Georgia Department of Community Health Validation of Performance Measures for Peach State Health Plan 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 Peach State Health Plan 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..................................................................................................................................... 8 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 Peach State Health Plan Validation of Performance Measures State of Georgia Page i PeachState_GA2011-12_CMO_PMV_F6_0812 Validation of Performance Measures for Peach State Health Plan 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 Peach State Health Plan (Peach State). Information about Peach State appears in Table 1. CMO Name: CMO Location: CMO Contact: Contact Telephone Number: Contact E-mail Address: Site Visit Date: Table 1--Peach State Information Peach State Health Plan 3200 Highlands Parkway SE, Suite 300 Smyrna, GA 30082 Joyce McElwain, Senior Director, Quality Improvement (QI) 678.556.2344 jmcelwain@centene.com March 6, 2012 Peach State Health Plan Validation of Performance Measures State of Georgia Page 1 PeachState_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 Peach State Performance Measure Rate Calculation by: 1. Low Birth Weight Rate (AHRQ) Peach State 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) Peach State Peach State Peach State Peach State Peach State Peach State In addition, Peach State was required to report a selected set of Healthcare Effectiveness Data and Information Set (HEDIS) measures to DCH. Peach State was required to contract with an NCQAlicensed audit organization and undergo a NCQA HEDIS Compliance AuditTM. 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). Peach State Health Plan Validation of Performance Measures State of Georgia Page 2 PeachState_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 Peach State, 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 Peach State 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 Peach State 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 Peach State approximately one week prior to the on-site visit. HSAG also conducted a pre-on-site conference call with Peach State 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 Peach State. Some team members, including the lead auditor, participated in the on-site meetings at Peach State; others conducted their work at HSAG's offices. Peach State'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 Jennifer Lenz, MPH, CHCA Lead Auditor David Mabb, MS, CHCA Associate Director, Audits Ron Holcomb, AS Source Code Reviewer Tammy GianFrancisco Project Leader Table 3--Validation Team Skills and Expertise Certified HEDIS auditor, performance measure validation knowledge, health care quality expertise, and interviewing skills Certified HEDIS auditor, HEDIS knowledge, source code review manager, and statistics and analysis. Source code review Overall project coordination and communications Peach State Health Plan Validation of Performance Measures State of Georgia Page 3 PeachState_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: Peach State completed and submitted the required and relevant portions of its Roadmap for review by the validation team. The validation team used the 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 Peach State 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 Peach State on March 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 Peach State 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 Peach State 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 findings Peach State Health Plan Validation of Performance Measures State of Georgia Page 4 PeachState_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES 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 Peach State staff members who were involved with performance measure reporting. Table 4 lists key Peach State interviewees: Chevron Cardenas Donna McIntosh Clyde White Ron Purisma Vandana Pandita Joyce McElwain Dean Greeson Mark Smith Tony Ward Loni Eaton Heather House Yolanda Spivey Vicki Pitlajk Dana Sulton Luke Ferguson Kimberly Weakley Detra Friley Wanda Lee Jason Rosen Tony Masgio Janet Johnson Name Table 4--List of Peach State Interviewees Title Sr. Director, Member and Provider Services Director, Compliance VP, Compliance Manager, QI Analytics Director, Accreditation Sr. Director, QI Senior Medical Director Manager, Corporate Encounters (Georgia) Director, Claims Manager, Claims Support Services Supervisor, Claims Senior Director, Data Analytics Director, Claims (Farmington) Encounters Specialist EPO (Georgia) Encounters Analyst (Georgia) Senior Director, Provider Operations Manager, Provider Data Manager HEDIS Analyst IT Integration, Corporate IT Integration, Corporate Peach State Health Plan Validation of Performance Measures State of Georgia Page 5 PeachState_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 Peach State, 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 Peach State were: Acceptable Not acceptable Data Control Peach State'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 Peach State 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 Peach State 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 Peach State. 