Trends in perceived cost as a barrier to medical care, 1991-1996

Applying High-Value Care Principles in a Pediatric Case: A Workshop for Health Professions Students

INTRODUCTION

The cost of health care in the US is rapidly rising. Understanding the financial cost of medical care is an important competency for physicians and physicians-in-training. Medical students in their clinical clerkships are being exposed to health care decision-making often for the first time and are forming habits they will carry throughout their training and careers. Teaching high-value care (HVC) principles is crucial for students as they will be the future leaders in health care.

METHODS

This 1-hour workshop was interactive and aimed to prepare medical students to apply HVC when making medical decisions. The topic of HVC was initially introduced by eliciting tests that students want to order and highlighting the concept of whether or not a test changes the management of the patient. This exercise was followed by a PowerPoint presentation which discussed HVC, Choosing Wisely guidelines in pediatrics, and how to communicate with parents and patients about this topic.

RESULTS

Of third-year medical students, 125 participated in the workshop, with a survey response rate of 90% (n = 112). Ninety-nine percent reported that this workshop was helpful, and 97% reported that they will change their practice to reflect more cost-conscious care. Most students reported that their knowledge of HVC improved after the session, with 88% reporting scores of 3 (moderately improved) or 4 (significantly improved).

DISCUSSION

This ready-to-implement workshop offered students an understanding of how the cost of medical care impacts patients and families and how to practice cost-conscious care in pediatrics.

Postponing a General Practitioner Visit: Describing Social Differences in Thirty-One European Countries

OBJECTIVE

To describe social differences in postponing a general practitioner visit in 31 European countries and to explore whether primary care strength is associated with postponement rates.

DATA SOURCES

Between October 2011 and December 2013, the multicountry QUALICOPC study collected data on 61,931 patients and 7,183 general practitioners throughout Europe.

STUDY DESIGN

Access to primary care was measured by asking the patients whether they postponed a general practitioner visit in the past year. Social differences were described according to patients' self-rated household income, education, ethnicity, and gender.

DATA COLLECTION/EXTRACTION METHODS

Data were analyzed using multivariable and multilevel binomial logistic regression analyses.

PRINCIPAL FINDINGS

According to the variance-decomposition in the multilevel analysis, most of the variance can be explained by patient characteristics. Postponement of general practitioner care is higher for patients with a low self-rated household income, a low education level, and a migration background. In addition, although the point estimates are consistent with a substantial effect, no statistically significant association between primary care strength and postponement in the 31 countries is determined.

CONCLUSIONS

Despite the universal and egalitarian goals of health care systems, access to general practitioner care in Europe is still determined by patients' socioeconomic status (self-rated household income and education) and migration background.

Patients' Financially Driven Delay of GP Visits: Is It Less Likely to Occur in Stronger Primary Care Systems?

Available evidence has suggested that strong primary care (PC) systems are associated with better outcomes. This study aims to investigate whether PC strength is specifically related to the prevalence of patients' financially driven postponement of general practitioner (GP) care. Therefore, data from a cross-sectional multicountry study in 33 countries among GPs and their patients were analyzed using multilevel logistic regression modelling. According to the results, the variation between countries in the levels of patients' postponement of seeking GP care for financial reasons was large. More than one third of these cross-country differences could be explained by characteristics of the health care system and the GP practices. In particular, PC systems with good accessibility and those systems that offer comprehensive care were associated with lower levels of financially driven delay. Consequently, we can conclude that well-organized PC systems can compensate for the negative influence of individual characteristics (socioeconomic position) on the care-seeking behaviors of patients.

Racial and Ethnic Disparities in Health Insurance Coverage: Dynamics of Gaining and Losing Coverage over the Life-Course

Health insurance coverage varies substantially between racial and ethnic groups in the United States. Compared to non-Hispanic whites, African Americans and people of Hispanic origin had persistently lower insurance coverage rates at all ages. This article describes age- and group-specific dynamics of insurance gain and loss that contribute to inequalities found in traditional cross-sectional studies. It uses the longitudinal 2008 Panel of the Survey of Income and Program Participation (N=114,345) to describe age-specific patterns of disparity prior to the Affordable Care Act (ACA). A formal decomposition on increment-decrement life-tables of insurance gain and loss shows that coverage disparities are predominately driven by minority groups' greater propensity to lose the insurance that they already have. Uninsured African Americans were faster to gain insurance than non-Hispanic whites but their high rates of insurance loss more than negated this advantage. Disparities from greater rates of loss among minority groups emerge rapidly at the end of childhood and persist throughout adulthood. This is especially true for African Americans and Hispanics and their relative disadvantages again heighten in their 40s and 50s.

