sion. Claims data are an especially important source of information on care received by PLWHA given the large number who are Medicaid beneficiaries: an estimated 47 percent of PLWHA who were receiving regular medical care were Medicaid beneficiaries in FY 2007 (Kates, 2011). As more PLWHA become eligible for Medicaid and commercial health insurance as a result of the Patient Protection and Affordable Care Act (ACA, P.L. 111-148), claims data are likely to become an even more useful source of data for monitoring HIV care. Despite the many advantages of claims data, the influence of reimbursement policies needs to be taken into consideration when using claims data for health services research (Crystal et al., 2007).

Health plan reimbursement policies may “carve out” certain services such as behavioral health, transportation, dental, and pharmacy benefits so that a separate organization is responsible for payment. As a result, the primary insurer may not have a record of the carved-out service in its claims data (Hicks, 2003; Joins et al., 2007). Carve-out arrangements are often used in the Medicaid program when Medicaid managed care organizations (MCOs) contract with other entities to provide services to which beneficiaries are entitled, as per the state Medicaid agencies’ contract with the MCO.1 An MCO may decide to carve out a benefit because it lacks in-house expertise to meet a particular patient need or because it does not have the infrastructure necessary to administer a benefit (e.g., transportation services) (Joins et al., 2007). Carve-out arrangements parse benefits out to multiple entities, and it is often challenging for these entities to communicate and exchange data with one another in order to coordinate patient care effectively (Joins et al., 2007).2 Carve-outs may also make it difficult to combine data at the patient level for research or monitoring purposes. Carve-out arrangements may pose a challenge to the estimation of indicators that require prescription drug dispensing data, or data on receipt of mental health or transportation services, since these services are among those that are most likely to be carved out of a health plan.

A health plan’s claims data also will not contain data on care for which

________________

1In FY 2007, 71 percent of Medicaid enrollees with HIV had some of their care paid for through Medicaid managed care (Kates, 2011).

2The Lewin Group performed an assessment of carve-out and carve-in arrangements for pharmacy benefits within Medicaid MCOs (Joines et al., 2007). Among the advantages to MCOs with carve-in arrangements were that providers were more likely to have real-time access to pharmaceutical data to help prevent potential drug interactions and polypharmacy (unwanted duplication of drugs), identify inappropriate use of drugs, monitor controlled substance usage, and other interventions. Some representatives of carve-out MCOs reported that they do not always have access to real-time claims data to determine what medications patients are taking. The report noted the importance of data system integration to ensure real-time transfer of pharmaceutical information, both for MCOs that carve their pharmaceutical services out to other entities and for carve-in MCOs who may contract with a pharmacy benefits management group to manage pharmacy benefits (Joines et al., 2007).



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement