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State Health Facts

www.statehealthfacts.org
Kaiser Family Foundation
Katherine Cargill-Willis, April 11, 2005

This report, and the web site it summarizes, consists of a number of tables for every state regarding a variety of issues. After defining the terms and reporting on general demographics, I have selected the variables that are relevant to people with disabilities and created a table for each for Ohio and the country as a whole.

Demographics and the Economy

VARIABLE	OHIO 2003	OHIO 2004	U.S. 2003	U.S. 2004
Unemployment rate in 2004 compared to 2003	6.2	5.9	5.7	5.4
Percent of Persons with a disability in 2003	17.3%	-	18.3%	-
Average number of days with limited activity per 30 days*	2.4	-	2.1	-

* Days with limited activity per 30 days: Limited activity days are the average number of days in the past 30 days that a person could not perform work or household tasks due to physical or mental illness.

Health Maintenance Organizations
(HMOs)

VARIABLE	OHIO	U.S.
Number of HMO*	18	424
HMO Enrollment in 2003	2,061,149	66,047,928
HMO Penetration*	18.0%	23.7%

* HMO: An entity that offers prepaid, comprehensive health coverage for both hospital and physician services with specific health care providers using a fixed structure or capitated rates.

*State penetration was calculated with state population data from the U.S. Census Bureau as of July 1, 2003.

Insurance Reform

Although all fifty states require insurance carriers to offer coverage to small groups and individuals regardless of claim history, health status, only ten states require insurers to charge everyone the same premium rate. The premium is not permitted to vary according to the actuarial risk presented by an individual and Ohio is not one of them. Ohio is one of thirty-one states that apply a pre-existing condition exclusion limiting the number of times a health insurance carrier can exclude coverage for a condition that was that was already present prior to the start of the effective date of new coverage. All states require carriers to renew policies with small groups or individuals regardless of claim experience. The definition of ‘small group’ varies from state to state. In Ohio a small group is a group between two to fifty people.

Health Care and Budgets

VARIABLE	OHIO	U.S.
State Health Care Expenditures (in millions) SFY 2001	$10,491	290,686
Health Care Expenditure as a percentage of Gross State Product	2.5%	NA

State Mandated Benefits

Ohio has few mandates concerning health benefits from insurance companies. Parity requires insurers to provide benefits for mental illnesses that are equal to the benefits provided for physical illnesses. Twenty-two states have mental health parity but Ohio is not one of them. Ohio also does not have mandated clinical trials, although nineteen states do; nor does Ohio require insurance companies to provide coverage for diabetic supplies, equipment, and/or outpatient management training although forty-seven states do. With regard to physical disabilities, in Ohio insurance companies are not required to provide newborn screening tests as twelve other states do. The state also does not require a managed care continuity of care provision, although thirty-states have such a requirement. Finally, concerning cancer screening, Ohio requires insurers to cover breast and cervical screenings; all states require breast cancer screening coverage and twenty-six states require cervical screening coverage. But Ohio does not require insurers to cover colorectal or prostrate screenings; eighteen states require colorectal cancer and twenty-six require prostate screenings.

Medicaid & State Children Health Insurance Program
(SCHIP)

VARIABLE	OHIO	U.S.
Total Medicaid Spending	$10,272,962,257	$266,817,101,410
Current Monthly SCHIP Enrollment*- 12/03	128,602	3,927,411
Percent Change in SCHIP Enrollment from 12/02-12/03	6%	4%
SCHIP Program Type	Medicaid Expansion	NA
State Share of SCHIP Expenditures	$52,316,821	$1,606,966,644
Federal Share	$129,032,772	$3,706,056,505
Total Expenditure	$181,349,593	$5,313,023,149
SCHIP Federal Matching Rate	72%	NA

* The State Children's Health Insurance Program (SCHIP) is a state-administered program funded jointly by states and the federal government allowing states to expand health coverage to uninsured, low-income children and, in some cases, other populations that are not eligible for Medicaid.

