Medicaid Status Research Articles

How Does Medicaid-Managed Care Impact Reporting of Medicaid Status?

To resolve a conflict in the literature on whether Medicaid-Managed Care (MMC) impacts the Medicaid Undercount. California county-level data (1995-1997) on MMC penetration, public use data from the Current Population Survey (CPS) (1995-1997), and restricted CPS data matched to administrative records on Medicaid enrollment (2001-2002). We explore the robustness of previous results from the literature first using aggregate data and alternative models. We then examine CPS data linked to Medicaid enrollment data to estimate models of Medicaid reporting errors related to MMC. The Census Bureau linked administrative data on Medicaid enrollment to the CPS. Other data used were public use. We find similar results to a previous study using aggregate data that suggest that MMC worsens reporting of Medicaid enrollment. However, using alternative methods we find those results are not statistically significant and can have opposite signs. Our linked CPS microdata analysis suggests that MMC improves reporting. The article concludes with implications of these results for policy makers. It is unlikely that increased MMC penetration explains the increased Medicaid Undercount.

Primary Payer Status Affects Mortality for Major Surgical Operations

Medicaid and Uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes following major surgical operations in the United States is dependent on primary payer status. From 2003 to 2007, 893,658 major surgical operations were evaluated using the Nationwide Inpatient Sample (NIS) database: lung resection, esophagectomy, colectomy, pancreatectomy, gastrectomy, abdominal aortic aneurysm repair, hip replacement, and coronary artery bypass. Patients were stratified by primary payer status: Medicare (n = 491,829), Medicaid (n = 40,259), Private Insurance (n = 337,535), and Uninsured (n = 24,035). Multivariate regression models were applied to assess outcomes. Unadjusted mortality for Medicare (4.4%; odds ratio [OR], 3.51), Medicaid (3.7%; OR, 2.86), and Uninsured (3.2%; OR, 2.51) patient groups were higher compared to Private Insurance groups (1.3%, P < 0.001). Mortality was lowest for Private Insurance patients independent of operation. After controlling for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid payer status was associated with the longest length of stay and highest total costs (P < 0.001). Medicaid (P < 0.001) and Uninsured (P < 0.001) payer status independently conferred the highest adjusted risks of mortality. Medicaid and Uninsured payer status confers increased risk-adjusted mortality. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors or operation. These differences serve as an important proxy for larger socioeconomic and health system-related issues that could be targeted to improve surgical outcomes for US Patients.

Poster Abstracts from the AAAP 20th Annual Meeting and Symposium

Poster Abstracts from the AAAP 20th Annual Meeting and Symposium

A Case-Control Study of Asthma and Ovarian Cancer

ABSTRACT Epidemiologic studies have found inverse associations between allergy and the development of certain tumors. The authors sought to determine if there was an association between asthma and ovarian cancer. A case-control study was conducted using Florida hospital data (year 2001). Discharge diagnoses were coded using the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification). Cases were 1,582 women whose principal discharge diagnosis was a malignant neoplasm of the ovary. Two control series were used: 4,744 women whose principal diagnosis was an upper limb bone fracture, and 21,830 women whose principal diagnosis was an acute myocardial infarction. Odds ratios (ORs) adjusted for age, race-ethnicity, Medicaid status, obesity, and smoking were calculated. Cases were 30% less likely than fracture control to be asthmatics (adjusted OR = 0.70, 95% confidence interval [CI]: 0.49–0.99, p = .04). Similarly, cases when compared to acute myocardial infarction controls were significantly less likely to have asthma (adjusted OR = 0.62, 95% CI: 0.45–0.87, p = .005). The results of this statewide exploratory study suggest that individuals with asthma may have a lower risk of developing ovarian cancer than nonasthmatics.

