Validation of performance measures for WellCare of Georgia, Inc., measurement period: calendar year 2011; validation period: state fiscal year 2012 [Aug. 23, 2012]

Metadata
Text

Collection:: Georgia Government Publications
Serial:: Validation of performance measures for WellCare of Georgia, Inc.
Title:: Validation of performance measures for WellCare of Georgia, Inc., measurement period: calendar year 2011; validation period: state fiscal year 2012 [Aug. 23, 2012]
Creator:: Georgia. Department of Community Health
Contributor to Resource:: Georgia. Department of Community Health
Publisher:: Atlanta, Ga. : Georgia. Department of Community Health
Phoenix, AZ : Health Services Advisory Group
Date of Original:: 2012-08-23
Subject:: WellCare of Georgia--Periodicals.
Managed care plans (Medical care)--Georgia--Periodicals.
Managed care plans (Medical care)--Georgia--Evaluation--Periodicals.
Soins intégrés de santé--Géorgie (État)--Périodiques.
Soins intégrés de santé--Géorgie (État)--Évaluation--Périodiques.
Georgia Government Documents--Serial
Location:: United States, Georgia, 32.75042, -83.50018
Medium:: state government records
Type:: Text
Format:: application/pdf
Description:: Prepared by HSAG
External Identifiers:: Call Number GA C900 .S1 V33 2012
Metadata URL:: https://dlg.galileo.usg.edu/id:dlg_ggpd_y-ga-bc900-b-ps1-bv33-b2012-belec-p-btext
Digital Object URL:: https://dlg.galileo.usg.edu/do:dlg_ggpd_y-ga-bc900-b-ps1-bv33-b2012-belec-p-btext
Language:: eng
Holding Institution:: University of Georgia. Map and Government Information Library
Rights:

Georgia Department of Community Health
Validation of Performance Measures for
WellCare of Georgia, Inc.
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 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 ....................................................................................................... 9 Supplemental Data ............................................................................................................................ 9 Data Integration ................................................................................................................................. 9 Performance Measure Specific Findings......................................................................................... 10 Validation Findings ............................................................................................................................ 11
Appendix A--Data Integration and Control Findings ..................................................................... A-1 Appendix B--Denominator and Numerator Validation Findings ................................................... B-1
Appendix C--Performance Measure Results .................................................................................. C-1
Appendices D and E--Final Audited HEDIS Results ...................................................................... D-1

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Validation of Performance Measures
for 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. 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 WellCare of Georgia, Inc. (WellCare). Information about WellCare appears in Table 1.

Table 1--WellCare of Georgia, Inc. Information

CMO Name: CMO Location: CMO Contact:

WellCare of Georgia, Inc. 211 Perimeter Parkway, Suite 800 Atlanta, GA 30346
Linda Simmons, RN

Contact Telephone Number:

770.913.2182

Contact E-mail Address:

Linda.Simmons2@wellcare.com

Site Visit Date:

April 1819, 2012

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

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

Performance Measure

Rate Calculation by:

1. Low Birth Weight Rate (AHRQ)

WellCare

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)

WellCare WellCare WellCare WellCare WellCare WellCare

In addition, WellCare was required to report a selected set of Healthcare Effectiveness Data and Information Set (HEDIS) measures to DCH. WellCare 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).

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Description of Validation Activities

Pre-Audit Strategy
HSAG conducted the validation activities as outlined in the CMS performance measure validation protocol. To complete the validation activities for 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 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 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 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
Wendy Talbot, MPH, CHCA Associate Director, Audits
Allen Iovannisci, MS, CHCA Lead Auditor
David Mabb, MS, CHCA Associate Director, Audits Dan Moore, MPA Source Code Reviewer Tammy GianFrancisco Project Leader

Table 3--Validation Team Skills and Expertise
Management of audit department, certified HEDIS auditor, HEDIS knowledge, interviewing skills, and statistics and analysis. Certified HEDIS auditor, HEDIS knowledge, data integration, systems review and analysis, source code review, and health care analytics
Certified HEDIS auditor, HEDIS knowledge, source code review manager, and statistics and analysis.
Source code review
Overall project coordination and communications

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Technical Methods of Data Collection and Analysis
The CMS performance measure validation protocol identifies key types of data that should be reviewed as part of the validation process. The following list describes the type of data collected and how HSAG conducted an analysis of these data:
NCQA's HEDIS 2012 Roadmap: WellCare completed and submitted the required and relevant portions of its Roadmap for review by the validation team. The validation team used responses from the Roadmap to complete the pre-on-site systems assessment.
Source code (programming language) for performance measures: HSAG requested and received source code from WellCare 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 WellCare on April 18 and 19, 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 WellCare 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 WellCare 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

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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 WellCare staff members who were involved with performance measure reporting. Table 4 lists key WellCare interviewees:

Sharon Nisbet

Name

Tom Clegg

Bob Klopotek

Mike Leist

Shawn Chandler

Danny Sharpe

Gary Chu

Lee Falk

Oscar Ruiz

Renard Edwards

Cesar Collazo

Susan Swiontek

John Villanova

Claudius Connor

Kim Pace

Lissette Salemi

Damanyes Escribano

Patricia Strickland

Nancy Dasch

Lee Genco

Esther Morales

Linda Simmons

Table 4--List of WellCare Interviewees Title
Vice President, Quality and Performance Improvement HEDIS Specialist Vice President, Information Technology Vice President, Information Technology Manager, Quality Analytics Director, Quality Project Manager, Information Technology Team Lead, EDI Operations Manager, Operational Audits Manager, Claims Manager, Front End Operations Manager, Claims Delegation Manager, Encounters Director, Enrollment Supervisor, Enrollment Manager, Enrollment Senior Provider Network Connections Analyst Senior Manager, Configurations Manager, IT Application Development, EDI Senior Director, Pharmacy Benefit Relations Vice President, Quality (North Division) Senior Director, Quality (Georgia, South Division)

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Tamika Graham Kressi Maricle Kim Nguyen Colleen Hampton Andre Greenwood

Name

Table 4--List of WellCare Interviewees Title
Project Manager, Quality Improvement Manager Georgia Medicaid Contract Georgia Medicaid Contract Georgia Medicaid Contract

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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 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
WellCare'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 WellCare 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 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 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

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Validation Results
The validation team evaluated WellCare'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)
WellCare underwent a system upgrade during the measurement year for its Peradigm system. The upgrade provided the necessary Health Insurance Portability and Accountability Act of 1996 (HIPAA) changes to some fields including Present on Admission (POA). WellCare ensured appropriate system test plans were in place prior to the upgrade and performed regression testing to ensure all data remained neutral. The auditor conducted a regression test during the on-site visit and found no issues.
WellCare only employs industry-standard codes (e.g., ICD-9-CM, CPT, DRG, HCPCS); and system edits ensured that all characters were captured, principle codes were identified, and secondary codes were captured. Non-standard coding schemes were not employed during the measurement year. WellCare used standard submission forms and was able to capture all fields relevant to reporting. Processes included sufficient edit checks and ensured accurate entry of submitted data in WellCare's transaction files. In addition, 100 percent of all transactions were submitted electronically. All files were logged and monitored by the EDI Operations team. Data completeness was not an issue at WellCare since all claims were reimbursed on a fee-for-service (FFS) basis.
Enrollment Data
There were no concerns with the processing of enrollment files received from DCH. Monthly files were received and loaded into WellCare's data system. Processing of membership information complied with standards. There were sufficient edit checks in place to ensure that loaded files did not contain errors. The enrollment files were reconciled monthly against the capitation file as an additional validation check to ensure that all eligible members were being captured for service and payment. WellCare did not have any issues with membership data during 2011. There were no backlogs of applications since DCH provided the eligibility files. There were minimal retro-activity enrollments during the year. PeachCare for Kids enrollment data were submitted in standard 834 format, and updates were validated against internal applications.
Provider Data
Provider data processing and identification were not relevant to the measures under review.

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VALIDATION OF PERFORMANCE MEASURES
Medical Record Review Process
WellCare 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
WellCare did not use any supplemental data sources for reporting the selected performance measure rates.
Data Integration
WellCare consolidated data from several different data sources and platforms. WellCare maintained sufficient processes to integrate these data sources for reporting. Statistical Analysis Software (SAS) coding was used to develop the source code to produce the measures. The SAS code was reviewed and approved for use by the audit team. The source code was validated against the AHRQ and CHIPRA specifications to ensure accuracy. WellCare provided sufficient documentation ensuring that appropriate fields were mapped. The audit team conducted primary source verification on several members for each measure to ensure the source code was accurately collecting information relevant to the measures under review. All primary source data were found to be compliant.

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

Table 5--Key Review Results for WellCare

Performance Measures

Key Review Findings

1. Low Birth Weight Rate (AHRQ)

No concerns identified

2. Cesarean Delivery Rate (AHRQ)

No concerns identified

3.

Percentage of Eligibles That Received Preventive Dental Services (CHIPRA)

No concerns identified

4.

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

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

5.

Percentage of Eligibles That Received Dental Treatment Services (CHIPRA)

No concerns identified

6.

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

No concerns identified

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

No concerns identified

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Validation 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 WellCare for each performance measure rate. For additional information regarding performance measure rates, see Appendix C of this report.

Table 7--Validation Findings for WellCare

Performance Measures

Validation Finding

1. Low Birth Weight Rate (AHRQ)

Report

2. Cesarean Delivery Rate (AHRQ)

Report

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

Report

4.

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

Not Report

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

Report

6.

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

Report

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

Report

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Appendix A. Data Integration and Control Findings
for WellCare of Georgia, Inc.
Appendix A, which follows this page, contains the data integration and control findings for WellCare.

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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 1819, 2012 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).

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DATA INTEGRATION AND CONTROL FINDINGS

Data Integration and Control Element

Not Met Met N/A

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

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

Prescribed data cutoff dates are followed.

Comments

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

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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.

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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 1819, 2012 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.

Not applicable to the measures being reported.

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

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

Exclusion criteria included in the performance measure specifications are followed.

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

Population estimates were not used.

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DENOMINATOR AND NUMERATOR VALIDATION FINDINGS

Table B-2--Numerator Validation Findings for 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 nonstandard codes.

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Appendix C. Performance Measure Results
for WellCare of Georgia, Inc.
Appendix C, which follows this page, contains WellCare's performance measure results.

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Appendix C. Performance Measure Results
for WellCare of Georgia, Inc.

Indicator 1--Low Birth Weight Rate
Table C-1--Indicator 1 for WellCare of Georgia, Inc.
Low Birth Weight Rate

Rate (per 100) 7.7

Indicator 2--Cesarean Delivery Rate
Table C-2--Indicator 2 for WellCare of Georgia, Inc.
Cesarean Delivery Rate

Rate (per 100) 31.2

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

Table C-3--Indicator 3 for WellCare of Georgia, Inc.
Preventive Dental Services

Rate 51.7%

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PERFORMANCE MEASURE RESULTS

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

Table C-4--Indicator 4 for WellCare of Georgia, Inc.
Otitis Media with Effusion

Rate 0.0%

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

Table C-5--Indicator 5 for WellCare of Georgia, Inc.
Dental Treatment Services

Rate 24.0%

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

Table C-6--Indicator 6 for WellCare of Georgia, Inc.
Asthma ER

Rate 9.3%

Indicator 7--Annual Pediatric Hemoglobin (HbA1c) Testing

Table C-7--Indicator 7 for WellCare of Georgia, Inc.
Pediatric HbA1c Testing

Rate 74.7%

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Appendix D. Final Audited HEDIS Results
for WellCare of Georgia, Inc.
Appendices D and E, which follow this page, contain WellCare's final audited HEDIS results.

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Appendix D. Final Audited HEDIS Results
for WellCare of Georgia, Inc.

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--WellCare of Georgia, Inc.

Measure

CMO Rate

Adolescent Well-Care Visits

41.4% Hybrid

Adults' Access to Preventive/Ambulatory Health Services--Ages 2044 Years
Adults' Access to Preventive/Ambulatory Health Services--Ages 4564 Years

86.0% 90.3%

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

NA

Adults' Access to Preventive/Ambulatory Health Services--Total
Adult BMI Assessment Annual Dental Visit--Ages 23 Years
Annual Dental Visit--Ages 46 Years
Annual Dental Visit--Ages 710 Years Annual Dental Visit--Ages 1114 Years Annual Dental Visit--Ages 1518 Years Annual Dental Visit--Ages 1921 Years
Annual Dental Visit--Total Annual Monitoring for Patients on Persistent Medications--Total Antidepressant Medication Management--Effective Acute Phase Treatment Antidepressant Medication Management--Effective Continuation Phase
Treatment Appropriate Testing for Children with Pharyngitis Appropriate Treatment for Children with Upper Respiratory Infection (URI)1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis1
Breast Cancer Screening Call Abandonment

86.5%
NR 50.0% 77.5% 80.2% 73.0% 62.0% 41.7% 70.5% 86.0% 49.1% 33.6% 71.4% 77.0% 17.5% 56.4% 1.2%

WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia

Page D-1 WellCare_GA2011-12_CMO_PMV_F6_0812

FINAL AUDITED HEDIS RESULTS

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--WellCare of Georgia, Inc.

Measure

CMO Rate

Call Answer Timeliness

86.3%

Cervical Cancer Screening
Cholesterol Management for Patients with Cardiovascular Conditions-- LDL-C Screening
Cholesterol Management for Patients with Cardiovascular Conditions-- LDL-C Control

66.9% Hybrid 77.6% Hybrid 20.1% Hybrid

Childhood Immunization Status--Combo 3

81.0% Hybrid

Childhood Immunization Status--Combo 10

20.2% Hybrid

Children's and Adolescents' Access to Primary Care Providers--Ages 12 24 Months

97.0%

Children's and Adolescents' Access to Primary Care Providers--Ages 25 Months6 Years
Children's and Adolescents' Access to Primary Care Providers--Ages 711 Years
Children's and Adolescents' Access to Primary Care Providers--Ages 12 19 Years
Chlamydia Screening in Women--Total

91.3% 91.5% 88.7% 48.9%

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

29.6% Hybrid

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

51.6% Hybrid

Comprehensive Diabetes Care--Eye Exam

44.5% Hybrid

Comprehensive Diabetes Care--HbA1c Good Control <7.0

32.3% Hybrid

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

42.5% Hybrid 51.6% Hybrid

Comprehensive Diabetes Care--HbA1c Testing

80.3% Hybrid

Comprehensive Diabetes Care--LDL-C Level

25.2% Hybrid

WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia

Page D-2 WellCare_GA2011-12_CMO_PMV_F6_0812

FINAL AUDITED HEDIS RESULTS

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--WellCare of Georgia, Inc.

Measure

CMO Rate

Comprehensive Diabetes Care--LDL-C Screening

71.7% Hybrid

Comprehensive Diabetes Care--Medical Attention to Nephropathy Controlling High Blood Pressure
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis Follow-Up After Hospitalization for Mental Illness--30-Day Follow-Up

71.9% Hybrid 46.2% Hybrid
62.5% 75.1%

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

57.1% 40.0% 54.5%

Frequency of Ongoing Prenatal Care--< 21 Percent Frequency of Ongoing Prenatal Care--2140 Percent

21.4% Hybrid 5.4% Hybrid

Frequency of Ongoing Prenatal Care--4160 Percent

7.5% Hybrid

Frequency of Ongoing Prenatal Care--6180 Percent

12.7% Hybrid

Frequency of Ongoing Prenatal Care--81+ Percent

53.0% Hybrid

Human Papillomavirus Vaccine for Female Adolescents

NR

Identification of Alcohol and Other Drug Services

Rates reported in Appendix E

Immunizations for Adolescents--Combo 1 Initiation and Engagement of AOD Dependence Treatment--Initiation Initiation and Engagement of AOD Dependence Treatment--Engagement

70.1% Hybrid 35.7% 9.0%

WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia

Page D-3 WellCare_GA2011-12_CMO_PMV_F6_0812

FINAL AUDITED HEDIS RESULTS

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--WellCare of Georgia, Inc.

Measure

CMO Rate

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

Rates reported in Appendix E

Lead Screening in Children

77.6% Hybrid

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

51.0% 30.6%

Persistence of Beta-Blocker Treatment After a Heart Attack

NA

Pharmacotherapy Management of COPD Exacerbation--Systemic Corticosteroid

63.2%

Pharmacotherapy Management of COPD Exacerbation--Bronchodilator

81.1%

Prenatal and Postpartum Care--Postpartum Care

63.0% Hybrid

Prenatal and Postpartum Care--Timeliness of Prenatal Care

80.5% Hybrid

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
Use of Imaging Studies for Low Back Pain1

92.4% 89.1% 74.9% 80.6% 90.6% 73.2%

Use of Spirometry Testing in the Assessment and Diagnosis of COPD

38.4%

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

56.9% Hybrid

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

50.4% Hybrid

WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia

Page D-4 WellCare_GA2011-12_CMO_PMV_F6_0812

FINAL AUDITED HEDIS RESULTS

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--WellCare of Georgia, Inc.

Measure

CMO Rate

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

37.0% Hybrid

Well-Child Visits in the First 15 Months of Life--Zero Visits Well-Child Visits in the First 15 Months of Life--One Visit Well-Child Visits in the First 15 Months of Life--Two Visits Well-Child Visits in the First 15 Months of Life--Three Visits Well-Child Visits in the First 15 Months of Life--Four Visits 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 Weeks of Pregnancy at Time of Enrollment Race/Ethnicity Diversity of Membership Language Diversity of Membership

2.2% Hybrid 1.9% Hybrid 3.2% Hybrid 4.6% Hybrid 10.5% Hybrid 16.3% Hybrid 61.3% Hybrid 66.2% Hybrid Rates reported in Appendix E Rates reported in Appendix E
NR NR NR NR Rates reported in Appendix E Rates reported in Appendix E Rates reported in Appendix E

WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia

Page D-5 WellCare_GA2011-12_CMO_PMV_F6_0812

FINAL AUDITED HEDIS RESULTS

CMO Audited Calendar Year 2011 HEDIS Performance Measure Report--WellCare of Georgia, Inc.

Measure

CMO Rate

Ambulatory Care--Total

Rates reported in Appendix E

Relative Resource Use for People with Diabetes

Rates reported in Appendix E

Relative Resource Use for People with Asthma

Rates reported in Appendix E

Relative Resource Use for People with Cardiovascular Conditions

Rates reported in Appendix E

Relative Resource Use for People with COPD

Rates reported in Appendix E

Relative Resource Use for People with Hypertension

Rates reported in Appendix E

Antibiotic Utilization--Total

Rates reported in Appendix E

1 Note: The measure is reported as an inverted rate. A higher rate indicates appropriate treatment of children with URI (i.e., the proportion for whom antibiotics were not prescribed). The rate is calculated as 1 minus the numerator divided by the eligible population.
2 Note: Lower rate is better.
NR: Not Required to Report.

WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia

Page D-6 WellCare_GA2011-12_CMO_PMV_F6_0812

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

Audit Review Table

WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, 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)

N

NR

NR

Weight Assessment and Counseling for Nutrition

and Physical Activity for Children/Adolescents

Y

(wcc)

BMI Percentile

56.9%

R

Counseling for Nutrition

50.4%

R

Counseling for Physical Activity

37.0%

R

Childhood Immunization Status (cis)

Y

DTaP

87.1%

R

IPV

97.6%

R

MMR

96.1%

R

HiB

97.1%

R

Hepatitis B

97.1%

R

VZV

95.9%

R

Pneumococcal Conjugate

87.6%

R

Hepatitis A

51.3%

R

Rotavirus

67.6%

R

Influenza

45.3%

R

Combination #2

85.2%

R

Combination #3

81.0%

R

Combination #4

47.4%

R

Combination #5

59.1%

R

Combination #6

39.9%

R

Combination #7

34.5%

R

Combination #8

26.3%

R

Combination #9

29.7%

R

Combination #10

20.2%

R

Immunizations for Adolescents (ima)

Y

Meningococcal

71.0%

R

Tdap/Td

84.7%

R

1 of 27

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

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

Combination #1

70.1%

R

Human Papillomavirus Vaccine for Female Adolescents (hpv)

N

NR

NR

Lead Screening in Children (lsc)

Y

77.6%

R

Breast Cancer Screening (bcs)

Y

56.4%

R

Cervical Cancer Screening (ccs)

Y

N

66.9%

R

Chlamydia Screening in Women (chl)

Y

16-20 Years

44.4%

R

21-24 Years

63.0%

R

Total

48.9%

R

Effectiveness of Care: Respiratory Conditions

Appropriate Testing for Children with Pharyngitis (cwp)

Y

Y

71.4%

R

Appropriate Treatment for Children With URI (uri)

Y

Y

77.0%

R

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

Y

Y

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

Y

Pharmacotherapy Management of COPD Exacerbation (pce)

Y

Y

Systemic Corticosteroid

Bronchodilator

Use of Appropriate Medications for People With Asthma (asm)

Y

Y

5-11 Years

12-18 Years

19-50 Years

51-64 Years

Total

Medication Management for People With Asthma (mma)

Y

Y

5-11 Years - Medication Compliance 50%

5-11 Years - Medication Compliance 75%

12-18 Years - Medication Compliance 50%

12-18 Years - Medication Compliance 75%

17.5%

R

38.4%

R

63.2%

R

81.1%

R

92.4%

R

89.1%

R

74.9%

R

80.6%

R

90.6%

R

51.7%

R

31.4%

R

49.3%

R

28.2%

R

2 of 27

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

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

19-50 Years - Medication Compliance 50%

50.0%

R

19-50 Years - Medication Compliance 75%

33.5%

R

51-64 Years - Medication Compliance 50%

NA

R

51-64 Years - Medication Compliance 75%

NA

R

Total - Medication Compliance 50%

51.0%

R

Total - Medication Compliance 75%

30.6%

R

Effectiveness of Care: Cardiovascular

Cholesterol Management for Patients With Cardiovascular Conditions (cmc)

Y

LDL-C Screening Performed

77.6%

R

LDL-C Control (<100 mg/dL)

20.1%

R

Controlling High Blood Pressure (cbp)

Y

N

46.2%

R

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

Y

Y

NA

R

Effectiveness of Care: Diabetes

Comprehensive Diabetes Care (cdc)

Y

Hemoglobin A1c (HbA1c) Testing

80.3%

R

HbA1c Poor Control (>9.0%)

51.6%

R

HbA1c Control (<8.0%)

42.5%

R

HbA1c Control (<7.0%)

32.3%

R

Eye Exam (Retinal) Performed

44.5%

R

LDL-C Screening Performed

71.7%

R

LDL-C Control (<100 mg/dL)

25.2%

R

Medical Attention for Nephropathy

71.9%

R

Blood Pressure Control (<140/80 mm Hg)

29.6%

R

Blood Pressure Control (<140/90 mm Hg)

51.6%

R

Effectiveness of Care: Musculoskeletal

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

Y

Y

62.5%

R

Use of Imaging Studies for Low Back Pain (lbp)

Y

73.2%

R

Effectiveness of Care: Behavioral Health

Antidepressant Medication Management (amm)

Y

Y

Effective Acute Phase Treatment

49.1%

R

Effective Continuation Phase Treatment

33.6%

R

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

3 of 27

August 2012

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

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

Y

Y

Initiation Phase

Continuation and Maintenance (C&M) Phase

Follow-Up After Hospitalization for Mental Illness (fuh)

Y

Y

30-Day Follow-Up

7-Day Follow-Up

Effectiveness of Care: Medication Management

Annual Monitoring for Patients on Persistent Medications (mpm)

Y

Y

ACE Inhibitors or ARBs

Digoxin

Diuretics

Anticonvulsants

Total

Access/Availability of Care

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

Y

20-44 Years

45-64 Years

65+ Years

Total

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

Y

12-24 Months

25 Months - 6 Years

7-11 Years

12-19 Years

Annual Dental Visit (adv)

Y

Y

2-3 Years

4-6 Years

7-10 Years

11-14 Years

15-18 Years

40.0%

R

54.5%

R

75.1%

R

57.1%

R

86.9%

R

NA

R

87.6%

R

61.1%

R

86.0%

R

86.0%

R

90.3%

R

NA

R

86.5%

R

97.0%

R

91.3%

R

91.5%

R

88.7%

R

50.0%

R

77.5%

R

80.2%

R

73.0%

R

62.0%

R

4 of 27

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

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

19-21 Years

41.7%

R

Total

70.5%

R

Initiation and Engagement of AOD Dependence Treatment (iet)

Y

Y

Initiation of AOD Treatment: 13-17 Years

35.3%

R

Engagement of AOD Treatment: 13-17 Years

15.9%

R

Initiation of AOD Treatment: 18+ Years

35.8%

R

Engagement of AOD Treatment: 18+ Years

7.1%

R

Initiation of AOD Treatment: Total

35.7%

R

Engagement of AOD Treatment: Total

9.0%

R

Prenatal and Postpartum Care (ppc)

Y

N

Timeliness of Prenatal Care

80.5%

R

Postpartum Care

63.0%

R

Call Answer Timeliness (cat)

Y

86.3%

R

Call Abandonment (cab)

Y

1.2%

R

Utilization

Frequency of Ongoing Prenatal Care (fpc)

Y

N

<21 Percent

21.4%

R

21-40 Percent

5.4%

R

41-60 Percent

7.5%

R

61-80 Percent

12.7%

R

81+ Percent

53.0%

R

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

Y

0 Visits

2.2%

R

1 Visit

1.9%

R

2 Visits

3.2%

R

3 Visits

4.6%

R

4 Visits

10.5%

R

5 Visits

16.3%

R

6+ Visits

61.3%

R

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

Y

66.2%

R

Adolescent Well-Care Visits (awc)

Y

Frequency of Selected Procedures (fsp)

Y

41.4%

R

R

5 of 27

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

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

Ambulatory Care: Total (amba)

Y

R

Ambulatory Care: Dual Eligibles (ambb)

Y

R

Ambulatory Care: Disabled (ambc)

Y

R

Ambulatory Care: Other (ambd)

Y

R

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

Y

R

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

Y

R

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

Y

R

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

Y

R

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

Y

Y

R

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

Y

Y

R

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

Y

Y

R

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

Y

Y

R

Mental Health Utilization: Total (mpta)

Y

Y

R

Mental Health Utilization: Dual Eligibles (mptb)

Y

Y

R

Mental Health Utilization: Disabled (mptc)

Y

Y

R

Mental Health Utilization: Other (mptd)

Y

Y

R

Antibiotic Utilization: Total (abxa)

Y

Y

R

Antibiotic Utilization: Dual Eligibles (abxb)

Y

Y

R

Antibiotic Utilization: Disabled (abxc)

Y

Y

R

Antibiotic Utilization: Other (abxd)

Y

Y

R

Relative Resource Use

Relative Resource Use for People With Diabetes (rdi)

Y

R

Relative Resource Use for People With Asthma (ras)

Y

Y

R

Relative Resource Use for People With Cardiovascular Conditions (rca)

Y

R

6 of 27

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

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

Relative Resource Use for People With

Y

Hypertension (rhy)

Relative Resource Use for People With COPD (rco)

Y

Health Plan Descriptive Information

Board Certification (bcr)

N

Total Membership (tlm)

N

Enrollment by Product Line: Total (enpa)

N

Enrollment by Product Line: Dual Eligibles (enpb)

N

Enrollment by Product Line: Disabled (enpc)

N

Enrollment by Product Line: Other (enpd)

N

Enrollment by State (ebs)

N

Race/Ethnicity Diversity of Membership (rdm)

Y

Language Diversity of Membership (ldm)

Y

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

Y

R R

NR NR NR NR NR NR NR R R

N

R

Reportable
Reportable
Measure Unselected Measure Unselected Measure Unselected Measure Unselected Measure Unselected Measure Unselected Measure Unselected
Reportable Reportable
Reportable

7 of 27

August 2012

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

Frequency of Selected Procedures (FSP)

WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj:

None)

Age

Male

Female

Total

0-9

1,845,004 1,798,662 3,643,666

10-19

1,066,678 1,121,999 2,188,677

15-44

1,121,307

20-44

70,264

669,838

30-64

60,461

45-64

15,668

53,323

Procedures

Procedure

Age

Sex

Number of / 1,000 Procedures Member

Years

0-19

Male

0

Female

2

0.0 <0.1

Bariatric weight loss surgery

20-44

Male

3

Female

48

<0.1 0.1

45-64

Male

2

0.1

Female

6

0.1

Tonsillectomy

0-9

Male &

3610

1.0

10-19

Female

1026

0.5

Hysterectomy, Abdominal

15-44

Female

400

0.4

45-64

56

1.1

Hysterectomy, Vaginal

15-44

Female

339

0.3

45-64

30

0.6

30-64

Male

2

<0.1

Cholecystectomy, Open

15-44

Female

17

45-64

0

<0.1 0.0

30-64

Male

40

0.7

Cholecystectomy, Closed (laparoscopic) 15-44

Female

963

0.9

45-64

47

0.9

Back Surgery

20-44

Male

55

0.8

Female

137

0.2

45-64

Male

13

0.8

Female

34

0.6

Mastectomy

15-44

Female

47

45-64

68

<0.1 1.3

Lumpectomy

15-44

Female

199

0.2

45-64

65

1.2

8 of 27

August 2012

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

Ambulatory Care: Total (AMBA)

WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj:

None)

Age

Member Months

<1

471,215

1-9

3,172,451

10-19

2,188,677

20-44

740,102

45-64

68,991

65-74

110

75-84

5

85+

2

Unknown

0

Total

6,641,553

Outpatient Visits

ED Visits

Age

Visits/ 1,000

Visits/ 1,000

Visits

Member

Visits

Member

Months

Months

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

381096 1055717 520377 323078
49536 84 7 0 0
2,329,895

808.8 332.8 237.8 436.5 718.0 763.6 1400.0
0.0
350.8

42221 154527 89972 100456
6663 0 0 0 0
393,839

89.6 48.7 41.1 135.7 96.6 0.0 0.0 0.0
59.3

9 of 27

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for WellCare Inpatient Utilization--General Hospital/Acute Care (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 1-9 10-19

471,215 3,172,451 2,188,677

20-44 45-64 65-74

740,102 68,991
110

75-84

5

85+

2

Unknown

0

Total

6,641,553 Total Inpatient

Age

Discharges /

Discharges

1,000 Member

Months

Days

Days / 1,000 Members Months

Average Length of
Stay

<1

3164

6.7

20383

43.3

6.4

1-9

3457

1.1

9907

3.1

2.9

10-19 20-44 45-64 65-74 75-84

7185

3.3

21182

9.7

2.9

27980

37.8

78145

105.6

2.8

980

14.2

4237

61.4

4.3

1

9.1

3

27.3

3.0

0

0.0

0

0.0

NA

85+ Unknown
Total

0

0.0

0

0.0

NA

0

0

NA

42,767

6.4

133,857

20.2

3.1

Medicine

Age

Discharges /

Discharges

1,000 Member

Months

Days

Days / 1,000 Members Months

Average Length of
Stay

<1 1-9 10-19

2426

5.1

10294

21.8

4.2

2631

0.8

6413

2.0

2.4

1256

0.6

3604

1.6

2.9

20-44 45-64 65-74

1745

2.4

5744

7.8

3.3

522

7.6

1924

27.9

3.7

1

9.1

3

27.3

3.0

75-84 85+ Unknown

0

0.0

0

0.0

NA

0

0.0

0

0.0

NA

0

0

NA

Total

8,581

1.3

27,982

4.2

3.3

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

738

1.6

10089

21.4

13.7

826

0.3

3494

1.1

4.2

759

0.3

3478

1.6

4.6

1416

1.9

5788

7.8

4.1

45-64

422

6.1

2202

31.9

5.2

10 of 27

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS Measure Results for WellCare Inpatient Utilization--General Hospital/Acute Care (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

4,161

0.6

25,051

3.8

Maternity*

Age

Discharges /

Discharges

1,000 Member

Months

Days

Days / 1,000 Members Months

10-19

5170

2.4

14100

6.4

20-44

24819

33.5

66613

90.0

45-64

36

0.5

111

1.6

Unknown

0

0

Total

30,025

10.0

80,824

27.0

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

NA NA NA NA 6.0
Average Length of
Stay
2.7 2.7 3.1 NA 2.7

11 of 27

August 2012

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

Identification of Alcohol and Other Drug Services: Total (IADA)
WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None)

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

Member Months (Any)

Male 2276221 554270
91882 31975 43266
40 0

Female 2225170 570998 322406 328549 196699
77 0

Total 4,501,391 1,125,268 414,288 360,524 239,965
117 0

Member Months (Inpatient)

Male 2276221 554270
91882 31975 43266
40 0

Female 2225170 570998 322406 328549 196699
77 0

Total 4,501,391 1,125,268 414,288 360,524 239,965
117 0

Member Months (Intensive

Outpatient/Partial Hospitalization)

Male

Female

Total

2276221 2225170 4,501,391

554270

570998 1,125,268

91882

322406

414,288

31975

328549

360,524

43266

196699

239,965

40

77

117

0

0

0

Member Months (Outpatient/ED)

Male 2276221 554270
91882 31975 43266
40 0

Female 2225170 570998 322406 328549 196699
77 0

Total 4,501,391 1,125,268 414,288 360,524 239,965
117 0

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

2,997,654
Sex
M F Total M F Total M F Total M F Total M F Total M F Total

3,643,899 6,641,553

Any Services

Number 71 64 135 801 447
1,248 243 842 1,085 291 1596 1,887 358 1034 1,392
0 0 0

Percent <0.1% <0.1% <0.1% 1.7% 0.9% 1.3% 3.2% 3.1% 3.1% 10.9% 5.8% 6.3% 9.9% 6.3% 7.0% 0.0% 0.0% 0.0%

2,997,654 3,643,899

Inpatient

Number 17 22 39 114 112 226 49 261 310 50 397 447 78 235 313 0 0 0

Percent <0.1% <0.1% <0.1% 0.2% 0.2% 0.2% 0.6% 1.0% 0.9% 1.9% 1.5% 1.5% 2.2% 1.4% 1.6% 0.0% 0.0% 0.0%

6,641,553 2,997,654

Intensive Outpatient/Partial
Hospitalization

Number

Percent

1

<0.1%

2

<0.1%

3

<0.1%

182

0.4%

67

0.1%

249

0.3%

37

0.5%

129

0.5%

166

0.5%

25

0.9%

270

1.0%

295

1.0%

34

0.9%

130

0.8%

164

0.8%

0

0.0%

0

0.0%

0

0.0%

3,643,899 6,641,553

Outpatient/ED

Number 55 42 97 695 345
1,040 204 629 833 253 1314 1,567 306 876 1,182
0 0 0

Percent <0.1% <0.1% <0.1% 1.5% 0.7% 1.1% 2.7% 2.3% 2.4% 9.5% 4.8% 5.2% 8.5% 5.3% 5.9% 0.0% 0.0% 0.0%

2,997,654

3,643,899

6,641,553

12 of 27

August 2012

Unknown Total

M F Total M F Total

0 0 0 1,764 3,983 5,747

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

NA

0

NA

0

NA

NA

0

NA

0

NA

NA

0

NA

0

NA

0.7%

308

0.1%

279

0.1%

1.3%

1,027

0.3%

598

0.2%

1.0%

1,335

0.2%

877

0.2%

0 0 0 1,513 3,206 4,719

NA NA NA 0.6% 1.1% 0.9%

13 of 27

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS 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)

Age

Member Months (Any)

Member Months (Inpatient)

Member Months (Intensive Outpatient/Partial Hospitalization)

Male

Female

Total

Male

Female

Total

Male

Female

Total

0-12

2276221 2225170 4,501,391 2276221 2225170 4,501,391 2276221 2225170 4,501,391

13-17

554270

570998 1,125,268 554270

570998 1,125,268 554270

570998 1,125,268

18-64

167123

847654 1,014,777 167123

847654 1,014,777 167123

847654 1,014,777

65+

40

77

117

40

77

117

40

77

117

Unknown

0

0

0

0

0

0

0

0

0

Total

2,997,654 3,643,899 6,641,553 2,997,654 3,643,899 6,641,553 2,997,654 3,643,899 6,641,553

Intensive

Age

Sex

Any Services

Inpatient

Outpatient/Partial Hospitalization

Outpatient/ED

Number

Percent

Number

Percent

Number

Percent

Number

Percent

M

15773

8.3%

186

0.1%

2667

1.4%

15346

8.1%

0-12

F

9313

5.0%

116

0.1%

1337

0.7%

9099

4.9%

Total

25,086

6.7%

302

0.1%

4,004

1.1%

24,445

6.5%

M

5895

12.8%

299

0.6%

1189

2.6%

5674

12.3%

13-17

F

5580

11.7%

452

0.9%

1056

2.2%

5397

11.3%

Total

11,475

12.2%

751

0.8%

2,245

2.4%

11,071

11.8%

M

1271

9.1%

130

0.9%

318

2.3%

1164

8.4%

18-64

F

7837

11.1%

538

0.8%

2224

3.1%

7260

10.3%

Total

9,108

10.8%

668

0.8%

2,542

3.0%

8,424

10.0%

M

0

0.0%

0

0.0%

0

0.0%

0

0.0%

65+

F

1

15.6%

0

0.0%

0

0.0%

1

15.6%

Total

1

10.3%

0

0.0%

0

0.0%

1

10.3%

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

22,939

9.2%

615

0.2%

4,174

1.7%

22,184

8.9%

Total

F

22,731

7.5%

1,106

0.4%

4,617

1.5%

21,757

7.2%

Total

45,670

8.3%

1,721

0.3%

8,791

1.6%

43,941

7.9%

Member Months (Outpatient/ED)

Male 2276221 554270 167123
40 0 2,997,654

Female 2225170 570998 847654
77 0 3,643,899

Total 4,501,391 1,125,268 1,014,777
117 0
6,641,553

14 of 27

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS 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

Male

Female

Total

0-9

1845004

1798662

3,643,666

10-17

985487

997506

1,982,993

18-34

123857

650955

774,812

35-49

36257

171332

207,589

50-64

7009

25367

32,376

65-74

39

71

110

75-84

1

4

5

85+

0

2

2

Unknown

0

0

0

Total

2,997,654 3,643,899

6,641,553

Antibiotic Utilization

Total Days Average

Total

Average Percentage

Total

Average Supplied for Days

Number of Scrips of Antibiotics

Age

Sex

Antibiotic Scrips PMPY

All

Supplied per Scrips for PMPY for of Concern of

Scrips for Antibiotics Antibiotic Antibiotic Antibiotics Anitbiotics all Antibiotic

Scrips

Scrip of Concern of Concern 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

242890 236862 479,752 62893 85944 148,837
9570 121210 130,780
4122 32206 36,328
852 4394 5,246
5 4 9 0 2 2 0 0 0 0 0 0 320,332 480,622 800,954

1.6

2254529

9.3

109635

0.7

1.6

2230293

9.4

99677

0.7

1.6

4,484,822

9.3

209,312

0.7

0.8

638907

10.2

27054

0.3

1.0

805161

9.4

34550

0.4

0.9

1,444,068

9.7

61,604

0.4

0.9

91664

9.6

3543

0.3

2.2

963493

7.9

39354

0.7

2.0

1,055,157

8.1

42,897

0.7

1.4

37709

9.1

1789

0.6

2.3

272094

8.4

13425

0.9

2.1

309,803

8.5

15,214

0.9

1.5

8472

9.9

360

0.6

2.1

37619

8.6

2167

1.0

1.9

46,091

8.8

2,527

0.9

1.5

38

7.6

4

1.2

0.7

38

9.5

2

0.3

1.0

76

8.4

6

0.7

0.0

0

NA

0

0.0

6.0

21

10.5

2

6.0

4.8

21

10.5

2

4.8

NA

0

NA

0

NA

0.0

0

NA

0

0.0

0.0

0

NA

0

0.0

NA

0

NA

0

NA

NA

0

NA

0

NA

NA

0

NA

0

NA

1.3

3,031,319

9.5

142,385

0.6

1.6

4,308,719

9.0

189,177

0.6

1.4

7,340,038

9.2

331,562

0.6

45.1% 42.1% 43.6% 43.0% 40.2% 41.4% 37.0% 32.5% 32.8% 43.4% 41.7% 41.9% 42.3% 49.3% 48.2% 80.0% 50.0% 66.7%
NA 100.0% 100.0%
NA NA NA NA NA NA 44.4% 39.4% 41.4%

15 of 27

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
16 of 27

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

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

Antibiotics of Concern Utilization

Total Quinolone
Scrips

Average Scrips PMPY
for Quinolones

Total Cephalosporin 2nd-
4th Generation
Scrips

Average Scrips PMPY for Cephalosporins 2nd-
4th Generation

Total Azithromyci
n and Clarithro-
mycin Scrips

Average Scrips PMPY for Azithromyci ns and Clarithromycins

Total Amoxicillin/ Clavulanate
Scrips

Average Scrips PMPY
for Amoxicillin/ Clavulanates

Total Ketolides
Scrips

Average Scrips PMPY for Ketolides

Total Clindamycin
Scrips

Average Total Misc.

Scrips PMPY Antibiotics of

for

Concern

Clindamycins Scrips

Average Scrips PMPY
for Misc. Antibiotics of
Concern

63 149 212 486 1476 1,962 550 9406 9,956 461 3998 4,459 120 714 834
2 1 3 0 1 1 0 0 0 0 0 0 1,682 15,745 17,427

<0.1 <0.1 <0.1 <0.1 <0.1 <0.1 0.1 0.2 0.2 0.2 0.3 0.3 0.2 0.3 0.3 0.6 0.2 0.3 0.0 3.0 2.4 NA 0.0 0.0 NA NA NA <0.1 0.1 <0.1

29110

0.2

27495

0.2

56,605

0.2

4138

0.1

5273

0.1

9,411

0.1

241

<0.1

2190

<0.1

2,431

<0.1

106

<0.1

789

0.1

895

0.1

21

<0.1

117

0.1

138

0.1

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

0

NA

0

0.0

0

0.0

0

NA

0

NA

0

NA

33,616

0.1

35,864

0.1

69,480

0.1

Total Absorbable Sulfonamide
Scrips

Average Scrips PMPY for Absorbable Sulfonamides

Total Aminoglycoside Scrips

Average Scrips PMPY for Aminoglycosides

11629

0.1

18250

0.1

29,879

0.1

4770

0.1

9339

0.1

14,109

0.1

1015

0.1

11333

0.2

12,348

0.2

24

<0.1

13

<0.1

37

<0.1

46

<0.1

56

<0.1

102

<0.1

1

<0.1

12

<0.1

13

<0.1

43084

0.3

34864

0.2

0

0.0

38230

0.3

31348

0.2

0

0.0

81,314

0.3

66,212

0.2

0

0.0

13304

0.2

7558

0.1

0

0.0

17329

0.2

8314

0.1

0

0.0

30,633

0.2

15,872

0.1

0

0.0

1628

0.2

661

0.1

0

0.0

17691

0.3

5742

0.1

0

0.0

19,319

0.3

6,403

0.1

0

0.0

705

0.2

290

0.1

0

0.0

5349

0.4

1971

0.1

0

0.0

6,054

0.3

2,261

0.1

0

0.0

119

0.2

60

0.1

0

0.0

829

0.4

334

0.2

0

0.0

948

0.4

394

0.1

0

0.0

0

0.0

2

0.6

0

0.0

1

0.2

0

0.0

0

0.0

1

0.1

2

0.2

0

0.0

0

0.0

0

0.0

0

0.0

0

0.0

1

3.0

0

0.0

0

0.0

1

2.4

0

0.0

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

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

0

NA

58,840

0.2

43,435

0.2

0

0.0

79,429

0.3

47,710

0.2

0

0.0

138,269

0.2

91,145

0.2

0

0.0

All Other Antibiotics Utilization

Total 1st Generation
Cephalosporin Scrips

Average Scrips PMPY for
1st Generation
Cephalosporins

Total Lincosamide
Scrips

Average Scrips PMPY
for Lincosamides

Total Macrolides (not azith. or
clarith.) Scrips

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

16000

0.1

0

0.0

364

<0.1

16390

0.1

0

0.0

325

<0.1

32,390

0.1

0

0.0

689

<0.1

6712

0.1

0

0.0

267

<0.1

7720

0.1

0

0.0

339

<0.1

14,432

0.1

0

0.0

606

<0.1

919

0.1

0

0.0

77

<0.1

8370

0.2

0

0.0

743

<0.1

9,289

0.1

0

0.0

820

<0.1

2485 2452 4,937 1556 2135 3,691 461 4299 4,760 224 1282 1,506
34 157 191
0 0 0 0 0 0 0 0 0 0 0 0 4,760 10,325 15,085
Total Penicillin
Scrips
104976 101346 206,322 18605 24044 42,649
2674 23334 26,008

<0.1

29

<0.1

<0.1

3

<0.1

<0.1

32

<0.1

<0.1

12

<0.1

<0.1

23

<0.1

<0.1

35

<0.1

<0.1

2

<0.1

0.1

26

<0.1

0.1

28

<0.1

0.1

3

<0.1

0.1

36

<0.1

0.1

39

<0.1

0.1

6

<0.1

0.1

16

<0.1

0.1

22

<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

NA

0

NA

0.0

0

0.0

0.0

0

0.0

NA

0

NA

NA

0

NA

NA

0

NA

<0.1

52

<0.1

<0.1

104

<0.1

<0.1

156

<0.1

Average Scrips PMPY for Penicillins

Total Tetracycline
Scrips

Average Scrips PMPY
for Tetracyclines

0.7

48

<0.1

0.7

33

<0.1

0.7

81

<0.1

0.2

5104

0.1

0.3

5115

0.1

0.3

10,219

0.1

0.3

1127

0.1

0.4

8535

0.2

0.4

9,662

0.1

Total Misc. Antibiotic
Scrips
214 828 1,042 335 4781 5,116 214 29529 29,743

Average Scrips PMPY for Misc. Antibiotics
<0.1 <0.1 <0.1 <0.1 0.1 <0.1 <0.1 0.5 0.5

August 2012

35-49 50-64 65-74 75-84 85+ Unknown Total

M

474

0.2

F

3271

0.2

Total

3,745

0.2

M

107

0.2

F

457

0.2

Total

564

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

NA

F

0

0.0

Total

0

0.0

M

0

NA

F

0

NA

Total

0

NA

M

17,995

0.1

F

42,650

0.1

Total

60,645

0.1

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

0

0.0

355

0.1

0

10

<0.1

2125

0.1

0

10

<0.1

2,480

0.1

0

0

0.0

80

0.1

0

1

<0.1

412

0.2

0

1

<0.1

492

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

NA

0

NA

0

0

0.0

0

0.0

0

0

0.0

0

0.0

0

0

NA

0

NA

0

0

NA

0

NA

0

0

NA

0

NA

0

71

<0.1

24,066

0.1

0

92

<0.1

35,017

0.1

0

163

<0.1

59,083

0.1

0

0.0

42

<0.1

974

0.3

342

0.1

146

<0.1

0.0

221

<0.1

6057

0.4

2385

0.2

4712

0.3

0.0

263

<0.1

7,031

0.4

2,727

0.2

4,858

0.3

0.0

11

<0.1

199

0.3

61

0.1

34

0.1

0.0

40

<0.1

715

0.3

276

0.1

326

0.2

0.0

51

<0.1

914

0.3

337

0.1

360

0.1

0.0

0

0.0

1

0.3

0

0.0

0

0.0

0.0

0

0.0

0

0.0

1

0.2

1

0.2

0.0

0

0.0

1

0.1

1

0.1

1

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

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

0

0.0

0

0.0

NA

0

NA

0

NA

0

NA

0

NA

NA

0

NA

0

NA

0

NA

0

NA

NA

0

NA

0

NA

0

NA

0

NA

0.0

761

<0.1

127,429

0.5

6,682

<0.1

943

<0.1

0.0

1,668

<0.1

155,496

0.5

16,345

0.1

40,177

0.1

0.0

2,429

<0.1

282,925

0.5

23,027

<0.1

41,120

0.1

17 of 27

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS 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 Diversity of Membership

Total Unduplicated Membership During the Measurement Year

781119

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

Direct Data Collection Method

Indirect Data Collection Method

Race

Direct Total Health Plan
Direct* CMS/State Database*

99.9% 0.0000000000 0.9992523546

Indirect 0.000000000

Total*

0

Other*

0.0000000000

Ethnicity

Direct Total Health Plan
Direct* CMS/State Database*

99.9% 0.0000000000 0.9992523546

Indirect 0.000000000

Total*

0

Other*

0.0000000000

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

*Enter percentage as a value between 0 and 1.

Hispanic or Latino

Not Hispanic or Latino

Number

Percentage

Number Percentage

NR

NR

1745

2.9%

NR

NR

34275

56.6%

NR

NR

601

1.0%

NR

NR

15028

24.8%

NR NR NR 16782 NR 16,782

NR NR NR 100.0% NR 100.0%

NR 8902 NR NR NR 60,551

NR 14.7%
NR NR NR 100.0%

Unknown

Total*

0.000747645 4

Total*

0.000747645 4

Unknown Ethnicity

Number Percentage

369965

52.6%

306981

43.6%

NR

NR

NR

NR

NR NR 8 26832 NR 703,786

NR NR <0.1% 3.8% NR 100.0%

Declined Ethnicity

Number Percentage

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

Total

Number Percentage

371,710

47.6%

341,256

43.7%

601

0.1%

15,028

1.9%

NR 8,902
8 43,614
NR 781,119

NR 1.1% <0.1% 5.6% NR 100.0%

18 of 27

August 2012

Department of Community Health, State of Georgia Audited CY 2011 HEDIS 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

CMS/State Databases

Other ThirdParty Source

Spoken Language Preferred for Health Care*

0.0000

1.0000

0.0000

Preferred Language for Written Materials*

0.0000

1.0000

0.0000

Other Language Needs*

0.0000

1.0000

*Enter percentage as a value between 0 and 1.

Spoken Language Preferred for Health Care

0.0000

Number Percentage

English

720547

92.2%

Non-English

60567

7.8%

Unknown

5

<0.1%

Declined

0

0.0%

Total*

781,119

100.0%

Language Preferred for Written Materials

Number

English

0

Non-English

0

Unknown

781119

Declined

0

Total*

781,119

Other Language Needs

Percentage 0.0% 0.0%
100.0% 0.0%
100.0%

Number

English

0

Non-English

0

Unknown

781119

Declined

0

Total*

781,119

*Should sum to 100%

Percentage 0.0% 0.0%
100.0% 0.0%
100.0%

19 of 27

August 2012

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

Weeks of Pregnancy at Time of Enrollment in MCO

(WOP)

WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None)

Measurement Year

Measurement Year

2011

Weeks of Pregnancy

Number Percentage

< 0 weeks

3123

10.5%

1-12 weeks 13-27 weeks

2929 17770

9.8% 59.5%

28 or more weeks

5060

17.0%

Unknown

965

3.2%

Total

29,847

100.0%

20 of 27

August 2012

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

Relative Resource Use for People With

Diabetes (RDI)

WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None)

Data Element
Inpatient Facility PMPM E&M Inpatient Services PMPM

Measure Data 235.7 12.3

E&M Outpatient Services PMPM

81.4

Surgery & Procedure Inpatient Services PMPM

10.9

Surgery & Procedure Outpatient Services PMPM
Imaging Services PMPM Laboratory Services PMPM
Pharmacy PMPM Inpatient Facility: Acute Inpatient: Medical Days
per 1000 MM Inpatient Facility: Acute Inpatient: Medical
Discharges per 1000 MM Inpatient Facility: Acute Inpatient: Surgery Days
per 1000 MM Inpatient Facility: Acute Inpatient: Surgery
Discharges per 1000 MM
Inpatient Facility: Nonacute Days per 1000 MM
Inpatient Facility: Nonacute Discharges per 1000 MM
Inpatient Facility Acute Medical ALOS Inpatient Facility Acute Surgery ALOS
Inpatient Facility Nonacute ALOS Total Inpatient Facility Acute ALOS
Total Inpatient Facility ALOS ED Discharges per 1000 MM Medical
Cardiac Cathereterization per 1000 MM Medical
PCI per 1000 MM Medical CABG per 1000 MM Medical
Carotid Endarterectomy per 1000 MM Medical
Carotid Artery Stenosis Diagnostic Test per 1000 MM Medical
Cardiac Computed Tomography per 1000 MM Medical
CAD Diagnostic Test Using EBCT/Nuclear Imaging Stress Tests per 1000 MM Medical
Eligible Population Exclusions
Eligible Population per 1,000 Member Months Medical
Eligible Population per 1,000 Member Months Pharmacy
NameBrandOnlyCount(N1)

70.4 74.7 63.8 194.6 75.7
22.3
20.3
4.7
0.0
0.0 3.4 4.4 NR 3.6 3.6 213.9 3.9 1.4 0.3 0.1
0.1
0.1
6.7 2319
52 84.4
84.4 13278

21 of 27

August 2012

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

NameBrandGenericExistsCount(N2) GenericOnlyCount (G1)
GenericNameBrandExistsCount (G2) Total Prescriptions (N1+N2+G1+G2)

5370 12627 100357 131,632.0

Generic Utilization Rate [(G1 + G2)/(N2+G1+G2)]

1.0

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

0.9

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

0.9

22 of 27

August 2012

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

Relative Resource Use for People With

Asthma (RAS)

WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None)

Data Element Inpatient Facility PMPM

Measure Data 24.0

E&M Inpatient Services PMPM

1.7

E&M Outpatient Services PMPM

52.9

Surgery & Procedure Inpatient Services PMPM

0.9

Surgery & Procedure Outpatient Services PMPM 14.5

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

11.7 8.2 133.0 9.2
3.2
0.9
0.3

Inpatient Facility: Nonacute Days per 1000 MM

0.0

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

0.0
2.9 2.8 NR 2.9 2.9 81.9 6107 873
84.2
84.2
42671 26670 15790 81376 166507.0

Generic Utilization Rate [(G1 + G2)/(N2+G1+G2)] 0.8

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

0.8

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

0.6

23 of 27

August 2012

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

Relative Resource Use for People With

Cardiovascular Conditions (RCA)

WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None)

Data Element Inpatient Facility PMPM

Measure Data 501.8

E&M Inpatient Services PMPM

28.0

E&M Outpatient Services PMPM

106.3

Surgery & Procedure Inpatient Services PMPM 45.4

Surgery & Procedure Outpatient Services PMPM
Imaging Services PMPM Laboratory Services PMPM
Pharmacy PMPM Inpatient Facility: Acute Inpatient: Medical Days
per 1000 MM Inpatient Facility: Acute Inpatient: Medical
Discharges per 1000 MM Inpatient Facility: Acute Inpatient: Surgery Days
per 1000 MM Inpatient Facility: Acute Inpatient: Surgery
Discharges per 1000 MM
Inpatient Facility: Nonacute Days per 1000 MM
Inpatient Facility: Nonacute Discharges per 1000 MM
Inpatient Facility Acute Medical ALOS Inpatient Facility Acute Surgery ALOS
Inpatient Facility Nonacute ALOS Total Inpatient Facility Acute ALOS
Total Inpatient Facility ALOS ED Discharges per 1000 MM Medical
Cardiac Cathereterization per 1000 MM Medical
PCI per 1000 MM Medical CABG per 1000 MM Medical
Carotid Endarterectomy per 1000 MM Medical
Carotid Artery Stenosis Diagnostic Test per 1000 MM Medical
Cardiac Computed Tomography per 1000 MM Medical
CAD Diagnostic Test Using EBCT/Nuclear Imaging Stress Tests per 1000 MM Medical
Eligible Population Exclusions
Eligible Population per 1,000 Member Months Medical
Eligible Population per 1,000 Member Months Pharmacy
NameBrandOnlyCount(N1)

97.7 122.8 101.5 286.9 95.1
34.4
63.0
14.3
0.0
0.0 2.8 4.4 NR 3.2 3.2 276.2 35.5 29.2 6.3 0.0
0.0
0.6
32.7 147
1 84.2
84.2 1822

24 of 27

August 2012

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

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

525 1223 10908 14478.0
1.0
1.0
0.8

25 of 27

August 2012

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

Relative Resource Use for People With

Hypertension (RHY)

WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None)

Data Element

Measure Data

Inpatient Facility PMPM

188.7

E&M Inpatient Services PMPM

10.0

E&M Outpatient Services PMPM

83.6

Surgery & Procedure Inpatient Services PMPM 13.0

Surgery & Procedure Outpatient Services PMPM 71.2

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

75.3 52.4 141.5 51.9
14.3
18.8
4.5

Inpatient Facility: Nonacute Days per 1000 MM

0.0

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

0.0
3.6 4.1 NR 3.7 3.7 211.0 4601 99
84.3
84.3
15768 8661 29829 197814 252072.0

Generic Utilization Rate [(G1 + G2)/(N2+G1+G2)] 1.0

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

1.0

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

0.9

26 of 27

August 2012

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

Relative Resource Use for People With

COPD (RCO)

WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None)

Data Element
Inpatient Facility PMPM E&M Inpatient Services PMPM

Measure Data 378.3 18.9

E&M Outpatient Services PMPM Surgery & Procedure Inpatient Services
PMPM Surgery & Procedure Outpatient Services
PMPM Imaging Services PMPM Laboratory Services PMPM

102.5 31.4
91.4 113.9 70.3

Pharmacy PMPM Inpatient Facility: Acute Inpatient: Medical
Days per 1000 MM Inpatient Facility: Acute Inpatient: Medical
Discharges per 1000 MM Inpatient Facility: Acute Inpatient: Surgery
Days per 1000 MM Inpatient Facility: Acute Inpatient: Surgery
Discharges per 1000 MM

209.3 92.0 23.4 45.0 9.2

Inpatient Facility: Nonacute Days per 1000 MM 0.0

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

0.0
3.9 4.9 NR 4.2 4.2 216.2 475 23
84.2
84.2
3851 1921 3915 28407 38094.0
0.9
0.9
0.8

27 of 27

August 2012