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Reeves SL, Dombkowski KJ, Madden B, Cogan L, Liu S, Kirby PB, Toomey SL. Considerations When Aggregating Data to Measure Performance Across Levels of the Health Care System. Acad Pediatr 2022; 22:S119-S124. [PMID: 35339238 PMCID: PMC9367211 DOI: 10.1016/j.acap.2021.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 11/08/2021] [Accepted: 11/21/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Measuring quality at varying levels of the health care system requires attribution, a process of determining the patients and services for which each level is responsible. However, it is important to ensure that attribution approaches are equitable; otherwise, individuals may be assigned differentially based upon social determinants of health. METHODS First, we used Medicaid claims (2010-2018) from Michigan to assess the proportion of children with sickle cell anemia who had less than 12 months enrollment within a single Medicaid health plan and could therefore not be attributed to a specific health plan. Second, we used the Medicaid Analytic eXtract data (2008-2009) from 26 states to simulate adapting the 30-Day Pediatric All-Condition Readmission measure to the Accountable Care Organization (ACO) level and examined the proportion of readmissions that could not be attributed. RESULTS For the sickle cell measure, an average of 300 children with sickle cell anemia were enrolled in Michigan Medicaid each year. The proportion of children that could not be attributed to a Medicaid health plan ranged from 12.2% to 89.0% across years. For the readmissions measure, of the 1,051,365 index admissions, 22% were excluded in the ACO-level analysis because of being unable to attribute the patient to a health plan for the 30 days post discharge. CONCLUSIONS When applying attribution models, it is essential to consider the potential to induce health disparities. Differential attribution may have unintentional consequences that deepen health disparities, particularly when considering incentive programs for health plans to improve the quality of care.
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Affiliation(s)
- SL Reeves
- Susan B Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan,Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - KJ Dombkowski
- Susan B Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - B Madden
- Susan B Meister Child Health Evaluation and Research (CHEAR) Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - L Cogan
- New York State Department of Health, Office of Quality and Patient Safety, Albany, New York,Department of Health Policy Management & Behavior, School of Public Health, University at Albany, Albany, New York
| | - S Liu
- Boston Children’s Hospital, Boston, Massachusetts
| | - PB Kirby
- Commonwealth Medicine Center for Health Policy and Research, University of Massachusetts Medical School, Quincy, Massachusetts
| | - SL Toomey
- Boston Children’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
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2
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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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Gordon SH, Lee Y, Ndumele CD, Vivier PM, Gutman R, Swaminathan S, Gadbois EA, Shield RR, Kind AJH, Trivedi AN. The Impact of Medicaid Managed Care Plan Type on Continuous Medicaid Enrollment: A Natural Experiment. Health Serv Res 2018; 53:3770-3789. [PMID: 29952062 DOI: 10.1111/1475-6773.13000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess the impact of assignment to a Medicaid-focused versus mixed managed care plan on continuity of Medicaid coverage. DATA SOURCES 2011-2016 Medicaid claims from a Northeastern state. STUDY DESIGN Following the exit of a Medicaid managed care insurer, Medicaid administrators prioritized provider networks in reassigning enrollees, but randomly assigned beneficiaries whose providers were equally represented in the two plans. We leveraged the natural experiment created by random plan assignment and conducted an instrumental variable analysis. DATA COLLECTION We analyzed Medicaid claims for 12,083 beneficiaries who were members of the exiting Blue Cross Blue Shield plan prior to January 1, 2011. PRINCIPAL FINDINGS Managed care plan type did not significantly impact continuous enrollment in the Medicaid program. Greater outpatient utilization and the presence of a special need among children were associated with longer enrollment in Medicaid. CONCLUSIONS Managed care plans did not differ in their capacity to keep Medicaid beneficiaries continuously enrolled in coverage, despite differences in plan features.
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Affiliation(s)
- Sarah H Gordon
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Yoojin Lee
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | | | - Patrick M Vivier
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI.,Hassenfeld Child Health Innovation Institute at Brown University, Providence, RI
| | - Roee Gutman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
| | - Shailender Swaminathan
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI.,Public Health Foundation of India, New Delhi, India
| | - Emily A Gadbois
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | - Renee R Shield
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI
| | - Amy Jo Haavisto Kind
- Department of Medicine, Geriatrics Division, University of Wisconsin School of Medicine and Public Health, William S. Middleton VA Hospital-GRECC, Madison, WI
| | - Amal N Trivedi
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI.,Providence VA Medical Center, Providence, RI
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Housing Instability and Children's Health Insurance Gaps. Acad Pediatr 2017; 17:732-738. [PMID: 28232258 PMCID: PMC6058677 DOI: 10.1016/j.acap.2017.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 02/07/2017] [Accepted: 02/14/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the extent to which housing instability is associated with gaps in health insurance coverage of preschool-age children. METHODS Secondary analysis of data from the Early Childhood Longitudinal Study-Birth Cohort, a nationally representative study of children born in the United States in 2001, was conducted to investigate associations between unstable housing-homelessness, multiple moves, or living with others and not paying rent-and children's subsequent health insurance gaps. Logistic regression was used to adjust for potentially confounding factors. RESULTS Ten percent of children were unstably housed at age 2, and 11% had a gap in health insurance between ages 2 and 4. Unstably housed children were more likely to have gaps in insurance compared to stably housed children (16% vs 10%). Controlling for potentially confounding factors, the odds of a child insurance gap were significantly higher in unstably housed families than in stably housed families (adjusted odds ratio 1.27; 95% confidence interval 1.01-1.61). The association was similar in alternative model specifications. CONCLUSIONS In a US nationally representative birth cohort, children who were unstably housed at age 2 were at higher risk, compared to their stably housed counterparts, of experiencing health insurance gaps between ages 2 and 4 years. The findings from this study suggest that policy efforts to delink health insurance renewal processes from mailing addresses, and potentially routine screenings for housing instability as well as referrals to appropriate resources by pediatricians, would help unstably housed children maintain health insurance.
