Georgia Department of Community Health Validation of Performance Measures for WellCare of Georgia, Inc. Measurement Period: Calendar Year 2012 Validation Period: State Fiscal Year 2013 Publish Date: September 20, 2013 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 ....................................................................................................... 4 Pre-Audit Strategy ............................................................................................................................. 4 Validation Team................................................................................................................................. 4 Technical Methods of Data Collection and Analysis.......................................................................... 5 On-Site Activities ............................................................................................................................... 5 Data Integration, Data Control, and Performance Measure Documentation ....................................... 8 Data Integration ................................................................................................................................. 8 Data Control ...................................................................................................................................... 8 Performance Measure Documentation.............................................................................................. 8 Validation Results ................................................................................................................................ 9 Medical Service Data (Claims/Encounters) ....................................................................................... 9 Enrollment Data............................................................................................................................... 10 Provider Data................................................................................................................................... 10 Medical Record Review Process ..................................................................................................... 10 Supplemental Data .......................................................................................................................... 11 Data Integration ............................................................................................................................... 11 Performance Measure Specific Findings......................................................................................... 11 Validation Findings ............................................................................................................................ 12 Appendix A. Data Integration and Control Findings ....................................................................... A-1 Appendix B. Denominator and Numerator Validation Findings..................................................... B-1 Appendix C. Performance Measure Results .................................................................................... C-1 Appendix D. Final Audited HEDIS Rates .......................................................................................... D-1 Appendix E. Performance Measure Validation Reporting Spreadsheet.........................................E-1 Appendix F. HEDIS Interactive Data Submission System Data ...................................................... F-1 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page i WellCare_GA2012-13_CMO_PMV_F1_0913 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. The 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). The 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, EQR Protocol 2: Validation of Performance Measures Reported by the MCO: A Mandatory Protocol for External Quality Review (EQR), Version 2.0, September 2012. 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 Audit Location: CMO Contact: WellCare of Georgia, Inc. 211 Perimeter Center Parkway, Suite 800 Atlanta, GA 30346 8735 Henderson Rd. Tampa, FL 33634 Jacqueline Collins, RN, CPHQ, Director, Quality Improvement Contact Telephone Number: 770.913.2175 Contact E-mail Address: Jacqueline.collins@wellcare.com Site Visit Date: April 1516, 2013 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 1 WellCare_GA2012-13_CMO_PMV_F1_0913 VALIDATION OF PERFORMANCE MEASURES Performance Measures Validated HSAG validated performance measures identified and selected by DCH for validation. All performance measures were selected from the Centers for Medicare & Medicaid Services' (CMS) Initial Core Set of Children's Health Care Quality Measures,1 the Initial Core Set of Health Care Quality Measures for Adults Enrolled in Medicaid,2 or the Agency for Healthcare Research and Quality (AHRQ). The measurement period was identified by DCH as calendar year (CY) 2012 for all measures except the two child core set dental measures. The dental measures were reported for federal fiscal year (FFY) 2012, which covered the time frame of October 1, 2011, through September 30, 2012, per CMS requirements. Table 2 lists the performance measures that HSAG validated and identifies who calculated the performance measure rates. Table 2--List of CY 2012 Performance Measures for WellCare Performance Measure 1. Annual Pediatric Hemoglobin (HbA1c) Testing (ages 517) Annual Percentage of Asthma Patients with One 2. or More Asthma-Related Emergency Room Visit (ages 220) 3. Cesarean Delivery Rate 4. Cesarean Rate for Nulliparous Singleton Vertex 5. Percentage of Eligibles that Received Dental Treatment Services 6. Percentage of Eligibles that Received Preventive Dental Services 7. Percentage of Live Births Weighing Less Than 2,500 Grams 8. Adult Asthma Admission Rate 9. Chronic Obstructive Pulmonary Disease (COPD) Admission Rate 10. Congestive Heart Failure Admission Rate 11. Diabetes, Short-Term Complications Admission Rate Method Hybrid3 Admin Admin Admin Admin Admin Admin Admin Admin Admin Admin Specifications CMS Child Core Set CMS Child Core Set AHRQ CMS Child Core Set4 CMS Child Core Set CMS Child Core Set CMS Child Core Set/AHRQ CMS Adult Core Set CMS Adult Core Set CMS Adult Core Set CMS Adult Core Set Rate Calculation by: WellCare WellCare WellCare WellCare WellCare WellCare WellCare WellCare WellCare WellCare WellCare 1 The Centers for Medicare & Medicaid Services. Initial Core Set of Children's Health Care Quality Measures, November 2012. 2 The Centers for Medicare & Medicaid Services. Initial Core Set of Health Care Quality Measures for Adults Enrolled in Medicaid, February 2013. 3 Hybrid measures require both administrative data and medical record review. 4 The CMS measure specifications were modified by HSAG. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 2 WellCare_GA2012-13_CMO_PMV_F1_0913 VALIDATION OF PERFORMANCE MEASURES In addition to the AHRQ and the CMS adult and child core set measures audited by HSAG, DCH required WellCare to report a selected set of Healthcare Effectiveness Data and Information Set (HEDIS) measures to DCH. WellCare was required to contract with an NCQA-licensed audit organization and undergo an NCQA HEDIS Compliance AuditTM. Final audited HEDIS measure results from NCQA's Interactive Data Submission System (IDSS) were submitted to HSAG and provided to DCH. Appendices D and E display the final audited HEDIS 2013 results for all required measures, covering the 2012 measurement period. 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. 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 3 WellCare_GA2012-13_CMO_PMV_F1_0913 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 2013 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. Table 3 lists the validation team members, their positions, and their skills and expertise. Table 3--Validation Team Name and Role Skills and Expertise Allen Iovannisci, MS, CHCA Lead Auditor Certified HEDIS auditor; performance measure knowledge, data integration, systems review, and analysis. Judy Yip, PhD Source Code Review Manager and Audit Specialist, Audits Auditing experience, HEDIS knowledge, performance measure knowledge, and source code review management. Tammy GianFrancisco Project Leader, Audits Performance measure validation coordination, communication, and scheduling. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 4 WellCare_GA2012-13_CMO_PMV_F1_0913 VALIDATION OF PERFORMANCE MEASURES Technical Methods of Data Collection and Analysis The CMS performance measures 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 2013 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 assessment of information systems. Source code (programming language) for performance measures: WellCare contracted with Inovalon, an NCQA-Certified software vendor, to calculate rates for both HEDIS and nonHEDIS measures. The source code review was conducted via a Web-assisted session where Inovalon explained the process and source code to HSAG's source code review team. Supporting documentation: HSAG requested 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 areas needing clarification for further follow-up. On-Site Activities HSAG conducted an on-site visit with WellCare on April 15 and 16, 2013. 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, focusing on the processing of claims and encounter data, provider 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 from the documentation review, expand or clarify outstanding issues, and ascertain that written policies and procedures were used and followed in daily practice. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 5 WellCare_GA2012-13_CMO_PMV_F1_0913 VALIDATION OF PERFORMANCE MEASURES 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 Thomas Clegg Danny Sharpe Gary Chu Tara Katt Chuck Beeman Bob Klopotek KimThao Nguyen Cesar Collazo Patricia Doyle Megan Jagger Candice Duffey Lee Falk Sean Fletcher Susan Swiontek Aaron Hahn Sunmi Janicek Lee Genco Brian Pogue Charlene Rohde Thomas Everett Sandy Hudson Claudius Conner Lissette Salemi Table 4--List of WellCare of Georgia, Inc. Interviewees Name Title Vice President, Quality and Performance Improvement Project Analyst Director, Quality Data Integrity Manager, Application Development Quality Improvement Project Manager, Sr. Sr. Director, Information Technology Vice President, Information Systems Director, Corporate Compliance Oversight Manager, Front End Director, Provider Service and Vendor Management Sr. Manager, National Vendor Management Manager, Claims Reporting Rules EDI Team Lead Sr. Manager Encounter Operations Manager, Delegation and Oversight Manager, Actuary (Level III) Director, Health Services Delegation and Oversight Sr. Director, Pharmacy Benefit Relations Director, Claims Sr. Manager, Claims Sr. Director, Configurations Director, Claims Audit Director, Enrollment Operations Manager, Enrollment WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 6 WellCare_GA2012-13_CMO_PMV_F1_0913 VALIDATION OF PERFORMANCE MEASURES Andrew Duffen Amy Russo Patricia Strickland Alicia Martin Terri Pokraka Michelle Saulsberry Jackie Collins Tiffany King Beatrice Clebert Brian Donnelly Table 4--List of WellCare of Georgia, Inc. Interviewees Name Title Director Corporate Network Integrity Sr. Director, Provider Resolution Sr. Manager, Configuration Sr. Manager, Configurations Director, Field Quality Improvement--IL Sr. Manager, Network Management Director, Field Quality Improvement--GA Claims Audit Specialist, Lead Hospital Contracting Manager Supervisor, Enterprise Intake Ops WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 7 WellCare_GA2012-13_CMO_PMV_F1_0913 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 8 WellCare_GA2012-13_CMO_PMV_F1_0913 VALIDATION OF PERFORMANCE MEASURES Validation Results The validation team evaluated WellCare's data systems for processing of each type of data used for reporting DCH performance measure rates. General findings are indicated below: Medical Service Data (Claims/Encounters) WellCare was fully compliant with the capture and processing of medical service data. WellCare did not experience any system changes during the measurement year, and only employed industrystandard codes (e.g., ICD-9-CM, CPT, DRG, and HCPCS). System edits ensured that all characters were captured and primary and secondary codes were identified. Nonstandard coding schemes were not employed during the measurement year. The medical claims/encounter system was consistent with industry standards and compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards to date. Claim submissions were accepted in both paper and electronic format. Paper claims were routed to clearinghouses for scanning and transmitted to WellCare in standard 837 compliant format. This process ensured that 100 percent of all claims were processed electronically. WellCare's policies and procedures included sufficient edit checks and monitoring of all transaction files. All electronic files were logged and monitored by the EDI Operations team. Approximately 99 percent of all clean claims were processed within nine days. WellCare reimbursed all claims on a fee-for-service (FFS) basis, and therefore, data completeness issues were minimized. WellCare also had a provider incentive payment available for the completion of HEDIS services and submission of the claims for the services. This further ensured data completeness for the measures. Complete and accurate claims were required to be submitted no later than the first week of January for the prior year to receive an incentive payment. Physicians were provided a list of noncompliant members and the needed services, so they could proactively contact, schedule, and provide the services prior to the end of the year. The pharmacy vendor, Catalyst Rx, was acquired by SXC Health Solutions in July 2012. The new combined organization is known as Catamaran. The acquisition did not result in any system changes for WellCare. Catamaran kept the adjudication platform, and the process remained the same. Catamaran processed all pharmacy claims electronically and provided the invoices to WellCare. The pharmacy claims data were validated weekly with the receipt of every invoice. There were no discrepancies identified in the measurement year, and WellCare had good oversight of the vendor to ensure all submissions were complete and accurate. The vendor for dental services was DentaQuest. The vendor conducted numerous claim checks on the entry and migration of claims data throughout the system. In addition, audits of claims entry occur on a routine basis, ensuring accurate data for WellCare. Batch counts and total claims entered were matched to control totals to ensure WellCare received 100 percent of all dental claims. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 9 WellCare_GA2012-13_CMO_PMV_F1_0913 VALIDATION OF PERFORMANCE MEASURES WellCare's staff also incorporated a new process during the measurement year to track encounter submissions from vendors on a monthly basis. This process was an additional edit check to ensure data completeness. There were no concerns with WellCare's medical service data. Enrollment Data There were no concerns with the processing of enrollment files received from DCH. Monthly files were received and loaded into WellCare's enrollment system. WellCare's system contained sufficient data elements to capture multiple enrollment spans and identification numbers as well as a file to capture the unique member identifier. WellCare's policies and procedures provided sufficient edit checks to ensure enrollment files were accurately loaded and free of errors. The enrollment files were reconciled monthly against the capitation file as an additional validation to ensure all eligible members were being captured for service and payment. WellCare did not have any issues with membership data during 2012. There were no backlogs of applications since DCH provided the eligibility files. There were minimal retroactive enrollments during the year. PeachCare for Kids enrollment data were submitted in standard 834 format, and updates were validated against internal applications. Provider Data WellCare used Cactus for the provider credentialing system and Xcelys to store the practitioner specialty data for claims payments. Monthly audits were conducted for accuracy of the provider information entered into the Cactus database. WellCare's provider data system, Xcelys, contained appropriate mappings for all provider specialties. WellCare's policies, procedures, log forms, and training manuals for data submission ensured accuracy and completeness and verified that the organization has mechanisms for transferring information to the appropriate location within Xcelys. There were appropriate procedures in place for processing provider additions, deletions, and changes. All relevant fields were captured and mapped to ensure measure-appropriate measure reporting. The organization effectively monitored the quality and accuracy of its electronic submissions daily. Transmissions of provider data were properly controlled by logs, verification of record counts, and edit checking. There were no concerns with WellCare's processing of provider data. Medical Record Review Process WellCare was fully compliant with the medical record review reporting requirements. WellCare used Outcomes Health Information Systems, Inc., a medical record vendor, to procure medical records and abstract medical record data. HSAG reviewed the hybrid tools and corresponding instructions of this vendor's system. Reviewer qualifications, training, and oversight were appropriate. WellCare's oversight of the medical record vendor was appropriate. Due to reporting a new State-required hybrid measure, a convenience sample was required and subsequently passed review. WellCare passed the medical record review validation process for the Annual Pediatric Hemoglobin (HbA1c) Testing (ages 517) measure. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 10 WellCare_GA2012-13_CMO_PMV_F1_0913 VALIDATION OF PERFORMANCE MEASURES Supplemental Data WellCare did not use any supplemental data sources for reporting the selected performance measures under review; therefore, this standard is not applicable. Data Integration WellCare contracted with Inovalon, an NCQA-Certified software vendor, for calculating the 2013 performance measure rates. WellCare had a thorough and detailed process in place to ensure no data were lost during the data integration process. A uniform format was created for each data type to avoid data integration issues during the compilation process. WellCare consolidated data from several different data sources and platforms, and provided sufficient documentation ensuring that appropriate fields were mapped to Inovalon's specifications for the data file submissions. In addition, Inovalon maintained sufficient processes to integrate these data sources for reporting. Communication between WellCare and Inovalon allowed the teams to work out any issues prior to final submission and calculation of the rates. The audit team conducted primary source verification on every measure to ensure the Inovalon source code was accurately calculating the information relevant to the measures under review. All primary source data were found to be compliant. In addition, Inovalon's source code was reviewed by HSAG's source code review team and found to be compliant with the measure specifications. There were no concerns with WellCare's data integration process. 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 of Georgia, Inc. Performance Measures Key Review Findings 1. Annual Pediatric Hemoglobin (HbA1c) Testing (ages 517) No concerns were identified. 2. Annual Percentage of Asthma Patients with One or More AsthmaRelated Emergency Room Visit (ages 220) No concerns were identified. 3. Cesarean Delivery Rate No concerns were identified. 4. Cesarean Rate for Nulliparous Singleton Vertex No concerns were identified. 5. Percentage of Eligibles that Received Dental Treatment Services No concerns were identified. 6. Percentage of Eligibles that Received Preventive Dental Services No concerns were identified. 7. Percentage of Live Births Weighing Less Than 2,500 Grams No concerns were identified. 8. Adult Asthma Admission Rate No concerns were identified. 9. Chronic Obstructive Pulmonary Disease (COPD) Admission Rate No concerns were identified. 10. Congestive Heart Failure Admission Rate No concerns were identified. 11. Diabetes, Short-Term Complications Admission Rate No concerns were identified. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 11 WellCare_GA2012-13_CMO_PMV_F1_0913 VALIDATION OF PERFORMANCE MEASURES Validation Findings HSAG provided an audit designation for each performance measure as defined in Table 6: Report (R) Table 6--Validation Findings Definitions The organization followed the specifications and produced a reportable rate or result for the measure. Not Reportable (NR) 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--Key Review Results for WellCare of Georgia, Inc. Performance Measures Validation Finding 1. Annual Pediatric Hemoglobin (HbA1c) Testing (ages 517) R 2. Annual Percentage of Asthma Patients with One or More AsthmaRelated Emergency Room Visit (ages 220) R 3. Cesarean Delivery Rate R 4. Cesarean Rate for Nulliparous Singleton Vertex R 5. Percentage of Eligibles that Received Dental Treatment Services R 6. Percentage of Eligibles that Received Preventive Dental Services R 7. Percentage of Live Births Weighing Less Than 2,500 Grams R 8. Adult Asthma Admission Rate R 9. Chronic Obstructive Pulmonary Disease (COPD) Admission Rate R 10. Congestive Heart Failure Admission Rate R 11. Diabetes, Short-Term Complications Admission Rate R WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page 12 WellCare_GA2012-13_CMO_PMV_F1_0913 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 1516, 2013 Allen Iovannisci, MS, CHCA Table A-1--Data Integration and Control Findings for WellCare of Georgia, Inc. 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_GA2012-13_CMO_PMV_F1_0913 DATA INTEGRATION AND CONTROL FINDINGS Table A-1--Data Integration and Control Findings for WellCare of Georgia, Inc. Data Integration and Control Element Not Met Met N/A Comments 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. 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_GA2012-13_CMO_PMV_F1_0913 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 1516, 2013 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. 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). 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_GA2012-13_CMO_PMV_F1_0913 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. WellCare did not use any nonstandard codes. 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 of Georgia, Inc. Validation of Performance Measures State of Georgia Page B-2 WellCare_GA2012-13_CMO_PMV_F1_0913 Appendix C. Performance Measure Results for WellCare of Georgia, Inc. Performance Measure 1--Annual Pediatric Hemoglobin (HbA1c) Testing (ages 517) Table C-1--Performance Measure 1 for WellCare of Georgia, Inc. Annual Pediatric Hemoglobin (HbA1c) Testing (ages 517) Rate 82.97% Performance Measure 2--Annual Percentage of Asthma Patients with One or More Asthma-Related Emergency Room Visit (ages 220) Table C-2--Performance Measure 2 for WellCare of Georgia, Inc. Annual Percentage of Asthma Patients with One or More Asthma-Related Emergency Room Visit (ages 220) Rate 12.23% Performance Measure 3--Cesarean Delivery Rate Table C-3--Performance Measure 3 for WellCare of Georgia, Inc. Cesarean Delivery Rate Rate 29.10% Performance Measure 4--Cesarean Rate for Nulliparous Singleton Vertex Table C-4--Performance Measure 4 for WellCare of Georgia, Inc. Cesarean Rate for Nulliparous Singleton Vertex Rate 16.86% WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page C-1 WellCare_GA2012-13_CMO_PMV_F1_0913 PERFORMANCE MEASURE RESULTS Performance Measure 5--Percentage of Eligibles that Received Dental Treatment Services Table C-5--Performance Measure 5 for WellCare of Georgia, Inc. Percentage of Eligibles that Received Dental Treatment Services Rate 24.32% Performance Measure 6--Percentage of Eligibles that Received Preventive Dental Services Table C-6--Performance Measure 6 for WellCare of Georgia, Inc. Percentage of Eligibles that Received Preventive Dental Services Rate 52.52% Performance Measure 7--Percentage of Live Births Weighing Less Than 2,500 Grams Table C-7--Performance Measure 7 for WellCare of Georgia, Inc. Percentage of Live Births Weighing Less Than 2,500 Grams Rate 8.02% Performance Measure 8--Adult Asthma Admission Rate Table C-8--Performance Measure 8 for WellCare of Georgia, Inc. Adult Asthma Admission Rate Rate (Per 100,000) 71.17 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page C-2 WellCare_GA2012-13_CMO_PMV_F1_0913 PERFORMANCE MEASURE RESULTS Performance Measure 9--Chronic Obstructive Pulmonary Disease (COPD) Admission Rate Table C-9--Performance Measure 9 for WellCare of Georgia, Inc. Chronic Obstructive Pulmonary Disease (COPD) Admission Rate Rate (Per 100,000) 19.24 Performance Measure 10--Congestive Heart Failure Admission Rate Table C-10--Performance Measure 10 for WellCare of Georgia, Inc. Congestive Heart Failure Admission Rate Rate (Per 100,000) 41.04 Performance Measure 11--Diabetes, Short-Term Complications Admission Rate Table C-11--Performance Measure 11 for WellCare of Georgia, Inc. Diabetes, Short-Term Complications Admission Rate Rate (Per 100,000) 27.82 WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page C-3 WellCare_GA2012-13_CMO_PMV_F1_0913 Appendix D. Final Audited HEDIS Rates for WellCare of Georgia, Inc. Table D-1--CMO Audited Calendar Year 2012 HEDIS Performance Measure Report for WellCare of Georgia, Inc. Measure CMO Rate Adolescent Well-Care Visits 51.58% Adults' Access to Preventive/Ambulatory Health Services-- Ages 2044 Years Adults' Access to Preventive/Ambulatory Health Services-- Ages 4564 Years Adults' Access to Preventive/Ambulatory Health Services-- Ages 65+ Years 85.81% 91.21% Denominator fewer than 30 Adults' Access to Preventive/Ambulatory Health Services--Total 86.49% Adult BMI Assessment 67.88% Annual Dental Visit--Ages 23 Years 52.22% Annual Dental Visit--Ages 46 Years 77.61% Annual Dental Visit--Ages 710 Years 80.37% Annual Dental Visit--Ages 1114 Years 73.72% Annual Dental Visit--Ages 1518 Years 63.06% Annual Dental Visit--Ages 1921 Years 41.88% Annual Dental Visit--Total Annual Monitoring for Patients on Persistent Medications-- ACE Inhibitors or ARBs Annual Monitoring for Patients on Persistent Medications-- Anticonvulsants Annual Monitoring for Patients on Persistent Medications--Digoxin 71.48% 88.51% 63.68% Denominator fewer than 30 Annual Monitoring for Patients on Persistent Medications--Diuretics 87.85% Annual Monitoring for Patients on Persistent Medications--Total Antibiotic Utilization--Percent of Antibiotics of Concern of All Antibiotic Scrips--Total Antidepressant Medication Management--Effective Acute Phase Treatment Antidepressant Medication Management--Effective Continuation Phase Treatment Appropriate Testing for Children with Pharyngitis 87.06% 42.78% 50.00% 32.74% 75.70% WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-1 WellCare_GA2012-13_CMO_PMV_F1_0913 FINAL AUDITED HEDIS RATES Table D-1--CMO Audited Calendar Year 2012 HEDIS Performance Measure Report for WellCare of Georgia, Inc. Measure CMO Rate Appropriate Treatment for Children with Upper Respiratory Infection (URI)* 79.95% Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis* 16.30% Breast Cancer Screening 55.78% Call Answer Timeliness 85.10% Cervical Cancer Screening Cholesterol Management for Patients with Cardiovascular Conditions-- LDL-C Screening Cholesterol Management for Patients with Cardiovascular Conditions-- LDL-C Control Childhood Immunization Status--Combo 3 72.51% 89.39% 34.85% 78.83% Childhood Immunization Status--Combo 6 42.82% Childhood Immunization Status--Combo 10 Children's and Adolescents' Access to Primary Care Practitioners -- Ages 1224 Months Children's and Adolescents' Access to Primary Care Practitioners -- Ages 25 Months6 Years Children's and Adolescents' Access to Primary Care Practitioners -- Ages 711 Years Children's and Adolescents' Access to Primary Care Practitioners -- Ages 1219 Years Chlamydia Screening in Women 38.44% 97.56% 91.63% 91.80% 89.57% 48.66% Comprehensive Diabetes Care--Blood Pressure Control <140/80 28.47% Comprehensive Diabetes Care--Blood Pressure Control <140/90 51.64% Comprehensive Diabetes Care--Eye Exam 40.51% Comprehensive Diabetes Care--HbA1c Control <7.0 32.36% Comprehensive Diabetes Care--HbA1c Control <8.0 39.05% Comprehensive Diabetes Care--HbA1c Poor Control >9.0** 54.01% Comprehensive Diabetes Care--HbA1c Testing 78.47% Comprehensive Diabetes Care--LDL-C Screening 69.71% Comprehensive Diabetes Care--LDL-C Control 28.10% Comprehensive Diabetes Care--Medical Attention to Nephropathy 72.81% WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-2 WellCare_GA2012-13_CMO_PMV_F1_0913 FINAL AUDITED HEDIS RATES Table D-1--CMO Audited Calendar Year 2012 HEDIS Performance Measure Report for WellCare of Georgia, Inc. Measure CMO Rate Controlling High Blood Pressure 49.64% Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 62.20% Follow-Up After Hospitalization for Mental Illness--30 Day Follow-Up 77.16% 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 Frequency of Ongoing Prenatal Care--< 21 Percent 60.37% 39.39% 53.10% 12.90% Frequency of Ongoing Prenatal Care--2140 Percent 5.11% Frequency of Ongoing Prenatal Care--4160 Percent 5.60% Frequency of Ongoing Prenatal Care--6180 Percent 13.87% Frequency of Ongoing Prenatal Care--81+ Percent Human Papillomavirus Vaccine for Female Adolescents Immunizations for Adolescents--Combo 1 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment--Initiation of Treatment Initiation and Engagement of Alcohol and Other Drug Dependence Treatment--Engagement of Treatment Inpatient Utilization--General Hospital/Acute Care--Total Lead Screening in Children Asthma Medication Ratio--Total: 564 Years Medication Management for People with Asthma-- Total-Medication Compliance 50% Medication Management for People with Asthma-- Total-Medication Compliance 75% Persistence of Beta-Blocker Treatment After a Heart Attack Pharmacotherapy Management of COPD Exacerbation-- Systemic Corticosteroid Pharmacotherapy Management of COPD Exacerbation-- Bronchodilator Prenatal and Postpartum Care--Postpartum Care Prenatal and Postpartum Care--Timeliness of Prenatal Care 62.53% 19.95% 70.98% 48.28% 12.27% Rates reported in Appendix F 75.34% 63.72% 43.85% 20.55% Denominator fewer than 30 73.28% 84.73% 62.53% 84.18% WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-3 WellCare_GA2012-13_CMO_PMV_F1_0913 FINAL AUDITED HEDIS RATES Table D-1--CMO Audited Calendar Year 2012 HEDIS Performance Measure Report for WellCare of Georgia, Inc. Measure CMO Rate Use of Appropriate Medications for People with Asthma-- Ages 511 Years Use of Appropriate Medications for People with Asthma-- Ages 1218 Years 90.56% 88.16% Use of Appropriate Medications for People with Asthma-- Ages 1950 Years Use of Appropriate Medications for People with Asthma-- Ages 5164 Years 75.65% Denominator fewer than 30 Use of Appropriate Medications for People with Asthma--Total 89.12% Use of Imaging Studies for Low Back Pain* 73.93% Use of Spirometry Testing in the Assessment and Diagnosis of COPD Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--Total BMI Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--Total Nutrition Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents--Total Physical Activity Well-Child Visits in the First 15 Months of Life--Zero Visits 39.62% 38.69% 55.47% 42.09% 3.06% Well-Child Visits in the First 15 Months of Life--One Visit 3.32% Well-Child Visits in the First 15 Months of Life--Two Visits 2.55% Well-Child Visits in the First 15 Months of Life--Three Visits 6.12% Well-Child Visits in the First 15 Months of Life--Four Visits 7.65% Well-Child Visits in the First 15 Months of Life--Five Visits 10.71% Well-Child Visits in the First 15 Months of Life--Six or More Visits 66.58% Well-Child Visits in the Third, Fourth, Fifth, and Sixth Years of Life 68.46% Ambulatory Care Rates reported in Appendix F Board Certification Rates reported in Appendix F Enrollment by Product Line--Total Rates reported in Appendix F Enrollment by State Rates reported in Appendix F Frequency of Selected Procedures Rates reported in Appendix F Identification of Alcohol and Other Drug Services--Total Rates reported in Appendix F Language Diversity of Membership Rates reported in Appendix F Mental Health Utilization Rates reported in Appendix F WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-4 WellCare_GA2012-13_CMO_PMV_F1_0913 FINAL AUDITED HEDIS RATES Table D-1--CMO Audited Calendar Year 2012 HEDIS Performance Measure Report for WellCare of Georgia, Inc. Measure CMO Rate Race/Ethnicity Diversity of Membership Rates reported in Appendix F Total Membership Rates reported in Appendix F Weeks of Pregnancy at Time of Enrollment Rates reported in Appendix F * The measure is reported as an inverted rate. A higher rate indicates appropriate treatment of children with URI, for example (i.e., the proportion for whom antibiotics were not prescribed). The rate is calculated as 1 minus the numerator divided by the eligible population. ** Lower rate is better. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page D-5 WellCare_GA2012-13_CMO_PMV_F1_0913 Appendix E. Performance Measure Validation Reporting Spreadsheet for WellCare of Georgia, Inc. Appendix E contains WellCare of Georgia, Inc.'s performance measure validation reporting spreadsheet. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page E-1 WellCare_GA2012-13_CMO_PMV_F1_0913 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare 2013 Validation of Performance Measures Rate Reporting Template CMO Name: WellCare of Georgia, Inc. CMO Contact Name and Title: Jacqueline Collins - Director , Field Quality Improvement CMO Contact Email: Jacqueline.Collins@wellcare.com Comments: 1 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Cesarean Delivery Rate Data Element Reporting Year General Measure Data 2013 Data collection methodology (administrative) A Eligible population 26388 Numerator events by administrative data 7679 Reported rate 29.10 2 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Percentage of Eligibles that Received Preventive Dental Services Data Element Reporting Year General Measure Data 2013 Data collection methodology (administrative) A Eligible population 594174 Numerator events by administrative data 312073 Reported rate 52.52% 3 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Percentage of Eligibles that Received Dental Treatment Services Data Element General Measure Data Reporting Year 2013 Data collection methodology (administrative) Eligible population A 594174 Numerator events by administrative data 144531 Reported rate 24.32% 4 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Cesarean Rate for Nulliparous Singleton Vertex Data Element Reporting Year General Measure Data 2013 Data collection methodology (administrative) A Eligible population 9627 Numerator events by administrative data 1623 Reported rate 16.86% 5 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Percentage of Live Births Weighing Less Than 2,500 Grams Data Element General Measure Data Reporting Year 2013 Data collection methodology (administrative) A Eligible population 27680 Numerator events by administrative data 2220 Reported rate 8.02 6 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Annual Percentage of Asthma Patients with One or More Asthma-Related Emergency Room Visit (ages 2-20) Data Element General Measure Data Reporting Year Data collection methodology (administrative) 2013 A Eligible population 60122 Numerator events by administrative data 7354 Reported rate 12.23% 7 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Annual Pediatric Hemoglobin (HbA1c) Testing (ages 5-17) Data Element Reporting Year General Measure Data 2013 Data collection methodology (hybrid) H Eligible population 778 Denominator 411 Numerator events by administrative data 331 Numerator events by medical records 10 Numerator Total 341 Reported rate 82.97% 8 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Diabetes, Short-Term Complications Admission Rate Data Element General Measure Data Reporting Year 2013 Data collection methodology (administrative) A Eligible population 366644 Numerator events by administrative data 102 Reported rate (Per 100,000 Members) 28 9 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Chronic Obstructive Pulmonary Disease (COPD) Admission Rate Data Element General Measure Data Reporting Year 2013 Data collection methodology (administrative) A Eligible population 155958 Numerator events by administrative data 30 Reported rate (Per 100,000 Members) 19 10 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Congestive Heart Failure (CHF) Admission Rate Data Element General Measure Data Reporting Year 2013 Data collection methodology (administrative) A Eligible population 155958 Numerator events by administrative data 64 Reported rate (Per 100,000 Members) 41 11 of 12 September 2013 Appendix E: Department of Community Health, State of Georgia Validated CY 2012 Performance Measures for WellCare Adult Asthma Admission Rate Data Element Reporting Year General Measure Data 2013 Data collection methodology (administrative) A Eligible population 155958 Numerator events by administrative data 111 Reported rate (Per 100,000 Members) 71 12 of 12 September 2013 Appendix F. HEDIS Interactive Data Submission System Data for WellCare of Georgia, Inc. Appendix F contains WellCare of Georgia, Inc.'s reported IDSS data. WellCare of Georgia, Inc. Validation of Performance Measures State of Georgia Page F-1 WellCare_GA2012-13_CMO_PMV_F1_0913 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 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 - 2012 The Plan lock has been applied to this submission. Pharmacy Reversal - Pharmacy Reversals NOT Included Measure/Data Element Report Measure Benefit Offered Rotated Measure Rate Reportable Effectiveness of Care: Prevention and Screening Adult BMI Assessment (aba) Y N 67.88% R Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Y N (wcc) BMI Percentile 38.69% R Counseling for Nutrition 55.47% R Counseling for Physical Activity 42.09% R Childhood Immunization Status (cis) Y N DTaP 88.56% R IPV 96.11% R MMR 94.16% R HiB 95.13% R Hepatitis B 94.65% R VZV 94.16% R Pneumococcal Conjugate 85.40% R Hepatitis A 94.40% R Rotavirus 74.21% R Influenza 47.20% R Combination #2 84.43% R Combination #3 78.83% R Combination #4 78.35% R Combination #5 64.72% R Combination #6 42.82% R Combination #7 64.48% R Combination #8 42.58% R Combination #9 38.69% R Combination #10 38.44% R Immunizations for Adolescents (ima) Y Meningococcal 72.99% R 1 of 139 Comment Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Tdap/Td 80.75% R Combination #1 70.98% R Human Papillomavirus Vaccine for Female Adolescents (hpv) Y 19.95% R Lead Screening in Children (lsc) Y N 75.34% R Breast Cancer Screening (bcs) Y 55.78% R Cervical Cancer Screening (ccs) Y 72.51% R Chlamydia Screening in Women (chl) Y 16-20 Years 44.26% R 21-24 Years 62.42% R Total 48.66% R Effectiveness of Care: Respiratory Conditions Appropriate Testing for Children with Pharyngitis (cwp) Y Y 75.70% R Appropriate Treatment for Children With URI (uri) Y Y 79.95% 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% 16.30% R 39.62% R 73.28% R 84.73% R 90.56% R 88.16% R 75.65% R NA R 89.12% R 44.39% R 20.41% R 41.40% R 2 of 139 Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 12-18 Years - Medication Compliance 75% 19.20% R 19-50 Years - Medication Compliance 50% 54.15% R 19-50 Years - Medication Compliance 75% 33.17% R 51-64 Years - Medication Compliance 50% NA R 51-64 Years - Medication Compliance 75% NA R Total - Medication Compliance 50% 43.85% R Total - Medication Compliance 75% 20.55% R Asthma Medication Ratio (amr) Y Y 5-11 Years 65.62% R 12-18 Years 62.25% R 19-50 Years 45.90% R 51-64 Years NA R Total 63.72% R Effectiveness of Care: Cardiovascular Cholesterol Management for Patients With Cardiovascular Conditions (cmc) Y N LDL-C Screening Performed 89.39% R LDL-C Control (<100 mg/dL) 34.85% R Controlling High Blood Pressure (cbp) Y 49.64% R Persistence of Beta-Blocker Treatment After a Y Y Heart Attack (pbh) NA R Effectiveness of Care: Diabetes Comprehensive Diabetes Care (cdc) Y N Hemoglobin A1c (HbA1c) Testing 78.47% R HbA1c Poor Control (>9.0%) 54.01% R HbA1c Control (<8.0%) 39.05% R HbA1c Control (<7.0%) 32.36% R Eye Exam (Retinal) Performed 40.51% R LDL-C Screening Performed 69.71% R LDL-C Control (<100 mg/dL) 28.10% R Medical Attention for Nephropathy 72.81% R Blood Pressure Control (<140/80 mm Hg) 28.47% R Blood Pressure Control (<140/90 mm Hg) 51.64% R Effectiveness of Care: Musculoskeletal Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis (art) Y Y 62.20% R 3 of 139 Reportable Reportable Reportable Denominator fewer than 30 Denominator fewer than 30 Reportable Reportable Reportable Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Use of Imaging Studies for Low Back Pain (lbp) Y Effectiveness of Care: Behavioral Health Antidepressant Medication Management (amm) Y Y Effective Acute Phase Treatment Effective Continuation Phase Treatment 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 Y Y (fuh) 30-Day Follow-Up 7-Day Follow-Up Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Y Y Medication (ssd) Diabetes Monitoring for People With Diabetes and Schizophrenia (smd) Y Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (smc) Y Adherence to Antipsychotic Medications for Individuals With Schizophrenia (saa) Y Y 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 73.93% R 50.00% R 32.74% R 39.39% R 53.10% R 77.16% R 60.37% R 84.93% R NA R NA R 39.80% R 88.51% R NA R 87.85% R 63.68% R 87.06% R 4 of 139 Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Denominator fewer than 30 Denominator fewer than 30 Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 20-44 Years 45-64 Years 65+ Years Total Children and Adolescents' Access to Primary Care Practitioners (cap) Y 12-24 Months 25 Months - 6 Years 7-11 Years 12-19 Years Annual Dental Visit (adv) Y Y 2-3 Years 4-6 Years 7-10 Years 11-14 Years 15-18 Years 19-21 Years Total Initiation and Engagement of AOD Dependence Treatment (iet) Y Y Initiation of AOD Treatment: 13-17 Years Engagement of AOD Treatment: 13-17 Years Initiation of AOD Treatment: 18+ Years Engagement of AOD Treatment: 18+ Years Initiation of AOD Treatment: Total Engagement of AOD Treatment: Total Prenatal and Postpartum Care (ppc) Y Timeliness of Prenatal Care Postpartum Care Call Answer Timeliness (cat) Y Utilization Frequency of Ongoing Prenatal Care (fpc) Y <21 Percent 21-40 Percent 41-60 Percent 61-80 Percent 85.81% R 91.21% R NA R 86.49% R 97.56% R 91.63% R 91.80% R 89.57% R 52.22% R 77.61% R 80.37% R 73.72% R 63.06% R 41.88% R 71.48% R 49.07% R 17.44% R 48.07% R 10.93% R 48.28% R 12.27% R 84.18% R 62.53% R 85.10% R 12.90% R 5.11% R 5.60% R 13.87% R 5 of 139 Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 81+ Percent 62.53% R Well-Child Visits in the First 15 Months of Life (w15) Y N 0 Visits 3.06% R 1 Visit 3.32% R 2 Visits 2.55% R 3 Visits 6.12% R 4 Visits 7.65% R 5 Visits 10.71% R 6+ Visits 66.58% R Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (w34) Y Adolescent Well-Care Visits (awc) Y Frequency of Selected Procedures (fsp) Y Ambulatory Care: Total (amba) Y N 68.46% R N 51.58% R R R Ambulatory Care: Dual Eligibles (ambb) N NR Ambulatory Care: Disabled (ambc) N NR Ambulatory Care: Other (ambd) N NR Inpatient Utilization--General Hospital/Acute Care: Total (ipua) Y R Inpatient Utilization--General Hospital/Acute Care: Dual Eligibles (ipub) N NR Inpatient Utilization--General Hospital/Acute Care: Disabled (ipuc) N NR Inpatient Utilization--General Hospital/Acute Care: Other (ipud) N NR Identification of Alcohol and Other Drug Services: Total (iada) Y Y R Identification of Alcohol and Other Drug Services: Dual Eligibles (iadb) N N NR Identification of Alcohol and Other Drug Services: Disabled (iadc) N N NR Identification of Alcohol and Other Drug Services: Other (iadd) N N NR Mental Health Utilization: Total (mpta) Y Y R Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Measure Unselected Measure Unselected Measure Unselected Reportable Measure Unselected Measure Unselected Measure Unselected Reportable Measure Unselected Measure Unselected Measure Unselected Reportable 6 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Mental Health Utilization: Dual Eligibles (mptb) N N NR Mental Health Utilization: Disabled (mptc) N N NR Mental Health Utilization: Other (mptd) N N NR Antibiotic Utilization: Total (abxa) Y Y R Antibiotic Utilization: Dual Eligibles (abxb) N N NR Antibiotic Utilization: Disabled (abxc) N N NR Antibiotic Utilization: Other (abxd) N N NR Relative Resource Use Relative Resource Use for People With Diabetes (rdi) Y R Relative Resource Use for People With Asthma (ras) Y Y R Relative Resource Use for People With Cardiovascular Conditions (rca) Y R Relative Resource Use for People With Hypertension (rhy) Y R Relative Resource Use for People With COPD (rco) Y R Health Plan Descriptive Information Board Certification (bcr) Y R Total Membership (tlm) Y R Enrollment by Product Line: Total (enpa) Y R Enrollment by Product Line: Dual Eligibles (enpb) N NR Enrollment by Product Line: Disabled (enpc) N NR Enrollment by Product Line: Other (enpd) N NR Enrollment by State (ebs) Y R Race/Ethnicity Diversity of Membership (rdm) Y R Language Diversity of Membership (ldm) Y R Weeks of Pregnancy at Time of Enrollment in MCO (wop) Y R Measure Unselected Measure Unselected Measure Unselected Reportable Measure Unselected Measure Unselected Measure Unselected Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Measure Unselected Measure Unselected Measure Unselected Reportable Reportable Reportable Reportable 7 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Adult BMI Assessment (ABA) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative or hybrid) Eligible population Number of numerator events by administrative data in eligible population (before exclusions) Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of administrative data records excluded Number of medical records excluded Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 H 14257 675 4.73% 411 0.05 432 34 7.87% 0 0 0 0 0 411 33 246 67.88% 63.25% 72.52% 8 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element BMI Percentile 3-11 years 12-17 years Total Counseling for Nutrition 3-11 years 12-17 years Total Counseling for Physical Activity 3-11 years 12-17 years Total Measurement year 2012 2012 2012 Data collection methodology H H H (administrative or hybrid) Eligible population 153983 69005 222,988 153983 69005 222,988 153983 69005 222,988 Number of numerator events by administrative data in eligible population (before exclusions) 8581 3684 12,265 3155 1597 4,752 2418 1130 3,548 Current year's administrative rate (before exclusions) 5.57% 5.34% 5.50% 2.05% 2.31% 2.13% 1.57% 1.64% 1.59% Minimum required sample size (MRSS) or 411 411 411 other sample size Oversampling rate 0.05 0.05 0.05 Final sample size 432 432 432 Number of numerator events by 9 6 15 4 2 6 4 1 5 administrative data in FSS Administrative rate on FSS 2.08% 1.39% 3.47% 0.93% 0.46% 1.39% 0.93% 0.23% 1.16% Number of original sample records 0 0 0 excluded because of valid data errors Number of administrative data records 0 0 0 excluded Number of medical records excluded 0 0 0 Number of employee/dependent medical 0 0 0 records excluded Records added from the oversample list 0 0 0 Denominator 298 113 411 298 113 411 298 113 411 Numerator events by administrative data 8 6 14 4 2 6 4 1 5 Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval 101 36.58% 30.94% 42.21% 44 44.25% 34.65% 53.85% 145 38.69% 33.86% 43.52% 161 55.37% 49.56% 61.18% 61 55.75% 46.15% 65.35% 222 55.47% 50.55% 60.40% 105 36.58% 30.94% 42.21% 63 56.64% 47.06% 66.22% 168 42.09% 37.20% 46.99% 9 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Childhood Immunization Status (CIS) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element General Measure DTaP IPV MMR HiB Data Measurement year 2012 Data collection methodology (administrative or hybrid) H Eligible population 13946 Number of numerator events by admin data in eligible population (before exclusions) 11860 13263 13124 13246 Current year's administrative rate (before exclusions) 85.04% 95.10% 94.11% 94.98% Minimum required sample size (MRSS) or other sample Size 411 Oversampling rate 0.05 Final sample size 432 Number of numerator events by admin data in FSS 375 411 406 408 Administrative rate on FSS 86.81% 95.14% 93.98% 94.44% Number of original records excluded because of valid data errors 0 Number of administrative data records excluded 0 Number of medical data records excluded 0 Number of employee/dependent medical records excluded 0 Records added from the oversample list 0 Denominator 411 Numerator events by administrative data 357 391 387 389 Number of numerator events by medical records Reported rate 7 88.56% 4 96.11% 0 94.16% 2 95.13% Hepatitis B 12853 92.16% 397 91.90% 377 12 94.65% VZV 13181 94.51% 406 93.98% 387 0 94.16% Pneumococcal Conjugate Hepatitis A 11747 84.23% 13036 93.47% 364 84.26% 406 93.98% 346 5 85.40% 388 0 94.40% 10 of 139 September 2013 Lower 95% confidence interval Upper 95% confidence interval Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 85.37% 91.76% 94.12% 98.10% 91.77% 96.55% 92.93% 97.34% 92.35% 96.94% 91.77% 96.55% 81.87% 88.94% 92.06% 96.75% 11 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Rotavirus Influenza Combination Combination Combination Combination Combination Combination Combination Combination Combination 2 3 4 5 6 7 8 9 10 9677 69.39% 5934 42.55% 11214 80.41% 10669 76.50% 10550 75.65% 8275 59.34% 5207 37.34% 8197 58.78% 5184 37.17% 4297 30.81% 4277 30.67% 307 71.06% 197 45.60% 350 81.02% 327 75.69% 325 75.23% 262 60.65% 172 39.81% 261 60.42% 171 39.58% 154 35.65% 153 35.42% 294 11 74.21% 191 3 47.20% 334 13 84.43% 312 12 78.83% 310 12 78.35% 251 15 64.72% 167 9 42.82% 250 15 64.48% 166 9 42.58% 149 10 38.69% 148 10 38.44% 12 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 69.86% 78.56% 42.25% 52.15% 80.80% 88.06% 74.76% 82.90% 74.24% 82.45% 59.98% 69.46% 37.92% 47.73% 59.73% 69.23% 37.68% 47.48% 33.86% 43.52% 33.62% 43.27% 13 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Immunizations for Adolescents (IMA) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative or hybrid) Eligible population Number of numerator events by admin data in eligible population (before exclusions) Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample Size Oversampling rate Final sample size Number of numerator events by admin data in FSS Administrative rate on FSS Number of original records excluded because of valid data errors Number of administrative data records excluded General Measure Data 2012 H 16045 348 0.05 366 0 0 Meningococcal 11878 74.03% 265 72.40% Tdap/Td Combination 1 13585 84.67% 11686 72.83% 293 80.05% 258 70.49% Number of medical data records excluded 0 Number of employee/dependent medical records excluded 0 Records added from the oversample list 0 Denominator 348 Numerator events by administrative data 251 279 244 14 of 139 September 2013 Number of numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 3 72.99% 68.18% 77.80% 2 80.75% 76.46% 85.03% 3 70.98% 66.06% 75.89% 15 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Human Papillomavirus Vaccine for Female Adolescents (HPV) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative or hybrid) Eligible population Number of numerator events by administrative data in eligible population (before exclusions) Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of administrative data records excluded Number of medical data records excluded Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 H 7965 1390 17.45% 411 0.05 432 83 19.21% 0 0 0 0 0 411 76 6 19.95% 15.97% 23.94% 16 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Lead Screening in Children (LSC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Lead Screening in Children Data Elements which do not apply to the selected data collection methodology will not appear Measurement year Data collection methodology (administrative or hybrid) Eligible population Number of numerator events by admin data in eligible population (before exclusions) Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of administrative data records excluded Number of medical data records excluded Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval General Measure Data 2012 H 13946 10524 75.46% 296 0.05 311 225 72.35% 0 0 0 0 0 296 215 8 75.34% 70.26% 80.42% 17 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Breast Cancer Screening (BCS) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval General Measure Data 2012 A 2639 1472 55.78% 53.86% 57.69% 18 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Cervical Cancer Screening (CCS) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative or hybrid) Eligible population Number of numerator events by administrative data in eligible population (before exclusions) Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of administrative data records excluded Number of medical data records excluded Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 H 22195 14847 66.89% 371 0.05 390 257 65.90% 0 0 0 0 0 371 244 25 72.51% 67.83% 77.18% 19 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Chlamydia Screening in Women (CHL) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval General Measure Data 2012 A 16-20 years 21-24 years 9879 4372 44.26% 43.27% 45.24% 3164 1975 62.42% 60.72% 64.12% Total 13,043 6,347 48.66% 47.80% 49.52% 20 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Appropriate Testing for Children with Pharyngitis (CWP) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 24721 18714 75.70% 75.16% 76.24% 21 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Appropriate Treatment for Children With URI (URI) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 35156 7050 79.95% 79.53% 80.37% 22 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Total numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 1368 1145 16.30% 14.31% 18.30% 23 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 106 42 39.62% 29.84% 49.41% 24 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Pharmacotherapy Management of COPD Exacerbation (PCE) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Pharmacotherapy Management of COPD Exacerbation Data Elements Measure Data Systemic corticosteroid Bronchodilator Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval 2012 A 131 96 73.28% 65.32% 81.24% 111 84.73% 78.19% 91.27% 25 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Use of Appropriate Medications for People With Asthma (ASM) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element General Measure Data 5-11 years 12-18 years 19-50 years 51-64 years Measurement year 2012 Data collection methodology (administrative) A Eligible population 4398 2263 271 26 Number of required exclusions 324 164 246 57 Numerator events by administrative data 3983 1995 205 18 Reported rate Lower 95% confidence interval Upper 95% confidence interval 90.56% 88.16% 75.65% NA 89.69% 86.80% 70.35% NA 91.44% 89.51% 80.94% NA Total 6,958 791 6,201 89.12% 88.38% 89.86% 26 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Medication Management for People With Asthma (MMA) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) 5-11 years 12-18 years 19-50 years 51-64 years Data Element General Measure Data Medication Medication Medication Medication Medication Medication Medication Medication Compliance Compliance Compliance Compliance Compliance Compliance Compliance Compliance 50% 75% 50% 75% 50% 75% 50% 75% Measurement year 2012 Data collection methodology (administrative) A Eligible population 3983 1995 205 18 Number of required exclusions 739 432 312 65 Numerator events by administrative data 1768 813 826 383 111 68 14 10 Reported rate 44.39% 20.41% 41.40% 19.20% 54.15% 33.17% NA NA Lower 95% confidence interval 42.83% 19.15% 39.22% 17.44% 47.08% 26.48% NA NA Upper 95% confidence interval 45.94% 21.68% 43.59% 20.95% 61.21% 39.86% NA NA 27 of 139 September 2013 Total Medication Medication Compliance Compliance 50% 75% 6,201 1,548 2,719 1,274 43.85% 42.60% 45.09% 20.55% 19.53% 21.56% Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 28 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Asthma Medication Ratio (AMR) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measure Data 5-11 years 12-18 years 19-50 years 51-64 years Measurement year 2012 Data collection methodology (administrative) A Eligible population 4378 2249 268 26 Number of required exclusions 344 178 249 57 Numerator events by administrative data 2873 1400 123 14 Reported rate Lower 95% confidence interval Upper 95% confidence interval 65.62% 62.25% 45.90% NA 64.21% 60.22% 39.74% NA 67.04% 64.28% 52.05% NA Total 6,921 828 4,410 63.72% 62.58% 64.86% 29 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Cholesterol Management for Patients With Cardiovascular Conditions (CMC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative or hybrid) Eligible population Number of numerator events by administrative data in eligible population (before exclusions) Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval General Measure Data 2012 H 132 132 0.05 132 0 0 0 132 LDL-C LDL-C level Screening <100 mg/dL 114 86.36% 20 15.15% 115 87.12% 17 12.88% 115 3 89.39% 83.76% 95.03% 17 29 34.85% 26.34% 43.36% 30 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Controlling High Blood Pressure (CBP) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (hybrid) Eligible population Number of numerator events by administrative data in eligible population (before exclusions) Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of records excluded because of false positive diagnoses Number of administrative data records excluded Number of medical data records excluded Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval General Measure Data 2012 H 4625 0 0.00% 411 0.1 453 0 0.00% 24 24 1 0 0 24 411 0 204 49.64% 44.68% 54.59% 31 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 24 17 NA NA NA 32 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Comprehensive Diabetes Care (CDC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element HbA1c Testing HbA1c Poor Control (>9.0%) HbA1c Control (<8.0%) HbA1c Control (<7.0%) for a Selected Population Eye Exam Measurement year Data collection methodology (administrative or hybrid) Eligible population 2012 H 2487 2012 H 2487 2012 H 2487 2012 H 2154 2012 H 2487 Number of numerator events by administrative data in eligible population 1870 2047 363 283 846 (before optional exclusions) Current year's administrative rate (before optional exclusions) 75.19% 82.31% 14.60% 13.14% 34.02% Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS 548 0.15 631 484 76.70% 548 0.15 631 556 88.11% 548 0.15 631 64 10.14% 548 0.15 631 44 6.97% 548 0.15 631 231 36.61% Number of original sample records excluded because of valid data errors 0 0 0 0 0 Number of optional administrative data records excluded 0 0 0 0 0 Number of optional medical data records excluded 0 0 0 0 0 Number of HbA1c <7 required medical records excluded 32 Number of HbA1c <7 required administrative data records excluded 87 Number of employee/dependent medical records excluded 0 0 0 0 0 Records added from the oversample list 0 0 0 0 0 LDL-C Screening 2012 Blood LDL-C Level <100 mg/dL Medical Attention for Nephropathy Pressure Controlled <140/80 mm Hg 2012 2012 2012 H H H H 2487 2487 2487 2487 1638 326 1643 17 65.86% 548 0.15 631 436 69.10% 0 0 0 13.11% 548 0.15 631 51 8.08% 0 0 0 66.06% 548 0.15 631 437 69.26% 0 0 0 0.68% 548 0.15 631 5 0.79% 0 0 0 0 0 0 0 0 0 0 0 33 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval 548 418 12 78.47% 74.93% 82.00% 548 215 81 54.01% 49.75% 58.28% 548 55 159 39.05% 34.88% 43.23% 445 37 107 32.36% 27.90% 36.82% 548 205 17 40.51% 36.31% 44.71% 548 376 6 69.71% 65.77% 73.65% 548 46 108 28.10% 24.25% 31.96% 548 381 18 72.81% 68.99% 76.63% 548 5 151 28.47% 24.60% 32.34% 34 of 139 September 2013 Blood Pressure Controlled <140/90 mm Hg 2012 H 2487 26 1.05% 548 0.15 631 7 1.11% 0 0 0 0 0 35 of 139 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare September 2013 548 7 276 51.64% 47.37% 55.92% Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 36 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Disease Modifying Anti-Rheumatic Drug therapy in Rheumatoid Arthritis (ART) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 82 51 62.20% 51.09% 73.30% 37 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Use of Imaging Studies for Low Back Pain (LBP) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence Interval Upper 95% confidence Interval Measure Data 2012 A 1845 481 73.93% 71.90% 75.96% 38 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Antidepressant Medication Management (AMM) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval General Measure Data 2012 A 1234 Effective Acute Phase Treatment Effective Continuation Phase Treatment 617 50.00% 47.17% 52.83% 404 32.74% 30.08% 35.40% 39 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Follow-Up Care for Children Prescribed ADHD Medication (ADD) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval General Measure Data 2012 A Initiation Phase Continuation and Maintenance Phase 6639 2615 39.39% 38.21% 40.57% 1241 659 53.10% 50.29% 55.92% 40 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Follow-Up After Hospitalization for Mental Illness (FUH) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval General Measure Data 2012 A 2180 30-day 7-day follow- follow-up up 1682 77.16% 75.37% 78.94% 1316 60.37% 58.29% 62.44% 41 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medication (SSD) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Number of required exclusions Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 491 400 417 84.93% 81.66% 88.20% 42 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Number of optional exclusions Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 24 0 11 NA NA NA 43 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 1 0 NA NA NA 44 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Number of required exclusions Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 98 45 39 39.80% 29.59% 50.00% 45 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Annual Monitoring for Patients on Persistent Medications (MPM) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element General Measure Data ACE Inhibitors or ARBs Digoxin Diuretics Anticonvulsants Measurement year 2012 Data collection methodology (administrative) A Eligible population 2036 22 1910 190 Numerator events by administrative data 1802 19 1678 121 Reported rate Lower 95% confidence interval Upper 95% confidence interval 88.51% NA 87.85% 63.68% 87.10% NA 86.36% 56.58% 89.92% NA 89.34% 70.79% Total 4,158 3,620 87.06% 86.03% 88.09% 46 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Adults' Access to Preventive/Ambulatory Health Services (AAP) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element General Measure Data 20-44 years 45-64 years 65+ years Total Measurement year 2012 Data collection methodology (administrative) A Eligible population 24969 3606 5 28,580 Numerator events by administrative data 21426 3289 4 24,719 Reported rate Lower 95% confidence interval Upper 95% confidence interval 85.81% 91.21% NA 86.49% 85.38% 90.27% NA 86.09% 86.25% 92.15% NA 86.89% 47 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Children and Adolescents' Access to Primary Care Practitioners (CAP) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element General Measure Data 12-24 months 25 months 6 years 7-11 years 12-19 years Measurement year 2012 Data collection methodology (administrative) A Eligible population 21341 102928 67330 73563 Numerator events by administrative data 20820 94314 61809 65891 Reported rate Lower 95% confidence interval Upper 95% confidence interval 97.56% 97.35% 97.77% 91.63% 91.46% 91.80% 91.80% 91.59% 92.01% 89.57% 89.35% 89.79% 48 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Annual Dental Visit (ADV) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measure Data 2-3 Years 4-6 Years 7-10 Years 11-14 Years 15-18 Years 19-21 Years Measurement year 2012 Data collection methodology (administrative) A