Georgia Department of Community Health Validation of Performance Measures for WellCare of Georgia, Inc. Measurement Period: Calendar Year 2010 Validation Period: State Fiscal Year 2011 Publish Date: July 15, 2011 3133 East Camelback Road, Suite 300 Phoenix, AZ 85016 Phone 602.264.6382 Fax 602.241.0757 CONTENTS for WellCare of Georgia, Inc. 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 ....................................... 7 Data Integration ................................................................................................................................. 7 Data Control ...................................................................................................................................... 7 Performance Measure Documentation.............................................................................................. 7 Validation Results ................................................................................................................................ 8 Medical Service Data (Claims/Encounters) ....................................................................................... 8 Enrollment Data................................................................................................................................. 8 Provider Data..................................................................................................................................... 8 Medical Record Review Process....................................................................................................... 8 Supplemental Data ............................................................................................................................ 8 Data Integration ................................................................................................................................. 9 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 Appendix D--Final Audited HEDIS Results ..................................................................................... D-1 Appendix E--Audited CY 2010 HEDIS Utilization Measure Results ...............................................E-1 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page i WellCare_GA2010-11_CMO_PMV_F1_0711 Validation of Performance Measures for WellCare of Georgia, Inc. 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. 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 WellCare of Georgia, Inc. (WellCare). Information about WellCare appears in Table 1. CMO Name: CMO Location: CMO Contact: Contact Telephone Number: Contact E-mail Address: Site Visit Date: Table 1--WellCare Information WellCare of Georgia, Inc. 211 Perimeter Center Parkway, NW, Suite 800 Atlanta, GA 30346 Jesse Thomas, President, South Division (678) 327-0939 ext. 3080 Jesse.Thomas@wellcare.com April 20 and 21, 2011 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 1 WellCare_GA2010-11_CMO_PMV_F1_0711 VALIDATION OF PERFORMANCE MEASURES Performance Measures Validated HSAG validated performance measures identified and selected by DCH for validation. Four performance measures were selected from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicator set and one performance measure was developed by DCH. The measurement period was identified by DCH as calendar year (CY) 2010. Table 2 lists the performance measures validated and who calculated the performance measure. Table 2--List of CY 2010 Performance Measures for WellCare Performance Measure Calculation by: 1. Cesarean Delivery Rate--AHRQ measure WellCare 2. Low Birth Weight Rate--AHRQ measure WellCare 3. Asthma ED/Urgent Care Visits--DCH-developed measure WellCare 4. Diabetes Short-Term Complications Admission Rate--AHRQ measure WellCare 5. Asthma Admission Rate--AHRQ measure WellCare In addition, each CMO was required to report a selected set of Healthcare Effectiveness Data and Information Set (HEDIS) measures to DCH. The CMOs were 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 validated and displayed within this report as data sources for the annual EQR technical report. Appendices D and E display the final audited HEDIS 2010 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). WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 2 WellCare_GA2010-11_CMO_PMV_F1_0711 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. In order to complete the validation activities for WellCare, 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 WellCare outlining the steps in the performance measure validation process. The document request letter included a request for a completed Information Systems Capabilities Assessment Tool (ISCAT), or Appendix Z of the CMS protocol; source code for each performance measure; portions of the HEDIS 2011 Record of Administration, Data Management, and Processes (Roadmap); and any additional supporting documentation necessary to complete the audit. HSAG responded to ISCAT/Roadmap-related questions directly from WellCare 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 WellCare approximately one week prior to the on-site visit. HSAG also conducted a pre-on-site conference call with WellCare to discuss any outstanding ISCAT/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 WellCare. Some team members, including the lead auditor, participated in the onsite meetings at WellCare; others conducted their work at HSAG's offices. WellCare'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 Melissa C. Brashears, CPA, MBA Executive Director, Audits Charles Chapin, MS, CHCA Lead Auditor David Mabb, MS, CHCA Associate Director/Audits Allen Iovannisci, MS, CHCA Secondary Auditor Dan Moore, MPA Source Code Reviewer Table 3--Validation Team Skills and Expertise Management of Audit Department, HEDIS knowledge, interviewing skills, financial data analysis, and certified public accountant Certified HEDIS auditor, HEDIS knowledge, statistician, health care analyst, and computer programming Source code review management Certified HEDIS auditor, HEDIS knowledge, data integration, systems review, and analysis Source code review WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 3 WellCare_GA2010-11_CMO_PMV_F1_0711 VALIDATION OF PERFORMANCE MEASURES Name / Role Kelly Stewart, BA, HCSA Project Coordinator Table 3--Validation Team Skills and Expertise Overall project coordination and communications 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: Information Systems Capabilities Assessment Tool (ISCAT): A modified version of the ISCAT was requested and received from WellCare. In preparing the ISCAT document, HSAG removed questions that were already addressed in WellCare's National Committee for Quality Assurance (NCQA) Roadmap. Upon receipt by HSAG, the ISCAT underwent a cursory review to ensure all sections were completed and all attachments were present. The validation team then reviewed all ISCAT documents, noting issues or items that needed further follow-up. The validation team used information included in the ISCAT to complete the review tools, as applicable. NCQA's HEDIS 2011 Roadmap: WellCare completed and submitted portions of its Roadmap for review by the validation team. The validation team combined the responses from the ISCAT review and Roadmap to complete the pre-on-site systems assessment. Source code (programming language) for performance measures: HSAG requested source code from CMOs that calculate their performance measures by using automated computer code. HSAG requested and received source code from WellCare. 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 WellCare on April 20-21, 2011. 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 WellCare staff members involved in the performance measure activities. The review WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 4 WellCare_GA2010-11_CMO_PMV_F1_0711 VALIDATION OF PERFORMANCE MEASURES 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 measures, 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 ISCAT/Roadmap and supporting documentation: The review included processes used for collecting, storing, validating, and reporting performance measure data. This session was designed to be interactive with key WellCare staff members so that the validation team could obtain a complete picture of all the steps taken to generate the performance measures. The goal of the session was to obtain a confidence level as to the degree of compliance with written documentation compared to actual process. HSAG conducted interviews to confirm 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 measures. 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 ISCAT/Roadmap and the on-site visit, and revisited the documentation requirements for any post-visit activities. HSAG conducted several interviews with key WellCare staff members who were involved with performance measure reporting. Table 4 lists key WellCare interviewees: Chuck Beeman Bob Klopotek Tom Clegg Deb Prosser Amie Cook Linda Simmons James Johnson Sharon Nisbet Gary Chu Name Table 4--List of WellCare Interviewees Title Senior Director of Information Technology (IT)/Informatics/Encounters Vice President, IT Core Systems HEDIS Specialist Manager, Quality Improvement Quality Improvement Project Manager Director, Quality Improvement Senior Manager, IT Operations (Georgia) Senior Director, Medical Informatics Senior Project Manager WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 5 WellCare_GA2010-11_CMO_PMV_F1_0711 VALIDATION OF PERFORMANCE MEASURES Danny Sharpe Brian Donnelly Jessica Belser Oscar Ruiz Claudius Conner Grover Edwards Celina Pangelinan Nanette Fudge Melodie DiPierro Dora Wilson Carlissa Felton Esther Morales Susan Swiontek Lisa Sells Gary Fitzgerald Kevin Rodriguez Name Table 4--List of WellCare Interviewees Title Manager, Data Warehouse Provider Network Connectivity Analyst Senior Manager, Quality Improvement Analytics Manager, Operational Audits Director, Enrollment Manager, Mailing Services and Electronic Data Interchange (EDI) Operations Manager, Regional Operations/Claims Manager, Configuration Operations Compliance GA Market Chief Operating Officer Senior Security Administrator Vice President of Quality Improvement and Operations Manager, Claims Delegation Director, Configurations Compliance and Regulatory (Illinois) Senior Compliance Auditor WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 6 WellCare_GA2010-11_CMO_PMV_F1_0711 VALIDATION OF PERFORMANCE MEASURES Data Integration, Data Control, and Performance Measure Documentation There are several aspects crucial to the calculation of performance measures. 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 to calculate valid performance measures. 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 WellCare, 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 WellCare were: Acceptable Not acceptable Data Control The organizational infrastructure of a CMO must support all necessary information systems. Each CMO's 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 used by WellCare, 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 WellCare 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 WellCare. HSAG reviewed all related documentation, which included the completed ISCAT/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 WellCare was: Acceptable Not acceptable WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 7 WellCare_GA2010-11_CMO_PMV_F1_0711 VALIDATION OF PERFORMANCE MEASURES Validation Results The validation team evaluated WellCare's data systems for processing of each type of data used for reporting the DCH performance measures. General findings are indicated below: Medical Service Data (Claims/Encounters) WellCare had a sound transactional system and processes in place for inpatient claims. The transactional system, Peradigm, remained stable through 2010; there were no conversions or changes to either the system or WellCare's processes. Detailed steps were in place to ensure data accuracy. Only standard codes and forms were accepted in Peradigm, and front-end processing included SNIP-level validation and edits. In addition, 97 percent of data were submitted electronically with MoveIt software used to automatically transfer the files from the FTP site. All files were logged and monitored by the EDI Operations Team. Data completeness for inpatient claims was not an issue at WellCare since all facilities were reimbursed based on fee for service. Enrollment Data WellCare had comprehensive systems in place to track, monitor, and verify its Medicaid and PeachCare for Kids enrollment data. Membership files were downloaded monthly and daily from the State in a Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant 834 format. An internal application, Enrollment to Fulfillment (E2F), was used to validate the member data and update Peradigm. Monthly reconciliation occurred between the enrollment data loaded into Peradigm and the State files. The State switched its fiscal agent to HP Enterprise Services (HP) in October 2010. The transition and implementation period went relatively smoothly and had no impact on measure reporting. The process had sufficient oversight. There were no major changes internally to the system or process during the reporting year, and the membership population remained stable. Provider Data Provider data processing and identification were not relevant to the measures under review. Medical Record Review Process WellCare reported all measures using administrative data only. Medical record review was not performed and, therefore, was not evaluated under the scope of this review. Supplemental Data WellCare did not use any supplemental data sources for reporting the selected performance measures. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 8 WellCare_GA2010-11_CMO_PMV_F1_0711 VALIDATION OF PERFORMANCE MEASURES Data Integration WellCare extracted the claims and enrollment data directly from Peradigm for reporting. Statistical Analysis Software (SAS) was used to develop source code internally. The code was verified, tested, and updated when appropriate, and the process and step-by-step procedures were well documented. Only diagnosis-related groups (DRGs) were collected, and no coding issues arose due to medical severity diagnosis-related groups (MS-DRGs). The SAS analyst/programmer was highly skilled, experienced, and familiar with the AHRQ measure specifications. In addition, WellCare employed a HEDIS specialist in the Corporate Quality Improvement Department who assisted and verified all steps of the data integration process. Performance Measure Specific Findings Based on all validation activities, the HSAG Validation Team determined validation results for each performance measure. Table 5 displays the key review results. For detailed information, see Appendix B of this report. Table 5--Key Review Results for WellCare Performance Measures 1. Cesarean Delivery Rate--AHRQ measure 2. Low Birth Weight Rate--AHRQ measure 3. Asthma ED/Urgent Care Visits--DCH-developed measure 4. Diabetes Short-Term Complications Admission Rate--AHRQ measure 5. Asthma Admission Rate--AHRQ measure Key Review Findings No concerns identified No concerns identified No concerns identified No concerns identified No concerns identified WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 9 WellCare_GA2010-11_CMO_PMV_F1_0711 VALIDATION OF PERFORMANCE MEASURES Validation Findings The CMS performance measure validation protocol identifies four validation findings for each performance measure, which are defined in Table 6. Table 6--Validation Findings Definitions Fully Compliant (FC) Indicates that the performance measure was fully compliant with DCH specifications. Substantially Compliant (SC) Indicates that the performance measure was substantially compliant with DCH specifications and had only minor deviations that did not significantly bias the reported rate. Not Valid (NV) Indicates that the performance measure deviated from DCH specifications such that the reported rate was significantly biased. This designation is also assigned to measures for which no rate was reported, although reporting of the rate was required. Not Applicable (NA) Indicates that the performance measure was not reported because the CMO did not have any Medicaid consumers who qualified for that denominator. According to the 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 met. Consequently, it is possible that an error for a single audit element may result in a designation of Not Valid (NV) because the impact of the error biased the reported performance measure 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 Substantially Compliant (SC). Table 7 shows the final validation findings for WellCare for each performance measure. For additional information regarding performance measure results, see Appendix C of this report. Table 7--Validation Findings for WellCare Performance Measures 1. Cesarean Delivery Rate--AHRQ measure 2. Low Birth Weight Rate--AHRQ measure 3. Asthma ED/Urgent Care Visits--DCH-developed measure 4. Diabetes Short-Term Complications Admission Rate--AHRQ measure 5. Asthma Admission Rate--AHRQ measure Validation Finding Fully Compliant Fully Compliant Fully Compliant Fully Compliant Fully Compliant WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 10 WellCare_GA2010-11_CMO_PMV_F1_0711 Appendix A. Data Integration and Control Findings for WellCare of Georgia, Inc. Appendix A, which follows this page, contains the data integration and control findings for WellCare. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page A-i WellCare_GA2010-11_CMO_PMV_F1_0711 Appendix A. Data Integration and Control Findings for WellCare of Georgia, Inc. Documentation Worksheet CMO Name: On-Site Visit Date: Reviewers: WellCare of Georgia, Inc. April 2021, 2011 Charles A. Chapin, MS, CHCA; and Allen Iovannisci, MS, 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. 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). WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page A-1 WellCare_GA2010-11_CMO_PMV_F1_0711 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. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page A-2 WellCare_GA2010-11_CMO_PMV_F1_0711 Appendix B. Denominator and Numerator Validation Findings for WellCare of Georgia, Inc. Appendix B, which follows this page, contains the denominator and numerator validation findings for WellCare. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page B-i WellCare_GA2010-11_CMO_PMV_F1_0711 Appendix B. Denominator and Numerator Validation Findings for WellCare of Georgia, Inc. Reviewer Worksheets CMO Name: On-Site Visit Date: Reviewers: WellCare of Georgia, Inc. April 2021, 2011 Charles A. Chapin, MS, CHCA; and Allen Iovannisci, MS, CHCA Table B-1--Denominator Validation Findings for WellCare of Georgia, Inc. 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. Calculations of member months and years were not required for the measures under review. 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. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page B-1 WellCare_GA2010-11_CMO_PMV_F1_0711 DENOMINATOR AND NUMERATOR VALIDATION FINDINGS Table B-2--Numerator Validation Findings for WellCare of Georgia, Inc. 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). WellCare did not use any nonstandard codes. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page B-2 WellCare_GA2010-11_CMO_PMV_F1_0711 Appendix C. Performance Measure Results for WellCare of Georgia, Inc. Appendix C, which follows this page, contains WellCare's performance measure results. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page C-i WellCare_GA2010-11_CMO_PMV_F1_0711 Appendix C. Performance Measure Results for WellCare of Georgia, Inc. Indicator 1--Cesarean Delivery Rate Cesarean Delivery Rate Table C-1--Indicator 1 for WellCare of Georgia, Inc. Denominator 24,043 Numerator 7,480 Rate (per 100) 31.11 The Cesarean Delivery rate remained relatively stable. There was a slight increase of 0.65 over the prior 2009 rate of 30.46. The number of total deliveries decreased from 26,030 to 24,043, a 7.6 percent decline. Indicator 2--Low Birth Weight Rate Low Birth Weight Rate Table C-2--Indicator 2 for WellCare of Georgia, Inc. Denominator 26,761 Numerator 2,016 Rate (per 100) 7.53 The Low Birth Weight rate increased slightly from 6.89 in 2009 to 7.53 in 2010; an increase of 9.3 percent. However, the number of total births declined by 6 percent from 28,482 to 26,761 births. Indicator 3--Asthma Emergency Department/Urgent Care Visits Rate Table C-3--Indicator 3 for WellCare of Georgia, Inc. Denominator Asthma ED/Urgent Care Visits Rate 679,972 Numerator 8,628 Rate 1.27% The Asthma Emergency Department/Urgent Care Visits rate remained relatively stable with just a slight decrease from 1.44 percent in 2009 to 1.27 percent in 2010, whereas the eligible denominator increased by 3.6 percent from 656,341 to 679,972 in the same time period. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page C-1 WellCare_GA2010-11_CMO_PMV_F1_0711 PERFORMANCE MEASURE RESULTS Indicator 4--Diabetes Short-Term Complications Admission Rate Table C-4--Indicator 4 for WellCare of Georgia, Inc. Denominator Diabetes Short-Term Complications Admission Rate 346,043 Numerator 69 Rate (per 100,000) 19.94 The Diabetes Short-Term Complications Admission rate declined substantially between 2009 and 2010, from 28.59 to 19.94 per 100,000, a decrease of 30 percent. This decrease may have been partially attributed to specifications clarification and programming changes made since the previous year's submissions. The eligible denominator increased from 307,747 to 346,043 (38,296 additional members), while the numerators for this measure dropped from 88 to 69. Indicator 5--Asthma Admission Rate Asthma Admission Rate Table C-5--Indicator 5 for WellCare of Georgia, Inc. Denominator 513,091 Numerator 520 Rate (per 100,000) 101.35 The Asthma Admission rate decreased from 104.73 per 100,000 members in 2009 to 101.35 per 100,000 members in 2010. The decrease may have been partially due to clarification of the measure specifications and reporting timeframe. The number of asthma numerator cases varied only slightly between years (514 and 520, respectively), whereas the number of eligible members in the denominator increased by 22,290 members, a 4.5 percent increase. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page C-2 WellCare_GA2010-11_CMO_PMV_F1_0711 Appendix D. Final Audited HEDIS Results for WellCare of Georgia, Inc. Appendix D, which follows this page, contains the final audited HEDIS results for WellCare. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-i WellCare_GA2010-11_CMO_PMV_F1_0711 Appendix D. Final Audited HEDIS Results for WellCare of Georgia, Inc. For discussion purposes--CMO audited calendar year 2010 HEDIS performance measure results were not available at the time of this draft. CMO Audited Calendar Year 2010 HEDIS Performance Measure Report--WellCare of Georgia, Inc. Measure Numerator Denominator CMO Rate Well-Child Visits in the First 15 Months of Life--Zero Visits1 11 411 2.68% Hybrid Well-Child Visits in the First 15 Months of Life--One Visit 11 411 2.68% Hybrid Well-Child Visits in the First 15 Months of Life--Two Visits 12 411 2.92% Hybrid Well-Child Visits in the First 15 Months of Life--Three Visits 26 411 6.33% Hybrid Well-Child Visits in the First 15 Months of Life--Four Visits 38 411 9.25% Hybrid Well-Child Visits in the First 15 Months of Life--Five Visits 70 411 17.03% Hybrid Well-Child Visits in the First 15 Months of Life--Six or More Visits 243 411 59.12% Hybrid Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life 266 411 64.72% Hybrid Adolescent Well-Care Visits Children's and Adolescents' Access to Primary Care Providers--Ages 1224 Months 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 156 22,313 96,317 54,164 411 23,093 105,715 58,972 37.96% Hybrid 96.62% 91.11% 91.85% Children's and Adolescents' Access to Primary Care Providers--Ages 1219 Years 55,454 62,308 89.00% Adults' Access to Preventive/Ambulatory Health Services--Ages 2044 Years 20,238 23,688 85.44% Childhood Immunization Status--Combo 3 297 411 72.26% Hybrid Lead Screening in Children 300 411 72.99% Hybrid WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-1 WellCare_GA2010-11_CMO_PMV_F1_0711 FINAL AUDITED HEDIS RESULTS CMO Audited Calendar Year 2010 HEDIS Performance Measure Report--WellCare of Georgia, Inc. Measure Numerator Denominator CMO Rate Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--BMI Percentile 125 411 (Total) Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--Counseling for 201 411 Nutrition (Total) 30.41% Hybrid 48.91% Hybrid Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--Counseling for 127 411 Physical Activity (Total) 30.90% Hybrid Follow-Up Care for Children Prescribed ADHD Medication--Initiation Phase 2,665 6,459 41.26% Follow-Up Care for Children Prescribed ADHD Medication--Continuation and 696 Maintenance Phase 1,336 52.10% Annual Dental Visit--Ages 23 Years 19888 43,742 45.47% Annual Dental Visit--Ages 46 Years 47,337 63,423 74.64% Annual Dental Visit--Ages 710 Years 56,028 72,067 77.74% Annual Dental Visit--Ages 1114 Years 42,803 60,685 70.53% Annual Dental Visit--Ages 1518 Years Annual Dental Visit--Ages 1921 Years Annual Dental Visit--Total Cervical Cancer Screening Breast Cancer Screening Comprehensive Diabetes Care--HbA1c Testing 28,117 1,116 195,289 301 1,259 449 46,772 2,723 289,412 411 2,358 548 60.12% 40.98% 67.48% 73.24% Hybrid 53.39% 82.30% Hybrid Comprehensive Diabetes Care--HbA1c Poor Control1 285 548 52.01% Hybrid Comprehensive Diabetes Care--HbA1c Good Control <8.0 215 548 Comprehensive Diabetes Care--HbA1c Good Control <7.0 129 434 39.23% Hybrid 29.72% Hybrid WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-2 WellCare_GA2010-11_CMO_PMV_F1_0711 FINAL AUDITED HEDIS RESULTS CMO Audited Calendar Year 2010 HEDIS Performance Measure Report--WellCare of Georgia, Inc. Measure Numerator Denominator CMO Rate Comprehensive Diabetes Care--Eye Exam 261 548 47.63% Hybrid Comprehensive Diabetes Care--LDL-C Screening Comprehensive Diabetes Care--LDL-C Level Comprehensive Diabetes Care--Medical Attention to Nephropathy Comprehensive Diabetes Care--Blood Pressure Control <140/80 Comprehensive Diabetes Care--Blood Pressure Control <140/90 Use of Appropriate Medications for People with Asthma--Ages 5-11 Years Use of Appropriate Medications for People with Asthma--Ages 12-50 Years Use of Appropriate Medications for People with Asthma--Total Follow-Up After Hospitalization for Mental Illness--30-Day Follow-Up Follow-Up After Hospitalization for Mental Illness--7-Day Follow-Up Inpatient Utilization--General Hospital/Acute Care Prenatal and Postpartum Care--Timeliness of Prenatal Care Prenatal and Postpartum Care--Postpartum Care Frequency of Ongoing Prenatal Care--< 21 Percent Frequency of Ongoing Prenatal Care--2140 Percent Frequency of Ongoing Prenatal Care--4160 Percent Frequency of Ongoing Prenatal Care--6180 Percent 410 135 392 183 312 3,651 2,068 5,719 1,301 952 348 260 66 17 17 52 548 74.82% Hybrid 548 24.64% Hybrid 548 71.53% Hybrid 548 33.39% Hybrid 548 56.93% Hybrid 3,948 92.48% 2,231 88.72% 6,279 91.08% 1,763 73.79% 1,763 54.00% Rates reported in Appendix E 411 84.67% Hybrid 411 63.26% Hybrid 411 16.06% Hybrid 411 4.14% Hybrid 411 4.14% Hybrid 411 12.65% Hybrid WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-3 WellCare_GA2010-11_CMO_PMV_F1_0711 FINAL AUDITED HEDIS RESULTS CMO Audited Calendar Year 2010 HEDIS Performance Measure Report--WellCare of Georgia, Inc. Measure Numerator Denominator CMO Rate Frequency of Ongoing Prenatal Care--81+ Percent 259 411 63.02% Hybrid Weeks of Pregnancy at Time of Enrollment-- < 0 Weeks Weeks of Pregnancy at Time of Enrollment-- < 112 Weeks Weeks of Pregnancy at Time of Enrollment-- < 1327 Weeks 3,176 3,166 16,954 28,468 28,468 28,468 11.16% 11.12% 59.55% Weeks of Pregnancy at Time of Enrollment-- < 28 or More Weeks Weeks of Pregnancy at Time of Enrollment--Unknown Weeks of Pregnancy at Time of Enrollment--Total 4,353 819 28,468 28,468 28,468 28,468 15.29% 2.88% 100.00% Appropriate Treatment For Children With Upper Respiratory Infection (URI)2 11,043 49,000 77.46% Mental Health Utilization Call Abandonment1 Antibiotic Utilization Race/Ethnicity Diversity of Membership 9,081 Rates reported in Appendix E 529,400 1.72% Rates reported in Appendix E Rates reported in Appendix E Language Diversity of Membership Rates reported in Appendix E Ambulatory Care--Outpatient 2,425,505 371.71 Ambulatory Care--ED Visits 402,380 61.66 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. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-4 WellCare_GA2010-11_CMO_PMV_F1_0711 Appendix E. Audited CY 2010 HEDIS Utilization Measure Results for WellCare of Georgia, Inc. Appendix E, which follows this page, contains WellCare's audited CY 2010 HEDIS utilization measure results. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page E-i WellCare_GA2010-11_CMO_PMV_F1_0711 Department of Community Health, State of Georgia Audited CY 2010 HEDIS Utilization Measure Results for WellCare Inpatient Utilization - General Hospital/Acute Care: Total (IPUA) Inpatient Utilization--General Hospital/Acute Care: Total (IPUA) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age Member Months <1 499,327 1-9 3,154,264 10-19 2,099,490 20-44 705,385 45-64 66,691 65-74 183 75-84 2 85+ 1 Unknown 0 Total 6,525,343 Total Inpatient Age Discharge s Discharges / 1,000 Member Months Days Days / 1,000 Members Months Average Length of Stay <1 3482 6.97 23920 47.90 6.87 1-9 3830 1.21 11389 3.61 2.97 10-19 7608 3.62 22777 10.85 2.99 20-44 27185 38.54 75661 107.26 2.78 45-64 1099 16.48 5163 77.42 4.70 65-74 1 5.46 5 27.32 5.00 75-84 0 0.00 0 0.00 NA 85+ 0 0.00 0 0.00 NA Unknown 0 0 NA Total 43,205 6.62 138,915 21.29 3.22 Medicine Age Discharge s Discharges / 1,000 Member Months Days Days / 1,000 Members Months Average Length of Stay <1 2721 5.45 12276 24.59 4.51 1-9 2943 0.93 7589 2.41 2.58 10-19 1287 0.61 3965 1.89 3.08 20-44 1734 2.46 5670 8.04 3.27 45-64 592 8.88 2199 32.97 3.71 65-74 1 5.46 5 27.32 5.00 75-84 0 0.00 0 0.00 NA 85+ 0 0.00 0 0.00 NA Unknown 0 0 NA Total 9,278 1.42 31,704 4.86 3.42 1 of 2 July 2011 Department of Community Health, State of Georgia Audited CY 2010 HEDIS Utilization Measure Results for WellCare Inpatient Utilization - General Hospital/Acute Care: Total (IPUA) Surgery Age Discharge s Discharges / 1,000 Member Months Days Days / 1,000 Members Months Average Length of Stay <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total 761 887 841 1604 483 0 0 0 0 4,576 1.52 11644 0.28 3800 0.40 3909 2.27 6462 7.24 2888 0.00 0 0.00 0 0.00 0 0 0.70 28,703 Maternity* 23.32 1.20 1.86 9.16 43.30 0.00 0.00 0.00 4.40 15.30 4.28 4.65 4.03 5.98 NA NA NA NA 6.27 Age Discharge s Discharges / 1,000 Member Months Days Days / 1,000 Members Months Average Length of Stay 10-19 5480 2.61 14903 7.10 2.72 20-44 23847 33.81 63529 90.06 2.66 45-64 24 0.36 76 1.14 3.17 Unknown 0 0 NA Total 29,351 10.22 78,508 27.34 2.67 *The maternity category is calculated using member months for members 1064 years. 2 of 2 July 2011 Department of Community Health, State of Georgia Audited CY 2010 HEDIS Utilization Measure Results for WellCare Mental Health Utilization: Total (MPTA) Mental Health Utilization: Total (MPTA) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, 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 2257582 2208649 4,466,231 2257582 2208649 4,466,231 2257582 2208649 4,466,231 13-17 534856 552892 1,087,748 534856 552892 1,087,748 534856 552892 1,087,748 18-64 158159 813019 971,178 158159 813019 971,178 158159 813019 971,178 65+ 26 160 186 26 160 186 26 160 186 Unknown 0 0 0 0 0 0 0 0 0 Total Age 2,950,623 Sex 3,574,720 6,525,343 Any Services Number Percent 2,950,623 3,574,720 Inpatient Number Percent 6,525,343 2,950,623 Intensive Outpatient/Partial Number Percent 3,574,720 6,525,343 Outpatient/ED Number Percent M 14328 7.62% 173 0.09% 2513 1.34% 14055 7.47% 0-12 F 8445 4.59% 107 0.06% 1255 0.68% 8318 4.52% Total 22,773 6.12% 280 0.08% 3,768 1.01% 22,373 6.01% M 5435 12.19% 318 0.71% 1146 2.57% 5300 11.89% 13-17 F 5206 11.30% 476 1.03% 1063 2.31% 5039 10.94% Total 10,641 11.74% 794 0.88% 2,209 2.44% 10,339 11.41% M 1167 8.85% 108 0.82% 300 2.28% 1076 8.16% 18-64 F 7415 10.94% 637 0.94% 2201 3.25% 6910 10.20% Total 8,582 10.60% 745 0.92% 2,501 3.09% 7,986 9.87% M 0 0.00% 0 0.00% 0 0.00% 0 0.00% 65+ F 0 0.00% 0 0.00% 0 0.00% 0 0.00% Total 0 0.00% 0 0.00% 0 0.00% 0 0.00% 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 20,930 8.51% 599 0.24% 3,959 1.61% 20,431 8.31% Total F 21,066 7.07% 1,220 0.41% 4,519 1.52% 20,267 6.80% Total 41,996 7.72% 1,819 0.33% 8,478 1.56% 40,698 7.48% Member Months (Outpatient/ED) Male 2257582 534856 158159 26 0 2,950,623 Female 2208649 552892 813019 160 0 3,574,720 Total 4,466,231 1,087,748 971,178 186 0 6,525,343 1 of 1 July 2011 Department of Community Health, State of Georgia Audited CY 2010 HEDIS Utilization Measure Results for WellCare Antibiotic Utilization: Total (ABXA) Antibiotic Utilization: Total (ABXA) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Pharmacy Benefit Member Months 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 50-64 65-74 75-84 85+ Unknown Total Male 1848596 943842 117595 33808 6756 26 0 0 0 2,950,623 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 Female Total 1804995 3,653,591 956546 1,900,388 625460 743,055 163350 197,158 24209 30,965 157 183 2 2 1 1 0 0 3,574,720 6,525,343 Antibiotic Utilization Percentag Total Antibiotic Scrips Average Scrips PMPY for Antibiotics Total Days Supplied for All Antibiotic Scrips Average Days Supplied per Antibiotic Scrip Total Average e of Number of Scrips Antibiotics Scrips for PMPY for of Antibiotics Anitbiotics Concern of of of all Concern Concern Antibiotic Scrips 255608 1.66 2376816 9.30 118313 0.77 46.29% 245431 1.63 2310248 9.41 106187 0.71 43.27% 501,039 1.65 4,687,064 9.35 224,500 0.74 44.81% 62983 0.80 628652 9.98 28122 0.36 44.65% 83992 1.05 784812 9.34 34947 0.44 41.61% 146,975 0.93 1,413,464 9.62 63,069 0.40 42.91% 9311 0.95 90159 9.68 3639 0.37 39.08% 115617 2.22 914758 7.91 38839 0.75 33.59% 124,928 2.02 1,004,917 8.04 42,478 0.69 34.00% 3951 1.40 36293 9.19 1759 0.62 44.52% 29988 2.20 251190 8.38 13043 0.96 43.49% 33,939 2.07 287,483 8.47 14,802 0.90 43.61% 792 1.41 7716 9.74 381 0.68 48.11% 4024 1.99 35413 8.80 1989 0.99 49.43% 4,816 1.87 43,129 8.96 2,370 0.92 49.21% 0 0.00 0 NA 0 0.00 NA 23 1.76 211 9.17 14 1.07 60.87% 23 1.51 211 9.17 14 0.92 60.87% 0 NA 0 NA 0 NA NA 1 6.00 7 7.00 1 6.00 100.00% 1 6.00 7 7.00 1 6.00 100.00% 0 NA 0 NA 0 NA NA 0 0.00 0 NA 0 0.00 NA 0 0.00 0 NA 0 0.00 NA 0 NA 0 NA 0 NA NA 0 NA 0 NA 0 NA NA 0 NA 0 NA 0 NA NA 332,645 1.35 3,139,636 9.44 152,214 0.62 45.76% 479,076 1.61 4,296,639 8.97 195,020 0.65 40.71% 811,721 1.49 7,436,275 9.16 347,234 0.64 42.78% 1 of 3 July 2011 Department of Community Health, State of Georgia Audited CY 2010 HEDIS Utilization Measure Results for WellCare Antibiotic Utilization: Total (ABXA) 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 Antibiotics of Concern Utilization Total Quinolone Scrips Average Average Scrips PMPY for Quinolone s Total Cephalosporin 2nd- 4th Generatio n Scrips Scrips PMPY for Cephalosporins 2nd-4th Generatio n Total Azithromy cin and Clarithro- mycin Scrips Average Average Scrips Total Scrips PMPY for Amoxicilli PMPY for Azithromy n/ Amoxicilli cins and Clavulanat n/ Clarithro- e Scrips Clavulanat mycins es Total Ketolides Scrips 82 0.00 32467 0.21 44213 0.29 39134 0.25 0 134 0.00 30513 0.20 39477 0.26 33796 0.22 0 216 0.00 62,980 0.21 83,690 0.27 72,930 0.24 0 590 0.01 4366 0.06 14041 0.18 7654 0.10 0 1501 0.02 5593 0.07 17427 0.22 8599 0.11 0 2,091 0.01 9,959 0.06 31,468 0.20 16,253 0.10 0 629 0.06 262 0.03 1583 0.16 762 0.08 0 9519 0.18 2350 0.05 17839 0.34 5581 0.11 0 10,148 0.16 2,612 0.04 19,422 0.31 6,343 0.10 0 520 0.18 101 0.04 656 0.23 301 0.11 0 4034 0.30 740 0.05 5241 0.39 1934 0.14 0 4,554 0.28 841 0.05 5,897 0.36 2,235 0.14 0 123 0.22 21 0.04 136 0.24 54 0.10 0 707 0.35 109 0.05 774 0.38 273 0.14 0 830 0.32 130 0.05 910 0.35 327 0.13 0 0 0.00 0 0.00 0 0.00 0 0.00 0 5 0.38 0 0.00 3 0.23 4 0.31 0 5 0.33 0 0.00 3 0.20 4 0.26 0 0 NA 0 NA 0 NA 0 NA 0 1 6.00 0 0.00 0 0.00 0 0.00 0 1 6.00 0 0.00 0 0.00 0 0.00 0 0 NA 0 NA 0 NA 0 NA 0 0 0.00 0 0.00 0 0.00 0 0.00 0 0 0.00 0 0.00 0 0.00 0 0.00 0 0 NA 0 NA 0 NA 0 NA 0 0 NA 0 NA 0 NA 0 NA 0 0 NA 0 NA 0 NA 0 NA 0 1,944 0.01 37,217 0.15 60,629 0.25 47,905 0.19 0 15,901 0.05 39,305 0.13 80,761 0.27 50,187 0.17 0 17,845 0.03 76,522 0.14 141,390 0.26 98,092 0.18 0 Average Scrips PMPY for Ketolides Average Average Total Misc. Scrips Total Scrips Antibiotics PMPY for Clindamyc PMPY for of Misc. in Scrips Clindamyc Concern Antibiotics ins Scrips of Concern 0.00 2378 0.02 39 0.00 0.00 2251 0.01 16 0.00 0.00 4,629 0.02 55 0.00 0.00 1455 0.02 16 0.00 0.00 1820 0.02 7 0.00 0.00 3,275 0.02 23 0.00 0.00 400 0.04 3 0.00 0.00 3527 0.07 23 0.00 0.00 3,927 0.06 26 0.00 0.00 174 0.06 7 0.00 0.00 1057 0.08 37 0.00 0.00 1,231 0.07 44 0.00 0.00 33 0.06 14 0.02 0.00 119 0.06 7 0.00 0.00 152 0.06 21 0.01 0.00 0 0.00 0 0.00 0.00 2 0.15 0 0.00 0.00 2 0.13 0 0.00 NA 0 NA 0 NA 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 NA 0 NA 0 NA 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 NA 0 NA 0 NA NA 0 NA 0 NA NA 0 NA 0 NA 0.00 4,440 0.02 79 0.00 0.00 8,776 0.03 90 0.00 0.00 13,216 0.02 169 0.00 2 of 3 July 2011 Department of Community Health, State of Georgia Audited CY 2010 HEDIS Utilization Measure Results for WellCare Antibiotic Utilization: Total (ABXA) 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 All Other Antibiotics Utilization Total Absorbabl e Sulfonami de Scrips Average Scrips PMPY for Absorbabl e Sulfonami des Total Aminoglycoside Scrips Average Average Total 1st Scrips Scrips Generatio PMPY for Total PMPY for n Cephalo- 1st Lincosami Amino- sporin Generatio de Scrips glycosides Scrips n Cephalo- sporins Average Scrips PMPY for Lincosami des Total Macrolide s (not azith. or clarith.) Scrips 12389 0.08 31 0.00 15683 0.10 0 0.00 487 18589 0.12 36 0.00 15465 0.10 0 0.00 433 30,978 0.10 67 0.00 31,148 0.10 0 0.00 920 4729 0.06 26 0.00 6570 0.08 0 0.00 300 8909 0.11 39 0.00 7213 0.09 0 0.00 387 13,638 0.09 65 0.00 13,783 0.09 0 0.00 687 963 0.10 1 0.00 879 0.09 0 0.00 92 10697 0.21 2 0.00 8048 0.15 0 0.00 906 11,660 0.19 3 0.00 8,927 0.14 0 0.00 998 411 0.15 8 0.00 367 0.13 0 0.00 43 3173 0.23 15 0.00 1969 0.14 0 0.00 262 3,584 0.22 23 0.00 2,336 0.14 0 0.00 305 107 0.19 0 0.00 63 0.11 0 0.00 3 390 0.19 0 0.00 317 0.16 0 0.00 36 497 0.19 0 0.00 380 0.15 0 0.00 39 0 0.00 0 0.00 0 0.00 0 0.00 0 2 0.15 0 0.00 2 0.15 0 0.00 0 2 0.13 0 0.00 2 0.13 0 0.00 0 0 NA 0 NA 0 NA 0 NA 0 0 0.00 0 0.00 0 0.00 0 0.00 0 0 0.00 0 0.00 0 0.00 0 0.00 0 0 NA 0 NA 0 NA 0 NA 0 0 0.00 0 0.00 0 0.00 0 0.00 0 0 0.00 0 0.00 0 0.00 0 0.00 0 0 NA 0 NA 0 NA 0 NA 0 0 NA 0 NA 0 NA 0 NA 0 0 NA 0 NA 0 NA 0 NA 0 18,599 0.08 66 0.00 23,562 0.10 0 0.00 925 41,760 0.14 92 0.00 33,014 0.11 0 0.00 2,024 60,359 0.11 158 0.00 56,576 0.10 0 0.00 2,949 Average Scrips PMPY for Macrolide s (not azith. or clarith.) 0.00 0.00 0.00 0.00 0.00 0.00 0.01 0.02 0.02 0.02 0.02 0.02 0.01 0.02 0.02 0.00 0.00 0.00 NA 0.00 0.00 NA 0.00 0.00 NA NA NA 0.00 0.01 0.01 Total Penicillin Scrips 108417 103904 212,321 18314 22870 41,184 2527 22001 24,528 924 5415 6,339 166 707 873 0 2 2 0 0 0 0 0 0 0 0 0 130,348 154,899 285,247 Average Scrips PMPY for Penicillins Total Tetracycli ne Scrips 0.70 47 0.69 35 0.70 82 0.23 4626 0.29 5073 0.26 9,699 0.26 1038 0.42 8174 0.40 9,212 0.33 311 0.40 2099 0.39 2,410 0.29 46 0.35 272 0.34 318 0.00 0 0.15 0 0.13 0 NA 0 0.00 0 0.00 0 NA 0 0.00 0 0.00 0 NA 0 NA 0 NA 0 0.53 6,068 0.52 15,653 0.52 21,721 Average Average Scrips Total Misc. Scrips PMPY for Antibiotic PMPY for Tetracycli Scrips Misc. nes Antibiotics 0.00 241 0.00 0.00 782 0.01 0.00 1,023 0.00 0.06 296 0.00 0.06 4554 0.06 0.06 4,850 0.03 0.11 172 0.02 0.16 26950 0.52 0.15 27,122 0.44 0.11 128 0.05 0.15 4012 0.29 0.15 4,140 0.25 0.08 26 0.05 0.13 313 0.16 0.12 339 0.13 0.00 0 0.00 0.00 3 0.23 0.00 3 0.20 NA 0 NA 0.00 0 0.00 0.00 0 0.00 NA 0 NA 0.00 0 0.00 0.00 0 0.00 NA 0 NA NA 0 NA NA 0 NA 0.02 863 0.00 0.05 36,614 0.12 0.04 37,477 0.07 3 of 3 July 2011 Department of Community Health, State of Georgia Audited CY 2010 HEDIS Utilization Measure Results for WellCare Race/Ethnicity Diversity of Membership (RDM) Race/Ethnicity Diversity of Membership (RDM) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Race/Ethnicity Percentage of Data Collected Using Direct Data Collection Methods Direct number of members Eligible Population Race/Ethnicity Percentage of Data Collected Using Indirect Data Collection Methods 0 Indirect number of 0 members Total unduplicated membership during the measurement year (this number represents the total number of members regardless of data collection method) 767612 Total unduplicated membership during the measurement year (this number represents the total number of members regardless of data collection method) 767612 Direct number and percentage of members CMS/State databases percentage of members Other Percentage of Members 0.00% 1.0000 0.0000 Indirect (e.g. surname analysis/geo-coding) number and percentage of members 0.00% 1 of 2 July 2011 Department of Community Health, State of Georgia Audited CY 2010 HEDIS Utilization Measure Results for WellCare Race/Ethnicity Diversity of Membership (RDM) Race Hispanic or Latino Number Percentage White 0 Black or African American 0 American-Indian and Alaska Native 0 Asian 0 Native Hawaiian and Other Pacific 0 Islanders Some Other Race 0 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% Two or More Races 0 0.00% Unknown Declined Total Measure 16206 100.00% 0 0.00% 16,206 100.00% Direct/Indirect Percentage of plan members Percentage Measure Percentage of members for whom the organization has race information through direct data collection methods .9382 Percentage of members for whom the organization has race information through indirect data collection methods Not Hispanic or Latino Number Percentag e 4951 8.58% Unknown Ethnicity Number Percentag e 357677 51.56% Declined Ethnicity Number Percentag e 0 NR Total Number Percentag e 362,628 47.24% 30790 53.33% 304726 43.93% 0 NR 335,516 43.71% 512 13656 0.89% 0 0.00% 0 23.65% 0 0.00% 0 NR 512 0.07% NR 13,656 1.78% 2 0.00% 0 0.00% 0 NR 2 0.00% 7824 0 0 0 57,735 13.55% 0 0.00% 0 0.00% 5 0.00% 0 0.00% 31263 4.51% 0 0.00% 0 0.00% 0 100.00% 693,671 100.00% 0 NR 7,824 1.02% NR 5 0.00% NR 47,469 6.18% NR 0 0.00% NR 767,612 100.00% Percentage 0.0000 Percentage of members for whom the organization has ethnicity information through direct data collection methods .09633 Percentage of members for whom the organization has ethnicity information through indirect data collection methods 0.0000 2 of 2 July 2011 Department of Community Health, State of Georgia Audited CY 2010 HEDIS Utilization Measure Results for WellCare Language Diversity of Membership (LDM) Language Diversity of Membership (LDM) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Percentage of Members With Known Language Value from Each Data Source Category Health Plan Direct Spoken Language Preferred for 0 Health Care* Preferred Language for Written 0 Materials* Other Language Needs* 0 CMS/State Databases 0 0 0 Other Third-Party Source 0 0 0 *Enter percentage as a value between 0 and 1. Spoken Language Preferred for Health Care Number Percentage English 709841 92.47% Non-English 51744 6.74% Unknown 6027 0.79% Declined 0 0.00% Total: this should sum to 100% 767,612 100.00% Language Preferred for Written Materials Number Percentage English 0 0.00% Non-English 0 0.00% Unknown 767612 100.00% Declined 0 0.00% Total: this should sum to 100% 767,612 100.00% Other Languages Needs Number Percentage English 0 0.00% Non-English 0 0.00% Unknown 767612 100.00% Declined 0 0.00% Total: this should sum to 100% 767,612 100.00% 1 of 1 July 2011