UMass Medical School Center for Health Policy and Research A Commonwealth Medicine Center of Distinction November 2007 MassHealth Managed Care HEDIS® 2007 Final Report Prepared by: Center for Health Policy and Research (CHPR) in collaboration with the Mass- Health Office of Acute and Ambulatory Care (OAAC) and the MassHealth Behavioral Health Program (MHBH) Project Team: Center for Health Policy and Research Ann Lawthers Greg Leung Rebecca Ouellette Heather Strother David Tringali Jianying Zhang Office of Acute and Ambulatory Care Louise Bannister Sharon Hanson Marlene Kane Susan Maguire Mary Ann Mark Lana Miller Liza Rudell MassHealth Behavioral Health Program John DeLuca Data Analysis and Performance Measurement Amina Khan Nicole Tibbetts ================================================================= Table of Contents Executive Summary Introduction Organization of the MassHealth Managed Care HEDIS 2007 Report Health Plan Profiles .........................................11 Data Collection and Analysis Methods..........................13 Staying Healthy ..............................................17 Breast Cancer Screening.......................................18 Cervical Cancer Screening ....................................22 Prenatal and Postpartum Care .................................24 Frequency of Ongoing Prenatal Care ...........................26 Living With Illness...........................................29 Comprehensive Diabetes Care...................................30 Controlling High Blood Pressure...............................42 Antidepressant Medication Management..........................46 Follow-up After Hospitalization for Mental Illness ...........50 Follow-up Care for Children Prescribed Attention-Deficit/ Hyperactivity Disorder (ADHD) Medication .....................54 Initiation and Engagement of Alcohol and Other Drug Dependency Treatment ....................................58 Getting Better ...............................................61 Appropriate Treatment for Children with Upper Respiratory Infection ..................................62 Appendix A: MassHealth Regions and Service Areas .............65 Appendix B: Frequency of Ongoing Prenatal Care (<21%, 21-40%, 41-60% and 61-80% of expected visits) .........67 Appendix C: PCC Plan Antidepressant Medication Management Rates for Members with Basic, Essential and Non-Basic/Non-Essential Coverage ...............69 Appendix D: PCC Plan Follow-up After Hospitalization for Mental Illness Rates for Members with Basic, Essential and Non-Basic/Non-Essential Coverage ...............71 Appendix E: PCC Plan Follow-up Care for Children Prescribed ADHD Medication Rates for Members with Basic, Essential and Non-Basic/Non-Essential Coverage References.....73 Appendix F: Initiation and Engagement of Alcohol and Other Drug Dependency Treatment (Age-Stratified Rates)....75 Appendix G: Initiation and Engagement of Alcohol and Other Drug Dependency Treatment (Age-Stratified Rates for Members with Basic, Essential, and Non-Basic/Non-Essential Coverage) ............................79 References ...................................................82 November 2007| MassHealth Managed Care HEDIS 2007 Report 2 2 Executive Summary The MassHealth Managed Care HEDIS 2007 Report presents information on the quality of care provided by the five health plans serving the Mass- Health managed care population (Boston Medical Center HealthNet Plan, Fallon Community Health Plan, Neighborhood Health Plan, Network Health, and the Primary Care Clinician Plan). This assessment was conducted by the Center for Health Policy and Research (CHPR), the MassHealth Office of Acute and Ambulatory Care (OAAC) and the MassHealth Behavioral Health Program (MHBH) by using a subset of HEDIS (Healthcare Effectiveness Data and Information Set) measures. HEDIS was developed by the National Committee for Quality Assurance (NCQA) and is the most widely used set of standardized performance measures to evaluate and report on the quality of care delivered by health care organizations. Through this collaborative project, CHPR, OAAC and MHBH have evaluated a broad range of clinical and service areas that are of importance to MassHealth members, policy makers and program staff. Measures Selected for HEDIS 2007 The MassHealth measurement set for 2007 focused on three domains: “staying healthy” (i.e., breast and cervical cancer screening and prenatal and postpartum care), “living with illness” (i.e., treatment for depression, diabetes care, hypertension control, follow-up after psychiatric hospitalizations, follow-up care for children prescribed attention- deficit/hyperactivity disorder medication, and substance abuse treatment) and “getting better” (i.e., appropriate use of antibiotics for upper respiratory infection). HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) . Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA) . Summary of Overall Results Results from the MassHealth Managed Care HEDIS 2007 project demonstrate that MassHealth plans performed well overall when compared to the 2007 rates for other Medicaid plans around the country. For the purpose of this report, we conducted tests of statistical significance and compared the performance of individual MassHealth plans with that of the top 25% of all Medicaid plans reporting HEDIS data for 2007 (represented by the 2007 national Medicaid 75th percentile, obtained from NCQA’s Quality Compass database.) MassHealth plans generally reported rates that were significantly better than the 2007 national Medicaid 75th percentile for the measures assessing breast cancer screening (52-64 age group only), cervical cancer screening, antidepressant medication management (optimal practitioner contacts only), follow-up care for children prescribed attention-deficit/hyperactivity disorder (ADHD) medication (initiation phase only), and the engagement of alcohol and other drug dependency treatment. MassHealth plan results were mixed for the Prenatal and Postpartum Care and Frequency of Ongoing Prenatal Care measures, with some plans performing below the benchmark and some plans withrates that were statistically no different from the benchmark. MassHealth plan performance on the Comprehensive Diabetes Care measure was static, with all plans reporting rates that were statistically no different from the benchmark and no different from past performance. Significant changes to the criteria for several measures meant that no benchmarks were available and/or comparisons to past performance were not possible, including the 42-51age stratification for the breast cancer screening measure and the cervical cancer screening, controlling high blood pressure and follow-up care for children prescribed ADHD medication measures. November 2007| MassHealth Managed Care HEDIS 2007 Report Executive Summary (continued) Executive Summary (continued) Breast Cancer Screening • MassHealth managed care members aged 4251 had a breast cancer screening rate of 58.9%. Because this is a first-year measure, there is no benchmark and comparison to past performance is not possible. • MassHealth managed care members aged 5264 had a breast cancer screening rate of 68.2%. All five MassHealth plans performed significantly better than the 2007 national Medicaid 75th percentile (59.2%). • One plan (PCCP) reported a rate for the 52-64 age group that was significantly better than its HEDIS 2005 rate. Cervical Cancer Screening • The MassHealth managed care cervical cancer screening rate was 78.6%. Three Mass- Health managed care plans performed significantly better than the 2007 national Medicaid 75th percentile (72.0%). • NCQA raised the lower age limit for this measure from 18 to 21 since last reported by Mass- Health. Therefore, comparison to past performance is not possible. Prenatal and Postpartum Care • The MassHealth managed care timeliness of prenatal care rate was 86.1%. None of the MassHealth managed care plans performed significantly better than the 2007 national Medicaid 75th percentile (88.7%), although four plans had rates that were not statistically different from this benchmark. • One plan (PCCP) reported a timeliness of prenatal care rate that was significantly better than its HEDIS 2005 rate. • The MassHealth managed care postpartum care rate was 59.0%. None of the MassHealth managed care plans performed significantly better than the 2007 national Medicaid 75th percentile (65.5%), although three plans had rates that were not statistically different from this benchmark. • One plan (PCCP) reported a postpartum care rate that was significantly better than its HEDIS 2005 rate. Frequency of Ongoing Prenatal Care • Nearly sixty-two percent (61.7%) of Mass- Health managed care live births had more than 81% of the expected number of prenatal visits. None of the MassHealth managed care plans performed significantly better than the 2007 national Medicaid 75th percentile (71.7%), although two plans had rates that were not statistically different from this benchmark. • None of the MassHealth managed care plans reported a 2007 postpartum care rate that was significantly better than its 2005 rate. Comprehensive Diabetes Care • This measure assesses nine areas of diabetes care: HbA1c testing, HbA1c good and poor control, LDL testing, LDL control, blood pressure control (2 rates), eye exams, and screening for kidney disease. • MassHealth managed care plans had rates that were significantly better or statistically no different from the national Medicaid 75th percentile, for the six rates for which benchmarks are available. • For the six measures collected by MassHealth for 2006, MassHealth plans had 2007 rates that were statistically no different from their 2006 rates, with one exception. Four Mass- Health managed care plans had rates for the monitoring kidney disease measure that were significantly better than their 2006 rates. Controlling High Blood Pressure • MassHealth’s blood pressure control rate for MassHealth managed care members aged 1845 with hypertension was 54.1%. Because this is a new age stratification for this measure, there is no benchmark and comparison to past performance is not possible. • MassHealth’s blood pressure control rate for MassHealth managed care members aged 4685 with hypertension was 54.7%. Because of changes NCQA made to the definition of blood pressure control, there is no benchmark and comparison to past performance is not possible. Antidepressant Medication Management • The MassHealth managed care rate for optimal practitioner contacts during the 84-day acute treatment phase was 31.4%. Three MassHealth managed care plans had rates that were significantly better than the 2007 national Medicaid 75th percentile (27.0%). Two plans (PCCP and NH) had 2007 rates that were significantly better than their 2005 rates. • The MassHealth managed care rate for effective acute phase treatment was 47.9%. Two MassHealth plans had rates that were significantly better than the 2007 national Medicaid 75th percentile (47.9%). One plan (PCCP) had a 2007 rate that was significantly better than the plan’s 2005 rate. • The MassHealth managed care rate for effective continuation phase treatment was 32.9%. Two MassHealth plans had rates that were significantly better than the 2007 national Medicaid 75th percentile (32.4%). One plan (PCCP) had a 2007 rate that was significantly better than the plan’s 2005 rate. Follow-up After Hospitalization for Mental Illness • The MassHealth managed care 7-day follow- up rate was 56.9%. One plan had a rate that was significantly better than the 2007 national Medicaid percentile. One plan (PCCP) had a 2007 rate that was significantly better than the plan’s 2005 rate. November 2007| MassHealth Managed Care HEDIS 2007 Report 4 4 Executive Summary (continued) • The MassHealth managed care 30-day follow- up rate was 76.2%. Two plans had rates that were significantly better than the 2007 national Medicaid percentile (75.9%). Two plans (PCCP and NHP) had 2007 rates that were significantly better than their 2005 rate. Follow-up Care for Children Prescribed Attention- Deficit/Hyperactivity Disorder (ADHD) Medication • The MassHealth managed care initiation phase treatment rate (i.e., the percentage of children with one follow-up visit within 30 days of ADHD prescription) was 54.1%. Four MassHealth managed care plans had rates that were significantly better than the 2007 national Medicaid 75th percentile (38.7%). Since this a new measure for MassHealth reporting, comparison to past MassHealth performance is not possible. • The MassHealth managed care continuation and maintenance phase treatment rate (% of children who remained on ADHD medication for 210 days and had two additional follow-up visits) was 61.3%. Due to an error by NCQA, benchmarks for this rate are not available. Since this is a new measure for MassHealth reporting, comparison to past MassHealth performance is not possible. Initiation and Engagement of Alcohol and Other Drug Dependency Treatment • The MassHealth managed care rate for the initiation of alcohol and other drug dependency treatment was 49.4%. One plan had a rate that was significantly better than the 2007 national Medicaid 75th percentile. Three plans (PCCP, NH and BMCHP) had 2005 rates that were significantly better than their 2007 rates. • The MassHealth managed care rate for the engagement of alcohol and other drug dependency treatment was 20.6%. Four MassHealth plans had rates that were significantly better than the 2007 national Medicaid 75th percentile (15.1%). One plan (PCCP) had a 2007 rate that was significantly better than its 2005 rate. Appropriate Treatment for Children with Upper Respiratory Infection • The MassHealth managed care rate for appropriate use of antibiotics in children with upper respiratory infection was 87.9%. Two Mass- Health plans had rates that were significantly better than the 2007 national Medicaid 75th percentile (89.3%). One plan (PCCP) had a 2007 rate that was significantly better than its 2005 rate. November 2007| MassHealth Managed Care HEDIS 2007 Report Summary of MassHealth Managed Care HEDIS 2007 Results HEDIS 2007 Measure 2007 National Medicaid 75th Percentile PCCP rate NHP rate NH rate FCHP rate BMCHP rate Breast Cancer Screening Age 42-51 * —-57.2% 63.8% 58.9% 62.9% 61.3% Age 52-69 59.2% 66.9% . 70.5% . 67.3% . 73.9% . 76.3% Cervical Cancer Screening 72.0% 74.1% 85.2% . 75.6% 85.2% . 81.0% Prenatal and Postpartum Care Timeliness of Prenatal Care 88.7% 88.1% 87.1% 71.0% . 89.2% 90.3% Postpartum Care 65.5% 55.2% . 56.1% . 60.8% 67.2% 64.2% Frequency of Ongoing Prenatal Care > 81+ percent 71.7% 62.3% . 67.2% 49.4% . 72.8% 62.0% Comprehensive Diabetes Care *** HbA1C Screening 84.3% -91.2% . 83.7% 90.4% . 88.8% Poor HbA1c Control ** 39.7% -31.9% . 41.8% 31.1% . 41.4% Good HbA1c Control * —--35.8% 29.2% 29.9% 34.8% LDL-C Screening 77.9% -80.0% 81.3% 77.8% 77.9% LDL-C level <100 mg/dL 37.2% -35.0% 37.0% 35.3% 35.3% Eye Exam 62.7% -70.3% . 62.8% 67.7% 74.7% Monitoring Nephropathy 81.8% -83.2% 78.3% 76.6% 83.7% Blood Pressure <130/80 * —--34.5% 38.2% 45.5% 34.3% Blood Pressure <140/90 * —--68.4% 66.9% 77.8% 67.9% Controlling High Blood Pressure Age 18-45 * —-52.6% 59.5% 56.6% 64.1% 52.0% Age 46-85 * —-53.2% 63.6% 56.2% 70.9% 55.6% * Benchmarks are not available for this measure. ** This measure is the percentage of members whose HbA1c was in poor control. Therefore, a lower rate indicates better performance. *** PCCP did not collect the Comprehensive Diabetes Care measure for HEDIS 2007. . Indicates a rate that is significantly better than the 2007 national Medicaid 75th percentile. Key: PCCP—Primary Care Clinician Plan FCHP—Fallon Community Health Plan . Indicates a rate that is significantly worse than the 2007 national Medicaid 75th percentile. NHP—Neighborhood Health Plan BMCHP—Boston Medical Center HealthNet Plan NH—Network Health November 2007| MassHealth Managed Care HEDIS 2007 Report 6 6 Summary of MassHealth Managed Care HEDIS 2007 Results (continued) HEDIS 2007 Measure 2007 National Medicaid 75th Percentile PCCP rate NHP rate NH rate FCHP rate BMCHP rate Antidepressant Medication Management Optimal Practitioner Contacts 27.0% 29.3% . 35.3% . 30.5% 27.2% 34.4% Effective Acute Phase Tx 47.9% 52.7% . 45.9% 55.1% . 49.4% 35.4% Effective Continuation Phase Tx 32.4% 38.1% . 26.8% . 43.6% . 37.0% 20.0% Follow-up After Hospitalization for Mental Illness 7 Days 58.0% 55.7% . 71.8% . 58.2% 58.3% 55.6% 30 Days 75.9% 74.1% . 91.9% . 77.0% 79.8% 78.4% Follow-Up Care for Children Prescribed AttentionDeficit/ Hyperactivity Medication Initiation 38.7% 63.6% . 60.7% . 63.4% . 67.9% . 31.8% Continuation and Maintenance * —75.1% 63.2% 70.7% -35.9% Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Initiation Total 50.0% 47.2% . 48.2% 48.1% 53.2% 56.7% Engagement Total 15.1% 19.2% . 39.5% . 14.9% 23.4% . 22.0% Appropriate Treatment for Children with Upper Respiratory Infection 89.3% 84.0% . 91.8% . 88.0% . 90.1% 91.1% * Benchmarks are not available for this measure. . Indicates a rate that is significantly better than the 2007 national Medicaid 75th percentile. Key: PCCP—Primary Care Clinician Plan FCHP—Fallon Community Health Plan NHP—Neighborhood Health Plan BMCHP—Boston Medical Center HealthNet Plan . Indicates a rate that is significantly worse than the 2007 national Medicaid 75th percentile. NH—Network Health November 2007| MassHealth Managed Care HEDIS 2007 Report Introduction Introduction November 2007| MassHealth Managed Care HEDIS 2007 Report 8 8 Introduction Purpose of the Report This report presents the results of the Mass- Health Managed Care HEDIS 2007 project. This report was designed to be used by MassHealth program managers and by managed care organization (MCO) managers to identify plan performance on select Healthcare Effectiveness Data and Information Set (HEDIS) measures, compare performance with that of other MassHealth managed care plans and with national benchmarks, identify opportunities for improvement, and set quality improvement goals. Project Background The Center for Health Policy and Research (CHPR) collaborated with the MassHealth Office of Acute and Ambulatory Care (OAAC) and the MassHealth Behavioral Health Program (MHBH) to conduct an annual assessment of the performance of all MassHealth managed care organizations (MCOs) and the Primary Care Clinician Plan (PCCP), the primary care case management program administered by the Executive Office of Health and Human Services (EOHHS). CHPR, OAAC and MHBH conduct this annual assessment by using a subset of HEDIS measures. Developed by the National Committee for Quality Assurance (NCQA), HEDIS is the most widely used set of standardized performance measures to measure and report on the quality of ambulatory care delivered by health care organizations. HEDIS includes clinical measures, as well as measures of access to care and utilization of services. The measures selected for the MassHealth Managed Care HEDIS 2007 project assess the performance of the five MassHealth plans that pro vided health care services to MassHealth managed care members during the 2006 calendar year. The five MassHealth plans included in this report are the Primary Care Clinician Plan (PCCP), Neighborhood Health Plan (NHP), Network Health (NH), Fallon Community Health Plan (FCHP), and Boston Medical Center HealthNet Plan (BMCHP). Descriptive information about each health plan can be found in the Health Plan Profiles section on page 11. MassHealth HEDIS 2007 Measures MassHealth selected eleven measures for the HEDIS 2007 project. The eleven measures included in this report assess health care quality in three key areas: clinical quality, access and availability of care, and use of services. The clinical quality measures included in this report provide information about preventive services, the management of chronic illness, and the treatment of acute illness. The specific topics evaluated in this report are breast and cervical cancer screening, comprehensive diabetes care, controlling hypertension, antidepressant medication management, appropriate follow-up for people hospitalized with mental illness, and appropriate use of antibiotics in children with upper respiratory infections. The access and availability of care measures included in this report provide information about the ability of members to get the basic and important services they need. The specific topics evaluated in this report are prenatal and postpartum care visits and the initiation and engagement of alcohol and other drug dependency treatment. Use of service measures provide information about what services health plan members utilize. The specific services evaluated in this report are the frequency of prenatal visits, measured as the percentage of expected visits adjusted for gestational age at birth and the month that the member enrolled in the health plan. Note: MassHealth assessed member satisfaction through the administration of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey. Results of the Mass- Health CAHPS measurement effort can be found in the MassHealth CAHPS 2006 report produced by CHPR in collaboration with the UMASS Center for Survey Research (CSR). November 2007| MassHealth Managed Care HEDIS 2007 Report Organization of the MassHealth Managed Care HEDIS 2007 Report This report presents the results of the MassHealth Managed Care HEDIS 2007 project in three sections. These sections are based on the consumer reporting domains used in NCQA’s health plan report cards (i.e., Staying Healthy, Living with Illness and Getting Better). These domains group clinical and access to care HEDIS measures with similar characteristics. REPORT SECTION DEFINITION MEASURES SELECTED BY MASSHEALTH FOR HEDIS 2007 REPORTING Staying Healthy These measures provide information about how well a plan provides services that maintain good health and prevent illness. • Breast Cancer Screening • Cervical Cancer Screening • Frequency of Ongoing Prenatal Care • Prenatal and Postpartum Care Living with Illness These measures provide information about how well a plan helps people manage chronic illness. • Antidepressant Medication Management • Comprehensive Diabetes Care • Controlling High Blood Pressure • Follow-up After Hospitalization for Mental Illness • Follow-up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication • Initiation and Engagement of Alcohol and Other Drug Dependency Treatment Getting Better This measure provides information about how well a plan helps people recover from illness. • Appropriate Treatment for Children with Upper Respiratory Infection This report also includes seven appendices that provide more detailed results: • Appendix A includes a list of the MassHealth regions and the service areas the regions cover. • Appendix B includes the <21%, 21-40%, 41-60% and 61-80% of expected visit rates for the Frequency of Ongoing Prenatal Care measure. • Appendix C presents data for the Antidepressant Medication Management measure for PCCP members with Basic, Essential and Non-Basic/Non- Essential coverage. • Appendix D presents data for the Follow-up After Hospitalization for Mental Illness measure for PCCP members with Basic, Essential and Non-Basic/ Non-Essential coverage. • Appendix E presents data for the Follow-up Care for Children Prescribed ADHD Medication measure for PCCP members with Basic, Essential and Non-Basic/Non-Essential coverage. • Appendix F includes the age-stratified results for the Initiation and Engagement of Alcohol and Other Drug Dependency Treatment measure. • Appendix G includes the age-stratified results for the Initiation and Engagement of Alcohol and Other Drug Dependency Treatment measure for PCCP members with Basic, Essential and Non-Basic/Non-Essential coverage. November 2007| MassHealth Managed Care HEDIS 2007 Report 10 10 Organization of the MassHealth Managed Care HEDIS 2007 Report Name of Information on the intent measure of each measure, including any clinical guidelines on which it is based Comparison of plan rates with the comparison and benchmark data Statistical summary comparing plan rates to comparison rates named at the top of each column .. 2007 rate is significantly above the comparison rate .. 2007 rate is not significantly different from the comparison rate .. 2007 rate is significantly below the comparison rate Analysis of results, including opportunities for improvement Individual HEDIS 2007 plan data including numerator, eligible population (where applicable) denominator, reported rate, and upper and lower confidence intervals The 2007 national Medicaid 75th percentile is listed as an benchmark. The 2007 national Medicaid 90th percentile, 2007 national Medicaid mean, 2007 Massachusetts Commercial mean, and 2007 MassHealth weighted mean and median are listed as comparison rates Historical data from HEDIS 2005/2006, if available and if there were no significant changes to the measure’s specifications that prohibited comparisons to HEDIS 2005 November 2007| MassHealth Managed Care HEDIS 2007 Report Health Plan Profiles Health Plan Profiles MassHealth managed care plans provided care to over 690,000 Massachusetts residents as of December 31, 2006. The MassHealth Managed Care HEDIS 2007 report includes data from the five MassHealth plans serving members enrolled in managed care. This report does not reflect care provided to MassHealth members receiving their health care services outside of the five managed care plans. The following profiles provide some basic information about each plan and its members. The data chart on the next page provides a statistical summary of the demographic characteristics of each plan’s population. Appendix A lists the service areas that are located within each MassHealth geographic region listed below. (Note: The term “MCO” is used throughout the report to indicate the four capitated managed care plans serving MassHealth members—Neighborhood Health Plan, Network Health, Fallon Community Health Plan, and Boston Medical Center HealthNet Plan.) Primary Care Clinician Plan (PCCP) • Primary care case management program administered by the Executive Office of Health and Human Services (EOHHS). • Statewide managed care option for Mass- Health members eligible for managed care. • 304,411 MassHealth members as of December 31, 2006. • Provider network includes group practices, community health centers, hospital outpatient departments, hospital-licensed health centers, nurse practitioners, and individual practitioners. • Behavioral health services are managedthrough a carve-out contract with the Massachusetts Behavioral Health Partnership (MBHP). • HEDIS data for select measures were collected separately for PCCP members with Essential coverage. MassHealth Essential covers individuals ages 19-64 who are long-term unemployed and ineligible for MassHealth Basic (certain individuals with non-citizen status are also eligible). PCCP is the only Mass- Health plan serving members with Essential coverage. Approximately seventeen percent (17%) of the PCCP’s membership has Mass- Health Essential coverage. Neighborhood Health Plan (NHP) • Non-profit managed care organization that serves primarily Medicaid members. • 116,253 MassHealth members as of December 31, 2006. • Service areas throughout the State (Western, Central, Northern and Southern Massachusetts as well as Greater Boston). • Provider network includes mostly community health centers in addition to Harvard Vanguard Medical Associates, group practices, and hospital- based clinics. • Behavioral health services are managedthrough a carve-out contract with BeaconHealth Strategies. Network Health (NH) • Managed care organization serving Massachusetts Medicaid (MassHealth) and Commonwealth Care populations owned and operated by Cambridge Health Alliance. • Network Health works with a network of more than 13,000 primary care providers and specialists who serve members located in more than 300 cities and towns across Massachusetts. • 91,437 MassHealth members as of December 31, 2006. • Primary service areas in Central, Northern and Western Massachusetts, Greater Boston, and South Shore. • Provider network includes community health centers, group practices, hospital outpatient departments, and individual practitioners. • Behavioral health services are provided by Network Health providers. Fallon Community Health Plan (FCHP) • Non-profit managed care organization that serves the commercial, Medicare, and Medicaid populations. • 11,141 MassHealth members as of December 31, 2006. • Service area is in Central Massachusetts. • Behavioral health services are managedthrough a carve-out contract with BeaconHealth Services. • Provider network for MassHealth members is exclusively through Fallon Clinic sites. Boston Medical Center HealthNet Plan (BMCHP) • Medicaid-only provider-sponsored health plan, owned and operated by Boston Medical Center, the largest public safety-net hospital inBoston. • 167,277 MassHealth members as of December 31, 