Pressures on safety net access: the level of managed care penetration and uninsurance rate in a community. (41/7828)

OBJECTIVE: To examine the effects of managed care penetration and the uninsurance rate in an area on access to care of low-income uninsured persons and to compare differences in access between low-income insured and uninsured persons across these different market areas. DATA SOURCES: Primarily the Community Tracking Study household survey. Other market-level data were obtained from the Community Tracking Study physician survey, American Hospital Association annual survey of hospitals, Area Resource File, HCFA Administrative Data, Bureau of Primary Care data on Community Health Centers. STUDY DESIGN: Individuals are grouped based on the level of managed care penetration and uninsurance rate in the site where they reside. Measures of managed care include overall managed care penetration in the site, and the level of Medicaid managed care penetration in the state. Uninsurance rate is defined as the percentage of people uninsured in the site. Measures of access include the percentage with a usual source of care, percentage with any ambulatory care use, and percentage of persons who reported unmet medical care needs. Estimates are adjusted to control for other confounding factors, including both individual and market-level characteristics. DATA COLLECTION: A survey, primarily telephoned, of households concentrated in 60 sites, defined as metropolitan statistical areas and nonmetropolitan areas. PRINCIPAL FINDINGS: Access to care for low-income uninsured persons is lower in states with high Medicaid managed care penetration, compared to uninsured persons in states with low Medicaid managed care penetration. Access to care for low-income uninsured persons is also lower in areas with high uninsurance rates. The "access gap" (differences in access between insured and uninsured persons) is also larger in areas with high Medicaid managed care penetration and areas with high uninsurance rates. CONCLUSIONS: Efforts to achieve cost savings under managed care may result in financial pressures that limit cross-subsidization of care to the medically indigent, particularly for those providers who are heavily dependent on Medicaid revenue. High demand for care (as reflected in high uninsurance rates) may further strain limited resources for indigent care, further limiting access to care for uninsured persons.  (+info)

Changes in access to care, 1977-1996: the role of health insurance. (42/7828)

OBJECTIVE: To describe changes in Americans' access to care over the last 20 years focusing on the uninsured, Hispanic American, and young adult populations, and to analyze the factors underlying these changes with a particular focus on the role of health insurance. DATA SOURCES/STUDY SETTING: Data from the 1977 National Medical Care Expenditure Survey, the 1987 National Medical Expenditure Survey, and the 1996 Medical Expenditure Panel Survey. STUDY DESIGN: Focusing on whether each individual has a usual source of health care, we present descriptive statistics and algebraic decompositions. DATA COLLECTION/EXTRACTION METHODS: We combine data from the household surveys with questions from access to care supplements that were administered each time. PRINCIPAL FINDINGS: Hispanic Americans and young adults age 18-24 are more likely to lack a usual source of care than other Americans; these inequalities increased over the period studied and cannot be explained solely by changes in health insurance coverage. CONCLUSIONS: Although increasing health insurance coverage will likely improve access to care among Hispanics and young adults, our findings suggest that the expansion of insurance coverage will not be sufficient to eliminate current disparities in access to care.  (+info)

A community-wide infant mortality review: findings and implications. (43/7828)

The authors present the results of a community-wide infant mortality review, describe implications for the delivery of maternal and child health services, and discuss the value of such reviews in addressing local public health concerns. The review included an analysis of birth and death certificates and medical record data; maternal interviews; review of cases and development of recommendations by provider panels; and convening of community groups to develop strategies to improve the health and health care of women and infants. The review focused on 287 infant deaths during 1990-1993. More than half of all neonatal deaths were attributable to "previable" or "borderline viable" births. Sexually transmitted infections were the most frequently identified underlying risk, and smoking was the most frequently identified prenatal risk. Homelessness, physical and sexual abuse, and alcohol use were at least twice as likely among women whose babies died than among a high risk comparison group. Panelists identified fragmented health care over the course of women's reproductive lives as a predominant theme. The authors conclude that: (a) The focus of maternal and child health care should shift to a model of women's health care that addresses the chronicity of social and clinical risks. (b) Infant mortality reviews are a valuable tool for community education, systems review, and policy development and can be applied to other public health issues with local significance. (c) Expectations about the review process's ability to produce conclusions about causality or recommendations narrowly geared to reducing infant mortality rates need to be reframed. (d) The model will be strengthened by greater participation of families affected by infant death.  (+info)

Access and use of medications in HIV disease. (44/7828)

OBJECTIVE: To examine if measures of access to medical care are associated with outpatient use of antiretroviral and Pneumocystis carinii pneumonia (PCP) medications among a cohort of individuals with HIV disease. DATA SOURCES: Adults who participated in a series of up to six interviews as part of the AIDS Costs and Services Utilization Survey (ACSUS). ACSUS, a panel survey of persons with HIV disease, was undertaken from 1991 through 1992. STUDY DESIGN: The Andersen Behavioral Model of Health Services Use provided the conceptual framework for the study. Logistic regression analyses with generalized estimating equations were conducted to determine the effects of predisposing, enabling, and need-for-care factors on the odds of antiretroviral or PCP medication use. The analytic sample consisted of 1,586 respondents whose 7,652 interviews provided the data. PRINCIPAL FINDINGS: The multivariate analysis showed that being female (OR = 0.76; 95% C.I. = 0.60-0.95), ages 15 to 24 years (OR = 0.64; 95% C.I. = 0.44-0.92), and having a hospitalization (OR = 0.73; 95% C.I. = 0.63-0.84) were associated with lower odds of using antiretrovirals. African American race (OR = 1.30; 95% C.I. = 1.04-1.62), having both public and private insurance (OR = 2.11; 95% C.I. = 1.47-3.03), attending counseling (OR = 1.17; 95% C.I. = 1.02-1.34), having a usual source of care (OR = 1.70; 95% C.I. = 1.38-2.11), and clinical trials participation (OR = 1.52; 95% C.I. = 1.23-1.87) were associated with a higher odds of use. Similar results were obtained for analyses of PCP medication use. CONCLUSIONS: Sociodemographic differences exist in access and use of prescription drugs within the ACSUS cohort. The results suggest that women and those ages 15 to 24 years have poor access to some medications that improve survival in HIV disease.  (+info)

Clinical services for sleep disorders. (45/7828)

Children's sleep disorders are common and often harmful to development and well being. The clinical services available to affected children and their families need to be improved. At present, professional interest and expertise in sleep disorders medicine is severely limited by the paucity of appropriate teaching and training. The work of a mainly tertiary sleep disorders clinic was reviewed, which showed that accurate diagnosis of a wide range of sleep disorders is possible, and that treatment needs can be specified. Although families appreciated such assessment, the outcome was unsatisfactory in many cases, often because treatment recommendations were not implemented by referrers. Reasons for this appear to include poor communication between referrers and families, and unavailability of treatment resources. A three tier system of service provision is proposed to improve this situation, which rests essentially on better professional training in the sleep disorders field.  (+info)

Essential drugs in the new international economic environment. (46/7828)

Recent global developments in the regulation of trade and intellectual property rights threaten to hinder the access of populations in developing countries to essential drugs. The authors argue for state intervention in the health and pharmaceutical markets in order to guarantee equitable access to these products.  (+info)

For debate--Does health care save lives? (47/7828)

The contribution of health care to the health of a population has long been controversial. In the 1970s, McKeown and Illich argued that health care had made little contribution to population health and may actually be damaging it. There is, however, a growing body of evidence that health care now has a demonstrable effect on health at a population level, albeit subject to certain methodological limitations that affect the precision of the estimates of scale. In particular, there is emerging evidence that reduced access to high quality medical care may contribute to the east-west gap in mortality in Europe and to social inequalities in mortality in some industrialised countries. These findings apply both to overall measures of mortality amenable to medical care as well as to death rates in particular age groups and from particular conditions, where the association between policy and outcome tends to be clearer. These findings have implications for those who seek to promote health at population or individual level. Primarily, there needs to be a stronger link between public health and health care, with those in public health recognising that health care can make a difference and those in health care recognising the right of public health to challenge what they do.  (+info)

Out-of-pocket payments for health care in Croatia: implications for equity. (48/7828)

AIM: To assess the distribution of out-of-pocket payments for health care in Croatia by income groups. METHODS: The study is based on data from 1994 out-of-pocket health expenditure survey carried out through interviews of randomly selected adults in two major cities of Croatia, Zagreb and Split. We analyzed co-payments for public health care services and other payments related to private practice, non-prescription medicaments, or informal payments to health care providers. Spending of each income group was analyzed as a share of its income and as proportion of total payments. RESULTS: We found an inequitable pattern of out-of-pocket health care payments. Burden of out-of-pocket expenditure was not equally distributed among income groups, with persons from the low income group paying about six times larger share of their income than the high income group. When we compared the proportions of income received by different groups with the proportions of their payments, the results indicated (again) that the low income persons payed proportionally more than those with high income. CONCLUSION: Distribution of out-of-pocket payments in Croatia is regressive, with a greater burden falling on lower income persons. Possible introduction of the mix of health care financing would need reconsideration of the policy measures to balance equity and efficiency.  (+info)