Validation of performance measures for AMERIGROUP Community Care: measurement period: calendar year 2011; validation period: state fiscal year 2012

Georgia Department of Community Health
Validation of Performance Measures for
AMERIGROUP Community Care
Measurement Period: Calendar Year 2011 Validation Period: State Fiscal Year 2012
Publish Date: August 23, 2012
3133 East Camelback Road, Suite 300 Phoenix, AZ 85016 Phone 602.264.6382 Fax 602.241.0757

CONTENTS
for AMERIGROUP Community Care
Validation of Performance Measures ................................................................................................... 1 Validation Overview ............................................................................................................................. 1 Care Management Organization (CMO) Information ........................................................................... 1 Performance Measures Validated........................................................................................................ 2 Description of Validation Activities ....................................................................................................... 3 Pre-Audit Strategy ............................................................................................................................. 3 Validation Team................................................................................................................................. 3 Technical Methods of Data Collection and Analysis.......................................................................... 4 On-Site Activities ............................................................................................................................... 4 Data Integration, Data Control, and Performance Measure Documentation ....................................... 6 Data Integration ................................................................................................................................. 6 Data Control ...................................................................................................................................... 6 Performance Measure Documentation.............................................................................................. 6 Validation Results ................................................................................................................................ 7 Medical Service Data (Claims/Encounters) ....................................................................................... 7 Enrollment Data................................................................................................................................. 7 Provider Data..................................................................................................................................... 7 Medical Record Review Process....................................................................................................... 8 Supplemental Data ............................................................................................................................ 8 Data Integration ................................................................................................................................. 8 Performance Measure Specific Findings........................................................................................... 9 Validation Findings ............................................................................................................................ 10
Appendix A--Data Integration and Control Findings ..................................................................... A-1 Appendix B--Denominator and Numerator Validation Findings ................................................... B-1 Appendix C--Performance Measure Results .................................................................................. C-1
Appendices D and E--Final Audited HEDIS Results ...................................................................... D-1

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Validation of Performance Measures
for AMERIGROUP Community Care

Validation Overview
Validation of performance measures is one of three mandatory external quality review (EQR) activities that the Balanced Budget Act of 1997 (BBA) requires state Medicaid agencies to perform. Health Services Advisory Group, Inc. (HSAG), the external quality review organization (EQRO) for the Department of Community Health (DCH), conducted the validation activities. DCH contracts with three care management organizations (CMOs) to provide services to Medicaid managed care enrollees and PeachCare for Kids enrollees. PeachCare for Kids is the name of Georgia's stand-alone Children's Health Insurance Program (CHIP). DCH identified a set of performance measures that were calculated and reported by the CMOs for validation. HSAG conducted the validation activities as outlined in the Centers for Medicare & Medicaid Services (CMS) publication, Validating Performance Measures: A Protocol for Use in Conducting External Quality Review Activities, Final Protocol, Version 1.0, May 1, 2002 (CMS performance measure validation protocol).

Care Management Organization (CMO) Information
HSAG validated performance measures calculated and reported by AMERIGROUP Community Care (AMERIGROUP). Information about AMERIGROUP appears in Table 1.

Table 1--AMERIGROUP Community Care Information

CMO Name: CMO Location: CMO Contact:

AMERIGROUP Community Care 303 Perimeter Center North, Suite 400 Atlanta, GA 30346
Joanne Soublis, Risk Control and Compliance Officer

Contact Telephone Number:

678.587.4876

Contact E-mail Address:

JSoubli@amerigroupcorp.com

Site Visit Date:

April 56, 2012

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Performance Measures Validated
HSAG validated performance measures identified and selected by DCH for validation. Two performance measures were selected from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicator set, and five performance measures were selected from the Children's Health Insurance Program Reauthorization Act (CHIPRA) Initial Core Set of Children's Health Care Quality Measures. The measurement period was identified by DCH as calendar year (CY) 2011 for all measures except the two CHIPRA dental measures. They were reported for federal fiscal year (FFY) 2011 per CMS requirements. Table 2 lists the performance measures that HSAG validated and identifies who calculated the performance measure rates.

Table 2--List of CY 2011 Performance Measures for AMERIGROUP

Performance Measure

Rate Calculation by:

1. Low Birth Weight Rate (AHRQ)

AMERIGROUP

2. Cesarean Delivery Rate (AHRQ)

3.

Percentage of Eligibles That Received Preventive Dental Services (CHIPRA)

4.

Otitis Media With Effusion (OME)--Avoidance of Inappropriate Use of Systemic Antimicrobials (CHIPRA)

5.

Percentage of Eligibles That Received Dental Treatment Services (CHIPRA)

6.

Annual Percentage of Asthma Patients With One or More AsthmaRelated Emergency Room Visits (CHIPRA)

7. Annual Pediatric Hemoglobin (HbA1c) Testing (CHIPRA)

AMERIGROUP AMERIGROUP AMERIGROUP AMERIGROUP AMERIGROUP AMERIGROUP

In addition, AMERIGROUP was required to report a selected set of Healthcare Effectiveness Data and Information Set (HEDIS) measures to DCH. AMERIGROUP was required to contract with an NCQA-licensed audit organization and undergo an NCQA HEDIS Compliance Audit. Final
audited HEDIS measure results were submitted to DCH via NCQA's Interactive Data Submission
System (IDSS) and provided to HSAG. HSAG will use these results in addition to the measures
HSAG validated and displayed within this report as data sources for the annual EQR technical
report. Appendices D and E display the final audited HEDIS 2012 results for all required measures.

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). HEDIS Compliance AuditTM is a trademark of the National Committee for Quality Assurance (NCQA).

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Description of Validation Activities

Pre-Audit Strategy
HSAG conducted the validation activities as outlined in the CMS performance measure validation protocol. To complete the validation activities for AMERIGROUP, HSAG obtained a list of the measures that were selected by DCH for validation.
HSAG then prepared a document request letter that was submitted to AMERIGROUP outlining the steps in the performance measure validation process. The document request letter included a request for source code for each performance measure; a completed HEDIS 2012 Record of Administration, Data Management, and Processes (Roadmap); and any additional supporting documentation necessary to complete the audit. HSAG responded to Roadmap-related questions received directly from AMERIGROUP during the pre-on-site phase.
For the on-site visit, HSAG prepared an agenda describing all visit activities and indicating the type of staffing needed for each session. HSAG provided the agenda to AMERIGROUP approximately one week prior to the on-site visit. HSAG also conducted a pre-on-site conference call with AMERIGROUP to discuss any outstanding Roadmap questions and on-site visit activity expectations.

Validation Team
The HSAG Performance Measure Validation Team was composed of a lead auditor and validation team members. HSAG assembled the team based on the skills required for the validation and requirements of AMERIGROUP. Some team members, including the lead auditor, participated in the on-site meetings at AMERIGROUP; others conducted their work at HSAG's offices. AMERIGROUP's validation team was composed of the following members in the designated positions. Table 3 lists the validation team members, their positions, and their skills and expertise.

Name / Role
Wendy Talbot, MPH, CHCA Lead Auditor
John Couzins, MPH, CHCA Secondary Auditor
David Mabb, MS, CHCA Associate Director, Audits Tammy GianFrancisco Project Leader

Table 3--Validation Team Skills and Expertise
Management of audit department, certified HEDIS auditor, HEDIS knowledge, interviewing skills, and statistics and analysis.
Audit knowledge and experience, performance measure development, and statistical analysis
Certified HEDIS auditor, HEDIS knowledge, source code review manager, and statistics and analysis.
Overall project coordination and communications

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Technical Methods of Data Collection and Analysis
The CMS performance measure validation protocol identifies key types of data that should be reviewed as part of the validation process. The following list describes the type of data collected and how HSAG conducted an analysis of these data:
NCQA's HEDIS 2012 Roadmap: AMERIGROUP completed and submitted the required and relevant portions of its Roadmap for review by the validation team. The validation team used responses from the Roadmap to complete the pre-on-site systems assessment.
Source code (programming language) for performance measures: HSAG requested and received source code from AMERIGROUP that calculated its performance measure rates using automated computer code. The validation team completed a line-by-line code review and observation of program logic flow to ensure compliance with State measure definitions during the on-site visit. Source code reviewers identified areas of deviation and shared them with the lead auditor to evaluate the impact of the deviation on the measure and assess the degree of bias (if any).
Supporting documentation: HSAG requested any documentation that would provide reviewers with additional information to complete the validation process, including policies and procedures, file layouts, system flow diagrams, system log files, and data collection process descriptions. The validation team reviewed all supporting documentation, identifying issues or clarifications for further follow-up.

On-Site Activities
HSAG conducted an on-site visit with AMERIGROUP on April 5 and 6, 2012. HSAG collected information using several methods, including interviews, system demonstration, review of data output files, primary source verification, observation of data processing, and review of data reports. The on-site visit activities are described as follows:
Opening meeting: The opening meeting included an introduction of the validation team and key AMERIGROUP staff members involved in the performance measure activities. The review purpose, the required documentation, basic meeting logistics, and queries to be performed were discussed.
Evaluation of system compliance: The evaluation included a review of the information systems assessment, focusing on the processing of claims and encounter data, patient data, and inpatient data. Additionally, the review evaluated the processes used to collect and calculate the performance measure rates, including accurate numerator and denominator identification and algorithmic compliance (which evaluated whether rate calculations were performed correctly, all data were combined appropriately, and numerator events were counted accurately).
Review of Roadmap and supporting documentation: The review included processes used for collecting, storing, validating, and reporting performance measure rates. This session was designed to be interactive with key AMERIGROUP staff members so that the validation team could obtain a complete picture of all the steps taken to generate the performance measure rates. The goal of the session was to obtain a confidence level as to the degree of compliance with written documentation compared to the actual process. HSAG conducted interviews to confirm

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findings from the documentation review, expand or clarify outstanding issues, and ascertain that written policies and procedures were used and followed in daily practice.
Overview of data integration and control procedures: The overview included discussion and observation of source code logic, a review of how all data sources were combined, and a review of how the analytic file was produced for the reporting of selected performance measure rates. HSAG performed primary source verification to further validate the output files and reviewed backup documentation on data integration. HSAG also addressed data control and security procedures during this session.
Closing conference: The closing conference included a summation of preliminary findings based on the review of the Roadmap and the on-site visit, and revisited the documentation requirements for any post-visit activities.
HSAG conducted several interviews with key AMERIGROUP staff members who were involved with performance measure reporting. Table 4 lists key AMERIGROUP interviewees:

Tawonna Ingram Gail Brown Angela Evans Frank Rowan Joanne Soublis Jiong Huang Stacy Williams Sarah Rivera Judy Jusinski Heather Hayhoe Donna Graves Erik Vazquetelles James Vergonio Joan Finnegan Jamie Giron Roger Pinckney Kathleen King Joe Hayes

Table 4--List of AMERIGROUP Community Care Interviewees

Name

Title Director, Health Promotions/HEDIS

Manager, Performance Reporting

Manager, Performance Reporting

Business Operations Analyst III

Risk Control and Compliance Officer

AVP, Quality Management

Manager

AVP, Quality Management

Manager, Medical Record Review

Manager, Medical Record Review

Claims

AVP, Claims

Director, Enrollment

Business Analyst

Manager, Enrollment

Business Analyst

Dental Account Manager

AVP, Security and Compliance

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Data Integration, Data Control, and Performance Measure Documentation
There are several aspects crucial to the calculation of performance measure rates. These include data integration, data control, and documentation of performance measure calculations. Each of the following sections describes the validation processes used and the validation findings. For more detailed information, see Appendix A of this report.
Data Integration
Accurate data integration is essential for calculating valid performance measure rates. The steps used to combine various data sources (including claims/encounter data, eligibility data, and other administrative data) must be carefully controlled and validated. HSAG validated the data integration process used by AMERIGROUP, which included a review of file consolidations or extracts, a comparison of source data to warehouse files, data integration documentation, source code, production activity logs, and linking mechanisms. Overall, the validation team determined that the data integration processes in place at AMERIGROUP were:
Acceptable Not acceptable
Data Control
AMERIGROUP's organizational infrastructure must support all necessary information systems; and its quality assurance practices and backup procedures must be sound to ensure timely and accurate processing of data, and to provide data protection in the event of a disaster. HSAG validated the data control processes AMERIGROUP used which included a review of disaster recovery procedures, data backup protocols, and related policies and procedures. Overall, the validation team determined that the data control processes in place at AMERIGROUP were:
Acceptable Not acceptable
Performance Measure Documentation
Sufficient, complete documentation is necessary to support validation activities. While interviews and system demonstrations provided supplementary information, the majority of the validation review findings were based on documentation provided by AMERIGROUP. HSAG reviewed all related documentation, which included the completed Roadmap, job logs, computer programming code, output files, work flow diagrams, narrative descriptions of performance measure calculations, and other related documentation. Overall, the validation team determined that the documentation of performance measure calculations by AMERIGROUP was:
Acceptable Not acceptable

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Validation Results
The validation team evaluated AMERIGROUP's data systems for processing of each type of data used for reporting the DCH performance measure rates. General findings are indicated below:
Medical Service Data (Claims/Encounters)
AMERIGROUP continued to use Facets for its claims processing system. Paper claims were received and scanned, and keying vendors were used to process the files. There were two keying vendors used during the measurement year, and all files were transmitted back to AMERIGROUP in a standard Health Insurance Portability and Accountability Act of 1996 (HIPAA) 834 format. AMERIGROUP received electronic claims directly from providers via a Web portal or from one of three clearinghouses during the measurement year. Electronic claims account for approximately 89 percent of all claims across all markets. There were appropriate controls, reconciliation processes, and tracking mechanisms in place to monitor accurate and complete transmission of both paper and electronic claims. As claims were received and accepted, a nightly process would load the claims into Facets where they were either pended or auto-adjudicated. The auto-adjudication rate during the measurement year was 75 percent, and pended claims were worked daily, oldest to newest, by examiners. AMERIGROUP's Quality Assurance staff conducted random, statistically valid monthly audits to evaluate the financial, payment, and statistical accuracy of claims processing. There were no issues detected during the measurement year.
Vendor data were received from Caremark (pharmacy) for CY 2011. These data were included to identify diabetic children for the Annual Pediatric Hemoglobin (HbA1c) Testing CHIPRA measure. These data were received and processed according to established timelines between AMERIGROUP and Caremark. The vendor team had oversight of all data received and worked closely with the vendors to ensure data were received timely and completely. There were no concerns with the pharmacy data processing.
Enrollment Data
Electronic enrollment data were received monthly from the DCH's enrollment broker. These data were processed, reconciled, and loaded into Facets once all errors were resolved. Errors were worked through the Membership Enrollment and Editing Tool (MEET) process. AMERIGROUP had numerous validation steps to ensure data were complete and accurate, such as the load total reports and membership record counts. Reconciliations of enrollment data in Facets to the monthly files and capitation files were performed to ensure complete and accurate data. AMERIGROUP reported no issues with receiving enrollment data from DCH during 2011. All data files were received and timely processed.
Provider Data
For five of the seven audited measures, provider data processing and identification were not relevant. The two CMS CHIPRA dental measures required that the preventive and treatment service

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VALIDATION OF PERFORMANCE MEASURES
be rendered by a dental provider. For these two measures, the dental provider was identified during primary source verification and also when the source code was reviewed with MedAssurant, the vendor who programmed these two measures. There were no concerns identified.
Medical Record Review Process
AMERIGROUP was only required to submit administrative rates for the HSAG-validated performance measure rates; therefore, no HSAG-validated measures used the hybrid method, and medical record review was not required.
Supplemental Data
AMERIGROUP did not use any supplemental data sources for reporting the selected performance measure rates.
Data Integration
All data sources used for reporting were stored in the data warehouse. AMERIGROUP had thorough and detailed processes in place to ensure that no data were lost during the data integration process. A team of AMERIGROUP staff members was responsible for generating the source code to run the two AHRQ measures; and AMERIGROUP contracted with MedAssurant, an NCQACertified software vendor, to write the code for the five CHIPRA measures. The code for all measures was reviewed and approved prior to final rate generation. Primary source verification was performed on all of the measures during the on-site visit, and no issues were identified. AMERIGROUP had sufficient processes in place to ensure data security and integrity. During 2011, there were no data lost or system downtimes reported.

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Performance Measure Specific Findings
Based on all validation activities, the HSAG Performance Measure Validation Team determined validation results for each performance measure rate. Table 5 displays the key review results. For detailed information, see Appendix B of this report.

Table 5--Key Review Results for AMERIGROUP Community Care

Performance Measures

Key Review Findings

1. Low Birth Weight Rate (AHRQ)

No concerns identified

2. Cesarean Delivery Rate (AHRQ)

No concerns identified

3.

Percentage of Eligibles That Received Preventive Dental Services (CHIPRA)

No concerns identified

4.

Otitis Media With Effusion (OME)--Avoidance of Inappropriate Use of Systemic Antimicrobials (CHIPRA)

The specifications were followed to calculate this measure; however, Georgia providers do not submit CPT Category II codes, so rates could not be calculated.

5.

Percentage of Eligibles That Received Dental Treatment Services (CHIPRA)

No concerns identified

6.

Annual Percentage of Asthma Patients With One or More Asthma-Related Emergency Room Visits (CHIPRA)

No concerns identified

7. Annual Pediatric Hemoglobin (HbA1c) Testing (CHIPRA)

No concerns identified

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VALIDATION OF PERFORMANCE MEASURES

Validation Findings
HSAG provided an audit designation for each performance measure as defined in Table 6:

Report (R)
Not Report (NR)

Table 6--Validation Findings Definitions
The organization followed the specifications and produced a reportable rate or result for the measure.
The calculated rate was materially biased, or the organization chose not to report the measure, or the organization was not required to report the measure.

According to the CMS protocol, the validation finding for each measure is determined by the magnitude of the errors detected for the audit elements, not by the number of audit elements determined to be "Not Reportable." Consequently, it is possible that an error for a single audit element may result in a designation of "NR" because the impact of the error biased the reported performance measure rate by more than 5 percentage points. Conversely, it is also possible that several audit element errors may have little impact on the reported rate, resulting in a measure designation of "R."
Table 7 shows the final validation findings for AMERIGROUP for each performance measure rate. For additional information regarding performance measure rates, see Appendix C of this report.

Table 7--Validation Findings for AMERIGROUP Community Care

Performance Measures

Validation Finding

1. Low Birth Weight Rate (AHRQ)

Report

2. Cesarean Delivery Rate (AHRQ)

Report

3. Percentage of Eligibles That Received Preventive Dental Services (CHIPRA)

Report

4.

Otitis Media With Effusion (OME)--Avoidance of Inappropriate Use of Systemic Antimicrobials (CHIPRA)

Not Report

5. Percentage of Eligibles That Received Dental Treatment Services (CHIPRA)

Report

6.

Annual Percentage of Asthma Patients With One or More Asthma-Related Emergency Room Visits (CHIPRA)

Report

7. Annual Pediatric Hemoglobin (HbA1c) Testing (CHIPRA)

Report

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Appendix A. Data Integration and Control Findings
for AMERIGROUP Community Care
Appendix A, which follows this page, contains the data integration and control findings for AMERIGROUP Community Care.

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Appendix A. Data Integration and Control Findings
for AMERIGROUP Community Care

Documentation Worksheet

CMO Name: On-Site Visit Date: Reviewers:

AMERIGROUP Community Care April 56, 2012 Wendy Talbot and John Couzins

Data Integration and Control Element

Not Met Met N/A

Comments

Accuracy of data transfers to assigned performance measure data repository

The CMO accurately and completely processes transfer data from the transaction files (e.g., membership, provider, encounter/claims) into the performance measure data repository used to keep the data until the calculations of the performance measures have been completed and validated.

Samples of data from the performance measure data repository are complete and accurate.

Accuracy of file consolidations, extracts, and derivations

The CMO's processes to consolidate diversified files and to extract required information from the performance measure data repository are appropriate.

Actual results of file consolidations or extracts are consistent with those that should have resulted according to documented algorithms or specifications.

Procedures for coordinating the activities of multiple subcontractors ensure the accurate, timely, and complete integration of data into the performance measure database.

AMERIGROUP contracted with MedAssurant to program the CHIPRA measures.

Computer program reports or documentation reflect vendor coordination activities, and no data necessary to performance measure reporting are lost or inappropriately modified during transfer.

If the CMO uses a performance measure data repository, its structure and format facilitates any required programming necessary to calculate and report required performance measures.

The performance measure data repository's design, program flow charts, and source codes enable analyses and reports.

Proper linkage mechanisms are employed to join data from all necessary sources (e.g., identifying a member with a given disease/condition).

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DATA INTEGRATION AND CONTROL FINDINGS

Data Integration and Control Element

Not Met Met N/A

Assurance of effective management of report production and of the reporting software.

Documentation governing the production process, including CMO production activity logs and the CMO staff review of report runs, is adequate.

Prescribed data cutoff dates are followed.

Comments

The CMO retains copies of files or databases used for performance measure reporting in case results need to be reproduced.
The reporting software program is properly documented with respect to every aspect of the performance measure data repository, including building, maintaining, managing, testing, and report production.
The CMO's processes and documentation comply with the CMO standards associated with reporting program specifications, code review, and testing.

AMERIGROUP contracted with MedAssurant to program the CHIPRA measures.

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Appendix B. Denominator and Numerator Validation Findings
for AMERIGROUP Community Care
Appendix B, which follows this page, contains the denominator and numerator validation findings for AMERIGROUP Community Care.

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Appendix B. Denominator and Numerator Validation Findings
for AMERIGROUP Community Care

Reviewer Worksheets

CMO Name: On-Site Visit Date: Reviewers:

AMERIGROUP Community Care April 56, 2012 Wendy Talbot and John Couzins

Table B-1--Denominator Validation Findings for AMERIGROUP Community Care

Audit Element

Not Met Met N/A

Comments

For each of the performance measures, all members of the relevant populations identified in the performance measure specifications are included in the population from which the denominator is produced.

Adequate programming logic or source code exists to appropriately identify all relevant members of the specified denominator population for each of the performance measures.

The CMO correctly calculates member months and member years if applicable to the performance measure.

Not applicable to the measures being reported.

The CMO properly evaluates the completeness and accuracy of any codes used to identify medical events, such as diagnoses, procedures, or prescriptions, and these codes are appropriately identified and applied as specified in each performance measure.

If any time parameters are required by the specifications of the performance measure, they are followed (e.g., cutoff dates for data collection, counting 30 calendar days after discharge from a hospital, etc.).

Exclusion criteria included in the performance measure specifications are followed.

Systems or methods used by the CMO to estimate populations when they cannot be accurately or completely counted (e.g., newborns) are valid.

Population estimates were not used.

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DENOMINATOR AND NUMERATOR VALIDATION FINDINGS

Table B-2--Numerator Validation Findings for AMERIGROUP Community Care

Audit Element

Not Met Met N/A

Comments

The CMO uses the appropriate data, including linked data from separate data sets, to identify the entire at-risk population.

Qualifying medical events (such as diagnoses, procedures, prescriptions, etc.) are properly identified and confirmed for inclusion in terms of time and services.

The CMO avoids or eliminates all double-counted members or numerator events.
Any nonstandard codes used in determining the numerator are mapped to a standard coding scheme in a manner that is consistent, complete, and reproducible, as evidenced by a review of the programming logic or a demonstration of the program.
If any time parameters are required by the specifications of the performance measure, they are followed (i.e., the measured event occurred during the time period specified or defined in the performance measure).

AMERIGROUP did not use nonstandard codes.

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Appendix C. Performance Measure Results
for AMERIGROUP Community Care
Appendix C, which follows this page, contains AMERIGROUP's performance measure results.

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Appendix C. Performance Measure Results
for AMERIGROUP Community Care

Indicator 1--Low Birth Weight Rate

Table C-1--Indicator 1 for AMERIGROUP Community Care
Rate (per 100)

Low Birth Weight Rate

7.0

Indicator 2--Cesarean Delivery

Table C-2--Indicator 2 for AMERIGROUP Community Care

Rate (per 100)

Cesarean Delivery Rate

33.6

Indicator 3--Percentage of Eligibles that Received Preventive Dental Services

Table C-3--Indicator 3 for AMERIGROUP Community Care
Preventive Dental Services

Rate 49.5%

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PERFORMANCE MEASURE RESULTS

Indicator 4--Otitis Media with Effusion (OME)--Avoidance of Inappropriate Use of Systemic Antimicrobials

Table C-4--Indicator 4 for AMERIGROUP Community Care
Otitis Media with Effusion

Rate 0.0%

Indicator 5--Percentage of Eligibles that Received Dental Treatment Services

Table C-5--Indicator 5 for AMERIGROUP Community Care
Dental Treatment Services

Rate 23.8%

Indicator 6--Annual Percentage of Asthma Patients with One or More Asthma-Related Emergency Room Visit

Table C-6--Indicator 6 for AMERIGROUP Community Care
Asthma ER

Rate 11.9%

Indicator 7--Annual Pediatric Hemoglobin (HbA1c) Testing

Table C-7--Indicator 7 for AMERIGROUP Community Care
Pediatric HbA1c Testing

Rate 75.6%

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Appendix D. Final Audited HEDIS Results
for AMERIGROUP Community Care
Appendices D and E, which follow this page, contain AMERIGROUP's final audited HEDIS results.

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Appendix D. Final Audited HEDIS Results
for AMERIGROUP Community Care

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--AMERIGROUP Community Care

Measure

CMO Rate

Adolescent Well-Care Visits

43.9% Hybrid

Adults' Access to Preventive/Ambulatory Health Services-- Ages 2044 Years

84.3%

Adults' Access to Preventive/Ambulatory Health Services-- Ages 4564 Years

88.9%

Adults' Access to Preventive/Ambulatory Health Services-- Ages 65+ Years

NA

Adults' Access to Preventive/Ambulatory Health Services--Total

85.0%

Adult BMI Assessment Annual Dental Visit--Ages 23 Years Annual Dental Visit--Ages 46 Years

4.4% 47.7% 76.8%

Annual Dental Visit--Ages 710 Years
Annual Dental Visit--Ages 1114 Years
Annual Dental Visit--Ages 1518 Years
Annual Dental Visit--Ages 1921 Years
Annual Dental Visit--Total
Annual Monitoring for Patients on Persistent Medications--Total Antidepressant Medication Management--Effective Acute Phase
Treatment Antidepressant Medication Management--Effective Continuation
Phase Treatment Appropriate Testing for Children with Pharyngitis Appropriate Treatment for Children with Upper Respiratory
Infection (URI)1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis1
Breast Cancer Screening

79.6% 72.1% 61.1% 37.6% 69.7% 88.0% 47.1% 32.0% 76.5% 79.2% 16.7% 55.9%

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FINAL AUDITED HEDIS RESULTS

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--AMERIGROUP Community Care

Measure

CMO Rate

Call Abandonment

1.0%

Call Answer Timeliness

87.7%

Cervical Cancer Screening
Cholesterol Management for Patients with Cardiovascular Conditions--LDL-C Screening
Cholesterol Management for Patients with Cardiovascular Conditions--LDL-C Control
Childhood Immunization Status--Combo 3

74.1% Hybrid 87.5% Hybrid 27.5% Hybrid 80.0% Hybrid

Childhood Immunization Status--Combo 10

10.4% Hybrid

Children's and Adolescents' Access to Primary Care Providers-- Ages 1224 Months

97.4%

Children's and Adolescents' Access to Primary Care Providers-- Ages 25 Months6 Years
Children's and Adolescents' Access to Primary Care Providers-- Ages 711 Years
Children's and Adolescents' Access to Primary Care Providers-- Ages 1219 Years

91.2% 92.5% 89.8%

Chlamydia Screening in Women--Total

52.8%

Comprehensive Diabetes Care--Blood Pressure Control <140/80

32.2% Hybrid

Comprehensive Diabetes Care--Blood Pressure Control <140/90

58.2% Hybrid

Comprehensive Diabetes Care--Eye Exam

43.2% Hybrid

Comprehensive Diabetes Care--HbA1c Good Control <7.0

32.1% Hybrid

Comprehensive Diabetes Care--HbA1c Good Control <8.0 Comprehensive Diabetes Care--HbA1c Poor Control2

41.8% Hybrid 51.2% Hybrid

Comprehensive Diabetes Care--HbA1c Testing

79.8% Hybrid

AMERIGROUP Community Care Validation of Performance Measures State of Georgia

Page D-2 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812

FINAL AUDITED HEDIS RESULTS

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--AMERIGROUP Community Care

Measure

CMO Rate

Comprehensive Diabetes Care--LDL-C Level

26.4% Hybrid

Comprehensive Diabetes Care--LDL-C Screening
Comprehensive Diabetes Care--Medical Attention to Nephropathy
Controlling High Blood Pressure
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
Follow-Up After Hospitalization for Mental Illness--30-Day Follow-Up
Follow-Up After Hospitalization for Mental Illness--7-Day FollowUp
Follow-Up Care for Children Prescribed ADHD Medication-- Initiation Phase
Follow-Up Care for Children Prescribed ADHD Medication-- Continuation and Maintenance Phase
Frequency of Ongoing Prenatal Care--< 21 Percent
Frequency of Ongoing Prenatal Care--2140 Percent
Frequency of Ongoing Prenatal Care--4160 Percent

72.6% Hybrid 72.4% Hybrid
NR3 48.2% Hybrid
44.2% 71.4% 48.4% 44.3%
61.2%
7.9% Hybrid 3.0% Hybrid 6.1% Hybrid

Frequency of Ongoing Prenatal Care--6180 Percent

10.7% Hybrid

Frequency of Ongoing Prenatal Care--81+ Percent
Human Papillomavirus Vaccine for Female Adolescents
Immunizations for Adolescents--Combo 1 Initiation and Engagement of AOD Dependence Treatment--
Initiation Initiation and Engagement of AOD Dependence Treatment--
Engagement

72.3% Hybrid 12.5%
67.6% Hybrid 42.5% 11.7%

AMERIGROUP Community Care Validation of Performance Measures State of Georgia

Page D-3 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812

FINAL AUDITED HEDIS RESULTS

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--AMERIGROUP Community Care

Measure

CMO Rate

Inpatient Utilization--General Hospital/Acute Care--Total

Rates reported in Appendix E

Lead Screening in Children

76.7% Hybrid

Medication Management for People with Asthma-- Total-Medication Compliance 50%
Medication Management for People with Asthma-- Total-Medication Compliance 75%

44.0% 20.1%

Persistence of Beta-Blocker Treatment After a Heart Attack

NA

Pharmacotherapy Management of COPD Exacerbation-- Systemic Corticosteroid
Pharmacotherapy Management of COPD Exacerbation-- Bronchodilator
Prenatal and Postpartum Care--Postpartum Care3
Prenatal and Postpartum Care--Timeliness of Prenatal Care3
Use of Appropriate Medications for People with Asthma-- Ages 511 Years
Use of Appropriate Medications for People with Asthma-- Ages 1218 Years
Use of Appropriate Medications for People with Asthma-- Ages 1950 Years
Use of Appropriate Medications for People with Asthma-- Ages 5164 Years

73.8%
88.1% NR3 65.7% Hybrid NR3 90.5% Hybrid 92.4%
90.5%
63.8%
NA

Use of Appropriate Medications for People with Asthma--Total

90.7%

Use of Imaging Studies for Low Back Pain1
Use of Spirometry Testing in the Assessment and Diagnosis of COPD

75.7% 40.9%

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--BMI Percentile (Total)

33.3% Hybrid

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--Counseling for Nutrition (Total)

58.3% Hybrid

AMERIGROUP Community Care Validation of Performance Measures State of Georgia

Page D-4 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812

FINAL AUDITED HEDIS RESULTS

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--AMERIGROUP Community Care

Measure

CMO Rate

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--Counseling for Physical
Activity (Total)

44.9% Hybrid

Well-Child Visits in the First 15 Months of Life--Zero Visits

1.9% Hybrid

Well-Child Visits in the First 15 Months of Life--One Visit

3.0% Hybrid

Well-Child Visits in the First 15 Months of Life--Two Visits

3.5% Hybrid

Well-Child Visits in the First 15 Months of Life--Three Visits

3.7% Hybrid

Well-Child Visits in the First 15 Months of Life--Four Visits

6.8% Hybrid

Well-Child Visits in the First 15 Months of Life--Five Visits
Well-Child Visits in the First 15 Months of Life--Six or More Visits
Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life

