Employer-sponsored Insurance Plans Research Articles

Trends in Telerehabilitation Utilization in the United States 2020-2021

ObjectiveTo examine telerehabilitation utilization in the United States (US) during the first 2 years of the pandemic. DesignWe performed a retrospective analysis of outpatient insurance claims from the IBM MarketScan Commercial Claims and Encounters Database to identify the number and proportion of patients using telerehabilitation from 2020 to 2021. Telerehabilitation was identified based on the presence of specific code modifiers and place of service. SettingRetrospective claims analysis. ParticipantsIndividuals living in the United States with employer-sponsored insurance plans using outpatient physical or occupational therapy (PT/OT) (N=2,007,524). InterventionsNot applicable. Main Outcome MeasureNumber and proportion of outpatient PT/OT visits completed via telerehabilitation. ResultsWe identified 21,026,608 PT/OT visits among 2,007,524 patients. Overall, 49,974 (2.5%) patients received ≥1 telerehabilitation visit during the specified timeframe. We observed trends in utilization over time, with utilization peaking in April 2020 when 10.9% of all PT/OT visits were conducted by telerehabilitation. We also observed geographic trends with lower rates of utilization identified in rural areas. State-by-state utilization rates ranged from 10.4% (California) to 0.3% (Wyoming). ConclusionTelerehabilitation may be underutilized as a means of improving access to PT/OT, especially in rural areas of the country. Further research is needed to examine contributing factors to low observed utilization rates, such as provider and patient perceptions of telerehabilitation.

Century-Long Trends in the Financing and Ownership of American Health Care.

Who pays for health care-and who owns it-determine what care is delivered, who receives it, and who profits from it. We examined trends in health care ownership and financing over a century. We used multiple historical and current data sources (including data from the American Medical Association, the American Hospital Association, government publications and surveys, and analyses of Medicare Provider of Services files) to classify health care provider ownership as: public, private (for-profit), and private (not-for-profit). We used US Census data to classify physicians' employers as public, not-for-profit, or for-profit entities or "self-employed." We combined estimates from the official National Health Expenditures Accounts with other data sources to determine the public vs. private share of health care spending since 1923; we calculated a "comprehensive" public share metric that accounted for public subsidization of private health expenditures, mostly via the tax exemption for employer-sponsored insurance plans or government purchase of such plans for public employees. For-profit ownership of most health care subsectors has risen in recent decades and now predominates in several (including nursing facilities, ambulatory surgical facilities, dialysis facilities, hospices, and home health agencies). However, most community hospitals remain not-for-profit. Additionally, over the past century, a growing share of physicians identify as employees. Meanwhile, the comprehensive taxpayer-financed share of health care spending has increased dramatically from 9% in 1923 to 69% in 2020, with taxpayer-financed subsidies to private expenditures accounting for much of the recent growth. American health care is increasingly publicly financed yet investor owned, a trend accompanied by rising costs and, recently, worsening population health. A reassessment of the US mode of health care financing and ownership appears warranted.

Out-of-Network Care in Commercially Insured Pediatric Patients According to Medical Complexity.

Commercial health plans establish networks and require much higher cost sharing for out-of-network (OON) care. Yet, the adequacy of health plan networks for access to pediatric specialists, especially for children with medical complexity, is largely unknown. To examine differences in OON care and associated cost-sharing payments for commercially insured children with different levels of medical complexity. Cross-sectional study using a nationwide commercial claims database. Enrollees 0-18 years old in employer-sponsored insurance plans. The Pediatric Medical Complexity Algorithm was used to classify individuals into 3 levels of medical complexity: children with no chronic disease, children with non-complex chronic diseases, and children with complex chronic diseases. OON care rates, cost-sharing payments for OON care and in-network care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing. The study sample included 6,399,006 individuals with no chronic disease, 1,674,450 with noncomplex chronic diseases, and 603,237 with complex chronic diseases. Children with noncomplex chronic diseases were more likely to encounter OON care by 6.77 percentage points with higher cost-sharing by $288 for OON care, relative to those with no chronic disease. For those with complex chronic diseases, these differences rose to 16.08 percentage points and $599, respectively. Among children who saw behavioral health providers, rates of OON care were especially high. Commercially insured children with medical complexity experience higher rates of OON care with higher OON cost-sharing payments compared with those with no chronic disease.

Comparing Gold-standard Copayment and Coinsurance Values From Claims Processing Engines to Values Derived From Behavioral Health Claims Databases.

While researchers use patient expenditures in claims data to estimate insurance benefit features, little evidence exists to indicate whether the resulting measures are accurate. To develop and test an algorithm for deriving copayment and coinsurance values from behavioral health claims data. Employer-sponsored insurance plans from 2011 to 2013 for a national managed behavioral health organization (MBHO). Twelve benefit features, distinguishing between carve-in and carve-out, in-network and out-of-network, inpatient and outpatient, and copayment and coinsurance, were created. Measures drew from claims (claims-derived measures), and benefit feature data from a claims processing engine database (true measures). We calculate sensitivity and specificity of the claims-derived measures' ability to accurately determine if a benefit feature was required and for plan-years requiring the benefit feature, the accuracy of the claims-derived measures. Accuracy rates using the minimum, 25th, 50th, 75th, and maximum claims value for a plan-year were compared. Sensitivity (82% or higher for all but 3 benefit features) and specificity (95% or higher for all but 2 benefit features) were relatively high. Accuracy rates were highest using the 75th or maximum claims value, depending on the benefit feature, and ranged from 69% to 99% for all benefit features except for out-of-network inpatient coinsurance. For most plan-years, claims-derived measures correctly identify required specialty mental health copayments and coinsurance, although the claims-derived measures' accuracy varies across benefit design features. This information should be considered when creating claims-derived benefit features to use for policy analysis.

Physician Practice Pattern Variations in Common Clinical Scenarios Within 5 US Metropolitan Areas

While variations in quality of care have been described between US regions, physician-level practice pattern variations within regions remain poorly understood, notably among specialists. To examine within-area physician-level variations in decision-making in common clinical scenarios where guidelines specifying appropriateness or quality of care exist. This cross-sectional study used 2016 through 2019 data from a large nationwide network of commercial insurers, provided by Health Intelligence Company, LLC, within 5 metropolitan statistical areas (MSAs). Physician-level variations in appropriateness and quality of care were measured using 14 common clinical scenarios involving 7 specialties. The measures were constructed using public quality measure definitions, clinical guidelines, and appropriateness criteria from the clinical literature. Physician performance was calculated using a multilevel model adjusted for patient age, sex, risk score, and socioeconomic status with physician random effects. Measure reliability for each physician was calculated using the signal-to-noise approach. Within-MSA variation was calculated between physician quintiles adjusted for patient attributes, with the first quintile denoting highest quality or appropriateness and the fifth quintile reflecting the opposite. Data were analyzed March through October 2021. Fourteen measures of quality or appropriateness of care, with 2 measures each in the domains of cardiology, endocrinology, gastroenterology, pulmonology, obstetrics, orthopedics, and neurosurgery. A total of 8788 physicians were included across the 5 MSAs, and about 2.5 million unique patient-physician pairs were included in the measures. Within the 5 MSAs, on average, patients in the measures were 34.7 to 40.7 years old, 49.1% to 52.3% female, had a mean risk score of 0.8 to 1.0, and more likely to have an employer-sponsored insurance plan that was either self-insured or fully insured (59.8% to 97.6%). Within MSAs, physician-level variations were qualitatively similar across measures. For example, statin therapy in patients with coronary artery disease ranged from 54.3% to 70.9% in the first quintile of cardiologists to 30.5% to 42.6% in the fifth quintile. Upper endoscopy in patients with gastroesophageal reflux disease without alarm symptoms spanned 14.6% to 16.9% in the first quintile of gastroenterologists to 28.2% to 33.8% in the fifth quintile. Among patients with new knee or hip osteoarthritis, 2.1% to 3.4% received arthroscopy in the first quintile of orthopedic surgeons, whereas 25.5% to 30.7% did in the fifth quintile. Appropriate prenatal screening among pregnant patients ranged from 82.6% to 93.6% in the first quintile of obstetricians to 30.9% to 65.7% in the fifth quintile. Within MSAs, adjusted differences between quintiles approximated unadjusted differences. Measure reliability, which can reflect consistency and reproducibility, exceeded 70.0% across nearly all measures in all MSAs. In this cross-sectional study of 5 US metropolitan areas, sizeable physician-level practice variations were found across common clinical scenarios and specialties. Understanding the sources of these variations may inform efforts to improve the value of care.

Cost-Sharing Disparities for Out-of-Network Care for Adults With Behavioral Health Conditions

Individuals in the United States with mental illnesses and substance use disorders can face major access barriers from limited provider (eg, clinicians and facilities) networks in health insurance plans. To evaluate the cost-sharing payments for out-of-network (OON) care for private insurance plan enrollees with mental health conditions, alcohol use disorders, or drug use disorders compared with those with congestive heart failure (CHF) or diabetes. This cross-sectional study used data from a large commercial claims database from 2012 to 2017. The study included adults with mental health conditions, with alcohol use disorders, with drug use disorders, with CHF, and with diabetes who were aged 18 to 64 years and enrolled in employer-sponsored insurance plans. Main outcomes included OON care during hospitalization, OON care during outpatient care, cost-sharing payments with OON care, OON cost sharing as a proportion of total health care spending, and OON cost sharing as a proportion of total cost sharing. The study sample included 3 209 929 enrollees with mental health conditions (mean [SD] age, 45.9 [12.6] years; 64.8% women), 294 550 with alcohol use disorders (mean [SD] age, 42.8 [13.4] years; 60.9% men), 321 535 with drug use disorders (mean [SD] age, 41.1 [13.9] years; 59.1% men), 178 701 with CHF (mean [SD] age, 53.8 [8.9] years; 62.6% men), and 1 383 398 with diabetes (mean [SD] age, 52.5 [9.0] years; 58.9% men). Enrollees with behavioral conditions were more likely to encounter OON clinicians in inpatient and outpatient settings. For instance, those with drug use disorders were 12.9 percentage points (95% CI, 12.5-13.2 percentage points; P < .001) more likely to have inpatient OON care than those with CHF and 15.3 percentage points (95% CI, 15.1-15.6 percentage points; P < .001) more likely to receive outpatient OON care. Behavioral conditions also had higher cost sharing for OON care. For example, individuals with mental health conditions had cost-sharing payments for OON care $341 (95% CI, $331-$351) higher than those with diabetes (P < .001), individuals with drug use disorders had cost-sharing payments for OON care $1242 (95% CI, $1209-$1276) higher than those with diabetes (P < .001), and individuals with alcohol use disorders had cost-sharing payments for OON care $1138 (95% CI, $1101-$1174) higher than those with diabetes (P < .001). The OON care rates and cost-sharing payments were much higher when enrollees sought care from behavioral clinicians and facilities. In this cross-sectional study of enrollees in commercial insurance plans, cost sharing for OON care among those with behavioral health conditions was significantly higher than those with chronic physical conditions. These disparities may be indicative of limited in-network availability for behavioral health care.

Box 12, IRS W-2, to the Rescue: The Effect of Transferring Pre-Tax Employer-Sponsored Health Insurance Funds to Employees On After-Tax Income, Federal Income and Payroll Taxes, Health Insurance Premiums, and Health Care Costs

