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Booman A, Stratton K, Vesco KK, O'Malley J, Schmidt T, Boone‐Heinonen J, Snowden JM. Insurance coverage and discontinuity during pregnancy: Frequency and associations documented in the PROMISE cohort. Health Serv Res 2024; 59:e14265. [PMID: 38123135 PMCID: PMC10915475 DOI: 10.1111/1475-6773.14265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE To describe insurance patterns and discontinuity during pregnancy, which may affect the experiences of the pregnant person: their timely access to care, continuity of care, and health outcomes. DATA SOURCES AND STUDY SETTING Data are from the PROMISE study, which utilizes data from community-based health care organizations (CHCOs) (e.g., federally qualified health centers that serve patients regardless of insurance status or ability to pay) in the United States from 2005 to 2021. STUDY DESIGN This descriptive study was a cohort utilizing longitudinal electronic health record data. DATA COLLECTION/EXTRACTION METHODS Insurance type at each encounter was recorded in the clinical database and coded as Private, Public, and Uninsured. Pregnant people were categorized into one of several insurance patterns. We analyzed the frequency and timing of insurance changes and care utilization within each group. PRINCIPAL FINDINGS Continuous public insurance was the most common insurance pattern (69.2%), followed by uninsured/public discontinuity (11.8%), with 6.4% experiencing uninsurance throughout the entirety of pregnancy. Insurance discontinuity was experienced by 16.6% of pregnant people; a majority of these reflect people transitioning to public insurance. Those with continuous public insurance had the highest frequency of inadequate prenatal care (19.5%), while those with all three types of insurance during pregnancy had the highest percentage of intensive prenatal care (16.5%). The majority (71.7%-81.2%) of those with a discontinuous pattern experienced a single insurance change. CONCLUSIONS Insurance discontinuity and uninsurance are common within our population of pregnant people seeking care at CHCOs. Our findings suggest that insurance status should be regarded as a dynamic rather than a static characteristic during pregnancy and should be measured accordingly. Future research is needed to assess the drivers of perinatal insurance discontinuity and if and how these discontinuities may affect health care access, utilization, and birth outcomes.
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Affiliation(s)
- Anna Booman
- School of Public HealthOregon Health & Science University‐Portland State UniversityPortlandOregonUSA
| | - Kalera Stratton
- School of Public HealthOregon Health & Science University‐Portland State UniversityPortlandOregonUSA
| | | | | | | | - Janne Boone‐Heinonen
- School of Public HealthOregon Health & Science University‐Portland State UniversityPortlandOregonUSA
| | - Jonathan M. Snowden
- School of Public HealthOregon Health & Science University‐Portland State UniversityPortlandOregonUSA
- Department of Obstetrics and GynecologyOregon Health & Science UniversityPortlandOregonUSA
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Anyigbo C, Todd E, Tumin D, Kusma J. Health Insurance Coverage Gaps Among Children With a History of Adversity. Med Care Res Rev 2023; 80:648-658. [PMID: 37329285 DOI: 10.1177/10775587231180673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Health insurance stability among children with adverse childhood experiences (ACEs) is essential for accessing health care services. This cross-sectional study used an extensive, multi-year, nationally representative database of children aged 0 to 17 to examine the association between ACE scores and continuous or intermittent lack of health insurance over a 12-month period. Secondary outcomes were reported reasons for coverage gaps. Compared with children having 0 ACEs, those with 4+ ACEs had a higher likelihood of being part-year uninsured rather than year-round private insured (relative risk ratio [RRR]: 4.20; 95% CI: 3.25, 5.43), year-round public insured (RRR: 1.37; 95% CI: 1.06, 1.76), or year-round uninsured (RRR: 2.28; 95% confidence interval [CI]: 1.63, 3.21). Among children who experienced part-year or year-round uninsurance, a higher ACE score was associated with a greater likelihood of coverage gap due to difficulties with the application or renewal process. Policy changes to reduce administrative burdens may improve health insurance stability and access to health care among children who endure ACEs.
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Affiliation(s)
- Chidiogo Anyigbo
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Emmalee Todd
- Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Dmitry Tumin
- Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Jennifer Kusma
- Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago IL, USA
- Mary Ann & J.Milburn Smith Child Health Outcomes, Research and Evaluation Center; Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Omenuko NJ, Tafesse Y, Magacha HM, Nriagu VC, Anazor SO, Nwaneki CM, Okeke F, Ezeano C, Jideofor C. Racial Disparities In In-Hospital Mortality of Children and Adolescents Under 20 Years With Type 1 Diabetes Mellitus. Cureus 2023; 15:e43999. [PMID: 37746475 PMCID: PMC10517728 DOI: 10.7759/cureus.43999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND In the United States, racial disparities in health outcomes continue to be a major problem with far-reaching effects on equity in healthcare and public health. Children and teenagers with type 1 diabetes are a disadvantaged demographic that has particular difficulties in managing their condition and getting access to healthcare. Despite improvements in the treatment of diabetes, little study has examined how much racial disparities in in-hospital mortality affect this particular demographic. By examining racial differences in in-hospital mortality rates among children and adolescents with type 1 diabetes in the United States, this study seeks to close this gap. METHODS This cross-sectional study utilized data from the Healthcare Cost and Utilization Project's (HCUP) Kids' Inpatient Database (KID) for 2012. The KID is a nationally representative sample of pediatric discharges from US hospitals. A total of 20,107 patients who were admitted with type 1 diabetes were included in this study. The primary outcome was the patient's in-hospital mortality status. The primary predictor variable was the race of the patient. Six potential confounders were chosen based on previous literature: age, sex, hospital location, obesity, weight loss, electrolyte disorders status, and median household income. Descriptive statistics and bivariate analyses were done. Multivariate analysis was conducted while controlling for potential confounders. Odd ratios with a 95% confidence interval and probability value were reported. Statistical Analysis System (SAS) version 9.4 for Windows (SAS Institute Inc., Cary, NC, USA) was used for the statistical analysis. RESULTS A total of 20,107 patients were included in this study. Of the patients included, 78.6%, 5.3%, 5.9%, and 10.2% were of age groups <4, 5-9, 10-14, and 15-18, respectively. Among the patients, 64.3% were female. Whites stood at 54.3%, while Hispanic, Black, and other races accounted for 17.2%, 21.8%, and 6.7% respectively. After adjusting for all other variables, children, and young adults of Asian and Pacific Islanders (OR=1.948; 95% CI 1.015,3.738) had 94% higher odds of in-hospital mortality compared to their White counterparts. Children and young adults aged 5-9 (OR=0.29; 95% CI 0.13,0.649) had 71% lower odds of in-hospital mortality compared to those aged 4 or under. Those aged 10-14 (OR=0.155; 95% CI 0.077,0.313) had 85% lower odds of in-hospital mortality compared to those aged 4 or under, while those aged 15-19 (OR=0.172; 95% CI 0.100,0.296) had 83% lower odds of in-hospital mortality compared to those aged 4 or under. Children and young adults who had weight loss (OR=4.474; 95% CI 2.557,7.826) had almost five times higher odds of in-hospital mortality compared to those without weight loss, while children and young adults who had electrolyte disorders (OR=5.131; 95% CI 3.429,7.679) had five times higher odds of in-hospital mortality compared to those without electrolyte disorders. CONCLUSION The results show young adults of Asian and Pacific Islanders have higher odds of in-hospital mortality compared to their White counterparts and this study highlights the urgent need for focused measures designed to lessen these inequalities and enhance health equity. The implementation of culturally sensitive healthcare practices, addressing social determinants of health, and enhancing access to high-quality diabetes care should all be priorities.
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Affiliation(s)
- Nnamdi J Omenuko
- Hematology and Oncology, The University of Chicago Medicine, Chicago, USA
| | - Yordanos Tafesse
- Hematology and Oncology, The University of Chicago Medicine, Chicago, USA
| | - Hezborn M Magacha
- Internal Medicine, East Tennessee State University, Johnson City, USA
| | - Valentine C Nriagu
- Epidemiology and Public Health, East Tennessee State University, Johnson City, USA
- Internal Medicine, Maimonides Medical Center, New York, USA
| | - Sandra O Anazor
- Obstetrics and Gynecology, Corewell Health West/Michigan State University, Grand Rapids, USA
- Public Health, East Tennessee State University, Johnson City, USA
| | - Chisom M Nwaneki
- Internal Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - Francis Okeke
- Epidemiology and Public Health, East Tennessee State University, Johnson City, USA
| | - Chimezirim Ezeano
- Epidemiology and Public Health, University of North Texas Health Science Center, Fort Worth, USA
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Bhardwaj P, Coleman RM, Rivera-Zengotita ML, Rees JH, Bernier AV. Delayed Care and Diagnosis in a 10-Year-Old With Chronic Polydipsia, Polyuria, and Rapidly Progressive Puberty. Clin Pediatr (Phila) 2023; 62:658-663. [PMID: 36419213 DOI: 10.1177/00099228221139334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | - Rachel M Coleman
- Department of Pediatrics, University of Florida Health Shands Hospital, Gainesville, FL, USA
| | - Marie L Rivera-Zengotita
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida Health College of Medicine, Gainesville, FL, USA
| | - John H Rees
- Department of Radiology, Division of Neuroradiology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Angelina V Bernier
- Department of Pediatric Endocrinology, University of Florida Health Shands Hospital, Gainesville, FL, USA
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Ramalingam N, Darias E, Soeder E, Castro G, Lozano J. The Effect of Health Insurance Status on School Attendance. Cureus 2023; 15:e35366. [PMID: 36994262 PMCID: PMC10042512 DOI: 10.7759/cureus.35366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Educational achievement is impacted by a student's ability to be present and motivated in the classroom. Since health and education influence one another, disparities in health insurance status among children may exert educationally relevant consequences. However, the association between health insurance coverage and school absenteeism remains poorly understood. Our study aims to assess the association between not having/having gaps in health insurance coverage and an increased number of missed school days. Methods A historical cohort study was performed via secondary analysis of data collected as part of the 2018 National Survey of Children's Health (NSCH). We included children enrolled in school between the ages of 6-17 years and who provided answers to survey questions involving our two variables of interest: health insurance status and missed school days. Our data analysis included 1) a descriptive analysis of the baseline sample characteristics, 2) a bivariate analysis to determine the association between baseline characteristics/confounding variables and the outcome, and 3) a multivariable regression analysis using logistic regression to determine the association of interest while controlling for potential confounding variables. Results A total of 21,498 respondents were included. The unadjusted odds of chronic absenteeism were found to be 16% (OR=1.16) higher in children without insurance or with gaps in insurance compared to children with consistent insurance throughout the year, but the association was not statistically significant (95% CI 0.74 - 1.82, p=0.051). After adjustment by age, sex, race, Hispanic ethnicity, and confounding variables, the odds of chronic absenteeism in children without insurance or with gaps in insurance remained statistically insignificant (aOR=1.05; 95% CI 0.64 - 1.73, p=0.848) compared to those with consistent insurance coverage. Conclusions According to our analysis, the data do not support our hypothesis of a significant difference in missed school days (greater than or equal to 11 missed days of school) among those children who had health insurance compared to those without health insurance/had gaps in insurance coverage.
