The association between insurance type and cost-related delay in care: a survey.
ABSTRACT: Massachusetts has insurance rates similar to those projected under the Affordable Care Act, but many of the state's patients are insured through private insurance plans with high out-of-pocket costs. We aimed to explore the relationship between insurance type (private vs public) and delays in care due to cost, stratified by income.Cross-sectional study.We conducted a study of English-speaking adults recruited from the waiting rooms of the emergency department or outpatient clinics of a large healthcare system in western Massachusetts. Our primary outcome was the association between insurance type and cost-related delay in care, stratified by income.Of 800 individuals approached, 619 (77%) completed the survey. Participants were 60.6% male and 40.2% white, 37.2% Hispanic, and 12.6% black. The majority (61.4%) of those surveyed had public insurance, 34.1% had private insurance, and 4.5% were uninsured. Overall, 13.3% reported delays in seeking care that were related to cost. The impact of insurance on delay of care differed significantly by income tertile (P = .02): in the middle-income group ($12,500 to <$25,000 per person annually), privately insured respondents were more likely to delay care due to cost compared with publicly insured subjects (15.6% vs 8.1%; odds ratio [OR], 4.4; 95% confidence interval [CI], 1.9-10.2, unadjusted; OR, 2.2; 95% CI, 0.9-5.8, adjusted).Cost-related delays in care are prevalent despite the presence of an insurance mandate. Middle-income, privately insured patients report more cost-related delays in care compared with publicly insured patients with similar incomes.
Project description:Massachusetts' health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type.To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts' second largest safety net hospital between July 25, 2009 and March 20, 2010.Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured.Access to care improved less than access to insurance following Massachusetts' health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.
Project description:<h4>Importance</h4>Timely receipt of treatment for cancer is an important aspect of health care quality. It is unknown how delays of surgery for melanoma vary by insurance type.<h4>Objective</h4>To analyze factors associated with delays between diagnosis and surgery for melanoma in patients with Medicare, Medicaid, or private insurance.<h4>Design, setting, and participants</h4>Retrospective cohort study of patients who received a diagnosis of melanoma between 2004 and 2011 in North Carolina using data from the North Carolina Cancer Registry linked to administrative claims from Medicare, Medicaid, and private insurance. Inclusion criteria were incident patients with a diagnosis of melanoma stage 0 to III and with continuous insurance enrollment from at least 1 month prior to the month of diagnosis to 12 months after diagnosis of melanoma.<h4>Main outcomes and measures</h4>Surgical delay, defined as definitive surgical excision occurring more than 6 weeks after melanoma diagnosis. Generalized linear models with log link, Poisson distributions, and robust standard errors were used to estimate adjusted risk ratios (RRs) to model risk of delay in definitive surgery.<h4>Results</h4>A total of 7629 patients were included (4210 [55%] female; mean [SD] age, 64  years), 48% (n?=?3631) Medicare, 48% (n?=?3667) privately insured, and 4% (n?=?331) Medicaid patients. Privately insured patients were least likely to experience a delay in definitive surgery, followed by Medicare and Medicaid patients (519 [14%], 609 [17%], and 79 [24%], respectively; P?<?.001). After demographic adjustment, the risk of surgical delay was significantly increased in patients with Medicaid compared with private insurance (RR, 1.36; 95% CI, 1.09-1.70). Delays were more likely in nonwhite patients (RR, 1.38; 95% CI, 1.02-1.87). Surgical delays were less likely if the physician performing the surgery (RR, 0.82; 95% CI, 0.72-0.93) or the diagnosing clinician (RR, 0.81; 95% CI, 0.71-0.93) was a dermatologist as compared with a nondermatologist.<h4>Conclusion and relevance</h4>Surgical treatment delays were common but were less prevalent in patients diagnosed or surgically treated by a dermatologist. Medicaid patients experienced the most surgical delays. A reduction in delays in melanoma surgery could be achieved through better access to specialty care and cross-disciplinary coordination.
Project description:The cost of mental health services has always been a great barrier to accessing care for people with mental health problems. This article documents changes in insurance coverage and cost for mental health services for people with public insurance, private insurance, and no coverage. In 2009-10 people with mental health problems were more likely to have public insurance and less likely to have private insurance than in 1999-2000. Although access to specialty care remained relatively stable for people with mental illnesses, cost barriers to care increased among the uninsured and the privately insured who had serious mental illnesses. The rise in cost barriers among those with private insurance suggests that the current financing of care in the private insurance market is insufficient to alleviate cost burdens and has implications for reforms under the Affordable Care Act. People with mental health problems who are newly eligible to purchase private insurance under the act might still encounter high cost barriers to accessing care.
