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Holm J, Pagán JA, Silver D. The Impact of Medicaid Accountable Care Organizations on Health Care Utilization, Quality Measures, Health Outcomes and Costs from 2012 to 2023: A Scoping Review. Med Care Res Rev 2024:10775587241241984. [PMID: 38618890 DOI: 10.1177/10775587241241984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Most of the evidence regarding the success of ACOs is from the Medicare program. This review evaluates the impacts of ACOs within the Medicaid population. We identified 32 relevant studies published between 2012 and 2023 which analyzed the association of Medicaid ACOs and health care utilization (n = 21), quality measures (n = 18), health outcomes (n = 10), and cost reduction (n = 3). The results of our review regarding the effectiveness of Medicaid ACOs are mixed. Significant improvements included increased primary care visits, reduced admissions, and reduced inpatient stays. Cost reductions were reported in a few studies, and savings were largely dependent on length of attribution and years elapsed after ACO implementation. Adopting the ACO model for the Medicaid population brings some different challenges from those with the Medicare population, which may limit its success, particularly given differences in state Medicaid programs.
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Marthey D, Ramy M, Ukert B. Who do freestanding emergency departments treat? Comparing Texas hospitals to satellite and independent freestanding departments in 2021 and 2022. Health Serv Res 2024. [PMID: 38515240 DOI: 10.1111/1475-6773.14304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
OBJECTIVE The objective was to describe characteristics of emergency department visits to Texas satellite and independent freestanding emergency departments (FrEDs) relative to hospital emergency departments (EDs). DATA SOURCES AND STUDY SETTING The study used all 2021-2022 hospital and FrED discharges from the publicly available Texas Emergency Department Public Use Data Files (PUDF). STUDY DESIGN We conducted a descriptive analysis, comparing patient and visit characteristics at satellite and independent FrEDs and hospital EDs using chi-square tests. We characterized the top 20 diagnoses and procedures ranked by volume, treatment intensity, and potentially avoidable ED use. DATA COLLECTION/EXTRACTION METHODS Discharge data from 2021 to 2022 were combined for the analysis, and ED data at critical access hospitals were excluded. PRINCIPAL FINDINGS Our sample consisted of 21,605,421 ED visits, 76% occurring at hospitals, 12% at satellite FrEDs, and 12% at independent FrEDs. Compared with hospitals and satellite FrEDs, patients to independent FrEDs were younger, healthier, more likely covered by private insurance, and less likely to be identified as non-Hispanic Black or Hispanic. Visits at satellite and independent FrEDs were more likely to be of moderate and low intensity and potentially avoidable. CONCLUSIONS Our results underscore the need to address potentially avoidable utilization of emergency services.
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Affiliation(s)
- Daniel Marthey
- Texas A&M University, Department of Health Policy and Management, College Station, Texas, USA
| | - Maya Ramy
- The School of Medicine, Texas A&M University School of Medicine, Bryan, Texas, USA
| | - Benjamin Ukert
- Texas A&M University, Department of Health Policy and Management, College Station, Texas, USA
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Kavanaugh ML, Hussain R, Little AC. Unfulfilled and method-specific contraceptive preferences among reproductive-aged contraceptive users in Arizona, Iowa, New Jersey, and Wisconsin. Health Serv Res 2024. [PMID: 38456362 DOI: 10.1111/1475-6773.14297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE To identify characteristics associated with unfulfilled contraceptive preferences, document reasons for these unfulfilled preferences, and examine how these unfulfilled preferences vary across specific method users. DATA SOURCES AND STUDY SETTING We draw on secondary baseline data from 4660 reproductive-aged contraceptive users in the Arizona, Iowa, New Jersey, and Wisconsin Surveys of Women (SoWs), state-representative surveys fielded between October 2018 and August 2020 across the four states. STUDY DESIGN This is an observational cross-sectional study, which examined associations between individuals' reproductive health-related experiences and contraceptive preferences, adjusting for sociodemographic characteristics. Our primary outcome of interest is having an unfulfilled contraceptive preference, and a key independent variable is experience of high-quality contraceptive care. We also examine specific contraceptive method preferences according to current method used, as well as reasons for not using a preferred method. DATA COLLECTION/EXTRACTION METHODS Survey respondents who indicated use of any contraceptive method within the last 3 months prior to the survey were eligible for inclusion in this analysis. PRINCIPAL FINDINGS Overall, 23% reported preferring to use a method other than their current method, ranging from 17% in Iowa to 26% in New Jersey. Young age (18-24), using methods not requiring provider involvement, and not receiving quality contraceptive care were key attributes associated with unfulfilled contraceptive preferences. Those using emergency contraception and fertility awareness-based methods had some of the highest levels of unfulfilled contraceptive preferences, while pills, condoms, partner vasectomy, and IUDs were identified as the most preferred methods. Reasons for not using preferred contraceptive methods fell largely into one of two buckets: system-level or interpersonal/individual reasons. CONCLUSIONS Our findings highlight that avenues for decreasing the gap between contraceptive methods used and those preferred to be used may lie with healthcare providers and funding streams that support the delivery of contraceptive care.
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Affiliation(s)
| | - Rubina Hussain
- Research Division, Guttmacher Institute, New York, New York, USA
| | - Ashley C Little
- Research Division, Guttmacher Institute, New York, New York, USA
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Eck CS, Jiang C, Petersen LA. Veterans Health Administration enrollees' choice of care setting relates to the expansion of care options: Evidence from screening colonoscopies before and after the MISSION Act. Health Serv Res 2024; 59:e14241. [PMID: 37750415 PMCID: PMC10771906 DOI: 10.1111/1475-6773.14241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023] Open
Abstract
OBJECTIVE To estimate whether those enrolled in the Veterans Health Administration (VHA) were less likely to use VHA-delivered colorectal cancer screening colonoscopies after the MISSION Act. DATA SOURCES AND STUDY SETTING Secondary data were collected on VHA-enrolled Veterans from FY2017-FY2021. STUDY DESIGN This retrospective cross-sectional study measured the volume and share of screening colonoscopies that were VHA-delivered over time and by drive time eligibility-defined as living more than 60 min away from the nearest VHA specialty-care clinic. We used a multivariable logistic regression to adjust for patient and facility factors. DATA EXTRACTION Data were extracted for VHA enrollees (n = 773,766) who underwent a screening colonoscopy either performed or purchased by the VHA from FY2017-FY2021. PRINCIPAL FINDINGS In the 9 months after the implementation of the MISSION Act, and before the onset of the Covid-19 pandemic, the average monthly VHA-share of screening colonoscopies decreased by 3 percentage points (pp; 95% confidence interval [CI] = [-4 to -2 pp]) for the non-drive time eligible group and it decreased by 16 pp (95% CI = [-22 to -9 pp]) for the drive time eligible group. The total number of screening colonoscopies did not significantly change in either group during this time period. After adjusting for patient characteristics, a linear time trend, and parent facility fixed effects, implementation of the MISSION Act was associated with a reduction in the probability of a VHA-delivered screening colonoscopy (average marginal effect [AME]: -2.5 pp; 95% CI = [-5.1 to 0.0 pp]) for the non-drive time eligible group. The drive time eligible group (AME: -9.4 pp; 95% CI = [-13.2 to -5.5 pp]) experienced a larger change. CONCLUSIONS The VHA-share of screening colonoscopies among VHA enrollees fell in the 9 months immediately after the passage of the MISSION Act. This decline was larger for VHA enrollees who were targeted for eligibility due to a longer drive time. These results suggest that the MISSION Act led to more VHA-purchased care among targeted VHA enrollees, though it is unclear whether total utilization increased.
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Affiliation(s)
- Chase S. Eck
- Michael E. DeBakey VA Medical CenterHoustonTexasUSA
- Center for Innovations in QualityEffectiveness, and Safety (IQuESt)HoustonTexasUSA
- Section of Health Services Research, Department of MedicineBaylor College of MedicineHoustonTexasUSA
| | - Cheng Jiang
- Michael E. DeBakey VA Medical CenterHoustonTexasUSA
- Center for Innovations in QualityEffectiveness, and Safety (IQuESt)HoustonTexasUSA
- Section of Health Services Research, Department of MedicineBaylor College of MedicineHoustonTexasUSA
| | - Laura A. Petersen
- Michael E. DeBakey VA Medical CenterHoustonTexasUSA
- Center for Innovations in QualityEffectiveness, and Safety (IQuESt)HoustonTexasUSA
- Section of Health Services Research, Department of MedicineBaylor College of MedicineHoustonTexasUSA
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Feyman Y, Pizer SD, Shafer PR, Frakt AB, Garrido MM. Measuring restrictiveness of Medicare Advantage networks: A claims-based approach. Health Serv Res 2024; 59:e14255. [PMID: 37953067 PMCID: PMC10771910 DOI: 10.1111/1475-6773.14255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE To develop and validate a measure of provider network restrictiveness in the Medicare Advantage (MA) population. DATA SOURCES Prescription drug event data and beneficiary information for Part D enrollees from the Center for Medicare and Medicaid Services, along with prescriber identifiers; geographic variables from the Area Health Resources Files. STUDY DESIGN A prediction model was used to predict the unique number of primary care providers that would have been seen by MA beneficiaries absent network restrictions. The model was trained and validated on Traditional Medicare (TM) beneficiaries. A pseudo-Poisson and a random forest model were evaluated. An observed-to-expected (O/E) ratio was calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based the TM prediction model. Multivariable linear models were used to assess the relationship between network restrictiveness and plan and market factors. DATA COLLECTION/EXTRACTION METHODS Prescription drug event data were obtained for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017. PRINCIPAL FINDINGS Health Maintenance Organization plans were more restrictive (O/E = 55.5%; 95% CI 55.3%-55.7%) than Health Maintenance Organization-Point of Service plans (67.2%; 95% CI 66.7%-67.8%) or Preferred Provider Organization plans (74.7%; 95% CI 74.3%-75.1%), and rural areas had more restrictive networks (31.6%; 95% CI 29.0%-34.2%) than metropolitan areas (61.5%; 95% CI 61.3%-61.7%). Multivariable results confirmed these findings, and also indicated that increased provider supply was associated with less restrictive networks. CONCLUSIONS We developed a means of estimating provider network restrictiveness in MA from claims data. Our results validate the approach, providing confidence for wider application (e.g., for other markets and specialties) and use for regulation.
