Primary Care Continuity and Health Care Expenditures in

a Depressed Sample of Florida Medicaid Recipients

Andrea M. Lee, M.S.Robert G. Frank, Ph.D.Zoe N. Swaine, M.S.

Natalie C. Blevins, M.S.Heather Steingraber, B.S.

Continuity of Care• Definition:

– healthcare events experienced as coherent and connected

– consistent with the patient’s medical needs and personal context

• In primary care:

– relationship between a single provider and a patient

– extends beyond specific episodes of illness or disease

Continuity of Care

• Patients who maintain a continuous relationship with a primary care provider are – more satisfied with their care (Gulliford et al., 2007)

– more likely to take medications correctly (Becker et al., 1974)

– more likely to be diagnosed early for chronic diseases (Koopman et al., 2003)

Continuity of Care

• Lower health care utilization – Reduced likelihood of emergency

department utilization in children (Christakis et al., 2001; Brousseau et al., 2004)

– Reductions in hospitalizations, emergency department visits in the elderly (Weiss & Blustein, 1996; Wasson et al., 1984; Burge, Lawson, & Johnston, 2003)

• Lower health care expenditures

• No studies on psychological populations

Depression & primary care

• One of the most prevalent disorders in primary care (Ballenger et al., 1999)

• Depressed individuals tend to have (Simon

et al., 1995):

– lower overall physical functioning

– more disability days

– higher rates of health care utilization

Depression & Medicaid

• 13% of enrollees use Medicaid mental health benefits (Mark et al., 2003)

• Medicaid’s spending for mental health services accounted for over 50% of all public mental health expenditures in 2003 (kff.org)

• Projected to increase up to 2/3 by 2013 (kff.org)

Present study

• Association between continuity of care and health care expenditures in depressed Medicaid enrollees

• Higher continuity of care hypothesized to be associated with lower expenditures

• Florida Medicaid claims data

• Cross-sectional

Participants

• 8,680 participants

• Ages 18-65

• 78% female; 22% male

• 42% White, 14% Black, 38% other, 6% Hispanic

Measure of continuity of care

• Modified, Modified Continuity Index (MMCI)

• Continuous variable, ranging from 0 to 1 – 1 indicates high continuity of care

.1]) visitsof (1/[#-1

1]). visitsof [#Providers/ of (#1

MMCI

Distribution of continuity of care

0

10

20

30

40

50

60

Percentage of Sample

0.0 - 0.19 0.2 - 0.39 0.4 - 0.59 0.6 - 0.79 0.8 - 1.0

Continuity of Care Index Scores

Statistical analyses

• Logistic regression for expenditures with large proportion of zeroes – inpatient, outpatient, and emergency room expenditures

• Log-linear multiple regression– inpatient, outpatient, emergency room, pharmacy,

medical, and total expenditures

• Controlled for age, sex, race, number of medical comorbidities, and number of prescription drugs

Results• Higher continuity of care associated with:

– a lower likelihood of having any expenditures for:• Inpatient (odds ratio: 0.20, p < .01)

• Outpatient (odds ratio: 0.69, p < .01)

• Emergency room (odds ratio: 0.58, p < .01)

– lower expenditures for total, medical, inpatient, outpatient, emergency room expenditures (p < .01)

– higher pharmacy expenditures (p < .01)

Limitations

• Unable to differentiate between provider type and practice site in identifying primary care provider

• ICD-9 codes limited reliability – subject to error and only captures provider – identified depression (not undetected or undiagnosed depression)

Conclusions

• Improving continuity of care in depressed Medicaid recipients may impact overall health care spending

• Pharmacy expenditures were higher with higher continuity of care, which may be due to better medication management

Conclusions

• Relatively few enrollees with low continuity of care to target for policy change, but can have a measurable impact

0

10

20

30

40

50

60

Percentage of Sample

0.0 -0.19

0.2 -0.39

0.4 -0.59

0.6 -0.79

0.8 - 1.0

Continuity of Care Index Scores

Depression

• Acknowledgements:• Robert Frank• Natalie Blevins• Zoë Swaine• Eleni Dimoulas• Heather Steingraber• Jianyi Zhang• Allyson Hall