Journal of the Louisiana State Medical Society
Table 4: Adjusted odds ratios for receipt of developmental screening as a function of having a medical home among US children five years and younger, National Survey of Children’s Health 2007 ( N =22,270) Null Random intercept Random intercept and slope P value aOR a,c (95% CI) P value b aOR a,c (95% CI) P value b 1.25 (1.11-1.39) 0.001 1.24 (1.10-1.38) 0.002 Variance 0.142 0.001 0.120 0.002 0.138 0.010 ICC 0.041 0.035 0.040 DF 2 21 22 AIC 22,092.11 19,935.24 19,901.51 BIC 22,108.13 20,101.56 20,075.74 Likelihood ratio tests Log likelihood -11,044.06 -9,946.62 -9,928.75 Deviance d 2,194.88 35.74 DF 2 19 1 half P value 0.0000 0.0117 Abbreviations: CI=confidence interval; N =study population size; n =sample size; aOR=adjusted odds ratios; ICC=intra-class correlation coefficient; DF=degrees of freedom; AIC=Akaike’s information criterion; BIC=Bayesian’s information criterion. a Adjusted odds ratios and corresponding 95% CI refer to the population-weighted estimate. b Two-sided P value <0.05 are computed using Wald Chi-square tests. c Models adjusted for age, insurance, race, special healthcare need, family structure, and census bureau region. d Deviance is the computed difference in log likelihood values obtained with MLR estimators.
State and Federal Health Policy Implications - Racial Disparities
confounders, was insurance type. Public health insurance coverage increased PDS odds by 36% compared to private and by 30% compared to the uninsured. This may reflect the Medicaid Early Periodic Screening, Diagnosis, and Treatment Program. 15 It may also indicate that clinicians consider Medicaid-covered children at high risk for poorer health outcomes and subsequently are more inclined to provide PDS. Another theory is that private carriers sel- dom pay or inadequately reimburse for PDS, something of concern for privately owned clinics given the extended office visit required to provide PDS. 3 However, we may see such disparities minimized as a result of the preventive health service stipulations outlined in the affordable care act (ACA). 16 For example, health plans must cover 25 pre- ventive health services for children at no additional charge (copayment, coinsurance, or unmet yearly deductible) to the insured. 16 Among these 25, are five behavioral assess- ments organized to occur during specified age periods and two autism screenings: one at 18 months and another at 24 months, developmental screenings for children under three years of age, and other salient development evaluations. 16 As a result of the mandate, the PDS policy has moved from “best practice” under AAP to an assurance as part of a child/ family’s healthcare coverage. 1,16
Another significant confounder was race. This is an important confounder that is related to state residence and adult quality of life. For example, the 2010 census disability age-adjusted rates reveal racial differences: NH-Black 22.3 versus NH-White 17.6. 13 These rate differences suggest that all things being equal, a higher disability burden is experienced among NH-Black adults. Linked to this, is disproportionately greater public health capacity and fund- ing requirement on southern states, which have the highest concentration of the nation’s NH-Black population. This infrastructure demand is more taxing given the relatively low wealth of these states, distribution of other compet- ing health indicators, and higher proportion of publically funded healthcare coverage. The ACA may again provide the tools to decrease racial disparities through the inclusion of the patient navigator program. 17 Also referred to as patient advocacy, the goals of this program are to reduce healthcare disparities; increase access to care; improve health outcomes, particularly for chronic diseases; and assist patients with navigating the complex systemof healthcare services. 17 Such a program is in concert with the MH model.
116 J La State Med Soc VOL 166 May/June 2014
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