Catherine G. McLaughlin

The impact of health plan report cards on managed care enrollment

How does the release of health plan performance ratings influence employee health plan choice? A natural experiment at General Motors (GM) Corporation provides valuable evidence on this question. During the 1997 open enrollment period, GM disseminated a health plan report card for the first time. By comparing 1996 and 1997 enrollment patterns, our analysis estimates the impact of the report card information while accounting for fixed, unobserved plan traits. Results indicate that employees are less likely to enroll in plans requiring relatively high out-of-pocket contributions. Results with respect to report card ratings suggest that individuals avoid health plans with many below average ratings.

Small-area Variation in Hospital Discharge Rates: Do Socioeconomic Variables Matter?

Although numerous studies have been made of the determinants of smallarea variation in hospital discharge rates, there is still disagreement about the role of socioeconomic factors. The lack of consensus stems, in part, from the difficulty in comparing results across studies that use different units and methods of analysis. Many of the studies using well-defined hospital service areas did not have the data needed to conduct a controlled analysis of the determinants of hospital utilization. Most of the studies that have performed controlled analyses have relied on larger geopolitical areas, which are not believed to capture self-contained health care systems. The study described here used a consistent set of data, three methods of analysis, and two units of analysis to test the importance of socioeconomic characteristics in explaining the variation in medical and surgical discharge rates in Michigan. Socioeconomic factors are found to be statistically significant determinants of the variation in both medical and surgical discharge rates, whether the method of analysis is simple correlations or multiple regressions, and whether the unit of analysis is the county or a well-designed hospital service area. These results suggest that previous small-area variation studies may have incorrectly concluded that socioeconomic characteristics do not explain differences in utilization rates.

Access to Care: Remembering Old Lessons

More than 20 years ago, Penchansky and Thomas (1981) published an article titled “The Concept of Access: Definition and Relationship to Consumer Satisfaction.” In the opening sentence to this article, they note: “‘access’ is a major concern in health care policy and is one of the most frequently used words in discussions of the health care system.” The same is certainly true today. In many policy discussions, access is equated with health insurance coverage. Although those who have defined access have all included other, nonfinancial, aspects of access in their definitions (Donabedian 1973; Penchansky and Thomas 1981; Millman 1993), we must still often remind ourselves of the importance of each aspect and the interplay between the different aspects. As conceived by Penchansky and Thomas, access reflects the fit between characteristics and expectations of the providers and the clients. They grouped these characteristics into five As of access to care: affordability, availability, accessibility, accommodation, and acceptability. Affordability is determined by how the providers charges relate to the clients ability and willingness to pay for services. Availability measures the extent to which the provider has the requisite resources, such as personnel and technology, to meet the needs of the client. Accessibility refers to geographic accessibility, which is determined by how easily the client can physically reach the providers location. Accommodation reflects the extent to which the providers operation is organized in ways that meet the constraints and preferences of the client. Of greatest concern are hours of operation, how telephone communications are handled, and the clients ability to receive care without prior appointments.And finally, acceptability captures the extent to which the client is comfortable with the more immutable characteristics of the provider, and vice versa.These characteristics include the age, sex, social class, and ethnicity of the provider (and of the client), as well as the diagnosis and type of coverage of the client. We must also remember that these five As of access form a chain that is no stronger than its weakest link. For example, improving affordability by providing health insurance will not significantly improve access and utilization if the other four dimensions have not also been addressed. Often neglected are the characteristics of the provider and the client that influence acceptability. Taylor et al. (2002) estimate that providing universal coverage through a Medicare buy-in for women aged 50–62 would result in a modest increase in mammography rates, from 72.7 percent to 75–79 percent. Like the work by Hofer and Katz (1996), who compared mammography rates for women in Canada and the United States, this research highlights the role in achieving access of client socioeconomic characteristics that influence acceptability. Similarly, equating access with availability of resources will miss other characteristics of the provider and the clients that may be barriers to access. As Iwashyna et al. (2002) conclude, “intercounty heterogeneity in hospice use is substantial, and may not be related to the set-up of the medical care system.” Their research also finds that simply controlling for differences in the composition of measured individual-level characteristics did not explain variation in use. Not only is the mere presence of facilities not an adequate measure of availability, it misses the more important issue of goodness of fit, that is, the interaction between the characteristics of the providers and the expectations of the clients that determine the acceptability of the resources. Perhaps a more reliable measure of the goodness of fit between provider and client is whether someone has a regular physician and a regular site of care, since it can be seen as reflecting availability, accessibility, accommodation, and acceptability. The results of Xu (2002) highlight the importance of this goodness of fit between provider and client in influencing use of preventive services. However, the full picture on access does not emerge because the role of affordability in influencing utilization, controlling for differences in having a usual source of care, is not reported. The growing body of research investigating racial and ethnic differences in the utilization of various medical and dental care services points to the critical role played by all of the dimensions of access, particularly availability, accessibility, and acceptability. Although Gilbert et al. (2002) found that affordability was certainly a barrier to access to adequate dental care for African Americans and non-Hispanic whites in their sample, also important were other nonfinancial predictors that varied in both significance and effect between the two groups. The challenge to researchers is, first, to recognize the interdependence between the different dimensions of access, and second, and more difficult, to find appropriate measures of these dimensions. Only then will their findings provide the basis for policy changes that will be truly effective in improving access.

