Continuous Improvement and the Expansion of Quality Measurement

Continuous Improvement and the Expansion of Quality Measurement T h e S t a t e o f H e a l t h C a r e Q u a l i t y 2 0 1 1

Continuous Improvement and the Expansion of Quality Measurement T h e S t a t e o f H e a l t h C a r e Q u a l i t y 2 0 1 1

2 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E This Report and the data contained herein are protected by copyright and other intellectual property laws or treaties. Unauthorized copying or use is prohibited. HEDIS is a registered trademark of NCQA. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality. Portions of this report were prepared using select data provided by the Centers for Medicare & Medicaid Services (CMS) pursuant to a data use agreement. The contents of the report represent the sole views of NCQA and have not been approved, reviewed or endorsed by CMS or by any other federal agency. 2011 by the National Committee for Quality Assurance. All rights reserved. Printed in the U.S.A. To order this or other publications, contact NCQA Customer Support at 888-275-7585 or log on to www.ncqa.org.

T h e S tat e o f H e a l t h C a r e Q u a l i t y 2 0 1 1 ta b l e o f c o n t e n T S 3 President s Message........................................................... 5 Introduction................................................................ 7 Executive Summary........................................................... 8 HEDIS Measures of Care....................................................... 24 Safety and Potential Waste Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis.......................... 26 Use of Imaging Studies for Lower Back Pain.......................................... 28 Relative Resource Use.......................................................... 30 Wellness and Prevention Adult BMI Assessment.......................................................... 36 Flu Shots for Adults........................................................... 38 Breast Cancer Screening........................................................ 40 Cervical Cancer Screening...................................................... 42 Colorectal Cancer Screening..................................................... 44 Medical Assistance With Smoking and Tobacco Use Cessation............................. 46 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack................................ 48 Comprehensive Diabetes Care.................................................... 50 Controlling High Blood Pressure................................................... 54 Cholesterol Management for Patients With Cardiovascular Conditions....................... 56 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis..................... 58 Use of Appropriate Medications for People With Asthma................................. 60 Use of Spirometry Testing in the Assessment and Diagnosis of COPD........................ 62 Pharmacotherapy Management of COPD Exacerbation.................................. 64 Annual Monitoring for Patients on Persistent Medications................................. 66 Antidepressant Medication Management............................................ 68 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment.................. 70 Measures Targeted at Children and Adolescents Appropriate Treatment for Children With Upper Respiratory Infection*....................... 72 Lead Screening in Children*..................................................... 74 Ambulatory Care: Emergency Department Visits....................................... 75 Prenatal and Postpartum Care & Frequency of Ongoing Prenatal Care....................... 77 Chlamydia Screening in Women.................................................. 80 Follow-Up After Hospitalization for Mental Illness...................................... 82 Appropriate Testing for Children With Pharyngitis...................................... 84 Well-Child Visits in the First 15 Months of Life and in the Third, Fourth, Fifth and Sixth Years of Life... 86 Adolescent Well-Care Visits...................................................... 88 Children and Adolescents Access to Primary Care Practitioners............................ 90 Follow-Up Care for Children Prescribed ADHD Medication............................... 93 Childhood Immunization Status................................................... 95 Immunizations for Adolescents................................................... 101 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents... 103 * As part of the Pediatric Quality Measures Program, states are working with AHRQ and CMS to report Children s Initial Core Set measures at the state level in order to assess the quality of Medicaid and CHIP. All measures in this section except the two noted are in the Children s Initial Core Set.

4 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Measures Targeted at Older Adults Fall Risk Management......................................................... 105 Medication in the Elderly....................................................... 107 Management of Urinary Incontinence in Older Adults.................................. 109 Physical Activity in Older Adults.................................................. 111 Glaucoma Screening in Older Adults.............................................. 113 Osteoporosis Testing in Older Women............................................. 115 Osteoporosis Management in Women Who Had a Fracture.............................. 117 Consumer and Patient Engagement and Experience............................. 119 Methodology Overview..................................................... 127 Appendices HEDIS Effectiveness of Care Measures: 2010 National HMO Averages...................... 130 HEDIS Effectiveness of Care Measures: 2010 National PPO Averages...................... 134 CAHPS Member Satisfaction Measures: 2010 National HMO Averages..................... 137 CAHPS Member Satisfaction Measures: 2010 National PPO Averages...................... 138 Accredited vs. Nonaccredited Plans: 2010 Commercial HMO Averages..................... 139 Accredited vs. Nonaccredited Plans: 2010 Commercial PPO Averages...................... 142 Accredited vs. Nonaccredited Plans: 2010 Medicaid HMO Averages....................... 145 Accredited vs. Nonaccredited Plans: 2010 Medicare HMO Averages....................... 148 Accredited vs. Nonaccredited Plans: 2010 Medicare PPO Averages........................ 150 Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Commercial HMOs................. 152 Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Commercial PPOs.................. 155 Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicaid HMOs................... 158 Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicare HMOs................... 161 Publicly Reporting vs. Nonpublicly Reporting Plans: 2010 Medicare PPOs................... 163 HMOs vs. PPOs, Commercial Plans............................................... 165 HMOs vs. PPOs, Medicare Plans................................................. 167 HMOs vs. PPOs, Commercial Plans............................................... 169 HMOs vs. PPOs, Medicare Plans................................................. 170 Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Commercial HMOs..... 171 Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Commercial PPOs...... 174 Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicaid HMOs...... 177 Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicare HMOs...... 180 Variation in Plan Performance: The 90th Percentile vs. The 10th Percentile: Medicare PPOs....... 182 References................................................................. 184 Acknowledgments......................................................... 199

T H E S TAT E o f H E A l T H C A R E Q U A L I T Y 2 0 1 1 P R E S I D E N T s M E S S A G E 5 PRESIDENT s MESSAGE Dear Colleague: Every autumn, NCQA updates the nation on how consistently health plans deliver high-quality care. This, our 15th State of Health Care Quality Report, is a snapshot of an industry that is moving in the right direction, but has opportunities for further improvement. We find encouraging signs of rising quality. Across diverse measures of care, performance is improving, and insurers can be proud of what they have accomplished. We also note that some insurers are not reporting and that for some measures, we have not seen the gains in performance we would like. Three features distinguish this year s report. First, it is longer than in past years because it includes, for the first time, comparisons between HMOs and PPOs across all measures. That we are able to fill a report with PPO data tracked over time is a significant step in quality s story. Not long ago, few PPOs quantified or disclosed results. Now, measurement and transparency are more common, though there is room to add more PPO reporting. The rising tide of PPO reporting is a credit to PPOs that have worked hard to fashion themselves into data-driven organizations that collect and report results. Their willingness to evaluate themselves and be transparent is a boon to consumers, a third of whom are enrolled in PPOs. A second distinct feature of this report is a focus on longer-term trends a departure from our usual concentration on one-year changes in performance. In a fast-paced society where attention spans seem to grow ever shorter, it s easy to overlook the cumulative benefits of determined, incremental gains. Yet stepping back to look at the long term confirms that the industry has come far. The data show that insurers commitment to measurement, transparency and accountability has, over the years, improved care, saved lives and reduced suffering. Finally, this report looks ahead to consider how quality measurement can help address what is arguably our country s most ominous long-term threat ballooning health care costs. It is important to grasp that the most insidious cost problems are often problems of quality extra costs resulting from preventable medical errors, overtreatment and ineffective care. An

6 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E increasingly common response to the cost crisis is to drop coverage or increase deductibles, a reaction that can also be understood as a quality issue. After all, not having coverage is the ultimate quality gap. Reducing care as the main strategy for containing costs is a siren s song: it might seem irresistible or inevitable, but it is ultimately destructive. A more sustainable approach is to stretch our health care dollars and get better results by emphasizing a value agenda. This report identifies ways that health plans can be catalysts to transform health care from a system that prizes volume to one that emphasizes value. In particular, we call on health plans to redefine their roles to take advantage of existing tools that can spur and complement delivery system reforms. These changes are important because value s delicate intersection of cost and quality is no longer just nice to have; it s a necessity. Thank you for your interest in these vital topics. And thank you for doing all you can to improve the state of health care quality.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 I N T R o D U C T I o n 7 INTRoDUCTIon NCQA produces The State of Health Care Quality Report every year to call attention to key quality issues the United States faces and to drive improvement in the delivery of evidence-based medicine. This report documents performance trends over time, tracks variation in care and recommends quality improvements. Thousands of consumers, health insurance executives, benefits managers, policy makers, academics, consultants and journalists read this report. More than 1,000 health plans voluntarily disclose the clinical quality, customer experience and resource use data that are the report s foundation. All data are rigorously audited. Consumer experience information is independently collected and verified. We commend all the health plans that contributed data for this report, and for the commitment to accountability and quality improvement that they show in opting to disclose their performance results publicly. Electronic copies of this report are available free of charge at NCQA s Web site, www.ncqa.org. Printed copies are available for purchase by calling 888-275-7585. We appreciate your interest in these topics and welcome your feedback. You can reach us at communications@ncqa.org.

8 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E E x E C U T I V E S U M M A Ry The Healthcare Effectiveness Data and Information Set (HEDIS ) continually changes to capture better information and new medical knowledge and to reflect purchaser and consumer needs. HEDIS was developed by forward-thinking employers and quality experts in the late 1980s; since the early 1990s, it has been the national standard for health plan performance reporting. NCQA s goal is for HEDIS measures to have strong evidence and be meaningful, valid and practical. With the addition of preferred provider organization (PPO) performance results to HEDIS, we can now compare PPOs with HMOs. We consider these comparisons some surprising, many encouraging to be the key findings of this year s State of Health Care Quality report. PPOs on the Rise, Show They Improve by Measuring, Too With some exceptions, commercial HMO performance is typically higher than PPO performance. One reason may be that HMOs have traditionally had more tools to manage care: care coordination processes, selective contracting and more bargaining power over providers. Differences in information collection or populations could be factors, as could benefit design. HMOs usually have lower cost sharing for services than PPOs, and higher PPO cost sharing might reduce use of recommended services. That said, some PPOs offered by health plans that also offer HMOs perform very well. Differences between HMOs and PPOs in how they collect data for hybrid measures have traditionally made it difficult to compare results. But there are indicators where PPOs perform at virtually the same level as HMOs for example, in the Use of Appropriate Medications for Asthma measure. PPOs are catching up on other measures, as well, by making bigger year-toyear gains. Interestingly, there are also performance differences between commercial HMOs and PPOs for some patient experience measures. Many readers will recall that health plan members preferred PPOs to HMOs because of fewer restrictions and larger networks. In 2005, PPO members were more likely to give a high rating than HMO members were. But times have changed, and there is a widening gap in performance: in 2010, HMO results were 6 percentage points higher than PPO results. The gap might be related to the rise in cost sharing including deductibles for PPOs.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 E x E C U T I V E S U M M A R y 9 One example where HMO results are higher than PPO results is in the share of members who rated their health plan a 9 or 10 on a 10-point scale. Figure 1. PerCEntage of CoMMErCIal HMO and PPO MEMbers Who Rate their Plan 9 or 10, 2005 2010 100 90 80 70 60 50 40 30 20 10 0 2005 2006 2007 2008 2009 2010 HMO PPO Performance patterns between Medicare HMOs and PPOs are quite different. While HMOs outperform PPOs on some measures, PPOs outperform HMOs on several others, notably on measures related to drug therapy and monitoring. For example, on Pharmacological Management of COPD Systemic Corticosteroids, the average Medicare PPO rate is 69.6 percent and the average Medicare HMO rate is 66.6 percent. Medicare has required HMOs and PPOs to report the same quality measures. The Medicare star rating system that will send additional payments to high-performing plans is neutral to whether a plan is a HMO or PPO. These policies may be driving higher PPO performance in Medicare. Other reasons for higher PPO performance could be geographic differences or variations in the nature of the participating PPOs.

10 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Comparisons across product line Commercial, Medicaid and Medicare product measures reflect varying policy and population differences, but we can compare performance on measures reported by all product lines. On these measures, Medicaid performance tends to be worse than commercial or Medicare performance. Exceptions are Chlamydia Screening for Women and Persistence of Beta-Blocker Treatment After a Heart Attack. One reason for Medicaid s lower performance might be that its population faces challenging economic circumstances; for example, transportation to doctor appointments may be an issue. Even though this pattern holds for the overall population, we do see some Medicaid plans with very high performance, suggesting that some of the challenges of caring for this population may be surmountable. Medicare and commercial performance relative to each other varies by measure. Medicare outperforms commercial plans on several intermediate outcome measures and process measures. Comparison With Last Year s Findings Childhood immunizations In last year s State of Health Care Quality report, NCQA noted a significant drop in childhood immunizations in commercial health plans. This drop also appeared in the Centers for Disease Control and Prevention s national data. Reasons for the drop include widespread concern about the (disproven) potential for some immunizations to lead to autism; other explanations were the rise in cost sharing and the economic downturn. The 2010 data do not show a full recovery for commercial health plans. The Combination 2 Childhood Immunization Rate for commercial HMOs had a slight uptick, but the numbers were not statistically significant. Medicaid results held steady. There was a drop in the H influenza type B (HiB) immunization rate, which might have been caused by a temporary shortage of vaccine, and a small gain in the polio (IPV) immunization rate. Overall pattern 2009 to 2010 Although several measures showed important gains including Colorectal Cancer Screening, Use of Spirometry Testing in the Assessment and Diagnosis of COPD and Pharmacotherapy Management of COPD many measures showed little meaningful change. Commercial and Medicare PPOs displayed significant performance improvement and showed progress in closing the performance gap with HMOs.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 E x E C U T I V E S U M M A R y 11 HEDIS: Responding to Evidence and to Purchaser Needs Early quality measures were developed specifically for HMOs, and focused on use of recommended services. Today, measures are reported by other types of health plans, as well as some fee-for-service (ffs) programs like Medicaid. Public payers (Medicare, Medicaid and the Federal Employees Health Benefit [FEHB] program) and private payers (including those in the Evalu8 tool) use HEDIS measures. Figure 2. Eye Exams for diabetics MedICare 80 70 60 Screening Rate 50 40 30 20 10 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 HMO PPO NCQA now specifies HEDIS measures for individual clinician and clinician groups, using both conventional data sources and electronic health records (EHR). HEDIS the most widely used measures for ambulatory care includes measures of outcome; measures of overuse and resource use; and measures of care coordination. Outcome measures NCQA measures of outcome include intermediate outcome measures that reflect test results, as well as patient experience. They capture cholesterol control, blood pressure control and blood sugar (HbA1c) control in diabetics. Patient experience of care measured through the Consumer Assessment of Healthcare Providers and Systems (CAHPS ) is another important measure of outcome.

12 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Top 10 and Bottom 10 States Location, location, location is not only the mantra of the real estate industry it s relevant to health care, too. Past editions of the State of Health Care Quality Report showed that quality varies by Census Bureau region. This year s analysis of top 10 and bottom 10 states is more specific: it shows that some states are outliers within their own regions. Cohort calculations of top 10, bottom 10 and middle 32 states include Puerto Rico and Washington, D.C. The calculations are based on mean rates of four measures: Comprehensive Diabetes Care (nine indicators), Controlling High Blood Pressure (one indicator), Persistence of Beta-Blocker Treatment After a Heart Attack and Cholesterol Management for Patients With Cardiovascular Conditions (two indicators). No state went from the top cohort to the bottom cohort (or vice versa) from 2009 to 2010. Top 10 cohort Middle 32 cohort bottom 10 cohort d Rose to 2010 cohort from 2009 fell to 2010 cohort from 2009 d d d d d d d d! d d d d d d d d

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 E x E C U T I V E S U M M A R y 13 Quality Measurement and the Million Hearts Initiative Gains in HEDIS measures relevant to heart disease provide momentum for CDC s Million Hearts initiative. Millions Hearts launched in September 2011 and aims to prevent 1 million heart attacks in five years. Performance on six heart-related measures improved in the four years the measures held their current specifications five improved by almost three percentage points. These steady gains confirm that what gets measured gets improved, especially when measurement becomes a habit that insurers sustain. IMProvEMEnt in Measures related to Heart disease CoMMErCIal HMOs 90 80 70 60 Mean Rate 50 40 30 20 10 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit Persistence of Beta-Blocker Treatment After a Heart Attack Controlling High Blood Pressure* Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) Physical Activity in Older Adults Advice (MEDICARE HMOs) * Measure respecification in 2005 accounts for some of the 2005-2006 performance change. Overuse and resource use HEDIS emerged during an era when consumers were concerned that HMOs would deny needed care. Initial HEDIS measures focused on transparency around the use of proven therapies and preventive care.

14 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E As health care spending skyrocketed and recognition of wasteful spending caught the nation s attention, NCQA invested in measures to prevent overuse. Examples of these measures are Imaging Studies for Low Back Pain and Avoidance of Antibiotic Treatments in Adults With Acute Bronchitis. NCQA s Relative Resource Use measures help purchasers determine which plans provide the highest quality of care with the lowest use of resources. Care coordination Many experts point to duplicate procedures and poor transitions between providers and settings as examples of wasteful spending and poor quality. Several HEDIS measures capture the results of care coordination and chronic disease management: Annual Monitoring of Patients on Persistent Medications and Follow-Up After Hospitalization for Mental Illness are two of them. NCQA is also developing measures, standards and programs to assess and recognize care coordination and case management. NCQA s Patient-Centered Medical Home (PCMH) program and new Accountable Care Organization (ACO) program aim to improve care coordination. They target the clinical practices and delivery system levels. Responding to the evidence NCQA works with clinical experts to develop and revise HEDIS measures based on evidence. Measures start with guidelines grounded in robust findings. When the evidence base changes, so do the measures. HEDIS measures for clinicians In response to requests for measures below the health plan level, NCQA collaborated with the American Medical Association to develop HEDIS physician measures that assess clinical performance of ambulatory practices. These measures are widely used in the Medicare Physician Quality Reporting System, the Meaningful Use programs and NCQA s Clinical Practice Recognition programs. The NCQA Diabetes Recognition program is supported by private sector initiatives, including the New York State Diabetes Campaign, led by the New York State Health Foundation. EHR measures NCQA is working closely with the Office of the National Coordinator for Health Information Technology, the Centers for Medicare & Medicaid Services (CMS) and the National Quality Forum (NQF) to translate HEDIS measures into electronic formats. EHRs will simplify reporting of quality measures. They have the potential to apply clinical logic, based on quality measures, to improve care in different settings. They also create opportunities for developing measures that were previously set aside because of the burden of data collection.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 E x E C U T I V E S U M M A R y 15 Figure 3. Trends in ColorECtal CanCEr screening for CoMMErCIal HMOs, 2004 2010 100 90 80 70 60 50 40 30 20 10 0 2004 2005 2006 2007 2008 2009 2010 The Importance of Public Reporting in Improving Health Plan Performance Many health plans have stepped up to the challenge of collecting, reporting performance data and being held accountable. Plans disclosure of quality information using reliable, audited, standardized measures helps purchasers and consumers learn which plans and clinicians have the best results. NCQA credits public reporting and plans commitment to improving for the progress we have seen overall. The next section highlights significant gains in performance over time. Our discussion focuses on commercial HMOs, for which we have the longest series of data. We compare trends across plan types and product lines. Of the 32 HEDIS Effectiveness of Care measures, 23 show clear trends of improvement. While year-to-year gains are often quite small, they are steady over time. Only one measure showed unmistakable signs of worsening Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis. One example of progress is Colorectal Cancer Screening, with an almost 2 percentage point increase (to 62.6 percent) between 2009 and 2010 for commercial HMOs. Introduced in 2004,

16 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E this measure has shown steady gains. Similar gains have transpired for Medicare HMOs, although they have not reached the same level overall. Figure 4. Trends in HbA1c screening for People With diabetes for CoMMErCIal HMOs, 1999 2010 100 90 80 70 60 50 40 30 20 10 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 HbA1c Screening for People With Diabetes, introduced with a suite of diabetes measures in 1999, is another example of growth. The screening rate has risen steadily over the past 11 years, progressing from 75 percent in 1999 to almost 90 percent in 2010 for commercial HMOs. We have seen similar gains across HMOs, PPOs and product lines, with Medicare performing best. Performance on Medical Attention for Nephropathy has more than doubled for commercial HMOs. From 36 percent in the first year, it rose to almost 84 percent in 2010. (The 2005 addition of ACE/ARB therapy to the measure s qualifying criteria accounts for some of the performance gain.) Like the HbA1c screening measure, all plan types, in all product lines, have experienced gains. Medicare HMOs had the strongest performance of all groups (89.2 percent) in 2010.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 E x E C U T I V E S U M M A R y 17 Figure 5. Trends in MedICal Attention for nephropathy for People With diabetes for CoMMErCIal HMOs, 1999 2010 100 90 80 70 60 50 40 30 20 10 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Health plans have shown steady increases on most consumer experience measures, which are based on a rating scale of 0 10. Of seven CAHPS indicators, six showed consistent, gradual improvement. Health plans that report quality publicly and have earned NCQA Accreditation based on their performance should be applauded for achieving these gains. Public and private purchasers, including Medicare, have contributed to this effort by offering incentives for plans and providers to report and improve quality. Complementary policies can create even stronger improvement incentives. NCQA incorporates HEDIS results into accreditation levels and health plan rankings. Differentiating among health plans gives credit to the work of excellent performers and signals the results to consumers and purchasers. Even stronger incentives can flow from pay-for-performance programs, which are used by many Medicaid agencies and the Medicare Advantage (MA) program. Health plans with the best performance on quality might win additional payments; Medicaid plans might be assigned more

18 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E members. Purchasers that want to expedite performance gains may want to create incentives around measures where there has been little progress. Public reporting alone might not be a strong enough incentive to lead to change. The record on overuse measures is disappointing, and suggests other factors are at play. For example, we have seen virtually no change during the six-year history of Use of Imaging Studies for Low Back Pain. And although overuse of antibiotics leads to development of antibiotic-resistant strains of bacteria, performance on Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis has worsened, falling from almost 29 percent (successful avoidance) to 22.5 percent for commercial HMOs in 2010. One reason for this might be that providers have difficulty resisting patients demand for a pill to address symptoms. Implications: A Vision of High-Value Health Plans In the 1990s, many policy makers thought health plans were the vehicle to better quality of care and lower costs. The notion of managed competition underpinned the Clinton health reform proposals. Proponents envisioned that health plans would compete on cost, and drive consumer choice through transparency. HMOs would combine their insurance function with active management of patient care. Advocates saw opportunities to avoid emergency room use and hospital care by improving benefit design, networks and other programs. What happened instead was managed care backlash : members rebelled against limited provider networks and utilization review. 1 And the rise of self-insured employers led to increased contracting with PPO networks, rather than with full-risk-bearing HMOs. One big difference between earlier ideas about health reform and the 2010 Patient Protection and Affordable Care Act (PPACA) is an expectation that change should happen in the health care delivery system. The locus is the clinician s office and, to a lesser extent, the hospital. Programs like PCMH and the Meaningful Use of Health Information Technology (HIT) initiative push small practices to track patients care over time and across settings and to report and benchmark their performance against quality measures derived from medical evidence. The ACO program reflects this vision on a larger scale. The model involves a collection of clinician practices (and possibly hospitals) taking collective responsibility for improving patient care and lowering costs.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 E x E C U T I V E S U M M A R y 19 Changes to payment incentives will allow organizations to share savings for reducing unnecessary care. Proponents hope ACOs will invest in strategies and technologies to help patients manage chronic disease. The goal is to avoid emergency room and hospital care. Some might ask, if the delivery system embraces better coordination, patient management and integration, why do we need health plans? How do health plans add value if physicians and hospitals deliver better care? What can health plans do? It is worth noting that health plans will continue to be the entities holding insurance risk. Organizations committed to delivery system innovations will likely be wary of holding full insurance risk and managing population health. Thus, health plans will continue to serve this important purpose for some payers. Health plans have experience managing insurance risk and are regulated by states to ensure stability and financial soundness. They hold reserves and have processes to account for claims that have been incurred but not recorded; they can pool risk and access commercial reinsurance policies. They have data that enable analysis of services and use predictive modeling to target interventions like case management to high-risk populations. Health plans offering coverage in Medicaid, Medicare and Exchanges (2014) will have to bear financial risk. They also will have roles in benefit and coverage design, as well as collecting and reporting quality results. The following section describes a value agenda for health plans and suggests a vision for highvalue health plans. NCQA sees a strong role for health plans to nurture and promote changes at the delivery-system level. Fostering delivery-system reforms Health plans can lead or partner with other payers (employers, Medicaid, Medicare) to sponsor PCMH and ACO projects. They can change payment methods to encourage these programs, set participation standards and offer technical support. Health plans can also work with hospitals to implement safety initiatives and reduce readmissions. Health plans can provide data to practices to help them manage and coordinate care. They can offer incentives to invest in and use HIT, can explain the benefits of these innovations to members and can identify participating providers.

20 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Designing benefits and coverage Most recent changes in benefit design have involved setting coverage limits and increasing cost sharing through higher deductibles. However, health plans and purchasers can collaborate to develop benefits that encourage members to select care that improves their health and deter members from using services that are dangerous or ineffective. An application of this idea is value-based insurance design. It reduces cost sharing for services with the greatest value; for example, proven preventive care and maintenance therapies for chronic conditions. Another example is reference pricing, which steers physicians and patients to the most effective treatments by tying reimbursement for an item or service to the price of the most effective treatment. Less effective treatments are still covered by the plan, but members pay more for them. Collecting data from claims, enrollment, patients and medical records Health plans ability to aggregate data creates opportunities to report on care for their populations and for practices. Because of their size and experience, health plans can manage a diverse group of patients across sites of care. 2 George Isham, medical director of Health Partners in Minnesota, identified key areas where health plans contribute: Paying, collecting and aggregating bills. Billing records describe patients conditions and the care they received. Combined with enrollment information from pharmacies and laboratories, and extracts from medical records, these records form the basis of quality measurement. Collecting data and using it to inform the three-part aim in the National Quality Strategy (better care, healthy people/healthy communities and affordable care). Plans know how to turn information into quality measures. Cultivating transparency and displaying information for the public. Hospitals and nursing homes are becoming accustomed to transparency, but it is still rare among physicians and in outpatient settings. Small numbers and a lack of specialty care measures have hindered progress. Physicians and their representatives have not embraced public performance reporting. Developing quality improvement projects. Health plans have significant experience helping providers improve care. Collaborating to develop innovations in performance measurement and data analysis. Health plans have had success identifying high-risk patients and deploying inventive case management.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 E x E C U T I V E S U M M A R y 21 Putting the network together ACOs may eventually become health plans. Short of that, they may serve as the provider network for an employer- or provider-sponsored Medicare Advantage or Medicaid plan. But many purchasers need to offer coverage across a state or even across the country and health plans must assemble entire networks to meet this need. Health plans can use cost sharing to guide patients to high-value hospitals and providers. They can identify hospitals that are Centers of Excellence for treating high-cost or high-risk conditions. Then, they can make them preferred providers with the lowest cost sharing for patients. This approach could also reward hospitals or other providers that have strong patient safety records. The high-value plan of the future should rely heavily on value metrics to select its network. Ensuring that members have access to physicians with good credentials is an important part of consumer protection and of NCQA Health Plan Accreditation. But excellent health plans must also measure the performance of providers. They must use that information to build networks and report the information to consumers. Activating patients Because health plans will continue to hold risk and enroll members, they are uniquely situated to connect with patients and make them active partners in their health and wellness. Plans could pursue the following strategies to engage patients. Conduct wellness and health promotion through health appraisals and other strategies. Use financial incentives to encourage participation in programs designed to improve health. Smoking cessation and weight loss are two examples. Incorporate benefit design incentives that promote the best care and providers. Publicly report provider performance and involvement in delivery system reforms. Provide members with incentives to use decision aids to choose therapies. Cover palliative and end-of-life care and implement strategies to ensure that providers know and follow patient preferences and decisions. Survey enrollees about their experiences and how they rate providers. Then, use this information to provide feedback to physicians and construct networks. Make other options available to patients who opt out of ACOs.

22 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Health plans serving low-income patients and those with multiple chronic conditions also can invest in care management, which concentrates the focus on providing or connecting patients to health care and other service providers. While some of this work is moving to the delivery system, small clinical practices may not have the resources to invest in dedicated staff to do this work; health plans can either provide it or make available care coordination to share across multiple practices. How do we get health plans to high value? NCQA s experience has demonstrated that what gets measured gets improved. Many of our expectations for health plans could be turned into performance measures or standards, allowing health plans to review programs and policies against clear, detailed program elements. We have developed several programs that let high-performing health plans earn NCQA Recognition or NCQA Distinction. Most recently we created a distinction program for plans committed to improving multicultural care. Pay for performance might be successful in furthering the value agenda by awarding higher payments to plans that demonstrate high value. Many state Medicaid agencies have such programs; the Medicare Advantage program will soon, as well. Measures of health plan value could be added to that program or used to give health plans extra credit. Additionally, the Exchanges created by the PPACA could direct participants into plans that offer value. High-value plans could be visibly rewarded on the Exchanges report cards or listed prominently on the national Web portal. Information about high-value plans could be presented when consumers are first comparing plans. However, Exchanges must be mindful of choice fatigue, which can result from consumers having too much information and too many options. Exchanges can be architects of choice that guide people toward better value and quality, but the success of health reform depends on galvanizing consumers, not overwhelming them. Regardless of the specific approach, policy makers and purchasers should seize opportunities to work with health plans. Collaboration can improve health care and markets.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 E x E C U T I V E S U M M A R y 23 Conclusion The Dartmouth Group has shown that cost and quality do not have to be a trade-off, but how do we get to affordable, quality health care? We must focus on buying value in health care, but the politics are challenging. Our current marketplace is fractured; providers have different approaches for working with each sector. Patients are confused and vulnerable, and appeals to their fears have succeeded. It is challenging in this environment to implement strong, synchronized strategies to improve coordination and delivery of care. Health plans can be drivers of improvements to cost and quality in health care markets. As market makers, they should pursue strategies to activate and engage members. Leading-edge health plans devote significant resources to keeping their members healthy. Health plans need to construct value choices at the provider level so patients do not overpay and are not over-treated or victims of medical errors. NCQA s objective in seeking a value agenda is to advance the triple aim improving the individual s experience of care and the population s health, and reducing the overall cost of care. Ultimately, consumers hold the power to reshape insurance markets. The concept of a new insurance marketplace, facilitated by Exchanges, flows from the premise that consumers will be motivated to compare health plans. Measures based on CAHPS and HEDIS are a logical place to start. Endnotes 1. Draper, D.A., R.E. Hurley, C.S. Lesser, B.C. Strunk. 202. The Changing Face Of Managed Care. Health Affairs, Jan-Feb;21(1):11 23. 2. Enthoven, A. 1993. The History and Principles of Managed Competition. Health Affairs, Vol 12, Supplement 1, 24 48.

24 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS MEASURES of CARE About HEDIS The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by most HMOs and PPOs plans to measure performance on important dimensions of care and service. By providing objective, clinical performance data measures against a detailed set of measurement criteria, HEDIS helps purchasers and consumers compare health plans performance. HEDIS measures address a broad range of important health issues: Antibiotic use Asthma Breast, cervical and colorectal cancers Care for older adults Childhood immunizations Cholesterol management Diabetes High blood pressure Medication management Mental illness Smoking Prenatal and postpartum care HEDIS includes the Consumer Assessment of Healthcare Providers and Systems (CAHPS) 4.0 Survey. The CAHPS survey measures members experiences with their health care in areas such as claims processing and getting needed care quickly, and asks them to rate their health plan on a scale of 0 10. HEDIS 2011 data collected for this report generally reflect services delivered during calendar year 2010. To ensure validity of HEDIS results, certified analysts rigorously audit all data, using a process NCQA designed. See the appendices for more details about national averages and performance trends. Hos Measures Medicare Health Outcomes Survey (HOS) measures evaluate the physical and mental health of seniors enrolled in Medicare and are the first patient-based self-report of health status as a measure of quality of care in elderly populations. Including HOS in HEDIS measurement creates a broader scope of measures to evaluate the quality of care provided by health plans for the Medicare population. Included in this report are four HOS measures:

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 25 Fall Risk Management Management of Urinary Incontinence in Older Adults Osteoporosis Testing in Older Adults Physical Activity in Older Adults. Terms NA: Measure rates have no available data. In some instances, data are not collected for a measure in a product line. Rate: The statistical mean for reported data. Each measure is described by an average rate for each applicable product line. A Note on Medicare Survey Data Medicare CAHPS survey data of consumer experience and HEDIS measures collected through the survey (such as Flu Shots for Adults and Medical Assistance With Smoking and Tobacco Use Cessation) are not available when NCQA prints the State of Health Care Quality Report in September. NCQA will issue an updated version of this report that includes those data in November.

26 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E AvoIDANCE of ANTIbioTIC TREATMENT IN ADUlTS WITH ACUTE bronchitis S a f E T y A N D P o T E N T I A l W A S T E Acute bronchitis clinically presents as a cough lasting more than five days (typically, from one to three weeks). About 90 percent of cases are caused by a virus. 1,2 The Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis measure evaluates whether adults were treated appropriately by not receiving antibiotics, which are not indicated and may contribute to antibiotic resistance. Acute bronchitis affects approximately Diminished effectiveness of antibiotics 5 percent of U.S. adults annually and against bacterial infections, particularly continues to rank among the top 10 for use in patients who may need them conditions for which patients seek treatment to fight future, life-threatening bacterial in clinical settings. 1 infections, poses a significant public health concern. When resistance makes widelyused antibiotics ineffective, an alternative Antibiotics are prescribed in more than 60 percent of bronchitis cases; of those, 80 treatment may not be available, 7 or percent were unnecessary, according to the physicians may use more potent antibiotics, Centers for Disease Control and Prevention which are often more toxic and more (CDC) guidelines. 1,2 Antibiotic treatment expensive. This can result in longer hospital is not usually appropriate for acute stays, more serious side effects and bronchitis, with the exception of comorbid increased financial burden on the system diseases requiring antibiotics. 3 and on patients. 8 The Case for Improvement More than $1.1 billion is spent annually on unnecessary antibiotics for respiratory infections in adults. 4 Treating drug-resistant pathogens poses a significant burden on the system through repeated health care visits and greater risk of disease complications and hospitalizations which lead to increased health care costs. 5,6 HEDIS Measure Definition This measure assesses the percentage of adults 18 64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription on or three days after an episode. A higher rate indicates better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 27 Results Antibiotic treatment is only infrequently appropriate for acute bronchitis. Misuse or overuse can be avoided by prescribing treatment when necessary, as well as informing patients and clinicians regarding the appropriate use of antibiotics. TreatMEnt Rate Year HMO PPO HMO PPO HMO 2010 22.5 21.3 NA NA 23.5 2009 24.0 22.6 NA NA 25.6 2008 24.6 26.8 NA NA 25.8 2007 25.4 29.3 NA NA 25.9 2006 28.7 29.7 NA NA 28.0 S a f E T y A N D P o T E N T I A l W A S T E

28 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E USE of IMAGING STUDIES for LoWER back PAIN S a f E T y A N D P o T E N T I A l W A S T E Back pain is one of America s most common medical problems. An estimated 75 percent 85 percent of Americans will experience back pain at some point, 1 and approximately 25 percent of Americans will experience at least one day of back pain during any three-month period. 2 Although imaging is used to diagnose the cause of low back pain, it is costly and ineffective. Less than 1 percent of radiographs identify a specific cause of low back pain. 3 The Use of Imaging Studies for Low Back Pain measure assesses the number of patients with lower back pain who did not get an X-ray, MRI or CT scan as part of their treatment. Although a variety of minor injuries and The Case for Improvement conditions can lead to back pain, most On average, patients with low back pain acute low back pain is benign and selflimiting. Imaging studies are not required with back pain spend an average of have higher overall medical costs. Patients for diagnosis. 8 $7,211, while comparable patients without back pain spend an average of $2,400 Studies have shown that patients treated over a two-year period. Patients with low without imaging experience no difference back pain who opt for surgery incur an in health outcomes. 4,5 Abnormalities average of $34,000 in direct medical costs. 8 discovered through imaging were as common in individuals without back pain According to the Agency for Healthcare as they were in individuals with low back Research and Quality (AHRQ), almost pain. 4 18,000 Americans sought medical attention for low back pain in 2008. Additionally, Imaging for early, acute low back pain medical care for these individuals cost can lead to surgery. Complications from approximately $35 billion dollars, with unnecessary surgery can prolong back imaging driving much of the cost. 6,7 pain or lead to permanent disability. 5

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 29 HEDIS Measure Definition The percentage of adults with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI or CT scan) within 28 days of the diagnosis. Results With the use of costly imaging studies failing to produce positive health outcomes for patients with low back pain, X-ray, MRI and CT scans should primarily be used for patients with neurologic deficits or other serious underlying conditions. Year Imaging StudIEs for Low Back Pain HMO PPO HMO PPO HMO 2010 74.2 73.3 NA NA 75.5 2009 73.9 72.7 NA NA 76.1 2008 73.1 72.3 NA NA 75.7 2007 74.6 73.3 NA NA 77.3 2006 73.9 72.1 NA NA 78.3 2005 75.4 72.6 NA NA 79.0 S a f E T y A N D P o T E N T I A l W A S T E

30 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E RelATIVE RESoURCE USE S a f E T y A N D P o T E N T I A l W A S T E NCQA s Relative Resource Use (RRU) measures indicate how intensively health plans use heath care resources (e.g., doctor visits, hospital stays, surgery, drugs) compared with other plans in the same region, adjusted for the population of members they serve. When combined with NCQA HEDIS quality measures, RRU measures reveal value. RRU measures help health care purchasers identify health plans that deliver high-quality care while managing associated costs. The table below is a hypothetical example of RRU results for plans in one region for patients with diabetes. Scores above 1.0 indicate higher-than-average use, while scores below 1.0 indicate lower-than-average use. In this example, Plan D is highlighted because it offers an appealing combination of above-average quality and below-average resource use. HypotHEtICal diabetes rru in a single region Diabetes Medical Resource Use Plan Quality Score Combined Medical Inpatient Hospital Evaluation & Management Surgery & Procedures Rx Drugs Plan A 1.06 1.14 1.32 1.00 0.89 1.14 Plan B 1.10 0.85 0.96 0.74 0.73 1.12 Plan C 1.10 0.80 0.84 0.79 0.71 1.16 Plan D 1.14 0.74 0.77 0.85 0.56 1.13 Plan E 0.97 0.73 0.79 0.76 0.54 1.19 NCQA collects RRU data for five conditions that account for more than 60 percent of all health spending: asthma, cardiovascular disease, COPD, diabetes and hypertension. Overall, RRU measures reveal that the amount of services used to treat people often has little correlation to the quality of care. To allow fair comparison of plans, RRU measures feature risk adjustment and price standardization of services. The goal of risk adjustment is to eliminate sources of variation that neither health plans nor providers can control. Factors used in risk adjustment include age, gender and presence of other serious health conditions. Standardized prices are assigned to each unit of service delivered to health plan members and reported by service category (e.g., inpatient hospital care, evaluation and management, surgery and other procedures, diagnostic lab and imaging, prescription drugs) for each of the five conditions.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 31 Looking at quality and resource use scores together, purchasers should be most interested in plans that are high in quality and low in resource use. As depicted in the following scatterplots, scores that place health plans in the upper left quadrant are generally considered most desirable (above-average quality, below-average resource use). Health plans in the lower right quadrant are less desirable (below-average quality, above-average resource use). This report focuses on the three rru measures where discrepancies between plans resource use and resulting quality are most pronounced: hypertension, diabetes and certain cardiovascular conditions. We do not show commercial rru scatterplots because they have changed little since last year s State of Health Care Quality Report and are available in NCQA s Quality Compass product. Conversely, we show Medicare and Medicaid results because we did not do so in last year s report, and because the data are not available in Quality Compass. S a f E T y A N D P o T E N T I A l W A S T E Upcoming Refinements to rru Updated Risk Adjustment Approach: NCQA moved to an improved risk adjustment approach that was adapted from the Center for Medicare & Medicaid Service s (CMS) Hierarchical Condition Category (HCC) case-mix adjustment approach. The revised risk adjustment considers disease severity and number of comorbidities, in addition to other factors that inform the cost of care delivered to health plan members. Measure Enhancement: NCQA expanded its measurement of specific procedures, particularly for diabetes and cardiovascular care, to provide plans with actionable information about the frequently performed services that significantly contribute to resource use. Examples of these procedures include cardiac catheterization; carotid artery stenosis diagnostic tests; electron beam computed tomography and nuclear imaging stress tests for coronary artery disease; and cardiac computed tomography screening. Reporting risk adjusted utilization of these services, alongside cost information, is expected to increase meaning and actionability of measure results. Pharmacy Prescription Utilization: To provide more detail for the prescription drugs service category, NCQA added generic and name-brand utilization rates to the five measures. Compared with the previous format, the data now capture how well a plan manages its pharmacy costs with respect to generic, brand-name and multisource drugs.

