Andrea M. Lee, M.S. Robert G. Frank, Ph.D. Zoe N. Swaine, M.S. Natalie C. Blevins, M.S.

1. 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.

2. 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

3. 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)

4. 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

5. 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

6. 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)

7. 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

8. Participants • 8,680 participants • Ages 18-65 • 78% female; 22% male • 42% White, 14% Black, 38% other, 6% Hispanic

9. Measure of continuity of care • Modified, Modified Continuity Index (MMCI) • Continuous variable, ranging from 0 to 1 • 1 indicates high continuity of care

10. Distribution of continuity of care

11. 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

12. 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)

13. 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)

14. 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

15. Conclusions • Relatively few enrollees with low continuity of care to target for policy change, but can have a measurable impact

16. Acknowledgements: • Robert Frank • Natalie Blevins • Zoë Swaine • Eleni Dimoulas • Heather Steingraber • Jianyi Zhang • Allyson Hall