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Eisinger EC, Chen AT, Ramadan OI, Morgan AU, Delgado MK, Kaufman EJ. Health Care Use Among Patients Retroactively Insured via a Hospital-Based Insurance Linkage Program. J Gen Intern Med 2024; 39:1977-1984. [PMID: 38483779 PMCID: PMC11306664 DOI: 10.1007/s11606-024-08712-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/27/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVE Over 25% of the 27 million uninsured individuals in the United States are eligible for Medicaid. Many hospitals have insurance linkage programs that assist eligible patients with enrollment, but little is known about the impact of these programs on care utilization. This research assessed health care utilization and health outcomes among patients enrolled in Medicaid via a hospital-based insurance linkage program. METHODS This retrospective cohort study included adults aged 18-64 admitted to the hospital from 2016 to 2021. Those who obtained insurance retroactively via insurance linkage (RI) were compared with those who presented with Medicaid (MI) or remained uninsured (UI). The primary outcome was the presence of at least one visit with a primary care provider (PCP) in the 12 months following index admission. Secondary outcomes included having an assigned PCP, ED revisits, and hospital readmissions. For patients with diabetes and hypertension, 12-month hemoglobin A1c (HbA1c) and blood pressure (BP) readings were tracked. RESULTS Of 3882 patients admitted with no insurance, 2905 (74.8%) were enrolled in insurance (RI). In multivariable analysis, RI patients were 14% more likely (OR 1.14, p = 0.020) to have completed at least one PCP visit by 12 months after index admission compared to those with preexisting Medicaid (MI), and uninsured patients were 29% less likely (OR 0.71, p = 0.003). MI and RI patients also had more ED revisits (p < 0.001) and greater 12-month reductions in blood pressure (p < 0.001) compared with uninsured patients. CONCLUSION Hospital-based insurance linkage reached three-quarters of uninsured patients and was associated with increased utilization of acute and outpatient health care services. An acute care encounter represents an opportunity to connect patients to insurance, a key step toward improving their health outcomes.
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Affiliation(s)
- Ella C Eisinger
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Angela T Chen
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Health Care Management Department, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
| | - Omar I Ramadan
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna U Morgan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M Kit Delgado
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elinore J Kaufman
- The Center for Surgical Health, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of Trauma, Surgical Critical Care & Emergency Surgery, Penn Presbyterian Medical Center, Philadelphia, PA, USA.
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Gurewich D, Kressin N, Bokhour BG, Linsky AM, Dichter ME, Hunt KJ, Fix GM, Niles BL. Randomised controlled trial evaluating the effects of screening and referral for social determinants of health on Veterans' outcomes: protocol. BMJ Open 2022; 12:e058972. [PMID: 36153033 PMCID: PMC9511545 DOI: 10.1136/bmjopen-2021-058972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 08/12/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Health policy leaders recommend screening and referral (S&R) for unmet social needs (eg, food) in clinical settings, and the American Heart Association recently concluded that the most significant opportunities for reducing cardiovascular disease (CVD) death and disability lie with addressing the social determinants of CVD outcomes. A limited but promising evidence base supports these recommendations, but more rigorous research is needed to guide health care-based S&R efforts. Funded by the Veteran Health Administration (VA), the study described in this paper will assess the efficacy of S&R on Veterans' connections to new resources to address social needs, reduction of unmet needs and health-related outcomes (adherence, utilisation and clinical outcomes). METHODS AND ANALYSIS We will conduct a 1-year mixed-methods randomised controlled trial at three VA sites, enrolling Veterans with CVD and CVD-risk. 880 Veterans experiencing one or more social needs will be randomised within each site (n=293 per site) to one of three study arms representing referral mechanisms of varying intensity (screening only, screening and provision of resource sheet(s), screening and provision of resource sheet(s) plus social work assistance). For each Veteran, we will examine associations of unmet social needs with health-related outcomes at baseline, and longitudinally compare the impact of each approach on connection to new resources (primary outcome) and follow-up outcomes over a 12-month period. We will additionally conduct qualitative interviews with key stakeholders, including Veterans to identify potential explanatory factors related to the relative success of the interventions. ETHICS AND DISSEMINATION Ethics approval was obtained from the VA Central Internal Review Board on 13 July 2021 (reference #: 20-07-Amendment No. 02). Findings will be disseminated through reports, lay summaries, policy briefs, academic publications, and conference presentations. TRIAL REGISTRATION NUMBER NCT04977583.