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Affiliation(s)
- Yevgeniy Feyman
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
- Partnered Evidence‐Based Policy Resource Center, Boston VA Healthcare SystemBostonMassachusettsUSA
| | - Steven D. Pizer
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
- Partnered Evidence‐Based Policy Resource Center, Boston VA Healthcare SystemBostonMassachusettsUSA
| | - Paul R. Shafer
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
- Partnered Evidence‐Based Policy Resource Center, Boston VA Healthcare SystemBostonMassachusettsUSA
| | - Austin B. Frakt
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
- Partnered Evidence‐Based Policy Resource Center, Boston VA Healthcare SystemBostonMassachusettsUSA
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Melissa M. Garrido
- Department of Health Law, Policy and ManagementBoston University School of Public HealthBostonMassachusettsUSA
- Partnered Evidence‐Based Policy Resource Center, Boston VA Healthcare SystemBostonMassachusettsUSA
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Chung K, Hughes MC, Koushkaki SR, Risberg MR, Alcantara M, Amico JM. Hospice Capacity to Provide General Inpatient Care: Emergency Department Utilization and Live Discharge Among Cancer Patients. Am J Hosp Palliat Care 2024; 41:63-72. [PMID: 37088870 DOI: 10.1177/10499091231170598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
General inpatient (GIP) hospice care is used only minimally for hospice patients, and more than a quarter of Medicare hospice facilities do not provide GIP care. To determine the impact of hospices' capacity to provide on emergency department use during hospice enrollment and live discharge from hospice, we used Surveillance, Epidemiology, and End Results-Medicare linked data and CMS Provider of Services data from 2007 to 2013 from ten states and two metropolitan regions. Grouping hospices into three GIP care provision categories: 1) no-GIP; 2) GIP-contract; and 3) GIP-IHF where hospices directly provide GIP care in their own inpatient hospice facility (IHF), we built a multilevel logistic model that accounted for unobserved hospice characteristics. Nearly 9% of the study sample received GIP care, of which 82% received such care in the last week of discharge. GIP-IHF hospices had lower live discharge rates than no-GIP hospices (AOR: .61; 95% CI: .47-.79; P < .001) and GIP-contract hospices (AOR: .84; 95% CI: .70-1.00; P < .05). Similarly, GIP-contract hospices were also associated with a decreased risk of live discharge, compared to no-GIP hospices (AOR: .76; CI: .62-.92; P < .05). There was no difference in emergency department use between no-GIP hospices and hospices with such capacity. Our results suggest that hospices capable of providing GIP care have lower live discharge rates than their counterparts. However, the fact that GIP care tends to be provided too close to death limits its effectiveness in preventing avoidable emergency department use.
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Affiliation(s)
- Kyusuk Chung
- Department of Health Sciences, California State University Northridge, Northridge, CA, USA
| | - M Courtney Hughes
- Northern Illinois University, School of Health Studies, DeKalb, IL, USA
| | | | - Mia Richelle Risberg
- Department of Health Sciences, California State University Northridge, Northridge, CA, USA
| | - Michelle Alcantara
- Department of Health Sciences, California State University Northridge, Northridge, CA, USA
| | - Jennifer M Amico
- Kaiser Foundation Hospitals, Medical Group Administration, Woodland Hills, CA, USA
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He F, Gasdaska A, White L, Tang Y, Beadles C. Participation in a Medicare advanced primary care model and the delivery of high-value services. Health Serv Res 2023; 58:1266-1291. [PMID: 37557935 PMCID: PMC10622300 DOI: 10.1111/1475-6773.14213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Abstract
OBJECTIVE To evaluate whether primary care providers' participation in the Comprehensive Primary Care Plus Initiative (CPC+) was associated with changes in their delivery of high-value services. DATA SOURCES Medicare Physician & Other Practitioners public use files from 2013 to 2019, 2017 to 2019 Medicare Part B claims for a 5% random sample of Medicare Fee-for-Service (FFS) beneficiaries, the Area Health Resources File, the National Plan & Provider Enumeration System files, and public use datasets from the Centers for Medicare & Medicaid Services Physician Compare. STUDY DESIGN We used a difference-in-difference approach with a propensity score-matched comparison group to estimate the association of CPC+ participation with the delivery of annual wellness visits (AWVs), advance care planning (ACP), flu shots, counseling to prevent tobacco use, and depression screening. These services are prominent examples of high-value services, providing benefits to patients at a reasonable cost. We examined both the likelihood of delivering these services within a year and the count of services delivered per 1000 Medicare FFS beneficiaries per year. DATA COLLECTION/EXTRACTION METHODS Secondary data are linked at the provider level. PRINCIPAL FINDINGS We find that CPC+ participation was associated with increases in the likelihood of delivering AWVs (13.03 percentage points by CPC+'s third year, p < 0.001) and the number of AWVs per 1000 Medicare FFS beneficiaries (44 more AWVs by CPC+'s third year, p < 0.001). We also find that CPC+ participation was associated with more flu shots per 1000 beneficiaries (52 more shots by CPC+'s third year, p < 0.001) but not with the likelihood of delivering flu shots. We did not find consistent evidence for the association between CPC+ participation and ACP services, counseling to prevent tobacco use, or depression screening. CONCLUSIONS CPC+ participation was associated with increases in the delivery of AWVs and flu shots, but not other high-value services.
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Affiliation(s)
- Fang He
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Angela Gasdaska
- Institute for Advanced Analytics, North Carolina State UniversityRaleighNorth CarolinaUSA
| | - Lindsay White
- Department of Medical Ethics & Health PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yan Tang
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
| | - Chris Beadles
- RTI InternationalResearch Triangle ParkNorth CarolinaUSA
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James HO, Koller C, Nasuti LJ, Auerbach DI, Wilson IB. Comparing ambulatory commercial spending in Rhode Island and Massachusetts, 2016-2019. Health Serv Res 2023; 58:1172-1177. [PMID: 37177796 PMCID: PMC10622295 DOI: 10.1111/1475-6773.14169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVE To evaluate trends and drivers of commercial ambulatory spending and price variation. DATA SOURCES AND STUDY SETTING Commercial claims data from the Massachusetts and Rhode Island All-Payer Claims Databases from 2016 to 2019. STUDY DESIGN Observational study of spending in major ambulatory care settings. We calculated per member per year spending, average price, and utilization rates to consider drivers of spending, and constructed site-specific price indices to evaluate price variation. DATA COLLECTION/EXTRACTION METHODS We analyzed commercial claims data from All-Payer Claims Databases in the two states. PRINCIPAL FINDINGS Ambulatory spending levels in Massachusetts were 38.0% higher than those in Rhode Island in 2019. Overall utilization rates were similar, but Massachusetts had a 6.2 percentage point higher share of visits occurring in hospital outpatient departments (HOPD). Average prices were 31.5% higher in Massachusetts in 2016 and 36.4% higher in 2019. We observed extensive price variation in both states across both office and HOPD settings. CONCLUSIONS States seeking to address increases in health care spending, including those with cost growth benchmarks and rate review policies, should consider additional interventions that mitigate market failures in the establishment of commercial health care prices.
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Affiliation(s)
- Hannah O. James
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
- Massachusetts Health Policy CommissionBostonMassachusettsUSA
| | - Christopher Koller
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
| | - Laura J. Nasuti
- Massachusetts Health Policy CommissionBostonMassachusettsUSA
| | | | - Ira B. Wilson
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRhode IslandUSA
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Grove LR, Berkowitz SA, Cuddeback G, Pink GH, Stearns SC, Stürmer T, Domino ME. Permanent Supportive Housing Receipt and Health Care Use Among Adults With Disabilities. Med Care Res Rev 2023; 80:596-607. [PMID: 37366069 PMCID: PMC10637096 DOI: 10.1177/10775587231183192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/10/2023] [Indexed: 06/28/2023]
Abstract
This study assessed whether permanent supportive housing (PSH) participation is associated with health service use among a population of adults with disabilities, including people transitioning into PSH from community and institutional settings. Our primary data sources were 2014 to 2018 secondary data from a PSH program in North Carolina linked to Medicaid claims. We used propensity score weighting to estimate the average treatment effect on the treated of PSH participation. All models were stratified by whether individuals were in institutional or community settings prior to PSH. In weighted analyses, among individuals who were institutionalized prior to PSH, PSH participation was associated with greater hospitalizations and emergency department (ED) visits and fewer primary care visits during the follow-up period, compared with similar individuals who largely remained institutionalized. Individuals who entered PSH from community settings did not have significantly different health service use from similar comparison group members during the 12-month follow-up period.
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Affiliation(s)
| | | | | | | | | | - Til Stürmer
- The University of North Carolina at Chapel Hill, USA
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Travaglini LE, Bennett M, Kacmarek CN, Kuykendall L, Coakley G, Lucksted A. Barriers to accessing pain management services among veterans with bipolar disorder. Health Serv Res 2023; 58:1224-1232. [PMID: 37667502 PMCID: PMC10622259 DOI: 10.1111/1475-6773.14221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023] Open
Abstract
OBJECTIVE To identify barriers veterans with bipolar disorder face to accessing chronic pain management services within a Veterans Affairs (VA) health care system. DATA SOURCES AND STUDY SETTING Veterans (n = 15) with chronic pain and bipolar disorder and providers (n = 15) working within a mid-Atlantic VA health care system. Data were collected from August 2017-June 2018. STUDY DESIGN Veteran interviews focused on their chronic pain experiences and treatment, including barriers that arose when trying to access pain management services. Provider interviews focused on whether they address chronic pain with veteran patients and, if so, what considerations arise when addressing pain in veterans with bipolar disorder and other serious mental illnesses. DATA COLLECTION Veterans were at least 18 years old, had a confirmed bipolar disorder and chronic pain diagnosis, and engaged in outpatient care within the VA health care system. Clinicians provided direct care services to veterans within the same VA. Interviews lasted approximately 60 min and were transcribed and analyzed using a rapid analysis protocol. PRINCIPAL FINDINGS Four major themes emerged from veteran and provider interviews: siloed care (unintegrated and uncoordinated mental and physical health care), mental health primacy (prioritization of mental health symptoms at expense of physical health symptoms), lagging expectations (unfamiliarity with comprehensive evidence-based pain management options), and provider-patient communication concerns (inefficient communication about pain concerns and treatment options). CONCLUSIONS Veterans with co-occurring pain and bipolar disorder face unique barriers that compromise equitable access to evidence-based pain treatment. Our findings suggest that educating providers about bipolar disorder and other serious mental illnesses and the benefit of effective non-pharmacological pain interventions for this group may improve care coordination and care quality and reduce access disparities.
