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Biomedical subjects

P J Cunningham

Publications and source records attributed to P J Cunningham.

At least 19 recordsLinked to original sources
PubMed2001

Does managed care enable more low income persons to identify a usual source of care? Implications for access to care.

BACKGROUND: By requiring or encouraging enrollees to obtain a usual source of care, managed care programs hope to improve access to care without incurring higher costs. OBJECTIVES: (1) To examine the effects of managed care on the likelihood of low-income persons having a usual source of care and a usual physician, and; (2) To examine the association between usual source of care and access. RESEARCH DESIGN: Cross-sectional survey of households conducted during 1996 and 1997. SUBJECTS: A nationally representative sample of 14,271 low-income persons. MEASURES: Usual source of care, usual physician, managed care enrollment, managed care penetration. RESULTS: High managed care penetration in the community is associated with a lower likelihood of having a usual source of care for uninsured persons (54.8% vs. 62.2% in low penetration areas) as well as a lower likelihood of having a usual physician (60% vs. 72.8%). Managed care has only marginal effects on the likelihood of having a usual source of care for privately insured and Medicaid beneficiaries. Having a usual physician substantially reduces unmet medical needs for the insured but less so for the uninsured. CONCLUSIONS: Having a usual physician can be an effective tool in improving access to care for low-income populations, although it is most effective when combined with insurance coverage. However, the effectiveness of managed care in linking more low-income persons to a medical home is uncertain, and may have unintended consequences for uninsured persons.

Adult↗
PubMed2001

What accounts for differences in uninsurance rates across communities?

Using data from the 1996-97 Community Tracking Study household survey, this study examines variations in uninsurance rates across communities in the United States. Specifically, regression-based decomposition is used to identify factors that account for high rates of uninsurance in some communities. Differences in explained rates between "high uninsurance" and "low uninsurance" communities are the result of differences in the racial/ethnic composition and socioeconomic status of the population (33%), differences in employment characteristics (26%), and state Medicaid eligibility requirements (12.7%). Although higher costs are associated with a higher likelihood that individuals are uninsured, high-cost communities tend to have lower rates of uninsurance as a result of other factors. Despite the large number of identifiable factors included in the analysis, there is still a substantial amount of unexplained regional variation in uninsurance rates.

Adult↗
PubMed2001

Physicians pulling back from charity care.

Physicians have long provided care to the medically indigent for free or at reduced rates. However, recent findings from the Center for Studying Health System Change (HSC) indicate that the proportion of physicians providing charity care dropped from 76 percent to 72 percent between 1997 and 1999. In the short term, most medically indigent people are still getting care. But policy makers should take note that reduced physician participation in charity care will hurt the poor if-as projected-growth in physician supply slows and the number of uninsured rises along with escalating health care costs. This Issue Brief discusses the extent of the decline in physician provision of charity care, the reasons for the decline and implications for the future of the safety net.

Forecasting↗
PubMed2001

Racial and ethnic differences in access to medical care in managed care plans.

OBJECTIVE: To examine the extent to which access differences between racial/ethnic minorities and whites in managed care plans are greater than such differences in other types of health plans. DATA SOURCE: A nationally representative sample of 4,811 African American, 3,379 Hispanic, and 33,737 white nonelderly persons with public or private health insurance. STUDY DESIGN/DATA COLLECTION: A cross-sectional survey of households was conducted during 1996 and 1997. Commonly used measures of access to and utilization of medical care were constructed for individuals: (1) percentage of visits with a usual provider, (2) percentage with a regular provider, (3) visit with a physician in the past year, (4) hospital ER use, (5) last visit was to a specialist. PRINCIPAL FINDINGS: Fewer than 74 percent of Hispanics and African Americans had a regular provider compared to more than 78 percent of white Americans. Hispanics were least likely to have had their last doctor visit with a specialist (22 percent) compared to African Americans (26 percent) and whites (28 percent). Differences between ethnic/racial minorities and whites in managed care plans are similar to differences observed in non-managed care plans. Americans of all racial and ethnic backgrounds in managed care plans with gatekeeping are more likely to have a usual source of care, a regular provider, and lower use of specialists compared to persons in plans without gatekeeping. CONCLUSION: Although greater access to primary care was shown among African Americans and Hispanics in managed care plans, the extent of the disparities between racial/ethnic minorities and whites in managed care is similar to disparities in other types of health plans.

