Improved prediction of medical expenditures and health care utilization using an updated chronic disease score and claims data

ObjectiveTo predict future medical expenditures, health care utilization, and mortality in Switzerland using an updated chronic disease score (CDS), a chronic morbidity measure based on pharmacy data.Study Design and SettingWe performed a cohort study using medical claims data from insured persons enrolled in 2009 and 2010. Patient's characteristics, chronic conditions, and health care costs from baseline were used to calculate each patient's disease score. Two-part regression models were fit to predict health care expenditures, utilization, and mortality during the following year using the score's baseline values. We calculated the proportion of explained variation for each regression model to assess their performance.ResultsThe CDS model, controlled for sociodemographics and health insurance plan, showed a significant improvement in explained variance of health care costs, outpatient costs, and outpatient visits in 2010. Future outpatient visits were predicted best with an R² of 29.2% (age group: 18–65 years) and 22.9% (>65 years), and models predicted future mortality with a c-statistic of 0.8.ConclusionThe CDS showed reasonable predictive validity of future health care utilization and medical expenditure based on pharmacy dispensing data, which may support health care decision makers in the planning delivery systems and resource allocation.     

L’effet du non-recours aux soins médicaux et dentaires sur les dépenses de santé des personnes ayant une maladie chronique

BackgroundPeople with chronic disease often have dental (especially periodontal) disorders. Nevertheless, people with chronic disease seek dental care less often than others. We wanted to know if there is a relationship between the consumption of medical care and the consumption of dental care, and if so if the relationship is especially strong for people with chronic disease.MethodsWe conducted a longitudinal study that combined two data-sets: consumption data from the French National Health Insurance Fund and health and socioeconomic welfare data collected with a dedicated national survey. We studied healthcare expenditure and analyzed the association between healthcare consumption, health status and healthcare expenditure over a four-year period (2010–2013).ResultsPeople who did not seek medical or dental care in 2010 exhibited irregular consumer behavior thereafter. This pattern was particularly evident among those with chronic disease whose healthcare expenditures did not stabilize during the study period compared with the rest of the study population. Among people who did not seek medical care in 2010, variation in average dental care expenditure was 91% in people with chronic disease versus 42% for those without chronic disease. Lack of medical care during the first year of the study was also associated with greater expenditure-delay in people with chronic disease (77%) compared with 15% in people without chronic disease.ConclusionThe lack of medical or dental care in 2010 for people with chronic disease did not lead to an increase in medical and dental consumption in the following years. The catch-up delay was longer than four years. This highlights a problem of monitoring and identifies a marginalized population within the healthcare system.     

The influence of English proficiency on access to care

Objective. The number of individuals with limited English proficiency in the USA is large and rapidly growing. Consequently, addressing language barriers in access to medical care is becoming increasingly important. Previous studies have reported that individuals with limited English proficiency have more difficulty gaining access to care, compared to English-proficient individuals. We assessed the impact of English language proficiency on access to medical care, accounting for health and socioeconomic status, using nationally representative data.

Design. Cross-sectional data from the 2006 National Health Interview Survey (n=29,868). The main outcome measures of interest were self-reported delayed medical care, forgone needed care, and visits to a health care professional.

Results. In unadjusted analyses, individuals with limited English proficiency were more likely to forgo needed medical care and less likely to have a health care visit, compared to individuals who were proficient in English. There was no significant association between language proficiency and reports of delayed care. After accounting for individuals’ health and socioeconomic status, only the relationship between limited English proficiency and health care visits remained statistically significant. Most associations between language proficiency and access to care did not differ across various racial/ethnic groups.

Conclusion. Results indicate that the choice of access measure may influence conclusions about language barriers in health care. Given the growing proportion of US residents with limited English proficiency, health care settings need to better address potential language barriers.     

