Out-of-pocket health spending and the rural underinsured

Multiple studies have documented higher uninsurance rates among rural compared to urban residents, yet the relative adequacy of coverage among rural residents with private health insurance remains unclear. This study estimates underinsurance rates among privately insured rural residents (both adjacent and nonadjacent to urban areas) and the characteristics associated with rural underinsurance. We found that 6 percent of privately insured urban residents were underinsured; the rate increased to 10 percent for rural adjacent and 12 percent for rural nonadjacent residents. Multivariate analyses suggest that rural residents' underinsurance status is related to the design of the private plans through which they have coverage.     

Nursing Home and Market Factors and Risk-Adjusted Hospitalization Rates Among Urban,Micropolitan, and Rural Nursing Homes

ObjectivesHospitalizations are common among long-stay nursing home (NH) residents, but the role of rurality in hospitalization is understudied. This study examines the relationships between rurality, NH, and market characteristics and NH quarterly risk-adjusted hospitalization rates of long-stay residents over 10 quarters (2011 Q2-2013 Q3).DesignThe longitudinal associations of NH and market factors and hospitalization rates were modeled separately on urban, micropolitan, and rural NHs using generalized estimating equation models and a fully interacted model of all NH and market characteristics with micropolitan and rural indicators to test significance of differences compared with urban NHs.Setting and ParticipantsIn total, 14,600 unique NHs.MeasuresRisk-adjusted hospitalization rates were calculated from 2011 to 2013 national Medicare claims and NH Minimum Data Set 3.0. Rurality was defined based on the 2010 Rural Urban Commuting Area codes. NH and market characteristics were extracted from Certification and Survey Provider Enhanced Reporting and Area Health Resources File.ResultsOver the study period, risk-adjusted hospitalization rates averaged 9.8% (standard deviation = 8.2%). No difference was found in the overall hospitalization rates of long-stay NH residents among urban, micropolitan, and rural NHs. Generalized estimating equation models show that urban NHs with higher percentages of Medicare and Medicaid residents and any nurse practitioner/physician assistant were associated with lower rates, but these associations were insignificant in rural settings. Higher registered nurse to total nurses ratio was only associated with lower hospitalization rates in urban settings. Higher median household income was associated with lower hospitalization rates in micropolitan and rural NHs.Conclusions/ImplicationsRurality is not associated with hospitalization rates of long-stay residents, but NH and market factors (eg, payer distribution, staffing, and population income) may affect hospitalization differently in micropolitan/rural NHs than urban NHs. Future intervention on hospitalization should target factors unique to micropolitan/rural NHs which adopt strategies appropriate to their setting.     

Access to maternity care in rural Washington: its effect on neonatal outcomes and resource use.

OBJECTIVES: This study sought to ascertain the effects of poor local access to obstetric care on the risks of having a neonate diagnosed as non-normal, a long hospital stay, and/or high hospital charges. METHODS: Washington State birth certificates linked with hospital discharge abstracts of mothers and neonates were used to study 29809 births to residents of rural areas. Births to women from rural areas where more than two thirds of the women left for care were compared with births to women from rural areas where fewer than one third left for care. RESULTS: Poor local access to providers of obstetric care was associated with a significantly greater risk of having a non-normal neonate for both Medicaid and privately insured patients. However, poor local access to care was consistently associated with higher charges and increased hospital length of stay only if the patient was privately insured. CONCLUSIONS: These results indicate that local maternity services may help prevent non-normal births to rural women and, among privately insured women, might decrease use of neonatal resources.     

The health care experiences of rural Medicaid beneficiaries

Medicaid plays a vital role in rural America, yet, because of data limitations, little research exists on the health care experiences of low-income rural adults. We use data from the National Survey of America's Families, with its oversample of low-income populations, to examine differences in access to and use of care between urban and rural Medicaid beneficiaries, and between Medicaid beneficiaries and low-income privately insured adults in urban and rural areas. We find evidence that access to care under Medicaid is worse than under private insurance in both urban and rural areas; however, Medicaid beneficiaries have a more consistent level of access across urban and rural areas than do low-income privately insured people.     

Evaluation of hospitalization costs and associated factors among maternity stays involving low-risk and moderate- to high-risk childbirths in the United States

Objectives: This study aimed to assess the costs of childbirth and to identify factors associated with such hospital costs for low- and moderate/high-risk childbirth groups.

Methods: All hospitalizations for childbirth between 2010–2014 in the Premier Perspective Hospital Database were identified. Risk category for each birth was defined by the age of the subject and/or presence of specific maternal comorbidities and obstetric risk factors. Hospital childbirth costs were determined and stratified by risk groups. Factors associated with costs for each risk group were evaluated by multiple regression.

Results: Among 2,367,195 hospitalizations for childbirth, vaginal birth was the most common delivery method (n = 1,596,757; 68%). Among women characterized as moderate/high-risk, 42% (n = 642,495) had C-sections, while 11% (n = 90,211) of women categorized as low-risk had C-sections. The proportion of women with serious maternal morbidity among moderate/high-risk vs. low-risk women was 2% (n = 29,496) vs. 0.3% (n = 2749), respectively. The mean costs for moderate/high-risk vs. low-risk hospitalizations were $6145 (median = $5760) and $5397 (median = $5001), respectively (p < 0.0001). Factors significantly associated with costs for moderate/high-risk hospitalizations included delivery type (C-section vs. vaginal birth), LOS, urban/rural hospital status, geographic regions, calendar year of hospitalization, teaching status, payer types and serious maternal morbidity. Similar factors were found to impact costs among low-risk hospitalizations.

Conclusions: Characteristics such as delivery type, LOS, geographical region, teaching status, serious maternal morbidity and hospital urban/rural status were shown to impact hospital costs of childbirth. Screening and prevention strategies of factors that negatively impact costs may aid in reducing the hospitalization costs associated with childbirths.     

Primary Cesarean Section Rates in Uninsured, Medicaid and Insured Populations of Predominantly Rural Northern New England

Many studies in the United States during the past two decades have reported consistently lower cesarean section rates in women of lower socioeconomic status as defined by census tract, insurance status, or maternal level of educational attainment. This study sought to determine whether cesarean section rates in predominantly rural northern New England are lower for lower, compared with higher socioeconomic groups, as they are reported nationally and in more urban areas. Age-adjusted, primary cesarean section rates for privately insured, Medicaid and uninsured women were calculated using 1990 to 1992 uniform hospital discharge data for Maine, New Hampshire and Vermont. Age-adjusted cesarean section rates for insured women (15.71 percent) were significantly higher than those for Medicaid (14.35 percent) and uninsured (12.85 percent) women. These differences in the cesarean section rate between the insured and poorer populations in northern New England are much less than those reported elsewhere in the country.     

Race,Medicaid Coverage,and Equity in Maternal Morbidity

BackgroundSevere maternal morbidity (SMM) affects 50,000 deliveries in the United States annually, with around 1.5 times the rates among Medicaid-covered relative to privately covered deliveries. Furthermore, large racial inequities exist in SMM for non-Hispanic Black women and Hispanic women with rates being 2.1 and 1.4 times higher than White women, respectively. This study aimed to compare the differences in SMM among women of different races/ethnicities and delivery insurance types. Quantifying the rates of SMM based on the intersection of race/ethnicity and insurance status can help to elucidate how multiple forms of oppression and racism may contribute to the substantial inequities in SMM among Black women.MethodsUsing hospital discharge data from the Healthcare Cost and Utilization Project National Inpatient Sample (years 2016 and 2017), we conducted multivariate logistic models to evaluate equity in maternal outcomes among women with different primary payers, overall and stratified by race/ethnicity.ResultsWe found a rate of SMM equal to 138.3 per 10,000 deliveries. Differences in the rate of SMM among non-Hispanic Black, non-Hispanic Asian, and Hispanic women relative to White women were lower among Medicaid-covered deliveries relative to deliveries of all payer types. For example, among all payers, Black women had 2.17 (221.3 vs. 102.1 per 10,000) times the rate of SMM compared with White women; however, among Medicaid-covered deliveries, Black women had 1.84 (227.3 vs. 123.2) times the rate. Despite increased risk associated with Medicaid coverage (adjusted odds ratio, 1.12; 95% confidence interval, 1.07–1.16), the risk was no longer significant in the stratified regression including Black women (adjusted odds ratio, 1.06; 95% confidence interval, 0.98–1.15).ConclusionsOur findings suggest that Black women with Medicaid do not have higher rates of SMM relative to Black women with private insurance. National and state policy efforts should continue to focus on addressing structural racism and other socioeconomic drivers of adverse maternal outcomes, including barriers to high-quality care among women with Medicaid coverage.     

