As part of IBC?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 or above
national standards.
HEDIS® data evaluation
IBC used the data from HEDIS® to evaluate hospital
discharges and the frequency rates of selected cardiac
procedures.
Hospital utilization
Hospital utilization comparison acute discharges per 1,000 (Table 1) show that
Keystone 65 HMO and Personal
Choice 65SM PPO rates continue to improve and remain within the
relevant national 10th and 90th percentiles as the appropriate thresholds for
over/under utilization.
Table 1: Hospital utilization comparison acute discharges per
1,000
HEDIS® year 2012
HEDIS® year 2013
Product
Rate
Threshold
Threshold status
Rate
Threshold
Threshold status
Personal Choice
65 HMO members
346.31
193.14 ?
355.92
Within
286.89
189.91 ?
359.05
Within
Personal Choice
65 PPO
301.65
193.14 ?
355.92
Within
277.40
189.91 ?
359.05
Within
Use of services
IBC also measured the frequency of selected procedure rates for cardiac
angioplasty, cardiac catheterization, and
coronary artery bypass graft (CABG). Based on a comparison of 2013
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. Three cohorts fell above both national and
regional established thresholds. These rates
are measured according to age group and gender, and IBC recognizes the
probability of unequal variance as an issue
with the cardiac procedure rates.
CAHPS data evaluation
IBC 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 rate for getting needed composite care for Keystone 65 HMO members during
2013 (Table 2) rose significantly
above the national threshold. In addition, the rate for members who are
referred to a specialist remained significantly
better than the national threshold. Both of these rates may be attributed to
the emergence of the Patient-Centered
Medical Home (PCMH) model as primary care in 2010. The rate for ease of care
also increased in 2013 after
remaining stagnant for three years, indicating that members feel they are still
receiving all of the medically appropriate
studies.
Table 2: CAHPS Member Satisfaction Data ? Keystone 65 HMO
2012
2013
Criteria
Keystone
65 HMO
members
National
average
Threshold
status
Keystone
65 HMO
members
National
average
Threshold
status
In the last six months, how often was it easy to get care, tests, or treatment
you thought you needed?
3.64
3.60
Within
3.67
3.60
Within
In the last six months, how often was it easy to get appointments with a
specialist?
3.61
3.54
Above*
3.64
3.56
Above*
Getting needed care composite
3.64
3.57
Within
3.67
3.58
Above*
*Threshold status significantly better/worse than the
national average
Personal Choice 65 PPO
The rate for Personal Choice 65 PPO members during 2013 (Table 3) remained
within the national threshold,
including an increase in the rate for ease of care.
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 are no significant barriers to members receiving
appropriate care noted.
Table 3: CAHPS Member Satisfaction Data ? Personal Choice 65
PPO
2012
2013
Criteria
Personal
Choice
65 HMO
members
National
average
Threshold
status
Personal
Choice
65 HMO
members
National
average
Threshold
status
In the last six months, how often was it easy to get care, tests, or treatment
you thought you needed?
3.61
3.60
Within
3.64
3.60
Within
In the last six months, how often was it easy to get appointments with a
specialist?
3.61
3.54
Within
3.61
3.56
Within
Getting needed care composite
3.61
3.57
Within
3.61
3.58
Within
For more information
To learn more about HEDIS®, view Highlighting HEDIS® articles
that have been published in Partners in Health UpdateSM.
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.