1. Primary Care Continuity and Health Care Expenditures in a Depressed Sample of Florida Medicaid Recipients Andrea M. Lee, M.S. Robert G. Frank, Ph.D. Zoe N. Swaine, M.S. Natalie C. Blevins, M.S. Heather Steingraber, B.S.

2. Continuity of Care Definition: –healthcare events experienced as coherent and connected –consistent with the patient’s medical needs and personal context In primary care: –relationship between a single provider and a patient –extends beyond specific episodes of illness or disease

3. Continuity of Care Patients who maintain a continuous relationship with a primary care provider are –more satisfied with their care (Gulliford et al., 2007) –more likely to take medications correctly (Becker et al., 1974) –more likely to be diagnosed early for chronic diseases (Koopman et al., 2003)

4. Continuity of Care Lower health care utilization –Reduced likelihood of emergency department utilization in children (Christakis et al., 2001; Brousseau et al., 2004) –Reductions in hospitalizations, emergency department visits in the elderly (Weiss & Blustein, 1996; Wasson et al., 1984; Burge, Lawson, & Johnston, 2003) Lower health care expenditures No studies on psychological populations

5. Depression & primary care One of the most prevalent disorders in primary care (Ballenger et al., 1999) Depressed individuals tend to have (Simon et al., 1995) : –lower overall physical functioning –more disability days –higher rates of health care utilization

6. Depression & Medicaid 13% of enrollees use Medicaid mental health benefits (Mark et al., 2003) Medicaid’s spending for mental health services accounted for over 50% of all public mental health expenditures in 2003 (kff.org) Projected to increase up to 2/3 by 2013 (kff.org)

7. Present study Association between continuity of care and health care expenditures in depressed Medicaid enrollees Higher continuity of care hypothesized to be associated with lower expenditures Florida Medicaid claims data Cross-sectional

8. Participants 8,680 participants Ages 18-65 78% female; 22% male 42% White, 14% Black, 38% other, 6% Hispanic

9. Measure of continuity of care Modified, Modified Continuity Index (MMCI) Continuous variable, ranging from 0 to 1 –1 indicates high continuity of care

10. Distribution of continuity of care

11. Statistical analyses Logistic regression for expenditures with large proportion of zeroes –inpatient, outpatient, and emergency room expenditures Log-linear multiple regression –inpatient, outpatient, emergency room, pharmacy, medical, and total expenditures Controlled for age, sex, race, number of medical comorbidities, and number of prescription drugs

12. Results Higher continuity of care associated with: –a lower likelihood of having any expenditures for: Inpatient (odds ratio: 0.20, p <.01) Outpatient (odds ratio: 0.69, p <.01) Emergency room (odds ratio: 0.58, p <.01) –lower expenditures for total, medical, inpatient, outpatient, emergency room expenditures (p <.01) –higher pharmacy expenditures (p <.01)

13. Limitations Unable to differentiate between provider type and practice site in identifying primary care provider ICD-9 codes limited reliability – subject to error and only captures provider – identified depression (not undetected or undiagnosed depression)

14. Conclusions Improving continuity of care in depressed Medicaid recipients may impact overall health care spending Pharmacy expenditures were higher with higher continuity of care, which may be due to better medication management

15. Conclusions Relatively few enrollees with low continuity of care to target for policy change, but can have a measurable impact

16. Acknowledgements: Robert Frank Natalie Blevins Zoë Swaine Eleni Dimoulas Heather Steingraber Jianyi Zhang Allyson Hall