Last data update: Jun 03, 2024. (Total: 46935 publications since 2009)
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Characteristics of Medicare Advantage and fee-for-service beneficiaries upon enrollment in Medicare at age 65
Miller EA , Decker SL , Parker JD . J Ambul Care Manage 2016 39 (3) 231-41 Previous research has found differences in characteristics of beneficiaries enrolled in Medicare fee-for-service versus Medicare Advantage (MA), but there has been limited research using more recent MA enrollment data. We used 1997-2005 National Health Interview Survey data linked to 2000-2009 Medicare enrollment data to compare characteristics of Medicare beneficiaries before their initial enrollment into Medicare fee-for-service or MA at age 65 and whether the characteristics of beneficiaries changed from 2006 to 2009 compared with 2000 to 2005. During this period of MA growth, the greatest increase in enrollment appears to have come from those with no chronic conditions and men. |
Health information technology adoption in the emergency department
Selck FW , Decker SL . Health Serv Res 2016 51 (1) 32-47 OBJECTIVE: To describe the trend in health information technology (IT) systems adoption in hospital emergency departments (EDs) and its effect on ED efficiency and resource use. DATA SOURCES: 2007-2010 National Hospital Ambulatory Medical Care Survey - ED Component. STUDY DESIGN: We assessed changes in the percent of visits to EDs with health IT capability and the estimated effect on waiting time to see a provider, visit length, and resource use. PRINCIPAL FINDINGS: The percent of ED visits that took place in an ED with at least a basic health IT or an advanced IT system increased from 25.2 and 3.1 percent in 2007 to 69.1 and 30.6 percent in 2010, respectively (p < .05). Controlling for ED fixed effects, waiting times were reduced by 6.0 minutes in advanced IT-equipped EDs (p < .05), and the number of tests ordered increased by 9 percent (p < .01). In models using a 1-year lag, advanced systems also showed an increase in the number of medications and images ordered per visit. CONCLUSIONS: Almost a third of visits now occur in EDs with advanced IT capability. While advanced IT adoption may decrease wait times, resource use during ED visits may also increase depending on how long the system has been in place. We were not able to determine if these changes indicated more appropriate care. |
Association between diagnosed diabetes and trouble seeing, National Health Interview Survey, 2011-13
Lipton BJ , Decker SL . J Diabetes 2015 7 (5) 743-6 Approximately 21 million individuals in the US have diagnosed diabetes.1 Diabetic retinopathy, a progressive condition that can ultimately lead to blindness, affects approximately 29% of adults aged 40 years and older with diabetes.2 Diabetes is also associated with an increased likelihood of other conditions that may affect vision, such as cataracts and glaucoma.3 We assessed the association between diagnosed diabetes and self-reported trouble seeing while controlling for other covariates that may affect vision. | | The present study used 2011–13 data from the National Health Interview Survey (NHIS).4 The NHIS is a nationally representative sample of US households, with one adult member of each family selected to complete a more in-depth survey. Final 2011–13 sample adult response rates ranged from 61% to 66%. Respondents were asked if they had trouble seeing even when wearing usual vision correction. Possible responses included “yes”, “no”, and “don’t know”, and were used to create a binary variable equal to one for those who did and zero for those who did not report trouble seeing (responses of “don’t know” and refusals [accounting for <0.01% of responses] were considered missing). Those who reported receiving a diabetes diagnosis from a healthcare provider were classified as having diabetes. The sample consisted of adults aged 25 years and older with complete demographic, comorbidity, vision, and diabetes information.5 |
The effect of health insurance coverage on medical care utilization and health outcomes: evidence from Medicaid adult vision benefits
Lipton BJ , Decker SL . J Health Econ 2015 44 320-32 Increasing the proportion of adults that have regular, comprehensive eye exams and reducing visual impairment due to uncorrected refractive error and other common eye health problems are federal health objectives. We examine the effect of vision insurance on eye care utilization and vision health outcomes by taking advantage of quasi-experimental variation in Medicaid coverage of adult vision care. Using a difference-in-difference-in-difference approach, we find that Medicaid beneficiaries with vision coverage are 4.4 percentage points (p<0.01) more likely to have seen an eye doctor in the past year, 5.3 percentage points (p<0.01) less likely to report needing but not purchasing eyeglasses or contacts due to cost, 2.0 percentage points (p<0.05) less likely to report difficulty seeing with usual vision correction, and 1.2 percentage points (p<0.01) less likely to have a functional limitation due to vision. |
The effect of Medicaid adult vision coverage on the likelihood of appropriate correction of distance vision: evidence from the National Health and Nutrition Examination Survey
Lipton BJ , Decker SL . Soc Sci Med 2015 150 258-67 BACKGROUND: Medicaid is the main public health insurance program for individuals with low income in the United States. Some state Medicaid programs cover preventive eye care services and vision correction, while others cover emergency eye care only. Similar to other optional benefits, states may add and drop adult vision benefits over time. RESEARCH OBJECTIVE: This article examines whether providing adult vision benefits is associated with an increase in the percentage of low-income individuals with appropriately corrected distance vision as measured during an eye exam. METHODOLOGY: We estimate the effect of Medicaid vision coverage on the likelihood of having appropriately corrected distance vision using examination data from the 2001-2008 National Health and Nutrition Examination Survey. We compare vision outcomes for Medicaid beneficiaries (n = 712) and other low income adults not enrolled in Medicaid (n = 4786) before and after changes to state vision coverage policies. FINDINGS: Between 29 and 33 states provided Medicaid adult vision benefits during 2001-2008, depending on the year. Our findings imply that Medicaid adult vision coverage is associated with a significant increase in the percentage of Medicaid beneficiaries with appropriately corrected distance vision of up to 10 percentage points. CONCLUSION: Providing vision coverage to adults on Medicaid significantly increases the likelihood of appropriate correction of distance vision. Further research on the impact of vision coverage on related functional outcomes and the effects of Medicaid coverage of other services may be appropriate. |
Do Medicaid benefit expansions have teeth? The effect of Medicaid adult dental coverage on the use of dental services and oral health
Decker SL , Lipton BJ . J Health Econ 2015 44 212-225 This article examines the effect of Medicaid adult dental coverage on use of dental care and dental health outcomes using state-level variation in dental coverage during 2000-2012. Our findings imply that dental coverage is associated with an increase in the likelihood of a recent dental visit, with the size of the effect increasing with Medicaid payment rates to dentists, and a reduction in the likelihood of untreated dental caries. We are among the first to detect an effect of Medicaid coverage on a clinical health outcome other than mortality. These findings may have implications for states expanding Medicaid coverage to adults with incomes of up to 138% of the federal poverty threshold under the Affordable Care Act as most of these states offer an adult dental benefit. |
Did the 2009 American Recovery and Reinvestment Act affect dietary intake of low-income individuals?
Waehrer G , Deb P , Decker SL . Econ Hum Biol 2015 19 170-183 This paper examines the relationship between increased Supplemental Nutritional Assistance Program (SNAP) benefits following the 2009 American Recovery and Reinvestment Act (ARRA) and the diet quality of individuals from SNAP-eligible compared to ineligible (those with somewhat higher income) households using data from the 2007-2010 National Health and Nutrition Examination Survey. The ARRA increased SNAP monthly benefits by 13.6% of the maximum allotment for a given household size, equivalent to an increase of $24 to $144 for one-to-eight person households respectively. In the full sample, we find that these increases in SNAP benefits are not associated with changes in nutrient intake and diet quality. However, among those with no more than a high school education, higher SNAP benefits are associated with a 46% increase in the mean caloric share from sugar-sweetened beverages (SSBs) and a decrease in overall diet quality especially for those at the lower end of the diet quality distribution, amounting to a 9% decline at the 25th percentile. |
ACA provisions associated with increase in percentage of young adult women initiating and completing the HPV vaccine
Lipton BJ , Decker SL . Health Aff (Millwood) 2015 34 (5) 757-64 Affordable Care Act provisions implemented in 2010 required insurance plans to offer dependent coverage to people ages 19-25 and to provide targeted preventive services with zero cost sharing. These provisions both increased the percentage of young adults with any source of health insurance coverage and improved the generosity of coverage. We examined how these provisions affected use of the human papillomavirus (HPV) vaccine, which is among the most expensive of recommended vaccines, among young adult women. Using 2008-12 data from the National Health Interview Survey, we estimated that the 2010 policy implementation increased the likelihood of HPV vaccine initiation and completion by 7.7 and 5.8 percentage points, respectively, for women ages 19-25 relative to a control group of women age 18 or 26. These estimates translate to approximately 1.1 million young women initiating and 854,000 young women completing the vaccine series. |
