What was the research about?
Children who do not have health insurance are less likely to get necessary care, such as regular checkups to identify health problems early and vaccines to prevent common diseases. Low-cost public health insurance (Medicaid) is available to many children whose families can’t get private insurance. But signing up for Medicaid and keeping it can be hard.
The research team wanted to see if using a health insurance enrollment tracking form could help families get and keep health insurance and access health care. They developed a tracking form that community health centers used with electronic health records. The form tracked the help given to families applying for Medicaid. This included providing updates on the status of insurance applications and next steps.
What were the results?
The community health centers that had the tracking form used it with only 15 percent of children who visited the community health centers.
When the tracking form was used in their health records, uninsured children were more likely to get and keep health insurance. They were also more likely to come back to the doctor within six months of when the centers started using the tracking form, get all their checkups in the first 15 months after birth, and get all their recommended shots on time.
Who was in the study?
The research team looked at the health records of 27,251 children who got health care at eight community health centers in Oregon. The children either had no insurance or they had Medicaid. The children were from low-income families of diverse racial and ethnic backgrounds. The four community health centers that had access to the tracking form used it with 2,240 children.
What did the research team do?
The research team looked at electronic health records from the eight community health centers. All eight centers used the same kind of electronic health record. Four centers added the tracking form to their electronic health records. The other four used electronic health records without the tracking form. The research team looked at differences in getting health insurance and health care between children at clinics with the tracking form and children at clinics without the tracking form. In the study, the community health centers that had the tracking forms did not end up using them with all the children. The research team also compared children who did and did not have the tracking forms used at the centers that had the forms.
What were the limits of the study?
All research studies have some limits. In this study, the research team couldn’t say for sure that the tracking form was the reason children got and kept health insurance and got health care. There may have been other reasons for these results. For example, the community health centers that used the form may have been different from the community health centers that did not use the form. Likewise, patients who had the tracking form used in their health records might have been different from patients at the same center who did not have the form. Also, there were changes being made to children’s insurance coverage at the time of this study. The center staff did not use the tracking form with all their patients as the research team had wanted. This may have changed the results of the study. Future studies could look at how to get health center staff to use the form with all patients. This would help the research team understand if the tracking form led to patients getting health insurance and better health care.
How can people use the results?
Community health centers may decide to use electronic health records with tracking forms to help more children get health insurance and health care.
To compare the effects of using electronic health records (EHRs) equipped with insurance enrollment tracking forms versus using nonautomated and nonstandardized tracking outside of EHRs on pediatric patients’ health insurance status, healthcare utilization, and receipt of recommended pediatric care in community health centers (CHCs).
|Design||Retrospective cohort study|
|Population||Electronic health records of 27,251 pediatric patients receiving care at 8 CHCs in Oregon|
Primary: obtaining and maintaining insurance coverage
Secondary: odds of return visit after uninsured visit, odds of being uninsured at return visit, rate of receiving recommended pediatric care
|Timeframe||18-month follow-up for primary outcomes|
The research team developed a health insurance enrollment tracking form (the “tracking form”) to be used with EHRs to help families obtain and maintain coverage. The tracking form enabled CHC staff to assist patients with health insurance enrollment. CHC staff used the form to track the status of patients’ insurance applications. The research team conducted an 18-month retrospective cohort study to evaluate the form’s use in intervention clinics.
The study included eight CHCs that used the same EHR system. During the study period, four CHCs used the tracking form to monitor patients’ insurance enrollment progress. Four control CHCs did not use the form. Researchers matched control CHCs to intervention CHCs based on the ratio of children to adults, the percentage of patients of Hispanic ethnicity, and the length of EHR experience. All CHCs in the study served patients from low-income and ethnically diverse backgrounds. They also served children who were either uninsured or on Medicaid.
The research team identified three cohorts of children who had one or more visits at a participating CHC during the study period:
- Intervention patients: Children who visited intervention CHCs and for whom staff used the tracking form (n=2,240).
- Within-clinic comparison patients: Children who visited intervention CHCs and for whom staff did not use the tracking form (n=12,784).
- Control-clinic patients: Children who visited a control CHC where the tracking form was not implemented (n=12,227).
The research team reviewed EHR and Medicaid data to see if children for whom the tracking form was used were more or less likely to have insurance coverage at follow-up visits; return for a clinic visit in the first six months of the study; and receive recommended pediatric care.
