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Walter AW, Ellis RP, Yuan Y. Health care utilization and spending among privately insured children with medical complexity. J Child Health Care 2019; 23:213-231. [PMID: 30025469 DOI: 10.1177/1367493518785778] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Children with medical complexity have high health service utilization and health expenditures that can impose significant financial burdens. This study examined these issues for families with children enrolled in US private health plans. Using IBM Watson/Truven Analytics℠ MarketScan® commercial claims and encounters data (2012-2014), we analyzed through regression models, the differences in health care utilization and spending of disaggregated health care services by health plan types and children's medical complexity levels. Children in consumer-driven and high-deductible plans had much higher out-of-pocket spending and cost shares than those in health maintenance organizations and preferred provider organizations (PPOs). Children with complex chronic conditions had higher service utilization and out-of-pocket expenditures while having lower cost shares on various categories of services than those without any chronic condition. Compared to families covered by PPOs, those with high-deductible or consumer-driven plans were 2.7 and 1.7 times more likely to spend over US$1000 out of pocket on their children's medical care, respectively. Families with higher complexity levels were more likely to experience financial burdens from expenditures on children's medical services. In conclusion, policymakers and families with children need to be cognizant of the significant financial burdens that can arise from children's complex medical needs and health plan demand-side cost sharing.
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Affiliation(s)
- Angela Wangari Walter
- 1 Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, Lowell, MA, USA
| | - Randall P Ellis
- 2 Department of Economics, Boston University, Boston, MA, USA
| | - Yiyang Yuan
- 3 Department of Quantitative Health Sciences, Graduate School of Biomedical Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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2
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Houtrow A, Murphy N, Kuo DZ, Apkon S, Brei TJ, Davidson LF, Davis BE, Ellerbeck KA, Hyman SL, Leppert MO, Noritz GH, Stille CJ, Yin L. Prescribing Physical, Occupational, and Speech Therapy Services for Children With Disabilities. Pediatrics 2019; 143:peds.2019-0285. [PMID: 30910917 DOI: 10.1542/peds.2019-0285] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pediatric health care providers are frequently responsible for prescribing physical, occupational, and speech therapies and monitoring therapeutic progress for children with temporary or permanent disabilities in their practices. This clinical report will provide pediatricians and other pediatric health care providers with information about how best to manage the therapeutic needs of their patients in the medical home by reviewing the International Classification of Functioning, Disability and Health; describing the general goals of habilitative and rehabilitative therapies; delineating the types, locations, and benefits of therapy services; and detailing how to write a therapy prescription and include therapists in the medical home neighborhood.
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Affiliation(s)
- Amy Houtrow
- Department of Physical Medicine and Rehabilitation and Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Nancy Murphy
- Division of Pediatric Physical Medicine and Rehabilitation, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Hirschi M, Walter AW, Wilson K, Jankovsky K, Dworetzky B, Comeau M, Bachman SS. Access to care among children with disabilities enrolled in the MassHealth CommonHealth Buy-In program. J Child Health Care 2019; 23:6-19. [PMID: 29772924 DOI: 10.1177/1367493518777310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Children with disabilities utilize more health-care services and incur higher costs than other children do. Medicaid Buy-In programs for children with disabilities have the potential to increase access to benefits while reducing out-of-pocket costs for families whose income exceeds Medicaid eligibility. This study sought to understand how parents and caregivers of Massachusetts children with disabilities perceive access to care under CommonHealth, Massachusetts's Medicaid Buy-In program. Parents and caregivers ( n = 615) whose children were enrolled in CommonHealth participated in a survey assessing the impact of the program. Qualitative data were coded across five access domains-availability, accessibility, accommodation, affordability, and acceptability. Data suggest that CommonHealth improves access to care for children with disabilities by providing the benefits that were limited in scope or unavailable through other insurance before enrollment and by making available services more affordable. Policy and administrative changes could improve the program and further increase access to care for children with complex, costly conditions. Adopting a Medicaid Buy-In program may be an effective way for states to create a pathway to Medicaid for children with disabilities whose family income is too high for Medicaid and who have unmet needs and/or whose families incur high out-of-pocket costs for their care.
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Affiliation(s)
- Melissa Hirschi
- 1 Department of Social Work, University of Memphis, Memphis, TN, USA
| | - Angela Wangari Walter
- 2 Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts Lowell, MA, USA
| | - Kasey Wilson
- 3 School of Social Work, Boston University, Boston, MA, USA
| | - Kate Jankovsky
- 4 Colorado Department of Public Health and Environment, Denver, CO, USA
| | | | - Meg Comeau
- 6 Center for Advancing Health Policy and Practice, Boston University, Boston, MA, USA
| | - Sara S Bachman
- 6 Center for Advancing Health Policy and Practice, Boston University, Boston, MA, USA
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Schrager SM, Arthur KC, Nelson J, Edwards AR, Murphy JM, Mangione-Smith R, Chen AY. Development and Validation of a Method to Identify Children With Social Complexity Risk Factors. Pediatrics 2016; 138:peds.2015-3787. [PMID: 27516527 DOI: 10.1542/peds.2015-3787] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We sought to develop and validate a method to identify social complexity risk factors (eg, limited English proficiency) using Minnesota state administrative data. A secondary objective was to examine the relationship between social complexity and caregiver-reported need for care coordination. METHODS A total of 460 caregivers of children with noncomplex chronic conditions enrolled in a Minnesota public health care program were surveyed and administrative data on these caregivers and children were obtained. We validated the administrative measures by examining their concordance with caregiver-reported indicators of social complexity risk factors using tetrachoric correlations. Logistic regression analyses subsequently assessed the association between social complexity risk factors identified using Minnesota's state administrative data and caregiver-reported need for care coordination, adjusting for child demographics. RESULTS Concordance between administrative and caregiver-reported data was moderate to high (correlation range 0.31-0.94, all P values <.01), with only current homelessness (r = -0.01, P = .95) failing to align significantly between the data sources. The presence of any social complexity risk factor was significantly associated with need for care coordination before (unadjusted odds ratio = 1.65; 95% confidence interval, 1.07-2.53) but not after adjusting for child demographic factors (adjusted odds ratio = 1.53; 95% confidence interval, 0.98-2.37). CONCLUSIONS Social complexity risk factors may be accurately obtained from state administrative data. The presence of these risk factors may heighten a family's need for care coordination and/or other services for children with chronic illness, even those not considered medically complex.
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Affiliation(s)
- Sheree M Schrager
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California;
| | - Kimberly C Arthur
- Seattle Children's Hospital and Seattle Children's Research Institute, Seattle, Washington
| | - Justine Nelson
- Minnesota Department of Human Services, St. Paul, Minnesota
| | | | - J Michael Murphy
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Rita Mangione-Smith
- Seattle Children's Hospital and Seattle Children's Research Institute, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington; and
| | - Alex Y Chen
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California
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DeJong NA, Wood CT, Morreale MC, Ellis C, Davis D, Fernandez J, Steiner MJ. Identifying Social Determinants of Health and Legal Needs for Children With Special Health Care Needs. Clin Pediatr (Phila) 2016; 55:272-7. [PMID: 26130392 DOI: 10.1177/0009922815591959] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Children with special health care needs (CSHCN) require comprehensive care with high levels of community and government assistance. Medical-legal partnerships may be particularly suited to address needs for this population. To explore this, we conducted in-depth telephone interviews of families of CSHCN cared for in the primary care practice of our tertiary care children's hospital. The majority of the sample (N = 46) had been late on housing payments and 17% of homeowners had been threatened with foreclosure. Families frequently reported denial of public benefits. Approximately 10% had executed advance planning documents such as guardianship plans for the children or wills for the parents. A minority of families had sought help from community agencies or lawyers. Less than one third had ever discussed any of the issues with health care providers, but two thirds were likely or very likely to in the future. CSHCN may especially benefit from the social support of a medical-legal partnership.
