Patient Experience Of Provider Refusal Of Medicaid Coverage And Its Implications.

Previous studies show that many physicians do not accept new patients with Medicaid coverage, but no study has examined Medicaid enrollees' actual experience of provider refusal of their coverage and its implications. Using the 2012 National Health Interview Survey, we estimate provider refusal of health insurance coverage reported by 23,992 adults with continuous coverage for the past 12 months. We find that among Medicaid enrollees, 6.73% reported their coverage being refused by a provider in 2012, a rate higher than that in Medicare and private insurance by 4.07 (p<.01) and 3.68 (p<.001) percentage points, respectively. Refusal of Medicaid coverage is associated with delaying needed care, using emergency room (ER) as a usual source of care, and perceiving current coverage as worse than last year. In view of the Affordable Care Act's (ACA) Medicaid expansion, future studies should continue monitoring enrollees' experience of coverage refusal.

Seeking health information online: does limited healthcare access matter?

Consumers facing barriers to healthcare access may use online health information seeking and online communication with physicians, but the empirical relationship has not been sufficiently analyzed. Our study examines the association of barriers to healthcare access with consumers' health-related information searching on the internet, use of health chat groups, and email communication with physicians, using data from 27,210 adults from the 2009 National Health Interview Survey. Individuals with financial barriers to healthcare access, difficulty getting timely appointments with doctors, and conflicts in scheduling during clinic hours are more likely to search for general health information online than those without these access barriers. Those unable to get timely appointments with physicians are more likely to participate in health chat groups and email physicians. The internet may offer a low-cost source of health information and could help meet the heightened demand for health-related information among those facing access barriers to care.

Racial-ethnic disparities in use of antidepressants in private coverage: implications for the Affordable Care Act.

OBJECTIVE: The objective of this study was to examine racial-ethnic disparities in the use of antidepressants among people with private coverage and people with public insurance or no coverage. METHODS: Data were from Medical Expenditure Panel Surveys (2006-2010), and logistic regression was used for the analysis. RESULTS: Among persons with depression and private coverage, racial-ethnic minority groups were significantly less likely than non-Hispanic whites to use antidepressants (N=4,468; adjusted odds ratio [AOR]=.50, 95% confidence interval [CI]=.33-.66 for non-Hispanic blacks; AOR=.70, CI=.55-.89 for Hispanics). No significant racial-ethnic disparity in the use of antidepressants was found in Medicare (N=1,944), Medicaid (N=2,125), and uninsured populations (N=1,679). For all racial-ethnic groups, persons with no insurance coverage had much lower rates of antidepressant use than their insured counterparts. CONCLUSIONS: A wide racial-ethnic gap in the use of antidepressants existed in private coverage. As the nation continues to implement the Affordable Care Act, which will increase the number of enrollees from racial-ethnic minority groups in private plans, continuing efforts will be needed to reduce racial-ethnic disparities in the use of antidepressants.

Demand for prescription drugs under non-linear pricing in Medicare Part D.

We estimate the price elasticity of prescription drug use in Medicare Part D, which features a non-linear price schedule due to a coverage gap. We analyze patterns of drug utilization prior to the coverage gap, where the "effective price" is higher than the actual copayment for drugs because consumers anticipate that more spending will make them more likely to reach the gap. We find that enrollees' total pre-gap drug spending is sensitive to their effective prices: the estimated price elasticity of drug spending ranges between [Formula: see text]0.14 and [Formula: see text]0.36. This finding suggests that filling in the coverage gap, as mandated by the health care reform legislation passed in 2010, will influence drug utilization prior to the gap. A simulation analysis indicates that closing the gap could increase Part D spending by a larger amount than projected, with additional pre-gap costs among those who do not hit the gap.

Competition and quality in home health care markets.