17.5% Hybrid 63.6% Hybrid 73.6% Hybrid

Frequency of Selected Procedures

Rates reported in Appendix E

Mental Health Utilization--Total

Rates reported in Appendix E

Board Certification

Rates reported in Appendix E

Total Membership

Rates reported in Appendix E

Enrollment by Product Line--Total

Rates reported in Appendix E

Enrollment by State Identification of Alcohol and Other Drug Services--Total

Rates reported in Appendix E Rates reported in Appendix E

Weeks of Pregnancy at Time of Enrollment

Rates reported in Appendix E

AMERIGROUP Community Care Validation of Performance Measures State of Georgia

Page D-5 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812

FINAL AUDITED HEDIS RESULTS

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--AMERIGROUP Community Care

Measure

CMO Rate

Race/Ethnicity Diversity of Membership

Rates reported in Appendix E

Language Diversity of Membership

Rates reported in Appendix E

Ambulatory Care--Total

Rates reported in Appendix E

Relative Resource Use for People with Diabetes

Rates reported in Appendix E

Relative Resource Use for People with Asthma

Rates reported in Appendix E

Relative Resource Use for People with Cardiovascular Conditions

Rates reported in Appendix E

Relative Resource Use for People with COPD

Rates reported in Appendix E

Relative Resource Use for People with Hypertension

Rates reported in Appendix E

Antibiotic Utilization--Total

Rates reported in Appendix E

1 Note: The measure is reported as an inverted rate. A higher rate indicates appropriate treatment of children with URI (i.e., the proportion for whom antibiotics were not prescribed). The rate is calculated as 1 minus the numerator divided by the eligible population.
2 Lower rate is better.
3 Note: The plan chose to rotate the measure. Measure rotation allows the health plan to use the audited and reportable rate from the previous year as specified by NCQA in HEDIS 2012 Technical Specifications for Health Plans, Volume 2; however, rotation is not allowed by DCH. Therefore, the rotated rate is not reportable with DCH.

AMERIGROUP Community Care Validation of Performance Measures State of Georgia

Page D-6 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812

Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP

Audit Review Table

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None); Measurement Year - 2011

The Auditor lock has been applied to this submission.

Measure/Data Element

Report Measure

Benefit Offered

Rotated Measure

Rate

Reportable

Comment

Effectiveness of Care: Prevention and Screening

Adult BMI Assessment (aba)

Y

4.4%

R

Reportable

Weight Assessment and Counseling for Nutrition

and Physical Activity for Children/Adolescents

Y

(wcc)

BMI Percentile

33.3%

R

Reportable

Counseling for Nutrition

58.3%

R

Reportable

Counseling for Physical Activity

44.9%

R

Reportable

Childhood Immunization Status (cis)

Y

DTaP

88.5%

R

Reportable

IPV

97.1%

R

Reportable

MMR

93.3%

R

Reportable

HiB

96.0%

R

Reportable

Hepatitis B

96.7%

R

Reportable

VZV

95.1%

R

Reportable

Pneumococcal Conjugate

86.3%

R

Reportable

Hepatitis A

47.9%

R

Reportable

Rotavirus

45.7%

R

Reportable

Influenza

37.7%

R

Reportable

Combination #2

84.3%

R

Reportable

Combination #3

80.0%

R

Reportable

Combination #4

44.3%

R

Reportable

Combination #5

38.1%

R

Reportable

Combination #6

35.0%

R

Reportable

Combination #7

20.6%

R

Reportable

Combination #8

20.6%

R

Reportable

Combination #9

18.2%

R

Reportable

Combination #10

10.4%

R

Reportable

Immunizations for Adolescents (ima)

Y

Meningococcal

70.3%

R

Reportable

Tdap/Td

79.8%

R

Reportable

1 of 32

August 2012

Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP

Combination #1

67.6%

R

Human Papillomavirus Vaccine for Female Adolescents (hpv)

Y

12.5%

R

Lead Screening in Children (lsc)

Y

76.7%

R

Breast Cancer Screening (bcs)

Y

55.9%

R

Cervical Cancer Screening (ccs)

Y

N

74.1%

R

Chlamydia Screening in Women (chl)

Y

16-20 Years

49.5%

R

21-24 Years

64.8%

R

Total

52.8%

R

Effectiveness of Care: Respiratory Conditions

Appropriate Testing for Children with Pharyngitis (cwp)

Y

Y

76.5%

R

Appropriate Treatment for Children With URI (uri)

Y

Y

79.2%

R

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (aab)

Y

Y

Use of Spirometry Testing in the Assessment and Diagnosis of COPD (spr)

Y

Pharmacotherapy Management of COPD Exacerbation (pce)

Y

Y

Systemic Corticosteroid

Bronchodilator

Use of Appropriate Medications for People With Asthma (asm)

Y

Y

5-11 Years

12-18 Years

19-50 Years

51-64 Years

Total

Medication Management for People With Asthma (mma)

Y

Y

5-11 Years - Medication Compliance 50%

5-11 Years - Medication Compliance 75%

12-18 Years - Medication Compliance 50%

12-18 Years - Medication Compliance 75%

16.7%

R

40.9%

R

73.8%

R

88.1%

R

92.4%

R

90.5%

R

63.8%

R

NA

R

90.7%

R

44.1%

R

20.0%

R

43.7%

R

20.3%

R

2 of 32

Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable
Reportable
Reportable
Reportable Reportable
Reportable Reportable
Reportable Reportable Reportable Denominator fewer than 30 Reportable
Reportable Reportable Reportable Reportable
August 2012

Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP

19-50 Years - Medication Compliance 50%

43.2%

R

19-50 Years - Medication Compliance 75%

19.8%

R

51-64 Years - Medication Compliance 50%

NA

R

51-64 Years - Medication Compliance 75%

NA

R

Total - Medication Compliance 50%

44.0%

R

Total - Medication Compliance 75% Effectiveness of Care: Cardiovascular

20.1%

R

Cholesterol Management for Patients With Cardiovascular Conditions (cmc)

Y

LDL-C Screening Performed

87.5%

R

LDL-C Control (<100 mg/dL)

Controlling High Blood Pressure (cbp)

Y

27.5%

R

Y1

48.2%

R

Persistence of Beta-Blocker Treatment After a Heart Attack (pbh)

Y

Y

NA

R

Effectiveness of Care: Diabetes

Comprehensive Diabetes Care (cdc)

Y

Hemoglobin A1c (HbA1c) Testing

79.8%

R

HbA1c Poor Control (>9.0%)

51.2%

R

HbA1c Control (<8.0%)

41.8%

R

HbA1c Control (<7.0%)

32.1%

R

Eye Exam (Retinal) Performed

43.2%

R

LDL-C Screening Performed

72.6%

R

LDL-C Control (<100 mg/dL)

26.4%

R

Medical Attention for Nephropathy

72.4%

R

Blood Pressure Control (<140/80 mm Hg)

32.2%

R

Blood Pressure Control (<140/90 mm Hg)

58.2%

R

Effectiveness of Care: Musculoskeletal

Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis (art)

Y

Y

44.2%

R

Use of Imaging Studies for Low Back Pain (lbp)

Y

75.7%

R

Effectiveness of Care: Behavioral Health

Antidepressant Medication Management (amm)

Y

Y

Effective Acute Phase Treatment

47.1%

R

Effective Continuation Phase Treatment

32.0%

R

Reportable Reportable Denominator fewer than 30 Denominator fewer than 30 Reportable Reportable
Reportable Reportable Reportable Denominator fewer than 30
Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable
Reportable Reportable
Reportable Reportable

3 of 32

August 2012

Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP

Follow-Up Care for Children Prescribed ADHD Medication (add)

Y

Y

Initiation Phase

Continuation and Maintenance (C&M) Phase

Follow-Up After Hospitalization for Mental Illness (fuh)

Y

Y

30-Day Follow-Up

7-Day Follow-Up

Effectiveness of Care: Medication Management

Annual Monitoring for Patients on Persistent Medications (mpm)

Y

Y

ACE Inhibitors or ARBs

Digoxin

Diuretics

Anticonvulsants

Total

Access/Availability of Care

Adults' Access to Preventive/Ambulatory Health Services (aap)

Y

20-44 Years

45-64 Years

65+ Years

Total

Children and Adolescents' Access to Primary Care Practitioners (cap)

Y

12-24 Months

25 Months - 6 Years

7-11 Years

12-19 Years

Annual Dental Visit (adv)

Y

Y

2-3 Years

4-6 Years

7-10 Years

11-14 Years

15-18 Years

44.3%

R

61.2%

R

71.4%

R

48.4%

R

89.3%

R

NA

R

88.4%

R

65.3%

R

88.0%

R

84.3%

R

88.9%

R

NA

R

85.0%

R

97.4%

R

91.2%

R

92.5%

R

89.8%

R

47.7%

R

76.8%

R

79.6%

R

72.1%

R

61.1%

R

4 of 32

Reportable Reportable
Reportable Reportable
Reportable Denominator fewer than 30
Reportable Reportable Reportable
Reportable Reportable Denominator fewer than 30 Reportable
Reportable Reportable Reportable Reportable
Reportable Reportable Reportable Reportable Reportable
August 2012

Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP

19-21 Years

37.6%

R

Total

69.7%

R

Initiation and Engagement of AOD Dependence Treatment (iet)

Y

Y

Initiation of AOD Treatment: 13-17 Years

39.0%

R

Engagement of AOD Treatment: 13-17 Years

14.1%

R

Initiation of AOD Treatment: 18+ Years

43.6%

R

Engagement of AOD Treatment: 18+ Years

11.0%

R

Initiation of AOD Treatment: Total

42.5%

R

Engagement of AOD Treatment: Total

Prenatal and Postpartum Care (ppc)

Y

Timeliness of Prenatal Care

11.7%

R

Y1

90.5%

R

Postpartum Care

65.7%

R

Call Answer Timeliness (cat)

Y

87.7%

R

Call Abandonment (cab)

Y

1.0%

R

Utilization

Frequency of Ongoing Prenatal Care (fpc)

Y

N

<21 Percent

7.9%

R

21-40 Percent

3.0%

R

41-60 Percent

6.1%

R

61-80 Percent

10.7%

R

81+ Percent

72.3%

R

Well-Child Visits in the First 15 Months of Life (w15)

Y

0 Visits

1.9%

R

1 Visit

3.0%

R

2 Visits

3.5%

R

3 Visits

3.7%

R

4 Visits

6.8%

R

5 Visits

17.5%

R

6+ Visits

63.6%

R

Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (w34)

Y

73.6%

R

Adolescent Well-Care Visits (awc)

Y

43.9%

R

Frequency of Selected Procedures (fsp)

Y

R

Ambulatory Care: Total (amba)

Y

R

5 of 32

Reportable Reportable
Reportable Reportable Reportable Reportable Reportable Reportable
Reportable Reportable Reportable Reportable
Reportable Reportable Reportable Reportable Reportable
Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable
August 2012

Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP

Ambulatory Care: Dual Eligibles (ambb)

N

NR

Ambulatory Care: Disabled (ambc)

N

NR

Ambulatory Care: Other (ambd)

N

NR

Inpatient Utilization--General Hospital/Acute Care: Total (ipua)

Y

R

Inpatient Utilization--General Hospital/Acute Care: Dual Eligibles (ipub)

N

NR

Inpatient Utilization--General Hospital/Acute Care: Disabled (ipuc)

N

NR

Inpatient Utilization--General Hospital/Acute Care: Other (ipud)

N

NR

Identification of Alcohol and Other Drug Services: Total (iada)

Y

Y

R

Identification of Alcohol and Other Drug Services: Dual Eligibles (iadb)

N

N

NR

Identification of Alcohol and Other Drug Services: Disabled (iadc)

N

N

NR

Identification of Alcohol and Other Drug Services: Other (iadd)

N

N

NR

Mental Health Utilization: Total (mpta)

Y

Y

R

Mental Health Utilization: Dual Eligibles (mptb)

N

N

NR

Mental Health Utilization: Disabled (mptc)

N

N

NR

Mental Health Utilization: Other (mptd)

N

N

NR

Antibiotic Utilization: Total (abxa)

Y

Y

R

Antibiotic Utilization: Dual Eligibles (abxb)

N

N

NR

Antibiotic Utilization: Disabled (abxc)

N

N

NR

Antibiotic Utilization: Other (abxd)

N

N

NR

Relative Resource Use

Relative Resource Use for People With Diabetes (rdi)

Y

R

Relative Resource Use for People With Asthma (ras)

Y

Y

R

Relative Resource Use for People With Cardiovascular Conditions (rca)

Y

R

Relative Resource Use for People With Hypertension (rhy)

Y

R

6 of 32

Measure Unselected Measure Unselected Measure Unselected
Reportable Measure Unselected Measure Unselected Measure Unselected
Reportable Measure Unselected Measure Unselected Measure Unselected
Reportable Measure Unselected Measure Unselected Measure Unselected
Reportable Measure Unselected Measure Unselected Measure Unselected
Reportable Reportable Reportable Reportable
August 2012

Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP

Relative Resource Use for People With COPD (rco)

Y

R

Reportable

Health Plan Descriptive Information

Board Certification (bcr)

Y

R

Reportable

Total Membership (tlm)

Y

R

Reportable

Enrollment by Product Line: Total (enpa)

Y

R

Reportable

Enrollment by Product Line: Dual Eligibles (enpb)

N

NR

Measure Unselected

Enrollment by Product Line: Disabled (enpc)

N

NR

Measure Unselected

Enrollment by Product Line: Other (enpd)

N

NR

Measure Unselected

Enrollment by State (ebs)

Y

R

Reportable

Race/Ethnicity Diversity of Membership (rdm)

Y

R

Reportable

Language Diversity of Membership (ldm)

Y

R

Reportable

Weeks of Pregnancy at Time of Enrollment in MCO (wop)

Y

N

R

Reportable

1 Note: Plan chose to rotate the measure. Measure rotation allows the health plan to use the audited and reportable rate from the previous year as specified by NCQA in the HEDIS 2012 Technical Specifications for Health Plans, Volume 2; however, rotation is not allowed by DCH; therefore, the rotated rate is not reportable with DCH.

7 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Frequency of Selected Procedures (FSP)

Frequency of Selected Procedures (FSP)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid,

Spec Area: None, Spec Proj: None)

Age

Male

Female

Total

0-9

843,530

817,840 1,661,402

10-19

538,704

549,003 1,087,707

15-44

541,790

20-44

34,146

320,437

30-64

30,618

45-64

8,345

28,049

Procedures

Procedure

Age

Sex

Number of / 1,000 Procedures Member

Years

0-19

Male

0

0.0

Female

0

0.0

Bariatric weight loss surgery

20-44

Male

1

Female

34

<0.1 0.1

45-64

Male

0

0.0

Female

3

0.1

Tonsillectomy

0-9

Male &

1403

0.8

10-19

Female

409

0.4

Hysterectomy, Abdominal

15-44

Female

157

0.3

45-64

27

1.0

Hysterectomy, Vaginal

15-44

Female

151

0.3

45-64

20

0.7

30-64

Male

0

0.0

Cholecystectomy, Open

15-44

Female

5

45-64

1

<0.1 <0.1

30-64

Male

17

0.6

Cholecystectomy, Closed (laparoscopic) 15-44

Female

460

0.8

45-64

28

1.0

Back Surgery

20-44

Male

22

0.6

Female

65

0.2

45-64

Male

12

1.4

Female

15

0.5

Mastectomy

15-44

Female

22

45-64

48

<0.1 1.7

Lumpectomy

15-44

Female

101

0.2

45-64

42

1.5

8 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Ambulatory Care: Total (AMBA)

Ambulatory Care: Total (AMBA)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid,

Spec Area: None, Spec Proj: None)

Age

Member Months

<1

248,526

1-9

1,412,876

10-19

1,087,707

20-44

354,583

45-64

36,394

65-74

74

75-84

7

85+

1

Unknown

0

Total

3,140,168

Outpatient Visits

ED Visits

Age

Visits/ 1,000

Visits/ 1,000

Visits

Member

Visits

Member

Months

Months

<1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total

189565 455843 249385 157218 27035
63 9 0 0 1,079,118

762.8 322.6 229.3 443.4 742.8 851.4 1285.7
0.0
343.6

22619 64645 40173 43671 2956
8 0 0 0 174,072

91.0 45.8 36.9 123.2 81.2 108.1 0.0 0.0
55.4

9 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP Inpatient Utilization - General Hospital/Acute Care: Total (IPUA)

Inpatient Utilization--General Hospital/Acute Care: Total (IPUA)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

Age

Member Months

<1

248,526

1-9

1,412,876

10-19 20-44 45-64

1,087,707 354,583 36,394

65-74

74

75-84

7

85+

1

Unknown Total

0 3,140,168
Total Inpatient

Age

Discharges /

Discharges

1,000 Member

Months

Days

Days / 1,000 Members Months

Average Length of
Stay

<1

1329

5.3

10513

42.3

7.9

1-9 10-19 20-44 45-64 65-74

1117

0.8

3857

2.7

3.5

3088

2.8

9508

8.7

3.1

13562

38.2

37920

106.9

2.8

403

11.1

1969

54.1

4.9

8

108.1

25

337.8

3.1

75-84 85+ Unknown

0

0.0

0

0.0

NA

0

0.0

0

0.0

NA

0

0

NA

Total

19,507

6.2

63,792

20.3

3.3

Medicine

Age

Discharges /

Discharges

1,000 Member

Months

Days

Days / 1,000 Members Months

Average Length of
Stay

<1

1002

4.0

5076

20.4

5.1

1-9

856

0.6

2476

1.8

2.9

10-19 20-44 45-64

457

0.4

1585

1.5

3.5

641

1.8

2277

6.4

3.6

232

6.4

890

24.5

3.8

65-74 75-84 85+

7

94.6

22

297.3

3.1

0

0.0

0

0.0

NA

0

0.0

0

0.0

NA

Unknown Total

0

0

NA

3,195

1.0

12,326

3.9

3.9

Surgery

Age

Discharges /

Discharges

1,000 Member

Months

Days

Days / 1,000 Members Months

Average Length of
Stay

<1

327

1.3

5437

21.9

16.6

1-9 10-19

261

0.2

1381

1.0

5.3

265

0.2

1790

1.6

6.8

20-44

539

1.5

3046

8.6

5.7

10 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP Inpatient Utilization - General Hospital/Acute Care: Total (IPUA)

45-64

159

4.4

1024

28.1

65-74

1

13.5

3

40.5

75-84

0

0.0

0

0.0

85+

0

0.0

0

0.0

Unknown

0

0

Total

1,552

0.5

12,681

4.0

Maternity*

Age

Discharges /

Discharges

1,000 Member

Months

Days

Days / 1,000 Members Months

10-19

2366

2.2

6133

5.6

20-44

12382

34.9

32597

91.9

45-64

12

0.3

55

1.5

Unknown

0

0

Total

14,760

10.0

38,785

26.2

*The maternity category is calculated using member months for members 10-64 years.

6.4 3.0 NA NA NA 8.2
Average Length of
Stay
2.6 2.6 4.6 NA 2.6

11 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP Identification of Alcohol and Other Drug Services: Total (IADA)

Identification of Alcohol and Other Drug Services: Total (IADA)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

Age

Member Months (Any)

Member Months (Inpatient)

Member Months (Intensive Outpatient/Partial Hospitalization)

Male

Female

Total

Male

Female

Total

Male

Female

Total

0-12

1056388 1024375 2,080,763 1056388 1024375 2,080,763 1056388 1024375 2,080,763

13-17

283363

283064

566,427

283363

283064

566,427

283363

283064

566,427

18-24

47362

147364

194,726

47362

147364

194,726

47362

147364

194,726

25-34

15552

159787

175,339

15552

159787

175,339

15552

159787

175,339

35-64

22060

100739

122,799

22060

100739

122,799

22060

100739

122,799

65+

6

76

82

6

76

82

6

76

82

Unknown

0

0

0

0

0

0

0

0

0

Member Months (Outpatient/ED)

Male 1056388 283363
47362 15552 22060
6 0

Female 1024375 283064 147364 159787 100739
76 0

Total 2,080,763 566,427 194,726 175,339 122,799
82 0

Total Age 0-12 13-17 18-24 25-34 35-64 65+

1,424,731
Sex
M F Total M F Total M F Total M F Total M F Total M F Total

1,715,405 3,140,136

Any Services

Number 38 24 62 415 193 608 92 390 482 98 797 895 159 539 698 0 0 0

Percent <0.1% <0.1% <0.1% 1.8% 0.8% 1.3% 2.3% 3.2% 3.0% 7.6% 6.0% 6.1% 8.6% 6.4% 6.8% 0.0% 0.0% 0.0%

1,424,731 1,715,405

Inpatient

Number 9 4 13 49 41 90 27
135 162 25 251 276 42 134 176
0 0 0

Percent <0.1% <0.1% <0.1% 0.2% 0.2% 0.2% 0.7% 1.1% 1.0% 1.9% 1.9% 1.9% 2.3% 1.6% 1.7% 0.0% 0.0% 0.0%

3,140,136 1,424,731

Intensive Outpatient/Partial
Hospitalization

Number

Percent

0

0.0%

0

0.0%

0

0.0%

14

0.1%

6

<0.1%

20

<0.1%

4

0.1%

11

0.1%

15

0.1%

2

0.2%

25

0.2%

27

0.2%

6

0.3%

18

0.2%

24

0.2%

0

0.0%

0

0.0%

0

0.0%

1,715,405 3,140,136

Outpatient/ED

Number 30 21 51 380 162 542 78 287 365 89 653 742 140 470 610 0 0 0

Percent <0.1% <0.1% <0.1% 1.6% 0.7% 1.1% 2.0% 2.3% 2.2% 6.9% 4.9% 5.1% 7.6% 5.6% 6.0% 0.0% 0.0% 0.0%

1,424,731

1,715,405

3,140,136

12 of 32

August 2012

Unknown Total

M F Total M F Total

0 0 0 802 1,943 2,745

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP Identification of Alcohol and Other Drug Services: Total (IADA)

