Problems With Access to Dental Care for Medicaid-Insured Children: What Caregivers Think

OBJECTIVES: This study aimed to gain insight into the experiences, attitudes, and perceptions of a racially and ethnically diverse group of caregivers regarding barriers to dental care for their Medicaid-insured children. METHODS: Criterion-purposive sampling was used to select participants for 11 focus groups, which were conducted in North Carolina. Seventy-seven caregivers of diverse ethnic and racial backgrounds participated. Full recordings of sessions were obtained and transcribed. A comprehensive content review of all data, including line-by-line analysis, was conducted. RESULTS: Negative experiences with the dental care system discouraged many caregivers in the focus groups from obtaining dental services for their Medicaid-insured children. Searching for providers, arranging an appointment where choices were severely limited, and finding transportation left caregivers describing themselves as discouraged and exhausted. Caregivers who successfully negotiated these barriers felt that they encountered additional barriers in the dental care setting, including long waiting times and judgmental, disrespectful, and discriminatory behavior from staff and providers because of their race and public assistance status. CONCLUSIONS: Current proposals to solve the dental access problem probably will be insufficient until barriers identified by caregivers are addressed.     

Factors Associated With Health Care Access and Outcome

This study aims to (1) assess ethnic differences in health care access and health outcome between Asian Americans and Whites and between Asian American subgroups, (2) examine effects of cultural factors, and (3) investigate moderating effects of health risk behaviors between cultural characteristics and health care access and outcome. Data were derived from the 2007 California Health Interview Survey. Asian Americans (n = 4,462) and Whites (n = 4,470) were included. There were significant ethnic differences in health care access and health perception between Asian Americans and Whites and across Asian American subgroups. Health risk behaviors moderated relationships between cultural factors and health care access and outcome. Findings reveal that ethnicity affects an individual's health care access and health perception, and their health behaviors are an important factor that may improve or worsen outcomes. This study may increase our knowledge base of research and interventions to enhance ethnic minority populations' health care accessibility and perceptions.     

County-Level Poverty Is Equally Associated With Unmet Health Care Needs in Rural and Urban Settings

Context: Regional poverty is associated with reduced access to health care. Whether this relationship is equally strong in both rural and urban settings or is affected by the contextual and individual-level characteristics that distinguish these areas, is unclear. Purpose: Compare the association between regional poverty with self-reported unmet need, a marker of health care access, by rural/urban setting. Methods: Multilevel, cross-sectional analysis of a state-representative sample of 39,953 adults stratified by rural/urban status, linked at the county level to data describing contextual characteristics. Weighted random intercept models examined the independent association of regional poverty with unmet needs, controlling for a range of contextual and individual-level characteristics. Findings: The unadjusted association between regional poverty levels and unmet needs was similar in both rural (OR = 1.06 [95% CI, 1.04-1.08]) and urban (OR = 1.03 [1.02-1.05]) settings. Adjusting for other contextual characteristics increased the size of the association in both rural (OR = 1.11 [1.04-1.19]) and urban (OR = 1.11 [1.05-1.18]) settings. Further adjustment for individual characteristics had little additional effect in rural (OR = 1.10 [1.00-1.20]) or urban (OR = 1.11 [1.01-1.22]) settings. Conclusions: To better meet the health care needs of all Americans, health care systems in areas with high regional poverty should acknowledge the relationship between poverty and unmet health care needs. Investments, or other interventions, that reduce regional poverty may be useful strategies for improving health through better access to health care.     

Does Rural Residence Affect Access to Prenatal Care in Oregon?

