Peter J. Cunningham

Beyond Parity: Primary Care Physicians’ Perspectives On Access To Mental Health Care

About two-thirds of primary care physicians (PCPs) reported in 2004-05 that they could not get outpatient mental health services for patients-a rate that was at least twice as high as that for other services. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access. The probability of having mental health access problems for patients varied by physician practice, health system, and policy factors. The results suggest that implementing mental health parity nationally will reduce some but not all of the barriers to mental health care.

Financial Burden Of Health Care, 2001–2004

Analysis of data from the Medical Expenditure Panel Survey (MEPS) shows that rising out-of-pocket expenses and stagnant incomes increased health spendings financial burden for families in 2001-2004, especially for the privately insured. High financial burdens among those with nongroup coverage increased by more than one-third. Despite evidence of increased cost sharing in private insurance plans, our analysis does not show that privately insured people paid a higher share of their total health care bill in 2004 compared to 2001. Financial burdens have increased to the point at which private insurance is no longer able to provide financial protection for an increasing number of families.

The effects of medicaid reimbursement on the access to care of medicaid enrollees : A community perspective

Previous research has not found a strong association between Medicaid reimbursement levels and enrollees’ access to medical care, even though higher fees increase the acceptance of Medicaid patients by physicians. This study shows that high Medicaid acceptance rates by physicians in a community are more important than fee levels per se in affecting enrollees’ access to medical care. Although high fee levels increase the probability that individual physicians will accept Medicaid patients, high fee levels do not necessarily lead to high levels of physician Medicaid acceptance in an area. Numerous other physician practice, health system, and community characteristics also affect Medicaid acceptance. The effects of Medicaid fees on Medicaid acceptance are substantially lower in areas with high Medicaid managed care penetration and for physicians who practice in institutional settings. The results suggest that a broad range of factors need to be considered to increase access to physicians for Medicaid enrollees.

The Case of Disability in the Family: Impact on Health Care Utilization and Expenditures for Nondisabled Members

Families with a disabled member undergo heightened emotional and financial stress, which can arise from caring for the person with one or more disabilities over the life course or at the end of life. Because health care resources are strained by the needs of the disabled family member, nondisabled members are often limited in health care access and utilization when they are most in need of care. This analysis uses the National Medical Expenditure Survey to describe families with disabled members, based on multiple definitions of disability, and to examine health care utilization and expenditures by nondisabled family members. Indications of higher use of medical care by adult, nondisabled members of such families support the frequent reports in the literature of stress occurring in these situations. The signals of a household rationing effect for families near and at poverty levels should alert policy makers to consider the needs of the whole family when creating or modifying assistance programs.

The Growing Financial Burden Of Health Care: National And State Trends, 2001–2006

The financial burden of health care--the ratio of total out-of-pocket spending for health care services and premiums to total family income--continues to increase nationally. As a result of this trend, more people have been exposed to high costs and lack essential services. This study examines trends nationally and among selected states between 2001 and 2006. The results show considerable state-to-state variation associated mainly with differences in family income and, to a lesser extent, out-of-pocket spending for insurance premiums. Nationally, middle- and higher-income people with private insurance experienced the largest increases in financial burden. Moreover, almost 30 percent of the U.S. population either had a high financial burden of health costs or were uninsured. These facts underscore that escalating health care costs affect all socioeconomic strata, not just the poor.

Raising Low ‘Patient Activation’ Rates Among Hispanic Immigrants May Equal Expanded Coverage In Reducing Access Disparities

There is a growing consensus that activating consumers to become better managers of their health is an essential component of US health care reform. We measured how activated blacks, whites, and Hispanics are-that is, how confident, skillful, and knowledgeable they are about taking an active role in improving their health and health care. We found that patient activation among blacks and Hispanics was low, relative to that of whites. For example, 24.8 percent of Hispanics were at the highest level of patient activation, compared to 39.5 percent of blacks and 45.3 percent of whites. Among Hispanic immigrants, low acculturation and lack of familiarity with the US health care system contribute to low activation. The findings indicate that increasing activation levels among Hispanic immigrants may be as important as expanding insurance coverage in reducing disparities in unmet medical need.

