Insurance patterns and instability from 2006 to 2016.

BACKGROUND: There is a rich literature on insurance coverage and its impacts on health care. Many recent studies have examined the impacts of the Affordable Care Act (ACA) and found that it had positive effects on health insurance coverage and health care usage. Most of the literature, however, has focused on insurance coverage at a single point in time, while research on insurance instability is underrepresented, even though it could significantly impact health outcomes. The aim of this study is to examine changes and implications of insurance instability among nonelderly adults from 2006 to 2016, covering the Great Recession and post-ACA periods. METHODS: Using 2006-to-2016 Medical Expenditure Panel Survey data, we identify seven insurance patterns and analyze them by race/ethnicity, age, geography, income, and medical conditions. We then use multivariable linear models to analyze the relationship between insurance instability and health care status, access, and utilization. Logistic, Poisson and nonlinear models test the robustness of our results. RESULTS: The post-ACA period 2015-2016 saw the lowest ever-uninsured rate (25.68% or 67.91 million). The largest decrease in insurance instability was among adults aged 19-25, low-income families, Hispanics, the western population, and the healthy population. Like the always-uninsured, those with other insurance gaps experienced a lack of access to care and decreased preventive care and other services. CONCLUSIONS: Despite the post-ACA instability reduction, over 25% of the U.S. population continued to have insurance gaps over a two-year period. Disparities continued to exist between income groups, race/ethnicities, and regions. Repealing ACA could exacerbate insurance instability and disparities between different groups, which in turn could lead to adverse health outcomes.

Impact of the Medicare hospital readmissions reduction program on vulnerable populations.

BACKGROUND: The Hospital Readmissions Reduction Program (HRRP) was established by the 2010 Patient Protection and Affordable Care Act (ACA) in an effort to reduce excess hospital readmissions, lower health care costs, and improve patient safety and outcomes. Although studies have examined the policy's overall impacts and differences by hospital types, research is limited on its effects for different types of vulnerable populations. The aim of this study was to analyze the impact of the HRRP on readmissions for three targeted conditions (acute myocardial infarction, heart failure, and pneumonia) among four types of vulnerable populations, including low-income patients, patients served by hospitals that serve a high percentage of low-income or Medicaid patients, and high-risk patients at the highest quartile of the Elixhauser comorbidity index score. METHODS: Data on patient and hospital information came from the Nationwide Readmission Database (NRD), which contained all discharges from community hospitals in 27 states during 2010-2014. Using difference-in-difference (DD) models, linear probability regressions were conducted for the entire sample and sub-samples of patients and hospitals in order to isolate the effect of the HRRP on vulnerable populations. Multiple combinations of treatment and control groups and triple difference (DDD) methods were used for testing the robustness of the results. All models controlled for the patient and hospital characteristics. RESULTS: There have been statistically significant reductions in readmission rates overall as well as for vulnerable populations, especially for acute myocardial infarction patients in hospitals serving the largest percentage of low-income patients and high-risk patients. There is also evidence of spillover effects for non-targeted conditions among Medicare patients compared to privately insured patients. CONCLUSIONS: The HRRP appears to have created the right incentives for reducing readmissions not only overall but also for vulnerable populations, accruing societal benefits in addition to previously found reductions in costs. As the reduction in the rate of readmissions is not consistent across patient and hospital groups, there could be benefits to adjusting the policy according to the socioeconomic status of a hospital's patients and neighborhood.

Medicaid Expansion, HIV Testing, and HIV-Related Risk Behaviors in the United States, 2010-2017.

Objectives. To examine the relationship between Medicaid expansion under the 2010 Patient Protection and Affordable Care Act and both HIV testing and risk behavior among nonelderly adults in the United States.Methods. We pooled 2010 to 2017 data from the Behavioral Risk Factor Surveillance System and focused our main analysis on respondents aged between 25 and 64 years from families with incomes below 138% of the federal poverty level. We used the difference-in-difference method and sample-weighted multivariable models to control for individual, state-area-level, and trend factors.Results. Medicaid expansion was associated with a significant 3.22-percentage-point increase in HIV test rates (P < .01) for individuals below 138% of the federal poverty level, with the largest impacts on non-Hispanic Blacks, age groups 35 to 44 years and 55 to 64 years, and rural areas. Expansion was not related to changes in HIV-related risk behavior.Conclusions. Medicaid expansion promoted HIV testing without increasing HIV risk behavior, but there were large disparities across race/ethnicity, age, and geographic area types.Public Health Implications. Nonexpansion states, mostly in the South, might have missed an opportunity to increase HIV test rates, which could have serious future health and financial consequences.

