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 AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page i AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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 AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page 1 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES 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). AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page 2 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES 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 AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page 3 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES 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 AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page 4 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES 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 AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page 5 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES 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 AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page 6 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES 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 AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page 7 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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. AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page 8 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES 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 AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page 9 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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 AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page 10 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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. AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page A-i AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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). AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page A-1 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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. AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page A-2 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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. AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page B-i AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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. AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page B-1 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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. AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page B-2 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 Appendix C. Performance Measure Results for AMERIGROUP Community Care Appendix C, which follows this page, contains AMERIGROUP's performance measure results. AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page C-i AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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% AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page C-1 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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% AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page C-2 AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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. AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page D-i AMERIGROUP_GA2011-12_CMO_PMV_F6_0812 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% AMERIGROUP Community Care Validation of Performance Measures State of Georgia Page D-1 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 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