Project description:Disparities in patterns of care and outcomes for ambulatory-care sensitive childhood conditions such as community-acquired pneumonia (CAP) persist. However, the influence of insurance status on length of stay (LOS) for children hospitalized with CAP remains unexplored.Secondary analysis of children (<18 years) hospitalized with CAP sampled in the Kids' Inpatient Database (KID) for years 1997, 2000, 2003, and 2006. Insurance status (private, public, uninsured) was based on claims data. Hospital LOS was calculated in days. Taking into account the complex sampling design, negative binomial regression models produced adjusted estimates of incidence rate ratios (IRR) for hospital LOS for children by insurance status.There was little variation in the categories of insurance status of children hospitalized with CAP between 1997 and 2006, with at least 40% privately insured, at least 40% publicly insured, and at least 5% uninsured in each sampled year. In all years, publicly insured children had a significantly longer hospital stay than privately insured children, and uninsured children had a significantly shorter hospital stay than privately insured children. These observed differences persisted after multivariate adjustment.Differences in LOS between uninsured, publicly insured, and privately insured children with CAP raise concerns about potential differences in hospital discharge practices related to insurance status and type. As healthcare reform is implemented, policy makers should strengthen efforts to reduce these disparities in order to achieve health for the population.
Project description:BACKGROUND:Medicaid expansion among previously uninsured individuals has led to improved healthcare access. However, considerably lower reimbursement rates of Medicaid have raised concerns on the unintended consequence of lower utilization of life-saving therapies and inferior outcomes compared with private insurance. We examined the rates of revascularization and in-hospital mortality among Medicaid beneficiaries versus privately insured individuals hospitalized with ST-segment-elevation myocardial infarction (STEMI). METHODS AND RESULTS:We queried the National Inpatient Sample from 2012 to 2015 for STEMI hospitalizations with Medicaid or private insurance as primary payer. Hospitalizations with the following criteria were excluded: (1) age <18 or ?65 years, (2) transfer to another acute care facility, and (3) left against medical advice. Outcomes were compared in propensity score-matched cohort based on demographics, socioeconomic status (income based), clinical comorbidities, including drug and alcohol use, STEMI acuity (cardiac arrest and cardiogenic shock), and hospital characteristics. A total of 42 645 and 171 545 STEMI hospitalizations were identified as having Medicaid and private insurance, respectively. In unadjusted analyses, Medicaid beneficiaries with STEMI had lower rates of coronary revascularization (88.9% versus 92.3%; odds ratio, 0.67; 95% CI, 0.65-0.70) and higher rates of in-hospital mortality (4.9% versus 2.8%; odds ratio, 1.81; 95% CI, 1.72-1.91) compared with privately insured individuals ( P<0.001 for both). In propensity-matched cohort of 40 870 hospitalizations per group, similar results for lower rates of revascularization (89.1% versus 91.1%; odds ratio, 0.80; 95% CI, 0.76-0.84) and higher in-hospital mortality (4.9% versus 3.7%; odds ratio, 1.35; 95% CI, 1.26-1.45) were observed in Medicaid compared with private insurance, despite extensive matching ( P<0.001 for both). CONCLUSIONS:Medicaid beneficiaries with STEMI had lower rates of revascularization, although small absolute difference, and higher in-hospital mortality compared with privately insured individuals. Further studies are needed to identify and understand the variation in STEMI outcomes by insurance status.
Project description:Medicaid patients are known to have reduced access to care compared with privately insured patients; however, quantifying this disparity with large controlled studies remains a challenge. This meta-analysis evaluates the disparity in health services accessibility of appointments between Medicaid and privately insured patients through audit studies of health care appointments and schedules. Audit studies evaluating different types of outpatient physician practices were selected. Studies were categorized based on the characteristics of the simulated patient scenario. The relative risk of appointment availability was calculated for all different types of audit scenario characteristics. As a secondary analysis, appointment availability was compared pre- versus post-Medicaid expansion. Overall, 34 audit studies were identified, which demonstrated that Medicaid insurance is associated with a 1.6-fold lower likelihood in successfully scheduling a primary care appointment and a 3.3-fold lower likelihood in successfully scheduling a specialty appointment when compared with private insurance. In this first meta-analysis comparing appointment availability between Medicaid and privately insured patients, we demonstrate Medicaid patients have greater difficulty obtaining appointments compared with privately insured patients across a variety of medical scenarios.
