Does "mainstreaming" guarantee access to care for medicaid recipients with asthma?

OBJECTIVE: Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated. DESIGN: Cross-sectional survey. SETTING/PARTICIPANTS: A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group. MEASUREMENTS AND MAIN RESULTS: We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patients covered by the state's Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Cal patients were more likely to report at least one access problem compared to non-Medi-Cal patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction. CONCLUSIONS: Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves.     

Medicaid, managed care, and the care of patients hospitalized for acute myocardial infarction

BACKGROUND: TennCare, beginning in January 1994, channeled all Medicaid-eligible patients into managed care while expanding Medicaid coverage to large numbers of previously uninsured patients. We assessed the impact of TennCare on (1) coronary revascularization of patients who had had an acute myocardial infarction (AMI), (2) the likelihood of the patient having a usual provider of care after discharge from the hospital, and (3) health and functional status 1 to 3 years after the index AMI. METHODS AND RESULTS: With the use of 1996 to 1997 survey data from 438 patients hospitalized for AMI in 1993 and 1995 who were under age 65 years at the index admission, multivariate analysis was used to calculate effects of TennCare on utilization and outcomes. TennCare patients were as likely as privately insured patients to have received coronary revascularization within 30 days of the index AMI (odds ratio 0.87, P =.69). Persons enrolled in TennCare and in traditional Medicaid who received a revascularization procedure were much less likely to have received coronary angioplasty than coronary bypass surgery than were the privately insured (TennCare: odds ratio 0.37, P =.05; Medicaid: odds ratio 0.28, P =.08). Virtually all TennCare enrollees (94%) reported having a usual provider of care in the year before the survey versus 85% for privately insured patients with AMI in 1995 (P =.05). On health and functional status, TennCare enrollees overall fared as well as those with private insurance. CONCLUSIONS: Our results suggest that TennCare brought patients who otherwise would have been uninsured or enrolled in Medicaid into the medical mainstream, measured both in terms of utilization of services and health and functional status.     

Factors Associated with Non-Attendance at Pediatric Subspecialty Asthma Clinics

Background. Children with Medicaid insurance are less likely to receive subspecialty asthma care than non-Medicaid patients. However, it is not clear if such disparities are due to non-attendance at scheduled visits by patients. Objective. To determine factors associated with non-attendance at scheduled visits for pediatric subspecialty asthma care. Design/Methods. We conducted a cross-sectional study of children with scheduled visits at three asthma clinics during a 12-month period. Our outcome of interest was patient non-attendance for a scheduled visit, controlling for age, gender, new patient status, type of insurance, severity of illness, distance to clinic, clinic site, month, and weekday of scheduled visit. We used logistic regression for multivariate comparisons and controlled for clustering effects for children with multiple scheduled visits. Results. There were 1236 scheduled visits for 857 unique patients. Median age: 7 years (IQR 3-11); median distance traveled: 24 miles (IQR 13-41); 20% had Medicaid insurance. The non-attendance rate was 8%. In multivariate analysis, Medicaid insurance (OR 2.33, 95% CI 1.45-3.74) and visits scheduled in September-December (3.26, 2.08-5.11) were associated with non-attendance. Conclusions. Children with Medicaid insurance are less likely to attend scheduled visits for subspecialty asthma care, controlling for seasonal variation. Programs designed to address disparities in pediatric asthma outcomes regarding subspecialist care may improve their effectiveness by addressing barriers to attendance and anticipating poor attendance in the fall season.     

Transition to Managed Care Impacts Health Care Service Utilization by Children Insured by Medicaid

Purpose. To evaluate the impact of transition to managed care from fee for service on asthma service utilization among Maryland Medicaid insured children. Methods. Healthcare claims from 1997-2000 for children with asthma insured by Maryland Medicaid were extracted and analyzed. Results. Between 1997-2000, inhaled corticosteroid use increased as a proportion of all asthma medications. Outpatient asthma visits increased from 4.2% to 5.9% of all outpatient claims as both asthma-related hospitalizations and emergency department visits decreased. Conclusions. Restructuring of Maryland Medicaid for children from fee for service to managed care was associated with improvement in asthma-related healthcare utilization claims.     