Acceptance of new Medicaid patients by primary care physicians and experiences with physician availability among children on Medicaid or the Children's Health Insurance Program
Decker SL . Health Serv Res 2015 50 (5) 1508-27 OBJECTIVE: To estimate the relationship between physicians' acceptance of new Medicaid patients and access to health care. DATA SOURCES: The National Ambulatory Medical Care Survey (NAMCS) Electronic Health Records Survey and the National Health Interview Survey (NHIS) 2011/2012. STUDY DESIGN: Linear probability models estimated the relationship between measures of experiences with physician availability among children on Medicaid or the Children's Health Insurance Program (CHIP) from the NHIS and state-level estimates of the percent of primary care physicians accepting new Medicaid patients from the NAMCS, controlling for other factors. PRINCIPAL FINDINGS: Nearly 16 percent of children with a significant health condition or development delay had a doctor's office or clinic indicate that the child's health insurance was not accepted in states with less than 60 percent of physicians accepting new Medicaid patients, compared to less than 4 percent in states with at least 75 percent of physicians accepting new Medicaid patients. Adjusted estimates and estimates for other measures of access to care were similar. CONCLUSIONS: Measures of experiences with physician availability for children on Medicaid/CHIP were generally good, though better in states where more primary care physicians accepted new Medicaid patients. |
The effects of mandated health insurance benefits for autism on out-of-pocket costs and access to treatment
Chatterji P , Decker SL , Markowitz S . J Policy Anal Manage 2015 34 (2) 328-53 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. |
Characteristics of uninsured low-income adults in states expanding vs not expanding Medicaid
Decker SL , Kenney GM , Long SK . JAMA Intern Med 2014 174 (6) 988-9 When the Supreme Court ruled that under the Patient Protection and Affordable Care Act, states could not be compelled to expand Medicaid,1 it opened an unusual divide for public insurance coverage in the United States. Starting January 1, 2014, adults 19 to 64 years with family income up to 138% of the federal poverty line (133% plus a 5% income disregard) became eligible for Medicaid in 25 states and the District of Columbia (expansion states). In the remaining 25 states (nonexpansion states), while adults with incomes between 100% and 138% of the federal poverty line qualify for subsidized insurance coverage through the new marketplaces, those with income below the poverty line will not qualify and therefore are likely to remain uninsured. Previous estimates indicate that more uninsured adults who could have been made Medicaid eligible live in nonexpansion states (8.5 million) than in expansion states (6.6 million).2 | We studied the characteristics of low-income (income no more than 138% of the poverty line) citizens aged 19 to 64 years in expansion and nonexpansion states before the 2014 expansion. We included noncitizens who have been in the United States at least 5 years since some may also be Medicaid eligible.3 We used data from the National Health Interview Survey, 2010–2012,4 the conduct of which was approved by the ethics review board of the National Center for Health Statistics. To describe possible health care needs of low-income adults in the 2 groups of states, we compared several measures of health status and the use of and access to health care reported by respondents to the National Health Interview Survey. Analyses were weighted to the civilian noninstitutionalized population, and SEs accounted for the complex design of the survey (Stata version 12; StataCorp LP). We used t tests (dichotomous variables) and the χ2 test (categorical variables) to infer statistical significance of differences between groups. |
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
Decker SL , Kostova D , Kenney GM , Long SK . JAMA 2013 309 (24) 2579-86 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. |
Two-thirds of primary care physicians accepted new medicaid patients in 2011-12: a baseline to measure future acceptance rates
Decker SL . Health Aff (Millwood) 2013 32 (7) 1183-7 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. |
The Affordable Care Act has led to significant gains in health insurance and access to care for young adults
Sommers BD , Buchmueller T , Decker SL , Carey C , Kronick R . Health Aff (Millwood) 2013 32 (1) 165-74 The Affordable Care Act enables young adults to remain as dependents on their parents' health insurance until age twenty-six, and recent evidence suggests that as many as three million young adults have gained coverage as a result. However, there has been no evidence yet on the policy's effect on access to care, and questions remain about the coverage impact on important subgroups. Using data from two nationally representative surveys, comparing young adults who gained access to dependent coverage to a control group (adults ages 26-34) who were not affected by the new policy, we found sizable coverage gains for adults ages 19-25. The gains continued to grow throughout 2011 (up 6.7 percentage points from September 2010 to September 2011), with the largest gains seen in unmarried adults, nonstudents, and men. Analysis of the timing of the policy impact suggested that early gains in coverage were greatest for people in worse health. We found strong evidence of increased access to care because of the law, with significant reductions in the number of young adults who delayed getting care and in those who did not receive needed care because of cost. |
Experience and education of home health administrators and nursing home administrators and the relationship to establishment ownership
Decker FH , Decker SL . J Health Hum Serv Adm 2012 35 (2) 149-69 Administrators in long-term care may have an important influence on quality of care. Limited prior research has described the characteristics of nursing home administrators. Despite growing emphasis on home health care as an alternative to nursing homes, almost no research has described the characteristics of administrators of home health agencies. Using the 2004 National Nursing Home Survey and the 2007 National Home and Hospice Care Survey, we describe the career experience of administrators, and examine the relationship between experience and education of administrators both within and across the nursing home and home health sectors. We also explore the characteristics of nursing homes and home health agencies, including establishment ownership (e.g., nonchain not-for-profit), that are associated with being able to attract administrators with the most experience. We find that home health administrators have, on average, less experience than nursing home administrators. Among home health agencies, administrators with the least experience also tend to have less education. In nursing homes, administrators with less experience tend to have more education. Results from multivariate analysis suggest that chain for-profits may be the least able to attract experienced administrators. More research on the effects of different levels of experience and education among administrators is needed. |
In 2011 nearly one-third of physicians said they would not accept new medicaid patients, but rising fees may help
Decker SL . Health Aff (Millwood) 2012 31 (8) 1673-9 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. |
Exogenous predictors of national performance measures for emergency department crowding
Pines JM , Decker SL , Hu T . Ann Emerg Med 2012 60 (3) 293-8 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 hospital's 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. |
Health service use among the previously uninsured: is subsidized health insurance enough?
Decker SL , Doshi JA , Knaup AE , Polsky D . Health Econ 2012 21 (10) 1155-68 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. (Copyright (c) 2011 John Wiley & Sons, Ltd.) |
Most physicians were eligible for federal incentives in 2011, but few had EHR systems that met meaningful-use criteria
Hsiao CJ , Decker SL , Hing E , Sisk JE . Health Aff (Millwood) 2012 31 (5) 1100-7 As more physicians adopt electronic health record systems in their practices, policy interest is focusing on whether physicians are ready to meet the federal "meaningful use" criteria-a vital threshold to qualify for financial incentives. In our analysis of a 2011 nationally representative survey of office-based physicians, we found that 91 percent of physicians were eligible for Medicare or Medicaid meaningful-use incentives. About half of all physicians intended to apply. However, only 11 percent both intended to apply for the incentives and had electronic health record systems with the capabilities to support even two-thirds of the stage 1 core objectives required for meaningful use. Although the federal Medicare incentives will be available through 2016, and Medicaid incentives through 2021, widespread gaps in readiness throughout the states illustrate the challenges physicians face in meeting the federal schedule for the incentive programs. |
Physicians in nonprimary care and small practices and those age 55 and older lag in adopting electronic health record systems
Decker SL , Jamoom EW , Sisk JE . Health Aff (Millwood) 2012 31 (5) 1108-14 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. |