2006. • Primary service areas in Western and Southern Massachusetts and Greater Boston. • Provider network includes community health centers, hospital outpatient departments, and group and individual practices. • Behavioral health services are provided by Boston Medical Center HealthNet Plan providers. Differences in Populations Served by Mass- Health Plans HEDIS measures are not designed for case-mix adjustment. Rates presented here do not take into account the physical and mental health status (including disability status) of the members included in the measures. The data on the next page describe each plan’s population in terms of age, gender, and disability status. It is important for readers to consider the differences in the characteristics of each plan’s population when reviewing and comparing the HEDIS 2007 performance of the five plans. November 2007| MassHealth Managed Care HEDIS 2007 Report 11 12 12 Health Plan Profiles: Demographic Characteristics of the Plan Populations MassHealth Plan Total MassHealth Managed Care Members as of 12/31/06 Female Disabled Mean Age 0-11 yrs 12-17 yrs 18-39 yrs 40-64 yrs 65+ yrs** Primary Care Clinician Plan Without Essential population* 255,887 56.4% 29.9% 25.43 28.1% 17.9% 26.8% 26.8% 0.4% Essential population only 48,524 33.3% 0.0% 38.78 0.0% 0.0% 52.4% 47.0% 0.6% Neighborhood Health Plan 116,253 60.4% 3.4% 18.35 41.6% 18.1% 27.8% 12.4% 0.1% Network Health 91,437 57.1% 6.9% 18.95 41.7% 15.2% 29.2% 13.9% 0.1% Fallon Community Health Plan 11,141 59.8% 9.4% 20.84 36.5% 15.2% 32.3% 16.0% 0.1% Boston Medical Center HealthNet Plan 167,277 58.4% 9.5% 18.4 42.7% 16.9% 27.3% 13.0% 0.1% Total for MassHealth Managed Care Program 690,519 56.1% 15.0% 22.5 33.9% 16.1% 29.3% 20.6% 0.2% Source: MMIS * HEDIS results based on this PCCP population are compared to MCO results throughout the main body of the report. ** MassHealth managed care plans generally serve members under the age of 65. A small number of MassHealth managed care members were 65 years of age or older as of 12/31/2006 and had not yet had their coverage terminated. MassHealth members 65 years and older were included in the eligible populations for the HEDIS 2007 measures whenever the specifications for the measure included the 65 and older population, the members’ coverage was not yet terminated, and the members met all eligible population criteria such as the continuous enrollment and enrollment anchor date requirements. Statistically Significant Differences Among the Plans Female Members: All four MCOs had a significantly higher proportion of female members than PCCP (p<.005). Both NHP and FCHP had a significantly higher proportion of females than NH and BMCHP. Disabled Members: PCCP had a significantly higher proportion of disabled members than any of the four MCOs (p<.005). FCHP and BMCHP both had a higher proportion of disabled members than NHP and NH. Mean Age of Members: All four MCOs had a population whose mean age was significantly lower than that of PCCP (p<.005). FCHP’s population had a mean age that was significantly higher than that of BMCHP, NHP, and NH (p<.005). November 2007| MassHealth Managed Care HEDIS 2007 Report Data Collection and Analysis Methods Data Collection and Submission In November 2006, the MassHealth Office of Acute and Ambulatory Care (OAAC) provided the MassHealth plans with a list of the measures to be collected for HEDIS 2007. The list of measures was developed by key stakeholders within MassHealth, including stakeholders within OAAC, the Office of Clinical Affairs (OCA), and the MassHealth Behavioral Health Program (MHBH). In general, each plan was responsible for collecting the measures according to the HEDIS 2007 Technical Specifications and for reporting the data using NCQA’s Interactive Data Submission System (IDSS). Each plan submitted its results to both NCQA and CHPR. MassHealth does not require plans to undergo an NCQA HEDIS Compliance Audit™. NCQA HEDIS Compliance Audits are independent reviews conducted by organizations or individuals licensed or certified by NCQA. The purpose of the audit is to validate a plan’s HEDIS results by verifying the integrity of the plan’s data collection and calculation processes. All plans undergoing NCQA Accreditation must have their HEDIS data audited (one MassHealth plan (FCHP) is currently NCQA-Accredited and several other plans are preparing for future accreditation reviews). NCQA reports only audited data in Quality Compass, a database of regional and national Medicaid, Medicare and Commercial performance benchmarks. Three plans, BMCHP, NHP and FCHP, voluntarily submitted audited HEDIS 2007 data to NCQA and CHPR. Eligible Population For each HEDIS measure, NCQA specifies the Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA). eligible population by defining the age, continuous enrollment, enrollment gap, and diagnosis or event criteria that a member must meet to be eligible for a measure. Age: The age requirements for Medicaid HEDIS measures vary by measure. The MassHealth managed care program serves members under the age of 65. Occasionally, members 65 and older appear in the denominator of a MassHealth plan’s HEDIS rates. This may occur for several valid reasons, including instances where a member turns 65 during the measurement year and did not yet have their coverage terminated as of the measure’s anchor date. MassHealth plans are responsible for a member’s care until his or her coverage is terminated. Therefore, Mass- Health members 65 years and older were included in the eligible populations for the HEDIS 2007 measures whenever the specifications for the measure included the 65 and older population, the members’ coverage had not yet been terminated, and the members met all eligible population criteria such as the continuous enrollment and enrollment anchor date requirements. Continuous enrollment: The continuous enrollment criteria varies for each measure and specifies the minimum amount of time that a member must be enrolled in a MassHealth plan before becoming eligible for that plan’s HEDIS measure. Continuous enrollment ensures that a plan has had adequate time to deliver services to the member before being held accountable for providing those services. Enrollment gap: The specifications for most measures allow members to have a gap in enrollment during the continuous enrollment period and still be eligible for the measure. The allowable gap is specified for each measure but is generally defined for the Medicaid population as one gap of up to 45 days. Diagnosis/event criteria: Some measures require a member to have a specific diagnosis or health care event to be included in the denominator. Diagnoses are defined by specific administrative codes (e.g., ICD-9, CPT). Other health care events may include prescriptions, hospitalizations, or outpatient visits. The measure descriptions included in this report do not include every requirement for the eligible populations (e.g., enrollment gaps). For complete specifications for each measure included in this report, please see HEDIS 2007 Volume 2: Technical Specifications. MassHealth Coverage Types Included in HEDIS 2007 MassHealth has several Medicaid coverage types whose members are eligible to enroll in any of the five MassHealth plans including Basic, Standard, CommonHealth, and Family Assistance. Members with one coverage type, Mass- Health Essential, may only enroll in the PCC Plan. MassHealth Essential covers individuals ages 19-64 who are long-term unemployed and ineligible for MassHealth Basic (certain individuals with non-citizen status are also eligible). Approximately sixteen percent (15.9%) of the PCC Plan’s managed care membership has Mass- Health Essential coverage. During the planning for the MassHealth Managed Care HEDIS 2007 project, it was decided that the NCQA HEDIS Compliance Audit™ is a trademark of the National Committee for Quality Assurance (NCQA). November 2007| MassHealth Managed Care HEDIS 2007 Report 13 14 14 Data Collection and Analysis Methods (continued) PCC Plan would submit HEDIS 2007 data for all of its coverage types for the measures where the population covered by the measure (e.g., age range) includes the population included in the coverage type. This coverage types include Basic, Essential and non-Basic/non-Essential coverage. The measures that include these coverage type breakouts include the Antidepressant Medication Management, Follow-up after Hospitalization for Mental Illness, Follow-up Care for Children Prescribed ADHD Medication, and the Initiation and Engagement of Alcohol and Other Drug Dependency Treatment measures. The data for the PCC Plan population without members with Essential coverage is used in all tables and charts in the main body of the report. Administrative vs. Hybrid Data Collection HEDIS measures are collected through one of two data collection methods—the administrative method or the hybrid method. The administrative method requires plans to identify the denominator and numerator using claims or encounter data, or data from other administrative databases. Plans calculate the administrative measures using programs developed by plan staff or Certified HEDIS SoftwareSM purchased from a vendor. For measures collected through the administrative method, the denominator includes all members who satisfy all criteria specified in the measure including any age and continuous enrollment requirements (these members are known as the “eligible population”). The plan’s HEDIS rate is based on all members in the denominator who are found through administrative data to have received the service reported in the numerator (e.g., visit, treatment, etc.). Certified HEDIS SoftwareSM is a service mark of the National Committee for Quality Assurance (NCQA). The hybrid method requires plans to identify the numerator through both administrative and medical record data. Plans may collect medical record data using plan staff and a plan-developed data collection tool. Plans may also contract with a vendor for the tool, staffing, or both. For measures collected using the hybrid method, the denominator consists of a systematic sample of members drawn from the measure’s eligible population. This systematic sample generally consists of a minimum required sample size of 411 members plus an over sample determined by the plan to account for valid exclusions and contraindications. The measure’s rate is based on members in the sample (411) who are found through either administrative or medical record data to have received the service reported in the numerator. Plans may report data with denominators smaller than 411 for two reasons: 1) the plan had a small eligible population or 2) the plan reduced its sample size based on its current year’s administrative rate or the previous year’s audited rate, according to NCQA’s specifications. It is important to note that performance on a hybrid measure can be impacted by the ability of a plan or its contracted vendor to locate and obtain member medical records. Per NCQA’s specifications, members for whom no medical record documentation is found are considered noncompliant with the measure. Data Analysis Throughout this report, HEDIS 2007 results from each plan are compared to several benchmarks and comparison rates, including the 2007 national Medicaid 75th percentile, 2007 national Medicaid mean, and 2007 Massachusetts Commercial mean. In addition, CHPR calculated MassHealth medians and weighted means from the 2007 data. 2007 National Medicaid 75th Percentile For this report, the 2007 national Medicaid 75th percentile serves as the primary benchmark to which plan performance is compared (including statistical significance). CHPR obtained the 2007 national Medicaid data from NCQA’s Quality Compass. NCQA releases Quality Compass in July of each year with the rates for Commercial and Medicare plans. NCQA provides the national Medicaid data in a supplement that is released in late Fall. Other Comparison Rates Included in this Report The other comparison rates included in the data tables of this report are the 2007 national Medicaid mean, national Medicaid 90th percentile, Massachusetts Commercial mean, MassHealth weighted mean, and MassHealth median. The 2007 national Medicaid mean is the average performance of all Medicaid plans that submitted HEDIS 2007 data. The 2007 national Medicaid 90th percentile represents a level of performance that was exceeded by only the top 10% of all Medicaid plans that submitted HEDIS 2007 data. The 2007 Massachusetts Commercial mean is the average performance of all Massachusetts Commercial plans that submitted audited HEDIS 2007 data to NCQA. Although the populations served by Massachusetts Commercial plans differ from the population served by MassHealth, the Massachusetts Commercial mean may be an appropriate goal for MassHealth plans in some November 2007| MassHealth Managed Care HEDIS 2007 Report Data Collection and Analysis Methods (continued) instances. The 2007 MassHealth weighted mean is a weighted average of the rates of the five Mass- Health plans. The weighted average was calculated by multiplying the performance rate for each plan by the number of individuals who met the eligibility criteria for the measure. The values were then summed across plans and divided by the total eligible population for all the plans. Because the MassHealth mean is a weighted average, the effect of a plan’s performance on the mean depends on the size of that plan. The largest Mass- Health plan (PCCP) serves 44.1% of all Mass- Health members and the smallest (FCHP) serves only 1.6%. Because of the differences in the size of the populations served by the plans, the Mass- Health weighted mean was not used for tests of statistical significance. The weighted mean is still an appropriate statistic to indicate overall Mass- Health performance on a measure, however. The 2007 MassHealth median is also provided and is the middle value of the set of values represented by the individual plan rates. Caveats for the Interpretation of Results All data analyses have limitations and those presented here are no exception. Late Submission of Data by Plans Three MassHealth plans requested and were granted extensions to submit data after the original due date. These plans (BMCHP, FCHP and NH) submitted data late to CHPR and to NCQA for varying reasons, including problems with subcontracted software vendors, medical record review vendors, NCQA auditors, and difficulties using the new NCQA data submission