Red blood cell transfusion therapy for sickle cell patients with frequent painful events.

BACKGROUND: Recurrent pain events or chronic pain are among the most common complications of sickle cell disease. Despite attempts to maximize adherence to and dosing of hydroxyurea, some patients continue to suffer from pain. Our institution developed a program to initiate chronic red blood cell transfusions for one year in patients clinically deemed to have high healthcare utilization from sickle cell pain, despite being prescribed hydroxyurea. PROCEDURE: An institutional review board approved retrospective study to evaluate the health outcomes associated with a one-year red blood cell transfusion protocol in sickle cell patients experiencing recurrent pain events as compared with the health outcomes for these patients in the one year prior to receiving transfusion therapy. We performed a matched-pair analysis using a Wilcoxon signed rank to determine the impact of transfusion therapy on clinic visits, emergency department visits, hospital admissions, hospitalization days, and opioid prescriptions filled. RESULTS: One year of transfusion therapy significantly reduced the number of total emergency department visits for pain (6 vs 2.5 pain visits/year, P = 0.005), mean hospitalizations for pain (3.4 vs 0.9 pain admissions/year), and mean hospital days per year for pain crisis (23.5 vs 4.5, P = 0.0001), as compared with the one year prior to transfusion therapy. We identified no significant difference in opioid prescriptions filled during the year of transfusion therapy. CONCLUSION: Patients with frequent pain episodes may benefit from one year of transfusion therapy.

Creating a Virtual Meeting Platform Via Online Survey Tool: Leveraging Community Engagement Technology in the Early Days of COVID-19.

At the outset of the COVID-19 pandemic, Alabama's Title V Children and Youth with Special Health Care Needs (CYSHCN) team was forced to innovate in order to gather community input and to prioritize the findings of the 2020 Title V Maternal and Child Health Five-Year Comprehensive Needs Assessment. On a shortened timeline, the team pivoted from a full-day, in-person meeting of professionals and family representatives to an asynchronous, online "meeting" that included all planned and necessary content, allowed for comment by community members, and resulted in a prioritized list of needs. This needs assessment process showed that by using a platform like the online survey tool, Qualtrics, in an innovative way, programs can capture broader, more diverse perspectives without sacrificing quality of communication, content, or feedback. It shows the possibility for strengthening maternal and child health (MCH) systems and other systems of care though rich engagement. This model can be easily replicated in other survey tools, benefiting other states that are faced with difficulties convening geographically dispersed professionals and communities.

The Rise in Pediatric Obesity-Related Conditions and Costs in Public Insurance Programs: Evidence from Alabama.

Background: The increase in pediatric obesity rates is well documented. The extent of corresponding increases in diagnoses of obesity-related conditions (Ob-Cs) and associated medical costs for children in public insurance programs is unknown. Methods: Retrospective claims data linked to enrollees' demographic data for Alabama's Children's Health Insurance Program (ALL Kids) 1999-2015 were used. Multivariate linear probability models were used to estimate the likelihood of having any Ob-C diagnoses. Two-part models for inpatient, outpatient, emergency department (ED), and overall costs were estimated. Results: The proportion of enrollees with Ob-C diagnoses almost doubled from 1.3% to 2.5%. The likelihood of diagnoses increased over time (0.0994 percentage points per year, p < 0.001). Statistically higher rates of increase were seen for minority and lowest-income enrollees and for those getting preventive well visits. Costs for those with Ob-Cs increased relative to those without over time, particularly inpatient and outpatient costs. Conclusions: Prevalence of Ob-C diagnoses and costs have increased substantially. This may partly be because of underdiagnoses/underreporting in the past. However, evidence suggests that underdiagnoses are still a major issue.

Assessing the Quality Measure for Follow-up Care After Children's Psychiatric Hospitalizations.

