Treating underinsurance

The financial burden experienced by families of preterm infants after NICU discharge

BACKGROUND AND OBJECTIVES

Describe the financial burden and worry that families of preterm infants experience after discharge from the neonatal intensive care unit (NICU).

METHODS

We surveyed 365 parents of preterm infants in a cross-sectional study regarding socio-demographics, supplemental security income (SSI), and financial worry. We completed a multivariable logistic regression model to examine the adjusted association of financial worry with modifiable factors.

RESULTS

We found that 53% of participants worried about healthcare costs after NICU discharge. After adjusting for socio-demographic and infant characteristics, we identified that, aOR (95% CI), out-of-pocket costs from the NICU index hospitalization, 3.51 (1.7, 7.26) and durable medical equipment use, 2.41 (1.11, 5.23) was associated with increased financial worry while enrollment in SSI, 0.38 (0.19, 0.76) was associated with decreased financial worry.

CONCLUSIONS

We identified factors that could contribute to financial burden after NICU discharge that may advise future work to target financial support systems.

State-Level Surveillance of Underinsurance and Health Care-Related Financial Burden

BACKGROUND

The Affordable Care Act (ACA) has reduced uninsurance, but underinsurance, health care-related financial burden, and dental uninsurance may not follow suit. Underinsurance is associated with reduced access to care, household debt, and bankruptcy but has been difficult to track without economic data.

METHODS

We used readily available state-level survey data to build a model that states can adopt to implement surveillance over underinsurance and health care-related financial burden, as well as assess related disparities and health profiles.

RESULTS

The state prevalence of underinsurance and dental uninsurance did not change in the first year of the ACA's individual mandate. Underinsurance was associated with poorer health-related quality-of-life measures: compared with the fully insured, underinsured adults had an adjusted odds ratio of 2.40 (95% CI, 1.71-3.38) of fair or poor general health.

CONCLUSION

Tracking underinsurance and medical debt can help public health and health care access stakeholders evaluate which mechanisms (deductibles, co-pays, uncovered services, or is proportionately priced health care services and products) are barriers to care and improved health outcomes.

Child Health Disparities in the 21st Century

The topic of persistent child health disparities remains a priority for policymakers and a concern for pediatric clinicians. Health disparities are defined as differences in adverse health outcomes for specific health indicators that exist across sub-groups of the population, frequently between minority and majority populations. This review will highlight the gains that have been made since the 1990s as well as describe disparities that have persisted or have worsened into the 21st century. It will also examine the most potent social determinants and their impact on the major disparities in mortality, preventive care, chronic disease, mental health, educational outcomes, and exposure to selected environmental toxins. Each section concludes with a description of interventions and innovations that have been successful in reducing child health disparities.

Medicaid status is associated with higher surgical site infection rates after spine surgery

STUDY DESIGN

The Spine End Results Registry (2003-2004) is a registry of prospectively collected data of all patients undergoing spinal surgery at the University of Washington Medical Center and Harborview Medical Center. Insurance data were prospectively collected and used in multivariate analysis to determine risk of perioperative complications.

OBJECTIVE

Given the negative financial impact of surgical site infections (SSIs) and the higher overall complication rates of patients with a Medicaid payer status, we hypothesized that a Medicaid payer status would have a significantly higher SSI rate.

SUMMARY OF BACKGROUND DATA

The medical literature demonstrates lesser outcomes and increased complication rates in patients who have public insurance than those who have private insurance. No one has shown that patients with a Medicaid payer status compared with Medicare and privately insured patients have a significantly increased SSI rate for spine surgery.

METHODS

The prospectively collected Spine End Results Registry provided data for analysis. SSI was defined as treatment requiring operative debridement. Demographic, social, medical, and the surgical severity index risk factors were assessed against the exposure of payer status for the surgical procedure.

RESULTS

The population included Medicare (N = 354), Medicaid (N = 334), the Veterans' Administration (N = 39), private insurers (N = 603), and self-pay (N = 42). Those patients whose insurer was Medicaid had a 2.06 odds (95% confidence interval: 1.19-3.58, P = 0.01) of having a SSI compared with the privately insured.

CONCLUSION

The study highlights the increased cost of spine surgical procedures for patients with a Medicaid payer status with the passage of the Patient Protection and Affordable Care Act of 2010. The Patient Protection and Affordable Care Act of 2010 provisions could cause a reduction in reimbursement to the hospital for taking care of patients with Medicaid insurance due to their higher complication rates and higher costs. This very issue could inadvertently lead to access limitations.

LEVEL OF EVIDENCE

3.