Ohio’s Distribution of Medicaid Spending on Acute Care in 2003

VARIABLE	OHIO $	OHIO %	U.S. $	U.S. %
Inpatient Hospital	1,275,543.492	25.3	36,129,557,896	23.1
Physician, Lab and X-ray	539,461,016	10.7	9,850,419,434	6.3
Outpatient Services*	624,656,030	12.4	17,735,523,160	11.3
Prescribed Drugs	1,194,818,011	23.7	26,603,237,818	16.8
Other Services*	507,100,610	10.1	17,902,244,553	11.8
Payments to Medicare*	149,671,995	3.0	6,968,740,810	4.1
Managed Care and Health Plans*	753,634,970	14.9	40,328,095,170	25.0
Total	5,044,886,124	100	155,517,818,840	100

* Outpatient Services include outpatient hospital and clinic services, as well as payments made to rural health clinics and federally qualified health centers (FQHCs).

* Other Services include dental, other practitioners, abortion, sterilization, transportation, physical and occupational therapy, services for individuals with speech, hearing and language disorders, programs of all-inclusive care for the elderly (PACE), dentures, eyeglasses, prosthetic devices, other diagnostic and rehabilitative services, and other uncategorized services.

* Payments to Medicare are primarily premiums paid by Medicaid for Medicare enrollees. Medicaid may also pay Medicare cost-sharing for some individuals, but these amounts typically should be reported as payments for other services (e.g., inpatient hospital).

* Managed Care & Health Plans include payments to health maintenance organizations (HMOs), prepaid health plans (PHPs), and other health plans, as well as primary care case management (PCCM) fees.

Medicaid Spending on Long-term Care

VARIABLE	OHIO $	OHIO %	U.S. $	U.S. %
ICF-MR	1,006,884,554	20.2	11,915,454,089	12.3
Mental Heath Facilities	337,288,708	6.8	4,909,852,261	5.1
Nursing Facilities	2,647,297,226	53.1	45,137,415,944	46.5
Home Health and Personal Care	998,370,192	20.0	35,063,285,079	36.1
Total	4,989,940,680	100	97,026,007,372	100

Ohio Distribution of Medicaid Service by Spending

VARIABLE	OHIO $	OHIO %	U.S. $	U.S. %
Acute Care*	5,044,886,124	49.1	155,517,818,840	58.3
Long-Term Care*	4,989,940,680	48.6	97,026,007,732	36.4
Disproportionate Share Hospital*	238,135,453	2.3	14,273,275,198	5.3
Total	10,272,962,257	100	266,817,101,410	100

* Acute care services include inpatient, physician, lab, X-ray, outpatient, clinic, prescription drugs, family planning, dental, vision, other practitioners' care, payments to managed care organizations, and payments to Medicare.

* Long-term care services include nursing facilities, intermediate care facilities for the mentally retarded, mental health, home health services, and personal care support services.

Medicaid Enrollment in Managed Care by Plan Type

VARIABLE	OHIO	U.S.
HIO*	0	531,349
Commercial-MCO*	151,026	9,920,954
Medicaid-only MCO	284,662	6,848,585
PCCM*	0	6,142,646
PHIP*	0	7,468,909
PAHP*	0	2,999,392
PACE	458	5,670
Other	0	190,216
Total	436,146	34,107,721

* HIO: A Health Insuring Organization is a managed care entity which, by law, is exempt from certain rules governing MCO program operation such as the requirement for beneficiaries to have a choice of at least two managed care entities in mandatory programs.

* Commercial MCO: A Commercial Managed Care Organization is a health maintenance organization, an eligible organization with a contract under §1876 or a Medicare+Choice organization, a provider sponsored organization or any other private or public organization, which meets the requirements of §1902(w). A Commercial MCO provides comprehensive services to both Medicaid and commercial and/or Medicare.

* Medicaid-only MCO: A Medicaid-only Managed Care Organization provides comprehensive services to only Medicaid beneficiaries, not to commercial or Medicare enrollees.

* PCCM: A Primary Care Management Provider is a provider (usually a physician, physician group practice, or an entity employing or having other arrangements with such physicians, but sometimes with such physicians, nurse practitioners, nurse midwives, or physician assistants who contract directly with the State to locate, coordinate, and monitor covered primary care (and sometimes additional services). This category also includes those PIHPs that contract with the state as “primary care case managers.”

* PIHP: A Prepaid Inpatient Health Plan is a plan that provides less than comprehensive services on an at-risk or other than state plan reimbursement basis; and provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional service.

