Disparities in Realized Access: Patterns of Health Services Utilization by Insurance Status among Children with Asthma in Puerto Rico

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1 Disparities in Realized Access: Patterns of Health Services Utilization by Insurance Status among Children with Asthma in Puerto Rico Ruth Ríos-Motta, PhD, José A. Capriles-Quirós, MD, MPH, MHSA, Mario H. Rodríguez-Sánchez, PhD, MPH and Yelitza Sánchez- Rodríguez, MS. Puerto Rico Health Services Research Institute Health Services Administration Department, University of Puerto Rico Graduate School of Public Health

2 Asthma in Children Asthma is the most common chronic illness of childhood. Puerto Rican children highest prevalence of asthma among various ethnic minority groups in the United States. 10% for mainland non-latino whites 12% for mainland Hispanics 13% for mainland African American children 30% for Puerto Rico Commonwealth (Ortega, et. al., 2002) 14.5% in patients insured by a major health insurance company in Puerto Rico (Pérez-Perdomo, et al.,1999)

3 Use of of Healthcare Services among Asthmatic Children Increased morbidity has been associated with diminished accessibility to appropriate outpatient health services increased tendencies to use hospital Emergency Departments (ED) as primary sources of care (Bratton, 2002; Halfon and Newacheck, 1993; Miller, 2000; Ortega & Calderon (2000) Frequent use of the hospital Emergency Departments (ED) as primary sources of care have been associated with increased morbidity, higher treatment costs, adverse clinical outcomes for children with asthma

4 Use of of Healthcare Services among Asthmatic Children The reduction of ED visits for asthma care is one of the national targets Healthy People Most asthma hospitalizations for children are preventable with adequate disease management described in National Educational Prevention Program (NAEPP).

5 Use of of Healthcare Services among Asthmatic Children Demographic and economic factors may play an important role in observed persistent differences in utilization patterns even controlling for symptoms among asthma patients: Race/ ethnicity Insurance status Family income (Ortega et al., 2001).

6 Use Use of of Healthcare Services among among Puerto Puerto Rican RicanChildren with with Asthma 59.6% of Puerto Rican children with asthma had the highest number of doctor s office visits (Pérez-Perdomo et al.,1999) Behavioral Risk Factor Surveillance System: 50.0% children with asthma visited the ED 27.0% had hospital admissions in the previous year. Children with Medicaid used the ED more frequently for asthma services than privately insured children (Ortega & Calderon, 2000).

7 Healthcare System Reform in Puerto Rico 1993, integration of public and private healthcare delivery systems. The government privatized public healthcare facilities. Private health insurance companies extended health insurance coverage to the medically indigent population. Enrollees were issued private health insurance cards that enabled them to access private health care Capitation: payment system for primary care providers. The Island was divided in 10 regions by geographic proximity

8 Study Aim Describe health services utilization patterns by insurance status [Medicaid-Managed Care (MC) and Fee-For-Service (FFS)] in a sample of pediatric asthma patients in Puerto Rico during year Physicians Office visits Emergency Department (ED) services use Hospitalization

9 Figure 1 Framework for Classifying Topics and Issues in Health Services Research Health Policy Federal, State, Local Structure Delivery System Availability, Organization, Financing Population at Risk Predisposing, Enabling, Need Environment Physical, Social, Economic Process Realized Access Utilization Satisfaction Health Risks Environmental, Behavioral Intermediate Outcomes Efficiency Production, Allocative Effectiveness Population, Clinical Equity Procedural, Substantive Ultimate Outcomes Health Individuals, Community

10 Cross sectional design Secondary Data Analysis Methods Sample: beneficiaries of the Puerto Rico Health Care Reform (MMC, Medicaid-Managed Care) and group with private insurance (FFS, Fee-For-Service) from the same Health Insurance Company This study explores the patterns of health care utilization for people under 18 years old diagnosed with asthma (ICDC: 493.0, 493.1, 493.2, 493.9) Claims files (n=24,154) for 2001 Exclusion criteria: Children with only one office visit or one claim for drugs were excluded. This was done to minimize the possibility of including persons with non-reliable or suspected diagnosis of asthma.

11 Private Health Insurance Plan Major health insurance company in PR. Fee for service Has an extensive network of participants and providers (more than 13,000 providers and health facilities) Assures the most accessibility to medical/hospital services on the Island.

12 Medicaid-Managed Care Health Plan Is the Managed Care division of the same major private health insurance company. Capitation Participates in the Puerto Rico Healthcare Reform since Extensive and comprehensive medical and hospital benefits at the lowest possible cost. The plan also covers dental, pharmacy and laboratory services.

13 Analysis Unadjusted rates of 12-months utilization of office visits, ED services, and hospital admissions by insurance status Chi-square significance tests were used to examine associations between health insurance plan by age, gender, socioeconomic index, and health care services use. Multiple logistic regression models were used to determine the effect of type of insurance (FFS and MC) on last 12-months use of each health care setting (physician visits, ED use, and number of hospitalizations) including the following covariates: age, gender, and socioeconomic index

14 Socio-demographicProfile

15 Percent Mean Distribution Age by Health of Insurance Gender by Type Health Insurance Type Percent Distribution of Socioeconomic Status (SES) by Health Insurance Type 79.7% % 42.1% 43.1% % 57.9% 56.9% 20.3% Female High SES Managed Care Managed Care Managed Care Male Low SES Fee-For-Service Fee-For-Service Fee-For-Service

16 Results

17 Figure 5 Percent Distribution of Office Visits in a Year by Health Insurance Type* 59.8% 55.0% 38.7% 37.9% 7.1% 1.5% * p< to 4 5 or more Managed Care Fee-For-Service Office visits

18 Figure 6 Office Visits Means by Health Insurance Type* 6.7 (SD=11.1) 0.92 (SD=1.1) * p<.05 Managed Care Fee-For-Service

19 Figure 7 Emergency Department Visits Means by Health Insurance Type* 3.6 (SD=3.7) 1.3(SD=0.9) * p<.05 Managed Care Fee-For-Service

20 Hospitalizations Mean by Health Insurance Type * 4.0 (SD=4.1) 1.1(SD=.35) * p<.05 Managed Care Figure 8 Fee-For-Service

21 Table 1: Results of Logistic Regression Analyses of Last Year Health Services Use for Asthma Office Visits O.R. (95% CI) ED Use O.R. (95% CI) Hospital Admissions O.R. (95% CI) Medicaid-Managed Care MMC ( ) ( ) ( ) Fee-For-Services Note: Unweighted data. Odds ratios (ORs) are adjusted for gender, age, year, socioeconomic Index, and services use. CI= 95% Confidence Interval

22 Conclusions The FFS group is more likely to visit the physicians offices and showed consistently more office visits than those enrolled in the MMC Plan. MMC patients are three times more likely to use ED services that those enrolled in the FFS group Our findings support that lower SES children under MMC plan evidenced health care use disparities when compared to higher SES asthmatic children in Puerto Rico (FFS).

23 Conclusions These results corroborate previous findings. A study with a sample of children with parentreported asthma in Puerto Rico, informed that those attending public schools had more ED visits, hospitalizations, and missed school days than children in private schools (Nazario et al., 2004). Medicaid insured asthmatic children were twice more likely to use ED services than their privately insured counterparts (Ortega & Calderon, 2000).

24 Conclusions Future studies should further Explore alternative explanations for these disparities Evaluate the quality of the care provided. Study the primary care physicians follow-up system and the referral system for the asthma patient, focusing the efforts on assessing how the system structure and the quality of services have an impact on asthma

25 Limitations The findings have to be interpreted based on the limitations of the use of claims (administrative) database. This data was collected primarily for administrative purposes. Limited independent measures of asthma severity

26 Acknowledgements This research project is supported by the Agency of Healthcare Research and Quality, Grant No. 1 R24 HS

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