Use of the tracking form. Intervention CHCs only used the tracking form with 15 percent of all pediatric patients.
Insurance coverage. At the intervention CHCs, intervention patients had higher rates of continuous insurance coverage than within-clinic comparison patients. Fewer intervention patients had Medicaid coverage for less than half of the post-intervention period compared with the within-clinic comparison patients and control-clinic patients.
Intervention patients who were uninsured were more likely to gain Medicaid coverage than uninsured within-clinic comparison patients (adjusted odds ratio [aOR]=1.76; 95% confidence interval [95%CI] 1.60-1.93) or control-clinic patients (aOR=2.28; 95% CI 1.91-2.72). In addition, insured intervention patients were less likely to lose coverage than insured within-clinic comparison patients (aOR=0.71; 95% CI 0.53-0.94) or control-clinic patients (aOR=0.55; 95% CI 0.45-0.67).
Among patients who visited a CHC while uninsured and who returned for a subsequent visit, intervention patients were less likely to be uninsured than within-clinic comparison patients (aOR=0.46, 95% CI 0.24-0.88); but there was no difference between intervention and control-clinic patients.
Healthcare utilization. Intervention patients were more likely to return for at least one follow-up CHC visit compared to the within-clinic comparison patients (aOR=1.83, 95% CI 1.39-2.40); however, there was no difference between intervention and control-clinic patients.
Receiving recommended pediatric care. Intervention patients were more likely to receive recommended well-child visits and be up to date on immunizations than within-clinic comparison and control-clinic patients. More intervention patients (63%) received the recommended pediatric care in the first 15 months of life than within-clinic control patients (39%, p <0.001) and control-clinic patients (53%, p <0.002)). Intervention patients were significantly more likely to be up to date on immunizations than both comparison groups (p <0.05).
This study captured correlations between the EHR tracking form and the outcomes described. It could not establish causality for several reasons. Because this was not a randomized study, differences between the clinics and the patient populations could be responsible for the results. The follow-up period may have been too short to adequately review form uptake and impact. Finally, the form was used with only 15 percent of eligible patients at the intervention CHCs. The research team attributed this to concurrent initiatives that also required CHC staff to submit different tracking data on insurance enrollment support and payment tracking, which may have overburdened staff. Likewise, Medicaid coverage end dates that had been built into the EHR system were no longer accurate after Oregon extended coverage end dates for those reapplying for Medicaid in response to the surge of applications and increased processing times resulting from Medicaid expansion.
Conclusions and Relevance
EHRs equipped with health insurance enrollment tracking forms may help increase insurance coverage, decrease the chance of losing coverage at the time of reenrollment, and increase the use of recommended care among pediatric patients in CHCs. However, drawing conclusions about causal relationships between the tracking form and the study outcomes would require CHC staff to use the tracking form with more patients.
Future Research Needs
Future research could continue to examine how EHR-based insurance enrollment tracking forms help patients obtain and maintain insurance coverage.
Final Research Report
View this project's final research report.
More to Explore...
View this project's study protocol.
Related Journal Citations
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
The awardee made the following revisions in response to peer review:
- The awardee presented more detail to explain that intervention and comparison group participants were equivalent at the start of the study, in that the awardee recruited participants using the target clinics, regardless of whether the patients were already seeking help with insurance enrollment.
- The awardee confirmed that all participants in the study had gone through at least one reenrollment period for Medicaid benefits. Therefore, all participants had an opportunity to use the study’s intervention tool. In addition, the awardee confirmed that the intervention and control clinics had workflows already in place to flag any patients who were at risk of losing insurance coverage. As a result, the awardee had an equal likelihood of identifying patients in either the intervention or comparison group who lacked insurance, or who were at risk of losing insurance.
- The awardee edited the methods and intervention section to explain that the Tracking and Documentation Form tool ties to enrollment assistance actions taken for individual patients, if clinic staff entered the need for enrollment assistance in the form. The investigators were able to link patients’ use of the tool to insurance enrollment status and dates only retrospectively.
- The awardee revised the report to make study conclusions more tentative, responding to reviewers’ note that low use of the tool in intervention clinics reflected inherent difficulties in - intervention studies based on electronic health records and clinic workflows.
Conflict of Interest Disclosures
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