Medical home disparities for children by insurance type and state of residence

Health Insurance Coverage, Clinical Outcomes, and Health-Related Quality of Life Among Youth Born to Women Living With HIV

BACKGROUND

Although sustained access to health care is essential, little is known about the relationship between insurance coverage and health among people born to women living with HIV (WLHIV).

SETTING

Prospective cohort studies of youth and young adults born to WLHIV from 2007 to 2019.

METHODS

We used adjusted generalized estimating equation models to estimate mean differences in, and relative risks (RRs) of, health-related quality of life (HR-QoL) and HIV disease measures over time by insurance status. HR-QoL scales with limited variability were dichotomized. Modified Poisson models were used to estimate RRs.

RESULTS

Six hundred sixty-nine Adolescent Master Protocol (AMP) youth [66% living with perinatally-acquired HIV (PHIV), 72% Black] and 939 AMP Up/AMP Up Lite young adults (89% PHIV, 68% Black) reported insurance. Most were publicly insured (87% youth, 67% young adults). Privately insured young adults living with PHIV had lower risk of antiretroviral therapy nonadherence [adjusted RR (aRR): 0.82, 95% CI: 0.70 to 0.97] than those with public insurance. There was a lower risk of suboptimal role functioning for young adults with private insurance (aRR: 0.58, 95% CI: 0.35 to 0.97) and those unaware of their coverage (aRR: 0.41, 95% CI: 0.21 to 0.78). Young adults with private insurance had higher health perception scores than those with public insurance (adjusted mean difference: 3.87, 95% CI: 0.37 to 7.38). For youth, we observed no differences in HR-QOL and HIV disease measures by insurance.

CONCLUSION

These findings suggest meaningful differences in antiretroviral therapy adherence and some HR-QoL outcomes by health insurance coverage among young adults born to WLHIV.

Most Children With Medical Complexity Do Not Receive Care in Well-Functioning Health Care Systems

OBJECTIVES

To describe the access of children with medical complexity (CMC) to well-functioning health care systems. To examine the relationships between medical complexity status and this outcome and its component indicators.

PATIENTS AND METHODS

Secondary analysis of children in the National Survey of Children's Health combined 2016-2017 data set who received care in well-functioning health systems. Secondary outcomes included this measure's component indicators. The χ2 analyses were used to examine associations between child and family characteristics and the primary outcome. Adjusted multivariable logistic regression was used to examine relationships between medical complexity status and primary and secondary outcomes. Using these regression models, we examined the interaction between medical complexity status and household income.

RESULTS

CMC accounted for 1.6% of the weighted sample (n = 1.2 million children). Few CMC (7.6%) received care in a well-functioning health care system. CMC were significantly less likely than children with special health care needs (CSHCN) (odds ratio, 0.3) of meeting criteria for this primary outcome. Attainment rates for secondary outcomes (families feeling like partners in care; receives care within a medical home; received needed health care) were significantly lower among CMC than CSHCN. Family income was significantly associated with likelihood of meeting criteria for primary and secondary outcomes; however, the relationships between medical complexity status and our outcomes did not differ by income level.

CONCLUSIONS

CMC are less likely than other CSHCN to report receiving care in well-functioning health care systems at all income levels. Further efforts are necessary to better adapt current health care systems to meet the unique needs of CMC.

Specialized primary care medical home: A positive impact on continuity of care among autistic adults

LAY ABSTRACT

There is a nationally recognized need for innovative healthcare delivery models to improve care continuity for autistic adults as they age out of pediatric and into adult healthcare systems. One possible model of care delivery is called the "medical home". The medical home is not a residential home, but a system where a patient's healthcare is coordinated through a primary care physician to ensure necessary care is received when and where the patient needs it. We compared the continuity of care among autistic adult patients at a specialized primary care medical home designed to remove barriers to care for autistic adults, called the CAST, to matched national samples of autistic adults with private insurance or Medicare. Continuity of primary care among CAST patients was significantly better than that of matched national samples of autistic adult Medicare beneficiaries and similar to that of privately insured autistic adults. Our findings suggest that medical homes, like CAST, are a promising solution to improve healthcare delivery for the growing population of autistic adults.