Factors Associated with Non-Attendance at Pediatric Subspecialty Asthma Clinics

Background. Children with Medicaid insurance are less likely to receive subspecialty asthma care than non-Medicaid patients. However, it is not clear if such disparities are due to non-attendance at scheduled visits by patients. Objective. To determine factors associated with non-attendance at scheduled visits for pediatric subspecialty asthma care. Design/Methods. We conducted a cross-sectional study of children with scheduled visits at three asthma clinics during a 12-month period. Our outcome of interest was patient non-attendance for a scheduled visit, controlling for age, gender, new patient status, type of insurance, severity of illness, distance to clinic, clinic site, month, and weekday of scheduled visit. We used logistic regression for multivariate comparisons and controlled for clustering effects for children with multiple scheduled visits. Results. There were 1236 scheduled visits for 857 unique patients. Median age: 7 years (IQR 3–11); median distance traveled: 24 miles (IQR 13–41); 20% had Medicaid insurance. The non-attendance rate was 8%. In multivariate analysis, Medicaid insurance (OR 2.33, 95% CI 1.45–3.74) and visits scheduled in September–December (3.26, 2.08–5.11) were associated with non-attendance. Conclusions. Children with Medicaid insurance are less likely to attend scheduled visits for subspecialty asthma care, controlling for seasonal variation. Programs designed to address disparities in pediatric asthma outcomes regarding subspecialist care may improve their effectiveness by addressing barriers to attendance and anticipating poor attendance in the fall season.     

Health care disparities in the acute management of venous thromboembolism based on insurance status in the U.S.

Acute venous thromboembolism (VTE) is common, costly, and potentially lethal. Therapeutic anticoagulation requires timely, closely monitored medical follow-up. If ineffective, clinical outcomes worsen and resource utilization increases. This risk may be magnified in uninsured patients. This study examined VTE care in hospital patients and investigated differences based on insurance status. We performed a retrospective chart review on medical VTE patients at an academic teaching hospital between December 1, 2007 and April 30, 2009. We reviewed medical records for demographics, insurance, admission status, length of stay (LOS), and 30-day Emergency Department (ED) recidivism and hospital readmission. Measured outcomes were analyzed based on payer source. We identified 234 medical VTE patients; 67 patients were uninsured (28.6%). 106 patients (45.3%) presented with deep vein thrombosis only. Most VTE patients were admitted to the hospital (171; 73.1%), including all 128 pulmonary embolism patients. Admitted uninsured patients averaged a LOS of 5.5 versus 3.7 days for insured (P = 0.03), with ED recidivism rates of 26.1 versus 11.3%, respectively (P = 0.02). Average cost for all VTE care in uninsured patients was 12,297 versus12,297 versus 7,758 for insured patients (P = 0.04). This study identified disparities in medical care and resource utilization for medical VTE patients based on insurance. Uninsured VTE patients were hospitalized nearly two additional days and were more than two times as likely to return to the ED within 30 days compared to insured patients. Additional research is needed to explain these disparities, and to explore system improvements for the uninsured VTE patient.     

Transition to Managed Care Impacts Health Care Service Utilization by Children Insured by Medicaid

Purpose. To evaluate the impact of transition to managed care from fee for service on asthma service utilization among Maryland Medicaid insured children. Methods. Healthcare claims from 1997–2000 for children with asthma insured by Maryland Medicaid were extracted and analyzed. Results. Between 1997–2000, inhaled corticosteroid use increased as a proportion of all asthma medications. Outpatient asthma visits increased from 4.2% to 5.9% of all outpatient claims as both asthma-related hospitalizations and emergency department visits decreased. Conclusions. Restructuring of Maryland Medicaid for children from fee for service to managed care was associated with improvement in asthma-related healthcare utilization claims.     

The association between hospital readmission and insurance provider among adults with asthma.

CONTEXT: Asthma is ranked as the ninth most common chronic condition in the U.S., and its annual direct costs from hospital services alone are estimated at $3.1 billion. Hospitalization rates due to asthma reveal several disparities and may be attributed to recent changes in the healthcare delivery system, including the penetration of managed care. OBJECTIVE: To examine the relationship between 7-day hospital readmission and insurance provider among adults with asthma. DDESIGN: A retrospective cohort study that included patients aged 18-64 with a principal diagnosis of asthma, who were discharged from acute nonfederal hospitals in New Jersey between 1 January 1993 and 31 December 1996. In the absence of unique patient identifiers, a linkage system was used to match subsequent readmissions for the same patient to the first admission. MMAIN OUTCOME MEASURE: Seven-day readmission. RESULTS: Results showed a significantly increased risk of 7-day readmission for managed care patients as compared to indemnity patients (OR= 1.67, 1.10-2.53). Shorter lengths of stay were associated with greater odds of readmission (LOS=0: OR=5.17, 2.49-10.75, LOS=1: OR=2.30, 1.30-4.07). CONCLUSIONS: Managed care patients have shorter lengths of stay as compared to indemnity patients, which leads to an increased risk of returning to the hospital within a short period of time. In trying to provide cost-effective patient care, we may be discharging patients prematurely.     

The Association Between Hospital Readmission and Insurance Provider Among Adults with Asthma

Context. Asthma is ranked as the ninth most common chronic condition in the U.S., and its annual direct costs from hospital services alone are estimated at $3.1 billion. Hospitalization rates due to asthma reveal several disparities and may be attributed to recent changes in the healthcare delivery system, including the penetration of managed care. Objective. To examine the relationship between 7-day hospital readmission and insurance provider among adults with asthma. Design. A retrospective cohort study that included patients aged 18-64 with a principal diagnosis of asthma, who were discharged from acute nonfederal hospitals in New Jersey between 1 January 1993 and 31 December 1996. In the absence of unique patient identifiers, a linkage system was used to match subsequent readmissions for the same patient to the first admission. Main Outcome Measure. Seven-day readmission. Results. Results showed a significantly increased risk of 7-day readmission for managed care patients as compared to indemnity patients (OR = 1.67, 1.10-2.53). Shorter lengths of stay were associated with greater odds of readmission (LOS = 0: OR = 5.17, 2.49-10.75, LOS = 1: OR = 2.30, 1.30-4.07). Conclusions. Managed care patients have shorter lengths of stay as compared to indemnity patients, which leads to an increased risk of returning to the hospital within a short period of time. In trying to provide cost-effective patient care, we may be discharging patients prematurely.     

Gaps in health insurance coverage and emergency department use among children with asthma

Background: Gaps in health insurance coverage may complicate asthma management and increase emergency department (ED) use. Using two nationally-representative surveys, we characterize the prevalence of coverage gaps among children with asthma, and describe their association with ED visits in this population. Methods: De-identified data were obtained from the 2016 National Survey of Children’s Health (NSCH) and National Health Interview Survey (NHIS). Among children with asthma, we classified coverage over the past year as: (1) continuous private, (2) continuous public, (3) gap in coverage, and (4) continuously uninsured. The primary outcome was all-cause ED visits in the past year (both surveys). Secondary outcomes included unmet health care needs (NSCH), asthma-related ED visits or hospitalizations (NHIS) and asthma exacerbations (NHIS). Results: The analysis included 3739 (NSCH) and 854 (NHIS) children with asthma, representing a population of 5.5 million children in the US. Estimated prevalence of coverage gaps was 5% in the NSCH and 3% in the NHIS. On multivariable ordinal logistic regression using NSCH data, coverage gaps were associated with increased all-cause ED use (OR?=?2.5; 95% CI: 1.3, 4.7, p?=?0.005), compared to continuous private coverage. Further analysis confirmed higher odds of unmet health care needs, asthma exacerbations, and asthma-related ED visits among children with coverage gaps. Conclusions: Children with asthma who experience insurance coverage gaps have increased ED use, possibly related to poorer access to appropriate health care. Protecting insurance coverage continuity may reduce ED use and improve clinical outcomes in this population.     

Gender Differences in Asthma Experience and Disease Care in a Managed Care Organization

The purpose of this study was to describe gender differences in asthma in a managed care organization. We collected data from a patient survey, electronic administrative data, and hard-copy chart reviews. Women reported significantly lower general health status, more symptoms and greater severity of asthma, more activity limitations, more use of asthma-relieving medications, and more acute visits for asthma than men. Conversely, women tended to report better asthma care measures. These gender disparities warrant further study to support appropriate adjustment of clinical care and health-care-related services for women.     

Asthma Exacerbations in North American Adults: Who Are the “Frequent Fliers” in the Emergency Department?

OBJECTIVE: To characterize adult asthma patients according to frequency of emergency department (ED) visits in the past year. DESIGN: Adults presenting with acute asthma to 83 US EDs underwent structured interviews in the ED and by telephone 2 weeks later. RESULTS: The 3,151 enrolled patients were classified into four groups: those reporting no ED visits in the past year (27%), one to two visits (27%), three to five visits (25%), and six or more visits (21%). The number of ED visits (NEDV) was associated with older age, nonwhite race, lower socioeconomic status, and several markers of chronic asthma severity (all p < 0.001). NEDV was strongly associated with Medicaid insurance (17% among those with no visits, 22% with one to two visits, 30% with three to five visits, 39% with six or more visits; p < 0.001). NEDV was unrelated to gender or having a primary care provider (PCP). In a multivariate model, independent predictors of high ED use (six or more visits a year) were nonwhite race, Medicaid, other public, and no insurance, and markers of chronic asthma severity. Patients with six or more ED visits accounted for 67% of all prior ED visits in the past year. CONCLUSIONS: High NEDV is associated with characteristics that may help with identification of "frequent fliers" in the ED. A better understanding of these characteristics may advance ongoing efforts to decrease asthma health-care disparities, including differential access to primary asthma care. National guidelines recommend specific ED treatments then referral to a PCP. Although longitudinal care is surely important, attempts to reduce frequent ED asthma visits may be better directed toward more specific preventive and educational needs.     

