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Independence's utilization remains within national/regional standards of care

April 29, 2016

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As part of Independence's annual review process, we obtain data from the Healthcare Effectiveness Data and Information Set (HEDIS®) Quality Compass® of hospital discharges and frequency rates of selected cardiac procedures to help evaluate utilization for our Keystone Health Plan East (KHPE) HMO and Personal Choice® PPO commercial and Keystone 65 HMO and Personal Choice 65SM PPO Medicare Advantage members. The results showed that utilization remains within national and regional standards for most indicators.

HEDIS® rates must score between the 10th and 90th national percentiles, as published by NCQA's Quality Compass, to be considered as meeting the goal. Because utilization is typically higher in this part of the country, as compared to the rest of the United States, the Plan may include the 10th and 90th Mid-Atlantic Regional percentiles as thresholds for appropriate utilization when calculating its score.

Hospital utilization

Hospital utilization comparison of acute discharges per 1,000 shows that the overall HMO and PPO rates remain within the relevant national or regional 10th and 90th percentiles as the appropriate thresholds for over/under utilization. Comparison of HEDIS® rates for KHPE HMO, Keystone 65 HMO, and Personal Choice 65 PPO showed a decreased hospital utilization rate between 2014 and 2015, and Personal Choice PPO showed an increase from 2014 to 2015. Members enrolled in Medicare Advantage programs show a higher rate of change than previous years.

Use of services

Independence also measured the frequency of selected procedure rates for cardiac angioplasty, cardiac catheterization, and coronary artery bypass graft (CABG) according to age and gender. Based on a comparison of 2015 HEDIS® utilization rates with respect to established thresholds, utilization for use of services for these identified indicators were within the established threshold for most age/gender categories.

There were two indicators that were above national and regional thresholds: cardiac catheterization and angioplasty in males younger than age 65 who were enrolled in Personal Choice 65 PPO. 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.

For more information

To learn more about HEDIS®, visit our website 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.

Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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