Children who are medically fragile in North Carolina: using Medicaid data to estimate prevalence and medical care costs in 2004.

OBJECTIVES: The purpose of this paper is to demonstrate a method of using medical insurance paid claims and enrollment data to estimate the prevalence of selected health conditions in a population and to profile associated medical care costs. The examples presented here use North Carolina Medicaid data to produce estimates for children ages 0-19 who are medically fragile. These children with serious health conditions are a small subset of all children with special health care needs. METHODS: The children who are medically fragile were identified through selected procedure and durable medical equipment codes. We profiled the expenditures for all medical services provided to these children during 2004. RESULTS: 1,914 children ages 0-19 enrolled in Medicaid were identified as medically fragile (0.22 percent). The amount paid by Medicaid for these children during 2004 for all medical services was $133.8 million, or $69,906 per child. By comparison, the average expenditure by Medicaid during 2004 for a randomly selected group of children receiving well-child care visits was $3,181 per child. The $133.8 million of Medicaid expenditures for the children who are medically fragile represents 6.8 percent of the nearly $2 billion spent by Medicaid in 2004 for all medical services for all children ages 0-19. CONCLUSIONS: This study presents a standard methodology to identify children with specific health conditions and describe their medical care costs. Our example uses Medicaid claims and enrollment data to measure prevalence and costs among children who are medically fragile. This approach could be replicated for other health care payer data bases and also in other geographic areas.

Medical homes for children with special healthcare needs in North Carolina.

BACKGROUND: The American Academy of Pediatrics defines a medical home as medical care for children that is accessible, continuous, comprehensive, family-centered, coordinated, and compassionate. North Carolina uses the medical home concept as a model for providing high quality care to children with special healthcare needs (CSHCN). However, until recently, information on medical homes for CSHCN in North Carolina has not been available. METHODS: Using North Carolina data from the National Survey of Children with Special Health Care Needs (2000-2002), we describe the characteristics of children having a special healthcare need. We conducted bivariate analysis of socio-demographic factors with medical home and its five components (family-centered care, effective care coordination, personal doctor or nurse, usual source of care, and referrals for specialty care) and multivariate analysis to identify the predictors of having a medical home. RESULTS: Fifty-six percent of CSHCN in North Carolina have a medical home. White CSHCN are 1.7 times more likely to have a medical home compared to non-white CSHCN. CSHCN with no functional limitations are 1.6 times more likely to have a medical home compared to children with some or severe limitations of their functional status. CONCLUSIONS: Current, population-based information about CSHCN and their families is essential for assessing needs and evaluating pediatric initiatives at the state level. Disparities among CSHCN due to race and functional status should be considered in organizing services for CSHCN in North Carolina.