The Impact of Private Insurance Coverage on Veterans' Use of VA Care: Insurance and Selection Effects

Objective. To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage.
Data Sources. The 1999 National Health Survey of Veteran Enrollees merged with VA administrative data, with other information drawn from American Hospital Association data and the Area Resource File.
Study Design. We modeled VA enrollees' decision of having private insurance coverage and its impact on use of VA care controlling for sociodemographic information, patients' health status, VA priority status and access to VA and non-VA alternatives. We estimated the true impact of insurance on the use of VA care by teasing out potential selection bias. Bias came from two sources: a security selection effect (sicker enrollees purchase private insurance for extra security and use more VA and non-VA care) and a preference selection effect (VA enrollees who prefer non-VA care may purchase private insurance and use less VA care).
Principal Findings. VA enrollees with private insurance coverage were less likely to use VA care. Security selection dominated preference selection and naïve models that did not control for selection effects consistently underestimated the insurance effect.
Conclusions. Our results indicate that prior research, which has not controlled for insurance selection effects, may have underestimated the potential impact of any private insurance policy change, which may in turn affect VA enrollees' private insurance coverage and consequently their use of VA care. From the decline in private insurance coverage from 1999 to 2002, we projected an increase of 29,400 patients and 158 million dollars for VA health care services.     

Early Impact of the Affordable Care Act on Health Insurance Coverage of Young Adults

Research Objective

To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parent''s private health plan. Nearly one-in-three young adults lacked coverage before the ACA.

Study Design, Methods, and Data

Data from the Current Population Survey 2005–2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws.

Principal Findings

This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law.

Conclusions and Implications

ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.     

The Compliance of End-of-Life Care Preferences Among Older Adults and Its Facilitators and Barriers: A Scoping Review

ObjectivesTo explore the compliance of end-of-life (EOL) care preferences, and the facilitators and barriers of promoting quality of EOL care among older adults.DesignA scoping review was used to identify key themes in the compliance of EOL care preferences among older adults.Setting and participantsStudies published between 2009 and 2020 were identified from the Medline and Cochrane libraries. Eligible articles containing components related to the compliance of EOL care preferences among older adults were selected.MeasuresThe eligible articles were thematically synthesized. Factors that affected the compliance of EOL care preferences among older adults were identified from the key components.ResultsIn total, 35 articles were included to identify the key components in the compliance of EOL care preferences: (1) supportive policy, (2) supportive environment, (3) cultural characteristics, (4) advance care planning (ACP), (5) the concordance of EOL care preferences between patients and surrogate decision makers, (6) prognosis awareness, and (7) patient's health status and the type of disease. Facilitators for the compliance of EOL care preferences included enactment of relevant policy, sufficient care institutions, the utilization of ACP, and poor health status. Barriers included lack of supportive policy, different culture, and low utilization of ACP.Conclusions/ImplicationsThe compliance of EOL care preferences was low among older adults. The compliance of EOL care preferences can be improved through relevant policy development and the utilization of ACP.     

上海市长期护理保险服务提供现状及监管对策分析

目的:梳理当前上海市长期护理保险服务提供现状,并从服务环节涉及的各个主体及其相互之间的关系入手,为切实提高服务质量提供可行的监管对策。方法:运用政策梳理、二次数据采集以及与关键知情人访谈的方法,为评价长期护理保险服务环节的成效、经验及潜在监管问题提供证据支撑。结果:截至2020年底,上海市长期护理保险共服务失能老人55.58万人,每千名户籍老人可拥有10.25个养老护理员(医疗照护)。制度设计中各类服务标准规范、细则和惩罚措施还不够完善,监管APP的功能有待进一步强化。结论:对服务提供方增加规制并为护理机构赋权,同时,积极引入视频监控、RFID电子标签等新技术,充分发挥信息化监管的力量。     

Effects of Global Budgeting on the Distribution of Dentists and Use of Dental Care in Taiwan

Objective. To examine the effects of global budgeting on the distribution of dentists and the use and cost of dental care in Taiwan.
Data Sources. (1) Monthly dental claim data from January 1996 to December 2001 for the entire insured population in Taiwan. (2) The 1996–2001 population information for the cities, counties and townships in Taiwan, abstracted from the Taiwan-Fukien Demographic Fact Book .
Study Design. Longitudinal, using the autocorrelation model.
Principal Findings. Results indicated decline in dental care utilization, particularly after the implementation of dental global budgeting. With few exceptions, dental global budgeting did not improve the distribution of dental care and dentist supply.
Conclusions. The experience of the dental global budget program in Taiwan suggested that dental global budgeting might contain dental care utilization and that several conditions might have to be met in order for the reimbursement system to have effective redistributive impact on dental care and dentist supply.     

