects paid nothing for each ED visit; 34.8%
paid $1-5; 22.8% paid $10-15; 13.6% paid $20-35; and 5.4%
paid $50-100. Similarly, 24.9% of Medicare subjects paid
nothing per visit; 70.7% paid $1-15; and 2.5% paid $20-50. In
January 2000, 52.1% of the commercial subjects and 60.8% of
the Medicare subjects experienced an increase in their
copayment level.
Principal Findings: In subjects with commercial insurance,
there were reductions in ED visits of 12% with the $20-35
copayment (RR=0.88, 95% CI: 0.87–0.89), and 23% with the
$50-100 copayment (RR=0.77, 95%CI: 0.76–0.77). Despite this
reduction in emergency care, there were no increases in the
rate of hospitalizations, ICU admissions, or deaths, e.g.
relative hospitalization rates of 0.96 (95%CI: 0.94 – 0.98) and
0.90 (95% CI: 0.87 – 0.93) with the $20-35 and $50-100 levels
respectively. In subjects with Medicare, there also were no
increases in adverse health outcomes, e.g. relative
hospitalization rate of 0.99 (95% CI: 0.97–1.02) with a $20-50
copayment. There also was a 4% reduction in ED visits
(RR=0.96, 95%CI: 0.94–0.97) with a $20-50 copayment.
Conclusions: Cost-sharing for emergency care appeared to
reduce use of the ED without leading to more adverse health
outcomes.
Implications for Policy, Delivery or Practice: Modest levels
(up to $50–100) of cost-sharing appear to be safe on average
for patients with Medicare or commercial insurance.
Additional research is needed to examine temporal trends in
cost-sharing effects and the impact of higher amounts of costsharing.
Primary Funding Source: AHRQ
• Cost-Sharing for Emergency Care – Is It Safe? Findings
on Health Outcomes from the Safety and Financial
Ramifications of ED Copayments (SAFE) Study
John Hsu, M.D., M.B.A., MSCE, Maggie Price, M.A., Richard
Brand, Ph.D., Bruce Fireman, M.A., Joseph Newhouse, Ph.D.,
Joseph Selby, M.D., M.P.H.
• Self-Reported Effects of Prescription Drug Cost-Sharing:
Decreased Adherence and Increased Financial Burden
Mary Reed, M.P.H., Vicki Fung, B.A., Bruce Fireman, M.A.,
John Hsu, M.D., M.B.A., M.S.CE
Presented by: John Hsu, M.D., M.B.A., MSCE, Division of
Research, Kaiser Permanente, 2000 Broadway, Oakland, CA
94612; Tel: 510.891.3601; Fax: 510.891.3606; E-mail:
jth@dor.kaiser.org
Research Objective: Despite the increasing use of patient
cost-sharing, limited information exists about its clinical
consequences. We examined the impact of cost-sharing for
emergency care on adverse health outcomes.
Study Design: In a large natural experiment, we examined the
effect of emergency department (ED) copayment levels on
adverse health outcomes between 1999-2001 for two
Presented by: Mary Reed, M.P.H., Division of Research,
Kaiser Permanente, 2000 Broadway, Oakland, CA 94612; Tel:
510.891.3808; Fax: 510.891.3606; E-mail: mer@dor.kaiser.org
Research Objective: We investigated patient knowledge of
their cost-sharing structure for prescription drugs and their
self-reported behavioral responses, including drug adherence.
Study Design: We conducted a cross-sectional telephoneinterview study among a random sample of adult integrated
delivery system (IDS) members, with over-sampling of
members age 65 years or older. Subjects reported how much
they paid per drug, whether they paid different amounts for
generic and brand-name drugs (tiers), and whether they had a
drug benefit cap. Subjects then reported whether their cost-
sharing amount affected their adherence to treatment (e.g.
taking less than prescribed, and not filling or refilling
prescriptions) or affected their behavior as a financial burden
(e.g. switching to a cheaper medication, borrowing money to
pay for medications).
Population Studied: The 926 subjects (response-rate=72%)
had a mean age of 67 years, tended to be female (57%), and to
have Medicare insurance (71%). In addition, 74% reported
White race; 44% reported having “excellent” or “very good”
health status; 67% reported less than a college-graduate
education; and 43% reported an annual household income of
less than $35,000.
Principal Findings: Among respondents, 94% reported
having any cost-sharing; 60% reported having tiered
copayments, and 31% reported having a benefit cap.
Comparing with actual benefits, 86% of subjects accurately
reported whether they had a cap or not; 75% were accurate
about having tiered copayments or not; 70% were accurate
about their generic copayment amount; and 44% were
accurate about their brand-name copayment amount. Overall,
11% of all subjects reported not taking their medications as
prescribed because of the cost. In multivariate logistic models,
subjects who perceived having a generic copayment of >$10
(OR 2.7, 95%CI:1.2-6.1), perceived having tiered copayments
(OR=2.3, 95% CI:1.2-4.4), or perceived having a cap (OR=1.9,
95% CI:1.1-3.5) were more likely to report being non-adherent,
as were patients who took more medications, and those who
had lower income. Furthermore, 20% of all subjects reported
that cost affected their behavior as a financial burden. In the
multivariate models, subjects who perceived having generic
copayments >$5 (OR=1.9, 95% CI:1.1-3.5), or tiered
copayments (OR=2.9, 95% CI:1.7-5.2) were significantly more
likely to report a financial burden-related behavior, as were
patients who took more medications, were <age 65, female,
married, or had lower income. In contrast, patients’ actual
copayment amount did not demonstrate any statistically
significantly association with either of the self-reported
behaviors.
Conclusions: Patients appeared to have general knowledge of
their cost-sharing structures, but less knowledge about the
specific amounts. Patients’ perceived level of cost-sharing
influenced whether the patients followed their prescription
drug regimen, and changed the way they obtained their
prescriptions.
Implications for Policy, Delivery or Practice: Patient
perceptions of their cost-sharing structure may strongly
influence their behavior, yet many patients do not know their
actual cost-sharing details. Moreover, some cost-sharing
structures such as tiered copayments appear to create barriers
to care, rather than shift resource use. Additional research is
needed on the clinical and economic ramifications of
prescription medication cost-sharing.
Primary Funding Source: AHRQ, Kaiser Foundation
Research Institute
• The Impact of Premiums on Wisconsin’s BadgerCare
Program
Nathan West, M.P.A., Norma Gavin, Ph.D., Jamie Chriqui,
Ph.D., Nancy Lenfestey, M.H.A.
Presented by: Nathan West, M.P.A., Research Health Analyst,
Division of Health Economics Research, RTI International,
3040 Cornwallis Road, Research Triangle Park, NC 27709; Tel:
919.541.6816; Fax: 919.990.8454; E-mail: nathanwest@rti.org
Research Objective: As states have expanded health
insurance coverage to uninsured, low–income children and
families through Medicaid waivers and the State Children’s
Health Insurance Programs (SCHIP), interest in beneficiary
cost sharing though monthly premiums has grown. Premiums
have both benefits and costs. While premiums make SCHIP
programs more like private insurance and may reduce the
social stigma sometimes associated with public programs,
critics argue that premiums can reduce participation, increase
churning and leave the uninsured without access to quality
health care. This paper investigates the effects that premiums
have had on program participation, enrollment patterns, and
health care experiences for enrollees of BadgerCare,
Wisconsin’s SCHIP program.
Study Design: Information on the impact of premiums on
participation was obtained from a computer-assisted
household telephone survey conducted with BadgerCare
families and eligible non-enrolled families, drawn from lists of
families with children participating in the National School
Lunch Program (NSLP) during the 2001/02 school year.
Information on disenrollment and reenrollment rates for
premium paying and non-premium paying BadgerCare
enrollees were estimated from administrative enrollment
records with Kaplan-Meier survival curves and Cox
proportional hazard models. Information on the reasons for
disenrollment among premium-paying families and on their
experiences following disenrollment was obtained from a mail
survey of premium-paying families with one or more members
who had disenrolled from BadgerCare in the first half of 2002.
Population Studied: BadgerCare participants whose family
incomes were 150 – 200% percent of the federal poverty level
(FPL) and therefore were required to pay monthly premiums
approximately 3 percent of their income.
Principal Findings: We found little evidence that premiums
significantly reduced program participation; only 10 percent
listed the premium amount being too high as a reason for not
enrolling. Furthermore, 83 percent of the premium-paying
families thought the premium amount was reasonable. We
found little to no evidence that premium payments increased
churning. In fact, because of the mandatory waiting period of
6 months for premium-paying families following
disenrollment, these families were more likely than other
BadgerCare families to delay reenrollment in the short term.
Premiums were a major reason for disenrollment.
Approximately 25 percent of disenrolled premium-paying
families noted problems paying the premiums. When these
families left the program most members experienced a period
of uninsurance for several months, and those that obtained
new coverage experienced a deterioration of access to health
care and had greater unmet health care needs.
Conclusions: BadgerCare’s modest premiums have not been
a major deterrent to program participation nor do they appear
to increase churning. However, a number of families had
difficulties paying the premium and subsequently left the
program, experiencing greater unmet needs.
Implications for Policy, Delivery or Practice: Because of the
adverse health care effects that can result, states should
consider temporary assistance programs for families who
have difficulties paying monthly premiums and are subject to
being involuntarily disenrolled from the program.
Primary Funding Source: CMS
Call for Papers
Access to Healthcare & Insurance
Chair: Joel Cantor, Sc.D.
Monday, June 7 • 10:30 a.m.-12:00 p.m.
• The Disabled and Access to Care in Managed Care
Teresa Coughlin, Sharon Long, Ph.D.
Presented by: Teresa Coughlin, Principal Research Associate,
Health Policy Center, Urban Institute, 2100 M Street, N.W.,
Washington, DC 20037; Tel: 202.261.5639; Fax: 202.223.1149;
E-mail: tcoughli@ui.urban.org
Research Objective: To gain an understanding of how the
disabled individuals fare under managed care.
Study Design: Using the 1997 to 2001 National Health
Interview Surveys as the principal data source, we examine
how managed care--relative to the more traditional fee-forservice reimbursement system—affects access to care and
use of medical services among disabled, non-aged adults. For
the analysis we focus on Medicaid beneficiaries and use a
variety of measures to define disability—such as SSI
enrollment or level of functional impairment. Employing a
difference-in-differences approach, we compare changes in
disabled Medicaid beneficiaries’ access and use in areas that
shifted from FFS to managed care between 1997 and 2001 to
changes in disabled Medicaid beneficiaries’ access and use in
areas that remained FFS or had Medicaid managed care
throughout the time interval. In making these comparisons,
multivariate modeling was used to control for health status,
individual and family characteristics. We also control for local
health care market characteristics such as number of
physicians and number of hospital beds in the counties. In
addition, we account for the strength of the local health care
safety net by including variables that measure county
unemployment and poverty rates. Our outcome measures
include emergency room use, number of inpatient care stays,
number of encounters with health care professionals, extent of
and reasons for unmet need, and presence and type of usual
source of care.
Population Studied: A national sample of disabled, non-aged
Medicaid beneficiaries.
Principal Findings: Preliminary findings suggest that
managed care has limited effects on access to and use of
health care among disabled Medicaid beneficiaries. For
example, we find no differences between the share of
managed care and FFS beneficiaries who had an encounter
with a health care professional. Similarly, we found no
evidence of a significant reduction in the proportion of
managed care and FFS beneficiaries who had had a hospital
stay. The results did show some positive effects in that
managed care beneficiaries somewhat less likely to report
have an unmet health care need.
Conclusions: On balance, health care access and use for
disabled Medicaid beneficiaries enrolled in managed care
were not significantly different from disabled beneficiaries
enrolled in FFS Medicaid.
Implications for Policy, Delivery or Practice: While several
recent studies have examined the impacts of managed care,
few have focused on the disabled—a particularly vulnerable
population under managed care given their diverse and
complex health care needs. Given that states are increasingly
looking at managed care programs for their disabled Medicaid
enrollees as a way to stem program costs—with California’s
Governor Schwarzenegger’s recent proposal to transition
disabled Medi-Cal beneficiaries into managed care being
especially noteworthy—the study findings suggest that cost
savings may be realized without significantly compromising
access to care.
Primary Funding Source: CMS
• Effects of the State Children’s Health Insurance Program
(SCHIP) on Access to Care, Use of Services and Health
Status
Lisa Dubay, Sc.M., Genevieve Kenney, Ph.D., Amy Davidoff,
Ph.D.
Presented by: Lisa Dubay, Sc.M., Principal Research
Associate, Health Policy Center, The Urban Institute, 2100 M
Street, N.W., Washington, DC 20037; Tel: 202.261.5667; Fax:
202.223.1149; E-mail: ldubay@ui.urban.org
Research Objective: To estimate the effects of the SCHIP
program on access to care, use of services and health status
at the population level.
Study Design: We used a pre-post design, with a comparison
group, comparing changes in access, use of services, and
health status before and after SCHIP implementation. The
treatment group consisted of newly (SCHIP) eligible children
and the comparison group included children with incomes
slightly above the eligibility thresholds for SCHIP. Estimated
difference-in-difference regression models controlled for
observable child, family, and area characteristics. Data were
from the 1996, 1999, and 2002 National Survey of America’s
Families (NSAF), and the 1997, 2000, and 2001 National
Health Interview Survey (NHIS). Access and use measures
included usual source of care, unmet need for medical and
other services, number and type of provider visits, and out-ofpocket spending. We also examined general health status,
change in health status, school days missed, and the presence
of asthma, anemia, and frequent headaches or ear infections.
Treatment and comparison groups were identified using an
algorithm that incorporates federal and state specific SCHIP
eligibility requirements to replicate the eligibility determination
process.
Population Studied: Children aged 0-17 years.
Principal Findings: Estimates indicate that among eligible
children, the SCHIP expansions were associated with a 4 to 6
percentage point increase in the probability of having a dental
visit (NHIS, NSAF) and a 4 percentage point increase in the
probability of an eye care visit within the year (NHIS). SCHIP
also led to a decrease in the number of hospital visits and to
lower unmet medical needs among eligible children (NSAF).
There was a downward shift in out-of-pocket spending among
eligible children, with a 5 percentage point reduction in the
proportion with spending over $500 (NHIS). There was also a
2 percentage point increase in reported diagnosis of asthma,
likely reflecting increased provider access (NHIS). An increase
in satisfaction with care of about 4 percentage points was also
observed (NSAF). The implied impacts are substantially
greater for eligible children enrolled in the SCHIP expansions
than for all children in the income eligible group since many of
these children maintained their private coverage over this
period. We did not find effects on use of other health services,
or other measures of health status.
Conclusions: The eligibility expansions improved some
measures of access for children, and the out-of-pocket burden
on families was reduced. Gaps remain for other components
of access.
Implications for Policy, Delivery or Practice: Further
progress in improving access to care for SCHIP eligible
children may require additional targeted enrollment of
uninsured children and attention to potential barriers to care
among enrolled children. Such changes are increasingly
unlikely, given the dire fiscal situation in many states, which
have led some states to establish enrollment caps and cut
back on outreach. Under the current policy environment, the
recent improvements in access documented in this study are
at risk of being reversed.
Primary Funding Source: , The Robert Wood Johnson
Foundation and the Maternal and Child Health Bureau, HRSA,
U.S. Department of Health and Human Services.
• Physician Supply and Effectiveness of the Primary Health
Care System
James Laditka, D.A., Ph.D., Sarah Laditka, Ph.D., Janice Probst,
Ph.D.
Presented by: Sarah Laditka, Ph.D., Associate Professor and
MHA Program Director, Health Services Policy and
Management, University of South Carolina, Arnold School of
Public Health, 800 Sumter Street, Columbia, SC 29208; Tel:
803.777.1496; Fax: 803.777.1836; E-mail: sladitka@gwm.sc.edu
Research Objective: Federal policy works to increase
physician supply in shortage areas, which can be rural or
urban. The premise is that people in low supply areas lack
access to primary care, and thus may have poorer health
outcomes. Yet studies of physician supply effects have mixed
findings. We study effects of supply on hospitalization for
ambulatory care sensitive conditions (ACSH). Also called
potentially preventable hospitalization, ACSH is a commonly
used indicator of the effectiveness of primary care. The ACSH
indicator informs federal health policy, and that of many
states.
Study Design: We used a dataset of county ACSH rates
compiled by the Safety Net Monitoring Initiative of the Agency
for Healthcare Research and Quality, using ACSH risks that
were adjusted for physician practice style. The data were
supplemented with data from the Area Resource File, the
Behavioral Risk Factor Surveillance System, the Centers for
Disease Control and Prevention, the Environmental Protection
Agency, and the National Center for Health Statistics. We
restricted the analysis to states in which the majority of
counties had available data. Logistic regression estimated
ACSH risk. Physician supply was measured, in separate
analyses, as a continuous variable (MDs/100,000) and in
quartiles. Rural areas were modeled separately, with
separately defined supply quartiles. Controls included health
system and use characteristics, demographic and socioeconomic characteristics, population health measures, air
quality, and county/area factors.
Population Studied: Children (0-17), younger adults (18-39),
and middle age adults (40-64) in 664 counties of twenty U.S.
states.
Principal Findings: Controlling for all other factors, increased
physician supply is associated with lower ACSH risks in urban
areas for children (p=.003), younger adults (p=.019), and
middle age adults (p<.0001). In all models, standardized
estimates indicate that physician supply is one of the most
important factors associated with ACSH variation. Results are
more pronounced for urban than for rural areas. In the urban
quartile analysis, areas with greatest supply had notably lower
ACSH risks than those with least supply, for all three age
groups (p=.039; p=.017, p<.0001, respectively). The greatest
effect was for middle age adults, where there was doseresponse relationship between increasing supply and ACSH
risk reduction.
Conclusions: Children and working age adults in areas with
greater physician supply had lower ACSH rates. For middle
age adults in urban areas, there was dose-response
relationship between supply and ACSH risk reduction. Weaker
results for rural areas may be attributable to a smaller rural
sample (n=216), less supply variation among rural areas, or
the omission of counties with the lowest supply.
Implications for Policy, Delivery or Practice: Primary care
physician supply affects the performance of the primary care
system positively. Policies promoting physician placement in
underserved areas, including the National Health Service
Corps, state loan repayment programs, and Title VII training
programs, should receive continued support. Innovative local
efforts to induce physicians to locate in poor and remote areas
should be explored. Results suggest that increasing the
number of primary care physicians may be beneficial at all
supply levels.
Primary Funding Source: South Carolina Rural Health
Research Center
• How Well Does Medicaid Work in Improving Access to
Care?
Sharon Long, Ph.D., Teresa Coughlin, M.P.H., Jennifer King,
B.A.
Presented by: Sharon Long, Ph.D., Principal Research
Associate, Health Policy, Urban Institute, 2100 M Street, N.W.,
Washington, DC 20037; Tel: 202.261.5656; Fax: 202.223.1149;
E-mail: slong@ui.urban.org
Research Objective: To provide an assessment of how well
the Medicaid program is working at providing access to and
use of health care for low-income mothers.
Study Design: Using instrumental variables methods to
control for selection into insurance coverage, we estimate the
effect of Medicaid coverage on access to and use of health
care relative to private coverage and being uninsured. We use
the 1997 and 1999 National Survey of America’s Families
(NSAF), with state and county information drawn from the
Area Resource File and other sources.
Population Studied: Women with children in families with
incomes below 200 percent of the federal poverty level.
Principal Findings: We find that Medicaid beneficiaries’
access and use is significantly better than that obtained by the
uninsured. By controlling for insurance selection, the analysis
showed that the benefits of having Medicaid coverage versus
being uninsured are substantially larger than what was
estimated when selection is not accounted for. Our results
also indicate that Medicaid beneficiaries’ access to care is
comparable to that of the privately insured. Without controls
for insurance selection, access for Medicaid beneficiaries is
found to be significantly worse than for the low-income
privately insured.
Conclusions: Our results show that the Medicaid program
improves access to care relative to being without insurance for
low-income mothers. Moreover, our results indicate that,
after controlling for selection into insurance status, Medicaid
beneficiaries achieve access levels comparable to the privately
insured. Our results also indicate that prior research, which
has not controlled for selection into insurance coverage, has
likely understated the gains of Medicaid relative to
uninsurance and overstated the gains of private coverage
relative to Medicaid.
Implications for Policy, Delivery or Practice: Our findings
indicate that the Medicaid program has substantially
improved access to care for those who would otherwise be
uninsured, bringing them up to the levels of access reported
by those with private insurance coverage. Our results also
highlight the importance of using appropriate analytic
methods in assessing the impacts of policy changes.
Primary Funding Source: , The Henry J. Kaiser Family
Foundation (The Kaiser Comission on Medicaid and the
Uninsured)
• Ambulatory Care Sensitive Condition Hospitalizations
among Elderly Medicare and Medicaid (Dual) Enrollees
Marlene Niefeld, M.P.P.
Presented by: Marlene Niefeld, M.P.P., Doctoral Candidate,
Department of Health Policy and Management, Johns
Hopkins Bloomberg School of Public Health, 272 Yale Court,
Arnold, MD 21012; Tel: 410.647.6687; Fax: 410.647.6687; Email: mniefeld@jhsph.edu
Research Objective: The first objective was to analyze the
relationship between perceived access to care barriers and
likelihood of preventable hospitalization. Out-of-pocket costs
and organizational barriers to specialty and long-term care
were expected to increase the likelihood of an ambulatory care
sensitive condition (ACSC) hospitalization. The second
objective was to analyze the association of prior ACSC to
future ACSC hospitalization to examine care management
over time.
Study Design: Data are from a 1999 6-state survey of elderly
dual enrollees (n=2,128) funded by The Robert Wood Johnson
Foundation and The Commonwealth Fund,1999 and 2000
Inpatient Medicare Claims data matched to the population
surveyed, and the Area Resource File. ACSC’s were defined by
panels of physicians as conditions that should not require
hospitalization if timely and appropriate ambulatory care was
provided. The ICD-9-CM code reported as the primary
diagnosis for each hospitalization was used to determine
whether a hospitalization could be classified as potentially
preventable. ACSC hospitalizations were included as a
dependent variable in the analysis if they occurred within 12
months after the survey interview. Logistic regression
analyses controlling for predisposing, enabling, and need
characteristics were conducted on all dual enrollees to identify
characteristics associated with ACSC hospitalization.
Population Studied: Community-resident Medicare
beneficiaries aged 65 and older who were continuously
enrolled in Medicaid for the previous 12 months was the
population of interest. Previous research has shown that dual
enrollees were more likely than Medicare beneficiaries with
private supplemental insurance to have no physician office
visits in a one-year period, and were less likely to receive
specific types of preventive care, follow-up care, and medical
testing.
Principal Findings: Twenty-five percent of all hospitalizations
within one year were preventable for elderly dual enrollees.
Dual enrollees with out-of-pocket costs were 1.45 times more
likely than those without out-of-pocket costs to experience a
preventable hospitalization, those with 5 or more chronic
conditions were 1.64 times more likely than those with 0-2
chronic conditions to have a preventable hospitalization, and
for each additional prescription medications taken in the
previous month the likelihood of a preventable hospitalization
increased by 12 percent. Prior preventable hospitalization also
increased the likelihood of a subsequent preventable
hospitalization by 9.00 times.
Conclusions: Despite the comprehensive insurance coverage
provided by the Medicare and Medicaid programs to elderly
dual enrollees, and the fact that virtually all communitydwelling dual enrollees reported that they had a usual source
of care, access to care and care management problems
remain. The high rates of preventable hospitalization in this
population, and the fact that persons with multiple chronic
conditions, previous ACSC hospitalizations, and multiple
prescription medications were more likely to experience
subsequent ACSC hospitalizations, indicate a need for
improving the current system of chronic disease
management.
Implications for Policy, Delivery or Practice: These results
suggest that any out-of-pocket costs present a burden for lowincome populations. They also indicate the need for several
innovations in the health care delivery system. It has been
hypothesized that coordination of care between multiple
providers and innovations in medical informatics to improve
prescription drug management will improve care among
vulnerable populations. In order to accomplish these
innovations, reimbursement to physicians and hospitals may
need to be changed.
Primary Funding Source: AHRQ
Call for Papers
Insurance Coverage Issues & Effects
Chair: Jessica Banthin, Ph.D.
Tuesday, June 8 • 9:15 a.m.-10:45 p.m.
• "Churning": SCHIP Coverage Discontinuity and Its
Consequences
Julia Costich, J.D.
Presented by: Julia Costich, J.D., Assistant Professor, School
of Public Health, University of Kentucky, 121 Washington
Street, Lexington, KY 40536; Tel: 859.257.8709; Fax:
859.257.3909; E-mail: jfcost0@uky.edu
Research Objective: This study assesses the extent to which
children enrolled in the Kentucky Children's Health Insurance
Program (KCHIP) or Kentucky Medicaid renew coverage in a
timely manner, and the effect of discontinuities in coverage in
the context of state health policy. Repeated loss of coverage
followed by re-enrollment is referred to here as churning.
Study Design: Data on coverage renewals and new
enrollments were provided by the state Department for
Medicaid Services. We analyzed KCHIP and Medicaid data in
tandem because of prior findings that many families' incomes
fluctuate between the eligibility criteria for the two programs.
Coverage renewal can be accomplished by mail but initial
application requires an in-person interview at the local
eligibility determination office. We therefore tested the
hypothesis that families would take the steps necessary to
renew children's coverage in a timely manner. The study
design compared timely renewal rates with the volume of
"new" applications as a proportion of total enrollment. Our
second hypothesis was that county rates of successful renewal
would relate to the proportion of all children enrolled in
KCHIP or Medicaid because information about renewal
procedures would be more readily available in counties with
high rates of enrollment. We compared enrollment rates by
county with renewal rates and "new" approvals by county to
test this hypothesis.
Population Studied: Children and youth enrolled in KCHIP or
Medicaid during the 2003 state fiscal year.
Principal Findings: Statewide, only 56 percent of eligible
children had timely coverage renewal. While far from optimal,
this finding is consistent with renewal rates in other studies.
New application approvals equaled 53 percent of total
combined KCHIP and children's Medicaid enrollment,
although total enrollment increased by only 4 percent. The
clear implication is that about 87.5 percent (about 254,600) of
those whose coverage was not renewed on time regained
coverage through the new application process. The rate of
successful coverage renewal ranged from 30 percent in the
state's most affluent county to 78 percent in one of the
poorest; the percentage of children enrolled in KCHIP or
Medicaid was modestly reliable in predicting the rate of timely
renewal.
Conclusions: Despite the availabilty of a computer-generated
mailed renewal form, timely renewal rates for KCHIP and
children's Medicaid are unacceptably low. Previous studies
have characterized the renewal form as hard to decipher, and
families complained of not receiving renewal information in a
timely manner. While the re-entry of most children through
new applications is encouraging, it represents an
inappropriate use of state agency resources.
Implications for Policy, Delivery or Practice: The high
volume of families whose children's coverage was not
renewed in time and associated administrative cost imply that
the state (as well as eligible children) would benefit by
dedicating resources to improving the legibility of the renewal
form and supporting families in the renewal process.
Primary Funding Source: RWJF
• Effects of the State Children’s Health Insurance Program
(SCHIP) on Health Insurance and Access to Care for
Children with Special Health Care Needs (CSHCN)
Amy Davidoff, Ph.D., Genevieve Kenney, Ph.D., Lisa Dubay,
Sc.M.
Presented by: Amy Davidoff, Ph.D., Senior Research
Associate, Health Policy Center, Urban Institute, 2100 M
Street, N.W., Washington, DC 20037; Tel: 202.261.5259; Fax:
202.223.1149; E-mail: adavidof@ui.urban.org
Research Objective: To estimate the effects of SCHIP
expansions in public insurance eligibility on insurance
coverage and access to care for CSHCN, compared to children
without special health needs.
Study Design: We used a pre-post design with a comparison
group, to examine changes in coverage, access, use of
services, and health status, before and after SCHIP
implementation. The treatment group consisted of newly
(SCHIP) eligible CSHCN. We used multiple comparison
groups, including children with incomes slightly above the
eligibility thresholds. Estimated difference-in-difference
regression models controlled for observable child, family, and
area characteristics. We also examined spillover effects for
children previously eligible for Medicaid. Data were from the
1997, 2000, and 2001 National Health Interview Survey.
Access and use measures included usual source of care,
unmet need for medical and other services, number and type
of provider visits, and out-of-pocket spending. Treatment and
comparison groups were identified using an algorithm that
incorporates federal and state specific SCHIP eligibility
requirements to replicate the eligibility determination process.
Population Studied: Children 0-17 years. CSHCN were
identified based on reported diagnosis of a serious chronic
condition (asthma, heart disease, diabetes, etc.), or reported
limitation of activity caused by a chronic health condition.
Principal Findings: Approximately 10 percent of newly eligible
CSHCN enrolled in SCHIP. This was associated with a 3
percentage point decline in private coverage (ns), and a 6
percentage point or 27 percent decrease in the probability of
being uninsured. Despite decreased uninsurance rates, 15
percent of SCHIP eligible CSHCN remained uninsured. The
SCHIP expansions resulted in a 9 percentage point decline in
any unmet need, most of which came from reductions in
unmet dental care need, but there was also a negative effect
on unmet prescription drug need. There was an increase in
the probability of dental care and eye care visits, and a
downward shift in family out-of-pocket spending. We failed to
find effects on other types of provider visits or service use, and
there were no significant effects on health status. For children
without chronic conditions, we found greater declines in
private coverage and smaller reductions in the probability of
being uninsured. Impacts on access and use were similar.
Conclusions: The SCHIP expansions reduced the proportion
of uninsured CSHCN, but there is still a group of eligible
children who lack coverage, thus additional progress is
possible. The eligibility expansions improved some measures
of access for CSHCN, but gaps remain for other components
of access, and there is no evidence in the short run of
improvements in health status.
Implications for Policy, Delivery or Practice: Further
progress in reducing uninsurance and improving access to
care may require additional targeted outreach to CSHCN.
Furthermore, SCHIP plans may need to enhance the scope of
covered benefits or restructure contracts with provider plans,
so as to facilitate access to care for enrolled CSHCN. These
types of changes may be increasingly unlikely, given the poor
financial environments in the states. In fact, many states have
made various retrenchments in SCHIP coverage. As CSHCN
have not generally received special protections, the recent
progress documented in this study may be reversed.
Primary Funding Source: HRSA
• Costs of Enrolling Children in Medicaid and SCHIP
Gerry Fairbrother, Ph.D, Melinda Dutton, J.D., Deborah
Bachrach, J.D., Kerry-Ann Newell, M.S., Patricia Boozang,
M.P.H., Rachel Cooper, M.A.