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Affiliation(s)
- Neal A DeJong
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Charles T Wood
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | | | | | - Darragh Davis
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | | | - Michael J Steiner
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
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Smith AJ, Oswald D, Bodurtha J. Trends in Unmet Need for Genetic Counseling Among Children With Special Health Care Needs, 2001-2010. Acad Pediatr 2015; 15:544-50. [PMID: 26162247 DOI: 10.1016/j.acap.2015.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 05/16/2015] [Accepted: 05/24/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Access to genetic counseling is increasingly important to guide families' and clinicians' decision making, yet there is limited research on accessibility and affordability of counseling for families with children with special health care needs (CSHCN). Our study's objectives were to measure changes in unmet need for genetic counseling for CSHCN from 2001 to 2010 and to characterize child, family, and health system factors associated with unmet need. METHODS We used parent-reported data from the 2001, 2005-2006, and 2009-2010 National Survey of Children With Special Health Care Needs. We used a logistic regression model to measure the impact of survey year, child (sex, age, severity of health condition), family (primary language, household income, insurance, financial problems related to cost of CSHCN's health care), and health system factors (region, genetic counselors per capita, having a usual source of care) on access to genetic counseling. RESULTS Unmet need for genetic counseling increased significantly in 2009-2010 compared to 2001 (odds ratio 1.89; 95% confidence interval [CI] 1.44-2.47). Being older (adjusted odds ratio [aOR] 1.04; 95% CI 1.02-1.06), having severe health limitations (aOR 1.72; 95% CI 1.16-2.58), being uninsured (aOR 3.56; 95% CI 2.16-5.87), and having family financial problems due to health care costs (aOR 1.90; 95% CI 1.52-2.38) were significantly associated with greater unmet need for genetic counseling. Having a usual source of care was associated with decreased unmet need (aOR 0.55; 95% CI 0.37-0.83). CONCLUSIONS Unmet need for genetic counseling has increased over the past 12 years. Uninsurance and financial problems related to health care costs were the largest drivers of unmet need over time.
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Affiliation(s)
| | - Donald Oswald
- Partnership for People With Disabilities, Virginia Commonwealth University, Richmond, Va.
| | - Joann Bodurtha
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins School of Medicine, Baltimore, Md
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Bachman SS, Comeau M, Dworetzky B, Hamershock R, Hirschi M. The Louisiana Family Opportunity Act Medicaid Buy-in Program. Matern Child Health J 2015; 19:2568-77. [PMID: 26169811 DOI: 10.1007/s10995-015-1775-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The Family Opportunity Act Medicaid Buy-In Program (FOA) allows states to expand Medicaid coverage to children who meet selected disability and income eligibility criteria. FOA programs may help address family financial hardship as a result of underinsurance. We provide specific information about the FOA program and report the first results of a survey of parents or guardians of children with disabilities who were enrolled in Louisiana's FOA program. METHODS A convenience sample of families enrolled in the program (N = 52) responded to questions derived from the National Survey of Children with Special Health Care Needs (CSHCN). These results were compared to two groups of Louisiana families of CSHCN that had responded to the 2009/10 national survey. RESULTS Data suggest that children enrolled in the Louisiana FOA are younger than those enrolled in Supplemental Security Income, are more likely to have functional losses, and, perhaps due to their age, are less likely to have difficulty with anxiety, depression, or behavior problems. FOA families are less likely than families in either group to report receiving help with care coordination, and more likely to report financial problems due to their child's health. Respondents were also more likely to report that they received all the therapy services and specialty care they needed. CONCLUSIONS The FOA program thus appears to be filling a niche in coverage needs among families of children with disabilities in Louisiana.
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Affiliation(s)
- Sara S Bachman
- Health and Disability Working Group, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA.
| | - Meg Comeau
- Health and Disability Working Group, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Beth Dworetzky
- Health and Disability Working Group, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Rose Hamershock
- Health and Disability Working Group, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Melissa Hirschi
- Health and Disability Working Group, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
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Jena AB, Ho O, Goldman DP, Karaca-Mandic P. The Impact of the US Food and Drug Administration Chlorofluorocarbon Ban on Out-of-pocket Costs and Use of Albuterol Inhalers Among Individuals With Asthma. JAMA Intern Med 2015; 175:1171-9. [PMID: 25962128 PMCID: PMC4494980 DOI: 10.1001/jamainternmed.2015.1665] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The US Clean Air Act prohibits use of nonessential ozone-depleting substances. In 2005, the US Food and Drug Administration announced the ban of chlorofluorocarbon (CFC) albuterol inhalers by December 31, 2008. The policy resulted in the controversial replacement of generic CFC inhalers by more expensive, branded hydrofluoroalkane inhalers. The policy's impact on out-of-pocket costs and utilization of albuterol is unknown. OBJECTIVE To study the impact of the US Food and Drug Administration's CFC ban on out-of-pocket costs and utilization of albuterol inhalers. DESIGN, SETTING, AND PARTICIPANTS Using private insurance data from January 1, 2004, to December 31, 2010, we investigated the effect of the CFC ban on out-of-pocket costs and utilization of albuterol inhalers among individuals with asthma (109,428 adults; 37,281 children), as well as asthma-related hospitalizations, emergency department visits, and outpatient visits. We estimated multivariable models adjusted for age, sex, comorbidities, and mean out-of-pocket costs of albuterol inhalers in an individual's drug plan. We analyzed whether effects varied between adults vs children and those with persistent vs nonpersistent asthma. MAIN OUTCOMES AND MEASURES Pharmacy claims for albuterol inhalers, as well as asthma-related hospitalizations, emergency department visits, and outpatient visits. RESULTS The mean out-of-pocket albuterol cost rose from $13.60 (95% CI, $13.40-$13.70) per prescription in 2004 to $25.00 (95% CI, $24.80-$25.20) immediately after the 2008 ban. By the end of 2010, costs had lowered to $21.00 (95% CI, $20.80-$21.20) per prescription. Overall albuterol inhaler use steadily declined from 2004 to 2010. Steep declines in use of generic CFC inhalers occurred after the fourth quarter of 2006 and were almost fully offset by increases in use of hydrofluoroalkane inhalers. In multivariable analyses, a $10 increase in out-of-pocket albuterol prescription costs was estimated to lower utilization by 0.92 percentage points (95% CI, -1.39 to -0.44; P < .001) for adults and 0.54 percentage points (95% CI, -0.84 to -0.24; P = .001) for children, with no difference between adults vs children and patients with persistent vs nonpersistent asthma and with no impact on asthma-related hospitalizations, emergency department visits, and outpatient visits. CONCLUSIONS AND RELEVANCE The Federal ban of CFC inhalers led to large relative increases in out-of-pocket albuterol costs among privately insured individuals with asthma and modest declines in utilization. The policy's impact on individuals without insurance, who faced greater cost increases, is unknown.
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Affiliation(s)
- Anupam B Jena
- Department of Medicine, Massachusetts General Hospital, Boston2National Bureau of Economic Research, Cambridge, Massachusetts3Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Oliver Ho
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Dana P Goldman
- National Bureau of Economic Research, Cambridge, Massachusetts4Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
| | - Pinar Karaca-Mandic
- National Bureau of Economic Research, Cambridge, Massachusetts5Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
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Ghandour RM, Comeau M, Tobias C, Dworetzky B, Hamershock R, Honberg L, Mann MY, Bachman SS. Assuring Adequate Health Insurance for Children With Special Health Care Needs: Progress From 2001 to 2009-2010. Acad Pediatr 2015; 15:451-60. [PMID: 25864809 DOI: 10.1016/j.acap.2015.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/13/2015] [Accepted: 02/04/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report on coverage and adequacy of health insurance for children with special health care needs (CSHCN) in 2009-2010 and assess changes since 2001. METHODS Data were from the National Survey of Children with Special Health Care Needs (NS-CSHCN), a random-digit telephone survey with 40,243 (2009-2010) and 38,866 (2001) completed interviews. Consistency and adequacy of insurance was measured by: 1) coverage status, 2) gaps in coverage, 3) coverage of needed services, 4) reasonableness of uncovered costs, and 5) ability to see needed providers, as reported by parents. Bivariate and multivariable analyses were conducted to assess factors associated with adequate insurance coverage in 2009-2010. Unadjusted and adjusted prevalence estimates were examined to identify changes in the type of insurance coverage and the proportion of CSHCN with adequate coverage by insurance type. RESULTS The proportion of CSHCN with private coverage decreased from 64.7% to 50.7% between 2001 and 2009-2010, while public coverage increased from 21.7% to 34.7%; the proportion of CSHCN without any insurance declined from 5.2% to 3.5%. The proportion of CSHCN with adequate coverage varied over time and by insurance type: among privately covered CSHCN, the proportion with adequate coverage declined (62.6% to 59.6%), while among publicly covered CSHCN, the proportion with adequate insurance increased (63.0% to 70.7%). Publicly insured CSHCN experienced improvements in each of the 3 adequacy components. CONCLUSIONS There has been a continued shift from private to public coverage, which is more affordable, offers benefits that are more likely to meet CSHCN needs, and allowed CSHCN to see necessary providers.
