Oregon Health Research & Evaluation Collaborative

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Oregon Health Research & Evaluation Collaborative. Initial Evaluation Results Of the Impact of Oregon Health Plan Copay and Premium Changes Jeanene Smith MD, MPH Office for Oregon Health Policy and Research RWJF SCI Meeting - June 2004. What is OHREC ?. Vision: - PowerPoint PPT Presentation

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  • Oregon Health Research & Evaluation Collaborative Initial Evaluation Results Of the Impact of Oregon Health Plan Copay and Premium Changes

    Jeanene Smith MD, MPHOffice for Oregon Health Policy and ResearchRWJF SCI Meeting - June 2004

  • What is OHREC ?Vision: Providing the opportunity for collaborative effort among health services researchers focusing on the Oregon Health Plan.

    Mission: To investigate, evaluate and effectively disseminate health services information in the interest of informing health policy in Oregon.

  • Who is involved with OHREC ?Office for Oregon Health Policy and ResearchDept. of Human Services, including Medicaid (OMAP) and the Health Cluster (Public Health)Family Health Insurance Assistance ProgramHealth services researchers fromOregon Health & Science UniversityPortland State UniversityCenter for Outcomes Research/Providence Health SystemsCareOregon A Non-Profit Medicaid-only HMOOther outside health services researchers

  • What kind of research has OHREC been doing?Administrative Data review and analysisMedicaid Agency (OMAP) databasesMajor University Hospital Emergency Dept. discharge data.Prospective cohort survey of those enrolled in OHP at the time of the new changes; First wave was six months after changes, a second wave scheduled for Summer 2004

  • OHP 2 and Budget CutsNew 1115 and HIFA Waiver Oct 2002Two-tiered Benefit package OHP Plus & OHP StandardPremium and Copay changes to OHP StandardFederal match for premium subsidy program (FHIAP) Severe Budget Crisis leads to Major cutsTo OHP Standard March 2003Loss of outpatient Mental Health/Chemical dependency Treatment benefitsInitially cut Rx drugs, reinstated after 2 weeksLoss of Durable Medical and Non-emerg. Transp

  • Premium Changes to OHPPremium AmountsActual amounts per person about the same, with additional increments added to smooth increase:i.e. Increased for 11-50% FPL from $6 to $9, previously 0- 50% FPL had been $6No discount for couplesRange: $6-$20/month/per personChange in administrationNo waiver for zero income, homelessOne missed payment results in disenrollment (Previous could pay past due, then reapply)Six-month lock-out for non-payment

  • OHP Standard fee-for-service and managed care copaysInpatient Hospital$250 per admissionOutpatient Surgery $20 per surgeryEmergency Room$50 (waived if admitted)Physician services$5 per visitPreventive/Immuniz.ExemptLab and X-ray$3 per lab or x-rayAmbulance$50Home health care$5 per visitPhys. & Occu. therapy$5 per visit

  • Why the premium and copay policy changes?Increase revenue/decrease state costs to afford to expand coverage in the OHP2 waiver request (Originally aimed for 185% FPL, had to hold at 100% FPL)Encourage maintenance of coverage even when clients werent illTo make OHP Standard more like commercial as a transition step for enrollees

  • So what happened?Impacts on Access

    Impacts on Enrollment

    Impacts on Utilization

  • Impacts on AccessHigher unmet need for health care in those who have lost coverage60% report unmet need80% report unmet mental health needPersons with chronic illness who lost coverage were more likely to report unmet needWorry about cost was the primary reason for unmet health care needs

  • Impacts on EnrollmentEnrollment in OHP Standard declined by ~45% after OHP2 implementationPremium cost was the most common reported reason for loss of coverageMost (76%) who lose coverage remained uninsuredLow-income, single adults have been most susceptible to the premium administrative changes in OHP, with the zero income group most affected (58% decline)

  • Impacts on Enrollment

    New enrollments among the zero income group dropped sharply and have not returned to pre-waiver levels

    48% reported they would reapply if premiums were decreased by $3 a month

  • Impacts on Utilization

    Those who have lost coverage were nearly 3 times more likely to have no usual source of care

    Those who have lost coverage are more likely to skip filling a prescription due to cost (57% vs. 48% for those remaining on OHP)

  • Impacts on UtilizationDirect impacts on other parts of the health care safety net--4-5 times more likely to go to the Emergency Dept. for careThis is increased in the lowest income group, especially those with chronic diseases

  • Impacts on Utilization Change in type of coverage and type of visit at Oregons major teaching hospital:17% in visits to the OHSU ED by uninsured patientsLoss of employer sponsored insurance and loss of OHP contributed equally20% decrease in visits by OHP-covered patients at OHSU ED37% in mental health-related visits in OHSU ED200% in chemical dependency-related visits at OHSU ED.

