The 130th Annual Meeting of APHA

Abstract #48451

Gerry Fairbrother, PhD¹, Aparna Jain, MPH¹, Mehran S. Massoudi, PhD, MPH², and Arfana Haidery, MPH¹. (1) Division of Health and Science Policy, The New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029, (212)822-7398, gfairbro@nyam.org, (2) Health Services Research and Evaluation Branch, National Immunization Program, Centers for Disease Control and Prevention, 1600 Clifton Road, NE; Mailstop E-52, Atlanta, GA 30333

The purpose of this study is to show the effect of continuous enrollment requirements on the number of Medicaid children who are part of the HEDIS sample for the childhood immunization performance measure.

Background: The HEDIS reporting requirements are a key tool for accountability in managed care. Under HEDIS, managed care plans report on performance on select indicators, including childhood immunization coverage, but only for individuals who have been enrolled continuously in the given plan for 12 months.

Design: Data were collected from administrative databases at the Centers for Medicaid and Medicare Services (CMS) and 12 states with high Medicaid managed care penetration on the number of children who had turned two during the reporting year and met the HEDIS continuous enrollment requirement.

Results: On average in the 12 states, only 39% of the children in managed care plans met the continuous enrollment requirement. However, CMS data showed that 78% of children had been in Medicaid (but not the same plan) continuously for 12 months. Both plan-specific rates and overall Medicaid rates varied greatly across the states, from 15% to 72% (for plan-specific rates) and from 32% to 87% (for overall Medicaid rates).

Conclusions: The continuous enrollment requirement may mean that many vulnerable children fall outside of the accountability structure.

Learning Objectives:

• Audience will understand the effect of the continuous enrollment requirement on accountability for managed care plans. Audience will understand that these requirements mean that managed care plans are not accountable for performance of many children.

Keywords: Accountability, Managed Care

Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.