Effects of Hospital Type and Distance on Lymph Node Assessment for Colon Cancer Among Metropolitan and Nonmetropolitan Patients in Appalachia.

We studied differences in access to large or accredited cancer programs as a possible explanation for geographic disparities in adherence to the national guideline on lymph node assessment for Stages I to III colon cancer. State cancer registries were linked with Medicare claims of patients diagnosed from 2006 to 2008 from Appalachian counties of four states. Metropolitan and nonmetropolitan patients differed on adherence, proximity to high-volume or accredited hospitals, and hospital type. We modeled effects of hospital type on adherence with ordinary least squares and instrumental variables (instrumenting for hospital type with relative distance). The evidence was strongest for improved adherence in high-volume hospitals for nonmetropolitan patients. We estimate that roughly 100 deaths might be prevented over 5 years among each year's incident cases if the nonmetropolitan disparity in hospital volume were eliminated nationally. We conclude that regionalization or targeting smaller hospitals would improve adherence in nonmetropolitan areas, but also argue for improving adherence generally.

Reducing Medicaid Churning: Extending Eligibility For Twelve Months Or To End Of Calendar Year Is Most Effective.

Medicaid churning--the constant exit and reentry of beneficiaries as their eligibility changes--has long been a problem for both Medicaid administrators and recipients. Churning will continue under the Affordable Care Act because, despite new federal rules, Medicaid eligibility will continue to be based on current monthly income. We developed a longitudinal simulation model to evaluate four policy options for modifying or extending Medicaid eligibility to reduce churning. The simulations suggest that two options--extending eligibility either to the end of a calendar year or for twelve months after enrollment--would be the most effective methods for reducing churning. The other options--a three-month extension or eligibility based on projected annual income--would reduce churning to a lesser extent. States should consider implementation of the option that best balances costs while improving access to coverage and, thereby, the health of Medicaid enrollees.

New estimates of gaps and transitions in health insurance.

Changes in individual or family circumstances cause many Americans to experience gaps and transitions in public and private health insurance. Using data from the 2004-2007 Survey of Income and Program Participation, this article updates earlier analyses of insurance gaps and transitions. Eighty-nine million people (one third of nonelderly Americans) were uninsured for at least 1 month during those 4 years. Approximately 23 million lost insurance more than once. The analyses call attention to the continuing instability and insecurity of health insurance, can inform implementation of national reforms, and establish a recent baseline that will be helpful in evaluating the reforms' effects on coverage stability.

Use of psychotropic medications by US cancer survivors.

OBJECTIVES: This study aimed to describe national utilization of psychotropic medications by adult cancer survivors in the USA and to estimate the extra use of psychotropic medications that is attributable to cancer survivorship. METHODS: Prescription data for 2001-2006 from the Medical Expenditure Panel Survey (MEPS) were linked to the data identifying cancer survivors from the National Health Interview Survey, the MEPS sampling frame. The sample was limited to adults 25 years of age and older. Propensity score matching was used to estimate the effects of cancer survivorship on utilization of psychotropic medications by comparing cancer survivors and other adults in MEPS. Utilization was measured as any use during a calendar year and the number of prescriptions purchased (including refills). Analyses were stratified by gender and age, distinguishing adults younger than 65 years from those 65 years and older. RESULTS: Nineteen percent of cancer survivors under age 65 years and 16% of survivors age 65 years and older used psychotropic medications. Sixteen percent of younger survivors used antidepressants, 7% used antianxiety medications. For older survivors, utilization rates for these two drug types were 11% and 7%, respectively. The increase in any use attributable to cancer amounted to 4-5 percentage points for younger survivors (p < 0.05) and 2-3 percentage points for older survivors (p < 0.05), depending on gender. CONCLUSION: Increased use of psychotropic medications by cancer survivors, compared with other adults, suggests that survivorship presents ongoing psychological challenges.

Maintaining coverage, affordability, and shared responsibility when income and employment change.

The Affordable Care Act builds on existing sources of public and private health insurance, while creating new health insurance exchanges and subsidies. A potential disadvantage of preserving many sources of health insurance is the likelihood of abrupt changes in coverage or financial responsibility when individual circumstances change. This brief describes four policy challenges related to such changes: adjusting premium and cost-sharing subsidies when incomes change; coordinating eligibility for premium credits, Medicaid, and the Children's Health Insurance Program; encouraging and facilitating continuous coverage; and minimizing transitions between individual and small-business exchanges. Policy recommendations to reduce uncertainty, simplify coverage decisions, and minimize insurance transitions include extending coverage to the open enrollment period at the end of the year, generous treatment of income gains in correcting premium tax credits, and unifying the small-business and individual exchanges.

Medical expenditures of adult cancer survivors aged <65 years in the United States.

