Jean M. Mitchell

Georgetown University, Washington, Washington, D.C., United States

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Publications (56)314.21 Total impact

  • Jean M. Mitchell · Kathleen Carey
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    ABSTRACT: Background: Ambulatory surgery centers (ASCs) are freestanding facilities that specialize in surgical and diagnostic procedures that do not require an overnight stay. While it is generally assumed that ASCs are less costly than hospital outpatient surgery departments, there is sparse empirical evidence regarding their relative production costs. Objectives: To estimate ASC production costs using financial and claims records for procedures performed by surgery centers that specialize in gastroenterology procedures (colonoscopy and endoscopy). Research design: We estimate production costs in ASCs that specialize in gastroenterology procedures using financial cost and patient discharge data from Pennsylvania for the time period 2004-2013. We focus on the 2 primary procedures (colonoscopies and endoscopies) performed at each ASC. We use our estimates to predict average costs for each procedure and then compare predicted costs to Medicare ACS payments for these procedures. Results: Comparisons of the costs of each procedure with 2013 national Medicare ASC payment rates suggest that Medicare payments exceed production costs for both colonoscopy and endoscopy. Conclusions: This study demonstrated that it is feasible to estimate production costs for procedures performed in freestanding surgery centers. The procedure-specific cost estimates can then be compared with ASC payment rates to ascertain if payments are aligned with costs. This approach can serve as an evaluation template for CMS and private insurers who are concerned that ASC facility payments for specific procedures may be excessive.
    No preview · Article · Nov 2015 · Medical Care
  • Jean M. Mitchell · Elizabeth A. Conklin
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    ABSTRACT: Objective To identify factors that affect whether patients diagnosed with either leukemia or lymphoma receive a stem cell transplant and secondly if receipt of stem cell transplantation is linked to improved survival.DataCalifornia inpatient discharge records (2002–2003) for patients with either leukemia or lymphoma linked with vital statistics death records (2002–2005).Study DesignBivariate Probit treatment effects model that accounts for both the type of treatment received and survival while controlling for nonrandom selection due to unobservable factors.Principal FindingsHaving private insurance coverage and residence in a well-educated county increased the chances a patient with either disease received HSCT. Increasing age and travel distance to the nearest transplant hospital had the opposite effect. Receipt of HSCT had a significant impact on mortality. We found the probability of death was 4.3 percentage points higher for leukemia patients who did NOT have HSCT. Receipt of HSCT reduced the chances of dying by almost 50 percent. The likelihood of death among lymphoma patients who underwent HSCT was almost 5 percentage points lower, a 70 percent reduction in the probability of death.Conclusions The findings raise concern about access to expensive, but highly effective cancer treatments for patients with certain hematologic malignancies.
    No preview · Article · Jul 2014 · Health Services Research
  • Jean M. Mitchell

    No preview · Article · Feb 2014 · New England Journal of Medicine
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    Jean M Mitchell
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    ABSTRACT: Some urology groups have integrated intensity-modulated radiation therapy (IMRT), a radiation treatment with a high reimbursement rate, into their practice. This is permitted by the exception for in-office ancillary services in the federal prohibition against self-referral. I examined the association between ownership of IMRT services and use of IMRT to treat prostate cancer. Using Medicare claims from 2005 through 2010, I constructed two samples: one comprising 35 self-referring urology groups in private practice and a matched control group comprising 35 non-self-referring urology groups in private practice, and the other comprising non-self-referring urologists employed at 11 National Comprehensive Cancer Network centers matched with 11 self-referring urology groups in private practice. I compared the use of IMRT in the periods before and during ownership and used a difference-in-differences analysis to evaluate changes in IMRT use according to self-referral status. The rate of IMRT use by self-referring urologists in private practice increased from 13.1 to 32.3%, an increase of 19.2 percentage points (P<0.001). Among non-self-referring urologists, the rate of IMRT use increased from 14.3 to 15.6%, an increase of 1.3 percentage points (P=0.05). The unadjusted difference-in-differences effect was 17.9 percentage points (P<0.001). The regression-adjusted increase in IMRT use associated with self-referral was 16.4 percentage points (P<0.001). The rate of IMRT use by urologists working at National Comprehensive Cancer Network centers remained stable at 8.0% but increased by 33.0 percentage points among the 11 matched self-referring urology groups. The regression-adjusted difference-in-differences effect was 29.3 percentage points (P<0.001). Urologists who acquired ownership of IMRT services increased their use of IMRT substantially more than urologists who did not own such services. Allowing urologists to self-refer for IMRT may contribute to increased use of this expensive therapy. (Funded by the American Society for Radiation Oncology.).