Presented by: Gerry Fairbrother, Ph.D., Senior Scientist,
Health and Science Policy, New York Academy of Medicine,
1216 Fifth Avenue, New York, NY 10029; Tel: 212.822.7398;
Fax: 212.822.7369; E-mail: gfairbro@nyam.org
Research Objective: The purpose of this study is to assess
the administrative cost of enrolling children into public health
insurance programs under the current enrollment process in
New York City and to estimate how much of this cost could be
saved if application requirements were simplified.
Study Design: Interviews with key staff members were used
to identify the main components of the enrollment process.
Overall costs were assessed for these components using 2001
expenditure reports for three managed care organizations
(MCO’s). Structured questionnaires were used to determine
time spent in enrollment activities during the typical
enrollment process and during a simplified post-September
11th process. Activities were organized into four functional
categories: 1) outreach and health insurance education, 2)
application completion/documentation, 3) quality assurance,
and 4) application submission and troubleshooting. Costs
and cost savings associated with these activities were
determined using staff estimates of time spent and average
salaries and benefits associated with each staff member.
Population Studied: The population studied was children
enrolled in Medicaid and SCHIP through New York City
MCOs in 2000/2001.
Principal Findings: The average administrative cost to enroll
a child in health insurance was approximately $280. Time
spent by enrollment workers was categorized into five major
functional areas: eligibility screening (16%), gathering
documents (20%), application process (27%), outreach and
health education (18%) and other enrollment activities (19%).
Up to 80% of the enrollment cost is associated with the
complicated guidelines and calculations of the eligibility
process while outreach and health insurance education
account for approximately 20% of enrollment costs.
Enrollment costs could be reduced by 40% ($282 to $166)
under a simplified system.
Conclusions: Our cost estimate is equivalent to more than
two months premium paid to MCOs in New York.
Complexities in the enrollment process result in higher
administrative costs. Administrative costs absorb significant
funds that could be realized as costs savings or distributed
elsewhere.
Implications for Policy, Delivery or Practice: Many states
are responding to budget deficits by increasing administrative
barriers to enrollment. Such barriers will decrease the number
of people served by these programs and consequently reduce
overall program costs in the short term. However, in the long
run, these barriers will result in significant administrative costs
making the case for simplification more compelling than ever.
Primary Funding Source: , The Foundation for Child
Development
• Churning: Disenrollment and Reenrollment in
Wisconsin’s Medicaid and BadgerCare Programs
Nancy Lenfestey, MHA, Norma Gavin, Ph.D., Nathan West,
M.P.A.
Presented by: Nancy Lenfestey, MHA, Public Health Policy
Analyst, RTI International, 3040 Cornwallis Road, Research
Triangle Park, NC 27709; Tel: 919.316.3364; Fax: 919.990.8454;
E-mail: nlenfestey@rti.org
Research Objective: Churning, the process of repeatedly
coming in and out of a health insurance program, can have
adverse health and financial consequences. Discontinuities in
coverage may lead to foregone preventive care, increased
severity of illness and health care expenditures, and higher
administrative costs. This study investigates disenrollment
and reenrollment in Wisconsin’s Medicaid and BadgerCare
programs to provide information on churning. Differences in
patterns of disenrollment and reenrollment are examined for
adult and child enrollees by eligibility group, cash assistance
status, racial/ethnic group, and time period---pre- and postBadgerCare.
Study Design: A record was created for each episode of
enrollment, defined as a period of continuous enrollment in
Medicaid/BadgerCare regardless of switches between the two
programs or between eligibility groups within programs.
Kaplan-Meier survival curves and Cox proportional hazard
models of the length of enrollment episodes and the number
of months between episodes were estimated for new and
newly ended episodes, respectively, in two different time
periods: 1) a 2-year period preceding BadgerCare
implementation, and 2) a 2-year period following BadgerCare
implementation. Survival curves and hazard rates were
compared for the first 32 months from enrollment and
disenrollment.
Population Studied: Medicaid and BadgerCare enrolled
adults (> 18 years) and children by age group (0 to 5 and 6 to
18 years) in three different enrollment categories ---AFDCrelated, Healthy Start, and BadgerCare.
Principal Findings: Disenrollment and reenrollment rates
were similar among BadgerCare and Medicaid beneficiaries.
Enrollment episodes were substantially longer for Medicaid
enrollees following BadgerCare implementation. This result
was most dramatic for adult Healthy Start pregnant women;
only 12% remained enrolled 12 months from enrollment prior
to BadgerCare whereas 40% did so following BadgerCare.
Children were less likely than adults and younger children
were less likely than older children to disenroll early; cash
assistance recipients were less likely to disenroll early than
enrollees not receiving cash assistance; and Hispanics were
more likely to disenroll early than white non-Hispanics.
Furthermore, short periods of disenrollment between two
enrollment periods were common among all enrollees, and
were even more prevalent following BadgerCare
implementation. As many as 15 to 20% of children reenrolled
after only 1 month and 60 to 70% had reenrolled within the
first 32 months following disenrollment. Children, cash
assistance recipients, and minorities were more likely to
reenroll after short periods of time relative to other enrollees.
BadgerCare beneficiaries were somewhat less likely to reenroll
than AFDC-related Medicaid beneficiaries.
Conclusions: While evidence shows that churning is a
substantial problem, particularly among children and
minorities, continuity of coverage has improved significantly
in Wisconsin’s Medicaid program since the implementation of
BadgerCare.
Implications for Policy, Delivery or Practice: The high
amount of churning among children and minorities should be
investigated further to determine possible adverse effects on
compliance with recommended well-child visit and
immunization schedules.
Primary Funding Source: CMS
Related Posters
Poster Session A
Sunday, June 6 • 6:45 p.m.-8:00 p.m.
• S-CHIP and Children’s Usage in Georgia and Alabama:
Does Structure Matter?
E. Kathleen Adams, Ph.D., Janet Bronstein, Ph.D., Curtis S.
Florence, Ph.D.
Presented by: E. Kathleen Adams, Ph.D., Professor, Health
Policy and Management, Rollins School of Public Health,
Emory University, 1518 Clifton Road, N.E., Atlanta, GA 30322;
Tel: 404.727.9370; Fax: 404-727-9198; E-mail:
eadam01@sph.emory.edu
Research Objective: State variation in benefits, eligibility,
administrative features and provider networks under their
Child Health Insurance Programs (S-CHIP) affects children’s
access and utilization. We examine primary, preventive and
emergency room (ER) utilization among children enrolled in a
Medicaid look-alike versus a stand-alone CHIP program
compared to Medicaid children.
Study Design: Medicaid claims, enrollment and provider data
are used to measure children’s utilization quarterly, 19992000, as a function of demographics, provider availability and
enrollment in Medicaid versus CHIP. Children are categorized
as: 1) CHIP only; 2) Medicaid only; 3) CHIP with Medicaid
history; or 4) Medicaid with CHIP history. Provider availability
reflects distance to closest participating providers and
presence of certain provider types in their zip.
Population Studied: Random samples of Medicaid children
plus all PeachCare kids in Georgia (98,000) and ALLKids in
Alabama (35,000) were studied. PeachCare, a Medicaid lookalike program, uses the same physician network and fee
schedule as the state’s Medicaid’s primary care case
management program (pccm). ALLKids subcontracts to Blue
Cross and Blue Shield (BCBS) of Alabama, using their
physician network and fee rates but does not assign a primary
care gatekeeper.
Principal Findings: Provider availability appeared greater for
ALLKids where 75 percent had a large volume office physician
in their zip versus 66 percent of PeachCare kids. Using state
data and controlling for provider access, PeachCare kids were
less likely than Medicaid children in the same delivery system
to receive primary or well-child care as well as ER visits. This
may reflect higher incomes and fewer health problems among
CHIP kids but the lower use of preventive care is inconsistent.
On the other hand, ALLKids had significantly higher odds of
any primary care and preventive care visits among users of
preventive care than Medicaid children under the Alabama
pccm system. Unexpectedly, they were more likely than
Medicaid children to use the ER at least once but users did
have fewer visits. Pooled data better measure the delivery
system effects under ALLKids since they can be compared to
CHIP kids in pccm. Results indicate the patterns are similar
though magnitudes are lower. A key difference is that ALLKids
are not more likely to use the ER compared to Medicaid, but
are compared to CHIP kids in pccm based on pooled data.
Conclusions: If CHIP is integrated into an existing provider
network and not accompanied by fee increases utilization may
be constrained by overall participating provider availability. In
contrast, there appears to be strong delivery system effects on
utilization where CHIP kids have private-like coverage, greater
provider availability and no managed care. The lack of
gatekeeping, however, may result in unnecessary visits to the
ER although appropriate triage may occur once children visit
the ER.
Implications for Policy, Delivery or Practice: These results
indicate that the design features of CHIP matter. The private
stand-alone system appears to provider better access in terms
of not only provider availability but receipt of primary and
preventive care. While the costs of such a system are higher
these could potentially be constrained by primary care
gatekeeping.
Primary Funding Source: AHRQ, Child Health Insurance
Research Initiative (CHIRI)
• Physician Continuity and Association with Satisfaction,
Trust and Preventive Services in the Rural Southeast
Katrina Donahue, M.D., M.P.H., Evan Ashkin, M.D., Donald
Pathman, M.D., M.P.H.
Presented by: Evan Ashkin, M.D., Clinical Assistant Professor,
Department of Family Medicine, University of North Carolina,
1008 Green Street, Durham, NC 27701; Tel: 919.361.2644; Fax:
919.484.0849; E-mail: evan_ashkin@med.unc.edu
Research Objective: Physicians and patients report placing a
high value on continuity in healthcare. In an era of rapid
change in our health care system, these long term
relationships can be affected. Our study examines (1)
characteristics of rural patients who have longer relationships
with their physicians and (2) whether the length of this
relationship is associated with various aspects of satisfaction
and trust, counseling on behavioral issues (smoking, physical
activity, nutrition) and receiving preventive services
(mammogram, pap, flu shot, colon screening and
cholesterol).
Study Design: Cross-sectional data on health care access
indicators were obtained from participants in the Southern
Rural Access Program (SRAP) using a computer-assisted
telephone interview system (CATI) from October 2002 to July
2003.
Population Studied: SRAP respondents (N=3176) who
indicated they see a particular physician for their care. SRAP
includes 4879 participants in non metropolitan counties of
eight southern states (Alabama, Arkansas, Georgia, Louisiana,
Mississippi, South Carolina, Texas and West Virginia.
Principal Findings: 10.8% (N=319) had seen the same
physician for the past 12 months, 11.8% (N=369) for the
previous 13-24 months, 20.7% (N=669) for the past 25-60
months and 56.7% (N=1819) for more than 60 months.
Compared to persons with 12 months or less continuity, a
higher proportion of respondents with 5 years or more
continuity were Caucasian (65.5% versus 59.8%, p <0.01), had
insurance (77.2% versus 68.6%, p<0.01), had income greater
than $25,000 ( 62.5% versus 48.5%, p< 0.001) and reported
good to excellent health (76.0% versus 69.4%, p<0.05) .
When participants saw a physician for more than 12 months,
there were no significant differences. There were also no
significant differences for age, gender or education. Fewer
respondents with 5 years or more of continuity reported not
being satisfied with their overall health care (3.7% versus
8.7%, p<0.01), but these differences disappeared with at least
24 months of continuity. There were no significant differences
found for other satisfaction and trust variables or for any of
the preventive and counseling services, except those who
reported seeing a physician for 12 months or less were more
likely to report being counseled in nutrition over the past year
(55.8% versus 47.7%, p<0.05).
Conclusions: Over half of the participants in the SRAP report
seeing the same physician for more than 5 years. Participants
who change (or who are forced to change) physicians after
one 1 year have decreased satisfaction with overall healthcare
and tend to report poor health status. Differences in
demographic, satisfaction, and physician counseling resolved
after a person had been seeing a physician for more than 2
years.
Implications for Policy, Delivery or Practice: It is
encouraging that there are little to no differences in preventive
health services and counseling services by years of continuity.
However, differences in reported health status indicate
continuity may still be important for those who are ill. This
group could be at risk when continuity is jeopardized.
Primary Funding Source: RWJF
• Design Considerations in the Evaluation of the
Integrated Health Outreach System Project
Craig Blakely, Ph.D., M.P.H., James Burdine, Dr.P.H., Alicia
Dorsey, Ph.D., Petra Reyna, M Ed, Monica Wendel, M.S.,
M.P.H., Miguel Zuniga, M.D., Dr.PH
Presented by: Craig Blakely, Ph.D., M.P.H., Head,
Department of Health Policy and Management, School of
Rural Public Health, 3000 Briarcrest Drive, Suite 300, Bryan,
TX 77802; Tel: 979.458.0937; Fax: 979.458.4264; E-mail:
blakely@srph.tamu.edu
Research Objective: The Robert Wood Johnson Foundation
in a joint effort with HRSA, funded an evaluation of the
Integrated Health Outreach Project. The research objectives
of this project are to evaluate the impact of the overall strategy
as well as specific components in building community
capacity, the capacity of lay health workers, and participating
health care organizations to more effective collaborate and as
a result, increase acccess to care for colonia residents
Study Design: Seven different data collection activities were
built into the design for this effort looking at: community
leaders, the promotoras (lay health workers), health care
organizations, and colonia residents.
Population Studied: Health care organizations, promotoras,
colonia residents and community leaders were all studied in
the various aspects of this evaluation.
Principal Findings: This paper will focus on the challenges of
the overall initial evaluation design, and subsequently
challenges to the implementation of that design. Significant
factors included in this discussion are the impact of changes
in federal, state and local health policy (e.g., reimbursement
rates) on each of the study populations as well as the overall
system of care.
Conclusions: At the third year in a four year study,
conclusions are primarily observations related to the success
of the various data collection activities. However, while
prelmiinary results suggest the project is on track in meeting
its goals, early data also point toward the potential for
substantial changes in collaborative community service
delivery and other proximal outcomes projected by the project
model.
Implications for Policy, Delivery or Practice: Designing an
evaluation of a complex community-based intervention to
improve access to care to a medically indigent population
yields important information for consideration in changes in
health policy. Policy makers and service providers must
recognize and consider this information in shaping future
health policy. Further, as the field of community prevention
research ages, the importance of translating research to
practice grows considerably. Illustrations of community-based
projects that directly affect the way communities address their
own health problems provide important data for the field.
Primary Funding Source: RWJF, HRSA
• The Impact of SCHIP on Health Insurance Coverage
Rates for Children
Lynn Blewett, M.A., Ph.D., Michael Davern, Ph.D., Gestur
Davidson, Ph.D., Holly Rodin, M.P.A.
Presented by: Lynn Blewett, M.A., Ph.D., Assistant Professor,
Health Services Research and Policy, University of MN, School
of Public Health, 420 Delaware Street, S.E., MMC 729,
Minneapolis, MN 55455; Tel: 612.626.4739; Fax: 612.624.2196;
E-mail: blewe001@umn.edu
Research Objective: Recent national data document the
decrease in the number of uninsured children while the
number of uninsured adults continues to rise. This study
examines the impact of SCHIP and other public program
expansions in reducing the number of uninsured children for
each of the 50 states and the District of Columbia.
Study Design: We use data on children age 18 and under
from the CPS annual demographic supplement for two time
periods: pre-SCHIP 1996-1998 and post-SCHIP 2002-2003.
We estimated a multinomial logistic regression predicting
whether a child was uninsured, covered by public insurance,
or by private insurance for each time period. We include
family economic and demographic characteristics along with
the individual child’s demographic characteristics as
covariates in the model. We use the parameter estimates
generated by this model to “recycle” all the CPS cases
(whether pre or post SCHIP) through two counterfactual
scenarios: (1) all the respondents were from the pre-period,
(2) all the respondents were from the post period. We
compare the resulting predicted recycled probabilities for each
state and calculate the change in health insurance coverage
between the pre and post periods controlling for economic
and demographic characteristics of respondents.
Population Studied: Non-institutionalized children age 18
and under in each state and DC.
Principal Findings: We found significant increases in the
percent of children enrolled in public insurance in all 50 states
(1.9% increase in Colorado to a 4.8% increase in New
Mexico); significant decreases in the percent of uninsured
children (from 0.7% in Iowa to 2.7% in New Mexico); and
significant decrease in private health insurance coverage (from
–3.5% in Vermont to -.7% in Colorado) in 35 of the states. We
found that public program participation increased the most
for children with incomes below 200% of the poverty.
Conclusions: SCHIP and other public program expansions
aimed at children have succeeded in enrolling children in
public programs and reducing the numbers of uninsured for
all states and the District of Columbia. One concern with
these program expansions has been the amount of
substitution of public for private coverage that would occur as
a result. Our analysis is consistent with the expectation that a
limited amount of substitution is occurring and public
program expansions were the greatest for those with the
lowest incomes.
Implications for Policy, Delivery or Practice: At a time when
health insurance coverage was declining for adults, significant
progress was made in reducing the number of uninsured
children. SCHIP and public program expansions were key to
preventing a similar increase in the number of uninsrued
children. This finding is robust across all states with different
eligibility and other SCHIP program specifications and rates of
enrollment, suggesting that additional factors are playing a
role in getting more children enrolled in public health
insurance. State outreach, administrative simplification, as
well as larger outreach efforts such as “Cover All Kids” are all
enabling families to enroll eligible children in public programs
nationwide.
Primary Funding Source: RWJF
• Cervical Cancer Screening among Elderly Women: The
Effects of Health Beliefs vs. Insurance Coverage
Tyrone Borders, Ph.D.
Presented by: Tyrone Borders, Ph.D., Assistant Professor and
Chief, Health Services Research, Texas Tech University Health
Sciences Center, 3601 4th Street, MS 8161, Lubbock, TX
79430; Tel: 806.743.6984; Fax: 806.743.1292; E-mail:
tyrone.borders@ttuhsc.edu
Research Objective: To examine the effects of emotional
barriers, anxiety about cervical cancer screenings, and the
perceived importance of cervical cancer screenings versus the
effect of insurance coverage on the odds of utilizing Pap tests.
Study Design: A retrospective cohort study in which older
women were asked to report about their utilization of Pap
tests over the previous two years, their beliefs and attitudes
about Pap tests, and their insurance coverage for Pap tests.
Multivariate logistic regression analyses were conducted to
model the probability of receiving Pap tests.
Population Studied: Data were collected through a
population-based telephone survey of 1,338 elderly women
(age 65 and older) residing in the 111-county region
comprising West Texas.
Principal Findings: Insurance coverage for Pap tests and
perceptions of the importance of Pap tests had the largest
effects on whether elderly women received a Pap smear in the
previous two years. Women with insurance covering Pap tests
had a much higher odds (OR=5.19, 95% CI=3.86, 6.80) of
receiving a Pap test than those without insurance. Those who
perceived that Pap tests were important for the prevention of
cancer had a higher odds (OR=3.69, 95% CI=2.40, 5.67) of
receiving a Pap test than those who perceived that they were
unimportant. Emotional barriers and anxiety were not
significantly associated with Pap test utilization.
Conclusions: Among older women, insurance coverage for
Pap tests and perceptions of the importance of Pap tests have
a strong impact on Pap test utilization.
Implications for Policy, Delivery or Practice: Health policy
makers should consider further expanding health insurance
coverage to older women to cover Pap smears. Among those
women who have insurance coverage, medical care providers
and public health workers should promote the benefits of Pap
tests in preventing cervical cancer.
Primary Funding Source: U.S. Administration on Aging
• Most Veterans Obtain Cardiac Revascularization Outside
VHA
William Weeks, M.D., M.B.A., David Bott, Ph.D., David Bott,
Ph.D., Dorothy Bazos, Ph.D., Michael Racz, M.A., Steven
Wright, Ph.D., Elliott Fisher, M.D.
Presented by: David Bott, Ph.D., Research Associate, Center
for the Evaluative Clinical Sciences, Dartmouth Medical
School, 7251 Strasenburgh Hall, Room 313B, Hanover, NH
03755-3863; Tel: 603.650.1958; Fax: 603.650.1935; E-mail:
david.m.bott@dartmouth.edu
Research Objective: VHA seeks to provide comprehensive,
coordinated care through a regional referral network.
However, many veterans use multiple healthcare systems to
obtain care. We sought to determine whether veterans rely on
VHA or private sector for cardiac revascularization.
Study Design: Matching enrollment and utilization data from
VHA to utilization data from New York’s Cardiac Surgery
Reporting System (CSRS), we were able to create a
comprehensive file of coronary artery bypass grafting (CABG)
surgeries and percutaneous coronary interventions (PCI)
provided to male enrolled veterans in New York in 1997. We
determined the site of intervention (VHA or private sector)
and risk-adjusted mortality quartile for private sector hospitals,
and compared utilization rates by veterans to non-veterans for
two age groups (45-64 and 65+).
Population Studied: VA enrolled male veterans aged 45 or
older with residence in New York during study period.
Principal Findings: Male veterans aged 45-64 underwent
more CABG (4.29/1000 vs. 2.82/1000, p<.001) and PCI
(5.55/1000 vs. 4.32/1000, p<.001) than male non-veterans,
while those aged 65+ underwent fewer CABG (7.57/1000 vs.
8.15/1000, p=.051) and PCI (6.59/1000 vs. 7.69/1000,
p<.001). Older veterans who underwent private sector CABG
were more likely to use hospitals ranked in the lowest versus
highest quartile of risk-adjusted mortality (OR 1.30, 95%
CI:1.03-1.64). Veterans aged 45-64 received 41% of their
CABGs and 35% of their PCIs within VHA, while veterans 65
and older received 19% of their CABGs and 18% of their PCIs
within VHA.
Conclusions: Both younger and older veterans receive the
majority of their cardiovascular interventions in the private
sector compared to the VA.
Implications for Policy, Delivery or Practice: Efforts to
improve care for veterans will require collaboration with
private sector care systems including Medicare.
Primary Funding Source: VA
• Changes in the Hospitalized Uninsured from 1997 to
2002
Ellen Campbell, Ph.D., Tifini Preliou, B.A., Suzette Grant,
Pharm.D student
Presented by: Ellen Campbell, Ph.D., Assistant Professor,
Economic, Social & Administrative Pharmacy, Florida A&M
University, College of Pharmacy - Dyson Building, Tallahassee,
FL 32307; Tel: 850.599.3082; Fax: 850.412.7548; E-mail:
ellen.campbell@famu.edu
Research Objective: The U.S. health care system has
undergone many changes in the past decade including an
increased emphasis on cost cutting managed care, the
passage of the Portability Act of 1996, and the passage and
revision of the Balanced Budget Act. Health policies aimed at
reducing the number of uninsured have been called
fragmented and incremental. Overall, the 1990s enhanced
access for some individuals through SCHIP and HIPAA, but
tightened the financial situation particularly on safety net
providers. Changes over this period have lead to a reduction
in health benefits offered to low income workers, while
increasing health insurance premiums make it more difficult
for the uninsured to obtain coverage. Moreover, this period
saw widespread changes in hospital affiliations with a growth
in multihospital systems. How have these system-wide
changes affected the composition and needs of the
uninsured?
In this paper we examine the characteristics of the uninsured
and their safety net providers, and how they have changed
during the recent period of health care system transition.
Study Design: Using discharge abstracts from the State of
Florida for uninsured patients hospitalized in the years 1997
and 2002, we compare differences in patient characteristics
such as age, race and primary diagnosis. We also examine
differences in safety net facility characteristics such as
geographic location, ownership and teaching status. Since the
data utilized here comprises the entire population of Florida
hospitalizations, sample statistics will not be reported. All
observed differences are exact for the population studied.
Population Studied: Uninsured patients hospitalized in a
Florida short-term general hospital in the years 1997 and
2002.
Principal Findings: Preliminary analysis of over 4 million
hospitalizations during the periods studied indicates that the
proportion of uninsured has changed very little between 1997
and 2002, however the profile of the hospitalized uninsured
has changed over this 5-year period. As expected with the
implementation of SCHIP there was a reduction in the
proportion of uninsured children, with adults (18-64)
accounting for a larger proportion of the uninsured. As
indicated by other studies, there was a large increase in the
proportion of white Hispanics among the uninsured, while the
proportion of non-Hispanic whites decreased. Finally, there
appears to be increasing use of the emergency room by the
uninsured indicating less access to primary care providers.
Further analysis will be performed on changes in diagnoses
and hospital characteristics.
Conclusions: Although there has been little change in the
proportion of uninsured in the U.S., the characteristics of this
vulnerable population has changed over the past 5 years.
Implications for Policy, Delivery or Practice: By identifying
how the uninsured population has changed in recent years,
this study can be used to guide future health care policy.
• The Influence of Consumers’ Experiences with Care on
Health Services Utilization in the Oregon Health Plan
Matthew Carlson, Ph.D., David Mosen, Ph.D., M.P.H., Charles
Gallia, M.A.
Presented by: Matthew Carlson, Ph.D., Assistant Professor,
Department of Sociology, Portland State University, P.O. Box
751, Portland, OR 97207; Tel: 503.725.9554; Fax: (503) 725.3957;
E-mail: carlsonm@pdx.edu
Research Objective: This paper examines disparities in
patient satisfaction and access to health care and explores the
net impact of satisfaction and access on use of preventive,
outpatient and emergency department use.
Study Design: Data are derived from Oregon's statewide
Medicaid CAHPS survey (response rate=51%). Survey data
were merged with health care claims for preventive, outpatient
and ER use in the 6 months before and 6 months after survey
administration.
Population Studied: 512 adults enrolled in 1998-2000 in the
largest Non-Profit Health Plan Serving Oregon Health Plan
enrollees.
Principal Findings: Predisposing and enabling characteristics
explained satisfaction, but did not predict use after controlling
for satisfaction. Need characteristics (health status) predicted
poor perceived access but increased utilization. Health care
ratings and prior health care use predicted outpatient and ER
use.
Conclusions: Health care utilization, including outpatient and
ER use, is directly influenced by consumers' experiences with
their care and indirectly influenced by predisposing and
enabling characteristics. ER users who have positive
experiences with their care are more likely to continue to use
the ER.
Implications for Policy, Delivery or Practice: Improving
appropriate use of health care services and reducing
innapropriate use among Medicaid enrollees requires
understanding the complex interplay between individual
characteristics, expectations, and experiences with care.
• Welfare Reform’s Influence on Healthcare Use among
Young Children
Daniel Choi, B.A., Laura Amsden, M.P.H., M.S.W., Jane Holl,
M.D., M.P.H.
Presented by: Daniel Choi, B.A., Project Coordinator,
Feinberg School of Medicine, Northwestern University,
Institute for Health Services Research and Policy Studies, 339
E. Chicago Avenue, Chicago, IL 60611; Tel: 312.503.2834; Fax:
312.503.2936; E-mail: dkchoi@northwestern.edu
Research Objective: To describe the healthcare use among
young children whose mothers were affected by the 1996
“welfare reform” policies aimed at promoting work and
reducing receipt of welfare.
Study Design: The study is a five-year longitudinal panel study
(1999-2004) consisting of annual in-person interviews, linked
administrative data and medical chart reviews. Phase I:
During the annual interview, mothers provided names/contact
information of all of their child’s medical providers since the
previous interview. Using this information, the child’s
medical charts were obtained. Phase II: Abstraction and
coding of medical chart data included information about wellchild and other visits (i.e., sick, emergency, follow-up,
hospital) including ICD9 codes, treatment plans,
immunization records, developmental milestones, indications
of abuse/neglect and birth history. Phase III: Data was
aggregated into appropriate timeframes, and bivariate and
multivariate analyses were conducted.
Population Studied: The study includes a random stratified
sample of mothers (n=1,363) receiving welfare in the fall 1998
in Illinois and a sub-sample of their children (n=554), 0-3 years
of age at Year 1 of the study.
Principal Findings: Annual response rates were between 9095%. Medical charts have been retrieved for 91% of the child
sample and to date, ~50% of charts have been abstracted
(n=265). Approximately 80% of children remained covered by
Medicaid during the study; average age of children in Year 3
was 4.6 years (1-10 years); average household income of
children in Year 3 was ~$15,761. Children 1-2 years of age
averaged 3.5 age appropriate well-child visits; children 2-5
years averaged 5.1 visits, and children 6-10 averaged 5.4 visits.
Children of all ages received ~40% of the American Academy
of Pediatrics recommended well-child visits. Children of
working mothers had significantly more age appropriate wellchild visits (4.9) than children whose mothers were not
working (4.0, p<.05). Children of either working or nonworking mothers had significantly more other visits (9.0 and
7.5, respectively) than well-child visits (4.9 and 3.9,
respectively, p<.001).
Conclusions: While all children in this population received an
inadequate number of age appropriate well-child visits, work
promotion policies may have contributed to improved wellchild care. Nevertheless, children of mothers affected by
welfare reform, regardless of their mother’s work status, had
more other visits than well-child visits.
Implications for Policy, Delivery or Practice: Welfare reform
appears to have a modest influence on well-child care visits.
Further study is needed to examine the impact of the large
number of children’s other healthcare visits on a mother’s
ability to achieve work promotion/welfare reduction goals.
Primary Funding Source: NICHD (UO1 HD39148)
• Medicaid Patients Who Left Hospitals Against Medical
Advice: Trend Analysis
Kyusuk Chung, Ph.D., Ross Mullner, Ph.D., Sally Freels, Ph.D.
Presented by: Kyusuk Chung, Ph.D., University Professor,
Health Administration, Governors State University, 1
University Parkway, University Park, IL 60466; Tel:
708.534.4047; Fax: 708.534.801; E-mail: k-chung@govst.edu
Research Objective: It has been well documented that,
compared with patients who are regularly discharged, those
who leave against medical advice (hereafter AMA) are more
often Medicaid recipients. Patients leaving AMA were known
to have multiple readmissions with longer lengths of hospital
stay. There have been intervention programs and this study
examines whether AMA discharges among Medicaid
recipients have significantly decreased across time, taking into
account confounding factors including shorter stays
associated with managed care and a potentially overestimated
AMA size implied by recent studies suggesting that hospitals
tend to report transfers as AMA discharges to get reimbursed
fully.
Study Design: Data are from the National Center for Health
Statistics’ National Hospital Discharge Survey. For each of
the years 1980, 1985, 1990, 1995, and 2000, a separate logistic
multiple regression model was fit using a binary indicator for
AMA as the dependent variable. Covariates included
diagnoses (substance/alcohol-related mental disorder and
other mental disorders), length of stay, hospital
characteristics, and patient characteristics. Length of stay was
used as a covariate because with managed care, length of stay
has been shortened and there are typically shorter stays of
patients with AMA discharges. Length of stay can also control
for the suspicious AMA discharges that have a same day
admission to another hospital. The significance of changes in
effects across time was evaluated by fitting a single model
using data from all of the five years pooled together. The
variable YEAR was entered as a single continuous variable,
and interactions were tested between year and each of the
other independent variables. If the effect of a given
independent variable has increased or decreased
systematically from 1980 to 2000, the trend is reflected in the
corresponding interaction term with year.
Population Studied: adult patients discharged alive from
Non-Federal short-stay hospitals in the United States.
Principal Findings: The relative odds ratio of leaving AMA for
Medicaid discharges significantly increased during the study
period compared to their counterparts who are privately
insured (OR: 1.95, 2.12, 2.72, 2.60 and 3.19, respectively for the
year 1980, 1985, 1990, 1995, and 2000) (p<.0001). As
expected, substance-related mental disorders was a strong
predictor of AMA discharges, but its relative odds ratios
significantly decreased (OR: 23.62, 24.36, 21.02, 16.04 and
13.40) (p<.0001). Alcohol-related mental disorders and other
mental disorders showed similar linear trends. Finally, the
relative odds ratio for stays of less than one day compared
with stays of 7 and more fluctuated (OR: 15.51, 11.88, 7.30,
10.00 and 23.41) (p=0.46).
Conclusions: AMA discharge rates among Medicaid patients
significantly increased relative to those that are privately
insured. This happened despite a rapid decrease in AMA rates
among those with mental disorders who tend to account for a
majority of AMA discharges.
Implications for Policy, Delivery or Practice: Our finding
implies that intervention programs may not have been
effective in reducing AMA discharges for Medicaid patients
relative to those that are privately insured. For states that
have grappled with rising Medicaid costs, it is necessary to
review current Medicaid discharge planning policies to ensure
that institutions participating in Medicaid provide more
effective discharge planning.
Primary Funding Source: GSU fund
• Do Nonprofit Hospitals Pay Their Way and Justify
Favorable Tax Treatment?
Helen Citkina, Ph.D.
Presented by: Helen Citkina, Ph.D., Postdoctoral Scholar,
School of Public Health, University of California, Berkeley, 140
Warren Hall, MC7360, Berkeley, CA 94720; Tel: 510.849.2838;
Fax: 510.643.1853; E-mail: hcitkina@uclink.berkeley.edu
Research Objective: This study addresses the effect of
hospital ownership on the delivery of services to the medically
indigent patients and their communities. Thus, it defines and
quantifies two measures of community benefits,
uncompensated care and broad community dividends, to
evaluate whether amount of community benefits provided by a
tax-exempt hospital is at least equal to the value of the tax
subsidy plus the amount of community dividends provided by
an investor-owned hospital. We also try to address whether
investor-owned hospitals locate in areas with lower need for
community benefits. Lastly, the study investigates what
community and hospital market characteristics (such as
hospital competition, concentration, and managed care
penetration) affect hospital supply of community benefits.
Study Design: We use regression analysis, TSLS, to estimate
the effect that hospital ownership has on hospital’s supply of
community benefits.
Population Studied: We use three years of data (1998-2000)
to assess the impact of area, health care system and financial
pressures on two measures of community benefits by
California’s general acute care hospitals. Hospital-level data
came from the Annual Hospital Disclosure Reports published
by Caifornia’s Office of Statewide Health Planning and
Development (OSHPD). The analyses exclude specialty
hospitals, long-term care facilities as well as Kaiser hospitals
since they treat Kaiser members only and do not report to
OSHPD. Then the sample was reduced to 869 non-profit and
investor-owned hospitals (government and district hospitals
were excluded).
Principal Findings: Using data from 1998 to 2000 from
general acute care hospitals in California we find that the
amount of community dividends provided by a tax-exempt
hospital is equivalent to the value of the tax contributions plus
the amount of community dividends provided by an investorowned hospital in a similar market although investor-owned
hospitals indirectly locate in better-insured areas. These
results are sensitive to the definition of community benefits.
Hospitals located in more competitive markets with higher
managed care penetration supply fewer community dividends.
Conclusions: Non-profit ownership is related to the volume
of community benefits supplied by a hospital. The answer to
the question whether non-profit hospitals justify their taxexempt status depends on the definition of community
benefits. Since investor-owned hospitals are located to face
lower demand for community benefits, then non-profit
hospitals provide community services by locating in areas with
higher demand for charity care and by operating emergency
room services that uninsured often use. Without tax subsidies
such areas and uninsured population may be underserved.
Therefore, tax-exemption is justified once we define
community dividends broadly as well as in providing care in
underserved areas and populations.
Implications for Policy, Delivery or Practice: Results of this
research suggest more explicit identification of the community
benefits expected of non-profit hospitals in return for special
tax treatment.
• The Impact of Health Services Regulation on Insurance
Coverage
Christopher Conover, Ph.D.
Presented by: Christopher Conover, Ph.D., Assistant Research
Professor, Terry Sanford Institute of Public Policy, Duke
University, Box 90253, Durham, NC 27708; Tel: 919.684.8026;
Fax: 919.684.6246; E-mail: conoverc@hpolicy.duke.edu
Research Objective: To assess the impact of health services
regulation on the cost of health care and its ancillary impacts
on number of uninsured
Study Design: Literature synthesis of research on the benefits
and costs of federal and state health services regulations,
including regulation of health facilities, health professionals,
health insurance, FDA and medical malpractice.
Population Studied: Net impact of health services regulation
was calculated as percent of personal health care expenditures
and projected effect on number of uninsured estimated using
standard elasticity estimates.
Principal Findings: The net economic impact of health
services regulations equals 9.6 percent of personal health care
expenditures. Approximately 7 million uninsured (1/6 of
uninsured total) may be attributable to regulatory costs.
Conclusions: The net impact of regulation is sizable in the
health care industry, in excess of $130 billion a year,
contributing to the large number of uninsured and diverting
resources that otherwise could more than finance universal
coverage.
Implications for Policy, Delivery or Practice: Reductions in
health services regulations offer an important components of
strategies to expand coverage.
Primary Funding Source: AHRQ
• A CAP that Works: The Southeastern Kentucky
Community Access Program
Julia Costich, J.D., Ph.D., Frances Feltner, R.N.
Presented by: Julia Costich, J.D., Ph.D., Assistant Professor,
School of Public Health, Univ. of Kentucky, 121 Washington
Street, Lexington, KY 40536; Tel: 859.257.6712; Fax:
859.257.3909; E-mail: jfcost0@uky.edu
Research Objective: The Southeast Kentucky Community
Access Program (SKYCAP) has won national acclaim for its
service to low-income uninsured residents of four Appalachian
counties. This study assesses SKYCAP's effectiveness in
reducing emergency department visits and hospitalizations in
the target population and suggests directions for further
inquiry to identify elements of successful CAPs.
Study Design: We compared service utilization by SKYCAP
enrollees in the 12 months before SKYCAP enrollment with
utilization in the 12 post-enrollment months, noting variation
by targeted health problem and type of service. We derived
estimates of cost savings associated with the avoidance of
unreimbursed hospital care using median reimbursement
rates for the same or similar services.
Population Studied: Uninsured, low-income clients of a fourcounty Community Access Program in southeastern Kentucky
diagnosed with heart disease, diabetes, asthma, hypertension,
or mental illness.
Principal Findings: Most of SKYCAP's staff are lay health
workers from the communities they serve, and this staffing
contributes to both the cost-effectiveness of the program and
its ability to serve hard-to-reach persons with limited trust in
the health care system. SKYCAP enrollment was effective in
reducing clients' need for hospital-based care. When
utilization rates in the 12 pre-enrollment and 12 postenrollment months were compared, emergency department
visits dropped by 92 percent and hospitalizations dropped by
88 percent across all diagnoses. The greatest cost savings
were realized for clients with diagnoses that posed the highest
risk of true health emergencies, notably heart disease, and
with asthma, for which only one hospitalization occurred
following program enrollment. Consistent access to
prescription drugs and routine health monitoring were critical
to SKYCAP's achievements. The savings in unreimbursed
emergency department and inpatient care alone equalled 244
percent of HRSA's investment in the CAP grant for the year.
SKYCAP's success is particularly noteworthy because it
operates in a chronically under-resourced region.
Conclusions: SKYCAP exemplifies the potential achievements
of Community Access Programs: not only has it reduced the
burden of uncompensated care in a region with high rates of
uninsurance and chronic disease, but it has improved the
quality of life for the large majority of its clients at strikingly
low cost. This outcome has been achieved by attending to
clients' essential health care needs, notably prescription drugs
and outpatient services. Savings have been realized primarily
by the hospital sector, while costs in the form of
uncompensated care have been borne primarily by physicians
in the SKYCAP service area. For those physicians who are not
hospital employees, this pattern of cost-shifting may make
SKYCAP difficult to sustain. Loss of federal funding in this
under-resourced region is also a constant threat.
Implications for Policy, Delivery or Practice: The striking
success and low unit cost of the SKYCAP program argue in
favor of continued federal and state funding for similar
community-based initiatives. SKYCAP also illustrates the
potential problems of a health care system that forces underresourced localities to take on the added burden of care for
those who suffer the effects of longstanding lack of health care
access. Findings from SKYCAP suggest that broad
implementation of its model could have a significant impact
on the burden of chronic disease care nationally.
Primary Funding Source: HRSA
• Hospital Use by Dual Medicare-Medicaid Eligibles in Risk
Health Maintenance Organizations and Fee-for-Service,
California, 1991-1996
Nasreen Dhanani, Ph.D., June O'Leary, Ph.D, Elizabeth Sloss,
Ph.D., Glenn Melnick, Ph.D.
Presented by: Nasreen Dhanani, Ph.D., Consultant, Health,
RAND Corporation, 1700 Main Street, Santa Monica, CA
90401; Tel: 310.393.0411 Ext. 6214; Fax: 310.451.7061; E-mail:
dhanani@rand.org
Research Objective: To establish rates of inpatient hospital
use among dual Medicare-Medicaid eligibles in Medicare risk
health maintenance organizations (HMO) and provide
comparisons with similar populations in Medicare fee-forservice (FFS) in California from 1991 through 1996
Study Design: Enrollment data on Medicare beneficiaries
from the Centers for Medicare and Medicaid Services (CMS)
were linked to inpatient discharge data from the California
Office of Statewide Health Planning and Development for
1991-1996. Three measures of inpatient use were estimated:
(1) admissions per thousand beneficiaries, (2) total days per
thousand beneficiaries, and (3) average length of stay in days.
Measures were also computed by age and gender. The unit of
analysis is person-year.
Population Studied: The sample included all dual MedicareMedicaid eligibles, 65 years of age and older, enrolled in a
Medicare risk HMO or covered by Parts A and B of traditional
FFS Medicare in California between 1991 and 1996. The
sample for each year was restricted to Medicare beneficiaries
who were Medicaid-eligible for at least one month during that
year. Beneficiaries with end-stage renal disease were
excluded.
Principal Findings: In California, enrollment of dual eligibles
in Medicare risk HMOs increased from 5.9% in 1991 to 13.1%
in 1996 and the number of person-years among all dual
eligibles increased from 415,739 to 452,129 during this period.
At the beginning of the period, dual-eligibles in Medicare
HMOs used slightly more than half the inpatient days per
thousand beneficiaries as FFS dual-eligibles. The difference
narrowed over time from 2228 (HMO) vs. 3982 (FFS) days per
thousand beneficiaries in 1991 to 1792 (HMO) vs. 2775 (FFS)
days per thousand beneficiaries in 1996. In 1991 and 1996,
the differences were due to lower rates of admission and
shorter lengths of stay for dual-eligibles in risk HMOs. Several
socio-demographic differences persist between dual eligibles
in FFS and HMO.
Conclusions: Dual eligibles in Medicare risk HMOs had lower
admission rates, shorter lengths of stay, and fewer inpatient
hospital days than the dual eligibles in Medicare FFS.
Implications for Policy, Delivery or Practice: To date,
measures of hospital use by dual-eligibles while enrolled in
HMOs have not been reported. These data on inpatient
utilization among dual eligibles in Medicare risk HMOs
provide important baseline information that can be used to
monitor this group of vulnerable beneficiaries in managed
care systems.
Primary Funding Source: RWJF, ASPE/DHHS
• Enrolling Children in Public Insurance: SCHIP, Medicaid
and the Impact of State Policy Choices
Karl Kronebusch, Ph.D., Brian Elbel, M.P.H.
• Factors Influencing Medicaid Recipient Switching
Behavior in Medicaid MCOs
Cheryl Fahlman, Ph.D.
Presented by: Brian Elbel, M.P.H., Doctoral Student, Health
Policy and Administration, Yale University School of Public
Health, P.O. Box 208034, New Haven, CT 06520; Tel:
203.809.0517; Fax: 203.785.6287; E-mail: brian.elbel@yale.edu
Research Objective: The Balanced Budget Act of 1997
established federal grants to the states to create state
children's health insurance programs. This presented the
states with a number of implementation choices concerning
administrative models for the new programs, as well as
choices about eligibility standards, enrollment simplification,
crowd-out and cost sharing requirements. At the same time,
the states were also implementing welfare reform. We
describe the most important of these implementation choices
and, using data from the Current Population Survey, we
estimate the impacts of these policy choices in this multiprogram environment.
Study Design: Cross-sectional, using the 2001 Current
Population Survey. The probability of enrollment in Medicaid,
SCHIP, Private Insurance and any Insurance was estimated
using a logit model. This allows us to assess the impact of
state Medicaid, SCHIP, and TANF policy choices on children’s
health insurance enrollment.
Population Studied: Children 17 and under in the United
States with family incomes of less than 400% of the Federal
Poverty Level.
Principal Findings: The results indicate that SCHIP programs
that are administered as Medicaid expansions are more
successful in enrolling children than either separate SCHIP
plans or combination programs. States that remove asset
tests and implement presumptive eligibility and selfdeclaration of income have higher enrollment levels.
Continuous eligibility and adoption of mail-in applications
have no effect on overall enrollment. Waiting periods and
premiums reduce enrollment. Stringent welfare reform
reduces children's enrollment, despite federal policy that was
intended to protect children from the consequences of welfare
reform. The negative impacts of a number of these policy
reforms substantially reduce enrollment, potentially offsetting
the more favorable impacts of other policy choices.
Conclusions: We estimate that if all states adopted the policy
options that facilitate program use, enrollment for children
with family incomes less than 200 percent of the poverty line
could be raised from the current rate of 42 percent to 58
percent.
Implications for Policy, Delivery or Practice: Policy makers
and researchers advocate enrollment simplifications as a
means to increase enrollment. However, while some of these
policy choices can lead to an increase in enrollment, some do
not. In addition, many welfare policies actually lead to a
decrease in enrollment. If the goal is to increase enrollment in
children’s health programs, policy makers can and should
adopt the successful policies and avoid those that reduce
enrollment.
Presented by: Cheryl Fahlman, Ph.D., Senior Research
Associate, HRET, 325 Seventh Avenue, N.W., Washington, DC
20004; Tel: 202.638.1100; Fax: 202.626.2255; E-mail:
cfahlman@netzero.net
Research Objective: The primary aim of this study was to
provide an understanding of factors influencing Maryland
Medicaid recipients’ MCO switching behavior.
Study Design: The research built upon a large natural
experiment, in which approximately 319,000 Medicaid
recipients were enrolled in 9 MCO plans between June and
December 1997, in conjunction with the Maryland Medicaid
HealthChoice program. The study used enrollment data, feefor-service claims, and MCO encounter data to follow the
cohort through their transition from fee-for-service into
HealthChoice. Utilization data, both medical and drug, were
collected from July 1996 to December 2000. Logistic
regression techniques were used to estimate the determinants
of switching behavior. Threetypes of switches were
investigated including those related to initial enrollment (free
switch), an interruption in Medicaid eligibility, and anniversary
switches. Domains analyzed were: the recipient’s stock of
health capital, health shocks, perceived returns on health
investment, and perceived quality of the source MCO.
Population Studied: Five thousand eight hundred and four
children qualified for the asthma cohort based on age
(between 5 and 18 years old at time of MCO enrollment), a
minimum of 3 months of continuous Medicaid enrollment
during the baseline FFS period, and evidence of asthma at
baseline.
Principal Findings: The majority of recipients (60.0%) did
not switch MCOs at any time during their HealthChoice
enrollment. Yet 40.0% experienced at least one switch during
their enrollment; with a small minority of recipients (0.3%)
having four switches during the study period.
The multivariate models suggest that claims/encounter and
eligibility data can explain some of the individual decisions
regarding staying or switching MCOs among pediatric
Medicaid recipients with asthma.
Only 252 (4.5%) of recipients elected to take a free switch
unexpectedly the method of initial enrollment (auto vs. self)
did not play a significant role in the decision process.
Recipients with a usual provider relationship were actually
more likely to undertake a free switch, yet asthma itself does
not appear to play a role in the decision to undertake a free
switch.
Auto-enrolled recipients who switch due to an interruption in
Medicaid eligibility almost 50% more likely to switch MCOs.
The presence of a usual provider relationship was not
predictive of whether recipients switched or not, but the
directionality showed that recipients with a relationship were
slightly (17%) less likely to switch.
For recipients eligible for an anniversary switch, recipients
with a usual provider relationship were 32% more likely to
remain with their original MCO. System-level characteristics
of MCO quality did not appear to influence provide additional
information to recipients’ decision process.
Conclusions: Individual health stock characteristics played an
inconsistent role in switching decisions. Although a large
segment of the study cohort was auto-enrolled by the State,
and auto-enrollment played a part in some of decisions to
switch MCOS, but it was not consistent. While the presence
of a usual provider relationship was important in switching
decisions. The source MCO plays an important role in the
decision process, becoming more pronounced with later
switching decisions. Since system-level characteristics did not
influence the decision process, this suggests there is some
unmeasured characteristic of the MCO that plays an
important role. The relationship between the smaller MCOs
and FreeState was consistent throughout all the switching
decisions modeled in this study, where the smaller MCOs
were more likely to have recipients who made the decision to
switch.
Implications for Policy, Delivery or Practice: States should
reduce the level of auto-enrollment for Medicaid recipients.
Using a variety of outreach methods, some states have
reduced their auto-enrollment rate to between one and eleven
percent. Certain marketing approaches work better in
different populations, yet DHMH only used written materials,
and significant problems were encountered during the
process. Although the startup phase of HealthChoice is
completed, the program is continually enrolling new recipients
and re-enrolling those with interruptions in eligibility.
The state should emphasize the development of a usual
provider relationship for every recipient. The State, MCO, and
provider can all play a role in the development of this
relationship. When designing HealthChoice, Maryland
Medicaid recognized the importance of patient-provider
relationship by encouraging the inclusion of historic providers
in the provider network. Yet for many recipients, access to
these providers did not translate into explicit decisions to
follow a particular provider. Moreover, the failure to do so
appears based on this study’s findings, to predispose
recipients to future switches among MCOs.
Primary Funding Source: Dissertation
• Effect of Stable Insurance on Access and Use of Health
Care for Children in Low-Income Areas of New York City
Gerry Fairbrother, Ph.D., Roberta Scheinman, M.P.H., Beth
Osthimer, JD, Kerry-Ann Newell, M.S.
Presented by: Gerry Fairbrother, Ph.D., Senior Scientist,
Health and Science Policy, New York Academy of Medicine,
1216 Fifth Avenue, New York, NY 10029; Tel: 212.822.7398;
Fax: 212.822.7369; E-mail: gfairbro@nyam.org
Research Objective: The purpose of this study is to examine
how access and use varies by length of time uninsured or
insured through public coverage for low-income children.
Study Design: A cross-sectional random-digit dial survey of
parents of publicly insured or uninsured children was
conducted in New York City from December 2002 to February
2003. Questions about access to and use of medical care
were asked about a focal child (n=1172). Length of time
uninsured or insured was ascertained. Access and use were
compared for children in four categories: insured for more
than 12 months; insured for less than 12 months; uninsured
for less than 6 months; uninsured for more than 6 months.
Population Studied: The population studied was children
who were publicly insured or uninsured in New York City from
December 2002 to February 2003
Principal Findings: Chi-square bivariate comparisons of
access and use in the four time-insured categories revealed a
gradient based on time insured. The likelihood of not having
a usual source of care increased with time insured (p<.01) as
did the likelihood of not seeing a particular medical provider
(p<.01). Long term uninsured children were also less likely to
have well care visits (p<.05), prescriptions filled (p<.01), and
dental visits (p<.05) than shorter term uninsured and insured
children. The level of delayed or unmet need for well care
visits (p<.05), prescription medication (p<.01) and dental
visits (p<.05) increased with time uninsured. Multivariate
analyses controlling for demographic factors confirmed the
gradient evident in the bivariate results. Using children
insured for a year or more as a reference group, the odds
ratios increased across the time insured categories for all
access and use variables.
Conclusions: In this sample, presence or absence of
insurance predicted access and utilization. The longer the
time insured, the greater the access to and use of care;
conversely, the longer the spell of uninsurance, the poorer the
access to and use of care. Thus, stability in coverage is
important.
Implications for Policy, Delivery or Practice: It is important
to put in place policies that promote stability of coverage.
Such policies would include those that promote retention of
eligible children in public insurance programs through
streamlined and simplified renewal processes. We need to
ensure that gains in simplification made due to expansion of
public insurance programs in the late 1990’s are not rolled
back during more difficult economic times.
Primary Funding Source: Altman Foundation and William T.
Grant Foundation
• Why Are Latinos the Most Uninsured Racial/Ethnic
Group of US Children?
Glenn Flores, M.D., Milagros Abreu, M.D., Sandra Tomany,
M.S.
Presented by: Glenn Flores, M.D., Director, Community
Outcomes; Associate Director, Center for the Advancement of
Urban Children, Pediatrics, Medical College of
Wisconsin/Children's Hospital of Wisconsin, 8701 Watertown
Plank Road, Milwaukee, WI 53226; Tel: 414.456.4454; Fax:
414.456.6385; E-mail: gflores@mail.mcw.edu
Research Objective: Latinos continue to be the most
uninsured racial/ethnic group of US children, with 23% (over 3
million) uninsured (compared with 14% African-American,
12% Asian/Pacific Islander, and 8% white children who are
uninsured). Among poor uninsured children, Latinos
outnumber all other racial/ethnic groups, including whites.
Not enough is known, however, about the risk factors for and
consequences of uninsurance in Latino children. The goal of
this study, therefore, was to identify risk factors for and
consequences of being uninsured in Latino children.
Study Design: Cross-sectional survey of 1,100 parents (900
Latino) at urban, predominantly Latino community sites,
including supermarkets, beauty salons, and laundromats.
Subjects were asked 76 questions on access and health
insurance. “Uninsured” was defined as the parent reporting
that the child had no health insurance coverage at the time the
parent was interviewed.
Population Studied: Parents/legal guardians of 1,100
community-dwelling children in predominantly Latino
communities in the greater Boston area known to have high
rates of uninsurance.
Principal Findings: Uninsured Latino children (n = 167) were
significantly more likely than insured Latino children to be
older (mean age: 9 vs. 7 years; P<0.001), poor (89% vs. 72%;
P<0.001), and to have parents who are limited in English
proficiency (86% vs. 65%; P<0.001), non-US citizens (87% vs.
64%; P<0.001), have lived in the US for < 10 years (59% vs.
39%; P<0.001), married and living with the spouse (67% vs.
51%; P<0.001), and both employed (35% vs. 27%; P<0.001).
33% of parents had applied for insurance for their child but
were rejected or experienced problems, 51% had
unsuccessfully applied for Medicaid in the past, and only 14%
had heard of the State Children's Health Insurance Program
(SCHIP) available in their state. Uninsured Latinos were less
likely than their insured counterparts to have a regular
physician (84% vs. 99%; P<0.001), and significantly more
likely to not be brought in for needed medical care due to
expense (22% vs. 9%; P<0.001), lacking insurance (25% vs.
12%; P<0.001), difficulty making appointments (32% vs. 19%;
P<0.001), inconvenient office hours (18% vs. 11%; P<0.001),
and cultural issues (13% vs. 4%; P<0.001). After adjustment in
multivariate analyses, having parents who are undocumented
(odds ratio [OR], 6.3; 95% CI, 3.3-12.2) or documented (OR,
2.1; 95% CI, 1.2-3.8) immigrants, poverty (OR, 2.7; 95% CI, 1.64.6), having both parents work (OR, 2.3; 95% CI, 1.1-4.7), and
the child’s age (OR, 1.1; 95% CI 1.06-1.14) were the only factors
significantly associated with a child being uninsured, with
neither Latino ethnicity nor any other of 5 variables (the
number of siblings, parental educational attainment, marital
status, English proficiency, and the number of years parents
have resided in the US) associated with lack of insurance
coverage. Compared with insured Latino children, uninsured
Latino children had 34 times the odds (95% CI, 12.7-88.8) of
having no regular physician, and were significantly more likely
to not be brought in for needed medical care due to expense
(OR, 2.9; 95% CI, 1.8-4.7), lack of health insurance (OR, 2.7;
95% CI, 1.7-4.2), difficulty making appointments (OR, 2.0; 95%
CI, 1.3-2.9), and cultural barriers (OR, 3.4; 95% CI, 1.8-6.5).
Conclusions: After adjustment, parental non-citizenship,
having two parents work, poverty, and older child age are
associated with being an uninsured child, but Latino ethnicity
is not. The higher prevalence of other risk factors appears to
account for Latino children’s high risk of being uninsured.
Uninsured Latino children are significantly more likely than
insured Latino children to have no regular physician, and to
not get needed medical care due to expense, lack of health
insurance, difficulty making appointments, and cultural
barriers.
Implications for Policy, Delivery or Practice: Uninsured
Latino children are at great risk for having no regular
healthcare provider, and face multiple financial and nonfinancial access barriers to needed medical care. The study
findings indicate specific high-risk Latino populations that
might benefit most from targeted Medicaid and SCHIP
outreach and enrollment, including children with immigrant
parents and in families where both parents work, older
children, and children living in poverty.
• County-Level Approaches to Increasing Access to Care
for the Uninsured: The California Story
Annette Gardner, Ph.D., M.P.H., James Kahn, M.D., M.P.H.
Presented by: Annette Gardner, Ph.D., M.P.H., Principal
Public Administrative Analyst, Institute for Health Policy
Studies, University of California, San Francisco, P.O. Box
0936, San Francisco, CA 94143; Tel: 415.514.1543; Fax:
415.476.0705; E-mail: algard@itsa.ucsf.edu
Research Objective: In California, counties are responsible
for addressing the health care needs of the uninsured,
including reducing barriers to care and ensuring appropriate
use of services. The last several years have witnessed
significant initiatives in some counties to create and launch
county-level health care access initiatives, e.g., Santa Clara
County's Healthy Kids insurance program and service
expansions such as new clinic facilities. In the face of limited
federal and state reform, and with new funds (e.g., Tobacco
Settlement), counties have demonstrated the willingness and
ability to undertake these initiatives. UCSF has been
conducting research on these programs since 2001, including
administering a 58-county survey describing the distribution
of innovative health-care access efforts in 2002 . We
anticipate re-administering this survey in early 2004,
deepening our understanding of county capacity to engage in
significant reform under adverse economic conditions,
particularly their willingness to undertake coverage
expansions. Our research objectives are:
1. Update the inventory of county-level health care access
programs and compare to 2002;
2. Assess the impact of key factors like rising number of
uninsured and the state budget shortfall on county ability to
undertake health care access programs, particularly coverage
expansions.
3. Identify the resources required by counties to undertake
these initiative
Study Design: We intend to re-administer the internet-based
58-county survey that was administered in early 2004. The
Survey will be amended to provide a more detailed inventory
of coverage expansions, e.g., funding sources, key
stakeholders. We had a very good response rate with the 2002
Survey (75%) and will work to increase this rate while
addressing questions surfaced by the first survey such as type
of coverage approaches being used and actual number of
enrollees.
Population Studied: 58 California counties
Principal Findings: Our findings from the 2002 study
indicated that California counties as a whole had made
progress in connecting people to insurance and services.
While coverage expansions are desired by many they were
implemented by few counties, particularly those counties with
a public Medicaid managed care plan. Since the 2002 study,
in the face of state and local budget shortfalls, we have seen
significant activity in the area of coverage expansions for youth
using tobacco funds (Prop 10). Additionally, a local funder,
the California HealthCare Foundation, is providing planning
and implementation grants to numerous counties to launch
coverage programs. The readministration of the survey would
allow us to capture these new initiatives and better assess the
likelihood of future local expansions
Conclusions: TBD. We will focus on changes since 2002 in
distribution of access initiatives and discuss the factors that
facilitate or impede progress by counties.
Implications for Policy, Delivery or Practice: Though county
or local-level coverage expansions are underway in California
and in other states, there are some who argue that true reform
can only happen at the federal level. However, in the absence
of federal or state reform, it behooves decisionmakers and
researchers to better understand local efforts--capacity, best
practices, outcomes--and consider how these efforts might
inform state and federal policy. Second, we have found it
useful to think of access to care for the uninsured as a
"patchwork" of initiatives, with an emphasis on understanding
how these approaches--services, coverage, outreach--can best
work together. For some California counties, service
expansions are easier to undertake, particularly if the county
has a county-run health care system. This study will allow us
to increase our understanding of how access programs work
in tandem
• Capitation Risk Adjustment for High Risk Populations: A
Test of Alternative Predictive Functions
Greg Gifford, B.A., M.A., Ph.D., Dave Knutson, Michael Finch,
Ph.D.
Presented by: Greg Gifford, B.A., M.A., Ph.D., Research
Scientist, Health, State of Minnesota, 121 East Seventh, St.
Paul, MN 55101; E-mail: greg.gifford@health.state.mn.us
Research Objective: To evaluate the relative performance of
an untransformed ordinary least squares (UNT) vs. a square
root, “complexity adjusted” (SQR) prediction model for use in
risk adjusting capitation rates for adults with physical
disabilities, and other high risk populations.
Study Design: . Concurrent simulation, comparative analysis.
Two distinct capitation risk adjustment models based on the
Chronic Illness and Disability Payment System (CDPS) were
tested and compared for each of the Medicaid Only and
Medicare/Medicaid Dually Eligible sub-populations (N =
10,847 and N = 6,315 respectively) of the larger population of
adults with physical disabilities eligible for MA in CY 1997.
The two competing models were compared to evaluate the
relative predictive performance of alternative mathematical
forms of the prediction functions. The two models tested
were distinguished by the nature of the dependent variable –
CY 1997 charges/payments per member per month (PMPM):
(1) untransformed, vs. (2) the square root of total payments
PMPM. Both models included a prediction error adjustment the “complexity” adjustment. The models were compared
with respect to both individual and group level measures of
predictive performance.
Population Studied: This study was conducted as part of the
evaluation of the feasibility of capitation risk adjustment for a
voluntary, prepaid managed care demonstration designed for
the adult Medicaid (MA) eligible population with physical
disabilities that began September 1, 2001 – the Minnesota
Disability Health Options (MnDHO) project. Secondary data
representing the population of 17,162 adults with physical
disabilities eligible for MA in calendar year 1997 was used for
this study. Program eligibility and diagnosis data were used to
explain/predict total charges/payments for calendar year (CY)
1997.
Principal Findings: For both the MA Only and Dual Eligible
sub-populations, the SQR model predicted mean
charges/payments more accurately than the UNT model for
most of the non-random groups studied. However, the
individual level results (i.e., adjusted R2) were equivocal (MA
Only: R2UNT = 0.363; R2SQR = 0.365; Duals: R2UNT = 0.179;
R2SQR = 0.151).
Conclusions: Since non-random group level performance was
more important to the feasibility of capitation risk adjustment
for MnDHO than individual level performance, we concluded
that the SQR function outperformed the UNT function. A
reasonable interpretation of the results is that the square root
model better and more efficiently accommodates any nonlinearity and interactions involved in relationships among
diseases and “costs” than an UNT model. We recommended
the “square root complexity adjusted” model for MnDHO
based on earlier similar tests, and these results support that
recommendation.
Implications for Policy, Delivery or Practice: The state
planned to implement this prediction function in its program
payment model. In addition, to evaluate the generalizability of
the square root model, we recommend its testing for other
high risk populations (e.g., Medicare frail elderly).
• Spill-over Effects of Medicaid Managed Care on the
Uninsured
Jessica Haberer, M.D., Bowen Garrett, Ph.D., Loren Baker,
Ph.D.
Presented by: Jessica Haberer, M.D., Medicine Fellow, Center
for Primary Care and Outcomes Research, Stanford University,
117 Encina Commons, Stanford, CA 94305; Tel: 650.723.1163;
Fax: 650.723.1919; E-mail: haberer@healthpolicy.stanford.edu
Research Objective: In addition to affecting the Medicaid
population, many policymakers and clinicians are concerned
that the rise of Medicaid managed care (MMC) may negatively
affect the viability and functioning of the health care safety net.
If so, the care of uninsured patients may suffer. This study
aims to determine if the implementation of MMC from 19942001 had spill-over effects on perceived access to care for
uninsured populations.
Study Design: Data from the National Health Interview
Survey (NHIS) was merged with county-level data on MMC
plans. Data on MMC plans included the year of
implementation, mandatory versus voluntary enrollment, use
of primary care case management and use of health
maintenance organizations. Five measures of access to care
were investigated: delay in getting care due to cost, needing
but not getting care due to cost, having a usual source of care,
using emergency services as a usual source of care, and
having any doctor visits in the past year. Multiple regression
analyses were conducted using the first difference method to
account for fixed county-level effects. All findings were
controlled for gender, age, race, ethnicity, income, health
status, and education. Because the NHIS was redesigned in
1997, all regressions were conducted on data from 1994-1996
and 1997-2001 separately, as well as from 1994-2001 together.
Results were then compared to evaluate any influence of the
redesign.
Population Studied: The NHIS samples the noninstitutionalized, civilian population of the United States. This
study investigated the uninsured population in the NHIS from
1994-2001. The uninsured were divided into three age groups:
adults (25-64 years old), young adults (18-24 years old) and
children (less than 18 years old). Uninsured individuals with
chronic heart disease, diabetes and asthma were also studied
separately, as were individuals with varying levels of selfreported health status.
Principal Findings: None of the access to care measures
indicated a consistent effect of any type of Medicaid managed
care on the uninsured. Some statistically significant effects
were seen in the age and chronic disease subgroups of the
uninsured; however, they showed improvement in some
measures and worsening in other measures within each
subgroup. Further, no consistent differences were found
between the uninsured with fair or poor health and the
uninsured with good, very good or excellent health.
Conclusions: The implementation of Medicaid managed care
from 1994-2001 did not have a systematic effect on perceived
access to care for the uninsured.
Implications for Policy, Delivery or Practice: This study
suggests that the implementation of Medicaid managed care
has not negatively affected the ability of the health care safety
net to care for the uninsured. This finding, however, only
reflects perceptions of access to care. Further studies are
needed to determine if the actual delivery of services has been
affected.
Primary Funding Source: AHRQ
• Examination of Total Healthcare Expenditures for
Patients on Long Acting Opioid Medications for the
Treatment of Chronic Pain in a Medicaid Population
Kevin Hawkins, Ph.D., Patricia Grossman, PharmD, Lucinda
Orsini, DPM, M.P.H., Ron Ozminkowski, Ph.D., Onur Baser,
Ph.D.
Presented by: Kevin Hawkins, Ph.D., Senior Economist,
Outcomes Research & Econometrics, The Medstat Group, 777
E. Eisenhower, Ann Arbor, MI 49230; Tel: 734.913.3145; Fax:
734.913.3200; E-mail: kevin.hawkins@medstat.com
Research Objective: To identify factors associated with total
annual healthcare expenditures for Medicaid patients
prescribed a Long Acting Opioid (LAO) medication for chronic
pain management. The LAOs considered were transdermal
fentanyl (TF), controlled release morphine sulfate (CRMS) and
controlled release oxycodone (CRO).
Study Design: Medicaid beneficiaries from three states during
1999 - 2000 were studied. Patients were followed for at least
one year, starting with their first LAO prescription in 1999.
Patients who did not have a LAO in the six months prior to
that index date were labeled ‘incident’, while patients with a
history of LAO use were labeled as ‘prevalent’. Patients were
then grouped by the opioid they received on the index date.
Disease-type, demographics, health status, healthcare
utilization, and expenditures were measured and compared
among the three LAO cohorts. LAO costs and total annual
healthcare expenditures by LAO cohort were compared using
descriptive and multivariate analyses, for the incident and
prevalent patient samples.
Population Studied: 13,360 patients were included in the
study. Of these, two thirds were incident and one third was
prevalent. Forty nine percent of the patients were on CRO,
23% on TF, and the remaining 28% were on CRMS.
Principal Findings: Descriptive results indicate that incident
(I) and prevalent (P) LOA annual cost for CRO ($1,361 I;
$4,146 P) were significantly higher than costs observed for TF
($1,202 I; $3,061 P) or CRMS ($919 I; $3,572 P) (p<0.01).
After controlling for confounding characteristics, total annual
health expenditures in the CRO incidence sample were similar
to the CRMS sample. However, total annual healthcare
expenditures for the CRO population were significantly lower
than expenditures for the TF population, with an annual cost
savings of about $916 (p<0.01). Economic differences were
not noted among the prevalent LAO populations.
Conclusions: : In the incident sample, patients on TF cost
about $916 more per year (p<0.01), on average, compared to
similar CRMS and CRO patients. Expenditure differences were
not observed in the prevalent populations.
Implications for Policy, Delivery or Practice: Total cost, not
just pharmaceutical costs, should be considered when making
policy decisions about insurance coverage for LAO drugs.
Primary Funding Source: Purdue Pharma
• Quality of Care Variations among Diabetic Medicaid
Beneficiaries: What the Data Can Tell Us
Ronda Hughes, Ph.D., M.H.S., R.N., Barbara Starfield, M.D.,
M.P.H., Helen Burstin, M.D., M.P.H.
Presented by: Ronda Hughes, Ph.D., M.H.S., R.N., Health
Scientist Administrator, Center for Primary Care, Prevention,
and Clinical Partnerships, Agency for Healthcare Research and
Quality, 540 Gaither Road, Rockville, MD 20852; Tel:
301.427.1578; Fax: 301.427.1595; E-mail: rhughes@ahrq.gov
Research Objective: This multi-state study evaluates the
impact of Medicaid managed care on resource utilization
among adult beneficiaries with diabetes by type of Medicaid
eligibility and sets forth the methodological challenges in
using claims data from multiple states. It is hypothesized that
as patients move into managed care arrangements, the
clinical detail of the administrative data diminishes, therefore
limiting the ability to assess the quality of care.
Study Design: This study uses State Medicaid Research Files
(SMRF) maintained by the Centers for Medicare and Medicaid
Services for 1996 through 1998, to assess outpatient and
inpatient utilization among all adult Medicaid beneficiaries,
age 18 and over. This includes patients that qualify for
Medicaid services under the Aid for Families with Dependent
Children (now Section 1931 eligibility) income provisions, the
blind and disabled part including Supplemental Security
Income (SSI), and the aged provisions of the Medicaid
program.
SMRF data were used to assess the diagnostic information
associated with specific health care services, including rates of
hospitalizations for diabetes and other conditions, diabetic
measures including use of injectibles and oral hypoglycemics,
utilization of outpatient services, and co-morbidities. Diabetic
patients were identified if they had at least two diagnoses for
diabetes during the year. Diabetic adult beneficiaries were
further stratified by: 1.) length of enrollment in Medicaid (e.g.,
individuals enrolled in Medicaid 0 – 5 months, 6 to 12
months, and at least 12 continuous months); 2.) enrollment in
managed care or fee-for-service (FFS); and 3.) type of eligibility
(e.g., AFDC, blind and disabled non elderly, and elderly).
Population Studied: Adult Medicaid beneficiaries with
diabetes.
Principal Findings: Using available data, this study found that
frequencies of receipt of care for diabetics was limited by
whether Medicaid patients were in managed care.
Hospitalization rates with a primary diagnosis of diabetes
ranged from 8.1 to 364.9 and the average number of
emergency department visits was 2.6. Utilization differences
in hemoglobin A1c measurement at least once in 12 months
or a lipid profile in the past two years varied among subpopulations and states by as much as 22.6 percent.
Hospitalizations, emergency department visits, and rates and
having a retinal eye exam increased with age and number of
co-morbidities. There were significant variations in number of
outpatient visits and type of services utilized among the
different enrollee groups, associated with the completeness of
the clinical content of the data.
Conclusions: As the clinical content of the SMRF for
outpatient services was limited, findings must be interpreted
cautiously. The methodological issues involved in using the
Medicaid claims data for purposes of government oversight
and quality of care improvement initiatives can prohibit use of
the data for assessing the quality of care if outpatient data is
available for only certain Medicaid sub-populations. Managed
care penetration, effects the ability to examine utilization for
diabetics due to data availability.
Implications for Policy, Delivery or Practice: The
implications of these findings for health care policy and future
research will be discussed, including future research using
state maintained Medicaid claims files as well as implications
for investigation of utilization among dual eligibles and
individuals with multiple chronic conditions.
• Patterns of Health Insurance Coverage in a Rural
Hispanic Border Community
Tricia Johnson, Ph.D., Amy Bartels, M.P.H.
Presented by: Tricia Johnson, Ph.D., Assistant Professor,
Department of Health Systems Management, Rush University
Medical Center, 1700 West Van Buren Street, TOB Suite 126B,
Chicago, IL 60612; Tel: 312.942.7107; Fax: 312.942.4957; Email: tricia_j_johnson@rsh.net
Research Objective: This study uses micro-data from a
unique community health data system to study the patterns of
insurance coverage for children who utilized health care
services over a three-year period of time across race and
ethnicity, age, and geographic proximity to health care
providers.
Study Design: We use data from health care providers and
health-related organizations in Yuma County, Arizona to
create the Yuma County Community Health Data System
(YCHDS). The YCHDS merges data from the hospital system,
federally qualified community health centers, private pediatric
practices, state Medicaid and immunization data, employerbased health insurance and a survey of primarily Hispanic
neighborhoods.
We create seven main patterns of health insurance coverage
experienced by children utilizing some form of health care in
each of three years. The patterns are comprised of Medicaid
or SCHIP, private insurance and spells without insurance.
Population Studied: Yuma County is a sparsely populated
county spanning more than 5,000 square miles in the
southwestern corner of Arizona. The county’s proximity to the
Mexican border; the presence of relatively large numbers of
migrant workers; and the presence of a relatively small
population in a large geographic area are characteristics that
make it especially difficult for children to obtain adequate
health insurance coverage and to access primary care. More
than 60% of children age 0-19 are Hispanic. The sample
includes 19,020 children ages 0 to 17 in 1999 who utilized at
least one service in each of the three years of study, 1999 to
2001.
Principal Findings: Nearly three-quarters of the children in
the sample have a single consistent source of coverage, either
Medicaid or private insurance, across the three years. An
additional 16% switch between Medicaid and private
insurance with no uninsured spells. Overall, 89% of the
children experienced no uninsured spell of medical care
during the three-year study period, while 11% of the children
experienced at least one spell of medical care without
insurance. Nearly 7% of the children switched between
Medicaid and no insurance.
Conclusions: We show that having no insurance coverage is
not synonymous with receiving no medical care. In this very
low income community, where nearly one in four families with
dependent children live below the federal poverty line, more
than one in ten children experienced at least one spell of
medical care without insurance over three years. Most
children seeking medical care, however, experience one year or
less without insurance.
Implications for Policy, Delivery or Practice: In an effort to
reduce Medicaid expenditures, states such as Arizona are
considering a shift to more frequent re-enrollment and
eligibility checks. These changes, coupled with the lack of
assistance with re-enrollment processes, are likely to increase
churning between Medicaid and no insurance. Maintaining a
consistent source of health care coverage is likely to reduce
unnecessary and inappropriate health care utilization for lowincome children.
• The Impact of Demographic and Labor Force
Participation Changes on Health Care Utilization
Tricia Johnson, Ph.D., William Johnson, Ph.D., Amy Bartels,
M.P.H.
Presented by: Tricia Johnson, Ph.D., Assistant Professor,
Department of Health Systems Management, Rush University
Medical Center, 1700 West Van Buren Street, TOB Suite 126B,
Chicago, IL 60612; Tel: 312.942.7107; Fax: 312.942.4957; Email: tricia_j_johnson@rsh.net
Research Objective: The first members of the baby boom
generation are now approaching the ages when the incidence
of disability increases. The increases are likely to overwhelm
public and private insurance and the welfare plans that serve
persons with disabilities unless the plans are significantly
changed. This project examines the effects of the changing
size and composition of the baby boom-aged labor force on
the types of disabilities qualifying for Social Security Disability
Insurance (SSDI) and Medicare for men and women age 40 to
64. In addition, we explore how health care utilization and
expenditures differ across disabling conditions.
Study Design: This study is a retrospective cross-sectional
analysis of disability benefits and health care utilization by
disabled persons who receive SSDI. The number of disabled
persons age 40 to 64 who meet SSDI program requirements
and receive benefits is estimated using the SIPP. The
Medicare Current Beneficiary Survey (MCBS) is used to
examine differences in the types of disabling conditions for
men and women. The absolute growth in SSDI and Medicare
participation by disabled persons is projected through 2025 by
type of disabling condition, and a series of simulations are
used to explore how changes in the rates and types of medical
conditions, composition of the labor force and other factors
will impact SSDI and Medicare.
Population Studied: Respondents age 40 to 64 in the 1996
Panel of the SIPP and Medicare beneficiaries age 40 to 64
who participated in the MCBS between 1996 and 2000.
Principal Findings: Less than one-third of disabled men and
women receive SSDI and Medicare benefits, and a substantial
proportion receive no benefit. The proportion of women
eligible for SSDI will continue to increase, but remain constant
for men through 2010, with the largest growth for women age
55 to 64. A smaller percentage of women will continue to
qualify for SSDI and Medicare, due to lower labor force
participation rates and lesser recent work experience. Results
are compounded by the changing nature of disabilities, with a
disproportionate share of disabled women suffering mental
illnesses and musculoskeletal conditions. The inherent
uncertainty in these types of illnesses results in a greater
difficulty in demonstrating that the illness is permanently
disabling and a greater likelihood of a disability application
being denied.
Conclusions: A shift to more chronic soft tissue illnesses and
mental disorders could greatly impact the costs of health care
for Medicare and other payers, particularly if these disorders
are associated with more intensive service utilization over
time. Changes in the types of disabling conditions, coupled
with an increase in the population age 40 to 64, are likely to
dramatically increase the costs and utilization of health care.
Implications for Policy, Delivery or Practice: The number of
disabled persons qualifying for SSDI and Medicare is expected
to increase by 28 percent by the year 2010, and the impact will
be even greater over the next 25 years, as the baby boom
generation reaches the age of retirement. Gaps and
duplications of coverage among programs providing disability
benefits are potentially serious problems.
Primary Funding Source: Disability Research Institute
• Utilization of Medical Specialists by Immigrants in
British Columbia, Canada
Alice Chen, MC, M.S.c, Ph.D. Candidate, Arminée Kazanjian,
DrSoc, Arminée Kazanjian, DrSoc, Marie Desmeules, M.Sc.,
Doug Manuel, M.D., Bilkis Vissandjée, Ph.D., Elizabeth
Ruddick
Presented by: Arminée Kazanjian, DrSoc, Professor, Health
Care and Epidemiology, University of British Columbia, 5804
Fairview Avenue, Vancouver, B.C., V6T 1Z3; Tel:
604.822.4618; Fax: 604.822.4994; E-mail: a.kazanjian@ubc.ca
Research Objective: This study looks at access to medical
specialties by examining patterns of physician service
utilization by immigrants in British Columbia
Study Design: As part of a large Canadian immigrant health
study, a database consisting of information on immigrants
who landed in Canada between 1985 and 2000 and whose
stated destination was British Columbia was linked to that
province’s administrative health records for the same time
period. Since most physicians in B.C. are paid directly by the
province for each service provided, the provincial health
records contain rather comprehensive data on physician
services received by each immigrant. Using such
administrative databases allows the analysis of the utilization
records of the entire cohort of immigrants during the period
under study while avoiding sampling and reporting biases
inherent in other types of study design.
Population Studied: All immigrants who landed in Canada
between 1985 and 2000 and whose stated destination was
British Columbia. Controls were randomly selected from the
rest of B.C.’s population and individually matched to the
immigrants by age, sex, health region and landing year.
Principal Findings: Close to 420,000 immigration records
were successfully linked to health records. Results show that,
overall, immigrants made fewer visits to physicians than
controls during the study period. Of the physician visits, the
proportion of visits to specialists is lower for the immigrants.
However, there is variation by specialty and the condition
being treated. Immigrants are much less likely than controls
to visit psychiatrists.
Conclusions: In general, immigrants receive more of their
health care from general practitioners than specialists. There
are differences among specialties.
Implications for Policy, Delivery or Practice: As an
immigrant receiving country, Canada is becoming increasingly
diverse. And since the majority of recent immigrants come
from non-European regions, the challenge for health policy
makers and service planners is to meet the health care needs
of such a culturally diverse population. Under the universal
health care principle operative in Canada, there should be few
financial barriers to health services for immigrants. The
differential rates of utilization of physician services, especially
specialist services, between immigrants and non-immigrants
in this study suggest that factors other than health care
coverage affect utilization. Other barriers to services need to
be identified in order to achieve equitable access.
Primary Funding Source: Canadian Population Health
Initiative
• Impact of Health Insurance Benefits on Wages
Patricia Ketsche, Ph.D., M.H.A., William Custer, Ph.D.
Presented by: Patricia Ketsche, Ph.D., M.H.A., Assistant
Professor, Institute of Health Administration, Georgia State
University, MSC 4A1473, 33 Gilmer Street, S.E., Unit 4, Atlanta,
GA 30303-3084; Tel: 404.651.2993; Fax: 404.651.1230; E-mail:
pketsche@gsu.edu
Research Objective: Economic theory suggests workers will
opt for employment without health insurance if cash wages
exceed the value the worker places on coverage plus wages
paid in alternative employment with benefits. Therefore, there
must be a negative wage differential for workers with coverage
when compared to similarly productive workers without
coverage. This wage penalty is difficult to identify empirically
because of the correlation between productivity, income and
coverage. Identifying the wage differentional is important to
understanding risk pooling and estimating the effect of health
policy. This study contributes to the existing literature by
using a unique data set to estimate wages as a function of
health insurance while controlling for total compensation.
Study Design: We use Georgia’s 159 counties to isolate
distinct labor and health care markets and identify distinct
equations for total compensation and wages. Total
compensation at the firm is estimated as a function of firm
characteristics, the total productivity of the labor force as
determined by their age and tenure, and the differential cost of
labor in each market that is determined by the local cost of
living, educational level, and population density. The
composition of that compensation in terms of wages depends
upon firm characteristics, worker characteristics such as age
and gender that determine the demand for coverage, and local
health care market characteristics that influence access and
cost of care in the absence of coverage. The correlation
between error terms implies joint estimation of the two
equations. The key variable for this study is the effect of
coverage offered on wages.
Population Studied: We use survey data collected under a
State Planning Grant project from over 1400 Georgia
employers in 2002. The mail survey collected information
about all benefits offered including health insurance and some
work force characteristics. From the ES202 file it was possible
to identify total wages paid, number of employees and
industry. We imputed total average compensation for the
workforce by adjusting wages for benefits using estimates of
average costs obtained from the Bureau of Labor and
Statistics.
Principal Findings: Although a reduced form equation
identifies a positive relationship between wages and coverage,
simultaneous regression while holding total compensation
constant identifies a significant negative effect of health
insurance on average cash wages. We identify an average
wage reduction of 9 percent at firms offering health insurance.
Conclusions: Workers with employment-based health
insurance receive bear the cost through reduced cash
compensation.
Implications for Policy, Delivery or Practice: Wages adjust
downward at firms offering health insurance. Expanding
coverage at firms currently not offering benefits will reduce
wages to workers at those firms. In order for tax credits to
expand coverage, they must be sufficiently generous that any
wage reduction to employees is less than or equal to the value
placed on coverage by those employees. This will create a
potential windfall to firms where workers currently receive part
of their compensation in the form of health insurance.
Primary Funding Source: HRSA
• Is Participation of Low-Income Elderly Cancer Patients in
Medicaid Associated with Breast Cancer Diagnosis at
Earlier Stages of the Disease?
Siran Koroukian, Ph.D., M.S.N., M.H.A., Thomas Cook,
M.P.H., Fang Xu, M.S., Kristen Mikelbank, M.A., David Litaker,
M.D., Ph.D., Gregory Cooper, M.D.
Presented by: Siran Koroukian, Ph.D., M.S.N., M.H.A.,
Assistant Professor, Epidemiology and Biostatistics, Case
Western Reserve University, 10900 Euclid Avenue, Cleveland,
OH 44106-4945; Tel: 216.368.3197; Fax: 216.368.3970; E-mail:
sxk15@case.edu
Research Objective: Advanced-Stage Cancer (ASC) is a
strong predictor of poor cancer prognosis, and, for cancers
that are amenable to screening, ASC can be indicative of poor
access to and/or utilization of cancer screening services.
Although Part B Medicare provides coverage for many cancer
screening services, the coinsurance and deductibles
associated with the receipt of such services can be prohibitive
to low-income Medicare beneficiaries (LIMBs). Medicaid, as a
public source of supplemental health insurance coverage
(SHIC) is likely to at least partially remove financial barriers,
and improve access to and utilization of such services among
LIMBs. The aim of this study is to determine whether
participation of LIMBs in Medicaid is associated with
decreased likelihood of ASC.
Study Design: Older women diagnosed with breast cancer
during the 3-year period 1996-1998 were identified through the
Ohio Cancer Incidence Surveillance System (OCISS), a data
source with an estimated 95% rate of completeness relative to
breast cancer. The study cohort was limited to women 70
years of age or older to increase the likelihood they were
enrolled in Medicare. OCISS records were linked with Ohio
Medicaid enrollment files, using patient identifiers. Individuals
also enrolled in Medicaid, or the dually eligible, were identified
as such if OCISS and Medicaid records were linked
successfully, and if the patient had been enrolled in Medicaid
at least 3 months prior to cancer diagnosis. Individuals were
categorized as having ASC, if the OCISS record carried a
Surveillance, Epidemiology, and End Results (SEER) summary
stage of Regional, Distant, or Unstaged/Unknown stage of
cancer. The geocoded residence address of the patient at the
time of cancer diagnosis was used to retrieve variables from
the U.S. Census Bureau at the census tract level to act as a
surrogate marker for cancer patients’ socioeconomic status
(SES). Factor analysis of selected census indicators was used
to create a smaller set of composite measures which reflect
dimensions of concentrated disadvantage, socioeconomic
status and educational attainment, residential stability and
neighborhood age structure. Hierarchical logistic regression
models were developed to account simultaneously for
individual- and community-level attributes, and to assess the
association of ASC with Medicaid status after adjusting for
census tract SES. In particular, we tested an interaction
between Medicaid status and SES to assess the effect of
Medicaid status at various levels of social or economic
disadvantage.
Population Studied: Medicare beneficiaries diagnosed with
breast cancer.
Principal Findings: A total of 9,433 patients 70 years of age or
older were identified through OCISS, of whom, 9.1% were
identified as dually eligible. The proportion of patients
diagnosed with ASC was 47.9% and 33.1% respectively in the
dually eligible and all others (p < 0.001). Medicaid status was
independently associated with ASC both in bivariate and
multivariate models, adjusting for SES (adjusted odds ratio:
1.71, 95% confidence interval: 1.48-1.99). Of note, the
interaction term of Medicaid status and income was negative
and borderline statistically significant (coefficient: -0.14,
p=0.053), suggesting a modest benefit of receiving SHIC
relative to ASC, with increasing levels of poverty at the
community level.
Conclusions: The findings suggest that Medicaid status may
have little or no additional benefits relative to access to and/or
utilization of cancer screening services. However, due to the
use of SES measures at the community level, we may not have
been able to fully address residual confounding.
Implications for Policy, Delivery or Practice: The findings do
not support the notion that increased access to care may be
associated with greater utilization of cancer screening
services. Other dimensions of access to and use of cancer
screening services in this economically disadvantaged
population need to be evaluated.
Primary Funding Source: NCI, American Cancer Society
• Effects of Medicaid Managed Care and Medicaid
Managed Care Penetration on Potentially Avoidable
Maternity Complications
Sarah Laditka, Ph.D., James Laditka, D.A., Ph.D., Kevin
Bennett, M.S.
Presented by: Sarah Laditka, Ph.D., Associate Professor and
MHA Program Director, Health Services Policy and
Management, Arnold School of Public Health, University of
South Carolina, 800 Sumter Street, HESC Building, Room
116F, Columbia, SC 29208; Tel: 803.777.1496; Fax: (803) 7771836; E-mail: sladitka@gwm.sc.edu
Research Objective: We examined differences in pregnancy
outcomes associated with prenatal care in Medicaid managed
care (MMC) and Medicaid fee-for-service (MFFS). MMC may
enhance care coordination and improve outcomes.
Alternatively, it may provide incentives for under-provision of
services. We also examined the impact of MMC penetration.
As penetration increases, outcomes may improve for MMC
enrollees, due to knowledge and efficiency gains associated
with increasing program size.
Study Design: The outcome studied was Potentially Avoidable
Maternity Complications (PAMCs). The indicator, defined by
obstetricians/gynecologists, uses hospital discharge data to
identify pregnancy-related complications that may often be
prevented through accessible prenatal care of reasonable
quality. We used year 2000 State Inpatient Data for Florida,
Maryland, and New York, and also pooled 1995-2000 data for
New York, supplemented with the Area Resource File and the
American Hospital Association Annual Survey. To
approximate population risks, data were restricted to delivery
hospitalizations. Multi-level logistic analysis estimated PAMC
risk, with a random effect at the level of patients’ counties of
residence. MMC penetration was defined as the MMC rate
among deliveries covered by Medicaid in the patient’s
residence county in New York and Florida, and as the rate in
the hospital’s county in Maryland. Individual controls
included age, race, and comorbidities. Area controls included
education, income, and health system measures.
Population Studied: 74,627 delivery hospitalizations for
women enrolled in Medicaid in Florida, 20,732 in Maryland,
and 84,300 for year 2000 in New York. 547,077 such
hospitalizations for New York, 1995-2000.
Principal Findings: In Florida, 14.6% of Medicaid deliveries
were in MMC. PAMC risk did not differ between MMC and
MFFS. In Maryland, 77.5% of deliveries were in MMC, where
PAMC risk was 52% lower than in MFFS (p<.0001). In New
York, 16.2% of deliveries were in MMC, where PAMC risk was
26% lower than in MFFS (p=.0001). Penetration did not
affect risk in annual data. In the pooled New York State
analysis, each 1% increase in penetration was associated with
an average 1% PAMC risk reduction for those in MMC
(p<.001). There was also evidence that the risk reduction
increased with increasing penetration (p<.0001).
Conclusions: MMC was not associated with increased PAMC
risk. In two states, PAMC risk was notably lower in MMC than
in MFFS. MMC may offer successful care management,
lowering the risk of adverse outcomes, or provide other
services to produce accessible and successful care. Lack of
evidence of an impact of MMC penetration in annual data
may result from limited data. Pooling six years of New York
State data produced results suggesting MMC becomes more
effective as its penetration in patients’ counties increases.
Implications for Policy, Delivery or Practice: MMC may
provide comparable or better care for pregnant women than
MFFS. Outcomes associated with prenatal care were
improved for those in MMC as MMC penetration increased.
Although based on the experience of only one large state, this
result suggests that MMC performance may benefit from
effects associated with program size.
Primary Funding Source: HRSA
• Distance to the Nearest Public HIV Test Site: Does It
Matter?
Arleen Leibowitz, Ph.D., Stephanie Taylor, Ph.D., M.P.H., Paul
Ong, Ph.D.
Presented by: Arleen Leibowitz, Ph.D., Professor, Policy
Studies, UCLA, 6345 Public Policy Building, MC 165606, Los
Angeles, CA 90095; Tel: 310.206.8653; Fax: 310.206.0337; Email: arleen@ucla.edu
Research Objective: Efforts have been made to provide free
HIV tests to higher-risk, uninsured or lower income persons
by offering tests at publicly-funded clinics and locating test
sites conveniently nearby. This has lead to geographic
variations in HIV-testing site availability. Persons required to
travel greater distances to publicly-funded test sites might
forego HIV-testing because of the time costs involved.
However, the relationship between test site proximity and
individuals’ HIV-testing has gone relatively unexamined. This
study examined the relationship between HIV-testing and the
distance between individuals’ residences and the nearest
publicly-funded HIV test site to address two questions, “Are
people living further away from public HIV-testing sites less
likely to test for HIV at public sites?”. If so, “Are those living
further away more likely to forgo HIV testing entirely, or do
they simply go to other types of test sites?”
Study Design: Data was from the 1999 Los Angeles (L.A.)
County Health Survey, a random digit-dialed population
survey. Nested logistic regression analyses were conducted to
examine if distance to the nearest public test site was related
to: 1) testing/not testing, and, 2) among those testing, which
of three types of sites were utilized: a) public b) physician
office/laboratory or c) other sites such as at-home tests.
