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Wisconsin Department of Employee Trust Funds header image It's Your Choice 2016 State of Wisconsin Group Health Insurance Program
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Wisconsin Department Of Employee Trust Funds

It's Your Choice 2016


State of Wisconsin
Group Health Insurance Program
(State Employees, Retirees, Continuants and Graduate Assistants)

2015 Health Plan Report Card

It’s Your Choice Fall 2015: Health Plan Performance Ratings

Introduction
Annually the Department of Employee Trust Funds (ETF) calculates and reports health plan performance for two primary purposes:

- Provide information to ETF members to assist in their health plan selection based on performance; and

- Assign a “quality credit” based on an “Overall Performance” composite, which is used in tiering health plans.

This document serves as the final technical specifications of the measures and composites used for “It’s Your Choice” (IYC) materials to be released fall 2015.  This final version comes after hosting two conference calls with health plans to walk through the draft document and field initial questions and comments.  After the conference calls, a review period ensued to collect further feedback from ETF participating health plans.

List of the measures and the composites

The performance ratings are based on the following measures:

  • HEDIS,
  • CAHPS, and
  • ETF member grievance rate. 

The HEDIS and CAHPS measures are aggregated into four composites.  The ETF member grievances is a standalone measure and not a composite. 

The HEDIS measures listed below are based on 2015 technical specifications.  The CAHPS survey is based on 5.0H adult commercial version of the survey.

1. Quality composite

  1. Controlling High Blood Pressure (< 140/90 mm Hg) (CBP) [HEDIS vol. 2, p 132]
  2. Comprehensive Diabetes Care (CDC) [HEDIS vol. 2, p 142].  Mean of the following 3 measure results:
    - BP control (< 140/90 mm Hg)
    - HbA1c control (< 8%)
  3. Breast Cancer Screening (BCS) [HEDIS vol. 2, p 78]
  4. Colorectal Cancer Screening (COL) [HEDIS vol. 2, p 86]
  5. Medical Assistance with Smoking and Tobacco Use Cessation (MSC) [HEDIS vol. 2, p 229].  Mean of the following 3 CAHPS questions:
    - Advising Smokers & Tobacco Users to Quit:  sum of “sometimes”, “usually” & “always” [CAHPS Q47]
    - Discussing Cessation Medication:  sum of “sometimes”, “usually” & “always” [CAHPS Q48]
    - Discussing Cessation Strategies:  sum of “sometimes”, “usually” & “always” [CAHPS Q49]
  6. Health plan rating:  sum of “9” & “10” [CAHPS Q42]
  7. Primary Care Physician rating:  sum of “9” & “10” [CAHPS Q23]
  8. Specialty Care Physician rating:  sum of “9” & “10” [CAHPS Q27]

2. Care Coordination composite

  1. Ambulatory Care: Emergency department visits: age total (AMB) [HEDIS vol. 2, p 293]
  2. Plan All-Cause Readmissions: age total of males & females (PCR) [HEDIS vol. 2, p 318]
  3. Follow-Up After Hospitalization for Mental Illness: 7 day follow up (FUH) [HEDIS vol. 2, p 177]
  4. Antidepressant Medication Management: Effective Continuation phase treatment (AMM) [HEDIS vol. 2, p 168]
  5. Follow-Up Care for Children Prescribed ADHD Medication: Continuation & maintenance phase (ADD) [HEDIS vol. 2, p 172]
  6. Medication Management for People with Asthma: Controller medication at least 75% of treatment period, age total (MMA) [HEDIS vol. 2, p 123]
  7. Care Coordination:  rate of “always” [CAHPS Q22]

3. Grievance measure

  1. Grievance Rate per 1,000 ETF members

4. Overuse of Services composite

  1. Appropriate Treatment for Children with Upper Respiratory Infection (URI) [HEDIS vol. 2, p 106]
  2. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) [HEDIS vol. 2, p 109]
  3. Use of Imaging Studies for Low Back Pain (LBP) [HEDIS vol. 2, p 163]
  4. Appropriate Testing for Children With Pharyngitis (CWP) [HEDIS vol. 2, p 102]

5. Overall Performance composite

  1. Controlling High Blood Pressure (< 140/90 mm Hg) (CBP) [HEDIS vol. 2, p 132]
  2. Comprehensive Diabetes Care: BP control (< 140/90 mm Hg) (CDC) [HEDIS vol. 2, p 142]
  3. Plan All-Cause Readmissions: age total of males & females (PCR) [HEDIS vol. 2, p 318]
  4. Antidepressant Medication Management: Effective continuation phase treatment (AMM) [HEDIS vol. 2, p 168]
  5. Medication Management for People with Asthma: Controller medication at least 75% of treatment period, age total (MMA) [HEDIS vol. 2, p 123]
  6. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB) [HEDIS vol. 2, p 109]
  7. Health plan rating:  sum of “9” & “10” [CAHPS Q42]
  8. Care Coordination:  rate of “always” [CAHPS Q22]
  9. Appropriate Testing for Children With Pharyngitis (CWP) [HEDIS vol. 2, p 102]

Calculation of the measure results
HEDIS
As noted above, the HEDIS measure technical specifications are 2015.  The specific volume of the HEDIS technical specifications, three character code and page number are noted after each measure above for ease of reference.  The results are taken from the health plan’s “Interactive Data Submission System” (IDSS) file, which the health plan’s NCQA certified vendor submits to the health plan.  The health plan provided the IDSS file to ETF in mid-2015.