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 Peach State was: Acceptable Not acceptable Peach State Health Plan Validation of Performance Measures State of Georgia Page 6 PeachState_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES Validation Results The validation team evaluated Peach State'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) Peach State uses AMISYS to process claims and has no capitated providers. Therefore, all providers must submit a claim for the purpose of payment. Peach State receives a high percentage of claims electronically, approximately 90 percent, which leaves a small number of claims for manual processing. There were sufficient edit checks in place for the processing of electronic claims and electronic data interchange (EDI) files. Paper claims are processed at Peach State's claims processing center in Farmington, New Mexico. Peach State conducts monthly audits of its claims processors and provides feedback to the claims processors regarding keying errors. While there was sufficient training and oversight of the manual claims process, the auditor recommends that Peach State formally document data entry results in addition to the financial accuracy results. Peach State had sufficient edit checks in place to detect invalid codes, only accepts industry standard codes, and does not use any homegrown codes. Peach State primarily receives delivery claims through a global bill, receives inpatient revenue codes, and uses a DRG grouper. Peach State delegates claims processing functions for pharmacy and dental services. The pharmacy vendor, US Script, provided pharmacy data to Peach State at least weekly. Paid, denied, and reversal information was included on the file. The data are loaded into a separate table in the data warehouse for the purposes of HEDIS reporting. Peach State indicated it conducts financial reconciliation of pharmacy data for the purposes of vendor oversight; however, this information could not be produced for the auditor. Peach State did provide claims information by month for the 2011 calendar year. The volume was consistent; therefore, there were no concerns with complete data. Peach State uses DentaQuest for dental claims processing. Data are received every two weeks on a flat file, and the files are loaded into Peach State's data warehouse as medical claims. Both paid and denied claims are included in the DentaQuest files. All dental providers are paid fee-for-service. The auditor identified no concerns with Peach State's ability to capture complete and accurate data; however, the auditor encourages Peach State to formally implement and document a process that monitors vendor volume. Enrollment Data Peach State receives three types of enrollment files from Hewlett Packard (HP), DCH's Medicaid Management Information System (MMIS) vendor. The files include a daily change file, a monthly full file, and the end-of-month adjustment file. All files are posted to the FTP site from HP and retrieved and processed by Peach State. Peach State had sufficient procedures in place to systematically identify discrepancies for local enrollment processors to update. Enrollment information is housed in AMISYS. Peach State indicated that there were some issues with Peach State Health Plan Validation of Performance Measures State of Georgia Page 7 PeachState_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES processing data in April 2011 for newborns that had not been included on the daily file since March 25, 2011. To resolve the issue, the DCH provided Peach State with an ad hoc file; and members were manually loaded in the system, which took approximately three-to-four days to process. Peach State had very good processes in place to ensure monthly oversight of manually entered data. Newborns are assigned a Medicaid ID at the time of enrollment and are sometimes passed from DCH to Peach State as "baby boy," etc. The newborns are not linked to their mothers, and Peach State is dependent on DCH's files to show the member as a duplicate or member merge. Peach State has a process to forward potential duplicates to the DCH for research and resolution. There were no concerns identified with Peach State's ability to process eligibility data. Provider Data Peach State used a CACTUS database for provider data through July 2011. Beginning in August 2011, Peach State implemented Portico to house all provider data. Portico interfaces electronically with the AMISYS system for the purposes of claims payment. Dental provider information is received through a file feed at the corporate location and uploaded into the Portico system monthly. The system is able to capture provider specialties at the individual level; however, federally qualified health centers (FQHCs) are built on a facility number; therefore, the rendering provider and associated provider type are not captured on these claims. This can result in under/over reporting for measures that require a provider type. There were no issues identified with the conversion from CACTUS to Portico. Peach State should work toward requiring FQHCs to submit the rendering provider for all claims to capture the provider type. Medical Record Review Process Peach State 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 The auditor verified that Peach State did not use any sources of supplemental data. Data Integration Peach State produced its own rates for the two AHRQ measures (Cesarean Delivery Rate, and Low Birth Weight Rate), and used its vendor, MedAssurant, to calculate the CMS CHIPRA measures. Peach State loaded data into its data warehouse for the purposes of producing the measures. As part of the data integration review, the auditor reviewed a MedAssurant data load report showing that all data files were processed completely and accurately. Overall, there were no concerns with Peach State's integration of data to produce valid rates. Peach State Health Plan Validation of Performance Measures State of Georgia Page 8 PeachState_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 Peach State 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 Peach State Health Plan Validation of Performance Measures State of Georgia Page 9 PeachState_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 Peach State for each performance measure. For additional information regarding performance measure rates, see Appendix C of this report. Table 7--Validation Findings for Peach State 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 Peach State Health Plan Validation of Performance Measures State of Georgia Page 10 PeachState_GA2011-12_CMO_PMV_F6_0812 Appendix A. Data Integration and Control Findings for Peach State Health Plan Appendix A, which follows this page, contains the data integration and control findings for Peach State. Peach State Health Plan Validation of Performance Measures State of Georgia Page A-i PeachState_GA2011-12_CMO_PMV_F6_0812 Appendix A. Data Integration and Control Findings for Peach State Health Plan Documentation Worksheet CMO Name: On-Site Visit Date: Reviewers: Peach State Health Plan March 6, 2012 Jennifer Lenz, MPH, CHCA 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. All measures were administrative; therefore, no samples were drawn. 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. 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). Peach State Health Plan Validation of Performance Measures State of Georgia Page A-1 PeachState_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. Peach State Health Plan Validation of Performance Measures State of Georgia Page A-2 PeachState_GA2011-12_CMO_PMV_F6_0812 Appendix B. Denominator and Numerator Validation Findings for Peach State Health Plan Appendix B, which follows this page, contains the denominator and numerator validation findings for Peach State. Peach State Health Plan Validation of Performance Measures State of Georgia Page B-i PeachState_GA2011-12_CMO_PMV_F6_0812 Appendix B. Denominator and Numerator Validation Findings for Peach State Health Plan Reviewer Worksheets CMO Name: On-Site Visit Date: Reviewers: Peach State Health Plan March 6, 2012 Jennifer Lenz, MPH, CHCA Table B-1--Denominator Validation Findings for Peach State Health Plan 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. Peach State Health Plan Validation of Performance Measures State of Georgia Page B-1 PeachState_GA2011-12_CMO_PMV_F6_0812 DENOMINATOR AND NUMERATOR VALIDATION FINDINGS Table B-2--Numerator Validation Findings for Peach State Health Plan 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). The CMO did not use nonstandard codes. Peach State Health Plan Validation of Performance Measures State of Georgia Page B-2 PeachState_GA2011-12_CMO_PMV_F6_0812 Appendix C. Performance Measure Results for Peach State Health Plan Appendix C, which follows this page, contains Peach State's performance measure results. Peach State Health Plan Validation of Performance Measures State of Georgia Page C-i PeachState_GA2011-12_CMO_PMV_F6_0812 Appendix C. Performance Measure Results for Peach State Health Plan Indicator 1--Low Birth Weight Rate Table C-1--Indicator 1 for Peach State Health Plan Low Birth Weight Rate Rate (per 100) 7.0 Indicator 2--Cesarean Delivery Rate Table C-2--Indicator 2 for Peach State Health Plan Cesarean Delivery Rate Rate (per 100) 31.9 Indicator 3--Percentage of Eligibles that Received Preventive Dental Services Table C-3--Indicator 3 for Peach State Health Plan Preventive Dental Services Rate 45.9% Peach State Health Plan Validation of Performance Measures State of Georgia Page C-1 PeachState_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 Peach State Health Plan Otitis Media with Effusion Rate 37.9% Indicator 5--Percentage of Eligibles that Received Dental Treatment Services Table C-5--Indicator 5 for Peach State Health Plan Dental Treatment Services Rate 22.1% Indicator 6--Annual Percentage of Asthma Patients with One or More Asthma-Related Emergency Room Visit Table C-6--Indicator 6 for Peach State Health Plan Asthma ER Rate 11.8% Indicator 7--Annual Pediatric Hemoglobin (HbA1c) Testing Table C-7--Indicator 7 for Peach State Health Plan Pediatric HbA1c Testing Rate 82.0% Peach State Health Plan Validation of Performance Measures State of Georgia Page C-2 PeachState_GA2011-12_CMO_PMV_F6_0812 Appendix D. Final Audited HEDIS Results for Peach State Health Plan Appendices D and E, which follow this page, contain Peach State's final audited HEDIS results. Peach State Health Plan Validation of Performance Measures State of Georgia Page D-i PeachState_GA2011-12_CMO_PMV_F6_0812 Appendix D. Final Audited HEDIS Results for Peach State Health Plan CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--Peach State Health Plan Measure CMO Rate Adolescent Well-Care Visits 38.5% Adults' Access to Preventive/Ambulatory Health Services--Ages 2044 Years Adults' Access to Preventive/Ambulatory Health Services--Ages 4564 Years 84.8% 88.6% Adults' Access to Preventive/Ambulatory Health Services--Ages 65+ Years NA Adults' Access to Preventive/Ambulatory Health Services--Total 85.2% Adult BMI Assessment Annual Dental Visit--Ages 23 Years 48.0% Hybrid 43.9% Annual Dental Visit--Ages 46 Years 75.6% 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 Repertory Infection (URI) 2 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 2 Breast Cancer Screening Call Abandonment 78.6% 70.5% 58.9% 39.2% 67.5% 83.8% 38.4% 23.4% 68.8% 77.8% 20.6% 52.9% 1.6% Peach State Health Plan Validation of Performance Measures State of Georgia Page D-1 PeachState_GA2011-12_CMO_PMV_F6_0812 FINAL AUDITED HEDIS RESULTS CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--Peach State Health Plan Measure CMO Rate Call Answer Timeliness 87.4% 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 70.0% Hybrid 77.6% Hybrid 19.0% Hybrid 76.6% Hybrid Childhood Immunization Status--Combo 10 17.6% Hybrid Children's and Adolescents' Access to Primary Care Providers--Ages 12 24 Months 95.7% Children's and Adolescents' Access to Primary Care Providers--Ages 25 Months6 Years Children's and Adolescents' Access to Primary Care Providers--Ages 7 11 Years Children's and Adolescents' Access to Primary Care Providers--Ages 12 19 Years Chlamydia Screening in Women--Total 90.5% 90.3% 87.2% 60.2% Comprehensive Diabetes Care--Blood Pressure Control <140/80 36.1% Hybrid Comprehensive Diabetes Care--Blood Pressure Control <140/90 58.0% Hybrid Comprehensive Diabetes Care--Eye Exam 53.7% Hybrid Comprehensive Diabetes Care--HbA1c Good Control <7.0 28.8% Hybrid Comprehensive Diabetes Care--HbA1c Good Control <8.0 Comprehensive Diabetes Care--HbA1c Poor Control1 37.4% Hybrid 54.5% Hybrid Comprehensive Diabetes Care--HbA1c Testing 77.4% Hybrid Comprehensive Diabetes Care--LDL-C Level 27.5% Hybrid Peach State Health Plan Validation of Performance Measures State of Georgia Page D-2 PeachState_GA2011-12_CMO_PMV_F6_0812 FINAL AUDITED HEDIS RESULTS CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--Peach State Health Plan Measure CMO Rate Comprehensive Diabetes Care--LDL-C Screening 65.5% Hybrid Comprehensive Diabetes Care--Medical Attention to Nephropathy Controlling High Blood Pressure 3 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis Follow-Up After Hospitalization for Mental Illness--30-Day Follow-Up 71.1% Hybrid NR 47.6% Hybrid 72.5% 74.6% Follow-Up After Hospitalization for Mental Illness--7-Day Follow-Up Follow-Up Care for Children Prescribed ADHD Medication--Initiation Phase Follow-Up Care for Children Prescribed ADHD Medication-- Continuation and Maintenance Phase 51.3% 43.7% 57.4% Frequency of Ongoing Prenatal Care--< 21 Percent Frequency of Ongoing Prenatal Care--2140 Percent 7.9% Hybrid 3.9% Hybrid Frequency of Ongoing Prenatal Care--4160 Percent 5.1% Hybrid Frequency of Ongoing Prenatal Care--6180 Percent 12.5% Hybrid Frequency of Ongoing Prenatal Care--81+ Percent 70.5% Hybrid Human Papillomavirus Vaccine for Female Adolescents 17.7% Immunizations for Adolescents--Combo 1 70.8% Hybrid Initiation and Engagement of AOD Dependence Treatment--Initiation 34.6% Initiation and Engagement of AOD Dependence Treatment--Engagement 8.7% Inpatient Utilization--General Hospital/Acute Care--Total Rates reported in Appendix E Peach State Health Plan Validation of Performance Measures State of Georgia Page D-3 PeachState_GA2011-12_CMO_PMV_F6_0812 FINAL AUDITED HEDIS RESULTS CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--Peach State Health Plan Measure CMO Rate Lead Screening in Children 70.8% Hybrid Medication Management for People with Asthma--Total-Medication Compliance 50% 40.6% Medication Management for People with Asthma--Total-Medication Compliance 75% 17.1% Persistence of Beta-Blocker Treatment After a Heart Attack NA Pharmacotherapy Management of COPD Exacerbation--Systemic Corticosteroid 69.6% Pharmacotherapy Management of COPD Exacerbation--Bronchodilator 87.0% Prenatal and Postpartum Care--Postpartum Care 61.7% Hybrid Prenatal and Postpartum Care--Timeliness of Prenatal Care 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 Use of Appropriate Medications for People with Asthma--Total 85.8% Hybrid 91.3% 90.6% 73.6% NA 90.4% Use of Imaging Studies for Low Back Pain 2 75.8% Use of Spirometry Testing in the Assessment and Diagnosis of COPD 43.2% Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--BMI Percentile (Total) 22.7% Hybrid Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--Counseling for Nutrition (Total) 40.7% Hybrid Peach State Health Plan Validation of Performance Measures State of Georgia Page D-4 PeachState_GA2011-12_CMO_PMV_F6_0812 FINAL AUDITED HEDIS RESULTS CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--Peach State Health Plan Measure CMO Rate Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--Counseling for Physical Activity (Total) 29.4% Hybrid Well-Child Visits in the First 15 Months of Life--Zero Visits 7.2% Hybrid Well-Child Visits in the First 15 Months of Life--One Visit 3.5% Hybrid Well-Child Visits in the First 15 Months of Life--Two Visits 3.0% Hybrid Well-Child Visits in the First 15 Months of Life--Three Visits 7.4% Hybrid Well-Child Visits in the First 15 Months of Life--Four Visits 11.3% 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 Frequency of Selected Procedures Mental Health Utilization--Total Board Certification Total Membership Enrollment by Product Line--Total Enrollment by State Identification of Alcohol and Other Drug Services--Total Weeks of Pregnancy at Time of Enrollment Race/Ethnicity Diversity of Membership 17.1% Hybrid 50.5% Hybrid 67.4% Hybrid Rates reported in Appendix E Rates reported in Appendix E NR Rates reported in Appendix E Rates reported in Appendix E Rates reported in Appendix E Rates reported in Appendix E Rates reported in Appendix E Rates reported in Appendix E Peach State Health Plan Validation of Performance Measures State of Georgia Page D-5 PeachState_GA2011-12_CMO_PMV_F6_0812 FINAL AUDITED HEDIS RESULTS CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--Peach State Health Plan Measure CMO Rate Language Diversity of Membership Rates reported in Appendix E Ambulatory Care--Total Rates reported in Appendix E Relative Resource Use for People with Diabetes NR Relative Resource Use for People with Asthma NR Relative Resource Use for People with Cardiovascular Conditions NR Relative Resource Use for People with COPD NR Relative Resource Use for People with Hypertension NR Antibiotic Utilization--Total Rates reported in Appendix E 1 Note: Lower rate is better. 2 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. 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. Peach State Health Plan Validation of Performance Measures State of Georgia Page D-6 PeachState_GA2011-12_CMO_PMV_F6_0812 Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Audit Review Table Peach State Health Plan (Org ID: 6625, SubID: 9227, 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 Effectiveness of Care: Prevention and Screening Adult BMI Assessment (aba) Y 48.0% R Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Y (wcc) BMI Percentile 22.7% R Counseling for Nutrition 40.7% R Counseling for Physical Activity 29.4% R Childhood Immunization Status (cis) Y DTaP 83.8% R IPV 96.8% R MMR 94.2% R HiB 95.6% R Hepatitis B 95.6% R VZV 95.4% R Pneumococcal Conjugate 85.2% R Hepatitis A 45.8% R Rotavirus 66.7% R Influenza 36.3% R Combination #2 80.6% R Combination #3 76.6% R Combination #4 42.6% R Combination #5 58.6% R Combination #6 34.0% R Combination #7 33.3% R Combination #8 20.8% R Combination #9 28.0% R Combination #10 17.6% R Immunizations for Adolescents (ima) Y Meningococcal 72.7% R Tdap/Td 81.9% R Combination #1 70.8% R Human Papillomavirus Vaccine for Female Y Adolescents (hpv) 17.7% R Lead Screening in Children (lsc) Y 70.8% R Breast Cancer Screening (bcs) Y 52.9% R Cervical Cancer Screening (ccs) Y N 70.0% R Chlamydia Screening in Women (chl) Y 16-20 Years 55.6% R 21-24 Years 72.3% R Total 60.2% R Effectiveness of Care: Respiratory Conditions Appropriate Testing for Children with Pharyngitis Y Y (cwp) 68.8% R Appropriate Treatment for Children With URI (uri) Y Y 77.8% 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 Y Y Asthma (asm) 