The care of HIV-infected adults in rural areas of the United States.

OBJECTIVE: This study describes the population of HIV-infected adults receiving care in rural areas of the United States and compares HIV care received in rural and urban areas. METHODS: Interviews were conducted with a nationally representative sample of 367 HIV-infected adults receiving health care in rural areas and 2806 HIV-infected adults receiving health care in urban areas of the contiguous United States. RESULTS: We estimate that 4800 HIV-infected persons received medical care in rural areas during the first half of 1996. Patients in rural HIV care were more likely than patients in urban HIV care to receive care from providers seeing few (<10) HIV-infected patients (38% vs. 3%; p <.001). Rural care patients were less likely than urban care patients to have taken highly active antiretroviral agents (57% vs. 73%; p <.001) or Pneumocystis carinii pneumonia prophylactic medication when indicated (60% vs. 75%; p =.006). CONCLUSIONS: Few American adults received HIV care in rural areas of the United States. Our findings suggest ongoing disparities between urban and rural areas in access to high-quality HIV care.

The concentration of health care expenditures, revisited.

In two previous publications, we described the distribution of health care expenditures among the civilian, noninstitutionalized U.S. population, specifically in terms of the share of aggregate expenditures accounted for by the top spenders in the distribution. Our focus revealed considerably skewed distribution, with a relatively small proportion of the population accounting for a large share of expenditures. In this paper we update our previous tabulations (last computed using data more than a decade old) with new data from the 1996 Medical Expenditure Panel Survey (MEPS). Our findings show that the skewed concentration of health care expenditures has remained very stable; 5 percent of the population accounts for the majority of health expenditures.

The effect of fear on access to care among undocumented Latino immigrants.

The passage of California's Proposition 187 in 1994 intensified debate over health care access for the undocumented population. Under Proposition 187, physicians would have been required to report the undocumented immigrants to immigration authorities. Even before 187, some undocumented may have been wary to come in contact with the medical care system. This paper examines whether concerns about one's immigration status serves as a deterrent to seeking care. These concerns may be resurfacing, with changes under the 1996 welfare reform legislation and related amendments that affect eligibility of non-citizen immigrants for public programs and states' ability to provide care to undocumented immigrants. Therefore, representative in-person surveys of undocumented Latinos were conducted in Houston, El Paso, Fresno, and Los Angeles in neighborhoods with significant concentrations of Latinos. It was found that 39% of the undocumented adult immigrants expressed fear about receiving medical services because of undocumented status. Those reporting fear were likelier to report inability acquiring medical and dental care, prescription drugs, and eyeglasses. Hence it can be concluded that concern about immigration status decreases the likelihood of receiving care.

Health care use among undocumented Latino immigrants.

Using data from a 1996/1997 survey of undocumented Latino immigrants in four sites, we examine reasons for coming to the United States, use of health care services, and participation in government programs. We find that undocumented Latinos come to this country primarily for jobs. Their ambulatory health care use is low compared with that of all Latinos and all persons nationally, and their rates of hospitalization are comparable except for hospitalization for childbirth. Almost half of married undocumented Latinos have a child who is a U.S. citizen. Excluding undocumented immigrants from receiving government-funded health care services is unlikely to reduce the level of immigration and likely to affect the well-being of children who are U.S. citizens living in immigrant households.

National probability samples in studies of low-prevalence diseases. Part I: Perspectives and lessons from the HIV cost and services utilization study.

