NEW YORK STATE DEPARTMENT OF HEALTH Office of Quality and Patient Safety

Transcription

1 NEW YORK STATE DEPARTMENT OF HEALTH Office of Quality and Patient Safety EXTERNAL QUALITY REVIEW TECHNICAL REPORT FOR New York State Catholic Health Plan, Inc. [Fidelis Health Plan, Inc.] Published May 2014

2 Table of Contents I. About This Report... 1 II. Corporate Profile... 2 III. Enrollment and Provider Network... 3 Enrollment/Disenrollment... 3 Provider Network... 6 NYSDOH Primary Care and OB/GYN Access and Availability Survey IV. Utilization Encounter Data...12 Health Screenings...12 QARR Use of Services Measures...13 V. Quality Indicators Validation of Performance Measures Reported by Plans and Performance Measures Calculated by the NYSDOH...14 Summary of HEDIS 2013 Information System Audit...14 QARR Access to/availability of Care Measures...19 QARR Prenatal Care Measures Calculated by the NYSDOH...20 Consumer Satisfaction...21 Quality Performance Matrix Analysis 2012 Measurement Year...22 Quality Incentive PQI/Compliance/Satisfaction/Quality Points...24 Performance Improvement Project...26 Clinical Study...28 Health Disparities...30 VI. Health Information Technology VII. Deficiencies and Appeals Compliance with NYS Structure and Operation Standards...33 External Appeals Summary Report...36 VIII. Financial Data IX. Strengths and Opportunities for Improvement Strengths...39 Opportunities for Improvement...39 Recommendations...40 Response to Previous Year s Recommendations...40 X. Appendix References...44

3 List of Figures Figure 1: Membership: Medicaid Figure 1a: Membership: Other Product Lines Figure 1b: Enrollment Trends All Product Lines... 3 Figure 2: Medicaid Enrollee Age and Sex Distribution December Figure 2a: Percentage of Medicaid Enrollees by Age December Figure 3: Medicaid Enrollees by Aid Category December Figure 4: Methods of Medicaid Enrollment Figure 5: Disenrollment Rates Figure 6: Providers by Specialties Medicaid 2012 (Q4)... 6 Figure 6a: Ratio of Enrollees to Providers Medicaid 2012 (Q4)... 7 Figure 6b: Medicaid PCPs with an Open Panel (Q4)... 7 Figure 7: QARR Board Certification Rates Figure 8a: Access and Availability Survey Region Details Figure 8b: Primary Care and OB/GYN Access and Availability Survey Figure 9: Medicaid/FHP Encounter Data Figure 10: Health Screenings Figure 11: QARR Use of Services Figure 12: QARR Plan Performance Rates Figure 12a: QARR Medicaid/FHP Rates for Selected Measures Figure 13: QARR Access to/availability of Care Measures Figure 14: QARR Prenatal Care Measures Calculated by the NYSDOH Figure 15: Child CAHPS Figure 16: Quality Performance Matrix 2012 Measurement Year Figure 17: Quality Incentive PQI/Compliance/Satisfaction/Quality Points Figure 17a: Quality Incentive PQI/Compliance/Satisfaction/Quality Measures and Points Figure 18: Performance Improvement Project Figure 19: MCO Use of Health Information Technology 2012 Survey of NYS MCOs Figure 20: Focused Review Types Figure 21: Summary of Citations Figure 22: External Appeals Figure 23: Selected Financial Ratios Figure 23a: Trends for Selected Financial Ratios Fidelis Health Plan, Inc. Page i of ii

4 Acronyms Used in This Report (in alphabetical order) ALOS: AO: CHP: COM (C): DBA: DSS: EQR: EQRO: F/A: FAR: FFS: FHP: FTE: Average Length of Stay Area Office Child Health Plus Commercial Doing Business As Data Submission System External Quality Review External Quality Review Organization Failed Audit Final Audit Report Fee For Service Family Health Plus Full Time Equivalent OB/GYN: OPMC: OP: OQPS: PCP: PIP: PNDS: POC: PMPY: PTMY: PHSP: Obstetrician/Gynecologist Office of Professional Medical Conduct Optimal Practitioner Contact Office of Quality and Patient Safety Primary Care Practitioner/Provider Performance Improvement Project Provider Network Data System Plan of Corrective Action Per Member Per Year Per Thousand Member Years Prepaid Health Services Plans Q1: First Quarter (Jan. March) Q2: Second Quarter (Apr. June) Q3: Third Quarter (July Sept.) Q4: Fourth Quarter (Oct. Dec.) QARR: Quality Assurance Reporting Requirements HEDIS: Health Effectiveness Data and Information Set HIE: Health Information Exchange HIT: Health Information Technology HMO: Health Maintenance Organization HPN: Health Provider Network MCO: Managed Care Organization MED (M): Medicaid MMC: Medicaid Managed Care MMCOR: Medicaid Managed Care Operating Report N: Denominator N/A: Not Available NCQA: National Committee for Quality Assurance NP: Not Provided NR: Not Reported NV: Not Valid NYC: New York City NYCRR: New York Code Rules and Regulations NYSDOH: New York State Department of Health R: Rotated ROS: Rest of State RY: Reporting Year SN: Safety Net SOD: Statement of Deficiency SS: Small Sample (Less than 30) SSI: Supplemental Security Income SWA: Statewide Average TANF: Temporary Aid to Needy Families TR: Technical Report UR: Utilization Review Fidelis Health Plan, Inc. Page ii of ii