Racial differences in dementia care among nursing home residents
Sengupta M , Decker SL , Harris-Kojetin L , Jones A . J Aging Health 2012 24 (4) 711-31 OBJECTIVE: This article aims to describe potential racial differences in dementia care among nursing home residents with dementia. METHODS: Using data from the 2004 National Nursing Home Survey (NNHS) in regression models, the authors examine whether non-Whites are less likely than Whites to receive special dementia care-defined as receiving special dementia care services or being in a dementia special care unit (SCU)-and whether this difference derives from differences in resident or facility characteristics. RESULTS: The authors find that non-Whites are 4.3 percentage points less likely than Whites to receive special dementia care. DISCUSSION: The fact that non-Whites are more likely to rely on Medicaid and less likely to pay out of pocket for nursing home care explains part but not all of the difference. Most of the difference is due to the fact that non-Whites reside in facilities that are less likely to have special dementia care services or dementia care units, particularly for-profit facilities and those in the South. |
Emergency department volume and racial and ethnic differences in waiting times in the United States
Sonnenfeld N , Pitts SR , Schappert SM , Decker SL . Med Care 2012 50 (4) 335-41 BACKGROUND: Racial and ethnic differences in emergency department (ED) waiting times have been observed previously. OBJECTIVES: We explored how adjusting for ED attributes, particularly visit volume, affected racial/ethnic differences in waiting time. RESEARCH DESIGN: We constructed linear models using generalized estimating equations with 2007-2008 National Hospital Ambulatory Medical Care Survey data. SUBJECTS: We analyzed data from 54,819 visits to 431 US EDs. MEASURES: Our dependent variable was waiting time, measured from arrival to time seen by physician, and was log transformed because it was skewed. Primary independent variables were individual race/ethnicity (Hispanic and non-Hispanic white, black, other) and ED race/ethnicity composition (covariates for percentages of Hispanics, blacks, and others). Covariates included patient age, triage assessment, arrival by ambulance, payment source, volume, region, and teaching hospital. RESULTS: Geometric mean waiting times were 27.3, 37.7, and 32.7 minutes for visits by white, black, and Hispanic patients. Patients waited significantly longer at EDs serving higher percentages of black patients; per 25 point increase in percent black patients served, waiting times increased by 23% (unadjusted) and 13% (adjusted). Within EDs, black patients waited 9% (unadjusted) and 4% (adjusted) longer than whites. The ED attribute most strongly associated with waiting times was visit volume. Waiting times were about half as long at low-volume compared with high-volume EDs (P<0.001). For Hispanic patients, differences were smaller and less robust to model choice. CONCLUSIONS: Non-Hispanic black patients wait longer for ED care than whites primarily because of where they receive that care. ED volume may explain some across-ED differences. |
Trends in emergency department visits among Medicaid patients
Sonnenfeld N , Decker SL , Schappert SM . JAMA 2011 306 (11) 1202-3; author reply 1203 Dr Tang and colleagues1 concluded that emergency department (ED) visit rates have been increasing most among Medicaid patients. We believe this conclusion may be unwarranted. The analysis does not appear to have incorporated changes that occurred over the years in the coding of the variable “primary expected source of payment” in the data source used by the authors, the National Hospital Ambulatory Medical Care Survey (NHAMCS) conducted by the National Center for Health Statistics (NCHS). The only information on payment sources that NHAMCS collected from 1997 through 2004 was the primary expected source of payment.2 Starting in 2005, hospital respondents could indicate multiple expected sources of payment per visit and did not designate a primary source. From 2005 through 2007, the data files included separate variables for each expected payment source plus a variable that assigned the primary expected source using a hierarchy with Medicaid first, followed by Medicare, private insurance, worker's compensation, self-payment, and no charge. | We suspect that many hospital respondents from 1997 through 2004 reported Medicare as the primary expected payment source for patients dually eligible for Medicare and Medicaid. It appears that for 2007, Tang et al used NHAMCS’ hierarchical payment variable that classified dual eligibles as having Medicaid. This approach led to a report of ED visit rates between 1997 and 2007 that increased by 36.5% for adult patients with Medicaid and decreased by 2.5% for Medicare (Table in the article). We recomputed the number of visits by coding the primary payment source for dually eligible patients as Medicare instead of Medicaid for 2007. Using information in the Table1 to generate denominators for the visit rate, the estimated number of ED visits for Medicaid patients would be 14.2 million and the visit rate 759.9 per 1000; for Medicare, the number of visits would be 19.9 million and the visit rate 485.9 per 1000. Therefore, the visit rate for adults from 1997 through 2007 would increase 9.5% for Medicaid and 17.6% for Medicare. These latter estimates may be more realistic than those presented by Tang et al. |
