Using analyses of Medicaid claims data, state decision-makers can better monitor newly identified challenges, prioritize needs, and improve the quality of medical care within their Medicaid programs. Specifically, claims analyses can help Medicaid officials to identify geographic areas or populations with unusually high or low utilization. They can also help officials to identify providers whose practice may deviate from clinical protocols. Given the relatively high cost for treating many of the conditions of interest (e.g., HIV/AIDS), these claims analyses may prove highly cost-effective.
The methodology behind such analyses has grown alongside the development of widely accepted clinical standards of care for HIV and other conditions. Using available disease algorithms, researchers can capture a population with the condition of interest and isolate their claims history. Matching this with eligibility information allows the researchers to further refine the population by period of enrollment. They can then assess conformity to these guidelines by quantifying multiple access and quality measures (e.g., PAP smears within last two years, or clinically indicated prescriptions or diagnostic tests per person year). Analyses can be further stratified by demographic characteristics, including race, sex, age, county of residence.
This presentation will describe the methods used in several recent Medicaid claims analysis in multiple states. Examples will include HIV-related claims, but the presenters will discuss the use of these methods in other contexts.
Learning Objectives: At the conclusion of the session, participants will be able to: (1) assess the value of these methods in their respective policy environments (2) devise an approach to the analysis of local or state claims data (3) discuss cogently the use of Medicaid claims analysis with state colleagues
Keywords: Medicaid, Information Technology
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: The Lewin Group (though minimally)
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: Vice President