This document summarizes preliminary findings from research on the effects of Medicaid policy changes in Kentucky and Idaho between 2005-2008. In Kentucky, the introduction of copays for services like physician visits and prescriptions led to small decreases in use, while increased reimbursement rates later saw a small increase. Idaho saw improved dental access and preventive care rates after introducing annual exams and managed dental care. Participation in new health assistance programs was low based on initial surveys. The research aims to understand how these policy changes impacted Medicaid beneficiaries' access to and use of health services.

1. The Effects of Medicaid Policy
Changes on Adults’ Service Use Patterns in
Kentucky
Kent ck and Idaho
Genevieve Kenney y Urban Institute
James Marton Georgia State University
Jennifer Pelletier Urban Institute
Ariel Klein Urban Institute
Jeffrey Talbert University of Kentucky
AcademyHealth Annual Research Meeting
June 27 2010
J 27,
Funded by the State Health Access Reform Evaluation, a national program of the
Robert Wood Johnson Foundation
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

2. Medicaid Policy Changes Made
Between 2005 to 2008 in Kentucky
• KY policies introduced in July 2006:
– $3-$6 copays for physician office visits
p y p y
– $2 copays for dental visits (# of allowable visits reduced to 1 / year)
– $50 copayment for inpatient hospital stays
– $1 $3
$1-$3 copayments for prescriptions (service limits on the number of
prescriptions - 4 per month with a maximum of 3 brand name drugs
and higher copays on brand name drugs)
– 5% coinsurance (up to $6) for non-emergency use of the ER
( p ) g y
• KY out-of-pocket maximums of $225 for medical services
and $225 for prescriptions also put in place in July 2006
• KY increased reimbursement rates for preventive care and
E&M codes in July 2007 and in January 2008
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

3. Medicaid Policy Changes Made in
2006 and 2007 in Idaho
• Annual wellness exam added to adult benefit packages
• Tobacco Cessation and Weight Management Preventive
Health Assistance benefits become available to adults who
qualify
– To qualify for Tobacco benefit, adult must be a current smoker
who wants to quit
– To qualify for Weight Management benefit, adult must have BMI
of less than 18.5 or 30 or greater.
• Dental coverage for non-disabled enrollees outsourced to a
managed care organization and reimbursement rates for
d i ti d i b t t f
adults’ services increased by an average of 3.9%
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

4. Research Questions
R hQ i
Kentucky
• Did the new 2006 primary care, dental care, inpatient stay, prescription
drug, and ER copayments lead to decreases in the receipt of care?
• Did the 2007 and 2008 reimbursement rate increases for evaluation
and management services lead to increases in the number of physician
office visits?
ffi i it ?
Idaho
• Did the addition of an annual wellness benefit result in receipt of
preventive care among adults? What are the characteristics of the
ti d lt ? Wh t th h t i ti f th
adults who received preventive care?
• Did the tobacco cessation and weight management benefits succeed in
changing beneficiary behavior?
• Did the move to a managed care delivery system for dental care
improve non-disabled beneficiaries’ access to dental care?
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

5. Office Visits in KY – Multivariate Results
• J l 2006: $3-$6 copays for office visits introduced
July 2006 $3 $6 f ffi i it i t d d
– We find no statistically significant change in the probability of having at
least 1 office visit annually post July 2006.
• Because of the reimbursement rate increases for preventive
office visits in July 2007 and January 2008, we also
2008
estimated a specification with separate year dummies:
– We find a very small (.35 percentage point or .4%) decline in the
probability of having at least 1 office visit for fiscal year July 2006 June
2006-June
2007 (p = .033) and a small (.20 percentage point or .23%), but
statistically insignificant, increase in the probability of having at least 1
office visit for fiscal year July 2007-June 2008.
• Negative binomial models give similar results in terms of
signs and statistical significance.
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

6. Dental Visits, Inpatient Stays,
ER use in KY –
Multivariate Results
• July 2006: $2 copays for dental visits introduced as well as a reduction in the
number of annual allowable visits to 1 per year.
p y
– We find no statistically significant change in the probability of having at least 1 dental visit
annually, but a statistically significant reduction in the number of annual dental visits (p <
.001).
– July 2006: $50 copay for inpatient stays introduced
– We find a very small (.41 percentage point or 2.28%) decrease in the probability of having at
least 1 inpatient stay annually (p = .002) and a statistically significant reduction in the number
of annual inpatient stays (p < .001).
– July 2006: 5% coinsurance (up to $6) for non-emergency use of the ER
– We find a 1 percentage point (or 1.94%) increase in the probability of having at least 1 ER visit
annually (p < .001) and a statistically significant increase in the number of ER visits (p < .001).
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

7. Prescription use in KY –
P i ti i
Multivariate Results
– July 2006: $1-$3 copays for prescriptions introduced (also new service
limits on the number of prescriptions - 4 per month with a maximum of
3 brand name drugs)
– We find no statistically significant change in the probability of having at least 1
prescription annually.
– We also find that the average number of monthly generic prescriptions
increases slightly (p < .001) after July 2006 (from 2.18 per month to 2.43 per
month) while the average number of name brand prescriptions falls slightly (p
< .001) after July 2006 (from 1.29 per month to 1.10 per month).
– Increased use of generics could lead to cost savings in this large category of Medicaid
p
expenditure.
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

8. Idaho - Descriptive Results
• After moving to managed care, the share of adults who had any dental
visit increased by 2.5 percentage points (from 45.5% to 48.0%).
i it i db 25 t i t (f 45 5% t 48 0%)
• Likewise, the share of adults who had any preventive dental visit
increased by 2.4 percentage points (from 21.8% to 24.2%)
i db 24 t i t (f 21 8% t 24 2%)
• After introduction of the annual wellness benefit, 8.9% of adult
beneficiaries
b fi i i received a preventive medical check-up i a 12-month
i d ti di l h k in 12 th
period. Preventive care receipt is:
– 10.3 percent among those who did not receive any care at an FQHC
(preventive care receipt among those who did visit an FQHC may not be
counted in the claims);
– Higher among women than men (11.6% vs. 1.7%):
– Higher among adult TANF recipients than SSI recipients (11.4% vs.
7.2%).
7 2%)
– Rates also vary by region in the state, ranging from 5.6% to 15.6%.
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

9. Idaho- Personal Health Assistance
Benefits Results
• Overall, participation in the personal health assistance benefits appears low: in
2009, about 1000 people were in the weight management benefit and 360
people were in the tobacco cessation benefit but do not know size of eligible
pool
• The state conducted a survey of participants, which resulted in 56 respondents
y p p , p
to the weight management survey and 39 respondents to the tobacco cessation
survey
– While the sample sizes are very small, the majority of respondents reported that
small
they gained/lost weight as intended on the weight management program (88%, 95%
C.I. 76%-95%)
– F
Fewer respondents reported successfully quitting smoking as a result of their
d t t d f ll itti ki lt f th i
participation in the tobacco cessation program (20%, 95% C.I. 10%-38%)—other
information on the survey suggests that this could relate to fact that the benefit only
covers 7 weeks of tobacco cessation drugs while the full treatment is 12 weeks.
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

10. Idaho- Multivariate Results
• DD estimates indicate that non-disabled adults are
5.4
5 4 percentage points more likely to have an annual
i lik l h l
dental visit after introduction of managed care and
2.0
2 0 percentage points more likely to have received a
preventive dental visit after introduction of managed
care
• Simple pre-post models without the use of a
pre post
comparison group found results in the same direction
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

11. Limitations
• Inaccuracies in coding practices in the claims data may
understate the extent of preventive care received
• Can not assess extent to which copays are being collected
in KY
• Not controlling for possibly confounding changes in case
mix or service delivery system with a simple pre-post
design
• Length of post period may not allow sufficient time for
impacts to be felt
p cs o e
• No information available on content of care being provided
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