Current tax law prevents workers from trading pre-tax employer-sponsored insurance (ESI) premiums for greater after-tax take-home income. Many workers thus may pay for health plans that are more expensive or have different features from plans they would directly choose for themselves. The tax subsidization of ESI also likely leads to excessive spending on health care because it lowers its costs relative to other non tax-subsidized goods and services. Some propose limiting or eliminating this employer-based health insurance tax exemption for these reasons; its regressivity; and its drain of potential tax revenues. Because of the long history and popular support for ESI, we consider these proposals as practically and politically infeasible. Instead, we simulate the financial results of expanding employee choice and ability to control costs within the traditional structure of ESI by allowing employees, either through Health Reimbursement Accounts (HRAs) or other tax-free mechanisms, to receive their employers’ premium contribution directly and then purchase health insurance themselves from a larger number of health plans than those currently offered to them. The minimal choice in most current ESI plans may force enrollees into plans that do not reflect their preferences and thus imposes an allocative cost. Some empirical research indicates that enrollees would welcome expansion in their choice of plans and that it yields beneficial financial results. Other research, however, indicates that choice overload leads to sub-optimal selection results. It is likely that differences in the educational and transparency support resources partially explain these conflicting results. In our simulation, employees could deduct for income tax purposes the amount used for insurance and, if they spend less than the amount transferred, adjusted for a cross-subsidization holdback from lower-cost employees to higher-cost ones, take the remainder as taxed income. The simulation indicates that annual after-tax household income would have grown by $101–$252 billion and federal tax revenues increased by $39–$163 billion, depending on the concentration of risk in the ESI pool. Lower- and middle-income households gained proportionately more income than higher income ones. The greater take-up of slimmed down policies leads to reduced net spending in the health care delivery system, which, because of the large size of the ESI enrollee pool, would likely spill over to governmental health care programs. These results are based on three specific assumptions about the concentration of risk in the corporate pool and complete ESI implementation of our proposal. Research about the impact of reduced coverage insurance policies generally indicates that they are significantly lower priced. As for health status, the nation’s largest social science experiment, conducted primarily in the 1970s, found that reduced coverage had no impact except for low-income people who are currently covered by Medicaid and the Affordable Care Act. However, subsequent analysis revealed that reduced coverage affected the use of preventive care, even if it was fully insured. Harnessing consumer choice requires a fully transparent and informative ESI system. Informed employee insurance selections require an adequate choice of reasonable insurance plans, disclosure by employers of their contributions, how much employee take-home wages are reduced to pay for ESI, the actuarial value of the plans, and how those employee contributions and actuarial values compare to peer firms and change over time. This enhanced disclosure will likely cause an increase in plan choice. Instructional and navigational support also appear to be key to effective choice of insurance plans.

Health Care Spending Under Employer-Sponsored Insurance: A 10-Year Retrospective.

Using a national sample of health care claims data from the Health Care Cost Institute, we found that total spending per capita (not including premiums) on health services for enrollees in employer-sponsored insurance plans increased by 44percent from 2007 through 2016 (average annual growth of 4.1percent). Spending increased across all major categories of health services, although the increases were not uniform across years or categories. Growth rates for total per capita spending generally slowed after 2009 but increased between 2014 and 2016. Spending on outpatient services grew more quickly (average annual growth of 5.7percent) compared to spending on the other types of services. However, the overall distribution of spending across categories remained largely unchanged. In the context of the dramatic economic and policy events that have taken place since 2007-including the Great Recession, the Affordable Care Act, and numerous medical innovations-this assessment of ten-year spending trends provides insights into how the largest insured population in the US contributes to health care spending growth.

Allocation of Health Care Resources: Principles for Decision-making.

