Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the current and projected demographics and health care needs of patients served by the Department of Veterans Affairs (VA). The number of U.S. veterans will continue to decline over the next decade, and the demographic mix and geographic locations of these veterans will change. While the number of veterans using VA health care has increased over time, demand will level off in the coming years. Veterans have more favorable economic circumstances than non-veterans, but they are also older and more likely to be diagnosed with many health conditions. Not all veterans are eligible for or use VA health care. Whether and to what extent an eligible veteran uses VA health care depends on a number of factors, including access to other sources of health care. Veterans who rely on VA health care are older and less healthy than veterans who do not, and the prevalence of costly conditions in this population is projected to increase. Potential changes to VA policy and the context for VA health care, including effects of the Affordable Care Act, could affect demand. Analysis of a range of data sources provided insight into how the veteran population is likely to change in the next decade.

Pre-Deployment Stress, Mental Health, and Help-Seeking Behaviors Among Marines

The Marine Corps Operational Stress Control and Readiness (OSCAR) program is designed to provide mental health support to marines by embedding mental health personnel within Marine Corps units and increasing the capability of officers and senior noncommissioned officers to improve the early recognition and intervention of marines exhibiting signs of stress. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury have asked RAND to evaluate the OSCAR program. As part of this evaluation, RAND conducted a large survey of marines who were preparing for a deployment to Iraq or Afghanistan in 2010 or 2011. This article describes the methods and findings from this survey. The results are among the first to shed light on the pre-deployment mental health status of marines, as well as the social resources they draw on when coping with stress and their attitudes about seeking help for stress-related problems. The 2,620 marines in the survey sample had high rates of positive screens for current major depressive disorder (12.5 percent) and high-risk drinking (25.7 percent) and reported having experienced more potentially traumatic events over their lifetime than adult males in the general population. Marines in the sample also reported relying on peers for support with stress and perceiving moderate levels of support from the Marine Corps for addressing stress problems.

Emergency Department Patient Experience of Care Survey: Development and Field Test

The Centers for Medicare & Medicaid Services (CMS) have implemented Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys to assess patient experience in a number of settings. Following CAHPS principles, RAND researchers designed and field tested an Emergency Department Patient Experience of Care Survey that consists of three survey instruments for use with adult patients who have visited the emergency department (ED). One instrument is for use with those patients who are discharged to the community following their ED visit; the other two are for use with those patients who are admitted to the hospital from the ED (one for use on its own and one to supplement an existing inpatient survey). The authors conducted a field test of these instruments in 12 hospitals in late 2013 and early 2014 and analyzed the resulting data from 4,101 ED patients. The analyses identified four composite measures (measures composed of responses to multiple survey questions) and ten measures that are each composed of a single survey question. As of September 2014, CMS plans to conduct additional testing on these instruments.

An Evaluation of the Implementation and Perceived Utility of the Airman Resilience Training Program

Since 2001, the U.S. Military has been functioning at an operational tempo that is historically high for the all-volunteer force in which service members are deploying for extended periods on a repeated basis. Even with the drawdown of troops from Iraq in 2011, some service members are returning from deployment experiencing difficulties handling stress, mental health problems, or deficits caused by a traumatic brain injury (TBI). In response to these challenges, the U.S. Department of Defense (DoD) has implemented numerous programs to support service members and their families in these areas. In 2009, the Assistant Secretary of Defense for Health Affairs asked the RAND National Defense Research Institute to develop a comprehensive catalog of existing programs sponsored or funded by DoD to support psychological health and care for TBI, to create tools to support ongoing assessment and evaluation of the DoD portfolio of programs, and to conduct evaluations of a subset of these programs. This article describes RAND's assessment of an Air Force program, Airman Resilience Training (ART), which is a psychoeducational program designed to improve airmen's reactions to stress during and after deployment and to increase the use of mental health services when needed. ART was initiated in November 2010, replacing a previous program named Landing Gear, which had been in place since April 2008. The RAND study took place from August 2011 through November 2011. This study will be of particular interest to officials within the Air Force who are responsible for the psychological health and well-being of airmen, as well as to others within the military who are developing programs for service members to help them cope with stress while in combat situations and after returning from deployment.

A Program Manager's Guide for Program Improvement in Ongoing Psychological Health and Traumatic Brain Injury Programs

Between 2001 and 2011, the U.S. Department of Defense has implemented numerous programs to support service members and their families in coping with the stressors from a decade of the longstanding conflicts in Iraq and Afghanistan. These programs, which address both psychological health and traumatic brain injury (TBI), number in the hundreds and vary in their size, scope, and target population. To ensure that resources are wisely invested and maximize the benefits of such programs, RAND developed a tool to help assess program performance, consider options for improvement, implement solutions, then assess whether the changes worked, with the intention of helping those responsible for managing or implementing programs to conduct assessments of how well the program is performing and to implement solutions for improving performance. Specifically, the tool is intended to provide practical guidance in program improvement and continuous quality improvement for all programs.

