Hawaii Quest 1115 Annual Report 2006

   EMBED

Share

  • Rating

  • Date

    December 1969
  • Size

    796.9KB
  • Views

    638
  • Categories

Preview only show first 6 pages with water mark for full document please download

Transcript

Medicaid Section 1115 Demonstration Waiver Annual Report FYE June 30, 2006 Med-QUEST Division Department of Human Services State of Hawaii Reported dated April 2, 2007 Table of Contents Executive Summary ........................................................................................................................ 3 Overview..................................................................................................................................... 6 Goals and Objectives .................................................................................................................. 6 Key Waivers in the Demonstration............................................................................................. 7 Impacted Population Groups....................................................................................................... 7 Hypotheses about the Outcomes of the Demonstration.............................................................. 8 A Brief History of the Implementation of the Demonstration.................................................... 9 Evaluation Design........................................................................................................................... 9 The Management and Coordination............................................................................................ 9 The Specific Metrics, Methodologies & Rationales ................................................................. 11 The Analysis Plan ..................................................................................................................... 12 Integration of the State Quality Improvement Strategy............................................................ 13 Measures ....................................................................................................................................... 14 U.S. Census Measures............................................................................................................... 14 HEDIS Measures ...................................................................................................................... 21 EPSDT Measures ...................................................................................................................... 38 CAHPS Measures ..................................................................................................................... 42 Physicians’ Assessment Measures............................................................................................ 48 Med-QUEST Internal Measures ............................................................................................... 53 Appendix A – Description of Measures........................................................................................ 58 U.S. Census Measures............................................................................................................... 58 HEDIS Measures ...................................................................................................................... 61 EPSDT Measures ...................................................................................................................... 70 CAHPS Measures ..................................................................................................................... 72 Physicians’ Assessment Measures............................................................................................ 76 Med-QUEST Internal Measures ............................................................................................... 80 Appendix B – Discussion of Statistical Terminology................................................................... 83 Appendix C – Development of Hawaii Targets for U.S. Census Measures ................................. 86 QUEST Annual Report FYE June 30, 2006 Page 2 of 87 Executive Summary The fiscal year period from July 1, 2005 to June 30, 2006 recorded the 12th demonstration year for the QUEST Medicaid section 1115 demonstration waiver. This past year the QUEST program has focused its efforts on several initiatives: • Preparing and updating the QUEST medical request-for-proposal (RFP) for distribution to plans wishing to bid during the next contract period, which runs from April 1, 2007 to June 30, 2009. The final draft of the QUEST RFP was mailed out in November of 2006. Planning for the implementation of the QUEST Adult Coverage Expansion (QUEST-ACE), which will provide medical assistance to a childless adult who is unable to enroll in the QUEST program due to the limitations of the statewide enrollment cap of QUEST as indicated in HAR §17-1727-26. The QUEST-ACE benefit package will encompass the same limited package of benefits currently provided under the QUEST-Net program. Depending on other employment factors, some recipients will be assessed a premium share of 50% of the QUEST-ACE premium. This program will further the reach of the QUEST demonstration, reducing the number of uninsured and underinsured adults in our community. Planning for the implementation of QUEST Adult Preventative Dental benefit, which will provide limited preventative and restorative dental benefits up to a $500 limit per person per State fiscal year. This will include x-rays and fillings. Also part of the benefit will be a $1,000 denture benefit, which will be allowed toward one set every five years. This program extension is scheduled was implemented in December of 2006, and is available to all QUEST programs including QUEST-Net and QUEST-ACE. The QUEST Adult Preventative Dental benefit will improve the oral health of the QUEST adult population. Planning for the implementation of QUEST Expanded Access (QExA), where the majority of the Medicaid Fee-For-Service population will be integrated into QUEST managed care plans. The additional QExA service mix is projected to include medical services for all aged (individual 65 years and older), blind, and disabled individuals, as well to expand the services to include long-term care services (both institutional and home and communitybased waiver services). This expansion, if approved, will further extend the reach of QUEST to some of our community’s most vulnerable and fragile individuals. • • • • Preparing for the implementation of The Deficit Reduction Act (DRA). The new provisions under Section 6036 of the DRA of 2005 discontinued the practice of self-attestation of Citizenship and Identity. Although the Department’s goal to preserve the eligibility of current recipients to insure continuation of medical coverage while complying with the new Federal requirements was quite challenging, the potential use of scarce funds on individuals that should not be a part of QUEST is wasteful and takes away funds from those truly in need. • Compliance with the Health Insurance Portability and Accountability Act (HIPAA), which in large part involves the safeguarding of an individual's protected health information. MedQUEST continually monitors federal HIPAA Privacy, Security and TCS compliance QUEST Annual Report FYE June 30, 2006 Page 3 of 87 throughout the Division, and actively develops policies and procedures, conducts on-going reviews of existing practices, conducts periodic audits of division compliance efforts, and ensures training of staff. A high level of service to QUEST recipients demands strict compliance with HIPAA. • Streamlining and simplifying the eligibility process for QUEST recipients. Some specific examples are the use of the pre-printed Eligibility Renewal Forms during the annual eligibility renewals, not requiring families with children to turn in a Renewal Form if the information has not changed (so called “passive renewals”), and the expediting of the application process for pregnant women and children, through the use of the Medical Assistance Application For Children and Pregnant Women Only form. These efforts serve to remove barriers of access to medical care for the uninsured or underinsured. There has been much accomplished over this past year with the QUEST program. Yet based on the scores for the various measures and how they compare to our target scores, there is much room for improvement with the scores of the measures in this report. There are a few reasons that might explain why, in general, the scores are not as close to target as we would like: • Target scores were set retro-actively: Optimally, target scores are set at the beginning of the reporting period and communicated to all health plans. This process sets clear benchmarks of performance, clarifies expectations at the end of the reporting period, and improves the chances of positive outcomes. The targets for this report were established after the reporting period began. Without clear expectations it is not surprising for several of the statewide and plan-specific measures to have missed their targets – sometimes by wide margins. Going forward, these targets will be communicated as early as possible to the health plans. Little health plan monitoring: Med-QUEST has not monitored the performance of the health plans as closely as we would have liked to in the recent past. More specifically, there has not been a formal measuring tool implemented with regular periodic updates and feedback. Although the plans have been submitting HEDIS scores and participating in surveys related to their QUEST membership, the plans have not been required to submit audited HEDIS data, they have not seen these measures reported comprehensively in one place, reported over a period of time, compared to other plans in the State of Hawaii, and benchmarked to nationally recognized target scores. We hope that once this measuring tool is introduced to the plans and regularly updated on an annual basis, the health plans will be on notice that we are serious about looking at their performance. No financial incentives built into contract: The plans have not had any financial incentive or disincentive for performing well in the measures in this report. Penalties and/or incentives are powerful motivating tools, and we hope to expand the usage of these in the future to affect and improve performance in these measures. The health plans perception of “more work, same pay”: This is somewhat related to the previous point. From a purely financial perspective, any additional resources that a health plan invests to improve the scores of the measures in this report come directly out of the plan’s bottom line. Any medical cost savings from improvements in scores are not tangible and difficult to measure – it is almost impossible to quantify that something didn’t happen QUEST Annual Report FYE June 30, 2006 Page 4 of 87 • • • because of something you did. As an example, how many NICU days did a plan prevent if their HEDIS Prenatal score improved by 1.0%? What may aide in changing this thought process is the introduction of this measuring tool, which will highlight where plans are performing well and where they are not, and how they compare with other plans, other states, and a national average. That being said, it is hard to deny that, overall, Kaiser raw scores are higher than the other two plans. Kaiser is consistently rated as one of the 10 best health plans in the country from many different sources. We believe there are several reasons that Kaiser’s raw scores are better: • Kaiser’s Staff Model: Physicians and members “choose” to be part of Kaiser, which we believe creates a positive bias for their scores. Physicians are happier because they do not have to deal with malpractice insurance, contracting, and accounts receivable issues that are a time and energy drain on independent physicians. This frees the Kaiser physician to focus solely on practicing medicine, as well as providing a clear path to standardizing patient care. And the Kaiser members seem to understand and “buy-in” to the Kaiser system of delivering medical care, and actively choose to become a Kaiser member. This improves compliance with scheduled visits as well as strengthens the physician-to-patient relationship. No auto enrollment: Kaiser has requested to not participate in auto enrollment since 2003, so only members that actively choose Kaiser are enrolled in their system. A plan has a better chance of managing a stable population than managing a variable population, and not having members auto enrolled into your plan encourages population stability. Integrated information system: Recently Kaiser Hawaii has installed parts of the EPIC healthcare system. This system enables all Kaiser doctors to see the results of all tests done to the Kaiser members, provides electronic reminders during doctor visits for annual/quarterly/monthly preventative or immunization interventions, and enables members to conduct a multitude of tasks online – things like check results of tests or radiological services, make doctor appointments, and see recommended intervals for childhood immunizations. EPIC makes it very easy for all Kaiser doctors and members to follow standardized guidelines of medical care, which in turn improves the scores posted by Kaiser QUEST. • • QUEST Annual Report FYE June 30, 2006 Page 5 of 87 Information about the Demonstration Overview Hawaii’s QUEST Expanded is a state wide comprehensive section 1115 (a) demonstration that expands Medicaid coverage to children and adults originally implemented on August 1, 1994. The demonstration creates a public purchasing pool that arranges for health care through capitated managed care plans. The State converted approximately 108,000 recipients from three public funded medical assistance programs into the initial demonstration including: 70,000 Aid to Families with Dependent Children (AFDC-related) individuals; 19,000 General Assistance program individuals (of which 9,900 were children whom the State was already receiving Federal financial participation); and 20,000 former State funded SCHIP program individuals. This demonstration builds upon the Hawaii Prepaid Health Care Act, an ERISA waiver, which requires all employers to provide insurance coverage to any employee working more than 20 hours per week. Together these programs have resulted in an unprecedented State, private/public partnership that directly impacts the rate of uninsurance. The extension of Hawaii’s Section 1115 demonstration on February 1, 2006, continues the State’s current coverage, while also expanding coverage to children from 200 percent through 300 percent of the Federal Poverty Level (FPL) using title XXI funding. Hawaii will also expand coverage to another new group; the QUEST Adult Coverage Expansion (QUEST-ACE) who are adult individuals up to 100 percent of the FPL who are not otherwise eligible for coverage. The current extension will expire on June 30, 2008. Goals and Objectives From the very beginning of the QUEST demonstration, the goals and objectives have been centered on improving the overall health of the indigent, fiscal management, clinical access and quality of care, and provider availability. The specific objectives are listed below: • • • • • Improve health outcomes and reduce inappropriate utilization. That by continuing to serve recipients in a coordinated care-managed environment, the overall health of Hawaii’s most vulnerable citizens will continue to improve. Decrease the percentage of uninsured individuals in the State. Expand coverage to children from 200 percent through 300 percent of the Federal Poverty Level (FPL) using title XXI funding. Continue the predictable and slower rate of expenditure growth associated with managed care. QUEST Annual Report FYE June 30, 2006 Page 6 of 87 Key Waivers in the Demonstration The following are the waivers that are currently in effect for this demonstration: • Medically Needy - Section 1902(a)(10)(C). To enable the State to limit medically needy spend-down eligibility for QUEST to those individuals whose gross incomes, before any spenddown calculation, are at or below 300 percent of the Federal poverty level. This is not comparable to spend-down eligibility for the aged, blind and disabled eligibility groups, which have no gross income limit. Amount Duration and Scope - Section 1902(a)(10)(B). To permit managed care organizations (MCO) providing QUEST, QUEST-Net and QUEST-ACE coverage to provide additional benefits that may not be available to enrollees in other plans or to Medicaid recipients not enrolled in an MCO. Financial Responsibility/Deeming - Section 1902(a)(17)(D). To allow the State to determine eligibility using the income of household members whose income may be taken into account under the AFDC-income rules. If the household income so calculated exceeds QUEST Expanded limits, the State shall determine eligibility using Medicaid financial responsibility and deeming rules. To also allow the State to deem financial support from parents and legal guardians when determining eligibility for adults who are age 18 or older but under age 21, and who are claimed as tax dependents by their parents or legal guardians. Three Month Retroactive Eligibility - Section 1902(a)(34). To enable the State to waive the requirement to provide medical assistance for up to three months prior to the date that an application for assistance is made because QUEST Expanded eligibility begins on the date of the application. Quality Review of Eligibility - Section 1902(a)(4). To enable the State to be exempt from the current administrative procedure of reviewing the eligibility process and to allow the State to continue to follow Medicaid Eligibility Quality Control (MEQC) plan procedures approved by CMS on October 11, 1996, when reviewing eligibility determinations for Demonstration enrollees. The State remains relieved of any liability from disallowance for errors that exceed the three (3) percent tolerance. Freedom of Choice - Section 1902(a)(23). To enable Hawaii to restrict the freedom of choice of providers. • • • • • Impacted Population Groups Based on the goals and objectives of this demonstration, the targeted populations groups to be impacted are the most vulnerable and needy who do not have access to any other form of healthcare coverage. Individuals and family members who are sixty-five years old or older, or are blind, or are disabled are generally disqualified from the eligible groups. The scope of the population groups impacted by the demonstration has consistently and regularly been expanding from its initial focus. In its current form, the following populations are expected to benefit from this demonstration: QUEST Annual Report FYE June 30, 2006 Page 7 of 87 • • • • • Pregnant women in families whose income is up to 185 percent of the FPL. Infants and children in families whose income is up to 300 percent of the FPL. Adults and families with dependent children whose income is up to 100 percent of the FPL. Childless adults whose income is up to 100 percent of the FPL. Uninsured individuals in general. Hypotheses about the Outcomes of the Demonstration The state’s hypotheses about the outcomes of the demonstration are based on the goals and objectives, as well as the impacted populations groups mentioned earlier in this report. The following outcomes are expected in this demonstration: • • • The percentage of uninsured individuals in the State of Hawaii will decrease to 8.2%. The percentage of children from 200 percent through 300 percent of the Federal Poverty Level (FPL) that are insured will decrease to 5.9%. The statewide QUEST rate of women receiving a prenatal care visit in the first trimester or within 42 days of enrollment will be at or higher than the national Medicaid 75th percentile score. The statewide QUEST rate of children who had six or more well-child visits with a primary care practitioner during their first 15 months of life will be at or higher than the national Medicaid 75th percentile score. The statewide QUEST rate of adult diabetic members who have had at least two glycohemoglobin level tests in the reporting year will be at or higher than the national Medicaid 75th percentile score. The statewide QUEST rate of members 6 years of age and older as of the date of a mental health discharge who were seen on an ambulatory basis or were in intermediate treatment with a mental health provider within 30 days of hospital discharge will be at or higher than the national Medicaid 75th percentile score. The percentage of well newborns to total newborns in the QUEST population will increase to 94.0%. The statewide QUEST CAHPS rating for getting needed care will be at or higher than the national Medicaid mean score. • • • • • QUEST Annual Report FYE June 30, 2006 Page 8 of 87 • The total cost of the demonstration program (premium payments and administrative costs) will be no greater than the comparable FFS program cost for the current recipients if the demonstration did not exist. A Brief History of the Implementation of the Demonstration The QUEST 1115 demonstration was originally implemented on August 1, 1993, and has since been extended a total of four times. In most of the extension applications there has been a subsequent and cumulative expansion of the scope of the targeted recipients covered by QUEST. A brief history of the demonstration follows below: Date Proposal Submitted: Date Proposal Approved: Date Implemented: Date Extension Proposal Submitted: Date Extension Proposal Approved: Date Extension Expires: Date Extension Proposal Submitted: Date Extension Proposal Approved: Date Extension Expires: Date Extension Proposal Submitted: Date Extension Proposal Submitted: Date Extension Expires: Date Extension Proposal Submitted: Date Revised Extension Proposal Submitted: Temporary 30-Day Extension: Temporary 60-Day Extension: Temporary 30-Day Extension: Temporary 30-Day Extension: Temporary 30-Day Extension: Temporary 30-Day Extension: Date Extension Proposal Approved: Date Extension Expires: April 19, 1993 July 16, 1993 August 1, 1994 April 1, 1998 September 30, 1998 March 31, 1998 November 19, 2001 March 18, 2002 March 31, 2005 July 30, 2004 October 8, 2004 June 30, 2005 January 21, 2005 August 30, 2006 June 30, 2004 July 30, 2005 September 30, 2005 October 30, 2005 November 30, 2005 December 30 2005 January 30, 2006 June 30, 2008 Evaluation Design The Management and Coordination Organization Conducting the Evaluation The evaluation will be conducted internally within Med-QUEST, primarily by Jon Fujii (Research Officer). Contributions will also be made by Leslie Tawata (Health Coverage Management Branch Administrator), Dr. Lynette Honbo (Medical Consultant), Alan Takahashi (Enrollment Branch Administrator), Noreen Moon-Ng (Policy & Program Development Branch QUEST Annual Report FYE June 30, 2006 Page 9 of 87 Administrator), Brian Pang (Finance Officer), Kendrick Abe (Healthcare Business Analyst), Angie Payne (former Acting MedQUEST Administrator), and Kathy Ramento (Secretary). Timeline for Implementation of the Evaluation and for Deliverables • • • October 2006 – Begin gathering data for the evaluation. November 2006 – Continue data gathering. Begin data testing and validation. December 2006 – Continue and finalize data gathering, testing and validation. Preliminary findings will be compared with targeted objectives and summarized. Reflections will be made on changes over time as well as comparisons to national and selected state averages. January 2007 – Analysis of outcomes and value creation of the demonstration. February 2007 through March 2007 – Analysis of internal and external factors driving the scores, and how these factors can be positively impacted. • • QUEST Annual Report FYE June 30, 2006 Page 10 of 87 The Specific Metrics, Methodologies & Rationales The Measures When observing the various measures below, and unless stated otherwise, remember that a higher numeric score is considered positive and a lower numeric score is considered negative. Measures U.S. Census Measures Uninsured Percentage (#) Uninsured Children (Age 0-18) Percentage (#) Percent of Children (Age 0-18) between 200% and 300% FPL who are Uninsured (#) HEDIS Measures Prenatal Care PPC Postpartum care PPC Maternity Average Length of Stay MAT Well Child Visits in the First 15 Months of Life, 6 or more W15 Child Immunizations Status, Combination 2 CIS Hemoglobin A1c Tested CDC Hemoglobin A1c Poorly Controlled CDC (#) Retinal Examination CDC Follow-Up After Hospitalization for Mental Illness, Within 30 Days FUH Mental Health Utilization – Percentage of Members Receiving Services MPT Emergency Department Visits, per 1,000 member months AMB Percentage of Well Newborns to Total Newborns EPSDT Measures Screening Ratio Participant Ratio CAHPS Measures Rating of Health Plan Rating of All Healthcare Getting Needed Care Getting Care Quickly Physicians’ Assessment Measures Attitude toward Hawaii Med-QUEST Satisfaction with reimbursement from the Med-QUEST health plan Does the health plan personnel have the necessary professional knowledge Impact of the health plan’s UM (prior authorizations) on quality care Med-QUEST Internal Measures Budget Neutrality Savings Quest Member Months Expenditures for QUEST Uncompensated Care Costs Expenditures for QUEST-ACE Program LT = longitudinal comparison Reported Years 2000 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2002 – 2005 2006 2006 2006 2006 2002, 2006 2002, 2006 2002, 2006 2002, 2006 DY 12 2006 2007 2007 - 2008 Comparisons LT, ST, NT LT, ST, NT LT, ST, NT LT, PL, NT LT, PL, NT LT, PL, NT LT, PL, NT LT, PL, NT LT, PL, NT LT, PL, NT LT, PL, NT LT, PL, NT LT, PL, NT LT, PL, NT LT, PL, NT LT, PL LT, PL PL, NT PL, NT PL, NT PL, NT LT, PL LT, PL LT, PL LT, PL LT LT, PL LT LT Actual Score 9.1% 17.2% 10.0% 72.9%↓ 57.1%↓ 2.46 51.7%↓ 67.6%↓ 81.3%↓ 59.9%↓ 53.1% 72.2% 9.0%↓ 36.7↓ 92.6% 91.9%↑ 68.5% 62.2%↑ 60.6%↑ 73.5% 45.4% 40.8% 27.7% 33.5% 27.2% 12,359,340 1,805,359 17,558,000 Target Score 8.2% 15.5% 5.9% 86.7% 64.5% 2.85 56.3% 71.4% 84.1% 37.8% 54.9% 70.6% 9.7% 57.5 N/A 80% 80% 52.6% 54.1% 74.6% 44.9% N/A N/A N/A N/A >0 N/A N/A N/A N/A ↑ Indicates a score that is significantly better than the target score. QUEST Annual Report FYE June 30, 2006 Page 11 of 87 ST = comparison with other states NT = national comparison PL = QUEST plan comparison ↓ Indicates a score that is significantly worse than the target score (#) Unlike the other measures, for this measure higher numeric scores are considered negative and lower numeric scores are considered positive. Accordingly, the targets for the HEDIS measures represent the score for the national Medicaid 25th %ile, NOT the score for the 75th %ile. For a discussion on the specifics of each measure, please see Appendix A. For a discussion on the calculation of the 95% confidence interval used and how it will be displayed in this report, please see Appendix B. When Data on each Measure will be Collected Data will be collected in the months from October 2006 through January 2007. The Population Groups of Enrollees for which Data will be Analyzed • • • • • • • Uninsured individuals. Children in families whose income is from 200 percent through 300 percent of the FPL. Pregnant women. Infants. Children up to 15 months old. Diabetics. Mental health patients. The Analysis Plan The methods by which the data collected will be analyzed, including the statistical methodologies to be used The results of the data collection and calculation will be various values for the given period. These results will be displayed in both tabular as well as graphical formats. For most measures, a longitudinal comparison will be made among the various years’ Hawaii statewide QUEST scores. Another comparison will be among the various plans’ scores. Where applicable, other state and/or national comparisons will also be reviewed. Where possible, statistical analysis to determine that any two values are actually different will be performed using a 95% confidence level. A determination will be made if unexpected or expected factors are influencing the calculated values. These factors could be internal to DHS, specific to a plan’s operations, or external at a state or national level. If so, and if data points are available, multiple regression analysis will be QUEST Annual Report FYE June 30, 2006 Page 12 of 87 performed to validate these suspicions. Either way, there will be a discussion on how we believe these factors are exerting influence on the values. Integration of the State Quality Improvement Strategy Several of the measures in this report are the same metrics identified in the State Quality Improvement Strategy. There are also measures that are not a part of the State Quality Improvement Strategy. In discussions with key personnel, it was determined that the measures for this Annual Draft Report need not be a sub-set of, nor mutually exclusive from, the metrics that are in the State Quality Improvement Strategy. QUEST Annual Report FYE June 30, 2006 Page 13 of 87 Measures The graphs used to illustrate the various measures are, unless otherwise noted, scaled from 0% to 100%. This was done to facilitate comparisons between graphs and to present a consistent scale of measurement. Please see Appendix A for detailed descriptions of the measures used in this report. Appendix B will highlight the 95% confidence interval calculation and discuss how it will be displayed in this report. U.S. Census Measures The U.S. Census measures are included in this report to measure various statewide medical uninsured rates in Hawaii. The U.S. Census measures are based on public information available from the U.S Census Bureau website. These measures range from very broad measures of the Hawaii uninsured population, to very specific gender, age, and FPL specific uninsured rates in Hawaii. All of the data was obtained using the Current Population Survey (CPS) Table Creator tool, which enables the user to create customized reports using the various database fields. The stated year in the various measures represent the year in which the survey was taken. Three types of analysis are done for each U.S. Census measure. First, a longitudinal analysis is completed on the Hawaii statewide rates to determine if there are broad trends in the measure over a period of several years. Scores are reported for each year from 2000 to 2005. Second, a comparison of the Hawaii statewide score, three comparison states’ scores, and the national average score in 2005 is done to observe any differences between how Hawaii is managing its uninsured population and how the comparison states are managing their populations. The comparison states, chosen for their relative comparability of size and maturity of demonstration project, are Maryland, Massachusetts and Rhode Island. Maryland’s waiver began on 6/2/1997, Massachusetts’ on 7/1/1997, and Rhode Island’s on 8/1/1994. Third, the scores for Hawaii, the three comparison states, and national average are reported each year over a period year from 2000 to 2005. State initiatives often take years to come into fruition, and these graphs will compare and contrast these trends by state over time. For all analyses, comparisons are made to the National Average score in the relevant reporting year. Comparisons are also made to Hawaii Target scores, which are calculated for each measure based on expected changes to the most recent year’s actual score. Finally, for the first two analyses a 95% confidence interval is calculated for each score to determine the significance of any differences in scores. For a discussion on the specifics of each U.S. Census measure, please see Appendix A. Please see Appendix B for a detailed discussion on how the statewide rates, and 95% confidence intervals, are calculated. Details on the calculations of the Hawaii Target scores can be found in Appendix C. For all of the U.S. Census measures, lower numeric scores are considered positive and higher numeric scores are considered negative. The graphs used to illustrate the various measures are scaled from either 0% to 20%, or 0% to 30%, to reflect the historical range of uninsured percentage scores. QUEST Annual Report FYE June 30, 2006 Page 14 of 87 Uninsured Percentage Statewide - Longitudinal 20% U.S. Census Measures Uninsured as a Percent of Total Population Statewide - Longitudinal • The Hawaii statewide rate of the total 15% population without healthcare insurance has varied in a narrow 10% range between 9% and 10% from 2000 to 2005, with the highest 5% rate of 10.1% occurring in 2003 and the lowest rate of 9.1% occurring 0% 2000 2001 in 2005. Over time, the 10.8% 11.0% 95% CI Up 9.4% 9.6% Rate rate has risen from 8.0% 8.3% 95% CI Low 9.4% in 2000 to the high in 2003, then decreased to the low in 2005. 2005 National Average = 15.9% 2006 Hawaii Target = 8.8% 2002 11.4% 10.0% 8.7% 2003 11.5% 10.1% 8.8% 2004 10.7% 9.4% 8.0% 2005 10.4% 9.1% 7.7% • • At the 95% confidence level, the uninsured rate for any given year is not significantly different from the other years reported. At the 95% confidence level, the Hawaii statewide uninsured rate for each year is significantly lower than the 2005 national average rate of 15.9%. Also, the Hawaii Target rate of 8.8% is not significantly different from the Hawaii statewide uninsured rate for each year. By State - in 2005 U.S. Census Measures Uninsured as a Percent of Total Population By State - in 2005 20% • 15% 10% 2006 Hawaii Target = 8.8% 5% 0% 95% CI Up Rate 95% CI Low United States 16.0% 15.9% 15.7% Hawaii 10.4% 9.1% 7.7% Maryland 15.7% 14.1% 12.6% Massachusetts 10.9% 9.8% 8.6% Rhode Island 13.6% 11.9% 10.1% When compared to other states’ uninsured rates, Hawaii does quite well. Hawaii’s 2005 rate of 9.1% was the lowest of the comparison states – Maryland, Massachusetts, and Rhode Island. The closest state was Massachusetts with a 2005 rate of 9.8%. Rhode Island and Maryland trailed farther behind. All comparison states reported rates lower than the 2005 QUEST Annual Report FYE June 30, 2006 Page 15 of 87 national average rate of 15.9%. • At the 95% confidence level, the Hawaii uninsured rate was not significantly different from Massachusetts or Rhode Island. Hawaii’s rate was significantly lower than Maryland, as well as lower than the national average rate. At the 95% confidence level, the Hawaii uninsured rate is not significantly different from the Hawaii Target rate of 8.8%. Of the comparison states, only the Massachusetts rate is not significantly from the Hawaii Target rate. U.S. Census Measures Uninsured as a Percent of Total Population By State - from 2000 to 2005 20% • By State - from 2000 to 2005 • While the predominant trend in other states and nationwide has been for 15% the uninsured rate to increase from 2000 to 10% 2005, Hawaii rate has been virtually flat to marginally decreasing. 5% As the other three states in this comparison have 0% had rate increases that United States range from 1.1% to Hawaii 4.5%, Hawaii’s rate Maryland Massachusetts actually dropped by Rhode Island 0.3%. The national rate moved up by 1.7% over the same period. 2006 Hawaii Target = 8.8% 2000 14.2% 9.4% 10.4% 8.7% 7.4% 2001 14.6% 9.6% 12.3% 8.2% 7.7% 2002 15.2% 10.0% 13.4% 10.0% 9.8% 2003 15.6% 10.1% 13.9% 10.7% 10.3% 2004 15.6% 9.4% 14.3% 11.7% 10.9% 2005 15.9% 9.1% 14.1% 9.8% 11.9% • The period from 2000 to 2005 saw Hawaii go from the third lowest uninsured rate to the overall lowest rate. Conversely, in the same period Rhode Island went from having the overall lowest rate to having the third lowest rate. Maryland remainded as the state with the highest rate for all years. The national rate remained higher than all of the comparison states for each year from 2000 to 2005. The Hawaii target rate of 8.8% is lower than any of the reported rates from between 2002 and 2005. Only Massachusetts and Rhode Island in 2000 and 2001 reported rates lower than the Hawaii target rate. • Discussion of Results Hawaii’s decrease in its uninsured percentage is partially attributable to the increase in the number of Medicaid eligible populations due to the various Medicaid expansion programs Hawaii has implemented since 2000. More programs mean more opportunities for healthcare coverage for Hawaii’s uninsured. Also, Hawaii’s seasonally adjusted rate of unemployment has decreased over the 2000 – 2005 period, going from 4.4% in January 2000 to 2.6% in December QUEST Annual Report FYE June 30, 2006 Page 16 of 87 2005. Lower unemployment can lead to greater access to employee sponsored healthcare coverage. Uninsured Children (Age 0-18) Percentage Statewide - Longitudinal • The Hawaii statewide rate of children in the total population without healthcare insurance has varied widely from 13% to 21% in the period from 2002 to 2005. The rate in 2002 was the highest at 21.1% while the lowest rate of 12.8% occurred in 2004. 30% U.S. Census Measures Uninsured Children (Age 0-18) as a Percent of Total Uninsured Statewide - Longitudinal 20% 2005 National Average = 19.4% 2006 Hawaii Target = 15.5% 10% • At the 95% confidence 25.7% 23.4% 16.8% 21.7% 95% CI Up 21.1% 18.9% 12.8% 17.2% Rate level, the Hawaii rate of 16.5% 14.4% 8.9% 12.8% 95% CI Low uninsured children from 2002 to 2005 was not significantly different from each other. Also, the rates in all but one year, 2004, were not significantly different from the 2005 national average rate of 19.4%. The rate in 2004 was significantly lower than the 2005 national average. 2002 2003 2004 2005 0% • At the 95% confidence level, the Hawaii target rate of 15.5% is not significantly different from the Hawaii rate of uninsured children from 2003 through 2005. The Hawaii rate in 2002 is significantly higher than the Hawaii U.S. Census Measures Uninsured Children (Age 0-18) as a Percent of Total Uninsured target rate. By State - in 2005 30% By State - in 2005 20% • 2006 Hawaii Target = 15.5% 10% 0% 95% CI Up Rate 95% CI Low United States 19.9% 19.4% 18.9% Hawaii 21.7% 17.2% 12.8% Maryland 19.8% 16.6% 13.5% Massachusetts 17.1% 12.8% 8.4% Rhode Island 20.9% 16.8% 12.7% Hawaii’s 2005 rate of uninsured children, at 17.2%, is in the highest when compared to other comparison states. Massachusetts comes in with the lowest rate at QUEST Annual Report FYE June 30, 2006 Page 17 of 87 12.8%, with Maryland (16.6%) and Rhode Island (16.8%) having rates closer to Hawaii’s rate. The 2005 national average rate of 19.4% was higher that all of the states’ rates. • At the 95% confidence level, Hawaii, rate of uninsured children is not significantly different than the rates for Rhode Island, Maryland, and the national average rate. Only Massachusetts has a rate that is significantly lower than the national average rate, but their rate is not significantly different than Hawaii’s rate. The small sample sizes used to calculate the state rates necessitate large confidence intervals. • At the 95% confidence level, the Hawaii target rate of 15.5% is not significantly different from any of the reported state’s rate of uninsured children. The national average rate is significantly higher than the Hawaii target rate. U.S. Census Measures Uninsured Children (Age 0-18) as a Percent of Total Uninsured By State -- from 2002 to 2005 30% By State - from 2002 to 2005 • Most of the reported states showed decreases in the rate of uninsured children from 2002 to 2005. Hawaii’s rate dropped 3.9% from 2002 to 2005, although the rate in 2005 is higher than the 2004 rate. Only Rhode Island had a higher rate in 2005 (16.8%) than in 2002 (12.5%). 20% 2006 Hawaii Target = 15.5% 10% 0% United States Hawaii Maryland Massachusetts Rhode Island 2002 21.3% 21.1% 20.5% 14.9% 12.5% 2003 20.3% 18.9% 16.5% 19.9% 14.8% 2004 19.2% 12.8% 18.0% 13.0% 16.5% 2005 19.4% 17.2% 16.6% 12.8% 16.8% • Of the reported states, Hawaii had the highest rate of uninsured children in 2002. After briefly having the lowest rate of all the states in 2004 (12.8%), Hawaii also reported the highest rate in 2005. The Hawaii target rate of uninsured children of 15.5% is lower than three of the four reported years for Hawaii’s rate. Only Massachusetts rate in 2005 (12.5%) is below the target rate; all other states’ rates and the national average rate is above the target. • Discussion of Results • The reasons for the decreasing trend in the overall uninsured percentage apply to the decreasing trend in the uninsured children percentage as well. Additionally, with the State of Hawaii funded programs for immigrant children and implementation of “passive renewals”, more children are becoming eligible and fewer cases are being closed due to incomplete eligibility reviews. The many steps taken to streamlining and simplifying the eligibility process for QUEST recipients were discussed in the Executive Summary, and these steps are QUEST Annual Report FYE June 30, 2006 Page 18 of 87 a large reason for the overall downtrend in the uninsured children rate over the four reported years. Percent of Children (Age 0-18) Between 200% and 300% FPL who are Uninsured Statewide - Longitudinal • The Hawaii statewide rate of children in households with income between 200% and 300% of the Federal Poverty U.S. Census Measures Level (FPL) who are Percentage of Children (Age 0-18) Between 200% FPL and 300% FPL who are Uninsured Statewide - Longitudinal uninsured varied between 5% and 10% 20% from 2002 to 2005. The lowest rate of 15% 4.8% occurred in 2004, and the highest rate of 10.0% occurred in 10% 2005. While the rates dipped in the middle years, Hawaii started 5% and ended up with nearly the same rate. 2005 National Average = 12.0% 2006 Hawaii Target = 5.9% At the 95% confidence level, the Hawaii rates 5.1% 3.2% 1.2% 5.8% 95% CI Low of uninsured children between 200% and 300% FPL from between 2002 to 2005 were not significantly different from each other. The rates in 2002 and 2005 were not significantly different from the 2005 national average of 19.4%. Showing some improvement, the rates in 2003 and 2004 were significantly lower than the 2005 national average. 2002 2003 2004 2005 95% CI Up Rate 14.2% 9.7% 10.7% 6.9% 8.3% 4.8% 14.2% 10.0% 0% • • At the 95% confidence level, the Hawaii rates of uninsured children between 200% and 300% FPL from between 2002 to 2005 were not significantly different from the Hawaii target rate of 5.9%. A major factor causing this is the very wide confidence intervals. By State - in 2005 • Hawaii’s 2005 rate of uninsured children between 200% and 300% FPL of 10.0% was only bested by the Rhode Island rate of 7.1%. Masschusetts (10.2%) and Maryland (14.1%) recorded higher rates. The 2005 national average rate was 12.0%. At the 95% confidence level, Hawaii, rate of uninsured children between 200% and 300% FPL is not significantly different than the rates for all three of the comparison states or the national average rate. Only Rhode Island has a rate that is significantly lower than the national average rate. Again, small sample sizes used to calculate the state rates necessitate large confidence intervals. QUEST Annual Report FYE June 30, 2006 Page 19 of 87 • • At the 95% confidence level, the Hawaii target rate of 5.9% was not significantly different than the Hawaii, Massachusetts & Rhode Island rate of uninsured children between 200% and 300% FPL. Again, very wide confidence intervals are a factor in the target not being different than these states’ rates. Maryland had a rate that was higher than the Hawaii target rate. U.S. Census Measures Percentage of Children (Age 0-18) Between 200% FPL and 300% FPL who are Uninsured By State - in 2005 20% 15% 10% 2006 Hawaii Target = 5.9% 5% 0% 95% CI Up Rate 95% CI Low United States 12.6% 12.0% 11.5% Hawaii 14.2% 10.0% 5.8% Maryland 18.4% 14.1% 9.7% Massachusetts 14.9% 10.2% 5.4% Rhode Island 10.9% 7.1% 3.4% By State - from 2002 to 2005 • The recent trend in the rate of uninsured children between 200% and 300% FPL from 2002 to 2005 is clearly higher, as every single state recorded increased rates. Hawaii’s rate increase of 0.3% was the lowest increase of the group. The increases in the comparison states’ rates ranged from 2.5% U.S. Census Measures (Maryland) to 5.1% Percentage of Children (Age 0-18) Between 200% FPL and 300% FPL who are Uninsured By State - from 2002 to 2005 (Rhode Island). Each of the states showed much 20% variation in their yearover-year scores. 15% • 10% 5% 2006 Hawaii Target = 5.9% 0% United States Hawaii Maryland Massachusetts Rhode Island 2002 11.3% 9.7% 11.6% 6.3% 2.0% 2003 10.6% 6.9% 8.4% 10.3% 7.0% 2004 11.6% 4.8% 8.2% 7.8% 7.5% 2005 12.0% 10.0% 14.1% 10.2% 7.1% Of the reported states, Rhode Island had the lowest rate of uninsured children between 200% and 300% FPL in both 2002 and 2005. Hawaii briefly having the lowest rate of all the states in 2004 (4.8%), but started and ended up mid-pack. • The Hawaii target rate of 5.9% was lower than most of the 2002 through 2005 reported rates of uninsured children between 200% and 300% FPL, save the 2002 Rhode Island rate (2.0%) and the 2004 Hawaii rate (4.8%). QUEST Annual Report FYE June 30, 2006 Page 20 of 87 HEDIS Measures The Health Plan Employer Data & Information Set (HEDIS) measures are included in this report to measure both the quality of healthcare delivered to, as well as the overall healthcare utilization levels of, the Hawaii QUEST recipients. The HEDIS measures mostly involve ratios of a target behavior over the entire population that is eligible for that behavior. Occasionally ratios are reported on a sample of the population instead of the entire population, but on these occasions there are intensive internal claim audits are applied to the sample encounters. The HEDIS measures are based on self-reported HEDIS reports received from the three individual plans that are contracted with Med-QUEST – AlohaCare, HMSA, and Kaiser. HEDIS reports from the plans are based on a fiscal year period, a twelve-month period beginning in July 1 and ending on June 30 of the report year, and are due to Med-QUEST on December 31 of the report year. These are sent via electronic file to MedQUEST, and are then compiled to create composite HEDIS measures for the entire QUEST population for a single year. The plans are required to report on all of the HEDIS measures in each year. The definitions of the various HEDIS measures reported by the plans are no different from the national standard HEDIS definitions. All three plans use HEDIS-approved software programs to calculate their scores. Since the plans are not required to conduct a comprehensive audit of the HEDIS scores before reporting them to Med-QUEST, the HEDIS data submitted by the plans may or may not be audited by a third party. Annual audits on how the plans calculate and report their HEDIS scores are conducted by the External Quality Review Organization (EQRO) entity under contract with, and under the direction of, Med-QUEST. Typically, these audits only involve a sample of three HEDIS measures. The measures presented below are a small sample of the complete set of HEDIS measures that are reported each year, Two types of analysis are done for most of the HEDIS measures. First, a longitudinal analysis is completed on the statewide QUEST rates to determine if there are broad trends in the measure over a period of several years. Scores are reported for each year from 2002 to 2005. Second, a comparison of the three plans’ scores and the statewide QUEST score in 2005 is done to observe any differences between health plans in the management of their population. For both analyses, comparisons are made to the 2005 National Medicaid Median score and the 2005 National Medicaid 75th Percentile score to bring perspective to where we score on a national level. When available, the National Medicaid 75th Percentile score will be the target score for all of the HEDIS measures. Finally, a 95% confidence interval is calculated for each score to determine the significance of any differences in scores. For a discussion on the specifics of each HEDIS measure, please see Appendix A. Please see Appendix B for a detailed discussion on how the statewide rates, and 95% confidence intervals, are calculated. For all of the HEDIS measures except for the Maternity Average Length of Stay and Hemoglobin A1c Poorly Controlled, higher numeric scores are considered positive and lower numeric scores are considered negative; for these measures lower numeric scores are considered positive and higher numeric scores are considered negative. QUEST Annual Report FYE June 30, 2006 Page 21 of 87 Prenatal Care Statewide - Longitudinal HEDIS Measures Prenatal Care (PPC) Statewide - Longitudinal 100% 2005 National Medicaid 75th %ile = 86.7% 2005 National Medicaid Median = 81.5% • 75% 50% 25% The statewide QUEST rate of women receiving a prenatal care visit in the first trimester or within 42 days of enrollment has varied between 70% and 78% from 2002 to 2005, with the highest rate of 77.7% occurring in 2004 and the lowest rate of 70.9% occurring in 2002. At the 95% confidence 70.9% 76.1% 77.7% 72.9% level, the rate of prenatal Rate 69.0% 73.7% 75.4% 70.6% 95% Lower care visits in 2002 is significantly lower that the rates in both 2003 and 2004. There is no significant difference in the rate between the two middle years (2003 and 2004). 2002 2003 2004 2005 95% Upper 72.7% 78.4% 80.1% 75.1% 0% • • At the 95% confidence level, statewide QUEST rates of prenatal care visits for all the years 2002 through 2005 are all significantly lower than the 2005 national Medicaid median score of 81.5%. The 2005 national Medicaid 75th percentile score was 86.7%. By Plan – in 2005 • Of the three plans’ 2005 rates, Kaiser had the highest rate of prenatal care visits at 75.3%, followed by HMSA at 73.2% and AlohaCare at 68.4%. Both Kaiser and HMSA were higher that the 2005 statewide QUEST average of 72.9%. HEDIS Measures Prenatal Care (PPC) By Plan -- in 2005 100% 2005 National Medicaid 75th %ile = 86.7% 2005 National Medicaid Median = 81.5% 75% 50% 25% 0% • At the 95% confidence 75.1% 73.0% 77.6% 78.6% 95% Upper 72.9% 68.4% 73.2% 75.3% Rate level, the rates of 70.6% 63.8% 68.8% 72.0% 95% Lower prenatal care visits for the three plans were not significantly different from each other or the statewide QUEST average. Hawaii QUEST AlohaCare (Hybrid) HMSA (Admin) Kaiser (Admin) QUEST Annual Report FYE June 30, 2006 Page 22 of 87 • At the 95% confidence level, the rates of prenatal care visits for the three plans are all significantly lower than the 2005 national Medicaid median score of 81.5%. The 2005 national Medicaid 75th percentile score was 86.7%. Discussion of Results Cultural factors impact this score with several Polynesian and Asian cultures not traditionally receiving prenatal care. This is the most prevalent factor causing low prenatal visits scores. Targeted member education on the benefits of prenatal care is a possible intervention to improve these scores. Postpartum Care Statewide - Longitudinal • The statewide QUEST rate of a postpartum care visit on or between 21 and 56 days after delivery has varied HEDIS Measures between 47% and 57% Postpartum Care (PPC) from 2002 to 2005. Statewide - Longitudinal There has been a 100% continuous increase in the rate from a low of 47.2% in 2002 to a 75% high of 57.1% in 2005. 2005 National Medicaid 75th %ile = 64.5% 2005 National Medicaid Median = 58.4% 50% • 25% 0% 95% Upper Rate 95% Lower 2002 49.2% 47.2% 45.2% 2003 52.0% 49.2% 46.5% 2004 59.5% 56.7% 53.9% 2005 59.6% 57.1% 54.6% At the 95% confidence level, there is no significant difference in the rates of postpartum care visits in 2002 and 2003; the same can be said for the rates in 2004 and 2005. However, the jump in the rate from 2003 to 2004 is significant at the 95% confidence level. • At the 95% confidence level, statewide QUEST rates of postpartum care visits for the years 2002 and 2003 are significantly lower than the 2005 national Medicaid median score of 58.4%. The QUEST rates for 2004 and 2005, however, are not significantly different from this same 2005 national Medicaid median score. All four years’ QUEST rates were significantly below the 2005 national Medicaid 75th percentile score of 64.5%. QUEST Annual Report FYE June 30, 2006 Page 23 of 87 By Plan – in 2005 • In 2005, Kaiser had the highest rate of postpartum care visits at 67.2%, followed by HMSA at 54.5% and AlohaCare at 42.6%. Both HMSA and AlohaCare had rates that were below the 2005 statewide QUEST average of 57.1% HEDIS Measures Postpartum Care (PPC) By Plan -- in 2005 100% 75% 2005 National Medicaid 75th %ile = 64.5% 2005 National Medicaid Median = 58.4% 50% 25% 0% 95% Upper Rate Hawaii QUEST 59.6% 57.1% AlohaCare (Hybrid) 47.5% 42.6% HMSA (Admin) 59.5% 54.5% Kaiser (Admin) 70.8% 67.2% • At the 95% 54.6% 37.7% 49.6% 63.7% 95% Lower confidence level, the rates of postpartum care visits for the three plans were ALL significantly different from each other. Accordingly, only the HMSA rate was not significantly different than the 2005 statewide QUEST average. The Kaiser rate was significantly higher, and the AlohaCare rate significantly lower, than the 2005 statewide QUEST average. At the 95% confidence level, the 2005 national Medicaid median score of 58.4% was significantly above the AlohaCare rate of postpartum care visits, and not significantly different from the HMSA rate. The Kaiser rate was significantly above the 2005 national Medicaid median score, as well as not significantly different that the 2005 national Medicaid 75th percentile score of 64.5%. • Discussion of Results The low postpartum rate is also linked to the same cultural differences mentioned with respect to the prenatal visit measure. Similar member educational interventions may be utilized to improve this measure. Maternity Average Length of Stay This is an administrative measure that reports the entire population of data. Therefore, no confidence interval is needed or reported. The graphs used to illustrate this measure are scaled from 0.00 to 3.00 to reflect the reduced normal range of maternity discharge rates QUEST Annual Report FYE June 30, 2006 Page 24 of 87 Statewide - Longitudinal HEDIS Measures Maternity Average Length of Stay (MAT), per 1,000 Member Months Statewide - Longitudinal 3.00 2005 National Medicaid Median = 2.59 • 2.78 2005 National Medicaid 75th %ile = 2.85 2.34 2.00 2.43 2.46 1.00 The statewide QUEST maternity average length of stay (ALOS) for all deliveries ranged from 2.3 to 2.8 between 2002 and 2005. After a rate of 2.34 in 2002, there was a jump to a rate of 2.78 in 2004 followed by a decrease to a 2005 rate of 2.46. 0.00 Maternity ALOS reported for 2002, 2003 2002 2003 2004 2005 and 2005 were all lower than both the national Medicaid median score of 2.6 and the 2005 national 75th percentile score of 2.85. The 2.78 ALOS reported in 2004 was higher than the national median but lower than the national 75th percentile score. • By Plan – in 2005 • In 2005, Kaiser had the lowest maternity ALOS at 2.27, followed by AlohaCare at 2.49 and HMSA at 2.50. Only Kaiser had a rate that was below the 2005 statewide QUEST average of 2.46. All three plans had maternity ALOS at or below both the 2005 national Medicaid 75th percentile score of 2.85 and the 2005 national Medicaid median score of 2.6. HEDIS Measures Maternity Average Length of Stay (MAT), per 1,000 Member Months By Plan – in 2005 3.00 2005 National Medicaid 75th %ile = 2.85 2005 National Medicaid Median = 2.59 2.46 2.00 2.49 2.50 2.27 • 1.00 0.00 Hawaii QUEST AlohaCare (Admin) HMSA (Admin) Kaiser (Admin) QUEST Annual Report FYE June 30, 2006 Page 25 of 87 Well Child Visits Statewide - Longitudinal HEDIS Measures Well Child Visits in the First 15 Months of Life (W15) - Six or More Visits Statewide - Longitudinal 100% • 75% 2005 National Medicaid 75th %ile = 56.3% 50% 2005 National Medicaid Median = 46.4% 25% 0% 95% CI Up Rate 95% CI Low 2002 60.7% 58.9% 57.1% 2003 58.2% 56.1% 54.0% 2004 54.2% 52.6% 51.0% 2005 53.1% 51.7% 50.3% The statewide QUEST rate of children who had six or more wellchild visits with a primary care practitioner during their first 15 months of life has ranged from 51% to 59% between 2002 and 2005. There has been a steady decline from a high rate of 58.9% in 2002 to a low rate of 51.7% in 2005. At the 95% confidence level, there is no significant difference between any adjacent years’ rates of well child visits. Comparing rates that are two years apart, though, results in significant differences. The QUEST rate in 2002 is significantly higher than the rate in 2004, and the QUEST rate in 2003 is significantly higher than the rate in 2005. Statewide QUEST rates of well child visits for all four years are significantly higher, at the 95% confidence level, than the 2005 national Medicaid median score of 46.4%. When comparing to the 2005 national Medicaid 75th percentile score of 56.3%, the QUEST rate in 2002 is significantly above, the QUEST rates in 2004 and 2005 are significantly below, and the QUEST rate for 2003 is not significantly different. • • QUEST Annual Report FYE June 30, 2006 Page 26 of 87 By Plan – in 2005 • In 2005, Kaiser had the highest rate of well child visits at 64.4%, followed by AlohaCare at 51.5% and HMSA at 49.0%. Both AlohaCare and HMSA had rates that were below the 2005 statewide QUEST average of 51.7%. 100% HEDIS Measures Well Child Visits in the First 15 Months of Life (W15) - Six or More Visits By Plan -- in 2006 75% 2005 National Medicaid 75th %ile = 56.3% 50% 2005 National Medicaid Median = 46.4% 25% • Hawaii QUEST AlohaCare (Admin) HMSA (Admin) Kaiser (Admin) At the 95% confidence 53.1% 54.3% 50.9% 68.3% 95% CI Up level, the rates of well 51.7% 51.5% 49.0% 64.4% Rate 50.3% 48.7% 47.1% 60.5% 95% CI Low child visits for AlohaCare and HMSA were not significantly different from the 2005 statewide QUEST average. The Kaiser rate was significantly higher than the other two plans’ rates and the 2005 statewide QUEST average. 0% • At the 95% confidence level, all three plans’ rates of well child visits were significantly higher than the 2005 national Medicaid median score of 46.4%. The rates for both AlohaCare and Kaiser were significantly below the 2005 national Medicaid 75th percentile score of 56.3%. At the 95% confidence level, the Kaiser rate was significantly higher than the 2005 national Medicaid 75th percentile score. Discussion of Results A possible reason for this measure to be lower than target and decreasing over time is that the physician’s are not happy with reimbursement so they are not actively reminding patients to come in for visits. An EPSDT educational blitz with physicians so they know that they can be paid higher for these visits may could be utilized to improve these scores. QUEST Annual Report FYE June 30, 2006 Page 27 of 87 Childhood Immunization Statewide - Longitudinal HEDIS Measures Childhood Immunization Status (CIS) - Combination 2 Statewide - Longitudinal 100% • 2005 National Medicaid 75th %ile = 78.5% 75% 2005 National Medicaid Median = 72.4% 50% 25% 0% 95% CI Up Rate 95% CI Low 2002 78.2% 75.8% 73.3% 2003 72.4% 69.7% 67.1% 2004 70.8% 68.2% 65.6% 2005 70.3% 67.6% 65.0% The statewide QUEST rate of children who had the complete set of Combination 2 immunizations on or before their second birthday ranged from 67% to 76 % between 2002 and 2005. The change in the rate over the four years can be described as a slow decrease after a large fall from a rate of 75.8% in 2002 to a rate of 69.7% in 2003. • At the 95% confidence level, there is no significant difference between the immunization rates in 2003, 2004 & 2005. The rate for 2002 is significantly higher than the rates for 2003, 2004 & 2005. At the 95% confidence level, the statewide QUEST immunization rate in 2002 was significantly higher than the 2005 national Medicaid 75th percentile score of 71.4%. The QUEST rate in 2003 was not significantly different from the 75th percentile score. QUEST rates for both 2004 and 2005 were not significantly different from the 2005 national Medicaid median score HEDIS Measures of 66.0%. Childhood Immunization Status (CIS) - Combination 2 By Plan -- in 2005 100% • By Plan – in 2005 • In 2005, Kaiser had the highest immunization rate at 90.0%, followed by HMSA at 59.2% and AlohaCare at 53.3%. Both AlohaCare and HMSA had rates that were below the 2005 statewide QUEST average of 67.6%. 2005 National Medicaid 75th %ile = 78.5% 75% 2005 National Medicaid Median = 72.4% 50% 25% 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 70.3% 67.6% 65.0% AlohaCare (Hybrid) 58.2% 53.3% 48.3% HMSA (Admin) 64.2% 59.2% 54.3% Kaiser (Hybrid) 93.0% 90.0% 87.0% QUEST Annual Report FYE June 30, 2006 Page 28 of 87 • At the 95% confidence level, the immunization rates for AlohaCare and HMSA were both significantly lower than the 2005 statewide QUEST average. The Kaiser rate was significantly higher than the other two plans’ rates and the 2005 statewide QUEST average. Both HMSA and AlohaCare had immunization rates in 2005, at the 95% confidence level, that were significantly below the 2005 national Medicaid median score of 66.0%. The 2005 rate for Kaiser was significantly above both the 2005 national Medicaid median score and the 2005 national Medicaid 75th percentile score of 71.4%, at a 95% confidence level. • Discussion of Results Cultural issues mentioned previously may also be negatively affecting this measure as well, with similar educational interventions as a possible ways to improve scores. Hemoglobin A1c Tested Statewide - Longitudinal • The statewide QUEST rate of adult diabetic members who have had at least two glycohemoglobin level tests in the reporting year varied tightly between 79% and 81% from 2002 to 2005. HEDIS Measures At the 95% confidence level, the statewide QUEST diabetic testing rates in all four years were not significantly different. Hemoglobin A1c Tested (CDC) Statewide - Longitudinal 100% 2005 National Medicaid 75th %ile = 84.9% • 75% 2005 National Medicaid Median = 77.4% 50% • At the 95% confidence 25% level, the statewide QUEST diabetic testing rates in 2002, 0% 2002 2003 2004 2005 2003 & 2004 were not 82.5% 82.2% 81.1% 83.6% 95% CI Up 80.1% 80.0% 79.0% 81.3% Rate significantly different 77.7% 77.7% 76.9% 79.0% 95% CI Low than the 2005 national Medicaid median score of 78.4%. The QUEST rate in 2005 was significantly higher than the 2005 national Medicaid median score, but significantly lower than the 2005 national Medicaid 75th percentile score of 84.1%. By Plan – in 2005 QUEST Annual Report FYE June 30, 2006 Page 29 of 87 • In 2005, Kaiser had the highest diabetic testing rate at 88.0%, followed by AlohaCare at 78.8% and HMSA at HEDIS Measures 78.6%. Both Hemoglobin A1c Tested (CDC) By Plan -- in 2005 AlohaCare and HMSA had rates that were 100% below the 2005 statewide QUEST 75% average of 81.3%. 2005 National Medicaid 75th %ile = 84.9% 2005 National Medicaid Median = 77.4% 50% • 25% 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 83.6% 81.3% 79.0% AlohaCare (Hybrid) 82.9% 78.8% 74.8% HMSA (Hybrid) 82.7% 78.6% 74.5% Kaiser (Hybrid) 91.7% 88.0% 84.3% At the 95% confidence level, the diabetic testing rates for AlohaCare, HMSA & the statewide QUEST average are not significantly different. The rate for Kaiser is significantly higher than the 2005 statewide QUEST average. • At the 95% confidence level, the diabetic testing rates for AlohaCare and HMSA are not significantly different than the 2005 national Medicaid median score of 78.4%. The rate for Kaiser is significantly higher than the 2005 national Medicaid 75th percentile score of 84.1% at the 95% confidence level. Discussion of Results This is a relatively new measure and new way of thinking for physicians. As more physicians are educated that this is the best practice for diabetes, the measure should improve. The most recent scores in 2005 showed promising improvement. Hemoglobin A1c Poorly Controlled This measure is the only one of two measures in this study where lower scores are considered positive and higher scores are considered negative. Statewide - Longitudinal As 2005 is the first year as a HEDIS required measure, a longitudinal graph was not done. By Plan – in 2005 • The statewide QUEST rate of adult diabetic members who’s most recent glycohemoglobin level score was considered poorly controlled (score of > 9.0%, or score was missing, or had no test in the past year) was 59.9% in 2005. Of the plans whose rate was lower than the statewide QUEST average, Kaiser had the lowest poorly controlled diabetic rate at 47.5% followed by HMSA at 55.0%. AlohaCare had a rate of 74.5% QUEST Annual Report FYE June 30, 2006 Page 30 of 87 HEDIS Measures Hemoglobin A1c Poorly Controlled (CDC) By Plan -- in 2005 100% • 75% 50% 2006 National Medicaid Median = 45.2% 2006 National Medicaid 75th %ile = 37.3% 25% 0% 95% CI Up Rate At the 95% confidence level, the poorly controlled diabetic rates for HMSA & Kaiser were not significantly different. The rate for Kaiser was significantly lower than the 2005 statewide QUEST average, and AlohaCare’s rate was as significantly higher than the same average. Hawaii QUEST 62.8% 59.9% 56.9% AlohaCare (Hybrid) 79.4% 74.5% 69.5% HMSA (Hybrid) 59.9% 55.0% 50.0% Kaiser (Hybrid) 52.9% 47.5% 42.2% 95% CI Low At the 95% confidence level, the poorly controlled diabetic rates for AlohaCare, HMSA & the statewide QUEST average were significantly higher than the 2005 national Medicaid median score of 47.5%. The rate for Kaiser was not significantly different from the 2005 national Medicaid median score, but significantly higher the 2005 national Medicaid 25th percentile score of 37.8%. • Discussion of Results Hawaii has a high rate of diabetes due to Polynesian populations (similar to Native Americans). This is also a cultural issue on medication and disease management. Again, a possible solution to the low scores with this measure is physician education on best practices. Retinal Examination Statewide - Longitudinal • 100% HEDIS Measures Retinal Examination (CDC) Statewide - Longitudinal The statewide QUEST 75% rate of diabetic members 31 years and 50% older who have had a retinal examination in the reporting year 25% varied from 40% to 53% from 2002 to 0% 2005. After an initial 2002 49.4% 95% CI Up drop in the rate from 47.0% Rate 47.0% in 2002 to 44.6% 95% CI Low 40.7% in 2003, the rate increased over two years to reach 53.1% in 2005. 2005 National Medicaid 75th %ile = 61.5% 2005 National Medicaid Median = 50.8% 2003 43.4% 40.7% 37.9% 2004 51.5% 48.6% 45.7% 2005 56.1% 53.1% 50.2% • At the 95% confidence level, the statewide QUEST retinal exam rates in 2002 and 2004 were not significantly different. The rate in 2003 was significantly lower than the other three years. QUEST Annual Report FYE June 30, 2006 Page 31 of 87 • At the 95% confidence level, the statewide QUEST retinal exam rate in 2003 was the only year that was significantly lower than the 2005 national Medicaid median score of 46.9%. The statewide rates in 2002 and 2004 were both not significantly different from the national median. The 2005 national Medicaid 75th percentile score of 54.9% was not significantly different from the statewide score in 2005. By Plan – in 2005 HEDIS Measures Retinal Examination (CDC) By Plan -- in 2005 100% • 75% 2005 National Medicaid 75th %ile = 61.5% 50% 2005 National Medicaid Median = 50.8% In 2005, Kaiser had the highest retinal exam rate at 64.8%, followed by AlohaCare at 49.9% and HMSA at 47.2%. Only the Kaiser rate was higher than the 2005 statewide QUEST rate of 53.1%. At the 95% confidence level, the retinal exam rates for AlohaCare, 0% Hawaii QUEST AlohaCare (Hybrid) HMSA (Hybrid) Kaiser (Hybrid) HMSA & the statewide 56.1% 54.8% 52.2% 70.2% 95% CI Up QUEST average are not 53.1% 49.9% 47.2% 64.8% Rate 50.2% 44.9% 42.3% 55.8% 95% CI Low significantly different. The rate for Kaiser is significantly higher than the 2005 statewide QUEST average as well as higher than the HMSA’s rate. 25% • • At the 95% confidence level, the retinal exam rates for AlohaCare and HMSA are not significantly different than the 2005 national Medicaid median score of 46.9%. The rate for Kaiser is significantly higher than the 2005 national Medicaid 75th percentile score of 54.9%. Discussion of Results As with the Hemoglobin tests, this is a relatively new measure and new way of thinking for physicians. As more physicians are educated that this is the best practice for diabetes, the measure should improve. Again, the most recent scores in 2005 showed promising improvement. QUEST Annual Report FYE June 30, 2006 Page 32 of 87 Follow-Up After Hospitalization for Mental Illness Statewide Longitudinal • 100% HEDIS Measures Follow-Up After Hospitalization for Mental Illness (FUH) - Within 30 Days Statewide - Longitudinal The statewide QUEST rate of 75% members 6 years of age and older as of the date of a mental 50% health discharge who were seen on an 25% ambulatory basis or were in intermediate treatment with a 0% 2002 2003 2004 2005 mental health 66.0% 81.2% 77.7% 77.3% 95% CI Up 61.9% 77.9% 74.3% 72.2% Rate provider within 30 57.7% 74.7% 70.8% 67.1% 95% CI Low days of hospital discharge ranged from 62% to 78 % between 2002 and 2005. After a rate of 61.9% in 2002, there was a jump to a rate of 77.9% in 2003 followed by a slow decrease to a 2005 rate of 72.2%. 2005 National Medicaid 75th %ile = 73.0% 2005 National Medicaid Median = 59.3% • • At the 95% confidence level, the follow-up rates in 2003, 2004 & 2005 were not significantly different. The rate in 2002 was significantly lower that the three years that followed. At the 95% confidence level, the statewide QUEST follow-up rate in 2002 was not significantly different than the 2005 national Medicaid median score of 58.4%. The QUEST rates in both 2003 and 2004 were significantly higher than the 2005 national Medicaid 75th percentile score of 70.6%. The 2005 QUEST rate was not significantly different from the 2005 national Medicaid 75th percentile score but significantly higher than the 2005 national Medicaid median score. HEDIS Measures Follow-Up After Hospitalization for Mental Illness (FUH) - Within 30 Days By Plan -- in 2005 100% By Plan – in 2005 • In 2005, Kaiser had the highest follow-up rate at 76.1%, followed by AlohaCare at 71.2% and HMSA at 70.5%. Both AlohaCare and HMSA had rates that were below the 2005 statewide QUEST average of 72.2%. 75% 2005 National Medicaid 75th %ile = 73.0% 2005 National Medicaid Median = 59.3% 50% 25% 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 77.3% 72.2% 67.1% AlohaCare (Admin) 77.7% 71.2% 64.8% HMSA (Admin) 85.1% 70.5% 55.8% Kaiser (Admin) 87.1% 76.1% 65.2% QUEST Annual Report FYE June 30, 2006 Page 33 of 87 • At the 95% confidence level, there are no significant differences in the follow-up rates for all three plans in 2005. Also, the three plans’ rates are not significantly different from the 2005 statewide QUEST average. The follow-up rates for all three plans, at the 95% confidence level, are not significantly different from the 2005 national Medicaid 75th percentile score of 70.6%. The rates for Kaiser and AlohaCare are also significantly higher than the 2005 national Medicaid median score of 58.4%. • Discussion of Results Med-QUEST has a mental health carve–out (SMI and SEBD) for parts of the statewide Medicaid mental health population. About half of the population in the carve-out is in QUEST. HMSA and APS/Magellan, who administer the mental health carve-out, have been honored for the performance of the carve-out and how well it serves its members. This may be a large factor in the strong performance of this measure. Mental Health Utilization This is an administrative measure that reports the entire population of data. Therefore, no confidence interval is needed or reported. The graphs used to illustrate this measure are scaled from 0% to 12% to reflect the reduced normal range of mental health utilization scores. Statewide - Longitudinal • The statewide QUEST percentage of members receiving any mental health services (inpatient, day/night care, and ambulatory) ranged from 8% to 10 % between 2002 and 2005. After a rate of 8.6% in 2002, there was a jump to a rate of 9.6% in 2003 followed by a slow decrease to a 2005 rate of 9.0%. HEDIS Measures Mental Health Utilization (MPT) - Any Mental Health Services Statewide - Longitudinal 12% 2005 National Medicaid 75th %ile = 10.6% 9.6% 8.6% 9.4% 9.0% 2005 National Medicaid Median = 6.1% 6% • 2002 2003 2004 2005 Mental health service rates reported from 2002 to 2005 were all above the national Medicaid median score of 6.4%, and were all below the 2005 national Medicaid 75th percentile score of 9.7%. 0% By Plan – in 2005 QUEST Annual Report FYE June 30, 2006 Page 34 of 87 • HEDIS Measures Mental Health Utilization (MPT) - Any Mental Health Services By Plan – in 2005 12% 2005 National Medicaid 75th %ile = 10.6% 10.9% 9.0% 7.0% 6% 2005 National Medicaid Median = 6.1% 6.3% In 2005, HMSA had the highest mental health service rate at 10.9%, followed by AlohaCare at 7.0% and Kaiser at 6.3%. Both AlohaCare and Kaiser had rates that were below the 2005 statewide QUEST average of 9.0%. The Kaiser rate was lower than the 2005 national Medicaid 0% median score of 6.4%. Hawaii QUEST AlohaCare (Admin) HMSA (Admin) Kaiser (Admin) AlohaCare’s rate was above the national Median but below the 2005 national Medicaid 75th percentile score of 9.7%. The HMSA rate was above the national 75th percentile score. Discussion of Results The results of this measure are also probably related to the carve-out that HMSA and APS/Magellan administers so well. Emergency Department Visits This is an administrative measure that reports the rate of occurrence of a measure within the entire population of data. Therefore, no confidence interval is needed or reported. The graphs used to illustrate this measure are scaled from 0 to 60 to reflect the reduced normal range of emergency department (ED) visit scores. Statewide - Longitudinal • The statewide QUEST rate of ED visits per 1,000 member months ranged from 34 to 38 between 2002 and 2005. After a rate of 34.9 in 2002, there was a jump to a rate of 36.4 in 2003 and to 37.7 in 2004, followed by a decrease to a 2005 rate of 36.7. The statewide QUEST QUEST Annual Report FYE June 30, 2006 Page 35 of 87 75 • HEDIS Measures Emergency Department Visits (AMB), per 1,000 Member Months Statewide - Longitudinal 2005 National Medicaid 75th %ile = 62.6 2005 National Medicaid Median = 56.9 50 34.9 25 36.4 37.7 36.7 0 • 2002 2003 2004 2005 rates of ED visits reported from 2002 to 2005 were all below the national Medicaid median score of 51.4. The 2005 national Medicaid 75th percentile score was 57.5. By Plan – in 2005 • In 2005, AlohaCare had the highest rate of ED visits at 43.7, followed by HMSA at 37.5 and Kaiser at 18.3. Both AlohaCare and HMSA had rates that were above the 2005 statewide QUEST average of 36.7. 75 HEDIS Measures Emergency Department Visits (AMB), per 1,000 Member Months By Plan – in 2005 2005 National Medicaid 75th %ile = 62.6 2005 National Medicaid Median = 56.9 50 43.7 36.7 25 37.5 18.3 • The all three plans’ rate 0 of ED visits was lower Hawaii QUEST AlohaCare (Admin) HMSA (Admin) Kaiser (Admin) than the 2005 national Medicaid median score of 51.4. The 2005 national Medicaid 75th percentile score was 57.5. Discussion of Results All QUEST plans have put in place programs to educate their members on appropriate use of the emergency room. Plans also have been looking at offering more after hours urgent care, especially on the neighbor islands. These factors may explain the low rates of emergency department visits when compared to national benchmarks. Percentage of Well Newborns to Total Newborns This percentage is based on the standard HEDIS score of Births and Average Lengths of Stay, Newborns (NEW). Although this percentage is not actually reported in the standard HEDIS form, the numerator and denominator for this measure come straight off the standard NEW HEDIS measure. Also, there is no national median or 75 percentile score for this percentage. QUEST Annual Report FYE June 30, 2006 Page 36 of 87 HEDIS Measures Percentage of Well Newborn Discharges to Total Newborn Discharges Statewide - Longitudinal 100% Statewide - Longitudinal • The statewide QUEST percentage of well newborns to total newborns varied from 92% to 93% in the years 2002 to 2005. The percentage in 2002 of 93.2% was the highest, and the 92.2% reported in 2003 was the lowest, over the four reported years. Percentages for years 2004 and 2005 fell in between these scores. 75% 50% 25% 0% 95% CI Up Rate 95% CI Low 2002 94.0% 93.2% 92.4% 2003 93.0% 92.2% 91.4% 2004 93.7% 93.0% 92.3% 2005 93.3% 92.6% 91.9% • At the 95% confidence level, and even with very narrow confidence intervals, the statewide QUEST percentage of well newborns in 2002 through 2005 were not significantly different. By Plan – in 2005 • In 2005, HMSA had the highest percentage of well newborns at 92.9%, followed by Kaiser at 92.8% and at AlohaCare 92.2%. Only the AlohaCare percentage was lower than the 2005 statewide QUEST rate of 92.6%. At the 95% confidence level, the percentage of well newborns for AlohaCare, HMSA, Kaiser & the statewide QUEST average are not significantly different. HEDIS Measures Percentage of Well Newborn Discharges to Total Newborn Discharges By Plan -- in 2005 100% 75% 50% • 25% 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 93.3% 92.6% 91.9% AlohaCare (Admin) 93.4% 92.2% 90.9% HMSA (Admin) 93.8% 92.9% 91.9% Kaiser (Admin) 94.6% 92.8% 90.9% QUEST Annual Report FYE June 30, 2006 Page 37 of 87 EPSDT Measures The EPSDT measures are included in this report to measure the degree of comprehensive and preventive child healthcare for individuals under the age of 21. The EPSDT measures are based on self-reported EPSDT reports received from the three individual plans that are contracted with Med-QUEST – AlohaCare, HMSA, and Kaiser. All three plans create custom queries to calculate their scores, and all of the EPSDT measures are reported in each year. The format of the various EPSDT measures reported by the plans is no different from the national standard EPSDT format, but there are differences in the periodicity of visits by state. Audits on how the plans calculate and report their EPSDT scores are not currently conducted; future plan audits on the EPSDT calculation and reporting are being considered. EPSDT reports from the plans are based on a fiscal year period, a twelve month period beginning in October 1 and ending on September 30 of the report year, and are due to Med-QUEST on the last day of February in the year following the report year. The measures presented below are a small sample of the complete set of EPSDT measures that are reported each year. Two types of analysis are done for each EPSDT measure. First, a longitudinal analysis is completed on the statewide QUEST rates to determine if there are broad trends in the measure over a period of several years. Scores are reported for each year from 2002 to 2005. Second, a comparison of the three plans’ scores and the statewide QUEST score in 2005 is done to observe any differences between health plans in the management of their population. For both analyses, comparisons are made to the CMS National Goal score of 80% to bring perspective to where we score on a national level. Finally, a 95% confidence interval is calculated for each score to determine the significance of any differences in scores. For a discussion on the specifics of each EPSDT measure, please see Appendix A. Please see Appendix B for a detailed discussion on how the statewide rates, and 95% confidence intervals, are calculated. For all of the EPSDT measures, higher numeric scores are considered positive and lower numeric scores are considered negative. QUEST Annual Report FYE June 30, 2006 Page 38 of 87 Screening Ratio Statewide - Longitudinal 100% EPSDT Measures Screening Ratio Statewide - Longitudinal • The statewide QUEST EPSDT ratio of actual screenings received over expected screenings ranged from 92% to 97 % between 2002 and 2005. Over four years, the ratios show a declining trend. The highest ratio was recorded in 2002 at 96.6%, and the lowest ratio of 91.9% was recorded in 2005. CMS National Goal = 80% 75% 50% 25% 0% 95% CI Up Rate 95% CI Low 2002 96.8% 96.6% 96.5% 2003 93.9% 93.8% 93.6% 2004 94.7% 94.5% 94.3% 2005 92.1% 91.9% 91.7% • • At the 95% confidence level, and largely because of razor-thin confidence intervals, the screening ratios for each of the reported years are significantly different from each other. At the 95% confidence level, the screening ratios for each of the reported years are significantly higher than CMS National Goal of 80.0%. By Plan – in 2005 EPSDT Measures Screening Ratio By Plan -- in 2005 100% • CMS National Goal = 80% 75% 50% In 2005, Kaiser had the highest screening ratio at 100.0%, followed by HMSA at 93.0% and AlohaCare at 87.7%. AlohaCare had a ratio that was below the 2005 statewide QUEST average of 91.9%. At the 95% confidence level, there are significant differences in the screening ratios for all three plans in 2005. Also, the three plans’ ratios are all significantly different QUEST Annual Report FYE June 30, 2006 Page 39 of 87 25% • 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 92.1% 91.9% 91.7% AlohaCare 88.1% 87.7% 87.3% HMSA 93.2% 93.0% 92.8% Kaiser 100.0% 100.0% 100.0% from the 2005 statewide QUEST average. • At the 95% confidence level, the screening ratios for all three plans in 2005 are significantly higher than CMS National Goal of 80.0%. Discussion of Results A possible reason for the low AlohaCare score could be because they quit using an EPSDT form and went to administrative reporting. Moving away from an EPSDT form may increase the difficulty in following the guidelines, which in turn may lower their score. Participant Ratio Statewide - Longitudinal • The statewide QUEST EPSDT ratio of actual participants receiving screenings over expected participants receiving screenings ranged from 68% to 71% between 2002 and 2005. There was little variance over the four years rates, with 2004 posting the highest rate (70.5%) and 2003 recording the lowest rate (68.3%). 