ABSTRACT:  Context: Identifying how maternal residential location affects late initiation of prenatal care is important for policy planning and allocation of resources for intervention. Purpose: To determine how rural residence and other social and demographic characteristics affect late initiation of prenatal care, and how residence status is associated with self-reported barriers to accessing early prenatal care. Methods: This observational study used data from the 2003 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) (N = 1,508), with late initiation of prenatal care (after the first trimester) as the primary outcome. We used Rural-Urban Commuting Area (RUCA) codes to categorize maternal residence as urban, large rural, or small/isolated rural. Multivariate logistic regression was used to evaluate whether category of residence was associated with late initiation of prenatal care after adjusting for other maternal factors. Association between categories of barriers to prenatal care and maternal category of residence were determined using the Cochran-Mantel-Haenszel test of association. Findings: We found no significant association between residence category and late initiation of prenatal care, or residence category and barriers to prenatal care initiation. Urban women tended to be over age 34 or nonwhite. Women from large rural areas were more likely to be younger than 18 years, unmarried, and have an unintended pregnancy. Women from small rural areas were more likely to use tobacco during pregnancy. Conclusions: Maternal residence category is not associated with late initiation of prenatal care or with barriers to initiation of prenatal care. Differences in maternal risk profiles by location suggest possible new foci for programs, such as tobacco education in small rural areas .     

Quality of Care for Acute Myocardial Infarction in Rural and Urban US Hospitals

CONTEXT: Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. PURPOSE: To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers. METHODS: This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality. FINDINGS: Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals' patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]). CONCLUSIONS: Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.     

Insurance-Based Discrimination During Prenatal Care,Labor, and Delivery: Perceptions of Oregon Mothers

The purpose of this study was to improve understanding of who experiences insurance-based discrimination during prenatal care, labor, and delivery and how their health care may differ from that of other women. We pooled data from the 1998–1999, 2000, and 2001 Oregon Pregnancy Risk Assessment Monitoring System and conducted univariate, bivariate, and multivariate analyses. The women who perceived that they had been treated differently by health care providers during prenatal care, labor, or delivery based on their insurance status were largely a lower income group. Insurance-based discrimination was significantly associated with lower annual household incomes, being unable to pay bills during pregnancy, and being without employer-sponsored insurance for their baby’s delivery, when adjusted for other factors. Insurance-based discrimination was less likely among Hispanic mothers. With respect to the relationship between insurance-based discrimination and receipt of health care, our findings were mixed. Insurance-based discrimination was not significantly associated with the number of topics covered by providers during prenatal care. In contrast, insurance-based discrimination was significantly associated with fewer breastfeeding support actions taken at the hospital and with having had a provider discuss birth control after delivery among women with employer sponsored insurance. These findings draw attention to the need to better understand women’s experiences and perceptions of insurance-based discrimination during prenatal care, labor, and delivery.     

Urban and Rural Differences in Health Insurance and Access to Care

This study considers differences in access to health care and insurance characteristics between residents of urban and rural areas. Data were collected from a telephone survey of 10,310 randomly selected households in Minnesota. Sub-samples of 400 group-insured, individually insured, intermittently insured, and uninsured people, were asked about access to health care. Those with group or individual insurance were also asked about the costs and characteristics of their insurance policies.
Rural areas had a higher proportion of uninsured and individually insured respondents than urban areas. Among those who purchased insurance through an employer, rural residents had fewer covered benefits than urban residents (5.1 vs 5.7, P < 0.01) and were more likely to have a deductible (80% versus 40%, P < 0.01). In spite of this, rural uninsured residents were more likely to have a regular source of care than urban residents (69% versus 51%, P < 0.01), and were less likely to have delayed care when they thought it was necessary (21% versus 32%, P<0.01). These differences were confirmed by multivariate analysis.
Rural residents with group insurance have higher out-of-pocket costs and fewer benefits. Uninsured rural residents may have better access to health care than their urban counterparts. Attempts to expand access to health care need to consider how the current structure of employment-based insurance creates inequities for individuals in rural areas as well as the burdens this structure may place on rural providers.     