Characterizing emergency department patients who reported work-related injuries and illnesses

BACKGROUND

Per a Congressional directive and funding, this study describes worker and workplace characteristics of emergency department (ED) patients who reported their injury/illness to their employer. The study also responds to Congress's request to enumerate injured/ill self-employed workers and workers with chronic conditions.

METHODS

We conducted a follow-back study on injured/ill workers, including self-employed, identified from a national ED surveillance system from June 2012 through December 2013.

RESULTS

An estimated 3,357,000 (95%CI: 2,516,000-4,199,000) workers treated in EDs reported their injury/illness to their employer or were self-employed. Of those, 202,000 (95%CI: 133,000-272,000) had a chronic condition. Of all reporters, excluding self-employed, 77% indicated they received instructions as to whom to report.

CONCLUSION

The study did not identify underreporting issues and revealed that medical records data may not be appropriate for assessing underreporting. Additional research is needed to examine workplace characteristics that encourage injury and illness reporting. Am. J. Ind. Med. 59:610-620, 2016. © 2016 Wiley Periodicals, Inc.

The geographic concentration of US adult obesity prevalence and associated social, economic, and environmental factors

OBJECTIVE

This study used spatial statistical methods to test the hypotheses that county-level adult obesity prevalence in the United States is (1) regionally concentrated at significant levels, and (2) linked to local-level factors, after controlling for state-level effects.

METHODS

Data were obtained from the Centers for Disease Control and Prevention and other secondary sources. The units of analysis were counties. The dependent variable was the age-adjusted percentage of adults who were obese in 2009 (body mass index >30 kg/m2).

RESULTS

The prevalence of county-level obesity varied from 13.5% to 47.9% with a mean of 30.3%. Obesity prevalence across counties was not spatially random: 15.8% belonged to high-obesity regions and 13.5% belonged to low-obesity regions. Obesity was positively associated with unemployment, outpatient healthcare visits, physical inactivity, female-headed families, black populations, and less education. Obesity was negatively correlated with physician numbers, natural amenities, percent ≥65 years, Hispanic populations, and larger population size. A number of variables were notable for not reaching significance after controlling for other factors, including poverty and food environment measures.

CONCLUSIONS

The findings demonstrate the importance of local-level factors in explaining geographic variation in obesity prevalence, and thus hold implications for geographically targeted interventions to combat the obesity epidemic.

Barriers to eye care among people aged 40 years and older with diagnosed diabetes, 2006-2010

OBJECTIVE We examine barriers to receiving recommended eye care among people aged ≥40 years with diagnosed diabetes. RESEARCH DESIGN AND METHODS We analyzed 2006-2010 Behavioral Risk Factor Surveillance System data from 22 states (n = 27,699). Respondents who had not sought eye care in the preceding 12 months were asked the main reason why. We categorized the reasons as cost/lack of insurance, no need, no eye doctor/travel/appointment, and other (meaning everything else). We used multinomial logistic regression to control for race/ethnicity, education, income, and other selected covariates. RESULTS Among adults with diagnosed diabetes, nonadherence to the recommended annual eye examinations was 23.5%. The most commonly reported reasons for not receiving eye care in the preceding 12 months were "no need" and "cost or lack of insurance" (39.7 and 32.3%, respectively). Other reasons were "no eye doctor," "no transportation" or "could not get appointment" (6.4%), and "other" (21.5%). After controlling for covariates, adults aged 40-64 years were more likely than those aged ≥65 years (relative risk ratio [RRR] = 2.79; 95% CI 2.01-3.89) and women were more likely than men (RRR = 2.33; 95% CI 1.75-3.14) to report "cost or lack of insurance" as their main reason. However, people aged 40-64 years were less likely than those aged ≥65 years to report "no need" (RRR = 0.51; 95% CI 0.39-0.67) as their main reason. CONCLUSIONS Addressing concerns about "cost or lack of insurance" for adults under 65 years and "no perceived need" among those 65 years and older could help improve eye care service utilization among people with diabetes.