* PAHP: A Prepaid Ambulatory Health Plan is a prepaid ambulatory health plan that provides less than comprehensive services on an at-risk or other than state plan reimbursement basis, and does not provide, arrange for, or otherwise have responsibility for the provision of any inpatient hospital or institutional services. There are several types of PAHPs that states use to deliver a range of services. For example, a Dental PAHP is a managed care entity that provides only dental services.

* PACE: The Program for All-inclusive Care provides pre-paid, capitated comprehensive, health care services to the frail elderly.

* Other: When the structure of the managed care plan is not considered a PCCM, PIHP, PAHP, Commercial MCO, Medicaid-only MCO, HIO, or PACE.

Medicare-2002

VARIABLE	OHIO	U.S.
Total Dual Eligibles *	219,000	7,200,000
Total Dual Eligibles as a share of all Medicaid Enrollees	13%	14%
Total Dual Eligibles as a share of Senior and Disabled Medicaid Enrollees	51%	58%
Total Dual Eligibles as a share of Senior Medicaid Enrollees	89%	91%
Total Dual Eligibles as a share of disabled Medicaid Enrollees	29%	34%
Total Full Dual Eligibles*	179,000	6,126,000
Full Dual Eligibles as a share of all Dual Eligibles	82%	85%

* Dual eligibles receive Medicare (Part A and Part B) and also some form of Medicaid assistance. This group includes “Full” dual eligibles, those people receiving full Medicaid benefits (i.e., prescription drugs and nursing home care) and Medicaid coverage of Medicare's financial requirements, and “Partial” dual eligibles, those people receiving some level of assistance with Medicare cost-sharing and premiums only.

Social Security Disability Income-2003
(SSDI)

VARIABLE	OHIO	U.S.
Total SSDI beneficiaries, ages 18-64	258,167	6,545,965
Total Social Security Disability Insurance (SSDI) Beneficiaries Ages 18-64 as a Percent of Population (18-64),	3.6%	3.6%

Supplemental Security Income
(SSI)

SSI is a federal entitlement program that provides cash assistance to low-income aged, blind, and disabled individuals. People receiving SSI benefits are eligible for Medicaid coverage in all states except "section 209(b)" states, which have opted to use their more restrictive 1972 criteria in determining Medicaid eligibility for SSI recipients. Section 209(b) of the 1972 amendments to the Social Security Act allowed states the option of continuing to use their own eligibility criteria in determining Medicaid eligibility for the elderly and disabled rather than extending Medicaid coverage to all of those individuals who qualify for SSI benefits. As of 2001, Ohio was one of only eleven states electing the "209(b)" option to apply their 1972 eligibility criteria to aged or disabled individuals receiving SSI benefits for purposes of determining Medicaid eligibility.

VARIABLE	OHIO	U.S.
Total SSI Beneficiaries	243,679	6,901,622
SSI Beneficiaries as % of the population	2.1%	2.4%
Senior SSI	15,938	1,232,642
Senior SSI as % of Population 65 and Older	1.1%	3.4%
Blind and Disabled SSI	227,741	5,668,980
Blind and Disabled SSI as % of Population	2.0%	1.9%

Medicare Advantage

The Medicare Advantage (MA) program was created as part of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) 2003. The Medicare Advantage program replaced the Medicare+Choice program giving beneficiaries the option to receive their healthcare through a variety of private health plans.

VARIABLE	OHIO	U.S.
Total Medicare Advantage Enrollment*	216,462	5,120,966

* Includes coordinated care plan (CCP) contracts, preferred provider organization (PPO) demonstration contracts, cost contracts, private fee-for-service (PFFS) contracts, and other demonstration contracts. Excludes health care prepayment plans (HCPPs) and PACE plans.

Payment rate is weighted by Medicare Advantage enrollees in coordinated care plan (CCP) contracts, preferred provider organization (PPO) demonstration contracts, and cost contracts in each county.

Total Medicare Advantage Enrollment by Plan Type

VARIABLE	OHIO #	OHIO %	U.S. #	U.S. %
CCP	191,121	88.3	4,624,850	90.3
Other Plans	25,341	11.7	496,116	9.7
All Plans	216,462	100	5,120,966	100

Medicare Advantage Contracts by Plan Type

VARIABLE	OHIO #	OHIO %	U.S. #	U.S. %
CCP/PPO Demo*	14	82.4	178	76.1
Other Plans	3	17.6	56	23.9
All Plans	17	100	234	100

*CCP: Coordinated Care Plan

* PPO: Preferred Provider Organization

Ohio’s Distribution of Personal Health Care Spending by Service (in millions) - FY 2000

Personal health care expenditures measure spending for all privately and publicly funded personal health care services and products (hospital care, physician services, nursing home care, prescription drugs, etc.) by state of residence. Costs such as insurance program administration, research, and construction expenses are not included in this total.

