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ABSTRACT: Discussions of health care delivery and payment reforms have largely been silent about how behavioral health could be incorporated into reform initiatives. This paper draws attention to four patient populations defined by the severity of their behavioral health conditions and insurance status. It discusses the potentials and limitations of three prominent models promoted by the Affordable Care Act to serve populations with behavioral health conditions: the Patient-Centered Medical Home, the Health Home initiative within Medicaid, and the Accountable Care Organization. To incorporate behavioral health into health reform, policymakers and practitioners may consider embedding in the reform efforts explicit tools-accountability measures and payment designs-to improve access to and quality of care for patients with behavioral health needs.
The Journal of Behavioral Health Services & Research 11/2012; · 1.32 Impact Factor
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Journal of General Internal Medicine 02/2012; · 2.83 Impact Factor
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ABSTRACT: With substantial morbidity and functional impairment, older patients receiving home health care are especially susceptible to the adverse effects of unsafe or ineffective medications. Home health agencies’ medication review and reconciliation services, however, provide an added mechanism of medication safety that could offset this risk.
To estimate the prevalence of potentially inappropriate medications (PIMs) among current elderly home health patients in the US.
Cross-sectional analysis using data from the 2007 National Home and Hospice Care Survey.
3,124 home health patients 65 years of age or older on at least one medication.
Prevalence and classification of PIM use and the association between PIM use and patient and home health agency characteristics.Key Results In 2007, 38% (95% CI: 36-41) of elderly home health patients were taking at least one PIM. Polypharmacy was associated with an increased risk of PIM use; admission to home health care from a nursing home or other sub-acute facility (compared to admission from the community) and a payment source other than Medicare or Medicaid were associated with a decreased risk of PIM use.
The prevalence of PIM use in older home health patients is high despite potential mechanisms for improved safety. Policies to improve the review and reconciliation processes within home health agencies and to improve physician-home health clinician collaboration are likely needed to lower the prevalence of PIM use in older home health patients.
Journal of General Internal Medicine 10/2011; 27(3):304-10. · 2.83 Impact Factor
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ABSTRACT: Collaborative depression care management (DCM), by addressing barriers disproportionately affecting patients of racial/ethnic minority and low education, may reduce disparities in depression treatment and outcomes.
To examine the effects of DCM on treatment disparities by education and race/ethnicity in older depressed primary care patients.
Analysis of data from the randomized controlled trial Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT).
Twenty primary care practices.
A total of 396 individuals 60 years or older with major depression. We conducted model-based analysis to estimate potentially differential intervention effects by education, independent of those by race/ethnicity (and vice versa).
Algorithm-based recommendations to physicians and care management by care managers.
Antidepressant use, depressive symptoms, and intensity of DCM over 2 years.
The PROSPECT intervention had a larger and more lasting effect in less-educated patients. At month 12, the intervention increased the rate of adequate antidepressant use by 14.2 percentage points (pps) (95% confidence interval [CI], 1.7 to 26.4 pps) in the no-college group compared with a null effect in the college-educated group (-9.2 pps [95% CI, -25.0 to 2.7 pps]); at month 24, the intervention reduced depressive symptoms by 2.6 pps on the Hamilton Depression Rating Scale (95% CI, -4.6 to -0.4 pps) in no-college patients, 3.8 pps (95% CI, -6.8 to -0.4) more than in the college group. The intervention benefitted non-Hispanic white patients more than minority patients. Intensity of DCM received by minorities was 60% to 70% of that received by white patients after the initial phase but did not differ by education.
The PROSPECT intervention substantially reduced disparities by patient education but did not mitigate racial/ethnic disparities in depression treatment and outcomes. Incorporation of culturally tailored strategies in DCM models may be needed to extend their benefits to minorities.
clinicaltrials.gov Identifier for PROSPECT: NCT00279682.
Archives of general psychiatry 06/2011; 68(6):627-36. · 12.26 Impact Factor
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ABSTRACT: To design a bundled case rate for Collaborative Care for Depression (CCD) that aligns incentives with evidence-based depression care in primary care.
A clinical information system used by all care managers in a randomized controlled trial of CCD for older primary care patients.
We conducted an empirical investigation of factors accounting for variation in CCD resource use over time and across patients. CCD resource use at the patient-episode and patient-month levels was measured by number of care manager contacts and direct patient contact time and analyzed with count data (Poisson or negative binomial) models.