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Affiliation(s)
- Deborah Gurewich
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Nancy Kressin
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Barbara G Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan School of Medicine, Worcester, MA, USA
| | - Amy M Linsky
- Center for Healthcare Organization and Implementation Research, VA Boston Health Care System, Boston, Massachusetts, USA
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- General Internal Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Melissa E Dichter
- Center for Health Equity Research and Promotion (CHERP), Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- School of Social Work, Temple University, Philadelphia, Pennsylvania, USA
| | - Kelly J Hunt
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H Johnson VAMC, Charleston, South Carolina, USA
| | - Gemmae M Fix
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Barbara L Niles
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
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Pidgeon H, McKinney D, Tan-Creevy J, Shah M, Ansari S, Gottlieb M. Thinking Beyond the Emergency Department: Addressing Homelessness in Residency Education. Ann Emerg Med 2021; 79:397-403. [PMID: 34607743 DOI: 10.1016/j.annemergmed.2021.07.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Harrison Pidgeon
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL.
| | - Dennis McKinney
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Jeny Tan-Creevy
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Meeta Shah
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Sobia Ansari
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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Gurewich D, Garg A, Kressin NR. Addressing Social Determinants of Health Within Healthcare Delivery Systems: a Framework to Ground and Inform Health Outcomes. J Gen Intern Med 2020; 35:1571-1575. [PMID: 32076989 PMCID: PMC7210348 DOI: 10.1007/s11606-020-05720-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/24/2019] [Accepted: 02/04/2020] [Indexed: 01/08/2023]
Abstract
Social determinants of health (SDoH) are the conditions in which people live and work that shape access to essential social and economic resources. Calls for healthcare systems to intervene on unmet social needs have stimulated several large-scale initiatives across the country. Yet, such activities are underway in the absence of a unifying conceptual framework outlining the potential mechanisms by which healthcare-based unmet social need interventions can improve health outcomes. Drawing on theoretical foundations and empirical evidence about the relationship between unmet social needs and health, the authors developed the OASIS (Outcomes from Addressing SDoH in Systems) conceptual framework to map the known and hypothesized pathways by which unmet social need screening and referral interventions may impact outcomes. The OASIS framework may help guide policy makers, healthcare system leaders, clinicians, and researchers to utilize a more unified approach in their efforts to implement and evaluate unmet social need interventions and thus foster the development of an evidence base to inform healthcare systems to more effectively mitigate the consequences of unmet social needs. Adopting an overarching conceptual framework for addressing unmet social needs by healthcare systems holds promise for better achieving health equity and promoting health at the individual and population levels.
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Affiliation(s)
- Deborah Gurewich
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA. .,Boston University School of Medicine, Boston Medical Center, Boston, MA, USA.
| | - Arvin Garg
- Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Nancy R Kressin
- VA Boston Healthcare System, Center for Healthcare Organization and Implementation Research, Boston, MA, USA.,Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
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Rees CA, Monuteaux MC, Raphael JL, Michelson KA. Disparities in Pediatric Mortality by Neighborhood Income in United States Emergency Departments. J Pediatr 2020; 219:209-215.e3. [PMID: 31610934 DOI: 10.1016/j.jpeds.2019.09.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/03/2019] [Accepted: 09/10/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate emergency department (ED) pediatric mortality by patient neighborhood income. STUDY DESIGN We calculated the incidence of ED pediatric mortality via a cross-sectional study of children <18 years who died in an ED using the Nationwide Emergency Department Sample and US Census from 2012 to 2016. The main exposure was median income for the patient's zip code tabulation area quartile. To determine factors associated with ED mortality, we modeled mortality using negative binomial regression. We used an interaction term between neighborhood income and insurance type to evaluate their relationship to mortality. RESULTS There were 64 893 ED deaths during the study period (incidence 17.3 per 100 000 person-years). The incidence of ED mortality increased with decreasing neighborhood income: compared with the wealthiest income quartile, the poorest, second, and third quartiles had adjusted incidence rate ratios (aIRRs) of 1.79 (95% CI 1.63-1.96), 1.42 (95% CI 1.29-1.55), and 1.23 (95% CI 1.12-1.36), respectively. The incidence of ED mortality was greater among uninsured children (aIRR 4.96, 95% CI 4.55-5.41) and publicly insured children (aIRR 2.69, 95% CI 2.51-2.88) compared with privately insured children. The interaction term showed no consistent relationship between neighborhood income and insurance with ED mortality. CONCLUSIONS Children from poorer neighborhoods have greater ED mortality rates than children from greater-income neighborhoods. Improved access to health insurance in the US may lead to reduced pediatric mortality, as ED mortality was greatest in uninsured children. Development of interventions to improve upstream determinants of health that contribute to ED mortality are needed.
