Kathleen C. Thomas

Access to care for children with autism in the context of state Medicaid reimbursement

This paper examines the role of state residence and Medicaid reimbursement rates in explaining the relationship between having autism and access to care for children. Three questions are addressed: (1) Is there variation across states in the relationship between having autism and access to care? (2) Does taking account of state residence explain a significant amount of the variation in this relationship? (3) Does accounting for Medicaid reimbursement rates enhance our understanding of this relationship? Data from the 2005 National Survey of Children with Special Health Care Needs were combined with state characteristics to estimate a hierarchical generalized linear model of the association between state residence, Medicaid reimbursement rate and problems accessing care for children with special health care needs with and without autism. Findings indicate there is significant variation between states in the relationship between having autism and problems accessing care, and accounting for state residence explains a significant amount of variation in the model. Medicaid reimbursement rates have an independent effect on access to care for children with autism: when families raising children with autism live in states with higher reimbursement rates, they have lower odds of experiencing problems accessing care. The state context in which families live impacts access to care for children with autism. Moreover, when families live in states with higher Medicaid reimbursement rates, they are less likely to experience problems getting care. The value of this analysis is that it helps identify where to look for strategies to improve access.

Effect of medicaid expansion on workforce participation for people with disabilities

OBJECTIVES To use data from the Health Reform Monitoring Survey (HRMS) to examine differences in employment among community-living, working-age adults (aged 18-64 years) with disabilities who live in Medicaid expansion states and nonexpansion states. METHODS Analyses used difference-in-differences to compare trends in pooled, cross-sectional estimates of employment by state expansion status for 2740 HRMS respondents reporting a disability, adjusting for individual and state characteristics. RESULTS After the Affordable Care Act (ACA), respondents in expansion states were significantly more likely to be employed compared with those in nonexpansion states (38.0% vs 31.9%; P = .011). CONCLUSIONS Prior to the ACA, many people with disabilities were required to live in poverty to maintain their Medicaid eligibility. With Medicaid expansion, they can now enter the workforce, increase earnings, and maintain coverage. Public Health Implications. Medicaid expansion may improve employment for people with disabilities.

Demographic profile of families and children in the Study to Explore Early Development (SEED): Case-control study of autism spectrum disorder

BACKGROUND The Study to Explore Early Development (SEED) is designed to enhance knowledge of autism spectrum disorder characteristics and etiologies. OBJECTIVE This paper describes the demographic profile of enrolled families and examines sociodemographic differences between children with autism spectrum disorder and children with other developmental problems or who are typically developing. METHODS This multi-site case-control study used health, education, and birth certificate records to identify and enroll children aged 2-5 years into one of three groups: 1) cases (children with autism spectrum disorder), 2) developmental delay or disorder controls, or 3) general population controls. Study group classification was based on sampling source, prior diagnoses, and study screening tests and developmental evaluations. The childs primary caregiver provided demographic characteristics through a telephone (or occasionally face-to-face) interview. Groups were compared using ANOVA, chi-squared test, or multinomial logistic regression as appropriate. RESULTS Of 2768 study children, sizeable proportions were born to mothers of non-White race (31.7%), Hispanic ethnicity (11.4%), and foreign birth (17.6%); 33.0% of households had incomes below the US median. The autism spectrum disorder and population control groups differed significantly on nearly all sociodemographic parameters. In contrast, the autism spectrum disorder and developmental delay or disorder groups had generally similar sociodemographic characteristics. CONCLUSIONS SEED enrolled a sociodemographically diverse sample, which will allow further, in-depth exploration of sociodemographic differences between study groups and provide novel opportunities to explore sociodemographic influences on etiologic risk factor associations with autism spectrum disorder and phenotypic subtypes.

Fostering Activation Among Latino Parents of Children With Mental Health Needs: An RCT

OBJECTIVE Latino families raising children with mental health and other special health care needs report greater dissatisfaction with care compared with other families. Activation is a promising strategy to eliminate disparities. This study examined the comparative effectiveness of MePrEPA, an activation intervention for Latino parents whose children receive mental health services. METHODS A randomized controlled trial (N=172) was conducted in a Spanish-language mental health clinic to assess the effectiveness of MePrEPA, a four-week group psychoeducational intervention to enhance parent activation among Latino parents, compared with a parent-support control group. Inclusion criteria were raising a child who receives services for mental health needs and ability to attend weekly sessions. Outcomes were parent activation, education activation, quality of school interaction, and parent mental health. Effectiveness of the intervention was tested with a difference-in-difference approach estimating linear mixed models. Heterogeneity of treatment effect was examined. RESULTS MePrEPA enhanced parent activation (β=5.98, 95% confidence interval [CI]=1.42-10.53), education activation (β=7.98, CI=3.01-12.94), and quality of school interaction (β=1.83, CI=.14-3.52) to a greater degree than did a parent-support control group. The interventions impact on parent activation and education outcomes was greater for participants whose children were covered by Medicaid and were novices to therapy and those with low activation at baseline. No statistically significant effects were observed in parent mental health. CONCLUSIONS Activation among Latino parents was improved with MePrEPA, which can be readily incorporated in current practices by mental health clinics. Future work should replicate findings in a large number of sites, adding behavioral measures and distal impacts while examining MePrEPAs effects across settings and populations.

Patterns of healthcare use and employment among people with disabilities.