Episode-level resource use varies substantially with patient's time in the program. Monthly use declines sharply in the first 6 months regardless of treatment response or remission status, but it remains stable afterwards. An adjusted episode or monthly case rate design better matches payment with variation in resource use compared with a fixed design.
Our findings lend support to an episode payment adjusted by number of months receiving CCD and a monthly payment adjusted by the ordinal month. Nonpayment tools including program certification and performance evaluation and reward systems are needed to fully align incentives.
Health Services Research 05/2011; 46(5):1436-51. · 2.16 Impact Factor
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ABSTRACT: This study estimated the prevalence of diagnosed depression among elderly Medicare fee-for-service home health patients and identified demographic, functional, and care utilization characteristics associated with the diagnosis.
Data from the 2007 National Home and Hospice Care Survey were analyzed to generate nationally representative estimates. Chi square and Wald tests, corrected for the sampling design, tested for differences in categorical and continuous measures, respectively.
Nationally, 6.4% (N=42,192) of the study population received a diagnosis of depression, which was associated with younger age (p=.016), lack of a primary caregiver other than the home care agency (p<.001), a lower likelihood of receiving medical social services (p=.010), and a greater likelihood of using antidepressants (p<.001).
The rate of diagnosed depression was higher than the rate found in a previous study but lower than rates in studies that used diagnostic interviews or screening tools. Diagnosed depression was associated with a limited number of patient characteristics.
Psychiatric services (Washington, D.C.) 05/2011; 62(5):538-40. · 2.81 Impact Factor
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ABSTRACT: Our study objectives were to examine race/ethnicity-related and insurance-related differences in the timeliness of emergency care for a nationally representative sample of adults and to explore the role of uncertainty and location of care in explaining overall differences. We estimated a logistic regression model with hospital fixed effects to derive estimates of within-hospital group differences in the likelihood of waiting for more than 60 minutes to see a physician for several presenting conditions. We further estimated a model without hospital fixed effects to derive overall group differences. We observed race/ethnicity-related and payer-related differences in the timeliness of a medical screening exam for abdominal pain and chest pain visits but not for extremity laceration visits. Overall (within- and between-hospitals) differences in waiting time were due to patients receiving different care from the same hospital and from patients receiving care from different hospitals.
Journal of Health Care for the Poor and Underserved 01/2011; 22(2):606-20. · 1.10 Impact Factor
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ABSTRACT: Previous studies have documented substantial differences by patient race/ethnicity and insurance in the use of high-volume surgical providers. The extent to which regional availability of surgical capabilities explains such differences has not been examined.
To examine the existence of racial/ethnic and payer differences in using high-volume hospitals and surgeons for coronary artery bypass graft (CABG) in the state of Florida and to study the role of regional availability of high-volume providers in explaining the differences.
We conducted descriptive analysis of the distribution of CABG providers and patient populations by race/ethnicity and insurance across the 19 Hospital Referral Regions (HRRs) in Florida. We estimated logistic regressions of using a high-volume provider to derive estimates of overall group differences. We further estimated models with HRR fixed effects to derive within-HRR differences. We derived implications by comparing findings based on the 2 sets of models.
Non-Hispanic black patients were 58% as likely (95% CI: 52%, 65%), Hispanic patients were 84% as likely (95% CI: 77%, 90%), to have received CABGs at a high-volume hospital, compared with non-Hispanic whites. Controlling for inter-HRR differences eliminated almost all racial/ethnic differences. Substantial differences in using high-volume providers existed between Medicaid/uninsured and privately insured patients and such differences persisted within HRRs.
Unequal distribution of CABG capabilities coupled with racial/ethnic concentration in residence across Florida HRRs accounted for almost all racial/ethnic differences in using high-volume hospitals. Factors other than availability of surgical resources were responsible for differences between Medicaid/uninsured and privately insured patients.
Medical care 08/2009; 47(7):794-802. · 3.24 Impact Factor
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ABSTRACT: To estimate the effect of an evidence-based depression care management (DCM) intervention on the initiation and appropriate use of antidepressant in primary care patients with late-life depression.
Secondary analysis of data from a randomized trial.
Community, primary care.
Randomly selected individuals aged 60 and older with routine appointments at 20 primary care clinics randomized to provide a systematic DCM intervention or care as usual.