100% EPSDT Measures Participant Ratio Statewide - Longitudinal CMS National Goal = 80% 75% 50% 25% 0% 95% CI Up Rate 95% CI Low 2002 70.7% 70.4% 70.0% 2003 68.6% 68.3% 68.0% 2004 71.0% 70.5% 70.1% 2005 68.8% 68.5% 68.1% • At the 95% confidence level, the participant ratios in 2002 and 2004 were not significantly different. The ratios in 2003 and 2005 were also not significantly different. But there was a significant difference between the 2002/2004 ratios and the 2003/2005 ratios. At the 95% confidence level, the 2002 through 2005 statewide QUEST participant ratios are significantly lower than CMS National Goal of 80.0%. • By Plan – in 2005 • In 2005, Kaiser had the highest participant ratio at 76.1%, followed by HMSA at 69.7% and AlohaCare at 62.7%. Both Kaiser and HMSA had rates that were above the 2005 statewide QUEST average of 68.5%. QUEST Annual Report FYE June 30, 2006 Page 40 of 87 • EPSDT Measures Participant Ratio By Plan -- in 2005 100% CMS National Goal = 80% 75% 50% At the 95% confidence level, there are significant differences in the participant ratios for all three plans in 2005. Also, the three plans’ rates are all significantly different from the 2005 statewide QUEST average. 25% At the 95% confidence level, the 0% Hawaii QUEST AlohaCare HMSA Kaiser AlohaCare and 68.8% 63.3% 70.1% 82.5% 95% CI Up 68.5% 62.7% 69.7% 81.7% Rate HMSA participant 68.1% 62.1% 69.3% 81.0% 95% CI Low ratios are significantly lower than CMS National Goal of 80.0%. The Kaiser ratio is significantly higher than CMS National Goal. • QUEST Annual Report FYE June 30, 2006 Page 41 of 87 CAHPS Measures The Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures are included in this report to measure the degree of recipient satisfaction with Hawaii Med-QUEST. Med-QUEST is required by the State of Hawaii to conduct an annual HEDIS CAPHS member survey. The CAHPS measures are based on annual surveys conducted by the EQRO entity under contract with, and under the direction of, Med-QUEST. The method of these surveys and the definitions of the various CAHPS measures strictly adhere to required national standard CAHPS specifications. The surveys were sent to a random sample of recipients. The overall survey response rate was 43% in 2005 and 39% in 2006. The “question summary rates” are reported for the different measures used in this report. The Adult Medicaid surveys was done in 2004 & 2006, and are the data used in this report. The Child Medicaid survey was done in 2005, but since the results often differ dramatically from the Adult survey the Child data was not reported here. Going forward and as required by the State of Hawaii, these surveys will continue to be done annually, with the Child and Adult surveys being done in alternating years. The measures presented below are but a small sample of the entire slate of questions that were presented on the survey. Two types of analysis are done for each CAHPS measure. First, a longitudinal analysis is completed on the statewide QUEST rates to determine if there are broad trends in the measure over a period of several years. Scores are reported for 2004 to 2006. Second, a comparison of the three plans’ scores and the statewide QUEST score in 2006 is done to observe any differences between health plans in the management of and communication with their population. For both analyses, a comparison is made to the 2005 National Medicaid Mean score to bring perspective to where we score on a national level; at the time of the study the 2006 National Medicaid Mean score was not available. The National Medicaid Mean score will be the target score for all of the CAHPS measures. Finally, a 95% confidence interval is calculated for each score to determine the significance of any differences in scores. Please see Appendix B for a detailed discussion on how the 95% confidence intervals are calculated. For a discussion on the specifics of each CAHPS measure, please see Appendix A. Please see Appendix B for a detailed discussion on how the statewide rates, and 95% confidence intervals, are calculated. For the CAHPS measures, higher numeric scores are considered positive and lower numeric scores are considered negative. QUEST Annual Report FYE June 30, 2006 Page 42 of 87 Rating of Health Plan Statewide – Longitudinal • The statewide QUEST overall health plan rating was 58.5% in 2004 and 62.2% in 2006. At the 95% confidence level, the statewide health plan ratings in 2004 and 2006 were not significantly different from each other. Rate 100% CAHPS Measures Rating of Health Plan Statewide - Longitudinal 75% 2005 NCQA National Medicaid Mean = 52.6% 50% • 25% 0% 95% CI Up 2004 60.9% 58.5% 56.1% 2006 64.7% 62.2% 59.8% • At the 95% confidence level, the statewide health plan ratings in 2004 and 2006 were both significantly higher than the 2005 national Medicaid mean score of 52.6%. 95% CI Low By Plan – in 2006 CAHPS Measures Rating of Health Plan By Plan - in 2006 100% • 75% 2005 NCQA National Medicaid Mean = 52.6% 50% In 2006, Kaiser had the highest overall health plan rating at 66.8%, followed by HMSA at 59.8% and AlohaCare at 58.9%. Only the Kaiser rate was higher than the 2005 statewide QUEST rate of 62.2%. At the 95% confidence level, the health plan ratings for AlohaCare, HMSA, Kaiser & the statewide QUEST average are not significantly different. 25% • 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 64.7% 62.2% 59.8% AlohaCare 63.8% 58.9% 54.1% HMSA 63.9% 59.8% 55.7% Kaiser 70.6% 66.8% 62.9% • At the 95% confidence level, the health plan ratings for AlohaCare, HMSA & Kaiser are significantly higher than the 2005 national Medicaid mean score of 52.6%. QUEST Annual Report FYE June 30, 2006 Page 43 of 87 Discussion of Results Some of the reasons given in the executive summary for Kaiser’s higher scores could apply here. Rating of All Healthcare Statewide - Longitudinal • The statewide QUEST overall health care rating was 56.3% in 2004 and 60.6% in 2006. At the 95% confidence level, the statewide overall health care ratings in 2004 and 2006 were not significantly different from each other. 100% CAHPS Measures Rating of All Health Care Statewide - Longitudinal 75% 50% 2005 NCQA National Medicaid Mean = 54.1% • 25% 0% 95% CI Up Rate 95% CI Low 2004 59.2% 56.3% 53.5% 2006 63.5% 60.6% 57.6% • At the 95% confidence level, the statewide overall health care rating in 2004 was not significantly different than the 2005 national Medicaid mean score of 54.1%. However, the 2006 rating was significantly higher than the 2005 national Medicaid mean score. By Plan – in 2006 CAHPS Measures Rating of All Health Care By Plan - in 2006 100% • 75% 50% 2005 NCQA National Medicaid Mean = 54.1% In 2006, Kaiser had the highest overall health care rating at 66.3%, followed by HMSA at 58.5% and AlohaCare at 54.9%. Only the Kaiser rate was higher than the 2005 statewide QUEST rate of 60.6%. At the 95% confidence level, the health care ratings for AlohaCare, HMSA, Kaiser & the statewide QUEST average are not significantly different. 25% • 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 63.5% 60.6% 57.6% AlohaCare 60.9% 54.9% 48.9% HMSA 63.3% 58.5% 53.7% Kaiser 71.0% 66.3% 61.7% • The 2006 health care ratings for AlohaCare & HMSA, at the 95% confidence level, are not significantly different than the 2005 national Medicaid mean score of 54.1%, at the 95% QUEST Annual Report FYE June 30, 2006 Page 44 of 87 confidence level. Kaiser’s rating, though, was significantly higher than the national Medicaid mean. Discussion of Results Again, some of the reasons given in the executive summary for Kaiser’s higher scores could apply here. Getting Needed Care 100% CAHPS Measures Getting Needed Care Statewide - Longitudinal Statewide - Longitudinal • The statewide QUEST rating for getting needed care was 71.2% in 2004 and 73.5% in 2006. At the 95% confidence level, the statewide ratings for getting needed care in 2004 and 2006 were not significantly different from each other. 75% 2005 NCQA National Medicaid Mean = 74.6% 50% • 25% 0% 95% CI Up Rate 95% CI Low 2004 74.0% 71.2% 70.2% 2006 75.5% 73.5% 71.5% • At the 95% confidence level, the statewide rating for getting needed care in 2006 was not significantly different than the 2005 national Medicaid mean score of 74.6%. Unfortunately, the 2004 rating was significantly lower than the 2005 national Medicaid mean score. By Plan – in 2006 • Kaiser had the highest 2006 rating for getting needed care at 66.8%, followed by HMSA at 70.9% and AlohaCare at 70.3%. Only the Kaiser rate was higher than the 2005 statewide QUEST rate of 73.5%. At the 95% confidence level, the Kaiser rating for CAHPS Measures Getting Needed Care By Plan - in 2006 100% 75% 2005 NCQA National Medicaid Mean = 74.6% 50% 25% • 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 75.5% 73.5% 71.5% AlohaCare 74.4% 70.3% 66.2% HMSA 74.3% 70.9% 67.5% Kaiser 81.0% 77.9% 74.9% QUEST Annual Report FYE June 30, 2006 Page 45 of 87 getting needed care was significantly higher than AlohaCare & HMSA ratings. All three plans’ ratings were not significantly different from the statewide QUEST average. • At the 95% confidence level, the rating for getting needed care for AlohaCare & HMSA are significantly lower than the 2005 national Medicaid mean score of 74.6%. Kaiser’s rating was not significantly different from the 2005 national Medicaid mean. CAHPS Measures Getting Care Quickly Statewide - Longitudinal 100% Getting Care Quickly Statewide - Longitudinal 75% • 50% 2005 NCQA National Medicaid Mean = 44.9% The statewide QUEST rating for getting care quickly was 44.2% in 2004 and 45.4% in 2006. At the 95% confidence level, the statewide ratings for getting care quickly in 2004 and 2006 were not significantly different from each other. • 25% 0% 95% CI Up Rate 95% CI Low 2004 46.3% 44.2% 42.1% 2006 47.6% 45.4% 43.2% • At the 95% confidence level, the statewide ratings for getting care quickly in 2004 and 2006 was not significantly different than the 2005 national Medicaid mean score of 44.9%. By Plan – in 2006 • In 2006, Kaiser had the highest overall rating for getting care quickly at 66.3%, followed by HMSA at 58.5% and AlohaCare at 54.9%. Only the Kaiser rate was higher than the 2005 statewide QUEST rate of 60.6%. At the 95% confidence level, the ratings for getting care quickly for AlohaCare, HMSA, Kaiser & the statewide QUEST average are not CAHPS Measures Getting Care Quickly By Plan - in 2006 100% 75% 50% 2005 NCQA National Medicaid Mean = 44.9% 25% • 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 47.6% 45.4% 43.2% AlohaCare 48.2% 43.7% 39.1% HMSA 46.7% 43.1% 39.4% Kaiser 52.2% 48.7% 45.1% QUEST Annual Report FYE June 30, 2006 Page 46 of 87 significantly different. • The 2006 ratings for getting care quickly for AlohaCare & HMSA, at the 95% confidence level, are not significantly different than the 2005 national Medicaid mean score of 54.1%, at the 95% confidence level. Kaiser’s rating, though, was significantly higher than the national Medicaid mean. QUEST Annual Report FYE June 30, 2006 Page 47 of 87 Physicians’ Assessment Measures The Physician Assessment measures are included in this report to measure the degree of provider satisfaction with the Hawaii Med-QUEST program as well as the individual plans that contract with Med-QUEST to provide services to the QUEST recipients. The survey includes ONLY physicians and related professionals. The Physician Assessment measures are based on surveys conducted by the EQRO entity under contract with, and under the direction of, Med-QUEST. The scores are based on clean responses from a survey of randomly selected PCPs and high-volume specialties, and are expressed as percentage scores and related variances. The overall survey response rate was 30% in 2002 and 26% in 2006. The measures for the 2002 and 2006 years were based on surveys carried out in the fall of 2002 and the spring of 2006, respectively. Going forward, these surveys will not be done every year. The measures presented below are but a small sample of the entire slate of questions that were presented on the survey. Two types of analysis are done for each Physician Assessment measure. First, a longitudinal analysis is completed on the statewide QUEST rates to determine if there are broad trends in the measure over a period of several years. Scores are reported for 2002 and 2006. Second, a comparison of the three plans’ scores and the statewide QUEST score in 2006 is done to observe any differences between health plans in the management of and communication with their physicians. For both analyses, unfortunately, there are no national standards that can bring perspective to where we score on a national level. Finally, for both analyses a 95% confidence interval is calculated for each score to determine the significance of any differences in scores. For a discussion on the specifics of each Physician Assessment measure, please see Appendix A. Please see Appendix B for a detailed discussion on how the statewide rates, and 95% confidence intervals, are calculated. For the Physician Assessment measures, higher numeric scores are considered positive and lower numeric scores are considered negative. QUEST Annual Report FYE June 30, 2006 Page 48 of 87 Personal Attitude Toward Hawaii QUEST Statewide - Longitudinal • The statewide QUEST rate of physicians that have a positive personal attitude toward Hawaii QUEST was 42.7% in 2002 and 40.8% in 2006. At the 95% confidence level, the statewide rate of positive attitudes in 2002 and 2006 were not significantly different. Physicians' Assessment Measures Personal Attitude Toward Hawaii QUEST = Positive Statewide - Longitudinal 100% 75% 50% • 25% 0% 95% CI Up Rate 95% CI Low 2002 48.6% 42.7% 36.8% 2006 47.3% 40.8% 34.4% By Plan – in 2006 • Physicians' Assessment Measures Personal Attitude Toward Hawaii QUEST = Positive By Plan -- in 2006 100% 75% 50% In 2006, Kaiser’s physicians had the highest rate of positive attitudes at 48.8%, followed by AlohaCare’s physicians at 39.3% and HMSA’s physicians at 35.5%. Only the Kaiser rate was higher than the 2006 statewide QUEST rate of 40.8%. At the 95% confidence level, the physician positive attitude rate for AlohaCare, HMSA, Kaiser & the statewide QUEST average are not significantly different. 25% • 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 47.3% 40.8% 34.4% AlohaCare 47.5% 39.3% 31.0% HMSA 42.8% 35.5% 28.3% Kaiser 59.7% 48.8% 37.8% QUEST Annual Report FYE June 30, 2006 Page 49 of 87 Satisfaction with the Rate of Reimbursement Physicians' Assessment Measures Satisfaction with the Rate of Rembursement from Hawaii QUEST = Satisfied Statewide - Longitudinal 100% Statewide - Longitudinal • The statewide QUEST rate of physicians that are satisfied with the rate of reimbursement from Hawaii QUEST was 26.1% in 2002 and 27.7% in 2006. At the 95% confidence level, the statewide rate of physician reimbursement satisfaction in 2002 and 2006 were not significantly different. 75% 50% 25% • 0% 95% CI Up Rate 95% CI Low 2002 30.5% 26.1% 21.6% 2006 32.2% 27.7% 23.2% By Plan – in 2006 • In 2006, Kaiser’s physicians had the highest rate of reimbursement satisfaction at 32.8%, followed by HMSA’s physicians at 21.3% and AlohaCare’s physicians at 20.9%. Only the Kaiser rate was higher than the 2006 statewide QUEST rate of 27.7%. Physicians' Assessment Measures Satisfaction with the Rate of Rembursement from Hawaii QUEST = Satisfied By Plan -- in 2006 100% 75% 50% 25% • 0% At the 95% confidence 95% CI Up 32.2% 25.5% 25.6% 40.9% 27.7% 20.9% 21.3% 32.8% Rate level, the rate of 23.2% 16.3% 16.9% 24.7% 95% CI Low physician reimbursement satisfaction for AlohaCare, HMSA, Kaiser & the statewide QUEST average are not significantly different. Hawaii QUEST AlohaCare HMSA Kaiser QUEST Annual Report FYE June 30, 2006 Page 50 of 87 Necessary Knowledge and Expertise of Health Plan Personnel Statewide - Longitudinal Physicians' Assessment Measures Professional & Knowledgeable Health Plan Personnel = Yes, Definitely Statewide - Longitudinal 100% • 75% 50% The statewide QUEST rate of physicians who feel health plan personnel the have the necessary professional knowledge and expertise was 28.0% in 2002 and 33.5% in 2006. At the 95% confidence level, the statewide rates of physicians rating their health plan personnel as knowledgeable in 2002 and 2006 were not 25% • 0% 95% CI Up Rate 95% CI Low 2002 32.6% 28.0% 23.3% 2006 38.5% 33.5% 28.6% significantly different. By Plan – in 2006 • In 2006, 42.5% of Kaiser’s physicians rated their health plan personnel as knowledgeable, followed by 30.4% of Physicians' Assessment Measures AlohaCare’s physicians Professional & Knowledgeable Health Plan Personnel = Yes, Definitely and 28.7% of HMSA’s By Plan -- in 2006 100% physicians. Only the Kaiser rate was higher than the 2006 statewide 75% QUEST rate of 33.5%. At the 95% confidence level, the rate of physicians rating their health plan personnel as knowledgeable for AlohaCare, HMSA, Kaiser & the statewide QUEST average are not significantly different. 