Changing Clinical Characteristics
of the Uninsured: Implications for
Funding Care for the Uninsured
Kenneth E. Thorpe, Ph.D.
Robert W. Woodruff Professor and Chair
Department of Health Policy and Management
Rollins School of Public Health
Emory University
kthorpe@sph.emory.edu
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Overview
• Most prevalent medical conditions among the
uninsured have changed over time
• Largest increase in prevalence and spending
associated with several chronic conditions
• Observed a large increase in chronic disease
prevalence among part year uninsured. This change
raises major clinical management issues.
• Care for many of these patient more effectively
provided at better value with changes in the structure
of the “safety net”.
• This would entail a focus on primary care,
prevention, risk appraisals, and care coordination
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Overview
• Means “safety net” needs to be
horizontally integrated rather than
“hospital-only” focused.
• This will require changes in how we pay
for the uninsured since this episodic
model of care is driven by Medicare
and Medicaid DSH payment policies
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Overview
• Current financing policy through Medicare
and Medicaid DSH reinforce an inefficient,
expensive model of caring for chronic care
patients as it forces most care to be hospital
based
• Need alternative financing approaches
– Pay for prevention
– Pay for full coverage clinically recommended care
for the uninsured (medical home concept)
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Storyline
• How have the clinical characteristics of
uninsured and Medicaid adults
changed over time?
• What implications does this have for
the delivery and financing of care?
• Examine trends from 1987 through
2003
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Ten Most Prevalent Medical
Conditions, Full-Year Uninsured Adults
Aged 18-64, 1987 and 2003 (% Adults
with condition)
Conditions
1987
2003
Trauma
17.3%
8.8%
Pulmonary Conditions
6.4%
6.4%
Mental Disorders
4.2%
6.0%
Hypertension
6.4%
5.8%
Arthritis
4.4%
3.4%
Diabetes
2.1%
2.8%
Heart Disease
3.1%
1.8%
Births
2.9%
1.5%
Central Nervous
2.5%
1.9%
Cancer
Source: NMES and MEPS
1.4%
1.1%
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Most Prevalent Among Part-Year
Uninsured Adults 18-64, 1987 and
2003
CONDITIONS
1987
2003
Pulmonary Disorders
8.6%
9.3%
Trauma
21.6%
11.7%
Hypertension
5.3%
9.4%
Mental Disorders
4.7%
10.8%
Osteoarthritis
4.0%
2.7%
Heart Disease
4.7%
3.2%
Central Nervous
3.7%
4.0%
Diabetes
1.9%
3.8%
Source: NMES and MEPS
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Most Prevalent Conditions Among Noninstitutionalized Medicaid Adults 18-64, 1987
and 2003
1987
2003
Mental Disorders
9.5%
24.9%
Pulmonary
Conditions
13.3%
20.0%
Hypertension
12.1%
16.5%
Trauma
18.7%
15.3%
Births
11.4%
12.8%
Osteoarthritis
11.1%
11.0%
Diabetes
6.0%
10.3%
Heart Disease
9.0%
8.7%
Source: NMES and MEPS
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
% Distribution of Spending, Top Medical
Conditions, Full-year Uninsured Adults, 1987
and 2003, All Conditions
1987
2003
Prescription Drugs
9.5%
28.0%
Inpatient Hospital
56.7%
28.8%
ER
4.1%
9.2%
OPP Visits
13.8%
8.4%
Physicians
14.2%
25.5%
Home Health
1.4%
0.1%
Dental
0.3%
-
TOTAL
100%
100%
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Top Ten Most Expensive Medical Conditions,
Adults 18-64, Medicaid and Full-Year
Uninsured, 2003 (Billions of 2001 $)
Medicaid
Trauma
Mental Disorders
Births
Pulmonary Disorders
Heart Disease
Diabetes
Cancer
Hypertension
Arthritis
Kidney Disease
$9.3
$9.1
$7.6
$4.3
$4.8
$3.8
$3.3
$3.1
$3.2
$3.0
FY
Uninsured
$2.6
$1.8
$1.4
$1.7
$1.6
$0.8
$0.7
$0.9
$0.8
$0.3
Source: NMES and MPES
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Total
$11.9
$10.9
$9.0
$6.0
$6.4
$4.6
$4.0
$4.0
$4.0
$3.3
CONCLUSIONS
• Changes in clinical mix of uninsured adults leading
to increase spending on prescription drugs,
outpatient services and away from inpatient
hospitalization (similar to private insurance trends)
• Current federal DSH policies for financing care for
the uninsured has not changed – retained hospital
focus. Though some flexibility available through
waivers
• Need to re-think institutionalized based approach for
financing and delivering care for uninsured
• Instead focus on patient-central not provider-based
approach that provides funding across full-spectrum
of medical care needs
Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA