Moving toward evidence based health policy in california s medicaid program
1 / 41

Moving Toward Evidence-Based Health Policy in California's Medicaid Program - PowerPoint PPT Presentation

  • Uploaded on
  • Presentation posted in: General

Moving Toward Evidence-Based Health Policy in California's Medicaid Program. Andrew B. Bindman, MD Professor Medicine, Health Policy, Epidemiology & Biostatistics University of California San Francisco. Research Interest. Health consequences of public policies

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.

Download Presentation

Moving Toward Evidence-Based Health Policy in California's Medicaid Program

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript

Moving toward evidence based health policy in california s medicaid program l.jpg

Moving Toward Evidence-Based Health Policy in California's Medicaid Program

Andrew B. Bindman, MD

Professor Medicine, Health Policy, Epidemiology & Biostatistics

University of California San Francisco

Research interest l.jpg

Research Interest

  • Health consequences of public policies

  • Access to and quality of care for low-income, diverse, and patient populations vulnerable to poor health because of their social circumstances

  • Tied to clinical and teaching activities at San Francisco General Hospital

Scientific research advocacy l.jpg

Scientific Research/Advocacy

  • Possible to advocate without research

  • Evidence-based approach may provide a more compelling means to reach group consensus on the truth and strategy

  • Scientific approach comes with responsibilities (scientific integrity, ethical obligation to publish results)

Medi cal california s medicaid program l.jpg

Medi-Cal: California’s Medicaid Program

  • 6.6 million beneficiaries

  • $40 billion this past year

  • 2nd largest use of general fund (17%)

  • Pays for 1 in every 2 births in the state

  • Covers 2 of 3 nursing home patients

  • Half of beneficiaries are Latino

Medi cal s challenges l.jpg

Medi-Cal’s Challenges

  • Cost of program outpacing other state programs/funds to support it

  • Data systems offer limited assessment of access, quality, value

  • Constraints on state government salaries results in brain drain

  • Bureaucracy makes it challenging to contract for help

Camri l.jpg


  • California Medicaid Research Institute

  • Collaborative partnership between University of California and California Department of Health Care Services (Medi-Cal)

  • Focus is on health policy research, evaluation, and technical assistance

  • Similar model in several other states

Opportunity for uc l.jpg

Opportunity for UC

  • To develop new knowledge that can contribute to evidence based decision-making for an important state health program

  • To participate in the development and use of data systems that can improve the assessment of access, cost and quality of Medi-Cal program

  • To create a training environment for future health policy decision-makers and investigators

Camri steering committee l.jpg

CaMRI Steering Committee

  • UCSF (Host Campus)

    • Andrew Bindman, Director

    • Claire Brindis, Associate Director

  • UCB

    • Richard Scheffler, Associate Director

  • UCLA

    • Richard (Rick) Brown, Associate Director

  • UCSD

    • Richard (Rick) Kronick, Associate Director

How camri works l.jpg

How CaMRI works

  • Interagency Agreement/project template

  • Regular dialogue between Medi-Cal and UC

  • State support as well as federal matching of UC’s certified public expenditures

  • Facilitate Medi-Cal’s access to UC experts

  • Enhance UC access to Medi-Cal data

Scope of work l.jpg

Scope of Work

  • Beneficiaries

    • health services and support needs

    • utilization patterns

    • health outcomes

    • beneficiary satisfaction

  • Program benefits

    • scope, duration and frequency of benefits

    • clinical- or cost-effectiveness of benefits

  • Program eligibility

    • Service/cost implications of eligibility expansions or reductions

    • outreach, enrollment and retention

Scope of work cont l.jpg

Scope of Work (cont)

  • Health care delivery systems

    • fee-for-service and managed care

    • use and effectiveness of health IT

    • incentive payment systems

    • quality improvement programs

    • costs/benefits of delivery models

  • Program administration

    • enrollment/re-determination processes

    • provider enrollment processes

    • effectiveness of cost controls/UM

Challenges l.jpg


  • Logistics of data sharing

  • Political nature of annual budget process

  • Understanding each others culture, timing, and expectations for gauging success

  • Building sustained trust in the partnership

Land mines to avoid l.jpg

Land Mines to Avoid

  • Conflicts of interest

  • Compromising UC’s role as a trusted independent voice

  • Compromising DHCS competitiveness in the market place

National advisory committee l.jpg

National Advisory Committee

  • To help protect us from the land mines

  • Panel of state and national experts who will serve as a sounding board and advisory body to our process

  • Connect our work to related work nationally and in other states

Example project eligibility re determination l.jpg

Example Project:Eligibility Re-determination

  • More than half of Medicaid beneficiaries nationwide have interruptions in coverage

  • State laws vary regarding duration of eligibility re-determination period

Study questions l.jpg

Study Questions

How does the administrative burden of re-enrollment in Medicaid effect the continuity of coverage?

What are the health and cost consequences of interruptions in Medicaid enrollment?