system. The impact of these problems and of the extra time given to these plans to complete their submission on HEDIS 2007 rates is unknown. Medical Record Procurement A plan’s ability (or that of its contracted vendor) to locate and obtain medical records as well as the quality of medical record documentation can affect performance on hybrid measures. Per NCQA’s specifications, members for whom no medical record documentation was found were considered non-compliant with the measure. This applied for records that could not be located and obtained as well as for medical records that contained incomplete documentation (e.g., indication of a test but no date or result). Lack of Case-Mix Adjustment The specifications for collecting HEDIS measures do not allow case-mix adjustment or risk- adjustment for existing co-morbidities, disability (physical or mental), or severity of disease. Therefore, it is difficult to determine whether differences among unadjusted plan rates were due to differences in the quality of care or use of services, or differences in the health of the populations served by the plans. CHPR and MassHealth are working on new methodologies to analyze MassHealth HEDIS results to address this issue for future reports. Demographic Differences in Plan Membership In addition to disability status, the populations served by each plan may have differed in other demographic characteristics such as age, gender, and geographic residence. As shown through the plan profile chart on page 12, PCCP has a higher proportion of members who are male or disabled as well as an older mean member age. Other differences among the plans are noted on page 12. The impact of these differences on MassHealth HEDIS 2007 rates is unknown. Overlapping Provider Networks Many providers caring for MassHealth members have contracts with multiple plans. Overlapping provider networks may affect the ability of any one plan to influence provider behavior. Variation in Data Collection Procedures Each plan collects and reports its own HEDIS data. Although there are standard specifications for collecting HEDIS measures, MassHealth does not audit the plans’ data collection methods. Factors that may influence the collection of HEDIS data by plans include: - Use of software to calculate the administrative measures, - Use of a tool and/or abstractors from an external medical record review vendor, - Completeness of administrative data due to claims lags, - Amount of time in the field collecting medical record data, - The overall sample size for medical record review (plans with small eligible populations could have samples smaller than 411 members), - Staffing changes among the plan’s HEDIS team, - Voluntary review by an NCQA-Certified HEDIS auditor, - Choice of administrative or hybrid data collection method for measures that allow either method. November 2007| MassHealth Managed Care HEDIS 2007 Report 15 November 2007| MassHealth Managed Care HEDIS 2007 Report Staying Healthy Staying Healthy November 2007| MassHealth Managed Care HEDIS 2007 Report 17 Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile The 2007 national Medicaid 75th percentile for this measure is not available. Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile The 2007 national Medicaid 75th percentile for this measure is not available. Breast Cancer Screening Nationally, the incidence of breast cancer has declined over the past decade. The incidence of new breast cancers detected at a late stage, however, has not declined since 1987.1 The odds of having late-stage cancer are highest among women who did not receive a breast cancer screening.2 Mammography is the gold standard for early detection of breast cancer and is a statistically significant predictor of breast cancer survival.3 The current national clinical guidelines of leading organizations such as the American Cancer Society, American College of Obstetricians and Gynecologists, and U.S. Preventive Health Services Task Force recommend that women at average risk begin annual mammography at age 40.4 Despite these recommendations, recent studies, including an analysis of data from the Behavioral Risk Factor Surveillance System (BRFSS), have indicated a downward trend in national mammography rates for women over 40.5 Although current national clinical guidelines recommend annual screening, this HEDIS measure assesses whether women are screened once every two years. The percentage of women 42-51 years of age as of December 31, 2006 who had one or more mammograms during 2005 or 2006. The percentage of women 52-69 years of age as of December 31, 2006 who had one or more mammograms during 2005 or 2006. Ages 42-51 KEY: 61.3% 62.9% 58.9% 63.8% 57.2% 58.9% 0% 20% 40% 60% 80% 100% B M CHP FCHP NH NHP P CCP M assHealth Weighted M ean MA Co m m Mean Nat'l M caid Mean Nat'l M caid 75th P ctile n/a Ages 52-69 76.3% 73.9% 67.3% 70.5% 66.9% 68.2% 79.6% 54.8% 59.2% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP M assHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile Understanding the Results NCQA changed the age requirements for this measure, decreasing the lower age limit from 52 to 42, starting with HEDIS 2007. The measure is now reported in two age stratifications. The first age stratification (42-51) is considered a new measure for HEDIS 2007; therefore, no benchmarks are available for this age group. The other age stratification (5269) corresponds to the previous HEDIS Breast Cancer Screening measure and benchmarks for that age stratification are available. Since the Breast Cancer Screening measure was last reported by MassHealth plans, NCQA changed the specifications to require plans to report this measure using administrative (claims) data only. Plans are no longer allowed to supplement their administrative data with information from medical records to calculate breast cancer screening rates. The HEDIS Breast Cancer Screening measure evaluates whether women had at least one mammogram in the previous two years. MassHealth members aged 42-51 had lower rates of breast cancer screening (58.9%) compared to members aged 52-69 (68.2%). For members aged 42-51, plan rates for breast cancer screening ranged from 57.2% to 63.8%. For members aged 52-69, plan rates for breast cancer screening ranged from 66.9% to 76.3%. All five Mass- Health plans had rates for the 52-69 year age group that were significantly better than the benchmark rate (59.2%). Two important considerations for evaluating the HEDIS 2007 Breast Cancer Screening results are the quality of the data sources used to calculate breast screening rates and the (Continued on p. 20) November 2007| MassHealth Managed Care HEDIS 2007 Report Breast Cancer Screening Statistical Summary– Ages 42-51 Comparison to 2007 Rates: PCCP(A) NHP(A) NH(A) FCHP(A) BMCHP(A) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2005 Rate n/a* MassHealth Plan Rates 2007 Comparison Rates Nat'l Mcaid 90th Pctile: —-Nat'l Mcaid Mean: —- Nat'l Mcaid 75th Pctile: —-MA Commercial Mean: —- MassHealth Weighted Mean: MassHealth Median: 58.9% 61.3% 2005 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP 2007 Num Den Rate LCL UCL PCCP (A) 7,358 12,866 57.2% 56.3% 58.0% NHP (A) 1,669 2,614 63.8% 62.0% 65.7% NH (A) 911 1548 58.9% 56.4% 61.3% FCHP (A) 176 280 62.9% 57.0% 68.7% BMCHP (A) 2,126 3,468 61.3% 59.7% 62.9% n/a* * Previous data and some comparison rates are not available for this age stratification. Statistical Summary– Ages 52-69 Comparison to 2007 Rates: PCCP(A) NHP(A) NH(A) FCHP(A) BMCHP(A) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2005 Rate .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 65.2% Nat'l Mcaid Mean: Nat'l Mcaid 75th Pctile: 59.2% MA Commercial Mean: 54.8% 79.6% MassHealth Weighted Mean: MassHealth Median: 68.2% 70.5% MassHealth Plan Rates 2007 Num Den Rate LCL UCL 2005 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP (A) 8,273 12,361 (A) 469 665 (A) 538 799 (A) 113 153 (A) 1,360 1,782 66.9% 66.1% 67.8% 67.0% 74.1% 64.0% 70.6% 66.6% 81.1% 74.3% 78.3% PCCP NHP NH FCHP BMCHP (A) 8,226 12,665 (A) 249 335 (A) 324 503 (A) 114 162 (H) 321 411 65.0% 64.1% 65.8% 79.2% 68.7% 77.7% 82.2% 69.5% 60.1% 63.0% 74.0% 70.5% 74.3% 67.3% 64.4% 73.9% 70.4% 76.3% 78.1% The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2007. Num indicates Numerator Elig indicates the Eligible Population Den indicates Denominator LCL indicates Lower Confidence Level UCL indicates Upper Confidence Level (A) = Measure was collected using administrative method (H) = Measure was collected using hybrid method Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom no medical record documentation is found are considered non-compliant with the measure. Legend: .. 2007 rate is significantly above the comparison rate. .. 2007 rate is not significantly different from the comparison rate. .. 2007 rate is significantly below the comparison rate. November 2007| MassHealth Managed Care HEDIS 2007 Report 20 20 Breast Cancer Screening Understanding the Results (continued) ongoing controversy over universal screening for women ages 40-49 years.6 The HEDIS Breast Cancer Screening measure is now calculated using administrative data only. There is some evidence that reliance on administrative data may yield rates that underestimate breast cancer screening in the measured population.7 Although medical record review may offer more accurate data on screening, medical record review is costly and the quality of medical record data is subject to problems such as incomplete charts, patients with multiple charts, and other data collection problems. HEDIS 2007 is the first HEDIS measurement set to require plans to report breast screening rates for the 40-49 year old population. Despite some current clinical guidelines that recommend universal annual screening beginning with age 40 and the cost-effectiveness of screening this population there is ongoing controversy over the benefits of subjecting women ages 40-49 to population- based breast cancer screening.8 Some researchers suggest that clinicians tailor breast cancer screening practices for women 40-49 years based on individual risk for breast cancer as well as the benefits and risks for screening.9 The ongoing controversy around screening women ages 40-49 years of age may lead to slower adoption of current clinical guidelines by some providers and lower HEDIS rates for this group. November 2007| MassHealth Managed Care HEDIS 2007 Report November 2007| MassHealth Managed Care HEDIS 2007 Report 21 Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile The 2007 national Medicaid 75th percentile for this measure is not available. Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile The 2007 national Medicaid 75th percentile for this measure is not available. Cervical Cancer Screening The National Cancer Institute estimates that there will be 11,150 new cases of cervical cancer in the United States in 2007 with 3,670 deaths. Cervical cancer is the second leading cause of death from cancer in women ages 20-39.12 With a 73% survival rate, cervical cancer is highly curable, particularly if it is detected and treated early. Because early stage cervical cancers usually have no symptoms, regular Pap tests are crucial to identifying cancers before they becomes invasive. According to the American Cancer Society, between 60% and 80% of women with newly diagnosed invasive cervical cancer have not had a Pap test in the past 5 years, and many of these women have never had a Pap test. Cervical Cancer Screening Understanding the Results The percentage of women 21-64 who received one or more Pap tests to screen for cervical cancer in the preceding three years (2004-2006). 81.0% 85.2% 75.6% 85.2% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP M assHealth Weighted M ean MA Co mm M ean Nat'l M caid M ean Nat'l M caid 75th P ctile * Benchmarks are unavailable for this measure. 74.1% 78.6% n/a* KEY: NCQA changed the age requirements for this measure, raising the lower age limit from 18 to 21, starting with HEDIS 2007. The measure’s age range of 21-64 corresponds with current guidelines that recommend initiation of cervical cancer screening approximately three years after the onset of sexual activity but no later than age 21. Because NCQA changed the age range for this measure, no benchmarks are available and comparison to past performance is not possible. Seventy-nine percent (78.6%) of MassHealth members aged 21-64 received one or more Pap tests to screen for cervical cancer in the preceding three years. Plan rates for cervical cancer screening ranged from 74.1% to 85.2%. The HEDIS Cervical Cancer Screening measure evaluates whether women had at least one Pap test in the previous three years. Many providers continue to provide their patients with annual Pap tests. In fact, many doctors are reluctant to reduce the frequency of screening to every 3 years because annual Pap tests bring women into their office and many women prefer annual screening.13 One of the greatest factors for screening is physician recommendation; lack of physician recommendation contributes to underuse of the Pap test.15 Other factors contributing to cervical cancer screening rates include access to preventive services and using personalized communications. November 2007| MassHealth Managed Care HEDIS 2007 Report Cervical Cancer Screening Statistical Summary Comparison to 2007 Rates: PCCP(H) NHP(H) NH(H) FCHP(H) BMCHP(H) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2005 Rate* n/a * 2007 Comparison Rates MassHealth Plan Rates 2005 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP Elig2007 Num Den Rate LCL UCL PCCP (H) 243 328 74.1% 69.2% 79.0% NHP (H) 350 411 85.2% 81.6% 88.7% NH (H) 248 328 75.6% 70.8% 80.4% FCHP (H) 350 411 85.2% 81.6% 88.7% BMCHP (H) 333 411 81.0% 77.1% 84.9% Elig 35,592 18,145 10,920 1,936 24,992 Nat'l Mcaid 90th Pctile: 77.4% Nat'l Mcaid Mean: 65.7% MassHealth Weighted Mean: 78.6% Nat'l Mcaid 75th Pctile: 72.0% MA Commercial Mean: 86.1% MassHealth Median: 81.0% n/a** * Due to changes in the specifications of this measure, benchmark comparisons are not appropriate for this cycle. ** Due to changes in the specifications of this measure, results from previous cycles are not comparable. Legend: Num indicates Numerator (A) = Measure was collected using administrative method .. 2007 rate is significantly above the comparison rate. Elig indicates the Eligible Population (H) = Measure was collected using hybrid method .. 2007 rate is not significantly different from the comparison rate. Den indicates Denominator Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor can .. 2007 rate is significantly below the comparison rate. LCL indicates Lower Confidence Level impact performance on a hybrid measure. Per NCQA’s specifications, members for whom no UCL indicates Upper Confidence Level medical record documentation is found are considered non-compliant with the measure. The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2007. November 2007| MassHealth Managed Care HEDIS 2007 Report Prenatal and Postpartum Care Prenatal and Postpartum Care The U.S. infant mortality rate, the rate at which babies less than one year of age die, has declined steadily over the past four decades. Despite this, the U.S. infant mortality rate ranked 28th among all industrialized nations in 2005.15 The leading causes of infant mortality in the U.S. are congenital malformations, disorders related to pre-term birth and low-birth weight, and Sudden Infant Death Syndrome (SIDS).16 Prenatal visits in the first trimester provide an opportunity for early risk assessment (including screening for tobacco, alcohol, drug use and domestic violence), health promotion (including discussion of exercise habits and environmental hazards) and medical, nutritional and psychosocial interventions that can help ensure good clinical outcomes for both mother and child. Similarly, routine postpartum care between three and eight weeks after delivery help to ensure good outcomes. These visits provide the opportunity for not only a physical exam, but also counseling on continued breastfeeding, family planning and post-partum depression.17 Understanding the Results Timeliness of Prenatal Care Postpartum Care The percentage of live births where the mother received a prenatal care visit in the first trimester or within 42 days of enrollment in the health plan. The percentage of live births where the mother had a postpartum visit on or between 21 and 56 days after delivery. 90.3% 89.2% 71.0% 87.1% 88.1% 86.1% 95.2% 81.2% 88.7% 0% 20% 40% 60% 80% 100 % BM CHP FCHP NH NHP PCCP MassHealth Weighted M ean MA Co mm M ean Nat'l M caid M ean Nat'l M caid 75th P ctile 64.2% 67.2% 60.8% 56.1% 55.2% 59.0% 85.6% 59.1% 65.5% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP MassHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile KEY: Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile Eighty-six percent (86.1%) of MassHealth members had a prenatal visit in the first trimester or within 42 days of enroll- ment. None of the MassHealth plans performed significantly better than the national Medicaid 75th percentile (88.7%), however, four plan’s rates were statistically no different from the benchmark rate. Fifty-nine percent (59.0%) of MassHealth members had a postpartum visit on or between 21 and 56 days after deliv- ery. None of the MassHealth plans performed significantly better than the national Medicaid 75th percentile (65.5%), however, three plan’s rates were statistically no different from the benchmark rate. Some external analyses of national HEDIS timeliness of pre- natal care rates questioned whether rates were driven by data collection issues and were not an accurate reflection of the quality of prenatal care. One study found significantly higher rates of prenatal visits in the first trimester through patient survey and medical record review compared to HE- DIS rates based on administrative data or administrative data combined with medical record data, that HEDIS rates are heavily influenced by missing medical records, and that using the baby’s birth date (from administrative data) yields underestimated rates when delivery occurs before the esti- mated delivery date (EDD).18 November 2007| MassHealth Managed Care HEDIS 2007 Report Prenatal and Postpartum Care Statistical Summary— Timeliness of Prenatal Care Comparison to 2007 Rates: 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 91.5% Nat'l Mcaid 75th Pctile: 88.7% Nat'l Mcaid Mean: MA Commercial Mean: 81.2% 95.2% MassHealth Weighted Mean: 86.1% MassHealth Median: 88.1%Nat’l Mcaid 75th Nat’l Mcaid MA Comm Plan’s 2005 PCCP(H) Pctile Mean Mean Rate MassHealth Plan Rates .. .. .. .. 2007 Num DenElig Rate LCL UCL 2005 Num DenElig Rate LCL UCL NHP(H) .. .. .. .. PCCP (H) 362 4115,150 88.1% 84.8% 91.3% PCCP (H) 284 4115,560 69.1% 64.5% 73.7% 94.5% 83.4% 97.3% 93.9% 88.7% 75.3% 90.8% 88.1% NH(H) FCHP(A) .. .. .. .. .. .. .. .. NHP NH FCHP (H) 351 403 (H) 292 411 (H) 256 287 3,303 2,164 287 87.1% 83.7% 90.5% 66.5% 75.6% 85.4% 93.0% NHP NH FCHP (H) (H) (H) 359 392 326 411 220 234 2,758 1,628 236 91.6% 71.0% 79.3% 89.2% 94.0% BMCHP(H) .. .. .. .. BMCHP (H) 371 4114,408 90.3% 87.3% 93.3% BMCHP (H) 374 4113,430 91.0% Statistical Summary— Postpartum Care Comparison to 2007 Rates: 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 71.1% Nat'l Mcaid 75th Pctile: 65.5% Nat'l Mcaid Mean: MA Commercial Mean: 59.1% 85.6% MassHealth Weighted Mean: MassHealth Median: 59.0% 60.8%Nat’l Mcaid Nat’l Mcaid MA Comm Plan’s 2005 Mean Mean Rate75th Pctile MassHealth Plan Rates PCCP(H) .. .. .. .. 2007 Num DenElig Rate LCL UCL 2005 Num DenElig Rate LCL UCL NHP(H) .. .. .. .. PCCP (H) 227 4115150 55.2% 50.3% 60.2% PCCP 179 411(H) 5,560 43.6% 38.6% 48.5% 62.9% 65.4% 72.9% 65.0% 52.9% 55.7% 60.4% 55.2% NH(H) .. .. .. .. NHP (H) 226 4033303 56.1% 51.1% 61.0% NHP 227 392(H) 2,758 57.9% FCHP(H) .. .. .. .. BMCHP(H) .. .. .. .. NH FCHP BMCHP (H) 250 411 (H) 193 287 (H) 264 411 2164 287 4408 60.8% 56.0% 65.7% 61.6% 72.9% 59.5% 69.0% NH FCHP BMCHP 249 411 156 234 247 411 (H) (H) (H) 1,628 236 3,430 60.6% 67.2% 66.7% 60.1%64.2% Num indicates Numerator Elig indicates the Eligible Population Den indicates Denominator LCL indicates Lower Confidence Level UCL indicates Upper Confidence Level (A) = Measure was collected using administrative method (H) = Measure was collected using hybrid method Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom no medical record documentation is found are considered non-compliant with the measure. Legend: .. 2007 rate is significantly above the comparison rate. .. 2007 rate is not significantly different from the comparison rate. .. 2007 rate is significantly below the comparison rate. The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2007. November 2007| MassHealth Managed Care HEDIS 2007 Report 26 Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile 26 Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile Frequency of Ongoing Prenatal Care Ongoing monitoring throughout pregnancy is necessary to prevent complications that can threaten the health of both mother and child, to monitor fetal development, and to help prepare the woman for delivery. The American College of Obstetrics and Gynecology (ACOG) recommends that women have prenatal visits every four weeks for the first 28 weeks of pregnancy, every two to three weeks for the seven weeks thereafter, and then weekly until delivery. (Although the HEDIS measure is based on the ACOG guidelines, many MassHealth managed care plans follow guidelines from the Massachusetts Health Quality Partnership which recommends monthly visits up to 28 weeks, visits every two weeks until 36 weeks, and then visits once a week until delivery.) The percentage of expected visits a women has throughout her pregnancy, based on gestational age and the time of enrollment, provides important information on the adequacy of prenatal care. This measure only provides information on the number of visits, however, and does not indicate whether the timing, content or distribution of those visits throughout the pregnancy was appropriate. = 81% of Expected Visits Understanding the Results The percentage of live births where the mother received 81 percent or more of the expected number of prenatal care visits, adjusted for gestational age and the month that the member enrolled in the health plan. This meas- ure uses the same denominator as the Prenatal and Postpartum Care measure. Sixty-two percent (61.7%) of MassHealth members 81% or more of the expected number of prenatal visits, adjusted for gestational age and the month that the member enrolled in the health plan. None of the MassHealth plans performed significantly better than the benchmark rate (71.7%). Performance on this measure varied widely. Individual plan rates ranged from 49.4% to 72.8% of members receiving more than 81% of the expected number of prenatal visits, adjusted for gestational age and the month that the member enrolled in the health plan. There are a number of factors that may contribute to whether women receive the recommended number of prenatal visits including logistical barriers such as transportation and child care for other children and psychosocial barriers such as fear and negative attitudes.19-22 KEY: 62.0% 72.8% 49.4% 67.2% 62.3% 61.7% 58.6% 71.7% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP M assHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile Medicaid only measure November 2007| MassHealth Managed Care HEDIS 2007 Report Frequency of Ongoing Prenatal Care Statistical Summary— =81% of Expected Visits Comparison to 2007 Rates: PCCP(H) NHP(H) NH(H) FCHP(H) BMCHP(H) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean * Plan’s 2004 Rate .. .. n/a .. .. n/a .. .. n/a .. .. n/a .. .. n/a .. .. .. .. .. 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 78.6% Nat'l Mcaid Mean: 58.6% MassHealth Weighted Mean: 61.7% Nat'l Mcaid 75th Pctile: 71.7% MA Commercial Mean: n/a * MassHealth Median: 62.3% MassHealth Plan Rates 2007 Num Elig Den Rate LCL UCL 2005 Num Elig Den Rate LCL UCL PCCP NHP NH FCHP BMCHP (H) 256 (H) 271 (H) 203 (H) 209 (H) 255 5,150 3,303 2164 287 4,408 411 403 411 287 411 62.3% 57.5% 67.1% 62.5% 72.0% 44.4% 54.3% 67.5% 78.1% 57.2% 66.9% PCCP NHP NH FCHP BMCHP (H) (H) (H) (H) (H) 224 322 231 165 296 5,560 2,758 1,628 236 3,430 411 392 411 234 411 54.5% 49.6% 78.2% 51.3% 64.5% 67.6% 59.4% 86.1% 61.1% 76.6% 76.5% 67.2% 82.1% 49.4% 56.2% 72.8% 70.5% 62.0% 72.0% * This is a Medicaid-only measure Legend: Num indicates Numerator (A) = Measure was collected using administrative method .. 2006 rate is significantly above the comparison rate. Elig indicates the Eligible Population (H) = Measure was collected using hybrid method .. 2006 rate is not significantly different from the comparison rate. Den indicates Denominator Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor .. 2006 rate is significantly below the comparison rate. LCL indicates Lower Confidence Level can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom UCL indicates Upper Confidence Level no medical record documentation is found are considered non-compliant with the measure. The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2007. November 2007| MassHealth Managed Care HEDIS 2007 Report November 2007| MassHealth Managed Care HEDIS 2007 Report Living With Illness Living With Illness November 2007| MassHealth Managed Care HEDIS 2007 Report 29 30 30 Comprehensive Diabetes Care Nearly 21 million Americans had type 1 or type 2 diabetes in 2005 and the prevalence of diabetes has increased nearly 5% annually between 1990 and 2005.23 Diabetes is the sixth leading case of death in the U.S. For those living with diabetes, it can lead to significant health complications such as heart disease, kidney disease, blindness and amputations.24 Controlling levels of blood glucose, blood pressure, and cholesterol are key to preventing diabetes- related complications. This composite HEDIS measure assesses the effectiveness of diabetes care provided to MassHealth members using a single sample of members ages 18-75* who have type 1 or type 2 diabetes. HbA1c Testing Understanding the Results 0% 20% 40% 60% 80% 100% ** PCCP did not collect or report the Comprehensive Diabetes Care measure for HEDIS 2007. The percentage of members 18-75* years of age with type 1 or type 2 diabetes who had at least one hemoglo- bin A1c (HbA1c) test during 2006. MassHealth required MassHealth plans to report the Comprehensive Diabetes Care measure two years in a row (HEDIS 2006 and HEDIS 2007) in order to align MassHealth’s measurement requirements with NCQA’s measure rotation schedule. PCCP did not report the Comprehensive Diabetes Care measure for HEDIS 2007. Nat'l M caid 75th Pctile 84.3% Some important changes were made to this measure. The LDL-C control <130 mg/dL was retired for HEDIS 2007, but the LDL-C control <100 mg/dL was retained. Three new indicators were Nat'l M caid Mean 78.0% added: two measures of blood pressure control (<130/80 and <140/90) and a measure of good HbA1c control (<7.0%). The addition of these three indicators aligns the overall measure with the MA Comm 91.5% clinical guidelines promoted by the American Diabetes Association. Mean MassHealth Weighted M ean 88.3% Eighty-eight percent (88.3%) of MassHealth members 18-75 years of age with diabetes had a HbA1c test performed during 2006. Individual plan rates ranged from 83.7% to 91.2%. Three PCCP ** MassHealth plans had rates that were significantly better than the benchmark rate (84.3%). All four plans had 2007 rates that were statistically no different than their 2006 rates. NHP 91.2% NH 83.7% FCHP 90.4% 88.8% BM CHP KEY: * This measure’s age range is 18-75. The MassHealth managed care program Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile generally serves members under the age of 65. Members 65 and older occasionally appear in the denominator of a plan’s HEDIS rate due to a number of valid reasons (see page 13 for more information). MassHealth members 65 and older were included in the eligible population for this measure if the member met all eligible population criteria, including enrollment criteria. November 2007| MassHealth Managed Care HEDIS 2007 Report Comprehensive Diabetes Care Good HbA1c Control (<7.0%) Poor HbA1c Control (>9.0%) Understanding the Results The percentage of members 18-75* years of age with The percentage of members 18-75* years of age with type 1 or type 2 diabetes whose most recent HbA1c test type 1 or type 2 diabetes whose most recent HbA1c during 2006 was > 9.0% (poor control). A lower rate test during 2006 was < 7.0% (good control). indicates better performance for this measure. 41.4% 31.1% 41.8% 31.9% 39.0% 23.4% 48.7% 39.7% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP * MassHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile * PCCP did not collect or report the Comprehensive Diabetes Care measure for HEDIS 2007. ** No benchmarks are available. KEY: Comparison rates (Source of National and MA Commercial data: Quality Compass, 2006) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile The 2007 national Medicaid 75th percentile for this measure is not available. 34.8% 29.9% 29.2% 35.8% 33.7% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP * MassHealth Weighted M ean MA Co mm Mean ** Nat'l M caid Mean ** Nat'l M caid 75th P ctile ** n/a ** * This measure’s age range is 18-75. The MassHealth managed care program generally serves members under the age of 65. Members 65 and older occasionally appear in the denominator of a plan’s HEDIS rate due to a number of valid reasons (see page 13 for more information). MassHealth members 65 and older were included in the eligible population for this measure if the member met all eligible population criteria, including enrollment criteria. Thirty-nine percent (39.0%) of MassHealth members 18-75 years of age with diabetes had poor HbA1c control (>9.0%). Individual plan rates ranged from 31.1% to 41.8%. (For this measure, a lower rate means better performance.) Two plans had rates that were significantly lower than the benchmark rate (39.7%), indicating performance that is better than the benchmark. All four plans had 2007 rates that were statistically no different than their 2006 rates. Thirty-four percent (33.7%) of MassHealth members 18-75 years of age with diabetes had good HbA1c control (<7.0%) as indicated by their most recent HbA1c test result during the measurement year. (For this measure, a higher rate means better performance.) Individual plan rates ranged from 29.2% to 35.8%. Because this is a first-year measure, no benchmarks are available for comparison. November 2007| MassHealth Managed Care HEDIS 2007 Report 32 32 Comprehensive Diabetes Care Statistical Summary—HbA1c Testing Comparison to 2007 Rates: PCCP(H) * NHP(H) NH(H) FCHP(H) BMCHP(H) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2006 Rate n/a n/a n/a .. .. .. .. .. .. .. .. .. .. .. .. n/a .. .. .. .. 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 89.1% Nat'l Mcaid Mean: 78.0% MassHealth Weighted Mean: 88.3% Nat'l Mcaid 75th Pctile: 84.3% MA Commercial Mean: 91.5% MassHealth Median: 89.6% MassHealth Plan Rates 2006 Num Den Rate LCL UCL PCCP 355 411 86.4% 82.9% 89.8% NHP 375 411 91.2% 88.4% 94.1% NH 350 411 85.2% 81.6% 88.7% FCHP 142 151 94.0% 89.9% 98.1% BMCHP 373 411 90.8% 87.8% 93.7% (H) (H) (H) (H) (H) Elig 11,659 1,054 1,105 155 2,793 2007 Num Den Rate LCL UCL PCCP * . . . . . . NHP (H) 375 411 91.2% 88.4% 94.1% NH (H) 344 411 83.7% 80.0% 87.4% FCHP (H) 151 167 90.4% 85.7% 95.2% BMCHP (H) 365 411 88.8% 85.6% 92.0% Elig . 1,392 1,290 170 3,210 * PCCP did not collect or report the Comprehensive Diabetes Care measure for HEDIS 2007. Statistical Summary—Poor HbA1c Control (>9.0) Comparison to 2007 Rates: PCCP(H) * NHP(H) NH(H) FCHP(H) BMCHP(H) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2006 Rate n/a n/a n/a .. .. .. .. .. .. .. .. .. .. .. .. n/a .. .. .. .. 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 32.1% Nat'l Mcaid Mean: 48.7% MassHealth Weighted Mean: 39.0% Nat'l Mcaid 75th Pctile: 39.7% MA Commercial Mean: 23.4% MassHealth Median: 36.7% MassHealth Plan Rates 2007 Num Elig Den Rate LCL UCL 2006 Num Elig Den Rate LCL UCL PCCP * NHP NH FCHP BMCHP . . (H) 131 (H) 172 (H) 52 170 . 1,392 1,290 170 3,210 . 411 411 167 411 . . . 27.2% 36.5% 37.0% 46.7% 23.8% 38.5% 36.5% 46.2% PCCP NHP NH FCHP BMCHP (H) (H) (H) (H) (H) 200 134 211 41 139 11,659 1,054 1,105 155 2,793 411 411 411 151 411 48.7% 43.7% 53.6% 27.9% 37.3% 46.4% 56.3% 19.7% 34.6% 29.1% 38.5% 31.9% 32.6% 41.8% 51.3% 31.1% 27.2% 41.4% 33.8% Legend: .. 2007 rate is significantly below the comparison rate. .. 2007 rate is not significantly different from the comparison rate. .. 2007 rate is significantly above the comparison rate. Num indicates Numerator Elig indicates the Eligible Population Den indicates Denominator LCL indicates Lower Confidence Level UCL indicates Upper Confidence Level (A) = Measure was collected using administrative method (H) = Measure was collected using hybrid method Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom no medical record documentation is found are considered non-compliant with the measure. The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2006. November 2007| MassHealth Managed Care HEDIS 2007 Report Comprehensive Diabetes Care Statistical Summary—Good HbA1c Control (<7.0) Comparison to 2007 Rates: PCCP(H) * NHP(H) NH(H) FCHP(H) BMCHP(H) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2006 Rate** n/a** 2007 Comparison Rates Nat'l Mcaid 90th Pctile: —-Nat'l Mcaid Mean: —-MassHealth Weighted Mean: 33.7% Nat'l Mcaid 75th Pctile: —-MA Commercial Mean: —-MassHealth Median: 32.4% MassHealth Plan Rates 2006 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP Elig2007 Num Den Rate LCL UCL PCCP * . . . . . . NHP (H) 147 411 35.8% 31.0% 40.5% NH (H) 120 411 29.2% 24.7% 33.7% FCHP (H) 50 167 29.9% 22.7% 37.2% BMCHP (H) 143 411 34.8% 30.1% 39.5% Elig . 1392 1290 170 3210 n/a** * PCCP did not collect or report the Comprehensive Diabetes Care measure for HEDIS 2007. ** This measure is new for 2007 - previous data and some comparisons rates are unavailable. Legend: .. 2007 rate is significantly above the comparison rate. .. 2007 rate is not significantly different from the comparison rate. .. 2007 rate is significantly below the comparison rate. Num indicates Numerator Elig indicates the Eligible Population Den indicates Denominator LCL indicates Lower Confidence Level UCL indicates Upper Confidence Level (A) = Measure was collected using administrative method (H) = Measure was collected using hybrid method Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom no medical record documentation is found are considered non-compliant with the measure. The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2006. November 2007| MassHealth Managed Care HEDIS 2007 Report 34 34 Comprehensive Diabetes Care LDL-C Testing Understanding the Results Good LDL Control 77.9% 77.8% 80.0% 79.1% 71.1% 77.9% 0% 20% 40% 60% 80% 100% * PCCP did not collect or report the Comprehensive Diabetes Care measure for HEDIS 2007. KEY: Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile The percentage of adults 18 to 75* years of age with type 1 or type 2 diabetes who had an LDL-C test in 2006. The percentage of adults 18 to 75* years of age with type 1 or type 2 diabetes whose most recent LDL-C test during 2006 was <100 mg/dL. 81.3% 86.5% BM CHP FCHP NH NHP PCCP * MassHealth Weighted M ean MA Co m m Mean Nat'l M caid Mean Nat'l M caid 75th P ctile 35.3% 35.3% 37.0% 35.0% 35.6% 44.9% 30.6% 37.2% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP * MassHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile * This measure’s age range is 18-75. The MassHealth managed care program generally serves members under the age of 65. Members 65 and older occasionally appear in the denominator of a plan’s HEDIS rate due to a number of valid reasons (see page 13 for more information). MassHealth members 65 and older were included in the eligible population for this measure if the member met all eligible population criteria, including enrollment criteria. NCQA made changes to both LDL cholesterol testing and control measures for HEDIS 2007 by restricting the criteria to require testing during the measurement year. For previous measurement cycles, tests from the measurement year and the year before were allowed. As such, 2007 rates for both of these measures cannot be compared to those from 2006. Seventy-nine percent (79.1%) of MassHealth members 18-75 years of age with diabetes had an LDL cholesterol test during 2006. Individual plan rates ranged from 77.8% to 81.3%. None of the Mass- Health plans had a rate that was significantly different from the benchmark rate (77.9%). The target goal of cholesterol management in people with diabetes is an LDL less than 100 mg/dL. Thirty-six percent (35.6%) of MassHealth members 18-75 years of age with diabetes had their most recent cholesterol level in 2006 controlled to <100mg/ dL. Individual plan ranged from 35.0% to 37.0%. None of the MassHealth plans had a rate that was significantly above or no different from the benchmark rate (37.2%). November 2007| MassHealth Managed Care HEDIS 2007 Report Comprehensive Diabetes Care Comprehensive Diabetes Care Statistical Summary—LDL-C Screening Comparison to 2007 Rates: 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 81.0% Nat'l Mcaid Mean: 71.1% MassHealth Weighted Mean: 79.1% Nat'l Mcaid 75th Pctile: 77.9% MA Commercial Mean: 86.5% MassHealth Median: 79.0%Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2006 Rate PCCP(H) * n/a n/a n/a n/a NHP(H) .. .. .. .. NH(H) .. .. .. .. FCHP(H) .. .. .. .. BMCHP(H) .. .. .. .. MassHealth Plan Rates 2006 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP Elig2007 Num Den Rate LCL UCL PCCP * . . . . . . NHP (H) 329 411 80.0% 76.1% 84.0% NH (H) 334 411 81.3% 77.4% 85.2% FCHP (H) 130 167 77.8% 71.2% 84.4% BMCHP (H) 320 411 77.9% 73.7% 82.0% Elig . 1,392 1,290 170 3,210 n/a** * PCCP did not collect or report the Comprehensive Diabetes Care measure for HEDIS 2007. ** This measure is new for 2007 - previous data and some comparisons rates are unavailable. Statistical Summary—Good LDL-C Control - <100 mg/dL Comparison to 2007 Rates: Nat'l Mcaid 90th Pctile: 44.1% Nat'l Mcaid Mean: 30.6% MassHealth Weighted Mean: 35.6% Nat’l Nat’l MA Plan’s Nat'l Mcaid 75th Pctile: 37.2% MA Commercial Mean: 44.9% MassHealth Median: 35.3% Mcaid 75th Mcaid Comm 2006 Pctile Mean Mean Rate Rate n/a** MassHealth Plan Rates PCCP(H) * 2007 Num Elig Den LCL UCL 2006 Num Elig Den LCL UCL PCCP * n/a n/a n/a n/a .. . . .. PCCP NHP(H) .. ...... NHP (H) 144 1,392 411 Rate .35.0% 30.3% 39.8% NHP NH(H) ........ NH (H) 152 1,290 411 37.0% 32.2% 41.8% NH FCHP(H) .. ...... FCHP (H) 59 170 167 35.3% 27.8% 42.9% FCHP BMCHP(H) BMCHP (H) 145 3,210 411 35.3% 30.5% 40.0% BMCHP .. ...... 2007 Comparison Rates Num indicates Numerator Elig indicates the Eligible Population Den indicates Denominator LCL indicates Lower Confidence Level UCL indicates Upper Confidence Level (A) = Measure was collected using administrative method (H) = Measure was collected using hybrid method Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom no medical record documentation is found are considered non-compliant with the measure. Legend: .. 2007 rate is significantly above the comparison rate. .. 2007 rate is not significantly different from the comparison rate. .. 2007 rate is significantly below the comparison rate. November 2007| MassHealth Managed Care HEDIS 2007 Report The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2007. 36 36 Comprehensive Diabetes Care Eye Exams Understanding the Results Monitoring Kidney Disease The percentage of adults 18 to 75* years of age with The percentage of adults 18 to 75* years of age with type 1 or type 2 diabetes who had a retinal or dilated type 1 or type 2 diabetes who were screened for kid- eye exam by an eye care professional in 2006 or a ney disease (nephropathy) during 2006 (adults with a negative retinal exam by an eye care professional in history of the disease were also considered compli2005. ant). 74.7% 67.7% 62.8% 70.3% 71.0% 71.0% 51.4% 62.7% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP * MassHealth Weighted M ean MA Co m m Mean Nat'l M caid Mean Nat'l M caid 75th P ctile * PCCP did not collect or report the Comprehensive Diabetes Care measure for HEDIS 2007. KEY: Comparison rates (Source of National and MA Commercial data: Quality Compass, 2006) Rate is significantly above the 2006 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2006 national Medicaid 75th percentile * This measure’s age range is 18-75. The MassHealth managed care program generally serves members under the age of 65. Members 65 and older occasionally appear in the denominator of a plan’s HEDIS rate due to a number of valid reasons (see page 13 for more information). MassHealth members 65 and older were included in the eligible population for this measure if the member met all eligible population criteria, including enrollment criteria. Seventy-one percent (71.0%) of MassHealth members 18-75 years of age with diabetes had an eye exam in 2006 or a negative eye exam in 2005. Individual plan rates ranged from 62.8% to 74.7%. Two plans had rates that were significantly above the benchmark rate (62.7%). None of the plans had rates that were statistically significant compared to their 2006 rates. Beginning with HEDIS 2007, NCQA allowed the use of ACE/ARBs to count toward numerator compliance for the monitoring kidney disease measure. Therefore, 2007 rates cannot be compared to those from 2006. Eighty-two percent (82.2%) of MassHealth members 18-75 years of age with diabetes were either screened for kidney disease in 2006 or had evidence of disease. Individual plan rates ranged from 76.6% to 83.7%. None of the MassHealth plans had a rate that was statistically different from the benchmark rate (81.8%). 83.7% 76.6% 78.3% 83.2% 82.2% 84.9% 74.6% 81.8% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP * MassHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile November 2007| MassHealth Managed Care HEDIS 2007 Report Comprehensive Diabetes Care Statistical Summary—Eye Exams Comparison to 2007 Rates: PCCP(H) * NHP(H) NH(H) FCHP(H) BMCHP(H) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2006 Rate n/a n/a n/a .. .. .. .. .. .. .. .. .. .. .. .. n/a .. .. .. .. 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 68.3% Nat'l Mcaid Mean: 51.4% MassHealth Weighted Mean: 71.0% Nat'l Mcaid 75th Pctile: 62.7% MA Commercial Mean: 71.0% MassHealth Median: 69.0% MassHealth Plan Rates 2007 Num DenElig Rate LCL UCL 2006 Num DenElig Rate LCL UCL PCCP * NHP NH FCHP BMCHP . . . (H) 289 411 (H) 258 411 (H) 113 167 (H) 307 411 . 1392 1290 170 3210 . . . 65.8% 74.9% 58.0% 67.6% 60.3% 75.1% 70.4% 79.0% PCCP NHP NH FCHP BMCHP (H) (H) (H) (H) (H) 223 411 269 411 246 411 85 151 287 411 11,659 1,054 1,105 155 2,793 54.3% 49.3% 59.2% 60.7% 70.2% 55.0% 64.7% 48.0% 64.5% 65.3% 74.4% 70.3% 65.5% 62.8% 59.9% 67.7% 56.3% 74.7% 69.8% * The PCCP did not collect or report the Comprehensive Diabetes Care measure for HEDIS 2007. ** This measure is new for 2007 - previous data and some comparisons rates are unavailable. Statistical Summary—Monitoring Kidney Disease Comparison to 2007 Rates: PCCP(H) * NHP(H) NH(H) FCHP(H) BMCHP(H) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2006 Rate n/a n/a n/a .. .. .. .. .. .. .. .. .. .. .. .. n/a n/a n/a n/a n/a 2006 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP Elig 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 85.5% Nat'l Mcaid Mean: 74.6% MassHealth Weighted Mean: 82.2% Nat'l Mcaid 75th Pctile: 81.8% MA Commercial Mean: 84.9% MassHealth Median: 80.8% MassHealth Plan Rates 2007 Num Den Rate LCL UCL PCCP * . . . . . . NHP (H) 342 411 83.2% 79.5% 86.9% NH (H) 322 411 78.3% 74.2% 82.4% FCHP (H) 128 167 76.6% 69.9% 83.4% BMCHP (H) 344 411 83.7% 80.0% 87.4% Elig . 1392 1290 170 3210 n/a** Legend: Num indicates Numerator (A) = Measure was collected using administrative method .. 2007 rate is significantly above the comparison rate. Elig indicates the Eligible Population (H) = Measure was collected using hybrid method .. 2007 rate is not significantly different from the comparison rate. Den indicates Denominator Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor .. 2007 rate is significantly below the comparison rate. LCL indicates Lower Confidence Level can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom UCL indicates Upper Confidence Level no medical record documentation is found are considered non-compliant with the measure. The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2007. November 2007| MassHealth Managed Care HEDIS 2007 Report 38 38 Comprehensive Diabetes Care Blood Pressure Control (<130/80) Understanding the Results Blood Pressure Control (<140/90) The percentage of adults 18 to 75* years of age with type 1 or type 2 diabetes whose most recent blood pressure reading in 2006 was <130/80 mm Hg. The percentage of adults 18 to 75* years of age with type 1 or type 2 diabetes whose most recent blood pressure reading in 2006 was <140/90 mm Hg. 34.3% 45.5% 38.2% 34.5% 35.5% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP * MassHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile n/a * PCCP did not collect or report the Comprehensive Diabetes Care measure for HEDIS 2007. KEY: Comparison rates (Source of National and MA Commercial data: Quality Compass, 2006) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile The 2007 national Medicaid 75th percentile for this measure is not available. 67.9% 77.8% 66.9% 68.4% 68.1% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP * MassHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile n/a * This measure’s age range is 18-75. The MassHealth managed care program generally serves members under the age of 65. Members 65 and older occasionally appear in the denominator of a plan’s HEDIS rate due to a number of valid reasons (see page 13 for more information). MassHealth members 65 and older were included in the eligible population for this measure if the member met all eligible population criteria, including enrollment criteria. Both blood pressure control measures (<130/80 and <140/90) were added for HEDIS 2007. Because these are first-year measures, no benchmarks are available and comparison to past performance is not possible. The addition of these indicators aligns the measure more closely with the clinical guidelines promoted by the American Diabetes Association. Thirty-six percent (35.5%) of MassHealth members 1875 years old had their blood pressure controlled to less than 130/80 during the measurement year. Individual plan rates ranged from 34.3% to 45.5%. Sixty-eight percent (68.1%) of MassHealth members 18-75 years old had their blood pressure controlled to less than 140/90 during the measurement year. Individual plan rates ranged from 66.9% to 77.8%. November 2007| MassHealth Managed Care HEDIS 2007 Report Comprehensive Diabetes Care Statistical Summary—Blood Pressure Control (<130/80) Comparison to 2007 Rates: PCCP(H) * NHP(H) NH(H) FCHP(H) BMCHP(H) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2006 Rate** n/a** 2007 Comparison Rates Nat'l Mcaid 90th Pctile: —-Nat'l Mcaid Mean: —-MassHealth Weighted Mean: 35.5% Nat'l Mcaid 75th Pctile: —-MA Commercial Mean: —-MassHealth Median: 36.4% MassHealth Plan Rates 2006 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP Elig2006 Num Den Rate LCL UCL PCCP * . . . . . . NHP (H) 142 411 34.5% 29.8% 39.3% NH (H) 157 411 38.2% 33.4% 43.0% FCHP (H) 76 167 45.5% 37.7% 53.4% BMCHP (H) 141 411 34.3% 29.6% 39.0% Elig . 1392 1290 170 3210 n/a** * PCCP did not collect or report the Comprehensive Diabetes Care measure for HEDIS 2007. ** This measure is new for 2007, so previous data and some comparison rates are not available. Statistical Summary—Blood Pressure Control (<140/90) Comparison to 2007 Rates: PCCP(H) * NHP(H) NH(H) FCHP(H) BMCHP(H) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2006 Rate** n/a** 2007 Comparison Rates Nat'l Mcaid 90th Pctile: —-Nat'l Mcaid Mean: —-MassHealth Weighted Mean: 68.1% Nat'l Mcaid 75th Pctile: —-MA Commercial Mean: —-MassHealth Median: 68.2% MassHealth Plan Rates 2006 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP Elig2006 Num Den Rate LCL UCL PCCP * . . . . . . NHP (H) 281 411 68.4% 63.8% 73.0% NH (H) 275 411 66.9% 62.2% 71.6% FCHP (H) 130 167 77.8% 71.2% 84.4% BMCHP (H) 279 411 67.9% 63.2% 72.5% Elig . 1392 1290 170 3210 n/a** Legend: .. 2007 rate is significantly above the comparison rate. Num indicates Numerator Elig indicates the Eligible Population (A) = Measure was collected using administrative method (H) = Measure was collected using hybrid method .. 2007 rate is not significantly different from the comparison rate. Den indicates Denominator Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor .. 2007 rate is significantly below the comparison rate. LCL indicates Lower Confidence Level can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom UCL indicates Upper Confidence Level no medical record documentation is found are considered non-compliant with the measure. The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2007. November 2007| MassHealth Managed Care HEDIS 2007 Report 40 40 Comprehensive Diabetes Care Understanding the Results (continued) Successful diabetes care requires effective communication between physicians and other health care professionals and their patients so that information on the importance of screenings and self management tools and skills for this chronic disease can be relayed. Patients must learn to practice effective self management strategies such as monitoring blood glucose levels, eating healthfully, getting adequate exercise, and taking medications for blood pressure and cholesterol control, if necessary, to prevent or manage diabetes complications. 25 Several individual and organizational factors impact the communication between physicians and patients regarding self management strategies and are associated with the quality of diabetes care. Some of these factors include: • limited health literacy.26 • limited English proficiency.26 • low self-efficacy or confidence in the ability to perform healthy behaviors, and26,27 • presence and intensity of diabetes disease management programs.28 Individuals with diabetes typically need support from resources in addition to providers to successfully self manage their diabetes. A recent evaluation of self-management support programs found that a weekly automated telephone disease management program helped individuals with diabetes set and achieve goals for diabetes self management behaviors.25 This program was especially helpful for individuals with communication barriers such as limited English proficiency or low health literacy. The American Diabetes Association’s 2006 version of Standards of Medical Care in Diabetes recommends strategies for improving diabetes care, several of which target changes at the nexus of care between physicians and patients and include the following: • incorporating diabetes care guidelines into the point of service • providing diabetes self management education to patients • access to care management services, and • use of electronic medical record technology to identify patients requiring assessments or treatment modifications. Additionally, an area that is critical for diabetes care is preventing or managing heart disease. Unfortunately, a recent survey conducted by ADA found that only 18 percent of people with diabetes believed that they were at increased risk of developing heart disease.29 Increasing awareness regarding the risk of heart disease for patients with diabetes may help improve blood pressure and cholesterol control rates in the future. November 2007| MassHealth Managed Care HEDIS 2007 Report November 2007| MassHealth Managed Care HEDIS 2007 Report 41 42 all eligible population criteria, including enrollment criteria. 42 all eligible population criteria, including enrollment criteria. Controlling Blood Pressure Nearly one-third of the U.S. population has hypertension and only 30% of those people have their blood pressure in good control.30 The HEDIS Controlling High Blood Pressure measure defines blood pressure control as <140/90, a less stringent requirement than some current clinical guidelines such as the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure or JNCVIII, which defines good control as <130/80. Lifestyle modifications such as increased exercise and reduced salt intake can help individuals control their blood pressure. In addition, antihypertensive pharmacotherapy is effective in controlling blood pressure and has been associated with reduced incidence of stroke, heart at- The percentage of members 18-45 years of age who had a diagnosis of hypertension and whose most recent blood pressure in 2006 was adequately controlled (<140/90). The percentage of members 46-85* years of age who had a diagnosis of hypertension and whose most recent blood pressure in 2006 was adequately controlled (<140/90). tack, and heart failure.31 Ages 18-45 52.0% 64.1% 56.6% 59.5% 52.6% 54.1% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP MassHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile KEY: n/a Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile The 2007 national Medicaid 75th percentile for this measure is not available. Ages 46-85 55.6% 70.9% 56.2% 63.6% 53.2% 54.7% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP MassHealth Weighted M ean MA Co m m Mean Nat'l M caid Mean Nat'l M caid 75th P ctile n/a * This measure’s age range is 18-85. The MassHealth managed care program generally serves members under the age of 65. Members 65 and older occasionally appear in the denominator of a plan’s HEDIS rate due to a number of valid reasons (see page 13 for more information). MassHealth members 65 and older were included in the eligible population for this measure if the member met Understanding the Results For HEDIS 2007, NCQA decreased the lower age limit of this measure from 46 to 18. This measure is now reported in two age stratifications. The first age stratification (18-45) is considered a new measure for HEDIS 2007; therefore, no benchmarks are available for this age group. Although the other age stratification (46-85) corresponds to the previous HEDIS Controlling High Blood Pressure measure, NCQA also changed the definition of control from =140/90 to <140/90. This change in the definition of control means no benchmarks are available and comparison to past performance is not possible. Fifty-four percent (54.1%) of MassHealth members aged 18-45 had their most recent blood pressure in 2006 controlled to <140/90. Individual plan rates ranged from 52.0% to 64.1%. Fifty-five percent (54.7%) of MassHealth members aged 46-85 had their most recent blood pressure in 2006 controlled to <140/90. Individual plan rates ranged from 53.2% to 70.9%. (Continued on page 44) November 2007| MassHealth Managed Care HEDIS 2007 Report Controlling Blood Pressure Statistical Summary— Ages 18-45 Comparison to 2007 Rates: Nat’l Nat’l MA Plan’s Nat'l Mcaid 75th Pctile: —-MA Commercial Mean: —-MassHealth Median: 56.6% Mcaid 75th Mcaid Comm 2005 Pctile Mean Mean Rate* Nat'l Mcaid 90th Pctile: —-Nat'l Mcaid Mean: —-MassHealth Weighted Mean: 54.1% 2005 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP Elig2007 Num Den Rate LCL UCL PCCP (H) 50 95 52.6% 42.1% 63.2% NHP (H) 122 205 59.5% 52.5% 66.5% NH (H) 86 152 56.6% 48.4% 64.8% FCHP (H) 41 64 64.1% 51.5% 76.6% BMCHP (H) 79 152 52.0% 43.7% 60.2% Elig 2,730 944 563 74 1,568 n/a* * Due to changes in the specifications of this measure, previous data and some comparison rates are unavailable. MassHealth Plan Rates 2007 Comparison Rates PCCP(H) NHP(H) NH(H) n/a* FCHP(H) BMCHP(H) Statistical Summary— Ages 46-85 Comparison to 2007 Rates: Nat’l Nat’l MA Plan’s Nat'l Mcaid 75th Pctile: —-MA Commercial Mean: —-MassHealth Median: 56.2% Mcaid 75th Mcaid Comm 2005 Pctile Mean Mean Rate* PCCP(H) NHP(H) NH(H) FCHP(H) BMCHP(H) Nat'l Mcaid 90th Pctile: —-Nat'l Mcaid Mean: —-MassHealth Weighted Mean: 54.7% 2005 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP Elig2007 Num Den Rate LCL UCL PCCP (H) 168 316 53.2% 47.5% 58.8% NHP (H) 131 9,003 206 63.6% 56.8% 70.4% NH (H) 127 226 56.2% 49.5% 62.9% FCHP (H) 95 804 134 70.9% 62.8% 79.0% BMCHP (H) 144 259 55.6% 49.4% 61.8% 2,326 Elig 901 137 n/a* MassHealth Plan Rates 2006 Comparison Rates n/a* Legend: .. 2007 rate is significantly above the comparison rate. .. 2007 rate is not significantly different from the comparison rate. .. 2007 rate is significantly below the comparison rate. Num indicates Numerator (A) = Measure was collected using administrative method Den indicates Denominator (H) = Measure was collected using hybrid method LCL indicates Lower Confidence Level Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor UCL indicates Upper Confidence Level can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom no medical record documentation is found are considered non-compliant with the measure. The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2007. November 2007| MassHealth Managed Care HEDIS 2007 Report 44 44 Controlling High Blood Pressure Understanding the Results (continued) The definition of blood pressure control currently used for the HEDIS Controlling High Blood Pressure measure is <140/90, a criteria that is less stringent than other clinical guidelines. The HEDIS measure’s definition of the eligible population includes all members who meet the diagnosis criteria for hypertension and does not exclude higher risk populations such as members with diabetes (the one exception is that the measure does exclude members with a diagnosis of end stage renal disease.). Although a control threshold of <140/90 may be appropriate for certain populations, it may not be an appropriate threshold for more complicated members, such as those with co-morbid diabetes or heart disease, who should have their blood pressure controlled to at least <130/80.33 Uncontrolled hypertension is associated with lack of adherence to drug treatment and a lack of access to health care.34,35 An external review of this HEDIS measure demonstrated that patients who meet the HEDIS blood pressure measure may take fewer blood pressure drugs and have lower antihypertensive drug costs than patients who do not meet the measure.36 A number of patient factors may be related to adherence to hypertension treatment plans (and therefore blood pressure control) such as the severity of the hypertension, number of comorbitidies, and side effects to treatment. Strategies to improve patient adherence to hypertension treatment include designing treatment plans to reflect patient preferences and lifestyles, identifying specific blood pressure targets, in structing patients to perform self-management, and discussing strategies for managing side effects. 37 November 2007| MassHealth Managed Care HEDIS 2007 Report November 2007| MassHealth Managed Care HEDIS 2007 Report 45 46 46 Antidepressant Medication Management Antidepressants are effective in treating depression, however poor adherence is often an issue especially among lower socioeconomic populations.38 Discontinuing antidepressants prematurely can lead to increased risk of depression relapse and development of new episodes of depression.39 The HEDIS Antidepressant Medication Management measure assesses three aspects of the successful pharmacological management of depression for newly diagnosed MassHealth members 18 years of age and older. A recent study using the HEDIS Antidepressant Medication Management measure on a commercial population found that only 19% of patients achieved overall adherence for all three of the measure’s indicators (optimal practitioner contacts, effective The percentage of members 18 years of age and older The percentage of members 18 years of age and older who where diagnosed with a new episode of depression who were diagnosed with a new episode of depression, and treated with antidepressant medication and who re- were treated with antidepressant medication and remained mained on an antidepressant drug for at least 180 days. on an antidepressant drug during the entire 84-day Acute Treatment Phase. acute phase treatment and effective continuation phase treatment).40 Optimal Practitioner Contacts The percentage of members 18 years of age and older who were diagnosed with a new episode of depression and treated with antidepressant medication, and who had at least three follow-up contacts with a practitioner coded with a mental health diagnosis during the 84-day Acute Treatment Phase. Nat'l M caid 27.0% 75th Pctile Nat'l M caid 21.3% Mean MA Co mm Mean 29.2% M assHealth Weighted M ean 31.4% PCCP 29.3% NHP 35.3% NH 30.5% FCHP 27.2% BM CHP 34.4% 0% 20% 40% 60% 80% 100% KEY: Comparison rates (Source of National and MA Commercial data: Quality Compass, 2006) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile Effective Acute Phase 35.4% 49.4% 55.1% 45.9% 52.7% 47.9% 62.8% 42.9% 47.9% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP MassHealth Weighted M ean MA Co m m Mean Nat'l M caid Mean Nat'l M caid 75th P ctile Effective Continuation Phase 20.0% 37.0% 43.6% 26.8% 38.1% 32.9% 47.5% 27.5% 32.4% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP MassHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile November 2007| MassHealth Managed Care HEDIS 2007 Report Antidepressant Medication Management Statistical Summary—Optimal Practitioner Contacts Comparison to 2007 Rates: PCCP(A) NHP(A) NH(A) FCHP(A) BMCHP(A) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2005 Rate .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 31.8% Nat'l Mcaid Mean: Nat'l Mcaid 75th Pctile: 27.0% MA Commercial Mean: 21.3% MassHealth Weighted Mean: 31.4% 29.2% MassHealth Median: 30.5% MassHealth Plan Rates 2007 Num Den Rate LCL UCL 2005 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP (A) 614 2,092 (A) 199 564 (A) 140 459 (A) 22 81 (A) 343 998 29.3% 27.4% 31.3% 31.3% 39.3% 26.2% 34.8% 16.9% 37.5% 31.4% 37.4% PCCP NHP NH FCHP BMCHP (A) 461 2,454 (A) 151 504 (A) 51 356 (A) 27 77 (A) 293 834 18.8% 17.2% 20.4% 34.1% 18.1% 46.4% 38.4% 25.9% 10.5% 23.8% 31.8% 35.3% 30.0% 30.5% 14.3% 27.2% 35.1% 34.4% 35.1% Statistical Summary—Effective Acute Phase Comparison to 2007 Rates: PCCP(A) NHP(A) NH(A) FCHP(A) BMCHP(A) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2005 Rate .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 51.1% Nat'l Mcaid Mean: Nat'l Mcaid 75th Pctile: 47.9% MA Commercial Mean: 42.9% MassHealth Weighted Mean: 47.9% 62.8% MassHealth Median: 49.4% MassHealth Plan Rates 2007 Num Den Rate LCL UCL 2005 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP (A) 1,102 2,092 (A) 259 564 (A) 253 459 (A) 40 81 (A) 353 998 52.7% 50.5% 54.8% 41.7% 50.1% 50.5% 59.8% 37.9% 60.9% 32.4% 38.4% PCCP NHP NH FCHP BMCHP (A) 1,180 2,454 (A) 208 504 (A) 185 356 (A) 34 77 (A) 288 834 48.1% 46.1% 50.1% 45.7% 57.3% 55.9% 37.8% 36.9% 46.6% 32.4% 31.2% 45.9% 41.3% 55.1% 52.0% 49.4% 44.2% 35.4% 34.5% Legend: .. 2007 rate is significantly above the comparison rate. .. 2007 rate is not significantly different from the comparison rate. .. 2007 rate is significantly below the comparison rate. Num indicates Numerator (A) = Measure was collected using administrative method Den indicates Denominator (H) = Measure was collected using hybrid method LCL indicates Lower Confidence Level Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor UCL indicates Upper Confidence Level can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom no medical record documentation is found are considered non-compliant with the measure. The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2007. November 2007| MassHealth Managed Care HEDIS 2007 Report 48 48 Antidepressant Medication Management Statistical Summary—Effective Continuation Phase Comparison to 2007 Rates: PCCP(A) NHP(A) NH(A) FCHP(A) BMCHP(A) Nat’l Mcaid 75th Pctile Nat’l Mcaid Mean MA Comm Mean Plan’s 2005 Rate .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 2007 Comparison Rates Nat'l Mcaid 90th Pctile: 34.8% Nat'l Mcaid Mean: Nat'l Mcaid 75th Pctile: 32.4% MA Commercial Mean: 27.5% MassHealth Weighted Mean: 32.9% 47.5% MassHealth Median: 37.0% MassHealth Plan Rates 2007 Num Den Rate LCL UCL 2005 Num Den Rate LCL UCL PCCP NHP NH FCHP BMCHP (A) 798 2,092 (A) 151 564 (A) 200 459 (A) 30 81 (A) 200 998 38.1% 36.0% 40.3% 23.0% 30.5% 38.9% 48.2% 25.9% 48.2% 17.5% 22.6% PCCP NHP NH FCHP BMCHP (A) 799 2,454 (A) 124 504 (A) 132 356 (A) 17 77 (A) 162 834 32.6% 30.7% 34.4% 28.5% 42.2% 32.0% 22.2% 20.7% 31.9% 12.2% 16.7% 26.8% 24.6% 43.6% 37.1% 37.0% 22.1% 20.0% 19.4% The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2007. Understanding the Results Thirty-one percent (31.4%) of MassHealth members who were diagnosed with a new episode of depression and treated with antidepressant medication had at least three follow-up contacts with a practitioner during the 84-day Acute Phase. Individual plan rates ranged from 27.2% to 35.3%. Three plans had rates of optimal practitioner contact that were significantly above the benchmark rate (27.0%). Forty-eight percent (47.9%) of members with a new episode of depression and treated with antidepressant medication remained on an antidepressant drug during the entire 84-day Acute Treatment Phase. Individual plan rates ranged from 35.4% to 55.1%. Two plans had rates of effective acute phase treatment that were significantly above the benchmark rate (47.9%) and one plan had a rate significantly below the benchmark. Finally, thirty-three percent (32.9%) of members who were diagnosed with a new episode of depression and treated with antidepressant medication remained on an antidepressant drug for at least 180 days. Individual plan rates ranged from 20% to 43.6%. Two plans had a rate significantly above the benchmark rate (32.4%) and two plans had a rate significantly below the benchmark. There are a number of factors that are associated with antidepressant non-adherence: • Antidepressant discontinuation during the first 30 days is more likely among Hispanics, patients with fewer than 12 years of education, and patients Legend: .. 2007 rate is significantly above the comparison rate. .. 2007 rate is not significantly different from the comparison rate. .. 2007 rate is significantly below the comparison rate. Num indicates Numerator Den indicates Denominator LCL indicates Lower Confidence Level UCL indicates Upper Confidence Level (A) = Measure was collected using administrative method (H) = Measure was collected using hybrid method Note: The ability to locate and obtain medical records by a plan or a plan’s contracted vendor can impact performance on a hybrid measure. Per NCQA’s specifications, members for whom no medical record documentation is found are considered non-compliant with the measure. November 2007| MassHealth Managed Care HEDIS 2007 Report Antidepressant Medication Management Understanding the Results with low family income as compared with those with middle and high income.38 • Comorbid substance use, use of older generation antidepressants, and living in lower income neighborhoods is associated with lower rates of adherence.41 • Being treated by a non-psychiatric specialist as opposed to a primary care physician or psychiatrist is associated with higher odds of nonadherence. 42 • Younger patient age is associated with greater rates of nonadherence.41 Conversely, receiving mental health specialty care in addition to being prescribed antidepressants is associated with higher rates of adherence: • Patients are significantly more likely to continue antidepressant treatment past 30 days if they receive psychotherapy.41 • Receipt of mental health specialty care in addition to antidepressants is strongly associated with adherence to an antidepressant regi40,41 men. The following quality improvement strategies may improve rates of adherence to antidepressants: • Improving provider-patient communication can have a positive impact on rates of adherence to antidepressants. Specifically, three key messages increase the odds of being adherent to antidepressant treatment. These consist of talking with patients about expectations with respect to change in mood and potential side effects, and letting patients know what to do if they have questions about the medication.43 • Implementing a telephone care management program for outpatients prescribed antidepressants by primary care physicians can help improve adherence rates.44 • However, a more recent study revealed that this same type of model did not improve adherence rates over usual care for patients prescribed antidepressants by psychiatrists.45 • Implementing a telemedicine model for primary care clinics that lack on-site psychiatrists can improve adherence rates, especially in rural communities with limited access to psychiatrists. 46 The source of the National Medicaid 90th Percentile, National Medicaid 75th Percentile, National Medicaid Mean, and MA Commercial Mean is Quality Compass, 2006. November 2007| MassHealth Managed Care HEDIS 2007 Report 49 50 50 Follow-up After Hospitalization for Mental Illness Research has shown the importance of timely follow-up for individuals discharged from a psychiatric hospitalization. Patients who follow-up with outpatient appointments have a lower readmission rate than those that don’t.47 Studies have shown that longer intervals between discharge and outpatient visits are associated with increased odds of missing appointments underscoring the importance of expedient aftercare upon discharge.48,49 7 Day Understanding the Results 30 Day The percentage of members 6 years of age and older who The percentage of members 6 years of age and older who were discharged after treatment of selected mental health were discharged after treatment of selected mental health disorders and who were seen on an ambulatory basis or disorders and who were seen on an ambulatory basis or were in intermediate treatment with a mental health pro-were in intermediate treatment with a mental health provider vider within 7 days after discharge. within 30 days after discharge. 55.6% 58.3% 58.2% 71.8% 55.7% 56.9% 67.3% 39.1% 58.0% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP MassHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile KEY: Comparison rates (Source of National and MA Commercial data: Quality Compass, 2007) Rate is significantly above the 2007 national Medicaid 75th percentile Rate is not significantly different from the 2007 national Medicaid 75th percentile Rate is significantly below the 2007 national Medicaid 75th percentile 78.4% 79.8% 77.0% 91.9% 74.1% 76.2% 84.0% 57.7% 75.9% 0% 20% 40% 60% 80% 100% BM CHP FCHP NH NHP PCCP MassHealth Weighted M ean MA Co mm Mean Nat'l M caid Mean Nat'l M caid 75th P ctile Fifty-seven percent (56.9%) of MassHealth members 6 years of age and older who were hospitalized for treatment of mental illness had a follow-up visit within seven days of discharge. Individual plan rates ranged from 55.6% to 71.8%. One plan had a 7-day follow-up rate that was significantly above the benchmark rate (58%). Although PCCP’s rate (55.7%) was significantly below the benchmark rate, it was a significant improvement compared with the 2005 rate (46.0%). The other four plans had rates that were statistically no different than their 2005 rates. Seventy-six percent (76.2%) of MassHealth members 6 years of age and older who were hospitalized for treatment of mental illness had a follow-up visit within thirty days of discharge. Individual plan rates ranged from 74.1% to 91.9%. Two plans had a 30-day follow- up rate that was significantly above the benchmark rate (75.9%), while one plan had a rate significantly below the benchmark. Two plans had 2007 rates significantly above their 2005 rates for this measure. Several factors are associated with missed outpatient appointments after discharge from a psychiatric hospitalization, including: • Involuntary legal status at hospital discharge or leaving the hospital against medical advice (Continued on page 52) November 2007| MassHealth Managed Care HEDIS 2007 Report Follow-up After Hospitalization for Mental Illness Statistical Summary—7 Day