Impact of State Mandatory Insurance Coverage on Selected Diabetes Care Services

Impact of State Mandatory Health Insurance Coverage on the Utilization of Selected Diabetes Care Services Rui Li, Ph.D. Ping Zhang, Ph.D. Dekeely Hartsfield, M.P.H Division of Diabetes Translation Centers for Disease Control and Prevention Contact: Rli2@cdc.gov The findings and conclusions in this presentation have not been formally disseminated by the Centers for Disease Control and Prevention and should not be construed to represent any agency determination or policy 2 14 million diagnosed with diabetes 7 million with un-diagnosed diabetes 41 million with pre-diabetes NHANES Diabetes is Serious and Costly in US Seven percent of US population Serious complications Cost more than 132 billion per year in 2002 Complications can be prevented or delayed 4 Research question State Mandatory Laws and Regulations Utilization of the services Health Insurance Coverage 5 State Mandates Affect private insurance Group and individual policies from Insurance companies or HMOs within a state Self-insured companies are exempted by Employee Retirement Income Security Act (ERISA) 30-50% employees are exempted Forty-six states and D.C. have mandate 6 Name of the States with Laws and Effective Year Effective Year 1987 1994 WI MN, NY FL ME, NJ, RI, WV AK, NV, NM, OK, TN, TX CO, CT, GA, IN, KS, KY, LA, MD, MS, MO, NH, NC, VT, WA AZ, IL, IA, PA, VA AK, CA, DE, MA, NE, SC, SD, UT HI, MI, WY, D.C. MT, OR 7 States 1995 1996 1997 1998 1999 2000 2001 2002 Coverage of State Mandates Coverage Self-management education Medical nutritional therapy Therapeutic foot wear Periodical eye and foot exams HbA1c test General coverage of pharmaceuticals, devices, and supplies Devices for insulin self-administration Number of states 40 24 12 3 5 41 23 32 34 31 1 1 8 Monitors and strips Insulin Oral agents High-risk assessment Vaccination Hypotheses Mandate Coverage Coverage of Monitors and strips HbA1c test Self-management education (SME) Eye exams Annual foot exams Foot exams Footwear Having all three Having Law 9 Increase Utilization DSMG Outcome Lower HbA1c level Annual eye exams Lower Mortality Less eye complications Less foot complications Data Sources Behavioral Risk Factors Surveillance Survey (BRFSS) 1996-2000  Annual, state-based, random telephonesurvey of 150,000-210,000 communitydwelling US adults (aged 18 or older)  Survey questions designed by CDC  Core questionnaire required to report by states  More than 40 states reported special diabetes module 10 Study Population People with self-reported diabetes 9215 observations in the final analysis Health insurance type Employer provided Self-bought 11 Econometric model Prob (Utilizationi,k,t)= Logit ( + 1*Lawk,t=m + 2*Lawk,t>m + 3*Zi + 4*Xk + 5*Timet)+  Z—Individual characteristics X—State level characteristics i—Individual indicator k—State indicator t—Time indicator m—Year that law took effect We used STATA 8 survey commands to do all the analysis 12 Dependent Variables based on Healthy People 2010 National Goals for Diabetes If Self-monitoring blood glucose (DSMG) at least once daily  “About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a health professional.” If receiving annual eye dilated exams  “When was the last time you had an eye exam in which the pupils were dilated? This would have made you temporarily sensitive to bright light.” 13 Dependent Variables (Cont’d) If receiving annual foot exams  “About how many times in the last year has a health professional checked your feet for any sores or irritations?” If receiving all three services 14 Results Before mandate First year of Mandate 100% 80% 60% 40% 20% 0% Daily SMBG Annual foot exams Annual eye exams *** * *** The follow ing years * ** Healthy People 2010 Goal * Combine Figure I. Percentage of People with Diabetes Using the Selected Diabetes Care Services Before and After Mandate (unadjusted) 15 Effect of State Mandates on Daily Self-monitoring Blood Glucose level Coefficient (s.e.) First Year (monitors & strips) a 0.02 (0.03) Years after 0.05* (0.02) First year (SME)b Years after 0.01 (0.03) 0.04 (0.02) First year (HbA1c test)c Years after 0.09 (0.05) 0.02 (0.03) a,b,c: Results were from three regressions for different law components The reported coefficients were marginal probabilities *: p<=0.05; **: p<=0.01; ***: p<=0.001 16 Effects of State Mandates on Annual Eye Exams Coefficient (s.e.) First year (SME) Years after -0.01 (0.03) 0.01 (0.02) First year (eye exams) Years after 0.01 (0.03) -0.03 (0.03) 17 Effects of State Mandates on Annual Foot Exams Coefficient( s.e.) First year (SME) Years after First year (foot exam) Years after First year (foot wear) 0.05 (0.03) 0.04 (0.02)& 0.11 (0.07) 0.02 (0.03) 0.06 (0.04) Years after &: significant at 0.1 level 0.04 (0.03) 18 Effects of Having State Mandate on Receiving all Three Services Coefficient (s.e.) First year Years after 0.07** (0.03) 0.04** (0.02) 19 Conclusion and Implications State mandatory health insurance coverage has some effect on the utilization of selected diabetes care services Coverage on diabetes monitor and strips increased likelihood of daily SMBG State mandated did not have an effect on annual eye and foot exams Increased SMBG increased likelihood of receiving all three services Further studies are needed to understand why the state mandates had limited effect on selected diabetes services 20