Lisa Simpson

Health Care for Children and Youth in the United States: 2001 Annual Report on Access, Utilization, Quality, and Expenditures

OBJECTIVESnTo provide an update on insurance coverage, use of health care services, and health expenditures for children and youth in the United States and new information on parents perceived quality of care for their children and to provide information on variation in hospitalizations for children from a 24-state hospital discharge data source.nnnMETHODSnThe data on insurance coverage, utilization, expenditures, and perceived quality of care come from the Medical Expenditure Panel Survey. The data on hospitalizations come from the Nationwide Inpatient Sample, which is part of the Healthcare Cost and Utilization Project. Both data sets are maintained by the Agency for Healthcare Research and Quality.nnnRESULTSnIn 2000, 64.5% of children were privately insured, 21.6% were insured through public sources, and 13.9% were uninsured. Children aged 15-17 years were more likely to be uninsured than children 1-4 years old. Children without health insurance coverage were less likely to use health care services, and when they did, their rates of utilization and expenditures were lower than insured children. Publicly insured children were the most likely to use hospital inpatient and emergency department (ED) care. Being black or Hispanic and living in families with incomes below 200% of the poverty line were associated with lower utilization and expenditures. A small proportion of children account for the bulk of health care expenditures: approximately 80% of all childrens health care expenditures are attributable to 20% of children who used medical services. Although most parents report that their experiences with health care for their children are good, there are significant variations by type of insurance coverage. There are substantial differences in average length of hospitalization across the United States, ranging from 2.9-4.1 days, and rates of hospital admission through the ED, which vary across states from 10%-25%. Injuries are a major reason for hospitalization, accounting for 1 in 6 hospital stays among 10- to 14-year-olds. In the 10- to 17-year age group, more than 1 in 7 hospital stays are due to mental disorders. Among 15- to 17-year-olds, more than one third of all hospital stays are related to childbirth and pregnancy. The top 10 most common conditions treated in the hospital account for 40%-60% of all hospital stays.nnnCONCLUSIONnChildrens use of health care services varies considerably by the type of health insurance coverage, race/ethnicity, and family income. Quality of care, as measured by parents experiences of care, also varies by type of coverage. There is substantial variation in use of hospital services across states.

Annual Report on Health Care for Children and Youth in the United States: Trends in Racial/Ethnic, Income, and Insurance Disparities Over Time, 2002–2009

OBJECTIVEnTo examine trends in childrens health access, utilization, and expenditures over time (2002-2009) by race/ethnicity, income, and insurance status/expected payer.nnnMETHODSnData include a nationally representative random sample of children in the United States in 2002-2009 from the Medical Expenditure Panel Survey (MEPS) and a nationwide sample of pediatric hospitalizations in 2005 and 2009 from the Healthcare Cost and Utilization Project (HCUP).nnnRESULTSnThe percentage of children with private insurance coverage declined from 65.3% in 2002 to 60.6% in 2009. At the same time, the percentage of publicly insured children increased from 27.0% in 2002 to 33.1% in 2009. Fewer children reported being uninsured in 2009 (6.3%) compared to 2002 (7.7%). The most significant progress was for Hispanic children, for whom the percentage of uninsured dropped from 15.0% in 2002 to 10.3% in 2009. The uninsured were consistently the least likely to have access to a usual source of care, and this disparity remained unchanged in 2009. Non-Hispanic whites were most likely to report a usual source of care in both 2002 and 2009. The percentage of children with a doctor visit improved for whites and Hispanics (2009 vs 2002). In contrast, black children saw no improvement during this time period. Between 2002 and 2009, childrens average total health care expenditures increased from

Annual Report on Access to and Utilization of Health Care for Children and Youth in the United States—2000

1294 to

Health Care for Children and Youth in the United States: 2002 Report on Trends in Access, Utilization, Quality, and Expenditures

1914. Average total expenditures nearly doubled between 2002 and 2009 for white children with private health insurance. Among infants, hospitalizations for pneumonia decreased in absolute number (41,000 to 34,000) and as a share of discharges (0.8% to 0.7%). Fluid and electrolyte disorders also decreased over time. Influenza appeared only in 2009 in the list of top 15 diagnoses with 11,000 hospitalization cases. For children aged 1 to 17, asthma hospitalization increased in absolute number (from 119,000 to 134,000) and share of discharges (6.6% to 7.6%). Skin infections appeared in the top 15 categories in 2009, with 57,000 cases (3.3% of total).nnnCONCLUSIONSnDespite significant improvement in insurance coverage, disparities by race/ethnicity and income persist in access to and use of care. Hispanic children experienced progress in a number of measures, while black children did not. Because racial/ethnic and socioeconomic disparities are often reported as single cross-sectional studies, our approach is innovative and improves on prior studies by examining population trends during the time period 2002-2009. Our study sheds light on childrens disparities during the most recent economic crisis.

Annual Report on Health Care for Children and Youth in the United States: Focus on Trends in Hospital Use and Quality

OBJECTIVEnThis report provides an update on insurance coverage, use of health care services, and health expenditures for children and youth in the United States. In addition, the report provides information on variation in hospitalizations for children from a new 22-state hospital discharge data source.nnnMETHODSnThe data on insurance coverage, utilization, and expenditures come from the Medical Expenditure Panel Survey. The data on hospitalizations come from the Database for Pediatric Studies, which is part of the Healthcare Cost and Utilization Project. Both data sets have been prepared by the Agency for Healthcare Research and Quality.nnnRESULTSnFew changes in insurance coverage occurred between 1996 and 1998. About two thirds of American children are covered by private insurance and 19% by public sources; the remaining 15% are uninsured. Of the 71.5% of children who have at least 1 doctors office visit, the average number of visits was 3.9, but this ranged from 2.7 among the uninsured to 4.2 for those with private insurance. Slightly more than half of children had a prescription, and these averaged 5.4 prescriptions. The majority of children (85%) incur medical expenditures, averaging

Medicaid, hospital financial stress, and the incidence of adverse medical events for children.

1019 for children with any expenditure. Private health insurance was by far the largest payer of medical care expenses for children, even more so than among the general population. However, nearly 21% of expenditures for childrens health care were paid out of pocket by childrens families. The data also show substantial differences in average length of hospitalization across states, ranging from 2.7 to 4.0 days, and rates of hospital admission through the emergency department, which vary across states from 9% to 23%. Injuries are a major reason for hospitalization, accounting for 1 in 6 hospital stays among 10- to 14-year-olds. In the 10-17 age group, 1 in 7 hospital stays are due to mental disorders. Among 15- to 17-year-olds, more than one third of all hospital stays are related to childbirth and pregnancy.nnnCONCLUSIONnChildrens use of health care services varies considerably by what type of health insurance coverage they have. Expenditures for children entail a substantial out-of-pocket component, which may be quite large for children with major health problems and which may represent a significant burden on lower-income families. Substantial variation in hospitalization exits across states.

Annual Report on Children's Health Care: Dental and Orthodontic Utilization and Expenditures for Children, 2010–2012

OBJECTIVEnTo examine changes in insurance coverage, health care utilization, perceived quality of care, and expenditures for children and youth in the United States using data from 1987-2001.nnnMETHODSnThree national health care databases serve as the sources of data for this report. The Medical Expenditure Panel Survey (1996-2001) provides data on insurance coverage, utilization, expenditures, and perceived quality of care. The National Medical Expenditure Survey (1987) provides additional data on utilization and expenditures. The Nationwide Inpatient Sample (1995-2000) from the Healthcare Cost and Utilization Project provides information on hospitalizations.nnnRESULTSnThe percent of children uninsured for an entire year declined from 10.4% in 1996 to 7.7% in 1999. Most changes in childrens health care occurred between 1987 and the late 1990s. Overall utilization of hospital-based services has declined significantly since 1987, especially for inpatient hospitalization. Several of the observed changes from 1987 varied significantly by type of health insurance coverage, poverty status, and geographic region. Quality of care data indicate some improvement between 2000 and 2001, which varies by insurance coverage. Overall, mean length of stay of hospitalizations did not change significantly from 1995 to 2000, but changes in the prevalence of hospitalizations and the length of stay associated with age-specific diagnoses were evident during this time period.nnnCONCLUSIONSnHealth care for children and youth has changed significantly since 1987, with most of the changes occurring between 1987 and 1996. Insurance coverage has improved, the site of care has shifted toward ambulatory sites, hospital utilization has declined, and expenditures on children as a proportion of total expenditures have decreased. Variation in these changes is evident by insurance status, poverty, and region.

