presented at academy health annual research meeting, june 25-27, 2006, seattle, wa changing clinical...
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Changing Clinical Characteristics of the Uninsured: Implications for Funding Care for the Uninsured
Kenneth E. Thorpe, Ph.D.Kenneth E. Thorpe, Ph.D.Robert W. Woodruff Professor and Chair
Department of Health Policy and ManagementRollins School of Public Health
Emory [email protected]
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Overview
• Most prevalent medical conditions among the uninsured have changed over time
• Largest increase in prevalence and spending associated with several chronic conditions
• Observed a large increase in chronic disease prevalence among part year uninsured. This change raises major clinical management issues.
• Care for many of these patient more effectively provided at better value with changes in the structure of the “safety net”.
• This would entail a focus on primary care, prevention, risk appraisals, and care coordination
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Overview
• Means “safety net” needs to be horizontally integrated rather than “hospital-only” focused.
• This will require changes in how we pay for the uninsured since this episodic model of care is driven by Medicare and Medicaid DSH payment policies
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Overview
• Current financing policy through Medicare and Medicaid DSH reinforce an inefficient, expensive model of caring for chronic care patients as it forces most care to be hospital based
• Need alternative financing approaches– Pay for prevention– Pay for full coverage clinically recommended care
for the uninsured (medical home concept)
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Storyline
• How have the clinical characteristics of uninsured and Medicaid adults changed over time?
• What implications does this have for the delivery and financing of care?
• Examine trends from 1987 through 2003
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Ten Most Prevalent Medical Conditions, Full-Year Uninsured Adults Aged 18-64, 1987 and 2003 (% Adults with condition)
Source: NMES and MEPS
ConditionsConditions 19871987 20032003
Trauma 17.3% 8.8%
Pulmonary Conditions 6.4% 6.4%
Mental DisordersMental Disorders 4.2%4.2% 6.0%6.0%
Hypertension 6.4% 5.8%
Arthritis 4.4% 3.4%
DiabetesDiabetes 2.1%2.1% 2.8%2.8%
Heart Disease 3.1% 1.8%
Births 2.9% 1.5%
Central Nervous 2.5% 1.9%
Cancer 1.4% 1.1%
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Most Prevalent Among Part-Year Uninsured Adults 18-64, 1987 and 2003
Source: NMES and MEPS
CONDITIONSCONDITIONS 19871987 20032003
Pulmonary DisordersPulmonary Disorders 8.6%8.6% 9.3%9.3%
Trauma 21.6% 11.7%
Hypertension 5.3% 9.4%
Mental Disorders 4.7% 10.8%
Osteoarthritis 4.0% 2.7%
Heart Disease 4.7% 3.2%
Central Nervous 3.7% 4.0%
Diabetes 1.9% 3.8%
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Most Prevalent Conditions Among Non-institutionalized Medicaid Adults 18-64, 1987 and 2003
Source: NMES and MEPS
19871987 20032003
Mental DisordersMental Disorders 9.5%9.5% 24.9%24.9%
Pulmonary Conditions
13.3% 20.0%
Hypertension 12.1% 16.5%
Trauma 18.7% 15.3%
Births 11.4% 12.8%
Osteoarthritis 11.1% 11.0%
DiabetesDiabetes 6.0%6.0% 10.3%10.3%
Heart Disease 9.0% 8.7%
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
% Distribution of Spending, Top Medical Conditions, Full-year Uninsured Adults, 1987 and 2003, All Conditions
19871987 20032003
Prescription Drugs 9.5% 28.0%
Inpatient Hospital 56.7% 28.8%
ER 4.1% 9.2%
OPP Visits 13.8% 8.4%
Physicians 14.2% 25.5%
Home Health 1.4% 0.1%
Dental 0.3% -
TOTAL 100% 100%
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
Top Ten Most Expensive Medical Conditions, Adults 18-64, Medicaid and Full-Year Uninsured, 2003 (Billions of 2001 $)
Medicaid FY TotalUninsured
Trauma $9.3 $2.6 $11.9Mental Disorders $9.1 $1.8 $10.9Births $7.6 $1.4 $9.0Pulmonary Disorders $4.3 $1.7 $6.0Heart Disease $4.8 $1.6 $6.4Diabetes $3.8 $0.8 $4.6Cancer $3.3 $0.7 $4.0Hypertension $3.1 $0.9 $4.0Arthritis $3.2 $0.8 $4.0Kidney Disease $3.0 $0.3 $3.3
Source: NMES and MPES
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Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA
CONCLUSIONS
• Changes in clinical mix of uninsured adults leading to increase spending on prescription drugs, outpatient services and away from inpatient hospitalization (similar to private insurance trends)
• Current federal DSH policies for financing care for the uninsured has not changed – retained hospital focus. Though some flexibility available through waivers
• Need to re-think institutionalized based approach for financing and delivering care for uninsured
• Instead focus on patient-central not provider-based approach that provides funding across full-spectrum of medical care needs