QARR Report Series, Issue No. 4 of 5
2013
2013 Health Plan Service Use in New York State
A Report on the use of Inpatient, Emergency roo m, and Other Health Services
State of New York
Andrew M. Cuomo, Governor
Department of Health
Nirav R. Shah, M.D., M.P.H., Commissioner
Table of Contents
Mental Health Utilization
Section 1. Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Commercial Health Maintenance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Section 2. Access to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Commercial Preferred Provider Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Commercial Health Maintenance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Commercial Preferred Provider Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Identification of Alcohol and Other Drug Services
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Commercial Health Maintenance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Child Health Plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Commercial Preferred Provider Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Section 3. Use of Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Initiation and Engagement of Alcohol and Other Drug
Dependence Treatment
Outpatient Utilization
Commercial Health Maintenance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
Commercial Health Maintenance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Commercial Preferred Provider Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
Commercial Preferred Provider Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Plan All-Cause Readmissions
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Commercial Health Maintenance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Child Health Plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
Commercial Preferred Provider Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Frequency of Selected Procedures
Section 4. Prevention Quality Indicators (PQIs) and
Pediatric Quality Indicators (PDIs) . . . . . . . . . . . . . . . . . . . . . . .50
Commercial Health Maintenance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Commercial Preferred Provider Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Section 5. Antibiotic Utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Child Health Plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Commercial Health Maintenance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Commercial Preferred Provider Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Inpatient Use of Services
Commercial Health Maintenance Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Commercial Preferred Provider Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Child Health Plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Section 6. Technical Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
Child Health Plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
2013 Health Plan Service Use in New York State Report
2
Overview
Section 1
Introduction
Types of Insurance
The 2013 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 2013 New York State Managed Care Plan Performance Report and electronic Quality
Assurance Reporting Requirements (eQARR) 2013, which contain quality of care and
member satisfaction information. eQARR 2013 is an interactive, web-based report with
statewide and regional information, which is available at http://www.nyhealth.gov. The data
in this report reflects services provided during 2012.
Information on four types of managed care insurance is included in this report: Commercial
HMO (CO), Commercial PPO (PPO), Medicaid (MA), and Child Health Plus (CHP).
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.
This includes people who are eligible for Medicaid managed care and Family Health Plus (New York State’s [NYS] expansion program for
adults age 19 to 64).
Child Health Plus (CHP)
Government-sponsored health insurance, although individuals may pay part of the 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 New York State’s version of the federal State Children’s Health
Insurance Program (SCHIP) for people up to age 19.
2013 Health Plan Service Use in New York State Report
3
Overview
Section 1
Who Reports?
Audit Requirements
Managed care plans that were in operation during the
entire 2012 calendar year were required to report data.
This report contains information on 28 distinct organizations. Eleven organizations reported on commercial HMO
enrollees; 10 reported on Commercial PPO members; 17
reported on their Medicaid enrollees; 18 reported on Child
Health Plus enrollees; and 3 reported on HIV Special
Needs Plan (SNP) enrollees. One HIV SNP had only
partial year enrollment and the plan-specific results are
suppressed in this report, although the data were included
in the calculation of the statewide averages. 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 two plans (HealthNow 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.
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.
Data Sources
Data in this report are collected from Commercial HMOs,
PPOs, Medicaid, and Child Health Plus managed care
plans in compliance with 2013 Quality Assurance
Reporting Requirements (QARR) and NCQA 2013
Healthcare Effectiveness Data and Information Set
(HEDIS®) technical specifications and guidelines.
2013 Health Plan Service Use in New York State Report
Performance Ratings
Each section contains measures of access to care or
utilization of services with results for each plan and the
statewide average.
Access to Care measures, Initiation and Engagement of
Alcohol and Other Drug Dependence Treatment, as well as
Prevention Quality Indicators 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 whether the
plan performed above the 90th percentile (▲) or below the
10th 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.
4
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 Health Services 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: 518-486-9012
E-mail: [email protected]
Access to Care
Section 2
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.
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
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 7–19 years, within the last two years. The measure is divided into four age groups: 12–24 months, 25 months–6 years,
7–11 years, and 12–19 years (12–18 years for Child Health Plus). (CO, PPO, MA, CHP)
Adults’ Access to Preventive and
Ambulatory Health Services
The percentage of adults, 20 years of age 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: 20–44 years, 45–64 years, and 65 years and older. (CO, PPO, MA)
2013 Health Plan Service Use in New York State Report
5
Access to Care
Section 2
Commercial HMO
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Children and Adolescents’ Access to Primary Care Practitioners
12–24 Months
97
99
-85
99
96
100
100
100
99
97
97
25 Months–6 Years
94
97
86
91
97
93
96
97
96
96
94
95
▲
▼
▲
▼
▲
▲
▲
▲
LEGEND
▲
▼
95
99
86
92
99
95
98
99
98
97
96
96
▼
▲
▼
▼
▲
▼
▲
▲
▲
▲
12–19 Years
91
97
83
86
96
92
95
97
95
94
92
93
▼
▲
▼
▼
▲
▼
▲
▲
▲
▲
▼
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.
2013 Health Plan Service Use in New York State Report
▲
▼
▼
▲
▼
▲
▲
7–11 Years
6
Access to Care
Section 2
Commercial HMO
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Adults’ Access to Preventive and Ambulatory Health Services
20–44 Years
94
96
90
94
97
93
95
95
95
95
93
95
94
97
92
95
98
94
96
97
97
96
95
96
▼
▲
▼
▼
▲
▼
▼
LEGEND
▼
▲
▼
▼
▲
▼
▲
▲
65 Years and Older
95
98
84
95
98
93
98
98
98
97
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 from the statewide average.
2013 Health Plan Service Use in New York State Report
45–64 Years
7
Access to Care
Section 2
Commercial PPO
Health Plan
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Children and Adolescents’ Access to Primary Care Practitioners
12–24 Months
25 Months–6 Years
7–11 Years
98 ▲
99 ▲
97 ▲
93 ▼
94 ▼
95
96
99 ▲
98 ▲
96 ▲
95
94 ▲
97 ▲
94 ▲
90 ▼
90 ▼
93
91
96 ▲
95 ▲
92
92
95 ▲
98 ▲
95 ▲
92 ▼
91 ▼
94
95
98 ▲
96 ▲
96 ▲
94
LEGEND
92 ▲
96 ▲
92 ▲
88 ▼
88 ▼
90
93
94 ▲
94 ▲
92 ▲
90
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.
2013 Health Plan Service Use in New York State Report
12–19 Years
8
Access to Care
Section 2
Commercial PPO
Health Plan
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Adults’ Access to Preventive and Ambulatory Health Services
20–44 Years
45–64 Years
65 Years and Older
94
95 ▲
94
93 ▼
95 ▲
93 ▼
93
94
96 ▲
94
94
95
96 ▲
95
94 ▼
96 ▲
94 ▼
94 ▼
96 ▲
97 ▲
96 ▲
95
95 ▼
98 ▲
95 ▼
95 ▼
98 ▲
89 ▼
94 ▼
97
98 ▲
98 ▲
97
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.
2013 Health Plan Service Use in New York State Report
9
Access to Care
Section 2
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Children and Adolescents’ Access to Primary Care Practitioners
12–24 Months
25 Months–6 Years
7–11 Years
12–19 Years
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health’s MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
95 ▼
99 ▲
98 ▲
98 ▲
96 ▼
96
99 ▲
96
98 ▲
99 ▲
99 ▲
94 ▼
97
99 ▲
96
98
96
97
91 ▼
94 ▲
90 ▼
94 ▲
94 ▲
94 ▲
94
94 ▲
95 ▲
93
93
92 ▼
94
93
95 ▲
91 ▼
94
93
94 ▼
97 ▲
95 ▼
96
97 ▲
97 ▲
95
97 ▲
96
95
96
95 ▼
95 ▼
93 ▼
96
93 ▼
96
96
89 ▼
93
92
93
95 ▲
94 ▲
94 ▲
94 ▲
93
94
93
90 ▼
91 ▼
92
94 ▲
90 ▼
92
93
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
SNP Statewide
-100 ▲
88
-90 ▲
86
-94
93
-89 ▲
86
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 from the statewide average.
2013 Health Plan Service Use in New York State Report
10
Access to Care
Section 2
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Adults’ Access to Preventive and Ambulatory Health Services
20–44 Years
45–64 Years
65 Years and Older
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health’s MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
81 ▼
88 ▲
87 ▲
85 ▲
84
82 ▼
86 ▲
86 ▲
86 ▲
85 ▲
88 ▲
81 ▼
82 ▼
87 ▲
85 ▲
85 ▲
82 ▼
84
88 ▼
91
90
90
90
88 ▼
89
92 ▲
90
90
91
90
90
91
90
89 ▼
91
90
86 ▼
93
92
91 ▲
88 ▼
88 ▼
86
91 ▲
91
85
94
90
90
93
89
90
89
90
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
SNP Statewide
99 ▲
95 ▼
97
99
98 ▼
99
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 from the statewide average.
2013 Health Plan Service Use in New York State Report
-100
100
11
Access to Care
Section 2
Child Health Plus Managed Care Plans
Health Plan
Affinity Health Plan
CDPHP
Empire
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
Statewide
Children and Adolescents’ Access to Primary Care Practitioners
12–24 Months
100
100
99
100
100
100
99
100
98
100
--97
97 ▼
100
100
100
-100
LEGEND
7–11 Years
12–19 Years
95
97
97 ▲
96
96
98 ▲
96
97
96
96
99
98
92 ▼
95
96
97
97
95
96
97 ▼
99 ▲
99 ▲
98
98
99 ▲
98
98
98
98
97
99
95 ▼
97 ▼
98
98
98
98
98
95 ▼
98 ▲
99 ▲
97 ▲
95 ▼
99 ▲
96
97
96
96
100
98
91 ▼
95 ▼
98
98 ▲
95
97
96
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.
2013 Health Plan Service Use in New York State Report
25 Months–6 Years
12
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 above presents the differences in member access by payer and age group. Commercial HMO (CO), Commercial PPO (PPO) and Child Health Plus (CHP) payers are at or
above 90% for members regardless of age group. Medicaid (MA) is at or above 90% for all age groups except for members between 20 and 44 years of age.
*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.
2013 Health Plan Service Use in New York State Report
13
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 PPO, and Child Health Plus
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.
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.
Utilization rates for Outpatient Use of Services, Inpatient Use of Services, 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
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-to-expected 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. Rates are the percentage of
members who receive mental health services. (CO, PPO, MA)
Identification of Alcohol and
Other Drug 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)
2013 Health Plan Service Use in New York State Report
14
Use of Services
Section 3
Commercial HMO
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Outpatient Utilization
Emergency Room Visits
186
249
147
202
216
240
179
188
226
153
182
192
▲
▼
▲
▼
4,636
4,627
4,436
4,833
4,629
4,848
4,367
4,275
4,745
4,536
3,859
4,585
▲
▲
▼
▼
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
Outpatient Visits
15
Use of Services
Section 3
Commercial PPO
Health Plan
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Outpatient Utilization
Emergency Room Visits
160
213
162
181
204
301 ▲
186
221
152 ▼
193
188
4,431
4,252
4,409
4,735
4,139
4,522
4,766
4,135 ▼
4,944
5,424 ▲
4,793
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
Outpatient Visits
16
Use of Services
Section 3
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health’s MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
SNP Statewide
Outpatient Utilization
Emergency Room Visits
602
964
838
564
452
456
710
605
720
807
905
691
651
775
366
792
369
590
▲
▲
▼
▼
896
870
863
4,089
5,689
4,764
5,760
6,049
4,503
4,415
5,716
5,732
4,466
5,234
4,967
5,296
5,313
6,148
4,470
5,727
5,329
▼
▲
▼
▲
13,949
9,106
11,155
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
Outpatient Visits
17
Use of Services
Section 3
Child Health Plus Managed Care Plans
Health Plan
Affinity Health Plan
CDPHP
Empire
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
Statewide
Outpatient Utilization
Emergency Room Visits
313
359
196 ▼
354
291
218
250
306
324
359
300
229
396 ▲
361 ▲
217 ▼
229
328
248
290
2,732 ▼
4,564
5,436 ▲
4,069
4,045
4,763
3,325
3,897
3,777
4,167
4,082
4,855
3,234 ▼
3,393
4,463
5,190 ▲
3,825
4,365
4,194
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
Outpatient Visits
18
Use of Services
Section 3
Outpatient Utilization: Statewide Average Across Payers
Emergency Room Visits by Age Group
700
Rate (1,000 member years)
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 (MA) rates are higher than Commercial HMO (CO), Commercial PPO (PPO) and
Child Health Plus (CHP).
2013 Health Plan Service Use in New York State Report
19
Use of Services
Section 3
Commercial HMO
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Frequency of Selected Procedures
Angioplasty
Ages 45 and Above
Female
Male
2.1▲
1.3
-1.4
1.8
1.8
1.6
1.4
1.7
1.2▼
-1.5
Coronary Artery Bypass Graft
Ages 45 and Above
Female
Male
6.6
4.4▼
-7.5▲
6.8
6.4
5.3
5.8
6.2
6.7
5.8
6.3
---------0.2
-0.3
5.9
4.5
-5.4
5.7
5.8
6.2
5.6
5.8
3.7▼
6.3▲
5.1
8.0
6.7▼
-10.6
7.6
8.6
13.0▲
11.8
9.1
7.6
10.2
9.3
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
1.9
1.8
-1.2▼
2.0
1.5
1.4
2.1▲
1.9
1.5
-1.6
Cardiac Catheterization
Ages 45 and Above
Female
Male
20
Use of Services
Section 3
Commercial HMO
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Frequency of Selected Procedures
Laproscopic
Cholecystectomy
Female
Male
Ages
Ages
15 & Above
30 & Above
3.4
7.0▲
-3.6
5.5
3.1
6.0
6.1
6.2
3.0▼
6.1
4.3
1.8
3.3▲
-2.0
3.0
1.5▼
2.9
2.6
2.7
1.6
2.6
2.1
Back Surgery
Ages 20 & Above
Female
1.8
2.9
-1.9
3.5
1.3▼
3.7
3.5
3.8
1.6
3.8▲
2.3
2.1
3.4
-2.4
4.3▲
1.6▼
3.6
3.2
3.7
1.9
