MAX. As an increasingly larger share of Medicaid enrollees MEDICAID POLICY BRIEF

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1 MAX CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICAID POLICY BRIEF Brief 14 December 2012 The Avilbility nd Usbility of Behviorl Helth Orgniztion Encounter Dt in MAX 2009 Jessic Nysenbum, Ellen Bouchery, Roslie Mlsberger As n incresingly lrger shre of Medicid enrollees receives behviorl helth services through mnged cre rrngements, the encounter dt tht sttes receive from mnged cre orgniztions hve the potentil to provide reserchers nd policymkers with vluble insight into the cre needs nd service use of Medicid mnged cre enrollees. However, not ll sttes report encounter dt, nd for those tht do, we know little bout the qulity nd completeness of the dt. This issue brief documents detiled nlysis of the behviorl helth orgniztion (BHO) encounter dt in the 2009 Medicid Anlytic extrct files (MAX 2009) nd ssesses the vibility of using these dt for reserch. Introduction Medicid pid for 26 percent of ll mentl helth (MH) nd substnce buse (SA) services delivered in the United Sttes in 2005, mking it the lrgest source of pyment for these services (Substnce Abuse nd Mentl Helth Services Administrtion 2010). Reserchers nd policymkers interested in studying the MH nd SA services delivered nd enrollees served under Medicid require relible source of dt. Medicid Anlytic extrct (MAX) files contin dt on Medicid enrollment nd service utiliztion in ll sttes nd the District of Columbi nd re enhnced to support reserch, mking them n excellent source of dt for nlysis of MH nd SA tretment under Medicid. The MAX files include dt from mnged cre orgniztions (MCOs) tht contrct with sttes to provide services to beneficiries in exchnge for flt cpittion pyment. These encounter dt reflect services provided nd dignosis informtion, but not informtion on expenditures. Encounter dt re becoming more importnt in reserch on Medicid MH nd SA service provision becuse these services re incresingly being delivered through comprehensive MCOs tht contrct to provide the full rnge of medicl services (helth mintennce orgniztions or HMOs) nd by those tht contrct to provide only behviorl helth About This Series The MAX Medicid policy issue brief series highlights the essentil role MAX dt cn ply in nlyzing the Medicid progrm. MAX is set of nnul, person-level dt files on Medicid eligibility, service utiliztion, nd pyments tht re derived from stte reporting of Medicid eligibility nd clims dt into the Medicid Sttisticl Informtion System (MSIS). MAX is n enhnced, reserchfriendly version of MSIS tht includes finl djudicted clims bsed on the dte of service, nd dt tht hve undergone dditionl qulity checks nd corrections. CMS produces MAX specificlly for reserch purposes. For more informtion bout MAX, plese visit: cms.gov/reserch-sttistics-dt-nd-systems/computer-dt-nd-systems/mediciddtsourcesgeninfo/ MAXGenerlInformtion.html. services (BHOs). The percentge of Medicid recipients enrolled in comprehensive mnged cre incresed from 41 to 50 percent between 2004 nd 2008 (Borck et l. 2012). The percentge enrolled in BHO incresed from 13 to 22 percent in the sme period (Borck et l. 2012). The vilbility, completeness, nd qulity of the MAX encounter dt, however, hve been reviewed only recently nd only to limited extent. This brief is one in series tht is intended to fill this gp, providing reserchers nd policymkers with informtion on encounter dt in MAX so tht they cn mke better decisions bout whether to include these dt in their nlyses. The two prior briefs in this series (Dodd et l nd Byrd et l. 2012) exmined the usbility of encounter dt for comprehensive MCOs in the MAX clims files, nd the uthors drew promising conclusions bout the dt s potentil in this regrd. This brief goes one step further by exmining BHO encounter dt in MAX It provides bckground on Medicid MH 1