Nature of state s medi cal data l.jpg

Nature of State’s Medi-Cal data

  • Claims (eg hospital, outpt, pharmacy)

  • No claims for managed care (~50%)

  • Monthly eligibility

  • No record of beneficiaries after they lose coverage

Slide19 l.jpg


DHS: Medi-Cal Enrollment Database

  • Demographics

  • Monthly enrollment history

  • Aid Category (e.g. TANF or SSI)

  • FFS, managed care

  • Other insurance



Linked CA Hospital Discharge and Medicaid Eligibility Files

OSHPD: Hospital Discharge Data



  • Diagnosis (ICD-9 Code)

  • Month/Year of admission

  • Payer

Creating a valid link l.jpg

Creating a Valid Link

  • Deterministic match on SS#

  • Probabilistic match with partial SS#, DOB, and sex

  • Validated match with separate Medi-Cal payment records

  • 98% success in matching

  • Least success with <1 year olds

Study design l.jpg

Study Design

  • All individuals 1-64 years with at least 1 month of

    Medicaid coverage Jan 1998 to December 2002

  • Outcome

    Time to a hospital admission for an ambulatory care sensitive condition

  • Main predictor

    Continuous or interrupted Medicaid coverage between enrollment and time of admission

Slide22 l.jpg

ACS Conditions

Ambulatory Care Sensitive Conditions:AHRQ Prevention Quality Indicators

  • Condition with acute course and window for intervention

  • Condition with chronic course amenable to self-management

Chronic Conditions:

  • Asthma

  • Hypertension

  • COPD

  • Diabetes Mellitus

  • Heart Failure

  • Angina

Acute Conditions:

  • Dehydration

  • Ruptured Appendicitis

  • Cellulitis

  • Bacterial Pneumonia

  • Urinary Tract Infection

Ca medicaid population 1998 2002 l.jpg

CA Medicaid Population: 1998-2002

Reverse causality l.jpg

Reverse Causality

  • Interruption in coverage might not predict worse health outcome so much as worse health might predict whether or not have interrupted coverage

  • Bias of higher admissions among those with continuous coverage

  • Consider option of using subjects as their own control

Survival analysis of medicaid coverage and interruption spells on acs hospitalizations l.jpg

Survival Analysis of Medicaid Coverage and Interruption Spells on ACS Hospitalizations



Medicaid Coverage

ACS Admission


(2003 or 65 Years)

ACS Admission

New Spell



Interruption of Coverage

New Spell

ACS Admission


(2003 or 65 Years)



Censored (2003 or 65 Years)

Acs hospitalization rates continuous vs interrupted medicaid beneficiaries l.jpg

ACS Hospitalization Rates: Continuous vs Interrupted Medicaid Beneficiaries

Probability of acs hospitalization over time by medicaid coverage status l.jpg

Probability of ACS Hospitalization Over Time by Medicaid Coverage Status

Cumulative Probability

Time (Months)

Adjusted risk of acs hospitalization l.jpg

Adjusted Risk of ACS Hospitalization

Limitations l.jpg


  • Do not have measures of disease prevalence or health status differences between those with continuous versus interrupted Medicaid coverage

  • Limited information on the subsequent health insurance status of those with interrupted Medicaid coverage

Natural experiment of interrupted medicaid coverage l.jpg

Natural Experiment of Interrupted Medicaid Coverage

  • California extended Medicaid eligibility re-determination period for all children in California from every 6 to every 12 months on January 1, 2001

  • Extension of eligibility re-determination period should be associated with an increase in continuity of Medicaid coverage, but should not except through its influence on continuity of coverage affect the health status of children.

Pre post study of re enrollment policy change for children l.jpg

Pre/Post Study of Re-Enrollment Policy Change for Children

  • Children 1-17 years with a minimum of 1 month of Medicaid coverage in California

  • Outcome = time to a hospital admission for an ambulatory care sensitive condition

  • Main predictor = time period

    • Pre policy change = 1/99-12/00

    • Post policy change = 1/01 -12/02

Children 1 17 years in california medicaid before and after extension of re determination period l.jpg

Children 1-17 Years in California Medicaid Before and After Extension of Re-Determination Period

Children with continuous medicaid enrollment by time period l.jpg

Children with Continuous Medicaid Enrollment by Time Period




Years of Enrollment

Probability of a hospitalization for an acs condition over time l.jpg

Probability of a Hospitalization for an ACS Condition Over Time

Children adjusted risk of acs hospitalization l.jpg

Children: Adjusted Risk of ACS Hospitalization

Comparison group adults in medicaid l.jpg

Comparison Group: Adults in Medicaid

  • Medicaid eligibility re-determination period did not change during study period for adults in California

  • Adults with Medicaid coverage

    • 1999-2000 = 62%

    • 2001-2002 = 60%

  • Adjusted relative hazard of a hospitalization for an ACS condition for adults in post vs pre period= 1.11

Hospital savings and medicaid coverage costs associated with enrollment extension in 2001 2002 l.jpg

Hospital Savings and Medicaid Coverage Costs Associated with Enrollment Extension in 2001 – 2002

Who is paying the bill l.jpg

Who Is Paying the Bill?

  • Among hospitalized children

    • 60% re-gained Medi-Cal

    • 33% had another form of insurance

    • 7% uninsured

Other hidden costs of interrupted coverage l.jpg

Other Hidden Costs of Interrupted Coverage

  • Administrative costs of more frequent eligibility re-determination

  • Costs of more frequent emergency room visits

  • Costs of hospitaliations of other potentially avoidable hospitalizations

Policy implications l.jpg

Policy Implications

  • States need to become more aware of the hidden costs in their Medicaid eligibility policies

  • Continuity of Medicaid coverage can support better health and decrease wasteful spending on hospitalizations that could have been avoided with less costly outpatient care

Slide41 l.jpg

Research Partnership with State Government

  • Opportunity to link HSR with a needy/receptive customer

  • Steep learning curve for each party

  • Building capacity takes time

  • Can experience challenges in trying to publish results of 1 state

  • Significant public service component that university needs guidance on how to measure/value

  • Login