Black or African American↗
PubMed2000

Recent trends in children's health insurance coverage: no gains for low-income children.

The percentage of low-income children who have health insurance has not changed over the last few years, despite expansions in public coverage through Medicaid and the State Children's Health Insurance Program (SCHIP). Data from 1996-1997 and 1998-1999 from the Center for Studying Health System Change (HSC) find that while the proportion of low-income children with public coverage has increased, the percentage with private insurance coverage has decreased sharply, resulting in no net change in the percentage who are uninsured. This Issue Brief describes these recent changes in public and private coverage. Possible factors that may explain these changes are discussed, including increases in private insurance premiums, substitution of public for private coverage and changes in the characteristics of low-income persons. The study did not determine conclusively the causes of the changes in coverage.

Child↗
PubMed1999

The case of disability in the family: impact on health care utilization and expenditures for nondisabled members.

Families with a disabled member undergo heightened emotional and financial stress, which can arise from caring for the person with one or more disabilities over the life course or at the end of life. Because health care resources are strained by the needs of the disabled family member, nondisabled members are often limited in health care access and utilization when they are most in need of care. This analysis uses the National Medical Expenditure Survey to describe families with disabled members, based on multiple definitions of disability, and to examine health care utilization and expenditures by nondisabled family members. Indications of higher use of medical care by adult, nondisabled members of such families support the frequent reports in the literature of stress occurring in these situations. The signals of a household rationing effect for families near and at poverty levels should alert policy makers to consider the needs of the whole family when creating or modifying assistance programs.

Activities of Daily Living↗
PubMed1999

Pressures on safety net access: the level of managed care penetration and uninsurance rate in a community.

OBJECTIVE: To examine the effects of managed care penetration and the uninsurance rate in an area on access to care of low-income uninsured persons and to compare differences in access between low-income insured and uninsured persons across these different market areas. DATA SOURCES: Primarily the Community Tracking Study household survey. Other market-level data were obtained from the Community Tracking Study physician survey, American Hospital Association annual survey of hospitals, Area Resource File, HCFA Administrative Data, Bureau of Primary Care data on Community Health Centers. STUDY DESIGN: Individuals are grouped based on the level of managed care penetration and uninsurance rate in the site where they reside. Measures of managed care include overall managed care penetration in the site, and the level of Medicaid managed care penetration in the state. Uninsurance rate is defined as the percentage of people uninsured in the site. Measures of access include the percentage with a usual source of care, percentage with any ambulatory care use, and percentage of persons who reported unmet medical care needs. Estimates are adjusted to control for other confounding factors, including both individual and market-level characteristics. DATA COLLECTION: A survey, primarily telephoned, of households concentrated in 60 sites, defined as metropolitan statistical areas and nonmetropolitan areas. PRINCIPAL FINDINGS: Access to care for low-income uninsured persons is lower in states with high Medicaid managed care penetration, compared to uninsured persons in states with low Medicaid managed care penetration. Access to care for low-income uninsured persons is also lower in areas with high uninsurance rates. The "access gap" (differences in access between insured and uninsured persons) is also larger in areas with high Medicaid managed care penetration and areas with high uninsurance rates. CONCLUSIONS: Efforts to achieve cost savings under managed care may result in financial pressures that limit cross-subsidization of care to the medically indigent, particularly for those providers who are heavily dependent on Medicaid revenue. High demand for care (as reflected in high uninsurance rates) may further strain limited resources for indigent care, further limiting access to care for uninsured persons.

