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PubMed1992

Mammography knowledge and intentions among insured women.

UNLABELLED: METHOD. A survey was conducted among 1,113 randomly selected insured state university employees to evaluate knowledge of the American Cancer Society mammography guidelines, awareness of insurance coverage for screening mammograms, previous guideline adherence, and future mammography intentions. RESULTS: The survey, which included two mailings with follow-up phone cells of nonresponders, had a refusal rate of 6%. Respondents were relatively more likely to know the guideline for older age groups; 77% knew the guidelines for women 50+. Over one-third of the responders were not aware that their insurance policy covered screening mammograms. For women who had never had a mammogram, insurance knowledge was significantly related to intentions to have a mammogram in the future. Previous screening adherence, as well as future intentions, was positively related to the age of the respondent. The results are contrasted with those of previous studies, and the implications for the content of future breast cancer screening campaigns are discussed.

Adult↗
PubMed2006

Pregnant mothers out of the perinatal regionalization's reach.

INTRODUCTION: Birth of very low birth weight (VLBW) infants outside subspecialty perinatal centers increases risk for death and major morbidities. OBJECTIVE: The purpose of this study is to evaluate barriers to utilizing a regional perinatal center for the birth of VLBW infants to mothers not living in the immediate vicinity of the center. METHODS: We conducted a retrospective cohort study of VLBW infants residing in the catchment area of a community level II, Specialty Neonatal Unit (SN) admitted to a Regional Subspecialty Neonatal Intensive Care Unit (RC) between January 1999 and December 31, 2004. Maternal demographics and prenatal care as well as outcomes were compared by place of birth. RESULTS: Out of 98 VLBW infants admitted to the RC, 49 (50%) were delivered outside the RC (out-born) and 49 (50%) were born at the RC (in-born). There was no statistical difference in insurance coverage, race, gestational age, severity of illness or maternal demographic factors between out-born and in-born infants. Less than adequate prenatal care rather than distance of maternal residence from the RC was associated with birth outside the RC. Adjusting for prenatal care, distance of residence from the RC increased the risk for delivering outside the center in the subset of mothers insured by Medicaid. CONCLUSIONS: Mothers of VLBW infants who received less than adequate prenatal care and did not live in the vicinity of a subspecialty center had an increased risk for delivery outside that center compared to those with adequate care. Appropriate place of birth for VLBW infants to low-income mothers may be influenced by the distance of their residence to an RC.

Cohort Studies↗
PubMed2005

Patient visits to a hospital-based alternative medicine clinic from 1997 through 2002: experience from an integrated healthcare system.

OBJECTIVE: Efforts to integrate complementary and alternative medicine (CAM) into conventional healthcare systems raise questions about expected levels of CAM use and its cost in an integrated system. This paper documents actual patient usage of a hospital-based alternative medicine clinic that has been operating on a conventional healthcare campus since 1993. SETTING: Hennepin Faculty Associates (HFA) is a multispecialty physician organization serving the Hennepin County Medical Center (HCMC), a public teaching hospital in downtown Minneapolis. In 1993, HFA opened an alternative medicine clinic, primarily providing acupuncture. The clinic has since expanded services to offer chiropractic, massage/bodywork, and herbs. Administrative claims data showing visit dates, treatment received, payment source, charges, and patient complaints are available from 1997 through 2002. RESULTS: Of all HFA patients who received conventional care on the HCMC campus every year (1997-2002), 6.5% also received care at the Alternative Medicine Clinic (AMC). Nearly 80% of AMC patients received third-party reimbursement for AMC services. Averaged over 6 years, self-pay patients had 3.2 visits per year and incurred $173 in charges per year; patients with a mixture of third-party payment sources had 8.0 visits per year and incurred $634 in charges per year. Number of visits per patient per year remained relatively constant over the 6 years, except for patients aged 65 or older, who showed an increase in number of visits, particularly for acupuncture. CONCLUSIONS: This report contributes a new perspective on use of CAM in the general population. Results from this perspective differ markedly from those provided by published survey data, showing a lower prevalence of use and lower charges incurred. Concern that insurance coverage for CAM would increase healthcare costs dramatically are not substantiated by these data.