BACKGROUND: To the authors' knowledge, this is the first study to provide national estimates of medical expenditures for all adult cancer survivors aged <65 years. Most studies of expenditures for cancer survivors in this age group have been based on the Medical Expenditure Panel Survey (MEPS) and were limited to "affected survivors." METHODS: MEPS expenditure data for 2001 to 2007 were linked to data identifying all survivors from the National Health Interview Survey (NHIS), which is the MEPS sampling frame. The sample was comprised of adults ages 25 to 64 years. Propensity-score matching was used to estimate the effects of cancer on average total and out-of-pocket expenditures for all services and separately for prescriptions. Probit models were used to estimate effects on the probability of exceeding different expenditure thresholds. RESULTS: Mean annual expenditures on all services in 2007 were $16,910 ± $3911 for survivors who were newly diagnosed with cancer, $7992 ± $972 for survivors who had been diagnosed in previous years, and $3303 ± $103 for other adults. Fifty-three percent of survivors were not identified in MEPS but only by linking to NHIS. Expenditures for all survivors averaged approximately $9300 compared with $13,600 for "affected survivors." For previously diagnosed survivors, the increase in mean expenditures attributable to cancer was approximately $4000 to $5000 annually. On average, relatively little of the increase was paid out of pocket, but cancer nearly doubled the risk of high out-of-pocket expenditures. CONCLUSIONS: Previous MEPS analyses overstated average expenditures for all survivors. Nevertheless, the current results indicated that the increase in expenditures attributable to cancer is substantial, even for longer term survivors, and that cancer increases the relative risk of high out-of-pocket expenditures.

Cancer survivorship, health insurance, and employment transitions among older workers.

This study examined the effect of job-related health insurance on employment transitions (labor force exits, reductions in hours, and job changes) of older working cancer survivors. Using multivariate models, we compared longitudinal data for the period 1997-2002 from the Penn State Cancer Survivor Study to similar data for workers with no cancer history in the Health and Retirement Study, who were also ages 55 to 64 at follow-up. The interaction of cancer survivorship with health insurance at diagnosis was negative and significant in predicting labor force exits, job changes, and transitions to part-time employment for both genders. The differential effect of job-related health insurance on the labor market dynamics of cancer survivors represents an additional component of the economic and psychosocial burden of cancer on survivors.

Transitioning to Medicare before age sixty-five.

Disabled workers who start receiving Social Security Disability Income (SSDI) must wait twenty-four months to qualify for Medicare. Legislation introduced in Congress would eliminate this waiting period, to guarantee that people with disabilities severe enough to qualify for SSDI will not be uninsured. We provide a longitudinal view of Medicare enrollment before age sixty-five by following a national sample of people ages 55-64. One person in six was covered by Medicare before turning sixty-five. A quarter of new enrollees were uninsured during the waiting period. There were great disparities in reliance on Medicare and coverage in the waiting period.

Meeting the need for personal care among the elderly: does Medicaid home care spending matter?

OBJECTIVE: To determine whether Medicaid home care spending reduces the proportion of the disabled elderly population who do not get help with personal care. DATA SOURCES: Data on Medicaid home care spending per poor elderly person in each state is merged with data from the Medicare Current Beneficiary Survey for 1992, 1996, and 2000. The sample (n=6,067) includes elderly persons living in the community who have at least one limitation in activities of daily living (ADLs). STUDY DESIGN: Using a repeated cross-section analysis, the probability of not getting help with an ADL is estimated as a function of Medicaid home care spending, individual income, interactions between income and spending, and a set of individual characteristics. Because Medicaid home care spending is targeted at the low-income population, it is not expected to affect the population with higher incomes. We exploit this difference by using higher-income groups as comparison groups to assess whether unobserved state characteristics bias the estimates. PRINCIPAL FINDINGS: Among the low-income disabled elderly, the probability of not receiving help with an ADL limitation is about 10 percentage points lower in states in the top quartile of per capita Medicaid home care spending than in other states. No such association is observed in higher-income groups. These results are robust to a set of sensitivity analyses of the methods. CONCLUSION: These findings should reassure state and federal policymakers considering expanding Medicaid home care programs that they do deliver services to low-income people with long-term care needs and reduce the percent of those who are not getting help.

Responding to employment concerns of cancer survivors.

The report on cancer survivorship recently released by the Institute of Medicine called on providers to become familiar with the employment rights of survivors, to offer them information about employment rights and programs, and to help minimize the adverse effects of cancer on employment. This review is designed to help providers respond to the Institute of Medicine's recommendations by describing relevant employment and health insurance protections, nationally accessible services and information sources for survivors, functional limitations that may affect survivors' work, and a variety of rehabilitation services that may be helpful for survivors with disabling residual effects of cancer and its treatment. It also suggests directions for further efforts on the part of public and private cancer organizations, researchers, and clinicians to address the employment concerns of survivors.

Low-income children's preventive services use: implications of parents' Medicaid status.