Eligible population 38249 65818 76153 67673 49666 2636 Numerator events by administrative data 19972 51084 61202 49887 31320 1104 Reported rate Lower 95% confidence interval Upper 95% confidence interval 52.22% 51.71% 52.72% 77.61% 77.29% 77.93% 80.37% 80.08% 80.65% 73.72% 73.39% 74.05% 63.06% 62.64% 63.49% 41.88% 39.98% 43.78% Total 300,195 214,569 71.48% 71.31% 71.64% 49 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Initiation and Engagement of AOD Dependence Treatment (IET) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Elements General Measure Data 13-17 years Initiation of Engagement AOD of AOD Treatment Treatment 18+ years Initiation of Engagement AOD of AOD Treatment Treatment Measurement year 2012 Data collection methodology (administrative) A Eligible population 648 2515 Numerator events by administrative data 318 113 1209 275 Reported rate 49.07% 17.44% 48.07% 10.93% Lower 95% confidence interval 45.15% 14.44% 46.10% 9.69% Upper 95% confidence interval 53.00% 20.44% 50.04% 12.17% Total Initiation of AOD Treatment Engagement of AOD Treatment 3,163 1,527 388 48.28% 12.27% 46.52% 11.11% 50.03% 13.43% 50 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Prenatal and Postpartum Care (PPC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative or hybrid) Eligible population Number of numerator events by administrative data in eligible population (before exclusions) Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Timeliness of Prenatal Care 2012 H 27243 Postpartum Care 2012 H 27243 10375 10303 38.08% 411 0.05 432 160 37.04% 2 0 2 411 154 192 84.18% 80.54% 87.83% 37.82% 411 0.05 432 144 33.33% 2 0 2 411 138 119 62.53% 57.73% 67.33% 51 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Call Answer Timeliness (CAT) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative) Eligible population Numerator events by administrative data Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 A 530463 451448 85.10% 85.01% 85.20% 52 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Frequency of Ongoing Prenatal Care (FPC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element General Measure Data <21 Percent 21-40 Percent 41-60 Percent 61-80 Percent Measurement year 2012 Data collection methodology (administrative or hybrid) H Eligible population 27243 Number of numerator events by administrative data in eligible population (before exclusions) 17913 4689 1851 1119 Current year's administrative rate (before exclusions) 65.75% 17.21% 6.79% 4.11% Minimum required sample size (MRSS) or other sample size 411 Oversampling rate 0.05 Final sample size (FSS) 432 Number of numerator events by administrative data in FSS 276 79 27 23 Administrative rate on FSS 63.89% 18.29% 6.25% 5.32% Number of original sample records excluded because of valid data errors 2 Number of employee/dependent medical records excluded 0 Records added from the oversample list 2 Denominator 411 Numerator events by administrative data 50 14 6 10 Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval 3 12.90% 9.53% 16.26% 7 5.11% 2.86% 7.36% 17 5.60% 3.25% 7.94% 47 13.87% 10.41% 17.33% 81+ Percent 1671 6.13% 27 6.25% 30 227 62.53% 57.73% 67.33% 53 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Well-Child Visits in the First 15 Months of Life (W15) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measure Data 0 visits 1 visit 2 visits Measurement year 2012 Data collection methodology (administrative or hybrid) H Eligible population 15912 Number of numerator events by administrative data in eligible population (before exclusions) 468 602 822 Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size 392 Oversampling rate 0.05 Final sample size (FSS) 412 Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors 0 Number of employee/dependent medical records excluded 0 Records added from the oversample list 0 Denominator 392 Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval 2.94% 3.78% 5.17% 18 4.37% 19 4.61% 21 5.10% 12 0 3.06% 1.23% 4.89% 11 2 3.32% 1.42% 5.22% 10 0 2.55% 0.86% 4.24% 3 visits 1163 7.31% 37 8.98% 21 3 6.12% 3.62% 8.62% 4 visits 1701 10.69% 38 9.22% 19 11 7.65% 4.89% 10.41% 5 visits 6 or more visits 2855 17.94% 8301 52.17% 69 16.75% 210 50.97% 27 15 10.71% 7.52% 13.90% 205 56 66.58% 61.78% 71.38% 54 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Adolescent Well-Care Visits (AWC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative or hybrid) Eligible population Number of numerator events by administrative data in eligible population (before exclusions) Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 H 101932 43459 42.64% 411 0.05 432 207 47.92% 0 0 0 411 197 15 51.58% 46.63% 56.53% 55 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Data Element Measurement year Data collection methodology (administrative or hybrid) Eligible population Number of numerator events by administrative data in eligible population (before exclusions) Current year's administrative rate (before exclusions) Minimum required sample size (MRSS) or other sample size Oversampling rate Final sample size (FSS) Number of numerator events by administrative data in FSS Administrative rate on FSS Number of original sample records excluded because of valid data errors Number of employee/dependent medical records excluded Records added from the oversample list Denominator Numerator events by administrative data Numerator events by medical records Reported rate Lower 95% confidence interval Upper 95% confidence interval Measure Data 2012 H 86526 56930 65.80% 371 0.05 390 258 66.15% 0 0 0 371 245 9 68.46% 63.60% 73.33% 56 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Frequency of Selected Procedures (FSP) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age 0-9 10-19 15-44 20-44 30-64 45-64 Male 1,840,826 1,107,046 68,158 59,288 15,040 Female 1,790,797 1,149,439 1,109,463 657,657 52,635 Total 3,631,679 2,256,502 Procedure Age Sex Number of Procedures Procedures / 1,000 Member Years Bariatric weight loss surgery Tonsillectomy Hysterectomy, Abdominal Hysterectomy, Vaginal Cholecystectomy, Open Cholecystectomy (laparoscopic) Back Surgery 0-19 Male 0 0.00 Female 2 0.00 20-44 Male 4 0.06 Female 55 0.08 45-64 Male 0 0.00 Female 6 0.11 0-9 Male & 3375 0.93 10-19 Female 910 0.40 15-44 Female 343 0.31 45-64 44 0.84 15-44 335 0.30 Female 45-64 47 0.89 30-64 Male 1 0.02 15-44 Female 21 0.02 45-64 1 0.02 30-64 Male 24 0.40 15-44 Female 970 0.87 45-64 36 0.68 20-44 Male 53 0.78 Female 132 0.20 45-64 Male 22 1.46 Female 46 0.87 57 of 139 September 2013 Mastectomy Lumpectomy Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 15-44 Female 49 0.04 45-64 65 1.23 15-44 Female 178 0.16 45-64 69 1.31 58 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Ambulatory Care: Total (AMBA) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total Member Months 469,334 3,162,345 2,256,502 725,815 67,675 89 4 1 0 6,681,765 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 431864 1184326 606952 347003 54433 44 1 0 0 2,624,623 920.16 374.51 268.98 478.09 804.33 494.38 250.00 0.00 392.80 47662 169845 97562 104113 7104 4 0 0 0 426,290 101.55 53.71 43.24 143.44 104.97 44.94 0.00 0.00 63.80 59 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Ambulatory Care: Dual Eligibles (AMBB) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total Member Months NR NR NR NR NR NR NR NR NR NR 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 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 60 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Ambulatory Care: Disabled (AMBC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total Member Months NR NR NR NR NR NR NR NR NR NR 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 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 61 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Ambulatory Care: Other (AMBD) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total Member Months NR NR NR NR NR NR NR NR NR NR 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 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 62 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 <1 469,334 1-9 3,162,345 10-19 2,256,502 20-44 725,815 45-64 67,675 65-74 89 75-84 4 85+ 1 Unknown 0 Total 6,681,765 Total Inpatient Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total 4116 8.77 24722 52.67 6.01 4234 1.34 11991 3.79 2.83 8016 3.55 22390 9.92 2.79 33773 46.53 89604 123.45 2.65 1165 17.21 4626 68.36 3.97 0 0.00 0 0.00 NA 0 0.00 0 0.00 NA 0 0.00 0 0.00 NA 0 0 NA 51,304 7.68 153,333 22.95 2.99 Medicine Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 3284 7.00 11840 25.23 3.61 63 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total 3299 1.04 7724 2.44 2.34 1479 0.66 4100 1.82 2.77 2305 3.18 7189 9.90 3.12 702 10.37 2233 33.00 3.18 0 0.00 0 0.00 NA 0 0.00 0 0.00 NA 0 0.00 0 0.00 NA 0 0 NA 11,069 1.66 33,086 4.95 2.99 Surgery Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total 832 1.77 935 0.30 927 0.41 1492 2.06 434 6.41 0 0.00 0 0.00 0 0.00 0 4,620 0.69 Maternity* 12882 4267 4242 7328 2315 0 0 0 0 31,034 27.45 1.35 1.88 10.10 34.21 0.00 0.00 0.00 4.64 15.48 4.56 4.58 4.91 5.33 NA NA NA NA 6.72 Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay 10-19 5610 2.49 14048 6.23 2.50 20-44 29976 41.30 75087 103.45 2.50 45-64 29 0.43 78 1.15 2.69 Unknown 0 0 NA Total 35,615 11.68 89,213 29.25 2.50 *The maternity category is calculated using member months for members 10-64 years. 64 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Inpatient Utilization--General Hospital/Acute Care: Dual Eligibles (IPUB) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age Member Months <1 NR 1-9 NR 10-19 NR 20-44 NR 45-64 NR 65-74 NR 75-84 NR 85+ NR Unknown NR Total NR Total Inpatient Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Medicine NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 NR NR NR NR NR 65 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Surgery NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Maternity* NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay 10-19 NR NR NR NR NR 20-44 NR NR NR NR NR 45-64 NR NR NR NR NR Unknown NR NR NR Total NR NR NR NR NR *The maternity category is calculated using member months for members 10-64 years. 66 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Inpatient Utilization--General Hospital/Acute Care: Disabled (IPUC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age Member Months <1 NR 1-9 NR 10-19 NR 20-44 NR 45-64 NR 65-74 NR 75-84 NR 85+ NR Unknown NR Total NR Total Inpatient Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Medicine NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 NR NR NR NR NR 67 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Surgery NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Maternity* NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay 10-19 NR NR NR NR NR 20-44 NR NR NR NR NR 45-64 NR NR NR NR NR Unknown NR NR NR Total NR NR NR NR NR *The maternity category is calculated using member months for members 10-64 years. 68 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Inpatient Utilization--General Hospital/Acute Care: Other (IPUD) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age Member Months <1 NR 1-9 NR 10-19 NR 20-44 NR 45-64 NR 65-74 NR 75-84 NR 85+ NR Unknown NR Total NR Total Inpatient Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Medicine NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 NR NR NR NR NR 69 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Surgery NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay <1 1-9 10-19 20-44 45-64 65-74 75-84 85+ Unknown Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Maternity* NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Discharges / Days / 1,000 Average Age Discharges 1,000 Member Days Members Length of Months Months Stay 10-19 NR NR NR NR NR 20-44 NR NR NR NR NR 45-64 NR NR NR NR NR Unknown NR NR NR Total NR NR NR NR NR *The maternity category is calculated using member months for members 10-64 years. 70 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 2286598 578034 93094 30755 42589 42 0 Female 2230569 590990 305536 325383 198050 52 0 Total 4,517,167 1,169,024 398,630 356,138 240,639 94 0 Member Months (Inpatient) Male 2286598 578034 93094 30755 42589 42 0 Female 2230569 590990 305536 325383 198050 52 0 Total 4,517,167 1,169,024 398,630 356,138 240,639 94 0 Member Months (Intensive Outpatient/Partial Hospitalization) Male Female Total 2286598 2230569 4,517,167 578034 590990 1,169,024 93094 305536 398,630 30755 325383 356,138 42589 198050 240,639 42 52 94 0 0 0 Member Months (Outpa Male 2286598 578034 93094 30755 42589 42 0 Female 2230569 590990 305536 325383 198050 52 0 Total Age 0-12 13-17 18-24 25-34 35-64 65+ 3,031,112 Sex M F Total M F Total M F Total M F Total M F Total M F 3,650,580 6,681,692 Any Services Number 81 62 143 763 411 1,174 236 864 1,100 262 1835 2,097 368 1104 1,472 0 0 Percent 0.04% 0.03% 0.04% 1.58% 0.83% 1.21% 3.04% 3.39% 3.31% 10.22% 6.77% 7.07% 10.37% 6.69% 7.34% 0.00% 0.00% 3,031,112 3,650,580 Inpatient Number 12 9 21 116 100 216 62 319 381 62 591 653 82 302 384 0 0 Percent 0.01% 0.00% 0.01% 0.24% 0.20% 0.22% 0.80% 1.25% 1.15% 2.42% 2.18% 2.20% 2.31% 1.83% 1.91% 0.00% 0.00% 6,681,692 3,031,112 Intensive Outpatient/Partial Hospitalization Number 2 0 2 37 23 60 Percent 0.00% 0.00% 0.00% 0.08% 0.05% 0.06% 9 0.12% 27 0.11% 36 0.11% 8 0.31% 58 0.21% 66 0.22% 8 0.23% 42 0.25% 50 0.25% 0 0.00% 0 0.00% 3,650,580 6,681,692 Outpatient/ED Number 69 54 123 681 340 1,021 201 658 859 231 1529 1,760 334 946 1,280 0 0 Percent 0.04% 0.03% 0.03% 1.41% 0.69% 1.05% 2.59% 2.58% 2.59% 9.01% 5.64% 5.93% 9.41% 5.73% 6.38% 0.00% 0.00% 3,031,112 3,650,580 71 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Unknown Total Total 0 0.00% 0 0.00% 0 0.00% 0 0.00% M 0 NA 0 NA 0 NA 0 NA F 0 NA 0 NA 0 NA 0 NA Total 0 NA 0 NA 0 NA 0 NA M 1,710 0.68% 334 0.13% 64 0.03% 1,516 0.60% F 4,276 1.41% 1,321 0.43% 150 0.05% 3,527 1.16% Total 5,986 1.08% 1,655 0.30% 214 0.04% 5,043 0.91% 72 of 139 September 2013 atient/ED) Total 4,517,167 1,169,024 398,630 356,138 240,639 94 0 6,681,692 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 73 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Identification of Alcohol and Other Drug Services: Dual Eligibles (IADB) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Member Months (Any) Age Member Months (Inpatient) Member Months (Intensive Outpatient/Partial Hospitalization) Male Female Total Male Female Total Male Female Total 0-12 NR NR NR NR NR NR NR NR NR 13-17 NR NR NR NR NR NR NR NR NR 18-24 NR NR NR NR NR NR NR NR NR 25-34 NR NR NR NR NR NR NR NR NR 35-64 NR NR NR NR NR NR NR NR NR 65+ NR NR NR NR NR NR NR NR NR Unknown NR NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR NR Age Sex Any Services Inpatient Intensive Outpatient/Partial Hospitalization Outpatient/ED 0-12 Number Percent Number Percent Number Percent Number Percent M NR NR NR NR NR NR NR NR F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 13-17 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 18-24 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 25-34 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 35-64 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 65+ F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Member Months (Outpa Male NR NR NR NR NR NR NR NR Female NR NR NR NR NR NR NR NR 74 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Unknown F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Total F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR 75 of 139 September 2013 atient/ED) Total NR NR NR NR NR NR NR NR Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 76 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Identification of Alcohol and Other Drug Services: Disabled (IADC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Member Months (Any) Age Member Months (Inpatient) Member Months (Intensive Outpatient/Partial Hospitalization) Male Female Total Male Female Total Male Female Total 0-12 NR NR NR NR NR NR NR NR NR 13-17 NR NR NR NR NR NR NR NR NR 18-24 NR NR NR NR NR NR NR NR NR 25-34 NR NR NR NR NR NR NR NR NR 35-64 NR NR NR NR NR NR NR NR NR 65+ NR NR NR NR NR NR NR NR NR Unknown NR NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR NR Age Sex Any Services Inpatient Intensive Outpatient/Partial Hospitalization Outpatient/ED 0-12 Number Percent Number Percent Number Percent Number Percent M NR NR NR NR NR NR NR NR F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 13-17 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 18-24 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 25-34 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 35-64 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 65+ F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Member Months (Outpa Male NR NR NR NR NR NR NR NR Female NR NR NR NR NR NR NR NR 77 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Unknown F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Total F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR 78 of 139 September 2013 atient/ED) Total NR NR NR NR NR NR NR NR Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 79 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Identification of Alcohol and Other Drug Services: Other (IADD) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Member Months (Any) Age Member Months (Inpatient) Member Months (Intensive Outpatient/Partial Hospitalization) Male Female Total Male Female Total Male Female Total 0-12 NR NR NR NR NR NR NR NR NR 13-17 NR NR NR NR NR NR NR NR NR 18-24 NR NR NR NR NR NR NR NR NR 25-34 NR NR NR NR NR NR NR NR NR 35-64 NR NR NR NR NR NR NR NR NR 65+ NR NR NR NR NR NR NR NR NR Unknown NR NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR NR Age Sex Any Services Inpatient Intensive Outpatient/Partial Hospitalization Outpatient/ED 0-12 Number Percent Number Percent Number Percent Number Percent M NR NR NR NR NR NR NR NR F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M 13-17 F NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M 18-24 F NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 25-34 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M 35-64 F NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 65+ F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Member Months (Outpa Male NR NR NR NR NR NR NR NR Female NR NR NR NR NR NR NR NR 80 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Unknown F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Total F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR 81 of 139 September 2013 atient/ED) Total NR NR NR NR NR NR NR NR Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 82 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Mental Health Utilization: Total (MPTA) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Member Months (Any) Age Member Months (Inpatient) Member Months (Intensive Outpatient/Partial Hospitalization) Male Female Total Male Female Total Male Female Total 0-12 2286598 2230569 4,517,167 2286598 2230569 4,517,167 2286598 2230569 4,517,167 13-17 578034 590990 1,169,024 578034 590990 1,169,024 578034 590990 1,169,024 18-64 166438 828969 995,407 166438 828969 995,407 166438 828969 995,407 65+ 42 52 94 42 52 94 42 52 94 Unknown 0 0 0 0 0 0 0 0 0 Total 3,031,112 3,650,580 6,681,692 3,031,112 3,650,580 6,681,692 3,031,112 3,650,580 6,681,692 Age Sex Any Services Inpatient Intensive Outpatient/Partial Hospitalization Outpatient/ED Number Percent Number Percent Number Percent Number Percent M 16754 8.79% 307 0.16% 128 0.07% 16719 8.77% 0-12 F 10053 5.41% 168 0.09% 63 0.03% 10021 5.39% Total 26,807 7.12% 475 0.13% 191 0.05% 26,740 7.10% M 6197 12.86% 411 0.85% 116 0.24% 6123 12.71% 13-17 F 6127 12.44% 665 1.35% 150 0.30% 6039 12.26% Total 12,324 12.65% 1,076 1.10% 266 0.27% 12,162 12.48% M 1332 9.60% 151 1.09% 29 0.21% 1290 9.30% 18-64 F 8180 11.84% 745 1.08% 121 0.18% 7984 11.56% Total 9,512 11.47% 896 1.08% 150 0.18% 9,274 11.18% M 0 0.00% 0 0.00% 0 0.00% 0 0.00% 65+ F 0 0.00% 0 0.00% 0 0.00% 0 0.00% Total 0 0.00% 0 0.00% 0 0.00% 0 0.00% M 0 NA 0 NA 0 NA 0 NA Unknown F 0 NA 0 NA 0 NA 0 NA Total 0 NA 0 NA 0 NA 0 NA M 24,283 9.61% 869 0.34% 273 0.11% 24,132 9.55% Total F 24,360 8.01% 1,578 0.52% 334 0.11% 24,044 7.90% Total 48,643 8.74% 2,447 0.44% 607 0.11% 48,176 8.65% Member Months (Outpa Male 2286598 578034 166438 42 0 3,031,112 Female 2230569 590990 828969 52 0 3,650,580 83 of 139 September 2013 atient/ED) Total 4,517,167 1,169,024 995,407 94 0 6,681,692 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 84 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Mental Health Utilization: Dual Eligibles (MPTB) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Member Months (Any) Age Member Months (Inpatient) Member Months (Intensive Outpatient/Partial Hospitalization) Male Female Total Male Female Total Male Female Total 0-12 NR NR NR NR NR NR NR NR NR 13-17 NR NR NR NR NR NR NR NR NR 18-64 NR NR NR NR NR NR NR NR NR 65+ NR NR NR NR NR NR NR NR NR Unknown NR NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR NR Age Sex Any Services Inpatient Intensive Outpatient/Partial Hospitalization Outpatient/ED Number Percent Number Percent Number Percent Number Percent M NR NR NR NR NR NR NR NR 0-12 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 13-17 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 18-64 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 65+ F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Unknown F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Total F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR Member Months (Outpa Male NR NR NR NR NR NR Female NR NR NR NR NR NR 85 of 139 September 2013 atient/ED) Total NR NR NR NR NR NR Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 86 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Mental Health Utilization: Disabled (MPTC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Member Months (Any) Age Member Months (Inpatient) Member Months (Intensive Outpatient/Partial Hospitalization) Male Female Total Male Female Total Male Female Total 0-12 NR NR NR NR NR NR NR NR NR 13-17 NR NR NR NR NR NR NR NR NR 18-64 NR NR NR NR NR NR NR NR NR 65+ NR NR NR NR NR NR NR NR NR Unknown NR NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR NR Age Sex Any Services Inpatient Intensive Outpatient/Partial Hospitalization Outpatient/ED Number Percent Number Percent Number Percent Number Percent M NR NR NR NR NR NR NR NR 0-12 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 13-17 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 18-64 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 65+ F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Unknown F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Total F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR Member Months (Outpa Male NR NR NR NR NR NR Female NR NR NR NR NR NR 87 of 139 September 2013 atient/ED) Total NR NR NR NR NR NR Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 88 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Mental Health Utilization: Other (MPTD) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Member Months (Any) Age Member Months (Inpatient) Member Months (Intensive Outpatient/Partial Hospitalization) Male Female Total Male Female Total Male Female Total 0-12 NR NR NR NR NR NR NR NR NR 13-17 NR NR NR NR NR NR NR NR NR 18-64 NR NR NR NR NR NR NR NR NR 65+ NR NR NR NR NR NR NR NR NR Unknown NR NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR NR Age Sex Any Services Inpatient Intensive Outpatient/Partial Hospitalization Outpatient/ED Number Percent Number Percent Number Percent Number Percent M NR NR NR NR NR NR NR NR 0-12 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 13-17 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 18-64 F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR 65+ F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Unknown F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR M NR NR NR NR NR NR NR NR Total F NR NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR NR Member Months (Outpa Male NR NR NR NR NR NR Female NR NR NR NR NR NR 89 of 139 September 2013 atient/ED) Total NR NR NR NR NR NR Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 90 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 1840826 1790797 3,631,623 10-17 1023806 1030762 2,054,568 18-34 123849 630919 754,768 35-49 35857 172613 208,470 50-64 6732 25437 32,169 65-74 41 48 89 75-84 1 3 4 85+ 0 1 1 Unknown 0 0 0 Total 3,031,112 3,650,580 6,681,692 Antibiotic Utilization Age Sex Total Antibiotic Scrips Average Scrips PMPY for Antibiotics Total Days Supplied for All Antibiotic Scrips Average Days Supplied per Antibiotic Scrip Total Number of Scrips for Antibiotics of Concern Average Scrips PMPY for Anitbiotics of Concern Percentage of Antibiotics of Concern of all Antibiotic Scrips M 221675 1.45 2058573 9.29 102431 0.67 46.21% 0-9 F 215469 1.44 2024899 9.40 93133 0.62 43.22% Total 437,144 1.44 4,083,472 9.34 195,564 0.65 44.74% M 61804 0.72 624333 10.10 27791 0.33 44.97% 10-17 F 82024 0.95 783189 9.55 34797 0.41 42.42% Total 143,828 0.84 1,407,522 9.79 62,588 0.37 43.52% M 8876 0.86 84330 9.50 3455 0.33 38.93% 18-34 F 109316 2.08 864671 7.91 37206 0.71 34.04% Total 118,192 1.88 949,001 8.03 40,661 0.65 34.40% M 3886 1.30 35861 9.23 1638 0.55 42.15% 35-49 F 31466 2.19 266057 8.46 13461 0.94 42.78% Total 35,352 2.03 301,918 8.54 15,099 0.87 42.71% M 765 1.36 6729 8.80 359 0.64 46.93% 50-64 F 4488 2.12 38878 8.66 2202 1.04 49.06% 91 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 65-74 75-84 85+ Unknown Total Age 0-9 10-17 18-34 35-49 Total M F Total M F Total M F Total M F Total M F Total Sex M F Total M F Total M F Total M F Total 5,253 3 2 5 0 0 0 0 0 0 0 0 0 297,009 442,765 739,774 Total Quinolone Scrips 79 133 212 505 1451 1,956 590 8711 9,301 453 4219 4,672 1.96 45,607 8.68 2,561 0.96 48.75% 0.88 26 8.67 2 0.59 66.67% 0.50 15 7.50 2 0.50 100.00% 0.67 41 8.20 4 0.54 80.00% 0.00 0 NA 0 0.00 NA 0.00 0 NA 0 0.00 NA 0.00 0 NA 0 0.00 NA NA 0 NA 0 NA NA 0.00 0 NA 0 0.00 NA 0.00 0 NA 0 0.00 NA NA 0 NA 0 NA NA NA 0 NA 0 NA NA NA 0 NA 0 NA NA 1.18 2,809,852 9.46 135,676 0.54 45.68% 1.46 3,977,709 8.98 180,801 0.59 40.83% 1.33 6,787,561 9.18 316,477 0.57 42.78% Antibiotics of Concern Utilization Average Scrips PMPY for Quinolones Total Cephalosporin 2nd- 4th Generation Scrips Average Scrips PMPY for Cephalosporins 2nd- 4th Total Azithromycin and Clarithromycin Scrips Generation Average Scrips PMPY for Azithromycins and Clarithro- mycins Total Amoxicillin/ Clavulanate Scrips Average Scrips PMPY for Amoxicillin/ Clavulanates Total Ketolides Scrips 0.00 26494 0.17 41268 0.27 32204 0.21 0 0.00 25273 0.17 37248 0.25 28267 0.19 0 0.00 51,767 0.17 78,516 0.26 60,471 0.20 0 0.01 3927 0.05 14383 0.17 7467 0.09 0 0.02 5395 0.06 17730 0.21 8132 0.09 0 0.01 9,322 0.05 32,113 0.19 15,599 0.09 0 0.06 222 0.02 1588 0.15 657 0.06 0 0.17 2114 0.04 17010 0.32 5290 0.10 0 0.15 2,336 0.04 18,598 0.30 5,947 0.09 0 0.15 105 0.04 613 0.21 267 0.09 0 0.29 786 0.05 5197 0.36 1987 0.14 0 0.27 891 0.05 5,810 0.33 2,254 0.13 0 92 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 50-64 65-74 75-84 85+ Unknown Total Age 0-9 10-17 18-34 35-49 M F Total M F Total M F Total M F Total M F Total M F Total Sex M F Total M F Total M F Total M F 93 798 891 1 1 2 0 0 0 0 0 0 0 0 0 1,721 15,313 17,034 0.17 35 0.06 133 0.38 126 0.06 776 0.33 161 0.06 909 0.29 0 0.00 1 0.25 0 0.00 0 0.27 0 0.00 1 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 NA 0 NA 0 0.00 0 0.00 0 0.00 0 0.00 0 NA 0 NA 0 NA 0 NA 0 NA 0 NA 0 0.01 30,783 0.12 57,986 0.05 33,694 0.11 77,961 0.03 64,477 0.12 135,947 0.24 50 0.09 0 0.37 307 0.14 0 0.34 357 0.13 0 0.29 0 0.00 0 0.00 1 0.25 0 0.13 1 0.13 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 NA 0 NA 0 0.00 0 0.00 0 0.00 0 0.00 0 NA 0 NA 0 NA 0 NA 0 NA 0 NA 0 0.23 40,645 0.16 0 0.26 43,984 0.14 0 0.24 84,629 0.15 0 All Other Antibiotics Utilization Total Absorbable Sulfonamide Scrips Average Scrips PMPY for Absorbable Sulfonamides Total Aminoglycoside Scrips Average Scrips PMPY for Aminoglycosides Total 1st Generation Cephalosporin Scrips Average Scrips PMPY for 1st Generation Cephalosporins Total Lincosamide Scrips Total Average Scrips Macrolides PMPY for (not azith. or Lincosamides clarith.) Scrips 10227 0.07 15 0.00 13357 0.09 0 0.00 227 15703 0.11 10 0.00 14213 0.10 0 0.00 271 25,930 0.09 25 0.00 27,570 0.09 0 0.00 498 4362 0.05 26 0.00 6132 0.07 0 0.00 223 8176 0.10 54 0.00 6991 0.08 0 0.00 219 12,538 0.07 80 0.00 13,123 0.08 0 0.00 442 863 0.08 0 0.00 786 0.08 0 0.00 61 9658 0.18 9 0.00 7756 0.15 0 0.00 486 10,521 0.17 9 0.00 8,542 0.14 0 0.00 547 474 0.16 0 0.00 362 0.12 0 0.00 25 3234 0.22 4 0.00 2016 0.14 0 0.00 174 93 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Total 3,708 0.21 4 0.00 2,378 0.14 0 M 93 0.17 0 0.00 64 0.11 0 50-64 F 408 0.19 0 0.00 373 0.18 0 Total 501 0.19 0 0.00 437 0.16 0 M 0 0.00 0 0.00 0 0.00 0 65-74 F 0 0.00 0 0.00 0 0.00 0 Total 0 0.00 0 0.00 0 0.00 0 M 0 0.00 0 0.00 0 0.00 0 75-84 F 0 0.00 0 0.00 0 0.00 0 Total 0 0.00 0 0.00 0 0.00 0 M 0 NA 0 NA 0 NA 0 85+ F 0 0.00 0 0.00 0 0.00 0 Total 0 0.00 0 0.00 0 0.00 0 M 0 NA 0 NA 0 NA 0 Unknown F 0 NA 0 NA 0 NA 0 Total 0 NA 0 NA 0 NA 0 M 16,019 0.06 41 0.00 20,701 0.08 0 Total F 37,179 0.12 77 0.00 31,349 0.10 0 Total 53,198 0.10 118 0.00 52,050 0.09 0 0.00 199 0.00 5 0.00 34 0.00 39 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 NA 0 0.00 0 0.00 0 NA 0 NA 0 NA 0 0.00 541 0.00 1,184 0.00 1,725 94 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 95 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Average Scrips PMPY for Ketolides Total Clindamycin Scrips Average Scrips PMPY for Clindamycins Total Misc. Antibiotics of Concern Scrips Average Scrips PMPY for Misc. Antibiotics of Concern 0.00 2362 0.02 24 0.00 0.00 2185 0.01 27 0.00 0.00 4,547 0.02 51 0.00 0.00 1475 0.02 34 0.00 0.00 2067 0.02 22 0.00 0.00 3,542 0.02 56 0.00 0.00 386 0.04 12 0.00 0.00 4037 0.08 44 0.00 0.00 4,423 0.07 56 0.00 0.00 198 0.07 2 0.00 0.00 1207 0.08 65 0.00 0.00 1,405 0.08 67 0.00 96 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 0.00 42 0.07 6 0.01 0.00 173 0.08 22 0.01 0.00 215 0.08 28 0.01 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 NA 0 NA 0 NA 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 NA 0 NA 0 NA NA 0 NA 0 NA NA 0 NA 0 NA 0.00 4,463 0.02 78 0.00 0.00 9,669 0.03 180 0.00 0.00 14,132 0.03 258 0.00 Average Scrips PMPY for Total Penicillin Macrolides Scrips (not azith. or Average Scrips PMPY for Penicillins clarith.) 