Coverage & Access
Call for Papers
Coverage Expansions & the Uninsured
Chair: Catherine McLaughlin, University of Michigan
Sunday, June 26 • 5:30 pm – 7:00 pm
●Who Benefits When States Expand Medicaid Coverage to
Parents?
Susan H. Busch, Ph.D., Elizabeth Vigdor, Ph.D.
Presented By: Susan H. Busch, Ph.D., Assistant Professor,
Health Policy, Yale Medical School, 60 College Street, New
Haven, CT 06520; Tel: (203)785-2927; Email:
susan.busch@yale.edu
Research Objective: One common metric used to assess
competing health insurance reform proposals is the increase
in insurance rates caused by the program. Yet policy makers
may also be interested in other outcomes, including any
changes in health that arise from increased insurance
coverage. Few studies have examined differences between
proposals in who becomes insured. We expect that those with
either chronic conditions or health risk factors will be more
likely to benefit from becoming insured. We examine who
becomes insured under one proposed policy for increasing
insurance coverage rates – expanding Medicaid to low income
parents.
Study Design: We consider whether low income individuals
with chronic conditions (diabetes), health risk factors
(smoking, obesity) or those in fair or poor health were more
likely to become insured or use needed health services than
other low income individuals under the parent
Medicaid/SCHIP expansions. We use instrumental variable
regressions to study the effects of these policies. We
instrument for actual eligibility using a simulated eligibility
measure for each state and year.
Population Studied: National Data come from the Behavioral
Risk Factor Surveillance System (BRFSS) and the Current
Population Survey (CPS) from 1996-2002.
Principal Findings: We find that when states expand income
eligibility levels for parents those most likely to take up
coverage have chronic conditions or additional risk factors for
disease. Additionally, we find that parents with these
conditions are less likely to report foregoing needed care due
to cost in expansion states. For example, we find that 20
percent of newly eligible, uninsured smokers enrolled in public
coverage after the expansions, compared with only 10 percent
of newly eligible, uninsured non-smokers. Examining use of
services, there was no change in foregoing needed care due to
cost in the non-smoking group, but a 25 percent reduction in
foregoing needed care due to cost for the smoking group.
Unlike previous research, we find that Medicaid expansions at
these income levels did not have differential effects by
race/ethnicity on health care utilization.
Conclusions: In considering public coverage expansions, the
fact that vulnerable groups were more likely to take up
coverage suggests these programs will have important health
benefits to parents.
Implications for Policy, Delivery, or Practice: This work
suggests that health outcomes should be considered as well
as the number of newly insured individuals when comparing
competing health insurance proposals. The recent Medicaid
expansions appear to have improved coverage
disproportionately for individuals who are most likely to
benefit from having health insurance: low income people with
chronic conditions or health risk factors. Policies that use a
different mechanism for increasing coverage may be more or
less successful at targeting these groups, which has
implications for the efficiency of health system reforms.
Primary Funding Source: No Funding
●Does Imputation Bias Lead to Finding Significantly More
Uninsured in the Current Population Survey’s Estimates of
Health Insurance Coverage?
Michael Davern, Ph.D., Lynn A. Blewett, Ph.D., Holly Rodin,
MS, Kathleen Thiede Call, Ph.D.
Presented By: Michael Davern, Ph.D., Assistant Professor,
SHADAC, University of Minnesota, 2221 University Avenue SE,
Suite 345, Minneapolis, MN 55414; Tel: (612) 625-4835; Fax:
(612) 624-1493; Email: daver004@umn.edu
Research Objective: Determine whether the imputation
procedure used by the US Census Bureau to replace missing
data produces bias in the estimates of health insurance
coverage in the Current Population Survey’s Annual Social and
Economic Supplement (ASEC).
Study Design: Twelve percent of the ASEC health insurance
coverage values are missing and imputed by the US Census
Bureau. We compare the health insurance coverage of
imputed respondents in the 2003 Current Population Survey’s
ASEC to those without imputed health insurance coverage.
We compare demographic characteristics of the two groups
and model the likelihood of having insurance coverage given
the data are imputed controlling for the same demographic
characteristics.
Population Studied: The non-institutionalized population in
2003.
Principal Findings: Although properly specified imputation
can alter basic distributional summary statistics (e.g., means,
rates and variances) from the statistics calculated using
complete cases only, it should not transform the relationships
among variables. In other words, imputation should not
create significant covariances between variables that were not
there before the imputation, nor should it reduce the
magnitude of significant covarainces between variables that
were there prior to imputation. In the 2003 ASEC, 59.7% of
18-64 year old adults have commercial health insurance
coverage if they have imputed data. However, 72.4% of the
non-full supplement imputations have commercial health
insurance coverage. Furthermore, imputed cases have a
26.7% uninsurance rate while all other 18-64 year old adults in
the CPS have an uninsurance rate of 14.6%. Part of this
differential is due to demographic difference between those
with imputed data and those without, but having imputed
data remains a significant predictor of health insurance
coverage in multivariate models controlling for the
demographics.
Conclusions: The imputed ASEC data seem to be coding too
many people to be uninsured and too many people to have
both public and private insurance coverage. The US Census
Bureau should consider reviewing and altering its imputation
specifications.
Implications for Policy, Delivery, or Practice: The ASEC is
likely to be imputing too many people to be uninsured,
resulting in a count of the total number of people who are
uninsured being too high. We attempt to quantify how much
higher the estimates from the ASEC are due to this imputation
problem and depending on the simulation its anywhere from
1-4 million people too high.
Primary Funding Source: RWJF
●How Long Do People Remain Medically Uninsured?
Julia Prentice, Ph.D.
Presented By: Julia Prentice, Ph.D., Health Services Research
Fellow, Bedford VAMC, Center for Health Quality, Outcomes
and Economic Research, 200 Springs Road (152), Bedford,
MA 01730; Tel: (781)687-2882; Email: jprentic@bu.edu
Research Objective: It is essential to know how long people
remain uninsured because policy options to decrease the
number of uninsured will differ if people remain uninsured for
short versus long periods. However, due to limitations in the
type of data collected, past research estimating the length of
uninsured spells has only included spells that begin during a
defined observation period, i.e. new spells, and has excluded
spells already in progress at the beginning of this observation
period. Only including new spells may exclude the chronically
uninsured leading to an underestimate of the average length
of uninsured spells. This project uses a new data set that has
duration information on both new spells and spells in
progress to examine how the average length of uninsured
spells varies if 1. only new spells are included, 2. only spells in
progress are included and 3. all spells are included.
Study Design: Data comes from the Los Angeles Family and
Neighborhood Survey, L.A. FANS, which interviewed 2,623
adults from 65 different census tracts in Los Angeles County.
L.A. FANS collected monthly information on health insurance
coverage for the two-year period before the interview. Unlike
earlier studies, L.A. FANS collected information on the start
date of insurance spells already in progress at the beginning of
this two-year period. Thus, both new spells that began during
the two year period and spells in progress at the beginning of
the two year period can be included in analyses estimating
duration of uninsured spells. The median duration of
uninsured spells were calculated by survival analysis using
Kaplan-Meier estimation. The median duration of uninsured
spells was compared between a sample that included only
new spells, a sample that included only spells in progress and
a sample that included all spells.
Population Studied: Working age adults (18-64 years old)
who experienced at least one uninsured spell during the two
year period before they were interviewed.
Principal Findings: Of the 946 uninsured spells experienced
by respondents during the two-year EHC, 745 (79%) are spells
in progress. Only 201 spells (21%) would be included in
analyses that are limited to new spells. The median duration
of an uninsured spell was 17 months when only including new
spells, 43 months when including both new spells and spells
in progress and 59 months when including only spells in
progress.
Conclusions: The exclusion of spells in progress at the
beginning of an observation period severely underestimates
the median duration of uninsured spells. Future research
should include both spells in progress and new spells.
Implications for Policy, Delivery, or Practice: Surveys that
collect information on health insurance over time, such as the
Survey for Income and Program Participation or the Medial
Expenditure Panel Survey, should ask respondents how long
they have been in their current health insurance spell at the
start of the observation period. This would allow researchers
to include both spells in progress and new spells in analyses
providing a more accurate estimate of how long people
remain uninsured.
Primary Funding Source: VA
●Use of Preventive Services by the High-Income
Uninsured
Joseph Ross, M.D., Susan H. Busch, Ph.D.
Presented By: Joseph Ross, M.D., Robert Wood Johnson
Clinical Scholar, Department of Internal Medicine, Yale
University, IE-61 SHM, P.O. Box 208088, New Haven, CT
06520; Tel: (203) 785-5920; Fax: (203) 785-3461; Email:
joseph.s.ross@yale.edu
Research Objective: Uninsured adults are less likely than
insured adults to receive appropriate preventive care and
disease treatment. The disparity between insured and
uninsured is greater for more costly services compared to less
costly services. It is unknown if the growing numbers of
uninsured adults with higher incomes experience these same
negative consequences or if their higher incomes allow them
to purchase appropriate health care. Our objective was to
compare nationally representative estimates of the proportion
of uninsured and insured adults, categorized by annual
household income, receiving clinically indicated cancer
prevention services.
Study Design: We used the 2002 Behavior Risk Factor
Surveillance System, a random household telephone survey,
to obtain data on health insurance, health status, use of
preventive services, and socio-demographic information.
Annual household incomes were categorized as less than
$35,000, $35,000-$50,000, $50,000-$75,000, and greater than
$75,000. Clinically indicated cancer prevention services
examined include rates of Pap smears within three years for
women aged 18 to 64 with an intact uterus, mammogram and
clinical breast exam within two years for women aged 40 to
64, and fecal occult blood testing within two years and
sigmoidoscopy or colonoscopy within five years for adults
aged 50 to 64. Pap smear and fecal occult blood testing were
considered less costly, while mammogram, sigmoidoscopy,
and colonoscopy were considered more costly. We
determined proportions of respondents who had received
these preventive services, adjusting for socio-demographic
characteristics and health status.
Population Studied: A representative U.S. sample of 194,943
adults aged 18 to 64 years.
Principal Findings: Fifteen percent of our sample lacked
insurance. The uninsured were more likely to be young, male,
non-white, poor, not employed for wages, not college
educated, single, and report fair or poor health status.
Uninsured adults were less likely than insured adults to
receive fecal occult blood testing (20% vs. 36%, p<0.01) and
sigmoidoscopy or colonoscopy (17% vs. 36%, p<0.01).
Uninsured women were less likely than insured women to
receive a Pap smear (78% vs. 91%, p<0.01) and a
mammogram and clinical breast exam (45% vs. 75%, p<0.01).
Within each income category, the uninsured remained less
likely than the insured to receive any of the examined clinically
indicated preventive services (p<0.01). When compared
across annual household income categories, adjusted odds of
the insured receiving any of the examined preventive services
(compared to the uninsured) were not significantly different.
Conclusions: Uninsured adults were less likely to receive
clinically indicated cancer prevention services than insured
adults. Compared to insured adults, uninsured adults from
wealthier households were just as unlikely as uninsured adults
from poorer households to receive clinically indicated cancer
prevention services, regardless of the cost of the service.
Implications for Policy, Delivery, or Practice: Policy-makers
must assume that all uninsured adults experience negative
consequences from lacking health insurance. Importantly,
greater household income does not diminish this risk. This
study raises questions about the perceived value of cancer
prevention services and whether individuals who make
discretionary purchases of health care, such as those enrolled
in Health Savings Accounts, will obtain them appropriately.
Primary Funding Source: No Funding
●Are Adults Benefiting from State Coverage Expansions?
Stephen Zuckerman, Ph.D., Sharon Long, Ph.D., John Graves,
BA
Presented By: Stephen Zuckerman, Ph.D., Principal Research
Associate, Health Policy Center, The Urban Institute, 2100 M
Street NW, Washington, DC 20037; Tel: (202)261-5679; Fax:
(202)223-1149; Email: szuckerm@ui.urban.org
Research Objective: During the late 1990s, a small number
of states implemented major expansions of public coverage
for adults. Some states focused on the parents of children
eligible for Medicaid and SCHIP, while others expanded
coverage to broader groups of low-income adults. Moreover,
income eligibility standards varied across states. The
programs we examine are from California, Massachusetts,
New Jersey and Wisconsin. Our goal is to study the effects of
these programs on eligible adults with respect to public
coverage, displacement of private coverage and health care
access and use.
Study Design: We use a difference-in-differences (DD)
framework that compares changes among eligible adults in
states with expansions to near-eligible adults within each state
as well as to -adults with comparable characteristics in states
without expansions. Such comparison groups provide the
counterfactual for what would have happened if a state’s
coverage rules had remained fixed. Because DD estimates
may be sensitive to the choice of the comparison states, we
draw on several different comparison groups to explore the
robustness of our estimates.
Population Studied: Low-income adults eligible for public
insurance coverage in California, Massachusetts, New Jersey
and Wisconsin under the program rules in place in each state
in 2002. Data on low-income adults are drawn from the 1997,
1999 and 2002 rounds of the National Survey of America’s
Families (NSAF), a nationally representative survey of children
and non-aged adults. The survey oversamples families with
incomes below 200 percent of the federal poverty level and
families in 13 study states (including the four study states) and
allows us to compare outcomes prior to and following the
coverage expansions.
Principal Findings: All four of these coverage expansions
significantly increased public coverage for adults, with more
coverage obtained in states with more generous expansion
efforts. Private coverage eroded (especially in New Jersey),
but the findings are not consistently significant across all four
states. The only state in which adult uninsurance rates fell
significantly was Wisconsin. We find little impact on overall
access and use, although there is some evidence of greater
effects in states with more generous expansions in coverage.
The consistency of the impact estimates across multiple
states using multiple comparison groups provides support for
the reliability of the conclusions from this study.
Conclusions: Of the four states studied, Wisconsin’s
Badgercare program had the greatest impact on insurance
coverage among low-income adults. Although private
coverage offset some of the increase in public coverage, the
results show that the overall gains were large enough so as to
translate into improved access in Wisconsin.
Implications for Policy, Delivery, or Practice: Public
programs that expand eligibility for insurance coverage among
low-income adults should expect to experience increased
enrollment. The results from this study show that many
adults are willing to enroll when given the opportunity.
Policymakers need to recognize that crowd-out of private
coverage should be expected, but the extent is likely to depend
on both the features of the public program and the local
health care market. Access to and use of care may improve if
overall insurance coverage is increased.
Primary Funding Source: RWJF
Call for Papers
Public & Private Health Insurance
Chair: Jose Escarce, University of California, Los Angeles
Monday, June 27 • 2:30 pm – 4:00 pm
●Changes in Health for the Uninsured after Reaching Ageeligibility for Medicare
David W. Baker, M.D., MPH, Joseph M. Feinglass, Ph.D.,
Ramon Durazo-Arvizu, Ph.D., Whitney Perkins Witt, Ph.D.,
Joseph J. Sudano, Ph.D., Jason A. Thompson, BA
Presented By: David W. Baker, M.D., MPH, Chief, Division of
General Internal Medicine, Medicine, Northwestern
University, 676 Saint Clair, Suite 200, Chicago, IL 60611; Tel:
(312)696-0917; Fax: (312)695-0951; Email: dbaker1@nmff.org
Research Objective: Uninsured adults in late middle age are
more likely to have a health decline than the privately insured.
It is unclear if this increased risk of adverse health outcomes
persists for a period of time even after gaining insurance or
whether gaining health insurance leads to improved health.
This study examined these issues among a cohort of U.S.
adults who gained Medicare coverage based upon ageeligibility.
Study Design: Prospective cohort study.
Population Studied: Population Studied: We used data from
the Health and Retirement Study (HRS), a prospective study
of U.S. adults aged 51-61 in 1992 with interviews every 2 years.
We analyzed the `96, `98, `00, and `02 data files and
identified the first interview at which participants reached age
65 and reported having Medicare (t0). Changes in health were
defined for 1) the two-year period during which subjects
transitioned to Medicare (t-2 to t0), and 2) the subsequent
two year period (t0 to t2). Self-reported overall health was
measured as excellent, very good, good, fair, or poor. Physical
difficulties were measured with 4 dichotomous items
assessing participants' difficulty walking or climbing stairs
(“Mobility”) and 6 items measuring difficulty peforming
instrumental activities of daily living (“Agility”). We used
multivariate logistic and multinomial regression to analyze
whether being uninsured prior to Medicare was associated
with worse outcomes after adjusting for baseline health,
sociodemographics, and health behaviors.
Principal Findings: During the period in which subjects
transitioned to Medicare coverage (t0 to t2), previously
uninsured individuals (N=441) were more likely than those
who previously had private insurance (N=2978) to have a
major decline in overall health (adjusted relative risk [ARR]
1.46; 95% CI 1.03 – 2.04) and a new physical difficulty
affecting Mobility (ARR 1.24; 95% CI 0.96 – 1.56) or Agility
(ARR 1.33; 95% CI 1.12 – 1.54). In contrast, during the
subsequent two years after the first HRS interview when
participants had gained Medicare coverage (t0 to t+2), the
previously uninsured no longer had worse outcomes
compared to those who previously had private insurance: ARR
major decline in overall health 1.14 (95% CI 0.76 – 1.68; p =
0.52), ARR major decline or death 1.21 (95% CI 0.85 – 1.70;
p=0.52), ARRs new Mobility difficulty 0.93 (95% CI 0.67 –
1.26), and ARR new Agility difficulty 1.07 (95% CI 0.85 – 1.31).
During both periods, adjusted rates of improvement in overall
health and physical functioning were not associated with
insurance coverage prior to Medicare.
Conclusions: Gaining Medicare coverage does not lead to
immediate health benefits for individuals who were uninsured
prior to reaching age 65, but after two or more years of
continuous coverage the increased risk for adverse health
outcomes among the previously uninsured disappears.
Implications for Policy, Delivery, or Practice: Lowering the
age of eligibility for Medicare could yield significant health
benefits that could partially offset the cost of expanding
coverage. Earlier studies of the health effects of expanding
insurance probably underestimate these health benefits
because previously uninsured individuals continue to have
higher risk for adverse health outcomes for a period of time
after gaining coverage.
Primary Funding Source: AHRQ
●The Impact of Increased Cost Sharing on Adults Enrolled
in Medicaid: Early Results from a Prospective Cohort
Study
Bill Wright, Ph.D., Matthew J. Carlson, Ph.D., Tina Edlund,
M.S., Jennifer DeVoe, M.D., Ph.D., Charles Gallia, Jeanene
Smith, M.D.
Presented By: Matthew Carlson, Ph.D., Assistant Professor,
Sociology, Portland State University, PO Box 751, Portland, OR
97207; Tel: (503) 725-9554; Fax: (503) 725-3957; Email:
carlsonm@pdx.edu
Research Objective: The objectives of this ongoing study are
to assess the short and long-term impact of policy changes,
including increased premiums and co-pays, on individuals’
insurance coverage, access to and utilization of health care,
financial solvency, and health status.
Study Design: Baseline survey findings from a prospective
cohort study are reported. Mail-return surveys were obtained
from a stratified random sample of Oregon Health Plan
Members (n=1783, RR=34%). In order to assess impact of
increased cost sharing, two groups are compared: those who
reported leaving OHP because they could not afford increased
costs and those who left the OHP for other reasons including
increased income, obtaining other insurance coverage, or
failing to turn in application.
Population Studied: Adults age 19 and older who were
enrolled in the Oregon Health Plan(OHP)for at least thirty
days prior to February 15, 2003, just prior to the initial wave of
program changes for the OHP Standard population.
Principal Findings: Baseline results from an ongoing cohort
study suggest that even modest increases in cost sharing led
to widespread disenrollment, especially among the poorest
OHP members. More than 40% of OHP enrolled adults
reported losing coverage in the 6 months following program
changes. Of those leaving, 44% reported leaving because of
increased costs. Compared to those who left for other
reasons, those who left OHP because of increased cost
sharing reported significantly higher unmet health care needs
(71% vs. 47%), were more likely to report no usual source of
care (28% vs. 21%), or the emergency department as the
usual source of care (12% vs. 4%) and were more likely to
have an emergency department visit (42% vs. 19%).
Additionally, those who left because of cost had higher levels
of medical debt, and were more likely to reporting being
refused care due to unpaid medical bills (20% vs. 6%).
Conclusions: These findings suggest that Medicaid cost
saving strategies requiring higher out-of-pocket expenditures
for low-income individuals are likely to have cascading effects
including decreased enrollment among the very poor,
increased unmet need, reduced primary care use, and
increased emergency department utilization.
Implications for Policy, Delivery, or Practice: Observed
short-term consequences may have long term implications for
increased health care costs and poor health outcomes among
low income adults.
Primary Funding Source: RWJF
●Charity Care, Risk Pooling, and the Decline in Private
Health Insurance
Michael Chernew, Ph.D., David Cutler, Ph.D., Patricia Keenan,
Ph.D.
Presented By: Michael Chernew, Ph.D., Professor, Health
Management and Policy, University of Michigan, 109
Observatory, Ann Arbor, MI 48109-2029; Tel: (734)936-1193;
Fax: (734)764-4338; Email: mchernew@umich.edu
Research Objective: Textbook economic theory suggests that
rising medical expenditures ought to increase the utility of
health insurance coverage because insurance mitigates risk.
As medical costs increase, the variability of spending will
usually rise as well, and so the insurance product becomes
more valuable. Yet a growing body of empirical work finds an
inverse relationship between health insurance premiums and
the propensity for individuals to have coverage. We examine
possible explanations for these empirical regularities, focusing
on risk pooling and availability of charity care.
Study Design: We use linear probability models and IV
methods to relate changes in insurance premiums at the MSA
level to coverage. Explanations for declining coverage are
assessed by estimating models separately by sub-populations
and by including an interaction between premiums and charity
care availability. The model uses extensive individual and
market covariates to controls for a range of other explanations
for declining coverage.
Population Studied: We analyze two cohorts of non-elderly
individuals from the Current Population Survey: one cohort
from 1988-1990 and the second from 1997-1999.
Principal Findings: Like existing literature, we find that rising
insurance premiums are associated with declining coverage.
The effects were strongest among the young, which is
consistent with the risk pooling explanation for the
relationship between premiums and coverage. The effect of
rising premiums was greatest in markets with greater
availability of charity care, which is consistent with the view
that the availability of charity care, shown by other researchers
to be associated with lower coverage rates, also increases the
sensitivity of individuals to premiums. We estimate that if no
charity care had been available the effect of rising premiums
on coverage in the 1990s would have been half as large as was
observed.