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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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Freund KM, Isabelle AP, Hanchate AD, Kalish RL, Kapoor A, Bak S, Mishuris RG, Shroff SM, Battaglia TA. The impact of health insurance reform on insurance instability. J Health Care Poor Underserved 2015; 25:95-108. [PMID: 24583490 DOI: 10.1353/hpu.2014.0061] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We investigated the impact of the 2006 Massachusetts health care reform on insurance coverage and stability among minority and underserved women. We examined 36 months of insurance claims among 1,946 women who had abnormal cancer screening at six community health centers pre-(2004-2005) and post-(2007-2008) insurance reform. We examined frequency of switches in insurance coverage as measures of longitudinal insurance instability. On the date of their abnormal cancer screening test, 36% of subjects were publicly insured and 31% were uninsured. Post-reform, the percent ever uninsured declined from 39% to 29% (p .001) and those consistently uninsured declined from 23% to 16%. To assess if insurance instability changed between the pre- and post-reform periods, we conducted Poisson regression models, adjusted for patient demographics and length of time in care. These revealed no significant differences from the pre- to post-reform period in annual rates of insurance switches, incident rate ratio 0.98 (95%- CI 0.88-1.09). Our analysis is limited by changes in the populations in the pre- and post-reform period and inability to capture care outside of the health system network. Insurance reform increased stability as measured by decreasing uninsured rates without increasing insurance switches.
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Lee JY, Divaris K, DeWalt DA, Baker AD, Gizlice Z, Rozier RG, Vann WF. Caregivers' health literacy and gaps in children's Medicaid enrollment: findings from the Carolina Oral Health Literacy Study. PLoS One 2014; 9:e110178. [PMID: 25303271 PMCID: PMC4193870 DOI: 10.1371/journal.pone.0110178] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 09/18/2014] [Indexed: 11/23/2022] Open
Abstract
Background and Objectives Recent evidence supports a link between caregivers’ health literacy and their children’s health and use of health services. Disruptions in children’s health insurance coverage have been linked to poor health care and outcomes. We examined young children’s Medicaid enrollment patterns in a well-characterized cohort of child/caregivers dyads and investigated the association of caregivers’ low health literacy with the incidence of enrollment gaps. Methods We relied upon Medicaid enrollment data for 1208 children (mean age = 19 months) enrolled in the Carolina Oral Health Literacy project during 2008–09. The median follow-up was 25 months. Health literacy was measured using the Newest Vital Sign (NVS). Analyses relied on descriptive, bivariate, and multivariate methods based on Poisson modeling. Findings One-third of children experienced one or more enrollment gaps; most were short in duration (median = 5 months). The risk of gaps was inversely associated with caregivers’ age, with a 2% relative risk decrease for each added year. Low health literacy was associated with a modestly elevated risk increase [Incidence Rate Ratio (IRR) = 1.17 (95% confidence interval (CI) 0.88–1.57)] for enrollment disruptions; however, this estimate was substantially elevated among caregivers with less than a high school education [IRR = 1.52 (95% CI 0.99–2.35); homogeneity p<0.2]. Conclusions Our findings provide initial support for a possible role of caregivers’ health literacy as a determinant of children’s Medicaid enrollment gaps. Although the association between health literacy and enrollment gaps was not confirmed statistically, we found that it was markedly stronger among caregivers with low educational attainment. This population, as well as young caregivers, may be the most vulnerable to the negative effects of low health literacy.
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Affiliation(s)
- Jessica Y. Lee
- Department of Pediatric Dentistry, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- * E-mail:
| | - Kimon Divaris
- Department of Pediatric Dentistry, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Darren A. DeWalt
- School of Medicine and Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - A. Diane Baker
- Department of Pediatric Dentistry, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Ziya Gizlice
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - R. Gary Rozier
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - William F. Vann
- Department of Pediatric Dentistry, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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8
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Simon AE, Schoendorf KC. Medicaid enrollment gap length and number of Medicaid enrollment periods among US children. Am J Public Health 2014; 104:e55-61. [PMID: 25033135 DOI: 10.2105/ajph.2014.301976] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined gap length, characteristics associated with gap length, and number of enrollment periods among Medicaid-enrolled children in the United States. METHODS We linked the 2004 National Health Interview Survey to Medicaid Analytic eXtract files for 1999 through 2008. We examined linkage-eligible children aged 5 to 13 years in the 2004 National Health Interview Survey who disenrolled from Medicaid. We generated Kaplan-Meier curves of time to reenrollment. We used Cox proportional hazards models to assess the effect of sociodemographic variables on time to reenrollment. We compared the percentage of children enrolled 4 or more times across sociodemographic groups. RESULTS. Of children who disenrolled from Medicaid, 35.8%, 47.1%, 63.5%, 70.8%, and 79.1% of children had reenrolled in Medicaid by 6 months, 1, 3, 5, and 10 years, respectively. Children who were younger, poorer, or of minority race/ethnicity or had lower educated parents had shorter gaps in Medicaid and were more likely to have had 4 or more Medicaid enrollment periods. CONCLUSIONS Nearly half of US children who disenrolled from Medicaid reenrolled within 1 year. Children with traditionally high-risk demographic characteristics had shorter gaps in Medicaid enrollment and were more likely to have more periods of Medicaid enrollment.
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Affiliation(s)
- Alan E Simon
- Alan E. Simon and Kenneth C. Schoendorf are with the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD. Kenneth C. Schoendorf is also with the US Public Health Service, Rockville, MD
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Guevara JP, Moon J, Hines EM, Fremont E, Wong A, Forrest CB, Silber JH, Pati S. Continuity of Public Insurance Coverage. Med Care Res Rev 2013; 71:115-37. [DOI: 10.1177/1077558713504245] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.
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Affiliation(s)
| | - Jeanhee Moon
- Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Ettya Fremont
- Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Angie Wong
- Stony Brook Long Island Children’s Hospital, Stony Brook, NY, USA
| | | | | | - Susmita Pati
- Stony Brook Long Island Children’s Hospital, Stony Brook, NY, USA
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Hill LL, Hovell M, Blumberg E, Kelley N, Baird S, Sipan C, Schmitz K, Friedman L. Gaps between Adolescent Risk Behaviors and Disclosure during Outpatient Visits. INTERNATIONAL JOURNAL OF FAMILY MEDICINE 2013; 2013:718568. [PMID: 23710357 PMCID: PMC3655594 DOI: 10.1155/2013/718568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 04/06/2013] [Accepted: 04/08/2013] [Indexed: 06/02/2023]
Abstract
Objective. The purpose of this study was to determine the gaps between disclosed high-risk behaviors in low-income, mainly Hispanic youth and the identification of these risks by health care providers. Methods. This cross-sectional study included youth 13-19 years old who participated in a study on latent tuberculosis treatment. Youth were interviewed at baseline by bilingual research assistants; the provider visit was assessed by the chart review. Results. Of 221 youth, the majority (96%) were identified as Hispanic, 45% were foreign-born, and 46% were male. A total of 399 risk behaviors were revealed to research staff by the participants; only 24 risk behaviors were revealed to providers. Conclusions. The majority of risk behaviors based on the chart review were neither queried nor disclosed to the physicians. Physicians providing care to adolescents should consider strategies to improve disclosure as a necessary precursor to interventions.