3.6
2.6
Female
Male
0.8
1.4
-1.2
1.4
0.9
1.3
0.8
1.6▲
0.7▼
-1.0
---0.3▲
-0.2▼
0.3
--0.3
-0.3
Prostatectomy
Ages 45 & Above
Male only
3.4
2.4▼
-2.6
4.0▲
2.4
2.8
2.9
3.7
2.8
2.7
2.9
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Male
Bariatric Weight Loss
Surgery
21
Use of Services
Section 3
Commercial HMO
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
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
4.5
4.4
-4.9 ▲
3.4
3.8
4.4
4.0
3.8
4.1
3.4 ▼
4.1
1.9 ▲
1.5
-1.3
1.7
1.0 ▼
1.2
1.3
1.6
1.5
1.4
1.4
3.7
2.1
-3.0
3.8 ▲
2.6
3.1
3.4
3.1
2.0 ▼
2.2
2.7
-1.5
-0.8
1.3
0.6
1.9 ▲
1.9
1.3
0.5 ▼
1.9
1.0
2.9 ▼
6.3
-3.3
6.1
2.9
8.6 ▲
7.8
7.0
3.9
7.9
5.0
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
22
Use of Services
Section 3
Commercial PPO
Health Plan
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Frequency of Selected Procedures
Angioplasty
Ages 45 and Above
Female
Male
1.8
1.5
1.4
1.4
1.8
2.4▲
--1.2▼
2.2
1.8
6.2
5.6
6.1
5.5▼
6.6
7.4▲
6.7
5.8
6.1
7.2
6.4
0.4
--0.3
0.3▼
----0.6▲
0.4
1.8
1.9▲
1.1
1.4
1.6
1.1▼
-1.3
1.3
1.9
1.6
Cardiac Catheterization
Ages 45 and Above
Female
Male
4.5
4.9
4.2
5.1
5.4
5.4
4.9
4.2
3.2▼
6.9▲
5.5
7.4
6.8▼
8.5
8.2
8.7
9.3
7.7
8.1
6.9
10.1▲
8.8
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Coronary Artery Bypass Graft
Ages 45 and Above
Female
Male
23
Use of Services
Section 3
Commercial PPO
Health Plan
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Frequency of Selected Procedures
Laproscopic
Cholecystectomy
Female
Male
Ages
Ages
15 & Above 30 & Above
3.2
6.0
3.3
4.4
6.0▲
3.2
3.5
5.8
2.4▼
3.9
4.1
1.7
2.7▲
1.8
2.1
2.6
1.9
-2.6
1.5▼
2.4
2.2
Bariatric Weight Loss
Surgery
Female
Male
Female
2.1
3.3
1.8
2.7
3.5▲
1.6▼
-2.7
2.3
2.5
2.5
2.3
3.2
2.1
2.9
3.7▲
2.1▼
-3.4
2.7
3.0
2.9
0.7
1.1
0.5▼
1.0
1.6▲
0.9
-1.4
0.7
1.0
1.0
Male
0.2
-0.2▼
0.3
0.4▲
0.3
--0.2
0.4
0.3
Prostatectomy
Ages 45 & Above
Male only
3.3
2.2
2.5
2.5
2.8
2.6
-2.1▼
3.6
3.6▲
3.0
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Back Surgery
Ages 20 & Above
24
Use of Services
Section 3
Commercial PPO
Health Plan
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Frequency of Selected Procedures for Women and Children
Lumpectomy
Ages 15 & Above
Mastectomy
Ages 15 & Above
4.2
4.4
4.0
3.7
3.3 ▼
4.4
4.9 ▲
4.0
4.8
4.6
4.1
1.5
1.5
1.3 ▼
1.3
1.4
1.5
-1.4
1.6 ▲
1.4
1.4
2.3
1.9
2.3
2.6
3.4
2.9
3.2
3.6 ▲
1.8 ▼
2.2
2.5
Vaginal
Hysterectomy
Ages 15 & Above
0.7
1.2
0.6 ▼
1.4
2.0 ▲
0.9
-1.1
0.7
0.8
1.1
Tonsillectomy
Ages 0–19
4.0
6.1
3.8
4.7
6.8▲
3.8▼
-5.2
3.9
4.8
4.8
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Abdominal
Hysterectomy
Ages 15 & Above
25
Use of Services
Section 3
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health’s MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
Frequency of Selected Procedures
Angioplasty
Ages 45 and Above
Female
Male
2.5 ▼
-4.5 ▲
3.0
1.9 ▼
3.8
-3.0
4.3
--4.4
4.9 ▲
-3.3
-3.4
3.4
8.3 ▼
9.4
9.4
9.2
8.9 ▼
11.1
-9.2
9.1
--12.3 ▲
13.4 ▲
-10.0
-12.0
9.9
---0.4 ▼
---0.5 ▲
---------0.5
1.5
--1.8
1.5
1.4 ▼
-1.5
---1.8
2.4 ▲
-1.7
--1.7
Cardiac Catheterization
Ages 45 and Above
Female
Male
10.0
10.8
12.3
9.6
7.6 ▼
9.9
17.0 ▲
10.3
12.5
17.1 ▲
15.5
9.6
13.4
12.8
7.9 ▼
13.0
10.2
10.1
14.3
16.1
13.3
13.4
13.0 ▼
13.4
22.5 ▲
14.1
16.5
13.8
13.6
14.7
16.8 ▲
15.8
13.3
10.5 ▼
13.3
14.0
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Coronary Artery Bypass Graft
Ages 45 and Above
Female
Male
26
Use of Services
Section 3
Medicaid Health Plans
Frequency of Selected Procedures
Laproscopic
Cholecystectomy
Medicaid Managed Care Plans (MMC)
Female
Ages 15–64
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health’s MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
5.0
11.4 ▲
10.5
6.7
3.6
2.0 ▼
10.6 ▲
4.2
9.4
7.3
8.5
3.9
5.4
9.2
4.3
7.8
3.3 ▼
5.3
Back Surgery
Ages 20–64
Male
Ages 30–64
Female
1.6 ▼
3.6 ▲
3.4 ▲
2.8
1.6
1.7
-1.8
---1.2 ▼
1.7
-1.8
-2.1
2.1
1.0
5.9 ▲
4.4
2.4
1.6
0.8 ▼
6.2 ▲
1.2
3.3
5.4
4.0
0.7 ▼
1.2
3.3
1.3
4.8
-1.8
1.3
7.2 ▲
5.6
2.9
2.3
1.2 ▼
6.3 ▲
1.5
4.1
5.3
6.1
0.9 ▼
1.5
-1.5
5.8
-2.3
Female
Male
0.9
1.4
1.2
1.1
1.1
0.4 ▼
1.6 ▲
1.0
1.5 ▲
--0.4 ▼
0.6
-0.8
--0.9
---0.3
0.4 ▲
--0.2 ▼
------0.2
--0.2
Prostatectomy
Ages 45 and Above
Male only
1.9
--1.9
1.9
1.6 ▼
-2.5
---1.7
3.7 ▲
-2.2
--2.1
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Male
Bariatric Weight Loss
Surgery
Ages 0–64
27
Use of Services
Section 3
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health’s MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
Frequency of Selected Procedures for Women and Children
Lumpectomy
Ages 15–64
Mastectomy
Ages 15–64
3.0
3.3
2.4 ▼
3.6 ▲
3.6
3.3
3.3
3.0
3.1
3.2
-2.6 ▼
3.7 ▲
-3.6
2.7
2.8
3.2
0.6
-0.5 ▼
0.7
0.6
0.6
-0.7
---0.5
1.2 ▲
-0.8
--0.7
2.2
2.4
5.3 ▲
2.5
1.8 ▼
2.0
3.5
2.5
4.0
4.2 ▲
3.9
1.5 ▼
2.2
3.3
2.1
2.9
1.9
2.4
Vaginal
Hysterectomy
Ages 15–64
0.6
1.6
2.3 ▲
1.2
0.5
0.4 ▼
1.8
0.7
-2.2 ▲
-0.4 ▼
0.6
-0.7
--0.9
Tonsillectomy
Ages 0–19
4.0
8.4
7.7
5.5
3.0
3.0
12.1 ▲
3.1
4.9
10.6
7.2
2.1 ▼
4.5
6.2
3.5
11.4 ▲
2.1 ▼
4.4
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Abdominal
Hysterectomy
Ages 15–64
28
Use of Services
Section 3
Child Health Plus Managed Care Plans
Health Plan
Frequency of Selected Procedures for Children
Tonsillectomy
Ages 0–19
Affinity Health Plan
CDPHP
Empire
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
Statewide
4.0
9.9
4.3
9.5
6.4
3.4
2.4 ▼
12.4
2.9 ▼
3.6
---5.2
13.3 ▲
4.7
13.4 ▲
-5.6
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
29
Use of Services
Section 3
Frequency of Selected Procedures: Statewide Average 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
0
14
12
10
8
6
4
2
0
CO
PPO
CO
MA
MA
Payer
Payer
Female
PPO
Female
Male
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.
2013 Health Plan Service Use in New York State Report
30
Use of Services
Section 3
Commercial HMO
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Inpatient Use of Services: Discharges and Total Days
Medicine
Discharges
Total Days
27
18 ▼
23
27 ▲
21
35 ▲
15 ▼
21
24
23
19
24
109 ▲
69
91
104
66
142 ▲
57 ▼
70
99
86
61 ▼
90
Surgery
Discharges
Total Days
18
19
14
17
19
17
13 ▼
22 ▲
19
14 ▼
20 ▲
16
94
107▲
77
102
72
102
64▼
103▲
77
72▼
85
84
13 ▲
10
4▼
13 ▲
12
8▼
10
12
10
13
12
11
41 ▲
28
13 ▼
39
33
23 ▼
26
35
27
41 ▲
31
33
Total
Discharges
Total Days
56
47
42 ▼
56 ▲
50
59 ▲
36 ▼
54
53
49
49
50
239
200
181
240 ▲
167 ▼
265 ▲
141 ▼
203
206
193
173
203
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
Maternity
Discharges
Total Days
31
Use of Services
Section 3
Commercial HMO
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Inpatient Use of Services: Average Length of Stay
Medicine
ALOS
Surgery
ALOS
Maternity
ALOS
4.1 ▲
3.8
3.9
3.8
3.2 ▼
4.0
3.9
3.3
4.1 ▲
3.7
3.3 ▼
3.8
5.1
5.5
5.5
5.8 ▲
3.9 ▼
6.1 ▲
4.7
4.7
3.9 ▼
5.1
4.2
5.1
3.1 ▲
2.7
3.0
2.9
2.7
3.0
2.8
2.8
2.6 ▼
3.2 ▲
2.6 ▼
2.9
4.2
4.3
4.3 ▲
4.3
3.3 ▼
4.5 ▲
4.0
3.8
3.9
4.0
3.5 ▼
4.1
ALOS = Total Days/Total Discharges
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
Total Inpatient
ALOS
32
Use of Services
Section 3
Commercial PPO
Health Plan
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Inpatient Use of Services: Discharges and Total Days
Medicine
Discharges Total Days
19
18 ▼
19
19
19
24
29 ▲
19
23
NV
20
77
68
79
67
55 ▼
103 ▲
102
72
85
NV
72
15
18
14 ▼
15
17
18 ▲
17
16
15
NV
16
68
96 ▲
72
76
64
94
86
60 ▼
75
NV
74
Maternity
Discharges Total Days
16 ▲
12
14
16
13
13
6▼
12
14
NV
14
48 ▲
33
44
45
34
37
18 ▼
30
44
NV
42
Total
Discharges Total Days
47
46
45
48
47
54 ▲
51
45 ▼
50
NV
48
185
192
188
182
149 ▼
229 ▲
205
163
197
NV
182
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
NV Plan submitted invalid data
2013 Health Plan Service Use in New York State Report
Surgery
Discharges Total Days
33
Use of Services
Section 3
Commercial PPO
Health Plan
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Inpatient Use of Services: Average Length of Stay
Medicine
ALOS
4.1
3.8
4.1
3.6
3.0 ▼
4.2 ▲
3.5
3.9
3.7
NV
3.7
Maternity
ALOS
Total Inpatient
ALOS
4.7
5.4 ▲
5.1
4.9
3.7 ▼
5.1
5.2
3.8
5.0
NV
4.7
3.0
2.8
3.2 ▲
2.9
2.6 ▼
3.0
3.0
2.6
3.1
NV
2.9
4.0
4.2
4.2
3.8
3.1 ▼
4.3 ▲
4.0
3.6
3.9
NV
3.8
ALOS = Total Days/Total Discharges
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
NV Plan submitted invalid data
2013 Health Plan Service Use in New York State Report
Surgery
ALOS
34
Use of Services
Section 3
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Inpatient Use of Services: Discharges and Total Days
Medicine
Discharges
Total Days
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health’s MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
SNP Statewide
53
51
43
41
54
35 ▼
35
62 ▲
43
51
43
54
59 ▲
55
31 ▼
40
39
47
311
275
291
Surgery
Discharges Total Days
210
241 ▲
128
154
221
140
129
231
169
180
163
205
236 ▲
225
124 ▼
116 ▼
129
180
1,434
1,482
1,451
101
116
83
113
116
63 ▼
97
97
153 ▲
179 ▲
69 ▼
76
95
88
82
105
83
96
30
28
37
268
275
326
50
47
47
36
27 ▼
40
39
54
69 ▲
48
42
54
60 ▲
52
41
44
17 ▼
45
7
9
6
152
128
120
98
79 ▼
118
102
162
205 ▲
137
114
161
181 ▲
144
111
119
37 ▼
128
28
30
24
Total
Discharges
Total Days
103
103
97
87
90
75
77
115 ▲
111
112
89
103
116 ▲
109
73 ▼
96
64 ▼
95
348
311
335
423
446
295
340
394
288
289
443
452
458 ▲
318
391
456 ▲
414
287 ▼
308
242 ▼
368
1,730
1,785
1,800
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
14
19
20
20
17
11 ▼
17
15
24 ▲
27 ▲
17
12
16
17
12
24
11 ▼
16
Maternity
Discharges
Total Days
35
Use of Services
Section 3
Medicaid Health Plans
Inpatient Use of Services: Average Length of Stay
Medicine
ALOS
Surgery
ALOS
Maternity
ALOS
Total Inpatient
ALOS
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health’s MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
4.0
4.8 ▲
3.0 ▼
3.8
4.1 ▲
4.0
3.7
3.7
3.9
3.6
3.8
3.8
4.0
4.1
4.0
2.9 ▼
3.3
3.8
7.4 ▲
6.1
4.1 ▼
5.6
6.9
5.7
5.7
6.6
6.5
6.6
4.1 ▼
6.3
6.1
5.0
6.6
4.4
7.2 ▲
6.1
3.1 ▲
2.7
2.5 ▼
2.7
2.9
2.9
2.6
3.0
3.0
2.9
2.7
3.0
3.0 ▲
2.8
2.7
2.7
2.2 ▼
2.9
4.1
4.4 ▲
3.1 ▼
3.9
4.4 ▲
3.8
3.8
3.9
4.1
4.1
3.6
3.8
3.9
3.8
3.9
3.2 ▼
3.8
3.9
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
SNP Statewide
4.6
5.4
5.0
8.9
9.8
8.7
4.0
3.4
3.7
5.0
5.7
5.4
Medicaid Managed Care Plans (MMC)
ALOS = Total Days/Total Discharges
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
36
Use of Services
Section 3
Child Health Plus Managed Care Plans
Health Plan
Affinity Health Plan
CDPHP
Empire
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
Statewide
Inpatient Use of Services: Discharges and Total Days
Medicine
Discharges
Total Days
14
11
11
8▼
10
11
12
10
17 ▲
10
-14
14
20 ▲
-9▼
11
12
11
41
34
29
20 ▼
27
29
33
32
57 ▲
31
44
27
46
68 ▲
23
29
21 ▼
41
33
5
4
4
4▼
5
5
4
3▼
6
6▲
--6
7▲
-4
--5
23
20
22
11 ▼
18
26 ▲
18
22
19
24
-19
25
28 ▲
-15
12 ▼
20
19
Total
Discharges
20
17
15
12 ▲
16
17
17
14
24 ▲
17
-18
21
29 ▲
11 ▼
13
15
20
17
Total Days
69
57
52
32 ▼
49
55
55
55
78 ▲
58
60
46
75
101 ▲
33 ▼
45
37
67
54
Rates are per 1,000 member years.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Surgery
Discharges
Total Days
37
Use of Services
Section 3
Child Health Plus Managed Care Plans
Health Plan
Affinity Health Plan
CDPHP
Empire
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
Statewide
Inpatient Use of Services: Average Length of Stay
Medicine
ALOS
Surgery
ALOS
3.0
3.1
2.8
2.4
2.8
2.5
2.7
3.1
3.3
3.2
-1.9
3.4
3.3
-3.3
2.0
3.3
2.9
4.7
4.7
5.1
3.1
3.7
4.7
5.0
7.1
3.1
3.7
--4.4
4.1
-3.6
--4.1
▲
▼
▲
▼
▲
▼
3.4
3.4
3.4
2.6
3.1
3.2
3.3
4.0
3.3
3.3
-2.6
3.6
3.5
2.9
3.4
2.4
3.4
3.3
▲
▼
▲
▼
ALOS = Total Days/Total Discharges
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
▲
▼
Total Inpatient
ALOS
38
Use of Services
Section 3
Inpatient Use of Services: Statewide Average Across Payers
Inpatient Discharges by Category
Inpatient Average Length of Stay by Category
100
7
6
80
Average Length of Stay
(per 1,000 member years)
Discharges
(per 1,000 member years)
90
70
60
50
40
30
20
5
4
3
2
1
10
0
0
Medicine
Surgery
Maternity
Total
Medicine
Service Category
CO
PPO
Surgery
Maternity
Total
Service Category
MA
CO
PPO
MA
The graph on the left illustrates the distribution of inpatient discharges by service category for Medicaid (MA), Commercial HMO (CO) and Commercial PPO (PPO) payers. MA has
the highest medicine and maternity discharge rates, which leads to the highest total inpatient discharge rate for MA. The graph on the right shows the inpatient average length of stay is
similar across payers for each category even though the discharge rate varies across payers.