5 I. About This Report New York State (NYS) is dedicated to providing and maintaining the highest quality of care for enrollees in managed health care plans. The New York State Department of Health s (NYSDOH) Office of Quality and Patient Safety (OQPS) employs an ongoing strategy to improve the quality of care provided to plan enrollees, to ensure the accountability of these plans and to maintain the continuity of care to the public. The technical reports are individualized reports on the managed care organizations (MCOs) certified to provide Medicaid coverage in NYS. In accordance with federal requirements, these reports summarize the results of the 2012 External Quality Review (EQR) to evaluate access to, timeliness of and quality of care provided to NYS Medicaid beneficiaries. Mandatory EQR-related activities (as per Federal Regulation 42 CFR ) reported include validation of performance improvement projects (PIPs), validation of plan-reported and NYSDOHcalculated performance measures and review for plan compliance with NYSDOH structure and operation standards. Optional EQR-related activities (as per Federal Regulation 42 CFR ) reported include administration of a consumer survey of quality of care (CAHPS ) by an NCQA-certified vendor and technical assistance by the NYS EQRO to plans regarding PIPs and reporting performance measures. Other data incorporated to provide additional background on the MCOs include the following: health plan corporate structure, enrollment and disenrollment data, provider network information, encounter data summaries, PQI/compliance/satisfaction/quality points and incentive, appeal summaries and financial ratios. These reports are organized into the following domains: Corporate Profile, Enrollment and Provider Network, Utilization, Quality Indicators, Health Information Technology, Deficiencies and Appeals, and Financial Data. Although the reports focus primarily on Medicaid and Child Health Plus (CHP) data, selected sections of these reports also include data from the plans Family Health Plus (FHP) and Commercial product lines. Additionally, when available and appropriate, the plans data are compared with statewide benchmarks. Unless otherwise noted, when benchmarks are utilized for rates other than HEDIS /QARR or CAHPS, comparative statements are based on differences determined by standard deviations: a difference of one standard deviation is used to determine rates that are higher or lower than the statewide average. Section IX provides an assessment of the MCO s strengths and opportunities for improvement in the areas of accessibility, timeliness and quality of services. For areas in which the plan has opportunities for improvement, recommendations for improving the quality of the MCO s health care services are provided. To achieve full compliance with federal regulations, this section also includes an assessment of the degree to which the MCO has effectively addressed the recommendations for quality improvement made by the NYS EQRO in the previous year s EQR report. The MCO was given the opportunity to describe current and proposed interventions that address areas of concern, as well as an opportunity to explain areas that the MCO did not feel were within its ability to improve. The response by the MCO is appended to this section of the report. In an effort to provide the most consistent presentation of this varied information, the technical report is prepared based on data for the most current calendar year available. Where trending is desirable, data for prior calendar years may also be included. This report includes data for. Fidelis Health Plan, Inc. Page 1 of 45

6 II. Corporate Profile Fidelis Care New York (Fidelis) is a statewide, not-for-profit prepaid health services plan (PHSP) that services Medicaid, Family Health Plus (FHP), Child Health Plus (CHP) and Managed Long-Term Care (MLTC) populations. The following report presents plan-specific information for the Medicaid line of business and selected information for the FHP and CHP product lines. Plan ID: DOH Area Office: MARO, WRO Corporate Status: PHSP Tax Status: Not-for-profit Medicaid Managed Care Start Date: November 3, 1993 Product Line(s): Medicaid, FHP, CHP and MLTC Contact Information: Queens Blvd. Rego Park, NY (718) NCQA Accreditation as of 8/8/13: Did not apply Medicaid Dental Benefit Status (as of July 2012): Provided Participating Counties and Programs Albany Mcaid CHP FHP Allegany Mcaid CHP FHP Bronx Mcaid CHP FHP Broome Mcaid CHP FHP Cattaraugus Mcaid CHP FHP Cayuga Mcaid CHP FHP Chautauqua Mcaid CHP FHP Chemung Mcaid CHP FHP Chenango Mcaid CHP FHP Clinton Mcaid CHP FHP Columbia Mcaid CHP FHP Cortland Mcaid CHP FHP Delaware Mcaid CHP FHP Dutchess Mcaid CHP FHP Erie Mcaid CHP FHP Essex Mcaid CHP FHP Franklin Mcaid CHP FHP Fulton Mcaid CHP FHP Genesee Mcaid CHP FHP Greene Mcaid CHP FHP Hamilton Mcaid CHP FHP Herkimer Mcaid CHP FHP Kings Mcaid CHP FHP Lewis Mcaid CHP FHP Livingston Mcaid CHP FHP Madison Mcaid CHP FHP Monroe Mcaid CHP FHP Montgomery Mcaid CHP FHP Nassau Mcaid CHP FHP New York Mcaid CHP FHP Niagara Mcaid CHP FHP Oneida Mcaid CHP FHP Onondaga Mcaid CHP FHP Ontario Mcaid CHP FHP Orange Mcaid CHP FHP Orleans Mcaid CHP FHP Oswego Mcaid CHP FHP Otsego Mcaid CHP FHP Putnam Mcaid CHP FHP Queens Mcaid CHP FHP Rensselaer Mcaid CHP FHP Richmond Mcaid CHP FHP Rockland Mcaid CHP FHP Saratoga Mcaid CHP FHP Schenectady Mcaid CHP FHP Schoharie Mcaid CHP FHP Schuyler Mcaid CHP FHP St. Lawrence Mcaid CHP FHP Steuben Mcaid CHP FHP Suffolk Mcaid CHP FHP Sullivan Mcaid CHP FHP Tioga Mcaid CHP FHP Tompkins Mcaid CHP FHP Ulster Mcaid CHP FHP Warren Mcaid CHP FHP Washington Mcaid CHP FHP Wayne Mcaid CHP FHP Westchester Mcaid CHP FHP Wyoming Mcaid CHP FHP Fidelis Health Plan, Inc. Page 2 of 45

7 III. Enrollment and Provider Network Enrollment/Disenrollment Figure 1 depicts total membership for the plan s Medicaid product line for calendar years 2010 to 2012, as well as the percent change from the previous year. Membership has fluctuated over this period, decreasing by 1.8% from 2010 to 2011 and increasing by 21.2% from 2011 to Figure 1a represents the membership for other product lines carried by the plan. Figure 1b trends Medicaid membership and membership in these other product lines. Figure 1: Membership: Medicaid Number of Members 477, , ,638 % Change From Previous Year -1.8% 21.2% Data Source: MEDS II Figure 1a: Membership: Other Product Lines FHP 84,663 94,770 86,873 CHP 68,939 74,560 64,382 Data Source: Managed Care Enrollment Report Figure 1b: Enrollment Trends All Product Lines Fidelis Health Plan, Inc. Page 3 of 45

8 Figures 2 and 2a give a breakdown of the plan s membership by age and sex as of December 31, 2012, for the Medicaid product line. Children under 20 years of age comprise 48.7% of the total Medicaid enrollment, with 23.8% in the 5-14 year age group. Thirty-four percent (33.9%) of the plan s Medicaid membership is women between the ages of (women most likely to utilize OB/GYN services). The Figures also indicate whether the plan s rate was above (indicated by ) or below (indicated by ) the statewide average. The plan s age distribution of enrollees is similar to the statewide distribution. Figure 2: Medicaid Enrollee Age and Sex Distribution December 2012 Age in Years Male Female Total Plan Distribution Statewide Medicaid Under 1 10,024 9,561 19, % 4.0% ,056 31,225 64, % 12.6% ,178 66, , % 24.9% ,626 28,897 57, % 10.0% , , , % 30.1% ,469 55, , % 16.8% 65 and Over 3,334 5,315 8, % 1.7% Total 263, , ,638 Under , , , % 51.5% Females , % 33.3% Data source: MEDS II 1 Females between the ages of 15 to 64 were grouped for this category, since this grouping is inclusive of most women utilizing OB/GYN providers. Figure 2a: Percentage of Medicaid Enrollees by Age December 2012 Fidelis Health Plan, Inc. Page 4 of 45

9 A breakdown of plan membership by aid category, as reported by the NYSDOH for December 31, 2012, is shown in Figure 3. The distribution of members in the three aid categories is similar to the statewide distribution. Figure 3: Medicaid Enrollees by Aid Category December 2012 Fidelis Statewide TANF: Temporary Aid to Needy Families SN: Safety Net SSI: Supplemental Security Income The percentage of members by each method of enrollment in the plan s Medicaid product line for 2010 through 2012 is presented in Figure 4. Whether a plan received a qualifying Medicaid auto-assignment quality algorithm score is also available for each of these years. These scores determine 75% of auto-assignee distribution. Fidelis received a score qualifying the plan for Medicaid auto assignment in 2010, 2011 and Figure 4: Methods of Medicaid Enrollment Fidelis SWA Fidelis SWA Fidelis SWA Category Medicaid Auto-Assigned 5.8% 4.2% 6.3% 4.0% 0.0% 5.0% Self-Selected % 95.7% 93.7% 96.0% 100.0% 95.0% Qualifying Score 2 Y Y Y 1 These figures include new enrollees and enrollees who have transferred from another plan. 2 Qualifying scores are based on the PQI, compliance, quality and satisfaction points that a plan achieves. For further information on how these scores are calculated, see Figure 17. Fidelis Health Plan, Inc. Page 5 of 45

10 Figure 5 shows the plan s 2012 Medicaid and FHP disenrollment rates. Rates above the statewide average are indicated by, and rates below the statewide average are indicated by. Rates are calculated as a percentage of the total enrollment. Figure 5: Disenrollment Rates 2012 Enrollment Status 1 Medicaid FHP Fidelis SWA Fidelis SWA Voluntary Disenrollment 0.26% 0.32% 0.20% 0.25% Involuntary Disenrollment 0.08% 0.10% 0.06% 0.08% Loss of Eligibility 2.13% 2.16% 2.83% 2.84% Still Enrolled 97.54% 97.43% 96.91% 96.83% 1 These data are derived from aggregating monthly enrollment figures. Provider Network Figure 6 shows the percentages of various provider types in the plan s Medicaid product line for the fourth quarter of 2012 in comparison to the statewide rates. PCPs are 18.1% of all providers in Fidelis provider network, which is similar to the statewide percentage of 20.2%. Other Specialties providers account for a higher percentage of the plan s provider network than is seen statewide, while Behavioral Health providers account for a lower percentage. For this figure, plan percentages above statewide rates are indicated by, while percentages below the statewide rates are indicated by. Figure 6: Providers by Specialties Medicaid 2012 (Q4) Specialty Type Number % of Total Panel % Statewide Medicaid Primary Care Providers 7, % 20.2% Pediatrics 2, % 4.8% Family Practice 1, % 3.9% Internal Medicine 3, % 9.4% Other PCPs % 2.1% OB/GYN Specialty 1 1, % 4.1% Behavioral Health 3, % 21.6% Other Specialties 28, % 44.6% Non-PCP Nurse Practitioners 1, % 3.8% Dentistry 2 4,002 Total (excluding dentists) 43,829 Data Source: HPN 1 Includes OB/GYN specialists, certified nurse midwives and OB/GYN nurse practitioners. 2 Dental providers are not included in the provider distribution by specialty nor total provider count, since not all plans provided a dental benefit prior to July Fidelis Health Plan, Inc. Page 6 of 45

11 Figure 6a displays the ratio of enrollees to providers, as well as the number of Full Time Equivalents (FTEs), and the ratio of enrollees to FTEs for the Medicaid product line of Fidelis. Statewide data are also included. For this figure, rates above the 90 th percentile are indicated by, while rates below the 10 th percentile are indicated by. Note that a higher percentile indicates fewer providers per enrollee. Figure 6a: Ratio of Enrollees to Providers Medicaid 2012 (Q4) Fidelis Specialty Type Ratio of Enrollees to Providers Total Number of FTEs Ratio of Enrollees to FTEs Medicaid Median 1 Ratio of Enrollees to Providers Statewide Total Number of FTEs Median 1 Ratio of Enrollees to FTEs Primary Care Providers 72:1 2, :1 60:1 15, :1 Pediatrics (Under age 20) 136:1 135:1 OB/GYN (Females aged 15-64) 100:1 97:1 Behavioral Health 144:1 60:1 Data Source: Derived Medicaid ratios calculated from MEDS II enrollment data and HPN provider data. 1 The statewide median was used for this figure, as opposed to an average, to control for substantial variability due to outliers. The number of Medicaid PCPs with an Open Panel is presented in Figure 6b for the fourth quarters of 2010 through Panels are considered open if a provider has less than 1,500 Medicaid members. For this figure, rates above the statewide average are indicated by, while rates below the statewide average are indicated by. Figure 6b: Medicaid PCPs with an Open Panel (Q4) Fidelis Statewide Fidelis Statewide Fidelis Statewide Number % of Providers % of Providers Number % of Providers % of Providers Number % of Providers Medicaid Providers with Open Panel 8, % 96.2% 8, % 95.9% 8, % 94.8% Data Source: HPN % of Providers Fidelis Health Plan, Inc. Page 7 of 45

12 Figure 7 displays QARR Board Certification rates for 2010 through 2012 of providers in the plan s network in comparison to the statewide averages (SWAs). The Figure also indicates whether the plan s rate was above (indicated by ) or below (indicated by ) the statewide average. The plan s 2012 Medicaid and CHP Board Certification rates were higher than the statewide averages for Family Medicine, Internal Medicine and Pediatricians. Figure 7: QARR Board Certification Rates Provider Type Fidelis SWA Fidelis SWA Fidelis SWA Medicaid Family Medicine 84% 80% 84% 80% 83% 78% Internal Medicine 83% 81% 83% 81% 83% 80% Pediatricians 85% 82% 85% 82% 86% 81% OB/GYN 77% 76% 78% 77% 77% 74% Geriatricians 71% 73% 67% 73% 73% 70% Other Physician Specialists 80% 79% 79% 80% 78% 78% Child Health Plus (CHP) Family Medicine 84% 79% 83% 77% Internal Medicine 83% 80% 83% 79% Pediatricians 85% 81% 86% 80% OB/GYN 78% 77% 77% 75% Geriatricians 67% 70% 73% 69% Other Physician Specialists 79% 80% 78% 78% Fidelis Health Plan, Inc. Page 8 of 45

13 NYSDOH Primary Care and OB/GYN Access and Availability Survey 2012 On behalf of the NYSDOH s Division of Health Plan Contracting and Oversight, the NYS EQRO conducts the Medicaid Managed Care Access and Availability Survey to assess the compliance of network providers in NYS MCOs with appointment timeframe requirements as per the NYS Medicaid/Family Health Plus Managed Care Contract. The survey evaluates the availability of routine and non-urgent sick office hour appointments with primary care physicians, including OB/GYNs, as well as the availability of after hours access. The timeliness standard for routine office hour appointments with PCPs and OB/GYNs is within 28 days of the enrollee s request, while non-urgent sick office hour appointments with PCPs and OB/GYNs must be scheduled within 72 hours (excluding weekends and holidays) as clinically indicated. Prenatal appointments with OB/GYN providers within the 2 nd trimester must be given within 14 days, while 3 rd trimester appointments must be given within 7 days. After hours access is considered compliant if a live voice representing the named provider is reached or if the named provider s beeper number is reached. A random sample of 240 provider sites was selected from each region in which a health plan operated and provided primary care as a Medicaid and/or Family Health Plus benefit. Of these 240 provider sites, 120 were surveyed for routine appointments, 80 were surveyed for non-urgent sick appointments and 40 were surveyed for after hours access. For MCOs with less than the 240 available provider sites, all providers were selected. For call type categories in which compliance is below the 75% threshold, plans will receive a Statement Of Deficiency (SOD) issued by the NYSDOH and will be required to develop a Plan Of Correction (POC). These POCs must be approved by the NYSDOH before implementation. Following an allowable time period for plans to execute their POCs, a resurvey will be conducted of the failed providers. Figure 8a displays the seven regions in New York State, as well as the health plans operating in each region that offered primary care and obstetrics/gynecological benefits to its Medicaid members at the time of the survey. Fidelis Health Plan, Inc. Page 9 of 45

14 Figure 8a: Access and Availability Survey Region Details 2012 Region Counties Plans Operating In Region 1 - Buffalo Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans and Wyoming Excellus Health Plan, Inc.; Fidelis Care New York; HealthNow New York, Inc.; Independent Health Association, Inc.; MVP Health Plan, Inc. and Univera Community Health, Inc. 2 - Rochester Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Wayne and Yates 3 - Syracuse Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence, Tioga and Tompkins 4 - Northeastern Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington 5 - New Rochelle Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster and Westchester 6 - New York City Bronx, Kings, New York, Queens and Richmond Excellus Health Plan, Inc.; Fidelis Care New York and MVP Health Plan, Inc. Capital District Physicians Health Plan, Inc.; Excellus Health Plan, Inc.; Fidelis Care New York; SCHC Total Care, Inc. and UnitedHealthcare Community Plan Capital District Physicians Health Plan, Inc.; Excellus Health Plan, Inc.; Fidelis Care New York; UnitedHealthcare Community Plan and WellCare of New York, Inc. Affinity Health Plan, Inc.; AMERIGROUP New York, LLC; Fidelis Care New York; Health Insurance Plan of Greater New York; Hudson Health Plan, Inc.; MVP Health Plan, Inc.; UnitedHealthcare Community Plan and WellCare of New York, Inc. Affinity Health Plan, Inc.; AMERIGROUP New York, LLC; Amida Care, Inc.; Fidelis Care New York; Healthfirst PHSP, Inc.; Health Insurance Plan of Greater New York; MetroPlus Health Plan, Inc.; MetroPlus Health Plan, Inc. Special Needs Plan; UnitedHealthcare Community Plan; VNS Choice SelectHealth and WellCare of New York, Inc. 7 - Long Island Nassau and Suffolk Affinity Health Plan, Inc.; AMERIGROUP New York, LLC; Fidelis Care New York; Healthfirst PHSP, Inc.; Health Insurance Plan of Greater New York and UnitedHealthcare Community Plan Fidelis Health Plan, Inc. Page 10 of 45

15 Figure 8b illustrates the plan s Primary Care and OB/GYN Access and Availability results for Fidelis exceeded the 75% threshold for routine appointments in Regions 5 and 7, non-urgent sick appointments in Regions 5 and 6, and after hours access in Regions 2 and 4. Figure 8b: Primary Care and OB/GYN Access and Availability Survey 2012 Region Call Type Fidelis Region Average Routine 61.8% 65.0% 1 Non-Urgent "Sick" 50.7% 58.4% After Hours Access 62.9% 69.2% Routine 63.3% 56.8% 2 Non-Urgent "Sick" 67.5% 63.6% After Hours Access 90.0% 82.6% Routine 54.2% 51.5% 3 Non-Urgent "Sick" 58.8% 60.1% After Hours Access 72.5% 72.9% Routine 68.4% 65.7% 4 Non-Urgent "Sick" 67.6% 70.0% After Hours Access 76.3% 77.6% Routine 85.8% 78.4% 5 Non-Urgent "Sick" 78.8% 78.2% After Hours Access 70.0% 74.5% Routine 70.8% 72.4% 6 Non-Urgent "Sick" 83.8% 68.7% After Hours Access 37.5% 58.8% Routine 80.8% 70.0% 7 Non-Urgent "Sick" 67.5% 66.8% After Hours Access 57.5% 71.4% Fidelis Health Plan, Inc. Page 11 of 45

16 IV. Utilization This section of the report explores utilization of the health plan s services by examining encounter and health screening data, as well as QARR Use of Services rates. Encounter Data Figure 9 depicts selected Medicaid encounter data for 2010 through The plan s rates for these periods are also compared to the statewide averages. For this figure, rates above the statewide average are indicated by, while rates below the statewide average are indicated by. Figure 9: Medicaid/FHP Encounter Data Encounters (PMPY) Fidelis SWA Fidelis SWA Fidelis SWA PCPs and OB/GYNs Specialty Emergency Room Inpatient Admissions Dental Medicaid Dental FHP Data Source: MEDS II PMPY: Per Member Per Year Health Screenings In accordance with 13.6(a)(ii) of the Medicaid Managed Care and Family Health Plus Model Contract, plans must make reasonable efforts to contact new enrollees within 30 days of enrollment either in person, by telephone or by mail and conduct a brief health screening to assess special health care needs (e.g., prenatal care or behavioral health services), as well as language and communication needs. Plans are required to submit a quarterly report to the NYSDOH showing the percentage of new enrollees for which the plan was able to complete health screenings. In 2012, Medicaid rates for Enrollee Health Screenings ranged from 2.8% to 41.6%, statewide, while FHP rates for Enrollee Health Screenings ranged from 2.1% to 56.2%. Figure 10 summarizes the percentage of Medicaid and FHP enrollees receiving health screenings within 30 days of enrollment from 2010 through 2012, in addition to displaying the statewide averages for these years. For this figure, rates above the statewide average are indicated by, and rates below the statewide average are indicated by. Figure 10: Health Screenings Fidelis SWA Fidelis SWA Fidelis SWA Medicaid Enrollee Health Screenings 25.8% 35.5% 22.9% 33.4% 12.9% 24.8% FHP Enrollee Health Screenings 26.8% 32.4% 22.2% 29.2% 17.0% 30.0% Fidelis Health Plan, Inc. Page 12 of 45

17 QARR Use of Services Measures For this domain of measures, the QARR reports assess performance by indicating whether the plan s rates reached the 90 th or 10 th percentiles. Figure 11 lists the Use of Services rates for the selected plan product lines for 2010 through The Figure indicates whether the plan s rate was higher than 90% of all rates for that measure (indicated by ) or whether the plan s rate was lower than 90% of all rates for that measure (indicated by ). Figure 11: QARR Use of Services Medicaid/FHP Child Health Plus SWA SWA Measure Outpatient Utilization (PTMY) Outpatient Visits 5,160 5,689 5,760 5,329 3,630 3,911 4,045 4,194 Outpatient ER Visits Inpatient ALOS Medicine Surgery Maternity N/A N/A Total (Medicine, Surgery & Maternity) Inpatient Utilization (PTMY) Medicine Cases Surgery Cases Maternity Cases N/A N/A Total Cases PTMY: Per Thousand Member Years ALOS: Average Length of Stay. These rates are measured in days. N/A: Data not available. Fidelis Health Plan, Inc. Page 13 of 45

18 V. Quality Indicators To measure the quality of care provided by the plans, the State prepares and reviews a number of reports on a variety of quality indicators. This section is a summary of findings from these reports, including HEDIS /QARR 2013 audit findings, as well as results of quality improvement studies, enrollee surveys and plan Performance Improvement Projects (PIPs). Validation of Performance Measures Reported by Plans and Performance Measures Calculated by the NYSDOH Performance measures are reported and validated using several methodologies. Plans submitted member- and provider-level data for several measures to the NYSDOH. The NYS EQRO audited all member- and providerlevel data for internal consistency. Several performance measures are calculated by the NYSDOH, with source code validated by the NYS EQRO. Finally, plans report a subset of HEDIS measures to the NYSDOH annually, along with several NYS-specific measures. Plan-reported performance measures were validated as per HEDIS 2013 Compliance Audit TM specifications developed by the National Committee for Quality Assurance (NCQA). The results of each plan s HEDIS 2013 Compliance Audit TM are summarized in its Final Audit Report (FAR). Summary of HEDIS 2013 Information System Audit As part of the HEDIS 2013 Compliance Audit TM, auditors assessed the plan s compliance with NCQA standards in the six designated information system categories, as follows: 1. Sound Coding Methods for Medical Data 2. Data Capture, Transfer and Entry Medical Data 3. Data Capture, Transfer and Entry Membership Data 4. Data Capture, Transfer and Entry Practitioner Data 5. Data Integration Required to Meet the Demands of Accurate HEDIS Reporting 6. Control Procedures that Support HEDIS Reporting and Integrity In addition, two HEDIS -related documentation categories were assessed: 1. Documentation 2. Outsourced or Delegated HEDIS Reporting Functions The NYS EQRO provided technical assistance to plans throughout the performance measure reporting process in the following forms: 1) introductory and technical workshops prior to the audit, 2) readiness reviews for new plans, 3) serving as a liaison between the plans and NCQA to clarify questions regarding measure specifications, 4) preparation of and technical support for the Data Submission System (DSS) used to submit data to the NYSDOH and 5) clarifications to plan questions regarding the submission of member- and provider-level data, as well as general questions regarding the audit process. The HEDIS 2013 Final Audit Report (FAR) prepared for Fidelis indicates that the plan had no significant problems in any area related to reporting. Though the plan demonstrated compliance with all areas of the Information Systems, there were some minimal issues noted with IS 1.0 Medical Services Data Sound Coding Methods and Data Capture, Transfer and Entry, IS 2.0 Enrollment Data Data Capture, Transfer and Entry, IS 3.0 Practitioner Data Data Capture, Transfer and Entry, IS 4.0 Medical Record Review Processes- Training, Sampling, Abstraction, and Oversight and IS 5.0 Supplemental Data- Capture, Transfer and Entry. However, the plan was in compliance in all areas of measure determination required for successful HEDIS /QARR reporting. The plan used NCQA-certified software to produce HEDIS measures. Supplemental databases were used to capture additional data. These databases were validated and determined to be HEDIS -compliant by the auditors. The plan passed Medical Record Review for the two measures validated. The plan was able to report all measures for its Medicaid and CHP product lines. Fidelis Health Plan, Inc. Page 14 of 45

