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Gutiérrez Á, López-Anuarbe M, Webster NJ, Mahmoudi E. Rural-Urban Health Care Cost Differences Among Latinx Adults With and Without Dementia in the United States. J Aging Health 2024; 36:559-569. [PMID: 37899581 DOI: 10.1177/08982643231207517] [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: 10/31/2023]
Abstract
OBJECTIVES To compare rural-urban health care costs among Latinx adults ages 51+ and examine variations by dementia status. METHODS Data are from the Health and Retirement Study (2006-2018 waves; n = 15,567). We inflation-adjusted all health care costs using the 2021 consumer price index. Geographic context and dementia status were the main exposure variables. We applied multivariate two-part generalized linear models and adjusted for sociodemographic and health characteristics. RESULTS Rural residents had higher total health care costs, regardless of dementia status. Total health care costs were $850 higher in rural ($2,640) compared to urban ($1,789) areas (p < .001). Out-of-pocket costs were $870 higher in rural ($2,677) compared to urban ($1,806) areas (p < .001). Dementia status was not an effect modifier. DISCUSSION Health care costs are disproportionately higher among Latinx rural, relative to urban, residents. Addressing health care costs among Latinx rural residents is a public health priority.
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Affiliation(s)
- Ángela Gutiérrez
- Department of Social Medicine, Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA
| | | | - Noah J Webster
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Elham Mahmoudi
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
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Gutiérrez Á, Cronin CE, Franz B, Muniz-Terrera G. Alzheimer's Centers in US Hospitals: Enough to Adequately Address Dementia Care Nationwide? J Aging Health 2024; 36:458-470. [PMID: 37699204 DOI: 10.1177/08982643231200691] [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: 09/14/2023]
Abstract
Objectives: To investigate the availability of Alzheimer's Centers (ACs) in US hospitals. Methods: Utilizing the American Hospital Association Annual Survey, Area Health Resource File, and US Census (n = 3251), we employed multivariable logistic regression to examine hospital, county, and regional predictors of AC availability. Results: Large hospitals (>399 beds) had approximately 14 times higher odds of having an AC than small hospitals (<50 beds; OR = 14.0; 95% CI = 6.44 - 30.46). Counties with a higher proportion of Latino residents, relative to non-Latino Whites, had lower odds of having an AC (OR = .05; 95% CI = .01 - .41). Northeastern (OR = 1.92; 95% CI = 1.15 - 3.22) and Midwestern (OR = 2.12; 95% CI = 1.34 - 3.37) hospitals had higher odds of having an AC than Southern hospitals. Discussion: To address dementia needs and disparities, investment in a national infrastructure is critical.
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Affiliation(s)
- Ángela Gutiérrez
- Department of Social Medicine, Heritage College of Osteopathic Medicine, Ohio University, Athens OH, USA
| | - Cory E Cronin
- College of Health Sciences and Professions, Ohio University, Athens OH, USA
| | - Berkeley Franz
- Department of Social Medicine, Heritage College of Osteopathic Medicine, Ohio University, Athens OH, USA
| | - Graciela Muniz-Terrera
- Department of Social Medicine, Heritage College of Osteopathic Medicine, Ohio University, Athens OH, USA
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Valera P, Malarkey S, Smith N, McLaughlin C. Exploring the role of telehealth: A novel approach to group-based smoking cessation treatment for men incarcerated in a rural state prison. J Telemed Telecare 2024; 30:142-150. [PMID: 34524911 DOI: 10.1177/1357633x211034734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Tobacco smoking remains an important public health issue in the United States (US), specifically among people who are incarcerated. There is little to no information about smoking behaviors of incarcerated people in rural areas and there is a lack of resources for smoking cessation interventions in rural settings. Telehealth might be efficient for delivering care to incarcerated people in rural areas. The purpose of this study was to determine the feasibility of delivering group-based smoking cessation treatment via telehealth to incarcerated male smokers in a rural prison. METHODS A 6-week group-based smoking cessation treatment program was conducted with 1-month follow up. Video conferencing was used from Weeks 2-5 to deliver treatment. A cross-sectional survey was administered collecting measures including criminal justice experience, smoking behaviors, withdrawal and triggers, mental health, physical health, and substance use. Baseline exhaled carbon monoxide (CO) levels were collected at Session 1, and a final CO level at Session 6 and 1-month follow-up. RESULTS Twenty (n = 20) incarcerated male smokers were recruited from a rural prison facility. The majority of the inmates were White (85%). Approximately, 80% of the inmates smoked about 20 or more cigarettes per day, and on average smoked for 28 years (SD = 9). Most inmates scored a moderate or high dependence score on the Fagerström Test for Nicotine Dependence. CONCLUSION Telehealth programs such as video conferencing smoking cessation treatment ought to be implemented to reduce tobacco-related disparities among incarcerated smokers housed in rural prisons.
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Affiliation(s)
- Pamela Valera
- School of Public Health, Rutgers the State University of New Jersey, USA
| | - Sarah Malarkey
- School of Public Health, Rutgers the State University of New Jersey, USA
| | - Nadia Smith
- School of Public Health, Rutgers the State University of New Jersey, USA
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Heindl B, Howard G, Clarkson S, Kamin Mukaz D, Lackland D, Muntner P, Jackson EA. Urban-rural differences in hypertension prevalence, blood pressure control, and systolic blood pressure levels. J Hum Hypertens 2023; 37:1112-1118. [PMID: 37407675 DOI: 10.1038/s41371-023-00842-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 09/05/2022] [Accepted: 05/30/2023] [Indexed: 07/07/2023]
Abstract
Higher rates of cardiovascular events have been observed among rural residents compared with urban. Hypertension and lack of blood pressure (BP) control are risk factors for cardiovascular events. We compared the prevalence of hypertension and controlled BP, and the distribution of systolic blood pressure (SBP), by urban-rural residence. Participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study, a prospective cohort of Black and White adults aged ≥45 years, were categorized as either urban, large rural, or small-isolated rural, by using the Rural-Urban Commuting Area (RUCA) categorization B system. Oucomes were hypertension prevalence (BP ≥ 140/90 mmHg or antihypertensive use), BP control (BP < 140/90 among participants on antihypertensive medication), and the distribution of SBP. Counfounders were age, race, sex, antihypertensive medication use, and US Census Bureau division. The analysis included 26,133 participants (80.3% urban, 11.6% large-rural, 8.2% small-isolated rural). The unadjusted prevalence of hypertension was not different between groups. However, after adjustment, the odds of hypertension was higher among participants in the large rural group (odds ratio [OR] 1.17; 95% confidence interval [CI], 1.08-1.27) and small-isolated rural group (OR 1.19; 95% CI, 1.08-1.30), compared with the urban group. There was no evidence of an adjusted difference in BP control for those taking antihypertensive medications. Adjusted differences in SBP were greater for both rural groups, compared with urban, at the higher percentiles of SBP. Rural residence was associated with a higher adjusted odds of hypertension and higher SBP.
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Affiliation(s)
- Brittain Heindl
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stephen Clarkson
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Debora Kamin Mukaz
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Daniel Lackland
- Department of Neurology, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Paul Muntner
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elizabeth A Jackson
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA.
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Willingness to Pay to Improve Quality of Public Healthcare Services in Mauritius. Healthcare (Basel) 2021; 10:healthcare10010043. [PMID: 35052206 PMCID: PMC8774898 DOI: 10.3390/healthcare10010043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 11/17/2022] Open
Abstract
Mauritius has a universal free healthcare system, based on the Beveridge model which is financed by taxpayers. There are growing considerations over improving quality of healthcare services. The purpose of the study is to employ a contingency valuation (CV) to investigate the willingness of Mauritians people to pay to improve the quality of public healthcare services and the associated determinants using the double-bounded dichotomous choice model. A drop off survey with a sample size of 974 respondents from the working population is used. The empirical analysis shows that the majority of the sample was willing to pay for improving quality of public healthcare services. Other than the conventional determinants of respondents’ demographic and socioeconomic characteristics, the findings support the assertion that psycho-social constructs such as the Theory of Planned Behaviour, Norm-Activation, Public Good Theory, and Perceived Response Efficacy are found to significantly affect Willingness-to-Pay (WTP). The results of this study might be of use to policymakers to help with both priority setting and fund allocation.
