Survey of CIC Program Participants: Who Joined and How Did They Change Their Care-Seeking Behavior? Catherine McLaughlin University of Michigan Erin Fries.

Survey of CIC Program Participants: Survey of CIC Program Participants: Who Joined and How Did They Change Who Joined and How Did They Change

Their Care-Seeking Behavior?Their Care-Seeking Behavior?

Catherine McLaughlin University of Michigan

Erin Fries TaylorMathematica Policy Research

WebCast Presentation

CIC programsJune 23, 2004

Alameda County: Family CareAlameda County: Family Care• Insurance product for parents of children enrolled in

Alameda Alliance for Health• 300% FPL or less

Austin: I-CareAustin: I-Care• Not an insurance product, collaboration of area

hospitals and charity care organizations• 250% FPL or less

Southern Maine: CarePartnersSouthern Maine: CarePartners• Donated care model • 150% FPL or less

Survey in 3 CIC SitesSurvey in 3 CIC Sites

Research QuestionsResearch Questions• Who joined?

• Changes in care-seeking behavior?

• Changes in satisfaction and perceived access?

• Differences by race/ethnicity? • Alameda and Austin

• Differences by chronic illness? • Southern Maine

• Who stays and who leaves?

Survey ContentSurvey Content

• Household information• Demographics• Income and employment • Previous health insurance coverage (asked

at baseline)• Health status and utilization• Usual source of care, unmet need• Satisfaction, attitudes

Wave 1 DetailsWave 1 Details

• Site provided contact information on all new enrollees over a period of 4-6 months

• Completed interviews in Wave 1-AlamedaAlameda: 471 adults (Aug 01–Jan 02)

88% response rate

-AustinAustin: 347 adults (Feb–Aug 02)

87% response rate

-S MaineS Maine: 300 adults (Nov 01–June 02)

93% response rate

Baseline Survey DataBaseline Survey Data

• Who participates in each CIC program?

• Were there differences in characteristics by race/ethnicity?

• Were there differences in characteristics by chronic illness?

Selected Socio-DemographicsSelected Socio-Demographics

AlamedaAlameda AustinAustin S. MaineS. Maine

Female 63% 60% 66%

Married 78% 48% 20%

Median age 34 34 43

Median hshld size 4 4 2

Homeowners 34% 29% 43%

Born outside US 89% 64% 3%

Income, Employment, and Previous Income, Employment, and Previous Insurance StatusInsurance Status

AlamedaAlameda AustinAustin S. MaineS. MaineMedian hshld income $23k $17k $13k

Currently employed 52% 69% 50%

Avg. hours worked (among workers)

38 36 32

Some coverage in previous year

49% 25% 47%

Never had coverage before CIC program

31% 54% 15%

Race/Ethnic/Language Composition: Race/Ethnic/Language Composition: Alameda County Alameda County

Latinos

Asians

Others

Spanish-speaking (48%)

English-speaking (5%)

English-speaking (7%) Cantonese-speaking (30%)


Selected Socio-demographics by Selected Socio-demographics by Race/Ethnicity: Alameda CountyRace/Ethnicity: Alameda County

Latino Asian Other

Average Age 32 39 34

% Married 75% 87% 63%

Avg. Household Size 5 4.3 3.9

Avg. Education (yrs.) 10.9 11.9 13.4

Avg. Annual Household Income

$23K $34K $34K

% Born Outside US 93% 97% 11%

Race/Ethnic/Language Composition: Race/Ethnic/Language Composition: AustinAustin

Latinos

Spanish-speaking (50%)


Whites English-speaking (16%)

Others English-speaking (12%)

Selected Socio-demographics Selected Socio-demographics by Race/Ethnicity: Austinby Race/Ethnicity: Austin

Span-sp Latino

(n=174)

Eng-sp Latino

(n=75)

Other

(n=42)

White, NH

(n=56)

Avg. Age 35 35 41 38

% Married 63% 32% 50% 21%

Avg. Household Size 4.3 3.6 3.2 2.4

Avg. Education (yrs.) 10.8 11.8 13. 13.0

Avg. Annual Hshld. Income (2001)

$17K $18K $25K $18K

% Born Outside US 97% 33% 57% 7%

Baseline Health Status and Care-Baseline Health Status and Care-Seeking BehaviorSeeking Behavior


Fair or poor health status 22% 35% 30%

Chronic or limiting condition 12% 22% 53%

No health care utilization

(previous 12 months)

35% 32% 10%

Median out-of-pocket costs (previous 12 months)

<$50 $100-299 $300-499

Preventive Services in Previous YearPreventive Services in Previous Year


Physical Exam

Blood Pressure Check

Breast Exam (among women)

Pap Smear (among women)