ArcGIS software provided measures of distance between
residences and nearest public test sites in miles. Travel time
was estimated using the distance measures and reports of car
ownership. Interactions terms were used to estimate if
distance was a greater barrier to testing for persons: 1)
without insurance, 2) having lower incomes (less than twice
the federal poverty level), 3) having higher-risk sex behaviors
(not always using condoms and having more than one
partner), or 4) without regular sources of care. Models
included weights and ten individual characteristics related to
HIV-testing.
Population Studied: The sample was a 1999 random
probability sample of L.A. adults (n=5,414). A third were
Latino, 10% were African American, 12% were Asian Pacific
Islanders, and 4% were “Other”.
Principal Findings: Persons living further away from public
test sites were less likely to test for HIV. This effect was
stronger for low income persons. Persons with higher-risk sex
behaviors living further from public test sites were more likely
to substitute testing at a physician office or other type of site.
All these results held regardless of whether the mile or time
measure was used. However, uninsured persons were affected
only by their travel time and were affected in two ways – those
living further away were more likely to go without testing than
those with greater proximity to public test sites and also more
likely to test at a non-physician site instead of a public site.
Travel time for all was negatively related to the likelihood of
testing, even for travel times of less than 20 minutes.
Conclusions: The distance to free HIV-testing clinics matters.
Lower income and uninsured persons appeared most
vulnerable to test site location.
Implications for Policy, Delivery or Practice: Providing very
convenient testing opportunities to those who are poor,
uninsured, or engaged in higher-risk behaviors might increase
voluntary testing and counseling for HIV.
• Medicaid Managed Care and Children’s Access and Use
of Health Care Services
Ana Lopez-De Fede, Ph.D
Presented by: Ana Lopez-De Fede, Ph.D, Research Associate
Professor, Institute for Families in Society, University of South
Carolina, 937 Assembly Street, Carolina Plaza, Columbia, SC
29208; Tel: 803.777.5789; Fax: 803.777.1793; E-mail:
adefede@sc.edu
Research Objective: Although recent literature has posited
numerous accounts of the effect of Medicaid managed care,
there is no conclusive evidence that enrollment in Medicaid
managed care leads to increased access to health care
services and cost containment. The primary objective was to
analyze the impact of managed care on cost and access to
and use of health care services among Medicaid recipients.
Study Design: Medicaid claims data were used to examine
differences and changes in cost, access to care and use of
health services among two groups of children, i.e., Medicaid
managed care Physician Enhanced Managed Care Program
(PEP) enrollees and recipients enrolled in Medicaid fee-for
services (FFS). A retrospective quasi-experimental design
with non-equivalent groups was used to examine costs, and
access to and use of health care services. Multiple logistic
regression analysis examined these factors and enrollment in
Medicaid managed care.
Population Studied: The study population consisted of
children ages birth to eighteen continuously enrolled for a
minimum of ninety days in either in the Medicaid managed
care primary care case management initiative (PEP) or the
Medicaid managed care fee-for-services initiative (FFSM).
Medicaid administrative data was used to examine the costs
and access to and use of health care services of children in the
study population, with paid claims from July 1, 1999 to June
30, 2000.
Principal Findings: Of the 34,926 Medicaid recipients 10,502
(30 percent) were identified as enrolled in managed care.
Average annual costs ($1,167) were lower for children enrolled
in Medicaid managed care compare to children enrolled
($1,893) in Medicaid fee-for-services. Younger children with
chronic condition were more widely represented in Medicaid
managed care and had higher rates of hospitalizations; visits
to specialty care providers, and related costs. Conversely,
lower adherence to primary care services was widespread
among children in Medicaid managed care. Twelve percent
had a primary care visit, and fewer than 50 percent had an
annual routine physical exam. Overall, Medicaid managed
care enrollment was associated with older children and lower
access to and use of health care services
Conclusions: The results of this study suggest that children in
Medicaid managed care experience far more difficulties
accessing health care than those in Medicaid fee-for-services.
Prevalence and utilization of health care services in a Medicaid
managed care population of children were lower than previous
estimates reported nationally and by health maintenance
organizations.
Implications for Policy, Delivery or Practice: The study
findings support the use of claims to measure health care
utilization as a reasonable proxy for access to health care
services. As a result of the Balanced Budget Act which
eliminated the need for states to implement a waiver to
institute mandatory managed care programs, the share of
children enrolling in Medicaid managed care programs are
likely to increase over time. Despite the implementation of
voluntary managed care, knowledge is needed on its effect.
This research addressed the information gap by examining the
effect of managed care on access and use of care among
children enrolled in Medicaid in South Carolina,
Primary Funding Source: Science Department of Health and
Human Services
• Primary Care Practices May Lack the Capacity To
Adequately Treat Asthma
Robert Lowe, M.D., M.P.H., David Nicklin, M.D., Staci
Maroney, M.P.H., A. Russell Localio, JD, M.S., Donald
Schwarz, M.D., Sankey Williams, M.D.
Presented by: Robert Lowe, M.D., M.P.H., Associate
Professor, Center for Policy and Research in Emergency
Medicine, Oregon Health & Science University, 3181 S.W. Sam
Jackson Park Road, CR114, Portland, OR 97239; Tel:
503.494.7134; Fax: 503.494.4640; E-mail: lowero@ohsu.edu
Research Objective: Asthma is prevalent among inner city,
low-income residents, including many Medicaid beneficiaries,
and efforts have been made to encourage these patients to
seek care from their primary care providers (PCPs) rather than
in the ED. The purpose of this study was to determine whether
PCPs serving a Medicaid population had the equipment and
capacity to treat asthma according to guidelines issued by the
National Asthma Education and Prevention Program
(NAEPP).
Study Design: This observational study consisted of on-site
data collection at primary care practice sites affiliated with a
Medicaid HMO, conducted between June 1999 and February
2000. At each site, office staff were asked about availability of
equipment recommended under NAEPP guidelines.
Population Studied: Three hundred fifty-three primary care
practices affiliated with a single Medicaid HMO were studied.
Principal Findings: Of 337 sites treating children, 93 (28%)
lacked nebulizers for bronchodilators. Of 338 sites treating
adults, 135 (40%) lacked peak flow meters. Office staff
reported having inhalers with spacers at only 262 (74%) of 353
sites. Of 325 sites asked if they had written, customizable
action plans for asthmatics, 76 (24%) reported having them
but only 49 (15%) were able to provide a copy.
Conclusions: In this sample of primary care practices serving
Medicaid patients, office staff reported that many practices did
not have the equipment to comply with accepted guidelines
for the management of asthma. This study is limited by the
data collection process, in that physicians were not
interviewed and some office staff may not have been aware
that the equipment was available. Nevertheless, the results
suggest that many practices may not be equipped to provide
care for asthmatics according to NAEPP guidelines.
Implications for Policy, Delivery or Practice: Availability of a
"medical home" through Medicaid managed care is not
sufficient to assure access to necessary services at that
medical home. In addition to focussing on access to primary
care, Medicaid managed care must focus on the
comprehensiveness of services provided.
Primary Funding Source: AHRQ
• Has Managed Care Improved Accessibility of Urgent
Care for Medicaid Patients?
Robert Lowe, M.D., M.P.H., Staci Maroney, M.P.H., Sankey
Williams, M.D., Donald Schwarz, M.D., M.P.H., M.B.A., Lucy
Wolf Tuton, Ph.D., A. Russell Localio, JD, M.S.
Presented by: Robert Lowe, M.D., M.P.H., Associate
Professor, Center for Policy and Research in Emergency
Medicine, Oregon Health & Science University, 3181 S.W. Sam
Jackson Park Road, CR114, Portland, OR 97239; Tel:
503.494.7134; Fax: 503.494.4640; E-mail: lowero@ohsu.edu
Research Objective: A 1994 study described barriers for
Medicaid patients seeking urgent care from primary care
providers. Since 1994, much of Medicaid has shifted from feefor-service to managed care, partly in the hope that managed
care's assignment of patients to "medical homes" would
improve access to care. The objective of our study was to
determine the accessibility of urgent primary care visits
among providers in one Medicaid managed care organization
(MCO).
Study Design: Following a protocol adopted from the 1994
study, research staff acting as simulated patients called
primary care practices, randomly selected from sites
contracting with the Medicaid MCO. Three different staff
members called each practice on different weekdays,
indicating that they were Medicaid patients assigned to the
practice and needed urgent appointments. Staff followed a
scripted algorithm, describing their symptoms and specifically
requesting appointments within 24 hours and evening
appointments. Calls were categorized on a 6-point scale,
based on promptness of available appointments. If the 3 calls
to a practice led to different results, the median result was
used for analysis.
Population Studied: Three hundred fifty-three primary care
practice sites affiliated with the Medicaid managed care
organization were randomly selected from the primary care
practice roster of the MCO. Of these sites, 44 were excluded
because they had closed permanently or for reasons
precluding the simulation (e.g., office personnel asked for a
valid Medicaid ID number), leaving 309 sites in the study.
Principal Findings: Of the 309 eligible sites, no appointment
could be made at 75 (24%) of sites - often because the
practice was not open. Callers could be seen the same or next
day at 168 (54%) of sites (compared to 35% in the 1994
study), and the same or next evening at 23 (7%) of sites (the
same proportion as in the 1994 study).
Conclusions: Because the 1994 study included many
communities and our study includes only one, formal
comparison of results is not meaningful. However it is clear
that, in primary care sites affiliated with this Medicaid MCO,
access to urgent care remains limited.
Implications for Policy, Delivery or Practice: Providing a
“medical home” to Medicaid beneficiaries through managed
care has not solved the problem of access to care. Until policymakers succeed in implementing and enforcing requirements
for prompt access to care, even Medicaid beneficiaries who
have designated primary care providers may be forced to rely
on emergency departments for urgent care.
Primary Funding Source: AHRQ
• Impact of Oregon Health Plan Cutbacks on Emergency
Department Use
Robert Lowe, M.D., M.P.H., K. John McConnell, Ph.D., Jodi
Lapidus, Ph.D., Cody Weathers, BS, Annette Adams, M.P.H.,
Beverly Bauman, M.D.
Presented by: Robert Lowe, M.D., M.P.H., Associate
Professor, Center for Policy and Research in Emergency
Medicine, Oregon Health & Science University, 3181 S.W. Sam
Jackson Park Road, CR114, Portland, OR 97239; Tel:
503.494.7134; Fax: 503.494.4640; E-mail: lowero@ohsu.edu
Research Objective: The Oregon Health Plan (OHP), begun
in 1994, expanded Oregon's Medicaid program to cover an
additional 100,000 Oregonians. In March, 2003, OHP
cutbacks affected this "expansion population" in 3 ways: (1)
premiums; (2) co-payments ($5 for primary care visits and $50
for emergency department visits); and (3) reduced scope of
coverage (including loss of out-patient coverage for most
mental health and chemical dependency problems). A useful
measure of access to care for a population is emergency
department (ED) use. The purpose of this study was to
compare ED use before and after the OHP cutbacks.
Study Design: This time series study compared ED use in an
urban teaching hospital in the first 3 months after the OHP
cutbacks with the same 3 months of 2002.
Population Studied: We used computerized billing data to
ascertain payment class and diagnoses for all ED visits.
Percent changes in visits were calculated; 95% confidence
intervals (CIs) are presented unless they include 0, making the
change not significant (NS) at the 0.05 level.
Principal Findings: There was a 20% (CI 16%-23%) decrease
in ED visits by OHP beneficiaries after the cutbacks, an 8% (CI
3%-12%) decrease in visits by commercially insured patients,
and a 17% (CI 10%-24%) increase in visits by uninsured
patients. Alcohol-related visits by OHP beneficiaries fell by 5%
(NS), while alcohol-related visits by uninsured patients rose by
136% (CI 55% -267%). Drug-related visits by OHP
beneficiaries rose by 57% (NS), while drug-related visits by
uninsured patients rose by 200% (CI 37%-625%). Other
mental health visits by OHP beneficiaries fell by 12% (NS),
while increasing by 37% (CI 1%-87%) for uninsured patients.
There was a 3.5% reduction in the number of OHP
beneficiaries in the hospital service area during the study
period.
Conclusions: The reduction in ED visits by OHP patients may
be partially due to the new co-payments for ED visits, even
though these co-payments were rarely collected. The rise in
ED visits among the uninsured may be due to OHP cutbacks,
but it may also be due to loss of commercial insurance or to
decreased availability of non-ED "safety net" clinics serving
uninsured patients.
Implications for Policy, Delivery or Practice: Whatever the
cause of increased ED visits among uninsured patients, this
finding points to a worrisome reduction in access to medical
care for uninsured Oregonians.
Primary Funding Source: RWJF
• An Assessment of Coordination Efforts between State
SCHIP and Title V Programs in the Case of SCHIPEnrolled Children with Special Health Care Needs
Anne Markus, J.D., Ph.D., Sara Rosenbaum, J.D., Soeurette
Cyprien
Presented by: Anne Markus, J.D., Ph.D., Assistant Research
Professor, Health Policy, The George Washington University
Medical Center, 2021 K Street, N.W., Suite 800, Washington,
DC 20006; Tel: 202.530.2339; Fax: 202.296.0025; E-mail:
armarkus@gwu.edu
Research Objective: To explore the level of interaction and
coordination between Title V Maternal and Child Health
Services Block Grant programs that serve children with special
health care needs (Title V CSHCN programs) and separatelyadministered SCHIP programs in the provision of services
needed by CSHCNs.
Study Design: Qualitative methods combining a review of
research findings on states’ early experience with SCHIP,
which together covered a majority of separately-administered
SCHIP programs (51%) and SCHIP enrollees (74%), an
analysis of the coordination and benefit provisions of
separately-administered state SCHIP plans filed with CMS as
of December 2000 (n=35), and a written survey of Title V
agencies in states with separately-administered SCHIP
programs conducted in 2001 regarding changes to their
CSHCN program after SCHIP was enacted and benefits
available to CSHCN under SCHIP and Title V (response
rate=51%).
Population Studied: 35 states with separately-administered
SCHIP programs.
Principal Findings: First, states have used the flexibility
provided under SCHIP to adopt benefit packages that are
generally less comprehensive than Medicaid. Although these
benefit packages work well for the vast majority of children
who are healthy, they can result in CSHCNs facing gaps in
needed services. Second, a handful of states have used their
Title V programs to attempt to fill the gaps in coverage for
CSHCNs created by scaled-back SCHIP benefit packages. The
vast majority of states, however, have not taken such steps.
Third, even among the handful of states that have sought to
coordinate their Title V and SCHIP programs to improve
coverage for CSHCNs, some of these children - particularly
those with extensive behavioral health needs - are likely to find
it difficult to navigate the system and, once they do, to still
face gaps in coverage.
Conclusions: The limitations on SCHIP benefits are likely to
have a disproportionate and potentially significant effect on
CSHCNs. Although there are some exceptions, states
generally have not used their Title V programs to fill effectively
the gaps in care for CSHCNs created by a scaled back SCHIP
benefit package. These children thus face the limitations of
the SCHIP benefit package with nowhere else to turn for
needed specialty care.
Implications for Policy, Delivery or Practice: As states take
advantage of renewed flexibility under the Health Insurance
Flexibility and Accountability demonstration initiative to redesign Medicaid and SCHIP, they may want to pay particular
attention to children and adults with special needs.
Mobilizing the multiple state agencies whose mission is to
serve such individuals at the program design stage to create a
system where these individuals can be directed to the
appropriate sources of care, and coordinating the delivery of
services once the program is implemented would help ensure
that fewer CSHCNs and other individuals with special needs
fall through the cracks and more of them receive services
filling in the gaps left by scaled-back benefit packages under
reengineered public health insurance programs.
Primary Funding Source: , Kaiser Commission on Medicaid
and the Uninsured, Kaiser Family Foundation.
• Insurers' Coverage Decision Making of Selected Services
for SCHIP-Enrolled Children With Special Health Care
Needs
Anne Markus, J.D., Ph.D., Sara Rosenbaum, J.D., Jill Joseph,
M.D., Ph.D., Ruth Stein, M.D.
Presented by: Anne Markus, J.D., Ph.D., Assistant Research
Professor, Health Policy, The George Washington University
Medical Center, 2021 K Street, N.W., Suite 800, Washington,
DC 21075; Tel: 202.530.2339; Fax: 202.296.0025; E-mail:
armarkus@gwu.edu
Research Objective: To explore how Medicaid- and SCHIPparticipating managed care organizations (MCOs) make
coverage decisions for SCHIP-enrolled children with special
health care needs (CSHCNs); to assess the impact of these
decisions for pediatric access to care.
Study Design: Case studies of coverage decisions combining
(1) SCHIP plan and contract language analysis of the extent of
coverage of benefits more critical to CSHCNs with (2)
telephone interviews of the medical directors of Medicaid- and
SCHIP-participating MCOs. Researchers presented
interviewees with two hypothetical patient scenarios, asking
them to decide whether they would have provided a select
number of services, identical in each scenario, without
restriction, limit or special review, with some limitations, or
not at all. Where appropriate, respondents also provided the
likely basis for their decision.
Population Studied: Purposive sample of 71 medical
directors of Medicaid- and SCHIP-participating MCOs in 14
states that issue separate managed care contracts for the two
programs interviewed between March and June 2002 (13%
participated from 6 states covering 46% of all SCHIP
enrollees; 49% explicitly declined to participate; and 38% did
not respond to repeated invitations to participate).
Principal Findings: Insurers’ decisions varied by type of
coverage, category of benefit, acuity of the children’s medical
condition, and state of residence. First, insurers generally
restricted certain services most needed by CSHCNs, such as
speech and physical therapy, motorized wheelchairs, assistive
communication devices, and enabling transportation, under
SCHIP in ways not permissible under Medicaid. Second, with
one exception, insurers were not in agreement on the
coverage of any specific service, but overall they provided
coverage beyond the limits and exclusions of the state
program. Third, the less acute the condition experienced by
the child, the more frequently insurers imposed exclusions,
particularly in the coverage of speech therapy and hearing
aids. Finally, while insurers would have provided more
generous coverage than required by the state for the majority
of services queried, in four states, there were discrepancies,
notably in the area of assistive communication devices,
speech therapy, hearing aids, and motorized wheelchairs,
between some insurers’ decisions and the state requirements,
with insurers excluding services when these services arguably
should have been covered according to the plan and contract
language.
Conclusions: Our findings support our hypothesis that the
variability and the limits in coverage and benefits found in
separate SCHIP programs can influence access to care by
children, including CSHCNs.
Implications for Policy, Delivery or Practice: While SCHIP
extends coverage to previously uninsured CSHCNs, the
benefits offered by state programs vary greatly and are
generally less comprehensive than those covered under
Medicaid. Under SCHIP, coverage at current levels may not
be sufficient to care for CSHCNs, making the availability of
external reviews of insurers’ coverage decisions and the
coordination with other sources of care important
components of SCHIP program design. Additional research is
needed to measure and compare actual use of services by
CSHCNs who have SCHIP and Medicaid coverage.
Primary Funding Source: HRSA
• Exploring Cost as an Access Barrier to Mammography
Screening
Ann McAlearney, Sc.D., Katherine Whitney, M.P.H., Cathy
Tatum, M.A., Electra Paskett, Ph.D.
Presented by: Ann McAlearney, Sc.D., Assistant Professor,
Division of Health Services Management and Policy, The Ohio
State University, 1583 Perry Street, Atwell 246, Columbus, OH
43210-1234; Tel: 614.438.6869; Fax: 614.438.6859; E-mail:
mcalearney.1@osu.edu
Research Objective: Despite considerable advances in
scientific understanding of the disease, breast cancer
continues to be a significant public health problem in the
United States, with estimates that in 2003 breast cancer
claimed the lives of 39,800 women, and another 211,300
women were diagnosed with the disease. Although still
controversial, it is generally accepted that mammography
represents the best opportunity for early detection of breast
cancer. However, in 2000, 24 percent of women over age 40
had not had a mammogram within the past two years. This
research was designed to evaluate how issues related to cost
affect mammography use within a rural population of lowincome women.
Study Design: Baseline survey data for the full study
population—897 women--were used to evaluate the impact of
cost as a self-reported barrier to receiving mammograms,
both historically and at follow-up. Chi square tests were
performed to investigate bivariate relationships between
independent variables and dependent variables related to cost.
Logistic regression analysis was used to calculate odds ratios
and 95 percent confidence intervals for multivariable
associations. Multinomial logistic regression analysis was
used in cases where the outcome variable had more than two
response levels.
Population Studied: The study population consisted of
women who were not within guidelines for mammography
and who were part of a randomized, controlled study to
assess the efficacy of an individualized health education
intervention delivered by a lay health educator on improving
rates of breast cancer screening among women aged 40 and
older who were patients of a county health clinic. This study
took place in a predominantly rural, multi-racial county in
North Carolina.
Principal Findings: Over half of all respondents noted cost
was a barrier to obtaining a mammogram, and cost was the
most frequently cited reason for why women had not had a
mammogram within the past two years—26 percent, or had
never had a mammogram—20 percent. When asked about
cost, the majority of women overestimated the cost of a
mammogram, while only one quarter had an appropriate
perception of this cost. Women who identified cost as a
barrier were nearly nine times more likely to underestimate
their level of insurance coverage; women with no insurance
were almost 16 times more likely to note cost as a barrier.
Among women who received an intervention to improve
mammography rates, women who reported cost as a problem
were just as likely to get a mammogram as those who did not
report cost to be a barrier; in contrast, noting cost as a barrier
was significantly associated with not receiving a mammogram
in the control population.
Conclusions: Cost reportedly made it difficult for over half of
a population of rural, poor women to get a mammogram.
However, only one-quarter of this population had an
appropriate perception of the cost of a mammogram.
Appropriate knowledge of mammogram cost and/or
insurance coverage can reduce this barrier, as shown by no
difference in mammogram rates among women with a cost
barrier reported and those without this barrier in the
intervention group.
Implications for Policy, Delivery or Practice: Providing
women with information about the actual out of pocket cost of
mammograms may reduce the impact of cost as a barrier, as
demonstrated within a population of low-income, rural
women.
• Treatment Stacking as a Response to Distance Barriers
among VA Patients with Psychoses
John McCarthy, Ph.D., Frederic Blow, Ph.D., John Fortney,
Ph.D., John Piette, Ph.D.
Presented by: John McCarthy, Ph.D., Research Investigator,
HSR&D and SMITREC, Department of Veterans Affairs, P.O.
Box 130170, Ann Arbor, MI 48113-0170; Tel: 734.769.7100 Ext.
6253; Fax: 734.761.2617; E-mail: John.McCarthy2@med.va.gov
Research Objective: Patients and providers may reduce the
negative impact of geographic accessibility barriers by
combining clinic stops into single outpatient visits. As noted
by Veterans Affairs (VA) administrators and the Government
Accounting Office (GAO/HEHS-96-31), a consequence of such
“stacking” is that analyses of visit day volume may
overestimate distance effects. However, no studies have
demonstrated a relationship between stacking and distance.
This study evaluates distance as a predictor of clinic stop
stacking among VA patients diagnosed with psychotic
disorders. We also examine interrelationships among
distance, psychosis type, and stacking.
Study Design: We assessed straight-line distance to the
nearest VA outpatient service. Using random intercepts
hierarchical regression (cluster = nearest outpatient provider),
we evaluated distance effects on treatment stacking
(outpatient clinic stops per visit), adjusting for age, gender,
ethnicity, marital status, VA service connection, and site and
Charlson comorbidities at initial use. Psychosis and
interactions with distance were also included.
Population Studied: We categorized VA patients with
psychoses in FY00 (N=192,982) as having schizophrenia,
bipolar disorder, or other psychoses. Exclusion criteria were:
homelessness; institutional stays of 150+ days; death; and
missing data. The analytic dataset consisted of 142,055
patients.
Principal Findings: Median clinic stops per visit were 1.45
among patients with schizophrenia, 1.55 among patients with
bipolar disorder, and 1.60 among patients with other
psychoses. Distance was associated with significant increases
in stacking (p<0.0001). Controlling for other predictors,
patients had 6% more clinic stops for every ten miles
separating them from care. Those with bipolar disorders were
most likely to stack generally and in response to distance.
Separate analysis indicated that distance remains a barrier to
clinic stop volume.
Conclusions: With increased distance from care, patients with
psychoses were more likely to stack clinic stops within visit
days. Relative to patients with bipolar disorders, patients with
schizophrenia or other psychoses were less likely to stack in
response to distance barriers. While clinic stop stacking may
reduce the impact of distance barriers, distance remains a
barrier to utilization even when measured in terms of clinic
stop volume.
Implications for Policy, Delivery or Practice: This work
presents national data on increased clinic stop stacking as a
response to distance barriers among patients with psychoses.
Treatment stacking may reduce accessibility barriers, yet
distance remains a barrier to outpatient care.
Primary Funding Source: VA
• Treatment Retention among VA Patients with Psychoses:
Health System Factors
John McCarthy, Ph.D., Kristen Barry, Ph.D., Frederic Blow,
Ph.D., Ellen Fischer, Ph.D., Teresa Hudson, PharmD,
Rosalinda Ignacio, M.S.
Presented by: John McCarthy, Ph.D., Research Investigator,
HSR&D Field Program, Department of Veterans Affairs, P.O.
Box 130170, Ann Arbor, MI 48113-0170; Tel: 734.769.7100 Ext.
6253; Fax: 734.761.2617; E-mail: John.McCarthy2@med.va.gov
Research Objective: Despite high morbidity and ongoing
treatment needs, patients with psychoses are difficult to retain
in care. The purpose of this study was to evaluate the
influence of geographic accessibility and VA and non-VA
service availability on retention, adjusting for patient
characteristics.
Study Design: This was a three-year cohort study of 125,286
VA (Department of Veterans Affairs) patients with
schizophrenia or bipolar disorder in FY98. Survival analysis
was used to model time to first 12-month gap in VA care over
three years, FY99-FY01. Covariates included age, gender,
race/ethnicity, marital status, psychosis type, Charlson
comorbidity, last treatment location in FY98, and days since
last VA care (at end of FY98). Geographic accessibility was
operationalized as straight-line distance to nearest VA medical
center. Service availability was assessed using county-level VA
hospital beds and non-VA beds, per 1000 residents. Patients
who died before gaps were censored.
Population Studied: Patients in the VA health care system
diagnosed with schizophrenia or bipolar disorder in FY98
(N=125,286).
Principal Findings: Over three years, 7585 patients (6%) had
a 12-month gap in VA care. Individuals who were younger,
male, non-white, unmarried, had bipolar disorder, low medical
morbidity, an inpatient psychiatric treatment location, or
resided farther from VAMCs were more likely to drop out of
care. Greater VA bed availability improved retention, while
non-VA availability was not significant.
Conclusions: Among VA patients with psychoses, patient
predisposing and need characteristics strongly predict
retention in care. Distance increases risks of substantial gaps
in treatment. VA service availability improves retention,
however retention may not be sensitive to the availability of
non-VA providers.
Implications for Policy, Delivery or Practice: Geographic
barriers remain a challenge for treatment retention.
Moreover, when patients with psychoses fall out of care, nonVA services may not substitute for VA care.
Primary Funding Source: VA
• Disruptive Behaviors among VA Nursing Home
Residents: Assessing the Impact of Psychoses and
Dementia
John McCarthy, Ph.D., Frederic Blow, Ph.D., Helen Kales,
M.D.
Presented by: John McCarthy, Ph.D., Research Investigator,
HSR&D and SMITREC, Department of Veterans Affairs, P.O.
Box 130170, Ann Arbor, MI 48113-0170; Tel: 734.769.7100 Ext.
6253; Fax: 734.761.2617; E-mail: John.McCarthy2@med.va.gov
Research Objective: Nursing home providers may be
reluctant to admit individuals with psychotic disorders
because of concerns regarding disruptive behavior. While
recent studies have examined behavior problems among
residents with dementia, little is known about the relative
prevalence of such problems among residents with psychoses.
The purpose of this study was to assess the relative
prevalence of disruptive behaviors among nursing home
residents with psychoses, as compared to other subgroups of
nursing home residents, especially those with dementia.
Study Design: This uses cross-sectional administrative data
regarding nursing home behaviors. Using diagnosis and
utilization data from the Department of Veterans Affairs (VA)
Patient Treatment File and Outpatient Care files, we evaluate
whether residents received diagnoses of psychosis and/or
dementia during the prior six months. In separate multiple
regressions, we assess diagnostic correlates of verbal
disruptive behavior, physical aggression, and socially
inappropriate behavior. Analyses controlled for age, gender,
length of stay, Resource Utilization Group, Activities of Daily
Living limitations (eating, mobility, transfer, toileting), service
connection, depression, substance abuse/dependence and
coma status. We include interaction terms to assess the
impact of having both psychosis and dementia. In sensitivity
analyses, we compare residents with psychoses but without
dementia to residents with dementia but without psychoses.
Population Studied: We examine patient assessments for
9,661 VA nursing home residents in April, 2000.
Principal Findings: Nearly half (46.2%) of all residents
received psychosis or dementia diagnoses: 17.6% had
psychoses, 28.6% had dementia without psychoses. Among
all residents, 4.7% had both conditions. In all three models,
psychosis and dementia were associated with increased
behavior problems (p<0.0001). Supplemental models
limited to individuals with psychoses (and without dementia)
or dementia (and without psychoses) indicate that individuals
with psychoses had increased risk of verbal disruptive
behaviors, yet comparable risks of socially inappropriate and
of physically aggressive behaviors.
Conclusions: In general, nursing home residents with
psychoses have elevated risks of disruptive behaviors,
comparable to residents with dementia. Direct comparisons
to residents with dementia indicate that residents with
psychoses have increased risks of verbal disruptions, yet
comparable risks of socially inappropriate and physically
aggressive behavior.
Implications for Policy, Delivery or Practice: Survey
research indicates that nursing home administrators may be
unwilling to admit individuals with serious mental illness due
to concerns regarding disruptive behaviors. We find increased
risk of disruptive behaviors among residents with psychoses,
yet, with the exception of verbal disruptive behavior problems,
risks among residents with psychoses were comparable to
those among residents with dementia. Further research is
needed to identify optimal delivery practices to meet the longterm care needs of individuals with serious mental illness.
Primary Funding Source: VA
• Enrollment Effects of Recent Changes in the Oregon
Health Plan
John McConnell, Ph.D., Neal Wallace, Ph.D., Charles Gallia,
M.P.A.