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Karim MA, Singal AG, Ohsfeldt RL, Morrisey MA, Kum HC. Health services utilization, out-of-pocket expenditure, and underinsurance among insured non-elderly cancer survivors in the United States, 2011-2015. Cancer Med 2021; 10:5513-5523. [PMID: 34327859 PMCID: PMC8366084 DOI: 10.1002/cam4.4103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND High out-of-pocket (OOP) expenditure and inadequate insurance coverage may adversely affect cancer survivors. We aimed to characterize the extent and correlates of healthcare utilization, OOP expenditures, and underinsurance among insured cancer survivors. METHODS We used 2011-2015 Medical Expenditure Panel Survey data to identify a nationally representative sample of insured non-elderly adult (age 18-64 years) cancer survivors. We used negative binomial, two-part (logistic and Generalized Linear Model with log link and gamma distribution), and logistic regression models to quantify healthcare utilization, OOP expenditures, and underinsurance, respectively, and identified sociodemographic correlates for each outcome. RESULTS We identified 2738 insured non-elderly cancer survivors. Adjusted average utilization of ambulatory, non-ambulatory, prescription medication, and dental services was 14.4, 0.51, 24.9, and 1.4 events per person per year, respectively. Higher ambulatory and dental services utilization were observed in older adults, females, non-Hispanic Whites, survivors with a college degree and high income, compared to their counterparts. Nearly all (97.7%) survivors had some OOP expenditures, with a mean adjusted OOP expenditure of $1552 per person per year. Adjusted mean OOP expenditures for ambulatory, non-ambulatory, prescription medication, dental, and other health services were $653, $161, $428, $194, and $83, respectively. Sociodemographic variations in service-specific OOP expenditures were generally consistent with respective utilization patterns. Overall, 8.8% of the survivors were underinsured. CONCLUSION Many insured non-elderly cancer survivors allocate a substantial portion of their OOP expenditure for healthcare-related services and experience financial vulnerability, resulting in nearly 8.8% of the survivors being underinsured. Utilization of healthcare services varies across sociodemographic groups.
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Affiliation(s)
- Mohammad A Karim
- Population Informatics Laboratory, Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Amit G Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert L Ohsfeldt
- Population Informatics Laboratory, Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Michael A Morrisey
- Population Informatics Laboratory, Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Hye-Chung Kum
- Population Informatics Laboratory, Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX, USA
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Fairfield KM, Black AW, Ziller EC, Murray K, Lucas FL, Waterston LB, Korsen N, Ineza D, Han PKJ. Area Deprivation Index and Rurality in Relation to Lung Cancer Prevalence and Mortality in a Rural State. JNCI Cancer Spectr 2020; 4:pkaa011. [PMID: 32676551 PMCID: PMC7353952 DOI: 10.1093/jncics/pkaa011] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/03/2020] [Accepted: 02/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background We sought to describe lung cancer prevalence and mortality in relation to socioeconomic deprivation and rurality. Methods We conducted a population-based cross-sectional analysis of prevalent lung cancers from a statewide all-payer claims dataset from 2012 to 2016, lung cancer deaths in Maine from the state death registry from 2012 to 2016, rurality, and area deprivation index (ADI), a geographic area-based measure of socioeconomic deprivation. Analyses examined rate ratios for lung cancer prevalence and mortality according to rurality (small and isolated rural, large rural, or urban) and ADI (quintiles, with highest reflecting the most deprivation) and after adjusting for age, sex, and area-level smoking rates as determined by the Behavioral Risk Factor Surveillance System. Results Among 1 223 006 adults aged 20 years and older during the 5-year observation period, 8297 received lung cancer care, and 4616 died. Lung cancer prevalence and mortality were positively associated with increasing rurality, but these associations did not persist after adjusting for age, sex, and smoking rates. Lung cancer prevalence and mortality were positively associated with increasing ADI in models adjusted for age, sex, and smoking rates (prevalence rate ratio for ADI quintile 5 compared with quintile 1 = 1.41, 95% confidence interval [CI] =1.30 to 1.54) and mortality rate ratio = 1.59, 95% CI = 1.41 to 1.79). Conclusion Socioeconomic deprivation, but not rurality, was associated with higher lung cancer prevalence and mortality. Interventions should target populations with socioeconomic deprivation, rather than rurality per se, and aim to reduce lung cancer risk via tobacco treatment and control interventions and to improve patient access to lung cancer prevention, screening, and treatment services.
