Transcript Medicaid Enrollees are Poorer and Sicker Than the Low

Access to Care in
The Medicaid Program
Andrew B. Bindman, MD
Professor of Medicine, Health Policy,
Epidemiology & Biostatistics
University of California San Francisco
Medicaid Expenditures by Service, 2006
DSH Payments
5.6%
Home Health and
Personal Care
14.8%
Inpatient
14.1%
Physician/ Lab/ X-ray
3.8%
Mental Health
1.0%
Long-Term
Care
35.8%
ICF/MR
4.3%
Nursing
Facilities
15.7%
Outpatient
/Clinic
6.8%
Acute
Care
58.5%
Drugs
5.5%
Payments to Medicare
3.3%
Other Acute
6.9%
Payments to MCOs
18.0%
Total = $304.0 billion
Urban Institute based on CMS Form 64 prepared for Kaiser Commission on Medicaid and the Uninsured.
Medicaid as Share of National Health Care Spending
2007
42%
16%
17%
13%
Total Health Hospital Care Professional
Services and
Services
Supplies
$2,098
$697
$702
8%
Nursing
Home Care
$131
Prescription
Drugs
$228
Total National Spending (billions)
CMS Office of the Actuary, National Health Statistics Group, National Health Expenditure Accounts, 2009.
Access Problems by Insurance Status
Medicaid
Private
Uninsured
52%
32%
23%
13%
10% 10%
9%
4% 3%
Adults
Children
No Usual Source of Care
KCMU analysis of 2007 NHIS data
3%
Adults
2% 1%
Children
Needed Care but Did Not Get It
State Budget Challenges Could Impact
Medicaid Beneficiaries’ Access
• Reductions in Provider Payments
• Reductions in Enrollment
• Managed Care
Physician Participation by Insurance Type
% Accepting All New Patients
1996-97
% Accepting No New Patients
2004-05
71% 72%
1996-97
2004-05
75% 73%
51% 52%
19% 21%
4%
Medicaid
Private
Medicare
Medicaid
4%
Private
3%
3%
Medicare
Cunningham, Peter and May, Jessica. “Medicaid Patients Increasingly Concentrated Among MDs.” 2006
Factors Contributing to Physicians Participating
in Care of Medicaid Patients
• Participation is voluntary
• Some avoid Medicaid patients due to
• Patient characteristics and complexities
• Concerns about being sued
• Administrative hassles/payment delays
• Participation varies most strongly in association
with state payment rates
• On average, Medicaid pays 70% of Medicare
payments
Physicians’ Acceptance of Medicaid Patients
and Fee Levels, 2001
US
Low-Fee High-Fee
States
States
All Physicians (%)
62
52
68
Primary Care
Physicians (%)
54
47
58
Specialist
Physicians (%)
67
55
75
Zuckerman et al, Health Affairs, 2004
Medicaid Eligibility
• Any person who meets Medicaid eligibility
criteria is entitled to benefit – no wait list
• Federal requirement of at least annual
determination of eligibility
• Many states require or are considering more
frequent determination of eligibility
• State determined frequency and ease of
Medicaid eligibility process affects the number
of beneficiaries with enrollment gaps
Children without Gaps in Medicaid Coverage in CA
Before and After Eligibility Determination Increased
from 6 to 12 Months
70%
Percentage
60%
62%
50%
40%
30%
49%
20%
10%
0%
Pre: 1999-2000
Post: 2001-2002
Years of Enrollment
Bindman, et al. Medical Care, 2008
Preventable Hospitalizations Increase with
Interruptions in Medicaid Coverage
20%
15%
10%
Interrupted
5%
Continuous
Time (Months)
Bindman et al, Annals of Internal Medicine, 2008
60
54
48
42
36
30
24
18
12
6
0%
0
Cumulative Probability
25%
Medicaid Managed Care
• Delivery model used in most states
• Potential to improve access through requirement for
a primary care provider
• Concern that access to high cost services (eg
specialists) could be limited to save money
• Some states looking to expand mandatory Medicaid
managed care for a larger proportion of their
beneficiaries
Medicaid Managed Care Enrollees as a Percent of State
Medicaid Enrollees, June 2007
NH
VT
WA
MT
ND
MN
OR
ID
WI
RI
MI
WY
PA
IA
NE
NV
ILIL
WV
DE
VA
KS
MO
KY
NC
TN
OK
AZ
NM
AK
MD
DC
SC
AR
MS
TX
CT
NJ
OH
IN
UT
CO
MA
NY
SD
CA
ME
AL
GA
LA
FL
HI
U.S. Average = 64.1% FPL
0 - 60% (13 states)
61-70% (17 states including DC)
71-80% (7 states)
81-100% (14 states)
SOURCE: Medicaid Managed Care Penetration Rates by State as of June 30, 2007, CMS, HHS