Psychiatr News February 2, 2007
Volume 42, Number 3, page 5
© 2007 American Psychiatric Association
Insurance Coverage Interruptions Linked to Treatment-Cost Increases
Rich Daly
Depressed patients' emergency-room visits spiked 170-fold after returning
to the Medicaid program from a break in their coverage.
Medicaid beneficiaries with depression who returned to the program after a
temporary loss of coverage cost the program more and needed to use more
services than they did before their coverage was interrupted.
The jump in costs and utilization of inpatient and emergency-room services
was especially pronounced among beneficiaries with a documented disability.
The study followed several research studies that found that people who need
medical care reduced their care when they lost public or private
insurance.
"Given these previous findings, it is reasonable to presume that when
most individuals lose their Medicaid coverage, they stop consuming health
services," wrote the study authors. "For some individuals,
especially those with chronic conditions, health status may deteriorate to the
point where acute care is needed."
The study, "Changes in Health Care Use and Costs After a Break in
Medicaid Coverage Among Persons With Depression," by Jeffrey Harman,
Ph.D., and colleagues at the Florida Center for Medicaid and the Uninsured at
the University of Florida, appears in the January Psychiatric
Services.
The findings are similar to another study that found Medicaid beneficiaries
with schizophrenia who had disruptions in their coverage required
significantly more inpatient psychiatric services after coverage was restored
than did similar beneficiaries with continuous access to coverage. The study,
also by Harman and colleagues, was published in the July 2003 Psychiatric
Services.
The depression study findings were based on information from 1,946
beneficiaries who received depression care in the Florida Medicaid program
from 1999 through 2002 and who had at least a 30-day disruption in coverage.
The researchers used the data to assess the beneficiaries' utilization of
Medicaid services in the three months before and three months after the period
in which they went without Medicaid coverage.
Researchers did not determine the amount of care received during the period
in which subjects went without coverage. The period of interrupted coverage
ranged from 32 to 1,219 days, with a median of 284 days.
Hospitalization More Likely
The researchers found that the beneficiaries with disruptions in their
Medicaid coverage were more likely to undergo hospitalization and to remain
hospitalized for significantly more days in the three months after returning
to Medicaid than in the three months before losing Medicaid coverage. Among
the beneficiaries in the study, 126 (6.4 percent) had more hospitalizations
after the Medicaid benefits were interrupted than they did before the coverage
interruption, while only 65 (3.3 percent) had fewer hospitalizations after
their benefits were disrupted. There were no changes in hospitalizations among
the other study beneficiaries.
The researchers also found a 170-fold increase in the number of
emergency-room visits after the coverage was interrupted. The study found that
295 beneficiaries (15 percent) whose Medicaid coverage was interrupted had an
increase in emergency-care visits after they were again covered by Medicaid.
One beneficiary had fewer emergency visits, and 1,653 had no change in the
three months after their Medicaid coverage was restored.
"This finding suggests that the emergency department serves as a
major entry point for people returning to care," said the researchers.
They speculated that the emergency-care visit may have been the catalyst for
the beneficiaries' re-enrollment in Medicaid, but they did not explicitly try
to prove that link.
The interval between emergency visits also showed the effect of
interruptions in Medicaid coverage. The time between such visits shrank
considerably when care was interrupted, with depression patients seeking such
care every 170 days after losing and regaining their Medicaid access; these
individuals sought emergency care every 206 days before the disruption. The
longer the disruption in care lasted, the more likely the individual was to
seek out emergency-room care. Individuals with interruptions of less than two
months had significantly fewer emergency-care visits after returning to
Medicaid than did beneficiaries who lost access to care for more than seven
months.
Costs Rise With Coverage Interruption
The study also found that 964 beneficiaries (50 percent) ran up increased
expenditures after their Medicaid coverage was restored, while 917 (47
percent) spent less after they returned to the Medicaid program. Beneficiaries
who were younger and female were more likely to have increases in
expenditures, while older, male, African-American beneficiaries were the least
likely group to incur increases in spending.
Individuals who were eligible for Medicaid because of a disability were 28
percent more likely to have an increase in expenditures than were
beneficiaries who were eligible through other noneconomic factors such as age
or pregnancy. Increased expenditures also were associated with individuals
whose Medicaid eligibility continued to stem from their depression-based
disability—rather than a disability attributed to another reason.
"Policymakers could use this information to target policies for
enrollees who are most likely to be adversely affected by interruptions in
coverage," the authors said, about participants the study found most
likely to be affected by the coverage disruptions.
They cautioned that the findings do not establish definitively that access
to care and use of care dropped during the periods when the study subjects
went without Medicaid coverage, because they have no way of knowing what types
of services were used during those intervals. Previous studies found that most
Medicaid beneficiaries who lost coverage became uninsured and accessed care
much less frequently than when they were covered by the program.
"Changes in Health Care Use and Costs After a Break in
Medicaid Coverage Among Persons With Depression" is posted at
<http://ps.psychiatryonline.org/cgi/reprint/58/1/49>.
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