The effects of health insurance and a usual source of care on a child's receipt of health care

Access to Specialty Care for Commercially Insured Youths With Type 1 and Type 2 Diabetes

Importance

Youths with type 2 diabetes are at higher risk for complications compared with peers with type 1 diabetes, though few studies have evaluated differences in access to specialty care.

Objective

To compare claims with diabetes specialists for youths with type 1 vs type 2 diabetes and the association between specialist claims with multidisciplinary and acute care utilization.

Design, Setting, and Participants

This cross-sectional study used Optum Clinformatics Data Mart commercial claims. Individuals included in the study were youths younger than 19 years with type 1 or 2 diabetes as determined by a validated algorithm and prescription claims. Data were collected for youths with at least 80% enrollment in a commercial health plan from December 1, 2018, to December 31, 2019. Statistical analysis was performed from September 2022 to January 2024.

Main Outcomes and Measures

The primary outcome was the number of ambulatory claims from an endocrine and/or diabetes physician or advanced practice clinician associated with a diabetes diagnosis code; secondary outcomes included multidisciplinary and acute care claims.

Results

Claims were analyzed for 4772 youths (mean [SD] age, 13.6 [3.7] years; 4300 [90.1%] type 1 diabetes; 472 [9.9%] type 2 diabetes; 2465 [51.7%] male; 128 [2.7%] Asian, 303 [6.4] Black or African American, 429 [9.0%] Hispanic or Latino, 3366 [70.5%] non-Hispanic White, and 546 [11.4%] unknown race and ethnicity). Specialist claims were lower in type 2 compared with type 1 diabetes (incidence rate ratio [IRR], 0.61 [95% CI, 0.52-0.72]; P < .001) in propensity score-weighted analyses. The presence of a comorbidity was associated with increased specialist claims for type 1 diabetes (IRR, 1.07 [95% CI, 1.03-1.10]) and decreased claims for type 2 diabetes (IRR, 0.77 [95% CI, 0.67-0.87]). Pooling diagnosis groups and adjusted for covariates, each additional specialist claim was associated with increased odds of a claim with a diabetes care and education specialist (odds ratio [OR], 1.31 [95% CI, 1.25-1.36]), dietitian (OR, 1.14 [95% CI, 1.09-1.19]), and behavioral health clinician (OR, 1.16 [95% CI, 1.12-1.20]). For acute care claims, each additional specialist claim was associated with increased odds of admission (OR, 1.17 [95% CI, 1.11-1.24]) but not for emergency claims (OR, 1.03 [95% CI, 0.98-1.82]).

Conclusions and Relevance

This cross-sectional study found that youths with type 2 diabetes were significantly less likely to have specialist claims despite insurance coverage, indicating other barriers to care, which may include medical complexity. Access to diabetes specialists influences engagement with multidisciplinary services. The association between increasing ambulatory clinician services and admissions suggests high utilization by a subgroup of patients at greater risk for poor outcomes.

Juvenile Justice-Involved Youth: Preventive Health Services Received Prior to Detention

Few studies on youth in the juvenile justice system describe preventive services received at community health visits. We determined preventive services received at their most recent visit to a health care provider through a cross-sectional survey of youth at a detention center. Data on their health outcomes were abstracted from medical records. Many did not receive comprehensive screenings for sexual health, mental health symptoms, or substance use at well-child visits in the past year. Health outcomes were not significantly different from those who did not attend a well visit in the past year. Limited preventive screenings could explain why well checks did not influence health outcomes; therefore, providers should incorporate recommended screenings into sick visits as well as preventive visits.

Creation of a linked cohort of children and their parents in a large, national electronic health record dataset

To examine which parental health care and health factors are most strongly associated with a child's receipt of recommended care we must be able to link children to their parents in electronic health record data. Yet, there is not an easy way to link these data.To identify a national cohort of children that link to at least one parent in the same electronic health record dataset and describe their demographics.Methodology to link parents and children in electronic health records and descriptive sociodemographic data.Children with at least one encounter with a primary care clinician between Januray 1, 2007 and December 12, 2018 to a community health center in the OCHIN national network. We identified parents of these children who also had at least one encounter to a community health center in the network using emergency contact and guarantor record fields.A total of 227,552 children had parents with a linkable patient record. After exclusions, our final cohort included 213,513 distinct children with either one or two parent-links. 82% of children linked to a mother only, 14% linked to a father only, and 4% linked to both a mother and a father. Most families consisted of only one linked child (61%).We were able to link 33% of children to a parent in electronic health record data from a large network of community health centers across the United States. Further analyses utilizing these linkages will allow examination of the multi-level factors that impact a child's receipt of recommended health care.

