Research on Disparities in Primary Health Care in Rural versus Urban Areas: Select Perspectives.

Much of the differences in health care outcomes can be attributed to the differential rates of primary health care utilization and resource allocation across population subgroups [...].

Medicare Advantage and postdischarge quality: evidence from hospital readmissions.

OBJECTIVES: To compare relative readmission rates for beneficiaries enrolled in Medicare Advantage (MA) and traditional Medicare (TM) as suggestive evidence of changes in postdischarge care coordination and the quality of care delivered to Medicare beneficiaries. STUDY DESIGN: We used the Agency for Healthcare Research and Quality's 2009 and 2014 Healthcare Cost and Utilization Project State Inpatient Databases for 4 states with reliable sources of payment identifiers, linking these data to local area characteristics. Our outcome was the probability of a hospital readmission within 30 days of an index admission. We computed readmission rates overall and by subgroups, including for patients with multiple chronic conditions, by patients' state of residence, and by type of index admission. METHODS: We estimated linear probability models with hospital fixed effects including a wide array of patient-level characteristics relating to health status and sociodemographic characteristics. Standard errors were adjusted for clustering at the area level. RESULTS: Significantly lower all-cause readmission rates were found among MA enrollees relative to those in TM in both 2009 and 2014, suggesting an association between MA enrollment and higher quality of care. However, over the 2009-2014 period, MA enrollment was not associated with an increased reduction in readmission rates relative to TM. CONCLUSIONS: Although our focus was on a single measure of performance, the claims that managed care plans are spearheading changes in the delivery system are not supported by our finding that relative readmission rates were stable over the 2009-2014 period.

Multilevel Risk Factors for Hospital Readmission Among Patients With Opioid Use Disorder in Selected US States: Role of Socioeconomic Characteristics of Patients and Their Community.

RESEARCH OBJECTIVE: Using a multilevel framework, the study examines the association of socioeconomic characteristics of the individual and the community with all-cause 30-day readmission risks for patients hospitalized with a principal diagnosis of opioid use disorder (OUD). STUDY DESIGN: The study uses hospital discharge data of adult (18+) patients in 5 US states for 2014 from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, linked to community and hospital characteristics using data from Health Resources and Services Administration and American Hospital Association, respectively. A multilevel logistic regression model is applied on data pooled over 5 states adjusting for patient, hospital, and community characteristics. PRINCIPAL FINDINGS: Higher primary care access, as measured by density of primary care providers, is associated with reduced readmission risks among patients with OUD. Medicare is associated with the highest readmission risk (odds ratio [OR] = 2.0, P < .01) compared to private coverage, while Medicaid coverage is also associated with elevated risk (OR = 1.71, P < .01). Being self-pay or covered by other payers carried a similar risk to private coverage. Urban patients had higher readmission rates than rural patients. CONCLUSIONS: Patients' risk of readmission following hospitalization for OUD varies according to availability of primary care providers, expected payer, and geographic location. Understanding which patients are most at risk may allow policy makers to design interventions to prevent readmissions and improve patient outcomes. Future studies may wish to focus on understanding when a decreased readmission rate represents better patient outcomes and when it represents difficulty accessing health care.

Racial/Ethnic Disparities in Readmissions in US Hospitals: The Role of Insurance Coverage.

We examine differences in rates of 30-day readmissions across patients by race/ethnicity and the extent to which these differences were moderated by insurance coverage. We use hospital discharge data of patients in the 18 years and above age group for 5 US states, California, Florida, Missouri, New York, and Tennessee for 2009, the latest year prior to the start of Centers for Medicare & Medicaid Services' Hospital Compare program of public reporting of hospital performance on 30-day readmissions. We use logistic regression models by state to estimate the association between insurance status, race, and the likelihood of a readmission within 30 days of an index hospital admission for any cause. Overall in 5 states, non-Hispanic blacks had a slightly higher risk of 30-day readmissions relative to non-Hispanic whites, although this pattern varied by state and insurance coverage. We found higher readmission risk for non-Hispanic blacks, compared with non-Hispanic whites, among those covered by Medicare and private insurance, but lower risk among uninsured and similar risk among Medicaid. Hispanics had lower risk of readmissions relative to non-Hispanic whites, and this pattern was common across subgroups with private, Medicaid, and no insurance coverage. Uninsurance was associated with lower risk of readmissions among minorities but higher risk of readmissions among non-Hispanic whites relative to private insurance. The study found that risk of readmissions by racial ethnic groups varies by insurance status, with lower readmission rates among minorities who were uninsured compared with those with private insurance or Medicare, suggesting that lower readmission rates may not always be construed as a good outcome, because it could result from a lack of insurance coverage and poor access to care, particularly among the minorities.

