Journal of General Internal Medicine

, Volume 17, Issue 12, pp 905–913

Insurance and quality of care for adults with acute asthma

  • Timothy G. Ferris
  • David Blumenthal
  • Prescott G. Woodruff
  • Sunday Clark
  • Carlos A. CamargoJr.
  • the MARC Investigators
Original Articles

Abstract

OBJECTIVE: The relationship between health care insurance and quality of medical care remains incompletely studied. We sought to determine whether type of patient insurance is related to quality of care and subsequent outcomes for patients who arrive in the emergency department (ED) for acute asthma.

DESIGN: Using prospectively collected data from the Multicenter Airway Research Collaboration, we compared measures of quality of pre-ED care, acute severity, and short-term outcomes across 4 insurance categories: managed care, indemnity, Medicaid, and uninsured.

SETTING AND PARTICIPANTS: Emergency departments at 57 academic medical centers enrolled 1,019 adults with acute asthma.

RESULTS: Patients with managed care ranked first and uninsured patients ranked last on all 7 unadjusted quality measures. After controlling for covariates, uninsured patients had significantly lower quality of care than indemnity patients for 5 of 7 measures and had lower initial peak expiratory flow rates than indemnity insured patients. Patients with managed care insurance were more likely than indemnity-insured patients to identify a primary care physician and report using inhaled steroids in the month prior to arrival in the ED. Patients with Medicaid insurance were more likely than indemnity-insured patients to use the ED as their usual source of care for problems with asthma. We found no differences in patient outcomes among the insurance categories we studied.

CONCLUSIONS: Uninsured patients had consistently poorer quality of care and than insured patients. Despite differences in indicators of quality of care between types of insurance, we found no differences in short-term patient outcomes by type of insurance.