Project description:OBJECTIVE:To measure the likelihood of delivery by caesarean section (C-section) for publicly insured births as compared with privately insured births, across all hospitals and within private hospitals. DESIGN:Repeated cross-sectional analysis. SETTING:The universe of hospital births in 15 regions of Chile. PARTICIPANTS:2 405 082 singleton births between 2001 and 2014. OUTCOME MEASURES:C-section rates by type of hospital and type of insurance; contribution to overall C-section rates of subgroups by type of insurance and type of hospital; adjusted OR of privately insured births delivered by C-section compared with publicly insured births, across all hospitals and within private hospitals; percentage of discharges related to maternal morbidity and mortality across groups; length of stay after delivery. RESULTS:An increasing percentage of publicly insured births occur in private facilities each year. Approximately three out of four publicly insured births in private hospitals are delivered by C-section. The adjusted odd of C-section delivery in a private maternity unit is lower for those privately insured than for those with public insurance: OR 0.6, 95% CI 0.56 to 0.64. There is no evidence that these women would have been more likely to have a C-section out of medical necessity. CONCLUSIONS:We find an association between high C-section rates and publicly insured women delivering at private institutions in Chile, and show that this group is driving the overall high and growing rates. There is a need for a more informed surveillance on the part of the public insurance system of its private providers' C-section practices.
Project description:OBJECTIVES:To examine the association between type of health insurance (public, uninsured, private, or other) and oral health outcomes for children in the United States using nationally representative surveillance data. METHODS:Using the National Health and Nutrition Examination Survey (2011/12-2013/14), logistic regression models were used to estimate the odds of any dental caries and any untreated caries by type of health insurance (public, uninsured, private, and other) for children aged 2-19 years, with adjustment for relevant individual and socioeconomic characteristics. RESULTS:Among 6,057 children, the odds of having any dental caries or untreated caries was not significantly different for publicly insured and uninsured children compared to privately insured children, when adjusting for family income and education. Children in families with income to poverty ratios <200 percent had greater odds of caries and untreated caries relative to children in families with income to poverty ratios ?400 percent. Children with less educated parents also experienced greater odds of caries and untreated caries. CONCLUSIONS:Oral health outcomes, after adjusting for covariates, were similar for children with public and private health insurance. However, children in low-income families and with less educated parents had greater odds of untreated caries and dental caries, suggesting that initiatives focused on publicly insured populations may miss other vulnerable children of low socioeconomic status.
Project description:Among considerable efforts to improve quality of surgical care, expedited measures such as a selective referral to high-volume institutions have been advocated. Our objective was to examine whether racial, insurance and/or socioeconomic disparities exist in the use of high-volume hospitals for complex surgical oncological procedures within the USA.Patients undergoing colectomy, cystectomy, oesophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy or prostatectomy were identified retrospectively, using the Nationwide Inpatient Sample, between years 1999 and 2009. This resulted in a weighted estimate of 2 508 916 patients.Distribution of patients according to race, insurance and income characteristics was examined according to low-volume and high-volume hospitals (highest 20% of patients according to the procedure-specific mean annual volume). Generalised linear regression models for prediction of access to high-volume hospitals were performed.Insurance providers and county income levels varied differently according to patients' race. Most Caucasians resided in wealthier counties, regardless of insurance types (private/Medicare), while most African Americans resided in less wealthy counties (?$24 999), despite being privately insured. In general, Caucasians, privately insured, and those residing in wealthier counties (?$45 000) were more likely to receive surgery at high-volume hospitals, even after adjustment for all other patient-specific characteristics. Depending on the procedure, some disparities were more prominent, but the overall trend suggests a collinear effect for race, insurance type and county income levels.Prevailing disparities exist according to several patient and sociodemographic characteristics for utilisation of high-volume hospitals. Efforts should be made to directly reduce such disparities and ensure equal healthcare delivery.
Project description:As of 2014, 37 states have passed mandates requiring many private health insurance policies to cover diagnostic and treatment services for autism spectrum disorders (ASDs). We explore whether ASD mandates are associated with out-of-pocket costs, financial burden, and cost or insurance-related problems with access to treatment among privately insured children with special health care needs (CSHCNs). We use difference-in-difference and difference-in-difference-in-difference approaches, comparing pre--post mandate changes in outcomes among CSHCN who have ASD versus CSHCN other than ASD. Data come from the 2005 to 2006 and the 2009 to 2010 waves of the National Survey of CSHCN. Based on the model used, our findings show no statistically significant association between state ASD mandates and caregivers' reports about financial burden, access to care, and unmet need for services. However, we do find some evidence that ASD mandates may have beneficial effects in states in which greater percentages of privately insured individuals are subject to the mandates. We caution that we do not study the characteristics of ASD mandates in detail, and most ASD mandates have gone into effect very recently during our study period.