19 Figure 12 displays 2010, 2011 and 2012 QARR performance rates, as well as the statewide averages (SWAs). The figure indicates whether the plan s rate was statistically better than the SWA (indicated by ) or whether the plan s rate was statistically worse than the SWA (indicated by ). Figure 12a illustrates selected 2012 measures for the Medicaid product line in comparison to the SWAs. R: NR: NP: SS: Table Notes for Figure 12 Rotated measure Not reported Dental benefit not provided Sample size too small to report (less than 30 members) but included in the statewide average. Fidelis Health Plan, Inc. Page 15 of 45

20 Figure 12: QARR Plan Performance Rates Measure Medicaid/FHP Child Health Plus (CHP) 2012 SWA Adolescent Immunization-Combo R R Adolescent Well-Care Visits Adult BMI Assessment 72 R Annual Dental Visit (Ages 2-18) Annual Monitoring for Patients on Persistent Medications- Combined Rate Antidepressant Medication Management-Effective Acute Phase Treatment Appropriate Asthma Medications- 3+ Controllers (Ages 19-64) Appropriate Testing for Pharyngitis Appropriate Treatment for Upper Respiratory Infection Avoidance of Antibiotics Therapy in Adults with Acute Bronchitis Breast Cancer Screening Cervical Cancer Screening Chlamydia Screening (Ages 16-24) Controlling High Blood Pressure 70 R Customer Service and Information for Children Drug Therapy for Rheumatoid Arthritis Follow-Up After Hospitalization for Mental Illness Within 7 Days Follow-Up Care for Children Prescribed ADHD Medication: Initiation Phase Frequency of Ongoing Prenatal Care 84 R Getting Care Needed for Children Medical Management for People with Asthma 50% of Days Covered R Fidelis Health Plan, Inc. Page 16 of SWA

21 Figure 12: QARR Plan Performance Rates (Continued) Measure Medicaid/FHP Persistence of Beta-Blocker Treatment R Rating of Health Plan for Children Pharmacotherapy Management of COPD Exacerbation Corticosteroid Postpartum Care 73 R Timeliness of Prenatal Care 93 R Use of Imaging for Low Back Pain Child Health Plus (CHP) SWA SWA Viral Load Monitoring Well-Child & Preventive Care Visits in 3rd, 4th, 5th & 6th Year of Life Well-Child & Preventive Care Visits in First 15 Months of Life (6+ Visits) Fidelis Health Plan, Inc. Page 17 of 45

22 Figure 12a: QARR Medicaid/FHP Rates for Selected Measures 2012 Fidelis Statewide Fidelis Health Plan, Inc. Page 18 of 45

23 QARR Access to/availability of Care Measures The QARR Access to/availability of Care measures examine the percentages of children and adults who access certain services, including PCPs or preventive services, prenatal and postpartum care and dental services for selected product lines. Figure 13 displays the Access to/availability of Care measures for QARR 2010 through The figure indicates whether the plan s rate was higher than 90% of all plans for that measure (indicated by ) or whether the plan s rate was lower than 90% of plans for that measure (indicated by ). Figure 13: QARR Access to/availability of Care Measures Medicaid/FHP Child Health Plus SWA SWA Measure Children and Adolescents Access to PCPs (CAP) months 97% 98% 98% 97% 99% 99% 100% 100% 25 months 6 years 93% 94% 94% 93% 95% 96% 96% 96% 7 11 years 94% 95% 96% 96% 97% 97% 98% 98% years 91% 92% 93% 93% 95% 95% 95% 96% Adults Access to Preventive/Ambulatory Services (AAP) years 82% 83% 85% 84% years 88% 89% 90% 90% 65+ years 89% 90% 91% 90% Access to Other Services Timeliness of Prenatal Care 93% R 89% 88% Postpartum Care 73% R 77% 70% Annual Dental Visit* 57% 59% 60% 56% 65% 66% 65% 64% R: Rotated measure *For the Annual Dental Visit measure, the Medicaid/FHP age group is 2-21 years, while the Child Health Plus age group is 2-18 years. Fidelis Health Plan, Inc. Page 19 of 45