Effect of Having a Usual Source of Care on Medical Expenses - Using the Korea Health Panel Data

BACKGROUND

There is a controversy about the effect of having a usual source of care on medical expenses. Although many studies have shown lower medical expenses in a group with a usual source of care, some have shown higher medical expenses in such a group. This study aimed to empirically demonstrate the effect of having a usual source of care on medical expenses.

METHODS

The participants included those aged 20 years and older who responded to the questionnaire about "having a usual source of care" from the Korean Health Panel Data of 2012, 2013, and 2016 (6,120; 6,593; and 7,598 respectively). Those who responded with "I do not get sick easily" or "I rarely visit medical institutions" as the reasons for not having a usual source of care were excluded. The panel regression with random effects model was performed to analyze the effect of having a usual source of care on medical expenses.

RESULTS

The group having a usual source of care spent 20% less on inpatient expenses and 25% less on clinic expenses than the group without a usual source of care. Particularly, the group having a clinic-level usual source of care spent 12% less on total medical expenses, 9% less on outpatient expenses, 35% less on inpatient expenses, and 74% less on hospital expenses, but 29% more on clinic expenses than the group without a usual source of care.

CONCLUSION

This study confirmed that medical expenses decreased in the group with a usual source of care, especially a clinic-level usual source of care (USC), than in the group without a usual source of care. Encouraging people to have a clinic-level USC can control excessive medical expenses and induce desirable medical care utilization.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.

Acculturation is associated with asthma burden and pulmonary function in Latino youth: The GALA II study

BACKGROUND

Acculturation is an important predictor of asthma in Latino youth, specifically Mexican Americans. Less is known about acculturation and pulmonary function measures.

OBJECTIVE

We sought to estimate the association of acculturation measures with asthma and pulmonary function in Latino youth and determine whether this association varies across Latino subgroups.

METHODS

We included 1849 Latinos (302 Caribbean Spanish, 193 Central or South Americans, 1136 Mexican Americans, and 218 other Latino children) aged 8 to 21 years from 4 urban regions in the United States. Acculturation measures include nativity status, age of immigration, language of preference, and generation in the United States. We used multivariable logistic and linear regression models to quantify the association of acculturation factors with the presence of asthma (case-control study) and pulmonary function (case-only study), adjusting for demographic, socioenvironmental, and clinical variables.

RESULTS

For all acculturation measures (nativity status, age of immigration, language of preference, and generation in the United States), greater levels of acculturation were associated with greater odds of asthma. Among cases, high (English preference) and medium (equal preference for Spanish and English) levels of language acculturation were associated with decreased bronchodilator response compared with low (Spanish preference) levels (P = .009 and .02, respectively). Similarly, high language acculturation was associated with increased FEV₁ compared with low language acculturation (P = .02). There was insufficient evidence of heterogeneity for associations across Latino subgroups.

CONCLUSIONS

Acculturation was associated with diagnosed asthma and pulmonary function in Latino children and is an important factor to consider in the management of Latino youth with asthma.

The Patient-Centered Medical Home: How Is It Related to Quality and Equity Among the General Adult Population?

This study investigates whether patient-reported characteristics of the medical home are associated with improved quality and equity of preventive care, advice on health habits, and emergency department use. We used adjusted risk ratios to examine the association between medical home characteristics and care measures based on the 2010 Medical Expenditure Panel Survey. Medical home characteristics are associated with 6 of the 11 outcome measures, including flu shots, smoking advice, exercise advice, nutrition advice, all advice, and emergency department visits. Educational and income groups benefit relatively equally from medical home characteristics. However, compared with insurance and access to a provider, medical home characteristics have little influence on overall disparities in care. In sum, our findings support that medical home characteristics can improve quality and reduce emergency visits but we find no evidence that medical home characteristics alleviate disparities in care.

Using the electronic health record for assessment of health insurance in community health centers

OBJECTIVE

To demonstrate use of the electronic health record (EHR) for health insurance surveillance and identify factors associated with lack of coverage.

MATERIALS AND METHODS

Using EHR data, we conducted a retrospective, longitudinal cohort study of adult patients (n = 279 654) within a national network of community health centers during a 2-year period (2012-2013).

