Joel C. Cantor

Medical Expenditures during the Last Year of Life: Findings from the 1992–1996 Medicare Current Beneficiary Survey

OBJECTIVE To compare medical expenditures for the elderly (65 years old) over the last year of life with those for nonterminal years. DATA SOURCE From the 1992-1996 Medicare Current Beneficiary Survey (MCBS) data from about ten thousand elderly persons each year. STUDY DESIGN Medical expenditures for the last year of life and nonterminal years by source of payment and type of care were estimated using robust covariance linear model approaches applied to MCBS data. DATA COLLECTION The MCBS is a panel survey of a complex weighted multilevel random sample of Medicare beneficiaries. A structured questionnaire is administered at four-month intervals to collect all medical costs by payer and service. Medicare costs are validated by claims records. PRINCIPAL FINDINGS From 1992 to 1996, mean annual medical expenditures (1996 dollars) for persons aged 65 and older were

Early Impact of the Affordable Care Act on Health Insurance Coverage of Young Adults

37,581 during the last year of life versus

The fragmentation of hospital use among a cohort of high utilizers: implications for emerging care coordination strategies for patients with multiple chronic conditions.

7,365 for nonterminal years. Mean total last-year-of-life expenditures did not differ greatly by age at death. However, non-Medicare last-year-of-life expenditures were higher and Medicare last-year-of-life expenditures were lower for those dying at older ages. Last-year-of-life expenses constituted 22 percent of all medical, 26 percent of Medicare, 18 percent of all non-Medicare expenditures, and 25 percent of Medicaid expenditures. CONCLUSIONS While health services delivered near the end of life will continue to consume large portions of medical dollars, the portion paid by non-Medicare sources will likely rise as the population ages. Policies promoting improved allocation of resources for end-of-life care may not affect non-Medicare expenditures, which disproportionately support chronic and custodial care.

Mortality amenable to health care in the United States: the roles of demographics and health systems performance.

RESEARCH OBJECTIVE To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parents private health plan. Nearly one-in-three young adults lacked coverage before the ACA. STUDY DESIGN, METHODS, AND DATA: Data from the Current Population Survey 2005-2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws. PRINCIPAL FINDINGS This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law. CONCLUSIONS AND IMPLICATIONS ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.

Accessibility of Primary Care Services in Safety Net Clinics in New York City

Background:Use of multiple hospitals by patients with multiple chronic conditions (MCC) may undermine emerging care coordination initiatives. Objective:The aim of this study was to assess the prevalence and correlates of fragmented hospital use among high users with MCC and derive implications for care management. Research Design:Using all-payer hospital billing data, we follow a 2-year cohort of patients with at least 2 inpatient stays, identifying those with MCC and calculating the percentage using multiple hospitals and applying multivariate Poisson regression to predict correlates of multiple hospital use. Subjects:The subjects included in our study were New Jersey adults with at least 2 inpatient stays during a 24-month period between 2007 and 2010. Results:Nearly 80% of the study cohort had ≥2 chronic conditions and >30% had fragmented hospital use. The probability of visiting multiple hospitals was positively associated with the number of chronic conditions present at admission, total number of admissions, lower hospital market concentration, and injury or behavioral health diagnoses. Over 40% of patients with ≥4 stays had multiple hospital use. Conclusions:Fragmentation of hospital care occurs frequently among high utilizers with MCC. Although multiple hospital use is not necessarily inappropriate, it may present barriers to effective care coordination for complex patients with MCC, leading to higher costs or worse outcomes. Leaders of innovative delivery reforms such as Accountable Care Organizations should monitor and coordinate care for multiple hospital users, especially those with MCC.

Demographics of disenrollment from SCHIP: evidence from NJ KidCare.

This article examines associations of socio-demographic and health-care indicators, and the statistic ‘mortality amenable to health care’ (amenable mortality) across the US states. There is over two-fold variation in amenable mortality, strongly associated with the percentages of state populations that are poor or black. Controlling for poverty and race with bi- and multi-variate analyses, several indicators of health system performance, such as hospital readmission rates and preventive care for diabetics, are significantly associated with amenable mortality. A significant crude association of ‘uninsurance’ and amenable mortality rates is no longer statistically significant when poverty and race are controlled. Overall, there appear to be opportunities for states to focus on specific modifiable health system performance indicators. Comparative rates of amenable mortality should be useful for estimating potential gains in population health from delivering more timely and effective care and for tracking the health outcomes of efforts to improve health system performance.

Expanding Health Insurance Coverage: Who Will Pay?

OBJECTIVES This study analyzed data from a survey of New York City ambulatory care facilities to determine primary care accessibility for low-income patients, as evidenced by the availability of enabling services, after-hours coverage, and policies for serving the uninsured. METHODS Ambulatory care facilities were surveyed in 1997, and analysis was performed on a set of measures related to access to care. Only sites that provided comprehensive primary care services were included in the analysis. For comparison, site were classified by sponsorship (public, nonprofit voluntary hospital, federally qualified health center, non-hospital-sponsored community health center). RESULTS Publicly sponsored sites and federally qualified health center sites showed the strongest performance across nearly all the measures of accessibility that were examined. CONCLUSIONS As safety net clinics confront the financial strain of implementing mandatory Medicaid managed care while also dealing with declining Medicaid caseloads and increasing numbers of uninsured, their ability to sustain the policies and services that support primary care accessibility may be threatened.

Implications of the Growing Use of Wireless Telephones for Health Care Opinion Polls

The State Childrens Health Insurance Program (SCHIP) provides health insurance coverage for children in low-income families. Although there is evidence of substantial disenrollment from SCHIP, few studies have examined how disenrollment varies by demographic characteristics. This study uses data from administrative records of all 41,881 children enrolled prior to April 2000 in NJ KidCare (New Jerseys SCHIP) separate state plans for families with incomes between 133% and 350% of the Federal Poverty Level. Survival methods were used to analyze disenrollment according to demographic and plan characteristics. Reasons for disenrollment were also studied. Overall, 18.9% of children disenrolled within 12 months of enrollment. Disenrollment was higher among non-Hispanic black children, children aged 1 to 5, and children without siblings in NJ KidCare than among their counterparts. Surprisingly, English speakers had the highest disenrollment rate of all language groups. Children in families with moderate income categories for whom premium contributions were required were 3 times as likely as lower-income children to disenroll, principally due to non-payment of premiums. To maximize retention in SCHIP and ensure access to care and continuity of care for low-income children, research is needed concerning why some groups disenroll more quickly.

State Medicaid Expansion and Changes in Hospital Volume According to Payer

Recent discussions on extending health insurance to the more than thirty million uninsured Americans have focused on two strategies: expanding the Medicaid program and mandating that employers sponsor coverage for their employees. This analysis, using a microsimulation model of the U.S. health care financing system, suggests that these two options would result in very different distributions of financial burden. Employer-sponsored coverage is financed in a highly regressive fashion, in contrast to the Medicaid program, which is proportional to income. Furthermore, the burden of paying for health care under Medicaid varies little among generations, whereas the cost of employer-sponsored care is lowest in households headed by persons over sixty-five years old. Low health status populations do not pay disproportionately higher taxes or premiums to finance either the Medicaid program or employer-sponsored coverage. Their incomes, however, are more effectively protected by Medicaid, because it offers more comprehensive benefits.

Holes in the Safety Net: A Case Study of Access to Prescription Drugs and Specialty Care

OBJECTIVE To assess the effect of wireless telephone substitution in a survey of health care reform opinions. DATA SOURCE Survey of New Jersey adults conducted by landline and wireless telephones from June 1 to July 9, 2007. STUDY DESIGN Eighty-one survey measures are compared by wireless status. Logistic regression is used to confirm landline-wireless gaps in support for coverage reforms, controlling for population differences. Weights adjust for selection probability, complex sample design, and demographic distributions. PRINCIPAL FINDINGS Significant differences by wireless status were found in many survey measures. Wireless users were significantly more likely to favor coverage reforms. Higher support for government-sponsored universal coverage, income-related state coverage subsidies, and an individual mandate remain after adjustment for demographic variables. CONCLUSIONS Opinion polls excluding wireless users are likely to understate support for coverage reforms.