Does the integration of TB medical services in the general hospital improve the quality of TB care? Evidence from a case study in China

BACKGROUND

Moving the clinical services from tuberculosis (TB) dispensary to the integrated county hospital (called integrated approach) has been practiced in China; however, it is unknown the quality of TB care in the integrated approach and in the dispensary approach.

METHODS

A total of 202 new TB patients were investigated using structured questionnaires in three counties implementing the integrated approach and one county implementing the dispensary approach. The quality of TB care is measured based on success rate of treatment, medical expenditure, health system delay and second-line drug use.

RESULTS

The integrated approach showed a high success treatment rate. The medical expenditure in the integrated approach was USD 432, significantly lower than that in the dispensary approach (Z = -5.771, P < 0.001). The integrated approach had a shorter health system delay (5 days) than the dispensary approach (32 days). Twenty-six percent of patients in integrated hospitals were prescribed with second-line TB drugs, significantly lower than that in the TB dispensary (47%, χ(2) = 7.452, P = 0.006). However, the medical expenditure, use of second-line anti-TB drug and liver-protection drugs indeed varied greatly across the three integrated hospitals.

CONCLUSIONS

The integrated approach showed better quality of TB care, but the performance of the integrated hospitals varied greatly. A method to standardize TB treatment and management of this approach is urgent.

Lack of access due to costs remains a problem for some in Massachusetts despite the state's health reforms

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer. The state needs to implement new strategies to build on the promise of universal coverage and address specific needs of vulnerable populations, such as limiting out-of-pocket spending for this group. Also, more data are needed on the social determinants of health to identify specific barriers related to cost and access for vulnerable groups that general insurance reforms may not address.

Unhealthy and uninsured: exploring racial differences in health and health insurance coverage using a life table approach

Millions of people in the United States do not have health insurance, and wide racial and ethnic disparities exist in coverage. Current research provides a limited description of this problem, focusing on the number or proportion of individuals without insurance at a single time point or for a short period. Moreover, the literature provides no sense of the joint risk of being uninsured and in need of medical care. In this article, we use a life table approach to calculate health- and insurance-specific life expectancies for whites and blacks, thereby providing estimates of the duration of exposure to different insurance and health states over a typical lifetime. We find that, on average, Americans can expect to spend well over a decade without health insurance during a typical lifetime and that 40% of these years are spent in less-healthy categories. Findings also reveal a significant racial gap: despite their shorter overall life expectancy, blacks have a longer uninsured life expectancy than whites, and this racial gap consists entirely of less-healthy years. Racial disparities in insurance coverage are thus likely more severe than indicated by previous research.

Cost as a barrier to screening mammography among underserved women

BACKGROUND

Breast cancer is a troublesome health problem, particularly among underserved and minority women. Early detection through screening mammography can reduce the impact of this disease, yet it remains underused. Objective. We examined cost as a barrier to screening mammography and studied the accuracy of women's perceptions of the cost of a mammogram among a rural, low-income, tri-racial (white, Native American and African American) population in need of a mammogram.

DESIGN

We interviewed 897 women age 40 and older, asking about cost as a barrier to mammography and perceptions about the actual costs of a screening mammogram. Face-to-face interviews were conducted between 1998 and 2000 among women participating in a randomized, controlled study to evaluate a health education intervention to improve mammography screening rates in an underserved population. All data used in these analyses were from the baseline interviews.

RESULTS

Cost acted as a barrier to screening mammography for a majority of the participants (53%). More than half of these women (52%), however, overestimated the cost of a screening mammogram, and overestimation of the cost was significantly related to mentioning cost as a barrier (OR 1.56, 95% CI 1.04-2.33). Higher estimates of out-of-pocket costs were associated with reporting cost as a barrier to mammography (OR 2.25, 95% CI 1.43-3.52 for $1-50 and OR 12.64, 95% CI 6.61-24.17 for >$50). Factors such as race, income and employment status were not related to reporting cost as a barrier to screening mammography.