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Affiliation(s)
- Linda L. Hill
- School of Medicine, University of California, San Diego, CA 92093, USA
- Department of Family and Preventive Medicine, UCSD, 9500 Gilman Drive, MS 0811, La Jolla, CA 92093-0811, USA
| | - Melbourne Hovell
- Center for Behavioral Epidemiology and Community Health (C-BEACH), Graduate School of Public Health, San Diego State University, San Diego, CA 92182, USA
| | - Elaine Blumberg
- Center for Behavioral Epidemiology and Community Health (C-BEACH), Graduate School of Public Health, San Diego State University, San Diego, CA 92182, USA
| | - Norma Kelley
- Center for Behavioral Epidemiology and Community Health (C-BEACH), Graduate School of Public Health, San Diego State University, San Diego, CA 92182, USA
| | - Sara Baird
- Department of Family Medicine, University of Washington, Seattle, WA 98195-6390, USA
| | - Carol Sipan
- Center for Behavioral Epidemiology and Community Health (C-BEACH), Graduate School of Public Health, San Diego State University, San Diego, CA 92182, USA
| | - Katharine Schmitz
- Center for Behavioral Epidemiology and Community Health (C-BEACH), Graduate School of Public Health, San Diego State University, San Diego, CA 92182, USA
| | - Lawrence Friedman
- School of Medicine, University of California, San Diego, CA 92093, USA
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11
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Aalsma MC, Blythe MJ, Tong Y, Harezlak J, Rosenman MB. Insurance Status of Urban Detained Adolescents. JOURNAL OF CORRECTIONAL HEALTH CARE 2012; 18:274-84. [DOI: 10.1177/1078345812455629] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew C. Aalsma
- Department of Pediatrics, Section of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Margaret J. Blythe
- Department of Pediatrics, Section of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yan Tong
- Department of Medicine, Division of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jaroslaw Harezlak
- Department of Medicine, Division of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Public Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Marc B. Rosenman
- Department of Pediatrics, Children’s Health Services Research, Indiana University School of Medicine, and Regenstrief Institute, Indianapolis, IN, USA
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DeCamp LR, Bundy DG. Generational status, health insurance, and public benefit participation among low-income Latino children. Matern Child Health J 2012; 16:735-43. [PMID: 21505783 DOI: 10.1007/s10995-011-0779-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The objectives of this study were to (1) measure health insurance coverage and continuity across generational subgroups of Latino children, and (2) determine if participation in public benefit programs is associated with increased health insurance coverage and continuity. We analyzed data on 25,388 children income-eligible for public insurance from the 2003 to 2004 National Survey of Children's Health and stratified Latinos by generational status. First- and second-generation Latino children were more likely to be uninsured (58 and 19%, respectively) than third-generation children (9.5%). Second-generation Latino children were similarly likely to be currently insured by public insurance as third-generation children (61 and 62%, respectively), but less likely to have private insurance (19 and 29%, respectively). Second-generation Latino children were slightly more likely than third-generation children to have discontinuous insurance during the year (19 and 15%, respectively). Compared with children in families where English was the primary home language, children in families where English was not the primary home language had higher odds of being uninsured versus having continuous insurance coverage (OR: 2.19; 95% CI [1.33-3.62]). Among second-generation Latino children, participation in the Food Stamp (OR 0.26; 95% CI [0.14-0.48]) or Women, Infants, and Children (OR 0.40; 95% CI [0.25-0.66]) programs was associated with reduced odds of being uninsured. Insurance disparities are concentrated among first- and second-generation Latino children. For second-generation Latino children, connection to other public benefit programs may promote enrollment in public insurance.
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Affiliation(s)
- Lisa Ross DeCamp
- Robert Wood Johnson Foundation Clinical Scholars Program, Center for Child and Community Health Research, University of Michigan, Mason F Lord Bldg, Ste. 4200, 5200 Eastern Ave, Baltimore, MD 21224, USA.
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Hill HD, Shaefer HL. Covered today, sick tomorrow? Trends and correlates of children's health insurance instability. Med Care Res Rev 2012; 68:523-36. [PMID: 21903663 DOI: 10.1177/1077558711398877] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many children with health insurance will experience gaps in coverage over time, potentially reducing their access to and use of preventive health care services. This article uses the Survey of Income and Program Participation to examine how the stability of children's health insurance changed between 1990 and 2005 and to identify dynamic aspects of family life associated with transitions in coverage. Children's health insurance instability has increased since the early 1990s, due to greater movement between insured and uninsured states and between private and public insurance coverage. Changes in the employment and marital status of the family head are highly associated with an increased risk of a child losing and gaining public and private coverage, largely in hypothesized directions. The exception is that marital dissolution and job loss are associated with an increased probability of a child losing public insurance, despite there being no clear policy explanation for such a relationship.
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Affiliation(s)
- Heather D Hill
- School of Social Service Administration, University of Chicago, Chicago, IL 60637, USA.