OBJECTIVES: Medicaid and Children's Health Insurance Program plans publicly report quality measures, including follow-up care after psychiatric hospitalization. We aimed to understand failure to meet this measure, including measurement definitions and enrollee characteristics, while investigating how follow-up affects subsequent psychiatric hospitalizations and emergency department (ED) visits. METHODS: Administrative data representing Alabama's Children's Health Insurance Program from 2013 to 2016 were used to identify qualifying psychiatric hospitalizations and follow-up care with a mental health provider within 7 to 30 days of discharge. Using relaxed measure definitions, follow-up care was extended to include visits at 45 to 60 days and visits to a primary care provider. Logit regressions estimated enrollee characteristics associated with follow-up care and, separately, the likelihood of subsequent psychiatric hospitalizations and/or ED visits within 30, 60, and 120 days. RESULTS: We observed 1072 psychiatric hospitalizations during the study period. Of these, 356 (33.2%) received follow-up within 7 days and 566 (52.8%) received it within 30 days. Relaxed measure definitions captured minimal additional follow-up visits. The likelihood of follow-up was lower for both 7 days (-18 percentage points; 95% confidence interval [CI] -26 to -10 percentage points) and 30 days (-26 percentage points; 95% CI -35 to -17 percentage points) regarding hospitalization stays of ≥8 days. Meeting the measure reduced the likelihood of subsequent psychiatric hospitalizations within 60 days by 3 percentage points (95% CI -6 to -1 percentage point). CONCLUSIONS: Among children, receipt of timely follow-up care after a psychiatric hospitalization is low and not sensitive to measurement definitions. Follow-up care may reduce the need for future psychiatric hospitalizations and/or ED visits.

Impact of Mental Health Parity and Addiction Equity Act on Costs and Utilization in Alabama's Children's Health Insurance Program.

OBJECTIVE: The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 mandates equivalent insurance coverage for mental health (MH) and substance use disorders (SUD) to other medical and surgical services covered by group insurance plans, Medicaid, and Children's Health Insurance Programs (CHIP). We explored the impact of MHPAEA on enrollees in ALL Kids, the Alabama CHIP. METHODS: We use ALL Kids claims data for October 2008 to December 2014. October 2008 through September 2009 marks the period before MHPAEA implementation. We evaluated changes in MH/SUD-related utilization and program costs and changes in racial/ethnic disparities in the use of MH/SUD services for ALL Kids enrollees using 2-part models. This allowed analyses of changes from no use to any use, as well as in intensity of use. RESULTS: No significant effect was found on overall MH service-use. There were statistically significant increases in inpatient visits and length of stay and some increase in overall MH costs. These increases may not be clinically important and were concentrated in 2009 to 2011. Disparities in utilization between African-American and non-Hispanic white enrollees were somewhat exacerbated, whereas disparities between other minorities and non-Hispanic whites were reduced. CONCLUSIONS: Findings indicate that MHPAEA led to a 14.3% increase in inpatient visits, a 12.5% increase in length of inpatient stay, and a 7.8% increase in MH costs. The increases appear limited to 2009 to 2011, suggesting existing pent-up "needs" among enrollees for added MH/SUD services that resulted in a temporary spike in service use and cost immediately after MHPAEA, which subsequently subsided.

Meta-analysis of aggression and/or hostility-related events in children and adolescents treated with fluoxetine compared with placebo.

This meta-analysis assessed aggression and/or hostility-related events in children and adolescents treated with fluoxetine (n = 376) compared with placebo (n = 255). Aggression and/or hostility-related events were identified in 2.1% of fluoxetine versus 3.1% of placebo-treated patients (p = 0.588). This analysis fails to support an association between fluoxetine treatment and increased risk of aggression and/or hostility-related events in children and adolescents compared with placebo.

An assessment of the CHIP/Medicaid quality measure for ADHD.