Organization of Care for Acute Myocardial Infarction in Rural and Urban Hospitals in Kansas

CONTEXT: One in 4 Americans lives in a rural community and relies on rural hospitals and medical systems for emergent care of acute myocardial infarctions (AMI). The infrastructure and organization of AMI care in rural and urban Kansas hospitals was examined. METHODS: Using a nominal group process, key elements within hospitals that might influence quality of AMI care were identified, including personnel, equipment, organizational systems, and quality improvement activities. These elements were included in a survey of 45 rural and 12 urban Kansas hospitals. FINDINGS: Though emergency 911 systems were widely available in both urban and rural communities, paramedics and advanced cardiac life support were less likely to be available in rural communities. Few rural hospitals were capable of emergent catheterization, angioplasty, or coronary artery bypass surgery; cardiologists, though readily available by phone, were rarely available on-site. Nevertheless, most rural ambulances could not bypass local hospitals. Most rural hospitals transferred the vast majority of their patients to urban medical centers within an average distance of 78 miles. Standardized protocols were used for emergent AMI care in 67% of urban and 62% of rural hospitals. Hospitals included aspirin in 53% and beta-blockers in 28% of either protocols or standing orders. CONCLUSIONS: Although faced with more limited resources, some rural hospitals, like their urban counterparts, have implemented protocols to address emergent care of AMI patients. Nevertheless, many of these protocols omit crucial aspects of AMI care. Rural and urban hospitals should jointly develop systems that assure consistent, rapid delivery of AMI care.     

Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured

Objectives. We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care.Methods. Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n = 2975) and those who had Medicaid (n = 1485).Results. Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR] = 5.0; 95% confidence interval [CI] = 3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR = 1.83; 95% CI = 1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia.Conclusions. Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.Lack of health insurance is associated with lower rates of preventive care, delays in necessary care, forgone care, medical bankruptcy, and increased mortality.1–5 The Affordable Care Act (ACA; Pub L No. 111–148) expanded Medicaid insurance for people with low incomes (< 138% of the federal poverty level [FPL]) in 31 states. However, whether Medicaid coverage improves health outcomes remains controversial. Several studies described differences in chronic disease prevalence and control between uninsured persons and those with Medicaid, but have not been designed or powered to explore whether Medicaid coverage might cause these differences.6–8Some have suggested that Medicaid’s low reimbursement rates discourage physician acceptance of Medicaid patients, limiting access to care and resulting in poor health outcomes.9,10 Recently, the Oregon Health Insurance Experiment (OHIE), a randomized, controlled trial, found that Medicaid coverage increased health care use, improved patients’ financial security and self-reported health, lowered depression rates, and raised diabetes diagnosis rates.11–13 However, the OHIE did not find improvements in other important health outcomes such as control of other chronic diseases, fueling Medicaid’s critics.14,15The rigorous design of the OHIE provides strong evidence on the impact of Medicaid in the Portland, Oregon, metropolitan area where it was conducted. However, Portland’s relatively robust medical safety net for the uninsured16,17 may have attenuated the potential for health improvements from Medicaid expansion compared with other locales, or the United States as a whole.We used the nationally representative National Health and Nutrition Examination Survey (NHANES) to compare outpatient physician visit frequency among the uninsured and comparable persons with Medicaid coverage. We also assessed whether individuals with major chronic conditions had been previously diagnosed with the condition, and whether it was under control.     

Intensive Care in Critical Access Hospitals

CONTEXT: Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. PURPOSE: To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community. METHODS: A semistructured interview of directors of nursing at CAHs that provide intensive care services. RESULTS: Two thirds of CAHs that provide intensive care do so in a distinct unit. Most have continuous or computerized electrocardiography and ventilators. Other ICU equipment common in larger hospitals was reported less frequently. Nurse:patient ratio ranged from 1:1 to 1:3, and some or all nursing staff have advanced cardiac life support certification. Most CAHs admit patients to the ICU daily or weekly, primarily treating cardiac, respiratory, gastrointestinal, endocrine, and drug- or alcohol-related conditions. ICUs are also used for postsurgical recovery. Respondents felt that closure of the ICU would be burdensome to patients and families, result in lost revenue, negatively impact staff, and affect the community's perception of the hospital. CONCLUSIONS: Intensive care services provided by CAHs fall along a continuum, ranging from care in a unit that resembles a scaled-down version of ICUs in larger hospitals to care in closely monitored medical-surgical beds. Nurse to patient ratio, not technology, is arguably the defining characteristic of intensive care in CAHs. Respondents believe these services to be important to the well-being of the hospital and of the community.     

Rural Relevant Quality Measures for Critical Access Hospitals

Purpose: To identify current and future relevant quality measures for Critical Access Hospitals (CAHs). Methods: Three criteria (patient volume, internal usefulness for quality improvement, and external usefulness for public reporting and payment reform) were used to analyze quality measures for their relevance for CAHs. A 6‐member panel with expertise in rural hospital quality measurement and improvement provided input regarding the final measure selection. Findings: The relevant quality measures for CAHs include measures that are ready for reporting now and measures that need specifications to be finalized and/or a data reporting mechanism to be established. They include inpatient measures for specific medical conditions, global measures that address appropriate care across multiple medical conditions, and Emergency Department measures. Conclusions: All CAHs should publicly report on relevant quality measures. Acceptance of a single consolidated set of quality measures with common specifications for CAHs by all entities involved in regulation, accreditation, and payment; a phased process to implement the relevant measures; and the provision of technical assistance would help CAHs meet the challenge of reporting.     

Rural Medicare Beneficiaries'Use of Rural and Urban Hospitals

This report examines the use of rural and urban hospitals by rural Medicare beneficiaries. Many rural Medicare beneficiaries are treated in urban hospitals, primarily for specialized care that is not available locally. This study examines Medicare inpatient hospital discharge data for rural beneficiaries from fiscal year 1990 to fiscal year 1998. Utilization patterns by diagnosis-related group (DRG) are examined for fiscal year (FY) 1997. The percentage of rural beneficiaries treated in urban hospitals ranged from 30 percent to 36 percent during the study period. For the most frequently occurring DRGs among rural beneficiaries, which were those for routine conditions, treatment occurred predominantly in rural hospitals. The conditions most often responsible for rural beneficiaries' use of urban hospitals during this period reflected the need for coronary and other specialized surgical care. The stability of volume and case-mix throughout the study period underscores the viability of rural hospitals during a period of substantial change in the organization of health care provision.     

Rural/Urban Differences in Barriers to and Burden of Care for Children With Special Health Care Needs

PURPOSE: To examine the barriers and difficulties experienced by rural families of children with special health care needs (CSHCN) in caring for their children. METHODS: The National Survey of Children with Special Health Care Needs was used to examine rural-urban differences in types of providers used, reasons CSHCN had unmet health care needs, insurance and financial difficulties encountered, and the family burden of providing the child's medical care. We present both unadjusted and adjusted results to allow consideration of the causes of rural-urban differences. FINDINGS: Rural CSHCN are less likely to be seen by a pediatrician than urban children. They are more likely to have unmet health care needs due to transportation difficulties or because care was not available in the area; there were minimal other differences in barriers to care. Families of rural CSHCN are more likely to report financial difficulties associated with their children's medical needs and more likely to provide care at home for their children. CONCLUSIONS: Examining results from both unadjusted and adjusted odds ratios shows that the burden of care for families of rural CSHCN stems both from socioeconomic differences and health system differences. Policies aimed at achieving equity for rural children will require focusing on both individual factors and the health care infrastructure, including increasing insurance coverage to lessen financial difficulties and addressing the availability of providers in rural areas.     

