Background
Impact of Restrictive State Policies
on Utilization and Expenditures in
the Medicaid Program
„
Roberto Vargas, MD, MPH1,2
Carole Gresenz,
Gresenz, PhD2
Jessie Riposo,
Riposo, MS2
Jeannette Rogowski,
Rogowski, PhD3
José
José Escarce, MD, PhD1,2
For state Medicaid programs, the Deficit
Reduction Act eliminated
„
Need to offer all benefits to all enrollees
„
Requirement of states to get federal waivers
before limiting benefits or imposing coco-pays
and cost sharing
„
Mandatory periods of public comment prior to
implementing such changes
1.Division of General Internal Medicine and Health Services Research, David Geffen
School of Medicine at UCLA
2.RAND Health
3.University of Medicine and Dentistry New Jersey, School of Public Health
Restrictive Policies and Medicaid
„
„
Restrictive drug policies have been
associated with lower rates of prescription
filling and more intensive use of acute care,
nursing homes and higher overall costs
Cost sharing and limits on physician visits in
Medicaid have varying effects on physician
visits rates but no significant impact on
overall costs.
Aims
„
To examine the effects of restrictive policies
on use of care by a nationally representative
sample of Medicaid enrollees over a sixsix-year
period
Data Sources
„
State Medicaid Summaries from 19971997-2002
„
„
services and coco-pays)
Adults 1818-64 with at least one full calendar
year of data in MEPS
Summaries of state plan benefits including
scope of medical care (Limits on visits and
„
Study Sample
„
We excluded:
„
Patients who were pregnant
The Medical Expenditure Panel Survey
„
Had additional forms of insurance
(MEPS), 19971997-2002
„
Were enrolled inn Managed care or HMO’
HMO’s
1
Study Design
Outcomes
„
Cross sectional, yearly analytic files of respondents
„
Multivariate regression models and simulations
„
Estimate the impact of state policy variation
„
„
Controlling for individual characteristics, health
care market factors, and community contextual
„
factors
Utilization:
„
Outpatient officeoffice-based physician visits
„
Outpatient office visits (non(non-physician and physician)
„
Emergency room visits
„
Inpatient acute care hospital admissions
Expenditures:
„
Prescription drug expenditures
„
Total healthcare expenditures excluding vision and
dental services
Key Independent Variables:
Medicaid Restrictive Policies
„
„
Any physician visit coco-pay
„
Any emergency room visit coco-pay
„
Any prescription drug coco-pay
„
Inpatient admission coco-pay for stay of greater
than $21
„
Any inpatient coco-pay charged daily
„
OfficeOffice-based physician visit limit
„
Less than or equal to three prescription limit per
month
„
Regression Models:
„
OfficeOffice-based visits: Negative binomial model
„
Any emergency room: Logit model
„
Any inpatient night: Logit model
„
Expenditures: selected TwoTwo-part models
Simulations:
„
Descriptive Data:
Individual Characteristics
IndividualIndividual-Level Variables
Female
Analysis
We simulated values for the utilization and
expenditures weighted for the MEPS sampling design
Descriptive Data:
Outcomes
Utilization and Expenditures
64%
Mean (Std Err)/
%
NonNon- Hispanic Black
28%
# OfficeOffice-based physician visits
5.70 (0.33)
Hispanic
21%
# Total officeoffice-based visits
Any emergency room visit %
8.03 (0.69)
Other NonNon-White
5%
NonNon-Hispanic White
46%
Prescription expenditures
$1098.28 (56.92)
SSI Recipient
41%
Total medical expenditures
$4575.92 (320.53)
Income<poverty
59%
Less than high school
48%
Any inpatient admission %
24%
14%
2
Descriptive Data:
Restrictive Medicaid Policies
Policy
Regression Results
1997
Any Physician Visit Co pay
18
Limit on number of Physician Visits
17
Any Emergency Room Co pay
4
Prescription Co pay
29
Limit on number of prescriptions per month
11
Inpatient Admissions Co pay
14
Inpatient Daily Co pay
5
„
Visit limit policies had no significant impact on
visits that included nonnon-physician care,
emergency room visits, or inpatient hospital stays
„