Hospital Utilization and Costs Among Preterm Infants by Payer: Nationwide Inpatient Sample, 2009

Objectives To describe hospital utilization and costs associated with preterm or low birth weight births (preterm/LBW) by payer prior to implementation of the Affordable Care Act and to identify areas for improvement in the quality of care received among preterm/LBW infants. Methods Hospital utilization—defined as mean length of stay (LOS, days), secondary diagnoses for birth hospitalizations, primary diagnoses for rehospitalizations, and transfer status—and costs were described among preterm/LBW infants using the 2009 Nationwide Inpatient Sample. Results Approximately 9.1 % of included hospitalizations (n = 4,167,900) were births among preterm/LBW infants; however, these birth hospitalizations accounted for 43.4 % of total costs. Rehospitalizations of all infants occurred at a rate of 5.9 % overall, but accounted for 22.6 % of total costs. This pattern was observed across all payer types. The prevalence of rehospitalizations was nearly twice as high among preterm/LBW infants covered by Medicaid (7.6 %) compared to commercially-insured infants (4.3 %). Neonatal transfers were more common among preterm/LBW infants whose deliveries and hospitalizations were covered by Medicaid (7.3 %) versus commercial insurance (6.5 %). Uninsured/self-pay preterm and LBW infants died in-hospital during the first year of life at a rate of 91 per 1000 discharges—nearly three times higher than preterm and LBW infants covered by either Medicaid (37 per 1000) or commercial insurance (32 per 1000). Conclusions When comparing preterm/LBW infants whose births were covered by Medicaid and commercial insurance, there were few differences in length of hospital stays and costs. However, opportunities for improvement within Medicaid and CHIP exist with regard to reducing rehospitalizations and neonatal transfers.     

Hospitals, managed care, and the charity caseload in California

We ask whether increasing HMO penetration causes hospitals to cut back on charity care using California hospital discharge data for 1988-1996. There is little evidence at the hospital level that private hospitals respond to HMOs by turning away uninsured and/or Medicaid patients. In the for-profit sector hospitals actually reduce the share of privately insured patients and increase the shares of Medicare patients and Medicaid births. Apparently, HMO penetration reduces the price paid by privately insured patients, making them relatively less attractive to for-profit hospitals.     

The influence of payer mix on electronic health record adoption by physicians

BACKGROUND: Numerous studies have examined the relationship between physician practice characteristics and electronic health record (EHR) adoption. Little is known about how payer mix influences physicians' decisions to implement EHR systems. PURPOSE: This study examines how different proportions of Medicare, Medicaid, and privately insured patients in physicians' practices influence EHR adoption. METHODOLOGY: Data from a large-scale survey of physician's use of information technologies in Florida were analyzed. Physicians were categorized based on their responses to questions regarding the proportion of patients in their practice that use Medicare, Medicaid, or private insurance products. The binary dependent variable of interest was EHR adoption among physicians. Adjusted odds ratios (ORs) were computed using logistic regression modeling techniques. The model examined the effect of changes in each payer type on EHR adoption, controlling for various practice characteristics. FINDINGS: Physicians with the highest percentage of Medicaid patients in their practices were significantly less likely to indicate using an EHR system when compared with those in the low-volume Medicaid group (OR = 0.690; 95% confidence interval [CI] = 0.50-0.95). No differences in EHR adoption were detected among physicians in the low, median, and high Medicare volume classifications. Among the private payer classifications, physicians whose practices were in the median group indicated significantly greater EHR use than those with relatively low levels of privately insured patients (OR = 1.62; 95% CI = 1.16-2.27). Those in the high-volume private payer group were also more likely than the low-volume group to have an EHR system, but this trend did not reach statistical significance (OR = 1.44; 95% CI = 0.96-2.16). PRACTICE IMPLICATIONS: Governmental insurance programs are either not influencing or negatively influencing EHR adoption among physicians in Florida. Given the quality and cost benefits associated with EHR use (particularly for health care payers), policymakers should consider strategies to incentivize or reward EHR adoption among doctors who care for Medicare and Medicaid patients.     