Adult↗
PubMed1998

Adult dental visits in California: successes and challenges.

OBJECTIVES: This study sought to estimate and characterize the proportion of California adults who visited a dentist in the preceding year and to identify reasons for not going. METHODS: In 1995, 4,029 adults were interviewed by telephone as part of the California Behavioral Risk Factor Surveillance System. Items included recentness of a dental visit, dental insurance status, and number of teeth lost due to disease. Persons who had not seen a dentist within the preceding year were asked the main reason they had not gone. RESULTS: In 1995, 65.9% of adults reported visiting a dentist in the preceding twelve months. Use of dental services was greater among persons aged 35 years or older (70.4%) than among those aged 18-34 years (58.4%) and among those with dental insurance (74.9%) than those without (54.4%). Dental visits were less likely among adults living at or below 200 percent of the federal poverty level, those with less than a high school education, and the edentulous. Reasons most commonly cited for not seeing a dentist were no perceived reason to go (37.2%), cost (30.7%), and fear (9.2%). CONCLUSION: Substantial variation in use of dental services exists among California's adults. Achieving equity in access and opportunity for disease prevention in this state may require expanded dental insurance coverage and serious efforts in oral health promotion.

Adolescent↗
PubMed2004

Clinical decisions regarding HbA1c results in primary care: a report from CaReNet and HPRN.

OBJECTIVE: To describe decisions made by primary care providers on elevated HbA(1c) results and their reasons for not intensifying therapy. RESEARCH DESIGN AND METHODS: In this cross-sectional study, a provider survey was administered in two practice-based research networks when HbA(1c) results were reviewed on all nonpregnant patients >18 years old with type 2 diabetes. Univariate and Mantel-Hantel analyses assessed associations between patient characteristics and clinical decisions. RESULTS: A total of 483 surveys were completed by at least 88 providers at 19 clinics. Most patients were female (62.5%), mean age was 60 years, and 28.6% were Hispanic. The overall action rate on HbA(1c) results >/=7% (n = 294) was 70.7%. Patients who were black or had Medicare without medication insurance had lower rates of action on HbA(1c) >/=7 and >/=8%, respectively (P < 0.05). The most common reasons providers reported for inaction were "patient improving/doing well," "competing demands," and "hypoglycemic risk." CONCLUSIONS: Primary care providers generally adhere to national glycemic control guidelines, although there may be disparities in black patients and patients without medication insurance coverage. A variety of reasons were given when control was not intensified.

Adult↗
PubMed1990

Visual impairment in a rural Appalachian community. Prevalence and causes.

A population-based survey of 1136 subjects aged 40 years and older was conducted in a rural valley of Kentucky to determine the nature and extent of visual disability in an underserved area of rural America. Data on corrected visual acuity and ocular history, along with demographic, socioeconomic, and health care utilization parameters, were gathered. Those subjects with an acuity below 20/60 in either eye underwent a comprehensive ophthalmologic examination. The prevalence of binocular blindness (acuity worse than 20/400 in the better eye) was 0.44% and of monocular blindness (acuity worse than 20/400 in one eye) was 3.3%, approximately twice the national rates. The chief cause of bilateral visual impairment was macular degeneration among men and cataract among women. Cataract, trauma, and amblyopia were the major causes of monocular visual impairment in both sexes. Risk factor analysis revealed younger age, higher education, active employment, access to a health care facility, and comprehensive health insurance coverage to be inversely associated with visual impairment.

Adult↗
PubMed1998

A longitudinal study of hospitalization rates for patients with chronic disease: results from the Medical Outcomes Study.