Maternal Medical Complexity: Impact on Prenatal Health Care Spending among Women at Low Risk for Cesarean Section

BackgroundObstetric procedures are among the most expensive health care services, yet relatively little is known about health care spending among pregnant women, particularly the commercially-insured.ObjectiveThe objective of this study was to examine the association between maternal medical complexity, as a result of having one or more comorbid conditions, and health care spending during the prenatal period among a national sample of 95,663 commercially-insured women at low risk for cesarean delivery.MethodsWe conducted secondary analyses of 2010–2011 inpatient, outpatient, and professional claims for health care services from the Health Care Cost Institute. Allowed charges were summed for the prenatal and childbirth periods. Ordinary least squares regressions tested associations between maternal health conditions and health care expenditures during pregnancy.ResultsThirty-four percent of pregnant women had one or more comorbidities; 8% had two or more. Pregnant women with one or more comorbidities had significantly higher allowed charges than those without comorbidities (p < .001). Spending during the prenatal period was nearly three times higher for women with preexisting diabetes compared with women with no comorbid conditions. Average levels of prenatal period spending associated with maternal comorbidities were similar for women who had vaginal and cesarean deliveries. Patient characteristics accounted for 30% of the variance in prenatal period expenditures.ConclusionsThe impact of maternal comorbidities, and in particular preexisting diabetes, on prenatal care expenditures should be taken into account as provider payment reforms, such as pay-for performance incentives and bundled payments for episodes of care, extend to maternal and child health-related services.     

Prenatal Care as a Gateway to Other Health Care: A Qualitative Study

IntroductionPopulations with higher rates of being uninsured in the United States have inconsistent access to health care and struggle to find care that fits their needs. For many without access to regular health care, prenatal care can be an entry point for obtaining care related—and unrelated—to pregnancy. We aimed to understand people's lived experience of whether and how pregnancy status enables access to health care unrelated to pregnancy.MethodsThis is a secondary analysis of 18 in-depth interviews collected between June 2015 and May 2017 as part of the Multistate Abortion Prenatal Study. Participants were new obstetrics patients at prenatal clinics in southern Louisiana and Baltimore, Maryland. Interviews were qualitatively analyzed using iterative thematic techniques to identify themes related to experiences navigating health care services on entry to prenatal care.Main FindingsMost participants were insured through Medicaid, and all participants had low incomes. Pregnancy status enabled access to health insurance for many participants. Prenatal care facilitated access to non–pregnancy-related health care that participants had otherwise been unable to obtain before their current pregnancies. However, entry into prenatal care did not mean all participants’ health needs were adequately addressed and some reported ongoing unmet medical needs.ConclusionsOur findings point to pregnancy as a gateway to health care (and insurance) and, further, illustrate how prenatal care can serve as a gateway to other medical care. Participants’ experiences demonstrate how access to health care for women with low incomes can be dependent on pregnancy status, even for non–pregnancy-related health needs.     

Health Care Utilization and Unmet Needs in Chinese Older Adults With Multimorbidity and Functional Impairment

ObjectivesChina has the world's largest aging population, of which 46% have multimorbidity and 38% have functional impairment. Older adults with multimorbidity often suffer functional impairment as well; however, it is not clear how current health care services have been used in this population. This study aimed to compare health care utilization among Chinese older adults at different levels of chronic disease and functional impairment.DesignA cross-sectional design. Multivariate 2-part models were used to examine the probability and frequency of health care utilization.Setting and ParticipantsData were from 5166 adults aged 65 or older from the 2015 wave of the China Health and Retirement Longitudinal Study. The sample included 22% without any chronic condition, 27% with 1 chronic condition, 44% with multimorbidity, and 7% with multimorbidity and functional impairment.MeasuresHealth care utilization included outpatient visits, inpatient visits, and unmet hospitalization needs.ResultsAs the number of chronic conditions and functional impairments increased, older adults tend to access health care more. Older adults with both multimorbidity and functional impairment tend to use health care services most, but still reported the highest level of unmet hospitalization needs among all groups.Conclusions and ImplicationsChinese older adults with multimorbidity and functional impairment may have experienced multiple barriers in accessing health care. Social programs should be created to make health care more accessible among older adults. The health care delivery system could be oriented to home-based medical care, which have been found effective in delivering high-quality care and reducing health care costs.     