Conclusions: The decline in coverage associated with rising
coverage likely reflects several phenomenon. Our results
suggest one important effect is that as health care costs rise,
the implicit subsidy from low risk to high risk consumers rises,
which appears to lead some low risk consumers to opt out of
coverage. Moreover, charity care provides and alternative to
coverage for some individuals and as the costs of coverage
rise the relative attractiveness of charity care may also
increase, causing further deterioration in the coverage rate.
Implications for Policy, Delivery, or Practice: The new era of
rising medical spending we have recently entered could have a
major impact on private insurance coverage. Moreover, the
decline in coverage caused by rising premiums will place a
greater burden on charity care providers. Though important
in a time of declining coverage, bolstering the strained charity
care system may further exacerbate the decline in coverage,
posing a policy dilemma in responding to increases in the
uninsured population.
Primary Funding Source: RWJF, NIA, Sloan Foundation
●A Statewide Study of Frequent Users of Emergency
Departments in Massachusetts
Kathleen Fuda, Ph.D., Rachel Immekus, MS, MPH
Presented By: Kathleen Fuda, Ph.D., Data Analysis Manager,
Health Policy Institute, Boston University, 53 Bay State Road,
Boston, MA 02215; Tel: (617)353-8900; Fax: (617)353-6393;
Email: fuda@bu.edu
Research Objective: Frequent use of the emergency
department (ED) is often attributed to lack of insurance or
otherwise reduced access to primary care. Most studies of
frequent users of ED visits in the United States rely on data
from only one or at most several hospitals, or include only ED
visits resulting in discharges to the patient's home. We
combined statewide data for Massachusetts inpatient
discharges, outpatient observation stays, and outpatient ED
visits, in order to include all visits to all Massachusetts EDs
regardless of disposition. We analyzed these data to
characterize ED frequent users and to look for evidence that
frequent use of the ED is attributable to lack of access to
primary care.
Study Design: Statewide encounter-level data for outpatient
ED visits was combined with data on ED visits that resulted in
outpatient observation stays or inpatient admissions to
produce a database of all ED visits to Massachusetts hospitals
in FY2003 (2.78 million records). Using encrypted social
security numbers (SSNs), or a constructed patient identifier
when SSNs were missing, records were aggregated to the
patient level. Individuals with five or more ED visits were
considered frequent users. Frequent and non-frequent users
were compared on demographic, payer, and clinical
characteristics. This study was supplemented with analysis of
additional Massachusetts-specific data from the National
Survey of American Families (NSAF), which included data on
primary care use by ED visitors.
Population Studied: All patients who made at least one visit
to an emergency department in Massachusetts in FY 2003,
with a special emphasis on Massachusetts residents.
Principal Findings: Only one percent of Massachusetts
residents made five or more ED visits in FY 2003, but they
comprised 3.7% of all ED visitors and made 17.1% of all ED
visits that year. Over half of frequent users visited multiple
EDs. Frequent users appeared to be sicker than non-frequent
users, as they were more likely to be elderly, to be admitted to
an inpatient stay, to have a disposition of death at the last ED
visit, and to receive relatively intense levels of service in the
ED. A mental health- or substance abuse-related primary
diagnosis was found for 11.3% of visits by frequent users
compared to 3.7% of visits by non-frequent users. However,
frequent users are not a homogeneous population, and
frequent users among the enrollees of different payer groups
have distinctive diagnostic profiles. A larger percentage of
patients insured by either Medicaid or Medicare are frequent
users than are the uninsured or the privately insured. It was
also found that only 28% of frequent users in FY02 were also
frequent users in FY03. NSAF data indicated that frequent ED
users were heavier users of primary care visits than were nonfrequent users.
Conclusions: The large proportion of frequent users that use
multiple EDs indicates the importance of using data that
draws from all EDs in a large area. Although frequent users
are a very small subset of the population as a whole, they
account for a substantial fraction of ED visits. Frequent users
are not a homogenous population in terms of clinical
characteristics, but mental health and substance abuse
diagnoses are much more common among frequent users as
a whole. The publicly-insured are more likely to be frequent
users than are the uninsured or those with private insurance.
Overall, frequent users in Massachusetts do not appear to be
substituting ED visits for primary care visits.
Implications for Policy, Delivery, or Practice: Interventions
to reduce frequent ED visits, to the extent they are needed at
all, should be targeted to the subset of frequent users that is
most likely to continue to use the ED at high rates. The
heterogeneity of frequent users makes it important to carefully
analyze the intended targets to assess what is driving their
high utilization rates, and to tailor programs accordingly.
Efforts to merely link frequent users to primary care providers
are likely to be unsuccessful.
Primary Funding Source: MA Division of Health Care
Finance and Policy
●The Effects of Welfare Reform on Health Insurance of
Immigrants and their Children – Differences by
Immigration Status
Ithai Zvi Lurie, MA
Presented By: Ithai Zvi Lurie, MA, Research Associate,
Institute for Policy Research, Northwestern University, 2040
Sheridan Road, Evanston, IL 60208-4100; Tel: (847) 733-7425;
Email: i-lurie@northwestern.edu
Research Objective: Investigate the impact of the welfare
reform legislation on public and private health insurance
coverage for non-citizens by examining two related issues.
First, the study explores whether health insurance coverage of
non-citizens fell as a consequence of the 1996 Personal
Responsibility and Work Opportunity Reconciliation Act
(PROWRA). The reduction in public insurance eligibility
should have a direct effect on non-citizen public coverage.
However, private insurance may have increased to partly or
completely offset the drop in public coverage (reverse crowdout effect). Second, the study identifies whether the reduction
in eligibility for non-permanent residents and permanent
residents had an unexpected effect on others who did not lose
eligibility (chilling effect).
Study Design: The 1996 Personal Responsibility and Work
Opportunity Reconciliation Act (PRWORA) represented the
most profound change in the welfare system since the Great
Society programs were launched. As part of this sweeping
change, eligibility requirements for a number of government
programs were fundamentally altered. The changes made to
eligibility requirements had particularly important implication
for immigrants. Specifically, immigrants without permanent
resident status and immigrants with permanent resident
status who arrived after PRWORA was enacted lost eligibility
for a number of programs, including Medicaid.
Using data from the Survey of Income and Program
Participation (SIPP) from 1996 and 2001 in order to explicitly
identify who is a permanent resident and who is not. This
distinction allows this study to better identify individuals who
should and should not have been affected by PRWORA.
Population Studied: This study uses data from the Survey of
Income and Program Participation (SIPP) from 1996 and
2001, a national representative sample. Overall there are
about 141 thousand non elderly individuals. Foreign born
adults represent about 13% of the adult sample and their
children represent and about 15% of the children sample.
Principal Findings: Non-permanent residents experienced a
large drop in public coverage, while permanent residents did
not. The drop in public coverage comes with a significant
increase in private coverage. This reverse crowd-out effect
eliminates most of the decline in coverage. In addition there is
a significant chilling effect for citizen children of nonpermanent residents’ parents. These children lost almost 12
percentage points of public coverage relative to citizen
children of natives and gained very little in private coverage.
Conversely, there is no evidence of a chilling effect for citizen
children of permanent resident parents. As well there is some
evidence of a chilling effect for foreign-born adults that lost
federal eligibility, but who could have obtained Medicaid from
their respective states.
Conclusions: This study shows the importance of identifying
precisely the individuals targeted by policy changes. In the
context of PROWRA, evaluating the effects of the policy for
non-citizens as a group without distinguishing between
permanent residents and non-permanent residents can result
in misleading conclusions.
Implications for Policy, Delivery, or Practice: The Medicaid
outreach programs that states enacted after SCHIP
implementation should put more emphasis on attracting
citizen children of non-permanent resident parents.
Primary Funding Source: No Funding
Call for Papers
The Health Care Safety Net
Chair: Michael Chernew, University of Michigan
Tuesday, June 28 • 10:30 am – 12:00 pm
●Which Safety Net Services Make a Difference in Health
Care Use?
Janet Bronstein, Ph.D., Shailender Swaminathan, Ph.D.
Presented By: Janet Bronstein, Ph.D., Professor, Health Care
Organization and Policy, University of Alabama at
Birmingham, 1350 3rd Avenue South, RPHB 330, Birmingham,
AL 35209-0022; Tel: (205) 975-8962; Fax: (205) 934-3347;
Email: jbronste@uab.edu
Research Objective: Due in part to empirical challenges,
studies have not consistently identified a positive relationship
between safety net services in a community and access to
care. This study assesses (1) whether different types of safety
net services have different effects on access for adults and
children, (2) whether these effects differ across insurance
groups, and (3) whether these effects vary across different
aspects of health care access.
Study Design: Using survey data we control for a range of
predisposing, need and enabling characteristics, along with
some community context measures, to assess whether
community level measures of physician acceptance of
Medicaid patients, provision of charity care, federally
supported community health centers (CHC’s) and
public/teaching hospital emergency departments and clinics
(public EDs) have an impact on usual source of care, unmet
needs and actual use of physician and emergency department
services. Impact is measured as the differential association
between access to care and these safety net services for
publicly insured and uninsured individuals (separately)
compared to their impact on the privately or Medicare insured
population.
Population Studied: Our study population of 44,439 adults
and 9,085 children were respondents to the 2000-2001 round
of the household component of the Community Tracking
Study (CTS). Data from the CTS physician survey, the 2000
census, AHA survey and Area Resource File are used for safety
net and community context measures for the 60 communities
represented in the CTS sample. All safety net measures are
adjusted for the size of the relevant populations and then
ranked across the 60 communities; quintile of relative
availability of the service is used as the indicator in the
regression analyses. Standard errors in regressions are
adjusted for the stratified sample and for the clustering of
respondents into community sites.
Principal Findings: Uninsured, but not publicly insured
adults and children have poorer access to care by all measures
than the privately insured, and other individual characteristics
are associated with access and use as would be expected.
Controlling for these and for community level factors, we find
that uninsured adults have more physician visits where there
are more CHC’s and more emergency visits where there are
more public EDs. Both uninsured and publicly insured adults
report fewer unmet needs in communities with more public
EDs. Publicly insured children are more likely to have a usual
source of care where more doctors participate in Medicaid but
where fewer provide charity care. Publicly insured adults are
more likely to have a usual source where more doctors provide
charity care and there are fewer community health centers and
Medicaid participating physicians. No safety net services
improve the likelihood of a usual source of care for uninsured
adults or children.
Conclusions: This study suggests that different components
of the health care safety net tend to serve different
components of the vulnerable population, both by age and by
insurance status, and to meet different aspects of the health
care needs of these different groups.
Implications for Policy, Delivery, or Practice: Components
of the safety net are not interchangeable; communities need a
diverse mix of services to meet the access needs of vulnerable
populations.
Primary Funding Source: UK Center for Poverty Research
●Awareness of Safety Net Providers by Uninsured Persons
Peter Cunningham, Ph.D., Jack Hadley, Ph.D., Genevieve
Kenney, Ph.D., Amy Davidoff, Ph.D.
Presented By: Peter Cunningham, Ph.D., Senior Health
Researcher, Center for Studying Health System Change, 600
Maryland Avenue, SW, Suite 550, Washington, DC 20024; Tel:
(202)484-4242; Fax: (202)484-9258; Email:
pcunningham@hschange.org
Research Objective: It is generally acknowledged that health
care providers who offer services for free or at reduced cost
play an important role in providing at least a minimum level of
access to care to uninsured persons. However, the
effectiveness of these safety net providers may be limited to
the extent that many uninsured aren’t aware of these
providers. This research examines the extent to which
uninsured persons are or are not aware of safety net providers
in their communities; examines a variety of health system,
policy, and sociodemographic characteristics associated with
safety net awareness; and explores the implications of
awareness or lack of awareness for access to care.
Study Design: Data are based on the 2003 Community
Tracking Study household survey. The survey included
questions asked of uninsured persons and their family
members as to whether or not they paid full or reduced cost at
their usual source of medical care, or if they were aware of
providers in their community who offered affordable care to
uninsured persons. Uninsured respondents who were aware
of safety net providers were also asked the type of place (e.g.
physician’s office, hospital-based facility, clinic). A
multinomial logistic regression analysis is conducted to
examine the effects of various health system, policy, and
sociodemographic characteristics on awareness of the
different types of safety net providers. We focus especially on
the effects of local safety net capacity on awareness, such as
safety net hospitals, community health centers, and physician
charity care, as well as the impact of Community Access
Program (CAP) grants, all obtained through secondary data
and linked to the CTS household survey. We also examine
whether awareness of safety net providers is associated with
fewer unmet medical needs.
Population Studied: Nonelderly uninsured persons.
Principal Findings: Less than half of the uninsured (47.5
percent) reported that they used or were aware of a safety net
provider in their community that offered subsidized services
to the uninsured. Among those uninsured who were aware of
a safety net provider, most identified clinics and health centers
(44.6 percent) and physician’s offices (26.1 percent) as the
safety net provider they were aware of. Fewer uninsured
identified hospital outpatient clinics (12.9 percent) and
emergency departments (8.3 percent) as safety net providers.
The results of the regression analysis show that higher
capacity of safety net hospitals, CHCs, and physician charity
care increases awareness of safety net providers. The
presence of CAP grants in the community also increases
safety net awareness. Nevertheless, many uninsured remain
unaware of safety net providers despite living in close
proximity to a safety net provider. Awareness of safety net
providers was also associated with fewer unmet medical
needs.
Conclusions: Many uninsured are not aware of safety net
providers, including many who live near a major safety net
provider such as a public hospital or community health center.
Greater awareness of safety net providers is associated with
improved access, although further research is needed to more
firmly establish the causal link between safety net awareness
and access.
Implications for Policy, Delivery, or Practice: Increasing
awareness of safety net providers may be as important in
improving access as increasing capacity in the system. Just
as outreach efforts have been critical for enrolling eligible
children in public insurance programs, outreach activities may
be important in increasing awareness of safety net providers
by uninsured persons.
Primary Funding Source: RWJF
●Copayments and Emergency Departments: Effective
Incentives or Effects Unintended?
Mary Price, MA, Richard Brand, Ph.D., Joseph Newhouse,
Ph.D., Joseph Selby, M.D., MPH, John Hsu, M.D., MBA,
MSCE
Presented By: Mary Price, MA, Senior Consulting Data
Analyst, Division of Research, Kaiser Permanente Northern
California, 442 Brimhall Street, St. Paul, MN 55105; Tel: (651)
690-1981; Fax: (651) 690-1981; Email: Maggie.Price@kp.org
Research Objective: Cost-sharing theoretically encourages
patients to make more efficient choices about where to seek
care. We investigated the effect of emergency department
(ED) copayments on ED visits for non-emergency and
emergency reasons.
Study Design: We examined the association between the size
of ED copayments and the rate of non-emergent and
emergent ED visits (1999–2001) in a large prepaid integrated
delivery system. We classified ED copayments into five
categories: no copayment, $1-5, $10-15, $20-35 and $50-100
per visit. We used the New York University ED Diagnosis
Algorithm to classify visits as non-emergent or emergent. This
algorithm assigns probabilities to one non-emergent and
three emergent categories for each visit’s ICD-9 diagnosis; the
sum of the four probabilities equals 100%. We classified visits
as non-emergencies when the probability was at least 75% that
the visit diagnosis was in the non-emergent category, and as
emergencies when the sum of the probabilities for the three
emergent categories was at least 75%. Visits with both
emergency and non-emergency diagnoses were classified as
emergencies; visits also could be indeterminate if the
probabilities were below 75% for either type of visit. We
compared relative rates of non-emergent and emergent ED
visits by copayment level using a negative binomial mixedeffects model applied to annual utilization counts, adjusting
for year, and for age, gender, SES, comorbidity, prior
utilization (ED, office, hospital), having a regular physician,
drug cost-sharing level, and medical center using a propensity
score. We repeated the analysis using a Poisson mixed-effects
model applied to monthly utilization counts.
Population Studied: All subjects were commercially insured
members of the IDS in January 1999. Of these 2,257,445
subjects, 23.4% paid no copayment, 34.8% paid $1-5, 22.8%
paid $10-15, 13.6% paid $20-35, and 5.4% paid $50-100 per ED
visit in 1999. In January 2000, 52% of subjects had their
copayment increase.
Principal Findings: There were 1,041,719 ED visits (19992001): 51,692 and 299,005 were for non-emergent and
emergent diagnoses respectively. Compared to no copayment,
the relative rate of non-emergent visits decreased 3%
(RR=0.97, 95% CI: 0.94–0.99), 6% (RR=0.94, 95% CI: 0.91–
0.98), 14% (RR=0.86, 95% CI: 0.83–0.88), and 28% (RR=0.72,
95% CI: 0.69–0.76) with the $1-5, $10-15, $20-35, and $50-100
copayments respectively. For emergent ED visits, compared
with no copayment, there was no effect with the $1-5 and $1015 copayments, and visit rates decreased 6% (RR=0.94, 95%
CI: 0.93–0.95) and 13% (RR=0.87, 95% CI: 0.85–0.89) with the
$20-35 and $50-100 copayments respectively. The findings
were robust across analytic approaches.
Conclusions: Patients with higher copayments were less likely
to seek care from the ED for non-emergency reasons; there
was a smaller copayment effect on visits for emergency
reasons.
Implications for Policy, Delivery, or Practice: These
preliminary data suggest that copayments do influence patient
decisions about seeking care from the ED. In particular, these
incentives appear to encourage patients to reduce use of the
ED for non-emergencies. Further research is needed to assess
the clinical and economic effects, especially with large
copayments.
Primary Funding Source: AHRQ
●Healthcare Markets, the Safety Net and Access to Care
Among the Uninsured
Carole Roan Gresenz, Ph.D., Jeannette Rogowski, Ph.D., Jose
J. Escarce, Ph.D., M.D.
Presented By: Carole Roan Gresenz, Ph.D., Senior Economist,
RAND Corporation, 1200 South Hayes Street, Arlington, VA
22202; Tel: (703)413-1100 x5419; Fax: (703)414-4726; Email:
gresenz@rand.org
Research Objective: We use nationally representative data
including observations on more than 12,000 uninsured adults
to provide new insight into the relationship between access to
care and not only the structure and capacity of the safety net
but also the healthcare market more generally.
Study Design: We use Medical Expenditure Panel Survey
(MEPS) data linked with data from multiple secondary
sources. To describe the healthcare safety net and market
structure in each individual’s location, we derive variables
from the American Hospital Association Annual Survey of
Hospitals, Area Resource File, the InterStudy Regional Market
Analysis database, the Bureau of Primary Healthcare (BPHC)
Physicians Uniform Data System, the Current Population
Survey, Census of Governments, and the Census Bureau’s
Annual Survey of State and Local Government Finances. A
major innovation of this research is the calculation of detailed
measures of safety net availability: We calculate the distance
between each uninsured individual and the nearest BPHC
provider, public hospital and emergency room. We analyze
outpatient care utilization (office-based physician and nonphysician visits, emergency department visits) and medical
expenditures. We simulate utilization for a number of health
care market and safety net values using standardized
predictions.
Population Studied: Uninsured adults in the U.S.
Principal Findings: Distances between the rural uninsured
and safety net providers such as hospital emergency rooms,
public hospitals, migrant health centers, public housing
primary care programs, and community health centers are
significantly associated with utilization of a variety of
healthcare services. In urban areas, we find that the
percentage of individuals in the area who are uninsured and
the pervasiveness and competitiveness of managed care have
a significant relationship with healthcare utilization.
Conclusions: Facilitating transport to safety net providers and
increasing the number of such providers are likely to improve
access to care among the rural uninsured. Our findings for
urban areas suggest that particular attention be paid to the
uninsured living in areas where many of those insured are
covered by managed care, and especially so where little
competition among managed care organizations exists.
Ironically, the “backlash” against managed care may result in
improved access to care for some uninsured, although the
salutary effects would be offset to the extent that the backlash
also results in increasing healthcare costs, greater numbers of
uninsured, and more competition for healthcare resources.
Implications for Policy, Delivery, or Practice: Absent the
universal provision of health insurance, policy approaches to
alleviating the barriers to access facing the uninsured include
incremental efforts to increase the affordability and availability
of public or private health insurance as well as measures to
increase the accessibility of healthcare for the remaining
uninsured. Our findings shed light on areas of focus for the
latter class of measures.
Primary Funding Source: AHRQ
●The Shortage of On-Call Specialist Physician Coverage in
U.S. Hospitals
Benjamin Vanlandingham, M.D., MPH, Neil R. Powe, M.D.,
MPH, MBA, Barbara Marone, Marie Diener-West, Ph.D., Haya
R. Rubin, M.D., Ph.D.
Presented By: Benjamin Vanlandingham, M.D., MPH, Fellow,
Robert Wood Johnson Clinical Scholars Program, Johns
Hopkins University, 600 North Wolfe Street, Carnegie 291,
Baltimore, MD 21287; Tel: 410-614-6037; Email:
bvanlandingham@jhmi.edu
Research Objective: Anecdotal reports suggest that hospitals
are losing the support of physician specialists to provide oncall coverage as a backup to physicians providing care to
patients in emergency departments (ED) and in the hospital.
The objective of this study was to measure the extent to which
hospitals lack on-call coverage by specialists and to explore
the factors that might be associated with on-call coverage
shortages such as location, the community-level supply of
specialists, the cost of professional liability insurance and the
penetration of ambulatory-surgery centers (ASCs) and
specialty hospitals.
Study Design: This was a national cross-sectional study in
which we administered a standardized questionnaire to
hospital ED directors asking them whether they have a
problem with inadequate on-call coverage. For each of 11
specialties, respondents also reported 1) the percentage of
days their hospitals had formal on-call coverage during a
preceding three-month period and 2) the perceived degree of
importance in having on-call coverage with respect to the
needs of the patient population at their hospital. Data were
also collected on payer mix for ED patients, community-level
estimates of specialist supply, the cost of professional liability
insurance and the penetration of ASCs and specialty hospitals.
Population Studied: Medical directors of emergency
departments at acute-care general hospitals in the U.S.
(N=4428). Specialty and federally-owned hospitals were
excluded.
Principal Findings: Two-thirds [68% (95% CI, 66-70%)] of
respondents reported that on-call coverage is inadequate to
meet the needs of their patients. On-call coverage problems
were reported in more often in urban [73% (95% CI 70-75%)]
than rural [60% (95% CI, 57-64%)] hospitals and were similar
in geographic regions of the country. The greatest shortage of
specialists was in hand surgery: among hospitals where hand
surgery coverage is perceived to be “very or extremely
important for overall patient outcomes,” 69% (95% CI, 6572%) of hospitals has less than full-time coverage. Hospitals
also have less than full-time coverage for plastic surgery
(52%), neurosurgery (49%), ENT (44%), psychiatry (42%).