The Effects of SCHIP on Children’s Health Insurance Coverage: Early Evidence from the Community Tracking Study

The State Children’s Health Insurance Program (SCHIP) was designed to increase the number of children with health insurance coverage without resulting in large numbers of children substituting public coverage for private insurance. This study uses data from the Community Tracking Study collected before and after SCHIP implementation to examine the effects of increases in eligibility for public coverage on children’s health insurance coverage. Using a regression-based difference-in-differences approach, the authors find that increases in eligibility for public coverage did increase the likelihood of having Medicaid or other state coverage versus being uninsured for the primary SCHIP target population—children in families with incomes between 100 and 200 percent of the federal poverty level. However, eligibility increases also increased the likelihood of having public coverage versus private insurance for this income group, indicating that SCHIP expansions resulted in substitution of public for private insurance. In fact, simulation results indicate that the initial impact of SCHIP on private insurance coverage has been far greater than on uninsurance rates. These results reflect the early stages of SCHIP implementation, however, and are subject to change as the SCHIP programs mature.

Does managed care enable more low income persons to identify a usual source of care? Implications for access to care.

Background.By requiring or encouraging enrollees to obtain a usual source of care, managed care programs hope to improve access to care without incurring higher costs. Objectives.(1) To examine the effects of managed care on the likelihood of low-income persons having a usual source of care and a usual physician, and; (2) To examine the association between usual source of care and access. Research Design. Cross-sectional survey of households conducted during 1996 and 1997. Subjects.A nationally representative sample of 14,271 low-income persons. Measures.Usual source of care, usual physician, managed care enrollment, managed care penetration. Results.High managed care penetration in the community is associated with a lower likelihood of having a usual source of care for uninsured persons (54.8% vs. 62.2% in low penetration areas) as well as a lower likelihood of having a usual physician (60% vs. 72.8%). Managed care has only marginal effects on the likelihood of having a usual source of care for privately insured and Medicaid beneficiaries. Having a usual physician substantially reduces unmet medical needs for the insured but less so for the uninsured. Conclusions.Having a usual physician can be an effective tool in improving access to care for low-income populations, although it is most effective when combined with insurance coverage. However, the effectiveness of managed care in linking more low-income persons to a medical home is uncertain, and may have unintended consequences for uninsured persons.

THE USE OF AMBULATORY HEALTH CARE SERVICES BY AMERICAN INDIANS WITH DISABILITIES

Although most American Indians and Alaska Natives have access to health care through the Indian Health Service (IHS), it is uncertain whether IHS is able to provide all necessary health services to those with disabilities. Although IHS eligibles can use health services other than those provided or sponsored by IHS, this may be precluded by high rates of poverty, low rates of other health insurance coverage, and the lack of private providers in many areas inhabited by this population. Using data from the 1987 Survey of American Indians and Alaska Natives—the only nationally representative health care survey of persons eligible for IHS—this study examines the use of ambulatory health care for IHS eligibles with disabilities. Comparisons with the total US population showed similar rates of ambulatory care use for most categories of disability, but a higher frequency of use for the total US population. Findings also show that IHS provides most of the health care for its eligible population, although non-IHS care is also used. After controlling for the effects of sociodemographic characteristics and health insurance coverage, variables indicating disabilities due to health problems were found to have statistically significant effects on the likelihood of using non-IHS care. Furthermore, persons with activity limitations had a higher than average likelihood of using most of their health care at non-IHS providers. These findings suggest that for some persons with disabilities, it is necessary to supplement IHS care with services from other providers.

Qualitative Methods: A Crucial Tool for Understanding Changes in Health Systems and Health Care Delivery

The article by Bryan Weiner and colleagues (“Use of Qualitative Methods in Published Health Services and Management Research: A Ten-Year Review”) provides a review of the contribution of qualitative research to the knowledge base of health services research and how it has changed over the past 10 years (Weiner, Amick, Lund, Lee, & Hoff, 2011). Although qualitative studies still contribute to a relatively small (and apparently decreasing) share of the total number of articles in the nine major health services research and management journals, it is noteworthy that these articles are cited as frequently as articles using quantitative methods. Clearly there is a role for qualitative research in studies of health systems, but this role is still not well understood or even widely appreciated. One limitation of the study by Weiner et al. is that their review was restricted to nine health services and management journals. Although these include some of the most prestigious journals in the field, they do not necessarily reflect the full impact that qualitative research has had on the knowledge base or on health policy. We believe that the interest and acceptance of qualitative research has grown, as well as its importance and influence among policy makers and directors of public programs, although the results of such research are often not published in academic journals. We have seen the importance of qualitative methods most directly through our experience with the Community Tracking Study (CTS), which since 1996 has included household and physician surveys, as well as site visits to 12 randomly selected Medical Care Research and Review 68(1) 34 –40