Key words

asthma acute asthma emergency department primary care quality insurance managed care length of stay uninsured Medicaid 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Landon BE, Wilson IB, Cleary PD. A conceptual model of the effects of health care organizations on the quality of medical care. JAMA. 1998;279:1377–82.PubMedCrossRefGoogle Scholar
  2. 2.
    Ayanian JZ, Weissman JS, Schneider EC, Ginsberg JA, Zaslavsky AM. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284:2061–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Weissman JS, Epstein AM. Falling Through the Safety Net: Insurance Status and Access to Health Care. Baltimore: Johns Hopkins University Press; 1994.Google Scholar
  4. 4.
    Addington W. No Health Insurance? It’s Enough to Make You Sick. Philadelphia: American College of Physicians/American Society of Internal Medicine; 2000.Google Scholar
  5. 5.
    Adams Dudley R, Miller RH, Korenbrot TY, Luft H. The impact of financial incentives on quality of health care. Milbank Q. 1998;76:649–86.CrossRefGoogle Scholar
  6. 6.
    Hellinger FJ. The effect of managed care on quality: a review of recent evidence. Arch Intern Med. 1998;158:833–41.PubMedCrossRefGoogle Scholar
  7. 7.
    Miller RH, Luft HS. Managed care plan performance since 1980: a literature analysis. JAMA. 1994;271:1512–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Miller RH, Luft HS. Does managed care lead to better or worse quality of care? Health Aff (Millwood). 1997;16:7–25.CrossRefGoogle Scholar
  9. 9.
    Soumerai SB, McLaughlin TJ, Gurwitz JH, et al. Timeliness and quality of care for elderly patients with acute myocardial infarction under health maintenance organization vs fee-for-service insurance. Arch Intern Med. 1999;159:2013–20.PubMedCrossRefGoogle Scholar
  10. 10.
    Ferris TG, Crain EF, Oken E, Wang L, Clark S, Camargo CA. Insurance and quality of care for children with acute asthma. Ambul Pediatr. 2001;1:267–74.PubMedCrossRefGoogle Scholar
  11. 11.
    Hartert TV, Windon HH, Peebles RS, Freidhoff KR, Togias A. Inadequate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med. 1996;100:395–405.CrossRefGoogle Scholar
  12. 12.
    Donahue JG, Weiss ST, Livingston JM, Goetsch MA, Greineder DK, Platt R. Inhaled steroids and the risk of hospitalization for asthma. JAMA. 1997;277:887–91.PubMedCrossRefGoogle Scholar
  13. 13.
    Homer CJ, Szilagyi P, Rodewald L, et al. Does quality of care affect rates of hospitalization for childhood asthma? Pediatrics. 1996;98:18–23.PubMedGoogle Scholar
  14. 14.
    Windsor RA, Bailey WC, Richards JM Jr, Manzella B, Soong SJ, Brooks M. Evaluation of the efficacy and cost effectiveness of health education methods to increase medication adherence among adults with asthma. Am J Public Health. 1990;80:1519–21.PubMedGoogle Scholar
  15. 15.
    Berg J, Dunbar-Jacob J, Sereika SM. An evaluation of a self-management program for adults with asthma. Clin Nurs Res. 1997;6:225–38.PubMedCrossRefGoogle Scholar
  16. 16.
    Bailey WC, Richards JM Jr, Brooks CM, Soong SJ, Windsor RA, Manzella BA. A randomized trial to improve self-management practices of adults with asthma. Arch Intern Med. 1990;150:1664–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Cote J, Cartier A, Robichaud P, et al. Influence on asthma morbidity of asthma education programs based on self-management plans following treatment optimization. Am J Respir Crit Care Med. 1997;155:1509–14.PubMedGoogle Scholar
  18. 18.
    Greineder DK, Loane KC, Parks P. Reduction in resource utilization by an asthma outreach program. Arch Pediatr Adolesc Med. 1995;149:415–20.PubMedGoogle Scholar
  19. 19.
    Seidman JJ, Weiss KB. Health plans’ use of asthma quality improvement projects to meet NCQA accreditation standards. Am J Manag Care. 2001;7:567–72.PubMedGoogle Scholar
  20. 20.
    Homer CJ. Asthma disease management. N Engl J Med. 1997;337:1461–3.PubMedCrossRefGoogle Scholar
  21. 21.
    Billings J, Kretz SE, Rose R, et al. National Asthma Education and Prevention Program working group report on financing of asthma care. Am J Respir Crit Care Med. 1996;154:S119–30.PubMedGoogle Scholar
  22. 22.
    Eisenberg JM, Power EJ. Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality. JAMA. 2000;284:2100–7.PubMedCrossRefGoogle Scholar
  23. 23.
    http://healthcarepartners.org/marc. Accessed 6/12/02.Google Scholar
  24. 24.
    Finkelstein JA, Brown RW, Schneider LC, et al. Quality of care for preschool children with asthma: the role of social factors and practice setting. Pediatrics. 1995;95:389–94.PubMedGoogle Scholar
  25. 25.
    Lieu TA, Quesenberry CP Jr, Capra AM, Sorel ME, Martin KE, Mendoza GR. Outpatient management practices associated with reduced risk of pediatric asthma hospitalization and emergency department visits. Pediatrics. 1997;100:334–41.PubMedCrossRefGoogle Scholar
  26. 26.
    DeVellis RF. Scale Development: Theory and Application. Vol 26. Newbury Park: Sage Publications; 1991.Google Scholar
  27. 27.
    Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. 1999;159:179–87.PubMedGoogle Scholar
  28. 28.
