Family Structure and Children’s Use of Ambulatory Care

Impact of Restrictive State Policieson Utilization and Expenditures inthe Medicaid ProgramImpact of Restrictive State Policieson Utilization and Expenditures inthe Medicaid Program

Roberto Vargas, MD, MPH1,2Roberto Vargas, MD, MPH1,2

Carole Gresenz, PhD2Carole Gresenz, PhD2

Jessie Riposo, MS2Jessie Riposo, MS2

Jeannette Rogowski, PhD3Jeannette Rogowski, PhD3

José Escarce, MD, PhD1,2José Escarce, MD, PhD1,2

1.Division of General Internal Medicine and Health Services Research, David GeffenSchool of Medicine at UCLA

2.RAND Health

3.University of Medicine and Dentistry New Jersey, School of Public Health

BackgroundBackground

For state Medicaid programs, the DeficitReduction Act eliminatedFor state Medicaid programs, the DeficitReduction Act eliminated

Need to offer all benefits to all enrolleesNeed to offer all benefits to all enrollees

Requirement of states to get federal waiversbefore limiting benefits or imposing co-paysand cost sharingRequirement of states to get federal waiversbefore limiting benefits or imposing co-paysand cost sharing

Mandatory periods of public comment prior toimplementing such changesMandatory periods of public comment prior toimplementing such changes

Restrictive Policies and MedicaidRestrictive Policies and Medicaid

Restrictive drug policies have beenassociated with lower rates of prescriptionfilling and more intensive use of acute care,nursing homes and higher overall costsRestrictive drug policies have beenassociated with lower rates of prescriptionfilling and more intensive use of acute care,nursing homes and higher overall costs

Cost sharing and limits on physician visits inMedicaid have varying effects on physicianvisits rates but no significant impact onoverall costs.Cost sharing and limits on physician visits inMedicaid have varying effects on physicianvisits rates but no significant impact onoverall costs.

AimsAims

To examine the effects of restrictive policieson use of care by a nationally representativesample of Medicaid enrollees over a six-yearperiodTo examine the effects of restrictive policieson use of care by a nationally representativesample of Medicaid enrollees over a six-yearperiod

Data SourcesData Sources

State Medicaid Summaries from 1997-2002State Medicaid Summaries from 1997-2002

Summaries of state plan benefits includingscope of medical care (Limits on visits andservices and co-pays)Summaries of state plan benefits includingscope of medical care (Limits on visits andservices and co-pays)

The Medical Expenditure Panel Survey(MEPS), 1997-2002The Medical Expenditure Panel Survey(MEPS), 1997-2002

Study SampleStudy Sample

Adults 18-64 with at least one full calendaryear of data in MEPSAdults 18-64 with at least one full calendaryear of data in MEPS

We excluded:We excluded:

Patients who were pregnantPatients who were pregnant

Had additional forms of insuranceHad additional forms of insurance

Were enrolled inn Managed care or HMO’sWere enrolled inn Managed care or HMO’s

Study DesignStudy Design

Cross sectional, yearly analytic files of respondentsCross sectional, yearly analytic files of respondents

Multivariate regression models and simulationsMultivariate regression models and simulations

Estimate the impact of state policy variationEstimate the impact of state policy variation

Controlling for individual characteristics, healthcare market factors, and community contextualfactorsControlling for individual characteristics, healthcare market factors, and community contextualfactors

OutcomesOutcomes

Utilization:Utilization:

Outpatient office-based physician visitsOutpatient office-based physician visits

Outpatient office visits (non-physician and physician)Outpatient office visits (non-physician and physician)

Emergency room visitsEmergency room visits

Inpatient acute care hospital admissionsInpatient acute care hospital admissions

Expenditures:Expenditures:

Prescription drug expendituresPrescription drug expenditures

Total healthcare expenditures excluding vision anddental servicesTotal healthcare expenditures excluding vision anddental services

