Understanding Cost and Utilization Profiles of Children with Special Health Care Needs Bureau of Mat

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Understanding Cost and Utilization Profiles of
Children with Special Health Care NeedsBureau
of Maternal and Child Health ServicesDivision
of Services for CSHCNFeb 10, 2003

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Clinical Risk GroupsCRGs

• John M. Neff MD
• Center for Children with Special Needs,
  Childrens Hospital and Regional Medical Center,
  Seattle, Washington

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Administrative Data SetsWhat They Can
DoIdentify Children by Diagnosis and Severity
to

• Case manage and track
• Risk adjustment
• Understand cost allocation

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Administrative Data SetsWhat They Can Not Do

• Provide geographical prevalence data
• Identify individuals who do not interact with
  health plan
• Include non-plan costs

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CRGs Description

• CRGs are a categorical clinical model that uses
  claims data to assign each patient to a single
  mutually exclusive risk category and severity
  level
• (CRGs have been developed by NACHRI and 3m Health
  Information Systems)

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With the use of administrative data- Who do CRGs
identify?Who do CRGs miss?
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Comparison of CRGs and Pediatric Literature with
respect to Prevalence Estimates of Selected
Conditions
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3M CRG Classification of NWMBChildren-1999

• Healthy (includes non-users) 85.2
  29,446
• Significant Acute
  5.2 1,807
• Single Minor Chronic
  4.4 1,510
• Multiple Minor Chronic 0.2
  75
• Single Dominant/Moderate Chronic 4.5
  1,546
• Multiple Significant Chronic 2s 3s 0.4
  126
• Malignancies (Metastatic) 0.05
  17
• Catastrophic
  0.05 17
• -------------------------------
• TOTAL 100.00 34,544

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CRG Status by Severity Distribution, NWMB CY99
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Average Total CY99 Charges Per Patient by CRG
Status Severity