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Behavioral Health Data Report:
Behavioral Health Measures
Across Medicaid Managed Care Plans and Models
Health and Human Services Commission
August 2004
TABLE OF CONTENTS
INTRODUCTION..............................................................................................................................................................3
ACCESS MEASURES.......................................................................................................................................................6
Behavioral Health Claims Payment Timeliness ............................................................................................................6
Behavioral Health Provider Network...........................................................................................................................11
HEDIS Mental Health Services Utilization .................................................................................................................16
HEDIS Chemical Dependency Services Utilization....................................................................................................22
QUALITY MEASURES..................................................................................................................................................27
HEDIS Follow-Up After Hospitalization for Mental Illness.......................................................................................27
FINANCIAL MEASURES..............................................................................................................................................33
Behavioral Health Expenditures as a Percentage of Total Expenditures.....................................................................33
APPENDIX A ...................................................................................................................................................................37
APPENDIX B ...................................................................................................................................................................42
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INTRODUCTION
Why is the State publishing this information?
The central goal of this project is to collect and analyze behavioral health (mental health and chemical dependency) data across the
Medicaid managed care programs (STAR1, STAR+PLUS2, NorthSTAR3 and PCCM4). Previous research and recent legislation have
pointed to the need to more closely evaluate and regularly publish key behavioral health measures.
In December 2002, the Health and Human Services Commission (HHSC) published a legislatively mandated report, Behavioral
Health in Managed Care: A Review of Texas Medicaid Models5. The report noted that the only Medicaid managed care model to
regularly publish behavioral health performance measures is the NorthSTAR model, via the program’s quarterly data book. One of
the Report’s main recommendations was that the State identify, collect and publish key behavioral health measures for Medicaid
managed care to assist the State in program monitoring and improvement. This effort is a direct outgrowth of that recommendation.
Additionally, SB 1182 (78th Legislature, Regular Session) requires HHSC to regularly monitor behavioral health services within the
Medicaid managed care program. Regular publication and analysis of data related to these services is a key component of HHSC’s
plan to fulfill this legislative mandate.
Lastly, recent research has shown that while treatment and management of many health conditions has improved, treatment of
behavioral health conditions remain a critical shortcoming in the health care system. The State of Health Care Quality 20036 by the
National Committee for Quality Assurance (NCQA) reported that mental health conditions are a notable exception to the trend toward
improvement in health plan performance and treatment. By regularly publishing behavioral health measures, HHSC intends to
increase the level of transparency and accountability for Medicaid managed care behavioral health services. HHSC believes that this
effort to measure and report key behavioral health measures is a necessary first step toward meaningful quality improvement.
Why did the State choose these measures?
These measures were chosen because they provide data that can be used to evaluate the performance of the various program models
and individual health plans and therefore can be a tool to improve behavioral health care within Medicaid managed care. Research has
1
http://www.hhsc.state.tx.us/medicaid/mc/exp/faq.html#1
2
http://www.hhsc.state.tx.us/starplus/starplus.htm
3
http://www.mhmr.state.tx.us/CentralOffice/northstar/northstarhomepage.html
4
http://www.hhsc.state.tx.us/medicaid/mc/exp/faq/faq.html
5
www.hhsc.state.tx.us/Medicaid/reports/BHMC2002/rpt_TOC.html
6
http://www.ncqa.org/Communications/News/sohc2003.htm
Page 3 of 43
shown that some data indicators are early warning signs of potential problems within a managed care program.7 For example, high
readmission rates to inpatient psychiatric or substance abuse care may indicate an inappropriate discharge decision and / or the
absence of adequate community services.
During this initial analysis of behavioral health measures across multiple managed care models, the State chose a limited set of
available measures which are likely to indicate potential problems. Some of these measures were created by the State to evaluate
utilization or quality. Other measures were taken from nationally used performance measurement tools, such as the Health Plan
Employer Data Information Set (HEDIS). HEDIS is a set of standardized performance measures created to allow purchasers and
consumers to compare the performance of managed care plans. While HEDIS has some limitations (for example, use of HEDIS
specifications allows comparison to national benchmarks, but may not always accommodate the nuances of a particular program), it is
generally considered the industry standard for performance measurement.
A benefit of HEDIS data is that it allows for comparison of Texas data with national benchmarks, so that plan performance can be
compared against a consistent and meaningful yardstick. Readers will note that in many of the measures, a “HEDIS mean” is reported
as a benchmark. The HEDIS mean is derived from data that Medicaid managed care plans across the country submit to the National
Committee on Quality Assurance’s (NCQA) HEDIS project. For comparison purposes, the Medicaid managed care plans’ results are
shown at the 50th percentile and are labeled “HEDIS mean.”
What will the State do with this information?
The State will use this information to monitor behavioral health services and make improvements where data show potential problems
at the health plan level, or across programs. Where deficiencies are identified, the State will work closely with the health plans to
make program improvements. The State will monitor these measures over time to determine their usefulness in program evaluation
and improvement. Some measures may ultimately be revised, or new measures added.
What should readers be aware of when evaluating this information?
• While it is helpful to compare Texas measures to national benchmarks so that performance can be measured against a standard
reference point, there are issues specific to Texas that should be taken into consideration. For example, as noted by NCQA8,
Texas exists in a region of the country (South Central) that routinely is reported as having poor performance in terms of quality
indicators. There may be a number of factors contributing to this trend, such as the fact that Texas has poverty rates higher than
7
Substance Abuse and Mental Health Services Administration (SAMHSA). Implementing an Early Warning System: A Manual for State Evaluation of
Medicaid Behavioral Health Managed Care. Rockville, Maryland: U.S. Department of Health and Human Services; 2002.
8
National Committee for Quality Assurance. The State of Health Care Quality: 2003. Washington, D.C.: National Committee for Quality Assurance; 2003.
Page 4 of 43
much of country and a high percentage of minorities. Research has shown that both poverty and minority status can influence
an individual’s access to care.
• Some limited deviations from the HEDIS specifications were made during data collection and analysis to adapt to Texas
Medicaid managed care. Thus, the HEDIS measures presented in this report are not necessarily consistent with data submitted
by those Texas Medicaid managed care plans which separately report data to HEDIS. (Appendix B provides additional
information regarding HEDIS specifications.)
• Any comparisons across models should be done with care. Each model operates differently and has a different case mix,
which will impact the amount and type of services used. For example, the SSI population, which tend overall to have greater
medical and behavioral health needs than the TANF population, are a significant component of NorthSTAR and STAR+PLUS
models, but make up a very small percentage of the STAR membership. In summary, comparisons across models may not
offer an “apples to apples” comparison.
• The tables in this report do not contain state psychiatric hospital usage for adults age 21 and over. (Federal Medicaid law
prohibits Medicaid reimbursements for adults in freestanding psychiatric facilities). Thus, the actual mental health inpatient
usage is somewhat higher than what is reflected in the utilization tables.
• Some models include populations other than clients enrolled only in Medicaid (i.e. NorthSTAR serves indigent clients and
STAR+PLUS serves clients who are dually enrolled in Medicaid and Medicare.) Unless otherwise noted, the information in
the report relates solely to “Medicaid only” clients.
• The HEDIS measures included in this report only capture Medicaid data. Thus, readers should note that services provided to
clients who are dually eligible for both Medicaid and Medicare may have received services paid for by Medicare which are not
reflected in this data.
• The time periods within the data presented were constructed to reflect the time frames that were the closest together across
models. Different time periods were used for the same measure across models to put forward the most accurate set of data
possible.
• Since the time periods for some of the measures are a number of months old, they occasionally reflect measures for plans that
no longer contract with the State to provide Medicaid Managed Care. Appendix A provides a crosswalk of the plans and the
BHO subcontractors for the time periods covered by this report (state fiscal years 2003 and 2004).
Page 5 of 43
Access Measures
Behavioral Health Claims Payment Timeliness
Why is this Information Important? Claims payment timeliness relates to access to care because prompt payment to service
providers is necessary to maintain a viable treatment network. This measure helps the State to identify payment delays that can create
or increase provider financial stress, which may undermine access to services. The current Medicaid managed care contracts require
health plans to pay or deny 90 percent of clean claims within 30 days. This contract standard is the benchmark for this measure.
Historically, HHSC has tracked claims payment performance at the health plan level rather than at the subcontractor level. Thus, a
health plan’s overall claims payment timeliness may have been reported at 90%, even if claims payment for a subcontracted service,
such as behavioral health, did not meet this target. In order to better monitor claims payment timeliness, HHSC has recently required
plans to report claims payment timeliness at the subcontractor level.
Time Period: State Fiscal Year 2003, 3rd and 4th Quarters
Findings:
The findings and the charts below relate specifically to behavioral health claims. Thus, while some plans are shown to have not met
the target of paying or denying 90 percent of clean behavioral health claims within 30 days, these plans may have met the claims
payment contract standard for all claims.
STAR: During both the 3rd and 4th quarters of fiscal year 2003, the majority of STAR plans met the claims payment contract standard
by paying or denying 90 percent of clean behavioral health claims within 30 days. Of the plans that did not meet the 30-day target, all
were within 11 percentage points of the 30-day target. The plan that missed the target by the largest margin, Amerigroup, was in the
process of transitioning to “in-house” provision of behavioral health services from the use of a behavioral health organization. This
change in arrangement is likely to have contributed to the plan’s performance on this measure. (The STAR plans that operate in
Dallas - Amerigroup, Parkland and Texas Health Network - do not pay BH claims, since NorthSTAR provides behavioral health
services for members of these plans.)
STAR+PLUS: During the 3rd quarter of fiscal year 2003, neither of the STAR+PLUS plans met the claims payment contract standard
by paying or denying 90 percent of clean behavioral health claims within 30 days. By the 4th quarter, one plan had met the standard
and the other plan was within 3 percentage points of the standard. One of the two STAR+PLUS plans, Amerigroup, was in the
Page 6 of 43
process of transitioning to “in-house” provision of behavioral health services from the use of a behavioral health organization during
the 3rd quarter of FY 2003 which may explain the plan’s inability to meet the claim performance target during this period.
NorthSTAR: During both the 3rd and 4th quarter of fiscal year 2003, Value Options, the only health plan within the NorthSTAR
model, met the contract standard for paying or denying 90 percent of clean claims within 30 days.
Implications: Timely payment of claims is an important element in assuring a sound behavioral health network. The current
managed care contracts require plans to pay or deny 90 percent of clean claims within 30 days. NorthSTAR was the only model to
meet this 30-day target across all plans. Within both STAR and STAR+PLUS, some plans were unable to meet the contract
requirement related to claims payment timeliness. Where behavioral health claims are processed or paid by a subcontracted entity,
such as a behavioral health organization, the managed care organization with which the state has contracted remains responsible for
meeting the contractual requirements regarding claims payment timeliness. In instances where a health plan has not met the contract
standard, the State monitors performance and pursues corrective actions where necessary.
Page 7 of 43
STAR Behavioral Health Organization Claims Processed Within 30 Days
(SFY 2003, 3rd and 4th Quarter)
Behavioral Health Organization Average
Travis: Superior - Tejas
Travis: HMO Blue - Magellan
Service Delivery Area: Plan Name - BHO Name
Tarrant: JPS STAR - Innovative Resource Group*
Tarrant: HMO Blue - Magellan
Tarrant: Amerigroup - Value Options/In House**
Lubbock: HMO Blue - Magellan
Lubbock: FirstCare - SW Health Alliance
3rd Quarter
Harris: TX Children's Health Plan - CompCare
4th Quarter
Harris: HMO Blue - CompCare
Harris: Community Health Choice - CompCare
Harris: Amerigroup - Value Options
El Paso: Superior - Tejas
El Paso: El Paso First - Tejas*
Bexar: Superior - Tejas
Bexar: HMO Blue - Magellan
Bexar: Community First - In House
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
* No HMO claims process performance report submitted
** Amerigroup moved behavioral health services and claims payment "In House" during the 4th quarter of SFY 2003
Data Source: HMO self reported and unverified claims data
Table Note:
1. The solid bar at the 90th percentile represents the benchmark for this measure.
2. Plans that operate in the NorthSTAR area are not included, since NorthSTAR pays behavioral health claims for these plans.
Page 8 of 43
STAR+PLUS Behavioral Health O rganization Claim s Processed W ithin 30 Days
(SFY 2003, 3rd and 4th Q uarter)
Service Delivery Area: Plan Name - BHO Name
Behavioral Health O rganization
Average
Harris: Evercare - Com pCare
3rd Quarter
4th Quarter
Harris: Am erigroup - Value
O ptions
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Data Source: HMO self-reported and unverified claims performance data.
Table Note:
1. Evercare replaced HMO Blue on 4/1/03, during the 3rd quarter of SFY 2003.
2. The solid bar at the 90th percentile represents the benchmark for this measure.
Page 9 of 43
NorthSTAR Behavioral Health Organization Claims Processed Within 30 Days
(SFY 2003, 3rd and 4th Quarter)
Service Delivery Area: Plan Name - BHO Name
Dallas: NorthSTAR - Value 3rd Quarter
Options 4th Quarter
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Data Source: HMO self-reported and unverified claims performance data
Table Note:
1. The solid bar at the 90th percentile represents the benchmark for this measure.
Page 10 of 43
Behavioral Health Provider Network
Why is this Information Important? Provider network information indicates whether there are a sufficient number of providers in
various behavioral health specialty areas to provide reasonable access to enrollees seeking behavioral health care. A lack of sufficient
providers overall, or in a certain specialty, such as psychiatry, can indicate the potential for enrollees to face difficulty accessing care.
Determining whether a particular health plan has an adequate behavioral health network in place is somewhat subjective, since there is
not a benchmark for what constitutes an adequate network. However, by accounting for the difference in the number of enrollees per
plan by calculating the number of providers per 1,000 enrollees, it is possible to compare the number of providers across plans and
within plans over time. Where a plan appears to have a deficiency in its provider network, the State can then look more closely at
other areas, such as overall use of behavioral health services, to determine if there is a potential access to care issue.
The information reported in the following tables and described in the findings section, below, is taken from data reported by the plans
to HHSC via the state’s enrollment broker, Maximus. In the past, this data has been incomplete, and it is suspected that there remain
some areas where plans have not reported their full provider networks. Additionally, the only types of inpatient behavioral health
facilities captured for these tables were TCADA facilities and psychiatric hospitals. Thus, this may not represent the full array of
behavioral health inpatient facilities in a plan’s provider network, since some plans also use psychiatric beds within a general acute
hospital.
Time Period: January 2004 for STAR and STAR+PLUS; September -November 2003 for NorthSTAR
Findings:
STAR: When providers per 1,000 enrollees are averaged across each plan and service delivery area, there is an average of 1.40
psychiatrists, 2.63 mental health professionals and .03 behavioral health facilities. There is some variation across STAR plans in
terms number of behavioral health providers per 1,000 enrollees. For example, the number of psychiatrists ranges from .09 to 3.50 per
1,000 enrollees across all STAR plans.
STAR+PLUS: When providers per 1,000 enrollees are averaged across both STAR+PLUS plans, there is an average of 2.90
psychiatrists, 4.19 mental health professionals and .07 behavioral health facilities. There is significant variation in the number of plan-
reported behavioral health providers across the 2 plans in the STAR+PLUS model, with Amerigroup reporting a much more extensive
behavioral health network than that reported by Evercare.
Page 11 of 43
NorthSTAR: In NorthSTAR, there is an average of .17 psychiatrists, 1.19 mental health professionals and .10 behavioral health
facilities per 1,000 Medicaid enrollees. NorthSTAR enrollees also have access to a number of non-traditional services, such as dual
diagnosis services and specialized female services for women with substance abuse disorders. For more detailed information on the
NorthSTAR provider network, please refer to the NorthSTAR databook at:
http://www.mhmr.state.tx.us/CentralOffice/northstar/northstarhomepage.html.
Implications:
Within both STAR and STAR+PLUS, there are individual plans which, at least according to plan reported data, have behavioral health
networks that appear to have gaps which could present barriers to care for their enrollees. It is likely that in many cases, what appears
to be an inadequate network is in fact the result of poor reporting by the health plans. HHSC will follow up with the health plans that
appear to have inadequate networks to verify if the reported information is correct, and if so, to work to remedy the problem. In
particular, HHSC is focusing attention on improving network adequacy in the next procurement cycle for Medicaid managed care.
Page 12 of 43
STAR Health Plans’ Behavioral Health Provider Networks
January 2004 – Health Plan Submitted Information
Health Plan by Service Delivery Area Total Psychiatrists / Behavioral Health Inpatient MH &
Enrollment Psychiatrists per Professionals CD Facilities /
1000 members / BH Professionals Facilities per
per 1000 members 1000 members
AmeriGroup – Harris SDA + EXP 103,326 146 / 1.41 230 / 2.23 3 / 0.03
AmeriGroup – Tarrant SDA 99,393 65 / 0.65 169 / 1.70 3 / 0.03
Texas Childrens – Harris SDA + EXP 54,056 57 / 1.05 177 / 3.27 3/ 0.06
Community First – Bexar SDA 43,658 92 / 2.11 187 / 4.28 2 / 0.05
Community Health Choice – Harris SDA + EXP 47,197 165 / 3.50 252 / 5.34 4 / 0.08
El Paso First – El Paso SDA 22,391 2 / 0.09 1 / 0.04 0 / 0.00
FirstCare – Lubbock SDA 15,657 35 / 2.24 3 / 0.19 0 / 0.00
JPS Metro West – Tarrant SDA 11,936 20 / 1.68 56 / 4.69 0 / 0.00
Superior – Bexar SDA 31,751 61 / 1.92 120 / 3.78 1 / 0.03
Superior – El Paso SDA 32,644 12 / .37 55 / 1.68 1 / 0.03
Superior – Travis SDA 69,857 28 / 0.40 116 / 1.66 3 / 0.04
Average of Providers Per 1,000 Enrollees 1.40 2.63 0.03
Table Notes:
1. The first number in each column is the total number of providers, the second is the calculation of providers per 1,000 enrollees.
2. STAR Health Plans operating in the Dallas Service Delivery Area (Amerigroup and Parkland) are not represented, because
behavioral health care in the Dallas SDA is carved-out to NorthSTAR.
3. Behavioral Health Professionals = Psychologists, Licensed Professional Counselors, Licensed Masters Social Workers, Licensed
Marriage and Family Counselors, Licensed Chemical Dependency Counselors.
4. It is suspected that this these figures are an under-reporting of the plan’s networks, see page 11 for additional information.
Page 13 of 43
STAR+PLUS Health Plans’ Behavioral Health Provider Networks
January 2004 – Health Plan Submitted Information
Health Plan by Service Delivery Area Total Psychiatrists / Behavioral Health Inpatient MH &
Enrollment Psychiatrists per Professionals CD Facilities /
1000 members / BH Professionals Facilities per 1000
per 1000 members members
AmeriGroup – Harris SDA 22,057 127 / 5.76 181 / 8.21 3 / 0.14
Evercare – Harris SDA 28,546 1 / 0.04 5 / 0.18 0 / 0.00
Average Number of Providers Per 1,000 2.90 4.19 0.07
Enrollees
Table Notes:
1. The first number in each column is the total number of providers. The second number is the calculation of providers per 1,000
enrollees.
2. Behavioral Health Professionals = psychologists, licensed professional counselors, Licensed Masters Social Workers, Licensed
Marriage and Family Counselors, Licensed Chemical Dependency Counselors.
3. It is suspected that this these figures are an under-reporting of the plan’s networks, see page 11 for additional information
Page 14 of 43
NorthSTAR Behavioral Health Provider Networks
Data from September – November 2003
Health Plan Total Medicaid Psychiatrists / Behavioral Health Inpatient MH &
Enrollment Psychiatrists per Professionals CD Facilities /
1000 members / BH Professionals Facilities per 1000
per 1000 members members
ValueOptions – Dallas SDA 316,258 55 / 0.17 377 / 1.19 33 / 0.10
Table Notes:
1. The first number in each column is the total number of providers. The second number is the calculation of providers per 1,000
enrollees.
2. Behavioral Health Professionals = Psychologists, Licensed Professional Counselors, Licensed Masters Social Workers, Licensed
Marriage and Family Counselors, Licensed Chemical Dependency Counselors.
3. The number of psychiatrists reported (55) does not include those psychiatrists who work within a facility-based environment. If
all the psychiatrists providing services to NorthSTAR enrollees were included (i.e. those practicing within an inpatient or
residential facility), then the total would be 144 psychiatrists.
4. Total enrollment figure includes only Medicaid enrollees and does not include indigent clients who are also enrolled in
NorthSTAR.
Page 15 of 43
HEDIS MENTAL HEALTH SERVICES UTILIZATION –MEMBERS RECEIVING
INPATIENT, DAY/NIGHT, AMBULATORY SERVICES
Why is this Information Important? Behavioral health service utilization provides information related to quality and cost of care.
As with physical health care, a large proportion of mental health and substance abuse dollars are spent on inpatient treatment. In
1997, over 32 percent of behavioral health care expenditures were for hospital based services while 35 percent of health care
expenditures were devoted to hospital care. More restrictive levels of care do not necessarily translate into higher quality service.
Studies have shown that outpatient treatment for mental health and substance abuse disorders is as efficacious as treatment in an
inpatient setting.9 Moreover, outpatient care can be less costly than inpatient. Many managed behavioral health care plans have
attempted to contain costs and increase quality of care by placing limits on inpatient care and increasing access to evidence-based
treatments provided in community settings such as Multisystemic therapy, family preservation and Assertive Community Treatment.10
This table provides an overall picture of mental health utilization across all services, and also provides more detailed information
regarding what types of services are being utilized. The column “any mental health use” provides information regarding the
percentage of members in the model or plan who used a mental health service, often referred to as a penetration rate. The table also
provides utilization information on “day/night (e.g. partial hospitalization) and inpatient services. The HEDIS mean for Medicaid
plans are provided as a benchmark against which Texas information can be compared. Readers should be aware that, as was noted in
the introduction, the figures presented for all of the models excludes state psychiatric hospital data for adults.