CONCLUSIONS

Among a group of tri-racial, low-income, rural women who were in need of a mammogram, cost was a common barrier. Overestimating the cost, however, was significantly and positively associated with reporting cost as a barrier. Providing information about the actual cost women have to pay for mammograms may lessen the role of cost as a barrier to mammography screening, especially for underserved women, potentially improving utilization rates.

Gender disparities in adult health: an examination of three measures of morbidity

Recent examinations of gender differences in physical health suggest that women's disadvantage may be smaller than previously assumed, varying by health status measure and age. Using data from the 1997-2001 National Health Interview Surveys, we examine gender-by-age differences in life-threatening medical conditions, functional limitations, and self-rated health and consider whether potential mediating mechanisms (e.g., socioeconomic status, behavioral factors) operate uniformly across health measures. The results show that the gender gap is smallest for life-threatening medical conditions and that men do increasingly worse with age. For self-rated health, men are more likely to report excellent health at younger ages, but with increasing age this gap closes. Only for functional limitations do we find a consistent pattern of female disadvantage: Women report more functional limitations than men, and the gap increases with age. The ability of explanatory mechanisms to account for these patterns varies by the health measure examined.

The effect of income question design in health surveys on family income, poverty and eligibility estimates

OBJECTIVE

To compare systematic differences between an "omnibus" income measure that asks for total family income amounts with a central survey item and an aggregated income measure that sums specific amounts of income obtained from multiple income sources from everyone within a family.

DATA SOURCE

The 2001 Current Population Survey-Demographic Supplement (CPS-DS). Data were collected from 78,000 households from February through April 2001.

STUDY DESIGN

First, we compare the omnibus family income to the aggregated family income amounts for each family. Second, we use the various aggregated family income sources to predict whether there is a mismatch between the omnibus and aggregated family income amounts. Finally, we assign a new aggregated amount of income that is restricted to be within the range of the omnibus amount to observe differences in poverty rates.

DATA COLLECTION

Data were extracted from University of Michigan's ICPSR website.

PRINCIPAL FINDINGS

There is a great deal of variation between the omnibus family income measure and the aggregated family income measure, with the omnibus amount generally being lower than the aggregated. As a result, the percent of people estimated to be in poverty is higher using the omnibus income item.

CONCLUSIONS

Health surveys generally rely on an omnibus income measure and analysts should be aware that the income estimates derived from it are limited with respect to poverty determination, and the related concept of eligibility estimation. Analysts of health surveys should also consider matching respondents or multiple imputation to improve the usability of the data.

Measuring contextual characteristics for community health

OBJECTIVE

To conceptualize and measure community contextual influences on population health and health disparities.

DATA SOURCES

We use traditional and nontraditional secondary sources of data comprising a comprehensive array of community characteristics.

STUDY DESIGN

Using a consultative process, we identify 12 overarching dimensions of contextual characteristics that may affect community health, as well as specific subcomponents relating to each dimension.

DATA COLLECTION

An extensive geocoded library of data indicators relating to each dimension and subcomponent for metropolitan areas in the United States is assembled.

PRINCIPAL FINDINGS

We describe the development of community contextual health profiles, present the rationale supporting each of the profile dimensions, and provide examples of relevant data sources.

CONCLUSIONS

Our conceptual framework for community contextual characteristics, including a specified set of dimensions and components, can provide practical ways to monitor health-related aspects of the economic, social, and physical environments in which people live. We suggest several guiding principles useful for understanding how aspects of contextual characteristics can affect health and health disparities.

Crossing the border for health care: access and primary care characteristics for young children of Latino farm workers along the US-Mexico border

OBJECTIVES

To examine prevalence and correlates of cross-border health care for children of Latino farm workers in counties near the US-Mexico border and to compare access and primary care in the United States and Mexico.

METHODS

Two hundred ninety-seven parents at Head Start centers in San Diego and Imperial counties were surveyed regarding percentage of health care received in Mexico and the United States, access, and primary care characteristics.

RESULTS

More than half of all health care was reported as received in Mexico. Reasons for Mexican use revolved around cost, accessibility, and perceptions of effectiveness. Parents of insured children reported slightly more US care, yet even this group reported approximately half of health care in Mexico. Insurance status was related to having a regular source of care, while uninsured children reporting most care in Mexico were less likely than uninsured children in the United States to have had a routine health care visit. Primary care characteristics were related to insurance status and source of care. Uninsured children reporting most care in Mexico fared better in some aspects of primary care than uninsured children reporting most care in the United States and as well as children with insurance receiving care in the United States or Mexico.

