When coverage expands: children's health insurance program as a natural experiment in use of health care services.

BACKGROUND: Expanding insurance coverage is designed to improve access to primary care and reduce use of emergency department (ED) services. Whether expanding coverage achieves this is of paramount importance as the United States prepares for the Affordable Care Act. OBJECTIVES: Emergency and outpatient department use was examined after the State Children's Health Insurance Program (CHIP) coverage expansion, focusing on adolescents (a major target group for CHIP) versus young adults (not targeted). The hypothesis was that coverage would increase use of outpatient services, and ED use would decrease. METHODS: Using the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), the years 1992-1996 were analyzed as baseline and then compared to use patterns in 1999-2009, after the CHIP launch. Primary outcomes were population-adjusted annual visits to ED versus nonemergency outpatient settings. Interrupted time series were performed on use rates to ED and outpatient departments between adolescents (11 to 18 years old) and young adults (19 to 29 years old) in the pre-CHIP and CHIP periods. Outpatient-to-ED ratios were calculated and compared across time periods. A stratified analysis by payer and sex was also performed. RESULTS: The mean number of outpatient adolescent visits increased by 299 visits per 1,000 persons (95% confidence interval [CI] = 140 to 457), while there was no statistically significant increase in young adult outpatient visits across time periods. There was no statistically significant change in the mean number of adolescent ED visits across time periods, while young adult ED use increased by 48 visits per 1,000 persons (95% CI = 24 to 73). The adolescent outpatient-to-ED ratio increased by 1.0 (95% CI = 0.49 to 1.6), while the young adults ratio decreased by 0.53 across time periods (95% CI = -0.90 to -0.16). CONCLUSIONS: Since CHIP, adolescent non-ED outpatient visits have increased, while ED visits have remained unchanged. In comparison to young adults, expanding insurance coverage to adolescents improved use of health care services and suggests a shift to non-ED settings. Expanding insurance through the Affordable Care Act of 2010 will likely increase use of outpatient services, but may not decrease ED volumes.

Variation in inpatient tonsillectomy costs within and between US hospitals attributable to postoperative complications.

BACKGROUND: Tonsillectomy is the second most common inpatient procedure in US children. However, the factors that influence tonsillectomy-related costs are unknown. OBJECTIVE: The objective of the study was to describe variation in US inpatient tonsillectomy costs and examine whether postoperative complications contribute to these disparities in costs. RESEARCH DESIGN: This is a retrospective cohort study of the 2009 Nationwide Inpatient Sample. Hierarchical, mixed-effects linear regression modeling was used to analyze the association between postoperative complications and cost, controlling for clinically relevant characteristics such as age, number of chronic comorbidity indicators, and hospital mean complication rates. We also estimated the variance in cost attributable to the treating hospital using the intraclass correlation coefficient. SUBJECTS: The study cohort comprised 12,512 adult and pediatric patients undergoing tonsillectomy or adenotonsillectomy in the inpatient setting. MEASURES: Cost, posttonsillectomy hemorrhage, and mechanical ventilator use at the individual encounter and at hospital level were evaluated. RESULTS: The aggregate cost of tonsillectomies in the cohort was $94.2 million. The median cost per encounter across all hospitals was $4393 (interquartile range, $3279-$6981), whereas the mean cost was $7525 (95% confidence interval, $6453-$8597). Mechanical ventilation was associated with an adjusted increase of $30,081 per encounter (95% confidence interval, $18,199-$41,964). The intraclass correlation coefficient declined from 0.117 to 0.070 after adjusting for mean hospital mechanical ventilation rate, which accounted for 40.2% of the interhospital variation in cost. CONCLUSIONS: Use of mechanical ventilation significantly increases the cost of inpatient tonsillectomy care. Further research should examine risk factors contributing to higher rates of mechanical ventilation after tonsillectomy, which in turn can guide systemic quality improvement interventions to reduce costs.

The voices of limited English proficiency Latina mothers on pediatric primary care: lessons for the medical home.

The objective of this study is to inform medical home implementation in practices serving limited English proficiency Latino families by exploring limited English proficiency Latina mothers' experiences with, and expectations for, pediatric primary care. In partnership with a federally-qualified community health center in an urban Latino neighborhood, we conducted semi-structured interviews with 38 low-income Latina mothers. Eligible participants identified a pediatric primary care provider for their child and had at least one child 3 years old or younger, to increase the probability of frequent recent interactions with health care providers. Interview transcripts were coded and analyzed through an iterative and collaborative process to identify participants' satisfaction with and expectations for pediatric primary care. About half of the mothers interviewed were satisfied with their primary care experiences. Mothers suggested many ways to improve the quality of pediatric primary care for their children to better meet the needs of their families. These included: encouraging providers to invest more in their relationship with families, providing reliable same-day sick care, expanding hours, improving access to language services, and improving care coordination services. Limited English proficiency Latina mothers expect high-quality pediatric primary care consistent with the medical home model. Current efforts to improve primary care quality through application of the medical home model are thus relevant to this population, but should focus on the parent-provider relationship and timely access to care. Promoting this model among practices that serve limited English proficiency Latino families could improve engagement and satisfaction with primary care.

Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996-2006.

BACKGROUND: Traditionally, thyroid surgery has been an inpatient procedure due to the risk of several well-documented complications. Recent research suggests that for selected patients, outpatient thyroid surgery is safe and feasible, with the additional potential benefit of cost savings. In recognition of these observations, we hypothesized that there would be an increase in U.S. outpatient thyroidectomies with a concurrent decline in inpatient thyroidectomies over time. METHODS: Comparative cross-sectional analyses of the National Survey of Ambulatory Surgery (NSAS) and Nationwide Inpatient Sample (NIS) databases from 1996 and 2006 were performed. All cases of thyroid surgery were extracted, as well as data on age, sex, and insurance status. Diagnoses and surgical cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and treatment codes. Hospital charges were acquired from the NIS 1996 and 2006 and NSAS 2006 releases, using imputed data where necessary. After survey weights were applied, patient characteristics, diagnoses, and procedures were compared for inpatient versus outpatient procedures. RESULTS: The total number of thyroidectomies increased 39%, from 66,864 to 92,931 cases per year during the study timeframe. Outpatient procedures increased by 61%, while inpatient procedures increased by 30%. The proportion of privately insured inpatients declined slightly from 63.8% to 60.1%, while those covered by Medicare increased from 22.8% to 25.8%. In contrast, the proportion of privately insured outpatients declined sharply from 76.8% to 39.9%, while those covered by Medicare rose from 17.2% to 45.7%. These trends coincided with a small increase in the mean inpatient age from 50.2 to 52.3 years and a larger increase in the mean outpatient age from 50.7 to 58.1 years. Inflation-adjusted per-capita charges for inpatient thyroidectomies more than doubled from $9,934 in 1996 to $22,537 in 2006, while aggregate national inpatient charges tripled from $464 million to $1.37 billion. By comparison, per-capita charges for outpatient thyroidectomy totaled $7,222 in 2006. CONCLUSIONS: From 1996 to 2006, there has been a concurrent modest increase in inpatient and pronounced increase in outpatient thyroidectomies in the United States, with a consequential demographic shift and economic impact.

Payer leverage and hospital compliance with a benchmark: a population-based observational study.

BACKGROUND: Since 1976, Medicare has linked reimbursement for hospitals performing organ transplants to the attainment of certain benchmarks, including transplant volume. While Medicare is a stakeholder in all transplant services, its role in renal transplantation is likely greater, given its coverage of end-stage renal disease. Thus, Medicare's transplant experience allows us to examine the role of payer leverage in motivating hospital benchmark compliance. METHODS: Nationally representative discharge data for kidney (n = 29,272), liver (n = 7,988), heart (n = 3,530), and lung (n = 1,880) transplants from the Nationwide Inpatient Sample (1993-2003) were employed. Logistic regression techniques with robust variance estimators were used to examine the relationship between hospital volume compliance and Medicare market share; generalized estimating equations were used to explore the association between patient-level operative mortality and hospital volume compliance. RESULTS: Medicare's transplant market share varied by organ [57%, 28%, 27%, and 18% for kidney, lung, heart, and liver transplants, respectively (P < 0.001)]. Volume-based benchmark compliance varied by transplant type [85%, 75%, 44%, and 39% for kidney, liver, heart, and lung transplants, respectively (P < 0.001)], despite a lower odds of operative mortality at compliant hospitals. Adjusting for organ supply, high market leverage was independently associated with compliance at hospitals transplanting kidneys (OR, 143.00; 95% CI, 18.53-1103.49), hearts (OR, 2.84; 95% CI, 1.51-5.34), and lungs (OR, 3.24; 95% CI, 1.57-6.67). CONCLUSION: These data highlight the influence of payer leverage-an important contextual factor in value-based purchasing initiatives. For uncommon diagnoses, these data suggest that at least 30% of a provider's patients might need to be "at risk" for an incentive to motivate compliance.

Assessment of torture and ill treatment of detainees in Mexico: attitudes and experiences of forensic physicians.