Overweight Among Low-income Texas Preschoolers Aged 2 to 4 Years

Objective Determine child/maternal factors associated with overweight among 2- to 4-year-olds enrolled in the Texas Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Design Matched child and maternal data collected by self-report of the mother during WIC certification. These data were extracted from existing statewide WIC databases and merged. Setting Texas WIC children aged 2 to 4 years in April 2006. Participants Final sample was 22,837 mother–child dyads. Main Outcome Measure Dependent variable—child overweight; independent variables: Child-related—gender, age, race/ethnicity, Medicaid status, living area, and dental problems; Maternal-related—certification status, age, times certified, overweight, high maternal weight gain, and gestational diabetes. Analysis Bivariate relationships at P < .05 were included in the logistic regression. Results Living in a nonborder urban area associated with greater odds of overweight compared to living in a border area. Mother's overweight, high gestational weight gain, and gestational diabetes associated with greater odds of child overweight. Conclusions and Implications Several child- and maternal-related factors were found to be associated with overweight in Texas WIC preschoolers. Health interventions should target 4-year-old Hispanic children living in nonborder urban areas and mothers who are overweight, have high gestational weight gain, or have gestational diabetes.

The criteria used by private general practitioners in Bloemfontein for the diagnosis and referral of asthma patients aged 6–15 years

ABSTRACTBackgroundParticipants in the study were general practitioners (GPs) in private practice in Bloemfontein, South Africa.ObjectivesTo determine and evaluate the criteria employed by GPs in Bloemfontein to diagnose and refer chronic and acute asthma patients aged 6–15 years and to investigate the actual diagnostic criteria used by GPs, as compared to the theoretical (i.e. textbook) criteria.MethodA descriptive study was performed. A questionnaire was designed to investigate which methods of diagnosis were employed by GPs with regard to childhood asthma. The questionnaire was distributed to GPs who fulfilled certain inclusion criteria and were selected by means of simple random sampling. Statistical analysis of data was done by the Department of Biostatistics, University of the Free State, and results were summarised as frequencies and percentages.ResultsCertain elements were lacking with regard to the patients’ histories taken by GPs. These included severity and frequency of attacks, as well as precipitating factors, such as smoking in the family and allergies. A worrisome number of GPs did not seem to be aware of the exact clinical picture of asthma in children and some failed to use the prescribed guidelines proposed for diagnosis of this condition in young patients. Most GPs indicated that they refer asthmatic children to private specialists, although this practice depended on the medical aid status of the patient's parents/guardian.ConclusionAs portrayed by the feedback obtained from these Bloemfontein-based GPs, it could be presumed that the diagnosis of asthma in children did not always meet the standard criteria.

Comparing Lead Poisoning Risk Assessment Methods: Census Block Group Characteristics vs. Zip Codes as Predictors

We determined which children should be tested for elevated blood lead levels (BLLs) in the face of financial and practical barriers to universal screening efforts and within 2009 Centers for Disease Control and Prevention recommendations allowing health departments to develop BLL screening strategies. We used the Michigan database of BLL tests from 1998 through 2005, which contains address, Medicaid eligibility, and race data. Linking addresses to U.S. Census 2000 data by block group provided neighborhood sociodemographic and housing characteristics. To derive an equation predicting BLL, we treated BLL as a continuous variable and used Hierarchical Linear Modeling to estimate the prediction equation. Census block groups explained more variance in BLL than tracts and much more than dichotomized zip code risk (which is current pediatric practice). Housing built before 1940, socioeconomic status and racial/ethnic characteristics of the block group, child characteristics, and empirical Bayesian residuals explained more than 41% of the variance in BLL during 1998-2001. By contrast, zip code risk and Medicaid status only explained 15% of the BLL variance. An equation using 1998-2001 BLL data predicted well for BLL tests performed in 2002-2005. While those who received BLL tests had above-average risk, this method produced minimal bias in using the prediction equation for all children. Our equation offers better specificity and sensitivity than using dichotomized zip codes and Medicaid status, thereby identifying more high-risk children while also offering substantial cost savings. Our prediction equation can be used with a simple Internet-based program that allows health-care providers to enter minimal information and determine whether a BLL test is recommended.

Socioeconomic and Other Predictors of Colonoscopy Preparation Quality

Suboptimal bowel preparation prior to colonoscopy is a common occurrence, with a deleterious impact on colonoscopy effectiveness. Established risk factors for suboptimal bowel preparation have been proposed, but social factors, such as socioeconomic status and marital status, have not been investigated. The aim of this study was to evaluate sociodemographic factors, including insurance status and marital status, as predictive of suboptimal preparation. We analyzed a database of 12,430 consecutive colonoscopies during a 28-month period at Columbia University Medical Center. We collected the following variables: age, gender, indication for colonoscopy, location (inpatient vs. outpatient), race, marital status, and Medicaid status. Preparation quality was recorded and dichotomized as optimal or suboptimal. We employed multivariate regression to determine independent risk factors for suboptimal bowel preparation. Among the 10,921 examinations in which bowel preparation was recorded, suboptimal preparation occurred in 34% of Medicaid patients versus 18% of non-Medicaid patients (P < 0.0001); this remained significant in the multivariate analysis (odds ratio (OR) 1.84, 95% CI 1.61-2.11). Married patients had decreased rates of suboptimal preparation (OR 0.89, 95% CI 0.80-0.98). Other variables associated with suboptimal preparation included increased age (OR per 10 years 1.09, 95% CI 1.05-1.14), male gender (OR 1.44, 95% CI 1.31-1.59), inpatient status (OR 1.51, 95% CI 1.26-1.80), and later time of day (OR 1.89, 95% CI 1.71-2.09). Unmarried status and Medicaid status are predictive of suboptimal bowel preparation. Future studies are warranted to identify how these social conditions predict bowel preparation quality and to implement interventions to optimize bowel preparation in vulnerable populations.

Factors Associated with Hepatitis A Vaccination Receipt in One-Year-Olds in the State of Michigan

The objectives of this study were to determine factors associated with hepatitis A vaccination and to assess overall hepatitis A vaccination coverage levels among one-year-olds in Michigan. The study population was the first hepatitis A vaccination-eligible birth cohort (n = 134 226) enrolled in the Michigan Care Improvement Registry (MCIR) after 2006 recommendations were made to routinely vaccinate all one-year-olds. All children whose first birthday occurred on or between May 1, 2006 and April 31, 2007 were included in the study population. Racial/ethnic minorities had increased odds of receiving the hepatitis A vaccination in Michigan, and Medicaid and WIC status modified this relationship. Fully understanding these relationships will be useful in targeting vaccination outreach and education programs.

Metabolic Risk Factors Among Medicaid Outpatients With Schizophrenia Receiving Second-Generation Antipsychotics

Metabolic Risk Factors Among Medicaid Outpatients With Schizophrenia Receiving Second-Generation Antipsychotics

A New Measure of Medication Affordability

This study developed a new measure of medication affordability that examines out-of-pocket drug expenses relative to available household resources. The authors assessed the spending patterns of ~2.1 million poor households (≤100% federal poverty level) of adults aged 51 and older by Medicaid status. The data were drawn from the 2000–2001 Health and Retirement Study. Household spending was categorized into three broad types: basic living, health care, and discretionary. Older (aged 51 or older) poor households without Medicaid allocated about 72% of their total resources ($17,421, SE $783) to basic living needs. In comparison, those with Medicaid had scarcer total resources ($12,498, SE $423) and allocated 85% to basic living needs. Medication costs consumed the largest proportion of health care expenses for both types of poor households (Medicaid: $463, SE $67; non-Medicaid: $970, SE $102). After paying for basic living needs and health care costs, these families had, on average, only $16 left each week. Poor families have very few resources available for anything beyond basic living needs, even when they have Medicaid coverage. There is no great reservoir of discretionary funds to pay for increases in cost-sharing under Medicaid and Medicare Part D.

