HIP Health Plans of Florida and New York utilizes the PRA instrument to risk stratify newly enrolled Medicare+ Choice members in order to expeditiously assign them to care management follow-up. Our study goal was to examine the predictive value of the PRA based on service utilization as a measure for health. It was surprising that the association between the PRA score and service utilization did not show any significant correlation. Indeed, only a small percentage of members (<10%) were flagged as high or moderate risk. Interestingly for those new members that did not complete the survey (~20%) (due to refusal, disenrollment, sudden death, etc.), the average utilization was 32% higher than those members surveyed (p=0.023). Our findings suggest that enrollment limitations of HCFA’s mandated process for new Medicare enrollees may have a serious design issue that is adversely effecting member health. The untimeliness of the PRA caused members to be lost to care management. The regulatory milieu that seeks to avoid the perception of “cherry-picking” or biasing risk pools may need reexamination. While surveying new Medicare enrollees may have the benefit of identifying high risk members that are more likely to use services, the mandated process may be a serious impediment to diagnosing and safeguarding peoples lives.
Learning Objectives: 1)To examine the predictive value of the PRA based on service utilization as a measure for health 2) To discuss potential limitations of HCFA’s mandated enrollment process for new Medicare enrollees
Keywords: Managed Care, Risk Assessment
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: HIP Health Plan
University of Minnesota
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: employment