38%

59%

30%

44%

31%

61%

22%

34%

53%

84%

55%

50%

36%

6%43%

12% 3%

36%

23%

38%

2%

1%

62%9%

20%

8% 1%

Doctor's Office

Hospital Outpatient

Other Clinic or Health

Hospital ER or Urgent

Some Other Place

AlamedaAlameda

AustinAustin S. MaineS. Maine

Usual Source of Care:

Alameda: Health and Care-Seeking Behaviors: Alameda: Health and Care-Seeking Behaviors: Themes by Race/Ethnicity Themes by Race/Ethnicity

• Asians and Latinas reported worse health status, but fewer chronic conditions

• Cantonese-speaking Asians rated health status lower than English-speaking Asians

• Latinas and Other were more likely to have an ER visit or a doctor visit

• Asians reported lowest out-of pocket costs and Other reported the highest

More on Baseline Health in Alameda: More on Baseline Health in Alameda: Themes by Race/EthnicityThemes by Race/Ethnicity

• Cantonese-speaking Asians were most likely to have no health care utilization

• Those in Other category were most likely to report unmet need

Austin: Utilization Rates By Race/EthnicityAustin: Utilization Rates By Race/Ethnicity

White, Non-Latino

English Speaking

Latino

Spanish Speaking

Latino

Other

ER Visit 36% 39% 24% 36%

Hospital Stay 9% 9% 6% 5%

Doctor Visit 68% 61% 52% 62%

No Utilization 18% 27% 39% 29%

Median Out-of- Pocket Costs

$200 $200 $75 $200

Baseline Health and Care-Seeking Baseline Health and Care-Seeking Behaviors: Themes by Race/EthnicityBehaviors: Themes by Race/Ethnicity

Alameda CountyAlameda County• Cantonese-speaking Asians were most likely to have no

health care utilization, but also report worse health status than English-speaking Asians

AustinAustin• Spanish-speaking Latinos were most likely to have no health

care utilization, but also report worse health status than English-speaking Latinos

In both Alameda and Austin, Latinos report worse health status and, at the same time, fewer report chronic or limiting condition(s) than other participants

Self-Reported Health Status by Self-Reported Health Status by Race/EthnicityRace/Ethnicity

0%

20%

40%

60%

80%

100%

Spanish-speakingHispanic

English-speakingHispanic

Other White non-Hispanic0%

20%

40%

60%

80%

100%

Hispanic Cantonese-speakingAsians

English-speaking

Asians

Other

VeryGood,ExcellentGood

Poor/Fair

Alameda Austin

S. Maine: Baseline Utilization Rates S. Maine: Baseline Utilization Rates by Presence of Chronic Conditionby Presence of Chronic Condition

Those with limiting or chronic condition(s)

Those without condition(s)

Percent Average number

(among those with visits)

Percent Average number

(among those with visits)

Hospital Stay 23% 2.2 12% 1.4

ER Visit 58% 3.5 44% 2.4

Doctor Visit 86% 9.0 77% 5.3

S. Maine: Out-of-Pocket Health Care S. Maine: Out-of-Pocket Health Care Costs in Previous Year (if Costs>0)Costs in Previous Year (if Costs>0)

0%

5%

10%

15%

20%

25%

30%

35%

$0 $200 $400 $600 $800 $1,000

Those with limiting orchronic condition(s)Those with nocondition

Having a Usual Source of Care Having a Usual Source of Care Made a Difference in:Made a Difference in:

• Having any physician visits, ER visits, or hospital stays

• Receiving preventive care– Physical exam

– Blood pressure check

– Breast exam (among females)

– Pap smear (among females)

• Having a personal health care provider

Having Insurance Coverage in Last Having Insurance Coverage in Last 12 Months Made a Difference in12 Months Made a Difference in::• Having any physician visits• Receiving preventive care:

– Physical exam– Blood pressure check– Breast exam (among females)– Pap smear (among females)

• Having a usual source of care and a personal health care provider

Research Questions: ChangesResearch Questions: Changes• Changes in health status, health care utilization, and

care-seeking behavior?– e.g., decrease ED use, increase preventive care

• Changes in satisfaction and perceived access?– e.g., less self-reported unmet need

• Are there race/ethnic differences in these changes?• Are there differences in changes for those with a

chronic condition?