32 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E S a f E T y A N D P o T E N T I A l W A S T E Quality (Indexed Ratio) MedICare HMOs: diabetes 1.5 1 0.5 0.5 1 1.5 RRU (Indexed Ratio) MedICare PPOs: diabetes 1.5 Quality (Indexed Ratio) 1 0.5 0.5 1 1.5 RRU (Indexed Ratio)

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 33 Quality (Indexed Ratio) MedICare HMOs: Cardiovascular Conditions 1.5 1 0.5 0.5 1 1.5 RRU (Indexed Ratio) S a f E T y A N D P o T E N T I A l W A S T E MedICare PPOs: Cardiovascular Conditions 1.5 Quality (Indexed Ratio) 1 0.5 0.5 1 1.5 RRU (Indexed Ratio)

34 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E S a f E T y A N D P o T E N T I A l W A S T E Quality (Indexed Ratio) MedICare HMOs: HyPErtension 1.5 1 0.5 0.5 1 1.5 RRU (Indexed Ratio) MedICare PPOs: HyPErtension 1.5 Quality (Indexed Ratio) 1 0.5 0.5 1 1.5 RRU (Indexed Ratio)

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 35 Quality (Indexed Ratio) MedICaid HMOs: diabetes 1.5 1 0.5 0.5 1 1.5 RRU (Indexed Ratio) MedICaid HMOs: Cardiovascular Conditions S a f E T y A N D P o T E N T I A l W A S T E 1.5 Quality (Indexed Ratio) 1 0.5 0.5 1 1.5 RRU (Indexed Ratio) MedICaid HMOs: HyPErtension 1.5 Quality (Indexed Ratio) 1 0.5 0.5 1 1.5 RRU (Indexed Ratio)

36 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E ADUlt BMI ASSESSMENT W e l l N E S S A N D P R E V E N T I o n Obesity is responsible for more deaths in the U.S. than AIDS, all cancers and all accidents combined. 1 Individuals are identified as being overweight or obese if their weight range is greater than is generally considered healthy for their height. 2 Obesity is measured by body mass index (BMI), which estimates body fat and gauges risk for high body-fat diseases. 3 The Adult Body Mass Index Assessment measure evaluates the percentage of adults who have their BMI measured regularly to assess their risk for overweight or obesity, and/or risk for related health complications. According to the Centers for Disease The Case for Improvement Control and Prevention (CDC), more than According to a 2009 study by the two-thirds of U.S. adults are overweight CDC and RTI International, a research or obese and more than one-third are organization, 6 the direct and indirect considered obese. 4 cost of obesity is more than $147 billion annually. Obese patients spend 42 percent Overweight and obesity occur from more for their medical care than those in a consuming too many calories and not healthy weight range an average $1,429 engaging in enough physical activity to more per year. The study found that compensate. This can be the result of a Medicare, Medicaid and private insurers number of factors, including behavior, increased spending due to obesity from 6.5 environment, culture and socioeconomic percent in 1998 to 9.1 percent in 2006. status. Genes and metabolism can also This amounts to a $40 billion increase in affect weight. 5 medical sending through 2006, including a As few as 31 percent of U.S. adults report $7 billion increase in Medicare prescription that they participate in regular leisuretime physical activity: three sessions per drug costs. 7 Obesity can cause a number of serious week of vigorous physical activity lasting medical conditions, including type 2 20 minutes or more, or five sessions per diabetes, heart disease and high blood week of light-to-moderate physical activity pressure, and increases the risk of strokes lasting 30 minutes or more. Approximately and certain types of cancers. 8 40 percent report no leisure-time physical activity. 4

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 37 Obese men are more likely to develop cancer of the colon, rectum or prostate; obese women are more likely to develop cancer of the gallbladder, uterus, cervix or ovaries. 8 HEDIS Measure Definition The percentage of adults 18 74 years of age who had an outpatient visit and who had their BMI documented during the measurement year or the year prior to the measurement year. AssessMEnt Rate Year HMO PPO HMO PPO HMO 2010 40.7 11.6 50.4 36.6 42.2 2009 41.3 15.7 38.8 24.1 34.6 W e l l N E S S A N D P R E V E N T I o n Results Weight loss and physical activity are recommended for people who are overweight or obese. Losing 5 percent 10 percent of body weight will help lower an obese person s risk of developing diseases associated with obesity. 4

38 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Flu ShoTS for ADUlTS W e l l N E S S A N D P R E V E N T I o n Each year, 5 percent 20 percent of Americans contract influenza (flu). More than 200,000 people are hospitalized from flu-related complications, which include pneumonia, dehydration and deterioration of chronic health conditions, such as heart failure, diabetes and asthma. 1 The Flu Shots for Adults Ages 50 64 measure assesses whether adults received an influenza vaccination (flu shot). Flu especially affects the health of people A single flu epidemic can result in more 50 64 2 years of age. One third of all than $3 billion in direct hospitalization Americans 50 64 have one or more costs alone. 8 chronic medical conditions that puts Flu shots have been shown to be highly them at increased risk for serious flu cost-effective for adults 50 64. complications. 3 9 The vaccination is estimated to cost just $16.70 Flu shots are the most effective way to per person vaccinated, including direct and prevent severe illness or death resulting indirect medical costs and costs associated from influenza and its complications. 4 with potential side-effects. 10 Influenza vaccines may prevent 50 percent 60 percent of hospitalizations and 68 percent of deaths from flu-related complications for this age group. 5 The Case for Improvement In 2008, only 67 percent of adults between 50 and 64 reported receiving an influenza vaccination. 6 Over the course of an average flu season, more than 15,000 lives could be saved if 90 percent vaccination coverage was achieved annually. 7 HEDIS Measure Definition A rolling average represents the percentage of commercial members 50 64 years of age who received an influenza vaccination between September 1 of the measurement year and the date when the CAHPS 4.0H survey was completed.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 39 Results Flu shots for adults ages 50 64 could save thousands of lives and result in dramatic cost savings for the health care system. VaCCInation Rate Year HMO PPO HMO PPO HMO 2010 52.5 51.6 NA NA NA 2009 51.3 50.5 64.5 65.1 NA 2008 49.8 49.2 65.8 66.7 NA 2007 48.6 48.1 68.6 68.9 NA 2006 45.6 44.5 67.8 68.2 NA 2005 36.2 37.1 70.3 69.9 NA 2004 38.9 NA 74.8 NA NA W e l l N E S S A N D P R E V E N T I o n 2003 47.9 NA 74.4 NA NA 2002 44.0 NA 72.5 NA NA 2001 30.3 NA 71.2 NA NA

40 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Breast CANCER SCREENING W e l l N E S S A N D P R E V E N T I o n Breast cancer is one of the most common types of cancers, and accounts for a quarter of all new cancer diagnoses among women in the U.S. 1 The Breast Cancer Screening measure assesses whether women between 40 and 69 years of age received a mammogram screening for breast cancer. Breast cancer is the second cause of cancer The Case for Improvement deaths in women (after lung cancer). 2 Breast cancer treatment costs in the U.S. total nearly $7 billion a year, including $2 Breast cancer deaths have decreased over billion spent on late-stage treatment. 5 Lowincome women are less likely to have had the years, thanks to early detection using mammography. Screening every two years a mammogram within the past two years, decreases the risk of mortality by more increasing their risk of late-stage diagnosis than 16 percent in women between 50 and and decreasing their chance of survival. 7 69, compared with no screening. 3 Early detection of breast cancer by About 70 percent 80 percent of breast mammography may lead to greater cancers occur in women who have no range of treatment options that include family history of breast cancer. These less-aggressive surgery and less-invasive cancers occur because of genetic therapy. 7 abnormalities that happen as a result of the aging process, 4 and there is a clear The five-year survival rate for women connection between age and developing who are diagnosed early is 98 percent, breast cancer. 5,6 compared with the late-diagnosed breast cancer survival rate of only 23 percent. 2 Mammogram screening has demonstrated reductions in breast cancer mortality HEDIS Measure Definition and there is a clear connection between The percentage of women 40 69 years of age developing breast cancer and age. 5,6 who had at least one mammogram to screen for breast cancer in the past two years.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 41 Results Early detection and better treatment have resulted in increased survival rates for women with breast cancer. If breast cancer is diagnosed when it is in its earliest stages, treatment may be more effective and less expensive. 5 ScrEEning Rate Year HMO PPO HMO PPO HMO 2010 70.8 67.0 68.5 65.8 51.3 2009 71.3 67.1 69.3 65.5 52.4 2008 70.2 66.0 68.0 65.2 50.8 2007 69.1 64.6 67.3 64.5 49.8 2006 68.9 63.5 69.5 68.6 49.1 2005 72.0 63.9 71.6 69.0 53.9 2004 73.4 NA 74.0 NA 54.1 W e l l N E S S A N D P R E V E N T I o n 2003 75.3 NA 74.0 NA 55.9 2002 74.9 NA 74.5 NA 56.0 2001 75.5 NA 75.3 NA 55.1 2000 74.5 NA NA NA NA 1999 73.4 NA NA NA NA

42 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E CERVICAl CANCER SCREENING W e l l N E S S A N D P R E V E N T I o n Cervical cancer is nearly 100 percent preventable, yet it is the second most common cancer among women worldwide. 1,2 In the United States, about 12,000 women are diagnosed with cervical cancer each year, resulting in more than 4,000 deaths. 3,4 The Cervical Cancer Screening measure assesses whether women between 21 and 64 years of age received screening for cervical cancer using a Pap test. For women in whom pre-cancerous lesions All women are at risk for cervical cancer were detected through Pap tests, the and women with the lowest levels of likelihood of survival is nearly 100 percent education tend to have fewer screenings in with appropriate evaluation, treatment and their lifetime. 4 follow up. 1,3 A woman who does not have regular Pap In 2008, the prevalence of recent Pap tests significantly increases her chances of test use was lowest among older women, developing cervical cancer. 3 women with no health insurance and recent immigrants. 1 HEDIS Measure Definition The percentage of women 21 64 years of age The Case for Improvement who received one or more Pap test to screen The total cost of treatment for cervical for cervical cancer in the past three years. cancer is $300 million $400 million annually. 2 Results Cervical cancer incidence and mortality rates Between 60 percent and 80 percent of have decreased 67 percent over the past women with advanced cervical cancer three decades. Most of the reduction can have not had a Pap test in the past five be attributed to the Pap test, which detects years. 1 cervical cancer and precancerous lesions. 1

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 43 ScrEEning Rate Year HMO PPO HMO PPO HMO 2010 77.0 74.5 NA NA 67.2 2009 77.3 74.6 NA NA 65.8 2008 80.7 74.0 NA NA 66.0 2007 81.7 73.5 NA NA 64.8 2006 81.0 72.6 NA NA 65.7 2005 81.8 74.6 NA NA 65.2 2004 80.9 NA NA NA 64.7 W e l l N E S S A N D P R E V E N T I o n 2003 81.8 NA NA NA 64.0 2002 80.5 NA NA NA 62.2 2001 80.0 NA NA NA 61.1 2000 78.1 NA NA NA NA 1999 71.8 NA NA NA NA

44 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E C o l o R E C TA l C A N C E R S C R E E N I N G W e l l N E S S A N D P R E V E N T I o n In 2010 an estimated 142,570 men and women were diagnosed with colon cancer, and approximately 51,370 died from the disease, making it the second leading cause of cancer death in the United States. 1,2 The Colorectal Cancer Screening measure assesses whether adults 50 75 years of age received screening for colorectal cancer, based on the recommendation of the U.S. Preventive Services Task Force. 3 Symptoms are not common in colorectal Deaths associated with colorectal cancer cancer until the disease has progressed declined in 2010, continuing a 15-year and chances of survival have decreased. 4 trend attributed to increased screening Treatment in the disease s earliest stage is and early detection. 3,10 Between 2003 highly successful, with a five-year survival and 2007, 35 states saw decreases in the rate of 74 percent. 5 number of new cases of colorectal cancer, 11 but regional variation exists. Most colorectal cancers occur in people without a family history of colorectal Screening for colorectal cancer is shown cancer. 6 While screening is extremely to be cost effective for the health care effective in detecting colorectal cancer, it system. The cost of screening far outweighs remains underutilized. the costs of treating more progressive colorectal cancer. 12 The Case for Improvement Doctors recommendations have been Approximately half of American adults do found to be a major predictor of whether not receive the necessary colorectal cancer patients receive the supported screening. 13 screening. 7 Screening rates for colorectal cancer lag behind other cancer screening HEDIS Measure Definition rates. 8 The percentage of adults 50 75 years of age Fecal occult blood tests, colonoscopy and who had appropriate screening for colorectal flexible sigmoidoscopy are shown to be cancer with any of the following tests: fecal effective screening methods. 6 Colorectal occult blood test during the measurement screen of individuals with no symptoms year; flexible sigmoidoscopy during the can identify polyps whose removal can measurement year or the four years prior to prevent more than 90 percent of colorectal the measurement year; or colonoscopy during cancers. 9

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 45 the measurement year or in any of the nine years prior to the measurement year. Results Colorectal cancer screening in asymptomatic adults between 50 and 75 can catch dangerous polyps before they become cancerous, or can detect colorectal cancer in its early stages, when treatment is most effective. ScrEEning Rate Year HMO PPO HMO PPO HMO 2010 62.6 47.6 57.6 41.0 NA 2009 60.7 47.0 54.9 40.1 NA 2008 58.6 45.3 53.1 41.8 NA 2007 55.6 42.5 50.4 39.5 NA 2006 54.5 42.1 53.3 47.1 NA 2005 52.3 43.4 54.0 49.7 NA 2004 49.0 NA 52.6 NA NA W e l l N E S S A N D P R E V E N T I o n

46 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E MEDICAl ASSISTANCE WITH SmokING AND TobACCo USE CESSATIon W e l l N E S S A N D P R E V E N T I o n Smoking is the second most common cause of death in the world, causing almost a half-million deaths annually, 1 and it is by far the most directly preventable cause of death and disability in the United States. 2,3 In 2009, almost 18 percent of adults in the U.S. more than 40 million people were smokers. 2 The Medical Assistance With Smoking and Tobacco Use Cessation measure assesses whether adults who use tobacco products receive counseling, medications and strategies to help them quit. Although consumption of cigarettes economic burden of smoking is estimated continues to decline and the number of to be $193 billion per year. 9 In an people who are heavy smokers (i.e., 18-month period, smokers incur 18 percent smoke a pack each day) has dropped higher health care charges than people significantly, 5 the consumption of cigars who never smoked. 7 and smokeless tobacco is on the rise. 6 Women and minorities receive advice More than 70 percent of smokers want to about quitting smoking less frequently than quit and more than 40 percent try to quit men who smoke. 11,12 each year. 7 Less than 7 percent succeed in kicking the habit. 7 HEDIS Measure Definition This measure evaluates three facets of The Case for Improvement providing medical assistance with smoking Studies have shown that a physician s and tobacco use cessations. advice to quit is an important motivator Advising Smokers and Tobacco Users to Quit. for smokers attempting to quit,8 but fewer A rolling average represents the percentage than half of smokers receive cessation of adults 18 years of age and older who are counseling. 9 Doctors and other health care current smokers or tobacco users and who providers can improve a patient s outcome received cessation advice from a physician in as little as three minutes, according to during the measurement year. the Public Health Service Guidelines. 10 Research indicates that the more intense the Discussing Cessation Medication. A rolling intervention, the higher the likelihood that average represents the percentage of smokers will quit successfully. 8 adults 18 years of age and older who are current smokers or tobacco users and who Annual smoking-related health care costs discussed or were recommended cessation are estimated at $96 billion. 9 When medications by a physician during the productivity losses are considered, the total measurement year.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 47 Discussing Cessation Strategies. A rolling average represents the percentage of adults 18 years of age and older who are current smokers or tobacco users who discussed or were provided cessation methods or strategies by a physician during the measurement year. Results Care providers play an important role in supporting smokers efforts to quit. Smoking cessation practices are among the most advantageous methods for reducing smokingrelated deaths and health care costs. 2 Year Discussing Cessation StrategIEs HMO PPO HMO PPO HMO 2010 45.0 39.0 NA NA 38.5 2008 49.7 43.3 NA NA 40.8 2007 48.0 44.2 NA NA 39.2 2006 43.2 42.6 NA NA 36.7 2005 38.9 35.1 NA NA 33.9 2004 36.8 NA NA NA 32.7 2003 36.0 NA NA NA 32.3 W e l l N E S S A N D P R E V E N T I o n Year Advising smokers and TobaCCo Users to Quit HMO PPO HMO PPO HMO 2010 76.7 71.7 NA NA 73.6 2009 NA NA 77.9 75.2 NA 2008 76.7 71.6 76.9 76.5 69.3 2007 75.8 71.0 75.8 75.4 69.4 2006 73.8 70.1 76.1 77.3 68.2 2005 71.2 66.9 75.5 77.3 65.6 2004 69.6 NA 64.7 NA 66.7 2003 68.6 NA 62.9 NA 65.8 2002 67.7 NA 61.6 NA 63.6 2001 65.7 NA 60.9 NA 63.9 2000 66.3 NA NA NA NA Year Discussing Cessation MedICations HMO PPO HMO PPO HMO 2010 52.4 47.2 NA NA 42.7 2008 54.4 50.9 NA NA 40.6 2007 50.9 49.6 NA NA 38.7 2006 43.9 43.8 NA NA 35.1 2005 39.4 36.7 NA NA 31.8 2004 37.8 NA NA NA 31.3 2003 37.6 NA NA NA 31.5

48 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E PERSISTENCE of beta-blocker TREATMENT AfTER a HEART ATTACk C H R o N I C D I S E A S E M A N A G E M E N T Heart attacks occur when blood clots obscure the main blood vessel that feeds the heart. Loss of blood flow may permanently damage the heart tissue. 1 Each year, an estimated 785,000 Americans suffer a heart attack. Of these, 470,000 have had at least one heart attack before, and 150,000 are under the age of 65. 2,3 The Persistence of Beta-Blocker Treatment After a Heart Attack measure reports the number of people who had a heart attack and received beta-blocker treatment during the six months following their discharge from the hospital. Beta-blocker therapy has been shown to If beta-blocker adherence could be reduce mortality when used after a heart increased to 100 percent in first-time attack. 4 These drugs can also reduce heart attack survivors for 20 years, an patients risk for hospital readmission in the estimated 62,000 heart attacks would be first year. 5 prevented, 72,000 deaths from coronary heart disease avoided, 447,000 life-years Beta-blocker therapy restores blood flow, gained and $18 million saved. 10,11 which reduces damage to the heart muscle. Beta-blockers slow heart rate, lower blood Although the elderly benefit from betablocker therapy, many patients are not pressure and prevent irregular heartbeats by blocking nervous impulses or stress prescribed these medications. Of all adults responses to the heart. 6,7 who are good candidates for beta-blocker medication, only 43.8 percent of nursing The Case for Improvement home residents and 61.4 percent of Despite beta-blockers effectiveness, community-dwelling residents receive betablockers. Research has shown that mortality adherence to beta-blocker therapy is poor. Only 45 percent of patients consistently is significantly lower for nursing home took their medications in the first year after patients who receive beta-blockers. 12 discharge. 8 Lack of adherence has been shown to increase patients risk of dying. 9

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 49 HEDIS Measure Definition The percentage of adults 18 years of age and older during the measurement year who were hospitalized with a diagnosis of AMI and discharged alive from July 1 of the year prior to the measurement year to June 30 of the measurement year, and who received persistent beta-blocker treatment for six months after discharge. Results The Persistence of Beta-Blocker Treatment After Heart Attack measure provides insight into the number of heart attack patients receiving appropriate care with medications proven effective in reducing cardiac-related mortality. TreatMEnt Rate Year HMO PPO HMO PPO HMO 2010 75.5 71.3 83.1 82.5 76.3 2009 74.4 69.6 82.6 78.9 76.6 2008 75.0 68.8 79.7 76.7 73.6 2007 71.9 62.9 75.5 70.4 62.0 2006 72.5 65.5 69.6 70.9 68.1 2005 70.2 64.3 65.4 58.5 69.8 C H R o N I C D I S E A S E M A N A G E M E N T

50 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E C o M P R E H E N S I V E D I A b E T E S C A R E C H R o N I C D I S E A S E M A N A G E M E N T Diabetes is the seventh leading cause of death in the United States. For people with diabetes, the risk of death is twice that of people without diabetes. 1,2 Diabetes, especially when unmanaged, may lead to blindness, heart disease and limb amputation. 1 It is also the leading cause of kidney failure, accounting for 45 percent of new cases. 3 People with diabetes face tripled risk of stroke, compared with people who have normal blood sugar levels. 4 Almost 26 million Americans are diabetic Between 1980 and 2006, the number of and an additional 79 million adults are hospitalizations for patients with diabetes prediabetic. 1 The number of diabetics is more than doubled. 5 Diabetes was the increasing dramatically, due in large part primary diagnosis in almost 550,000 to the rising number of Americans who are hospitalizations in 2009, when the average overweight or obese. 2 medical charge was $12,849 for diabetes without complications and $29,851 for The Comprehensive Diabetes Care measure diabetes with complications. 6 assesses whether patients receive guidelinerecommended care and achieve control levels Improving blood sugar control has shown for their blood sugar, cholesterol and blood to result in lower health care use and pressure. better overall satisfaction with diabetes treatment. 7,8 People who controlled their The Case for Improvement diabetes also reported improved quality of In 2007, diabetes was estimated to cost the life and emotional well-being. 9 U.S. economy $174 billion. Of this, $116 billion was attributed to the cost of medical HEDIS Measure Definition care. Another $58 billion was lost through The percentage of adults 18 75 years of age disability, missed work days and premature with diabetes (type 1 and type 2) who had mortality. 2 each of the following: Hemoglobin A1c (HbA1c) testing HbA1c poor control (>9.0%) HbA1c control (<8.0%) HbA1c control (<7.0%) for a selected population

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 51 LDL-C screening LDL-C control (<100 mg/dl) Medical attention for nephropathy BP control (<140/80 mm Hg) BP control (<140/90 mm Hg). Results Although many people live with diabetes years after diagnosis, it is a costly condition that leads to serious and potentially fatal health complications. Comprehensive diabetes control can improve the quality of life for millions of Americans and save billions of health care dollars. Year Blood Pressure Control (<140/90 MM Hg) HMO PPO HMO PPO HMO 2010 65.7 51.1 62.3 55.6 60.4 2009 65.1 46.3 60.5 49.0 59.8 2008 65.6 0.3 59.5 0.3 56.9 2007 63.9 0.1 58.9 0.3 55.6 Year Eye Exams HMO PPO HMO PPO HMO 2010 57.7 45.5 64.6 62.3 53.1 C H R o N I C D I S E A S E M A N A G E M E N T Year Blood Pressure Control (<130/80 MM Hg) HMO PPO HMO PPO HMO 2009 33.9 23.6 33.3 26.7 32.2 2008 33.4 0.2 31.8 0.2 30.7 2007 32.1 0.1 31.7 0.1 29.6 2009 56.5 42.6 63.5 59.4 52.7 2008 56.5 35.8 60.8 52.2 52.8 2007 55.0 34.0 62.7 50.4 49.8 2006 54.6 36.1 62.3 53.8 51.4 2005 54.8 42.7 66.5 53.8 48.6 2004 50.9 NA 67.2 NA 44.9 2003 48.8 NA 64.9 NA 45.0 2002 51.7 NA 68.4 NA 46.8 2001 52.1 NA 66.0 NA 46.4 2000 48.1 NA NA NA NA 1999 45.3 NA NA NA NA

52 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E C H R o N I C D I S E A S E M A N A G E M E N T HbA1c screening Year HMO PPO HMO PPO HMO 2010 89.9 85.2 90.4 90.6 82.0 2009 89.2 83.3 89.6 89.3 80.6 2008 89.0 79.5 88.3 85.7 80.5 2007 88.1 75.6 88.1 81.9 77.3 2006 87.5 72.1 87.2 83.3 78.0 2005 87.5 82.8 88.9 80.0 76.1 2004 86.5 NA 89.1 NA 75.9 2003 84.6 NA 87.9 NA 74.8 2002 82.6 NA 85.0 NA 73.0 2001 81.4 NA 85.7 NA 71.6 2000 78.4 NA NA NA NA 1999 75.0 NA NA NA NA Year Good GlyCEMIC Control (HbA1c <8%) HMO PPO HMO PPO HMO 2010 62.3 50.2 65.6 57.3 46.9 2009 61.6 48.0 63.7 51.8 45.7 Year Poor GlyCEMIC Control (HbA1c >9%) HMO PPO HMO PPO HMO 2010 27.3 46.6 25.9 35.2 44.0 2009 28.2 44.6 28.0 41.3 44.9 2008 28.4 74.4 29.4 67.0 44.8 2007 29.4 84.1 29.0 74.7 48.0 2006 29.6 75.9 27.3 71.8 48.7 Good GlyCEMIC Control (HbA1c <7% for a selected Population) Year HMO PPO HMO PPO HMO 2010 42.5 28.2 NA NA 34.7 2009 42.1 30.3 NA NA 33.9 2008 43.3 13.5 43.4 23.4 32.9 2007 43.1 10.0 46.2 21.7 31.4 2005 29.7 55.4 23.6 27.3 49.2 2004 30.7 NA 22.3 NA 48.6 2003 32.0 NA 23.4 NA 48.6 2002 33.9 NA 24.5 NA 48.9 2001 36.9 NA 26.8 NA 48.3 2000 42.5 NA NA NA NA 1999 44.9 NA NA NA NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 53 LDL Cholesterol screening Year HMO PPO HMO PPO HMO 2010 85.6 79.9 87.8 86.3 74.7 2009 85.0 78.6 87.3 85.5 74.2 2008 84.8 74.7 86.3 82.3 74.1 2007 83.9 72.7 85.7 80.0 70.8 2006 83.3 67.4 84.8 79.4 71.1 2005 92.3 87.0 93.3 87.1 80.6 2004 91.0 NA 93.5 NA 79.6 2003 88.4 NA 91.1 NA 75.9 2002 85.1 NA 87.9 NA 70.8 2001 81.4 NA 85.7 NA 66.5 2000 76.5 NA NA NA NA 1999 69.0 NA NA NA NA Year MedICal Attention for nephropathy HMO PPO HMO PPO HMO 2010 83.6 74.3 89.2 87.3 77.7 2009 82.9 69.9 88.6 85.2 76.9 2008 82.4 65.9 87.9 82.1 76.6 2007 80.6 64.2 85.7 81.7 74.3 2006 79.7 60.7 85.4 83.0 74.6 2005 55.1 44.4 60.3 51.5 48.9 2004 52.0 NA 58.6 NA 46.7 2003 48.2 NA 53.6 NA 43.7 2002 51.8 NA 57.3 NA 48.2 2001 46.3 NA 51.9 NA 42.3 2000 41.3 NA NA NA NA 1999 36.0 NA NA NA NA C H R o N I C D I S E A S E M A N A G E M E N T LDL Cholesterol Control (<100 mg/dl) Year HMO PPO HMO PPO HMO 2010 47.7 37.3 52.1 45.9 34.6 2009 47.0 36.8 50.0 40.5 33.5 2008 45.5 14.8 48.7 24.3 33.8 2007 43.8 10.4 46.8 22.4 31.3 2006 43.0 14.4 46.9 20.4 30.6 2005 43.8 24.4 50.0 48.4 32.7 2004 40.2 NA 47.6 NA 30.6

54 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E CoNTRollING HIGH Blood PRESSURE C H R o N I C D I S E A S E M A N A G E M E N T High blood pressure, or hypertension, occurs when the force of blood against artery walls increases, leading to greater risk of heart disease. High blood pressure may result when the arteries narrow or when the amount of blood the heart pumps increases. 1 The Controlling High Blood Pressure measure assesses whether adults with high blood pressure manage their condition by taking steps to lower their blood pressure and keep their scores within the normal range. Approximately 76.4 million (33.5 percent) of people in the United States have high blood pressure. 2, 5 High blood pressure puts people at risk for heart attacks and strokes. 3 Over a lifetime, people with hypertension have twice the risk of stroke, compared with those without hypertension. 4 Although the risk of developing hypertension increases with age, 9 nearly one in five young adults between the ages of 24 and 32 has high blood pressure. Of these, only half are aware that they have the condition. 6 A study conducted by The National High Blood Pressure Education Program in 2002 indicated that reducing blood pressure by 5 mm Hg decreased death from stroke by 14 percent, death from coronary heart disease by 9 percent and death from all causes by 7 percent. 9 The Case for Improvement In 2007, over 46 million ambulatory care visits were attributed to hypertension. 7 Hypertension was listed as a primary or secondary diagnosis in over 8.7 million hospital admissions. 1 The associated direct and indirect medical costs were estimated to be $43.5 billion. 1 Approximately 69 percent of people who suffer a first heart attack, 77 percent of people who have a stroke and 79 percent of people with congestive heart failure have high blood pressure. 1 Only half of people with hypertension 10, 11 control their high blood pressure. Life expectancy for people with hypertension is 5.1 years shorter for men and 4.9 years shorter for women, compared with individuals who have normal blood pressure. 8

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 55 HEDIS Measure Definition The percentage of adults 18 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90) during the measurement year. Results Controlling hypertension is an important step in preventing cardiovascular disease. Interventions to lower blood pressure can be an effective way to improve longevity and other health outcomes for a vast number of Americans. Control Rate Year HMO PPO HMO PPO HMO 2010 63.4 56.7 61.9 55.7 55.6 2009 64.1 48.3 59.8 54.8 55.3 2008 63.4 NA 58.5 NA 55.8 2007 62.2 NA 57.6 NA 53.5 2006 59.7 48.9 56.8 51.2 53.1 2005 68.8 60.9 66.4 60.6 61.5 2004 66.8 NA 64.6 NA 61.4 2003 62.2 NA 61.4 NA 58.6 2002 58.4 NA 56.9 NA 52.3 C H R o N I C D I S E A S E M A N A G E M E N T 2001 55.4 NA 53.6 NA 53.0 2000 51.5 NA NA NA NA 1999 39.0 NA NA NA NA

56 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E CholESTERol MANAGEMENT for PATIENTS WITH CARDIoVASCUlAR CoNDITIoNS C H R o N I C D I S E A S E M A N A G E M E N T High cholesterol puts people at increased risk for heart disease when fatty deposits adhere to artery walls and make it more difficult for blood to flow. Reduced blood flow limits the amount of oxygen reaching the heart, which could lead to heart failure, and low blood circulation to the brain could lead to a stroke. 1,2 An estimated 82 million American adults have some form of cardiovascular disease. 3 Each year more than 600,000 die, making heart disease the leading cause of death in the United States. 4 The Cholesterol Management for Patients with Cardiovascular Conditions measure assesses whether adults who have cardiovascular conditions are screened for high cholesterol. High cholesterol has no symptoms, making Lowering the level of LDL cholesterol in screening vital to diagnosing and treating patients with coronary heart disease this harbinger of heart disease before reduces the risk that patients will suffer serious damage occurs. 5 another cardiac event or stroke. 8 Lifestyle changes, like physical activity, a low-fat Reducing LDL-C ( bad cholesterol) levels diet and drug therapy, such as statins, have has been shown to lower the occurrence of been found to be effective ways to lower adverse cardiovascular events. 6 LDL cholesterol. 8,9 The Case for Improvement Researchers from the American Heart Association predict that by 2030, more than 40 percent of the U.S. population will have some form of cardiovascular disease. The estimated direct medical costs to treat these individuals will triple during this time frame, from $273 billion to $818 billion annually. 7 If the American population decreased its total cholesterol levels by 10 percent, new cases of cardiovascular disease would drop an estimated 30 percent. 3 HEDIS Measure Definition The percentage of adults 18 75 years of age who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from January 1 November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 57 the measurement year and the year prior to the measurement year and had each of the following during the measurement year: LDL-C screening LDL-C control (<100 mg/dl). Results Most high cholesterol cases are silent threats to patients heart health, especially for those who have already experienced heart trouble. Appropriate screening helps doctors and patients make lifestyle and medication changes to lower high cholesterol and prevent additional heart problems. LDL Cholesterol screening Year HMO PPO HMO PPO HMO 2010 88.9 81.3 88.5 87.1 82.0 2009 88.4 80.2 88.4 86.7 80.7 2008 88.9 75.2 88.6 85.6 79.6 2007 88.2 74.4 87.9 84.4 76.3 2006 87.5 68.2 88.0 84.6 75.5 LDL Control (<100 mg/dl) Year HMO PPO HMO PPO HMO 2010 59.9 45.2 56.7 50.6 42.8 C H R o N I C D I S E A S E M A N A G E M E N T 2009 59.2 42.3 55.7 47.2 41.2 2008 59.7 17.3 56.7 27.4 40.1 2007 58.7 13.4 55.9 23.2 38.3 2006 56.6 16.8 56.0 28.0 35.5

58 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E DISEASE MoDIfyING ANTI-RHEUMATIC DRUG T H E R A P y I N R H E U M AT o I D A RT H R I T I S C H R o N I C D I S E A S E M A N A G E M E N T Rheumatoid arthritis (RA) is a chronic inflammatory disease in which the immune system attacks healthy joints. 1 It causes joint destruction, bone erosion and damage to muscles, kidneys and other organs. 2 RA affects 1.5 million Americans. 3 The Disease Modifying Anti-Rheumatic Drug Therapy (DMARD) in Rheumatoid Arthritis measure assesses whether RA patients receive medications that slow the disease s progression and help them maintain functional capacity longer. People with persistent RA are at greater risk The Case for Improvement for premature death. 4 In particular, people Arthritis and related conditions, including with RA die from heart-related problems at RA, cost the U.S. economy $128 billion higher rates than people without RA. 5 each year. Direct costs, like medical expenses, are estimated at $81 billion, Arthritis and other rheumatic conditions and indirect costs, such as lost wages and are the most common causes of disability disability payments, are estimated at $47 in the United States. Approximately billion. 8 850,000 adults reported being disabled by RA more than blindness, deafness, bone In 2009, RA was the principal diagnosis in fracture, cancer and diabetes combined. 6 over 16,000 hospitalizations. On average, each visit lasted 4 days and cost nearly Although there is no cure for RA, DMARDs $36,000. 9 may effectively protect joints and minimize inflammation, slowing progression of the Approximately 60 percent of people with disease and reducing pain. 7 RA become too ill to work after 10 years of the disease. 10 HEDIS Measure Definition The percentage of diagnosed adults with rheumatoid arthritis who were dispensed at least one ambulatory prescription for a DMARD.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 59 Results RA is a debilitating disease affecting over one million Americans. Although there is no cure for RA, treatment with DMARDs can slow the disease s progression, reduce pain and lower medical and disability costs. TreatMEnt Rate Year HMO PPO HMO PPO HMO 2010 87.7 87.0 72.8 77.8 70.1 2009 86.4 86.6 72.3 76.4 70.5 2008 85.7 81.5 70.4 75.1 69.4 2007 85.3 78.9 68.7 73.5 68.1 2006 84.8 82.3 68.2 69.7 67.6 C H R o N I C D I S E A S E M A N A G E M E N T

60 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E USE of APPRoPRIATE MEDICATIoNS for People WITH ASTHMA C H R o N I C D I S E A S E M A N A G E M E N T Asthma, a long-term lung disease that affects the ability to breathe in both adults and children, has become one of the most prevalent chronic diseases over the past 20 years. 1 The Use of Appropriate Medications for People With Asthma measure assesses whether adults and children diagnosed with persistent asthma receive appropriate therapeutic medications. In 2009, approximately 24.6 million Adults and children with persistent asthma Americans (17.5 million adults and 7.1 are at increased risk of complications. 1 million children) reported having asthma. 2 Among the four million individuals who reported missing at least one work or Treatment that aligns with clinical school day due to asthma attacks, at least guidelines reduces the severity of symptoms one in seven (13.6 percent) required and the occurrence of asthma-related additional outpatient treatment. 6 events (e.g., hospitalizations, emergency department visits). 3 MEasurE DEFINITIon According to the Asthma Regional Council, The percentage of adults 5 50 years of two-thirds of adults and children who age during the measurement year who display asthma symptoms are considered were identified as having persistent asthma not well controlled or very poorly and who were appropriately prescribed controlled as defined by clinical practice medication during the measurement year. guidelines. 4 Results The Case for Improvement Adults and children with asthma can manage The financial burden of asthma is nearly their symptoms through use of long-term $56 billion annually. 5 control medications and environmental changes to reduce exposure to irritants. 6 Asthma is a leading cause of lost productivity and absenteeism. In 2008 there were 10.5 million missed work days for adults and 14.2 million missed school days for children 5 17 years of age. 2

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 61 5 11 years Year HMO PPO HMO PPO HMO 2010 96.7 97.0 NA NA 91.8 2009 96.6 97.0 NA NA 91.8 12 50 years Year HMO PPO HMO PPO HMO 2010 91.8 91.8 NA NA 85.8 2009 91.4 91.6 NA NA 86.0 Overall Rate Year HMO PPO HMO PPO HMO 2010 92.9 93.0 NA NA 88.4 2009 92.7 92.8 NA NA 88.6 2008 92.4 92.7 NA NA 88.7 2007 92.3 92.9 NA NA 86.9 2006 91.6 92.7 NA NA 87.1 2005 89.9 91.6 NA NA 85.7 2004 72.9 NA NA NA 64.5 2003 71.4 NA NA NA 64.1 2002 67.9 NA NA NA 62.5 C H R o N I C D I S E A S E M A N A G E M E N T 2001 65.6 NA NA NA 60.1 2000 62.6 NA NA NA NA 1999 57.7 NA NA NA NA

62 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E USE of SPIRoMETRy TESTING IN THE ASSESSMENT AND DIAGNoSIS of COPD C H R o N I C D I S E A S E M A N A G E M E N T Chronic obstructive pulmonary disease (COPD), characterized by blocked airflow and diminished capacity to breathe, is a major health problem in the U.S. The most significant risk factor is long-term cigarette smoking. 1,2 Other factors include old age and exposure to occupational and environmental pollutants. The Use of Spirometry Testing in the Assessment and Diagnosis of COPD measure evaluates whether adults with a new COPD diagnosis received a spirometry test, which helps in early diagnosis and enables appropriate treatment planning. COPD ranks as the fourth leading cause of The Case for Improvement death in the United States. 3 In 2010, total annual costs were estimated to exceed $50 billion $29.5 billion of this According to the Global Initiative for was for direct health care costs, including Chronic Obstructive Lung Disease hospitalizations, drugs and physician guidelines, the spirometry test is an office and emergency department visits. 1,6 effective and objective screening tool. 4 It Of direct costs, 40 65-year-old patients measures how much and how fast one can represented 67 percent of physician office breathe air in and out to assess how well visits and 43 percent of hospitalizations. oxygen is delivered to the lungs. Disability and premature death from COPD Early detection of COPD is crucial cost an additional $14.1 billion in lost for promoting smoking cessation and income. 1 instituting appropriate pharmacological and nonpharmacological therapy before In 2008, 13.1 million adults over 18 were patients reach more costly stages of the estimated to have COPD, 1,5 but close to disease. 3,4 24 million U.S. adults have evidence of impaired lung function, which indicates underdiagnosis 1,5

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 63 HEDIS Measure Definition This measure estimates the percentage of adults 40 years of age and older with a new diagnosis or newly active COPD who received spirometry testing to confirm the diagnosis. Results Spirometry tests can improve health outcomes through early detection; promoting smoking cessation; administration of influenza and pneumococcal vaccines; and permitting earlier initiation of pharmacological and nonpharmacological treatments. 7,8 Testing Rate Year HMO PPO HMO PPO HMO 2010 41.7 40.2 33.9 35.3 31.3 2009 38.8 36.7 28.5 28.8 28.6 2008 37.6 36.4 27.7 26.5 29.3 2007 35.7 33.7 27.2 25.4 28.4 2006 36.1 33.7 26.2 30.2 27.3 C H R o N I C D I S E A S E M A N A G E M E N T

64 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E PHARMACoTHERAPy MANAGEMENT of COPD ExACERbATIon C H R o N I C D I S E A S E M A N A G E M E N T Chronic obstructive pulmonary disease (COPD) exacerbations are characterized by acute worsening of clinical symptoms (e.g., breathlessness or sputum production). Exacerbations may range from temporary decline in functional status to fatal events. 1,2 After an exacerbation, patients symptoms and lung function can take several weeks to recover to baseline, and quality of life declines drastically. 2 The Pharmacotherapy Management of COPD Exacerbation measure evaluates whether patients received appropriate medical treatment after an event and assesses effective outpatient management of the disease. COPD exacerbations are responsible for The Case for Improvement the majority of COPD-related costs from COPD exacerbations are estimated to unscheduled physician and emergency result in approximately 110,000 deaths room visits and hospitalizations. 2 and more than 500,000 hospitalizations annually. More than $18 billion is spent Exacerbations have contributed to an on direct costs every year. 4 Hospital increase in COPD-related mortality, from admissions for COPD exacerbations 21.4 to 43.3 deaths per 100,000 persons average a 10-day length of stay, at a cost in the U.S. in the last two decades. 1 of $10,000 per stay. 5,6 According to the Global Initiative for Chronic Obstructive Lung Disease guidelines, inhaled bronchodilators are a cornerstone of treatment for COPD exacerbation. 3,4 Short-term corticosteroid therapy may also be required. 5,6 Approximately one-third of patients discharged from the emergency department with acute exacerbations have recurrent symptoms within 14 days, and 17 percent relapse and require hospitalization a good indicator that patients are not getting the care they require. 3 Benefits of appropriate medical treatment include decreased duration of hospital stays and less likelihood of treatment failure. Patients also exhibit decreased frequency of exacerbations and maintain longer disease-free intervals. 5

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 65 HEDIS Measure Definition The percentage of adults 40 years and older who experience an COPD exacerbation event and who were given appropriate medication therapy to manage an exacerbation. As identified by claims, a COPD exacerbation is an inpatient or ED visit with a primary discharge diagnosis of COPD. Results COPD medications aimed at controlling symptoms have been shown to increase exercise capacity, improve health status and reduce exacerbations. 5,7 Decreasing the frequency of an exacerbation has shown to slow the progression of COPD and should be a critical goal of care management. 2,5 BronCHodilators Year HMO PPO HMO PPO HMO 2010 77.8 73.5 78.2 76.1 82.1 2009 78.0 75.0 76.2 74.9 80.7 2008 76.1 68.1 74.1 71.3 78.2 SystEMIC CortICosteroids Year HMO PPO HMO PPO HMO 2010 69.8 66.2 66.6 69.6 65.3 2009 66.1 64.1 60.9 64.2 61.8 2008 67.0 58.2 60.0 60.8 61.7 C H R o N I C D I S E A S E M A N A G E M E N T

66 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E ANNUAl MoNIToRING for PATIENTS o n P E R S I S T E N T M E D I C AT I o N S C H R o N I C D I S E A S E M A N A G E M E N T Adverse drug events trigger 700,000 emergency department (ED) visits a year. A quarter of those visits come from adults 65 years and older. Approximately 120,000 hospital visits a year are attributable to adverse drug events, and older adults are seven times more likely to be hospitalized after an ED visit compared to the rest of the population. 1 The Annual Monitoring for Patients on Persistent Medications measure assesses whether adults were properly monitored for selected medications usually prescribed for long-term use. Adults over 65 consume more health care to the ED for other reasons. 5 Better methods than any other age group, and prescribing to identify and monitor adverse drug events medications to the elderly is the most may reduce avoidable hospitalizations. 3,6 common clinical decision doctors make. 2 HEDIS Measure Definition Allergic reactions and unintentional overdoses This measure assesses the percentage of adults are two of the most common adverse drug 18 years of age and older who received at least reactions that cause hospitalization. Rates 180 treatment days of ambulatory medication may improve with ongoing monitoring and therapy for the following therapeutic agents quality improvement. 3 during the measurement year and at least one therapeutic monitoring event for the therapeutic The Case for Improvement agent in the measurement year. Adverse drug events are responsible for $4 billion dollars of extra medical costs annually. 4 Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) Adverse drug events present a public Digoxin health concern as over-the-counter drugs become more available and more drugs Diuretics are prescribed in an outpatient setting. Anticonvulsants In one study, patients brought to the ED with adverse drug events caused by outpatient medications were shown to spend between three and eight more days in the hospital in the six-month period post ED visit, compared with patients admitted A combined rate is also reported. Results When patients do not adhere to a drug regimen, they have high rates of inpatient and outpatient health resource use. 7 Continued

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 67 monitoring of patients on persistent medications would reduce the likelihood of hospitalization and ED visits and increase adherence rates. ACE InHIbitors or arbs Year HMO PPO HMO PPO HMO 2010 81.6 78.4 90.7 90.8 86.0 2009 80.8 77.6 89.6 89.8 85.9 2008 79.4 76.4 86.7 88.8 84.8 2007 77.2 75.6 84.8 87.8 82.5 2006 74.8 66.3 82.7 83.9 79.9 Digoxin Year HMO PPO HMO PPO HMO 2010 84.6 79.1 93.1 92.7 89.7 2009 83.6 77.9 92.0 92.2 88.9 2008 81.9 76.6 90.4 91.1 88.5 2007 79.7 75.7 87.9 90.4 84.9 2006 77.3 64.2 86.2 87.1 83.0 DiuretICs C H R o N I C D I S E A S E M A N A G E M E N T AntIConvulsants Year HMO PPO HMO PPO HMO 2010 60.4 57.9 68.2 69.1 67.7 2009 62.0 59.2 69.7 68.5 68.7 2008 61.7 59.0 67.5 70.0 68.7 2007 59.6 56.3 65.1 66.0 65.9 2006 59.4 49.8 63.6 64.9 63.6 Year HMO PPO HMO PPO HMO 2010 81.0 78.1 90.9 91.2 85.5 2009 80.4 77.2 89.8 90.3 85.4 2008 79.1 76.1 87.1 89.1 84.2 2007 76.8 75.2 84.8 87.6 81.3 2006 74.4 65.7 83.0 84.1 79.1 Combined Year HMO PPO HMO PPO HMO 2010 80.9 77.8 90.2 90.6 83.9 2009 80.3 77.0 89.2 89.7 83.2 2008 78.9 75.8 86.3 88.6 82.6 2007 76.6 74.9 84.3 87.2 80.1 2006 74.3 65.6 82.2 83.6 77.7

68 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E A N T I D E P R E S S A N T M E D I C AT I o n M A N A G E M E N T C H R o N I C D I S E A S E M A N A G E M E N T Major depression is considered a serious medical illness; it affects approximately 5 percent 8 percent of American adults. 1 Depression is the leading cause of disability in the United States. 1 Symptoms include persistent sadness, loss of energy, loss of appetite and inability to concentrate. 2 The Antidepressant Medication Management measure assesses short-term and long-term medication adherence rates for adults newly diagnosed with depression. According to evidence-based guidelines, Inefficiencies in diagnosing and applying medication management reduces the risk evidence-based treatments for depression of relapse and reoccurrence for patients add to loss of productivity and affect with depression. Without antidepressant mental and physical well-being. 7,8 medication, 50 percent 80 percent of The risk of physical and functional patients have major depressive relapses impairments because of missed work and reoccurrences. 3 or school can increase as well-being The need for antidepressant medication deteriorates. Responsible, evidence-based increases as the severity of depression medication management may improve the intensifies. 2 secondary impact of the disease. 9 The Case for Improvement Major depression accounts for a variety of indirect economic costs resulting from personal developmental delays and productivity losses. 4 Personal income loss for people with depression reaches an average of $10,400 annually, with a lifetime total cost of $300,000. 5 Individuals with depression take an average of 10 sick days a year. 6 Time missed from work or school due to depression is higher than many anxiety and emotional disorders. HEDIS Measure Definition The percentage of adults 18 years of age and older who were diagnosed with a new episode of major depression and treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported. Effective Acute Phase Treatment. The percentage of newly diagnosed and treated people who remained on an antidepressant medication for at least 84 days (12 weeks).

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 69 Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated people who remained on an antidepressant medication for at least 180 days (6 months). Results Measurement of both rates will address the incomplete prescribing and use of antidepressants that contribute to negative economic, clinical and public health outcomes. 10 Improvements in antidepressant medication adherence will reduce the burden of relapse and reoccurrence. 11 Continuation Phase Year HMO PPO HMO PPO HMO 2010 48.3 48.1 51.9 55.7 34.4 2009 46.2 46.4 50.6 51.0 33.0 2008 46.3 46.4 49.3 48.9 31.8 2007 46.1 47.6 48.7 48.7 27.4 2006 45.1 46.6 45.1 40.9 27.5 2005 45.0 48.4 41.1 31.1 29.7 2004 44.3 NA 42.4 NA 30.4 2003 44.1 NA 39.2 NA 29.3 2002 42.8 NA 37.7 NA 32.4 C H R o N I C D I S E A S E M A N A G E M E N T Year Acute Phase HMO PPO HMO PPO HMO 2001 40.1 NA 36.8 NA 30.0 2000 40.1 NA NA NA NA 1999 42.1 NA NA NA NA 2010 64.7 64.3 65.0 67.4 50.7 2009 62.9 63.2 63.7 63.4 49.6 2008 63.1 63.1 62.5 61.6 48.2 2007 62.9 63.8 61.2 61.0 42.8 2006 61.1 63.6 58.2 56.7 42.9 2005 61.3 65.6 55.0 49.2 45.1 2004 60.9 NA 56.4 NA 46.4 2003 60.7 NA 53.3 NA 46.2 2002 59.8 NA 52.1 NA 47.5 2001 56.9 NA 51.2 NA 45.5 2000 57.4 NA NA NA NA 1999 58.8 NA NA NA NA

70 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E INITIATIon AND ENGAGEMENT of Alcohol A N D o T H E R D R U G D E P E N D E N C E T R E AT M E N T C H R o N I C D I S E A S E M A N A G E M E N T In 2009, an estimated 21.8 million persons 12 or older were classified with substance dependence or abuse. Of these, 70 percent were dependent on or abused alcohol, 15 percent abused or were dependent on both alcohol and illicit drugs and 16 percent were dependent on or abused illicit drugs. 1,2 The Initiation and Engagement of Alcohol and Other Drug Dependence Treatment measure monitors whether adolescents and adult members with an episode of alcohol or drug dependence initiated and followed up on necessary treatment. The primary goals of drug abuse or Treatment is essential to stem the economic addiction treatment are abstinence, relapse and human costs associated AOD prevention and rehabilitation. Less than dependence or addiction. Treatment 20 percent of people diagnosed with frequency and intensity of engagement is substance abuse and less than 40 percent important for successful outcomes. 3,7 of those with addiction problems seek treatment. 3 HEDIS Measure Definition This measure asses the percentage of adolescent One in four deaths in the U.S. is attributed and adults with a new episode of AOD to alcohol, tobacco or illicit drugs. 6 dependence who received the following care. The Case for Improvement Total overall costs of substance abuse in the U.S., including productivity, health and crime-related costs, exceed $600 billion annually. Every American adult pays nearly $1,000 per year for the damages of addiction. 4,5 The health burden of substance use includes the harmful effects of acute intoxication, substance use-associated injury and violence and the consequences of numerous medical and psychiatric disorders associated with chronic alcohol and other drug (AOD) use. 6 Initiation of AOD Treatment. The percentage of people who initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. Engagement of AOD Treatment. The percentage of people with a diagnosis of AOD use or dependence who initiated treatment and had two or more additional services within 30 days of the initiation visit.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 71 Results Research suggests that treatment reduces drug use, improves health and job performance, reduces involvement with the criminal justice system, reduces family dysfunction and improves quality of life. 3,7 EngagEMEnt Year HMO PPO HMO PPO HMO 2010 15.6 16.0 3.7 4.8 14.2 2009 16.1 15.7 4.6 4.2 12.3 2008 16.2 16.2 4.3 9.4 12.4 Initiation Year HMO PPO HMO PPO HMO 2010 42.7 40.8 44.6 57.4 42.9 2009 42.7 41.8 46.2 57.4 44.3 2008 42.4 42.6 45.9 49.1 44.5 2007 44.5 46.0 50.4 56.5 45.6 2006 43.2 49.0 50.3 50.0 43.3 2005 44.5 45.8 50.9 52.3 40.7 2004 45.9 NA 52.6 NA 45.7 C H R o N I C D I S E A S E M A N A G E M E N T 2007 15.2 15.2 4.5 6.3 14.4 2006 13.8 16.0 4.5 7.0 11.7 2005 14.1 15.3 4.7 3.2 9.7 2004 15.5 NA 7.1 NA 11.9

72 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPRoPRIATE TREATMENT for CHIlDREN WITH UPPER RESPIRATory InfECTIon M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Upper respiratory infections (URI) are self-regulating viral infections that cannot be treated by antibiotics. 1 Despite this, clinical practice trends show that antibiotics are often prescribed, leading to a trend in overuse and growing antimicrobial resistance among patients. 1 Also known as the common cold, URIs target the lining of the throat and nose, resulting in fever, congestion, coughing and other symptoms. 2 The Appropriate Treatment for Children With Upper Respiratory Infection measure evaluates whether children were properly treated for URIs by not receiving antibiotics unless deemed appropriate by a clinician. Approximately over 100 million antibiotic Studies have shown that up to 60 percent prescriptions are written in the ambulatory of patients with colds or URIs seen in the care setting every year. 3 emergency department are prescribed antibiotics, which have not demonstrated According to the Centers for Disease improvement in clinical outcomes. 5 Control and Prevention, antibiotics were prescribed during 68 percent of URI visits. Overuse of antibiotics is a significant issue Of these visits, 80 percent did not require in URI treatment. A survey conducted the prescription of antibiotics as defined by in 2004 illustrated that among children practice guidelines. 4 seen in a primary practice, outpatient or emergency department setting, those In 2005, there were 1.17 billion visits diagnosed with viral URIs experienced to ambulatory clinics and emergency even higher rates of antibiotic prescription, departments. 11 percent (130 million visits) even though antibiotics are ineffective for were for acute respiratory infections. 7 treating viral infections. 8 The Case for Improvement In the U.S., URIs are responsible for nearly $17 billion in direct costs (e.g., physician services and treatment because of complications) and $22.5 billion in indirect costs (e.g., absenteeism and lost productivity) every year. 6

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 73 HEDIS Measure Definition The percentage of children 3 months 18 years of age who were diagnosed with a URI and were not dispensed an antibiotic prescription. Results Antibiotic treatment is only infrequently appropriate for URIs. Misuse or overuse can be avoided by prescribing treatment when necessary, as well as educating patients and clinicians about the use of antibiotics in treating URIs. 8 TreatMEnt Rate Year HMO PPO HMO PPO HMO 2010 85.1 83.7 NA NA 87.2 2009 84.1 82.5 NA NA 86.0 2008 83.9 83.3 NA NA 85.5 2007 83.5 83.0 NA NA 84.1 2006 82.8 82.1 NA NA 83.4 2005 82.9 81.9 NA NA 82.4 2004 82.7 NA NA NA 79.9 M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

74 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Lead SCREENING IN CHIlDREN M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Lead poisoning is highly toxic and can cause cognitive impairment, behavioral disorders, seizures and death. 1,2 Children are especially at risk for developing lead poisoning. Approximately 250,000 children under the age of 5 have elevated blood lead levels (>10 micrograms of lead per deciliter of blood). 3 The Lead Screening in Children measure gauges the number of children tested for lead poisoning before they turn 2. The two most common methods of screening children for lead poisoning are venous blood sampling (inserting a needle into a vein) and capillary blood sampling (finger or heel stick). 4 Children with elevated blood lead levels have increased all-cause mortality. 5 The Case for Improvement Although lead-based paints were banned for use in housing units in 1978, approximately 24 million homes in the United States contain lead paint and elevated levels of lead-contaminated house dust. More than 4 million of these homes are inhabited by young children. 6 The total annual costs of environmental pollutants are estimated at $76.6 billion. Of this, $50.9 billion is attributable to lead poisoning. 7 remained consistently high, even though they have declined for the overall population by 84 percent since 1988. 8 HEDIS Measure Definition This measure assesses the percentage of children 2 years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday. Results Lead poisoning is a common medical condition causing serious bodily harm in children, one of the most vulnerable of populations. Screening is an inexpensive way to detect the presence of lead in a child s environment and reduce further exposure. ScrEEning Rate Year HMO PPO HMO PPO HMO Low-income children, non-hispanic Black children and children living in housing built before 1950 are disproportionately affected by lead poisoning. For these populations, blood lead levels have 2010 NA NA NA NA 66.2 2009 NA NA NA NA 66.4 2008 NA NA NA NA 66.7

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 75 A m b u l AT o ry C A R E: E M E R G E N C y D E PA RT M E N T V I S I T S Although visits to the emergency department (ED) do not indicate poor quality of care, unnecessary use of emergency care may signal a lack of access to more appropriate sources of medical attention. 1 The Ambulatory Care: ED Visits measure assesses the number of people who visited the ED during the measurement year. In 2007 there were nearly 120 million ED visits, an increase of 23 percent from 1997. Of these, more than 34 percent occurred during normal business hours. 2 Approximately 40 percent of ED visits are Time spent waiting is costly in terms of not urgent. Many of these visits occur when productivity. More than 65 percent of patients cannot be seen by their primary people visiting the ED spent over two hours care physician. 3 in the facility. Almost 9 percent left before being seen by a physician. 2 The Case for Improvement Avoidable use of urgent care contributes to HEDIS Measure Definition ED overcrowding, an increasingly common This measure summarizes utilization of problem in the United States. 4 More than ambulatory care by calculating the number of 48 percent of EDs are at or over patient ED visits per measurement year. capacity, 5 which can be a threat to patient safety and public health. 6 Results When possible, unnecessary ED visits should Increased ED wait time is frustrating for be avoided; they lead to ED overcrowding, patients, especially when they visit the ED increased wait time and lower patient for routine care. Research has shown that satisfaction. Access to other sources of patients with urgent symptoms are more ambulatory care can improve patient satisfied with their emergency care than outcomes and keep the quality of care high. patients with nonurgent symptoms. 7 M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

76 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Visits Per 1,000 MEMber Months Year HMO PPO HMO PPO HMO 2010 187.4 174.0 450.3 379.0 62.0 2009 196.7 182.5 461.4 371.1 67.4 2008 194.5 181.3 459.1 395.7 60.2 2007 200.8 191.1 457.9 411.3 61.4 2006 200.5 188.7 403.9 375.2 56.6 2005 187.5 186.0 316.0 264.0 54.4 2004 177.5 NA 306.3 NA 48.5 2003 181.3 NA 292.3 NA 49.2 2002 182.6 NA 279.8 NA 49.4 2001 176.9 NA 276.1 NA 46.2 2000 164.3 NA NA NA NA 1999 150.3 NA NA NA NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 77 PRENATAl AND PoSTPARTUM CARE & frequency of ongoing PRENATAl CARE Among the 4.3 million deliveries in 2008, 94 percent listed some type of pregnancy complication. 1,2 Each year, more than 500,000 pregnant women across the U.S. deliver babies with potentially avoidable complications such as preterm birth, low birthweight and pre-eclampsia. 2 The Prenatal and Postpartum Care and Frequency of Ongoing Prenatal Care measures assess whether women have access to timely and consistent prenatal and postpartum care. Diabetes, hypertension and postpartum for $17.4 billion, or nearly 5 percent of depression are the most commonly reported total hospital costs in the U.S. 1 health conditions among pregnant women. 3 Women who failed to receive prenatal care Prenatal care during the first trimester were almost three times more likely to have helps to improve maternal health and a low-birthweight infant than women who survival, and results in improved infant had care, resulting in expected hospital survival by linking women who have highrisk pregnancies to better obstetrical and women who received prenatal care. 5 cost savings of more than $1,000 for neonatal care. 3 Women who receive only the minimal Postpartum care encompasses management amount of prenatal care are at high risk of the mother and the newborn infant for pregnancy complication and negative and is aimed at detecting early parenting birth outcomes. 8,10 More than 11 percent problems and performing physical exams of pregnant women receive inadequate and postpartum depression screenings. 4 prenatal care each year. 9 M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S The Case for Improvement Hospital stays with pregnancy-related complications tended to be longer (2.7 2.9 days) than without complicating conditions (1.9 days). Maternal stays with complicating conditions were also about 50 percent more costly ($8,000) than those without complications ($2,600). In 2008, maternal stays with pregnancy and delivery-related complications accounted Early, comprehensive and continuous prenatal and postpartum care can promote healthier pregnancies and reduce the risk of costly, adverse birth outcomes and postpartum depression. 6,7

78 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S HEDIS Measure Definition This measure has two indicators related to deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. Timeliness of Prenatal Care: The percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment in the health plan. Postpartum Care: The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. The Frequency of Ongoing Prenatal Care measure assesses the percentage of Medicaid deliveries between November 6 of the year prior to the measurement year and November 5 of the measure year that received the following number of expected prenatal visits: <21 percent of expected visits 21 percent 40 percent of expected visits Results Research confirms that maternal health before conception, throughout pregnancy and during the postpartum period influences not only birth outcomes but also morbidity, as infants move into adulthood. 6,7 Timeliness of Prenatal Care Year HMO PPO HMO PPO HMO 2010 91.0 75.7 NA NA 83.7 2009 93.1 61.9 NA NA 83.4 2008 92.4 55.5 NA NA 81.9 2007 91.9 46.0 NA NA 81.5 2006 90.6 61.9 NA NA 81.2 2005 91.8 74.6 NA NA 79.6 2004 90.8 NA NA NA 78.2 2003 89.4 NA NA NA 76.5 2002 86.7 NA NA NA 70.4 2001 85.1 NA NA NA 72.9 41 percent 60 percent of expected visits 61 percent 80 percent of expected visits 81 percent of expected visits.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 79 Year Postpartum visit between 21 and 56 Days After delivery HMO PPO HMO PPO HMO 2010 80.7 65.9 NA NA 64.4 2009 83.6 54.1 NA NA 64.1 2008 82.8 45.8 NA NA 62.6 2007 82.0 41.6 NA NA 58.6 2006 79.9 46.3 NA NA 59.1 2005 81.5 62.8 NA NA 57.2 2004 80.6 NA NA NA 56.5 2003 80.3 NA NA NA 55.3 2002 77.0 NA NA NA 52.1 2001 77.0 NA NA NA 53.0 FrEQuency of Prenatal Care visits >80% of ExPECted visits Year HMO PPO HMO PPO HMO 2010 NA NA NA NA 61.1 2009 NA NA NA NA 61.6 2008 NA NA NA NA 58.7 2007 NA NA NA NA 59.6 2006 NA NA NA NA 58.6 2005 NA NA NA NA 55.8 2004 NA NA NA NA 51.5 2003 NA NA NA NA 48.2 2002 NA NA NA NA 41.0 2001 NA NA NA NA 39.2 M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

80 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E ChlAMyDIA SCREENING IN WoMEN M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Chlamydia is the most commonly reported bacterial sexually transmitted disease in the United States, occurring most often among adolescent and young adult females. 1,2 Chlamydia is often known as a silent disease because most infected people are asymptomatic. 1 Untreated chlamydia infections can lead to serious and irreversible complications, including pelvic inflammatory disease (PID), infertility and increased risk of becoming infected with HIV. 1,3 The Chlamydia Screening in Women measure looks at the percentage of non-pregnant, sexually active women 24 years of age and younger who are screened annually for chlamydia, as recommended by the U.S. Preventive Services Task Force. 4 Approximately 75 percent of chlamydia partners of infected women and difficulties infections in women and 95 percent in men in measuring the public health impact. 2 are asymptomatic, resulting in delayed Multiple chlamydia infections increase a medical care and treatment. 5 woman s risk of serious reproductive health Between 10 percent and 15 percent of complications. 7 untreated chlamydia infections result in PID, which can lead to ectopic pregnancy HEDIS Measure Definition and infertility. 1 As many as 15 percent of The percentage of women 16 24 years of age women with PID will become infertile. 5 who were identified as sexually active and who had at least one test for chlamydia during The Case for Improvement the measurement year. The estimated annual cost of chlamydia infections is approximately $647 million. Results The lifetime medical cost of chlamydia is If recommended annual chlamydia screening about $315 per case for females. If the guidelines were followed, as many as 60,000 infection leads to PID, treatment can range cases of PID, 8,000 cases of chronic pelvic between $1,060 to $3,180 per case. 6 pain and 7,500 cases of infertility could be prevented each year. 8 Chlamydia is easily detected and treated, but screening remains underutilized. Challenges affecting annual screening rates include lack of awareness, social stigma, barriers to finding and treating sex

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 81 16 20 years Year HMO PPO HMO PPO HMO 2010 40.8 38.1 NA NA 54.6 2009 41.0 37.7 NA NA 54.4 2008 40.1 36.7 NA NA 52.7 2007 36.4 32.4 NA NA 48.6 2006 36.2 29.4 NA NA 50.5 2005 34.4 26.2 NA NA 49.2 2004 32.6 NA NA NA 45.9 2003 30.4 NA NA NA 44.3 2002 26.7 NA NA NA 40.8 2001 24.5 NA NA NA 39.6 2000 23.6 NA NA NA NA 1999 18.5 NA NA NA NA 21 24 years Year HMO PPO HMO PPO HMO 2010 45.7 41.9 NA NA 62.3 2009 45.4 41.4 NA NA 61.6 2008 43.5 39.4 NA NA 59.4 2007 39.2 34.9 NA NA 54.0 2006 38.0 31.2 NA NA 55.0 2005 35.2 27.6 NA NA 52.5 2004 31.7 NA NA NA 49.0 2003 29.1 NA NA NA 46.0 2002 24.5 NA NA NA 41.5 2001 22.1 NA NA NA 41.1 2000 20.7 NA NA NA NA 1999 16.0 NA NA NA NA Total Rate Year HMO PPO HMO PPO HMO M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S 2010 43.1 40.0 NA NA 57.5 2009 43.1 39.5 NA NA 56.7 2008 41.7 38.0 NA NA 54.9 2007 38.1 33.8 NA NA 50.7 2006 37.3 30.4 NA NA 52.4 2005 34.9 26.9 NA NA 50.7 2004 32.2 NA NA NA 47.2 2003 29.7 NA NA NA 44.9 2002 25.4 NA NA NA 40.9 2001 23.1 NA NA NA 40.4

82 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Follow-Up AfTER HoSPITAlizATIon for MENTAl IllNESS M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Mental illness affects about 1 in 4 adults, and approximately 15 million adults in the United States suffer from a serious mental illness. 1,2 Less than half of adults with a serious mental illness receive treatment or counseling. 2 The Follow-Up After Hospitalization for Mental Illness measure assesses whether patients 6 years of age and older who were hospitalized for treatment of selected mental health disorders were seen by a mental health provider. Mental illness accounts for more burden deaths each year, and could be caused by from disease than all forms of cancer untreated depression. 8 combined. 3 In 2008, 30 million adults received The World Health Organization has treatment for mental health problems. 9 In reported that 4 of the 10 leading causes of 2005, more than 2 million patients were disability in the U.S. and other developed discharged from a hospital with a mental countries are mental disorders. By 2020, disorder. 10 it is expected that mental illness will be the leading cause of disability in the world for HEDIS Measure Definition women and children. 4 The percentage of discharges for members 6 years of age and older who were Half of first-time psychiatric patients were hospitalized for treatment of selected mental readmitted within two years of hospital health disorders and who had an outpatient discharge; appropriate follow-up care visit, an intensive outpatient encounter or is known to reduce the risk of repeat partial hospitalization with a mental health hospitalization. 5,6 practitioner. The measure separately identifies the percentage of members who received The Case for Improvement follow-up within 7 and 30 days of discharge. The economic burden of serious mental illness is estimated at $317 billion dollars Results and includes the cost of health services, Proper follow-up treatment for psychiatric loss of earning and disability benefits. 7 hospitalization can lead to improved quality Suicide is the 11th leading cause of of life for patients, families and society as a death in the U.S., accounting for 30,000 whole.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 83 WitHIn 7 Days Post-dIsCHarge Year HMO PPO HMO PPO HMO 2010 59.7 54.2 37.4 39.1 44.6 2009 58.7 52.6 37.3 40.6 42.9 2008 57.2 49.8 38.1 37.3 42.6 2007 55.6 41.9 37.0 33.3 42.5 2006 56.7 48.3 36.9 38.5 39.1 2005 55.8 49.9 39.2 47.1 39.2 2004 55.9 NA 40.1 NA 38.0 2003 54.4 NA 38.8 NA 37.7 2002 52.7 NA 38.7 NA 37.2 2001 51.3 NA 37.2 NA 33.2 2000 48.2 NA NA NA NA 1999 47.4 NA NA NA NA WitHIn 30 Days Post-dIsCHarge Year HMO PPO HMO PPO HMO 2010 77.4 74.1 55.4 61.2 63.8 2009 76.8 72.1 54.8 60.5 60.2 2008 76.1 71.4 56.5 55.5 61.7 2007 74.0 63.4 54.4 50.2 61.0 2006 75.8 68.1 56.3 58.3 57.7 2005 75.9 70.7 59.4 60.1 56.8 2004 75.9 NA 60.7 NA 54.9 2003 74.4 NA 60.3 NA 56.4 2002 73.6 NA 60.6 NA 56.7 2001 73.2 NA 60.6 NA 52.2 2000 71.2 NA NA NA NA 1999 70.1 NA NA NA NA M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

84 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPRoPRIATE TESTING for CHIlDREN W I T H P H A Ry N G I T I S M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Over the last 10 years, the Centers for Disease Control and Prevention (CDC) have increased efforts to prevent the misuse of antibiotics to treat respiratory infections, particularly pharyngitis. Pharyngitis, or sore throat, is common in children and adolescents and can be caused by a bacteria or virus. 1 The Appropriate Testing for Children With Pharyngitis measure evaluates whether children are properly treated for pharyngitis after undergoing diagnostic testing, thereby avoiding the build-up of antibiotic resistance. Pharyngitis affects a large number of Infections resulting from pharyngitis can individuals and is responsible for 12 have lifestyle and productivity effects. One million primary care visits each year in the study found that both children and parents U.S. 2 missed a notable number of school and work days because of pharyngitis-related The bacteria most commonly associated treatment and management. 7 with pharyngitis (Group A streptococcus) is responsible for up to 30 percent of HEDIS Measure Definition pharyngitis cases in children. 3 In winter The percentage of children 2 18 years of and early spring, up to 15 percent of age who were diagnosed with pharyngitis school-age children may carry the bacteria and dispensed an antibiotic, and who also without displaying symptoms. 4 received a group A streptococcus test for the episode. A higher rate represents better The Case for Improvement performance (i.e., appropriate testing). Pharyngitis has a significant financial burden on children and adults alike, Results costing an estimated $224 million Antibiotic treatment is only infrequently $539 million and resulting in 1,300 deaths appropriate for pharyngitis. The availability every year. 5 of RADT has made it easier to perform Pharyngitis often is overdiagnosed. While diagnostics, thereby potentially reducing there are differing opinions on performing antibiotic use and preventing the spread of rapid antigen detection testing (RADT) and drug-resistant strains of pharyngitis. 8 throat cultures, clinical guidelines strongly recommend performing a diagnostic test or a throat culture before treatment. 6

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 85 Testing Rate Year HMO PPO HMO PPO HMO 2010 77.6 76.6 NA NA 64.9 2009 77.4 75.5 NA NA 62.3 2008 75.6 74.1 NA NA 61.4 2007 74.7 73.5 NA NA 58.7 2006 72.7 69.4 NA NA 56.0 2005 69.7 64.5 NA NA 52.0 2004 72.6 NA NA NA 54.4 M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

86 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E Well-CHIld VISITS IN THE first 15 MoNTHS of life AND IN THE THIRD, FoURTH, fifth AND SixTH years of life M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S The beginning years of childhood are filled with rapid growth and development. Well-child visits offer doctors the opportunity to evaluate children s physical, emotional and social developmental progress. 1,2 The Well-Child Visits measures assess the number of children that met with a primary care practitioner during their most important developmental milestones. Primary care practitioners may detect Development delays occur in approximately health problems and developmental 13 percent of American children and have delays early and initiate interventions that high costs to society. 7,8 Over the course eliminate problems or lessen their effect of a lifetime, untreated developmental over the long term. 1,2 delays and disabilities are estimated to cost between $417,000 in direct medical costs Well-child visits facilitate communication and indirect lost productivity per child. 9 between children, care providers and doctors. 3 Primary care practitioners can HEDIS Measure Definition promote healthy behaviors and provide Well-Child Visits in the First 15 Months of Life: anticipatory guidance on a variety of The percentage of children who turned 15 topics, including injury prevention, physical months old during the measurement year and activity and nutrition. 4 had the following number of well-child visits with a primary care physician during the first The Case for Improvement 15 months of life: The number of children younger than 6 who received well-child visits increased No well-child visits from 84 percent in 2000 to 87 percent One well-child visit in 2008, 1 but almost one million children Two well child visits under 6 received no preventive medical Three well-child visits care of any kind in 2007. 5 Four well-child visits Children with incomplete well-child care Five well-child visits during the first six months of life are 60 Six or more well-child visits. percent more likely to visit the emergency department than children with complete well-child care. 6

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 87 Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life: The percentage of children 3 6 years of age who received one or more well-child visits with a primary care practitioner during the measurement year. Results Primary care doctors are an important resource for parents. Well-child visits facilitate communication about health between care givers and physicians. Screening for physical, emotional, social and developmental progress is vital to ensuring the health of children during their most vulnerable years and well into adulthood. Year Ages 3 6 years: One or More Well-CHIld visits HMO PPO HMO PPO HMO 2010 71.6 67.8 NA NA 71.9 2009 70.3 66.0 NA NA 71.6 2008 69.8 63.6 NA NA 69.7 2007 67.8 60.7 NA NA 65.3 2006 66.7 61.6 NA NA 66.8 2005 65.6 54.5 NA NA 63.6 2004 64.4 NA NA NA 62.4 2003 62.7 NA NA NA 60.7 2002 60.4 NA NA NA 58.2 2001 57.5 NA NA NA 56.0 2000 54.2 NA NA NA NA 1999 51.3 NA NA NA NA M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

88 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E AdolESCENT Well-CARE VISITS M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Adolescence is a time marked by transition. As children become adults, they face new physical, emotional and social challenges that may affect their health. 1 Because of changing patterns of illness and death among youth over the last two decades, increased screening and health counseling have become especially important. 2,3 The Adolescent Well-Care Visits measure assesses the number of adolescents who received preventive care. Risk taking behaviors, such as substance doctors can provide counseling or initiate use, drunk driving, risky sexual activity and health interventions. 6 smoking, often begin in adolescence. These behaviors put youth at increased risk for The Case for Improvement sexually transmitted diseases, unintended Adolescents are the least likely to have pregnancy, injury or death. 2,3 In 2009, access to health care, and use less primary almost 20 percent of high school students care, than any age group. 3 The proportion smoked tobacco. More than 6 percent used of children who receive well-care visits cocaine and 24 percent reported binge declines with age. Only 70 percent of drinking (i.e., had five or more alcoholic 10 14-year-olds and 67 percent of drinks within a couple of hours). 4 15 17-year-olds received preventive health care in 2008. 2 For those who did have a Many chronic diseases seen in adults begin well-child visit, only 10 percent received all in childhood, when eating habits and recommended preventive services. 7 physical activity levels are often established. 3 With obesity among adolescents in the In 2007, nearly 13,299 deaths from U.S. on the rise, this is especially troubling. unintentional injury (such as from a car Obesity can lead to type 2 diabetes, heart accident) were reported among adolescents disease and certain cancers. 5 between the ages of 15 and 19. 8 The total lifetime medical costs for adolescents who Adolescent well-care visits are an survive is estimated to be $25 billion. 9 effective way for doctors to present health promotion advice that is timely and relevant to adolescents development and well-being. The average preventive visit lasts about 20 minutes; during this time,

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 89 Each year, preventable adolescent deaths cost an estimated $33.5 billion in direct medical costs, and lifetime indirect and direct costs are more than $700 billion. 10 For those that survive, the total lifetime medical costs for these individuals is estimated to be $25 billion. 9 HEDIS Measure Definition The percentage of enrolled adolescents and young adults 12 21 years of age who had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN practitioner during the measurement year. Results While most adolescents are healthy, changes in their physical and social circumstances put them at increased risk for serious and longterm health effects of risky behaviors. Yearly well-care visits offer primary care providers the opportunity to provide the screening and health counseling services adolescents need to stay healthy. Year At least One CoMPrEHEnsive Well-Care visit HMO PPO HMO PPO HMO 2010 42.7 39.2 NA NA 48.1 2009 42.5 38.3 NA NA 47.7 2008 42.9 36.2 NA NA 45.9 2007 41.8 34.7 NA NA 42.1 2006 40.3 34.6 NA NA 43.6 2005 38.8 29.3 NA NA 40.7 2004 38.2 NA NA NA 40.0 2003 37.1 NA NA NA 37.5 2002 35.8 NA NA NA 37.1 2001 33.1 NA NA NA 32.6 2000 30.9 NA NA NA NA 1999 28.9 NA NA NA NA M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

90 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E CHIlDREN AND AdolESCENTS ACCESS t o P R I M A Ry C A R E P R A C T I T I o N E R S M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Children and adolescents need access to primary care practitioners (PCP) to ensure their optimal health and well-being. 1 PCPs play an important role in preventing illness and death in the young. 2 The Children and Adolescents Access to Primary Care Practitioners measure assesses whether children and adolescents were able to obtain medical attention from a PCP, such as a family doctor, internist, pediatrician or general practitioner. In 2007, more than five million children For adolescents, inaccessible care can put 0 17 years of age had no usual source them at risk for developing chronic disease, of care; the same number had one or substance-use disorders and risk-taking more unmet medical need during the year. sexual behaviors. 8-10 Almost six million children were without a doctor or nurse who knew their medical HEDIS Measure Definition history. 4 The percentage of children and young adults 12 months to 19 years of age who had a Although the primary care workforce visit with a PCP. The measure reports on four increased by 35 percent between 1996 separate percentages: and 2006, almost one million children live in areas with no PCP. Children and Children 12 24 months who had a visit adolescents living in rural areas are with a PCP during the measurement year affected disproportionately. 5 Children 25 months 6 years who had a visit with a PCP during the measure year The Case for Improvement Fewer than half of children and Children 7 11 years who had a visit with adolescents in the United States receive the a PCP during the measure year or the year recommended amount of preventive care. 3 prior to the measurement year Accessible primary care reduces hospital use and maintains quality of care. 6 Access to primary care is an effective way to reduce expensive hospitalizations and curb rising health care costs. 7 Adolescents 12 19 years who had a visit with a PCP during the measurement year or the year prior to the measurement year.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 91 Results Improving access to PCPs may reduce unnecessary medical costs and advance health outcomes for children and adolescents by enabling them to receive preventive services, screening and timely treatment from clinicians who know their medical histories and serve as a medical home. CHIldren 12 24 Months Year HMO PPO HMO PPO HMO 2010 97.5 96.9 NA NA 96.1 2009 97.5 96.2 NA NA 95.2 2008 96.7 95.4 NA NA 95.0 2007 96.9 93.7 NA NA 93.4 2006 97.0 94.2 NA NA 94.1 2005 97.0 95.0 NA NA 92.6 2004 96.8 NA NA NA 92.3 2003 96.3 NA NA NA 92.4 2002 95.7 NA NA NA 91.1 CHIldren 25 Months 6 years Year HMO PPO HMO PPO HMO 2010 91.2 89.1 NA NA 88.3 2009 91.6 89.1 NA NA 88.3 2008 89.7 87.4 NA NA 87.2 2007 89.4 86.3 NA NA 84.3 2006 89.3 86.3 NA NA 84.9 2005 89.3 85.7 NA NA 83.1 2004 88.1 NA NA NA 81.9 2003 88.5 NA NA NA 82.1 2002 87.2 NA NA NA 80.0 2001 85.7 NA NA NA 79.3 2000 82.4 NA NA NA NA 1999 81.3 NA NA NA NA M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S 2001 95.2 NA NA NA 90.7 2000 92.5 NA NA NA NA 1999 91.2 NA NA NA NA

92 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S CHIldren 7 11 years Year HMO PPO HMO PPO HMO 2010 91.6 89.4 NA NA 90.2 2009 91.4 89.0 NA NA 90.3 2008 89.9 87.4 NA NA 87.8 2007 89.5 86.8 NA NA 85.9 2006 89.2 85.7 NA NA 85.9 2005 88.6 83.4 NA NA 83.4 2004 88.5 NA NA NA 82.5 2003 88.5 NA NA NA 82.1 2002 87.4 NA NA NA 80.3 2001 85.8 NA NA NA 79.3 2000 83.6 NA NA NA NA 1999 82.6 NA NA NA NA AdolesCEnts 12 19 years Year HMO PPO HMO PPO HMO 2010 89.2 86.8 NA NA 88.1 2009 89.0 86.1 NA NA 87.9 2008 87.3 84.2 NA NA 85.3 2007 86.9 83.4 NA NA 82.7 2006 86.6 82.3 NA NA 83.2 2005 86.1 79.8 NA NA 80.9 2004 85.5 NA NA NA 79.3 2003 85.8 NA NA NA 79.6

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 93 Follow-Up CARE for CHIlDREN PRESCRIbED ADHD MEDICATIon Attention deficit/hyperactivity disorder (ADHD) typically begins in childhood and often persists into adulthood. 1 The disorder is characterized by inattention and impulsiveness, which can result in academic underachievement, family issues and behavioral problems. 2,3 The Follow-Up Care for Children Prescribed ADHD Medication measure assesses two rates of follow-up care for children between 6 and 12 years of age who are prescribed ADHD medication. ADHD is one of the most common mental HEDIS Measure Definition disorders in children. Almost 4 percent of The following two rates of this measure assess children in the United States between the ages follow-up care for children prescribed an of 4 and 10 are medicated for ADHD. 1,4,5 ADHD medication: Data from the National Health Interview Initiation Phase: The percentage of children Survey suggest that roughly half of children between 6 and 12 years of age diagnosed between 6 and 11 who are diagnosed with with ADHD who had one follow-up ADHD may also have a learning disorder. 3 visit with a practitioner with prescribing The combination of attention problems authority within 30 days of their first caused by ADHD and the learning disorder prescription of ADHD medication. can make it hard for a child to succeed Continuation and Maintenance Phase: in school. Boys are twice as likely to have The percentage of children between 6 ADHD than girls. 1,3 and 12 years of age with a prescription for ADHD medication who remained on The Case for Improvement the medication for at least 210 days and The annual cost of illness for ADHD in the had at least two follow-up visits with a U.S. is estimated to be more than $42 billion. 6 practitioner in the 9 months subsequent to ADHD may culminate in significant health the Initiation Phase. care-related costs, including frequent unintentional injuries, co-occurring Results psychiatric conditions and productivity loss. 7 Medications used to treat ADHD have known side effects and, like all medications, need to Combining behavioral therapy with be closely monitored by a practitioner with medication has been shown to improve prescribing authority. behavior and could lead to a decrease in medication dependence. 8 M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

94 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Initiation Year HMO PPO HMO PPO HMO 2010 38.8 38.1 NA NA 38.1 2009 36.6 35.4 NA NA 36.6 2008 35.8 34.1 NA NA 34.4 2007 33.7 31.8 NA NA 33.5 2006 33.0 30.6 NA NA 31.8 Continuation Year HMO PPO HMO PPO HMO 2010 43.4 43.3 NA NA 43.9 2009 41.7 39.0 NA NA 41.7 2008 40.2 37.1 NA NA 39.5 2007 38.7 34.2 NA NA 38.9 2006 38.1 30.0 NA NA 34.0

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 95 C H I l D H o o d I M M U N I z AT I o n S TAT U S Immunizing a child not only protects the child s health but also the health of the community, especially for those who are not immunized. 1 Infants and toddlers are particularly vulnerable to infectious diseases because their immune systems have not built up the necessary defenses to fight infection. 2,3 The Childhood Immunization Status measure looks at the percentage of children 2 years of age who receive all immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC). 4 Most childhood vaccines are between The perception among some parents that 90 percent and 99 percent effective in vaccines are unsafe for their children was preventing diseases. 5 heightened in recent years by several factors, including the number of vaccines in Statistics show dramatic declines in the recommended childhood immunization vaccine-preventable diseases in the U.S. schedule, the presence of conflicting when compared with the pre-vaccine vaccine-safety information and scientifically era. Cases of diphtheria, polio and refuted yet widely publicized theories that smallpox declined by 100 percent; cases link vaccines to chronic health problems or of bacterial meningitis, measles, mumps, developmental disabilities such as autism. 10 rubella, congenital rubella syndrome and tetanus, by 98 percent 99 percent; cases According to the CDC s National of hepatitis A, by 91 percent; cases of Immunization Survey, nearly 40 percent of whooping cough, by 93 percent; cases parents of toddlers delay or refuse at least of chickenpox, by 89 percent; cases of one recommended immunization for their hepatitis B, by 83 percent; and cases of children each year. 11 pneumonia, by 74 percent. 6 HEDIS Measure Definition The Case for Improvement The percentage of children 2 years of Vaccination of each U.S. child according age who had four diphtheria, tetanus and to the current childhood immunization acellular pertussis (DTaP); three polio (IPV); schedule prevents approximately 42,000 one measles, mumps and rubella (MMR); deaths and 20 million cases of disease and three H influenza type B (HiB); three hepatitis saves nearly $14 billion in direct costs and B (HepB); one chickenpox (VZV); four $69 billion in societal costs each year. 8,9 pneumococcal conjugate (PCV); two hepatitis M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

96 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. This measure calculates a rate for each vaccine and nine separate combination rates; including a comprehensive rate. Results Immunizations are a safe and important way parents protect their children s health. 2 The diseases childhood vaccines are meant to prevent are most likely to occur when children are very young and the risk of complications is highest. Without these recommended vaccines, a child must contract a disease in order to become immune to the germ or virus that causes it, which can be extremely dangerous for younger children whose immune systems may not be strong enough to fight off infections. It is because of childhood immunizations that the majority of many once-common diseases are now at their lowest levels in history. 12 DTaP/dt Year HMO PPO HMO PPO HMO 2010 86.3 64.7 NA NA 80.2 2009 85.4 59.9 NA NA 79.6 2008 87.2 47.7 NA NA 78.6 2007 86.9 42.4 NA NA 77.8 2006 87.2 39.2 NA NA 79.3 2005 86.1 62.8 NA NA 76.9 2004 85.9 NA NA NA 75.6 2003 84.3 NA NA NA 72.6 2002 80.1 NA NA NA 69.4 2001 81.5 NA NA NA 71.2 2000 80.4 NA NA NA NA 1999 78.7 NA NA NA NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 97 HEPatitis B Year HMO PPO HMO PPO HMO 2010 90.2 58.7 NA NA 90.1 2009 90.1 53.7 NA NA 89.1 2008 91.8 38.7 NA NA 88.3 2007 91.3 35.8 NA NA 87.2 2006 91.0 31.1 NA NA 88.4 2005 90.0 57.7 NA NA 85.4 2004 87.2 NA NA NA 81.9 2003 85.8 NA NA NA 79.5 2002 81.9 NA NA NA 76.2 2001 79.9 NA NA NA 75.4 2000 77.9 NA NA NA NA 1999 75.5 NA NA NA NA HIb Year HMO PPO HMO PPO HMO 2010 94.3 75.5 NA NA 90.3 2009 94.8 74.8 NA NA 93.7 2008 94.8 66.3 NA NA 93.4 2007 93.1 53.6 NA NA 87.7 2006 93.4 49.2 NA NA 89.1 2005 92.9 72.6 NA NA 86.8 2004 87.7 NA NA NA 79.1 2003 86.1 NA NA NA 77.7 2002 83.2 NA NA NA 73.8 2001 83.4 NA NA NA 74.9 2000 82.7 NA NA NA NA 1999 80.7 NA NA NA NA M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

98 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S IPV Year HMO PPO HMO PPO HMO 2010 91.8 71.1 NA NA 90.8 2009 91.1 65.3 NA NA 89.0 2008 92.1 52.6 NA NA 87.9 2007 91.5 47.5 NA NA 87.3 2006 91.4 43.0 NA NA 87.9 2005 90.3 66.7 NA NA 84.7 2004 90.1 NA NA NA 84.8 2003 88.7 NA NA NA 83.1 2002 86.0 NA NA NA 80.3 2001 85.4 NA NA NA 79.1 2000 84.2 NA NA NA NA 1999 82.6 NA NA NA NA MMR Year HMO PPO HMO PPO HMO 2010 90.8 82.7 NA NA 90.6 2009 90.6 80.5 NA NA 91.2 2008 93.5 76.4 NA NA 90.9 2007 93.5 76.3 NA NA 90.4 2006 93.6 75.0 NA NA 91.1 2005 93.0 86.2 NA NA 89.6 2004 92.3 NA NA NA 88.1 2003 91.5 NA NA NA 87.4 2002 90.1 NA NA NA 84.4 2001 89.4 NA NA NA 83.7 2000 88.4 NA NA NA NA 1999 87.0 NA NA NA NA PneumocoCCal Conjugate (PCV) Year HMO PPO HMO PPO HMO 2010 85.6 65.6 NA NA 79.4 2009 84.6 60.1 NA NA 77.6 2008 84.8 47.8 NA NA 75.6 2007 83.6 42.3 NA NA 73.8 2006 72.8 37.1 NA NA 68.3

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 99 VZV Year HMO PPO HMO PPO HMO 2010 90.8 82.2 NA NA 90.0 2009 90.6 79.7 NA NA 90.6 2008 92.0 74.8 NA NA 89.7 2007 91.9 74.4 NA NA 88.7 2006 90.9 72.0 NA NA 88.9 2005 89.9 82.0 NA NA 86.6 2004 87.5 NA NA NA 84.7 2003 85.7 NA NA NA 81.8 2002 82.0 NA NA NA 76.4 2001 75.3 NA NA NA 73.6 2000 70.5 NA NA NA NA 1999 63.8 NA NA NA NA Combination 2 (dtap, IPV, MMR, HIb, HEPatitis B and VZV) Year HMO PPO HMO PPO HMO 2010 78.5 48.5 NA NA 74.1 2009 77.7 43.1 NA NA 74.3 2008 81.2 30.6 NA NA 73.7 2007 80.8 30.1 NA NA 72.1 2006 79.8 24.5 NA NA 73.4 2005 77.7 54.8 NA NA 70.5 2004 72.5 NA NA NA 63.1 2003 69.8 NA NA NA 58.5 2002 62.5 NA NA NA 53.2 2001 57.6 NA NA NA 52.5 2000 53.5 NA NA NA NA 1999 47.5 NA NA NA NA Combination 3 (dtap, IPV, MMR, HIb, HEPatitis B, VZV and PCV) M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Year HMO PPO HMO PPO HMO 2010 75.1 46.1 NA NA 69.9 2009 73.4 40.4 NA NA 69.4 2008 76.6 28.5 NA NA 67.6 2007 75.5 27.6 NA NA 65.4 2006 65.7 22.4 NA NA 60.9

100 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Year HEPatitis A HMO PPO HMO PPO HMO 2010 35.4 28.6 NA NA 36.5 Year Rotavirus HMO PPO HMO PPO HMO 2010 63.5 51.9 NA NA 57.6 Year Influenza HMO PPO HMO PPO HMO 2010 57.1 51.1 NA NA 43.6 Combination 10 (dtap, IPV, MMR, HIb, HEPatitis A, HEPatitis B, VZV, PCV, Rotavirus and Influenza) IMMunIZations for AdolesCEnts: MeningocoCCal Year HMO PPO HMO PPO HMO 2010 55.2 43.8 NA NA 56.3 Year IMMunIZations for AdolesCEnts: Tdap/Td HMO PPO HMO PPO HMO 2010 69.5 55.3 NA NA 67.8 Year IMMunIZations for AdolesCEnts: Combination 1 (MeningocoCCal, Tdap/Td) HMO PPO HMO PPO HMO 2010 51.6 39.4 NA NA 52.2 Year HMO PPO HMO PPO HMO 2010 18.5 10.4 NA NA 15.2

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 101 I M M U N I z AT I o N S f o r A d o l E S C E N T S Adolescence is considered the healthiest period of one s life. This is, in large part, thanks to childhood immunizations. Recommended adolescent immunizations can help maintain wellbeing and provide protection against vaccine-preventable diseases that extend into adulthood. 1 The Immunizations for Adolescents measure assesses the percentage of adolescents who were vaccinated against four vaccine-preventable diseases: meningococcal meningitis, tetanus, diphtheria and pertussis (whooping cough). Protection against some childhood Despite what is understood about vaccinated diseases can wear off as the effectiveness of recommended children get older, requiring booster shots immunizations in protecting against to maintain immunity. 2 For example, serious, sometimes fatal diseases, Tdap is the booster shot for the tetanus, adolescent immunization rates are low. 5 diphtheria and pertussis vaccine received Reasons frequently cited for low adolescent in childhood. 3 immunization rates include lack of Prior to vaccines, the U.S. averaged regular preventive care visits that provide approximately 500 600 cases of tetanus, an opportunity for vaccination; lack of 100,000 200,000 cases of diphtheria and awareness of the need for immunizations; 175,000 cases of pertussis each year. 3 inaccurate risk assessments by parents and Today, because of vaccines, the number of adolescents about vaccine-preventable tetanus cases has declined by 98 percent, diseases; and financial barriers. 1,6,7 diphtheria cases by 100 percent and pertussis cases by 93 percent. 4 HEDIS Measure Definition The percentage of adolescents 13 years of The Case for Improvement age who had one dose of meningococcal Vaccine-preventable diseases not only vaccine and one tetanus, diphtheria toxoids have a direct impact on the infected and and acellular pertussis vaccine (Tdap) or one their families, but also carry a high price tetanus, diphtheria toxoids vaccine (Td) by tag for society as a whole. Direct medical their 13th birthday. The measure calculates a costs and indirect societal costs exceed $10 rate for each vaccine and one combination billion per year. 5 rate. M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

102 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S Results Today, fewer infections are seen, thanks to vaccines, but that does not mean the viruses and bacteria that cause the infections do not still exist. Infectious diseases and death are still common among the unimmunized. Americans should continue to be immunized, to prevent future cases of illness. 5 IMMunIZations for AdolesCEnts MeningocoCCal Year HMO PPO HMO PPO HMO 2010 55.2 43.8 NA NA 56.3 Year IMMunIZations for AdolesCEnts Tdap/Td HMO PPO HMO PPO HMO 2010 69.5 55.3 NA NA 67.8 IMMunIZations for AdolesCEnts Combination 1 (MeningocoCCal, Tdap/Td) Year HMO PPO HMO PPO HMO 2010 51.6 39.4 NA NA 52.2

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 103 WEIGHT ASSESSMENT AND CoUNSElING for NUTRITIon AND PhySICAl ACTIVITy for CHIlDREN/AdolESCENTS The prevalence of overweight and obesity among young people in the U.S. has increased dramatically in the past few decades; it has more than doubled in children and tripled in adolescents. 1 Childhood obesity has become a health crisis that affects children s healthy growth and development and increases their risks for serious health problems later in life. 2 The Weight Assessment and Counseling for Nutrition and Physical Activity in Children/Adolescents measure evaluates the percentage of children and adolescents who are regularly screened for weight problems and have received counseling about healthy eating and physical activity. An estimated 17 percent (12.5 million) of direct and indirect costs of obesity 9.1 all children and adolescents in the U.S. are percent of medical spending. 6,7 overweight or obese. 2,3 Obese children are more likely to have high Overweight and obesity occurs when more blood pressure and high cholesterol, risk calories are consumed than the body can factors for cardiovascular disease; increased burn during physical activity. 4 risk of impaired glucose tolerance, insulin resistance and type 2 diabetes; breathing Childhood overweight and obesity is problems, including sleep apnea and determined by measuring body mass index asthma; joint problems and musculoskeletal (BMI). A child with a BMI at or above the discomfort; fatty liver disease; gallstones; 85th percentile but lower than the 95th and gastroesophageal reflux. 7 percentile for children of the same sex and age is classified as overweight. A child Obese children and adolescents are with a BMI at or above the 95th percentile at greater risk of having social and for children of the same age and sex is psychological problems, including classified as obese. 5 discrimination and poor self-esteem, which can continue into adulthood. 7 The Case for Improvement According to a 2009 study, the cost of HEDIS Measure Definition hospitalizations related to childhood The percentage of children 3 17 years of age obesity rose from $125.9 million in 2001 who had an outpatient visit with a primary to $237.6 million in 2005. America spends care physician or an OB/GYN and who had as much as $147 billion annually on the evidence of BMI percentile documentation and counseling for nutrition and physical activity M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S

104 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T C H I l D R E N A N D A d o l E S C E N T S during the measurement year. Because BMI norms for youths vary with age and gender, this measure evaluates whether BMI percentile is assessed rather than an absolute BMI value. Results If children are overweight or obese, obesity in adulthood is likely to be more severe. Adult obesity is associated with a number of serious health conditions, including heart disease, diabetes and some cancers. 8 It is important for parents and care providers to monitor a child s weight status. Children need guidance on maintaining healthy eating and exercising habits. Year BMI PerCEntile (Overall) HMO PPO HMO PPO HMO 2010 35.2 10.9 NA NA 37.3 2009 35.4 17.4 NA NA 30.3 Counseling for Nutrition (Overall) Year Counseling for PhysICal activity (Overall) HMO PPO HMO PPO HMO 2010 35.3 10.5 NA NA 36.7 2009 36.5 17.6 NA NA 32.5 FrEQuency of Prenatal Care visits <21% of ExPECted visits Year HMO PPO HMO PPO HMO 2010 NA NA NA NA 10.4 2009 NA NA NA NA 10.3 2008 NA NA NA NA 11.9 2007 NA NA NA NA 12.4 2006 NA NA NA NA 13.5 2005 NA NA NA NA 16.7 2004 NA NA NA NA 17.9 2003 NA NA NA NA 21.3 2002 NA NA NA NA 27.6 2001 NA NA NA NA 33.1 Year HMO PPO HMO PPO HMO 2010 37.4 11.8 NA NA 45.6 2009 41.0 20.3 NA NA 41.9

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 105 Fall RISk MANAGEMENT Falls among older adults are a growing national concern because of the financial and societal costs associated with falls and the expanding body of evidence that falls can be reduced. 1,2 The Fall Risk Management measure assesses whether adults over 65 years of age who are at risk of falling discussed their problem with their practitioner and received an appropriate intervention, if necessary. Among adults 65 and older, falls are the Many older adults who fall develop a fear leading cause of injury and death each of falling that may cause them to limit year one in every three adults experiences their activities, leading to reduced mobility a fall. 2 Falls are also the most common and loss of physical fitness, which in turn cause of nonfatal injuries and hospital increases their actual risk of falling. 3 admissions for trauma. 3 The chances of falling and of being seriously injured in a HEDIS Measure Definition fall increase with age. 2,3 The two components of this survey measure assess different facets of fall risk management. Most falls result in fractures. 3,4 The percentage of Medicare adults 75 The Case for Improvement years of age and older, or adults 65 74 Direct medical costs of falls total more than years of age with balance or walking $19.3 billion $349 million for fatal falls problems or a fall in the past 12 months, and $19 billion for nonfatal fall injuries. 6,7 who were seen by a practitioner in the This translates to $26 billion in dollars. 7 past 12 months and who discussed falls Hospitalizations and visits to the emergency or problems with balance or walking with department make up more than 80 percent their current practitioner. of the costs. 7 The percentage of Medicare adults 65 In 2009, 2.2 million adults were treated years of age and older who had a fall or in emergency departments for nonfatal had problems with balance or walking in fall injuries; more than 581,000 of these the past 12 months, who were seen by a patients were hospitalized. 5 practitioner in the past 12 months and who received fall risk intervention from their current practitioner. M E A S U R E S T A R G E T E D A T O l D E R A D U l T S

106 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T O l D E R A D U l T S Results A discussion between provider and patient regarding falls identifies risk factors related to vision, muscle strength and reflexes important information for developing an appropriate intervention plan. 2 Discussion Year HMO PPO HMO PPO HMO 2010 NA NA 32.8 31.1 NA 2009 NA NA 31.1 30.3 NA 2008 NA NA 31.3 30.7 NA 2007 NA NA 29.4 28.1 NA 2006 NA NA 27.5 26.9 NA ManagEMEnt Year HMO PPO HMO PPO HMO 2010 NA NA 60.1 55.3 NA 2009 NA NA 57.7 54.7 NA 2008 NA NA 57.8 54.6 NA 2007 NA NA 55.8 53.4 NA 2006 NA NA 56.0 54.2 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 107 MEDICATIon IN THE ElDERly The elderly are twice as likely as younger adults to have an adverse drug reaction and are seven times more likely to be hospitalized as the result of an adverse drug event. 1 The Use of High-Risk Medications in the Elderly measure assesses how often elderly individuals are exposed to potentially harmful drugs. 2-4 The Potentially Harmful Drug-Disease Interactions in the Elderly measure assesses how often patients with a specific diagnosis are prescribed high-risk medications that are considered potentially dangerous. In a 2002 2005 study of 384 American hospitals, 49 percent of patients received at least one potentially inappropriate medication; among patients 65 years of age and older, 13 percent were given a potentially harmful medication. 5 In a study that measured potentially inappropriate medication use in the elderly, 40 percent of the population filled at least one prescription for such medications and 13 percent filled two or more. 6 The Case for Improvement Exposure to high-risk medications increases health care costs, including medication costs, an estimated $7.2 billion annually. 7 The use of high-risk medications increases the risk for hospitalization, death and adverse health outcomes. 6,8 Mobility problems from dementia are exacerbated by the use of high-risk medications, and patients exposed to these medications are more likely to be admitted to long-term care facilities. 9 Prescribing harmful drugs to the elderly population puts them at risk for further complications, which include falls, fractures and longer duration of illnesses. Data from a multidisciplinary falls clinic and a cooperative adverse drug event surveillance project show that patients on five or more medications are twice as likely to have impaired balance and are at higher risk for further inappropriate medication use. 1,10 HEDIS Measure Definition The measures assess two different dimensions of medication management in the Medicare population 65 years of age and older. Potentially Harmful Drug-Disease Interactions in the Elderly The percentage of adults 65 and older who have evidence of an underlying disease, condition or health concern and who were dispensed an ambulatory prescription for a M E A S U R E S T A R G E T E D A T O l D E R A D U l T S

108 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T O l D E R A D U l T S contraindicated medication, concurrent with or after the diagnosis. Use of High-Risk Medications in the Elderly The percentage of adults 65 and older who received at least one high-risk medication and the percentage of adults 65 and older who received at least two different high-risk medications. A combined rate is reported. Results Currently, close to a quarter of all Medicare patients are prescribed one potentially harmful medication. Although some drugs are harmful regardless of a patient s current health, some drugs prescribed for patients with a specific disease are associated with poor physical and cognitive performance, including balance disorders and an increased likelihood of falls. 9,11 Potentially Harmful DrugdIsease Interactions in the Elderly: Overall Rate* Year Use of High-rIsk MedICations in the Elderly: At least One MedICation* HMO PPO HMO PPO HMO 2010 NA NA 22.1 21.9 NA 2009 NA NA 23.0 22.3 NA 2008 NA NA 23.4 22.1 NA 2007 NA NA 23.2 22.1 NA 2006 NA NA 23.1 23.1 NA Year Use of High-rIsk MedICations in the Elderly: At least two MedICations* HMO PPO HMO PPO HMO 2010 NA NA 5.1 5.1 NA 2009 NA NA 5.7 5.3 NA 2008 NA NA 6.0 5.4 NA 2007 NA NA 6.0 5.3 NA 2006 NA NA 5.9 6.5 NA Year HMO PPO HMO PPO HMO 2010 NA NA 23.3 21.8 NA 2009 NA NA 23.2 21.8 NA 2008 NA NA 23.0 21.7 NA 2007 NA NA 21.8 21.5 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 109 MANAGEMENT of URINARy INCoNTINENCE IN OlDER ADUlTS Urinary incontinence (UI) is involuntary loss of urine. 1,2 It is largely underestimated because fewer than half of affected patients report it to their providers, partly because it is believed to be an inevitable part of aging. 3 In the older population, UI is the result of several factors that include comorbid conditions, multiple medications and functional and cognitive impairment. 1 The Management of Urinary Incontinence in Older Adults measure assesses whether adults over the age of 65 were asked about UI symptoms and received appropriate treatment. UI prevalence increases with age and is elderly, the incidence of UI is 15 percent a major cause of admittance to nursing 33 percent. 5,6 homes. It is more common in older UI further puts older adults at risk for falls, women its prevalence in older men is fractions and functional impairment. It is approximately one-third that of women. 1 associated with poor self-rated health, Many studies report that females with UI impaired quality of life, social isolation, seek help in very low percentages (ranging depressive symptoms and dependence on from 14 percent 38 percent). Another caregivers. 8 study found that 74 percent of women with UI symptoms waited for one year before HEDIS Measure Definition seeking help, and 46 percent waited for This patient survey measure assesses the three years. 4,5 diagnosis and management of UI in older adults. M E A S U R E S T A R G E T E D A T O l D E R A D U l T S The Case for Improvement The estimated total annual cost of UI is about $32 billion, or approximately $3,565 per individual with UI. The largest components are management costs and expenses associated with nursing home admissions attributable to UI. 7 Given a rapidly aging population, the incidence and prevalence of UI continues to be a major problem. Among homebound Discussing UI. The percentage of Medicare adults 65 and older who reported having a problem with urine leakage in the past six months and discussed their problem with their current practitioner. Receiving UI Treatment. The percentage of Medicare adults 65 and older who reported having a urine leakage problem in the past six months and received treatment for their current urine leakage problem.

110 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T O l D E R A D U l T S Results Routinely asking older patients about their symptoms, combined with appropriate treatment, is associated with minimal adverse outcomes, satisfactory results for many patients and possible prevention of the need for medical or surgical intervention. 9 Discussion Year HMO PPO HMO PPO HMO 2010 NA NA 58.2 57.9 NA 2009 NA NA 57.1 58.2 NA 2008 NA NA 57.3 58.0 NA 2007 NA NA 57.8 57.7 NA TreatMEnt Year HMO PPO HMO PPO HMO 2010 NA NA 36.0 36.3 NA 2009 NA NA 35.5 37.4 NA 2008 NA NA 35.4 36.3 NA 2007 NA NA 35.4 35.6 NA 2006 NA NA 35.3 36.8 NA 2005 NA NA 33.3 34.8 NA 2006 NA NA 56.8 57.3 NA 2005 NA NA 56.0 55.8 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 111 PhySICAl ACTIVITy IN OlDER ADUlTS Physical activity in older adults is an important part of managing chronic diseases like diabetes, obesity and high blood pressure. Physical activity helps older adults maintain their ability to live independently and reduces the risk of falling and fracturing bones. 1,2 The Physical Activity in Older Adults measure assesses whether older adults have either discussed or received advice from their physician about exercise. Lack of physical activity is one of the major $2,200 per person could be saved in causes of obesity. About 14 percent of health care costs every year. 3,5 all deaths in the U.S. can be attributed to The number of older Americans is insufficient physical activity and inadequate expected to double in the next two nutrition. 3 decades. Approximately 95 percent of Physical inactivity increases with age. health care spending for older adults is Data from the Centers for Disease Control attributed to chronic conditions. Lack of and Prevention reveal that 28 percent 34 physical activity among older adults is percent of adults 65 74 are inactive and an independent risk factor for a range of engage in little or no physical activity, and chronic diseases. 3,5 80 percent of older 35 percent 44 percent of adults 75 or adults have at least one chronic condition; older are not as active as they should be. 4 50 percent have at least two. M E A S U R E S T A R G E T E D A T O l D E R A D U l T S Regular exercise and increased aerobic fitness are associated with a decrease in all-cause mortality and morbidity in older adults. 1 Research proves that older adults have more to gain from physical activity than younger adults. 1,2 The Case for Improvement The medical costs for inactive adults are substantially higher than for active adults, and the cost of inactivity increases with age. If inactive older adults increased their physical activity to 90 minutes per week, Regular physical activity for older adults has beneficial health effects on a variety of health outcomes, including decreased risk of early death, heart disease and diabetes; weight loss; fall prevention; reduced depression; and improved cognitive function. 6,7 HEDIS Measure Definition This survey-based measure assesses the percentage of Medicare adults age 65 and older who had a doctor s visit in the past 12 months and who:

112 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T O l D E R A D U l T S Spoke with a with a doctor or other health provider about their level of exercise or physical activity Received advice to start, increase or maintain their level of exercise or physical activity. Results Strong evidence suggests that physical activity reduces the risk of developing chronic diseases and should be a high priority for preventing and treating disease and disability in older adults. 7 AdvICE Year HMO PPO HMO PPO HMO 2010 NA NA 47.9 47.6 NA 2009 NA NA 46.9 47.8 NA 2008 NA NA 47.0 47.1 NA 2007 NA NA 46.1 46.7 NA 2006 NA NA 45.2 48.8 NA 2005 NA NA 43.7 46.3 NA Discussion Year HMO PPO HMO PPO HMO 2010 NA NA 52.3 53.9 NA 2009 NA NA 51.3 54.4 NA 2008 NA NA 51.5 54.0 NA 2007 NA NA 51.1 53.0 NA 2006 NA NA 50.3 53.6 NA 2005 NA NA 50.6 53.7 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 113 GlAUCoMA SCREENING IN OlDER ADUlTS Glaucoma represents a family of diseases commonly associated with optic nerve damage and changes in the visual field (narrowing of the eyes usual scope of vision). Disease development is gradual, starting with blind spots and progressing up to complete blindness, with little or no warning signs or symptoms. 1 The Glaucoma Screening in Older Adults measure assesses whether older adults received an eye exam to check for this condition. Elevated eye pressure and older age are Glaucoma-associated visual impairment key risk factors. With an aging population, affects the quality of life and the ability to the prevalence and incidence of glaucoma function independently, hampering basic continue to rise. 2,3 daily activities. Vision loss among the elderly has been shown to result in social isolation, Untreated glaucoma is the second leading family stress and a greater tendency to cause of irreversible blindness in the U.S. 1,2 experience other health conditions. 2,3 Among African Americans, glaucoma is the leading cause of blindness African HEDIS Measure Definition Americans are six to eight times more likely The percentage of Medicare adults 65 than Caucasians to have glaucoma. 3,4 years and older without a prior diagnosis of glaucoma or glaucoma suspect, who The Case for Improvement received a glaucoma eye exam by an eyecare professional for the early identification of Managed care organizations spend approximately $1 billion ($2,000 per glaucomatous conditions. patient) annually to treat glaucoma. Treatment costs increase significantly as the disease progresses. 6 M E A S U R E S T A R G E T E D A T O l D E R A D U l T S At least 4.2 million people in the United States have glaucoma, but only half of them know that they have it. Another 5 10 million have elevated eye pressure and are at risk of developing glaucoma. 5

114 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T O l D E R A D U l T S Results Glaucoma s asymptomatic progression points to the importance of early detection and treatment, which can prevent, slow or stop vision loss. 6 ScrEEning Rate Year HMO PPO HMO PPO HMO 2010 NA NA 63.8 65.1 NA 2009 NA NA 62.3 63.7 NA 2008 NA NA 59.8 62.2 NA 2007 NA NA 59.5 62.6 NA 2006 NA NA 62.2 63.3 NA 2005 NA NA 61.5 64.5 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 115 OsteoporoSIS TESTING IN OlDER WoMEN Osteoporosis is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures. It mostly affects elderly women. Disease development is gradual, progressing without symptoms until a lowenergy fall or minor activity fractures a bone. 1 The Osteoporosis Testing in Older Women measure assesses whether women over the age of 65 reported receiving a bone density test. According to the National Osteoporosis Osteoporosis is responsible for more than Foundation, about 12 million Americans 1.5 million fractures each year, and results have osteoporosis and approximately 52.4 in 500,000 hospital admissions, 800,000 million over the age of 50 have low bone emergency room visits, 2.6 million density which puts them at increased physician visits and 180,000 nursing home risk for developing the disease. About 80 admissions annually. 4,5 percent of those affected are women. 2 Despite being a covered service under One in two women and one in four men Medicare with no out-of-pocket costs, bone over 50 will have an osteoporosis-related density tests are underutilized by elderly, fracture in their lifetime, most commonly of at-risk populations. In 2005 only an the hip, wrist or spine. 1,2 estimated 30 percent of Medicare women enrollees received a bone density test. 5 The Case for Improvement In 2008, the annual direct medical costs HEDIS Measure Definition of osteoporosis and fractures ranged from This survey based measure assesses the $17 billion to $22 billion. By 2025, annual percentage of Medicare women 65 years fractures and costs are expected to rise by of age and older who report ever having almost 50 percent. The most rapid growth received a bone density test to check for is estimated for people 65 74 years of osteoporosis. age. 3,4 M E A S U R E S T A R G E T E D A T O l D E R A D U l T S

116 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T O l D E R A D U l T S Results Bone density screenings are an important strategy for reducing the rate of fractures among women over the age of 65. 6,7 Testing Year HMO PPO HMO PPO HMO 2010 NA NA 68.5 73.4 NA 2009 NA NA 68.0 72.8 NA 2008 NA NA 66.7 72.0 NA 2007 NA NA 65.7 70.3 NA 2006 NA NA 64.4 71.3 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 H E D I S M E A S U R E S o f C A R E 117 OsteoporoSIS MANAGEMENT IN WoMEN Who HAD a fracture Osteoporosis is a weakening of the bones that puts patients at risk for bone fracture. 1 Fragility fractures, like those caused by osteoporosis, are associated with chronic pain, skeletal deformities, loss of independence and increased mortality. 6 By 2012, over 12 million Americans over the age of 50 are expected to have osteoporosis. 4 The Osteoporosis Management in Women Who Had a Fracture measure assesses whether women suffering from bone fractures received a bone density test to determine if bone fragility was the underlying cause of the fracture. Women are more likely to develop Osteoporosis is underdiagnosed and osteoporosis than men. Women lose bone undertreated. Only one-third of patients density with age, 2 and a woman over with fragility fractures receive appropriate 50 has a 50 percent chance of having testing and treatment for osteoporosis. 6 an osteoporosis-related fracture in her Osteoporosis is asymptomatic in the early lifetime. 3 Once a woman has a fracture, stages of the disease, so most people are she is at four times greater risk for another not aware that they have the condition. 6 fracture. 3 A fracture may be an indicator of the presence of osteoporosis. 3,5 A bone mineral density test is the most effective method for determining bone Osteoporosis treatment costs $17 billion health, and can identify osteoporosis, annually. 7 Direct medical costs are determine risk for fractures and assess predicted to increase to $25.3 billion response to osteoporosis treatment. 3 annually by 2025. 8 Each year, fragility The U.S. Preventive Services Task Force fractures are estimated to result in 500,000 recommends that osteoporosis screening hospitalizations, 800,000 emergency begin at 65 for most women. Women at department visits, 2.6 million doctors visits increased risk for osteoporotic fractures and 180,000 nursing home placements. 9 should begin screening at age 60. 4 M E A S U R E S T A R G E T E D A T O l D E R A D U l T S The Case for Improvement More than 300,000 hip fractures occur each year due to osteoporosis. Of these, 42,000 people die as a result. 7

118 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E M E A S U R E S T A R G E T E D A T O l D E R A D U l T S HEDIS Measure Definition The percentage of women 67 years of age and older who suffered a fracture and who had either a bone mineral density test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture. Results Osteoporosis may lead to painful bone fractures that limit mobility and put patients at risk for other adverse health conditions. Osteoporosis therapy has the potential to reduce the risk of fracture by nearly 50 percent. 10 Screening and treatment can significantly improve health outcomes by preventing fractures. TreatMEnt Rate Year HMO PPO HMO PPO HMO 2010 NA NA 20.7 18.5 NA 2009 NA NA 20.7 18.1 NA 2008 NA NA 20.7 18.0 NA 2007 NA NA 20.4 17.8 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 C A H P S 119 CoNSUMER AND PATIENT ENGAGEMENT AND ExPERIENCE The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is a public/ private initiative to develop standardized surveys of patients experiences with ambulatory and facility-level care in commercial and Medicaid plans. Surveys were developed with the Agency for Healthcare Research and Quality (AHRQ). CAHPS data address areas such as patient ease of obtaining information from a health plan; timeliness of service; and speed and accuracy of claim processing. CAHPS results offer an indication of how well health care organizations meet member expectations. Rating of Health Plan Respondents were asked to give their health plan an overall rating, with 0 equaling worst health plan possible and 10 equaling best health plan possible. The tables below represent the percentage of respondents who rated their health plans either 9 or 10. Year Rating of Health Plan: Rating of 9 or 10 HMO PPO HMO PPO HMO 2010 40.3 33.7 NA NA 54.7 2009 38.3 32.4 59.0 52.2 52.5 2008 39.1 34.2 60.7 53.4 55.3 2007 37.1 31.8 61.1 52.9 53.3 2006 38.0 35.9 61.7 53.9 52.4 C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E 2005 39.8 43.1 61.3 54.2 54.0 2004 38.4 NA 57.5 NA 52.3 2003 36.7 NA 53.3 NA 51.7 2002 36.0 NA 60.5 NA 51.5 2001 37.4 NA 62.4 NA 69.1 2000 34.7 NA NA NA NA 1999 32.6 NA NA NA NA

120 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E Rating of Health Care Respondents were asked to give their health care an overall rating, with 0 equaling worst health plan possible and 10 equaling best health plan possible. The tables below represent the percentage of respondents who rated their health plans either 9 or 10. Year Rating of Health Care: Rating of 9 or 10 HMO PPO HMO PPO HMO 2010 50.7 48.1 NA NA 48.8 2009 48.7 46.6 56.2 57.4 47.0 2008 48.7 46.7 56.2 56.4 48.1 2007 47.2 45.8 55.9 55.0 46.8 2006 47.0 48.3 62.0 62.7 46.2 2005 53.4 55.6 69.1 72.2 54.1 2004 52.1 NA 68.7 NA 53.5 2003 51.5 NA 67.5 NA 52.8 2002 49.4 NA 67.8 NA 53.0 2001 47.5 NA 68.8 NA 71.3 2000 45.6 NA NA NA NA 1999 44.1 NA NA NA NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 C A H P S 121 Getting Needed Care The Getting Needed Care composite measures members perception of how easy it was to get care from their doctor and from specialists in the last 12 months. Members were asked how often they were able to: See a specialist when they needed one Obtain the care, tests or treatment they believed were necessary. Responses were Never, Sometimes, Usually and Always. The rates displayed represent the average percentage of health plan members nationwide who responded Always. Getting needed Care: Always Year HMO PPO HMO PPO HMO 2010 53.9 53.9 NA NA 50.1 2009 52.9 52.7 63.6 64.4 48.5 2008 52.6 52.6 62.4 61.9 49.4 2007 50.4 49.5 62.0 63.4 48.7 2006 50.1 51.2 62.6 64.6 46.7 2005 80.1 84.7 95.9 97.0 73.4 2004 79.3 NA 95.7 NA 73.8 2003 78.4 NA 94.9 NA 72.1 C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E 2002 76.9 NA 94.8 NA 72.3 2001 76.7 NA 94.9 NA 75.4 2000 75.4 NA NA NA NA

