Marc W. Zodet

Health care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by income.

OBJECTIVES To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States. METHODS Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patients zip code of residence is used to assign community-level income to individual hospitalizations. RESULTS Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children. CONCLUSIONS While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.

Annual Report on Health Care for Children and Youth in the United States: Focus on Injury-Related Emergency Department Utilization and Expenditures

OBJECTIVE To examine state differences in childrens utilization of injury-related emergency department (ED) care across 14 states, benchmarking aggregate state estimates against national expenditure estimates for outpatient injury-related ED care. METHODS A retrospective analysis was performed using the 2003 State Emergency Department Databases and State Inpatient Databases from the Healthcare Cost and Utilization Project and data from the Medical Expenditure Panel Survey. Pediatric ED visits with any injury International Classification of Diseases Ninth Version Clinical Modification (ICD-9-CM) diagnosis code were selected. The Barell Injury Diagnosis Matrix, ICDMAP-90 software, and the Trauma Information Exchange Program data were used to classify injuries, produce injury severity scores, and examine utilization in trauma centers. Aggregate and state-specific descriptive analyses compared differences in patient and injury characteristics and admission status by age, severity of injury, and expected payer. RESULTS Over 1.5 million or nearly one-third of ED visits were for pediatric injuries in the 14 states studied. Nationally, 5.4% of children had an injury-related ED visit, and approximately

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

2.3 billion was spent on outpatient injury-related ED visits in 2003. The pattern of injury-related ED visit care varied considerably by state. For example, injury-related ED visit rates ranged from 63.3 to 164.4 per 1000 children. Infants, adolescents, children from very low income communities, and children from nonmetropolitan and nonmicropolitan areas were more likely to have an injury-related ED visit than their peers. Although patient characteristics were fairly consistent across states, admission rates and expected source of payment for injury-related ED visits varied considerably by state. Hospital admission rates ranged from 1.5% to 4.4% of injury-related ED visits and expected payer estimates ranged from 37.1% to 71.0% of visits billed to private insurance, 17.9% to 47.0% billed to Medicaid, and 2.1% to 10.4% billed as uninsured. CONCLUSIONS This study suggests that injuries account for a significant portion of pediatric ED visits. There is substantial variation in ED use and hospital admissions for injured children across states and payers. This variation suggests that there are several opportunities for improvement in emergency care for children. To better understand the underlying reason for the variation, multivariate and hypothesis-driven research should focus on the nature and outcomes of injury-related ED care in the context of small area practice patterns and state programs, policies, and care system characteristics.

Determinants of Utilization and Expenditures for Episodes of Ambulatory Physical Therapy Among Adults

OBJECTIVE To 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. METHODS Three 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. RESULTS The 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. CONCLUSIONS Health 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.

Implications of the accuracy of MEPS prescription drug data for health services research

Background Comprehensive information on determinants and patterns of use and spending for ambulatory physical therapy services is needed to inform health planning and policy decisions. Most research in the literature on this topic is limited to specific payers, age groups, and conditions. Objective The purpose of this study was to examine factors associated with the resource intensity of physical therapy episodes for adults in the United States as measured by number of visits and expenses per visit. Design This study was a secondary analysis of longitudinal survey data from the Medical Expenditure Panel Survey (MEPS) panels 9, 10, and 11. Methods An analytic file was created based on data from the longitudinal data files for 3 MEPS panels and the annual office-based and hospital outpatient event files. A total of 1,377 episodes of physical therapy care were identified. Variation in both the total number of visits per episode and expenses per visit was examined by fitting regression models to evaluate the effects of selected independent variables classified into 4 categories: episode-level variables, demographic characteristics, geographic variables, and health status indicators. Results Average total expenses per episode (in 2007 dollars) were

The 2008 prevalence of chiropractic use in the US adult population.

1,184 (median=

Medical care utilization for work-related injuries in the United States 2002-2006.

651), with an average number of visits per episode of 9.6 (median=6.0) and average expenses per visit of

Clinical, demographic, and geographic determinants of variation in chiropractic episodes of care for adults using the 2005-2008 Medical Expenditure Panel Survey.

130 (median=

Validity of Reported Medicare Part D Enrollment in the Medical Expenditure Panel Survey

95). Significant variation by geographic characteristics, sex, and one comorbid condition (high blood pressure) was found in the number of visits model. In the expenditures model, expenses per visit were associated with age/insurance coverage, setting (hospital outpatient versus office based), primary condition category, and mental health status. Limitations Limitations include limited sample sizes of physical therapy users and lack of detailed clinical information. Conclusions Variability in the resource intensity of physical therapy episodes is influenced to some degree by nonclinical variables.

An assessment of the impact of two distinct survey design modifications on health care utilization estimates in the medical expenditure panel survey

This paper assesses the quality of the Medical Expenditure Panel Survey (MEPS) drug data and the impact that misreporting prescription drug data has on descriptive and behavioral analyses. It does this by matching MEPS participants with Medicare Part D coverage during the period 2006–2007 to their Part D claims data. In the validation sample, the number of drug fills and total expenditures are reasonably accurate compared with claims. Household respondents tended to underreport the number of different drugs taken, but tended to overreport the number of fills of each drug. Behavioral analyses of the determinants of medication use and expenditures were largely unaffected because underreporting cut across most sociodemographic groups.