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Affiliation(s)
- Kathleen M Fairfield
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME 04101, USA
| | - Adam W Black
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME 04101, USA
| | - Erika C Ziller
- Muskie School of Public Service, University of Southern Maine, Portland, ME 04101, USA
| | - Kimberly Murray
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME 04101, USA
| | - F Lee Lucas
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME 04101, USA
| | - Leo B Waterston
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME 04101, USA
| | - Neil Korsen
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME 04101, USA
| | | | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME 04101, USA
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Haakenstad A, Hawkins SS, Pace LE, Cohen J. Rural-urban disparities in colonoscopies after the elimination of patient cost-sharing by the Affordable Care Act. Prev Med 2019; 129:105877. [PMID: 31669176 DOI: 10.1016/j.ypmed.2019.105877] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/02/2019] [Accepted: 10/23/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Improving the prevention and early detection of colorectal cancer is a priority for reducing rural-urban disparities in colorectal cancer mortality. By eliminating out-of-pocket (OOP) costs for preventive colonoscopies, the Affordable Care Act (ACA) could have reduced rural-urban disparities in screening. METHODS We used the Maine Health Data Organization All-Payer Claims Database including all commercially-insured and Medicare beneficiaries aged 50-75 between 2009 and 2012. Rural-urban commuting areas were used to classify rural/urban residence. ICD-9 and CPT codes identified colonoscopies. We summed all OOP payments per patient-day. An interrupted time series model estimated the impact of the ACA on trends in rural-urban disparities in colonoscopy rates and OOP costs. RESULTS Before the ACA, colonoscopy rates were 16% lower in rural than urban areas (5.1% vs. 6.1% of enrollees annually) and median OOP costs were nearly double ($195 vs. $98). The ACA reduced median OOP payments by $94 (p = .001) initially and $4 monthly (p = .038) in rural areas, and $63 (p < .001) in urban areas. The rural-urban gap in OOP payments dropped by $4 monthly (p = .007). The ACA also reduced rural-urban disparities in colonoscopy rates (disparity decrease of 0.005 (6%) monthly, p < .001). The rural-urban gap in colonoscopy rates declined 40% relative to the pre-ACA period by December 2012. CONCLUSIONS The ACA was associated with significant reductions in rural-urban disparities in colonoscopies in Maine, suggesting that OOP costs are an important barrier for rural residents. Further research is needed to determine whether increased uptake, particularly in rural areas, translated into better patient outcomes for colorectal cancer.
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Affiliation(s)
- Annie Haakenstad
- Harvard T.H. Chan School of Public Health, United States of America.
| | | | - Lydia E Pace
- Brigham and Women's Hospital, United States of America
| | - Jessica Cohen
- Harvard T.H. Chan School of Public Health, United States of America
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Oyarte M, Espinoza M, Balmaceda C, Villegas R, Cabieses B, Díaz J. Out-of-Pocket Expenditures in Health and Medications in Chile: Comparative Analysis Between 1997, 2007, and 2012. Value Health Reg Issues 2018; 17:202-209. [DOI: 10.1016/j.vhri.2018.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 07/31/2018] [Accepted: 09/04/2018] [Indexed: 10/27/2022]
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Zimmermann K, Carnahan LR, Paulsey E, Molina Y. Health care eligibility and availability and health care reform: Are we addressing rural women's barriers to accessing care? J Health Care Poor Underserved 2018; 27:204-219. [PMID: 27818424 DOI: 10.1353/hpu.2016.0177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Rural populations in the U.S. face numerous barriers to health care access. The Patient Protection and Affordable Care Act (PPACA) was developed in part to reduce health care access barriers. We report rural women's access barriers and the PPACA elements that address these barriers as well as potential gaps. METHODS For this qualitative study, we analyzed two datasets using a common framework. We used content analysis to understand rural, focus group participants' access barriers prior to PPACA implementation. Subsequently, we analyzed the PPACA text. RESULTS Participants described health care access barriers in two domains: availability and eligibility. The PPACA proposes solutions within each domain, including health care workforce training, Medicaid expansion, and employer-based health care provisions. However, in rural settings, access barriers likely persist. DISCUSSION While elements of the PPACA address some health care access barriers, additional research and policy development are needed to comprehensively and equitably address persistent access barriers for rural women.