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Affiliation(s)
- Reem M Ghandour
- US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Epidemiology and Research, Division of Epidemiology, Rockville, Md.
| | - Meg Comeau
- Catalyst Center, Health and Disability Working Group, Boston University School of Public Health, Boston, Mass
| | - Carol Tobias
- Catalyst Center, Health and Disability Working Group, Boston University School of Public Health, Boston, Mass
| | - Beth Dworetzky
- Catalyst Center, Health and Disability Working Group, Boston University School of Public Health, Boston, Mass
| | - Rose Hamershock
- Catalyst Center, Health and Disability Working Group, Boston University School of Public Health, Boston, Mass
| | | | - Marie Y Mann
- Division of Services for Children With Special Health Care Needs, Rockville, Md
| | - Sara S Bachman
- Catalyst Center, Health and Disability Working Group, Boston University School of Public Health, Boston, Mass
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Abstract
The Patient Protection and Affordable Care Act (ACA) was designed to (1) decrease the number of uninsured Americans, (2) make health insurance and health care affordable, and (3) improve health outcomes and performance of the health care system. During the design of ACA, children in general and children and youth with special health care needs and disabilities (CYSHCN) were not a priority because before ACA, a higher proportion of children than adults had insurance coverage through private family plans, Medicaid, or the State Children's Health Insurance Programs (CHIP). ACA benefits CYSHCN through provisions designed to make health insurance coverage universal and continuous, affordable, and adequate. Among the limitations of ACA for CYSHCN are the exemption of plans that had been in existence before ACA, lack of national standards for insurance benefits, possible elimination or reductions in funding for CHIP, and limited experience with new delivery models for improving care while reducing costs. Advocacy efforts on behalf of CYSHCN must track implementation of ACA at the federal and the state levels. Systems and payment reforms must emphasize access and quality improvements for CYSHCN over cost savings. Developmental-behavioral pediatrics must be represented at the policy level and in the design of new delivery models to assure high quality and cost-effective care for CYSHCN.
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Wilson K, Hirschi M, Comeau M, Bronheim S, Bachman SS. Disparities in insurance coverage among children with special health care needs: how social workers can promote social and economic justice. HEALTH & SOCIAL WORK 2014; 39:121-127. [PMID: 24946429 DOI: 10.1093/hsw/hlu015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Ghandour RM, Hirai AH, Blumberg SJ, Strickland BB, Kogan MD. Financial and nonfinancial burden among families of CSHCN: changes between 2001 and 2009-2010. Acad Pediatr 2014; 14:92-100. [PMID: 24369874 PMCID: PMC4930276 DOI: 10.1016/j.acap.2013.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 10/01/2013] [Accepted: 10/09/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We use the latest data to explore multiple dimensions of financial burden among children with special health care needs (CSHCN) and their families in 2009-2010 and changes since 2001. METHODS Five burden indicators were assessed using the 2001 and 2009-2010 National Surveys of CSHCN: past-year health-related out-of-pocket expenses of ≥$1,000 or ≥ 3% of household income; perceived financial problems; changes in family employment; and >10 hours of weekly care provision/coordination. Unadjusted and adjusted prevalence estimates were used to assess burden in 2009-2010 and calculate absolute and relative measures of change since 2001. Prevalence rate ratios for each burden type in 2009-2010 compared to 2001 were estimated by logistic regression. RESULTS Nearly half of CSHCN and their families experienced some form of burden in 2009-2010. The percentage of CSHCN living in families that paid ≥$1,000 or ≥ 3% of household income out of pocket for health care rose 120% and 35%, respectively, between 2001 and 2009-2010, while the prevalence of caregiving and employment burdens declined. Relative to 2001, in 2009-2010, CSHCN who were privately insured or least affected by their conditions were 1.7 times as likely to live in families that paid ≥ 3% of household income out of pocket, while publicly insured children were 20% less likely to do so and those most severely affected were 12% more likely to do so. CONCLUSIONS Over the past decade, increases in financial burden and declines in employment and caregiving burdens were observed for CSHCN families. Public insurance expansions may have buffered increases in financial burden, yet disparities persist.
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Affiliation(s)
- Reem M Ghandour
- US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Epidemiology and Research, Rockville, MD.
| | - Ashley H Hirai
- US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Epidemiology and Research, Rockville, MD
| | - Stephen J Blumberg
- US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, Hyattsville, MD
| | - Bonnie B Strickland
- US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Division of Services for Children With Special Health Care Needs, Rockville, MD
| | - Michael D Kogan
- US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Epidemiology and Research, Rockville, MD
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Miller JE, Nugent CN, Gaboda D, Russell LB. Reasons for unmet need for child and family health services among children with special health care needs with and without medical homes. PLoS One 2013; 8:e82570. [PMID: 24340042 PMCID: PMC3858312 DOI: 10.1371/journal.pone.0082570] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 10/24/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Medical homes, an important component of U.S. health reform, were first developed to help families of children with special health care needs (CSHCN) find and coordinate services, and reduce their children's unmet need for health services. We hypothesize that CSHCN lacking medical homes are more likely than those with medical homes to report health system delivery or coverage problems as the specific reasons for unmet need. METHODS Data are from the 2005-2006 National Survey of Children with Special Health Care Needs (NS-CSHCN), a national, population-based survey of 40,723 CSHCN. We studied whether lacking a medical home was associated with 9 specific reasons for unmet need for 11 types of medical services, controlling for health insurance, child's health, and sociodemographic characteristics. RESULTS Weighted to the national population, 17% of CSHCN reported at least one unmet health service need in the previous year. CSHCN without medical homes were 2 to 3 times as likely to report unmet need for child or family health services, and more likely to report no referral (OR= 3.3), dissatisfaction with provider (OR=2.5), service not available in area (OR= 2.1), can't find provider who accepts insurance (OR=1.8), and health plan problems (OR=1.4) as reasons for unmet need (all p<0.05). CONCLUSIONS CSHCN without medical homes were more likely than those with medical homes to report health system delivery or coverage reasons for unmet child health service needs. Attributable risk estimates suggest that if the 50% of CSHCN who lacked medical homes had one, overall unmet need for child health services could be reduced by as much as 35% and unmet need for family health services by 40%.
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Affiliation(s)
- Jane E. Miller
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey, United States of America
- Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, New Jersey, United States of America
| | - Colleen N. Nugent
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey, United States of America
| | - Dorothy Gaboda
- Center for State Health Policy, Rutgers University, New Brunswick, New Jersey, United States of America
| | - Louise B. Russell
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey, United States of America
- Department of Economics, Rutgers University, New Brunswick, New Jersey, United States of America
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Spears W, Pascoe J, Khamis H, McNicholas CI, Eberhart G. Parents' perspectives on their children's health insurance: plight of the underinsured. J Pediatr 2013; 162:403-8.e1. [PMID: 22921826 DOI: 10.1016/j.jpeds.2012.07.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 05/21/2012] [Accepted: 07/17/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence and correlates of children's underinsurance within a primary care, practice-based research network. STUDY DESIGN A survey of 13 practices within the Southwestern Ohio Ambulatory Research Network using the Medical Expenses for Children Survey in 2009 and 2010 yielded a sample of 2972 parents of children >6 months old with health insurance in the previous 12 months. Data were analyzed using bivariate and loglinear model analyses. RESULTS Of the study children, 17.2% were classified as underinsured because of their inability to pay for ≥ 1 of their pediatrician's recommendations for care in the past 12 months. In addition, 15.5% reported it was harder to get medical care for their child in the past 3 years, and 6.5% indicated that their child's health had suffered. Multivariate analysis reveals complex relationships among the 3 factors related to ability to obtain care and between these factors and sociodemographic and health status factors. Across education and income categories, the underinsured rate ranged from 57% to 93% for parents who reported their child's health had suffered. CONCLUSIONS One in 6 parents reported that their child was underinsured. A similar percentage reported that it had become more difficult to get needed medical care over the past 3 years. The relationship between the perception that an underinsured child's health has suffered is much stronger for the highest socioeconomic category in this sample than for the other categories; 93% of these families were underinsured in 2009. It is possible that high deductible features of insurance plans contribute to these circumstances.