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Affiliation(s)
- Chris A Rees
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jean L Raphael
- Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, TX
| | - Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Wright BJ, Garcia-Alexander G, Weller MA, Baicker K. Low-Cost Behavioral Nudges Increase Medicaid Take-Up Among Eligible Residents Of Oregon. Health Aff (Millwood) 2018; 36:838-845. [PMID: 28461350 DOI: 10.1377/hlthaff.2016.1325] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Efforts to reduce the ranks of the uninsured hinge on take-up of available programs and subsidies, but take-up of even free insurance is often less than complete. The evidence of the effectiveness of policies aiming to increase take-up is limited. We used a randomized controlled design to evaluate the impact of improved communication and behaviorally informed "nudges" designed to increase Medicaid take-up among eligible populations. Fielding randomized interventions in two different study populations in Oregon, we found that even very low-cost interventions substantially increased enrollment. Effects were larger in a population whose members had already expressed interest in obtaining coverage, but the effects were more persistent in low-income populations whose members were already enrolled in other state assistance programs but had not expressed interest in health insurance. The effects were similar across different demographic groups. Our results suggest that improving the design of enrollment processes and using low-cost mass-outreach efforts have the potential to substantially increase insurance coverage of vulnerable populations.
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Affiliation(s)
- Bill J Wright
- Bill J. Wright is a research scientist at the Center for Outcomes Research and Education of Providence Health and Services, in Portland, Oregon
| | - Ginny Garcia-Alexander
- Ginny Garcia-Alexander is an associate professor of sociology at Portland State University, in Oregon
| | - Margarette A Weller
- Margarette A. Weller is a project manager at the Center for Outcomes Research and Education of Providence Health and Services
| | - Katherine Baicker
- Katherine Baicker is a professor of health economics in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
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Emergency department-based health insurance enrollment for children: does linkage lead to insurance retention and utilization? Pediatr Emerg Care 2015; 31:169-72. [PMID: 25742607 DOI: 10.1097/pec.0000000000000340] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although 40% of emergency departments (EDs) report having an insurance linkage program, no studies have evaluated the long-term success of these programs. This study aimed to examine insurance retention and utilization by children initially referred to insurance by our ED insurance linkage program. METHODS We retrospectively examined insurance records of all uninsured children successfully enrolled in public insurance by the insurance linkage program established in our suburban academic ED between 2004 and 2009. Emergency department-enrolled children were matched by age, sex, program, and year of enrollment to a control group of children from the same county who were enrolled in non-ED settings. Wilcoxon signed rank and χ tests were used to compare enrollment and claims variables. RESULTS Emergency department-enrolled children retained insurance for longer, had a higher reenrollment rate, and were higher users of insurance. The average length of enrollment for ED children was 734 days versus 597 days in the control group. Eighty percent of the ED cohort reenrolled in insurance after initial eligibility expiration versus 64% of the control group. Children enrolled via the ED averaged 26 claims (vs 12 claims) and $20,087 (vs $5216) in hospital charges per year of enrollment. This higher utilization was reflected in increased primary care, specialty care, ED visits, inpatient, and mental health claims in the ED group. CONCLUSIONS Emergency department-based insurance enrollment programs have the potential to improve access to health care for children. Policies aimed at expanding insurance enrollment among the uninsured population, including the Affordable Care Act, may consider the ED's potential as an effective enrollment site.
