Sonoma County Medical Services Program (2008)

October 20, 2008

Prepared for Indigent Health Group

Marion Deeds, Director of Economic Assistance, Human Services Department

Lynn Scuri, Manager of Planning and Population Health, Department of Health Services

Kim Seamans, Section Manager of Medi-Cal Eligibility, Human Services Department

Prepared by Division of Planning, Research and Evaluation

Marla Stuart, Director

Tara Smith, Planner Analyst

Graphics Assistance provided by the Division of Administration

Lee Lewis, Systems and Program Analyst

Page

Summary ......................................................................................................................................... 1

Description of CMSP ...................................................................................................................... 2

Purpose of Study ............................................................................................................................. 2

Methodology ................................................................................................................................... 3

Description of CMSP Recipients .................................................................................................... 4

Tables and Graphs

1. Number of Enrollees by Month........................................................................................... 4

2. Aid Codes by Month ........................................................................................................... 5

3. CMSP Patterns of Enrollments ........................................................................................... 6

4. CMSP Recipient Demographics ....................................................................................... 10

5. Months on CMSP by Demographic .................................................................................. 11

Conclusions ................................................................................................................................... 12

Recommendations ......................................................................................................................... 12

Endnotes ........................................................................................................................................ 13

Report on Sonoma County CMSP, M. Stuart, HSD PRE, October 20, 2008, page 1

The number of Sonoma County CMSP enrollees is increasing (page 4)

� 11,977 different Sonoma County residents received CMSP in the 20 months beginning December 2006 and continuing through July, 2008. This represents 4% of the adult population age 19-65. On average, 4,228 residents received CMSP each month January through July, 2008. Comparatively, approximately 54,000 Sonoma County residents received Medi-Cal in July, 2008.

� The number of residents receiving CMSP each month increased from 3,431 in December 2006 to 4,440 in July 2008 (a 29% increase). From 1999-2006, the Sonoma County population age 19-59 increased 4.33%.

� In 2008 (January through July), an average of 468 individuals each month are new CMSP enrollees (11% of all enrollees in the month). These individuals did not receive CMSP in the previous 12 months.

� NATIONAL COMPARISON: This growth in the Sonoma County CMSP caseload reflects the

national trend of increasing numbers of individuals without health insurance. 18% of the US population does not have health insurance (46.5 million people). 12.9% of the US population did

not have health insurance in 1987.

37% of Sonoma County CMSP recipients are “churning” (page 7)

� 60% of CMSP recipients have predictable acute enrollment patterns

� 3% of CMSP recipients receive CMSP continually.

� 37% of CMSP recipients move on and off CMSP. This represents over 1,600 Sonoma County residents each month who do not have reliable and consistent medical coverage.

� NATIONAL COMPARISON: Senior citizens, Latino’s, and low-income individuals are most likely to lack medical insurance for extended periods of time.2

The most common Sonoma County CMSP recipient is a white male younger than 60 (page 11)

� However, when compared to the Sonoma County population, Sonoma County CMSP recipients are disproportionately Hispanic males under age 29.

� NATIONAL COMPARISON: People of color are less likely to have health insurance.1 80% of

uninsured people in the United States live in families with one or more full-time workers. 9

Impact

HEALTH IMPACT: Uninsured Americans have higher rates of mortality, poor health outcomes, are less likely to receive preventive care, and are more likely to require inpatient care.3 The number of excess

deaths in 2000 among uninsured adults was estimated at 18,000.9

ECONOMIC IMPACT: People without health insurance are often unable to pay for their medical care.

The cost of uncompensated medical care was $41 billion in 2004. Federal, state and local governments reimburse health care providers for 85% of these costs.9

Recommendations (page 13)

CMSP regulations should promote continued medical coverage for eligible individuals to improve the health of Sonoma County and to reduce uncompensated medical care costs.