OBJECTIVES: We analyzed a standard children's quality measure for attention-deficit/hyperactivity disorder (ADHD) using data from a single state to understand the characteristics of those meeting the measure, potential barriers to meeting the measure, and how meeting the measure affected outcomes. STUDY DESIGN: Retrospective study using claims from Alabama's Children's Health Insurance Program from 1999 to 2012. METHODS: We calculated the quality measure for ADHD care, as specified within CMS' Child Core Set and with an expanded denominator. We described the eligible population meeting the measure, assessed potential barriers, and measured the association with health expenditures using logit regressions and log-Poisson models. RESULTS: Among those receiving ADHD medication, 11% of enrollees were eligible for annual measure calculation during our study period. Calculated as specified by CMS, 38% of enrollees met the measure. Using an expanded denominator of 7615 eligible medication episodes, 14% met all aspects of the measure. Primary reasons for failing to meet the measure were lacking medication coverage (64%) and lacking a follow-up visit within 30 days (62%). The rate of meeting the measure decreased with age and was lower for black enrollees. Health service utilization and costs were greater among children meeting the measure. CONCLUSIONS: Too few children are eligible for inclusion, and systematic differences exist among those who meet the measure. The measure may be sensitive to arbitrary criteria while missing potentially relevant clinical care. Refinements to the measure should be considered to improve generalizability to all children with ADHD and improve clinical relevance. States must consider additional analyses to direct quality improvement.

Interaction of phosphorylated Rab11-FIP2 with Eps15 regulates apical junction composition.

MARK2 regulates the establishment of polarity in Madin-Darby canine kidney (MDCK) cells in part through phosphorylation of serine 227 of Rab11-FIP2. We identified Eps15 as an interacting partner of phospho-S227-Rab11-FIP2 (pS227-FIP2). During recovery from low calcium, Eps15 localized to the lateral membrane before pS227-FIP2 arrival. Later in recovery, Eps15 and pS227-FIP2 colocalized at the lateral membrane. In MDCK cells expressing the pseudophosphorylated FIP2 mutant FIP2(S227E), during recovery from low calcium, Eps15 was trapped and never localized to the lateral membrane. Mutation of any of the three NPF domains within GFP-FIP2(S227E) rescued Eps15 localization at the lateral membrane and reestablished single-lumen cyst formation in GFP-FIP2(S227E)-expressing cells in three-dimensional (3D) culture. Whereas expression of GFP-FIP2(S227E) induced the loss of E-cadherin and occludin, mutation of any of the NPF domains of GFP-FIP2(S227E) reestablished both proteins at the apical junctions. Knockdown of Eps15 altered the spatial and temporal localization of pS227-FIP2 and also elicited formation of multiple lumens in MDCK 3D cysts. Thus an interaction of Eps15 and pS227-FIP2 at the appropriate time and location in polarizing cells is necessary for proper establishment of epithelial polarity.

The Great Recession of 2007-2009 and Public Insurance Coverage for Children in Alabama: Enrollment and Claims Data from 1999-2011.

OBJECTIVES: This study examined the impact of the Great Recession of 2007-2009 on public health insurance enrollment and expenditures in Alabama. Our analysis was designed to provide a framework for other states to conduct similar analyses to better understand the relationship between macroeconomic conditions and public health insurance costs. METHODS: We analyzed enrollment and claims data from Medicaid and the Children's Health Insurance Program (CHIP) in Alabama from 1999 through 2011. We examined the relationship between county-level unemployment rates and enrollment in Medicaid and CHIP, as well as total county-level expenditures in the two programs. We used linear regressions with county fixed effects to estimate the impact of unemployment changes on enrollment and expenditures after controlling for population and programmatic changes in eligibility and cost sharing. RESULTS: A one-percentage-point increase in a county's unemployment rate was associated with a 4.3% increase in Medicaid enrollment, a 0.9% increase in CHIP enrollment, and an overall increase in public health insurance enrollment of 3.7%. Each percentage-point increase in unemployment was associated with a 6.2% increase in total public health insurance expenditures on children, with Medicaid spending rising by 7.5% and CHIP spending rising by 1.8%. In response to the 6.4 percentage-point increase in the state's unemployment rate during the Great Recession, combined enrollment of children in Alabama's public health insurance programs increased by 24% and total expenditures rose by 40%. CONCLUSION: Recessions have a substantial impact on the number of children enrolled in CHIP and Medicaid, and a disproportionate impact on program spending. Programs should be aware of the likely magnitudes of the effects in their budget planning.

Preventive Dental Care and Long-Term Dental Outcomes among ALL Kids Enrollees.

OBJECTIVE: To investigate whether early or regular preventive dental visit (PDV) reduces restorative or emergency dental care and costs for low-income children. STUDY SETTING: Enrollees during 1998-2012 in the Alabama CHIP program, ALL Kids. STUDY DESIGN: Retrospective cohort study using claims data for children continuously enrolled in ALL Kids for at least 4 years. Analyses are conducted separately for children 0-4 years, 4-9 years, and >9 years. For 0-4 years, the intervention of interest is whether they have at least one PDV before age 3. For the other two age groups, interventions of interest are if they have regular PDVs during each of the first 3 years, and if they have claims for a sealant in the first 3 years. Outcomes-namely restorative and emergency dental service and costs-are measured in the fourth year. To account for selection into PDV, a high-dimensional propensity scores approach is utilized. DATA EXTRACTION: Claims data were obtained from ALL Kids. PRINCIPAL FINDINGS: Only sealants are associated with a reduced likelihood of using restorative and emergency services and costs. CONCLUSIONS: Whether PDVs without sealants actually reduce restorative/emergency pediatric dental services is questionable. Further research into benefits of PDV is needed.

Health Expenditure Concentration and Characteristics of High-Cost Enrollees in CHIP.

Devising effective cost-containment strategies in public insurance programs requires understanding the distribution of health care spending and characteristics of high-cost enrollees. The aim was to characterize high-cost enrollees in a state's public insurance program and determine whether expenditure inequality changes over time, or with changes in cost-sharing policies or program eligibility. We use 1999-2011 claims and enrollment data from the Alabama Children's Health Insurance Program, ALL Kids. All children enrolled in ALL Kids were included in our study, including multiple years of enrollment (N = 1,031,600 enrollee-months). We examine the distribution of costs over time, whether this distribution changes after increases in cost sharing and expanded eligibility, patient characteristics that predict high-cost status, and examine health services used by high-cost children to identify what is preventable. The top 10% (1%) of enrollees account for about 65.5% (24.7%) of total program costs. Inpatient and outpatient costs are the largest components of costs incurred by high-cost utilizers. Non-urgent emergency department costs are a relatively small portion. Average expenditure increases over time, particularly after expanded eligibility, and the share of costs incurred by the top 10% and 1% increases slightly. Multivariable logistic regression results indicate that infants and older teens, Caucasian children, and those with chronic conditions are more likely to be high-cost utilizers. Increased cost sharing does not reduce cost concentration or average expenditure among high-cost utilizers. These findings suggest that identifying and targeting potentially preventable costs among high-cost utilizers are called for to help reduce costs in public insurance programs.

Adverse Selection in the Children's Health Insurance Program.

This study investigates whether new enrollees in the Alabama Children's Health Insurance Program have different claims experience from renewing enrollees who do not have a lapse in coverage and from continuing enrollees. The analysis compared health services utilization in the first month of enrollment for new enrollees (who had not been in the program for at least 12 months) with utilization among continuing enrollees. A second analysis compared first-month utilization of those who renew immediately with those who waited at least 2 months to renew. A 2-part model estimated the probability of usage and then the extent of usage conditional on any utilization. Claims data for 826 866 child-years over the period from 1999 to 2012 were used. New enrollees annually constituted a stable 40% share of participants. Among those enrolled in the program, 13.5% renewed on time and 86.5% of enrollees were late to renew their enrollment. In the multivariate 2-part models, controlling for age, gender, race, income eligibility category, and year, new enrollees had overall first-month claims experience that was nearly $29 less than continuing enrollees. This was driven by lower ambulatory use. Late renewals had overall first-month claims experience that was $10 less than immediate renewals. However, controlling for the presence of chronic health conditions, there was no statistically meaningful difference in the first-month claims experience of late and early renewals. Thus, differences in claims experience between new and continuing enrollees and between early and late renewals are small, with greater spending found among continuing and early renewing participants. Higher claims experience by early renewals is attributable to having chronic health conditions.

Enrollment, expenditures, and utilization after CHIP expansion: evidence from Alabama.

OBJECTIVE: In October 2009, Alabama expanded eligibility in its Children's Health Insurance Program (CHIP), known as ALL Kids, from 200% to 300% of the federal poverty level (FPL). We examined the expenditures, utilization, and enrollment behavior of expansion enrollees relative to traditional enrollees (100-200% FPL) and assessed the impact of expansion on total program expenditures. METHODS: We compared unadjusted mean person-month-level expenditures and utilization of expansion enrollees and various categories of existing enrollees and used a 2-part modeling strategy to examine differences after controlling for enrollee characteristics. We used probit models to examine adjusted differences in reenrollment behavior by eligibility category. RESULTS: Expansion enrollees had higher total monthly expenditures ($10.33, P < .05) than traditional ALL Kids enrollees, including higher outpatient ($5.35, P < .001) and dental ($0.85, P < .01) expenditures but lower emergency department (-$1.34, P < .001) expenditures. Expansion enrollees had marginally lower utilization of emergency department services for low-severity conditions and higher utilization of physician outpatient visits. Expansion enrollees were 4.47 percentage points (P < .001) more likely to reenroll before their contract expiration date than traditional ALL Kids enrollees. As of October 2012, expansion enrollees accounted for approximately 20% of ALL Kids enrollment and expenditures. CONCLUSIONS: The expansion population was characterized by moderately higher health expenditures and utilization, and more persistent enrollment relative to fee group enrollees who are subject to the same levels of cost sharing and annual premiums. Although states are prohibited from changing program eligibility until 2019, the costs associated with the expansion population will be important to future policy decisions.

Can increases in CHIP copayments reduce program expenditures on prescription drugs?

OBJECTIVE: The primary aim is to explore whether prescription drug expenditures by enrollees changed in Alabama's CHIP program, ALL Kids, after copayment increases in fiscal year 2004. The subsidiary aim is to explore whether non-pharmaceutical expenditures also changed. DATA SOURCES: Data on ALL Kids enrollees between 1999-2007, obtained from claims files and the state's administrative database. STUDY DESIGN: We used data on children who were enrolled between one and three years both before and after the changes to the copayment schedule, and estimate regression models with individual-level fixed effects to control for time-invariant heterogeneity at the child level. This allows an accurate estimate of how program expenditures change for the same individual following copayment changes. Primary outcomes of interest are expenditures for prescription drugs by class and brand-name and generic versions. We estimate models for the likelihood of any use of prescription drugs and expenditure level conditional on use. PRINCIPAL FINDINGS: Following the copayment increase, the probability of any expenditure decline by 5.8%, brand name drugs by 6.9%, generic drugs by 7.4%. Conditional on any use, program expenditures decline by 7.9% for all drugs, by 9.6% for brand name drugs, and 6.2% for generic drugs. The largest declines are for antihistamine drugs; the least declines are for Central Nervous System agents. Declines are smaller and statistically weaker for children with chronic health conditions. Concurrent declines are also seen for non-pharmaceutical medical expenditures. CONCLUSIONS: Copayment increases appear to reduce program expenditures on prescription drugs per enrollee and may be a useful tool for controlling program costs.

Characteristics of low-severity emergency department use among CHIP enrollees.

OBJECTIVES: To describe patient characteristics among those utilizing the emergency department (ED) for low-severity conditions (ie, conditions potentially treatable or manageable in a primary care setting). STUDY DESIGN: A pooled cross-sectional study of administrative claims for ED visits among enrollees in Alabama's Children's Health Insurance Program (CHIP), ALL Kids, from January 1, 1999, through December 31, 2010. METHODS: Severity of visit was categorized based on primary diagnosis code using an established claims-based algorithm. Logistic regression was used to identify patient characteristics that predicted low-severity ED visits relative to high-severity visits. RESULTS: Of a total of 141,709 qualifying ED visits, 97,961 (69%) were classified as low severity, 33,941 (24%) as intermediate severity, and 9807 (7%) as high severity. Based on absolute risk differences, we found that among children utilizing the ED, low-severity visits were more likely than high-severity visits among children who were noncompliant with recommended well-child care (1.2 percentage points, 95% confidence interval [CI], 0.4-1.9); children who were nonurban residents (urban vs isolated: 1.6 percentage points, 95% CI, 1.0-2.2; urban vs small rural: 1.1 percentage points, 95% CI, 0.5-1.7); children without chronic disease (10.3 percentage points, 95% CI, 9.9-10.7) and children whose ED visits were on Sunday versus weekdays (0.9 percentage point, 95% CI, 0.6-1.3), and on Saturday versus weekdays (1.2 percentage points; 95% CI, 0.8-1.6). CONCLUSIONS: Our results suggest that improving access to primary care on weekends and in rural areas are potential ways to improve the efficient use of ED services.

Measuring prevention more broadly: an empirical assessment of CHIPRA core measures.

OBJECTIVE: To assess limitations of using select Children's Health Insurance Program Reauthorization Act (CHIPRA) core claims-based measures in capturing the preventive services that may occur in the clinical setting. METHODS: We use claims data from ALL Kids, the Alabama Children's Health Insurance Program (CHIP), to calculate each of four quality measures under two alternative definitions: (1) the formal claims-based guidelines outlined in the CMS Technical Specifications, and (2) a broader definition of appropriate claims for identifying preventive service use. Additionally, we examine the extent to which these two claims-based approaches to measuring quality differ in assessments of disparities in quality of care across subgroups of children. RESULTS: Statistically significant differences in rates were identified when comparing the two definitions for calculating each quality measure. Measure differences ranged from a 1.9 percentage point change for measure #13 (receiving preventive dental services) to a 25.5 percentage point change for measure #12 (adolescent well-care visit). We were able to identify subgroups based upon family income, rural location, and chronic disease status with differences in quality within the core measures. However, some identified disparities were sensitive to the approach used to calculate the quality measure. CONCLUSIONS: Differences in CHIP design and structure, across states and over time, may limit the usefulness of select claims-based core measures for detecting disparities accurately. Additional guidance and research may be necessary before reporting of the measures becomes mandatory.

Effectiveness of preventive dental visits in reducing nonpreventive dental visits and expenditures.

BACKGROUND AND OBJECTIVE: Although preventive dental visits are considered important for maintaining pediatric oral health, there is relatively little research showing that they reduce subsequent nonpreventive dental visits or costs. At least 1 study seemed to find that early preventive dental care is associated with more restorative and emergency visits. Previous studies are limited by their inability to account for unmeasurable factors that may lead children to "select" into using both more preventive and nonpreventive dental care. We used econometric techniques that minimize selection bias to assess the effectiveness of preventive dental care in reducing subsequent nonpreventive dental service utilization among children. METHODS: Using data from Alabama's Children's Health Insurance Program (CHIP), 1998-2010., a cohort study of children's dental service utilization was conducted. Outcomes were 1-year lagged nonpreventive dental care and expenditures, and overall dental and medical expenditures. Children who were continuously enrolled for at least 3 years were included. Separate models were estimated for children aged <8 years (n = 14 972) and those aged ≥8 years (n = 21 833). RESULTS: More preventive visits were associated with fewer subsequent nonpreventive dental visits and lower nonpreventive dental expenditures for both groups. However, more preventive visits did not reduce overall dental or medical (inclusive of dental) expenditures. CONCLUSIONS: Preventive dental visits can reduce subsequent nonpreventive visits and expenditures for children continuously enrolled in CHIP. However, they may not reduce overall program costs. Effective empirical research in this area must continue to address unobserved confounders and selection issues.

