preliminary results of the special health care needs focused study tuesday, june 19, 2007 1:15 p.m....
TRANSCRIPT
Preliminary Results of the Special Health Care Needs
Focused Study
Tuesday, June 19, 20071:15 p.m. –1:45 p.m.
David Mabb, MS, CHCA
Sr. Director, Statistical Evaluation
Study Purpose
• To determine how members with special health care needs are identified, and assessed for special health care needs.
• To identity potential improvements to the identification process that may ensure more efficient, accurate identification, and assessment of people with special health care needs.
Study Population
• The time period for the data collection was January 1, 2006 through June 30, 2006 (with some variation for newer plans).
• All members enrolled in HMOs, PSNs, or MediPass (for the PMHPs) for at least one month during the time period.
Study Population
• 13 Health Maintenance Organizations (HMOs)
• 1 Provider Service Network (PSN)
• 5 Prepaid Mental Health Plans (PMHPs)
Sample Sizes
• No sampling was performed; all data analysis used administrative data and included the entire MCO population.
Study Indicators
Study Indicator #1: Identification of members with special health care needs.
• The denominator for this indicator consisted of the member roster for each month of the data collection period.
• The numerator was those members identified as potentially having a special health care need.
Study Indicators
Study Indicator #2: Members assessed and monitored for special health care needs.
• Denominator - members identified as potentially having a special health care need as defined in study indicator #1.
• Numerator #1 - members who were assessed for a special health care need.
• Numerator #2 - members who were monitored
for their special health care need.
Study Indicators
Study Indicator #3: Identification of members with special health care needs using a standardized methodology.
• Denominator - member roster for each month of the data collection period (i.e., the same denominator as Indicator #1).
• Numerator - members identified as potentially
having a special health care need as defined by the standardized methodology, developed for the purposes of this study.
Study Findings
Time Period* Members with a Potential SHCN
HMOs & PSN PMHPs**
January, 2006 8.3% 5.2%
February, 2006 8.8% 5.2%
March, 2006 8.9% 5.7%
April, 2006 9.0% 5.3%
May, 2006 9.1% 5.7%
June, 2006 9.3% 5.6%
Average 8.9% 5.5%
* One MCO submitted data for an alternate time period (July – Dec 2006). Results are incorporated into the six month time period displayed above.
**Based on all MediPass eligible members who can receive services from the PMHP.
Study Findings
0
5
10
15
20
25
A B C D E F G H I J K L M N
Perc
ent
Percentage of members identified with a potential SHCN, by MCO
Study Findings
MCOProvider
or CM ReferralMember Referral
Health Risk Assessment
ICD-9 Diagnosis
CodesEligibility Data
ACS SHCN Report
A X X X X X
B X X X
C X X X
D X X X X
E X X X
F X X X
G X X X X X X
H X X X X
I X X X
J X X X X X
L X X X
K X X X Few X
M X X X X
N X X X X
Study Findings
• A member may be identified with a potential SHCN, but the assessment and/or monitoring may actually begin in the following month, or later.
• A member referred by a provider may not need to have an assessment.
• The definition of assessment may not be well-defined. For example, MCOs may consider assessment as the time the person was identified with a potential SHCN, or as the time the SHCN was confirmed.
• An assessment may not have been performed.
The rates for assessment and monitoring varied greatly by individual MCOs. The following were identified as possible reasons for the substantial differences in rates:
Conclusions
• None of the MCOs interpreted the contract definition in the same manner and used the same methods to identify individuals with SHCNs.
• The variation in the methods used accounted for at least part of the vast differences in the rates of identification among the MCOs.
• The findings indicate that for the HMOs and PSN, those that do not use ICD-9 codes to identify members with potential SHCN have the lowest rates of identification.
Next Steps
• MCOs submit data for study indicator #3. (This step should be completed as of June 15th)
• HSAG completes analysis for study indicator #3. • HSAG provides final report to AHCA.
Questions and Answers