Heather Angier

Insurance + Access ≠ Health Care: Typology of Barriers to Health Care Access for Low-Income Families

PURPOSE Public health insurance programs have expanded coverage for the poor, and family physicians provide essential services to these vulnerable populations. Despite these efforts, many Americans do not have access to basic medical care. This study was designed to identify barriers faced by low-income parents when accessing health care for their children and how insurance status affects their reporting of these barriers. METHODS A mixed methods analysis was undertaken using 722 responses to an open-ended question on a health care access survey instrument that asked low-income Oregon families, “Is there anything else you would like to tell us?” Themes were identified using immersion/crystallization techniques. Pertinent demographic attributes were used to conduct matrix coded queries. RESULTS Families reported 3 major barriers: lack of insurance coverage, poor access to services, and unaffordable costs. Disproportionate reporting of these themes was most notable based on insurance status. A higher percentage of uninsured parents (87%) reported experiencing difficulties obtaining insurance coverage compared with 40% of those with insurance. Few of the uninsured expressed concerns about access to services or health care costs (19%). Access concerns were the most common among publicly insured families, and costs were more often mentioned by families with private insurance. Families made a clear distinction between insurance and access, and having one or both elements did not assure care. Our analyses uncovered a 3-part typology of barriers to health care for low-income families. CONCLUSIONS Barriers to health care can be insurmountable for low-income families, even those with insurance coverage. Patients who do not seek care in a family medicine clinic are not necessarily getting their care elsewhere.

Revision surgery following operations for lumbar stenosis

BACKGROUND For carefully selected patients with lumbar stenosis, decompression surgery is more efficacious than nonoperative treatment. However, some patients undergo repeat surgery, often because of complications, the failure to achieve solid fusion following arthrodesis procedures, or persistent symptoms. We assessed the probability of repeat surgery following operations for the treatment of lumbar stenosis and examined its association with patient age, comorbidity, previous surgery, and the type of surgical procedure. METHODS We performed a retrospective cohort analysis of Medicare claims. The index operation was performed in 2004 (n = 31,543), with follow-up obtained through 2008. Operations were grouped by complexity as decompression alone, simple arthrodesis (one or two disc levels and a single surgical approach), or complex arthrodesis (more than two disc levels or combined anterior and posterior approach). Reoperation rates were calculated for each follow-up year, and the time to reoperation was analyzed with proportional hazards models. RESULTS The probability of repeat surgery fell with increasing patient age or comorbidity. Aside from age, the strongest predictor was previous lumbar surgery: at four years the reoperation rate was 17.2% among patients who had had lumbar surgery prior to the index operation, compared with 10.6% among those with no prior surgery (p < 0.001). At one year, the reoperation rate for patients who had been managed with decompression alone was slightly higher than that for patients who had been managed with simple arthrodesis, but by four years the rates for these two groups were identical (10.7%) and were lower than the rate for patients who had been managed with complex arthrodesis (13.5%) (p < 0.001). This difference persisted after adjusting for demographic and clinical features (hazard ratio for complex arthrodesis versus decompression 1.56, 95% confidence interval, 1.26 to 1.92). A device-related complication was reported at the time of 29.2% of reoperations following an initial arthrodesis procedure. CONCLUSIONS The likelihood of repeat surgery for spinal stenosis declined with increasing age and comorbidity, perhaps because of concern for greater risks. The strongest clinical predictor of repeat surgery was a lumbar spine operation prior to the index operation. Arthrodeses were not significantly associated with lower rates of repeat surgery after the first postoperative year, and patients who had had complex arthrodeses had the highest rate of reoperations.

Use of Bone Morphogenetic Proteins in Spinal Fusion Surgery for Older Adults With Lumbar Stenosis : Trends, Complications, Repeat Surgery, and Charges

Study Design. Retrospective cohort study of Medicare claims. Objective. Examine trends and patterns in the use of bone morphogenetic proteins (BMP) in surgery for lumbar stenosis; compare complications, reoperation rates, and charges for patients undergoing lumbar fusion with and without BMP. Summary of Background Data. Small, randomized trials have demonstrated higher rates of solid fusion with BMP than with allograft bone alone, with few complications and, in some studies, reduced rates of revision surgery. However, complication and reoperation rates from large population-based cohorts in routine care are unavailable. Methods. We identified patients with a primary diagnosis of lumbar stenosis who had fusion surgery in 2003 or 2004 (n = 16,822). We identified factors associated with BMP use: major medical complications during the index hospitalization, rates of rehospitalization within 30 days, and rates of reoperation within 4 years of follow-up (through 2008). Results. Use of BMP increased rapidly, from 5.5% of fusion cases in 2003 to 28.1% of fusion cases in 2008. BMP use was greater among patients with previous surgery and among those having complex fusion procedures (combined anterior and posterior approach, or greater than 2 disc levels). Major medical complications, wound complications, and 30-day rehospitalization rates were nearly identical with or without BMP. Reoperation rates were also very similar, even after stratifying by previous surgery or surgical complexity, and after adjusting for demographic and clinical features. On average, adjusted hospital charges for operations involving BMP were about

An Early Look at Rates of Uninsured Safety Net Clinic Visits After the Affordable Care Act

15,000 more than hospital charges for fusions without BMP, though reimbursement under Medicares Diagnosis-Related Group system averaged only about

Feasibility of Evaluating the CHIPRA Care Quality Measures in Electronic Health Record Data

850 more. Significantly fewer patients receiving BMP were discharged to a skilled nursing facility (15.9% vs. 19.0%, P < 0.001). Conclusion. In this older population having fusion surgery for lumbar stenosis, uptake of BMP was rapid, and greatest among patients with prior surgery or having complex fusion procedures. BMP appeared safe in the perioperative period, with no increase in major medical complications. Use of BMP was associated with greater hospital charges but fewer nursing home discharges, and was not associated with reduced likelihood of reoperation.

Parent and child usual source of care and children's receipt of health care services.

PURPOSE The Affordable Care Act of 2010 supports marked expansions in Medicaid coverage in the United States. As of January 1, 2014, a total of 25 states and the District of Columbia expanded their Medicaid programs. We tested the hypothesis that rates of uninsured safety net clinic visits would significantly decrease in states that implemented Medicaid expansion, compared with states that did not. METHODS We undertook a longitudinal observational study of coverage status for adult visits in community health centers, from 12 months before Medicaid expansion (January 1, 2013 to December 31, 2013) through 6 months after expansion (January 1, 2014 to June 30, 2014). We analyzed data from 156 clinics in the OCHIN practice-based research network, with a shared electronic health record, located in 9 states (5 expanded Medicaid coverage and 4 did not). RESULTS Analyses were based on 333,655 nonpregnant adult patients and their 1,276,298 in-person billed encounters. Overall, clinics in the expansion states had a 40% decrease in the rate of uninsured visits in the postexpansion period and a 36% increase in the rate of Medicaid-covered visits. In contrast, clinics in the nonexpansion states had a significant 16% decline in the rate of uninsured visits but no change in the rate of Medicaid-covered visits. CONCLUSIONS There was a substantial decrease in uninsured community health center visits and a significant increase in Medicaid-covered visits in study clinics in states that expanded Medicaid in 2014, whereas study clinics in states opting out of the expansion continued to have a high rate of uninsured visits. These findings suggest that Affordable Care Act–related Medicaid expansions have successfully decreased the number of uninsured safety net patients in the United States.

Characterizing a Practice-based Research Network: Oregon Rural Practice-based Research Network (ORPRN) Survey Tools

The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) includes provisions for identifying standardized pediatric care quality measures. These 24 “CHIPRA measures” were designed to be evaluated by using claims data from health insurance plan populations. Such data have limited ability to evaluate population health, especially among uninsured people. The rapid expansion of data from electronic health records (EHRs) may help address this limitation by augmenting claims data in care quality assessments. We outline how to operationalize many of the CHIPRA measures for application in EHR data through a case study of a network of >40 outpatient community health centers in 2009–2010 with a single EHR. We assess the differences seen when applying the original claims-based versus adapted EHR-based specifications, using 2 CHIPRA measures (Chlamydia screening among sexually active female patients; BMI percentile documentation) as examples. Sixteen of the original CHIPRA measures could feasibly be evaluated in this dataset. Three main adaptations were necessary (specifying a visit-based population denominator, calculating some pregnancy-related factors by using EHR data, substituting for medication dispense data). Although it is feasible to adapt many of the CHIPRA measures for use in outpatient EHR data, information is gained and lost depending on how numerators and denominators are specified. We suggest first steps toward application of the CHIPRA measures in uninsured populations, and in EHR data. The results highlight the importance of considering the limitations of the original CHIPRA measures in care quality evaluations.

Obtaining Health Care Services for Low-Income Children: A Hierarchy of Needs

PURPOSE In the United States, children who have a usual source of care (USC) have better access to health care than those who do not, but little is known about how parental USC affects children’s access. We examined the association between child and parent USC patterns and children’s access to health care services. METHODS We undertook a secondary analysis of nationally representative, cross-sectional data from children participating in the 2002–2007 Medical Expenditure Panel Survey (n = 56,302). We assessed 10 outcome measures: insurance coverage gaps, no doctor visits in the past year, less than yearly dental visits, unmet medical and prescription needs, delayed care, problems getting care, and unmet preventive counseling needs regarding healthy eating, regular exercise, car safety devices, and bicycle helmets. RESULTS Among children, 78.6% had a USC and at least 1 parent with a USC, whereas 12.4% had a USC but no parent USC. Children with a USC but no parent USC had a higher likelihood of several unmet needs, including an insurance coverage gap (adjusted risk ratio [aRR] 1.33; 95% confidence interval [CI], 1.21–1.47), an unmet medical or prescription need (aRR 1.70; 95% CI 1.09–2.65), and no yearly dental visits (aRR 1.12; 95% CI 1.06–1.18), compared with children with a USC whose parent(s) had a USC. CONCLUSIONS Among children with a USC, having no parent USC was associated with a higher likelihood of reporting unmet needs when compared with children whose parent(s) had a USC. Policy reforms should ensure access to a USC for all family members.

The Effects of Health Insurance and a Usual Source of Care on a Child's Receipt of Health Care

Objective: To present the survey methods and instruments used to characterize a geographically and professionally diverse rural practice-based research network (PBRN). Methods: A cross-sectional study of Oregon PBRN (ORPRN) member practices and clinicians using a 3-part survey including a survey of the practices, of clinician members, and an anonymous survey of clinician satisfaction. Results: A total of 31 of 32 (97%) participating ORPRN practices completed the practice survey, 96 of 129 (74%) clinicians within these practices completed the clinician member survey, and 81 of 129 (63%) clinicians completed an anonymous survey of clinician satisfaction. The survey provided a detailed description of the structure of member practices, patient and clinician demographics, services provided by the practices, and access to specialty and ancillary services. Conclusions: Survey tools that describe the network practices and individual clinician characteristics contribute to an understanding of the research capacity of an individual PBRN.

Using Electronic Health Records to Conduct Children’s Health Insurance Surveillance

Introduction. Basic health care is beyond the reach of many families, partly due to lack of health insurance. Many of those with insurance also experience unmet need and limited access. In this study, low-income parents illuminate barriers to obtaining health care services for their children. Methods. We surveyed a random sample of families from Oregon’s food stamp population with children eligible for public insurance, based on household income. Mixed-methods included: (1) multivariable analysis of data from 2,681 completed surveys, and (2) qualitative study of written narratives from 722 parents. Results. Lack of health insurance was the most consistent predictor of unmet health care needs in the quantitative analysis. Qualitatively, health insurance instability, lack of access to services despite having insurance, and unaffordable costs were major concerns. Conclusions. Parents in this low-income population view insurance coverage as different from access to services, and reported a hierarchy of needs. Insurance was the primary concern; access and costs were secondary.