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Affiliation(s)
- Letitia E. Travaglini
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), VA Maryland Health Care SystemBaltimoreMarylandUSA
| | - Melanie Bennett
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), VA Maryland Health Care SystemBaltimoreMarylandUSA
- Department of PsychiatryUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Corinne N. Kacmarek
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), VA Maryland Health Care SystemBaltimoreMarylandUSA
- Department of PsychiatryUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Lorrianne Kuykendall
- Office of Research and Development, Washington DC VA Medical CenterWashingtonDCUSA
| | - Gabriella Coakley
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), VA Maryland Health Care SystemBaltimoreMarylandUSA
- Department of PsychologyLoyola University MarylandBaltimoreMarylandUSA
| | - Alicia Lucksted
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), VA Maryland Health Care SystemBaltimoreMarylandUSA
- Department of PsychiatryUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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Hwang G. The impact of access to prenatal health insurance for noncitizen women on child health. Health Serv Res 2023; 58:1066-1076. [PMID: 37438931 PMCID: PMC10480078 DOI: 10.1111/1475-6773.14198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023] Open
Abstract
OBJECTIVE To estimate the effects of prenatal public health insurance targeting noncitizens on the health of U.S.-born children of noncitizen mothers beyond birth outcomes. DATA SOURCES AND STUDY SETTING This paper uses the restricted version of the 1998-2014 National Health Interview Survey with state-level geographic identifiers. STUDY DESIGN The empirical strategy compares outcomes in states that adopted the Children's Health Insurance Plan (CHIP) Unborn Child Option with states that never adopted or adopted it at different times, controlling for differences in the pre-treatment period. I use a flexible event-study analysis to quantify the effects of the Unborn Child Option on noncitizen women's health insurance coverage, health care utilization, and their children's health. DATA COLLECTION/EXTRACTION METHODS All data are derived from pre-existing sources. PRINCIPAL FINDINGS The study finds that the impact of the Unborn Child Option is a 4.7%-point increase in public health insurance coverage (p < 0.01) and 0.48 more doctor's office visits (p < 0.1) annually among noncitizens of childbearing ages. Subsequently, the reform leads to a 7%-point rise in the rate of parents reporting their 4-6-year-old children are in "excellent" or "very good" health (p < 0.01). While no improvements are evident at birth and at younger ages, observed health improvements begin to appear by preschool age. CONCLUSIONS The study contributes to the literature by providing evidence that certain benefits of in-utero public health insurance targeting noncitizens may appear several years after birth, specifically around preschool age.
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Affiliation(s)
- Grace Hwang
- Health Analysis DivisionCongressional Budget OfficeWashingtonDCUSA
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Mellor JM, McInerney M, Garrow RC, Sabik LM. The impact of Medicaid expansion on spending and utilization by older low-income Medicare beneficiaries. Health Serv Res 2023; 58:1024-1034. [PMID: 37011907 PMCID: PMC10480074 DOI: 10.1111/1475-6773.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
OBJECTIVE To examine indirect spillover effects of Affordable Care Act (ACA) Medicaid expansions to working-age adults on health care coverage, spending, and utilization by older low-income Medicare beneficiaries. DATA SOURCES 2010-2018 Health and Retirement Study survey data linked to annual Medicare beneficiary summary files. STUDY DESIGN We estimated individual-level difference-in-differences models of total spending for inpatient, institutional outpatient, physician/professional provider services; inpatient stays, outpatient visits, physician visits; and Medicaid and Part A and B Medicare coverage. We compared changes in outcomes before and after Medicaid expansion in expansion versus nonexpansion states. DATA COLLECTION/EXTRACTION METHODS The sample included low-income respondents aged 69 and older with linked Medicare data, enrolled in full-year traditional Medicare, and residing in the community. PRINCIPAL FINDINGS ACA Medicaid expansion was associated with a 9.8 percentage point increase in Medicaid coverage (95% CI: 0.020-0.176), a 4.4 percentage point increase in having any institutional outpatient spending (95% CI: 0.005-0.083), and a positive but statistically insignificant 2.4 percentage point change in Part B enrollment (95% CI: -0.003 to 0.050, p = 0.079). CONCLUSIONS ACA Medicaid expansion was associated with more institutional outpatient spending among older low-income Medicare beneficiaries. Increased care costs should be weighed against potential benefits from increased realized access to care.
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Affiliation(s)
- Jennifer M. Mellor
- Department of EconomicsWilliam & MaryChancellors Hall, 300 James Blair DriveWilliamsburgVirginia23185USA
| | - Melissa McInerney
- Department of EconomicsTufts University, Joyce Cummings Center177 College AvenueMedfordMassachusetts02155USA
- National Bureau of Economic Research1050 Massachusetts AvenueCambridgeMassachusetts02138USA
| | - Renee C. Garrow
- Federal Reserve Board20th Street and Constitution Ave NWWashingtonDC20551USA
| | - Lindsay M. Sabik
- Department of Health Policy & ManagementUniversity of Pittsburgh School of Public Health130 DeSoto St., A610PittsburghPennsylvania15261USA
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Mallinson DC, Elwert F, Ehrenthal DB. Spillover Effects of Prenatal Care Coordination on Older Siblings Beyond the Mother-Infant Dyad. Med Care 2023; 61:206-215. [PMID: 36893405 PMCID: PMC10009763 DOI: 10.1097/mlr.0000000000001822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND Pregnancy care coordination increases preventive care receipt for mothers and infants. Whether such services affect other family members' health care is unknown. OBJECTIVE To estimate the spillover effect of maternal exposure to Wisconsin Medicaid's Prenatal Care Coordination (PNCC) program during pregnancy with a younger sibling on the preventive care receipt for an older child. RESEARCH DESIGN Gain-score regressions-a sibling fixed effects strategy-estimated spillover effects while controlling for unobserved family-level confounders. SUBJECTS Data came from a longitudinal cohort of linked Wisconsin birth records and Medicaid claims. We sampled 21,332 sibling pairs (one older; one younger) who were born during 2008-2015, who were <4 years apart in age, and whose births were Medicaid-covered. In all, 4773 (22.4%) mothers received PNCC during pregnancy with the younger sibling. MEASURES The exposure was maternal PNCC receipt during pregnancy with the younger sibling (none; any). The outcome was the older sibling's number of preventive care visits or preventive care services in the younger sibling's first year of life. RESULTS Overall, maternal exposure to PNCC during pregnancy with the younger sibling did not affect older siblings' preventive care. However, among siblings who were 3 to <4 years apart in age, there was a positive spillover on the older sibling's receipt of care by 0.26 visits (95% CI: 0.11, 0.40 visits) and by 0.34 services (95% CI: 0.12, 0.55 services). CONCLUSION PNCC may only have spillover effects on siblings' preventive care in selected subpopulations but not in the broader population of Wisconsin families.
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Affiliation(s)
- David C. Mallinson
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, United States
| | - Felix Elwert
- Department of Sociology, College of Letters and Sciences, University of Wisconsin-Madison, United States
- Department of Biostatistics and Medical Informatics, School of Medicine and Public Health, University of Wisconsin-Madison, United States
- Center for Demography and Ecology, University of Wisconsin-Madison, United States
| | - Deborah B. Ehrenthal
- Department of Biobehavioral Health, College of Health and Human Development, Pennsylvania State University, University Park, Pennsylvania, United States
- Social Science Research Institute, Pennsylvania State University, University Park, Pennsylvania, United States
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14
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Creedon TB, Zuvekas SH, Hill SC, Ali MM, McClellan C, Dey JG. Effects of Medicaid expansion on insurance coverage and health services use among adults with disabilities newly eligible for Medicaid. Health Serv Res 2022; 57 Suppl 2:183-194. [PMID: 35811358 PMCID: PMC9660429 DOI: 10.1111/1475-6773.14034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To estimate the effects of Affordable Care Act (ACA) Medicaid expansion on insurance and health services use for adults with disabilities who were newly eligible for Medicaid. DATA SOURCES 2008-2018 Medical Expenditure Panel Survey data. STUDY DESIGN We used the Agency for Healthcare Research and Quality (AHRQ) PUBSIM model to identify adults aged 26-64 years with disabilities who were newly Medicaid-eligible in expansion states or would have been eligible in non-expansion states had those states opted to expand. Outcomes included insurance coverage; access to care; receipt of primary care, outpatient specialty physician services, and preventive services; and out-of-pocket health care spending. To estimate the effects of Medicaid expansion, we used two-way fixed effects models and a triple differences framework to compare pre-post changes in each outcome in expansion and non-expansion states for adults with and without disabilities. EXTRACTION METHODS We simulated Medicaid eligibility with the AHRQ PUBSIM model, which uses state-specific Medicaid rules and MEPS data on family relationships, state of residence, and income. PRINCIPAL FINDINGS Among adults with disabilities who were newly eligible for Medicaid, Medicaid expansion was associated with significant increases in full-year Medicaid coverage (35.9 percentage points [pp], p < 0.001), receipt of primary care (15.5 pp, p < 0.01), and receipt of flu shots (19.2 pp, p < 0.01), and a significant decrease in out-of-pocket spending (-$457, p < 0.01). There were larger improvements for adults with disabilities compared to those without disabilities in full-year Medicaid coverage (11.0 pp, p < 0.01) and receipt of flu shots (18.0 pp, p < 0.05). CONCLUSIONS Medicaid expansion was associated with improvements in full-year insurance coverage, receipt of primary and preventive care, and out-of-pocket spending for adults with disabilities who were newly eligible for Medicaid. For insurance coverage, preventive care, and some primary care measures, there were differentially larger improvements for adults with disabilities than for those without disabilities.