Measurement Properties of the Centers for Epidemiological Studies Depression Scale (CES-D) in a Sample of African American and Non-Hispanic White Pregnant Women

This study investigated the appropriateness of using the CES-D scale for comparing depressive symptoms among pregnant women of different races. Black and White women were matched on education, age, Medicaid status, and marital status-living arrangements. The matching procedure yielded a study sample of 375 in each ethnic group. Using a confirmatory factor analysis, the fit of several factor models for the CES-D was evaluated. One CES-D item, "everything was an effort", showed a low item-total correlation (0.04 among blacks, 0.22 among whites) and was excluded from further analysis. After imposing the constraints of equal factor loadings and factor covariance across both groups, a two-factor model with 19 CES-D items provided a good fit. Only the loading for the "was happy" item displayed a small difference between the two groups. Furthermore, the correlations between the original 20-item and the unbiased 18-item scales were r = 0.994 for Whites and r = 0.992 for Blacks. The results suggest that the 20-item CES-D can be used to compare depressive symptoms in White and Black pregnant women without introducing significant ethnic-racial bias in the measurement of these symptoms.

Health Insurance and the Development of Diabetic Complications

Lack of health insurance can adversely affect access to medical care which leads to poor disease outcome. Few studies examine the effects of no insurance on the development of diabetes complications. The objective of this study was to determine if there is an association between health insurance status and the outcome of complications among a group of diabetic patients admitted to a teaching hospital on the Texas-Mexico border. A retrospective case-control study was conducted over a one-year period. Multiple imputations were used to address missing values. We examined 82 diabetics who had one or more complications and 83 diabetic controls without complications. A complication was defined as a current skin or soft-tissue infection or a limb amputation. The main exposure was health insurance status, a three-level variable: no health insurance, Medicaid, and other insurance (referent). Logistic regression was used to calculate health insurance odds ratios (OR) adjusted for age, sex, and a history of recent trauma. Patients with no health insurance were twice as likely to have a diabetic complication as patients in the referent category: adjusted OR = 2.22, P = 0.03. An association between Medicaid status and complications was not detected (adjusted OR = 1.16, P = 0.78). Not having health insurance was a risk factor for developing diabetic complications in a group of predominantly Hispanic patients.

Correlates of hospice use in elders with cancer

9579 Background: Use of hospice has remained relatively low. We aim to identify correlates of hospice in elders with cancer, hypothesizing that the presence of functional limitations and geriatric syndromes are associated with hospice use, independently of age and comorbidities. Methods: The study population included Ohio residents age 65 years or older, diagnosed with breast (n=774), prostate (n=271), or colorectal cancer (n=1,011) during the period 07/1999–12/2001, receiving care through the Medicare fee-for-service system, and first receiving home health care (HHC) in the 30 days before or after cancer diagnosis. This strategy was aimed at obtaining clinical data at baseline, as documented in the HHC Outcome Assessment Information Set (OASIS). Our data source consisted of records from the Ohio Cancer Incidence Surveillance System (OCISS) linked with Medicare data, and the OASIS. In addition to descriptive analyses, multivariable logistic regression analysis was conducted to evaluate the association between hospice use, comorbidity, functional limitations, and geriatric syndromes, after adjusting for patient and tumor attributes. Results: Respectively across the anatomic cancer sites, hospice was used by 9.8%, 22.5%, and 25.1%, of patients. Hospice use increased significantly with age, and was higher among men than women. No differences in hospice use were observed by race, Medicaid status, or the presence of comorbidities. Conversely, hospice use was significantly higher (p &lt; 0.001) among patients with functional limitations (24.0% vs. 16.5% in all others), and those with geriatric syndromes (23.8% vs. 15.3% in all others). Results from the multivariable logistic regression analysis indicated that comorbidities and functional limitations were not associated with hospice use, whereas patients with geriatric syndromes were 1.5 times as likely as those without geriatric syndromes to use hospice (adjusted odds ratio (AOR): 1.5, 95% confidence interval (1.2–1.9). Conclusions: The findings highlight the importance of clinical data that extend beyond comorbidities, when analyzing hospice use. Given marked differences in the disease trajectory across the anatomical cancer sites, future studies should analyze these associations separately in breast, prostate, and colorectal cancer patients. No significant financial relationships to disclose.