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Affiliation(s)
- William Spears
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, OH 45404, USA.
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Underinsurance in Children with Special Health Care Needs: The Impact of Definition on Findings. Matern Child Health J 2012; 17:1478-87. [DOI: 10.1007/s10995-012-1155-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Unmet need, cost burden, and communication problems in SCHIP by special health care needs status. Matern Child Health J 2012; 16:850-9. [PMID: 21516298 DOI: 10.1007/s10995-011-0805-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Children with special health care needs (CSHCN) require more health care than other children; hence adequate health insurance is critical. The Maternal and Child Health Bureau defined three components of adequacy: (1) coverage of needed benefits and services; (2) reasonable costs; and (3) ability to see needed providers. This study compares cost burden, access to care, and patient/provider communication within New Jersey's SCHIP for CSHCN versus those without such needs. We used data from the 2003 NJ FamilyCare (NJFC) Supplement to the New Jersey Family Health Survey on 444 children enrolled in NJFC and 145 children disenrolled from NJFC but covered by other insurance at the time of the survey. The CSHCN Screener was used to identify CSHCN. CSHCN in NJFC had 1.5 times the odds of an unmet need for health care; 2.7 times the odds of a cost burden; and 2.2 times the odds of any coverage or service inadequacy than those without SHCN, even when demographic factors and NJFC plan level (which is based on income) were taken into account. CSHCN enrolled in NJFC have more difficulties in some areas of access to care and cost burden. Patterns of access to care, cost burden, and patient/provider communication were similar for children formerly in NJFC who had other types of insurance at the time of the survey. Future studies should use comprehensive measures of adequacy of coverage, including attitudinal, structural and economic perspectives.
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Baker JR, Riske B, Voutsis M, Cutter S, Presley R. Insurance, home therapy, and prophylaxis in U.S. youth with severe hemophilia. Am J Prev Med 2011; 41:S338-45. [PMID: 22099356 DOI: 10.1016/j.amepre.2011.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 08/19/2011] [Accepted: 09/06/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Home infusion therapy, particularly on a prophylactic regimen, is linked with reduced morbidity among youth with severe hemophilia. However, the association of insurance coverage with these home therapies is unknown. PURPOSE This study explores the connections among insurance, home infusion therapy, and prophylaxis treatment in a nationwide cohort of 3380 boys and young men (aged 2 to 20 years) with severe hemophilia. These youth obtained care at one of 129 federally supported hemophilia treatment centers (HTCs), and enrolled in the CDC's bleeding disorder surveillance project. METHODS Multiple regression was used to analyze the independent association among risk factors, including insurance, and both home infusion and prophylaxis. Data were obtained between January 1, 2008, and December 31, 2010, and analyzed in 2011. RESULTS Ninety percent used home therapy and 78% a prophylaxis regimen. Only 2% were uninsured. Health insurance was significantly associated with prophylaxis, but not with home therapy. Lower prophylaxis utilization rates were independently associated with having Medicaid, "other," and no insurance as compared to having private insurance. Race, age, inhibitor status, and HTC utilization were also independently associated with both home therapy and prophylaxis. CONCLUSIONS Youth with severe hemophilia who annually obtain care within the U.S. HTC network had a high level of health insurance, home therapy, and prophylaxis. Exploration of factors associated with insurance coverage and yearly HTC utilization, and interventions to optimize home infusion and prophylaxis among youth of African-American and "other" race/ethnic backgrounds are warranted.
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Affiliation(s)
- Judith R Baker
- Department of Pediatric Hematology/Oncology, University of California Los Angeles, Los Angeles, California 90095, USA.
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Houtrow AJ, Okumura MJ, Hilton JF, Rehm RS. Profiling health and health-related services for children with special health care needs with and without disabilities. Acad Pediatr 2011; 11:508-16. [PMID: 21962936 PMCID: PMC3215793 DOI: 10.1016/j.acap.2011.08.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 08/16/2011] [Accepted: 08/18/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The aims of this study were to profile and compare the health and health services characteristics for children with special health care needs (CSHCN), with and without disabilities, and to determine factors associated with unmet need. METHODS Secondary data analysis of the 2005-2006 National Survey of Children with Special Health Care Needs was conducted. The sociodemographics, health, and health services of CSHCN with and without disabilities were compared. Multivariable logistic regression was employed to examine factors associated with unmet need for health services. RESULTS Children from minority racial and ethnic groups and children living in or near poverty were over-represented among CSHCN with disabilities, compared with other CSHCN. Statistically higher percentages of CSHCN with disabilities had behavioral problems (39.6% vs 25.2%), anxiety/depressed mood (46.1% vs 24.0%), and trouble making/keeping friends (38.1% vs 15.6%) compared with other CSHCN. Thirty-two percent of CSHCN with disabilities received care in a medical home compared with 51% of other CSHCN. CSHCN with disabilities had higher rates of need and unmet need than other CSHCN for specialty care, therapy services, mental health services, home health, assistive devices, medical supplies, and durable medical equipment. The adjusted odds of unmet need for CSHCN with disabilities were 71% higher than for other CSHCN. CONCLUSION CSHCN with disabilities had more severe health conditions and more health services need, but they less commonly received care within a medical home and had more unmet need. These health care inequities should be amenable to policy and health service delivery interventions to improve outcomes for CSHCN with disabilities.
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Affiliation(s)
- Amy J Houtrow
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.
| | - Megumi J Okumura
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Joan F Hilton
- Department of Biostatistics, University of California San Francisco, San Francisco, CA
| | - Roberta S Rehm
- Department of Family Health Care Nursing, University of California San Francisco, San Francisco, CA
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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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20
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Connolly CA, Gibson ME. The "white plague" and color: children, race, and tuberculosis in Virginia 1900-1935. J Pediatr Nurs 2011; 26:230-8. [PMID: 21601147 PMCID: PMC3100539 DOI: 10.1016/j.pedn.2010.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Revised: 01/15/2010] [Accepted: 01/27/2010] [Indexed: 11/25/2022]
Abstract
Drawing on a wealth of primary documents, this historical research describes nurses' efforts regarding early 20th century pediatric tuberculosis care in Virginia. Virginia nurses played a leadership role in designing a template for children's care. Ultimately, however, their legacy is a mixed one. They helped forge a system funded by a complicated, poorly coordinated, race- and class-based mix of public and private support that is now delivered through an idiosyncratic web of community, state, and federal programs. However, they also took courageous action, and their efforts improved the lives of many children. By so doing, they helped invent pediatric nursing.
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Bethell CD, Kogan MD, Strickland BB, Schor EL, Robertson J, Newacheck PW. A national and state profile of leading health problems and health care quality for US children: key insurance disparities and across-state variations. Acad Pediatr 2011; 11:S22-33. [PMID: 21570014 DOI: 10.1016/j.acap.2010.08.011] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 08/19/2010] [Accepted: 08/27/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Parent/consumer-reported data is valuable and necessary for population-based assessment of many key child health and health care quality measures relevant to both the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 and the Patient Protection and Affordable Care Act of 2010 (ACA). OBJECTIVES The aim of this study was to evaluate national and state prevalence of health problems and special health care needs in US children; to estimate health care quality related to adequacy and consistency of insurance coverage, access to specialist, mental health and preventive medical and dental care, developmental screening, and whether children meet criteria for having a medical home, including care coordination and family centeredness; and to assess differences in health and health care quality for children by insurance type, special health care needs status, race/ethnicity, and/or state of residence. METHODS National and state level estimates were derived from the 2007 National Survey of Children's Health (N = 91,642; children aged 0-17 years). Variations between children with public versus private sector health insurance, special health care needs, specific conditions, race/ethnicity, and across states were evaluated using multivariate logistic regression and/or standardized statistical tests. RESULTS An estimated 43% of US children (32 million) currently have at least 1 of 20 chronic health conditions assessed, increasing to 54.1% when overweight, obesity, or being at risk for developmental delays are included; 19.2% (14.2 million) have conditions resulting in a special health care need, a 1.6 point increase since 2003. Compared with privately insured children, the prevalence, complexity, and severity of health problems were systematically greater for the 29.1% of all children who are publicly insured children after adjusting for variations in demographic and socioeconomic factors. Forty-five percent of all children in the United States scored positively on a minimal quality composite measure: 1) adequate insurance, 2) preventive care visit, and 3) medical home. A 22.2 point difference existed across states and there were wide variations by health condition (autism, 22.8, to asthma, 39.4). After adjustment for demographic and health status differences, quality of care varied between children with public versus private health insurance on all but the following 3 measures: not receiving needed mental health services, care coordination, and performance on the minimal quality composite. A 4.60 fold (gaps in insurance) to 1.27 fold (preventive dental and medical care visits) difference in quality scores was observed across states. Notable disparities were observed among publicly insured children according to race/ethnicity and across all children by special needs status and household income. CONCLUSIONS Findings emphasize the importance of health care insurance duration and adequacy, health care access, chronic condition management, and other quality of care goals reflected in the 2009 CHIPRA legislation and the ACA. Despite disparities, similarities for public and privately insured children speak to the pervasive nature of availability, coverage, and access issues for mental health services in the United States, as well as the system-wide problem of care coordination and accessing specialist care for all children. Variations across states in key areas amenable to state policy and program management support cross-state learning and improvement efforts.
