Andrea M. Lee, M.S. Robert G. Frank, Ph.D. Zoe N. Swaine, M.S. Natalie C. Blevins, M.S.
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Transcript of Andrea M. Lee, M.S. Robert G. Frank, Ph.D. Zoe N. Swaine, M.S. Natalie C. Blevins, M.S.
Primary Care Continuity and Health Care Expenditures in
a Depressed Sample of Florida Medicaid Recipients
Andrea M. Lee, M.S.Robert G. Frank, Ph.D.Zoe N. Swaine, M.S.
Natalie C. Blevins, M.S.Heather Steingraber, B.S.
Continuity of Care• Definition:
– healthcare events experienced as coherent and connected
– consistent with the patient’s medical needs and personal context
• In primary care:
– relationship between a single provider and a patient
– extends beyond specific episodes of illness or disease
Continuity of Care
• Patients who maintain a continuous relationship with a primary care provider are – more satisfied with their care (Gulliford et al., 2007)
– more likely to take medications correctly (Becker et al., 1974)
– more likely to be diagnosed early for chronic diseases (Koopman et al., 2003)
Continuity of Care
• Lower health care utilization – Reduced likelihood of emergency
department utilization in children (Christakis et al., 2001; Brousseau et al., 2004)
– Reductions in hospitalizations, emergency department visits in the elderly (Weiss & Blustein, 1996; Wasson et al., 1984; Burge, Lawson, & Johnston, 2003)
• Lower health care expenditures
• No studies on psychological populations
Depression & primary care
• One of the most prevalent disorders in primary care (Ballenger et al., 1999)
• Depressed individuals tend to have (Simon
et al., 1995):
– lower overall physical functioning
– more disability days
– higher rates of health care utilization
Depression & Medicaid
• 13% of enrollees use Medicaid mental health benefits (Mark et al., 2003)
• Medicaid’s spending for mental health services accounted for over 50% of all public mental health expenditures in 2003 (kff.org)
• Projected to increase up to 2/3 by 2013 (kff.org)
Present study
• Association between continuity of care and health care expenditures in depressed Medicaid enrollees
• Higher continuity of care hypothesized to be associated with lower expenditures
• Florida Medicaid claims data
• Cross-sectional
Participants
• 8,680 participants
• Ages 18-65
• 78% female; 22% male
• 42% White, 14% Black, 38% other, 6% Hispanic
Measure of continuity of care
• Modified, Modified Continuity Index (MMCI)
• Continuous variable, ranging from 0 to 1 – 1 indicates high continuity of care
.1]) visitsof (1/[#-1
1]). visitsof [#Providers/ of (#1
MMCI
Distribution of continuity of care
0
10
20
30
40
50
60
Percentage of Sample
0.0 - 0.19 0.2 - 0.39 0.4 - 0.59 0.6 - 0.79 0.8 - 1.0
Continuity of Care Index Scores
Statistical analyses
• Logistic regression for expenditures with large proportion of zeroes – inpatient, outpatient, and emergency room expenditures
• Log-linear multiple regression– inpatient, outpatient, emergency room, pharmacy,
medical, and total expenditures
• Controlled for age, sex, race, number of medical comorbidities, and number of prescription drugs
Results• Higher continuity of care associated with:
– a lower likelihood of having any expenditures for:• Inpatient (odds ratio: 0.20, p < .01)
• Outpatient (odds ratio: 0.69, p < .01)
• Emergency room (odds ratio: 0.58, p < .01)
– lower expenditures for total, medical, inpatient, outpatient, emergency room expenditures (p < .01)
– higher pharmacy expenditures (p < .01)
Limitations
• Unable to differentiate between provider type and practice site in identifying primary care provider
• ICD-9 codes limited reliability – subject to error and only captures provider – identified depression (not undetected or undiagnosed depression)
Conclusions
• Improving continuity of care in depressed Medicaid recipients may impact overall health care spending
• Pharmacy expenditures were higher with higher continuity of care, which may be due to better medication management
Conclusions
• Relatively few enrollees with low continuity of care to target for policy change, but can have a measurable impact
0
10
20
30
40
50
60
Percentage of Sample
0.0 -0.19
0.2 -0.39
0.4 -0.59
0.6 -0.79
0.8 - 1.0
Continuity of Care Index Scores
Depression
• Acknowledgements:• Robert Frank• Natalie Blevins• Zoë Swaine• Eleni Dimoulas• Heather Steingraber• Jianyi Zhang• Allyson Hall