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Affiliation(s)
- Timothy B. Creedon
- Office of the Assistant Secretary for Planning and EvaluationUS Department of Health and Human ServicesWashingtonDistrict of ColumbiaUSA
| | - Samuel H. Zuvekas
- Agency for Healthcare Research and QualityUS Department of Health and Human ServicesRockvilleMarylandUSA
| | - Steven C. Hill
- Agency for Healthcare Research and QualityUS Department of Health and Human ServicesRockvilleMarylandUSA
| | - Mir M. Ali
- Office of the Assistant Secretary for Planning and EvaluationUS Department of Health and Human ServicesWashingtonDistrict of ColumbiaUSA
| | - Chandler McClellan
- Agency for Healthcare Research and QualityUS Department of Health and Human ServicesRockvilleMarylandUSA
| | - Judith G. Dey
- Office of the Assistant Secretary for Planning and EvaluationUS Department of Health and Human ServicesWashingtonDistrict of ColumbiaUSA
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15
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Sen AP, Singh Y, Anderson GF. Site-based payment differentials for ambulatory services among individuals with commercial insurance. Health Serv Res 2022; 57:1165-1174. [PMID: 35041209 PMCID: PMC9441285 DOI: 10.1111/1475-6773.13935] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/24/2021] [Accepted: 12/21/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare prices paid by commercial insurers for ambulatory services in physician office and hospital outpatient settings. DATA SOURCES MarketScan Commercial Claims and Encounters database obtained from Truven Health Analytics. STUDY DESIGN We examined ambulatory service claims for a sample of privately insured individuals who were continuously enrolled in a health maintenance organization plan, preferred provider organization plan, high-deductible/consumer-driven health plan, or exclusive provider organization plan in 2018. We categorized services into five categories: Evaluation & Management, Medical Services & Procedures, Pathology/Lab, Radiology, and Surgical. We identified services commonly provided in both outpatient and office settings and computed the price differential between outpatient and office services overall and for each service category, controlling for observable patient characteristics and geography. DATA COLLECTION We examined 89 services (defined by Current Procedural Terminology [CPT] code) that were provided in both office and outpatient settings in our sample (102.7 million claims, 8.3 million individuals). PRINCIPAL FINDINGS Adjusting for patient and geographic characteristics and across all services, total payment for an ambulatory service was, on average, 145% higher in a hospital outpatient department than the same service in a physician office. Out-of-pocket spending was 109% higher. Price differences between outpatient and office services were highest for pathology/laboratory services. Patients receiving services in outpatient departments had higher mean risk scores and received more services on the date of their visit (in addition to the index CPT being studied) than patients receiving the same index CPT in a physician's office. CONCLUSIONS Payments in hospital outpatient departments were significantly higher than payments for the same services in physician offices among commercially insured patients. Policies such as site-neutral payment would lower costs and could reduce incentives for further consolidation in health care markets. Care must be given to adjusting for patient severity across settings.
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Affiliation(s)
- Aditi P. Sen
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Present address:
Health Care Cost Institute, 1100 G Street NWWashington, DC 20005USA
| | - Yashaswini Singh
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Gerard F. Anderson
- Department of Health Policy and ManagementJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
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16
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Beauchamp AM, Kalra A, Scroggins H, Pahl B, Pitt A, Skaliks A, Jetelina KK. Identifying Violence Against Persons at a Safety-Net Hospital: Evidence from the First Six Months of Implementation. Health Serv Res 2022. [PMID: 35502497 DOI: 10.1111/1475-6773.13997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the prevalence and predictors of screening for violence against persons and victim service utilization within an integrated safety-net health system. STUDY SETTING Emergency Department (ED) at Parkland Hospital -- Dallas County's largest safety-net provider of services for minority and under-/un-insured patients. STUDY DESIGN Prospective, longitudinal study during the first six-months of a universal violence against persons screener. DATA COLLECTION Health records were extracted for all patients with a visit to the ED between January - July, 2021. Modeling described the patient population across screening (screened vs. not screened) and, among those screened, the results (positive vs. negative), average time spent in the ED, and referral patterns for victim services. PRINCIPAL FINDINGS 65,563 unique patients with 95,555 encounters occurred during the study period. Seventy-one percent (n= 67,535) were screened for violence against persons and, of those, 2% screened positive (n= 1,349). Of patients that screened positive, 1,178 (87%) were referred to and 806 (60%) received care at victim services. Implementing screening did not increase ED length of stay. CONCLUSIONS Systematic implementation of comprehensive violence screening at a safety-net system can result in a robust identification and timely referrals to victim services.
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Affiliation(s)
- Alaina M Beauchamp
- PhD Candidate, The University of Texas Health Science Center at Houston School of Public Health, Department of Epidemiology, Human Genetics, & Environmental Sciences 2777 N Stemmons Fwy, Ste. 8400, Dallas, TX
| | - Anjali Kalra
- Medical Student, University of Texas Southwestern Medical School 5323 Harry Hines Blvd, Dallas, TX.,Master of Public Health Student, The University of Texas Health Science Center at Houston School of Public Health, Department of Epidemiology, Human Genetics, & Environmental Sciences 2777 N Stemmons Fwy, Ste. 8400, Dallas, TX
| | - Heather Scroggins
- Sr. Clinical Informaticist Specialist, Parkland Health and Hospital System 7602 Albany Ln, Arlington, TX
| | - Brittany Pahl
- Nursing Director for Forensic Nursing and Community Programs, Parkland Health and Hospital System 5200 Harry Hines Blvd, Dallas, TX
| | - Amanda Pitt
- Magnet Program Manager, Parkland Health and Hospital System 5200 Harry Hines Blvd, Dallas, TX
| | - Andrea Skaliks
- Sr. Bilingual Counselor for Victim Intervention Program/Rape Crisis Center, Parkland Health and Hospital System 5200 Harry Hines Blvd, Dallas, TX
| | - Katelyn K Jetelina
- Assistant Professor, The University of Texas Health Science Center at Houston School of Public Health, Department of Epidemiology, Human Genetics, & Environmental Sciences 2777 N Stemmons Fwy, Ste. 8400, Dallas, TX
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17
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Abstract
Pregnancy-related complaints are a significant driver of emergency room (ER) utilization among women. Because of additional time for patient education and provider relationships, group prenatal care may reduce ER visits among pregnant women by helping them identify appropriate care settings, improving understanding of common pregnancy discomforts, and reducing risky health behaviors. We conducted a retrospective cohort study, utilizing Medicaid claims and birth certificate data from a statewide expansion of group care, to compare ER utilization between pregnant women participating in group prenatal care and individual prenatal care. Using propensity score matching methods, we found that group care was associated with a significant reduction in the likelihood of having any ER utilization (-5.9% among women receiving any group care and -6.0% among women attending at least five group care sessions). These findings suggest that group care may reduce ER utilization among pregnant women and encourage appropriate health care utilization during pregnancy.
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Affiliation(s)
| | | | | | - Ana Laboy
- Georgia State University, Atlanta, GA, USA
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18
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Vakkalanka JP, Lund BC, Arndt S, Field W, Charlton M, Ward MM, Carnahan RM. Therapeutic relationships between Veterans and buprenorphine providers and effects on treatment retention. Health Serv Res 2021; 57:392-402. [PMID: 34854083 DOI: 10.1111/1475-6773.13919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/27/2021] [Accepted: 11/19/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To examine the extent to which there was any therapeutic relationship between Veterans and their initial buprenorphine provider and whether the presence of this relationship influenced treatment retention. DATA SOURCES National, secondary administrative data used from the Veterans Health Administration (VHA), 2008-2017. STUDY DESIGN Retrospective cohort study. The primary exposure was a therapeutic relationship between the Veteran and buprenorphine provider, defined as the presence of a previous visit or medication prescribed by the provider in the 2 years preceding buprenorphine treatment initiation. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year. DATA COLLECTION/EXTRACTION METHODS Adult Veterans (age ≥ 18 years) diagnosed with opioid use disorder and treated with buprenorphine or buprenorphine/naloxone within the VHA system were included in this study. We excluded those receiving buprenorphine patches, those with documentation of a metastatic tumor diagnosis within 2 years prior to buprenorphine initiation, and those without geographical information on rurality. PRINCIPAL FINDINGS A total of 28,791 Veterans were included in the study. Within the overall study sample, 56.3% (n = 16,206) of Veterans previously had at least one outpatient encounter with their initial buprenorphine provider, and 24.9% (n = 7174) of Veterans previously had at least one prescription from that provider in the 2 years preceding buprenorphine initiation. There was no significant or clinically meaningful association between therapeutic relationship history and treatment retention when defined as visit history (aHR: 0.99; 95% CI: 0.96, 1.02) or medication history (aHR: 1.03; 95% CI: 1.00, 1.07). CONCLUSIONS Veterans initiating buprenorphine frequently did not have a therapeutic history with their initial buprenorphine provider, but this relationship was not associated with treatment retention. Future work should investigate how the quality of Veteran-provider therapeutic relationships influences opioid use dependence management and whether eliminating training requirements for providers might affect access to buprenorphine, and subsequently, treatment initiation and retention.
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Affiliation(s)
- Jayamalathi Priyanka Vakkalanka
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA.,Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Brian C Lund
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Stephan Arndt
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, USA.,Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - William Field
- Department of Occupational and Environmental Health, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Mary Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Ryan M Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
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19
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Duminy L, Sivapragasam NR, Matchar DB, Visaria A, Ansah JP, Blankart CR, Schoenenberger L. Validation and application of a needs-based segmentation tool for cross-country comparisons. Health Serv Res 2021; 56 Suppl 3:1394-1404. [PMID: 34755337 PMCID: PMC8579203 DOI: 10.1111/1475-6773.13873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/28/2021] [Accepted: 08/09/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To compare countries' health care needs by segmenting populations into a set of needs-based health states. DATA SOURCES We used seven waves of the Survey of Health, Aging and Retirement in Europe (SHARE) panel survey data. STUDY DESIGN We developed the Cross-Country Simple Segmentation Tool (CCSST), a validated clinician-administered instrument for categorizing older individuals by distinct, homogeneous health and related social service needs. Using clinical indicators, self-reported physician diagnosis of chronic disease, and performance-based tests conducted during the survey interview, individuals were assigned to 1-5 global impressions (GI) segments and assessed for having any of the four identifiable complicating factors (CFs). We used Cox proportional hazard models to estimate the risk of mortality by segment. First, we show the segmentation cross-sectionally to assess cross-country differences in the fraction of individuals with different levels of medical needs. Second, we compare the differences in the rate at which individuals transition between those levels and death. DATA COLLECTION/EXTRACTION METHODS We segmented 270,208 observations (from Austria, Belgium, Czech Republic, Denmark, France, Germany, Greece, Israel, Italy, the Netherlands, Poland, Spain, Sweden, and Switzerland) from 96,396 individuals into GI and CF categories. PRINCIPAL FINDINGS The CCSST is a valid tool for segmenting populations into needs-based states, showing Switzerland with the lowest fraction of individuals in high medical needs segments, followed by Denmark and Sweden, and Poland with the highest fraction, followed by Italy and Israel. Comparing hazard ratios of transitioning between health states may help identify country-specific areas for analysis of ecological and cultural risk factors. CONCLUSIONS The CCSST is an innovative tool for aggregate cross-country comparisons of both health needs and transitions between them. A cross-country comparison gives policy makers an effective means of comparing national health system performance and provides targeted guidance on how to identify strategies for curbing the rise of high-need, high-cost patients.