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Grembowski D, Leibbrand C. A conceptual model of health insurance stability in the United States health care system. Health Serv Manage Res 2022:9514848221146677. [DOI: 10.1177/09514848221146677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In the U.S. health care system, people under age 65 are at risk of losing and regaining health insurance coverage over their lifetimes, which has important consequences for their physical and mental health. Despite the importance of insurance stability, we have an incomplete understanding about the complex factors influencing whether people lose and regain coverage. To advance our understanding of the dynamics of health insurance coverage and guide future research, our purpose is to present a new conceptual model of health insurance stability, where instability is defined as a person’s loss or change of coverage, which can occur more than once in a lifetime. Drawing from theory and evidence in the literature, we posit that personal and plan characteristics, the health system, and the environmental context – economic, social/cultural, political/judicial, and geographic – drive health insurance stability over the life course and are understudied. Studies are needed to identify the populations most at risk of experiencing insurance instability and vulnerability in health outcomes that results from such insecurity, which may suggest reforms and health policies at the individual, health system, or environment levels to reduce those risks.
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Affiliation(s)
- David Grembowski
- Health Systems and Population Health, University of Washington, Seattle, WA, USA
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Goldman AL, Gordon SH. Coverage Disruptions and Transitions Across the ACA's Medicaid/Marketplace Income Cutoff. J Gen Intern Med 2022; 37:3570-3576. [PMID: 35277806 PMCID: PMC9585127 DOI: 10.1007/s11606-022-07437-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 01/26/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Affordable Care Act takes a "patchwork" approach to expanding coverage: Medicaid covers individuals with incomes 138% of the federal poverty level (FPL) in expansion states, while subsidized Marketplace insurance is available to those above this income cutoff. OBJECTIVE To characterize the magnitude of churning between Medicaid and Marketplace coverage and to examine the impact of the 138% FPL income cutoff on stability of coverage. DESIGN We measured the incidence of transitions between Medicaid and Marketplace coverage. Then, we used a differences-in-differences framework to compare insurance churning in Medicaid expansion and non-expansion states, before and after the ACA, among adults with incomes 100-200% of poverty. PARTICIPANTS Non-elderly adult respondents of the Medical Expenditure Panel Survey 2010-2018 MAIN MEASURES: The annual proportion of adults who (1) transitioned between Medicaid and Marketplace coverage; (2) experienced any coverage disruption. KEY RESULTS One million U.S. adults transitioned between Medicaid and Marketplace coverage annually. The 138% FPL cutoff in expansion states was not associated with an increase in insurance churning among individuals with incomes close to the cutoff. CONCLUSIONS Transitions between Medicaid and Marketplace insurance are uncommon-far lower than pre-ACA analyses predicted. The 138% income cutoff does not to contribute significantly to insurance disruptions.
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Affiliation(s)
- Anna L Goldman
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
- Boston Medical Center, Boston, MA, USA.
| | - Sarah H Gordon
- Boston University School of Public Health, Boston, MA, USA
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Albright BB, Nitecki R, Chino F, Chino JP, Havrilesky LJ, Aviki EM, Moss HA. Catastrophic health expenditures, insurance churn, and nonemployment among gynecologic cancer patients in the United States. Am J Obstet Gynecol 2022; 226:384.e1-384.e13. [PMID: 34597606 PMCID: PMC10016333 DOI: 10.1016/j.ajog.2021.09.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND In recent years, there has been growing recognition of the financial burden of severe illness, including associations with higher rates of nonemployment, uninsurance, and catastrophic out-of-pocket health spending. Patients with gynecologic cancer often require expensive and prolonged treatments, potentially disrupting employment and insurance coverage access, and putting patients and their families at risk for catastrophic health expenditures. OBJECTIVE This study aimed to describe the prevalence of insurance churn, nonemployment, and catastrophic health expenditures among nonelderly patients with gynecologic cancer in the United States, to compare within subgroups and to other populations and assess for changes associated with the Affordable Care Act. STUDY DESIGN We identified respondents aged 18 to 64 years from the Medical Expenditure Panel Survey, 2006 to 2017, who reported care related to gynecologic cancer in a given year, and a propensity-matched cohort of patients without cancer and patients with cancers of other sites, as comparison groups. We applied survey weights to extrapolate to the US population, and we described patterns of insurance churn (any uninsurance or insurance loss or change), catastrophic health expenditures (>10% annual family income), and nonemployment. Characteristics and outcomes between groups were compared with the adjusted Wald test. RESULTS We identified 683 respondents reporting care related to a gynecologic cancer diagnosis from 2006 to 2017, representing an estimated annual population of 532,400 patients (95% confidence interval, 462,000-502,700). More than 64% of patients reported at least 1 of 3 primary negative outcomes of any uninsurance, part-year nonemployment, and catastrophic health expenditures, with 22.4% reporting at least 2 of 3 outcomes. Catastrophic health spending was uncommon without nonemployment or uninsurance reported during that year (1.2% of the population). Compared with patients with other cancers, patients with gynecologic cancer were younger and more likely with low education and low family income (≤250% federal poverty level). They reported higher annual risks of insurance loss (8.8% vs 4.8%; P=.03), any uninsurance (22.6% vs 14.0%; P=.002), and part-year nonemployment (55.3% vs 44.6%; P=.005) but similar risks of catastrophic spending (12.6% vs 12.2%; P=.84). Patients with gynecologic cancer from low-income families faced a higher risk of catastrophic expenditures than those of higher icomes (24.4% vs 2.9%; P<.001). Among the patients from low-income families, Medicaid coverage was associated with a lower risk of catastrophic spending than private insurance. After the Affordable Care Act implementation, we observed reductions in the risk of uninsurance, but there was no significant change in the risk of catastrophic spending among patients with gynecologic cancer. CONCLUSION Patients with gynecologic cancer faced high risks of uninsurance, nonemployment, and catastrophic health expenditures, particularly among patients from low-income families. Catastrophic spending was uncommon in the absence of either nonemployment or uninsurance in a given year.
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Affiliation(s)
- Benjamin B Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC.
| | - Roni Nitecki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Laura J Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Emeline M Aviki
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Haley A Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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The association between healthcare resource allocation and health status: an empirical insight with visual analytics. J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-021-01651-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Soo RA, Seto T, Gray JE, Thiel E, Taylor A, Sawyer W, Karimi P, Marchlewicz E, Brouillette M. Treatment Patterns in Patients with Locally Advanced or Metastatic Non-Small-Cell Lung Cancer Treated with Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitors: Analysis of US Insurance Claims Databases. Drugs Real World Outcomes 2021; 9:31-41. [PMID: 34510401 PMCID: PMC8844326 DOI: 10.1007/s40801-021-00272-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2021] [Indexed: 11/30/2022] Open
Abstract
Background Most patients with epidermal growth factor receptor mutation-positive (EGFRm) non-small-cell lung cancer (NSCLC) acquire resistance to first-line (1L) first- or second-generation (1G/2G) EGFR-TKIs; therefore, it is important to optimize 1L treatment to improve patient outcomes. Objective To retrospectively examine treatment patterns in locally advanced/metastatic NSCLC using MarketScan® Commercial and Medicare Supplemental Databases (all US census regions). Patients and methods Adults with a lung cancer diagnosis code between 1 January 2015–31 March 2018 were analyzed from diagnosis (index) through a variable-length follow-up. Patients had ≥ 1 pharmacy claim for 1G/2G EGFR-TKIs on or within 60 days post-index. Data were stratified by presence or absence of central nervous system (CNS) metastases (30 days pre-index through study end). Results 578 patients were included (median age 63 years, 64% female). Median follow-up was 13.5 months. The most frequently prescribed 1L EGFR-TKI was erlotinib (414/578, 72%). Median time to 1L treatment discontinuation was 8.2 (95% confidence interval (CI) 6.9, 9.0) months in patients diagnosed with CNS metastases at any time, and 7.7 (95% CI 6.9, 8.9) months in patients without CNS metastases. 270/578 patients (47%) discontinued 1L EGFR-TKIs; 209/270 (77%) initiated second-line (2L) therapy, most frequently osimertinib (96/209, 46%). Conclusions In an analysis of US claims data, nearly half of patients discontinued 1L EGFR-TKIs, and 46% who initiated 2L received osimertinib. As nearly a quarter of patients who discontinued 1L EGFR-TKIs did not receive 2L treatment, this study highlights the need for optimal 1L treatment in EGFRm locally advanced/metastatic NSCLC. Supplementary Information The online version contains supplementary material available at 10.1007/s40801-021-00272-5.
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Affiliation(s)
- Ross A Soo
- Department of Haematology-Oncology, National University Cancer Institute, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 7, Singapore, 119228, Singapore.