This article examines the effect of parents' Medicaid status on the use of preventive health services by young children. Using data from the 1996 Medical Expenditure Panel Survey (MEPS), we analyzed a logit model for receipt of any well-child visits (WCVs) that compared three groups of low-income children. The three groups, defined by the joint insurance status of children and their parents, involved Medicaid pairs (both the child and the parent had Medicaid throughout the year), mixed pairs (the child had Medicaid and the parent was uninsured), and uninsured pairs (both child and parent were uninsured). Medicaid coverage for children was positively associated with receipt of any WCVs. However, the utilization effect of Medicaid coverage for children was significantly larger when the parent was also on Medicaid instead of being uninsured. Considering uninsured children with uninsured parents in 1996, enrolling only the children in Medicaid would have increased the percentage with WCVs from 29 to 43 percent according to simulations with the logit model. If the parents were enrolled in Medicaid as well, the percentage of children with any WCVs would have increased to 67 percent.

Battery-powered health insurance? Stability in coverage of the uninsured.

This study assesses the stability of Americans' health insurance status over a four-year period. Relatively few Americans were continuously uninsured for the four years 1996 to 1999, but a sizable number of the uninsured lacked a stable source of coverage. At least as many people were repeatedly uninsured as experienced a single gap in otherwise stable coverage. Given these dynamics, policymakers should think of "uninsured" as referring not to people, but rather to gaps in coverage over time. Reforms that stop short of universal coverage should be evaluated in terms of their likely effects on the continuity and stability of coverage.

Health insurance for Americans approaching age sixty-five: an analysis of options for incremental reform.

This article provides a systematic evaluation of the options for incremental health insurance reforms aimed at older Americans nearing age sixty-five. It presents three basic arguments for giving special consideration to this age group: (1) early retirement and its effect on access to employer insurance; (2) changes in health and health care expenses associated with increasing age; (3) the vulnerability to unexpected economic or health "shocks" that will affect people throughout their retirement. The analysis of policy options begins by specifying criteria for evaluating alternative approaches to reform. The proposed criteria emphasize that reforms for this age group should be designed to fit with other financial plans and decisions made during such a transitional stage of life. Policy options should be judged according to fundamental goals such as equity and efficiency, not simply ranked according to the number of uninsured who will gain coverage. After offering a comprehensive catalog and evaluation of available options, the analysis identifies and discusses a preferred approach-which preserves choices while offering universal and subsidized access to Medicare before age sixty-five.

Effect of CAHPS performance information on health plan choices by Iowa Medicaid beneficiaries.

This evaluation tested if Consumer Assessment of Health Plans Study (CAHPS) information on plan performance affected health plan choices by new beneficiaries in Iowa Medicaid. New cases entering Medicaid in selected counties during February through May 2000 were assigned randomly to experimental or control groups. The control group received standard Medicaid enrollment materials, and the experimental group received these materials plus a CAHPS report. We found that CAHPS information did not affect health plan choices by Iowa Medicaid beneficiaries, similar to previously reported findings for New Jersey Medicaid. However, it did affect plan choice in an earlier laboratory experiment. The value of this information may be limited to a subset of receptive consumers who actively study information received, even then only when (1) ratings of available plans differ greatly, (2) ratings differ from prior beliefs about plan quality, and (3) reports are easy to understand.

Effects of CAHPS health plan performance information on plan choices by New Jersey Medicaid beneficiaries.

OBJECTIVE: To assess the effects of CAHPS health plan performance information on plan choices and decision processes by New Jersey Medicaid beneficiaries. DATA SOURCES/STUDY SETTING: The study sample was a statewide sample of all new Medicaid cases that chose Medicaid health plans during April 1998. The study used state data on health maintenance organization (HMO) enrollments and survey data for a subset of these cases. STUDY DESIGN: An experimental design was used, with new Medicaid cases randomly assigned to experimental or control groups. The experimental group received a CAHPS report along with the standard enrollment materials, and the control group did not. DATA COLLECTION: The HMO enrollment data were obtained from the state in June 1998, and evaluation survey data were collected from July to October 1998. PRINCIPAL FINDINGS: No effects of CAHPS information on HMO choices were found for the total sample. Further examination revealed that only about half the Medicaid cases said they received and read the plan report and there was an HMO with dominant Medicaid market share but low CAHPS performance scores. The subset of cases who read the report and did not choose this dominant HMO chose HMOs with higher CAHPS scores, on average, than did those in an equivalent control group. CONCLUSIONS: Health plan performance information can influence plan choices by Medicaid beneficiaries, but will do so only if they actually read it. These findings suggest a need for enhancing dissemination of the information as well as further education to encourage informed choices.

Testing the effect of quality reports on the health plan choices of Medicare beneficiaries.

This article describes a laboratory experiment that used a convenience sample of 225 Medicare beneficiaries to test the effects of comparative quality information on plan choice. Providing information about quality did not significantly influence the choice between Original Medicare and a health maintenance organization (HMO), but did affect the choice of HMO. Results from this experiment suggest that information about plan quality may not be effective in encouraging beneficiaries to leave Original Medicare and join HMOs that are rated high in quality. Furthermore, beneficiaries choosing among HMOs were not inclined to select a low-cost HMO, even when it was rated higher in quality. Implications for policy are discussed.