Use Pre/Post Comparison: Wave I Use Pre/Post Comparison: Wave I vs. Wave II + Wave IIIvs. Wave II + Wave III

• Utilization data for the 12 months before and for the 12 months post-enrolling– Continuous enrollees and those who disenrolled– Possible “seam bias” (doublecounting), so rely

more on “Yes/No used” than the count data of how many visits

– Change = used only before or used only after enrolling

Number of Respondents by WaveNumber of Respondents by Wave

Wave 1 Wave 2* Wave 3*

Alameda 471 401

380 enrollees

371

330 enrollees

Austin 347 299

232 enrollees

253

174 enrollees

S. Maine 300 266

182 enrollees

233

89 enrollees

*Continued high response rates (>80%)

Alameda: Comparisons of Medical Care UseAlameda: Comparisons of Medical Care UseBefore and After EnrollmentBefore and After Enrollment

Doc use

ED use

Hosp use

After enrollment only 33% 12% 4%

Before enrollment only 5 10 7

Both before and after enrollment

47 8 1

Neither before or after enrollment

14 70 88

change

no change

N=330, survey respondents who were continuously enrolled in CIC

Alameda: Comparisons of ED Use Before and Alameda: Comparisons of ED Use Before and After Enrollment by Race/EthnicityAfter Enrollment by Race/Ethnicity

Asian Latino Other

After enrollment only 10% 15% 12%

Before enrollment only 7 13 6


2*** 10*** 21***


81*** 62*** 62***

change

no change

Note: there are no statistically significant differences for hospital use

Austin: Comparisons of Medical Care UseAustin: Comparisons of Medical Care UseBefore and After EnrollmentBefore and After Enrollment

0 15 52Both before and after enrollment

6163 Before enrollment only

9% 16% 32%After enrollment only

855213Neither before or after enrollment

Hosp use

ED use

Doc use

change

no change

N=164, survey respondents who were continuously enrolled in CIC

Austin: Comparisons of Use Before and After Austin: Comparisons of Use Before and After Enrollment by EthnicityEnrollment by Ethnicity

4**16**Neither before nor after enrollment

48116Number of respondents

OtherLatino

63*48*Both before and after enrollment

43Before enrollment only

29%32%After enrollment only

Doctor Use

change

no change

5253

2113

1716

10%19%

OtherLatino

ED use

48116

S. Maine: Comparisons of Medical Care UseS. Maine: Comparisons of Medical Care UseBefore and After EnrollmentBefore and After Enrollment

124383Both before and after enrollment


9%12%17%After enrollment only


Hosp use

ED use

Doc use

change

no change

N = 99, survey respondents who were continuously enrolled in CIC

S. Maine: Comparisons of Use Before and S. Maine: Comparisons of Use Before and After by Presence of Chronic IllnessAfter by Presence of Chronic Illness

Doctor Use ED Use

Chronic Not Chronic Not

After enrollment only 9%** 25%** 13% 11%

Before enrollment only 0 0 18 18


91** 75** 51 34

Neither before nor after enrollment

0 0 18** 36**

Number of Respondents 45 44 45 44

change

no change

*p<0.10, **p<0.05, ***p<0.01, significantly different by presence of chronic illness

Alameda: Comparisons in Preventive Care Alameda: Comparisons in Preventive Care Use Before and After Enrollment, EnrolleesUse Before and After Enrollment, Enrollees

Physical exam

Blood pressure

After enrollment only 38% 29%

Before enrollment only 7 7


31 51


24 14

no changechange

Austin: Comparisons in Preventive Care Use Austin: Comparisons in Preventive Care Use Before and After EnrollmentBefore and After Enrollment


5 5Before enrollment only

27% 36%After enrollment only


Blood pressure

Physical exam

no changechange

S. Maine: Changes in Preventive Care Use S. Maine: Changes in Preventive Care Use Before and After Enrollment, EnrolleesBefore and After Enrollment, Enrollees


3 4Before enrollment only

15% 34%After enrollment only


Blood pressure

Physical exam

no changechange

Women’s Preventive Care in Alameda: Women’s Preventive Care in Alameda: Comparisons Before and After EnrollmentComparisons Before and After Enrollment

Breast exam Pap smear

After enrollment only 38% 35%



19 33


32 21

change

no change

N = 220 women

Women’s Preventive Care in Austin: Women’s Preventive Care in Austin: Comparisons Before and After EnrollmentComparisons Before and After Enrollment




41% 41% After enrollment only

Pap smearBreast exam

change

no change

N = 98 women

Women’s Preventive Care in S. Maine: Women’s Preventive Care in S. Maine: Comparisons Before and After EnrollmentComparisons Before and After Enrollment




27%27% After enrollment only

Pap smearBreast exam

change

no change

N = 62 women

S. Maine: Comparisons of Breast Exams Before S. Maine: Comparisons of Breast Exams Before and After by Presence of Chronic Illnessand After by Presence of Chronic Illness

Chronic Not

After enrollment only 13%** 41%**



37 44


37** 9**

Number of Respondents 30 32

no changechange

Were There Changes Over Time Were There Changes Over Time in Medical Care Use?in Medical Care Use?• In all 3 sites, there was a noticeable increase in

physician visits and an even larger increase in the number receiving physical exams, PAP smears, and breast exams.

