The Quality of Diabetes Care by Insurance Status

The Quality of Diabetes Care by Insurance Status at Community Health Centers James Zhang, PhD, MS  Anne Kirchhoff, MPH  Jennifer Walk, MS  Cynthia Schaefer, APRN, BC + Loretta Heuer, PhD, RN ± Marshall Chin, MD MPH  The University of Chicago, + University of Evansville, ±University of North Dakota AcademyHealth ARM, 2006 Background • Community Health Centers (CHCs) play a critical role in improving access to quality care -- 13 million Americans -- 40% uninsured and over 1/3 on Medicaid -- President Bush’s priority CHC Capacity and Health Insurance • Should expanding health services and expanding health insurance be viewed as substitute or complementary? Aim of this Analysis To compare the quality of care for diabetes patients by insurance status at CHCs Study Design • 27 CHCs in 17 West Central and Midwest states in 2002 • 2,052 random diabetes patients • Retrospective chart audits Methods • Multivariate logistic regressions • Five insurance groups, using no-insurance group as reference, adjusted for age, gender, race, urban location, seven comorbidities, and site fixed effects Process of Care and Outcome Measures • Dependent variables: 6 NCQA HEDIS Diabetes process of care and outcome measures – HbA1c testing – HbA1c > 9.5% – Eye exam – Lipid profile – LDL cholesterol < 130 mg/dL – Urine microalbumin CHC Patient Sample Characteristics (N=2,052) • • • • • Mean age 54 60% female 20% African American 29% Hispanic 41% cared at urban setting Socio-demographic Distribution by Insurance Status No Insurance (33%) Age (years, s.d.) Female (N, %) African American (N, %) Medicare (24%) Medicaid (15%) Dual Eligibles (7%) 64 (13) 96 (66) Private (13%) Other (7%) 48 (12) 396 (58) 67 (11) 286 (58) 49 (13) 218 (71) 49 (11) 158 (57) 49 (12) 78 (54) 112 (16) 99 (20) 100 (33) 41 (28) 59 (21) 7 (5) Hispanic (N, %) Urban (N, %) 286 (42) 60 (12) 49 (16) 29 (20) 54 (20) 108 (74) 411 (60) 147 (30) 163 (53) 22 (15) 84(30) 17 (12) Comorbidity/Complication Distribution by Insurance Status No Insurance Medicare Medicaid Dual Eligibles Private Other Hypertension Myocardial Infarction Retinopathy Neuropathy Peripheral Vascular Disease Renal Failure Proteinuria 55 2 5 10 83 7 6 14 69 4 9 14 80 3 10 14 64 2 4 7 63 3 9 8 2 2 13 8 8 15 5 5 14 6 6 12 3 3 12 1 0 3 % in each insurance group Performance Measures by Insurance Status No Insurance HbA1c testing 89 Medicare 92 Medicaid 89 Dual Eligibles 96 Private 94 Other 86 HbA1c > 9.5% Eye Exam Lipid Profile LDL < 130 Urine Microalbumin 27 44 67 71 40 11 47 72 71 44 21 44 66 73 38 9 41 76 75 37 15 52 80 71 43 22 39 73 73 31 % in each insurance group. p<=0.05, p<0.10, when compared to no-insurance group, adjusted for all other insurance groups, age, gender, race, urban location, seven comorbidities, and site fixed effects in multivariate logistic regressions Conclusion • Those with health insurance received better or at least comparable quality of care when compared to those without insurance – Medicare and Dual Eligible better – Private insurance better Policy Implications • Should expanding health services and expanding health insurance be viewed as substitute or complementary? • Couple expanding CHC service locations with increasing insurance coverage to improve quality of care