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Flores G, Walker C, Lin H, Lee M, Fierro M, Henry M, Massey K, Portillo A. Design, methods, and baseline characteristics of the Kids' Health Insurance by Educating Lots of Parents (Kids' HELP) trial: a randomized, controlled trial of the effectiveness of parent mentors in insuring uninsured minority children. Contemp Clin Trials 2014; 40:124-37. [PMID: 25476583 DOI: 10.1016/j.cct.2014.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 11/19/2014] [Accepted: 11/20/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND & OBJECTIVES Six million US children have no health insurance, and substantial racial/ethnic disparities exist. The design, methods, and baseline characteristics are described for Kids' Health Insurance by Educating Lots of Parents (Kids' HELP), the first randomized, clinical trial of the effectiveness of Parent Mentors (PMs) in insuring uninsured minority children. METHODS & RESEARCH DESIGN Latino and African-American children eligible for but not enrolled in Medicaid/CHIP were randomized to PMs, or a control group receiving traditional Medicaid/CHIP outreach. PMs are experienced parents with ≥1 Medicaid/CHIP-covered children. PMs received two days of training, and provide intervention families with information on Medicaid/CHIP eligibility, assistance with application submission, and help maintaining coverage. Primary outcomes include obtaining health insurance, time interval to obtain coverage, and parental satisfaction. A blinded assessor contacts subjects monthly for one year to monitor outcomes. RESULTS Of 49,361 candidates screened, 329 fulfilled eligibility criteria and were randomized. The mean age is seven years for children and 32 years for caregivers; 2/3 are Latino, 1/3 are African-American, and the mean annual family income is $21,857. Half of caregivers were unaware that their uninsured child is Medicaid/CHIP eligible, and 95% of uninsured children had prior insurance. Fifteen PMs completed two-day training sessions. All PMs are female and minority, 60% are unemployed, and the mean annual family income is $20,913. Post-PM-training, overall knowledge/skills test scores significantly increased, and 100% reported being very satisfied/satisfied with the training. CONCLUSIONS Kids' HELP successfully reached target populations, met participant enrollment goals, and recruited and trained PMs.
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Affiliation(s)
- Glenn Flores
- Division of General Pediatrics, Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9063, USA; Division of General Pediatrics, Children's Medical Center Dallas, 1935 Medical District Dr, Dallas, TX 75235, USA.
| | - Candy Walker
- Division of General Pediatrics, Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9063, USA
| | - Hua Lin
- Division of General Pediatrics, Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9063, USA
| | - Michael Lee
- Division of General Pediatrics, Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9063, USA; Division of General Pediatrics, Children's Medical Center Dallas, 1935 Medical District Dr, Dallas, TX 75235, USA
| | - Marco Fierro
- Division of General Pediatrics, Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9063, USA
| | - Monica Henry
- Division of General Pediatrics, Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9063, USA
| | - Kenneth Massey
- Division of General Pediatrics, Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9063, USA
| | - Alberto Portillo
- Division of General Pediatrics, Department of Pediatrics, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9063, USA
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Jia L, Yuan B, Huang F, Lu Y, Garner P, Meng Q. Strategies for expanding health insurance coverage in vulnerable populations. Cochrane Database Syst Rev 2014; 2014:CD008194. [PMID: 25425010 PMCID: PMC4455226 DOI: 10.1002/14651858.cd008194.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Health insurance has the potential to improve access to health care and protect people from the financial risks of diseases. However, health insurance coverage is often low, particularly for people most in need of protection, including children and other vulnerable populations. OBJECTIVES To assess the effectiveness of strategies for expanding health insurance coverage in vulnerable populations. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library. www.thecochranelibrary.com (searched 2 November 2012), PubMed (searched 1 November 2012), EMBASE (searched 6 July 2012), Global Health (searched 6 July 2012), IBSS (searched 6 July 2012), WHO Library Database (WHOLIS) (searched 1 November 2012), IDEAS (searched 1 November 2012), ISI-Proceedings (searched 1 November 2012),OpenGrey (changed from OpenSIGLE) (searched 1 November 2012), African Index Medicus (searched 1 November 2012), BLDS (searched 1 November 2012), Econlit (searched 1 November 2012), ELDIS (searched 1 November 2012), ERIC (searched 1 November 2012), HERDIN NeON Database (searched 1 November 2012), IndMED (searched 1 November 2012), JSTOR (searched 1 November 2012), LILACS(searched 1 November 2012), NTIS (searched 1 November 2012), PAIS (searched 6 July 2012), Popline (searched 1 November 2012), ProQuest Dissertation &Theses Database (searched 1 November 2012), PsycINFO (searched 6 July 2012), SSRN (searched 1 November 2012), Thai Index Medicus (searched 1 November 2012), World Bank (searched 2 November 2012), WanFang (searched 3 November 2012), China National Knowledge Infrastructure (CHKD-CNKI) (searched 2 November 2012).In addition, we searched the reference lists of included studies and carried out a citation search for the included studies via Web of Science to find other potentially relevant studies. SELECTION CRITERIA Randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and Interrupted time series (ITS) studies that evaluated the effects of strategies on increasing health insurance coverage for vulnerable populations. We defined strategies as measures to improve the enrolment of vulnerable populations into health insurance schemes. Two categories and six specified strategies were identified as the interventions. DATA COLLECTION AND ANALYSIS At least two review authors independently extracted data and assessed the risk of bias. We undertook a structured synthesis. MAIN RESULTS We included two studies, both from the United States. People offered health insurance information and application support by community-based case managers were probably more likely to enrol their children into health insurance programmes (risk ratio (RR) 1.68, 95% confidence interval (CI) 1.44 to 1.96, moderate quality evidence) and were probably more likely to continue insuring their children (RR 2.59, 95% CI 1.95 to 3.44, moderate quality evidence). Of all the children that were insured, those in the intervention group may have been insured quicker (47.3 fewer days, 95% CI 20.6 to 74.0 fewer days, low quality evidence) and parents may have been more satisfied on average (satisfaction score average difference 1.07, 95% CI 0.72 to 1.42, low quality evidence).In the second study applications were handed out in emergency departments at hospitals, compared to not handing out applications, and may have had an effect on enrolment (RR 1.5, 95% CI 1.03 to 2.18, low quality evidence). AUTHORS' CONCLUSIONS Community-based case managers who provide health insurance information, application support, and negotiate with the insurer probably increase enrolment of children in health insurance schemes. However, the transferability of this intervention to other populations or other settings is uncertain. Handing out insurance application materials in hospital emergency departments may help increase the enrolment of children in health insurance schemes. Further studies evaluating the effectiveness of different strategies for expanding health insurance coverage in vulnerable population are needed in different settings, with careful attention given to study design.
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Affiliation(s)
- Liying Jia
- Shandong UniversityCenter for Health Management and Policy, Key Lab for Health Economics and Policy Research, Ministry of HealthJinanShandongChina250012
- Ministry of HealthKey Lab for Health Economics and Policy ResearchShandongChina
| | - Beibei Yuan
- Peking UniversityChina Center for Health Development Studies (CCHDS)38 Xueyuan RoadBeijingBeijingChina100191
| | - Fei Huang
- Shandong UniversityCenter for Health Management and PolicyJinanChina
| | - Ying Lu
- Shandong UniversityCenter for Health Management and PolicyJinanChina
| | - Paul Garner
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
| | - Qingyue Meng
- Peking UniversityChina Center for Health Development Studies (CCHDS)38 Xueyuan RoadBeijingBeijingChina100191
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Kanak M, Delgado MK, Camargo CA, Wang NE. Availability of insurance linkage programs in U.S. Emergency departments. West J Emerg Med 2014; 15:529-35. [PMID: 25035763 PMCID: PMC4100863 DOI: 10.5811/westjem.2014.4.20223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 03/22/2014] [Accepted: 04/15/2014] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION As millions of uninsured citizens who use emergency department (ED) services are now eligible for health insurance under the Affordable Care Act, the ED is ideally situated to facilitate linkage to insurance. Forty percent of U.S. EDs report having an insurance linkage program. This is the first national study to examine the characteristics of EDs that offer or do not offer these programs. METHODS This was a secondary analysis of data from the National Survey for Preventive Health Services in U.S. EDs conducted in 2008-09. We compared EDs with and without insurance programs across demographic and operational factors using univariate analysis. We then tested our hypotheses using multivariable logistic regression. We also further examined program capacity and priority among the sub-group of EDs with no insurance linkage program. RESULTS After adjustment, ED-insurance linkage programs were more likely to be located in the West (RR= 2.06, 95% CI = 1.33 - 2.72). The proportion of uninsured patients in an ED, teaching hospital status, and public ownership status were not associated with insurance linkage availability. EDs with linkage programs also offer more preventive services (RR = 1.87, 95% CI = 1.37-2.35) and have greater social worker availability (RR = 1.71, 95% CI = 1.12-2.33) than those who do not. Four of five EDs with a patient mix of ≥25% uninsured and no insurance linkage program reported that they could not offer a program with existing staff and funding. CONCLUSION Availability of insurance linkage programs in the ED is not associated with the proportion of uninsured patients served by an ED. Policy or hospital-based interventions to increase insurance linkage should first target the 27% of EDs with high rates of uninsured patients that lack adequate program capacity. Further research on barriers to implementation and cost effectiveness may help to facilitate increased adoption of insurance linkage programs.
