Access to Care: An Insurance Card that Means Something

Getting to the Finish LineJuly 14, 2009

Amy Rosenthal, New England Alliance for Children’s HealthTom Vitaglione, North Carolina Action for Children

Joe Touschner, Center for Children and Families

Access to care

• System-wide challenge

• Evaluating Medicaid and CHIP: what is the appropriate comparison?

• Primary vs. specialty

Medicaid/CHIP Coverage and Access to Care

Source: Kaiser Commission on Medicaid and the Uninsured analysis of National Center for Health Statistics, CDC. 2007. Summary of Health Statistics for U.S. Children: NHIS, 2007. Note: Questions about dental care were analyzed for children age 2-17. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. An asterisk (*) means in the past 12 months.

1%4%

2% 3%

13%

28%

4%3% 3%2%

12%

6%3%

18%17%

32%

24%

13%

No Usual Souceof Care

PostponedSeeking CareDue to Cost*

Needed Care butDid Not Get itDue to Cost*

Last MD Contact>2 Years Ago

Unmet DentalNeed Due to

Cost*

Last Dental Visit>2 Years Ago

Employer/Other Private Medicaid/Other Public Uninsured

Recent studies: Mixed Results

• Ku 2009– After adjusting for health status and

sociodemographic factors, there were no significant differences between Medicaid children and the privately insured in emergency, outpatient, or inpatient hospital use; there was higher prescription drug use among Medicaid children.

• Hoilette, Clark, Gebremariam, & Davis 2009– Among the insured, publicly insured children had

twice the odds of reporting an unmet need compared with privately insured children.

Recent studies: Mixed Results

• Skinner & Mayer 2007 – Literature review focused on specialty care showed

that children with public coverage have better access to specialty care than uninsured children, but poorer access compared to privately insured children.

• Selden & Hudson 2006– Differences between public and private coverage are

reduced (and often reversed) when we control for other characteristics of children and their families.

Oral health care

• Less than 30% of children in Medicaid obtain any dental care in a year

• 25% receive preventive dental care

• Corresponding rates for privately insured children are about double

Oral health care

• Dentist participation in Medicaid is low

• Low provider payments are are only one reason:– 41 states increased payments

1999-2006, but only 25 increased utilization

– But no state increased utilization without increasing payment rates

Access to care in Medicaid and CHIP

• Measured nationally, access to preventive and primary care in Medicaid and CHIP is on par with access among children who have private insurance.

• Oral health and specialty care may have challenges

• How much does state experience vary?

Problem

•Chronic illness accounts for vast amounts of healthcare costs•Majority of chronic patients do not receive appropriate care•Primary care providers feel limited in their ability•Local public health, mental health, and community providers are not coordinated with PCPs

Problems as Goals

• Need to improve outcomes

• Need to control costs

Primary Strategies

• Provide a medical home

• Develop community networks capable of managing care

• Develop systems to improve the care of chronic illness

Community Care NC

• 14 networks with more than 3500 PCPs (1200 medical homes)

• Includes local health, mental health, hospitals and safety net clinics

• Each has P/T medical director, a clinical coordinator, a PharmD, and care managers

• PCPs receive $2.50 pm/pm• Netwrorks receive $3.00 pm/pm

Evidence-Based Guidelines

• Adopted by consensus• All networks: Asthma Diabetes Pharm Mgt. ED Utilization Mgt.

• Optional: Child Development ADD/ADHD Gastroenteritis Others (hi cost; hi utilization)

Results/Care

• Asthma 34% lower hospital admission rate 8% lower ED rate

• Diabetes 15% increase in quality measures

• Child Development Developmental Screening rate 15% (2000) 85% (2005)

Results/Money

• 2004 Cost $10.2 m Savings $225 m

• 2006 Savings $231m

For more information

Tricia Brookspab62@georgetown.edu202-365-9148

Our website:http://ccf.georgetown.edu/

Say Ahhh! Our child health policy blog:http://www.theccfblog.org/