2 nd SA service coverge, Medicid eligibility, nd the impct of MH nd SA delivery systems; describes methods for ssessing the vilbility, completeness, nd qulity of the MAX encounter dt; presents findings from our nlysis of BHO enrollment, cpittion, nd encounter dt; nd summrizes our conclusions. Bckground To ssess the vilbility nd completeness of BHO encounter dt, we compred the level of services reported for BHO enrollees in encounter dt to the level of services reported in fee-for-service (FFS) clims for enrollees in sttes tht provide behviorl helth services through FFS. This comprison is not strightforwrd for severl resons. First, there is substntil vrition between sttes, nd thus between stte-contrcted BHO plns, in the behviorl helth services covered by Medicid. Second, the sttes lso vry in terms of the subpopultions eligible for Medicid nd those enrolled in mnged cre. Finlly, the services received by Medicid enrollees with similr cre needs my differ depending on whether they re delivered through BHO or through FFS Medicid. Vrition in MH nd SA Service Coverge Assessing the vilbility nd completeness of BHO encounter dt is complicted by stte-to-stte vrition in Medicid service coverge. According to federl guidelines, sttes must cover certin ctegories of services ( mndtory services ), nd they my receive mtching federl funds for other ctegories of services if they choose to cover them ( optionl services ). Mediclly necessry inptient hospitl cre nd physicin services for MH or SA re mndtory. The sme is true for erly nd periodic screening, dignostic, nd tretment (EPSDT) services for individuls younger thn 21 yers old. MH nd SA tretment needs identified s prt of these screenings must be covered in ll sttes. However, services for individuls ge 22 to 64 in institutions for mentl disese generlly cnnot be covered under Medicid. Medicid coverge of other MH nd SA services is optionl, which ultimtely mens tht the services my be covered in some sttes but not in others. Optionl MH nd SA services include psychologist services, clinicl socil worker services, prescription drugs, personl ssistnce, dignostic screening, rehbilittion nd preventive services, outptient hospitl services, clinic services, community supports, service coordintion, nd cse mngement. It is lso noteworthy tht sttes covering specific benefit my vry gretly in the generosity of the benefit nd limittions of coverge. BHOs my contrct with stte Medicid gencies to provide only subset of the behviorl helth services covered by the stte. For exmple, the BHO might provide MH services while SA tretment services re covered through FFS. Colordo is n exmple of this rrngement. In ddition, in sttes tht use both comprehensive MCOs nd BHOs to deliver services, both orgniztions my provide some level of coverge for MH nd SA services. In these sttes, MCOs typiclly cover bsic behviorl helth services provided in primry cre settings, wheres BHOs provide more specilized nd complex services. For exmple, Michign s MCOs cover outptient mentl helth services, but the stte lso hs BHOs, which cover specilized services such s community living supports, crisis interventions, nd extended observtion beds. In some sttes, specific providers or services (for exmple, Crisis nd MH Rehbilittion in Iow) my lso be excluded from BHO coverge. Vrition in Behviorl Helth Needs of Medicid Enrollees To receive federl mtching funds, stte Medicid progrms must cover ll individuls in certin eligibility groups. Sttes lso hve the option to cover individuls in certin dditionl groups who do not meet the income nd resource thresholds set by the federl government for mndtory coverge. The mndtory groups include low-income women nd children, low-income Medicre enrollees, nd individuls eligible for the Supplementl Security Income (SSI) progrm. The optionl groups include mediclly needy individuls, higher-income children nd pregnnt women, the institutionlized ged nd disbled, nd people eligible through 1115 demonstrtion wivers. These popultions vry widely in their need for behviorl helth services, nd sttes vry in the degree to which they enroll ech of these groups in mnged cre. We therefore nlyzed the MAX dt by bsis-ofeligibility (BOE) ctegory dult, children, disbled, nd ged when mking comprisons cross sttes nd plns. Impct of BHOs on the Delivery of Medicid Behviorl Helth Services Finlly, the services received by Medicid enrollees with similr cre needs my differ depending on whether they re delivered through BHO or through FFS Medicid. BHOs my help sttes control behviorl helthcre costs (Shirk 2008). A review of the reserch from 1990 through 2005 (Muery 2006) on mnged MH cre indictes tht providing MH services through n MCO cn reduce the cost of cre. The techniques used by BHOs to reduce costs include prior uthoriztion nd medicl necessity requirements, selective contrcting with providers nd trnsferring risk to their providers, nd phrmcy benefit mngement. As result, mnged MH cre orgniztions hve been ble to reduce the verge number of outptient visits per user, the probbility of inptient dmissions, the length of sty for inptient tretment, nd the cost per unit of cre. We consider these impcts on utiliztion when evluting the comprisons of service use between BHOs nd FFS Medicid below. 2