12. Policy Implications
• Our general finding in Kentucky is very little or no impact of the modest
copayments on utilization across several categories of service--small impacts
on office visits and prescriptions; Without knowing underlying cause of the
observed patterns, can not fully understand implications
• Adults in Idaho Medicaid have very low levels of preventive care receipt,
y p p,
indicating that physicians and beneficiaries may be missing opportunities for
counseling on prevention and chronic disease management.
• The Beha ioral PHA benefits in Idaho have low enrollment to date and are not
Behavioral ha e lo
structured in a way that can be expected to achieve widespread behavior
change.
• Need to invest in data systems: track progress with respect to preventive care
receipt; examine content of care; and assess extent to which beneficiaries are
receiving appropriate follow-up care for problems that are diagnosed
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

13. Genevieve Kenney
Senior Fellow
The Urban Institute
(202) 261-5568
JKenney@urban.org
JK @ b
www.urban.org
www.healthpolicycenter.org
URBAN INSTITUTE

14. Motivation
• Idaho and Kentucky introduced policy
changes aimed at:
– increasing emphasis on and access to wellness
and prevention services
– Controlling Medicaid cost growth
– encouraging more effective use of state
Medicaid
M di id resources and greater involvement of
d t i l t f
Medicaid beneficiaries in their health care
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

15. •
Kentucky Sample Kentucky
We use administrative claims and enrollment data from Kent ck
se administrati e
Medicaid to build a dataset consisting of all full fiscal years of coverage
between 2005-2008 for non-institutionalized, non-elderly adult enrollees
( g
(aged 19-64).
)
• In building this dataset, we excluded person-months with missing values
for key variables, such as demographics or eligibility category, and the
person-months representing dual coverage. We drop full years of coverage
h i d l d f ll f
in which there was a mid-year switch in the category of eligibility or in the
benefit package.
• We also exclude enrollees in Louisville-region counties, because all
Medicaid enrollees in those counties are enrolled in a capitated managed
care plan (
p (Passport). Roughly 16% of our full fiscal y
p ) g y years of coverage
g
represent Passport coverage.
• We are left with 341,367 full fiscal y
, years of FFS Medicaid coverage
g
generated by 164,209 unique individuals.
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

16. Kentucky Analyses
• Descriptive analysis of receipt of care across several different service
categories (any office visits, any dental visits, any inpatient stays, any
prescription use, and any ER visits) after the introduction of the
i ti d i it ) ft th i t d ti f th
copays.
• Logistic regression analysis with marginal effects to examine the
impact of the KY reforms on the probability of the receipt of any care
over a 12-month period across the different service categories with
controls for age, race, gender, and geographic location.
• Count models are also estimated to examine the impact of the KY
reforms on the annual number of visits across the different service
categories.
t i
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

17. Idaho Sample
• We use administrative claims and enrollment data from Idaho
Medicaid to build a dataset consisting of all full years of coverage
between 2004-2008 for non-institutionalized, non-elderly adult
b t 2004 2008 f i tit ti li d ld l d lt
enrollees (aged 19-64).
• I building this dataset, we excluded person-months with missing
In b ildi thi d t t l d d th ith i i
values for key variables, such as demographics or eligibility category,
and the person-months representing dual coverage. We also exclude
e o ees w o ece ved a t e ca e
enrollees who received all their care at a Federally Qualified Health
ede a y Qua ed ea t
Center (FQHC) due to the absence of claims data for these providers
(about 8.5% of the sample).
• We have 52,346 person-years in the physician visit dataset and 52,245
person-years in the dental visit dataset.
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION

18. Idaho Analyses
• Case study analyses to assess policy changes included key stakeholder
interviews with current and former Medicaid officials, providers, provider
associations,
associations and advocacy groups and a small state survey of participants in
the tobacco cessation and weight management benefits
• Descriptive analysis of receipt of any preventive visit after introduction of
p y p yp
policy changes
• Descriptive analysis of receipt of any dental visit and any preventive dental
visit before and after implementation of policy changes
isit polic
• Logistic regression analysis with marginal effects of receipt of any dental visit
and any preventive dental visit over a 12 month period with controls for age,
12-month
race, gender, FQHC use, and geographic location using disabled population as
a comparison group (Difference in differences estimate)
URBAN INSTITUTE PRELIMINARY FINDINGS: NOT FOR QUOTATION OR DISTRIBUTION