Racial and ethnic disparities among state Medicaid programs for breast cancer screening

Breast cancer screening by mammography has been shown to reduce breast cancer morbidity and mortality. The use of mammography screening though varies by race, ethnicity, and, sociodemographic characteristics. Medicaid is an important source of insurance in the US for low-income beneficiaries, who are disproportionately members of racial or ethnic minorities, and who are less likely to be screened than women with higher socioeconomic statuses. We used 2006-2008 data from Medicaid claims and enrollment files to assess racial or ethnic and geographic disparities in the use of breast cancer screening among Medicaid-insured women at the state level. There were disparities in the use of mammography among racial or ethnic groups relative to white women, and the use of mammography varied across the 44 states studied. African American and American Indian women were significantly less likely than white women to use mammography in 30% and 39% of the 44 states analyzed, respectively, whereas Hispanic and Asian American women were the minority groups most likely to receive screening compared with white women. There are racial or ethnic disparities in breast cancer screening at the state level, which indicates that analyses conducted by only using national data not stratified by insurance coverage are insufficient to identify vulnerable populations for interventions to increase the use of mammography, as recommended.

Medicare managed care plan performance: a comparison across hospitalization types

OBJECTIVE

The study evaluates the performance of Medicare managed care (Medicare Advantage [MA]) Plans in comparison to Medicare fee-for-service (FFS) Plans in three states with historically high Medicare managed care penetration (New York, California, Florida), in terms of lowering the risks of preventable or ambulatory care sensitive conditions (ACSC) hospital admissions and providing increased referrals for admissions for specialty procedures.

STUDY DESIGN/METHODS

Using 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP-SID) of the Agency for Healthcare Research and Quality, ACSC admissions are compared with 'marker' admissions and 'referral-sensitive' admissions, using a multinomial logistic regression approach. The year 2004 represents a strategic time to test the impact of MA on preventable hospitalizations, because the HMOs dominated the market composition in that time period.

FINDINGS

MA enrollees in California experienced 22% lower relative risk (RRR= 0.78, p<0.01), those in Florida experienced 16% lower relative risk (RRR= 0.84, p<0.01), while those in New York experienced 9% lower relative risk (RRR=0.91, p<0.01) of preventable (versus marker) admissions compared to their FFS counterparts. MA enrollees in New York experienced 37% higher relative risk (RRR=1.37, p<0.01) and those in Florida had 41% higher relative risk (RRR=1.41, p<0.01)-while MA enrollees in California had 13% lower relative risk (RRR=0.87, p<0.01)-of referral-sensitive (versus marker) admissions compared to their FFS counterparts.

CONCLUSION

While MA plans were associated with reductions in preventable hospitalizations in all three states, the effects on referral-sensitive admissions varied, with California experiencing lower relative risk of referral-sensitive admissions for MA plan enrollees. The lower relative risk of preventable admissions for MA plan enrollees in New York and Florida became more pronounced after accounting for selection bias.

Managed care and the diffusion of endoscopy in fee-for-service Medicare

OBJECTIVE

To determine whether Medicare managed care penetration impacted the diffusion of endoscopy services (sigmoidoscopy, colonoscopy) among the fee-for-service (FFS) Medicare population during 2001-2006.

METHODS

We model utilization rates for colonoscopy or sigmoidoscopy as impacted by both market supply and demand factors. We use spatial regression to perform ecological analysis of county-area utilization rates over two time intervals (2001-2003, 2004-2006) following Medicare benefits expansion in 2001 to cover colonoscopy for persons of average risk. We examine each technology in separate cross-sectional regressions estimated over early and later periods to assess differential effects on diffusion over time. We discuss selection factors in managed care markets and how failure to control perfectly for market selection might impact our managed care spillover estimates.

RESULTS

Areas with worse socioeconomic conditions have lower utilization rates, especially for colonoscopy. Holding constant statistically the socioeconomic factors, we find that managed care spillover effects onto FFS Medicare utilization rates are negative for colonoscopy and positive for sigmoidoscopy. The spatial lag estimates are conservative and interpreted as a lower bound on true effects. Our findings suggest that managed care presence fostered persistence of the older technology during a time when it was rapidly being replaced by the newer technology.

The effects of safety net hospital closures and conversions on patient travel distance to hospital services

OBJECTIVE

To examine the effects of safety net hospital (SNH) closure and for-profit conversion on uninsured, Medicaid, and racial/ethnic minorities. DATA SOURCES/EXTRACTION METHODS: Hospital discharge data for selected states merged with other sources.

STUDY DESIGN

We examined travel distance for patients treated in urban hospitals for five diagnosis categories: ambulatory care sensitive conditions, referral sensitive conditions, marker conditions, births, and mental health and substance abuse. We assess how travel was affected for patients after SNH events. Our multivariate models controlled for patient, hospital, health system, and neighborhood characteristics.

PRINCIPAL FINDINGS

Our results suggested that certain groups of uninsured and Medicaid patients experienced greater disruption in patterns of care, especially Hispanic uninsured and Medicaid women hospitalized for births. In addition, relative to privately insured individuals in SNH event communities, greater travel for mental health and substance abuse care was present for the uninsured.

CONCLUSIONS

Closure or for-profit conversions of SNHs appear to have detrimental access effects on particular subgroups of disadvantaged populations, although our results are somewhat inconclusive due to potential power issues. Policy makers may need to pay special attention to these patient subgroups and also to easing transportation barriers when dealing with disruptions resulting from reductions in SNH resources.

Building a biomedical cyberinfrastructure for collaborative research

For the potential power of genome-wide association studies (GWAS) and translational medicine to be realized, the biomedical research community must adopt standard measures, vocabularies, and systems to establish an extensible biomedical cyberinfrastructure. Incorporating standard measures will greatly facilitate combining and comparing studies via meta-analysis. Incorporating consensus-based and well-established measures into various studies should reduce the variability across studies due to attributes of measurement, making findings across studies more comparable. This article describes two well-established consensus-based approaches to identifying standard measures and systems: PhenX (consensus measures for phenotypes and eXposures), and the Open Geospatial Consortium (OGC). NIH support for these efforts has produced the PhenX Toolkit, an assembled catalog of standard measures for use in GWAS and other large-scale genomic research efforts, and the RTI Spatial Impact Factor Database (SIFD), a comprehensive repository of geo-referenced variables and extensive meta-data that conforms to OGC standards. The need for coordinated development of cyberinfrastructure to support measures and systems that enhance collaboration and data interoperability is clear; this paper includes a discussion of standard protocols for ensuring data compatibility and interoperability. Adopting a cyberinfrastructure that includes standard measures and vocabularies, and open-source systems architecture, such as the two well-established systems discussed here, will enhance the potential of future biomedical and translational research. Establishing and maintaining the cyberinfrastructure will require a fundamental change in the way researchers think about study design, collaboration, and data storage and analysis.

Managed care, distance traveled, and hospital market definition

Does managed care insurance require patients to travel farther to receive hospital care? This question has major implications for antitrust policy and access to care. In spite of a general presumption that the answer is "yes," the question cannot be settled by a priori reasoning. Managed care has two effects on distance: 1) the direct effect of steering managed care consumers to particular hospitals, and 2) the indirect effect of higher managed care market share changing the market environment for consumers in general. The net effect of managed care on distance traveled could go either way. This paper measures both direct and indirect effects in a unique application of a spatial interaction model. We use individual discharge data, including payer information, from hospitals in 14 California counties over the period 1984-1993. We find that the direct effect leads to longer distances, but the indirect effect leads to shorter distances. Neither effect is large. Surprisingly, the net effect is slightly negative.

Effects of selective contracting on hospital efficiency, costs and accessibility

This paper exploits a natural experiment in the state of California, to show that pro-competitive healthcare policy may have unintended long-term liabilities unless the system as a whole is carefully designed to preserve access to care for the poor. California's Medicaid Reform Act of 1982 increased competition among hospitals in urban areas, with legislation which allowed direction of patients to more efficient providers via selective contracting. This slowed the average rate of hospital cost inflation, and saved the state billions of dollars. The substantial short-term savings have been documented in empirical research, but little attention has been paid to the longer-term effects of the reforms. We find that Medicaid contracts were awarded to more efficient hospitals. The distributional effects post-reform resulted in efficiency gains for most hospitals, but costs escalated for over half of the public hospitals in the sample, as their uncompensated care burdens rose. Public hospitals continued to fail during the period, leaving over half of California's counties without a county hospital by 1990. Because public hospitals provide the vast majority of healthcare for the poor in California, there is reason for concern about erosion of their access to care as an unintended outcome of pro-competitive reforms.

Tacit collusion among hospitals in price competitive markets

Horizontal and vertical mergers, and coalition and network building activity have recently escalated in the US hospital industry in response to actual and threatened increases in competition. Parties to this industry's consolidation state that increased efficiency is the primary motive. However, increased consolidation may lead to increased awareness of inter-dependence, and facilitate 'conscious parallelism', or tacit collusion. In conjunction with this, selective contracting practices by payors with hospitals for negotiated prices may have increased the awareness of interdependence among price-competing hospitals. We posit that cost asymmetries arising from first-mover advantages to merged hospitals and multihospital chain members may be used strategically in local markets to facilitate tacit arrival at profit maximizing prices. Thus, hospital mergers and acquisitions which enhance efficiency in the short run may not yield net gains to society in the long run, as they may alter incentives which parameterize the potential for implicit cooperation. This outcome depends upon mitigating local market conditions, such as capacity utilization and market power held by payors. The current view that safeguarding emerging price competition is important necessitates careful analysis of how merger is likely to affect bargaining power between hospitals and purchasers. This complexity precludes the use of simple antitrust rules or guidelines in this industry.

The behavior of multihospital chains in increasingly competitive California hospital markets: pro- or anti-competitive?

In previous literature, no evidence of competitive advantage has been found from hospital affiliation with chains. In this paper, the role of chains in hospital adaptation to a more competitive environment is examined further. Two dimensions of hospital behavior are examined: the propensity to engage in contractual arrangements with insurers, and the effect of a changed competitive environment on preferred acquisition targets by chains. We find evidence that chains behave pro-competitively in the short run, and discuss policy implications of the observed market restructuring in the longer run.