2013 Health Plan Service Use in New York State Report
39
Use of Services
Section 3
Commercial HMO
Mental Health Utilization
Health Plan
Outpatient/
Emergency Room
Female
Male
Total
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
8.0
11.5 ▲
3.9 ▼
6.6
9.4 ▲
6.3 ▼
9.0
9.2
8.1
7.4
6.9
7.9
6.1
8.3 ▲
3.6 ▼
4.7 ▼
6.5 ▲
4.8
6.2
6.3
5.8
5.3
4.8
5.6
7.1
10.0 ▲
3.7 ▼
5.7
8.1 ▲
5.6 ▼
7.6
7.8
7.0
6.4
5.9
6.8
0.2
0.4 ▲
-0.2
0.2 ▼
0.2
0.3
0.3
0.2
0.2
0.2
0.2
0.2
0.3 ▲
-0.2
0.1 ▼
0.2
0.3
0.2
0.2
0.2
0.2
0.2
Total
0.2
0.3 ▲
-0.2
0.2 ▼
0.2
0.3
0.2
0.2
0.2
0.2
0.2
Any Service
Female
Male
8.1
11.5 ▲
3.9 ▼
6.7
9.5 ▲
6.4 ▼
9.1
9.2
8.2
7.5
6.9
7.9
6.2
8.3▲
3.7▼
4.8 ▼
6.5▲
4.8
6.2
6.3
5.9
5.4
4.8
5.7
Total
7.2
10.0 ▲
3.8 ▼
5.7
8.1 ▲
5.6 ▼
7.7
7.8
7.1
6.5
5.9
6.9
Results are a percentage of the eligible population.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Inpatient
Female
Male
40
Use of Services
Section 3
Commercial PPO
Mental Health Utilization
Health Plan
Outpatient/
Emergency Room
Female
Male
Total
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
10.2
10.1
8.4
7.5
8.3
6.2
4.4 ▼
7.8
12.5 ▲
10.0
9.0
7.2
6.7
6.1
5.3
5.5
4.7
4.4 ▼
5.4
9.5 ▲
7.5
6.5
8.7
8.4
7.2
6.4
6.9
5.5
4.4 ▼
6.6
11.1 ▲
8.8
7.7
0.2
0.3 ▲
0.2 ▼
0.2
0.2
0.2
-0.2
0.2
0.2
0.2
0.2
0.2 ▲
0.1 ▼
0.2
0.2
0.2
-0.1
0.2
0.1
0.2
Total
0.2
0.3 ▲
0.2 ▼
0.2
0.2
0.2
0.2
0.2
0.2
0.2
0.2
Female
Any Service
Male
Total
10.2
10.1
8.5
7.6
8.3
6.2
4.4 ▼
7.8
12.5 ▲
10.0
9.0
7.3
6.7
6.1
5.3
5.5
4.8
4.5 ▼
5.4
9.5 ▲
7.5
6.5
8.8
8.4
7.3
6.4
6.9
5.5
4.5 ▼
6.6
11.1 ▲
8.8
7.8
Results are a percentage of the eligible population.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Female
Inpatient
Male
41
Use of Services
Section 3
Medicaid Health Plans
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health’s MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
SNP Statewide
Mental Health Utilization
Outpatient/
Emergency Room
Female
Male
Total
Inpatient
Female
Male
Total
Any Service
Female
Male
Total
8.7
14.6
13.8
9.1
7.8
5.1 ▼
15.9 ▲
7.3
12.7
12.1
16.7 ▲
8.9
6.5
15.2
7.6
10.9
5.4 ▼
8.6
7.7
12.6
11.5
7.7
6.6
4.3 ▼
13.7 ▲
6.6
10.8
9.9
13.8 ▲
9.7
5.8
12.2
6.1
8.8
4.1 ▼
7.6
8.3
13.7
12.8
8.5
7.3
4.8 ▼
14.9 ▲
7.0
11.9
11.1
15.5 ▲
9.3
6.2
13.9
6.9
10.0
4.8 ▼
8.2
0.4
1.2 ▲
0.6
0.5
0.4
0.3 ▼
1.2 ▲
0.3
0.7
0.8
0.7
0.4
0.3 ▼
0.7
0.4
0.7
0.3
0.4
0.4
1.3 ▲
0.6
0.6
0.5
0.3 ▼
1.2 ▲
0.4
0.8
0.7
0.6
0.4
0.4
0.8
0.4
0.9
0.3 ▼
0.5
0.4
1.2 ▲
0.6
0.6
0.5
0.3 ▼
1.2 ▲
0.4
0.8
0.7
0.7
0.4
0.4
0.7
0.4
0.8
0.3 ▼
0.5
8.8
14.8
13.9
9.3
8.0
5.2 ▼
14.4
7.3
12.8
12.3
17.0 ▲
8.3
6.6
15.5 ▲
7.6
10.9
5.5 ▼
8.6
7.9
12.9▲
11.6
7.9
6.8
4.4▼
12.1
6.7
10.9
10.0
14.1▲
8.9
5.9
12.6
6.1
8.9
4.2▼
7.6
8.4
14.0
12.9
8.7
7.5
4.8 ▼
13.4
7.1
12.0
11.3
15.7 ▲
8.5
6.3
14.2 ▲
6.9
10.0
4.9 ▼
8.2
38.2
28.9
31.1
36.5
26.8
30.9
37.1
27.7
30.9
3.2
1.5
2.1
2.2
1.3
1.7
2.5
1.4
1.8
38.8
29.1
31.6
37.0
27.0
31.4
37.7
27.9
31.5
Results are a percentage of the eligible population.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
42
Use of Services
Section 3
Commercial HMO
Health Plan
Identification of Alcohol and Other Drug Services
Outpatient/
Emergency Room
Female
Male
Total
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
0.7
1.1
0.6 ▼
0.7
0.8
0.7
1.1 ▲
1.1 ▲
1.0
0.6 ▼
1.0
0.8
1.2 ▼
2.1
1.3
1.5
1.9
1.5
2.4 ▲
2.4
1.8
1.1 ▼
2.5 ▲
1.7
0.9
1.5
0.9 ▼
1.1
1.3
1.0
1.8 ▲
1.7
1.3
0.8 ▼
1.8 ▲
1.2
0.2
0.2
-0.2
0.2 ▼
0.2
0.2
0.3 ▲
0.2
0.2
0.3
0.2
0.5
0.4
-0.5
0.4
0.5 ▲
0.3 ▼
0.5
0.5
0.4
0.5
0.4
Total
0.3
0.3
-0.4
0.3
0.4
0.3 ▼
0.4 ▲
0.3
0.3
0.4
0.3
Any Service
Female
Male
0.8
1.1
0.8 ▼
0.9
0.9
0.8
1.2 ▲
1.2 ▲
1.1
0.7 ▼
1.2
0.9
1.5
2.2
1.4 ▼
1.8
2.1
1.8
2.5
2.6 ▲
2.0
1.4 ▼
2.8 ▲
1.9
Total
1.1
1.6
1.1 ▼
1.3
1.5
1.2
1.9
1.9 ▲
1.5
1.0 ▼
2.0 ▲
1.4
Results are a percentage of the eligible population.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
- - Sample too small to report
2013 Health Plan Service Use in New York State Report
Inpatient
Female
Male
43
Use of Services
Section 3
Commercial PPO
Health Plan
Identification of Alcohol and Other Drug Services
Outpatient/
Emergency Room
Female
Male
Total
Female
Inpatient
Male
Total
Female
Any Service
Male
Total
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
0.7
1.0 ▲
0.6 ▼
0.7
0.9
0.6
0.7
0.9
0.6
0.7
1.3
2.0
1.2
1.2
2.0 ▲
1.3
1.8
1.7
1.0 ▼
1.4
1.0
1.5 ▲
0.9
0.9
1.5
1.0
1.1
1.3
0.8 ▼
1.0
0.2
0.3 ▲
0.1 ▼
0.2
0.2
0.2
0.2
0.2
0.2
0.2
0.4
0.6 ▲
0.3 ▼
0.3
0.4
0.4
0.5
0.4
0.4
0.3
0.3
0.4 ▲
0.2 ▼
0.3
0.3
0.3
0.3
0.3
0.3
0.2
0.8
1.0
0.6 ▼
0.8
1.0 ▲
0.8
0.8
1.0
0.7
0.7
1.5
2.1
1.3
1.4
2.2 ▲
1.5
2.1
1.9
1.2 ▼
1.5
1.1
1.6
1.0
1.1
1.6 ▲
1.1
1.3
1.4
1.0 ▼
1.1
Statewide
0.7
1.4
1.0
0.2
0.4
0.3
0.8
1.5
1.2
Results are a percentage of the eligible population.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
44
Use of Services
Section 3
Statewide Average Across Payers
Identification of Alcohol and Other Drug Services
Percent of Members with Service (%)
Gender Distribution of Alcohol and Other Drug Services Utilization for Commercial HMO and PPO Payers
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
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.
2013 Health Plan Service Use in New York State Report
45
Use of Services
Commercial HMO
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Section 3
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Initiation
Engagement
54
44
40
42
34
44
38
43
39
44
41
42
16
21
10
19
12
14
17
17
14
16
14
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.
2013 Health Plan Service Use in New York State Report
▲
46
Use of Services
Commercial PPO
Health Plan
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Section 3
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Initiation
52 ▲
43
40
45 ▲
35 ▼
41
45
41
45 ▲
38 ▼
42
20 ▲
18
18
18
14 ▼
13 ▼
14
15
19
20 ▲
18
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.
2013 Health Plan Service Use in New York State Report
Engagement
47
Use of Services
Section 3
Commercial HMO
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of New York
Empire
Excellus Blue Cross Blue Shield
HIP
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera HealthCare
50th Percentile Expected Rate NYS
Plan All-Cause Readmissions
Expected Rate
O/E Ratio
11.94%
11.19%
11.11%
11.99%
10.45% ▼
12.31% ▲
11.58%
11.06%
11.29%
11.23%
10.99%
11.23%
0.719
0.739
0.748
0.781
0.809
0.697
0.661
0.722
0.669
0.767
0.801
0.741
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.
The statewide average is represented by the 50th Percentile Expected Rate for this measure.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
48
Use of Services
Section 3
Commercial PPO
Health Plan
Aetna
CDPHP
Connecticut General Life Insurance Company
Empire
Excellus Blue Cross Blue Shield
GHI PPO
HIP
MVP
Oxford
United Healthcare Insurance PPO
50th Percentile Expected Rate NYS
Plan All-Cause Readmissions
Expected Rate
O/E Ratio
10.46%
11.23%
10.31% ▼
11.02%
10.73%
11.92%
12.32% ▲
11.01%
11.63%
11.05%
11.03%
0.743
0.748
0.752
0.764
0.767
0.754
0.826
0.723
0.794
0.772
0.750
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.
The statewide average is represented by the 50th Percentile Expected Rate for this measure.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
49
Prevention Quality Indicators (PQIs) and Pediatric Quality Indicators (PDIs)
Prevention Quality Indicators (PQIs) and Pediatric Quality Indicators (PDIs) quantify
hospital admissions that most likely could have been avoided through effective outpatient
care. PQIs/PDIs include specific diagnoses that can be managed without hospitalization.
There are two adult PQI measures and two child PDI measures in this section. The child
measures include one asthma measure and one composite measure that represents all
other qualifying discharge diagnoses excluding the asthma measure. The adult measures
include one respiratory composite measure of asthma and chronic obstructive pulmonary
disease (COPD), and one composite measure of all other qualifying discharge diagnoses
excluding the respiratory components. The asthma/respiratory specific measures were
separated from the composites due to the volume of ‘at-risk’ admissions. The goal of
PQIs/PDIs is to have fewer potentially avoidable hospital admissions; therefore a lower
Section 4
rate is desirable. Symbols are provided to indicate whether the plan performed statistically
significantly better (▲) or worse (▼) than the statewide average.
Since certain demographic factors, such as age and health status, can influence the
likelihood that an enrollee will experience a PQI admission, the results are risk adjusted to
allow for more accurate comparison between a plan’s result and the statewide average.
Details about the indicators used in the composites, the criteria for qualifying hospital
admissions, and the factors used in risk adjustment are available in the Technical Notes
Section.
The data source for these measures is the Medicaid managed care data for hospital
admissions which occurred in calendar year 2012. NYS DOH calculates these results and
only Medicaid managed care data are presented.
Measure
Description (Type of Insurance)
Adult Respiratory PQI
The percentage of hospital admissions for adults that are potentially avoidable. This is a measure of potentially avoidable admissions for
asthma in young adults (ages 18-39) and chronic obstructive pulmonary disease (COPD) in adults. The plan results are risk-adjusted.
A low rate is desirable. (MA)
Adult Composite PQI
(Excludes Respiratory)
The percentage of hospital admissions for adults that are potentially avoidable. This is a composite measure of nine indicators,
representing potentially avoidable admissions for diagnoses including diabetes, angina, hypertension, congestive heart failure, dehydration,
bacterial pneumonia, and urinary tract infections. The plan results are risk-adjusted. A low rate is desirable. (MA)
Pediatric Asthma PDI
The percentage of hospital admissions for children that are potentially avoidable. This is a measure of potentially avoidable admissions for
asthma. The plan results are risk-adjusted. A low rate is desirable. (MA)
Pediatric Composite PDI
(Excludes Asthma)
The percentage of hospital admissions for children that are potentially avoidable. This is a composite measure of three indicators,
representing potentially avoidable admissions for diagnoses including diabetes, gastroenteritis, and urinary tract infections. The plan results
are risk-adjusted. A low rate is desirable. (MA)
2013 Health Plan Service Use in New York State Report
50
Prevention Quality Indicators (PQIs) and Pediatric Quality Indicators (PDIs)
Medicaid Health Plans
Prevention Quality Indicators (PQIs)
Adult Respiratory PQI
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health's MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
PQI
At Risk Admissions
3,672
1,357
3,393
13,488
4,486
4,515
1,032
13,211
1,782
1,037
697
8,514
4,612
816
4,151
783
1,232
68,778
LEGEND
Adjusted PQI*
7.40
7.26
6.13
6.91
6.18
8.16
6.92
7.63
7.39
6.74
6.32
8.10 ▼
7.42
4.82
6.92
4.89
4.97 ▲
7.20
Adult Composite PQI
(Except Respiratory Components)
PQI
Adjusted PQI*
At Risk Admissions
3,679
1,359
3,403
13,501
4,487
4,517
1,032
13,219
1,785
1,038
699
8,521
4,612
818
4,160
783
1,232
68,845
13.00
12.72
14.06
13.34
13.65
12.42
16.51
12.79
14.05
15.24
15.66
14.51 ▼
14.03
14.06
12.95
15.00
11.31
13.48
Results are a percentage of “at risk” admissions.