The RAND Online Measure Repository for Evaluating Psychological Health and Traumatic Brain Injury Programs

Since 2001, U.S. military forces have been engaged in extended conflicts in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, the operational tempo may raise the risk of mental health problems, such as post-traumatic stress disorder (PTSD) and major depression, and consequences from traumatic brain injury (TBI). To support servicemembers and their families as they cope with these challenges, the U.S. Department of Defense has implemented numerous programs addressing biological, social, spiritual, and holistic influences on psychological health along the resilience, prevention, and treatment continuum that focus on a variety of clinical and nonclinical concerns. As these efforts have proliferated, evaluating their effectiveness has become increasingly important. To support the design and implementation of program evaluation, RAND developed the RAND Online Measure Repository (ROMR) which indexes and describes measures related to psychological health and TBI. The ROMR is a publicly accessible, online, searchable database containing 171 measures related to psychological health and TBI. This article describes the rationale for developing the ROMR, the content included in the ROMR, and its potential in both civilian and military populations. The ROMR includes information about measure domains, psychometrics, number of items, and costs, which can inform the selection of measures for program evaluations. Included measures address domains of primary importance to psychological health (PTSD, depression, anxiety, suicidal ideation, and resiliency) and TBI (cognition, executive functioning, and memory). Also identified are measures relevant to military units, such as unit cohesion and force readiness.

The Development and Application of the RAND Program Classification Tool

As a result of extended military engagements in Iraq and Afghanistan during the past decade, the U.S. Department of Defense (DoD) has implemented numerous programs to support servicemembers and family members who experience difficulty handling stress, face mental health challenges, or are affected by a traumatic brain injury (TBI). As these efforts have proliferated, it has become more challenging to monitor these programs and to avoid duplication. To support DoD in this area, RAND compiled a comprehensive catalog of DoD-funded programs that address psychological health and TBI. In creating the catalog of programs, RAND recognized the need to consistently describe and compare multiple programs according to a set of core program characteristics, driven largely by the lack of a single, clear, widely accepted operational definition of what constitutes a program. To do this, RAND developed the RAND Program Classification Tool (R-PCT) to allow users to describe and compare programs, particularly those related to psychological health and TBI, along eight key dimensions that that define a program. The tool consists of a set of questions and responses for consistently describing various aspects of programs, along with detailed guidance regarding how to select the appropriate responses. The purpose of this article is to describe the R-PCT, to help potential users understand how it was developed, and to explain how the tool can be used.

A Systematic Process to Facilitate Evidence-Informed Decisionmaking Regarding Program Expansion

While the Department of Defense supports more than 200 psychological health and traumatic brain injury programs, it lacks an approach and process to systematically develop, track, and assess the performance of this portfolio of programs. Further, there is not yet a uniform approach to decisionmaking around program support and expansion of particularly promising, evidence-based programs. This lack of centralized oversight may result in the proliferation of untested programs that are developed without an evidence base; an inefficient use of resources; and added cost and administrative inefficiencies. RAND researchers developed a potential model and tools to support a centralized, systematic, and ongoing process to help in making decisions around continued program support, and by which expansion can be facilitated. This study includes two tools. The first is a Program Abstraction Form, which collects relevant background information from programs and asks explicitly about program effectiveness and the design of the program evaluation used to assess program effectiveness, as a poor evaluation design may lead to incorrect conclusions about the effectiveness of the program. The second is the RAND Program Expansion Tool, which provides a standardized summary of the quality and outcome of a program evaluation. The focus of these tools is on decisionmaking around program expansion, and does not preclude or address initial funding decisions of particularly promising new programs that may not yet have a solid evidence base.

CMS Innovation Center Health Care Innovation Awards: Evaluation Plan

The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care.

Many emergency department visits could be managed at urgent care centers and retail clinics

Americans seek a large amount of nonemergency care in emergency departments, where they often encounter long waits to be seen. Urgent care centers and retail clinics have emerged as alternatives to the emergency department for nonemergency care. We estimate that 13.7-27.1 percent of all emergency department visits could take place at one of these alternative sites, with a potential cost savings of approximately $4.4 billion annually. The primary conditions that could be treated at these sites include minor acute illnesses, strains, and fractures. There is some evidence that patients can safely direct themselves to these alternative sites. However, more research is needed to ensure that care of equivalent quality is provided at urgent care centers and retail clinics compared to emergency departments.

Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families

Over the last decade, U.S. military forces have been engaged in extended conflicts that are characterized by increased operational tempo, most notably in Iraq and Afghanistan. While most military personnel cope well across the deployment cycle, many will experience difficulties handling stress at some point; will face psychological health challenges, such as post-traumatic stress disorder or major depression; or will be affected by the short- and long-term psychological and cognitive consequences of a traumatic brain injury (TBI). Over the past several years, the Department of Defense (DoD) has implemented numerous programs that address various components of psychological health along the resilience, prevention, and treatment continuum and focus on a variety of clinical and nonclinical concerns. This article provides detail from an evaluation of 211 programs currently sponsored or funded by DoD to address psychological health and TBI, along with descriptions of how programs relate to other available resources and care settings. It also provides recommendations for clarifying the role of programs, examining gaps in routine service delivery that could be filled by programs, and reducing implementation barriers. Barriers include inadequate funding and resources, concerns about the stigma associated with receiving psychological health services, and inability to have servicemembers spend adequate time in programs. The authors found that there is significant duplication of effort, both within and across branches of service. As each program develops its methods independently, it is difficult to determine which approaches work and which are ineffective. Recommendations include strategic planning, centralized coordination, and information-sharing across branches of service, combined with rigorous evaluation. Programs should be evaluated and tracked in a database, and evidence-based interventions should be used to support program efforts.

