Neighborhood Health Plan of Rhode Island

1
Neighborhood Health PlanofRhode Island
HEDIS 2005 Results CAHPS 2005 Results
Neighborhood is rated as one of the Top 10
Medicaid plans in the nation for Effectiveness
of Care. This means that Neighborhoods members
are in good hands! Neighborhood is committed to
providing the best care available. -National
Committee for Quality Assurance (NCQA)
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA). CAHPS is
a registered trademark of the Agency for
Healthcare Research and Quality (AHRQ).
2
HEDIS 2005 Overview
Overview HEDIS stands for Health Plan Employer
Data and Information Set. It is the most widely
used standardized set of performance measures in
the managed care industry. HEDIS development and
maintenance is sponsored and supported by the
National Committee for Quality Assurance (NCQA).
NCQA expects health plans to use annual HEDIS
results in the development of their quality work
plans and in the development of ongoing
continuous improvement processes. Methodology HED
IS measures are specified for one of three data
collection methodologies administrative, hybrid
or survey. The Administrative method uses claims
data to identify the denominator and numerator.
In this case, the denominator will include all
eligible Medicaid members. The Hybrid method
uses both administrative and medical record data
to identify the denominator and numerator. The
Hybrid denominator consists of a systematic
sample of members drawn from the eligible
population. Member satisfaction is assessed
through surveys. Careful sample requirements
include continuous enrollment information. All
measurement processes must pass an external audit
by an NCQA-certified HEDIS auditor. HEDIS 2005
represents services through Calendar Year (CY)
2004. Benchmarks NCQA requires accredited
health plans to report a selected set of HEDIS
performance measures to NCQA. Favorable
comparison of a plans HEDIS results to a
benchmark will enhance the overall accreditation
score from NCQA. Two sets of benchmarks are used
in this report 1) the Medicaid Accreditation
2005 benchmarks published by NCQA, and 2) the
Quality Compass 2004 90th percentile. Regional
thresholds have not been established due to the
small number of participating Medicaid plans.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
3
HEDIS 2005 Overview (Continued)

• Measures
• There are 61 measures in the full HEDIS 2005
  reporting set. These measures are divided into
  eight categories or domains. These domains
  include
• Effectiveness of Care
• Access/Availability of Care
• Satisfaction with the Experience of Care
• Health Plan Stability
• Use of Services
• Cost of Care
• Informed Health Care Choices
• Health Plan Descriptive Information
• Measures Included in This Report
• Neighborhood Health Plan of Rhode Island (NHPRI)
  is reporting 22 performance measures in this
  report. A selected set of these measures will be
  reported to NCQA for accreditation purposes and
  to the Rhode Island Department of Health for
  public reporting.
• Significance Testing
• Significant differences among the HEDIS 2005 and
  HEDIS 2004 scores at the p lt 0.05 level have been
  noted for the Effectiveness of Care and
  Access/Availability of Care measures.

HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
4
HEDIS 2005 Audit

• As data collection methods vary among health
  plans, an audit of HEDIS results by an
  independent agency ensures that HEDIS
  specifications have been met. NHPRIs HEDIS 2005
  results underwent a rigorous audit by Ernst
  Young LLP (EY), a national auditing firm
  certified by NCQA.
• NHPRI passed the audit in the opinion of EY,
  NHPRI has prepared these HEDIS measures according
  to specifications and can report these measures
  to NCQA for consideration during the
  accreditation process.
• 2005 marked the first year NHPRI used a
  NCQA-certified HEDIS software vendor, QMark, to
  calculate its measures.

HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
5
HEDIS 2005 Results Childhood Immunization Status

• Description
• The percentage of children who turned
• two years old during 2003 and were
• up-to-date with immunizations.
• NHPRI results
• 4 DTP (diphtheria-tetanus-pertussis) 86
• 3 OPV/IPV (oral or injectable polio virus) 95.
• 1 MMR (measles-mumps-rubella) 94.
• 3 Hib (haemophilus influenza type B) 83.
• 3 Hep B (hepatitis B) 89.
• 1 VZV (chicken pox) 91.
• Combo 1 70.
• (all required DPT, OPV, HIB, MMR, HEP B)
• Combo 2 (combo 1 and VZV) 68
• NHPRIs rate ranked above the 75th
• percentile.
• Rotated Measure

- Medicaid Accreditation 2005 90th Percentile
(CIS Combo 2 70)
2003 2004 Improvement Initiatives NHPRI
provided to high volume primary care sites their
performance rates and a list of their patients
who did not meet immunization standards was made
available upon request. The Plan educated
members about the benefits of childhood
immunization, provided children turning one year
of age a birthday card reminding parents about
lead screening and timely immunizations. The
plan provided a performance-based incentive for
selected large primary care sites.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
6
HEDIS 2005 Results Adolescent Immunization
Status

• Description
• The percentage of members who turned 13 during
  2003 and were
• up-to-date with immunizations.
• NHPRI results
• 1 MMR (measles-mumps-rubella) 90
• 3 Hep B (hepatitis B) 76
• 1 VZV (chicken pox) 77
• Combo 1 (MMR and Hep B) 76
• Combo 2 (all immunizations) 67
• NHPRIs rate ranked above the 90th percentile.
• Rotated Measure

- Medicaid Accreditation 2005 90th Percentile
(AIS 55)
2003 2004 Improvement Initiatives NHPRI
provided to high volume primary care sites their
performance rates and a list of their patients
who did not meet immunization standards was made
available upon request. The Plan also educated
members about the benefits of adolescent
immunization, and provided a performance-based
incentive for selected large primary care sites.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
7
HEDIS 2005 Results Breast Cancer Screening
Description Breast cancer screening measures the
percentage of women age 50 through 69 years who
had a mammogram during 2003 or 2004. NHPRIs
rate ranked in the 90th percentile.
- Medicaid Accreditation 2005 90th Percentile
(BCS 67)
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
8
HEDIS 2005 Results Cervical Cancer Screening

• Description
• The percentage of women 21-64 years old, who
  received one or more Pap tests during the three
  year period
• 2002 - 2004.
• NHPRIs rate ranked above the
• 90th percentile.

- Medicaid Accreditation 2005 90th Percentile
(CCS 67)
The HEDIS 2005 rate is significantly higher than
the HEDIS 2003 rate. The measure was rotated in
2004.
2004 Improvement Initiatives NHPRI provided to
high volume primary care sites their performance
rates and a list of their patients who required a
pap smear was made available upon request. NHPRI
also continued sending out a Reminder letter in
English and Spanish, emphasizing the importance
of regular screening for cervical cancer,
chlamydia, and other Sexually Transmitted
Diseases (STDs) female members received the
letter during their birthday month. The Plan
also provided a performance-based incentive for
selected large primary care sites.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
9
HEDIS 2005 Results Appropriate Treatment For
Children With Upper
Respiratory Infection

• Description
• The percentage of children 3 months to 18 years
  of age who were diagnosed with upper respiratory
  infection and were not dispensed an antibiotic
  prescription on or 3 days after the Episode Date.

2004 Improvement Initiatives NHPRI staff
attended HEALTHs annual School Nurse Teacher
Conference in March 2004 and distributed over 200
English and Spanish posters and pads, Coughing?
Runny Nose? Earache?, teaching the differences
between viral and bacterial infections, and
explaining the appropriate use of antibiotics.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
10
HEDIS 2005 Results Appropriate Testing For
Children With Pharyngitis

• Description
• The percentage of children 2 18 years of age
  who were diagnosed with pharyngitis, prescribed
  an antibiotic and who received a group A
  streptococcus test for the episode.

The HEDIS 2005 rate is significantly higher than
the HEDIS 2004 rate.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
11
HEDIS 2005 Results Chlamydia Screening in Women

• Description
• The percentage of women age 16 through 25 years
  identified as sexually active, who had at least
  one test for chlamydia during 2004.
• NHPRIs rate ranked close to the 50th percentile
  in the ages 16-20 category and the 21-26 category.

The age range changed from 21-26 to 21-25
starting with HEDIS 2004.
Quality Compass 2004 90th Percentile (63, 62,
62)
2004 Improvement Initiatives NHPRI provided to
high volume primary care sites their performance
rates. NHPRI also continued sending out a
Reminder letter in English and Spanish,
emphasizing the importance of regular screening
for cervical cancer, chlamydia, and other
Sexually Transmitted Diseases (STDs) female
members receive the letter during their birthday
month. As part of a collaborative effort between
the three RI health plans, HEALTH, Quality
Partners of RI, and local womens health leaders,
a total of 2,100 chlamydia screening toolkits
were mailed in August 2004 to PCPs and OB/GYNs
throughout RI. The toolkit included the USPSTF
Screening guideline, a resource list of local
labs that process urine screenings, STD
information and reporting forms from HEALTH, and
patient education forms in English and Spanish.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
12
HEDIS 2005 Results Controlling High Blood
Pressure
Description The percentage of members age 46
through 85 with diagnosed hypertension whose
blood pressure was adequately controlled
(lt140/90). NHPRIs rate ranked in the 90th
percentile.
- Medicaid Accreditation 2005 90th Percentile
(65)
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
13
HEDIS 2005 Results Comprehensive Diabetes Care
- Medicaid Accreditation 2005 90th Percentile
(83, 60, 74, 54) Quality Compass 2004 90th
Percentile (70, 60)