3 Dt nd Methods Severl types of dt re included in MAX for BHO plns. MAX includes enrollment dt, cpittion clims, 1 nd encounter dt for BHO plns, nd ll three types of dt re needed for mny nlyses. However, reporting of BHO dt vries significntly cross sttes, nd few sttes report ll three types of dt. Most sttes report BHO enrollment dt, fewer report cpittion dt, nd even fewer report encounter dt. In ddition, mny sttes use multiple BHO plns to serve their Medicid beneficiries, nd the vilbility of dt vries by pln. The nlysis described here is bsed on n exmintion of MAX 2009 dt for BHO enrollees nd FFS enrollees. We restricted our nlysis to enrollees eligible for full Medicid benefits 2 nd to BHO plns with t lest 10 cpittion clims nd 10 encounter records. This threshold ws set low so tht most plns would be included in our initil nlysis of completeness. Dt for some BHO plns, such s those in Knss, were reported under more thn one pln identifiction number. Consequently, we combined the dt reported in these plns. Although FFS dt in MAX hs some completeness nd qulity issues, the informtion is generlly considered to be usble for reserch. Therefore, to determine whether the BHO encounter dt re lso generlly usble for reserch, we compred metrics of completeness nd qulity for BHOs to similr metrics for six sttes tht primrily cover MH nd SA services on FFS bsis: Albm, Alsk, Arknss, Illinois, Louisin, nd Mississippi. There re no BHOs in these sttes, nd enrollment in comprehensive MCOs ws very limited or nonexistent. 3 We first exmined BHO enrollment nd cpittion clim reporting in the 16 nlysis sttes with BHOs. We then exmined the completeness of encounter dt reporting in ech MAX clim file type: inptient (IP), long-term cre (LT), outptient (OT) nd prescription drugs (RX). While BHOs typiclly do not cover long-term cre services, specilty psychitric nd SA hospitl clims re reported in the LT file. We conducted n initil nlysis on the volume of the RX nd LT dt, but did not conduct detiled nlysis on these dt types since only smll mount of dt ws reported. For those plns with substntil reporting, we ssessed the qulity of encounter dt in the IP nd OT files. In the IP file, we clculted the number of clims per 1,000 person months of enrollment (PME). 4 In the OT file, we clculted the number of clims per PME, the percentge of BHO enrollees with ny encounter records, nd the number of clims per user of services. In sttes nd files with sufficiently complete dt, we nlyzed dt qulity in both the OT nd IP files by evluting the percentge of clims tht included primry dignosis, principl procedure code, nd revenue code. In ddition, in the IP file we lso ssessed the verge length of sty nd the verge number of dignosis nd revenue codes reported on IP encounter clims. We compred the dt completeness nd qulity metrics for the BHO plns to reference rnges estimted on the bsis of observed MH nd SA clims nd enrollment dt in the six FFS sttes. The rnges represent the minimum nd mximum vlue of the completeness nd qulity metrics observed in the individul FFS sttes in For exmple, the number of outptient clims per enrolled month mong the disbled rnged from 0.19 in Louisin to 2.11 in Arknss. Stte BHO encounter dt ws deemed sufficiently complete for nlysis if the completeness metrics for ech BOE group reported were within or exceeded the rnge for the FFS sttes. Becuse of the vrition in MH nd SA service coverge cross the sttes, exceeding the rnge observed for the FFS sttes is likely to indicte tht stte s coverge exceeds tht of the FFS sttes nlyzed. Thus, in our nlysis of dt qulity, BHO plns whose metrics were within or exceeded the rnge observed for the FFS sttes were deemed to hve met initil qulity checks. Using the 2009 Ntionl Summry of Stte Medicid Mnged Cre Progrms (CMS 2010), we divided BHO plns into two groups: those covering MH services nd those covering both MH nd SA services. In the OT file, psychitric services re identified by the MAX type of service (TOS) code=53. The services identified by TOS=53 include counseling, therpy, ssessment, crisis intervention, community supports, socil rehbilittion, therpeutic foster cre, electroshock/electroconvulsive therpy, cognitive behviorl therpy, prtil hospitliztion, crisis residentil therpy, SA services, detoxifiction, services relted to utism, nd smoking cesstion services. Becuse this group of services is similr to the services covered by mny BHO plns, we used TOS=53 to identify the set of OT file comprison clims for the FFS sttes. For BHO plns tht cover only MH services (plns in Colordo, Florid, nd New Mexico), we limited FFS reference rnges to services for TOS=53 with primry dignosis code of MH. MH nd SA clims in the IP file cnnot be identified by TOS code becuse the psychitric service type is used only in the OT file. MH nd SA clims for FFS sttes in the IP file were identified bsed on whether they hd n MH or SA primry dignosis code. Findings In this section, we report the findings for the vilbility of enrollment nd cpittion dt, the completeness of encounter dt reporting, nd the qulity of the informtion reported on the encounter records. 3

