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1.  Correction to “Hospital-Level Variation in the Use of Intensive Care” 
Health Services Research  2013;48(2 Pt 1):681.
PMCID: PMC3626339
2.  HSR Update – December 2012 
Health Services Research  2012;47(6):ix.
PMCID: PMC3523365
3.  Comparative Cost-Effectiveness of Interventions to Improve Medication Adherence after Myocardial Infarction 
Health Services Research  2012;47(6):2097-2117.
To evaluate the comparative cost-effectiveness of interventions to improve adherence to evidence-based medications among postmyocardial infarction (MI) patients.
Data Sources/Study Setting
Cost-effectiveness analysis.
Study Design
We developed a Markov model simulating a hypothetical cohort of 65-year-old post-MI patients who were prescribed secondary prevention medications. We evaluated mailed education, disease management, polypill use, and combinations of these interventions. The analysis was performed from a societal perspective over a lifetime horizon. The main outcome was an incremental cost-effectiveness ratio (ICER) as measured by cost per quality-adjusted life year (QALY) gained.
Data Collection/Extraction Methods
Model inputs were extracted from published literature.
Principal Findings
Compared with usual care, only mailed education had both improved health outcomes and reduced spending. Mailed education plus disease management, disease management, polypill use, polypill use plus mailed education, and polypill use plus disease management cost were $74,600, $69,200, $133,000, $113,000, and $142,900 per QALY gained, respectively. In an incremental analysis, only mailed education had an ICER of less than $100,000 per QALY and was therefore the optimal strategy. Polypill use, particularly when combined with mailed education, could be cost effective, and potentially cost saving if its price decreased to less than $100 per month.
Mailed education and a polypill, once available, may be the cost-saving strategies for improving post-MI medication adherence.
PMCID: PMC3523366  PMID: 22998129
Cost-effectiveness; adherence; myocardial infarction
4.  The Impact of Hospital Pay-for-Performance on Hospital and Medicare Costs 
Health Services Research  2012;47(6):2118-2136.
To evaluate the effects of Medicare's hospital pay-for-performance demonstration project on hospital revenues, costs, and margins and on Medicare costs.
Data Sources/Study Setting
All health care utilization for Medicare beneficiaries hospitalized for acute myocardial infarction (AMI; ICD-9-CM code 410.x1) in fiscal years 2002–2005 from Medicare claims, containing 420,211 admissions with AMI.
Study Design
We test for changes in hospital costs and revenues and Medicare payments among 260 hospitals participating in the Medicare hospital pay-for-performance demonstration project and a group of 780 propensity-score-matched comparison hospitals. Effects were estimated using a difference-in-difference model with hospital fixed effects, testing for changes in costs among pay-for-performance hospitals above and beyond changes in comparison hospitals.
Principal Findings
We found no significant effect of pay-for-performance on hospital financials (revenues, costs, and margins) or Medicare payments (index hospitalization and 1 year after admission) for AMI patients.
Pay-for-performance in the CMS hospital demonstration project had minimal impact on hospital financials and Medicare payments to providers. As P4P extends to all hospitals under the Affordable Care Act, these results provide some estimates of the impact of P4P and emphasize our need for a better understanding of the financial implications of P4P on providers and payers if we want to create sustainable and effective programs to improve health care value.
PMCID: PMC3523367  PMID: 23088391
Pay-for-performance; health care costs; hospitals; Medicare
5.  Adoption of Diagnostic Technology and Variation in Caesarean Section Rates: A Test of the Practice Style Hypothesis in Norway 
Health Services Research  2012;47(6):2169-2189.
To examine whether the introduction of advanced diagnostic technology in maternity care has led to less variation in type of delivery between hospitals in Norway.
Data Sources
The Medical Birth Registry of Norway provided detailed medical information for 1.7 million deliveries from 1967 to 2005. Information about diagnostic technology was collected directly from the maternity units.
Study Design
The data were analyzed using a two-level binary logistic model with Caesarean section as the outcome measure. Level one contained variables that characterized the health status of the mother and child. Hospitals are level two. A heterogeneous variance structure was specified for the hospital level, where the error variance was allowed to vary according to the following types of diagnostic technology: two-dimensional ultrasound, cardiotocography, ST waveform analysis, and fetal blood analyses.
Principal Finding
There was a marked variation in Caesarean section rates between hospitals up to 1973. After this the variation diminished markedly. This was due to the introduction of ultrasound and cardiotocography.
Diagnostic technology reduced clinical uncertainty about the diagnosis of risk factors of the mother and child during delivery, and variation in type of delivery between hospitals was reduced accordingly. The results support the practice style hypothesis.
PMCID: PMC3523370  PMID: 22594486
Medical practice variation; Caesarean section; diagnostic technology; uncertainty; practice style
6.  A Two-Compartment Mixed-Effects Gamma Regression Model for Quantifying Between-Unit Variability in Length of Stay among Children Admitted to Intensive Care 
Health Services Research  2012;47(6):2190-2203.
To quantify between-unit variability in mean length of stay (LoS) between intensive care units (ICUs) after adjusting for differences in case mix using a method that does not require arbitrary trimming of data.
An analysis of registry data from pediatric ICUs (PICUs) in Australia and New Zealand.
Study Design
The relationships between patient LoS and associated patient factors were modeled as a log-linear function of the covariates using two gamma distributions. The predicted distribution is estimated as a weighted average of the two distributions where the relative weighting is conditional on the patient's elective status.
Data Collection
Data for 12,763 admissions submitted to the Australian and New Zealand Paediatric Intensive Care Registry from the eight dedicated PICUs in Australia and New Zealand in 2007 and 2008.
Principal Findings
The two distributions of the mixture model accurately described the distribution of short- and long-stay patients in ICUs. After adjusting for patient case mix, several sites had a statistically significant effect on patient LoS.
The two-compartment model characterizes ICU LoS for short- and long-stay patients more effectively than a single-compartment model. There is significant site-level variation in the LoS among children admitted to ICUs in Australia and New Zealand. Differences in the site-level variation between short- and long-stay patients indicate differences in discharge practice.
PMCID: PMC3523371  PMID: 22594550
Quality indicators; pediatrics; length of stay; intensive care; risk adjustment
7.  Is There a Statistical Relationship between Economic Crises and Changes in Government Health Expenditure Growth? An Analysis of Twenty-Four European Countries 
Health Services Research  2012;47(6):2204-2224.
To identify whether, by what means, and the extent to which historically, government health care expenditure growth in Europe has changed following economic crises.
Data Sources
Organization for Economic Cooperation and Development Health Data 2011.
Study Design
Cross-country fixed effects multiple regression analysis is used to determine whether statutory health care expenditure growth in the year after economic crises differs from that which would otherwise be predicted by general economic trends. Better understanding of the mechanisms involved is achieved by distinguishing between policy responses which lead to cost-shifting and all others.
In the year after an economic downturn, public health care expenditure grows more slowly than would have been expected given the longer term economic climate. Cost-shifting and other policy responses are both associated with these slowdowns. However, while changes in tax-derived expenditure are associated with both cost-shifting and other policy responses following a crisis, changes in expenditure derived from social insurance have been associated only with changes in cost-shifting.
Disproportionate cuts to the health sector, as well as reliance on cost-shifting to slow growth in health care expenditure, serve as a warning in terms of potentially negative effects on equity, efficiency, and quality of health services and, potentially, health outcomes following economic crises.
PMCID: PMC3523372  PMID: 22670771
Health economics; health care financing/insurance/premiums; comparative health systems/international health; health care organizations and systems
8.  Clinical Quality Performance in U.S. Health Centers 
Health Services Research  2012;47(6):2225-2249.
To describe current clinical quality among the nation's community health centers and to examine health center characteristics associated with performance excellence.
Data Sources
National data from the 2009 Uniform Data System.
Data Collection/Extraction Methods
Health centers reviewed patient records and reported aggregate data to the Uniform Data System.
Study Design
Six measures were examined: first-trimester prenatal care, childhood immunization completion, Pap tests, low birth weight, controlled hypertension, and controlled diabetes. The top 25 percent performing centers were compared with lower performing (bottom 75 percent) centers on these measures. Logistic regressions were utilized to assess the impact of patient, provider, and institutional characteristics on health center performance.
Principal Findings
Clinical care and outcomes among health centers were generally comparable to national averages. For instance, 67 percent of pregnant patients received timely prenatal care (national = 68 percent), 69 percent of children achieved immunization completion (national = 67 percent), and 63 percent of hypertensive patients had blood pressure under control (national = 48 percent). Depending on the measure, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well.
Health centers provide quality care at rates comparable to national averages. Performance may be improved by increasing insurance coverage among patients and increasing the ratios of physicians and enabling service providers to patients.
PMCID: PMC3523373  PMID: 22594465
Quality of care; primary care; community health; health care delivery
9.  Chronic Illness and Patient Satisfaction 
Health Services Research  2012;47(6):2250-2272.
To examine how the relationship between patient characteristics, patient experience with the health care system, and overall satisfaction with care varies with illness complexity.
Data Sources/Study Setting
Telephone survey in 14 U.S. geographical areas.
Study Design
Structural equation modeling was used to examine how relationships among patient characteristics, three constructs representing patient experience with the health care system, and overall satisfaction with care vary across patients by number of chronic illnesses.
Data Collection/Extraction Methods
Random digital dial telephone survey of adults with one or more chronic illnesses.
Principal Findings
Patients with more chronic illnesses report higher overall satisfaction. The total effects of better patient–provider interaction and support for patient self-management are associated with higher satisfaction for all levels of chronic illness. The latter effect increases with illness burden. Older, female, or insured patients are more satisfied; highly educated patients are less satisfied.
Providers seeking to improve their patient satisfaction scores could do so by considering patient characteristics when accepting new patients or deciding who to refer to other providers for treatment. However, our findings suggest constructive actions that providers can take to improve their patient satisfaction scores without selection on patient characteristics.
PMCID: PMC3523374  PMID: 22515159
Chronic disease; patient assessment/satisfaction; LISREL
10.  The Patient-Centered Medical Home and Patient Experience 
Health Services Research  2012;47(6):2273-2295.
To examine the relationship between practices' reported use of patient-centered medical home (PCMH) processes and patients' perceptions of their care experience.
Data Source
Primary survey data from 393 physician practices and 1,304 patients receiving care in those practices.
Study Design
This is an observational, cross-sectional study. Using standard ordinary least-squares and a sample selection model, we estimated the association between patients' care experience and the use of PCMH processes in the practices where they receive care.
Data Collection
We linked data from a nationally representative survey of individuals with chronic disease and two nationally representative surveys of physician practices.
Principal Findings
We found that practices' use of PCMH processes was not associated with patient experience after controlling for sample selection as well as practice and patient characteristics.
In our study, which was large, but somewhat limited in its measures of the PCMH and of patient experience, we found no association between PCMH processes and patient experience. The continued accumulation of evidence related to the possibilities of the PCMH, how PCMH is measured, and how the impact of PCMH is gauged provides important information for health care decision makers.
PMCID: PMC3523375  PMID: 22670806
Patient-centered medical home; patient care experience; primary care; chronic disease
11.  Assisted Living Expansion and the Market for Nursing Home Care 
Health Services Research  2012;47(6):2296-2315.
To analyze the effect of market-level changes in assisted living supply on nursing home utilization and resident acuity.
Data Sources
Primary data on the supply of assisted living over time were collected from 13 states from 1993 through 2007 and merged with nursing home-level data from the Online Survey Certification and Reporting System and market-level information from the Area Resource File.
Study Design
Least squares regression specification incorporating market and time-fixed effects.
Principal Findings
A 10 percent increase in assisted living capacity led to a 1.4 percent decline in private-pay nursing home occupancy and a 0.2–0.6 percent increase in patient acuity.
Assisted living serves as a potential substitute for nursing home care for some healthier individuals with greater financial resources, suggesting implications for policy makers, providers, and consumers.
PMCID: PMC3523376  PMID: 22578039
Assisted living; nursing homes; utilization; acuity
12.  A Nonparametric Statistical Method That Improves Physician Cost of Care Analysis 
Health Services Research  2012;47(6):2398-2417.
To develop a compositing method that demonstrates improved performance compared with commonly used tests for statistical analysis of physician cost of care data.
Data Source
Commercial preferred provider organization (PPO) claims data for internists from a large metropolitan area.
