The Effects of Medicaid Policy
Changes on Adults’ Service Use Patterns in
Kent ck and Idaho
Kentucky
Genevieve Kenneyy
James Marton
Jennifer Pelletier
Ariel Klein
Jeffrey Talbert
Urban Institute
Georgia State University
Urban Institute
Urban Institute
University of Kentucky
AcademyHealth Annual Research Meeting
J
June
27
27, 2010
Funded by the State Health Access Reform Evaluation, a national program of the
Robert Wood Johnson Foundation
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Medicaid Policy Changes Made
Between 2005 to 2008 in Kentucky
• KY policies introduced in July 2006:
–
–
–
–
$3-$6 copays
p y for physician
p y
office visits
$2 copays for dental visits (# of allowable visits reduced to 1 / year)
$50 copayment for inpatient hospital stays
$1-$3
$1
$3 copayments for prescriptions (service limits on the number of
prescriptions - 4 per month with a maximum of 3 brand name drugs
and higher copays on brand name drugs)
– 5% coinsurance ((upp to $6)) for non-emergency
g y use of the ER
• KY out-of-pocket maximums of $225 for medical services
and $225 for prescriptions also put in place in July 2006
• KY increased reimbursement rates for preventive care and
E&M codes in July 2007 and in January 2008
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Medicaid Policy Changes Made in
2006 and 2007 in Idaho
• Annual wellness exam added to adult benefit packages
• Tobacco Cessation and Weight Management Preventive
Health Assistance benefits become available to adults who
qualify
– To qualify for Tobacco benefit, adult must be a current smoker
who wants to quit
– To qualify for Weight Management benefit, adult must have BMI
of less than 18.5 or 30 or greater.
• Dental coverage for non-disabled enrollees outsourced to a
managedd care organization
i ti andd reimbursement
i b
t rates
t for
f
adults’ services increased by an average of 3.9%
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
R
Research
h Questions
Q
i
Kentucky
• Did the new 2006 primary care, dental care, inpatient stay, prescription
drug, and ER copayments lead to decreases in the receipt of care?
• Did the 2007 and 2008 reimbursement rate increases for evaluation
and management services lead to increases in the number of physician
office
ffi visits?
i it ?
Idaho
• Did the addition of an annual wellness benefit result in receipt of
preventive
ti care among adults?
d lt ? What
Wh t are the
th characteristics
h
t i ti off the
th
adults who received preventive care?
• Did the tobacco cessation and weight management benefits succeed in
changing beneficiary behavior?
• Did the move to a managed care delivery system for dental care
improve non-disabled beneficiaries’ access to dental care?
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Office Visits in KY – Multivariate Results
• July
J l 2006:
2006 $3-$6
$3 $6 copays for
f office
ffi visits
i it introduced
i t d d
– We find no statistically significant change in the probability of having at
least 1 office visit annually post July 2006.
• Because of the reimbursement rate increases for preventive
office visits in July 2007 and January 2008,
2008 we also
estimated a specification with separate year dummies:
– We find a very small (.35 percentage point or .4%) decline in the
probability of having at least 1 office visit for fiscal year July 2006
2006-June
June
2007 (p = .033) and a small (.20 percentage point or .23%), but
statistically insignificant, increase in the probability of having at least 1
office visit for fiscal year July 2007-June 2008.
• Negative binomial models give similar results in terms of
signs and statistical significance.
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Dental Visits, Inpatient Stays,
ER use in KY –
Multivariate Results
•
July 2006: $2 copays for dental visits introduced as well as a reduction in the
number of annual allowable visits to 1 pper year.
y
–
We find no statistically significant change in the probability of having at least 1 dental visit
annually, but a statistically significant reduction in the number of annual dental visits (p <
.001).
– July 2006: $50 copay for inpatient stays introduced
–
We find a very small (.41 percentage point or 2.28%) decrease in the probability of having at
least 1 inpatient stay annually (p = .002) and a statistically significant reduction in the number
of annual inpatient stays (p < .001).