| | - Takashi Seto
- Department of Thoracic Oncology, NHO Kyushu Cancer Center, 3-1-1 Notame, Minami-ku, Fukuoka, 811-1395, Japan
| | - Jhanelle E Gray
- Department of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Ellen Thiel
- Custom Data Analytics, IBM Watson Health, Cambridge, MA, USA
| | - Aliki Taylor
- Oncology Business Unit, AstraZeneca, Cambridge, UK
| | | | - Parisa Karimi
- Oncology Business Unit, AstraZeneca, Gaithersburg, MD, USA
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Albright BB, Chino F, Chino JP, Havrilesky LJ, Aviki EM, Moss HA. Associations of Insurance Churn and Catastrophic Health Expenditures With Implementation of the Affordable Care Act Among Nonelderly Patients With Cancer in the United States. JAMA Netw Open 2021; 4:e2124280. [PMID: 34495338 PMCID: PMC8427370 DOI: 10.1001/jamanetworkopen.2021.24280] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Health insurance coverage is dynamic in the United States, potentially changing from month to month. The Patient Protection and Affordable Care Act (ACA) aimed to stabilize markets and reduce financial burden, particularly among those with preexisting conditions. OBJECTIVE To describe the risks of insurance churn (ie, gain, loss, or change in coverage) and catastrophic health expenditures among nonelderly patients with cancer in the United States, assessing for changes associated with ACA implementation. DESIGN, SETTING, AND PARTICIPANTS This retrospective, cross-sectional study uses data from the Medical Expenditure Panel Survey, a representative sample of the US population from 2005 to 2018. Respondents included were younger than 65 years, identified by health care use associated with a cancer diagnosis code in the given year. Statistical analysis was conducted from July 30, 2020, to January 5, 2021. EXPOSURES The Patient Protection and Affordable Care Act. MAIN OUTCOMES AND MEASURES Survey weights were applied to generate estimates for the US population. Annual risks of insurance churn (ie, any uninsurance or insurance change or loss) and catastrophic health expenditures (spending >10% income) were calculated, comparing subgroups with the adjusted Wald test. Weighted multivariable linear regression was used to assess for changes associated with ACA implementation. RESULTS From 6069 respondents, we estimated a weighted mean of 4.78 million nonelderly patients (95% CI, 4.55-5.01 million; female patients: weighted mean, 63.9% [95% CI, 62.2%-65.7%]; mean age, 50.3 years [95% CI, 49.7-50.8 years]) with cancer annually in the United States. Patients with cancer experienced lower annual risks of insurance loss (5.3% [95% CI, 4.5%-6.1%] vs 7.6% [95% CI, 7.4%-7.8%]) and any uninsurance (14.6% [95% CI, 13.3%-16.0%] vs 24.1% [95% CI, 23.5%-24.7%]) but increased risk of catastrophic health expenditures (expenses alone: 12.4% [95% CI, 11.2%-13.6%] vs 6.3% [95% CI, 6.2%-6.5%]; including premiums: 26.6% [95% CI, 25.0%-28.1%] vs 16.5% [95% CI, 16.1%-16.8%]; P < .001) relative to the population without cancer. Patients with cancer from low-income families and with full-year private coverage were at particularly high risk of catastrophic health expenditures (including premiums: 81.7% [95% CI, 74.6%-88.9%]). After adjustment, low income was the factor most strongly associated with both insurance churn and catastrophic spending, associated with annual risk increases of 6.5% (95% CI, 4.2%-8.8%) for insurance loss, 17.3% (95% CI, 13.4%-21.2%) for any uninsurance, and 37.4% (95% CI, 33.3%-41.6%) for catastrophic expenditures excluding premiums (P < .001). In adjusted models relative to 2005-2009, full ACA implementation (2014-2018) was associated with a decreased annual risk of any uninsurance (-4.2%; 95% CI, -7.4% to -1.0%; P = .01) and catastrophic spending by expenses alone (-3.0%; 95% CI, -5.3% to -0.8%; P = .008) but not including premiums (0.4%; 95% CI, -2.8% to 4.5%; P = .82). CONCLUSIONS AND RELEVANCE In this cross-sectional study, US patients with cancer faced significant annual risks of insurance churn and catastrophic health spending. Despite some improvements with ACA implementation, large burdens remained, and further reform is needed to protect this population from excessive hardship.
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Affiliation(s)
- Benjamin B. Albright
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Fumiko Chino
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Junzo P. Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Emeline M. Aviki
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Haley A. Moss
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
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Wolfson JA. Poverty and Survival in Childhood Cancer: A Framework to Move Toward Systemic Change. J Natl Cancer Inst 2021; 113:227-230. [PMID: 33227815 DOI: 10.1093/jnci/djaa108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 12/30/2022] Open
Affiliation(s)
- Julie Anna Wolfson
- Division of Pediatric Hematology-Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL, USA
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Lee LK, Todd H, Galbraith AA. Children's Coverage Vulnerabilities With Loss of a Parent's Employer-Sponsored Insurance. Pediatrics 2021; 147:peds.2020-032730. [PMID: 33446507 DOI: 10.1542/peds.2020-032730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts;
| | - Hannah Todd
- Baylor College of Medicine, Houston, Texas; and
| | - Alison A Galbraith
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
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Goldman AL, Sommers BD. Among Low-Income Adults Enrolled In Medicaid, Churning Decreased After The Affordable Care Act. Health Aff (Millwood) 2020; 39:85-93. [PMID: 31905055 DOI: 10.1377/hlthaff.2019.00378] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Coverage disruptions and coverage loss occur frequently among Medicaid enrollees and are associated with delayed health care access and reduced medication adherence. Little is known about the effect on churning of the expansion of eligibility for Medicaid under the Affordable Care Act (ACA), which had the potential to reduce coverage disruptions as a result of increased outreach and more generous income eligibility criteria. We used a difference-in-differences framework to compare rates of coverage disruption in expansion versus nonexpansion states, and in subgroups of states that used alternative expansion strategies. We found that among low-income Medicaid beneficiaries ages 19-64, disruption in coverage decreased 4.3 percentage points in the post-ACA period in expansion states compared to nonexpansion states, and there was a similar decrease in the share of people who experienced a period without any insurance. Men, people of color, and those without chronic illnesses experienced the largest improvements in coverage continuity. Coverage disruptions declined in both traditional expansion states and those that used Section 1115 waivers for expansion. Our quasi-experimental study provides the first nationwide evidence that Medicaid expansion led to decreased rates of coverage disruption. We estimate that half a million fewer adults experienced an episode of churning annually.
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Affiliation(s)
- Anna L Goldman
- Anna L. Goldman ( Anna. Goldman@BMC. org ) is an assistant professor of medicine in the Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, in Massachusetts
| | - Benjamin D Sommers
- Benjamin D. Sommers is a professor of health policy and economics in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and an associate professor of medicine at Brigham and Women's Hospital, both in Boston
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15
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Outpatient healthcare access and utilization for neonatal abstinence syndrome children: A systematic review. J Clin Transl Sci 2019; 4:389-397. [PMID: 33244427 PMCID: PMC7681131 DOI: 10.1017/cts.2019.407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: The objective of this study was to systematically assess the literature regarding postnatal healthcare utilization and barriers/facilitators of healthcare in neonatal abstinence syndrome (NAS) children. Methods: A systematic search was performed in PubMed, Cochrane Database of Systematic Reviews, PsychINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science to identify peer-reviewed research. Eligible studies were peer-reviewed articles reporting on broad aspects of primary and specialty healthcare utilization and access in NAS children. Three investigators independently reviewed all articles and extracted data. Study bias was assessed using the Newcastle–Ottawa Assessment Scale and the National Institute of Health Study Quality Assessment Tool. Results: This review identified 14 articles that met criteria. NAS children have poorer outpatient appointment adherence and have a higher rate of being lost to follow-up. These children have overall poorer health indicated by a significantly higher risk of ER visits, hospital readmission, and early childhood mortality compared with non-NAS infants. Intensive multidisciplinary support provided through outpatient weaning programs facilitates healthcare utilization and could serve as a model that could be applied to other healthcare fields to improve the health among this population. Conclusions: This review investigated the difficulties in accessing outpatient care as well as the utilization of such care for NAS infants. NAS infants tend to have decreased access to and utilization of outpatient healthcare following hospital birth discharge. Outpatient weaning programs have proven to be effective; however, these programs require intensive resources and care coordination that has yet to be implemented into other healthcare areas for NAS children.
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16
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Jones RE, Babb J, Gee KM, Beres AL. An investigation of social determinants of health and outcomes in pediatric nonaccidental trauma. Pediatr Surg Int 2019; 35:869-877. [PMID: 31147762 DOI: 10.1007/s00383-019-04491-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Nonaccidental trauma (NAT) is a leading cause of pediatric mortality and disability. We examined our institution's experience with NAT to determine if socioeconomic status is correlated with patient outcomes. METHODS NAT cases were reviewed retrospectively. Socioeconomic determinants included insurance status and race; outcomes included mortality, discharge disability and disposition. Correlations were identified using t test, Fisher's exact test, and logistic regression. RESULTS The cohort comprised of 337 patients, with an overall uninsured rate of 5.6%. This rate was achieved by insuring 64.7% of the cohort after admission. Non-survivors were more likely to have no insurance coverage (14.8% versus 4.8%, p = 0.041). Regression revealed that uninsured had 8 times (95% CI 1.7-38.7, p = 0.008) higher in-hospital mortality than those with insurance when controlling for injury severity. Additionally, injury severity score ≥ 15, transfer from outside hospital, need for ICU or operative treatment were predictive of mortality. Adjusted risk factors for severe disability at discharge did not include insurance status or race, while ISS ≥ 15 and ICU stay were predictive. CONCLUSIONS There are significant associations of insurance status with pediatric NAT outcomes, highlighting that determinants other than disease severity may influence mortality and morbidity. High-risk patients should be identified to develop strategies to improve outcomes.
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Affiliation(s)
- Ruth Ellen Jones
- Division of Pediatric Surgery, Department of Surgery, Children's Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., 1935 Medical District Drive, D-2000, Dallas, TX, 75235, USA
| | - Jacqueline Babb
- Division of Pediatric Surgery, Department of Surgery, Children's Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., 1935 Medical District Drive, D-2000, Dallas, TX, 75235, USA
| | - Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, Children's Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., 1935 Medical District Drive, D-2000, Dallas, TX, 75235, USA
| | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, Children's Health, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., 1935 Medical District Drive, D-2000, Dallas, TX, 75235, USA.
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17
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Patterns of Health Insurance Discontinuity and Children’s Access to Health Care. Matern Child Health J 2019; 23:667-677. [DOI: 10.1007/s10995-018-2681-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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18
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McCray N. Child health care coverage and reductions in child physical abuse. Heliyon 2018; 4:e00945. [PMID: 30839846 PMCID: PMC6251011 DOI: 10.1016/j.heliyon.2018.e00945] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 09/01/2018] [Accepted: 11/14/2018] [Indexed: 11/30/2022] Open
Abstract
Children in the United States suffered almost 118,000 cases of physical abuse in 2015. One factor that might help decrease child physical abuse is health care coverage. This paper presents a justification for a link between health care coverage and reductions in child physical abuse and, though it does not assess specific causal mechanisms, examines evidence for such a connection. The paper uses panel data linear regression analysis to explore state level physical abuse and health care coverage rates. Findings indicate a statistically significant relationship between increases in child health care coverage rates, including both private coverage and Medicaid coverage, and decreases in child physical abuse.
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19
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Baggio S, Tran NT, Barnert ES, Gétaz L, Heller P, Wolff H. Lack of health insurance among juvenile offenders: a predictor of inappropriate healthcare use and reincarceration? Public Health 2018; 166:25-33. [PMID: 30439553 DOI: 10.1016/j.puhe.2018.09.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 08/15/2018] [Accepted: 09/30/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Relationships between the health insurance status and healthcare use among justice-involved youths transitioning into adulthood is an underexplored topic, even if transition to adulthood is a crucial time period for healthcare outcomes. To fill in these knowledge gaps, this study had two aims: (1) to examine trajectories of health insurance coverage and healthcare use among serious juvenile offenders transitioning into adulthood; and (2) to explore associations between the lack of health insurance, healthcare use and reincarceration. STUDY DESIGN We conducted a secondary analysis on the data of the US longitudinal Pathways to Desistance study between ages 20 and 23 years (2000-2010). METHODS Participant data on health insurance coverage, healthcare use, reincarceration and sociodemographic variables (n = 1215) were extracted and analysed using descriptive statistics, generalized linear regressions and cross-lagged panel models. RESULTS About half of the young offenders had no health insurance coverage or intermittent coverage between the age of 20 and 23 years. Emergency services were used (≥17.4%), notably more by insured participants and were increasingly used over time. Being uninsured at the age of 20 years was associated with reincarceration at the age of 23 years (b = -0.052, p = 0.014, odd-ratio = 0.95), but incarceration at the age of 20 years did not predict the insurance status at the age of 23 years (b = 0.009, p = 0.792). CONCLUSIONS Serious juvenile offenders, especially if uninsured, faced major barriers to accessing health care and often reported an inappropriate healthcare use. This likely led to reincarceration. The lack of continuity of care and of access to health care may, therefore, increase health disparities, and efforts are needed to mitigate detrimental outcomes, by effective in and out of detention coordination of health insurance coverage and among health services.
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Affiliation(s)
- S Baggio
- Division of Prison Health, Geneva University Hospitals and University of Geneva, Chemin du Petit Bel Air 2, 1226 Thônex, Switzerland; Life Course and Social Inequality Research Centre, University of Lausanne, Bâtiment Géopolis, 1015 Lausanne, Switzerland.
| | - N T Tran
- Division of Prison Health, Geneva University Hospitals and University of Geneva, Chemin du Petit Bel Air 2, 1226 Thônex, Switzerland; Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology, PO Box 123, Broadway, NSW 2007, Australia.
| | - E S Barnert
- Department of Pediatrics, David Geffen School of Medicine at UCLA, University of California, 10833 Le Conte Ave, Los Angeles, CA, USA.
| | - L Gétaz
- Division of Prison Health, Geneva University Hospitals and University of Geneva, Chemin du Petit Bel Air 2, 1226 Thônex, Switzerland.
| | - P Heller
- Division of Prison Health, Geneva University Hospitals and University of Geneva, Chemin du Petit Bel Air 2, 1226 Thônex, Switzerland.
| | - H Wolff
- Division of Prison Health, Geneva University Hospitals and University of Geneva, Chemin du Petit Bel Air 2, 1226 Thônex, Switzerland.
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20
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Gushue C, Miller R, Sheikh S, Allen ED, Tobias JD, Hayes D, Tumin D. Gaps in health insurance coverage and emergency department use among children with asthma. J Asthma 2018; 56:1070-1078. [PMID: 30365346 DOI: 10.1080/02770903.2018.1523929] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background: Gaps in health insurance coverage may complicate asthma management and increase emergency department (ED) use. Using two nationally-representative surveys, we characterize the prevalence of coverage gaps among children with asthma, and describe their association with ED visits in this population. Methods: De-identified data were obtained from the 2016 National Survey of Children's Health (NSCH) and National Health Interview Survey (NHIS). Among children with asthma, we classified coverage over the past year as: (1) continuous private, (2) continuous public, (3) gap in coverage, and (4) continuously uninsured. The primary outcome was all-cause ED visits in the past year (both surveys). Secondary outcomes included unmet health care needs (NSCH), asthma-related ED visits or hospitalizations (NHIS) and asthma exacerbations (NHIS). Results: The analysis included 3739 (NSCH) and 854 (NHIS) children with asthma, representing a population of 5.5 million children in the US. Estimated prevalence of coverage gaps was 5% in the NSCH and 3% in the NHIS. On multivariable ordinal logistic regression using NSCH data, coverage gaps were associated with increased all-cause ED use (OR = 2.5; 95% CI: 1.3, 4.7, p = 0.005), compared to continuous private coverage. Further analysis confirmed higher odds of unmet health care needs, asthma exacerbations, and asthma-related ED visits among children with coverage gaps. Conclusions: Children with asthma who experience insurance coverage gaps have increased ED use, possibly related to poorer access to appropriate health care. Protecting insurance coverage continuity may reduce ED use and improve clinical outcomes in this population.
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Affiliation(s)
- Courtney Gushue
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Rebecca Miller
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Shahid Sheikh
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Elizabeth D Allen
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Don Hayes
- Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pulmonary and Critical Care Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
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21
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The Effect of the Affordable Care Act's Dependent Coverage Provisionon Health Insurance Gaps for Young Adults With SpecialHealthcare Needs. J Adolesc Health 2018; 63:445-450. [PMID: 30108024 DOI: 10.1016/j.jadohealth.2018.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 05/09/2018] [Accepted: 05/09/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE This study examined the impact of the 2010 Affordable Care Act's dependent coverage provision on gaps in insurance coverage for young adults with special healthcare needs (YASHCN). METHODS We used the 2008 Survey on Income and Program Participation, a longitudinal survey covering 2008-2013. Our sample was comprised of 3,316 YASHCN ages 19-29. We used a difference-in-differenceregression approach to assess the effect of the dependent coverage provision on the probability that a YASHCN experienced a gap in insurance coverage. We compared outcomes for a treatment group, YASHCN ages 19-25, and a control group, YASHCN ages 27-29, before and after the 2010 policy change. The longitudinal data allow us to estimate regressions that control for individual and time fixed effects. RESULTS After controlling for fixed effects and other confounding variables, we found that extending coverage until age 26 for YASHCN was associated with reduced insurance gaps. Specifically, our estimates suggest that the Affordable Care Act dependent coverage provision was associated with reduced insurance gaps among YASHCN by 2.4 percentage points. CONCLUSIONS The Affordable Care Act dependent coverage provision helped mitigate the number ofinsurance gaps experienced by YASHCN. This is of particular importance to YASHCN, as they are a vulnerablepopulation and their continuity of insurance coverage is a critical part of their transition into adulthood.
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22
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Preterm infants are less likely to have a family-centered medical home than term-born peers. J Perinatol 2018; 38:1391-1397. [PMID: 30046181 DOI: 10.1038/s41372-018-0180-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/15/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The family-centered medical home (FCMH) is the recommended healthcare delivery model for children. It is unknown how frequently preterm (PT) children receive care in a FCMH and how this affects health services use. STUDY DESIGN We studied 18,397 children aged 0-3 years in the 2010/2011 National Survey of Children's Health. We compared PT (<37 weeks) and full-term (FT) children on rates of FCMH and receiving prescribed health services. Regression models included sex, race, income, insurance status, and having a special health care need (SHCN). RESULTS PT children were significantly less likely to have a FCMH (57% vs. 66%) compared to FT peers despite higher rates of SHCN (16% vs. 5%). PT children were less likely to receive prescribed services (aOR 0.34, 95% CI 0.34, 0.34); lacking a FCMH explained 69% of this effect. CONCLUSIONS Ensuring PT children have access to medical homes may decrease unmet service needs post-hospital discharge.
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23
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Taylor T, Salyakina D. Health Care Access Barriers Bring Children to Emergency Rooms More Frequently: A Representative Survey. Popul Health Manag 2018; 22:262-271. [PMID: 30160608 PMCID: PMC6555172 DOI: 10.1089/pop.2018.0089] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Children may visit the emergency department (ED) regularly in part because they and their caregivers may be experiencing barriers to appropriate and timely pediatric care. However, assessing the wide range of potential barriers to access to care that children and their caregivers may experience is often a challenge. The objective of this study was to assess the barriers to pediatric health care reported by caregivers and to examine the association between those reported barriers to care with the frequency of children's ED visits in the past 12 months. Assessment of ED utilization and access to care barriers was made through a telephone interview survey conducted as part of a broader Community Health Needs Assessment in 2015. A weighted community sample of adult caregivers (N = 1057) of children between the ages of 0-17 residing in Miami-Dade, Broward, and Palm Beach counties, Florida were contacted. This study found that multiple ED visits (≥2 vs. 0) in the past 12 months by a child were most strongly associated with access to care barriers attributed to language and culture (relative risk [RR] = 2.51), trouble finding a doctor (RR = 1.86), scheduling an appointment (RR = 1.68), and transportation access (RR = 1.73). These findings suggest that access to care barriers experienced by households may exacerbate the risk of a child experiencing repeated visits to the ED in a year. Findings are discussed further in the context of actionable population health management strategies to reduce risk of frequent ED utilization by children.
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Affiliation(s)
- Thom Taylor
- Nicklaus Children's Research Institute, Miami, Florida
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24
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Pati S, Calixte R, Wong A, Huang J, Baba Z, Luan X, Cnaan A. Maternal and child patterns of Medicaid retention: a prospective cohort study. BMC Pediatr 2018; 18:275. [PMID: 30131062 PMCID: PMC6103876 DOI: 10.1186/s12887-018-1242-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 08/02/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND We sought to determine whether maternal Medicaid retention influences child Medicaid retention because caregivers play a critical role in assuring children's health access. METHODS We conducted a longitudinal prospective cohort study of a convenience sample of 604 Medicaid-eligible mother-child dyads followed from the infant's birth through 24 months of age with parent surveys. Individual enrollment status was abstracted from administrative Medicaid eligibility files. Generalized estimating equations quantified the effect of maternal Medicaid enrollment status on child Medicaid retention, adjusting for relevant covariates. Because varying lengths of gaps may have different effects on child health outcomes, Medicaid enrollment status was further categorized by length of gap: any gap, > 14-days, and > 60-days. RESULTS This cohort consists primarily of African-American (94%), unmarried mothers (88%), with a mean age of 23.2 years. In multivariable analysis, children whose mothers experienced any gaps in coverage had 12.6 times greater odds of experiencing gaps when compared to children whose mothers were continuously enrolled. Use of varying thresholds to define coverage gaps resulted in similar odds ratios (> 14-day gap = 11.8, > 60-day gap = 16.8). Cash assistance receipt and maternal knowledge of differences between Temporary Assistance to Needy Families and Medicaid eligibility criteria demonstrated strong protective effects against child Medicaid disenrollment. CONCLUSIONS Medicaid disenrollment remains a significant policy problem and maternal Medicaid retention patterns show strong effects on child Medicaid retention. Policymakers need to invest in effective outreach strategies, including family-friendly application processes, to reduce enrollment barriers so that all eligible families can take advantage of these coverage opportunities.