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14
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Comparing types of health insurance for children: a public option versus a private option. Med Care 2011; 49:818-27. [PMID: 21478781 DOI: 10.1097/mlr.0b013e3182159e4d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Many states have expanded public health insurance programs for children, and further expansions were proposed in recent national reform initiatives; yet the expansion of public insurance plans and the inclusion of a public option in state insurance exchange programs sparked controversies and raised new questions with regard to the quality and adequacy of various insurance types. OBJECTIVES We aimed to examine the comparative effectiveness of public versus private coverage on parental-reported children's access to health care in low-income and middle-income families. METHODS/PARTICIPANTS/MEASURES: We conducted secondary data analyses of the nationally representative Medical Expenditure Panel Survey, pooling years 2002 to 2006. We assessed univariate and multivariate associations between child's full-year insurance type and parental-reported unmet health care and preventive counseling needs among children in low-income (n=28,338) and middle-income families (n=13,160). RESULTS Among children in families earning <200% of the federal poverty level, those with public insurance were significantly less likely to have no usual source of care compared with privately insured children (adjusted relative risk, 0.79; 95% confidence interval, 0.63-0.99). This was the only significant difference in 50 logistic regression models comparing unmet health care and preventive counseling needs among low-income and middle-income children with public versus private coverage. CONCLUSIONS The striking similarities in reported rates of unmet needs among children with public versus private coverage in both low-income and middle-income groups suggest that a public children's insurance option may be equivalent to a private option in guaranteeing access to necessary health care services for all children.
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Abstract
OBJECTIVES To outline the prevalence and disparities of asthma among school-aged urban minority youth, causal pathways through which poorly controlled asthma adversely affects academic achievement, and proven or promising approaches for schools to address these problems. METHODS Literature review. RESULTS Asthma is the most common chronic disease affecting youth in the United States; almost 10 million youth under 18 (14%) have received a diagnosis and 6.8 million (9%) have active asthma. Average annual prevalence estimates were approximately 45% higher for Black versus White children (12.8% vs. 8.8%), as were average annual estimates of asthma attacks (8.4% vs. 5.8%). Urban minority youth have highly elevated prevalence of poorly controlled asthma as evidenced by overuse of emergency departments and under-use of efficacious medications. Poorly controlled asthma has functional consequences on cognition, connectedness with school, and absenteeism. Exemplary asthma programs include management and support systems, school health and mental health services, asthma education, healthy school environments, physical education and activity, and coordination of school, family, and community efforts. CONCLUSIONS Asthma and, more importantly, poorly controlled asthma are highly and disproportionately prevalent among school-aged urban minority youth, has a negative impact on academic achievement through its effects on cognition, school connectedness, and absenteeism, and effective practices are available for schools to address this problem. To reduce the adverse effects of poorly controlled asthma on learning, a multifaceted approach to asthma control and prevention in which schools can and must play a central role is essential.
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Affiliation(s)
- Charles E Basch
- Department of Health and Behavior Studies, Teachers College, Columbia University, 525 West 120th Street, New York, NY 10027, USA.
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Peterson TH, Peterson T, Armon C, Todd J. Insurance-associated disparities in hospitalization outcomes of Michigan children. J Pediatr 2011; 158:313-8.e1-2. [PMID: 20864119 DOI: 10.1016/j.jpeds.2010.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 07/15/2010] [Accepted: 08/09/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To investigate whether children in Michigan with private insurance have better hospitalization-related outcomes than those with public or no insurance. STUDY DESIGN Population-based hospitalization rates were calculated for newborns and children aged <18 years in Michigan for the years 2001-2006 and stratified by age, disease grouping, and health insurance status using inpatient records from the Michigan Inpatient Database and population estimates from the US Census Current Population Survey. RESULTS Michigan children with public/no insurance had significantly higher overall hospital admission rates and admission rates for ambulatory-sensitive conditions, and were more likely to be admitted through the emergency room, compared with those with private health insurance. Similarly, newborns with public/no insurance had significantly higher rates of hospitalization-related outcomes. Hospital charges per child were higher in the public/no insurance population, translating to potential excess charges of between $309.8 and $401.8 million in 2006. CONCLUSIONS There are disparities in health outcomes and charges between Michigan children and newborns with public/no insurance and those with private health insurance, presenting a significant opportunity to improve the efficiency and efficacy of care.
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Affiliation(s)
- Thomas H Peterson
- Department of Quality, Helen DeVos Children's Hospital, Grand Rapids, MI, USA.
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DeVoe JE, Ray M, Krois L, Carlson MJ. Uncertain health insurance coverage and unmet children's health care needs. Fam Med 2010; 42:121-132. [PMID: 20135570 PMCID: PMC4918751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND AND OBJECTIVES The State Children's Health Insurance Program (SCHIP) has improved insurance coverage rates. However, children's enrollment status in SCHIP frequently changes, which can leave families with uncertainty about their children's coverage status. We examined whether insurance uncertainty was associated with unmet health care needs. METHODS We compared self-reported survey data from 2,681 low-income Oregon families to state administrative data and identified children with uncertain coverage. We conducted cross-sectional multivariate analyses using a series of logistic regression models to test the association between uncertain coverage and unmet health care needs. RESULTS The health insurance status for 13.2% of children was uncertain. After adjustments, children in this uncertain "gray zone" had higher odds of reporting unmet medical (odds ratio [OR] =1.73; 95% confidence interval [CI]=1.07, 2.79), dental (OR=2.41; 95% CI=1.63, 3.56), prescription (OR=1.64, 95% CI=1.08, 2,48), and counseling needs (OR=3.52; 95% CI=1.56, 7.98), when compared with publicly insured children whose parents were certain about their enrollment status. CONCLUSIONS Uncertain children's insurance coverage was associated with higher rates of unmet health care needs. Clinicians and educators can play a role in keeping patients out of insurance gray zones by (1) developing practice interventions to assist families in confirming enrollment and maintaining coverage and (2) advocating for policy changes that minimize insurance enrollment and retention barriers.
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Affiliation(s)
- Jennifer E DeVoe
- Oregon Health and Science University, Department of Family Medicine, 3181 Sam Jackson Park Road, Mailcode: FM, Portland, OR 97239, USA.
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DeVoe JE. Educaid: what if the US systems of education and health care were more alike? Fam Med 2009; 41:652-655. [PMID: 19816829 PMCID: PMC4916771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
What if access to an education in the United States required insurance, leaving millions of children without a school? Would public insurance for education--Educaid look like public insurance for medical care--Medicaid? This essay describes a fictional education system analogous to our current health care system as a means to highlight some of US health care's failings. It incorporates real comments from parents whom we have interviewed about their experiences gaining access to health care services for their children. My purpose is to challenge each reader to consider the future for both the US education and health care systems, the urgent need for reform, and how major reforms might affect our children.
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Affiliation(s)
- Jennifer E DeVoe
- Department of Family Medicine, Oregon Health and Science University, Portland, OR 97239, USA.
