Sandra L. Decker

In 2011 Nearly One-Third Of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help

When fully implemented, the Affordable Care Act will expand the number of people with health insurance. This raises questions about the capacity of the health care workforce to meet increased demand. I used data on office-based physicians from the 2011 National Ambulatory Medical Care Survey Electronic Medical Records Supplement to summarize the percentage of physicians currently accepting any new patients. Although 96 percent of physicians accepted new patients in 2011, rates varied by payment source: 31 percent of physicians were unwilling to accept any new Medicaid patients; 17 percent would not accept new Medicare patients; and 18 percent of physicians would not accept new privately insured patients. Physicians in smaller practices and those in metropolitan areas were less likely than others to accept new Medicaid patients. Higher state Medicaid-to-Medicare fee ratios were correlated with greater acceptance of new Medicaid patients. The findings serve as a useful baseline from which to measure the anticipated impact of Affordable Care Act provisions that could boost Medicaid payment rates to primary care physicians in some states while increasing the number of people with health care coverage.

Has public health insurance for older children reduced disparities in access to care and health outcomes

This paper investigates the effects of expanding public health insurance eligibility for older children. Using data from the National Health Interview Surveys from 1986 to 2005, we first show that although income continues to be an important predictor of childrens health status, the importance of income for predicting health has fallen for children 9-17 in recent years. We then investigate the extent to which the dramatic expansions in public health insurance coverage for these children in the past decade are responsible for the decline in the importance of income. We find that while eligibility for public health insurance unambiguously improves current utilization of preventive care, it has little effect on current health status. However, we find some evidence that Medicaid eligibility in early childhood has positive effects on future health. This may indicate that adequate medical care early on puts children on a better health trajectory, resulting in better health as they grow.

Health Status, Risk Factors, and Medical Conditions Among Persons Enrolled in Medicaid vs Uninsured Low-Income Adults Potentially Eligible for Medicaid Under the Affordable Care Act

IMPORTANCE Under the Affordable Care Act (ACA), states can extend Medicaid eligibility to nearly all adults with income no more than 138% of the federal poverty level. Uncertainty exists regarding the scope of medical services required for new enrollees. OBJECTIVE To document the health care needs and health risks of uninsured adults who could gain Medicaid coverage under the ACA. These data will help physicians, other clinicians, and state Medicaid programs prepare for the possible expansions. DESIGN, SETTING, AND PATIENTS Data from the National Health and Nutrition Examination Survey 2007-2010 were used to analyze health conditions among a nationally representative sample of 1042 uninsured adults aged 19 through 64 years with income no more than 138% of the federal poverty level, compared with 471 low-income adults currently enrolled in Medicaid. MAIN OUTCOMES AND MEASURES Prevalence and control of diabetes, hypertension, and hypercholesterolemia based on examinations and laboratory tests, measures of self-reported health status including medical conditions, and risk factors such as measured obesity status. RESULTS Compared with those already enrolled in Medicaid, uninsured adults were less likely to be obese and sedentary and less likely to report a physical, mental, or emotional limitation. They also were less likely to have several chronic conditions. For example, 30.1% (95% CI, 26.8%-33.4%) of uninsured adults had hypertension, hypercholesterolemia, or diabetes compared with 38.6% (95% CI, 32.0%-45.3%) of those enrolled in Medicaid (P = .02). However, if they had these conditions, uninsured adults were less likely to be aware of them and less likely to have them controlled. For example, 80.1% (95% CI, 75.2%-85.1%) of the uninsured adults with at least 1 of these 3 conditions had at least 1 uncontrolled condition, compared with 63.4% (95% CI, 53.7%-73.1%) of adults enrolled in Medicaid. CONCLUSION AND RELEVANCE Compared with adults currently enrolled in Medicaid, uninsured low-income adults potentially eligible to enroll in Medicaid under the ACA had a lower prevalence of many chronic conditions. A substantial proportion of currently uninsured adults with chronic conditions did not have good disease control; projections based on sample weighting suggest this may represent 3.5 million persons (95% CI, 2.9 million-4.2 million). These adults may need initial intensive medical care following Medicaid enrollment.

Physicians In Nonprimary Care And Small Practices And Those Age 55 And Older Lag In Adopting Electronic Health Record Systems

By 2011 more than half of all office-based physicians were using electronic health record systems, but only about one-third of those physicians had systems with basic features such as the abilities to record information on patient demographics, view laboratory and imaging results, maintain problem lists, compile clinical notes, or manage computerized prescription ordering. Basic features are considered important to realize the potential of these systems to improve health care. We found that although trends in adoption of electronic health record systems across geographic regions converged from 2002 through 2011, adoption continued to lag for non-primary care specialists, physicians age fifty-five and older, and physicians in small (1-2 providers) and physician-owned practices. Federal policies are specifically aimed at encouraging primary care providers and small practices to achieve widespread use of electronic health records. To achieve their nationwide adoption, federal policies may also have to focus on encouraging adoption among non-primary care specialists, as well as addressing persistent gaps in the use of electronic record systems by practice size, physician age, and ownership status.

Two-Thirds Of Primary Care Physicians Accepted New Medicaid Patients In 2011–12: A Baseline To Measure Future Acceptance Rates

As part of the Affordable Care Act, primary care physicians providing services to patients insured through Medicaid in some states will receive higher payments in 2013 and 2014 than in the past. Payments for some services will increase to match Medicare rates. This change may lead to wider acceptance of new Medicaid patients among primary care providers. Using data from the 2011-12 National Ambulatory Medical Care Survey Electronic Medical Records Supplement, I summarize baseline rates of acceptance of new Medicaid patients among office-based physicians by specialty and practice type. I also report state-level acceptance rates for both primary care and other physicians. About 33 percent of primary care physicians (those in general and family medicine, internal medicine, or pediatrics) did not accept new Medicaid patients in 2011-12, ranging from a low of 8.9 percent in Minnesota to a high of 54.0 percent in New Jersey. Primary care physicians in New Jersey, California, Alabama, and Missouri were less likely than the national average to accept new Medicaid patients in 2011-12. The data presented here provide a baseline for comparison of new Medicaid acceptance rates in 2013-14.

