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PubMed2000

Factors associated with tympanostomy tube insertion among preschool-aged children in the United States.

OBJECTIVES: Recurrent and persistent otitis media is often treated by tympanostomy tube insertion to ventilate the middle ear and restore hearing. This study examined the factors that predict which children are most likely to receive tympanostomy tubes through 3 years of age. METHODS: Multiple logistic regression was conducted on data from a nationally representative sample of children (N = 8285). RESULTS: By 3 years of age, 6.8% of US children had tubes inserted. Logistic regression indicated that after control for number of ear infections, children without any gaps in health insurance, who attended a day-care center, who were White, whose birth-weight was less than 1500 g, and who lived in the Midwest or South were significantly more likely to have tympanostomy tubes. CONCLUSIONS: These data suggest that differences exist as to who receives tubes. Of particular concern are differences by race/ethnicity and continuity of health insurance coverage. With expansions in health care coverage to larger proportions of uninsured children, it will be important to monitor these programs to ensure that all children who may need tympanostomy tubes have access to them.

Child, Preschool↗
PubMed2005

Insurance status and the use of guideline therapy in the treatment of selected cancers.

PURPOSE: This study estimates the impact of type of insurance coverage on the receipt of guideline therapy in a population-based sample of cancer patients treated in the community. PATIENTS AND METHODS: Patients (n = 7,134) from the National Cancer Institute's Patterns of Care studies who were newly diagnosed with 11 different types of cancer were analyzed. The definition of guideline therapy was based on the National Comprehensive Cancer Network treatment recommendations. Insurance status was categorized as a mutually exclusive hierarchical variable (no insurance, any private insurance, any Medicaid, Medicare only, and all other). Multivariate analyses were used to examine the association between insurance and receipt of guideline therapy. RESULTS: Adjusting for clinical and nonclinical variables, insurance status was a modest, although statistically significant, determinant of receipt of guideline therapy, with 65% of the privately insured patients receiving recommended therapy compared with 60% of patients with Medicaid. Seventy percent of the uninsured patients received guideline therapy, which was nonsignificantly different compared with private insurance. When stratified by race, insurance was a statistically significant predictor of the receipt of guideline therapy only for non-Hispanic blacks. CONCLUSION: Overall, levels of guideline treatment were lower than expected and particularly low for patients with Medicaid or Medicare only. The use of guideline therapy for ovarian and cervical cancer patients and for patients with rectal cancers was unrelated to type of insurance. Of particular concern is the significantly lower use of guideline therapy for non-Hispanic black patients with Medicaid. After adjusting for other factors, only half of these patients received guideline therapy.

Adult↗
PubMedDate not supplied

State implementation of the Breast and Cervical Cancer Prevention and Treatment Act of 2000: a collaborative effort among government agencies.

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP),administered by the Centers for Disease Control and Prevention through grants to states, tribes, and territories, has successfully provided breast and cervical cancer screening and diagnostic services to low-income women since 1990. On October 24, 2000, Congress passed the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) authorizing states, if they chose, to provide Medicaid coverage for treatment services for women screened under theNBCCEDP. Under BCCPTA, uninsured women younger than age 65 who are screened through the NBCCEDP and found to have breast or cervical cancer (or precancerous conditions) may gain access to Medicaid services for and during their cancer treatment. Implementation of the BCCPTA requires collaboration and coordination among many government agencies, including the Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, state Medicaid directors, and directors of state and tribal grant programs. This article describes the implementation of the program and demonstrates to policy makers that coordinating resources among government agencies can facilitate the rapid adoption of public health programs as pathways for specific populations to gain access to publicly funded health insurance coverage.

Breast Neoplasms↗
PubMed2005

Clinical preventive services: when is the juice worth the squeeze?

This paper provides an overview of clinical preventive services, including a definition of such services and the role of the U.S. Preventive Services Task Force in recommending which services should be routinely offered to patients. It also describes efforts to analyze the cost effectiveness of clinical preventive services and reviews the insurance coverage policies of private and public payers. Barriers to increased uptake of appropriate services are discussed, and policy-relevant issues are summarized.

Community Participation↗
PubMed2001

Receipt of cancer screening procedures among Hispanic and non-Hispanic health maintenance organization members.

BACKGROUND: Hispanic Americans have been shown to receive fewer cancer screening procedures than nonminority populations. Although lack of insurance or a regular source of care appear to be important determinants, cultural factors also have been suggested. This study examines whether Hispanic patients receive cancer screening at the same rate as the non-Hispanic population when both groups have equivalent insurance and a regular source of care. METHODS: Receipt of five cancer screening procedures (mammography, Pap test, fecal occult blood testing, breast examination, and rectal examination) was determined for adult health maintenance organization (HMO) members who met appropriate age and gender criteria. Rates of receipt were compared for 2 cohorts over a 2-year period: Hispanic members identified by surname and a comparison group, a 10% random sample of the non-Spanish surnamed members. Only members with at least one HMO contact over the study period were included. Logistic regression was used to test whether being in the Hispanic group was associated with decreased likelihood of receiving the procedure at least once over the 2 years, adjusting for potential confounders. RESULTS: Among the comparison group, a high proportion received each recommended procedure at least once (0.70-0.86). The proportions were very similar for the Hispanic group (0.67-0.84). None of the rates differed statistically for the two groups. CONCLUSIONS: Hispanic HMO members received cancer screening at the same high rate as non-Hispanics, suggesting that insurance coverage and continuity of care are more important than cultural factors in determining rates of cancer screening receipt.

Adult↗
PubMed2001

Access to mental health services and health sector social capital.

Mental health services are underused relative to mental illness rates. We hypothesized a positive correlation between use of mental health services and community-level health care social capital. Community Tracking Study data from 43 cities (N = 43,278), merged with the National Profile of Local Health Departments and other sources, show that use of mental health services was greater when public health districts collaborated with managed care organizations and other community groups, independent of individual predictors and health care system variables. Use was also positively associated with community levels of public insurance coverage and with direct public health provision of behavioral health care services. Research is needed to understand the mechanisms by which social capital may improve access to mental health services.

Adult↗
PubMed2005

A look at working-age caregivers' roles, health concerns, and need for support.

The role of informal caregivers is becoming increasingly important as the U.S. population continues to age and cost-containment strategies promote shorter hospital stays. There are currently 16 million working-age adults caring for a sick or disabled family member, according to data from the Commonwealth Fund Biennial Health Insurance Survey. Caregivers are less likely to be working, to miss days of work when they are employed, and to lack health insurance coverage. This may leave them financially vulnerable and unable to obtain needed health care. Indeed, one-half of caregivers reported not getting care because of cost issues, and three of five caregivers experienced problems with medical bills. Policies to expand Medicaid and Medicare would improve caregivers' ability to access health care for themselves and their families, as well as help eliminate the financial strain of going without health insurance.

Adult↗
PubMed2005

The decision-making process of health care utilization in Mexico.

Using individual-level data from the 2000 Mexican Survey of Satisfaction with Health Services we estimate a two-part negative binomial hurdle model to evaluate the decision-making process of health care utilization in Mexico. We find that there are income-related differences in utilization associated with the first visit to a physician, as well as substantial utilization differences by region, employment, insurance and financial status. There are also income-related differences in the first visit to a specialist but not in the number of days hospitalized. The results suggest that increasing initial access to services via income and insurance coverage and providing financial resources to underserved regions can substantially improve access to care and, ultimately, population health.

Adult↗
PubMed1999

Injuries in competitive swimming.

Competitive swimming is commonly thought to be an injury-free sport. Traumatic and overuse injuries do occur, especially if one includes accidents occurring to both athletes and spectators, and accidents resulting from some of the newer diving and starting techniques. United States Swimming, Incorporated, the national governing body for competitive swimming, and provider of insurance coverage for most of the swimming clubs in the United States, keeps track of reported injuries to club members, and requires specific safety accreditation for member coaches. These data provide an informative view on injuries to competitive swimmers.

Athletic Injuries↗
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↗
PubMed2003

Review and analysis of incremental approaches to meeting the needs of the uninsured and under-insured.

The US healthcare delivery system, by all accounts, is the most advanced and sophisticated healthcare system in the world. Clinical advances in diagnostic and therapeutic regimens, superior performance in biomedical research, and the development and use of the latest management and medical technologies are all hallmarks of the system. While the US healthcare system has been extremely successful, concerns remain about access to care for a large segment of the population. This article examined the various approaches that have been adopted and those that are being proposed to bridge the existing gap in health insurance coverage. The underlying assumptions of the proposed strategies were examined, and the conditions necessary for the successful implementation of these strategies were also discussed.

Adolescent↗
PubMed2005

Update: health insurance and utilization of care among rural adolescents.

CONTEXT: Adolescence is critical for the development of adult health habits. Disparities between rural and urban adolescents and between minority and white youth can have life-long consequences. PURPOSE: To compare health insurance coverage and ambulatory care contacts between rural minority adolescents and white and urban adolescents. METHODS: Cross-sectional design using data from the 1999-2000 National Health Interview Survey, a nationally representative sample of US households. Analysis was restricted to white, black, and Hispanic children aged 12 through 17 (8,503 observations). Outcome measures included health insurance, ambulatory visit within past year, usual source of care (USOC), and well visit within past year. Independent variables included race, residence, demographics, facilitating/enabling characteristics, and need. RESULTS: Across races, rural adolescents were as likely to have insurance (86.8% vs 87.7%) but less likely to report a preventive visit (60.1% vs 65.5%) than urban children; residence did not affect the likelihood of a visit or a USOC. Minority rural adolescents were less likely than whites to be insured, report a visit, or have a USOC. Most race-based differences were not significant in multivariate analysis holding constant living situation, caretaker education, income, and insurance. Low caretaker English fluency, limited almost exclusively to Hispanics, was an impediment to all outcomes. CONCLUSIONS: Most barriers to care among rural and minority youth are attributable to factors originating outside the health care system, such as language, living situation, caretaker education, and income. A combination of outreach activities and programs to enhance rural schools and economic opportunities will be needed to improve coverage and utilization among adolescents.

Adolescent↗
PubMed2003

Psychiatric medication use among Manhattan residents following the World Trade Center disaster.

To assess medication use in New York after the September 11th attacks, a telephone survey was conducted in October 2001 (N = 1,008). The prevalence of psychiatric medication use 30 days before the disaster was 8.9 and 11.6% 30 days after, a small but significant increase. The most important factor predicting postdisaster use was predisaster use--92% of those who used medications postdisaster used them predisaster. In addition, 3.3% used psychiatric medications 30 days postdisaster, but not 30 days before. Those who had panic attacks, posttraumatic stress disorder (PTSD), and insurance coverage, were the most likely medicated (26.5%). However, among those who used postdisaster medications (n = 129), new users tended to be those with panic attacks (44.1%) and those with panic attacks and PTSD (69.2%).

Adult↗
PubMed1999

State-level variation in Medicare spending.

Theoretically, Medicare provides one standard benefit package to all enrollees. But because of State-level variations in populations, service supply, and local practice patterns, national policy changes may have unequal impacts on access and service utilization. Across-the-board policy changes may create hardships in one area while appropriately discouraging use in another area. In this article, the authors describe State-level variations in Medicare enrollees, their insurance coverage, 1995 Medicare and beneficiary spending patterns in aggregate, per capita, and by service, and certain spending patterns for dually eligible beneficiaries. These data are useful for considering the State-level effects of payment reform.

Accounting↗
PubMed1999

Understand the overlap between FMLA and COBRA.

An employer's obligation to continue an eligible employee's medical insurance under the Family and Medical Leave Act overlaps with the employee's right to continued medical insurance coverage under the provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). To avoid liability traps resulting from the overlap, employers, plan sponsors and plan administrators must have a good understanding of the two laws and keep accurate records.

Aged↗
PubMedDate not supplied

Parental behavior and child health.

In this paper we document the ways in which parental behavior and socioeconomic status affect children's health. We examine parental behavior in both the prenatal period and childhood. We present evidence on the correlation of this behavior with income and parents' socioeconomic status, and on the ways in which parents' actions affect children's health. We conclude that while health insurance coverage and advances in medical treatment may be important determinants of children's health, they cannot be the only pillars: Protecting children's health also calls for a broader set of policies that target parents' health-related behavior.

Adolescent↗
PubMedDate not supplied

Exploring racial disparity in posttraumatic stress disorder diagnosis: implications for care of African American women.

OBJECTIVE: To explore factors contributing to disparities in posttraumatic stress disorder (PTSD) diagnosis between African Americans and White Americans, while controlling for gender and class by using a data set limited to poor women. DESIGN: A cross-sectional epidemiological secondary analysis. SETTING: Michigan Medicaid fee-for-service claims data from 1994 through 1997. SAMPLE: A total of 20,298 African American and White American adolescents and adult women, including 2,996 with PTSD diagnosis. MAIN OUTCOME MEASURES: Victimization, PTSD diagnosis, psychiatric and somatic comorbidities, and PTSD treatment. RESULTS: African American women were under-represented in the group diagnosed with PTSD (12% versus 31% in the comparison group), despite having equal rates of hospitalization for rape and battering. They were less likely to be diagnosed with comorbidities associated with complex PTSD, such as dissociative disorder (OR = 0.259, p < .001) or borderline personality disorder (OR = 0.178, p < .001), but were equally likely to be diagnosed with conduct disorder, schizophrenia, or substance abuse. African American women were 40% less likely to have continuous insurance coverage. CONCLUSIONS: Patient, provider, and system factors appear to interact to create disparities in PTSD diagnosis and treatment. Attention to case finding and provider or system bias may help reduce disparities.

Adolescent↗
PubMed2005

Medicaid insurance policy for youths involved in the criminal justice system.

Juvenile justice and Medicaid agencies share an interest in serving delinquent youths, many of whom have a relatively poor health status. However, many state and local Medicaid policies result in these youths having no insurance coverage, making access to needed services difficult. A nationally representative survey of state and community juvenile justice and Medicaid agencies was conducted to assess Medicaid policies. Evidence from the survey suggests that in some areas delinquent youths are actively disenrolled from Medicaid benefits, and in others little effort is made to connect them to Medicaid coverage. Discrepancies between justice agency and Medicaid agency responses point to poor communication and coordination. Overall, the survey identified several opportunities for policy intervention to enhance access to services for justice-involved youths.

Adolescent↗