Time Period: March 1, 2002 – February 28, 2003 for STAR; January 1, 2003 – December 31, 2003 for STAR+PLUS; February
1, 2002 – January 31, 2003 for NorthSTAR
Findings:
In reviewing the measures it is important to keep in mind that the three models (STAR, STAR+PLUS and NorthSTAR) serve a
different case mix. Since STAR tends to serve mostly individuals who are on Medicaid because they have low incomes, rather than a
disability (such as a serious mental illness), it would be expected that utilization of behavioral health services within STAR would be
less than that within NorthSTAR or STAR+PLUS, both of which serve a high number of individuals with disabilities.
9
Harrison P., Hoffman N., Gibbs L., Hollister C.D., Luxemberg M., Determinants of chemical dependency treatment placement: Clinical, economic and logistic
factors. Psychotherapy, 1988: 25(3):356-364.
10
U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General—Executive Summary. Rockville, MD: U.S. Department of
Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health,
National Institute of Mental Health, 1999.
Page 16 of 43
STAR: Utilization of mental health services within the STAR model is low – 2.51 percent of enrollees used any mental health service
during the quarter compared to the HEDIS 2002 average of 6.10 percent. Within the model, there was a fair degree of variation
among the STAR plans, with overall utilization ranging from a low of 1.88 percent to a high of 3.81 percent. This general degree of
variation (roughly three fold) is present in each of the service types – inpatient, day/night, and ambulatory care. For STAR health
plans overall, the service category with the highest use is ambulatory services followed by day/night and then inpatient services.
When compared against the HEDIS benchmarks, STAR enrollees used fewer ambulatory services (2.37 compared to 5.9 percent) had
a greater use of day/night services (.22 percent compared to .10 percent) and lower use of inpatient services (.17 percent compared to
.60 percent).
STAR+PLUS: STAR+PLUS enrollees have significantly higher overall mental health care use than the HEDIS benchmark (12.1
percent compared to 6.10 percent for Medicaid plans reporting to HEDIS). There is an extremely wide variation in the usage of
mental health services among the two STAR+PLUS plans, with HMO Blue far exceeding the HEDIS benchmarks, and Amerigroup’s
mental health usage reported at less than the HEDIS benchmarks. For both STAR+PLUS plans, the service category with the highest
use is ambulatory services followed by inpatient services and then by day/night services. When compared against the HEDIS
benchmarks, mental health ambulatory service utilization was higher among STAR+PLUS enrollees, with 11.02 percent of
STAR+PLUS enrollees accessing ambulatory care as compared to the 5.9 percent HEDIS benchmark. STAR+PLUS enrollees, on
average, also used day/night services and inpatient services at greater rates than the HEDIS benchmarks. As noted above, the
STAR+PLUS model’s tendency to surpass HEDIS benchmarks is driven by the particularly high rates of mental health utilization of
one of the two health plans and the fact that the STAR+PLUS model serves only people with disabilities.
NorthSTAR: The NorthSTAR Medicaid enrollees have somewhat lower overall mental health care use than the HEDIS benchmark
(3.58 percent compared to 6.10 percent for Medicaid plans reporting to HEDIS). The service category with the highest use is
ambulatory services followed by day/night and inpatient services. Mental health ambulatory service utilization was lower among
NorthSTAR enrollees compared to enrollees in plans reporting for HEDIS measures with 3.36 percent of NorthSTAR enrollees
accessing ambulatory care as compared to the 5.9 percent HEDIS benchmark. NorthSTAR data revealed higher use of day/night
services and lower use of inpatient services when compared to HEDIS measures.
Implications: With the exception of the single STAR+PLUS plan that exceeded HEDIS benchmarks, mental health utilization across
all models and plans within Texas Medicaid managed care is lower than HEDIS benchmarks. To some degree, this may be a
reflection of factors specific to Texas that have been shown to have a negative impact on mental health services utilization, such as a
lack of behavioral health specialists or a greater percentage of minority enrollees. Utilization trends will need to be studied over time
and looked at in connection to other indicators to determine if additional efforts are necessary to ensure that enrollees have appropriate
Page 17 of 43
access to mental health services. Such an analysis will also need to consider the case mix of the population, to account for the fact that
the models serve clients of differing health status and rates of disability.
In particular, low utilization of mental health services in STAR is an issue that will need to be more closely investigated. It is possible
that the low utilization is a reflection of the lower need for mental health services. On the other hand, it may also be possible that
STAR enrollees are underserved. One factor that may contribute to underutilization of mental health services is enrollee’s ethnicity.
National studies have found that among Hispanic Americans with a mental disorder, fewer than 1 in 11 contact mental health
specialists, while fewer than 1 in 5 contact general health care providers. Among Hispanic immigrants with mental disorders, fewer
than 1 in 20 use services from mental health specialists, while fewer than 1 in 10 use services from general health care providers.11
The State will need to conduct more detailed breakdowns of the STAR population to explore this issue further and to determine
whether low utilization is a result of enrollees encountering barriers to accessing mental health services, and if so, what remedies
would be required.
11
http://www.surgeongeneral.gov/library/mentalhealth/cre/fact3.asp
Page 18 of 43
HEDIS Mental Health Utilization - Members Receiving Inpatient, Day/Night, Ambulatory Services
STAR MCO - M arch 1, 2002 to February 28, 2003
10%
9%
8%
7%
HEDIS 2002 Mean
6%
5%
4%
STAR Using HEDIS
3% definitions
2%
1%
0%
STA R Using Co mmunity
HEDIS 2002 A mCare P arkland JP S Co mmunity
HEDIS A merigro up Superio r HM O B lue First Care Health El P aso First
M ean (TCHP ) Co mmunity M etro West First
definitio ns Cho ice
A ny M H Use 6.10% 2.51% 1.88% 2.83% 2.87% N/A 3.00% 3.00% 2.65% 1.88% 3.81% 2.23%
Inpatient M H 0.60% 0.17% 0.14% 0.12% 0.18% N/A 0.32% 0.24% 0.03% 0.09% 0.26% 0.05%
Day/Night M H 0.10% 0.22% 0.22% 0.09% 0.09% N/A 0.19% 0.52% 0.12% 0.18% 0.33% 0.06%
A mbulato ry M H 5.90% 2.37% 1.75% 2.75% 2.75% N/A 2.67% 2.83% 2.59% 1.73% 3.57% 2.15%
Table Notes:
1. Data from AmCare (no longer in business) and Texas Children’s Health Plan was unable to be used for this purpose.
2. Parkland and Amerigroup figures include behavioral health services provided to plan members by NorthSTAR.
Page 19 of 43
HEDIS Mental Health Utilization - Members Receiving Inpatient, Day/Night, Ambulatory Services
STAR+PLUS - January 1, 2003 to December 31, 2003
20%
18%
16%
STAR+PLUS Using HEDIS
14%
definitions
12%
10%
8%
HEDIS 2002 Mean
6%
4%
2%
0%
HEDIS 2002 Mean STAR+PLUS Using HEDIS definitions HMO Blue Amerigroup
Any MH Use 6.10% 12.16% 19.02% 4.27%
Inpatient MH 0.60% 2.45% 4.38% 0.22%
Day/Night MH 0.10% 0.16% 0.27% 0.03%
Ambulatory MH 5.90% 11.02% 17.08% 4.05%
Page 20 of 43
HEDIS Mental Health Utilization - Members Receiving Inpatient, Day/Night, Ambulatory Services
NorthSTAR BHO - February 1, 2002 to January 31, 2003
10%
9%
8%
7% HEDIS 2002 Mean
6%
5% NorthSTAR using HEDIS
definitions
4%
3%
2%
1%
0%
HEDIS 2002 M ean No rthSTA R using HEDIS definitio ns
A ny M H Use 6.10% 3.58%
Inpatient M H 0.60% 0.33%
Day/Night M H 0.10% 0.82%
A mbulato ry M H 5.90% 3.36%
Page 21 of 43
HEDIS CHEMICAL DEPENDENCY SERVICES UTILIZATION –MEMBERS RECEIVING
INPATIENT, DAY/NIGHT, AMBULATORY SERVICES
Why is this Information Important? According to the 2002 National Survey of Drug Use and Health, an estimated 19.5 million
Americans, or 8.3 percent of the population aged 12 or older, were current illicit drug users.12 Additionally, among individuals
diagnosed with a mental disorder, many also have co-occurring chemical dependency disorders. Prevalence data from the Texas
Department of Mental Health and Mental Retardation for fiscal year 2003 show that among individuals in the department’s priority
population for mental health services, 25 percent also have a chemical dependency disorder. Thus, effective treatment of mental
disorders for many individuals also requires treatment of co-occurring chemical dependency disorders. Rates of the use of substance
abuse/chemical dependency services are an important indicator as to whether clients in Medicaid managed care are able to access the
substance abuse benefit, to the degree that it is available within each model’s benefit.
In Texas, Medicaid has historically covered few chemical dependency services for adults – this remains true in the STAR and
STAR+PLUS programs. In both STAR and STAR+PLUS, the only required benefits are hospital–based detoxification services and
outpatient treatment for adolescents. However, plans may choose to expand the minimum level of substance abuse benefit as value
added services. The NorthSTAR program, due to the focus on behavioral health and inclusion of state and local chemical dependency
treatment funds, has a richer package of behavioral health services.
Time Period: February 1, 2002 – January 31, 2003 for STAR; January 1, 2003 – December 31, 2003 for STAR+PLUS; March
1, 2002 – February 28, 2003 for NorthSTAR
Findings:
STAR: Utilization of chemical dependency services in the STAR model is low – .09 percent of STAR enrollees used any chemical
dependency service. This is significantly less than the HEDIS 2002 mean of .70 percent for any chemical dependency use. The
percentages of use for the STAR model as a whole are too low to make any statements regarding use of a particular type of chemical
dependency service in relation to another (i.e. inpatient verses outpatient). Utilization rates among the STAR plans varied, ranging
from a high of.18 percent for Parkland Community health plan to low of .03 percent for JPS Metro West. The comparatively high rate
of chemical dependency utilization for both Parkland and Amerigroup is due to the fact that behavioral health usage for enrollees of
12
SAMHSA 2002 National Survey of Drug Use and Health. Substance Abuse and Mental Health Services Administration. www.samhsa.gov/oas/nhsda/htm
Page 22 of 43
these plans residing the Dallas service delivery area is provided by NorthSTAR. If the STAR enrollees who are served by
NorthSTAR for behavioral health needs were removed from the calculations, the overall STAR average would be lower.
STAR+PLUS: Utilization of chemical dependency services in the STAR+PLUS model is relatively high – 1.14 percent of STAR
enrollees used any chemical dependency service, which exceeds the HEDIS mean of .70 percent for use of any chemical dependency
service. There is significant variation between the two STAR+PLUS plans, with 1.73 percent of HMO Blue enrollees using any
chemical dependency service during the reporting period, compared with .46 percent for Amerigroup members. Across both plans,
inpatient CD use was greater than day/night or outpatient usage, although this trend was more pronounced in the case of HMO Blue
than Amerigroup.
NorthSTAR: In NorthSTAR, .24 percent of Medicaid enrollees used any chemical dependency service, which is lower than the
HEDIS mean of .70 percent. The majority of chemical dependency services in NorthSTAR occurred in an ambulatory setting,
followed by inpatient and then day/night services.
Implications: The HEDIS mean of chemical dependency services utilization of less than 1 percent demonstrates that chemical
dependency use within the Medicaid managed care plan is low across the county, due most likely to the minimal role that Medicaid
has historically played in funding chemical dependency services. Both STAR and NorthSTAR models have usage rates lower than
HEDIS, while one plan in STAR+PLUS exceeds the HEDIS average. However, a relatively low utilization of chemical dependency
services should be expected, based on HEDIS reporting and the minimal role of Medicaid in funding chemical dependency services.
Page 23 of 43
HEDIS Chemical Dependency Utilization - Members Receiving Inpatient, Day/Night,
Ambulatory Services
1.00% STAR MCO - March 1, 2002 to February 28, 2003
0.90%
0.80%
HEDIS 2002 Mean
0.70%
0.60%
0.50%
0.40%
0.30%
0.20% STAR Mean
0.10%
0.00%
HEDIS 2002 AmCare Parkland Community JPS Community
STAR Mean Amerigroup Superior HMO Blue First Care El Paso First
Mean (TCHP) Community Health Choice MetroWest First
Any CD Use 0.70% 0.09% 0.08% 0.11% 0.08% N/A 0.04% 0.18% 0.04% 0.03% 0.07% 0.07%
Inpatient CD 0.20% 0.04% 0.03% 0.05% 0.02% N/A 0.01% 0.08% 0.02% 0.03% 0.03% 0.01%
Day/Night CD 0.00% 0.01% 0.01% 0.00% 0.00% N/A 0.00% 0.05% 0.00% 0.01% 0.01% 0.00%
Ambulatory CD 0.60% 0.06% 0.05% 0.09% 0.05% N/A 0.03% 0.10% 0.02% 0.00% 0.05% 0.06%
Table Notes:
1. Data from AmCare (no longer in business) and Texas Children’s Health Plan was unable to be used for this purpose.
2. Parkland and Amerigroup figures include behavioral health services provided to plan members by NorthSTAR.
Page 24 of 43
HEDIS Chemical Dependency Utilization - Members Receiving Inpatient, Day/Night,
Ambulatory Services
STAR+PLUS - January 1, 2003 to December 31, 2003
10%
9%
8%
7%
6%
5%
4%
3%
2%
STAR+PLUS Mean
HEDIS 2002 Mean
1%
0%
HEDIS 2002 Mean STAR+PLUS Mean HMO Blue Amerigroup
Any CD Use 0.70% 1.14% 1.73% 0.46%
Inpatient CD 0.20% 0.63% 0.98% 0.24%
Day/Night CD 0.00% 0.02% 0.04% 0.00%
Ambulatory CD 0.60% 0.54% 0.80% 0.23%
Page 25 of 43
HEDIS Chemical Dependency Utilization - Members Receiving Inpatient, Day/Night, Ambulatory
Services
NorthSTAR BHO - February 1, 2002 to January 31, 2003
10%
9%
8%
7%
6%
5%
4%
3%
NorthSTAR using HEDIS
2% HEDIS 2002 mean
definitions
1%
0%
HEDIS 2002 mean No rthSTA R using HEDIS definitio ns
A ny CD 0.70% 0.24%
Inpatient CD 0.20% 1
0.1 %
Day/Night CD 0.00% 0.05%
A mbulato ry CD 0.60% 0.14%
Page 26 of 43
QUALITY MEASURES
HEDIS Follow-Up After Hospitalization For Mental Illness
Why is this Information Important? Some evidence suggests that enrollees with behavioral health conditions in managed care may
face problems with continuity of care and poor quality of care. Ensuring continuity of care and providing follow-up in the community
after inpatient stays for mental illness have been shown to reduce enrollees’ health care costs and to improve their outcomes of care.13
The HEDIS measure regarding follow-up after hospitalization for mental illness is often indicative of a MCO’s approach to quality of
care for enrollees with mental illness. A high rate of re-hospitalization to inpatient psychiatric or substance abuse care suggests that
patients may not have been stabilized prior to discharge, discharge planning was inadequate, or the follow up care in the community
was not sufficient to support the patient.14 This table shows the percent of enrollees who received inpatient treatment for a mental
health disorder and had a mental health follow up (either an outpatient or a day program visit) within 7 and 30 days after discharge.
