title: Evaluating Medicaid HMOs when encounter data are missing: case of developmentally delayed children.
abstract: In evaluating Medicaid Health Maintenance Organizations (HMOs), crucial information regarding severity of illness of patients is often missing--in part because encounter data are not available. If we assume that patients are either in the HMO or in fee-for-service (FFS) plans (i.e., no in or out migration); then severity of HMO patients can be deduced from encounters of FFS patients. We applied this approach to effectiveness of HMO services for developmentally delayed children. Data supported the assumption of a closed system. Data also showed that over 12 months, severity of FFS patients declined. Therefore, we inferred that the HMO was attracting sicker patients. The HMO was paid less than FFS plan, despite the fact that it attracted sicker patients.
authors.affiliation: Health System Management Program, College of Nursing and Health Sciences, George Mason University, Fairfax, Virginia, 4400 University Drive, Fairfax, VA 22030-4444, USA. Falemi@gmu.edu
authors.forename: Farrokh
authors.initials: F
authors.lastname: Alemi
authors.forename: P J
authors.initials: PJ
authors.lastname: Maddox
authors.forename: Valentin
authors.initials: V
authors.lastname: Prudius
authors.forename: Victoria
authors.initials: V
authors.lastname: Doyon
mesh_terms: D002648:Child; D002658:Developmental Disabilities / Q000145:classification / Q000453:epidemiology*; D019988:Children with Disabilities / Q000145:classification / Q000706:statistics & numerical data*; D018588:Fee-for-Service Plans / Q000706:statistics & numerical data; D006279:Health Maintenance Organizations / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data; D006302:Health Services Research; D006801:Humans; D015273:Insurance Selection Bias; D008484:Medicaid / Q000706:statistics & numerical data*; D015233:Models, Statistical; D012720:Severity of Illness Index; D014481:United States / Q000453:epidemiology; D014600:Utilization Review