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Purpose: Rural-dwelling Department of Veterans Affairs (VA) enrollees are at high risk for a wide variety of mental health-related disorders. The objective of this study is to examine the variation in the types of mental and nonmental health services received by rural VA enrollees who have a mental healthrelated diagnosis. Methods: The Andersen and Aday behavioral model of health services use and the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey (MEPS) data were used to examine how VA enrollees with mental health-related diagnoses accessed places of care from 1999 to 2009. Population survey weights were applied to the MEPS data, and logit regression was conducted to model how predisposing, enabling, and need factors influence rural veteran health services use (measured by visits to different places of care). Analyses were performed on the subpopulations: rural VA, rural non- VA, urban VA, and urban non-VA enrollees. Findings: For all types of care, both rural and urban VA enrollees received care from inpatient, outpatient, office-based, and emergency room settings at higher odds than urban non-VA enrollees. Rural VA enrollees also received all types of care from inpatient, office-based, and emergency room settings at higher odds than urban VA enrollees. Rural VA enrollees had higher odds of a mental health visit of any kind compared to urban VA and non-VA enrollees. Conclusions: Based on these variations, the VA may want to develop strategies to increase screening efforts in inpatient settings and emergency rooms to further capture rural VA enrollees who have undiagnosed mental health conditions. [ABSTRACT FROM AUTHOR]

The study examined whether high cost-sharing policies for physician care are associated with reduced care utilization and costs differently between individuals with and without chronic conditions. Findings from this study contribute to the benefit structure design of health plans that may improve care delivery efficiencies and maintain health outcomes among chronically ill individuals. The study used the 2010-2011 Medical Expenditure Panel Survey data with a retrospective cohort study design. Difference in difference, negative binomial regression, and generalized linear models were employed to analyze the utilization and cost data. In order to account for national survey sampling design, weight and variance were adjusted. The study sample consisted of 4,368 individuals. Multivariate analysis and sensitivity analysis found consistent patterns between utilization and cost models. High cost-sharing policies for physician care were not associated with different levels of reductions in care utilization and costs between chronically ill people and healthy people (all at p > 0.05). However, the stratification analysis indicated that chronically ill people reduced physician care use and costs to the similarly significant extent as healthy people in response to high cost-sharing policies. Relative to non-chronically ill individuals, chronically ill individuals may decrease their care utilization and expenditures to a similarly significant extent in response to increased physician care cost sharing. This may be due to patients' inability to discern care cost-effectiveness, a short observation window, and chronic condition characteristics. It is possible that, in the long run, these sick people would demonstrate substantial demands for downstream medical care, such as inpatient care, and there could ultimately be a total cost increase for them and their families at the micro level. Health plans need to be cautious of policies for chronically ill private enrollees, such as considering a low cost-sharing policy for physician care or primary care. Individuals with chronic conditions may consider insurance plans with low levels of cost sharing in physician care, especially when more public information about health plan features and designs is available to facilitate their decision-making process. Future studies should examine this research question with a longer observation period and with more measures, such as physician behaviors. [ABSTRACT FROM AUTHOR]

Objective To determine the impact of Florida's Medicaid Demonstration 4 years post-implementation on per member per month ( PMPM) Medicaid expenditures and whether receiving care through HMOs versus provider service networks ( PSNs) in the Demonstration was associated with PMPM expenditures. Data Florida Medicaid claims from two fiscal years prior to implementation of the Demonstration ( FY0405, FY0506) and the first four fiscal years after implementation ( FY0607- FY0910) from two urban Demonstration counties and two urban non-Demonstration counties. Study Design A difference-in-difference approach was used to compare changes in enrollee expenditures before and after implementation of the Demonstration overall and specifically for HMOs and PSNs. Data Extraction Claims data were extracted for enrollees in the Demonstration and non-Demonstration counties and collapsed into monthly amounts ( N = 26,819,987 person-months). Principal Findings Among SSI enrollees, the Demonstration resulted in lower increases in PMPM expenditures over time ($40) compared with the non-Demonstration counties ($186), with Demonstration PSNs lowering PMPM expenditures by $7 more than HMOs. Savings were also seen among TANF enrollees but to a lesser extent. Conclusions The Medicaid Demonstration in Florida appears to result in lower PMPM expenditures. Demonstration PSNs generated slightly greater reductions in expenditures compared to Demonstration HMOs. PSNs appear to be a promising model for delivering care to Medicaid enrollees. [ABSTRACT FROM AUTHOR]