Rates of antidepressant use and dose adequacy of patients in the two study arms were compared at each patient assessment (baseline, 4, 8, and 12 months). For patients without any antidepressant treatment at baseline, a longitudinal analysis was conducted using multilevel logistic models to compare the rate of antidepressant treatment initiation, dose adequacy when initiation was first recorded, and continued therapy for at least 4 months after initiation between study arms. All analyses were conducted for the entire sample and then repeated for the subsample with major or clinically significant minor depression at baseline.
Rates of antidepressant use and dose adequacy increased over the first year in patients assigned to the DCM intervention, whereas the same rates held constant in usual care patients. In longitudinal analyses, the DCM intervention had a significant effect on initiation of antidepressant treatment (adjusted odds ratio (OR)=5.63, P<.001) and continuation of antidepressant medication for at least 4 months (OR=6.57, P=.04) for patients who were depressed at baseline.
Evidence-based DCM models are highly effective at improving antidepressant treatment in older primary care patients.
Journal of the American Geriatrics Society 05/2009; 57(5):895-900. · 3.74 Impact Factor
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ABSTRACT: This study used the 2004 Florida Inpatient Discharge Data to examine the existence and the underlying mechanisms of the African American (AA)/white differences in behavioral inpatient diagnosis across a diverse patient population. Findings suggest that discharges of AA patients in Florida were at least twice as likely to have received a primary psychotic vs. affective or substance-related diagnosis, and this held true after between-hospital differences were controlled for. Furthermore, AA (vs. white) race was associated with a ratio of 3.3 in the population rate of hospitalization with a primary psychotic diagnosis, as compared to a ratio of 0.8 and 0.7 for affective and substance-related disorders, respectively. These findings demonstrated the wide existence of racial differences in behavioral inpatient diagnosis and the important role of clinician diagnostic behaviors as opposed to systems-level factors (such as racial differences in access to care and care-seeking behaviors) in leading to observed differences.
The Journal of Behavioral Health Services & Research 08/2008; 35(3):347-57. · 1.32 Impact Factor
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ABSTRACT: To determine the extent to which socioeconomic and racial/ethnic differences in cancer screening discussion between a patient and his/her primary care physician are due to "within-physician" differences (the fact that patients were treated differently by the same physicians) versus "between-physician" differences (that they were treated by a different group of physicians).
We use data from the baseline patient and physician surveys of two community trials from the Communication in Medical Care (CMC) research series. The two studies combined provide an analysis sample of 5,978 patients ages 50-80 nested within 191 primary care physicians who practiced throughout Southern California.
Our main outcomes of interest are whether the physician has ever talked to the patient about fecal occult blood test (FOBT; for colorectal cancer screening), mammogram (for breast cancer screening, female patients only) and the prostate-specific antigen test (PSA, male patients only). We consider five racial/ethnic groups: non-Hispanic white, non-Hispanic black, Hispanic, Asian, and other race/ethnicity. We measure socioeconomic status by both income and education. For each type of cancer screening discussion, we first estimate a probit model that includes patient characteristics as the only covariates to assess the overall differences. We then add physician fixed effects to derive estimates of "within-" versus "between-" physician differences.
There was a strong education gradient in the discussion of all three types of cancer screening and most of the education differences arose within physicians. Disparities by income were less consistent across different screening methods, but seemed to have arisen mainly because of "between-physician" differences. Asians were much less likely, compared with whites, to have received discussion about FOBT and PSA and these differences were mainly "within-physician" differences. Black female patients, however, were much more likely, compared with whites treated by the same physicians, to have discussed mammogram with their physicians.
Differences in cancer screening discussion along the different dimensions of patient SES may have arisen because of very different mechanisms and therefore call for a combination of interventions. Physicians need to be aware of the persistent disparities by patient education in clinical communication regarding cancer screening and tailor their efforts to the needs of low-education patients. Quality-improvement efforts targeted at physicians practicing in low-income communities may also be effective in addressing disparities in cancer screening communication by patient income.
Health Services Research 07/2007; 42(3 Pt 1):950-70. · 2.16 Impact Factor
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ABSTRACT: The past two decades have seen a dramatic increase in the prevalence of obesity in the US population. Although increasing
obesity was observed in every sociodemographic group, at every point in time groups with lower education, African Americans
and Native Americans, and women in lower income households had higher rates of obesity and related chronic conditions such
as diabetes. Also noteworthy is the much faster increase of severe obesity compared with moderate obesity, which added further
strain to the health care system and proved especially challenging to health care providers. We provide data on the populationwide
trends in weight gain, economic consequences of health care cost growth and the socioeconomic disparities in obesity and diabetes.