VARIABLE	OHIO	U.S.
Personal Health care Expenditures (in millions) SYF 2000	$46,981	$1,136,115
Average Annual Growth in Personal Health Care Expenditures from 1980 to 2000	8.0%	8.7%

Distribution of Personal Health Care Expenditures by Service (in millions), FY 2000

VARIABLE	OHIO $	OHIO %	U.S. $	U.S. %
Hospital care	17,291	36.8	413,131	36.4
Physician & Other Professional Services	12,091	25.7	328,983	29
Drug and Other Medical Nondurables	6,387	13.6	151,926	13.4
Nursing Home Care	5,612	11.9	95,296	8.4
Dental Services	2,233	4.8	60,726	5.3
Home Health Care	1,491	3.2	31,616	2.8
Medical Durables	692	1.5	17,750	1.6
Other Personal Health Care	1,182	2.5	36,687	3.2
Total	46,981	100	1,136,115	100

Nursing Homes

VARIABLE	OHIO	U.S.
Number of Residents	71,420	1,346,686
Residents as % of 65+ Population	4.7%	3.8
Number of Certified Nursing Facilities	868	15,162
Deficiencies per Facility	6.0	6.3
Percent with No Deficiencies	10.5%	10%

Top Ten Deficiencies in Nursing Homes in 2002

VARIABLE	OHIO	U.S.
Accidents*	24	23
Accident Prevention*	30	20
Comprehensive Care Plans*	18	17
Dignity*	16	16
Food Sanitation*	38	33
Housekeeping*	22	18
Infection Control*	14	14
Pressure Sores*	22	16
Professional Standards*	24	20
Quality of Care*	21	25

Deficiencies at nursing facilities are cited by state surveyors when specific standards are violated and can result in a negative impact on the health and safety of residents.

* Accidents: Resident environments must remain as free of accident hazards as possible.

* Accident Prevention: Residents must receive adequate supervision and assistance to prevent accidents.

* Comprehensive Care Plans: Facilities must develop individualized comprehensive care plans to help ensure that each resident receives necessary personalized care and services.

* Dignity: Facilities must create an atmosphere that promotes each resident’s dignity and individuality.

* Food Sanitation: Facilities must store, prepare, distribute, and serve food under sanitary conditions.

* Housekeeping: Facilities must maintain a sanitary, orderly, and comfortable environment.

* Infection Control: Facilities must investigate, control, and prevent infections through an infection control program, determine procedures for individual cases and document them accurately.

* Professional Standards: Facilities must ensure that the services they provide meet professional standards of quality.

* Quality of Care: Residents must be provided the necessary care and services to enable them to achieve their highest levels of physical, mental, and psychosocial well-being.

Patients’ Rights

An external review applies to any health-insuring corporation that denies, reduces or terminates coverage. A grievance must be filed to the superintendent of insurance within 60 days of the notice by the insured. Ohio is one of forty-five states that mandate such a review. Only ten states mandates health plan liability, Ohio does not. Ohio is one of thirty-two states that ban financial incentives to providers. Twenty-six states mandate direct access to providers, but Ohio is not one of them. Ohio, along with thirty-one other state,s mandates standing referrals for on-going care with a specialist. Finally Ohio does not mandate licensing of their health plan directors, unlike thirty-two other states.

Ohio, along with thirty-nine other states, has drug formulary requirements. Drug formularies are lists of drugs created by managed care organizations (MCOs) that are designed to include the most cost-effective, safe, and clinically appropriate drugs for prescription by the plans' prescribers. States regulate the use of drug formularies either by requiring MCOs to provide to enrollees and prospective enrollees information about their formulary, such as the drugs contained in the formulary (Disclosure), or by establishing certain procedures related to the formulary, such as a process for enrollees to obtain nonformulary drugs (Procedure). Ohio has established procedures related to their formulary.

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