Study Design
We created a nonparametric composite performance metric that maintains risk adjustment using the Wilcoxon rank-sum (WRS) test. We compared the resulting algorithm to the parametric observed-to-expected ratio, with and without a statistical test, for stability of physician cost ratings among different outlier trimming methods and across two partially overlapping time periods.
Principal Findings
The WRS algorithm showed significantly greater within-physician stability among several typical outlier trimming and capping methods. The algorithm also showed significantly greater within-physician stability when the same physicians were analyzed across time periods.
The nonparametric algorithm described is a more robust and more stable methodology for evaluating physician cost of care than commonly used observed-to-expected ratio techniques. Use of such an algorithm can improve physician cost assessment for important current applications such as public reporting, pay for performance, and tiered benefit design.
PMCID: PMC3523381  PMID: 22524195
Statistical methods; physician profiling; nonparametric statistics; cost-efficiency; efficiency index
13.  AcademyHealth Update 
Health Services Research  2012;47(5):ix-x.
PMCID: PMC3513603
14.  Introducing the Best of the AcademyHealth Annual Research Meeting 
Health Services Research  2012;47(5):1771-1772.
PMCID: PMC3513604  PMID: 22985029
15.  Early Impact of the Affordable Care Act on Health Insurance Coverage of Young Adults 
Health Services Research  2012;47(5):1773-1790.
Research Objective
To evaluate one of the first implemented provisions of the Patient Protection and Affordable Care Act (ACA), which permits young adults up to age 26 to enroll as dependents on a parent's private health plan. Nearly one-in-three young adults lacked coverage before the ACA.
Study Design, Methods, and Data
Data from the Current Population Survey 2005–2011 are used to estimate linear probability models within a difference-in-differences framework to estimate how the ACA affected coverage of eligible young adults compared to slightly older adults. Multivariate models control for individual characteristics, economic trends, and prior state-dependent coverage laws.
Principal Findings
This ACA provision led to a rapid and substantial increase in the share of young adults with dependent coverage and a reduction in their uninsured rate in the early months of implementation. Models accounting for prior state dependent expansions suggest greater policy impact in 2010 among young adults who were also eligible under a state law.
Conclusions and Implications
ACA-dependent coverage expansion represents a rare public policy success in the effort to cover the uninsured. Still, this policy may have later unintended consequences for premiums for alternative forms of coverage and employer-offered rates for young adult workers.
PMCID: PMC3513605  PMID: 22924684
Health care reform; health insurance regulation; health policy; health economics
16.  What Hospital Inpatient Services Contributed the Most to the 2001–2006 Growth in the Cost per Case? 
Health Services Research  2012;47(5):1814-1835.
To demonstrate a refined cost-estimation method that converts detailed charges for inpatient stays into costs at the department level to enable analyses that can unravel the sources of rapid growth in inpatient costs.
Data Sources
Healthcare Cost and Utilization Project State Inpatient Databases and Medicare Cost Reports for all community, nonrehabilitation hospitals in nine states that reported detailed charges in 2001 and 2006 (n = 10,280,416 discharges).
Study Design
We examined the cost per discharge across all discharges and five subgroups (medical, surgical, congestive heart failure, septicemia, and osteoarthritis).
Data Collection/Extraction Methods
We created cost-to-charge ratios (CCRs) for 13 cost-center or department-level buckets using the Medicare Cost Reports. We mapped service-code-level charges to a CCR with an internally developed crosswalk to estimate costs at the service-code level.
Principal Findings
Supplies and devices were leading contributors (24.2 percent) to the increase in mean cost per discharge across all discharges. Intensive care unit and room and board (semiprivate) charges also substantially contributed (17.6 percent and 11.3 percent, respectively). Imaging and other advanced technological services were not major contributors (4.9 percent).
Payers and policy makers may want to explore hospital stay costs that are rapidly rising to better understand their increases and effectiveness.
PMCID: PMC3513607  PMID: 22946883
17.  The Relationship between Mental Health Diagnosis and Treatment with Second-Generation Antipsychotics over Time: A National Study of U.S. Medicaid-Enrolled Children 
Health Services Research  2012;47(5):1836-1860.
To describe the relationship between mental health diagnosis and treatment with antipsychotics among U.S. Medicaid-enrolled children over time.