Multiple Chronic Conditions and Disparities in 30-Day Hospital Readmissions Among Nonelderly Adults.

This study examines the patterns of 30-day hospital readmissions by race/ethnicity and multiple chronic conditions (MCC) burden among nonelderly adult patients. We used hospital discharge data of patients in the 18- to 64-year age group in 5 US states, California, Florida, Missouri, New York, and Tennessee, for 2009 from the Healthcare Cost and Utilization Project State Inpatient Database (HCUP-SID) of the Agency for Healthcare Research and Quality, linked to contextual and provider data from the Health Resources and Services Administration. A multilevel logistic regression model was used for data pooled over 5 states, adjusting for patient, hospital, and community characteristics. Controlling for other covariates, the study found that a higher MCC burden was associated with a higher all-cause 30-day readmission risk. We found considerable heterogeneity in levels of readmission risk among racial/ethnic subgroups stratified by chronic conditions. Among patients with a lowest MCC burden, African Americans had the highest risk of readmission, but with a higher MCC burden, the risk of readmission increased most for Hispanics.

Changes in Case-Mix and Health Outcomes of Medicare Fee-for-Service Beneficiaries and Managed Care Enrollees During the Years 1992-2011.

BACKGROUND: Recent studies suggest that managed care enrollees (MCEs) and fee-for-service beneficiaries (FFSBs) have become similar in case-mix over time; but comparisons of health outcomes have yielded mixed results. OBJECTIVE: To examine changes in differentials between MCEs and FFSBs both in case-mix and health outcomes over time. DESIGN: Temporal study of the linked Health and Retirement Study (HRS) and Medicare data, comparing case-mix and health outcomes between MCEs and FFSBs across 3 time periods: 1992-1998, 1999-2004, and 2005-2011. We used multivariable analysis, stratified by, and pooled across the study periods. The unit of analysis was the person-wave (n=167,204). SUBJECTS: HRS participants who were also enrolled in Medicare. MEASURES: Outcome measures included self-reported fair/poor health, 2-year self-rated worse health, and 2-year mortality. Our main covariate was a composite measure of multimorbidity (MM), MM0-MM3, defined as the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. RESULTS: The case-mix differential between MCEs and FFSBs persisted over time. Results from multivariable models on the pooled data and incorporating interaction terms between managed care status and study period indicated that MCEs and FFSBs were as likely to die within 2 years from the HRS interview (P=0.073). This likelihood remained unchanged across the study periods. However, MCEs were more likely than FFSBs to report fair/poor health in the third study period (change in probability for the interaction term: 0.024, P=0.008), but less likely to rate their health worse in the last 2 years, albeit at borderline significance (change in probability: -0.021, P=0.059). CONCLUSIONS: Despite the persistence of selection bias, the differential in self-reported fair/poor status between MCEs and FFSBs seems to be closing over time.

The ACA's Zero Cost-Sharing Mandate and Trends in Out-of-Pocket Expenditures on Well-Child and Screening Mammography Visits.

BACKGROUND: Starting in September of 2010, the Patient Protection and Affordable Care Act required most health insurance policies to cover evidence-based preventive care with no cost-sharing (no copays, coinsurance, or deductibles). It is unknown, however, whether declines in out-of-pocket costs for preventive services are large enough to prompt increases in utilization, the ultimate goal of the policy. METHODS: In this study, we use a nationally representative sample of ambulatory care visits to estimate the impact of the zero cost-sharing mandate on out-of-pocket expenditures on well-child and screening mammography visits. Estimates are made using 2-part interrupted time-series models, with well-woman visits serving as the control group because they were not covered under the zero cost-sharing mandate until after our study period. RESULTS: Results indicate a substantial reduction in out-of-pocket costs attributable to the Affordable Care Act. Between January 2011 and September 2012, the zero cost-sharing mandate reduced per-visit out-of-pocket costs for well-child visits from $18.46 to $8.08 (56%) and out-of-pocket costs for screening mammography visits from $25.43 to $6.50 (74%). No reduction was apparent for well-woman visits. CONCLUSIONS: The Affordable Care Act's zero cost-sharing mandate for preventive care has had a large impact on out-of-pocket expenditures for well-child and mammography visits. To increase preventive service use, research is needed to better understand barriers to obtaining preventive care that are not directly related to cost.