50% • 25% 0% 95% CI Up Rate 95% CI Up Hawaii QUEST 38.5% 33.5% 28.6% AlohaCare 35.9% 30.4% 24.9% HMSA 33.8% 28.7% 23.6% Kaiser 51.3% 42.5% 33.7% QUEST Annual Report FYE June 30, 2006 Page 51 of 87 Impact of the Health Plan’s UM - Prior Authorizations Statewide - Longitudinal • The statewide QUEST rate of physicians rating their health plan’s prior authorizations as having a positive impact on quality of care was 34.1% in 2002 and 27.2% in 2006. At the 95% confidence level, the statewide rate of positive prior authorization impact in 2002 and 2006 were not significantly different. Rate 95% CI Low Physicians' Assessment Measures Impact of Health Plan’s UM (Prior Authorizations) on Quality Care = Positive Statewide - Longitudinal 100% 75% • 50% 25% 0% 95% CI Up 2002 38.7% 34.1% 29.6% 2006 32.0% 27.2% 22.4% By Plan – in 2006 • In 2006, 34.8% of Kaiser’s physicians rated as positive the impact or prior authorizations, followed by 21.3% of HMSA’s physicians and 20.9% of Physicians' Assessment Measures Impact of Health Plan’s UM (Prior Authorizations) on Quality Care = Positive AlohaCare’s By Plan -- in 2006 100% physicians. Only the Kaiser rate was higher than the 2006 statewide 75% QUEST rate of 27.2%. • 50% 25% 0% 95% CI Up Rate 95% CI Up Hawaii QUEST 32.0% 27.2% 22.4% AlohaCare 25.6% 20.9% 16.3% HMSA 25.7% 21.3% 16.9% Kaiser 43.0% 34.8% 26.7% At the 95% confidence level, the rate of positive prior authorization impact for AlohaCare, HMSA, Kaiser & the statewide QUEST average are not significantly different. QUEST Annual Report FYE June 30, 2006 Page 52 of 87 Med-QUEST Internal Measures The Med-QUEST internal measures are included in this report to measure the financial aspects of the Hawaii Med-QUEST program. How is money being spent, and on how many and what type of recipients, is the focus of these measures. Enrollment and demographic data that is maintained internally at Med-QUEST will be used. Eligibility, enrollment and demographic data are both input and audited internally at MedQUEST. Eligibility workers meet with the recipients and collect demographic and financial data, which they then input into the eligibility system (HAWI). This data is externally validated with records from other State of Hawaii departments. Customer service employees then work with the recipients and the HAWI eligibility data to determine and set-up recipient QUEST enrollment in the enrollment system (HPMMIS). There is a separate team of employees that is dedicated to auditing and validating suspect enrollment or demographic data sitting in HAWI and/or HPMMIS. Records with suspected errors are researched and validated. As an example, a recent twelve-month sample of eligibility files had a record error rate of 1.69%. The member month measure used is a sum of member months, and will consist of entire populations based on reports run at the end of each month. The capitation payment file is a detail of all capitation payments made to each plan, and is the source of member month data. This file has enrollments for retro payments reflected in the month that payment was made. Initial months are paid pro-rated daily amounts based on the start date. Termination always occurs at the end of the month, except for retro termination for disability. Actual Budget Neutrality figures for the Med-QUEST program will be collected from the same files that produce enrollment information. The total amount paid to the plans each month for medical services will be separated between demonstration and non-demonstration totals. The demonstration enrollment will be used to compute the budget medical cost based on an inflationadjusted per member per month figure from CMS. Expenditures for the Uncompensated Care Costs and the QUEST-ACE program are also reported measures. For a discussion on the specifics of each Med-QUEST internal measure, please see Appendix A. QUEST Annual Report FYE June 30, 2006 Page 53 of 87 Budget Neutrality Savings Budget neutrality savings is a reflection of the fiscal performance of the waiver. Specifically, it compares the expenditures with the waiver in place – inclusive of all the demonstration group costs -- against the hypothetical expenditures if the waiver were not in place at all. If the “With Waiver” expenditures are less than the “Without Waiver” expenditures, then Budget Neutrality Savings will result. The following table details the budget neutrality calculation for the Demonstration Year 12 (DY12) of the QUEST waiver. The overall savings were a negative $133,812,141, which will be adjusted in March 2007 by moving $146,171,481 of expenditures from DY12 to DY11. With these adjustments the budget neutrality savings in demonstration year 12 through December 31, 2006 is $12,359,340. These savings do not include any carryover savings from the previous demonstration and are strictly from the current approved waiver. DY12 WITHOUT WAIVER: Ceiling Children Adults Ceiling Without DSH DSH Total Ceiling WITH WAIVER: Pre-Waiver Groups Current 1902 R 2 Others Children Adults Subtotal Pre-Waiver Demonstration Groups Adults-Expansion Supplemental-Governmental Supplemental-Private Subtotal Demonstration Total Expenditures Per CMS-64 Waiver Premium Share (Not reported on 64 Waiver) Total Expenditures 246,276,436 155,763,970 402,040,407 80,364,047 482,404,454 154,515,702 41,256,748 178,246,556 110,177,243 484,196,249 127,483,270 5,996,173 133,479,443 617,675,692 (1,459,097) 616,216,595 DY Budget Neutrality Savings (1) (1) Adjustment of $146,171,481 will be made on the 3/07 64 to move expenditures from DY12 to DY11 (133,812,141) QUEST Annual Report FYE June 30, 2006 Page 54 of 87 Quest Member Months The most basic measure of how many members you are impacting through your waiver program is member months. The capitation payment file, which is a detail of all capitation payments made to each plan, is used to calculate these figures. Medicaid Eligibility Groups FPL Level and/or other qualifying Criteria Qtr. End Qtr. End Qtr. End Qtr. End 9/30/05 12/31/05 3/31/06 6/30/06 Mandatory State Plan Groups Pregnant women and infants under age 1 Children 1-5 Children 6-18 Up to 185 % FPL Up to 133% FPL Up to 100% FPL 36,381 77,554 124,058 70,074 36,215 38,586 39,459 75,880 78,949 79,910 123,125 125,555 126,874 66,903 67,158 66,846 Adult AFDC related family members Up to 100% FPL covered by Section 1931 Transitional Medicaid (Section 1925) Coverage is for two six-month or one four-month periods due to increased earnings or child support, respectively, make an individual ineligible for continued coverage under Section 1931. In the second six month period, family income may not exceed 185% FPL 8,164 9,095 7,635 6,064 Optional State Plan Groups Foster Children (19-20 years old) receiving Up to 100% FPL foster care maintenance payments or under an adoption assistance agreement Children through the S-CHIP Medicaid 101 - 200% FPL and for whom the State is claiming Title XXI expansion funding Medically Needy Adults and Children Up to 300% FPL, if individuals otherwise eligible under State Plan groups described above spend down to Medicaid income limits. (Benefits are FFS) Children who are not eligible for SCHIP 201- 300% FPL - who could be eligible through 1902 (r) (2) and for whom the State is claiming Title XIX funding. Eligibility criteria requiring prior enrollment in QUEST or Medicaid fee for service is eliminated in QUEST Expanded. Section 1925 Transitional Medicaid Adults Coverage is for two six-month periods due to increased earnings, or for four months due to receipt of child support, either of which would otherwise make an individual ineligible for continued coverage under Section 1931. In the second six month period, family income may not exceed 185% FPL 106 45,868 0 100 46,694 0 116 47,066 0 132 48,046 0 0 0 0 0 4,085 5,413 4,569 3,992 Demonstration Eligible Groups Adult AFDC related family members who Up to 100% FPL (using TANF methodology) are TANF cash recipients who are otherwise ineligible for Medicaid. Childless adults who are General Up to 100% FPL (using GA methodology) Assistance (GA) cash recipients but are otherwise ineligible for Medicaid. Childless adults who meet Medicaid asset Up to 100% FPL (subject to an enrollment cap presently set at limits. 125,000) Quest Net Adults Up to 100% FPL Eligible to enroll in QUEST but elected QUEST Net Quest Net Adults Up to 300% FPL but exceed QUEST asset or income 1,314 9,642 67,868 1,521 2,313 380 9,383 66,444 1,122 2,570 192 9,571 68,604 1,100 2,674 39 9,616 67,659 959 2,812 QUEST-Net-Children Demonstration Eligible Groups Children who could be eligible for SCHIP 201-300% FPL for whom the State is claiming Title XXI funding. Eligibility criteria requiring prior enrollment in QUEST or Medicaid fee for service is eliminated in QUEST Expanded. 2,183 451,131 2,036 2,299 2,386 Total Member Months 445,360 454,074 454,794 QUEST Annual Report FYE June 30, 2006 Page 55 of 87 Expenditures for QUEST Uncompensated Care Costs Under the current waiver the Uncompensated Care Cost (UCC) allows Hawaii to claim up to $15 million in federal funding per demonstration year. These expenditures consist of subsidies made by the state legislature to the Hawaii Hospital System Corporation (HHSC) for the public facilities and UCC payments made to private hospitals. These payments made to the private facilities are a small portion of the total UCC made by these facilities. Total UCC reported by the private facilities exceed $100 million per year. The UCC expenditures made for the most recent period (State Fiscal Year Ended 6/30/2007) is as follows: Facility Castle Medical Center Hawaii Pacific Health - Kapiolani Hawaii Pacific Health - Straub Hawaii Pacific Health - Wilcox Memorial Hospital Kahuku Hospital Kaiser Foundation Hospital Kuakini Medical Center Molokai General Hospital North Hawaii Community Hospital Rehabilitation Hospital of the Pacific St. Francis Medical Center The Queen's Medical Center Wahiawa General Hospital Kahi Mohala Total Amount 1,040,000 2,965,500 1,494,000 400,500 159,500 639,000 779,000 85,500 210,500 213,000 3,621,500 5,112,000 646,000 192,000 17,558,000 Expenditures for QUEST-ACE Program The QUEST Adult Coverage Expansion (QUEST-ACE) is a new program that will provide medical assistance to a childless adult who is unable to enroll in the QUEST program due to the limitations of the statewide enrollment cap of QUEST as indicated in §17-1727-26. The enrollment cap for this program is currently set by CMS at 12,000. The QUEST-ACE benefit package will encompass the same limited package of benefits currently provided under the QUEST-Net program, which includes limited medical benefits and preventative dental benefits. Self-employed persons may have a premium share to buy into this program. A childless adult under the QUEST-ACE program is defined as a person who is: • • • Between nineteen years of age through age 64; Is not a child under age twenty-one who is in foster care placement or is covered by a subsidized adoption agreement; and Does not have a dependent child in the home. QUEST Annual Report FYE June 30, 2006 Page 56 of 87 QUEST-ACE will be offering coverage for recipients beginning on March 1, 2007. We are currently in the implementation planning and execution phase for QUEST-ACE. Part of the planning involves building in markers on enrollment that will enable data extraction focused solely on the QUEST-ACE recipients. To date, expenditures that have been purchased but not paid for include television advertising spots on various local stations, radio advertising spots on various local stations, posters on city buses, printing costs for color flyers informing potential member of the program specifics, and other printing and administrative costs. The budget for the roll-out of QUEST-ACE is $100,000. Beginning with the next QUEST Annual Report, data will be reported on actual expenditures for this group of recipients. QUEST Annual Report FYE June 30, 2006 Page 57 of 87 Appendix A – Description of Measures U.S. Census Measures Uninsured Percentage Measure Description This measure measures the percentage of the population that is uninsured. Performance Standards 2006 Hawaii Target of 8.2%. Enrollment Period N/A Methodology Denominator The entire population. According to the U.S. Census Bureau: The universe for the Current Population Survey (CPS) includes the civilian noninstitutional population of the United States and members of the Armed Forces in the United States living off post or with their families on post, but excludes all other members of the Armed Forces. Numerator All uninsured persons in the population. A person is uninsured if he/she is NOT covered by health insurance at any time in a twelve-month period. According to the U.S. Census Bureau: A person was considered covered by health insurance at some time during the year if he or she was covered by at least one of the following types of coverage: Employer/union, privately purchased (not related to employment), Medicare, Medicaid, military health care (military, CHAMPUS, CHAMPVA, VA, Indian Health Services), someone outside the household, or other. Data Source The U.S. Census Bureau’s annual Current Population Survey (CPS), Annual Social and Economic Supplement, 2001 -2006. Reporting Formats The measure is reported longitudinally (broken out by year for the State of Hawaii), by state (State of Hawaii, selected comparison states, and the total U.S.) for the latest year, and by state over several years. National Procedure Standard CPS survey techniques and methods. Reporting Period Years 2000 through 2005. QUEST Annual Report FYE June 30, 2006 Page 58 of 87 HI-Common Subsystem Requirements N/A Uninsured Children (Age 0-18) Percentage Measure Description This measure measures the percentage of children in the uninsured population Performance Standards 2006 Hawaii Target of 15.5%. Enrollment Period N/A Methodology Denominator All uninsured persons in the population. A person is uninsured if he/she is NOT covered by health insurance at any time in a twelve-month period. According to the U.S. Census Bureau: A person was considered covered by health insurance at some time during the year if he or she was covered by at least one of the following types of coverage: Employer/union, privately purchased (not related to employment), Medicare, Medicaid, military health care (military, CHAMPUS, CHAMPVA, VA, Indian Health Services), someone outside the household, or other. Numerator All uninsured children in the population. According to the U.S. Census Bureau: The term "children" …….are all persons under 18 years, excluding people who maintain households, families, or subfamilies as a reference person or spouse. The age that determines if a person is a child or an adult is different in Hawaii, where children are defined as all people under 19 years. This is the definition of children used in this statistic, regardless of the population being measured. Data Source The U.S. Census Bureau’s annual Current Population Survey (CPS), Annual Social and Economic Supplement, 2001 -2006. Reporting Formats The measure is reported longitudinally (broken out by year for the State of Hawaii), by state (State of Hawaii, selected comparison states, and the total U.S.) for the latest year, and by state over several years. National Procedure Standard CPS survey techniques and methods. Reporting Period Years 2002 through 2005. QUEST Annual Report FYE June 30, 2006 Page 59 of 87 HI-Common Subsystem Requirements N/A Percent of Children (Age 0-18) Between 200% and 300% FPL who are Uninsured Measure Description This measure measures the percentage of children at the 200% - 300% Federal Poverty Level (FPL) that were uninsured. Performance Standards 2006 Hawaii Target of 5.8%. Enrollment Period N/A Methodology Denominator All children in the population at the 200% - 300% FPL. According to the U.S. Census Bureau: The term "children" …….are all persons under 18 years, excluding people who maintain households, families, or subfamilies as a reference person or spouse. The age that determines if a person is a child or an adult is different in Hawaii, where children are defined as all people under 19 years. This is the definition of children used in this statistic, regardless of the population being measured. The Census Bureau uses a set of money income thresholds that vary by family size and composition to detect whom is poor. If a family’s total income is less than that family’s threshold, then that family, and every individual in it, is considered poor. This family and every individual in it would be at the 100% FPL level. If a family’s income is three times the money income threshold, then every individual in that family would be at the 300% FPL level. Numerator All uninsured children in the population at the 200% - 300% FPL. A person is uninsured if he/she is NOT covered by health insurance at any time in a twelve-month period. According to the U.S. Census Bureau: A person was considered covered by health insurance at some time during the year if he or she was covered by at least one of the following types of coverage: Employer/union, privately purchased (not related to employment), Medicare, Medicaid, military health care (military, CHAMPUS, CHAMPVA, VA, Indian Health Services), someone outside the household, or other. Data Source The U.S. Census Bureau’s annual Current Population Survey (CPS), Annual Social and Economic Supplement, 2001 -2006. Reporting Formats The measure is reported longitudinally (broken out by year for the State of Hawaii), by state (State of Hawaii, selected comparison states, and the total U.S.) for the latest year, and by state over several years. QUEST Annual Report FYE June 30, 2006 Page 60 of 87 National Procedure Standard CPS survey techniques and methods. Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A HEDIS Measures Prenatal Care & Postpartum Care Statistic Description This statistic measures the percentage of women who had live births during the reporting period, who were enrolled in a plan for 280 days or more prior to delivery through 56 days after delivery (allowing no more than one break in enrollment not to exceed 45 days and not to occur in the first trimester), and who received: • A prenatal care visit in the first trimester or within 42 days of enrollment. • A postpartum visit on or between 21 and 56 days after delivery. Separate prenatal and postpartum percentages are calculated on the same population. Performance Standards The HEDIS national Medicaid 75th percentile score. Enrollment Period Women who had live births during the reporting period, who were enrolled in a plan for 40 weeks (280 days) or more prior to delivery through 56 days after delivery (allowing no more than one break in enrollment, not to exceed 45 days and not to occur in the first trimester). The reporting period for the live births is between November 6 of the year prior to the measurement year and November 5 of the measurement year. The first trimester is defined as between 176 and 280 days prior to delivery. Methodology Denominator The number of women who had live births during the reporting period, who were enrolled in a plan for 40 weeks (280 days) or more prior to delivery through 56 days after delivery (allowing no more than one break in enrollment, not to exceed 45 days and not to occur in the first trimester). Numerator • For prenatal care: The number of women in the denominator who received a prenatal care visit in the first trimester or within 42 days of enrollment. QUEST Annual Report FYE June 30, 2006 Page 61 of 87 • For postpartum care: The number of women in the denominator who received a postpartum visit on or between 21 and 56 days after delivery. Data Source The annual HEDIS reports received from the health plans. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard HEDIS standard reporting guidelines are followed. Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A Maternity Average Length of Stay Statistic Description This statistic measures utilization of maternity-related care for enrolled females who had live births during the measurement year. Live births are to include vaginal deliveries as well as Cesarean section (C-section) deliveries. Performance Standards The HEDIS national Medicaid 25th percentile score. Enrollment Period Women who had live births during the reporting period. Methodology Total deliveries are defined as the sum of vaginal and cesarean deliveries. Multiple births count as one delivery, and at-home deliveries are excluded. Vaginal deliveries are defined as encounters that have any one of the following codes: • DRG between 372 and 375, inclusive • CPT code = 59400, 59409, 59410, 59610, 59612, or 59614 • ICD-9-CM code = 74.0, 74.1, 74.2, 74.4, or 74.99 Cesarean deliveries are defined as encounters that have any one of the following codes: • DRG = 370 or 371 • CPT code = 59510, 59514, 59515, 59618, 59620, or 59622 • ICD-9-CM code between 72.0 and 73.99, inclusive, or 650 Data Source The annual HEDIS reports received from the health plans. QUEST Annual Report FYE June 30, 2006 Page 62 of 87 Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard HEDIS standard reporting guidelines are followed. . The measures are reported by age and sex, as well as separated by vaginal and c-section deliveries, but only the cumulative figure is used for this measure. Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A Well Child Visits in the First 15 Months of Life, 6 or More Statistic Description This statistic measures the percentage of children who turned 15 months old during the reporting period, who were continuously enrolled in a plan from 31 days - 15 months of age (with no more than one break in coverage of no more than 45 days), and who had six or more well-child visits with a primary care practitioner during their first 15 months of life. Performance Standards The HEDIS national Medicaid 75th percentile score. Enrollment Period Children who turned 15 months old during the reporting period and who were continuously enrolled in a plan from 31 days - 15 months of age (with no more than one break in coverage of no more than 45 days). Methodology Denominator This number of children who turned 15 months old during the reporting period and who were continuously enrolled in a plan from 31 days - 15 months of age (with no more than one break in coverage of no more than 45 days). Numerator The number of children in the denominator who had six or more well-child visits with a primary care practitioner during their first 15 months of life. Each child can appear in the numerator only once. Data Source The annual HEDIS reports received from the health plans. QUEST Annual Report FYE June 30, 2006 Page 63 of 87 Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard HEDIS standard reporting guidelines are followed. The children who received exactly zero, one, two, three, four, and five well-child visits are also part of the standard set of HEDIS well-child measures, but are not reported here. Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A Childhood Immunization Status, Combination 2 Statistic Description This statistic measures the percentage of children who became 2 years old during the reporting period, who were continuously enrolled in a plan for 12 months preceding their second birthday (allowing for no more than one gap in enrollment up to 45 days), and who had received all the required vaccinations in Combination 2 on or before their second birthday. The required vaccinations for Combination 2 are as follows: four doses of DTP or DtaP (diptheria-tenanus), three doses of IPV (polio), one dose of MMR (measles, mumps, rubella), three doses HiB (haemophilus influenza type b), three doses of hepatitis B, one dose of VZV (chicken pox). Performance Standards The HEDIS national Medicaid 75th percentile score. Enrollment Period Children who became 2 years old during the reporting period, who were continuously enrolled in a plan for 12 months preceding their second birthday (allowing for no more than one gap in enrollment up to 45 days). Methodology Denominator The number of children who became 2 years old during the reporting period, who were continuously enrolled in a plan for 12 months preceding their second birthday (allowing for no more than one gap in enrollment up to 45 days). Numerator The number of children in the denominator who have received the required Combination 2 vaccinations on or before their second birthday. Data Source The annual HEDIS reports received from the health plans. QUEST Annual Report FYE June 30, 2006 Page 64 of 87 Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard HEDIS standard reporting guidelines are followed. The children who received DtaP/DT, IPV, MMR, HiB, Hepatitis B, VZV vaccines at specified rates are reported individually as part of the standard set of HEDIS well-child measures, but are not reported here. Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A Hemoglobin A1c Tested, HbA1c Poorly Controlled & Retinal Examination Statistic Description The percentage of members 18-75 years of age with diabetes (type 1 and type 2), who were enrolled in a plan for the entire reporting period (allowing no more than one break in enrollment not to exceed 45 days), who had each of the following: • Hemoglobin A1c (HbA1c) Tested • Hemoglobin A1c (HbA1c) Poorly Controlled • Retinal Examination Performance Standards The HEDIS national Medicaid 75th percentile score for Hemoglobin A1c Tested and Retinal Examination. The HEDIS national Medicaid 25th percentile score for Hemoglobin A1c Poorly Controlled. Enrollment Period Members 18-75 years of age with diabetes (type 1 and type 2), whom were enrolled in a plan for the entire reporting period (allowing no more than one break in enrollment not to exceed 45 days). Methodology Denominator The number of members 18-75 years of age with diabetes (type 1 and type 2), who were enrolled in a plan for the entire reporting period (allowing no more than one break in enrollment not to exceed 45 days). Numerator The number of members in the denominator who had each of the following: • Hemoglobin A1c (HbA1c) test QUEST Annual Report FYE June 30, 2006 Page 65 of 87 • • HbA1c poorly controlled (a score of >9.0%, or no score reported, or no test done in the enrollment period) Eye exam (retinal) performed Data Source The annual HEDIS reports received from the health plans. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard HEDIS standard reporting guidelines are followed. The following measures are part of the standard set of HEDIS diabetes measures, but are not reported here: • LDL-C screening performed • LDL-C controlled (<130 mg/dL) • LDL-C controlled (<110 mg/dL) • Kidney disease (nephropathy) monitored Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A Follow-Up After Hospitalization for Mental Illness, Within 30 Days Statistic Description This statistic measures the percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and, within 30 days of hospital discharge, who were seen on an ambulatory basis or were in intermediate treatment with a mental health provider. This statistic is also reported for follow-up visits within 7 days, but this is not used in this measure. Performance Standards The HEDIS national Medicaid 75th percentile score. Enrollment Period Members 6 years of age and older as of the date of discharge, who were hospitalized for treatment of selected mental health disorders, and who were continuously enrolled for 30 days after discharge. Methodology Denominator QUEST Annual Report FYE June 30, 2006 Page 66 of 87 The number of members 6 years of age and older as of the date of discharge, who were hospitalized for treatment of selected mental health disorders, and who were continuously enrolled for 30 days after discharge. Numerator The number of members in the denominator who were seen on an ambulatory basis or were in intermediate treatment with a mental health provider within 30 days of hospital discharge. Data Source The annual HEDIS reports received from the health plans. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard HEDIS standard reporting guidelines are followed. The patients receiving a follow-up visit within 7 Days is part of the standard set of HEDIS FUH measures, but is not reported here: Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A Mental Health Utilization – Percentage of Members Receiving Inpatient and Intermediate Care and Ambulatory Services Statistic Description The number and percentage or members receiving any of the following during the measurement year: • Inpatient mental health services • Intermediate mental health services • Ambulatory mental health services Performance Standards The HEDIS national Medicaid 75th percentile score. Enrollment Period The enrollment period for this report is the fiscal year 2006, or the period beginning on July 1, 2005 and ending on June 30, 2006. Methodology Denominator All QUEST members in the reporting period. QUEST Annual Report FYE June 30, 2006 Page 67 of 87 Numerator The number of members in the denominator who had any of the following: • Inpatient mental health services • Intermediate mental health services • Ambulatory mental health services Data Source The annual HEDIS reports received from the health plans. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard HEDIS standard reporting guidelines are followed. The measures are reported by age and sex, but a cumulative figure is used for this measure. Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A Emergency Department visits/1000 member months Statistic Description This statistic measures the number of emergency department (ED) visits per 1,000 member months. Performance Standards The HEDIS national Medicaid 75th percentile score. Enrollment Period The enrollment period for this report is the fiscal year 2006, or the period beginning on July 1, 2005 and ending on June 30, 2006. Methodology Denominator All QUEST members in the reporting period. Numerator The count of ED visits in the reporting period. The following are some conditions on the numerator: • ED visits that result in an inpatient stay is excluded. • All ED visits are counted the same, regardless of intensity of services or length of stay in ED. QUEST Annual Report FYE June 30, 2006 Page 68 of 87 • • Only one ED visits is counted per date of service. Visits to urgent care centers are excluded. Data Source The annual HEDIS reports received from the health plans. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard HEDIS standard reporting guidelines are followed. The rates of outpatient visits, ambulatory surgeries/procedures, and observation room visits are also reported, and the information is broken out by age brackets, but only the cumulative ER figure is used for this measure. Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A Percentage of Well-Newborns to Total Newborns Statistic Description This statistic measures the percentage of well-newborns to total newborns. Performance Standards The HEDIS national Medicaid 75th percentile score. Enrollment Period Newborns discharged in the fiscal year 2006 reporting period, or the period beginning on July 1, 2005 and ending on June 30, 2006. Methodology Denominator All newborns discharged in the reporting period. Numerator All well-newborns discharged in the reporting period, where well-newborns are defined as newborns NOT considered complex newborns. The following are how to define well-newborns: • Their LOS is less than five days, and • They did not expire in the hospital, and • The MCO is able to track the total LOS if the newborn is transferred between facilities. QUEST Annual Report FYE June 30, 2006 Page 69 of 87 Data Source The annual HEDIS reports received from the health plans. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard There are no deviations from the HEDIS standards. The percent reported is a figure derived from the standard HEDIS reported measures, but is not a standard measure itself. Discharges and days are reported for well-newborns and complex newborns, and are broken out by age of mother. Per 1,000 figures are also calculated. None of these measures that are actually a part of the HEDIS standard set are reported here. Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A EPSDT Measures Screening Ratio Statistic Description This statistic measures the total EPSDT screens administered over the total expected number of EPSDT screens. Performance Standards The CMS National Goal is a screening ratio of 80%. Enrollment Period EPSDT activity in the fiscal year 2006 reporting period, or the period beginning on October 1, 2005 and ending on September 30, 2006. Methodology Denominator The total expected EPSDT screens in the reporting period. The expected number of screens varies with the age bracket of the recipient. This total is the sum of the products of recipient count by age bracket multiplied by expected EPSDT screens for that age bracket. Numerator The total actual EPSDT screens administered to recipients in the reporting period. QUEST Annual Report FYE June 30, 2006 Page 70 of 87 Data Source The annual EPSDT reports received from the health plans. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard EPSDT standard reporting guidelines are followed. Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A Participant Ratio Statistic Description This statistic measures the total count of recipient that received EPSDT screens over the total expected number of recipients of EPSDT screens. Performance Standards The CMS National Goal is a participant ratio of 80%. Enrollment Period Recipients enrolled in the fiscal year 2006 reporting period, or the period beginning on October 1, 2005 and ending on September 30, 2006. Methodology Denominator The total expected number of recipients of EPSDT screens in the reporting period. The expected number of recipients varies with the age bracket of the recipient and the length of time they are enrolled. Each recipient is counted only once in the reporting period. Numerator The total count of recipient that received EPSDT screens in the reporting period. Data Source The annual EPSDT reports received from the health plans. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. QUEST Annual Report FYE June 30, 2006 Page 71 of 87 National Procedure Standard EPSDT standard reporting guidelines are followed. Reporting Period Years 2002 through 2005. HI-Common Subsystem Requirements N/A CAHPS Measures It should be noted that only the Adult Medicaid survey results are reported. The Child Medicaid survey results are NOT reported here. Ratings of Health Plan Statistic Description This statistic measures the percentage of survey respondents providing a “top box” response to the following question (#52): “Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan?”. Performance Standards The CAHPS national mean score. Enrollment Period Recipients eligible for the CAHPS survey needed to fit the following profile: • Were health plan members at the time the sample was drawn. • Were age 18 years or older as of December 31, 2005. • Were continuously enrolled in the health plan for five of the past six months. • Had Medicaid (QUEST) as their primary payer There were 4,050 randomly selected members that were initially sent a survey. Methodology The survey was administered by the Health Services Advisory Group (HSAG), the External Quality Review Organization (EQRO) contracted by Med-QUEST. Members from all three health plans participated in this survey. Members had the opportunity to complete the survey in either of two ways, via an English version mailed to members or via a follow-up telephone interview. For both methods, the survey period was from February 2006 through April 2006. A total of 1,546 randomly selected members completed the survey, which resulted in an overall response rate of 39.23%. A “top box” response for this statistic is a score of “9 or 10”. QUEST Annual Report FYE June 30, 2006 Page 72 of 87 Data Source The CAHPS reports received from the EQRO. Reporting Formats The measure is reported by plan for the latest year. National Procedure Standard CAHPS standard reporting guidelines are followed. Reporting Period Years 2004 & 2006. HI-Common Subsystem Requirements N/A Ratings of All Healthcare Statistic Description This statistic measures the percentage of survey respondents providing a “top box” response to the following question (#35): “Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 6 months?”. Performance Standards The CAHPS national mean score. Enrollment Period Recipients eligible for the CAHPS survey needed to fit the following profile: • Were health plan members at the time the sample was drawn. • Were age 18 years or older as of December 31, 2005. • Were continuously enrolled in the health plan for five of the past six months. • Had Medicaid (QUEST) as their primary payer There were 4,050 randomly selected members that were initially sent a survey. Methodology The survey was administered by the Health Services Advisory Group (HSAG), the External Quality Review Organization (EQRO) contracted by Med-QUEST. Members from all three health plans participated in this survey. Members had the opportunity to complete the survey in either of two ways, via an English version mailed to members or via a follow-up telephone interview. For both methods, the survey period was from February 2006 through April 2006. A total of 1,546 randomly selected members completed the survey, which resulted in an overall response rate of 39.23%. A “top box” response for this statistic is a score of “9 or 10”. QUEST Annual Report FYE June 30, 2006 Page 73 of 87 Data Source The CAHPS reports received from the EQRO. Reporting Formats The measure is reported by plan for the latest year. National Procedure Standard CAHPS standard reporting guidelines are followed. Reporting Period Years 2004 & 2006. HI-Common Subsystem Requirements N/A Getting Needed Care Statistic Description This statistic is a composite percentage score of four survey questions related to getting needed care. Performance Standards The CAHPS national mean score. Enrollment Period Recipients eligible for the CAHPS survey needed to fit the following profile: • Were health plan members at the time the sample was drawn. • Were age 18 years or older as of December 31, 2005. • Were continuously enrolled in the health plan for five of the past six months. • Had Medicaid (QUEST) as their primary payer There were 4,050 randomly selected members that were initially sent a survey. Methodology The survey was administered by the Health Services Advisory Group (HSAG), the External Quality Review Organization (EQRO) contracted by Med-QUEST. Members from all three health plans participated in this survey. Members had the opportunity to complete the survey in either of two ways, via an English version mailed to members or via a follow-up telephone interview. For both methods, the survey period was from February 2006 through April 2006. A total of 1,546 randomly selected members completed the survey, which resulted in an overall response rate of 39.23%. There were three response options for each of the four questions: • A big problem • A small problem • Not a problem QUEST Annual Report FYE June 30, 2006 Page 74 of 87 For each individual question, a score of “0” is assigned if one of the first two responses was chosen, and a score of “1” was assigned if the third response was chosen. The individual scores for the four questions, and for all of the respondents, are then weight-averaged to determine the composite percentage score. Data Source The CAHPS reports received from the EQRO. Reporting Formats The measure is reported by plan for the latest year. National Procedure Standard CAHPS standard reporting guidelines are