Preliminary Results of the Special Health Care Needs Focused Study Tuesday, June 19, :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 & PSNPMHPs** January, %5.2% February, %5.2% March, %5.7% April, %5.3% May, %5.7% June, %5.6% Average8.9%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 Percentage of members identified with a potential SHCN, by MCO

Study Findings X - indicates the MCO currently uses this method. MCO Provider or CM Referral Member Referral Health Risk Assessment ICD-9 Diagnosis Codes Eligibility Data ACS SHCN Report AXXXXX BXXX CXXX DXXXX EXXX FXXX GXXXXXX HXXXX IXXX JXXXXX LXXX KXXXFewX MXXXX NXXXX

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 15 th ) HSAG completes analysis for study indicator #3. HSAG provides final report to AHCA.

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