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Purpose – This study analyzed individual factors of race and dual eligibility on emergency room (ER) utilization of older adult Medicare patients treated by RHCs in CMS Region 4.

Methodology/approach – A prospective, longitudinal design was employed to analyze health disparities that potentially exist among RHC Medicare beneficiary patients (+65) in terms of ER use. The years of investigation were 2010 through 2012, using mixed multilevel, binary logistic regression.

Findings – This study found that dual eligible RHC patients utilized ER services at higher rates than nondual eligible, Medicare only RHC patients at: 77%, 80%, and 66%, in 2010, 2011, and 2012, respectively; and above the White reference group, Black RHC Medicare patients utilized ER services at higher rates of: 18%, 20%, and 34%, in 2010, 2011, and 2012, respectively.

Research limitations/implications – Regarding limitations, cohort data observations within the window of 3 years were only analyzed; regarding generalizability, in different CMS regions, results will likely vary; and linking other variables together in the study was limited by the accessible data. Future research should consider these limitations, and attempt to refine. The findings support that dual Medicare and Medicaid eligibility, as a proxy measure of socioeconomic status, and race continue to influence higher rates of ER utilization in CMS Region 4.

Originality/value – In terms of ER utilization disparities, persistently, as recent as 2012, Black, dual eligible RHC Medicare beneficiary patients age 65 years and over may be twice as likely to utilize ER services for care than their counterparts in the Southeastern United States.

This study is to examine factors contributing to the variability in chronic obstructive pulmonary disorder (COPD) and asthma hospitalization rates when the influence of patient characteristics is being simultaneously considered by applying a risk adjustment method.

A longitudinal analysis of COPD and asthma hospitalization of rural Medicare beneficiaries in 427 rural health clinics (RHCs) was conducted utilizing administrative data and inpatient and outpatient claims from Region 4. The repeated measures of risk-adjusted COPD and asthma admission rate were analyzed by growth curve modeling. A generalized estimating equation (GEE) method was used to identify the relevance of selected predictors in accounting for the variability in risk-adjusted admission rates for COPD and asthma.

Both adjusted and unadjusted rates of COPD admission showed a slight decline from 2010 to 2013. The growth curve modeling showed the annual rates of change were gradually accentuated through time. GEE revealed that a moderate amount of variance (marginal R ² = 0.66) in the risk-adjusted hospital admission rates for COPD and asthma was accounted for by contextual, ecological, and organizational variables.

The contextual, ecological, and organizational factors are those associated with RHCs, not hospitals. We cannot infer how the variability in hospital practices in RHC service areas may have contributed to the disparities in admissions. Identification of RHCs with substantially higher rates than an average rate can portray the need for further enhancement of needed ambulatory or primary care services for the specific groups of RHCs. Because the risk-adjusted rates of hospitalization do not vary by classification of rural area, future research should address the variation in a specific COPD and asthma condition of RHC patients.

Risk-adjusted admission rates for COPD and asthma are influenced by the synergism of multiple contextual, ecological, and organizational factors instead of a single factor.

The implementation of the Patient Protection and Affordable Care Act has facilitated the development of an innovative and integrated delivery care system, Accountable Care Organizations (ACOs). It is timely, to identify how health care managers in rural health clinics (RHCs) are responding to the ACO model. This research examines RHC managers’ perceived benefits and barriers for implementing ACOs from an organizational ecology perspective.

A survey was conducted in spring of 2012 covering the present RHC network working infrastructures – (1) Organizational social network; (2) organizational care delivery structure; (3) ACO knowledge, perceived benefits, and perceived barriers; (4) quality and disease management programs; and (5) health information technology (HIT) infrastructure. One thousand one hundred sixty clinics were surveyed in the United States. They cover eight southeastern states (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) and California. A total of 91 responses were received.

RHC managers’ personal perceptions on ACO’s benefits and knowledge level explained the most variance in their willingness to join ACOs. Individual perceptions appear to be more influential than organizational and context factors in the predictive analysis.

The study is primarily focused in the Southeastern region of the United States. The generalizability is limited to this region. The predictors of RHCs’ participation in ACOs are germane to guide the development of organizational strategies for enhancing the general knowledge about the innovativeness of delivering coordinated care and containing health care costs inspired by the Affordable Care Act.

RHCs are lagged behind the growth curve of ACO adoption. The diffusion of new knowledge about pros and cons of ACO is essential to reinforce the health care reform in the United States.

The relationships of physician practice characteristics, care management effectiveness, autonomy, and managed care involvement, and physicians’ practice and career satisfaction were investigated. A panel sample (N=660) of 6800 physicians was made up of eleven physicians randomly selected from each of the sixty communities. Three latent constructs include care management effectiveness, practice autonomy, and openness in private practice. Multilevel modeling was performed. A statistically insignificant association was found between the perceived effectiveness of care management and physician satisfaction, holding the practice characteristics and other perception factors constant. The study demonstrated direct effects of practice characteristics and care management effectiveness on the practice of gate-keeping functions and on earnings. Only two contextual variables, managed care penetration and median income in the study communities, were related to physicians’ practice.

Understanding the determinants of health services use is essential for planning for effective services, particularly health care policies in a newly independent state, the Republic of Kazakhstan. The main purpose of this study is to examine the relative importance of social capital factors in affecting the variation in health status and use of health services, using structural equation modeling. The results show that health status is a strong predictor of health services use when the effect of social capital is held constant; and that social capital is directly linked with health status.

Measures of health status and prior service use have been considered promising predictors of future health expenditures, particularly when used for risk-adjustment models in capitation payment systems. While the use of health status as a future predictor has its difficulty in terms of measurement accuracy and implementation costs, using prior utilization as the base for the calculation of future health expenditures also has its concerns. Based on a three-stage cross-lagged model in a longitudinal study design, this study showed that prior utilization has both a direct and an indirect effect on subsequent utilization. However, the real net effect of prior utilization on subsequent utilization can be overestimated by 25%, if the effect of health status is not taken into account.

This chapter provides both an introduction to the volume and a brief review of literature on technology, communications, and health disparities.

Literature review.

The chapter argues for the importance of greater examination of technology, communications, and their linkages to health disparities and other related factors.

Reviews the topic of technology, communication, and health disparities and previews this book.