Identification of targets for improving access to care in persons with long term physical disabilities

BackgroundPeople with long-term physical disability (LTPD) continue to experience difficulties in accessing health care despite the focus of highlighting disparities in the last two decades.ObjectivesTo describe health care utilization, accommodations and barriers experienced while accessing health care, and reasons why individuals delay or skip health care among people with LTPD.MethodsThe current study was a part of a larger longitudinal survey administered to individuals with physical disability associated with one of four long-term conditions (MS; SCI; PPS; MD). Measures included demographics, health care utilization, barriers to health care, and reasons for delaying or skipping medical care from the sixth wave of data from 2015 to 2016.ResultsRoughly 90% of all participants (N = 1159) saw at least one medical provider within 12 months. The most encountered barrier participants reported experiencing within that time was an office that did not have a safe transfer device to move them to an exam table (69%). Participants’ physical function, quality of life, status of living with a spouse, diagnostic condition, and sex (male) were significantly associated with endorsing a barrier in accessing health care. The inability to afford out of pocket expenses was the highest reported reason for delaying health care.ConclusionsPeople with LTPD access a variety of health care, including rehabilitation services, and continue to experience barriers when doing so. While understanding barriers individuals experience when accessing health care is important, it is equally important to document the type of care they delay or skip due to barriers.     

A systematic search and technical review of online information pertaining to medical care for people with disability

BackgroundLittle is known about the availability and technical quality of online information related to the medical care of people with disability, despite the potential of this information to alter clinical interactions and treatment decisions.ObjectivesThis review examines the utility of internet search engines for finding information related to medical care for people with disability, identifies common sources of this online information, and assesses the presence of technical attributes which allow for its critical evaluation.MethodsExhaustive systematic searches were conducted on two popular search engines (Google and Yahoo) using six search phrases. Resources were coded to categorize presenting organization, format, and technical quality.ResultsOnly 8.9% of results included information related to medical care for people with disability. Analyzed resources were most often from non-profit organizations (31.7%) in website format (60.2%). The composite technical quality score for all included resources had a median and mode of three on a scale of six.ConclusionsOnline information related to medical care for people with disability is not only difficult to locate, but has generally low technical quality. These findings have implications for health information professionals, patients, care providers, and information developers.     

¿Es la financiación sanitaria suficiente y adecuada?

IntroductionThe object of this short paper is to present the results of Spanish public health care expenditures projections until 2013 according to the expected impact of the main demographic and technological health cost drivers.Matherial and methodsFuture annual health expenditures are estimated using a simple method based on the decomposition of the past main growth factors in two scenarios. The main cost drivers considered were the following: demography, which includes the increasing number of people and the impact of population ageing; the increase in the price of health care inputs above the general price level; and the impact of changes in medical practice related with expanding medical technology.Results and discussionIn 2013, public health care expenditure may be around 5.7% and 6% of gross domestic product (GDP); that is, at least, between 0.24 and 0.53 additional GDP points will be spent on public health care. The main factor responsible for the future expenditure increase will continue to be the increase in the average health service intensity, followed by demographic factors. In the base-case scenario, public expenditure increase until 2013 will be compatible with a real 2.5% annual increase in consumption of non-health goods and services. In order to finance the future costs, the Spanish population will have to devote to public health expenditure less than 7% of income increase until 2013.Conclusion and perspectivesDespite being important, the expected Spanish GDP growth until 2013 may be enough to finance the increase in public health expenditure as a result of the impact of demographic changes. Expanding medical technology is expected to continue being the main driver of future costs.     

Predicting barriers to primary care for patients with disabilities: A mixed methods study of practice administrators

BackgroundPeople with disabilities continue to be identified as a group who experience disparate health/health care. They are less likely to engage in some health care services. Structural barriers are often identified as one of the reasons for the underutilization of some health care services by people with disabilities. However, to date no study has been conducted to understand why structural barriers persist twenty years after the Americans with Disabilities Act (ADA) became law.ObjectivesWe examined the relationship between primary care practice administrators' knowledge of the ADA and the number of accessibility barriers that patients with mobility disabilities might encounter.MethodsPrimary care practice administrators who were members of a medical management organization were surveyed between December 20, 2011, and January 17, 2012. A mixed methods research design was employed. Data were analyzed using a Guttman scale, linear and multiple linear regression.ResultsADA knowledge questions conformed to a valid Guttman scale. There was a significant inverse relationship between practice administrators' knowledge of the ADA and the number of barriers reported in their clinics. Age of the administrators and buildings built before 1993 were also significant predictors of the number of barriers.ConclusionThis study helps to identify medical practices that are more likely to have access barriers and have the greatest need for ADA compliance interventions. Results from this study highlight practice administrators' need for specific knowledge of the ADA as it applies to their medical practice. Efforts are needed to improve disability training for health professionals.     

