Andrew B. Bindman

Primary care and receipt of preventive services

OBJECTIVE: To examine whether health insurance, a regular place of care, and optimal primary care are independently associated with receiving preventive care services.DESIGN: A cross-sectional telephone survey.SETTING: Population based.PARTICIPANTS: Probability sample of 3,846 English-speaking and Spanish-speaking women between the ages of 18 and 64 in urban California.INTERVENTIONS: Women were asked about their demographic characteristics, financial status, health insurance status, need for ongoing care, regular place of care, and receipt of blood pressure screening, clinical breast examinations, mammograms, and Pap smears. Women who reported a regular place of care were asked about four components of primary care: availability, continuity, comprehensiveness, and communication.MEASUREMENTS AND MAIN RESULTS: In multivariate analyses that controlled for differences in demographics, financial status, and need for ongoing care, having a regular place of care was the most important factor associated with receiving preventive care services (p<.0001). Having health insurance (p<.001) and receiving optimal primary care from the regular place of care (p<.01) further significantly increased the likelihood of receiving preventive care services.CONCLUSION: A regular source of care is the single most important factor associated with the receipt of preventive services, but optimal primary care from a regular place increases the likelihood that women will receive preventive care.

Emergency department visits for ambulatory care sensitive conditions: Insights into preventable hospitalizations

Objectives.To explore whether differences in disease prevalence, disease severity, or emergency department (ED) admission thresholds explain why black persons, Medicaid, and uninsured patients have higher hospitalization rates for ambulatory care sensitive (ACS) conditions. Materials and methods.The National Hospital Ambulatory Care Survey was used to analyze the ED utilization, disease severity (assessed by triage category), hospitalization rates, and follow-up plans for adults with five chronic ACS conditions (asthma, chronic obstructive lung disease, congestive heart failure, diabetes mellitus, and hypertension). The National Health Interview Survey was used to estimate the prevalence of these conditions in similarly aged US adults. Results.Black persons, Medicaid, and uninsured patients make up a disproportionate share of ED visits for these chronic ACS conditions. Cumulative prevalence of these conditions was higher in black persons (33%) compared with white persons (27%) and Hispanic persons (22%), but did not differ among the payment groups. All race or payment groups were assigned to similar triage categories and similar percentages of their ED visits resulted in hospitalization. Black persons and Hispanic persons (odds ratios for both = 0.7), were less likely than white persons, whereas Medicaid and uninsured patients (odds ratios for both = 0.8), were less likely than private patients to have follow-up with the physician who referred them to the ED. Conclusions.The disproportionate ED utilization for chronic ACS conditions by black persons and Medicaid patients does not appear to be explained by either differences in disease prevalence or disease severity. Follow-up arrangements for black persons, Medicaid, and uninsured patients suggest that they are less likely to have ongoing primary care. Barriers to primary care appear to contribute to the higher ED and hospital utilization rates seen in these groups.

HIV testing within at-risk populations in the United States and the reasons for seeking or avoiding HIV testing.

Objectives: We determined proportions of high‐risk persons tested for HIV, the reasons for testing and not testing, and attitudes and perceptions regarding HIV testing, information that is critical for planning prevention programs. Methods: Cross‐sectional interview study of persons at high risk for HIV infection (men who have sex with men [MSM]; injection drug users [IDUs]; and heterosexual persons recruited from gay bars, street outreach, and sexually transmitted disease clinics) among six states participating in the HIV Testing Survey (HITS) in 1995 to 1996 (HITS‐I) and 1998 to 1999 (HITS‐II). Results: Overall testing rates were lower in the HITS‐I (1226/1599 [77%]) than in the HITS‐II (1375/1711 [80%]) (p = .01). Persons <25 years old tested less frequently than those >25 years old (HITS‐I: 71 % vs. 78%, respectively, p = .007; HITS‐II: 63% vs. 85%, respectively, p < .001). The main reasons for testing and not testing were the same in both surveys, but the proportions of reasons for not testing differed (e.g., “unlikely exposed to HIV” [HITS‐I (17%) vs. HITS‐II (30%), p < .0001], “afraid of finding out HIV‐positive” [HITS‐I (27%) vs. HITS‐II (18%), p < .0001]). Attitudes regarding HIV testing differed among tested and untested respondents, especially among MSM. Conclusions: HIV testing rates were higher in the HITS‐II, but testing rates decreased among the youngest respondents. Denial of HIV risk factors and fear of being HIV‐positive were the principal reasons for not being tested. Availability of new HIV therapies may have contributed to decreased fear of finding out that one is HIV infected as a reason to avoid testing. The increased proportion of persons at risk who did not test because they believed they were unlikely to have been exposed highlights the need for prevention efforts to address risk perceptions.