Clinical inertia, the failure to adjust antihypertensive medications during patient visits with uncontrolled hypertension, is thought to be a common problem. This retrospective study used 5 years of electronic medical records from a multispecialty group practice to examine the association between physician and patient characteristics and clinical inertia. Hierarchical linear models ( HLMs) were used to examine (1) differences in physician and patient characteristics among patients with and without clinical inertia, and (2) the association between clinical inertia and future uncontrolled hypertension. Overall, 66% of patients experienced clinical inertia. Clinical inertia was associated with one physician characteristic, patient volume (odds ratio [ OR]=0.998). However, clinical inertia was associated with multiple patient characteristics, including patient age ( OR=1.021), commercial insurance ( OR=0.804), and obesity ( OR=1.805). Finally, patients with clinical inertia had 2.9 times the odds of uncontrolled hypertension at their final visit in the study period. These findings may aid the design of interventions to reduce clinical inertia. [ABSTRACT FROM AUTHOR]

To determine the impact of Florida's Medicaid Reform Demonstration on per member per month (PMPM) Medicaid expenditures. Florida Medicaid claims data from the two fiscal years before implementation of the Demonstration (FY0405, FY0506) and the first two fiscal years after implementation (FY0607, FY0708) from two reform counties and two nonreform counties. A difference-in-difference approach was used to compare changes in expenditures before and after implementation of reforms between the reform counties and the nonreform counties. Medicaid claims and eligibility files were extracted for enrollees in the reform and nonreform counties and collapsed into monthly amounts ( N=16,875,467). When examining the entire population, the reforms had little impact on PMPM expenditures, particularly among SSI enrollees. PMPM expenditures for SSI enrollees increased by an additional U.S.$0.35 in the reform counties compared with the nonreform counties and increased by an additional U.S.$2.38 for Temporary Assistance for Needy Families (TANF) enrollees. An analysis that limited the sample to individuals with at least 3 or 6 months of observations pre- and postimplementation, however, showed reduced PMPM expenditures of U.S.$11.15-U.S.$19.44 PMPM for both the SSI and TANF populations. Although Medicaid reforms in Florida did not result in significant reductions in PMPM expenditures when examining the full population, it does appear that expenditure reductions may be achieved among Medicaid enrollees with more stable enrollment, who have more exposure to managed care activities and may have more health care needs than the overall Medicaid population. [ABSTRACT FROM AUTHOR]

Objective: To assess the association between rurality and depression care. Methods: Data were extracted for 10,319 individuals with self-reported depression in the Medical Expenditure Panel Survey. Pharmacotherapy was defined as an antidepressant prescription fill, and minimally adequate pharmacotherapy was defined as receipt of at least 4 antidepressant fills. Psychotherapy was defined as an outpatient counseling visit, and minimally adequate psychotherapy was defined as ≥ 8 visits. Rurality was defined using Metropolitan Statistical Areas (MSAs) and Rural Urban Continuum Codes (RUCCs). Results: Over the year, 65.1% received depression treatment, including 58.8% with at least 1 antidepressant prescription fill and 24.5% with at least 1 psychotherapy visit. Among those in treatment, 56.2% had minimally adequate pharmacotherapy treatment and 36.3% had minimally adequate psychotherapy treatment. Overall, there were no significant rural-urban differences in receipt of any type of formal depression treatment. However, rural residence was associated with significantly higher odds of receiving pharmacotherapy (MSA: OR 1.16 [95% CI, 1.01-1.34; P= .04] and RUCC: OR 1.04 [95% CI, 1.00-1.08; P= .05]), and significantly lower odds of receiving psychotherapy (MSA: OR 0.62 [95% CI, 0.53-0.74; P < .01] and RUCC: OR 0.91 [95% CI, 0.88-0.94; P < .001]). Rural residence was not significantly associated with the adequacy of pharmacotherapy, but it was significantly associated with the adequacy of psychotherapy (MSA: OR 0.53 [95% CI, 0.41-0.69; P < .01] and RUCC: OR 0.92 [95% CI, 0.86-0.99; P= .02]). Psychiatrists per capita were a mediator in the psychotherapy analyses. Conclusions: Rural individuals are more reliant on pharmacotherapy than psychotherapy. This may be a concern if individuals in rural areas turn to pharmacotherapy because psychotherapists are unavailable rather than because they have a preference for pharmacotherapy. [ABSTRACT FROM AUTHOR]