On-call coverage shortages were related to the proportion of
uninsured patients in the hospital ED, but not to the supply of
specialists.
Conclusions: A large proportion of hospitals have unmet
need for on-call specialist coverage based on ED directors’
perceptions of coverage requirements. On-call coverage
shortages are found for several specialties and in both urban
and rural hospitals and in all regions of the country. The
problem is related to the lack of health insurance and does not
appear related to physician supply
Implications for Policy, Delivery, or Practice: The shortage
of on-call coverage is an emerging trend that threatens the
integrity of the health care safety net, placing patients at
potential risk for injury. This is one of the first studies at the
national level demonstrating the scope of this problem. Until
now, responsibility for adequate on-call staffing has rested
with individual hospital administrators, but their efforts
appear to be failing. Further study about the effect on patient
outcomes warranted.
Primary Funding Source: RWJF
Related Posters
Poster Session B
Monday, June 27 • 6:15 pm – 7:30 pm
●Price Elasticity of Demand for Non-Group Health
Insurance
David Auerbach, Ph.D., Sabina Ohri, Ph.D. candidate
Presented By: David Auerbach, Ph.D., Associate Analyst,
Health and Human Resources, Congressional Budget Office,
2500 Davis Avenue, Alexandria, VA 22302; Tel: (202) 2262669; Fax: (202) 225-3149; Email: david.auerbach@cbo.gov
Research Objective: To estimate the price elasticity of
demand for nongroup health insurance, both as a pure
elasticity and as the more useful "percent of the uninsured
would take up coverage in response to a given premium
subsidy". Two secondary objectives are to investigate whether
this elasticity varies among poor or sick subpopulations and
whether state regulations concerning nongroup underwriting
impact insurance takeup in expected ways.
Study Design: We extracted a subsample of nonelderly
without access to ESI from the SIPP (data from 2002). We
then imputed offered nongroup premiums, focusing on as
much exogenous variation as possible (tax deductibility
among the self-employed and state-level premium
compression/community rating regulations prevailing in
2001). We use the latter variation in an instrumental variables
probit model that yields a similar response to the premium as
does the simpler reduced form probit equation.
Population Studied: Primarily, 1,840 single, working,
nonelderly respondents in the 17th month of the 2001 panel of
the Survey of Income and Program Participation who do not
have offers of employer-sponsored insurance.
Principal Findings: Elasticity of demand is roughly -.56,
indicating that a 10% reduction in premiums would cause a
5.6% increase in coverage rates. Since initial coverage rates in
our sample were low, however, this premium reduction would
result in just under a 1% reduction in the uninsured. State
premium compression and community rating regulations of
nongroup insurance do appear to improve coverage among
the unhealthy at the slight expense of coverage among the
healthy.
Conclusions: Our effect of premiums on coverage rates is
consistent with a recent study analyzing working families in
California that used geographic variation in offered premiums.
Analyses (including our own) that use primarily endogenous
sources of premium variation (e.g., age, sex, health status)
appear to obtain larger premium responses.
Implications for Policy, Delivery, or Practice: Our findings
support the contentions of some modelers that subsidies or
tax credits for nongroup insurance would probably not
generate a large response among the uninsured. If our results
generalized to the entire population of uninsured without
offers of employer-sponsored insurance (~30 million at a
point in time) then a 40% premium subsidy would result in
roughly 1 million uninsured taking up coverage.
Primary Funding Source: No Funding Source
●Access and Travel to Cancer Services Among Rural
Colorectal Cancer Patients
Laura-Mae Baldwin, M.D., MPH, Eric Larson, Ph.D., Yong Cai,
Ph.D., George Wright, Ph.D., Sharon Dobie, M.D., Gary Hart,
Ph.D.
Presented By: Laura-Mae Baldwin, M.D., MPH, Professor,
Family Medicine, University of Washington School of
Medicine, Box 354982, Seattle, WA 98195; Tel: (206) 685-4799;
Fax: (206) 616-4768; Email: lmb@u.washington.edu
Research Objective: To examine the degree to which rural,
Medicare-insured colorectal cancer patients have cancer care
services available locally, and to determine rural patients'
travel patterns to these services.
Study Design: Cross-sectional, descriptive study using
Surveillance, Epidemiology, and End Results (SEER) program
data for colorectal cancer patients diagnosed between 1992
and 1996 linked with their 1991-1998 Medicare claims. Travel
distances between patients' ZIP codes and the ZIP codes of
their closest and actual cancer care physicians were calculated
using software developed at the Dartmouth Center for the
Evaluative and Clinical Sciences.
Population Studied: 27,143 stage I-III colorectal cancer
patients age 66 and older reported to one of 11 SEER cancer
registries between 1992 and 1996. Rural-Urban Commuting
Area (RUCA) codes were used to classify patients' residence
locations as urban (n=22,366), large rural (n=1696), small
rural (n=1575), and remote rural (n=1506).
Principal Findings: Over 90% of patients in all rural and
urban areas live within 30 miles of a surgeon who performed
colorectal resections, and close to or over 90% of patients in
all areas live within 30 miles of a physician who administered
chemotherapy. Radiation therapy is much less available to
rural patients, with only 21% of remote rural, 31% of small
rural, and 58% of large rural area residents within 30 miles of a
physician who administered radiation therapy. Despite the
availability of surgeons and chemotherapy administrators in
all geographic areas, substantial proportions of rural colorectal
cancer patients travel to urban or less rural areas for these
services. For example, 16.9% of colorectal cancer patients
living in large rural areas, 37.6% living in small rural areas, and
45.4% living in remote rural areas received their cancer
surgery in an urban area. These patients receiving care in
urban areas traveled a median of 70, 50, and 48 miles,
respectively, to their surgical care.
Conclusions: Access to surgical and chemotherapy services
for colorectal cancer patients is roughly equivalent for urban
and rural residents, regardless of their degree of rurality.
Despite this relatively uniform access, large proportions of
cancer patients bypass services in their local areas, traveling
great distances to surgical and chemotherapy care. Radiation
therapy, unlike other cancer care services, is much less
available in rural areas.
Implications for Policy, Delivery, or Practice: The distance
to radiation therapy, often requiring daily treatment, likely
represents a substantial barrier to its use by many rural
elderly, for whom transportation may be not be readily
available. Supporting transportation services for these elderly
may be needed to ensure equitable access to this important
cancer service. At the same time, this study demonstrates
that many rural elderly are bypassing local surgical and
chemotherapy services, raising questions about whether the
local resources are saturated, or whether patients are
choosing more distant services. Further research exploring
the reasons for these travel patterns will elucidate whether
rural areas need to recruit additional cancer care specialists, or
ensure that patients are aware of and satisfied with the
services available to them locally.
Primary Funding Source: NCI
●The Impact of Surgical Infection on Hospital Resource
Utilization and Patient Access to Care in Orthopaedic
Surgery
Kevin Bozic, M.D., MBA, Michael D. Ries, M.D.
Presented By: Kevin Bozic, M.D., MBA, Assistant Professor in
Residence, Institute for Health Policy Studies, University of
California, San Francisco, 500 Parnassus, MU 320W, San
Francisco, CA 94143-0728; Tel: (415) 476-3900; Fax: (415) 4761304; Email: bozick@orthosurg.ucsf.edu
Research Objective: Acute and chronic deep surgical
infections can have significant clinical and economic
implications for patients, surgeons, hospitals, and payors.
Surgical infections often results in the need for multiple reoperations, prolonged use of intravenous and oral antibiotics,
extended inpatient and outpatient rehabilitation, and frequent
follow-up visits. Futhermore, the lack of incremental
reimbursement associated with treating surgical infections
has resulted in strong financial disincentives for hospitals and
surgeons to provide care for these patients. This purpose of
this study was to assess the impact of surgical infections
associated with a common orthopaedic procedure, total hip
replacement, on hospital and surgeon resource utilization and
patient access to care.
Study Design: Clinical, demographic, and economic data
were obtained for a cohort of patients who underwent revision
total hip replacement (THR) for a diagnosis of infection
(Group 1) during a 2 year period at a tertiary care referral
hospital. Similar data were collected during the same time
period for a cohort of patients who underwent revision THR
for aseptic causes (Group 2) and a cohort of patients who
underwent primary THR (Group 3). Quantitative variables
were compared between patient groups using the Kruskal-
Wallis nonparametric rank test. Categorical variables were
compared using the Fisher’s exact test.
Population Studied: Patients who underwent primary or
revision total hip replacement at a tertiary care referral
hospital during a two year period.
Principal Findings: Septic revision THR procedures were
associated with longer operative time, more blood loss, and a
higher number of complications than aseptic revisions or
primary THR. Septic revisions were also associated with a
higher total number of hospitalizations, total hospital days,
total number of operative episodes, total hospital costs, total
outpatient encounters, and total outpatient charges during the
12 month period following the index procedure. During the
time period of the study, referrals for patients with infected
total hip replacements increased from 3% to 24% of all
orthopaedic referrals to our tertiary care hospital.
Conclusions: The treatment of patients with infected total hip
replacement is associated with significantly greater hospital
and physician resource utilization than aseptic revision THR
or primary THR. The lack of incremental reimbursement
associated with these procedures has resulted in strong
financial disincentives for physicians and hospitals to provide
treatment for patients with infected total hip replacements.
Implications for Policy, Delivery, or Practice: Surgical
infections pose significant clinical and economic challenges
for surgeons, patients, and hospitals. The results of our study
suggest that fewer hospitals and surgeons in our region are
willing to provide care for patients with infected total hip
replacements, which has resulted in a dramatic increase in the
number of patients with infected THRs who are referred to our
institution for treatment. Given the additional resources
required to provide care for these challenging patients, these
findings have significant implications with respect to hospital
financial viability, patient access to care, and ultimately patient
outcomes.
Primary Funding Source: Orthopaedic Research & Education
Foundation Health Services Grant
●The Clustering of Safety Net Services and their Resource
Supports Across Communities
Janet Bronstein, Ph.D.
Presented By: Janet Bronstein, Ph.D., Professor, Health Care
Organization and Policy, University of Alabama at
Birmingham, 1350 3rd Avenue South, RPHB 330, Birmingham,
AL 35209-0022; Tel: (205) 975-8962; Fax: (205) 934-3347;
Email: jbronste@uab.edu
Research Objective: Case studies and reviews indicate that a
heterogeneous mix of health care services serve as the safety
net for publicly insured and uninsured vulnerable populations.
However, it is not known whether communities themselves
tend to support a diverse mix of safety net service types or
whether communities with different types of resources tend to
“specialize” in different service types. This study has two
objectives: (1) To describe the typical clustering pattern of
different types of safety net services across communities, and
(2) to assess whether different safety net services are linked to
different types of resources.
Study Design: Data are compiled on resources and safety net
services available in 60 U.S. communities. Factor analysis is
used to describe the clustering pattern for seven safety net
services in these communities. A comparison of the means of
available resources in communities with above or below the
median capacity of each safety net service indicates which
services are most commonly linked to which types of
resources.
Population Studied: Data from the physician survey
component of the Center for Studying Health System Change
Community Tracking Study (CTS) are used to estimate
measures of physician acceptance of Medicaid and physician
charity care hours provided in the 60 communities included in
the CTS. AHA, ARF and census data are used to measure the
number of Community Health Centers (CHC’s), public and
teaching and children’s hospital beds and emergency
departments and clinics. All measures are adjusted for the
size of the relevant vulnerable population.
Principal Findings: Factor analysis indicates three
overlapping clusters of safety net services across
communities. Physician participation in Medicaid and
provision of charity care tend to co-occur with children’s
hospital beds and outpatient facilities; these communities
tend not to have federally subsidized CHC’s. Public/teaching
hospital beds occur in the absence of children’s hospital
resources, but in the presence of physician participation in
Medicaid. Public/teaching hospital outpatient facilities cooccur with beds in these hospitals but in the absence of
strong participation in Medicaid by physicians. Physician
based safety net services are much more common in higher
income communities where more of the population is
privately insured and there are more physicians per capita.
Public/teaching beds are more common where more of the
otherwise uninsured population is covered by public insurance
and where there are a larger proportion of Blacks in the
population. Public/teaching outpatient facilities are more
common in communities with fewer Hispanics and with less
income inequality across the population.
Conclusions: Communities do not typically maintain a broad
array of safety net services, but tend to have either physician
based, public/teaching hospital based or CHC based services.
Different types of resources support different sets of services.
CHC’s are the least vulnerable to changes in local resources
but tend to be isolated from other types of safety net services.
Implications for Policy, Delivery, or Practice: Failures of the
safety net are unlikely to occur across the board, but more
likely to be isolated in communities dependent on services
supported by highly stressed resources. Safety net monitoring
systems must be localized.
Primary Funding Source: UK Center for Poverty Research
●Health Uninsurance in North Dakota: Demographic,
Economic and Geographic Predictors
Mike Cogan, Ph.D., Kyle Muus, Ph.D., Alana Knudson, Ph.D.,
John Baird, M.D.
Presented By: Mike Cogan, Ph.D., Assistant Professor, Center
for Rural Health, University of North Dakota, PO Box 9037,
Grand Forks, ND 58202; Tel: (701)777-3848; Fax: (701)7776779; Email: mcogan@medicine.nodak.edu
Research Objective: Specific research questions included:
*What percent of North Dakotans are uninsured? *Are there
significant differences in uninsured rates by geographic
residential location (small rural, large rural, urban)? *Are there
significant differences in uninsured rates by key demographic
factors, including gender, age group, income level and
race/ethnicity? *Which factors are significant predictors of
health insurance status?
Study Design: In spring 2004, data were collected through
telephone interviews of a random selection of North Dakota
households. A total of 3,199 interviews were completed from
4,641 households contacted, yielding a response rate of
68.9%. Of particular interest was to examine health insurance
coverage by demographics (e.g., age, gender, race, income),
employment-related factors, and rural-urban residential
location.
Population Studied: North Dakota household residents.
Principal Findings: Findings indicated an overall state
uninsured rate of 8.2%, or approximately 52,000 persons. This
figure compares favorably to the national estimated rate of
15%. By geographic region, it was found that residents of
small rural areas were most likely to be uninsured (9.1%),
compared to large rural (7.7%) and urban areas (7.4%).
Further breakdown indicated that 44.5% of the uninsured
resided in small rural areas (population less than 5,000). This
number is more than twice the national percentage as
reported in the landmark study Health Insurance Coverage in
Rural America (2003). In addition, Native Americans (31.7%)
and those reporting more than one race (11.5%) were
significantly more likely to be uninsured than Whites (6.9%).
Binary logistic regression was conducted to determine which
of these independent variables were significant predictors of
health insurance status. Results indicated:
*Males were 1.2 times more likely to be uninsured than
females. *Married persons were 2.2 times more likely to have
health insurance than unmarried North Dakotans. *Those
who had attended college were more than three times more
likely to have health insurance than those with a high school
diploma or less. *Employed persons were 4.5 times more
likely to have health insurance than unemployed persons.
*Those who did not serve in the military were 1.8 times more
likely to have health insurance than those who did serve in the
military. *Persons working in firms with 11-50 employees were
1.4 more likely to be insured than persons working in oneperson firms. *Persons residing in households with an
income above 200% of the federal poverty level were 6.8
times more likely to have health insurance than persons
residing in a household with an income below 100% of the
federal poverty level.
Conclusions: Results assisted health department personnel
and policy makers in devising and reviewing policy options for
increasing health insurance access among at-risk subgroups
of North Dakotans. Similar to other states, North Dakota’s
budgetary woes restricted the nature, breadth and scope of
these options. The presentation will include discussion on a
series of 'budget-neutral' options for increasing access to
health insurance coverage among rural/underserved
populations.
Implications for Policy, Delivery, or Practice: Extending
health coverage for low-income residents and children in
North Dakota is an important policy and health objective for
state health department personnel and policy makers. Efforts
to extend coverage should include consideration of building
upon the state's current public programs (Medicaid and SCHIP) to increase the number of eligible persons. For Native
Americans, additional efforts are needed to increase
awareness of and enrollment in public programs designed to
increase access to health care coverage among indigent adults
and children. Finally, additional federal funds should be
directed to strengthen the ability of the Indian Health Service
to address problems of health care access among Native
people, particularly those in isolated, remote areas, such as
rural North Dakota.
Primary Funding Source: HRSA
●The Southeastern Kentucky Community Access Program:
How it Worked and Why
Julia Costich, JD, Ph.D.
Presented By: Julia Costich, JD, Ph.D., Director, Kentucky
Injury Prevention & Research Center, 333 Waller Avenue,
Lexington, KY 40504; Tel: (859) 257-6712; Fax: (859) 257-3909;
Email: julia.costich@uky.edu
Research Objective: To contribute to the replication of a
successful program to increase health care access in a
chronically underserved population by identifying critical
program components and strategies.
Study Design: Interviews with program staff and clients,
analysis of enrollment and utilization data, and comparison
with similarly structured but less successful programs are
used to link specific program elements with outcomes.
Population Studied: Adult residents of the Appalachian
region of southeastern Kentucky who enrolled in the program
for management of one of 5 targeted chronic conditions:
severe mental illness, diabetes, heart disease, hypertension,
and asthma.
Principal Findings: The program served 15 percent of the 4county service area's population in its 4 years of funding,
suggesting a broad potential impact. Critical elements
identified by staff and clients include cultural competence,
establishment of trust, and dependability of service provision.
Prescription drug access had the greatest impact for those
with severe mental illness, while lifestyle changes were
important for those with cardiovascular diagnoses.
Conclusions: These data demonstrate the burden of chronic
illness in the population served and the benefits derived from
relatively minor expense to address long-unmet needs. The
termination of federal funding for Community Access
Programs, while appropriate in many cases, leaves the
chronically underserved at risk for relapse into the costly and
burdensome illness from which this program offered some
relief.
Implications for Policy, Delivery, or Practice: The reasons
why a few Community Access Programs succeeded when
most did not meet objectives should receive closer attention
to avoid further deterioration of already challenged
populations and promote successful replication.
Primary Funding Source: HRSA
●Results of a Randomized Trial of Transtheoretical ModelBased Interventions for Informed Choice in the Medicare
Population
Carol Cummins, MEd, MLIS, Deborah Levesque, Ph.D., James
Prochaska, Ph.D., David Miranda, Ph.D., Amy Heller, Ph.D.
Presented By: Carol Cummins, MEd, MLIS, Senior Project
Manager, Pro-Change Behavior Systems, Inc., PO Box 755,
West Kingston, RI 02892; Tel: (401) 874-7023; Fax: (401) 8744103; Email: ccummins@prochange.com
Research Objective: To assess the efficacy of a
Transtheoretical Model-based, or stage-based, manual and
computer-administered expert system intervention developed
for the Centers for Medicare and Medicaid Services to
increase participation in informed health plan choice among
new Medicare enrollees.
Study Design: In Study One, the efficacy of the manual alone
was tested primarily among 900 individuals with no access to
a computer. In Study Two, the efficacy of the manual plus
computer expert system was assessed among 451 individuals
who did have computer access. Individuals in each study were
randomly assigned to an intervention group that received the
intervention materials, or to a control group that did not. The
interventions were delivered to participants’ homes via mail.
About one month later, individuals in the intervention groups
were mailed a brief survey assessing the “acceptability” of the
materials. A follow-up survey was administered six months
post-baseline to assess the efficacy of the interventions.
Outcomes included Medicare knowledge, stage of change for
comparing Medicare health plans, information-seeking, and
satisfaction with Medicare information.
Population Studied: Participants were randomly selected
from the Center for Medicare and Medicaid Service’s Initial
Enrollment File, a data repository for persons who were going
to turn 65 in the next three months. The sample was 83
percent white and 57 percent female.
Principal Findings: The intervention materials, designed to
be user-friendly and appropriate for individuals in all stages of
change for comparing plans, were well received by study
participants. About three-quarters of Study One participants
who returned the acceptability survey had read more than half
the manual. A majority of respondents found the manual to
be easy to use and understand, attractive, and informative; 87
percent still had the manual, 68 percent thought they’d use it
again, and 85 percent reported that they would recommend it
to a friend. At follow-up, compared to participants in the
control group, Study One participants in the intervention
group had higher scores on objective and subjective measures
of knowledge about the Medicare program, were more likely to
think that the Medicare program was understandable, and
were more likely to be satisfied or very satisfied with Medicare
information. Study Two participants in the intervention group
had higher scores on objective measures of knowledge and
where about twice as likely to have used the Medicare
program’s educational materials. Effect sizes were similar in
magnitude to effects found in randomized trials of
Transtheoretical Model-based programs for health behavior
change.
Conclusions: The Transtheoretical Model-based manual and
expert system interventions were received positively by users
and increased informed choice among new Medicare
enrollees.
Implications for Policy, Delivery, or Practice: Like other
programs based on the Transtheoretical Model, the stagebased interventions designed to increase informed choice
among new Medicare enrollees can have an enormous impact
when applied on a population basis. In the next phase of this
research, Pro-Change will work with the Centers for Medicare
and Medicaid Services to enhance the interventions to
increase their impact and facilitate dissemination. For
example, the materials may be adapted for dissemination by
employers.
Primary Funding Source: CMS
●Validating Health Insurance Coverage Survey Estimates:
A Comparison Between Self-Reported Coverage and
Administrative Data Records
Michael Davern, Ph.D., Kathleen Thiede Call, Ph.D., Jeanette
Ziegenfuss, Gestur Davidson, Ph.D., Timothy Beebe, Ph.D.,
Lynn A. Blewett, Ph.D.
Presented By: Michael Davern, Ph.D., Assistant Professor,
SHADAC, University of Minneosta, 2221 University Avenue SE,
Suite 345, Minneapolis, MN 55414; Tel: (612) 625-4835; Fax:
(612) 624-1493; Email: daver004@umn.edu
Research Objective: To examine the validity of estimates of
health insurance coverage obtained from self-report survey
data by comparing them to a health plan’s enrollment data to
(1) assess whether health plan enrollees self-report being
uninsured and (2) asses whether health plan enrollees are
able to correctly identify the type of health insurance coverage
they are enrolled in.
Study Design: We included a health insurance coverage
screener within a smoking survey administered to adult
enrollees in the Blue Cross and Blue Shield of Minnesota
Health Plan (BCBS-MN). The survey had a 61.5% response
rate. From these responses we are able to validate selfreported health insurance status against the actual type of
coverage using BCBS enrollment files.
Population Studied: The population of BCBS health plan
enrollees represents approximately one third of Minnesota
adults. We drew a stratified random sample of 4,575 adult
members (18 and over) of BCBS-MN representing four major
payers: (1) Medicaid enrollees, (2) MinnesotaCare enrollees
(a Minnesota-specific public health insurance program), (3)
commercial enrollees and (4) commercial enrollees 65 years
and over with Medicare supplemental.
Principal Findings: Consistent with past research, we found a
small upward bias—of 0.4% points—in the rate of
uninsurance arising from individuals with insurance coverage
answering the survey as though they were uninsured. No one
type of enrollment group was more likely than any other to
falsely report not having coverage; specifically, Medicaid
enrollees were not more likely to answer they were uninsured
than commercial enrollees. We also found that “falsepositive” Medicaid responses by those not on Medicaid
accounted for approximately 75% of the total survey estimate
of those enrolled in Medicaid.
Conclusions: This study suggests that the Medicaid
“undercount” does not arise in any quantitatively meaningful
way from those on Medicaid answering health insurance
surveys as though they were uninsured. As a result, we
suggest that making post-survey adjustments to the number
of uninsured to make the survey estimate match the Medicaid
administrative data may be inappropriate. In addition, we
found that a large proportion of the total self-reported count of
Medicaid enrollees from the survey were contributed by
individuals who were enrolled in primarily MinnesotaCare and
commercial insurance.
Implications for Policy, Delivery, or Practice: Current health
insurance survey designs are good for determining whether
someone is or is not uninsured. The current designs,
however, are not as good at determining what type of
insurance coverage a person has, and are especially poor in
determining the specific type of public coverage a person has.
This information is useful to understanding the potential bias
in estimates of uninsurance and provides information to those
evaluating current models designed to adjust for the
“Medicaid undercount” when estimating rates of uninsurance
based on survey data. Attention should be given to
redesigning surveys of health insurance coverage in ways that
might reduce the amount of “false-positive” responses given
to public programs such as Medicaid and MinnesotaCare.
Primary Funding Source: Blue Cross and Blue Shield of
Minnesota
●Immigrants May Extend The Impending Aging BabyBoomers’ Effect In This Country Further Than Anticipated.
Martey Dodoo, Ph.D., Robert L. Phillips, M.D., MSPH, Jessica
L. McCann, MA, Ginger Ruddy, M.D., Larry A. Green, M.D.,
Lisa S. Klein
Presented By: Martey Dodoo, Ph.D., Senior Economist, The
Robert Graham Center, 1350 Connecticut Avenue N W, Suite
201, Washington, DC 20036; Tel: (202)331-3360; Fax: (202)3313374; Email: mdodoo@aafp.org
Research Objective: To analyze the effect of US immigration
on the age distribution of the US population, the impending
baby-boomers’ aging, and its implications for Medicare and
the US health care system.
Study Design: Analyzed the components of population
change in the U.S. over the last 24 years, particularly the
contribution of net immigration to that change. Assessed the
size and age-distribution of the US population including the
baby-boom age-group cohort. Assessed the size and age
distribution of legal and official estimates of illegal
immigration into the US relative to the baby-boom cohort.
Undertook computer simulations of the period and cohort
effects on the US population of the current rate of annual
influx of the immigrants, and the influx of immigrants when
the baby-boomers retire and labor markets tighten, using
Census Bureau projections.
Population Studied: Age-specific data on the US population,
immigration to the U.S., and the U.S. labor force from 1980 to
2003
Principal Findings: New immigrants make up almost half of
the net annual increase in the U.S. population. Immigrants are
always younger than the general U.S. population. About half of
new immigrants are 25 to 44 years old with an average age
below 37, compared to less than 40 percent of the US
population between 25 to 44 and an average age above 37.
Over time the demographic and cumulative effect of these
immigrants will result in the relative swelling of the ranks of
the age groups following the baby-boomers, extending the
effect of the aging of a large segment of the population
beyond the year 2031.
Conclusions: The future population of the United States may
include large cohorts of older people, not only as the babyboomers age, but if current trends persist, continuing past the
baby-boomers with new cohorts of immigrants exacerbating
our health resource demands.
Implications for Policy, Delivery, or Practice: Policy makers
and health planners should take into account these
immigration population effects as there is likely to be an
increased need for medical care by an older population that
will probably continue for a longer time than previously
anticipated. These effects are likely to have policy implications
for Medicare, Social Security, the medical infrastructure, and
the healthcare workforce.
Primary Funding Source: No Funding Source
●Differences Between Rural and Urban Communities on
Referral and Utilization Patterns in Cardiovascular Patients
Dawn Finnie, MPA, James Naessens, MPH, Stephanie
Anderson, BS, Rosa Cabanela, Ph.D.
Presented By: Dawn Finnie, M.P.A., Health Services Analyst,
Health Care Policy and Research, Mayo Clinic, 200 2nd Street
SW, Rochester, MN 55905; Tel: (507) 288-3346; Fax: (507) 2841731; Email: finnie.dawn@mayo.edu
Research Objective: Assess the effect of the urban-rural
continuum on cardiovascular referral patients
Study Design: Secondary administrative data from a large,
Midwestern multi-specialty group practice was used for
patients seen in 2003. These patients were classified by
distance traveled from home: local(<=50 miles), regional (51120 miles), and distant (121+ miles). Patients were also
identified as physician-referred or self-referred. Classification
of patient residence on the urban-rural continuum was
determined using the 2003 Rural-Urban Continuum Codes
developed by the Economic Research Service of the USDA.
These continuum codes were sub-grouped into three
categories: metro, non-metro, and rural.
Population Studied: Data on all patients (n=96,703) seen on
an outpatient basis by a cardiovascular provider at a large
Midwestern multi-specialty group practice in 2003 were
identified. An episode of illness classification system was
applied to all services at the practice during 2003 for these
patients. Episodes in which an urban-rural continuum code
could not be determined (n=3462), such as for international
patients, were excluded. Information was also obtained on
whether the patient was physician or self referred and the
distance traveled for care. Patients were classified on the rural
urban continuum using the 2003 Rural-Urban Continuum
Codes developed by the Economic Research Service of the
USDA. Physician utilization and referral patterns were
compared among the different rural-urban classifications.
Analysis incorporated adjustments for distance traveled,
patient age and source of payment.
Principal Findings: A total of 83,476 episodes were
generated on patients in which an urban-rural continuum
code could be determined. Of these episodes, 19.1% were
cardiovascular-related. 61.0% of patients originated from
metro counties, 32.0.% from non-metro counties, and 7.0%
from rural counties. Patients from rural areas were less likely
to be self-referred (22.1%) than patients from metro areas
(26.8%). A higher percentage of episodes were classified as
Other Cardiovascular Symptoms (includes tachycardia,
palpitations, and murmurs) among non-rural (6.5%) patients
vs. rural (4.7%) patients. Data will be presented which
investigates the differences on type and severity of
cardiovascular problem and extent of comorbidities among
metro, non-metro and rural patients. Furthermore, the
relationship between referral source and rural status will be
presented.
Conclusions: Episode patterns of self-referral and physician
referral to cardiovascular providers appear to differ among
patients originating in metro, non-metro and rural
environments. Whether these differences are due to differing
prevalence of disease, availability of medical care or provider
and patient preferences needs to be studied further.
Implications for Policy, Delivery, or Practice: Limited
availability of primary and general medical care may affect
access to cardiology services. Patients from rural areas
appear to be referred to cardiology with different
cardiovascular disease severity and type than patients from
metro and non-metro areas. More care is needed in rural
areas. Further studies are needed to assess other specialties.
Primary Funding Source: No Funding Source
●Racial Disparity in Cardiovascular Procedures Within the
Veterans Health Administratio: The Role of Hospitals
Peter Groeneveld, M.D., MS, Gregory Kruse, MSc, Zhen Chen,
Ph.D., David Asch, M.D., MBA
Presented By: Gregory Kruse, MSc, Health Care Systems
Department, Wharton School, University of Pennsylvania,
1909 Pine Street; Philadelphia, PA 19103; Tel: (215)868-2553;
Email: gkruse@wharton.upenn.edu
Research Objective: Prior studies suggest blacks receive
fewer cardiac procedures than whites in Veterans Affairs
Medical Centers (VAMCs), but the reasons for this are
unclear. Variation in procedure use among VA hospitals may
play an important role, particularly if VAMCs with larger black
patient populations are less likely to perform procedures than
VAMCs with predominantly white patient populations.
Study Design: We examined hospital discharge data from the
VA's Patient Treatment File, a database that comprises all VA
healthcare utilization nationwide. Assuming that rapid-growth
procedures would be the most likely to demonstrate variation
in use, we selected nine predominantly inpatient
cardiovascular procedures that rapidly increased in volume
throughout the VA healthcare system between 1998-2003.
Records from all VAMC hospitalizations between 1998-2003
were examined for codes indicating receipt of the target
procedures. We also used the recorded race of each admitted
patient to determine the racial composition of each VAMC's
inpatient population for each year. Patient-level logistic
regression models were used to generate propensity scores
for each cardiac procedure based on patients' diagnoses,
comorbidities, age, race, sex, and year of admission. The
annual sums of hospitalized patients' propensity scores for
each VAMC were included in a series of nine hospital-level,
negative binomial regression models predicting utilization of
each of the nine technologies. Covariates included each
VAMC's inpatient racial composition, academic affiliation, and
urban/non-urban location. Model parameters were estimated
using generalized estimating equations.
Population Studied: All patients admitted to Department of
Veterans Affairs Medical Centers from 1997-2003.
Principal Findings: Cardiac procedures were performed in
119 VA hospitals during 1997-2003, with the percentage of
black inpatients at each center varying from <0.1% to 77%.
Our regression models indicated that a 10% increase in a
VAMC's black patient population was associated with lower
rates of open mitral valvuloplasty (rate ratio [RR] 0.80, 95%
confidence interval [CI] 0.69-0.92) and bioprosthetic aortic
valve replacement (RR 0.81, 95% CI 0.68-0.98). However,
there were no significant differences between hospitals with
large and small black patient populations in the use of
coronary arterial stents (p=0.99), coronary angioplasty without
stenting (p=0.67), non-coronary arterial stents (p=0.66), dualchamber pacemakers (p=0.62), implantable cardioverterdefibrillators (p=0.70), transmyocardial revascularization
(p=0.55), or negative contrast cardiograms (p=0.55).
Conclusions: VAMCs with larger black inpatient populations
performed new cardiac procedures at essentially the same
frequencies as VAMCs with predominantly white inpatient
populations. The only procedures that were more commonly
performed in predominantly white VAMCs were cardiac valve
replacement surgeries.
Implications for Policy, Delivery, or Practice: These results
suggest that racial differences in procedure utilization within
the VA system are more likely attributable to local, withinhospital factors rather than clinical performance differences
between VAMCs.
Primary Funding Source: University of Pennsylvania
Research Foundation
●Standard and Rapid HIV Testing Practices in Safety Net
Hospitals
Romana Hasnain-Wynia, Ph.D., Gretchen Williams Torres,
MPP, Heidi Whitmore, MPP, Jeremy Pickreign, MS, JK
Stanger, BA, Ray Kang, BA, Gloria J. Bazzoli, Ph.D.
Presented By: Romana Hasnain-Wynia, Ph.D., Senior
Director, Health Research and Educational Trust, Health
Research and Educational Trust, One North Franklin, 30th
floor, Chicago, IL 60606; Tel: (312)422-2643; Fax: (312)4224568; Email: rhasnain@aha.org
Research Objective: The CDC estimates that 1 in 4 people
living with HIV in the US are unaware of their HIV status. The
use of rapid HIV testing in hospitals yields an opportunity to
readily identify HIV infections and refer these patients to care.
There continue to be missed opportunities for early HIV
testing in hospital settings that often serve as a primary
access point for many at-risk or HIV-infected patients. The US
health system relies on the hospital safety net to provide care
to the uninsured and indigent, however little is known about
safety net hospitals’ HIV testing practices. The objective of
this paper is to examine standard and rapid HIV testing
practices in safety net and non-safety net hospitals.
Study Design: Surveys on HIV testing were mailed to the
universe of 4,497 non-federal, short-term hospitals. 1,230
hospitals completed the survey for a 27.4% response rate.
Data were weighted to adjust for non-response. Focusing on
the 623 metro hospitals, we calculate safety net status from
the American Hospital Association database.
Population Studied: We identified and classified hospitals
into three categories by their safety net status, core safety net
(4.8%), voluntary safety net (15.9%) and non-safety net
(79.3%), based on the actual amount of uncompensated care
provided.
Principal Findings: 98% of core safety-net hospitals offer HIV
testing compared to 94% of non-safety net hospitals. 10% of
core safety net hospitals offer inpatient HIV testing compared
to 1% of voluntary safety-net hospitals. 10% of core safety net
hospitals offer HIV testing in their emergency departments
compared to 0% of voluntary safety-net hospitals. 34% of
labor and delivery units in core safety net hospitals offer HIV
testing compared to 18% in non-safety net hospitals. 7% of
outpatient centers in core safety net hospitals offer HIV
testing compared to 2 % in non-safety net hospitals (all values
significant at p<0.05). Knowledge of rapid HIV testing is
similar across core safety net, voluntary set net and non-safety
net hospitals. 47% of non-safety net hospitals do not use
rapid testing versus 28% of safety net hospitals. 41% of
emergency departments in core safety net hospitals provide
rapid testing versus 21% in non-safety net hospitals. 32%
percent of labor and delivery departments in core safety net
hospitals provide rapid testing versus 17% in non-safety-net
hospitals. 14% of outpatient centers in safety net hospitals use
rapid testing compared to 5.5% in non-safety net hospitals (all
values significant at p<.05).
Conclusions: Safety net hospitals are more likely to provide
HIV testing compared to non-safety net hospitals. However,
given the CDC recommendations for universal testing for (1)
all pregnant women and (2) all patients in hospitals serving
high prevalence communities (greater than 1%), overall
testing rates are low.
Implications for Policy, Delivery, or Practice: HIV testing is
more likely to take place in core safety net hospitals. Given the
important role safety net hospitals play in providing care to
the indigent and to at-risk populations, policymakers should
provide incentives to support HIV testing and follow-up care.
Primary Funding Source: CDC
●Rurality and Disparities in Mental Health Treatment
Emily Hauenstein, Ph.D., LCP, APRN, BC, Stephen Petterson,
Ph.D., Douglas Wagner, Ph.D., Virginia Rovnyak, Ph.D.,
Elizabeth Merwin, Ph.D., MSN, Barbara Heise, MSN, NP
Presented By: Emily Hauenstein, Ph.D., LCP, APRN, BC,
Associate Professor, School of Nursing, University of Virginia,
PO Box 800782, Charlottesville, VA 22908; Tel: (434)9240093; Fax: (434)982-1809; Email: ejh7m@virginia.edu
Research Objective: To assess urban-rural differences in
mental health treatment rates and pathways to care among
non-elderly adults using a refined measure of rurality.
Study Design: We use data from the Medical Expenditure
Panel Survey (MEPS) to examine the relationship between
rurality and mental health treatment. We exploit the
longitudinal design of the MEPS to examine treatment over
four-month intervals subsequent to interviews, using up to
three observation periods per respondent. Three measures
of mental health treatment are examined: any medical visit
related to a mental health condition, visits associated with
specialized care and the number of visits in the observation
period. We use the Urban-Rural Continuum as an ordinal
measure of rurality, which classifies metropolitan counties on
the basis of the size of the metropolitan area and
nonmetropolitan counties on the basis of their urbanization
and their adjacency to metropolitan areas. Binary logistic and
linear regression analyses are performed to estimate
differences in mental health treatment, adjusting for
demographic, need, and access variables. Variance
estimation is based on the clustered survey design of the
MEPS; the weights and design variables take multiple
observations of an individual into account.
Population Studied: The sample consists of adults aged 18 to
64 in the first four panels of the MEPS, covering a period from
1996 to 2000. The MEPS is a large nationally-representative
panel survey of households designed to provide estimates of
the use of health services, medical expenditures and sources
of payment. The sample size is 34,801 respondents, yielding
100,339 person-interview observations. Of these respondents,
10% reside in the three most rural types of counties on the
urban-rural continuum.
Principal Findings: Rural residents are significantly less likely
to obtain mental health treatment, especially specialized
treatment, than urban residents despite evidence of greater
need among rural residents. These disparities persist after
controlling for measures of reported mental health, age,
marital status, region, schooling, income, and insured status.
Other things being equal, the odds of any type of mental
health treatment for an urban person were 35% greater than
the odds for a rural person; the odds of receiving mental
health specialty care were 37% greater for urban residents than
rural residents. By contrast, there are no substantial urbanrural differences in the number of visits for the subset of
respondents with at least one visit. Our results also suggest
different pathways to care. In particular, the association
between reported mental health and receipt of treatment is
stronger in more urbanized areas, while the association
between reported physical health and treatment is stronger in
more rural areas.
Conclusions: Limited access to mental health services and
other characteristics of rural areas reduces the rural
population's receipt of mental health visits, despite higher
needs.
Implications for Policy, Delivery, or Practice: Residents
living in rural counties may have unique problems that put
them at greater risk for mental health problems. Inadequate
services and mental health delivery mechanisms may heighten
that risk by reducing overall access to treatment.
Primary Funding Source: NIMH
●Access to Care and Utilization among Children: The
Effects of Public and Private Coverage
Julie Hudson, Ph.D.
Presented By: Julie Hudson, Ph.D., Economist, Center for
Financing, Access, and Cost Trends, Agency for Healthcare
Research and Quality, 540 Gaither Road, Rockville, MD 20850;
Tel: ( 301)427-1683; Fax: (310)427-1277
Research Objective: We examine the relationship between
health insurance coverage and children’s access to and
utilization of medical care. We present results for a wide
range of access measures, including having a usual source of
care (USC) and delaying or going without needed medical care
for financial reasons. We also examine indicators for
ambulatory visits, well-child visits, dental visits, emergency
room use, and inpatient hospital stays.
Study Design: We pool data from the first seven years (19962002) of the Medical Expenditure Panel Survey (MEPS).
Pooling yields a large sample of children, enabling us to
analyze access and utilization using simple descriptive
statistics, multivariate analysis, and instrumental variables
estimation (IV). In particular, our IV estimates offer insights
into the widespread concern than conventional estimates
overstate the effect of coverage, because children with
coverage may have greater health risks than those without
coverage.
Population Studied: Children in the civilian
noninstitutionalized population of the United States who are
covered by private, public, or no health insurance.
Principal Findings: As previous studies have found, public
and private coverage are both associated with large increases
in access and utilization. Simple mean comparisons suggest
that private coverage has a larger effect than does public
coverage. This difference is reduced (and often changes sign)
when we control for other characteristics of children and their
families. IV coverage effect estimates are larger than
conventional estimates, mitigating concerns that conventional
estimates are overstated.
Conclusions: Public coverage and private coverage are both
associated with large increases in access to and utilization of
medical care.
Implications for Policy, Delivery, or Practice: Our results
highlight the importance of reducing uninsurance among
children.
Primary Funding Source: AHRQ
first 6 months of 1999. Of the 38,358 colorectal cancer
patients, 2,887 (7.5%) had colectomy surgery in the first six
months of 1999. Evidence of chemotherapy administration
was found in 1999 Medicare or VA files for 887 (30.7%) of the
colectomy patients. Mean time between surgery and start of
chemotherapy, for patients who received chemotherapy after
surgery, was 57.4 days (approximately 8 weeks). Mean time
between surgery and chemotherapy was longer for patients
who used both VA and Medicare providers than for “Medicare
only” users (60.5 days v 53.6 days; P<.05). Mean time
between surgery and chemotherapy was similar for dual
system users and for “VA only” users (60.5 days v 56.2 days;
P<.5). It is not clear if these differences are clinically different.
Multivariate analysis across provider types is continuing.
Conclusions: These early results suggest that elderly
colorectal cancer patients using more than one system of care
may experience delays in receipt of adjuvant therapy. Studies
of outcomes that adjust for cancer stage and comorbidity will
be needed to determine if the delays are clinically significant.
Implications for Policy, Delivery, or Practice: While it is well
documented that initial surgery and adjuvant therapy are key
to disease-free and long-term survival in colon cancer,
variations in care exist. Patients using more than one
healthcare system are particularly vulnerable, because
coordination of care across systems of care may be lacking,
resulting in delays in care.
Primary Funding Source: VA
●Timing of Surgical and Adjuvant Therapy for Colorectal
Cancer
Denise Hynes, Ph.D., MPH, RN, Ruth A. Perrin, MA, Qiuying
Zhang, MS, Kristin Koelling, MS, Min-Woong Sohn, Ph.D.
●Expanding Health Insurance to Cover at-Risk Populations
in a Rural State: Qualitative Results from the Nebraska
State Planning Grant.
Katherine Jones, Ph.D., Erin Carlson, MPH, Roslyn FraserMaginn, BA, Brandi Shay, BA, Katherine Jones, Ph.D.
Presented By: Denise Hynes, Ph.D., MPH, RN, Senior Health
Scientist, Midwest Center for Health Services and Policy
Research, Veterans Administration, PO Box 5000 (151H),
Hines, IL 60141; Tel: (708)202-2413; Fax: (708)202-2415;
Email: Denise.Hynes@med.va.gov
Research Objective: To assess and compare colorectal
cancer initial surgical and adjuvant treatment patterns for
elderly patients across the Veterans Administration and
Medicare systems of care
Study Design: Based on a quality of care theoretical model,
the study links data from multiple comprehensive data
sources for a retrospective cohort of colorectal cancer patients
to characterize and compare patient demographic
characteristics, comorbidity, timing and type of cancer surgery
and timing and type of adjuvant therapy. Provider type (VA or
Medicare) and geographic region are compared. Calendar year
1999 comprises the study period.
Population Studied: A retrospective cohort of 1999 incident
and prevalent colorectal cancer patients, identified from VA
and Medicare data, who are at least 66 years old and eligible
to use both VA and Medicare healthcare
Principal Findings: Using an ICD9CM code algorithm to
identify colon and rectal cancer patients in Medicare claims
and VA utilization files, we identified 38,358 unique patients.
Of those, 3,882 (10.1%) died in 1999 and by the end of 2003 a
total of 17,166 (44.8%) of the patients had died. To increase
the likelihood that evidence of adjuvant therapy would appear
in the 1999 medical record, further analysis was restricted to
colorectal cancer patients who had a colectomy during the
Presented By: Katherine Jones, Ph.D., Assistant Professor,
Preventive and Societal Medicine, University of Nebraska
Medical Center, 984350 Omaha, NE 68198-4350; Tel: (402)
559-8913; Fax: (402)559-7259; Email: kjonesj@unmc.edu
Research Objective: To inform policymakers about the lived
experiences of Nebraskans at risk of being uninsured and
underinsured, and the factors small employers consider when
deciding whether to offer health insurance.