Medicare’s Policy Not To Pay For Treating Hospital-Acquired Conditions: The Impact

In 2008 Medicare stopped reimbursing hospitals for treating eight avoidable hospital-acquired conditions. Using 2006 California data, we modeled the financial impact of this policy on six such conditions. Hospital-acquired conditions were present in 0.11 percent of acute inpatient Medicare discharges; only 3 percent of these were affected by the policy. Payment reductions were negligible (0.001 percent, or

Cross sectional study of primary care groups in London: association of measures of socioeconomic and health status with hospital admission rates

0.1 million-equivalent to

Interruptions in Medicaid Coverage and Risk for Hospitalization for Ambulatory Care–Sensitive Conditions

1.1 million nationwide) and are unlikely to encourage providers to improve quality. Options to strengthen the incentives include further payment modifications for hospital-acquired conditions or expanding the hospital-acquired condition policy to exclude payment for consequences, additional procedures, and readmissions.

Comparison of specialty referral rates in the United Kingdom and the United States: retrospective cohort analysis.

Abstract Objectives: To calculate socioeconomic and health status measures for the primary care groups in London and to examine the association between these measures and hospital admission rates. Design: Cross sectional study. Setting: 66 primary care groups in London, total list size 8.0 million people. Main outcome measures: Elective and emergency standardised hospital admission ratios; standardised admission rates for diabetes and asthma. Results: Standardised hospital admission ratios varied from 74 to 116 for total admissions and from 50 to 124 for emergency admissions. Directly standardised admission rates for asthma varied from 152 to 801 per 100 000 (mean 364) and for diabetes from 235 to 1034 per 100 000 (mean 538). There were large differences in the mortality, socioeconomic, and general practice characteristics of the primary care groups. Hospital admission rates were significantly correlated with many of the measures of chronic illness and deprivation. The strongest correlations were with disability living allowance (R=0.64 for total admissions and R=0.62 for emergency admissions, P<0.0001). Practice characteristics were less strongly associated with hospital admission rates. Conclusions: It is feasible to produce a range of socioeconomic, health status, and practice measures for primary care groups for use in needs assessment and in planning and monitoring health services. These measures show that primary care groups have highly variable patient and practice characteristics and that hospital admission rates are associated with chronic illness and deprivation. These variations will need to be taken into account when assessing performance.

Monitoring the Consequences of Uninsurance: A Review of Methodologies:

Context Many persons in the United States experience interruptions in their health insurance coverage. Contribution This study of hospitalized California adults with Medicaid found an association between interruptions in coverage and a higher rate of hospitalization for ambulatory caresensitive conditions, such as heart failure, diabetes, and chronic obstructive pulmonary disease. Caution The study sample was limited to hospitalized patients, and some patients with interrupted coverage may have obtained private insurance. Implication Interruptions in insurance coverage were associated with hospitalization for ambulatory caresensitive conditions. Policies that reduce the interruptions in coverage might prevent some of these hospitalizations. The Editors Many U.S. citizens experience interruptions in health insurance coverage. A total of 85 million persons, or 38% of the U.S. population, younger than age 65 years were uninsured for at least part of a 3-year period (1). Low-income U.S. citizens are particularly at risk for periodic lack of insurance. Many poor persons move in and out of the Medicaid program with periods of being uninsured in between (2, 3). Medicaid reenrollment policies affect the number of beneficiaries who experience interruptions in their coverage. A shorter period for eligibility redetermination creates an administrative barrier to continuous coverage (4). Federal law requires that Medicaid eligibility be redetermined at least annually, but many states require this assessment at a shorter interval. In California, for example, adults need to redemonstrate their eligibility for Medicaid every 3 months. Research suggests that individuals with interrupted insurance coverage are less likely to receive primary care and preventive services (5). One potentially useful but as yet unexplored measure of morbidity and costs associated with interrupted Medicaid coverage is hospitalizations for ambulatory caresensitive conditions. Ambulatory caresensitive conditions, such as asthma, diabetes, and hypertension, are conditions that can often be managed with timely and effective treatment in an outpatient setting, thereby preventing hospitalization (6). Hospital admissions for these conditions reflect a decline in health status and, by association, the health consequences of access barriers. We performed a retrospective cohort study to determine whether interruptions in Medicaid enrollment are associated with an increased risk for hospitalizations in adults with ambulatory caresensitive conditions. Methods Data To conduct the analysis, the 1998 to 2002 California hospital patient discharge data available from the California Office of Statewide Health Planning and Development was linked with the Medicaid Monthly Eligibility File for the corresponding period from the California Department of Health Services. A deterministic match was done with social security numbers, sex, and year of birth available in both files, and a probabilistic match by using sex, date of birth, hospital identifier, and hospitalization dates was done on the residual to enhance the linkage. Judging by comparisons with separate Medicaid payment records, the California Department of Health Services estimated that more than 98% of Medicaid hospitalization records were successfully linked. Approximately 70% of the records were linked by using the deterministic method, and 27% were linked by using the probabilistic method (7). Furthermore, most records lacking a social security number needed for a deterministic match were for newborns, whom we excluded from this analysis. We were unable to correct for out-of-state hospitalizations of Medicaid beneficiaries. The California hospital patient discharge database includes a unique patient identifier and information about admission and discharge dates, patient demographic characteristics, diagnosis codes, and insurance status for the hospitalization. By linking the information available in the hospital discharge file with that available from the California Department of Health Services, we could confirm whether a hospitalized individual was in fact a Medicaid beneficiary and capture additional information on a monthly basis regarding Medicaid enrollment status, aid category, and whether the care was delivered through fee-for-service or managed care for all Medicaid beneficiaries, regardless of whether they were hospitalized. Furthermore, this linked file enabled us to capture hospitalizations for individuals who at one time may have had Medicaid coverage but did not have coverage at the time of a hospitalization. We limited our analysis to adults age 18 to 64 years. Outcome Measure We created longitudinal records of eligibility status and hospitalizations of any persons who were ever enrolled in Medicaid during the 5-year study period. We measured the duration of time within the study period from enrollment in Medicaid until the first hospitalization for an ambulatory caresensitive condition and the duration of time to subsequent hospitalizations thereafter. We classified hospitalizations in the patient discharge file as being for ambulatory caresensitive conditions on the basis of the definition provided by the Agency of Healthcare Research and Quality (AHRQ). We applied the AHRQ definitions of ambulatory caresensitive conditions, identifying hospitalizations in which the principal diagnosis International Classification of Disease, Ninth Edition, code was listed in the AHRQ 2001 guidelines (8). We have previously reported that these conditions comprise 26% of nonpregnancy-related hospitalizations for Medicaid beneficiaries in California (9). We compared the pattern of hospitalization rates for specific ambulatory caresensitive conditions between patients with continuous and those with interrupted Medicaid coverage. Because this pattern was quite similar, and for ease of interpretation and presentation, we followed the conventional practice of aggregating hospital admissions for any of the AHRQ ambulatory caresensitive conditions. Exposure Variable We modeled our primary exposure variable as a time-varying covariate indicating whether a beneficiary had or had not experienced an interruption of coverage. We identified an interruption of coverage when a monthly eligibility code after the first enrollment month was no longer present. The California Medicaid Monthly Enrollment file includes a code for Healthy Families, the California State Childrens Health Insurance Program (SCHIP). Healthy Families allows persons up to the age of 19 years to qualify for Medicaid-type benefits in California but at somewhat higher income levels. For the purposes of our analysis, we considered enrollment in Healthy Families as a form of Medicaid coverage and did not consider it to be an interruption in coverage if an individual changed between these 2 programs over time. We characterized all periods before the interruption as continuous and those after the interruption as being discontinuous. Potential Confounders We measured several characteristics of beneficiaries that could influence their risk for a hospitalization for an ambulatory caresensitive condition as well as their risk for interrupted Medicaid coverage. These included demographic characteristics, Medicaid aid category, Medicaid health care delivery model, and forms of insurance other than Medicaid. Many of these variables are used to determine payment and were therefore complete in the data set. However, 68807 beneficiaries (1%) had missing information on race/ethnicity and were classified with those reported as other. Beneficiary demographic characteristics and Medicaid aid category provide an estimate of health status. We categorized aid category as Temporary Assistance to Needy Families (TANF), Supplemental Security Income (SSI), or other by using previously described algorithms (10). Medicaid eligibility through TANF is available to low-income children and their parents regardless of their health status. On the other hand, beneficiaries enrolled in Medicaid through the SSI program are eligible as a result of a chronic disability and therefore tend to be sicker on average than those eligible through TANF (11). From calculations using the Medi-Cal eligibility file data, we determined that most (83%) of the other group is composed of low-income persons whose incomes are too high for them to qualify for Medicaid but who subsequently do qualify for the medically needy aid category because of their acute out-of-pocket spending on health care services. The remainder of the other group is primarily women who are eligible on the basis of a pregnancy (12%) and persons who are eligible through one of several immigration-related programs (4%). The AHRQ provides an option for including the Elixhauser comorbid condition measure in the calculation of ambulatory caresensitive hospitalization rates (12). Incorporating diagnoses from administrative data in risk adjustment could introduce overadjustment if the comorbid conditions are a product of the same access-to-care barriers that result in hospitalizations for ambulatory caresensitive conditions. Nonetheless, we performed additional analyses incorporating the Elixhauser comorbid condition measure and found that its inclusion did not substantially affect our findings. Therefore, to simplify the presentation, we have chosen not to display these results. Except for the managed care indicator variable, all potential confounders were measured when beneficiaries enrolled in Medicaid. We classified Medicaid beneficiaries as being in managed care depending on whether they spent most of their enrollment time before a hospitalization for an ambulatory caresensitive condition in managed care. This was necessary because some beneficiaries changed between fee-for-service and managed care during their enrollment time. Statistical Analysis We performed descriptive analysis of the characteristics of Medicaid beneficiaries who did and

Chronic Kidney Disease in the Urban Poor

Although several studies have shown that US physicians make greater use of medical technologiesthan UK physicians, no study has examined variation in specialty referral rates, the step before specialised procedures. We compared rates of referral to specialists in the United Kingdom and the United States. To hold the effects of gatekeeping systems constant, we studied US managed care settings that used a structured referral process similar to that in the United Kingdom. We included non-pregnant patients aged 0 to 64 years, with at least six months of enrolment on a health plan or general practice registration and at least one consultation with their primary care physician during 1996 (US) or 1997 (UK). The US sample comprised 384 693 patients from five health maintenance organisations. All US patients had been assigned physician gatekeepers, who authorised specialty referrals. We used the general practice research database for the UK sample (n=757,680).1 We measured referral rates as the annual percentage of patients with a new referral to a specialist physician. In the United …

Effect of managed care on preventable hospitalization rates in California.

The proportion of the United States population without health insurance continues to grow. How will this affect the health of the nation? Prior research suggests that the uninsured are at risk for poor health outcomes. They use fewer medical services and have higher mortality rates than do insured persons. The episodic nature of uninsurance and its prevalence among disadvantaged groups makes it difficult to ascertain the health effects of uninsurance. The goal of this review is to assist researchers and policy makers in choosing methodologies to assess the effects of uninsurance. It provides a compendium of methods that have been used to examine the health consequences of uninsurance, the populations in which these methods have been used, and the strengths and weaknesses of different approaches. The review highlights the need for more longitudinal studies that focus on community-based samples of the uninsured.