0.00 95133 0.62 0.00 91283 0.61 0.00 186,416 0.62 0.00 17952 0.21 0.00 22278 0.26 0.00 40,230 0.23 0.01 2473 0.24 0.01 20675 0.39 0.01 23,148 0.37 0.01 906 0.30 0.01 5657 0.39 Total Tetracycline Scrips 67 47 114 4994 5336 10,330 1049 7310 8,359 343 2292 Average Scrips PMPY for Tetracyclines 0.00 0.00 0.00 0.06 0.06 0.06 0.10 0.14 0.13 0.11 0.16 Total Misc. Antibiotic Scrips 218 809 1,027 324 4173 4,497 189 26216 26,405 138 4628 Average Scrips PMPY for Misc. Antibiotics 0.00 0.01 0.00 0.00 0.05 0.03 0.02 0.50 0.42 0.05 0.32 97 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 0.01 6,563 0.38 2,635 0.15 4,766 0.27 0.01 153 0.27 57 0.10 34 0.06 0.02 749 0.35 307 0.14 415 0.20 0.01 902 0.34 364 0.14 449 0.17 0.00 1 0.29 0 0.00 0 0.00 0.00 0 0.00 0 0.00 0 0.00 0.00 1 0.13 0 0.00 0 0.00 0.00 0 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 0 0.00 NA 0 NA 0 NA 0 NA 0.00 0 0.00 0 0.00 0 0.00 0.00 0 0.00 0 0.00 0 0.00 NA 0 NA 0 NA 0 NA NA 0 NA 0 NA 0 NA NA 0 NA 0 NA 0 NA 0.00 116,618 0.46 6,510 0.03 903 0.00 0.00 140,642 0.46 15,292 0.05 36,241 0.12 0.00 257,260 0.46 21,802 0.04 37,144 0.07 98 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Antibiotic Utilization: Dual Eligibles (ABXB) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Member Months Member Months Age Male Female Total 0-9 NR NR NR 10-17 NR NR NR 18-34 NR NR NR 35-49 NR NR NR 50-64 NR NR NR 65-74 NR NR NR 75-84 NR NR NR 85+ NR NR NR Unknown NR NR NR Total NR NR NR Antibiotic Utilization Age Sex Total Antibiotic Scrips Average Total Days Scrips PMPY Supplied for All for Antibiotics Antibiotic Scrips Average Days Supplied per Antibiotic Scrip Total Number of Scrips for Antibiotics of Concern Average Scrips PMPY for Anitbiotics of Concern Percentage of Antibiotics of Concern of all Antibiotic Scrips M NR NR NR 0-9 F NR NR NR Total NR NR NR M NR NR NR 10-17 F NR NR NR Total NR NR NR M NR NR NR 18-34 F NR NR NR Total NR NR NR M NR NR NR 35-49 F NR NR NR Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 99 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 50-64 65-74 75-84 85+ Unknown Total Age 0-9 10-17 18-34 M F Total M F Total M F Total M F Total M F Total M F Total Sex M F Total M F Total M F Total M NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 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 Azithromycin and Clarithromycin Scrips Average Scrips PMPY for Azithromycins and Clarithromycins Total Amoxicillin/ Clavulanate Scrips Average Scrips PMPY for Amoxicillin/ Clavulanates NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 100 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 35-49 50-64 65-74 75-84 85+ Unknown Total Age 0-9 10-17 18-34 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 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR All Other Antibiotics Utilization Total Absorbable Sulfonamide Scrips Average Scrips PMPY for Absorbable Sulfonamides Total Aminoglycoside Scrips Average Scrips PMPY for Aminoglycosides Total 1st Generation Cephalosporin Scrips Average Scrips PMPY for 1st Generation Cephalosporins Total Average Scrips Lincosamide PMPY for Scrips Lincosamides NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 101 of 139 September 2013 M NR 35-49 F NR Total NR M NR 50-64 F NR Total NR M NR 65-74 F NR Total NR M NR 75-84 F NR Total NR M NR 85+ F NR Total NR M NR Unknown F NR Total NR M NR Total F NR Total NR Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 102 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 103 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Total Ketolides Scrips Average Scrips PMPY for Ketolides Total Clindamycin Scrips Total Misc. Average Scrips Average Scrips PMPY for Clindamycins Antibiotics of Concern Scrips PMPY for Misc. Antibiotics of Concern NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 104 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total Macrolides (not azith. or clarith.) Scrips Average Scrips PMPY for Macrolides (not azith. or clarith.) NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total Penicillin Scrips NR NR NR NR NR NR NR NR NR Average Scrips Total Average Scrips Total Misc. PMPY for Tetracycline PMPY for Antibiotic Penicillins Scrips Tetracyclines Scrips Average Scrips PMPY for Misc. Antibiotics NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 105 of 139 September 2013 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 106 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Antibiotic Utilization: Disabled (ABXC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Member Months Member Months Age Male Female Total 0-9 NR NR NR 10-17 NR NR NR 18-34 NR NR NR 35-49 NR NR NR 50-64 NR NR NR 65-74 NR NR NR 75-84 NR NR NR 85+ NR NR NR Unknown NR NR NR Total NR NR NR Antibiotic Utilization Age Sex Total Antibiotic Scrips Average Scrips Total Days PMPY for Supplied for All Antibiotics Antibiotic Scrips Average Days Supplied per Antibiotic Scrip Total Number of Scrips for Antibiotics of Concern Average Scrips PMPY for Anitbiotics of Concern 0-9 10-17 18-34 35-49 M NR NR NR F NR NR NR Total NR NR NR M NR NR NR F NR NR NR Total NR NR NR M NR NR NR F NR NR NR Total NR NR NR M NR NR NR F NR NR NR Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 107 of 139 September 2013 50-64 65-74 75-84 85+ Unknown Total Age 0-9 10-17 18-34 108 of 139 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare M F Total M F Total M F Total M F Total M F Total M F Total Sex M F Total M F Total M F Total M NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Antibiotics of Concern Utilization Total Quinolone Scrips Average Scrips PMPY for Quinolones Total Cephalosporin 2nd-4th Generation Scrips Average Scrips Total PMPY for Cephalosporins 2nd-4th Generation Azithromycin and Clarithromycin Scrips Average Scrips PMPY for Azithromycins and Clarithromycins NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR September 2013 35-49 50-64 65-74 75-84 85+ Unknown Total Age 0-9 10-17 18-34 109 of 139 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR All Other Antibiotics U Total Absorbable Sulfonamide Scrips Average Scrips PMPY for Absorbable Sulfonamides Total Aminoglycoside Scrips Average Scrips PMPY for Aminoglycosides Total 1st Generation Cephalosporin Scrips Average Scrips PMPY for 1st Generation Cephalosporins NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR September 2013 35-49 50-64 65-74 75-84 85+ Unknown Total Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare M NR NR NR F NR NR NR Total NR NR NR M NR NR NR F NR NR NR Total NR NR NR M NR NR NR F NR NR NR Total NR NR NR M NR NR NR F NR NR NR Total NR NR NR M NR NR NR F NR NR NR Total NR NR NR M NR NR NR F NR NR NR Total NR NR NR M NR NR NR F NR NR NR Total NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 110 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Percentage of Antibiotics of Concern of all Antibiotic Scrips NR NR NR NR NR NR NR NR NR NR NR NR 111 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total Amoxicillin/ Clavulanate Scrips Average Scrips PMPY for Amoxicillin/ Clavulanates Total Ketolides Scrips Average Scrips PMPY for Ketolides Total Clindamycin Scrips Total Misc. Average Scrips PMPY for Clindamycins Antibiotics of Concern Scrips Average Scrips PMPY for Misc. Antibiotics of Concern NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 112 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Utilization NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total Lincosamide Scrips Average Scrips PMPY for Lincosamides Total Macrolides (not azith. or clarith.) Scrips Average Scrips PMPY for Macrolides (not azith. or clarith.) NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total Penicillin Scrips NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Average Scrips Total Average Scrips Total Misc. PMPY for Tetracycline PMPY for Antibiotic Penicillins Scrips Tetracyclines Scrips Average Scrips PMPY for Misc. Antibiotics NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 113 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 114 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Antibiotic Utilization: Other (ABXD) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Member Months Member Months Age Male Female Total 0-9 NR NR NR 10-17 NR NR NR 18-34 NR NR NR 35-49 NR NR NR 50-64 NR NR NR 65-74 NR NR NR 75-84 NR NR NR 85+ NR NR NR Unknown NR NR NR Total NR NR NR Antibiotic Utilization Age Sex Total Antibiotic Scrips Average Scrips Total Days PMPY for Supplied for All Antibiotics Antibiotic Scrips Average Days Supplied per Antibiotic Scrip Total Number of Scrips for Antibiotics of Concern Average Scrips PMPY for Anitbiotics of Concern Percentage of Antibiotics of Concern of all Antibiotic Scrips M NR NR NR NR NR NR NR 0-9 F NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR M NR NR NR NR NR NR NR 10-17 F NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR M NR NR NR NR NR NR NR 18-34 F NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR M NR NR NR NR NR NR NR 35-49 F NR NR NR NR NR NR NR Total NR NR NR NR NR NR NR 115 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 50-64 65-74 75-84 85+ Unknown Total Age 0-9 10-17 18-34 M F Total M F Total M F Total M F Total M F Total M F Total Sex M F Total M F Total M F Total M NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 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 Azithromycin and Clarithromycin Scrips Average Scrips PMPY for Azithromycins and Clarithromycins Total Amoxicillin/ Clavulanate Scrips Average Scrips PMPY for Amoxicillin/ Clavulanates NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 116 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 35-49 50-64 65-74 75-84 85+ Unknown Total Age 0-9 10-17 18-34 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 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR All Other Antibiotics Utilization Total Absorbable Sulfonamide Scrips Average Scrips PMPY for Absorbable Sulfonamides Total Aminoglycoside Scrips Average Scrips PMPY for Aminoglycosides Total 1st Generation Cephalosporin Scrips Average Scrips PMPY for 1st Generation Cephalosporins Total Average Scrips Lincosamide PMPY for Scrips Lincosamides NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 117 of 139 September 2013 M NR 35-49 F NR Total NR M NR 50-64 F NR Total NR M NR 65-74 F NR Total NR M NR 75-84 F NR Total NR M NR 85+ F NR Total NR M NR Unknown F NR Total NR M NR Total F NR Total NR Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 118 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 119 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Total Ketolides Scrips Average Scrips PMPY for Ketolides Total Clindamycin Scrips Average Scrips PMPY for Clindamycins Total Misc. Antibiotics of Concern Scrips Average Scrips PMPY for Misc. Antibiotics of Concern NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 120 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total Macrolides (not azith. or clarith.) Scrips Average Scrips PMPY for Macrolides (not azith. or clarith.) NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total Penicillin Scrips NR NR NR NR NR NR NR NR NR Average Scrips PMPY for Penicillins Total Tetracycline Scrips Average Scrips PMPY for Tetracyclines Total Misc. Antibiotic Scrips Average Scrips PMPY for Misc. Antibiotics NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 121 of 139 September 2013 NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 122 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Board Certification (BCR) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Type of Physician Family Medicine Internal Medicine OB/GYN physicians Pediatricians Geriatricians Other physician specialists Number of Physicians in Each Practice Area 1282 1321 896 1105 39 4474 Board Certification Number Percent 863 827 542 682 27 2608 67.32% 62.60% 60.49% 61.72% 69.23% 58.29% 123 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Total Membership (TLM) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Product/Product Line HMO (Total) Medicaid Commercial Medicare (cost or risk) Other PPO (Total) Medicaid Commercial Medicare (cost or risk) Other POS (Total) Medicaid Commercial Medicare (cost or risk) Other FFS (Total) Medicaid Commercial Medicare (cost or risk) Other Total * Total number of members in each category as of December 31 of the measurement year. Total Number of Members* 572,311 572311 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 572,311 124 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Enrollment by Product Line: Total (ENPA) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age <1 1-4 5-9 10-14 15-17 18-19 0-19 Subtotal 0-19 Subtotal: % 20-24 25-29 30-34 35-39 40-44 20-44 Subtotal 20-44 Subtotal: % 45-49 50-54 55-59 60-64 45-64 Subtotal 45-64 Subtotal: % 65-69 70-74 75-79 80-84 85-89 >=90 >=65 Subtotal >=65 Subtotal: % Age Unknown Male Member Months 237364 747508 855954 702309 321497 83240 2,947,872 97.25% 9854 14056 16699 15693 11856 68,158 2.25% 8308 4521 1718 493 15,040 0.50% 35 6 0 1 0 0 42 0.00% 0 Female Member Months 231923 720325 838549 697633 333129 118677 2,940,236 80.54% 186859 178669 146714 94364 51051 657,657 18.02% 27198 15085 6643 3709 52,635 1.44% 48 0 3 0 0 1 52 0.00% 0 Total Member Months 469,287 1,467,833 1,694,503 1,399,942 654,626 201,917 5,888,108 88.12% 196,713 192,725 163,413 110,057 62,907 725,815 10.86% 35,506 19,606 8,361 4,202 67,675 1.01% 83 6 3 1 0 1 94 0.00% 0 125 of 139 September 2013 Total Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 3,031,112 3,650,580 6,681,692 126 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Enrollment by Product Line: Dual Eligibles (ENPB) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age <1 1-4 5-9 10-14 15-17 18-19 0-19 Subtotal 0-19 Subtotal: % 20-24 25-29 30-34 35-39 40-44 20-44 Subtotal 20-44 Subtotal: % 45-49 50-54 55-59 60-64 45-64 Subtotal 45-64 Subtotal: % 65-69 70-74 75-79 80-84 85-89 >=90 >=65 Subtotal >=65 Subtotal: % Age Unknown Male Member Months NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Female Member Months NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total Member Months NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 127 of 139 September 2013 Total Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR 128 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Enrollment by Product Line: Disabled (ENPC) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age <1 1-4 5-9 10-14 15-17 18-19 0-19 Subtotal 0-19 Subtotal: % 20-24 25-29 30-34 35-39 40-44 20-44 Subtotal 20-44 Subtotal: % 45-49 50-54 55-59 60-64 45-64 Subtotal 45-64 Subtotal: % 65-69 70-74 75-79 80-84 85-89 >=90 >=65 Subtotal >=65 Subtotal: % Age Unknown Male Member Months NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Female Member Months NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total Member Months NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 129 of 139 September 2013 Total Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR 130 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Enrollment by Product Line: Other (ENPD) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) Age <1 1-4 5-9 10-14 15-17 18-19 0-19 Subtotal 0-19 Subtotal: % 20-24 25-29 30-34 35-39 40-44 20-44 Subtotal 20-44 Subtotal: % 45-49 50-54 55-59 60-64 45-64 Subtotal 45-64 Subtotal: % 65-69 70-74 75-79 80-84 85-89 >=90 >=65 Subtotal >=65 Subtotal: % Age Unknown Male Member Months NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Female Member Months NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR Total Member Months NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR 131 of 139 September 2013 Total Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare NR NR NR 132 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Enrollment by State (EBS) WellCare of Georgia, Inc. (Org ID: 4538, SubID: 10032, Medicaid, Spec Area: None, Spec Proj: None) State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico Number 32 0 1 1 6 1 0 0 0 47 572111 0 0 15 1 1 0 7 2 0 2 1 2 0 4 7 0 0 0 0 5 0 133 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Commonwealth of Northern Marianas Puerto Rico Virgin Islands Other TOTAL 9 6 0 7 5 1 0 1 14 0 5 13 0 0 1 2 0 1 0 0 0 0 0 0 1 0 572,312 134 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 774412 Percentage of Members for Whom the Organization has Race/Ethnicity Information by Data Collection Direct Data Collection Method Indirect Data Collection Method Unknown Direct Total 100.00% Race Health Plan Direct* CMS/State Database* 0.0000 1.0000 Indirect Total* 0.0000 Total* 0.0000 Other* 0.0000 Direct Total 100.00% Ethnicity Health Plan Direct* CMS/State Database* 0.0000 1.0000 Indirect Total* 0.0000 Total* 0.0000 Other* 0.0000 *Enter percentage as a value between 0 and 1. Race Hispanic or Latino Not Hispanic or Latino Number Percentage Number Percentage Unknown Ethnicity Number Percentage White 0 0.00% 1847 3.60% 311328 43.97% Black or African American 0 0.00% 28965 56.49% 260994 36.86% American-Indian and Alaska Native 0 0.00% 488 0.95% 0 0.00% Asian 0 0.00% 11791 22.99% 0 0.00% Native Hawaiian and Other Pacific Islanders 0 0.00% 473 0.92% 0 0.00% Some Other Race 0 0.00% 7713 15.04% 0 0.00% Two or More Races 0 0.00% 0 0.00% 3 0.00% Unknown 15079 100.00% 0 0.00% 135731 19.17% Declined 0 0.00% 0 0.00% 0 0.00% Total 15,079 100.00% 51,277 100.00% 708,056 100.00% Declined Ethnicity Number Percentage 0 NR 0 NR 0 NR 0 NR 0 NR 0 NR 0 NR 0 NR 0 NR 0 NR Tot Number 313,175 289,959 488 11,791 473 7,713 3 150,810 0 774,412 135 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare tal Percentage 40.44% 37.44% 0.06% 1.52% 0.06% 1.00% 0.00% 19.47% 0.00% 100.00% 136 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 0.8506 0.1494 Preferred Language for Written Materials* 0.0000 Other Language Needs* 0.0000 *Enter percentage as a value between 0 and 1. Spoken Language Preferred for Health Care Number English 713570 Non-English 54704 Unknown 6138 Declined 0 Total* 774,412 Language Preferred for Written Materials Number English 713479 Non-English 54699 Unknown 