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Affiliation(s)
- Mia Kanak
- Stanford University School of Medicine, Stanford, California
| | - M Kit Delgado
- Department of Emergency Medicine and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - N Ewen Wang
- Division of Emergency Medicine, Stanford University School of Medicine, Stanford, California
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Meng Q, Yuan B, Jia L, Wang J, Yu B, Gao J, Garner P. Expanding health insurance coverage in vulnerable groups: a systematic review of options. Health Policy Plan 2010; 26:93-104. [DOI: 10.1093/heapol/czq038] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Chen CC, Yamada T, Smith J, Chiu IM. Improving children's healthcare through state health insurance programs: an emerging need. Health Policy 2010; 99:72-82. [PMID: 20705355 DOI: 10.1016/j.healthpol.2010.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2010] [Revised: 07/05/2010] [Accepted: 07/12/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVES State Children's Health Insurance Program (SCHIP) in the USA plays a critical role in healthcare service utilization. This study assesses children's needs for healthcare services among the variations of SCHIP. METHODS This study applies the PRECEDE-PROCEED behavioral model to analyze the behavior of children with healthcare needs and unmet healthcare needs by using the National Survey of Children with Special Healthcare Needs of the USA. RESULTS Children who were previously under a Medicaid program are apt to enroll in SCHIP programs. SCHIP children with healthcare needs are more likely than comparable non-SCHIP children to use hospital outpatient departments instead of using doctors' offices and health centers. Children under the SCHIP single and SCHIP combination programs are more likely to use doctors' offices and health centers than those in the Medicaid expansion program. SCHIP combination or SCHIP Medicaid expansion states are significantly less likely to have unmet healthcare needs than children in SCHIP single states. CONCLUSIONS Medicaid has a significant impact on the SCHIP program. There is a substitution of healthcare service facilities between hospital outpatient departments and either the doctors' offices or health centers.
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Affiliation(s)
- Chia-Ching Chen
- Department of Epidemiology and Community Health, School of Health Sciences & Practice, New York Medical College, NY 10595, USA. ChiaChing
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Meng Q, Yuan B, Jia L, Wang J, Garner P. Outreach strategies for expanding health insurance coverage in children. Cochrane Database Syst Rev 2010:CD008194. [PMID: 20687096 DOI: 10.1002/14651858.cd008194.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Health insurance has the potential to improve access to health care and protect people from healthcare costs when they are ill. However, coverage is often low, particularly in people most in need of protection. OBJECTIVES To assess the effectiveness of outreach strategies for expanding insurance coverage of children who are eligible for health insurance schemes. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) Specialised Register (The Cochrane Library 2009, Issue 2), PubMed (January 1951 to January 2010), EMBASE (January 1966 to April 2009), PsycINFO (January 1967 to April 2009) and other relevant databases and websites. In addition, we searched the reference lists of included studies and relevant reviews, and carried out a citation search for included studies to find more potentially relevant studies. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before-after studies and interrupted time series which evaluated the effects of outreach strategies on increasing health insurance coverage for children. We defined outreach strategies as measures to improve the implementation of existing health insurance to enrol more eligible populations. This included increasing awareness of schemes, modifying enrolment, improving management and organis ation of insurance schemes, and mixed strategies. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias . We narratively summari sed the data. MAIN RESULTS We included two studies, both from the United States. One randomised controlled trial study with a low risk of bias showed that community- based case managers who provided health insurance information, application support, and negotiated with the insurer were effective in enrolling and maintaining enrolment of Latino American children into health insurance schemes (n = 257). The second quasi-randomised controlled trial, with an unclear risk of bias (n = 223), indicated that handing out insurance application materials in hospital emergenc y departments can increase enrolment of children into health insurance. AUTHORS' CONCLUSIONS The two studies included in this review provide evidence that in the US providing health insurance information and application assistance, and handing out application materials in hospital emergency departments can probably both improve insurance coverage of children. Further studies evaluating the effectiveness of different outreach strategies for expanding health insurance coverage of children in different countries are needed, with careful attention given to study design.