Reporting CAHPS and HEDIS data by race/ethnicity for Medicare beneficiaries

OBJECTIVE

To produce reliable and informative health plan performance data by race/ethnicity for the Medicare beneficiary population and to consider appropriate presentation strategies.

DATA SOURCES

Patient experience data from the 2008-2009 Medicare Advantage (MA) and fee-for-service (FFS) CAHPS surveys and 2008-2009 HEDIS data (MA beneficiaries only).

STUDY DESIGN

Mixed effects linear (and binomial) regression models estimated the reliability and statistical informativeness of CAHPS (HEDIS) measures.

PRINCIPAL FINDINGS

Seven CAHPS and seven HEDIS measures were reliable and informative for four racial/ethnic subgroups-Whites, Blacks, Hispanics, and Asian/Pacific Islanders-at sample sizes of 100 beneficiaries (200 for prescription drug plans). Although many plans lacked adequate sample size for reporting group-specific data, reportable plans contained a large majority of beneficiaries from each of the four racial/ethnic groups.

CONCLUSIONS

Statistically reliable and valid information on health plan performance can be reported by race/ethnicity. Many beneficiaries may have difficulty understanding such reports, however, even with careful guidance. Thus, it is recommended that health plan performance data by subgroups be reported as supplemental data and only for plans meeting sample size requirements.

Behavioral Health in the District of Columbia: Assessing Need and Evaluating the Public System of Care

This article shares findings from a study of the public behavioral health care system in the District of Columbia, including the prevalence of mental health disorders and substance use, the organization and financing of public behavioral health services, utilization of public behavioral health services, and priorities for improvement. The authors' analyses found that prevalence of mental health conditions resembles patterns nationally, among both adults and youth. Substance use disorders are more prevalent among adults and comparatively lower for the youth population, compared to national patterns. Potentially 60 percent of adults and 72 percent of adolescents enrolled in Medicaid managed care may have unmet need for depression services. Based on claims data, 45 percent of children and 41 percent of adults enrolled in Mental Health Rehabilitation Services programs have gaps in care that exceed six months during a 12-month period. Participants in focus groups and stakeholder interviews highlighted such challenges as gaps in care and difficulties in coordination of care for particular populations and services. High-level priorities include reducing unmet need for public mental health care, tracking and coordinating care, improving the availability and accessibility of substance use treatment services, and upgrading the data infrastructure.

Policy Implications of the Use of Retail Clinics

Retail clinics, located within larger retail stores, treat a limited number of acute conditions and offer a small set of preventive services. Although there are nearly 1,200 such clinics in the United States, a great deal about their utilization, relationships with other parts of the health care system, and quality of care remains unknown. The federal government has taken only limited action regarding retail clinics, and little evidence exists about the potential costs and benefits of integrating retail clinics into federal programs and initiatives. Through a literature review, semistructured interviews, and a panel of experts, the authors show that retail clinics have established a niche in the health care system based on their convenience and customer service. Levels of patient satisfaction and of the quality and appropriateness of care appear comparable to those of other provider types. However, we know little about the effects of retail clinic use on preventive services, care coordination, and care continuity. As clinics begin to expand into other areas of care, including chronic disease management, and as the number of patients with insurance increases and the shortage of primary care physicians continues, answering outstanding questions about retail clinics' role in the health care system will become even more important. These changes will create new opportunities for health policy to influence both how retail clinics function and the ways in which their care is integrated with that of other providers.

Health information management and perceptions of the quality of care for children with tracheotomy: a qualitative study

Background

Children with tracheotomy receive health care from an array of providers within various hospital and community health system sectors. Previous studies have highlighted substandard health information exchange between families and these sectors. The aim of this study was to investigate the perceptions and experiences of parents and providers with regard to health information management, care plan development and coordination for children with tracheotomy, and strategies to improve health information management for these children.

Methods

Individual and group interviews were performed with eight parents and fifteen healthcare (primary and specialty care, nursing, therapist, equipment) providers of children with tracheotomy. The primary tracheotomy-associated diagnoses for the children were neuromuscular impairment (n = 3), airway anomaly (n = 2) and chronic lung disease (n = 3). Two independent reviewers conducted deep reading and line-by-line coding of all transcribed interviews to discover themes associated with the objectives.

Results

Children with tracheotomy in this study had healthcare providers with poorly defined roles and responsibilities who did not actively communicate with one another. Providers were often unsure where to find documentation relating to a child's tracheotomy equipment settings and home nursing orders, and perceived that these situations contributed to medical errors and delayed equipment needs. Parents created a home record that was shared with multiple providers to track the care that their children received but many considered this a burden better suited to providers. Providers benefited from the parent records, but questioned their accuracy regarding critical tracheotomy care plan information such as ventilator settings. Parents and providers endorsed potential improvement in this environment such as a comprehensive internet-based health record that could be shared among parents and providers, and between various clinical sites.

Conclusions

Participants described disorganized tracheotomy care and health information mismanagement that could help guide future investigations into the impact of improved health information systems for children with tracheotomy. Strategies with the potential to improve tracheotomy care delivery could include defined roles and responsibilities for tracheotomy providers, and improved organization and parent support for maintenance of home-based tracheotomy records with web-based software applications, personal health record platforms and health record data authentication techniques.