Time Period: February 1, 2002 – January 31, 2003 for STAR; December 1, 2001 – November 30, 2002 for STAR+PLUS; and
February 1, 2002 – January 31, 2003 for NorthSTAR.
Findings:
STAR: Within the STAR model, 16 percent of enrollees had an outpatient follow-up within 7 days of an inpatient admission for
mental illness. This is significantly lower than the HEDIS mean of 36.9 percent for follow-up within 7 days. Among the 10 STAR
plans, performance on the 7-day measure ranged from a low of 1.18 percent, to a high of 24.4 percent. Approximately 31 percent of
STAR MCO enrollees had a follow-up within 30 days of their inpatient admissions, compared to the HEDIS mean of 52 percent. Plan
performance for the 30-day measure ranged from 8.24 percent to 42.76 percent. For PCCM, 29 percent of the enrollees had an
outpatient follow-up within 7 days of an inpatient admission for mental illness and 59 percent had a follow-up visit within 30 days.
Parkland Community Health Plan, Community Health Choice, and Amerigroup had the most positive findings, although none of them
approached the Medicaid national average. Both Parkland and Amerigroup plans operate in the NorthSTAR service delivery area.
13
Fortney J, Sullivan G, Williams K, Jackson C, Morton SC, Koegel P. Measuring continuity of care for clients of public mental health systems. Health
Services Research. 2003; 38(4): 1157-1175.
14
Substance Abuse and Mental Health Services Administration (SAMHSA). Implementing an Early Warning System: A Manual for State Evaluation of
Medicaid Behavioral Health Managed Care. Rockville, Maryland: U.S. Department of Health and Human Services; 2002.
Page 27 of 43
Parkland Community Health Plan operates solely within the NorthSTAR area, while Amerigroup operates in the NorthSTAR area and
in other service delivery areas. Therefore, all behavioral health services for enrollees in Parkland and some enrollees in Amerigroup
are provided by NorthSTAR. If enrollees of Parkland and Amerigroup who were served by NorthSTAR were removed from the
calculations, the overall STAR average would be lowered.
STAR+PLUS: Within STAR+PLUS, 21 percent of enrollees had an outpatient follow-up within 7 days of an inpatient admission for
mental illness and approximately 41 percent had a follow-up within 30 days of their inpatient admissions. The STAR+PLUS Program
overall average is lower than the average for Medicaid Programs reporting to HEDIS, particularly for the 7-day follow-up. The
HEDIS mean follow-up at 7 days is 32 percent and 52 percent for follow-up at 30 days post an inpatient stay for mental illness. The
Amerigroup follow-up results are unusually low for 7 and 30 day follow-up at 4 percent and 7 percent; respectively. The low rate of
follow –up after discharge for Amerigroup may be explained to some degree by the fact that the number of discharges eligible for
inclusion in this measure from Amerigroup was extremely small, thus the data available may not provide an accurate reflection of the
service trends for this plan. This also explains why the low follow-up rate for Amerigroup did not significantly affect the overall
average for all of STAR+PLUS.
NorthSTAR: Within NorthSTAR, 30.6 percent of Medicaid enrollees had an outpatient follow-up within 7 days of an inpatient
discharge for mental illness. Approximately 58 percent of enrollees had a follow-up within 30 days of their inpatient hospitalization.
The NorthSTAR average is essentially equivalent to the average for Medicaid Programs reporting to HEDIS for 7-day follow-up and
higher than the national average for 30-day follow-up.
Implications:
In Medicaid plans across the country, both the 7-day and 30-day rates have reached a plateau. Nationally, there is also significant
variation among plans on this measure – with the top 10th of Medicaid plans having rates 3 times higher than the bottom 10th for the 7
day follow-up, and up to twice as high for the 30-day follow up.15 These factors indicate that this is a measure where plans have
varying systems and processes to monitor mental health admissions and where states may need to increase oversight and instigate
more direct interaction with plans.
Program structure may also be an issue that the State should evaluate as influencing this performance measure. NorthSTAR program
data for follow-up after mental health hospitalization are comparable to the HEDIS benchmarks and better than the results obtained for
the STAR and STAR+PLUS models. Since NorthSTAR, a behavioral health carve-out program, performed better on this measure
15
National Committee for Quality Assurance, “State of Health Care Quality: 2003” Washington D.C. available on the web at
http://www.ncqa.org/Communications/News/sohc2003.htm
Page 28 of 43
than either STAR or STAR+PLUS models, this may indicate that the carve-out program offers opportunities for improved quality of
care.
It’s worth noting that the HEDIS specification for this measure requires that the follow-up must be provided by a mental health, rather
than a primary care, practitioner. Thus, there may be some instances within all the models, where follow up care was provided, but
was not captured in this measure because a mental health practitioner did not provide the care.
Page 29 of 43
HEDIS Follow-Up After Hospitalizaton for Mental Illne
STAR MCOs - February 1, 2002 to January 31, 2003
100%
90%
80%
70%
HEDIS
2002
60%
Benchmark
50%
40%
STAR
Mean
30%
20%
10%
0%
Community
All STAR HEDIS AmCare Parkland JPS Community El Paso
PCCM Amerigroup Superior HMO Blue First Care Health
MCOs 2002 Mean (TCHP) Community MetroWest First First
Choice
7 Days 16.16% 36.90% 29.77% 21.37% 12.41% 10.65% N/A 1.18% 24.24% 20.83% 14.29% 13.12% 0.00%
30 Days 31.25% 56.30% 59.58% 35.55% 32.85% 21.30% N/A 8.24% 42.76% 37.50% 14.29% 35.52% 0.00%
Table Note:
1. Parkland and Amerigroup figures include behavioral health services provided to plan members by NorthSTAR.
2. Data from AmCare (no longer in business) and Texas Children’s were unable to be used for this purpose.
Page 30 of 43
HEDIS Follow-Up After Hospitalizaton for Mental Illness
STAR+PLUS MCOs - December 1, 2001 to November 30, 2002
100%
90%
80%
70%
HEDIS
60% 2002
Benchmark
50% STAR+PLUS
Mean
40%
30%
20%
10%
0%
All STAR+PLUS MCOs HEDIS 2002 Medicaid Mean HMO Blue Amerigroup
7 Days 21.14% 32.00% 21.68% 3.57%
30 Days 41.12% 52.50% 42.16% 7.14%
Includes Medicaid Only
Page 31 of 43
HEDIS Follow-Up After Hospitalizaton for Mental Illness
NorthSTAR BHO - February 1, 2002 to January 31, 2003
100%
90%
80%
70% NorthSTAR using HEDIS
definitions
HEDIS 2002 Mean
60%
50%
40% STAR MCO Mean
30%
20%
10%
0%
STA R M CO M ean HEDIS 2002 M ean No rthSTA R using HEDIS definitio ns
7 Days 6.1
1 6% 32.00% 30.60%
30 Days 31.25% 52.20% 57.68%
Page 32 of 43
FINANCIAL MEASURES
Behavioral Health Expenditures as a Percentage of Total Expenditures
Why is this Information Important? Expenditure data provides information as to the level of financial commitment a Medicaid
managed care plan is making towards the provision of behavioral health services. A standard benchmark for what an acceptable or
average level of expenditures on behavioral health as a percentage of total health care expenditures is not available. However,
tracking this measure across plans and over time is a helpful indicator of the level of resources committed to behavioral health.
Ideally, behavioral health expenditures should be tracked by service type, but at present, NorthSTAR is the only model where
expenditures for behavioral health services can by tracked by type of service (i.e. community vs. inpatient, etc.)
Time Period: State Fiscal Year 2003
Findings:
STAR: The average percentage of expenditures for behavioral health services, as a percentage of total expenditures, was 1.65 percent
for the STAR health plans. The percentage paid of behavioral health services ranged from 1.56 percent to 3.41 percent for all the
plans that provide behavioral health services.
STAR+PLUS: The average percentage of expenditures for behavioral health services, as a percentage of total expenditures, was 5.30
percent for the STAR+PLUS health plans. The percentage paid of behavioral health services ranged from 4.39 percent to 6.16 percent
for the two STAR+PLUS plans.
NorthSTAR: As a behavioral health carve out, all (100 percent) of the expenditures in NorthSTAR are related to behavioral health
services. While NorthSTAR does not lend itself to this type of comparison, in order to provide information regarding the percentage
of funds that are allocated to behavioral services for STAR members served by NorthSTAR, the expenditures for STAR members
within the NorthSTAR model were compared to the total expenses for the STAR plans operating in the Dallas Service Delivery Area.
The percentage of expenditures for behavioral health services, as a percentage of total expenditures, was 16.26 percent for STAR
enrollees within NorthSTAR. This is significantly greater than the percentage of expenditures for behavioral health within STAR or
STAR+PLUS. This is due to the fact that NorthSTAR provides a benefit package that is generally richer than the behavioral health
benefit packages offered by the STAR or STAR+PLUS models. For example, NorthSTAR includes certain services, such as
rehabilitation and targeted case management, that in other models are carved out of managed care and offered within the fee-for-
Page 33 of 43
service Medicaid program. Additionally, NorthSTAR integrates local, state and federal funds which allows the model to fund services
such as residential treatment for substance abuse to its enrollees that would otherwise be provided outside of the Medicaid managed
care model.
Implications: There is not a standard benchmark for the percentage of expenditures that a health plan should devote to behavioral
health services. To a large degree, determining what an appropriate figure would require taking into account the benefit package and
expected needs of the enrolled population. HHSC will evaluate this measure over time to attempt to determine an appropriate
benchmark or a more effective measure to monitor behavioral health expenditures.
Page 34 of 43
STAR – Behavioral Health Expenditures as a Percentage of Total Expenditures
12 months of unaudited data from the August 31, 2003 HMO Financial and Statistical Reports
Total Health Behavioral Behavioral Health as Notes
Services Health a Percentage of Total
Services Services
Bexar SDA:
Community First $ 62,007,603 $ 1,240,152 2.00%
HMO Blue $ 37,474,399 $ 665,912 1.78%
Superior $ 17,779,873 $ 359,965 2.02%
Dallas SDA:
AMERIGROUP $ 89,603,031 $ - N/A BH is carved out to NorthSTAR
Parkland $ 122,950,505 $ - N/A BH is carved out to NorthSTAR
El Paso SDA:
El Paso First $ 23,749,895 $ 369,970 1.56%
Superior $ 39,815,012 $ 952,480 2.39%
Harris SDA:
AMERIGROUP $ 147,491,716 $ 3,446,096 2.34%
Community Health Choice $ 84,594,813 $ 1,621,020 1.92%
HMO Blue $ 51,872,822 $ 1,194,873 2.30%
Texas Childrens $ 34,024,758 $ 1,160,688 3.41%
Lubbock SDA:
Firstcare $ 18,784,572 $ 513,722 2.73%
HMO Blue $ 3,573,508 $ 114,753 3.21%
Tarrant SDA:
AMERIGROUP $ 130,858,367 $ 2,240,684 1.71%
HMO Blue $ 34,926,085 $ 762,724 2.18%
JPS STAR (MetroWest) $ 14,206,277 $ 405,357 2.85%
Travis SDA:
HMO Blue $ 8,360,837 $ 184,957 2.21%
Superior $ 77,066,314 $ 1,615,353 2.10%
Total $ 913,713,236 $ 14,678,426 1.65%
Page 35 of 43
STAR+PLUS – Behavioral Health Expenditures as a Percentage of Total Expenditures
12 months of unaudited data from the August 31, 2003 (HHSC HMO Financial and Statistical Reports)
Total Health Services Behavioral Health Behavioral Health as
Services a Percent of Total
Services
Harris SDA:
Amerigroup $ 115,975,717 $ 5,095,803 4.39%
Evercare * $ 122,542,372 $ 7,543,504 6.16%
Total $ 238,518,089 $ 12,639,307 5.30%
*Evercare took over operations from HMO Blue on 4/1/04.
NorthSTAR – Behavioral Health Expenditures as a Percentage of Total Expenditures
For STAR Clients Enrolled in NorthSTAR
State Fiscal Year 2003 – HHSC HMO Financial and Statistical Reports and Data Provided By NorthSTAR Staff)
Total Health Services Behavioral Health Behavioral Health as
Services (Medicaid a Percent of Total
Funds within Services
NorthSTAR)
Dallas SDA:
Amerigroup $ 89,603,031
Parkland $ 122,950,505
Total Dallas SDA
Expenditures $ 212,553,536 $34,557,285 16.26%
Page 36 of 43
Appendix A
Listing of Plans by Service Delivery Area
for State Fiscal Years16 2003 and 2004
STAR Program
SFY 2003
Service Counties in Service Delivery Area Health Plan Behavioral Health Plan
Area
Bexar Bexar, Kendall, Comal, Guadalupe, Community First N/A – Behavioral health services provided “in-house”
Wilson, Atascosa, Medina
HMO Blue Magellan
Superior Tejas
Dallas Dallas, Collin, Ellis, Hunt, AMERIGROUP N/A – Behavioral health is carved-out to NorthSTAR
Kaufman, Navarro, Rockwell
Parkland N/A – Behavioral health is carved-out to NorthSTAR
El Paso El Paso, Hudspeth, Culberson Superior Tejas
El Paso First Tejas
Harris / Harris, Montgomery, Waller, Fort AMERIGROUP Value Options (BH moved “in-house” as of 7/1/2003)
Harris EXP Bend, Galveston, Brazoria
Community Health Choice CompCare
HMO Blue CompCare
16
In Texas, the state fiscal year runs from September 1 through August 31, i.e. state fiscal year 2003 began on September 1, 2002 and ended on August 31, 2003.
Page 37 of 43
Texas Children’s Health CompCare
Plan
Lubbock Lubbock, Crosby, Floyd, Garza, FirstCare CompCare
Hale, Hockley, Lamb, Lynn, Terry
HMO Blue Magellan
Tarrant Tarrant, Wise, Denton, Parker, AMERIGROUP Value Options (Behavioral health moved “In-house” during
Hood, Johnson as of 7/1/2003)
JPS Star (MetroWest) Innovative Resource Group
Travis Travis, Williamson, Lee, Bastrop, Superior Tejas
Blanco, Caldwell, Hays, Burnet
SFY 2004
Service Counties in Service Delivery Area Health Plan Behavioral Health Plan
Area
Bexar Bexar, Kendall, Comal, Guadalupe, Community First N/A – BH Services provided “in-house”
Wilson, Atascosa, Medina
Superior Tejas
Dallas Dallas, Collin, Ellis, Hunt, AMERIGROUP N/A – Behavioral health is carved-out to NorthSTAR
Kaufman, Navarro, Rockwell
Parkland N/A – Behavioral health is carved-out to NorthSTAR
El Paso El Paso, Hudspeth, Culberson Superior Tejas
El Paso First Tejas through May 31, 2004
“In-house” beginning June 1, 2004
Harris Harris, Montgomery, Waller, Fort AMERIGROUP N/A – BH Services provided “in-house”
Bend, Galveston, Brazoria
Community Health Choice CompCare through May 31, 2004
APS Healthcare beginning June 1, 2004
Page 38 of 43
Texas Children’s Health CompCare
Plan
Lubbock Lubbock, Crosby, Floyd, Garza, FirstCare CompCare
Hale, Hockley, Lamb, Lynn, Terry
Tarrant Tarrant, Wise, Denton, Parker, AMERIGROUP N/A – BH Services provided “in-house”
Hood, Johnson
JPS Star (MetroWest) Innovative Resource Group
Travis Travis, Williamson, Lee, Bastrop, Superior Tejas
Blanco, Caldwell, Hays, Burnet
Page 39 of 43
STAR+PLUS Program
SFY 2003
Service Counties in Service Delivery Area Health Plan Behavioral Health Plan
Area
Harris Harris HMO Blue (discontinued Compcare
operations and was
replaced by Evercare as of
4/1/03)
Evercare (began operations Compcare
on 4/1/03)
AMERIGROUP Value Options (Behavioral health moved “In-house” as of
7/1/2003)
SFY 2004
Service Counties in Service Delivery Area Health Plan Behavioral Health Plan
Area
Harris Harris Evercare Compcare
AMERIGROUP Value Options (Behavioral health moved “In-house” as of
7/1/2003)
Page 40 of 43
NorthSTAR Program
SFY 2003
Service Counties in Service Delivery Area Health Plan Behavioral Health Plan
Area
Dallas Dallas, Collin, Ellis, Hunt, AMERIGROUP Value Options, within NorthSTAR
Kaufman, Navarro, Rockwell
Parkland Value Options, within NorthSTAR
SFY 2004
Service Counties in Service Delivery Area Health Plan Behavioral Health Plan
Area
Dallas Dallas, Collin, Ellis, Hunt, AMERIGROUP Value Options, within NorthSTAR
Kaufman, Navarro, Rockwell
Parkland Value Options, within NorthSTAR
Page 41 of 43
Appendix B
Description of Data Sources for Each Measure
Claims Payment Timeliness
STAR and STAR+PLUS: The data for this measure is derived from HMO self-reported information on claims payment for UB 92
and HCFA 1500 claims forms (i.e. inpatient and outpatient claims). This information has not yet been audited or verified by HHSC.
HHSC does audit and verify HMO reports but the unaudited data is reported for this report in order to prevent the data lag that would
be present if only audited data were used.
NorthSTAR: This information is derived from the NorthSTAR databook, which is available at
http://www.mhmr.state.tx.us/CentralOffice/NorthSTAR/NorthStarhomepage.html. NorthSTAR uses a data warehouse and decision
support software to evaluate and manage the system of care. This data warehouse collects much of the information available in the
databook.
Behavioral Health Provider Network
STAR and STAR+PLUS:
Health plans are required to submit their provider network information to Maximus, the state’s enrollment broker for managed care.
HHSC has access to the information submitted to Maximus and has used this information to determine the number of behavioral
health providers within each health plan’s network. The accuracy of this data depends upon timely and correct submission of data by
the health plans to Maximus.
NorthSTAR: This provider network information is derived from the NorthSTAR databook, which is available at
http://www.mhmr.state.tx.us/CentralOffice/NorthSTAR/NorthStarhomepage.html
HEDIS Measures:
The data sources for the individual HEDIS measures contained in this report are described below. The State’s External Quality
Review Organization, the Institute for Child Health Policy (ICHP), compiled the HEDIS measures. In the development of this report,
ICHP used the 2003 HEDIS specifications. Some limited deviations from the HEDIS specifications were required. These deviations
from HEDIS Specifications are as follows:
1. Although HEDIS requires that all mental health utilization and follow up services be with a mental health practitioner, the
encounter data submitted to ICHP did not include provider type. In order to compensate, ICHP used revenue, diagnosis and
procedure codes to determine provider type.
Page 42 of 43
2. ICHP has added local codes to supplement identification of inpatient stay and other services.
Mental Health Utilization (HEDIS Measure)
The federal government requires that state Medicaid program have an ongoing independent external review of managed care
organizations’ quality of care. The Texas external quality review organization (EQRO) is the Institute for Child Health Policy
(ICHP). ICHP assesses access to care and quality of care for all of the Medicaid managed care models. ICHP collects the data for this
HEDIS measure as a part of its ongoing quality review activities. ICHP uses data submitted by the health plans. ICHP then validates
the data using a protocol that meets federal data validation requirements. ICHP supplements this validation process by medical record
reviews of the health plan data.
Chemical Dependency Utilization (HEDIS Measure)
The federal government requires that state Medicaid program have an ongoing independent external review of managed care
organizations’ quality of care. The Texas external quality review organization (EQRO) is the Institute for Child Health Policy
(ICHP). ICHP assesses access to care and quality of care for all of the Medicaid managed care models. ICHP collects the data for this
HEDIS measure as a part of its ongoing quality review activities. ICHP uses data submitted by the health plans. ICHP then validates
the data using a protocol that meets federal data validation requirements. ICHP supplements this validation process by medical record
reviews of the health plan data.
Follow – Up After Hospitalization for Mental Illness (HEDIS Measure)
The federal government requires that state Medicaid program have an ongoing independent external review of managed care
organizations’ quality of care. The Texas external quality review organization (EQRO) is the Institute for Child Health Policy
(ICHP). ICHP assesses access to care and quality of care for all of the Medicaid managed care models. ICHP collects the data for this
HEDIS measure as a part of its ongoing quality review activities. ICHP uses data submitted by the health plans. ICHP then validates
the data using a protocol that meets federal data validation requirements. ICHP supplements this validation process by medical record
reviews of the health plan data.
Behavioral Health Expenditures
STAR and STAR+PLUS: The data to calculate behavioral health expenditures is taken from unedited data for the annual financial
statistical reports submitted by health plans to HHSC.
NorthSTAR: This expenditure data is derived from both the unedited data for the annual financial statistical reports submitted by
health plans to HHSC and the total Medicaid enrollment figures by risk group.
Page 43 of 43
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