Decomposing Differences in Risk-Adjusted Rates of Emergency Department Visits Between Micropolitan and Urban Nursing Homes

ObjectivesNursing homes (NHs) in micropolitan areas are reported to have different facility and market factors than urban NHs, but how these factors contribute to differences in emergency department (ED) visits remains unknown. This study examined and quantified sources of micropolitan-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED (PAED) visits of long-stay residents.DesignThe 2011-2013 national Medicare claims and NH Minimum Data Set (MDS) 3.0 were analyzed. We implemented generalized estimating equation models to examine micropolitan-urban differences in ED rates and Blinder-Oaxaca decompositions to quantify the contributions of NH and market factors.Setting and ParticipantsThe study cohort included 12,883 unique privately owned, freestanding NHs from urban and micropolitan areas.MeasuresQuarterly risk-adjusted rates of any ED visits, outpatient ED visits, and PAED visits were calculated from Medicare claims and MDS. NH and market characteristics were extracted from the Certification And Survey Provider Enhanced Reporting and Area Health Resources File.ResultsOver the study period, risk-adjusted rates averaged 10.2%, 3.4%, and 3.3% for any ED, outpatient ED, and PAED visits, respectively. Compared with urban NHs, micropolitan NHs reported similar rates of any ED, but significantly higher rates of outpatient ED and PAED (β = 0.20% and 0.27%; both P < .05). Observable differences in NH characteristics (eg, number of beds, percentage Medicare or Medicaid residents, and employment of nurse practitioners and physician assistants) explained more than 20% of the micropolitan-urban differences in rates of outpatient ED and PAED visits; market factors (mainly Medicare Advantage penetration) explained about 46% of the differences in rates of outpatient ED visits.Conclusions and ImplicationsCompared with urban NHs, micropolitan NHs tend to utilize more avoidable emergency care that can be partially explained by facility size, payer mix, use of nurse practitioners and physician assistants, and market structure.     

Impact of the HealthChoice Program on Cesarean Section and Vaginal Birth after C-Section Deliveries: A Retrospective Analysis

Objective To assess the impact of the HealthChoice program in Maryland on cesarean section and vaginal birth after C-section deliveries. Study Design Pre-post design using a comparison group with Maryland State Inpatient Databases, part of the Healthcare Cost and Utilization Project, developed by the Agency for Healthcare Research and Quality. Although the combined 1995 and 2000 database contained over 1.2 million inpatient discharge records, the analysis included all hospital discharge abstracts for women in labor. To identify the delivery, Diagnoses-Related Groups (DRGs) 370–375 were used from the discharge data. Together, there were 128,743 births identified in both years. Methods Pregnant women enrolled in Medicaid managed care were compared pre-implementation and post implementation with pregnant women delivering babies under private insurance. The analysis computed difference-in-differences estimates using a logistic regression model that controlled for maternal characteristics, payment source, labor and delivery complications, and hospital characteristics. The outcome variables included Primary Cesarean, Repeat Cesarean, and Vaginal Birth after C-section. Results These results suggest that Medicaid managed care enrollees were less likely to undergo cesarean section deliveries relative to privately insured beneficiaries. Medicaid MCOs may have done a better job of limiting the growth in overused procedures than did MCOs and providers for privately insured women. Conclusion This study has shown that there has been an overall increase in the use of primary and repeat cesarean sections in Maryland hospitals. However, HealthChoice limited this increase for Medicaid enrollees relative to privately insured women. On the other hand, vaginal births after C-section have declined in Maryland.     

Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality

ObjectivesThis study explores the effect of Medicaid expansion under the Affordable Care Act on the maternal mortality ratio in the United States.MethodsA difference-in-differences research design was used to analyze the effect of Medicaid expansion on maternal mortality. Maternal mortality was defined with and without late maternal deaths, to substantiate the contribution of increased preconception and postpartum insurance coverage. To examine whether there was a racial difference in the effects of Medicaid expansion, models were stratified by the woman's race/ethnicity for non-Hispanic Black women, non-Hispanic White women, and Hispanic women.ResultsMedicaid expansion was significantly associated with lower maternal mortality by 7.01 maternal deaths per 100,000 live births (p = .002) relative to nonexpansion states. When maternal mortality definitions excluded late maternal deaths, Medicaid expansion was significantly associated with a decrease in maternal mortality per 100,000 live births by 6.65 (p = .004) relative to nonexpansion states. Medicaid expansion effects were concentrated among non-Hispanic Black mothers, suggesting that expansion could be contributing to decreasing racial disparities in maternal mortality.ConclusionsAlthough maternal mortality overall continues to increase in the United States, the maternal mortality ratio among Medicaid expansion states has increased much less compared with nonexpansion states. These results suggest that Medicaid expansion could be contributing to a relative decrease in the maternal mortality ratio in the United States. The decrease in the maternal mortality ratio is greater when maternal mortality estimates include late maternal deaths, suggesting that sustained insurance coverage after childbirth as well as improved preconception coverage could be contributing to decreasing maternal mortality.     

Medicaid Nursing Home Policies and Risk-Adjusted Rates of Emergency Department Visits: Does Rural Location Matter?

ObjectivesMedicaid nursing home (NH) reimbursement rates and bed-hold policies have been shown to be associated with hospitalization of urban NH residents, but their relationships with emergency department (ED) visits, especially in rural NHs, remain unknown. This study explores the relationships of Medicaid NH policies with three NH quarterly risk-adjusted rates of ED use for long-stay residents and evaluates whether the associations differed by NHs' geographical locations.DesignLongitudinal study of Medicaid policies and NH risk-adjusted rates over 3 quarters (2011 Q3, 2012 Q3, and 2013 Q3), using Generalized Estimating Equation (GEE) models.Setting and Participants14,514 unique NHs.MeasuresQuarterly risk-adjusted rates of any ED visit, ED visits without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) were calculated from national Medicare claims and NH Minimum Data Set 3.0. Medicaid policies were consolidated from several publicly available sources. NH and market characteristics were extracted from the Certification And Survey Provider Enhanced Reporting and the Area Health Resources File.ResultsIn 2012, states reimbursed NHs, on average, $162.60 per resident-day, and 36 states employed bed-hold policies. Although a $10 increase in reimbursement rates was associated with statistically significantly lower rates of any ED, outpatient ED, and PAED in both urban and micropolitan NHs (−0.79%, −1.09%, and −1.02% for urban NHs; −1.29%, −1.90%, and −3.22% for micropolitan NHs, respectively), it was not associated with any ED measure in rural NHs. Medicaid bed-hold polices were associated with about 9% to 12% lower rates of all types of ED visits in urban NHs, but were not related to any of the ED measures in micropolitan and rural NHs.Conclusions and ImplicationsAssociations of Medicaid NH policies with ED utilization are weaker in rural NHs than urban NHs. Yet, the financial viability of increasing Medicaid reimbursement to reduce the ED use may not be cost-effective.     