    Preview · Article · Oct 2013 · New England Journal of Medicine
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    Jean M Mitchell

    Preview · Article · Jun 2012 · Health Affairs
  • Jean M Mitchell
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    ABSTRACT: Federal law allows physicians in some circumstances to refer patients for additional services to a facility in which the physician has a financial interest. The practice of physician self-referral for imaging and pathology services has been criticized because it can lead to increased use and escalating health care expenditures, with little or no benefit to patients. This study examined Medicare claims for men in a set of geographically dispersed counties to determine how the "in-office ancillary services" exception affected the use of surgical pathology services and cancer detection rates associated with prostate biopsies. I found that self-referring urologists billed Medicare for 4.3 more specimens per prostate biopsy than the adjusted mean of 6 specimens per biopsy that non-self-referring urologists sent to independent pathology providers, a difference of almost 72 percent. Additionally, the regression-adjusted cancer detection rate in 2007 was twelve percentage points higher for men treated by urologists who did not self-refer. This suggests that financial incentives prompt self-referring urologists to perform prostate biopsies on men who are unlikely to have prostate cancer. These results support closing the loophole that permits self-referral to "in-office" pathology laboratories.
    No preview · Article · Apr 2012 · Health Affairs
  • Jean M Mitchell
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    ABSTRACT: Federal law prohibits a physician from referring Medicare patients for procedures or services to health care entities in which the physician has a financial relationship. This law has exceptions which enable physicians to self-refer under certain conditions. This study evaluates the effects of self-referral on use rates of surgical pathology services performed in conjunction with prostate biopsies and whether such changes are linked to urologist self-referral arrangements. A targeted market area case study design was employed to identify the sample from Medicare claims data. The sample included male beneficiaries who resided in geographically dispersed counties; were continuously enrolled in Medicare fee-for-service (FFS) during 2005-2007; and who met the criteria to be a potential candidate to undergo a prostate biopsy. Prostate biopsy procedures per 1000 male Medicare beneficiaries in each county; counts of surgical pathology specimens (jars) associated with prostate biopsy procedures per 1000 male Medicare beneficiaries in each county. Regression analysis shows the self-referral share (percentage) of total utilization was associated with significant increases in the use rate of prostate surgical pathology specimens (p<.01). The use rate of prostate surgical pathology specimens (jars) would be 41.5 units higher in a county where the self-referral share of total utilization was 50% compared to a county with no self-referral (share equals 0%). The findings show that urologist self-referral of prostate surgical pathology services results in increased utilization and higher Medicare spending. The results suggest that exceptions in federal and state self-referral prohibitions need to be reevaluated.
    No preview · Article · Jan 2012 · Medicare and Medicaid Research Review
  • Jean M Mitchell
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    ABSTRACT: Physician-owned specialty hospitals and ambulatory surgery centers have become commonplace in many markets throughout the United States. Little is known about whether the financial incentives linked to ownership affect frequency of outpatient surgery. To evaluate if financial incentives linked to physician ownership influence frequency of outpatient orthopedic surgical procedures. We analyzed 5 years of claims data from a large private insurer in Idaho to compare frequency by orthopedic surgeon owners and nonowners of surgical procedures that could be performed in either ambulatory surgery centers or hospital outpatient surgery departments. Frequency of use, calculated as number of patients treated with the specific diagnoses who received the surgical procedure of interest divided by the number of patients with such diagnoses treated by each physician. Age- and sex-adjusted odds ratios indicate that the likelihood of having carpal tunnel repair was 54% to 129% higher for patients of surgeon owners compared with surgeon nonowners. For rotator cuff repair, the adjusted odds ratios of having surgery were 33% to 100% higher for patients treated by physician owners. The age- and sex-adjusted probability of arthroscopic surgery was 27% to 78% higher for patients of surgeon owners compared with surgeon nonowners. The consistent finding of higher use rates by physician owners across time clearly suggests that financial incentives linked to ownership of either specialty hospitals or ambulatory surgery centers influence physicians' practice patterns.
    No preview · Article · Aug 2010 · Archives of surgery (Chicago, Ill.: 1960)
  • Jean M Mitchell · R Robert Lagalia
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    ABSTRACT: Since the late 1990s, the use of advanced diagnostic imaging modalities has increased by double-digit rates, outpacing the rate of increase of medical spending overall. In an attempt to assure the appropriate use of advanced imaging procedures, private insurers are increasingly contracting with radiology benefit management programs (RBMs) to reduce overall use and expenditures for radiology services. This article describes the services offered by RBMs and then presents trends in utilization of advanced imaging procedures from three health plans that adopted RBM prior authorization protocols. The implementation of prior authorization protocols by each plan was associated with declines in use of advanced imaging procedures, especially during the first year of the program. Although more rigorous empirical analysis is required in order to draw definitive conclusions, these trends suggest that RBM prior authorization initiatives may be a viable approach for addressing concerns about appropriate use of advanced imaging.
    No preview · Article · Mar 2009 · Medical Care Research and Review
  • Jean M Mitchell · Darrell J Gaskin
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    ABSTRACT: Although not widely recognized, tooth decay is the most common childhood chronic disease among children ages five to seventeen. Despite higher rates of dental caries and greater needs, low-income minority children enrolled in Medicaid are more likely to go untreated relative to their higher income counterparts. No research has examined this issue for children with special needs. We analyzed Medicaid enrollment and claims data for special-needs children enrolled in the District of Columbia Medicaid program to evaluate receipt of recommended preventive dental care. Use of preventive dental care is abysmally low and has declined over time. Enrollment in managed care rather than fee for service improves the likelihood that special-needs children receive recommended preventive dental services, whereas residing farther from the Metro is an impediment to receipt of dental care.
    No preview · Article · Nov 2008 · Journal of Health Politics Policy and Law
  • Jean M Mitchell
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    ABSTRACT: Although physician-owned specialty hospitals have become increasingly prevalent in recent years, little research has examined whether the financial incentives linked to ownership influence physicians' referral rates for services performed at the specialty hospital. We compared the practice patterns of physician owners of specialty hospitals in Oklahoma, before and after ownership, to the practice patterns of physician nonowners who treated similar cases over the same time period in Oklahoma markets without physician-owned specialty hospitals. We constructed episodes of care for injured workers with a primary diagnosis of back/spine disorders. We used pre-post comparisons and difference-in-differences analysis to evaluate changes in practice patterns for physician owners and nonowners over the time period spanned by the entry of the specialty hospital. Findings suggest the introduction of financial incentives linked to ownership coincided with a significant change in the practice patterns of physician owners, whereas such changes were not evident among physician nonowners. After physicians established ownership interests in a specialty hospital, the frequency of use of surgery, diagnostic, and ancillary services used in the treatment of injured workers with back/spine disorders increased significantly. Physician ownership of specialty hospitals altered the frequency of use for an array of procedures rendered to patients treated at these hospitals. Given the growth in physician-owned specialty hospitals, these findings suggest that health care expenditures will be substantially greater for patients treated at these institutions relative to persons who obtain care from nonself-referral providers.