OBJECTIVE: To prospectively compare inpatient and outpatient utilization rates between prepaid (PPD) and fee-for-service (FFS) insurance coverage for patients with chronic disease. DATA SOURCE/STUDY SETTING: Data from the Medical Outcomes Study, a longitudinal observational study of chronic disease patients conducted in Boston, Chicago, and Los Angeles. STUDY DESIGN: A four-year prospective study of resource utilization among 1,681 patients under treatment for hypertension, diabetes, myocardial infarction, or congestive heart failure in the practices of 367 clinicians. DATA COLLECTION/EXTRACTION METHODS: Insurance payment system (PPD or FFS), hospitalizations, and office visits were obtained from patient reports. Disease and severity indicators, sociodemographics, and self-reported functional status were used to adjust for patient mix and to compute expected utilization rates. PRINCIPAL FINDINGS: Compared to FFS, PPD patients had 31 percent fewer observed hospitalizations before adjustment for patient differences (p = .005) and 15 percent fewer hospitalizations than expected after adjustment (p = .078). The observed rate of FFS hospitalizations exceeded the expected rate by 9 percent. These results are not explained by system differences in patient mix or trends in hospital use over four years. Half of the PPD/FFS difference in hospitalization rate is due to intrinsic characteristics of the payment system itself. CONCLUSIONS: PPD patients with chronic medical conditions followed prospectively over four years, after extensive patient-mix adjustment, had 15 percent fewer hospitalizations than their FFS counterparts owing to differences intrinsic to the insurance reimbursement system.

Adult↗
PubMed1995

Employed women with alcohol problems who seek help from employee assistance programs. Description and comparisons.

After a brief description of employee assistance programs (EAP), we present data collected from 6,400 employees from 84 worksites who used the services of EAPs, a portion of whom were assessed by the EAP as having alcohol-related problems and/or received scores on the Alcohol Dependence Scale (ADS) indicative of a potential alcohol-related problem. In addition, data were collected at intake from the EAP administrators, and employment status of the employee clients was assessed 18 to 24 months later. These data indicate that EAPs are effective in sustaining the employment of most women with alcohol-related problems who seek services from EAPs and that EAPs' goal of early intervention is especially realized among women with alcohol problems. Other conclusions include: women with alcohol problems do not enter EAPs through routes that are strikingly different from those of men; many of the gender differences that are revealed are associated with job status differences; employed women with alcohol problems are detached from nuclear families, with markedly low rates of current marriage; even when married, spouses are less likely to play a role in the referral of women with alcohol problems than the spouses of the men; and, there is no clear indication that women are the target of any form of discrimination in the process of EAP utilization. However, women are considerably more likely to have less adequate insurance coverage, according to the EAP administrators' assessment reported at client intake, than their male counterparts, leading to treatment choices that may be less than appropriate.

Alcoholism↗
PubMed1995

Social consequences of psychiatric disorders, I: Educational attainment.

OBJECTIVE: This is the first in a series of investigations of the social consequences of psychiatric disorders based on the National Comorbidity Survey. Data on the relationship between preexisting psychiatric disorders and subsequent educational attainment are presented. METHOD: The National Comorbidity Survey is a nationally representative survey of 8,098 respondents in the age range 15-54 years. A subsample of 5,877 respondents completed a structured psychiatric interview and a detailed risk factor battery. Diagnoses of DSM-III-R anxiety disorders, mood disorders, substance use disorders, and conduct disorder were generated, and survival analyses were used to project data on school terminations to the total U.S. population. RESULTS: Early-onset psychiatric disorders are present in more than 3.5 million people in the age range of the National Comorbidity Survey who did not complete high school and close to 4.3 million who did not complete college. The most important disorders are conduct disorder among men and anxiety disorders among women. The proportion of school dropouts with psychiatric disorders has increased dramatically in recent cohorts, and persons with psychiatric disorders currently account for 14.2% of high school dropouts and 4.7% of college dropouts. CONCLUSIONS: Early-onset psychiatric disorders probably have a variety of adverse consequences. The results presented here show that truncated educational attainment is one of them. Debate concerning whether society can afford universal insurance coverage for the treatment of mental disorders needs to take these consequences into consideration.

Adolescent↗
PubMed1995

The introduction of deductibles for prescription drugs in a national health insurance: compulsory or voluntary?

We consider a situation of full insurance coverage for prescription drugs where, at a certain point in time, people are given the opportunity to take a deductible in exchange for a lower premium. Four determinants of this premium reduction can be considered: expected out-of-pocket payments, adverse selection effects, moral hazard effects, and administration costs. The purpose of this study is to analyse the first two determinants. Survey data of 17,242 insureds in the Netherlands have been used for this research. Results show that the expected out-of-pocket expenditures in case of a certain deductible amount depend strongly on age and gender. People in poor health could be given a larger premium discount if they would take a deductible than those in good health. This implies that a uniform premium discount would induce adverse selection. The effects of such selection have been simulated by using a survey question about the preference to take a general deductible. If the premium reductions for policies with a deductible are adjusted for age and gender, the selection effect will halve but will still be substantial. We conclude that, in the situation considered here, it is largely immaterial whether deductibles are compulsory or voluntary, provided premium reductions are allowed to depend on relevant risk factors.

Adolescent↗
PubMed2003

Access to health care for youth leaving foster care: Medicaid and SCHIP.

PURPOSE: To examine how Medicaid and the State Children's Health Insurance Program (SCHIP) could improve health care access for youth aging out of foster care, a vulnerable population with multiple health concerns. METHODS: On the basis of an analysis of state and federal laws, state plans and amendments, and a telephone survey of state officials, this article identifies options in Medicaid and SCHIP for states to provide health insurance coverage for these youth, examines states' use of available options, and highlights other relevant federal health care programs. RESULTS: Numerous Medicaid and SCHIP eligibility categories could provide coverage for older adolescents leaving foster care. The federal Foster Care Independence Act of 1999 (FCIA) created a new Medicaid expansion option for this group and other opportunities for states to address their health care needs. Numerous other federal programs also finance health care that could serve this population. CONCLUSIONS: The potential exists through Medicaid or SCHIP to ensure that nearly all former foster youth have health insurance as they leave state custody, but Medicaid and SCHIP cannot alone meet all health care needs of these youth. Financing available through other public programs is essential. A few states have adopted the new FCIA Medicaid expansion option for former foster youth, and a larger number have implemented other relevant Medicaid options. Additional states have used other innovative approaches to facilitate health care access. Most states could do much more. A major challenge is to find approaches that can be implemented during times of severe budgetary limitations.

Adolescent↗
PubMed1986

Medical care utilization by Hispanic children. How does it differ from black and white peers?

Factors associated with the utilization of medical care by Hispanic, black Non-Hispanic, and white Non-Hispanic children were analyzed using multivariate regression techniques on a Health Interview Survey sample. The findings indicate that Medicaid coverage was the sharpest enhancer of entry into care for Hispanics and blacks, contributing significantly to the amount of physician visits. While financial factors seemed more influential determinants of physician contacts for minorities, perceived health needs appeared to be important contributors to entry into health care for white children. Such differences reveal that important racial-ethnic disparities persist with respect to physician utilization among children. Improved insurance coverage for Hispanics, particularly children of Mexican origin, is suggested as an important intervention to facilitate access for this population.

Adolescent↗
PubMed2002

Dropping out of mental health treatment: patterns and predictors among epidemiological survey respondents in the United States and Ontario.

OBJECTIVE: The authors interviewed individuals treated for self-described mental health problems in the preceding year to examine patterns and predictors associated with dropping out of treatment. METHOD: Subjects were drawn from respondents to community epidemiological surveys carried out in representative samples of the United States and Ontario populations. Dropouts were those who had left mental health treatment during the prior year for reasons other than symptom improvement. The surveys also assessed potential dropout correlates: sociodemographic characteristics, attitudes about mental health care, disorder type, provider type, and treatment received. RESULTS: The proportion of dropouts did not significantly differ between the United States (19.2%) and Ontario (16.9%), nor did the effects of the predictors differ significantly between the two samples. Sociodemographic characteristics associated with treatment dropout included low income, young age, and, in the United States, lacking insurance coverage for mental health treatment. Patient attitudes associated with dropout included viewing mental health treatment as relatively ineffective and embarrassment about seeing a mental health provider. Respondents who received both medication and talk therapy were less likely to drop out than those who received single-modality treatments. CONCLUSIONS: Mental health treatment dropout is a serious problem, especially among patients who have low income, are young, lack insurance, are offered only single-modality treatments, and have negative attitudes about mental health care. Cost-effective interventions targeting these groups are needed to increase the proportion of patients who complete an adequate course of treatment.

Adolescent↗
PubMed1987

HMO membership, copayment, and initiation of care for cancer: a study of working adults.