    Silverman RA, Weber EJ, Callahan ML, Pollack CV, Woodruff PG, Camargo CA. A prospective multicenter study of patient factors associated with hospital admission among adults with acute asthma. [abstract]. Acad Emerg Med. 1998;5:375.CrossRefGoogle Scholar
  29. 29.
    Iezzoni LI. Dimensions of risk. In: Iezzoni LI, ed. Risk Adjustment for Measuring Healthcare Outcomes. 2nd ed. Chicago: Health Administration Press; 1997:610.Google Scholar
  30. 30.
    Rosenstreich DL, Eggleston P, Kattan M, et al. The role of cockroach allergen and exposure to cockroach allergen in causing morbidity among inner-city children. N Engl J Med. 1997;336:1356–63.PubMedCrossRefGoogle Scholar
  31. 31.
    Scanlon DP, Chernew M, Lave JR. Consumer health plan choice: current knowledge and future directions. Annu Rev Public Health. 1997;18:507–28.PubMedCrossRefGoogle Scholar
  32. 32.
    Ferris TG, Perrin JM, Manganello J, Chang Y, Causino N, Blumenthal D. Switching to gatekeeping: changes in expenditures and utilization for children. Pediatrics. 2001;108:283–90.PubMedCrossRefGoogle Scholar
  33. 33.
    Young MJ, Lenhart J, Wasser TE, Czerwonka C, Davidyock J, Sussman EJ. Evidence for the Will Rogers phenomenon in migration of employees to Managed Care plans. J Gen Intern Med. 1999;14:564–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Carrasquillo O, Himmelstein DU, Woolhandler S, Bor DH. Going bare: trends in health insurance coverage, 1989 through 1996. Am J Public Health. 1999;89:36–42.PubMedGoogle Scholar
  35. 35.
    Berk ML, Schur CL. Access to care: how much difference does Medicaid make? Health Aff (Millwood). 1998;17:169–80.CrossRefGoogle Scholar
  36. 36.
    Sox CM, Burstin HR, Edwards RA, O’Neil AC, Brennan TA. Hospital admissions through the emergency department: does insurance status matter? Am J Med. 1998;105:506–12.PubMedCrossRefGoogle Scholar
  37. 37.
    Grumbach K, Selby JV, Damberg C, et al. Resolving the gate-keeper conundrum: what patients value in primary care and referrals to specialists. JAMA. 1999;282:261–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Ferris TG, Chang Y, Blumenthal D, Pearson SD. Leaving gate-keeping behind—effects of opening access to specialists for adults in a health maintenance organization. N Engl J Med. 2001;345:1312–7.PubMedCrossRefGoogle Scholar
  39. 39.
    Christakis DA, Mell L, Koepsell TD, Zimmerman FJ, Connell FA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001;103:524–9.CrossRefGoogle Scholar
  40. 40.
    Wasson JH, Sauvigne AE, Mogielnicki RP, et al. Continuity of outpatient medical care in elderly men: a randomized trial. JAMA. 1984;252:2413–7.PubMedCrossRefGoogle Scholar
  41. 41.
    Weiss LJ, Blustein J. Faithful patients: the effect of long-term physician-patient relationships on costs and use of health care by older Americans. Am J Public Health. 1996;86:1742–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Starfield BL, Simborg DW, Horn SD, Yourtee SA. Continuity and coordination in primary care: their achievement and utility. Med Care. 1976;14:625–36.PubMedCrossRefGoogle Scholar
  43. 43.
    Wu AW, Young Y, Skinner EA, et al. Quality of care and outcomes of adults with asthma treated by specialists and generalists in managed care. Arch Intern Med. 2001;161:2554–60.PubMedCrossRefGoogle Scholar
  44. 44.
    Merrick NJ, Houchens R, Tillisch S, Berlow B, Landon C. Quality of hospital care of children with asthma: Medicaid versus privately insured patients. J Health Care Poor Underserved. 2001;12:192–207.PubMedGoogle Scholar
  45. 45.
    Carlisle R, Avery AJ, Marsh P. Primary care teams work harder in deprived areas. J Public Health Med. 2002;24:43–8.PubMedCrossRefGoogle Scholar
  46. 46.
    McConnochie KM, Russo MJ, McBride JT, Szilagyi PG, Brooks A, Roghmann KJ. Socioeconomic variation in asthma hospitalization: excess utilization or greater need? Pediatrics. 1999;103:e75.Google Scholar
  47. 47.
    Braveman P, Schaaf VM, Egerter S, Bennett T, Schecter W. Insurance-related differences in the risk of ruptured appendix. N Engl J Med. 1994;331:444–9.PubMedCrossRefGoogle Scholar
  48. 48.
    Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med. 1991;114:325–31.PubMedGoogle Scholar
  49. 49.
    Nelson DE, Thompson BL, Davenport NJ, Penaloza LJ. What people really know about their health insurance: a comparison of information obtained from individuals and their insurers. Am J Public Health. 2000;90:924–8.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2002

Authors and Affiliations

  • Timothy G. Ferris
    • 1
  • David Blumenthal
    • 1
  • Prescott G. Woodruff
    • 4
  • Sunday Clark
    • 2
  • Carlos A. CamargoJr.
    • 2
    • 3
  • the MARC Investigators
  1. 1.the Institute for Health Policy, Division of General MedicineMassachusetts General Hospital, Partners HealthCare System and Harvard Medical SchoolBoston
  2. 2.the Department of Emergency MedicineMassachusetts General HospitalBoston
  3. 3.Channing Laboratory, Department of MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBoston
  4. 4.the Division of Pulmonary and Critical Care Medicine, Department of MedicineUniversity of California at San FranciscoSan Francisco

Personalised recommendations