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Affiliation(s)
- Susmita Pati
- Division of Primary Care Pediatrics, State University of New York at Stony Brook, 100 Nicolls Rd, Stony Brook, NY 11794 USA
| | - Rose Calixte
- Division of Primary Care Pediatrics, State University of New York at Stony Brook, 100 Nicolls Rd, Stony Brook, NY 11794 USA
| | - Angie Wong
- Division of Primary Care Pediatrics, State University of New York at Stony Brook, 100 Nicolls Rd, Stony Brook, NY 11794 USA
| | - Jiayu Huang
- Division of Primary Care Pediatrics, State University of New York at Stony Brook, 100 Nicolls Rd, Stony Brook, NY 11794 USA
| | - Zeinab Baba
- Pediatric Generalist Research Group, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Xianqun Luan
- Healthcare Analytics Unit, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104 USA
| | - Avital Cnaan
- School of Medicine and Health Sciences, The George Washington University, 2121 I St NW, Washington, DC 20052 USA
- Center for Clinical and Translational Science, Children’s National Medical Center, 111 Michigan Ave NW, Washington, DC 20010 USA
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25
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Silber JH, Zeigler AE, Reiter JG, Hochman LL, Ludwig JM, Wang W, Calhoun SR, Pati S. Using Appendicitis to Improve Estimates of Childhood Medicaid Participation Rates. Acad Pediatr 2018; 18:593-600. [PMID: 29581042 DOI: 10.1016/j.acap.2018.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 02/23/2018] [Accepted: 03/17/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Administrative data are often used to estimate state Medicaid/Children's Health Insurance Program duration of enrollment and insurance continuity, but they are generally not used to estimate participation (the fraction of eligible children enrolled) because administrative data do not include reasons for disenrollment and cannot observe eligible never-enrolled children, causing estimates of eligible unenrolled to be inaccurate. Analysts are therefore forced to either utilize survey information that is not generally linkable to administrative claims or rely on duration and continuity measures derived from administrative data and forgo estimating claims-based participation. We introduce appendectomy-based participation (ABP) to estimate statewide participation rates using claims by taking advantage of a natural experiment around statewide appendicitis admissions to improve the accuracy of participation rate estimates. METHODS We used Medicaid Analytic eXtract (MAX) for 2008-2010; and the American Community Survey for 2008-2010 from 43 states to calculate ABP, continuity ratio, duration, and participation based on the American Community Survey (ACS). RESULTS In the validation study, median participation rate using ABP was 86% versus 87% for ACS-based participation estimates using logical edits and 84% without logical edits. Correlations between ABP and ACS with or without logical edits was 0.86 (P < .0001). Using regression analysis, ABP alone was a significant predictor of ACS (P < .0001) with or without logical edits, and adding duration and/or the continuity ratio did not significantly improve the model. CONCLUSION Using the ABP rate derived from administrative claims (MAX) is a valid method to estimate statewide public insurance participation rates in children.
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Affiliation(s)
- Jeffrey H Silber
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pa; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa; Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, Pa; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pa.
| | - Ashley E Zeigler
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Joseph G Reiter
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Lauren L Hochman
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Justin M Ludwig
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Wei Wang
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Shawna R Calhoun
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susmita Pati
- Division of Primary Care Pediatrics, Stony Brook University School of Medicine & Stony Brook Children's Hospital, Stony Brook, NY
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26
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DeVoe JE, Hoopes M, Nelson CA, Cohen DJ, Sumic A, Hall J, Angier H, Marino M, O'Malley JP, Gold R. Electronic health record tools to assist with children's insurance coverage: a mixed methods study. BMC Health Serv Res 2018; 18:354. [PMID: 29747644 PMCID: PMC5946500 DOI: 10.1186/s12913-018-3159-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/26/2018] [Indexed: 11/11/2022] Open
Abstract
Background Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children’s coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children’s insurance assistance. Methods We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784). Results Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14–1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68–0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64–2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53–0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used. Conclusions This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care. Trial registration ClinicalTrials.gov, NCT02298361; retrospectively registered on November 5, 2014. Electronic supplementary material The online version of this article (10.1186/s12913-018-3159-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jennifer E DeVoe
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA.,Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | - Megan Hoopes
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA
| | | | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | | | - Jennifer Hall
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | - Jean P O'Malley
- Department of Family Medicine, Oregon Health & Science University, 3181 Sam Jackson Road, Mail Code FM, Portland, OR, 97239, USA
| | - Rachel Gold
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA.,Kaiser Permanente Northwest Center for Health Research, 3800 N Interstate Avenue, Portland, OR, 97211, USA
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27
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Chen A, Lo Sasso AT, Richards MR. Supply-side effects from public insurance expansions: Evidence from physician labor markets. HEALTH ECONOMICS 2018; 27:690-708. [PMID: 29194846 DOI: 10.1002/hec.3625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 08/29/2017] [Accepted: 10/24/2017] [Indexed: 06/07/2023]
Abstract
Medicaid and the Child Health Insurance Programs (CHIP) are key sources of coverage for U.S. children. Established in 1997, CHIP allocated $40 billion of federal funds across the first 10 years but continued support required reauthorization. After 2 failed attempts in Congress, CHIP was finally reauthorized and significantly expanded in 2009. Although much is known about the demand-side policy effects, much less is understood about the policy's impact on providers. In this paper, we leverage a unique physician dataset to examine if and how pediatricians responded to the expansion of the public insurance program. We find that newly trained pediatricians are 8 percentage points more likely to subspecialize and as much as 17 percentage points more likely to enter private practice after the law passed. There is also suggestive evidence of greater private practice growth in more rural locations. The sharp supply-side changes that we observe indicate that expanding public insurance can have important spillover effects on provider training and practice choices.
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Affiliation(s)
- Alice Chen
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Anthony T Lo Sasso
- School of Public Health, Health Policy and Administration, Institute of Government and Public Affairs, University of Illinois-Chicago, Chicago, IL, USA
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28
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Abstract
This study assessed children's unmet health-care needs within different family types (two-parent biological/adoptive, two-parent stepfamily, and single-mother family type) using data from the 2011/2012 National Survey of Children's Health. Findings indicate that 10.4% of children in single-mother family types had unmet health-care needs compared to 8.7% of children from a two-parent stepfamily and 5.3% for those from two-parent biological/adoptive families. Further analyses revealed racial/ethnic disparities with Black children from two parent-biological/adoptive families being 1.54 (95% confidence interval 1.13, 2.05) times more likely to have unmet health-care needs, while Hispanic children were less likely to have unmet health-care needs relative to their white counterparts. Children from lower income two-parent families had a higher likelihood of unmet health-care needs. The noncontinuous insurance coverage was a risk factor for increasing unmet health-care needs across all three different family types. These findings show major differences in unmet health-care needs among children living in different family structure types. It is recommended that interventions for increasing access to care need to be tailored differently across various family types in order to achieve continuous and sufficient health-care services for our children.
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Affiliation(s)
- Katherine Irvin
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
| | - Farhan Fahim
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
| | - Saeed Alshehri
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
| | - Panagiota Kitsantas
- Department of Health Administration and Policy, George Mason University, Fairfax, VA, USA
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29
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Arthur KC, Lucenko BA, Sharkova IV, Xing J, Mangione-Smith R. Using State Administrative Data to Identify Social Complexity Risk Factors for Children. Ann Fam Med 2018; 16:62-69. [PMID: 29311178 PMCID: PMC5758323 DOI: 10.1370/afm.2134] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 04/25/2017] [Accepted: 06/14/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Screening for social determinants of health is challenging but critically important for optimizing child health outcomes. We aimed to test the feasibility of using an integrated state agency administrative database to identify social complexity risk factors and examined their relationship to emergency department (ED) use. METHODS We conducted a retrospective cohort study among children younger than 18 years with Washington State Medicaid insurance coverage (N = 505,367). We linked child and parent administrative data for this cohort to identify a set of social complexity risk factors, such as poverty and parent mental illness, that have either a known or hypothesized association with suboptimal health care use. Using multivariate analyses, we examined associations of each risk factor and of number of risk factors with the rate of ED use. RESULTS Nine of 11 identifiable social complexity risk factors were associated with a higher rate of ED use. Additionally, the rate increased as the number of risk factors increased from 0 to 5 or more, reaching approximately twice the rate when 5 or more risk factors were present in children aged younger than 5 years (incidence rate ratio = 1.92; 95% CI, 1.85-2.00) and in children aged 5 to 17 years (incidence rate ratio = 2.06; 95% CI, 1.99-2.14). CONCLUSIONS State administrative data can be used to identify social complexity risk factors associated with higher rates of ED use among Medicaid-insured children. State agencies could give primary care medical homes a social risk flag or score to facilitate targeted screening and identification of needed resources, potentially preventing future unnecessary ED use in this vulnerable population of children.
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Affiliation(s)
| | - Barbara A Lucenko
- Washington State Department of Social and Health Services, Division of Research and Data Analysis, Olympia, Washington
| | - Irina V Sharkova
- Washington State Department of Social and Health Services, Division of Research and Data Analysis, Olympia, Washington
| | - Jingping Xing
- Washington State Department of Social and Health Services, Division of Research and Data Analysis, Olympia, Washington
| | - Rita Mangione-Smith
- Seattle Children's Research Institute, Seattle, Washington.,University of Washington Department of Pediatrics, Seattle, Washington
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30
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Payments and Utilization of Immunization Services Among Children Enrolled in Fee-for-Service Medicaid. Med Care 2017; 56:54-61. [PMID: 29176369 DOI: 10.1097/mlr.0000000000000844] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the association between state Medicaid vaccine administration fees and children's receipt of immunization services. METHODS The study used the 2008-2012 Medicaid Analytic eXtract data and included children aged 0-17 years and continuously enrolled in a Medicaid fee-for-service plan in each study year. Analyses were restricted to 8 states with a Medicaid managed-care penetration rate <75%. Linear regressions were used to estimate the probability of children making ≥1 vaccination visit and the numbers of vaccination visits in the year as a function of state Medicaid vaccine administration fees, age group, sex, race/ethnicity, state unemployment rate, state managed-care penetration rate, and state and year-fixed effects. RESULTS A total of 1,678,288 children were included. In 2008-2012, the average proportion of children making ≥1 vaccination visit per year was 31% and the mean number of vaccination visits was 0.9. State Medicaid reimbursements for vaccine administration was positively associated with immunization service utilization; for every $1 increase in the payment amount, the probability of children making ≥1 vaccination visit increased by 0.72 percentage point (95% confidence interval, 0.23-1.21; P=0.01), representing a 2% increase from the mean and the number of vaccination visits increased by 0.03 (95% confidence interval, -0.00 to 0.06; P<0.1). The estimated effect was greater among younger children. CONCLUSION Higher Medicaid reimbursements for vaccine administration were associated with increased proportion of children receiving immunization services.
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31
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Kramer MR, Schneider EB, Kane JB, Margerison-Zilko C, Jones-Smith J, King K, Davis-Kean P, Grzywacz JG. Getting Under the Skin: Children's Health Disparities as Embodiment of Social Class. POPULATION RESEARCH AND POLICY REVIEW 2017; 36:671-697. [PMID: 29398742 PMCID: PMC5791911 DOI: 10.1007/s11113-017-9431-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 03/02/2017] [Indexed: 10/19/2022]
Abstract
Social class gradients in children's health and development are ubiquitous across time and geography. The authors develop a conceptual framework relating three actions of class-material allocation, salient group identity, and inter-group conflict-to the reproduction of class-based disparities in child health. A core proposition is that the actions of class stratification create variation in children's mesosystems and microsystems in distinct locations in the ecology of everyday life. Variation in mesosystems (e.g., health care, neighborhoods) and microsystems (e.g., family structure, housing) become manifest in a wide variety of specific experiences and environments that produce the behavioral and biological antecedents to health and disease among children. The framework is explored via a review of theoretical and empirical contributions from multiple disciplines and high-priority areas for future research are highlighted.
