Cunningham APPAM slides 11 09 15

Cunningham APPAM slides 11 09 15

• 1.
  The Effects ofEarly Medicaid Expansions in California on Inpatient Utilization of Safety Net Hospitals Peter Cunningham, Ph.D. Department of Health Behavior and Policy Virginia Commonwealth University
• 2.
  Acknowledgements Co-authors: Lindsay M. Sabik,Ph.D., Ali Bonakdar, PharmD, M.P.H., Virginia Commonwealth University Funded by the Robert Wood Johnson Foundation, State Health Access Reform Evaluation initiative
• 3.
  What is theEffect of Expanding Medicaid on Inpatient Utilization at Safety Net Hospitals? Improves payer mix -- Medicaid admissions increase, while uninsured admissions decrease Reduces the proportion of inpatient admissions that are “preventable” Possible “cherry-picking” of healthier Medicaid patients by non-safety net hospitals
• 4.
  California’s “Bridge toReform” Expanded coverage through the Low Income Health Program (LIHP) beginning in July, 2011 Eligibility for adults up to 200% of poverty, but eligibility varied across counties 700,000 persons enrolled in LIHP by end of 2013
• 5.
  Importance for SafetyNet Hospitals Pending reductions in Medicaid DSH assume increase in insured patients, fewer uninsured patients that require subsidized care Newly insured patients will have more options to get care at non-safety net hospitals Payment and delivery system reforms changing patterns of care utilization at hospitals
• 6.
  Research strategy Examine changesin inpatient utilization in California between 2010 and 2013 Compare changes to three neighboring states that did not expand coverage (AZ, NV, WA) Compare changes at safety net hospitals to changes at non-safety net hospitals
• 7.
  Data Healthcare Cost andUtilization Project (HCUP) State Inpatient Databases Inpatient Data from California Office of Statewide Health Planning and Development American Hospital Association Annual Survey
• 8.
  Key Methods Safety nethospitals defined as those with either “high market share” of uninsured patients or “high burden” of uninsured. Include only hospitals in metropolitan areas Employed difference-in-differences analysis Compare the “pre-LIHP” period (before July 1, 2011) to: • First post-implementation period (7/1/11 to 9/30/12) • Second post-implementation period (10/1/12 to 12/31/13)
• 9.
  Medicaid Inpatient Admissionsat Safety Net Hospitals 607 527 612 454 0 100 200 300 400 500 600 700 California Comparison states Quarterlyadmissions Pre-LIHP Post-LIHP
• 10.
  Uninsured Inpatient Admissionsat Safety Net Hospitals 187 170176 218 0 50 100 150 200 250 California Comparison states Quarterlyadmissions Pre-LIHP Post-LIHP
• 11.
  Quarterly inpatient admissions 5253 [VALUE]* 83* 75* [VALUE]* -100 -80 -60 -40 -20 0 20 40 60 80 100 SAFETY NET HOSPITALS NON-SAFETY NET HOSPITALS Quarterlyadmissions Change in second post-implementation period relative to comparison states All Medicaid Uninsured *Change from pre-LIHP period is statistically significant at .05 level
• 12.
  Percent of admissionsthat are uninsured 10.2 3.7 9.1* [VALUE]* [VALUE]* [VALUE]* 0 2 4 6 8 10 12 SAFETY NET HOSPITALS NON-SAFETY NET HOSPITALS Percentofadmissionsuninsured Change in second post-implementation period relative to comparison states Pre-LIHP Post-LIHP 1 Post-LIHP 2 *Change from Pre-LIHP period is statistically significant at .05 level
• 13.
  Quarterly preventable admissions -6 -3 13 [VALUE]* [VALUE]* -18* -30 -20 -10 0 10 20 30 40 SAFETYNET HOSPITALS NON-SAFETY NET HOSPITALS Quarterlypreventableadmissions Change in second post-implementation period relative to comparison states All Medicaid Uninsured *Change from pre-LIHP period is statistically significant at .05 level
• 14.
  Other Key Findings Acuitylevel of Medicaid admissions increased, while acuity of uninsured decreased. Acuity level of Medicaid admissions increased more at safety net hospitals Preventable admissions for uninsured patients decreased to a greater extent at safety net hospitals So far, no evidence that residual uninsured becoming increasingly concentrated at safety net hospitals
• 15.
  Policy implications Will changein payer mix be enough to offset potential loss of Medicaid DSH funds? How will payment and delivery reforms affect key assumptions about reducing public subsidies to safety net hospitals? Will Medicaid payment levels be sufficient for Medicaid patients that have higher acuity?