▲ Significantly better than statewide average
▼ Significantly worse than statewide average
* A lower rate is desirable for this measure
Note: Plans without symbols are not significantly different from the statewide average.
2013 Health Plan Service Use in New York State Report
Section 4
51
Prevention Quality Indicators (PQIs) and Pediatric Quality Indicators (PDIs)
Medicaid Health Plans
Pediatric Quality Indicators (PDIs)
Pediatric Asthma PDI
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health's MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
PDI
At Risk Admissions
859
250
560
2,517
893
1,490
162
3,502
369
230
140
2,673
1,454
140
871
160
372
16,642
LEGEND
Adjusted PDI*
24.08
16.12
21.23
23.44
21.62
23.05
16.49
23.04
15.87 ▲
22.43
22.27
26.26 ▼
21.70
11.18 ▲
21.59
19.10
18.79
22.94
Pediatric Composite PDI (Except Asthma)
PDI
At Risk Admissions
1,332
354
908
3,866
1,311
2,233
256
5,139
656
320
190
4,159
2,314
216
1,364
243
453
25,314
Adjusted PDI*
7.21 ▲
6.58
10.46
10.49
7.70
9.46
7.65
9.96
8.89
7.27
6.31
9.80
11.72 ▼
7.18
9.82
13.64
7.11
9.71
Results are a percentage of “at risk” admissions.
▲ Significantly better than statewide average
▼ Significantly worse than statewide average
* A lower rate is desirable for this measure
Note: Plans without symbols are not significantly different from the statewide average.
2013 Health Plan Service Use in New York State Report
Section 4
52
Antibiotic Utilization
Section 5
This section provides information on outpatient utilization of antibiotic prescriptions for
children (ages 0–17) and adults (ages 18+) during the measurement year. For Child Health
Plus managed care plans, rates are for children ages 0–17. 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.
2013 Health Plan Service Use in New York State Report
Antibiotics of concern in this report, as defined by HEDIS® 2013, include the following
antibiotic drug classes: amoxicillin/clavulanate, Azithromycin and clarithromycin,
Cephalosporin (includes second, third, and fourth generation), Clindamycin, Ketolide,
Quinolone, and miscellaneous other antibiotics of concern.
53
Section 5
Commercial HMO
Antibiotic Utilization
Children
Health Plan
Aetna
CDPHP
Easy Choice Health Plan of NY
Empire
Excellus BlueCross BlueShield
HIP (EmblemHealth)
HealthNow New York Inc.
Independent Health
MVP
Oxford
Univera Healthcare
Statewide
Antibiotic
Prescriptions
All
Concern
802
1409 ▲
714 ▼
549 ▼
927 ▲
752
906
840
907
912
881
874
435
647 ▲
390
305 ▼
388
389
403
355 ▼
434
491 ▲
390
432
Adults
%
Concern
of All
54
46
55 ▲
56 ▲
42 ▼
52
44
42 ▼
48
54
44
49
876
1365 ▲
694 ▼
733 ▼
927
853
863
896
966 ▲
894
835
899
528
724 ▲
389 ▼
456
450
511
446
456
513
543 ▲
427 ▼
510
%
Concern
of All
60
53
56
62 ▲
49 ▼
60
52
51 ▼
53
61 ▲
51 ▼
57
Antibiotic
Prescriptions
All
Concern
862
1373 ▲
696 ▼
695 ▼
927
836
871
884
956 ▲
898
845
894
512
709▲
389▼
424
437
490
437
436
499
533▲
419▼
495
%
Concern
of All
59 ▲
52
56
61 ▲
47 ▼
59 ▲
50
49 ▼
52
59 ▲
50
55
Rates are per 1,000 member years.
% Concern of All = Total prescriptions for antibiotics of concern/Total antibiotic prescriptions.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
Antibiotic
Prescriptions
All
Concern
All
54
Section 5
Commercial PPO
Antibiotic Utilization
Children
Health Plan
Aetna Life Insurance Company - New York
CDPHP Universal Benefits, Inc.
CGLIC (CHLIC)
Empire HealthChoice HMO, Inc.
Excellus BlueCross BlueShield
GHI (EmblemHealth)
HIP (EmblemHealth)
MVP Preferred PPO
Oxford Health Insurance Company, Inc. - New York
UnitedHealthcare Insurance Company of New York, Inc.
Statewide
Antibiotic
Prescriptions
All
Concern
833
1220 ▲
872
710 ▼
907
966
942
878
1000
903
856
Adults
%
Concern
of All
433
593 ▲
453
370 ▼
422
542
496
406
530
479
439
52
49
52
52
47
56 ▲
53
46 ▼
53
53
51
850
1142 ▲
838
700 ▼
873
909
863
870
1009
845
841
494
613 ▲
494
396 ▼
449
559
515
460
601
499
477
%
Concern
of All
58
54
59
57
51 ▼
61 ▲
60
53
60
59
57
Antibiotic
Prescriptions
All
Concern
846
1157 ▲
846
703 ▼
880
921
874
872
1007
858
845
481
609 ▲
484
390 ▼
444
555
513
449
584
495
468
%
Concern
of All
57
53
57
55
50 ▼
60 ▲
59
51
58
58
55
Rates are per 1,000 member years.
% Concern of All = Total prescriptions for antibiotics of concern/Total antibiotic prescriptions.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
Antibiotic
Prescriptions
All
Concern
All
55
Section 5
Medicaid Health Plans
Antibiotic Utilization
Children
Medicaid Managed Care Plans (MMC)
Affinity Health Plan
CDPHP
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health’s MediSource
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
MMC Statewide
HIV Special Needs Plans (SNP)
Amida Care
MetroPlus Health Plan
SNP Statewide
Antibiotic
Prescriptions
All
Concern
648 ▼
1018 ▲
900
935
1008
830
944
705
917
760
766
558 ▼
673
735
1324 ▲
808
723
834
507
509
498
Adults
%
Concern
of All
258 ▼
468
365
435
482 ▲
385
369
287
404
270
284
204 ▼
266
308
692 ▲
288
312
368
40
46
41
47
48 ▲
46
39
41
44
36 ▼
37
37
40
42
52 ▲
36 ▼
43
44
903
1360 ▲
1344
1134
1157
911
1340
986
1201
1301
1404 ▲
839 ▼
856 ▼
1118
1162
1173
893
1046
169
165
155
33
32
31
3358
2873
3025
LEGEND
425
626
584
565
633 ▲
479
624
474
583
596
607
387 ▼
391 ▼
503
672 ▲
507
480
519
1326
1069
1160
%
Concern
of All
Antibiotic
Prescriptions
All
Concern
47
46
43 ▼
50
55 ▲
53
47
48
49
46
43 ▼
46
46
45
58 ▲
43 ▼
54
50
805
1199 ▲
1145
1055
1099
877
1166
868
1056
1054
1106
708 ▼
773 ▼
941
1227 ▲
1025
839
957
39
37
38
3307
2602
2880
360
552
486
514
574▲
440
511
396
492
447
456
302▼
334▼
413
680▲
418
426
456
1305
965
1102
%
Concern
of All
45
46
42
49
52 ▲
50
44
46
47
42
41 ▼
43
43
44
55 ▲
41 ▼
51
48
39
37
38
Rates are per 1,000 member years.
