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November 4, 1992, Vol 268, No. 17 >
ARTICLE | November 4, 1992

Rates of Avoidable Hospitalization by Insurance Status in Massachusetts and Maryland FREE

Joel S. Weissman, PhD; Constantine Gatsonis, PhD; Arnold M. Epstein, MD, MA
[+] Author Affiliations

Reprint requests to the Department of Health Care Policy, Harvard Medical School, 25 Shattuck St, Parcel B, 1st Floor, Boston, MA 02115 (Dr Epstein).


JAMA. 1992;268(17):2388-2394. doi:10.1001/jama.1992.03490170060026
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References

Objective.  —To determine whether uninsured and Medicaid patients have higher rates of avoidable hospitalizations than do insured patients.

Design.  —We used 1987 computerized hospital discharge data to select a cross-sectional sample of hospitalized patients. Population estimates from the Current Population Survey were used to estimate rates of admission, standardized for age and sex.

Setting.  —Nonfederal acute care hospitals in Massachusetts and Maryland. Patients.—All patients under 65 years of age who were uninsured, privately insured, or insured by Medicaid. Hospitalizations for obstetric and psychiatric conditions were excluded.

Main Outcome Measures.  —Relative risk of admission for 12 avoidable hospital conditions (AHCs) identified by a physician panel.

Results.  —Uninsured and Medicaid patients were more likely than insured patients to be hospitalized for AHCs. Rates for uninsured patients were significantly greater than for privately insured patients in Massachusetts for 10 of 12 individual AHCs, and in Maryland for five of 12 AHCs. After adjustment for baseline utilization, the results were statistically significant for 10 of 12 AHCs in Massachusetts and seven of 12 AHCs in Maryland. For Medicaid patients, rates were significantly greater than for privately insured patients for all AHCs in each state before adjustment, and for nine of 12 and seven of 12 AHCs in each state, respectively, after adjustment for baseline utilization.

Conclusion.  —Our findings suggest that patients who are uninsured or who have Medicaid coverage have higher rates of hospitalization for conditions that can often be treated out of hospital or avoided altogether. Our approach is potentially useful for routine monitoring of access and quality of care for selected groups of patients.(JAMA. 1992;268:2388-2394)

REFERENCES

1 +
Robert Wood Johnson Foundation. Special Report: Access to Health Care in the United States: Results of a 1986 Survey . Princeton, NJ: Robert Wood Johnson Foundation; 1987;:2.
2 +
Aday LA, Andersen RM.  The national profile of access to medical care: where do we stand? Am J Public Health . 1984;;74:1331-1339.
3 +
Weissman JS, Fielding SL, Stern RS, Epstein AM.  Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med . 1991;; 114:325-331.
4 +
Weissman JS, Epstein AM.  Case mix and resource utilization by uninsured hospital patients in the Boston metropolitan area. JAMA . 1989;;261:3572-3576.
5 +
Wenneker MB, Weissman JS, Epstein AM.  The association of payer with utilization of cardiac procedures in Massachusetts. JAMA . 1990;;264:1255-1260.
6 +
Hadley J, Steinberg EP, Feder J.  Comparison of uninsured and privately insured hospital patients: condition on admission, resource use, and outcome. JAMA . 1991;;265:374-379.
7 +
Yergan J, Flood AB, Diehr P, LoGerfo JP.  Relationship between patient source of payment and the intensity of hospital services. Med Care . 1988;; 26:1111-1114.
8 +
Young GJ, Cohen BB.  Inequities in hospital care: the Massachusetts experience. Inquiry . 1991;;28:255-262.
9 +
Braveman P, Oliva G, Grisham Miller M, Reiter R, Egerter S.  Adverse outcomes and lack of health insurance among newborns in an eight-county area of California, 1982-1986. N Engl J Med . 1989;;321: 508-512.
10 +
Howell EM, Herz EJ, Wang R, Hirsch MB.  A comparison of Medicaid and non-Medicaid obstetrical care in California. Health Care Financing Rev . 1991;;12:1-16.
11 +
Lurie N, Ward NB, Shapiro MF, Gallego C, Vaghaiwalla R, Brook RH.  Termination of medical benefits: a follow-up study one year later. N Engl J Med . 1986;;314:1266-1268.
12 +
Brook RH, Ware JE, Rogers WH, et al.  Does free care improve adults' health? results from a randomized controlled trial. N Engl J Med . 1983;; 309:1426-1434.
13 +
Newhouse JP.  Controlled experimentation as research policy.  In: Ginzberg E, ed. Health Services Research: Accomplishments and Potential . Cambridge, Mass: Harvard University Press; 1991;:161-194.
14 +
Rutstein DD, Berenberg W, Chalmers TC, Child CG, Fishman AP, Perrin EB.  Measuring the quality of medical care: a clinical method. N Engl J Med . 1976;;294:582-588.
15 +
Rutstein DD, Berenberg W, Chalmers TC, Child CG, Fishman AP, Perrin EB.  Measuring the quality of medical care: revision of tables of indexes. N Engl J Med . 1977;;297:508.
16 +
Schwartz E, Kofie VY, Rivo M, Tuckson RV.  Black/white comparisons of deaths preventable by medical intervention: United States and the District of Columbia 1980-86. Int J Epidemiol . 1990;; 19:591-598.
17 +
Wissow LS, Gittelsohn AM, Szklo M, Starfield B, Mussman M.  Poverty, race and hospitalization for childhood asthma. Am J Public Health . 1988;; 78:777-782.
18 +
Carr W, Szapiro N, Heisler T, Krasner MI. Measuring Avoidable Deaths and Diseases in New York State . New York: United Hospital Fund of New York; 1988;. Series 8:5-54.
19 +
Woolhandler S, Himmelstein DU, Silber R, Bader M, Harnly M, Jones A.  Medical care and mortality: racial differences in preventable deaths. Int J Health Serv . 1985;;15:1-22.
20 +
Charlton JRH, Hartley RM, Silver R, Holland WW.  Geographical variation in mortality from conditions amenable to medical intervention in England and Wales. Lancet . 1983;;1:691-696.
21 +
Martini CJM, Allan B, Davison J, Backett EM.  Health indexes sensitive to medical care variation. Int J Health Serv . 1977;;7:293-309.
22 +
Buck C, Bull S.  Preventable cases of death vs infant mortality as an indicator of the quality of health services. Int J Health Serv . 1986;;16: 553-563.
23 +
Perloff JD, Ketke PR, Neckerman KM.  Physicians' decisions to limit Medicaid participation: determinants and policy implications. J Health Polit Policy Law . 1987;;12:221-235.
24 +
Craddick JW.  The medical management analysis system. QRB Qual Rev Bull . 1979;;5:2-8.
25 +
Solberg LI, Peterson KE, Ellis RW, et al.  The Minnesota project: a focused approach to ambulatory quality assessment. Inquiry . 1990;;27: 359-367.
26 +