122 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E Getting Care Quickly The Getting Care Quickly composite measures members perception of how quickly they received care when it was sought in the last 12 months. Members were asked how often they were able to: Receive needed care right away Get an appointment for health care at a doctor s office or clinic as soon as they thought care was needed. Responses were Never, Sometimes, Usually and Always. The rates displayed represent the average percentage of health plan members nationwide who responded Always. Getting Care QuICkly: Always Year HMO PPO HMO PPO HMO 2010 58.2 57.7 NA NA 56.2 2009 57.8 57.4 64.0 64.7 54.7 2008 57.6 56.2 63.7 64.6 55.7 2007 56.0 55.6 63.5 65.0 55.6 2006 56.8 57.5 65.4 67.0 53.4 2005 46.5 46.2 58.7 60.2 44.5 2004 45.5 NA 58.5 NA 44.2 2003 45.0 NA 57.2 NA 42.6 2002 43.9 NA 55.8 NA 44.1 2001 44.8 NA 60.0 NA 46.5 2000 45.8 NA NA NA NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 C A H P S 123 How Well Doctors Communicate The How Well Doctors Communicate composite measures members perception of the quality of communication with their personal doctor in the last 12 months. Members were asked how often their doctor: Explained things in a way that was easy to understand Listened carefully to them Showed respect for what they had to say Spent enough time with them. Responses were Never, Sometimes, Usually and Always. The rates displayed represent the average percentage of health plan members nationwide who responded Always. Year How Well Doctors CoMMunICate: Always HMO PPO HMO PPO HMO 2010 73.5 73.5 NA NA 69.1 2009 72.0 71.7 74.7 74.8 67.5 2008 71.1 70.7 75.3 74.8 68.0 2007 70.2 70.1 74.6 75.7 67.7 2006 70.3 71.5 75.0 76.2 66.7 C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E 2005 61.3 58.8 69.5 71.6 61.5 2004 60.2 NA 69.0 NA 60.8 2003 59.4 NA 68.6 NA 59.1 2002 57.7 NA 68.0 NA 59.9 2001 57.1 NA 68.5 NA 60.4 2000 58.4 NA NA NA NA

124 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E Rating of Personal Doctor Respondents were asked to give their personal doctor an overall rating, with 0 equaling worst personal doctor possible and 10 equaling best personal doctor possible. The tables below represent the percentage of respondents who rated their personal doctor either 9 or 10. Year Rating of Personal Doctor: Rating of 9 or 10 HMO PPO HMO PPO HMO 2010 65.0 62.8 NA NA 61.1 2009 63.2 61.2 73.3 73.9 60.1 2008 63.3 61.9 73.6 73.3 61.1 2007 62.1 61.7 73.6 73.8 60.4 2006 62.3 63.2 73.8 75.0 60.3 2005 52.8 54.0 67.8 70.9 59.2 2004 51.7 NA 67.5 NA 58.4 2003 51.9 NA 66.4 NA 58.9 2002 49.7 NA 65.2 NA 58.0 2001 50.5 NA 65.8 NA 76.5 2000 48.3 NA NA NA NA 1999 47.0 NA NA NA NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 C A H P S 125 Rating of Specialist Respondents were asked to give their specialist an overall rating, with 0 equaling worst specialist possible and 10 equaling best specialist possible. The tables below represent the percentage of respondents who rated their specialist either 9 or 10. Year Rating of specialist: Rating of 9 or 10 HMO PPO HMO PPO HMO 2010 64.1 61.9 NA NA 61.3 2009 61.8 60.4 69.3 70.8 60.5 2008 62.3 60.5 68.9 69.9 60.7 2007 61.7 60.5 69.2 70.2 60.8 2006 60.7 62.4 70.7 73.0 59.3 2005 57.2 59.1 67.7 71.7 60.2 2004 56.2 NA 67.5 NA 59.2 2003 55.8 NA 67.7 NA 58.3 2002 54.4 NA 67.7 NA 57.8 2001 54.6 NA 68.5 NA 75.3 2000 53.7 NA NA NA NA 1999 51.8 NA NA NA NA C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E

126 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E C o N S U M E R A N D P A T I E N T E N G A G E M E N T A N D E x P E R I E N C E Customer Service The Customer Service composite measures members perception of the usefulness and quality of customer service they experienced in the last 12 months (for those who tried to get information or help from their plan s customer service). Members were asked how often their health plan s customer service: Gave them the information or help they needed Treated them with courtesy and respect. Responses were Never, Sometimes, Usually and Always. The rates displayed represent the average percentage of health plan members nationwide who responded Always. CustoMEr service: Always Year HMO PPO HMO PPO HMO 2010 59.4 55.5 NA NA 59.5 2009 57.9 54.5 66.4 NA 57.9 2008 57.2 53.5 66.6 64.3 59.0 2007 55.4 50.7 66.5 62.5 57.3 2006 54.2 53.9 NA NA 49.7 2005 71.2 69.7 91.5 87.7 68.6 2004 71.0 NA 94.8 NA 69.8 2003 70.8 NA 94.5 NA 69.7 2002 70.4 NA 94.3 NA 67.4 2001 67.2 NA 94.8 NA 67.5 2000 66.6 NA NA NA NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 M E T H o d o l o g y o V E R V I E W 127 METHodology overview General Methods Data in this report are from HEDIS year 2011, which is measure year 2010 (January 1 December 31, 2010). Unless otherwise noted, all references to years in charts and tables are to measure years, not HEDIS years. Because The State of Health Care Quality Report focuses on health plan performance, summary tables are not weighted for the size of eligible populations. Most tables and appendices provide mean rates separately for each measure, or for each indicator in a measure. In most tables and appendices, rate means are provided side-by-side for commercial, Medicare and Medicaid product lines. Results for HMO and PPO plans are shown in separate tables. HMO plans include HMOs, HMO/POS combined, HMO/PPO/POS combined, HMO/PPO combined and POS. Only plans with the sole designation of PPO are shown as PPOs in tables. Some reporting periods are limited. For example, PPOs have reported substantial HEDIS data only since measure year 2005; Medicare and Medicaid performance data are reported only as far back as measure year 2001. Best States Identification of high-performing state cohorts is based on the state means of five measures: Diabetes (nine indicators), Hypertension (one indicator), Persistence of Beta-Blockers After a Heart Attack (one indicator) and Cholesterol Management for Patients With Cardiovascular Conditions (two indicators). The unweighted average of all indicators across all plans in a state is calculated for each state. No distinction is made among plans with respect to product line or reporting type. The composite means are ranked in descending order. The top 10 states compose the Best cohort. In the Diabetes quality composite, the Poor Glycemic Control Indicator is inverted before calculating the composite so that higher performance is indicated by a higher rate. Composite Measure Means by Region Analysis provides mean rates for several composite measures by U.S. Census region. The Childhood and Adolescent Immunizations summary rate comprises the rates for vaccinations

128 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E appropriate to each age group. Childhood vaccinations included in the composite are DTaP/ DT, hepatitis A, hepatitis B, HIB, IPV, MMR, pneumococcal conjugate and chicken pox vaccines, rotavirus, influenza and combinations. Adolescent vaccinations included in the composite are meningococcal, Tdap/Td and combinations. Consumer Experience is a summary of the following indicators: Getting Needed Care, Getting Care Quickly, How Well Doctors Communicate, Claims Processing, Customer Service, Rating of Personal Doctor, Rating of Specialist, Rating of All Health Care and Rating of Plan. All rating summaries reflect ratings of 9 or 10 and all composites correspond to responses of Always. The Diabetes composite summarizes the mean for the following indicators: Blood Pressure Control (<140/90 mm Hg), Eye Exams, HbA1c Screening, Poor Glycemic Control (>9%), LDL Cholesterol Screening, LDL Cholesterol Control (<100 mg/dl) and Medical Attention for Nephropathy. The Heart Disease composite summarizes performance on the following indicators: Persistence of Beta-Blockers After a Heart Attack; Controlling High Blood Pressure; Cholesterol Screening; and Management for Patients With Cardiovascular Conditions. The final rates presented are the unweighted averages of all indicators in the composites defined above, across all plans (by product line and reporting type) in each U.S. Census region. Plans that operate in more than one region are counted in each region summary. For example, a plan that operates in the Mountain and Pacific regions contributed data to the composite mean once for the Mountain region and once for the Pacific region. Relative Resource Use Health plans report case mix-adjusted measures of resource use related to five chronic illnesses: asthma, cardiovascular conditions, COPD, diabetes and hypertension. These measures incorporate cost and service frequency for each eligible member during the measurement year. All services administered to members identified with one of these conditions are attributed to the RRU measure for that condition.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 M E T H o d o l o g y o V E R V I E W 129 Each of the five RRU measures summarizes a health plan s utilization of several service categories: Inpatient Facility Evaluation and Management (E&M Inpatient and Outpatient) Procedure and Surgery (Inpatient and Outpatient) Ambulatory Pharmacy Services. NCQA calculates two observed-to-expected (O/E) ratios for each health plan, one for quality and one for resource use. An O/E ratio is a plan s actual quality level or resource use (the observed ), divided by an estimate of the quality level or resource use the plan would have if its population was the same as the average population of all other plans submitting data to NCQA (the expected ). To enable comparison within plan types (HMO or PPO), NCQA indexes O/E ratios by dividing each plan s ratio by the national average O/E for all HMOs or PPOs. For the resource use index, shown as the horizontal axis on RRU scatter plots, a ratio of 1.00 represents the average resource utilization for all HMOs or PPOs nationally. A ratio greater than 1.00 represents higher-than-expected use; a ratio less than 1.00 represents lower-than-expected use. For the quality index, otherwise known as the Effectiveness of Care ratio and shown as the vertical axis on RRU scatter plots, a ratio greater than 1.00 represents better-than-expected performance; a ratio less than 1.00 represents lower-than-expected performance. For example, a PPO with a ratio of 1.12 for quality and 1.15 for resource use delivered quality that was 12 percent better than the average PPO serving similar patients, and used 15 percent more resources than the PPO average. Descriptive statistics are provided for composites with up to 10 indicators. With the exception of the COPD quality RRU composite, the summary statistics for composite measures are the simple, unweighted average of all measures and indicators in the composite. Since 2 of the 3 COPD indicators describe the same dimension of care (Pharmacotherapy Management), each indicator receives a weight of one-half.

130 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 1: HEDIS EffECTIVENESS of CARE MEASURES: 2010 NATIoNAl HMO AVERAGES HEDIS EffECTIVENEss of CarE MEasurES NATIonal HMO averages 2010 MEASURE COMMERCIAL MEDICARE MEDICAID Safety and Potential Waste Imaging Studies for Low Back Pain 74.2 NA 75.5 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 22.5 NA 23.5 Ambulatory Care ED Visits per 1,000 Member Months 187.4 450.3 62.0 Wellness and Prevention Adult BMI Assessment 40.7 50.4 42.2 Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit 76.7 NA 73.6 Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 45.0 NA 38.5 52.4 NA 42.7 Flu Shots for Adults 52.5 NA NA Prenatal and Postpartum Care Timeliness of Prenatal Care 91.0 NA 83.7 Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 80.7 NA 64.4 Breast Cancer Screening 70.8 68.5 51.3 Cervical Cancer Screening 77.0 NA 67.2 Colorectal Cancer Screening 62.6 57.6 NA Chlamydia Screening in Women 16 20 Years 40.8 NA 54.6 Chlamydia Screening in Women 21 24 Years 45.7 NA 62.3 Chlamydia Screening in Women Total Rate 43.1 NA 57.5 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 75.5 83.1 76.3 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 65.7 62.3 60.4 Comprehensive Diabetes Care Eye Exams 57.7 64.6 53.1 Comprehensive Diabetes Care HbA1c Screening 89.9 90.4 82.0 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 42.5 NA 34.7 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 62.3 65.6 46.9 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 27.3 25.9 44.0 Comprehensive Diabetes Care LDL Cholesterol Screening 85.6 87.8 74.7 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 47.7 52.1 34.6 Comprehensive Diabetes Care Medical Attention for Nephropathy 83.6 89.2 77.7 Controlling High Blood Pressure 63.4 61.9 55.6 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening 88.9 88.5 82.0

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 131 HEDIS EffECTIVENEss of CarE MEasurES NATIonal HMO averages 2010 MEASURE COMMERCIAL MEDICARE MEDICAID Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 59.9 56.7 42.8 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 87.7 72.8 70.1 Use of Appropriate Medications for People With Asthma 5 11 Years 96.7 NA 91.8 Use of Appropriate Medications for People With Asthma 12 50 Years 91.8 NA 85.8 Use of Appropriate Medications for People With Asthma Overall Rate 92.9 NA 88.4 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 41.7 33.9 31.3 Pharmacotherapy Management of COPD Bronchodilators 77.8 78.2 82.1 Pharmacotherapy Management of COPD Systemic Corticosteroids 69.8 66.6 65.3 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 81.6 90.7 86.0 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 60.4 68.2 67.7 Annual Monitoring for Patients on Persistent Medications Digoxin 84.6 93.1 89.7 Annual Monitoring for Patients on Persistent Medications Diuretics 81.0 90.9 85.5 Annual Monitoring for Patients on Persistent Medications Combined 80.9 90.2 83.9 Antidepressant Medication Management Acute Phase 64.7 65.0 50.7 Antidepressant Medication Management Continuation Phase 48.3 51.9 34.4 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 59.7 37.4 44.6 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 77.4 55.4 63.8 Alcohol and Other Drug Dependence Treatment Engagement 15.6 3.7 14.2 Alcohol and Other Drug Dependence Treatment Initiation 42.7 44.6 42.9 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 77.6 NA 64.9 Appropriate Testing for Children With Upper Respiratory Infection 85.1 NA 87.2 Childhood Immunization Status DTaP/DT 86.3 NA 80.2 Childhood Immunization Status Hepatitis B 90.2 NA 90.1 Childhood Immunization Status HiB 94.3 NA 90.3 Childhood Immunization Status IPV 91.8 NA 90.8 Childhood Immunization Status MMR 90.8 NA 90.6 Childhood Immunization Status Pneumococcal Conjugate (PCV) 85.6 NA 79.4 Childhood Immunization Status VZV 90.8 NA 90.0 Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) 78.5 NA 74.1 Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 75.1 NA 69.9 Childhood Immunization Status Hepatitis A 35.4 NA 36.5 Childhood Immunization Status Rotavirus 63.5 NA 57.6

132 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES NATIonal HMO averages 2010 MEASURE COMMERCIAL MEDICARE MEDICAID Childhood Immunization Status Influenza 57.1 NA 43.6 Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 18.5 NA 15.2 Immunizations for Adolescents Meningococcal 55.2 NA 56.3 Immunizations for Adolescents Tdap/Td 69.5 NA 67.8 Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 51.6 NA 52.2 Follow-Up Care for Children Prescribed ADHD Medication Initiation 38.8 NA 38.1 Follow-Up Care for Children Prescribed ADHD Medication Continuation 43.4 NA 43.9 Lead Screening in Children NA NA 66.2 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI Percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 35.2 NA 37.3 37.4 NA 45.6 35.3 NA 36.7 Frequency of Prenatal Care Visits <21% of Expected Visits NA NA 10.4 Frequency of Prenatal Care Visits 21 40% of Expected Visits NA NA 6.9 Frequency of Prenatal Care Visits 41 60% of Expected Visits NA NA 8.1 Frequency of Prenatal Care Visits 61 80% of Expected Visits NA NA 13.6 Frequency of Prenatal Care Visits >80% of Expected Visits NA NA 61.1 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 1.6 NA 2.2 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 1.1 NA 2.2 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 1.3 NA 3.3 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 2.2 NA 5.7 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 4.9 NA 10.1 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 12.8 NA 16.1 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 76.3 NA 60.2 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 71.6 NA 71.9 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 42.7 NA 48.1 Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months 97.5 NA 96.1 Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years 91.2 NA 88.3 Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years 91.6 NA 90.2 Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years 89.2 NA 88.1

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 133 HEDIS EffECTIVENEss of CarE MEasurES NATIonal HMO averages 2010 MEASURE COMMERCIAL MEDICARE MEDICAID Measures Targeted Toward Older Adults Fall Risk Management Discussion NA 32.8 NA Fall Risk Management Management NA 60.1 NA Potentially Harmful Drug-Disease Interactions in the Elderly Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS* Potentially Harmful Drug-Disease Interactions in the Elderly Dementia and Tricyclic Antidepressants or Anticholinergic Agents* Potentially Harmful Drug-Disease Interactions in the Elderly Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents* NA 11.6 NA NA 28.7 NA NA 17.1 NA Potentially Harmful Drug-Disease Interactions in the Elderly Overall Rate* NA 23.3 NA Use of High-Risk Medications in the Elderly At Least One Medication* NA 22.1 NA Use of High-Risk Medications in the Elderly At Least Two Medications* NA 5.1 NA Management of Urinary Incontinence Discussion NA 58.2 NA Management of Urinary Incontinence Treatment NA 36.0 NA Physical Activity in Older Adults Advice NA 47.9 NA Physical Activity in Older Adults Discussion NA 52.3 NA Osteoporosis Testing in Older Women NA 68.5 NA Osteoporosis Management in Women Who Had a Fracture NA 20.7 NA Glaucoma Screening in Older Adults NA 63.8 NA *Lower rates signify better performance.

134 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 2: HEDIS EffECTIVENESS of CARE MEASURES: 2010 NATIoNAl PPO AVERAGES HEDIS EffECTIVENEss of CarE MEasurES NATIonal PPO averages 2010 MEASURE COMMERCIAL MEDICARE Safety and Potential Waste Imaging Studies for Low Back Pain 73.3 NA Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 21.3 NA Ambulatory Care ED Visits per 1,000 Member Months 174 379 Wellness and Prevention Adult BMI Assessment 11.6 36.6 Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit 71.7 NA Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies 39.0 NA Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 47.2 NA Flu Shots for Adults 51.6 NA Prenatal and Postpartum Care Timeliness of Prenatal Care 75.7 NA Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 65.9 NA Breast Cancer Screening 67.0 65.8 Cervical Cancer Screening 74.5 NA Colorectal Cancer Screening 47.6 41.0 Chlamydia Screening in Women 16 20 Years 38.1 NA Chlamydia Screening in Women 21 24 Years 41.9 NA Chlamydia Screening in Women Total Rate 40.0 NA Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 71.3 82.5 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 51.1 55.6 Comprehensive Diabetes Care Eye Exams 45.5 62.3 Comprehensive Diabetes Care HbA1c Screening 85.2 90.6 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 28.2 NA Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 50.2 57.3 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 46.6 35.2 Comprehensive Diabetes Care LDL Cholesterol Screening 79.9 86.3 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 37.3 45.9 Comprehensive Diabetes Care Medical Attention for Nephropathy 74.3 87.3 Controlling High Blood Pressure 56.7 55.7 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening 81.3 87.1 Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 45.2 50.6 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 87.0 77.8 Use of Appropriate Medications for People With Asthma 5 11 Years 97.0 NA Use of Appropriate Medications for People With Asthma 12 50 Years 91.8 NA Use of Appropriate Medications for People With Asthma Overall Rate 93.0 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 135 HEDIS EffECTIVENEss of CarE MEasurES NATIonal PPO averages 2010 MEASURE COMMERCIAL MEDICARE Use of Spirometry Testing in the Assessment and Diagnosis of COPD 40.2 35.3 Pharmacotherapy Management of COPD Bronchodilators 73.5 76.1 Pharmacotherapy Management of COPD Systemic Corticosteroids 66.2 69.6 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 78.4 90.8 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 57.9 69.1 Annual Monitoring for Patients on Persistent Medications Digoxin 79.1 92.7 Annual Monitoring for Patients on Persistent Medications Diuretics 78.1 91.2 Annual Monitoring for Patients on Persistent Medications Combined 77.8 90.6 Antidepressant Medication Management Acute Phase 64.3 67.4 Antidepressant Medication Management Continuation Phase 48.1 55.7 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 54.2 39.1 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 74.1 61.2 Alcohol and Other Drug Dependence Treatment Engagement 16.0 4.8 Alcohol and Other Drug Dependence Treatment Initiation 40.8 57.4 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 76.6 NA Appropriate Testing for Children With Upper Respiratory Infection 83.7 NA Childhood Immunization Status DTaP/DT 64.7 NA Childhood Immunization Status Hepatitis B 58.7 NA Childhood Immunization Status HiB 75.5 NA Childhood Immunization Status IPV 71.1 NA Childhood Immunization Status MMR 82.7 NA Childhood Immunization Status Pneumococcal Conjugate (PCV) 65.6 NA Childhood Immunization Status VZV 82.2 NA Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) 48.5 NA Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 46.1 NA Childhood Immunization Status Hepatitis A 28.6 NA Childhood Immunization Status Rotavirus 51.9 NA Childhood Immunization Status Influenza 51.1 NA Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 10.4 NA Immunizations for Adolescents Meningococcal 43.8 NA Immunizations for Adolescents Tdap/Td 55.3 NA Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 39.4 NA Follow-Up Care for Children Prescribed ADHD Medication Initiation 38.1 NA Follow-Up Care for Children Prescribed ADHD Medication Continuation 43.3 NA

136 N AT I o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES NATIonal PPO averages 2010 MEASURE COMMERCIAL MEDICARE Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI Percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 10.9 NA 11.8 NA 10.5 NA Well-Child Visits: Ages 0 15 Months No Well-Child Visits 2.9 NA Well-Child Visits: Ages 0 15 Months One Well-Child Visit 1.5 NA Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 1.7 NA Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 2.7 NA Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 5.3 NA Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 13.0 NA Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 72.8 NA Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 67.8 NA Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 39.2 NA Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months 96.9 NA Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years 89.1 NA Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years 89.4 NA Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years 86.8 NA Measures Targeted Toward Older Adults Fall Risk Management Discussion NA 31.1 Fall Risk Management Management NA 55.3 Potentially Harmful Drug-Disease Interactions in the Elderly Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS* Potentially Harmful Drug-Disease Interactions in the Elderly Dementia and Tricyclic Antidepressants or Anticholinergic Agents* Potentially Harmful Drug-Disease Interactions in the Elderly Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents* NA 11.7 NA 27.3 NA 16.3 Potentially Harmful Drug-Disease Interactions in the Elderly Overall Rate* NA 21.8 Use of High-Risk Medications in the Elderly At Least One Medication* NA 21.9 Use of High-Risk Medications in the Elderly At Least Two Medications* NA 5.1 Management of Urinary Incontinence Discussion NA 57.9 Management of Urinary Incontinence Treatment NA 36.3 Physical Activity in Older Adults Advice NA 47.6 Physical Activity in Older Adults Discussion NA 53.9 Osteoporosis Testing in Older Women NA 73.4 Osteoporosis Management in Women Who Had a Fracture NA 18.5 Glaucoma Screening in Older Adults NA 65.1 *Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 137 APPENDIx 3A: CAHPS MEMbER SATISfACTIon MEASURES: 2010 NATIoNAl HMO AVERAGES CAHPS MEMBER satisfaction MEasurES NATIonal HMO averages 2010 MEASURE COMMERCIAL MEDICARE MEDICAID Consumer and Patient Engagement and Experience Rating of Health Plan Rating of 8, 9 or 10 64.2 NA 72.4 Rating of Health Plan Rating of 9 or 10 40.3 NA 54.7 Rating of Health Care Rating of 8, 9 or 10 76.6 NA 68.9 Rating of Health Care Rating of 9 or 10 50.7 NA 48.8 Getting Needed Care Usually or Always 86.2 NA 76.0 Getting Needed Care Always 53.9 NA 50.1 Getting Care Quickly Usually or Always 86.5 NA 80.6 Getting Care Quickly Always 58.2 NA 56.2 How Well Doctors Communicate Usually or Always 93.9 NA 87.8 How Well Doctors Communicate Always 73.5 NA 69.1 Rating of Personal Doctor Rating of 8, 9 or 10 83.2 NA 76.4 Rating of Personal Doctor Rating of 9 or 10 65.0 NA 61.1 Rating of Specialist Rating of 8, 9 or 10 82.3 NA 76.9 Rating of Specialist Rating of 9 or 10 64.1 NA 61.3 Customer Service Usually or Always 84.5 NA 79.7 Customer Service Always 59.4 NA 59.5 Claims Processing Usually or Always 88.6 NA NA Claims Processing Always 55.5 NA NA

138 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 3B: CAHPS MEMbER SATISfACTIon MEASURES: 2010 NATIoNAl PPO AVERAGES CAHPS MEMBER satisfaction MEasurES NATIonal PPO averages 2010 MEASURE COMMERCIAL MEDICARE Consumer and Patient Engagement and Experience Rating of Health Plan Rating of 8, 9 or 10 58.6 NA Rating of Health Plan Rating of 9 or 10 33.7 NA Rating of Health Care Rating of 8, 9 or 10 75.6 NA Rating of Health Care Rating of 9 or 10 48.1 NA Getting Needed Care Usually or Always 86.6 NA Getting Needed Care Always 53.9 NA Getting Care Quickly Usually or Always 87.1 NA Getting Care Quickly Always 57.7 NA How Well Doctors Communicate Usually or Always 94.6 NA How Well Doctors Communicate Always 73.5 NA Rating of Personal Doctor Rating of 8, 9 or 10 82.8 NA Rating of Personal Doctor Rating of 9 or 10 62.8 NA Rating of Specialist Rating of 8, 9 or 10 81.6 NA Rating of Specialist Rating of 9 or 10 61.9 NA Customer Service Usually or Always 83.0 NA Customer Service Always 55.5 NA Claims Processing Usually or Always 87.8 NA Claims Processing Always 50.7 NA

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 139 APPENDIx 4A: ACCREDITED VS. NoNACCREDITED P l A N S: 2 0 1 0 C o M M E R C I A l H M O AV E R A G E S HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: COMMERCIal HMO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Safety and Potential Waste Imaging Studies for Low Back Pain 74.5 73.2 1.2 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 22.3 23.3-0.9 Ambulatory Care ED Visits per 1,000 Member Months 188.6 183.2 5.4 Wellness and Prevention Adult BMI Assessment 41.4 38.1 3.2 Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit 76.8 76.1 0.7 Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 45.1 44.6 0.5 52.4 52.2 0.3 Flu Shots for Adults 52.1 54.1-2.0 Prenatal and Postpartum Care Timeliness of Prenatal Care 92.1 86.6 5.5 Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 81.5 77.6 3.9 Breast Cancer Screening 71.2 69.5 1.7 Cervical Cancer Screening 77.7 74.5 3.2 Colorectal Cancer Screening 63.7 58.8 4.9 Chlamydia Screening in Women 16 20 Years 42.1 36.4 5.6 Chlamydia Screening in Women 21 24 Years 46.9 41.4 5.5 Chlamydia Screening in Women Total Rate 44.4 39.0 5.4 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 75.5 75.5 0.0 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 66.7 62.3 4.4 Comprehensive Diabetes Care Eye Exams 59.0 53.7 5.4 Comprehensive Diabetes Care HbA1c Screening 90.2 89.0 1.2 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 43.1 40.3 2.7 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 63.3 58.9 4.5 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 26.1 31.4-5.2 Comprehensive Diabetes Care LDL Cholesterol Screening 86.3 83.3 3.0 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 48.8 44.2 4.6 Comprehensive Diabetes Care Medical Attention for Nephropathy 84.2 81.3 2.9 Controlling High Blood Pressure 64.8 58.9 6.0

140 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: COMMERCIal HMO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 89.6 86.4 3.2 61.7 53.0 8.7 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 88.0 86.4 1.7 Use of Appropriate Medications for People With Asthma 5 11 Years 96.6 97.0-0.5 Use of Appropriate Medications for People With Asthma 12 50 Years 91.9 91.4 0.5 Use of Appropriate Medications for People With Asthma Overall Rate 92.9 92.7 0.2 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 42.2 40.1 2.1 Pharmacotherapy Management of COPD Bronchodilators 77.4 79.4-2.0 Pharmacotherapy Management of COPD Systemic Corticosteroids 69.3 72.1-2.8 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 81.6 81.5 0.2 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 60.6 59.6 1.0 Annual Monitoring for Patients on Persistent Medications Digoxin 84.7 84.4 0.3 Annual Monitoring for Patients on Persistent Medications Diuretics 80.9 81.3-0.4 Annual Monitoring for Patients on Persistent Medications Combined 80.9 81.0-0.1 Antidepressant Medication Management Acute Phase 64.6 65.1-0.5 Antidepressant Medication Management Continuation Phase 48.1 49.1-1.0 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 60.2 57.6 2.6 77.9 75.1 2.8 Alcohol and Other Drug Dependence Treatment Engagement 16.0 14.3 1.7 Alcohol and Other Drug Dependence Treatment Initiation 42.9 42.0 0.9 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 79.3 71.3 8.0 Appropriate Testing for Children With Upper Respiratory Infection 86.0 81.9 4.1 Childhood Immunization Status DTaP/DT 87.6 81.4 6.2 Childhood Immunization Status Hepatitis B 91.9 83.8 8.1 Childhood Immunization Status HiB 95.5 89.8 5.7 Childhood Immunization Status IPV 92.8 88.1 4.7 Childhood Immunization Status MMR 91.3 89.0 2.3 Childhood Immunization Status Pneumococcal Conjugate (PCV) 86.9 80.7 6.3 Childhood Immunization Status VZV 91.5 88.4 3.1 Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) 80.1 72.6 7.5

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 141 HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: COMMERCIal HMO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 76.5 69.4 7.1 Childhood Immunization Status Hepatitis A 35.0 37.0-2.1 Childhood Immunization Status Rotavirus 63.8 62.1 1.7 Childhood Immunization Status Influenza 58.1 53.5 4.6 Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 18.9 17.3 1.6 Immunizations for Adolescents Meningococcal 55.9 52.2 3.7 Immunizations for Adolescents Tdap/Td 69.6 69.0 0.7 Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 52.3 49.1 3.2 Follow-Up Care for Children Prescribed ADHD Medication Initiation 39.3 36.5 2.9 Follow-Up Care for Children Prescribed ADHD Medication Continuation 43.8 41.0 2.8 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI Percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 35.7 33.6 2.0 38.1 34.9 3.1 35.9 33.1 2.8 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 1.6 1.6 0.0 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 1.1 1.0 0.1 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 1.2 1.7-0.4 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 2.1 2.6-0.4 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 4.6 5.8-1.2 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 12.3 14.7-2.5 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 77.3 72.7 4.6 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 72.9 66.7 6.3 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 44.2 37.4 6.8 Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years *Lower rates signify better performance. 97.5 97.7-0.2 91.4 90.4 1.1 91.9 90.5 1.5 89.5 88.1 1.4

142 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 4B: ACCREDITED VS. NoNACCREDITED P l A N S: 2 0 1 0 C o M M E R C I A l P P O AV E R A G E S HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: COMMERCIal PPO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Safety and Potential Waste Imaging Studies for Low Back Pain 73.0 73.9-1.0 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 21.3 21.2 0.1 Ambulatory Care ED Visits per 1,000 Member Months 180.8 159.9 20.9 Wellness and Prevention Adult BMI Assessment 11.5 12.0-0.5 Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit 71.7 71.6 0.0 Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 39.0 38.9 0.0 47.3 46.9 0.4 Flu Shots for Adults 51.8 51.2 0.6 Prenatal and Postpartum Care Timeliness of Prenatal Care 72.5 82.2-9.7 Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 63.9 70.0-6.1 Breast Cancer Screening 67.5 66.1 1.3 Cervical Cancer Screening 74.8 74.0 0.8 Colorectal Cancer Screening 49.1 44.2 4.9 Chlamydia Screening in Women 16 20 Years 38.1 38.1 0.0 Chlamydia Screening in Women 21 24 Years 41.7 42.4-0.7 Chlamydia Screening in Women Total Rate 39.9 40.2-0.2 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 71.5 70.9 0.6 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 47.7 59.2-11.5 Comprehensive Diabetes Care Eye Exams 45.9 44.7 1.2 Comprehensive Diabetes Care HbA1c Screening 84.5 86.7-2.2 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 27.2 31.8-4.6 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 48.0 55.2-7.2 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 44.7 50.0-5.3 Comprehensive Diabetes Care LDL Cholesterol Screening 79.4 80.9-1.6 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 35.7 41.2-5.5 Comprehensive Diabetes Care Medical Attention for Nephropathy 72.2 79.0-6.8 Controlling High Blood Pressure 55.7 58.3-2.6 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening 80.6 82.8-2.1

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 143 HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: COMMERCIal PPO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 42.1 53.5-11.4 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 86.6 87.9-1.2 Use of Appropriate Medications for People With Asthma 5 11 Years 96.8 97.5-0.7 Use of Appropriate Medications for People With Asthma 12 50 Years 91.8 91.8 0.0 Use of Appropriate Medications for People With Asthma Overall Rate 93.0 93.0 0.0 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 39.8 41.0-1.1 Pharmacotherapy Management of COPD Bronchodilators 75.1 70.2 4.8 Pharmacotherapy Management of COPD Systemic Corticosteroids 66.9 64.7 2.2 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 78.1 79.2-1.1 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 57.3 59.3-2.1 Annual Monitoring for Patients on Persistent Medications Digoxin 79.2 78.9 0.3 Annual Monitoring for Patients on Persistent Medications Diuretics 77.8 78.7-0.9 Annual Monitoring for Patients on Persistent Medications Combined 77.5 78.5-1.0 Antidepressant Medication Management Acute Phase 64.3 64.5-0.3 Antidepressant Medication Management Continuation Phase 48.0 48.2-0.2 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 56.3 49.8 6.5 75.0 72.4 2.6 Alcohol and Other Drug Dependence Treatment Engagement 16.0 15.9 0.1 Alcohol and Other Drug Dependence Treatment Initiation 40.5 41.5-0.9 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 76.5 77.0-0.6 Appropriate Testing for Children With Upper Respiratory Infection 83.4 84.3-1.0 Childhood Immunization Status DTaP/DT 62.9 68.3-5.3 Childhood Immunization Status Hepatitis B 54.8 66.3-11.5 Childhood Immunization Status HiB 74.2 78.0-3.8 Childhood Immunization Status IPV 69.5 74.3-4.8 Childhood Immunization Status MMR 82.3 83.6-1.3 Childhood Immunization Status Pneumococcal Conjugate (PCV) 64.1 68.7-4.7 Childhood Immunization Status VZV 81.5 83.5-1.9 Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 44.4 56.7-12.3 42.2 54.0-11.8

144 N AT I o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: COMMERCIal PPO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Childhood Immunization Status Hepatitis A 28.1 29.6-1.4 Childhood Immunization Status Rotavirus 49.9 55.9-6.0 Childhood Immunization Status Influenza 50.3 52.7-2.4 Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 9.5 12.0-2.5 Immunizations for Adolescents Meningococcal 43.7 43.8-0.1 Immunizations for Adolescents Tdap/Td 55.3 55.1 0.2 Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 39.5 39.2 0.3 Follow-Up Care for Children Prescribed ADHD Medication Initiation 37.7 39.1-1.4 Follow-Up Care for Children Prescribed ADHD Medication Continuation 43.5 42.7 0.8 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI Percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 10.9 11.2-0.4 11.6 12.4-0.8 10.4 10.9-0.5 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 2.3 4.4-2.1 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 1.3 2.0-0.7 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 1.6 2.0-0.4 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 2.6 3.0-0.4 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 5.3 5.3-0.1 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 13.3 12.2 1.1 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 73.6 71.0 2.6 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 68.2 66.9 1.3 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 39.5 38.6 1.0 Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years *Lower rates signify better performance. 97.3 96.2 1.0 89.6 88.0 1.5 90.0 88.3 1.7 87.2 85.9 1.3

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 145 APPENDIx 5: ACCREDITED VS. NoNACCREDITED PlANS: 2010 MEDICAID HMO AVERAGES HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: MEDICAID HMO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Safety and Potential Waste Imaging Studies for Low Back Pain 74.9 76.0-1.1 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 22.4 24.5-2.2 Ambulatory Care ED Visits per 1,000 Member Months 64.1 60.1 4.0 Wellness and Prevention Adult BMI Assessment 45.6 38.1 7.5 Medical Assistance With Smoking and Tobacco Use Cessation 74.3 Advising Smokers and Tobacco Users to Quit 72.7 1.5 Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 39.5 37.1 2.4 44.0 40.8 3.2 Prenatal and Postpartum Care Timeliness of Prenatal Care 85.2 82.4 2.8 Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 65.2 63.7 1.4 Breast Cancer Screening 52.0 50.8 1.2 Cervical Cancer Screening 69.1 65.8 3.3 Chlamydia Screening in Women 16 20 Years 55.1 54.2 1.0 Chlamydia Screening in Women 21 24 Years 63.5 61.2 2.3 Chlamydia Screening in Women Total Rate 58.2 56.8 1.4 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 77.4 74.1 3.3 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 62.0 59.1 2.9 Comprehensive Diabetes Care Eye Exams 54.9 51.8 3.1 Comprehensive Diabetes Care HbA1c Screening 83.0 81.3 1.8 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 35.8 33.2 2.6 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 48.8 45.5 3.3 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 41.5 45.8-4.4 Comprehensive Diabetes Care LDL Cholesterol Screening 76.3 73.5 2.8 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 36.8 32.9 3.9 Comprehensive Diabetes Care Medical Attention for Nephropathy 79.2 76.5 2.6 Controlling High Blood Pressure 57.9 53.0 4.9 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 82.8 80.8 2.0 45.1 39.2 5.9

146 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: MEDICAID HMO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 71.1 68.4 2.7 Use of Appropriate Medications for People With Asthma 5 11 Years 91.7 91.9-0.2 Use of Appropriate Medications for People With Asthma 12 50 Years 85.8 85.8 0.0 Use of Appropriate Medications for People With Asthma Overall Rate 88.4 88.4 0.0 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 30.4 32.9-2.4 Pharmacotherapy Management of COPD Bronchodilators 82.3 81.7 0.6 Pharmacotherapy Management of COPD Systemic Corticosteroids 65.7 64.8 0.9 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 86.3 85.7 0.6 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 67.9 67.5 0.4 Annual Monitoring for Patients on Persistent Medications Digoxin 89.0 91.0-2.1 Annual Monitoring for Patients on Persistent Medications Diuretics 86.0 84.9 1.0 Annual Monitoring for Patients on Persistent Medications Combined 83.9 83.8 0.1 Antidepressant Medication Management Acute Phase 50.4 50.9-0.5 Antidepressant Medication Management Continuation Phase 33.5 35.1-1.5 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 48.2 41.8 6.4 66.8 61.4 5.4 Alcohol and Other Drug Dependence Treatment Engagement 15.6 13.1 2.5 Alcohol and Other Drug Dependence Treatment Initiation 47.2 39.5 7.7 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 63.9 65.9-2.0 Appropriate Testing for Children With Upper Respiratory Infection 86.3 88.0-1.7 Childhood Immunization Status DTaP/DT 81.3 79.3 1.9 Childhood Immunization Status Hepatitis B 91.0 89.3 1.7 Childhood Immunization Status HiB 91.3 89.4 1.9 Childhood Immunization Status IPV 91.6 90.2 1.5 Childhood Immunization Status MMR 91.5 89.9 1.6 Childhood Immunization Status Pneumococcal Conjugate (PCV) 80.9 78.1 2.8 Childhood Immunization Status VZV 91.1 89.2 1.9 Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 75.8 72.6 3.2 71.6 68.5 3.1 Childhood Immunization Status Hepatitis A 37.9 35.1 2.7 Childhood Immunization Status Rotavirus 59.8 55.6 4.2

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 147 HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: MEDICAID HMO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Childhood Immunization Status Influenza 45.0 42.2 2.7 Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 16.6 13.9 2.7 Immunizations for Adolescents Meningococcal 57.4 55.1 2.3 Immunizations for Adolescents Tdap/Td 68.7 66.9 1.8 Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 53.4 50.9 2.5 Follow-Up Care for Children Prescribed ADHD Medication Initiation 38.0 38.2-0.1 Follow-Up Care for Children Prescribed ADHD Medication Continuation 43.1 45.0-1.9 Lead Screening in Children 69.0 63.4 5.6 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI Percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 37.4 37.1 0.3 47.4 43.9 3.4 37.5 35.9 1.6 Frequency of Prenatal Care Visits <21% of Expected Visits 9.3 11.6-2.3 Frequency of Prenatal Care Visits 21 40% of Expected Visits 6.4 7.4-1.1 Frequency of Prenatal Care Visits 41 60% of Expected Visits 7.8 8.4-0.6 Frequency of Prenatal Care Visits 61 80% of Expected Visits 13.2 14.1-0.9 Frequency of Prenatal Care Visits >80% of Expected Visits 63.5 58.5 5.0 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 1.8 2.5-0.7 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 1.9 2.4-0.5 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 3.0 3.7-0.7 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 5.3 6.1-0.8 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 9.1 10.9-1.8 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 14.8 17.2-2.5 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 63.9 57.1 6.8 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 73.7 70.6 3.1 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 50.8 46.1 4.8 Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years *Lower rates signify better performance. 96.5 95.7 0.9 89.0 87.6 1.4 90.5 89.9 0.6 88.3 88.0 0.2

148 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 6A: ACCREDITED VS. NoNACCREDITED PlANS: 2010 MEDICARE HMO AVERAGES HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: MEDICarE HMO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Safety and Potential Waste Ambulatory Care ED Visits per 1,000 Member Months 362.5 501-138.5 Wellness and Prevention Adult BMI Assessment 56.0 47.1 9.0 Breast Cancer Screening 72.1 66.3 5.7 Colorectal Cancer Screening 64.9 53.3 11.6 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 83.9 82.2 1.7 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 65.4 60.4 4.9 Comprehensive Diabetes Care Eye Exams 70.0 61.4 8.6 Comprehensive Diabetes Care HbA1c Screening 92.2 89.3 2.9 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 72.3 61.7 10.6 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 19.0 29.9-10.9 Comprehensive Diabetes Care LDL Cholesterol Screening 89.8 86.7 3.2 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 58.2 48.6 9.6 Comprehensive Diabetes Care Medical Attention for Nephropathy 90.2 88.7 1.5 Controlling High Blood Pressure 66.5 59.1 7.4 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening 90.6 87.2 3.4 Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 63.5 52.5 11.0 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 76.4 70.2 6.1 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 37.5 31.4 6.1 Pharmacotherapy Management of COPD Bronchodilators 78.5 78.1 0.4 Pharmacotherapy Management of COPD Systemic Corticosteroids 69.6 64.6 5.0 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 91.2 90.4 0.8 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 68.9 67.8 1.1 Annual Monitoring for Patients on Persistent Medications Digoxin 93.7 92.7 0.9 Annual Monitoring for Patients on Persistent Medications Diuretics 91.4 90.6 0.8 Annual Monitoring for Patients on Persistent Medications Combined 90.9 89.7 1.2 Antidepressant Medication Management Acute Phase 67.4 63.0 4.4 Antidepressant Medication Management Continuation Phase 54.1 50.1 4.1 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 44.7 32.5 12.2

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 149 HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: MEDICarE HMO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 63.8 49.4 14.4 Alcohol and Other Drug Dependence Treatment Engagement 4.2 3.4 0.8 Alcohol and Other Drug Dependence Treatment Initiation 48.8 41.9 6.9 Measures Targeted Toward Older Adults Fall Risk Management Discussion 28.8 35.2-6.3 Fall Risk Management Management 58.0 61.3-3.4 Potentially Harmful Drug-Disease Interactions in the Elderly Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS* Potentially Harmful Drug-Disease Interactions in the Elderly Dementia and Tricyclic Antidepressants or Anticholinergic Agents* Potentially Harmful Drug-Disease Interactions in the Elderly Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents* 9.0 14.0-4.9 24.2 31.6-7.4 15.5 18.3-2.8 Potentially Harmful Drug-Disease Interactions in the Elderly Overall Rate* 19.9 25.3-5.4 Use of High-Risk Medications in the Elderly At Least One Medication* 18.6 24.1-5.5 Use of High-Risk Medications in the Elderly At Least Two Medications* 3.7 5.9-2.2 Management of Urinary Incontinence Discussion 57.3 58.8-1.5 Management of Urinary Incontinence Treatment 35.8 36.1-0.2 Physical Activity in Older Adults Advice 47.3 48.3-1.0 Physical Activity in Older Adults Discussion 53.3 51.8 1.6 Osteoporosis Testing in Older Women 73.0 65.9 7.1 Osteoporosis Management in Women Who Had a Fracture 23.5 18.5 5.0 Glaucoma Screening in Older Adults 67.0 61.9 5.1 * Lower rates signify better performance.

