Michael Dworsky

Quality of Care for Work-Associated Carpal Tunnel Syndrome

Objective: To evaluate the quality of care provided to individuals with workers’ compensation claims related to Carpal tunnel syndrome (CTS) and identify patient characteristics associated with receiving better care. Methods: We recruited subjects with new claims for CTS from 30 occupational clinics affiliated with Kaiser Permanente Northern California. We applied 45 process-oriented quality measures to 477 subjects’ medical records, and performed multivariate logistic regression to identify patient characteristics associated with quality. Results: Overall, 81.6% of care adhered to recommended standards. Certain tasks related to assessing and managing activity were underused. Patients with classic/probable Katz diagrams, positive electrodiagnostic tests, and higher incomes received better care. However, age, sex, and race/ethnicity were not associated with quality. Conclusions: Care processes for work-associated CTS frequently adhered to quality measures. Clinical factors were more strongly associated with quality than demographic and socioeconomic ones.

The Effect of the 2014 Medicaid Expansion on Insurance Coverage for Newly Eligible Childless Adults

This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RANDs publications do not necessarily reflect the opinions of its research clients and sponsors. R® is a registered trademark. iii Preface Following full implementation of the Affordable Care Acts (ACAs) coverage provisions on January 1, 2014, the share of U.S. adults without insurance fell substantially more in Medicaid expansion states than in nonexpansion states. These figures suggest that Medicaid expansion is succeeding at reducing uninsurance. However, existing estimates of the Medicaid expansions effects do not specifically examine take-up of Medicaid among adults who became newly eligible following the Medicaid expansion. This report used data from the 2009–2014 National Health Interview Survey with restricted-use state geocodes to measure the effect of state Medicaid expansion decisions on insurance coverage and the source of coverage among childless adults who became newly eligible for Medicaid in 2014. This report uses a differences-indifferences approach to compare newly eligible adults to similar adults in nonexpansion states who were not eligible for subsidized coverage through the Health Insurance Marketplace in 2014. This study addressed the following research questions: • How did Medicaid expansion affect insurance status for low-income childless adults who became newly eligible? • Of the newly eligible adults gaining Medicaid coverage because of the expansion, how many would otherwise have been uninsured, and how many would otherwise have been covered by private insurance? • Which subgroups of the newly eligible population were more or less likely to take up Medicaid coverage in 2014? This report may be of interest to state and federal health policymakers, as well as other analysts evaluating the ACA and the effects of Medicaid eligibility on insurance coverage. (RWJF) through its State Health Access Reform Evaluation (SHARE) initiative. SHARE is an RWJF national program …

Young Adults, Health Insurance Expansions and Hospital Services Utilization

Under the dependent coverage expansion (DCE) provision of health reform adult children up to 26 years of age whose parents have employer-sponsored or individual health insurance are eligible for insurance under their parents’ health plan. Using a difference-in-differences approach and the 2008–2014 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases we examined the impact of the DCE on hospital services use. In analyses of individuals age <26 years (compared to individuals over 26) we found a 1.5% increase in non-pregnancy related inpatient visits in 2010 through 2013 during the initial DCE period and a 1.6% increase in 2014 when other state expansions went into effect. We found that the impact of the DCE persisted into 2014 when many state insurance expansions occurred, although effects varied for states adopting and not adopting Medicaid expansions.

Using All-Payer Claims Databases to Study Insurance and Health Care Utilization Dynamics

C hurning on and off of insurance and across types of private and public insurance are common experiences for American families. Instability in the source of insurance frequently leads to short spells of uninsurance, and prior research shows that insurance instability has adverse consequences for access to primary care. Much of this literature has focused on Medicaid, the Children’s Health Insurance Program (CHIP), and other public programs, however, and less is known about how seamless insurance transitions from one insurance carrier to another (those with little or no transitory uninsurance) affect utilization of or access to care. In this issue of JGIM, Barnett et al. demonstrate how state all-payer claims databases (APCDs) can make it possible to address previously infeasible research questions about the relationship between insurance coverage and health care utilization. Using data from the linked enrollment and claims files of theMassachusetts APCD, the authors used propensity score matching to compare the trajectories of new physician visits and emergency department (ED) visits between continually insured non-elderly adults who changed insurance carriers (Bswitchers^) and those who remained covered by the same insurance carrier (Bnon-switchers^). The authors were also able to provide separate estimates for individuals who transitioned from one private insurer to another and for individuals who transitioned from Medicaid to private insurance. The authors find that insurance switching is a predictor of an immediate spike in visits with new primary care and specialist physicians. They estimate a far larger increase among patients switching from Medicaid to private insurance than among patients transitioning across private insurance carriers. No changes in ED visit frequency were observed among the privately insured; the authors’ headline estimates show a slight reduction in ED visits after switches from Medicaid to private coverage, although this finding is less robust than the changes in new physician visits. While this study provides limited detail on the mechanisms that explain these sharp increases in new physician visits, the more pronounced changes for Medicaid enrollees are consistent with the notion that differences across health plans in provider networks drive the observed behavior.