Three-Year Measured Weight Change in the African American Health Study

This study examines 3-year weight change in African Americans. Nine hundred and ninety-eight participants 49 to 65 years old were assessed at baseline and 3 years later. Weight was measured, and weight change was defined as clinically meaningful increases or decreases (+/- 5 kg). Potential risk factors were investigated using multinomial logistic regression. In-home measured weights were available for 752 participants (75%): 504 (67%) had stable weights, 131 (17%) gained more than 5 kg, and 117 (16%) lost more than 5 kg. Among all participants, the risks for weight gains were cancer, chronic obstructive pulmonary disease, lower income, and Medicaid status; the risks for weight losses were angina, cancer, high measured systolic blood pressure, asthma, and physical inactivity. Sex-stratified analyses reveal differences involving age, socioeconomic status, cancer, blood pressure, and lower body function. Three-year weight changes in middle-aged African Americans were frequent and significantly associated with several risk factors.

Evidence of localized clustering of gastroschisis births in North Carolina, 1999–2004

Examining the geographic distribution of birth defects can be useful in exploratory etiologic research. Identification of clusters of certain defects may uncover possible environmental or socio-economic risk factors and assist with the generation of hypotheses about underlying causes of these conditions. In North Carolina, the prevalence of gastroschisis, a serious abdominal wall defect, has increased over the past decade and anecdotal evidence from clinicians suggests the possibility of clustering of this condition. This study uses a spatial scan statistic to identify the location and extent of clusters of gastroschisis births in North Carolina between 1999 and 2004. Data on cases of gastroschisis were obtained from the North Carolina Birth Defect Monitoring Program (NCBDMP) and control births were chosen from all resident live births without birth defects contained in the North Carolina composite linked birth files. The clusters were controlled for five major risk factors (maternal age, race, parity, Medicaid status, maternal smoking) to ensure that the clusters were not artifacts of unequal population distribution. Results indicate a localized cluster of gastroschisis in the rural southern Piedmont of North Carolina which persists even after controlling for all major risk factors. Adjusting for these risk factors shifted the location of the cluster substantially, demonstrating the importance of adjusting for underlying population distribution. Since clusters persisted after adjusting for individual-level risk factors, environmental contaminants may explain the excess of gastroschisis cases. This study is among the first to assess spatial clustering of gastroschisis using GIS methods. This study also demonstrates the importance of controlling for covariates in spatial analysis and illustrates the usefulness of the spatial scan statistic in exploratory etiologic research.

Sociodemographic Trends in National Ambulatory Care Visits for Hepatitis C Virus Infection

Poor and non-white patients are disproportionately infected with the hepatitis C virus (HCV). The objective of this research is to determine sociodemographic patterns of HCV-related ambulatory care visits over time. Data from the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey-Outpatient (NHAMCS-OPD) for the years 1997–2005 were analyzed in 3-year intervals. Demographic and other variables were compared for each period, and multivariable logistic regression was performed to examine whether the likelihood of a visit being HCV-related (versus non-HCV) was independently associated with (1) race and/or (2) Medicaid status over time. The total number of HCV-related ambulatory visits more than doubled from 3,583,585 during the years 1997–1999 to 8,027,166 during 2003–2005. During this time, the proportion of non-whites and Medicaid recipients presenting for HCV-related visits approximately doubled (non-whites: 16% vs. 33%, P = 0.04; Medicaid recipients: 10% vs. 25%, P = 0.07). In 2003–2005, HCV-related visits were more than twice as likely to occur among non-white patients vs. white patients (OR = 2.49; 95% CI: 1.60–3.86) and patients on Medicaid vs. non-Medicaid (3.49; 1.79–6.80). Our results show that HCV-associated ambulatory care visits are increasing, with a greater proportion of visits occurring among non-white patients and Medicaid recipients.

