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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
On Being New...: Updated Disenrollment Rate
Adverse Consequences Versus Appropriate Use of Services
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Edgar R Black, M.D., Rochester, NY, USA Medical Director, Excellus BlueCross BlueShield, Peter Franks, M.D.
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Following publication of this article, additional information was provided by the insurance company. This information may affect interpretation of some of the study results. Specifically, the method of identifying “those who are new to a health plan” resulted in a substantial number of false-positives. This occurred because the approach used to identify new subscribers identified not only new subscribers but also individuals where other changes occurred including changing to a spouse’s coverage, some changes in marital status, change from parent’s to self- coverage, and changing to a new health plan with the same insurer. The precise contribution of each of these is unknown. However, the plan’s audited disenrollment rate as reported to NCQA during the study time period averaged 12.0%. This disenrollment rate does not include any of the situations noted above. Thus, the average disenrollment rate cited in the paper of 19.6% overstates the audited rate by about 50%. Some of these false positives reflect circumstances that probably would not result in changes in health care; others might result in changes in health care as enrollees make adjustments to new situations and new coverage. The net effect on the results and their interpretation is uncertain. However, if the observed differences in utilization (lower mammography rates, greater risk for avoidable hospitalization, and higher costs among “new” enrollees) reflect effects averaged across both true positives and false positives, then the likely effects among true positives would be greater. (Please note -- this is being submitted on behalf of Dr. Franks and myself.) Competing interests: None declared |
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Steven H Landers, Cleveland, OH Resident Physician, University Hospitals of Cleveland Department of Family Medicine
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Dr. Franks and colleagues address an important question; are there differences in utilization of medical services by patients new to a health plan compared with patients who have ongoing coverage(1)? The results show increased health care utilization by newly insured patients and decreased mammography rates. The authors conclude that there may be adverse effects of changing insurance. I am struck by the possibility that the increased utilization may be highlighting the beneficial effects of increased access by previously uninsured and underinsured individuals. This possibility was mentioned in the discussion, but I was disappointed this issue was not addressed more completely. Admittedly, I am very interested in issues related to health care access, and this may have biased my reading of the article
A recent study demonstrated that Medicare coverage leads to appropriate and desirable increases in use of clinical services for individuals that were previously uninsured (2). We also know that not all health plans offer the same access to needed care, there is growing recognition of the problem of underinsurance (3). A subset of people who switch health plans may do so in hopes of accessing previously denied services and better providers. Insurance companies are aware of this and call it adverse selection. The higher “avoidable hospitalizations,” may be the result of appropriately caring for chronic diseases that had been poorly managed because of previous access barriers.
If we knew the subjects’ previous insurance status, the study would be stronger. If the information is not available, a model based on regional uninsured and underinsured data may allow a sensitivity analysis to see if the findings of the study hold. I also wonder if the avoidable hospitalizations occurred early or late in their enrollment year? Dr. Franks and colleagues should be commended for their thoughtful analysis of this large, multi-year database. I believe, however, that more valuable information could be gleaned from this database regarding the negative and positive consequences of insurance status changes if these questions were addressed.
1. Peter Franks, Colin Cameron, and Klea D. Bertakis. On Being New to an Insurance Plan: Health Care Use Associated With the First Years in a Health Insurance Plan
Ann Fam Med 2003 1: 156-161.
2. McWilliams JM, Zaslavsky AM, Meara E, Ayanian JZ. Impact of Medicare coverage on basic clinical services for previously uninsured adults. JAMA. 2003 Aug 3;290(6):757-64.
3. Kaiser Commission on Medicaid and the Uninsured. Underinsured in America: Is Health Coverage Adequate? July 2002. Accessed from www.kff.org 10/8/2003.
Competing interests: None declared |
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