Adolescents' knowledge of their health insurance coverage

Influence of patient costs and requests on emergency physician decisionmaking

STUDY OBJECTIVES

We examine emergency physician knowledge of, attitudes about, and responses to patient cost-sharing in the emergency department (ED).

METHODS

A convenience sample of emergency physicians from an integrated delivery system completed a questionnaire including self-report questions about knowledge of and attitudes about cost-sharing and an experimental vignette. The vignette describes a patient with an uncomplicated asthma exacerbation, with a version in which she has a $100 ED visit copayment and a version in which she does not. Subjects responded with their "best judgment" of whether they would order a chest radiograph and their decision after specific patient request. We examined the frequency of responses overall and associated characteristics with chi(2) testing.

RESULTS

Of 204 respondents (349 eligible participants [58%]), 203 answered the vignette questions. No respondent reported that ordering a radiograph was clinically appropriate; however, 85% reported that they would order a radiograph if the patient requested it. There were no significant differences in the percentage of physicians ordering the test across the 2 versions. Overall, 77% of respondents reported having limited awareness of an individual patient's cost-sharing level; 67% reported that patient costs sometimes affect their clinical decisions; only 10% estimated changing their decisions in greater than 20% of encounters in which the cost-sharing level was known.

CONCLUSION

Emergency physicians are usually not aware of a patient's cost-sharing level and, in instances which they are, report that this knowledge rarely affects their clinical decisions. However, emergency physicians are responsive to patient requests, even when the treatment request differs from their clinical judgment.

Does parental report of insurance status agree with hospital administrative data for children presenting to the ED?

We screened nearly 10,000 consecutive parents presenting to EDs throughout the United States and examined whether parent/guardian self-report of insurance status agrees with hospital administrative data. We also examined the relationship of patient characteristics with any observed discordance.

Stigmatization of Hispanic children, pre-adolescents, and adolescents with mental illness: exploration using a national database

This paper examines descriptive statistics for the primary payer, length of stay, and admission source of an acute care hospitalization of Hispanic children--pre-adolescents, and adolescents with a primary psychiatric Diagnostic Related Group (DRG)--and relates these variables to the concept of stigma. This paper was a secondary analysis that used data from the National Inpatient Sample database. Psychosis was the most frequent diagnosis of Hispanic youth who were hospitalized. More Hispanic pre-adolescents had a psychiatric DRG than any other ethnic group but fewer Hispanic adolescents were diagnosed with a psychiatric DRG than any other ethnic group. For Hispanic pre-adolescents and adolescents, the primary payer was Medicaid versus private insurance for White pre-adolescents and adolescents. The length of stay was approximately the same for all ethnic groups. The admission source differed for Hispanic pre-adolescents and adolescents with the majority of pre-adolescents being admitted routinely and the majority of Hispanic adolescents being admitted through emergency departments. Recommendations are made for future research, clinical practice, and public policy related to the stigmatization of Hispanic children and adolescents with mental illness.

Insurance Policies and Perceived Quality of Primary Care Among Privately Insured Patients

CONTEXT

Little is known about whether some features of managed care widen disparities in patients' evaluations of primary care.

OBJECTIVES

We investigated whether the magnitudes of racial and ethnic/language-based differences in patients' evaluations of the quality of primary care vary by capitation and gatekeeping.

DESIGN

We used a telephone survey of a representative sample of the US noninstitutionalized population, Community Tracking Study Household Survey 1998-1999, and Followback Survey of respondents' insurance administrators.

SETTING AND PARTICIPANTS

Our sample was privately insured adults who saw a physician at least once during the year preceding the interview and whose last visit was to a primary care physician.

MAIN OUTCOME MEASURES

We measured patients' evaluations of (1) how well the physician listened, (2) how well the physician explained, and (3) how thorough and careful the physician was during the last visit.

RESULTS

Significant white-minority differences emerge more often in plans using capitation or gatekeeping than in other plans. The gaps in patients' evaluations of their primary care providers' (PCP) explanations and thoroughness between whites and Hispanics interviewed in English are larger when the PCP is capitated than when the PCP is not capitated. The gap in the evaluations of their PCP's explanations by whites and Hispanics interviewed in English is larger in plans that require referrals for specialist visits than in other plans. The magnitude of racial and ethnic/language-based gaps for Hispanics interviewed in Spanish, blacks, and Native American/Asian/Pacific Islanders do not differ by capitation and gatekeeping.