150 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 6B: ACCREDITED VS. NoNACCREDITED PlANS: 2010 MEDICARE PPO AVERAGES HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: MEDICarE PPO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Safety and Potential Waste Ambulatory Care ED Visits per 1,000 Member Months 382.8 377.9 4.9 Wellness and Prevention Adult BMI Assessment 42.1 34.9 7.1 Breast Cancer Screening 66.7 65.5 1.2 Colorectal Cancer Screening 45.3 39.8 5.5 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 82.0 82.7-0.7 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 61.3 53.9 7.4 Comprehensive Diabetes Care Eye Exams 66.5 61.1 5.5 Comprehensive Diabetes Care HbA1c Screening 91.7 90.2 1.5 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 68.2 54.3 13.9 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 23.8 38.5-14.6 Comprehensive Diabetes Care LDL Cholesterol Screening 87.9 85.8 2.1 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 53.5 43.7 9.8 Comprehensive Diabetes Care Medical Attention for Nephropathy 87.8 87.2 0.5 Controlling High Blood Pressure 61.7 53.9 7.9 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening 88.3 86.7 1.6 Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 57.9 48.3 9.6 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 79.2 77.4 1.8 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 32.4 36.5-4.1 Pharmacotherapy Management of COPD Bronchodilators 77.5 75.7 1.8 Pharmacotherapy Management of COPD Systemic Corticosteroids 66.9 70.3-3.4 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 90.4 90.9-0.5 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 68.0 69.4-1.3 Annual Monitoring for Patients on Persistent Medications Digoxin 93.0 92.6 0.4 Annual Monitoring for Patients on Persistent Medications Diuretics 91.0 91.3-0.3 Annual Monitoring for Patients on Persistent Medications Combined 90.3 90.7-0.4 Antidepressant Medication Management Acute Phase 65.9 67.9-2.0 Antidepressant Medication Management Continuation Phase 55.0 55.9-0.9 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 42.1 38.2 3.9

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 151 HEDIS EffECTIVENEss of CarE MEasurES ACCREDITED vs. nonaccredited Plans: MEDICarE PPO averages 2010 MEASURE ACCREDITED NONACCREDITED DIFFERENCE Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 63.1 60.7 2.4 Alcohol and Other Drug Dependence Treatment Engagement 4.4 4.9-0.4 Alcohol and Other Drug Dependence Treatment Initiation 50.3 59.4-9.1 Measures Targeted Toward Older Adults Fall Risk Management Discussion 30.1 31.3-1.3 Fall Risk Management Management 55.8 55.2 0.6 Potentially Harmful Drug-Disease Interactions in the Elderly Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS* Potentially Harmful Drug-Disease Interactions in the Elderly Dementia and Tricyclic Antidepressants or Anticholinergic Agents* Potentially Harmful Drug-Disease Interactions in the Elderly Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents* 9.5 12.5-2.9 24.0 28.5-4.5 14.0 17.1-3.1 Potentially Harmful Drug-Disease Interactions in the Elderly Overall Rate* 19.1 22.7-3.6 Use of High-Risk Medications in the Elderly At Least One Medication* 19.7 22.5-2.8 Use of High-Risk Medications in the Elderly At Least Two Medications* 4.3 5.3-1.0 Management of Urinary Incontinence Discussion 57.1 58.1-1.0 Management of Urinary Incontinence Treatment 37.1 36.1 1.0 Physical Activity in Older Adults Advice 48.5 47.3 1.1 Physical Activity in Older Adults Discussion 55.6 53.4 2.2 Osteoporosis Testing in Older Women 75.0 73.0 2.0 Osteoporosis Management in Women Who Had a Fracture 19.5 18.1 1.4 Glaucoma Screening in Older Adults 65.2 65.1 0.2 *Lower rates signify better performance.

152 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 7A: PublICly REPoRTING VS. NoNPUblICly REPoRTING PlANS: 2010 CoMMERCIAl HMoS HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: COMMERCIal HMO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Safety and Potential Waste Imaging Studies for Low Back Pain 74.4 72.7 1.7 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 22.4 24.1-1.7 Ambulatory Care ED Visits per 1,000 Member Months 186.9 192.3-5.4 Wellness and Prevention Adult BMI Assessment 40.8 38.5 2.3 Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 76.8 75.2 1.6 45.2 43.0 2.3 52.5 51.0 1.5 Flu Shots for Adults 52.3 54.4-2.1 Prenatal and Postpartum Care Timeliness of Prenatal Care 91.8 83.3 8.5 Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 81.6 72.7 9.0 Breast Cancer Screening 71.1 68.6 2.5 Cervical Cancer Screening 77.3 73.6 3.8 Colorectal Cancer Screening 63.1 58.7 4.4 Chlamydia Screening in Women 16 20 Years 41.3 36.6 4.7 Chlamydia Screening in Women 21 24 Years 46.2 41.4 4.8 Chlamydia Screening in Women Total Rate 43.6 39.1 4.5 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 75.6 75.0 0.6 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 66.0 62.6 3.5 Comprehensive Diabetes Care Eye Exams 58.5 51.9 6.6 Comprehensive Diabetes Care HbA1c Screening 90.1 88.5 1.6 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 42.8 38.7 4.1 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 62.8 58.1 4.7 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 26.8 31.6-4.8 Comprehensive Diabetes Care LDL Cholesterol Screening 85.7 84.3 1.4 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 48.0 45.4 2.6 Comprehensive Diabetes Care Medical Attention for Nephropathy 83.9 80.8 3.1 Controlling High Blood Pressure 63.8 59.6 4.3 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening 89.3 85.5 3.7

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 153 HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: COMMERCIal HMO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 60.8 51.0 9.8 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 87.8 86.9 0.8 Use of Appropriate Medications for People With Asthma 5 11 Years 96.7 96.7 0.0 Use of Appropriate Medications for People With Asthma 12 50 Years 91.7 92.1-0.4 Use of Appropriate Medications for People With Asthma Overall Rate 92.8 93.3-0.5 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 42.0 37.9 4.1 Pharmacotherapy Management of COPD Bronchodilators 77.6 80.1-2.5 Pharmacotherapy Management of COPD Systemic Corticosteroids 69.6 72.2-2.5 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 81.7 80.6 1.1 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 60.4 59.7 0.7 Annual Monitoring for Patients on Persistent Medications Digoxin 84.4 87.5-3.0 Annual Monitoring for Patients on Persistent Medications Diuretics 81.0 81.0 0.0 Annual Monitoring for Patients on Persistent Medications Combined 81.0 80.4 0.6 Antidepressant Medication Management Acute Phase 64.6 66.0-1.4 Antidepressant Medication Management Continuation Phase 48.2 49.4-1.1 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 59.9 57.0 2.9 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 77.5 75.2 2.3 Alcohol and Other Drug Dependence Treatment Engagement 15.9 12.4 3.5 Alcohol and Other Drug Dependence Treatment Initiation 43.2 37.4 5.7 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 78.8 67.7 11.1 Appropriate Testing for Children With Upper Respiratory Infection 85.5 81.4 4.1 Childhood Immunization Status DTaP/DT 87.3 77.4 9.9 Childhood Immunization Status Hepatitis B 91.6 77.4 14.2 Childhood Immunization Status HiB 95.2 86.1 9.1 Childhood Immunization Status IPV 92.7 83.8 8.9 Childhood Immunization Status MMR 91.2 87.5 3.7 Childhood Immunization Status Pneumococcal Conjugate (PCV) 86.7 76.2 10.5 Childhood Immunization Status VZV 91.3 87.0 4.2 Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 79.6 68.7 10.9 76.0 65.6 10.4 Childhood Immunization Status Hepatitis A 35.2 36.8-1.6

154 N AT I o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: COMMERCIal HMO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Childhood Immunization Status Rotavirus 63.8 60.9 2.9 Childhood Immunization Status Influenza 58.0 49.4 8.7 Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 18.7 16.7 2.0 Immunizations for Adolescents Meningococcal 55.2 54.2 1.0 Immunizations for Adolescents Tdap/Td 69.6 67.7 2.0 Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 51.7 51.2 0.4 Follow-Up Care for Children Prescribed ADHD Medication Initiation 39.1 34.3 4.8 Follow-Up Care for Children Prescribed ADHD Medication Continuation 43.7 37.6 6.2 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 35.5 32.3 3.2 37.6 35.1 2.4 35.6 31.9 3.6 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 1.6 1.8-0.2 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 1.1 0.6 0.5 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 1.3 1.8-0.5 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 2.2 2.4-0.2 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 4.8 5.7-1.0 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 12.5 15.9-3.5 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 76.8 71.7 5.2 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 72.4 64.5 7.8 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 43.5 35.7 7.8 Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years 97.5 97.1 0.5 91.4 89.3 2.1 Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years 91.9 89.3 2.6 Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years 89.5 86.9 2.6 *Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 155 APPENDIx 7B: PublICly REPoRTING VS. NoNPUblICly R E P o RT I N G P l A N S: 2 0 1 0 C o M M E R C I A l P P o S HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: COMMERCIal PPO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Safety and Potential Waste Imaging Studies for Low Back Pain 73.2 77.8-4.6 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 21.3 19.5 1.8 Ambulatory Care ED Visits per 1,000 Member Months 175.1 131.7 43.3 Wellness and Prevention Adult BMI Assessment 11.4 16.1-4.6 Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 71.7 71.7 0.0 39.0 35.2 3.8 47.3 41.6 5.7 Flu Shots for Adults 51.7 47.3 4.4 Prenatal and Postpartum Care Timeliness of Prenatal Care 76.1 62.0 14.1 Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 65.9 68.1-2.2 Breast Cancer Screening 67.1 63.9 3.2 Cervical Cancer Screening 74.5 73.1 1.5 Colorectal Cancer Screening 47.8 39.0 8.8 Chlamydia Screening in Women 16 20 Years 38.3 31.1 7.2 Chlamydia Screening in Women 21 24 Years 42.1 34.1 8.0 Chlamydia Screening in Women Total Rate 40.2 32.8 7.4 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 71.3 69.5 1.8 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 51.6 37.7 13.9 Comprehensive Diabetes Care Eye Exams 45.6 43.9 1.7 Comprehensive Diabetes Care HbA1c Screening 85.4 80.1 5.2 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 28.1 29.7-1.6 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 50.6 36.1 14.5 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 46.3 58.6-12.3 Comprehensive Diabetes Care LDL Cholesterol Screening 80.0 75.7 4.3 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 37.7 25.3 12.4 Comprehensive Diabetes Care Medical Attention for Nephropathy 74.3 76.0-1.6 Controlling High Blood Pressure 57.0 46.0 11.0

156 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: COMMERCIal PPO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 81.4 78.1 3.3 45.6 32.2 13.3 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 87.0 88.2-1.3 Use of Appropriate Medications for People With Asthma 5 11 Years 97.1 95.8 1.3 Use of Appropriate Medications for People With Asthma 12 50 Years 91.8 90.4 1.4 Use of Appropriate Medications for People With Asthma Overall Rate 93.1 91.6 1.4 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 40.2 37.5 2.7 Pharmacotherapy Management of COPD Bronchodilators 73.4 76.8-3.4 Pharmacotherapy Management of COPD Systemic Corticosteroids 66.3 59.2 7.1 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 78.4 77.6 0.8 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 57.9 60.5-2.6 Annual Monitoring for Patients on Persistent Medications Digoxin 79.1 82.1-3.1 Annual Monitoring for Patients on Persistent Medications Diuretics 78.1 77.3 0.8 Annual Monitoring for Patients on Persistent Medications Combined 77.9 76.9 1.0 Antidepressant Medication Management Acute Phase 64.5 60.3 4.2 Antidepressant Medication Management Continuation Phase 48.2 43.6 4.5 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 54.3 50.2 4.0 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 74.4 64.6 9.7 Alcohol and Other Drug Dependence Treatment Engagement 16.0 12.8 3.2 Alcohol and Other Drug Dependence Treatment Initiation 40.9 40.1 0.8 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 76.9 66.9 9.9 Appropriate Testing for Children With Upper Respiratory Infection 83.7 81.5 2.3 Childhood Immunization Status DTaP/DT 65.0 52.8 12.2 Childhood Immunization Status Hepatitis B 59.0 46.0 13.0 Childhood Immunization Status HiB 75.8 61.5 14.3 Childhood Immunization Status IPV 71.5 57.4 14.0 Childhood Immunization Status MMR 82.9 76.7 6.1 Childhood Immunization Status Pneumococcal Conjugate (PCV) 65.9 52.5 13.5 Childhood Immunization Status VZV 82.4 74.8 7.6 Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) 48.5 46.7 1.8

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 157 HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: COMMERCIal PPO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 46.1 44.9 1.2 Childhood Immunization Status Hepatitis A 28.6 30.2-1.6 Childhood Immunization Status Rotavirus 52.3 38.5 13.7 Childhood Immunization Status Influenza 51.3 42.7 8.6 Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 10.3 12.3-1.9 Immunizations for Adolescents Meningococcal 44.1 32.5 11.6 Immunizations for Adolescents Tdap/Td 55.5 46.5 9.0 Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 39.7 29.6 10.1 Follow-Up Care for Children Prescribed ADHD Medication Initiation 38.0 41.2-3.2 Follow-Up Care for Children Prescribed ADHD Medication Continuation 43.2 47.5-4.3 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 10.8 15.5-4.7 11.8 10.5 1.3 10.5 12.4-1.9 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 2.9 6.3-3.5 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 1.5 1.8-0.2 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 1.7 2.8-1.1 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 2.6 6.1-3.5 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 5.2 9.1-3.9 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 13.0 14.0-1.1 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 73.1 59.9 13.2 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 68.1 56.8 11.3 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 39.5 28.2 11.3 Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years 97.0 92.4 4.7 89.2 82.6 6.7 Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years 89.6 82.5 7.1 Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years 86.9 83.2 3.7 * Lower rates signify better performance.

158 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 8: PublICly REPoRTING VS. NoNPUblICly REPoRTING PlANS: 2010 MEDICAID HMoS HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: MEDICAID HMO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Safety and Potential Waste Imaging Studies for Low Back Pain 75.1 76.4-1.3 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 23.1 24.4-1.3 Ambulatory Care ED Visits per 1,000 Member Months 62.2 61.4 0.8 Wellness and Prevention Adult BMI Assessment 45.5 34.1 11.4 Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 74.0 72.7 1.3 39.1 36.9 2.2 43.7 40.0 3.7 Prenatal and Postpartum Care Timeliness of Prenatal Care 85.2 80.4 4.8 Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 65.2 62.5 2.7 Breast Cancer Screening 51.2 51.6-0.4 Cervical Cancer Screening 67.6 66.3 1.3 Chlamydia Screening in Women 16 20 Years 55.1 53.8 1.2 Chlamydia Screening in Women 21 24 Years 62.3 62.2 0.1 Chlamydia Screening in Women Total Rate 57.7 57.0 0.8 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 77.6 69.9 7.7 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 61.6 57.6 4.0 Comprehensive Diabetes Care Eye Exams 53.4 52.4 1.1 Comprehensive Diabetes Care HbA1c Screening 82.8 80.4 2.3 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 35.9 30.6 5.3 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 48.3 43.9 4.4 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 42.4 47.4-5.0 Comprehensive Diabetes Care LDL Cholesterol Screening 75.0 74.1 0.9 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 35.7 32.1 3.6 Comprehensive Diabetes Care Medical Attention for Nephropathy 78.2 76.4 1.9 Controlling High Blood Pressure 56.9 52.2 4.7 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 82.7 79.9 2.8 44.6 36.7 7.9

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 159 HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: MEDICAID HMO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 70.6 68.7 1.9 Use of Appropriate Medications for People With Asthma 5 11 Years 91.8 91.8 0.0 Use of Appropriate Medications for People With Asthma 12 50 Years 85.8 85.9-0.2 Use of Appropriate Medications for People With Asthma Overall Rate 88.5 88.1 0.4 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 30.4 34.2-3.8 Pharmacotherapy Management of COPD Bronchodilators 82.5 81.1 1.4 Pharmacotherapy Management of COPD Systemic Corticosteroids 65.4 65.2 0.2 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 86.3 85.5 0.8 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 68.4 66.1 2.4 Annual Monitoring for Patients on Persistent Medications Digoxin 89.3 91.1-1.8 Annual Monitoring for Patients on Persistent Medications Diuretics 85.9 84.6 1.2 Annual Monitoring for Patients on Persistent Medications Combined 84.0 83.6 0.4 Antidepressant Medication Management Acute Phase 50.0 52.0-1.9 Antidepressant Medication Management Continuation Phase 33.5 36.0-2.5 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 45.9 42.0 3.9 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 65.2 61.1 4.1 Alcohol and Other Drug Dependence Treatment Engagement 14.8 13.3 1.4 Alcohol and Other Drug Dependence Treatment Initiation 44.5 40.5 4.1 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 64.3 66.1-1.8 Appropriate Testing for Children With Upper Respiratory Infection 86.9 87.8-0.9 Childhood Immunization Status DTaP/DT 80.4 79.7 0.7 Childhood Immunization Status Hepatitis B 90.9 88.1 2.8 Childhood Immunization Status HiB 90.7 89.1 1.7 Childhood Immunization Status IPV 91.3 89.7 1.6 Childhood Immunization Status MMR 91.2 89.4 1.8 Childhood Immunization Status Pneumococcal Conjugate (PCV) 80.0 77.7 2.3 Childhood Immunization Status VZV 90.6 88.8 1.7 Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 74.8 72.5 2.3 70.7 67.9 2.8 Childhood Immunization Status Hepatitis A 37.4 34.1 3.3 Childhood Immunization Status Rotavirus 58.7 55.0 3.7 Childhood Immunization Status Influenza 43.9 42.6 1.3

160 N AT I o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: MEDICAID HMO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 16.0 13.3 2.8 Immunizations for Adolescents Meningococcal 56.9 54.9 2.1 Immunizations for Adolescents Tdap/Td 67.5 68.5-1.0 Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 52.9 50.6 2.3 Follow-Up Care for Children Prescribed ADHD Medication Initiation 38.8 36.7 2.1 Follow-Up Care for Children Prescribed ADHD Medication Continuation 45.0 41.3 3.7 Lead Screening in Children 66.7 65.1 1.7 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 38.8 33.6 5.2 48.2 39.1 9.1 38.2 32.8 5.5 Frequency of Prenatal Care Visits <21% of Expected Visits 8.8 14.3-5.4 Frequency of Prenatal Care Visits 21 40% of Expected Visits 6.1 8.8-2.7 Frequency of Prenatal Care Visits 41 60% of Expected Visits 7.6 9.3-1.7 Frequency of Prenatal Care Visits 61 80% of Expected Visits 13.3 14.3-1.0 Frequency of Prenatal Care Visits >80% of Expected Visits 64.2 53.3 10.9 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 2.1 2.3-0.2 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 2.1 2.3-0.2 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 3.3 3.5-0.2 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 5.7 5.8-0.2 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 9.7 10.8-1.2 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 15.5 17.3-1.8 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 61.4 57.5 4.0 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 72.2 71.2 0.9 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 48.9 46.2 2.7 Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years 96.0 96.2-0.2 88.1 88.6-0.5 Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years 90.2 90.2 0.0 Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years 88.1 88.2-0.1 *Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 161 APPENDIx 9A: PublICly REPoRTING VS. NoNPUblICly REPoRTING PlANS: 2010 MEDICARE HMoS HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: MEDICarE HMO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Safety and Potential Waste Ambulatory Care ED Visits per 1,000 Member Months 412.5 611.4-198.8 Wellness and Prevention Adult BMI Assessment 53.4 37.6 15.8 Breast Cancer Screening 69.8 62.8 7.0 Colorectal Cancer Screening 59.6 49.0 10.6 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 83.2 82.4 0.8 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 63.5 56.7 6.9 Comprehensive Diabetes Care Eye Exams 65.9 58.6 7.4 Comprehensive Diabetes Care HbA1c Screening 91.3 86.5 4.7 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 67.9 55.6 12.3 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 23.6 36.2-12.5 Comprehensive Diabetes Care LDL Cholesterol Screening 88.5 84.9 3.6 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 53.7 44.7 9.0 Comprehensive Diabetes Care Medical Attention for Nephropathy 89.7 87.2 2.5 Controlling High Blood Pressure 63.2 56.0 7.2 Cholesterol Management for Patients with Cardiovascular Conditions LDL Cholesterol Screening Cholesterol Management for Patients with Cardiovascular Conditions LDL Control (<100 mg/dl) 89.2 85.8 3.4 58.6 48.4 10.2 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 73.9 66.3 7.5 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 35.1 28.2 6.9 Pharmacotherapy Management of COPD Bronchodilators 78.2 78.3-0.1 Pharmacotherapy Management of COPD Systemic Corticosteroids 67.8 61.0 6.8 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 91.2 88.5 2.6 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 68.2 68.2 0.0 Annual Monitoring for Patients on Persistent Medications Digoxin 93.2 92.8 0.3 Annual Monitoring for Patients on Persistent Medications Diuretics 91.4 88.8 2.6 Annual Monitoring for Patients on Persistent Medications Combined 90.7 87.7 3.0 Antidepressant Medication Management Acute Phase 66.0 58.6 7.3 Antidepressant Medication Management Continuation Phase 52.7 47.1 5.5 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 38.9 30.0 8.9 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 56.6 48.6 8.0

162 N AT I o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: MEDICarE HMO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Alcohol and Other Drug Dependence Treatment Engagement 3.8 3.5 0.3 Alcohol and Other Drug Dependence Treatment Initiation 45.4 41.1 4.3 Measures Targeted Toward Older Adults Fall Risk Management Discussion 31.3 38.9-7.6 Fall Risk Management Management 59.1 64.3-5.2 Potentially Harmful Drug-Disease Interactions in the Elderly Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS* Potentially Harmful Drug-Disease Interactions in the Elderly Dementia and Tricyclic Antidepressants or Anticholinergic Agents* Potentially Harmful Drug-Disease Interactions in the Elderly Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents* 10.6 18.4-7.8 27.5 33.9-6.4 16.6 19.5-2.9 Potentially Harmful Drug-Disease Interactions in the Elderly Overall Rate* 22.2 27.7-5.4 Use of High-Risk Medications in the Elderly At Least One Medication* 21.2 26.1-4.9 Use of High-Risk Medications in the Elderly At Least Two Medications* 4.8 6.7-2.0 Management of Urinary Incontinence Discussion 57.8 60.3-2.5 Management of Urinary Incontinence Treatment 36.0 36.0-0.1 Physical Activity in Older Adults Advice 47.8 48.6-0.9 Physical Activity in Older Adults Discussion 52.8 50.6 2.2 Osteoporosis Testing in Older Women 69.8 63.2 6.6 Osteoporosis Management in Women Who Had a Fracture 21.6 15.9 5.7 Glaucoma Screening in Older Adults 65.0 58.5 6.5 *Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 163 APPENDIx 9B: PublICly REPoRTING VS. NoNPUblICly REPoRTING PlANS: 2010 MEDICARE PPoS HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: MEDICarE PPO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Safety and Potential Waste Ambulatory Care ED Visits per 1,000 Member Months 372.3 428.3-56.0 Wellness and Prevention Adult BMI Assessment 37.7 27.2 10.6 Breast Cancer Screening 65.8 65.7 0.0 Colorectal Cancer Screening 41.3 38.9 2.4 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 83.2 78.7 4.5 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 57.2 43.5 13.7 Comprehensive Diabetes Care Eye Exams 63.0 57.0 5.9 Comprehensive Diabetes Care HbA1c Screening 90.9 87.9 3.1 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 59.1 43.8 15.3 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 33.1 51.0-17.9 Comprehensive Diabetes Care LDL Cholesterol Screening 86.5 84.6 1.9 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 46.6 40.3 6.3 Comprehensive Diabetes Care Medical Attention for Nephropathy 87.4 87.1 0.3 Controlling High Blood Pressure 56.2 51.2 5.0 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 87.1 87.3-0.2 51.3 43.9 7.4 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 78.1 75.9 2.2 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 35.3 34.7 0.6 Pharmacotherapy Management of COPD Bronchodilators 76.7 71.5 5.2 Pharmacotherapy Management of COPD Systemic Corticosteroids 70.1 66.3 3.8 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 90.8 90.8 0.0 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 69.2 67.6 1.6 Annual Monitoring for Patients on Persistent Medications Digoxin 92.8 91.4 1.5 Annual Monitoring for Patients on Persistent Medications Diuretics 91.2 91.2 0.1 Annual Monitoring for Patients on Persistent Medications Combined 90.6 90.6 0.0 Antidepressant Medication Management Acute Phase 67.2 68.5-1.3 Antidepressant Medication Management Continuation Phase 55.5 56.9-1.4 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 40.7 28.6 12.2 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 62.3 54.2 8.1

164 N AT I o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES PublICly REPortIng vs. nonpublicly REPortIng Plans: MEDICarE PPO averages 2010 MEASURE PUBLIC NONPUBLIC DIFFERENCE Alcohol and Other Drug Dependence Treatment Engagement 4.6 6.2-1.6 Alcohol and Other Drug Dependence Treatment Initiation 57.8 53.3 4.5 Measures Targeted Toward Older Adults Fall Risk Management Discussion 31.0 31.6-0.6 Fall Risk Management Management 55.5 54.2 1.3 Potentially Harmful Drug-Disease Interactions in the Elderly Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS* Potentially Harmful Drug-Disease Interactions in the Elderly Dementia and Tricyclic Antidepressants or Anticholinergic Agents* Potentially Harmful Drug-Disease Interactions in the Elderly Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents* 10.8 19.1-8.3 27.0 29.9-2.9 16.1 18.0-1.9 Potentially Harmful Drug-Disease Interactions in the Elderly Overall Rate* 21.4 25.6-4.2 Use of High-Risk Medications in the Elderly At Least One Medication* 21.8 22.1-0.2 Use of High-Risk Medications in the Elderly At Least Two Medications* 5.0 5.3-0.3 Management of Urinary Incontinence Discussion 58.1 56.3 1.8 Management of Urinary Incontinence Treatment 36.6 34.3 2.3 Physical Activity in Older Adults Advice 47.5 48.7-1.3 Physical Activity in Older Adults Discussion 54.1 52.0 2.1 Osteoporosis Testing in Older Women 73.5 73.2 0.2 Osteoporosis Management in Women Who Had a Fracture 18.7 16.7 2.0 Glaucoma Screening in Older Adults 65.0 66.2-1.3 *Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 165 APPENDIx 10: HMoS VS. PPoS, CoMMERCIAl PlANS HEDIS EffECTIVENEss of CarE MEasurES HMos vs. PPos: COMMERCIal averages 2010 MEASURE HMO PPO DIFFERENCE Safety and Potential Waste Imaging Studies for Low Back Pain 74.2 73.3-0.9 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 22.5 21.3-1.2 Ambulatory Care ED Visits per 1,000 Member Months 187.4 174-13.4 Wellness and Prevention Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 76.7 71.7-5.0 45.0 39.0-6.0 52.4 47.2-5.1 Flu Shots for Adults 52.5 51.6-0.9 Breast Cancer Screening 70.8 67.0-3.8 Cervical Cancer Screening 77.0 74.5-2.4 Chlamydia Screening in Women 16 20 Years 40.8 38.1-2.7 Chlamydia Screening in Women 21 24 Years 45.7 41.9-3.8 Chlamydia Screening in Women Total Rate 43.1 40.0-3.1 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 75.5 71.3-4.2 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 87.7 87.0-0.7 Use of Appropriate Medications for People With Asthma 5 11 Years 96.7 97.0 0.4 Use of Appropriate Medications for People With Asthma 12 50 Years 91.8 91.8 0.0 Use of Appropriate Medications for People With Asthma Overall Rate 92.9 93.0 0.2 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 41.7 40.2-1.5 Pharmacotherapy Management of COPD Bronchodilators 77.8 73.5-4.3 Pharmacotherapy Management of COPD Systemic Corticosteroids 69.8 66.2-3.7 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 81.6 78.4-3.2 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 60.4 57.9-2.5 Annual Monitoring for Patients on Persistent Medications Digoxin 84.6 79.1-5.5 Annual Monitoring for Patients on Persistent Medications Diuretics 81.0 78.1-2.9 Annual Monitoring for Patients on Persistent Medications Combined 80.9 77.8-3.1 Antidepressant Medication Management Acute Phase 64.7 64.3-0.4 Antidepressant Medication Management Continuation Phase 48.3 48.1-0.3 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 59.7 54.2-5.6 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 77.4 74.1-3.2 Alcohol and Other Drug Dependence Treatment Engagement 15.6 16.0 0.3

166 N AT I o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES HMos vs. PPos: COMMERCIal averages 2010 MEASURE HMO PPO DIFFERENCE Alcohol and Other Drug Dependence Treatment Initiation 42.7 40.8-1.9 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 77.6 76.6-0.9 Appropriate Testing for Children With Upper Respiratory Infection 85.1 83.7-1.4 Follow-Up Care for Children Prescribed ADHD Medication Initiation 38.8 38.1-0.7 Follow-Up Care for Children Prescribed ADHD Medication Continuation 43.4 43.3-0.1 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 1.6 2.9 1.4 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 1.1 1.5 0.5 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 1.3 1.7 0.4 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 2.2 2.7 0.5 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 4.9 5.3 0.4 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 12.8 13.0 0.2 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 76.3 72.8-3.6 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 71.6 67.8-3.8 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 42.7 39.2-3.5 Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months 97.5 96.9-0.6 Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years 91.2 89.1-2.1 Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years 91.6 89.4-2.2 Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years 89.2 86.8-2.4 *Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 167 APPENDIx 11: HMoS VS. PPoS, MEDICARE PlANS HEDIS EffECTIVENEss of CarE MEasurES HMos vs. PPos: MEDICarE averages 2010 MEASURE HMO PPO DIFFERENCE Safety and Potential Waste Ambulatory Care ED Visits per 1,000 Member Months 450.3 379-71.2 Wellness and Prevention Breast Cancer Screening 68.5 65.8-2.7 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 83.1 82.5-0.6 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 72.8 77.8 5.1 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 33.9 35.3 1.4 Pharmacotherapy Management of COPD Bronchodilators 78.2 76.1-2.2 Pharmacotherapy Management of COPD Systemic Corticosteroids 66.6 69.6 3.0 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 90.7 90.8 0.1 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 68.2 69.1 0.9 Annual Monitoring for Patients on Persistent Medications Digoxin 93.1 92.7-0.5 Annual Monitoring for Patients on Persistent Medications Diuretics 90.9 91.2 0.4 Annual Monitoring for Patients on Persistent Medications Combined 90.2 90.6 0.5 Antidepressant Medication Management Acute Phase 65.0 67.4 2.4 Antidepressant Medication Management Continuation Phase 51.9 55.7 3.8 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 37.4 39.1 1.6 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 55.4 61.2 5.8 Alcohol and Other Drug Dependence Treatment Engagement 3.7 4.8 1.0 Alcohol and Other Drug Dependence Treatment Initiation 44.6 57.4 12.8 Measures Targeted Toward Older Adults Fall Risk Management Discussion 32.8 31.1-1.8 Fall Risk Management Management 60.1 55.3-4.8 Potentially Harmful Drug-Disease Interactions in the Elderly Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS* Potentially Harmful Drug-Disease Interactions in the Elderly Dementia and Tricyclic Antidepressants or Anticholinergic Agents* Potentially Harmful Drug-Disease Interactions in the Elderly Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents* 11.6 11.7 0.1 28.7 27.3-1.4 17.1 16.3-0.9 Potentially Harmful Drug-Disease Interactions in the Elderly Overall Rate* 23.3 21.8-1.4 Use of High-Risk Medications in the Elderly At Least One Medication* 22.1 21.9-0.2 Use of High-Risk Medications in the Elderly At Least Two Medications* 5.1 5.1-0.1 Management of Urinary Incontinence Discussion 58.2 57.9-0.4 Management of Urinary Incontinence Treatment 36.0 36.3 0.4 Physical Activity in Older Adults Advice 47.9 47.6-0.3

168 N AT I o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E HEDIS EffECTIVENEss of CarE MEasurES HMos vs. PPos: MEDICarE averages 2010 MEASURE HMO PPO DIFFERENCE Physical Activity in Older Adults Discussion 52.3 53.9 1.5 Osteoporosis Testing in Older Women 68.5 73.4 4.9 Osteoporosis Management in Women Who Had a Fracture 20.7 18.5-2.2 Glaucoma Screening in Older Adults 63.8 65.1 1.3 *Lower rates signify better performance.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 169 APPENDIx 12: HMoS VS. PPoS, CoMMERCIAl PlANS CAHPS MEMBER satisfaction MEasurES HMos vs. PPos: COMMERCIal averages 2010 MEASURE HMO PPO DIFFERENCE Consumer and Patient Engagement and Experience Rating of Health Plan Rating of 8, 9 or 10 64.2 58.6-5.6 Rating of Health Plan Rating of 9 or 10 40.3 33.7-6.6 Rating of Health Care Rating of 8, 9 or 10 76.6 75.6-1.0 Rating of Health Care Rating of 9 or 10 50.7 48.1-2.6 Getting Needed Care Usually or Always 86.2 86.6 0.4 Getting Needed Care Always 53.9 53.9 0.0 Getting Care Quickly Usually or Always 86.5 87.1 0.7 Getting Care Quickly Always 58.2 57.7-0.5 How Well Doctors Communicate Usually or Always 93.9 94.6 0.7 How Well Doctors Communicate Always 73.5 73.5 0.0 Rating of Personal Doctor Rating of 8, 9 or 10 83.2 82.8-0.4 Rating of Personal Doctor Rating of 9 or 10 65.0 62.8-2.2 Rating of Specialist Rating of 8, 9 or 10 82.3 81.6-0.7 Rating of Specialist Rating of 9 or 10 64.1 61.9-2.2 Customer Service Usually or Always 84.5 83.0-1.4 Customer Service Always 59.4 55.5-3.9 Claims Processing Usually or Always 88.6 87.8-0.8 Claims Processing Always 55.5 50.7-4.7