CONCLUSIONS

Children of farm workers living along the US-Mexico border, almost irrespective of insurance status, receive a large proportion of care in Mexico. Especially for uninsured children, parent reports of Mexican care characteristics compare favorably with that received in the United States. Mexican health care might be a buffer against vulnerability to poor health outcomes for these children.

Access to health services in an urban community: does source of care make a difference?

The importance of having a usual source of medical care is well established. Few studies, however, examine whether there are differences in health care utilization associated with the type of site used and whether having a primary clinician is more important than site in influencing utilization. The aim of this study was to examine these issues and assess the relative importance of usual source of care characteristics in determining access to a variety of health services. The study was based on a cross-sectional survey of a household probability sample of 695 adults from Central Harlem in New York City. Outcomes examined included use of hospitals as the regular source of care compared with other types of providers, having a usual clinician, receipt of various preventive health services, and illness-related utilization. Multiple logistic regression analysis indicated that men and people of lower socioeconomic status were significantly (P <or=.05) more likely to rely on hospitals alone as the usual source of care. People who exclusively used hospitals for ambulatory services were 72% less likely to have a primary clinician compared with those using other types of medical care sources. Having a usual source of care of any type was a significant predictor of receipt of five of eight health care services examined; having a main clinician was associated with four of the services. However, type of site used was unrelated to utilization. The impact of having a usual source of care appears to be independent of the effect of having a primary clinical provider, suggesting that having an initial portal into the health care system is as important as possessing an ongoing relationship with a clinician in ensuring access to services. Socioeconomic factors remain important influences on gaining entry into the health care system.

Differences in breast cancer screening rates: an issue of ethnicity or socioeconomics?

Previous reports suggest that use of preventive measures, such as screening mammography (SM), differs by ethnicity. It is unclear, however, if this is determined directly by ethnicity or indirectly by related socioeconomic factors. We studied self-reported data from 18,245 women aged 40-49 who participated in the Behavioral Risk Factor Surveillance System telephone survey in 1992 and 1993. Of these, 11,509 (63%) reported having obtained mammography within the preceding 2 years for screening purposes only. Using reports of other preventive healthcare behaviors, education level, socioeconomic status, and healthcare access problems as independent variables, bivariate associations were assessed, and a logistic regression model was developed. Models for each ethnic group were developed, with consistent results. Women who engaged in other preventive health measures, such as Pap smear (odds ratio [OR] 8.99, 95% confidence interval [CI] = 7.6-10.7), cholesterol measurement (OR 2.64, 95% CI = 2.3-3.0), and seatbelt use, were more likely to obtain SM. Women with healthcare access or insurance problems (OR 0. 59, 95% CI = 0.5-0.7) and current smokers (OR 0.71, CI = 0.6-0.8) had a lower likelihood of obtaining SM. Ethnicity, alcohol use, marital status, and education level were not significantly associated with women's reports of SM. Although ethnicity apparently does not influence a woman's likelihood of obtaining SM, access to healthcare and insurance and engaging in other healthy behaviors do. Health policy planners should consider the importance of these related factors when developing preventive health programs for women.

Gender differences in health care access indicators in an urban, low-income community

OBJECTIVES

This study examined factors associated with gender differences in health insurance coverage and having a usual source of medical care.

METHODS

In-person interviews were conducted with a community sample of 695 residents of Central Harlem, New York City. Predictors of the 2 outcome variables and the interaction of key variables with gender were analyzed via logistic regression.

RESULTS

No strong patterns emerged to explain gender differentials in having insurance coverage and having a usual provider. However, women employed full time had increased odds of insurance coverage, whereas employment had no similar effect among men. Public assistance evidenced a strong relationship with insurance coverage among both men and women. Socioeconomic factors and health insurance were important independent predictors of having a usual source of health care for men but had little effect among women.

CONCLUSIONS

Expanding the availability of both public insurance and affordable private coverage for men living in low-income communities is an important means of reducing gender disparities in access to health care. Public assistance is an important means of enabling access to health care for men as well as women.