Understanding
g the
Impact
p
of Insurance
Reform
Methodological Challenges and Solutions
Karen Freund MD MPH
B t University
Boston
U i
it S
School
h l off M
Medicine
di i
Boston Medical Center
What is our research
Question?
o Our ultimate question:
o “Do
“D iimprovements
t iin iinsurance coverage
improve care outcomes?”
o Hypothesis
H
th i
o Insurance reform reduces gaps in
insurance
o Reduced gaps in care results in care
when
h needed
d d
o Needed medical care utilization improves
h l h outcomes
health
Id l D
Ideal
Data
t S
Sett tto address
dd




Longitudinal cohort
Information on all insurance changes
changes,
coverage gaps
Health Care Utilization Data
Health Outcomes Data
Only exists in European countries with single
payer systems,
t
without
ith t changes/
h
/ gaps in
i
insurance…
S
Sources
off Data
D t

Consumers Surveys

I di id l IInsurance Pl
Individual
Plan D
Data
t

Utilization Databases

Clinical Data from practice/healthcare
system
What is y
your comparison
p
group?
• Cohort: Longitudinal changes
• Cross
C
S
Sectional:
ti
l P
Pre// postt reform
f
• Cross Sectional: Massachusetts vs. Other
states
• Methods to address confounding
g by
y
temporal trends
• Cross Sectional Difference in Differences
• Time Series Analysis
Consumers Surveys
Advantages



Can capture coverage
across insurance types
Women get care across
systems of care
((OB/Gyn,
y familyy
planning, primary care,
mental health)
h l h status, patient
health
i
reported outcomes
Disadvantages
 Limited utilization
 Limited ability to
assess quality of
care or outcomes
E
Examples
l off S
Survey D
Data
t


Massachusetts Health Reform Survey
MEPS - nationally representative
 longitudinal – each individual is surveyed
5 times over a 2 ½ year period
 health status,
 insurance status for every calendar
month,
 administrative data ((diagnoses
g
and
charges)
I
Insurance
Databases
D t b
Extensive utilization
 Exact eligibility data
 Don’t know what happens
pp
when
patient not enrolled


Few systems to link individual patients
across multiple insurance systems
Cross Sectional Utilization
Data
Advantages
 Standardized
Collection
 Comparisons
C
i
over
Time and between
l
locations
ti
Disadvantages
 No individual
insurance data
 No
N iindividual
di id l h
health
lth
status information
Example
p using
g Massachusetts
Discharge Data
Major gender/ race/ ethnicity
di
disparities
iti iin ““referralf
l sensitive
iti
procedures”
 These require source of primary care
 With health insurance reform , would
women, and minority women receive
a greater increase in procedures?

Hanchate A, Mass Health Reform: Poster , Sunday 6/27/2010 2:30 - 4:00 pm
Proceedure Rate / 10,0000 populaation
Baseline Musculoskeletal Procedure Rates by
G d and
Gender
db
by R
Race/Ethnicity
/Eth i it
# procedures/10,000: 2004-2006
100.0
90.00
90
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10 0
10.0
0.0
Female
Male
White
Black
Hispanic
Hanchate, 2010
% Change in Procedu
ure Rate / 10,000
Populattion
% Change
g ((Annual)) in Musculoskeletal
Procedure Rate: Pre- and Post-Reform
Comparison
18.0
16.0
14.0
12.0
10 0
10.0
8.0
6.0
4.0
2.0
00
0.0
Female
Male
Whites
Pre Reform
Blacks
Hispanic
Post Reform
Hanchate, 2010
D t from
Data
f
Clinical
Cli i l C
Care Sit
Site
Advantages
Disadvantages
 Extensive
E t
i d
data
t on
 Cannot
C
t see care
clinical variables,
outside of that
system
clinical
li i l status
t t
t
 May see patient
 Can see “switches” in
across multiple
insurance, but not
changes in insurance
“gaps” in coverage
Example
p of use of Clinical
Care Data






Boston Patient Navigation Research
Program
6 Community Health Centers
All women with abnormal breast and cervical
cancer screening
Extensive Clinical Data
Large proportion with Medicaid/ uninsured/
Commonwealth care
Insurance at each visit
H
Hypotheses
th
Uninsured with poorer outcomes
 Fewer uninsured in post period
 Those with p
private and p
public
insurance will have the greatest % of
timely resolution than those uninsured
 Commonwealth Care will have %
timely resolution similar to public and
private and greater than uninsured

Breast
east Patients
at e ts characteristics
c a acte st cs
pre and post reform
Pre Reform
% (N=208)
Age
18 – 40
6
41 – 64
81
65+
13
Race/Ethnicity White
23
Black
50
Hispanic
17
Other
9
Insurance
Public
38
Private
31
Uninsured
30
C
Commonwealth
lth C
Care
0
Post Reform
% (N=718)
9
77
13
29
37
33
1
31
32
27
9
Timely resolution after abnormal
b
breast
t cancer screening,
i
post insurance
su a ce reform
eo
80
**
**
60
%
Resolution
In 60 days
40
20
0
Private
Insurance
Public Insurance Commonwealth
Care
Uninsured
What about Gaps
p / Switches /
Churning?

R i
Review
d
data
t llooking
ki att switches
it h

Are switches related to outcome of
timely resolution?
Case: time to resolution 7+ months
D t
Date
I
Insurance
/Clinical
/Cli i l Event
E
t
6/2007
Medicaid
7/2007
Abnormal Pap Smear
8/2007
Medicaid
9/2007
Commonwealth Care
3/2008
Biopsy – Non-neoplastic finding
3/2008
Commonwealth Care
7/2008
Medicaid
Case: time to resolution 43 days
Date
Insurance / Clinical Event
11/2007
Medicaid
4/2008
Private
4/2008
Abnormal Pap Smear
5/2008
Pi t
Private
6/2008
p
py – Non-neoplastic
p
Colposcopy
6/2008
Private
8/2008
Medicaid
Summary
No one data base will likely allow us
t understand
to
d t d impact
i
t off health
h lth
insurance reform
 Need for multiple sources to assess
outcomes data
