Continuity Of Care For Florida Medicaid Primary Care .

Continuity of Care for FloridaMedicaid Primary CareUtilizers with PsychologicalConditionsRobert G. Frank, PhDNatalie C. BlevinsFebruary 23, 20041

Primary care is the most frequentsite for psychological treatment 50% of individuals with a psychological disorderseek treatment from PCP (Narrow, 1993) 25% of patients seen in PC suffer from apsychological disorder (Spitzer, 1995) Rates of MDD in PC range from 5-10% percent(Katon & Schulberg, 1992) Second to hypertension, depression is morecommon in PC than any other condition(Ballenger, 1999)2

Medicaid and Mental Health Medicaid pays for a broad range of MH services– acute hospital services– psychosocial rehabilitation– psychotropic medications 20% of total MH care spending in the U.S. camefrom Medicaid in 1997 (Frank, 2003) MH care accounts for 9-13% of total Medicaidspending (Mark, 2003) 20% of Medicaid beneficiaries used MH servicesin 1995 (Frank, 2003)3

Continuity of Care Patients are increasingly seen by an array ofproviders in a wide variety of organizations Raises significant concerns aboutfragmentation of care Especially relevant for Medicaid population4

Continuity of Care Studies have shown that patients with highcontinuity are– More satisfied with care– More likely to take medications correctly– More likely to have problems identified5

Continuity of Care Patient:– Perception that provider who knows them willcare for them in the future Provider:– Perception that they have sufficient knowledgeand information about a patient to best applytheir professional competence– Confidence that their care inputs will berecognized and pursued by other providers6

Role of continuity in preventinghospitalizations Continuity of care is associated withdecreased future likelihood ofhospitalization (Gill & Mainous, 1998) Policies that encourage patients toconcentrate their care with a single providermay lead to lower hospitalization rates andlower health care costs7

Current Study To our knowledge, no study has examined thecontinuity of care and associated health care costsof treating non-psychotic psychological conditionsin the Medicaid population Understanding this interaction in primary care,where most individuals seek treatment for nonpsychotic psychological conditions, allows formore appropriate management of these diseases,improvement of clinical outcomes, and reductionof costs8

Current Study To examine continuity effects for Medicaidprimary care patients with psychological diagnoses To operationalize and measure continuity of care To compare high continuity and low continuitypatients on demographic dimensions, utilization,and cost outcomes To develop models using continuity of care,psychological diagnoses, and demographics topredict utilization and cost in Medicaid9

Methodology Eligible study participants included all Florida MedicaidMedipass recipients with a diagnosis of a psychologicalcondition made by a primary care physician (i.e., FamilyPractice, General Practice, Internal Medicine, OB/GYN, orPediatrics) during the month of June 2001 Recipients were then systematically excluded if they were1) diagnosed with the same disorder within the previous180 days; 2) not continuously eligible for Medicaid 180days before the index diagnosis date; or 3) under the age of18 or over age 65 as of June 1, 2001.10

DiseaseICD-9 CodeCountAcute Reaction to Stress308.000Adj. React. w/ Anx. Mood309.240Adj. React. w/ mixed feactures309.281309.0-309.111Agoraphobia w/ panic300.211Agoraphobia w/o panic300.220Anxiety State Unspecified300.00210311210300.464300.0231MDD recurrent296.30-296.3627MDD single296.20-296.2637OCD300.300Other Anxiety State300.090Other isolated or simple phobia300.290Panic Disorder300.0122Phobia Unspecified300.200PTSD309.812Social Phobia300.230307.40-307.492Adj. React. w/ Dep. SxDepression NOSDysthymiaGeneralized Anxiety DisorderSpecific Disorders of Sleep11

Diagnostic ClustersCluster1Disease Presentation311210 (34%)309.0-309.111 (0.02%)MDD, single296.20-296.2637 (0. 06%)MDD, recurrent296.30-296.3627 (0.04%)300.464 (0.10%)300.00210 (34%)Panic Disorder300.0122 (0.04%)GAD300.0231 (0.05%)PTSD309.812 (0.003%)12Adj. React. w/ Dep. SxSpecific DepressionDysthymia3Nonspecific AnxietyAnxiety Unspecified4CountNonspecific DepressionDepression NOS2ICD-9 CodeSpecific Anxiety

Group123456789101112Diagnosis PresentationDepression unchangedAnxiety unchangedNonspecific Depression - Specific DepressionNonspecific Depression - Specific AnxietyNonspecific Depression - Nonspecific AnxietySpecific Depression - Nonspecific DepressionSpecific Depression - Nonspecific AnxietyNonspecific Anxiety - Specific DepressionNonspecific Anxiety - Specific AnxietyNonspecific Anxiety - Nonspecific DepressionSpecific Anxiety - Nonspecific DepressionSpecific Anxiety - Nonspecific AnxietyCount229174Average Paid ClaimsInpatient OutpatientERPhysician Pharmacy 4,159 148.93 266.73 38.20 63.65 3,300 136.86 268.33 37.74 55.61Total 76.95 62.1140 3,054 162.56 262.99 36.33 64.53 73.1523 3,101 113.57 264.35 50.23 65.40 78.486 4,003 130.06 290.36 34.70 75.79 99.7037 5,380 146.45 263.92 37.97 75.82 95.2517 4,143 91.73 243.17 32.27 75.31 80.7733 3,318 148.10 239.84 42.52 52.00 68.5933 3,724 116.70 263.80 53.60 70.27 84.989 5,099 152.38 177.68 35.66 45.71 66.805 7,697 39.87 332.30 33.74 51.37 111.276 1,604 102.36 245.39 41.54 59.02 62.4013

Continuity Score Adapted from Gill & Mainous (1998)CS 1- (No. of Providers/[No. of Medical Claims 0.1])1- (1/[No. of Medical Claims 0.1]) Range: 0-1– 0 (each claim different provider)– 1 (each claim same provider)14

Next Steps Increase sample size Examine continuity of care and diagnosisissues related to– Cost– Utilization (i.e., LOS, ER visits, ambulatoryvisits) Develop predictive models and likelihoodratios15

Dysthymia 300.4 64 Depression NOS 311 210 Anxiety State Unspecified 300.00 210 Agoraphobia w/o panic 300.22 0 Agoraphobia w/ panic 300.21 1 Adj. React. w/ Dep. Sx 309.0-309.1 11 Adj. React. w/ mixed feactures 309.28 1 Adj. React. w/ Anx. Mood 309.24 0 Acute Reaction to Stress 308.00 0 D