Krause Trudy Millard, Yay Donderici Elifnur, Ganduglia Cazaban Cecilia, Franzini Luisa
Department of Management, Policy and Community Health, University of Texas School of Public Health, Co-Director, UTSPH - Center for Healthcare Data Research, University of Texas School of Public Health, University of Texas School of Public Health, 1200 Pressler Street RAS E905, Houston, TX, 77030, USA.
Department of Management, Policy and Community Health, University of Texas School of Public Health, 1200 Pressler Street RAS E345, Houston, TX, 77030, USA.
BMC Health Serv Res. 2016 Jul 29;16:319. doi: 10.1186/s12913-016-1552-x.
Silent-members are members of a medical health plan who submit no claims for healthcare services in a benefit year despite 12 months of continuous-enrollment. This study was conducted to evaluate the future expenditure risk of commercial-insured members who avoid all medical care despite coverage. In order to determine if the silent-members were at greater risk, we compared them to members who received care in the anchor year (2009) but had low-expenditures. The low-expenditure members were assumed to represent persons without significant medical conditions and without care-avoidance behaviors. We examined the claims experience of a cohort of silent members in the 2 years after the silent year (2009) and compared it with the corresponding claims experience for a cohort of low-expenditure members from the same anchor year (2009).
Members of commercial health plans (BCBS of Texas) were selected based on continuous-enrollment in 2009. Two sub-groups were identified based on annual claims expenditure: Care avoiders were members with 12 months continuous-enrollment and no medical claims, and are thus referred to as "silent members" in the insurance industry. Low-Expenditure members were those with 12 months continuous-enrollment and total PMPY (per member per year) annual medical claims expenditure in the lowest 10th percentile of members with claims experience. "Low-expenditure" members served as a comparison group to the "silent members", under the assumption that such claimants were using benefits for minor healthcare issues as needed. Key variables were enrollment and expenditures. Enrollment data identified demographics and continuous-enrollment. Medical claims data were used to calculate utilization and expenditures. All claims data were de-identified and no consent was required, as approved by the Institutional Review Board. No research involved human subjects. Multivariate logistic regression models were applied.
Silent members who seek care in subsequent years have a greater probability of becoming high-expenditure claimants than those with low-expenditure experience.
For silent members who subsequently seek treatment, the probability of becoming high-expenditure is significantly greater than low-expenditure members from the anchor year. The implications of future high costs for silent members who become claimants may support the need for additional research to address the risks of care avoidance behaviors.
沉默成员是指在一个受益年度内尽管连续参保12个月但未提交任何医疗服务索赔的医疗保险计划成员。本研究旨在评估尽管有保险覆盖但避免所有医疗护理的商业保险成员未来的支出风险。为了确定沉默成员是否面临更大风险，我们将他们与在基准年（2009年）接受过治疗但支出较低的成员进行了比较。低支出成员被假定为没有重大医疗状况且没有避免就医行为的人群。我们研究了沉默年（2009年）后两年内一组沉默成员的索赔经历，并将其与来自同一基准年（2009年）的一组低支出成员的相应索赔经历进行了比较。
根据2009年的连续参保情况选择商业健康计划（德克萨斯州蓝十字蓝盾公司）的成员。根据年度索赔支出确定了两个亚组：避免就医者是连续参保12个月且无医疗索赔的成员，因此在保险行业中被称为“沉默成员”。低支出成员是指连续参保12个月且每年每人医疗索赔支出在有索赔经历成员的最低十分位的成员。“低支出”成员作为“沉默成员”的对照组，假设此类索赔者根据需要使用小额医疗保健福利。关键变量是参保情况和支出。参保数据确定了人口统计学特征和连续参保情况。医疗索赔数据用于计算利用率和支出。所有索赔数据均经过去识别处理，且经机构审查委员会批准无需获得同意。本研究不涉及人类受试者。应用了多变量逻辑回归模型。
在随后几年中寻求治疗的沉默成员比有低支出经历的成员更有可能成为高支出索赔者。
对于随后寻求治疗的沉默成员，成为高支出者的概率明显高于基准年的低支出成员。对于成为索赔者的沉默成员未来高成本的影响可能支持需要进行更多研究以应对避免就医行为风险的必要性。
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