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

Research Interest Health consequences of public policies 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 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 Tied to clinical and teaching activities at San Francisco General Hospital

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

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

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

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

Opportunity for UC To develop new knowledge that can contribute to evidence based decision- making for an important state health program 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 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 To create a training environment for future health policy decision-makers and investigators

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

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

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

Scope of Work (cont) Health care delivery systems 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 Program administration –enrollment/re-determination processes –provider enrollment processes –effectiveness of cost controls/UM

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

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

National Advisory Committee To help protect us from the land mines 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 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 Connect our work to related work nationally and in other states

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

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?

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

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

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

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

Ambulatory Care Sensitive Conditions: AHRQ Prevention Quality Indicators 1. Condition with acute course and window for intervention 2. Condition with chronic course amenable to self-management ACS Conditions Acute Conditions: –Dehydration –Ruptured Appendicitis –Cellulitis –Bacterial Pneumonia –Urinary Tract Infection Chronic Conditions: –Asthma –Hypertension –COPD –Diabetes Mellitus –Heart Failure –Angina

CA Medicaid Population: Interrupted Coverage Continuous Coverage N 5,289,687 (62%) 3, 252,319 (38%) 3, 252,319 (38%) Mean Age (yrs) % Female 5956 Race/Ethnicity (%) Hispanic Hispanic5147 Black Black1013 Asian Asian 711 White White 54 Other Other2724 Aid Group (%) TANF TANF3346 SSI SSI 516 Other Other6238 Managed Care (%) 2325 Other Insurance (%) 811

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

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

ACS Hospitalization Rates: Continuous vs Interrupted Medicaid Beneficiaries ContinuousInterrupted Number of ACS Hospitalizations 172,38722,759 Person Months 410,978,55221,158,749 Rate of Hospitalization for ACS Conditions/1000 person months

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

Adjusted Risk of ACS Hospitalization Demographics Relative Hazard P-value Interrupted Coverage 3.72<.0001 Age1.04<.0001 Female0.98<.0001 Race/Ethnicity Hispanic Hispanic2.32<.0001 Black Black4.23<.0001 Asian Asian0.87<.0001 Other Other2.59<.0001 Eligibility TANF TANF0.83<.0001 SSI SSI6.69<.0001 Managed Care Other Coverage 1.07<.0001

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

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 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. 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.

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 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 Outcome = time to a hospital admission for an ambulatory care sensitive condition Main predictor = time period Main predictor = time period –Pre policy change = 1/99-12/00 –Post policy change = 1/01 -12/02

Children 1-17 Years in California Medicaid Before and After Extension of Re-Determination Period N 3,288,171 3,288,1713,230,120 Mean Age (yrs) 99 % Female 5051 Ethnicity (%) Hispanic Hispanic5456 Black Black1312 Asian Asian88 Other Other2524 Aid Group (%) TANF TANF4750 SSI SSI33 Other Other5047 Managed Care (%) 4741

Children with Continuous Medicaid Enrollment by Time Period Years of Enrollment Percentage

Probability of a Hospitalization for an ACS Condition Over Time

Children: Adjusted Risk of ACS Hospitalization Relative Hazard P-Value P-Value Post policy <.0001 Age <.0001 Female Ethnicity Hispanic Hispanic <.0001 Black Black <.0001 Asian Asian Other Other <.0001 Aid Group TANF TANF <.0001 SSI SSI <.0001 Managed Care <.0001

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

Hospital Savings Reduction in number of hospital days 15,635 Average daily Medicaid payment for a hospitalization for an ACS condition $1,129 Total hospital savings $17,651,915 Medicaid Coverage Costs Increased number of continuously enrolled months of Medicaid coverage TANF/Other SSI SSI1,395,283 41,524 41,524 Average monthly capitation rate TANF/Other SSI SSI $96 $96$370 Total Medicaid Costs for increased coverage TANF/Other SSI SSI$134,393,685 $15,350,490 $15,350,490 Total Medicaid Coverage Costs $149,744,175 Hospital Savings and Medicaid Coverage Costs Associated with Enrollment Extension in 2001 – 2002

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

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

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

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