An enriched medical home intervention using community health workers improves adherence to immunization schedules

ImportanceDisparities in childhood vaccination rates persist.ObjectiveTo evaluate the impact of an enriched medical home intervention using community health workers on improving immunization adherence among young children.DesignThe intervention group received home visits from trained community health workers to support families in adhering to recommended care while the comparison group received usual care (i.e. no home visits/reminders). Immunization history and socio-demographic data were collected using medical records and a validated questionnaire. The doubly robust estimation of risk difference, which combines weighting via propensity score and outcome regression model, was used to compare immunization adherence rates between two groups.SettingPrimary care practices affiliated with a suburban tertiary care academic medical center serving a socioeconomically diverse population.ParticipantsThe study sample included children ≤2 years of age at enrollment who crossed at least one age time point of 3, 7, 15, or 24 months during their 6 months post-enrollment period.Main outcomes and measuresThe primary outcome was age-specific immunization up-to-date status defined by CDC guidelines. The primary predictor was participation in the intervention.ResultsThe analysis included 201 children in the usual care group and 110 children in the intervention group. The usual care and intervention groups were divided into subgroups of newborn and infant/toddler to account for prior immunization history. After adjusting for differences in group characteristics, we found a significant absolute increase in the up-to-date immunization likelihood for both newborns (20.9%, p = 0.01) and infants/toddlers (16.8%, p = 0.01) receiving the intervention when compared to their peers receiving usual clinical care.Conclusions and relevanceOur findings demonstrate the positive impact of an enriched medical home intervention using community health worker home visitation on early childhood immunization up-to-date status. With further study, this model may provide a cost-effective approach to improving childhood vaccination rates, especially for vulnerable groups.     

Disability,self-rated health,and time seeking medical care

BackgroundPopulation-level estimates of patient-reported time seeking medical care in the United States by disability status are unknown.ObjectiveTo estimate the likelihood of seeking medical care on an average day and the number of minutes spent traveling to, waiting for, and receiving medical care among those receiving care, by disability status.MethodsData are analyzed from the nationally representative 2008, 2010, and 2012–2016 American Time Use Surveys. Weighted logistic and linear regression models evaluate the association between sensory, cognitive, physical, or multiple disabilities and time spent seeking medical care, net of age, sex, race/ethnicity, education, employment, nativity, marital status, parental status, income, metropolitan area, and self-rated health.ResultsThe presence of a disability positively associates with the likelihood of seeking medical care on an average day. Patients with disabilities spend more total time in medical care than patients without disabilities as a result of longer clinical and travel time. These differences cannot be explained by sociodemographic disparities or by poorer self-rated health.ConclusionsPatient time burden is exacerbated by the presence of a disability. It is important to consider disability status along with other social disparities when evaluating the delivery of timely and equitable care.     

Systems of care among children and youth with special health care needs with and without adverse childhood events: National Survey of Children's Health 2016–2017

BackgroundKnowledge of adverse childhood events (ACEs), the associated access to healthcare and unmet needs among children and youth with special health care needs (CYSHCN) is limited.ObjectivesOur objectives were to compare the likelihood of CYSHCN versus non-CYSHCN experiencing one or more ACEs and document differences in receipt of recommended and needed health care among CYSHCN with and without ACEs.MethodsWe combined two years of data from the 2016 and 2017 National Survey of Children's Health (N = 71,181), providing a sample of 16,304 CYSHCN. Our primary outcome measures included eight adverse childhood events, compared to singular and aggregated ACEs among non-CYSHCN. We calculated associations between ACEs and secondary outcome measures for six components of well-functioning systems of care and unmet need for different types of health care using bivariate and multivariate analyses.ResultsCYSHCN were more likely to have each of the ACEs measured and were likelier to experience aggregated levels of ACEs compared to non-CYSHCN. The likelihood of CYSHCN having a medical home with family-centered and coordinated care decreased with increased ACEs, while one or more ACES increased the likelihood of having unmet needs for mental health care.ConclusionThe findings of the current study extend our understanding of the additional adverse event burden associated with special health care needs status, the accompanying limitations in access to family-centered and coordinated care in a medical home and unmet need for mental health care, indicating that much work remains in establishing appropriate care systems for this very vulnerable population.     