Data Sources/Study Setting
Medicaid Analytic Extract (MAX) files for 50 states and the District of Columbia from 2002 to 2007.
Study Design
Repeated cross-sectional design. Using logistic regression, outcomes of mental health diagnosis and filled prescriptions for antipsychotics were standardized across demographic and service use characteristics and reported as probabilities across age groups over time.
Data Collection
Center for Medicaid Services data extracted by means of age, ICD-9 codes, service use intensity, and National Drug Classification codes.
Principal Findings
Antipsychotic use increased by 62 percent, reaching 354,000 youth by 2007 (2.4 percent). Although youth with bipolar disorder, schizophrenia, and autism proportionally were more likely to receive antipsychotics, youth with attention deficit hyperactivity disorder (ADHD) and those with three or more mental health diagnoses were the largest consumers of antipsychotics over time; by 2007, youth with ADHD accounted for 50 percent of total antipsychotic use; 1 in 7 antipsychotic users were youth with ADHD as their only diagnosis.
In the context of safety concerns, disproportionate antipsychotic use among youth with nonapproved indications illustrates the need for more generalized efficacy data in pediatric populations.
PMCID: PMC3513608  PMID: 22946905
Antipsychotics; mental health; pediatrics; Medicaid
18.  Reporting of Quality Indicators and Improvement in Hospital Performance: The P.Re.Val.E. Regional Outcome Evaluation Program 
Health Services Research  2012;47(5):1880-1901.
To evaluate whether reporting of hospital performance was associated with a change in quality indicators in Italian hospitals.
Data Sources/Study Setting
Nationwide Hospital Information System for 2006–2009.
Study Design
We performed a pre-post evaluation in Lazio (before and after disclosure of the Regional Outcome Evaluation Program P.Re.Val.E.) and a comparative evaluation versus Italian regions without comparable programs. We analyzed risk-adjusted proportions of percutaneous coronary intervention (PCI), hip fractures operated on within 48 hours, and cesarean deliveries.
Data Collection/Extraction Methods
Using standardized ICD-9-CM coding algorithms, we selected 381,053 acute myocardial infarction patients, 250,712 hip fractures, and 1,736,970 women who had given birth.
Principal Findings
In Lazio PCI within 48 hours changed from 22.49 to 29.43 percent following reporting of the P.Re.Val.E results (relative increase, 31 percent; p < .001). In the other regions this proportion increased from 22.48 to 27.09 percent during the same time period (relative increase, 21 percent; p < .001). Hip fractures operated on within 48 hours increased from 11.73 to 15.78 percent (relative increase, 34 percent; p < .001) in Lazio, and not in other regions (29.36 to 28.57 percent). Cesarean deliveries did not decrease in Lazio (34.57–35.30 percent), and only slightly decreased in the other regions (30.49–28.11 percent).
Reporting of performance data may have a positive but limited impact on quality improvement. The evaluation of quality indicators remains paramount for public accountability.
PMCID: PMC3513610  PMID: 22985031
Quality of care; risk-adjusted indicators; administrative data
19.  Comparison of Distribution- and Anchor-Based Approaches to Infer Changes in Health-Related Quality of Life of Prostate Cancer Survivors 
Health Services Research  2012;47(5):1902-1925.
To determine the minimal important difference (MID) in generic and prostate-specific health-related quality of life (HRQoL) using distribution- and anchor-based methods.
Study Design and Setting
Prospective cohort study of 602 newly diagnosed prostate cancer patients recruited from an urban academic hospital and a Veterans Administration hospital. Participants completed generic (SF-36) and prostate-specific HRQoL surveys at baseline and at 3, 6, 12, and 24 months posttreatment. Anchor-based and distribution-based methods were used to develop MID estimates. We compared the proportion of participants returning to baseline based on MID estimates from the two methods.
MID estimates derived from combining distribution- and anchor-based methods for the SF-36 subscales are physical function = 7, role physical = 14, role emotional = 12, vitality = 9, mental health = 6, social function = 9, bodily pain = 9, and general health = 8; and for the prostate-specific scales are urinary function = 8, bowel function = 7, sexual function = 8, urinary bother = 9, bowel bother = 8, and sexual bother = 11. Proportions of participants returning to baseline values corresponding to MID estimates from the two methods were comparable.
This is the first study to assess the MID for generic and prostate-specific HRQoL using anchor-based and distribution-based methods. Although variation exists in the MID estimates derived from these two methods, the recovery patterns corresponding to these estimates were comparable.
PMCID: PMC3513611  PMID: 22417225
Prostate cancer; health-related quality of life; minimal important difference; anchor based; distribution based
20.  The Effectiveness of Chronic Care Management for Heart Failure: Meta-Regression Analyses to Explain the Heterogeneity in Outcomes 
Health Services Research  2012;47(5):1926-1959.
To support decision making on how to best redesign chronic care by studying the heterogeneity in effectiveness across chronic care management evaluations for heart failure.
Data Sources
Reviews and primary studies that evaluated chronic care management interventions.
Study Design
A systematic review including meta-regression analyses to investigate three potential sources of heterogeneity in effectiveness: study quality, length of follow-up, and number of chronic care model components.
Principal Findings
Our meta-analysis showed that chronic care management reduces mortality by a mean of 18 percent (95 percent CI: 0.72–0.94) and hospitalization by a mean of 18 percent (95 percent CI: 0.76–0.93) and improves quality of life by 7.14 points (95 percent CI: −9.55 to −4.72) on the Minnesota Living with Heart Failure questionnaire. We could not explain the considerable differences in hospitalization and quality of life across the studies.
Chronic care management significantly reduces mortality. Positive effects on hospitalization and quality of life were shown, however, with substantial heterogeneity in effectiveness. This heterogeneity is not explained by study quality, length of follow-up, or the number of chronic care model components. More attention to the development and implementation of chronic care management is needed to support informed decision making on how to best redesign chronic care.
PMCID: PMC3513612  PMID: 22417281
Heart failure; chronic care management; quality improvement; statistical heterogeneity; systematic review
21.  Care Coordination for the Chronically Ill: Understanding the Patient's Perspective 
Health Services Research  2012;47(5):1960-1979.
To identify factors associated with perception of care coordination problems among chronically ill patients.
Patient-level data were obtained from a random-digit dial telephone survey of adults with chronic conditions. The survey measured respondents' self-report of care coordination problems and level of patient activation, using the Patient Activation Measure (PAM-13). Logistic regression was used to assess association between respondents' self-report of care coordination problems and a set of patient characteristics.
Respondents in the highest activation stage had roughly 30–40 percent lower odds of reporting care coordination problems compared to those in the lowest stage (p < .01). Respondents with multiple chronic conditions were significantly more likely to report coordination problems than those with hypertension only. Respondents' race/ethnicity, employment, insurance status, income, and length of illness were not significantly associated with self-reported care coordination problems.
We conclude that patient activation and complexity of chronic illness are strongly associated with patients' self-report of care coordination problems. Developing targeted strategies to improve care coordination around these patient characteristics may be an effective way to address the issue.
PMCID: PMC3513613  PMID: 22985032
Chronic disease; quality of care/patient safety (measurement); patient assessment/satisfaction
22.  COBRA ARRA Subsidies: Was the Carrot Enticing Enough? 
Health Services Research  2012;47(5):1980-1998.
To help preserve continuity of health insurance coverage during the recent recession, the American Recovery and Reinvestment Act provided a 65 percent Consolidated Omnibus Budget Reconciliation Act (COBRA) premium subsidy for workers laid off in 2008–2010. We examined COBRA enrollment levels with the subsidy and the health, access, and financial consequences of enrollment decisions.
Study Design/Data Collection
Telephone interviews linked with health system databases for 561 respondents who were laid off in 2009 and eligible for the COBRA subsidy (80 percent response rate).
Principal Findings
Overall, 38 percent reported enrolling in COBRA and 54 percent reported having some gaps in insurance coverage since being laid off. After adjustments, we found that those who had higher cost-sharing, who had higher incomes, were older, or were sicker were more likely to enroll in COBRA. COBRA enrollees less frequently reported access problems or that their health suffered because of poor access, but they reported greater financial stress due to health care spending.
Despite the substantial subsidy, a majority of eligible individuals did not enroll in COBRA, and many reported insurance coverage gaps. Nonenrollees reported more access problems and that their health worsened. Without a mandate, subsidies may need to be widely publicized and larger to encourage health insurance enrollment among individuals who suffer a negative income shock.