We further di scuss the socioeconomic and environmental changes that are likely underlying mechanisms for the obesity epidemic
and related disparities. We conclude the chapter by discussing implications of these trends for the prevention and treatment
of diabetes and challenges and opportunities faced by the health care system and providers.
12/2006: pages 175-194;
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ABSTRACT: To estimate the effect of provider advice in routine clinical contacts on patient smoking cessation outcome.
The Sample Adult File from the 2001 National Health Interview Survey. We focus on adult patients who were either current smokers or quit during the last 12 months and had some contact with the health care providers or facilities they most often went to for acute or preventive care.
We estimate a joint model of self-reported smoking cessation and ever receiving advice to quit during medical visits in the past 12 months. Because providers are more likely to advise heavier smokers and/or patients already diagnosed with smoking-related conditions, we use provider advice for diet/nutrition and for physical activity reported by the same patient as instrumental variables for smoking cessation advice to mitigate the selection bias. We conduct additional analyses to examine the robustness of our estimate against the various scenarios by which the exclusion restriction of the instrumental variables may fail.
Provider advice doubles the chances of success in (self-reported) smoking cessation by their patients. The probability of quitting by the end of the 12-month reference period increased from 6.9 to 14.7 percent, an effect that is of both statistical (p < .001) and clinical significance.
Provider advice delivered in routine practice settings has a substantial effect on the success rate of smoking cessation among smoking patients. Providing advice consistently to all smoking patients, compared with routine care, is more effective than doubling the federal excise tax and, in the longer run, likely to outperform some of the other tobacco control policies such as banning smoking in private workplaces.
Health Services Research 12/2006; 41(6):2114-35. · 2.16 Impact Factor
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ABSTRACT: We used a quasiexperimental research design to measure the effect of state parity laws on the use of mental health care in the past year.
We pooled cross-sectional data from the 2001, 2002, and 2003 National Surveys on Drug Use and Health. Our sample included 83,531 adults 18 years of age or over with private health insurance stratified by the level of mental and emotional distress experienced in the worst month of the past year. We used a state and year-fixed effects approach to measure the effect of parity. Similar to a difference-in-difference analysis, the effect of parity was measured by comparing pre-/postchanges in mental health service use within states that switched active parity status to changes in service use within states that did not change parity status in the same calendar year. For each subgroup, we report predictions of the percentage point change in any mental health care use, prescription drug use, and outpatient care use resulting from parity laws.
Depending on the time window used to define active parity status, we found that parity increased the probability of using any mental health care in the past year by as much as 1.2 percentage points (P<0.01) for the lower distress group and by as much as 1.8 percentage points (P<0.05) in the middle distress group. We found no statistically significant changes in service use for the upper distress group. Whether measured differences were attributable to changes in the use of prescription drug or outpatient care also depended on the definition of active parity status.
Overall, the results of this study suggest that state parity laws succeeded in expanding access to mental health care for those with relatively mild mental health problems.
Medical Care 07/2006; 44(6):499-505. · 3.41 Impact Factor
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ABSTRACT: The objective of this study was to assess the socioeconomic circumstances of older patients with HIV and acquired immunodeficiency syndrome (AIDS). The investigators compared subjects from a national probability sample of 2,864 respondents from the HIV Cost and Services Utilization Study (HCSUS, 1996) with 9,810 subjects from Wave 1 (1992) of the Health and Retirement Survey (HRS). Bivariate analyses compare demographic characteristics, financial resources, and health insurance status between older and younger adults and between older adults with HIV and the general population. It was found that nearly 10% of the HIV-positive population is between the ages of 50 and 61 years. Older whites with HIV are mostly homosexual men who are more well educated, more often privately insured, and more financially stable than the HIV population as a whole. In contrast, older minorities with HIV possess few economic resources in either absolute or relative terms. The success of new drug therapies and the changing demographics of the HIV population necessitate innovative policies that promote labor force participation and continuous access to antiretroviral therapies.
Journal of Health Care for the Poor and Underserved 03/2005; 16(1):19-28. · 1.10 Impact Factor
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ABSTRACT: To examine whether highly active antiretroviral therapy (HAART) helps HIV-infected patients return to work, remain employed, and maintain hours of work.
Longitudinal data from a national probability sample of HIV+ patients older than 18 years old who made at least one visit in the contiguous United States in early 1996.
