Acknowledgments
Caring for the New Uninsured:
Hospital Charity Care for the Elderly
without Coverage
• Funding from Johnson & Johnson, Inc.
• Comments & contributions from:
Academy Health Annual Research Meeting
Tuesday June 27, 2006
Cecilia Huang
John Gantner
Susan Reinhard
Jasmine Rizzo
Michael Yedidia
Joel Cantor
Derek DeLia, Ph.D.
Rutgers Center for State Health Policy
1
The Elderly without Coverage
2
Study objectives
• Medicare as “universal insurance” for the elderly
1. Describe prevalence & growth in hospital CC
use by the elderly.
• 350,000 people in the U.S. elderly & uninsured in 2000
(Mold, Fryer, & Thomas, 2004)
2. Compare CC use by the elderly (65+) to
corresponding use by children (0-18) & nonelderly adults (19-64).
Mix of individuals not eligible for Medicare
Immigrants, Unusual work history
May also be Medicaid ineligible
• Likely rely on hospital charity care
• Little data to describe extent & trends in use
• Hospital CC database in NJ
3. Compare CC costs & services used by the
elderly to other age groups.
3
4
Study population & data
Major finding 1:
• Hospital charity care claims data in NJ, 19992004
• Hospital Charity Care Program
• Subsidies for CC to qualified low-income
uninsured residents
• Payment rate based on discounted Medicaid
rates
• Full Medicaid charges as “conservative”
estimate of CC costs
• Inflation adjusted to 2004 $ using MC-CPI
CC use by the elderly has
grown very rapidly.
5
6
1
Use of hospital CC by the elderly in NJ,
1999 vs. 2004
1999
2004
%Change
Outpatient visits
19,050
49,139
158%
Inpatient
admissions
Inpatient days
1,815
3,356
85%
19,021
22,813
20%
Costs
$26m
$48m
86%
Major finding 2:
The elderly have surpassed
children in their use of CC.
(Inflation-adjusted
Medicaid charges)
7
8
Percentage of outpatient CC visits
attributable to children vs. elderly
patients in NJ, 1999-2004
Non-elderly adults are the primary users
of hospital CC.
8%
"Typical" division of CC use by age
7%
6%
5%
4%
3%
2%
1%
0%
1999
Elderly
Non-elderly adults
2000
Children
2001
Children
2002
2003
2004
Elderly
9
10
Percentage of inpatient CC admissions
attributable to children vs. elderly
patients
Percentage of inpatient CC days
attributable to children vs. elderly
patients
8%
9%
8%
7%
7%
6%
6%
5%
4%
5%
4%
3%
3%
2%
1%
0%
2%
1%
0%
1999
2000
2001
Children
2002
2003
1999
2004
Elderly
2000
2001
Children
11
2002
2003
2004
Elderly
12
2
Percentage of CC “costs” attributable to
children vs. elderly patients
(Costs = Inflation-adjusted Medicaid charges)
Major finding 3:
7%
6%
Elderly CC patients use a
different mix of services and
generate a different
distribution of costs.
5%
4%
3%
2%
1%
0%
1999
2000
2001
Children
2002
2003
2004
Elderly
13
Most Common Major Diagnostic
Categories for Inpatient CC users
by Age, 2004
14
Average costs per inpatient CC
admission by age group, 2004
$7,061
MH/subst abuse
Pregnancy/birth
$5,356
Circulatory syst
$3,501
Nerv/sense org
Kidney/urinary
0%
10%
20%
30%
40%
Percentage of inpatient CC users by age
Elderly
Non-elderly adults
Children
Children
Non-elderly adults
Elderly
15
Average costs per outpatient CC visit by
age group, 2004
.0003
Distribution of inpatient CC costs by age
group, 2004
16
$492
Density
.0002
$441
0
.0001
$279
0
1000 0
20000
Do lla r s p e r p a tie n t
Ch ild r e n
Eld e r ly
30000
40000
No n - e ld e rly a d u lts
Children
17
Non-elderly adults
Elderly
18
3
Distribution of outpatient CC costs by
age group, 2004
Implications for SN hospitals
.004
• Use of CC by the elderly more common & more
expensive
0
.001
Density
.002
.003
==> higher costs per case
==> greater financial burden on SN hospitals
==> Shift to different service mix
==> increased demand for unreimbursed
services addressing needs of the elderly
0
500
1 00 0
15 00
Do lla rs pe r p a tie nt
Ch ild re n
Eld e rly
20 00
2 50 0
No n-e ld erly ad u lts
19
• Similar trends in other states?
SCHIP, Aging population, Immigration
20
Potential policy responses
• Medicare expansion
Economic constraints
Political constraints (coverage for immigrants)
• Direct SN support
Growing demand for unreimbursed care
High need/high cost population
21
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