Key Independent Variables:Medicaid Restrictive PoliciesKey Independent Variables:Medicaid Restrictive Policies

Any physician visit co-payAny physician visit co-pay

Any emergency room visit co-payAny emergency room visit co-pay

Any prescription drug co-payAny prescription drug co-pay

Inpatient admission co-pay for stay of greaterthan $21Inpatient admission co-pay for stay of greaterthan $21

Any inpatient co-pay charged dailyAny inpatient co-pay charged daily

Office-based physician visit limitOffice-based physician visit limit

Less than or equal to three prescription limit permonthLess than or equal to three prescription limit permonth

AnalysisAnalysis

Regression Models:Regression Models:

Office-based visits: Negative binomial modelOffice-based visits: Negative binomial model

Any emergency room: Logit modelAny emergency room: Logit model

Any inpatient night: Logit modelAny inpatient night: Logit model

Expenditures: selected Two-part modelsExpenditures: selected Two-part models

Simulations:Simulations:

We simulated values for the utilization andexpenditures weighted for the MEPS sampling designWe simulated values for the utilization andexpenditures weighted for the MEPS sampling design

Descriptive Data:Individual CharacteristicsDescriptive Data:Individual Characteristics

Individual-Level VariablesIndividual-Level Variables

FemaleFemale

64%64%

Non- Hispanic BlackNon- Hispanic Black

28%28%

HispanicHispanic

21%21%

Other Non-WhiteOther Non-White

5%5%

Non-Hispanic WhiteNon-Hispanic White

46%46%

SSI RecipientSSI Recipient

41%41%

Income<povertyIncome<poverty

59%59%

Less than high schoolLess than high school

48%48%

Descriptive Data:OutcomesDescriptive Data:Outcomes

Utilization and ExpendituresUtilization and Expenditures

Mean (Std Err)/Mean (Std Err)/

# Office-based physician visits# Office-based physician visits

5.70 (0.33)5.70 (0.33)

# Total office-based visits# Total office-based visits

8.03 (0.69)8.03 (0.69)

Any emergency room visit %Any emergency room visit %

24%24%

Any inpatient admission %Any inpatient admission %

14%14%

Prescription expendituresPrescription expenditures

$1098.28 (56.92)$1098.28 (56.92)

Total medical expendituresTotal medical expenditures

$4575.92 (320.53)$4575.92 (320.53)

Descriptive Data:Restrictive Medicaid PoliciesDescriptive Data:Restrictive Medicaid Policies

PolicyPolicy

19971997

Any Physician Visit Co payAny Physician Visit Co pay

1818

Limit on number of Physician VisitsLimit on number of Physician Visits

1717

Any Emergency Room Co payAny Emergency Room Co pay

Prescription Co payPrescription Co pay

2929

Limit on number of prescriptions per monthLimit on number of prescriptions per month

1111

Inpatient Admissions Co payInpatient Admissions Co pay

1414

Inpatient Daily Co payInpatient Daily Co pay

Regression ResultsRegression Results

Visit limit policies had no significant impact onvisits that included non-physician care,emergency room visits, or inpatient hospital staysVisit limit policies had no significant impact onvisits that included non-physician care,emergency room visits, or inpatient hospital stays

Limiting prescriptions to three per month had nosignificant effect on any of our utilization orexpenditure measuresLimiting prescriptions to three per month had nosignificant effect on any of our utilization orexpenditure measures

Per day inpatient co-pay was not associated withhospitalization rates or expendituresPer day inpatient co-pay was not associated withhospitalization rates or expenditures

Regression ResultsRegression Results

Co-pays for physician visitsCo-pays for physician visits

Lower Any ER visit rate (20% compared to25%; p<0.10)Lower Any ER visit rate (20% compared to25%; p<0.10)

Higher rates of inpatient hospitalization (18%compared to 13%; p<0.05)Higher rates of inpatient hospitalization (18%compared to 13%; p<0.05)

