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Transcript of 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]
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
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
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)
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
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%
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%
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%
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%
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
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