OBJECTIVE: To examine the trade-offs inherent in selecting a sample design for a national study of care for an uncommon disease, and the adaptations, opportunities and costs associated with the choice of national probability sampling in a study of HIV/AIDS. SETTING: A consortium of public and private funders, research organizations, community advocates, and local providers assembled to design and execute the study. DESIGN: Data collected by providers or collected for administrative purposes are limited by selectivity and concerns about validity. In studies based on convenience sampling, generalizability is uncertain. Multistage probability sampling through households may not produce sufficient cases of diseases that are not highly prevalent. In such cases, an attractive alternative design is multistage probability sampling through sites of care, in which all persons in the reference population have some chance of random selection through their medical providers, and in which included subjects are selected with known probability. DATA COLLECTION AND PRINCIPAL FINDINGS: Multistage national probability sampling through providers supplies uniquely valuable information, but will not represent populations not receiving medical care and may not provide sufficient cases in subpopulations of interest. Factors contributing to the substantial cost of such a design include the need to develop a sampling frame, the problems associated with recruitment of providers and subjects through medical providers, the need for buy-in from persons affected by the disease and their medical practitioners, as well as the need for a high participation rate. Broad representation from the national community of scholars with relevant expertise is desirable. Special problems are associated with organization of the research effort, with instrument development, and with data analysis and dissemination in such a consortium. CONCLUSIONS: Multistage probability sampling through providers can provide unbiased, nationally representative data on persons receiving regular medical care for uncommon diseases and can improve our ability to accurately study care and its outcomes for diseases such as HIV/AIDS. However, substantial costs and special circumstances are associated with the implementation of such efforts.

Unmet need for eyeglasses: results from the 1994 Robert Wood Johnson Access to Care Survey.

BACKGROUND: Although poor access to general medical care services has been documented widely, the unmet need for supplemental health care services--such as eyeglasses--has been largely ignored. This article documents the inability to obtain eyeglasses on the national level and for various subpopulations using the 1994 Robert Wood Johnson Foundation National Access to Care Survey. METHODS: The Survey, a followup to the 1993 National Health Interview Survey, collected data on respondents' inability to obtain health care services due to access barriers. The sample comprised 3,480 observations, weighted to represent the U.S. civilian non-institutionalized population. RESULTS: More than 5% of the U.S. population reported an unmet need for eyeglasses, and of these, more than 80% cited financial reasons as the primary barrier. Persons in poor health and blacks were most likely to face barriers to obtaining eyeglasses. CONCLUSION: Understanding this under-served population and their unmet needs can help policymakers formulate new initiatives. The focus on preventive care within managed care organizations may ease some barriers for the insured population. Policy should focus on uninsured and underinsured working individuals who cannot afford and do not receive public assistance for needed eye care.

Why primary care physicians join HMOs.

OBJECTIVE: To determine the reasons why primary care physicians affiliate with health maintenance organizations (HMOs) and assess how these reasons vary with personal and practice characteristics. STUDY DESIGN: A 1996 national telephone/mail survey of primary care physicians who were affiliated with at least 1 HMO plan for more than 9 months. METHODS: Survey responses were assessed according to geographic region, age, income, level of involvement in managed care, and HMO penetration rate. The sample consisted of 210 primary care physicians who played a role in the decision to affiliate. RESULTS: The overwhelming reason primary care physicians affiliated with an HMO was to retain patients. Eighty-three percent reported this as one of the reasons for affiliating and 59% reported it as the primary reason. Physicians with the greatest portion of income from managed care and physicians practicing in areas with high HMO penetration were most likely to report quality of life issues--such as more personal time, more predictable work hours, or reduced administrative burden--as the rationale for HMO plan affiliation. CONCLUSIONS: These findings support the view that the majority of HMO-affiliated physicians join HMOs to avoid a perceived penalty associated with lack of affiliation, rather than for positive reasons. The data also suggest that physicians with managed care experience affiliate more often for quality of life reasons.

The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium.

BACKGROUND AND METHODS: In order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas. RESULTS: During the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men who had had sex with men. Forty-six percent had incomes of less than $10,000 per year, 68 percent had public health insurance or no insurance, and 30 percent received care at teaching institutions. The estimated annual direct expenditures for the care of the patients seen during the first two months of 1996 were $5.1 billion; the expenditures for the estimated 335,000 HIV-infected adults seen at least as often as every six months were $6.7 billion, which is about $20,000 per patient per year. CONCLUSIONS: In this national survey we found that most HIV-infected adults who were receiving medical care had advanced disease. The patient population was disproportionately male, black, and poor. Many Americans with diagnosed or undiagnosed HIV infection are not receiving medical care at least as often as every six months. The total cost of medical care for HIV-infected Americans accounts for less than 1 percent of all direct personal health expenditures in the United States.

Access to care: how much difference does Medicaid make?