CONCLUSION

English-speaking Hispanics' perceptions of the quality of primary care may be more dissimilar from whites' when capitation or gatekeeping are used than when these policies are not used.

Cost-Sharing

BACKGROUND

The use of cost-sharing to control healthcare expenditures is increasing, but there is scant information about patients' knowledge of cost-sharing or its influence on behavior.

OBJECTIVE

The objective of this study was to evaluate what patients know about their individual levels of cost-sharing and how it influences decisions to seek care.

STUDY DESIGN

We conducted a cross-sectional telephone survey with a 69% response rate.

SUBJECTS

We studied a stratified random sample of 695 adult patients in an integrated delivery system: 266 subjects > or =65 years, 218 low-income subjects, and 211 subjects from the overall membership.

MEASURES

We used perceived and actual levels of copayments for emergency department (ED) visits, office visits, and prescription drugs; and self-reports of copayment-related behavior changes.

RESULTS

One third of subjects correctly reported their ED copayment, whereas three fourths correctly reported their prescription drug and office visit copayments. Over half of the subjects (57%) underestimated their ED copayment by $20 or more. Among patients who reported having any copayment, 11% described changing their behavior because of the copayment, ie, delayed or avoided emergency care. The perceived copayment level was strongly associated with behavior change (odds ratio, 3.9). Other significant factors included having more ED visits in the past 12 months and having a low health status.

CONCLUSIONS

Patients have less knowledge of their ED cost-sharing levels than for other services. The perceived copayment amount was strongly associated with avoidance of or delays in emergency care. Further research is needed to determine whether these responses reflect greater efficiency or harmful decisions.

Knowledge of health care benefits among patients with depression

OBJECTIVE

To evaluate the accuracy of patient self-reports of health care insurance coverage relative to actual health care benefits and to explore patient predictors of accuracy among patients with depression.

METHODS

Data were analyzed from 767 patients with current depressive symptoms and disorder who completed a self-report mail survey that included questions about health insurance and for whom we also obtained actual health care benefits records. Percentage agreement and kappa statistics were calculated for different types of benefits (medical visit, pharmacy and mental health visit copays, and mental health visit limits), and we used multivariate analysis to examine predictors of accuracy.

RESULTS

Accuracy of self-reports relative to administrative data were good for measures of medical visits and prescription copays (kappa = 0.79 and 0.64), but less accurate for measures of mental health benefits (kappa = 0.19 for copays and 0.40 for visit coverage). Recent use of health care services (past 6 months) increased the accuracy of medical benefits but not of mental health benefits. Inaccuracy of mental health benefits was in the direction of patients perceiving more generous coverage than was actually available to them. Men and those with greater wealth were more knowledgeable about their medical benefits. Those from a nonminority ethnic group, who were less satisfied, and were less sick had better knowledge about their mental health benefits.

CONCLUSIONS

Agreement between self-reports and actual benefits was stronger for general medical services than for mental health care. Background, experience, and sickness lead to more accurate recall of insurance information.

The impact of Medicaid-linked reimbursements on revenues of public sexually transmitted disease clinics

BACKGROUND

Public sexually transmitted disease (STD) clinics faced with decreased tax revenue and increased costs must evaluate alternative revenue sources.

GOAL

To report one public STD clinic's Medicaid-linked revenue and discuss the association between system characteristics and reimbursement potential.

DESIGN

This was a cross-sectional study of 4208 patients visiting the clinic for new problems during a 6-month period.

RESULTS

Of 458 Medicaid-enrolled patients, only 55% acknowledged enrollment at the time of visit. The clinic captured revenue for many of the remaining 45% through a centralized public health information/billing system, which submitted retroactive STD clinic claims when patients self-reported Medicaid enrollment at later visits to other public health clinics. These belated self-reports also contributed to Medicaid administrative-match reimbursements.

CONCLUSIONS

An estimated $100,000 (31% of the clinic's direct reimbursements for service) would have been lost in 2000, had detection of Medicaid enrollment been based exclusively on patients' self-reports at STD clinic visits.