1. Hellen Ransom, DHCE* 2. John M. Olsson, MD, CPE† 1. *Department of Bioethics and Interdisciplinary Studies, 2. †Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC * Abbreviations: CT: : computed tomography MCO: : managed care organization MRI: : magnetic resonance imaging Pediatricians engage in making decisions on allocation of health care resources on a daily basis. However, they may not be aware of the ethical principles underlying those decisions and how to apply those principles in the process of allocating health care resources. After completing this article, readers should be able to: 1. Identify the ethical principles that should be considered when making decisions on allocating health care resources. 2. Apply ethical principles in clinical settings with limited health care resources. 3. Discuss the role of the institutional ethics committee in assisting clinicians in making point-of-care health care allocation decisions. Health care resources are defined as all materials, personnel, facilities, funds, and anything else that can be used for providing health care services. Health care has long been a limited resource for which there has been an unlimited demand; everyone needs health care. Until the 20th century, US health care was allocated by the ability to pay or barter, with small numbers of individuals consuming the bulk of the resources, leaving few resources available to others. During the past 100 years, increased interest in good personal and public health resulted in the development of various forms of health insurance. Health insurance became available through employer-sponsored insurance plans and, in the 1960s, entitlement programs—including Medicare and Medicaid. In spite of the presence of these forms of payment, demands for all aspects of health care continue to exceed its available resources. Millions of people in the United States, including children, continue to lack health insurance or avenues to access health care resources. Likewise, the costs associated with health care have increased dramatically as technology has advanced, …

Medicaid Expansion and ACA Repeal: Evidence From Ohio.

To examine the health insurance coverage options for Medicaid expansion enrollees if the Affordable Care Act (ACA) is repealed, using evidence from Ohio, where more than half a million adults have enrolled in the state's Medicaid program through the ACA expansion. The Ohio Medicaid Assessment Survey interviewed 42 000 households in 2015. We report data from a unique battery of questions designed to identify insurance coverage immediately prior to Medicaid enrollment. Ninety-five percent of new Medicaid enrollees in Ohio did not have a private health insurance option immediately before enrollment. These new enrollees are predominantly older, low-income Whites with a high school education or less. Only 5% of new Medicaid enrollees were eligible for an employer-sponsored insurance plan to which they could potentially return in the case of repeal of the ACA. The vast majority of Medicaid expansion enrollees would have no plausible pathway to obtaining private-sector insurance if the ACA were repealed. Demographic similarities between the expansion population and 2016 exit polls suggest that coverage losses would fall disproportionately on members of the winning Republican coalition.

Over-the-Counter Access to Oral Contraception: Reproductive Autonomy on Pharmacy Shelves or a Political Trojan Horse?

Abstract During the fall of 2014, in what seemed like a change of heart, Republican congressional candidates began calling for a policy that reproductive rights advocates have supported for years. Over-the-counter (OTC) oral contraception (OC) became these candidates ' way to connect with the women alienated by the Republican Party in recent elections. They emphasized how OTC access would allow women themselves, not employers or the government, to have control over contraceptive decisions. Liberals responded that this new effort was just a Trojan horse--legalizing OTC access would not only increase the actual price tag on OC, but it would also remove OC from the Patient Protection and Affordable Care Act's extended insurance coverage of contraception. Additionally, reproductive rights advocates noted that it is the Food and Drug Administration (FDA ), not Congress, that legalizes OTC drugs, and the FDA has not received any applications from drug manufacturers who want to sell OC OTC. In reality, both sides have something of a valid argument. OTC OC would be an important step toward reproductive autonomy for American women. It is also correct, however, that an immediate liberalization of OTC presents several issues, economically, politically, and culturally. Despite these valid critiques, OTC access for OC is a change that is worth the time and effort to move past politics and get it right, for many reasons. Requiring insurance companies and Medicaid to reimburse women for OTC OC purchases is a step toward establishing an accessible market and ensuring corresponding reproductive autonomy for women in the United States, which should accompany legalization of OTC OC. INTRODUCTION In 2014, Americans spent a lot of time, energy, and money arguing about oral contraception (OC or control pills)--specifically, who should pay for it. Yet, the public debate surrounding whether employer-sponsored insurance plans should cover OC was mostly unproductive as far as advancing women's reproductive autonomy is concerned. That is because the current United States prescription-only access system for birth control pills fails to serve the needs of the women who stand to gain the most from access to OC. The employer mandate debate only took us further away from realizing a system that would promote access for all women--that is, legalizing an over-the-counter (OTC) Food and Drug Administration (FDA) designation for OC instead of limiting it to prescription-only status. Despite the seemingly groundbreaking contraceptive mandate in the Patient Protection and Affordable Care Act of 2010 (ACA), which transferred responsibility for the monetary cost of OC from women to their insurance companies, (1) all women's access to OC did not improve, nor was the controversy surrounding it reduced. The ACA's provision that insurers have to now pay for OC was intensely contentious among the American public, and the Supreme Court ruled in 2014 that employers with a religious objection to contraception do not have to comply with the ACA's employer mandate. (2) This controversy took attention away from the fact that, notwithstanding the obvious benefits of reducing the price of reproductive planning for women with employer insurance plans, the contraceptive mandate fails to help large segments of women, some of whom stand to benefit most from increased access to OC--specifically women who are unemployed, work part time, are undocumented, or are still on their parents' health insurance (3)--and fails to address the problematic nonmonetary costs of the prescription access system. OTC access would address these issues. With the approval of the American College of Obstetricians and Gynecologists, (4) OTC access is a safe proposal from a public health perspective and one that women want. (5) This Note argues that legalizing OTC access is safe, desirable, and furthers women's autonomy over reproductive decisions. …