Exogenous predictors of national performance measures for emergency department crowding.

STUDY OBJECTIVE We explore the relationship between exogenous-level predictors and performance on 4 emergency department (ED) throughput measures approved by the National Quality Forum: median ED length of visit for admitted and discharged patients, median waiting time, and rate of left without being seen. We seek to find predictors for benchmarking and public reporting. METHODS This was a study of 424 US hospitals that reported data to the National Hospital Ambulatory Care Survey in 2008 to 2009. Wald F tests and generalized linear models were used to test the relationship between exogenous variables (case mix, age mix, ED volume, teaching status, and Metropolitan Statistical Area status) and performance on the measures. RESULTS Median waiting time was 35 minutes (95% confidence interval [CI] 26 to 43 minutes), median length of visit for patients treated but not admitted was 131 minutes (95% CI 121 to 142 minutes), median length of visit for patients admitted was 244 minutes (95% CI 218 to 270 minutes), and rate of left without being seen was 1.3% (95% CI 0.9% to 1.8%). Most exogenous variables, including ED volume, Metropolitan Statistical Area, teaching hospital status, age mix, and case mix, demonstrated significant association with waiting times and lengths of visit. Older age and a higher proportion of respiratory complaints were associated with differences in rates of left without being seen. CONCLUSION Several exogenous factors outside of a hospitals control are associated with National Quality Forum-approved ED performance measures, which will have important implications for future benchmarking and public reporting of these data.

Use Of Medical Care For Chronic Conditions

We used nationally representative data from the National Center for Health Statistics to compare 1995-96 and 2005-06 ambulatory care visit and 1996 and 2006 hospital discharge rates for adults for eight major chronic conditions. For the eight conditions combined, ambulatory care visit rates rose 21 percent, while hospital discharge rates fell 9 percent. Discharge rates fell for heart disease, cancer, and cerebrovascular disease. Ambulatory care visit rates rose at least 30 percent for arthritis, hypertension, diabetes, and depression. Medicaid recipients and black adults obtain more of their ambulatory care in hospital emergency and outpatient departments and less in physician offices than others do.

The Effect of Medicaid Expansions in the Late 1980s and Early 1990s on the Labor Supply of Pregnant Women

A substantial body of research has found that expansions in Medicaid eligibility increased enrollment in Medicaid, reduced the rate of uninsured, and reduced the rate of private health insurance coverage (i.e., crowd-out). Notably, no published research has examined the labor supply mechanism by which crowd-out could occur. This study examines the effects of expansions in Medicaid eligibility for pregnant women in the late 1980s and the early 1990s on labor supply, which is one of the possible mechanisms underlying crowd-out. Estimates suggest that the 20 percentage point increase in Medicaid eligibility during the sample period was associated with an 11–13 percent decrease in the probability that a woman who gave birth in the past year was employed. Among unmarried women with less than a high school education, the change in Medicaid eligibility reduced employment by approximately 13 percent to 16 percent. We find that most of this reduction in labor supply was associated with crowd-out (i.e., movement from private to public insurance concurrent with the shift in labor supply).

Demographic and social characteristics and spending at the end of life.

In the United States and abroad, the aging of the population and changes in its demographic and social composition raise important considerations for the future of health care and the systems that pay for care. Studies in the United States on end-of-life expenditures and utilization focus primarily on Medicare and have reported differences in formal end-of-life spending and types of services used by age, race, gender, and other personal characteristics, with most notable differences attributed to age at death. Although overall health care spending tends to be higher for people who are white and women, these patterns tend to either reverse themselves or narrow at the end of life. However, age at death continues to be associated with large spending differences at the end of life, with end-of-life spending declining at older ages. Although different data sources, analytic methods, and definitions of end-of-life care make comparisons of the absolute level of end-of-life spending in the United States to that of other countries difficult, a reading of the existing literature reveals some similarities in the distribution of spending across patient characteristics, even across different systems of health care and insurance. In particular, end-of-life spending tends to decline with age, indicating that treatment intensity likely declines with age in most countries to varying degrees. Future international collaborations may help to make data collection and analysis efforts more comparable, enabling identification of factors associated with high-quality end-of-life care and helping health care planners across countries to learn from the successes of others.

Health service use among the previously uninsured: is subsidized health insurance enough?

Although it has been shown that gaining Medicare coverage at age 65 years increases health service use among the uninsured, difficulty in changing habits or differences in the characteristics of previously uninsured compared with insured individuals may mean that the previously uninsured continue to use the healthcare system differently from others. This study uses Medicare claims data linked to two different surveys--the National Health Interview Survey and the Health and Retirement Study--to describe the relationship between insurance status before age 65 years and the use of Medicare-covered services beginning at age 65 years. Although we do not find statistically significant differences in Medicare expenditures or in the number of hospitalizations by previous insurance status, we do find that individuals who were uninsured before age 65 years continue to use the healthcare system differently from those who were privately insured. Specifically, they have 16% fewer visits to office-based physicians but make 18% and 43% more visits to hospital emergency and outpatient departments, respectively. A key question for the future may be why the previously uninsured seem to continue to use the healthcare system differently from the previously insured. This question may be important to consider as health coverage expansions are implemented.