Access to Care for Rural Medicare Beneficiaries

This paper examines variations between urban and rural Medicare beneficiaries in three measures of access to care: self-reported access to care, satisfaction with care received and use of services. The assessment focuses on these measures and their relationship to adjacency to metropolitan areas. Comparisons are also provided for the relative effects of adjacency versus broader access barriers such as income. Data from the 1993 Medicare Current Beneficiary Survey are used. The analyses offer several new perspectives on access in rural areas. First, as perceived by respondents, rural residence does not indicate access problems; instead, Medicare beneficiaries in rural counties that are adjacent to urban areas and that have their own city of at least 10,000 people report higher levels of satisfaction and fewer self-reported access problems than do residents of urban counties. These results may stem either from differences in rural residents' expectations regarding access or willingness to accept appropriate substitutions. Preventive vaccination rates in rural areas are on par with or better than rates by beneficiaries in urban areas. The only services where utilization in rural areas was limited relative to urban areas were preventive cancer screening for women and dental care. Development of policies to address these specific service gaps may be warranted. Low income has a more pervasive and problematic relationship to self-reported access, satisfaction and utilization than does rural residence per se.     

The Vermont Model for Rural HIV Care Delivery: Eleven Years of Outcome Data Comparing Urban and Rural Clinics

Context: Provision of human immunodeficiency virus (HIV) care in rural areas has encountered unique barriers. Purpose: To compare medical outcomes of care provided at 3 HIV specialty clinics in rural Vermont with that provided at an urban HIV specialty clinic. Methods : This was a retrospective cohort study. Findings: Over an 11-year period 363 new patients received care, including 223 in the urban clinic and 140 in the rural clinics. Patients in the 2 cohorts were demographically similar and had similar initial CD4 counts and viral loads. There was no difference between the urban and rural clinic patients receiving Pneumocystis carinii prophylaxis (83.5% vs 86%, P= .38) or antiretroviral therapy (96.8% vs 97.5%, P= .79). Both rural and urban cohorts had similar decreases in median viral load from 1996 to 2006 (3,876 copies/mL to <50 copies/mL vs 8,331 copies/mL to <50 copies/mL) and change in percent of patients suppressed to <400 copies/mL (21.4%-69.3% vs 16%-71.4%, P= .11). Rural and urban cohorts had similar increases in median CD4 counts (275/mm³-350/mm³ vs 182 cells/mm³-379/mm³). A repeated measures regression analysis showed that neither fall in viral load (P= .91) nor rise in CD4 count (P= .64) were associated with urban versus rural site of care. Survival times, using a Cox proportional hazards model, were similar for urban and rural patients (hazard ratio for urban = 0.80 [95% CI, 0.39-1.61; P= .53]). Conclusions: This urban outreach model provides similar quality of care to persons receiving care in rural areas of Vermont as compared to those receiving care in the urban center.     

Health Care Access for Children With Special Health Care Needs in California

Objectives: This study examines health care access for children with special health care needs (CSHCN) in California, one of the nation’s most populous and diverse states. Methods: Data are from the National Survey of Children with Special Health Care Needs (NS-CSHCN), a nationally representative survey of access for U.S. children fielded by the National Center for Health Statistics (NCHS). California CSHCN and those in California’s Medicaid program are compared with CSHCN elsewhere on child health need, family enabling factors, health care enabling factors, system outcomes, and children’s experiences with care. Multivariable analysis identifies family and health care factors associated with system outcomes and children’s experiences with health care. Results: California parents generally report poorer experiences with care, lower performance on systems outcomes, and fewer health care and family enabling factors. The magnitude of disparity is greatest for CSHCN in Medi-Cal, although lower-income privately insured CSHCN in California also have poorer access than their counterparts in other states. Among CSHCN in Medicaid, greater condition impact and adolescent age are associated with poorer experiences in California for most measures. Disparities between California and other states persist even adjusting for family and health care factors in multivariable analysis. Conclusions: Performance gaps in California stem from population differences and apparent administrative barriers. Several statewide initiatives are addressing system barriers through supports to providers and information to parents.