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Affiliation(s)
- Christina D Bethell
- Department of Pediatrics, School of Medicine, Oregon Health & Science University, 707 SW Gaines Street, Mailcode CDRCP, Portland, Oregon 97239, USA.
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Jacobi JV, Watson SD, Restuccia R. Implementing health reform at the state level: access and care for vulnerable populations. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2011; 39 Suppl 1:69-72. [PMID: 21309901 DOI: 10.1111/j.1748-720x.2011.00570.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The Affordable Care Act1 (ACA) promises to improve access to coverage and care for two vulnerable groups: low-income persons who are excluded by a lack of resources and chronically ill and disabled people who are excluded by the dysfunction of our existing insurance and care delivery systems. ACA’s sprawling provisions raise a wealth of implementation challenges that are exacerbated by the compromises required to move reform through Congress. In particular, the compromise between regulatory/public program advocates and advocates for private, market-driven programs requires thoughtful regulatory coordination between public and private health systems.
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Kogan MD, Newacheck PW, Blumberg SJ, Ghandour RM, Singh GK, Strickland BB, van Dyck PC. Underinsurance among children in the United States. N Engl J Med 2010; 363:841-51. [PMID: 20818845 DOI: 10.1056/nejmsa0909994] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recent interest in policy regarding children's health insurance has focused on expanding coverage. Less attention has been devoted to the question of whether insurance sufficiently meets children's needs. METHODS We estimated underinsurance among U.S. children on the basis of data from the 2007 National Survey of Children's Health (sample size, 91,642 children) regarding parents' or guardians' judgments of whether their children's insurance covered needed services and providers and reasonably covered costs. Data on adequacy were combined with data on continuity of insurance coverage to classify children as never insured during the past year, sometimes insured during the past year, continuously insured but inadequately covered (i.e., underinsured), and continuously insured and adequately covered. We examined the association between this classification and five overall indicators of health care access and quality: delayed or forgone care, difficulty obtaining needed care from a specialist, no preventive care, no developmental screening at a preventive visit, and care not meeting the criteria of a medical home. RESULTS We estimated that in 2007, 11 million children were without health insurance for all or part of the year, and 22.7% of children with continuous insurance coverage--14.1 million children--were underinsured. Older children, Hispanic children, children in fair or poor health, and children with special health care needs were more likely to be underinsured. As compared with children who were continuously and adequately insured, uninsured and underinsured children were more likely to have problems with health care access and quality. CONCLUSIONS The number of underinsured children exceeded the number of children without insurance for all or part of the year studied. Access to health care and the quality of health care are suboptimal for uninsured and underinsured children. (Funded by the Health Resources and Services Administration.)
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Affiliation(s)
- Michael D Kogan
- Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services, Rockville, MD 20857, USA.
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Minnick ML, Boynton S, Ndirangu J, Furth S. Sex, race, and socioeconomic disparities in kidney disease in children. Semin Nephrol 2010; 30:26-32. [PMID: 20116645 DOI: 10.1016/j.semnephrol.2009.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Racial and gender differences in the prevalence and treatment of chronic kidney disease in US children have been reported. Girls have lower rates of kidney transplantation than boys. Incidence of end-stage renal disease is twice as high among black patients compared with whites. African Americans are less likely than white patients to achieve hemoglobin targets on dialysis, are more likely to be treated with hemodialysis, and to wait longer for a transplant. Reasons for these disparities in disease burden and treatment choices are not known, but possible causes include genetic factors and socioeconomic and sociocultural influences on accessing medical care.
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Affiliation(s)
- Maria Lourdes Minnick
- Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
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Kogan MD, Newacheck PW, Blumberg SJ, Heyman KM, Strickland BB, Singh GK, Zeni MB. State variation in underinsurance among children with special health care needs in the United States. Pediatrics 2010; 125:673-80. [PMID: 20211947 DOI: 10.1542/peds.2009-1055] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE National attention has focused on providing health insurance coverage for children. Less awareness has been given to underinsurance, particularly for children with special health care needs (CSHCN). Defined as having inadequate benefits, underinsurance may be a particular problem for CSHCN because of their greater needs for medical care. METHODS We used the 2005-2006 National Survey of Children With Special Health Care Needs, a nationally representative study of >40,000 CSHCN, to address state variations in underinsurance. CSHCN with health insurance were considered underinsured when a parent reported that the child's insurance did not usually or always cover needed services and providers or reasonably cover costs. We calculated the unadjusted prevalence of underinsurance for each state. Using logistic regression, we estimated state-specific odds and prevalence for underinsurance after adjusting for poverty level, race/ethnicity, gender, family structure, language use, insurance type, and severity of child's health condition. We also conducted multilevel analyses incorporating state-level contextual data on Medicaid and the State Children's Health Insurance Program. RESULTS Bivariate and multivariate analyses indicated that CSHCN's state of residence had a strong association with insurance adequacy. State-level unadjusted underinsurance rates ranged from 24% (Hawaii) to 38% (Illinois). After multivariate adjustments, the range was largely unchanged: 23% (Hawaii) to 38% (New Jersey). Multilevel analyses indicated that Medicaid income eligibility levels were inversely associated with the odds of being underinsured. CONCLUSIONS The individual-level and macro-level factors examined only partly explain state variations in underinsurance. Furthermore, the macro-level factors explained only a small portion of the variance; however, other macro-level factors may be relevant for the observed patterns.
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Affiliation(s)
- Michael D Kogan
- Health Resources and Services Administration, Maternal and Child Health Bureau, 5600 Fishers La, Room 18-41, Rockville, MD 20857, USA.
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How federal implementation choices can maximize the impact of CHIPRA on health care of children with developmental and behavioral needs. J Dev Behav Pediatr 2010; 31:238-43. [PMID: 20410702 DOI: 10.1097/dbp.0b013e3181d5a2c1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Regardless of the ultimate outcome of health reform, the Children's Health Insurance Program Reauthorization Act of 2009 set the stage for the potential to transform children's health care in the United States. The legislation included landmark provisions to find and enroll eligible low income children, as well as an unprecedented investment in quality measurement and demonstrations focused on improving health care delivery for children. However, many choices remain for the Federal government and states in implementing these provisions that could significantly affect their ultimate success. This commentary summarizes a larger report developed from legislative analysis and expert input and provides a set of recommendations for the federal government officials charged with implementing Children's Health Insurance Program Reauthorization Act. It focuses on two key provisions of the legislation which will be important regardless of the outcome of current health reform debates, enrollment and outreach and the broad set of quality related provisions, and explores the importance and specific potential impact of this legislation on children with developmental and behavioral needs.
