Identity Resolution: Identifying Relationships Among Clients Within the Texas Medicaid Program Rick Allgeyer, Ph.D. Strategic Decision Support Financial Services Division Texas Health and Human Services Commission August 2011

2 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.

3 Percent of Births Paid by Medicaid 48.7% 51.7% 53.6% 55.8% 56.5% 56.3% 47.5% Births to Texas Residents Medicaid Paid Births

4 Medicaid Expenditures - Births Millions of Dollars

5 Medicaid Newborn DRG Cost DRG % ClaimsAvg $ / Claim% of Cost 385 – Neonate Died or Trans2.1%$9,2727.9% 386 – Extreme Immaturity2.0%$63, % 387 – Prematurity w Major Problems 1.5%$17, % 388 – Prematurity wo Major Prob3.4%$3,3684.8% 389 – Full Term Neonate w Major Problems 3.4%$5,1767.3% 390 – Neonate w Other Significant Problems 11.0%$1,1665.3% 391 – Normal Newborn76.5%$ %

6 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.

7 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.

8 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.

9 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.

10 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.