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Affiliation(s)
- Lize Duminy
- Institute for Health Policy and Health EconomicsBern University of Applied SciencesBernSwitzerland
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
| | - Nirmali Ruth Sivapragasam
- Program in Health Services and Systems Research ServiceDuke‐NUS Medical School SingaporeSingaporeSingapore
| | - David Bruce Matchar
- Program in Health Services and Systems Research ServiceDuke‐NUS Medical School SingaporeSingaporeSingapore
- Duke University Medical CenterDuke UniversityDurhamNorth CarolinaUSA
| | - Abhijit Visaria
- Centre for Ageing Research and EducationDuke‐NUS Medical School SingaporeSingaporeSingapore
| | - John Pastor Ansah
- Program in Health Services and Systems Research ServiceDuke‐NUS Medical School SingaporeSingaporeSingapore
| | - Carl Rudolf Blankart
- Swiss Institute of Translational and Entrepreneurial MedicineBernSwitzerland
- KPM Center for Public ManagementUniversity of BernBernSwitzerland
| | - Lukas Schoenenberger
- Institute for Health Policy and Health EconomicsBern University of Applied SciencesBernSwitzerland
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20
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Mayfield CA, Geraci M, Dulin M, Eberth JM, Merchant AT. Social and demographic characteristics of frequent or high-charge emergency department users: A quantile regression application. J Eval Clin Pract 2021; 27:1271-1280. [PMID: 33511747 DOI: 10.1111/jep.13537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Heavy users of the emergency department (ED) are a heterogeneous population. Few studies have captured the social and demographic complexity of patients with the largest burden of ED use. Our objective was to model associations between social and demographic patient characteristics and quantiles of the distributions of ED use, defined as frequent and high-charge. METHODS We conducted a cross-sectional analysis of electronic health and billing records of 99 637 adults residing in an urban North Carolina county who visited an ED within Atrium Health, a large integrated health care system, in 2017. Mid-quantile and standard quantile regression models were used for count and continuous responses, respectively. Frequent and high-charge use outcomes were defined as the median (0.50) and upper quantiles (0.75, 0.95, 0.99) of the outcome distributions for total billed ED visits and associated charges during the study period. Patient characteristic predictors were: insurance coverage (Medicaid, Medicare, private, uninsured), total visits to ambulatory care during the study period (0, 1, >1), and patient demographics: age, gender, race, ethnicity, and living in an underprivileged community called a public health priority area (PHPA). RESULTS Results showed heterogeneous relationships that were stronger at higher quantiles. Having Medicaid or Medicare insurance was positively associated with ED visits and ED charges at most quantiles. Racial and geographic disparities were observed. Black patients had more ED visits and lower ED charges than their White counterparts at most quantiles of the outcome distributions. Patients living in PHPAs, had lower charges than their counterparts at the median but higher charges at the 0.95 and 0.99 quantiles. CONCLUSIONS The relationships between patient characteristics and frequent and high-charge use of the ED vary based on the level of use. These findings can be used to inform targeted interventions, tailored policy, and population health management initiatives.
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Affiliation(s)
- Carlene A Mayfield
- Department of Community Health, Atrium Health, Charlotte, North Carolina, USA
| | - Marco Geraci
- MEMOTEF Department, School of Economics, Sapienza, University of Rome, Rome, Italy.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | - Michael Dulin
- Academy for Population Health Innovation, University of North Carolina Charlotte and Mecklenburg County Health Department, Charlotte, North Carolina, USA
| | - Jan M Eberth
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.,Rural and Minority Health Research Center, University of South Carolina, Arnold School of Public Health, Columbia, South Carolina, USA
| | - Anwar T Merchant
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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21
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Kyle MA, Frakt AB. Patient administrative burden in the US health care system. Health Serv Res 2021; 56:755-765. [PMID: 34498259 DOI: 10.1111/1475-6773.13861] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To assess the prevalence of patient administrative tasks and whether they are associated with delayed and/or foregone care. DATA SOURCE March 2019 Health Reform Monitoring Survey. STUDY DESIGN We assess the prevalence of five common patient administrative tasks-scheduling, obtaining information, prior authorizations, resolving billing issues, and resolving premium problems-and associated administrative burden, defined as delayed and/or foregone care. Using multivariate logistic models, we examined the association of demographic characteristics with odds of doing tasks and experiencing burdens. Our outcome variables were five common types of administrative tasks as well as composite measures of any task, any delayed care, any foregone care, and any burden (combined delayed/foregone), respectively. DATA COLLECTION We developed and administered survey questions to a nationally representative sample of insured, nonelderly adults (n = 4155). PRINCIPAL FINDINGS The survey completion rate was 62%. Seventy-three percent of respondents reported performing at least one administrative task in the past year. About one in three task-doers, or 24.4% of respondents overall, reported delayed or foregone care due to an administrative task: Adjusted for demographics, disability status had the strongest association with administrative tasks (adjusted odds ratio [OR] 2.91, p < 0.001) and burden (adjusted OR 1.66, p < 0.001). Being a woman was associated with doing administrative tasks (adjusted OR 2.19, p < 0.001). Being a college graduate was associated with performing an administrative task (adjusted OR 2.79, p < 0.001), while higher income was associated with fewer subsequent burdens (adjusted OR 0.55, p < 0.01). CONCLUSIONS Patients frequently do administrative tasks that can create burdens resulting in delayed/foregone care. The prevalence of delayed/foregone care due to administrative tasks is comparable to similar estimates of cost-related barriers to care. Demographic disparities in burden warrant further attention. Enhancing measurement of patient administrative work and associated burdens may identify opportunities for assessing quality, value, and patient experience.
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Affiliation(s)
- Michael Anne Kyle
- Harvard Medical School, Boston, Massachusetts, USA.,Harvard Business School, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Austin B Frakt
- Boston VA Healthcare System, Boston, Massachusetts, USA.,Boston University School of Public Health, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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22
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Moura Junior V, Westover MB, Li F, Kimchi E, Kennedy M, Benson NM, Moura LM, Hsu J. Hospital complications among older adults: Better processes could reduce the risk of delirium. Health Serv Manage Res 2021; 35:154-163. [PMID: 34247525 DOI: 10.1177/09514848211028707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Using observational data and variation in hospital admissions across days of the week, we examined the association between ED boarding time and development of delirium within 72 hours of admission among patients aged 65+ years admitted to an inpatient neurology ward. We exploited a natural experiment created by potentially exogenous variation in boarding time across days of the week because of competition for the neurology floor beds. Using proportional hazard models adjusting for socio-demographic and clinical characteristics in a propensity score, we examined the time to delirium onset among 858 patients: 2/3 were admitted for stroke, with the remaining admitted for another acute neurologic event. Among all patients, 81.2% had at least one delirium risk factor in addition to age. All eligible patients received delirium prevention protocols upon admission to the floor and received at least one delirium screening event. While the clinical and social-demographic characteristics of admitted patients were comparable across days of the week, patients with ED arrival on Sunday or Tuesday were more likely to have had delayed floor admission (waiting time greater than 13 hours) and delirium (adjusted HR = 1.54, 95%CI:1.37-1.75). Delayed initiation of delirium prevention protocol appeared to be associated with greater risk of delirium within the initial 72 hours of a hospital admission.
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Affiliation(s)
- Valdery Moura Junior
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,Department of Management, Cass Business School, City, University of London, London, UK
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Feng Li
- Department of Management, Cass Business School, City, University of London, London, UK
| | - Eyal Kimchi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Nicole M Benson
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA.,McLean Hospital, Harvard Medical School, Belmont, MA
| | - Lidia Maria Moura
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - John Hsu
- Department of Medicine and Health Policy, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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23
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Vasan A, Morgan JW, Mitra N, Xu C, Long JA, Asch DA, Kangovi S. Effects of a standardized community health worker intervention on hospitalization among disadvantaged patients with multiple chronic conditions: A pooled analysis of three clinical trials. Health Serv Res 2020; 55 Suppl 2:894-901. [PMID: 32643163 PMCID: PMC7518822 DOI: 10.1111/1475-6773.13321] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To analyze the effects of a standardized community health worker (CHW) intervention on hospitalization. DATA SOURCES/STUDY SETTING Pooled data from three randomized clinical trials (n = 1340) conducted between 2011 and 2016. STUDY DESIGN The trials in this pooled analysis were conducted across diseases and settings, with a common study design, intervention, and outcome measures. Participants were patients living in high-poverty regions of Philadelphia and were predominantly Medicaid insured. They were randomly assigned to receive usual care versus IMPaCT, an intervention in which CHWs provide tailored social support, health behavior coaching, connection with resources, and health system navigation. Trial one (n = 446) tested two weeks of IMPaCT among hospitalized general medical patients. Trial two (n = 302) tested six months of IMPaCT among outpatients at two academic primary care clinics. Trial three (n = 592) tested six months of IMPaCT among outpatients at academic, Veterans Affairs (VA), and Federally Qualified Health Center primary care practices. DATA COLLECTION/EXTRACTION METHODS The primary outcome for this study was all-cause hospitalization, as measured by total number of hospital days per patient. Hospitalization data were collected from statewide or VA databases at 30 days postenrollment in Trial 1, twelve months postenrollment in Trial 2, and nine months postenrollment in Trial 3. PRINCIPAL FINDINGS Over 9398 observed patient months, the total number of hospital days per patient in the intervention group was 66 percent of the total in the control group (849 days for 674 intervention patients vs 1258 days for 660 control patients, incidence rate ratio (IRR) 0.66, P < .0001). This reduction was driven by fewer hospitalizations per patient (0.27 vs 0.34, P < .0001) and shorter mean length of stay (4.72 vs 5.57 days, P = .03). The intervention also decreased rates of hospitalization outside patients' primary health system (18.8 percent vs 34.8 percent, P = .0023). CONCLUSIONS Data from three randomized clinical trials across multiple settings show that a standardized CHW intervention reduced total hospital days and hospitalizations outside the primary health system. This is the largest analysis of randomized trials to demonstrate reductions in hospitalization with a health system-based social intervention.
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Affiliation(s)
- Aditi Vasan
- National Clinician Scholars Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,PolicyLab and Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John W Morgan
- National Clinician Scholars Program, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chang Xu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Judith A Long
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Corporal Michael J Crescenz VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania
| | - David A Asch
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Corporal Michael J Crescenz VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania
| | - Shreya Kangovi
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Corporal Michael J Crescenz VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, Pennsylvania.,Penn Center for Community Health Workers, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Van Houtven CH, Smith VA, Stechuchak KM, Berkowitz TSZ, Miller KEM, Shepherd-Banigan M, Kabat M, Henius J. Comprehensive support of family caregivers: Are there health system cost offsets? Health Serv Res 2020; 55:710-721. [PMID: 32621548 DOI: 10.1111/1475-6773.13312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To examine the effect of the Department of Veterans Affairs' (VA) Program of Comprehensive Assistance for Caregivers (PCAFC) on total VA health care costs for Veterans. DATA SOURCES VA claims. STUDY DESIGN Using a pre-post cohort design with nonequivalent control group, we estimated the effect of PCAFC on total VA costs up through 6 years. The treatment group included Veterans (n = 32 394) whose caregivers enrolled in PCAFC. The control group included an inverse probability of treatment weighted sample of Veterans whose caregivers were denied PCAFC enrollment (n = 38 402). DATA EXTRACTION May 2009-September 2017. PRINCIPAL FINDINGS Total VA costs pre-PCAFC application date were no different between groups. Veterans in PCAFC were estimated to have $13 227 in VA costs in the first 6 months post-PCAFC application, compared to $10 806 for controls. Estimated VA costs for both groups decreased in the first 3 years with a narrowing, but persistent and significant, difference, through 5.5 years. No significant difference in VA health care costs existed at 6 years, approximately $10 000 each, though confidence intervals reflect significant uncertainty in cost differences at 6 years. CONCLUSIONS Increased costs arose from increased outpatient costs of participants. Sample composition changes may explain lack of significance in cost differences at 6 years because these costs comprise of early appliers to PCAFC. Examining 10-year costs could elucidate whether there are long-term cost offsets from increased engagement in outpatient care.
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Affiliation(s)
- Courtney Harold Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC.,Duke-Margolis Center for Health Policy, Durham, NC
| | - Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC.,Division of General Internal Medicine, Department of Medicine, Duke University, Durham, NC
| | - Karen M Stechuchak
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Theodore S Z Berkowitz
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC
| | - Katherine E M Miller
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, NC
| | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, Durham, NC.,Department of Population Health Sciences, Duke University Medical Center, Durham, NC
| | - Margaret Kabat
- Caregiver Support Program, VA Central Office, Washington, DC
| | - Jennifer Henius
- Caregiver Support Program, VA Central Office, Washington, DC
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Abstract
Objective To disentangle the relationships among food insecurity, health care utilization, and health care expenditures. Data Sources/Study Setting We use national data on 13 465 adults (age ≥ 18) from the 2016 Medical Expenditure Panel Survey (MEPS), the first year of the food insecurity measures. Study Design We employ two‐stage empirical models (probit for any health care use/expenditure, ordinary least squares, and generalized linear models for amount of utilization/expenditure), controlling for demographics, health insurance, poverty status, chronic conditions, and other predictors. Principal Findings Our results show that the likelihood of any health care expenditure (total, inpatient, emergency department, outpatient, and pharmaceutical) is higher for marginal, low, and very low food secure individuals. Relative to food secure households, very low food secure households are 5.1 percentage points (P < .001) more likely to have any health care expenditure, and have total health care expenditures that are 24.8 percent higher (P = .011). However, once we include chronic conditions in the models (ie, high blood pressure, heart disease, stroke, emphysema, high cholesterol, cancer, diabetes, arthritis, and asthma), these underlying health conditions mitigate the differences in expenditures by food insecurity status (only the likelihood of any having any health care expenditure for very low food secure households remains statistically significant). Conclusions Policy makers and government agencies are focused on addressing deficiencies in social determinants of health and the resulting impacts on health status and health care utilization. Our results indicate that chronic conditions are strongly associated with food insecurity and higher health care spending. Efforts to alleviate food insecurity should consider the dual burden of chronic conditions. Finally, future research can address specific mechanisms underlying the relationships between food security, health, and health care.
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Affiliation(s)
- Emma Boswell Dean
- Department of Health Management and Policy, University of Miami Herbert Business School, Coral Gables, Florida
| | - Michael T French
- Department of Health Management and Policy, University of Miami Herbert Business School, Coral Gables, Florida
| | - Karoline Mortensen
- Department of Health Management and Policy, University of Miami Herbert Business School, Coral Gables, Florida
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Abstract
OBJECTIVE To develop a model for identifying clinic performance at fulfilling next-day and walk-in requests after adjusting for patient demographics and risk. DATA SOURCE Using Department of Veterans Affairs (VA) administrative data from 160 VA primary care clinics from 2014 to 2017. STUDY DESIGN Using a retrospective cohort design, we applied Bayesian hierarchical regression models to predict provision of timely care, with clinic-level random intercept and slope while adjusting for patient demographics and risk status. Timely care was defined as the provision of an appointment within 48 hours of any patient requesting the clinic's next available appointment or walking in to receive care. DATA COLLECTION/EXTRACTION METHODS We extracted 1 841 210 timely care requests from 613 263 patients. PRINCIPAL FINDINGS Across 160 primary care clinics, requests for timely care were fulfilled 86 percent of the time (range 83 percent-88 percent). Our model of timely care fit the data well, with a Bayesian R2 of .8. Over the four years of observation, we identified 25 clinics (16 percent) that were either struggling or excelling at providing timely care. CONCLUSION Statistical models of timely care allow for identification of clinics in need of improvement after adjusting for patient demographics and risk status. VA primary care clinics fulfilled 86 percent of timely care requests.
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Affiliation(s)
- Adam J Batten
- Primary Care Analytics Team, Veterans Health Administration, Seattle, Washington
| | - Matthew R Augustine
- Department of Medicine, James J Peters VA Medical Center, Bronx, New York.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karin M Nelson
- Primary Care Analytics Team, Veterans Health Administration, Seattle, Washington.,Department of Medicine, VA Puget Sound Healthcare System, Seattle, Washington.,Department of Medicine, University of Washington, Seattle, Washington
| | - Peter J Kaboli
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health and Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa.,Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
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27
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Pickens G, Karaca Z, Gibson TB, Cutler E, Dworsky M, Moore B, Wong HS. Changes in hospital service demand, cost, and patient illness severity following health reform. Health Serv Res 2019; 54:739-751. [PMID: 31070263 DOI: 10.1111/1475-6773.13165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To estimate the effects of the health insurance exchange and Medicaid coverage expansions on hospital inpatient and emergency department (ED) utilization rates, cost, and patient illness severity, and also to test the association between changes in outcomes and the size of the uninsured population eligible for coverage in states. DATA SOURCES Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases, 2011-2015, Nielsen Demographic Data, and the American Community Survey. STUDY DESIGN Retrospective study using fixed-effects regression to estimate the effects in expansion and nonexpansion states by age/sex demographic groups. FINDINGS In Medicaid expansion states, rates of uninsured inpatient discharges and ED visits fell sharply in many demographic groups. For example, uninsured inpatient discharge rates across groups, except young females, decreased by ≥39 percent per capita on average in expansion states. In nonexpansion states, uninsured utilization rates remained unchanged or increased slightly (0-9.2 percent). Changes in all-payer and private insurance rates were more muted. Changes in inpatient costs per discharge were negative, and all-payer inpatient costs per discharge declined <6 percent in most age/sex groups. The size of the uninsured population eligible for coverage was strongly associated with changes in outcomes. For example, among males aged 35-54 years in expansion states, there was a 0.793 percent decrease in the uninsured discharge rate per unit increase in the coverage expansion ratio (the ratio of the size of the population eligible for coverage to the size of the previously covered population within an age/sex/payer/geographic group). CONCLUSIONS Significant shifts in cost per discharge and patient severity were consistent with selective take-up of insurance. The "treatment intensity" of expansions may be useful for anticipating future effects.
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Affiliation(s)
| | - Zeynal Karaca
- U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Maryland
| | | | - Eli Cutler
- Qventis (Formerly of IBM Watson Health), Mountain View, California
| | | | | | - Herbert S Wong
- U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville, Maryland
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Leech TGJ, Irby-Shasanmi A, Mitchell AL. "Are you accepting new patients?" A pilot field experiment on telephone-based gatekeeping and Black patients' access to pediatric care. Health Serv Res 2018; 54 Suppl 1:234-242. [PMID: 30506767 PMCID: PMC6341201 DOI: 10.1111/1475-6773.13089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
STUDY OBJECTIVES To determine whether name and accent cues that the caller is Black shape physician offices' responses to telephone-based requests for well-child visits. METHOD AND DATA In this pilot study, we employed a quasi-experimental audit design and examined a stratified national sample of pediatric and family practice offices. Our final data include information from 205 audits (410 completed phone calls). Qualitative data were blind-coded into binary variables. Our case-control comparisons using McNemar's tests focused on acceptance of patients, withholding information, shaping conversations, and misattributions. FINDINGS Compared to the control group, "Black" auditors were less likely to be told an office was accepting new patients and were more likely to experience both withholding behaviors and misattributions about public insurance. The strength of associations varied according to whether the cue was based on name or accent. Additionally, the likelihood and ways office personnel communicated that they were not accepting patients varied by region. CONCLUSIONS Linguistic profiling over the telephone is an aspect of structural racism that should be further studied and perhaps integrated into efforts to promote equitable access to care. Future research should look reactions to both name and accent, taking practice characteristics and regional differences into consideration.