Using standardized encounters to understand reported racial/ethnic disparities in patient experiences with care

OBJECTIVE

To assess the extent to which racial/ethnic differences in ratings of patient experiences with health care represent true differences versus differences in expectations, how scales are used, or how identical physician-patient interactions are perceived by members of different groups.

STUDY SETTING

Primary data collection from a nationally representative online panel (n=567), including white, African American, and Latino respondents.

STUDY DESIGN

We administered questions on expectations of care, a series of written vignettes, a video-depicted doctor-patient interaction, and modified CAHPS Clinician and Group Doctor Communication items.

PRINCIPAL FINDINGS

Different groups reported generally similar expectations regarding physicians' behaviors and provided similar mean responses to CAHPS communication items in response to standardized encounters.

CONCLUSIONS

Preliminary evidence suggests that unlike more subjective global ratings, reported disparities in more specific and objective CAHPS composites may primarily reflect differences in experiences, rather than differences in expectations and scale use, adding to our confidence in using the latter to assess disparities.

Responses of Massachusetts hospitals to a state mandate to collect race, ethnicity and language data from patients: a qualitative study

BACKGROUND

A Massachusetts regulation implemented in 2007 has required all acute care hospitals to report patients' race, ethnicity and preferred language using standardized methodology based on self-reported information from patients. This study assessed implementation of the regulation and its impact on the use of race and ethnicity data in performance monitoring and quality improvement within hospitals.

METHODS

Thematic analysis of semi-structured interviews with executives from a representative sample of 28 Massachusetts hospitals in 2009.

RESULTS

The number of hospitals using race, ethnicity and language data internally beyond refining interpreter services increased substantially from 11 to 21 after the regulation. Thirteen of these hospitals were utilizing patient race and ethnicity data to identify disparities in quality performance measures for a variety of clinical processes and outcomes, while 16 had developed patient services and community outreach programs based on findings from these data. Commonly reported barriers to data utilization include small numbers within categories, insufficient resources, information system requirements, and lack of direction from the state.

CONCLUSIONS

The responses of Massachusetts hospitals to this new state regulation indicate that requiring the collection of race, ethnicity and language data can be an effective method to promote performance monitoring and quality improvement, thereby setting the stage for federal standards and incentive programs to eliminate racial and ethnic disparities in the quality of health care.

Hospital Executives’ Perspectives on Pay-for-Performance and Racial/Ethnic Disparities in Care

With increasing attention paid to reducing racial/ethnic disparities in care and the growth of pay-for-performance programs, policy makers and payers are considering the use of such incentive mechanisms to target disparities reduction. This article describes the results of qualitative interviews with hospital executives to assess the potential impact that such programs would have on hospitals and their minority patients. The authors find that executives have significant concerns regarding funding mechanisms and implementation costs, financial risks for safety net hospitals, and resource constraints, as well as how such programs can be used to create incentives to care for minority patients. The findings suggest that payers should be hesitant to use pay-for-performance as a mechanism for reducing disparities until a wide variety of concerns about the design of such programs can be addressed.

Reducing disparities and improving quality: understanding the needs of small primary care practices

OBJECTIVES

Small practices provide a significant proportion of care in the United States and should be an essential focus of efforts to reduce racial/ethnic disparities and improve the quality of care for minority patients. This project sought to identify the resources and tools small practices need to conduct quality improvement activities to reduce disparities.

DESIGN

We surveyed small practices about their capabilities for conducting quality improvement activities for minority and limited English proficiency patients. A subset of practices also completed a brief chart review.

SETTINGS

Grantees of the National Committee for Quality Assurance Program were independent practices required to have five or fewer physicians with little or no experience with quality improvement (mean number of physicians = 1.4). At least one-quarter of the patients served by the practice were required to be minorities.

PARTICIPANTS

Twenty-two practices from California and New Jersey.

MAIN OUTCOME MEASURES

Surveys assessed clinician preparedness, use of systematic processes, and availability of information technology to improve care for minority patients. The chart review exercise elicited information on challenges and enabling factors in recent encounters with racial/ethnic minority patients.

RESULTS

Small practices face considerable challenges in caring for minority patients. They have limited staff and fewer resources than larger group practices, increasing the difficulty of making improvements on their own. The main challenges identified were patient adherence to treatment recommendations, staffing, language barriers and lack of information systems.

CONCLUSIONS

Small practices will require substantial support from external organizations in order to contribute to national reductions in racial/ethnic disparities in health care.

Urgent care centers in the U.S.: findings from a national survey

Background

Due to long waits for primary care appointments and extended emergency department wait times, newer sites for episodic primary care services, such as urgent care centers, have developed. However, little is known about these centers. The purpose of this study is to provide information about the organization and functioning of urgent care centers based on a nationally representative U.S. sample.

Methods

We conducted a mail survey with telephone follow-up of urgent care centers identified via health insurers' websites, internet searches, and a trade association mailing list. Descriptive statistics are presented.

Results

Urgent care centers are open beyond typical office hours, and their scope of services is broader than that of many primary care offices. While these characteristics are similar to hospital emergency departments, such centers employ significant numbers of family physicians. The payer distribution is similar to that of primary care, and physicians' average salaries are comparable to those for family physicians overall. Urgent care centers report early adoption of electronic health records, though our findings are qualified by a lack of strictly comparable data.

