Impact of Medicare Part D on coverage, access, and disparities among new jersey seniors.

The authors used a population-based survey of New Jersey residents to assess outcomes associated with implementation of the Medicare Part D program. Between 2001 and 2009, there was a 24% increase in prescription drug coverage among elderly individuals, but also an increase in cost-related access problems. Compared with the pre-Part D period, seniors reporting access problems post-Part D were less likely to be uninsured and more likely to be publicly insured. Cost-related access disparities among elderly Blacks and Hispanics relative to elderly Whites persisted from 2001 to 2009, and were partly driven by ongoing disparities related to low income. Such cost-based access problems 3 years into implementation implies that they are not transitory and may reflect inadequate subsidy levels alongside the importance of physician advice about prescriptions in ensuring low-cost medication options for vulnerable patients. Finally, the findings, may also reflect success in enrolling high-need seniors into Part D.

Post-discharge follow-up visits and hospital utilization by Medicare patients, 2007-2010.

OBJECTIVE: Document trends in time to post-discharge follow-up visit for Medicare patients with an index admission for heart failure (HF), acute myocardial infarction (AMI), or community-acquired pneumonia (CAP). Determine factors predicting whether the first post-discharge utilization event is a follow-up visit, treat-and-release emergency department (ED) visit, or readmission. METHODS: Using Medicare claims data from 2007-2010, we plotted annual cumulative incidence functions for the time frame post-discharge to follow-up visit, accounting for competing risks with censoring at 30 days. We used multinomial probit regression to determine factors predicting the probability of first-occurring post-discharge utilization events within 30 days. RESULTS: For each cohort, the cumulative incidence of follow-up visits increased during the study period. For example, in 2010, 54.6% of HF patients had a follow-up visit within 10 days of discharge compared to 47.9% in 2007. Within each cohort, the largest increase in follow-up visits took place between 2008 and 2009. Follow-up visits were less likely for patients who were Black, Hispanic, and enrolled in Medicaid or Medicare Advantage, and they were more likely for patients with greater comorbidities and prior procedures as well as those with private or supplemental Medicare coverage. There were no changes in 30-day readmission rates. DISCUSSION: Although increases in follow-up visits may have been influenced by the introduction of publicly reported readmission rates in 2009, these increases did not continue in 2010 and were not associated with a change in readmissions. Patients who were Black, Hispanic, and/or enrolled in Medicaid or Medicare Advantage were less likely to have follow-up visits.

Reasons for unmet need for child and family health services among children with special health care needs with and without medical homes.

OBJECTIVES: Medical homes, an important component of U.S. health reform, were first developed to help families of children with special health care needs (CSHCN) find and coordinate services, and reduce their children's unmet need for health services. We hypothesize that CSHCN lacking medical homes are more likely than those with medical homes to report health system delivery or coverage problems as the specific reasons for unmet need. METHODS: Data are from the 2005-2006 National Survey of Children with Special Health Care Needs (NS-CSHCN), a national, population-based survey of 40,723 CSHCN. We studied whether lacking a medical home was associated with 9 specific reasons for unmet need for 11 types of medical services, controlling for health insurance, child's health, and sociodemographic characteristics. RESULTS: Weighted to the national population, 17% of CSHCN reported at least one unmet health service need in the previous year. CSHCN without medical homes were 2 to 3 times as likely to report unmet need for child or family health services, and more likely to report no referral (OR= 3.3), dissatisfaction with provider (OR=2.5), service not available in area (OR= 2.1), can't find provider who accepts insurance (OR=1.8), and health plan problems (OR=1.4) as reasons for unmet need (all p<0.05). CONCLUSIONS: CSHCN without medical homes were more likely than those with medical homes to report health system delivery or coverage reasons for unmet child health service needs. Attributable risk estimates suggest that if the 50% of CSHCN who lacked medical homes had one, overall unmet need for child health services could be reduced by as much as 35% and unmet need for family health services by 40%.

Race, education, and the treatment of depression in nursing homes.

OBJECTIVES: We investigate, among older adult nursing home residents diagnosed with depression, whether depression treatment differs by race and schooling, and whether differences by schooling differ by race. We examine whether Blacks and less educated residents are placed in facilities providing less treatment, and whether differences reflect disparities in care. METHOD: Data from the 2006 Nursing Home Minimum Data Set for 8 states (n = 124,431), are merged with facility information from the Online Survey Certification and Reporting system. Logistic regressions examine whether resident and/or facility characteristics explain treatment differences; treatment includes antidepressants and/or psychotherapy. RESULTS: Blacks receive less treatment (adj. OR = .79); differences by education are small. Facilities with more Medicaid enrollees, fewer high school graduates, or more Blacks provide less treatment. DISCUSSION: We found disparities at the resident and facility level. Facilities serving a low-SES (socioeconomic status), minority clientele tend to provide less depression care, but Blacks also receive less depression treatment than Whites within nursing homes (NHs).

Unmet need, cost burden, and communication problems in SCHIP by special health care needs status.

Children with special health care needs (CSHCN) require more health care than other children; hence adequate health insurance is critical. The Maternal and Child Health Bureau defined three components of adequacy: (1) coverage of needed benefits and services; (2) reasonable costs; and (3) ability to see needed providers. This study compares cost burden, access to care, and patient/provider communication within New Jersey's SCHIP for CSHCN versus those without such needs. We used data from the 2003 NJ FamilyCare (NJFC) Supplement to the New Jersey Family Health Survey on 444 children enrolled in NJFC and 145 children disenrolled from NJFC but covered by other insurance at the time of the survey. The CSHCN Screener was used to identify CSHCN. CSHCN in NJFC had 1.5 times the odds of an unmet need for health care; 2.7 times the odds of a cost burden; and 2.2 times the odds of any coverage or service inadequacy than those without SHCN, even when demographic factors and NJFC plan level (which is based on income) were taken into account. CSHCN enrolled in NJFC have more difficulties in some areas of access to care and cost burden. Patterns of access to care, cost burden, and patient/provider communication were similar for children formerly in NJFC who had other types of insurance at the time of the survey. Future studies should use comprehensive measures of adequacy of coverage, including attitudinal, structural and economic perspectives.

Patient preference for emergency care: can and should it be changed?

The authors use a statewide survey to examine care seeking behavior in the emergency department (ED). Most patients who go to the ED (69.3%) do so mainly for conditions they believe are urgent. Time before seeking ED care is highly variable from immediately (28.7%) to more than 1 week (7.0%) and is only weakly related to the perceived urgency of medical condition. Healthier individuals initiate ED care more rapidly than sicker patients. In retrospect, 80.4% of patients would go to the same ED if they had the same medical episode but this percentage falls substantially with increased ED waiting time. Subject to some limitations uncovered in model specification tests, the study highlights several correlates of ED care seeking behavior that may be useful for designing strategies to divert some patients away from the ED. It also raises larger questions, however, about whether diversion is optimal from patient and health system perspectives.

No longer undertreated? Depression diagnosis and antidepressant therapy in elderly long-stay nursing home residents, 1999 to 2007.

OBJECTIVES: To examine the evolution of depression identification and use of antidepressants in elderly long-stay nursing home residents from 1999 through 2007 and the associated sociodemographic and facility characteristics. DESIGN: Annual cross-sectional analysis of merged resident assessment data from the Minimum Data Set (MDS) and facility characteristics from the Online Survey Certification and Reporting data. SETTING: Nursing homes in eight states (5,445 facilities). PARTICIPANTS: Long-stay nursing home residents aged 65 and older (2,564,687 assessments). MEASUREMENTS: Physician-documented depression diagnoses recorded in the MDS were used to identify residents with depression; antidepressant use was measured using MDS information about residents' receipt of an antidepressant in the 7 days before assessment. RESULTS: Diagnosis of depression and antidepressant therapy in residents diagnosed increased at a rapid rate. By 2007, 51.8% of residents were diagnosed with depression, 82.8% of whom received an antidepressant. Adjusted odds of treatment were higher for younger residents, whites, and those with moderate impairment of cognitive function. CONCLUSION: This study demonstrates striking increases in depression diagnosis and treatment with antidepressant medications, but disparities persist without clear evidence about underlying mechanisms. More research is needed to assess effectiveness of antidepressant prescribing.

Parental eligibility and enrollment in state children's health insurance program: the roles of parental health, employment, and family structure.

We examined eligibility and enrollment among parents of children in New Jersey's State Children's Health Insurance Program following expansion of parental eligibility for NJ FamilyCare coverage. Data were from the 2003 NJ FamilyCare Family Health Survey (n = 416 families). Parental eligibility was higher in households without a full-time employed parent (odds ratio [OR] = 5.50; 95% confidence interval [CI] = 2.72, 11.14) and lower among single parents (OR = 0.38; 95% CI = 0.23, 0.61). Enrollment was higher among single parents (OR = 2.24; 95% CI = 1.17, 4.31). Roughly one third of eligible parents did not enroll, suggesting the need to increase awareness of parental eligibility and reduce barriers to enrollment.

Assessing medication exposures and outcomes in the frail elderly: assessing research challenges in nursing home pharmacotherapy.

BACKGROUND: Large administrative datasets such as Medicare and Medicaid claims have much potential utility in clinical and comparative effectiveness (CE) studies. Among their advantages are the inclusion of clinically heterogeneous populations, without exclusions typical in clinical trials; the ability to study extremely large study populations with power to examine differential outcomes across individual drugs, treatment effect modification, and the risk of uncommon outcomes. However, claims data by themselves are subject to many limitations, notably, in their lack of information on such clinical characteristics as functional status, behaviors, and symptoms, which are important both as outcomes and as covariates. METHODS: We describe data from multiple sources including standardized, electronically recorded clinical and functional data from the Nursing Home (NH) Minimum Data Set; prescription drug data from Medicaid and Medicare claims; and facility data. We present the strengths and challenges of using merged data about the NH population to study prescription drug exposures and outcomes in the frail elderly, and suggest strategies to address methodological difficulties. RESULTS: Merged data from NH sources can support unique study designs in CE research and provide great power. However, given the differing longitudinal structure, timing of observations, and other complex features of the underlying data sources, such studies pose many challenging design and analytic issues. CONCLUSIONS: Integrated data on the NH population have great potential for CE research among frail elderly persons, if methodological and measurement challenges can be adequately addressed.

Is there differential retention of children with special health care needs in the State Children's Health Insurance Program?

OBJECTIVE: The purpose of this work was to determine whether children with special health care needs in New Jersey's State Children's Health Insurance Program are less likely to become uninsured than children without special health care needs. PATIENTS AND METHODS: We used the 2003 New Jersey FamilyCare Supplement to the New Jersey Family Health Survey. Children were randomly selected from the universe of children enrolled in New Jersey FamilyCare as of May 2002, and their families were surveyed during 2003 (N = 675). The Children With Special Health Care Needs Screener was used to identify 5 types of special health care needs. We estimated multinomial logistic regression models of final enrollment status according to the presence of > or = 1 special health care need, controlling for demographic characteristics. RESULTS: Roughly 1 of every 5 children in New Jersey FamilyCare had > or = 1 special health care need. Older children and boys had greater odds of having special health care needs than others. Children with special health care needs had only one fourth the odds of becoming disenrolled and uninsured compared with children without special health care needs, even when controlling for age, gender, race/ethnicity, and insurance plan level. There was no difference in likelihood of finding other health insurance according to children with special health care needs status. CONCLUSIONS: Children with special health care needs were more likely than children without such needs to be covered by health insurance at the time of the survey, either by retaining State Children's Health Insurance Program coverage or by finding other insurance. The higher retention of children with special health care needs in New Jersey FamilyCare is good news for families of these children and their advocates. However, higher health care costs for these children should be considered in federal and state budget planning for the State Children's Health Insurance Program.

Creating needs-based tiered models for assisted living reimbursement.

PURPOSE: This research provides state policy makers and others interested in developing needs-based reimbursement models for Medicaid-funded assisted living with an evaluation of different methodologies that affect the structure and outcomes of these models. DESIGN AND METHODS: We used assessment data from Medicaid-enrolled assisted living residents and waiver-eligible community-dwelling individuals (N = 726) in order to evaluate five methodologies in the design of these tiered needs-based models. We used ordinary least squares regression analyses in order to evaluate each model's ability to predict the time needed to care for individuals with varying needs (e.g., activities of daily living limitations, dementia, special services.) RESULTS: These models varied in fit from .127 to a high of .357 using the adjusted R2 statistic. Both count and weighted models adequately predicted service needs and discriminated individuals into their appropriate tiers well. Weighted models with the largest score range worked best and provided more flexibility. IMPLICATIONS: Policy makers can tailor the generic tiered models developed with these methods to a state's population. Any state considering adoption of a needs-based tiered model will need to refine its model based on its assisted living population characteristics, its resources, and how the model fits its long-term care system. For the industry, these models can serve to identify levels of care needed in planning for staff time and skill mix required for assisted living as well as other long-term care populations.

Demographics of disenrollment from SCHIP: evidence from NJ KidCare.

The State Children's Health Insurance Program (SCHIP) provides health insurance coverage for children in low-income families. Although there is evidence of substantial disenrollment from SCHIP, few studies have examined how disenrollment varies by demographic characteristics. This study uses data from administrative records of all 41,881 children enrolled prior to April 2000 in NJ KidCare (New Jersey's SCHIP) separate state plans for families with incomes between 133% and 350% of the Federal Poverty Level. Survival methods were used to analyze disenrollment according to demographic and plan characteristics. Reasons for disenrollment were also studied. Overall, 18.9% of children disenrolled within 12 months of enrollment. Disenrollment was higher among non-Hispanic black children, children aged 1 to 5, and children without siblings in NJ KidCare than among their counterparts. Surprisingly, English speakers had the highest disenrollment rate of all language groups. Children in families with moderate income categories for whom premium contributions were required were 3 times as likely as lower-income children to disenroll, principally due to non-payment of premiums. To maximize retention in SCHIP and ensure access to care and continuity of care for low-income children, research is needed concerning why some groups disenroll more quickly.

Context or composition: what explains variation in SCHIP disenrollment?

OBJECTIVE: To investigate (1) the relative contributions of family and contextual characteristics to observed variation in disenrollment rates from the State Children's Health Insurance Program (SCHIP), and (2) whether context explains observed family-level patterns. DATA SOURCES: We use secondary data on 24,628 families enrolled in New Jersey's SCHIP program (NJ KidCare), and county-level data from the Area Resource File, the Census, and the NJ FamilyCare provider roster. STUDY DESIGN: Information on family characteristics, SCHIP plan, and dates of enrollment and disenrollment are taken from NJ KidCare administrative records, which provided surveillance data from January 1998 through April 2000. DATA COLLECTION/ANALYSIS: We estimate a multilevel discrete-time-hazards model of SCHIP disenrollment. FINDINGS: Families enrolled in plans involving cost-sharing, blacks, and those with only one enrolled child have higher than average rates of disenrollment. Disenrollment rates for blacks are lower in counties with a high share of black physicians. These characteristics account for part of the intercounty variation in disenrollment rates; remaining intercounty variation is largely explained by physician density or population density. POLICY IMPLICATIONS: It may be worthwhile to pay special attention to black families and counties with high disenrollment rates to address the reasons for their lower retention. Addressing cultural differences between physician and client and the geographic distribution of medical providers might reduce disenrollment.