Report on Sonoma County CMSP, M. Stuart, HSD PRE, May 30, 2008, page 2

In California, Medi-Cal (Medicaid) provides a array of programs to meet the health care of most low-income individuals. Medi-Cal coverage is available for all children through age 20 and for those 65 and older. In some cases, the parents of a child are also eligible for Medi-Cal. Other Medi-Cal programs provide coverage for adults in short-term nursing facilities, as well as those with specific medical needs such as dialysis, tuberculosis treatment, total intravenous nutrition, or breast or cervical cancer treatments. Established by California law in January 1983, the County Medical Services Program (CMSP) provides medical and dental care for medically indigent adults between the ages of 21 through 64 who are not eligible for Medi-Cal, who have an income at or below 200% of the federal poverty level of $10,4004 and who have less than $2,000 in liquid assets. Applicants are approved for one of five aid categories. Most applicants are eligible for standard CMSP coverage which is approved for six months and which covers all approved procedures or medications. Some applicants, based on their income, must pay a share of cost and are only approved for three months. “Share of cost” is the amount that these applicants must pay or obligate before CMSP coverage will pay the medical provider. This is similar to a co-pay in private insurance. Other applicants are approved for restricted benefits. These are emergency services only and are approved for two months. Restricted benefits are provided to residents who lack documentation of satisfactory immigration status or citizenship. Finally, CMSP can also be approved for an individual claiming disability while they complete the Medi-Cal disability application and for individuals receiving Long Term Care to supplement the Medi-Cal coverage.

CMSP is administered by the CMSP Governing Board comprised of county supervisors, administrators, health officials, and welfare directors. Benefits are administered by Anthem Blue Cross for medical, dental and vision and by Med-Impact for prescriptions. Thirty-four (34) small, rural counties currently participate in CMSP including Sonoma which is the second largest county with CMSP. These counties have a combined monthly caseload of 40,000 people and an annual budget of approximately $238 million derived from motor vehicle license fees, sales tax and county general revenue.5

In September 2007, the Sonoma County Human Services Department (HSD) and the Sonoma County Health Services Department (DHS) convened the Indigent Health Group. The overall purpose of the group is to gain better knowledge of the medically indigent in Sonoma County and to develop recommendations to reduce their obstacles to care. This study was designed to assist the Indigent Health Group’s activities by providing a better understanding of the Sonoma County CMSP population. Specifically, this study explored the following questions.

1. What are the characteristics of Sonoma County CMSP recipients? 2. What is the pattern of enrollment for Sonoma County CMSP recipients?

It is anticipated that this study will be useful to the following groups:

� HSD and DHS managers and executives for policy making. � HSD and DHS staff for practice guidance. � Sonoma County Administrator’s Office for information and policy development. � CMSP Governing Board for policy development.


Information about CMSP recipients was extracted from the California State Business Objects MEDS Database. A query was run for each of 20 months (December, 2006 through July, 2008). The following information was extracted for each recipient.

� Name � Case number � Date of birth � Gender � Ethnicity

� Primary language � Month of eligibility � Aid code � Amount of share of cost (if any)

Other information was of interest and attempts were made to include this information. However, this information was not, ultimately, available in a format that was reliable.

� Date and source all applications � Date of all approvals � Date of all denials � Date of all discontinuations

� General Assistance (GA) status � Zip code � Share of cost met � Earned and unearned income

All information was compiled in Excel, imported into the Statistical Package for the Social Sciences (SPSS), and restructured to maximize analysis options. The following analyses were employed:

� Descriptive statistics describe information with numbers. Frequency, percent and mean are reported here.

� Inferential statistics quantify the level of uncertainty when using sample information to describe a whole population. This report uses independent sample t-test (t) to examine the difference between two means and chi-square (X2) to examine the difference between two percents. With both statistics, a p-value of less than .03 indicates that the difference identified in the sample is most likely evident in the whole population.

� A cohort of CMSP recipients was selected to examine CMSP enrollment patterns over time. To conduct this longitudinal analysis, a subset of one month of CMSP recipients was selected. 563 individuals received CMSP benefits in January, 2007 but not in December, 2006. These individuals were selected as the January 2007 Cohort because they appeared to be starting a new enrollment period and because information for 19 consecutive months was available for them. Observing these individuals for 19 consecutive months (January, 2007 through July, 2008) provides information about trends in CMSP enrollment and differences between demographic groups.

The following pages describe Sonoma County CMSP recipients.


The number of Sonoma County CMSP enrollees is increasing ______________________________

TABLE 1: Number of Enrollees by Month

Year

Month

# CMSP

Enrollees

# New

Enrollees*

% New

Enrollees

# with

SOC+

% with

SOC

2006 Dec 3,431 508 15%

January 3,517 526 15%

February 3,449 489 14%

March 3,541 515 15%

April 3,591 528 15%

May 3,687 564 15%

June 3,722 564 15%

July 3,767 549 15%

August 3,881 576 15%

September 3,807 551 14%

October 3,877 550 14%

November 3,885 532 14%

December 3,862 549 14%

2007

2007 Average 3,716 541 15%

January 3,961 552 14% 505 13%

February 4,066 433 11% 482 12%

March 4,173 415 10% 511 12%

April 4,206 548 13% 544 13%

May 4,300 425 10% 576 13%

June 4,449 474 11% 602 14%

July 4,440 426 10% 609 14%

2008

2008 YTD Average 4,228 468 11% 547 13% * New enrollees are those in the month who were not enrolled in CMSP in the previous 12 months. + Share of Cost (SOC) is an amount that must be obligated by the enrollee to the healthcare provider before

CMSP coverage will pay the provider. This is similar to a co-pay in private insurance.

Sonoma County Human Services Department

Number of CMSP Enrollees

4,440

3,431

0

1,000

2,000

3,000

4,000

5,000

Dec 06

Jan 07

Feb 07

Mar 07

Apr 07

May 07

Jun 07

Jul 07

Aug 07

Sep 07

Oct 07

Nov 07

Dec 07

Jan 08

Feb 08

Mar 08

Apr 08

May 08

Jun 08

Jul 08

Number of CMSP Enrollees


TABLE 2: Aid Codes by Month (see definition for each aid code on following page)

84

No Share of Cost

85

Share of Cost

50

Restricted

(SOC)

50

Restricted

(no SOC)

