Comparing uninsured and privately insured hospital patients: admission severity, health outcomes and resource use.

This paper compares uninsured hospital patients with privately insured patients in terms of severity of illness on admission, emergency department use, leaving the hospital against medical advice, length of stay, and in-hospital mortality and morbidity rates. This cross-sectional study includes 29,237 admissions to 100 US hospitals in 1993 and 1994. We found that uninsured patients are sicker, indicating that hospitals should expect uninsured patients to have increased service needs. Our results indicate that the uninsured exhibit higher likelihood of leaving against medical advice, shorter lengths of stay and poorer health outcomes suggest that the uninsured may not be receiving necessary care. Further studies are needed.     

Quality of hospital care of children with asthma: Medicaid versus privately insured patients

Asthma is an important condition to study in the Medicaid population because it is the most frequent reason for hospital admission of Medicaid children, with rates substantially higher than those of non-Medicaid children. This study addressed how the quality of hospital care provided to children with asthma on Medicaid compares with that provided to privately insured children. Children inpatient records were studied in California, Georgia, and Michigan, comparing the care that was provided to standards created by a national panel of physician experts. Process-of-care analysis showed that Medicaid children in each state were more likely than privately insured children to be discharged on suboptimal medication regimens. This study concluded that hospitals serving Medicaid children, at least in these three states, are providing asthma inpatient care of fairly comparable quality to that of privately insured children. However, there remain significant problems surrounding outpatient medication regimens and follow-up care.     

Variations in hospital resource use for Medicare and privately insured populations in California

The amount of resources used in the care of chronically ill Medicare fee-for-service (FFS) patients varies widely across hospitals. We studied variations across California hospitals in hospital resource use for chronically ill patients covered by Medicare health maintenance organizations (HMOs) and private insurers and found substantial variation in all of the coverage groups studied. Resource-use measures based on Medicare FFS data often reflect patterns evident for other payers. Previous estimates of savings if the most resource-intensive hospitals more closely resembled less resource-intensive hospitals, based on just Medicare FFS spending, could underestimate possible savings when other payers are taken into account.     

Costs of poor birth outcomes among privately insured

Despite expansions in the public insurance coverage of pregnant women, concerns over poor birth outcomes remain. Poor birth outcomes occur among publicly and privately insured women, however, thereby imposing excess costs on employers and their insurers. Data from a large sample of privately insured for 1996 are used to examine these outcomes and costs. Almost one-fourth (24.3 percent) of the infants in our matched sample of 12,020 deliveries was premature or had other problems at birth. Costs for these infants accounted for 82 percent of the total $56 million spent on sample infants. The incremental cost of infants with poor birth outcomes versus those with normal, full-terms was approximately $14,600. We found that these relative costs had increased over time due perhaps to the increased technology and intensity of services used to save infant lives. We also found that factors other than maternal and infant complications affected cost variations. For example, employers located in the Northeast, hiring older mothers, and in unionized sectors have higher prenatal, delivery, and infant costs.     

Medicaid outpatient utilization for waterborne pathogenic illness following Hurricane Floyd

OBJECTIVES: Flooding provides an opportunity for epidemics of waterborne viral, protozoan, or bacterial diseases to develop in affected areas. Epidemic levels of disease may translate into higher than average levels of health services use, depending in part on help-seeking behaviors. The authors investigated whether the flooding that occurred as a result of Hurricane Floyd in September 1999 was associated with an increase in outpatient visits for waterborne diseases among Medicaid enrollees in eastern North Carolina. METHODS: Using a difference-in-differences estimation technique, the authors examined the change in outpatient visits by North Carolina Medicaid enrollees for selected waterborne diseases following the hurricane. The study focused on counties with high concentrations of hog farming that were mildly/moderately or severely affected by the hurricane, using unaffected counties and the year before the hurricane as controls. RESULTS: Small increases in Medicaid-covered outpatient visits were found in severely affected counties for two of the six pathogens selected for analysis, relative to unaffected counties. Larger increases in visits were found for nonspecific intestinal infections in both severely and moderately affected counties following the hurricane, relative to unaffected counties. CONCLUSIONS: The large increase in visits for ill-defined intestinal infection is noteworthy. The relative lack of increase in visits with specific pathogenic diagnoses may be attributable, at least in part, to a number of factors, including incomplete diagnostic information provided by treating clinicians, low treatment-seeking behavior, and use of non-Medicaid-funded emergency services.     

Healthcare and workloss costs associated with patients with persistent asthma in a privately insured population

OBJECTIVE: The objective of this study was to estimate annual healthcare and workloss costs of patients with persistent asthma by severity. METHODS: A persistent asthma patient sample (<65 years) was selected from an employer claims database. Asthma persistence and severity were determined by a novel algorithm based on Health Plan Employer Data and Information Set criteria, Leidy's Reliever and Oral Steroid Method, and Global Initiative for Asthma guidelines. Healthcare costs were compared between asthma patients and demographically matched controls and by asthma severity. RESULTS: Average annual excess costs for persistent patients were $4412 for health care and $924 for workloss (P < 0.01). Although costs for severe patients were higher than moderate patients (P < 0.05), moderate patients' costs were similar to that for mild patients. Persistent use of inhaled corticosteroids was lower in mild (9.0%) relative to moderate (78.1%) and severe (86.4%) patients. CONCLUSIONS: Persistent asthma is expensive. Underutilization of inhaled corticosteroids is higher in patients with mild persistent asthma.     

Variability in influenza vaccination opportunities and coverage among privately insured children

BackgroundUniversal influenza vaccination has been recommended since 2010, yet influenza vaccination rates among children aged 6 months to 17 years remain low compared with other routinely recommended childhood vaccines.ObjectiveAssess in-plan vaccination coverage, opportunities, and missed opportunities during the 2016–2017 influenza season.Study Design:Retrospective analyses using 2016–2017 MarketScan® data for 2,768,799 privately insured children aged 1–17 years by the end of 2016 who were continuously enrolled in the same insurance plan during the 2016–2017 influenza season (defined as August 1, 2016 through May 31, 2017). We assessed in-plan vaccination coverage (percentage receiving ≥ 1 dose of influenza vaccine from August 2016-May 2017) and vaccination opportunities (percentage with ≥ 1 provider visit between September 2016 – May 2017). Among children who remained unvaccinated at the end of the season, those with ≥ 1 influenza vaccination opportunity between September 2016-May 2017 were determined to have a missed opportunity.ResultsIn-plan vaccination coverage during the 2016–17 season was 67.7% in infants (born 2015), 49.5% in toddlers (born 2012–2014), 35.0% in school-aged children (born 2004–2011), and 22.3% in teenagers (born 1999–2003). Like vaccination coverage, vaccination opportunities decreased with age (infants: 97.7%, toddlers: 91.9%, school-aged children: 82.6%, teenagers: 79.3%). Among unvaccinated children, 93.1%, 84.1%, 73.6% and 73.6% of each age group had a missed opportunity for influenza vaccination.ConclusionOpportunities for and coverage with influenza vaccination vary even among privately insured children. Along with continued efforts to reduce missed opportunities, effective strategies to bring children to their doctor for annual influenza vaccination are needed, particularly for older children.     

Prenatal care comparisons among privately insured, uninsured, and Medicaid-enrolled women

Women without health insurance and those covered by Medicaid have been shown to obtain prenatal care later in pregnancy and make fewer visits for care than do women with private insurance. Factors that keep women from obtaining care include inadequate maternity care resources, difficulty in securing financial coverage, and the psychosocial issues of pregnancy. This study identified and compared prenatal care use patterns, insurance coverage changes, and psychosocial factors among 149 women in Minneapolis, MN, with private health insurance, Medicaid, and no health insurance. Little information has been available on the insurance status of women at the start of pregnancy and the paths subsequently taken to obtain financial coverage for prenatal care.     

Prenatal psychosocial needs: differences between a TennCare group and a privately insured group in Appalachia

The purpose of this study was to determine the prenatal psychosocial needs of a group of women enrolled in TennCare, a Medicaid managed care program designed to cover all otherwise uninsured people in Tennessee, and compare them with privately insured women. Face-to-face interviews were conducted using standard and reliable questionnaires with a convenience sample of 120 pregnant women between 14 and 44 years of age and 16 to 28 weeks gestation at three prenatal clinics in East Tennessee. Chi-square analysis revealed that the TennCare enrollees in East Tennessee were significantly more likely to report higher psychosocial needs in pregnancy than the privately insured group. Women enrolled in TennCare had a significantly higher incidence of physical abuse, depressive symptoms, and smoking than the privately insured group. Pregnancy provides a window of opportunity for assessing and intervening with vulnerable women enrolled in Medicaid managed care who report psychosocial problems.     

Effects of employer-offered high-deductible plans on low-value spending in the privately insured population

Enrollment in plans with high deductibles has increased more than seven-fold in the last decade. Proponents of these plans argue that high deductibles could reduce wasteful spending by providing patients with incentives to limit use of low-value services that offer little or no clinical benefit. Others are concerned that patients may respond to these incentives by reducing their use of medical services indiscriminately and regardless of clinical benefit, which may negatively impact health outcomes. This study uses individual-level insurance claims data (2008–2013) and plausibly exogenous changes in plan offerings within firms over time to estimate the intent-to-treat and local-average treatment effects of high-deductible plan offerings on spending on 24 low-value services received in the outpatient setting. We find that firm offer of a high-deductible plan leads to a 13.7% ($5.23) reduction in average enrollee spending on low-value outpatient services and a 5.2% ($105.77) reduction in overall outpatient spending. We also find reductions in spending on measures of low-value imaging and laboratory services. We find some evidence that offering high-deductible plans disproportionately reduces low-value spending relative to overall spending, indicating that deductibles may be a way to incentivize value-based decision making.