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% 19-50 Years - Medication Compliance 50% 19-50 Years - Medication Compliance 75% 20.6% R 43.2% R 69.6% R 87.0% R 91.3% R 90.6% R 73.6% R NA R 90.4% R 40.8% R 17.9% R 39.7% R 15.2% R 42.6% R 19.4% R Comment 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 Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable Reportable Reportable Reportable Reportable 1 of 20 August 2012 Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State 51-64 Years - Medication Compliance 50% NA R 51-64 Years - Medication Compliance 75% NA R Total - Medication Compliance 50% 40.6% R Total - Medication Compliance 75% 17.1% R Effectiveness of Care: Cardiovascular Cholesterol Management for Patients With Y Cardiovascular Conditions (cmc) LDL-C Screening Performed 77.6% R LDL-C Control (<100 mg/dL) Controlling High Blood Pressure (cbp) Y 19.0% R Y1 47.6% R Persistence of Beta-Blocker Treatment After a Y Y Heart Attack (pbh) NA R Effectiveness of Care: Diabetes Comprehensive Diabetes Care (cdc) Y Hemoglobin A1c (HbA1c) Testing 77.4% R HbA1c Poor Control (>9.0%) 54.5% R HbA1c Control (<8.0%) 37.4% R HbA1c Control (<7.0%) 28.8% R Eye Exam (Retinal) Performed 53.7% R LDL-C Screening Performed 65.5% R LDL-C Control (<100 mg/dL) 27.5% R Medical Attention for Nephropathy 71.1% R Blood Pressure Control (<140/80 mm Hg) 36.1% R Blood Pressure Control (<140/90 mm Hg) 58.0% R Effectiveness of Care: Musculoskeletal Disease Modifying Anti-Rheumatic Drug Therapy Y Y in Rheumatoid Arthritis (art) 72.5% R Use of Imaging Studies for Low Back Pain (lbp) Y 75.8% R Effectiveness of Care: Behavioral Health Antidepressant Medication Management (amm) Y Y Effective Acute Phase Treatment 38.4% R Effective Continuation Phase Treatment 23.4% R Follow-Up Care for Children Prescribed ADHD Y Y Medication (add) 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 Y Services (aap) 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 19-21 Years Total Initiation and Engagement of AOD Dependence Y Y Treatment (iet) Initiation of AOD Treatment: 13-17 Years Engagement of AOD Treatment: 13-17 Years 43.7% R 57.4% R 74.6% R 51.3% R 84.6% R NA R 84.9% R 65.2% R 83.8% R 84.8% R 88.6% R NA R 85.2% R 95.7% R 90.5% R 90.3% R 87.2% R 43.9% R 75.6% R 78.6% R 70.5% R 58.9% R 39.2% R 67.5% R 28.2% R 12.2% R 2 of 20 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 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 Reportable Reportable Reportable Reportable August 2012 Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Initiation of AOD Treatment: 18+ Years Engagement of AOD Treatment: 18+ Years Initiation of AOD Treatment: Total Engagement of AOD Treatment: Total Prenatal and Postpartum Care (ppc) Y Timeliness of Prenatal Care Postpartum Care Call Answer Timeliness (cat) Y Call Abandonment (cab) Y Utilization Frequency of Ongoing Prenatal Care (fpc) Y <21 Percent 21-40 Percent 41-60 Percent 61-80 Percent 81+ Percent Well-Child Visits in the First 15 Months of Life (w15) Y 0 Visits 1 Visit 2 Visits 3 Visits 4 Visits 5 Visits 6+ Visits 36.6% R 7.5% R 34.6% R 8.7% R N 85.8% R 61.7% R 87.4% R 1.6% R N 7.9% R 3.9% R 5.1% R 12.5% R 70.5% R 7.2% R 3.5% R 3.0% R 7.4% R 11.3% R 17.1% R 50.5% R Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (w34) Y 67.4% R Adolescent Well-Care Visits (awc) Y Frequency of Selected Procedures (fsp) Y Ambulatory Care: Total (amba) Y Ambulatory Care: Dual Eligibles (ambb) N Ambulatory Care: Disabled (ambc) N Ambulatory Care: Other (ambd) N Inpatient Utilization--General Hospital/Acute Care: Total (ipua) Y Inpatient Utilization--General Hospital/Acute Care: Dual Eligibles (ipub) N Inpatient Utilization--General Hospital/Acute Care: Disabled (ipuc) N Inpatient Utilization--General Hospital/Acute Care: N Other (ipud) Identification of Alcohol and Other Drug Services: Total (iada) Y Y Identification of Alcohol and Other Drug Services: Dual Eligibles (iadb) N N Identification of Alcohol and Other Drug Services: Disabled (iadc) N N Identification of Alcohol and Other Drug Services: Other (iadd) N N Mental Health Utilization: Total (mpta) Y Y Mental Health Utilization: Dual Eligibles (mptb) N N Mental Health Utilization: Disabled (mptc) Mental Health Utilization: Other (mptd) N N N N Antibiotic Utilization: Total (abxa) Y Y Antibiotic Utilization: Dual Eligibles (abxb) N N Antibiotic Utilization: Disabled (abxc) N N Antibiotic Utilization: Other (abxd) Relative Resource Use N N Relative Resource Use for People With Diabetes (rdi) N Relative Resource Use for People With Asthma (ras) N N Relative Resource Use for People With Cardiovascular Conditions (rca) N Relative Resource Use for People With N Hypertension (rhy) 38.5% R R R NR NR NR R NR NR NR R NR NR NR R NR NR NR R NR NR NR NR NR NR NR Relative Resource Use for People With COPD (rco) N NR Health Plan Descriptive Information Board Certification (bcr) Y NR Total Membership (tlm) Y R Enrollment by Product Line: Total (enpa) Y R Enrollment by Product Line: Dual Eligibles (enpb) N NR Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable 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 Measure Unselected Measure Unselected Measure Unselected Measure Unselected Measure Unselected Measure Unselected Measure Unselected Measure Unselected Calculated rate was materially biased Reportable Reportable Measure Unselected 3 of 20 August 2012 Appendix E: Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State 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 Y N R Reportable (wop) 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. 