The Association Between Medicaid Status and Broken Orthodontic Appointments is not Clearly Established

Article Title and Bibliographic Information Appointment keeping behavior of Medicaid vs non-Medicaid orthodontic patients. Horsley BP, Lindauer SJ, Shroff B, Tufekci E, Abubaker AO, Fowler CE, Maxfield BJ. Am J Orthod Dentofacial Orthop 2007;132: 49-53. Level of Evidence Level 3 (Other evidence) Strength of Recommendation Grade Not applicable Purpose/Question To determine if differences exist in the rates of broken appointments between Medicaid and non-Medicaid orthodontic patients. Source Of Funding Medical College of Virginia Orthodontic Education and Research Foundation. Type Of Study/Design Cross-sectional study

Racial Disparities in Pregnancy-Related Drinking Reduction

The purpose of this study was to investigate the likelihood that women of different racial and ethnic groups would reduce their alcohol consumption during pregnancy. Data came from 22 states participating in the Pregnancy Risk Assessment Monitoring System from 2001 to 2005. After stratifying the sample by preconception drinking level, logistic regressions were used to predict drinking reduction and cessation by the third trimester by race, controlling for age, education, marital status, Medicaid status, pregnancy intention, smoking status, and state. Overall, Black, Asian/Pacific Islander and Hispanic women were all significantly less likely than White women to reduce their heavy drinking after becoming pregnant. American Indian/Alaskan Native women who were moderate drinkers before conception were over 2 times more likely than White women to reduce drinking after becoming pregnant (OR 2.19, CI 0.71, 6.76), although this difference was non-significant (P = .17). Among those who binge drank in the months before pregnancy, compared to White women, Black (OR 0.26, CI 0.17-0.39), Hispanic (OR 0.19, CI 0.12-0.29), American Indian/Alaskan Native (OR 0.44 CI 0.20, 0.96), and Asian/Pacific Islander women (OR 0.11, CI 0.06-0.22) were all less likely to quit binge drinking while pregnant. Significant racial differences in pregnancy-related drinking reduction are evident, and may help explain racial disparities in FAS. Results suggest that more targeted efforts are needed to meet the national goals of preventing alcohol-exposed pregnancies.

Prepregnancy Obesity Prevalence in the United States, 2004–2005

To provide a current estimate of the prevalence of prepregnancy obesity in the United States. We analyzed 2004-2005 data from 26 states and New York City (n = 75,403 women) participating in the Pregnancy Risk Assessment Monitoring System, an ongoing, population-based surveillance system that collects information on maternal behaviors associated with pregnancy. Information was obtained from questionnaires self-administered after delivery or from linked birth certificates; prepregnancy body mass index was based on self-reported weight and height. Data were weighted to provide representative estimates of all women delivering a live birth in each particular state. In this study, about one in five women who delivered were obese; in some state, race/ethnicity, and Medicaid status subgroups, the prevalence was as high as one-third. State-specific prevalence varied widely and ranged from 13.9 to 25.1%. Black women had an obesity prevalence about 70% higher than white and Hispanic women (black: 29.1%; white: 17.4%; Hispanic: 17.4%); however, these race-specific rates varied notably by location. Obesity prevalence was 50% higher among women whose delivery was paid for by Medicaid than by other means (e.g., private insurance, cash, HMO). This prevalence makes maternal obesity and its resulting maternal morbidities (e.g., gestational diabetes mellitus) a common risk factor for a complicated pregnancy.