1. Insurance Continuity and Receipt of Diabetes Preventive Care in Oregon’s Community Health Centers

2. Research Team Jen DeVoe, Oregon Health & Science University Dept of Family Medicine Rachel Gold, Kaiser Permanente Center for Health Research Amit Shah, Multnomah County Health Department Susan Chauvie, Our Community Health Information Network

3. NATIONAL CONTEXT Community Health Centers (CHCs) provide crucial services to the uninsured and underinsured. To help CHCs improve services to vulnerable populations, novel evaluation techniques and research methods are needed.

4. OREGON CONTEXT Our Community Health Information Network (OCHIN), a non-profit collaboration of CHCs, manages collective “real time” electronic health data. Each patient has a unique OCHIN identifier; records are linked across clinics and patients can be tracked.

5. BROAD RESEARCH OBJECTIVES To develop and refine methods for studying OCHIN data. To demonstrate how the study of this data could be used to inform policy.

6. SPECIFIC RESEARCH OBJECTIVE How much does insurance matter in a community health center “medical home”? We aimed to assess the associations between continuity of insurance coverage and the likelihood of receiving diabetes preventive care services among adult patients in the OCHIN system.

7. METHODS – Data Source Our Community Health Information Network (OCHIN) >100 agencies, 300,000 clients, >800,000 annual visits. Complete set of EPICSystems Practice Management data available from all sites, starting in 2005. Direct link with state public insurance enrollment.

8. METHODS – Study Population Adults (aged >18 years) visiting OCHIN clinics with diabetes. Two-year period (2004-2005) Two visits associated with common ICD-9 code for diabetes mellitus 6,127 adults

9. METHODS – Study Variables Outcome Variables – four recommended diabetic preventive services, received at least once in 2005 (orders & billing data) Glycated hemoglobin (HbA1c) Lipid screening (LDL) Influenza vaccination (flu shot) Nephropathy screening (urine microalbumin)

10. METHODS – Study Variables Primary Independent Variable – insurance continuity (assessed quarterly) Uninsured all year Insured all year Partially insured Covariates – age, gender, race/ethnicity, household income.

11. METHODS – Analysis Descriptives Bivariate and Multivariate Logistic Regression Models SAS version 9.0

12. RESULTS—Descriptives Insurance Coverage, 2005 OCHIN Population N = 116,859 OCHIN Diabetics N=6,127 Continuously Insured35.4%53.5% Partially Insured18.3%16.2% Uninsured All Year46.3%30.3%

13. RESULTS—Descriptives Insurance Coverage, 2005 Total N Micro- albumin Flu shotLDLHbA1c Continuously Insured 3,28123.3%34.9%37.5% 53.4% Partially Insured 99520.8%31.8%34.0%50.8% Uninsured All Year 1,85116.7%26.6%34.5%56.5% Total 6,12720.9%31.9%36.0%53.9%

14. RESULTS—Multivariate Analyses Insurance Coverage, 2005 Micro- albumin Adj OR (95% CI)* Flu Shot Adj OR (95% CI)* LDL Adj OR (95% CI)* HbA1c Adj OR (95% CI)* Continuously Insured 1.47 (1.25, 1.74) 1.60 (1.39, 1.85) 1.24 (1.08, 1.43) 1.02 (0.88, 1.18) Partially Insured 1.24 (1.01, 1.53) 1.26 (1.05, 1.51) 0.95 (0.80, 1.13) 0.77 (0.65,0.92) Uninsured All Year 1.00 *Adjusted Odds Ratio (95% Confidence Interval); adjusted for age, gender, race/ethnicity, household income.

15. RESULTS—Multivariate Analyses Partial Insurance Coverage in 2005 Micro- albumin Adj OR (95% CI)* Flu Shot Adj OR (95% CI)* LDL Adj OR (95% CI)* HbA1c Adj OR (95% CI)* ¾ year 0.85 (0.58-1.25) 0.89 (0.64-1.24) 0.75 (0.54-1.05) 1.10 (0.79-1.53) ½ year 0.85 (0.56-1.27) 0.85 (0.60-1.20) 0.74 (0.52-1.06) 1.05 (0.74-1.48) ¼ year 1.00 *Adjusted Odds Ratio (95% Confidence Interval); adjusted for age, gender, race/ethnicity, household income.

16. SUMMARY CHCs care for a large percentage of uninsured and underinsured patients. Even with crucial access to CHCs, uninsured and partially insured diabetic patients had lower rates of preventive services, compared to those with continuous coverage.

17. POLICY IMPLICATIONS It cannot be an “either/or” proposition—we need both. Safety net clinics mitigate some but not all of the disadvantage from being uninsured. Discontinuous insurance coverage contributes to disrupted care, even in a medical home.

18. POLICY IMPLICATIONS Policy efforts must continue to strengthen the healthcare safety net delivery system while simultaneously creating solutions for continuous health insurance coverage and sustainable healthcare financing.

19. ACKNOWLEDGEMENTS Dr. Gold received support from the Oregon Clinical and Translational Research Institute (OCTRI), grant number UL1 RR024140 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research. Dr. DeVoe is currently funded by a K08 Mentored Clinical Scientist Award, grant number K08 HS 016181 from the Agency for Healthcare Research and Quality (AHRQ).

20. Independent Variables HgA1c Adjusted OR (95% CI) LDL Adjusted OR (95% CI) Flu Shot Adjusted OR (95% CI) Microalb Adjusted OR (95% CI) Health Insurance Status Uninsured Partial Insurance Continuously Insured 1.00 0.77 (0.65, 0.92) 1.02 (0.88, 1.18) 1.00 0.95 (0.80, 1.13) 1.24 (1.08, 1.43) 1.00 1.26 (1.05, 1.51) 1.60 (1.39, 1.85) 1.00 1.24 (1.01, 1.53) 1.47 (1.25, 1.74) Age >65 years 45-64 years 18-44 years 1.00 1.16 (1.00, 1.35) 1.07 (0.90, 1.27) 1.00 1.09 (0.93, 1.27) 1.14 (0.96, 1.35) 1.00 1.18 (1.01, 1.38) 0.83 (0.67, 0.99) 1.00 1.17 (0.97, 1.40) 1.08 (0.89, 1.33) Race/Ethnicity Non-Hispanic White Hispanic Non-Hispanic AI/AN Non-Hispanic API Non-Hispanic black Missing 1.00 1.81 (1.57, 2.08) 0.89 (0.48, 1.65) 1.54 (1.17, 2.03) 1.75 (1.38, 2.23) 0.85 (0.67, 1.07) 1.00 1.31 (1.14, 1.50) 0.44 (0.21, 0.92) 1.63 (1.26, 2.12) 1.74 (1.40, 2.17) 1.12 (0.87, 1.42) 1.00 1.62 (1.41, 1.86) 1.06 (0.55, 2.02) 1.74 (1.34, 2.25) 1.44 (1.15, 1.80) 1.25 (0.99, 1.58) 1.00 0.85 (0.72, 1.00) 0.90 (0.42, 1.90) 1.67 (1.26, 2.21) 1.65 (1.31, 2.08) 1.40 (1.06, 1.85) Household Income as Percentage of FPL >200% FPL 150% - <200% FPL 100% - <150% FPL 50% - <100% FPL <50% FPL Missing 1.00 1.55 (1.14, 2.09) 2.10 (1.65, 2.68) 1.34 (1.04, 1.71) 1.63 (1.24, 2.15) 0.43 (0.33, 0.58) 1.00 1.56 (1.14, 2.15) 2.24 (1.73, 2.91) 1.45 (1.12, 1.92) 1.72 (1.28, 2.31) 0.47 (0.34, 0.65) 1.00 1.13 (0.81, 1.57) 1.51 (1.15, 1.97) 1.36 (1.04, 1.79) 1.42 (1.05, 1.91) 1.43 (1.06, 1.93) 1.00 1.63 (1.07, 2.47) 2.89 (2.05, 4.08) 2.13 (1.50, 3.03) 2.20 (1.51, 3.20) 0.18 (0.10, 0.32)