Hospital Readmission Rates in U.S. States: Are Readmissions Higher Where More Patients with Multiple Chronic Conditions Cluster?

RESEARCH OBJECTIVE: This study examines small area variations in readmission rates to assess whether higher readmission rate in an area is associated with higher clusters of patients with multiple chronic conditions. STUDY DESIGN: The study uses hospital discharge data of adult (18+) patients in 6 U.S. states for 2009 from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, linked to contextual and provider data from Health Resources and Services Administration. A multivariate cross sectional design at primary care service area (PCSA) level is used. PRINCIPAL FINDINGS: Adjusting for area characteristics, the readmission rates were significantly higher in PCSAs having higher proportions of patients with 2-3 chronic conditions and those with 4+ chronic conditions, compared with areas with a higher concentration of patients with 0-1 chronic conditions. CONCLUSIONS: Using small area analysis, the study shows that areas with higher concentration of patients with increased comorbid conditions are more likely to have higher readmission rates.

Has access to care changed in minority communities? A study of preventable hospitalizations over time in selected States.

This study assesses the changes in access to care in minority communities by examining the association between preventable hospitalization rates and racial/ethnic composition of the community during 1995-2005. Using hospital discharge data from Healthcare Cost and Utilization Project State Inpatient Database of the Agency for Healthcare Research and Quality in 5 states and focusing on the nonelderly adults and elderly age groups, the study includes a multivariate cross-sectional design using preventable hospitalization rates by primary care service area as the outcome and racial/ethnic compositions of total hospital discharges by resident population in the primary care service area as the primary explanatory variables. The study indicates increases in barriers faced by minority adults in accessing primary care over time, with no similar evidence for the elderly subgroup.

The small area predictors of ambulatory care sensitive hospitalizations: a comparison of changes over time.

The hospital admission for ambulatory care sensitive conditions (ACSCs) is a validated indicator of impeded access to good primary and preventive care services. The authors examine the predictors of ACSC admissions in small geographic areas in two cross-sections spanning an 11-year time interval (1995-2005). Using hospital discharge data from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality for Arizona, California, Massachusetts, Maryland, New Jersey, and New York for the years 1995 and 2005, the study includes a multivariate cross-sectional design, using compositional factors describing the hospitalized populations and the contextual factors, all aggregated at the primary care service area level. The study uses ordinary least squares regressions with and without state fixed effects, adjusting for heteroscedasticity. Data is pooled over 2 years to assess the statistically significant changes in associations over time. ACSC admission rates were inversely related to the availability of local primary care physicians, and managed care was associated with declines in ACSC admissions for the elderly. Minorities, aged elderly, and percent under federal poverty level were found to be associated with higher ACSC rates. The comparative analysis for 2 years highlights significant declines in the association with ACSC rates of several factors including percent minorities and rurality. The two policy-driven factors, primary care physician capacity and Medicare-managed care penetration, were not found significantly more effective over time. Using small area analysis, the study indicates that improvements in socioeconomic conditions and geographic access may have helped improve the quality of primary care received by the elderly over the last decade, particularly among some minority groups.

Adverse events for hospitalized medicare patients: is there a difference between HMO and FFS enrollees?

The study examines the likelihood of adverse outcomes associated with selected hospital safety events for two groups of Medicare patients: those enrolled in health maintenance organizations (HMOs) versus those enrolled in fee-for-service (FFS) insurance plans. The authors hypothesize that HMO patients may receive different qualities of hospital services and/or physician services relative to FFS patients. Based on the Healthcare Cost and Utilization Project State Inpatient Database, the authors include discharge data on all hospitalized elderly Medicare patients in Florida in 2002 and use multivariate logistic regression models with adjustments for hospital-level clusters. The findings demonstrate that, after adjusting for hospital quality, Medicare HMO patients were at higher risk of adverse outcomes than Medicare FFS patients for iatrogenic pneumothorax, accidental puncture or laceration, and postoperative respiratory failure.

Preventable hospitalizations and Medicare managed care: a small area analysis.

OBJECTIVE: To examine the association between preventable hospitalization rates and proportions of managed care enrollment at the primary care service area level. STUDY DESIGN: Multivariate design. METHODS: The study used the Healthcare Cost and Utilization Project State Inpatient Data from the Agency for Healthcare Research and Quality for Arizona, Massachusetts, and New York for the years 1995 and 2005 to examine the association between preventable hospitalization rates and proportions of managed care enrollment in 1995 and 2005. The period 1995-2005 was marked by the beginning and end of several legislative and policy initiatives causing changes in elderly hospitalization patterns as well as Medicare managed care enrollment patterns. The study used ordinary least squares regressions, adjusting for heteroscedasticity. A cross-sectional analysis was used to examine the association each year. A pooled sample analysis over years tested the changes in relative contributions of managed care over time. RESULTS: Preventable hospitalization rates were inversely associated with Medicare managed enrollment in both years. This association was, however, found to be weaker in 2005 than in 1995. The decline in contributions of managed care was also statistically significant. CONCLUSIONS: Despite increased managed care enrollment, the role of Medicare managed care in explaining declines in preventable hospitalization rates diminished over time. The results could be explained by the growth of private fee-for-service types of managed care plans and the resultant decline in emphasis on care coordination relative to health maintenance organization plans.

Changes in preventable hospitalization patterns among the adults: a small area analysis of US states.

The study examines the variation and changes in preventable hospitalization (PH) rates across small areas over 1995-2005 in 5 US states for adults (aged 18-64 years). Using hospital discharge data from the Agency for Healthcare Research and Quality and contextual data from Health Resources and Services Administration, the study examines the role of managed care, primary care physician supply, and sociodemographic factors on adult PH rates. A stronger influence of minority and uninsured status, weaker contributions of managed care enrollment in the commercial as well as in the Medicaid markets, and weaker contributions of primary care density may have caused slower than expected reduction in adult PH rates.

Medicare managed care plan performance: a comparison across hospitalization types.

OBJECTIVE: The study evaluates the performance of Medicare managed care (Medicare Advantage [MA]) Plans in comparison to Medicare fee-for-service (FFS) Plans in three states with historically high Medicare managed care penetration (New York, California, Florida), in terms of lowering the risks of preventable or ambulatory care sensitive conditions (ACSC) hospital admissions and providing increased referrals for admissions for specialty procedures. STUDY DESIGN/METHODS: Using 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP-SID) of the Agency for Healthcare Research and Quality, ACSC admissions are compared with 'marker' admissions and 'referral-sensitive' admissions, using a multinomial logistic regression approach. The year 2004 represents a strategic time to test the impact of MA on preventable hospitalizations, because the HMOs dominated the market composition in that time period. FINDINGS: MA enrollees in California experienced 22% lower relative risk (RRR= 0.78, p<0.01), those in Florida experienced 16% lower relative risk (RRR= 0.84, p<0.01), while those in New York experienced 9% lower relative risk (RRR=0.91, p<0.01) of preventable (versus marker) admissions compared to their FFS counterparts. MA enrollees in New York experienced 37% higher relative risk (RRR=1.37, p<0.01) and those in Florida had 41% higher relative risk (RRR=1.41, p<0.01)-while MA enrollees in California had 13% lower relative risk (RRR=0.87, p<0.01)-of referral-sensitive (versus marker) admissions compared to their FFS counterparts. CONCLUSION: While MA plans were associated with reductions in preventable hospitalizations in all three states, the effects on referral-sensitive admissions varied, with California experiencing lower relative risk of referral-sensitive admissions for MA plan enrollees. The lower relative risk of preventable admissions for MA plan enrollees in New York and Florida became more pronounced after accounting for selection bias.

Medicare managed care and primary care quality: examining racial/ethnic effects across states.

The study assesses the role of Medicare Advantage (MA) plans in providing quality primary care in comparison to FFS Medicare in three states, New York, California, Florida, across three racial ethnic groups. The performance is measured in terms of providing better quality primary care, as defined by lowering the risks of preventable hospital admissions. Using 2004 hospital discharge data (HCUP-SID) of Agency for Healthcare Research and Quality for three states, a multivariate cross sectional design is used with individual admission as the unit of analysis. The study found that MA plans were associated with lower preventable hospitalizations relative to marker admissions. The benefit also spilled over to different racial and ethnic subgroups and in some states, e.g. CA and FL, MA enrollment was associated with significantly lower odds of minority admissions than of white admissions. These results may indicate a potentially favorable role of MA plans in attenuating racial/ethnic inequalities in primary care in some states.

