Impact of State Mandatory Health Insurance Coverage on the Care Services
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Impact of State Mandatory Health Insurance Coverage on the Utilization of Selected Diabetes Care Services The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy Rui Li, Ph.D. Ping Zhang, Ph.D. Dekeely Hartsfield, M.P.H Division of Diabetes Translation Centers for Disease Control and Prevention Contact: Rli2@cdc.gov 2 Diabetes is Serious and Costly in US Seven percent of US population Serious complications Cost more than 132 billion per year in 2002 Complications can be prevented or delayed 14 million diagnosed with diabetes 7 million with undiagnosed diabetes 41 million with pre-diabetes NHANES 4 Research question State Mandatory Laws and Regulations State Mandates Affect private insurance Group and individual policies from Insurance companies or HMOs within a state SelfSelf-insured companies are exempted by Utilization of the services Employee Retirement Income Security Act (ERISA) 3030-50% employees are exempted FortyForty-six states and D.C. have mandate Health Insurance Coverage 5 6 1 Name of the States with Laws and Effective Year Effective Year Coverage of State Mandates States Coverage Number of states 1987 1994 WI SelfSelf-management education 40 MN, NY Medical nutritional therapy 24 1995 1996 FL Therapeutic foot wear 12 ME, NJ, RI, WV Periodical eye and foot exams 3 1997 1998 AK, NV, NM, OK, TN, TX HbA1c test 1999 2000 AZ, IL, IA, PA, VA 2001 2002 HI, MI, WY, D.C. AK, CA, DE, MA, NE, SC, SD, UT MT, OR 7 Hypotheses Mandate Coverage Coverage of Monitors and strips Self-management education (SME) Eye exams Lower Mortality Annual foot exams Less eye complications Having all three Less foot complications Foot exams Footwear 23 Monitors and strips 32 Insulin 34 Oral agents 31 HighHigh-risk assessment 1 Vaccination 1 8 Behavioral Risk Factors Surveillance Survey (BRFSS) 19961996-2000 Lower HbA1c level Annual eye exams Devices for insulin selfself-administration Outcome DSMG HbA1c test 41 Data Sources Increase Utilization 5 General coverage of pharmaceuticals, devices, and supplies CO, CT, GA, IN, KS, KY, LA, MD, MS, MO, NH, NC, VT, WA Annual, statestate-based, random telephonetelephonesurvey of 150,000150,000-210,000 communitycommunitydwelling US adults (aged 18 or older) Survey questions designed by CDC Core questionnaire required to report by states More than 40 states reported special diabetes module Having Law 9 Study Population 10 Econometric model Prob (Utilizationi,k,t)= Logit (α + β1*Lawk,t=m k,t=m + β2*Lawk,t>m k,t>m + β3*Zi + β4*Xk + β5*Timet)+ ε People with selfself-reported diabetes 9215 observations in the final analysis Health insurance type Z—Individual characteristics X—State level characteristics i—Individual indicator k—State indicator t—Time indicator m—Year that law took effect Employer provided SelfSelf-bought We used STATA 8 survey commands to do all the analysis 11 12 2 Dependent Variables Dependent Variables (Cont’d) based on Healthy People 2010 National Goals for Diabetes If receiving annual foot exams If SelfSelf-monitoring blood glucose (DSMG) at least once daily “About how many times in the last year has a health professional checked your feet for any sores or irritations?” irritations?” “About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a health professional.” professional.” If receiving all three services If receiving annual eye dilated exams “When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.” light.” 13 Results 14 Effect of State Mandates on Daily SelfSelf-monitoring Blood Glucose level Before mandate Coefficient (s.e.) First year of Mandate 100% The follow ing years 80% 60% * ** First Year (monitors & strips) a 0.02 (0.03) Years after 0.05* (0.02) First year (SME) (SME)b 0.01 (0.03) Years after 0.04 (0.02) First year (HbA1c test)c 0.09 (0.05) Years after 0.02 (0.03) Healthy People 2010 Goal * *** 40% * *** 20% 0% Daily SMBG Annual foot exams Annual eye exams Combine a,b,c: Results were from three regressions for different law components The reported coefficients were marginal probabilities Figure I. Percentage of People with Diabetes Using the Selected Diabetes Care Services Before and After Mandate (unadjusted) 15 *: p<=0.05; **: p<=0.01; ***: p<=0.001 Effects of State Mandates on Annual Foot Exams Effects of State Mandates on Annual Eye Exams Coefficient( s.e.) Coefficient (s.e.) First year (SME) -0.01 (0.03) Years after 0.01 (0.02) First year (SME) 0.05 (0.03) Years after 0.04 (0.02)& First year (foot exam) Years after First year (eye exams) 0.01 (0.03) Years after -0.03 (0.03) 16 First year (foot wear) Years after 0.11 (0.07) 0.02 (0.03) 0.06 (0.04) 0.04 (0.03) &: significant at 0.1 level 17 18 3 Conclusion and Implications Effects of Having State Mandate on Receiving all Three Services State mandatory health insurance coverage has some effect on the utilization of selected diabetes care services Coefficient (s.e.) First year 0.07** (0.03) Years after 0.04** (0.02) Coverage on diabetes monitor and strips increased likelihood of daily SMBG State mandated did not have an effect on annual eye and foot exams Increased SMBG increased likelihood of receiving all three services Further studies are needed to understand why the state mandates had limited effect on selected diabetes services 19 20 4