Dental Care in Programs of All-Inclusive Care for the Elderly: Organizational Structures and Protocols

ObjectivesThis study uses a national model of community-based long-term services and supports, the Program of All-inclusive Care for the Elderly (PACE), to identify organizational structures and protocols that can facilitate the delivery of dental examinations.DesignWe developed an online survey instrument and conceptual model for this study representing 10 domains believed to characterize a quality PACE dental program.Setting and ParticipantsThe Qualtrics survey was distributed nationally to all 124 PACE programs in the 31 states PACE was available. Respondents in this study represented 35 programs (program response rate = 28.2%) in 23 states (state response rate = 74.2%).MethodsSelected independent variables from each of the 10 domains were tested against the reported delivery of dental examinations variable using the Kendall τ and χ². Twenty-nine programs were included in the final analysis.ResultsMost programs mandated a dental examination within 31–60 days of enrollment (63.6%). Few programs had a dental manual (15.6%) or any quality assurance for dental care (32.3%). A majority of programs (58.8%) stated that they had a protocol for enrollees to receive a cleaning every 6–12 months. Having a system for quality assurance for dental care, protocol for a cleaning every 6–12 months, mandating a comprehensive dental examination and providing preventive dental services onsite with built-in equipment, were all statistically associated with a higher reported delivery of dental examinations.Conclusion and ImplicationsOrganizations providing long-term services and supports, including PACE, can use these identified domains to develop minimal standards to ensure dental care is part of innovative models of community-based long-term services and supports. Implementing these domains can facilitate effective delivery of dental examinations that have the potential to support positive oral health and general health outcomes.     

The Impact of a Primary Care Telepsychiatry Program on Outcomes of Managed Care Older Adults

ObjectiveThe goal of this study was to assess the outcomes of a primary-based telepsychiatry intervention program for older managed care enrollees with depression/anxiety and with limited access to in-person psychiatric care.DesignA pre-post design was used to examine service use (n = 218) and severity of depression (n = 204). Enrollment, claims, and depression and anxiety score data were obtained from the medical group. The implementation process and self-reported outcomes were examined.Setting and ParticipantsThe program was funded by the Senior Care Action Network (SCAN) group and implemented by a large medical group serving older adults who were identified as needing outpatient psychiatric care, including those with psychiatric hospitalizations, depression/anxiety disorders, comorbid substance use disorders, or other multiple comorbidities.MethodsPoisson regressions were used to examine changes in predicted rates of outpatient services, emergency department visits, and hospitalizations up to 24 months prior and 24 months following the first telepsychiatry visit. Changes in predicted severity of depression up to 2 quarters prior and 3 quarters following the first telepsychiatry visit were examined.ResultsThe number of outpatient services declined significantly by 0.24 per patient per 6-month time frame following the first telepsychiatry visit. The number of emergency department visits and hospitalizations also declined after the first visit (0.07 and 0.03 per patient per 6-month time frame, respectively). Depression severity scores also declined in the quarters following the first visit (1.52). The medical group reported improvements in both wait time for appointments and no-show rates with the integration of telepsychiatry in primary care.Conclusions and ImplicationsThe telepsychiatry program lowered service use, depression severity, and increased better access to psychiatry care. The findings highlight the potential benefits of sustaining and expanding the telepsychiatry program by SCAN and other plans facing a limited supply of psychiatrists.     

Access to Health Insurance and Utilization of Substance Use Disorder Treatment: Evidence from the Affordable Care Act Dependent Coverage Provision

The relationship between insurance coverage and use of specialty substance use disorder (SUD) treatment is not well understood. In this study, we add to the literature by examining changes in admissions to SUD treatment following the implementation of a 2010 Affordable Care Act provision requiring health insurers to offer dependent coverage to young adult children of their beneficiaries under age 26. We use national administrative data on admissions to specialty SUD treatment and apply a difference‐in‐differences design to study effects of the expansion on the rate of treatment utilization among young adults and, among those in treatment, changes in insurance status and payment source. We find that admissions to treatment declined by 11% after the expansion. However, the share of young adults covered by private insurance increased by 5.4 percentage points and the share with private insurance as the payment source increased by 3.7 percentage points. This increase was largely offset by decreased payment from government sources. Copyright © 2017 John Wiley & Sons, Ltd.     

Quality of End-of-Life Care for Older Adults with Dementia during the COVID-19 Pandemic

ObjectivesEnd-of-life (EOL) care during the coronavirus disease 2019 (COVID-19) pandemic has been a concern under the overwhelming pressure of health care service systems. People with dementia often receive suboptimal EOL care; thus, they may be at particular risk of poor care quality during the COVID-19 pandemic. This study investigated the interaction between dementia and pandemic on the proxies’ overall ratings and ratings for 13 indicators.DesignA longitudinal study.Setting and ParticipantsData were collected from 1050 proxies for deceased participants in the National Health and Aging Trends Study, a nationally representative sample of community-dwelling Medicare beneficiaries aged ≥65 years. Participants were included if they had died between 2018 and 2021.MethodsParticipants were categorized into 4 groups depending on the period of death (before vs during the COVID-19 pandemic) and having no vs probable dementia, as defined by a previously validated algorithm. The quality of EOL care was assessed through postmortem interviews with bereaved caregivers. Multivariable binomial logistic regression analyses were performed to examine the main effects of dementia and pandemic period, and the interaction between dementia and pandemic on ratings of quality indicators.ResultsA total of 423 participants had probable dementia at the baseline. People with dementia who died were less likely to talk about religion in the last month of life than those without dementia. Decedents during the pandemic were more likely to have an overall rating of care as being not excellent than those before the onset of the pandemic. However, the interaction between dementia and pandemic was not significant in the 13 indicators and the overall rating of EOL care quality.Conclusion and ImplicationsMost EOL care indicators preserved the level of quality, regardless of dementia and the COVID-19 pandemic. Disparities in spiritual care may exist across people with and without dementia.     

The Effect of Medicaid on Health Care Consumption of Young Adults

All states provide Medicaid until the age of 19 years. After 19 years, young adults may become ineligible for Medicaid. Using the Medical Expenditure Panel Survey, we find that the resulting loss of Medicaid coverage causes substantial changes to the level and composition of health care use. The total number of visits to health care providers falls by over 60%, two‐thirds of which is due to a decline in office visits. Expenditures, in particular inpatient expenditures, also appear to fall sharply. Copyright © 2014 John Wiley & Sons, Ltd.     

Determinants of Post-acute Care Costs in Acutely Hospitalized Older Adults: The Hospital-ADL Study

ObjectivesAfter hospitalization, many older adults need post-acute care, including rehabilitation or home care. However, post-acute care expenses can be as high as the costs for the initial hospitalization. Detailed information on monthly post-acute health care expenditures and the characteristics of patients that make up for a large share of these expenditures is scarce. We aimed to calculate costs in acutely hospitalized older patients and identify patient characteristics that are associated with high post-acute care costs.DesignProspective multicenter cohort study (between October 2015 and June 2017).Setting and participants401 acutely hospitalized older persons from internal medicine, cardiology, and geriatric wards.MeasurementsOur primary outcome was mean post-acute care costs within 90 days postdischarge. Post-acute care costs included costs for unplanned readmissions, home care, nursing home care, general practice, and rehabilitation care. Three costs categories were defined: low [0-50th percentile (p0-50)], moderate (p50-75), and high (p75-100). Multinomial logistic regression analyses were conducted to assess the associations between costs and frailty, functional impairment, health-related quality of life, cognitive impairment, and depressive symptoms.ResultsCosts were distributed unevenly in the population, with the top 10.0% (n = 40) accounting for 52.1% of total post-acute care costs. Mean post-acute care costs were €4035 [standard deviation (SD) 4346] or $4560 (SD 4911). Frailty [odds ratio (OR) 3.44, 95% confidence interval (CI) 1.78-6.63], functional impairment (OR 1.80, 95% CI 1.03-3.16), and poor health-related quality of life (OR 1.89, 95% CI 1.09-3.28) at admission were associated with classification in the high-cost group, compared with the low-cost group.Conclusions/ImplicationsPost-acute care costs are substantial in a small portion of hospitalized older adults. Frailty, functional impairment, and poor health-related quality of life are associated with higher post-acute care costs and may be used as an indicator of such costs in practice.     

医保费用总额控制支付方式的实施效果分析

为了评价医保费用总额控制对医药费用及医疗机构经济运行的影响,文章选取了四川省若干家具有代表性的医疗机构,对实施总额控制的医疗机构和未实施总额控制的医疗机构进行对比。结果表明,总额控制下,费用控制效果不明显,且在一定程度上影响了医疗质量,限制了医疗机构的发展。在完善总额控制方面,应建立结余共享及风险共担制度,逐步实现由后付制向预付制转变。     

The Effect of Medicaid Managed Care on Prenatal Care: The Case of Puerto Rico

Objectives From 1994 to the year 2000 the government of Puerto Rico implemented a health care reform which included the mandatory enrollment of the entire Medicaid eligible population under Medicaid managed care (MMC) plans. This study assessed the effect of MMC on the use, initiation, utilization, and adequacy of prenatal care services over the reform period. Methods Using the vital records of all infants born alive in Puerto Rico from the year 1995–2000, a series of bivariate and multivariate analyses were conducted to assess the effect of insurance status (traditional Medicaid, MMC, private insurance and uninsured) on prenatal care utilization patterns. In order to assess the potential influence of selection bias in generating the health insurance assignments, propensity scores (PS) were estimated and entered into the multivariate regressions. Results MMC had a generally positive effect on the frequency and adequacy of prenatal care when compared with the experience of women covered by traditional Medicaid. However, the PS analyses suggested that self-selection may have generated part of the observed beneficial effects. Also, MMC reduced but did not eliminate the gap in the amount and adequacy of prenatal care received by pregnant women covered by Medicaid when compared to their counterparts covered by private insurance. Conclusions The Puerto Rico Health Reform to implement MMC for pregnant women was associated with a general improvement in prenatal care utilization. However, continued progress will be necessary for women covered by Medicaid to reach prenatal care utilization levels experienced by privately insured women.