Relationship between pharmacist density and adult influenza vaccination after controlling for individual and neighborhood effects.

OBJECTIVES: Since 2009, all 50 states have passed legislation to allow pharmacists to administer influenza vaccinations. Pharmacies have become the second most common place for influenza vaccination, after a doctor's office. The aim of this study was to provide nationally representative results on the relationship between pharmacist density and influenza vaccination after controlling for both individual- and county-level characteristics. DESIGN: Retrospective data analysis with the use of merged individual data from the 2008-2012 Behavioral Risk Factor Surveillance System (BRFSS) and county data from the 2010 Area Health Resources Files. Sample-weighted multivariate logistic models were estimated to predict influenza vaccinations with the use of number of pharmacists per 1000 population as the key predictor. SETTING AND PARTICIPANTS: BRFSS is a telephone-based national survey across 50 states. A nationally representative sample of 1,696,119 adults 18 years of age and older were included in this analysis. RESULTS: The number of pharmacists per 1000 population was associated with higher odds of influenza vaccination (adjusted odds ratio [AOR] 1.13, 95% confidence interval [CI] 1.11-1.15) and was significant for non-Hispanic whites (AOR 1.06, 95% CI 1.04-1.08) and Hispanics (AOR 1.35, 95% CI 1.24-1.48). It varied across county types and employment status. The largest effects were found in urban counties (AOR 1.16, 95% CI 1.11-1.21) and among the self-employed (AOR 1.18, 95% CI 1.10-1.26), homemakers (AOR 1.18, 95% CI 1.10-1.26), and the retired (AOR 1.18, 95% CI, 1.14-1.22). CONCLUSION: Pharmacists play an important role in influenza vaccination and are an important alternative to traditional settings such as doctors' offices and health clinics. Future research is needed to investigate reasons and barriers behind their different effects in different regions and population groups. By covering in-pharmacy vaccinations in health plans and removing other barriers, pharmacists can help to alleviate the shortage of other health care providers and help increase vaccination rates.

Limited Access to Healthcare among Hispanics in the US-Mexico Border Region.

OBJECTIVE: Using large national databases, we investigated how living in the US-Mexico border region further limited access to healthcare among the non-elderly Hispanic adult population after controlling individual and county-level characteristics. METHODS: The 2008-2012 individual-level data of non-elderly Hispanic adults from the Behavioral Risk Factor Surveillance System (BRFSS) were merged with county-level data from Area Health Resources File (AHRF). Multivariate logistic analyses were performed to predict insurance status and access to doctors using residency in the US-Mexico border region as the key predictor, adjusting individual and county-level factors. RESULTS: Controlling only individual characteristic, Hispanics living in the US-Mexico border region had significantly lower odds of having health insurance (adjusted odds ratio [AOR] = 0.51; 95% confidence interval [CI], 0.49-0.54) and access to doctors (AOR = 0.69; 95% CI, 0.66-0.72). After including county-level measurements of healthcare system capacity and other local characteristics, the border region continued to be associated with lower likelihood of healthcare access. CONCLUSION: Hispanic residents in the U.S.-Mexico border had less access to healthcare than their inland counterparts. The findings highlight unique features in this region and support policies and initiatives to improve minority healthcare access, particularly among disadvantaged populations in this region.

Relationship between local family physician supply and influenza vaccination after controlling for individual and neighborhood effects.

BACKGROUND: Family physicians (FPs) play an important role in influenza vaccination. We investigated how local FP supply is associated with influenza vaccination, controlling for both individual-level and county-level characteristics. METHODS: The 2008-2010 individual-level data from the Behavioral Risk Factor Surveillance System were merged with county-level data from the Area Resource File (n = 985,157). Multivariate logistic analyses were performed to predict influenza vaccination using the number of FPs per 1000 population as the key predictor, adjusting for individual-level demographic, socioeconomic, and health information, as well as county-level racial composition and income level. Additional analyses were performed across racial/ethnic and employment status categories. RESULTS: Increasing local FP supply was associated with higher odds (adjusted odds ratio [aOR], 1.58; 95% confidence interval [CI], 1.49-1.67) and varied across racial/ethnic groups (Hispanic: aOR, 2.05, 95% CI, 1.55-2.72; non-Hispanic white: aOR, 1.57, 95% CI, 1.48-1.66; non-Hispanic black: aOR, 1.49, 95% CI, 1.18-1.89), employment status categories, and county types. CONCLUSIONS: FP supply was significantly associated with influenza vaccination. The association was greatest among those who were Hispanic, residing in a rural area, or out of work. Our findings lend support to initiatives aimed at increasing the FP supply, particularly among disadvantaged populations.

