Health insurance, primary care, and preventable hospitalization of children in a large state

Abstract

Objectives: To analyze variations in the admission rate to hospitals of children with ambulatory care-sensitive (ACS) conditions and to test the relationship of ACS admission rates to insurance coverage, health maintenance organization (HMO) enrollment, availability of primary care, severity of illness, distance to hospital, and a number of other factors.

Study design: Hypotheses were derived from basic considerations about demand and use of primary care and preventive services and then were tested with a weighted linear regression model of the ACS admission rate for children residing in each county.

Patients and methods: The principal data were all hospital discharges for New York resident children admitted to hospitals in New York, Pennsylvania, New Jersey, or Connecticut in 1994. The data and methodology were noteworthy for including out-of-area hospital admissions.

Results: There was a substantial negative association of the ACS rate with private HMO coverage. There also were sizable negative effects of the availability of primary care services in physician offices and the distance traveled. Large differences related to racial and ethnic composition of the population were found independent of other determinants. There was a positive association with the proportion of all admissions (admissions for all conditions) covered by Medicaid or self-pay. Severity of illness and use of emergency departments were controlled. There was no independent effect of a location in New York City.

Conclusions: The results are consistent with smaller-scale studies suggesting that improved health insurance for children could reduce hospital admissions. Contracting with HMOs also appears to be beneficial. Independently, programs to increase the availability of primary and preventive services could substantially reduce ACS admissions.