Assessing Medical Need Among Children in Managed Care

本研究考察了风险评估模型如何很好地识别管理式护理计划中儿童的医疗需求，并将建立一个完整的信息儿科特定风险评估模型，该模型使用健康计划中所有可用的自动化数据。对儿科风险评估的独特挑战重视不足。我们的假设是，目前的风险模型不够敏感，无法正确识别儿童群体和有特殊需要的儿童的医疗需求。此外，由于这些模型用于调整管理医疗支付，我们预计医疗计划将有财务激励措施，以避免儿童和有孩子的家庭，特别是有特殊需要的儿童注册。本研究使用了一个由儿童风险评估研究中涉及的人数最多的数据集，包括190万人，其中包括515,729名儿童，本研究的具体目的是：1)确定当前的风险评估模型是否足够敏感，以确定管理医疗保健计划中儿童的预期医疗保健成本和利用率。我们将通过比较现有的针对一般人群的风险评估模型和少数针对儿科的风险评估模型，研究风险评估模型预测儿童和有儿童的家庭医疗需求的效果。将特别注意患有高费用慢性疾病的儿童的需要。2)评估是否存在不利于招收儿童和有儿童的家庭的健康计划。3)评估额外的健康状况信息如何提高风险评估工具的预测性能。这项研究是独特的，因为没有全面的研究检查了风险评估方法的敏感性，以确定管理护理儿童的医疗需求，而不管他们的保险来源。儿科风险评估研究也没有探索利用管理护理信息系统中所有可用信息的机会。

This study examines how well risk assessment models identify the medical needs of children in managed care plans and will build a full information pediatric specific risk assessment model that uses all of the automated data available from health plans. Inadequate attention has been paid to the unique challenges of pediatric risk assessment. Our hypothesis is that current risk models are not sensitive enough to correctly identify medical need among children as a group and among children with special needs. Moreover, because these models are used to adjust managed care payments, we expect health plans will have financial incentives to avoid enrolling children and families with children, particularly children with special needs. Using a dataset comprised of the largest number of people involved in a pediatric risk assessment study, 1.9 million people, including 515,729 children, the specific aims of this research are to: 1) Determine whether current risk assessment models are sensitive enough to identify expected healthcare cost and utilization for children in managed health care plans. We will study how well risk assessment models predict medical need among children and families with children by comparing existing risk assessment models focused on the general population to the few pediatric specific risk assessment models. Specific attention will be paid to the needs of children with high cost chronic medical conditions. 2) Evaluate if there exist financial disincentives for health plans to enroll children and families with children. 3) Assess how additional health status information improves the predictive performance of risk assessment instruments. This study is unique because no comprehensive research has examined the sensitivity of risk assessment methods to identify medical need among children in managed care regardless of their insurance source. Pediatric risk assessment research has also not explored opportunities to use all information available in managed care information systems.