Division of Quality Control Management, American Hospital Association. International Classification of Diseases, Ninth Revision, Clinical Modification . Chicago, Ill: American Hospital Publishing Inc; 1989;.
27 +
Data User Services Division, Data Access and Use Staff, Bureau of the Census.  User Note No. 1.  In: Current Population Survey, March 1988 Tape Technical Documentation . Washington, DC: Bureau of the Census; 1989;.
28 +
Moyer ME.  A revised look at the number of uninsured Americans. Health Aff . 1989;;8:102-110.
29 +
Roos NP, Wennberg JE, McPherson K.  Using diagnosis-related groups for studying variations in hospital admissions. Health Care Financing Rev . 1988;;9:53-62.
30 +
Christoffersson J, Conklin J, Gonnella J.  The impact of severity of illness on hospital costs. DRG Monitor . 1988;;6:1-8.
31 +
Gonnella J, Hornbrook M, Louis D.  Staging of disease: a case-mix measurement. JAMA . 1984;;251: 637-644.
32 +
Rundall T, Gordon N, Parker L, Perkins C. California residents with and without health insurance . Presented at the 119th annual meeting of the American Public Health Association; November 13, 1991;; Atlanta, Ga.
33 +
Billings J, Teicholz N.  Uninsured patients in District of Columbia hospitals. Health Aff . (Winter) 1990;;9:158-165.
34 +
Hsia DC, Krushat WM, Fagan AB, Tebbutt JA, Kusserow RP.  Accuracy of diagnostic coding for medicare patients under the prospective-payment system. N Engl J Med . 1988;;318:352-355.
35 +
Diehr P, Cain K, Connell F, Volinn E.  What is too much variation? the null hypothesis in small-area analysis. Health Serv Res . 1990;;24:741-771.
36 +
Brown ER.  Access to health insurance in the United States. Med Care Rev . 1989;;46:349-385.
37 +
Garfinkel S, Corder L, Dobson A.  Health services utilization in the US population by health insurance coverage.  In: National Medical Care Utilization and Expenditure Survey . Washington, DC: Office of Research and Demonstrations, Health Care Financing Administration; 1986;. Dept of Health and Human Services publication No. 20213. Series B, descriptive report No. 13.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Robert Wood Johnson Foundation. Special Report: Access to Health Care in the United States: Results of a 1986 Survey . Princeton, NJ: Robert Wood Johnson Foundation; 1987;:2.
2 +
Aday LA, Andersen RM.  The national profile of access to medical care: where do we stand? Am J Public Health . 1984;;74:1331-1339.
3 +
Weissman JS, Fielding SL, Stern RS, Epstein AM.  Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med . 1991;; 114:325-331.
4 +
Weissman JS, Epstein AM.  Case mix and resource utilization by uninsured hospital patients in the Boston metropolitan area. JAMA . 1989;;261:3572-3576.
5 +
Wenneker MB, Weissman JS, Epstein AM.  The association of payer with utilization of cardiac procedures in Massachusetts. JAMA . 1990;;264:1255-1260.
6 +
Hadley J, Steinberg EP, Feder J.  Comparison of uninsured and privately insured hospital patients: condition on admission, resource use, and outcome. JAMA . 1991;;265:374-379.
7 +
Yergan J, Flood AB, Diehr P, LoGerfo JP.  Relationship between patient source of payment and the intensity of hospital services. Med Care . 1988;; 26:1111-1114.
8 +
Young GJ, Cohen BB.  Inequities in hospital care: the Massachusetts experience. Inquiry . 1991;;28:255-262.
9 +
Braveman P, Oliva G, Grisham Miller M, Reiter R, Egerter S.  Adverse outcomes and lack of health insurance among newborns in an eight-county area of California, 1982-1986. N Engl J Med . 1989;;321: 508-512.
10 +
Howell EM, Herz EJ, Wang R, Hirsch MB.  A comparison of Medicaid and non-Medicaid obstetrical care in California. Health Care Financing Rev . 1991;;12:1-16.
11 +
Lurie N, Ward NB, Shapiro MF, Gallego C, Vaghaiwalla R, Brook RH.  Termination of medical benefits: a follow-up study one year later. N Engl J Med . 1986;;314:1266-1268.
12 +
Brook RH, Ware JE, Rogers WH, et al.  Does free care improve adults' health? results from a randomized controlled trial. N Engl J Med . 1983;; 309:1426-1434.
13 +
Newhouse JP.  Controlled experimentation as research policy.  In: Ginzberg E, ed. Health Services Research: Accomplishments and Potential . Cambridge, Mass: Harvard University Press; 1991;:161-194.
14 +
Rutstein DD, Berenberg W, Chalmers TC, Child CG, Fishman AP, Perrin EB.  Measuring the quality of medical care: a clinical method. N Engl J Med . 1976;;294:582-588.
15 +
Rutstein DD, Berenberg W, Chalmers TC, Child CG, Fishman AP, Perrin EB.  Measuring the quality of medical care: revision of tables of indexes. N Engl J Med . 1977;;297:508.
16 +
Schwartz E, Kofie VY, Rivo M, Tuckson RV.  Black/white comparisons of deaths preventable by medical intervention: United States and the District of Columbia 1980-86. Int J Epidemiol . 1990;; 19:591-598.
17 +
Wissow LS, Gittelsohn AM, Szklo M, Starfield B, Mussman M.  Poverty, race and hospitalization for childhood asthma. Am J Public Health . 1988;; 78:777-782.
18 +
Carr W, Szapiro N, Heisler T, Krasner MI. Measuring Avoidable Deaths and Diseases in New York State . New York: United Hospital Fund of New York; 1988;. Series 8:5-54.
19 +
Woolhandler S, Himmelstein DU, Silber R, Bader M, Harnly M, Jones A.  Medical care and mortality: racial differences in preventable deaths. Int J Health Serv . 1985;;15:1-22.
20 +
Charlton JRH, Hartley RM, Silver R, Holland WW.  Geographical variation in mortality from conditions amenable to medical intervention in England and Wales. Lancet . 1983;;1:691-696.
21 +
Martini CJM, Allan B, Davison J, Backett EM.  Health indexes sensitive to medical care variation. Int J Health Serv . 1977;;7:293-309.
22 +
Buck C, Bull S.  Preventable cases of death vs infant mortality as an indicator of the quality of health services. Int J Health Serv . 1986;;16: 553-563.
23 +
Perloff JD, Ketke PR, Neckerman KM.  Physicians' decisions to limit Medicaid participation: determinants and policy implications. J Health Polit Policy Law . 1987;;12:221-235.
24 +
Craddick JW.  The medical management analysis system. QRB Qual Rev Bull . 1979;;5:2-8.
25 +
Solberg LI, Peterson KE, Ellis RW, et al.  The Minnesota project: a focused approach to ambulatory quality assessment. Inquiry . 1990;;27: 359-367.
26 +
Division of Quality Control Management, American Hospital Association. International Classification of Diseases, Ninth Revision, Clinical Modification . Chicago, Ill: American Hospital Publishing Inc; 1989;.
27 +
Data User Services Division, Data Access and Use Staff, Bureau of the Census.  User Note No. 1.  In: Current Population Survey, March 1988 Tape Technical Documentation . Washington, DC: Bureau of the Census; 1989;.
28 +
Moyer ME.  A revised look at the number of uninsured Americans. Health Aff . 1989;;8:102-110.
29 +
Roos NP, Wennberg JE, McPherson K.  Using diagnosis-related groups for studying variations in hospital admissions. Health Care Financing Rev . 1988;;9:53-62.
30 +
Christoffersson J, Conklin J, Gonnella J.  The impact of severity of illness on hospital costs. DRG Monitor . 1988;;6:1-8.
31 +
Gonnella J, Hornbrook M, Louis D.  Staging of disease: a case-mix measurement. JAMA . 1984;;251: 637-644.
32 +
Rundall T, Gordon N, Parker L, Perkins C. California residents with and without health insurance . Presented at the 119th annual meeting of the American Public Health Association; November 13, 1991;; Atlanta, Ga.
33 +
Billings J, Teicholz N.  Uninsured patients in District of Columbia hospitals. Health Aff . (Winter) 1990;;9:158-165.
34 +
Hsia DC, Krushat WM, Fagan AB, Tebbutt JA, Kusserow RP.  Accuracy of diagnostic coding for medicare patients under the prospective-payment system. N Engl J Med . 1988;;318:352-355.
35 +
Diehr P, Cain K, Connell F, Volinn E.  What is too much variation? the null hypothesis in small-area analysis. Health Serv Res . 1990;;24:741-771.
36 +
Brown ER.  Access to health insurance in the United States. Med Care Rev . 1989;;46:349-385.
37 +
Garfinkel S, Corder L, Dobson A.  Health services utilization in the US population by health insurance coverage.  In: National Medical Care Utilization and Expenditure Survey . Washington, DC: Office of Research and Demonstrations, Health Care Financing Administration; 1986;. Dept of Health and Human Services publication No. 20213. Series B, descriptive report No. 13.

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