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Talbot JA, Ziller EC, Szlosek DA. Mental Health First Aid in Rural Communities: Appropriateness and Outcomes. J Rural Health 2016; 33:82-91. [DOI: 10.1111/jrh.12173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Jean A. Talbot
- Maine Rural Health Research Center, Muskie School of Public Service; Cutler Institute for Health and Social Policy, University of Southern Maine; Portland Maine
| | - Erika C. Ziller
- Maine Rural Health Research Center, Muskie School of Public Service; Cutler Institute for Health and Social Policy, University of Southern Maine; Portland Maine
| | - Donald A. Szlosek
- Maine Rural Health Research Center, Muskie School of Public Service; Cutler Institute for Health and Social Policy, University of Southern Maine; Portland Maine
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Baird KE. The incidence of high medical expenses by health status in seven developed countries. Health Policy 2015; 120:26-34. [PMID: 26694137 DOI: 10.1016/j.healthpol.2015.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 10/03/2015] [Accepted: 10/14/2015] [Indexed: 10/22/2022]
Abstract
Health care policy seeks to ensure that citizens are protected from the financial risk associated with needing health care. Yet rising health care costs in many countries are leading to a greater reliance on out-of-pocket (OOP) measures. This paper uses 2010 household survey data from seven countries to measure and compare the burden OOP expenses place on individuals. It compares countries based on the extent to which citizens with health problems devote a large share of their income to OOP expenses. The paper finds that in all countries but France, and to a lesser extent Slovenia, citizens with health problems face considerably higher medical costs than do those without. As many as one-quarter of less healthy citizens in the US, Poland, Russia and Israel devote a large share of their income to OOP expenses. The paper also finds a strong cross-national correlation between the degree to which citizens face high OOP expenses, and the disparities in OOP expenses between those with and without health problems. The levels of high OOP spending uncovered, and their inequitable impact on those with health problems in the seven countries, underscore the potential for OOP measures to undermine core objectives of health care systems, including those of equitable financing, equal access, and improved health among the population.
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Affiliation(s)
- Katherine Elizabeth Baird
- Division of Politics, Philosophy and Public Affairs, University of Washington Tacoma, 1900 Commerce Street, Tacoma, WA 98402, United States.
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Hill SK, Cantrell P, Edwards J, Dalton W. Factors Influencing Mental Health Screening and Treatment Among Women in a Rural South Central Appalachian Primary Care Clinic. J Rural Health 2015; 32:82-91. [PMID: 26249659 DOI: 10.1111/jrh.12134] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Some of the most significant mental health concerns among US adults are depression, anxiety, substance abuse, and intimate partner violence. These concerns represent an ever-growing portion of the primary care population, especially in rural areas. However, few studies have examined factors influencing screening and treatment of these concerns by primary care providers, particularly in Appalachia. This study explores barriers and facilitators to mental health screening and treatment among women at a rural, primary care clinic in Appalachia. METHODS Eighteen patients and 4 providers were interviewed face-to-face. Thematic analysis was used to identify emergent themes. FINDINGS Patients identified 3 barriers (stigma, lack of support, and lack of education) and 2 facilitators (integrated care and positive experiences with providers). Providers identified 4 barriers (operational barriers, mental health competence, predicted patient reactions, and patient attitudes) and 3 facilitators (clinic characteristics, provider characteristics, and patient and provider education). Generally, patients focused more on individual and social factors influencing mental health service use, while providers were more aware of training gaps, logistical factors at the clinic, and systemic issues within the larger health care system. Both participant types emphasized specific interpersonal qualities and the importance of integrated services. CONCLUSIONS Screening and treatment may be influenced by the availability and advertisement of integrated services, institutional support, strong patient-provider relationships, and provider training and experience. For rural south central Appalachia women, limited mental health resources may make these factors even more salient.
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Affiliation(s)
- Sarah K Hill
- Clinical Psychology Department, East Tennessee State University, Johnson City, Tennessee
| | - Peggy Cantrell
- Clinical Psychology Department, East Tennessee State University, Johnson City, Tennessee
| | - Joellen Edwards
- Center for Nursing Research, East Tennessee State University, Johnson City, Tennessee
| | - Will Dalton
- Clinical Psychology Department, East Tennessee State University, Johnson City, Tennessee
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Rural-Urban Differences in Health Care Expenditures: Empirical Data from US Households. ADVANCES IN PUBLIC HEALTH 2014. [DOI: 10.1155/2014/435780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Purpose. To estimate the rural-urban differences in expenditures of outpatient care, hospital inpatient care, hospital emergency room services, medications, and total services.Methods. This cross-sectional study used data from the 2010 Medical Expenditure Panel Survey. The overall sample size for the study was 22,772. Weighted frequencies, means, or percentages were estimated to illustrate the distribution of each variable. Five two-part utilization models were then fit to determine the likelihood of having nonzero expenses and to identify how residence in a rural versus urban area affected expenditures in our five expense categories. Quantile regressions were estimated to further explore relationships between residence and each quantile of nonzero expenditure.Results. The results of two-part model suggest that rural populations spent more on medications, while urban populations spent more on emergency care. However, no rural-urban difference was found in total health expenditures. The results of quantile regressions suggest that the highest users (at the upper quantiles) of medication and total expenditure experienced the strongest positive effects of living in rural areas.Conclusions. Total health expenditures do not seem to vary significantly across urban and rural areas. However, rurality does have important effects on those who make the most use of outpatient care and prescription medications. Reviewing total health expenditures for urban and rural populations is not enough. Policymakers should monitor the effects of geographic differences, especially in the highest expenditure quantiles, for specific types of health expenditures. Differences in the influence of rurality across this distribution of health expenditures may provide important guidance for interventions.
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Abstract
BACKGROUND Millions of adults will gain Medicaid or private insurance in 2014 under the Affordable Care Act, and prior research shows that underinsurance is common among middle-income adults. Less is known about underinsurance among low-income adults, particularly those with public insurance. OBJECTIVE To compare rates of underinsurance among low-income adults with private versus public insurance, and to identify predictors of being underinsured. DESIGN Descriptive and multivariate analysis of data from the 2005-2008 Medical Expenditure Panel Survey. PARTICIPANTS Adults 19-64 years of age with family income less than 125 % of the Federal Poverty Level (FPL) and full-year continuous coverage in one of four mutually exclusive insurance categories (N = 5,739): private insurance, Medicaid, Medicare, and combined Medicaid/Medicare coverage. MAIN MEASURES Prevalence of underinsurance among low-income adults, defined as out-of-pocket expenditures greater than 5 % of household income, delays/failure to obtain necessary medical care due to cost, or delays/failure to obtain necessary prescription medications due to cost. KEY RESULTS Criteria for underinsurance were met by 34.5 % of low-income adults. Unadjusted rates of underinsurance were 37.7 % in private coverage, 26.0 % in Medicaid, 65.1 % in Medicare, and 45.1 % among Medicaid/Medicare dual enrollees. Among underinsured adults, household income averaged $6,181 and out-of-pocket spending averaged $1,115. Due to cost, 8.1 % and 12.8 % deferred or delayed obtaining medical care or prescription medications, respectively. Predictors of underinsurance included being White, unemployed, and in poor health. After multivariate adjustment, Medicaid recipients were significantly less likely to be underinsured than privately insured adults (OR 0.22, 95 % CI 0.17-0.28). CONCLUSIONS Greater than one-third of low-income adults nationally were underinsured. Medicaid recipients were less likely to be underinsured than privately insured adults, indicating potential benefits of expanded Medicaid under health care reform. Nonetheless, more than one-quarter of Medicaid recipients were underinsured, highlighting the importance of addressing cost-related barriers to care even among those with public coverage.
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Affiliation(s)
- Hema Magge
- Division of General Pediatrics,, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Talbot JA, Coburn A, Croll Z, Ziller E. Rural considerations in establishing network adequacy standards for qualified health plans in state and regional health insurance exchanges. J Rural Health 2013; 29:327-35. [PMID: 23802935 DOI: 10.1111/jrh.12012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The Affordable Care Act (ACA) requires Health Insurance Exchanges (HIEs) to specify network adequacy standards for the Qualified Health Plans (QHPs) they offer to consumers. This article examines rural issues surrounding network adequacy standards, and offers recommendations for crafting standards that optimize rural access. METHOD This policy analysis reviews ACA requirements for QHP network adequacy standards, considering Medicaid managed care and Medicare Advantage (MA) standards as models. We analyze the implications of stringent vs flexible access standards in terms of how choices might affect health plans' participation in rural markets and rural enrollees' access to care. Finally, we propose strategies for designing standards with the degree of flexibility most likely to benefit rural consumers. FINDINGS A traditional approach to safeguarding rural access is to impose strict network adequacy standards on plans in rural areas. However, if strict standards prove difficult to meet due to rural provider scarcity, they might diminish QHPs' willingness to serve rural areas. Thus, they could exacerbate rather than alleviate rural access problems. CONCLUSIONS To benefit rural communities, network adequacy standards must be strong enough to provide real protections for beneficiaries, yet flexible enough to accommodate rural delivery system constraints and remain attainable for QHPs. Useful strategies to achieve this balance might include: adjusting standards according to degrees of rurality and rural utilization norms; counting midlevel clinicians toward fulfillment of patient-provider ratios; and allowing plans to ensure rural access through delivery system innovations such as telehealth.
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Affiliation(s)
- Jean A Talbot
- Muskie School of Public Service, University of Southern Maine, Portland, Maine 04103, USA. jean.talbot@.maine.edu
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Lavelle B, Lorenz FO, Wickrama KAS. What Explains Divorced Women's Poorer Health?: The Mediating Role of Health Insurance and Access to Health Care in a Rural Iowan Sample *. RURAL SOCIOLOGY 2012; 77:601-625. [PMID: 23457418 PMCID: PMC3583357 DOI: 10.1111/j.1549-0831.2012.00091.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The economic restructuring in rural areas in recent decades has been accompanied by rising marital instability. To examine the implications of the increase in divorce for the health of rural women, we examine how marital status predicts adequacy of health insurance coverage and health care access, and whether these factors help to account for the documented association between divorce and later illness. Analyzing longitudinal data from a cohort of over 400 married and recently divorced rural Iowan women, we decompose the total effect of divorce on physical illness a decade later using structural equation modeling. Divorced women are less likely to report adequate health insurance in the years following divorce, inhibiting their access to medical care and threatening their physical health. Full-time employment acts as a buffer against insurance loss for divorced women. The growth of marital instability in rural areas has had significant ramifications for women's health; the decline of adequate health insurance coverage following divorce explains a component of the association between divorced status and poorer long-term health outcomes.
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Lavarreda SA, Brown ER, Bolduc CD. Underinsurance in the United States: an interaction of costs to consumers, benefit design, and access to care. Annu Rev Public Health 2011; 32:471-82. [PMID: 21219167 DOI: 10.1146/annurev.publhealth.012809.103655] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Underinsurance is most commonly defined as the state in which people with medical coverage are still exposed to financial risk. We argue that the adequacy of health insurance coverage should also be assessed in terms of the adequacy of specific benefits coverage and access to care. Underinsurance can be understood conceptually as comprising three separate domains: (a) the economic features of health insurance, (b) the benefits covered, and (c) access to health services. The literature provides ample evidence that people who are underinsured have high financial risk and face barriers in access to care similar to those who are completely uninsured. In response to the growing recognition of the problems associated with underinsurance, the Patient Protection and Affordable Care Act of 2010 includes numerous provisions designed to limit costs to consumers, to assure a minimum set of benefits, and to enhance access to care, especially primary care.
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Affiliation(s)
- Shana Alex Lavarreda
- UCLA Center for Health Policy Research, University of California, Los Angeles, 90025, USA.
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Choi JK, Jeong HS, Shin JW, Yeo JY. Effects of the benefit extension policy on the burdening of health care expenditure for households with patients of chronic or serious case. HEALTH POLICY AND MANAGEMENT 2011. [DOI: 10.4332/kjhpa.2011.21.2.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Cunningham PJ. Explaining the Increase in Family Financial Pressures From Medical Bills Between 2003 and 2007: Do Affordability Thresholds Change Over Time? Med Care Res Rev 2010; 68:352-66. [DOI: 10.1177/1077558710378122] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study examines whether affordability thresholds for medical care as defined by families change over time. The results from two nationally representative surveys show that while financial stress from medical bills—defined as the percent with problems paying medical bills—increased between 2003 and 2007, greater out-of-pocket spending accounted for this increase only for higher-income persons with employer-sponsored insurance coverage. Increased spending did not account for an increase in medical bill problems among lower-income persons. Moreover, the increase in medical bill problems among low-income persons occurred at relatively low levels of out-of-pocket spending rather than at higher levels. The results suggest that “affordability thresholds” for medical care as defined by individuals and families are not stable over time, especially for lower-income persons, which has implications for setting affordability standards in health reform.
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Ziller EC, Anderson NJ, Coburn AF. Access to Rural Mental Health Services: Service Use and Out-of-Pocket Costs. J Rural Health 2010; 26:214-24. [DOI: 10.1111/j.1748-0361.2010.00291.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
The author examined the relationship among factors influencing the career satisfaction of 2,105 physicians. Data from the 2005 Community Tracking Study Physician Survey were used to obtain 5 latent factors. Structural equation modeling was then applied to extract information on factor interrelationships with physician satisfaction. The main results indicate that underinsurance is negatively associated with physician career satisfaction. Thus, spillover effects that are related to decreased physician satisfaction may increase with greater proportions of underinsurance.
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Affiliation(s)
- William R Pratt
- Department of Finance and Economics of the College of Business Administration, University of Texas-Pan American South Texas Border Health Disparities Center, TX, USA
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Abraham JM, Deleire T, Royalty AB. Moral hazard matters: measuring relative rates of underinsurance using threshold measures. Health Serv Res 2010; 45:806-24. [PMID: 20337736 DOI: 10.1111/j.1475-6773.2010.01084.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To illustrate the impact of moral hazard for estimating relative rates of underinsurance and to present an adjustment method to correct for this source of bias. DATA SOURCES/STUDY SETTING Secondary data from the 2005 Medical Expenditure Panel Survey (MEPS) are used in this study. We restrict attention to households that report having employer-sponsored insurance (ESI) for all members during the entire 2005 calendar year. STUDY DESIGN Individuals or households are often classified as underinsured if out-of-pocket spending on medical care relative to income exceeds some threshold. In this paper, we show that, without adjustment, this common threshold measure of underinsurance will underestimate the number with low levels of insurance coverage due to moral hazard. We propose an adjustment method and apply it to the specific case of estimating the difference in rates of underinsurance among small- versus large-firm workers with full-year ESI. DATA COLLECTION/EXTRACTION Data were abstracted from the MEPS website. All analyses were performed in Stata 9.2. PRINCIPAL FINDINGS Applying the adjustment, we find that the underinsurance rate of small-firm households increases by approximately 20 percent with the adjustment for moral hazard and the difference in underinsurance rates between large-firm and small-firm households widens substantially. CONCLUSIONS Adjusting for moral hazard makes a sizeable difference in the estimated prevalence of underinsurance using a threshold measure.
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Affiliation(s)
- Jean Marie Abraham
- Division of Health Policy and Management, University of Minnesota, 420 Delaware Street SE, MMC 729, Minneapolis, MN 55455
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Kilmer G, Bynum L, Balamurugan A. Access to and Use of Eye Care Services in Rural Arkansas. J Rural Health 2010; 26:30-5. [DOI: 10.1111/j.1748-0361.2009.00262.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Heflinger CA, Hoffman C. Double whammy? Rural youth with serious emotional disturbance and the transition to adulthood. J Rural Health 2009; 25:399-406. [PMID: 19780922 DOI: 10.1111/j.1748-0361.2009.00251.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT All youth, especially those with serious emotional disturbances (SED), face challenges as they transition to adulthood. Little is known about rural youth at risk for transition problems. PURPOSE To examine transition-age youth who use publicly funded services in rural and urban/suburban locations in Tennessee in order to describe youth at risk for transition difficulties who need policy and service planning. METHODS Using Medicaid enrollment and claims/encounter data, youth at high risk for transition difficulties were identified in the following groups: SED, at risk of or in foster care/state custody, intensive or frequent mental health services users, or diagnosed with major mental disorders, behavior disorders, mental retardation, or substance use. Membership in these groups was compared between youth living in rural and urban/suburban counties. Multivariate regression was used to examine factors related to multiple group membership. FINDINGS Rural youth were more likely to be in groups at high risk for problems transitioning to adulthood, and enrolled in Medicaid as uninsured/uninsurable, compared to their urban counterparts. The strongest factors associated with multiple risk group membership were being in state custody/foster care and receiving Supplemental Security Income (SSI). CONCLUSIONS Services are needed to support the transition to adulthood for youth at high risk of behavioral and adjustment problems. Systems to support coordinated planning and accountability are needed, including data on populations and services, and research on transition-age youth.
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Affiliation(s)
- Craig Anne Heflinger
- Department of Human and Organizational Development, Peabody College of Vanderbilt University, Nashville, TN 37203, USA.
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Health care access in rural areas: Evidence that hospitalization for ambulatory care-sensitive conditions in the United States may increase with the level of rurality. Health Place 2009; 15:731-40. [DOI: 10.1016/j.healthplace.2008.12.007] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2008] [Revised: 10/22/2008] [Accepted: 12/19/2008] [Indexed: 11/21/2022]
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Somkotra T, Lagrada LP. Which households are at risk of catastrophic health spending: experience in Thailand after universal coverage. Health Aff (Millwood) 2009; 28:w467-78. [PMID: 19336470 DOI: 10.1377/hlthaff.28.3.w467] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The impact of the universal coverage policy implementation in Thailand is demonstrated by the declining incidence of catastrophic health spending among Thai households-particularly among the poor. The households who remain at risk of catastrophe, as defined here, are better-off households, because of their preference for using private facilities. Others with increased likelihood of incurring catastrophic health expenditures are households with a greater proportion of elderly members, those having a member with a chronic illness or disability, and those having a member who experienced hospitalization. These determinants should prompt policy concerns to protect such households from financial catastrophe.
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Affiliation(s)
- Tewarit Somkotra
- Faculty of Dentistry, Chulalongkorn University in Bangkok, Thailand.
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