Co-payments and the use of emergency department services in the children's health insurance program.

Research suggests that more than half of all emergency department (ED) visits in the United States are for nonurgent conditions, leading to billions of dollars in potentially avoidable spending annually. In this study, we examine the effects of co-payment changes on ED utilization among children enrolled in ALL Kids, Alabama's Children's Health Insurance Program We separately model the effect of the 2003 co-payment increases on the monthly probability of any ED visit, and visits within three severity categories, using linear probability models that control for beneficiary characteristics and time trends that are allowed to vary in the pre- and postperiods. We observe a small decline in the probability of ED visits 1 year after the co-payment increase. However, low-severity visits, which we hypothesize to be more price sensitive, show no significant evidence of a decline. Our study suggests that the modest co-payment changes were not effective in improving the efficiency of ED utilization.

Did copayment changes reduce health service utilization among CHIP enrollees? Evidence from Alabama.

OBJECTIVE: To explore whether health care utilization changed among enrollees in Alabama's CHIP program, ALL Kids, following copayment increases at the beginning of fiscal year 2004. DATA SOURCES: Data on all ALL Kids enrollees over 1999-2009 are obtained from claims files and the state's administrative database. STUDY DESIGN: We use pooled month-level data for all enrollees and conduct covariate-adjusted segmented regression models. Health services considered are inpatient care, emergency department (ED) visits, brand-name prescription drugs, generic prescription drugs, physician office visits and outpatient-services, ambulance services, allergy treatments, and non-preventive dental services. Physician well-visits, preventive dental services, and service use by Native-Americans--which saw no copayment increases--serve as counterfactuals. PRINCIPAL FINDINGS: There are significant declines in utilization for inpatient care, physician visits, brand-name medications, and ED visits following the copayment increases. By and large, utilization did not decline, or declined only temporarily, for those services and for those enrollees that who not subject to increased copayments. CONCLUSIONS: Copayment increases reduced utilization of many health services among ALL Kids enrollees. Concerns remain regarding the long-term health consequences to low-income children of copayment-induced reductions in health care utilization.

The effects of premium changes on ALL Kids, Alabama's CHIP program.

OBJECTIVE: Describe the trends in enrollment and renewal in the Alabama Children's Health Insurance Plan (CHIP), ALL Kids, since its creation in 1998, and to estimate the effect that an annual premium increase, along with coincident increases in service copays, had on the decision to renew participation. BACKGROUND: Unlike many other CHIP programs, ALL Kids is a standalone program that provides year long enrollment and contracts with the state's Blue Cross and Blue Shield program for its network of providers and its provider fee structure. In October 2003 premiums for individual coverage were increased by $50 per year and copays by $1 to $3 per visit. POPULATION STUDIED: This study is based upon a sample of 569,650 person-year observations of 230,255 children enrolled in the ALL Kids program between 1999 and 2009. STUDY DESIGN: The study models enrollment as a time series of cross section renewal decisions and specifies a series of linear probability regression models to estimate the effect of changes in the premium shift on the decision to renew. A second analysis includes interaction effects of the premiums shift with demographics, health status, income and previous enrollment to estimate differential response across subgroups. PRINCIPAL FINDINGS: The increases in premiums and copays are estimated to have reduced program renewals by 6.1 to 8.3 percent depending upon how much time one allows for families to renew. Families with a child who has a chronic condition were more likely to renew coverage. However, those with chronic conditions, African-Americans and those with lower family incomes were more price-sensitive. CONCLUSIONS: An increase in annual premiums and visit copays had a modest impact on program reenrollment with effects comparable to those found in Florida, New Hampshire, Kansas and Arizona, but smaller than those in Kentucky and Georgia.