Conclusion

While their hours and scope of services reflect some characteristics of emergency departments, urgent care centers are in many ways similar to family medicine practices. As the health care system evolves to cope with expanding demands in the face of limited resources, it is unclear how patients with episodic care needs will be treated, and what role urgent care centers will play in their care.

Use of Advance Directives for Nursing Home Residents in the Emergency Department

Documented requests can ensure that patients' end-of-life care preferences are implemented, particularly in emergent circumstances. This study a) compared information on advance directives found in different sources of documentation in the hospital record of nursing home patients admitted through the emergency department and b) assessed emergency department clinicians' perceptions of how end-of-life care requests are communicated to them. Seven potential sources of documentation were reviewed in the medical records of 40 patients, and semistructured interviews were conducted with 10 emergency department clinicians. We found little concordance among sources of advance directive documentation. Our results suggest variability in documentation for nursing home patients on transfer to the emergency department, and that emergency department clinicians experience substantial difficulty in reliably obtaining information about advance directives. As treatment may vary based solely on available documentation, such information gaps may decrease the likelihood of adherence in the emergency department to patients' previously expressed care preferences.

Measuring racial and ethnic health care disparities in Massachusetts

Reducing racial and ethnic disparities in the quality of health care is a national policy priority; collecting race and ethnicity data from patients is a necessary first step in identifying and addressing these disparities. Recognizing this, Boston and Massachusetts recently enacted race and ethnicity data collection regulations affecting all acute care hospitals in the city and state. This paper describes the regulations and early lessons learned from implementing these data collection efforts in three areas: the design of data collection tools, uses of the data for eliminating disparities, and the role of the policy process in such efforts.

Who can't pay for health care?

BACKGROUND

In an era of rising health care costs, many Americans experience difficulty paying for needed health care services. With costs expected to continue rising, changes to private insurance plans and public programs aimed at containing costs may have a negative impact on Americans' ability to afford care.

OBJECTIVES

To provide estimates of the number of adults who avoid health care due to cost, and to assess the association of income, functional status, and type of insurance with the extent to which people with health insurance report financial barriers.

RESEARCH DESIGN

Cross-sectional observational study using data from the Commonwealth Fund 2001 Health Care Quality Survey, a nationally representative telephone survey.

PARTICIPANTS

U.S. adults age 18 and older (N=6,722).

MEASURES

Six measures of avoiding health care due to cost, including delaying or not seeking care; not filling prescription medicines; and not following recommended treatment plan.

RESULTS

The proportion of Americans with difficulty affording health care varies by income and health insurance coverage. Overall, 16.9% of Americans report at least 1 financial barrier. Among those with private insurance, the poor (28.4%), near poor (24.3%), and those with functional impairments (22.9%) were more likely to report avoiding care due to cost. In multivariate models, the uninsured are more likely (OR, 2.3; 95% CI, 1.7 to 3.0) to have trouble paying for care. Independent of insurance coverage and other demographic characteristics, the poor (OR, 3.6; 95% CI, 2.1 to 4.6), near poor (OR, 2.1; 95% CI, 1.9 to 3.7), and middle-income (OR, 1.8; 95% CI, 1.3 to 2.5) respondents as well as those with functional impairments (OR, 1.6; 95% CI, 1.3 to 2.0) are significantly more likely to avoid care due to cost.

CONCLUSIONS

Privately and publicly insured individuals who have low incomes or functional impairments encounter significant financial barriers to care despite having health insurance. Proposals to expand health insurance will need to address these barriers in order to be effective.

Hispanic healthcare disparities: challenging the myth of a monolithic Hispanic population

BACKGROUND

Hispanic Americans are often treated as a monolithic ethnic group with a single pattern of healthcare utilization. However, there could be considerable differences within this population. We examine the association between use of healthcare services and Hispanic Americans'country of ancestry or origin, language of interview, and length of time lived in the United States.

METHODS

Our data come from the Medical Expenditure Panel Survey, a nationally representative survey of healthcare use and expenditures. Descriptive statistics and logistic regression results are presented.

RESULTS

Multivariate models show that Mexicans and Cubans are less likely, and Puerto Ricans more likely, to have any emergency department visits than non-Hispanic whites. Mexicans, Central American/Caribbeans, and South Americans are less likely to have any prescription medications. All Hispanics are less likely to have any ambulatory visits and prescription medications, whereas only those with a Spanish-language interview are less likely to have emergency department visits and inpatient admissions. More recent immigrants are less likely to have any ambulatory care or emergency department visits, whereas all Hispanics born outside the United States are less likely to have any prescription medications.

CONCLUSIONS

The Hispanic population is composed of many different groups with diverse health needs and different barriers to accessing care. Misconceptions of Hispanics as a monolithic population lacking within-group diversity could function as a barrier to efforts aimed at providing appropriate care to Hispanic persons and could be 1 factor contributing to inequalities in the availability, use, and quality of healthcare services in this population.

Emergency department crowding: consensus development of potential measures

STUDY OBJECTIVE

We identify measures of emergency department (ED) and hospital workflow that would be of value in understanding, monitoring, and managing crowding.