RESULTS

Factors associated with higher odds of being uninsured (vs Medicaid-insured) included: male gender, age >25 years, Hispanic ethnicity, income above the federal poverty level, and rural residence (P < .01 for all). Among patients with no insurance at their initial visit (n = 114 000), 50% remained uninsured for every subsequent visit.

DISCUSSION

During the 2 years prior to 2014, many patients utilizing community health centers were unable to maintain stable health insurance coverage.

CONCLUSION

As patients gain access to health insurance under the Affordable Care Act, the EHR provides a novel approach to help track coverage and support vulnerable patients in gaining and maintaining coverage.

Location of Usual Source of Care among Children and Adolescents in the United States, 1997-2013

OBJECTIVES

To examine national trends in the percentage of children whose usual source of care is at a clinic, health center, or hospital outpatient department (hereafter "clinics") and whether trends differ by sociodemographic subpopulations.

STUDY DESIGN

Analysis of serial, cross-sectional, nationally representative in-person household surveys, the 1997-2013 National Health Interview Surveys, was conducted to identify children with a usual source of care (n = 190,571), and the percentage receiving that care in a clinic. We used joinpoint regression to identify changes in linear trends, and logistic regression with predictive margins to obtain per-year changes in percentages, both unadjusted and adjusted for sociodemographic factors. Interaction terms in logistic regressions were used to assess whether trends varied by sociodemographic subgroups.

RESULTS

Of all children with a usual source of care, the percentage receiving that care in a clinic declined 0.44 percentage points per year (P < .001) from 22.97% in 1997 to 19.31% in 2002. Thereafter, it increased approximately 0.57 percentage points per year (P < .001), reaching 26.1% in 2013. Trends for some sociodemographic subgroups varied from these overall trends. No changes were observed between 2003 and 2013 for non-Hispanic black and Medicaid/State Children's Health Insurance Program insured children.

CONCLUSIONS

This study shows that, although the percentage of children with a usual source of care in a clinic declined between 1997 and 2002, it has steadily increased since that time.

The Oregon experiment re-examined: the need to bolster primary care

John Heintzman and colleagues use less publicized evidence from Oregon to argue that unless access to primary care is improved, the benefits of widening the eligibility for public health insurance on individual and population health will be limited

Factors influencing family physicians' contribution to the child health care workforce

PURPOSE

We wanted to explore demographic and geographic factors associated with family physicians' provision of care to children.

METHODS

We analyzed the proportion of family physicians providing care to children using survey data collected by the American Board of Family Medicine from 2006 to 2009. Using a cross-sectional study design and logistic regression analysis, we examined the association of various physician demographic and geographic factors and providing care of children.

RESULTS

Younger age, female sex, and rural location are positive predictors of family physicians providing care to children: odds ratio (OR) = 0.97 (95% CI, 0.97-0.98), 1.19 (1.12-1.25), and 1.50 (1.39-1.62), respectively. Family physicians practicing in a partnership are more likely to provide care to children than those in group practice: OR = 1.53 (95% CI, 1.40-1.68). Family physicians practicing in areas with higher density of children are more likely to provide care to children: OR = 1.04 (95% CI, 1.03-1.05), while those in high-poverty areas are less likely 0.10 (95% CI, 0.10-0.10). Family physicians located in areas with no pediatricians are more likely to provide care to children than those in areas with higher pediatrician density: OR = 1.80 (95% CI, 1.59-2.01).

CONCLUSIONS

Various demographic and geographic factors influence the likelihood of family physicians providing care to children, findings that have important implications to policy efforts aimed at ensuring access to care for children.

Socioeconomic status and asthma control in African American youth in SAGE II

OBJECTIVE

African Americans are disproportionately burdened by asthma. We assessed the individual and joint contribution of socioeconomic status (SES) on asthma morbidity among African American youth.

METHODS

We examined 686 African Americans (8-21 years) with asthma. To account for the joint effects of SES, a composite index was derived from maternal educational attainment, household income, and insurance status. Ordinal logistic regression was used to estimate the individual and joint effect of SES on asthma control. Models were adjusted for age, sex, controller medication use, in utero smoke exposure, family history of asthma, family history of rhinitis, breastfeeding, daycare attendance, and mold exposure.