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Grosse SD. Sociodemographic Characteristics of Families of Children with Down Syndrome and the Economic Impacts of Child Disability on Families. INTERNATIONAL REVIEW OF RESEARCH IN MENTAL RETARDATION 2010. [DOI: 10.1016/s0074-7750(10)39009-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Thompson LA, Knapp CA, Saliba H, Giunta N, Shenkman EA, Nackashi J. The impact of insurance on satisfaction and family-centered care for CSHCN. Pediatrics 2009; 124 Suppl 4:S420-7. [PMID: 19948608 DOI: 10.1542/peds.2009-1255n] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Children with special health care needs (CSHCN) have worse health outcomes and satisfaction compared with children with typical needs. Although individual characteristics influence satisfaction and family-centered care, additional effects of health insurance and state child health policies are unknown. OBJECTIVES To determine if satisfaction and family-centered care varied among CSHCN, after adjusting for individual characteristics, according to insurance type and state child health policies. METHODS We performed descriptive and multivariate analyses by using demographic, insurance, and satisfaction data from the 2006 National Survey of Children With Special Health Care Needs (N = 40723). Additional state data included Medicaid and State Children's Health Insurance Program (SCHIP) characteristics and the supply of pediatricians. We supplemented the national findings with survey data from Florida's SCHIP comprehensive care program (CMS-Duval ["Ped-I-Care"]) for CSHCN (N = 300). RESULTS Nationally, 59.8% of parents were satisfied with their child's health services, and two thirds (65.7%) received family-centered care. Adjusting for individual predictors, those uninsured and those with public insurance were less satisfied (odds ratios [ORs]: 0.45 and 0.83, respectively) and received less family-centered care (ORs: 0.43 and 0.80, respectively) than privately insured children. Of note, satisfaction increased with state Medicaid spending. Survey data from Ped-I-Care yielded significantly higher satisfaction (91.7%) compared with national levels of satisfaction in the SCHIP (54.2%) and similar rates of family-centered care (65.6%). These results suggest that satisfaction is based more on experiences with health systems, whereas family-centered care reflects more on provider encounters. CONCLUSIONS Insurance type affects both satisfaction and family-centered care for CSHCN, and certain state-level health care characteristics affect satisfaction. Future studies should focus on interventions in the health care system to improve satisfaction and patient encounters for family-centered care.
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Affiliation(s)
- Lindsay A Thompson
- Department of Pediatrics, University of Florida, College of Medicine, Gainesville, FL 32608, USA.
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Honberg LE, Kogan MD, Allen D, Strickland BB, Newacheck PW. Progress in ensuring adequate health insurance for children with special health care needs. Pediatrics 2009; 124:1273-80. [PMID: 19822584 DOI: 10.1542/peds.2009-0372] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This article reports findings from the 2005-2006 National Survey of Children With Special Health Care Needs (NS-CSHCN) regarding the extent to which CSHCN have access to public or private health insurance that meets their needs. METHODS The HRSA Maternal and Child Health Bureau's health insurance core outcome was measured on the basis of whether a child had public or private coverage at the time of survey; continuity of coverage during the previous 12 months; and adequacy of coverage. Bivariate and multivariate statistical methods were used to assess independent predictors of respondents who met the health insurance core outcome and the impact of meeting the core outcome on measures of access and financial burden. Comparisons with a referent sample of children who did and did not have special needs and were included in the 2001 NS-CSHCN are also presented. RESULTS A total of 62.0% of CSHCN nationally met the health insurance core outcome in 2005-2006, up from 59.6% in 2001. Disparities by ethnicity and income remain, but some have narrowed, especially for Hispanic CSHCN. Children who did not meet the health insurance core outcome were more likely to have unmet needs and their families to experience financial problems. CSHCN were more likely to be insured than children without special needs but less likely to be adequately insured. CONCLUSIONS Results of the survey demonstrate that although a growing number of CSHCN have continuous and adequate health insurance, additional effort is needed to improve the adequacy of that insurance, particularly for children in vulnerable subpopulations.
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Affiliation(s)
- Lynda E Honberg
- Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, Maryland 20857, USA.
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Amaranto DJ, Abbas F, Krantz S, Pearce WH, Wang E, Kibbe MR. An evaluation of gender and racial disparity in the decision to treat surgically arterial disease. J Vasc Surg 2009; 50:1340-7. [PMID: 19837528 DOI: 10.1016/j.jvs.2009.07.089] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2009] [Revised: 07/16/2009] [Accepted: 07/19/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In 1994, our hospital reported a significant gender disparity in the treatment of peripheral artery disease (PAD). The objective of this study was to determine if this gender-based treatment disparity still persists after 15 years. METHODS A retrospective review of patients with PAD and carotid artery disease based on vascular laboratory studies was performed from January 2006 to February 2008. PAD was identified by ankle-brachial index <or= 0.9 or abnormal waveform. Treatable carotid artery disease was identified by symptomatic stenosis 60%-99% or asymptomatic stenosis 80%-99%. Patients with interventions before January 2006 were excluded. Demographics, risk factors, and interventions were recorded. Univariate and multivariate analyses were performed to identify risk factors and independent predictors of intervention. RESULTS Of 2,313 peripheral artery studies, 592 patients with PAD and no prior intervention were identified. Sixty-five (21.7%) of 299 men and 47 (16.0%) of 293 women underwent angioplasty, stenting, endarterectomy, or bypass grafting. This difference was not significant (P = .077). However, by multivariate analysis of patients with critical limb ischemia, Caucasian race was an independent predictor of intervention (P = .010; odds ratio [OR] 3.363). Of 3,505 carotid duplex studies, 253 patients with treatable carotid artery disease and no prior intervention were identified. Seventy-eight (52.7%) of 148 men and 43 (41.0%) of 105 women underwent carotid endarterectomy (CEA) or stenting. This difference was not significant (P = .065). However, by multivariate analysis, Caucasian race was identified as an independent predictor of intervention (P = .015, OR 3.033). Insurance status was not a predictor of intervention in either the PAD (P = .70) or carotid artery disease cohort (P = .99). CONCLUSION Our data reveal that gender was not an independent predictor of intervention for PAD or carotid artery disease; however, Caucasian race independently predicted a greater likelihood of intervention in PAD patients with critical limb ischemia and in the carotid artery disease cohort. This study demonstrates the importance of performance assessments in uncovering unsuspected treatment disparities.
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Affiliation(s)
- Daniel J Amaranto
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill 60611, USA
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Wang J, Wu Y, Zhou B, Zhang S, Zheng W, Chen K. Factors associated with non-use of inpatient hospital care service by elderly people in China. HEALTH & SOCIAL CARE IN THE COMMUNITY 2009; 17:476-484. [PMID: 19456901 DOI: 10.1111/j.1365-2524.2009.00849.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The objectives of this cross-sectional study were to estimate non-use of inpatient hospital care service by elderly people in China and to examine associations between service non-use during the past 12 months and an array of predisposing, enabling and need factors. Using a fully structured questionnaire, trained health personnel interviewed 4046 Chinese aged 60 and older in Zhejiang province selected by a two-stage stratified cluster sampling scheme between September and December 2007. Based on the Andersen behavioural model, hierarchical logistic regression analysis was used to explore the predictors of non-use of this service. The rate of non-use was 14.2% [95% confidence interval (CI), 13.1-15.3%] for inpatient hospital care service. Logistic regression analyses revealed that enabling factors were more important than either predisposing or need factors in predicting non-use of inpatient hospital care service.Predisposing factors other than education were not significant, and only the need factor of number of diseases was significant for non-use of inpatient hospital care service. The odds of non-use for those with a college or higher degree were 0.36 times (95% CI, 0.21-0.62) the odds for those with primary or lower education. The odds of non-use in the presence of 4-10 diseases and 1-3 diseases were 3.10 times (95% CI,1.96-4.89) and 2.14 times (95% CI, 1.45-3.14), respectively, of those having no disease. Among the four enabling factors, only degree of living satisfaction score was not significantly associated with non-use of inpatient hospital care service. For elderly persons with higher healthcare expenditure, joining new rural cooperative medical insurance or having low social support, the odds of reporting non-use of inpatient hospital care services were raised by a factor of 1.6-8.0. Findings indicated that, in the absence of universal and comprehensive medical insurance coverage,enabling factors are more important than either predisposing or need factors in predicting non-use.
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Affiliation(s)
- Junfang Wang
- Department of Epidemiology and Biostatistics, Zhejiang University School of Public Health, Hangzhou, China.