NA

0

NA

NA

0

NA

NA

0

NA

0.7%

152

0.1%

1.4%

565

0.4%

1.0%

717

0.3%

0

NA

0

0

NA

0

0

NA

0

26

<0.1%

717

60

<0.1%

1,593

86

<0.1%

2,310

NA NA NA 0.6% 1.1% 0.9%

13 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Mental Health Utilization: Total (MPTA)

Mental Health Utilization: Total (MPTA)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

Member Months (Any) Age

Member Months (Inpatient)

Member Months (Intensive Outpatient/Partial Hospitalization)

Male

Female

Total

Male

Female

Total

Male

Female

Total

0-12

1056388

1024375 2,080,763 1056388

1024375 2,080,763 1056388

1024375 2,080,763

13-17

283363

283064

566,427

283363

283064

566,427

283363

283064

566,427

18-64

84974

407890

492,864

84974

407890

492,864

84974

407890

492,864

65+

6

76

82

6

76

82

6

76

82

Unknown

0

0

0

0

0

0

0

0

0

Total

1,424,731 1,715,405 3,140,136 1,424,731 1,715,405 3,140,136 1,424,731 1,715,405 3,140,136

Age

Sex

Any Services

Inpatient

Intensive Outpatient/Partial
Hospitalization

Outpatient/ED

Number

Percent

Number

Percent

Number

Percent

Number

Percent

M

6571

7.5%

134

0.2%

47

0.1%

6551

7.4%

0-12

F

3816

4.5%

84

0.1%

32

<0.1%

3799

4.5%

Total

10,387

6.0%

218

0.1%

79

<0.1%

10,350

6.0%

M

2948

12.5%

236

1.0%

76

0.3%

2911

12.3%

13-17

F

2721

11.5%

312

1.3%

72

0.3%

2644

11.2%

Total

5,669

12.0%

548

1.2%

148

0.3%

5,555

11.8%

M

561

7.9%

80

1.1%

14

0.2%

534

7.5%

18-64

F

3465

10.2%

354

1.0%

65

0.2%

3351

9.9%

Total

4,026

9.8%

434

1.1%

79

0.2%

3,885

9.5%

M

65+

F

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

Total

0

0.0%

0

0.0%

0

0.0%

0

0.0%

M

0

NA

0

NA

0

NA

0

NA

Unknown

F

0

NA

0

NA

0

NA

0

NA

Total

0

NA

0

NA

0

NA

0

NA

M

10,080

8.5%

450

0.4%

137

0.1%

9,996

8.4%

Total

F

10,002

7.0%

750

0.5%

169

0.1%

9,794

6.9%

Total

20,082

7.7%

1,200

0.5%

306

0.1%

19,790

7.6%

Member Months (Outpatient/ED)

Male 1056388 283363
84974 6 0
1,424,731

Female 1024375 283064 407890
76 0 1,715,405

Total 2,080,763 566,427 492,864
82 0 3,140,136

14 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Antibiotic Utilization: Total (ABXA)

Antibiotic Utilization: Total (ABXA)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

Pharmacy Benefit Member Months

Age

Male

Female

Total

0-9

843530

817840

1,661,370

10-17

496221

489599

985,820

18-34

62914

307151

370,065

35-49

18151

87035

105,186

50-64

3909

13704

17,613

65-74

1

73

74

75-84

4

3

7

85+

1

0

1

Unknown

0

0

0

Total

1,424,731 1,715,405

3,140,136

Antibiotic Utilization

Age

Sex

Total Antibiotic
Scrips

Average Scrips PMPY for Antibiotics

Total Days Supplied for
All Antibiotic
Scrips

Average Days
Supplied per Antibiotic Scrip

Total Number of Scrips for Antibiotics of
Concern

Average Scrips PMPY for
Anitbiotics of Concern

Percentage of Antibiotics of
Concern of all Antibiotic
Scrips

M

90646

1.3

856713

9.5

39692

0.6

0-9

F

85828

1.3

818866

9.5

34866

0.5

Total

176,474

1.3

1,675,579

9.5

74,558

0.5

M

25377

0.6

263094

10.4

10791

0.3

10-17

F

33664

0.8

325265

9.7

13240

0.3

Total

59,041

0.7

588,359

10.0

24,031

0.3

M

4069

0.8

41803

10.3

1514

0.3

18-34

F

49380

1.9

392262

7.9

15955

0.6

Total

53,449

1.7

434,065

8.1

17,469

0.6

M

1812

1.2

15711

8.7

793

0.5

35-49

F

14272

2.0

121420

8.5

5744

0.8

Total

16,084

1.8

137,131

8.5

6,537

0.7

M

391

1.2

3674

9.4

177

0.5

50-64

F

2163

1.9

18932

8.8

1023

0.9

Total

2,554

1.7

22,606

8.9

1,200

0.8

M

0

0.0

0

NA

0

0.0

65-74

F

6

1.0

41

6.8

3

0.5

Total

6

1.0

41

6.8

3

0.5

M

0

0.0

0

NA

0

0.0

75-84

F

0

0.0

0

NA

0

0.0

Total

0

0.0

0

NA

0

0.0

M

0

0.0

0

NA

0

0.0

85+

F

0

NA

0

NA

0

NA

Total

0

0.0

0

NA

0

0.0

M

0

NA

0

NA

0

NA

Unknown

F

0

NA

0

NA

0

NA

Total

0

NA

0

NA

0

NA

M

122,295

1.0

1,180,995

9.7

52,967

0.4

Total

F

185,313

1.3

1,676,786

9.0

70,831

0.5

Total

307,608

1.2

2,857,781

9.3

123,798

0.5

43.8% 40.6% 42.2% 42.5% 39.3% 40.7% 37.2% 32.3% 32.7% 43.8% 40.2% 40.6% 45.3% 47.3% 47.0%
NA 50.0% 50.0%
NA NA NA NA NA NA NA NA NA 43.3% 38.2% 40.2%

15 of 32

August 2012

Age
0-9 10-17 18-34 35-49 50-64 65-74 75-84 85+ Unknown Total

Sex
M F Total M F Total M F Total M F Total M F Total M F Total M F Total M F Total M F Total M F Total

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Antibiotic Utilization: Total (ABXA)

Total Quinolone
Scrips
39 74 113 238 597 835 220 3572 3,792 214 1734 1,948 52 378 430 0 0 0 0 0 0 0 0 0 0 0 0 763 6,355 7,118

Average Scrips PMPY
for Quinolones
<0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 0.1 0.1 0.1 0.2 0.2 0.2 0.3 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 NA 0.0 NA NA NA <0.1 <0.1 <0.1

Antibiotics of Concern Utilization

Total Cephalosporin 2nd-
4th Generation
Scrips

Average

Scrips PMPY for Cephalosporins 2nd-
4th

Total Azithromycin and Clarithromycin Scrips

Average Scrips PMPY for
Azithromycins and Clarithro-
mycins

Generation

Total Amoxicillin/ Clavulanate
Scrips

Average Scrips PMPY
for Amoxicillin/ Clavulanates

8841

0.1

15696

0.2

14008

0.2

7952

0.1

13793

0.2

12017

0.2

16,793

0.1

29,489

0.2

26,025

0.2

1386

<0.1

5325

0.1

3106

0.1

1720

<0.1

6647

0.2

3401

0.1

3,106

<0.1

11,972

0.1

6,507

0.1

81

<0.1

707

0.1

324

0.1

944

<0.1

7235

0.3

2362

0.1

1,025

<0.1

7,942

0.3

2,686

0.1

49

<0.1

293

0.2

141

0.1

288

<0.1

2233

0.3

914

0.1

337

<0.1

2,526

0.3

1,055

0.1

7

<0.1

64

0.2

37

0.1

44

<0.1

410

0.4

134

0.1

51

<0.1

474

0.3

171

0.1

0

0.0

0

0.0

0

0.0

0

0.0

2

0.3

1

0.2

0

0.0

2

0.3

1

0.2

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

NA

0

NA

0

NA

0

0.0

0

0.0

0

0.0

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

10,364

0.1

22,085

0.2

17,616

0.1

10,948

0.1

30,320

0.2

18,829

0.1

21,312

0.1

52,405

0.2

36,445

0.1

Total Ketolides
Scrips
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Average Scrips PMPY for Ketolides

Total Clindamycin
Scrips

Average Scrips PMPY
for Clindamycins

Total Misc. Antibiotics of
Concern Scrips

Average Scrips PMPY
for Misc. Antibiotics of
Concern

0.0

1094

<0.1

14

<0.1

0.0

1025

<0.1

5

<0.1

0.0

2,119

<0.1

19

<0.1

0.0

732

<0.1

4

<0.1

0.0

871

<0.1

4

<0.1

0.0

1,603

<0.1

8

<0.1

0.0

179

<0.1

3

<0.1

0.0

1826

0.1

16

<0.1

0.0

2,005

0.1

19

<0.1

0.0

95

0.1

1

<0.1

0.0

563

0.1

12

<0.1

0.0

658

0.1

13

<0.1

0.0

17

0.1

0

0.0

0.0

57

<0.1

0

0.0

0.0

74

0.1

0

0.0

0.0

0

0.0

0

0.0

0.0

0

0.0

0

0.0

0.0

0

0.0

0

0.0

0.0

0

0.0

0

0.0

0.0

0

0.0

0

0.0

0.0

0

0.0

0

0.0

0.0

0

0.0

0

0.0

NA

0

NA

0

NA

0.0

0

0.0

0

0.0

NA

0

NA

0

NA

NA

0

NA

0

NA

NA

0

NA

0

NA

0.0

2,117

<0.1

22

<0.1

0.0

4,342

<0.1

37

<0.1

0.0

6,459

<0.1

59

<0.1

16 of 32

August 2012

Age
0-9 10-17 18-34 35-49 50-64 65-74 75-84 85+ Unknown Total

Sex
M F Total M F Total M F Total M F Total M F Total M F Total M F Total M F Total M F Total M F Total

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Antibiotic Utilization: Total (ABXA)

All Other Antibiotics Utilization

Total Absorbable Sulfonamide
Scrips

Average

Scrips PMPY Total Amino-

for

glycoside

Absorbable

Scrips

Sulfonamides

Average Scrips PMPY for Aminoglycosides

Total 1st Generation Cephalosporin Scrips

Average Scrips PMPY for 1st Generation Cephalosporins

Total Lincosamide
Scrips

Average Scrips PMPY
for Lincosamides

Total Macrolides (not azith. or
clarith.) Scrips

Average Scrips PMPY for Macrolides (not azith. or clarith.)