Admissions for CABG procedure in the elderly: was there a change in access to teaching hospitals after 1997?

The purpose of the study is to identify patient attributes associated with teaching hospital admissions in the elderly for coronary artery bypass graft (CABG), and to determine whether admission patterns in teaching hospitals by vulnerable subgroups of the elderly changed during 1997 to 2001, a period with significant changes in CABG admission patterns and financial situation faced by teaching hospitals. The study sample comprises elderly residents in two states, New York and Pennsylvania, and uses Healthcare Cost and Utilization Project State Inpatient data of the Agency for Health Care Research and Quality. Patient characteristics in major teaching hospitals are compared with those in rest of hospitals in a logistic regression framework using a pre-/postdesign, and controlling for county characteristics and resources, distance to hospitals, and hospital size and volume of procedures. Significant patient characteristics associated with a higher likelihood of admission to teaching hospitals included racial/ethnic minority status, transfer cases, Medicaid and private health maintenance organization insurance. A lower volume of CABG cases and an increased propensity to admit more complex cases characterized the admission patterns in teaching hospitals during 1997 to 2001. Although higher use of teaching hospitals by racial/ethnic minorities persisted, access for Medicaid patients disproportionately declined.

Impact of local resources on hospitalization patterns of Medicare beneficiaries and propensity to travel outside local markets.

PURPOSE: To examine how local health care resources impact travel patterns of patients age 65 and older across the rural urban continuum. METHODS: Information on inpatient hospital discharges was drawn from complete 2004 hospital discharge files from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for New York, California, and Florida, and the 2003 hospital discharge file for Pennsylvania. The study population was Medicare patients with admissions for ambulatory care sensitive conditions. Analysis was at the patient-level, and area contextual variables were developed at the Primary Care Service Area (PCSA) level. Local resources considered included inpatient supply, provider supply, supply of international medical graduates, and critical access hospitals (CAHs) in the patient's PCSA. FINDINGS: Findings generally confirmed enhanced retention of the elderly in local markets with greater availability of community resources, although we observed considerable heterogeneity across states. Community resource variables such as median household income or inpatient hospital capacity were stronger and more consistent predictors along the urban rural continuum than any of the provider or CAH variables. Only in California and New York did we see significant effects for provider supply or CAH, but they were robust across the 2 states and models of travel propensity, always reducing the travel propensity. CONCLUSIONS: Findings support policies aimed at augmenting supplies of critical access hospitals in rural communities, and increasing primary care physicians and hospital resources in both rural and urban communities.

Trends in racial disparities among the elderly for selected procedures.

The authors examine trends over 1997-2001 in racial or ethnic disparities in the utilization of three costly, referral-sensitive procedures among the elderly-coronary artery bypass grafting (CABG), percutaneous transluminal coronary angioplasty (PTCA), and hip/joint replacement. Using a multivariate framework, they undertake a simultaneous examination of the relationships between patient, local area context, and health systems on these admission types after comparing them to a control group. This period spans the implementation of the Balanced Budget Act and a major Department of Health and Human Services initiative to reduce disparities in cardiovascular and other diseases. Findings suggest increasing disparities for African Americans relative to Whites in their lower utilization of CABG and PTCA over time, and increasing disparities in the utilization of hip/joint replacement among other races' relative to Whites. The authors find that racial or ethnic disparities in use of referral-sensitive procedures did not narrow over 1997-2001.

Do HMOs reduce preventable hospitalizations for Medicare beneficiaries?

This study assesses the association of HMO enrollment with preventable hospitalizations among the elderly in four states. Using 2001 hospital discharge abstracts for elderly Medicare enrollees (age 65 and above) residing in four states (New York, Pennsylvania, Florida, and California), from the Healthcare Cost and Utilization Project (HCUP-SID) database of the Agency for Healthcare Research and Quality, we use a multivariate cross-sectional design with patient-level data for each state. Holding other factors such as demographics and illness severity constant, we find that in three out of four states, Medicare HMO patients had lower odds of a preventable admission versus marker admission than Medicare fee-for-service (FFS) patients. Moreover, in the two states with longest tenure and greatest Medicare HMO penetration, California and Florida, the reduction in preventable admissions among Medicare HMO patients was mainly concentrated among more ill patients. These findings add to the evidence that managed care outperforms traditional care among the elderly, rather than simply skimming off the healthiest populations.