Market-based solutions are often proposed to improve health care quality; yet evidence on the role of competition in quality in non-hospital settings is sparse. We examine the relationship between competition and quality in home health care. This market is different from other markets in that service delivery takes place in patients' homes, which implies low costs of market entry and exit for agencies. We use 6 years of panel data for Medicare beneficiaries during the early 2000s. We identify the competition effect from within-market variation in competition over time. We analyze three quality measures: functional improvements, the number of home health visits, and discharges without hospitalization. We find that the relationship between competition and home health quality is nonlinear and its pattern differs by quality measure. Competition has positive effects on functional improvements and the number of visits in most ranges, but in the most competitive markets, functional outcomes and the number of visits slightly drop. Competition has a negative effect on discharges without hospitalization that is strongest in the most competitive markets. This finding is different from prior research on hospital markets and suggests that market-specific environments should be considered in developing polices to promote competition.

Nonlinear pricing in drug benefits and medication use: the case of statin compliance in Medicare Part D.

OBJECTIVE: To examine how enrollees' statin compliance responds to expected prices in Medicare Part D, which features a nonlinear price schedule due to a coverage gap. DATA SOURCES/STUDY SETTING: Prescription Drug Event data for a 5 percent random sample of Medicare Advantage Prescription Drug Plan enrollees in 2008 who did not receive a low-income subsidy. STUDY DESIGN: We analyze statin compliance prior to the coverage gap, where the "effective price" is higher than the actual copayment for drugs because consumers anticipate that more spending will make them more likely to reach the gap. We construct each enrollee's effective price as her expected price at the end of the year, which is the weighted average between pre-gap and in-gap copayments with the weight being the predicted probability of hitting the gap. Compliance is defined as at least 80 percent of days covered. PRINCIPAL FINDINGS: Part D enrollees' pre-gap statin compliance decreases by 3.7-4.7 percentage points for a $10 increase in the effective price. CONCLUSION: The presence of a coverage gap decreases statin compliance prior to the gap, suggesting that incorporating expected future prices is important to assess the full impact of cost sharing on drug compliance under nonlinear price schedules.

National trends in the use of antidepressants between 1997 and 2009 and the role of Medicare Part D implementation.

OBJECTIVES: This study examined national trends in antidepressant use before and after implementation of Medicare Part D and compared utilization among individuals with different types of insurance. METHODS: The data source was the Medical Expenditure Panel Survey Household Component (1997-2009), and logistic regression was used for the analysis. RESULTS: The odds of antidepressant use among people with depression increased between 1997 and 2009 in each insurance group (Medicare: adjusted odds ratio [AOR]=3.30, 95% confidence interval [CI]=1.84-5.92; Medicaid: AOR=2.97, CI=2.01-4.40; dually eligible for Medicare and Medicaid: AOR=2.24, CI=1.11-4.54; and private coverage: AOR=6.63, CI=5.23-8.42). The odds of antidepressant use after implementation of Part D increased more among Medicare beneficiaries than among Medicaid beneficiaries (AOR=1.35, CI=1.05-1.72). CONCLUSIONS: The use of antidepressants among people with depression increased in all insurance groups up to 2009; however, the patterns of utilization and the degree of increase over time differed by insurance type.

Where are you from? A validation of the Foreigner Objectification Scale and the psychological correlates of foreigner objectification among Asian Americans and Latinos.

Many ethnic minorities in the United States consider themselves to be just as American as their European American counterparts. However, there is a persistent cultural stereotype of ethnic minorities as foreigners (i.e., the perpetual foreigner stereotype) that may be expressed during interpersonal interactions (i.e., foreigner objectification). The goal of the present study was to validate the Foreigner Objectification Scale, a brief self-report measure of perceived foreigner objectification, and to examine the psychological correlates of perceived foreigner objectification. Results indicated that the Foreigner Objectification Scale is structurally (i.e., factor structure) and metrically (i.e., factor loadings) invariant across foreign-born and U.S.-born Asian Americans and Latinos. Scalar (i.e., latent item intercepts) invariance was demonstrated for the two foreign-born groups and the two U.S.-born groups, but not across foreign-born and U.S.-born individuals. Multiple-group structural equation models indicated that, among U.S.-born individuals, perceived foreigner objectification was associated with less life satisfaction and more depressive symptoms, and was indirectly associated with lower self-esteem via identity denial, operationalized as the perception that one is not viewed by others as American. Among foreign-born individuals, perceived foreigner objectification was not significantly associated directly with self-esteem, life satisfaction, or depressive symptoms. However, perceived foreigner objectification was positively associated with identity denial, and identity denial was negatively associated with life satisfaction. This study illustrates the relevance of perceived foreigner objectification to the psychological well-being of U.S.-born Asian Americans and Latinos.

Comparison of statin adherence among beneficiaries in MA-PD plans versus PDPs.

BACKGROUND: Medicare Part D, which provides prescription drug coverage to Medicare beneficiaries, is delivered through either Medicare Advantage prescription drug (MA-PD) plans or stand-alone prescription drug plans (PDPs). MA-PD plans cover both drug therapy and other medical services, whereas PDPs provide prescription drug coverage only. Because of the potential substitutability between prescription drugs and other medical services, MA-PD plans may make greater efforts to improve enrollees' adherence to recommended medications than PDPs. Prescription drug benefits are more generous in MA-PD plans than in PDPs. OBJECTIVE: To assess statin adherence, comparing Medicare beneficiaries in MA-PD plans with those in PDPs. METHODS: We used records from the Chronic Condition Warehouse 2007 Prescription Drug Event (PDE) file, associated Plan Characteristics files, and the Beneficiary Summary File (BSF) for a 5% random sample of Medicare beneficiaries. The study sample comprised Medicare beneficiaries aged 65 years or older in 2006 who filled at least 1 prescription for a statin during 2007, excluding beneficiaries with low-income subsidy or end-stage renal disease and those without both Medicare Part A and Part B enrollment in 2007. Medication adherence was measured by medication possession ratio (MPR), defined as the sum of days supply for all statin prescriptions filled in 2007 minus the days supply that would have carried over into 2008 from the final 2007 prescription filled, divided by the total number of days from the fill date of the first statin prescription to December 31, 2007. A binary indicator of good adherence was defined as MPR exceeding 80%. Propensity-score matching was used to reduce differences in observed characteristics of enrollees in MA-PD plans and PDPs. The propensity score was based on sociodemographic characteristics and health risk measures, including Hierarchical Condition Category (HCC) scores. RESULTS: In the unmatched sample, the mean MPR was 70.57% for MA-PD enrollees versus 70.54% for PDP enrollees (P = 0.780), and the proportion of enrollees with good adherence was 46.7% for MA-PD plans versus 46.9% for PDPs (P = 0.262). In the matched sample, statin adherence was slightly better among MA-PD enrollees than PDP enrollees. Mean MPRs were 70.80% and 69.44%, and the percentages of enrollees with good adherence were 47.0% and 45.3% in MA-PD plans and PDPs, respectively (both P less than 0.001). CONCLUSIONS: During an early year of the Part D program, MA-PD enrollees had slightly better adherence to statin therapy than PDP enrollees. While the difference was statistically significant, it was very small and unlikely to lead to clinically meaningful consequences. Less than one-half of MA-PD and PDP enrollees had good adherence in statin use, suggesting room for improvement in both types of Part D plans. Continuing evaluations of adherence in diverse therapy classes are needed for Medicare Part D beneficiaries.

Public reporting and market area exit decisions by home health agencies.

OBJECTIVE: To examine whether home health agencies selectively discontinue services to areas with socio-economically disadvantaged people after the introduction of Home Health Compare (HHC), a public reporting program initiated by Medicare in 2003. STUDY DESIGN /METHODS: We focused on agencies' initial responses to HHC and examined selective market-area exits by agencies between 2002 and 2004. We measured HHC effects by the percentage of quality indicators reported in public HHC data in 2003. Socio-economic status was measured by per capita income and percent college-educated at the market-area level. DATA SOURCES: 2002 and 2004 Outcome and Assessment Information Set (OASIS); 2000 US Census file; 2004 Area Resource File; and 2002 Provider of Service File. PRINCIPAL FINDINGS: WE FOUND A SMALL AND WEAK EFFECT OF PUBLIC REPORTING ON SELECTIVE EXITS: a 10-percent increase in reporting (reporting one more indicator) increased the probability of leaving an area with less-educated people by 0.3 percentage points, compared with leaving an area with high education. CONCLUSION: The small level of market-area exits under public reporting is unlikely to be practically meaningful, suggesting that HHC did not lead to a disruption in access to home health care through selective exits during the initial year of the program.

Where would you go for your next hospitalization?

We examine the effects of diverse dimensions of hospital quality - including consumers' perceptions of unobserved attributes - on future hospital choice. We utilize consumers' stated preference weights to obtain hospital-specific estimates of perceptions about unmeasured attributes such as reputation. We report three findings. First, consumers' perceptions of reputation and medical services contribute substantially to utility for a hospital choice. Second, consumers tend to select hospitals with high clinical quality scores even before the scores are publicized. However, the effect of clinical quality on hospital choice is relatively small. Third, satisfaction with a prior hospital admission has a large impact on future hospital choice. Our findings suggest that including measures of consumers' experience in report cards may increase their responsiveness to publicized information, but other strategies are needed to overcome the large effects of consumers' beliefs about other quality attributes.

The impact of information disclosure on quality of care in HMO markets.

OBJECTIVE: To examine the impact of voluntary information disclosure on quality of care in Health Maintenance Organization (HMO) markets in the USA. SETTING: Commercial HMOs that collected a set of standardized quality meausures, Health Plan Employer Data and Information Set (HEDIS), between 1997 and 2000 in the USA (1062 HMO-years). After collecting the HEDIS data, some HMOs disclosed their HEDIS-quality scores to the public (disclosing HMOs), whereas some HMOs declined to disclose the information (non-disclosing HMOs). DESIGN: A secondary data analysis based on 4 years of quality scores of HMOs. The study uses non-disclosing plans as a control group. A treatment-effects model is used to address a potential bias associated with voluntary disclosure decisions by HMOs. MAIN OUTCOME MEASURE(S): The study focuses on 13 HEDIS clinical indicators. On the basis of these indicators, a plan-level composite score and four domain scores were constructed. The four domains are childhood immunizations, treatments/exams for chronic conditions, screening tests and maternity services. RESULTS: Public disclosure leads to an increase of 0.72 composite score units, which corresponds to ∼7% points in original quality scale (0-100%). The degree of quality improvement differed by the type of services. CONCLUSIONS: Public release of quality information had a significant and positive effect on quality in HMO markets during the earlier years of the voluntary disclosure program; however, the improvement was not universal across all quality measures.

Agency characteristics and changes in home health quality after Home Health Compare.

OBJECTIVE: This study examines the association between home health agency characteristics and quality improvement in home health care after Home Health Compare (HHC), a public-reporting initiative in the Medicare program. METHOD: We examined the changes in seven quality measures reported in HHC from 2003 to 2007. We used a linear regression model to examine whether quality changes over time differed by agency characteristics. RESULTS: We found improvements in quality after HHC in the indicators that measure patients' ability to independently manage daily activities; however, the use of emergent care did not change, and hospitalization rates increased during the study period. Agencies with low quality at baseline, not-for-profit or hospital-based agencies, and agencies with longer Medicare tenure showed greater improvement for some quality measures than their counterparts. DISCUSSION: There was large variation in the degree of quality improvement after HHC by quality indicators and by agency characteristics.

The first puff: forces in smoking initiation among Californians of Korean descent.

This study presents the correlates of initial exposure to cigarettes, variables associated with smoking prevalence and with continued smoking (or not) among adult Californians of Korean descent who have any initial exposure to cigarettes. Among those who have taken a puff, social contingencies contrast those who become current smokers from those who do not. Data were drawn from telephone interviews with adults (N = 2,830) developed from a random sampling of listed persons in California with Korean surnames during 2000-2001. Of the attempted interviews, 86% were completed; and 85% of the interviews were conducted in Korean. Nearly half of all respondents (49.0%) had been exposed to cigarettes, and 41.9% of these reported current smoking, according to Centers for Disease Control and Prevention criteria (currently smoke and have smoked 100 cigarettes during lifetime). Multivariate analysis suggests that social contingencies may influence both initial exposure to tobacco and continued smoking among Californians of Korean descent. Influences of acculturation on taking the first puff and on current smoking status diverged by gender. Social support increased the likelihood of the first puff among both genders, but the association was stronger among females than among males. Social reinforcers that lead to taking the first puff also discriminated between those who became current smokers and those who did not. Interventions should be directed at these variables among young Korean nonsmokers and new smokers.

Decreasing invasive pneumococcal disease in the elderly: a state-level analysis.

Evidence has accumulated supporting the relationship between the use of 7-valent pneumococcal conjugate vaccine (PCV7) in children and a decline in invasive pneumococcal disease (IPD) in the elderly. We conducted a state-level analysis of vaccination coverage rates among children 19-35 months of age and IPD hospitalization rates among elderly Medicare beneficiaries. Simple correlations were suggestive of a negative relationship. Multivariate analysis using a state fixed-effect model which helped control for the time invariant factors at the state level also indicated a negative relationship, and it was statistically significant, p = 0.035. The relationship between the use of 23-valent pneumococcal polysaccharide vaccine (PPV23) and IPD hospitalizations was not statistically significant using either method.

Proxy sources for information on nursing home residents' quality of life.

OBJECTIVES: This study explores how well staff and family proxies' reports on selected quality-of-life (QOL) domains (comfort, dignity, functional competence, privacy, meaningful activity, food enjoyment, relationships, security, and autonomy) correspond to residents' own reports. METHODS: We compared QOL domain scores for nursing home residents and 1,326 staff proxies and 989 family proxies at the individual and facility level using means, Pearson correlation statistics, and intraclass correlations. Regression models adjusted for residents' age, gender, length of stay, ability to perform activities of daily living, and cognition. RESULTS: For each domain in more than half the cases, proxy means were within 1 SD of the resident means. Resident and family proxy individual reports for selected domains were correlated at 0.14 to 0.46 (all p <.000). Resident and staff proxy individual reports were correlated at 0.13 to 0.37 (all p <.000). Correlation of mean levels by facility for staff proxies was 0.26 to 0.64 (generally p <.05) and for family proxies 0.13 to 0.61 (p <.01 except for one domain). DISCUSSION: Although staff and family proxy domain scores are significantly correlated with resident scores, the level of correlation suggests they cannot simply be substituted for resident reports of QOL. Determining how proxy reports can be used for residents who cannot be interviewed at all remains an unresolved challenge.

Improved care and outcomes among elderly medicare managed care beneficiaries with diabetes.

OBJECTIVE: To examine individual- and plan-level factors related to improved diabetes care and outcomes between 1999 and 2001 among elderly Medicare managed care beneficiaries with diabetes. STUDY DESIGN: Retrospective analysis of Medicare and individual-level Health Plan and Employer Data Information Set data. METHODS: We merged Medicare demographic information with person-level data regarding 6 comprehensive diabetes care measures provided by the National Committee on Quality Assurance for Medicare managed care enrollees for 1999. Then we identified those beneficiaries for whom comprehensive diabetes care information was also reported in 2001, and determined the improvement for each measure. Data on persons not meeting the comprehensive diabetes care criteria in 1999 were analyzed to determine the factors associated with appropriate care and outcomes in 2001. RESULTS: Of the 174 combinations of individual- or plan-level factors and comprehensive diabetes care measures, 167 showed significant improvements. Nonetheless, for most of the 6 comprehensive diabetes care measures, poor care occurred more frequently for black patients than for white patients, among individuals in for-profit versus not for profit plans, and among individuals in independent practice association plans compared with group and staff model plans. Among the beneficiaries whose healthcare failed to meet the comprehensive diabetes care guidelines in 1999, by 2001, care guidelines were met in approximately three fourths for hemoglobin A1c and low-density lipoprotein cholesterol testing, but in only one half for eye examinations, low-density lipoprotein cholesterol control, and nephropathy monitoring. CONCLUSIONS: Between 1999 and 2001, care of elderly Medicare patients with diabetes improved, including among individuals who previously had not received appropriate care. However, more improvement is needed to achieve equality among members of all race groups and plan types.