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Newacheck PW, Houtrow AJ, Romm DL, Kuhlthau KA, Bloom SR, Van Cleave JM, Perrin JM. The future of health insurance for children with special health care needs. Pediatrics 2009; 123:e940-7. [PMID: 19403486 DOI: 10.1542/peds.2008-2921] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Because of their elevated need for services, health insurance is particularly important for children with special health care needs. In this article we assess how well the current system is meeting the insurance needs of children with special health care needs and how emerging trends in health insurance may affect their well-being. METHODS We begin with a review of the evidence on the impact of health insurance on the health care experiences of children with special health care needs based on the peer-reviewed literature. We then assess how well the current system meets the needs of these children by using data from 2 editions of the National Survey of Children With Special Health Care Needs. Finally, we present an analysis of recent developments and emerging trends in the health insurance marketplace that may affect this population. RESULTS Although a high proportion of children with special health care needs have insurance at any point in time, nearly 40% are either uninsured at least part of the year or have coverage that is inadequate. Recent expansions in public coverage, although offset in part by a contraction in employer-based coverage, have led to modest but significant reductions in the number of uninsured children with special health care needs. Emerging insurance products, including consumer-directed health plans, may expose children with special health care needs and their families to greater financial risks. CONCLUSIONS Health insurance coverage has the potential to secure access to needed care and improve the quality of life for these children while protecting their families from financially burdensome health care expenses. Continued vigilance and advocacy for children and youth with special health care needs are needed to ensure that these children have access to adequate coverage and that they fare well under health care reform.
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Affiliation(s)
- Paul W Newacheck
- Department of Pediatrics, School of Medicine, University of California, 3333 California St, Suite 265, San Francisco, CA 94118, USA.
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Gnanasekaran SK, Boudreau AA, Soobader MJ, Yucel R, Hill K, Kuhlthau K. State policy environment and delayed or forgone care among children with special health care needs. Matern Child Health J 2009; 12:739-46. [PMID: 17975719 DOI: 10.1007/s10995-007-0296-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate if children with special health care needs (CSHCN) residing in states with more generous public insurance programs were less likely to report delayed or forgone care. METHODS We used multilevel modeling to evaluate state policy characteristics after controlling for individual characteristics. We used the 2001 National Survey of CSHCN for individual-level data (N=33,317) merged with state-level data, which included measures of the state's public insurance programs (Medicaid eligibility and enrollment, spending on Medicaid, SCHIP and Title V, and income eligibility levels), state poverty level and provider supply (including pediatric primary care and specialty providers). We also included a variable for state waivers for CSHCN requiring institutional level care. RESULTS Delayed or forgone care significantly varied among CSHCN between states, net of individual characteristics. Of all the state characteristics studied, only the Medicaid income eligibility levels influenced the risk of experiencing delayed care. CSHCN living in states with higher income eligibility thresholds or more generous eligibility levels were less likely to experience delayed care (OR 0.89(0.80,0.99); P<or=0.05). CONCLUSIONS By analyzing child health policy in the context of individual characteristics that may place a child at risk for delayed care, we determined that improving Medicaid eligibility levels improved the process of care for CSHCN.
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Affiliation(s)
- Sangeeth K Gnanasekaran
- Center for Child and Adolescent Health Policy, Massachusetts General Hospital, and Department of Pediatrics, Harvard Medical School, 50 Staniford Street, Suite 901, Boston, MA 02214, USA.
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Junfang W, Biao Z, Weijun Z, Zhang S, Yinyin W, Chen K. Perceived unmet need for hospitalization service among elderly Chinese people in Zhejiang province. J Public Health (Oxf) 2009; 31:530-40. [DOI: 10.1093/pubmed/fdp007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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The Impact of Insurance Instability on Children's Access, Utilization, and Satisfaction with Health Care. ACTA ACUST UNITED AC 2008; 8:321-8. [DOI: 10.1016/j.ambp.2008.04.007] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Revised: 03/05/2008] [Accepted: 04/04/2008] [Indexed: 11/21/2022]
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Abstract
OBJECTIVE We examined financial barriers to care experienced by US school-aged children with disabilities. METHODS Data from the 2005 National Health Interview Survey were analyzed. Children aged 5 to 17 years were classified into 4 health condition groups: children with activity limitations, disabling conditions, chronic asthma, or no health conditions. Financial barriers to care were defined as being unable to afford prescriptions, delaying medical care, and/or having forgone medical care because of concern about cost. Our study included 8870 school-aged children; 338 children had an activity limitation, 1535 had a disabling condition, 594 children had chronic asthma, and 6288 children had no health conditions. RESULTS Children with activity limitations were significantly more likely than children with no health conditions to experience all 3 financial barriers to care. Uninsured children with activity limitations, disabling conditions, or no health conditions had the highest prevalence of all financial barriers to care. Of children living greater than or equal to 200% Federal Poverty Level, children with activity limitations and disabling conditions were more likely than children with no health conditions to experience all 3 financial barriers to care. Multivariate analysis showed uninsured children (odds ratio, 7.40; 95% confidence interval, 5.28-10.37) and children with an activity limitation (odds ratio, 3.70; 95% CI, 2.37-5.76) were at highest risk for financial barriers to care. CONCLUSIONS Uninsured and privately insured children with activity limitations were significantly more likely to experience financial barriers. The results show that many uninsured children still experience financial barriers to care despite the creation of the State Children's Health Insurance Program.
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Benedict RE. Quality medical homes: meeting children's needs for therapeutic and supportive services. Pediatrics 2008; 121:e127-34. [PMID: 18056291 DOI: 10.1542/peds.2007-0066] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The objective of this study was to determine whether the quality of a medical home is associated with access to needed therapeutic and supportive services among children with special health care needs. METHODS Data from the 2000-2001 National Survey of Children With Special Health Care Needs were used in the analysis. The primary group of interest was children who were 0 to 17 years of age and needed therapeutic (n = 15,793) or supportive (n = 23,376) services. For each characteristic of a quality medical home, the percentage of children who needed and received therapeutic and supportive services was generated. Logistic regression was used to control for covariates while modeling the association between overall quality of a child's medical home and having unmet needs for therapeutic or supportive services. RESULTS Of all children identified as needing services, 16.2% had unmet therapeutic and 9.8% unmet supportive service needs. Only 23.9% of the children who needed therapeutic and 32.5% of children who needed supportive services met the criteria of having a quality medical home. High-quality care within medical homes was associated with a decreased likelihood of having unmet needs for therapeutic and supportive services. Each characteristic of a quality medical home was associated with unmet need, as were severity of the child's condition, family income of <200% of the federal poverty level, underinsurance, and maternal education beyond high school. CONCLUSIONS Among other factors, having a poor-quality medical home seems to be a barrier to receiving needed therapeutic or supportive services for children with special health care needs. Efforts on the part of pediatricians to establish quality medical homes for all children could have the added benefit of facilitating access to needed therapeutic and supportive services and promoting the health and well-being of children with special health care needs and their families.
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Affiliation(s)
- Ruth E Benedict
- University of Wisconsin, Department of Kinesiology, Program in Occupational Therapy, 3170 Medical Science Center, 1300 University Ave, Madison, WI 53706-1532, USA.
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Hill KS, Freeman LC, Yucel RM, Kuhlthau KA. Unmet need among children with special health care needs in Massachusetts. Matern Child Health J 2007; 12:650-61. [PMID: 17899342 DOI: 10.1007/s10995-007-0283-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Accepted: 08/30/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We partnered with a Massachusetts family workgroup to analyze state level data that would be most useful to consumers and advocates in Massachusetts. METHODS Massachusetts' and US data from the 2001 National Survey of Children with Special Health Care Needs (NSCSHCN) were analyzed. We examined types of need and prevalence of unmet need for all CSHCN and for more severely affected CSHCN. We also correlated unmet need to child and family characteristics using multivariate logistic regression. RESULTS In Massachusetts, 17% of CSHCN and 37% of children more severely affected did not receive needed care. CSHCN who were uninsured anytime during the previous year were nearly 5 times more likely to experience an unmet need (OR = 4.95, CI: 1.69-14.51). Children with more functional limitations (OR = 3.15; CI: 1.59-6.24) and unstable health care needs (OR = 3.26; CI: 1.33-8.00) were also more likely to experience an unmet need. Receiving coordinated care in a medical home (OR = 0.46; CI: 0.23-0.90) was associated with reduced reports of unmet need. CONCLUSIONS With input from families of CSHCN, researchers can direct their analyses to answering the questions and concerns most meaningful to families. We estimate that 1 in 6 CSHCN in Massachusetts did not receive needed care, with more than 1 in 3 CSHCN with a more severe condition experiencing an unmet need. Enabling factors were predictors of unmet need suggesting solutions such as expanding insurance coverage and improving services systems for CSHCN.