    No preview · Article · Aug 2008 · Medical Care
  • Jean M Mitchell
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    ABSTRACT: Recent reports by the Medicare Payment Advisory Commission have highlighted sharp increases in the use of advanced diagnostic imaging procedures among the Medicare fee-for-service population. Little research has examined whether such trends also exist among persons with generous private insurance coverage. Moreover, research documenting changes in the share of utilization linked to self-referral is nonexistent. Using data from a large private insurer in California, we document trends in utilization for magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) scans over the time period 2000-2004. We collected data that enable us to calculate relative changes in use rates by provider type (self-referral physicians, radiologists, hospitals, and independent diagnostic testing facilities). Examining trends in the share of utilization performed by provider type can offer insights as to the effects of self-referral on rates of use. Rates of use for the 3 advanced imaging modalities examined-MRI, CT, and PET-increased rapidly between 2000 and 2004. PET utilization increased by almost 400%, whereas the corresponding increases for MRI and CT exceeded 50%. Findings suggest that physician self-referral arrangements and independent diagnostic testing facilities seem to be contributing to this greater use of advanced imaging, especially for MRI and PET. In contrast, relative changes in use of advanced imaging performed at hospitals were small. Use rates for all 3 modalities were much higher in southern California compared with the northern region of the state. Use of highly reimbursed advanced imaging, a major driver of higher health care costs, should be based on clear clinical practice guidelines to ensure appropriate use.
    No preview · Article · Jun 2008 · Medical Care
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    Jean M Mitchell · Darrell J Gaskin · Chahira Kozma
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    ABSTRACT: Managed care plans that involve some form of capitation may have adverse effects on children with special health care needs because the financial incentives to control costs may result in under-treatment and restrict access to expensive services and specialty providers. Proponents highlight the advantages of a managed care model, including case management and coordination of services. In light of this debate, only a few state Medicaid programs have implemented a managed care option for children with special health care needs. This study evaluates the effects of plan choice (partially capitated managed care versus fee-for-service) on whether children with disabilities eligible for Supplemental Security Income (SSI) and enrolled in the District of Columbia's Medicaid program are in compliance with the guidelines for health supervision visits established by the American Academy of Pediatrics (AAP). Our findings, based on five years of claims data, show that SSI-eligible children with disabilities enrolled in a partially capitated managed care plan are significantly more likely to be in compliance with the AAP guidelines for health supervision visits compared to their fee-for-service counterparts. Moreover, we find that selection due to unobservable characteristics does not significantly bias the estimated program effects.
    Preview · Article · Feb 2008 · Inquiry: a journal of medical care organization, provision and financing
  • Jean M Mitchell
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    ABSTRACT: Physician ownership of specialty hospitals has become commonplace in recent years in several states where certificate-of-need laws do not exist. The study examines trends in utilization rates for complex and simple spinal fusion procedures performed on injured workers with back/spine disorders in two markets in Oklahoma. During the time period we examine, physician-owned spine or orthopedic specialty hospitals entered both market areas in Oklahoma. Because there were no market areas in Oklahoma without physician-owned spine or orthopedic hospitals to use as a comparison group, we also analyzed trends in utilization for these surgical procedures performed on Medicare beneficiaries. We compared utilization for these procedures in Oklahoma and three other states with a high concentration of physician-owned specialty hospitals (Kansas, South Dakota, and Arizona) to utilization rates for back surgery performed on Medicare patients who reside in the Northeast region. States in the Northeast constitute an appropriate control group because there are no physician-owned specialty hospitals in this region. Both analyses indicate that the entry of the physician-owned specialty hospitals was followed by substantial increases in the market area utilization rates for complex spinal fusion surgery. Conversely, such dramatic changes did not occur in the Northeast where physician-owned specialty hospitals do not exist. After considering but ruling out alternative explanations, the findings imply that the financial incentives linked to ownership coincided with significant changes in physicians' practice patterns.
    No preview · Article · Sep 2007 · Medical Care Research and Review
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    Jean M Mitchell
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    ABSTRACT: Using data from a large insurer in California, we identified the self-referral status of providers who billed for advanced imaging in 2004. Nearly 33 percent of providers who submitted bills for magnetic resonance imaging (MRI) scans, 22 percent of those who submitted bills for computed tomography (CT) scans, and 17 percent of those who submitted bills for positron-emission tomography (PET) scans were classified as "self-referral." Among them, 61 percent of those who billed for MRI and 64 percent of those who billed for CT did not own the imaging equipment. Rather, they were involved in lease or payment-per-scan referral arrangements that might violate federal and state laws.
