Identity Resolution: Identifying Relationships Among Clients Within the Texas Medicaid Program

Rick Allgeyer, Ph.D.

Strategic Decision SupportFinancial Services Division

Texas Health and Human Services CommissionAugust 2011

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Increasing Cost of Having Babies

The State of Texas’ Medicaid program is spending over $2.2 billion a year on birthing and delivery costs.

The cost of infant care is increasing by almost 10% each year.

A small number of very expensive infants account for over 50% of cost.

The factors that contribute to these ever increasing costs are not well understood.

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Percent of Births Paid by Medicaid

0

100,000

200,000

300,000

400,000

2001 2002 2003 2004 2005 2006 2007

48.7% 51.7% 53.6%55.8% 56.5% 56.3%

47.5%

Births to Texas Residents

Medicaid Paid Births

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Medicaid Expenditures - Births

$0

$500

$1,000

$1,500

$2,000

$2,500

2001 2002 2003 2004 2005 2006 2007

Total Cost

Infant Care

Maternity Care

Millions of Dollars

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Medicaid Newborn DRG Cost

DRG % Claims Avg $ / Claim % of Cost

385 – Neonate Died or Trans 2.1% $9,272 7.9%

386 – Extreme Immaturity 2.0% $63,124 51.3%

387 – Prematurity w Major Problems

1.5% $17,270 10.8%

388 – Prematurity wo Major Prob 3.4% $3,368 4.8%

389 – Full Term Neonate w Major Problems

3.4% $5,176 7.3%

390 – Neonate w Other Significant Problems

11.0% $1,166 5.3%

391 – Normal Newborn 76.5% $404 12.7%

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Needed Data

In order to conduct this analysis, state staff need to examine data from several disparate systems (registries and transaction systems). Including:

• Medicaid enrollment and eligibility data• Medicaid utilization claims• Hospital Discharge• Birth Certificates• Birth Defects Registry

These data come from vastly different systems, are produced for different reasons, and are administered by different entities.

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Business Case

Linking Medicaid birth data to State Vital Statistics Natality data

• Texas is currently expending in excess of $2.2 billion per year in birth and delivery related services.

• More than 55% of all births in Texas are paid by Medicaid.

• Costs related to infant care are growing almost 10% per year.

• NICU utilization is growing faster than expected.

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Business Case (cont.)

• Over 50% of costs are attributable to extremely premature infants, who account for about 2% of births.

• The relationship between risk factors identified on birth certificate and Medicaid DRG has not been established.

• The relationship between NICU utilization and these risk factors has not been established.

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Business Case (cont.)

It is very difficult to relate a newborn with the birth mother in transaction data.

Because of this, it is difficult to:• Examine patterns of maternal conditions associated

with poor birth outcomes;• Understand the medical history of birth mother; and• Know the birth outcomes of previous children.

Thus, it is impossible to identify high risk pregnancies.

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Other Cases

HHSC staff have identified other instances where identity resolution would improve policy decisions and business processes.

• Migration of children across Medicaid/CHIP.• Nursing home clients receiving acute care

services.• SSI children in foster care.• Utilization of other safety net programs.