how does health insurance buffer the consequences of intimate partner violence in ohio? kenneth j....

How does Health Insurance Buffer the Consequences of Intimate Partner

Violence in Ohio? 

Kenneth J. Steinman, PhD, MPHPhyllis Pirie, PHD

The Ohio State University College of Public Health

Erinn M. Hade, MSThe Ohio State University Center for Biostatistics

July 29, 2011Ohio Employer and Ohio Family Health Research Conference

Background

• IPV (intimate partner violence) is associated with greater health care utilization– $943 million / year (Corso et al., 2007)

• Common data sources– Insurance claims data (e.g., Coker; Rivara)

– Surveys (e.g., Breiding; Tjaeden)

Three Questions

• How common is IPV among select groups?

• How is IPV associated with adverse consequences?

• Does the association of IPV with emergency room use vary by insurance type?

Policy Implications

• Cost of covering the uninsured– Medicaid vs. employer-sponsored insurance

• Value of health-care-based IPV intervention

Ohio Family Health Survey

• Conducted most recently in 2008 & 2010

• Computer-Assisted Telephone Interviews

• Random Digit Dialing

• Over-sampling of ethnic minorities, select counties

• Representative of Ohio adults & households

Ohio Family Health Survey

2008 2010

n

(women 18-64)50,944 (23,083)

8,276

(3,468)

Response rate 34.6% 42.7% / 21.9%

Outcomes• Financial distress

– During the last 12 months, were there times when you had problems paying or were unable to pay for medical bills for yourself or anyone else in the family or household?

• Serious psychological distress– During the past 30 days, how often did you feel so sad that nothing

would cheer you up?• Unmet health needs

– Did you delay or avoid getting care that you needed, but that you could not afford?

• Fair or poor self rated health status– In general, would you say your health is excellent, very good, good,

fair, or poor?• ER use

– During the past 12 months, how many times were you a patient in a hospital emergency room?

Intimate Partner Violence

• Only measured physical abuse

• Past year

• Different measures in 2008, 2010

IPV measure - 2008

• During the past 12 months, how many times, if any, has anyone hit, slapped, pushed, kicked or physically hurt you?

• Think about the time of the most recent incident involving a person or persons who hit, slapped, pushed, kicked or physically hurt you. What was that person’s relationship to you? (open-ended)

What was that person’s relationship to you?

IPV measure - 2008

0 times

1+ times

04 Male/Female first date05 Someone you were dating06 Former boyfriend/girlfriend07 Current boyfriend/girlfriend or fiancé08 Spouse or live-in partner09 Former spouse or live-in partner

How many times…?

intimate partner violence

01 Stranger02 Coworker03 Professional caretaker 10 S/he is my Child11 S/he is my Stepchild12 Another family member13 Acquaintance/friend 97 OTHER98 DK99 REFUSED

Other violence

Not a case

IPV measure - 2010

• Has an intimate partner EVER used physical violence against you? This includes hitting, slapping, pushing, kicking, or hurting you in any way.

• When was the last time an intimate partner used physical violence against you?

Other Variables

• Age, ethnicity, region, marital status

• Socioeconomic status– Income, education

• Insurance status– Uninsured; Medicaid; Employer-sponsored;

Other

Data Analysis

• Generalized Linear Model– Poisson distribution, log link– Controlling for age, ethnicity, income, education,

marital status

• Weighted data; complex survey design

Three Questions

• How common is IPV among select groups?

• How is IPV associated with adverse consequences?

• Does the association of IPV with emergency room use vary by insurance type?

IPV prevalence

Lifetime Past-year

Unweighted n Prevalence 95% CI Prevalence 95% CI

Men 2,351 8.8% 7.5-10.1 3.1% 2.3-4.0

Women 3,473 18.4% 16.9-19.9 2.5% 1.8-3.2

Past-Year IPV prevalence among women

n Weighted % 95%CI

Uninsured 500 5.3 [2.9-7.7]

Medicaid 470 6.0 [3.0-8.5]

ESI (self) 1,282 1.2 [0.4-2.0]

ESI (spouse) 799 0.5 [0.0-1.1]

Other insurance 422 2.3 [0.5-4.1]

Veterans 79 1.4 [0.0-4.3]

Non-Veterans 3,394 2.5 [1.8-3.2]

In relationship with women

13 -- --

Ohio women experiencing past-year IPV: Proportions by insurance type

N=94,465

IPV past-year prevalence

2008 2010

Women 18-64 1.8% 2.5%

Uninsured 4.5% 5.3%

Medicaid 5.2% 6.0%

ESI 0.7% 0.9%

Three Questions

• How common is IPV among select groups?

• How is IPV associated with adverse consequences?

• Does the association of IPV with emergency room use vary by insurance type?

Prevalence of adverse consequences by length of time since most recent IPV

Note: results are unadjusted

Prevalence ratios (with 95%CI) of IPV with adverse consequences

PR=Prevalence Ratio, adjusted for age, ethnicity, income, education, marital status

Prevalence Ratio

Estimate 95%CI

Serious psychological distress 1.4 [1.1-1.8]

Fair/Poor self-rated health status 1.2 [0.8-1.8]

Financial distress 1.3 [1.0-1.6]

Three Questions

• How common is IPV among select groups?

• How is IPV associated with adverse consequences?

• Does the association of IPV with emergency room use vary by insurance type?

Association of IPV with ER Use: Variation by Insurance Status

PR=Prevalence Ratio, adjusted for age, ethnicity, income, education, marital status

Uninsured MedicaidEmployer-Sponsored Other

PR 95% CI PR 95% CI PR 95% CI PR 95% CI

2008 1.7 [1.3-2.3] 1.4 [1.1-1.7] 1.4 [0.9-2.2] 1.9 [1.1-3.2]

2010 1.9 [1.4-2.5] 1.0 [0.7-1.6] 0.8 [0.4-1.7] 0.8 [0.3-2.5]

Discussion

• IPV prevalence varies by insurance status

• IPV – ER use association varies by insurance status

• Less ability to pay delayed utilization more severe abuse greater utilization

Implications

• Providing health insurance to uninsured women may reduce ER use costs

• Other studies may underestimate IPV-HCU association

• Include insurance as a component of SES

• Supports value of health-care-based intervention

Thank you

kjsteinman@gmail.com