Medicaid payment levels to dentists and access to dental care among children and adolescents
Decker SL . JAMA 2011 306 (2) 187-93 CONTEXT: Although Medicaid removes most financial barriers to receipt of dental care among children and adolescents, Medicaid recipients may not be able to access dental care if dentists decline to participate in Medicaid because of low payment levels or other reasons. OBJECTIVE: To describe the association between state Medicaid dental fees in 2 years (2000 and 2008) and children's receipt of dental care. DESIGN, SETTING, AND PARTICIPANTS: Data on Medicaid dental fees in 2000 and 2008 for 42 states plus the District of Columbia were merged with data from 33,657 children and adolescents (aged 2-17 years) in the National Health Interview Survey (NHIS) for the years 2000-2001 and 2008-2009. Logit models were used to estimate the probability that children and adolescents had seen a dentist in the past 6 months as a function of the Medicaid prophylaxis fee and control variables including age group, race, poverty status, and state and year effects. The effect of fees on children with Medicaid relative to a control group, privately insured counterparts, served to separate Medicaid's effect on access to care from any correlation between the Medicaid fee or changes in fees by state and other attributes of states. MAIN OUTCOME MEASURE: Whether a child or adolescent had seen a dentist in the past 6 months. RESULTS: On average, Medicaid dental payment levels did not change significantly in inflation-adjusted terms between 2000 and 2008, although a difference existed for some states, including in 5 states plus the District of Columbia, where payments increased at least 50%. In 2008-2009, more children and adolescents covered by Medicaid (55%, 95% confidence interval [CI], 53%-57%) had seen a dentist in the past 6 months than did uninsured children (27%, 95% CI, 24%-30%), but fewer than children covered by private insurance (68%, 95% CI, 67%-70%). Changes in state Medicaid dental payment fees between 2000 and 2008 were positively associated with use of dental care among children and adolescents covered by Medicaid. For example, a $10 increase in the Medicaid prophylaxis payment level (from $20 to $30) was associated with a 3.92 percentage point (95% CI, 0.54-7.50) increase in the chance that a child or adolescent covered by Medicaid had seen a dentist. CONCLUSION: Higher Medicaid payment levels to dentists were associated with higher rates of receipt of dental care among children and adolescents. |
Decline in the United States black preterm/low birth weight rate in the 1990s: can the economic boom explain it?
Schempf AH , Decker SL . Ann Epidemiol 2010 20 (11) 862-7 PURPOSE: Macroeconomic improvements have been posited as an explanation of the decline in the Black preterm birth rate during the 1990s. This study assessed whether decreasing unemployment explained the decline in preterm, low birth weight births (PT-LBW) for Black women. METHODS: United States singleton births to non-Hispanic Black women ages 18 and over, conceived between 1990 and 2001, were pooled to examine PT-LBW trends by level of social advantage (approximated by education and marital status). The impact of the state-level unemployment rate in the first and second trimester of pregnancy was evaluated in multiple logistic regression models. RESULTS: During the 1990s, PT-LBW declined 11% among disadvantaged (unmarried, less than high school educated) Black women. Although the unemployment rate and PT-LBW were positively related, decreases in unemployment did not explain the decline in PT-LBW. Instead, improvements in prenatal care utilization and smoking behavior largely accounted for the temporal trend. CONCLUSIONS: Macroeconomic improvements, measured by unemployment, only marginally contributed to the Black PT-LBW trend in the 1990s. To effect further reductions, future studies should investigate other possible determinants of the proximate behavioral changes that did explain the trend (e.g., Earned Income Tax Credit expansions, increased, cigarette taxes/smoking legislation). |
Antipsychotic and benzodiazepine use among nursing home residents: findings from the 2004 National Nursing Home Survey