– July 2006: 5% coinsurance (up to $6) for non-emergency use of the ER
–
We find a 1 percentage point (or 1.94%) increase in the probability of having at least 1 ER visit
annually (p < .001) and a statistically significant increase in the number of ER visits (p < .001).
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Prescription
P
i ti use in
i KY –
Multivariate Results
– July 2006: $1-$3 copays for prescriptions introduced (also new service
limits on the number of prescriptions - 4 per month with a maximum of
3 brand name drugs)
–
We find no statistically significant change in the probability of having at least 1
prescription annually.
–
We also find that the average number of monthly generic prescriptions
increases slightly (p < .001) after July 2006 (from 2.18 per month to 2.43 per
month) while the average number of name brand prescriptions falls slightly (p
< .001) after July 2006 (from 1.29 per month to 1.10 per month).
–
Increased use of generics could lead to cost savings in this large category of Medicaid
p
expenditure.
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Idaho - Descriptive Results
• After moving to managed care, the share of adults who had any dental
visit
i it increased
i
d by
b 2.5
2 5 percentage
t
points
i t (from
(f
45.5%
45 5% to
t 48.0%).
48 0%)
• Likewise, the share of adults who had any preventive dental visit
i
increased
d by
b 2.4
2 4 percentage
t
points
i t (from
(f
21.8%
21 8% to
t 24.2%)
24 2%)
• After introduction of the annual wellness benefit, 8.9% of adult
b fi i i received
beneficiaries
i d a preventive
ti medical
di l check-up
h k
i a 12-month
in
12
th
period. Preventive care receipt is:
– 10.3 percent among those who did not receive any care at an FQHC
(preventive care receipt among those who did visit an FQHC may not be
counted in the claims);
– Higher among women than men (11.6% vs. 1.7%):
– Higher among adult TANF recipients than SSI recipients (11.4% vs.
7 2%)
7.2%).
– Rates also vary by region in the state, ranging from 5.6% to 15.6%.
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Idaho- Personal Health Assistance
Benefits Results
•
Overall, participation in the personal health assistance benefits appears low: in
2009, about 1000 people were in the weight management benefit and 360
people were in the tobacco cessation benefit but do not know size of eligible
pool
•
The state conducted a surveyy of participants,
p
p
, which resulted in 56 respondents
p
to the weight management survey and 39 respondents to the tobacco cessation
survey
– While the sample sizes are very small,
small the majority of respondents reported that
they gained/lost weight as intended on the weight management program (88%, 95%
C.I. 76%-95%)
– F
Fewer respondents
d t reported
t d successfully
f ll quitting
itti smoking
ki as a result
lt off their
th i
participation in the tobacco cessation program (20%, 95% C.I. 10%-38%)—other
information on the survey suggests that this could relate to fact that the benefit only
covers 7 weeks of tobacco cessation drugs while the full treatment is 12 weeks.
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Idaho- Multivariate Results
• DD estimates indicate that non-disabled adults are
5 4 percentage points
5.4
i more likely
lik l to have
h
an annuall
dental visit after introduction of managed care and
2 0 percentage points more likely to have received a
2.0
preventive dental visit after introduction of managed
care
• Simple pre-post
pre post models without the use of a
comparison group found results in the same direction
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Limitations
• Inaccuracies in coding practices in the claims data may
understate the extent of preventive care received
• Can not assess extent to which copays are being collected
in KY
• Not controlling for possibly confounding changes in case
mix or service delivery system with a simple pre-post
design
• Length of post period may not allow sufficient time for
p c s too be felt
e
impacts
• No information available on content of care being provided
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Policy Implications
•
Our general finding in Kentucky is very little or no impact of the modest
copayments on utilization across several categories of service--small impacts
on office visits and prescriptions; Without knowing underlying cause of the
observed patterns, can not fully understand implications
•
Adults in Idaho Medicaid have veryy low levels of preventive
p
care receipt,
p,
indicating that physicians and beneficiaries may be missing opportunities for
counseling on prevention and chronic disease management.
•
The Beha
Behavioral
ioral PHA benefits in Idaho have
ha e low
lo enrollment to date and are not
structured in a way that can be expected to achieve widespread behavior
change.
•
Need to invest in data systems: track progress with respect to preventive care
receipt; examine content of care; and assess extent to which beneficiaries are
receiving appropriate follow-up care for problems that are diagnosed
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Genevieve Kenney
Senior Fellow
The Urban Institute
(202) 261-5568
JK
JKenney@urban.org
@ b
www.urban.org
www.healthpolicycenter.org
URBAN INSTITUTE
Motivation
• Idaho and Kentucky introduced policy
changes aimed at:
– increasing emphasis on and access to wellness
and prevention services
– Controlling Medicaid cost growth
– encouraging more effective use of state
M di id resources andd greater
Medicaid
t involvement
i
l
t off
Medicaid beneficiaries in their health care
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
•
Kentucky
Sample
We use
se administrative
administrati e claims and enrollment data from Kentucky
Kent ck
Medicaid to build a dataset consisting of all full fiscal years of coverage
between 2005-2008 for non-institutionalized, non-elderly adult enrollees
((aged
g 19-64).
)
• In building this dataset, we excluded person-months with missing values
for key variables, such as demographics or eligibility category, and the
person-months
h representing
i dual
d l coverage. We drop
d
full
f ll years off coverage
in which there was a mid-year switch in the category of eligibility or in the
benefit package.
• We also exclude enrollees in Louisville-region counties, because all
Medicaid enrollees in those counties are enrolled in a capitated managed
care pplan ((Passport).
p ) Roughly
g y 16% of our full fiscal yyears of coverage
g
represent Passport coverage.
• We are left with 341,367
,
full fiscal yyears of FFS Medicaid coverage
g
generated by 164,209 unique individuals.
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Kentucky Analyses
• Descriptive analysis of receipt of care across several different service
categories (any office visits, any dental visits, any inpatient stays, any
prescription
i ti use, andd any ER visits)
i it ) after
ft the
th introduction
i t d ti off the
th
copays.
• Logistic regression analysis with marginal effects to examine the
impact of the KY reforms on the probability of the receipt of any care
over a 12-month period across the different service categories with
controls for age, race, gender, and geographic location.
• Count models are also estimated to examine the impact of the KY
reforms on the annual number of visits across the different service
categories.
t
i
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Idaho Sample
• We use administrative claims and enrollment data from Idaho
Medicaid to build a dataset consisting of all full years of coverage
b t
between
2004-2008
2004 2008 for
f non-institutionalized,
i tit ti li d non-elderly
ld l adult
d lt
enrollees (aged 19-64).
• IIn building
b ildi this
thi dataset,
d t t we excluded
l d d person-months
th with
ith missing
i i
values for key variables, such as demographics or eligibility category,
and the person-months representing dual coverage. We also exclude
eenrollees
o ees who
w o received
ece ved all
a their
t e care
ca e at a Federally
ede a y Qualified
Qua ed Health
ea t
Center (FQHC) due to the absence of claims data for these providers
(about 8.5% of the sample).
• We have 52,346 person-years in the physician visit dataset and 52,245
person-years in the dental visit dataset.
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION
Idaho Analyses
•
Case study analyses to assess policy changes included key stakeholder
interviews with current and former Medicaid officials, providers, provider
associations and advocacy groups and a small state survey of participants in
associations,
the tobacco cessation and weight management benefits
•
Descriptive
p
analysis
y of receipt
p of anyy preventive
p
visit after introduction of
policy changes
•
Descriptive analysis of receipt of any dental visit and any preventive dental
visit
isit before and after implementation of policy
polic changes
•
Logistic regression analysis with marginal effects of receipt of any dental visit
and any preventive dental visit over a 12
12-month
month period with controls for age,
race, gender, FQHC use, and geographic location using disabled population as
a comparison group (Difference in differences estimate)
URBAN INSTITUTE
PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION