QARR Report Series
Issue 4 of 5
2015 Health Plan Service Use
in New York State
A Report on the Use of Inpatient, Emergency Room, and Other Health Services
health.ny.gov
Table of Contents
Section 1. Overview ................................................................. 2
Section 2. Access to Care ....................................................... 4
Identification of Alcohol and Other Drug Services ...........................37
COMMERCIAL HMO ............................................................................. 37
COMMERCIAL PPO .............................................................................. 38
COMMERCIAL HMO ............................................................................... 5
STATEWIDE AVERAGES ACROSS PAYERS ..................................... 39
COMMERCIAL PPO ................................................................................ 7
MEDICAID MANAGED CARE.................................................................. 9
Initiation and Engagement of Alcohol and Other Drug Dependence
Treatment ........................................................................................40
STATEWIDE AVERAGES ACROSS PAYERS ...................................... 11
COMMERCIAL HMO ............................................................................. 40
Section 3. Use of Services ..................................................... 12
COMMERCIAL PPO .............................................................................. 41
Plan All-Cause Readmissions .........................................................42
Outpatient Utilization ....................................................................... 13
COMMERCIAL HMO ............................................................................. 42
COMMERCIAL HMO ............................................................................. 13
COMMERCIAL PPO .............................................................................. 43
COMMERCIAL PPO .............................................................................. 14
MEDICAID MANAGED CARE................................................................ 15
Section 4. Antibiotic Utilization .............................................44
STATEWIDE AVERAGES ACROSS PAYERS ...................................... 16
COMMERCIAL HMO ............................................................................. 45
Frequency of Selected Procedures ................................................ 17
COMMERCIAL PPO .............................................................................. 46
COMMERCIAL HMO ............................................................................. 17
MEDICAID MANAGED CARE ............................................................... 47
COMMERCIAL PPO .............................................................................. 20
MEDICAID MANAGED CARE................................................................ 23
STATEWIDE AVERAGES ACROSS PAYERS ...................................... 26
Inpatient Use of Services ................................................................ 27
COMMERCIAL HMO ............................................................................. 27
COMMERCIAL PPO .............................................................................. 29
MEDICAID MANAGED CARE................................................................ 31
STATEWIDE AVERAGES ACROSS PAYERS ...................................... 33
Mental Health Utilization ................................................................. 34
COMMERCIAL HMO ............................................................................. 34
COMMERCIAL PPO .............................................................................. 35
MEDICAID MANAGED CARE................................................................ 36
2015 Health Plan Service Use in New York State Report
1|Page
Overview
Section 1
Introduction
The 2015 Health Plan Service Use in New York State Report contains
information on children's and adults’ access to care and use of health
services. This report complements the 2015 New York State Health Plan
Comparison Report and electronic Quality Assurance Reporting
Requirements (eQARR) 2015, which contain quality of care and member
satisfaction information. eQARR 2015 is an interactive, web-based report
with statewide and regional information, which is available at
https://www.health.ny.gov/health_care/managed_care/reports/quality_perfor
mance_improvement.htm.
The data in this report reflects services provided during 2014.
Types of Insurance
Information on three types of managed care insurance is included in this
report: Commercial HMO (CO), Commercial PPO (PPO), Medicaid Managed
Care (MA) and Child Health Plus (CHP). Child Health Plus data has been
represented with Medicaid Managed Care data since 2014.
Types of Insurance
Description
Commercial HMO (CO)
Individual or employer-sponsored health insurance. This is a form of health insurance where a health plan contracts
with a network of providers to provide care; the member selects a primary care provider to coordinate care; and
referrals to some services or specialists may be required.
Commercial PPO (PPO)
Individual or employer-sponsored health insurance. This is a form of health insurance where a health plan contracts
with a network of providers to provide care; there is no primary care provider assignment; and referrals to some
services or specialists are not usually required.
Medicaid Managed Care (MA)
Government-sponsored health insurance. This is a form of health insurance where a health plan contracts with a
network of providers to provide care; the member selects a primary care provider to coordinate care; and referrals to
some services or specialists may be required.
Child Health Plus (CHP)
Government sponsored health insurance, although individuals may pay part of premium for some eligibility levels.
This is a form of health insurance where a health plan contracts with a network of providers to provide care; the
member selects a primary care provider to coordinate care; and referrals to some services or specialists may be
required. This is NYS's version of the federal State Children's Health Insurance Program (SCHIP) for people up to
age 19. Child Health Plus data has been represented with Medicaid Managed Care data since 2014.
2015 Health Plan Service Use in New York State Report
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Overview
Section 1
Who Reports?
Performance Ratings
Managed care plans that were in operation during the entire 2014 calendar
year were required to report data. This report contains information on 22
distinct organizations. Ten organizations reported on Commercial HMO
enrollees; 9 reported on Commercial PPO members; 16 reported on their
Medicaid and Child Health Plus enrollees; and 3 reported on HIV Special
Needs Plan (SNP) enrollees.
Each section contains measures of access to care or utilization of services
with results for each plan and the statewide average.
Please note when you are reviewing this report that not all health plans serve
commercial, Medicaid and/or Child Health Plus enrollees in every region of
the state. To determine which managed care plans participate in your area
please see our Managed Care Regional Consumer Guides. The National
Committee for Quality Assurance (NCQA) approved three plans (HealthNow,
Excellus BCBS, and Univera Healthcare) to report results using combined
Commercial HMO and PPO memberships. The results for the combined
reporting are displayed in the Commercial HMO tables. HIV SNP results are
presented in several sections of the report. For sections without HIV SNP
plan specific results displayed, the data are not presented due to small
sample sizes in the program, across the plans.
Data Sources
Data in this report are collected from Commercial HMOs, PPOs, Medicaid,
and Child Health Plus managed care plans in compliance with 2015 Quality
Assurance Reporting Requirements (QARR) and NCQA 2015 Healthcare
®
Effectiveness Data and Information Set (HEDIS ) technical specifications
and guidelines.
Audit Requirements
Prior to submission of their data to the New York State Department of Health,
all plans are required to participate in an audit of all required measures. The
audit is conducted by an independent auditor in adherence to NCQA’s
certified audit methodology. Only valid information is published in this report.
2015 Health Plan Service Use in New York State Report
Access to Care measures and Initiation and Engagement of Alcohol and
Other Drug Dependence Treatment are reported as a percentage of the
eligible population. Symbols are provided to indicate whether the plan
performed statistically significantly better (▲) or worse (▼) than the
statewide average. For all other measures, symbols are provided to indicate
th
th
whether the plan performed above the 90 percentile (▲) or below the 10
percentile (▼) for all plans included in the tables.
When comparing plan rates and associated significance ratings, you may
notice plans that have the same numerical rating but a different significance
rating. While this may seem like an error, plan significance ratings are based
on how much a plan's rate differs from the statewide average and the
number of individuals included in the rate. Therefore, plans can have the
same rate but have different significance ratings because their rates are
based on different numbers of enrollees.
Variations and/or extremes in utilization are difficult to interpret for plans with
low enrollment. Therefore, plans with fewer than 30 eligible members or
events are excluded from the statistical calculations of the percentiles, but
are still included in the calculation of the statewide averages. All rates based
on denominators of less than 30 or events less than 30 are reported in the
tables with a dashed line.
Feedback
We welcome suggestions and comments on ways the Department can
measure and report plan performance more effectively.
Please contact us at:
Bureau of Quality Measurement and Evaluation
Office of Quality and Patient Safety
New York State Department of Health
Corning Tower, Room 1938
Empire State Plaza
Albany, NY 12237
Telephone: 518-486-9012
Fax: 518-486-6098
E-mail: [email protected]
3|Page
Access to Care
Section 2
Access to care means health care is available, members know how to
obtain health care services when they need them, and use them when
necessary. The measures in this section describe the percentage of
enrollees in a managed care plan who had a visit with a primary care
provider within the specified time frame. Symbols are provided to
indicate whether the plan performed statistically significantly better
(▲) or worse (▼) than the statewide average.
Measure
Description (Type of Insurance)
Children and Adolescents’ Access to
Primary Care Practitioners
The percentage of children, ages 12 months to 6 years, who had a visit with a primary care practitioner
within the last year, or for children, ages 7 to 19 years, within the last two years. The measure is divided
into four age groups: 12 to 24 months, 25 months to 6 years, 7 to 11 years, and 12 to 19 years. (CO,
PPO, MA/CHP)
Adults’ Access to Preventive and
Ambulatory Health Services
The percentage of adults, ages 20 years and older, who had an ambulatory or preventive care visit within
the last year if they were insured by Medicaid, or within the last three years if they were commercially
insured. This measure is divided into three age groups: 20 to 44 years, 45 to 64 years, and 65 years and
older. (CO, PPO, MA)
2015 Health Plan Service Use in New York State Report
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Access to Care
Section 2
Commercial HMO
Children and Adolescents’ Access to Primary Care Practitioners
Health Plan
12–24 Months
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
99
99
88
98
96
100
99
99
98
100
98
▼
▼
▲
▲
LEGEND
25 Months–6 Years
95
97
90
95
93
97
97
96
96
94
95
▲
▼
▼
▲
▲
▲
▲
7–11 Years
96
99
94
96
95
98
99
98
97
97
97
▲
▼
▼
▼
▲
▲
▲
12–19 Years
93
97
92
93
92
96
97
95
95
94
94
▲
▼
▼
▼
▲
▲
▲
▲
Results are a percentage of the eligible population.
▲ Significantly better than statewide average
▼ Significantly worse than statewide average
Note: Plans without symbols are not significantly different than the statewide average.
2015 Health Plan Service Use in New York State Report
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Access to Care
Section 2
Commercial HMO
Adults’ Access to Preventive and Ambulatory Health Services
Health Plan
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
20–44 Years
93
95
90
95
92
95
94
94
94
94
94
▼
▲
▼
▲
▼
▲
LEGEND
45–64 Years
95
97
95
97
95
97
96
97
96
95
96
▼
▲
▼
▲
▼
▲
▲
▼
65 Years and Older
96
98
96
98
93
98
98
98
97
98
97
▲
▲
▼
▲
▲
▲
Results are a percentage of the eligible population.
▲ Significantly better than statewide average
▼ Significantly worse than statewide average
Note: Plans without symbols are not significantly different than the statewide average.
2015 Health Plan Service Use in New York State Report
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Access to Care
Section 2
Children and Adolescents’ Access to Primary Care Practitioners
Commercial PPO
Health Plan
12–24 Months
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
98
99
98
90
93
-98
97
99
96
▲
▲
▲
▼
▼
▲
▲
LEGEND
25 Months–6 Years
95
97
95
90
89
90
95
95
96
94
▲
▲
▲
▼
▼
▲
▲
7–11 Years
96
98
97
93
91
94
98
96
97
96
▲
▲
▼
▼
▲
▲
12–19 Years
93
97
93
88
87
89
94
94
93
92
▲
▲
▲
▼
▼
▲
▲
▲
Results are a percentage of the eligible population.
▲ Significantly better than statewide average
▼ Significantly worse than statewide average
-- Sample too small to report
Note: Plans without symbols are not significantly different than the statewide average.
2015 Health Plan Service Use in New York State Report
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Access to Care
Section 2
Adults’ Access to Preventive and Ambulatory Health Services
Commercial PPO
Health Plan
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
20–44 Years
94
95
94
92
91
89
93
95
94
94
▲
▼
▼
▼
▲
LEGEND
45–64 Years
96
96
95
94
94
89
96
97
96
96
▼
▼
▼
▲
65 Years and Older
96
98
96
94
88
96
97
98
98
97
▼
▲
▼
▼
▼
▲
▲
Results are a percentage of the eligible population.
▲ Significantly better than statewide average
▼ Significantly worse than statewide average
Note: Plans without symbols are not significantly different than the statewide average.
2015 Health Plan Service Use in New York State Report
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Access to Care
Section 2
Children and Adolescents’ Access to Primary Care Practitioners
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus Blue Cross Blue Shield
Fidelis Care New York, Inc.
HIP (EmblemHealth)
HealthNow New York Inc.
HealthPlus, an Amerigroup Company
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus
Total Care, A Today’s Options of New York
Health Plan
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
VNSNY CHOICE Select Health
SNP Statewide
12–24 Months
95
99
99
98
95
98
97
96
98
99
98
93
25 Months–6 Years
▼
▲
▲
▲
▼
▲
▲
▲
▼
93
94
95
95
93
93
96
95
93
92
93
92
▼
▲
▼
▲
▲
▼
▼
▼
▼
7–11 Years
96
98
97
97
96
97
98
97
96
95
96
96
▼
▲
▲
▼
▼
12–19 Years
93
96
96
94
94
95
96
94
94
93
94
91
▼
▲
▲
▲
▼
▼
98
90 ▼
94 ▼
93 ▼
97
98 ▲
93 ▼
97
96 ▲
91 ▼
93 ▼
94
97
95 ▼
97
97
96 ▲
93 ▼
94
94
---90
79
83
-82
-95
-92
-89
73 ▼
88
LEGEND
Results are a percentage of the eligible population.
▲ Significantly better than statewide average
▼ Significantly worse than statewide average
-- Sample too small to report
Note: Plans without symbols are not significantly different than the statewide average.
2015 Health Plan Service Use in New York State Report
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Access to Care
Section 2
Adults’ Access to Preventive and Ambulatory Health Services
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus Blue Cross Blue Shield
Fidelis Care New York, Inc.
HIP (EmblemHealth)
HealthNow New York Inc.
HealthPlus, an Amerigroup Company
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus
Total Care, A Today’s Options of New York
Health Plan
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
VNSNY CHOICE Select Health
SNP Statewide
20–44 Years
82
87
87
85
82
84
82
86
83
85
86
81
▼
▲
▲
▲
▼
▼
▲
▼
▲
▼
45–64 Years
89
92
92
91
89
89
89
93
89
90
91
90
▼
▲
▲
▼
▼
▼
▲
▼
▼
65 Years and Older
87 ▼
94
93
90
87 ▼
87
89
91 ▲
90
88
83
90
85
90
92
85 ▲
85
82 ▼
84
90 ▼
89 ▼
90
91
87 ▼
88
90
90
98
97
96
97
99
99
98
99
LEGEND
100
95
97
97
Results are a percentage of the eligible population.
▲ Significantly better than statewide average
▼ Significantly worse than statewide average
Note: Plans without symbols are not significantly different than the statewide average.
2015 Health Plan Service Use in New York State Report
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Access to Care
Section 2
Statewide Averages Across Payers
Access to Primary Care Practitioners
100
90
80
Percentage
70
60
50
40
30
20
10
0
12 - 24 Months
25 Months - 6 Years
7 - 11 Years
12 - 19 Years
20 - 44 Years*
45 - 64 Years*
65+ Years*
Age Group
CO
PPO
MA/CHP
The graph presents the differences in member access by payer and age group. Commercial HMO (CO) and Commercial PPO (PPO) are at or
above 90% for members regardless of age group. Medicaid/CHP (MA/CHP) is at or above 90% for all age groups except for members between 20
and 44 years of age. For age group 19 years and younger, MA and CHP are combined reporting.
* Please note that the time frame for visits for members ages 20 years or older varies by type of insurance. Medicaid percentages reflect visits in
the measurement year, while CO and PPO percentages reflect visits in the last three years.
2015 Health Plan Service Use in New York State Report
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Use of Services
Section 3
Managed care plans are required to submit inpatient and outpatient
utilization data such as hospital admissions and ambulatory surgery
rates. The data presented are calculated by the plans. Data applicable
to the Medicaid, Commercial HMO, and Commercial PPO populations
are reported separately. For Initiation and Engagement of Alcohol and
Other Drug Dependence Treatment, symbols are provided to indicate
whether the plan performed statistically significantly better (▲) or worse
(▼) than the statewide average. For all other measures, symbols are
provided to indicate whether the plan performed above the 90th
percentile (▲) or below the 10th percentile (▼) for all plans included in
the tables.
Utilization rates for Outpatient Use of Services, Inpatient Use of
Services, and Frequency of Selected Procedures are calculated per
1,000 member years (MY). Results for the Initiation and Engagement of
Alcohol and Other Drug Dependence Treatment, Mental Health
Utilization, as well as Identification of Alcohol and Drug Dependence
Services are calculated as percentage of the eligible population.
Average length of stay (ALOS) is calculated as the total number of days
divided by the total number of discharges (Days/Discharges = ALOS).
Total Inpatient Utilization is the sum of Medicine, Surgery, and
Maternity discharges and length of stay. Some discharges cannot be
grouped as medicine, maternity, or surgery, but are included in the
inpatient total. Therefore, total discharges and days may not be equal
to the sum of the three components. The rates for open
cholecystectomy and intensive outpatient or partial hospitalization rates
for alcohol and drugs are not displayed in the following tables, since the
results are not statistically significant due to small sample sizes and low
rates.
The Plan All-Cause Readmission rates are risk adjusted for presence of
surgeries, discharge condition, comorbidity, age, and gender. For this
measure, a lower rate is desirable. The O/E Ratio is the observed-toexpected ratio: The ratio of the plan's observed rate of readmission to
its expected rate of readmission.
Measure
Description (Type of Insurance)
Outpatient Utilization
Summarizes utilization of ambulatory services including outpatient visits and emergency room visits. Rates are per
1,000 member years (MY). (CO, PPO, MA/CHP).
Frequency of Selected Procedures
Provides a summary of high frequency procedures and rates are per 1,000 MY. (CO, PPO, MA/CHP)
Inpatient Utilization
Summarizes utilization of acute inpatient services in the categories of Medicine, Surgery, Maternity, and Total inpatient
utilization. Total discharges per 1,000 MY, total days per 1,000 MY, and ALOS are reported. (CO, PPO, MA/CHP)
Mental Health Utilization
Provides an overview of members who received inpatient, outpatient, and emergency room mental health treatment.
Rates are the percentage of members who receive mental health services. (CO, PPO, MA)
Identification of Alcohol and Other
Dependency Services
Provides an overview of members with an alcohol or other drug (AOD) dependence diagnosis and the extent to which
different levels of chemical dependency services are utilized. Rates are the percentage of members who receive
services. (CO, PPO)
Initiation and Engagement of Alcohol
and Other Drug Dependence
Treatment
Two percentages for members with AOD dependence are shown. The Initiation percentage is the percentage of
members who initiate treatment within 14 days of the diagnosis of AOD dependence. The Engagement percentage is
the percentage of members who engage in treatment within 30 days after initiation. (CO, PPO)
Plan All-Cause Readmissions
Provides the percentage of acute inpatient stays that were followed by an acute readmission for any diagnosis within 30
days. Both risk adjusted rates and the observed/expected probabilities are displayed. (CO, PPO)
2015 Health Plan Service Use in New York State Report
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Use of Services
Section 3
Commercial HMO
Health Plan
Outpatient Utilization
Emergency Room Visits
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
LEGEND
181
263 ▲
185
180
250
166
200
223
144 ▼
187
185
Outpatient Visits
4,508
4,674
4,608
4,035
4,504
4,077
3,819 ▼
4,704 ▲
4,411
3,863
4,264
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
2015 Health Plan Service Use in New York State Report
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Use of Services
Section 3
Commercial PPO
Health Plan
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
LEGEND
Outpatient Utilization
Emergency Room Visits
150
242
139 ▼
181
323 ▲
221
197
146
188
178
Outpatient Visits
4,227
4,152
4,387
4,131
4,659
5,860 ▲
3,933 ▼
4,937
5,430
4,730
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
2015 Health Plan Service Use in New York State Report
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Use of Services
Section 3
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Outpatient Utilization
Emergency Room Visits
Affinity Health Plan
CDPHP
Excellus Blue Cross Blue Shield
Fidelis Care New York, Inc.
HIP (EmblemHealth)
HealthNow New York Inc.
HealthPlus, an Amerigroup Company
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus
Total Care, A Today’s Options of New York
Health Plan
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
VNSNY CHOICE Select Health
SNP Statewide
LEGEND
Outpatient Visits
NV
782
664
548
459
603
424
599
588
784 ▲
958 ▲
675
NV
4,942
4,550
6,079 ▲
5,558
4,183 ▼
4,378
5,666
4,541
4,139 ▼
4,820
4,850
783
4,853
385 ▼
716
404 ▼
555
5,931 ▲
4,326
4,685
5,366
1,111 ▲
965
795 ▼
970
13,334 ▲
8,645 ▼
11,590
11,295
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
NV: Plan submitted invalid data.
2015 Health Plan Service Use in New York State Report
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Use of Services
Section 3
Outpatient Utilization
Statewide Averages Across Payers
Emergency Room Visits by Age Group
Rate (1,000 member years)
700
600
500
400
300
200
100
0
CO
PPO
MA/CHP
Payer
Ages 0 - 19
Ages 20 & Above
The graph illustrates the statewide rates of emergency room visits by age group and payer. Medicaid/CHP (MA/CHP) rates are higher than
Commercial HMO (CO) and Commercial PPO (PPO) rates. For age group 19 years and younger, MA and CHP are combined reporting.
2015 Health Plan Service Use in New York State Report
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Use of Services
Section 3
Commercial HMO
Frequency of Selected Procedures
Angioplasty
Ages 45 & Above
Health Plan
Female
Male
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
---1.6
2.2 ▲
1.1 ▼
1.5
1.9
1.3
-1.5
5.1
5.2
8.1 ▲
5.8
6.5
4.9 ▼
5.8
6.0
6.9
5.0
6.1
LEGEND
Coronary Artery Bypass Graft
Ages 45 & Above
Female
---0.2
------0.3
Cardiac Catheterization
Ages 45 & Above
Male
Female
-2.2 ▲
-1.4
1.4 ▼
1.6
1.7
1.5
1.4
-1.5
4.6
4.4
4.8
4.0
5.7 ▲
4.9
5.4
5.4
3.7 ▼
5.5
4.5
Male
8.4
8.8
10.7
6.9 ▼
10.8 ▲
8.6
10.5
9.1
8.3
8.2
8.5
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
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Use of Services
Section 3
Commercial HMO
Frequency of Selected Procedures
Laproscopic
Cholecystectomy
Health Plan
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Back Surgery
Ages 20 & Above
Bariatric Weight
Loss Surgery
Prostatectomy
Ages 45 &
Above
Female
Ages
15 & Above
Male
Ages
30 & Above
Female
Male
Female
Male
Male Only
2.7 ▼
5.6
2.7
5.6
2.9
4.8
5.0
5.2
2.7
7.5 ▲
4.2
2.0
2.6
-2.7
1.5 ▼
2.5
2.7
3.4
1.8
3.7 ▲
2.3
2.1
3.6
2.6
3.2
1.6
3.4
3.2
3.6
1.5 ▼
3.7 ▲
2.5
2.4
3.7
3.3
3.7
1.8 ▼
3.5
3.7
4.0 ▲
2.0
3.6
2.9
-1.3 ▲
-1.1
0.9
0.7
0.7
1.2
0.5 ▼
-0.9
---0.3 ▲
0.2 ▼
---0.2
-0.2
-2.6
-2.7
5.8 ▲
2.2 ▼
2.3
2.8
2.7
-3.0
LEGEND
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
18 | P a g e
Use of Services
Section 3
Commercial HMO
Health Plan
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Frequency of Selected Procedures for Women and Children
Lumpectomy
Ages 15 & Above
Mastectomy
Ages 15 & Above
Abdominal
Hysterectomy
Ages 15 & Above
Vaginal
Hysterectomy
Ages 15 & Above
Tonsillectomy
Ages 0–19
4.1
4.9 ▲
4.5
3.1 ▼
3.2
3.9
4.4
3.9
3.6
3.4
3.6
1.7
1.4
-1.6
0.8 ▼
1.6
1.5
1.7 ▲
1.7
-1.5
2.7
1.5 ▼
2.2
2.8 ▲
2.5
1.9
1.9
2.7
1.9
-2.3
-1.4
-1.9 ▲
0.6
1.7
1.3
1.2
0.5 ▼
-1.2
3.4
4.4
-5.2
2.1 ▼
7.1 ▲
7.0
5.3
2.9
6.7
4.4
LEGEND
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
19 | P a g e
Use of Services
Section 3
Commercial PPO
Frequency of Selected Procedures
Angioplasty
Ages 45 & Above
Coronary Artery Bypass
Graft
Ages 45 & Above
Cardiac Catheterization
Ages 45 & Above
Health Plan
Female
Male
Female
Male
Female
Male
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
1.3
1.5
1.2
1.3
1.8
--1.1 ▼
2.3 ▲
1.8
5.8
4.7 ▼
5.3
5.8
7.1
-5.0
6.5
8.2 ▲
6.8
0.2
--0.2 ▼
----0.6 ▲
0.4
1.5
1.9
1.2 ▼
1.2
---1.2
2.6 ▲
1.9
3.8
4.2
3.6
4.5
5.6
-4.1
3.4 ▼
6.8 ▲
5.3
7.4
8.6
6.6 ▼
8.5
9.2
-8.0
8.3
11.8 ▲
9.5
LEGEND
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
20 | P a g e
Use of Services
Section 3
Commercial PPO
Frequency of Selected Procedures
Laproscopic
Cholecystectomy
Health Plan
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Female
Ages
15 & Above
Male
Ages
30 & Above
2.9
5.5 ▲
2.8
3.6
3.2
-5.1
2.2 ▼
3.7
3.4
1.5
2.9 ▲
1.5 ▼
1.6
1.6
-2.5
1.7
2.4
2.0
LEGEND
Back Surgery
Ages 20 & Above
Female
2.0
3.0
1.9
1.9
1.4 ▼
-3.1 ▲
2.0
3.0
2.4
Male
2.3
3.6
2.5
2.1
1.5 ▼
-3.6
3.4
3.6 ▲
2.9
Bariatric Weight
Loss Surgery
Prostatectomy
Ages 45 &
Above
Female
Male
Male Only
0.5
1.3 ▲
0.4 ▼
0.7
1.1
--0.6
0.8
0.7
0.1 ▼
0.3 ▲
0.1
0.2
---0.2
0.3
0.2
2.6
2.2 ▼
2.9
2.3
2.6
-2.7
3.5
4.0 ▲
3.2
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
21 | P a g e
Use of Services
Section 3
Commercial PPO
Health Plan
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
LEGEND
Frequency of Selected Procedures for Women and Children
Lumpectomy
Ages 15 &
Above
Mastectomy
Ages 15 &
Above
Abdominal
Hysterectomy
Ages 15 &
Above
Vaginal
Hysterectomy
Ages 15 &
Above
Tonsillectomy
Ages 0–19
3.6
3.9
3.6
3.6
3.3
-3.3 ▼
4.2 ▲
4.2
3.9
1.6
1.5
1.4
1.2 ▼
1.3
-1.2
1.9 ▲
1.5
1.5
1.9
1.6 ▼
1.8
2.1
1.8
-2.6 ▲
1.7
2.1
2.0
0.7
1.8 ▲
0.6 ▼
0.8
--1.4
0.6
0.9
0.8
3.2
5.2 ▲
3.1
2.9
2.9 ▼
-3.9
3.1
3.7
3.4
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
22 | P a g e
Use of Services
Section 3
Medicaid Health Plans
Frequency of Selected Procedures
Angioplasty
Ages 45 & Above
Medicaid Managed Care Plans (MMC)
Female
Affinity Health Plan
CDPHP
Excellus Blue Cross Blue Shield
Fidelis Care New York, Inc.
HIP (EmblemHealth)
HealthNow New York Inc.
HealthPlus, an Amerigroup Company
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus
Total Care, A Today’s Options of New York
Health Plan
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
2.5 ▼
-4.4 ▲
3.2
2.8
-3.0
3.5
2.8
--3.4
-2.6
-3.1
3.1
LEGEND
Coronary Artery Bypass Graft
Ages 45 & Above
Male
Female
Male
7.1
6.4 ▼
7.6
8.7
8.9
-9.8
9.4
6.0 ▼
--10.0 ▲
---0.6 ▲
---0.4 ▼
-----
-4.3 ▲
2.5
1.9
1.5
-1.4 ▼
1.7
---1.6
-9.3
-11.9 ▲
8.8
--
--
---0.5
1.9
-2.4
1.8
Cardiac Catheterization
Ages 45 & Above
Female
Male
8.7
12.8 ▲
9.2
9.8
8.2 ▼
12.5
9.2
10.3
9.6
12.5
-9.7
12.2 ▼
17.7 ▲
13.3
13.5
13.1
15.9 ▲
13.5
14.4
14.1
15.5
-15.2
--
--
6.9 ▼
14.2 ▲
9.2
9.4
13.0 ▼
15.0
14.0
13.7
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
23 | P a g e
Use of Services
Section 3
Medicaid Health Plans
Frequency of Selected Procedures
Laproscopic
Cholecystectomy
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus Blue Cross Blue Shield
Fidelis Care New York
HIP (EmblemHealth)
HealthNow New York Inc.
HealthPlus, an Amerigroup Company
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus
Total Care, A Today’s Options of New York
Health Plan
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
Female
Ages
15–64
4.6
7.6
8.7 ▲
6.6
3.6
7.2
3.6 ▼
4.5
7.9
7.7
8.0
3.9
8.2
4.5
8.5 ▲
3.2 ▼
5.3
LEGEND
Male
Ages
30–64
1.5
3.7
4.0
2.8
2.1
-2.0
1.5
2.6
3.7
-1.4
▼
▲
▲
▼
Bariatric Weight
Loss Surgery
Ages 0–64
Back Surgery
Ages 20–64
Female
1.1
5.4
4.5
2.8
1.6
7.9
1.0
1.3
3.9
5.4
-0.7
--
4.3
2.0
-1.6
2.2
1.5
4.2
-2.1
▲
▼
▲
▼
Male
Female
Male
1.5
7.7 ▲
5.5
3.2
1.5
7.2 ▲
1.3
1.7
4.3
5.6
-1.0 ▼
0.6
1.2 ▲
0.9
0.8
0.8
-0.4 ▼
0.6
0.6
--0.4
---0.2
---0.1 ▼
-----
-2.1
5.6
1.0 ▼
2.5
-0.6
--0.6
-0.2 ▲
--0.1
Prostatectomy
Ages 45 &
Above
Male Only
1.9
--2.4
15.7 ▲
-1.8
2.5
---1.2 ▼
-2.0
--3.0
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
24 | P a g e
Use of Services
Section 3
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus Blue Cross Blue Shield
Fidelis Care New York
HIP (EmblemHealth)
HealthNow New York Inc.
HealthPlus, an Amerigroup Company
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus
Total Care, A Today’s Options of New York
Health Plan
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
Frequency of Selected Procedures for Women and Children
Lumpectomy
Ages 15–64
2.7
3.6
2.3
3.1
3.0
3.3
3.2
2.9
2.8
3.1
-2.1
▲
▼
▲
▼
Mastectomy
Ages 15–64
Abdominal
Hysterectomy
Ages 15–64
Vaginal
Hysterectomy
Ages 15–64
0.6
-1.0 ▲
0.7
0.7
-0.6
0.7
0.6
--0.4 ▼
2.1
1.9
3.8 ▲
2.2
1.7
2.9 ▲
1.3 ▼
2.4
2.2
2.8
-1.8
0.5
1.9 ▲
1.2
1.4
0.5
-0.5 ▼
0.7
1.2
--0.5
2.3
--
2.9
2.4
2.6
2.9
0.8
--0.7
LEGEND
2.2
1.7
1.9
1.4 ▼
2.1
-0.9
--0.9
Tonsillectomy
Ages 0–19
3.5
7.6
6.9
4.9
2.9
10.2 ▲
2.8
3.1
3.3
8.6
6.1
2.0 ▼
5.6
3.7
8.6 ▲
1.9 ▼
4.0
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
25 | P a g e
Use of Services
Section 3
Frequency of Selected Procedures
Statewide Averages Across Payers
Angioplasty (Ages 45 & Above) by Gender
Cardiac Catheterization (Ages 45 & Above) by
Gender
16
14
Rate (1,000 member years)
Rate (1,000 member years)
16
12
10
8
6
4
2
14
12
10
8
6
4
2
0
0
CO
PPO
MA
Payer
Female
Male
CO
PPO
MA
Payer
Female
Male
The graphs illustrate the statewide rates of cardiac catheterization and angioplasty utilization by gender and payer. Males are more likely to have
the procedures than females for all payers. Medicaid (MA) rates for both procedures are higher than Commercial payers (CO & PPO) for both
genders.
2015 Health Plan Service Use in New York State Report
26 | P a g e
Use of Services
Section 3
Commercial HMO
Inpatient Use of Services: Discharges and Total Days
Medicine
Health Plan
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Discharges
23
21
26
17
33 ▲
13 ▼
16
24
21
17
20
Total Days
104
88
102
60
132 ▲
46 ▼
59
97
81
61
78
LEGEND
Surgery
Discharges
17
18
21 ▲
17
17
14 ▼
18
20
14
18
16
Total Days
94
93
106
72
109 ▲
65 ▼
88
74
71
94
79
Maternity
Total
Discharges
Total Days
Discharges
12
10
13
14 ▲
8 ▼
9
13
9
12
13
11
33
28
40 ▲
36
22 ▼
24
35
25
36
34
32
51
48
58 ▲
45
57
38 ▼
45
52
45
46
47
Total Days
227
206
243
163
260 ▲
148 ▼
178
200
183
185
187
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
2015 Health Plan Service Use in New York State Report
27 | P a g e
Use of Services
Section 3
Commercial HMO
Health Plan
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
LEGEND
Inpatient Use of Services: Average Length of Stay
Medicine
ALOS
Surgery
ALOS
Maternity
ALOS
Total Inpatient
ALOS
4.4 ▲
4.2
3.9
3.6 ▼
4.0
3.6
3.7
4.1
3.9
3.6
3.9
5.4
5.1
5.1
4.4
6.4 ▲
4.8
4.9
3.7 ▼
5.1
5.3
5.0
2.8
2.8
3.0
2.6
2.8
2.7
2.7
2.7
3.0 ▲
2.6 ▼
2.8
4.4
4.3
4.2
3.6 ▼
4.6 ▲
3.9
4.0
3.8
4.1
4.0
4.0
ALOS = Total Days/Total Discharges
th
▲ 90 percentile or above
th
▼ 10 percentile or below
2015 Health Plan Service Use in New York State Report
28 | P a g e
Use of Services
Section 3
Commercial PPO
Inpatient Use of Services: Discharges and Total Days
Medicine
Health Plan
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of
New York, Inc.
Statewide
Discharges
Surgery
Maternity
Total
Total Days Discharges Total Days Discharges Total Days
Discharges
Total Days
16 ▼
19
16
22
23
29 ▲
17
21
69
80
66
86
98
115 ▲
60 ▼
83
12 ▼
17
13
14
16
17 ▲
15
14
60
82
66
78
89
101 ▲
52 ▼
73
15 ▲
10
15
13
9
5 ▼
11
13
45
29
46 ▲
39
29
12 ▼
29
41
41 ▼
45
42
48
46
51 ▲
41
47
167
187
172
197
213
227 ▲
141 ▼
191
NV
NV
NV
NV
NV
NV
NV
NV
19
77
14
71
14
41
45
183
LEGEND
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
NV: Plan submitted invalid data.
2015 Health Plan Service Use in New York State Report
29 | P a g e
Use of Services
Section 3
Commercial PPO
Health Plan
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
LEGEND
Inpatient Use of Services: Average Length of Stay
Medicine
ALOS
Surgery
ALOS
Maternity
ALOS
Total Inpatient
ALOS
4.4 ▲
4.2
4.1
4.0
4.3
3.9
3.6 ▼
3.9
NV
4.1
4.9
5.0
5.0
5.4
5.7
5.8 ▲
3.6 ▼
5.1
NV
5.1
2.9
2.8
3.1
2.9
3.1 ▲
2.6 ▼
2.7
3.1
NV
2.9
4.1
4.2
4.1
4.1
4.6 ▲
4.5
3.4 ▼
4.1
NV
4.1
ALOS = Total Days/Total Discharges
th
▲ 90 percentile or above
th
▼ 10 percentile or below
NV: Plan submitted invalid data.
2015 Health Plan Service Use in New York State Report
30 | P a g e
Use of Services
Section 3
Medicaid Health Plans
Inpatient Use of Services: Discharges and Total Days
Medicine
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus Blue Cross Blue Shield
Fidelis Care New York
HIP (EmblemHealth)
HealthNow New York Inc.
HealthPlus, an Amerigroup Company
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus
Total Care, A Today’s Options of New York
Health Plan
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
VNSNY CHOICE Select Health
SNP Statewide
Discharges
Total Days
Surgery
Discharges
NV
35
37
37
49 ▲
31 ▼
31 ▼
48
33
45
46
49
NV
135
140
151
205
115 ▼
126
240 ▲
163
171
164
204
NV
22
16
15
17
17
11
8
14
24
13
13
50 ▲
228 ▲
15
32
37
35
40
124 ▼
129
125
171
274
220 ▼
281 ▲
259
1,462
1,131 ▼
1,468 ▲
1,357
LEGEND
Maternity
Total Days
Total Days
Discharges
Total Days
NV
34
34
34
21 ▼
29
31
45 ▲
43
38
40
44 ▲
NV
95
88
89
61 ▼
74
92
134 ▲
126
105
106
134 ▲
NV
82
76
77
82
74
65 ▼
88
77
97 ▲
89
94
NV
353
304
299
377
299
271 ▼
383
347
444 ▲
319
388
103
43
130
94 ▲
422 ▲
12
22
12
13
86
132
92
85
36
32
19 ▼
36
97
84
51 ▼
102
70
82
63 ▼
79
280
323
258 ▼
330
29 ▼
30
50 ▲
36
240 ▼
258
427 ▲
301
17
27 ▲
10 ▼
18
308
257 ▼
334 ▲
299
1,719
1,415 ▼
1,905 ▲
1,676
▲
▼
▼
▲
NV
150
102
83
126
111
80
48
87
198
66
90
Discharges
Total
▲
▼
▲
▼
-8
-5
Results are per 1,000 member years.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
NV: Plan submitted invalid data.
2015 Health Plan Service Use in New York State Report
31 | P a g e
Use of Services
Section 3
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus Blue Cross Blue Shield
Fidelis Care New York
HIP (EmblemHealth)
HealthNow New York Inc.
HealthPlus, an Amerigroup Company
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus
Total Care, A Today’s Options of New York Health
Plan
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
VNSNY CHOICE Select Health
SNP Statewide
Inpatient Use of Services: Average Length of Stay
Medicine
ALOS
Surgery
ALOS
Maternity
ALOS
NV
3.8
3.8
4.1
4.2
3.7
4.0
5.0 ▲
4.9 ▲
3.8
3.6
4.1
NV
6.7
6.4
5.4 ▼
7.3
6.6
7.2
5.9
6.3
8.1 ▲
5.0 ▼
6.8
NV
2.8
2.6 ▼
2.6
2.9
2.6 ▼
2.9
3.0
2.9
2.7
2.7
3.0 ▲
NV
4.3
4.0
3.9
4.6
4.1
4.2
4.3
4.5
4.6
3.6
4.1
4.6
7.0
3.0 ▲
4.5
3.9
3.5 ▼
3.5 ▼
4.3
6.9
6.1
7.5 ▲
6.4
2.7
2.7
2.7
2.8
4.0
3.9
4.1
4.2
5.3 ▲
5.1 ▼
5.2
5.2
8.2 ▼
8.6 ▲
8.5
8.4
-3.6
-3.6
5.6
5.5 ▼
5.7 ▲
5.6
LEGEND
Total Inpatient
ALOS
▼
▲
▲
▼
ALOS = Total Days/Total Discharges
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
NV: Plan submitted invalid data.
2015 Health Plan Service Use in New York State Report
32 | P a g e
Use of Services
Section 3
Inpatient Use of Services
Statewide Averages Across Payers
Inpatient Discharges by Category
Inpatient Average Length of Stay by Category
80
70
60
50
40
30
20
10
0
Medicine
Surgery
Maternity
Total
Service Category
CO
PPO
MA/CHP
Average Length of Stay (per 1,000 member years)
Discharges (per 1,000 member years)
90
7
6
5
4
3
2
1
0
Medicine
Surgery
Maternity
Total
Service Category
CO
PPO
MA/CHP
The graph on the left illustrates the distribution of inpatient discharges by service category for Commercial HMO (CO), Commercial PPO (PPO), and
Medicaid/CHP (MA/CHP) payers. For age group 19 years and younger, MA and CHP are combined reporting. MA/CHP has the highest medicine
and maternity discharge rates, which leads to the highest total inpatient discharge rate across payers. The graph on the right shows the inpatient
average length of stay, with MA/CHP displaying the highest surgery average length of stay.
2015 Health Plan Service Use in New York State Report
33 | P a g e
Use of Services
Section 3
Commercial HMO
Mental Health Utilization
Outpatient/
Emergency Room
Health Plan
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Female
11.4
12.5 ▲
11.7
8.2
6.6 ▼
9.3
9.1
7.8
7.7
7.8
8.3
Inpatient
Male
Total
8.8
9.1 ▲
8.1
5.7
5.0 ▼
6.4
6.3
6.3
5.4
5.6
5.9
10.1
10.9 ▲
10.1
7.0
5.9 ▼
7.8
7.8
7.1
6.6
6.7
7.1
Any Service
Female
Male
Total
0.3
0.4 ▲
0.3
0.2
0.2
0.3
0.2
0.2
0.2 ▼
0.3
0.2
0.2
0.2 ▲
0.2
0.2 ▼
0.2
0.2
0.2
0.2
0.2
-0.2
0.2
0.3 ▲
0.3
0.2
0.2
0.3
0.2
0.2
0.2 ▼
0.2
0.2
Female
11.5
11.9 ▲
11.8
8.3
6.7 ▼
9.4
9.2
7.9
7.7
7.9
8.3
Male
Total
8.8 ▲
8.5
8.2
5.7
5.0 ▼
6.4
6.4
6.3
5.5
5.6
5.9
10.2
10.3 ▲
10.2
7.0
5.9 ▼
7.9
7.8
7.1
6.6
6.8
7.2
.
LEGEND
Results are a percentage of the eligible population.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
34 | P a g e
Use of Services
Section 3
Commercial PPO
Mental Health Utilization
Outpatient/
Emergency Room
Health Plan
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of
New York, Inc.
Statewide
Female
12.3
9.9
9.5
7.4
3.2
3.2 ▼
7.7
12.8 ▲
Inpatient
Male
Total
9.3
6.5
7.0
5.2
2.6 ▼
3.6
5.8
9.9 ▲
10.9
8.2
8.2
6.3
2.9 ▼
3.2
6.8
11.4 ▲
Any Service
Female
Male
Total
0.2
0.3 ▲
0.3
0.2
--0.2 ▼
0.2
0.2
0.2
0.2 ▲
0.2
--0.1 ▼
0.2
0.2
0.3 ▲
0.3
0.2
--0.1 ▼
0.2
Female
12.4
9.8
9.6
7.5
3.2
3.2 ▼
7.8
12.8 ▲
Male
Total
9.4
6.4
7.1
5.2
2.7 ▼
3.7
5.9
9.9 ▲
10.9
8.2
8.3
6.3
3.0 ▼
3.3
6.8
11.4 ▲
9.8
7.3
8.6
0.2
0.2
0.2
9.9
7.3
8.6
9.7
7.1
8.5
0.2
0.2
0.2
9.8
7.2
8.5
LEGEND
Results are a percentage of the eligible population.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
35 | P a g e
Use of Services
Section 3
Medicaid Health Plans
Mental Health Utilization
Outpatient/
Emergency Room
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus Blue Cross Blue Shield
Fidelis Care New York
HIP (EmblemHealth)
HealthNow New York Inc.
HealthPlus, an Amerigroup Company
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus
Total Care, A Today’s Options of New York
Health Plan
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
VNSNY CHOICE Select Health
SNP Statewide
Female
Male
Inpatient
Total
Female
7.4
14.9 ▲
14.0
9.8
9.1
14.4 ▲
5.7 ▼
7.1
13.4
13.4
14.0
6.2
6.3
13.1 ▲
12.0
8.3
7.6
12.8 ▲
5.1 ▼
6.3
11.2
10.8
11.6
6.6
6.9
14.1 ▲
13.1
9.1
8.4
13.7 ▲
5.5 ▼
6.8
12.4
12.3
13.0
6.4
0.5
0.9
0.5
0.5
0.4
0.8
0.3
0.4
0.7
0.7
0.7
0.4
13.8
11.1
12.6
8.4
10.1
5.2 ▼
8.7
7.1
8.4
4.0 ▼
7.6
7.7
9.4
4.6 ▼
8.2
47.8 ▲
25.8
18.5 ▼
30.6
41.2 ▲
23.1
17.8 ▼
28.2
43.4 ▲
24.2
18.0 ▼
29.1
LEGEND
Male
Any Service
Total
0.7
0.9 ▲
0.5
0.5
0.5
0.7 ▲
0.3 ▼
0.4
0.7
0.7
0.6
0.5
0.6
0.9
0.5
0.5
0.4
0.8
0.3
0.4
0.7
0.7
0.6
0.4
0.5
0.5
0.5
0.6
0.5
0.5
-2.1 ▲
2.1 ▼
1.6
▲
▲
▼
▼
Female
Male
Total
7.5
15.0 ▲
14.1
9.9
9.2
13.4
5.8 ▼
7.2
13.5
13.6
14.5 ▲
6.3
6.6
13.3 ▲
12.1 ▲
8.4
7.7
11.8
5.2 ▼
6.3
11.4
11.1
12.0
6.8
7.1
14.2 ▲
13.2
9.2
8.5
12.6
5.5 ▼
6.8
12.6
12.5
13.4 ▲
6.5
0.5
13.9
11.2
12.7
0.5
0.5
0.4 ▼
0.5
0.5
0.6
0.4
0.5
8.4
10.2
5.3 ▼
8.8
7.1
8.6
4.2 ▼
7.7
7.8
9.4
4.7 ▼
8.3
-1.9 ▲
1.6 ▼
1.4
0.6 ▼
2.0 ▲
1.8
1.4
47.9 ▲
26.5
19.4 ▼
31.1
41.3 ▲
23.8
18.5 ▼
28.7
43.5 ▲
24.9
18.8 ▼
29.6
▲
▲
▼
▼
Results are a percentage of the eligible population.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
36 | P a g e
Use of Services
Section 3
Commercial HMO
Identification of Alcohol and Other Drug Services
Outpatient/
Emergency Room
Inpatient
Any Service
Health Plan
Female
Male
Total
Female
Male
Total
Female
Male
Total
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
0.9
1.8 ▲
0.7
0.9
0.8
1.2
1.1
1.1
0.7 ▼
1.1
0.9
1.6
3.4 ▲
1.5
2.1
1.6
2.5
2.5
2.0
1.2 ▼
2.7
1.9
1.3
2.5 ▲
1.1
1.5
1.1
1.8
1.8
1.5
0.9 ▼
1.9
1.4
0.2
0.3
0.3
0.2
0.3
0.2
0.3
0.2
0.2 ▼
0.3 ▲
0.2
0.6
0.4
0.5
0.4
0.6 ▲
0.4 ▼
0.5
0.4
0.4
0.4
0.4
0.4
0.4
0.4
0.3
0.4 ▲
0.3 ▼
0.4
0.3
0.3
0.4
0.3
1.0
1.2
1.0
1.1
0.9
1.3
1.2
1.2
0.8 ▼
1.3 ▲
1.0
2.0
2.2
2.0
2.2
1.9
2.7
2.7
2.3
1.5 ▼
3.0 ▲
2.1
1.5
1.6
1.4
1.6
1.4
2.0
2.0
1.7
1.1 ▼
2.1 ▲
1.5
LEGEND
Results are a percentage of the eligible population.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
2015 Health Plan Service Use in New York State Report
37 | P a g e
Use of Services
Section 3
Commercial PPO
Identification of Alcohol and Other Drug Services
Outpatient/
Emergency Room
Inpatient
Any Service
Health Plan
Female
Male
Total
Female
Male
Total
Female
Male
Total
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of
New York, Inc.
Statewide
0.7
1.0
0.6
0.6
0.2 ▼
0.6
1.1 ▲
0.6
1.4
2.0
1.1
1.4
0.4 ▼
-2.1 ▲
1.1
1.1
1.5
0.9
1.0
0.3 ▼
0.8
1.6 ▲
0.9
0.2
0.3 ▲
0.1 ▼
0.2
--0.2
0.2
0.4
0.5 ▲
0.2
0.5
0.1 ▼
-0.4
0.4
0.3
0.4 ▲
0.2
0.3
0.1 ▼
-0.3
0.3
0.8
1.1
0.7
0.8
0.2 ▼
0.7
1.1 ▲
0.8
1.6
2.2
1.3
1.8
0.5 ▼
1.7
2.3 ▲
1.3
1.2
1.6
1.0
1.3
0.3 ▼
1.0
1.7 ▲
1.0
0.7
1.2
0.9
0.2
0.3
0.3
0.7
1.4
1.1
0.7
1.3
1.0
0.2
0.4
0.3
0.8
1.6
1.2
LEGEND
Results are a percentage of the eligible population.
th
▲ 90 percentile or above
th
▼ 10 percentile or below
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
38 | P a g e
Use of Services
Section 3
Identification of Alcohol and Other Drug Services
Statewide Averages Across Payers
Gender Distribution of Alcohol and Other Drug Services Utilization for Commercial
HMO and PPO Payers
Percent of Members with Service (%)
2.5
2
1.5
1
0.5
0
Outpatient / Emergency Room
Inpatient
Any Service
Service Type
CO-Female
CO-Male
PPO-Female
PPO-Male
The graph presents the utilization of alcohol and other drug services by service type and gender for Commercial HMO (CO) and PPO (PPO) payers.
Commercial HMO has higher rates than PPO for both genders for Outpatient/Emergency Room. Males have higher rates than females for both
payers.
2015 Health Plan Service Use in New York State Report
39 | P a g e
Use of Services
Commercial HMO
Section 3
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Health Plan
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Initiation
Engagement
40
34
36
33 ▼
46 ▲
37
41
35
39
43
37
16
14
13
14 ▼
17
19 ▲
16
16
16
16
16
LEGEND
Results are a percentage of the eligible population.
▲ Significantly better than statewide average
▼ Significantly worse than statewide average
Note: Plans without symbols are not significantly different from the statewide average.
2015 Health Plan Service Use in New York State Report
40 | P a g e
Use of Services
Commercial PPO
Section 3
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Health Plan
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Initiation
38
35
40
40
30
-38
40
37
38
LEGEND
Engagement
17
17
22 ▲
17
7 ▼
-17
18
18
18
Results are a percentage of the eligible population.
▲ Significantly better than statewide average
▼ Significantly worse than statewide average
-- Sample too small to report
Note: Plans without symbols are not significantly different from the statewide average.
2015 Health Plan Service Use in New York State Report
41 | P a g e
Use of Services
Section 3
Commercial HMO
Health Plan
Plan All-Cause Readmissions
Expected Rate
O/E Ratio
13.54% ▲
11.93%
12.73%
10.77% ▼
12.88%
12.08%
11.13%
11.56%
12.23%
12.41%
12.16%
0.574
0.834
0.664
0.749
0.860
0.766
0.740
0.716
0.830
0.779
0.758
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
th
50 Percentile Expected Rate NYS
NOTES
®
The Expected Rate is the Average Adjusted Probability total rate, which is risk-adjusted as per HEDIS .
The O/E Ratio is the Observed-to-Expected Ratio: The ratio of the plan's observed rate of readmission to its expected rate of readmission. The ratio indicates
whether the plan's rate is higher or lower than expected after taking into account the plan’s risk factors. When the ratio is < 1.0, the plan performed better than
expected.
th
The statewide average is represented by the 50 Percentile Expected Rate for this measure.
LEGEND
th
▲ 90 percentile or above
th
▼ 10 percentile or below
2015 Health Plan Service Use in New York State Report
42 | P a g e
Use of Services
Section 3
Commercial PPO
Health Plan
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of New York, Inc.
th
50 Percentile Expected Rate NYS
Plan All-Cause Readmissions
Expected Rate
O/E Ratio
12.06%
11.28%
11.13%
12.57%
9.76%
8.62% ▼
11.61%
12.76%
12.93% ▲
11.61%
0.657
0.763
0.720
0.690
0.893
1.128
0.664
0.840
0.736
0.736
NOTES
®
The Expected Rate is the Average Adjusted Probability total rate, which is risk-adjusted as per HEDIS .
The O/E Ratio is the Observed-to-Expected Ratio: The ratio of the plan's observed rate of readmission to its expected rate of readmission. The ratio indicates
whether the plan's rate is higher or lower than expected after taking into account the plan’s risk factors. When the ratio is < 1.0, the plan performed better than
expected.
th
The statewide average is represented by the 50 Percentile Expected Rate for this measure.
LEGEND
th
▲ 90 percentile or above
th
▼ 10 percentile or below
2015 Health Plan Service Use in New York State Report
43 | P a g e
Antibiotic Utilization
Section 4
Antibiotics of concern in this report, as defined by HEDIS® 2015,
include the following antibiotic drug classes:
This section provides information on outpatient utilization of antibiotic
prescriptions for children, ages 0 to 17 years, and adults, ages 18
years and older, during the measurement year. Number of all
antibiotic prescriptions per 1,000 member years, number of
prescriptions per 1,000 member years for antibiotics of concern, and
percentage of antibiotics of concern for all antibiotic prescriptions are
presented in the following tables. Symbols are provided to indicate
whether the plan rate is above the 90th percentile (▲) or below the
10th percentile (▼) for all plans included in the tables.
2015 Health Plan Service Use in New York State Report







Amoxicillin/clavulanate
Azithromycin and clarithromycin
Cephalosporin (includes second, third, and fourth generation)
Clindamycin
Ketolide
Quinolone
Miscellaneous other antibiotics of concern.
44 | P a g e
Antibiotic Utilization
Section 4
Commercial HMO
Antibiotic Utilization
Children
Antibiotic
Prescriptions
Health Plan
Aetna
CDPHP
Empire
Excellus Blue Cross Blue Shield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
All
634 ▼
768
661
797 ▲
687
673
672
783
765
764
754
Concern
303
308
322
313
312
262 ▼
266
323
365 ▲
296
323
LEGEND
th
▲ 90 percentile or above
th
▼ 10 percentile or below
2015 Health Plan Service Use in New York State Report
Adults
%
Concern
of All
48
40
49
39
45
39
40
41
48
39
43
▲
▼
▼
▼
Antibiotic
Prescriptions
All
702 ▼
846
901 ▲
792
837
702
745
880
798
799
793
Concern
408
423
530 ▲
383
480
350 ▼
372
441
463
403
421
All
%
Concern
of All
58
50
59 ▲
48 ▼
57
50
50
50
58
50
53
Antibiotic
Prescriptions
All
690 ▼
831
859
793
814
697
730
864 ▲
792
792
786
Concern
390
401
493 ▲
368
455
333 ▼
351
421
444
381
402
%
Concern
of All
57 ▲
48
57 ▲
46 ▼
56
48
48
49
56
48
51
Rates are per 1,000 member years.
% Concern of All = Total prescriptions for antibiotics of concern/Total antibiotic prescriptions.
45 | P a g e
Antibiotic Utilization
Section 4
Commercial PPO
Antibiotic Utilization
Children
Antibiotic
Prescriptions
Health Plan
Aetna
CDPHP
CGLIC/CHLIC
Empire
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP
Oxford
UnitedHealthcare Insurance Company of
New York, Inc.
Statewide
All
Concern
Adults
%
Concern
of All
Antibiotic
Prescriptions
All
Concern
All
%
Concern
of All
739
784
743
741
613 ▼
633
746
840 ▲
341
330
338
338
299 ▼
323
306
399 ▲
46
42
45
46
49
51 ▲
41 ▼
48
797
765
784
814
719
633 ▼
780
935 ▲
444
391
437
451
409
347 ▼
395
533 ▲
56
51
56
55
57
55
51
57
765
350
46
770
429
758
347
46
804
445
LEGEND
th
▲ 90 percentile or above
th
▼ 10 percentile or below
2015 Health Plan Service Use in New York State Report
Antibiotic
Prescriptions
All
Concern
%
Concern
of All
786
768
775
798
699
633 ▼
774
913 ▲
424
380
416
428
389
345 ▼
379
502 ▲
54
49 ▼
54
54
56 ▲
55
49 ▼
55
56
769
412
54
55
794
425
54
▼
▲
▼
▲
Rates are per 1,000 member years.
% Concern of All = Total prescriptions for antibiotics of concern/Total antibiotic prescriptions.
46 | P a g e
Antibiotic Utilization
Section 4
Medicaid Health Plans
Antibiotic Utilization
Children
Antibiotic
Prescriptions
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus Blue Cross Blue Shield
Fidelis Care New York
HIP (EmblemHealth)
HealthNow New York Inc.
HealthPlus, an Amerigroup Company
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus
Total Care, A Today’s Options of New
York Health Plan
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
VNSNY CHOICE Select Health
SNP Statewide
All
Concern
Adults
%
Concern
of All
Antibiotic
Prescriptions
All
Concern
All
%
Concern
of All
Antibiotic
Prescriptions
%
Concern
of All
All
Concern
754
979
985
997
924
1,002 ▲
888
789
944
950
860
642 ▼
326
422
382
460 ▲
459
431
432
344
415
391
294 ▼
268 ▼
43
43
39 ▼
46
50 ▲
43
49
44
44
41
34 ▼
42
370
39 ▼
865
1,141
1,206 ▲
1,102
998
1,163
913
921
1,134
1,171
1,128
775 ▼
406 ▼
509
494
539
530
540 ▲
477
433
540
521
408
357 ▼
47
45
41 ▼
49
53 ▲
46
52
47
48
44
36 ▼
46
35
1,201 ▲
494
41 ▼
524 ▲
249
217
311
47 ▲
36
39
41
1,099
1,091
782 ▼
998
593 ▲
493
412
485
54 ▲
45
53 ▲
49
1,109 ▲
908
713 ▼
895
563 ▲
381
351
408
51 ▲
42
49
46
-107 ▼
-123
16 ▼
31
36 ▲
27
5,084 ▲
2,365
2,123 ▼
3,346
2,030 ▲
906
865 ▼
1,330
40
38 ▼
41 ▲
40
4,990 ▲
2,179
2,085 ▼
3,216
1,988 ▲
832 ▼
849
1,275
40
38 ▼
41 ▲
40
592
822
790
861 ▲
807
826
861
618
779
687
568
491 ▼
211
338
283
357
348
311
383 ▲
229
307
237
171 ▼
167 ▼
36
41
36
41
43
38
44
37
39
34
30
34
686
237
1,121 ▲
692
562 ▼
767
836 ▲
344 ▼
494
459
LEGEND
th
▲ 90 percentile or above
th
▼ 10 percentile or below
▲
▼
▼
▼
953
Rates are per 1,000 member years.
% Concern of All = Total prescriptions for antibiotics of concern/Total antibiotic prescriptions.
-- Sample too small to report
2015 Health Plan Service Use in New York State Report
47 | P a g e