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Affiliation(s)
- Michael R Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, Atlanta, GA 30322
| | - Eric B Schneider
- Department of Economic History, London School of Economics and Political Science
| | | | - Claire Margerison-Zilko
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University
| | - Jessica Jones-Smith
- Department of International Health, Johns Hopkins Bloomberg School of Public Health
| | - Katherine King
- Department of Community and Family Medicine, Duke University
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32
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Wisk LE, Finkelstein JA, Toomey SL, Sawicki GS, Schuster MA, Galbraith AA. Impact of an Individual Mandate and Other Health Reforms on Dependent Coverage for Adolescents and Young Adults. Health Serv Res 2017; 53:1581-1599. [PMID: 28556901 DOI: 10.1111/1475-6773.12723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine the effect of state-level dependent coverage expansion (DCE) with and without other state health reforms on exit from dependent coverage for adolescents and young adults (AYA). DATA SOURCES Administrative longitudinal data for 131,542 privately insured AYA in Massachusetts (DCE with other reforms) versus Maine and New Hampshire (DCE without other reforms) across three periods: prereform (1/00-12/06), poststate reform (1/07-9/10), and postfederal reform (10/10-12/12). STUDY DESIGN A difference-in-differences estimator was used to determine the rate of exit from dependent coverage, age at exit from dependent coverage, and re-uptake of dependent coverage among AYA in states with comprehensive reforms versus DCE only. PRINCIPAL FINDINGS Implementation of DCE with other reforms was significantly associated with a 23 percent reduction in exit from dependent coverage among AYA compared to the reduction observed for DCE alone. Additionally, comprehensive reforms were associated with over two additional years of dependent coverage for the average AYA and a 33 percent increase in the odds of regaining dependent coverage after a prior loss. CONCLUSIONS Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA.
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Affiliation(s)
- Lauren E Wisk
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jonathan A Finkelstein
- Department of Pediatrics, Harvard Medical School, Boston, MA.,Division of General Pediatrics, Boston Children's Hospital, Boston, MA.,Center for Healthcare Research in Pediatrics (CHeRP), Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Sara L Toomey
- Department of Pediatrics, Harvard Medical School, Boston, MA.,Division of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Gregory S Sawicki
- Department of Pediatrics, Harvard Medical School, Boston, MA.,Division of General Pediatrics, Boston Children's Hospital, Boston, MA.,Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA
| | - Mark A Schuster
- Department of Pediatrics, Harvard Medical School, Boston, MA.,Division of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Alison A Galbraith
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA.,Center for Healthcare Research in Pediatrics (CHeRP), Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
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33
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Swartz K, Short PF, Graefe DR, Uberoi N. Reducing Medicaid Churning: Extending Eligibility For Twelve Months Or To End Of Calendar Year Is Most Effective. Health Aff (Millwood) 2016; 34:1180-7. [PMID: 26153313 DOI: 10.1377/hlthaff.2014.1204] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicaid churning--the constant exit and reentry of beneficiaries as their eligibility changes--has long been a problem for both Medicaid administrators and recipients. Churning will continue under the Affordable Care Act because, despite new federal rules, Medicaid eligibility will continue to be based on current monthly income. We developed a longitudinal simulation model to evaluate four policy options for modifying or extending Medicaid eligibility to reduce churning. The simulations suggest that two options--extending eligibility either to the end of a calendar year or for twelve months after enrollment--would be the most effective methods for reducing churning. The other options--a three-month extension or eligibility based on projected annual income--would reduce churning to a lesser extent. States should consider implementation of the option that best balances costs while improving access to coverage and, thereby, the health of Medicaid enrollees.
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Affiliation(s)
- Katherine Swartz
- Katherine Swartz is a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health, in Boston, Massachusetts
| | - Pamela Farley Short
- Pamela Farley Short is a professor in the Department of Health Policy and Administration at Pennsylvania State University, in University Park
| | - Deborah Roempke Graefe
- Deborah Roempke Graefe is a research associate at the Population Research Institute at Pennsylvania State University
| | - Namrata Uberoi
- Namrata Uberoi is an analyst in health care financing at the Congressional Research Service, in Washington, D.C
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34
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DeVoe J, Angier H, Hoopes M, Gold R. A new role for primary care teams in the United States after "Obamacare:" Track and improve health insurance coverage rates. Fam Med Community Health 2016; 4:63-67. [PMID: 28966926 PMCID: PMC5617364 DOI: 10.15212/fmch.2016.0117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Maintaining continuous health insurance coverage is important. With recent expansions in access to coverage in the United States after "Obamacare," primary care teams have a new role in helping to track and improve coverage rates and to provide outreach to patients. We describe efforts to longitudinally track health insurance rates using data from the electronic health record (EHR) of a primary care network and to use these data to support practice-based insurance outreach and assistance. Although we highlight a few examples from one network, we believe there is great potential for doing this type of work in a broad range of family medicine and community health clinics that provide continuity of care. By partnering with researchers through practice-based research networks and other similar collaboratives, primary care practices can greatly expand the use of EHR data and EHR-based tools targeting improvements in health insurance and quality health care.
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Affiliation(s)
| | | | | | - Rachel Gold
- Kaiser Permanente Center for Health Research Northwest Region, Portland, OR, USA
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35
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Larson K, Cull WL, Racine AD, Olson LM. Trends in Access to Health Care Services for US Children: 2000-2014. Pediatrics 2016; 138:peds.2016-2176. [PMID: 27940710 DOI: 10.1542/peds.2016-2176] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Recent years have witnessed substantial gains in health insurance coverage for children, but few studies have examined trends across a diverse set of access indicators. We examine US children's access to health services and whether trends vary by race/ethnicity and income. METHODS Analysis of 178 038 children ages 0 to 17 from the 2000 to 2014 National Health Interview Survey. Trends are examined for health insurance and 5 access indicators: no well-child visit in the year, no doctor office visit, no dental visit, no usual source of care, and unmet health needs. Logistic regression models add controls for sociodemographics and child health status. Statistical interactions test whether trends vary by race/ethnicity and income. RESULTS Among all children, uninsured rates declined from 12.1% in 2000 to 5.3% in 2014, with improvement across all 5 access indicators. Along with steep declines in the uninsured rate, Hispanic children had sizeable improvement for no doctor office (19.8% to 11.9%), no dental visit (43.2% to 21.8%), and no usual source of care (13.9% to 6.3%). Black children and those in poor and near-poor families also had large gains. Results from adjusted statistical interaction models showed more improvement for black and Hispanic children versus whites for 3 of 5 access indicators and for children in poor and near-poor families for 4 of 5 access indicators. CONCLUSIONS Children's access to health services has improved since 2000 with greater gains in vulnerable population groups. Findings support a need for continued support of health insurance for all children.
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Affiliation(s)
| | | | - Andrew D Racine
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Lynn M Olson
- Department of Research, American Academy of Pediatrics, Elk Grove Village, Illinois; and
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36
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Sommers BD, Gourevitch R, Maylone B, Blendon RJ, Epstein AM. Insurance Churning Rates For Low-Income Adults Under Health Reform: Lower Than Expected But Still Harmful For Many. Health Aff (Millwood) 2016; 35:1816-1824. [DOI: 10.1377/hlthaff.2016.0455] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Benjamin D. Sommers
- Benjamin D. Sommers ( ) is an assistant professor of health policy and economics in the Department of Health Policy and Management at the Harvard T. H. Chan School of Public Health, and an assistant professor of medicine at Harvard Medical School/Brigham and Women’s Hospital, all in Boston, Massachusetts
| | - Rebecca Gourevitch
- Rebecca Gourevitch is a research assistant at the Harvard T. H. Chan School of Public Health
| | - Bethany Maylone
- Bethany Maylone is a project manager in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health
| | - Robert J. Blendon
- Robert J. Blendon is the Richard L. Menschel Professor of Health Policy and Political Analysis in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health
| | - Arnold M. Epstein
- Arnold M. Epstein is the John H. Foster Professor of Health Policy and Management at the Harvard T. H. Chan School of Public Health
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37
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Abstract
BACKGROUND Transitions into and out of Medicaid, termed churning, may disrupt access to and continuity of care. Low-income, working adults who became eligible for Medicaid under the Affordable Care Act are particularly susceptible to income and employment changes that lead to churning. OBJECTIVE To compare health care use among adults who do and do not churn into and out of Medicaid. DATA Longitudinal data from 6 panels of the Medical Expenditure Panel Survey. METHODS We used differences-in-differences regression to compare health care use when adults reenrolled in Medicaid following a loss of coverage, to utilization in a control group of continuously enrolled adults. OUTCOME MEASURES Emergency department (ED) visits, ED visits resulting in an inpatient admission, and visits to office-based providers. RESULTS During the study period, 264 adults churned into and out of Medicaid and 627 had continuous coverage. Churning adults had an average of approximately 0.05 Medicaid-covered office-based visits per month 4 months before reenrolling in Medicaid, significantly below the rate of approximately 0.20 visits in the control group. Visits to office-based providers did not reach the control group rate until several months after churning adults had resumed Medicaid coverage. Our comparisons found no evidence of significantly elevated ED and inpatient admission rates in the churning group following reenrollment. CONCLUSIONS Adults who lose Medicaid tend to defer their use of office-based care to periods when they are insured. Although this suggests that enrollment disruptions lead to suboptimal timing of care, we do not find evidence that adults reenroll in Medicaid with elevated acute care needs.
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38
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Ray J, White M, Cannon P, Bowen C, O'Rourke K. Implementing the Florida Kidcare Open Enrollment Communications Campaign: A Framework for Mobilizing Community Partners to Reduce the Number of Uninsured Children. INTERNATIONAL QUARTERLY OF COMMUNITY HEALTH EDUCATION 2016; 26:365-77. [PMID: 17890182 DOI: 10.2190/iq.26.4.e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Florida ranks third among states with the lowest children's insurance coverage, due to constraints such as language barriers, multiple programs, documentation requirements, limited outreach, and short enrollment periods. In November 2004, Florida announced a 30-day children's health insurance enrollment period for January 2005 following an 18-month closure. This article describes the development, implementation, and evaluation of a communication plan creating coalitions between community partners, government agencies, and child advocacy groups to inform families. Over 96,000 families applied, almost five times any previous monthly enrollment. This campaign serves as a template for implementing strategies and engaging community partners to reduce the number of uninsured children.