Higher average total expenditures ($5,431compared to $4,271; p<0.05)Higher average total expenditures ($5,431compared to $4,271; p<0.05)

Regression ResultsRegression Results

Inpatient admission co-pays of greater than $21Inpatient admission co-pays of greater than $21

Fewer Admissions (9% compared to 15%;p<0.10)Fewer Admissions (9% compared to 15%;p<0.10)

ER visit co-paysER visit co-pays

Lower total expenditures ($3,719 compared to$4,665; p<0.01)Lower total expenditures ($3,719 compared to$4,665; p<0.01)

Regression ResultsRegression Results

Prescription drug co-pays:Prescription drug co-pays:

 Lower expenditures ($4,145 compared to $5,088;p<0.05) Lower expenditures ($4,145 compared to $5,088;p<0.05)

Prescription drug co-pays:Prescription drug co-pays:

Significantly lower average number of physicianoffice-based visits (5.58 compared to 6.70;p<0.05)Significantly lower average number of physicianoffice-based visits (5.58 compared to 6.70;p<0.05)

ConclusionsConclusions

Some co-pays were associated with lowerexpenditures and utilizationSome co-pays were associated with lowerexpenditures and utilization

Visit limit policies, no significant impact on eitheroutcomes of interestVisit limit policies, no significant impact on eitheroutcomes of interest

Certain restrictive policies are associated withunintended consequences such as the associationof physician visit co-pays with higherhospitalization rates and costsCertain restrictive policies are associated withunintended consequences such as the associationof physician visit co-pays with higherhospitalization rates and costs

ImplicationsImplications

Efforts to reduce costs through restrictive policieshave varying effects on utilization andexpendituresEfforts to reduce costs through restrictive policieshave varying effects on utilization andexpenditures

As states consider greater use of restrictive policiesthere is a need to monitor the impact of restrictivepolicies for unintended consequencesAs states consider greater use of restrictive policiesthere is a need to monitor the impact of restrictivepolicies for unintended consequences

Supplemental SlidesSupplemental Slides

ResultsResults

States Level Restrictive PoliciesStates Level Restrictive Policies

Policy Level VariablesPolicy Level Variables

19971997

19981998

19991999

2000*2000*

20012001

20022002

Any Physician Visit Co payAny Physician Visit Co pay

1818

1717

1919

Limit on number of PhysicianVisitsLimit on number of PhysicianVisits

1717

Physician Visit and Co payRestrictionPhysician Visit and Co payRestriction

*Data missing for one state*Data missing for one state

State Level ER Restrictive PoliciesState Level ER Restrictive Policies

Policy Level VariablesPolicy Level Variables

19971997

19981998

19991999

2000*2000*

20012001

20022002

Any Emergency Room Co payAny Emergency Room Co pay

Limit on number of EmergencyRoom VisitsLimit on number of EmergencyRoom Visits

Emergency Room Co pay and VisitRestrictionEmergency Room Co pay and VisitRestriction

*Data missing for one state*Data missing for one state

State Level Inpatient Admission PoliciesState Level Inpatient Admission Policies

Policy Level VariablesPolicy Level Variables

19971997

19981998

19991999

2000*2000*

20012001

20022002

Inpatient Admissions Co payInpatient Admissions Co pay

1414

1616

1515

Inpatient Daily Co payInpatient Daily Co pay

Inpatient Stay LimitInpatient Stay Limit

1212

1010

*Data missing for one state*Data missing for one state

State Level Prescription Drug PoliciesState Level Prescription Drug Policies

Policy Level VariablesPolicy Level Variables

19971997

19981998

19991999

2000*2000*

20012001

20022002

Prescription Co payPrescription Co pay

2929

3030

3131

3030

3131

Limit on number ofprescriptions per monthLimit on number ofprescriptions per month

1111

1212

1010

Both Rx Co pay and limitBoth Rx Co pay and limit

*Data missing for one state*Data missing for one state