170 N AT I o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 13: HMoS VS. PPoS, MEDICARE PlANS CAHPS MEMBER satisfaction MEasurES HMos vs. PPos: MEDICarE averages 2010 MEASURE HMO PPO DIFFERENCE Consumer and Patient Engagement and Experience Information not available for the October 2011 pre-publication edition of this report. Information will appear in the November 2011 final edition.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 171 APPENDIx 14A: VARIATIon IN PlAN PERfoRMANCE: THE 90TH PERCENTIle VS. THE 10TH PERCENTIle: CoMMERCIAl HMoS MEASURE Safety and Potential Waste HEDIS EffECTIVENEss of CarE MEasurES COMMERCIal HMO statistics 2010 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE Imaging Studies for Low Back Pain 82.0 66.4 15.6 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 31.6 15.0 16.6 Ambulatory Care ED Visits per 1,000 Member Months 231.8 139.9 91.8 Wellness and Prevention Adult BMI Assessment 76.9 1.2 75.7 Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit 85.2 67.2 18.0 Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 59.0 33.6 25.4 63.2 42.6 20.5 Flu Shots for Adults 62.4 43.9 18.6 Prenatal and Postpartum Care Timeliness of Prenatal Care 97.8 81.3 16.5 Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 90.7 66.7 24.0 Breast Cancer Screening 79.5 63.3 16.2 Cervical Cancer Screening 83.2 71.0 12.2 Colorectal Cancer Screening 74.2 48.9 25.3 Chlamydia Screening in Women 16 20 Years 53.9 29.3 24.5 Chlamydia Screening in Women 21 24 Years 61.4 32.6 28.9 Chlamydia Screening in Women Total Rate 56.7 30.6 26.1 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 87.5 64.1 23.4 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 75.9 52.4 23.5 Comprehensive Diabetes Care Eye Exams 75.3 40.4 34.9 Comprehensive Diabetes Care HbA1c Screening 94.2 85.6 8.5 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 51.0 34.3 16.7 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 72.0 52.3 19.7 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 16.8 37.8-21.0 Comprehensive Diabetes Care LDL Cholesterol Screening 91.0 80.0 11.0 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 57.2 37.2 20.0 Comprehensive Diabetes Care Medical Attention for Nephropathy 89.6 76.9 12.6 Controlling High Blood Pressure 74.1 51.3 22.8

172 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E MEASURE HEDIS EffECTIVENEss of CarE MEasurES COMMERCIal HMO statistics 2010 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE 93.7 84.7 9.0 72.0 48.1 23.9 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 93.7 81.4 12.2 Use of Appropriate Medications for People With Asthma 5 11 Years 99.2 94.1 5.1 Use of Appropriate Medications for People With Asthma 12 50 Years 95.0 88.1 6.9 Use of Appropriate Medications for People With Asthma Overall Rate 95.7 89.9 5.8 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 52.2 31.2 21.0 Pharmacotherapy Management of COPD Bronchodilators 86.5 67.5 19.0 Pharmacotherapy Management of COPD Systemic Corticosteroids 78.4 60.0 18.4 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 86.5 77.0 9.6 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 70.0 52.4 17.6 Annual Monitoring for Patients on Persistent Medications Digoxin 92.9 75.0 17.9 Annual Monitoring for Patients on Persistent Medications Diuretics 86.1 76.0 10.1 Annual Monitoring for Patients on Persistent Medications Combined 85.9 76.0 9.9 Antidepressant Medication Management Acute Phase 73.5 56.3 17.3 Antidepressant Medication Management Continuation Phase 56.7 39.1 17.6 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 75.0 43.7 31.3 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 88.5 66.2 22.3 Alcohol and Other Drug Dependence Treatment Engagement 22.8 8.3 14.5 Alcohol and Other Drug Dependence Treatment Initiation 52.9 32.0 20.8 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 90.5 62.8 27.7 Appropriate Testing for Children With Upper Respiratory Infection 94.5 75.4 19.1 Childhood Immunization Status DTaP/DT 92.5 80.5 12.0 Childhood Immunization Status Hepatitis B 95.9 84.9 11.0 Childhood Immunization Status HiB 97.8 90.9 6.9 Childhood Immunization Status IPV 96.4 87.4 9.1 Childhood Immunization Status MMR 94.9 86.7 8.3 Childhood Immunization Status Pneumococcal Conjugate (PCV) 92.0 79.8 12.2 Childhood Immunization Status VZV 94.6 87.4 7.3 Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 86.6 69.9 16.7 84.9 65.2 19.7

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 173 MEASURE HEDIS EffECTIVENEss of CarE MEasurES COMMERCIal HMO statistics 2010 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE Childhood Immunization Status Hepatitis A 54.6 20.0 34.6 Childhood Immunization Status Rotavirus 78.8 47.0 31.8 Childhood Immunization Status Influenza 70.1 41.8 28.2 Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 30.9 8.3 22.6 Immunizations for Adolescents Meningococcal 77.7 35.9 41.7 Immunizations for Adolescents Tdap/Td 91.9 46.1 45.8 Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 75.2 30.6 44.6 Follow-Up Care for Children Prescribed ADHD Medication Initiation 49.0 30.7 18.4 Follow-Up Care for Children Prescribed ADHD Medication Continuation 55.6 31.3 24.3 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI Percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 75.9 0.2 75.7 74.1 0.2 73.9 70.1 0.0 70.1 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 3.6 0.0 3.6 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 2.0 0.0 2.0 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 2.5 0.0 2.5 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 3.9 0.4 3.5 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 8.3 1.9 6.4 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 21.7 5.9 15.9 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 89.6 61.1 28.6 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 84.5 56.9 27.7 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 60.2 28.5 31.7 Children and Adolescents' Access to Primary Care Practitioners Children 12 24 Months Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years *Lower rates signify better performance. 99.4 95.4 4.0 95.7 86.2 9.4 96.7 86.8 9.9 95.1 83.5 11.6

174 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 14B: VARIATIon IN PlAN PERfoRMANCE: THE 90TH PERCENTIle VS. THE 10TH PERCENTIle: CoMMERCIAl PPoS MEASURE Safety and Potential Waste HEDIS EffECTIVENEss of CarE MEasurES COMMERCIal PPO statistics 2010 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE Imaging Studies for Low Back Pain 80.6 65.4 15.2 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 27.1 15.9 11.2 Ambulatory Care ED Visits per 1,000 Member Months 208.8 133.3 75.6 Wellness and Prevention Adult BMI Assessment 47.3 0.8 46.5 Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit 79.8 65.3 14.5 Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 47.0 32.6 14.4 55.6 38.8 16.7 Flu Shots for Adults 57.9 45.3 12.6 Prenatal and Postpartum Care Timeliness of Prenatal Care 96.0 41.6 54.4 Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 87.1 36.2 50.9 Breast Cancer Screening 72.5 62.2 10.3 Cervical Cancer Screening 79.0 69.2 9.8 Colorectal Cancer Screening 55.3 41.1 14.2 Chlamydia Screening in Women 16 20 Years 48.2 29.5 18.7 Chlamydia Screening in Women 21 24 Years 55.2 30.6 24.6 Chlamydia Screening in Women Total Rate 51.0 29.9 21.0 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 79.9 62.3 17.6 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 71.3 0.8 70.5 Comprehensive Diabetes Care Eye Exams 59.0 31.5 27.4 Comprehensive Diabetes Care HbA1c Screening 91.0 77.4 13.6 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 45.0 4.5 40.4 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 67.2 12.5 54.7 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 23.8 92.7-68.8 Comprehensive Diabetes Care LDL Cholesterol Screening 87.1 70.2 16.9 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 50.7 11.7 39.0 Comprehensive Diabetes Care Medical Attention for Nephropathy 84.4 57.6 26.8 Controlling High Blood Pressure 67.6 42.6 25.1 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening 89.9 68.2 21.7

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 175 MEASURE HEDIS EffECTIVENEss of CarE MEasurES COMMERCIal PPO statistics 2010 Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE 64.5 9.8 54.7 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 91.8 81.0 10.8 Use of Appropriate Medications for People With Asthma 5 11 Years 99.0 95.0 4.0 Use of Appropriate Medications for People With Asthma 12 50 Years 94.0 88.9 5.1 Use of Appropriate Medications for People With Asthma Overall Rate 95.4 90.6 4.7 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 48.5 32.8 15.7 Pharmacotherapy Management of COPD Bronchodilators 84.4 63.6 20.7 Pharmacotherapy Management of COPD Systemic Corticosteroids 78.7 52.5 26.1 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 83.0 73.0 10.0 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 64.5 50.8 13.8 Annual Monitoring for Patients on Persistent Medications Digoxin 85.9 71.0 14.9 Annual Monitoring for Patients on Persistent Medications Diuretics 83.1 72.9 10.2 Annual Monitoring for Patients on Persistent Medications Combined 82.6 72.5 10.1 Antidepressant Medication Management Acute Phase 69.6 59.6 10.0 Antidepressant Medication Management Continuation Phase 54.8 42.2 12.5 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 68.0 40.1 28.0 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 84.2 63.3 20.9 Alcohol and Other Drug Dependence Treatment Engagement 21.6 10.8 10.9 Alcohol and Other Drug Dependence Treatment Initiation 47.0 33.8 13.2 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 88.3 63.4 24.9 Appropriate Testing for Children With Upper Respiratory Infection 92.1 74.1 18.0 Childhood Immunization Status DTaP/DT 86.6 38.8 47.8 Childhood Immunization Status Hepatitis B 91.0 24.6 66.4 Childhood Immunization Status HiB 95.4 53.3 42.1 Childhood Immunization Status IPV 92.2 46.6 45.6 Childhood Immunization Status MMR 91.5 70.6 20.8 Childhood Immunization Status Pneumococcal Conjugate (PCV) 86.9 41.2 45.7 Childhood Immunization Status VZV 91.9 70.2 21.7 Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 78.5 18.5 59.9 75.0 17.2 57.8 Childhood Immunization Status Hepatitis A 37.9 17.7 20.2

176 N AT I o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E MEASURE HEDIS EffECTIVENEss of CarE MEasurES COMMERCIal PPO statistics 2010 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE Childhood Immunization Status Rotavirus 70.6 33.6 37.0 Childhood Immunization Status Influenza 65.2 35.4 29.8 Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 19.9 3.3 16.5 Immunizations for Adolescents Meningococcal 63.7 26.6 37.1 Immunizations for Adolescents Tdap/Td 77.0 37.6 39.4 Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 58.4 24.5 33.8 Follow-Up Care for Children Prescribed ADHD Medication Initiation 44.9 31.7 13.2 Follow-Up Care for Children Prescribed ADHD Medication Continuation 52.7 34.4 18.3 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI Percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 46.3 0.1 46.2 54.3 0.2 54.0 48.2 0.0 48.2 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 5.3 0.9 4.3 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 2.6 0.5 2.0 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 2.8 0.7 2.1 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 4.3 1.3 3.0 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 7.5 2.7 4.9 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 18.1 7.8 10.3 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 82.7 60.1 22.6 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 82.5 51.9 30.6 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 57.7 24.4 33.2 Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years 98.7 94.8 3.9 94.3 83.1 11.2 Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years 95.4 81.6 13.8 Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years *Lower rates signify better performance. 93.7 80.4 13.3

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 177 APPENDIx 15: VARIATIon IN PlAN PERfoRMANCE: THE 90TH PERCENTIle VS. THE 10TH PERCENTIle: MEDICAID HMoS MEASURE Safety and Potential Waste HEDIS EffECTIVENEss of CarE MEasurES MEDICAID HMO statistics 2010 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE Imaging Studies for Low Back Pain 82.3 67.0 15.2 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis 31.6 15.1 16.5 Ambulatory Care ED Visits per 1,000 Member Months 76.6 44.4 32.2 Wellness and Prevention Adult BMI Assessment 70.5 3.2 67.2 Medical Assistance With Smoking and Tobacco Use Cessation Advising Smokers and Tobacco Users to Quit 80.8 64.7 16.1 Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Strategies Medical Assistance With Smoking and Tobacco Use Cessation Discussing Cessation Medications 48.5 30.0 18.4 55.0 30.2 24.7 Prenatal and Postpartum Care Timeliness of Prenatal Care 93.3 71.4 21.9 Prenatal and Postpartum Care Postpartum Visit Between 21 and 56 Days After Delivery 75.2 53.7 21.5 Breast Cancer Screening 62.9 38.7 24.3 Cervical Cancer Screening 78.7 53.0 25.6 Chlamydia Screening in Women 16 20 Years 66.7 42.9 23.8 Chlamydia Screening in Women 21 24 Years 72.2 50.5 21.6 Chlamydia Screening in Women Total Rate 69.1 46.0 23.0 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 88.6 61.0 27.5 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 76.0 43.8 32.2 Comprehensive Diabetes Care Eye Exams 70.6 34.0 36.7 Comprehensive Diabetes Care HbA1c Screening 90.9 73.6 17.3 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <7% for a Selected Population) 44.4 23.6 20.8 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 59.1 33.8 25.4 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 29.1 60.4-31.2 Comprehensive Diabetes Care LDL Cholesterol Screening 84.2 63.7 20.5 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 45.9 21.5 24.4 Comprehensive Diabetes Care Medical Attention for Nephropathy 86.9 68.1 18.7 Controlling High Blood Pressure 67.6 42.1 25.5 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 89.1 74.4 14.6 57.1 28.9 28.3

178 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E MEASURE HEDIS EffECTIVENEss of CarE MEasurES MEDICAID HMO statistics 2010 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 83.2 53.3 29.8 Use of Appropriate Medications for People With Asthma 5 11 Years 96.0 87.5 8.5 Use of Appropriate Medications for People With Asthma 12 50 Years 91.3 79.8 11.4 Use of Appropriate Medications for People With Asthma Overall Rate 93.2 83.6 9.6 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 47.2 19.1 28.0 Pharmacotherapy Management of COPD Bronchodilators 89.3 71.1 18.2 Pharmacotherapy Management of COPD Systemic Corticosteroids 76.8 46.5 30.3 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 90.6 79.9 10.7 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 76.6 57.6 19.0 Annual Monitoring for Patients on Persistent Medications Digoxin 95.5 80.4 15.1 Annual Monitoring for Patients on Persistent Medications Diuretics 90.7 79.3 11.3 Annual Monitoring for Patients on Persistent Medications Combined 88.1 78.3 9.9 Antidepressant Medication Management Acute Phase 59.9 43.0 16.9 Antidepressant Medication Management Continuation Phase 44.2 25.7 18.5 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 68.3 23.0 45.3 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 82.6 36.0 46.6 Alcohol and Other Drug Dependence Treatment Engagement 25.9 2.0 23.9 Alcohol and Other Drug Dependence Treatment Initiation 60.7 30.0 30.7 Measures Targeted Toward Children and Adolescents Appropriate Testing for Children With Pharyngitis 83.0 45.1 37.9 Appropriate Testing for Children With Upper Respiratory Infection 94.8 79.2 15.6 Childhood Immunization Status DTaP/DT 88.5 70.8 17.7 Childhood Immunization Status Hepatitis B 95.9 82.9 13.0 Childhood Immunization Status HiB 96.1 84.3 11.8 Childhood Immunization Status IPV 95.9 85.6 10.2 Childhood Immunization Status MMR 95.4 86.1 9.3 Childhood Immunization Status Pneumococcal Conjugate (PCV) 88.8 68.8 20.0 Childhood Immunization Status VZV 95.1 85.4 9.7 Childhood Immunization Status Combination 2 (DTaP, IPV, MMR, HiB, Hepatitis B and VZV) Childhood Immunization Status Combination 3 (DTaP, IPV, MMR, HiB, Hepatitis B, VZV and PCV) 85.8 62.3 23.6 82.6 56.8 25.8 Childhood Immunization Status Hepatitis A 48.7 24.3 24.4 Childhood Immunization Status Rotavirus 72.2 43.6 28.7 Childhood Immunization Status Influenza 60.3 22.0 38.3

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 179 MEASURE HEDIS EffECTIVENEss of CarE MEasurES MEDICAID HMO statistics 2010 Childhood Immunization Status Combination 10 (DTaP, IPV, MMR, HiB, Hepatitis A, Hepatitis B, VZV, PCV, Rotavirus and Influenza) 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE 23.6 6.3 17.3 Immunizations for Adolescents Meningococcal 79.7 38.0 41.7 Immunizations for Adolescents Tdap/Td 87.8 45.3 42.5 Immunizations for Adolescents Combination 1 (Meningococcal, Tdap/Td) 75.5 33.8 41.7 Follow-Up Care for Children Prescribed ADHD Medication Initiation 50.7 24.9 25.8 Follow-Up Care for Children Prescribed ADHD Medication Continuation 62.5 23.0 39.5 Lead Screening in Children 87.6 34.6 53.0 Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents BMI Percentile (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Nutrition (Overall) Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescents Counseling for Physical Activity (Overall) 69.8 0.7 69.1 72.0 0.7 71.3 60.6 0.0 60.5 Frequency of Prenatal Care Visits <21% of Expected Visits 19.1 1.8 17.3 Frequency of Prenatal Care Visits 21 40% of Expected Visits 13.8 1.9 11.9 Frequency of Prenatal Care Visits 41 60% of Expected Visits 14.2 4.0 10.3 Frequency of Prenatal Care Visits 61 80% of Expected Visits 19.7 7.1 12.7 Frequency of Prenatal Care Visits >80% of Expected Visits 81.8 34.7 47.1 Well-Child Visits: Ages 0 15 Months No Well-Child Visits 4.4 0.5 3.9 Well-Child Visits: Ages 0 15 Months One Well-Child Visit 4.1 0.7 3.4 Well-Child Visits: Ages 0 15 Months Two Well-Child Visits 6.1 1.1 5.0 Well-Child Visits: Ages 0 15 Months Three Well-Child Visits 9.3 2.7 6.6 Well-Child Visits: Ages 0 15 Months Four Well-Child Visits 15.6 5.3 10.3 Well-Child Visits: Ages 0 15 Months Five Well-Child Visits 21.9 8.3 13.6 Well-Child Visits: Ages 0 15 Months Six or More Well-Child Visits 77.1 41.9 35.2 Well-Child Visits: Ages 3 6 Years One or More Well-Child Visits 82.9 60.9 22.0 Adolescent Well-Care Visits At Least One Comprehensive Well-Care Visit 64.1 35.0 29.1 Children and Adolescents Access to Primary Care Practitioners Children 12 24 Months Children and Adolescents Access to Primary Care Practitioners Children 25 Months 6 Years 98.6 92.6 6.0 92.7 82.0 10.7 Children and Adolescents Access to Primary Care Practitioners Children 7 11 Years 94.7 85.2 9.5 Children and Adolescents Access to Primary Care Practitioners Adolescents 12 19 Years *Lower rates signify better performance. 93.4 81.1 12.4

180 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 16A: VARIATIon IN PlAN PERfoRMANCE: THE 90TH PERCENTIle VS. THE 10TH PERCENTIle: MEDICARE HMoS MEASURE Safety and Potential Waste HEDIS EffECTIVENEss of CarE MEasurES MEDICarE HMO statistics 2010 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE Ambulatory Care ED Visits per 1,000 Member Months 782.1 248.3 533.8 Wellness and Prevention Adult BMI Assessment 80.2 16.8 63.4 Breast Cancer Screening 80.9 55.5 25.4 Colorectal Cancer Screening 75.6 40.0 35.5 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 91.6 72.4 19.2 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 75.1 48.5 26.6 Comprehensive Diabetes Care Eye Exams 79.3 49.7 29.6 Comprehensive Diabetes Care HbA1c Screening 95.9 84.0 12.0 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 80.2 47.8 32.4 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 11.3 45.0-33.7 Comprehensive Diabetes Care LDL Cholesterol Screening 94.1 81.3 12.8 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 65.4 37.0 28.4 Comprehensive Diabetes Care Medical Attention for Nephropathy 93.9 84.7 9.2 Controlling High Blood Pressure 74.4 47.7 26.7 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening 94.4 81.2 13.2 Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 72.2 40.6 31.5 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 85.0 58.4 26.6 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 46.9 20.5 26.4 Pharmacotherapy Management of COPD Bronchodilators 87.2 67.5 19.7 Pharmacotherapy Management of COPD Systemic Corticosteroids 76.8 53.6 23.2 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 94.9 86.1 8.8 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 81.3 56.4 24.8 Annual Monitoring for Patients on Persistent Medications Digoxin 97.0 88.4 8.6 Annual Monitoring for Patients on Persistent Medications Diuretics 95.1 86.2 8.8 Annual Monitoring for Patients on Persistent Medications Combined 94.5 85.9 8.6 Antidepressant Medication Management Acute Phase 77.4 51.8 25.7 Antidepressant Medication Management Continuation Phase 65.6 35.8 29.8 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 66.0 13.5 52.5 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 80.2 25.3 55.0

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 181 MEASURE HEDIS EffECTIVENEss of CarE MEasurES MEDICarE HMO statistics 2010 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE Alcohol and Other Drug Dependence Treatment Engagement 7.9 0.4 7.5 Alcohol and Other Drug Dependence Treatment Initiation 63.3 25.0 38.3 Measures Targeted Toward Older Adults Fall Risk Management Discussion 44.4 25.8 18.7 Fall Risk Management Management 69.8 51.6 18.2 Potentially Harmful Drug-Disease Interactions in the Elderly Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS* Potentially Harmful Drug-Disease Interactions in the Elderly Dementia and Tricyclic Antidepressants or Anticholinergic Agents* Potentially Harmful Drug-Disease Interactions in the Elderly Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents* 5.0 23.0-18.0 18.8 41.3-22.5 11.9 23.4-11.5 Potentially Harmful Drug-Disease Interactions in the Elderly Overall Rate* 15.8 32.4-16.6 Use of High-Risk Medications in the Elderly At Least One Medication* 13.2 33.1-19.8 Use of High-Risk Medications in the Elderly At Least Two Medications* 1.6 9.8-8.1 Management of Urinary Incontinence Discussion 64.3 50.9 13.4 Management of Urinary Incontinence Treatment 41.1 30.7 10.3 Physical Activity in Older Adults Advice 54.5 41.7 12.8 Physical Activity in Older Adults Discussion 60.3 44.7 15.6 Osteoporosis Testing in Older Women 80.6 54.4 26.2 Osteoporosis Management in Women Who Had a Fracture 29.8 12.0 17.9 Glaucoma Screening in Older Adults 77.9 48.0 29.9 *Lower rates signify better performance.

182 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E APPENDIx 16B: VARIATIon IN PlAN PERfoRMANCE: THE 90TH PERCENTIle VS. THE 10TH PERCENTIle: MEDICARE PPoS MEASURE Safety and Potential Waste HEDIS EffECTIVENEss of CarE MEasurES MEDICarE PPO statistics 2010 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE Ambulatory Care ED Visits per 1,000 Member Months 506.7 266.8 239.9 Wellness and Prevention Adult BMI Assessment 64.0 2.8 61.2 Breast Cancer Screening 77.5 54.1 23.4 Colorectal Cancer Screening 53.4 31.1 22.3 Chronic Disease Management Persistence of Beta-Blocker Treatment After a Heart Attack 89.9 72.1 17.8 Comprehensive Diabetes Care Blood Pressure Control (<140/90 mm Hg) 70.6 39.4 31.2 Comprehensive Diabetes Care Eye Exams 75.8 49.6 26.2 Comprehensive Diabetes Care HbA1c Screening 94.9 85.9 9.0 Comprehensive Diabetes Care Good Glycemic Control (HbA1c <8%) 76.1 31.7 44.4 Comprehensive Diabetes Care Poor Glycemic Control (HbA1c >9%)* 15.3 63.5-48.2 Comprehensive Diabetes Care LDL Cholesterol Screening 92.0 80.8 11.2 Comprehensive Diabetes Care LDL Cholesterol Control (<100 mg/dl) 60.3 29.0 31.4 Comprehensive Diabetes Care Medical Attention for Nephropathy 91.2 83.5 7.7 Controlling High Blood Pressure 69.0 41.6 27.4 Cholesterol Management for Patients With Cardiovascular Conditions LDL Cholesterol Screening 92.5 81.1 11.4 Cholesterol Management for Patients With Cardiovascular Conditions LDL Control (<100 mg/dl) 65.2 34.9 30.3 Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis 85.7 67.9 17.7 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 45.8 23.7 22.1 Pharmacotherapy Management of COPD Bronchodilators 84.4 67.2 17.3 Pharmacotherapy Management of COPD Systemic Corticosteroids 79.0 60.9 18.2 Annual Monitoring for Patients on Persistent Medications ACE Inhibitors or ARBs 93.6 87.6 6.0 Annual Monitoring for Patients on Persistent Medications Anticonvulsants 83.6 57.6 25.9 Annual Monitoring for Patients on Persistent Medications Digoxin 96.8 89.3 7.5 Annual Monitoring for Patients on Persistent Medications Diuretics 94.0 87.9 6.2 Annual Monitoring for Patients on Persistent Medications Combined 93.3 87.4 5.9 Antidepressant Medication Management Acute Phase 77.6 55.6 22.1 Antidepressant Medication Management Continuation Phase 66.3 42.7 23.6 Follow-Up After Hospitalization for Mental Illness Within 7 Days Post-Discharge 63.8 21.1 42.8 Follow-Up After Hospitalization for Mental Illness Within 30 Days Post-Discharge 78.7 47.2 31.6

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A P P E N D I C E S 183 MEASURE HEDIS EffECTIVENEss of CarE MEasurES MEDICarE PPO statistics 2010 90TH PERCENTILE 10TH PERCENTILE DIFFERENCE Alcohol and Other Drug Dependence Treatment Engagement 8.7 1.3 7.4 Alcohol and Other Drug Dependence Treatment Initiation 80.7 35.5 45.2 Measures Targeted Toward Older Adults Fall Risk Management Discussion 39.9 25.2 14.6 Fall Risk Management Management 65.9 46.6 19.3 Potentially Harmful Drug-Disease Interactions in the Elderly Chronic Renal Failure and NSAIDS or Cox-2 Selective NSAIDS* Potentially Harmful Drug-Disease Interactions in the Elderly Dementia and Tricyclic Antidepressants or Anticholinergic Agents* Potentially Harmful Drug-Disease Interactions in the Elderly Falls and Tricyclic Antidepressants, Antipsychotics and Sleep Agents* 4.3 20.0-15.7 17.7 38.3-20.5 10.5 22.2-11.7 Potentially Harmful Drug-Disease Interactions in the Elderly Overall Rate* 15.0 29.8-14.8 Use of High-Risk Medications in the Elderly At Least One Medication* 14.9 30.4-15.5 Use of High-Risk Medications in the Elderly At Least Two Medications* 1.9 8.4-6.5 Management of Urinary Incontinence Discussion 65.6 51.5 14.1 Management of Urinary Incontinence Treatment 42.1 31.1 10.9 Physical Activity in Older Adults Advice 52.7 41.6 11.1 Physical Activity in Older Adults Discussion 59.6 47.1 12.5 Osteoporosis Testing in Older Women 82.8 62.0 20.8 Osteoporosis Management in Women Who Had a Fracture 25.7 10.3 15.5 Glaucoma Screening in Older Adults 76.1 53.8 22.3 *Lower rates signify better performance.

184 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E RefERENCES AVOIdanCE of antibiotic treatment IN adults WITH ACutE bronchitis 1. Grijalva C.G., J.P. Nuorti, M. Griffin. 2009. Antibiotic prescription rates for acute respiratory tract infections in US ambulatory settings. JAMA. 302: 758 66. 2. Gonzales, R., et al. 2001. Principles of Appropriate Antibiotic Use for Treatment of Uncomplicated Acute Bronchitis: Background. Ann Intern Med. 134:521 9. 3. Irwin, R.S., et al. 2006. Diagnosis and Management of Cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest. 1S 292S. 4. Evertsen, J., D.J. Baumgardner, A. Regnery, I. Banerjee. 2010. Diagnosis and management of pneumonia and bronchitis in outpatient primary care practices. Prim Care Respir J. 19(3):237 41. 5. Centers for Disease Control and Prevention. 2010. Appropriate Antibiotic Use Saves lives, saves money, makes sense. http://www.cdc.gov/getsmart/healthcare/resources/factsheets/pdf/antibiotic-use.pdf (May 27, 2011) 6. Tan, T., et al. 2008. Antibiotic prescribing for self limiting respiratory tract infections in primary care: summary of NICE guidance. BMJ. 337:a437. 7. Steinman, M.A., A. Sauaia, J.H. Maselli, P.M. Houck, R. Gonzales. 2004. Office evaluation and treatment of elderly patients with acute bronchitis. J Am Geriatr Soc. 52(6):875 9. 8. Braman, S.S. 2006. Diagnosis and management of cough: ACCP Evidence-Based Clinical Practice Guidelines. Chest. 129:1S 23S. USE of IMagIng studies for lower back PAIN 1. American Association of Neurological Surgeons. June 2006. Low Back Pain. http://www.aans.org/patient%20information/ Conditions%20and%20Treatments/Low%20Back%20Pain.aspx (May 2011) 2. National Institute of Arthritis and Musculoskeletal and Skin Disease. July 2010. Back Pain. http://www.niams.nih.gov/health_info/ Back_Pain/default.asp (May 2011) 3. Manek, N.J., A.J. MacGregor. 2005. Epidemiology of Back Disorders: Prevalence, Risk Factors, and Prognosis. Current Opinion in Rheumatology, 17(2): 134 40. 4. Koes, B.W., M.W. van Tulder, S. Thomas. 2006. Diagnosis and Treatment of Low Back Pain. BMJ 332(7555):1430 434. 5. Jarvik, J.G., W. Hollingworth, B. Martin, S.S. Emerson, D.T. Gray, T.S. Overman, et al. 2003. Rapid Magnetic Resonance Imaging vs Radiographs for Patients with Low Back Pain: a Randomized Controlled Trial. JAMA 289(21):2810 18. 6. ARHQ, U.S. Department of Health and Human Services, 2008. Medical Expenditure Panel Survey (MEPS). http://www.meps.ahrq.gov/mepsweb/data_stats/quick_tables_results.jsp?component=1&subcomponent=0&tableseries=2&year=- 1&SearchMethod=1&Action=Search. (May 2011). 7. Chou, R., A. Qaseem, D.K. Owens, P. Shekelle. 2011. Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Annals of Internal Medicine 154: 181 9. 8. Ivanova, J. I., H. G. Birnbaum, M. Schiller, E. Kantor, B.M. Johnstone, R.W. Swindle. May 19, 2011. Real-world Practice Patterns, Health-care Utilization, and Cost in Patients with Low Back Pain: The Long Road to Guideline-concordant Care. Spine Journal. ADULT BMI assessment 1. American Medical Association. 2011. Promoting Healthy Lifestyles: Obesity. http://www.ama-assn.org/ama/pub/physician-resources/ public-health/promoting-healthy-lifestyles/obesity.page (June 13, 2011) 2. Centers for Disease Control and Prevention. 2010. Overweight and Obesity: Defining Overweight and Obesity. http://www.cdc.gov/ obesity/defining.html (July 13, 2011) 3. National Heart Lung and Blood Institute. 2011. Assessing Your Weight and Health Risk. http://www.nhlbi.nih.gov/health/public/heart/ obesity/lose_wt/risk.htm (June 13, 2011) 4. Weight-control Information Network. 2010. Statistics Related to Overweight and Obesity. NIDDK and NIH. http://win.niddk.nih.gov/ statistics/index.htm (June 13, 2011) 5. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Causes and Consequences. http://www.cdc.gov/obesity/ causes/index.html (June 13, 2011) 6. RTI International. 2011. About RTI. http://www.rti.org/page.cfm/about_rti (June 22, 2011) 7. Finkelstein, E.A., J.G. Trogdon, J.W. Cohen and W. Dietz. Annual Medical Spending Attributable to Obesity: Payer and Service-Specific Estimates. 2009. Health Affairs. 28(5); w822 w831. 8. Weight-control Information Network. 2008. Understanding Adult Obesity. NIDDK and NIH. http://win.niddk.nih.gov/publications/ understanding.htm#consequences (June 13, 2011).

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 R e f E R E N C E S 185 FLU SHots for adults 1. Centers for Disease Control and Prevention. Seasonal Influence (Flu). Updated September 15, 2010. http://www.cdc.gov/flu/about/qa/ disease.htm (May 2011) 2. Centers for Disease Control and Prevention. Seasonal Flu Shot. Updated February 8, 2011. http://www.cdc.gov/flu/about/qa/flushot. htm#whoshould (July 2011) 3. Centers for Disease Control and Prevention. 2008. Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 57:1 60 4. Centers for Disease Control and Prevention. Key Facts About Influenza (Flu) & Flu Vaccine. Updated September 15, 2010. http://www.cdc.gov/flu/keyfacts.htm#preventingseasonal (May, 2011) 5. Nichol, K.L. 2003. The efficacy, effectiveness and cost-effectiveness of inactivated influenza virus vaccines. Vaccine 21(16):1769 75. 6. Centers for Disease Control and Prevention. National Immunization Survey: Summer 2007. http://www.cdc.gov/vaccines/stats-surv/nis/ downloads/nis-adult-summer-2007.pdf (May 2011) 7. Centers for Disease Control and Prevention. 2009. Influenza Vaccination Coverage Among Children and Adults United States, 2008 2009 Influenza Season. MMWR Morb Mortal Wkly Rep 58(39): 1091 5. 8. National Foundation for Infectious Diseases. Facts About Influenza for Adults. Updated January 2010. http://www.nfid.org/pdf/ factsheets/influadult.pdf (May 2011) 9. Maciosek, M.V., L.I. Solberg, A.B. Coffield, N.M. Edwards, M.J. Goodman. Influenza vaccination health impact and cost effectiveness among adults aged 50 to 64 and 65 and older. Am J Prev Med 2006; 31(1):72 9. 10. Akazawa, M., J.L. Sindelar, A.D. Paltiel. 2003. Economic costs of influenza-related work absenteeism. Value Health 6(2):107 15. PREnatal and PostPartuM CarE & frequency of ongoing PREnatal CarE 1. Agency for Healthcare Research and Quality (AHRQ). 2011. Complicating Conditions of Pregnancy and Childbirth, 2008: Statistical Brief. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb113.pdf (June 6, 2011) 2. Centers for Disease Control and Prevention. Reproductive Health: Data and Statistics. http://www.cdc.gov/reproductivehealth/data_ Stats/index.htm (June 6, 2011) 3. Health Resources and Services Administration. Maternal Morbidity and Risk Factors in Pregnancy. http://mchb.hrsa.gov/whusa10/hstat/ mh/pages/236mmrfp.html (June 6, 2011) 4. Collins, J.L., J. Lehnherr, S.F. Posner, K.E. Toomey. 2009.Ties That Bind: Maternal and Child Health and Chronic Disease Prevention at the Centers for Disease Control and Prevention. http://www.cdc.gov/pcd/issues/2009/jan/08_0233.htm (June 6, 2011) 5. Weir, S., H.E. Posner, J. Zhang, G. Willis, J.D. Baxter, R.E. Clark. Predictors of Prenatal and Postpartum Care Adequacy in a Medicaid Managed Care Population. http://www.sciencedirect.com/science/article/pii/s1049386711000454 (June 6, 2011) 6. Dietz P.M., K.K. Vesco, W.M. Callaghan, D.J. Bachman, F.C. Bruce, C.J. Berg, et al. 2008. Postpartum screening for diabetes after a gestational diabetes mellitus-affected pregnancy. Obstetrics & Gynecology 112(4):868 74. 7. Deave, T., J. Heron, J. Evans, A. Emond. 2008. The impact of maternal depression in pregnancy on early child development. International Journal of Obstetrics and Gynaecology 115(8):1043 51. 8. Vintzileos, A., C. Ananth, J.C. Smulian, W.E. Scorza, R.A. Knuppel. 2002. The Impact of Prenatal Care on Post-Neonatal Deaths in the Presence and Absence of Antenatal High-risk Conditions. American Journal of Obstetrics and Gynecology; 187(5): 1258 62. 9. March of Dimes Foundation. PeriStats: Distribution of Prenatal Care Adequacy Categories. http://www.marchofdimes.com/peristats/ (June 2011) 10. Agency for Healthcare Research and Quality. Health Care Innovations Exchange: Group Visits Focused on Prenatal Care and Parenting Improve Birth Outcomes and Provider Efficiency. http://www.innovations.ahrq.gov/content.aspx?id=1909 (June 2011) BREast CanCER SCREENIng 1. BreastCancer.org. 2011. U.S. Breast Cancer Statistics. http://www.breastcancer.org/symptoms/understand_bc/statistics.jsp (June 10, 2011) 2. American Cancer Society. 2011. Cancer Facts & Figures 2011. http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/ documents/document/acspc-026238.pdf (May 29, 2011) 3. Mandelblatt J.S., K.A. Cronin, S. Bailey, D.A. Berry, H.J. de Koning, G. Draisma, et al. 2009. Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern Med. 151:738 47. 4. BreastCancer.org. 2011. Facts and Figures about Breast Cancer http://www.breastcancer.org/about_us/press_room/facts_figures.jsp (June 10, 2011) 5. National Business Group on Health. 2011. Pathways to Managing Cancer in the Workplace. http://www.businessgrouphealth.org/pdfs/ FINAL_Pathways_Managing_Cancer_2011.pdf (June 10, 2011) 6. Screening for Breast Cancer: An Update for the U.S. Preventive Services Task Force. 2009. Annals of Internal Medicine.151:738 47. http://www.annals.org/content/151/10/727.full.pdf+html (May 29, 2011) 7. American Cancer Society. 2010. Breast cancer facts and figures 2010-2011. http://www.cancer.org/acs/groups/content/@nho/ documents/document/f861009final90809pdf.pdf (May 29, 2011)

186 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E CErvICal CanCER SCREENIng 1. American Cancer Society. 2011. Cancer Prevention & Early Detection Facts & Figures 2011. http://www.cancer.org/acs/groups/ content/@epidemiologysurveilance/documents/document/acspc-029459.pdf (May 29, 2011) 2. Myers, E. 2008. The current and future role of screening in the era of HPV vaccination. Gynecologic Oncology 109.2.S31. 3. National Cervical Cancer Collation. Early Detection. http://www.nccc-online.org/health_news/early_detection.html (June 10, 2011) 4. Centers for Disease Control and Prevention. 2010. Cervical Cancer. http://www.cdc.gov/cancer/cervical/pdf/cervical_fs_0510.pdf (June 10, 2011) ColorECtal CanCER SCREENIng 1. National Cancer Institute. SEER Statistical Fact Sheets: Colon and Rectum. http://seer.cancer.gov/statfacts/html/colorect.html (May 2011) 2. American Cancer Society. Cancer Facts and Figures 2010. http://www.cancer.org/acs/groups/content/@nho/documents/document/ acspc-024113.pdf (May 2011) 3. U.S. Preventive Services Task Force. Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. AHRQ Publication 08-05124-EF-3, October 2008. http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm 4. Redaelli, A., C.W. Cranor, G.J. Okano, P.R. Reese. 2003. Screening, prevention and socioeconomic costs associated with the treatment of colorectal cancer. Pharmacoeconomics 21(17):1213 38. 5. American Cancer Society. Colorectal Cancer. What are the survival rates for colorectal cancer by state? http://www.cancer.org/cancer/ ColonandRectumCancer/DetailedGuide/colorectal-cancer-survival-rates (May 2011) 6. American Cancer Society. Colorectal Cancer. What are the risk factors for colorectal cancer? http://www.cancer.org/cancer/ ColonandRectumCancer/DetailedGuide/colorectal-cancer-risk-factors. (May 2011) 7. Centers for Disease Control and Prevention. National Health Interview Survey. http://www.cdc.gov/nchs/nhis.htm (May 2011) 8. Whitlock, E.P., J.S. Lin, E. Liles, et al. 2008. Screening for colorectal cancer: A targeted, updated systematic review for the U.S. Preventive Services Task Force. Annals 149: 638 58. 9. Rozen, P. 2004. Cancer of the gastrointestinal tract: early detection or early prevention? Eur J Cancer Prev 13(1):71 5. 10. National Cancer Institute. A Snapshot of Colorectal Cancer. http://www.cancer.gov/aboutnci/servingpeople/snapshots/colorectal.pdf (May 2011) 11. Centers for Disease Control and Prevention. Vital Signs: Colorectal Cancer Screening, Incidence, and Mortality United States, 2002 2010. July 8, 2011. Morbidity and Mortality Weekly Report (MMWR) 60(26): 844 89. http://www.cdc.gov/mmwr/preview/ mmwrhtml/mm6026a4.htm?s_cid=mm6026a4_w (July 2011) 12. Frazier, A., G.A. Colditz, C.S. Fuchs, K.M. Kuntz. 2000. Cost-effectiveness of screening for colorectal cancer in the general population. Journal of the American Medical Association, 284(15): 1954 61. 13. Beydoun, H.A., M.A. Beydoun. 2008. Predictors of colorectal cancer screening behaviors among average-risk older adults in the United States. Cancer Causes Control 19:339 59. CHlaMydIA SCREENIng IN WOMEN 1. Centers for Disease Control and Prevention. 2011. Sexually Transmitted Diseases: Chlamydia CDC Fact Sheet. http://www.cdc.gov/std/ chlamydia/stdfact-chlamydia.htm (June 2, 2011) 2. National Chlamydia Coalition. 2010. Research Briefs: Developments in STD Screening: Chlamydia Testing. 2010 Series, No.1. http://www.prevent.org/data/files/ncc/research%20brief%201%20std%20testing.pdf (June 2, 2011) 3. Centers for Disease Control and Prevention. 2010. Public Health Grand Rounds. Presentation: Chlamydia Prevention: Challenges and Strategies for Reducing Disease Burden. http://www.cdc.gov/about/grand-rounds/archives/2010/05-may.htm (June 2, 2011) 4. U.S. Preventive Services Task Force. June 2007. Screening for Chlamydia Infection. http://www.uspreventiveservicestaskforce.org/uspstf/ uspschlm.htm (June 2, 2011) 5. Centers for Disease Control and Prevention. 2011. Sexually Transmitted Diseases: Pelvic Inflammatory Disease (PID) CDC Fact Sheet. http://www.cdc.gov/std/pid/stdfact-pid.htm (June 27, 2011) 6. National Business Group on Health. 2011. Chlamydia (Screening). http://www.businessgrouphealth.org/preventive/topics/chlamydia. cfm (June 6, 2011) 7. Centers for Disease Control and Prevention. 2010. Sexually Transmitted Diseases (STDs): Chlamydia Treatment. http://www.cdc.gov/std/ chlamydia/treatment.htm (June 6, 2011) 8. The American Congress of Obstetricians and Gynecologists (ACOG). 2007. Spotlight on Chlamydia: Annual Screenings a Must for Young Women. http://www.acog.org/from_home/publications/press_releases/nr05-08-07-1.cfm (June 2, 2011)