4 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Frequency of Selected Procedures (FSP) Frequency of Selected Procedures (FSP) Peach State Health Plan (Org ID: 6625, SubID: 9227, Medicaid, Spec Area: None, Spec Proj: None) Age Male Female Total 0-9 997,475 977,039 1,974,514 10-19 564,259 592,582 1,156,841 15-44 618,891 20-44 33,610 378,997 30-64 28,813 45-64 8,063 28,544 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 15 <0.1 <0.1 45-64 Male 0 0.0 Female 0 0.0 Tonsillectomy 0-9 Male & 1541 0.8 10-19 Female 397 0.3 Hysterectomy, Abdominal 15-44 Female 153 0.2 45-64 30 1.1 Hysterectomy, Vaginal 15-44 Female 73 0.1 45-64 5 0.2 30-64 Male 0 0.0 Cholecystectomy, Open 15-44 Female 9 45-64 3 <0.1 0.1 30-64 Male 9 0.3 Cholecystectomy, Closed (laparoscopic) 15-44 Female 429 0.7 45-64 21 0.7 Back Surgery 20-44 Male 10 0.3 Female 53 0.1 45-64 Male 11 1.4 Female 11 0.4 Mastectomy 15-44 Female 31 0.1 45-64 32 1.1 Lumpectomy 15-44 Female 141 0.2 45-64 40 1.4 5 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Ambulatory Care: Total (AMBA) Ambulatory Care: Total (AMBA) Peach State Health Plan (Org ID: 6625, SubID: 9227, Medicaid, Spec Area: None, Spec Proj: None) Age Member Months <1 281,392 1-9 1,693,122 10-19 1,156,841 20-44 412,607 45-64 36,607 65-74 62 75-84 11 85+ 3 Unknown 0 Total 3,580,645 Outpatient Visits ED Visits Age Visits/ 1,000 Visits/ 1,000 Visits Member Visits Member Months Months <1 194908 692.7 20984 74.6 1-9 534110 315.5 76493 45.2 10-19 251830 217.7 41705 36.1 20-44 169619 411.1 45696 110.7 45-64 24748 676.0 2910 79.5 65-74 24 387.1 0 0.0 75-84 15 1363.6 1 90.9 85+ 0 0.0 0 0.0 Unknown 0 0 Total 1,175,254 328.2 187,789 52.4 6 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Inpatient Utilization--General Hospital/Acute Care: Total (IPUA) Inpatient Utilization--General Hospital/Acute Care: Total (IPUA) Peach State Health Plan (Org ID: 6625, SubID: 9227, Medicaid, Spec Area: None, Spec Proj: None) Age Member Months <1 1-9 10-19 281,392 1,693,122 1,156,841 20-44 45-64 65-74 412,607 36,607 62 75-84 11 85+ 3 Unknown 0 Total 3,580,645 Total Inpatient Age Discharges / Discharges 1,000 Member Months Days Days / 1,000 Members Months Average Length of Stay <1 1620 5.8 13090 46.5 8.1 1-9 1938 1.1 5798 3.4 3.0 10-19 20-44 45-64 65-74 75-84 3733 3.2 10738 9.3 2.9 16069 38.9 45162 109.5 2.8 443 12.1 2366 64.6 5.3 0 0.0 0 0.0 NA 0 0.0 0 0.0 NA 85+ Unknown Total 0 0.0 0 0.0 NA 0 0 NA 23,803 6.6 77,154 21.5 3.2 Medicine Age Discharges / Discharges 1,000 Member Months Days Days / 1,000 Members Months Average Length of Stay <1 1-9 10-19 1240 4.4 5869 20.9 4.7 1525 0.9 3853 2.3 2.5 678 0.6 2153 1.9 3.2 20-44 45-64 65-74 780 1.9 2885 7.0 3.7 252 6.9 1152 31.5 4.6 0 0.0 0 0.0 NA 75-84 85+ Unknown 0 0.0 0 0.0 NA 0 0.0 0 0.0 NA 0 0 NA Total 4,475 1.2 15,912 4.4 3.6 Surgery Age Discharges / Discharges 1,000 Member Months Days Days / 1,000 Members Months Average Length of Stay <1 1-9 10-19 20-44 380 1.4 7221 25.7 19.0 413 0.2 1945 1.1 4.7 382 0.3 1711 1.5 4.5 595 1.4 3123 7.6 5.2 45-64 176 4.8 1174 32.1 6.7 7 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Inpatient Utilization--General Hospital/Acute Care: Total (IPUA) 65-74 0 0.0 0 0.0 75-84 0 0.0 0 0.0 85+ 0 0.0 0 0.0 Unknown 0 0 Total 1,946 0.5 15,174 4.2 Maternity* Age Discharges / Discharges 1,000 Member Months Days Days / 1,000 Members Months 10-19 2673 2.3 6874 5.9 20-44 14694 35.6 39154 94.9 45-64 15 0.4 40 1.1 Unknown 0 0 Total 17,382 10.8 46,068 28.7 *The maternity category is calculated using member months for members 10-64 years. NA NA NA NA 7.8 Average Length of Stay 2.6 2.7 2.7 NA 2.7 8 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Identification of Alcohol and Other Drug Services: Total (IADA) Identification of Alcohol and Other Drug Services: Total (IADA) Peach State Health Plan (Org ID: 6625, SubID: 9227, Medicaid, Spec Area: None, Spec Proj: None) Age 0-12 13-17 18-24 25-34 35-64 65+ Unknown Member Months (Any) Male 1221894 296804 48402 15488 20819 26 0 Female 1199427 305406 182050 186257 104022 50 0 Total 2,421,321 602,210 230,452 201,745 124,841 76 0 Member Months (Inpatient) Male 1221894 296804 48402 15488 20819 26 0 Female 1199427 305406 182050 186257 104022 50 0 Total 2,421,321 602,210 230,452 201,745 124,841 76 0 Member Months (Intensive Outpatient/Partial Hospitalization) Male Female Total 1221894 1199427 2,421,321 296804 305406 602,210 48402 182050 230,452 15488 186257 201,745 20819 104022 124,841 26 50 76 0 0 0 Member Months (Outpatient/ED) Male 1221894 296804 48402 15488 20819 26 0 Female 1199427 305406 182050 186257 104022 50 0 Total 2,421,321 602,210 230,452 201,745 124,841 76 0 Total Age 0-12 13-17 18-24 25-34 35-64 65+ 1,603,433 Sex M F Total M F Total M F Total M F Total M F Total M F Total 1,977,212 3,580,645 Any Services Number 39 23 62 370 186 556 72 376 448 89 682 771 118 450 568 0 0 0 Percent <0.1% <0.1% <0.1% 1.5% 0.7% 1.1% 1.8% 2.5% 2.3% 6.9% 4.4% 4.6% 6.8% 5.2% 5.5% 0.0% 0.0% 0.0% 1,603,433 1,977,212 Inpatient Number 4 4 8 48 28 76 16 124 140 13 165 178 27 94 121 0 0 0 Percent <0.1% <0.1% <0.1% 0.2% 0.1% 0.2% 0.4% 0.8% 0.7% 1.0% 1.1% 1.1% 1.6% 1.1% 1.2% 0.0% 0.0% 0.0% 3,580,645 1,603,433 Intensive Outpatient/Partial Hospitalization Number Percent 0 0.0% 0 0.0% 0 0.0% 8 <0.1% 5 <0.1% 13 <0.1% 2 <0.1% 11 0.1% 13 0.1% 1 0.1% 33 0.2% 34 0.2% 4 0.2% 10 0.1% 14 0.1% 0 0.0% 0 0.0% 0 0.0% 1,977,212 3,580,645 Outpatient/ED Number 35 20 55 341 164 505 60 288 348 83 592 675 103 402 505 0 0 0 Percent <0.1% <0.1% <0.1% 1.4% 0.6% 1.0% 1.5% 1.9% 1.8% 6.4% 3.8% 4.0% 5.9% 4.6% 4.9% 0.0% 0.0% 0.0% 1,603,433 1,977,212 3,580,645 9 of 20 August 2012 Unknown Total M F Total M F Total 0 0 0 688 1,717 2,405 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Identification of Alcohol and Other Drug Services: Total (IADA) NA 0 NA NA 0 NA NA 0 NA 0.5% 108 0.1% 1.0% 415 0.3% 0.8% 523 0.2% 0 NA 0 0 NA 0 0 NA 0 15 <0.1% 622 59 <0.1% 1,466 74 <0.1% 2,088 NA NA NA 0.5% 0.9% 0.7% 10 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Mental Health Utilization: Total (MPTA) Mental Health Utilization: Total (MPTA) Peach State Health Plan (Org ID: 6625, SubID: 9227, 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 1221894 1199427 2,421,321 1221894 1199427 2,421,321 1221894 1199427 2,421,321 13-17 296804 305406 602,210 296804 305406 602,210 296804 305406 602,210 18-64 84709 472329 557,038 84709 472329 557,038 84709 472329 557,038 65+ 26 50 76 26 50 76 26 50 76 Unknown 0 0 0 0 0 0 0 0 0 Total 1,603,433 1,977,212 3,580,645 1,603,433 1,977,212 3,580,645 1,603,433 1,977,212 3,580,645 Intensive Age Sex Any Services Inpatient Outpatient/Partial Hospitalization Outpatient/ED Number Percent Number Percent Number Percent Number Percent M 7786 7.6% 118 0.1% 81 0.1% 7778 7.6% 0-12 F 4688 4.7% 58 0.1% 36 <0.1% 4680 4.7% Total 12,474 6.2% 176 0.1% 117 0.1% 12,458 6.2% M 3277 13.2% 189 0.8% 85 0.3% 3256 13.2% 13-17 F 2928 11.5% 257 1.0% 91 0.4% 2895 11.4% Total 6,205 12.4% 446 0.9% 176 0.4% 6,151 12.3% M 531 7.5% 49 0.7% 16 0.2% 519 7.4% 18-64 F 3828 9.7% 296 0.8% 65 0.2% 3749 9.5% Total 4,359 9.4% 345 0.7% 81 0.2% 4,268 9.2% M 0 0.0% 0 0.0% 0 0.0% 0 0.0% 65+ F 1 24.0% 0 0.0% 0 0.0% 1 24.0% Total 1 15.8% 0 0.0% 0 0.0% 1 15.8% 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 11,594 8.7% 356 0.3% 182 0.1% 11,553 8.6% Total F 11,445 6.9% 611 0.4% 192 0.1% 11,325 6.9% Total 23,039 7.7% 967 0.3% 374 0.1% 22,878 7.7% Member Months (Outpatient/ED) Male 1221894 296804 84709 26 0 1,603,433 Female 1199427 305406 472329 50 0 1,977,212 Total 2,421,321 602,210 557,038 76 0 3,580,645 11 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Antibiotic Utilization: Total (ABXA) Antibiotic Utilization: Total (ABXA) Peach State Health Plan (Org ID: 6625, SubID: 9227, Medicaid, Spec Area: None, Spec Proj: None) Pharmacy Benefit Member Months Age Male Female Total 0-9 997475 977039 1,974,514 10-17 521223 527794 1,049,017 18-34 63890 368307 432,197 35-49 17018 91019 108,037 50-64 3801 13003 16,804 65-74 15 47 62 75-84 8 3 11 85+ 3 0 3 Unknown 0 0 0 Total 1,603,433 1,977,212 3,580,645 Antibiotic Utilization Age Sex Total Antibiotic Scrips Total Days Average Average Scrips Supplied for Days PMPY for All Supplied per Antibiotics Antibiotic Antibiotic Scrips 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 0-9 10-17 18-34 35-49 50-64 65-74 75-84 85+ Unknown 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 M F Total 104804 101137 205,941 26186 35789 61,975 3906 57854 61,760 1597 14425 16,022 403 1913 2,316 1 0 1 1 1 2 0 0 0 0 0 0 136,898 211,119 348,017 1.3 943112 9.0 46977 0.6 44.8% 1.2 922633 9.1 42508 0.5 42.0% 1.3 1,865,745 9.1 89,485 0.5 43.5% 0.6 259132 9.9 11720 0.3 44.8% 0.8 327116 9.1 14683 0.3 41.0% 0.7 586,248 9.5 26,403 0.3 42.6% 0.7 38874 10.0 1461 0.3 37.4% 1.9 440153 7.6 17995 0.6 31.1% 1.7 479,027 7.8 19,456 0.5 31.5% 1.1 14103 8.8 711 0.5 44.5% 1.9 118390 8.2 5944 0.8 41.2% 1.8 132,493 8.3 6,655 0.7 41.5% 1.3 3828 9.5 177 0.6 43.9% 1.8 15430 8.1 958 0.9 50.1% 1.7 19,258 8.3 1,135 0.8 49.0% 0.8 15 15.0 1 0.8 100.0% 0.0 0 NA 0 0.0 NA 0.2 15 15.0 1 0.2 100.0% 1.5 5 5.0 1 1.5 0.0% 4.0 7 7.0 0 0.0 50.0% 2.2 12 6.0 1 1.1 50.0% 0.0 0 NA 0 0.0 NA NA 0 NA 0 NA NA 0.0 0 NA 0 0.0 NA NA 0 NA 0 NA NA NA 0 NA 0 NA NA NA 0 NA 0 NA NA 1.0 1,259,069 9.2 61,048 0.5 44.6% 1.3 1,823,729 8.6 82,088 0.5 38.9% 1.2 3,082,798 8.9 143,136 0.5 41.1% Antibiotics of Concern Utilization 12 of 20 August 2012 Age 0-9 10-17 18-34 35-49 50-64 65-74 75-84 85+ Unknown Total Age 0-9 10-17 18-34 35-49 13 of 20 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 Sex M F Total M F Total M F Total M F Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Antibiotic Utilization: Total (ABXA) Total Quinolone Scrips Total Average Scrips PMPY for Quinolones Cephalosporin 2nd- 4th Generation Scrips Average Scrips PMPY for Cephalosporins 2nd- 4th Generation Total Azithromycin and Clarithromycin Scrips Average Scrips PMPY for Azithromycins and Clarithro- mycins Total Amoxicillin/ Clavulanate Scrips Average Scrips PMPY for Amoxicillin/ Clavulanates Total Ketolides Scrips 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 52 81 133 186 599 785 206 4450 4,656 180 1853 2,033 61 334 395 1 0 1 0 0 0 0 0 0 0 0 0 686 7,317 8,003 <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 0.8 0.0 0.2 0.0 0.0 0.0 0.0 NA 0.0 NA NA NA <0.1 <0.1 <0.1 7951 7900 15,851 1049 1286 2,335 52 716 768 23 188 211 10 40 50 0 0 0 0 0 0 0 0 0 0 0 0 9,085 10,130 19,215 0.1 0.1 0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 <0.1 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 19812 0.2 17599 0.2 17328 0.2 15767 0.2 37,140 0.2 33,366 0.2 5765 0.1 3837 0.1 7633 0.2 4152 0.1 13,398 0.2 7,989 0.1 706 0.1 332 0.1 8289 0.3 2568 0.1 8,995 0.2 2,900 0.1 318 0.2 126 0.1 2425 0.3 885 0.1 2,743 0.3 1,011 0.1 68 0.2 26 0.1 402 0.4 113 0.1 470 0.3 139 0.1 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 1.5 0 0.0 0 0.0 0 0.0 1 1.1 0 0.0 0 0.0 0 0.0 0 NA 0 NA 0 0.0 0 0.0 0 NA 0 NA 0 NA 0 NA 0 NA 0 NA 26,670 0.2 21,920 0.2 36,077 0.2 23,485 0.1 62,747 0.2 45,405 0.2 All Other Antibiotics Utilization 0 0.0 1560 <0.1 3 <0.1 0 0.0 1423 <0.1 9 <0.1 0 0.0 2,983 <0.1 12 <0.1 0 0.0 881 <0.1 2 <0.1 0 0.0 1011 <0.1 2 <0.1 0 0.0 1,892 <0.1 4 <0.1 0 0.0 165 <0.1 0 0.0 0 0.0 1970 0.1 2 <0.1 0 0.0 2,135 0.1 2 <0.1 0 0.0 64 <0.1 0 0.0 0 0.0 586 0.1 7 <0.1 0 0.0 650 0.1 7 <0.1 0 0.0 11 <0.1 1 <0.1 0 0.0 66 0.1 3 <0.1 0 0.0 77 0.1 4 <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 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 0 0.0 2,681 <0.1 6 <0.1 0 0.0 5,056 <0.1 23 <0.1 0 0.0 7,737 <0.1 29 <0.1 Total Absorbable Sulfonamide Scrips Average Scrips PMPY for Absorbable Sulfonamides Total Aminoglycoside Scrips Average Scrips PMPY for Aminoglycosides Total 1st Generation Cephalosporin Scrips Average Scrips PMPY for 1st Total Generation Lincosamide Cephalo- Scrips sporins Average Scrips PMPY for Lincosamides Total Macrolides (not azith. or clarith.) Scrips Average Scrips PMPY for Macrolides (not azith. or clarith.) Total Penicillin Scrips Average Scrips PMPY for Penicillins Total Tetracycline Scrips Average Scrips PMPY for Tetracyclines Total Misc. Antibiotic Scrips 5358 0.1 14 <0.1 5693 0.1 0 0.0 133 <0.1 46461 0.6 19 <0.1 149 8064 0.1 5 <0.1 5602 0.1 0 0.0 112 <0.1 44407 0.5 12 <0.1 427 13,422 0.1 19 <0.1 11,295 0.1 0 0.0 245 <0.1 90,868 0.6 31 <0.1 576 1963 <0.1 7 <0.1 2333 0.1 0 0.0 105 <0.1 7763 0.2 2110 <0.1 185 3817 0.1 1 <0.1 2774 0.1 0 0.0 122 <0.1 9798 0.2 2268 0.1 2326 5,780 0.1 8 <0.1 5,107 0.1 0 0.0 227 <0.1 17,561 0.2 4,378 0.1 2,511 385 0.1 3 <0.1 353 0.1 0 0.0 34 <0.1 1072 0.2 483 0.1 115 5145 0.2 3 <0.1 3770 0.1 0 0.0 357 <0.1 10376 0.3 4266 0.1 15942 5,530 0.2 6 <0.1 4,123 0.1 0 0.0 391 <0.1 11,448 0.3 4,749 0.1 16,057 119 0.1 0 0.0 155 0.1 0 0.0 12 <0.1 395 0.3 127 0.1 78 1481 0.2 0 0.0 941 0.1 0 0.0 113 <0.1 2657 0.4 927 0.1 2362 Average Scrips PMPY for Misc. Antibiotics <0.1 <0.1 <0.1 <0.1 0.1 <0.1 <0.1 0.5 0.4 0.1 0.3 August 2012 50-64 65-74 75-84 85+ Unknown Total Total 1,600 0.2 M 54 0.2 F 177 0.2 Total 231 0.2 M 0 0.0 F 0 0.0 Total 0 0.0 M 0 0.0 F 0 0.0 Total 0 0.0 M 0 0.0 F 0 NA Total 0 0.0 M 0 NA F 0 NA Total 0 NA M 7,879 0.1 F 18,684 0.1 Total 26,563 0.1 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Antibiotic Utilization: Total (ABXA) 0 0.0 1,096 0.1 0 0.0 125 <0.1 3,052 0.3 1,054 0.1 2,440 0.3 0 0.0 33 0.1 0 0.0 2 <0.1 78 0.2 33 0.1 26 0.1 0 0.0 167 0.2 0 0.0 16 <0.1 302 0.3 101 0.1 192 0.2 0 0.0 200 0.1 0 0.0 18 <0.1 380 0.3 134 0.1 218 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 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 4.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 0 0.0 1 1.1 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 NA 0 NA 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 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 0 NA 24 <0.1 8,567 0.1 0 0.0 286 <0.1 55,769 0.4 2,772 <0.1 553 <0.1 9 <0.1 13,254 0.1 0 0.0 720 <0.1 67,540 0.4 7,574 <0.1 21,250 0.1 33 <0.1 21,821 0.1 0 0.0 1,006 <0.1 123,309 0.4 10,346 <0.1 21,803 0.1 14 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Total Membership (TLM) Total Membership (TLM) Peach State Health Plan (Org ID: 6625, SubID: 9227, Medicaid, Spec Area: None, Spec Proj: None) Product/Product Line Total Number of Members* HMO (Total) 296,716 Medicaid 296716 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 296,716 * Total number of members in each category as of December 31 of the measurement year. 15 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Enrollment by Product Line: Total (ENPA) Enrollment by Product Line: Total (ENPA) Peach State Health Plan (Org ID: 6625, SubID: 9227, Medicaid, Spec Area: None, Spec Proj: None) Male Female Total Age Member Member Member Months Months Months <1 142613 138779 281,392 1-4 425951 411824 837,775 5-9 428911 426436 855,347 10-14 354649 352688 707,337 15-17 166574 175106 341,680 18-19 43036 64788 107,824 0-19 Subtotal 1,561,734 1,569,621 3,131,355 0-19 Subtotal: % 97.4% 79.4% 87.5% 20-24 5366 117262 122,628 25-29 7494 106397 113,891 30-34 7994 79860 87,854 35-39 7176 49154 56,330 40-44 5580 26324 31,904 20-44 Subtotal 33,610 378,997 412,607 20-44 Subtotal: % 2.1% 19.2% 11.5% 45-49 4262 15541 19,803 50-54 2448 7591 10,039 55-59 956 3606 4,562 60-64 397 1806 2,203 45-64 Subtotal 8,063 28,544 36,607 45-64 Subtotal: % 0.5% 1.4% 1.0% 65-69 14 37 51 70-74 1 10 11 75-79 8 3 11 80-84 0 0 0 85-89 0 0 0 >=90 3 0 3 >=65 Subtotal 26 50 76 >=65 Subtotal: % <0.1% <0.1% <0.1% Age Unknown 0 0 0 Total 1,603,433 1,977,212 3,580,645 16 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Enrollment by State (EBS) Enrollment by State (EBS) Peach State Health Plan (Org ID: 6625, SubID: 9227, Medicaid, Spec Area: None, Spec Proj: None) State Number Alabama 30 Alaska 2 Arizona 5 Arkansas 0 California 5 Colorado 0 Connecticut 0 Delaware 2 District of Columbia 2 Florida 43 Georgia 295850 Hawaii 0 Idaho 0 Illinois 5 Indiana 2 Iowa 5 Kansas 0 Kentucky 7 Louisiana 4 Maine 0 Maryland 3 Massachusetts 5 Michigan 3 Minnesota 0 Mississippi 2 Missouri 4 Montana 0 Nebraska 1 Nevada 3 New Hampshire 0 New Jersey 2 New Mexico 2 New York 6 North Carolina 14 North Dakota 1 Ohio 4 Oklahoma 0 Oregon 0 Pennsylvania 4 Rhode Island 0 South Carolina 17 South Dakota 0 Tennessee 15 Texas 25 Utah 0 Vermont 0 Virginia 1 Washington 5 West Virginia 0 Wisconsin 1 17 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Enrollment by State (EBS) Wyoming American Samoa Federated States of Micronesia Guam Commonwealth of Northern Marianas Puerto Rico Virgin Islands Other TOTAL 0 0 0 0 0 0 0 639 296,719 18 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Race/Ethnicity Diversity of Membership (RDM) Race/Ethnicity Diversity of Membership (RDM) Peach State Health Plan (Org ID: 6625, SubID: 9227, Medicaid, Spec Area: None, Spec Proj: None) Race/Ethnicity Diversity of Membership Total Unduplicated Membership During the Measurement Year 425792 Percentage of Members for Whom the Organization has Race/Ethnicity Information by Data Collection Direct Data Collection Method Indirect Data Collection Method Unknown Direct Total 48.2% Race Health Plan Direct* CMS/State Database* 0.0000000000 .48151 Indirect 0.000000000 Total* 0 Total* .51849 Other* 0.0000000000 Direct Total 5.2% Ethnicity Health Plan Direct* CMS/State Database* 0.0000000000 .05158 Indirect 0.000000000 Total* 0 Total* .94842 Other* 0.0000000000 *Enter percentage as a value between 0 and 1. Race Hispanic or Latino Number Percentage Not Hispanic or Latino Number Percentage Unknown Ethnicity Number Percentage White 17048 76.6% 59049 30.8% 0 0.0% Black or African American 484 2.2% 117156 61.1% 0 0.0% American-Indian and Alaska Native 33 0.1% 161 0.1% 0 0.0% Asian 134 0.6% 5129 2.7% 0 0.0% Native Hawaiian and Other Pacific Islanders 75 0.3% 83 <0.1% 0 0.0% Some Other Race 4188 18.8% 1482 0.8% 0 0.0% Two or More Races 0 0.0% 0 0.0% 0 0.0% Unknown 291 1.3% 8590 4.5% 211889 100.0% Declined 0 0.0% 0 0.0% 0 0.0% Total 22,253 100.0% 191,650 100.0% 211,889 100.0% 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 76,097 17.9% 117,640 27.6% 194 <0.1% 5,263 1.2% 158 <0.1% 5,670 0 220,770 0 425,792 1.3% 0.0% 51.8% 0.0% 100.0% 19 of 20 August 2012 Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for Peach State Language Diversity of Membership (LDM) Language Diversity of Membership (LDM) Peach State Health Plan (Org ID: 6625, SubID: 9227, 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 1.000000000 0.000000000 0 0 0 *Enter percentage as a value between 0 and 1. Spoken Language Preferred for Health Care English Non-English Number 186547 11885 Percentage 43.8% 2.8% Unknown 227360 53.4% Declined 0 0.0% Total* 425,792 100.0% Language Preferred for Written Materials Number Percentage English 0 Non-English 0 Unknown 425792 Declined 0 Total* 425,792 Other Language Needs 0.0% 0.0% 100.0% 0.0% 100.0% English Non-English Unknown Number 0 0 425792 Percentage 0.0% 0.0% 100.0% Declined 0 Total* 425,792 *Should sum to 100% 0.0% 100.0% 20 of 20 August 2012