• Description
• The percentage of members with diabetes age 18
  through 75 years old, who had each of the
  following during 2004
• Hemoglobin A1c (HbA1c) tested
• HbA1c well controlled (lt9.0)
• LDL-C Control (LDL lt130 mg/dL)
• LDL-C Control (LDL lt100 mg/dL)
• Dilated eye exam performed
• Lipid profile performed
• Kidney disease monitored

2004 Improvement Initiatives NHPRI sent primary
care sites a quarterly list of their members with
diabetes, noting which members had claims for
four important milestones of diabetes care. Sites
were informed that the list was meant to be used
as a partial registry for diabetes patients to
aid in tracking their care. Members received
educational materials on nutrition to enhance
self-management. NHPRI did telephone outreach,
member education and care coordination for
members with no recent HbA1c test. NHPRI
supported expansion of a primary care
collaborative effort to improve diabetes care at
primary care sites.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
14
HEDIS 2005 Results Use of Appropriate
Medications for People with Asthma

• Description
• This process measure evaluates whether members,
  age 5 through 56 with persistent asthma are being
  prescribed medication acceptable as primary
  therapy for long-term control of asthma. process
  measure evaluates
• NHPRIs rate ranked above the 90th percentile in
  the 5-9 10-17 age groups and combined rates.
  The 18-56 age group rate ranked above the 75th
  percentile.

The HEDIS 2005 rate for Ages 5-9 and Combined are
significantly higher than the 2004 rates.
- Medicaid Accreditation 2005 90th Percentile
(71) Quality Compass 2004 90th Percentile
(74, 71, 75)
2004 Improvement Initiatives Quarterly NHPRI
sent primary care sites a list of their members
with persistent asthma, noting recent member
asthma medication use patterns and member
ER/hospital utilization for asthma. NHPRI
notified primary care providers every 3 months of
any member who had inappropriate short-acting
beta-agonist use and sent a report when any
member was hospitalized for asthma. The asthma
case manager followed up with members
hospitalized for asthma and with members
identified with inappropriate medication use to
ensure appropriate management. Asthma advocates
did home visits for asthma education and
environmental assessment for members with asthma
in 3 urban core communities. NHPRI sponsored 3
continuing medical education seminars for primary
care providers and medical staff from three urban
health centers. Members with asthma received
educational materials to encourage appropriate
asthma self-management.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
15
HEDIS 2005 Results Follow-Up After
Hospitalization
for Mental Illness

• Description
• The percentage of members age 6 and older who
  were hospitalized for treatment of selected
  mental health disorders and were seen on an
  ambulatory basis or were in day/night treatment
  with a mental health practitioner within 7 days
  and within 30 days of discharge.

The HEDIS 2005 rates are significantly higher
than the 2004 rates.
- Medicaid Accreditation 2005 90th Percentile
(60, 72)
2004 Improvement Initiatives The Aftercare
Coordinator of NHPRIs behavioral health partner,
Beacon Health Strategies, makes reminder calls to
members within 2 days of the members scheduled
appointment. To assist with this, Beacon created
a program in our clinical information system that
alerts the Aftercare Coordinator when a member
requires a reminder call. Beacon Utilization
Review Clinicians complete an aftercare
appointment screen at the time of discharge,
which serves as a tracking mechanism for the
Aftercare Coordinator to make reminder calls to
members and follow-up calls to providers. This
program also alerts the Aftercare Coordinator to
call the outpatient provider, within 2 days of
the members scheduled aftercare appointment, to
determine if the member attended the appointment.
If the member attended the visit, a successful
appointment is recorded. If the member fails to
keep the appointment, the Aftercare Coordinator
determines from the provider if the member
rescheduled, cancelled without rescheduling or
no-showed.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
16
HEDIS 2005 Results Antidepressant Medication
Management

• Description
• The percentage of members age 18 years and older
  as of April 30, 2004 who were diagnosed with a
  new episode of depression, treated with
  antidepressant medication, and
• 1) had at least 3 follow-up contacts with a PCP
  or mental health PCP during the 84-day Acute
  Treatment Phase (Contacts)
• 2) remained on an antidepressant drug during the
  entire 84-day Acute Treatment Phase (Effective
  Acute Phase Treatment)
• 3) remained on an antidepressant drug for at
  least 180 days (Effective Continuation Phase
  Treatment).
• NHPRIs rate ranked above the 50th percentile in
  practitioner contacts, acute phase treatment rate
  and the continuation phase treatment.