Gender Differences in Asthma Experience and Disease Care in a Managed Care Organization

The purpose of this study was to describe gender differences in asthma in a managed care organization. We collected data from a patient survey, electronic administrative data, and hard-copy chart reviews. Women reported significantly lower general health status, more symptoms and greater severity of asthma, more activity limitations, more use of asthma-relieving medications, and more acute visits for asthma than men. Conversely, women tended to report better asthma care measures. These gender disparities warrant further study to support appropriate adjustment of clinical care and health-care-related services for women.     

Cancer survival in Kentucky and health insurance coverage

BACKGROUND: Access to health insurance influences the amount and quality of health care received, which in turn is likely to be related to survival. Few studies have systematically examined cancer survival by individual level health insurance data from a state population-based cancer registry for 4 anatomic sites. METHODS: Men and women aged 18 to 99 years who were registered from 1995 to 1998 with the Kentucky Cancer Registry, Lexington, with colorectal, lung, breast, or prostate cancer were followed up through 1999. Three-year crude and relative survival proportion by 7 health insurance categories and by sex for all 4 sites were calculated. Poisson regression was used to model the risk of death (controlling for age group at diagnosis, sex, race, stage at diagnosis, and treatment) relative to expected deaths in the general population from all 4 cancers by health insurance category. RESULTS: Among patients with prostate cancer, 3-year relative survival proportion was 98% for the privately insured and 83% for the uninsured; comparable figures were 91% and 78% for patients with breast cancer; 71% and 53% for patients with colorectal cancer; and 23% and 13% for patients with lung cancer. For all 4 cancers the uninsured ranked fifth or sixth on survival, above patients with unknown insurance type or Medicaid/welfare. CONCLUSION: These findings confirm purported disparities in cancer care and point toward the need to make quality care accessible to all segments of the population.     

Variability in asthma quality and costs in children with different Medicaid insurance plans in Maricopa County

Objective: To describe the variation in asthma quality and costs among children with different Medicaid insurance plans. Methods: We used 2013 data from the Center for Health Information and Research, which houses a database that includes individuals who have Medicaid insurance in Arizona. We analyzed children ages 2–17 years-old who lived in Maricopa County, Arizona. Asthma medication ratio (AMR, a measure of appropriate asthma medication use), outpatient follow-up within 2 weeks after asthma-related hospitalization (a measure of continuity of care), asthma-related hospitalizations, and all emergency department (ED) visits were the primary quality metrics. Direct costs were reported in 2013 $US dollars. We used one-way analysis of variance to compare the health plans for AMR and per member cost (total, ER, and hospital), and the chi-squared test for the outpatient follow-up measure. We used coefficient of variation to identify variation of each measure across all individuals in the study. Results: In 2013, 90,652 children in Maricopa County were identified as having asthma. The average patient-weighted AMR for children with persistent asthma was 0.35, well short of the goal of ≥0.70, and only 36% of hospitalized asthma patients had outpatient follow-up within 2 weeks of hospitalization. AMR, total costs, and ED costs varied significantly (p <.0001) when comparing health plans while hospital costs and outpatient follow-up showed no significant variation. Conclusions: Targeting appropriate medication use for asthma may help reduce variation, improve outcomes, and increase healthcare value for children with asthma and Medicaid insurance in the US.     

