Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA Changing Clinical...

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]


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


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


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)


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


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%


Most Prevalent Among Part-Year Uninsured Adults 18-64, 1987 and 2003


CONDITIONSCONDITIONS 19871987 20032003

Pulmonary DisordersPulmonary Disorders 8.6%8.6% 9.3%9.3%

Trauma 21.6% 11.7%


Mental Disorders 4.7% 10.8%

Osteoarthritis 4.0% 2.7%


Central Nervous 3.7% 4.0%

Diabetes 1.9% 3.8%


Most Prevalent Conditions Among Non-institutionalized Medicaid Adults 18-64, 1987 and 2003


19871987 20032003

Mental DisordersMental Disorders 9.5%9.5% 24.9%24.9%

Pulmonary Conditions

13.3% 20.0%


Trauma 18.7% 15.3%

Births 11.4% 12.8%

Osteoarthritis 11.1% 11.0%

DiabetesDiabetes 6.0%6.0% 10.3%10.3%



% 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%


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


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

Presented at Academy Health Annual Research Meeting, June 25-27, 2006, Seattle, WA Changing Clinical...

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