Evaluating Child Health Plus in upstate New York: how much does providing health insurance to uninsured children increase health care costs?

BACKGROUND: In response to the increase in the number of American children without health insurance, new federal and state programs have been established to expand health insurance coverage for children. However, the presence of insurance reduces the price of care for families participating in these programs and stimulates the use of medical services, which leads to an increase in health care costs. In this article, we identified the additional expenditures associated with the provision of health insurance to previously uninsured children. METHODS: We estimated the expenditures on additional services using data from a study of children living in the Rochester, New York, area who were enrolled in the New York State Child Health Plus (CHPlus) program. CHPlus was designed specifically for low-income children without health insurance who were not eligible for Medicaid. The study sample consisted of 1910 children under the age of 6 who were initially enrolled in CHPlus between November 1, 1991 and August 1, 1993 and who had been enrolled for at least 9 continuous months. We used medical chart reviews to determine the level of primary care utilization, parent interviews for demographic information, as well as specialty care utilization, and we used claims data submitted to CHPlus for the year after enrollment to calculate health care expenditures. Using this information, we estimated a multivariate regression model to compute the average change in expenditures associated with a unit of utilization for a cross-section of service types while controlling for other factors that independently influenced total outpatient expenditures. RESULTS: Expenditures for outpatient services were closely related to primary care utilization-more utilization tended to increase expenditures. Age and the presence of a chronic condition both affected expenditures. Children with chronic conditions and infants tended to have more visits, but these visits were, on average, less expensive. Applying the average change in expenditures to the change in utilization that resulted from the presence of insurance, we estimated that the total increase in expenditures associated with CHPlus was $71.85 per child in the year after enrollment, or a 23% increase in expenditures. The cost increase was almost entirely associated with the provision of primary care. Almost three-quarters of the increase in outpatient expenditures was associated with increased acute and well-child care visits. CONCLUSIONS: CHPlus was associated with a modest increase in expenditures, mostly from additional outpatient utilization. Because the additional primary care provided to young children often has substantial long-term benefits, the relatively modest expenditure increases associated with the provision of insurance may be viewed as an investment in the future.

Evaluation of a state health insurance program for low-income children: implications for state child health insurance programs.

BACKGROUND: The State Child Health Insurance Program (SCHIP) is the largest public investment in child health care in 30 years, targeting 11 million uninsured children, yet little is known about the impact of health insurance on uninsured children. In 1991, New York State implemented Child Health Plus (CHPlus), a health insurance program that became a model for SCHIP: OBJECTIVE: To examine changes in access to care, utilization of services, and quality of care among children enrolled in CHPlus. DESIGN: A pre-post design was used to evaluate the health care experiences of children in the year before enrollment in CHPlus and during the year after CHPlus enrollment. SETTING: New York State, stratified into 4 regions: New York City, urban counties around New York City, upstate urban counties, and upstate rural counties. PARTICIPANTS: A total of 2126 children (0-12.99 years of age) who enrolled in CHPlus in 1992-1993. DATA COLLECTION: Parents were interviewed by telephone, and primary care medical charts were reviewed for 694 children (0-3. 99 years of age). ANALYSIS: Access, utilization, and quality of care measures for each child were compared for the year before and the year after CHPlus enrollment, controlling for age, geographic region, previous insurance coverage, and CHPlus plan type (indemnity or managed care). RESULTS: Enrollment in CHPlus was associated with fewer children lacking a medical home (5% before CHPlus vs 1% during CHPlus), with the greatest change occurring in New York City (11% vs 1%), where access before CHPlus was lowest. CHPlus was also associated with increased primary care visits: by 25% for preventive visits, by 52% for acute visits, and by 42% for total visits. The number of specialists seen during CHPlus was more than twice as high than before CHPlus. CHPlus was not associated with changes in emergency department utilization, although hospitalizations, which were not covered by CHPlus, were 36% lower during CHPlus coverage. Use of public health departments for immunizations declined by 64%, with more immunizations delivered in the medical home during CHPlus coverage. One third of parents reported improved quality of health care for their child as a result of CHPlus, and virtually none noted worse quality of care. CONCLUSIONS: This statewide health insurance program for low-income children was associated with improved access, utilization, and quality of care, suggesting that SCHIP has the potential to improve health care for low-income American children.

Preoperative diagnosis and postoperative management of adult patients with obstructive sleep apnea syndrome: a review of the literature.

Obstructive sleep apnea syndrome (OSAS) is a common yet potentially fatal disorder. Several reports and clinical studies have established anesthetic-related occurrences of near-fatal respiratory complications in persons with this syndrome, as well as cases of death reported in the medical literature linking OSAS and anesthesia. The postoperative period is a critical time for patients with OSAS recovering from general anesthesia. The purpose of the literature review is to determine current treatment protocols and standards of care for preoperative diagnosis and postoperative management of adults with OSAS in an effort to prevent respiratory complications. The literature review includes recent studies on diagnosis of patients with OSAS. A treatment protocol for the postoperative management of adults with OSAS is also presented. Conclusions are drawn from a summary of the literature review. Future implications for nursing practice and research are drawn from the summary.