Factors associated with first-time use of preventive services in the United States.

OBJECTIVE: To examine factors associated with first-time use of preventive services based on the Behavioral Model of Health Services Use. METHODS: Nine panels of the Medical Expenditure Panel Survey were merged to identify first-time users of 8 preventive services: blood pressure check, cholesterol screening, colonoscopy, flu vaccination, routine physical, Pap smear, mammogram, and clinical breast examination. Multivariate logistic regressions and sample weights were used. RESULTS: Insurance coverage, access to care, and racial/ethnic minorities are associated with higher odds of first-time use. Findings based on cross-sectional data may not be valid for first-time use. CONCLUSIONS: Increased insurance coverage, better access to care, and a focus on minority population can help nonusers of preventive care to make the transition.

Association between insurance gaps and continued antihypertension medication usage in a US national representative population.

BACKGROUND: Medication persistence is important for adequate control of blood pressure. In this article, we assess the association between gaps in insurance coverage and continued antihypertensive medication using a US national representative sample. METHODS: We used three recent panels from the Medical Expenditure Panel Survey (MEPS). Our sample included hypertensive individuals 18-65 years of age. We identified four insurance categories: (i) continuous coverage by private insurance, (ii) continuous coverage by public insurance, (iii) single or multiple gaps in coverage, and (iv) continuously uninsured. Binary logit models were used to analyze the association between interruptions in medication and insurance after controlling for socioeconomic factors. Patients with continuous private insurance were used as the reference group. Results were weighted to adjust for oversampling and clustering in the survey. RESULTS: There was no statistically significant difference in the probability of medication persistence between individuals with continuous private insurance (the reference group) and individuals with continuous public insurance (adjusted odds ratio (AOR) 1.324, 95% confidence interval (CI) 0.774-2.266, P = 0.304). Compared to the reference group, individuals with insurance gaps had lower odds of continuing their medication (AOR 0.636, 95% CI 0.418-0.0.969, P = 0.035). Continuously uninsured individuals had even lower odds of medication persistence (AOR 0.462, 95% CI 0.282-0.757, P = 0.002). Age, marital status, body mass index (BMI) change, and years of education were also associated with continued medication usage. CONCLUSION: Studies focusing on current insurance status may underestimate the impact of health insurance gaps and the population at risk. Continuous insurance coverage is needed to increase continued antihypertensive medication usage.

The effect of patient satisfaction with pharmacistconsultation on medication adherence: aninstrumental variable approach

There are limited studies on quantifying the impact of patient satisfaction with pharmacist consultation on patient medication adherence. Objectives: The objective of this study is to evaluate the effect of patient satisfaction with pharmacist consultation services on medication adherence in a large managed care organization. Methods: We analyzed data from a patient satisfaction survey of 6,916 patients who had used pharmacist consultation services in Kaiser Permanente Southern California from 1993 to 1996. We compared treating patient satisfaction as exogenous, in a single-equation probit model, with a bivariate probit model where patient satisfaction was treated as endogenous. Different sets of instrumental variables were employed, including measures of patients' emotional well-being and patients' propensity to fill their prescriptions at a non-Kaiser Permanente (KP) pharmacy. The Smith-Blundell test was used to test whether patient satisfaction was endogenous. Over-identification tests were used to test the validity of the instrumental variables. The Staiger-Stock weak instrument test was used to evaluate the explanatory power of the instrumental variables. Results: All tests indicated that the instrumental variables method was valid and the instrumental variables used have significant explanatory power. The single equation probit model indicated that the effect of patient satisfaction with pharmacist consultation was significant (p<0.010). However, the bivariate probit models revealed that the marginal effect of pharmacist consultation on medication adherence was significantly greater than the single equation probit. The effect increased from 7% to 30% (p<0.010) after controlling for endogeneity bias. Conclusion: After appropriate adjustment for endogeneity bias, patients satisfied with their pharmacy services are substantially more likely to adhere to their medication. The results have important policy implications given the increasing focus on the roles of pharmacists and regulatory changes in professional scope of practice (AU)

Hay pocos estudios que cuantifiquen el impacto de la satisfacción del paciente con la consulta farmacéutica sobre la adherencia a la medicación. Objetivos: El objetivo de este estudio es evaluar el efecto de la satisfacción del paciente con los servicios de consulta farmacéutica sobre la adherencia a la medicación en una gran organización de gestión de cuidados. Métodos: Analizamos datos de un cuestionario de satisfacción de 6.916 pacientes que habían usado consultas farmacéuticas de la Kaiser Permanente Southern California desde 1993 a 1996. Comparamos, tratando la satisfacción del paciente como exógena, en un modelo probit de una ecuación, con un modelo proibit bivariado donde la satisfacción se trató como endógena. Se utilizaron diferentes conjuntos de variables, incluyendo medidas del bienestar emocional de los pacientes y propensión de los pacientes a adquirir sus medicamentos en una farmacia no Kaiser Permanente (KP). Se usó el test Smith-Blundell para probar si la satisfacción del paciente era endógena. Se usaron test de sobre-identificación para probar la validez de las variables instrumentales. El instrumento débil de Staiger-Stock fue utilizado para evaluar el poder explicativo de las variables instrumentales. Resultados: Todos los métodos indicaron que el método de variables instrumentales utilizado tuvo poder explicativo. El modelo probit de una ecuación indicó que el efecto de la satisfacción del paciente con la consulta farmacéutica fue significativo (p<0,010). Sin embargo, el modelo probit bivariado revela que el efecto marginal de la consulta farmacéutica en la adherencia a la medicación fue significativamente mayor que en probit de una ecuación. El efecto se incrementó del 7% al 30% (p<0,010) después de controlar el sesgo de endogenicidad. Conclusión: Después del adecuado ajuste del sesgo de endogenicidad, los pacientes satisfechos con los servicios de sus farmacias tiene sustancialmente más probabilidad de cumplir su medicación. Los resultados tienen importantes implicaciones políticas dado el creciente enfoque en los papeles del farmacéutico y los cambios reglamentarios en el ámbito del ejercicio profesional (AU)

The effect of patient satisfaction with pharmacist consultation on medication adherence: an instrumental variable approach.

UNLABELLED: There are limited studies on quantifying the impact of patient satisfaction with pharmacist consultation on patient medication adherence. OBJECTIVES: The objective of this study is to evaluate the effect of patient satisfaction with pharmacist consultation services on medication adherence in a large managed care organization. METHODS: We analyzed data from a patient satisfaction survey of 6,916 patients who had used pharmacist consultation services in Kaiser Permanente Southern California from 1993 to 1996. We compared treating patient satisfaction as exogenous, in a single-equation probit model, with a bivariate probit model where patient satisfaction was treated as endogenous. Different sets of instrumental variables were employed, including measures of patients' emotional well-being and patients' propensity to fill their prescriptions at a non-Kaiser Permanente (KP) pharmacy. The Smith-Blundell test was used to test whether patient satisfaction was endogenous. Over-identification tests were used to test the validity of the instrumental variables. The Staiger-Stock weak instrument test was used to evaluate the explanatory power of the instrumental variables. RESULTS: All tests indicated that the instrumental variables method was valid and the instrumental variables used have significant explanatory power. The single equation probit model indicated that the effect of patient satisfaction with pharmacist consultation was significant (p<0.010). However, the bivariate probit models revealed that the marginal effect of pharmacist consultation on medication adherence was significantly greater than the single equation probit. The effect increased from 7% to 30% (p<0.010) after controlling for endogeneity bias. CONCLUSION: After appropriate adjustment for endogeneity bias, patients satisfied with their pharmacy services are substantially more likely to adhere to their medication. The results have important policy implications given the increasing focus on the roles of pharmacists and regulatory changes in professional scope of practice.

Government health expenditures and health outcomes.

This paper provides econometric evidence linking a country's per capita government health expenditures and per capita income to two health outcomes: under-five mortality and maternal mortality. Using instrumental variables techniques (GMM-H2SL), we estimate the elasticity of these outcomes with respect to government health expenditures and income while treating both variables as endogenous. Consequently, our elasticity estimates are larger in magnitude than those reported in literature, which may be biased up. The elasticity of under-five mortality with respect to government expenditures ranges from -0.25 to -0.42 with a mean value of -0.33. For maternal mortality the elasticity ranges from -0.42 to -0.52 with a mean value of -0.50. For developing countries, our results imply that while economic growth is certainly an important contributor to health outcomes, government spending on health is just as important a factor.