4 Enrollment nd Cpittion Dt Reporting In 2009, 18 sttes operted BHO plns in their Medicid progrm (Tble 1). 5 However, dt for only 16 of these sttes were vilble in MAX 2009 t the time of this study. 6 In ddition, our initil nlysis showed tht Uth did not report enrollment dt for its BHO. Most of the remining 15 sttes reported enrollment in the BHO progrm for mjority of Medicid beneficiries in ech eligibility ctegory (dults, children, ged, nd the disbled). However, the shre of beneficiries whose enrollment in BHOs ws reported vried widely cross the sttes, rnging from only six to seven percent of beneficiries enrolled per eligibility group in North Crolin to universl enrollment in Wshington (Tble 2). In some sttes, low enrollment rte reflects BHO operting in limited re. According to CMS s Ntionl Summry of Stte Medicid Mnged Cre Progrms, North Crolin s BHO operted in only five of 100 counties in In other sttes, low enrollment rte my reflect the exclusion of certin subpopultions from enrollment. Across the 15 sttes, enrollment in BHOs ws the lest common for the ged. Mny of these people re dul eligibles (those eligible for both Medicid nd Medicre), nd becuse responsibility for covering services for these individuls is split between Medicid nd Medicre, they re less likely to be enrolled in Medicid mnged cre pln. Of the 15 sttes tht report enrollment in BHO plns in MAX 2009, 11 of them lso report cpittion dt (Tble 1). 7 With the exception of Michign, ll sttes tht hd multiple plns nd tht reported cpittion dt did so for every pln. We nlyzed the rtio of cpittion clims to person months of enrollment t the pln level. A rtio close to one indictes tht cpittion pyment ws reported for nerly every month tht beneficiry ws enrolled in mnged cre pln. Most BHO plns with both enrollment nd cpittion dt hd cpittion clims per enrolled month rnging from 0.75 to 1.25, resonbly good rnge. Encounter Dt Reporting Seven sttes with both enrollment nd cpittion dt lso reported BHO encounter dt: Arizon, Colordo, Florid, Iow, Knss, New Mexico, nd North Crolin (Tble 3). North Crolin submitted only 24 encounter records, ll in the OT file, nd ws dropped from the nlysis. While we set the threshold for inclusion in the nlysis for prticulr pln to be 10 encounter nd 10 cpittion clims, we felt 24 encounter records for n entire stte were too few to merit nlysis. In ddition, we identified substntil nomlous reporting in New Mexico. 8 Therefore, we dropped New Mexico from the nlysis, nd do not recommend using its reported IP nd OT BHO encounter dt. Of the five Tble 1. Summry of Cpittion nd Encounter Dt Reporting in Sttes with BHOs, MAX 2009 Cpittion Dt Reporting Encounter Dt Reporting Stte Any Dt Reported All Plns Reporting Any Dt Reported Arizon X X X X Colordo X X X Florid X X X Hwii NA NA Iow X X X X Knss X X X X Msschusetts X X Michign X Nebrsk New Mexico X X X X X X X X North Crolin All Plns Reporting Oregon Pennsylvni X X Tennessee X X Texs Uth Wshington Wisconsin NA NA Totl Source: Mthemtic nlysis of the MAX 2009 PS, IP, LT, OT nd RX files. Note: At lest 10 clims, by type, hd to be present in the MAX files to count s being submitted. Hwii nd Wisconsin were excluded from the nlysis becuse their MSIS files (the source for MAX files) were unvilble or contined significnt dt problems. remining sttes, the volume of encounter dt vried substntilly. Arizon submitted over 9 million BHO records, wheres Knss submitted bout 3,000. Vrition ws lso evident in whether encounter dt ws submitted in ll file types. All five sttes submitted encounter records in the OT file, four submitted dt in the IP file (Arizon, Colordo, Florid, nd Iow), but only two submitted dt in the RX file, nd just two others submitted dt in the LT files. Arizon ws the only stte to submit BHO encounter dt in ll four MAX clim file types. The bsence of the dt in the RX nd LT files does not necessrily indicte problem; BHO plns do not commonly cover drugs nd my not provide the specilty psychitric hospitl services included in the LT file. 4