Study Design: Thirteen focus groups were conducted for the
Nebraska State Planning Grant to complement its household
survey. We used the stages of preparation, contact with key
contacts to negotiate and confirm participants, and follow-up
to lay groundwork for future contact. Incentives for
recruitment included a monetary stipend, transportation, a
light meal, and child care. The three Hispanic groups were
conducted in Spanish. For all groups conducted with minority
populations, a researcher co-moderated with the key contact.
Group proceedings were audio-recorded and transcribed to
allow coding and analysis using NVivo software. We identified
themes and subthemes unique and similar across all groups.
Population Studied: The household survey identified
populations likely to be uninsured. Thirteen focus groups
totaling 133 participants were conducted across Nebraska’s six
health planning regions. Nine groups included populations at
risk of being uninsured: urban African-Americans, urban
Native Americans, rural Hispanics (two groups), urban
Hispanics, young adults attending community college, lowincome adults (two groups), and refugees. Four employer
groups included urban employers with fewer than 50
employees, rural employers with fewer than 50 employees
(two groups), and rural self-employed or micro-employers
with 5 or fewer employees.
Principal Findings: All groups wanted access to affordable,
comprehensive health care for themselves and their families.
Reasons for not obtaining insurance were high cost and a
perceived lack of value due to high deductibles—paying for
basic necessities took precedence. High out-of-pocket costs
limited utilization of primary care by the uninsured and the
underinsured—those who purchased catastrophic coverage to
protect assets. The uninsured and underinsured described
fragmented care due to gaps in the safety net. The high cost of
premiums prevents small businesses from offering insurance,
which discourages community development and results in the
uninsured and underinsured incurring debt when obtaining
needed care. Immigrants, refugees, and young adults do not
understand the role insurance plays in access to care.
Conclusions: The uninsured and underinsured value the
security provided by insurance but use limited resources to
pay for basic necessities. The lack of affordable health
insurance affects quality of life: people are unable to fulfill
moral obligations to care for family and employees; they delay
or forgo needed care, allocate limited resources to their
children, and worry about debt. The cost of health insurance
impedes rural development as out-of-pocket costs prevent
spending in other economic sectors and lack of employersponsored insurance contributes to depopulation.
Quantitative studies of the uninsured do not capture the
difficulty those with catastrophic coverage experience in
paying for primary care.
Implications for Policy, Delivery, or Practice: Rural states
with diverse at-risk populations (immigrants, minorities, lowincome adults, the self-employed) and a high proportion of
small employers should identify the unique barriers to
coverage for each group so that limited resources are used to
improve coverage for those most likely to forego needed care
or incur debt paying for it. Additional research is needed to
understand the extent and effect of underinsurance in
Nebraska.
Primary Funding Source: HRSA
●Health Care Coverage and Access to Care: The Status of
Minnesota’s Veterans
Yvonne Jonk, Ph.D., Kathleen Thiede Call, Ph.D., Andrea H.
Cutting, MA, Heidi O’Connor, MS, Vishakha Bansiya, M.D.,
Kathleen Harrison, MBA, MPH
Presented By: Yvonne Jonk, Ph.D., Health Economist, Center
for Chronic Disease Outcomes Research, Minneapolis VA
Medical Center, One Veterans Drive 1110, Minneapolis, MN
55417; Tel: (612)467-3882; Fax: (612)725-2118; Email:
yjonk@umn.edu
Research Objective: The primary objective of this study is to
examine veterans’ reliance on health care services provided by
the Veterans Health Administration (VHA) within Minnesota
and estimate the potential effect on uninsurance rates if all
eligible veterans relied on VHA coverage. Secondary objectives
are to compare veterans and non-veterans’ by geographic
location, demographic characteristics, health status, and
health insurance coverage, and to compare insured and
uninsured veterans especially with regard to access to care.
Study Design: Data are from the 2001 Minnesota Health
Access Survey of a stratified random sample of over 27,000
respondents of whom 3,500 were self-identified veterans.
Though all veterans were eligible to obtain health care services
from the VHA in 2001, veterans not reporting VHA coverage
and having no other source of insurance coverage were
considered uninsured. Differences in weighted population
characteristics are reported. Logistic regression analysis is
used to identify factors associated with veterans' reliance on
VHA coverage.
Population Studied: A random sample of over 27,000
Minnesota residents of whom 3,500 were self-identified
veterans in 2001.
Principal Findings: Veterans represented 13.4% of the state's
adult population and 9.3% of the state’s uninsured non-elderly
adult population in 2001. Uninsured veterans were more likely
to be single, unemployed, living in rural areas, and in poorer
health than insured veterans. They also report constrained
access to services. Insured veterans were less reliant on VHA
coverage.
Conclusions: The state’s uninsurance rate would significantly
decrease if veterans relied on the VHA safety net.
Implications for Policy, Delivery, or Practice: If veterans’
insurance status matters in states with low uninsurance rates,
VHA coverage has broader implications for states with higher
veteran concentrations and higher uninsurance rates.
Primary Funding Source: HRSA
●Emergency Department Overcrowding in Large
Metropolitan Areas: From Bad to Worse
Phillip R. Kletke, Ph.D., Jon Gabel
Presented By: Phillip R. Kletke, Ph.D., Director, Health System
Studies, Health Research and Educational Trust, 1 North
Franklin, Chicago, IL 60616; Tel: (312)422-2641; Fax: (312)4224568; Email: pkletke@aha.org
Research Objective: To monitor the increasing prevalence of
overcrowding in the emergency departments (EDs) of
hospitals in large metropolitan areas; and to determine how
these EDs are responding to the growing demand for
emergency services.
Study Design: We conducted a survey of ED administrators in
the 729 ED hospitals in the 20 largest metropolitan areas of
the US. The field period was between February and June of
2004. The survey questionnaire collected data on: trends in
ED visits and ED capacity; the prevalence of ED overcrowding
and ambulance diversions; the perceived causes of
overcrowding; the methods used to minimize overcrowding
and ambulance diversions; and strategies used by EDs to
minimize excess demand for their services. EDs could
respond to the survey by mail, by fax, or on-line. We received
responses from 191 hospitals for a response rate of 29%. The
data are weighted to control for potential response bias.
Population Studied: Hospitals with EDs in large metropolitan
areas.
Principal Findings: ED overcrowding in large metropolitan
areas is worsening. Over 90% of the EDs indicated that the
demand for their services had increased in the past 3 years.
Average waiting time for emergency services was long: 20
minutes for emergent patients; 52 minutes for urgent patients;
and 76 minutes for non-urgent patients. Almost three-fourths
(73%) of the EDs indicated that the boarding of patients (i.e.,
housing patients in the ED due to the lack of beds or staff in
inpatient areas) had increased during the past three years.
More than half (52%) indicated that the incidence of
ambulance diversions (re-routing ambulances to more distant
hospitals because of overcrowding at the nearest ED) had
increased during the past 3 years. During 2003, hospitals
were on full or partial diversion for an average of 694 hours—
the equivalent of almost a full month. The most frequent
causes of diversions were bottlenecks in the processing of
patients—the lack of inpatient beds, the lack of available ICUs,
or the lack of ED capacity.
Conclusions: EDs are attempting to cope with overcrowding
in a variety of ways: coordinating the discharge of ED patients
with hospital admissions (77%); increasing ED staffing (73%);
increasing the use of contract workers (59%); increasing the
physical capacity of the ED (57%). Nevertheless, some EDs
are clearly losing the struggle. Because of overcrowding and
long waiting times, approximately 3% of ED patients who
complete triage leave the ED before being evaluated, perhaps
forgoing needed care.
Implications for Policy, Delivery, or Practice: Overcrowding
in hospital EDs has increased for at least the past 25 years,
and our findings indicate that this trend shows no signs of
abating. The prospect that EDs may become even more
overcrowded should generate considerable concern within the
health policy community. Overcrowding in the ED delays the
treatment of patients with emergent conditions and thus
prolongs their pain and suffering and increases the likelihood
of poor clinical outcomes. Furthermore, ED overcrowding
limits access to care to the most vulnerable of patients by
interfering with the ED’s ability to function as a safety net
provider to the poor, the uninsured, and Medicaid patients.
Primary Funding Source: RWJF
●Effects of the Missing Medigap Guarantee-Offer for
Disabled Beneficiaries
Jill Klingner, MS, RN
Presented By: Jill Klingner, MS, RN, Rural Health Research
Center, University of Minnesota, 1240 Juliet Avenue, St. Paul,
MN 55105; Tel: (651)698-8045; Email: klin0089@umn.edu
Research Objective: This study assessed the scope of
protection available to the Medicare-eligible under-age 65
disabled through supplemental insurance plans, including
Medicaid, Veterans Administration care, and employersponsored (ESSI) or individually purchased policies(IPSI). It
also estimated the effect of state Medigap guarantee-offer and
Medicaid eligibility policies on supplemental insurance
acquisition.
Study Design: This study is a longitudinal, natural experiment
comparing the supplemental insurance rates of disabled
Medicare beneficiaries across states with differing and
changing Medigap and Medicaid policies over the 5-year
period of 1997-2001. The Medicare Current Beneficiary Survey
(MCBS) provided information on personal characteristics,
health insurance, health status, functional status, chronic
conditions, and living arrangements. Additional information
on state Medicaid and Medigap policies were available from
CMS and state offices.
Population Studied: The study subjects are disabled, under65 Medicare beneficiaries in the MCBS sample for at least two
years between 1997-2001. Those who died before their second
complete year were excluded from the sample because their
information was incomplete. Those with eligibility due to End
Stage Renal Disease (ESRD) were excluded because their
Medicare benefits and experiences are different than those of
other Medicare beneficiaries under-65.
Principal Findings: The Medicare disabled are less likely than
the elderly to have Medicare supplemental health insurance
coverage. Reflecting their lower incomes, they are more likely
to have Medicaid. The largest difference in access to
additional coverage appears in the Medigap category. Only 8%
of the disabled purchase these policies. State policies
mandating Medigap-offering at eligibility strongly affects the
likelihood of enrollment.
Conclusions: Due to the increased barriers to supplemental
insurance and the higher health-related needs with fewer
resources the disabled person’s ability to maintain a health
regimen, to improve his or her health, or maintain his or her
health, or prevent deterioration of health, may be
compromised.
Implications for Policy, Delivery, or Practice: Access to
Medigap policies is greater for the elderly because of a 1990
federal law requiring Medigap policies to be available for all
age-eligible during their initial Medicare eligibility. Some states
mandate a guarantee-offer of this type (Medigap or IPSI) of
policy for the disabled at their initial eligibility. As of 1998,
disabled Medicare beneficiaries in only nine states had
guarantee access to Medigap policies without underwriting.
As of 2003, 22 states had guaranteed access to Medigap
policies for the disabled without underwriting.
An expansion of the federal or state policies requiring
Medigap offerings at initial eligibility for the disabled would
increase the proportion with Medicare supplemental
insurance and may have a positive effect on the health- and
functioning status of disabled under-65 beneficiaries.
Primary Funding Source: No Funding Source
●The Role of Technical Assistance in the Success of Rural
Health Networks: The ‘Right’ TA at the ‘Right’ Time
Patricia Kota, MSPL, RN, Dora Ward Kyabu, MPH, BA, Lindsey
Lonergan, MSH, BS
Presented By: Patricia Kota, MSPL, RN, Director, Community
Health Systems Development, Georgia Health Policy Center,
Andrew Young School of Policy Studies, 14 Marietta Street,
Atlanta, GA 30303; Tel: (404)463-9564; Fax: (404)651-3147;
Email: pjkota@gsu.edu
Research Objective: The development of rural health
networks is an inherently complex process involving an array
of rural health network grantees (RHNs). On the
presumption that standardized technical assistance processes
and tools improve efficiency and predictability, rural health
network grantees are provided technical assistance with health
information technology, business planning, and care
management implementation, among other topics. The
Georgia Health Policy Center has developed a proactive
technical approach grounded in the assertion that systematic
but flexible technical assistance, provided by experts in
relationships with networks, is the most effective and efficient
means to improve access to care for rural residents. The goal
of this analysis is to describe the impact of meaningful
technical assistance contact provided early in a network’s
development versus the impact of technical assistance
provided later.
Study Design: This qualitative study is based on case studies
of the Health Resources and Services Administration’s Office
of Rural Health Policy Rural Health Network grantees
receiving technical assistance from the Georgia Health Policy
Center. Case studies of three vertically integrated RHNs and
three horizontally integrated RHNs receiving technical
assistance visits in the first year of development are compared
with case studies of three vertically integrated RHNs and
three horizontally integrated RHNs receiving technical
assistance visits in the second year of development or later.
All RHNs are selected for homogeneity of budgets, overall
goals, and demographic factors in order to control for
extraneous factors influencing network success. Data sources
include monthly and quarterly reports, interviews with network
directors and technical assistance providers, and responses to
quality assurance surveys. Measures of success include
degree of governing board involvement, strategic and
business planning process and commitment, community
involvement as determined by formal involvement of
community leaders and citizens, and the level to which
networks adopt an integrated, holistic health approach.
Population Studied: Rural Health Networks recieving grants
from the Health REsources and Servies Administration.
Principal Findings: Analysis is presently underway. Expected
completion is May, 2005
Conclusions: Technical assistance is presumed to be of
benefit to rural health networks, but its effectiveness has not
been documented. By contrasting the impact of technical
assistance delivered early and later in the network
development process, we expect this study will demonstrate
the importance of providing technical assistance as early as
possible in the network development process.
Implications for Policy, Delivery, or Practice: The power of
technical assistance tailored to a community’s needs and
provided early and consistently throughout the process of
development or reformation of any community health system
may be immense. Demonstrating the impact of early
technical assistance to community health systems may
support the provision of this support to underserved
communities throughout the country, resulting in improved
health among the nation’s most needy populations and
increased return on investment for grantors.
Primary Funding Source: HRSA
●Expanding Health Care Access with DSH: Georgia's
Indigent Care Trust Fund
Glenn Landers, MBA, MHA,
Presented By: Glenn Landers, MBA, MHA, Senior Research
Associate, Georgia Health Policy Center, 14 Marietta Street,
Atlanta, GA 30303; Tel: (404)463-9562; Fax: (404)651-3147;
Email: glanders@gsu.edu
Research Objective: Evaluate the effectiveness of Georgia's
Indigent Care Trust Fund (ICTF) - the program created to
distribute federal disproportionate share hospital (DSH)
funds. Georgia is the only state that requires hospitals to
spend a portion their DSH awards on community-based
primary care.
Study Design: 1.) Systematic review of hospital primary care
plans. 2.) Written questionnaire 3.) Qualitative interviews with
hospital, public health, service agency, and state personnel.
Population Studied: 92 hospitals participating in Georgia's
Indigent Care Trust Fund
Principal Findings: 1.) About half of the hospitals studied
attempted some measurement of the impact of their primary
care programs on the community; slightly more than 20%
extensively measured impact; about 25% did not attempt to
measure program impact. 2.) More than 50% of the time,
programs reached the intended population - Medicaid clients
and the medically indigent; about 40% of the time, programs
reached unintended populations; less than 10% of the time,
programs did not reach the intended population at all. 3.)
Almost 60% of the time, hospitals engaged District Public
Health Directors in health planning to some degree; about
22% of the time, hospitals extensively engaged District Health
Directors; less than 20% of the time, hospitals did not engage
District Health Directors at all. 4.) Large hospitals were able to
leverage additional funds more effectively than smaller
hospitals. 5.) Hospitals were particularly successful in
leveraging their primary care dollars with indigent drug
programs.
Conclusions: The Indigent Care Trust Fund Primary Care Plan
requirement plays a vital role in Georgia's health care safety
net. Without it or comparable funding, fewer Georgians
would have access to primary health care services, and
uncompensated hospital expenses would most likely increase
due to individuals forgoing routine care and seeking hospital
emergency care once illness progresses.
Implications for Policy, Delivery, or Practice: Georgia's
primary care requirement is an innovative model for other
states that wish to expand access to uninsured individuals.
DSH funding targeted to community-based primary care has
the potential to reduce high cost inpatient admissions.
Primary Funding Source: Georgia Department of
Community Health
●Effect of Health Insurance on Workplace Absenteeism in
the US Workforce
Jennifer Lofland, PharM.D., MPH, Ph.D., Kevin D. Frick, Ph.D.
Presented By: Jennifer Lofland, PharM.D., MPH, Ph.D.,
Research Assistant Professor, Health Policy, Thomas Jefferson
University, 1015 Walnut Street, Suite 115, Philadelphia, PA
19107; Tel: (215)955-7348; Fax: (215)923-7583; Email:
jennifer.lofland@jefferson.edu
Research Objective: 1) To examine the relationship between
health insurance and the annual number of missed workdays,
2) to determine how this relationship is modified by one’s
level of access to care and healthcare use.
Study Design: This was a retrospective, pooled, crosssectional study using 1996 to 1999 data of the Medical
Expenditure Panel Survey. An access to care index was
developed using Rasch Partial Credit Analysis. A two-part
model was used to estimate the annual number of missed
workdays. The first part of the model estimated the probability
of incurring any missed workdays. Since the missed workdays
data had a skewed distribution, the number of missed
workdays was transformed using a logarithmic scale. For the
second part of the model, the number of log transformed
missed workdays, conditional on missing at least one
workday, was estimated.
Population Studied: Non-institutionalized, civilian, employed
individuals within the US.
Principal Findings: Of the 25,676 employed individuals,
13,957 (54%) reported missing time from work. Of those who
missed time from work, the mean (SE) annual number of
missed workdays was 4.3 (0.092). Having health insurance
was significantly associated with a decreased likelihood of
missing work (p=0.038). When access to care was included in
the model examining the relationship between having health
insurance and missed workdays, a higher level of access to
care was significantly (p=0.000) associated with missing a
greater number of workdays and the coefficient associated
with the health insurance coefficient decreased slightly from 0.017 to -0.046. However, health insurance was still not
associated with the number of missed workdays. When
healthcare use was included in the same model, 1) healthcare
use was significantly (p=0.000) associated with an increased
likelihood of missing work and missing a greater number of
workdays, 2) having health insurance was significantly
associated with missing a smaller number of workdays
(p=0.000), and 3) the health insurance coefficient decreased
from -0.017 to -0.081. When access to care and healthcare
use were simultaneously included in the model, the results
were the same as above.
Conclusions: Having health insurance at any time point over
the course of a year is significantly associated with a
decreased likelihood of missing work as well as missing a
smaller number of workdays. Access to care and healthcare
utilization are important explanatory variables. Healthcare
utilization appears to be a confounder between health
insurance and workplace absenteeism.
Implications for Policy, Delivery, or Practice: These results
suggest that the potential financial benefits of employers
ensuring that all employees have health coverage should to be
explored.
Primary Funding Source: AHRQ
●Changing Paterns of Care by Veterans
Judith Long, M.D., Daniel Polsky, Ph.D., Joshua Metlay, M.D.
Presented By: Judith A. Long, M.D., Physician Researcher,
Philadelphia VA CHERP, 1201 Blockley Hall, 423 Guardian
Drive, Philadelphia, PA 19104; Tel: (215)898-4311; Fax: (215)5738778; Email: jalong@mail.med.upenn.edu
Research Objective: We describe how characteristics of
veterans who use the VHA have changed from 1992 to 2000.
Study Design: We merged two waves of the National Survey
of Veterans to determine changing patterns of out-patient care
use. We evaluated, conditioning on receiving out-patient care,
the choice of veterans to receive at least some of their care
from the Veterans Health Administration (VHA).
Population Studied: Veterans
Principal Findings: Compared to veterans who receive all
their care outside of the VHA, there was an increase in the
relative number of VHA users who were 65 or older, less
educated, poor and had no additional health insurance.
Although the odds that a VHA user compared to a non-VHA
user had no additional health insurance in 1992 was 2.12 (95%
CI: 1.60-2.81), by 2000 the odds was 4.35 (95% CI 3.71-5.10).
The increase in use by the poor and less educated appears to
be driven by veterans who receive their care both within and
without the VHA (dual users).
Conclusions: Among users of out-patient care there was an
increase in the proportion of veterans using the VHA who are
older, without additional medical insurance and low-income.
Implications for Policy, Delivery, or Practice: An important
mandate of the VHA is to serve vulnerable veterans. Since the
VHA re-engineering of the mid 1990s the VHA seems to have
made significant strides toward fulfilling this mandate by
increasing the amount of care it provides to older, sicker, low
income veterans, as well as those veterans without additional
health insurance. Although there is still room for
improvement the VHA plays a vital role in the U.S. health care
safety net.
Primary Funding Source: VA
●Constructing an Index for Predicting Health Access
Deprivation in the U.S.
Jessica McCann, MA, Robert L. Phillips, M.D., MSPH, Martey
S. Dodoo, Ph.D.
Presented By: Jessica McCann, M.A., Analytic Geographer,
The Robert Graham Center, 1350 Connecticut Avenue, N W
Suite 201, Washington, DC 20036; Tel: (202)331-3360; Fax:
(202)331-3374; Email: jmccann@aafp.org
Research Objective: To use logistic modeling techniques in
constructing a health access deprivation index that will allow
us to determine the variables that best predict reported health
access problems in this country
Study Design: We reviewed the relevant literature and
identified variables that have been associated in some way
with health access and health deprivation in this country. We
modeled two measures of health care access deprivation
derived from the 2002 National Health Interview Survey
(NHIS): These were (1) was care delayed at anytime in the
past 12 months, and (2) a combination of was care delayed or
did respondent not get care at anytime in the past 12 months.
Using techniques and software for analyzing surveys with
complex designs like the NHIS, we identified independent
variables that had significant associations with the health care
access variables. We used those independent variables in
stepwise logistic regressions to determine the extent to which
these variables predict whether a person had care delayed or
did not get care, and the odds associated with these.
Population Studied: We used merged national data from the
person, household, and adult components of the 2002 NHIS.
The sample size was 31,044 persons 18 or more years old.
Principal Findings: Out of the 32 independent variables
identified in the literature as potential predictors of health
access deprivation, 23 were available in the NHIS. After further
deliberation, we tested 18 of these for significance and 16 were
found to be significantly associated with the delay of care or
not receiving care. In the sample analyzed, 15.6 percent had
care delayed and 19.4 percent delayed or did not get care. The
key results are that someone is most likely to have care
deprived, or to have care delayed, if they are female, do not
own a home, live in a single adult household, have a
functional limitation, smoke, have no usual source of care or
one place where they receive care, have no health insurance or
are less than 65 years old.
Conclusions: The results were as expected - that health
access is highly associated with a number of socioeconomic
variables. Variables such as being female, not owning a home,
living in a single adult household, having a functional
limitation, being a smoker, having no usual source of care or
one place where they receive care, having no health insurance,
and being less than 65 years old can be good predictors of
potential health access problems.
Implications for Policy, Delivery, or Practice: This study has
provided a model that may be used as a basis for local
community assessments and health planning. As a next step
the results of this study may be used as a foundation for
merging and using Census data to identify specific
communities and/or populations at risk of having health
access deprivation problems or issues.
Primary Funding Source: No Funding Source
●Regional Variation in ED Utilization by Oregon Health
Plan Enrollees
K. John McConnell, Ph.D., Robert A. Lowe, M.D., MPH,
Rochelle Fu, Ph.D., Annette A. Adams, MPH, Cody Weathers,
BS, Charles A. Gallia, MS, Judy Mohr-Peterson, Ph.D.
Presented By: K. John McConnell, Ph.D., Assistant Professor,
Center for Policy and Research in Emergency Medicine,
Oregon Health & Science University, 3181 SW Sam Jakcson
Park Road Mail Code CR-114, Portland, OR 97211; Tel: (503)
494-1989; Fax: (503)494-4640; Email: mcconnjo@ohsu.edu
Research Objective: Although high utilization of emergency
departments (EDs) has been well documented as a marker of
poor access to medical care, less is known about the regional
variations in access that occur among different medical
service areas. The objective of this study was to determine the
extent to which case-mix adjusted ED visits varied among 130
small market areas.
Study Design: This historical cohort study used Oregon
Health Plan administrative data to determine number of ED
visits, duration of enrollment, age, gender, race, ethnicity,
eligibility category, managed care/fee-for-service coverage,
pregnancy, and presence of 33 chronic medical conditions.
The enrollee's zip code was used to place each patient in one
of 130 primary care service areas (PCSAs). PCSAs were
developed by the Oregon Office of Rural Health and are based
on topography, social/political boundaries, and travel patterns
We used a zero-inflated negative binomial model to estimate
ED visits, adjusting for patient characteristics and chronic
medical conditions, and fixed effects for PCSAs. We then
examined the contribution to ED visits that could be attributed
to each PCSA. This approach was designed to identify the
variation in ED visits that could not be attributed to patient
characteristics.
Population Studied: 676,345 Oregon Health Plan
beneficiaries aged <65, enrolled in 2001 and 2002.
Principal Findings: Unadjusted rates of ED utilization in
different PCSAs varied from 0.15 visits/member/year (95% CI
0.11-0.19) to 1.5 visits/member/year (95% CI 1.4-1.6). Case-mix
adjusted rates showed a similar range, with a coefficient of
variation (CoV) of 0.4. Variations in ED use by region were
larger among older patients and patients enrolled in managed
care plans.
Conclusions: Rates of ED use vary substantially, by a factor of
10, among different medical service areas. These variations
remained even after adjusting for patient demographics and
comorbidities.
Implications for Policy, Delivery, or Practice: Variations in
ED use among these medical service areas suggest that some
communities have successfully provided access to care to the
underinsured, while others exhibit substantial barriers to care.
Understanding the factors that drive disparities in access in
different regions may lead to improvements in primary care
for these vulnerable populations. Improving primary care has
the potential to improve health outcomes and also lead to
more efficient allocation of health resources.
Primary Funding Source: Collins Foundation and Emergency
Medicine Foundation Riggs Family Grant
●Making Coverage for the Uninsured
Karen Minyard, Ph.D., Deborah Chollet, Ph.D., Laurie E.
Felland, MS, Lindsey Lonergan, MHS, Chris Parker, MBBS,
MPH
Presented By: Karen Minyard, Ph.D., Director, Georgia Health
Policy Center, Andrew Young School of Policy Studies, 14
Marietta Street, Atlanta, GA 30303; Tel: (404)651-3104; Fax:
(404)651-3147; Email: kminyard@gsu.edu
Research Objective: As health care costs and the number of
uninsured Americans continue to increase, community
initiatives across the country are steadfast in their efforts to
bridge the growing gap between public and private health
insurance coverage. The object of this research was to
understand how community initiatives have developed and
sustained financing to serve the uninsured and more
specifically to:
a. Describe efforts to increase coverage or access and impact
on target populations. b. Examine the cost effectiveness and
efficiency of operations. c. Identify factors that enhance or
challenge sustainability and expansion of the initiatives. d.
Understand the lessons for replication. e. Examine how
states and communities cooperate to close gaps in funding
and access.
Study Design: Five case studies were conducted over an 18
month period. Key study methods included: feedback on
research design from public and private experts; development
of site selection criteria: site selection; assembly of data
regarding the case-study community initiatives; development
of interview protocols; site visits with 10-25 key informants
from each site (a combined total of 84); follow-up integration
of information; coding and uploading interview notes to a
qualitative database (Atlas-ti); and team analysis of each site
and comparative analyses across sites. Analyses frameworks
included: intent; effectiveness; sustainability; replication;
state/community interface; and leadership.
Population Studied: Five case study sites (Wichita, Kansas;
Paris, Arkansas; Milwaukee, Wisconsin; Olympia, Washington;
and Forsyth, Georgia) were selected because of their
geographic and operational diversity. Each of these initiatives
attempts to provide coverage and/or access to care to
individuals who have difficulty finding or navigating
conventional insurance arrangements and public programs.
Principal Findings: All five local community initiatives
attempt to provide access and coverage to a specific
population: non-elderly adults. In each community, there is
evidence that providing more appropriate health care services
is cost effective for providers and the community at large.
Program leaders have fought hard to maintain momentum
and remain relevant despite diminishing grant funding. The
difficulty of replication can be attributed to the complexity of
the innovations and to differences in context between alpha
and beta sites. The context of community programs – the
presence of supportive public programs and/or strong private
insurance capacity is an essential success factor.
Conclusions: Encouraged by private foundations and
government efforts to strengthen local health care safety nets,
some communities have developed programs to piece
together access and financing for individuals and families who
live between the worlds of private insurance and public
coverage. These efforts attempt to weave the threads of
provider discounts, free care, and public financing into a more
coherent system of coverage and care.
Implications for Policy, Delivery, or Practice: Public policy
that supports provider participation and state-level leaders
who believe in local innovation are important to programs that
entail provider volunteerism or acceptance of reduced
compensation. Local programs can support or complement
state public and private insurance programs, but they are
unlikely to thrive independent of them.
Primary Funding Source: CWF, Healthcare Georgia
Foundation, Washington Health Foundation
●The Role of Targeted External Facilitation and Technical
Assistance in Improving the Clinical Relevance and
Financial Viability of Rural Health Systems
Karen Minyard, Ph.D., Tina Anderson Smith, MPH, Lindsey
Lonergan, MHS
Presented By: Karen Minyard, Ph.D., Director, Georgia Health
Policy Center, Andrew Young School of Policy Studies, 14
Marietta Street, Atlanta, GA 30303; Tel: (404)651-3104; Fax:
(404)651-3147; Email: kminyard@gsu.edu
Research Objective: The health care environments in many
rural communities in the United States have been in crisis for
more than a decade, yet community leaders are often not
organized to strengthen health and human services that
contribute to improved access and health status. Rural/urban
disparities exist in that rural Americans are generally older,
poorer, and sicker than their urban counterparts. This
research examines the role of targeted external facilitation and
technical assistance in improving the collaboration, clinical
relevance, and financial viability of rural health systems.
Study Design: Review of the literature, a survey of national
best practices, and pilot interventions in three rural
communities suggested a framework for building and
sustaining successful rural health systems. Case studies to
test the framework were conducted in 12 rural communities.
Each community experienced a fragile, failing health care
system. Each community was provided with external
facilitation and technical assistance during the study period.
Community specific information, technical assistance
resources, and outcomes were documented for each
community in 1999 and 2000. The data were examined
vertically (within each site) and horizontally (across sites) for
themes and outcomes. The framework was revised based on
learnings from the case studies.
Population Studied: Twelve rural communities in Georgia
were studied.
Principal Findings: The key modifications to the framework
were the time sequencing of the financial and clinical
outcomes and the introduction of contextual modifiers. When
provided with technical assistance, all 12 rural communities
were able to maintain or improve local collaboration. The
local collaboration was followed by financial gains in 9 of the
12 communities and clinical gains in 3 of the 12 communities.
Several things were found to moderate the theorized
relationships and process: Longer duration technical
assistance; an environment of crisis was not associated with
clinical or financial gains; and local strong leadership seemed
to be associated with improved outcomes.
Conclusions: Community leaders in areas with fragile, failing
health and health systems are often not organized to
strengthen health and human services that contribute to
improved access and health status. External neutral
facilitation can help local leaders representing hospitals,
physicians, public health, clinics, other health and human
services, government, business, schools, churches, and
philanthropies organize along a continuum from fragmented
to integrated local systems. Once the local collaboration
reaches a certain level and the ability to learn, plan, and
implement exists, local leaders are able to begin to strengthen
the local system. Local health system financial viability and
clinical relevance are theoretical precursors to access and
health status improvement.
Implications for Policy, Delivery, or Practice: Health and
health care are local. Local health systems provide the
foundation on which the overall health care system is built.
The overall system consists of national, state, and local public
and private programs, policies, and resources. Investment in
strong local health care systems can make a difference and is
an important investment in the health care system as a whole.
Primary Funding Source: Georgia Department of
Community Health
●The Effect of Medicare Managed Care Plan Benefit Levels
on Use of the VA Medical Care System
Robert Morgan, Ph.D., Dolly John, MPH, Jessica Davila Ph.D.,
Margaret Byrne, Ph.D., Raji Sundaravaradan, BS, Iris Wei, Dr.
PH, , Debora Paterniti, Ph.D., Nora Osemene, Pharm.D.,
Laura Petersen, M.D., MPH
Presented By: Robert Morgan, Ph.D., Senior Research
Scientist and Associate Professor, Houston Center for Quality
of Care and Utilization Studies, Michael E. DeBakey VA
Medical Center and Baylor College of Medicine, 2002
Holcombe Boulevard (152), Houston, TX 77030; Tel: (713) 7948635; Fax: (713) 748-7359; Email: rmorgan@bcm.tmc.edu
Research Objective: Changes in benefits provided by
Medicare managed care plans (Medicare HMOs) may affect
VA use among dually eligible veterans, possibly affecting the
continuity and quality of their health care. The purpose of this
study was to examine the relationship of Medicare HMO plan
benefit levels with VA outpatient, inpatient, and ER service use
by veterans enrolled in Medicare HMOs.
Study Design: We used national VA inpatient and outpatient
data for calendar year (CY) 2000 merged with CY 2000
national Medicare enrollment and plan benefit data. Plan
benefit packages were categorized as low, medium, and high
based on a combination of the physician and hospital co-pays,
as well as pharmacy and supplemental benefits (vision, dental,
hearing and podiatry). Logistic regression analyses were used
to examine any use of the VA during CY 2000, followed by
negative binomial regressions to examine magnitude of use
among VA users. Analyses were conducted separately for
outpatient, inpatient, and ER use, and were adjusted for age,
sex, race/ethnicity, VA priority level, income, Medicare state
buy-in status and metropolitan versus non-metropolitan
location.
Population Studied: Analyses were performed on data for
elderly (aged 65+) veterans who had any use of the VA health
system within the past five years and who were enrolled in an
Medicare HMO plan for some part of CY 2000 (N = 282,939).
Principal Findings: The level of Medicare HMO plan benefits
was significantly and monotonically related to the likelihood
that veterans would use the VA system for any of their health
care. Veterans enrolled in plans with high benefit and
medium benefit packages were less likely to use any VA
outpatient services than those enrolled in a plan with low
benefit levels (ORs = .68 [.65-.70] and .82 [.79-85],
respectively). Interestingly, among veterans who did use
outpatient care, those in high and medium benefit plans used
slightly more outpatient care than veterans in low benefit
plans (ORs = 1.08 [1.06-1.09] and 1.07 [1.05-1.08], respectively).
Similarly, veterans enrolled in high benefit and medium
benefit plans were significantly less likely to have a VA ER visit
than were those in low benefit plans, with enrollees in high
benefit plans being the least likely to have a VA ER visit (ORs =
.52 [.46-.58] and .83 [.73-.95] for high benefit and medium
benefit versus low benefit enrollees, respectively). There was
no association between plan benefit levels and VA inpatient
use.
Conclusions: This is the first demonstration that VA use
among Medicare HMO enrolled veterans varies directly with
the extent of benefits offered by their plans, particularly for
outpatient and ER care.
Implications for Policy, Delivery, or Practice: Our findings
strongly suggest that changes in Medicare HMO plan benefits
are likely to influence whether veterans turn to the VA for care
as an alternative or additional provider of care, ultimately
affecting resource availability at individual VA medical centers.
Primary Funding Source: VA
visit. Probit analysis will be conducted to analyze the effect of
coverage status and gains or losses of coverage on the
probability of a visit. Covariates include coverage status at
time of visit, whether an individual gained or lost coverage
over the study period, presence of chronic conditions, selfperceived health status, and demographic characteristics such
as age, gender, race/ethnicity, and income.
Population Studied: A two-year panel of nonelderly adults
(age 19-64) constructed from the 2000 and 2001 Medical
Expenditure Panel Survey (MEPS), a nationally representative
survey of the U.S. civilian, non-institutionalized population.
The unweighted sample of 5,737 represents 165,500,334 adults.
Principal Findings: Over the two year period, 68% of the
panel is continuously insured, 11% is continuously uninsured,
and 21% experience one or more transitions in health
insurance status. Health status of the three populations does
not differ significantly. Adults with a change in insurance
status account for 27% of all ED visits, while the continuously
insured and uninsured represent 18%. Preliminary results
suggest that people with a transition have twice as many visits
by the continuously insured or uninsured. Further analysis
will stratify ED visits by insurance status at the month of visit,
to see if the probability of an ED visit is greater when insured
or uninsured, and whether insurance gainers or losers are
more likely to have a visit.
Conclusions: Preliminary results suggest ED use might not
be driven by insurance status as much as it is driven by
changes in coverage status, highlighting the importance of
stable coverage.
Implications for Policy, Delivery, or Practice: Policymakers
need to take into account the dynamic aspect of insurance
coverage when designing programs aimed at improving the
care received by the uninsured, or relieving overcrowding of
EDs. Gaining a better understanding of the transitionally
uninsured allows us to see if stability of coverage is a more
important determinant of ED use than coverage itself.
Primary Funding Source: RWJF
●Health Insurance Transitions and Emergency
Department Utilization
Karoline Mortensen, MA, Catherine McLaughlin, Ph.D.
●Managing Care for Uninsured Patients: Five Success
Stories from America’s Public Hospitals and Health
Systems
Christina Moylan, MHS, Lynne Fagnani, MBA
Presented By: Karoline Mortensen, MA, Health Services
Organization & Policy, University of Michigan, 4000 Purdue
#149, Houston, TX 77005; Tel: (713)661 1526; Email:
karoline@umich.edu
Research Objective: Recent findings in the academic
literature suggest that, contrary to conventional wisdom, the
uninsured do not use the emergency department (ED) more
than the insured. Previous studies focus on the utilization of
the continuously insured and continuously uninsured, yet a
gap exists in studying people who transition into or out of
coverage, their coverage status at the time of ED visit, and
how ED utilization may vary depending on their insurance
status. The goal of this project is to examine ED utilization for
nonelderly adults who experience a transition (gain or loss of
insurance) in health insurance status, relative to the ED use of
the continuously insured and continuously uninsured.
Study Design: ED visits of adults followed over a two year
period are analyzed. Monthly health insurance coverage status
is linked to each episode of care. The unit of analysis is the ED
Presented By: Christina Moylan, MHS, Policy Advisor,
National Association of Public Hospitals and Health Systems,
1301 Pennsylvania Avenue, NW, Suite 950, Washington, DC
20004; Tel: (202) 585-0100; Fax: (202) 585-0101; Email:
cmoylan@naph.org
Research Objective: Collect descriptive information on
innovative public hospital and health systems programs that
use managed care principles in delivering health care services
to uninsured patients. Identify common programmatic
strategies and policy recommendations based upon the
research.
Study Design: Key informant telephone and on-site interviews
with five public hospitals and health systems with programs to
manage care for the uninsured. Hospitals were selected
based upon the age of the program, use of managed care
principles with uninsured patients, and demographic and
geographic diversity. The interview protocol included general
background, eligibility criteria, enrollment, enrollee
demographics, services and utilization, network structure and
provider payment, care management strategies, and program
costs, funding, and administration.
Population Studied: Boston Medical Center in Boston, MA
(Care Net Plan); Health and Hospital Corporation of Marion
County in Indianapolis, IN (Health Advantage); Jackson
Memorial Hospital in Miami, FL (Trust Care); Parkland Health
& Hospital System in Dallas, TX (Parkland HEALTHplus); and
VCU Health System Authority in Richmond, VA (Virginia
Coordinated Care for the Uninsured).
Principal Findings: While these models apply managed care
principles to caring for uninsured patients, they differ from
Medicaid and commercial managed care plans in that they are
not insurance products – there is no separate payment source
and no defined benefit package. The upper income eligibility
level ranges from a low of 150 percent of the FPL to a high of
200 percent of the FPL. All offer enrollees access to a
comprehensive set of services, including primary, specialty,
and inpatient care and operate using existing provider
networks. Care management strategies are targeted at
primary care, inpatient care management, discharge planning,
and chronic disease management. Costs are difficult to
quantify given the lack of a dedicated funding stream.
Conclusions: These models appear to be having a positive
impact on the continuity and quality of care for uninsured
patients. They offer interesting lessons learned for other
safety net providers and policymakers. Additional research is
needed to fully understand the impact of these programs on
continuity, quality of care, and health outcomes for uninsured
patients. Research is also needed to better understand the
costs and benefits of this approach.
Implications for Policy, Delivery, or Practice: For safety net
providers, these models offer valuable lessons learned about
how to create and administer these programs. For policy
makers, these models demonstrate that public hospitals and
health systems continue to fill the gap left by existing public
insurance programs and that it is essential to support these
efforts. There is also an opportunity to explore the benefits of
using health information technology (HIT), such as electronic
medical records, to manage care for uninsured patients. HIT
may be particularly beneficial with this population given the
high prevalence of chronic disease and the needed
coordination among providers.
Primary Funding Source: National Association of Public
Hospitals and Health Systems
●Unworried Parents of Well Children: a Look at Uninsured
Children who Reportedly do not Need Health Insurance
Kathleen S. O'Connor, MPH, Stephen Blumberg, Ph.D.,
Genevieve Kenney, Ph.D.
Presented By: Kathleen S. O'Connor, MPH, Survey
Statistician, Division of Health Interview Statistics, Centers for
Disease Control and Prevention, National Center for Health
Statistics, 3311 Toledo Road Room 2114, Hyattsville, MD
20782-2003; Tel: (301)458-4181; Fax: (301)458-4035; Email:
kdo7@cdc.gov
Research Objective: To examine the characteristics of lowincome uninsured children whose parents reported that health
insurance coverage was not needed.
Study Design: This study uses data from the 2001 National
Survey of Children with Special Health Care Needs, conducted
by the National Center for Health Statistics, Centers for
Disease Control and Prevention, on behalf of the Maternal and
Child Health Bureau of the Health Resources and Services
Administration. This random-digit-dial telephone survey
screened 373,055 children under 18 years of age for special
health care needs. In each household, up to one child with
special needs and one child without special needs were
randomly sampled for an interview that included questions
about health insurance coverage, health status, health care
access and utilization, and awareness of, experience with, and
intention to enroll in Medicaid or the State Children’s Health
Insurance Program (SCHIP). The survey respondent was the
parent or guardian who was most knowledgeable about the
child’s health.
Population Studied: Uninsured children from low-income
households whose parent or guardian said that public or
private health insurance coverage was not needed.
Principal Findings: When asked why their children did not
have health insurance, parents of 6.8% of the low-income
uninsured children gave either primary or secondary answers
that were categorized as “don’t need insurance/don’t get
sick”. Non-Hispanic children of American Indian or Alaska
Native (AIAN) race were more likely than low-income
uninsured children from any other racial or ethnic group to
reportedly not need insurance (15.2%). Hispanic children
were also more likely than non-Hispanic white children to
reportedly not need insurance (8.9% and 3.2% respectively).
After adjusting for the language of interview and
sociodemographic characteristics, the relationship of Hispanic
ethnicity to reported need for insurance was not statistically
significant. Instead, with both language of interview and
ethnicity in the regression model, the model revealed that
language of interview had a stronger relationship to reports of
not needing insurance. Many children who reportedly did not
need insurance were not receiving the preventive care that is
recommended by pediatricians and did not have a medical
home. Roughly half of the children reportedly not needing
insurance had parents who had heard of Medicaid or SCHIP
and said they would enroll their child in Medicaid or SCHIP if
told they were eligible.
Conclusions: Parents’ perceptions of the need for insurance
are related to children’s health status and health care use.
Lack of awareness of preventive care needs for healthy
children, of the availability of low-cost public health insurance
programs, and of the eligibility of most children from lowincome households were related to sociocultural
characteristics.
Implications for Policy, Delivery, or Practice: The majority
of children reportedly not needing insurance coverage had
parents who said they would enroll them in Medicaid or
SCHIP if told their child was eligible. However, for parents of
the small fraction of uninsured children who were generally
reported to be healthy and not need insurance, learning about
eligibility might not be sufficient to motivate participation in
Medicaid, SCHIP, and other insurance programs.
Primary Funding Source: HRSA, DHHS/ASPE
●Does Unauthorized Residency Status Determine Mexican
Immigrants' Access to Employer-Based Health Insurance?
Victoria D. Ojeda, Ph.D., MPH, Enrico Marcelli, Ph.D.
Presented By: Victoria D. Ojeda, Ph.D., MPH, NIMH PostDoctoral Research Fellow, Health Care Policy, Harvard
Medical School, 180 Longwood Avenue, Boston, MA 02115;
Tel: (617)432-0819; Email: ojeda@hcp.med.harvard.edu
Research Objective: To determine whether unauthorized
residency status explains low rates of employment-based
health coverage among unauthorized immigrants or whether
this outcome is predicted by other sociodemographic,
employment, or community characteristics.
Study Design: This study is based on data obtained from the
1994 and 2001 Los Angeles County Mexican Immigrant
Residency Status Surveys (LAC-MIRSS) and the March 19942003 Current Population Surveys (CPS). The LAC-MIRSS data
include information on adult respondents' residency status,
health insurance coverage, and other sociodemographic and
employment data. We first apply demographic predictors of
unauthorized residency status obtained from the 1994 and
2001 LAC-MIRSS (e.g., age, sex, years residing in the United
States, educational attainment) to the noncitizen foreign-born
Mexican adult population in the 1994-2003 March CPS to
estimate the proportion of unauthorized Mexican immigrants
who had employer-sponsored heath insurance. We next
analyze how unauthorized residency status influenced the
probability of having had job-based coverage using logistic
regression models and controlling for other
sociodemographic, employment, and neighborhood
characteristics.
Population Studied: The 1994 LAC-MIRSS sample includes
558 foreign-born Mexican adults residing in one of 275
randomly selected households within one of nine census
tracts in Los Angeles County. The 2001 LAC-MIRSS sample
includes 780 foreign-born Mexican adults residing in one of
456 randomly selected households within one of 125 census
blocks in Los Angeles County.
Principal Findings: Bivariate analyses demonstrate significant
differences in health insurance coverage rates
by residency status. Overall, more than two-thirds of
unauthorized immigrants are uninsured and about one-third
have some form of private or public health insurance. When
data are disaggregated by source of coverage, we find that
unauthorized immigrants have the lowest rates of employerbased coverage of the groups analyzed, with only about 1 of
every 10 covered through their workplace. However, results
from logistic regressions suggest that unauthorized status
was not a significant predictor of employer-based coverage.
Rather, unauthorized Mexican immigrants' lower coverage
rates through the workplace appear to have been a function of
time residing in the United States, educational attainment,
occupation, participation in local community groups, and
neighborhood homeownership.
Conclusions: This study provides new insight into patterns of
coverage among one subgroup of Latinos, unauthorized
Mexican immigrants. Results provide evidence of vulnerability
among working unauthorized immigrants residing in the U.S.
Contrary to expectations it is not unauthorized status per se
that determines immigrants' access to employer-based
coverage, but rather how immigrants are distributed in the
labor market, which is likely also due to human capital as
measured by their educational attainment, as well as social
factors such as civic participation and neighborhood
homeownership rates. In addition, length of time in the U.S.
may reflect level of integration into mainstream society, ability
to navigate workplace bureaucracies, and increased level of
experience in the workforce.
Implications for Policy, Delivery, or Practice: Continued
efforts to reduce the uninsured population and to expand
private health insurance coverage to low-wage sectors of the
labor market where unauthorized immigrants are likely to be
concentrated are needed. Making private coverage more
affordable is critical to safeguarding the health and access to
care of those individuals and their families as they are likely to
include children who are U.S citizens by birth.
Primary Funding Source: No Funding Source
●National Data on the Characteristics of Rural Residents
Hospitalized in Rural as Compared with Urban Hospitals
Maria Owings, Ph.D., Margaret Hall, Ph.D., Jill Marsteller,
Ph.D., Maria Owings, Ph.D.
Presented By: Maria Owings, Ph.D., Health statistician,
Hospital Care Statistics Branch, National Center for Health
Statistics, 3311 Toledo Road, Hyattsville, MD 20782; Tel:
(301)458-4409; Fax: (301)458-4032; Email: mowings@cdc.gov
Research Objective: To compare demographic and clinical
characteristics of 5.1 million rural residents discharged from
rural hospitals to 2.2 million rural residents who received
inpatient care in urban hospitals; and to examine the
availability of health services in their counties of residence.
Study Design: Data were from the 2001 National Hospital
Discharge Survey (NHDS). The survey gathered data on
diagnoses and procedures, length of stay, expected payment
source, and discharge disposition. Based on diagnosis codes,
the Charlson Index was calculated for each patient as a
measure of comorbidity burden. In addition, county FIPS
codes were used to link NHDS data with the Area Resource
File in order to obtain socioeconomic and health service
supply data on the counties where rural patients lived. The
June 2003 OMB definitions were employed to designate
patients' and hospitals' counties as urban (i.e. metropolitan)
or rural (all others, including micropolitan and noncore).
Population Studied: A nationally representative sample of
inpatients in short-stay, nonfederal hospitals in the United
States.
Principal Findings: Thirty percent of hospitalized rural
residents crossed over to urban areas to receive their inpatient
hospital care. These patients were younger, had more
procedures and longer stays than rural residents hospitalized
in rural hospitals. A smaller proportion of rural patients in
urban hospitals expected to pay with Medicare. Rural
residents hospitalized in urban hospitals were more likely than
their counterparts in rural hospitals to have cancer, circulatory
(including heart) diseases, nervous system or musculoskeletal
disorders, and injuries, and they were less likely to have
diseases of the endocrine, respiratory, digestive or
genitourinary systems. Rural patients in urban hospitals
averaged twice as many procedures performed during their
hospitalization as those in rural hospitals. Residential
counties of rural patients who crossed over to urban hospitals
had fewer active MDs and fewer short-term hospital beds per
capita than those of rural patients hospitalized in rural
hospitals. Counties of crossover patients also had fewer
hospitals with a cardiac intensive care unit. Consistent with
the limited availability of certain types of health services within
their counties, a relatively large share of rural crossover
patients received complex surgical procedures including
invasive cardiac procedures during hospitalization.
Conclusions: Many rural hospitals provide basic medical and
surgical care, but their ability to provide specialized surgery
and care for complex medical conditions may be limited.
Geographic disparities in access to technologically advanced
medical and surgical care may present barriers to the receipt
of timely and appropriate care for rural patients, especially the
elderly and the poor.
Implications for Policy, Delivery, or Practice: Research on
existing patterns of inpatient care for rural residents can be
helpful to both urban and rural hospitals as they develop
collaborative arrangements to ensure efficient use of
resources and the provision of high quality care that meets the
needs of all rural patients requiring hospitalization.
Primary Funding Source: CDC
●Stresses to the Safety Net: The Public Hospital
Perspective
Marsha Regenstein, Ph.D., Jennifer Huang, MS
Presented By: Marsha Regenstein, Ph.D., Director, National
Public Health and Hospital Institute, 1301 Pennsylvania
Avenue, NW, Suite 950, Washington, DC 20004; Tel: (202)
585-0100; Fax: (202) 585-0101; Email: mregenstein@naph.org
Research Objective: Safety net hospitals care for large
numbers of uninsured, low-income and vulnerable
populations. Given their mission, these hospital systems are
extremely dependent upon public sources of financing to
deliver high-quality care. The downturn in the economy over
the past several years has placed increasing stress on these
systems, with limited opportunities for new sources of
revenue. This study describes trends affecting the financial
viability of safety net hospitals across the country in light of
increasing demand for services. The study examines specific
challenges facing large safety net hospital systems in eight
states.
Study Design: A review was conducted of available national
surveys documenting utilization and financing of large public
hospitals in the United States. Data was drawn primarily from
the annual surveys of members of the National Association of
Public Hospitals and Health Systems (NAPH) and the
American Hospital Association. In-depth interviews were
conducted with chief executive officers, chief financial officers,
chief medical officers, emergency department directors and
other key leaders in safety net hospitals in eight states:
California, Florida, Georgia, Minnesota, New Mexico, New
York, Ohio and Texas. States were selected to provide
variation in terms of geographic location, diversity and size of
the uninsured population in the state, and characteristics of
the Medicaid program.
Population Studied: Approximately 120 public and not-forprofit safety net hospitals that are members of NAPH were
included in the study. These hospital systems collectively
accounted for nearly 1.5 million discharges, 30 million
outpatient visits, and over 5 million emergency department
visits in 2002. About 42% of outpatient visits are to patients
who are uninsured and another 27% are covered by Medicaid.
Principal Findings: Safety net hospitals have implemented
numerous programs over the past five years to improve
efficiencies and leverage scarce resources on behalf of their
patient populations. Increasingly, public hospitals are
dependent on federal Medicaid revenues for their financial
health and therefore are extremely sensitive to Medicaid
changes both at the federal and state level. With increasing
demand for services due to the growing numbers of
uninsured and underinsured individuals, CEOs and other
hospital leaders indicate that they have few options for
increasing revenue from other payer sources. Most juggle the
need for direct care with the need for capital improvements,
including advances in information technology.
Conclusions: Federal sources of financing, primarily from
Medicaid, are the single most important source of revenue for
safety net hospitals. Opportunities for improvements in safety
and efficiency rest with IT enhancements, although
investments in IT are difficult given heightened financial
stresses. With growing demand from uninsured,
underinsured, undocumented, and otherwise vulnerable
populations, efforts to curtail federal support will have
profound and immediate effects on safety net hospitals’ ability
to maintain current services within their communities.
Implications for Policy, Delivery, or Practice: Communities
have always turned to public hospitals for their health care
needs. However, without sustained support from public sector
financing, public hospitals will be forced to limit service
availability, limit eligibility for free or reduced care, or reduce
quality of care.
Primary Funding Source: Kaiser Family Foundation
●Estimating the Cost of Caring for the Uninsured in
California
Dylan Roby, M.Phil, Gerald Kominski, Ph.D.
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; Email: droby@ucla.edu
Research Objective: This study documents the relative
disparities in spending for direct personal health care services
between California’s uninsured and insured population (ages
0-64) and provides an estimate of the direct costs that would
be incurred if the uninsured were provided with health
insurance, while controlling for demographic differences and
health status.
Study Design: The 1998-2000 Medical Expenditure Panel
Survey (MEPS) was used in conjunction with the 2001
California Health Interview Survey (CHIS) in order to model
direct medical expenditures in the state of California based on
patient characteristics, health status, and various other
measures. Based on these direct expenditure models, we were
then able to project how much in direct expenditures would be
needed to cover the uninsured in the state.
Population Studied: Californians aged 0 to 64.
Principal Findings: The majority of personal health care
expenditures in the state come from full-year insured adults,
with $43.1 billion (69%) spent from private insurance, public
insurance, out-of-pocket costs, and other sources. Insured
children account for 18% of expenditures, or almost $11.3
billion. In comparison, spending by uninsured children and
adults constitutes a combined 12% of expenditures, a total of
$7.4 billion. However, if provided with health insurance, the
uninsured would spend about $14.8 billion in total on direct
health care if fully insured, compared to the $7.4 billion they
already spend out-of-pocket or that is paid on their behalf
from other public and private sources. This $7.4 billion
increase in expenditures represents a 12% increase in total
direct personal health care expenditures in the state. The
additional expense would be about $1,180 per uninsured
person in the state.
Conclusions: Covering the uninsured is a significant step in
improving the health status and quality of life for all
Californians by guaranteeing that no Californian will face
access barriers as a result of losing their health insurance. The
projections in this policy brief show that an expansion of
health insurance would increase direct expenditures. However,
it would also provide much needed care to the 6.3 million
people who lack health insurance, as well as provide equal
access to health care in the state.
Implications for Policy, Delivery, or Practice: Shifting
resources could enhance the ability of the state to insure the
uninsured, improving access to care and the health of
Californians. This increase in direct expenditures does not
reflect the billions of dollars spent to care for the uninsured
through funding from DSH, health center grants, or other
indirect subsidies. It will be important to consider the amount
of indirect sources of expenditures made on behalf of the
uninsured, and to develop options on how all these direct and
indirect sources of expenditures might be combined to
provide affordable insurance for California’s uninsured
population. In light of our estimates, the costs of an
insurance expansion may be more affordable if the state can
find mechanisms for redirecting current sources of public and
private expenditures on behalf of the uninsured.
Primary Funding Source: California Endowment
●Do Employers Respond to Public Hospitals Crowding
Out of Private Insurance?
Eric Seiber, Ph.D.
Presented By: Eric Seiber, Ph.D., Assistant Professor, Public
Health Sciences, Clemson University, 527 Edwards Hall,
Clemson, SC 29634; Tel: (864) 656-6206; Fax: (864) 656-6227;
Email: seiber@clemson.edu
Research Objective: Multiple studies have found public
health care services crowding out private insurance in the
United States. A separate literature reports increasing
numbers of employers deciding not to offer a group health
insurance plan to their employees. However, no study links
these two themes in the literature to examine the extent of
public insurance crowding out on the supply of employer
sponsored insurance plans. The objective of this study is to
decompose the public hospital crowd out effect into changes
in take-up and changes in the supply of employer sponsored
insurance.
Study Design: The study uses data from the 1995 Contingent
Workers Supplement in the Current Population Survey and
data from the 1995 American Hospital Association’s Annual
Hospital Survey to estimate a nested multinomial logit model
of workers’ insurance choice. A two tier choice set captures
both whether the employer offers a group plan and the
employee’s choice to participate, purchase on the individual
market, or to remain uninsured. Simulations decompose the
effect of public hospitals on the offer of employer sponsored
plans and the take-up of those plans. Separate simulations
are conducted for workers under the poverty line, 100-199%,
200-299%, and those over 300% of poverty.
Population Studied: Contingent workers in the 100 largest
Metropolitan Statistical Areas.
Principal Findings: The study finds public hospitals having a
significant crowding-out effect on demand and a modest
effect on the supply of employer sponsored insurance. The
simulations reveal the most substantial effects for the poor
and near-poor. A simulated doubling of public hospitals has
the uninsured rate increasing by five percent amongst the
poor and a three percent decrease in the offer of employer
sponsored plans (3% and 1% for the near poor).
Conclusions: The results indicate that employers do respond
to the availability of public substitutes, with each one percent
of private coverage crowded out by public hospitals being
matched by a 0.5-0.66% reduction in the availability of
employer sponsored insurance.
Implications for Policy, Delivery, or Practice: Faced with a
public hospital undergoing an ownership conversion,
employer sponsored insurance markets will catch workers that
previously used public hospitals, and policy makers should
focus their efforts on the unemployed and others with no
access to the employer sponsored insurance market.
Primary Funding Source: No Funding Source
●Economic Stress and the Safety Net
Peter Shin, Ph.D., MPH, Sara Rosenbaum, JD, Julie Darnell,
MHSA
Presented By: Peter Shin, Ph.D., MPH, Assistant Research
Professor, Center for Health Services Research and Policy,
George Washington University, 2021 K Street, NW Suite 800,
Washington, DC 20006; Tel: (202)530-2313; Fax: (202)2960025; Email: pshin@gwu.edu
Research Objective: This paper examines the impact of the
recent economic downturn on health centers in selected
communities, exploring the effect of declining private health
insurance coverage and the elevated unemployment levels
among lower wage workers, and assesses how recent
increases in federal appropriations relate to growing demand
for health center services as the number of low-income,
uninsured persons continues to rise, and challenges health
centers face as they experience widespread state cutbacks in
Medicaid – the single most important source of health center
financing.
Study Design: The study uses both a quantitative and
qualitative approach. The Uniform Data System is used to
provide new information on the demographic profile of health
center patients and the revenue sources available for financing
their care, including recent increases in federal discretionary
funding. The 2002 Uniform Data System (UDS), which
managed by the federal government, includes data on 843
health centers and 11 million users at more than 4,600 urban
and rural sites. The UDS data was also used to estimate the
proportion of each state's low-income and uninsured
population (along with 2001-2002 Kaiser Commission on
Medicaid and 2002-2003 new users of federally-funded health
centers from the National Association of Community Health
Centers). During 2002 and 2003, interviews were conducted
with health center staff in 8 urban and rural communities and
representatives from state and regional primary care
associations regarding the effects of the downturn on health
centers and their patients. Researchers selected urban and
rural communities located in states with elevated
unemployment rates related to the downturn using data from
the U.S. Department of Labor and based on Medicaid
generosity levels. Respondents were asked about the impact
of economic conditions on their financial support, patient
caseload and health status, and overall operations; whether
and how their experiences differed from health centers in less
affected communities around the state; and what actions if
any their state or local governments had taken to help them.
Respondents also provided additional data regarding their
patients, revenues, and staffing.
Population Studied: Given their location and their service
missions, health centers operate in the communities most
likely to bear the worst brunt of an economic downturn such
as the one that experts say began in March 2001. The
slowdown has been particularly difficult for lower wage
workers with limited job skills, and the very low level of job
growth in the current economic recovery suggests that
employment hardships for these Americans may continue for
some time. In addition to facing a rising number of patients
without jobs and who are at increased risk for lack of health
insurance, health centers have also had to weather state
Medicaid cutbacks and the loss of state and local operating
funds, as state budgets have constricted in response to
declining revenues. Even where Medicaid-enrolled health
center patients do not lose their coverage entirely, coverage
for important benefits and services may have been lost.
Principal Findings: The roughly 7% increase in federal
funding between 2002 and 2003 occurred at the same time as
the number of uninsured health center patients is estimated
to have risen by an even faster rate of 11.4%. From a national
perspective, for every one uninsured, low-income patient that
a health center is able to treat, there are an average of four
additional low-income, uninsured persons. Recent data
suggest that Medicaid is paying significantly more per patient
than are grant funds. Medicaid contributed on $450 per year
for each Medicaid patient served in 2002. In contrast, grant
payments provided only $299 per year for each uninsured
patient served in a health center. Therefore, Medicaid
coverage remains the largest revenue source for health centers
and is the engine that supports health center capacity during
an economic downturn. Health center respondents reported
that their centers felt the impact of the downturn in two ways.
First, respondents found that many patients lost coverage,
thereby complicating the provision of their health care and
driving down revenue expectations for the centers. Second,
respondents experienced a surge in new patients who lost
coverage as a result of either job cutbacks or unemployment
and were left without affordable health care. Respondents
further noted that their new, or newly uninsured, patients
tended to experience serious physical or mental conditions,
which they attributed either to the ramifications of job loss or
to underlying health problems that might have contributed to
job loss as the economy softened. Respondents noted that
while Medicaid payments were more generous than payment
levels from private insurers, revenues realized from newly
enrolled patients were inadequate to offset the surge in costs
that health centers experienced from having to rapidly expand
treatment for uninsured patients. Only in the District of
Columbia did the proportion of low-income health center
patients exceed 30% of the low-income population. In 20
states, health center penetration into the low-income
population was less than 10% of the low-income population.
Furthermore, in only 8 states did health centers reach at least
30 percent of the low-income uninsured population.
Conclusions: Findings underscore the fact that as essential as
health center grants are for supporting care for the uninsured,
establishing new health center sites and supporting and
improving existing services, the reach of these funds alone is
modest in relation to need. Even a program as favorably
regarded as the health center program has received federal
discretionary appropriations increases that pale in comparison
to the level of need, particularly at times when the economy
slows, the number of uninsured patients rises, and the
severity of problems seen at health centers increases. These
findings suggest that for health centers, just as for non-safety
net providers, health insurance remains the engine that drives
health care capacity and responsiveness. Its impact can be
measured both by the comprehensive benefit package it
provides health center patients and the cost-based payment
rates that it offers specifically to health centers. These rates
help ensure that federal discretionary grant funds tied to the
uninsured patient population are not spent to offset public
program payment shortfalls. Medicaid’s importance is such
that even in states with more limited programs and in
communities with high immigrant populations, health centers
report investing in Medicaid outreach and enrollment
assistance, not only to help patients secure coverage but also
because of Medicaid’s impact on the centers’ operating
capacity.
Implications for Policy, Delivery, or Practice: Federal
discretionary spending increases are, however, a vital means
of expanding the health center program. Such increases help
stabilize centers and support care for uninsured patients,
allow new health centers to be established and expand existing
programs, and support highly beneficial quality improvement
activities. But even in the case of a program as popular as
health centers, these discretionary funding investments are
modest in relation to the number of low-income persons
without health insurance. At the same time, the survival of
health centers is especially sensitive to federal and state
Medicaid policies in all areas: eligibility, enrollment, benefits
and coverage, and provider payment rates. Our discussions
with local health centers suggest that when economic
hardship hits families, even modest increases in the cost of
health care will deter them from seeking care for fear of
incurring expenses they absolutely cannot afford. Therefore,
reforms aimed at improving Medicaid’s reach into the newly
unemployed and uninsured lower wage workers are essential
to health centers.
Primary Funding Source: Kaiser Family Foundation
●Providers’ Lack of Knowledge as a Potential Barrier to
Clinical Trial Participation for Patients with Melanoma
Karyn Stitzenberg, M.D., MPH, Nancy E. Thomas, M.D.,
Ph.D., David W. Ollila, M.D.
Presented By: Karyn Stitzenberg, M.D., MPH, Fellow, Cecil G.
Sheps Center for Health Services Research and Department of
Surgery, University of North Carolina, 725 Airport Road, CB#
7590, Chapel Hill, NC 27599-7590; Tel: (919)966-9801; Fax:
(919)966-8806; Email: karyn_stitzenberg@unc.edu
Research Objective: Proven adjuvant therapies for patients
with metastatic melanoma are limited. Consequently, clinical
trials are often the best therapeutic option for patients with
metastatic melanoma. The purpose of this study is to assess
different providers’ awareness of the availability of clinical
trials for their patients with metastatic melanoma.
Study Design: A self-administered questionnaire was
developed to examine the practice and referral patterns of
melanoma providers in NC. Several questions specifically
addressed use of adjuvant therapy and clinical trials. The
survey was pilot tested then administered in three mailings
with phone follow-up after the second mailing to maximize
response. Pearson’s chi square was used to test associations
between provider characteristics and reported access to
clinical trials for metastatic melanoma. Provider
characteristics examined included: age, gender, race, years in
practice, practice type, melanoma patient volume, and
affiliation with an academic institution or cancer care network.
Population Studied: All licensed NC dermatologists and a
subset of licensed surgeons were selected for inclusion.
Surgeons were included if, according to a statewide inpatient
and ambulatory surgery discharge database, they performed at
least three melanoma procedures between 1998 and 2001.
Principal Findings: Overall response rate was 60%; 147/232
dermatologists and 116/206 surgeons. 3% of dermatologists
reported they enroll patients in trials, 66% reported access to
another physician who enrolls patients, and 28% reported no
access to clinical trials for metastatic melanoma. 11% of
surgeons reported they enroll patients in trials, 56% reported
access to another physician who enrolls patients, and 31%
reported no access to clinical trials for metastatic melanoma.
Even among surgeons who reported that they perform
surgical nodal staging for patients with melanoma, 29%
reported no access to trials. Surgeons who were affiliated with
an academic center and those who had seen >2 melanoma
patients in the past year were more likely to report access to
clinical trials than those without academic affiliations and
those who saw <3 melanoma patients in the past year (87%
vs. 65%, p=0.04 and 77% vs. 53%, p=0.009, respectively). In
contrast, for dermatologists, none of the factors examined
were associated with reported access to clinical trials.
Conclusions: For many patients with metastatic melanoma,
clinical trials may be the only adjuvant therapy option.
Despite this, roughly one third of melanoma providers
surveyed reported they had no access to clinical trials for
patients with metastatic melanoma. Providers’ lack of
knowledge of available options may present a significant
barrier to clinical trial participation for patients with
melanoma.
Implications for Policy, Delivery, or Practice: Educational
efforts directed at providers should be undertaken to improve
access to clinical trials for patients with metastatic melanoma.
Primary Funding Source: AHRQ
●Safety-Net Hospitals: Serving the Uninsured
Donald Stull, Ph.D., Roxanne Andrews, Ph.D., Irene Fraser,
Ph.D., Bernard Friedman, Ph.D.
Presented By: Donald Stull, Ph.D., Research Scientist,
MEDTAP, 7101 Wisconsin Ave, Suite 600, Bethesda, MD
20814; Tel: (301)654-9729; Email:
donald.stull@unitedbiosource.com
Research Objective: In 2000, the Institute of Medicine called
for improved monitoring of the structure, capacity, and
financial stability of the hospital safety net to meet the health
care needs of the uninsured and other vulnerable populations.
This analysis uses national data to describe how the burden of
caring for the uninsured is spread across the U.S. hospital
system and focuses on the characteristics of hospitals that
care for a higher proportion of the uninsured.
Study Design: The analysis uses discharge-level data from the
2001 Healthcare Cost and Utilization Project (HCUP)
Nationwide Inpatient Sample, supplemented with hospitallevel data from the American Hospital Association Annual
Survey of Hospitals and information from Medicare cost
reports. This combination of data yields a unique and
comprehensive picture of safety-net hospitals in the U.S.
Population Studied: This study provides national estimates
for all US community hospitals and their patients based on a
weighted 20 percent sample of community hospitals (nearly
1,000 hospitals and 7 million discharges).
Principal Findings: The study found that hospital care for the
uninsured is distributed unequally across U.S. hospitals. Ten
percent of hospitals accounted for approximately one third of
uninsured discharges: we defined these as “safety-net”
hospitals. Another 20% of hospitals accounted for an
additional one third of uninsured discharges. The remaining
70% of hospitals provided care for the other one third of
uninsured discharges. The analysis found that safety-net
hospitals are more likely to be small (less than 100 beds),
non-teaching, and to treat a higher share of Medicaid patients
and fewer privately insured patients. They also treat a mix of
patients with different conditions. This patient mix makes it
more difficult for them to cross-subsidize care for the
uninsured. As a result, a larger proportion of safety-net
hospitals experience financial losses. Losses were more
pronounced among non-teaching safety-net hospitals where
over 40% experienced a loss compared to 25% of the teaching
safety-net hospitals.
Conclusions: Safety-net hospitals provide critical access to
uninsured patients and other vulnerable populations.
Because of their typically small size, small profit margins, and
patient mix, they are among the most vulnerable of U.S.
hospitals.
Implications for Policy, Delivery, or Practice: As the number
of uninsured remains worrisome and persistent, the
availability of a strong safety net is vital. Given the financial
vulnerability of the safety-net hospitals, communities may
want to examine how they are paying for the care of the
uninsured. They also may want to consider developing
rewards for hospitals that take on the role of safety-net
provider or risk the possibility that some of these providers
will not be able to provide services with continuing losses.
Primary Funding Source: AHRQ
●National Underutilization of Cardiac Rehabilitation Postacute Myocardial Infarction Among Elderly Medicare
Patients
Jose A. Suaya, M.D., MBA, MPH, Donald S. Shepard, Ph.D.,
William B. Stason, M.D., MS, Grant Ritter, Ph.D., Sarita
Bhalotra, M.D., Ph.D., Gail K. Strickler, MA, MS
Presented By: Jose A. Suaya, M.D., MBA, MPH, The
Schneider Institute for Health Policy, Heller School, Brandeis
University, 415 South Street, MS 035, Waltham, MA 024549110; Tel: (781)736-3904; Fax: (781)736-3928; Email:
jsuaya@brandeis.edu
Research Objective: Cardiac rehabilitation (CR) as part of the
management of coronary heart disease is recommended by
the U.S. Department of Health and Human Services, and
many medical professional associations. Medicare
reimburses for outpatient CR up to three sessions per week
for 12 weeks (36 sessions) following acute myocardial
infarction (AMI), coronary artery bypass graft (CABG), or
stable angina pectoris. This study analyzes national utilization
of CR within 1 year after hospital discharge for AMI in elderly
Medicare patients, and describes unadjusted and adjusted
variations of CR use according to patients’ characteristics.
Study Design: Using Medicare claims, we identified a
retrospective cohort of patients with AMI in 1997. The
individual patient was the unit of analysis. Outcome variables
were use, onset, amount, and completion of CR within one
year after discharge. Independent variables included sex, age
group, race/ethnicity, socio-economic and education status,
severity of the hospitalization, management of the AMI, type
of discharge, major Census region, state of residence, and
type of patient’s residence (urban, rural). Univariate, bivariate
and multivariate analyses (binary logistic regression) were
used to determine unadjusted and adjusted rates of CR use
among candidates.
Population Studied: Patients included fee-for-service
Medicare beneficiaries aged 65 and above enrolled in both
Parts A and B, who had a first hospital admission in an U.S.
non-federal acute hospital in 1997 for AMI, a stay shorter than
32 days, and who survived at least 30 days after discharge. We
identified a cohort of 203,685 such individuals, who were
considered candidates for CR for preliminary analyses.
Extensions to 400,000 additional candidates are planned for
CR from other indications.
Principal Findings: Preliminary findings follow. Of the cohort,
27,537 (13.5%) received some outpatient CR within the first
year after discharge. Seventy one percent of users started CR
within two months after discharge; the average time from
discharge to start was 56 days; the average user received 24
sessions. Thirty-six percent of the CR users completed fewer
than 19 sessions and 20.5% completed 36 sessions.
Utilization rates were 16.0% among males, 14.4% among
whites, and 19.4% among patients younger than 75. Those
rates differed from those observed among females (10.8%),
blacks (4.9%), and patients older than 84 (2.5%). Mean days
from discharge to initiation of CR services also differed by sex
(males 54 vs. females 61 days), race (whites 56 vs. blacks 68
days) and age (56 days among patients younger than 75 years
vs. 53 days among patients aged 85 and above).
Conclusions: Despite national guidelines recommending the
use of CR, our analysis suggests that CR post-AMI is
underused among elderly Medicare beneficiaries. On average
one out of 8 candidates received CR in 1997 and recent rates
remain low. CR use varies markedly by patients’ demographic
and socio-economic characteristics and follows utilization
patterns of other preventive services.
Implications for Policy, Delivery, or Practice: Convincing
evidence supports the effectiveness of CR services in reducing
mortality and morbidity in patients with heart disease.
Reasons for this apparent underutilization of CR among post
AMI patients should be explored, including assessment of
physician opinions about CR, capacity in CR programs, and
the adequacy of Medicare reimbursement.
Primary Funding Source: CMS
●"It's Broke. Can We Fix It?": a Community Forum
Theatre Dialogue on Disparities in Acces to Health Care
John Sullivan, MA, Mathew Stanford, BA
Presented By: John Sullivan, MA, Co-Director: Public Forum
& Toxics Assistance, Preventive Medicine, Community Health,
National Institute of Environmental Health Sciences, Sealy
center for Environmental Health & Medicine, 301 University
Boulevard, Galveston, TX 77555; Tel: 409-747-1246; Fax: 409772-1790; Email: josulliv@utmb.edu
Research Objective: Purposes of the Forum included: 1)
using images and performative tools of TO to analyze social,
economic and cultural implications of health care disparities,
2) framing issue experientially to illustrate impacts of service
denial, and encourage audience empathy, 3) using interactive
facets of TO to encourage participatory dialogue and problemsolving among audience members and performers. (Dialogue
was expressed as actions by audience volunteers who entered
scene(s), replaced the oppressed protagonist or allied with
protagonist, and proposed solutions through stage actions.)
Study Design: A workshop convened for training in Theatre of
the Oppressed dramaturgy. Participants learned: 1) how
image tableaus may represent affective and conceptual
elements of the issue, 2) uses of dramatic structure to
sequence and focus personal stories, 3) development of
scenarios through improvisation, 4) uses of special structures
to deconstruct significance of scenic actions, and 5) using
audience interaction to invite dialogue, novel actions and
processing of spectator interventions. The show was
performed for community members in an informal space,
using an issue-specific sociometric exercise as a warm-up.
Audience selected one scene for the Forum process, and
spectators initiated interventions. Interventions were
processed, and closure scene was performed by original
protagonist.
Population Studied: 15 Workshop participants varied by SES /
Race / Ethnicity but all had direct experience with denial of
access to health care. Audience (64) varied across categories,
but medical students and health care professionals composed
>50%.
Principal Findings: The following perceptions, biases,
attitudes and differentiating characteristics emerged: 1) <12%
of audience had direct experience with denial of care, 2)
audience interventions express judgement that UTMB’s
Demand & Access Management Program (DAMP) for
rationing care poses a problem for medical ethics, 3) health
care access disparities compromise the social fabric of
communities, 4) strong ameliorative action is necessary to
“transform the system,” 5) none of the proposed interventions
gave the scenes satisfying closure.
Conclusions: This Theatre of the Oppressed Forum provided
a dynamic structure for dialogue and predisposed audiences
toward direct/authentic engagement with real life aspects of a
difficult and frustrating issue. Though no clear solutions
emerged, the audience demonstrated active empathy for the
uninsured, and political will to engage public policy-makers.
All participants, including primary care physicians, voiced an
urgent need for more detailed understanding of DAMP.
Audience members generally agreed that DAMP should be
simplified and infused with social justice.
Implications for Policy, Delivery, or Practice: Care
consumers and providers need basic information on
mechanics of DAMP – and similar systems – as well as the
fiscal parameters behind health care resource allocation. The
health care community also needs to engage in further
dialogue to develop ethical guidelines for navigating the health
care crisis that transcend free market pragmatism, the
designation of health care as solely a commodity, and moves
the dialogue into the realm of disparities in social justice (eg.
John Rawls’s difference principle, per audience member
suggestion).
Primary Funding Source: N/A, Institute for the Medical
Humantities @ UTMB / Health Care for All Texas (HCFAT)
●Participation in Breast Cancer Screening Through the
National Breast and Cervical Cancer Early Detection
Program, 2001-2002.
Florence Tangka, MS, Ph.D., Sajal C. Chattopadhyay, Ph.D.,
Joseph Dalaker, MMP, James G. Gardner, MSPH, Janet
Royalty, MS, Donald K. Blackman, Ph.D.
Presented By: Florence Tangka, MS, Ph.D., Economist,
Division of Cancer Prevention and Control, Centers for
Disease Control and Prevention, 4770 Buford Highway NE,
MS K-55, Atlanta, GA 30341; Tel: (770)488-1183; Fax: (770)4884639; Email: fbt9@cdc.gov
Research Objective: To estimate the number of women
eligible for NBCCEDP-funded breast cancer screening and the
percentage of them screened during 2001 and 2002.
Study Design: NBCCEDP data were used to obtain the
number of women who received NBCCEDP-funded breast
cancer screening. Data from the Annual Social and Economic
Supplement (ASEC) to the Current Population Survey (CPS)
were used to estimate the number of women eligible for
breast cancer screening through the NBCCEDP. NBCCEDP
data and CPS estimates were used to calculate the
percentages of eligible women, aged 40-64 and 50-64, at both
the national and state levels, who received an NBCCEDPfunded breast cancer screening. The rates are reported for
overlapping age groups because some states screen women
who are between the ages of 40 to 64 years, while other state
screen women who are between the ages of 50 to 64 years.
Population Studied: Women eligible(Low-income uninsured
women, aged 40-64 years old)for breast cancer screening
through the National Breast and Cervical Cancer Early
Detection Program.
Principal Findings: An estimated 7.3% (3.3 million) of all U.S.
women aged 40-64 were eligible for breast cancer screening
through the NBCCEDP. Approximately 12.6% of programeligible women aged 40-64 years and 20.9% of program-
eligible women aged 50-64 years received a breast cancer
screening via mammography through the NBCCEDP.
Screening rates varied substantially by state but not by racial
and ethnic group. For the 40-64 age group, the lowest state
level screening rate was 1.1%, and the highest screening rate
was 52.8%.
Conclusions: With current congressional appropriations and
screening mechanisms, rates of NBCCEDP-funded
mammography screening were 12.6% among program-eligible
women aged 40-64 and 20.9% among those aged 50-64.
These findings underscore the need for additional resources
and new strategies for recruitment and service delivery.
Implications for Policy, Delivery, or Practice: The estimates
reported in this article provide a valuable resource for the CDC
and its state partners for program assessment and planning
strategies to increase mammography screening among lowincome, uninsured women.
Primary Funding Source: No Funding Source
●An Evaluation of Contextual Factors in Breast and
Cervical Cancer Screening
Anne Tomolo, M.D., MPH, David Litaker, M.D., Ph.D., David
Aron, M.D., MS
Presented By: Anne Tomolo, M.D., MPH, Chief of Admitting,
Medicine, Louis Stokes Cleveland DVAMC, 10701 East
Boulevard, 170A (W), Cleveland, OH 44106; Tel: (216)2313292; Fax: (216)421-3008; Email: anne.tomolo@med.va.gov
Research Objective: Screening tests for cervical and breast
cancers are valuable in maintaining women’s health because
of their association with lower mortality through early
detection and treatment. Although having a usual source of
care and health insurance are characteristics of the individual
associated with higher screening rates, the extent to which
characteristics of the local health care system (HCS) and the
social and economic context in which women live also
influence receipt of these services has not been fully explored.
We examined the independent association between contextual
factors and breast and cervical cancer screening in women.
Study Design: The Ohio Family Health Survey, a crosssectional survey conducted in 1998 by telephone with a 53.1%
response rate assessed demographics, insurance status,
socioeconomic status, and health care needs of Ohio
residents. These data were linked at the county-level using
data from the 1998 Area Resource File and the 1990 U.S.
Census. Guided by the Behavioral Model of Health Care
Utilization, we identified operational measures for individuallevel and contextual characteristics potentially associated with
our outcome measure, the receipt of either breast or cervical
cancer screening in age-eligible women. Characteristics
reflecting the social and economic context included
urbanization, residence in an Appalachian county, and the
proportion of 1) residents living in poverty, 2) residents
completing high school, and 3) households headed by a
woman. HCS attributes included the supply of primary care
physicians (PCPs), the proportion of all physicians engaged in
primary care, the presence of a residency-training program,
designation as a medically underserved county, and the level
of managed care activity (MCA). Nested hierarchical logistic
regression models tested associations between contextual
factors and receipt of either breast or cervical cancer screening
tests, adjusting for individual-level characteristics.
Population Studied: A state-representative sample of 8473
women between the ages of 18-75 years old, living in urban,
suburban, and rural settings throughout Ohio.
Principal Findings: The weighted proportion of women
screened by either test was 60.1% (N=5094). There were
significant bivariate associations between receipt of screening
and individual characteristics: having a high school diploma,
continuous insurance, higher family income, a usual source of
care, being married/coupled, current employment, and better
rating of general health; and county characteristics: greater
supply of PCPs, presence of a physician-training program,
greater MCA, and increased urbanization (all p <0.001). After
accounting for both individual and contextual characteristics,
the following county characteristics were independent
predictors of receipt of either screening procedure: MCA
(adjusted Odds Ratio [AOR], 1.01 (1.00-1.01); p<0.01) and
poverty (AOR, 0.97 (0.95-0.99); p<0.01). Significant
associations remained with an individual’s current health
status, insurance status, education, and having a usual source
of care.
Conclusions: Characteristics of the HCS and those reflecting
economic context are associated with the likelihood a woman
will receive cancer screening services.
Implications for Policy, Delivery, or Practice: Although we
cannot infer the mechanisms through which this effect occurs,
our findings underscore the importance of context on the
health of the individual in developing more effective future
interventions that improve delivery of preventive services to
women.
Primary Funding Source: VA
●The Association of Distance to Care with Severity of
Disease, Length of Stay and Charges for Persons
Hospitalized with HIV/AIDS
Roberto Vargas, M.D. MPH, Paul Robinson, Ph.D., Susan
Ettner, Ph.D., William Cunningham, M.D., Ph.D.
Presented By: Roberto Vargas, M.D. MPH, Assistant
Professor, General Internal Medicine and Health Services
Research, UCLA School of Medicine, 911 Broxton Avenue, Los
Angeles, CA 90024; Tel: (310) 794 3703; Fax: (310) 794-0372;
Email: RBVargas@mednet.ucla.edu
Research Objective: Our study examines the association of
patient residential distance to the nearest HIV/AIDS medical
provider and nearest ancillary services site with severity of
disease, length of stay and hospital charges for patients with
HIV/AIDS admitted to acute care hospitals
Study Design: We combined data from the California Office
of Statewide Health Planning and Development 2000
discharge files, the AIDS Project Los Angeles list of HIV
services, and the 2000 Census. Our main predictors were
distances from the patient’s population-based zip code
centroid to the nearest HIV/AIDS medical provider site and
nearest ancillary care service site. Our outcomes were
dichotomized severity of disease indexes for conditions
present at the time of hospitalization: 1) Deyo Charlson 2)
Dartmouth Manitoba (DM) Charlson scores and 3) the
Severity Classification for AIDS Hospitalizations (SCAH);
length of stay and hospital charges were additional outcomes.
We used multiple logistic and linear regression to control for
differences in patient age, gender, race, and insurance status;
and levels of poverty, English language proficiency, racial and
ethnic segregation, education level and number of hospital
beds in the patient’s neighborhood of residence. Generalized
Estimating Equations were used to adjust the variance for
clustering by zip-code
Population Studied: We identified 3543 hospitalizations for
persons with HIV/AIDS in Los Angeles County in 2000.
Patients were 85% male, 56% white, 29% black, and 37%
Hispanic irrespective of race. Insurance coverage was 26%
Medicare, and 47% Medicaid and other indigent care
programs. Patients came from communities where, on
average, 35% of people had less than a high school education
and the ratio of households making less than $20,000 to
those making over $60,000 was 2:1
Principal Findings: Mean patient’s distance from care was
0.68 miles (range 0.03-13.3; s.d.0.82) from ancillary care
services and 1.81 miles (range 0.05-15.8; s.d.1.5) from medical
care services. Multiple logistic regressions suggested that a
greater distance to ancillary services was associated with a
significantly lower disease severity index among patients
admitted to acute care hospitals for both Charlson indexes,
Deyo: Odds Ratio (OR) 0.84, 95% Wald Confidence Interval
(CI) (0.73, 0.97) and DM: OR 0.86 CI (0.75,0.99) but not for
the SCAH index: OR 1.04 CI (0.93,1.16). Multiple linear
regressions suggested that greater distance from ancillary care
services was associated with a significantly greater length of
stay (estimate 0.078; p=0.002) but not with hospital charges
(estimate 0.044; p=0.120). Regression models did not show a
significant association between distance to medical care
provider and length of stay, charges or any severity indexes
Conclusions: Our results suggest that greater distance to
ancillary, but not medical, HIV services is associated with a
lower disease severity at admission and a longer length of
hospital stay during admission, implying a lower clinical
threshold for admission and a greater threshold for discharge
for patients from communities that are further away from
ancillary HIV care services
Implications for Policy, Delivery, or Practice: Improving
geographic access to ancillary services for persons with
HIV/AIDS may reduce hospitalizations and length of stay for
these patients
Primary Funding Source: National Center on Minority Health
and Health Disparities
●Surgical Release of Work-Related Carpal Tunnel
Syndrome: Geographical Variation in Utilization and
Associated Post-Surgical Outcomes
Radoslaw Wasiak, Ph.D., Glenn Pransky, M.D., MOccH
Presented By: Radoslaw Wasiak, Ph.D., Research Scientist,
Center for Disability Research, Liberty Mutual Research
Institute for Safety, 71 Frankland Road, Hopkinton, MA 01748;
Tel: (508)497-0242; Fax: (508)435-8136; Email:
radoslaw.wasiak@libertymutual.com
Research Objective: Medical treatment of compensated
work-related conditions has two objectives—improve injured
workers’ health status and allow safe and sustained return to
work (RTW). Theoretically, the choice of treatment method
should be based primarily on these objectives. Surgical
treatment of work-related carpal tunnel syndrome (CTS)
provides an opportunity to evaluate whether this occurs. The
traditional method of open release has been complemented
by an endoscopic procedure, particularly useful in work-related
cases due to the anticipated benefit of earlier RTW. The
objective of this study was to investigate the differences in
surgical treatment for work-related CTS across eight U.S.
states, and the associated post-surgical work disability
outcomes.
Study Design: From all workers’ compensation claims (WC)
reported to a single insurer during the 1995-1999 period, we
identified individuals with a one or two surgical procedures for
work-related CTS. Work disability duration was divided into
pre- and post-surgical duration according to the date of
surgery. Work disability duration included compensated lost
work days and compensated days at work in partial capacity.
Population Studied: Individuals with surgical release of
compensated work-related carpal tunnel syndrome.
Principal Findings: Among selected individuals (n=4,421),
about 20% were treated using the endoscopic procedure; this
percentage had a ten-fold variation across the eight
jurisdictions. However, utilization of endoscopic release did
not increase during the study period, despite reports of better
RTW outcomes. We found no statistically significant
differences in total work disability between alternative surgical
procedures; however, in all jurisdictions, those with
endoscopic releases had less lost work days (p < .01) and
more days at work in partial capacity (p < .01).
Conclusions: The highly jurisdictional nature of the U.S. WC
system, with significant differences in reimbursement levels
for endoscopic procedures, and geographical differences in
medical training were among the potential contributors to the
observed variation in utilization. The benefits of the
endoscopic technique show in redistribution of work disability
from total work loss to light duty arrangements.
Implications for Policy, Delivery, or Practice: Earlier RTW,
even in partial capacity, has been shown to increase patients’
likelihood for sustained long-term RTW. Given the potential
to increase the rate of early RTW in patients with a surgical
release of carpal tunnel, substantial short- and long-term gains
can be achieved by increasing the rate of endoscopic releases.
Primary Funding Source: No Funding Source