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Affiliation(s)
- Qingyue Meng
- Center for Health Management and Policy, Shandong University, Wenhua Xi Road 44, Jinan, Shandong, China, 250012
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Gordon JA. Social welfare in the hospital emergency department: the challenge of integrated community health care. Ann Emerg Med 2009; 53:603-4. [PMID: 19181421 DOI: 10.1016/j.annemergmed.2008.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 11/29/2008] [Accepted: 12/04/2008] [Indexed: 11/30/2022]
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Fleegler EW, Lieu TA, Wise PH, Muret-Wagstaff S. Families' health-related social problems and missed referral opportunities. Pediatrics 2007; 119:e1332-41. [PMID: 17545363 DOI: 10.1542/peds.2006-1505] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The objectives of this study were to characterize (1) families' cumulative burden of health-related social problems regarding access to health care, housing, food security, income security, and intimate partner violence; (2) families' experiences regarding screening and referral for social problems; and (3) parental acceptability of screening and referral. METHODS We surveyed 205 parents of children who were 0 to 6 years of age and attended 2 urban pediatric clinics for a well-child visit using a self-administered, computer-based questionnaire. The questionnaire included previously validated questions about health-related social problems and new questions about screening and referral in the past 12 months. RESULTS A total of 205 (79%) of 260 eligible families participated. Eighty-two percent of families reported > or = 1 health-related social problem; 54% experienced problems in > or = 2 social domains. Families experienced similar types and frequencies of problems despite demographic differences between clinics. One third of families reported no screening in any domain in the previous 12 months. Of 205 families, 143 (70%) identified at least 1 need for a referral; 101 (49%) expressed > or = 1 unmet referral need. Of families who reported receiving referrals, 115 referrals were received by 79 families; of the referrals made, 63% (73 of 115) led to contact with the referral agency, and 82% (60 of 73) of the referral agencies were considered helpful. A computer-based system in a pediatrician's office for future screening and referral for health-related social problems was deemed acceptable by 92% of parents. CONCLUSIONS Urban children and families reported a significant burden of health-related social problems yet infrequent pediatric screening or referral for these problems. Of families who reported receiving referrals, a majority contacted the recommended agencies and found them helpful. This study also demonstrates the feasibility of using a computer-based questionnaire to identify health-related social problems in a routine outpatient clinic setting.
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Affiliation(s)
- Eric W Fleegler
- Division of Emergency Medicine, MA-001, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115, USA.
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Rhodes KV, Iwashyna TJ. Child injury risks are close to home: parent psychosocial factors associated with child safety. Matern Child Health J 2007; 11:269-75. [PMID: 17216351 DOI: 10.1007/s10995-006-0171-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2006] [Accepted: 12/08/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In several populations, maternal depression has been associated with reduced child safety. In an urban pediatric Emergency Department, we examined the relationship between parental depression, social support, and domestic conflict and child safety behaviors. METHODS We studied consecutive patients in an Emergency Department. Trained interviewers used a structured instrument to assess patient, primary caregiver, and household demographics, socio-economic status, psychosocial factors, child safety behaviors (whether a gun was in the home, poisons were locked, a functioning smoke detector was present, and use of carseats or seatbelts), and whether the home was smoke-free. 1,116 patients provided adequate data. RESULTS Depression was associated with a modest and not statistically significant reduction in child safety behaviors in this population. Lack of social support and the presence of domestic conflict were robustly, independently, and statistically significantly associated with less safe homes. Domestic conflict was associated with more smoking in the home. CONCLUSION In our population, child safety was associated less with depression and more with parental lack of social support and domestic conflict. These can be assessed in a Emergency Department and may be amenable to intervention.
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Affiliation(s)
- Karin V Rhodes
- Division of Health Policy Research, Department of Emergency Medicine, School of Social Policy and Practice, University of Pennsylvania School of Medicine, 3815 Walnut St., Philadelphia, PA 19104, USA.
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Neuman MI, Radeos MS, Yang A, Gordon JA, Camargo CA. Does parental report of insurance status agree with hospital administrative data for children presenting to the ED? Am J Emerg Med 2007; 24:890-2. [PMID: 17098122 DOI: 10.1016/j.ajem.2006.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2005] [Revised: 03/10/2006] [Accepted: 03/10/2006] [Indexed: 11/25/2022] Open
Abstract
We screened nearly 10,000 consecutive parents presenting to EDs throughout the United States and examined whether parent/guardian self-report of insurance status agrees with hospital administrative data. We also examined the relationship of patient characteristics with any observed discordance.