Medicaid status is associated with higher complication rates after spine surgery

STUDY DESIGN

Multivariate analysis of prospectively collected registry data.

OBJECTIVE

To determine the effect of payor status on complication rates after spine surgery.

SUMMARY OF BACKGROUND DATA

Understanding the risk of perioperative complications is an essential aspect in improving patient outcomes. Previous studies have looked at complication rates after spine surgery and factors related to increased perioperative complications. In other areas of medicine, there has been a growing body of evidence gathered to evaluate the role of payor status on outcomes and complications. Several studies have found increased complication rates and inferior outcomes in the uninsured and Medicaid insured.

METHODS

The Spine End Results Registry (2003-2004) is a collection of prospectively collected data on all patients who underwent spine surgery at our 2 institutions. Extensive demographic data, including payor status, and medical information were prospectively recorded as described previously by Mirza et al. Medical complications were defined in detail a priori and were prospectively recorded for at least 2 years after surgery. Using univariate and multivariate analysis, we determined risk of postoperative medical complications dependent on payor status.

RESULTS

A total of 1591 patients underwent spine surgery in 2003 and 2004 that met our criteria and were included in our analysis. With the multivariate analysis and by controlling for age, patients whose insurer was Medicaid had a 1.68 odds ratio (95% confidence interval: 1.23-2.29; P = 0.001) of having any adverse event when compared with the privately insured.

CONCLUSION

After univariate and multivariate analyses, Medicaid insurance status was found to be a risk factor for postoperative complications. This corresponds to an ever-growing body of medical literature that has shown similar trends and raises the concern of underinsurance.

Parents' perspectives on their children's health insurance: plight of the underinsured

OBJECTIVES

To determine the prevalence and correlates of children's underinsurance within a primary care, practice-based research network.

STUDY DESIGN

A survey of 13 practices within the Southwestern Ohio Ambulatory Research Network using the Medical Expenses for Children Survey in 2009 and 2010 yielded a sample of 2972 parents of children >6 months old with health insurance in the previous 12 months. Data were analyzed using bivariate and loglinear model analyses.

RESULTS

Of the study children, 17.2% were classified as underinsured because of their inability to pay for ≥ 1 of their pediatrician's recommendations for care in the past 12 months. In addition, 15.5% reported it was harder to get medical care for their child in the past 3 years, and 6.5% indicated that their child's health had suffered. Multivariate analysis reveals complex relationships among the 3 factors related to ability to obtain care and between these factors and sociodemographic and health status factors. Across education and income categories, the underinsured rate ranged from 57% to 93% for parents who reported their child's health had suffered.

CONCLUSIONS

One in 6 parents reported that their child was underinsured. A similar percentage reported that it had become more difficult to get needed medical care over the past 3 years. The relationship between the perception that an underinsured child's health has suffered is much stronger for the highest socioeconomic category in this sample than for the other categories; 93% of these families were underinsured in 2009. It is possible that high deductible features of insurance plans contribute to these circumstances.

Medicare reimbursement policies and hemodialysis vascular access outcomes: a need for change

In March 2010, the Center for Medicare and Medicaid Services (CMS) convened several clinical technical expert panels (C-TEP) to provide recommendations for improving various aspects of hemodialysis management. One of the C-TEPs was tasked with recommending measures to decrease vascular access-related infections. The members of this C-TEP, who are the authors of this manuscript, concluded unanimously that the single most important measure would be to remove financial and regulatory barriers to timely placement and revision of hemodialysis fistulas and the concurrent avoidance of catheter use. The following position paper outlines the financial barriers to improved vascular access outcomes and our proposals for a future CMS demonstration project.

Advances in pediatric asthma in 2010: addressing the major issues

Last year's "Advances in pediatric asthma" concluded with the following statement: "If we can close these [remaining] gaps through better communication, improvements in the health care system and new insights into treatment, we will move closer to better methods to intervene early in the course of the disease and induce clinical remission as quickly as possible in most children." This year's summary will focus on recent advances in pediatric asthma that take steps moving forward as reported in Journal of Allergy and Clinical Immunology publications in 2010. Some of these recent reports show us how to improve asthma management through steps to better understand the natural history of asthma, individualize asthma care, reduce asthma exacerbations, and manage inner-city asthma and some potential new ways to use available medications to improve asthma control. It is clear that we have made many significant gains in managing asthma in children, but we have a ways to go to prevent asthma exacerbations, alter the natural history of the disease, and reduce health disparities in asthma care. Perhaps new directions in personalized medicine and improved health care access and communication will help maintain steady progress in alleviating the burden of this disease in children, especially young children.