Preference,knowledge and utilization of midwives,childbirth education classes and doulas among U.S. black and white women: implications for pregnancy and childbirth outcomes

ABSTRACT

This secondary analysis explored preference, knowledge and utilization of midwifery care, childbirth education and doula care among 627 black and white women at three Midwestern U.S. health clinics. Women who were white, more educated, not living in a high crime neighborhood, and privately insured were more likely to attend childbirth classes. Sociodemographic factors that predicted having heard about doula care included being more educated and having a partner. None of the sociodemographic variables predicted midwifery care. Education about existing childbearing resources and availability of low-cost options should be expanded, particularly for black women and those with low resources.     

The effect of Medicaid expansion on Medicaid participation,payer mix,and labor supply in primary care

Evidence of increased health care utilization associated with the Medicaid expansion suggests that clinicians increased capacity to meet demand. However, little is known about the mechanism underlying this response. Using a novel source of all-payer data, we quantified clinicians’ response to the Medicaid expansion – examining whether and how they changed their Medicaid participation decisions, payer mix, and overall labor supply. Primary care clinicians in expansion states provided an average of 49 additional appointments per year (a 21% relative increase) for patients insured by Medicaid, compared to clinicians in non-expansion states - with new-patient visits representing half (25 appointments) of this overall increase. Clinicians did not increase their labor supply to accommodate these additional appointments. They instead offset the 1.7 percentage point average increase in Medicaid payer mix with an equivalent reduction in commercial payer mix. However, this reduction in commercial patient share represented only a 2.8% relative decrease, with commercially insured patients still comprising the majority of the average clinician's patient panel. Subsample analyses revealed a larger increase in care for Medicaid patients among clinicians with high Medicaid participation preceding the eligibility expansion.     

Lengthening Spells of Uninsurance and Their Consequences

The lengths of time adults are without health insurance have increased since 1988, as shown by data from 1,235 household interviews completed during 1992 in Nebraska. Rural residents without insurance have experienced longer such spells than their urban counterparts. Thus, while rates of uninsurance are nearly the same between urban and rural residents, important differences exist. The relationship between insurance status and physician utilization is consistent during the five years (1989 to 1993) covered in this study. Continuously insured persons have the most physician visits, followed by those intermittently insured, followed by those continuously uninsured. The number of physician visits was expected to increase when respondents moved from uninsured to insured status. However, among urban respondents, the number of visits declined; among residents in rural frontier counties (fewer than six person per square mile) and for respondents in rural nonfrontier counties, there was no significant difference. This study points out some differences between rural and urban populations regarding insurance status, even when the overall rates of uninsurance are equal.     

Potential unintended pregnancies averted and cost savings associated with a revised Medicaid sterilization policy

ObjectiveMedicaid sterilization policy, which includes a mandatory 30-day waiting period between consent and the sterilization procedure, poses significant logistical barriers for many women who desire publicly funded sterilization. Our goal was to estimate the number of unintended pregnancies and the associated costs resulting from unfulfilled sterilization requests due to Medicaid policy barriers.Study DesignWe constructed a cost-effectiveness model from the health care payer perspective to determine the incremental cost over a 1-year time horizon of the current Medicaid sterilization policy compared to a hypothetical, revised policy in which women who desire a postpartum sterilization would face significantly reduced barriers. Probability estimates for potential outcomes in the model were based on published sources; costs of Medicaid-funded sterilizations and Medicaid-covered births were based on data from the Medicaid Statistical Information System and The Guttmacher Institute, respectively.ResultsWith the implementation of a revised Medicaid sterilization policy, we estimated that the number of fulfilled sterilization requests would increase by 45%, from 53.3% of all women having their sterilization requests fulfilled to 77.5%. Annually, this increase could potentially lead to over 29,000 unintended pregnancies averted and $215 million saved.ConclusionA revised Medicaid sterilization policy could potentially honor women’s reproductive decisions, reduce the number of unintended pregnancies and save a significant amount of public funds.ImplicationCompared to the current federal Medicaid sterilization policy, a hypothetical, revised policy that reduces logistical barriers for women who desire publicly funded, postpartum sterilization could potentially avert over 29,000 unintended pregnancies annually and therefore lead to cost savings of $215 million each year.