Shailender Swaminathan

Significant paternal contribution to the risk of small for gestational age

Objective  The aim of this study is to investigate both maternal and paternal contributions in the familial aggregation of small for gestational age.

Does Access to a Medical Home Differ According to Child and Family Characteristics, Including Special-Health-Care-Needs Status, Among Children in Alabama?

OBJECTIVE. Our goal was to examine relationships among access to a medical home, special-health-care-needs status, and child and family characteristics in one Southern state. We hypothesized that access to a medical home is influenced by several family and child sociodemographic characteristics, including special-health-care status. METHODS. We used data from the 2003 National Survey of Childrens Health. The study sample comprised all Alabama resident children. The main dependent variable was a medical home; the primary independent variable classified children according to children-with-special-health-care-needs status. We controlled for child age, gender, race, family structure, health status, insurance coverage, household education, and poverty. We first explored means or proportions for the study variables and then estimated multivariate logistic regression models. RESULTS. Children with special health care needs were significantly more likely than children without special health care needs to have a personal doctor or nurse, to have a preventive health care visit in the previous 12 months, and to have good communication with their provider. Children with special health care needs were also more likely to experience problems accessing specialty care, equipment, or services. Being uninsured, living at or near the federal poverty level, in a household where no one completed high school, being black, having less than excellent or good health, and living in a nontraditional family structure were characteristics associated with being less likely to have a medical home. In general, children-with-special-health-care-needs status was not related to having a medical home, but dependency on prescription medicine was. CONCLUSIONS. Assuring that all children, irrespective of family income, have access to and are enrolled in health insurance plans will move us closer to the national goal of having a medical home for all children, especially those with a special health care need, by 2010.

Medicare’s Payment Strategy For End-Stage Renal Disease Now Embraces Bundled Payment And Pay-For-Performance To Cut Costs

Since 1973 Medicare has provided health insurance coverage to all people who have been diagnosed with end-stage renal disease, or kidney failure. In this article we trace the history of payment policies in Medicares dialysis program from 1973 to 2011, while also providing some insight into the rationale for changes made over time. Initially, Medicare adopted a fee-for-service payment policy for dialysis care, using the same reimbursement standards employed in the broader Medicare program. However, driven by rapid spending growth in this population, the dialysis program has implemented innovative payment reforms, such as prospective bundled payments and pay-for-performance incentives. It is uncertain whether these strategies can stem the increase in the total cost of dialysis to Medicare, or whether they can do so without adversely affecting the quality of care. Future research on the intended and unintended consequences of payment reform will be critical.

Insurance Parity and the Use of Outpatient Mental Health Care Following a Psychiatric Hospitalization

CONTEXT Mental health services are typically subject to higher cost sharing than other health services. In 2008, the US Congress enacted legislation requiring parity in insurance coverage for mental health services in group health plans and Medicare Part B. OBJECTIVE To determine the relationship between mental health insurance parity and the use of timely follow-up care after a psychiatric hospitalization. DESIGN, SETTING, AND POPULATION We reviewed cost-sharing requirements for outpatient mental health and general medical services for 302 Medicare health plans from 2001 to 2006. Among 43 892 enrollees in 173 health plans who were hospitalized for a mental illness, we determined the relation between parity in cost sharing and receipt of timely outpatient mental health care after discharge using cross-sectional analyses of all Medicare plans and longitudinal analyses of 10 plans that discontinued parity compared with 10 matched control plans that maintained parity. MAIN OUTCOME MEASURES Outpatient mental health visits within 7 and 30 days following a discharge for a psychiatric hospitalization. RESULTS More than three-quarters of Medicare plans, representing 79% of Medicare enrollees, required greater cost sharing for mental health care compared with primary or specialty care. The adjusted rate of follow-up within 30 days after a psychiatric hospitalization was 10.9 percentage points greater (95% confidence interval [CI], 4.6-17.3; P < .001) in plans with equivalent cost sharing for mental health and primary care compared with plans with mental health cost sharing greater than primary and specialty care cost sharing. The association of parity with follow-up care was increased for enrollees from areas of low income and less education. Rates of follow-up visits within 30 days decreased by 7.7 percentage points (95% CI, -12.9 to -2.4; P = .004) in plans that discontinued parity and increased by 7.5 percentage points (95% CI, 2.0-12.9; P = .008) among control plans that maintained parity (adjusted difference in difference, 14.2 percentage points; 95% CI, 4.5-23.9; P = .007). CONCLUSION Medicare enrollees in health plans with insurance parity for mental health and primary care have markedly higher use of clinically appropriate mental health services following a psychiatric hospitalization.

