Chronically ill persons who are uninsured have higher out-of-pocket medical spending and are five times less likely to see a physician than their insured counterparts.by Wenke Hwang, Wendy Weller, Henry Ireys, and Gerard Anderson ABSTRACT: We examined out-of-pocket medical spending by persons with and without chronic conditions using data from the 1996 Medical Expenditure Panel Survey (MEPS). Our results show that mean out-of-pocket spending increased with the number of chronic conditions. The level of this spending also varied by age and insurance coverage, among other characteristics. Out-of-pocket spending for prescription drugs was substantial for both elderly and nonelderly persons with chronic conditions. As policymakers continue to use cost sharing and design of benefit packages to contain health spending, it is important to consider the impact of these policies on persons with chronic conditions and their families.L arge out-of-pocket expenditures for medical services have been shown to impede access to care, affect health status and quality of life, and leave insufficient income for other necessities. It is important to identify the characteristics of persons who are likely to spend large amounts out of pocket, to assess the impact of policy changes related to health insurance coverage. It is also important to know which services are most likely to generate large out-of-pocket expenditures. A review of the literature, however, reveals a dearth of recent comprehensive national estimates of out-of-pocket spending by the general population and for persons with chronic conditions. The few studies that are available have not identified the characteristics of persons with high out-of-pocket spending and have not examined the wide range of services used by persons with chronic

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During the last 20 years, the number of infants evaluated for permanent hearing loss at birth has increased dramatically with universal newborn hearing screening and intervention (UNHSI) programs operating in all US states and many territories. One of the most urgent challenges of UNHSI programs involves loss to follow-up among families whose infants screen positive for hearing loss. We surveyed 55 state and territorial UNHSI programs and conducted site visits with 8 state programs to evaluate progress in reaching program goals and to identify barriers to successful follow-up. We conclude that programs have made great strides in screening infants for hearing loss, but barriers to linking families of infants who do not pass the screening to further follow-up remain. We identified 4 areas in which there were barriers to follow-up (lack of service-system capacity, lack of provider knowledge, challenges to families in obtaining services, and information gaps), as well as successful strategies used by some states to address barriers within each of these areas. We also identified 5 key areas for future program improvements: (1) improving data systems to support surveillance and follow-up activities; (2) ensuring that all infants have a medical home; (3) building capacity beyond identified providers; (4) developing family support services; and (5) promoting the importance of early detection. Pediatrics 2010;126:S19-S27

Medical care for children with selected chronic health conditions is 2.5 to 20 times more expensive than children in general, depending on the condition. A relatively few children account for the majority of expenditures. Extensive variation in mean, median, and total expenditures suggests that different conditions will need to be kept distinct for purposes of establishing payment rates. Children with certain conditions are vulnerable to restrictions in specific services, depending on what restrictions are imposed by a financing program. Further analyses are needed to identify risk-adjustment strategies to support delivery of high-quality services to this population of children as they migrate into managed-care environments.

In an ideal world, effective programs would be disseminated on a large scale, but many obstacles block program diffusion. To date, little guidance has been provided by program designers on how to implement the program in different sites with different personnel and client populations. This article discusses the debate between the "fidelity camp" and the "reinvention camp" and suggests an approach that reconciles the two positions: fidelity should be maintained to the program's mechanism of operation; reinvention is permitted in implementation if the causal mechanism is preserved. Such an approach is essential for effective dissemination of preventive interventions that are successful in controlled trials.

A family support intervention can have beneficial effects on the mental health status of mothers of children with chronic illnesses. This type of intervention can be implemented in diverse pediatric settings.

Our results demonstrate modest positive effects of a family support intervention in promoting the adjustment of children with selective chronic health conditions. Including child life specialists in a community-based intervention may be especially salient for children with chronic illnesses who have low physical self-esteem. The intervention had a similar outcome for all diagnostic groups, suggesting that it could be effective for children with any chronic illness and implemented in a variety of pediatric settings.

Evaluated a 15-month social support intervention for mothers of children with JRA. Five mentors (mothers of young adults who have had JRA since childhood) were linked to mothers of children with JRA ages 2 to 11 for purposes of enhancing specific types of social support and overall mental health. The total number of reported mental health symptoms decreased in the experimental group and remained the same in the control group. The experimental group showed greater improvement on all indices of support relative to the control group. Trends in the data consistently favored the experimental group, but differences between the experimental and control group were statistically significant on few of the outcome measures. Results provide tentative evidence for positive effects of mentoring interventions for this population of parents.