title: Future expenditure risk of silent members: a statistical analysis.
abstract: Silent-members are members of a medical health plan who submit no claims for healthcare services in a benefit year despite 12 months of continuous-enrollment. This study was conducted to evaluate the future expenditure risk of commercial-insured members who avoid all medical care despite coverage. In order to determine if the silent-members were at greater risk, we compared them to members who received care in the anchor year (2009) but had low-expenditures. The low-expenditure members were assumed to represent persons without significant medical conditions and without care-avoidance behaviors. We examined the claims experience of a cohort of silent members in the 2 years after the silent year (2009) and compared it with the corresponding claims experience for a cohort of low-expenditure members from the same anchor year (2009).
  
  
  
  Members of commercial health plans (BCBS of Texas) were selected based on continuous-enrollment in 2009. Two sub-groups were identified based on annual claims expenditure: Care avoiders were members with 12 months continuous-enrollment and no medical claims, and are thus referred to as "silent members" in the insurance industry. Low-Expenditure members were those with 12 months continuous-enrollment and total PMPY (per member per year) annual medical claims expenditure in the lowest 10th percentile of members with claims experience. "Low-expenditure" members served as a comparison group to the "silent members", under the assumption that such claimants were using benefits for minor healthcare issues as needed. Key variables were enrollment and expenditures. Enrollment data identified demographics and continuous-enrollment. Medical claims data were used to calculate utilization and expenditures. All claims data were de-identified and no consent was required, as approved by the Institutional Review Board. No research involved human subjects. Multivariate logistic regression models were applied.
  
  
  
  Silent members who seek care in subsequent years have a greater probability of becoming high-expenditure claimants than those with low-expenditure experience.
  
  
  
  For silent members who subsequently seek treatment, the probability of becoming high-expenditure is significantly greater than low-expenditure members from the anchor year. The implications of future high costs for silent members who become claimants may support the need for additional research to address the risks of care avoidance behaviors.
authors.affiliation: Department of Management, Policy and Community Health, University of Texas School of Public Health, Co-Director, UTSPH - Center for Healthcare Data Research, University of Texas School of Public Health, University of Texas School of Public Health, 1200 Pressler Street RAS E905, Houston, TX, 77030, USA. Trudy.M.Krause@uth.tmc.edu.
authors.forename: Trudy Millard
authors.initials: TM
authors.lastname: Krause
authors.affiliation: Department of Management, Policy and Community Health, University of Texas School of Public Health, 1200 Pressler Street RAS E345, Houston, TX, 77030, USA.
authors.forename: Elifnur
authors.initials: E
authors.lastname: Yay Donderici
authors.affiliation: Department of Management, Policy and Community Health, University of Texas School of Public Health, Co-Director, UTSPH - Center for Healthcare Data Research, University of Texas School of Public Health, University of Texas School of Public Health, 1200 Pressler Street RAS E905, Houston, TX, 77030, USA.
authors.forename: Cecilia
authors.initials: C
authors.lastname: Ganduglia Cazaban
authors.affiliation: Department of Health Services Administration, School of Public Health, University of Maryland, 3310D SPH Building #255, College Park, MD, 20742-2611, USA.
authors.forename: Luisa
authors.initials: L
authors.lastname: Franzini
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D005544:Forecasting; D005102:Health Expenditures / Q000706:statistics & numerical data / Q000639:trends*; D006296:Health Services / Q000191:economics*; D006801:Humans; D007345:Insurance Claim Review; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D012307:Risk Factors; D013781:Texas; D055815:Young Adult
keywords: Care-avoidance; Claims-data; Expenditures; PMPY; Risk; Silent-members