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Watts KD, Seshadri R, Sullivan C, McColley SA. Increased prevalence of risk factors for morbidity and mortality in the US Hispanic CF population. Pediatr Pulmonol 2009; 44:594-601. [PMID: 19437506 DOI: 10.1002/ppul.21037] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hispanic ethnicity is an independent risk factor for increased morbidity and mortality in cystic fibrosis (CF) patients. In order to compare the prevalence of risk factors for morbidity and mortality between the Hispanic CF population and the non-Hispanic CF population, we performed a cross-sectional study of patients in the 2004 Cystic Fibrosis Foundation Patient Registry. Among 22,714 CF patients, 1,511 were identified as ethnic Hispanic. Hispanic patients were diagnosed earlier (2.8 vs. 3.3 years, P = 0.005) and acquired Pseudomonas aeruginosa at a younger age (6.6 years vs. 10 years, P < 0.001). FEV(1) was lower for Hispanic patients (81.5% vs. 87% predicted for those under 18 years old [P < 0.001] and 2.1 L vs. 2.3 L for those 18 years and older [P = 0.01]). Hispanic patients had similar or better nutritional status. Hispanic patients were more likely to be diagnosed with liver disease (OR 1.31 [1.1, 1.56]) but less likely to be diagnosed with depression (OR 0.53 [0.39, 0.68]), bone and joint disease (OR 0.55 [0.41, 0.71]), or CF-related diabetes (OR 0.53 [0.43, 0.62]). Hispanic patients had lower median income by zip code ($41,930 vs. $47,341; P < 0.001), a higher rate of government insurance (55.2% vs. 32.0%; P < 0.001), and greater percentage of mothers with less than a high school education (26.7% vs. 6.5%; P < 0.001). We conclude that there is an increased prevalence of important risk factors for morbidity and mortality in the Hispanic CF population.
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Financial and employment problems in families of children with special health care needs: implications for research and practice. J Pediatr Health Care 2009; 23:117-25. [PMID: 19232928 DOI: 10.1016/j.pedhc.2008.03.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2007] [Revised: 02/23/2008] [Accepted: 03/07/2008] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The purpose of this study was to identify factors related to financial burden among families of children with special needs and to identify specific provider-level activities associated with decreased risk for such burden. METHOD Data for secondary analysis are from the National Survey of Children with Special Health Care Needs (CSHCN). Logistic regression analysis of state-level data was conducted to identify significant predictors of financial and employment problems among families of children with SHCN in Minnesota. RESULTS Children with more severe conditions and whose family members provided health care at home were more likely to have parents report financial and employment problems due to the child's condition. On the other hand, families whose health care providers communicated well with other service providers and who helped them feel like partners in their child's care were significantly less likely to report financial and employment problems. DISCUSSION Pediatric nurses and nurse practitioners can use these findings as they work with families for optimal family outcomes. Advocacy and policy implications at state and federal levels also are discussed.
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Pati S, Danagoulian S. Immigrant children's reliance on public health insurance in the wake of immigration reform. Am J Public Health 2008; 98:2004-10. [PMID: 18799772 PMCID: PMC2636442 DOI: 10.2105/ajph.2007.125773] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2008] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We sought to determine whether the reversal of the public charge rule of the Illegal Immigration Reform and Immigrant Responsibility Act, which may have required families to pay for benefits previously received at no cost, led to immigrant children becoming increasingly reliant on public health insurance programs. METHODS We conducted a secondary data analysis focusing on low-income children sampled in the 1997 through 2004 versions of the National Health Interview Survey. RESULTS Between 1997 and 2004, public health insurance enrollments and the numbers of uninsured foreign-born children in the United States increased by 3.1% and 2.7%, respectively. Using multinomial logistic regression models to account for the substantial differences in socioeconomic status between foreign-born and US-born children, we found that low-income US-born children were just as likely as foreign-born children to have public health insurance coverage (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 0.89, 1.52) and that, after 2000, foreign-born children were 1.59 times (95% CI = 1.24, 2.05) more likely than were US-born children to be uninsured (vs publicly insured). CONCLUSIONS In the wake of the reversal of the public charge rule, immigrant children are increasingly likely to be uninsured as opposed to relying on public health insurance.
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Affiliation(s)
- Susmita Pati
- Center for Clinical Epidemiology and Biostatistics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
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Abstract
CONTEXT Millions of US children and adolescents lack health insurance coverage. Efforts to expand their insurance often focus on extending public coverage to uninsured parents. Less is known about the uninsured whose parents already have coverage. OBJECTIVE To identify predictors of uninsurance among US children and adolescents with insured parents. DESIGN AND SETTING Cross-sectional and full-year analyses of pooled 2002-2005 data from the nationally representative Medical Expenditure Panel Survey (MEPS). PARTICIPANTS Children and adolescents younger than 19 years in 4 yearly MEPS files with positive full-year weights who had at least 1 parent residing in the same household. There were 39,588 in the unweighted cross-sectional analysis and 39,710 in the unweighted full-year analysis. MAIN OUTCOME MEASURE Prevalence of uninsurance among children and adolescents with at least 1 insured parent; predictors of uninsurance among children with at least 1 insured parent. RESULTS In the cross-sectional study population, 1380 of 39,588 children and adolescents were uninsured with at least 1 insured parent (weighted prevalence, 3.3%; 95% confidence interval [CI], 3.0%-3.6%). In multivariate analyses of children and adolescents with at least 1 insured parent, those uninsured were more likely Hispanic (odds ratio [OR], 1.58; 95% CI, 1.23-2.03) than white, non-Hispanic; low income (OR, 2.02; 95% CI, 1.42-2.88) and middle income (OR, 1.48; 95% CI, 1.09-2.03) than high income; from single-parent homes (OR, 1.99; 95% CI, 1.59-2.49) than from homes with 2 married parents; and living with parents who had less than a high school education (OR, 1.44; 95% CI, 1.10-1.89) than those with at least 1 parent who had completed high school. Those whose parents had public coverage were less likely to be uninsured (OR, 0.64; 95% CI, 0.43-0.96) than were those whose parents reported private health insurance. These predictors remained significant in full-year analyses. Similar patterns of vulnerability were also found among a subset of uninsured children with privately covered parents. CONCLUSIONS Among all US children, more than 3% were uninsured with at least 1 insured parent. Predictors of such uninsurance included having low and middle income. Having a parent covered by only public insurance was associated with better children's coverage rates.
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Affiliation(s)
- Jennifer E. DeVoe
- Department of Family Medicine, Oregon Health and Science University, 3181 Sam Jackson Park Rd, mailcode: FM, Portland, OR 97239, Phone 503-494-8936, Fax 503-494-2746,
| | - Carrie Tillotson
- Oregon Health and Science University, 3181 Sam Jackson Park Rd, Portland, OR 97239,
| | - Lorraine S. Wallace
- University of Tennessee Graduate School of Medicine, Department of Family Medicine, 1924 Alcoa Highway, U-67, Knoxville, TN 37920,
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Caring for Children With Special Health Care Needs and Their Families: What Advanced Practice Nurses Need to Know. J Nurse Pract 2008. [DOI: 10.1016/j.nurpra.2008.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Nafiu OO, Chimbira WT, Woolford SJ, Tremper KK, Reynolds PI, Green GE. Does high BMI influence hospital charges in children undergoing adenotonsillectomy? Obesity (Silver Spring) 2008; 16:1667-71. [PMID: 18421267 DOI: 10.1038/oby.2008.234] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Obesity is a highly prevalent chronic problem with health and fiscal consequences. Data from adults and nonsurgical pediatric patients suggest that obesity has serious implications for the US economy. OBJECTIVE Our goal was to describe the impact of BMI on hospital charges in children undergoing adenotonsillectomy (AT). METHODS AND PROCEDURES We carried out a retrospective comparative analysis of the electronic anesthesia record and the charges from billing data from a large tertiary institution on children aged 3-18 years who had AT during the year 2005-2007. The main outcome measures were mean total hospital charges, likelihood of admission, and length of hospital stay (LOS). RESULTS Of 1,643 children, 68.9% were aged <10 years, 76% were whites, and 74.1% had private commercial insurance. Most (75.3%) children were discharged on the day of surgery. Obese and overweight children were more likely to be admitted than their normal-weight peers (X(2)=26.3, P<0.001). Among those admitted, BMI showed a positive correlation with LOS (r=0.20, P<0.001). Obese and overweight patients had significantly higher total hospital charges than their healthy-weight counterparts (P=0.001). Anesthesia, postanesthesia care unit (PACU), and pharmacy and laboratory charges were also higher for obese than normal-weight children (P<0.05). DISCUSSION Overweight and obese children undergoing AT accrued higher hospital charges and had longer postoperative LOS than their healthy-weight peers. If these findings are extendable to other surgical procedures, they could have far-reaching implications for the US economy.
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Affiliation(s)
- Olubukola O Nafiu
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA.
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DeVoe JE, Graham A, Krois L, Smith J, Fairbrother GL. "Mind the Gap" in children's health insurance coverage: does the length of a child's coverage gap matter? ACTA ACUST UNITED AC 2008; 8:129-34. [PMID: 18355742 DOI: 10.1016/j.ambp.2007.10.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Revised: 10/12/2007] [Accepted: 10/13/2007] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Gaps in health insurance coverage compromise access to health care services, but it is unclear whether the length of time without coverage is an important factor. This article examines how coverage gaps of different lengths affect access to health care among low-income children. METHODS We conducted a multivariable, cross-sectional analysis of statewide primary data from families in Oregon's food stamp population with children presumed eligible for publicly funded health insurance. The key independent variable was length of a child's insurance coverage gap; outcome variables were 6 measures of health care access. RESULTS More than 25% of children reported a coverage gap during the 12-month study period. Children most likely to have a gap were older, Hispanic, lived in households earning between 133% and 185% of the federal poverty level, and/or had an employed parent. After adjusting for these characteristics, in comparison with continuously insured children, a child with a gap of any length had a higher likelihood of unmet medical, prescription, and dental needs; no usual source of care; no doctor visits in the past year; and delayed urgent care. When comparing coverage gaps, children without coverage for longer than 6 months had a higher likelihood of unmet needs compared with children with a gap shorter than 6 months. In some cases, children with gaps longer than 6 months were similar to, or worse off than, children who had never been insured. CONCLUSIONS State policies should be designed to minimize gaps in public health insurance coverage in order to ensure children's continuous access to necessary services.
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Affiliation(s)
- Jennifer E DeVoe
- Department of Family Medicine, Oregon Health and Science University, Portland, Oregon 97239, USA.
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Halterman JS, Montes G, Shone LP, Szilagyi PG. The impact of health insurance gaps on access to care among children with asthma in the United States. ACTA ACUST UNITED AC 2008; 8:43-9. [PMID: 18191781 DOI: 10.1016/j.ambp.2007.10.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Revised: 08/21/2007] [Accepted: 10/01/2007] [Indexed: 10/21/2022]
Abstract
BACKGROUND Health insurance coverage is important to help assure children appropriate access to medical care and preventive services. Insurance gaps could be particularly problematic for children with asthma, since appropriate preventive care for these children depends on frequent, consistent contacts with health care providers. OBJECTIVE The aim of this study was to determine the association between insurance gaps and access to care among a nationally representative sample of children with asthma. METHODS The National Survey of Children's Health provided parent-report data for 8097 children with asthma. We identified children with continuous public or continuous private insurance and defined 3 groups with gaps in insurance coverage: those currently insured who had a lapse in coverage during the prior 12 months (gained insurance), those currently uninsured who had been insured at some time during the prior 12 months (lost insurance), and those with no health insurance at all during the prior 12 months (full-year uninsured). RESULTS Thirteen percent of children had coverage gaps (7% gained insurance, 4% lost insurance, and 2% were full-year uninsured). Many children with gaps in coverage had unmet needs for care (7.4%, 12.8%, and 15.1% among the gained insurance, lost insurance, and full-year uninsured groups, respectively). In multivariate models, we found significant associations between insurance gaps and every indicator of poor access to care among this population. CONCLUSIONS Many children with asthma have unmet health care needs and poor access to consistent primary care, and lack of continuous health insurance coverage may play an important role. Efforts are needed to ensure uninterrupted coverage for these children.
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Affiliation(s)
- Jill S Halterman
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Strong Children's Research Center, Rochester, NY 14642, USA.
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Shone LP, Lantz PM, Dick AW, Chernew ME, Szilagyi PG. Crowd-out in the State Children's Health Insurance Program (SCHIP): incidence, enrollee characteristics and experiences, and potential impact on New York's SCHIP. Health Serv Res 2008; 43:419-34. [PMID: 18199194 DOI: 10.1111/j.1475-6773.2007.00819.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The extent to which the State Children's Health Insurance Program (SCHIP) crowds our private insurance is poorly understood. OBJECTIVE To assess the incidence of crowd-out and enrollee characteristics associated with crowd-out. DATA Parent telephone survey for 2,644 children after enrollment in NY SCHIP. MEASURES AND ANALYSES: Crowd-out is measured based on enrollee reports of coverage (and loss of coverage) before SCHIP. Multivariate logistic regression is used to relate crowd-out to enrollee characteristics. PRINCIPAL FINDINGS Only 7.1 percent of SCHIP enrollees dropped private coverage < or =6 months before SCHIP, suggesting relatively modest crowd-out. Crowd-out was associated with some enrollee traits including income, but not with health status. IMPLICATIONS Most movement from private to public insurance in NY was not crowd-out. Under current program structure in NY, crowd-out concerns should not dampen enthusiasm for SCHIP.
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Affiliation(s)
- Laura P Shone
- Department of Pediatrics, School of Nursing, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 777, Rochester, NY, USA
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Brito A, Grant R, Overholt S, Aysola J, Pino I, Spalding SH, Prinz T, Redlener I. The enhanced medical home: the pediatric standard of care for medically underserved children. Adv Pediatr 2008; 55:9-28. [PMID: 19048725 DOI: 10.1016/j.yapd.2008.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Arturo Brito
- The Children's Health Fund, 215 West 125th Street, Suite 301, New York, NY 10017, USA.
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Federico SG, Steiner JF, Beaty B, Crane L, Kempe A. Disruptions in insurance coverage: patterns and relationship to health care access, unmet need, and utilization before enrollment in the State Children's Health Insurance Program. Pediatrics 2007; 120:e1009-16. [PMID: 17908722 DOI: 10.1542/peds.2006-3094] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The numbers and types of disruptions in insurance that children experience and the effects of these disruptions on health care measures have not been well characterized. OBJECTIVES Our goals were to (1) describe the number and patterns of insurance disruptions within a population of children newly enrolling into the State Children's Health Insurance Program and (2) assess the relationship among insurance disruptions and sociodemographic characteristics of these children and their families to specific measures of access to care, unmet need, and health care utilization during the year before enrollment. METHODS We conducted telephone interviews in families with children newly enrolling in the State Children's Health Insurance Program. Families reported on measures for each of the 12 months preceding enrollment. They were grouped by number of insurance disruptions in the year before enrollment: continuously uninsured, > or = 2 disruptions, 1 disruption, or continuously insured. RESULTS Of 920 families contacted, 739 (80%) completed the interview and 710 had useable data. Thirty-five percent reported being continuously uninsured, 42% were intermittently insured (> or = 2 disruptions: 28%; 1 disruption: 14%), and 23% were continuously insured during the previous year. The most common patterns of change were between privately insured and uninsured (49%) and Medicaid and uninsured (40%). The continuously uninsured were more likely to be Hispanic and older in age. Multivariate modeling confirmed a gradient between greater insurance disruption and less access to care, less utilization, and greater unmet medical need. Using the continuously uninsured as a reference group, the adjusted odds ratio for having a medical home varied from 2.5 for those with > or = 2 disruptions to 4.5 for the continuously insured and from 1.9 to 3.2, respectively, for using any regular/routine care. The odds ratio for unmet need for a prescription medication was 0.9 for > or = 2 disruptions and 0.5 for those with continuous insurance coverage. CONCLUSIONS There was significant disruption in insurance coverage in the year before State Children's Health Insurance Program enrollment. Most of these disruptions took the form of children previously enrolled in either Medicaid or private insurance becoming uninsured. Increasing numbers of disruptions were associated with less routine care and greater unmet medical need. These findings suggest that disruptions in insurance coverage for children should be minimized with the adoption of policies regarding continuous eligibility criteria for Medicaid and streamlining transitions between Medicaid, the State Children's Health Insurance Program, and private insurance.
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Affiliation(s)
- Steven G Federico
- Department of Pediatrics, University of Colorado Health Sciences Center, Denver, Colorado, USA.
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Abstract
OBJECTIVES The American and Canadian health care delivery systems impact pediatric surgical practice differently. We conducted a survey of Canada-trained pediatric surgeons practicing in the United States and Canada to compare their levels of satisfaction and to assess their health care system preferences. METHODS Pediatric surgeons who graduated from Canadian training programs between 1983 and 2002 were invited to complete a web-based questionnaire. They rated their satisfaction on a scale ranging from 1 (most) to 5 (least) with issues pertaining to quality of life, compensation, work environment, academics, and patient care. Surgeons who had experience in both the American and Canadian systems marked their preferences for each system as it impacted the same areas. RESULTS Sixty surgeons (65% practicing in the United States and 35% in Canada) of 94 eligible participants (64%) responded to the survey. Surgeons in the United States were more satisfied with their overall workload and patient care issues, whereas those in Canada were more satisfied with the system of health care reimbursement and the medicolegal environment. Among 38 surgeons who had experience in both systems, 26% had an overall preference for the Canadian system, 24% did for the American system, and half had no preference. CONCLUSIONS Canada-trained pediatric surgeons practicing in the United States are more satisfied with patient care issues, whereas those practicing in Canada are more satisfied with the medicolegal environment and the system of health care reimbursement. There is no overwhelming preference for either system among surgeons who had experience in both.
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Affiliation(s)
- Sherif Emil
- Division of Pediatric Surgery, University of California-Irvine Medical Center, Orange, CA 92868-3298, USA.
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Wang G, Watts C. Genetic Counseling, Insurance Status, and Elements of Medical Home: Analysis of the National Survey of Children with Special Health Care Needs. Matern Child Health J 2007; 11:559-67. [PMID: 17333384 DOI: 10.1007/s10995-007-0200-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2006] [Accepted: 02/11/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine associations between receiving genetic counseling and the enabling factors of insurance and medical home. METHODS This study uses data from the National Survey of Children with Special Health Care Needs (CSHCN). We use descriptive statistics to characterize families of CSHCN who needed and received genetic counseling as well as families who needed but did not receive genetic counseling. We conduct logistic regression to calculate the association between receiving genetic counseling, insurance status, and medical home while adjusting for child's age, mother's education, race, ethnicity, and severity of condition. RESULTS Seven percent of families with CSHCN, representing 643,432 CSHCN nationwide, reported needing genetic counseling in 2001. Of those in need of genetic counseling, an estimated 123,117 CSHCN reported not receiving genetic counseling. Compared to CSHCN with continuous insurance coverage, CSHCN with interrupted insurance coverage and CSHCN without insurance are significantly less likely to receive genetic counseling. The odds of receiving genetic counseling by CSHCN with medical homes are 2.70 times higher compared to peers without medical homes (95% CI: 1.58, 4.61; p </= .001). Among the four elements comprising medical home in this study, family-centered care is the only element significantly associated with receiving genetic counseling. CONCLUSIONS Our analysis presents evidence that receiving genetic counseling is positively associated with having continuous insurance coverage and receiving family-centered care. We discuss how researchers and policy makers may use these finding to explore strategies for improving care systems for CSHCN.
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Affiliation(s)
- Grace Wang
- Institute for Public Health Genetics, School of Public Health and Community Medicine, University of Washington, Box 354809, Seattle, WA 98105, USA
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Allred NJ, Wooten KG, Kong Y. The association of health insurance and continuous primary care in the medical home on vaccination coverage for 19- to 35-month-old children. Pediatrics 2007; 119 Suppl 1:S4-11. [PMID: 17272584 DOI: 10.1542/peds.2006-2089c] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Our goal was to examine the association of continuous care in the medical home and health insurance on up-to-date vaccination coverage by using data from the National Survey of Children's Health and the National Immunization Survey. METHODS Interviews were conducted with 5400 parents of 19- to 35-month-old children to collect data on demographics and medically-verified vaccinations. Health insurance coverage was categorized as always, intermittently, or uninsured for the previous 12 months. Insurance types were private, public, or uninsured. Having a personal doctor or nurse and receiving preventive health care in either the past 12 or 24 months constituted continuous primary care in the medical home. Children were up-to-date if they received all vaccinations by 19 to 35 months of age (>or=4 doses of diphtheria and tetanus toxoids and pertussis vaccine, >or=3 doses of poliovirus vaccine, >or=1 dose of any measles-containing vaccine, >or=3 doses of Haemophilus influenzae type b vaccine, and >or=3 doses of hepatitis B vaccine). RESULTS Bivariate analyses revealed children who were always insured had significantly higher vaccination coverage (83%) than those with lapses or uninsured during the past 12 months (75% and 71%, respectively). Those with continuous primary care in the medical home had significantly higher coverage than those who did not (83% vs 75%, respectively). In multivariate analysis, the same pattern of association was observed for insurance status and medical home, but the only statistically significant association was for children of never-married mothers who had significantly lower coverage (74%) compared with children of married mothers (84%). CONCLUSIONS Among children with the same insurance status and continuity of care in the medical home, children of single mothers were less likely to be up-to-date than children of married mothers. Interventions assisting single mothers to obtain preventive care for their children should be a priority.
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Affiliation(s)
- Norma J Allred
- National Center for Immunization and Respiratory Diseases, Division of Immunization Services, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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Oswald DP, Bodurtha JN, Willis JH, Moore MB. Underinsurance and key health outcomes for children with special health care needs. Pediatrics 2007; 119:e341-7. [PMID: 17210727 DOI: 10.1542/peds.2006-2218] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The objective was to examine the relationship between underinsurance and other core outcomes for children with special health care needs. METHODS This study analyzed data from the National Survey of Children With Special Health Care Needs. Two alternative definitions of underinsurance, designated attitudinal and economic, were investigated. Logistic regression models in which the response variables were the child's status for each of the target core outcomes and underinsurance status was a dichotomous predictor variable were created. In addition to underinsurance status, 10 other predictor variables were included in the model. RESULTS Underinsurance is associated with the Maternal and Child Health Bureau core outcomes for children with special health care needs related to satisfaction with care and partnering with families in decision-making, access to a medical home, community-based service delivery that is easy to use, and access to services to make transitions to adulthood. In each case, children with special health care needs who were underinsured had significantly poorer outcomes than did children who were adequately insured. CONCLUSIONS Although these results cannot clarify the cause of poorer outcomes, there are clear negative effects associated with the problem of underinsurance. Inadequate health care coverage for children with special health care needs may save dollars in the short-term but, if other outcomes are compromised, then children, their families, and society at large may pay a price in the longer term.
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Affiliation(s)
- Donald P Oswald
- Department of Psychiatry, Virginia Commonwealth University, Box 980489, Richmond, VA 23298, USA.
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Phillips RL, Bazemore AW, Dodoo MS, Shipman SA, Green LA. Family physicians in the child health care workforce: opportunities for collaboration in improving the health of children. Pediatrics 2006; 118:1200-6. [PMID: 16951016 DOI: 10.1542/peds.2006-0051] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatric workforce studies suggest that there may be a sufficient number of pediatricians for the current and projected US child population. These analyses do not fully consider the role of family medicine in the care of children. Family physicians provide 16% to 26% of visits for children, providing a medical home for one third of the child population, but face shrinking panels of children. Family medicine's role in children's health care is more stable in rural communities, for adolescents, and for underserved populations. For these populations, in particular, family medicine's role remains important. The erosion of the proportion of visits to family medicine is likely caused by the rapid rise in the number of pediatricians relative to a declining birth rate. Between 1981 and 2004, the general pediatrician population grew at 7 times the rate of the US population, and the family physician workforce grew at nearly 5 times the rate. The number of clinicians caring for children meets or exceeds most estimates of sufficiency; however, the workforce distribution is skewed, leaving certain populations and settings underserved. More than 5 million children and adolescents live in counties with no pediatrician. Unmet need, addressing health in the context of families and communities, and tackling "millennial morbidities" represent common ground for both specialties that could lead to specific, collaborative training, research, intervention, and advocacy.
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Affiliation(s)
- Robert L Phillips
- American Academy of Family Physicians, Robert Graham Cente4 for Policy Studies in Family Medicine and Primary Care, Washington, DC 20036, USA.
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