reports

The actual versus expected health care use among Healthy Kids enrollees

Gainesville, FL, USA: Institute for Child Health Policy, University of Florida.

Institute for Child Health Policy, University of Florida, Gainesville, FL, USA

As part of the program evaluation, the Healthy Kids Corporation is monitoring, on an ongoing basis, the extent to which enrollees are using health care services in a manner consistent with their expected pattern of use. The Healthy Kids Program was designed to improve children’s access to health care through the provision of insurance premiums and a private-sector provider network. Ensuring that children are using the appropriate amount of health care services is an important measure of their access to care while in the program. In addition, measuring the expected number of health care visits based on the children’s diagnoses, and comparing this number to the actual number of health care visits the children made is an essential process measure of healthcare quality. Particularly in a managed care environment where some consumers, health care providers, and policy makers are concerned about potential underuse of health care services, it is important to conduct an ongoing evaluation of the appropriateness of the children’s health care use.
Because the Healthy Kids Program is operating at many different sites and working with many different managed care companies, it is useful to compare the patterns of health care use across sites. However, such comparisons can be difficult to make unless the health care needs of the enrollees at each site are taken into consideration. Various methods have been developed to assess the risk that a provider or a managed care company has for experiencing high health care use and/or morbidity. Risk adjustment methods allow for meaningful comparisons of health care use from one setting to another by controlling for differences in patient severity. These methods can also be used to predict health care use and costs, thereby enhancing the ability of health care providers and administrators to plan effectively for their patient populations.
As part of the Healthy Kids Program evaluation, we analyze the impact of gender, age, and diagnosis on health care use using a software program called the Ambulatory Care Groups (ACG) Case-Mix Adjustment System.
The purpose of this report is to:
1. Describe the case-mix of the Healthy Kids by site. For purposes of confidentiality, the data are presented for Site 1 through Site 24, rather than by county name or health plan name (Site 16 is not included in this report – see paragraph below for details).
2. Present information about the health care use of the Healthy Kids for January 1, 2000 through December 31, 2000 at each site. Present information about how the actual use compares to the use that was expected based on the casemix of the enrollees.