David Mabb, MS, CHCA Sr. Director, Statistical Evaluation

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