3854

0.1

0

0.0

5840

0.1

0

0.0

125

<0.1

5904

0.1

2

<0.1

5834

0.1

0

0.0

97

<0.1

9,758

0.1

2

<0.1

11,674

0.1

0

0.0

222

<0.1

1805

<0.1

12

<0.1

2743

0.1

0

0.0

113

<0.1

3324

0.1

0

0.0

2983

0.1

0

0.0

122

<0.1

5,129

0.1

12

<0.1

5,726

0.1

0

0.0

235

<0.1

398

0.1

0

0.0

383

0.1

0

0.0

43

<0.1

4269

0.2

0

0.0

3453

0.1

0

0.0

288

<0.1

4,667

0.2

0

0.0

3,836

0.1

0

0.0

331

<0.1

168

0.1

0

0.0

164

0.1

0

0.0

19

<0.1

1519

0.2

0

0.0

1011

0.1

0

0.0

95

<0.1

1,687

0.2

0

0.0

1,175

0.1

0

0.0

114

<0.1

39

0.1

0

0.0

43

0.1

0

0.0

2

<0.1

230

0.2

0

0.0

194

0.2

0

0.0

19

<0.1

269

0.2

0

0.0

237

0.2

0

0.0

21

<0.1

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

NA

0

NA

0

NA

0

NA

0

NA

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

6,264

0.1

12

<0.1

9,173

0.1

0

0.0

302

<0.1

15,246

0.1

2

<0.1

13,475

0.1

0

0.0

621

<0.1

21,510

0.1

14

<0.1

22,648

0.1

0

0.0

923

<0.1

Total Penicillin
Scrips
40948 38705 79,653 7675 9660 17,335 1128 9227 10,355
468 2604 3,072
91 352 443
0 2 2 0 0 0 0 0 0 0 0 0 50,310 60,550 110,860

Average Scrips PMPY for Penicillins

Total Tetracycline
Scrips

Average Scrips PMPY
for Tetracyclines

Total Misc. Antibiotic
Scrips

Average Scrips PMPY for Misc. Antibiotics

0.6

26

<0.1

161

<0.1

0.6

21

<0.1

399

<0.1

0.6

47

<0.1

560

<0.1

0.2

2076

0.1

162

<0.1

0.2

2413

0.1

1922

<0.1

0.2

4,489

0.1

2,084

<0.1

0.2

507

0.1

96

<0.1

0.4

3537

0.1

12651

0.5

0.3

4,044

0.1

12,747

0.4

0.3

132

0.1

68

<0.1

0.4

1110

0.2

2189

0.3

0.4

1,242

0.1

2,257

0.3

0.3

25

0.1

14

<0.1

0.3

143

0.1

202

0.2

0.3

168

0.1

216

0.1

0.0

0

0.0

0

0.0

0.3

0

0.0

1

0.2

0.3

0

0.0

1

0.2

0.0

0

0.0

0

0.0

0.0

0

0.0

0

0.0

0.0

0

0.0

0

0.0

0.0

0

0.0

0

0.0

NA

0

NA

0

NA

0.0

0

0.0

0

0.0

NA

0

NA

0

NA

NA

0

NA

0

NA

NA

0

NA

0

NA

0.4

2,766

<0.1

501

<0.1

0.4

7,224

0.1

17,364

0.1

0.4

9,990

<0.1

17,865

0.1

17 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS
Measure Results for AMERIGROUP Board Certification (BCR)

Board Certification (BCR)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

Type of Physician

Number of Physicians in Each
Practice Area

Board Certification

Number

Percent

Family Medicine

916

723

78.9%

Internal Medicine

1759

1449

82.4%

OB/GYN physicians

735

634

86.3%

Pediatricians

1086

956

88.0%

Geriatricians

18

17

94.4%

Other physician specialists

4434

3904

88.0%

18 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Total Membership (TLM)

Total Membership (TLM)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

Product/Product Line

Total Number of Members*

HMO (Total)

256,661

Medicaid

256661

Commercial

0

Medicare (cost or risk)

0

Other

0

PPO (Total)

0

Medicaid

0

Commercial

0

Medicare (cost or risk)

0

Other

0

POS (Total)

0

Medicaid

0

Commercial

0

Medicare (cost or risk)

0

Other

0

FFS (Total)

0

Medicaid

0

Commercial

0

Medicare (cost or risk)

0

Other

0

Total

256,661

* Total number of members in each category as of December 31 of the measurement year.

19 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Enrollment by Product Line: Total (ENPA)

Enrollment by Product Line: Total (ENPA)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

Male

Female

Total

Age

Member

Member

Member

Months

Months

Months

<1

127018

121476

248,494

1-4

338683

327321

666,004

5-9

377829

369043

746,872

10-14

336841

327650

664,491

15-17

159380

161949

321,329

18-19

42483

59404

101,887

0-19 Subtotal

1,382,234 1,366,843 2,749,077

0-19 Subtotal: %

97.0%

79.7%

87.5%

20-24

4879

87960

92,839

25-29

6994

86893

93,887

30-34

8558

72894

81,452

35-39

7519

46099

53,618

40-44

6196

26591

32,787

20-44 Subtotal

34,146

320,437

354,583

20-44 Subtotal: %

2.4%

18.7%

11.3%

45-49

4436

14345

18,781

50-54

2485

7547

10,032

55-59

1091

3681

4,772

60-64

333

2476

2,809

45-64 Subtotal

8,345

28,049

36,394

45-64 Subtotal: %

0.6%

1.6%

1.2%

65-69

0

69

69

70-74

1

4

5

75-79

1

3

4

80-84

3

0

3

85-89

1

0

1

>=90

0

0

0

>=65 Subtotal

6

76

82

>=65 Subtotal: %

<0.1%

<0.1%

<0.1%

Age Unknown

0

0

0

Total

1,424,731 1,715,405 3,140,136

20 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Enrollment by State (EBS)

Enrollment by State (EBS)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

State

Number

Alabama

0

Alaska

0

Arizona

0

Arkansas

0

California

0

Colorado

0

Connecticut

0

Delaware

0

District of Columbia

0

Florida

0

Georgia

256661

Hawaii

0

Idaho

0

Illinois

0

Indiana

0

Iowa

0

Kansas

0

Kentucky

0

Louisiana

0

Maine

0

Maryland

0

Massachusetts

0

Michigan

0

Minnesota

0

Mississippi

0

Missouri

0

Montana

0

Nebraska

0

Nevada

0

New Hampshire

0

New Jersey

0

New Mexico

0

New York

0

North Carolina

0

North Dakota

0

Ohio

0

Oklahoma

0

Oregon

0

Pennsylvania

0

Rhode Island

0

South Carolina

0

South Dakota

0

Tennessee

0

Texas

0

Utah

0

Vermont

0

Virginia

0

Washington

0

West Virginia

0

21 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Enrollment by State (EBS)

Wisconsin Wyoming American Samoa Federated States of Micronesia
Guam Commonwealth of Northern Marianas
Puerto Rico Virgin Islands
Other TOTAL

0 0 0 0 0 0 0 0 0 256,661

22 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Race/Ethnicity Diversity of Membership (RDM)

Race/Ethnicity Diversity of Membership (RDM)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

Race/Ethnicity Diversity of Membership

Total Unduplicated Membership During the Measurement Year

379880

Percentage of Members for Whom the Organization has Race/Ethnicity Information by Data Collection

Direct Data Collection Method

Race

Direct Total Health Plan
Direct*
CMS/State Database*

92.5% 0.0000000000 0.924923600

Indirect Data Collection Method

Indirect 0.000000000

Total*

0

Other* 0.0000000000

Ethnicity

Direct Total Health Plan
Direct*
CMS/State Database*

3.3% 0.0000000000 0.032599700

Indirect 0.000000000

Total*

0

Other* 0.0000000000

Race
White Black or African American American-Indian and Alaska Native
Asian Native Hawaiian and Other Pacific
Islanders Some Other Race Two or More Races
Unknown Declined
Total

*Enter percentage as a value between 0 and 1.

Hispanic or Latino

Not Hispanic or Latino

Number

Percentage

Number Percentage

0

0.0%

519

100.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

0 0 12384 0 12,384

0.0% 0.0% 100.0% 0.0% 100.0%

0

0.0%

0

0.0%

0

0.0%

0

0.0%

519

100.0%

Unknown

Total*

0.075100000 0

Total* 0.967400000

Unknown Ethnicity

Number Percentage

170007

46.3%

167865

45.7%

306

0.1%

6273

1.7%

368

0.1%

6022 0
16136 0
366,977

1.6% 0.0% 4.4% 0.0% 100.0%

Declined Ethnicity

Number Percentage

0

NR

0

NR

0

NR

0

NR

0

NR

0

NR

0

NR

0

NR

0

NR

0

NR

Total

Number Percentage

170,526

44.9%

167,865

44.2%

306

0.1%

6,273

1.7%

368

0.1%

6,022 0
28,520 0
379,880

1.6% 0.0% 7.5% 0.0% 100.0%

23 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Language Diversity of Membership (LDM)

Language Diversity of Membership (LDM)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

Percentage of Members With Known Language Value from Each Data Source

Category

Health Plan Direct

CMS/State Databases

Other ThirdParty Source

Spoken Language Preferred for Health 0.000000000 1.000000000 0.000000000

Care*

0

0

0

Preferred Language for Written Materials*

0.000000000 1.000000000 0.000000000

0

0

0

Other Language Needs*

0.000000000 0.000000000 1.000000000

0

0

0

*Enter percentage as a value between 0 and 1. Spoken Language Preferred for Health Care

English Non-English

Number 257224 31789

Percentage 67.7% 8.4%

Unknown

90867

23.9%

Declined

0

0.0%

Total*

379,880

100.0%

Language Preferred for Written Materials

Number Percentage

English

257224

Non-English

31789

Unknown

90867

Declined

0

Total*

379,880

Other Language Needs

67.7% 8.4% 23.9% 0.0% 100.0%

English Non-English
Unknown

Number 0 0
379880

Percentage 0.0% 0.0%
100.0%

Declined

0

Total*

379,880

*Should sum to 100%

0.0% 100.0%

24 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Weeks of Pregnancy at Time of Enrollment in MCO (WOP)

Weeks of Pregnancy at Time of Enrollment in MCO (WOP)

AMERIGROUP Georgia Managed Care Company, Inc. (Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None, Spec Proj: None)

Measurement Year Measurement Year Weeks of Pregnancy
< 0 weeks 1-12 weeks 13-27 weeks 28 or more weeks Unknown
Total

2011 Number
1347 926 8461 2445 1100 14,279

Percentage 9.4% 6.5% 59.3% 17.1% 7.7%
100.00%

25 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Relative Resource Use for People with Diabetes (RDI)

Relative Resource Use for People With

Diabetes (RDI)

AMERIGROUP Georgia Managed Care Company, Inc.