BACKGROUND Employment rates among people with disabilities are low. Poor health is often cited as a barrier to work. Disability or a lack of disability-related resources may interfere with the ability to secure and maintain work. OBJECTIVE This paper presents an exploratory examination of the association between variation in service use and employment. METHODS The paper uses data from North Carolina Medicaid recipients age 18-64 who were eligible in fiscal year 2007 due to receipt of Supplemental Security Income (n = 60,190). Logistic regression was used to model employment as a function of variation in healthcare use, with conditional models stratifying by days of service use and unconditional models run by quantile of service use. RESULTS People with the least service use (< 12 days) had the highest employment rate (over 20%); those with the most service use (≥54 days) had the lowest employment rate (7.8%). Those in between displayed remarkably little variation in employment rate by level of service use. The amount of week-to-week variation in service use was positively associated with the probability of employment. CONCLUSIONS Among Medicaid enrollees with disabilities who use outpatient services, amount of service use is negatively associated with employment and variation in use is positively associated with employment. Future research involving more extensive administrative data, primary data collection, and the use of mixed methods would improve understanding of these findings.

Latina/o parent activation in children’s mental health treatment: The role of demographic and psychological factors.

Patient activation has recently emerged as a critical component of effective health care (Hibbard & Greene, 2013), but Latina/o populations demonstrate lower levels of activation compared to non-Latina/o Whites (Cunningham, Hibbard, & Gibbons, 2011). The current study examined demographic and psychological factors associated with immigrant Latina/o parent activation in parents seeking mental health services for their children. Additionally, the study tested whether psychological factors (parental depressive symptoms, parenting stress, perceived severity of child psychopathology) were associated with the effectiveness of an activation intervention among immigrant Latina/o parents (MEPREPA— short for “me preparo”/I prepare [MEtas, PReguntar, Escuchar, Preguntar para Aclarar/goals, questioning, listening, questioning to clarify]). Results demonstrated that parenting stress and perceived severity of child psychopathology were associated with lower levels of parent activation. Additionally, although there was a treatment effect for all parents, stratified group analyses suggested that parents with higher depressive symptoms and greater parenting stress benefited more from the MEPREPA intervention compared to controls. Stratified analyses also showed that the intervention had a greater positive impact on parent activation in health care among parents whose children had more severe symptoms. Clinical and research implications are discussed. La activación del paciente ha emergido recientemente como un componente vital en la asistencia médica efectiva (Hibbard & Greene, 2013), pero las poblaciones Latinas suelen demostrar niveles más bajos de activación en comparación con poblaciones blancas no-Latinas (Cunningham, Hibbard, & Gibbons, 2011). Este estudio examinó factores demográficos y psicológicos asociados con la activación en padres Latinos emigrantes con hijos en tratamiento de salud mental. Adicionalmente, el estudio investigó si factores psicológicos (síntomas depresivos de los padres, estrés parental, la severidad percibida de la patología del niño) fueron asociados con la efectividad de una intervención de activación para padres Latinos emigrantes (MEPREPA). Los resultados demostraron que el estrés parental y la severidad percibida de la patología del niño fueron asociados con niveles más bajos de activación del paciente. Adicionalmente, a pesar de que se encontró un efecto del tratamiento para todos los padres en el estudio, análisis estratificados de los grupos sugirieron que padres con síntomas depresivos mayores y un mayor estrés parental recibieron un mayor beneficio de la intervención en comparación con los padres en el grupo de control. Los análisis estratificados también demostraron que la intervención tuvo un mayor impacto positivo en la activación de los padres de niños con síntomas más graves. Se discuten implicaciones clínicas y de investigación en base de estos resultados.

Involving Latina/o parents in patient-centered outcomes research: Contributions to research study design, implementation and outcomes

Comparative effectiveness research (CER) is supported by policymakers as a way to provide service providers and patients with evidence‐based information to make better health‐care decisions and ultimately improve services for patients. However, Latina/o patients are rarely involved as study advisors, and there is a lack of documentation on how their voices contribute to the research process when they are included as collaborators.

Examination of Parent Insurance Ratings, Child Expenditures, and Financial Burden Among Children With Autism: A Mismatch Suggests New Hypotheses to Test

OBJECTIVE: Families raising children with autism contribute significant amounts to the cost of care. In this era of health care reform, families have more insurance choices, but people are unfamiliar with health insurance terms. This study uses 2 national data sets to examine health insurance ratings from parents raising children with autism and child expenditures to explore how these measures align. METHODS: Children with autism who met criteria for special health care needs and were continuously insured were examined. Data from the National Survey of Children With Special Health Care Needs 2009–2010 were used to examine parent report of adequate insurance (n = 3702). Pooled data from the Medical Expenditure Panel Survey 2002–2011 were used to examine expenditures (n = 346). Types of health insurance included private alone, Medicaid alone, and combined private and wrap-around Medicaid. RESULTS: Having Medicaid doubled the odds of reporting adequate insurance compared with private insurance alone (P < .0001), and children on Medicaid had the lowest out-of-pocket costs (

Family Experiences with the Diagnosis of Autism Spectrum Disorder: System Barriers and Facilitators of Efficient Diagnosis.

150, P < .0001). Children covered by combined private and wrap-around Medicaid had the highest total expenditures (

Medicaid Expansion as an Employment Incentive Program for People With Disabilities

11 596, P < .05) and the highest expenditures paid by their insurance (