Toward estimating the impact of changes in immigrants' insurance eligibility on hospital expenditures for uncompensated care

BACKGROUND: The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 gave states the option to withdraw Medicaid coverage of nonemergency care from most legal immigrants. Our goal was to assess the effect of PRWORA on hospital uncompensated care in the United States. METHODS: We collected the following state-level data for the period from 1994 through 1999: foreign-born, noncitizen population and health uninsurance rates (US Census Current Population Survey); percentage of teaching hospitals (American Hospital Association Annual Survey of Hospitals); and each state's decision whether to implement the PRWORA Medicaid bar for legal permanent residents or to continue offering nonemergency Medicaid coverage using state-only funds (Urban Institute). We modeled uncompensated care expenditures by state (also from the Annual Survey of Hospitals) in both univariate and multivariable regression analyses. RESULTS: When measured at the state level, there was no significant relationship between uncompensated care expenditures and states' percentage of noncitizen immigrants. Uninsurance rates were the only significant factor in predicting uncompensated hospital care expenditures by state. CONCLUSIONS: Reducing the number of uninsured patients would most surely reduce hospital expenditures for uncompensated care. However, data limitations hampered our efforts to obtain a monetary estimate of hospitals' financial losses due specifically to the immigrant eligibility changes in PRWORA. Quantifying the impact of these provisions on hospitals will require better data sources

Preventing avoidable hospital admission of older people.

The National Service Framework for Older People (Department of Health, 2001) stresses the importance of preventing unnecessary hospital admissions for older people. Such admissions arise when there is inadequate health and social support available in the community to meet the needs of this age group. This article reports on a study designed to evaluate the effectiveness of a programme of enhanced primary care support intended to reduce the risk of hospital admission for people aged 75 years and above. Nineteen patients out of a possible 322 in one GP practice were judged by GPs and district nurses to be "at risk" of avoidable hospital admission. All at-risk patients were visited by a GP or district nurse to review their needs for enhanced support, six patients subsequently accepting a referral for additional support. No statistically significant difference in the number of hospital admissions in the intervention group was observed compared with a group of patients with similar demographic characteristics but deemed not to be at such high risk, suggesting that the intervention might have been effective in reducing the number of avoidable hospital admissions

Clinical, provider and sociodemographic predictors of late initiation of antenatal care in England and Wales

Objective To identify factors that are predictive of late initiation of antenatal care in England and Wales. Design A multivariate binomial regression model was constructed to examine the association between clinical, provider and sociodemographic characteristics and late initiation of antenatal care. Setting Nine maternity units in Northern England and North Wales. Population A total of 20,771 women with a singleton pregnancy who delivered a liveborn or stillborn baby between 1 August 1994 and 31 July 1995. All analyses were based on the 17,765 (85.5%) women for whom information on gestational age at initial presentation for antenatal care and other variables incorporated into the regression model was retrievable from the case records Results Primiparous women of high obstetric risk were 13.4% more likely to initiate antenatal care after 10 weeks of gestation than a low risk reference group (adjusted OR 1.134, 95% CI 1.011, 1.272; P= 0.0312), and 34.3% more likely to initiate antenatal care after 18 weeks of gestation (adjusted OR 1.343, 95% CI 1.046, 1.724; P= 0.0208). This association between high obstetric risk status and late initiation of antenatal care was not replicated among multiparous women. When the effects of other independent variables on gestational age at booking were examined, the following characteristics were associated with failure to initiate antenatal care by 10 weeks of gestation (P≤ 0.05): maternal age at booking, smoking status, ethnicity, type of hospital at booking, the planned pattern of antenatal care and the planned place of delivery. Adopting a criterion of 18 weeks of gestation exacerbated the association between clinical and sociodemographic characteristics and late initiation of antenatal care, but appeared to dilute the association between provider characteristics and late initiation of antenatal care. Conclusions There is a pressing need for further research to identify the specific concerns of late bookers, to identify areas where new interventions might encourage the uptake of services and to gauge the likely impact of increased dissemination of information about the availability of antenatal care services