As part of IBC?s annual review process, we obtain data from the Healthcare Effectiveness Data and Information Set (HEDIS^® ) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) to help evaluate utilization for our Medicare Advantage HMO and PPO members. The results showed that utilization remains within or above national standards.

HEDIS^® data evaluation

IBC used the data from HEDIS^® to evaluate hospital discharges and the frequency rates of selected cardiac procedures.

Hospital utilization
Hospital utilization comparison acute discharges per 1,000 (Table 1) show that Keystone 65 HMO and Personal Choice 65^SM PPO rates continue to improve and remain within the relevant national 10th and 90th percentiles as the appropriate thresholds for over/under utilization.

Table 1: Hospital utilization comparison acute discharges per 1,000 HEDIS^® year 2012 HEDIS^® year 2013 Product Rate Threshold Threshold status Rate Threshold Threshold status Personal Choice 65 HMO members 346.31 193.14 ? 355.92 Within 286.89 189.91 ? 359.05 Within Personal Choice 65 PPO 301.65 193.14 ? 355.92 Within 277.40 189.91 ? 359.05 Within

Use of services
IBC also measured the frequency of selected procedure rates for cardiac angioplasty, cardiac catheterization, and coronary artery bypass graft (CABG). Based on a comparison of 2013 HEDIS^® utilization rates with respect to established thresholds, utilization for use of services for these identified indicators fell within the established threshold for most age/gender cohorts. Three cohorts fell above both national and regional established thresholds. These rates are measured according to age group and gender, and IBC recognizes the probability of unequal variance as an issue with the cardiac procedure rates.

CAHPS data evaluation

IBC used CAHPS data to evaluate composite care, including member perception of getting needed care in a timely manner and specialty care.

Keystone 65 HMO members
The rate for getting needed composite care for Keystone 65 HMO members during 2013 (Table 2) rose significantly above the national threshold. In addition, the rate for members who are referred to a specialist remained significantly better than the national threshold. Both of these rates may be attributed to the emergence of the Patient-Centered Medical Home (PCMH) model as primary care in 2010. The rate for ease of care also increased in 2013 after remaining stagnant for three years, indicating that members feel they are still receiving all of the medically appropriate studies.

Table 2: CAHPS Member Satisfaction Data ? Keystone 65 HMO 2012 2013 Criteria Keystone 65 HMO members National average Threshold status Keystone 65 HMO members National average Threshold status In the last six months, how often was it easy to get care, tests, or treatment you thought you needed? 3.64 3.60 Within 3.67 3.60 Within In the last six months, how often was it easy to get appointments with a specialist? 3.61 3.54 Above* 3.64 3.56 Above* Getting needed care composite 3.64 3.57 Within 3.67 3.58 Above*

*Threshold status significantly better/worse than the national average

Personal Choice 65 PPO
The rate for Personal Choice 65 PPO members during 2013 (Table 3) remained within the national threshold, including an increase in the rate for ease of care.

PPO members are not required to identify a primary care physician, and many PPO members with chronic conditions use a specialist as their primary physician. However, based on member responses regarding the ease of care and care composite, there are no significant barriers to members receiving appropriate care noted.

Table 3: CAHPS Member Satisfaction Data ? Personal Choice 65 PPO 2012 2013 Criteria Personal Choice 65 HMO members National average Threshold status Personal Choice 65 HMO members National average Threshold status In the last six months, how often was it easy to get care, tests, or treatment you thought you needed? 3.61 3.60 Within 3.64 3.60 Within In the last six months, how often was it easy to get appointments with a specialist? 3.61 3.54 Within 3.61 3.56 Within Getting needed care composite 3.61 3.57 Within 3.61 3.58 Within

For more information

To learn more about HEDIS^®, view Highlighting HEDIS^® articles that have been published in Partners in Health Update^SM. These articles are educational resources for understanding HEDIS^® measures. If you have feedback about the Highlighting HEDIS^® series or topic requests, please email us.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA). used with permission.