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 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page i WellCare_GA2011-12_CMO_PMV_F6_0812 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 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 1 WellCare_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES Performance Measures Validated HSAG validated performance measures identified and selected by DCH for validation. Two performance measures were selected from the Agency for Healthcare Research and Quality (AHRQ) Quality Indicator set, and five performance measures were selected from the Children's Health Insurance Program Reauthorization Act (CHIPRA) Initial Core Set of Children's Health Care Quality Measures. The measurement period was identified by DCH as calendar year (CY) 2011 for all measures except the two CHIPRA dental measures. They were reported for federal fiscal year (FFY) 2011 per CMS requirements. Table 2 lists the performance measures 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). WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 2 WellCare_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES Description of Validation Activities Pre-Audit Strategy HSAG conducted the validation activities as outlined in the CMS performance measure validation protocol. To complete the validation activities for 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 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 3 WellCare_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES Technical Methods of Data Collection and Analysis The CMS performance measure validation protocol identifies key types of data that should be reviewed as part of the validation process. The following list describes the type of data collected and how HSAG conducted an analysis of these data: NCQA's HEDIS 2012 Roadmap: 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 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 4 WellCare_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES from the documentation review, expand or clarify outstanding issues, and ascertain that written policies and procedures were used and followed in daily practice. Overview of data integration and control procedures: The overview included discussion and observation of source code logic, a review of how all data sources were combined, and a review of how the analytic file was produced for the reporting of selected performance measure rates. HSAG performed primary source verification to further validate the output files and reviewed backup documentation on data integration. HSAG also addressed data control and security procedures during this session. Closing conference: The closing conference included a summation of preliminary findings based on the review of the Roadmap and the on-site visit, and revisited the documentation requirements for any post-visit activities. HSAG conducted several interviews with key 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) WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 5 WellCare_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES 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 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 6 WellCare_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES Data Integration, Data Control, and Performance Measure Documentation There are several aspects crucial to the calculation of performance measure rates. These include data integration, data control, and documentation of performance measure calculations. Each of the following sections describes the validation processes used and the validation findings. For more detailed information, see Appendix A of this report. Data Integration Accurate data integration is essential for calculating valid performance measure rates. The steps used to combine various data sources (including claims/encounter data, eligibility data, and other administrative data) must be carefully controlled and validated. HSAG validated the data integration process used by 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 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 7 WellCare_GA2011-12_CMO_PMV_F6_0812 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 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. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 8 WellCare_GA2011-12_CMO_PMV_F6_0812 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. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 9 WellCare_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES Performance Measure Specific Findings Based on all validation activities, the HSAG Performance Measure Validation Team determined validation results for each performance measure rate. Table 5 displays the key review results. For detailed information, see Appendix B of this report. Table 5--Key Review Results for 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 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 10 WellCare_GA2011-12_CMO_PMV_F6_0812 VALIDATION OF PERFORMANCE MEASURES Validation Findings HSAG provided an audit designation for each performance measure as defined in Table 6: Report (R) Not Report (NR) Table 6--Validation Findings Definitions The organization followed the specifications and produced a reportable rate or result for the measure. The calculated rate was materially biased, or the organization chose not to report the measure, or the organization was not required to report the measure. According to the CMS protocol, the validation finding for each measure is determined by the magnitude of the errors detected for the audit elements, not by the number of audit elements determined to be "Not Reportable." Consequently, it is possible that an error for a single audit element may result in a designation of "NR" because the impact of the error biased the reported performance measure rate by more than 5 percentage points. Conversely, it is also possible that several audit element errors may have little impact on the reported rate, resulting in a measure designation of "R." Table 7 shows the final validation findings for 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 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 11 WellCare_GA2011-12_CMO_PMV_F6_0812 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_GA2011-12_CMO_PMV_F6_0812 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). WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page A-1 WellCare_GA2011-12_CMO_PMV_F6_0812 DATA INTEGRATION AND CONTROL FINDINGS Data Integration and Control Element Not Met Met N/A Assurance of effective management of report production and of the reporting software. Documentation governing the production process, including CMO production activity logs and the CMO staff review of report runs, is adequate. Prescribed data cutoff dates are followed. Comments The CMO retains copies of files or databases used for performance measure reporting in case results need to be reproduced. The reporting software program is properly documented with respect to every aspect of the performance measure data repository, including building, maintaining, managing, testing, and report production. The CMO's processes and documentation comply with the CMO standards associated with reporting program specifications, code review, and testing. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page A-2 WellCare_GA2011-12_CMO_PMV_F6_0812 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_GA2011-12_CMO_PMV_F6_0812 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. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page B-1 WellCare_GA2011-12_CMO_PMV_F6_0812 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. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page B-2 WellCare_GA2011-12_CMO_PMV_F6_0812 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_GA2011-12_CMO_PMV_F6_0812 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% WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page C-1 WellCare_GA2011-12_CMO_PMV_F6_0812 PERFORMANCE MEASURE RESULTS Indicator 4--Otitis Media with Effusion (OME)--Avoidance of Inappropriate Use of Systemic Antimicrobials Table C-4--Indicator 4 for 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% WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page C-2 WellCare_GA2011-12_CMO_PMV_F6_0812 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. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-i WellCare_GA2011-12_CMO_PMV_F6_0812 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