Impact of Social Capital on the Availability of Health Care Services

Children with special health care needs (CSHCN) and their families experience many structural, financial, psychosocial, and physical obstacles to accessing and fully utilizing a continuum of health care services, including a myriad of contextual barriers that are unique to their local communities. Social capital is one contextual barrier hypothesized in the literature to reduce access to health care services. To better understand the role of social capital in accessing health care services for this vulnerable population, a study was constructed using data from a large representative sample of CSHCNs. The analysis was conducted on data collected through the National Survey of Children's Health, a cross-sectional study of child health that includes information on physical and mental health; access to health care; and neighborhood, school, and social context. Logistic regression analyses were performed on a reduced, complete data set containing only CSHCN (n = 32,496) using 5 medical home variables and an investigator-constructed social capital composite score. Social capital was not found to be a complete mediator of individual medical home characteristics; however, each increase in the social capital scale reduced the odds of experiencing a delay in care of overall health care services by 12.5% (P = .006). The effects of social capital on the accessibility of health care services is significant and focusing on strengthening social capital within communities will improve overall health outcomes for this vulnerable group of children.

Trends in 30-Day Readmission for Medicaid and Privately Insured Pediatric Patients: 2010-2017

BACKGROUND

Children insured by Medicaid have higher readmission rates than privately insured children. However, little is known about whether this disparity has changed over time.

METHODS

Data from the 2010 to 2017 Healthcare Cost and Utilization Project Nationwide Readmissions Database were used to compare trends in 30-day readmission rates for children insured by Medicaid and private insurers. Patient-level crude and risk-adjusted readmission rates were compared by using Poisson regression. Hospital-level risk-adjusted readmission rates were compared between Medicaid- and privately insured patients within a hospital by using linear regression.

RESULTS

Approximately 60% of pediatric admissions were covered by Medicaid. From 2010 to 2017, the percentage of children with a complex or chronic condition increased for both Medicaid- and privately insured patients. Readmission rates were consistently higher for Medicaid beneficiaries from 2010 to 2017. Readmission rates declined slightly for both Medicaid- and privately insured patients; however, they declined faster for privately insured patients (rate ratio: 0.988 [95% confidence interval: 0.986-0.989] vs 0.995 [95% confidence interval: 0.994-0.996], P for interaction <.001]). After adjustment, readmission rates for Medicaid- and privately insured patients declined at a similar rate (P for interaction = .87). Risk-adjusted hospital readmission rates were also consistently higher for Medicaid beneficiaries. The within-hospital difference in readmission rates for Medicaid versus privately insured patients remained stable over time (slope for difference: 0.015 [SE 0.011], P = .019).

CONCLUSIONS

Readmission rates for Medicaid- and privately insured pediatric patients declined slightly from 2010 to 2017 but remained substantially higher among Medicaid beneficiaries suggesting a persistence of the disparity by insurance status.

Patient-Centered Medical Home Care for Adolescents in Need of Mental Health Treatment

PURPOSE

The patient-centered medical home (PCMH) has emerged as an optimal primary care model for all youth; however, little is known about the extent to which adolescents in need of mental health (MH) treatment receive care consistent with the PCMH. This study assessed (1) 10-year trends in PCMH care among U.S. adolescents according to MH need and (2) variations in PCMH care and its subcomponents among adolescents with MH need, by individual and family characteristics.

METHODS

This was a secondary analysis of Medical Expenditure Panel Survey data (2004-2013). The sample included adolescents aged 12-17 years with ≥1 office-based visits in the past year (N = 18,717). Questions assessing a usual source of care and care that is accessible, comprehensive, family-centered, and compassionate were used to define PCMH care. For adolescents with MH needs, multivariable logistic regression was used to describe the association between PCMH care and sample characteristics.

RESULTS

Fifty percent of adolescents experienced PCMH care, with little change between 2004 and 2013. Adolescents with MH need (N = 3,794) had significantly lower odds of experiencing PCMH care compared with those without MH need (odds ratio, .78; 95% confidence interval, .69-.87). Among adolescents with MH needs, being uninsured and living with a parent who did not graduate high school were negatively associated with PCMH care, whereas parental usual source of care was positively associated (odds ratio, 1.69; 95% confidence interval, 1.28-2.22).

CONCLUSIONS

Increasing care accessibility, integrating MH services into primary care settings, and targeting socioeconomically disadvantaged subgroups could improve rates of PCMH care among adolescents with MH needs.