PMCID: PMC3513614  PMID: 22515835
Premium subsidy; COBRA; individual mandate; care access
23.  Take-Up of Public Insurance and Crowd-Out of Private Insurance under Recent CHIP Expansions to Higher Income Children 
Health Services Research  2012;47(5):1999-2011.
To analyze the effects of states' expansions of Children's Health Insurance Program (CHIP) eligibility to children in higher income families on health insurance coverage outcomes.
Data Sources
2002–2009 Current Population Survey linked to multiple secondary data sources.
Study Design
Instrumental variables estimation of linear probability models. Outcomes are whether the child had any public insurance, any private insurance, or no insurance coverage during the year.
Principal Findings
Among children in families with incomes between two and four times the federal poverty line (FPL), four enrolled in CHIP for every 100 who became eligible. Roughly half of the newly eligible children who took up public insurance were previously uninsured. The upper bound “crowd-out” rate was estimated to be 46 percent.
The CHIP expansions to children in higher income families were associated with limited uptake of public coverage. Our results additionally suggest that there was crowd-out of private insurance coverage.
PMCID: PMC3513615  PMID: 22515792
CHIP; insurance; crowd-out
24.  Impacts of Rising Health Care Costs on Families with Employment-Based Private Insurance: A National Analysis with State Fixed Effects 
Health Services Research  2012;47(5):2012-2030.
Given the rapid growth of health care costs, some experts were concerned with erosion of employment-based private insurance (EBPI). This empirical analysis aims to quantify the concern.
Using the National Health Account, we generated a cost index to represent state-level annual cost growth. We merged it with the 1996–2003 Medical Expenditure Panel Survey. The unit of analysis is the family. We conducted both bivariate and multivariate logistic analyses.
The bivariate analysis found a significant inverse association between the cost index and the proportion of families receiving an offer of EBPI. The multivariate analysis showed that the cost index was significantly negatively associated with the likelihood of receiving an EBPI offer for the entire sample and for families in the first, second, and third quartiles of income distribution.
The cost index was also significantly negatively associated with the proportion of families with EBPI for the entire year for each family member (EBPI-EYEM). The multivariate analysis confirmed significance of the relationship for the entire sample, and for families in the second and third quartiles of income distribution.
Among the families with EBPI-EYEM, there was a positive relationship between the cost index and this group's likelihood of having out-of-pocket expenditures exceeding 10 percent of family income. The multivariate analysis confirmed significance of the relationship for the entire group and for families in the second and third quartiles of income distribution.
Rising health costs reduce EBPI availability and enrollment, and the financial protection provided by it, especially for middle-class families.
PMCID: PMC3513616  PMID: 22417314
Private insurance; health care costs; financial risk
25.  Racial/Ethnic Disparities in Health and Health Care among U.S. Adolescents 
Health Services Research  2012;47(5):2031-2059.
To examine racial/ethnic disparities in medical and oral health status, access to care, and use of services in U.S. adolescents.
Data Source
Secondary data analysis of the 2003 National Survey of Children's Health. The survey focus was children 0–17 years old.
Study Design
Bivariate and multivariable analyses were conducted for white, African American, Latino, Asian/Pacific Islander, American Indian/Alaskan Native, and multiracial adolescents 10–17 years old (n = 48,742) to identify disparities in 40 measures of health and health care.
Principal Findings
Certain disparities were especially marked for specific racial/ethnic groups and multiracial youth. These disparities included suboptimal health status and lack of a personal doctor or nurse for Latinos; suboptimal oral health and not receiving all needed medications in the past year for African Americans; no physician visit or mental health care in the past year for Asian/Pacific Islanders; overweight/obesity, uninsurance, problems getting specialty care, and no routine preventive visit in the past year for American Indian/Alaska Natives; and not receiving all needed dental care in multiracial youth.
U.S. adolescents experience many racial/ethnic disparities in health and health care. These findings indicate a need for ongoing identification and monitoring of and interventions for disparities for all five major racial/ethnic groups and multiracial adolescents.
PMCID: PMC3513617  PMID: 22417169
Race/ethnicity; adolescents; disparities; health

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