CAHPS
As noted above, the CAHPS instrument administered in 2015 was the 5.0H adult commercial version of the survey.  The specific CAHPS question number is noted after each measure for ease of reference.  The results are taken from the health plan’s “Survey Results Report”, which are downloaded from NCQA’s IDSS by the health plan.  In turn, the health plan provided the file to ETF in mid-2015.

HEDIS and CAHPS are reported for several national health plans: Anthem, Humana and UnitedHealthcare.  In these instances, ETF specified which results to submit so as to calculate performance based on their health plans that operate in Wisconsin.

Grievances
Each health plan annually submits the number of grievances to ETF in regard to ETF members.  ETF members consist of the following enrolled in a given health plan: a) State and Wisconsin Public Employers (WPE) active members, b) State graduate assistant members, c) State and WPE retired members and d) State and WPE members on COBRA.

The number of ETF member grievances serve as the numerator in the measure.  The denominator is the number of ETF members enrolled with a health plan the first day of the calendar year.  To reiterate:  the numerator and denominator is limited to ETF lives. 

In turn, the measure is calculated as a rate of grievances per 1,000 ETF members for each health plan.  This is reported as an individual measure as opposed to a composite comprised of a number of measures. 

The measure is reported as stated in the section below titled “Scoring composites”.  Health plans’ per 1,000 rates are used to compute the percentiles and to assign performance in one of the five strata (e.g. stars).  In the four composites, higher scores are “better”, which is reflected by a higher strata.  For grievances, the converse is “better”.  Meaning, the lower the rate the “better”.  Thus, the lower the rate, the higher the strata.

The grievance measure is based on grievance data provided from the prior calendar year.

Scoring measures within composites

Identifying benchmarks for measures
The benchmark used is based on ETF participating health plans’ performance in a given measure.  The measurement year of the benchmark data is the same as the measurement year used to compute the measure results of the health plans’ performance where possible.  Similarly regarding the version of the measure technical specifications:  where possible the same version of technical specifications is used for the health plans’ measure results as well as the benchmark.

By way of example for HEDIS measures: For IYC fall 2015 materials, both the benchmark and the health plans’ performance are based on HEDIS 2015 technical specifications where the measurement year is generally 2014.  “Generally” is noted here as for certain measures, more than one year of data is employed to compute the measure.

For each measure, performance across the ETF participating health plans is viewed against six benchmarks, which are stated as percentiles.  The lowest (or worst) score is represented as the lowest numeric percentile and the best score is portrayed as the highest percentile.  The six benchmarks by percentile are as follow:

 

 

Benchmarks

 

Health plan score at the 95th percentile

 

Health plan score at the 85th percentile

 

Health plan score at the 65th percentile

 

Health plan score at the 35th percentile

 

Health plan score at the 15th percentile

 

Health plan score at the 5th percentile

 

Scoring measures within composites
Measures within composites are assigned the following point value based on the highest level of performance attained against the following range of percentiles.

Benchmarks

Points

96th percentile & above

7

86th to 95th percentile

6

66th to 85th percentile

5

36th to 65th percentile

4

16th to 35th percentile

3

6th to 15th percentile

2

5th percentile & below

1

Not reported (NR): declined to report

0

 

There may be measures that are not applicable (NA) to a given health plan as defined by insufficient denominator for the NCQA certified vendor to calculate results.  In this case, the average point value is calculated for the other measures that comprise the given composite.  The average point value is inserted for the “NA” measure result.  As noted in the table above, instances of a health plan not reporting / declining to report results (NR) receives zero points for the given measure.

Scoring composites
For a given composite, each health plan’s score across the individual measures is summed.  So for example, in the “Overall Performance composite” we may have composite scores ranging from 22 to 52.  The health plan performance composite scores are used to calculate the percentiles.

Based on the percentiles, performance is assigned to one of five strata.  The five strata are assigned as follow:

Performance

Strata

91st percentile & above

5

71st to 90th percentile

4

31st to 70th percentile

3

11th to 30th percentile

2

10th percentile & below

1

Disclaimer:
Every effort has been made to ensure that this information is accurate, but may be subject to change. Please note revision dates located at the bottom of each page. In the event of conflicting information, federal law, state statute, state health contracts and/or policies and provisions established by the State of Wisconsin Group Insurance Board shall be followed.

This page was last modified on: 3/11/2016 11:36:02 AM