88

Disability

Pending

(no SOC)6

89

Disability

Pending

(SOC)6

8F

CMSP

Companion

(LTC) Month # % # % # % # % # % # % # %

Dec 06 2,821 82.2 447 13.0 84 2.4 60 1.7 14 0.4 0 0.0 5 0.1

Jan 07 2,888 82.1 462 13.1 87 2.5 62 1.8 12 0.3 0 0.0 6 0.2

Feb 07 2,852 82.7 437 12.7 94 2.7 49 1.4 10 0.3 0 0.0 7 0.2

Mar 07 2,922 82.5 458 12.9 91 2.6 54 1.5 9 0.3 1 0.0 6 0.2

Apr 07 2,954 82.3 465 13.0 98 2.7 60 1.7 7 0.2 2 0.1 5 0.1

May 07 3,009 81.6 493 13.4 101 2.7 67 1.8 8 0.2 2 0.1 7 0.2

Jun 07 3,043 81.8 502 13.5 101 2.7 57 1.5 8 0.2 4 0.1 7 0.2

Jul 07 3,089 82.0 486 12.9 99 2.6 55 1.5 25 0.7 6 0.2 7 0.2

Aug 07 3,124 80.5 499 12.9 101 2.6 62 1.6 75 1.9 13 0.3 7 0.2

Sep 07 3,040 79.9 472 12.4 94 2.5 61 1.6 117 3.1 18 0.5 5 0.1

Oct 07 3,074 79.3 478 12.3 96 2.5 51 1.3 154 4.0 21 0.5 3 0.1

Nov 07 3,070 79.0 459 11.8 92 2.4 44 1.1 189 4.9 29 0.8 2 0.1

Dec 07 3,014 78.0 469 12.1 52 1.4 72 1.9 224 5.8 28 0.7 3 0.1

07 Average 3,007 81.0 473 12.8 92 2.5 58 1.6 70 1.8 10 0.3 5 0.2

Jan 08 3,146 79.4 413 10.4 66 1.8 78 3.8 227 5.7 26 0.3 8 0.1

Feb 08 3,259 80.2 400 9.8 62 1.5 81 2.0 239 5.8 22 0.1 3 0.0

Mar 08 3,329 79.8 435 10.4 56 1.3 65 1.6 264 6.3 22 0.5 2 0.0

Apr 08 3,351 79.7 471 11.2 66 1.6 52 1.2 244 5.8 21 0.5 1 0.0

May 08 3,405 79.2 503 11.7 61 1.4 54 1.3 258 6.0 19 0.4 0 0.0

Jun 08 3,510 78.9 518 11.6 73 1.6 64 1.4 264 5.9 20 0.4 0 0.0

Jul 08 3,449 77.7 503 11.3 85 1.5 77 1.7 296 6.7 29 0.7 1 0.0

08 YTD Average 3,350 79.3 463 10.9 67 1.5 67 1.9 256 6.0 23 0.4 2 0.0


Aid Code Definitions

84 No share of cost (No SOC) – Individual does not incur any portion of the medical expense, as long as it is an approved procedure or medication.

85 Share of Cost (SOC) - Individual must first pay or be obligated to pay a monthly amount before CMSP begins. The share of cost amount is based on a person’s net nonexempt income minus their maintenance need.

50 Restricted – Individual is entitled to emergency services only. Restricted benefits are provided to residents who lack documentation of satisfactory immigration status or citizenship.

88 or 89 Disability Pending – An individual claiming disability is entitled to CMSP while they complete the Medi-Cal disability application, if otherwise eligible.

8F CMSP Companion (LTC) -Individual typically has both CMSP and Medi-Cal. The CMSP pays for any expense not related to Long Term Care; Medi-Cal covers the Long Term Care expense. (Long-Term Care is inpatient medical care which lasts for more than the month of admission and is expected to last for at least one full calendar month after the month of admission.)


37% of Sonoma County CMSP recipients are “churning”__________________________________

CMSP eligibility is approved for two months (restricted), three months (share of cost) or six months (no share of cost). Patterns of enrollment were examined for the 563 individuals in the January 2007 cohort (recipients who received CMSP benefits in January 2007 but not in December 2006). Enrollment activity was tracked for 19 months for these recipients (January 2007 through July 2008). This cohort represents a sample of all CMSP recipients.

� The most common CMSP enrollment longevity is six months (see pattern 1 in Table 3.1). Approximately 25% of CMSP recipients experience this single enrollment episode.

� Approximately 60% of CMSP recipients appear to receive benefits for an acute episode of care (see patterns 1-8 in Table 3.1).

� Approximately 3% of CMSP recipients appear to receive benefits continuously (see pattern 9 in Table 3.1).

� The remaining 37% of CMSP recipients appear to be “churning.” They move on and off CMSP in unpredictable patterns of enrollment. These enrollment patterns are illustrated in the Table 3.2.

TABLE 3.1: CMSP Patterns of Enrollment (cohort) � = enrolled �= not enrolled

2007 2008

# %

Cum

% J F M A M J J A S O N D J F M A M J J

# of

Months

1 142 25.22 25.22 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 6

2 62 11.01 36.23 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3

3 50 8.88 45.12 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2

4 26 4.62 49.73 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 12

5 21 3.73 53.46 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1

6 12 2.13 55.60 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4

7 12 2.13 57.73 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5

8 8 1.42 59.15 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 9

9 19 3.37 62.52 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 19

TABLE 3.2: CMSP Patterns of Enrollment (cohort) � = enrolled �= not enrolled

2007 2008

# %

Cum


# of

Months

10 19 3.37 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 18

11 7 1.24 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 1 18

12 5 0.89 68.03 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 18

13 5 0.89 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 17

14 3 0.53 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 1 1 17

15 2 0.36 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17

16 2 0.36 1 1 1 1 1 1 0 1 1 1 1 1 1 0 1 1 1 1 1 17

17 1 0.18 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 17

18 1 0.18 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 17

19 1 0.18 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 0 17

20 1 0.18 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 17

21 1 0.18 71.05 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 17


TABLE 3.2 (continued): CMSP Patterns of Enrollment (cohort) � = enrolled �= not enrolled

2007 2008

# %

Cum


# of

Months

22 3 0.53 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 1 16

23 3 0.53 1 1 1 1 1 1 0 1 1 1 1 1 1 0 0 1 1 1 1 16

24 3 0.53 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 16

25 2 0.36 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 1 1 1 16

26 1 0.18 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 16

27 1 0.18 73.36 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 16

28 4 0.71 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 1 15

29 3 0.53 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 1 1 1 15

30 2 0.36 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 15

31 1 0.18 1 1 1 0 0 0 1 1 1 0 1 1 1 1 1 1 1 1 1 15

32 1 0.18 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 1 1 1 1 15

33 1 0.18 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 0 0 0 15

34 1 0.18 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 1 1 1 0 15

35 1 0.18 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 1 1 1 15

36 1 0.18 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 1 1 1 0 15

37 1 0.18 76.20 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 0 0 15

38 3 0.53 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 1 1 1 1 14

39 2 0.36 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 0 1 1 14

40 1 0.18 1 1 1 0 0 1 1 1 0 0 0 1 1 1 1 1 1 1 1 14

41 1 0.18 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 1 0 0 14

42 1 0.18 1 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 1 1 14

43 1 0.18 1 1 1 1 1 1 0 1 1 1 1 1 1 0 0 0 0 1 1 14

44 1 0.18 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 14

45 1 0.18 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 14

46 1 0.18 78.33 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 14

47 3 0.53 1 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 1 1 1 13

48 2 0.36 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 1 13

49 1 0.18 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 1 13

50 1 0.18 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 0 0 0 13

51 1 0.18 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 13

52 1 0.18 1 1 1 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 1 13

53 1 0.18 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 1 1 13

54 1 0.18 80.28 1 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 13

55 5 0.89 1 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 1 12

56 5 0.89 1 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 1 1 0 12

57 3 0.53 1 1 1 1 1 1 0 1 1 1 1 1 1 0 0 0 0 0 0 12

58 2 0.36 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 1 1 0 0 12

59 2 0.36 1 1 1 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 0 12

60 2 0.36 1 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 0 0 0 12

61 1 0.18 1 0 0 0 0 0 0 1 1 1 1 1 1 1 0 1 1 1 1 12

62 1 0.18 1 1 1 0 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 12

63 1 0.18 84.19 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 0 0 0 12



2007 2008

# %

Cum


# of

Months

64 5 0.89 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 11

65 3 0.53 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 11

66 2 0.36 1 1 1 1 1 1 0 1 1 1 1 1 0 0 0 0 0 0 0 11

67 2 0.36 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 11

68 1 0.18 1 1 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 0 0 11

69 1 0.18 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 11

70 1 0.18 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 0 1 1 11

71 1 0.18 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 1 0 11

72 1 0.18 1 1 1 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 0 11

73 1 0.18 1 1 1 1 1 1 0 0 0 0 1 1 1 0 0 0 0 1 1 11

74 1 0.18 87.57 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 0 0 0 0 11

75 2 0.36 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 10

76 2 0.36 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 10

77 1 0.18 1 1 1 1 0 1 1 1 1 1 1 0 0 0 0 0 0 0 0 10

78 1 0.18 1 1 1 1 1 1 0 0 0 0 0 1 1 1 1 0 0 0 0 10

79 1 0.18 88.81 1 1 1 1 1 1 0 1 1 1 1 0 0 0 0 0 0 0 0 10

80 4 0.71 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 9

81 2 0.36 1 1 1 1 1 1 0 0 0 0 0 1 1 1 0 0 0 0 0 9

82 2 0.36 1 1 1 1 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 9

83 1 0.18 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 9

84 1 0.18 1 1 1 0 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 9

85 1 0.18 1 1 1 0 0 0 0 0 0 0 1 1 1 1 1 1 0 0 0 9

86 1 0.18 1 1 1 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 9

87 1 0.18 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 9

88 1 0.18 1 1 1 1 1 0 0 0 0 0 0 1 1 1 1 0 0 0 0 9

89 1 0.18 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 9

90 1 0.18 1 1 1 1 1 1 0 0 0 0 0 0 0 0 1 1 1 0 0 9

91 1 0.18 1 1 1 1 1 1 0 0 0 0 0 0 1 1 1 0 0 0 0 9

92 1 0.18 92.01 1 1 1 1 1 1 1 1 0 0 0 1 0 0 0 0 0 0 0 9

93 5 0.89 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 8

94 5 0.89 1 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 8

95 1 0.18 93.96 1 1 0 0 0 0 1 1 1 1 1 1 0 0 0 0 0 0 0 8

96 7 1.24 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 7

97 2 0.36 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 7

98 1 0.18 1 1 1 0 0 0 1 1 1 1 0 0 0 0 0 0 0 0 0 7

99 1 0.18 1 1 1 1 0 0 0 0 0 0 0 1 1 1 0 0 0 0 0 7

100 1 0.18 96.09 1 1 1 1 1 1 0 0 0 0 1 0 0 0 0 0 0 0 0 7

101 4 0.71 1 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 6

102 2 0.36 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 6

103 2 0.36 1 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 6

104 1 0.18 1 1 0 0 0 0 0 0 0 1 1 0 0 0 0 1 1 0 0 6

105 1 0.18 97.87 1 1 0 0 1 1 0 0 0 1 1 0 0 0 0 0 0 0 0 6



2007 2008

# %

Cum


# of

Months

106 1 0.18 1 1 0 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 5

107 1 0.18 1 1 0 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 5

108 1 0.18 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 5

109 1 0.18 1 1 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 5

110 1 0.18 98.76 1 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 5

111 2 0.36 1 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4

112 1 0.18 1 1 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 4

113 1 0.18 1 1 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 4

114 1 0.18 99.64 1 1 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 4

115 1 0.18 99.82 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3

116 1 0.18 100.00 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2


The most common Sonoma County CMSP recipient is a white male younger than 60 ___________

TABLE 4: CMSP Recipients Demographics (Compared to Sonoma County)

CMSP Recipients

Dec 06 – Mar 08 Ages 21-65 n=11,977

2006 Sonoma County

2006 Ages 21-65 n=286,1907 Statistic p

Number Percent Number Percent

Gender Female 4,879 40.8% 141,730 50% X2=404 .00 n=11,958 Male 7,079 59.2% 144,460 50%

Ethnicity White 7,708 66.1% 205,249 77.5% X2=2,000 .00 n=11,654 Hispanic or Latino 2,615 22.4% 42,865 16.2%

African American 551 4.7% 3,860 1.5%

Asian 340 2.9% 8,892 3.4%

Native American 307 2.6% 3,258 1.2%

Pacific Islander 133 1.1% 566 0.2%

Other or No Data 323 21,500

Age 21-29 140 24.9% 56,132 19.6% X2=35.57 .00 n=563 30-39 105 18.7% 73,692 25.7% (cohort only) 40-49 146 25.9% 80,113 28.0%

50-59 115 20.4% 59,554 20.8%

60-65 57 10.1% 16,699 5.8%


CMSP Recipients Compared to Sonoma County Population(All enrollees Jan 2007-Jul 2008: n=11,977. Cohort: n=563.)

0%

10%

20%

30%

40%

50%

60%

70%

80%

Female

Male

White

Hispanic or Latino

African American

Asian

Native American

Pacific Islander

Other

21-29

30-39

40-49

50-59

60-65

Percent of Population

CMSP Recipients

Sonoma County

Age

n=(563)

Ethnicity

(n=11,654)

Gender

(n=11,958)

The most common CMSP recipient is a White male under age 60.

However, CMSP recipients are more likely than the Sonoma County population to be Hispanic, or male, or under age 29.


TABLE 5: Months on CMSP by Demographic (cohort, n=563, from January 2007 through July 2008)

Demographic Sub-Groups

Average Number of Months

in 19 months

(Jan 07 – Jul 08) with CMSP Enrollment Statistic p

Age 21-29 (n=140)

30-39 (n=105)

40-49 (n=146)

50-59 (n=115)

60-65 (n=57)

4.42

7.61

8.77

10.43

7.49

F=10.92 .00

Ethnicity White (n=339)

Hispanic or Latino (n=140)

African American (n=27)

Asian (n=20)

Native American (n=14)

Pacific Islander (n=11)

8.79

5.69

9.48

8.80

12.21

10.73

F=10.55 .00

Primary

Language

Spanish (n=106)

English (n=447)

Other (n=10)

5.13

8.83

11.50

F=25.15 .00

Gender Female (n=238)

Male (n=325)

8.45

7.98

t=1.01 .31


Average Number of Months with CMSP EnrollmentJanuary 2007 through July 2008

Cohort n = 563

0

2

4

6

8

10

12

14

21-29

30-39

40-49

50-59

60-65

White

Hispanic or Latino

African American

Asian

Native American

Pacific Islander

Spanish

English

Other

Female

Male

Average Months on CMSP

Age

Ethnicity

Language

Gender

Average = 8.18

months


1. With certification periods of two months (restricted), three months (share of cost), and six months (no share

of cost) it appears difficult for recipients to maintain health coverage (based on patterns of enrollment), and presumably, to access preventive and chronic health care. CMSP appears to be utilized primarily by recipients as coverage for acute or emergency health needs.

2. A very small percent of Sonoma County CMSP enrollees (12%) have a share of cost. The three-month

certification period for recipients with a share of cost is not justified for such a small group. Increasing the share of cost certification period to six months would ease the burden for recipients, reduce workload (each CMSP re-application requires 59 minutes10), and presumably improve health outcomes.

3. Within the Sonoma County medically indigent population, Hispanic, Spanish-speaking individuals have

lower rates of coverage and coverage for shorter amounts of time. This may reflect the use of CMSP by undocumented residents of Sonoma County who are eligible for restricted CMSP.

1. Collect and report this information on an ongoing, monthly basis (from MEDS) for use in policy development

and practice management by the Human Services Department and the Department of Health Services. 2. Add information about utilization of medical care to more fully understand the types of health care received

by CMSP recipients and the impact of intermittent health coverage on health outcomes. 3. Conduct additional study to determine the impact of CMSP enrollment patterns on health outcomes in

Sonoma County. 4. Continue to explore, and promote (as appropriate), a longer CMSP certification period to promote improved

health. This may include testing, and if successful advocating for, self-recertification at six months and full recertification at 12 months.

5. Explore methods to reduce churning (recipients going on and off CMSP). For instance, explore the feasibility

of sending each recipient a reminder notice that their certification period will be ending in 15 (or 30) days and include instructions about how to renew the certification. Or, develop innovative strategies for utilizing the Certified Application Assisters (CAA) to assist with re-certification.


1 DeNaval-Walt, C., Proctor, B., and Smith, J. (2007). Income, Poverty and Health Insurance Coveragein the

United States: 2006 (U.S. Census Bureau, Current Population Reports). Washington, DC, U.S. Government Printing Office, 60-233.

2 Rhoades, J., Cohen, S. (2007, August). The Long-Term Uninsured in America, 2002-2005: Estimates for the

U.S. Population Under Age 65. Rockville, MD, Agency for Healthcare Research and Quality. 3 Lucey, P. (2001, January). An Access Program for Medially Indigent Individuals. Nursing Economics, 19.1,

12. 4 2008 HHS Poverty Guidelines (2008, January 23). Federal Register, 783:15, 3971-3972. 5 History of CMSP (2005). www.cmspcounties.org. 6 According to Clo Hair, Economic Assistance Program Specialist, an effort has been made to more correctly

use the “Disability Pending” aid code. First, a clerical worker was assigned to specifically work on referrals from the CMSP Governing Board. Second, reminders were made to staff at monthly technical meetings. And, third, programming was corrected in CalWIN to facilitate the use of the “Disability Pending” aid code.

7 American Fact Finder (2006). US. Census Bureau. www.factfinder.census.gov. 8 The disposition of the 21 individuals with only 1 month of CMSP eligibility is as follows:

Disposition # of Recipients % of Recipients

Converted to Medi-Cal 14 56%

Over Income 5 20%

Administrative Error 4 16%

Client Request 2 8%

9 The Uninsured: A Primer (2007, October). The Henry J. Kaiser Family Foundation. 10 Himes, D. et al (2007, June). County Medical Services Program Work Measurement Study Initiative. Robert

E. Nolan Company, Inc.

Documents

Sonoma County Medical Services Program (2008)