To Evacuate or Shelter in Place: Implications of Universal Hurricane Evacuation Policies on Nursing Home Residents

OBJECTIVE To examine the differential morbidity/mortality associated with evacuation versus sheltering in place for nursing home (NH) residents exposed to the 4 most recent Gulf hurricanes. METHODS Observational study using Medicare claims and NH data sources. We compared the differential mortality/morbidity for long-stay residents exposed to 4 recent hurricanes (Katrina, Rita, Gustav, and Ike) relative to those residing at the same NHs over the same time periods during the prior 2 nonhurricane years as a control. Using an instrumental variable analysis, we then evaluated the independent effect of evacuation on outcomes at 90 days. RESULTS Among 36,389 NH residents exposed to a storm, the 30- and 90-day mortality/hospitalization rates increased compared with nonhurricane control years. There were a cumulative total of 277 extra deaths and 872 extra hospitalizations at 30 days. At 90 days, 579 extra deaths and 544 extra hospitalizations were observed. Using the instrumental variable analysis, evacuation increased the probability of death at 90 days from 2.7% to 5.3% and hospitalization by 1.8% to 8.3%, independent of other factors. CONCLUSION Among residents exposed to hurricanes, evacuation significantly exacerbated subsequent morbidity/mortality.

Interpregnancy interval and subsequent perinatal outcomes among women delaying initiation of childbearing

Aim:  While delayed initiation of childbearing is associated with adverse perinatal outcomes, whether or not risk persists and whether interpregnancy interval (IPI) affects the subsequent pregnancy remains unclear.

Competition in Health Insurance Markets: Limitations of Current Measures for Policy Analysis:

Health care reform proposals often rely on increased competition in health insurance markets to drive improved performance in health care costs, access, and quality. We examine a range of data issues related to the measures of health insurance competition used in empirical studies published from 1994-2004. The literature relies exclusively on market structure and penetration variables to measure competition. While these measures are correlated, the degree of correlation is modest, suggesting that choice of measure could influence empirical results. Moreover, certain measurement issues such as the lack of data on PPO enrollment, the treatment of small firms, and omitted market characteristics also could affect the conclusions in empirical studies. Importantly, other types of measures related to competition (e.g., the availability of information on price and outcomes, degree of entry barriers, etc.) are important from both a theoretical and policy perspective, but their impact on market outcomes has not been widely studied.

Market and plan characteristics related to HMO quality and improvement.

Existing research on health plan performance examines whether variation in plans’ scores is related to enrollee and health plan traits, primarily using cross-sectional research designs. This study extends that literature by incorporating data on market characteristics using a longitudinal framework. We estimate multivariate growth models that relate plan performance on standard measures to market and HMO characteristics using an unbalanced panel of data for 1998 to 2002. We find that HMO competition is not associated with better performance or greater rates of improvement in performance on the HEDIS chronic care measures. HMO penetration, on the other hand, is positively associated with HEDIS performance in several of the chronic care process-and-outcomes measures but not with a greater rate of improvement through time. Our analysis indicates that a significant percentage of the unexplained variation in quality improvement is because of permanent, unobserved plan-level characteristics that future research should strive to identify.

The Influence of Maternal Mobility on Birth Outcomes of non-Hispanic Blacks

Background We investigated whether the “healthy migrant” effect is applicable to an internally mobile U.S.-born population, that is, whether infants born to women that moved within the United States had better birth outcomes compared to those infants whose mothers did not move. Methods This study used 1995–2001 National Center for Health Statistics live birth/infant death cohort files of singleton infants born in the U.S. to non-Hispanic Black women. Results Infants born to women who moved had significantly lower risks of low birth weight, preterm birth, and SGA compared to the non-mobile group. Conclusions There is evidence to support the healthy migrant effect in an internally migrant Black population. The findings of this study suggest infants of non-Hispanic Black mothers who were born in one state and moved prior to delivery had more positive birth outcomes when compared to those infants of women who did not move prior to delivery.

Effect of Forced Transitions on the Most Functionally Impaired Nursing Home Residents

To examine the hospitalization rate and mortality associated with forced mass transfer of nursing home (NH) residents with the highest levels of functional impairment.