Primary Care Continuity andHealth Care Expenditures in aDepressed Sample of FloridaMedicaid Recipients
Andrea M. Lee, M.S.
Robert G. Frank, Ph.D.
Zoe N. Swaine, M.S.
Natalie C. Blevins, M.S.
Heather Steingraber, B.S.
Continuity of Care
•Definition:
–healthcare events experienced as coherent andconnected
–consistent with the patient’s medical needs andpersonal context
•In primary care:
–relationship between a single provider and apatient
–extends beyond specific episodes of illness ordisease
Continuity of Care
•Patients who maintain a continuousrelationship with a primary care provider are
–more satisfied with their care (Gulliford et al., 2007)
–more likely to take medications correctly (Becker et al.,1974)
–more likely to be diagnosed early for chronicdiseases (Koopman et al., 2003)
Continuity of Care
•Lower health care utilization
–Reduced likelihood of emergency departmentutilization in children (Christakis et al., 2001; Brousseau et al.,2004)
–Reductions in hospitalizations, emergencydepartment visits in the elderly (Weiss & Blustein, 1996;Wasson et al., 1984; Burge, Lawson, & Johnston, 2003)
•Lower health care expenditures
•No studies on psychological populations
Depression & primary care
•One of the most prevalent disorders inprimary care (Ballenger et al., 1999)
•Depressed individuals tend to have (Simon et al.,1995):
–lower overall physical functioning
–more disability days
–higher rates of health care utilization
Depression & Medicaid
•13% of enrollees use Medicaid mental healthbenefits (Mark et al., 2003)
•Medicaid’s spending for mental healthservices accounted for over 50% of all publicmental health expenditures in 2003 (kff.org)
•Projected to increase up to 2/3 by 2013 (kff.org)
Present study
•Association between continuity of care andhealth care expenditures in depressedMedicaid enrollees
•Higher continuity of care hypothesized to beassociated with lower expenditures
•Florida Medicaid claims data
•Cross-sectional
Participants
•8,680 participants
•Ages 18-65
•78% female; 22% male
•42% White, 14% Black, 38% other, 6%Hispanic
Measure of continuity of care
•Modified, Modified Continuity Index(MMCI)
•Continuous variable, ranging from 0 to 1
–1 indicates high continuity of care
Distribution of continuity of care
Statistical analyses
•Logistic regression for expenditures with largeproportion of zeroes
–inpatient, outpatient, and emergency room expenditures
•Log-linear multiple regression
–inpatient, outpatient, emergency room, pharmacy, medical,and total expenditures
•Controlled for age, sex, race, number of medicalcomorbidities, and number of prescription drugs
Results
•Higher continuity of care associated with:
–a lower likelihood of having any expenditures for:
•Inpatient (odds ratio: 0.20, p < .01)
•Outpatient (odds ratio: 0.69, p < .01)
•Emergency room (odds ratio: 0.58, p < .01)
–lower expenditures for total, medical, inpatient,outpatient, emergency room expenditures (p < .01)
–higher pharmacy expenditures (p < .01)
Limitations
•Unable to differentiate between providertype and practice site in identifyingprimary care provider
•ICD-9 codes limited reliability – subject toerror and only captures provider –identified depression (not undetected orundiagnosed depression)
Conclusions
•Improving continuity of care indepressed Medicaid recipients mayimpact overall health care spending
•Pharmacy expenditures were higher withhigher continuity of care, which may bedue to better medication management
Conclusions
•Relatively fewenrollees with lowcontinuity of careto target for policychange, but canhave a measurableimpact
•Acknowledgements:
•Robert Frank
•Natalie Blevins
•Zoë Swaine
•Eleni Dimoulas
•Heather Steingraber
•Jianyi Zhang
•Allyson Hall