This study compares diagnosis and commencement of treatment for cancer among persons with fully financed fee-for-service coverage, persons with copaid fee-for-service coverage, and persons in an HMO (health maintenance organization). A total of 242 subjects actively employed at the time of their diagnosis were interviewed, typically within six months of beginning cancer treatment. After sex, age, income, education, residence (urban vs rural), and disease site and stage had been controlled, those who made copayments were found to have waited an average of 1.25 months longer (95 per cent confidence limit (cl) +/- .88) between initial suspicion of illness and obtaining a definitive diagnosis than those with full insurance coverage. Time from diagnosis until the beginning of treatment averaged .83 months longer (95 per cent cl +/- .41) for HMO members than those in fee-for-service. These relations were strongest in income categories equal to or exceeding $20,000 per year.

Employment↗
PubMed2000

What are the barriers to medical care for patients with newly diagnosed diabetes mellitus?

CONTEXT: Few data are available describing factors that prevent patients with newly diagnosed diabetes from seeking medical care. OBJECTIVE: To identify socioeconomic factors that act as barriers to healthcare among such patients. SETTING: A community-wide diabetes screening programme. PARTICIPANTS: One hundred and eighteen patients with newly identified diabetes mellitus out of 1,824 total screenings. INTERVENTIONS: Each newly identified person with diabetes was instructed to contact a physician for follow-up care. DESIGN: A follow-up survey was obtained from 89 (75%) subjects 9 +/- 7 months after diagnosis. MAIN OUTCOME MEASURE: Whether or not subjects had obtained follow-up care for their diabetes. RESULTS: Of seven variables examined, only lack of health insurance correctly predicted those patients who failed to seek medical care for their diabetes by multivariate analysis. CONCLUSIONS: Lack of health insurance coverage is the primary reason that patients with newly diagnosed diabetes fail to seek medical care.

Age Distribution↗
PubMed1995

The effect of dental insurance on the demand for dental services in the USA: a review.

Examines the primary studies which have contributed to dental care research. By reviewing background information, lays a foundation for the review of the current empirical evidence, which examines the effect of dental insurance coverage on the oral health of the American population, as well as the utilization and demand for dental services. Raises questions and implications for future research and practice.

Aged↗
PubMed1998

Physician visits in a farming-dependent county.

Physician visits in a farming-dependent county in the upper-Midwest were studied using a mail questionnaire. A 16 percent random sample of households yielded 426 surveys (60 percent response rate). The dependent variable was the natural log (plus one) of the number of times the respondent had seen a physician in the prior 12 months. Predisposing, enabling, and medical need variables were tested as potential predictors of medical care usage. Self-rated health status proved to be an important predictor, as was a history of hospitalization and being married. However, health insurance coverage and family income were not associated with increased physician visits. Implications for modifying the conceptual model employed to analyze medical care utilization in similar populations are discussed.

Adult↗
PubMed2001

Use and costs of ambulatory care services among Medicare enrollees with schizophrenia.

OBJECTIVE: The objective of this study was to identify predictors of the use and cost of ambulatory care services among Medicare recipients with schizophrenia. METHODS: The design was a cross-sectional analysis of Medicare claims in 1991. The study subjects were a 5 percent random sample of all persons in the United States who had at least one Medicare service claim in 1991 and who were diagnosed as having schizophrenia in any care setting. Outcome measures included use and cost of any ambulatory care service, individual therapy, psychiatric somatotherapy, group therapy, or family therapy. RESULTS: For nearly 25 percent of the total sample of 12,440, no claims were filed for ambulatory care services in 1991. The mean+/-SD number of ambulatory care visits during the year was 7.9+/-21. The most frequently used type of therapy was individual therapy (5+/-14 visits). The mean+/-SD yearly cost of care for persons who received ambulatory care services was $470+/-$1,028. Among persons under 65 years of age, Caucasians were about 1.5 times as likely as African Americans to have received an ambulatory care service and 1.3 times as likely to have received individual therapy. Persons who were 65 or older were less likely to have received any service. Among service recipients, costs of care were lower for African Americans and for older people. CONCLUSIONS: The use of Medicare-funded ambulatory care services by persons with schizophrenia varied by race and age. Further investigation is required to determine whether subgroups of individuals who do not have additional insurance coverage or access to services are receiving substandard care.

Aged↗