Adverse and Advantageous Selection in the Medicare Supplemental Market: A Bayesian Analysis of Prescription drug Expenditure

This paper develops an extended specification of the two-part model, which controls for unobservable self-selection and heterogeneity of health insurance, and analyzes the impact of Medicare supplemental plans on the prescription drug expenditure of the elderly, using a linked data set based on the Medicare Current Beneficiary Survey data for 2003-2004. The econometric analysis is conducted using a Bayesian econometric framework. We estimate the treatment effects for different counterfactuals and find significant evidence of endogeneity in plan choice and the presence of both adverse and advantageous selections in the supplemental insurance market. The average incentive effect is estimated to be $757 (2004 value) or 41% increase per person per year for the elderly enrolled in supplemental plans with drug coverage against the Medicare fee-for-service counterfactual and is $350 or 21% against the supplemental plans without drug coverage counterfactual. The incentive effect varies by different sources of drug coverage: highest for employer-sponsored insurance plans, followed by Medigap and managed medicare plans.

Integrated Ethics Programs In The Healthcare Industry

The healthcare industry of the United States is undergoing extensive change to meet the needs of the Affordable Care Act of 2010. Organizations need to comply with a new macro-regulatory environment and establish institutionally based strategies that meet mandated standards and processes. The Act represents a shift from employer-sponsored insurance plans to a system where, depending upon subjective evaluations of what is on offer, consumers can shop around and purchase insurance plans listed in a federal or state marketplace. This means that healthcare providers are under intense political and public scrutiny. The new competitive environment may accelerate the shift from care-focused to efficiency-focused management initiatives within the healthcare industry and is viewed by some as an opportunity for contextual ambidexterity and conflict to emerge. In addition to establishing compliance programs to manage employees’ ethical conduct in an effort to meet the narrow and deterministic demands of governmental pressure, organizations may also introduce ethical programs that reflect organizational commitment, individual integrity, and the willingness to admit mistakes and be creative in problem-solving exercises.