5 Tble 2. Percentge of Medicid Enrollees in BHOs by Bsis of Eligibility, MAX 2009 Adults Children Aged Disbled Arizon Colordo Florid Iow Knss Msschusetts Michign Nebrsk New Mexico North Crolin Oregon Pennsylvni Tennessee Texs Wshington Source: Mthemtic nlysis of MAX Tble 3. BHO Encounter Dt in MAX 2009, by File Type OT Clims IP Clims LT clims RX clims Arizon X X X X Colordo X X Florid X X X Iow X X Knss X Msschusetts Michign Nebrsk New Mexico X X X New York North Crolin X b Oregon Pennsylvni Tennessee Texs Wshington Totl Source: Mthemtic nlysis of MAX 2009 IP, LT, OT, nd RX files. New Mexico submitted BHO encounter dt in the OT nd IP file, but we identified substntil nomlous reporting, including dentl nd primry cre clims lbeled s BHO clims. Thus, we excluded the stte from our nlysis. b There re only 24 OT BHO encounter records for North Crolin. Encounter Dt Completeness Our nlysis of encounter dt completeness included only BHO plns tht reported substntil number of encounter records nd hd no substntil reporting nomlies identified in the IP nd the OT files. For 3 plns out of 7 in Colordo nd one pln out of 12 in Florid, no encounter dt were reported despite substntil enrollment in the pln. Thus, our nlysis of dt completeness in Florid nd Colordo is limited to reporting plns. BHOs in four sttes (Arizon, Colordo, Florid, nd Iow) reported IP encounter dt (Tble 4). IP encounter clims for dults, children, nd the disbled were reported in ll four sttes. In three of the sttes, the reported number of encounters per 1,000 PME ws within the rnge of the FFS sttes for ll BOE groups. Iow ws the exception in tht its rte of utiliztion ws within the FFS rnge for the disbled group but exceeded the FFS rnge for dults nd children. Bsed on the observed reporting rtes, we conclude tht the IP encounter dt for these four sttes ppers to be complete enough for nlysis mong plns reporting encounter dt. In the OT file, we exmined three completeness mesures: the number of clims per PME, the percentge of enrollees with n OT encounter record, nd the number of OT clims per service user (Tbles 5 nd 6). In Arizon, the number of clims per PME ws within the FFS reference rnge for children nd the ged nd exceeded this rnge for dults nd the disbled. In ddition, Arizon s dt were within or slightly bove the FFS rnges observed for the percentge of enrollees with n OT clim nd the number of clims per user for ll BOE groups with the exception of the percentge of enrollees with clim for the ged group. It is possible tht behviorl helth service use in Arizon exceeded the level in the FFS sttes becuse Arizon is more generous in its coverge of behviorl helth services. Arizon lso covers n optionl Medicid eligibility group, childless dults, who my on verge hve greter need for behviorl helth services thn dults typiclly enrolled in Medicid. Overll, the OT file encounter dt for Arizon pper to be well reported. We therefore believe tht these dt re likely to be usble for nlysis. Iow s number of OT file clims per enrolled month fell within the rnge of the FFS sttes for ll BOE groups. Iow s dt for ll eligibility groups ws within or exceeded the FFS rnge for the percentge of enrollees with n OT encounter record nd the number of clims per user. Bsed on these comprisons, we conclude tht Iow s dt is complete enough for nlysis. Findings on the completeness of Florid s OT file dt re mixed. The stte s dt did not fll within the FFS rnges for clims per month of enrollment for children nd the disbled, 5

6 Tble 4. Comprison of FFS nd BHO IP Clims per 1,000 Months Enrolled, MAX 2009 Stte Disbled Adults Children Aged BHOs Covering MH nd SA FFS Reference Rnge Arizon Iow NA BHOs Covering Only MH FFS Reference Rnge Colordo NA Florid Source: Mthemtic nlysis of MAX Note: Ech BHO pln hd to hve t lest 10 cpittion nd BHO encounter records to be included in this nlysis. All plns were included in the nlysis for Arizon, Iow, nd Knss. Three plns out of 7 in Colordo nd one pln out of 12 in Florid were excluded becuse they did not meet this threshold for encounter reporting, but they did hve substntil reported enrollment. Becuse of the smll number of IP clims per enrolled month, we scled this metric by 1,000 for nlysis. Tble 5. Comprison of FFS nd BHO OT Clims Per Month Enrolled, MAX 2009 Stte Disbled Adults Children Aged BHOs Covering MH nd SA FFS Reference Rnge Arizon Iow Knss BHOs Covering Only MH FFS Reference Rnge Colordo Florid Source: Mthemtic nlysis of MAX Note: Ech BHO pln hd to hve t lest 10 cpittion