  • Next steps for OregonLegislature Tries to Salvage OHP2 Reinstates Mental Health/Chem. Dependency benefits by August 2004Hospital and Managed Care tax to fund OHP StandardHowever:Budget cuts and a Ballot measure defeat for a temporary tax result in:OHP Standard Enrollment frozen as of July 1, 2004Reducing OHP Standard to only 25,000 by end of 2004

  • So what now for Oregon?Spry vs T. Thompson/HHS and Oregon Dept of Human Services lawsuitUS District court ruling prohibits copays on OHP Standard effective June 19, 2004Premiums arent considered cost-sharing and are allowedOHP Plus still has Medicaid nominal copays for some enrollees

  • OHREC Principal Investigators Economic Impact Studies (Premiums): John McConnell, Ph.D Oregon Health & Science Univ. (OHSU)Neil Wallace, Ph.D - Portland State UniversityEmergency Dept. Impact study: Robert Lowe MD, MPH - OHSUJohn McConnell, Ph.D - OHSUProspective Cohort Study: Matt Carlson, Ph.D Portland State UniversityBill Wright, Ph.D Centers for Outcomes Research and Education/Providence Health System

  • We hope to learn more -Planned OHREC research effortsMore in-depth look at cost shifts within OHP with the loss of some benefits, i.e. spending more on hospital since outpatient mental health cut?Statewide look at Emergency Departments use since the changes to OHPProspective cohort survey of those once enrolled in OHP Plus and OHP Standard over the next year or so

  • For more informationOffice for Oregon Health Policy and ResearchWebsite: www.ohpr.state.or.us - OHREC subsectionJeanene Smith 503-378-2422 ext 420 jeanene.smith@state.or.usTina Edlund or Lisa Krois at 503-731-3005 ext 354

    OHP Plus: categorically eligible, includes also pregnant women and all children (Medicaid and SCHIPAccess Impact:Cohort Those who lost coverage had higher unmet needs for medical care, urgent care, mental health care and prescription medications: 60% of those who lost coverage reporting unmet need vs 30% of those who remained covered Persons with chronic illness who lost coverage were more likely to report unmet health care needs, with 66% reporting unmet need vs. 32% of those that remained covered. Cost was the primary reason for unmet health care needs, with 725 reporting cost as the primary reason for unmet health needs.(RMC study: A series of federally funded studies of the impact of managed care on substance abuse treatment for the Medicaid population, 1996-present.) Access rates to substance abuse Tx more than doubled wit the onset of OHP, from 4% of the Medicaid population in 1993 to over 8% in 1998 Significant declines in alcohol, drug, and psychiatric problems 6 months after treatment entry, with improvement persisting through 12 months. These outcomes as good or better than a Washington state non-managed care comparison sample. Based on these studies, with the cuts to OHP Standard, 60% of OHP Adults (8,000 to 9,000 adults aged 18-64) statewide are no longer covered for these servicesFor certain types of treatment, methadone and detox, the percentages are even higherEnrollment Impact:Cohort Most who lost coverage remained uninsured (72% uninsured) The cost of premiums was the most common reason for loss of coverage (33.9%) The lowest income group was disproportionately affected by cost sharing (57% of those at 0-10% of FPL) Almost half would reapply if premiums were decreased (48% reported that they would reapply if premiums were reduced by $3.00)Economic Analysis Low-income, single individuals have been most susceptible to the premium administrative changes in OHP The group most significantly affected was beneficiaries with no reported income. Among these zero income individuals, enrollment fell from approximately 42,000 individuals in 2002 to approximately 17,500 in October 2003, a 58% drop.Policy Implications:More leniency in the payment of late premiums and the availability of premium waivers for zero-income clients are likely to improve enrollment among the poorest individuals. Some losses in revenue from such policies could potentially be regained through increased premiums for groups in higher income brackets.Consider Graph from Brief

    Enrollment Impact:Cohort Most who lost coverage remained uninsured (72% uninsured) The cost of premiums was the most common reason for loss of coverage (33.9%) The lowest income group was disproportionately affected by cost sharing (57% of those at 0-10% of FPL) Almost half would reapply if premiums were decreased (48% reported that they would reapply if premiums were reduced by $3.00)Economic Analysis Low-income, single individuals have been most susceptible to the premium administrative changes in OHP The group most significantly affected was beneficiaries with no reported income. Among these zero income individuals, enrollment fell from approximately 42,000 individuals in 2002 to approximately 17,500 in October 2003, a 58% drop.Policy Implications:More leniency in the payment of late premiums and the availability of premium waivers for zero-income clients are likely to improve enrollment among the poorest individuals. Some losses in revenue from such policies could potentially be regained through increased premiums for groups in higher income brackets.Consider Graph from Brief

    Utilization Impact:Cohort Those who lost coverage were nearly 3 times more likely to have no usual source of care and were 4-5 times more likely to report the Emergency Dept as usual source of care Loss of coverage increased the likelihood of an ED visit among individuals in the lowest income group especially those with chronic conditions.

    Utilization Impact:Cohort Those who lost coverage were nearly 3 times more likely to have no usual source of care and were 4-5 times more likely to report the Emergency Dept as usual source of care Loss of coverage increased the likelihood of an ED visit among individuals in the lowest income group especially those with chronic conditions.

    ED study: (Preliminary, first six months are analyzing further, results due by end of 2004 17 % increase in ED visits by patients without insurance 20% reduction in ED visits by OHP patients 200 % increase in ED in chem. Depend ED visits by patients without insurance 37% increase in other mental health ED visits by patients without insurance No sig. Changes in the proportions of ED visits classified as primary-care treatable, potential avoidable, or unavoidable emergency among either OHP beneficiaries or the uninsured.Policy Implic.:Increased ED use by the uninsured, esp for behavioral health problems, points to an urgent need to provide access to care for this population.

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