Improving the management of care for high-cost medicaid patients

Health Affairs

Volumn 26, Issue 6, 2007, Pages 1643-1655

  Billings, John ^a   Mijanovich, Tod ^a  

^a NEW YORK UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ALGORITHM; ARTICLE; COST BENEFIT ANALYSIS; DISEASE MANAGEMENT; ECONOMICS; HEALTH CARE COST; HEALTH CARE PLANNING; HOSPITALIZATION; HUMAN; MEDICAID; METHODOLOGY; RISK ASSESSMENT; SOCIAL PSYCHOLOGY; UNITED STATES; UTILIZATION REVIEW;

ALGORITHMS; COST-BENEFIT ANALYSIS; DISEASE MANAGEMENT; HEALTH CARE COSTS; HOSPITALIZATION; HUMANS; MEDICAID; RISK ASSESSMENT; SOCIAL VALUES; STATE HEALTH PLANS; UNITED STATES;

EID: 36849009686     PISSN: 02782715     EISSN: 02782715     Source Type: Journal    
DOI: 10.1377/hlthaff.26.6.1643     Document Type: Article

References (27)

1. See V. Smith et al., "Low Medicaid Spending Growth amid Rebounding State Revenues" (Menlo Park, Calif.: Henry J. Kaiser Family Foundation, October 2006).
2. A. Sommers and M. Cohen, "Medicaid's High Cost Enrollees: How Much Do They Drive Program Spending?" (Menlo Park, Calif.: Kaiser Family Foundation, March 2006).
3. J.L. Gillespie and L.F. Rossiter, "Medicaid Disease Management Programs: Findings from Three Leading U.S. State Programs," Disease Management and Health Outcomes 11, no. 6 (2003): 345-361. See also the Indiana Chronic Disease Management Program home page, http://www. indianacdmprogram.com;
4. Washington State Department of Social and Health Services, "Medicaid Disease Management Program Winds Down as DSHS Prepares New Approach for 2007," Press Release, 9 June 2006, http://www1.dshs.wa.gov/mediareleases/ 2006/pr06088.shtml (accessed 2 August 2007);
5. and OMPRO, "An Evaluation of the Management of Chronic Disease by Oregon Health Plan Managed Care Plans, 2003-2004," 19 August 2005, http://www.oregon.gov/DHS/healthplan/data_pubs/reports/diseasemgt0304.pdf (accessed 2 August 2007).
6. R.Z. Goetzel et al., "Return on Investment in Disease Management: A Review," Health Care Financing Review 26, no. 4 (2005): 1-19.
7. J. Billings et al., "Case Finding for Patients at Risk of Readmission to Hospital: Development of an Algorithm to Identify High Risk Patients," British Medical Journal 333, no. 7563 (2006): 327;
8. R.T. Meenan et al., "The Sensitivity and Specificity of Forecasting High-Cost Users of Medical Care," Medical Care 37, no. 8 (1999): 815-823;
9. D.M. Smith et al., "Predicting Non-Elective Hospital Readmissions: A Multi-Site Study," Journal of Clinical Epidemiology 53, no. 11 (2000): 1113-1118;
10. Y. Zhao et al., "Identifying Future High-Cost Cases through Predictive Modeling," Disease Management and Health Outcomes 11, no. 6 (2000): 389-397;
11. and A.K. Rosen et al., "Identifying Future High-Healthcare Users: Exploring the Value of Diagnostic and Prior Utilization Information," Disease Management and Health Outcomes 13, no. 1 (2005): 117-127.
12. SSI disabled adults are low-income people who are unable to engage in substantial gainful activity, whose condition can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than twelve months. For a more detailed description, see Social Security Administration, Understanding Supplemental Security Income: SSI Eligibility Requirements, 2007 Edition, http://www.socialsecurity.gov/ssi/text- eligibility-ussi.htm (accessed 2 August 2007). Patient swith serious and persistent mental illness (as identified by the New York State Department of Health), those with dual eligibility, HIV/AIDS patients, patients with end-stage renal disease (ESRD), residents of intermediate care facilities for the mentally retarded (ICF/MR), and others were "exempted" from mandatory enrollment (but allowed to enroll voluntarily). Disabled "spend-down" patients, certain patients in long-term care, "restricted recipient" patients, and others were "excluded" for enrollment.
13. For a full listing of exclusions and exemptions, see New York City Department of Health and Mental Hygiene, "New York City List of Exemption Categories," 2007, http:// www.nyc.gov/html/doh/html/hca/hca5.shtml (accessed 2 August 2007). About 8 percent of SSI disabled patients voluntarily enroll in managed care, and these patients were excluded from the analysis because claims data for these patients were not available.
14. For variables included in the model, see Appendix 1, online at http://content.healthaffairs.org/cgi/content/full/26/6/1643/DC1.
15. See J. Billings et al., Case Finding Algorithms for Patients at Risk of Re-Hospitalisation, PARR1 and PARR2, 22 February 2006, http://www.kingsfund.org.uk/document.rm?id=6209 (accessed 25 September 2007).
16. For information on the "archival" approach, as well as specific variable definitions and regression coefficients, see New York University, Center for Health and Public Service Research, "Variables Included in Stepwise Regression," http://www.nyu.edu/wagner/chpsr/CaseFindingAlgorithm. xls (accessed 25 September 2007).
17. See Appendix 2 online, as in Note 7.
18. See Appendix 3 online; ibid.
19. J. Billings et al., "Impact of Socioeconomic Status on Hospital Use in New York City," Health Affairs 12, no. 1 (1993): 162-173;
20. and J. Billings, J. Anderson, and L. Newman, "Recent Findings on Preventable Hospitalizations," Health Affairs 15, no. 3 (1996): 239-249.
21. For a listing of the top twenty-five International Classification of Diseases, Ninth Revision (ICD-9), codes for future admissions, see Appendix 4 online, as in Note 7.
22. E.H. Wagner, B.T. Austin, and M. von Korff, "Organizing Care for Patients with Chronic Illness," Millbank Quarterly 74, no. 4 (1996): 511-544.
23. For a list of ICD-9 codes for future admissions, see Appendix 4 online, as in Note 7.
24. D.P. Culhane, S. Metreaux, and T. Hadley, "Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental Illness in Supportive Housing," Housing Policy Debate 13, no. 1 (2002): 107-163;
25. and T.E. Martinez and M.R. Burt, "Impact of Permanent Supportive Housing on the Use of Acute Care Health Services by Homeless Adults," Psychiatric Services 57, no. 7 (2006): 992-999.
26. See Dartmouth Atlas of Health Care Data Tables, http://cecsweb.dartmouth.edu/release1.1/datatools/datatb_s1.php (accessed 6 September 2007).
27. Billings et al., Case Finding Algorithms.