Cathy Caldwell

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

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

Effectiveness of Preventive Dental Visits in Reducing Nonpreventive Dental Visits and Expenditures

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

Co-payments and the Use of Emergency Department Services in the Children’s Health Insurance Program:

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

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

OBJECTIVE Describe the trends in enrollment and renewal in the Alabama Childrens Health Insurance Plan (CHIP), ALL Kids, since its creation in 1998, and to estimate the effect that an annual premium increase, along with coincident increases in service copays, had on the decision to renew participation. BACKGROUND Unlike many other CHIP programs, ALL Kids is a standalone program that provides year long enrollment and contracts with the states Blue Cross and Blue Shield program for its network of providers and its provider fee structure. In October 2003 premiums for individual coverage were increased by

Continuity of Insurance Coverage and Ambulatory Care–Sensitive Hospitalizations/ED Visits: Evidence From the Children’s Health Insurance Program

50 per year and copays by

State Medicaid and Children’s Health Insurance Program’s Perspective on CHIPRA Core Measures

1 to

The Impact of CHIP Coverage on Children With Asthma in Alabama

3 per visit. POPULATION STUDIED This study is based upon a sample of 569,650 person-year observations of 230,255 children enrolled in the ALL Kids program between 1999 and 2009. STUDY DESIGN The study models enrollment as a time series of cross section renewal decisions and specifies a series of linear probability regression models to estimate the effect of changes in the premium shift on the decision to renew. A second analysis includes interaction effects of the premiums shift with demographics, health status, income and previous enrollment to estimate differential response across subgroups. PRINCIPAL FINDINGS The increases in premiums and copays are estimated to have reduced program renewals by 6.1 to 8.3 percent depending upon how much time one allows for families to renew. Families with a child who has a chronic condition were more likely to renew coverage. However, those with chronic conditions, African-Americans and those with lower family incomes were more price-sensitive. CONCLUSIONS An increase in annual premiums and visit copays had a modest impact on program reenrollment with effects comparable to those found in Florida, New Hampshire, Kansas and Arizona, but smaller than those in Kentucky and Georgia.

Can Increases in CHIP Copayments Reduce Program Expenditures on Prescription Drugs

Objective: To assess the effects of continuity of insurance coverage on treatment of ambulatory-care sensitive conditions (ACSC). Study Population: 42,382 children enrolled in ALL Kids (Alabama Children’s Health Insurance Program) for 3 or more years. Methods: We model annual hospitalizations and ED visits for six ACSCs identified by the AHRQ - bacterial pneumonia, dehydration, perforated appendix, urinary tract infection, gastroenteritis, and severe ear, nose and throat infection. Results: In unadjusted models, we find lower risk of ACSC hospitalizations and ED visits in the second and third years of continuous enrollment. Risk of hospitalization in year 3 was significantly lower for pneumonia (OR 0.608, 95% CI: 0.421-0.878) and gastroenteritis (OR 0.549, 95% CI: 0.404-0.746). These beneficial effects of duration of coverage disappear after controlling for age, year and other enrollee characteristics. Conclusions: Hospitalizations and ED visits for ACSCs are rare and do not decrease with additional years of coverage.

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

IMPROVING THE QUALITY of health care for children is a goal shared by many partners who serve the children of our country and certainly is a priority for Medicaid and the Children’s Health Insurance Program (CHIP) in every state. There are few tools to measure quality of care, especially for children, and mechanisms to compare the quality of children’s health care services across states, programs, delivery systems, etc, are lacking. The inclusion of a section on the quality of children’s health care in the Children’s Health Insurance Program Reauthorization

Enrollment, Expenditures, and Utilization After CHIP Expansion: Evidence From Alabama

This study evaluates the impact of coverage in ALL Kids, the Alabama Child Health Insurance Program (CHIP), by examining asthma-related utilization and outcomes among children continuously enrolled for 3 years (N = 1954)with persistent asthma at enrollment. Outcomes and costs were compared for the first, second, and third years of enrollment using repeated measures analysis of variance and controlling for age, gender, and year fixed-effects. Compared with subsequent years, first year enrollment utilization was higher for asthma-related hospitalizations (6% vs 2% vs 2%; P < .0001) and emergency visits (10% vs 3% vs 2%; P < .0001). Also decreasing were asthma-related outpatient visits (1.46 vs 1.12 vs 0.94; P < .0001), quick-relief prescriptions (2.6 vs 2.2 vs 2.1; P < .0001), and long-term control prescriptions (5.8 vs 5.2 vs 4.4; P < .0001). As a result, significant declines in the mean costs per child were observed. Ongoing ALL Kids coverage is associated with improved disease-management and lower costs for persistent asthma.