Your browser does not support JavaScript!
calculators
Member Education
forms and publications
news
about etf
frequently asked questions
contact etf
site map
related links
home
top of page
Wisconsin Department of Employee Trust Funds header image It's Your Choice 2017 Local Health Plan Insurance Program
members retirees employers governing boards careers at etf
skip to end of menu
2017 It's Your Choice - Local Health Plan Insurance for Employees and Retirees
Wisconsin Department Of Employee Trust Funds It's Your Choice 2017


Local Health Plan
Insurance for Employees
and Retirees
(PO6, PO16)


2016 Health Plan Report Card

Methodology

Introduction
Annually the Department of Employee Trust Funds 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 describes the methodology used for determining the ratings in this report card.

List of the measures and the composites

The performance ratings are based on the following measures:

  • Healthcare Effectiveness Data and Information Set (HEDIS),
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, 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 2016 technical specifications.  The CAHPS survey is based on the 5.0H adult commercial version of the survey. For ease of reference, the specific HEDIS three character code or specific CAHPS survey question is noted after each measure.

1. Overall Performance composite

  1. Controlling High Blood Pressure (CBP)
  2. Comprehensive Diabetes Care: blood pressure control (CDC)
  3. Plan All-Cause Readmissions: age total of males & females (PCR)
  4. Antidepressant Medication Management: effective continuation phase treatment (AMM)
  5. Medication Management for People with Asthma: controller medication at least 75% of treatment period, age total (MMA)
  6. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
  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)

2. Quality composite

  1. Controlling High Blood Pressure (CBP)
  2. Comprehensive Diabetes Care (CDC).  Mean of the following 2 measure results:
    - Blood Pressure Control (< 140/90 mm Hg)
    - Blood Sugar Control (HbA1c < 8%)
  3. Breast Cancer Screening (BCS)
  4. Colorectal Cancer Screening (COL)
  5. Health Plan Rating:  sum of “9” & “10” (CAHPS Q42)
  6. Primary Care Physician Rating:  sum of “9” & “10” (CAHPS Q23)
  7. Specialty Care Physician Rating:  sum of “9” & “10” (CAHPS Q27)

3. Care Coordination composite

  1. Ambulatory Care: Emergency Department Visits: age total (AMB)
  2. Plan All-Cause Readmissions: age total of males & females (PCR)
  3. Follow-Up After Hospitalization for Mental Illness: 7 day follow up (FUH)
  4. Antidepressant Medication Management: effective continuation phase treatment (AMM)
  5. Follow-Up Care for Children Prescribed ADHD Medication: continuation & maintenance phase (ADD)
  6. Medication Management for People with Asthma: controller medication at least 75% of treatment period, age total (MMA)
  7. Care Coordination:  rate of “always” (CAHPS Q22)

4. Overuse of Services composite

  1. Appropriate Treatment for Children with Upper Respiratory Infection (URI)
  2. Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
  3. Use of Imaging Studies for Low Back Pain (LBP)
  4. Appropriate Testing for Children With Pharyngitis (CWP)

5. Grievance measure

  1. Grievance Rate per 1,000 ETF Members

 


Calculation of the measure results
HEDIS
The results are taken from the health plan’s “Interactive Data Submission System” (IDSS) file, which the health plan’s National Committee for Quality Assurance (NCQA) certified vendor submits to the health plan.  The health plan provided the IDSS file to ETF in mid-2016.

CAHPS
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-2016.

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:

  1. State and Wisconsin Public Employers (WPE) active members,
  2. State graduate assistant members,
  3. State and WPE retired members and
  4. 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. 

This 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. 

This 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 2016 report card, both the benchmark and the health plans’ performance are based on HEDIS 2016 technical specifications where the measurement year is generally 2015.  “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 follows:

 

 

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.  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 follows:

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: 10/3/2016 2:40:55 PM