Health Services Accessibility↗
PubMed1999

Who declines employer-sponsored health insurance and is uninsured?

Twenty percent of all uninsured persons are offered health insurance by their employer or a family member's employer but choose not to enroll in the offered plan(s). Most persons who do not "take up" or enroll in available employer-sponsored coverage cite cost as the main reason why. This Issue Brief, based on two surveys conducted as part of the Center for Studying Health System Change's (HSC) Community Tracking Study, presents new findings on who declines employer-sponsored coverage and is uninsured as a result. Given the importance of cost in an individual's decision whether to enroll in employer-sponsored coverage, policy makers need to consider ways to address the problem identified by this study: low take-up rates among lower-income workers.

Age Factors↗
PubMed1998

Ability to obtain medical care for the uninsured: how much does it vary across communities?

CONTEXT: Communities differ in the way that medical care for medically indigent persons is organized and delivered, which is likely to result in differences across communities in the ability of uninsured persons to obtain medical care. Changes in the health care system, many of which are driven locally, may further exacerbate these differences. OBJECTIVE: To examine the extent of variation across US communities in the ability of uninsured persons to obtain medical care and the extent to which health status and other characteristics of the uninsured population account for these differences. DESIGN: Analysis of the 1996-1997 Community Tracking Study Household Survey. SETTING: A nationally representative sample of the US civilian, noninstitutionalized population residing in 60 randomly selected communities. Larger sample sizes were obtained for 12 of these communities, which were randomly selected to represent metropolitan areas in the United States with more than 200000 persons. PARTICIPANTS: A total of 60 446 individuals and 7200 uninsured persons. MAIN OUTCOME MEASURES: The percentage of persons who either did not obtain needed medical care in the previous year or postponed receiving needed medical care in the previous year. RESULTS: Differences between communities with the highest percentage of uninsured persons reporting difficulty obtaining care and communities with the lowest percentage were more than 2-fold (41.4% vs 18.5%, P<.05). Little of the variation across communities is accounted for by differences in health status or sociodemographic characteristics of the uninsured population. The pattern of variation across communities in the ability of uninsured persons to obtain medical care is not correlated with variations in the ability of privately insured persons to obtain care (Pearson r, 0.04). Simulation results indicate that expanding private or public insurance coverage would not only increase the ability of uninsured persons to obtain medical care but would also reduce the variation across communities. CONCLUSIONS: If people are uninsured, where they live is an important factor in determining the difficulty they have in obtaining care. This is likely to persist given that care for uninsured persons is driven largely by state and local policy, and health system changes are constraining clinicians' ability and willingness to serve uninsured persons in many parts of the country.

Data Collection↗
PubMed1998

Next steps in incremental health insurance expansions: who is most deserving?

President Clinton's proposal to allow near-elderly individuals--those between the ages of 55 and 64--to buy-in to Medicare is the latest initiative to expand health insurance coverage incrementally by targeting particular age groups. Health insurance expansions for children were passed last year, and assistance to young adults--those age 19 to 24--has also been discussed. The rationale for targeting individuals in these age groups is that they are presumed to be vulnerable. However, vulnerability to uninsurance includes not only the risk of being uninsured, but also the potential health and financial consequences that result from not having coverage, each of which varies substantially across age groups. This Issue Brief examines the vulnerability of the near-elderly and young adults with respect to uninsurance.

Adult↗
PubMed1998

CHIPing away at the problem of uninsured children.

The State Children's Health Insurance Program (CHIP), enacted one year ago this August, is the largest expansion of health insurance in more than three decades. One of the measures of its success will be whether state officials are able to enroll children who are eligible. Research conducted by Health System Change (HSC) shows that uninsured children are a diverse group, and that for CHIP to be successful, policy makers will need to target programs to specific groups and local market conditions. This Issue Brief discusses why children lack health insurance and the implications for implementing CHIP.

Budgets↗
PubMed1998

The uninsured getting care: where you live matters.