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Affiliation(s)
- Jodi Ray
- Lawton and Rhea Chiles Center for Healthy Mothers and Babies, FL, USA
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39
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Wilson FA, Araz OM, Thompson RW, Ringle JL, Mason WA, Stimpson JP. A decision support tool to determine cost-to-benefit of a family-centered in-home program for at-risk adolescents. EVALUATION AND PROGRAM PLANNING 2016; 56:43-49. [PMID: 27031834 DOI: 10.1016/j.evalprogplan.2016.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 03/01/2016] [Accepted: 03/07/2016] [Indexed: 06/05/2023]
Abstract
Family-centered program research has demonstrated its effectiveness in improving adolescent outcomes. However, given current fiscal constraints faced by governmental agencies, a recent report from the Institute of Medicine and National Research Council highlighted the need for cost-benefit analyses to inform decision making by policymakers. Furthermore, performance management tools such as balanced scorecards and dashboards do not generally include cost-benefit analyses. In this paper, we describe the development of an Excel-based decision support tool that can be used to evaluate a selected family-based program for at-risk children and adolescents relative to a comparison program or the status quo. This tool incorporates the use of an efficient, user-friendly interface with results provided in concise tabular and graphical formats that may be interpreted without need for substantial training in economic evaluation. To illustrate, we present an application of this tool to evaluate use of Boys Town's In-Home Family Services (IHFS) relative to detention and out-of-home placement in New York City. Use of the decision support tool can help mitigate the need for programs to contract experts in economic evaluation, especially when there are financial or time constraints.
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Affiliation(s)
- Fernando A Wilson
- University of Nebraska Medical Center, College of Public Health, 984350 Nebraska Medical Center, Omaha, NE 68198-4350, United States.
| | - Ozgur M Araz
- University of Nebraska-Lincoln, College of Business Administration, 1240 R Street, Lincoln, NE 68588-0491, United States
| | - Ronald W Thompson
- Boys Town National Research Institute, 14100 Crawford St., Boys Town, NE 68010, United States
| | - Jay L Ringle
- Boys Town National Research Institute, 14100 Crawford St., Boys Town, NE 68010, United States
| | - W Alex Mason
- Boys Town National Research Institute, 14100 Crawford St., Boys Town, NE 68010, United States
| | - Jim P Stimpson
- City University of New York, CUNY Graduate School of Public Health and Health Policy, 55 W. 125th St., New York, NY 10027, United States
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40
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Tebb KP, Sedlander E, Bausch S, Brindis CD. Opportunities and Challenges for Adolescent Health Under the Affordable Care Act. Matern Child Health J 2016; 19:2089-93. [PMID: 25724539 DOI: 10.1007/s10995-015-1737-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The purpose of this commentary is to highlight some of the key policy changes under the Patient Protection and Affordable Care Act (ACA) that have the potential to improve health care services for adolescents as well as to draw attention to challenges that have yet to be addressed. This commentary stems from our prior policy research, which examined the extent to which the health care needs of adolescents were being considered in the early implementation phases of the ACA. This study was informed by a literature review and interviews with health care administrators, health policy researchers, and adolescent medicine specialists. The ACA has significantly expanded health insurance access; however, inequities in coverage and access remain. Primarily, the structure and financing of adolescent health care needs to be improved to better support the delivery of patient-centered, comprehensive care for this special population. Additionally, improvements in youths' awareness of their benefits under the ACA as well as a greater appreciation of preventive visits are critical. Furthermore, an unanticipated consequence of the ACA is that it exacerbates the risk of confidentiality breaches through explanation of benefits and electronic health records, which can compromise adolescents' access and utilization of health care services. Greater attention to improving and sustaining health promoting behaviors within the context of the ACA is critical for it to truly have a positive impact on adolescent health.
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Affiliation(s)
- Kathleen P Tebb
- University of California San Francisco, San Francisco, CA, USA.
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41
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Health insurance coverage, care accessibility and affordability for adult survivors of childhood cancer: a cross-sectional study of a nationally representative database. J Cancer Surviv 2016; 10:964-971. [PMID: 27072683 DOI: 10.1007/s11764-016-0542-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 04/02/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE We describe national patterns of health insurance coverage and care accessibility and affordability in a national sample of adult childhood cancer survivors (CCS) compared to adults without cancer. METHODS Using data from the 2010-2014 National Health Interview Survey (NHIS), we selected a sample of all CCS age 21 to 65 years old and a 1:3 matched sample of controls without a history of cancer. We examined insurance coverage, care accessibility and affordability in CCS and controls. We tested for differences in the groups in bivariate analyses and multivariable logistic regression models. RESULTS Of all respondents age 21-65 in the full NHIS sample, 443 (0.35 %) were CCS. Fewer CCS were insured (76.4 %) compared to controls (81.4 %, p = 0.067). Significantly more CCS reported delaying medical care (24.7 vs 13.0 %), needing but not getting medical care in the previous 12 months (20.0 vs 10.0 %), and having trouble paying medical bills (40.3 vs 19.7 %) compared to controls (p < 0.0001 for all). More CCS reported trouble with care affordability in the previous 12 months compared to controls on six categories of care and for a combined measure of affordability (p < 0.0001 for composite of all). Adjusted analyses demonstrated that these differences comparing CCS to controls remained significant. CONCLUSIONS CCS report problems with health care accessibility and affordability. These analyses support the development of policies to assure that CCS have access to affordable services. IMPLICATIONS FOR CANCER SURVIVORS Efforts to improve access to high-quality and affordable insurance for CCS may help reduce the gaps in getting medical care and problems with affordability. Health care providers should be aware that such problems exist and should discuss affordability and ability to obtain care with patients.
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42
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DeVoe JE, Tillotson CJ, Marino M, O'Malley J, Angier H, Wallace LS, Gold R. Trends in Type of Health Insurance Coverage for US Children and Their Parents, 1998-2011. Acad Pediatr 2016; 16:192-9. [PMID: 26297668 PMCID: PMC4758913 DOI: 10.1016/j.acap.2015.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/22/2015] [Accepted: 06/15/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine trends in health insurance type among US children and their parents. METHODS Using the Medical Expenditure Panel Survey (1998-2011), we linked each child (n = 120,521; weighted n ≈ 70 million) with his or her parent or parents and assessed patterns of full-year health insurance type, stratified by income. We examined longitudinal insurance trends using joinpoint regression and further explored these trends with adjusted regression models. RESULTS When comparing 1998 to 2011, the percentage of low-income families with both child and parent or parents privately insured decreased from 29.2% to 19.1%, with an estimated decline of -0.86 (95% confidence interval, -1.10, -0.63) unadjusted percentage points per year; middle-income families experienced a drop from 74.5% to 66.3%, a yearly unadjusted percentage point decrease of -0.73 (95% confidence interval, -0.98, -0.48). The discordant pattern of publicly insured children with uninsured parents increased from 10.4% to 27.2% among low-income families and from 1.4% to 6.7% among middle-income families. Results from adjusted models were similar to joinpoint regression findings. CONCLUSIONS During the past decade, low- and middle-income US families experienced a decrease in the percentage of child-parent pairs with private health insurance and pairs without insurance. Concurrently, there was a rise in discordant coverage patterns-mainly publicly insured children with uninsured parents.
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Affiliation(s)
- Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, Portland, Ore
| | - Carrie J Tillotson
- Division of Biostatistics, Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Ore
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, Portland, Ore; Division of Biostatistics, Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Ore
| | - Jean O'Malley
- Division of Biostatistics, Department of Public Health and Preventive Medicine, Oregon Health & Science University, Portland, Ore
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, Ore.
| | - Lorraine S Wallace
- Department of Family Medicine, The Ohio State University, Columbus, Ohio
| | - Rachel Gold
- Center for Health Research, Kaiser Permanente Northwest, Portland, Ore
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Smits-Seemann RR, Kaul S, Hersh AO, Fluchel MN, Boucher KM, Kirchhoff AC, Smits-Seemann RR, Kaul S, Hersh AO, Fluchel MN, Boucher KM, Kirchhoff AC. ReCAP: Gaps in Insurance Coverage for Pediatric Patients With Acute Lymphoblastic Leukemia. J Oncol Pract 2016; 12:175-6; e207-14. [DOI: 10.1200/jop.2015.005686] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
QUESTION ASKED: We sought to determine the likelihood that pediatric and adolescent acute lymphoblastic leukemia (ALL) patients experience a gap in health insurance coverage in the first 2 years of therapy. SUMMARY ANSWER: We found that 12% of patients with ALL in our sample who had insurance at diagnosis experienced a gap in insurance coverage during the first 2 years of therapy; that is, they had one or more clinic encounter at which they did not have insurance. Patients with public insurance at diagnosis were more likely to experience an insurance gap than those with private insurance at diagnosis, and those diagnosed in more recent years were less likely to experience a gap. METHODS/APPROACH: We determined insurance status at all clinic encounters at a tertiary children’s hospital within 2 years of diagnosis for patients diagnosed with ALL between 1998 and 2010, and calculated the odds of a gap occurring on the basis of demographic and diagnostic variables. BIAS, CONFOUNDING FACTOR(S), DRAWBACKS: Our assessment is from years before the roll-out of key Patient Protection and Affordable Care Act provisions, which should improve insurance coverage for pediatric and adolescent patients with ALL. In addition, we lacked information on patient or caregiver socioeconomic status, which may be important for explaining insurance gaps. Finally, our assessment is based on a single institution. REAL-LIFE IMPLICATIONS: Gaps in health insurance may exacerbate the financial and emotional burden associated with pediatric and adolescent cancer. Understanding the likelihood that these gaps will occur, as well as predictors of insurance gaps, will allow social workers and other providers to help families manage anticipated changes in insurance, with the goal of reducing unnecessary burden. [Figure: see text]
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Affiliation(s)
- Rochelle R. Smits-Seemann
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Sapna Kaul
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Aimee O. Hersh
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Mark N. Fluchel
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Kenneth M. Boucher
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Anne C. Kirchhoff
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children’s Hospital, Salt Lake City, UT
| | - Rochelle R. Smits-Seemann
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
| | - Sapna Kaul
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
| | - Aimee O. Hersh
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
| | - Mark N. Fluchel
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
| | - Kenneth M. Boucher
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
| | - Anne C. Kirchhoff
- University of Utah; Huntsman Cancer Institute, University of Utah; and Primary Children's Hospital, Salt Lake City, UT
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Shin J, Lee TJ, Cho SI, Choe SA. Factors Determining Children's Private Health Insurance Enrolment and Healthcare Utilization Patterns: Evidence From the 2008 to 2011 Health Panel Data. J Prev Med Public Health 2015; 48:319-29. [PMID: 26639746 PMCID: PMC4676645 DOI: 10.3961/jpmph.15.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 11/16/2015] [Indexed: 12/01/2022] Open
Abstract
Objectives: Parental socioeconomic status (SES) exerts a substantial influence on children’s health. The purpose of this study was to examine factors determining children’s private health insurance (PHI) enrolment and children’s healthcare utilization according to PHI coverage. Methods: Korea Health Panel data from 2011 (n=3085) was used to explore the factors determining PHI enrolment in children younger than 15 years of age. A logit model contained health status and SES variables for both children and parents. A fixed effects model identified factors influencing healthcare utilization in children aged 10 years or younger, using 2008 to 2011 panel data (n=9084). Results: The factors determining children’s PHI enrolment included children’s age and sex and parents’ educational status, employment status, and household income quintile. PHI exerted a significant effect on outpatient cost, inpatient cost, and number of admissions. Number of outpatient visits and total length of stay were not affected by PHI status. The interaction between PHI and age group increased outpatient cost significantly. Conclusions: Children’s PHI enrolment was influenced by parents’ SES, while healthcare utilization was affected by health and disability status. Therefore, the results of this study suggest disparities in healthcare utilization according to PHI enrollment.
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Affiliation(s)
- Jawoon Shin
- Preventive Medicine Program, Graduate School of Public Health, Seoul National University, Seoul, Korea.,Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Tae-Jin Lee
- Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Sung-il Cho
- Graduate School of Public Health, Seoul National University, Seoul, Korea
| | - Seung Ah Choe
- Preventive Medicine Program, Graduate School of Public Health, Seoul National University, Seoul, Korea.,Graduate School of Public Health, Seoul National University, Seoul, Korea
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DeVoe JE, Tillotson CJ, Angier H, Wallace LS. Predictors of children's health insurance coverage discontinuity in 1998 versus 2009: parental coverage continuity plays a major role. Matern Child Health J 2015; 19:889-96. [PMID: 25070735 DOI: 10.1007/s10995-014-1590-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To identify predictors of coverage continuity for United States children and assess how they have changed in the first 12 years since implementation of the Children's Health Insurance Program in 1997. Using data from the nationally-representative Medical Expenditure Panel Survey, we used logistic regression to identify predictors of discontinuity in 1998 and 2009 and compared differences between the 2 years. Having parents without continuous coverage was the greatest predictor of a child's coverage gap in both 1998 and 2009. Compared to children with at least one parent continuously covered, children whose parents did not have continuous coverage had a significantly higher relative risk (RR) of a coverage gap [RR 17.96, 95 % confidence interval (CI) 14.48-22.29 in 1998; RR 12.88, 95 % CI 10.41-15.93 in 2009]. In adjusted models, parental continuous coverage was the only significant predictor of discontinuous coverage for children (with one exception in 2009). The magnitude of the pattern was higher for privately-insured children [adjusted relative risk (aRR) 29.17, 95 % CI 20.99-40.53 in 1998; aRR 25.54, 95 % CI 19.41-33.61 in 2009] than publicly-insured children (aRR 5.72, 95 % CI 4.06-8.06 in 1998; aRR 4.53, 95 % CI 3.40-6.04 in 2009). Parental coverage continuity has a major influence on children's coverage continuity; this association remained even after public health insurance expansions for children. The Affordable Care Act will increase coverage for many adults; however, 'churning' on and off programs due to income fluctuations could result in coverage discontinuities for parents. If parental coverage instability persists, these discontinuities may continue to have a negative impact on children's coverage stability as well.
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Affiliation(s)
- Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode FM, Portland, OR, 97239, USA,
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D’Agostino JA, Passarella M, Saynisch P, Martin AE, Macheras M, Lorch SA. Preterm Infant Attendance at Health Supervision Visits. Pediatrics 2015; 136:e794-802. [PMID: 26416939 PMCID: PMC4586727 DOI: 10.1542/peds.2015-0745] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess the adherence of premature infants with the American Academy of Pediatrics health supervision visit schedule, factors affecting adherence, and the association of adherence with preventive care. METHODS Retrospective cohort of all infants ≤35 weeks' gestation, born 2005 to 2009, receiving care at a 30-site primary care network for at least 24 months (n = 1854). Adherence was defined as having a health supervision visit within each expected time period during the first 18 months of life. Logistic regression identified sociodemographic and medical factors associated with nonadherence and risk-adjusted association between nonadherence and outcomes. RESULTS Only 43% received all expected health supervision visits. Those with Medicaid insurance (adjusted odds ratio [AOR] 0.46, 95% confidence interval [CI] 0.35-0.60), a visit without insurance (AOR 0.46, 95% CI 0.32-0.67), chronic illness (AOR 0.7, 95% CI 0.51-0.97), and black race (AOR 0.7, 95% CI 0.50-0.98) were less adherent, whereas provider continuity of care (AOR 2.89, 95% CI 1.92-4.37) and lower birth weight (AOR 1.67, 95% CI 1.02-2.73) increased adherence. Infants <100% adherent were less likely to be up to date with immunizations and receive recommended preventive care. In nearly half of missed visit windows, no health supervision visit was scheduled. CONCLUSIONS Fewer than half of premature infants were fully adherent with the preventive health schedule with associated gaps in health monitoring and immunization delays. These data suggest the importance of health supervision visits and the need to explore scheduling facilitators for those at risk for nonadherence.
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Affiliation(s)
- Jo Ann D’Agostino
- Department of Pediatrics, and,Center for Outcomes Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Molly Passarella
- Center for Outcomes Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Philip Saynisch
- Center for Outcomes Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ashley E. Martin
- Center for Outcomes Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle Macheras
- Center for Outcomes Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Scott A. Lorch
- Department of Pediatrics, and,Center for Outcomes Research, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania;,The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; and,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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Ward BW, Martinez ME. Health Insurance Status and Psychological Distress among U.S. Adults Aged 18-64 Years. Stress Health 2015; 31:324-35. [PMID: 24403273 PMCID: PMC4658514 DOI: 10.1002/smi.2559] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 11/06/2013] [Accepted: 11/20/2013] [Indexed: 11/07/2022]
Abstract
The purpose of this research was to examine the relationship between psychological distress and aspects of health insurance status, including lack of coverage, types of coverage and disruption in coverage, among US adults. Data from the 2001-2010 National Health Interview Survey were used to conduct analyses representative of the US adult population aged 18-64 years. Multivariate analyses regressed psychological distress on health insurance status while controlling for covariates. Adults with private or no health insurance coverage had lower levels of psychological distress than those with public/other coverage. Adults who recently (≤1 year) experienced a change in health insurance status had higher levels of distress than those who had not recently experienced a change. An interaction effect indicated that the relationship between recent change in health insurance status and distress was not dependent on whether an adult had private versus public/other coverage. However, for adults who had not experienced a change in status in the past year, the average absolute level of distress is higher among those with no coverage versus private coverage. Although significant relationships between psychological distress and health insurance status were identified, their strength was modest, with other demographic and health condition covariates also being potential sources of distress. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.
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Affiliation(s)
- Brian W. Ward
- Division of Health Interview Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, United States,Correspondence: Brian W. Ward, Division of Health Interview Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, 3311 Toledo Road, Room 2330, Hyattsville, MD 20782, United States
| | - Michael E. Martinez
- Division of Health Interview Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, United States
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48
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Angier H, Marino M, Sumic A, O'Malley J, Likumahuwa-Ackman S, Hoopes M, Nelson C, Gold R, Cohen D, Dickerson K, DeVoe JE. Innovative methods for parents and clinics to create tools for kids' care (IMPACCT Kids' Care) study protocol. Contemp Clin Trials 2015; 44:159-163. [PMID: 26291916 DOI: 10.1016/j.cct.2015.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/11/2015] [Accepted: 08/13/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite expansions in public health insurance, many children remain uninsured or experience gaps in coverage. Community health centers (CHCs) provide primary care to many children at risk for uninsurance and are well-positioned to help families obtain and retain children's coverage. Recent advances in health information technology (HIT) capabilities provide the means to create tools that could enhance CHCs' insurance outreach efforts. OBJECTIVE To present the study design, baseline patient characteristics, variables, and statistical methods for the Innovative Methods for Parents And Clinics to Create Tools for Kids' Care (IMPACCT Kids' Care) study. METHODS/DESIGN In this mixed methods study, we will design, test and refine health insurance outreach HIT tools through a user-centered process. We will then implement the tools in four CHCs and evaluate their effectiveness and barriers and facilitators to their implementation. To measure effectiveness, we will quantitatively assess health insurance coverage continuity and utilization of healthcare services for pediatric patients in intervention CHCs compared to matched control sites using electronic health record (EHR) and Oregon Medicaid administrative data over 18months pre- and 18months post-implementation (n=34,867 children). We will also qualitatively assess the implementation process to understand how the tools fit into the clinics' workflows and the CHC staff experiences with the tools. CONCLUSIONS This study creates, implements, and evaluates health insurance outreach HIT tools. The use of such tools will likely improve care delivery and health outcomes, reduce healthcare disparities for vulnerable populations, and enhance overall healthcare system performance. ClinicalTrials.gov Identifier: NCT02298361.
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Affiliation(s)
| | | | | | | | | | | | | | - Rachel Gold
- OCHIN, Inc., USA; Kaiser Permanente Center for Health Research, USA
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Use of qualitative methods and user-centered design to develop customized health information technology tools within federally qualified health centers to keep children insured. J Ambul Care Manage 2015; 37:148-54. [PMID: 24594562 DOI: 10.1097/jac.0000000000000016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lack of health insurance negatively impacts children's health. Despite federal initiatives to expand children's coverage and accelerate state outreach efforts, millions of US children remain uninsured or experience frequent gaps in coverage. Most current efforts to enroll and retain eligible children in public insurance programs take place outside of the health care system. This study is a partnership between patients' families, medical informaticists, federally qualified health center (FQHC) staff, and researchers to build and test information technology tools to help FQHCs reach uninsured children and those at risk for losing coverage.
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50
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Gold R, Burdick T, Angier H, Wallace L, Nelson C, Likumahuwa-Ackman S, Sumic A, DeVoe JE. Improve Synergy Between Health Information Exchange and Electronic Health Records to Increase Rates of Continuously Insured Patients. EGEMS 2015; 3:1158. [PMID: 26355818 PMCID: PMC4562735 DOI: 10.13063/2327-9214.1158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Introduction: The Affordable Care Act increases health insurance options, yet many Americans may struggle to consistently maintain coverage. While health care providers have traditionally not been involved in providing insurance enrollment support to their patients, the ability for them to do so now exists. We propose that providers could capitalize on the expansion of electronic health records (EHRs) and the advances in health information exchanges (HIEs) to improve their patients’ insurance coverage rates and continuity. Evidence for Argument: We describe a project in which we are building strategies for linking, and thus improving synergy between, payer and EHR data. Through this effort, care teams will have access to new automated tools and increased EHR functionality designed to help them assist their patients in obtaining and maintaining health insurance coverage. Suggestion for the Future: The convergence of increasing EHR adoption, improving HIE functionality, and expanding insurance coverage options, creates new opportunities for clinics to help their patients obtain public health insurance. Harnessing this nascent ability to exchange information between payers and providers may improve synergies between HIE and EHRs, and thus support clinic-based efforts to keep patients continuously insured.
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Affiliation(s)
- Rachel Gold
- OCHIN ; Kaiser Permanente Center for Health Research
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