Addressing Adverse Childhood Experiences Through the Affordable Care Act: Promising Advances and Missed Opportunities

OBJECTIVEnThe aim of this study was to describe selected trends in hospital inpatient care for children between 2000 and 2007.nnnSTUDY DESIGNnAnalysis was conducted of administrative data from annual nationwide databases of hospital discharges from the Agency for Healthcare Research and Qualitys Healthcare Cost and Utilization Project, along with survey data from a nationally representative random sample of children from the Medical Expenditure Panel Survey. Hospital utilization rates and expenses, risk-adjusted rates of potentially avoidable hospitalization, and safety indicators in the hospital are calculated and tracked with established and downloadable software.nnnRESULTSnThe rate of hospital discharges for children aged 15 to 17 years declined significantly, mainly due to fewer maternity-related discharges. The leading principal conditions by age group were similar to the report for 1995 to 2000; however, the rate of admissions for skin infections doubled to 9 per 10,000. Hospital cost per discharge increased by an annual average of 4.5% per year compared with 2.6% annual growth in the gross domestic product deflator. Medicaid is increasingly important relative to private insurance as a payer for hospital care for children. The rate of potentially preventable hospitalizations for both acute and chronic conditions declined substantially (18%, adjusted for age and gender). Several measures of patient safety improved--the rates of postoperative sepsis, iatrogenic pneumothorax, and selected infections due to medical care declined by 14.2%, 17.8%, and 23.5%, respectively. However, the rate of accidental punctures and lacerations and the rate of decubitus ulcer increased by 25.6% and 34.5%, respectively. The trends in safety indicators varied somewhat by age group, income quartile of zip codes, insurance, region, and type of location without a consistent pattern.nnnCONCLUSIONS/IMPLICATIONSnAlthough teenage pregnancy rates were declining, there was a worsening trend in skin infections. The latter may eventually be impacted by recent publication of new guidelines for treatment by office-based physicians. A gradually increasing role of Medicaid as a payer for hospital care for children will likely put an increasing strain on public resources in advance of the full implementation of the health insurance reforms recently enacted. The decline in potentially avoidable admissions reduces the use of the most expensive resources. For asthma and diabetes, children in the lowest income zip codes had persistently higher rates of admission, but the rate fell by one third during the period. Children in the South and West regions had substantial and significant declines in preventable admissions. Particular indicators of safety were improving, whereas others were worsening. Trends were not the same in all types of hospitals, all regions, and income categories. This is already a rich area for further research on the impact of quality improvement strategies; however, attention is needed to developing more tools to more thoroughly track quality of care for children.

Introduction to the 7th Annual Conference on the Science of Dissemination and Implementation: transforming health systems to optimize individual and population health

OBJECTIVEnTo assess the association between Medicaid-induced financial stress of a hospital and the probability of an adverse medical event for a pediatric discharge.nnnDATA SOURCESnSecondary data from the Nationwide Inpatient Sample, Agency for Healthcare Research and Qualitys Healthcare Cost and Utilization Project, and the American Hospital Associations Annual Survey of Hospitals. Study examines 985,896 pediatric discharges (children age 0-17), from 1,050 community hospitals in 26 states (representing 63 percent of the U.S. Medicaid population) between 2005 and 2007.nnnSTUDY DESIGNnWe estimate the probability of an adverse event, controlling for patient, hospital, and state characteristics, using an aggregated, composite measure to overcome rarity of individual events.nnnPRINCIPAL FINDINGSnChildren in hospitals with relatively high proportions of pediatric discharges that are more reliant on Medicaid reimbursement are more likely than children in other hospitals (odds ratio = 1.62) to experience an adverse event. Medicaid pediatric inpatients are more likely than privately insured patients (odds ratio = 1.10) to experience an adverse event.nnnCONCLUSIONSnHospital reliance on comparatively low Medicaid reimbursement may contribute to the problem of adverse medical events for hospitalized children. Policies to reduce adverse events should account for differences in underlying, contributing factors of these events.

Learning How to Learn: How AcademyHealth is Supporting Evidence Generation in a Transforming World

OBJECTIVEnTo examine general dental and orthodontic utilization and expenditures by health insurance status, public health insurance eligibility, and sociodemographic characteristics among children aged 0 to 17 years using data from 2010-2012.nnnMETHODSnNationally representative data from the Medical Expenditure Panel Survey (2010-2012) provided data on insurance status, public health insurance eligibility, and visits to dental providers for both general dental care and orthodontic care.nnnRESULTSnOverall, 41.9% of US children reported an annual dental office-based visit for general (nonorthodontic) dental care. Fewer Hispanic (34.7%) and non-Latino black children (34.8%) received dental care compared to non-Hispanic whites (47.3%) and Asians (40.3%). Children living in families with the lowest income were also the least likely to have a visit (32.9%) compared to children in the highest-income families (54.7%). Among children eligible for publicxa0coverage, Medicaid-eligible children had the lowest percentage of preventive dental visits (29.2%). Socioeconomic and racial/ethnic disparities in use and expenditures for orthodontic care are much greater than those for general and preventive dental care. Average expenditures for orthodontic care were