Barriers to Improving Patient Safety in India: Focus Groups with Providers in the Southern State of Kerala

Objective:To understand the perceptions of health care providers about barriers to improved patient safety in the Indian state of Kerala.Setting:One rural primary care clinic, one secondary care hospital and one tertiary care center in Kerala, India.Participants:16 doctors and 20 nurses participated in five focus groups.Results:Overall, there were 129 unique mentions of barriers to patient safety; these barriers were categorized into five major themes. ‘Limited resources’ was the most prominent theme, followed by barriers related to health systems issues, the medical culture, provider training and patient education/awareness.Conclusions:Although inadequate resources are likely a substantial challenge to the improvement of patient safety in India, other patient safety barriers such as health systems changes, training, and education, could be addressed with fewer resources. While initial approaches to improving patient safety in India and other low- and middle-income countries have focused on implementing processes that represent best practices, this study suggests that multifaceted interventions to also address more structural problems (such as resource constraints, systems issues, and medical culture) may be important.     

A Randomized Controlled Trial on Teaching Geriatric Medical Decision Making and Cost Consciousness With the Serious Game GeriatriX

ObjectiveMedical students often lack training in complex geriatric medical decision making. We therefore developed the serious game, GeriatriX, for training medical decision making with weighing patient preferences, and appropriateness and costs of medical care. We hypothesized that education with GeriatriX would improve the ability to deal with geriatric decision making and also increase cost consciousness.DesignA randomized, controlled pre-post measurement design.ParticipantsFifth-year medical students.InterventionPlaying the serious game GeriatriX as an additive to usual geriatric education.MeasurementsWe evaluated the effects of playing GeriatriX on self-perceived knowledge of geriatric themes and the self-perceived competence of weighing patient preferences, appropriateness, and costs of medical care in geriatric decision making. Cost consciousness was evaluated with a postmeasurement to estimate costs of different diagnostic tests.ResultsThere was a large positive increase in the self-perceived competence of weighing patient preferences, appropriateness, and costs of medical care in the intervention group (n = 71) (effect sizes of 0.7, 1.0, and 1.2, respectively), which was significantly better for the last 2 aspects than in the control group (n = 63). The intervention group performed better on cost consciousness. Although the self-perceived knowledge increased substantially on some geriatric topics, this improvement was not different between the intervention and control groups.ConclusionsAfter playing the serious game, GeriatriX, medical students have a higher self-perceived competence in weighing patient preferences, appropriateness, and costs of medical care in complex geriatric medical decision making. Playing GeriatriX also resulted in better cost consciousness. We therefore encourage wider use of GeriatriX to teach geriatrics in medical curricula and its further research on educational and health care outcomes.     

Understanding the Costs of Care for Cystic Fibrosis: An Analysis by Age and Health State

ObjectivesCystic fibrosis (CF) is an inherited disease that requires more intensive treatments as the disease progresses. Recent medical advancements have improved survival but have also increased costs. Our lack of understanding on the relationship between disease severity and lifetime health care costs is a major impediment to the timely economic assessment of new treatments.MethodsUsing data from three waves of the Australian Cystic Fibrosis Australia Data Registry, we estimate the annual costs of CF care by age and health state. We define health states on the basis of annual lung-function scores and patient’s organ transplant status. We exploit the longitudinal nature of the data to model disease progression, and we use this to estimate lifetime health care costs.ResultsThe mean annual health care cost for treating CF is US $15,571. Costs for patients with mild, moderate, and severe disease are US $10,151, US $25,647, and US $33,691, respectively. Lifetime health care costs are approximately US $306,332 (3.5% discount rate). The majority of costs are accounted for by hospital inpatients (58%), followed by pharmaceuticals (29%), medical services (10%), complications (2%), and diagnostic tests (1%).ConclusionsOur study is the first of its kind using the Australian Cystic Fibrosis Data Registry, and demonstrates the utility of longitudinal registry data for the purpose of economic analysis. Our results can be used as an input to future economic evaluations by providing analysts with a better understanding of the long-term cost impact when new treatments are developed.     

Which Components of Medical Homes Reduce the Time Burden on Families of Children with Special Health Care Needs?

ObjectivesTo examine which components of medical homes affect time families spend arranging/coordinating health care for their children with special health care needs (CSHCNs) and providing health care at home.ConclusionsThree of the five medical home components were associated with lower family time burdens arranging/coordinating and providing health care for children with chronic conditions. If the 55 percent of CSHCNs lacking medical homes had one, the share of families with time burdens arranging care could be reduced by 13 percent.