nd BHO encounter records to be included in this nlysis. All plns were included in the nlysis for Arizon, Iow, nd Knss. Three plns out of 7 in Colordo nd one pln out of 12 in Florid were excluded becuse they did not meet this threshold for encounter reporting, but they did hve substntil reported enrollment. Knss hs two BHOs. One covers only MH services, nd the other covers only SA services. Dt for these two plns were combined for the completeness nlysis. The stte reported BHO encounter records for ll BOEs, but the rte of OT clims per person-month of enrollment ws less thn.01 nd ws rounded to zero. Tble 6. Percentge of Enrollees with n OT File Clim nd the Number of Clims per Service User, MAX 2009 Percentge of Enrollees with n OT BHO Clim Number of OT Clims per Service User Stte Disbled Adults Children Aged Disbled Adults Children Aged BHOs Covering MH nd SA FFS Reference Rnge Arizon Iow Knss BHOs Covering Only MH FFS Reference Rnge Colordo Florid Source: Mthemtic nlysis of MAX Note: Ech BHO pln hd to hve t lest 10 cpittion nd BHO encounter records to be included in this nlysis. All plns were included in the nlysis for Arizon, Iow, nd Knss. Three plns out of 7 in Colordo nd one pln out of 12 in Florid were excluded becuse they did not meet this threshold for encounter reporting, but they did hve substntil reported enrollment. Knss hs two BHOs. One covers only MH services, nd the other covers only SA services. Dt for these two plns were combined for the completeness nlysis. The stte reported BHO encounter records for ll BOEs, but the percentge of enrollees with n OT clims ws less thn.01 nd ws rounded to zero for the ged. 6

7 but the dt did fll within this rnge for dults nd the ged. Florid s rtes for the percentge of enrollees with n OT clim nd the number of clims per user provide further evidence tht dt for children nd the disbled my be incomplete. Yet on these mesures, dt for Florid s dults nd the ged were comprble to dt in FFS sttes. The lower number of overll clims in Florid (reflected in the clims per PME mesure) my be due to incomplete reporting in subset of plns becuse clims per PME vried substntilly cross the 11 BHO plns reporting encounter dt in Florid. Overll, OT dt for Florid my be usble for reserch, but nlysts should be cutious in doing so nd my need to limit their nlysis to plns with substntil OT file reporting. The observed OT file utiliztion metrics for Knss nd Colordo were substntilly below the rnge observed in the FFS sttes. 9 The observed difference in utiliztion is too lrge to be fully relted to reductions in cre resulting from BHO cre mngement prctices. Thus, the OT encounter dt in these sttes did not meet the thresholds creted for this nlysis, nd the dt reported in these sttes is likely to be incomplete. Encounter Dt Qulity We reviewed the qulity of BHO encounter dt in four sttes (Tble 7). We did not include Knss becuse it reported no IP file dt nd very few OT file clims per enrolled month. For sttes tht hd multiple plns reporting, the qulity of the dt ws reviewed by pln, limiting our nlysis to plns with t lest 10 encounter records in given file. For the OT file, we reviewed whether t lest one dignosis code nd one procedure code were listed on the encounter records. Among the FFS comprison sttes, nerly 100 percent of OT clims hd t lest one dignosis code nd t lest one procedure code. In Arizon, Iow, nd Colordo, ll OT file encounter records hd t lest one dignosis nd one procedure code. Florid reported encounter dt for 11 plns; the shre of encounter records with dignosis code rnged from 76.0 to 85.7 percent cross the plns. For ll of Florid s plns, over 95 percent of encounter records hd procedure code. For the IP file, we ssessed qulity on the bsis of encounters for which there ws t lest one dignosis code nd one revenue code. 10 We lso looked t whether reported length of sty, number of dignosis codes per clim, nd number of revenue codes per clim were in rnge tht ws similr to the FFS comprison sttes. Nerly ll of the IP encounter records reported in Arizon, Colordo, nd Florid hd dignosis code nd revenue code. However, only 6 of the 11 plns reporting in Florid reported 10 or more IP encounter records. In Iow, ll IP encounter records included dignosis code, but none included revenue codes. Averge length of sty vried widely cross the plns, rnging from 4.1 to 15.5 dys per sty. The vrition my be relted to differences in severity of illness cross the popultion enrolled, in the proportions of vrious popultions enrolled (for exmple, disbled versus children), nd in the levels