Presented by: John McConnell, Ph.D., Research Assistant
Professor, Department of Emergency Medicine, Oregon
Health & Science University, 3181 S.W. Sam Jackson Park
Road, Mail Code CR114, Portland, OR 97239; Tel:
503.494.1989; Fax: 503.494.4640; E-mail:
mcconnjo@ohsu.edu
Research Objective: This study examines changes in rates of
disenrollment among the Oregon Health Plan (OHP)
expansion population. In February 2003, Oregon
implemented OHP2 that significantly changed the conditions
of coverage for individuals and families not otherwise eligible
under traditional Medicaid eligibility rules. Families and the
10-50% FPL group had premiums increased and premium
waivers were eliminated. New or increased service copayments and elimination of specific benefits were also
implemented. In May 2003, a six-month enrollment lockout
for premium non-payment was imposed. Subsequent to these
changes enrollment in the OHP expansion population
program declined by one-third.
Study Design: The study estimates a binary choice model
based on whether an individual or couple enrolled in one
month continues enrollment into the next. A difference in
difference approach is used to assess relative changes in
month to month disenrollment using dummy variables for
policy implementation time periods, enrollee characteristics,
and time by characteristic interactions. Enrollee characteristics
used in the study include FPL-based income groups
(excluding 85-100% FPL as a reference), age, gender, nonCaucasian ethnicity, non-English speaking, couple vs.
individual, and duration of enrollment greater than seven
months.
Population Studied: The study uses a sample of OHP
“expansion group” enrollees from August 2002 through
September 2003 who are either singles or couples and have
monthly income that remains consistent within a defined FPL
bracket. This sample contains over 83,000 individuals/couples
and over 500,000 monthly enrollment observations. Enrollees
are predominately single, Caucasian, and English speaking
with an average age in the mid-thirties. Gender is nearly evenly
distributed and slightly more than a third have continuous
enrollment periods of over seven months. More than 60% of
enrollees have income less than 50% FPL and two thirds of
these have no reported income.
Principal Findings: Both the initial OHP2 implementation
and the subsequent lockout policy disproportionately
increased disenrollment for the lowest income enrollees. The
lockout policy had more than three times the effect on
disenrollment than the original policy change. Notably its
impact was fairly uniform across all income groups with the
exception of a doubled effect on zero income cases.
Disenrollment actually lessened for couples that experienced
some of the largest premium increases, as well as non-English
speaking individuals. Age and having longer prior enrollment
were consistently and increasing protective to disenrollment.
Males and persons of non-Caucasian ethnicity were generally
at greater risk for disenrollment.
Conclusions: The loss of premium waivers and the lockout
policy appeared to have the greatest impact. Increased
premiums had mixed effects given the results for couples. The
strong and increasing protective effect for non-English
speaking enrollees is consistent with anecdotal information
indicating that safety-net providers supported premium
payments in the face of lockout and waiver loss.
Implications for Policy, Delivery or Practice: The availability
of social or safety net support networks to help support
extremely low income individuals with premium payments
may differentiate those who need premium waivers and
determine enrollment without them. Instability in income
and/or expenses, including additional out-of-pocket medical
expenses related to OHP2, may be key factors in the dramatic
impact of the lockout policy.
Primary Funding Source: Oregon Office of Health Plan Policy
& Research
• Changes in Longitudinal Medicaid Enrollment Patterns
Following Welfare Reform
Angela Merrill, Ph.D., Marilyn Ellwood, M.S.W.
Presented by: Angela Merrill, Ph.D., Researcher, Mathematica
Policy Research, 50 Church Street, 4th Floor, Cambridge, MA
02138; Tel: 617.491.7900 Ext. 237; Fax: 617.491.8044; E-mail:
amerrill@mathematica-mpr.com
Research Objective: This study examined patterns of
retention of Medicaid among families leaving “cash-related”
Medicaid coverage, and changes in these patterns following
welfare reform. Retention of Medicaid provides a key support
to families gaining employment, may help families remain off
cash assistance, and reduces rates of uninsurance among lowincome families.
Study Design: The study used Medicaid administrative data
for a descriptive analysis of enrollment patterns among
families enrolled in Medicaid before and after welfare reform.
We followed cohorts of AFDC leavers in 1993 and
TANF/Section 1931 leavers in 1998 and observed their
enrollment in different types of Medicaid immediately
following welfare exit and at one year after exit. Our data
allowed us to examine continued enrollment in specific types
of Medicaid, such as transitional medical assistance (TMA).
Population Studied: Adults and children enrolled in
AFDC/Section 1931 Medicaid in 1993-94 and 1998-1999 in
nine states: Arkansas, California, Kentucky, Maine, Michigan,
New Jersey, Pennsylvania, Washington, and Wisconsin.
Principal Findings: On average across the study states, 55
percent of adults and 62 percent of children retained their
Medicaid coverage after they exited TANF/Section 1931 in
1998. This was an improvement over the Medicaid retention
rates for AFDC leavers in 1993. In 1998, 32 percent of adults
who left TANF/Section 1931 coverage continued to qualify for
Medicaid using the TMA provisions on average, an
improvement over the TMA user rate in 1993. However, the
average months on TMA declined, and less than one quarter
remained enrolled in TMA for the full 12 months. On average,
one-quarter of adults had returned to Section 1931 Medicaid
coverage at one year after exit in 1998.
Conclusions: Although families leaving welfare were more
likely to retain their Medicaid coverage in 1998 than in 1993,
many who disenrolled could have continued to qualify for
coverage. Children, in particular, have many coverage options
for continuing Medicaid coverage that are being underutilized.
Although TMA use had improved in 1998, compared to 1993,
few adults remained enrolled the full 12 months.
Implications for Policy, Delivery or Practice: This study
supports further efforts by states and the federal government
to improve Medicaid retention for families leaving TANF and
Section 1931 Medicaid when finding work. Since the period of
study, many states have worked to educate workers and
clients on coverage options, continued to de-link cash
assistance and Medicaid enrollment systems, and expanded
their use of disregards to extend Section 1931 and TMA
coverage. Further steps at the federal level, such as easing
TMA quarterly reporting requirements, may improve the
proportion of adults who utilize this coverage for a full year.
Primary Funding Source: CMS
• Subsidizing Small Employers to Help Insure Low-Income
Workers: The Massachusetts Experience
Janet Mitchell, Ph.D., Joseph Burton, M.P.H., Deborah Osber,
M.P.H.
Presented by: Janet Mitchell, Ph.D., Research Director, RTI
International, 411 Waverley Oaks Road, Suite 330, Waltham,
MA 02452; Tel: 781.788.8100; Fax: 781.788.8101; E-mail:
jmitchell@rti.org
Research Objective: An increasing number of states are
implementing premium subsidy programs to help insure lowincome working families. Massachusetts is unique in
subsidizing not only low-income workers, but small employers
as well. Employers participating in the state’s program (the
Insurance Partnership, or IP) receive a fixed amount on behalf
of each low-income employee, with the dollar amount varying
by type of coverage (single vs. family). Employees receive an
additional subsidy for their share of the insurance premium. A
total of 3,500 small employers currently participate in the IP,
with 10,000 adults and children covered through the program.
However, little is known about other small employers in the
state and how many offer health insurance. This study
compares the characteristics of firms participating in the IP
with those of small firms who have not joined the IP.
Study Design: We conducted a mailed survey, with telephone
follow-up, of a sample of IP participating firms and a sample
of non-participating small firms in 2003. The response rate
was 47 percent, for a total sample of 1,142. Chi-squares were
used to compare characteristics of the two groups of firms.
Logistic regression will be used to model the factors
explaining participation in the IP.
Population Studied: Small firms (50 employees or less) in
Massachusetts.
Principal Findings: IP participants and non-participating
firms did not vary with respect to size, location, or industry
type (based on SIC code). The majority were self-employed or
very small (2-9 employees), and provided personal or
business services.
Prior to joining the IP, just over half (58%) of participating
firms had offered health insurance to their employees. The
subsidy allowed these firms to continue offering insurance (in
the face of steep premium increases) and, in some cases, to
expand benefits or coverage. For the remaining 42% of firms,
the subsidy allowed them to offer health insurance for the first
time.
Offer rates were similar for non-participating firms (62%),
with high premium costs cited as the main reason for not
offering insurance. Despite a major media campaign, only
one-quarter of these firms were familiar with the IP. The most
frequent reason for nonparticipation (or lack of interest in
participating, once the program was described) was that the
firm had no eligible employees (i.e., no employees with
incomes below 200% of FPL). Other reasons included: no
need (already offer insurance) or subsidy not adequate.
Conclusions: The lack of eligible low-income employees is a
key factor in firm non-participation. While this could be
interpreted as a lack of need for premium assistance among
non-participating firms, these firms were not any more likely
to offer insurance than were participants (prior to joining the
IP). This suggests that the income eligibility threshold is too
low relative to the cost of premiums in Massachusetts.
Implications for Policy, Delivery or Practice: In order to
further expand insurance coverage, state policymakers need to
consider raising the income eligibility threshold for employees
and disseminating information about the program more
broadly. However, both of these strategies will add to the
budget, at a time when policymakers are looking to save, not
spend, money.
Primary Funding Source: CMS
• Hospital Staff Responses to Denials of Concurrent
Utilization Review
Mary Ellen Murray, Ph.D., R.N.
Presented by: Mary Ellen Murray, Ph.D., R.N., Assistant
Professor, School of Nursing, University of Wisconsin Madison, 600 Highland Avenue, K6/340 CSC, Madison, WI
53792-2455; Tel: 608.263.6945; Fax: 608.263.5332; E-mail:
memurra1@wisc.edu
Research Objective: To examine the responses and attitudes
of hospital staff members who receive a denial of certification
for reimbursement when providing clinical information for
concurrent utilization review (UR).
Study Design: The UR process requires that care providers,
typically registered nurses employed by the hospital, report
clinical information to payers, or their representatives. This
information is related to the severity of illness of the patient as
well as the projected plan of care. Reviewers then make a
determination if the care meets criteria of medical necessity
and appropriateness and is allowable under the terms of the
hospital/payer contract and the individual insurance policy.
Care that meets these criteria is certified for reimbursement.
A qualitative design was used to study the responses and
attitudes of hospital staff members who received a denial of
certification during the 12-month study period. Each staff
member was asked to complete an audiotaped interview with
a research assistant. The taped interviews were subsequently
transcribed, and analyzed using the affinity process. The
analysis team consisted of 5 doctoral students in nursing and
the principal investigator.
Population Studied: The study was conducted at an
Academic Health Center. Interviews with hospital staff were
obtained for 99 of the 102 denials of reimbursement that
occurred in the one-year study period. Hospital staff who
conducted the UR process included nurse case managers
(N=18), clinical social workers (N=9), case manager
associates (N=8), and additional registered nurses (N=2) who
provided part-time support for the UR function. The 102
denials of certification for reimbursement were associated
with 26 different hospital clinical services and involved only
adult inpatients. Denials occurred most frequently in
psychiatry (21), orthopedics (11), neurology (9), transplant (7),
neurosurgery (7), surgical trauma (6), rehabilitation (5), and
peripheral vascular surgery (5). The remaining 18 clinical
services had only 1-4 denials each over the 12-month study
period.
Principal Findings: Key themes that emerged from the data
include: (1) Hospital staff refusal to accept responsibility for
informing patient or family members of the denial, (2)
Protective responses of patient by hospital staff when denial
occurs, (3) MD with limited or no involvement in the
utilization review process, (4) Initiation of adversarial payerprovider relationship when the payer makes a denial, (5)
Occasional recognition that the denial decision is correct and
payer/provider cooperative relationship is created, (6) Social
issues related to denials, and (7) Feelings of powerlessness of
UR staff to affect physician and payer decisions.
Conclusions: Participation in the concurrent utilization review
function produces conflict in hospital employees who perform
this function. These employees identify themselves as patient
advocates in opposition of payer pressures to reduce inpatient
utilization.
Implications for Policy, Delivery or Practice: This study
raises important questions about the responsibility of health
care providers to discuss financial issues related to patient
care and the potential conflict this causes within the
patient/healthcare provider relationship.
Primary Funding Source: AHRQ
• Emergency Department Utilization for Nonemergent
Health Conditions
Kyle Muus, Ph.D., Alana Knudson, Ph.D., Dmitri Poltavski,
Ph.D., Michelle Bowles, M.P.A.
Presented by: Kyle Muus, Ph.D., Assistant Professor, School
of Medicine and Health Sciences, UND Center for Rural
Health, P.O. Box 9037, Grand Forks, ND 58202; Tel:
701.777.3848; Fax: 701.777.6779; E-mail:
klmuus@medicine.nodak.edu
Research Objective: 1. Assess the extent to which North
Dakota hospital emergency departments (EDs) are utilized for
non-emergent conditions among (a) age cohorts, (b) payer
groups, and (c) frequent ED users.
2. Examine the extent to which EDs are utilized for oral healthrelated conditions.
Study Design: Descriptive; Secondary analysis
Population Studied: All ED patient visits (calendar year 2002)
from a randomly selected group of North Dakota hospitals
(N=58,660 patient visits).
Principal Findings: Among ED visits with classifiable
principal diagnoses (N=25,871), most cases were categorized
as ‘non-emergent’ (37%), followed by ‘emergent--preventable
with primary care’ (36%), ‘emergent--ED care needed-preventable/avoidable’ (8%), and ‘emergent--ED care needed-not preventable/ avoidable’ (20%).
Regarding ED use for nonurgent health conditions,
commercial insurance (32.4%), self-payers (25.6%) and
Medicaid (22.7%) comprised the largest shares of patient
volume. Worker’s Compensation had the highest percent of
its enrollees classified as non-emergent cases (68.6%).
The number of ED visits per patient ranged from 1-52, with 3%
of patients having four or more visits ('frequent ED users').
Medicaid enrollees comprised the largest volume of frequent
ED users (34.1%). IHS/PHS (7.8%) and Medicaid (7.7%) had
the highest percent of their enrollees as frequent ED users.
Approximately 1% (N=658) of all ED visits had an (nontrauma) oral health-related principal diagnosis. Self-payers and
Medicaid comprised nearly two-thirds (65.9%) of these cases.
Conclusions: North Dakota EDs are principally utilized for
nonurgent or primary care-treatable illnesses or injuries, with
commercially insured individuals comprising the largest share
of these ED visits. Health care costs could be curtailed by
efforts to re-direct patients with minor afflictions from
emergency care to outpatient ambulatory care settings.
Implications for Policy, Delivery or Practice: Broader patient
education efforts are needed regarding the roles of ambulatory
office and ED care, and the importance of preventive care and
continuity of care. In particular, state health policymakers
within the Worker's Compensation and Medicaid programs
should increase health education efforts among their enrollees
to promote appropriate use of health resources for reducing
costs.
Future studies are needed on ND rates/patterns of
uninsurance and underinsurance and barriers to adequate
insurance coverage, including as assessment of potential
avenues for increasing the affordability of health plans for
individuals, families and employers.
The findings on ED use for oral health-related conditions
warrant closer examination of barriers to preventive dental
care, particularly among Medicaid and uninsured North
Dakotans.
Primary Funding Source: Dakota Medical Foundation
• Health Services Utilization among Homeless Individuals
in Dallas, Texas
Paul Nakonezny, Ph.D., Michael Ojeda, M.S.
Presented by: Paul Nakonezny, Ph.D., Assistant Professor,
Health Promotion, University of North Texas, P.O. Box
310769, Denton, TX 76203; Tel: 940.565.2651; Fax:
940.565.4904; E-mail: nakonezny@coe.unt.edu
Research Objective: County hospitals need to explore
alternative modes of health services delivery to reduce the
high utilization of the hospital and emergency room setting
for primary care among the homeless population. One
alternative model being used by the Parkland Health and
Hospital System in Dallas, Texas, a large county hospital, is
the Homeless Outreach Medical Services (HOMES) program,
which uses two mobile medical units and a fixed site
outpatient clinic to provide primary health care to homeless
individuals. The current study examined the relationship
between outpatient utilization delivered via the HOMES
program and inpatient utilization among a sample of the
homeless population who were served by the Parkland Health
and Hospital System.
Study Design: A quasi-experimental design and health
services utilization data from 293 male and 288 female
homeless patients were used to address the research objective
of this study. The dependent variables were measurements of
inpatient and outpatient utilization of psychiatric, substance
abuse, and musculoskeletal services. These three diagnoses
were selected for analysis because they represent three of the
top five disease conditions most frequently diagnosed among
the homeless population being served by HOMES.
Outpatient utilization was measured as the number of visits to
the HOMES mobile medical units and fixed site clinic and
inpatient utilization was measured as the number of visits to
the Parkland inpatient units and emergency room between
June 01, 1992, to June 30, 1999. That is, each homeless
patient was matched on inpatient and outpatient utilization
for each diagnosis (psychiatric, substance abuse, and
musculoskeletal) and then utilization was measured across
the seven year time period. Inpatient and outpatient
utilization patterns by age, gender, and race were also
assessed. Data were analyzed using a split-plot repeated
measures MANOVA, one-way ANOVA, and simple linear
regression.
Population Studied: A sample of 581 homeless patients aged
20-64 years who used HOMES and the Parkland Health and
Hospital System in Dallas, Texas.
Principal Findings: Results suggested that, across the seven
year time period, homeless individuals, regardless of gender
and race, utilized the mobile medical units and outpatient
clinic services more than inpatient services for psychiatric,
substance abuse, and musculoskeletal conditions. Older
homeless adults (50-64 yrs of age) compared with younger
homeless individuals (20-49 yrs of age) utilized the mobile
medical units and outpatient clinic services more than
inpatient services for substance abuse and musculoskeletal
conditions, but they utilized inpatient services the most for
psychiatric-related conditions. This inpatient utilization is
perhaps a result of greater severity or progression of mental
illness among older homeless adults.
Conclusions: The HOMES program is an example of a health
care delivery model that addresses the complex and unique
health care needs of individuals who are homeless. The
outpatient utilization of health services is probably because
the HOMES program provides accessible, continuous,
comprehensive, appropriate, and sensitive health care to
homeless persons, free-of-charge and on a walk-in basis,
where homeless individuals congregate. The HOMES
program mitigates many of the barriers that prevent homeless
individuals from obtaining primary medical care.
Implications for Policy, Delivery or Practice: A significant
void exists between the medical needs of the homeless
population and the current health care system in the United
States. If hospital systems and the community are to be
successful in meeting the health care needs of the homeless
population, they must develop programs that are accessible-so that health problems do not go untreated, requiring more
costly inpatient care--and they must build a social support
network for homeless individuals to break down the social
isolation barrier. These programs also must be designed with
sensitivity to the multifaceted health problems of individuals
who are homeless and to the special needs associated with
homelessness.
• Health Insurance and the Hidden Unemployed
Lawrence Nitz, Ph.D., Gerard Russo, Ph.D., Sang Hyop Lee,
Ph.D.
Presented by: Lawrence Nitz, Ph.D., Professor, Political
Science, Political Science, University of Hawaii, 2424 Maile
Way, Room 640, Honolulu, HI 96822; Tel: 808.956.8665; Fax:
808.956.6877; E-mail: lnitz@hawaii.edu
Research Objective: The objective is to determine the degree
to which the employment status "delf-employed" hides a
group of low income persons without health insurance, who
may become unanticipated Medicaid participants in various
proposals to increase the income limits for state Medicaid
benefits.
Study Design: The study uses a logistic regression of health
insurance status against indicators for self-employment
status, income, education, gender, and income-self
employment interactions. The key questions are whether selfemployed individuals are less likely to be insured than those
working for others or in other social statuses, whether there is
an interaction between income and employment status that
would support the notion that "self employment" is in many
cases a brand of hidden unemployement, versus the notion
that "self employment" involves the voluntary acceptance of
health risks by rejecting health insurance.
Population Studied: The study population was the BRFSS
sampled from the Hawaii population in 2000, 2001, and
2002. The combined samples provide the basis for relatively
fine divisions of demographic indicators, notably employment
status, income and education.
Principal Findings: The logistic regression of insurance
status on the self-employment indicator clearly denotes more
acceptance of uninsured status by the self-employed. The role
of income suggests that higher income persons are more
likely to be insured. The interaction between self-employment
and income indicates that the higher the level of selfemployment income, the higher the likelihood of being
uninsured.
Conclusions: The picture of the self-employed as in part a
hidden layer of the poverty population is only partially
supported. Additional tabulations would be appropriate to
distinguish between those self-employed persons who earn
relatively well compared to their equally skilled compatriots
who work for others, and those whose self employment
income is markedly less than that expected for their level of
human captial.
Implications for Policy, Delivery or Practice: To the extent
that the self-employed are risk takers on their own accounts
and earn relatively well for their level of human capital,
increasing the income floor for Medicaid coverage may be
expected to draw few from this group as a woodwork effect.
On the other hand, to the extent that the self-employed are in
part voluntarily unemployed, increasing Medicaid floors may
draw participants who would not be anticipated on income
grounds alone.
Primary Funding Source: HRSA
• The Inpatient Utilization of California Medicare HMO
Disenrollees to Fee-For-Service: Implications for M+C
Enrollment Lock-In
June O’Leary, Ph.D., Elizabeth Sloss, Ph.D., Nasreen Dhanani,
Ph.D., Glenn Melnick, Ph.D.
Presented by: June O’Leary, Ph.D., Consultant, RAND, 1700
Main Street, PO Box 2138, Santa Monica, CA 90407-2138; Tel:
310.393.0411 Ext. 6284; Fax (310) 393-4818, 310.451.7061 Email: oleary@rand.org.
Research Objective: Previous research suggests that
disenrollees from Medicare health maintenance organizations
(HMO) are sicker and cost more on average than fee-forservice (FFS) beneficiaries or non-disenrollees. Whether
disenrollees use a higher or lower level of services prior to
disenrollment has different implications for why they use more
services post-disenrollment. The utilization of services by
Medicare beneficiaries while in an HMO has never been
observed. We examine the use of inpatient services prior to
and during enrollment in an HMO, and after disenrollment to
FFS.
Study Design: Enrollment data on Medicare beneficiaries
from the Centers for Medicare and Medicaid Services were
linked to inpatient hospital discharge data from the California
Office of Statewide Health Planning and Development for
January 1992 through December 1996. Three measures of
inpatient utilization were estimated: (1) admissions, (2) total
days, and (3) average length of stay. Since beneficiaries can
enroll and disenroll on a monthly basis, utilization was
calculated in person-months.
Population Studied: Three subgroups of Medicare
beneficiaries in California were identified: (1) beneficiaries who
disenroll from an HMO to FFS anytime between January 1993
and December 1995; (2) a sample of beneficiaries
continuously-enrolled in FFS; and (5) beneficiaries
continuously-enrolled in HMOs. Beneficiaries who met any of
the following criteria during any month were excluded: had
end-stage renal disease; were not continuously-entitled to
Medicare; did not have both Part A and B coverage; resided in
counties with fewer than 1,000 HMO enrollees; moved out of
California.
Principal Findings: Inpatient use by disenrollees to FFS is
higher on average than continuously-enrolled FFS or HMO
beneficiaries. The admission rate per person-month after
disenrollment was 0.086 versus0.043 before disenrollment for
those 27,720 beneficiaries who disenrolled to FFS sometime
between 1992 and 1995 and were enrolled in an HMO for at
least three months and remained in FFS for at least three
months or until death. A quarterly analysis of the year before
and after disenrollment suggests that admissions begin rising
prior to disenrollment.
Conclusions: Disenrollees to FFS are sicker on average than
continuously-enrolled HMO and FFS beneficiaries. Inpatient
use is lower while enrolled but rises prior to disenrollment
suggesting that a medical event might trigger disenrollment to
FFS. Further research is needed to determine whether
disenrollees experience difficulties obtaining care while
enrolled leading to use of services in FFS.
Implications for Policy, Delivery or Practice: Before the
lock-in policy that will restrict how often and when
beneficiaries can enroll and disenroll from HMOs is
implemented, a better understanding of how HMOs manage
the care of this population is needed.
Primary Funding Source: AHRQ, HHS/ASPE
• Do Parents’ Citizenship Statuses Predict U.S.-Born
Mexican-Origin Children’s Access to Job-Based Health
Insurance?
Victoria Ojeda, Ph.D., M.P.H.
Presented by: Victoria Ojeda, Ph.D., M.P.H., NIMH PostDoctoral Research Fellow, Health Care Policy, Harvard
Medical School, 180 Longwood Avenue, Boston, MA 02115;
Tel: 617.432.0819; Fax: 617.432.0173; E-mail:
ojeda@hcp.med.harvard.edu
Research Objective: Uninsurance is pervasive among Latino
children, in part because of their lower rates of job-based
coverage. This study reviews sources of health insurance
coverage among a population of U.S.-born Mexican-origin
children in working, two-parent families; data are
disaggregated by parents’ citizenship statuses.
This investigation examines whether parents' citizenship
statuses predict disparities in children's job-based insurance
coverage.
Study Design: This is a cross-sectional study, based on data
from the March 2001 supplement of the Current Population
Survey, a monthly survey of about 50,000 households
nationwide. The CPS sample is representative of the civilian
non-institutionalized population. Statistical methods used
include bivariate analyses and logistic regression techniques.
This study focuses on parents’ citizenship statuses as
determinants of Mexican-origin children’s coverage through
an employer in the context of other sociodemographic
characteristics. I tested the hypothesis that U.S.-born children
in working two-parent families headed by any combination of
noncitizen and citizen (i.e. naturalized citizens or native-born)
parents would be less likely to have coverage through an
employer than children in entirely native-born families.
Population Studied: U.S.-born Mexican-origin children
eighteen years or younger who are dependents and members
of working two-parent families are the focus of this study.
Native-born Mexican-origin children represent more than twothirds of all Latino children. I focus on children in two-parent
families since the presence of two adults allows for potentially
two workers in the workforce. Further, children in working
families may have the best chances for obtaining employerbased insurance, the most common source of insurance for
nonelderly populations, due to their families’ connections to
the labor market.
Principal Findings: Bivariate analyses show that U.S.-born
Mexican-origin children in two-parent working families headed
by at least one noncitizen parent are more likely to be
uninsured and less likely to have job-based insurance than
children in entirely native-born families. About one-third of
children living with two noncitizen parents are uninsured, and
29% have job-based insurance. Uninsured rates drop to 22%
for children in families with one citizen and one noncitizen
parent; 55% have job-based insurance.
Multivariate analyses suggest that parents’ citizenship
statuses are less significant predictors of workplace coverage,
after controlling for other sociodemographic and employment
characteristics. Children in families headed by two noncitizen
parents (OR=0.48) and children in families headed by one
naturalized parent and one U.S.-born parent (OR= 0.52) are
less likely than children in entirely native-born families to have
job-based insurance. Low-incomes, firm size, and
occupational distributions also play important roles in shaping
children’s access to job-based insurance.
Conclusions: Children in families headed by one noncitizen
and one citizen parent (either naturalized or U.S.-born) benefit
from having a citizen parent. Despite being in working twoparent families, children whose families are headed by two
noncitizen parents remain at risk for lacking job-based
insurance. Findings suggest that noncitizen parents face
important barriers to obtaining workplace coverage. Job-based
coverage is not always a successful coverage mechanism for
children living with two noncitizens. Future research may
expose barriers to coverage faced by subgroups of
noncitizens, including legal permanent residents.
Implications for Policy, Delivery or Practice: Policy
solutions are needed to reduce uninsurance and disparities in
job-based coverage among working families, including those
with immigrants and low incomes. Continued support for
safety-net programs may prove especially critical for working
families if insurance is not offered in the workplace and the
costs of health services, prescription drugs, and insurance in
the private market continue to rise.
Primary Funding Source: UCLA Dissertation Year Fellowship
• Expanding Health Insurance Coverage through the
States: Lessons from the California Health Insurance Act
of 2003
Thomas Oliver, Ph.D., M.H.A.
Presented by: Thomas Oliver, Ph.D., M.H.A., Associate
Professor, Health Policy and Management, Johns Hopkins
University, 624 N. Broadway, Room 403, Baltimore, MD
21205; Tel: 410.614.5967; Fax: 410.955.6959; E-mail:
toliver@jhsph.edu
Research Objective: To identify key factors in the health care
system and in the political system that facilitate major
expansions of health insurance coverage in the states.
Study Design: The study reviews the history of past initiatives
to secure universal or near-universal health insurance in
California and three sets of variables affecting the prospects
for new reforms: 1) the number and characteristics of the
uninsured population and how they are understood in the
policy community; 2) the basic design of proposals for
expanding coverage, particularly financing and administration;
and 3) political conditions, including the positions and
resources of key elected officials and interest groups, state
fiscal capacity, and federal support for major state expansions
of insurance coverage. The study draws upon personal
interviews with key participants in the policy community,
archival documents, and health services research and analysis.
Population Studied: N/A
Principal Findings: The paper finds that several key factors
changed to facilitate the enactment of the California Health
Insurance Act of 2003. Organized labor joined with organized
medicine to establish the core of a powerful coalition for
reform; key political leaders sponsored the legislation and
made it a high priority; the reform was viewed as a partial
solution, not a contributor, to the state's fiscal crisis; and the
recall election of the Democratic governor narrowed the
window of opportunity for action on this issue.
Conclusions: The conditions for adopting an employer
mandate and other health care reforms in California in 2003
suggest that comparable reforms are viable in other states and
that the issue of universal coverage is likely to achieve greater
prominence on the national policy agenda regardless of the
outcome of the 2004 presidential and congressional elections.
Implications for Policy, Delivery or Practice:
Primary Funding Source: California HealthCare Foundation
• Short Tenures in Medicaid Managed Care
Gerry Fairbrother, Ph.D., Heidi Park, Ph.D., Arfana Haidery,
M.P.H., Bradford H. Gray, Ph.D.
Presented by: Heidi Park, Ph.D., Research Associate, , The
New York Academy of Medicine, 1216 Fifth Avenue, New York,
NY 10029; Tel: 212.419.3525; E-mail: hpark@nyam.org
Research Objective: A recent study shows that children's
tenures in Medicaid managed care is shorter than in Medicaid
itself. The purpose of this study is to examine the reasons for
short tenures in Medicaid managed care and to better
understand the practices and policies that lead to the gap
between tenures in Medicaid and in health plans.
Study Design: This qualitative study was conducted in five
states: Arizona, Michigan, New York, Oregon and
Pennsylvania. The states were selected to provide variation in
geographical location and in experience with Medicaid
managed care. Semi-structured in-depth interviews were
conducted both face-to-face and by telephone with key
individuals at each state, which included State Medicaid and
Medicaid Managed Care officials, enrollment brokers, and
appropriate health plan personnel, including Medical
Directors and quality monitoring and enrollment staff.
Population Studied: Medicaid managed care enrollees
Principal Findings: Two factors emerged as the major
contributors to short tenures in Medicaid managed care: (1)
the gap between the time Medicaid coverage begins and
enrollment in the health plan, and (2) the frequency and ease
of Medicaid eligibility renewal and recertification. The gap in
Medicaid coverage and enrollment in a health plan occurs
because Medicaid coverage begins retroactively to the date of
application and Medicaid eligibility must be determined before
enrollment in a health plan. In our five study states, the
interval between the start of Medicaid coverage and the start
of health plan enrollment can be as long as 2 to 4 months. In
addition, we found that the frequent and burdensome
Medicaid renewal process often leads to breaks in enrollment,
not only in Medicaid itself, but also at the health plan. Failure
to renew on time can lead to another gap coverage. Care can
be delayed during these gaps because enrollees do not know
whether they have coverage.
Conclusions: Current enrollment policies and practices lead
to a gap in coverage in Medicaid and in Medicaid managed
care organizations, and often loss of coverage at Medicaid
renewal. This results in short enrollment tenures in health
plans. Short tenures can affect continuity of care, quality
monitoring, and the ability for health plans to manage costs.
Implications for Policy, Delivery or Practice: Recent
budgetary pressures have forced states to adopt policies that
will shorten tenures in Medicaid. It is important to recognize
that shortening eligibility periods and increasing hurdles in the
enrollment process will exacerbate the problem of short
tenures and make it more difficult to manage the care of these
enrollees.
Primary Funding Source: Center for Health Care Strategies
• The Effects of Coverage on Barriers to Prenatal Care
among Women
Marsha Regenstein, Ph.D., Jennifer Huang, M.S., Linda
Cummings, Ph.D., Donna Sickler, M.P.H.
Presented by: Marsha Regenstein, Ph.D., Vice President of
Research for National Association of Public Hospitals and
Health Systems and Director for National Public Health and
Hospital Institute, National Association of Public Hospitals
and Health Systems, 1301 Pennsylvania Avenue, N.W., Suite
950, Washington, DC 20004; Tel: 202.585.0105; Fax:
202.585.0101; E-mail: mregenstein@naph.org
Research Objective: To identify barriers to prenatal care and
utilization among low-income women delivering at large safety
institutions.
Study Design: A self-administered survey was given to eligible
patients post-delivery to identify barriers to prenatal care prior
to and during pregnancy. The survey response rate was 76.1
percent, with a total of 2,509 respondents. Surveys were
matched via unique identifiers to non-identifying information
collected from labor and delivery records. These records
included information about initiation of prenatal care,
demographics, and birth-related outcomes.
Population Studied: Twenty-six public hospitals and health
systems belonging to the National Association of Public
Hospitals and Health Systems were selected to participate.
These hospitals were selected to participate based on number
of expected births, geography, and patient demographics.
Women delivering during a two-week period in fall 2002 were
eligible to participate in the study.
Principal Findings: In terms of race, 83.4 percent of
respondents were non-white, compared to 42.2 percent of
women delivering nationwide. Women delivering at study
hospitals tend to be younger, less educated, and less likely to
be married than women nationally.
Women continuously uninsured throughout pregnancy were
more likely to indicate they missed or delayed prenatal care,
although women continuously insured throughout their
pregnancy also reported barriers to prenatal care.
Women who converted from uninsured to insured status
identified barriers to care at higher rates than continuously
insured.
Coverage differed significantly by race of respondent, with
Latina women at greatest risk for being uninsured. Medicaid
was by far the dominant insurer of Black women, with 71.2
percent indicating that they were on Medicaid at the time of
their delivery.
Although women across all races reported reasons for missing
or delaying care, for the majority of barriers, Latina women
were more likely than women of other races to report barriers
to prenatal care.
Conclusions: Despite the availability of safety net providers,
barriers to prenatal care are significant for both continuously
uninsured and continuously insured women, with more
obstacles for the continuously uninsured. Barriers remain for
women without coverage at the outset of pregnancy.
Implications for Policy, Delivery or Practice: The study
findings demonstrate the value of programs that provide
coverage to pregnant women and the effect that such
coverage has on low-income women’s self-reported
perceptions of barriers to care. Policies to increase coverage to
women pre-pregnancy would have additional benefits for
timely and adequate prenatal care. A combination of
strategies, including more comprehensive coverage and more
patient-centered care, may hold the greatest promise for
improving access to timely prenatal care for low-income
women.
Primary Funding Source: March of Dimes; American College
of Obstetricians and Gynecologists
• The Structure, Financing and Accessibility of Safety Net
Services in Ten U.S. Communities
Marsha Regenstein, Ph.D., MCP, Lea Nolan, MA, Peter Shin,
Ph.D., M.P.H., Marcia Wilson, M.B.A., Holly Mead, Bruce
Siegel, M.D., M.P.H.
Presented by: Marsha Regenstein, Ph.D., MCP, Assistant
Research Professor, Department of Health Policy, George
Washington University School of Public Health and Health
Services, 2021 K Street, N.W., Suite 800, Washington, DC
20006; Tel: 202.530.2310; Fax: 202.296.6922; E-mail:
marshar@gwu.edu
Research Objective: The nation's safety net provides care for
millions of uninsured and underserved individuals.
Communities rely on safety net hospitals, community health
centers, health departments, clinics and individual
practitioners to provide primary and specialty care, high-tech
emergency and trauma services, mental health and substance
abuse care, dental health and prevention and screening
services. Financing for these services is increasingly
constrained by tight state and local budgets, despite increases
in demand for care. This study assesses the structure,
financing and availability of safety net services in U.S.
communities and identifies opportunities for improving
access and strengthening service delivery.
Study Design: Ten communities were identified through a
national competitive process to undergo an assessment of the
local safety net. Data for the assessment were developed
through site visits, interviews with local stakeholders, and
review of secondary sources. Thirty focus groups were
conducted in six languages with residents who were likely to
use safety net services. Data from an emergency department
in each community were analyzed using an established
emergency department use profiling algorithm to determine
the percentage of visits that were non-emergent and/or
primary care treatable. A partner organization in each
community convened meetings of stakeholders at the start of
the assessment to describe the key issues affecting the safety
net and at the conclusion of the project to disseminate
findings from the assessment.
Population Studied: The focus of the project was on
uninsured and underserved residents in ten communities and
the health care providers who serve them. A secondary focus
was on patients using one safety net hospital emergency
department in these communities.
Principal Findings: All ten communities face substantial
challenges in preserving the safety net and meeting the needs
of residents. Experiences with state budget crises varied
across communities but generally involved changes in the
Medicaid program, decreases in state or local funding
streams, and increased demand for services, especially from
working uninsured or underinsured residents. Several of the
sites lacked sufficient primary care and uninsured and
underserved residents in most sites had significant difficulty
accessing timely and affordable specialty, dental, and mental
health services. Several sites had problems with coordination
of services across multiple sites of care or within systems
offering tiered services. Residents commonly used the
emergency departments of large safety net hospitals for nonemergent or primary care treatable conditions.
Conclusions: Communities would benefit from better
coordination among safety net providers. Such coordination is
essential to stretch limited resources across populations in
need of care. Enhancing access through expansions to public
programs may prove challenging, given budget constraints at
state and local levels. Use of the emergency department for
non-emergent or primary care treatable conditions varies
across the sites and reflects a myriad of factors related to
availability of alternative sites of care and patient preferences
and awareness of options.
Implications for Policy, Delivery or Practice: While some
communities are in need of additional health service capacity,
others may benefit from an emphasis on integration of
existing resources.
Primary Funding Source: RWJF
• Hospital Concentration, DSH Payments, and Access for
the Uninsured in Los Angeles County and the State of
California
Gerald Kominski, Ph.D., Dylan Roby, M.Phil.
Presented by: Dylan Roby, M.Phil., Senior Research Associate,
Center for Health Policy Research, UCLA, 10911 Weyburn
Avenue, Suite 300, Los Angeles, CA 90024; Tel: 310.794.3953;
Fax: 310.794.2686; E-mail: droby@ucla.edu
Research Objective: This project examines how recent trends
toward concentration within the hospital industry among
hospital chains and the increase in for-profit ownership
(specifically Tenet Healthcare Hospitals) affects access to
affordable healthcare in Los Angeles. Specifically, it
investigates the impact of hospital concentration on:
(1)
costs and revenues, which affects the affordability of
employer-provided coverage for those that have it, and
(2)
the competitive position of the public hospitals,
which have traditionally provided a safety net to the uninsured
and underinsured.
The primary focus of this study is Los Angeles County, since
for-profit hospital growth has been greatest in this region. For
comparison purposes, we also examined data for hospitals in
the rest of California, excluding Los Angeles County. We
examine how hospitals performed from 1995-2000 in Los
Angeles County and in the rest of California in providing care
to the uninsured, staying solvent, and taking advantage of
funding designed for safety net providers.
Study Design: The data sources used in this study are readily
available from the California Office of Statewide Health
Planning and Development (OSHPD) and the California
Department of Health Services. The main data set used in this
study is the Hospital Annual Financial Data files for 19952000. These data are reported on a hospital fiscal year basis
by each acute care hospital in California, and include
information on revenues, patient days, discharges, expenses
and other variables at the hospital level. Acute care hospitals
are defined by OSHPD as hospitals with at least half of their
patient days classified as acute.
The second source of data used in this study is
Disproportionate Share Hospital (DSH) payment data
collected by the Department of Health Services. These data
track DSH payment information for each hospital, and also
collects data on the transfer payments made by public
hospitals into the DSH fund. These data were only available
for 1998-2001.
Descriptive statistics were developed based on revenue, profit
margin, and patient mix variables for each group of hospitals
(private, non-profit, government, and Tenet-owned hospitals).
Population Studied: Acute care hospitals in California and
the city of Los Angeles from 1995-2000. The definition of
acute care hospitals does not include long-term care facilities,
or psychiatric or rehabilitation hospitals.
Principal Findings: There was an increase in the number of
hospitals in the county owned by hospital systems. For
example, Tenet Healthcare Corporation increased their market
share from 8% in 1995 to 15% in 2000. In addition, Tenet’s
concentration has greatly increased their payments from the
Disproportionate Share Hospital (DSH) program. In
California, Tenet owned 8 hospitals in 1995 that received DSH
payments; by 2000, they owned 17. In Los Angeles County,
Tenet went from owning one DSH hospital in 1995 to owning
6 by the year 2000.
Overall, Tenet added 14 hospitals statewide within five years.
This growth has occurred while Los Angeles County’s
government hospitals have been facing financial pressures
due to cutbacks and a growing uninsured population.
The average total margin for Tenet hospitals grew at a healthy
rate in Los Angeles County and the rest of California through
1999. From 1998 to 2000, total margins declined for all
hospitals in Los Angeles County and for all hospitals in the
rest of California except Tenet hospitals.
Operating expenses in Tenet hospitals were fairly stable, while
government hospitals in Los Angeles faced a serious problem
of rising expenses without sufficient growth in patient
revenue.
One factor that is largely responsible for Tenet’s ability to
achieve high profits in the current healthcare market is the
Disproportionate Share Hospital (DSH) payment system.
Conclusions: Tenet engaged in aggressive cost cutting, both
in Los Angeles and the rest of California, and this contributed
to its relatively high profit margins during 1995-2000. This is
clearly one of the potential advantages of hospital chains,
namely, that they can achieve greater efficiency than standalone facilities.
Tenet’s profit margins grew during the 1995-2000 period
because of its rapid increase in DSH payments, while other
hospitals in Los Angeles County and the rest of California
showed no growth in these payments. Yet during this same
period, Tenet’s share of uninsured patient days declined and
remained the lowest of any hospital group. Thus, at a time
when the County’s health care system has faced substantial
financial threats, Tenet was successful in rapidly increasing its
DSH payments without any increase in uninsured patient days
and with a large decline in the average severity of its patient
mix.
Implications for Policy, Delivery or Practice: Los Angeles
County government hospitals continue to struggle financially
while a greater portion of DHS payments continue to go to
Tenet hospitals. Unless limitations in the formula for
distributing DSH payments are addressed by the state
legislature, the efficiencies associated with hospital
concentration may continue to be offset by the costs imposed
on the public sector by aggressive revenue maximization
practices.
In addition, DSH payments to Tenet hospitals are not being
targeted toward hospitals where the poor and uninsured
recieve most of their care. This shift in the distribution of
safety net funding will affect the ability of government and
non-profit hospitals to provide care to the underserved.
Primary Funding Source: UCLA Institure for Labor and
Employment
• How Does Health Literacy Affect Individual Health
Outcomes—Is Health Communication the Missing Link?
Rafael Ruiz, Sc.M., Shoou-Yih Lee, Ph.D., Ahsan M. Arozullah,
M.D., M.P.H.
Presented by: Rafael Ruiz, Sc.M., Doctoral Student, Health
Policy and Administration, University of North Carolina at
Chapel Hill, School of Public Health, McGavran-Greenberg
CB#7411, Chapel Hill, NC 27599; Tel: 919.960.8402; Fax:
919.966.6961; E-mail: rruiz@email.unc.edu
Research Objective: Almost 25% of the U.S. population is
functionally illiterate, raising concerns about those individuals’
ability to navigate the healthcare system. Indeed, studies have
consistently shown that patients with a lower level of health
literacy tend to have worse health status and display more
risky health behaviors such as smoking and excessive
drinking. Many researchers have suggested that such adverse
outcomes may be due to inadequate communication between
low health literacy patients and their healthcare providers. In
other words, health communication may be a key mechanism
that mediates the impact of health literacy on individual health
outcomes. The study is intended to provide an empirical test
of this hypothesis.
Study Design: Data for this study were from a survey of
patients, presenting from June to October 2001, at a Veterans
Administration (VA) Hospital in Chicago. Four ordered probit
regression models were run in order to analyze various selfreported measures of health communication. Health literacy
was measured by the Rapid Estimate of Adult Literacy in
Medicine (REALM). Control variables included measures of
several socio-demographic factors and social capital.
Population Studied: Male patients of the Veterans
Administration Healthcare Systems.
Principal Findings: Contrary to our expectation, health
literacy did not show a statistically significant relationship with
any of the four health communication variables examined in
the analysis, suggesting that health communication did not
mediate the effect of health literacy on individual health status
and risky health behavior. In further analysis, we found that
functional and structural social support was negatively
correlated with health communication. Interestingly, having a
regular provider was negatively correlated with most of the
health communication variables.
Conclusions: Health communication did not appear to
explain the association of health literacy with health status and
health behavior. Improvement of health communication alone
may be ineffective in ameliorating the adverse health
outcomes of individuals with low health literacy.
Implications for Policy, Delivery or Practice: Programs
designed to improve patient-provider communication may be
inadequate in addressing the personal health problems of low
health literacy patients. Further research is needed to
understand how low health literacy is related to negative
health outcomes.
Primary Funding Source: Pfizer Foundation
• The Impact of State Children’s Health Insurance
Program (SCHIP) Expansion on Health Insurance
Coverage in Hawaii
Gerard Russo, Ph.D., Sang-Hyop Lee, Ph.D., Lawrence Nitz,
Ph.D., Thamana Lekprichakul, Ph.D.
Presented by: Gerard Russo, Ph.D., Associate Professor,
Department of Economics, University of Hawaii, 2424 Maile
Way, Saunders Hall 542, Honolulu, HI 96822; Tel:
808.956.7065; Fax: 808.956.4347; E-mail: russo@hawaii.edu
Research Objective: The purpose of this study is two-fold.
First, to assess the impact of the initial SCHIP expansion
which occurred in Hawaii July 1, 2000 and extended free
public insurance coverage to all children aged 0-18 years
residing in households with incomes not greater than 200%
of the Hawaii specific federal poverty level, FPL. Second, to
predict take-up of public coverage and crowd-out of private
insurance which may occur under a proposed expansion of
eligibility to children aged 0-18 years residing in households
with incomes between 200% and 300% of the federal poverty
level FPL.
Study Design: This study exploits the natural experiment of a
July 1, 2000 SCHIP expansion, which is reflected in survey
data, to estimate take-up and crowd-rates among newly
eligible beneficiaries. Prior to the implementation of SCHIP,
children in Hawaii were eligible for free medical assistance
under Medicaid financing per the following age-income
criteria. Children age 0 were eligible up to 185% of the Hawaii
specific FPL, children aged 1-5 years up to 133% FPL and
children aged 6-18 years up to 100% of the FPL. On July 1,
2000, SCHIP was implemented in Hawaii as a Medicaid
expansion and extended coverage to all children age 0-18 up
to 200% FPL. Thus, children under age 1 residing in families
with incomes between 186% and 200% FPL, children age 1-5
in families with incomes between 134% and 200% FPL and
children age 6-18 in families with incomes between 101% and
200% became newly eligible for free medical assistance
under SCHIP July 1, 2000. This treatment group is tracked in
1998-1999 before eligibility and in 2001-2002 after eligibility
and both direct and model-based estimates of insurance
status are produced. Children aged 0-18 years residing in
families with incomes between 201% and 250% the FPL have
been ineligible for public insurance throughout the period
1998-2002 and are used as a control group. The study uses a
difference-in-difference approach to sweep out non-policy
related effects. Estimates are based on multiple years of the
Hawaii Health Survey, confidential version and the Current
Population Survey, Annual Social and Economic Supplement,
public use version. Model-based estimates are also used to
project a response to increased eligibility up to 300% of the
FPL.
Population Studied: The study is exclusive to Hawaii
residents aged 0-18 years residing in households with incomes
between 0% and 300% of the Hawaii specific federal poverty
guidelines as published by the U.S. Department of Health and
Human Services. Weighted population estimates are
produced using the Hawaii Health Survey 1998-2002 and the
Hawaii sample of Current Population Survey 1998-2003.
Three groups are analyzed, children eligible for free public
insurance throughout the period, children who began the
period ineligible and became eligible in 2000 and children
who were ineligible throughout the period.
Principal Findings: The Initial SCHIP implementation of July
1, 2000, which brought public insurance eligibility to 200%
FPL, enrolled approximately 6000-7000 children with rather
modest displacement of private insurance. The proposed
further expansion to 300%, however, is projected to generate
dramatic crowd-out as households drop private family
coverage to enroll children in free public insurance.
Preliminary model-based estimates predict 29,000 new
children enrollees coming from households with incomes
between 201% and 300% of the FPL. Of these only 2000
would have been previously uninsured, while 27,000 would be
drawn from private insured families--a staggering rate of
crowd-out.
Conclusions: Because of a number of factors, including
Hawaii’s Pre-paid Health Care Act of 1974, which mandates
private sector employment-based coverage, middle-class
families are typically well insured. Of the approximately
50,000-55,000 children aged 0-18 years residing in families
with incomes between 201% and 300% of the FPL, only 20003000 are without health insurance coverage. As a result, a
generous public expansion which takes all comers up to 300%
FPL is likely to yield a large number of privately insured along
with the uninsured.
Implications for Policy, Delivery or Practice: A Hawaii
SCHIP expansion to 300% of the FPL will result in substantial
crowd-out of private insurance. Whether viewed from the
broad federal perspective or the narrow state budgetary
perspective, such an expansion would generate high public
expenditures per newly insured child and should therefore be
pursued with caution. A successful and sustainable expansion
of eligibility criteria must be accompanied by safeguards
against excessive private insurance crowd-out.
Primary Funding Source: HRSA, Hawaii State Department of
Health
• The Effect of Mandatory Employer-Sponsored Health
Insurance on Insurance Coverage and Employment in
Hawaii
Sang-Hyop Lee, Ph.D., Gerard Russo, Ph.D., Lawrence Nitz,
Ph.D.
Presented by: Gerard Russo, Ph.D., Associate Professor,
Department of Economics, University of Hawaii, 2424 Maile
Way, Saunders Hall 542, Honolulu, HI 96822; Tel:
808.956.7065; Fax: 808.956.4347; E-mail: russo@hawaii.edu
Research Objective: The purpose of this study is to examine
the impact of Hawaii’s mandatory employer-provided health
insurance on insurance coverage and employment structure in
Hawaii. We hypothesize that mandated employer-sponsored
health insurance has three effects on health insurance
coverage and the labor market. First, it increases employerprovided health insurance coverage for full-time workers. That
is, persons employed more that 20 hours per week. Second, it
changes the distribution of equilibrium employment by hours
worked as some employees seek and employers offer parttime employment to avoid the mandated benefit. Third,
people who are not matched with full-time jobs with employerprovided health insurance will switch to other types of
insurance, such as publicly provided health insurance or
spousal benefits, as an optimal response.
Study Design: Hawaii’s Pre-Paid Health Care Act of 1974 is a
unique law which requires private sector employers to offer
and employees to accept employer-sponsored health
insurance as a fringe benefit. Hawaii is the only State in the
Union with such a mandate as the Employee Retirement
Income Security Act, ERISA, generally prohibits States from
mandating health and retirement benefits. The Federal
government reserves that right, except in the case of Hawaii
which has a Congressionally sanctioned exemption. We
produce model-based estimates of employment patterns and
insurance coverage for working age adults for Hawaii, the U.S.
as a whole and several comparative States including Nevada
and Michigan controlling for worker characteristics and
industrial structure. We treat Hawaii as the factual and the
U.S., Michigan and Nevada estimates as the counter-factual.
That is, if Hawaii did not have an employer-mandate,
employment and coverage should mimic the rest of the
United States controlling for other factors. Therefore, the
difference in employment patterns and coverage can be
inferred to be due the employer-mandate, if other factors have
been properly controlled.
Population Studied: We produce model-based estimates of
employment by hours-worked and insurance coverage using
the Current Population Survey, Annual Social and Economic
Supplement 1988-2003. Estimates are for working age adults,
19-64 years, and are produced for Hawaii, Nevada, Michigan
and the U.S. overall.
Principal Findings: Our empirical evidence generally
supports all three hypotheses. First, private employmentbased insurance coverage for full-time workers is more
prevalent in Hawaii than the U.S. overall. Second, there is
substantial avoidance of the employer-mandate in Hawaii by
skirting the 20 hour rule. Third, switching to other types of
insurance is significant compared to the other states and the
U.S. overall.
Conclusions: Hawaii’s Pre-paid Health Care Act of 1974 has
increased insurance coverage overall. It has also generated
labor market sorting, as employees who prefer cash over
fringe benefits seek part-time employment and employers
happily accommodate to avoid the employer-mandate.
Implications for Policy, Delivery or Practice: Hawaii’s
employer-mandate has allowed policy-makers to increase
insurance coverage to Hawaii’s population while shifting a
portion of premiums to federal tax-payers via the federal tax
treatment of fringe benefits. While mandated coverage is
generally considered distorting, Hawaii’s 20 hour rule
provides a safety-valve which reduces any inefficiency
generated.
Primary Funding Source: HRSA, Hawaii State Department of
Health
• The Financial Feasibility of Healthcare System Reform
Steven Schramm
Presented by: Steven Schramm, Principal, Mercer
Government Human Services Consulting, 3131 East
Camelback, Suite 300, Phoenix, AZ 85016; Tel: 602.522.6500;
Fax: 602.957.9573; E-mail: steve.schramm@mercer.com
Research Objective: States provide critical laboratories to test
health system reform proposals. Our objective was to develop
a Statewide Health Care System Pricing Model that would
provide a baseline cost for all health care expenditures in a
state as well as a vehicle to price out the impact of various
statewide health care reform proposals on those expenditures.
Study Design: Actuarial analysis of four health care reform
proposals was conducted to determine who would be covered,
the cost per person and total cost. Mercer established
baseline cost and population estimates by pre-defined
insurance market segments under the current health care
delivery model. For insured individuals, this was done by
identifying their primary linkage to the health care coverage
marketplace – who provided their coverage. For the
uninsured, which by definition has no linkage to the primary
health care coverage marketplace, Mercer determined their
secondary linkage to the health care marketplace – where they
could receive health care coverage.
Mercer next developed baseline cost estimates for all
individuals according to their primary and secondary linkages
to the health care coverage marketplace. These baseline costs
were further delineated by major product type and key
category of service. Mercer then determined the funding
source associated with the cost of coverage by the four major
payor sources: employer, government/military, Medicaid, and
the uninsured. The funding was further split into employer
costs, out-of pocket costs, and administrative costs by payor
source.
For each health care reform proposal, Mercer shifted the
populations according to the program design of each reform
proposal. Mercer tracked the underlying risk of each
population as it moved among payor sources and product
types within each proposal. The impact of each health care
reform proposal was determined by;
•
the number of Arizonans who would be covered by
the various forms of public and private health insurance
•
the costs of extending coverage, and
•
the implicit shift in funding sources.
Population Studied: All Arizonans, by health care costs and
coverage category, excluding Medicare
Principal Findings: Creating a state tax credit would provide
coverage for 4% (38,000) of the currently uninsured
population, increasing total health spending by $33.4 million
annually. Expanding Medicaid through a sliding fee scale buyin would increase coverage by 14% (134,000), also at an
annual cost of $33.4 million. An employer mandate would
cover 48% of the uninsured (479,000) an increase of $400
million. Creating a ‘public utility’ to administer a universal,
single-payor system would cover 100% of the uninsured at an
increased annual cost of $600 million.
Conclusions: Creating a public utility was the most costeffective model on a per person basis. Tax credits and the
employer mandate were least cost-effective.
Implications for Policy, Delivery or Practice: Our analysis
has shown that health care reform proposals have widely
divergent impacts from a cost and coverage perspective.
Policy-makers need to be educated about the trade-offs among
cost and coverage in general as well specifically by payor
source. The health policy debate will be shaped not only by
how much reform costs, but who must pay for it.
Primary Funding Source: St. Luke's Health Initiatives
• Prehospital Time and Outcome in Pediatric Trauma
Roopa Seshadri, Ph.D., Denise Goodman, M.D., M.S.
Presented by: Roopa Seshadri, Ph.D., Assistant Professor,
Child Health Research Program, Northwestern University,
2300 Children's Plaza, #157, Chicago, IL 60614; Tel:
773.327.9646; Fax: 773.327.9688;
E-mail: r-seshadri@northwestern.edu
Research Objective: We sought to investigate the challenges
to regionalization of trauma services for children by
comparing outcomes between those treated in urban vs. nonurban settings. We hypothesized that children in non-urban
areas would have longer prehospital (PH) times (sum of
emergency medical services (EMS) response, scene, and
transport times) than those in urban areas, and would have
worse outcomes.
Study Design: This was a retrospective data analysis using
the Trauma Registry of the Illinois Department of Public
Health, covering 1999-2001. Outcome was defined as (1)
discharged from Emergency Department (ED); (2) further
medical care needed; and (3) expired. PH time was studied
using linear regression models, with urban vs. non-urban,
patient age, and PH Glasgow Coma Score (GCS) as
predictors, including the interaction effect of age and GCS. To
determine the effect of urban vs. non-urban and PH time on
ED and hospital outcomes, mixed-effect cumulative logit
models were used, with hospital as a clustering effect.
Population Studied: We studied children < 19 years of age.
The city of Chicago and its 6 surrounding counties comprised
the urban center, and was compared to the rest of the state.
Principal Findings: Approximately 8000 observations were
used. PH time was 35.2 +/- 17.2 mins non-urban vs. 29.7 +/10.3 mins urban (p < 0.001). Amongst the younger children
(<12 yrs), those with GCS < 13 have shorter PH time (p <
0.001). PH time does not affect ED outcome but is related to
ultimate hospital outcome (p < 0.001). If PH time is < 30
minutes, patients are 1.5 times as likely to have a better
outcome (p < 0.001; 95 % CI (1.4, 1.8)). There was no
difference in hospital outcome between urban and non-urban
children. The hospital-level clustering effect was negligible.
Conclusions: PH time is a significant determinant of hospital
outcome. This marker of access to care is more important
than is the distinction between urban vs. non-urban location.
The influence of PH time transcends ED events and carries
over into final hospital outcome.
Implications for Policy, Delivery or Practice: Our results
underscore the importance of early definitive hospital care in
pediatric trauma. Further insight into the factors determining
PH events may permit better regionalization of pediatric
trauma care and improved access for children.
• Disenrollment from Medicare Risk Health Maintenance
Organization to Fee-for-Service among Dual MedicareMedicaid Eligibles and Other Vulnerable Subgroups,
California, 1996-2001
Elizabeth Sloss, Ph.D., Melissa Lopez, Ph.D., June O’Leary,
Ph.D., Nasreen Dhanani, Ph.D., Glenn Melnick, Ph.D.
Presented by: Elizabeth Sloss, Ph.D., Natural Scientist,
Health, RAND, 1200 South Hayes Street, Arlington, VA 22202;
Tel: 703.413.1100 Ext. 5633; Fax: 703.414.4717; E-mail:
sloss@rand.org
Research Objective: To describe changes in rates of
disenrollment from Medicare risk health maintenance
organizations (HMO) to fee-for-service (FFS) from 1996
through 2001 among dual Medicare-Medicaid eligibles and
other vulnerable subgroups of Medicare beneficiaries in
California. Monthly and annual disenrollment patterns, as
well as rates for demographic and geographic subgroups, are
described for beneficiaries in Medicare risk HMOs.
Study Design: Disenrollment rates were computed for all
Medicare beneficiaries, dual eligibles, and other vulnerable
subgroups in California using enrollment data from the
Centers for Medicare and Medicaid Services (CMS) for 19962001. Other vulnerable beneficiary subgroups included
females, African-Americans, disabled, and 85 years or older.
Given the occurrence of monthly changes in entitlement and
HMO status, rates were calculated on a monthly basis and
then aggregated over 12 months to yield a disenrollment rate
per member-year. Disenrollment to FFS was defined as a
change from a risk HMO to FFS after which the beneficiary
remained in FFS for at least three months.
Population Studied: All Medicare beneficiaries eligible for
Part A and Part B, regardless of age, who were enrolled in a
Medicare risk HMO in California for at least one month
between January 1996 and December 2001. Beneficiaries
enrolled in cost-reimbursed HMOs, health care prepayment
plans or demonstrations were excluded.
Principal Findings: From 1996-2001, dual-eligibles
disenrolled from Medicare risk HMOs to FFS at annual rates
varying from 14% in 1996 to 18% in 2001. Disenrollment from
Medicare risk HMOs was lower among other vulnerable
subgroups, including females (2.5% in 1996 to 4.6% in 2001),
African-Americans (4.3% to 7.0%), disabled (4.3% to 8.0%),
and those 85 years or older (3.5% to 4.9%). The disenrollment
rates among dual eligibles were much higher than among all
Medicare beneficiaries (2.4% to 4.9% over 1996-2001). Rates
among other vulnerable subgroups were closer to all Medicare
beneficiaries. Monthly disenrollment rates peaked in
December almost all years and subgroups, with dual-eligibles
having higher rates than other vulnerable subgroups in all 12
months.
