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