6234 Declined 0 Total* 774,412 Other Language Needs Number English 0 Non-English 0 Unknown 774412 Declined 0 Total* 774,412 0.0000 0.0000 Percentage 92.14% 7.06% 0.79% 0.00% 100.00% Percentage 92.13% 7.06% 0.80% 0.00% 100.00% Percentage 0.00% 0.00% 100.00% 0.00% 100.00% 1.0000 1.0000 137 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare *Should sum to 100% 138 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 Weeks of Pregnancy < 0 weeks 1-12 weeks 13-27 weeks 28 or more weeks Unknown Total 2012 Number 3136 2458 17599 4431 2370 29,994 Percentage 10.46% 8.19% 58.68% 14.77% 7.90% 100.00% 139 of 139 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 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 - 2012 The Auditor lock has been applied to this submission. Pharmacy Reversal - Pharmacy Reversals NOT Included Measure/Data Element Report Measure Benefit Offered Rotated Measure Rate Reportable Effectiveness of Care: Prevention and Screening Adult BMI Assessment (aba) Y Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents Y (wcc) BMI Percentile Counseling for Nutrition Counseling for Physical Activity Childhood Immunization Status (cis) Y DTaP IPV MMR HiB Hepatitis B VZV Pneumococcal Conjugate Hepatitis A Rotavirus Influenza Combination #2 Combination #3 Combination #4 Combination #5 Combination #6 Combination #7 Combination #8 Combination #9 Combination #10 Immunizations for Adolescents (ima) Y N 67.88% R N 38.69% R 55.47% R 42.09% R N 88.56% R 96.11% R 94.16% R 95.13% R 94.65% R 94.16% R 85.40% R 94.40% R 74.21% R 47.20% R 84.43% R 78.83% R 78.35% R 64.72% R 42.82% R 64.48% R 42.58% R 38.69% R 38.44% R 1 of 17 Comment Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Meningococcal 72.99% R Tdap/Td 80.75% R Combination #1 70.98% R Human Papillomavirus Vaccine for Female Adolescents (hpv) Y 19.95% R Lead Screening in Children (lsc) Y N 75.34% R Breast Cancer Screening (bcs) Y 55.78% R Cervical Cancer Screening (ccs) Y 72.51% R Chlamydia Screening in Women (chl) Y 16-20 Years 44.26% R 21-24 Years 62.42% R Total 48.66% R Effectiveness of Care: Respiratory Conditions Appropriate Testing for Children with Pharyngitis (cwp) Y Y 75.70% R Appropriate Treatment for Children With URI (uri) Y Y 79.95% 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% 16.30% R 39.62% R 73.28% R 84.73% R 90.56% R 88.16% R 75.65% R NA R 89.12% R 44.39% R 20.41% R 2 of 17 Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 12-18 Years - Medication Compliance 50% 12-18 Years - Medication Compliance 75% 19-50 Years - Medication Compliance 50% 19-50 Years - Medication Compliance 75% 51-64 Years - Medication Compliance 50% 51-64 Years - Medication Compliance 75% Total - Medication Compliance 50% Total - Medication Compliance 75% Asthma Medication Ratio (amr) Y Y 5-11 Years 12-18 Years 19-50 Years 51-64 Years Total 41.40% R 19.20% R 54.15% R 33.17% R NA R NA R 43.85% R 20.55% R 65.62% R 62.25% R 45.90% R NA R 63.72% R Effectiveness of Care: Cardiovascular Cholesterol Management for Patients With Cardiovascular Conditions (cmc) Y N LDL-C Screening Performed 89.39% R LDL-C Control (<100 mg/dL) 34.85% R Controlling High Blood Pressure (cbp) Y 49.64% 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 HbA1c Poor Control (>9.0%) HbA1c Control (<8.0%) HbA1c Control (<7.0%) Eye Exam (Retinal) Performed LDL-C Screening Performed LDL-C Control (<100 mg/dL) Medical Attention for Nephropathy Blood Pressure Control (<140/80 mm Hg) Blood Pressure Control (<140/90 mm Hg) N 78.47% R 54.01% R 39.05% R 32.36% R 40.51% R 69.71% R 28.10% R 72.81% R 28.47% R 51.64% R 3 of 17 Reportable Reportable Reportable Reportable Denominator fewer than 30 Denominator fewer than 30 Reportable Reportable Reportable Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Effectiveness of Care: Musculoskeletal Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis (art) Y Y Use of Imaging Studies for Low Back Pain (lbp) Y Effectiveness of Care: Behavioral Health Antidepressant Medication Management (amm) Y Y Effective Acute Phase Treatment Effective Continuation Phase Treatment 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 Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Y Y Medication (ssd) Diabetes Monitoring for People With Diabetes and Schizophrenia (smd) Y Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (smc) Y Adherence to Antipsychotic Medications for Individuals With Schizophrenia (saa) Y Y 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 62.20% R 73.93% R 50.00% R 32.74% R 39.39% R 53.10% R 77.16% R 60.37% R 84.93% R NA R NA R 39.80% R 88.51% R NA R 87.85% R 63.68% R 87.06% R 4 of 17 Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Denominator fewer than 30 Denominator fewer than 30 Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 20-44 Years 45-64 Years 65+ Years Total Children and Adolescents' Access to Primary Care Practitioners (cap) Y 12-24 Months 25 Months - 6 Years 7-11 Years 12-19 Years Annual Dental Visit (adv) Y Y 2-3 Years 4-6 Years 7-10 Years 11-14 Years 15-18 Years 19-21 Years Total Initiation and Engagement of AOD Dependence Treatment (iet) Y Y Initiation of AOD Treatment: 13-17 Years Engagement of AOD Treatment: 13-17 Years Initiation of AOD Treatment: 18+ Years Engagement of AOD Treatment: 18+ Years Initiation of AOD Treatment: Total Engagement of AOD Treatment: Total Prenatal and Postpartum Care (ppc) Y Timeliness of Prenatal Care Postpartum Care Call Answer Timeliness (cat) Y Utilization Frequency of Ongoing Prenatal Care (fpc) Y <21 Percent 21-40 Percent 41-60 Percent 85.81% R 91.21% R NA R 86.49% R 97.56% R 91.63% R 91.80% R 89.57% R 52.22% R 77.61% R 80.37% R 73.72% R 63.06% R 41.88% R 71.48% R 49.07% R 17.44% R 48.07% R 10.93% R 48.28% R 12.27% R 84.18% R 62.53% R 85.10% R 12.90% R 5.11% R 5.60% R 5 of 17 Reportable Reportable Denominator fewer than 30 Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 61-80 Percent 13.87% R 81+ Percent 62.53% R Well-Child Visits in the First 15 Months of Life (w15) Y N 0 Visits 3.06% R 1 Visit 3.32% R 2 Visits 2.55% R 3 Visits 6.12% R 4 Visits 7.65% R 5 Visits 10.71% R 6+ Visits 66.58% R Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (w34) Y Adolescent Well-Care Visits (awc) Y Frequency of Selected Procedures (fsp) Y N 68.46% R N 51.58% R R Ambulatory Care: Total (amba) Y R Ambulatory Care: Dual Eligibles (ambb) N NR Ambulatory Care: Disabled (ambc) N NR Ambulatory Care: Other (ambd) N NR Inpatient Utilization--General Hospital/Acute Care: Y R Total (ipua) Inpatient Utilization--General Hospital/Acute Care: Dual Eligibles (ipub) N NR Inpatient Utilization--General Hospital/Acute Care: Disabled (ipuc) N NR Inpatient Utilization--General Hospital/Acute Care: Other (ipud) N NR Identification of Alcohol and Other Drug Services: Total (iada) Y Y R Identification of Alcohol and Other Drug Services: Dual Eligibles (iadb) N N NR Identification of Alcohol and Other Drug Services: Disabled (iadc) N N NR Identification of Alcohol and Other Drug Services: Other (iadd) N N NR Mental Health Utilization: Total (mpta) Y Y R 6 of 17 Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Measure Unselected Measure Unselected Measure Unselected Reportable Measure Unselected Measure Unselected Measure Unselected Reportable Measure Unselected Measure Unselected Measure Unselected Reportable September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Mental Health Utilization: Dual Eligibles (mptb) N N NR Mental Health Utilization: Disabled (mptc) N N NR Mental Health Utilization: Other (mptd) N N NR Antibiotic Utilization: Total (abxa) Y Y R Antibiotic Utilization: Dual Eligibles (abxb) N N NR Antibiotic Utilization: Disabled (abxc) N N NR Antibiotic Utilization: Other (abxd) N N NR Relative Resource Use Relative Resource Use for People With Diabetes (rdi) Y R Relative Resource Use for People With Asthma (ras) Y Y R Relative Resource Use for People With Cardiovascular Conditions (rca) Y R Relative Resource Use for People With Hypertension (rhy) Y R Relative Resource Use for People With COPD (rco) Y R Health Plan Descriptive Information Board Certification (bcr) Y R Total Membership (tlm) Y R Enrollment by Product Line: Total (enpa) Y R Enrollment by Product Line: Dual Eligibles (enpb) N NR Enrollment by Product Line: Disabled (enpc) N NR Enrollment by Product Line: Other (enpd) N NR Enrollment by State (ebs) Y R Race/Ethnicity Diversity of Membership (rdm) Y R Language Diversity of Membership (ldm) Y R Weeks of Pregnancy at Time of Enrollment in MCO (wop) Y R Measure Unselected Measure Unselected Measure Unselected Reportable Measure Unselected Measure Unselected Measure Unselected Reportable Reportable Reportable Reportable Reportable Reportable Reportable Reportable Measure Unselected Measure Unselected Measure Unselected Reportable Reportable Reportable Reportable 7 of 17 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 Eligible Population Exclusions Eligible Population per 1,000 Member Year Medical Eligible Population per 1,000 Member Year 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)] Inpatient Facility PMPM E&M Inpatient Services PMPM E&M Outpatient Services PMPM Surgery & Procedure Inpatient Services PMPM Surgery & Procedure Outpatient Services PMPM Imaging Services PMPM Laboratory Services PMPM Pharmacy PMPM Inpatient Facility: Acute Inpatient: Medical Days per 1000 MY Inpatient Facility: Acute Inpatient: Medical Discharges per 1000 MY Inpatient Facility: Acute Inpatient: Surgery Days per 1000 MY Inpatient Facility: Acute Inpatient: Surgery Discharges per 1000 MY Inpatient Facility: Nonacute Days per 1000 MY Inpatient Facility: Nonacute Discharges per 1000 MY Inpatient Facility Acute Medical ALOS Inpatient Facility Acute Surgery ALOS Inpatient Facility Nonacute ALOS Measure Data 2387 111 1,012.69 1,012.69 11775 5319 12320 97094 126,508.00 95.36% 94.81% 86.49% 291.94 13.78 90.75 13.27 60.69 77.52 69.35 160.13 1,184.51 339.83 209.16 47.94 0.00 0.00 3.49 4.36 NA 8 of 17 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Total Inpatient Facility Acute ALOS Total Inpatient Facility ALOS ED Discharges per 1000 MY Medical Cardiac Catheterization per 1000 MY Medical PCI per 1000 MY Medical CABG per 1000 MY Medical Carotid Endarterectomy per 1000 MY Medical Carotid Artery Stenosis Diagnostic Test per 1000 MY Medical Cardiac Computed Tomography per 1000 MY Medical CAD Diagnostic Test Using EBCT/Nuclear Imaging Stress Tests per 1000 MY Medical 3.59 3.59 2,612.13 21.64 5.52 2.12 0.42 1.27 1.27 120.06 9 of 17 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 Eligible Population Exclusions Eligible Population per 1,000 Member Year Medical Eligible Population per 1,000 Member Year 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)] Inpatient Facility PMPM E&M Inpatient Services PMPM E&M Outpatient Services PMPM Surgery & Procedure Inpatient Services PMPM Surgery & Procedure Outpatient Services PMPM Imaging Services PMPM Laboratory Services PMPM Pharmacy PMPM Inpatient Facility: Acute Inpatient: Medical Days per 1000 MY Inpatient Facility: Acute Inpatient: Medical Discharges per 1000 MY Inpatient Facility: Acute Inpatient: Surgery Days per 1000 MY Inpatient Facility: Acute Inpatient: Surgery Discharges per 1000 MY Inpatient Facility: Nonacute Days per 1000 MY Inpatient Facility: Nonacute Discharges per 1000 MY Inpatient Facility Acute Medical ALOS Inpatient Facility Acute Surgery ALOS Inpatient Facility Nonacute ALOS Measure Data 6955 794 1,011.33 1,011.33 38516 27614 15304 86964 168,398.00 78.74% 75.90% 60.73% 34.41 1.97 59.88 1.04 10.88 12.80 9.43 110.47 149.19 52.64 14.83 4.22 23.41 1.02 2.83 3.52 23.00 10 of 17 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Total Inpatient Facility Acute ALOS Total Inpatient Facility ALOS ED Discharges per 1000 MY Medical 2.88 3.24 1,038.96 11 of 17 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 Eligible Population Exclusions Eligible Population per 1,000 Member Year Medical Eligible Population per 1,000 Member Year 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)] Inpatient Facility PMPM E&M Inpatient Services PMPM E&M Outpatient Services PMPM Surgery & Procedure Inpatient Services PMPM Surgery & Procedure Outpatient Services PMPM Imaging Services PMPM Laboratory Services PMPM Pharmacy PMPM Inpatient Facility: Acute Inpatient: Medical Days per 1000 MY Inpatient Facility: Acute Inpatient: Medical Discharges per 1000 MY Inpatient Facility: Acute Inpatient: Surgery Days per 1000 MY Inpatient Facility: Acute Inpatient: Surgery Discharges per 1000 MY Inpatient Facility: Nonacute Days per 1000 MY Inpatient Facility: Nonacute Discharges per 1000 MY Inpatient Facility Acute Medical ALOS Inpatient Facility Acute Surgery ALOS Inpatient Facility Nonacute ALOS Measure Data 151 4 1,006.67 1,006.67 843 717 1209 10873 13,642.00 94.40% 93.81% 88.56% 802.49 36.27 124.17 80.54 83.68 123.38 98.72 248.61 2,133.33 560.00 1,113.33 206.67 0.00 0.00 3.81 5.39 NA 12 of 17 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Total Inpatient Facility Acute ALOS Total Inpatient Facility ALOS ED Discharges per 1000 MY Medical Cardiac Catheterization per 1000 MY Medical PCI per 1000 MY Medical CABG per 1000 MY Medical Carotid Endarterectomy per 1000 MY Medical Carotid Artery Stenosis Diagnostic Test per 1000 MY Medical Cardiac Computed Tomography per 1000 MY Medical CAD Diagnostic Test Using EBCT/Nuclear Imaging Stress Tests per 1000 MY Medical 4.23 4.23 2,806.67 120.00 120.00 60.00 6.67 26.67 0.00 520.00 13 of 17 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 Eligible Population Exclusions Eligible Population per 1,000 Member Year Medical Eligible Population per 1,000 Member Year 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)] Inpatient Facility PMPM E&M Inpatient Services PMPM E&M Outpatient Services PMPM Surgery & Procedure Inpatient Services PMPM Surgery & Procedure Outpatient Services PMPM Imaging Services PMPM Laboratory Services PMPM Pharmacy PMPM Inpatient Facility: Acute Inpatient: Medical Days per 1000 MY Inpatient Facility: Acute Inpatient: Medical Discharges per 1000 MY Inpatient Facility: Acute Inpatient: Surgery Days per 1000 MY Inpatient Facility: Acute Inpatient: Surgery Discharges per 1000 MY Inpatient Facility: Nonacute Days per 1000 MY Inpatient Facility: Nonacute Discharges per 1000 MY Inpatient Facility Acute Medical ALOS Inpatient Facility Acute Surgery ALOS Inpatient Facility Nonacute ALOS Measure Data 4830 529 1,012.28 1,012.28 13935 8874 28936 196703 248,448.00 96.22% 95.68% 90.82% 230.26 11.48 90.79 14.70 58.00 73.48 58.41 119.95 853.21 237.04 210.21 48.83 0.00 0.00 3.60 4.30 NA 14 of 17 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Total Inpatient Facility Acute ALOS Total Inpatient Facility ALOS ED Discharges per 1000 MY Medical 3.72 3.72 2,601.11 15 of 17 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare 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 Eligible Population Exclusions Eligible Population per 1,000 Member Year Medical Eligible Population per 1,000 Member Year 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)] Inpatient Facility PMPM E&M Inpatient Services PMPM E&M Outpatient Services PMPM Surgery & Procedure Inpatient Services PMPM Surgery & Procedure Outpatient Services PMPM Imaging Services PMPM Laboratory Services PMPM Pharmacy PMPM Inpatient Facility: Acute Inpatient: Medical Days per 1000 MY Inpatient Facility: Acute Inpatient: Medical Discharges per 1000 MY Inpatient Facility: Acute Inpatient: Surgery Days per 1000 MY Inpatient Facility: Acute Inpatient: Surgery Discharges per 1000 MY Inpatient Facility: Nonacute Days per 1000 MY Inpatient Facility: Nonacute Discharges per 1000 MY Inpatient Facility Acute Medical ALOS Inpatient Facility Acute Surgery ALOS Inpatient Facility Nonacute ALOS Measure Data 547 30 1,012.65 1,012.65 3308 2260 3939 30190 39,697.00 93.79% 93.04% 85.97% 448.50 23.37 112.32 23.05 84.94 104.00 82.44 213.87 1,601.36 462.82 336.93 72.20 81.46 5.55 3.46 4.67 14.67 16 of 17 September 2013 Appendix F: Department of Community Health, State of Georgia Audited CY 2012 HEDIS Measure Results for WellCare Total Inpatient Facility Acute ALOS Total Inpatient Facility ALOS ED Discharges per 1000 MY Medical 3.62 3.74 2,765.81 17 of 17 September 2013