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Abstract
OBJECTIVE (1) To examine usual source of care (USC) trends across four categories (No USC, Person USC, Person, in Facility USC, and Facility USC), and (2) to determine whether USC types are associated with emergency department (ED) visits and hospital admissions. DATA SOURCE 1996-2014 Medical Expenditure Panel Surveys. STUDY DESIGN We stratified each USC category, by age, region, gender, poverty, insurance, race/ethnicity, and education and used regression to determine the characteristics associated with USC types, ED visits, and hospital admissions. PRINCIPAL FINDINGS Those with No USC and Facility USCs increased 10 and 18 percent, respectively, while those with Person USCs decreased by 43 percent. Compared to those in the lowest income bracket, those in the highest income bracket were less likely to have a Facility USC. Among those with low incomes, individuals with No USC, Person, in Facility, and Facility USCs were more likely to have ED visits than those with Person USCs. CONCLUSIONS A growing number are reporting facilities as their USCs or none at all. The impact of these trends is uncertain, although we found that some USC types are associated with ED visits and hospital admissions. Tracking USCs will be crucial to measuring progress toward enhanced care efficiency.
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Affiliation(s)
| | | | | | | | - Larry Green
- University of Colorado School of MedicineAuroraCO
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30
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Vaughan Sarrazin M, Rosenthal GE, Turvey CL. Empirical-Based Typology of Health Care Utilization by Medicare Eligible Veterans. Health Serv Res 2018; 53 Suppl 3:5181-5200. [PMID: 29896771 DOI: 10.1111/1475-6773.12995] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Up to 70 percent of patients who receive care through Veterans Health Administration (VHA) facilities also receive care from non-VA providers. Using applied classification techniques, this study sought to improve understanding of how elderly VA patients use VA services and complementary use of non-VA care. METHODS The study included 1,721,900 veterans age 65 and older who were enrolled in VA and Medicare during 2013 with at least one VA encounter during 2013. Outpatient and inpatient encounters and medications received in VA were classified, and mutually exclusive patient subsets distinguished by patterns of VA service use were derived empirically using latent class analysis (LCA). Patient characteristics and complementary use of non-VA care were compared by patient subset. RESULTS Five patterns of VA service use were identified that were distinguished by quantity of VA medical and specialty services, medication complexity, and mental health services. Low VA Medical users tend to be healthier and rely on non-VA services, while High VA users have multiple high cost illnesses and concentrate their care in the VA. CONCLUSIONS VA patients distinguished by patterns of VA service use differ in illness burden and the use of non-VA services. This information may be useful for framing efforts to optimize access to care and care coordination for elderly VA patients.
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Affiliation(s)
- Mary Vaughan Sarrazin
- Iowa City VA Health Care System, Iowa City, IA.,Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Gary E Rosenthal
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC
| | - Carolyn L Turvey
- Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA.,Department of Psychiatry, University of Iowa, Iowa City, IA
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31
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Kolber MA, Rueda G, Sory JB. Modelling the impact of new patient visits on risk adjusted access at 2 clinics. J Eval Clin Pract 2018; 24:585-589. [PMID: 29878611 DOI: 10.1111/jep.12938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 03/29/2018] [Accepted: 04/02/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate the effect new outpatient clinic visits has on the availability of follow-up visits for established patients when patient visit frequency is risk adjusted. DATA SOURCES Diagnosis codes for patients from 2 Internal Medicine Clinics were extracted through billing data. STUDY DESIGN The HHS-HCC risk adjusted scores for each clinic were determined based upon the average of all clinic practitioners' profiles. These scores were then used to project encounter frequencies for established patients, and for new patients entering the clinic based on risk and time of entry into the clinics. PRINCIPAL FINDINGS A distinct mean risk frequency distribution for physicians in each clinic could be defined providing model parameters. Within the model, follow-up visit utilization at the highest risk adjusted visit frequencies would require more follow-up slots than currently available when new patient no-show rates and annual patient loss are included. Patients seen at an intermediate or lower visit risk adjusted frequency could be accommodated when new patient no-show rates and annual patient clinic loss are considered. CONCLUSIONS Value-based care is driven by control of cost while maintaining quality of care. In order to control cost, there has been a drive to increase visit frequency in primary care for those patients at increased risk. Adding new patients to primary care clinics limits the availability of follow-up slots that accrue over time for those at highest risk, thereby limiting disease and, potentially, cost control. If frequency of established care visits can be reduced by improved disease control, closing the practice to new patients, hiring health care extenders, or providing non-face to face care models then quality and cost of care may be improved.
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Affiliation(s)
- Michael A Kolber
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA.,University of Miami Miller School of Medicine, Miami, FL, USA
| | - Germán Rueda
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - John B Sory
- University of Miami Miller School of Medicine, Miami, FL, USA
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32
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Abstract
OBJECTIVE To assess the impact of preferences, socioeconomic status (SES), and supplemental insurance (SI) on racial/ethnic disparities in the probability and use of services at physicians' offices, hospitals, and emergency departments among Medicare beneficiaries enrolled in Part B. RESEARCH DESIGN AND SUBJECTS This study includes black and white beneficiaries from the 2009-2011 panel of the Medicare Current Beneficiary Survey who were enrolled in Medicare Part B. Logit and negative binomial multivariate regression analysis were used in conjunction with rank-and-replace methods to determine factors influencing utilization and black-white utilization disparities. PRINCIPAL FINDINGS Among Part B beneficiaries, significant disparities exist for each studied service. Examining contributing factors, 12-19 percent of the black-white health-adjusted difference in the probability of use is explained by differences in SES, whereas differences in the distribution of SI accounts for 20 percent or more. For volume, SES is found to account for 2-11 percent of differences with SI making up another 9-10 percent. CONCLUSIONS A substantial portion of the difference in black-white beneficiary use of outpatient services is due to SI. Policies aimed at increasing coverage are likely to increase the probability of visits with modest increases in volume.
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33
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Butala NM, Secemsky EA, Wasfy JH, Kennedy KF, Yeh RW. Seasonality and Readmission after Heart Failure, Myocardial Infarction, and Pneumonia. Health Serv Res 2017; 53:2185-2202. [PMID: 28857149 DOI: 10.1111/1475-6773.12747] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To investigate whether hospital readmission after admission for heart failure (HF), myocardial infarction (MI), and pneumonia varies by season. DATA SOURCES All patients in 2005-2009 Healthcare Cost and Utilization Project State Inpatient Databases for New York and California hospitalized for HF, MI, or pneumonia. STUDY DESIGN The relationship between discharge season and unplanned readmission within 30 days was evaluated using multivariate modified Poisson regression. PRINCIPAL FINDINGS Cohorts included 869,512 patients with HF, 448,945 patients with MI, and 813,593 patients with pneumonia. While admissions varied widely by season, readmission rates only ranged from 25.0 percent (spring) to 25.6 percent (winter) for HF (p > .05), 18.9 percent (summer) to 20.0 percent (winter) for MI (p < .001), and 19.4 percent (spring) to 20.3 percent (summer) for pneumonia (p < .001). In adjusted models, in New York, there was lower readmission in spring and fall (RR: 0.98, 95% CI: 0.96-0.99 for both) after admission for HF and higher readmission in spring (RR: 1.04, 95% CI: 1.01-1.07) after MI. In California, there was lower readmission in spring and winter (RR: 0.95, 95% CI: 0.93-0.96 and RR: 0.96, 95% CI: 0.94-0.98, respectively) after pneumonia. CONCLUSIONS Given marked seasonality in incidence and mortality of HF, MI, and pneumonia, the modest seasonality in readmissions suggests that readmissions may be more related to non-seasonally dependent factors than to the seasonal nature of these diseases.
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Affiliation(s)
- Neel M Butala
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Eric A Secemsky
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Kevin F Kennedy
- Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO
| | - Robert W Yeh
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA
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Wen H, Druss BG, Cummings JR. Effect of Medicaid Expansions on Health Insurance Coverage and Access to Care among Low-Income Adults with Behavioral Health Conditions. Health Serv Res 2015; 50:1787-809. [PMID: 26551430 DOI: 10.1111/1475-6773.12411] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To examine the effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions. DATA SOURCES/STUDY SETTING Nine years (2004-2012) of individual-level cross-sectional data from a restricted-access version of National Survey on Drug Use and Health. STUDY DESIGN A quasi-experimental difference-in-differences design comparing outcomes among residents in 14 states that implemented Medicaid expansions for low-income adults under the Section §1115 waiver with those residing in the rest of the country. DATA COLLECTION/EXTRACTION METHODS The analytic sample includes low-income adult respondents with household incomes below 200 percent of the federal poverty level who have a behavioral health condition: approximately 28,400 low-income adults have past-year serious psychological distress and 24,900 low-income adults have a past-year substance use disorder (SUD). PRINCIPAL FINDINGS Among low-income adults with behavioral health conditions, Medicaid expansions were associated with a reduction in the rate of uninsurance (p < .05), a reduction in the probability of perceiving an unmet need for mental health (MH) treatment (p < .05) and for SUD treatment (p < .05), as well as an increase in the probability of receiving MH treatment (p < .01). CONCLUSIONS The ongoing implementation of Medicaid expansions has the potential to improve health insurance coverage and access to care for low-income adults with behavioral health conditions.
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Affiliation(s)
- Hefei Wen
- Department of Health Management & Policy, University of Kentucky College of Public Health, Lexington, KY
| | - Benjamin G Druss
- Department of Health Policy & Management, Emory University Rollins School of Public Health, Atlanta, GA
| | - Janet R Cummings
- Department of Health Policy & Management, Emory University Rollins School of Public Health, Atlanta, GA
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35
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Abstract
OBJECTIVE To measure spillover effects of Medicare inpatient hospital prices on the nonelderly (under age 65). PRIMARY DATA SOURCES Healthcare Cost and Utilization Project State Inpatient Databases (10 states, 1995-2009) and Medicare Hospital Cost Reports. STUDY DESIGN Outcomes include nonelderly discharges, length of stay and case mix, staffed hospital bed-days, and the share of discharges and days provided to the elderly. We use metropolitan statistical areas as our markets. We use descriptive analyses comparing 1995 and 2009 and panel data fixed-effects regressions. We instrument for Medicare prices using accumulated changes in the Medicare payment formula. PRINCIPAL FINDINGS Medicare price reductions are strongly associated with reductions in nonelderly discharges and hospital capacity. A 10-percent reduction in the Medicare price is estimated to reduce discharges among the nonelderly by about 5 percent. Changes in the Medicare price are not associated with changes in the share of inpatient hospital care provided to the elderly versus nonelderly. CONCLUSIONS Medicare price reductions appear to broadly constrain hospital operations, with significant reductions in utilization among the nonelderly. The slow Medicare price growth under the Affordable Care Act may result in a spillover slowdown in hospital utilization and spending among the nonelderly.
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Cook BL, McGuire TG, Alegría M, Normand SL. Crowd-out and exposure effects of physical comorbidities on mental health care use: implications for racial-ethnic disparities in access. Health Serv Res 2011; 46:1259-80. [PMID: 21413984 PMCID: PMC3130831 DOI: 10.1111/j.1475-6773.2011.01253.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES In disparities models, researchers adjust for differences in "clinical need," including indicators of comorbidities. We reconsider this practice, assessing (1) if and how having a comorbidity changes the likelihood of recognition and treatment of mental illness; and (2) differences in mental health care disparities estimates with and without adjustment for comorbidities. DATA Longitudinal data from 2000 to 2007 Medical Expenditure Panel Survey (n=11,083) split into pre and postperiods for white, Latino, and black adults with probable need for mental health care. STUDY DESIGN First, we tested a crowd-out effect (comorbidities decrease initiation of mental health care after a primary care provider [PCP] visit) using logistic regression models and an exposure effect (comorbidities cause more PCP visits, increasing initiation of mental health care) using instrumental variable methods. Second, we assessed the impact of adjustment for comorbidities on disparity estimates. PRINCIPAL FINDINGS We found no evidence of a crowd-out effect but strong evidence for an exposure effect. Number of postperiod visits positively predicted initiation of mental health care. Adjusting for racial/ethnic differences in comorbidities increased black-white disparities and decreased Latino-white disparities. CONCLUSIONS Positive exposure findings suggest that intensive follow-up programs shown to reduce disparities in chronic-care management may have additional indirect effects on reducing mental health care disparities.
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Affiliation(s)
- Benjamin Lê Cook
- Center for Multicultural Mental Health Research, 120 Beacon Street, Somerville, MA 02143, USA.
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37
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Abstract
INTRODUCTION The ability to track improvement against racial/ethnic disparities in mental health care is hindered by the varying methods and disparity definitions used in previous research. DATA Nationally representative sample of whites, blacks, and Latinos from the 2002 to 2006 Medical Expenditure Panel Survey. Dependent variables are total, outpatient, and prescription drug mental health care expenditure. METHODS Rank- and propensity score-based methods concordant with the Institute of Medicine (IOM) definition of health care disparities were compared with commonly used disparities methods. To implement the IOM definition, we modeled expenditures using a two-part GLM, adjusted distributions of need variables, and predicted expenditures for each racial/ethnic group. FINDINGS Racial/ethnic disparities were significant for all expenditure measures. Disparity estimates from the IOM-concordant methods were similar to one another but greater than a method using the residual effect of race/ethnicity. Black-white and Latino-white disparities were found for any expenditure in each category and Latino-white disparities were significant in expenditure conditional on use. CONCLUSIONS Findings of disparities in access among blacks and disparities in access and expenditures after initiation among Latinos suggest the need for continued policy efforts targeting disparities reduction. In these data, the propensity score-based method and the rank-and-replace method were precise and adequate methods of implementing the IOM definition of disparity.
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Affiliation(s)
- Benjamin Lê Cook
- Center for Multicultural Mental Health Research, Instructor, Department of Psychiatry, Harvard Medical School, 120 Beacon St., 4th Floor, Somerville, MA 02143, USA.
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Abstract
OBJECTIVE To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage. DATA SOURCES The 1999 National Health Survey of Veteran Enrollees merged with VA administrative data, with other information drawn from American Hospital Association data and the Area Resource File. STUDY DESIGN We modeled VA enrollees' decision of having private insurance coverage and its impact on use of VA care controlling for sociodemographic information, patients' health status, VA priority status and access to VA and non-VA alternatives. We estimated the true impact of insurance on the use of VA care by teasing out potential selection bias. Bias came from two sources: a security selection effect (sicker enrollees purchase private insurance for extra security and use more VA and non-VA care) and a preference selection effect (VA enrollees who prefer non-VA care may purchase private insurance and use less VA care). PRINCIPAL FINDINGS VA enrollees with private insurance coverage were less likely to use VA care. Security selection dominated preference selection and naïve models that did not control for selection effects consistently underestimated the insurance effect. CONCLUSIONS Our results indicate that prior research, which has not controlled for insurance selection effects, may have underestimated the potential impact of any private insurance policy change, which may in turn affect VA enrollees' private insurance coverage and consequently their use of VA care. From the decline in private insurance coverage from 1999 to 2002, we projected an increase of 29,400 patients and 158 million dollars for VA health care services.
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Affiliation(s)
- Yujing Shen
- VA New Jersey Healthcare System Center for Healthcare Knowledge Management, East Orange VA Medical Center, 385 Tremont Avenue, Mailstop 129, East Orange, NJ 07018-1095, USA
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Gavin NI, Adams EK, Manning WG, Raskind-Hood C, Urato M. The impact of welfare reform on insurance coverage before pregnancy and the timing of prenatal care initiation. Health Serv Res 2007; 42:1564-88. [PMID: 17610438 PMCID: PMC1955278 DOI: 10.1111/j.1475-6773.2006.00667.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This study investigates the impact of welfare reform on insurance coverage before pregnancy and on first-trimester initiation of prenatal care (PNC) among pregnant women eligible for Medicaid under welfare-related eligibility criteria. DATA SOURCES We used pooled data from the Pregnancy Risk Assessment Monitoring System for eight states (AL, FL, ME, NY, OK, SC, WA, and WV) from 1996 through 1999. STUDY DESIGN We estimated a two-part logistic model of insurance coverage before pregnancy and first-trimester PNC initiation. The impact of welfare reform on insurance coverage before pregnancy was measured by marginal effects computed from coefficients of an interaction term for the postreform period and welfare-related eligibility and on PNC initiation by the same interaction term and the coefficients of insurance coverage adjusted for potential simultaneous equation bias. We compared the estimates from this model with results from simple logistic, ordinary least squares, and two-stage least squares models. PRINCIPAL FINDINGS Welfare reform had a significant negative impact on Medicaid coverage before pregnancy among welfare-related Medicaid eligibles. This drop resulted in a small decline in their first-trimester PNC initiation. Enrollment in Medicaid before pregnancy was independent of the decision to initiate PNC, and estimates of the effect of a reduction in Medicaid coverage before pregnancy on PNC initiation were consistent over the single- and two-stage models. Effects of private coverage were mixed. Welfare reform had no impact on first-trimester PNC beyond that from reduced Medicaid coverage in the pooled regression but separate state-specific regressions suggest additional effects from time and income constraints induced by welfare reform may have occurred in some states. CONCLUSIONS Welfare reform had significant adverse effects on insurance coverage and first-trimester PNC initiation among our nation's poorest women of childbearing age. Improved outreach and insurance options for these women are needed to meet national health goals.
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Affiliation(s)
- Norma I Gavin
- RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709-2194, USA
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McCarthy JF, Blow FC, Valenstein M, Fischer EP, Owen RR, Barry KL, Hudson TJ, Ignacio RV. Veterans Affairs Health System and mental health treatment retention among patients with serious mental illness: evaluating accessibility and availability barriers. Health Serv Res 2007; 42:1042-60. [PMID: 17489903 PMCID: PMC1955257 DOI: 10.1111/j.1475-6773.2006.00642.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE We examine the impact of two dimensions of access-geographic accessibility and availability-on VA health system and mental health treatment retention among patients with serious mental illness (SMI). METHODS Among 156,631 patients in the Veterans Affairs (VA) health care system with schizophrenia or bipolar disorder in fiscal year 1998 (FY98), we used Cox proportional hazards regression to model time to first 12-month gap in health system utilization, and in mental health services utilization, by the end of FY02. Geographic accessibility was operationalized as straight-line distance to nearest VA service site or VA psychiatric service site, respectively. Service availability was assessed using county-level VA hospital beds and non-VA beds per 1,000 county residents. Patients who died without a prior gap in care were censored. RESULTS There were 32, 943 patients (21 percent) with a 12-month gap in health system utilization; 65,386 (42 percent) had a 12-month gap in mental health services utilization. Gaps in VA health system utilization were more likely if patients were younger, nonwhite, unmarried, homeless, nonservice-connected, if they had bipolar disorder, less medical morbidity, an inpatient stay in FY98, or if they lived farther from care or in a county with fewer VA inpatient beds. Similar relationships were observed for mental health, however being older, female, and having greater morbidity were associated with increased risks of gaps, and number of VA beds was not significant. CONCLUSIONS Geographic accessibility and resource availability measures were associated with long-term continuity of care among patients with SMI. Increased distance from providers was associated with greater risks of 12-month gaps in health system and mental health services utilization. Lower VA inpatient bed availability was associated with increased risks of gaps in health system utilization. Study findings may inform efforts to improve treatment retention.
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Affiliation(s)
- John F McCarthy
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Martini EM, Garrett N, Lindquist T, Isham GJ. The boomers are coming: a total cost of care model of the impact of population aging on health care costs in the United States by Major Practice Category. Health Serv Res 2007; 42:201-18. [PMID: 17355589 PMCID: PMC1955745 DOI: 10.1111/j.1475-6773.2006.00607.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To project the impact of population aging on total U.S. health care per capita costs from 2000 to 2050 and for the range of clinical areas defined by Major Practice Categories (MPCs). DATA SOURCES Secondary data: HealthPartners health plan administrative data; U.S. Census Bureau population projections 2000-2050; and MEPS 2001 health care annual per capita costs. STUDY DESIGN We calculate MPC-specific age and gender per capita cost rates using cross-sectional data for 2002-2003 and project U.S. changes by MPC due to aging from 2000 to 2050. DATA COLLECTION METHODS HealthPartners data were grouped using purchased software. We developed and validated a method to include pharmacy costs for the uncovered. PRINCIPAL FINDINGS While total U.S. per capita costs due to aging from 2000 to 2050 are projected to increase 18 percent (0.3 percent annually), the impact by MPC ranges from a 55 percent increase in kidney disorders to a 12 percent decrease in pregnancy and infertility care. Over 80 percent of the increase in total per capita cost will result from just seven of the 22 total MPCs. CONCLUSIONS Understanding the differential impact of aging on costs at clinically specific levels is important for resource planning, to effectively address future medical needs of the aging U.S. population.
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Affiliation(s)
- E Mary Martini
- Health Informatics, HealthPartners, 8170 33rd Ave. S., Mail Stop 21108Q, Minneapolis, MN 55440-1309, USA
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