Conclusions: Annual disenrollment rates from Medicare risk
HMOs to FFS are higher among vulnerable beneficiaries than
among other Medicare beneficiaries, with the highest rates
among dual-eligibles. Disenrollment rates are considerably
higher in 2001 than in 1996.
Implications for Policy, Delivery or Practice: With high rates
of disenrollment from Medicare risk HMOs, providing
managed care options for vulnerable subgroups, especially
dual eligibles, will continue to be a challenge. If higher
disenrollment indicates lower satisfaction, it will be important
to monitor access to care and quality of care provided by risk
HMOs to these vulnerable beneficiaries. Updated studies of
the reasons for disenrollment would assist CMS in its efforts
to manage the care of vulnerable beneficiaries, and to
coordinate Medicare and Medicaid benefits for dual-eligibles.
Primary Funding Source: AHRQ
• A Wealth of Local Expertise – Putting Together a
Statewide Health Research and Evaluation Collaborative to
Encourage Evidence-Based Decision-Making in Oregon
Jeanene Smith, M.D., M.P.H., Lisa Krois, M.P.H., Tina Edlund,
M.P.H.
Presented by: Jeanene Smith, M.D., M.P.H., Deputy
Administrator, The Office for Oregon Health Policy &
Research, 800 N.E. Oregon Street, RM 607, Portland, OR
97232; Tel: 503.731.3005 Ext. 652; Fax: 503.872.6832; E-mail:
Jeanene.Smith@state.or.us
Research Objective: To inform policymakers as the
restructured Oregon Health Plan (OHP) faces significant cuts
in an ongoing budget crisis, the State of Oregon brought
together local health service researchers representing
managed care organizations, hospital systems, behavioral
health, advocates and interested stakeholders to form the
Oregon Health Research and Evaluation Collaborative
(OHREC). This unique collaborative provides the opportunity
for evaluative research to be conducted with local working
knowledge of Oregon’s health services system but
independent of the state. OHREC’s goals are to:
1.Facilitate research efforts to inform the legislature and
stakeholders on OHP issues
2.Procure grants to fund collaborative research projects to
study long-term impacts to Oregon Health Plan changes
3.Establish a working information network among health
services researchers and the state for improved
communication and efficiency of research efforts
4. Create a streamlined process for health services research on
the Oregon Health Plan.
Study Design: Multiple studies at the system, program and
individual level have been conducted with the focus of health
care delivery, benefit redesign, and the financial delivery
systems of the Oregon Health Plan. All studies where
conducted through the collaborative with results disseminated
back to Oregon’s decision makers.
Population Studied: Oregon’s Medicaid program (OHP);
vulnerable populations
Principal Findings: Research must be conducted in a timely
manner to remain relevant to issues facing decision-makers.
OHREC was successful in accomplishing this with several
initial projects, with its’ survey of Oregon’s Medically Needy
Program beneficiaries as a prime example. By conducting the
survey shortly after the program was cut due to the state’s
budget crisis, the results were quickly available and used by
policymakers as they designed a scaled-down, replacement
pharmacy assistance program for this vulnerable population.
Research can provide valuable information to decision-makers
but the key is getting it heard. Results must be disseminated
using appropriate language and in accessible formats in order
to be considered by policy makers. OHREC has used a variety
of communication strategies including, short public
presentations by researchers to policymakers and advocates,
two-page research briefs, Listservs and verbal dissemination
by staff to key policymaking bodies.
The success of a collaborative depends on building
relationships between policymakers and the researchers while
balancing the competing needs of academic and political
processes.
The vision/mission of a collaborative is as important to
retaining participating researchers as the potential for grant
monies.
Conclusions: The collaborative has proven to be a successful
model for facilitating research important to state health
services with scarce resources.
Multiple strategies must be employed in order to connect
research to policy makers.
A collaborative’s success depends upon a delicate balance of
researchers’ and policymakers’ needs
Implications for Policy, Delivery or Practice: Timely and
relevant research is important for evidence-based decision
making on health care policy. Linking policymakers to
researchers is key in order for this to happen.
Primary Funding Source: RWJF
• How Do Closures of Labor and Delivery Services Affect
Community Access to Care?
Joanne Spetz, Ph.D., Lisa Simonson Maiuro, Ph.D., Paul Kirby,
M.A.
Presented by: Joanne Spetz, Ph.D., Assistant Professor,
Community Health Systems, University of California, San
Francisco, 3333 California Street, Suite 410, San Francisco, CA
94118; Tel: 415.502.4443; Fax: 415.502.4992; E-mail:
jojo@alum.mit.edu
Research Objective: There is general consensus that
hospitals face many challenges in today’s health care
environment. Financial pressures may induce hospitals to
drop certain categories of services that are perceived as
unprofitable. As a result, some communities may lose access
to needed services, and this loss of service may affect access
to care.
Study Design: The study design relies on a combination of
quantitative and qualitative analysis to identify how hospital
services and access to these services has changed among
California hospitals. To begin, we examined changes in the
availability of hospital services using patient discharge data.
We grouped discharges into 48 categories, and then identified
hospitals that had a decline of 85% or more in any service
category. We did not examine closures of emergency rooms,
because this issue has been addressed in other studies.
Using the discharge data, we also created hospital service
measure of concentration, similar to a Herfindahl (HHI)
index, to reflect changes in the range of services provided by
hospitals. After identifying types of services most likely to
close, we conducted case studies to provide insight into how
communities are affected by service changes. These case
studies involved both data analysis and key informant
interviews.
Population Studied: All California hospitals that reported
patient discharge data to the Office of Statewide Health
Planning and Development (OSHPD) in 1995 and 2002.
Principal Findings: The service mix among hospitals that
have remained in operation over the time period was
remarkably stable as reflected by a hospital concentration
index. Among inpatient-based services, obstetric and
gynecological care was most affected. Less than 10% of
hospitals offering obstetric and gynecological care in 1995
eliminated this service by 2002. Rural hospitals were
disproportionately affected. In most cases, the hospitals had
low volumes of deliveries and did not offer labor and delivery
care for high-risk births. Case studies of hospitals that closed
their obstetric services found that there was little impact on
access to care in urban and near-urban communities, but
significant effects in rural areas.
Conclusions: Although there has been concern that financial
pressures are leading hospitals to eliminate critical
community services, we found little evidence of this occurring
on a widespread scale. Obstetric services were most
commonly eliminated, with a disproportionate share of
obstetric closures being in rural hospitals. Closure of obstetric
services in rural communities has significant effects on access
to care for community residents.
Implications for Policy, Delivery or Practice: There was not
a widespread closure of hospital services in the late 1990s.
This suggests that the financial pressures faced by hospitals
rarely leads to service closures. However, a number of
hospitals eliminated their labor and delivery services.
Closures of labor and delivery services have little effect on
access to care in urban communities. In rural communities,
however, labor and delivery closures result in significant
barriers to access to care for patients both in travel for delivery
and also in reduce community presence of obstetriciangynecologists. Policymakers and health care providers need to
pay particular attention to closures of services in rural regions.
Primary Funding Source: California HealthCare Foundation
• Geographic Access to Hospital-Based Perinatal Care for
At-Risk African American Women in South Carolina
John Stewart, MS, M.P.H., Ana Lopez-DeFede, Ph.D.
Presented by: John Stewart, MS, M.P.H., GIS Manager,
Institute for Families in Society, University of South Carolina,
937 Assembly Street, Suite 618, Columbia, SC 29208; Tel:
803.777.5516; Fax: 803.777.1793; E-mail: jstewart@gwm.sc.edu
Research Objective: Identify and map African American
women at risk for poor perinatal outcomes in a South Carolina
perinatal care region. Evaluate appropriate health care
accessibility by estimating travel distance to hospital-based
perinatal care for at-risk women.
Study Design: Data from the 2000 Census were used to
determine the number of African American women at risk for
poor perinatal outcomes (women ages 15 to 17 and 35 to 44)
in 24,949 census blocks comprising the Pee Dee perinatal
care region in South Carolina. Using a geographic information
system (GIS), area hospitals providing basic, specialty, and/or
subspecialty perinatal care were geocoded at the street
address level. A GIS network tool then was used to determine
actual road distance from each populated block centroid
(point representing the geographic center of a census block
with one or more at-risk women) to the nearest hospital(s)
providing basic perinatal care, specialty care, and subspecialty
care.
Population Studied: African American women ages 15 to 17
(N=5,355) and 35 to 44 (N=15,989) in an eight-county perinatal
care region in South Carolina.
Principal Findings: Geographic access to hospital-based
perinatal services varies markedly by level of care. On average,
African American women ages 15 to 17 live 9.3 miles from
basic perinatal services, 18.4 miles from specialty care, and
31.8 miles from subspecialty care. Similarly, African American
women ages 35 to 44 reside, on average, 9.2 miles from basic
care, 18.0 miles from specialty care, and 31.2 miles from
subspecialty care. Notably, 19.6% of younger women and
19.0% of older women live 50 miles or more from hospitalbased subspecialty perinatal care.
Conclusions: Distance from care may limit access to hospitalbased perinatal services (especially specialty and subspecialty
care) for at-risk African American women in the Pee Dee
region. Efforts to identify and serve geographically remote
subpopulations may improve perinatal outcomes and lower
health care costs. GIS technology can be used to locate
geographically remote at-risk subpopulations, identify
community-based perinatal care specialists (e.g.,
obstetricians, gynecologists) serving remote areas, coordinate
neonatal and maternal transportation to and from appropriate
perinatal care sites, and target perinatal health education
initiatives.
Implications for Policy, Delivery or Practice: Enhanced
coordination of regional perinatal care to improve perinatal
outcomes for geographically remote at-risk African American
women.
Primary Funding Source: SC Department of Health and
Human Services
• ZIP-Code Characteristics Correlated with Individuals'
HIV-Testing
Stephanie Taylor, Ph.D., M.P.H., Arleen Leibowitz, Ph.D., Paul
Simon, M.D., M.P.H.
Presented by: Stephanie Taylor, Ph.D., M.P.H., Associate
Social Scientist, Health, RAND, 1700 Main Street, P.O. Box
2138, Santa Monica, CA 90407; Tel: 310.393.0411 Ext. 7965;
Fax: 310.451.7062; E-mail: staylor@rand.org
Research Objective: To understand HIV-testing
impediments, most studies focus on individuals’
characteristics, ignoring the potential effect of individuals’
residential areas. This paper explores eleven ZIP code
characteristics as correlates of HIV-testing, controlling for
individuals’ characteristics. It is important for understanding
HIV-testing decisions because it documents the role of
individuals’ residential areas and individuals’ risk and
demographic factors. Identifying ZIP code-level correlates of
low testing rates, particularly in higher-risk areas, is potentially
important to public health agencies nationally. They can use
these insights to increase their outreach efforts in areas where
many higher-risk people reporting relatively low testing rates
reside.
Study Design: Individuals’ data was from the 1999 Los
Angeles (L.A.) County Health Survey, a random digit-dialed
population survey. A multi-level logistic regression analysis of
HIV-testing was conducted using two samples: 1) respondents
in all 233 ZIP codes and 2) the subset of persons in 20 regions
having larger proportions of respondents reporting “higherrisk” sex (defined as, in the prior year, not always using
condoms and having more than one partner). Regions were
merged, contiguous ZIP codes containing over 30
respondents each. Higher-risk regions were examined
because, given limited resources, it is important to focus HIV
prevention efforts where they could have the greatest impact –
where concentrations of residents at higher-risk for HIV live.
MLwiN software with full and restricted maximum likelihood
estimation methods was used.
Population Studied: The sample was a 1999 random
probability sample of L.A. adults (n=5,267). A third were
Latino, 10% were African American, 12% were Asian Pacific
Islanders, and 4% were “Other”.
Principal Findings: African American and Latino individuals
were more likely to test for HIV than Whites, consistent with
national trends and HIV/AIDS prevalence rates. However, a
different pattern of testing variation was evident at the ZIPcode level. Throughout L.A. and in higher-risk regions,
persons living in ZIP codes with greater proportions of African
Americans residents were more likely to test for HIV than in
persons living in predominately White or Latino areas,
regardless of individuals’ characteristics or neighborhoods’
number of AIDS cases and testing sites. However, residents
of predominately Latino areas were no more likely to test than
residents of mostly White neighborhoods. Furthermore,
persons living in neighborhoods with greater percentages of
married residents had lower testing rates, regardless of
individuals’ marital status or risky behaviors.
Conclusions: Latino individuals were more likely to test for
HIV than Whites. However, the average testing rate for all
residents of predominately Latino neighborhoods was lower
than that for all residents of African American neighborhoods.
The mechanism for this effect remains unknown.
Implications for Policy, Delivery or Practice: Future research
might attempt to elicit the HIV test-promoting mechanisms
present in African American neighborhoods but absent from
Latino communities. These might include replicable
mechanisms such as increased HIV-testing outreach or nonreplicable mechanisms such as social networks that spread
news of newly infected neighbors, subsequently prompting
persons to test. African Americans’ networks may be more
likely to affect individuals’ testing decisions than Latinos’
because the African American community has more openly
and aggressively addressed the HIV/AIDS issue than the
Latino community.
• Use of Chiropractic Services in the Rural South
Samruddhi Thaker, MBBS, M.H.A., Donald Pathman, M.D.,
M.P.H.
Presented by: Samruddhi Thaker, MBBS, M.H.A., Research
Associate, , Cecil G. Sheps Center for Health Services
Research, 725 Airport Road, Chapel Hill, NC 27516; Tel:
919.966.4371; Fax: 919.966.3811; E-mail:
thaker@mail.schsr.unc.edu
Research Objective: The use of chiropractic services has
grown over the past three decades; use in the South is lower
than in other parts of the U.S. Less is known about how often
rural individuals seek chiropractic services. This study
examines the use of chiropractic services among adults in the
rural South. We assess how chiropractic use varies with the
availability of chiropractors across states and relates to
individuals’ opinions of and access to physician care to assess
if chiropractors are used as substitutes for physician services.
Study Design: This is a secondary analysis of cross-sectional
data collected through a random-digit dialing survey in 150
rural counties in eight southern states—AL, AR, GA, LA, MS,
SC, TX, and WV—participating in the Robert Wood Johnson
Foundation’s Southern Rural Access Program. The survey
was conducted to determine access to outpatient services in
the rural south. The primary outcome variable for the present
study is subjects’ response to the question “In the past 12
months, have you been to see a chiropractor?” Analyses were
weighted to adjust for sampling probabilities and
demographic group response rates.
Population Studied: Respondents were randomly selected
from eligible adults living in the households contacted.
Eligible participants were age 18 and older who had lived in
the sampled county for at least a year and spoke English or
Spanish. 4,879 respondents completed the survey for a
response rate of 50.7%.
Principal Findings: Of the 4,869 adults answering the
question on chiropractic use, 353 (6.54%) reported seeing a
chiropractor in the previous year. Chiropractor use was more
common among whites than blacks (8% vs. 4%, p=0.001)
and among the married, more educated, employed, and
higher income individuals (p<0.05 for all). Chiropractic
service use varied from 3.2% to 9.8% across states
(p=0.0001) and tended to correlate with states’ chiropractorto-population ratios (r=0.61; p=0.1). 9% percent of those who
said the cost of physician care was problematic used
chiropractors compared with 6% who said the cost was not
problematic (p=0.005). Other barriers to physician care—lack
of health insurance, not having a usual source of care,
dissatisfaction with medical care, confidence in doctor’s
ability, and satisfaction with concern shown and getting
questions answered—were unrelated to the use of
chiropractors.
Conclusions: 6.54% of individuals in this southern rural adult
population reported chiropractic service use in the previous
year. Use was higher among those who were white, married,
more educated, employed and had higher incomes. Use
varied greatly across states in association with chiropractor-topopulation ratio. Except cost of physician care, people’s
experiences and perceptions of the care they received from
physicians were unrelated to their likelihood of having received
care from a chiropractor.
Implications for Policy, Delivery or Practice: These findings
provide information on the demographic characteristics of
individuals who use chiropractic services in the rural south.
We find some evidence that recent efforts of the National
Health Service Corps and Veterans Administration to enhance
chiropractor availability in underserved areas and in veteran
administration treatment settings, respectively, will increase
chiropractic service use by these populations.
Primary Funding Source: RWJF
• The Cost of State-Based Universal Health Care Coverage
Teresa Waters, Ph.D., Peter Budetti, M.D., JD, Linda Perloff,
Ph.D.
Presented by: Teresa Waters, Ph.D., Associate Professor,
Center for Health Services Research & Department of
Preventive Medicine, University of Tennessee Health Science
Center, 66 N. Pauline Street, Suite 463, Memphis, TN 38163;
Tel: 901.448.5826; Fax: 901.448.8009; E-mail:
twaters@utmem.edu
Research Objective: To analyze costs and cost savings
associated with various state-level options for universal health
care coverage.
Study Design: Data for the state of Illinois are used to
examine reform options. A model of current state health
expenditures was developed as a baseline. Four general
reform options were postulated and the financial impacts of
these changes derived using existing data and databases.
Population Studied: The population and expenditure patterns
of individuals in Illinois.
Principal Findings: Using decision analysis models, we find
that expanding coverage to all residents of Illinois would cost
between $2.2 and $4.5 billion in the first year, but that
incremental costs would diminish in subsequent years under
the single payer approaches, principally due to savings in
insurance overhead and administrative costs. By the 5th year
of implementation, single payer models providing universal
coverage would cost less than the current health care system
with 1.7 million uninsured. Using probabilistic sensitivity
analyses to allow key parameters to vary simulaneously, we
find that single payer reforms are a least-cost strategy in more
than 90 % of Monte Carlo iterations by the 8th year of
implementation.
Conclusions: State-level reforms appear to be a financiallyviable option for attaining universal health care coverage.
Implications for Policy, Delivery or Practice: The cost
savings associated with single payer models are too
significant to be ignored. Policies and programs that seek to
capture these savings could significantly curb health care
costinflation and produce sufficient additional funding to
provide coverage for the uninsured.
Primary Funding Source: Illinois Physician Committee for the
Defense of Medicine
• How Many Emergency Department Visits Are There?
Robin Weinick, Ph.D., Pamela Owens, Ph.D., Roxanne
Andrews, Ph.D., John Sommers, Ph.D., Steven Machlin, M.S.
Presented by: Robin Weinick, Ph.D., Senior Advisor for
Intramural Research/Senior Advisor for Safety Nets and Low
Income Populations, OPART, Agency for Healthcare Research
and Quality, 540 Gaither Road, Rockville, MD 20850; Tel:
301.427.1573; Fax: 301.427.1792; E-mail: rweinick@ahrq.gov
Research Objective: Early in 2003, Wears commented on an
article published in the Annals of Emergency Medicine that
used data from the Medical Expenditure Panel Survey (MEPS)
to study emergency department (ED) visits in the U.S. He
notes the large difference between the MEPS estimate of the
number of ED visits (43.8 million in 1998) and estimates from
the National Hospital Ambulatory Medical Care Survey
(NHAMCS, 100.4 million in 1998). While known
methodological differences between the surveys may
contribute to this difference, he concludes that such
differences account for only a small proportion of the
disparity. In this paper, we add comparisons with the
American Hospital Association Annual Survey (AHA) and the
National Health Interview Survey (NHIS). In addition, we use
administrative data from the Healthcare Cost and Utilization
Project (HCUP) to help improve these estimates for 2001.
Study Design: We compare national estimates derived from
two household-based surveys (the Medical Expenditure Panel
Survey (MEPS) and the National Health Interview Survey
(NHIS)) and two facility-based surveys (the National Hospital
Ambulatory Medical Care Survey (NHAMCS) and the
American Hospital Association Annual Survey (AHA)). We
also examine ED visits from the universe of discharge records
contained in the State Emergency Department Databases (9
states), State Ambulatory Surgery Databases (additional 9
states), and the State Inpatient Databases (additional 15
states), all part of the Healthcare Cost and Utilization Project
(HCUP). We compare the number of ED visits per hundred
population to better understand the differences between the
various data sources and to provide state and regional
comparisons.
Population Studied: Users of EDs in the U.S.
Principal Findings: Survey estimates of the number of ED
visits made by major data sources differ by as little as 1.5% to
as much as 92.8% (e.g., NHAMCS 107,490,000, AHA
105,865,778, and MEPS 55,758,852 visits), with data collected
from facilities providing higher estimates than that collected
from households. However, estimates from the AHA data
closely approximate state estimates collected from the
universe of ED discharges in HCUP (77 to 100%). ED visit
rates vary from 25 to 50 visits per 100 persons across the 9
states participating in all 3 HCUP databases.
Conclusions: Major data sources provide widely differing
estimates of the number of ED visits in the U.S. Householdbased surveys may suffer from underreporting due to
respondent bias.
Implications for Policy, Delivery or Practice: Knowing how
many ED visits occur in the U.S. annually is important for
health care planning, including both bed and staffing
requirements, and for monitoring access to care and
utilization patterns. In addition, a better understanding of the
types of ED visits that are missing from the NHIS and MEPS
data can help improve future research.
Primary Funding Source: AHRQ
• Who Can't Pay for Health Care?
Robin Weinick, Ph.D., Sepheen Byron, M.H.S., Arlene
Bierman, M.D., M.S.
Presented by: Robin Weinick, Ph.D., Senior Advisor for
Intramural Research/Senior Advisor for Safety Nets and Low
Income Populations, Office of Performance Accountability,
Technology, and Resources, Agency for Healthcare Research
and Quality, 540 Gaither Road, Rockville, MD 20850; Tel:
301.427.1573; Fax: 301.427.1792; E-mail: rweinick@ahrq.gov
Research Objective: In an era of rising health care costs and
budget constraints, an increasing number of Americans may
have difficulty paying for needed health care services. In this
study, we make use of a unique data set to estimate the
number of American adults who have problems paying for
health care and their characteristics, including health
insurance coverage and health status. We also present
information on the extent to which people who have private
health insurance coverage nonetheless report such difficulties.
Study Design: The Commonwealth Fund 2001 Health Care
Quality Survey collected detailed information about
experiences with health care from a nationally representative
sample of 6,722 adults ages 18 and older living in the
continental U.S. Measures used in this analysis include
having put off, postponed, or not sought medical care due to
cost in the past 12 months; not filling a prescription medicine
due to cost; having difficulty or not seeing a needed specialist
because could not afford to; not following the doctor’s advice
or treatment plan, or not getting a recommended test or
seeing a referred doctor because it cost too much; having
used alternative care because it is a cheaper way of getting
care; or having any of these problems. Bivariate comparisons
and logistic regressions were performed using Stata 7 to
account for the survey design.
Population Studied: Americans ages 18 and over.
Principal Findings: The proportion of American adults having
any one specific problem obtaining health care due to cost is
small, with estimates ranging from 2.1 to 6.9 percent.
However, the proportion of adults experiencing any of these
problems affording care is more substantial (16.9%),
including 14% of the privately insured and 22% of nonMedicare publicly insured. Of individuals reporting a
functional impairment, 25% reported at least one problem
affording care. Overall, Medicare beneficiaries reported fewer
financial barriers to care. These findings remained significant
in logistic regressions adjusting for sociodemographic
characteristics.
Conclusions: Some of our findings are encouraging:
Medicare enrollees on average report relatively lower
frequency of these problems and, net of other characteristics,
there are no racial or ethnic disparities in problems affording
health care. Other findings, however, are cause for concern.
Substantial proportions of Medicaid enrollees as well as
certain groups among those with private coverage, such as
those with low incomes, report problems paying for needed
health care. Such problems among those with substantial
functional impairments are also cause for concern. We
estimate that the number of American adults experiencing any
of these problems obtaining health care because of cost is
between 38.1 and 41.4 million.
Implications for Policy, Delivery or Practice: Some
individuals continue to encounter significant financial barriers
to care despite being privately or publicly insured. Individuals
with disabilities also experience problems. Proposals to
expand health insurance must address these barriers as well
as the specific issues of individuals with greater need.
Primary Funding Source: AHRQ
• The Impact of an Intervention Promoting Mass Transit
Use on Access to a Medical Home for Low-income,
Minority Urban Children
Serena Yang, M.D., Sujata Tipnis, M.D., M.P.H., Celina Saenz,
B.S., Nancy Kelly, M.D., M.P.H.
Presented by: Serena Yang, M.D., Clinical Post-doctoral
Fellow, Pediatrics, Baylor College of Medicine, 6621 Fannin
Street, MC-1540.00, Houston, TX 77030; Tel: 832.822.1549;
Fax: 832.825.3435; E-mail: sxyang1@texaschildrenshospital.org
Research Objective: To determine the impact of a mass
transit program on missed well child appointment rate for
children at risk for missing appointments at an urban clinic.
Study Design: This is a randomized controlled trial of an
intervention. Caregivers are randomized to 2 groups: those
who receive routine discharge instructions at the end of each
clinic visit (control), or those who receive bus tokens and
transit education in addition to routine discharge instructions
at all well-child visits (intervention). Participants are followed
for 6 months.
Population Studied: The Texas Children's Hospital Residents'
Primary Care Group (RPCG) Clinic provides primary health
care in an urban setting to a population that is primarily
minority and low-income with significant transportation
difficulties. This study targets caregivers of RPCG patients less
than 12 months old who are at risk for missing appointments
and who live within the mass transit service area.
Principal Findings: 136 participants have been enrolled. At
baseline, 55% reported they used their own car to reach clinic,
72% had never used public transit to clinic, and 25% reported
missing an appointment due to transportation. When asked
about their English-speaking ability using a 5-point rating
scale, 36% responded not well (4 out of 5) or not well at all (5
out of 5). A preliminary analysis of the 60 participants who
have completed the program reveals no significant difference
in missed well-child appointment rate between the groups.
However, within the intervention group, the receipt of multiple
intervention boosters (p<0.001) and a higher income level
(p=0.003) were associated with a lower missed appointment
rate.
Conclusions: Preliminary results show that the number of
exposures to the mass transit program may be important in
decreasing missed appointments, and that income level
appears to be an important factor associated with missed
appointments. Further data collection and analysis of the
remaining study participants will help clarify the impact of
mass transit coordination on alleviating access barriers for
low-income, minority families with transportation difficulties.
Implications for Policy, Delivery or Practice: Federallyfunded non-emergency medical transportation programs
which promote the usage of mass transit have demonstrated
significant cost savings for their respective State agencies.
Additional research is needed to demonstrate the impact of
the promotion of mass transit use on health outcomes of
vulnerable populations who have the greatest medical
transportation needs.
Primary Funding Source: American Academy of Pediatrics
• Vaccination Coverage in Employer-Sponsored SelfInsured Health Plans
Fangjun Zhou, Ph.D., Mark Messonnier, Ph.D., Jeanne Santoli,
M.D., Anjella Vargas-Rosales, M.S., Abigail Shefer, M.D.
Presented by: Fangjun Zhou, Ph.D., National Immunization
Program, Centers for Disease Control and Prevention, 1600
Clifton Road, N.E., MS E-52, Atlanta, GA 30333; Tel:
404.639.8251; Fax: 404.639.8614; E-mail: faz1@cdc.gov
Research Objective: To estimate the Diphtheria-tetanuspertussis (DTP) vaccination coverage based on vaccinations
administered in employer-sponsored self-insured health plans.
Study Design: We conducted a retrospective study of the
Medstat MarketScan database, which include enrollees
(children and adults) of approximately 100 self-insured health
insurance plans of 45 large employers each year. We selected
all children born between July 1, 1997 and June 30, 1998 who
were continuously enrolled until the end of 1999. The DTP
vaccination coverage among children aged 18 to 29 months
was estimated based on in-plan administration of 3 or more
doses of DTP vaccine (DTP3) and analyzed by characteristics
of the families and their health insurance plans.
Population Studied: Enrollees in the MarketScan database
Principal Findings: Overall DTP3 in-plan vaccination coverage
was 47.3%. The coverage rates for children residing in
metropolitan statistical areas (MSA) and non-MSAs were 52.7
and 31.1%, respectively; for children who enrolled in health
maintenance organization, point of service, preferred provider
organization and fee for service coverage rates were 79.3%,
77.3%, 32.3% and 18.9%, respectively; for children who
enrolled in capitated insurance plans coverage was 75.1% vs
non-capitated plans (34.3%). Of children with well-baby
coverage in their plan, 77.2% were vaccinated, while 26.3%
without that benefit were vaccinated.
Conclusions: Among employer-sponsored self-insured health
plans, vaccination coverage based on vaccinations
administered in-plan was highest in those that were capitated
and for those children in plans which had well-baby coverage.
Implications for Policy, Delivery or Practice: Knowledge of
how vaccination coverage is related to families and their
health plan characteristics may provide guidance for policymakers to improve vaccination among children in the U.S.
• Health Status Measurement During a Household
Evaluation of an Integrated Health Outreach Project
Targeting Colonia Residents in Hidalgo County, Texas
Miguel Zuniga, M.D., Dr.P.H., Craig Blakely, Ph.D., M.P.H.,
Martha Tromp, M.P.H., James Burdine, Dr.PH
Presented by: Miguel Zuniga, M.D., Dr.P.H., Assistant
Professor, Health Policy and Management, Texas A&M
University System School of Rural Public Health, 3000
Briarcrest Drive, Bryan, TX 77802; Tel: 979.862.4142; Fax:
979.862.8371; E-mail: mzuniga@srph.tamu.edu
Research Objective: To measure Colonia resident baseline
health status in project intervention to improve the ability of
lay health workers (promotoras) to impact health behaviors of
Colonia residents and to integrate their activities with the
actions of health providers in the area to change access and
utilization rates.
Study Design: Adult resident health status was measured
using the Short Form 8 Health Survey. This survey measures
physical and mental health domains and produces eight
health scales. These scales are Physical Functioning, Role
Physical, Bodily Pain, General Health, Vitality, Social
Functioning, Role Emotional, and Mental Health.
Respondents were selected randomly through selection of
block groups, then households, then residents within
households.
Population Studied: A household survey targeted 643
residents in two-intervention project Colonias and a nonintervention control Colonia in Hidalgo County.
Principal Findings: An overall response rate of 89% was
accomplished. The adult respondents had a mean age of 40
(18-86), 56% were female, 94% were Hispanic, and 68% were
married. The health status (SF-8) physical and mental
summary scales were statistically different (worse) than
national norms. With the exception of the mental health
scale, the remaining seven health scales were statistically
different (worse) than national norms. Health scale specific
comparisons for disease burden and insurance status are
presented.
Conclusions: The measurement of health status is a useful
tool for evaluation of community-based health interventions.
The health disparities in the mostly Hispanic population are
evident in their worse health scale score when compared to
the US national norms.
Implications for Policy, Delivery or Practice: The
measurement of health status is a practical strategy to assess
progress to the elimination of health disparities.
Primary Funding Source: RWJF