Estimating pediatric primary care provider visits in a capitated environment: encounter vs. claims databases.

Ernest P Schloss, Vicky Lewis, Nancy Martin, Marlene Pitts

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

PURPOSE: To evaluate the accuracy of insurance claims data indicating underutilization of primary care visits by children with special health care needs (CSHCN). DESIGN: The study was a retrospective comparison of primary care provider (PCP) utilization by 1,131 CSHCN, using secondary data from electronic claims-and-encounters databases in a Medicaid health maintenance organization (HMO) and a commercial HMO. METHODOLOGY: The study was conducted at the Children's Clinics for Rehabilitative Services (Children's Clinics) in Tucson, Ariz., a provider of specialty care to CSHCN. All the children in the study were eligible for specialty services under Arizona's statewide program for CSHCN and were simultaneously enrolled, from Oct. 1, 1995 through Sept. 30, 1996, in either one or both of the managed care plans for their primary care. Identical PCP-visit information for the same 1-year period was collected from the plans' claims-and-encounters databases, and the number of primary care visits as computed from both databases was compared. PRINCIPAL FINDINGS: Health plan claims data show that only 14 percent of the patients visited a PCP during the course of a year. The encounter data indicate that 59 percent of the same cohort had PCP visits. CONCLUSIONS: Encounter databases capture more information about PCP visits than insurance claims databases in capitated environments.

Original languageEnglish (US)
Pages (from-to)43-46
Number of pages4
JournalManaged care (Langhorne, Pa.)
Volume11
Issue number5
StatePublished - 2002

Fingerprint

Primary Health Care
Databases
Pediatrics
Delivery of Health Care
Health Maintenance Organizations
Insurance
Medicaid
Managed Care Programs
Child Care
Health

Cite this

Estimating pediatric primary care provider visits in a capitated environment : encounter vs. claims databases. / Schloss, Ernest P; Lewis, Vicky; Martin, Nancy; Pitts, Marlene.

In: Managed care (Langhorne, Pa.), Vol. 11, No. 5, 2002, p. 43-46.

Research output: Contribution to journalArticle

@article{9ba87532683e4282b63951c0a077d129,
title = "Estimating pediatric primary care provider visits in a capitated environment: encounter vs. claims databases.",
abstract = "PURPOSE: To evaluate the accuracy of insurance claims data indicating underutilization of primary care visits by children with special health care needs (CSHCN). DESIGN: The study was a retrospective comparison of primary care provider (PCP) utilization by 1,131 CSHCN, using secondary data from electronic claims-and-encounters databases in a Medicaid health maintenance organization (HMO) and a commercial HMO. METHODOLOGY: The study was conducted at the Children's Clinics for Rehabilitative Services (Children's Clinics) in Tucson, Ariz., a provider of specialty care to CSHCN. All the children in the study were eligible for specialty services under Arizona's statewide program for CSHCN and were simultaneously enrolled, from Oct. 1, 1995 through Sept. 30, 1996, in either one or both of the managed care plans for their primary care. Identical PCP-visit information for the same 1-year period was collected from the plans' claims-and-encounters databases, and the number of primary care visits as computed from both databases was compared. PRINCIPAL FINDINGS: Health plan claims data show that only 14 percent of the patients visited a PCP during the course of a year. The encounter data indicate that 59 percent of the same cohort had PCP visits. CONCLUSIONS: Encounter databases capture more information about PCP visits than insurance claims databases in capitated environments.",
author = "Schloss, {Ernest P} and Vicky Lewis and Nancy Martin and Marlene Pitts",
year = "2002",
language = "English (US)",
volume = "11",
pages = "43--46",
journal = "Managed Care",
issn = "1062-3388",
publisher = "MediMedia USA Inc.",
number = "5",

}

TY - JOUR

T1 - Estimating pediatric primary care provider visits in a capitated environment

T2 - encounter vs. claims databases.

AU - Schloss, Ernest P

AU - Lewis, Vicky

AU - Martin, Nancy

AU - Pitts, Marlene

PY - 2002

Y1 - 2002

N2 - PURPOSE: To evaluate the accuracy of insurance claims data indicating underutilization of primary care visits by children with special health care needs (CSHCN). DESIGN: The study was a retrospective comparison of primary care provider (PCP) utilization by 1,131 CSHCN, using secondary data from electronic claims-and-encounters databases in a Medicaid health maintenance organization (HMO) and a commercial HMO. METHODOLOGY: The study was conducted at the Children's Clinics for Rehabilitative Services (Children's Clinics) in Tucson, Ariz., a provider of specialty care to CSHCN. All the children in the study were eligible for specialty services under Arizona's statewide program for CSHCN and were simultaneously enrolled, from Oct. 1, 1995 through Sept. 30, 1996, in either one or both of the managed care plans for their primary care. Identical PCP-visit information for the same 1-year period was collected from the plans' claims-and-encounters databases, and the number of primary care visits as computed from both databases was compared. PRINCIPAL FINDINGS: Health plan claims data show that only 14 percent of the patients visited a PCP during the course of a year. The encounter data indicate that 59 percent of the same cohort had PCP visits. CONCLUSIONS: Encounter databases capture more information about PCP visits than insurance claims databases in capitated environments.

AB - PURPOSE: To evaluate the accuracy of insurance claims data indicating underutilization of primary care visits by children with special health care needs (CSHCN). DESIGN: The study was a retrospective comparison of primary care provider (PCP) utilization by 1,131 CSHCN, using secondary data from electronic claims-and-encounters databases in a Medicaid health maintenance organization (HMO) and a commercial HMO. METHODOLOGY: The study was conducted at the Children's Clinics for Rehabilitative Services (Children's Clinics) in Tucson, Ariz., a provider of specialty care to CSHCN. All the children in the study were eligible for specialty services under Arizona's statewide program for CSHCN and were simultaneously enrolled, from Oct. 1, 1995 through Sept. 30, 1996, in either one or both of the managed care plans for their primary care. Identical PCP-visit information for the same 1-year period was collected from the plans' claims-and-encounters databases, and the number of primary care visits as computed from both databases was compared. PRINCIPAL FINDINGS: Health plan claims data show that only 14 percent of the patients visited a PCP during the course of a year. The encounter data indicate that 59 percent of the same cohort had PCP visits. CONCLUSIONS: Encounter databases capture more information about PCP visits than insurance claims databases in capitated environments.

UR - http://www.scopus.com/inward/record.url?scp=0036582105&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=0036582105&partnerID=8YFLogxK

M3 - Article

C2 - 12061159

AN - SCOPUS:0036582105

VL - 11

SP - 43

EP - 46

JO - Managed Care

JF - Managed Care

SN - 1062-3388

IS - 5

ER -