• Only S. Maine showed a noticeable, although statistically insignificant, decrease in ED use

• No site showed a noticeable change in hospital use

Do Changes Over Time Differ Do Changes Over Time Differ in Different Populations?in Different Populations?

• In Alameda, changes in ED use varied significantly by race/ethnicity: Latinos were the most likely to go only before enrollment

• In S. Maine, those without a chronic condition were more likely to increase use of physician services and to have a breast exam

Different Use by Different PopulationsDifferent Use by Different Populations• Most of the differences in utilization by race/ethnicity and

by the presence of a chronic condition are differences in level of use, not change in use after enrolling– Asians were less likely to use physician, ED, and hospital

services both before and after enrollment– Latinos were more likely than Asians, but less likely than “other”

to use physician, ED, and hospital services both before and after– Those with a chronic condition were more likely to use ED and

hospital services both before and after

CaveatsCaveats

• Results are based on self-reported utilization data-Utilization (e.g., visits) tend to be under-reported-Procedures (e.g., pap smears) tend to be over-reported-Errors of omission increase with length of recall

DisenrollmentDisenrollment

• There were varying levels of disenrollment across the 3 sites, the highest in S. Maine

• What were the reasons given for leaving?

• Were disenrollees “different” from continuous enrollees?

• What happened to disenrollees in terms of coverage, utilization, satisfaction?

Possible Sample TransitionsPossible Sample Transitions

Wave 1

CarePartners

Wave 2

CarePartners

ESIMedicaidUninsured

Wave 3

CarePartners


N = 182

N = 84N = 73

N = 89N = 266

Example and numbers presented are for S. MaineExample and numbers presented are for S. Maine


Wave 1 Wave 2 Wave 3

CarePartners CarePartners CarePartners


N = 6

N = 266

N = 84

N = 182 N = 89


Wave 1 Wave 2 Wave 3

CarePartners CarePartners CarePartners



N = 71

N = 266

N = 84

N = 182 N = 89

Reasons for Disenrolling: S. MaineReasons for Disenrolling: S. Maine

• Became eligible for another program 37%72%

• R or spouse got job that offered coverage 31 14

• Income too high to remain eligible 21 8

• Didn’t complete program paperwork 8 4

• Didn’t think needed care 7 1

• Couldn’t afford to remain in program 6 3

• Moved away from area 5 4

• Was unhappy with program 2 3

• Some other reason 2 6

W2 W3

% of Participants by Insurance Status, % of Participants by Insurance Status, Waves 2 and 3Waves 2 and 3

• Wave 2 69 5 5 21

• Wave 3 69 4 8 18

ESI Medicaid Uninsured

Enrolled Disenrolled

Comparisons of Enrollees and Comparisons of Enrollees and Disenrollees by Insurance Status, Wave 2Disenrollees by Insurance Status, Wave 2

• % Female 31 25 43 37• % Married 25 8 36 25• % Employed 51 100 21 57• Hsehold Income $15k 32k 13k 19k• % ESI before 24 75 57 43• % Medicaid before 10 0 36 4

Enrolled Disenrolled ESI Medicaid Uninsured

Comparisons of Enrollees and Disenrollees Comparisons of Enrollees and Disenrollees by Health Status and Utilization, Wave 2by Health Status and Utilization, Wave 2

• % Fair or Poor HS 33 0 21 22• % with Condition 49 42 79 37• % Physician visit 93 100 93 91• % Hospital stay 15 8 23 14• % ED visit 2 2 3 3

Enrolled Disenrolled ESI Medicaid Uninsured

Emerging PatternsEmerging Patterns

• One group staying in program as long term source of coverage:– Part-time or self-employed workers who lack

access to ESI


• Two groups tend to be using CarePartners as stopgap measure:– Relatively healthy full-time workers who

(re)gained access to ESI– Relatively sicker unemployed persons who

became eligible for Medicaid


• Fourth group:– Those leaving the program who lost eligibility

or failed to fill in the proper paperwork and remain uninsured

Next StepsNext Steps

• Investigate further how utilization changes across time (pent-up demand?)

• Continue to explore differences in use, access, and attitudes by race/ethnicity

• Explore differences in use, access, and attitudes by presence of a chronic or limiting condition

• Continue analysis of factors that predict retention in the program

• Analyze changes in use and attitudes for disenrollees

Survey of CIC Program Participants: Who Joined and How Did They Change Their Care-Seeking Behavior? Catherine McLaughlin University of Michigan Erin Fries.

Documents

health care utilizationthose

alameda alliance

worse health status

health status lower

seline health status

baseline health

maineusual source of

englishspeaking asianslatinas