FLORIDA MEDICAID HEDIS 2010 RESULTS STATEWIDE AGGREGATE REPORT

Transcription

1 Agency for Health Care Administration FLORIDA MEDICAID HEDIS 2010 RESULTS STATEWIDE AGGREGATE REPORT June East Camelback Road, Suite 300 Phoenix, AZ Phone Fax

2 CONTENTS 1. Executive Summary Summary of Results Pediatric Care Women s Care Living With Illness Use of Services Access to Care Key Findings and Recommendations How to Get the Most From This Report Florida Medicaid HEDIS 2010 Measures Reform and Non-Reform HMOs and PSNs Name Key Measure Audit Results Dimensions of Care Changes to Measures Lead Screening in Children Childhood Immunization Status Cervical Cancer Screening Prenatal and Postpartum Care Controlling High Blood Pressure Comprehensive Diabetes Care Follow-Up Care for Children Prescribed ADHD Medication Use of Appropriate Medications for People With Asthma Antidepressant Medication Management Report Structure Performance Assessment Performance Levels Florida Medicaid Weighted Averages Interpreting and Using Reported Weighted Averages and Aggregate Results Performance Trend Analysis Significance Testing Calculation Methods: Administrative Versus Hybrid Administrative Method Hybrid Method Interpreting Results Understanding Sampling Error Pediatric Care Introduction Well-Child Visits Lead Screening in Children Childhood Immunization Status Immunizations for Adolescents Annual Dental Visit Follow-Up Care for Children Prescribed ADHD Medication Pediatric Care Findings and Recommendations Improvement Strategies Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page i

3 CONTENTS 4. Women s Care Introduction Cervical Cancer Screening Breast Cancer Screening Prenatal and Postpartum Care Timeliness of Prenatal Care Postpartum Care Women s Care Findings and Recommendations Improvement Strategies Living With Illness Introduction Comprehensive Diabetes Care HbA1c Testing and Control LDL-C Screening Eye Exam Medical Attention for Diabetic Nephropathy Controlling High Blood Pressure Persistence of Beta-Blocker Treatment After a Heart Attack Use of Appropriate Medications for People With Asthma Antidepressant Medication Management Adult BMI Assessment Living With Illness Findings and Recommendations Improvement Strategies Use of Services Introduction Ambulatory Care Mental Health Utilizations Use of Services Findings and Recommendations Improvement Strategies Access to Care Introduction Adults Access to Preventive/Ambulatory Health Services Access to Care Findings and Recommendations Improvement Strategies Appendix A. National HEDIS 2009 Medicaid Percentiles... A-1 Appendix B. HEDIS 2010 HMO/PSN Results Summary... B-1 Appendix C. Glossary... C-1 Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page ii

4 1. Executive Summary Introduction The Agency for Health Care Administration (AHCA) contracts with health maintenance organizations (HMOs) and provider service networks (PSNs) to provide managed health care services to Florida s Medicaid beneficiaries. As of March 2010, Florida s managed care population was 1,201,451. Of that number, 1,020,589 were HMO Medicaid enrollees and 180,862 were PSN Medicaid enrollees. 1-1 To evaluate performance levels, AHCA implemented a process to review the HMOs and PSNs qualityof-care outcomes and performance measures comparatively and objectively. One component of the evaluation process was based on the Healthcare Effectiveness Data and Information Set (HEDIS ), a set of performance data broadly accepted in the managed care environment as the industry standard to compare and measure health plan performance. 1-2 HEDIS is developed and maintained by the National Committee for Quality Assurance (NCQA). AHCA selected a set of HEDIS measures from the standard Medicaid HEDIS reporting set for evaluating performance of the HMOs and PSNs. Florida s Medicaid Reform Pilot Program is a comprehensive demonstration that seeks to improve the Medicaid delivery system. AHCA implemented the Medicaid Reform Pilot Program in July 2006, operating under an 1115 Research and Demonstration Waiver approved by the Centers for Medicare & Medicaid Services (CMS). Reform plans in the pilot program began providing services to Medicaid beneficiaries in two counties in September 2006, with expansion to three additional counties in September Reform plans operate as either HMOs or PSNs. If the plans operate in both Reform and Non-Reform counties, they can have both Reform and Non-Reform populations with separate benefits and requirements. HSAG began performance measure validation activities for the contracted Reform HMOs and PSNs during state fiscal year (SFY) AHCA expects its contracted HMOs and PSNs to support health care claim systems, membership data, provider files, and hardware/software management tools, which facilitate accurate and reliable reporting of HEDIS measures. AHCA has contracted with Health Services Advisory Group, Inc. (HSAG), to provide external quality review (EQR) services for the State s managed care program. The contract contains 11 core categories of activities to be completed by the external quality review organization (EQRO). One of the core categories requires an aggregate, strategic HEDIS analysis report. The EQRO is to objectively analyze the Florida HMOs and PSNs HEDIS results and evaluate the State s current performance levels relative to national Medicaid percentiles. HSAG has examined the measures along five different dimensions of care: Pediatric Care, Women s Care, Living With Illness, Use of Services, and Access to Care. This approach to the analysis was designed to encourage consideration of the measures as a whole rather than in isolation and to think about the strategic and tactical changes required to improve overall performance. 1-1 FloridaHealthFinder.gov, Health Plans by Florida County for all Medicaid Health Plans. Available at Accessed on January 19, HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 1-1

5 EXECUTIVE SUMMARY The data presented in this report (including the Florida Medicaid weighted averages) are derived from the HMOs /PSNs reporting year 2010 HEDIS data, which reflect calendar year 2009 as the measurement period. HSAG analyzed the Florida Medicaid HEDIS results in three ways: A weighted average comparison presents the Florida Medicaid 2010 results relative to the 2009 Florida Medicaid weighted averages and the national HEDIS 2009 Medicaid 50th percentiles. A performance profile analysis discusses the overall Florida Medicaid 2010 results and presents a summary of HMO and PSN performance relative to the Florida Medicaid performance levels. An HMO/PSN ranking analysis for each dimension of care (Sections 3 through 7) provides a more detailed comparison, presenting results relative to the Florida Medicaid performance levels and the national HEDIS 2009 Medicaid percentiles. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 1-2

6 EXECUTIVE SUMMARY Summary of Results Pediatric Care Figure 1-1 and Figure 1-2 compare Non-Reform and Reform weighted averages with AHCA performance targets for 10 of the 11 Pediatric Care measures. Since the Immunizations for Adolescents, Combination 1 (IMA) measure was a HEDIS 2010 measure, a performance target was not available. Well-Child Visits in the First 15 Months of Life Zero Visits was an inverted measure; a lower rate indicated better performance. 100% Figure 1-1 Florida Medicaid HEDIS 2010: Weighted Average Compared With the AHCA Performance Target Pediatric Care Pediatric Care 80% 60% 40% 20% 0% W15 0 Visits W15 6+ Visits W34 AWC LSC Non Reform Weighted Average Reform Weighted Average Performance Target W15, 0 Visits = Well-Child Visits in the First 15 Months of Life, Zero Visits W15, 6+ Visits = Well-Child Visits in the First 15 Months of Life, 6+ Visits W34 = Well-Child Visits in the 3rd 6th Years of Life AWC = Adolescent Well-Care Visits LSC = Lead Screening in Children Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 1-3

7 EXECUTIVE SUMMARY 100% Figure 1-2 Florida Medicaid HEDIS 2010: Weighted Average Compared With the AHCA Performance Target Pediatric Care (Continued) Pediatric Care (Continued) 80% 60% 40% 20% 0% CIS Combo2 CIS Combo3 IMA ADV ADD Initiation ADD Continuation Non Reform Weighted Average Reform Weighted Average Performance Target CIS, Combo2 = Childhood Immunization Status, Combination 2 CIS, Combo3 = Childhood Immunization Status, Combination 3 IMA = Immunizations for Adolescents, Combination 1 ADV = Annual Dental Visit, Total ADD, Initiation = Follow-up Care for Children Prescribed ADHD Medication, Initiation ADD, Continuation = Follow-up Care for Children Prescribed ADHD Medication, Continuation In 2010, Non-Reform plans reached AHCA targets for one measure (Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life). Reform plans exceeded the performance target for one measure (Follow-up Care for Children Prescribed ADHD Medication, Continuation). Overall, Non- Reform plans performed better in the Pediatric Care dimension than the Reform plans, performing at a higher rate on 7 of the 11 measures. For the Immunizations for Adolescents, Combination 1 measure, no AHCA performance target was available. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 1-4

8 EXECUTIVE SUMMARY Women s Care Figure 1-3 compares Non-Reform and Reform weighted averages with AHCA performance targets for four Women s Care measures. 100% Figure 1-3 Florida Medicaid HEDIS 2010: Weighted Average Compared With the AHCA Performance Target Women s Care Women's Care 80% 60% 40% 20% 0% CCS BCS PPC Prenatal PPC Postpartum Non Reform Weighted Average Reform Weighted Average Performance Target CCS = Cervical Cancer Screening BCS = Breast Cancer Screening PPC, Prenatal = Timeliness of Prenatal Care PPC, Postpartum = Postpartum Care Non-Reform plans performance in all four measures was below the corresponding AHCA targets. Reform plans exceeded the performance target in one measure (Breast Cancer Screening). Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 1-5

9 EXECUTIVE SUMMARY Living With Illness Figure 1-4 and Figure 1-5 compare Non-Reform and Reform weighted averages with AHCA performance targets for 12 of the 15 Living With Illness measures. Figure 1-4 Florida Medicaid HEDIS 2010: Weighted Average Compared With the AHCA Performance Target Living With Illness 100% Living With Illness 80% 60% 40% 20% 0% CDC HbA1c Testing CDC HbA1c Poor Control CDC HbA1c Control (<8%) CDC LDL C Screening CDC LDL C Control (<100 mg/dl) CDC Eye Exam CDC Nephropathy Non Reform Weighted Average Reform Weighted Average Performance Target CDC, HbA1c Testing = Diabetes Care, HbA1c Testing CDC, HbA1c Poor Control = Diabetes Care, HbA1c Poor Control CDC, HbA1c Control (<8%) = Diabetes Care, HbA1c Control (<8%) CDC, LDL-C Screening = Diabetes Care, LDL-C Screening CDC, LDL-C Control (<100 mg/dl) = Diabetes Care, LDL-C Control (<100 mg/dl) CDC, Eye Exam = Diabetes Care, Eye Exam (Retinal) Performed CDC, Nephropathy = Diabetes Care, Medical Attention for Nephropathy For the Comprehensive Diabetes Care HbA1c Control (<8%) measure, no AHCA performance target was available. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 1-6

10 EXECUTIVE SUMMARY Figure 1-5 Florida Medicaid HEDIS 2010: Weighted Average Compared With the AHCA Performance Target Living With Illness (Continued) 100% Living With Illness (Continued) 80% 60% 40% 20% 0% NA CBP PBH ASM 5 11 Years ASM Years ASM Total AMM Acute AMM Continuation ABA Non Reform Weighted Average Reform Weighted Average Performance Target Note: The total sum of eligible members reported by Reform plans was fewer than 30 (n=27) for the Persistence of Beta- Blocker Treatment After a Heart Attack measure. Instead of reporting the actual weighted average rate, NA is displayed in this figure. CBP = Controlling High Blood Pressure PBH = Persistence of Beta-Blocker Treatment After a Heart Attack ASM, 5-11 Years = Use of Appropriate Medications for People With Asthma, 5 11 Years ASM, Years = Use of Appropriate Medications for People With Asthma, Years ASM, Total = Use of Appropriate Medications for People With Asthma, Total AMM, Acute = Antidepressant Medication Management, Effective Acute Phase Treatment AMM, Continuation = Antidepressant Medication Management, Effective Continuation Phase Treatment ABA = Adult BMI Assessment Non-Reform plans performance in all 12 measures was below the corresponding AHCA targets, whereas the Reform plans exceeded performance targets in five measures (Diabetes Care LDL-C Screening and Medical Attention for Nephropathy, Antidepressant Medication Management Effective Acute Phase and Continuation Phase Treatment, and Adult BMI Assessment). Overall, Reform plans performed better in the Living With Illness dimension than the Non-Reform plans, with higher weighted averages for most of the measures. For the Use of Appropriate Medications for People With Asthma 5 11 Years and Use of Appropriate Medications for People With Asthma Years measures, no AHCA performance targets were available. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 1-7

11 EXECUTIVE SUMMARY Use of Services The HMOs and PSNs began collecting and reporting Use of Services data in SFY All plans offering ambulatory care or mental health benefits reported valid rates for the Ambulatory Care and Mental Health Utilization measures. Plan-specific results are displayed in Section 6 of this report. Use of Services data are descriptive in nature and are used to monitor patterns of utilization over time. Because the measures do not lend themselves to measuring the quality of care, HSAG did not compare plan performance on these measures. Access to Care Figure 1-6 compares Non-Reform and Reform weighted averages with AHCA performance targets for three of the four Access to Care measures. For the Adults Access to Preventive/Ambulatory Health Services Total measure, no AHCA performance target was available. 100% Figure 1-6 Florida Medicaid HEDIS 2010: Weighted Average Compared With the AHCA Performance Target Access to Care Access to Care 80% 60% 40% 20% 0% AAP Years AAP Years AAP 65+ Years AAP Total Non Reform Weighted Average Reform Weighted Average Performance Target AAP, Years = Adults' Access to Preventive/Ambulatory Health Services, Years AAP, Years = Adults' Access to Preventive/Ambulatory Health Services, Years AAP, 65+ Years = Adults' Access to Preventive/Ambulatory Health Services, 65+ Years AAP, Total = Adults' Access to Preventive/Ambulatory Health Services, Total In 2010, both Non-Reform and Reform plans performed below the corresponding AHCA targets in three of the four measures. Overall, Reform plans performed better in the Access to Care dimension than the Non-Reform plans, with higher weighted averages for all measures. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 1-8

12 EXECUTIVE SUMMARY Key Findings and Recommendations AHCA has established performance targets for a majority of the performance measures, which indicated opportunities for improvement across all dimensions of care. In the area of pediatric care, statewide performance met the performance targets for well-child visits for children 3 to 6 years of age and management of children on attention-deficit hyperactivity disorder (ADHD) medication. Across the state, performance on several indicators had substantial room for improvement, including well-child visits for infants and adolescents, lead screening, immunizations, and dental visits. Women s care also has some opportunities for improvement. While statewide performance on breast cancer screening was close to the AHCA target (Reform plans met the target, while Non- Reform was close behind), the remaining three indicators in the Women s Care dimension need improvement. Efforts for improvement should be focused on cervical cancer screening, and prenatal and postpartum care services. Statewide performance on some measures in the Living With Illness dimension was closer to AHCA targets than others, especially for the management of diabetes care, antidepressant medication management, and adult BMI (for the Reform plans). Performance on eye exams for diabetics was an exception and needs focused improvement, as well as blood pressure control and beta-blocker treatment, which performed farther below the AHCA targets. Finally, improvement and focus are needed in the Access to Care dimension, with statewide performance consistently falling below the AHCA targets. Managed care plans should focus on appropriate utilization based on outpatient visits that were lower than the national average and ED visits that were higher than the national average. Within each section of this report, HSAG offers specific improvement strategies that have shown to be effective based on the latest literature review. Most importantly, HSAG recommends that the plans select a small number of specific measures that need the most improvement for their populations. For these measures, plans should conduct a formal causal-barrier analysis to determine the specific issues within their plan population that are leading to the lower performance. Based on this process, plans can select appropriate interventions to address these identified barriers. Given the volume of performance measures that need improvement, plans will need to assess which strategies would be most effective for their populations and implement targeted strategies to bring about improvement in a carefully planned, cost-effective manner. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 1-9

13 2. How to Get the Most From This Report Florida Medicaid HEDIS 2010 Measures HEDIS includes a standard set of measures that can be reported by Medicaid health plans nationwide. AHCA selected 20 HEDIS measures from the standard Medicaid set and broke down the 20 measures into 42 distinct rates, shown in the following table. AHCA required a total of 31 Florida Reform and Non-Reform HMOs and PSNs to report the measures in The data presented in this report (including the Florida Medicaid weighted averages) were derived from the HMOs /PSNs reporting year 2010 HEDIS data, which reflected the measurement period of calendar year (CY) Standard HEDIS 2010 Measures Table 2-1 Florida Medicaid 2010 Measures 2010 AHCA Measures 1. Well-Child Visits in the First 15 Months of Life 1. Well-Child Visits in the First 15 Months of Life Zero Visits 2. Well-Child Visits in the First 15 Months of Life Six or More Visits 2. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life 3. Adolescent Well-Care Visits 4. Adolescent Well-Care Visits 4. Lead Screening in Children 5. Lead Screening in Children 3. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life 5. Childhood Immunization Status 6. Childhood Immunization Status Combination 2 7. Childhood Immunization Status Combination 3 6. Immunizations for Adolescents 8. Immunizations for Adolescents Combination 1 7. Annual Dental Visit 9. Annual Dental Visit Total 8. Follow-up Care for Children Prescribed ADHD Medication 10. Follow-Up Care for Children Prescribed ADHD Medication Initiation Phase 11. Follow-Up Care for Children Prescribed ADHD Medication Continuation and Maintenance Phase 9. Cervical Cancer Screening 12. Cervical Cancer Screening 10. Breast Cancer Screening 13. Breast Cancer Screening 11. Prenatal and Postpartum Care 14. Prenatal and Postpartum Care Timeliness of Prenatal Care 15. Prenatal and Postpartum Care Postpartum Care 12. Comprehensive Diabetes Care 16. Comprehensive Diabetes Care HbA1c Testing 17. Comprehensive Diabetes Care HbA1c Poor Control 18. Comprehensive Diabetes Care HbA1c Control (<8%) 19. Comprehensive Diabetes Care LDL-C Screening 20. Comprehensive Diabetes Care LDL-C Level (<100 mg/dl) 21. Comprehensive Diabetes Care Eye Exam (Retinal) Performed 22. Comprehensive Diabetes Care Medical Attention for Nephropathy 13. Controlling High Blood Pressure 23.Controlling High Blood Pressure 14. Persistence of Beta-Block Treatment After a Heart Attack 24. Persistence of Beta-Block Treatment After a Heart Attack 15. Use of Appropriate Medications for People With Asthma 25. Use of Appropriate Medications for People With Asthma 5 11 Years 26. Use of Appropriate Medications for People With Asthma Years 27. Use of Appropriate Medications for People With Asthma Total 16. Antidepressant Medication Management 28. Antidepressant Medication Management Effective Acute Phase Treatment 29. Antidepressant Medication Management Effective Continuation Phase Treatment Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-1

14 HOW TO GET THE MOST FROM THIS REPORT Standard HEDIS 2010 Measures Table 2-1 Florida Medicaid 2010 Measures 17. Adult BMI Assessment 30. Adult BMI Assessment 2010 AHCA Measures 18. Ambulatory Care 31. Ambulatory Care Outpatient Visits per 1,000 Member Months (MM) 32. Ambulatory Care ED Visits per 1,000 MM 33. Ambulatory Care Ambulatory Surgery/Procedures per 1,000 MM 34. Ambulatory Care Observation Room Stays per 1,000 MM 19. Mental Health Utilization 35. Mental Health Utilization Any Service 36. Mental Health Utilization Inpatient 37. Mental Health Utilization Intensive Outpatient/Partial Hospitalization 38. Mental Health Utilization Outpatient/ED 20. Adults Access to Preventive/Ambulatory Health Services 39. Adults Access to Preventive/Ambulatory Health Services Ages 20 to 44 Years 40. Adults Access to Preventive/Ambulatory Health Services Ages 45 to 64 Years 41. Adults Access to Preventive/Ambulatory Health Services Ages 65+ Years 42. Adults Access to Preventive/Ambulatory Health Services Total Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-2

15 HOW TO GET THE MOST FROM THIS REPORT Reform and Non-Reform HMOs and PSNs Name Key Figures in the following sections of the report show overall Reform and Non-Reform HMO and PSN performance for each of the measures. Below are the HMO and PSN names used in the tables and figures throughout this report. Table Florida Medicaid Reform and Non-Reform HMOs and PSNs Non-Reform Reform HMOs AMERIGROUP Community Care AMERIGROUP AMERIGROUP-R Coventry Health Care of Florida, Inc. Buena Vista Vista Citrus Health Care, Inc. Citrus Freedom Health, Inc. Freedom Freedom-R Wellcare Health Plans, Inc. HealthEase of Florida, Inc. HealthEase Healthy Palm Beaches, Inc. Healthy PB Humana Family c/o Humana Medical Plan, Inc. Humana Humana-R Jackson Memorial Health Plan JMH Molina Healthcare of Florida Molina Molina-R Preferred Medical Plan, Inc. Preferred Preferred-R Wellcare of Florida, Inc. Staywell of Florida, Inc. Staywell Sunshine State Health Plan Sunshine Sunshine-R Total Health Choice, Inc. Total Total-R United Healthcare of Florida, Inc. Americhoice United United-R Universal Health Care, Inc. Universal Universal-R Coventry Health Plan of Florida, Inc. VISTA Vista SF PSNs Access Health Solutions Access Health Children s Medical Services CMS First Coast Advantage First Coast Prestige Health Choice Prestige South Florida Community Care Network SFCCN SFCCN-R Measure Audit Results Through the audit process, each measure reported by an HMO/PSN is assigned a National Committee for Quality Assurance (NCQA)-defined audit result. Measures can receive one of four predefined audit results: Report, Not Applicable (NA), Not Report (NR), and No Benefit (NB). An audit result of Report indicates that the HMO/PSN complied with all HEDIS specifications to produce an unbiased, reportable rate or rates, which can be released for public reporting. Although an HMO/PSN may have complied with all applicable specifications, the denominator identified may be considered too small to report a valid rate. In this case, the measure would be assigned an NA audit result. An audit result of NR indicates that the rate could not be publicly reported because the Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-3

16 HOW TO GET THE MOST FROM THIS REPORT measure deviated from HEDIS specifications such that the reported rate was significantly biased or an HMO/PSN was not required to report the measure. A No Benefit audit result indicates that the HMO/PSN did not offer the benefit required by the measure. Dimensions of Care HSAG examined five different dimensions of care for Florida Medicaid members: Pediatric Care, Women s Care, Living With Illness, Use of Services, and Access to Care. This approach to the analysis was designed to encourage the HMOs/PSNs to consider the measures as a whole rather than in isolation and to think about the strategic and tactical changes required to improve overall performance. Changes to Measures For the 2010 HEDIS reporting year, NCQA modified some of the measures included in this report, which may have impacted trending and/or comparisons to national data. Lead Screening in Children Clarified requirements when reducing the sample size. Childhood Immunization Status Added the hepatitis A, rotavirus, and influenza vaccines. Clarified that pneumococcal conjugate vaccinations administered before 42 days after birth should not be counted as a numerator hit. Although AHCA did not require that the HMOs/PSNs report Combinations 4 through 10, NCQA did add Combinations 4 through 10 to this measure. Cervical Cancer Screening Clarified documentation of no endocervical cells. Prenatal and Postpartum Care Clarified that a notation of breastfeeding is acceptable for the evaluation of breasts component of the numerator. Controlling High Blood Pressure Clarified that patient-reported blood pressure readings are not acceptable. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-4

17 HOW TO GET THE MOST FROM THIS REPORT Comprehensive Diabetes Care Clarified that HbA1c control (<7.0 percent) is only reported for the commercial and Medicaid product lines. Clarified that patient-reported blood pressure readings are not acceptable. Follow-Up Care for Children Prescribed ADHD Medication Clarified that different medications should be identified using the Drug ID field in the National Drug Code (NDC) list. Use of Appropriate Medications for People With Asthma Lowered the upper age limit from 56 to 50 years of age. Modified the age stratifications to 5 to 11 years of age, 12 to 50 years of age, and the total. Clarified the dispensing event definition for prescriptions dispensed on the same day. Added exclusions for cystic fibrosis and acute respiratory failure. Antidepressant Medication Management Clarified negative diagnosis history for inpatient claims/encounters and transfers. Report Structure Each dimension of care has separate graphs and result interpretations for each measure for both the Non-Reform population and the Reform population. For example, for the first measure in the Pediatric Care dimension, Well-Child Visits in the First 15 Months of Life Zero Visits, the first graph compares the Non-Reform and Reform HEDIS 2010 weighted averages with the AHCA performance target and weighted averages from previous years, if available. AHCA s performance target is identified via a green line through each weighted average. Each performance target has a connected box with the numerical value of the target. The second and third graphs rank the Non- Reform and Reform HMOs and PSNs separately based on their reported rates. This pattern will be the same throughout the report. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-5

18 HOW TO GET THE MOST FROM THIS REPORT Performance Assessment The analysis in this report focuses on whether each HMO/PSN met the Florida performance target for each of the measures. Table 2-3 shows for each measure the corresponding HEDIS benchmark year and percentile used by AHCA for establishing the State s performance target. Table 2-3 Performance Target for Florida Medicaid 2010 Measures Standard HEDIS 2010 Measures Performance Target 1. Well-Child Visits in the First 15 Months of Life 25th percentile of HEDIS 2007 for Zero Visits 75th percentile of HEDIS 2007 for Six or More Visits 2. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years 75th percentile of HEDIS 2007 of Life 3. Adolescent Well-Care Visits 75th percentile of HEDIS Lead Screening in Children 75th percentile of HEDIS Childhood Immunization Status 75th percentile of HEDIS Immunizations for Adolescents 75th percentile of HEDIS 2011, which is not available yet 7. Annual Dental Visit 75th percentile of HEDIS Follow-up Care for Children Prescribed ADHD Medication 75th percentile of HEDIS Cervical Cancer Screening 75th percentile of HEDIS Breast Cancer Screening 75th percentile of HEDIS Prenatal and Postpartum Care 75th percentile of HEDIS Comprehensive Diabetes Care 25th percentile of HEDIS 2007 for HbA1c Poor Control No target for HbA1c Control (<8%) 75th percentile of HEDIS 2007 for other sub-measures 13. Controlling High Blood Pressure 75th percentile of HEDIS Persistence of Beta-Block Treatment After a Heart Attack 75th percentile of HEDIS Use of Appropriate Medications for People With Asthma 75th percentile of HEDIS 2008 for Total No target for each age group 16. Antidepressant Medication Management 75th percentile of HEDIS Adult BMI Assessment 75th percentile of HEDIS Ambulatory Care Not applicable 19. Mental Health Utilization Not applicable 20. Adults Access to Preventive/Ambulatory Health Services 75th percentile of HEDIS 2008 for each age group No target for Total Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-6

19 HOW TO GET THE MOST FROM THIS REPORT Performance Levels HSAG used NCQA s percentiles and ratios to conduct performance level analyses for each HMO/PSN. Results of the performance level analyses are displayed in Appendix B. The purpose of identifying performance levels is to compare the quality of services provided to Florida Medicaid beneficiaries and, ultimately, improve quality of care, as evident by the Florida Medicaid weighted average for each of the measures. Comparative information in this report is based on NCQA s national HEDIS 2009 Medicaid percentiles. The NCQA Medicaid HEDIS 2009 percentiles are based on aggregated national Medicaid data from calendar year The results in this report are rounded to first decimal place to be consistent with the display of the national percentiles. There are some instances in which the rounded rates may appear the same; however, the more precise rates are not identical. In these instances, the hierarchy of the scores in the graphs is displayed in the correct order. Florida Medicaid Weighted Averages The principal measure of overall Florida Medicaid performance on a given measure is the weighted average rate. The use of a weighted average, based on an HMO s/psn s eligible population for that measure, provides the most representative rate for its overall Florida Medicaid population. Weighting rates by the size of a health plan s eligible population ensures that rates for an HMO/ PSN with 125,000 members, for example, have a greater impact on the overall Florida Medicaid rate than rates for an HMO/PSN with 10,000 members. Interpreting and Using Reported Weighted Averages and Aggregate Results HSAG calculated the HEDIS 2010 Florida Medicaid weighted averages based on the reported rates and weighted the results by the reported eligible population size for each measure. This was a better estimate of care for all of Florida s Medicaid members than the average performance of Florida Medicaid HMOs/PSNs. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-7

20 HOW TO GET THE MOST FROM THIS REPORT Performance Trend Analysis The importance of trending the statewide weighted average is to identify whether the State as a whole performed better or worse than the previous year. The trending of results may enhance quality initiatives because results represent a period of time rather than a snapshot of performance at a given point. Trended results based on statistical testing of HEDIS 2009 and HEDIS 2010 rates for each measure are presented and discussed at the end of each dimension section using the symbols below: = Demonstrates a statistically significant improvement in performance. = Indicates no statistically significant change in performance. = Demonstrates a statistically significant decline in performance. Significance Testing In this report, differences between the HEDIS 2009 and HEDIS 2010 weighted averages for each measure are analyzed by comparing the 95-percent confidence intervals associated with the weighted averages. Years with weighted averages that are clearly different (i.e., a statistically significant difference of p.05) have confidence levels that did not overlap. There are conditions, however, in which small overlaps between the MCOs confidence intervals are statistically significant. A conservative approach is to consider rates with confidence levels that do not overlap as both substantively and statistically significant. Calculation Methods: Administrative Versus Hybrid Administrative Method The administrative method requires the HMOs/PSNs to identify their eligible populations (i.e., the denominator) using administrative data derived from claims and encounters (i.e., statistical claims). In addition, the numerator(s), or services provided to members in the eligible population, are derived solely from administrative data. Medical records cannot be used to retrieve information. When using the administrative method, the entire eligible population becomes the denominator and sampling is not allowed. The measures for which HEDIS methodology requires the administrative method and does not permit medical record review are: Adults Access to Preventive/Ambulatory Health Services Annual Dental Visit Antidepressant Medication Management Ambulatory Care Breast Cancer Screening Follow-Up Care for Children Prescribed ADHD Medication Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-8

21 HOW TO GET THE MOST FROM THIS REPORT Mental Health Utilization Persistence of Beta-Blocker Treatment After a Heart Attack Use of Appropriate Medications for People With Asthma The administrative method is cost efficient but can produce lower rates due to incomplete data submission by capitated providers. For example, an HMO/PSN has 10,000 members who qualify for the Prenatal and Postpartum Care measure. The HMO/PSN chooses to perform the administrative method and finds that 4,000 members out of the 10,000 have evidence of a postpartum visit using administrative data. The final rate for this measure using the administrative method would be 4,000/10,000, or 40 percent. Hybrid Method The hybrid method requires HMOs/PSNs to identify the eligible population using administrative data, then extract a systematic sample of members from the eligible population, which becomes the denominator. Administrative data are used to identify services provided to those members. Medical records must then be reviewed for those members who do not have evidence of a service being provided using administrative data. The hybrid method generally produces higher rates because the completeness of documentation in the medical record exceeds what is typically captured in administrative data; however, the medical record review component of the hybrid method is considered more labor intensive. For example, an HMO/PSN has 10,000 members who qualify for the Prenatal and Postpartum Care measure. The HMO/PSN chooses to use the hybrid method. After randomly selecting 411 eligible members, the HMO/PSN finds that 161 members have evidence of a postpartum visit using administrative data. The HMO/PSN then obtains and reviews medical records for the 250 members who do not have evidence of a postpartum visit using administrative data. Of those 250 members, 54 are found to have a postpartum visit recorded in the medical record. Therefore, the final rate for this measure using the hybrid method would be ( )/411, or 52 percent. Interpreting Results As expected, HEDIS results can differ to a greater or lesser extent among HMOs/PSNs and even across measures for the same HMO/PSN. Three questions should be asked when examining these data: 1. How accurate are the results? 2. How do Florida Medicaid rates compare with the corresponding AHCA performance target? 3. How are Florida Medicaid HMOs/PSNs performing overall? The following paragraphs address these questions and explain the methods used in this report to present the results in a way that may be easily and accurately interpreted. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-9

22 HOW TO GET THE MOST FROM THIS REPORT 1. How accurate are the results? AHCA required all the Florida HMOs/PSNs to have their results confirmed by an NCQA HEDIS Compliance Audit. TM, 2-1 As a result, any rate included in this report has been verified as an unbiased estimate of the measure. NCQA s HEDIS protocol is designed so that hybrid methodology produces results with a sampling error of ± 5 percentage points at a 95 percent confidence level. The effect of sampling error on the accuracy of results is best explained using an example. Suppose that an HMO/PSN used the hybrid method to derive a Comprehensive Diabetes Care LDL-C Screening rate of 52 percent. Because of sampling error, the true rate would actually be within ± 5 percentage points of this somewhere between 47 percent and 57 percent at a 95 percent confidence level. If the target is a rate of 55 percent, it cannot be said with certainty whether the true rate between 47 percent and 57 percent meets or does not meet the target level. To prevent such ambiguity, this report uses a standardized methodology that requires the reported rate to be at or above the threshold level to be considered as meeting the target. For internal purposes, HMOs/PSNs should understand the sampling error concept and consider this when implementing interventions. More information is provided in the Understanding Sampling Error subsection below. 2. How do Florida Medicaid rates compare with AHCA performance targets? For each measure, an HMO/PSN ranking presents the reported rate in order from highest to lowest, with a bar representing the AHCA performance target. This ranking provides a picture of how each plan performed relative to the AHCA established goals. For display purposes, any plan that reported a Not Applicable (NA) or No Benefit (NB) performance measure result was excluded from the measure-specific figures. 3. How are Florida Medicaid HMOs performing overall? For each dimension, a performance profile analysis compares the 2010 Florida Medicaid weighted average for each measure with the national HEDIS 2009 Medicaid 50th percentile. Understanding Sampling Error Correct interpretation of results for measures collected using the HEDIS hybrid method requires an understanding of sampling error. It is rarely possible logistically or financially to do medical record review for the entire eligible population for a given measure. Measures collected using the HEDIS hybrid method include only a sample from the eligible population, and statistical techniques are used to maximize the probability that the sample results reflect the experience of the entire eligible population. 2-1 NCQA HEDIS Compliance Audit TM is a trademark of NCQA. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-10

23 HOW TO GET THE MOST FROM THIS REPORT For results to be generalized to the entire population, the process of sample selection requires that everyone in the eligible population have an equal chance of being selected. The HEDIS hybrid method prescribes a systematic sampling process, selecting at least 411 members of the eligible population. HMOs/PSNs may use a 5 percent, 10 percent, 15 percent, or 20 percent oversample to replace invalid cases (for example, a male selected for the Cervical Cancer Screening measure). Figure 2-1 shows that if 411 health plan members are included in a measure, the margin of error is approximately ± 4.9 percent. The data in this figure are based on the assumption that the size of the eligible population is greater than 2,000. The smaller the sample included in the measure, the larger the sampling error. 40% Figure 2-1 Relationship of Sample Size to Sampling Error 30% 31.0% Sample Error 20% 10% 0% -10% -20% 19.6% -19.6% 13.9% 11.3% 9.8% 8.8% 8.0% 7.4% 6.9% 6.2% 5.7% 5.2% 4.9% 4.6% 4.4% 3.1% 3.0% 2.8% 2.7% 2.6% 2.5% -8.8% -8.0% -9.8% -11.3% -13.9% -3.1% -3.0% -2.8% -2.7% -2.6% -2.5% -7.4% -6.9% -6.2% -5.7% -5.2% -4.9% -4.6% -4.4% -30% -31.0% -40% ,000 1,100 1,200 1,300 1,400 1,500 Sample Size As Figure 2-1 shows, sample error gets smaller as the sample size gets larger. Consequently, when sample sizes are very large and sampling errors are very small, almost any difference is statistically significant. It does not mean that all such differences are important. On the other hand, the difference between two measured rates may not be statistically significant, but may, nevertheless, be important. The judgment of the reviewer is always a requisite for meaningful data interpretation. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 2-11

24 3. Pediatric Care Introduction Pediatric primary health care involves health promotion and disease prevention for children and adolescents. Immunizations and health checkups, when provided in a timely manner, are particularly important for young children. Failure to detect problems with growth, hearing, and vision may adversely affect children s future abilities and experiences. Early detection allows health care providers the best opportunity to detect developmental issues early and intervene, providing children the chance to grow and learn without health-related limitations. Children can begin having dental problems at an early age. Early childhood caries (formerly known as baby bottle tooth decay or nursing caries) are a major concern. Prevention of dental problems begins with children seeing their dentist in early childhood. The Pediatric Care dimension encompasses the following AHCA measures: Well-Child Visits in the First 15 Months of Life Zero Visits Well-Child Visits in the First 15 Months of Life Six or More Visits Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life Adolescent Well-Care Visits Lead Screening in Children Childhood Immunization Status Combination 2 Childhood Immunization Status Combination 3 Immunizations for Adolescents Combination 1 Annual Dental Visit Total Follow-up Care for Children Prescribed ADHD Medication Initiation Phase Follow-up Care for Children Prescribed ADHD Medication Continuation and Maintenance Phase Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 3-1

25 PEDIATRIC CARE Well-Child Visits Measure Definitions Well-Child Visits in the First 15 Months of Life Zero Visits calculates the percentage of enrolled members who turned 15 months of age during the measurement year, were continually enrolled in the Florida Medicaid Program from 31 days of age through 15 months of age, and received zero visits with a primary care practitioner (PCP) during their first 15 months of life. Well-Child Visits in the First 15 Months of Life Six or More Visits calculates the percentage of enrolled members who turned 15 months of age during the measurement year, were continuously enrolled in the Florida Medicaid Program from 31 days of age through 15 months of age, and received six or more visits with a PCP during their first 15 months of life. Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life calculates the percentage of members who were 3, 4, 5, or 6 years of age during the measurement year, were continuously enrolled during the measurement year, and received one or more well-child visits with a PCP during the measurement year. Adolescent Well-Care Visits calculates the percentage of enrolled members who were continuously enrolled during the measurement year, were between 12 and 21 years of age as of December 31 of the measurement year, and had at least one comprehensive well-care visit with a PCP or an obstetrician/gynecologist (OB/GYN) during the measurement year. Importance Regular checkups are crucial to detect physical, developmental, behavioral, and emotional problems at an early stage, and well-child exams include many needed medical services important to the health and well-being of infants and children. Doctors may also perform health exams and tests, such as vision screenings, hearing tests, or lab services. Vaccinations are often performed concurrently, resulting in a reduction in disease as well as savings in health costs over time. In addition to performing preventive services, well-child visits foster communication between parents and doctors. This allows doctors to offer guidance and counseling on a variety of health care topics, including safety, nutrition, normal development, and general health care. The American Medical Association (AMA) and the American Academy of Pediatrics (AAP) recommend timely, comprehensive well-child visits for children. Medicaid children who are up to date with well-child visits are approximately 48 percent less likely to have an avoidable hospitalization. 3-1 Children with poorer health status are more likely to not receive recommended well-child visits since these children tend to use more acute or specialty care. 3-2 Furthermore, there is evidence that timely preventive care in children has a positive impact on overall health care 3-1 Hakim, RB, Bye BV. Effectiveness of Compliance with Pediatric Preventive Care Guidelines Among Medicaid Beneficiaries. Pediatrics. 2001; 108(1): Yu SM, Bellamy HA, Kogan MD, et al. Factors That Influence Receipt of Recommended Preventive Pediatric Health and Dental Care. Pediatrics. Vol. 110 No. 6 December 2002, pp. e73. Available at: Accessed on: April 26, Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 3-2

26 PEDIATRIC CARE utilization. Researchers have found associations between increased well-child visits and reductions in avoidable hospitalizations, reductions in emergency department use, and improved child health. 3-3 Performance Results for Well-Child Visits in the First 15 Months of Life Zero Visits Figure 3-1 Florida Medicaid HEDIS 2010 Weighted Average Historical Comparison: Well-Child Visits in the First 15 Months of Life Zero Visits 10% Well Child Visits in the First 15 Months of Life, Zero Visits 8% 6% 5.3% 6.2% 4% 2.8% 3.0% 4.3% 2% 1.6% 0.7% 0% 2008 Weighted Average 2009 Weighted Average 2010 Weighted Average Non Reform Reform Performance Target For this measure, a lower rate indicates better care and performance. The HEDIS 2010 weighted averages for both Non-Reform and Reform plans were below AHCA s performance target. Non- Reform plans performed better than Reform plans by approximately 2 percentage points. Compared with the HEDIS 2009 results, both plan types declined in performance (their rates increased). The Reform weighted average exhibited a greater and statistically significant decline. 3-3 Selden TM. Compliance with Well-Child Visit Recommendations: Evidence From the Medical Expenditure Panel Survey, Pediatrics. Vol. 118 No. 6 December 2006, pp. e1766-e1778. Available at: Accessed on: April 26, Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 3-3

27 PEDIATRIC CARE Figure 3-2 Florida Medicaid HEDIS 2010 Non-Reform Health Plan Ranking: Well-Child Visits in the First 15 Months of Life Zero Visits Well-Child Visits in the First 15 Months of Life, Zero Visits Health Plan Performance Target Staywell AMERIGROUP Healthy PB United Weighted Average Humana HealthEase Citrus Buena Vista Vista SF SFCCN JMH Preferred Universal N Rate 0.7% % % % % 4.3% % % % % % % % % % 0% 5% 10% 15% 20% Note: Freedom, Molina, Prestige, Sunshine, and Total reported an NA, with a denominator of fewer than 30. For this measure, a lower rate indicates better care and performance. None of the plans reached the state s performance target. There was wide variation in rates among the plans, ranging from 1.7 percent to 17.8 percent. Of the 12 plans that also reported HEDIS 2009 rates, 4 showed an improvement in performance. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 3-4

28 PEDIATRIC CARE Figure 3-3 Florida Medicaid HEDIS 2010 Reform Health Plan Ranking: Well-Child Visits in the First 15 Months of Life Zero Visits Well-Child Visits in the First 15 Months of Life, Zero Visits Health Plan Performance Target N Rate 0.7% Humana-R AMERIGROUP-R First Coast Weighted Average Total-R Access Health SFCCN-R United-R Universal-R % % % 6.2% % % % % % 0% 5% 10% 15% 20% Note: CMS, Freedom-R, Molina-R, and Preferred-R reported an NA, with a denominator of fewer than 30. For this measure, a lower rate indicates better care and performance. None of the Reform plans reached the State s performance target. There was wide variation in rates among the plans, ranging from 2.0 percent to 17.9 percent. Compared with 2009, fewer plans reported rates for this measure. Of the plans that also reported rates for HEDIS 2009, all showed a decline in performance. Florida Medicaid HEDIS 2010 Results Statewide Aggregate Report Page 3-5