Patient-Centered Medical Home Measurement in School-Based Health Centers

School-based health centers (SBHCs) have been suggested as potential medical homes, yet minimal attention has been paid to measuring their patient-centered medical home (PCMH) implementation. The purposes of this article were to (1) develop an index to measure PCMH attributes in SBHCs, (2) use the SBHC PCMH Index to compare PCMH capacity between PCMH certified and non-PCMH SBHCs, and (3) examine differences in index scores between SBHCs based in schools with and without adolescents. A total of six PCMH dimensions in the SBHC PCMH Index were identified through factor analysis. These dimensions were collapsed into two domains: care quality and comprehensive care. SBHCs recognized as PCMHs had higher scores on the index, both domains, and four dimensions. SBHCs based in schools with just young children and those with adolescents scored similarly on the overall index, but analysis of individual index items shows their strengths and weaknesses in PCMH implementation.

Medicaid Managed Care Structures and Care Coordination

BACKGROUND

Child enrollment in Medicaid managed care (MMC) has expanded dramatically, primarily through state mandates. Care coordination is a key metric in MMC evaluation because it drives much of the proposed cost savings and may be associated with improved health outcomes and utilization. We evaluated the relationships between enrollment in 2 MMC structures, primary care case management (PCCM) and health maintenance organization (HMO) and access to and receipt of care coordination by children.

METHODS

Using data from the 2011/2012 National Survey of Children's Health and the Medicaid Statistical Information System state data mart, we conducted a retrospective, cross-sectional analysis of the relationships between fee-for-service, PCCM or HMO enrollment, and access to and receipt of care coordination. State-level univariate analyses and individual and state multilevel multivariable analyses evaluated correlations between MMC enrollment and care coordination, controlling for demographic characteristics and state financing levels.

RESULTS

In univariate and multilevel multivariable analyses, the PCCM penetration rate was significantly associated with increased access to care coordination (adjusted odds ratio: 1.23, P = .034) and receipt of care coordination (adjusted odds ratio: 1.37, P = .02). The HMO penetration rate was significantly associated with lower access to care coordination (adjusted odds ratio: 0.85, P = .05) and receipt of care coordination (adjusted odds ratio: 0.71, P < .001). Fee-for-service served as the referent.

CONCLUSIONS

State utilization of MMC varied widely. These data suggest that care coordination may be more effective in PCCM than HMO structures. States should consider care coordination outcomes when structuring their Medicaid programs.

Characteristics Associated with Patient-Centered Medical Home Capability in Health Centers: A Cross-Sectional Analysis

BACKGROUND

The patient-centered medical home (PCMH) model is being implemented in health centers (HCs) that provide comprehensive primary care to vulnerable populations.

OBJECTIVE

To identify characteristics associated with HCs' PCMH capability.

DESIGN

Cross-sectional analysis of a national dataset of Federally Qualified Health Centers (FQHCs) in 2009. Data for PCMH capability, HC, patient, neighborhood, and regional characteristics were combined from multiple sources.

PARTICIPANTS

A total of 706 (70 %) of 1014 FQHCs from the Health Resources and Services Administration Community Health Center Program, representing all 50 states and the District of Columbia.

MAIN MEASURES

PCMH capability was scored via the Commonwealth Fund National Survey of FQHCs through the Safety Net Medical Home Scale (0 [worst] to 100 [best]). HC, patient, neighborhood, and regional characteristics (all analyzed at the HC level) were measured from the Commonwealth survey, Uniform Data System, American Community Survey, American Medical Association physician data, and National Academy for State Health Policy data.

KEY RESULTS

Independent correlates of high PCMH capability included having an electronic health record (EHR) (11.7-point [95 % confidence interval, CI 10.2-13.3]), more types of financial performance incentives (0.7-point [95 % CI 0.2-1.1] higher total score per one additional type, maximum possible = 10), more types of hospital-HC affiliations (1.6-point [95 % CI 1.1-2.1] higher total score per one additional type, maximum possible = 6), and location in certain US census divisions. Among HCs with an EHR, location in a state with state-supported PCMH initiatives and PCMH payments was associated with high PCMH capability (2.8-point, 95 % CI 0.2-5.5). Other characteristics had small effect size based on the measure unit (e.g. 0.04-point [95 % CI 0-0.08] lower total score per one percentage point more minority patients), but the effects could be practically large at the extremes.

CONCLUSIONS

EHR adoption likely played a role in HCs' improvement in PCMH capability. Factors that appear to hold promise for supporting PCMH capability include a greater number of types of financial performance incentives, more types of hospital-HC affiliations, and state-level support and payment for PCMH activities.