    Preview · Article · May 2007 · Health Affairs
  • Jean M Mitchell · Darrell J Gaskin
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    ABSTRACT: The objective of this study was to evaluate how enrollment in a partially capitated managed care (MC) option versus the fee-for-service (FFS) system affects caregivers' ratings of dimensions of access to services among children with special health care needs (SHCN). The data were collected from telephone interviews during the summer and fall of 2002 with a random sample of 1088 caregivers of children with SHCN who qualified for Supplemental Security Income and therefore were enrolled the Medicaid program for children with SHCN in the District of Columbia. We used a 2-step procedure in which we first estimated plan choice and then constructed a selectivity correction to control for the potential selection bias linked to plan choice. We estimated the second stage equations predicting caregiver's ratings of dimensions of access as a function of the selectivity correction, the plan choice dummy variable and other exogenous variables. After controlling for the potential selection bias linked to plan choice and other confounding factors, we find that caregivers of children in FFS are significantly more likely than caregivers of children enrolled in the partially capitated MC plan to rate the following dimensions of access as either fair or poor: "access to specialists' care" (P < 0.01), "access to emergency room care" (P < 0.01), "convenience of the doctor's office" (P < 0.01), and "waiting time between making the appointment actual visit" (P < 0.05). We attribute these differences in caregivers' ratings of dimensions of access that exist between partially capitated MC and FFS enrollees to case management and care coordination services along with higher fees paid for pediatrician's and specialists' services available under MC option.
    No preview · Article · Mar 2007 · Medical Care
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    Cynthia R Schuster · Jean M Mitchell · Darrell J Gaskin
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    ABSTRACT: Little research has examined whether Medicaid managed care plans (MCPs) that incorporate case management are effective in coordinating services for children with special health care needs (CSHCN). This study evaluates the effects of enrollment of special needs children into a partially capitated MCP (with ongoing case management) versus the fee-for-service (FFS) option on use of therapeutic services, specifically speech, occupational, and physical therapy by site of service (school versus health care sector). Results show that special needs children enrolled in the partially capitated MCP are significantly more likely to obtain occupational and physical therapy at school relative to their FFS counterparts. Moreover, children enrolled in FFS are significantly less likely to be either regular or frequent users of each type of therapy relative to children enrolled in managed care. We attribute much of these disparities in use of therapeutic services at school to the availability of case management and coordination that is an integral component of the partially capitated MCP.
    Full-text · Article · Feb 2007 · Health care financing review
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    Jean M Mitchell
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    ABSTRACT: In recent years physician ownership of so-called limited-service hospitals has become commonplace in many states lacking certificate-of-need regulations. Empirical evidence documenting the effects of these facilities is sparse. This study compares practice patterns of physician-owners of limited-service cardiac hospitals and physician-nonowners who treat cardiac patients at competing full-service community hospitals. Analyses of six years of Arizona inpatient discharge data show that physician-owners treat higher volumes of profitable cardiac surgical diagnosis-related groups (DRGs), higher percentages of low-severity cases, and higher percentages of cases with generous insurance compared with physician-nonowners who treat cardiac patients in community hospitals.
    Preview · Article · Oct 2005 · Health Affairs
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    Jean M Mitchell · Darrell J Gaskin
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    ABSTRACT: To evaluate factors affecting plan choice (partially capitated managed care [MC] option versus the fee-for-service [FFS] system) and unmet needs for health care services among children who qualified for supplemental security income (SSI) because of a disability. We conducted telephone interviews during the summer and fall of 2002 with a random sample of close to 1,088 caregivers of SSI eligible children who resided in the District of Columbia. We employed a two-step procedure where we first estimated plan choice and then constructed a selectivity correction to control for the potential selection bias associated with plan choice. We included the selectivity correction, the dummy variable indicating plan choice and other exogenous regressors in the second stage equations predicting unmet need. The dependent variables in the second stage equations include: (1) having an unmet need for any service or equipment; (2) having an unmet need for physician or hospital services; (3) having an unmet need for medical equipment; (4) having an unmet need for prescription drugs; (5) having an unmet need for dental care. More disabled children (those with birth defects, chronic conditions, and/or more limitations in activities of daily living) were more likely to enroll in FFS. Children of caregivers with some college education were more likely to opt for FFS, whereas children from higher income households were more prone to enroll in the partially capitated MC plan. Children in FFS were 9.9 percentage points more likely than children enrolled in partially capitated MC to experience an unmet need for any type of health care services (p<.01), while FFS children were 4.5 percentage points more likely than partially capitated MC enrollees to incur a medical equipment unmet need (p<.05). FFS children were also more likely than partially capitated MC enrollees to experience unmet needs for prescription drugs and dental care, however these differences were only marginally significant. We speculate that the case management services available under the MC option, low Medicaid FFS reimbursements and provider availability account for some of the differences in unmet need that exist between partially capitated MC and FFS enrollees.