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Affiliation(s)
- Kristen S Hill
- Center for Child and Adolescent Health Policy, Massachusetts General Hospital for Children, 50 Staniford Street, Suite 901, Boston, MA 02114, 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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Mulvihill BA, Altarac M, Swaminathan S, Kirby RS, Kulczycki A, Ellis DE. Does access to a medical home differ according to child and family characteristics, including special-health-care-needs status, among children in Alabama? Pediatrics 2007; 119 Suppl 1:S107-13. [PMID: 17272577 DOI: 10.1542/peds.2006-2089p] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [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 relationships among access to a medical home, special-health-care-needs status, and child and family characteristics in one Southern state. We hypothesized that access to a medical home is influenced by several family and child sociodemographic characteristics, including special-health-care status. METHODS We used data from the 2003 National Survey of Children's Health. The study sample comprised all Alabama resident children. The main dependent variable was a medical home; the primary independent variable classified children according to children-with-special-health-care-needs status. We controlled for child age, gender, race, family structure, health status, insurance coverage, household education, and poverty. We first explored means or proportions for the study variables and then estimated multivariate logistic regression models. RESULTS Children with special health care needs were significantly more likely than children without special health care needs to have a personal doctor or nurse, to have a preventive health care visit in the previous 12 months, and to have good communication with their provider. Children with special health care needs were also more likely to experience problems accessing specialty care, equipment, or services. Being uninsured, living at or near the federal poverty level, in a household where no one completed high school, being black, having less than excellent or good health, and living in a nontraditional family structure were characteristics associated with being less likely to have a medical home. In general, children-with-special-health-care-needs status was not related to having a medical home, but dependency on prescription medicine was. CONCLUSIONS Assuring that all children, irrespective of family income, have access to and are enrolled in health insurance plans will move us closer to the national goal of having a medical home for all children, especially those with a special health care need, by 2010.
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Affiliation(s)
- Beverly A Mulvihill
- Department of Maternal and Child Health, School of Public Health, University of Alabama, Birmingham, Alabama 35294-0022, USA.
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Zeni MB, Sappenfield W, Thompson D, Chen H. Factors associated with not having a personal health care provider for children in Florida. Pediatrics 2007; 119 Suppl 1:S61-7. [PMID: 17272587 DOI: 10.1542/peds.2006-2089j] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE National recommendations by the American Academy of Pediatrics and the National Association of Pediatric Nurse Practitioners promote that all children obtain quality primary care through a consistent medical provider who can better assess, diagnose, and monitor a child's health. The purpose of this article was to identify characteristics of children in Florida without a personal health care provider. METHODS Florida data (N = 2116) from the 2003 National Survey of Children's Health were analyzed by using bivariate and multivariate methods. The dependent, or outcome, variable was a personal health care provider, defined in the National Survey of Children's Health as a personal doctor or nurse. RESULTS In Florida, 20.1% of children (0-17 years of age) do not have a personal health care provider compared with 16.7% in the United States. Children at greatest risk are those without health insurance. Other significant risk factors include family poverty up to 100% of federal poverty level, poverty level 100% to 199%, poverty level unknown, poverty level 200% to 399%, children aged 5 to 12 years, children aged 13 to 17 years, and Hispanic ethnicity. All the factors in the Florida model were also significant in the national model. CONCLUSIONS Lack of a personal health care provider is driven by larger community issues of health insurance, socioeconomic status, and ethnicity, including race, on a national level. To achieve the goal of a personal health care provider for children, a multifaceted approach needs to be considered. Knowing which children are without a personal health care provider provides valuable information for state policy-makers, program planners, and evaluators.
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Affiliation(s)
- Mary Beth Zeni
- College of Nursing, Florida State University, Tallahassee, Florida 32306, USA.
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Blewett LA, Ward A, Beebe TJ. How much health insurance is enough? Revisiting the concept of underinsurance. Med Care Res Rev 2007; 63:663-700. [PMID: 17099121 DOI: 10.1177/1077558706293634] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is little consensus on what constitutes adequate health insurance coverage. The concept of a lack of adequate coverage, or underinsurance, is a matter of ongoing debate. A measure of adequate coverage is of critical importance as the nature of health insurance products evolves. Changes to health coverage include more direct out-of-pocket spending by consumers and a reduction of covered benefits. This article updates and extends an earlier review of underinsurance measurement published in 1993. We present a conceptual approach to measuring underinsurance and provide a review of the empirical findings obtained from the application of these approaches. A discussion of the limitations in the selection of a measurement approach includes a review of the extant data sources used. We recommend a national effort to develop a consistent approach to monitor changes in the economic and structural dimensions of health insurance coverage with a concerted effort to define and measure underinsurance.
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Szilagyi PG, Shone LP, Klein JD, Bajorska A, Dick AW. Improved Health Care Among Children With Special Health Care Needs After Enrollment Into the State Children’s Health Insurance Program. ACTA ACUST UNITED AC 2007; 7:10-7. [PMID: 17261477 DOI: 10.1016/j.ambp.2006.09.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 09/05/2006] [Accepted: 09/22/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the impact of New York's State Children's Health Insurance Program (SCHIP) on health care for children with special health care needs (CSHCN). METHODS Little is known about the impact of health insurance on CSHCN. Parents of a stratified random sample of new enrollees onto New York's SCHIP were interviewed by telephone at enrollment (n = 2644) and 1 year later (n = 2290, 87% response). At baseline, the cohort of CSHCN was defined by means of the standardized CSHCN screener instrument. The impact of SCHIP was assessed for CSHCN and for subgroups of CSHCN stratified by prior insurance (uninsured or insured) or type of chronic condition (physical or mental/behavioral). Access (having a usual source of care [USC], unmet medical needs); and quality (continuity of care at the USC, parent rating of quality of care or worry about child) were measured. Bivariate and multivariate analyses compared measures 1 year before SCHIP versus the year during SCHIP. RESULTS A total of 398 (17%) of 2290 children had special health care needs identified at baseline. Enrollment onto SCHIP was generally associated with improved access: unmet needs for prescription medications declined 3-fold for all subgroups (eg, 36% to 9% among the previously uninsured) and unmet needs for specialty care declined >4-fold among CSHCN who were previously insured (48% to 10%) or had mental/behavioral conditions (32% to 2%; all P < .05). Enrollment was associated with improved continuity with the USC, parent-reported quality of care, and worry, irrespective of prior insurance or type of chronic condition (P < .05). CONCLUSIONS Enrollment onto New York's SCHIP improved medical care for CSHCN.
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Affiliation(s)
- Peter G Szilagyi
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Strong Memorial Hospital, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Jeffrey AE, Newacheck PW. Role of insurance for children with special health care needs: a synthesis of the evidence. Pediatrics 2006; 118:e1027-38. [PMID: 16966391 DOI: 10.1542/peds.2005-2527] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [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 Children with special health care needs constitute a particularly vulnerable subpopulation of children. Health insurance coverage has the potential to enhance access to care and improve the quality of life for these children while protecting their families from financially burdensome health care expenses. The purpose of this review is to assess and synthesize recent research in the peer-reviewed literature pertaining to the role of insurance for children with special health care needs. A marked increase in the volume of research on this topic makes this an opportune time to summarize these contributions and begin the process of formalizing an evidence base that can inform health policy decisions. Our intention is to further the evidence base by providing a literature-driven assessment of the role of health insurance in influencing access, utilization, satisfaction, quality, expenditures, and health outcomes for children with special health care needs. METHODS A systematic literature review was conducted on the effects of insurance status, insurance type, and insurance features on access, utilization, satisfaction, quality, expenditures, and health status. RESULTS The strongest evidence emerged for the positive effects of insurance on access and utilization. Limited evidence on the effect of insurance on satisfaction with care showed improved satisfaction ratings for the insured. The studies with findings relevant to out-of-pocket expenditures for insured versus uninsured children with special health care needs all found significantly higher out-of-pocket burden and financial problems among the uninsured. Evidence was mixed for the effects of insurance type (public or private) and insurance characteristics (eg, managed care or fee-for-service payment mechanisms) on outcomes. None of the studies that we reviewed attempted to assess the impact of health insurance on health outcomes. CONCLUSIONS Our review of the literature found plentiful evidence demonstrating the positive and substantial impact of insurance on access and utilization. There also is clear evidence that insurance protects families against financially burdensome expenses. The evidence is less conclusive for satisfaction and quality and is nonexistent for health status. These latter outcomes should be the focus of future studies.
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Affiliation(s)
- Aimee E Jeffrey
- Department of Social and Behavioral Sciences, University of California, San Francisco, CA, USA
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