Barriers to Care Coordination and Medical Home Implementation

BACKGROUND

Pediatricians are central in leading the family-centered medical home (FCMH), yet little is known about how provider-perceived barriers to and attitudes toward the FCMH affect implementation. This study aims to assess the relationship between pediatrician-perceived barriers to and attitudes toward FCMH and reported care coordination.

METHODS

Pediatricians working in ambulatory care responded to the American Academy of Pediatrics Periodic Survey of Fellows #79 (N = 572, response rate, 59%). Our primary care coordination outcomes were whether pediatricians were: (1) leading a multidisciplinary team; (2) developing care plans; and (3) connecting with support services. Independent variables included barriers to FCMH implementation (lack of communication skills, support services, and time). Associations between outcomes and barriers were assessed by multivariate logistic regression, controlling for pediatrician and practice characteristics.

RESULTS

Lack of sufficient personnel was significantly associated with fewer care coordination activities: leading a multidisciplinary team (odds ratio [OR], 0.53), developing care plans (OR, 0.51), and connecting with support services (OR, 0.42). Lacking communication skills was significantly associated with lower odds of development of care plans (OR, 0.56) and assistance with support services (OR, 0.64). Lack of time was significantly associated with lower odds of leading a multidisciplinary team (OR, 0.53). A pediatrician's belief that the FCMH encourages the use of preventive services was significantly associated with increased support services (OR, 2.06).

CONCLUSIONS

Pediatricians report a need for sufficient personnel and communication skills to provide care coordination, a core component of the FCMH. Interventions to boost FCMH implementation should focus on providing resources to develop these characteristics.

Practice-tailored facilitation to improve pediatric preventive care delivery: a randomized trial

OBJECTIVE

Evolving primary care models require methods to help practices achieve quality standards. This study assessed the effectiveness of a Practice-Tailored Facilitation Intervention for improving delivery of 3 pediatric preventive services.

METHODS

In this cluster-randomized trial, a practice facilitator implemented practice-tailored rapid-cycle feedback/change strategies for improving obesity screening/counseling, lead screening, and dental fluoride varnish application. Thirty practices were randomized to Early or Late Intervention, and outcomes assessed for 16 419 well-child visits. A multidisciplinary team characterized facilitation processes by using comparative case study methods.

RESULTS

Baseline performance was as follows: for Obesity: 3.5% successful performance in Early and 6.3% in Late practices, P = .74; Lead: 62.2% and 77.8% success, respectively, P = .11; and Fluoride: <0.1% success for all practices. Four months after randomization, performance rose in Early practices, to 82.8% for Obesity, 86.3% for Lead, and 89.1% for Fluoride, all P < .001 for improvement compared with Late practices' control time. During the full 6-month intervention, care improved versus baseline in all practices, for Obesity for Early practices to 86.5%, and for Late practices 88.9%; for Lead for Early practices to 87.5% and Late practices 94.5%; and for Fluoride, for Early practices to 78.9% and Late practices 81.9%, all P < .001 compared with baseline. Improvements were sustained 2 months after intervention. Successful facilitation involved multidisciplinary support, rapid-cycle problem solving feedback, and ongoing relationship-building, allowing individualizing facilitation approach and intensity based on 3 levels of practice need.

CONCLUSIONS

Practice-tailored Facilitation Intervention can lead to substantial, simultaneous, and sustained improvements in 3 domains, and holds promise as a broad-based method to advance pediatric preventive care.

Community health centers: medical homes for children?

OBJECTIVE

To explore medical home attributes of community health centers (CHCs) that provide care to low-income children nationwide compared to other providers for the poor.

METHODS

Cross-sectional study of children aged 0 to 17 years in the Medical Expenditure Panel Survey (MEPS; 2003 to 2009) who resided in families living at <200% of the federal poverty level (FPL) and had visits to a primary care setting. CHC visits were defined as a visit to a neighborhood/family health center, rural health clinic, or community health center. Independent measures included provider type, age, gender, race/ethnicity, insurance, FPL, number of parents at home, language, maternal education, health status, and special health care need. Dependent measures included 4 medical home attributes: accessibility, and family-centered, comprehensive, and compassionate care.

RESULTS

CHCs typically serve low-income children who are publicly insured or uninsured, come from racial/ethnic minority groups, and have poorer health status. Eighty percent to 90% of parents visiting both CHCs and other primary care providers rated high levels of family-centered, comprehensive, and compassionate care. However, CHCs had a 10% to 18% lower rating of accessibility (after-hours care, telephone access) even after controlling for sociodemographic characteristics. Racial/ethnic disparities existed at both settings, but these patterns did not differ between CHCs and other settings.