24 QARR Prenatal Care Measures Calculated by the NYSDOH Certain QARR prenatal care measures are calculated by the NYSDOH using birth data submitted by the plans, as well as from NYSDOH s Vital Statistics Birth File. Since some health events such as low birth weight births and cesarean deliveries do not occur randomly across all plans, risk adjustment is used to remove or reduce the effects of confounding factors that may influence a plan s rate. Figure 14 presents prenatal care rates calculated by the NYSDOH for QARR 2009 through Figure 14 indicates whether the plan s rate was significantly better than the average (indicated by ) or whether the plan s rate was significantly worse than the average (indicated by ). Figure 14: QARR Prenatal Care Measures Calculated by the NYSDOH Medicaid/FHP Measure Fidelis ROS Average Fidelis ROS Average Fidelis ROS Average NYC Risk-Adjusted Low Birth Weight* 7% 7% 6% 7% 7% 7% Prenatal Care in the First Trimester 71% 72% 72% 72% 74% 73% Risk-Adjusted Primary Cesarean Delivery* 18% 17% 17% 17% 16% 16% Vaginal Birth After Cesarean 17% 14% 18% 16% 20% 18% ROS Risk-Adjusted Low Birth Weight* 7% 7% 8% 8% 7% 7% Prenatal Care in the First Trimester 68% 69% 68% 70% 70% 71% Risk-Adjusted Primary Cesarean Delivery* 14% 15% 15% 16% 14% 15% Vaginal Birth After Cesarean 14% 11% 12% 11% 14% 11% *A low rate is desirable for this measure. NYC: New York City ROS: Rest of State Fidelis Health Plan, Inc. Page 20 of 45

25 Consumer Satisfaction In 2012, the Child CAHPS survey for Medicaid and CHP enrollees was conducted on behalf of the NYSDOH by an NCQA-certified survey vendor. Between September 2012 and December 2012, the survey was administered to parents and caretakers of Medicaid and CHP enrollees aged 0-17 years. Figure 15 displays the question category, the plan s rates and statewide averages for the 2012 measurement year. The figure also indicates whether the plan s rate was significantly better than the statewide average (SWA) (indicated by ) or whether the plan s rate was significantly worse than the SWA (indicated by ). Figure 15: Child CAHPS 2012 Measure Medicaid/CHP 2012 SWA Coordination of Care Getting Care Needed Satisfaction with Provider Communication Customer Service Collaborative Decision Making Getting Information Rating of Healthcare Rating of Personal Doctor Getting Care Quickly Rating of Counseling Overall Rating of Health Plan Rating of PCP Rating of Specialist Access to Specialized Services These indicators are composite measures. Fidelis Health Plan, Inc. Page 21 of 45

26 Quality Performance Matrix Analysis 2012 Measurement Year (Effectiveness of Care Measures) Figure 16 displays the Quality Performance Matrix, which predominantly summarizes Effectiveness of Care measures, though it also contains select Use of Services and Access to/availability of Care measures reported annually in the New York State Managed Care Plan Performance Report. This year s matrix includes 7 measures for the Medicaid product line and 4 for the Child Health Plus product line. Measures selected for the 2012 measurement year (MY) Quality Performance Matrix include only those with a 2011 Medicaid statewide average less than the benchmark described in the New York State Prevention Agenda or Medicaid Redesign Team goals. The matrix diagrams the plan s performance in relation to its previous year s quality rates and also compares its rates to those of other Medicaid Managed Care plans, through a percentile ranking. For the MY 2012 Quality Performance Matrix, the NYSDOH made modifications in order to focus on those measures in need of the most improvement statewide. For previous Measurement Years, the matrix included an extensive list of measures and the cell category (A-F) was determined by the year-over-year trend of the measure (vertical axis) and by any significant difference from the statewide average (horizontal axis). For the 2012 MY, the matrix was reformatted to maintain the year-over-year evaluation on the vertical axis, but to evaluate the plan s performance based on a percentile ranking on the horizontal axis. The new percentile ranking was partitioned into three categories: 0-49 th percentile, 50 th -80 th percentile and 90 th -100 th percentile. Additionally, the 2012 matrix includes only those measures for which the 2011 Medicaid statewide average was less than a predetermined benchmark. With the issuance of the 2008 MY matrix, the NYSDOH modified its MCO requirements for follow-up action. In previous years, MCOs were required to develop root cause analyses and plans of action for all measures reported in the D and F categories of the matrix. Starting with the 2008 MY matrix, MCOs are now required to follow-up on no more than three measures from the D and F categories of the matrix. However, if an MCO has more than three measures reported in the F category, the MCO must submit root cause analyses and plans of action on all measures reported in the F category. If an MCO has fewer than three measures reported in the F category, the remaining measures must be selected from the D category for a total of three measures. If the MCO has no measures in the D and F categories, the MCO is not required to follow-up. Fidelis Health Plan, Inc. Page 22 of 45

27 Figure 16: Quality Performance Matrix 2012 Measurement Year Percentile Ranking Trend * 0 to 49% 50 to 89% 90 to 100% C B A Adult BMI Assessment (M) D C B No Change Well-Child Visits in the First 15 Months of Life (6+ Visits) (CHP,M) Well-Child Visits in the 3rd, 4th, 5th and 6th Years of Life (CHP) Well-Care Visits for Adolescents (CHP) Cervical Cancer Screening (M) Annual Dental Visit - 2 to 21 Years (CHP) Controlling High Blood Pressure (M) Well-Child Visits in the 3rd, 4th, 5th and 6th Years of Life (M) Well-Care Visits for Adolescents (M) Annual Dental Visit - 2 to 21 Years (M) F D C CHP: Child Health Plus M: Medicaid and Family Health Plus *Trending analysis used rates from 2011 when the measure was not collected in Fidelis Health Plan, Inc. Page 23 of 45

28 Quality Incentive PQI/Compliance/Satisfaction/Quality Points The percentage of the potential financial incentive that a plan receives is based on quality of care, consumer satisfaction and compliance. Points earned are derived from an algorithm that considers QARR 2013 rates in comparison to statewide percentiles, the most recent Medicaid CAHPS scores and compliance information from 2011 and The total score, based out of 150 possible points, determines what percentage of the available premium increase the plan qualifies for. For 2012, there were four levels of incentive awards that could be achieved by plans based on the results. Figure 17 displays the points the plan earned from 2010 to 2012, as well as the percentage of the financial incentive that these points generated based on the previous measurement year s data. Figure 17a displays the measures that were used to calculate the 2012 incentive, as well as the points Fidelis earned for each measure. Figure 17: Quality Incentive PQI/Compliance/Satisfaction/Quality Points Category Fidelis SWA Fidelis SWA Fidelis SWA Total Points (150 Possible Points) PQI Points (20 Possible Points) Compliance Points (-20 Possible Points) Satisfaction Points (30 Possible Points) Quality Points* (100 Possible Points) Percentage of Financial Incentive Earned 60% 50% 75% * Quality Points presented here are normalized. Fidelis Health Plan, Inc. Page 24 of 45