The impact of accreditation on safety and cost of bariatric surgery

BackgroundThe objective of this study was to examine how much of the impact of the Centers for Medicare and Medicaid Services’ national coverage decision (NCD) on bariatric surgery was driven by the restriction of reimbursements to Centers of Excellence (COE). We used inpatient care data of those with employer-sponsored insurance plans across United States using the MarketScan Commercial Claims and Encounter Database (2003–2009). MethodsWe performed a retrospective cohort study evaluating the impact of the accreditation on subjects with a difference-in-difference approach (removing the temporal changes occurring in non-COEs) on rates of inpatient mortality, 90-day reoperations, complications, readmissions, and total payments. ResultsA total of 30,755 patients (43.9±11.0 years; 79.9% women) had bariatric surgery. A total of 17,896 patients underwent procedures at sites that became COEs (8455 pre-NCD and 9441 post-NCD, [+10.4%]) compared with 12,859 at non-COEs (6534 pre-NCD and 6325 post-NCD, [−3.3%]). Of the total number of bariatric procedures, laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable band procedures increased from 42.9% and 3.1% pre-NCD to 64.5% and 19.7% post-NCD, respectively. In the COEs, there were reductions in inpatient mortality (.3% to .1%; P = .02), 90-day reoperations (.8% to .5%; P = .006), complications (36.4% to 27.6%; P<.001), and readmissions (10.8% to 8.8%; P<.001) while payments remained similar ($24,543±$40,145 to $24,510±$37,769; P = .9). After distinguishing from temporal trends and differences occurring at non-COEs, 90-day reoperation (−.8%; P = .02) and complication rates (−2.7%; P = .01) were lower at the COEs after the NCD. ConclusionsThe accreditation-based NCD in bariatric surgery was associated with lower rates of reoperations and complications. Such policies may become a powerful tool to improve surgical safety and quality.

Colorado’s Patient-Centered Medical Home Pilot Met Numerous Obstacles, Yet Saw Results Such As Reduced Hospital Admissions

The Colorado Multipayer Patient-Centered Medical Home Pilot, which ran from May 2009 through April 2012, was one of the first voluntary multipayer medical home pilot projects in the country. Six health plans, the state's high-risk pool carrier, and sixteen family or internal medicine practices with approximately 100,000 patients participated. Although a full analysis is currently under way, preliminary results show that the pilot significantly reduced emergency department visits and also reduced hospital admissions, particularly for patients with multiple chronic conditions. One payer reported a return on its investment of 250-400 percent in the pilot. However, participants also ran into numerous obstacles. Among them: Many practices were left providing extra services to a large fraction of patients whose employer-sponsored insurance plans declined to pay the enhanced fees necessary to cover the cost of the patient-centered medical home expansion. The experience demonstrates that creating patient-centered medical homes and enabling them to be successful will take strong commitments and collaborative efforts on multiple fronts.

Health Risk Appraisals: How Much Do They Influence Employees’ Health Behavior?

Health plans often use health risk appraisals (HRAs) as a starting point in engaging members in behavioral change. We examine characteristics associated with the voluntary completion of HRAs among enrollees in employer-sponsored insurance plans. We compare health care use, costs, and participation in disease management programs for HRA completers and similar enrollees in plans that do not offer an HRA. Women, healthier people, and people in consumer-driven health plans (CDHPs) are more likely than others to complete an HRA. Among those who complete an HRA, use of office visits, prescription drugs, and cervical cancer screening increases compared to those who are not offered an HRA.

The National Nursing Assistant Survey: Improving the Evidence Base for Policy Initiatives to Strengthen the Certified Nursing Assistant Workforce

This study introduces the first National Nursing Assistant Survey (NNAS), a major advance in the data available about certified nursing assistants (CNAs) and a rich resource for evidence-based policy, practice, and applied research initiatives. We highlight potential uses of this new survey using select population estimates as examples of how the NNAS can be used to inform new policy directions. The NNAS is a nationally representative survey of 3,017 CNAs working in nursing homes, who were interviewed by phone in 2004-2005. Key survey components are recruitment; education; training and licensure; job history; family life; management and supervision; client relations; organizational commitment and job satisfaction; workplace environment; work-related injuries; and demographics. One in three CNAs received some kind of means-tested public assistance. More than half of CNAs incurred at least 1 work-related injury within the past year and almost one quarter were unable to work for at least 1 day due to the injury. Forty-two percent of uninsured CNAs cite not participating in their employer-sponsored insurance plan because they could not afford the plan. Years of experience do not translate into higher wages; CNAs with 10 or more years of experience averaged just $2/hr more than aides who started working in the field less than 1 year ago. This survey can be used to understand CNA workforce issues and challenges and to plan for sustainable solutions to stabilize this workforce. The NNAS can be linked to other existing data sets to examine more comprehensive and complex relationships among CNA, facility, resident, and community characteristics, thereby expanding its usefulness.