- Medicaid Accreditation 2005 90th Percentile
(44, 65, 46)

• 2004 Improvement Initiatives
• The NHPRI BH department analyzed the HEDIS
  antidepressant Optimal Practitioner contact
  measure to identify barriers and interventions
  for this measure. The NHPRI BH supervisor
  participated in QPI visits to review the HEDIS
  antidepressant measure with PCPs and to remind
  PCPs that they are allowed to bill for BH
  services. In addition, NHPRI and Beacon
  disseminated a Depression tool kit for primary
  care to provide resources for PCPs treating
  depression in their practices.

HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
17
HEDIS 2005 Results Medical Assistance with
Smoking Cessation Advising
Smokers to Quit

• Description
• This rate is calculated using combined responses
  from the HEDIS 2004 and 2005 CAHPS 3.0H Adult
  Medicaid survey. It measures the percent of
  current smokers or recent quitters, seen by a
  health plan provider, who received advice to quit
  smoking from a health plan provider.
• NHPRIs rate ranked above the 75th percentile.

- Medicaid Accreditation 2005 90th Percentile
(73)
2004 Improvement Initiatives NHPRI has two
tobacco treatment programs. The QuitNow program,
which is funded by the RI Department of Health,
provides face-to-face tobacco education/cessation
to patients at the Providence Community Health
Centers. Free nicotine replacement therapy
patches are provided to those participants who
are medically approved. The Baby and Me Smoke
Free program is sponsored by NHPRI and provides
telephonic education/cessation to pregnant NHPRI
Rite Care members. Referrals to Baby and Me Smoke
Free come from Bright Start, NHPRI's high risk
pregnancy program. Both programs provide
individualized counseling and education and are
designed to help participants quit tobacco use.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
18
HEDIS 2005 Results Medical Assistance with
Smoking Cessation - Discussing
Smoking Cessation Medications

• Description
• This rate is calculated using combined responses
  from the HEDIS 2004 and 2005 CAHPS 3.0H Adult
  Medicaid survey. It measures the percent of
  current smokers or recent quitters, seen by a
  health plan provider, whose practitioner
  recommended or discussed smoking cessation
  medications.

2004 Improvement Initiatives NHPRI has two
tobacco treatment programs. The QuitNow program,
which is funded by the RI Department of Health,
provides face-to-face tobacco education/cessation
to patients at the Providence Community Health
Centers. Free nicotine replacement therapy
patches are provided to those participants who
are medically approved. The Baby and Me Smoke
Free program is sponsored by NHPRI and provides
telephonic education/cessation to pregnant NHPRI
Rite Care members. Referrals to Baby and Me Smoke
Free come from Bright Start, NHPRI's high risk
pregnancy program. Both programs provide
individualized counseling and education and are
designed to help participants quit tobacco use.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
19
HEDIS 2005 Results Medical Assistance with
Smoking Cessation - Discussing
Smoking Cessation Strategies

• Description
• This rate is calculated using combined responses
  from the HEDIS 2004 and 2005 CAHPS 3.0H Adult
  Medicaid survey. It measures the percent of
  current smokers or recent quitters, seen by a
  health plan provider, whose practitioner
  recommended or discussed smoking cessation
  methods or strategies.

2004 Improvement Initiatives NHPRI has two
tobacco treatment programs. The QuitNow program,
which is funded by the RI Department of Health,
provides face-to-face tobacco education/cessation
to patients at the Providence Community Health
Centers. Free nicotine replacement therapy
patches are provided to those participants who
are medically approved. The Baby and Me Smoke
Free program is sponsored by NHPRI and provides
telephonic education/cessation to pregnant NHPRI
Rite Care members. Referrals to Baby and Me Smoke
Free come from Bright Start, NHPRI's high risk
pregnancy program. Both programs provide
individualized counseling and education and are
designed to help participants quit tobacco use.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
20
HEDIS 2005 Results Adults Access to
Preventive/Ambulatory Health Services

• Description
• The percentage of enrollees age 20 and older, who
  have had an ambulatory or preventive care visit
  during 2004.
• NHPRIs rate ranked close to the 90th percentile
  in all of the age categories.

The 2005 rates are significantly higher than the
2004 rates.
Quality Compass 2004 90th Percentile (87, 89,
91)
2004 Improvement Initiatives NHPRI provided to
high volume primary care sites their performance
rates and a list of their patients who did not
meet the access standard was made available upon
requests. NHPRIs members were educated on
routine preventive care guidelines. For this
measure, the Plan also provided a
performance-based incentive for selected large
primary care sites.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
21
HEDIS 2005 Results Childrens Access to Primary
Care Practitioners

• Description
• The percentage of enrollees between 12 months and
  19 years of age who have had a visit with a
  health plan primary care practitioner (PCP)
  during 2004.
• NHPRIs rate ranked above the 90th percentile for
  ages 12 months through 11 years.

The 2005 12-19yrs rate is significantly lower
than the 2004 rates.
Quality Compass 2004 90th Percentile (98, 91,
91)
2004 Improvement Initiatives NHPRI provided to
high volume primary care sites their performance
rates and a list of their patients who did not
meet the access standard was made available upon
request.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
22
HEDIS 2005 Results Claims Timeliness

• Description
• The percentage of all claims received by the MCO
  or its claims processing centers, from January 1,
  2004 December 1, 2004, that were paid or denied
  within 30 calendar days of receipt.

The HEDIS 2005 rate is significantly higher than
the 2004 rate.
2004 Improvement Initiatives NHPRI redesigned
the Claims Department, which included the
transfer of receipt/batching of claims/encounters
to the mailroom. System enhancements were
identified and implemented that streamlined the
processing of claims. IS provided a concentrated
EDI initiative to increase the number of
providers on EDI submission. There were three
Auto Audit edits implemented/enhanced.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
23
HEDIS 2005 Results Call Abandonment

• Description
• The percentage of calls received by the MCO
  member services call centers during 2004 that
  were abandoned by the caller before being
  answered by a live voice.

2004 Improvement Initiatives In the spring of
2004, the Member Services Call Center was
reorganized to allow representatives to be more
available to answer calls. The two major changes
were to remove the administrative tasks that
consumed the majority of the representatives
time and to have them performed by others not on
the phone. The call paths were realigned to
place a priority on member calls. One
representative now handles the volume of provider
calls while also directing providers to utilize
the Integrated Voice Response system. Processes
were reviewed to ensure that they were as
streamlined as possible and a new Member Services
Reference Manual was created to help assist
representatives in being more self-sufficient,
increase first-time resolution, and reduce member
complaints and unnecessary repeated calls.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
24
HEDIS 2005 Results Well-Child Visits in the
First 15 Months of Life
Quality Compass 2004 90th Percentile (62)

• Description
• The percentage of enrollees who turned 15 months
  old during 2003, and who received either zero,
  one, two, three, four, five, or six or more
  well-child visits with a PCP during their first
  15 months of life. A child should be included in
  only one numerator.

• NHPRIs rate for six or more visits ranked
  substantially above the 90th percentile.
• Rotated Measure

HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
25
HEDIS 2005 Results Well-Child Visits Third to
Sixth Year of Life

• Description
• The percentage of enrollees who turned three,
  four, five, or six years old during 2004 and who
  received one or more well-child visit(s) with a
  PCP during 2004.
• NHPRIs rate ranked above the 90th percentile.

Quality Compass 2004 90th Percentile (74)
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
26
HEDIS 2005 Results Adolescent Well-Care Visits

• Description
• The percentage of enrollees who were age 12
  through 21 years during 2004 and who had at least
  one comprehensive well-care visit with a PCP or
  an OB/GYN practitioner during 2004.
• NHPRIs rate ranked above the 90th percentile.

Quality Compass 2004 90th Percentile (52)
2004 Improvement Initiatives NHPRI provided
plan-wide and site-specific HEDIS 2004
performance rates to high volume primary care
sites, and a list of their patients who did not
meet well care standards was made available upon
request. The Plan offered a performance-based
incentive for selected non-community health
center, large primary care sites achieving an
Adolescent Well Care Visit rate of 70.
Additionally, NHPRI established a relationship
with the school-based health center coordinator
at Blackstone Valley Community Health Care, Inc.
and conducted a total of six student and three
parent focus groups regarding adolescent well
care visits in February and March 2004.
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
27
HEDIS 2005 Results Consumer Assessment of
Health Plans Survey

• Mail survey that measures the health care
  experience of randomly selected Medicaid adults
  (age 18 years or older), continuously enrolled
  for at least six months.
• Available in English and Spanish.
• Survey conducted by an NCQA-certified vendor, The
  Myers Group
• 1,755 members randomly selected for the survey,
  and 545 members responded (33).

HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA).
28
HEDIS 2005 Results CAHPS Summary
HEDIS is a registered trademark of the National
Committee for Quality Assurance (NCQA). CAHPS is
a registered trademark of the Agency for
Healthcare Research and Quality (AHRQ). Medicaid
Accreditation 2005 percentile ranking based on
benchmark.