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Affiliation(s)
- Mark I Neuman
- Division of Emergency Medicine, Children's Hospital, Boston, MA 02115, USA
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Morris DM, Gordon JA. The role of the emergency department in the care of homeless and disadvantaged populations. Emerg Med Clin North Am 2006; 24:839-48. [PMID: 16982342 DOI: 10.1016/j.emc.2006.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This article provides an overview of the role of the emergency department (ED) in the care of homeless and disadvantaged populations. It suggests that organized emergency medicine can have a significant impact on total community health by maintaining a universal "safety net" for the delivery of integrated health and human services. The epidemiology of social deprivation among ED patients is examined, with a particular focus on homelessness. Current research on the value of socio-medical integration in the ED setting is discussed, with emphasis on selected initiatives that have demonstrated feasibility, cost-effectiveness, and impact.
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Affiliation(s)
- David M Morris
- Department of Emergency Medicine, MetroWest Medical Center, Framingham Union Hospital, Framingham, MA 01702, USA.
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Abstract
PURPOSE OF REVIEW There are 8.4 million uninsured children in the United States. Many are eligible for coverage. Current literature on how lack of health insurance affects the quality and outcome of children's healthcare in the United States is reviewed, and effective solutions are identified. Recent policy changes have produced restrictions on basic preventive and curative services, despite concurrent major efforts to increase insurance coverage rates for children. RECENT FINDINGS With more than 70% of currently uninsured children eligible for either Medicaid or the State Children's Health Insurance Program, these public programs have not yet produced expected levels of coverage. Health systems and provider accountability for the primary care of uninsured children is not optimal. Families of uninsured children face non-financial access barriers to care such as lack of continuity with a primary care provider and inadequate visit time. These barriers are compounded for uninsured children with special healthcare needs. SUMMARY Pediatric primary care effectiveness is significantly reduced by insurance shortfalls. Lack of coverage inhibits appropriate care seeking; diminishes provider availability; compromises care content, quality, and satisfaction; and ultimately harms the entire family unit. However, provision of insurance alone is not a panacea.
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Affiliation(s)
- Yvonne W Fry-Johnson
- Maternal and Child Health Team, National Center of Primary Care, Morehouse School of Medicine, Atlanta, Georgia 30310-1495, USA.
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Abstract
PURPOSE OF REVIEW The State Children's Health Insurance Program expanded public health insurance to children who are ineligible for Medicaid yet unable to afford private health insurance. The program was a natural experiment, offering the opportunity to study the effects of expanding health insurance to a large population of children who would otherwise be uninsured. The State Children's Health Insurance Program is reviewed in the context of program goals, evaluation dimensions, past and current findings, and future directions. The studies and findings fall into five dimensions: (1) outreach/enrollment/uptake and profile of enrollees, (2) impact on insurance coverage and uninsured rates, (3) coverage dynamics, (4) impact on outcomes, and (5) costs. RECENT FINDINGS Older studies focused on outreach, enrollment, characteristics of enrollees, disenrollment, and coverage dynamics. Current studies report the impact of the program on outcomes--including access to care, quality, satisfaction, unmet need, and health outcomes--for the overall population of children and for vulnerable subgroups, including racial and ethnic minorities and children with chronic illness. A smaller number of studies address costs. SUMMARY The State Children's Health Insurance Program is evolving with demonstrated successes and areas for improvement. This information can enhance practicing pediatricians' understanding of barriers that face low-income children and families in seeking care for their children, can offer insight into what health insurance can and cannot do in terms of ameliorating those barriers, can provide insight into the prior experiences and current medical needs that a new enrollee in the program might have at the first visit to a practitioner, and can illuminate the challenges that low-income children and families may face in obtaining and maintaining health insurance coverage.
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Affiliation(s)
- Laura P Shone
- Department of Pediatrics, The Robert J Haggerty Child Health Services Research Laboratories, Strong Children's Research Center, Rochester, New York 14642, USA.
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Gordon JA. The science of common sense: integrating health and human services in the hospital emergency department. Ann Emerg Med 2005; 45:251-2. [PMID: 15726046 DOI: 10.1016/j.annemergmed.2004.10.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- James A Gordon
- Department of Emergency Medicine and Institute for Health Policy, Massachusetts General Hospital, 02114, USA.
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