% Concern of All = Total prescriptions for antibiotics of concern/Total antibiotic prescriptions.
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
Antibiotic
Prescriptions
All
Concern
All
56
Section 5
Child Health Plus Managed Care Plans
Antibiotic Utilization
Antibiotic Prescriptions
Health Plan
Affinity Health Plan
CDPHP
Empire
Excellus BlueCross BlueShield
Fidelis Care New York
HIP (EmblemHealth)
Health Plus (Amerigroup)
HealthNow New York Inc.
Healthfirst PHSP, Inc.
Hudson Health Plan
Independent Health
MVP
MetroPlus Health Plan
Neighborhood Health Providers
Total Care
UnitedHealthcare Community Plan
Univera Community Health
WellCare of New York
Statewide
All
Concern
% Concern of All
673
1046
1209 ▲
1033
872
1045
734
1009
675
791
935
979
437 ▼
552 ▼
1009
1113 ▲
882
766
910
293
508
658 ▲
477
416
570
382
427
319
360
376
458
180 ▼
246 ▼
499
631 ▲
384
358
450
44
49
54
46
48
55 ▲
52
42
47
46
40 ▼
47
41 ▼
45
49
57 ▲
44
47
49
Rates are per 1,000 member years.
% Concern of All = Total prescriptions for antibiotics of concern/Total antibiotic prescriptions.
LEGEND
▲ 90th Percentile or Above
▼ 10th Percentile or Below
2013 Health Plan Service Use in New York State Report
57
Technical Notes
Section 6
Prevention Quality Indicators and Pediatric Quality Indicators
Methodology
Developed by the Agency for Healthcare Research and Quality, the Prevention Quality Indicators
(PQIs) and Pediatric Quality Indicators (PDIs) quantify hospital admissions that most likely could
have been avoided through high-quality outpatient care.* The 4.4 version of AHRQ's PQIs and
PDIs were used with the 2012 hospital admissions. These indicators include several conditions,
such as asthma and diabetes that are known as ambulatory sensitive conditions (ASCs).
The methodology involves identifying the overall qualifying hospital admission events, identifying
the PQI and PDI hospital admission events and calculating an adult or pediatric PQI rate which is
risk adjusted for demographic factors to allow more accurate comparison of results that could be
influenced by plan action.
Data Source: 2012 Medicaid managed care encounter data
The resulting PQI or PDI is the percentage of the plan's 'at-risk admissions' that were potentially
preventable during the calendar year.
Software:
• 3M All-Payor Refined DRGs (APR-DRGs)
Measures
• 3M PQI logic
The four measures presented in this report are: 1) adult composite, 2) adult respiratory composite,
3) pediatric composite and 4) pediatric asthma. Each composite includes select adult and pediatric
PQIs/PDIs. The components of the three composite measures are listed below:
• 3M Clinical Risk Groups (CRGs)
Adult Eligible Admissions:
Admissions for Medicaid managed care enrollees ages 18 and above continuously enrolled in one
plan for 3 months.
Adult Composite PQIs
• Admissions for Diabetes short-term complications (PQI 1)
Pediatric Eligible Admissions:
• Admissions for Diabetes long-term complications (PQI 3)
Admissions for Medicaid managed care enrollees ages 90 days to 17 years continuously enrolled
in one plan for 3 months.
• Admissions for Hypertension (PQI 7)
• Admissions for Congestive Heart Failure (PQI 8)
Exclusions:
• Admissions for Dehydration (PQI 10)
• Admissions for Bacterial Pneumonia (PQI 11)
• Admissions classified by the APR-DRG grouper (version 29.0) as related to: pregnancy,
childbirth, newborns, mental illness, alcohol, and substance use.
• Admissions for Urinary Tract Infections (PQI 12)
• Any surgical admission, as defined by the APR-DRG grouper.
• Admissions for Angina without Procedure (PQI 13)
• Admissions for Uncontrolled Diabetes (PQI 14)
• Admissions classified in the highest severity categories, i.e., “major” or “extreme” severity of
illness.
Adult Respiratory PQIs
• Transfer admissions from another institution (hospital, nursing home, etc.).
• Admissions for Chronic Obstructive Pulmonary Disease (PQI 5)
• Observation day admissions and administratively denied inpatient claims.
• Admissions for Asthma in Younger Adults (PQI 15)
• In addition to the general exclusions, age criteria will also be applied to define the 'at-risk'
admissions for the four measures.
Pediatric Composite PDIs
• Admissions for Diabetes short-term complications (PDI 15)
• Admissions for Gastroenteritis (PDI 16)
• Admissions for Urinary Tract Infections (PDI 18)
Questions
If you have any questions or comments about this report please contact the Bureau of Health Services Evaluation at (518) 486-9012 or e-mail [email protected]
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Technical Notes
Section 6
Adult and Pediatric PQI/PDI Measure Denominators:
disproportionately represented among the plans, the plan rates were risk adjusted to reduce the
impact of these factors. Four separate models were developed to predict the likelihood that each
admission will be a PQI. Expected PQI and PDI rates were then calculated taking into account
each plan's case mix. The independent variables included in the models are the following:
The denominators, or 'at-risk admissions', for the four measures will include all hospital admissions that were not excluded by any one of the criteria described above and meet the age criteria
for the population specified as follows:
• Age
Adult only - all admissions for enrollees 18 years or older at the time of admission.
• Race/Ethnicity
Pediatric only - all asthma admissions for enrollees ages 2–17 at the time of admission. The pediatric composite include all admissions for enrollees 90 days old up to 17 years at the time of
admission for gastroenteritis and urinary tract infection PDIs and admissions of children ages 6 to
17 years for diabetes PDI.
• Gender
• Aid Category
• Clinical Risk Group (3M variable of health status)
Adult and Pediatric PQI/PDI Measure Numerators:
Observed PQI/PDI Rate:
The observed rate is the plan's numerator of PQI/PDI admissions divided by the plan's 'at-risk
admissions' for each measure.
'At-risk admissions' that qualified for more than one PQI or PDI during the year will be counted for
each admission in the numerator (and denominator) for each measure for which the admission
qualified.
Expected PQI /PDI Rate:
The expected rate is the number of predicted PQI/PDI admissions in the plan (based on the
characteristics of the plan's enrollees as defined by each disease specific prediction model)
divided by the plan's 'at-risk admissions' for each measure.
Adult Composite PQI
The numerator of the composite is the sum of the 'at-risk admissions' meeting criteria for any one
of the nine PQIs.
Adult Respiratory PQI
The numerator will include all 'at-risk admissions' with a primary diagnosis of asthma (defined by
PQI5 and PQI15 logic).
Risk-Adjusted PQI/PDI Rate:
The risk-adjusted rate is the observed rate divided by the expected rate multiplied by the
statewide rate.This risk-adjusted rate is used for comparing a plan's result to the statewide rate to
determine if the plan's performance is statistically better, worse, or about the same as the
statewide average.
Pediatric Composite PDI
The numerator of the composite is the sum of the 'at-risk admissions' meeting diagnosis and age
criteria for any one of the 3 PDIs. Age criteria vary for the 3 PDIs. Diabetes includes ages 6-17,
and Gastroenteritis and Urinary Tract Infection include children 90 days old up to 17 years.
Results
Pediatric Asthma PDI
The numerator will include all 'at-risk admissions' with a primary diagnosis of asthma (defined by
PDI14 logic).
The risk-adjusted rates for each plan are shown in this report. Please note that a low rate is
desirable; therefore plans that have significantly lower rates of avoidable admissions than the
overall average are noted to be better than the statewide average.
Risk Adjustment:
Because certain enrollee demographic factors, such as health status, may impact the likelihood
that an enrollee will experience a PQI admission, and these enrollee-specific factors may be
* http://www.qualityindicators.ahrq.gov/index.htm
Acknowledgement
Lead analyst: Lisa Balistreri, IPRO
Report layout: Veronica S. Byrne, IPRO
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