CONCLUSIONS

On the basis of parental reports, CHCs received similar ratings to other primary care providers for family-centered, comprehensive, and compassionate care, but lower ratings for accessibility. Further studies should examine strategies for practice transformation in CHCs to improve patient satisfaction and accessibility to optimize child health outcomes.

Medical home disparities are not created equal: differences in the medical home for children from different vulnerable groups

OBJECTIVE

To identify components of the medical home that contribute to medical home disparities for vulnerable children.

METHODS

Cross-sectional analysis of 2007 National Survey of Children's Health. Prevalence of components of the medical home were estimated by special health care needs (SHCN), race/ethnicity, primary language, and health insurance.

RESULTS

Medical home disparities for children with SHCN were driven by differences in getting help with care coordination, when needed (71% vs. 91% children without SHCN, p<.001). Medical home disparities for other groups were largely attributable to less family-centered care (Hispanic 49% and African American 55% vs. White 77%, p<.001; non-English primary language 37% vs. English 72%, p<.001; uninsured 45% and publicly insured 57% vs. privately insured 75%, p<.001).

CONCLUSIONS

The components of the medical home that contribute to medical home disparities differ between groups of vulnerable children. Medical home implementation may benefit from focusing on the specific needs of target populations.

Disparities in unmet need for care coordination: the national survey of children's health

OBJECTIVE

To determine (1) the proportion of parents who report a need for and receipt of effective care coordination for their child, (2) whether unmet care coordination needs differ by children with special health care needs (CSHCN) status and sociodemographic characteristics, and (3) whether having a personal provider or family-centered care mitigates disparities.

METHODS

This study was a cross-sectional analysis of the 2007 National Survey for Children's Health, a nationally representative survey of 91 642 parents. Outcome measures were parent report of need for and lack of effective care coordination. We also examined the effect of parent report of having a personal provider and family-centered care. We conducted weighted bivariate and multivariate analyses.

RESULTS

Forty-one percent of parents reported that their child needed care coordination. Among those who needed care coordination, 31% did not receive effective coordination. CSHCN (41%) were more likely than children without special health care needs (26%; P < .001) to have unmet care coordination needs. Latino (40%) and black (37%) children were more likely to have unmet needs than white (27%; P < .001) children. These patterns remained in multivariate analysis. Having a personal provider decreased the odds of having unmet need for care coordination but did not attenuate disparities. Receiving family-centered care mitigated disparities associated with race/ethnicity but not with health status or health insurance.

CONCLUSIONS

A considerable proportion of parents reported their child needed more care coordination than they received. This was especially true for parents of CSHCN and parents of black and Latino children. Interventions that enhance family-centered care might particularly contribute to reducing racial/ethnic disparities.

Association of care in a medical home and health care utilization among children with sickle cell disease

OBJECTIVE

Sickle cell disease (SCD) is marked by high utilization of medical services. The aim of this study was to determine whether having a patient-centered medical home (PCMH) is associated with a reduction in emergency care (ED) utilization or hospitalizations among children with SCD.

METHODS

We collected and analyzed data from parents of 150 children, ages 1 to 17 years, who received care within a large children's hospital. The primary dependent variables were rates of parent-reported ED visits and hospitalizations. The principal independent variable was parent-reported experience with an overall PCMH or its four individual components (regular provider, comprehensive care, family-centered care, and coordinated care). Multivariate negative binomial regression, yielding incident rate ratios (IRR), was used for analysis.

RESULTS

Children who received comprehensive care had half the rate of ED visits (IRR 0.51, 95% confidence interval, 0.33-0.78) and nearly half the rate of hospitalizations (IRR 0.56, 95% confidence interval, 0.33-0.93) compared to children without comprehensive care. No other component of the PCMH was significantly associated with ED visits or hospitalizations. Children reported to have excellent/very good/good health status had lower odds of ED visits and hospitalizations compared to those reported to be in fair/poor condition.

CONCLUSIONS

Children with SCD reported to experience comprehensive care had lower rates of ED encounters and hospitalizations after controlling for demographics and health status. The overall findings highlight that the provision of comprehensive care--having a usual source of care and no problems with referrals--may provide a strategy for improving pediatric SCD care.