Using the 1994 Robert Wood Johnson Foundation National Access to Care Survey, we examine the likelihood of having a usual source of care, inability to obtain needed care, and number of physician visits for persons with private insurance, Medicaid coverage, and no insurance. Inability to obtain services is surprisingly consistent: For each service, Medicaid enrollees were about half as likely as uninsured persons and about twice as likely as privately insured persons were to report difficulty. For other access measures, access for those on Medicaid more closely resembles that of the privately insured than that of the uninsured.

Choice of health plan: implications for access and satisfaction.

In this article, the authors examine why low-income persons choose a managed care plan and the effects of choice on access and satisfaction, using data from the 1995-96 Kaiser/Commonwealth Five-State Low-Income Survey. Two-thirds of those choosing a managed care plan cited costs or benefits as their primary reason. Logistic regressions indicate that choice of plan had a neutral or positive effect on access and satisfaction. Medicaid enrollees with choice were less likely than those without to have difficulty obtaining particular services, more likely to rate plan quality highly, and less likely to report major problems with plan rules.

The growth in the US uninsured population: trends in Hispanic subgroups, 1977 to 1992.

This paper presents trends in the growth in the US uninsured population, using cross-sectional national estimates from 1977, 1987, 1989, and 1992 and focusing specifically on coverage problems experienced by Hispanic Americans. An examination of the composition of uninsured persons added between 1977 and 1992 shows that almost 40% of the difference is accounted for by persons of Hispanic origin, with those of Mexican origin alone constituting 27%. In addition, the annual average rate of growth in the uninsured Hispanic population between 1977 and 1992 was 9.7%, compared with only 2.3% for the uninsured non-Hispanic population.

Can survey data be used to estimate physician practice costs?

Health policy makers rely on survey estimates of physician practice costs to set reimbursement rates. The Health Care Financing Administration has just funded a multimillion dollar effort to collect survey data that will be used to revise payments under the Medicare Fee Schedule. However, the ability of large-scale physician surveys to obtain accurate information about practice costs is not apparent. This article examines several of the key obstacles encountered when trying to obtain accurate estimates. Rates of both unit and item nonresponse over time are described; in general, there is a trend toward lower unit response rates and higher item response rates. The article also examines logical inconsistencies in data. The results suggest that physician surveys may not be the most appropriate source of data about physician practice expenses. Health policy makers concerned about provider reimbursement issues should seriously scrutinize the accuracy of results from physician practice cost surveys. This article concludes by suggesting alternative methodologies for incorporating physician practice costs into reimbursement rates.

Health care use by Hispanic adults: financial vs. non-financial determinants.

The purpose of this article is to assess the relative effects of financial and cultural factors, namely language spoken, on health care use by Hispanic adults. Using a national sample, we examine the determinants of having a usual source of care (USOC), use of physician visits, and likelihood of having blood pressure checked. Multivariate analysis reveals the following: Monolingual Spanish speakers were not significantly different from English speakers for the three dependent variables; having private insurance or Medicaid was positively related to all three dependent variables. We conclude that financial factors--primarily insurance--remain as the paramount barriers to care.

Profile of HIV disease in an American border city.

A previous study on patterns of migration of HIV-infected persons suggested that most patients in a rural setting in eastern Tennessee acquired their disease in an urban area, typically during a period of prolonged residence. Disease and disability were the most common reasons for returning to their hometown. We studied our urban, border-city HIV clinic population to see whether similar patterns of migration were discernible. Fifty-one of the 103 patients studied lived outside the El Paso/Juarez area when they contracted HIV infection. The major reason cited for returning home was a desire to return to family (25%). Those who returned and those who had never left showed no statistically significant difference in age, race, or risk factors. This study suggests that migration of HIV-infected patients back to their hometown does not appear to be an exclusively rural phenomenon.

Ability to obtain health care: recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey.

This DataWatch presents findings on Americans' ability to obtain health care. Data from the 1994 National Access to Care Survey sponsored by The Robert Wood Johnson Foundation suggest that earlier studies have underestimated the access problems facing Americans by not asking about supplementary services such as prescription drugs, eyeglasses, dental care, and mental health care or counseling. Using this more inclusive definition of health care needs, we estimate that 16.1 percent of Americans were unable to obtain at least one service they believed they needed. While income is highly correlated with unmet need, most persons reporting access problems are not poor.

