Is Fragmented Financing Bad for Your Health?

Health Care Financing and Economics, U.S. Department of Veterans Affairs, 150 South Huntington Ave. (152H), Boston, MA 02130, USA.
Inquiry: a journal of medical care organization, provision and financing (Impact Factor: 0.56). 07/2011; 48(2):109-22. DOI: 10.2307/23035407
Source: PubMed

ABSTRACT Americans finance health care through a variety of private insurance plans and public programs. This organizational fragmentation could threaten continuity of care and adversely affect outcomes. Using a large sample of veterans who were eligible for mixtures of Veterans Health Administration- and Medicare-financed care, we estimate a system of equations to account for simultaneity in the determination of financing configuration and the probability of hospitalization for an ambulatory care sensitive condition. We find that a change of one standard deviation in financing fragmentation increases the risk of an adverse outcome by one-fifth.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study attempts to develop a comprehensive set of comorbidity measures for use with large administrative inpatient datasets. The study involved clinical and empirical review of comorbidity measures, development of a framework that attempts to segregate comorbidities from other aspects of the patient's condition, development of a comorbidity algorithm, and testing on heterogeneous and homogeneous patient groups. Data were drawn from all adult, nonmaternal inpatients from 438 acute care hospitals in California in 1992 (n = 1,779,167). Outcome measures were those commonly available in administrative data: length of stay, hospital charges, and in-hospital death. A comprehensive set of 30 comorbidity measures was developed. The comorbidities were associated with substantial increases in length of stay, hospital charges, and mortality both for heterogeneous and homogeneous disease groups. Several comorbidities are described that are important predictors of outcomes, yet commonly are not measured. These include mental disorders, drug and alcohol abuse, obesity, coagulopathy, weight loss, and fluid and electrolyte disorders. The comorbidities had independent effects on outcomes and probably should not be simplified as an index because they affect outcomes differently among different patient groups. The present method addresses some of the limitations of previous measures. It is based on a comprehensive approach to identifying comorbidities and separates them from the primary reason for hospitalization, resulting in an expanded set of comorbidities that easily is applied without further refinement to administrative data for a wide range of diseases.
    Medical Care 02/1998; 36(1):8-27. DOI:10.1097/00005650-199801000-00004 · 2.94 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVE: To determine how frequently veterans use non-Department of Veterans Affairs (VA) sources of care in addition to primary care provided by the VA and to assess the association of this pattern of “dual use” to patient characteristics and satisfaction with VA care.DESIGN: Cross-sectional telephone survey of randomly selected patients from four VA medical centers.PARTICIPANTS: Of 1,240 eligible veterans, 830 (67%) participated in the survey.MEASUREMENTS AND MAIN RESULTS: Survey data were used to assess whether a veteran reported receiving primary care from both VA and non-VA sources of care, as well as the proportion of all primary care visits made to non-VA providers. Of 577 veterans who reported VA primary care visits, 159 (28%) also reported non-VA primary care visits. Among these dual users the mean proportion of non-VA primary care visits was 0.50. Multivariate analysis revealed that the odds of dual use were reduced for those without insurance (odds ratio [OR] 0.34; 95% confidence interval [CI] 0.18, 0.66) and with less education (OR 0.60; 95% CI 0.38, 0.92), while increased for those not satisfied with VA care (OR 2.40; 95% CI 1.40, 4.13). Among primary care dual users, the proportion of primary care visits made to non-VA providers was decreased for patients with heart disease ( p < .05) and patients with alcohol or drug dependence ( p < .05).CONCLUSIONS: Primary care dual use was common among these veterans. Those with more education, those with any type of insurance, and those not satisfied with VA care were more likely to be dual users. Non-VA care accounted for approximately half of dual users’ total primary care visits.
    Journal of General Internal Medicine 04/1999; 14(5):274 - 280. DOI:10.1046/j.1525-1497.1999.00335.x · 3.42 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To examine whether continuity of care with an individual health care provider is associated with the number of hospital emergency department (ED) visits in a statewide Medicaid population. A cross-sectional study based on a 100% sample of Delaware Medicaid claims for 1 year (July 1, 1993, to June 30, 1994). Continuity with a single provider during the year was computed for each participant. The state of Delaware. Continuously enrolled Medicaid clients aged 0 to 64 years who had made at least 3 physician office visits during the study year (N = 11,474). None. Likelihood of making a single ED visit or multiple ED visits during the study year. In multivariate analysis, continuity is associated with a significantly lower likelihood of making a single ED visit (odds ratio, 0.82; 95% confidence interval, 0.70-0.95), and is even more strongly associated with a lower likelihood of making multiple ED visits (odds ratio, 0.65; 95% confidence interval, 0.56-0.76). This study demonstrates that high provider continuity is associated with lower ED use for the Medicaid population. This suggests that strategies to improve continuity of care may result in lower ED use and possibly reduced health care costs. Such strategies may be more acceptable than current managed care policies that attempt to control costs by denying access to emergency care.
    Archives of Family Medicine 05/2000; 9(4):333-8.


1 Download
Available from