Limiting prescriptions to three per month had no
significant effect on any of our utilization or
expenditure measures
„
Per day inpatient coco-pay was not associated with
hospitalization rates or expenditures
Regression Results
„
Regression Results
CoCo-pays for physician visits
„
Lower Any ER visit rate (20% compared to
25%; p<0.10)
„
Higher rates of inpatient hospitalization (18%
compared to 13%; p<0.05)
„
Higher average total expenditures ($5,431
compared to $4,271; p<0.05)
„
„
„
Prescription drug coco-pays:
„
„
Lower expenditures ($4,145 compared to $5,088;
p<0.05)
Prescription drug coco-pays:
„
Significantly lower average number of physician
officeoffice-based visits (5.58 compared to 6.70;
p<0.05)
Fewer Admissions (9% compared to 15%;
p<0.10)
ER visit coco-pays
„
Regression Results
„
Inpatient admission coco-pays of greater than $21
Lower total expenditures ($3,719 compared to
$4,665; p<0.01)
Conclusions
„
Some coco-pays were associated with lower
expenditures and utilization
„
Visit limit policies, no significant impact on either
outcomes of interest
„
Certain restrictive policies are associated with
unintended consequences such as the association
of physician visit coco-pays with higher
hospitalization rates and costs
3
Implications
„
„
Efforts to reduce costs through restrictive policies
have varying effects on utilization and
expenditures
Supplemental Slides
As states consider greater use of restrictive policies
there is a need to monitor the impact of restrictive
policies for unintended consequences
Results
States Level Restrictive Policies
Simulation Physician Office- Physician and NonValue
Based Visits Physician Visits
Any ER Visit
Mean Std Err Mean Std Err Mean Std Err
Any Office-Based Doctors Visit
0
6.29
(0.37) 8.59
(0.62)
0.23
(0.02)
1
6.00
(0.48) 8.35
(0.84)
0.24
(0.02)
Any Inpatient
Hospital Night
Mean Std Err
0.15
(0.01)
0.13
(0.01)
Any Physician Visit Co pay
0.13**
0.18**
Simulation Variable
Any ER visit Co pay
0
1
0
1
6.08
6.38
6.24
4.88
(0.36)
(0.59)
(0.34)
(0.71)
8.68
8.07
(0.68)
(0.84)
8.52
7.94
(0.62)
(1.39)
0.25*
0.20*
0.23
0.24
(0.02)
(0.02)
(0.01)
(0.05)
Any Prescription
Drug Expenditure
(Spec 1)
Mean SE
1109.85 (53.88)
1158.08 (59.87)
Any Expenditure
(Spec 1)
Mean
SE
4367.27 (314.30)
4953.56 (472.73)
(0.01) 1115.04 (49.85) 4270.69** (267.43)
(0.02) 1152.68 (87.88) 5430.74** (546.01)
0.14
0.14
(0.01) 1120.45 (39.32) 4664.96*
(0.01) 1254.47 (146.76) 3718.50*
(255.82)
(686.33)
Any Prescription Co pay
0
1
6.70**
5.58**
(0.47)
(0.37)
8.75
8.18
(0.75)
(0.69)
0.22
0.25
(0.02)
(0.02)
0.15
0.14
(0.01) 1108.34 (57.79) 5087.92** (397.68)
(0.01) 1151.77 (62.87) 4144.60** (303.82)
Limit of Three Rx per Month
0
1
6.15
7.15
(0.33)
(1.47)
8.51
7.56
(0.61)
(1.53)
0.23
0.29
(0.01)
(0.09)
0.14
0.15
(0.01) 1126.5 (37.46) 4589.28
(0.05) 1364.48 (432.14) 5565.32
(256.60)
(2042.71)
Any Inpatient Admission Co pay
greater than $21 Per Stay
0
1
-
0.15*
0.09
(0.01)
(0.02)
(261.84)
(726.14)
-
-
-
4671.56
3778.01
Policy Level Variables
1997
1998
1999
Any Physician Visit Co pay
18
18
18
17
17
19
Limit on number of Physician
Visits
17
17
17
17
17
17
Physician Visit and Co pay
Restriction
7
7
7
8
7
7
2000 2001
*
2002
*Data missing for one state
*p<0.10; **p<0.05
State Level ER Restrictive Policies
State Level Inpatient Admission Policies
Policy Level Variables
Policy Level Variables
1997
1998 1999 2000 2001
*
1997
1998
1999
2000
*
2001
2002
Inpatient Admissions Co pay
14
16
16
15
15
15
2002
Any Emergency Room Co pay
4
4
4
4
4
4
Inpatient Daily Co pay
5
5
5
5
5
5
Limit on number of Emergency
Room Visits
4
4
4
4
4
4
Inpatient Stay Limit
12
12
12
12
10
10
Emergency Room Co pay and Visit
Restriction
1
1
1
1
1
1
*Data missing for one state
*Data missing for one state
4
State Level Prescription Drug Policies
Policy Level Variables
1997
1998
1999
Prescription Co pay
29
29
30
31
30
31
Limit on number of
prescriptions per month
11
12
12
12
10
10
Both Rx Co pay and limit
5
6
6
7
5
5
2000* 2001
2002
*Data missing for one state
5