Moving Toward Evidence-Based Health Policy in California's Medicaid Program

1. Moving Toward Evidence-Based Health Policy in California's Medicaid Program Andrew B. Bindman, MD Professor Medicine, Health Policy, Epidemiology & Biostatistics University of California San Francisco

3. Research Interest • Health consequences of public policies • Access to and quality of care for low-income, diverse, and patient populations vulnerable to poor health because of their social circumstances • Tied to clinical and teaching activities at San Francisco General Hospital

4. Scientific Research/Advocacy • Possible to advocate without research • Evidence-based approach may provide a more compelling means to reach group consensus on the truth and strategy • Scientific approach comes with responsibilities (scientific integrity, ethical obligation to publish results)

5. Medi-Cal: California’s Medicaid Program • 6.6 million beneficiaries • $40 billion this past year • 2nd largest use of general fund (17%) • Pays for 1 in every 2 births in the state • Covers 2 of 3 nursing home patients • Half of beneficiaries are Latino

6. Medi-Cal’s Challenges • Cost of program outpacing other state programs/funds to support it • Data systems offer limited assessment of access, quality, value • Constraints on state government salaries results in brain drain • Bureaucracy makes it challenging to contract for help

7. CaMRI • California Medicaid Research Institute • Collaborative partnership between University of California and California Department of Health Care Services (Medi-Cal) • Focus is on health policy research, evaluation, and technical assistance • Similar model in several other states

8. Opportunity for UC • To develop new knowledge that can contribute to evidence based decision-making for an important state health program • To participate in the development and use of data systems that can improve the assessment of access, cost and quality of Medi-Cal program • To create a training environment for future health policy decision-makers and investigators

9. CaMRI Steering Committee • UCSF (Host Campus) • Andrew Bindman, Director • Claire Brindis, Associate Director • UCB • Richard Scheffler, Associate Director • UCLA • Richard (Rick) Brown, Associate Director • UCSD • Richard (Rick) Kronick, Associate Director

10. How CaMRI works • Interagency Agreement/project template • Regular dialogue between Medi-Cal and UC • State support as well as federal matching of UC’s certified public expenditures • Facilitate Medi-Cal’s access to UC experts • Enhance UC access to Medi-Cal data

11. Scope of Work • Beneficiaries • health services and support needs • utilization patterns • health outcomes • beneficiary satisfaction • Program benefits • scope, duration and frequency of benefits • clinical- or cost-effectiveness of benefits • Program eligibility • Service/cost implications of eligibility expansions or reductions • outreach, enrollment and retention

12. Scope of Work (cont) • Health care delivery systems • fee-for-service and managed care • use and effectiveness of health IT • incentive payment systems • quality improvement programs • costs/benefits of delivery models • Program administration • enrollment/re-determination processes • provider enrollment processes • effectiveness of cost controls/UM

13. Challenges • Logistics of data sharing • Political nature of annual budget process • Understanding each others culture, timing, and expectations for gauging success • Building sustained trust in the partnership

14. Land Mines to Avoid • Conflicts of interest • Compromising UC’s role as a trusted independent voice • Compromising DHCS competitiveness in the market place

15. National Advisory Committee • To help protect us from the land mines • Panel of state and national experts who will serve as a sounding board and advisory body to our process • Connect our work to related work nationally and in other states

16. Example Project:Eligibility Re-determination • More than half of Medicaid beneficiaries nationwide have interruptions in coverage • State laws vary regarding duration of eligibility re-determination period

17. Study Questions How does the administrative burden of re-enrollment in Medicaid effect the continuity of coverage? What are the health and cost consequences of interruptions in Medicaid enrollment?

18. Nature of State’s Medi-Cal data • Claims (eg hospital, outpt, pharmacy) • No claims for managed care (~50%) • Monthly eligibility • No record of beneficiaries after they lose coverage

19. Linkage DHS: Medi-Cal Enrollment Database • Demographics • Monthly enrollment history • Aid Category (e.g. TANF or SSI) • FFS, managed care • Other insurance 1998 2003 Linked CA Hospital Discharge and Medicaid Eligibility Files OSHPD: Hospital Discharge Data 1998 2003 • Diagnosis (ICD-9 Code) • Month/Year of admission • Payer

20. Creating a Valid Link • Deterministic match on SS# • Probabilistic match with partial SS#, DOB, and sex • Validated match with separate Medi-Cal payment records • 98% success in matching • Least success with <1 year olds

21. Study Design • All individuals 1-64 years with at least 1 month of Medicaid coverage Jan 1998 to December 2002 • Outcome Time to a hospital admission for an ambulatory care sensitive condition • Main predictor Continuous or interrupted Medicaid coverage between enrollment and time of admission

22. ACS Conditions Ambulatory Care Sensitive Conditions:AHRQ Prevention Quality Indicators • Condition with acute course and window for intervention • Condition with chronic course amenable to self-management Chronic Conditions: • Asthma • Hypertension • COPD • Diabetes Mellitus • Heart Failure • Angina Acute Conditions: • Dehydration • Ruptured Appendicitis • Cellulitis • Bacterial Pneumonia • Urinary Tract Infection

23. CA Medicaid Population: 1998-2002

24. Reverse Causality • Interruption in coverage might not predict worse health outcome so much as worse health might predict whether or not have interrupted coverage • Bias of higher admissions among those with continuous coverage • Consider option of using subjects as their own control

25. Survival Analysis of Medicaid Coverage and Interruption Spells on ACS Hospitalizations Spell Months Medicaid Coverage ACS Admission Censored (2003 or 65 Years) ACS Admission New Spell or Months Interruption of Coverage New Spell ACS Admission Censored (2003 or 65 Years) or Months Censored (2003 or 65 Years)

26. ACS Hospitalization Rates: Continuous vs Interrupted Medicaid Beneficiaries

27. Probability of ACS Hospitalization Over Time by Medicaid Coverage Status Cumulative Probability Time (Months)

28. Adjusted Risk of ACS Hospitalization

29. Limitations • Do not have measures of disease prevalence or health status differences between those with continuous versus interrupted Medicaid coverage • Limited information on the subsequent health insurance status of those with interrupted Medicaid coverage

30. Natural Experiment of Interrupted Medicaid Coverage • California extended Medicaid eligibility re-determination period for all children in California from every 6 to every 12 months on January 1, 2001 • Extension of eligibility re-determination period should be associated with an increase in continuity of Medicaid coverage, but should not except through its influence on continuity of coverage affect the health status of children.

31. Pre/Post Study of Re-Enrollment Policy Change for Children • Children 1-17 years with a minimum of 1 month of Medicaid coverage in California • Outcome = time to a hospital admission for an ambulatory care sensitive condition • Main predictor = time period • Pre policy change = 1/99-12/00 • Post policy change = 1/01 -12/02

32. Children 1-17 Years in California Medicaid Before and After Extension of Re-Determination Period

33. Children with Continuous Medicaid Enrollment by Time Period 62 Percentage 49 Years of Enrollment

34. Probability of a Hospitalization for an ACS Condition Over Time

35. Children: Adjusted Risk of ACS Hospitalization

36. Comparison Group: Adults in Medicaid • Medicaid eligibility re-determination period did not change during study period for adults in California • Adults with Medicaid coverage • 1999-2000 = 62% • 2001-2002 = 60% • Adjusted relative hazard of a hospitalization for an ACS condition for adults in post vs pre period= 1.11

37. Hospital Savings and Medicaid Coverage Costs Associated with Enrollment Extension in 2001 – 2002

38. Who Is Paying the Bill? • Among hospitalized children • 60% re-gained Medi-Cal • 33% had another form of insurance • 7% uninsured

39. Other Hidden Costs of Interrupted Coverage • Administrative costs of more frequent eligibility re-determination • Costs of more frequent emergency room visits • Costs of hospitaliations of other potentially avoidable hospitalizations

40. Policy Implications • States need to become more aware of the hidden costs in their Medicaid eligibility policies • Continuity of Medicaid coverage can support better health and decrease wasteful spending on hospitalizations that could have been avoided with less costly outpatient care

41. Research Partnership with State Government • Opportunity to link HSR with a needy/receptive customer • Steep learning curve for each party • Building capacity takes time • Can experience challenges in trying to publish results of 1 state • Significant public service component that university needs guidance on how to measure/value