(Org ID: 7359, SubID: 10188, Medicaid, Spec Area: None,

Spec Proj: None)

Data Element

Measure Data

Inpatient Facility PMPM

206.8

E&M Inpatient Services PMPM

13.1

E&M Outpatient Services PMPM

84.5

Surgery & Procedure Inpatient Services PMPM

13.0

Surgery & Procedure Outpatient Services

74.4

PMPM

Imaging Services PMPM

63.3

Laboratory Services PMPM

32.3

Pharmacy PMPM

173.6

Inpatient Facility: Acute Inpatient: Medical Days per 1000 MM

69.5

Inpatient Facility: Acute Inpatient: Medical

18.2

Discharges per 1000 MM

Inpatient Facility: Acute Inpatient: Surgery Days per 1000 MM

17.3

Inpatient Facility: Acute Inpatient: Surgery Discharges per 1000 MM

3.3

Inpatient Facility: Nonacute Days per 1000

1.0

MM

Inpatient Facility: Nonacute Discharges per

0.1

1000 MM

Inpatient Facility Acute Medical ALOS

3.8

Inpatient Facility Acute Surgery ALOS

5.2

Inpatient Facility Nonacute ALOS

12.0

Total Inpatient Facility Acute ALOS

4.0

Total Inpatient Facility ALOS

4.1

ED Discharges per 1000 MM Medical

163.8

Cardiac Cathereterization per 1000 MM Medical

1.8

PCI per 1000 MM Medical

0.6

CABG per 1000 MM Medical

0.2

Carotid Endarterectomy per 1000 MM

0.2

Medical

Carotid Artery Stenosis Diagnostic Test per 1000 MM Medical

0.0

Cardiac Computed Tomography per 1000 MM Medical

0.1

CAD Diagnostic Test Using EBCT/Nuclear

8.4

Imaging Stress Tests per 1000 MM Medical

Eligible Population Exclusions
Eligible Population per 1,000 Member Months Medical

1061 62
84.5

26 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Relative Resource Use for People with Diabetes (RDI)

Eligible Population per 1,000 Member Months Pharmacy
NameBrandOnlyCount(N1) NameBrandGenericExistsCount(N2)
GenericOnlyCount (G1) GenericNameBrandExistsCount (G2) Total Prescriptions (N1+N2+G1+G2)
Generic Utilization Rate [(G1 + G2)/(N2+G1+G2)]
Generic Substitution Rate [(G2)/(N2+G2)] Overall Generic Utilization [(G1+G2)/(N1+N2+G1+G2)]

84.5
6390 2441 5475 41696 56002.0
1.0
0.9
0.8

27 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Relative Resource Use for People with Asthma (RAS)

Relative Resource Use for People With

Asthma (RAS)

AMERIGROUP Georgia Managed Care Company, Inc.

Data Element

Measure Data

Inpatient Facility PMPM

17.8

E&M Inpatient Services PMPM

1.3

E&M Outpatient Services PMPM

50.5

Surgery & Procedure Inpatient Services PMPM

0.8

Surgery & Procedure Outpatient Services

15.6

PMPM

Imaging Services PMPM

9.6

Laboratory Services PMPM

5.5

Pharmacy PMPM

114.6

Inpatient Facility: Acute Inpatient: Medical

8.0

Days per 1000 MM

Inpatient Facility: Acute Inpatient: Medical Discharges per 1000 MM

2.3

Inpatient Facility: Acute Inpatient: Surgery Days per 1000 MM

0.4

Inpatient Facility: Acute Inpatient: Surgery Discharges per 1000 MM

0.1

Inpatient Facility: Nonacute Days per 1000

1.0

MM

Inpatient Facility: Nonacute Discharges per 1000 MM

0.1

Inpatient Facility Acute Medical ALOS

3.5

Inpatient Facility Acute Surgery ALOS

4.0

Inpatient Facility Nonacute ALOS

13.7

Total Inpatient Facility Acute ALOS

3.5

Total Inpatient Facility ALOS

3.8

ED Discharges per 1000 MM Medical

74.5

Eligible Population

3424

Exclusions

434

Eligible Population per 1,000 Member Months Medical

84.1

Eligible Population per 1,000 Member Months 84.1 Pharmacy

NameBrandOnlyCount(N1)

23472

NameBrandGenericExistsCount(N2)

13565

GenericOnlyCount (G1)

7556

GenericNameBrandExistsCount (G2)

37724

Total Prescriptions (N1+N2+G1+G2)

82317.0

Generic Utilization Rate [(G1 +

0.8

G2)/(N2+G1+G2)]

Generic Substitution Rate [(G2)/(N2+G2)]

0.7

Overall Generic Utilization [(G1+G2)/(N1+N2+G1+G2)]

0.6

28 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP Relative Resource Use for People with Cardiovascular Conditions (RCA)

Relative Resource Use for People With

Cardiovascular Conditions (RCA)

AMERIGROUP Georgia Managed Care Company, Inc. (Org

Data Element

Measure Data

Inpatient Facility PMPM

608.4

E&M Inpatient Services PMPM

31.7

E&M Outpatient Services PMPM

113.4

Surgery & Procedure Inpatient Services PMPM

55.8

Surgery & Procedure Outpatient Services

88.9

PMPM

Imaging Services PMPM

82.6

Laboratory Services PMPM

36.3

Pharmacy PMPM

291.5

Inpatient Facility: Acute Inpatient: Medical Days per 1000 MM

153.2

Inpatient Facility: Acute Inpatient: Medical Discharges per 1000 MM

36.1

Inpatient Facility: Acute Inpatient: Surgery Days per 1000 MM

67.1

Inpatient Facility: Acute Inpatient: Surgery Discharges per 1000 MM

13.8

Inpatient Facility: Nonacute Days per 1000

0.0

MM

Inpatient Facility: Nonacute Discharges per 1000 MM

0.0

Inpatient Facility Acute Medical ALOS

4.2

Inpatient Facility Acute Surgery ALOS

4.9

Inpatient Facility Nonacute ALOS

NR

Total Inpatient Facility Acute ALOS

4.4

Total Inpatient Facility ALOS

4.4

ED Discharges per 1000 MM Medical

151.5

Cardiac Cathereterization per 1000 MM Medical

12.0

PCI per 1000 MM Medical

12.0

CABG per 1000 MM Medical

1.7

Carotid Endarterectomy per 1000 MM Medical 0.0

Carotid Artery Stenosis Diagnostic Test per 1000 MM Medical

0.0

Cardiac Computed Tomography per 1000 MM Medical

0.0

CAD Diagnostic Test Using EBCT/Nuclear

25.8

Imaging Stress Tests per 1000 MM Medical

Eligible Population

49

Exclusions

1

Eligible Population per 1,000 Member Months Medical

84.3

Eligible Population per 1,000 Member Months 84.3 Pharmacy

NameBrandOnlyCount(N1)

565

29 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP Relative Resource Use for People with Cardiovascular Conditions (RCA)

NameBrandGenericExistsCount(N2) GenericOnlyCount (G1)
GenericNameBrandExistsCount (G2) Total Prescriptions (N1+N2+G1+G2)
Generic Utilization Rate [(G1 + G2)/(N2+G1+G2)]
Generic Substitution Rate [(G2)/(N2+G2)] Overall Generic Utilization [(G1+G2)/(N1+N2+G1+G2)]

109 244 2651 3,569.0
1.0
1.0
0.8

30 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP Relative Resource Use for People with Hypertension (RHY)

Relative Resource Use for People With

Hypertension (RHY)

AMERIGROUP Georgia Managed Care Company, Inc. (Org

Data Element

Measure Data

Inpatient Facility PMPM

162.2

E&M Inpatient Services PMPM

9.4

E&M Outpatient Services PMPM

85.6

Surgery & Procedure Inpatient Services PMPM

14.0

Surgery & Procedure Outpatient Services

75.4

PMPM

Imaging Services PMPM

60.6

Laboratory Services PMPM

28.7

Pharmacy PMPM

140.6

Inpatient Facility: Acute Inpatient: Medical

50.2

Days per 1000 MM

Inpatient Facility: Acute Inpatient: Medical Discharges per 1000 MM

12.8

Inpatient Facility: Acute Inpatient: Surgery Days per 1000 MM

13.1

Inpatient Facility: Acute Inpatient: Surgery Discharges per 1000 MM

2.8

Inpatient Facility: Nonacute Days per 1000

0.0

MM

Inpatient Facility: Nonacute Discharges per 1000 MM

0.0

Inpatient Facility Acute Medical ALOS

3.9

Inpatient Facility Acute Surgery ALOS

4.6

Inpatient Facility Nonacute ALOS

NR

Total Inpatient Facility Acute ALOS

4.1

Total Inpatient Facility ALOS

4.1

ED Discharges per 1000 MM Medical

189.8

Eligible Population

1965

Exclusions

72

Eligible Population per 1,000 Member Months Medical

84.4

Eligible Population per 1,000 Member Months

84.4

Pharmacy

NameBrandOnlyCount(N1)

7723

NameBrandGenericExistsCount(N2)

3777

GenericOnlyCount (G1)

12438

GenericNameBrandExistsCount (G2)

76728

Total Prescriptions (N1+N2+G1+G2)

100,666.0

Generic Utilization Rate [(G1 +

1.0

G2)/(N2+G1+G2)]

Generic Substitution Rate [(G2)/(N2+G2)]

1.0

Overall Generic Utilization [(G1+G2)/(N1+N2+G1+G2)]

0.9

31 of 32

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for AMERIGROUP
Relative Resource Use for People with COPD (RCO)

Relative Resource Use for People With

COPD (RCO)

AMERIGROUP Georgia Managed Care Company, Inc. (Org

Data Element

Measure Data

Inpatient Facility PMPM

340.0

E&M Inpatient Services PMPM

18.5

E&M Outpatient Services PMPM

102.6

Surgery & Procedure Inpatient Services PMPM 22.0

Surgery & Procedure Outpatient Services PMPM
Imaging Services PMPM Laboratory Services PMPM
Pharmacy PMPM Inpatient Facility: Acute Inpatient: Medical
Days per 1000 MM Inpatient Facility: Acute Inpatient: Medical
Discharges per 1000 MM Inpatient Facility: Acute Inpatient: Surgery
Days per 1000 MM Inpatient Facility: Acute Inpatient: Surgery
Discharges per 1000 MM

100.7 93.5 32.3 233.8 92.6
23.2
41.3
5.2

Inpatient Facility: Nonacute Days per 1000 MM 4.8

Inpatient Facility: Nonacute Discharges per 1000 MM
Inpatient Facility Acute Medical ALOS Inpatient Facility Acute Surgery ALOS
Inpatient Facility Nonacute ALOS Total Inpatient Facility Acute ALOS
Total Inpatient Facility ALOS ED Discharges per 1000 MM Medical
Eligible Population Exclusions
Eligible Population per 1,000 Member Months Medical
Eligible Population per 1,000 Member Months Pharmacy
NameBrandOnlyCount(N1) NameBrandGenericExistsCount(N2)
GenericOnlyCount (G1) GenericNameBrandExistsCount (G2) Total Prescriptions (N1+N2+G1+G2)
Generic Utilization Rate [(G1 + G2)/(N2+G1+G2)]
Generic Substitution Rate [(G2)/(N2+G2)] Overall Generic Utilization [(G1+G2)/(N1+N2+G1+G2)]

0.4
4.0 7.9 12.0 4.7 4.8 237.7 211 15
84.6
84.6
1582 844 1562 10513 14501.0
0.9
0.9
0.8

32 of 32

August 2012