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Independence's Medicare utilization remains within national standards

April 1, 2015

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As part of Independence's annual review process, we obtain data from the Healthcare Effectiveness Data and Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) to help evaluate utilization for our Medicare Advantage HMO and PPO members. The results showed that utilization remains within national standards and members do not perceive significant barriers to getting appropriate care.

HEDIS® data evaluation

Independence used the data from HEDIS® to evaluate hospital discharges and the frequency rates of select cardiac procedures.

Hospital utilization
Hospital utilization comparisons of acute discharges per 1,000 (Table 1) show that Keystone 65 HMO and Personal Choice 65℠ PPO rates continue to improve and remain within the relevant national 10th and 90th percentiles as the appropriate thresholds for over/under utilization. Comparison of HEDIS® rates for Keystone 65 HMO reports a point change from 2013 – 2014 of 2.71 but an overall downward trend for the last three measurement years; comparison of HEDIS® rates for Personal Choice 65℠ PPO reports a point change of -20.01 from HEDIS 2013 to 2014, with a downward trend over the last three measurement years.

Table 1: Hospital utilization comparison acute discharges per 1,000
HEDIS® year201220132014Point change 2013 – 2014R–squaredTrending per 1000 members
RateRateRateThresholdThreshold status
Keystone 65 HMO members346.31286.89289.60170.83 ? 334.11Within2.7171.42%Down
Personal Choice 65 PPO301.65277.40257.39170.83 ? 334.11Within-20.0199.70%Down


Use of services
Independence also measured the frequency of selected procedure rates for cardiac angioplasty, cardiac catheterization, and coronary artery bypass graft (CABG). Based on a comparison of 2014 HEDIS® utilization rates with respect to established thresholds, utilization for use of services for these identified indicators fell within the established threshold for most age/gender cohorts. There were two cohorts that did not fall within national or regional thresholds and one cohort that fell above national, but within regional thresholds. These rates are measured according to age group and gender, and Independence recognizes the probability of unequal variance as an issue with the cardiac procedure rates.

CAHPS data evaluation

Independence used CAHPS data to evaluate composite care, including member perception of getting needed care in a timely manner and specialty care.

Keystone 65 HMO members
The rates for Keystone 65 HMO members getting needed care during 2014 (Table 2) remains within the national average. The point difference for members with Keystone 65 HMO CAHPS from 2013 to 2014 reports a change of -0.09 for all indicators measured for this report and shows a downward trend over the last three reporting years (2012 – 2014). The plan recognizes the difficulty in obtaining care and continues to actively recruit health care providers within the region, including reaching out to network providers via the Clinical Quality Committee for input into barriers to care that the plan may influence.

Table 2: CAHPS member satisfaction data — Keystone 65 HMO < td>-0.09
HEDIS® year 201220132014Point change 2013 – 2014R–squaredThree–year trend
RateRateRateNational averageThreshold status
In the last six months, how often was it easy to get care, tests, or treatment you thought you needed?3.643.673.583.57Within42.86%Down
In the last six months, how often was it easy to get appointments with a specialist?3.613.643.553.53Within-0.0942.86%Down
Getting needed care composite3.643.673.343.29Within-0.0942.86%Down

Personal Choice 65 PPO
The rate for Personal Choice 65 PPO members during 2014 (Table 3) for obtaining needed care, tests, and treatment and overall care composite increased from CAHPS 2013 – 2014 and fell significantly above the national average as reported by the Centers for Medicare & Medicaid Services.

The rate for Personal Choice 65 PPO members during 2014 (Table 3) for obtaining needed care, tests, and treatment and overall care composite increased from CAHPS 2013 to 2014 and is significantly above the national average as reported by the Centers for Medicare & Medicaid Services. Personal Choice 65 PPO members are not required to identify a primary care physician, and many PPO members with chronic conditions use a specialist as their primary physician. However, based on member responses regarding the ease of care and care composite, there were no significant barriers to members receiving appropriate care noted.

Table 3: CAHPS member satisfaction data — Personal Choice 65 PPO < td>0.09
HEDIS® year201220132014Point change 2013 – 2014R–squaredThree–year trend
RateRateRateNational averageThreshold status
In the last six months, how often was it easy to get care, tests, or treatment you thought you needed?3.613.643.733.57Above*92.31%Up
In the last six months, how often was it easy to get appointments with a specialist?3.613.613.523.53Within-0.0975.00%Down
Getting needed care composite3.613.613.373.29Above*0.0375.00%Up
*Threshold status significantly better/worse than the national average

For more information

To learn more about HEDIS®, go to our Highlighting HEDIS® page to view Highlighting HEDIS® articles that have been published in Partners in Health Update℠. These articles are educational resources for understanding HEDIS® measures. If you have feedback about the Highlighting HEDIS® series or topic requests, please email us.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Used with permission.

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