A substantial number of Americans--41 million people--do not have health insurance; this represents a 16 percent increase in the uninsured since 1990. Further, many studies show that the uninsured have significantly more difficulty than the insured in getting needed care. This Issue Brief discusses Health System Change (HSC) findings from its Community Tracking Study showing that the ability of those without coverage to get needed care varies considerably across communities. In addition, HSC's study shows that the personal characteristics of the uninsured explain very little of this regional variation. These findings are the first step in helping decision makers understand how the dynamics of communities and the safety nets within them affect the medically indigents' ability to obtain needed care.

Community Health Services↗
PubMed1996

Determinants of ambulatory mental health services use for school-age children and adolescents.

OBJECTIVE: To analyze a comprehensive multivariate model of the use of mental health-related ambulatory care services by children ages 6-17. STUDY SETTING: The 1987 National Medical Expenditure Survey, a national probability sample of the U.S. civilian noninstitutionalized population. STUDY DESIGN: A cross-sectional survey of a national probability sample of the U.S. population. Key independent variables include person-level mental health status, health care coverage, family income, and use of mental health services by other family members. DATA COLLECTION: Four in-person interviews were conducted during 1987 using structured questionnaires. A designated family respondent was used to answer questions for other family members, including children. PRINCIPAL FINDINGS: Children with poor mental health in high-income families were more than three times as likely to have a mental health-related visit than children with poor mental health in low-income families. The number of mental health-related visits and the likelihood of seeing a mental health specialist also increased along with family income. Mental health use by other family members was strongly associated with use. CONCLUSIONS: The results from this study provide strong evidence that the socioeconomic status of children is an important factor in explaining unmet need for mental health services.

Adolescent↗
PubMed1995

Access to ambulatory care for American Indians and Alaska Natives; the relative importance of personal and community resources.

The debate on health care reform in the United States has been greatly influenced by various national studies showing a strong relationship between lack of public or private health care coverage and inadequate access to health services. There is also much concern about deficiencies in the availability and delivery of services to certain population groups--especially for those living in the most remote and sparsely populated areas of the country. However, national studies have generally not demonstrated that the use of health services is strongly associated with urban/rural residence or the supply of medical providers. In this study, we show that national studies can obscure the problems of certain population groups including American Indians and Alaska Natives. Using data from the 1987 National Medical Expenditure Survey, the findings show that the availability of medical providers as well as place of residence were strongly associated with the use of health care by American Indians and Alaska Natives. Although American Indians and Alaska Natives included in this study were eligible to receive health care free of charge from the Indian Health Service (IHS), financial factors were also significantly associated with use due to the use of services other than those provided or sponsored by IHS. Also, the results show that while geographic and supply factors have only modest effects on the average travel time to medical providers for the U.S. population as a whole, travel times are dramatically longer for American Indians and Alaska Natives living in rural areas and where there are few medical providers. In addition, there appear to be fewer hospitalizations in areas where there are IHS outpatient services. We conclude by discussing the need for health care reform to take into account the diversity of a large country such as the U.S., and the special needs of population groups that are usually not adequately represented in national studies.

Adult↗
PubMed1995

The use of hospital emergency departments for nonurgent health problems: a national perspective.

The use of the hospital emergency department (ED) for nonurgent health problems has been a subject of considerable controversy, in part because there is no widely accepted definition of "nonurgent." Elimination or substantial reduction in nonurgent ED use is frequently offered as a strategy for reducing health expenditures. Previous studies, often limited to individual hospitals or communities, have limited generalizability and do not permit examination of multiple factors likely to influence nonurgent ED utilization or examination of ED use for nonurgent problems in the context of overall outpatient utilization. This analysis of the 1987 National Medical Expenditure Survey (NMES) provides a nationally representative examination of nonurgent ED utilization that describes the frequency of ED use for nonurgent problems, characteristics of individuals that are associated with an increased likelihood of nonurgent ED use, the use of other outpatient physician services, and expenditures associated with nonurgent ED visits.

Cost Control↗