METHODS

A national group of 74 experts developed 113 potential measures using a conceptual model of ED crowding that segmented the measures into input, throughput, and output categories. Ten investigators then used group consensus methods to revise and consolidate them into a refined set of 30 measures that were rated by all 74 experts, who used a magnitude estimation technique on a Web site. Each measure was compared with a standard to obtain numeric ratings for feasibility, affordability, early warning potential, long-term planning potential, a summary rating of operational usefulness, and research potential. After review of the comprehensiveness of the resulting measures, 8 additional measures were developed and also rated by all reviewers.

RESULTS

The original set of 113 measures (46 input, 35 throughput, and 32 output) was reduced to 38 through the iterative revision and rating process (15 input, 9 throughput, and 14 output). Summary scores in each rating category showed significant variation in ratings among the various potential measures. For measures that address similar concepts, the priority ranking depended on the rating category chosen.

CONCLUSION

The final 38 measures of ED and hospital workflow provide a useful pool from which EDs and policymakers can draw to improve their ability to understand and address the issue of ED crowding. These measures require rigorous testing for feasibility, reliability, and value.

Researching disparities: strategies for primary data collection

Comparatively little disparities research to date has focused on emergency medicine. However, the body of disparities research developed in other areas of health care has identified a number of issues that are directly applicable. To promote research on disparities in emergency medicine, this article addresses several of these issues related to collecting and classifying data on race/ethnicity and socioeconomic status and selected methodologic issues that are particularly important for evaluating disparities.

Differences between Hispanics and non-Hispanic Whites in use of hospital procedures for cerebrovascular disease

OBJECTIVE

This study examined disparities in the use of in-hospital diagnostic and therapeutic procedures for Hispanics with cerebrovascular disease compared to their non-Hispanic White counterparts.

DESIGN

This is a cross-sectional study using 1996 hospital administrative data.

METHODS

Hispanics and non-Hispanic Whites with diagnosis codes indicating occlusion or stenosis of precerebral arteries or transient cerebral ischemia were included, with a total of 18,674 New York patients (5.1% Hispanic) and 22,624 California patients (11.1% Hispanic). Adjusted odds ratios compared Hispanics with non-Hispanic Whites for six diagnostic and therapeutic procedures for cerebrovascular disease, controlling for patient and hospital characteristics.

RESULTS

Hispanics had higher rates of non-invasive diagnostic procedures (head CT scan, head/neck diagnostic ultrasound, echocardiogram, and head MRI). The odds of invasive diagnostic testing (cerebral arteriogram) and therapeutic procedures (carotid endarterectomy) were lower for Hispanics. Most findings remained unchanged in logistic regression models with patient and hospital characteristics. Adding a measure of the concentration of Hispanic patients by hospital eliminated or reduced observed differences between Hispanics and Whites.

CONCLUSIONS

Controlling for each hospital's experience with Hispanic patients eliminated or reduced the magnitude of the disparities in procedure use, suggesting that the concentration of Hispanic patients in a hospital is associated with different patterns of procedure use.

Racial and ethnic differences in access to and use of health care services, 1977 to 1996

This article focuses on racial and ethnic disparities in health care, describing both absolute differences and relative changes in access to care and the use of health services among whites, blacks, and Hispanics over the past two decades. Using data from a series of three nationally representative medical expenditure surveys, the authors present descriptive statistics on disparities in access and use between minorities and whites over time. They also use multivariate analyses to isolate the extent to which health insurance and income explain those disparities. The authors find that disparities increased between 1977 and 1996, particularly for Hispanic Americans. Results also show that approximately one half to three quarters of the disparities observed in 1996 would remain even if racial and ethnic disparities in income and health insurance coverage were eliminated.

A comparison of health care experiences for medicaid and commercially enrolled children in a large, nonprofit health maintenance organization

BACKGROUND

Proponents of Medicaid managed care have argued that this type of care offers the potential to provide mainstream health care for poor children and the elimination of the 2-tier system of care that has long existed for poor and nonpoor children. However, few studies have attempted to assess whether differences in access, utilization, and satisfaction exist between Medicaid and commercially sponsored children who are enrolled in the same managed care plan.

OBJECTIVE

To systematically answer the following research question: Within the same large, nonprofit, group-model health maintenance organization (HMO), how do children enrolled in Medicaid compare with children enrolled commercially across the domains of access, utilization, and satisfaction with care?

METHODS

We compared access, satisfaction, and utilization of services between Medicaid and commercially sponsored children enrolled in Kaiser Permanente of Northern California during 1998 through use of a telephone survey and administrative data. Kaiser Permanente is a nonprofit, integrated, group HMO that serves 2.8 million members in more than 15 counties in northern California. The sample for this survey included 510 Medicaid-enrolled children and 512 commercially enrolled children. An overall response rate of 82% was achieved. Bivariate and multivariate analyses were used to compare Medicaid and commercially enrolled children.

RESULTS

We found few differences between commercial and Medicaid enrollees across the domains of access, utilization, and satisfaction. Where access differences were present (problems in finding a personal care provider, problems getting care overall, and experiencing 1 or more barriers to care), the differences favored Medicaid-enrolled children. That is, Medicaid enrollees were reported to experience significantly fewer access problems and barriers than commercial enrollees, even after adjustment for confounding factors. Only one difference was found between Medicaid and commercial enrollees across the 6 utilization variables examined (volume of emergency department visits), and no differences were found among the 4 satisfaction and 2 global assessments of care received. Taken together, our results suggest that Medicaid-enrolled children experience as good as or better care than their commercially enrolled counterparts. However, there are other possible explanations for our findings. It may be that families of Medicaid-enrolled children hold their care providers to a lower standard than families of commercially enrolled children, given historic inequities in care between poor and nonpoor families. In addition, some degree of selection bias may be present in our sample, although that is true for both the Medicaid and commercial populations.

CONCLUSIONS

Our findings suggest that large commercial HMOs are capable of eliminating the access barriers and stigma traditionally associated with the Medicaid program. However, this conclusion must be tempered with the knowledge that other explanations for our findings may also be at play.

Annual report on access to and utilization of health care for children and youth in the United States--2000

OBJECTIVE

This report provides an update on insurance coverage, use of health care services, and health expenditures for children and youth in the United States. In addition, the report provides information on variation in hospitalizations for children from a new 22-state hospital discharge data source.

METHODS

The data on insurance coverage, utilization, and expenditures come from the Medical Expenditure Panel Survey. The data on hospitalizations come from the Database for Pediatric Studies, which is part of the Healthcare Cost and Utilization Project. Both data sets have been prepared by the Agency for Healthcare Research and Quality.

RESULTS

Few changes in insurance coverage occurred between 1996 and 1998. About two thirds of American children are covered by private insurance and 19% by public sources; the remaining 15% are uninsured. Of the 71.5% of children who have at least 1 doctor's office visit, the average number of visits was 3.9, but this ranged from 2.7 among the uninsured to 4.2 for those with private insurance. Slightly more than half of children had a prescription, and these averaged 5.4 prescriptions. The majority of children (85%) incur medical expenditures, averaging $1019 for children with any expenditure. Private health insurance was by far the largest payer of medical care expenses for children, even more so than among the general population. However, nearly 21% of expenditures for children's health care were paid out of pocket by children's families. The data also show substantial differences in average length of hospitalization across states, ranging from 2.7 to 4.0 days, and rates of hospital admission through the emergency department, which vary across states from 9% to 23%. Injuries are a major reason for hospitalization, accounting for 1 in 6 hospital stays among 10- to 14-year-olds. In the 10-17 age group, 1 in 7 hospital stays are due to mental disorders. Among 15- to 17-year-olds, more than one third of all hospital stays are related to childbirth and pregnancy.

CONCLUSION

Children's use of health care services varies considerably by what type of health insurance coverage they have. Expenditures for children entail a substantial out-of-pocket component, which may be quite large for children with major health problems and which may represent a significant burden on lower-income families. Substantial variation in hospitalization exits across states.

Racial/ethnic differences in children's access to care

OBJECTIVES

This study explored reasons for racial and ethnic differences in children's usual sources of care.

METHODS

Data from the 1996 Medical Expenditure Panel Survey were examined by means of logistic regression techniques.

RESULTS

Black and Hispanic children were substantially less likely than White children to have a usual source of care. These differences persisted after control for health insurance and socioeconomic status. Control for language ability, however, eliminated differences between Hispanic and White children.

CONCLUSIONS

Results suggest that the marked Hispanic disadvantage in children's access to care noted in earlier studies may be related to language ability.

Comparing the medical expenses of children with Medicaid and commercial insurance in an HMO

BACKGROUND

In recent years, growing numbers of children with Medicaid have been enrolled in managed care plans nationwide. Yet, large, commercial managed care plans are increasingly discontinuing their participation in Medicaid because of low Medicaid payment rates.

OBJECTIVE

To compare the healthcare utilization and costs of children with Medicaid and children with commercial insurance within the same health maintenance organization (HMO).

STUDY DESIGN

Retrospective study using electronically captured cost and utilization data.

PATIENTS AND METHODS

We compared the healthcare utilization and costs of children with Medicaid (n = 42,636) and children with commercial insurance (n = 159,651) who were members of the same large, nonprofit HMO at any time between January 1, 1995, and December 31, 1997. Medicaid children were grouped as income eligible, medically needy, and blind or disabled.

RESULTS

The unadjusted costs of income-eligible, Medicaid-insured children were not significantly different from those of commercially insured children. The medically needy were $25 per month more expensive than commercially insured children (P = 0.02), and the blind or disabled were $213 per month more expensive (P < .01). After adjusting for age and sex, income-eligible children were $5 per month more expensive than children with commercial insurance (P = .07), the medically needy were $20 per month more expensive (P = .02), and the blind or disabled were $216 per month more expensive (P < .01).

CONCLUSIONS

The costs of income-eligible, Medicaid-insured children in this HMO were similar to those of commercially insured children, but the costs for the medically needy and the blind and disabled were substantially higher.

An overview: eliminating racial, ethnic, and SES disparities in health care

The papers featured in this issue of the Health Care Financing Review were presented at "Eliminating Racial, Ethnic, and SES Disparities in Health Care: A Research Agenda for the New Millennium." This conference was held on October 15, 1999, in the Washington, DC., area and was co-sponsored by the Health Care Financing Administration (HCFA), the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research), and the Henry J. Kaiser Family Foundation. The conference was undertaken in response to the challenge posed by President Clinton's national goal of eliminating racial and ethnic disparities in six health domains by the year 2010.

Changes in access to care, 1977-1996: the role of health insurance

OBJECTIVE

To describe changes in Americans' access to care over the last 20 years focusing on the uninsured, Hispanic American, and young adult populations, and to analyze the factors underlying these changes with a particular focus on the role of health insurance.

DATA SOURCES/STUDY SETTING

Data from the 1977 National Medical Care Expenditure Survey, the 1987 National Medical Expenditure Survey, and the 1996 Medical Expenditure Panel Survey.

STUDY DESIGN

Focusing on whether each individual has a usual source of health care, we present descriptive statistics and algebraic decompositions.

DATA COLLECTION/EXTRACTION METHODS

We combine data from the household surveys with questions from access to care supplements that were administered each time.

PRINCIPAL FINDINGS

Hispanic Americans and young adults age 18-24 are more likely to lack a usual source of care than other Americans; these inequalities increased over the period studied and cannot be explained solely by changes in health insurance coverage.

CONCLUSIONS

Although increasing health insurance coverage will likely improve access to care among Hispanics and young adults, our findings suggest that the expansion of insurance coverage will not be sufficient to eliminate current disparities in access to care.

Children's health insurance coverage and family structure, 1977-1996

Using data from a series of nationally representative medical expenditure surveys, the authors document changes in children's health insurance coverage in a period of two decades. Overall, it is found that the proportion of children with private coverage declined, while the proportions publicly insured and uninsured increased. However, when the authors account for differences in family structure, they find striking disparities in children's insurance experiences. Contrary to overall trends, children in single-parent households made significant gains in private health insurance coverage after 1997 and experienced reductions in public insurance. Coincident with Medicaid expansions in the late 1980s, children in two-parent households experienced significant increases in public health insurance. It is found that the rise in the proportion of children who were uninsured in this period was largely a single-parent family phenomenon, and that parents' marital status, employment status, and family income are crucial factors associated with children's insurance status.

Health-related behaviors and the benefits of marriage for elderly persons

In this article, we investigate the relationship between health behaviors, marital status, and gender in the elderly population. We estimate logistic regression models to determine the factors that affect the likelihood of undertaking healthy behaviors. Using data from the 1987 National Medical Expenditure Survey, we find that marriage has positive impacts on health behaviors in the elderly population and that, when these effects differ by gender, they tend to be larger for elderly men than for elderly women. These results extend earlier findings showing that marriage encourages healthy behaviors for a younger population and demonstrate that these benefits continue later in life.

Children's health insurance, access to care, and health status: new findings

Despite various policy initiatives, a substantial number of children in the United States remain uninsured, have problems with access to health care, or are in fair or poor health. These difficulties are not evenly distributed across the population. Hispanic children, those whose parents have little education, and those who live in families without an employed parent are at disproportionately high risk of encountering these problems. Although multivariate analyses would be required to disentangle the complex relationships among these factors, these descriptive data reveal the segments of the population to which new health-related programs, such as CHIP-funded state plans, might most productively be directed. Issues concerning children's health are likely to remain on the national policy agenda for some time to come. Because MEPS is a continuing data collection effort, it will enable researchers and policymakers to follow trends in these issues over time. For example, MEPS data will support evaluations at the national level to determine whether children who lack health insurance or a usual source of care will actually face fewer barriers after CHIP-funded programs are implemented. This paper provides a baseline against which to evaluate the impact of CHIP and other policy changes on the health and well-being of America's children.

Usual sources of health care and barriers to care, 1996

This paper provides a brief overview of two major indicators of access to health care in America in 1996. The first is usual sources of health care (including reasons why Americans change their usual source of care); and the second, barriers families encounter in accessing needed care based upon measures from the 1996 Medical Expenditure Panel Survey (MEPS). Almost 18 percent of the population did not have a usual source of health care in 1996. Groups most likely to lack a usual source of health care included uninsured persons under age 65, all young adults ages 18-24, Hispanics and males. Americans living in the West and South were more likely to lack a usual source of health care than those in the Northeast and Midwest. The main reasons reported for lacking a usual source of care included the following: seldom or never getting sick, having recently moved or not knowing where to go, and the cost of medical care. Hispanics, uninsured persons under age 65 and persons living in the West were more likely to report cost as the main reason for lacking a usual source of care. Nearly 12 percent of American families had at least one member who changed his or her usual source of health care provider within the previous 12 months. Many switched because of problems of availability, insurance-related reasons or dissatisfaction with quality of care. Approximately 12.8 million families (11.6 percent of all families) encountered difficulty or delay in obtaining care or did not receive the health care services they needed. Families living in the Northeast, particularly within metropolitan statistical areas, were the least likely to encounter problems obtaining needed health care and families living in the West were the most likely to experience problems.

Women's use of preventive screening services: a comparison of HMO versus fee-for-service enrollees

Health maintenance organizations (HMOs) may relax some of the institutional barriers to using preventive screening services by requiring only a nominal copayment for such services and by promoting their use via educational programs. However, the gatekeeper system employed by HMOs may discourage the use of these services if referrals are required to access them. Using the 1987 National Medical Expenditure Survey and the 1992 National Health Interview Survey, the authors investigate whether HMO enrollment is associated with the use of preventive screening services for nonelderly, privately insured women. Employing models that control for self-selection into HMOs, the authors find that women who were enrolled in HMOs in 1987 were more likely to have received Pap smears and breast exams within the last year and to have ever received a mammogram when compared with women with fee-for-service coverage. By 1992, however, HMOs had lost this comparative advantage.