    Preview · Article · Oct 2005 · Health Services Research
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    Darrell J Gaskin · Jean M Mitchell
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    ABSTRACT: About 11-14% of children with special health care needs (CSHCN) have unmet needs during a given year. Little is known about the determinants of unmet health care needs for CSHCN. The objective of this study was to explore the association between access to care (unmet needs) among CSHCN and their caregivers' mental health status as well as children's mental health status. We surveyed a random sample of 1,088 caregivers of CSHCN who resided in the District of Columbia during the summer and fall of 2002. In the survey, we collected information on children's unmet needs mental health status (PARS) and their caregivers' mental health status (CES-D). We estimated the association between mental health status determinants of unmet needs adjusting for selection bias associated with plan choice (partially capitated managed care versus FFS) with an instrumental variables probit estimation technique. We used caregivers' preferences about physicians and hospitals networks, and whether the caregiver and child had the same last name to identify the plan choice equation. We found that caregivers with symptoms of depression were 26.3% more likely to report any unmet need, 67.6% more likely to report unmet hospital and physician need, 66.1% more likely to report unmet mental health care need and 38.8% more likely to report unmet need for other health care services. Caregivers of children with poor psychological adjustment were 26.3% more likely to report their child had an unmet need and 92.3% more likely to report an unmet mental health care need. Our analyses show that children whose caregivers experience symptoms of depression are significantly more likely to encounter difficulties obtaining needed medical and mental health care services. Furthermore, the findings reported here indicate that children with poor psychological adjustment are significantly more likely to experience unmet needs for medical and mental health care services. Our study has some limitations. First, most of the children in our sample are African-American, so these findings may differ for children of other races. Second, these findings may not be applicable to CSHCN who reside in rural areas. Third, we recognize the possibility that child and caregiver mental health is potentially endogenous. The mental health status of CSHCN and their caregivers are barriers to care. Policymakers should be concerned about the mental health status of children with special health care needs and their caregivers as such problems appear to be barriers to obtaining care. Therefore, to adequately address the access problems of children with special health care needs, policy must address the mental health problems of children and their caregivers. Providing mental health care for caregivers and children has the potential for improving overall access for CSHCN. IMPLICATION FOR FURTHER RESEARCH: Future research should determine the causal relationship between mental health problems of CSHCN and their caregivers and the level unmet health care needs.
    Full-text · Article · Apr 2005 · The Journal of Mental Health Policy and Economics

Publication Stats

2k Citations
314.21 Total Impact Points

Institutions

  • 1995-2015
    • Georgetown University
      • Lombardi Cancer Center
      Washington, Washington, D.C., United States
  • 1988-2005
    • Johns Hopkins University
      Baltimore, Maryland, United States
  • 2002
    • The Washington Institute
      Washington, Washington, D.C., United States
  • 1986-2000
    • Vanderbilt University
      • Department of Economics
      Нашвилл, Michigan, United States
  • 1996
    • Washington DC VA Medical Center
      Washington, Washington, D.C., United States
  • 1987-1994
    • Florida State University
      • Department of Economics
      Tallahassee, Florida, United States
  • 1992-1993
    • American University Washington D.C.
      Washington, Washington, D.C., United States