Local and commissural neuropeptide-containing projections of the nucleus of the solitary tract to the dorsal vagal complex in the pigeon.

The neuropeptide content of neurons of the nucleus of the solitary tract (NTS), which have local and commissural projections to the dorsal motor nucleus of the vagus (DMNX) and to NTS, were demonstrated in the pigeon (Columba livia) by using a combined fluorescein-bead retrograde-transport-immunofluorescence technique. The specific peptides studied were bombesin, cholecystokinin, enkephalin, galanin, neuropeptide Y, neurotensin, and substance P. Perikarya immunoreactive for bombesin were located in medial tier subnuclei of NTS and the caudal NTS. Most galanin- and substance P-immunoreactive cells were found in subnucleus medialis ventralis. Cells immunoreactive for neuropeptide Y were found in the medial tier of NTS and in the lateral tier, especially in subnucleus lateralis dorsalis intermedius. The majority of enkephalin- and neurotensin-immunoreactive cells were found centrally in subnuclei medialis dorsalis and medialis intermedius. Cells immunoreactive for cholecystokinin were located in subnuclei lateralis dorsalis pars anterior, medialis superficialis, and the caudal NTS. Based on the presence of retrogradely labeled cells, numerous neurons of the medial tier of NTS, but extremely few lateral tier NTS neurons, had projections to the ipsilateral and contralateral DMNX and NTS. The number of retrogradely labeled NTS cells was always greater ipsilaterally than contralaterally. The percentages of peptide-immunoreactive NTS cells that projected to the ipsilateral and contralateral DMNX were in the ranges of 29-61% and 10-48%, respectively. The percentages of peptide-immunoreactive NTS cells that projected to the contralateral NTS ranged from 13 to 60%. Peptide-immunoreactive NTS cells that have local and commissural projections to DMNX and NTS may act as interneurons in vagovagal reflex pathways and in the integration of visceral sensory and forebrain input to NTS and DMNX.

Nucleus of the solitary tract and dorsal motor nucleus of the vagus nerve of the pigeon: localization of peptide and 5-hydroxytryptamine immunoreactive fibers.

The distribution of peptide and serotonin fibers in the nucleus of the solitary tract (NTS) and the dorsal motor nucleus of the vagus nerve (DMNX) in the pigeon (Columba livia) was investigated immunocytochemically. This information was correlated with the viscerotopic organization of the nuclei and with central NTS circuitry to suggest the role of the neurochemical containing fibers in the regulation of organ function. The distribution of fibers containing cholecystokinin (CCK), calcitonin gene-related peptide (CGRP), enkephalin (ENK), neuropeptide Y (NPY), neurotensin (NT), substance P (SP), somatostatin (SS), vasoactive intestinal peptide (VIP), and 5-hydroxytryptamine (5-HT) was determined. Each substance had a distinct distribution within the subnuclei of NTS-DMNX, but certain generalities can be deduced. In the DMNX, fibers immunoreactive for ENK, NT, and SP were found in greatest concentration, while CGRP and 5-HT immunoreactive fibers were the least dense. This suggests that ENK, NT, and SP may have a significant modulatory effect on gastrointestinal functions. In the NTS overall, ENK, NT, SP, and VIP fibers were found in high density, CCK, NPY, SS, and 5-HT fibers were found in moderate density, and CGRP fibers were found in low density. However, some individual NTS subnuclei were found to contain moderate to high concentrations of each of the substances, including CGRP. Fibers containing CCK, ENK, NT, SP, SS, and VIP in the medial dorsal NTS subnuclei may regulate gastroesophageal functions. The caudal part of subnucleus lateralis parasolitarius did not contain most of the substances, which suggests that pulmonary function is not modulated by these neurochemicals. The boundaries of a subnucleus could sometimes be demarcated by a change in density of immunoreactive fibers between adjacent subnuclei. This was particularly evident in NTS subnuclei medialis dorsalis anterior centralis and lateralis parasolitarius, and in DMNX subnucleus posterior dorsalis magnocellularis. The selective distribution of peptide and serotonin immunoreactive fibers in various subnuclei of NTS-DMNX suggests that these substances may be differentially involved in neural circuits that mediate cardiovascular and gastrointestinal functions.