RESULTS

Participants were classified as Poorly Controlled Asthma (40.8%), Partially Controlled Asthma (29.7%), or Controlled Asthma (30.2%). Of the individual SES indicators, low income was the strongest predictor of poor asthma control. Children with low income had worse asthma control than those with higher income (OR 1.39; 95% CI 0.92-2.12). The SES index ranged from 4-9. SES was associated with 17% increased odds of poor asthma control with each decrease in the index (95% CI 1.05-1.32). The SES index was associated with asthma-related symptoms, nocturnal awakenings, limited activity, and missed school days.

CONCLUSIONS

The negative effects of SES were observed along the entire socioeconomic gradient, and the adverse asthma outcomes observed in African American youth were not limited to the very poor. We also found that the SES index may be a more consistent and useful predictor of poor asthma outcomes than each indicator alone.

The ADVANCE network: accelerating data value across a national community health center network

The ADVANCE (Accelerating Data Value Across a National Community Health Center Network) clinical data research network (CDRN) is led by the OCHIN Community Health Information Network in partnership with Health Choice Network and Fenway Health. The ADVANCE CDRN will ‘horizontally’ integrate outpatient electronic health record data for over one million federally qualified health center patients, and ‘vertically’ integrate hospital, health plan, and community data for these patients, often under-represented in research studies. Patient investigators, community investigators, and academic investigators with diverse expertise will work together to meet project goals related to data integration, patient engagement and recruitment, and the development of streamlined regulatory policies. By enhancing the data and research infrastructure of participating organizations, the ADVANCE CDRN will serve as a ‘community laboratory’ for including disadvantaged and vulnerable patients in patient-centered outcomes research that is aligned with the priorities of patients, clinics, and communities in our network.

Socioeconomic status and childhood asthma in urban minority youths. The GALA II and SAGE II studies

RATIONALE

The burden of asthma is highest among socioeconomically disadvantaged populations; however, its impact is differentially distributed among racial and ethnic groups.

OBJECTIVES

To assess the collective effect of maternal educational attainment, annual household income, and insurance type on childhood asthma among minority, urban youth.

METHODS

We included Mexican American (n = 485), other Latino (n = 217), and African American (n = 1,141) children (aged 8-21 yr) with and without asthma from the San Francisco Bay Area. An index was derived from maternal educational attainment, annual household income, and insurance type to assess the collective effect of socioeconomic status on predicting asthma. Logistic regression stratified by racial and ethnic group was used to estimate adjusted odds ratios (aOR) and their 95% confidence intervals (CI). We further examined whether acculturation explained the socioeconomic-asthma association in our Latino population.

MEASUREMENTS AND MAIN RESULTS

In the adjusted analyses, African American children had 23% greater odds of asthma with each decrease in the socioeconomic index (aOR, 1.23; 95% CI, 1.09-1.38). Conversely, Mexican American children have 17% reduced odds of asthma with each decrease in the socioeconomic index (aOR, 0.83; 95% CI, 0.72-0.96) and this relationship was not fully explained by acculturation. This association was not observed in the other Latino group.

CONCLUSIONS

Socioeconomic status plays an important role in predicting asthma, but has different effects depending on race and ethnicity. Further steps are necessary to better understand the risk factors through which socioeconomic status could operate in these populations to prevent asthma.

Parent and child usual source of care and children's receipt of health care services

PURPOSE In the United States, children who have a usual source of care (USC) have better access to health care than those who do not, but little is known about how parental USC affects children's access. We examined the association between child and parent USC patterns and children's access to health care services. METHODS We undertook a secondary analysis of nationally representative, cross-sectional data from children participating in the 2002-2007 Medical Expenditure Panel Survey (n = 56,302). We assessed 10 outcome measures: insurance coverage gaps, no doctor visits in the past year, less than yearly dental visits, unmet medical and prescription needs, delayed care, problems getting care, and unmet preventive counseling needs regarding healthy eating, regular exercise, car safety devices, and bicycle helmets. RESULTS Among children, 78.6% had a USC and at least 1 parent with a USC, whereas 12.4% had a USC but no parent USC. Children with a USC but no parent USC had a higher likelihood of several unmet needs, including an insurance coverage gap (adjusted risk ratio [aRR] 1.33; 95% confidence interval [CI], 1.21-1.47), an unmet medical or prescription need (aRR 1.70; 95% CI 1.09-2.65), and no yearly dental visits (aRR 1.12; 95% CI 1.06-1.18), compared with children with a USC whose parent(s) had a USC. CONCLUSIONS Among children with a USC, having no parent USC was associated with a higher likelihood of reporting unmet needs when compared with children whose parent(s) had a USC. Policy reforms should ensure access to a USC for all family members.