29 Figure 17a: Quality Incentive PQI/Compliance/Satisfaction/Quality Measures and Points 2012 Measure Fidelis PQI 10.0 Pediatric Asthma PQI (5 points) 2.5 Pediatric Composite PQI (5 points) 2.5 Adult Respiratory PQI (3 points) 1.5 Adult Composite PQI (7 points) 3.5 Compliance (-4 points each, except where noted) -4.0 MMCOR 0.0 MEDS 0.0 Access/Availability (-2 points) -2.0 Provider Directory (-2 points) -2.0 Member Services 0.0 QARR 0.0 Satisfaction (10 points each) 15.0 Rating of Health Plan (CAHPS ) 5.0 Getting Care Needed (CAHPS ) 5.0 Customer Service and Information (CAHPS ) 5.0 Quality (3.6 points each) 51.3 Adolescent Well-Care Visits 1.8 Adolescent Immunization Combo 0.0 Adult BMI Assessment 1.8 Annual Dental Visit (Ages 2-18) 2.7 Annual Monitoring for Patients on Persistent Medications - Combined Rate 3.6 Antidepressant Medication Management - Effective Acute Phase Treatment 2.7 Appropriate Asthma Medications- 3 or More Controllers (Ages 5-64) 1.8 Appropriate Testing for Children with Pharyngitis 3.6 Appropriate Treatment for Children with Upper Respiratory Infection (URI) 1.8 Avoidance of Antibiotics Therapy in Adults with Acute Bronchitis 1.8 Breast Cancer Screening 1.8 Cervical Cancer Screening 2.7 Chlamydia Screening in Women (Ages 16-24) 0.0 Controlling High Blood Pressure 2.7 Drug Therapy for Rheumatoid Arthritis 1.8 Follow-Up After Hospitalization for Mental Illness Within 7 days 0.0 Follow-Up Care for Children Prescribed ADHD Medication - Initiation Phase 1.8 Frequency of Ongoing Prenatal Care 2.7 Medical Management for People with Asthma 50% Covered (Ages 5-64) 1.8 Persistence of Beta-Blocker Treatment 0.0 Pharmacotherapy Management of COPD Exacerbation - Corticosteroid 2.7 Postpartum Care 3.6 Timeliness of Prenatal Care 1.8 Use of Imaging Studies for Low Back Pain 0.0 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 2.7 Viral Load Monitoring 1.8 Well-Child & Preventive Care Visits in the 3rd, 4th, 5th & 6th Year of Life 1.8 Well-Child & Preventive Care Visits in the First 15 Months of Life - 5 or More Visits 0.0 Total Points Earned MMCOR: Medicaid Managed Care Operating Report MEDS: Medicaid Encounter Data Set Fidelis Health Plan, Inc. Page 25 of 45

30 Performance Improvement Project Each plan is required by the Medicaid Health Maintenance Organization contract to conduct at least one Performance Improvement Project (PIP) each year. A PIP is a methodology for facilitating plan and providerbased improvements in quality of care. PIPs place emphasis on evaluating the success of interventions to improve quality of care. Through these projects, plans and providers determine what processes need to be improved and how they should be improved. The NYS EQRO provided technical assistance to plans throughout the PIP process in the following forms: 1) review of the plan s Project Proposal prior to the start of the PIP; 2) quarterly teleconferences with the plan for progress updates and problem-solving; 3) feedback on methodology, data collection tools and implementation of interventions and 4) feedback on drafts of the plan s final report. In addition, the NYS EQRO validated the plan s PIP by reviewing the project topic, aim statement, performance indicators, study population, sampling methods (if sampling was used), data collection procedures, data analysis and interpretation of project results, as well as assessing the plan s improvement strategies, the likelihood that the reported improvement is real improvement and whether the plan is likely to be able to sustain its documented improvement. Validation teams met quarterly to review any issues that could potentially impact the credibility of PIP results, thus ensuring consistency among validation teams. The validation process concluded with a summary of the strengths and opportunities for improvement in the conduct of the PIP, including any validation findings that indicated the credibility of the PIP results was at risk. Fidelis PIP topic is Eliminating Disparities in Asthma Care. Throughout the conduct of the PIP, the plan implemented the following interventions: Providers: - Documentation of patient assessment questionnaire entered into EMR prior to physician contact. Documents asthma severity and control in EMR. Medical Assistants to complete questionnaire with patient, enter into EMR including vital signs prior to patient contact with physician. Physician, therefore, has complete information in EMR. - Standing order to test peak flow on all patients with asthma at time of office visit prior to MD contact regardless of whether or not they are symptomatic. - Development/review of Asthma Action Plan for every patient with asthma. - Provide training and technical assistance to providers and staff in asthma basics and communication techniques as well as other identified needs. Focus on pharmaceutical treatment of Asthma, appropriate follow-up by patient/caregiver. Plan: Provide practice with names of patients having asthma-related ER visits. The report is made available bimonthly. Provide practice with names of patients having an asthma-related in-patient stay. The report is made available bimonthly. Provide practice with timely information on patients filling and refilling prescriptions for Long-Term Controller Meds. Provide practice with information on patients with an asthma diagnosis who have not had an outpatient visit with the PCP in the current year. Provided date of last encounter and name of practitioner at the time. Coordinate outreach to patients who have not had a PCP visit. Plan Partner (these interventions were planned; however, the plan partner withdrew from the project): Arrange home assessments and indicated environmental remediation for poorly controlled patients with environmental triggers. Develop improved communication with school nurses by establishing a process for communicating with the nurse and nurse supervisor providing information about services utilization, treatment changes, absenteeism, home remediation needs, etc. Figure 18 presents a summary of Fidelis PIP. Fidelis Health Plan, Inc. Page 26 of 45