Does time pressure create barriers for people to receive preventive health services?

ObjectiveRegular use of recommended preventive health services can promote good health and prevent disease. However, individuals may forgo obtaining preventive care when they are busy with competing activities and commitments. This study examined whether time pressure related to work obligations creates barriers to obtaining needed preventive health services.MethodsData from the 2002–2010 Medical Expenditure Panel Survey (MEPS) were used to measure the work hours of 61,034 employees (including 27,910 females) and their use of five preventive health services (flu vaccinations, routine check-ups, dental check-ups, mammograms and Pap smear). Multivariable logistic regression analyses were performed to test the association between working hours and use of each of those five services.ResultsIndividuals working long hours (> 60 per week) were significantly less likely to obtain dental check-ups (OR = 0.81, 95% CI: 0.72–0.91) and mammograms (OR = 0.47, 95% CI: 0.31–0.73). Working 51–60 h weekly was associated with less likelihood of receiving Pap smear (OR = 0.67, 95% CI: 0.46–0.96). No association was found for flu vaccination.ConclusionsTime pressure from work might create barriers for people to receive particular preventive health services, such as breast cancer screening, cervical cancer screening and dental check-ups. Health practitioners should be aware of this particular source of barriers to care.     

Do individuals respond to cost-sharing subsidies in their selections of marketplace health insurance plans?

The Affordable Care Act (ACA) provides assistance to low-income consumers through both premium subsidies and cost-sharing reductions (CSRs). Low-income consumers’ lack of health insurance literacy or information regarding CSRs may lead them to not take-up CSR benefits for which they are eligible. We use administrative data from 2014 to 2016 on roughly 22 million health insurance plan choices of low-income individuals enrolled in ACA Marketplace coverage to assess whether they behave in a manner consistent with being aware of the availability of CSRs. We take advantage of discontinuous changes in the schedule of CSR benefits to show that consumers are highly sensitive to the value of CSRs when selecting insurance plans and that a very low percentage select dominated plans. These findings suggest that CSR subsidies are salient to consumers and that the program is well designed to account for any lack of health insurance literacy among the low-income population it serves.     

Do sexual health services encourage teenagers to use condoms? A longitudinal study

OBJECTIVE: Sexual health services have the potential to encourage teenagers' condom use through both the free supply of condoms and counselling. This study investigated whether 15/16-year-olds who attended sexual health services used condoms more and had different beliefs about condoms compared to those who did not use these services. METHODS: First, a cross-sectional multivariate model investigated the association between service visits and condom consistency (a ratio of the number of times a condom was used to the number of times a teenager had sexual intercourse in the past year) in teenagers at age 15/16 years (n = 1013). Second, a longitudinal multivariate model examined links between service use and changes in condom-related cognitions measured at age 13/14 and age 15/16 years (n = 3432). RESULTS: Visiting a service for free condoms was linked with greater condom consistency, after controlling for attitudes towards condoms, condom purchase and other factors. Visiting a service for other purposes was associated with lower consistency. Obtaining free condoms from services predicted greater condom self-efficacy and personal responsibility, and lower negative feelings relating to sexual pleasure when condoms were used. However, visiting a service for other purposes predicted less positive attitudes towards dual protection. CONCLUSIONS: Obtaining free condoms from services was associated with greater condom use and positive changes in attitudes towards condoms, although the role of service counselling remains unclear. Services could do more to stress the need for continued dual protection against sexually transmitted infections (STIs) when prescribing the pill.     

Does employment-based private health insurance increase the use of covered health care services? A matching estimator approach

This study estimates the effect of employment-based private health insurance (EPHI) on the use of covered health care services based on Danish survey data collected in 2009. The paper provides some of the first estimates of how EPHI affects the use of health care services in a Scandinavian context. The effect of EPHI is estimated using propensity score matching. This method is shown to provide plausible estimates given the institutional setting of EPHI in Denmark and a wide set of relevant covariates. Considering the full sample of occupationally active, it is found that EPHI does not significantly affect the probability of having had any hospitalisations, physiotherapist, chiropractor, psychologist, specialist, or ambulatory contacts within a 12 month period. Restricting the analysis to the subsample of privately employed, the estimated effects for ambulatory contacts and hospitalisation are somewhat higher and statistically significant. More precisely, it is found that EPHI increases the probability of hospitalisation from 5.1 to 8.5% and the probability of having had any ambulatory contacts from 17.9 to 23.3% among the privately employed.     

Do family-planning workers in China support provision of sexual and reproductive health services to unmarried young people?

OBJECTIVE: To ascertain the perspectives of family-planning service providers in eight sites in China on the provision of sexual and reproductive health services to unmarried young people. METHODS: Data were drawn from a survey of 1927 family-planning workers and 16 focus group discussions conducted in eight sites in China in 1998-99. FINDINGS: Family-planning workers recognized the need to protect the sexual health of unmarried young people and were unambiguous about the need for government agencies to provide information and education on sexual and reproductive health to unmarried young people; however, perceptions about the appropriate age for and content of such education remained conservative. While about 70% of family-planning workers were willing to provide contraceptives to unmarried young people, and about 60% approved government provision of contraceptive services to unmarried young people, only one quarter agreed that the services could be extended to senior high schools. CONCLUSION: Family-planning workers in China are ambivalent about the provision of sexual and reproductive health services to unmarried young people, which potentially poses a significant obstacle to the adoption of safe sex behaviours by young people, as well as to the provision of sexual and reproductive health information and services to young unmarried people in China. Training programmes for family-planning workers are urgently needed to address this issue.     

Do people value their own future health differently from others' future health?

The purpose of this study was to investigate whether time preferences for own health are the same as time preferences for others' health. A random sample of the general public was sent a postal questionnaire containing six choices between ill health in the near future and ill health in the further future. They were asked to indicate the maximum duration of more distant ill health they would be willing to accept in return for a specified delay in the onset of the period of ill health. For half of the sample the questions were set in the context of their own health and for the other half in terms of others' health. The median implied discount rates were not statistically different, 0.061 for own health and 0.062 for others' health. A multilevel analysis of the determinants of these implied discount rates provided additional evidence of the similarity of time preferences for own health and others' health.     

Change in quality of life of people with stroke over time: True change or response shift?

In many studies, assessments of change in self-report measures such as health-related quality of life must account for potential response shift, including reconceptualization and changes in internal standards of measurement. Objective: The objective of our study was to compare healthy controls and individuals with stroke on the extent to which changes in internal standards and reconceptualization of health related quality of life (HRQL) occurs over the first 6 months post-stroke. Methods: Confirmatory factor analysis was used to assess invariance of the SF-36 measurement model over time among 238 individuals with stroke and 392 controls, separately. This procedure assessed changes over time in the factor loadings, variances, and covariances of responses, and compared the extent of change between individuals with stroke and those in the control group. In addition a multisample comparison was made between individuals with stroke and members of the control group at the first evaluation in order to assess invariance of the SF-36 measurement model between the groups. The controls were considered to be a proxy for the stroke cohort prior to the stroke. Results: We found no evidence of reconceptualization and changes in internal standards over time when the groups were assessed separately. There was a significant difference in the factor covariances (reconceptualization) between the two groups at the time of the first evaluation. However, measurement error was also significant for this comparison. Conclusion: This study indicates that the improvement in HRQL over time is real rather than a result of reconceptualization or a recalibration. If response shift does occur with stroke it is likely to be mediated by the event itself and not the recovery process.     

Social class inequalities in the use of and access to health services in Catalonia, Spain: what is the influence of supplemental private health insurance?

OBJECTIVE: To analyse social class inequalities in the access to and utilization of health services in Catalonia (Spain), and the influence of having private health insurance supplementing the National Health System (NHS) coverage. DESIGN: 1994 Catalan Health Interview Survey, a cross-sectional survey conducted in 1994. SETTING: Catalonia (Spain). STUDY PARTICIPANTS: The participants were a representative sample of people aged over 14 years from the non-institutionalized population of Catalonia (n = 12,245). MAIN OUTCOME MEASURES: Health services utilization, perceived health, having only NHS or NHS plus a private health insurance, and social class. RESULTS: Although one-quarter of the population of Catalonia had a supplemental private health insurance, percentages were very different according to social class, ranging from almost 50% for classes I and II to 16% for classes IV and V in both sexes. No inequalities by social class were observed for the utilization of non-preventive health care services (consultation with a health professional in the last 2 weeks and hospitalization in the last year) among persons with poor self-perceived health status, i.e. those in most need. However, social inequalities still remain in the use of health services provided only partially by the NHS, and when characteristics of last consultation are taken into account. Subjects who paid for a private service waited an average of 18.8 minutes less than those attending the NHS. Within the NHS, social classes IV and V waited longer (35.5 minutes) than social classes I and II (28.4 minutes). CONCLUSION: The NHS in Catalonia, Spain, has reduced inequalities in the use of health services. Social inequalities remain in the use of those health services provided only partially by the NHS.     

What determines the use of home care services by elderly people?

The objective of the present study was to investigate the determinants of use of statutory and private home care services by older people living in the community. A questionnaire was distributed to a stratified random sample of 2,000 elderly people living in the community registered with 11 general practices in a British city (equal numbers of men and women, aged 65-74 years, and 75 years or over). The outcome measures were the use of statutory or private home care services in the previous 3 months. Logistic regression was used to explore potential determinants of the use of these services. The response rate was 79%. Increasing age, not owning a car and being a widow(er) were associated with greater use of both statutory and private home care services, as was worse self-reported overall health. Worse physical functioning, worse emotional health, problems with cognition, foot problems and a greater number of falls were determinants of use of statutory and private services. Older age on leaving full-time education was associated with increased use of private home care services. Problems with eyesight were determinants for both types of home care services for women, but only private services for men. For women, leakage of urine was associated with greater use of private services. Social networks and social support were not generally associated with use of these services after controlling for demographic factors. Understanding the determinants for the use of both statutory and private home care services is important because of the increasing numbers of elderly people in the population and the policy to maintain older people in their own homes. Purchasers and providers should be able to address at least some of the modifiable predictors.     

Do socioeconomic gradients in women's health widen over time and with age?

A population-based study was conducted to investigate changes over time in women's well-being and health service use by socio-economic status and whether these varied by age. Data from 12,328 mid-age women (aged 45-50 years in 1996) and 10,430 older women (aged 70-75 years) from the Australian Longitudinal Study on Women's Health were analysed. The main outcome measures were changes in the eight dimensions of the Short Form General Health Survey (SF-36) adjusted for baseline scores, lifestyle and behavioural factors; health care utilisation at Survey 2; and rate of deaths (older cohort only). Cross-sectional analyses showed clear socioeconomic differentials in well-being for both cohorts. Differential changes in health across tertiles of socioeconomic status (SES) were more evident in the mid-age cohort than in the older cohort. For the mid-aged women in the low SES tertile, declines in physical functioning (adjusted mean change of -2.4, standard error (SE) 1.1) and general health perceptions (-1.5, SE 1.1) were larger than the high SES group (physical functioning -0.8 SE 1.1, general health perceptions -0.8 SE 1.2). In the older cohort, changes in SF-36 scores over time were similar for all SES groups but women in the high SES group had lower death rates than women in the low SES group (relative risk: 0.79, 95% confidence interval 0.64-0.98). Findings suggest that SES differentials in physical health seem to widen during women's mid-adult years but narrow in older age. Nevertheless, SES remains an important predictor of health, health service use and mortality in older Australian women.     

Do “Consumer-Directed” health plans bend the cost curve over time?

“Consumer-Directed” Health Plans (CDHPs), those with high deductibles and personal medical accounts, are intended to reduce health care spending through greater patient cost exposure. Prior research agrees that in the first year, CDHPs reduce spending. There is little research and in it results are mixed regarding the impact of CDHPs over the longer term. We add to this literature with an intent-to-treat, difference-in-differences analysis of health care spending over up to three years post CDHP offer among 13 million person-years of data from 54 large US firms, half of which offered CDHPs. To strengthen the identification, we balance observables over time within firm, by developing weights through a machine learning algorithm, generalized boosted regression. We find that spending is reduced for those in firms offering CDHPs in all three years post offer relative to firms continuing to offer lower-deductible plans. The reductions are driven by spending decreases in outpatient care and pharmaceuticals, with no evidence of increases in emergency department or inpatient care over the three-year window.     

Do Medicare HMOs still reduce health services use after controlling for selection bias?

This study models the relationship between Medicare beneficiary decisions to join Medicare HMOs and subsequent health services utilization. The relationship between health plan choice and utilization is thought to be endogenous because of favorable selection into HMOs. Previous studies found significantly lower inpatient utilization among Medicare HMO enrollees than among nonenrollees, but lacked strong controls for selection bias. Thus, a firm conclusion could not be drawn as to whether the observed differences were attributable to the HMO practice setting or to baseline differences in the illness profiles of the two groups studied. The present study uses simultaneous equations methods, including discrete factor estimation, to test the effect of Medicare HMOs on utilization when strong controls for selection bias are imposed. The model was run on a panel of 1993-1996 data from the Medicare Current Beneficiary Survey, supplemented with linked data on Medicare HMO characteristics and area supply characteristics. The study found that even when favorable selection is controlled for, Medicare HMOs significantly reduce both the probability of hospitalization and the number of inpatient days used by those who are hospitalized. Medicare HMOs do not, however, appear to reduce the use of physician services.