nd types of cre covered by pln. For ll the BHO plns, the verge number of dignosis codes reported ws within the rnge for the FFS sttes. In Arizon nd Colordo, the verge number of revenue codes reported ws in the rnge for the FFS sttes. In Florid, the number of revenue codes reported per clim exceeded the number reported in the FFS sttes for lmost every pln. As noted previously, Iow reported no revenue code informtion on the IP encounter dt. Cvets In our nlysis, we used selected FFS-bsed metrics to mke preliminry judgment bout the completeness nd qulity of BHO encounter dt. These metrics were limited to the experience of only six FFS sttes. In ddition, FFS dt re not without qulity issues. We reviewed informtion on dt reporting issues in the FFS sttes nd did not find ny significnt issues. However, if the FFS dt hve unknown problems, conclusions bout the encounter dt bsed on the FFS dt my be misleding. Dt users should lso be mindful of the fct tht we conducted preliminry nlysis cross plns, sttes, nd popultions. Becuse of vrition in service coverge nd popultions served in the FFS sttes nd BHO plns, we ccepted brod rnge of vlues for mny of the metrics. A stte s or pln s dt my meet our brod rnges lthough dt for specific subpopultions or services were not reported. Thus, more comprehensive nd trgeted vlidtion of the dt should be undertken before conclusions re drwn bout the suitbility of BHO encounter dt for prticulr study. 7

8 Tble 7. Anlysis of Encounter Dt Coding Qulity, MAX 2009 Pln BHOs Covering MH nd SA Percentge of OT Clims Percentge of IP Clims Averge Among IP Clims With Principl Dignosis Code With Principle Procedure Code With Principl Dignosis Code With Initil Revenue Code Length of Sty Number of Dignosis Codes Number of Revenue Codes FFS Reference Rnge Arizon Iow BHOs Covering Only MH FFS Reference Rnge Colordo NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Florid NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Source: Mthemtic nlysis of MAX Note: Ech BHO pln hd to hve t lest 10 BHO encounter records in the respective file to be included in this nlysis. Conclusions The initil ssessment of the vilbility, completeness, nd qulity of BHO encounter dt in MAX 2009 suggests tht only limited dt re vilble nd usble. Although 18 sttes operted BHOs in 2009, complete cpittion dt re currently vilble for only 10 sttes. IP encounter dt re vilble for four sttes (Arizon, Colordo, Iow, nd Florid), nd preliminry nlysis indictes tht these dt re sufficiently complete for nlysis (Tble 8). These dt generlly hve high qulity reporting in commonly nlyzed fields, lthough dt for Iow re missing revenue codes (Tble 7). OT file encounter dt re vilble for five sttes, but our nlysis suggests the dt re only sufficiently complete for nlysis in Arizon nd Iow. The findings for Florid were mixed. At the stte level the Florid encounter dt do not pper complete; however, reporting vried by pln nd my be sufficiently complete for nlysis for subset of plns. Although Medicid is the lrgest source of pyment for MH nd SA services, nd lmost qurter of Medicid enrollees received cre through BHO pln in 2008, the MAX 2009 dt re very limited in terms of ssessing the efficcy of the services provided through BHOs. Reporting by sttes of ccurte nd complete encounter dt into MSIS will be incresingly vitl for behviorl helth reserch especilly s the use of mnged cre in the Medicid progrm is further expnded. 8

9 Tble 8. Summry of Encounter Dt Completeness nd Qulity Findings, MAX 2009 Arizon Stte OT File IP File Completeness Qulity Completeness Qulity Dt sufficiently complete for nlysis Dt met initil qulity checks Dt sufficiently complete for nlysis Colordo Dt pper incomplete Dt met initil qulity checks Dt sufficiently complete for nlysis for 4 plns (out of 7) Florid Dt pper incomplete b Dt qulity vried by BHO pln Iow Dt sufficiently complete Dt met initil qulity checks for nlysis Dt sufficiently complete for nlysis for 11 plns (out of 12) Dt sufficiently complete for nlysis Dt met initil qulity checks Dt met initil qulity checks for 1 pln (out of 7) Dt met initil qulity checks for 6 plns (out of 11) Dt re missing revenue codes Knss Dt pper incomplete Dt were not nlyzed No dt submitted No dt submitted New Mexico Dt reported were nomlous Dt were not nlyzed Dt reported were nomlous Dt were not nlyzed nd were not nlyzed nd were not nlyzed North Crolin Very few clims were reported Dt were not nlyzed No dt submitted No dt submitted Source: Mthemtic nlysis of MAX Note: Ech BHO pln hd to hve t lest 10 cpittion nd BHO encounter records