Stevenson DG , Decker SL , Dwyer LL , Huskamp HA , Grabowski DC , Metzger ED , Mitchell SL . Am J Geriatr Psychiatry 2010 18 (12) 1078-92 OBJECTIVES: To document the extent and appropriateness of use of antipsychotics and benzodiazepines among nursing home residents using a nationally representative survey. METHODS: Cross-sectional analysis of the 2004 National Nursing Home Survey. Bivariate and multivariate analyses examined relationships between resident and facility characteristics and antipsychotic and benzodiazepine use by appropriateness classification among residents aged 60 years and older (N = 12,090). Resident diagnoses and information about behavioral problems were used to categorize antipsychotic and benzodiazepine use as appropriate, potentially appropriate, or having no appropriate indication. RESULTS: More than one quarter (26%) of nursing home residents used an antipsychotic medication, 40% of whom had no appropriate indication for such use. Among the 13% of residents who took benzodiazepines, 42% had no appropriate indication. In adjusted analyses, the odds of residents taking an antipsychotic without an appropriate indication were highest for residents with diagnoses of depression (odds ratio [OR] = 1.31; 95% confidence interval [CI]: 1.12-1.53), dementia (OR = 1.82; 95% CI: 1.52-2.18), and with behavioral symptoms (OR = 1.97, 95% CI: 1.56-2.50). The odds of potentially inappropriate antipsychotic use increased as the percentage of Medicaid residents in a facility increased (OR = 1.08, 95% CI: 1.02-1.15) and decreased as the percentage of Medicare residents increased (OR = 0.46, 95% CI: 0.25-0.83). The odds of taking a benzodiazepine without an appropriate indication were highest among residents who were female (OR = 1.44; 95% CI: 1.18-1.75), white (OR = 1.95; 95% CI: 1.47-2.60), and had behavioral symptoms (OR = 1.69; 95% CI: 1.41-2.01). CONCLUSION: Antipsychotics and benzodiazepines seem to be commonly prescribed to residents lacking an appropriate indication for their use. |
Population aging and the use of office-based physician services
Cherry D , Lucas C , Decker SL . NCHS Data Brief 2010 (41) 1-8 KEY FINDINGS: From 1998 to 2008, the proportion of physician office-based visits in the United States became increasingly concentrated on those aged 45 and over. The intensity of physician office visits, as measured by medications prescribed or continued, imaging tests ordered or provided, and time spent with physicians, also became increasingly concentrated on those aged 45 and over. Although most physicians accept Medicare patients, acceptance of Medicare was higher among ophthalmologists and general surgeons than among general or family practitioners, internists, and psychiatrists. Over the past 30 years, the specialty concentration of visits has shifted significantly. In 1978, 62 percent of visits by patients aged 65 and over were to primary care physicians compared with 45 percent in 2008. The percentage of visits to physicians with a medical or surgical specialty increased from 37 percent to 55 percent. |
Changes in Medicaid physician fees and patterns of ambulatory care
Decker SL . Inquiry 2009 46 (3) 291-304 Controlling for state fixed effects and other factors, this paper estimates the effect of the generosity of Medicaid physician payment levels on the volume and site of ambulatory care received by Medicaid patients compared to privately insured patients. Results indicate that cuts in Medicaid physician fees lead to statistically significant reductions in the number of visits for Medicaid patients compared to privately insured patients. Cuts in fees also lead to a statistically significant shift away from physician offices and toward hospital emergency departments and especially outpatient departments. Primary diagnoses for which site of care shifts are most pronounced include hypertension, asthma, urinary tract infections, and diabetes. |
Trends in diabetes treatment patterns among primary care providers
Decker SL , Burt CW , Sisk JE . J Ambul Care Manage 2009 32 (4) 333-341 Using data from the National Ambulatory Medical Care Survey, logit models tested for trends in the probability that visits by adult diabetes patients to their primary care providers included recommended treatment measures, such as a prescription for an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-II receptor blocker (ARB), blood pressure measurement, and diet/nutrition or exercise counseling. Results indicated that the probability that visits included prescription of an ACE or ARB and blood pressure measurement increased significantly over the 1997-2005 period, while the probability that visits documented provision of exercise counseling rose since 2001. |
Demographic and social characteristics and spending at the end of life
Shugarman LR , Decker SL , Bercovitz A . J Pain Symptom Manage 2009 38 (1) 15-26 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. |
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