We consider the effect of HAART on three employment outcomes: (1) returning to work within six months of treatment, conditional on not working pretreatment; (2) remaining employed within six months of treatment, conditional on working pretreatment; (3) hours of work conditional on working at the second follow-up survey. We use a bivariate probit model to jointly model employment and treatment with HAART for the first two outcomes and the two-stage least squares method for hours of work. State policies regarding prescription drug coverage are used as instrumental variables for HAART to account for a key source of potential bias-the more severely ill tend to have the most difficulty working, but are also the most likely to be on HAART.
Our results indicate that HAART increases the probability of remaining employed by HIV patients and hours of work for those working within six months of treatment. In the case of remaining employed, the employment effect (an increase from 58 percent to 94 percent in the probability of remaining employed) is statistically significant and the related incremental income is sizable compared to the incremental costs of HAART. Sensitivity analyses demonstrate that the results are robust to different specifications for insurance coverage.
Patients who are working are more likely to remain employed because of treatment with HAART. HAART prescribed to patients in less advanced stages of the infection may lead to the greatest gain in employment.
Health Services Research 01/2005; 39(6 Pt 1):1691-712. · 2.16 Impact Factor
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ABSTRACT: To assess the impacts of recent state mental health parity legislation on perceived quality of health insurance coverage, perceived access to needed health care, and use of mental health specialty services by individuals with likely need for mental health care.
The study sample came from two waves of a national household survey first fielded in 1997-1998 and then in 2000-2001. The analysis used a subset of the sample.
The study took the Difference-in-Difference-in-Difference approach to investigate changes in self-perceived quality of health insurance coverage and access to needed health care, and use of mental health specialty care by the group with mental disorders (relative to those without) in states with parity legislation of different comprehensiveness (relative to the nonparity states) in the years after the law (relative to before the law).
Overall, there were no significant or consistent effects of the parity legislation. Descriptive statistics showed significant changes in some (but not all) outcome variables, but these results disappeared in detailed statistical analyses by controlling for important covariates.
The null findings of the effects of state mental health parity mandates suggest that under ERISA (Employee Retirement Income Security Act), the scope of state parity legislation may have been restricted because of large proportion of self-insured employers. Furthermore, comprehensiveness of state legislation appears to be related to the traditional level of use of mental health specialty care, which becomes another confounder for the potential policy effects.
Health Services Research 11/2004; 39(5):1361-77. · 2.16 Impact Factor
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ABSTRACT: The objective of this study was to provide national estimates of the impact of common pain conditions such as back pain, chronic headache, self-reported arthritis, and unspecified chronic pain on the use of health services and quality of care among persons with depression.
This was a cross-sectional study of data from a U.S. national household survey conducted in 1997-1998. The participants were 1,486 community-dwelling adults who met criteria for major depression or dysthymia according to the Composite International Diagnostic Interview Short-Form.
Depressed persons with comorbid pain (N=938) were older, had lower incomes, and reported more severe psychiatric distress than depressed persons who did not have pain. When sociodemographic characteristics and severity of psychological distress were adjusted for, comorbid pain was associated with about 20 percent more visits to medical providers by patients who made at least one visit during a year. However, the patients with comorbid pain were about 20 percent less likely to see a mental health specialist than patients without pain. Pain was also shown to be associated with greater use of complementary or alternative medicine but not with differences in the use of antidepressants.
Comorbid pain among persons with depression is associated with more intensive use of general medical services but lower rates of use of mental health services.
Psychiatric Services 06/2003; 54(5):693-7. · 2.38 Impact Factor
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Psychiatric Services 12/2002; 53(11):1373. · 2.38 Impact Factor
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Yuhua Bao
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ABSTRACT: Studies attempting to project the impact of providing health coverage to the uninsured population have demonstrated considerable variation in the estimated costs of mental health care. Different modeling approaches to project health care use and costs have been shown to address some data characteristics well, but not all of them. Using data from Health Care for Communities, a recent national household survey, this paper attempts to estimate and predict the use of mental health outpatient services if insurance coverage were extended to the uninsured. The study employs two-part models, with the second part based on an ordinary least squares (OLS) approach and a generalized linear model (GLM), and a zero-inflated negative binomial model (ZINB). Estimates and predictions are not sensitive to the modeling approaches chosen, although the ZINB model out performs the two-part models in terms of out-of-sample prediction.
Inquiry: a journal of medical care organization, provision and financing 02/2002; 39(2):168-83. · 0.83 Impact Factor