Cigarette Advertising and Magazine Coverage of the Hazards of Smoking a Statistical Analysis

Abstract Background. Health professionals have charged that magazines that depend on revenues from cigarette advertising are less likely to publish articles on the dangers of smoking for fear of offending cigarette manufacturers. Special concern has focused on magazines directed to women. Restricted coverage of smoking hazards could lead readers to underestimate the risks of smoking in relation to other health risks. Methods. Using logistic-regression analysis of a sample of 99 U.S. magazines published during 25 years (1959 through 1969 and 1973 through 1986), we analyzed the probability that the magazines would publish articles on the risks of smoking in relation to whether they carried advertisements for cigarettes and in relation to the proportion of their advertising revenues derived from cigarette advertisements. We controlled for other factors that might influence coverage. Results. The probability of publishing an article on the risks of smoking in a given year was 11.9 percent for magazines that d...

Differences in Prevalence, Treatment, and Outcomes of Asthma Among a Diverse Population of Children With Equal Access to Care: Findings From a Study in the Military Health System

OBJECTIVE To assess racial and ethnic differences in asthma prevalence, treatment patterns, and outcomes among a diverse population of children with equal access to health care. DESIGN Retrospective cohort analysis. SETTING The Military Health System. PARTICIPANTS A total of 822 900 children aged 2 through 17 years continuously enrolled throughout 2007 in TRICARE Prime, a health maintenance organization-type benefit provided by the Department of Defense. MAIN OUTCOME MEASURES Prevalence of diagnosed asthma, potentially avoidable asthma hospitalizations, asthma-related emergency department visits, visits to asthma specialists, and use of asthma medications among children aged 2 to 4, 5 to 10, and 11 to 17 years. RESULTS Black and Hispanic children in all age groups were significantly more likely to have an asthma diagnosis than white children (ranging from odds ratio [OR]=1.16; 95% confidence interval [CI], 1.09-1.24; to OR=2.00; 95% CI, 1.93-2.07). Black children in all age groups and Hispanic children aged 5 to 10 years were significantly more likely to have any potentially avoidable asthma hospitalizations and asthma-related emergency department visits (ranging from OR=1.24; 95% CI, 1.11-1.37; to OR=1.99; 95% CI, 1.37-2.88) and were significantly less likely to visit a specialist (ranging from OR=0.71; 95% CI, 0.61-0.82; to OR=0.88; 95% CI, 0.79-0.98) compared with white children. Black children in all age categories were significantly more likely to have filled any prescriptions for inhaled corticosteroids compared with white children (ranging from OR=1.11; 95% CI, 1.02-1.21; to OR=1.11; 95% CI, 1.04-1.19). CONCLUSIONS Despite universal health insurance coverage, we found evidence of racial and ethnic differences in asthma prevalence, treatment, and outcomes.

Hispanics and Health Insurance Coverage : The Rising Disparity

Background:Many reports have focused attention on the rising percentage of adults in the United States without health insurance. This hides the fact that the uninsured rate for non-Hispanic nonelderly adults has held fairly steady since 1983, while the rate for Hispanics has increased. Objectives:To document the trends in the coverage rate by source of coverage for different population groups between 1983 and 2003 and suggest how changes in the composition of these groups have contributed to these trends. Research Design:We stack panels of the Survey of Income and Program Participation to create a nationally representative 20-year pooled cross-section of nonelderly adults. We calculate actual trends in insurance coverage as well as 2 hypothetical time series that disentangle the effect of the decreasing coverage rate for Hispanics from the growth of the Hispanic adult population. Results:Although the increase in uninsured rate is largest for Hispanic noncitizens, US-born Hispanics also have a significant upward trend, primarily driven by a decrease in private coverage, with little change in public coverage. Although the increase in the Hispanic population contributed to the increase in the number of uninsured adults, the widening coverage disparity was more important. Conclusions:Hispanic nonelderly adults, both US-born and immigrants, have fallen behind non-Hispanic nonelderly adults in insurance coverage. Although combinations of economic growth and private and public insurance policy changes have maintained, and in some cases improved, overall coverage rates for non-Hispanics, these changes have not helped Hispanic adults, leading to increased disparities in coverage.

A Copayment Increase for Prescription Drugs: The Long-Term and Short-Term Effects on Use and Expenditures

This study estimates the effects of an increase in an outpatient prescription drug copayment using a natural experiment based upon a large firm that implemented such an increase. The findings suggest that the primary effect of a copayment increase is attenuation of the trend in prescription drug utilization. We also find an initial reduction in expenditures, with the effects on spending diminishing. Employees with an existing chronic illness and those without a chronic illness show a similar, inelastic response to a copayment increase; employees with a newly diagnosed chronic illness have a more inelastic response.

Treatment and outcomes for congestive heart failure by race/ethnicity in TRICARE.

BackgroundEquitable access to health insurance coverage may improve outcomes of care for chronic health conditions and mitigate racial/ethnic health disparities. This study examines racial/ethnic disparities in the treatment and outcomes of care for TRICARE beneficiaries with congestive heart failure (CHF). MethodsUsing a retrospective cohort analysis, we examined demographic characteristics, sources of care, and comorbid conditions for 2183 beneficiaries of the Military Health Systems TRICARE program (representing 115,584 beneficiaries after adjusting for survey weights) with CHF. Treatments included use of CHF-related medications, while the outcome of interest was any CHF-related potentially avoidable hospitalizations (PAHs). ResultsWhile African Americans were less likely than whites to have received beta blockers and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers following a CHF diagnosis (P<0.0001). Hispanics were, in some cases, equally likely as whites to receive pharmacological treatments for CHF. In multivariate models, there were no significant racial/ethnic differences in the odds of a PAH; age greater than 65 was the most significant predictor of a PAH. ConclusionsThis study suggests that although there are some racial and ethnic disparities in the receipt of pharmacological therapy for CHF among TRICARE beneficiaries, these differences do not translate into disparities in the likelihood of a PAH. The findings support previous research suggesting that equal access to care may mitigate racial/ethnic health disparities.

Beyond Affordability: The Impact of Nonfinancial Barriers on Access for Uninsured Adults in Three Diverse Communities

Most proposals to improve access for uninsured adults focus on removing financial barriers to health care. Health services researchers have long recognized, however, that access to care is a multidimensional concept consisting of both financial and nonfinancial dimensions. While financial barriers faced by those without health insurance have been well-documented, it is not known to what degree nonfinancial barriers limit access for those without coverage. In this study we sought to identify the types and frequencies of nonfinancial access barriers faced by low-income uninsured adults, as well as determine how frequently nonfinancial barriers coexist with financial access barriers in this population. We conducted a telephone survey of 1,118 low-income uninsured adults in Alameda, California, Austin, Texas, and Southern Maine who had enrolled in local access programs funded through the Robert Wood Johnson Foundation’s Communities in Charge initiative. Financial barriers were the most often cited barrier to access in each of the three groups, though nonfinancial barriers were often cited as well. Across all three populations, one-third to one-half of respondents with financial access barriers also cited one or more nonfinancial barriers as contributing to their problems accessing health care. Our results suggest that many uninsured adults face nonfinancial health care barriers in addition to their well-documented financial challenges. Health reform efforts must address both types of barriers in order to maximally improve access for the uninsured population.

Competition Versus Regulation: Some Empirical Evidence

In response to dramatic rises in health care costs, policymakers have been debating the relative merits of regulatory and competitive strategies as a means of containing costs. One major activity espoused by proponents of competition is the growth of health maintenance organizations (HMOs) which, in their opinion, will result in the market better determining efficient levels of utilization and costs. Extending this argument, the larger the percent of the population in a market area who enroll in HMOs, the greater the market-forcing effect of HMOs in reducing overall hospital expenditures; that is, if HMOs are providing lower-cost care, then the fee-for-service system will be forced to reduce costs in order to be competitive. The authors studied the 25 largest SMSAs from 1971-1981, and controlling for environmental conditions in each market, they examined the impact of both HMO growth and regulatory activity on costs and utilization. They conclude that neither competition nor regulation had a significant impact in reducing overall hospital costs. While there may have been some impact in specific communities, no generalizable effect could be observed. However, the authors did find that increases in costs and utilization were essentially driven by supply factors such as the number of hospital beds or medical specialists in a given community.