Objectives: To assess the effect of the co-occurrence of four common chronic medical conditions (hypertension, diabetes mellitus, arthritis, heart disease) on the probability of receiving adequate depression treatment. Design: Retrospective analysis of the 2000 and 2001 Medical Expenditure Panel Surveys (MEPS). Setting: Households in the United States. Participants: MEPS respondents aged 65 and older with self-reported depression (N=498). Measurements: Adequate depression treatment is defined as receiving eight psychotherapy sessions or filling at least four antidepressant prescriptions at a minimally adequate dosage. Comorbid diabetes mellitus, hypertension, heart disease, and arthritis in older persons with depression were identified from patient self-report. Results: An estimated 34% (95% confidence interval=28–39%) of older persons with self-reported depression received an adequate course of depression treatment during a calendar year. Having hypertension or diabetes mellitus was associated with significantly greater odds of receiving adequate depression care (hypertension odds ratio (OR)=1.81, P=.02; diabetes mellitus OR=1.77, P=.03). Having heart disease or arthritis was not significantly associated with the odds of receiving adequate depression care. Conclusion: Some chronic medical conditions are associated with a greater likelihood of receiving adequate depression care; comorbid medical conditions do not result in lower quality of depression treatment in older persons. The high prevalence rates of comorbid depression and low rates of adequate depression care in elderly persons with chronic illnesses point to the importance of improving primary care depression treatment or enhancing specialty mental health referral. [ABSTRACT FROM AUTHOR]

To examine how nursing home characteristics impacted the number of lawsuits filed against the facilities in the United States during 1997–2001.A stratified random sample of 2,378 nursing home in 45 states from 1997–2001. Data were obtained from Westlaw's Adverse Filings: Lawsuits database, the Centers for Medicare and Medicaid Services' (CMS) Online Survey, Certification, and Reporting (OSCAR) database, state complaint surveys, and through primary data.Negative binomial regression was used to explain total lawsuit variance by year. Explanatory variables included (a) facility characteristics—including staffing, number of beds, multistate system membership, for-profit ownership, (b) quality indicators—including total number and type of quality survey deficiencies, pressure sore development, and (c) market area—state has resident rights statutes, state complaint information. Resident acuity levels and year effects were controlled for.Nursing homes were identified and linked to Westlaw data that was searched for the number of lawsuits filed against the home, and then linked to OSCAR data and a primary data analysis of multistate chain membership.Staffing levels for certified nursing assistants (CNAs) and registered nurses (RNs) and multistate chain membership were negatively related with higher numbers of lawsuits. More deficiencies on the licensing survey, larger, for-profit nursing homes, and being located in resident rights states were positively related with higher numbers of lawsuits.This study suggests that nursing homes that meet long-stay staffing standards and minimum quality indicators, are nonprofit, smaller, and not located in resident rights states will experience fewer lawsuits. [ABSTRACT FROM AUTHOR]

The objective of this study was to estimate mean annual out-of-pocket (OOP) healthcare expenditures of Americans aged 65 and older with self-reported depression and compare these expenditures with the OOP expenditures of older Americans with hypertension, heart disease, diabetes mellitus, and arthritis. Data from the 1999 Medical Expenditure Panel Survey, which employs a nationally representative stratified random sample of households in the United States, were used to estimate mean OOP expenditures for health care during 1999. The data were limited to observations on individuals aged 65 and older living in households in the United States included in the 1999 Medical Expenditure Panel Survey sample (N=2,730). Mean OOP expenditures for older Americans with depression were $1,835 in 1999. Most of the spending ($1,090) was for prescription drugs in this population. For patients with depression, only 8% of total OOP spending was for depression-specific services and treatments. Mean OOP spending was greater for persons with depression than it was for older Americans with hypertension ($1,181) and arthritis ($1,190), whereas OOP spending for depression was similar to spending of older Americans with heart disease ($1,412) and diabetes mellitus ($1,527). Older Americans with depression have high OOP expenditures, with most of this spending for health services and drugs to treat general medical conditions. [ABSTRACT FROM AUTHOR]