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 R e f E R E N C E S 187 MEDICal assistance WITH SMokIng and tobacco use CEssatIon 1. Centers for Disease Control and Prevention. 2008. Smoking Attributable Mortality, Years of Potential Life Lost, and Productivity Losses United States, 2000-2004. MMWR 57(45): 1226 228. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm#tab 2. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System: Nationwide 2009 Data. Adults Who Are Current Smokers. http://apps.nccd.cdc.gov/brfss/page.asp?cat=tu&yr=2009&state=ub#tu (May 2011) 3. Office of the Surgeon General. 2004. The Health Consequences of Smoking: A Report of the Surgeon General. Department of Health and Human Services. Updated 2004. http://www.cdc.gov/tobacco/data_statistics/sgr/2004/complete_report/index.htm (March 17, 2010) 4. American Lung Association. General Smoking Facts. 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The direct and indirect costs of employee depression, anxiety, and emotional disorders An employer case study. J of Occ and Envt Med. 51(5):564 77. 7. Birnbaum, H.G., Kessler, R.C., Kelley, D., Ben-Hamadi, R., Joish, V.N., Greenberg, P.E. 2010. Employer burden of mild, moderate, and severe major depressive disorder: mental health services utilization and costs, and work performance. Depression and Anxiety. 27(1):78 89. 8. Wang, J., N. Schmitz N. 2010. Does job strain interact with psychosocial factors outside of the workplace in relation to the risk of major depression? The Canadian National Population Health Survey. Soc. Psychiatry. [Epub ahead of print]. 9. American Psychiatric Association. 2010 Practice guideline for the treatment of patients with major depressive disorder. Third edition. http://www.guideline.gov/content.aspx?id=24158 (May 31, 2011) 10. Lauber, C., J.L. Bowen. 2010. Low mood and employment: when affective disorders are intertwined with the workplace a UK perspective. Int. Rev. Psychiatry. 22(2):173 82. 11. Hunot, V.M., R. Horne, M.N. Leese, R.C. Churchill. 2007. A cohort study of adherence to antidepressants in primary care: the influence of antidepressant concerns and treatment preferences. Prim Care Companion J Clin Psychiatry. 9:91 9.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 R e f E R E N C E S 191 FOLLOW-UP after HosPItalIZatIon for MEntal IllnEss 1. Kessler R.C., W.T. Chiu, O. Demler, E.E. Walters. 2005. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry 62(6):617 27. 2. The Substance Abuse and Mental Health Services Administration. 2008. Serious Mental Illness Among Adults http://oas.samhsa. gov/2k2/smi/smi.cfm (June 10, 2011) 3. Mental Health: A Report of the Surgeon General Chapter 1: Introduction and Themes. http://www.surgeongeneral.gov/library/ mentalhealth/chapter1/sec1.html (June 10, 2011) 4. National Alliance on Mental Illness. 2011. What is Mental Illness: Mental Illness Facts. http://www.nami.org/template. cfm?section=about_mental_illness (June 10, 2011) 5. Larkin, G.L., R.P. Smith, A.L. Beautrais. 2008. Trends in U.S. emergency department visits for suicide attempts, 1992 2001. Crisis 29(2):73 80. 6. Cougnard, A., M. Parrot, S. Grolleau, E. Kalmi, A. Desage, D. Misdarhi, et al. 2006. Pattern of health service utilization and predictors of readmission after a first admission for psychosis: a 2-year-follow-up study. Acta Psychiatr Scand 113(4):340 9. 7. Insel, Thomas R. 2008. Assessing the Economic Costs of Serious Mental Illness. The Am J Psychiat http://ajp.psychiatryonline.org/cgi/ reprint/165/6/663 (June 10, 2011) 8. National Alliance on Mental Illness. 2011. The Impact and Cost of Mental Illness: The Case of Depression. http://www.nami.org/ Template.cfm?Section=Policymakers_Toolkit&Template=/ContentManagement/ContentDisplay.cfm&ContentID=19043 (June 10, 2011) 9. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2008. Results from the 2008 National Survey on Drug Use and Health: National Finding. NSDUH Series H-34, DHHS Publication No. SMA 08-4343. Rockville, MD. http://oas.samhsa.gov/nsduh/2k8nsduh/2k8results.pdf (June 10, 2011) 10. DeFrances, C.J., M.J. Hall. 2007. National Hospital Discharge Survey. Advance data from vital and health statistics. No. 385. http:// www.cdc.gov/nchs/data/ad/ad385.pdf (June 10, 2011) INITIatIon and EngagEMEnt of alcohol and other drug DEPEndENCE treatment 1. Substance Abuse and Mental Health Services Administration (SAMHSA). 2009. Results from the 2009 National Survey on Drug Use and Health. http://oas.samhsa.gov/nsduh/2k9nsduh/2k9results.htm (June 10, 2011) 2. National Institute on Drug Abuse (NIDA). 2011. NIDA InfoFacts: Nationwide Trends. http://www.drugabuse.gov/pdf/infofacts/ NationTrends.pdf (June 10, 2011) 3. Frederic, C.B., S.J. Bartels, L.M. Brockmann, A.D. Van Citters. 2010. Evidence-Based Practices for Preventing Substance Abuse and Mental Health Problems in Older Adults. Excerpt: Prevention of Substance Misuse Problems: Alcohol Misuse. www.public-health.uiowa. edu/icmha/.../evidence-basedcareforalcohol.doc (June 10, 2011) 4. National Institute on Drug Abuse. 2010. Monitoring the Future: National results on adolescent drug use. http://monitoringthefuture.org/ pubs/monographs/mtf-overview2010.pdf 5. Keyes, K.M., M.L. Hatzenbuehler, K.A. McLaughlin, B. Link, M. Olfson, B.F. Grant. 2010. Stigma and Treatment for Alcohol Disorders in the United States. American Journal of Epidemiology 172 (12): 1364 72. 6. National Institute on Drug Abuse. 2010. Comorbidity: Addiction and Other Mental Illnesses. http://www.drugabuse.gov/pdf/ RRComorbidity.pdf (June 10, 2010) 7. Substance Abuse and Mental Health Services Administration (SAMHSA). 2006. Report to Congress: Addictions Treatment Workforce Development. http://www.pfr.samhsa.gov/docs/report_to_congress.pdf (June 10, 2010) APProPRIatE TEstIng for CHIldrEN WITH PHaryngITIS 1. Wisconsin Department of Health Services. 2010. Disease Fact Sheet Series: Streptococcal Pharyngitis. http://www.dhs.wisconsin.gov/ communicable/factsheets/streptococcalpharyngitis.htm (May 31, 2011) 2. Huhtala, T.A. 2011. Updates on Sinusitis, Pharyngitis and UTI. February 27 March 4, Salt Lake City, Utah. 3. Wessels, M.R. 2011. Streptococcal Pharyngitis. New England Journal of Medicine 364: 648 55. 4. Gerber, M.A., R.S. Baltimore, C.B. Eaton, M. Gewitz, A.H. Rowley, S.T. Shulman, K.A. Taubert. 2009. Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis: A Scientific Statement From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed by the American Academy of Pediatrics. Circulation 119: 1541 51. 5. Lee, G.M., J.A. Salomon, C. Gay, J.K. Hammitt. 2010. Preferences for health outcomes associated with Group A Streptococcal disease and vaccination. Health and Quality of Life Outcomes 8:28. 6. Undeland, D.K., T.J. Kowalski, W.L. Berth, J.D. Gundrum. 2010. Appropriately Prescribing Antibiotics for Patients with Pharyngitis: A Physician-Based Approach vs a Nurse-Only Triage and Treatment Algorithm. Mayo Clin Proc 85(11): 1011 15. 7. Pfoh, E., M.R. Wessels, D. Goldmann, G.M. Lee. 2008. Burden and Economic Cost of Group A Streptococcal Pharyngitis. Pediatrics 121(2): 229 34. 8. Ayanruoh, S., M. Waseem, Frances Quee, Alyssa Humphrey, Toussaint Reynolds. 2009. Impact of Rapid Streptococcal Test on Antibiotic Use in a Pediatric Emergency Department. Pediatric Emergency Care 25(11): 748 50.

192 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E WEll-CHIld VISIts IN THE FIrst 15 MontHS of LIFE and IN THE THIrd, fourth, FIftH and SIxtH YEars of LIFE 1. Child Trends Data Bank. 2010. Well-Child Visits. http://www.childtrendsdatabank.org/?q=node/85 (June 2011) 2. Brown, B., M. Weitzman, et al., The Commonwealth Fund. Early Child Development in Social Context: A Chartbook. http://www.commonwealthfund.org/content/publications/chartbooks/2004/sep/early-child-development-in-social-context--a- Chartbook.aspx (June 2011) 3. National Institutes of Health Medline Plus. Well-child Visits. Updated January 17, 2011. http://www.nlm.nih.gov/medlineplus/ency/ article/001928.htm (June 2011) 4. Chung, P.J., T.C. Lee, J.L. Morrison, M.A. Schuster. 2006. Preventive Care for Children in the United States: Quality and Barriers. Annual Review of Public Health; 27: 491 515. 5. National Survey of Children s Health. NSCH 2007. Child and Adolescent Health measurement Initiative, Data Resource Center for Child and Adolescent Health. http://nschdata.org (June 2011) 6. Hakim, R.B., D.S. Ronsaville. 2002. Effect of Compliance with Health Supervision Guidelines Among U.S. Infants on Emergency Department Visits. Archives of Pediatric and Adolescent Medicine; 156: 1015 20. 7. Rosenberg, S.A., D. Zhang, C.C. Robinson. 2008. Prevalence of Developmental Delays and participation in Early Intervention Services for Young Children. Pediatrics; 121(6): e1503 e1509. 8. Sice, L. The Commonwealth Fund. 2007. Developmental Screening in Primary Care: The Effectiveness of Current Practice and Recommendations for Improvement. http://www.commonwealthfund.org/usr_doc/1082_sices_developmental_screening_primary_care. pdf?section=4039 (June 2011) 9. Honeycutt, A.A., S.D. Grosse, L.J. Dunlap et al. 2003. Economic Costs of Mental Retardation, Cerebral Palsy, Hearing Loss, and Vision Impairment. In B.M. Altman, S.N. Barnett, G.E. Hendershot, S.A. Larson, eds., Using Survey Data to Study Disability: Results from the National Health Interview Survey on Disability, Vol. 3. Amsterdam: Elsevier, 207 28. ADOLESCEnt WEll-CarE VISIts 1. National Quality Measures Clearinghouse. Adolescent Well-care Visits. http://www.qualitymeasures.ahrq.gov/content.aspx?id=15051 (June 2011) 2. American Medical Association. Guidelines for Adolescent Preventive Services: Recommendations Monograph. http://www.ama-assn. org//resources/doc/ad-hlth/gapsmono.pdf (June 2011) 3. American Academy of Pediatrics. 2008. Achieving Quality Health Services for Adolescents. Pediatrics. 121(6):1263 270. 4. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance: Tobacco Use. http://apps.nccd.cdc.gov/youthonline/app/ Default.aspx (June 2011) 5. National Institutes of Health. PubMed Health: Obesity. Updated October 12, 2010. http://www.ncbi.nlm.nih.gov/pubmedhealth/ PMH0004552/ (June 2011) 6. American Academy of Pediatrics. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition. http://brightfutures.aap.org/pdfs/preventive%20services%20pdfs/forward%20and%20introduction.pdf (June 2011) 7. Irwin, C.E., Jr., S.H. Adams, M.J. Park, P.W. Newacheck. 2009. Preventive Care For Adolescents: Few Get Visits and Fewer Get Services. Pediatrics. 123(4): e565 72. 8. Finkelstein, E.A., P.S. Corso, T.R. Miller. 2006. Incidence and Economic Burden of Injuries in the United States. New York: Oxford University Press 9. Park, M.J., T.M. Macdonald, E.M. Ozer, et al., 2001. Investing in Clinical Preventive Health Services for Adolescents. University of California, San Francisco 10. Health Resources and Services Administration. Child Health USA 2010. http://www.mchb.hrsa.gov/chusa10/hstat/hsa/pages/200hsa. html (June 2011) CHIldrEN and adolescents ACCEss to PRIMary CarE PraCTITIonErs 1. American Academy of Pediatrics. Scope of Health Care Benefits for Children From Birth Through Age 21. http://aappolicy. aappublications.org/cgi/reprint/pediatrics;117/3/979.pdf (June 2011) 2. Hensley-Quinn, M., E. Osius. National Academy for State Health Policy. 2008. SCHIP and Adolescents: An Overview and Opportunities for States. http://www.nashp.org/sites/default/files/shpbriefing_adolescents.pdf (June 2011) 3. Starfield, B., L. Shi, J. Macinko. 2005. Contribution of Primary Care to Health Systems and Health. Milbank Quarterly. 83(3): 457 502. 4. Chung, P.J., T.C. Lee, J.L. Morrison, M.A. Schuster. 2006. Preventive Care for Children in the United States: Quality and Barriers. Annual Review of Public Health. 27: 491 515. 5. National Survey of Children s Health (NSCH). 2007. Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health. http://nschdata.org (June 2011) 6. Chipman, S.A., J. Lan, C. Chang, D.C. Goodman. 2010. Geographic Maldistribution of Primary Care for Children. Pediatrics. 127(6): e1626. 7. Friedberg, M.W., P.S. Hussey, E.C. Schneider. 2010. Primary Care: A Critical Review of the Evidence on Quality and Costs of Health Care. Health Affairs. 29(5): 766 72. 8. Bodenheimer and Fernandez. 2005. High and Rising Health Care Costs. Part 4: Can Costs Be Controlled While Preserving Quality? Ann Intern Med. 143:26 31.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 R e f E R E N C E S 193 9. American Academy of Pediatrics. 2008. Achieving Quality Health Services for Adolescents. Pediatrics. 121(6):1263 270. 10. American Academy of Pediatrics. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd Edition. http://brightfutures.aap.org/pdfs/preventive%20services%20pdfs/forward%20and%20introduction.pdf (June 2011) FOLLOW-UP CarE for CHIldrEN PRESCRIBED adhd MEDICatIon 1. Visser, S.N., R.H. Bitsko, M.L. Danielson, R. Perou, S.J. Blumberg. 2010. Increasing Prevalence of Parent-Reported Attention-Deficit/ Hyperactivity Disorder Among Children - United States, 2003 and 2007. Morbidity and Mortality Weekly Report. 59(44):1439 43. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm?s_cid=mm5944a3_w (June 10, 2011) 2. Centers for Disease Control and Prevention. 2010. Attention-Deficit / Hyperactivity Disorder (ADHD) Symptoms and Diagnosis. http://www.cdc.gov/ncbddd/adhd/diagnosis.html (June 10, 2011) 3. Centers for Disease Control and Prevention. 2010. Attention-Deficit / Hyperactivity Disorder (ADHD) Other Concerns & Conditions. http://www.cdc.gov/ncbddd/adhd/conditions.html (June 10, 2011) 4. Guevara, J., P. Lozano, T. Wickizer, L. Mell, H. Gephart. 2002. Psychotropic medication use in a population of children who have attention-deficit/hyperactivity disorder. Pediatrics. 109(5):733 9. 5. National Institutes of Health Fact Sheet. 2011. Attention Deficit Hyperactivity Disorder (ADHD). http://report.nih.gov/nihfactsheets/ ViewFactSheet.aspx?csid=25&key=A#A (June 10, 2011) 6. Pelham, W.E, E.M. Foster, J.A. Robb. 2007. The economic impact of attention-deficit/hyperactivity disorder in children and adolescents. J Pediatr Psychol. 32(6):711 27. 7. Matza, L.S., C. Paramore, M. Prasad. 2005. A review of the economic burden of ADHD. Cost Eff Resour Alloc. 3:5. 8. Brown, R.T., R.W. Amler, W.S. Freeman, J.M. Perrin, M.T. Stein, H.M. Feldman, K. Pierce, M.L. Wolraich. 2005. Treatment of Attention- Deficit/Hyperactivity Disorder: Overview of the Evidence. Pediatrics. 115(6):e749 57. APProPRIatE treatment for CHIldrEN WITH UPPER RESPIratory InfECTIon 1. Hart, A.M. 2007. An Evidence-Based Approach to the Diagnosis and Management of Acute Respiratory Infections. Journal for Nursing Practitioners 3(9): 607 11. 2. Lucile Packard Children s Hospital at Stanford. 2011. Upper Respiratory Infection (URI, or Common Cold). http://www.lpch.org/ DiseaseHealthInfo/HealthLibrary/respire/uricold.html (June 1, 2011) 3. Wong, D.M., D.A. Blumberg, L.G. Lowe. 2006. Guidelines for the Use of Antibiotics in Acute Upper Respiratory Tract Infections. Am Fam Physician 74(6): 956 66. 4. Centers for Disease Control and Prevention. 2011. Get Smart: Know When Antibiotics Work. Facts About Antibiotic Resistance. http:// www.cdc.gov/getsmart/antibiotic-use/fast-facts.html#ref2 (May 26, 2011) 5. Ong, S., J. Nakase, G.J. Moran, D.J. Karras, M.J. Kuehnert, D.A. Talan. 2007. Antibiotic Use for Emergency Department Patients with Upper Respiratory Infections: Prescribing Practices, Patient Expectations, and Patient Satisfaction. Ann Emerg Med 50: 213 20. 6. Fendrick, A.M., A.S. Monto, B. Nightengale, M. Sarnes. 2003. The Economic Burden of Non-Influenza-Related Viral Respiratory Tract Infection in the United States. Arch Intern Med 163: 487 94. 7. Linder, J.A. 2007. Improving Care for Acute Respiratory Infections: Better Systems, Not Better Microbiology. Clin Infect Dis 45(9): 1189 91. 8. Friedman, B., D. Schwabe-Warf, R. Goldman. 2011. Reducing inappropriate antibiotic use among children with influenza infection. Can Fam Physician 57(1): 42 4. CHIldHood IMMunIZatIon status 1. Centers for Disease Control and Prevention. 2009. Vaccines & Immunizations: How Vaccines Prevent Disease. http://www.cdc.gov/ vaccines/vac-gen/howvpd.htm (June 1, 2011) 2. Centers for Disease Control and Prevention. 2011. Vaccines & Immunizations: Infants and Toddlers. http://www.cdc.gov/vaccines/specgrps/infants-toddlers.htm (June 1, 2011) 3. Centers for Disease Control and Prevention. 2010. Vaccines & Immunizations: 10 Things You Need to Know About Immunizations. http:// www.cdc.gov/vaccines/vac-gen/10-shouldknow.htm (June 6, 2011) 4. Centers for Disease Control and Prevention. 2011. General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report (MMWR). January 28, 2011. 60(RR02);1 60. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm?s_cid=rr6002a1_e 5. American Academy of Pediatrics. Children s Health Topics: Immunizations/Vaccines. http://www.aap.org/healthtopics/immunizations. cfm (June 6, 2011) 6. HealthyChildren. American Academy of Pediatrics. 2011. Safety & Prevention: Why Immunize Your Child. http://www.healthychildren. org/english/safety-prevention/immunizations/pages/why-immunize-your-child.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=error%3a+no+local+token (June 1, 2011) 7. Immunization Action Coalition. 2010. Vaccines work! CDC statistics demonstrate dramatic declines in vaccine-preventable diseases when compared with the pre-vaccine era. http://www.immunize.org/catg.d/p4037.pdf (June 6, 2011)

194 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E 8. Zhou, F. Updated economic evaluation of the routine childhood immunization schedule in the United States. Presented at the 45th National Immunization Conference. Washington, DC; March 28 31, 2011. 9. Centers for Disease Control and Prevention. 2011. Ten Great Public Health Achievements United States, 2001 2010. MMWR Morbidity and Mortality Weekly Report May 20, 2011. 60(19):619-623. 10. Kennedy, A., M. Basket, K. Sheedy. 2011. Identifying and Addressing Vaccine-Safety Concerns Among Parents: Vaccine Attitudes, Concerns, and Information Sources Reported by Parents of Young Children: Results From the 2009 HealthStyles Survey. Pediatrics 2011; 127 (Suppl 1):S92 S99. 11. Centers for Disease Control and Prevention. 2011. Vaccines & Immunizations. Statistics and Surveillance: U.S. Vaccination Coverage Reported via NIS. http://www.cdc.gov/vaccines/stats-surv/nis/default.htm#nis (July 12, 2011) 12. U.S. National Library of Medicine. MedlinePlus. 2011. Childhood Immunization. http://www.nlm.nih.gov/medlineplus/ childhoodimmunization.html (June 6, 2011) IMMunIZatIons for adolescents 1. American Medical Association. 2008. Improving Adolescent Immunizations. http://www.ama-assn.org/resources/doc/public-health/ ad_immunizations_mon.pdf (June 8, 2011) 2. Centers for Disease Control and Prevention. 2011. Preteen and Teen Vaccines: For Parents. http://www.cdc.gov/vaccines/who/teens/ for-parents.html (June 7, 2011) 3. Centers for Disease Control and Prevention. 2011. Preteen and Teen Vaccines: Tdap Vaccine for Preteens and Teens. http://www.cdc. gov/vaccines/who/teens/vaccines/tdap.html (June 8, 2011) 4. Immunization Action Coalition. 2010. Vaccines work! CDC statistics demonstrate dramatic declines in vaccine-preventable diseases when compared with the pre-vaccine era. http://www.immunize.org/catg.d/p4037.pdf (June 6, 2011) 5. National Foundation for Infectious Diseases. 2009. Adolescent Vaccination. 10 Reasons To Be Vaccinated. http://www.adolescentvaccination. org/ten_reasons.htm (June 9, 2011) 6. Broder, K.R., A.C. Cohn, B. Schwartz, J.D. Klein, M.M. Fisher, D.B. Fishbein, C. Mijalski, G.B. Burstein, M.E. Vernon-Smiley, M.M. McCauley, C.J. Wibbelsman. 2008. Adolescent Immunizations and Other Clinical Preventive Services: A Needle and a Hook? Pediatrics 121(Suppl 1):S25 S34. 7. Lee, G.M., S.A. Lorick, E. Pfoh, K. Kleinman, D. Fishbein. Adolescent Immunizations: Missed Opportunities for Prevention. 2008. Pediatrics 122(4):711 17. Lead screening in CHIldren 1. Needleman, H.L. 2004. Lead poisoning. Annual Review of Medicine 55:209 22. 2. Environmental Protection Agency. Lead in Paint, Dust, and Soil: Health effects of lead. http://www.epa.gov/lead/pubs/leadinfo. htm#health (May 2011) 3. General Lead Information. National Center for Environmental Health http://www.cdc.gov/nceh/lead/ (May, 2011) 4. United States Preventive Services Task Force (USPSTF). 1996. Chapter 23, Screening for Elevated Lead Levels in Childhood and Pregnancy. Guide to Clinical Preventive Services. Second Edition. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hscps2ed1996& part=a12872 (March 9, 2009) 5. Lustberg, M., E. Silbergeld. Blood lead levels and mortality. 2002. Arch Intern Med Nov 25;162(21):2443 9. 6. Lead: Prevention Tips. National Center for Environmental Health. Updated June 2009. http://www.cdc.gov/nceh/lead/tips.htm (May 2011) 7. Trasande, L., Y. Liu. Reducing The Staggering Costs of Environmental Disease in Children. 2011. Health Affairs, 30(5): 863 70. 8. Jones, et al. 2009. Trends in Blood Lead Levels and Blood Lead Testing Among US Children Aged 1 to 5 Years, 1988 2004. Pediatrics March; 123(3):e376 85. WEIGHT assessment and CounsELIng for nutrition and PHysICal ACTIVIty for CHIldrEN/adolESCEnts 1. American Academy of Pediatrics. Prevention and Treatment of Childhood Overweight and Obesity: About Childhood Obesity. http://www.aap.org/obesity/about.html (June 9, 2011) 2. National Child Care Information and Technical Assistance Center. 2010. Childhood Obesity Prevention. http://nccic.acf.hhs.gov/ poptopics/childobesity.html (June 9, 2011) 3. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Data and Statistics. http://www.cdc.gov/obesity/ childhood/data.html (June 9, 2011) 4. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Causes and Consequences. http://www.cdc.gov/obesity/ causes/index.html (June 9, 2011) 5. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Basics About Childhood Obesity. http://www.cdc.gov/ obesity/childhood/basics.html (June 9, 2011) 6. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Economic Consequences. http://www.cdc.gov/obesity/ causes/economics.html (July 12, 2011)

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 R e f E R E N C E S 195 7. Finkelstein, E.A., J.G. Trogdon, J.W. Cohen, W. Dietz. 2009. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 28(5): w822 w831. 8. Centers for Disease Control and Prevention. 2011. Overweight and Obesity: Basics About Childhood Obesity. http://www.cdc.gov/ obesity/childhood/basics.html (June 9, 2011) FALL RIsk ManagEMEnt 1. American Occupational Therapy Association. 2010. Analysis of Medicare Policy in Relation to Preventing Falls Among Older Adults. http://www.aota.org/practitioners/practiceareas/aging/falls/key/analysis.aspx (May 27, 2011) 2. American Geriatrics Society. 2010. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. http://www.americangeriatrics.org/files/documents/health_care_pros/jags.falls. Guidelines.pdf. (May 27, 2011) 3. Centers for Disease Control and Prevention. 2010. Falls Among Older Adults: An Overview. http://www.cdc.gov/ HomeandRecreationalSafety/Falls/adultfalls.html (May 27, 2011) 4. Centers for Disease Control and Prevention. 2008. Self-Reported Falls and Fall-Related Injuries Among Persons Aged >65 Years United States. Morb Mortal Wkly Rep 57(09);225 9. 5. Business Group on Health. 2011. Injuries from Falls: Fact Sheet. http://www.businessgrouphealth.org/pdfs/04811%20nbgh%20 InjuryPrevnt%20FactSheet_FALLS.pdf (May 27, 2011) 6. Centers for Disease Control and Prevention. 2011. Cost of Fall Injuries in Older Persons in the United States. http://www.cdc.gov/ HomeandRecreationalSafety/falls/data/cost-estimates.html (May 27, 2011) 7. Centers for Disease Control and Prevention. 2011. Cost of Fall Injuries in Older Persons in the United States. http://www.cdc.gov/ HomeandRecreationalSafety/falls/data/cost-estimates.html (May 27, 2011) MEDICatIon IN THE EldErly 1. Budnitz, D., et al. 2006. National surveillance of emergency department visits for outpatient adverse drug events. JAMA 296:1858 66. 2. Zhan, C., et al. 2001. Potentially inappropriate medication use in the community-dwelling elderly. JAMA 286(22):2823 68. 3. Beers, M.H. 1997. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med 157:1531 6. 4. Rothberg, M.B., P.S. Pekow, F. Liu, et al. 2008. Potentially inappropriate medication use in hospitalized elders. J Hosp Med 3(2):91 102. 5. Fick, D.M., et al. 2003. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med 163:2716 24. 6. Fick, D.M., L.C. Mion, M.H. Beers, J.L. Waller. 2008. Health Outcomes Associated With Potentially Inappropriate Medication Use in Older Adults. Res Nurs Health 31(1):42 51. 7. Fu, A.Z., J.A. Jiang, J.H. Reeves, J.E. Fincham, G.G. Liu, M. Perri. 2007. Potentially inappropriate medication use and healthcare expenditures in the US community-dwelling elderly. Med Care 45:472 476. 8. Jano, E., R. Aparaus. 2007. Healthcare Outcomes Associated with Beers Criteria: A Systematic Review. Ann Pharmacother 41:438 48. 9. The American Geriatrics Society (AGS) and British Geriatrics Society (BGS). Panel on the Clinical Practice Guideline for the Prevention of Falls in Older Persons. Clinical practice guideline: Prevention of falls in older persons. http://www.americangeriatrics.org/health_care_ professionals/clinical_practice/clinical_guidelines_recommendations/2010/ (June 2, 2011) 10. Flores, E.K., R. Henry, D.W. Stewart. 2011. Pharmacist s Role in an Interdisciplinary Falls Clinic. SouthMed J 104(2):143 6. 11. Hilmer, S.N., D.E. Mager, E.M. Simonsick, Y. Cao, S.M. Ling, G. Windham, T.B. Harris, J.T. Hanlon, S.M. Rubin, R.L. Shorr, et al. 2007. A drug burden index to define the functional burden of medications in older people. Arch Intern Med 167:781 7. ManagEMEnt of urinary INContINENCE IN older adults 1. DuBeau, C.E., G.A. Kuchel, T. Johnson, et al. 2009. Incontinence in the Frail Elderly. In: Incontinence, 4th ed. P. Abrams, L. Cardozo, S. Khoury, A. Wein. 961 1024. Plymouth, UK: Health Publication Ltd. 2. Morrison, A., R. Levy. 2006. Fraction of nursing home admissions attributable to urinary incontinence. Value Health 9(4):272. 3. Holroyd-Leduc, J.M., S.E. Straus. 2004. Management of Urinary Incontinence in Women. JAMA 291(8):996 9. 4. Koch, L.H. 2006. Help-seeking behaviors of women with urinary incontinence: an integrative literature review. J Midwifery Women s Health 51(6):39 44. 5. Gomelsky, A., R.R. Dmochowski. 2011. Urinary Incontinence in the Aging Female: Etiology Pathophysiology and Treatment Options. Aging health 7(1):79 88. 6. Buckley, B.S., M.C. Lapitan. 2010. Prevalence of urinary incontinence in men, women, and children current evidence: findings of the Fourth International Consultation on Incontinence. Urology 76:265. 7. Levy, R., N. Muller. 2006. Urinary incontinence: economic burden and new choices in pharmaceutical treatment. Adv Ther 23(4):556 73. 8. Thum, L.P., A. Wagg. 2009. Management of urinary incontinence in the elderly. Aging Health 5(5), 647 53. 9. Society of Obstetricians and Gynaecologists of Canada (SOGC). 2006. Conservative management of urinary incontinence. J Obstet Gynaecol Can 28(12):1113 8.

196 n at i o N A l c o M M I T T E E f o r Q U A l I T y A S S U R A N C E PHysICal ACTIVIty IN older adults 1. Ashe, M.C., W.C. Miller, J.J. Eng, L. Noreau. 2009. Older adults, chronic disease and leisure-time physical activity. Gerontology 55(1) 64 72. 2. Elsawy, B., K.E. Higgins. 2010. Physical Activity Guidelines for Older Adults. American Family Physician. 81(1):55 9. 3. Centers for Disease Control and Prevention (CDC). 2008. Preventing Obesity and Chronic Diseases Through Good Nutrition and Physical Activity. http://www.cdc.gov/nccdphp/publications/factsheets/prevention/pdf/obesity.pdf (May 27, 2011) 4. Centers for Disease Control and Prevention (CDC). 2011. Healthy Aging. Helping People To Live Long and Productive Lives and Enjoy a Good Quality Of Life. http://www.cdc.gov/chronicdisease/resources/publications/aag/aging.htm (May 27, 2011) 5. Ackermann, R.T., B., Williams, H.Q. Nguyen, E.M. Berke, et al. 2008. Healthcare Cost Differences with Participation in a Community Based Group Physical Activity Benefit for Medicare Managed Care Health Plan Members. Journal of the American Geriatrics Society; 56(8): 1459 65. 6. Chodzko-Zajko, W.J., D. Proctor, F.M. Singh, C.T. Minson, et al. 2009. Exercise and Physical Activity for Older Adults. Medicine & Science in Sports & Exercise 41(7) 1510 30. 7. Nelson, M.E., J. Rejeski, S.N. Blair, P.W. Duncan, P.W., et al. Physical Activity and Public Health in Older Adults: Recommendation from the American College of Sports Medicine and the American Heart Association. http://www.acsm.org/am/template.cfm?section=home_ page&template=/cm/contentdisplay.cfm&contentid=7789 (May 27, 2011) GLAUCOMA SCREENIng IN older adults 1. Goldberg, L.D. 2008. The Case for Glaucoma Screening: A look at the effect of early detection on healthcare costs. Ophthalmology Management. Available at http://www.ophmanagement.com/article.aspx?article=101274 (May 27, 2011) 2. The Foundation of the American Academy of Ophthalmology. 2007. Glaucoma. Eye Care America. http://eyecareamerica.org/ eyecare/conditions/glaucoma/index.cfm (May 27, 2011) 3. National Eye Institute. 2010. Facts about Glaucoma. http://www.nei.nih.gov/health/glaucoma/glaucoma_facts.asp (May 27, 2011) 4. Centers for Medicare & Medicaid Services. 2010. Medicare Preventive Services: Glaucoma. https://www.cms.gov/mlnproducts/ downloads/glaucoma.pdf (May 27, 2011) 5. National Eye Institute. Vision Problems in the U.S. http://www.preventblindness.org/vpus/2008_update/vpus_2008_update.pdf (May 27, 2011) 6. Fiscella, R.G., J. Lee, E. Davis, J. Walt. 2009. Cost of Illness of Glaucoma: A Critical and Systematic Review. Pharmaco Economics 27 (3) 189 98. 7. McKinnon, S.J., L.D. Goldberg, P. Peeples, J.G. Walt, T.J. Bramley. 2008. Current Management of Glaucoma and the Need for Complete Therapy. American Journal of Managed Care 14: S20 S27. OSTEOPorosIS ManagEMEnt IN WOMEN WHO Had A fracture 1. Mayo Clinic. Osteoporosis Basics. http://www.mayoclinic.com/health/osteoporosis/ds00128 (June 2011) 2. Vondracek, S.F., S.A. Linnebur. 2009. Diagnosis and management of osteoporosis in the older senior. Clin Interv Aging 4:121 39. 3. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Once is Enough: A Guide to Preventing Future Fractures. Updated 2009. http://my.clevelandclinic.org/documents/rheumatology_immunology/oa01.pdf (June 2011). 4. U.S. Preventive Services Task Force. January 18, 2011. Screening for Osteoporosis: U.S. Preventive Service Task Force Recommendation Statement. Annals of Internal Medicine; 154: 356 64. 5. Singh, S., R. Foster, K.M. Khan. 2011. Accident or Osteoporosis? Survey of Community Follow-up After Low-Trauma Fracture. Canadian Family Physician; 57(4): e128 33. 6. Lewiecki, E.M. 2008. Prevention and Treatment of Postmenopausal Osteoporosis. Obstetrics and Gynecology Clinics of North America; 35(2): 301 15. 7. The Joint Commission. 2008. Improving and Measuring Osteoporosis Management. http://www.jointcommission.org/assets/1/18/ OsteoMono_REVFinal_31208.pdf (June 2011) 8. Burge, R.T., B. Dawson-Hughes, A.B. King, et al., 2007. Incidence and Economic Burden of osteoporosis Related Fractures in the United States, 2005 2025. Journal of Bone Mineral Research; 22(3): 465 75. 9. U.S. Department of Health and Human Services. Bone Health and Osteoporosis (A Report of the Surgeon General). 2004. Rockville, MD: US Dept of Health and Human Services, Public Health Service, Office of the Surgeon General. 10. Majumadr, S.R. 2008. Recent Trends in Osteoporosis Treatment After Hip Fracture: Improving but Wholly Inadequate. Journal of Rheumatology 35(2): 190 1902.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 R e f E R E N C E S 197 OSTEOPorosIS TEstIng IN older WOMEN 1. National Osteoporosis Foundation. 2008. Fact Sheet. http://216.247.61.108/professionals/nof_fact_sheet.pdf (June 6, 2011) 2. Bone Health Learning Center. Osteoporosis in 2011. http://www.healthline.com/health-feature/osteoporosis-2011 (June 8, 2011) 3. Burge, R., B. Dawson-Hughes, D.H. Solomon, J.B. Wong, A. King, A. Tosteson. 2007. Incidence and economic burden of osteoporosisrelated fractures in the United States, 2005 2025. Journal of Bone and Mineral Research 22(3):465 75. 4. Blume, S.W., J.R. Curtis. 2011. Medical costs of osteoporosis in the elderly Medicare population. Osteoporosis International 22(6):1835 44. 5. Becker, D.J., M.L. Kilgore, M.A. Morrisey. 2010. The societal burden of osteoporosis. Current Rheumatology Report 12(3):186 91. 6. Saag, S.G., P. Geusens. Progress in Osteoporosis and Fracture Prevention: Focus on Postmenopausal Women. 2009. Arthritis Research & Therapy 11(5):251. 7. Ioannidis, G., A. Papaioannou, L. Thabane, A. Gafni, A. Hodsman, B. Kvern, A. Walsh, F. Jiwa, J.D. Adachi. 2009. Family physicians personal and practice characteristics that are associated with improved utilization of bone mineral density testing and osteoporosis medication prescribing. Population Health Management 12(3):131 8.

T H E S TAT E o f H E A l T H C A R E Q U A l I T y 2 0 1 1 A c k n o w l E D G M E N T S 199 AcknowlEDGMENTS Health Plans The 2011 State of Health Care Quality Report would not be possible without the public reporting of performance results by the 740 HMO and POS plans and 302 PPO plans this report analyzes. Those plans collectively cover more than 118 million Americans, and are to be commended for their commitment to quality improvement. Staff NCQA employees who helped create this report include: Communications Ashley Carter Paul Cotton Andy Reynolds, MBA Apoorva Stull, MA Sarah Thomas, MS Data Collection Operations Garcene Duckett Felicia Fridie Robin Gant Carla Pacheco Michele Taylor Information Systems Bob Chisholm Jonathan Cook Paul Jackovich Judy Jiao Bing Li Bhuvaneshwari Maruthac Raghav Seshadri Subra Shanmugam Helen Zhang Performance Measurement Dawn Alayon, MPH, CPH Sepheen C. Byron, MHS Jennifer Chemi Mohua Choudhury Jeremy Gottlich Candice Groseclose Benjamin Hamlin, MPH Mallory L. N. Johnson, MPA Divya Pamnani, MHSA Milesh M. Patel, MS Bob Rehm, MBA Dana T. Rey, MPH Careema Yusuf, MPH Publications Carolyn Moeller, MHS Policy Judy Lacourciere Quality Solutions Group Phyllis Torda, MA

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