to be included in this nlysis. All plns were included in the nlysis for Arizon, Iow, nd Knss. Three plns out of 7 in Colordo nd one pln out of 12 in Florid were excluded becuse they did not meet this threshold for encounter reporting, but they did hve substntil reported enrollment. We did not nlyze Knss dt for qulity becuse it reported no IP file dt nd very few OT file clims per enrolled month. b Dt pper to be incomplete overll for the 11 plns reporting encounter dt in Florid. Reported clims per person-month of enrollment vried substntilly by pln. Reporting for subset of plns my be complete. References Borck, R., A. Dodd, A. Zltinov, S. Verghese, R. Mlsberger, nd C. Petroski. The Medicid Anlytic Extrct 2008 Chrtbook. Wshington, DC: CMS, Byrd, Vivin L.H., Allison Hedley Dodd, Roslie Mlsberger, nd Ashley Zltinov. Assessing the Usbility of MAX 2008 Encounter Dt for Enrollees in Comprehensive Mnged Cre. Wshington, DC: CMS, July Buck, J.A. The Looming Expnsion nd Trnsformtion of Public Substnce Abuse Tretment Under the Affordble Cre Act. Helth Affirs, vol. 30, no. 8, August 2011, pp Centers for Medicre & Medicid Services Ntionl Summry of Stte Medicid Mnged Cre Progrms. Bltimore, MD: CMS, Dt nd Systems Group. Dodd, A.H., J. Nysenbum, nd A. Zltinov. Assessing the Usbility of the MAX 2007 Inptient nd Prescription Encounter Dt for Enrollees in Comprehensive Mnged Cre. Wshington, DC: CMS, April Muery, D.R., L. Vquerno, R. Sethi, J. Jee, nd L. Chimento. Mnged Mentl Helth Cre: Findings from the Literture, DHHS Pub. No. SMA Rockville, MD: Substnce Abuse nd Mentl Helth Services Administrtion, Shirk, Cynthi. Medicid nd Mentl Helth Services. Ntionl Helth Policy Forum. Bckground Pper No. 66. October 23, Substnce Abuse nd Mentl Helth Services Administrtion. Ntionl Expenditures for Mentl Helth Services nd Substnce Abuse Tretment, DHHS Pub. No. SMA Rockville, MD: SAMHSA, Endnotes 1 Cpittion clims re records showing the mount Medicid pys to helth plns per enrollee per month for ll services covered by the mnged cre pln. 2 People with missing eligibility informtion nd Medicid beneficiries in the following restricted-benefit eligibility ctegories were excluded from our nlysis: S-CHIP only, fmily plnning only, liens with restricted benefits only, duls with restricted benefits only, nd prescription drug only. Also excluded were other people enrolled s restricted-benefit group whose only benefit from Medicid is tht the progrm pys their premiums for purchsing privte helth insurnce coverge. 3 In these sttes, we excluded from our nlysis the smll number of enrollees in comprehensive MCOs, including enrollment in Progrm for All-Inclusive Cre for the Elderly (PACE). 4 This mesure ws scled by 1,000 becuse of the smll number of clims per PME for inptient services. 5 Georgi reported its PASARR pln s BHO in MAX 2009 nd submitted enrollment nd encounter records for this pln. However, ccording to the Ntionl Summry of Stte Medicid Mnged Cre Progrms, this pln becme FFS rrngement in 2007 nd ws phsed out in Therefore, we excluded Georgi from our nlysis. 6 Creting MAX file requires seven qurters of stte reporting of Medicid eligibility nd clims dt into MSIS. When dt submissions re delyed, or when initil submissions re not pproved becuse of qulity concerns, the MAX file is delyed s well. Hwii nd Wisconsin hd BHO plns in 2009, but the dt were not vilble for nlysis. 9

10 7 New York reported smll number of BHO cpittion clims, but becuse the stte did not hve BHO in 2009, these dt were reporting error. 8 Dentl nd primry cre services pper to hve been incorrectly ssigned to the BHO pln. 9 Knss ws only within the FFS rnge for the ged group for the number of clims per service user. Colordo ws below the FFS rnge for clims per enrolled month for the disbled nd children nd t the bottom of this rnge for dults nd the ged. However, the stte ws below the FFS rnge for the percentge of enrollees with clim for ll BOE groups except children, where it ws t the bottom of the rnge. Colordo ws below the FFS rnge for the number of clims per service user for ll BOE groups except the ged. 10 We initilly reviewed procedure coding on the BHO encounter nd comprison FFS stte IP file clims, but less thn hlf of clims in the FFS comprison sttes included procedure code nd in one of the FFS sttes only 3.8 percent of clims included procedure code. For further informtion on this issue brief series, visit our website t Princeton, NJ Ann Arbor, MI Cmbridge, MA Chicgo, IL Oklnd, CA Wshington, DC Mthemtic is registered trdemrk of Mthemtic Policy Reserch, Inc. 10