Health insurance status and hypertension monitoring and control in the United States

BACKGROUND: In this study, we examined whether insurance status (private, Medicare, Medicaid, no insurance) was associated with the odds of blood pressure (BP) monitoring and control. METHODS: We used data from the National Health and Nutrition Examination Surveys (NHANES) conducted in 1999 through 2002, defining hypertension as either self-report of elevated BP or an elevated BP value on examination. We conducted multivariate analyses adjusting for age, income, race/ethnicity, body mass index, and medical comorbidities. RESULTS: Among all hypertensive participants, only 58% of the uninsured had a BP check within 6 months, compared to 82% of the privately insured. Overall, uninsured individuals (adjusted odds ratio 0.63, 95% CI 0.44-0.92) were at lower odds of adequate BP control than the privately insured. Among treated participants, the uninsured were at lower odds of adequate control (adjusted OR 0.42, 95% CI 0.23-0.73) than the privately insured. Among participants who self-reported hypertension but were not taking antihypertensive medications, the odds of elevated BP did not differ by insurance status. No differences in BP control were observed for participants with Medicare or Medicaid compared to those with private insurance, in any comparisons. CONCLUSIONS: Lack of insurance is associated with lower rates of BP control among treated hypertensives, whereas the odds of elevated BP are similar among untreated hypertensives with different insurance status. Variation in BP control between the uninsured and privately insured with hypertension is likely related to differences in appropriate treatment intensification or adherence, rather than differences in rates of treatment initiation.     

Ethnicity and access to care in systemic lupus erythematosus

Objective. To define access to care and to examine the relationship between ethnicity and access to care in systemic lupus erythematosus (SLE). Methods. A review of published literature was supplemented with preliminary data from a pilot study. Data from patient interviews, chart reviews, and insurer surveys were collected at 2 sites and used to develop several measures of access. The relationship between ethnicity and access was examined through chi-square analyses, difference of means testing, and multivariate regression. Results. Although African-American SLE patients appear less likely to be privately insured and more likely to be uninsured, no significant differences in utilization rates were detected between ethnic groups. Uninsured patients, however, had significantly fewer physician visits than both the Medicaid and the privately insured patients. Multivariate regression results confirm a strong and negative relationship between physician visits and patient coinsurance rates. Conclusion. Careful examination of multiple dimensions of access may highlight differences between ethnic groups. Further research is necessary to document these differences and explore their relationships to outcomes.     

Understanding of asthma management: Medicaid parents' perspectives

OBJECTIVE: This article explores parental caregiver perspectives on barriers to asthma care in the Medicaid system. METHODS: Focus groups were held for parents of children with persistent asthma to identify barriers to asthma care for children insured by Medicaid in the Ypsilanti, MI area. Semistructured questions regarding health goals, asthma care, and access were used. Themes were defined as distinct categories or concepts regarding aspects of asthma care and coded. RESULTS: Thirty-six adults participated in four focus groups, 89% were the biological mother, and 64% were African American. Major themes identified included caregiver emotions, caregiver/patient knowledge, environmental issues, school/daycare support, Medicaid health-care system issues, the role of medical providers, and emerging adolescence. Parents demonstrated asthma awareness but were not confident in their role as the child's disease manager. A specific gap was seen in the caregiver's level of self-efficacy to control exposure to asthma triggers, monitor the child's symptoms, and modify medications based on asthma symptoms. CONCLUSION: Medicaid-insured families face unique barriers related to income and insurance limitations as well as issues common to others with asthma. Caregivers demonstrated a high level of asthma knowledge, but like other caregivers gaps between knowledge and behavior existed. Barriers to asthma care that may be specific to Medicaid-insured patients included difficulty maintaining continuity of care due to physician participation in Medicaid programs, and concerns about possible differences in asthma care from health-care providers due to their Medicaid insurance status.     

The Association Between Hospital Readmission and Insurance Provider Among Adults with Asthma

Context. Asthma is ranked as the ninth most common chronic condition in the U.S., and its annual direct costs from hospital services alone are estimated at $3.1 billion. Hospitalization rates due to asthma reveal several disparities and may be attributed to recent changes in the healthcare delivery system, including the penetration of managed care. Objective. To examine the relationship between 7‐day hospital readmission and insurance provider among adults with asthma. Design. A retrospective cohort study that included patients aged 18–64 with a principal diagnosis of asthma, who were discharged from acute nonfederal hospitals in New Jersey between 1 January 1993 and 31 December 1996. In the absence of unique patient identifiers, a linkage system was used to match subsequent readmissions for the same patient to the first admission. Main Outcome Measure. Seven‐day readmission. Results. Results showed a significantly increased risk of 7‐day readmission for managed care patients as compared to indemnity patients (OR = 1.67, 1.10–2.53). Shorter lengths of stay were associated with greater odds of readmission (LOS = 0: OR = 5.17, 2.49–10.75, LOS = 1: OR = 2.30, 1.30–4.07). Conclusions. Managed care patients have shorter lengths of stay as compared to indemnity patients, which leads to an increased risk of returning to the hospital within a short period of time. In trying to provide cost‐effective patient care, we may be discharging patients prematurely.