CONTEXT: International and Mexican human rights organizations have documented torture of detainees (ie, those held and indicted but not sentenced) in all 31 states and the Federal District of Mexico, but little is known about the attitudes and experiences of forensic physicians examining detainees. OBJECTIVE: To assess forensic physicians' experiences with and attitudes toward the nature and extent of torture and ill treatment among detainees examined in the previous year. DESIGN, SETTING, AND PARTICIPANTS: With the support of the Mexican Office of the Federal Attorney General, as part of a larger initiative to implement governmental reforms to eradicate torture in Mexico, an anonymous, self-administered, written, 80-item survey designed to assess correspondence of physician practices and attitudes with international standards on forensic investigation and documentation of torture was distributed to all federal forensic physicians (n = 115) and a convenience sample of state forensic physicians (n = 99) in Mexico in 2002. MAIN OUTCOME MEASURES: Estimates of the numbers of federal detainees medically evaluated and numbers of cases of suspected, alleged, and documented torture or ill treatment among federal detainees; factors interfering with documentation of forensic evidence; physicians' attitudes toward torture; measures that would help them document torture; and recommendations for reform. RESULTS: Survey responses were received from 93 (81%) federal and 91 (92%) state forensic physicians. Forty-nine percent of federal physicians and 58% of state physicians reported that torture is a severe problem for detainees in Mexico. Federal physicians estimated that they had conducted 26 445 to 30 650 or more medical evaluations of the 13 000 federal detainees in the past year and that between 1658 and 4850 of these detainees had alleged torture; these physicians also estimated that they had documented evidence of torture in a range of 285 to 1090 cases. Forty percent of respondents had suspected torture and/or ill treatment of detainees examined during the previous year, 64% had examined detainees who alleged these practices had occurred, and 49% had documented forensic evidence of torture among these detainees. Respondents reported that lack of photographic equipment and services (58%), inadequate monitoring and accuracy of medical examinations (36%), inadequate documentation of torture (29%), limitations in their training (28%), fear of reprisals for documenting torture (23%), and fear of coercion by police officials (18%) are factors that interfere with documentation of torture and ill treatment of detainees. Respondents further reported the need for additional training (98%), standardized protocols and documentation procedures for use in cases of alleged or suspected torture and/or ill treatment (81%), and monitoring to ensure the quality and accuracy of medical evaluations (95%). CONCLUSIONS: Torture and ill treatment of detainees is a major problem in Mexico facilitated by multiple medical and legal factors. Mexican forensic physicians support measures to improve forensic documentation of torture and ill treatment of detainees.

Medicaid managed care: are academic medical centers penalized by attracting patients with high-cost conditions?

OBJECTIVE: To determine whether case-mix and health utilization disparities exist between Medicaid enrollees within a Michigan managed care organization (MCO) who selected primary care providers (PCPs) affiliated with a major academic medical center (AMC) and enrollees who selected community providers. STUDY DESIGN: A retrospective cohort study using cost estimates obtained from claims data and based on a standardized Medicaid fee schedule. METHODS: We established the prevalence of 25 high-cost chronic medical conditions from the claims data for capitated Medicaid enrollees from January 1, 1997, through October 31, 1999. We assessed differences in healthcare cost estimates per member for Medicaid enrollees at AMC primary care sites versus other community sites using t tests and linear regressions, including analyses stratified for Temporary Assistance for Needy Families (TANF) and Aid to Blind and Disabled (ABAD) programs. RESULTS: Enrollees with AMC providers had a much higher cumulative prevalence of the 25 high-cost chronic medical conditions (95.6 per 1000 enrollees versus 65.6 per 1000; P < .001), and virtually all of this difference was confined to ABAD enrollees. Estimated total costs were also higher for ABAD Medicaid enrollees at the AMC sites than for those at community sites. The average total services and pharmacy cost estimates per ABAD member were $1219 higher per member per year at the AMC sites (P < .001), primarily from costs of inpatient hospitalizations. Regression analyses demonstrated that differences in the prevalence of the 25 high-cost chronic medical conditions accounted for about 50% of the cost differences observed between sites. These analyses suggest that at least half of the observed cost disparity was due to adverse selection. CONCLUSIONS: This study found both significant case-mix and cost disparities for ABAD patients, suggesting that AMC primary care sites experienced substantial adverse selection. Unless approaches to account for adverse selection are put in place, this phenomenon could jeopardize ABAD Medicaid recipients' ongoing access to needed medical care.

The rheumatoid hand: a predictable disease with unpredictable surgical practice patterns.

OBJECTIVES: To evaluate variation in fusion, arthroplasty, and tenosynovectomy rates among rheumatoid arthritis (RA) patients across states; to evaluate associations between surgery rates and the density of hand surgeons; and to evaluate differences in treatment by sex of the patient. METHODS: Data were obtained from the 1996 and 1997 Healthcare Cost and Utilization Project database. The procedure codes for fusion, arthroplasty, and tenosynovectomy were matched to patients with the diagnostic code of RA, which provided the total number of procedures performed in each state. The smoothed estimates of the RA population for each state were derived from age/sex strata in the 1995 US census using age/sex-adjusted RA prevalence data from the Third National Health and Nutrition Examination Survey. The number of hand surgeons was from the 1996 American Society for Surgery of the Hand. RESULTS: Procedure rates across states varied from 9-fold to 12-fold for all 3 procedures. The rates of the reconstructive procedures-fusion and arthroplasty-were highly correlated in each state, but these 2 procedures were only moderately correlated with tenosynovectomy. Surgeon density and procedure rates were minimally correlated. Procedure rates differed by patient sex, with significantly more arthroplasty and fusion procedures performed in women. More tenosynovectomy procedures were performed in men, and they were also performed at a younger age in men. CONCLUSIONS: Significant large area variations are present in the surgical management of the rheumatoid hand, but the correlations between reconstructive and early intervention procedures are modest. These rate differences are not explained by the number of hand surgeons, disease prevalence, or demographic composition of the states. However, men are more likely to receive more aggressive early surgical interventions, and women are more likely to receive end-stage reconstructive surgery.