Insurance for children with special health care needs: patterns of coverage and burden on families to provide adequate insurance.

To update national estimates of insurance coverage for children with special health care needs (CSHCN) to reflect better the current economic and policy environment and to examine the burden on families and adequacy of coverage. I analyzed data on children who were aged 0 to 17 and included in the sample child files of the 2000 and 2001 National Health Interview Survey (NHIS). CSHCN were identified using a noncategorical approach. Various measures of insurance coverage type, premium contributions, unmet need for care, and out-of-pocket spending were compared for CSHCN and children without special needs across all incomes and stratified by poverty status. Compared with other children, CSHCN had higher rates of public insurance (29.8% vs 18.5%), lower rates of private insurance (62.5% vs 69.1%), and a smaller percentage without insurance (8.1% vs 11.5%). More than 13% of low-income CSHCN were uninsured. Most (78.1%) families of CSHCN contributed to private insurance premiums. Family premium contributions for employer-sponsored insurance plans averaged 2058 dollars, or 4.4% of income; premiums for private nongroup insurance were higher (3593 dollars) and consumed a larger percentage of income (6.6%). For children with insurance, rates of unmet need for specific services were relatively low, suggesting that insurance coverage was adequate. However, almost 20% of low-income CSHCN experienced some form of unmet need and of out-of-pocket spending was significantly higher for families with CSHCN compared with those without CSHCN. CSHCN are more likely to have insurance coverage, but among low-income CSHCN, lack of insurance remains a problem. In addition, the burden on families of CSHCN to provide insurance is greater, yet coverage purchased is not always adequate to meet the needs of many children and places addition burdens on families to pay directly for care.

Diabetes in employer-sponsored health insurance.

To examine medical and mental health care expenditures for large numbers of individuals with diabetes enrolled in employment-sponsored insurance plans. Health insurance billing data for approximately 1.3 million individuals enrolled in health insurance plans sponsored by 862 large self-insured employers nationwide were used to examine employer expenditures and consumer out-of-pocket payments for 20,937 people identified with diabetes. These expenditures were compared with expenditures for individuals with other chronic illnesses. Main outcome measures were covered charges, insurance plan reimbursements, and estimated consumer out-of-pocket payments for both medical and mental health services. A total of 1.7% of enrollees were identified as having diabetes and approximately 11% of those used at least one mental health service during 1996. Health care expenditures were three times higher for those with diabetes compared with all health care consumers in these insurance plans, but when compared with individuals with other chronic illnesses such as heart disease, HIV/AIDS, cancer, and asthma, those with diabetes were not more expensive for employers' insurance plans. Diabetes accounts for 6.5% of total health plan expenditures. Diabetes is not more expensive for either consumers or their employer-sponsored insurance plans than other chronic illnesses.

Costs and duration of care for lower extremity ulcers in patients with diabetes

Medical and pharmaceutical insurance claims associated with lower extremity diabetic ulcers were examined retrospectively to better understand the costs and duration of treatment in clinical practice. The study population consisted of working-age individuals (18 to 64 years old) with health care benefits provided through private employer-sponsored insurance plans. Diagnostic information contained in the claims database was used to identify the severity of the ulcers, and the charges associated with treatment were based on claims data. Claims for lower extremity ulcers were found in 5.1% of individuals with diabetes. Although many lower extremity ulcers heal with standard treatment, some are more resistant to treatment and require costly ongoing medical care. Almost half of these cases were associated with deep infection, osteomyelitis, or amputation. Total payments for treatment of lower extremity ulcers in this population averaged $2687 per patient per year, or $4595 per ulcer episode, with inpatient expenditures accounting for more than 80% of these costs. Costs were significantly higher for patients with more severe ulcers or with inadequate vascular status in the affected limb. We concluded that lower extremity ulcers occur in a large number of working-age people with diabetes and contribute significantly to the morbidity associated with this disease. The high cost of treating diabetic foot ulcers suggested by this analysis argues for the development of better treatment strategies and outcomes assessments for these patients.