followed. Reporting Period Years 2004 & 2006. HI-Common Subsystem Requirements N/A Getting Care Quickly Statistic Description This statistic is a composite percentage score of four survey questions related to getting care quickly. Performance Standards The CAHPS national mean score. Enrollment Period Recipients eligible for the CAHPS survey needed to fit the following profile: • Were health plan members at the time the sample was drawn. • Were age 18 years or older as of December 31, 2005. • Were continuously enrolled in the health plan for five of the past six months. • Had Medicaid (QUEST) as their primary payer There were 4,050 randomly selected members that were initially sent a survey. Methodology The survey was administered by the Health Services Advisory Group (HSAG), the External Quality Review Organization (EQRO) contracted by Med-QUEST. Members from all three health plans participated in this survey. Members had the opportunity to complete the survey in either of two ways, via an English version mailed to members or via a follow-up telephone interview. For both methods, the survey period was from February 2006 through April 2006. A total of 1,546 randomly selected members completed the survey, which resulted in an overall response rate of 39.23%. QUEST Annual Report FYE June 30, 2006 Page 75 of 87 There were four response options for each of the four questions: • Never • Sometimes • Usually • Always For each individual question, a score of “0” is assigned if one of the first three responses was chosen, and a score of “1” was assigned if the fourth response was chosen. The individual scores for the four questions, and for all of the respondents, are then weight-averaged to determine the composite percentage score. Data Source The CAHPS reports received from the EQRO. Reporting Formats The measure is reported by plan for the latest year. National Procedure Standard CAHPS standard reporting guidelines are followed. Reporting Period Years 2004 & 2006. HI-Common Subsystem Requirements N/A Physicians’ Assessment Measures Attitude toward Hawaii QUEST, in general Statistic Description This statistic measures the percentage of survey respondents providing a “positive” response to the following question: “How would you describe your own personal attitude toward: Hawaii QUEST, in general”. Performance Standards N/A Enrollment Period Physicians eligible for the Physicians’ Assessment Measures survey needed to be contracted with the plans, and either PCPs or specialists from on of the following high volume specialties: • Cardiology • Gastroenterology • Ophthalmology • Otolaryngology • Psychiatry QUEST Annual Report FYE June 30, 2006 Page 76 of 87 Methodology The survey was administered by the Health Services Advisory Group (HSAG), the External Quality Review Organization (EQRO) contracted by Med-QUEST. Physicians from all three health plans participated in this survey. The surveys were mailed to randomly selected physicians, with a second copy set four weeks later to non-respondents. The survey period was from February 2006 through March 2006. A total of 229 randomly selected physicians completed the survey, which resulted in an overall response rate of 26%. The respondents had to select a response from 7-point scale where -3 = very negative, 0 = neutral, and +3 = very positive. A “positive” response for this statistic is a score of “+1, +2 or +3”. A response of “not enough experience to answer” is an option on this question, but when chosen these are excluded from the score calculation. Data Source The Physicians’ Assessment reports received from the EQRO. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard N/A Reporting Period Years 2002 & 2006. HI-Common Subsystem Requirements N/A Satisfaction with the rate of reimbursement from the Med-QUEST health plan Statistic Description This statistic measures the percentage of survey respondents providing a “satisfied” response to the following question: “How would you describe your satisfaction with the rate or reimbursement (pay schedule) or compensation you get from the QUEST health plans and/or CAMHD?” Performance Standards N/A Enrollment Period Physicians eligible for the Physicians’ Assessment Measures survey needed to be contracted with the plans, and either PCPs or specialists from on of the following high volume specialties: • Cardiology • Gastroenterology • Ophthalmology • Otolaryngology QUEST Annual Report FYE June 30, 2006 Page 77 of 87 • Psychiatry Methodology The survey was administered by the Health Services Advisory Group (HSAG), the External Quality Review Organization (EQRO) contracted by Med-QUEST. Physicians from all three health plans participated in this survey. The surveys were mailed to randomly selected physicians, with a second copy set four weeks later to non-respondents. The survey period was from February 2006 through March 2006. A total of 229 randomly selected physicians completed the survey, which resulted in an overall response rate of 26%. The respondents had to select a response from 7-point scale where -3 = very dissatisfied, 0 = neutral, and +3 = very satisfied. A “satisfied” response for this statistic is a score of “+1, +2 or +3”. A response of “not enough experience to answer” is an option on this question, but when chosen these are excluded from the score calculation. Data Source The Physicians’ Assessment reports received from the EQRO. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard N/A Reporting Period Years 2002 & 2006. HI-Common Subsystem Requirements N/A Does the health plan personnel have the necessary professional knowledge and expertise Statistic Description This statistic measures the percentage of survey respondents providing a “yes, definitely” response to the following question: “When you need to discuss a patient’s course of care or a denial or service by the QUEST health plan/CAMHD, does the person you speak with at the QUEST health plan/CAMHD have the necessary professional knowledge and expertise?” Performance Standards N/A Enrollment Period Physicians eligible for the Physicians’ Assessment Measures survey needed to be contracted with the plans, and either PCPs or specialists from on of the following high volume specialties: • Cardiology QUEST Annual Report FYE June 30, 2006 Page 78 of 87 • • • • Gastroenterology Ophthalmology Otolaryngology Psychiatry Methodology The survey was administered by the Health Services Advisory Group (HSAG), the External Quality Review Organization (EQRO) contracted by Med-QUEST. Physicians from all three health plans participated in this survey. The surveys were mailed to randomly selected physicians, with a second copy set four weeks later to non-respondents. The survey period was from February 2006 through March 2006. A total of 229 randomly selected physicians completed the survey, which resulted in an overall response rate of 26%. The respondents had to select a response from three options: • No • Yes, somewhat • Yes, definitely. A response of “not enough experience to answer” is an option on this question, but when chosen these are excluded from the score calculation. Data Source The Physicians’ Assessment reports received from the EQRO. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard N/A Reporting Period Years 2002 & 2006. HI-Common Subsystem Requirements N/A Impact of the health plan’s UM (prior authorizations) on your ability to provide quality care Statistic Description This statistic measures the percentage of survey respondents providing a “positive” response to the following question: “During the last 12 months, what has been the impact of the QUEST health plan’s/CAMHD’s utilization management on your ability to provide quality care for your patients in the QUEST health plan or CAMHD? Prior Authorizations” Performance Standards N/A QUEST Annual Report FYE June 30, 2006 Page 79 of 87 Enrollment Period Physicians eligible for the Physicians’ Assessment Measures survey needed to be contracted with the plans, and either PCPs or specialists from on of the following high volume specialties: • Cardiology • Gastroenterology • Ophthalmology • Otolaryngology • Psychiatry Methodology The survey was administered by the Health Services Advisory Group (HSAG), the External Quality Review Organization (EQRO) contracted by Med-QUEST. Physicians from all three health plans participated in this survey. The surveys were mailed to randomly selected physicians, with a second copy set four weeks later to non-respondents. The survey period was from February 2006 through March 2006. A total of 229 randomly selected physicians completed the survey, which resulted in an overall response rate of 26%. The respondents had to select a response from 7-point scale where -3 = strong negative, 0 = neutral, and +3 = strong positive. A “positive” response for this statistic is a score of “+1, +2 or +3”. A response of “not enough experience to answer” is an option on this question, but when chosen these are excluded from the score calculation. Data Source The Physicians’ Assessment reports received from the EQRO. Reporting Formats The measure is reported longitudinally (broken out by year for the Hawaii statewide weighted average), and by plan for the latest year. National Procedure Standard N/A Reporting Period Years 2002 & 2006. HI-Common Subsystem Requirements N/A Med-QUEST Internal Measures Budget Neutrality Savings Statistic Description This statistic compares the expenditures under the current waiver to the expenditures that would be in place if the waiver were not in place. In the instance where the with-waiver current expenditures are lower than the without-waiver current expenditures, budget neutrality saving are a result. QUEST Annual Report FYE June 30, 2006 Page 80 of 87 Performance Standards Budget Neutrality Savings > $0. Enrollment Period Payments and expenditures for DY12. Methodology First the without waiver expenditure calculation is made. This is based on the current membership for the pre-waiver enrollment groups multiplied by an inflation-adjusted pmpm expenditure rate. Then the with waiver expenditures calculation is made. This is the actual expenditures that have occurred over the measurement period. Where the actual expenditures are less than the without waiver expenditures, budget neutrality savings are had. Data Source The actual capitation payment files paid to the health plans. Reporting Formats The measure is reported for the current year. In the future, it will be reported longitudinally. National Procedure Standard N/A Reporting Period DY12 (7/1/2005 – 6/30/2006) HI-Common Subsystem Requirements N/A QUEST Member Months Statistic Description This statistic calculates the number of member months that the QUEST program serves. Performance Standards N/A Enrollment Period Member months reported in period from 7/1/2005 – 6/30/2006. Member months that are retro adds or drops are recorded in the month reported. Methodology The member months are calculated based on the capitation payment file made to the health plans. Only whole member month are reported. Pro-rated daily amounts are paid for terminating enrollments. QUEST Annual Report FYE June 30, 2006 Page 81 of 87 Data Source The actual capitation payment files paid to the health plans. Reporting Formats The measure is reported for the current year. In the future, it will be reported longitudinally. National Procedure Standard N/A Reporting Period DY12 (7/1/2005 – 6/30/2006) HI-Common Subsystem Requirements N/A Expenditures for QUEST Uncompensated Care Costs There is an annual $15 million cap on the authorized Uncompensated Care Costs (UCC). Payments are limited to the lesser of the actual UCC cost or the $15 million cap. Expenditures for QUEST-ACE Program Theses are dollars spent to implement and outreach to the QUEST-ACE population. QUEST Annual Report FYE June 30, 2006 Page 82 of 87 Appendix B – Discussion of Statistical Terminology Calculation Method for Hawaii Statewide Rates In the report year there were three plans contracted to provide services to QUEST recipients: • AlohaCare • Hawaii Medical Service Association (HMSA) • Kaiser Permanente (Kaiser) A weighted-average calculation is used to calculate the Hawaii statewide rate. In most cases the measure we are concerned with is a percentage, or the result of dividing a numerator by a denominator. When applying the weight-average calculation, the numerators for the three plans are summed up first. Then the denominators for the three plans are summed up separately. Then the sum total of the numerators is divided by the sum total of the denominators. The result is the Hawaii statewide weighted-average for that measure. The following table is an example of an actual calculation for the HEDIS measure Follow-Up After Hospitalization for Mental Illness (FUH) - Within 30 Days in the year 2005: FUH - 30 Days AlohaCare HMSA Kaiser Hawaii statewide Numerator Denominator 146 205 31 44 51 67 228 316 Rate 71.2% 70.5% 76.1% 72.2% Each row contains the numerator, denominator & rate for by plan for this measure. The last row has the Hawaii statewide figures, where the numerator (228) is the sum of the three individual plans’ numerators, the denominator (316) is the sum of the three individual plans’ denominators, and the Hawaii statewide rate (72.2%) is the 228 divided by the 316. 95% Confidence Interval of a Proportion Most of the measures in this report rely on data obtained by sampling data. Sampling is an efficient way to draw a conclusion on a targeted population, or more specifically determine the true population proportion, without having to survey the entire population. To better quantify the certainty of these conclusions, a 95% confidence interval is calculated. The calculation of a confidence interval is based on the assumption of a symmetric and normal sample, and the ability to apply the Central Limit Theorem to such samples. This assumption is most easily fulfilled by a large sample size. Normally a sample size of at least 30 will assure the ability to apply the Central Limit Theorem to the sample. This specific calculation is used with the U.S. Census, EPSDT, CAHPS & Physicians’ Assessment measures only. The method used to calculate a 95% confidence interval is expressed in the formula below: QUEST Annual Report FYE June 30, 2006 Page 83 of 87 Lower 95% Range = π - 1.96 [ (π(1- π)) /n]^.5 Upper 95% Range = π + 1.96 [ (π(1- π)) /n]^.5 π = the sample proportion of success n = the sample size 1.96 = the number of standard errors away from π, on one side of a two-tailed normal distribution, where there is a 95% probability of finding the true population proportion. 95% Confidence Interval of a Proportion with Continuity Correction A continuity correction factor is appropriate when the sample size is not overwhelmingly large, and when the value for nπ or n(1- π) is between 5 and 10. The 95 % confidence interval calculation changes slightly when adding a factor for continuity correction, effectively increasing the interval over a regular 95% confidence interval calculation. This specific calculation is used with the HEDIS measures only. The method used to calculate a 95% confidence interval with continuity correction is expressed in the formula below: Lower 95% Range = π - 1.96 [ (π(1- π)) /n]^.5 - 1/(2n) Upper 95% Range = π + 1.96 [ (π(1- π)) /n]^.5 + 1/(2n) π = the sample proportion of success n = the sample size 1.96 = the number of standard errors away from π, on one side of a two-tailed normal distribution, where there is a 95% probability of finding the true population proportion. QUEST Annual Report FYE June 30, 2006 Page 84 of 87 Explanation of Graphs Showing the 95% Confidence Intervals The measure category, measure name, and comparison category are listed in the graph title. HEDIS Measures Hemoglobin A1c Tested (CDC) By Plan -- in 2005 100% 2005 National Medicaid 75th %ile = 84.1% 2005 National Medicaid Median = 78.4% If available, the national targets will be displayed as solid and dotted lines. 75% 50% The actual values of the upper 95% confidence interval (95% CI Up) and the lower 95% confidence interval (95% CI Low) are displayed here. 25% 0% 95% CI Up Rate 95% CI Low Hawaii QUEST 83.6% 81.3% 79.1% AlohaCare (Hybrid) 82.8% 78.8% 74.9% HMSA (Hybrid) 82.6% 78.6% 74.6% Kaiser (Hybrid) 91.5% 88.0% 84.4% The different populations being reported and compared in this graph are named in this row. The top edge of these bars graphically represent the upper 95% confidence interval, and the bottom edge represents the lower 95% confidence interval. Each measure category has a unique bar color. QUEST Annual Report FYE June 30, 2006 Page 85 of 87 Appendix C – Development of Hawaii Targets for U.S. Census Measures The basic method for developing these targets was to start with the 2005 Hawaii base rate, and then adjust up or down the numerator and denominator for expected program increases and estimated 2006 U.S. Census changes to the Hawaii population. The estimated 2006 U.S. Census changes are as of July 1, 2006 and were released to the public on December 22, 2006. The resulting adjusted numerator and denominator give us the 2006 Hawaii target rate. Uninsured Percentage The 2006 Hawaii target rate for Uninsured Percentage is 8.8%, slightly lower than the 2005 actual rate of 9.1%. The factors driving the target numerator lower are the expected increases in the S-CHIP EXP and QUEST-ACE populations over the next year, while factors driving the numerator higher are estimated 2006 increases in Hawaii births, deaths, and international migration. The target denominator is being driven higher primarily by the estimated 2006 increases in Hawaii births, deaths, and international migration, offset by estimated decreases in the internal migration. The table below summarizes the analysis, with the whole numbers stated in thousands: Numerator Denominator 116.0 1,279.0 (3.0) (7.5) 0.8 8.6 6.7 3.6 113.0 1,291.2 Rate 9.1% 2005 Hawaii Base S-CHIP EXP QUEST-ACE 2006 US Census (births/deaths) 2006 US Census (immigrants) 2006 Hawaii Target 8.8% Uninsured Children Percentage The 2006 Hawaii target rate for Uninsured Children Percentage is 15.5%, down from the 2005 actual rate of 17.2%. The factor driving the target numerator lower is the expected increase in the S-CHIP EXP population over the next year, while factors driving the numerator higher are estimated 2006 increases in Hawaii births and net migration. The target denominator is being driven higher primarily by the estimated 2006 increases in Hawaii births, deaths, and international migration, offset by estimated decreases in the internal migration. The table below summarizes the analysis, with the whole numbers stated in thousands: Numerator Denominator 20.0 116.0 (3.0) 1.1 0.8 0.1 0.3 18.2 117.1 Rate 17.2% 2005 Hawaii Base S-CHIP EXP 2006 US Census (births) 2006 US Census (net migration) 2006 Hawaii Target 15.5% QUEST Annual Report FYE June 30, 2006 Page 86 of 87 Percent of Children between 200% and 300% FPL who are Uninsured The 2006 Hawaii target rate for Percent of Children between 200% and 300% FPL who are Uninsured is 5.5%, lower than the 2005 actual rate of 10.0%. The factor driving the target numerator lower is the expected increase in the S-CHIP EXP population over the next year, while factors driving the numerator higher are estimated 2006 increases in Hawaii births and net migration. The target denominator is being driven higher primarily by the estimated 2006 increases in Hawaii births, deaths, and international migration, offset by estimated decreases in the internal migration. The table below summarizes the analysis, with the whole numbers stated in thousands: Numerator Denominator 7.0 70.0 (3.0) 0.1 0.0 0.0 0.0 4.1 70.1 Rate 10.0% 2005 Hawaii Base S-CHIP EXP 2006 US Census (births) 2006 US Census (net migration) 2006 Hawaii Target 5.9% QUEST Annual Report FYE June 30, 2006 Page 87 of 87