Table 1.
Sensitivity and specificity of claims-derived measures in determining when the benefit feature is required or is not required
| True measure = not required |
True measure = required |
Specificity TN/(TN+FP) |
Sensitivity TP/(FN+TP) |
|||
|---|---|---|---|---|---|---|
| Claims-derived measure† = | Claims-derived measure† = | |||||
| Not required (TN) |
Required (FP) |
Not required (FN) |
Required (TP) |
|||
| Copayment, INN | ||||||
| Inpatient | % | % | ||||
| Carve-in | 1916 (78%) | 96 (4%) | 11 (0.5%) | 443 (18%) | 95 | 97 |
| Carve-out | 1330 (77%) | 1 (0.1%) | 16 (1%) | 371 (22%) | 99.9 | 96 |
| Outpatient | ||||||
| Carve-in | 2400 (54%) | 539 (12%) | 30 (1%) | 1486 (33%) | 82 | 98 |
| Carve-out | 2860 (60%) | 14 (0.3%) | 6 (0.1%) | 1881 (40%) | 99 | 99 |
| Coinsurance, INN | ||||||
| Inpatient | ||||||
| Carve-in | 221 (9%) | 20 (1%) | 150 (6%) | 2074 (84%) | 92 | 93 |
| Carve-out | 733 (43%) | 13 (1%) | 133 (8%) | 838 (49%) | 98 | 86 |
| Outpatient | ||||||
| Carve-in | 1157 (26%) | 839 (19%) | 235 (5%) | 2218 (50%) | 58 | 90 |
| Carve-out | 1901 (40%) | 8 (0.1%) | 593 (12%) | 2259 (47%) | 99 | 79 |
| Coinsurance, OON | ||||||
| Inpatient | ||||||
| Carve-in | 5 (1%) | 0 (0%) | 135 (18%) | 623 (82%) | 100 | 82 |
| Carve-out | 12 (3%) | 0 (0%) | 150 (32%) | 315 (68%) | 100 | 68 |
| Outpatient | ||||||
| Carve-in | 13 (0.5%) | 0 (0%) | 579 (22%) | 2092 (78%) | 100 | 78 |
| Carve-out | 2 (0.1%) | 0 (0%) | 830 (29%) | 2043 (71%) | 100 | 71 |
TN: True negative; FP: False positive; FN: False negative; TP: True positive; INN: In-network; OON: Out-of-network
†
The claims-derived measure was designated as “No benefit feature required” when all claims observations indicated the absence of the benefit feature. The claims-derived measure was designated as “Benefit feature required” when at least one claims observation indicated the presence of the benefit feature.