hawaii quest 1115 annual report 2006

8/14/2019 Hawaii QUEST 1115 Annual Report 2006

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Medicaid Section 1115 Demonstration Waiver

Annual Report

FYE June 30, 2006

Med-QUEST Division

Department of Human Services

State of Hawaii

Reported dated April 2, 2007


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QUEST Annual ReportFYE June 30, 2006

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Table of Contents

Executive Summary........................................................................................................................ 3Overview..................................................................................................................................... 6Goals and Objectives .................................................................................................................. 6Key Waivers in the Demonstration............................................................................................. 7Impacted Population Groups....................................................................................................... 7Hypotheses about the Outcomes of the Demonstration.............................................................. 8A Brief History of the Implementation of the Demonstration.................................................... 9

Evaluation Design........................................................................................................................... 9The Management and Coordination............................................................................................ 9The Specific Metrics, Methodologies & Rationales ................................................................. 11The Analysis Plan ..................................................................................................................... 12Integration of the State Quality Improvement Strategy............................................................ 13

Measures ....................................................................................................................................... 14U.S. Census Measures............................................................................................................... 14HEDIS Measures ...................................................................................................................... 21EPSDT Measures ...................................................................................................................... 38CAHPS Measures ..................................................................................................................... 42Physicians Assessment Measures............................................................................................ 48Med-QUEST Internal Measures ............................................................................................... 53

Appendix A Description of Measures........................................................................................ 58U.S. Census Measures............................................................................................................... 58HEDIS Measures ...................................................................................................................... 61EPSDT Measures ...................................................................................................................... 70CAHPS Measures ..................................................................................................................... 72Physicians Assessment Measures............................................................................................ 76Med-QUEST Internal Measures ............................................................................................... 80

Appendix B Discussion of Statistical Terminology................................................................... 83Appendix C Development of Hawaii Targets for U.S. Census Measures ................................. 86


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Executive Summary

The fiscal year period from July 1, 2005 to June 30, 2006 recorded the 12th

demonstration yearfor the QUEST Medicaid section 1115 demonstration waiver. This past year the QUESTprogram has focused its efforts on several initiatives:

Preparing and updating the QUEST medical request-for-proposal (RFP) for distribution toplans wishing to bid during the next contract period, which runs from April 1, 2007 to June30, 2009. The final draft of the QUEST RFP was mailed out in November of 2006.

Planning for the implementation of the QUEST Adult Coverage Expansion (QUEST-ACE),which will provide medical assistance to a childless adult who is unable to enroll in theQUEST program due to the limitations of the statewide enrollment cap of QUEST asindicated in HAR 17-1727-26. The QUEST-ACE benefit package will encompass the samelimited package of benefits currently provided under the QUEST-Net program. Dependingon other employment factors, some recipients will be assessed a premium share of 50% of

the QUEST-ACE premium. This program will further the reach of the QUESTdemonstration, reducing the number of uninsured and underinsured adults in our community.

Planning for the implementation of QUEST Adult Preventative Dental benefit, which willprovide limited preventative and restorative dental benefits up to a $500 limit per person perState fiscal year. This will include x-rays and fillings. Also part of the benefit will be a$1,000 denture benefit, which will be allowed toward one set every five years. Thisprogram extension is scheduled was implemented in December of 2006, and is available toall QUEST programs including QUEST-Net and QUEST-ACE. The QUEST AdultPreventative Dental benefit will improve the oral health of the QUEST adult population.

Planning for the implementation of QUEST Expanded Access (QExA), where the majority ofthe Medicaid Fee-For-Service population will be integrated into QUEST managed care plans.The additional QExA service mix is projected to include medical services for all aged(individual 65 years and older), blind, and disabled individuals, as well to expand theservices to include long-term care services (both institutional and home and community-based waiver services). This expansion, if approved, will further extend the reach of QUESTto some of our communitys most vulnerable and fragile individuals.

Preparing for the implementation of The Deficit Reduction Act (DRA). The new provisionsunder Section 6036 of the DRA of 2005 discontinued the practice of self-attestation ofCitizenship and Identity. Although the Departments goal to preserve the eligibility of

current recipients to insure continuation of medical coverage while complying with the newFederal requirements was quite challenging, the potential use of scarce funds on individualsthat should not be a part of QUEST is wasteful and takes away funds from those truly inneed.

Compliance with the Health Insurance Portability and Accountability Act (HIPAA), which inlarge part involves the safeguarding of an individual's protected health information. Med-QUEST continually monitors federal HIPAA Privacy, Security and TCS compliance


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throughout the Division, and actively develops policies and procedures, conducts on-goingreviews of existing practices, conducts periodic audits of division compliance efforts, andensures training of staff. A high level of service to QUEST recipients demands strictcompliance with HIPAA.

Streamlining and simplifying the eligibility process for QUEST recipients. Some specificexamples are the use of the pre-printed Eligibility Renewal Forms during the annualeligibility renewals, not requiring families with children to turn in a Renewal Form if theinformation has not changed (so called passive renewals), and the expediting of theapplication process for pregnant women and children, through the use of the MedicalAssistance Application For Children and Pregnant Women Only form. These efforts serve toremove barriers of access to medical care for the uninsured or underinsured.

There has been much accomplished over this past year with the QUEST program. Yet based onthe scores for the various measures and how they compare to our target scores, there is muchroom for improvement with the scores of the measures in this report. There are a few reasonsthat might explain why, in general, the scores are not as close to target as we would like:

Target scores were set retro-actively: Optimally, target scores are set at the beginning of thereporting period and communicated to all health plans. This process sets clear benchmarksof performance, clarifies expectations at the end of the reporting period, and improves thechances of positive outcomes. The targets for this report were established after the reportingperiod began. Without clear expectations it is not surprising for several of the statewide andplan-specific measures to have missed their targets sometimes by wide margins. Goingforward, these targets will be communicated as early as possible to the health plans.

Little health plan monitoring: Med-QUEST has not monitored the performance of the healthplans as closely as we would have liked to in the recent past. More specifically, there has not

been a formal measuring tool implemented with regular periodic updates and feedback.Although the plans have been submitting HEDIS scores and participating in surveys relatedto their QUEST membership, the plans have not been required to submit audited HEDISdata, they have not seen these measures reported comprehensively in one place, reported overa period of time, compared to other plans in the State of Hawaii, and benchmarked tonationally recognized target scores. We hope that once this measuring tool is introduced tothe plans and regularly updated on an annual basis, the health plans will be on notice that weare serious about looking at their performance.

No financial incentives built into contract: The plans have not had any financial incentive ordisincentive for performing well in the measures in this report. Penalties and/or incentives

are powerful motivating tools, and we hope to expand the usage of these in the future toaffect and improve performance in these measures.

The health plans perception of more work, same pay: This is somewhat related to theprevious point. From a purely financial perspective, any additional resources that a healthplan invests to improve the scores of the measures in this report come directly out of theplans bottom line. Any medical cost savings from improvements in scores are not tangibleand difficult to measure it is almost impossible to quantify that something didnt happen


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because of something you did. As an example, how many NICU days did a plan prevent iftheir HEDIS Prenatal score improved by 1.0%? What may aide in changing this thoughtprocess is the introduction of this measuring tool, which will highlight where plans areperforming well and where they are not, and how they compare with other plans, other states,and a national average.

That being said, it is hard to deny that, overall, Kaiser raw scores are higher than the other twoplans. Kaiser is consistently rated as one of the 10 best health plans in the country from manydifferent sources. We believe there are several reasons that Kaisers raw scores are better:

Kaisers Staff Model: Physicians and members choose to be part of Kaiser, which webelieve creates a positive bias for their scores. Physicians are happier because they do nothave to deal with malpractice insurance, contracting, and accounts receivable issues that are atime and energy drain on independent physicians. This frees the Kaiser physician to focussolely on practicing medicine, as well as providing a clear path to standardizing patient care.And the Kaiser members seem to understand and buy-in to the Kaiser system of deliveringmedical care, and actively choose to become a Kaiser member. This improves compliancewith scheduled visits as well as strengthens the physician-to-patient relationship.

No auto enrollment: Kaiser has requested to not participate in auto enrollment since 2003, soonly members that actively choose Kaiser are enrolled in their system. A plan has a betterchance of managing a stable population than managing a variable population, and not havingmembers auto enrolled into your plan encourages population stability.

Integrated information system: Recently Kaiser Hawaii has installed parts of the EPIChealthcare system. This system enables all Kaiser doctors to see the results of all tests doneto the Kaiser members, provides electronic reminders during doctor visits forannual/quarterly/monthly preventative or immunization interventions, and enables members

to conduct a multitude of tasks online things like check results of tests or radiologicalservices, make doctor appointments, and see recommended intervals for childhoodimmunizations. EPIC makes it very easy for all Kaiser doctors and members to followstandardized guidelines of medical care, which in turn improves the scores posted by KaiserQUEST.


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Information about the Demonstration

Overview

Hawaiis QUEST Expanded is a state wide comprehensive section 1115 (a) demonstration that

expands Medicaid coverage to children and adults originally implemented on August 1, 1994.The demonstration creates a public purchasing pool that arranges for health care throughcapitated managed care plans. The State converted approximately 108,000 recipients from threepublic funded medical assistance programs into the initial demonstration including: 70,000 Aidto Families with Dependent Children (AFDC-related) individuals; 19,000 General Assistanceprogram individuals (of which 9,900 were children whom the State was already receivingFederal financial participation); and 20,000 former State funded SCHIP program individuals.

This demonstration builds upon the Hawaii Prepaid Health Care Act, an ERISA waiver, whichrequires all employers to provide insurance coverage to any employee working more than 20hours per week. Together these programs have resulted in an unprecedented State, private/public

partnership that directly impacts the rate of uninsurance.

The extension of Hawaiis Section 1115 demonstration on February 1, 2006, continues theStates current coverage, while also expanding coverage to children from 200 percent through300 percent of the Federal Poverty Level (FPL) using title XXI funding. Hawaii will alsoexpand coverage to another new group; the QUEST Adult Coverage Expansion (QUEST-ACE)who are adult individuals up to 100 percent of the FPL who are not otherwise eligible forcoverage. The current extension will expire on June 30, 2008.

Goals and Objectives

From the very beginning of the QUEST demonstration, the goals and objectives have beencentered on improving the overall health of the indigent, fiscal management, clinical access andquality of care, and provider availability. The specific objectives are listed below:

Improve health outcomes and reduce inappropriate utilization.

That by continuing to serve recipients in a coordinated care-managed environment, theoverall health of Hawaiis most vulnerable citizens will continue to improve.

Decrease the percentage of uninsured individuals in the State.

Expand coverage to children from 200 percent through 300 percent of the Federal PovertyLevel (FPL) using title XXI funding.

Continue the predictable and slower rate of expenditure growth associated with managedcare.


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Key Waivers in the Demonstration

The following are the waivers that are currently in effect for this demonstration:

Medically Needy - Section 1902(a)(10)(C). To enable the State to limit medically needyspend-down eligibility for QUEST to those individuals whose gross incomes, before any

spenddown calculation, are at or below 300 percent of the Federal poverty level. This is notcomparable to spend-down eligibility for the aged, blind and disabled eligibility groups,which have no gross income limit.

Amount Duration and Scope - Section 1902(a)(10)(B). To permit managed careorganizations (MCO) providing QUEST, QUEST-Net and QUEST-ACE coverage to provideadditional benefits that may not be available to enrollees in other plans or to Medicaidrecipients not enrolled in an MCO.

Financial Responsibility/Deeming - Section 1902(a)(17)(D). To allow the State to determineeligibility using the income of household members whose income may be taken into account

under the AFDC-income rules. If the household income so calculated exceeds QUESTExpanded limits, the State shall determine eligibility using Medicaid financial responsibilityand deeming rules. To also allow the State to deem financial support from parents and legalguardians when determining eligibility for adults who are age 18 or older but under age 21,and who are claimed as tax dependents by their parents or legal guardians.

Three Month Retroactive Eligibility - Section 1902(a)(34). To enable the State to waive therequirement to provide medical assistance for up to three months prior to the date that anapplication for assistance is made because QUEST Expanded eligibility begins on the date ofthe application.

Quality Review of Eligibility - Section 1902(a)(4). To enable the State to be exempt fromthe current administrative procedure of reviewing the eligibility process and to allow theState to continue to follow Medicaid Eligibility Quality Control (MEQC) plan proceduresapproved by CMS on October 11, 1996, when reviewing eligibility determinations forDemonstration enrollees. The State remains relieved of any liability from disallowance forerrors that exceed the three (3) percent tolerance.

Freedom of Choice - Section 1902(a)(23). To enable Hawaii to restrict the freedom of choiceof providers.

Impacted Population Groups

Based on the goals and objectives of this demonstration, the targeted populations groups to beimpacted are the most vulnerable and needy who do not have access to any other form ofhealthcare coverage. Individuals and family members who are sixty-five years old or older, orare blind, or are disabled are generally disqualified from the eligible groups. The scope of thepopulation groups impacted by the demonstration has consistently and regularly been expandingfrom its initial focus. In its current form, the following populations are expected to benefit fromthis demonstration:


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Pregnant women in families whose income is up to 185 percent of the FPL.

Infants and children in families whose income is up to 300 percent of the FPL.

Adults and families with dependent children whose income is up to 100 percent of the FPL.

Childless adults whose income is up to 100 percent of the FPL.

Uninsured individuals in general.

Hypotheses about the Outcomes of the Demonstration

The states hypotheses about the outcomes of the demonstration are based on the goals andobjectives, as well as the impacted populations groups mentioned earlier in this report. Thefollowing outcomes are expected in this demonstration:

The percentage of uninsured individuals in the State of Hawaii will decrease to 8.2%.

The percentage of children from 200 percent through 300 percent of the Federal PovertyLevel (FPL) that are insured will decrease to 5.9%.

The statewide QUEST rate of women receiving a prenatal care visit in the first trimester orwithin 42 days of enrollment will be at or higher than the national Medicaid 75th percentilescore.

The statewide QUEST rate of children who had six or more well-child visits with a primarycare practitioner during their first 15 months of life will be at or higher than the national

Medicaid 75th percentile score.

The statewide QUEST rate of adult diabetic members who have had at least twoglycohemoglobin level tests in the reporting year will be at or higher than the nationalMedicaid 75th percentile score.

The statewide QUEST rate of members 6 years of age and older as of the date of a mentalhealth discharge who were seen on an ambulatory basis or were in intermediate treatmentwith a mental health provider within 30 days of hospital discharge will be at or higher thanthe national Medicaid 75th percentile score.

The percentage of well newborns to total newborns in the QUEST population will increase to94.0%.

The statewide QUEST CAHPS rating for getting needed care will be at or higher than thenational Medicaid mean score.


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The total cost of the demonstration program (premium payments and administrative costs)will be no greater than the comparable FFS program cost for the current recipients if thedemonstration did not exist.

A Brief History of the Implementation of the Demonstration

The QUEST 1115 demonstration was originally implemented on August 1, 1993, and has sincebeen extended a total of four times. In most of the extension applications there has been asubsequent and cumulative expansion of the scope of the targeted recipients covered by QUEST.A brief history of the demonstration follows below:

Date Proposal Submitted: April 19, 1993Date Proposal Approved: July 16, 1993Date Implemented: August 1, 1994

Date Extension Proposal Submitted: April 1, 1998Date Extension Proposal Approved: September 30, 1998Date Extension Expires: March 31, 1998

Date Extension Proposal Submitted: November 19, 2001Date Extension Proposal Approved: March 18, 2002Date Extension Expires: March 31, 2005

Date Extension Proposal Submitted: July 30, 2004Date Extension Proposal Submitted: October 8, 2004Date Extension Expires: June 30, 2005

Date Extension Proposal Submitted: January 21, 2005Date Revised Extension Proposal Submitted: August 30, 2006

Temporary 30-Day Extension: June 30, 2004Temporary 60-Day Extension: July 30, 2005Temporary 30-Day Extension: September 30, 2005Temporary 30-Day Extension: October 30, 2005Temporary 30-Day Extension: November 30, 2005Temporary 30-Day Extension: December 30 2005Date Extension Proposal Approved: January 30, 2006Date Extension Expires: June 30, 2008

Evaluation Design

The Management and Coordination

Organization Conducting the Evaluation

The evaluation will be conducted internally within Med-QUEST, primarily by Jon Fujii(Research Officer). Contributions will also be made by Leslie Tawata (Health CoverageManagement Branch Administrator), Dr. Lynette Honbo (Medical Consultant), Alan Takahashi(Enrollment Branch Administrator), Noreen Moon-Ng (Policy & Program Development Branch


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Administrator), Brian Pang (Finance Officer), Kendrick Abe (Healthcare Business Analyst),Angie Payne (former Acting MedQUEST Administrator), and Kathy Ramento (Secretary).

Timeline for Implementation of the Evaluation and for Deliverables

October 2006 Begin gathering data for the evaluation.

November 2006 Continue data gathering. Begin data testing and validation.

December 2006 Continue and finalize data gathering, testing and validation. Preliminaryfindings will be compared with targeted objectives and summarized. Reflections will bemade on changes over time as well as comparisons to national and selected state averages.

January 2007 Analysis of outcomes and value creation of the demonstration.

February 2007 through March 2007 Analysis of internal and external factors driving thescores, and how these factors can be positively impacted.


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The Specific Metrics, Methodologies & Rationales

The Measures

When observing the various measures below, and unless stated otherwise, remember that ahigher numeric score is considered positive and a lower numeric score is considered negative.

Measures Reported

Years

Comparisons Actual

Score

Target

ScoreU.S. Census Measures

Uninsured Percentage (#) 2000 2005 LT, ST, NT 9.1% 8.2%

Uninsured Children (Age 0-18) Percentage (#) 2002 2005 LT, ST, NT 17.2% 15.5%

Percent of Children (Age 0-18) between 200% and300% FPL who are Uninsured (#)

2002 2005 LT, ST, NT 10.0% 5.9%

HEDIS Measures

Prenatal Care PPC 2002 2005 LT, PL, NT 72.9% 86.7%

Postpartum care PPC 2002 2005 LT, PL, NT 57.1% 64.5%

Maternity Average Length of Stay MAT 2002 2005 LT, PL, NT 2.46 2.85

Well Child Visits in the First 15 Months of Life, 6 or

more W15

2002 2005 LT, PL, NT 51.7% 56.3%

Child Immunizations Status, Combination 2 CIS 2002 2005 LT, PL, NT 67.6% 71.4%

Hemoglobin A1c Tested CDC 2002 2005 LT, PL, NT 81.3% 84.1%

Hemoglobin A1c Poorly Controlled CDC (#) 2002 2005 LT, PL, NT 59.9% 37.8%

Retinal Examination CDC 2002 2005 LT, PL, NT 53.1% 54.9%

Follow-Up After Hospitalization for Mental Illness,Within 30 Days FUH

2002 2005 LT, PL, NT 72.2% 70.6%

Mental Health Utilization Percentage of MembersReceiving Services MPT

2002 2005 LT, PL, NT 9.0% 9.7%

Emergency Department Visits, per 1,000 membermonths AMB

2002 2005 LT, PL, NT 36.7 57.5

Percentage of Well Newborns to Total Newborns 2002 2005 LT, PL, NT 92.6% N/A

EPSDT Measures

Screening Ratio 2002 2005 LT, PL 91.9% 80%Participant Ratio 2002 2005 LT, PL 68.5% 80%

CAHPS Measures

Rating of Health Plan 2006 PL, NT 62.2% 52.6%

Rating of All Healthcare 2006 PL, NT 60.6% 54.1%

Getting Needed Care 2006 PL, NT 73.5% 74.6%

Getting Care Quickly 2006 PL, NT 45.4% 44.9%

Physicians Assessment Measures

Attitude toward Hawaii Med-QUEST 2002, 2006 LT, PL 40.8% N/A

Satisfaction with reimbursement from the Med-QUESThealth plan

2002, 2006 LT, PL 27.7% N/A

Does the health plan personnel have the necessaryprofessional knowledge

2002, 2006 LT, PL 33.5% N/A

Impact of the health plans UM (prior authorizations)on quality care

2002, 2006 LT, PL 27.2% N/A

Med-QUEST Internal Measures

Budget Neutrality Savings DY 12 LT 12,359,340 > 0

Quest Member Months 2006 LT, PL 1,805,359 N/A

Expenditures for QUEST Uncompensated Care Costs 2007 LT 17,558,000 N/A

Expenditures for QUEST-ACE Program 2007 - 2008 LT N/A N/A

LT = longitudinal comparison Indicates a score that is significantly better than the target score.


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ST = comparison with other states Indicates a score that is significantly worse than the target scoreNT = national comparisonPL = QUEST plan comparison

(#) Unlike the other measures, for this measure higher numeric scores are considered negative and lower numeric scores areconsidered positive. Accordingly, the targets for the HEDIS measures represent the score for the national Medicaid 25th %ile,

NOT the score for the 75th %ile.

For a discussion on the specifics of each measure, please see Appendix A. For a discussion onthe calculation of the 95% confidence interval used and how it will be displayed in this report,please see Appendix B.

When Data on each Measure will be Collected

Data will be collected in the months from October 2006 through January 2007.

The Population Groups of Enrollees for which Data will be Analyzed

Uninsured individuals.

Children in families whose income is from 200 percent through 300 percent of the FPL.

Pregnant women.

Infants.

Children up to 15 months old.

Diabetics.

Mental health patients.

The Analysis Plan

The methods by which the data collected will be analyzed, including thestatistical methodologies to be used

The results of the data collection and calculation will be various values for the given period.These results will be displayed in both tabular as well as graphical formats. For most measures,a longitudinal comparison will be made among the various years Hawaii statewide QUEST

scores. Another comparison will be among the various plans scores. Where applicable, otherstate and/or national comparisons will also be reviewed. Where possible, statistical analysis todetermine that any two values are actually different will be performed using a 95% confidencelevel.

A determination will be made if unexpected or expected factors are influencing the calculatedvalues. These factors could be internal to DHS, specific to a plans operations, or external at astate or national level. If so, and if data points are available, multiple regression analysis will be


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performed to validate these suspicions. Either way, there will be a discussion on how we believethese factors are exerting influence on the values.

Integration of the State Quality Improvement Strategy

Several of the measures in this report are the same metrics identified in the State QualityImprovement Strategy. There are also measures that are not a part of the State QualityImprovement Strategy. In discussions with key personnel, it was determined that the measuresfor this Annual Draft Report need not be a sub-set of, nor mutually exclusive from, the metricsthat are in the State Quality Improvement Strategy.


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Measures

The graphs used to illustrate the various measures are, unless otherwise noted, scaled from 0% to100%. This was done to facilitate comparisons between graphs and to present a consistent scaleof measurement. Please see Appendix A for detailed descriptions of the measures used in thisreport. Appendix B will highlight the 95% confidence interval calculation and discuss how itwill be displayed in this report.

U.S. Census Measures

The U.S. Census measures are included in this report to measure various statewide medicaluninsured rates in Hawaii.

The U.S. Census measures are based on public information available from the U.S CensusBureau website. These measures range from very broad measures of the Hawaii uninsuredpopulation, to very specific gender, age, and FPL specific uninsured rates in Hawaii. All of the

data was obtained using the Current Population Survey (CPS) Table Creator tool, which enablesthe user to create customized reports using the various database fields. The stated year in thevarious measures represent the year in which the survey was taken.

Three types of analysis are done for each U.S. Census measure. First, a longitudinal analysis iscompleted on the Hawaii statewide rates to determine if there are broad trends in the measureover a period of several years. Scores are reported for each year from 2000 to 2005. Second, acomparison of the Hawaii statewide score, three comparison states scores, and the nationalaverage score in 2005 is done to observe any differences between how Hawaii is managing itsuninsured population and how the comparison states are managing their populations. Thecomparison states, chosen for their relative comparability of size and maturity of demonstration

project, are Maryland, Massachusetts and Rhode Island. Marylands waiver began on 6/2/1997,Massachusetts on 7/1/1997, and Rhode Islands on 8/1/1994. Third, the scores for Hawaii, thethree comparison states, and national average are reported each year over a period year from2000 to 2005. State initiatives often take years to come into fruition, and these graphs willcompare and contrast these trends by state over time. For all analyses, comparisons are made tothe National Average score in the relevant reporting year. Comparisons are also made to HawaiiTarget scores, which are calculated for each measure based on expected changes to the mostrecent years actual score. Finally, for the first two analyses a 95% confidence interval iscalculated for each score to determine the significance of any differences in scores.

For a discussion on the specifics of each U.S. Census measure, please see Appendix A. Please

see Appendix B for a detailed discussion on how the statewide rates, and 95% confidenceintervals, are calculated. Details on the calculations of the Hawaii Target scores can be found inAppendix C.

For all of the U.S. Census measures, lower numeric scores are considered positive and highernumeric scores are considered negative. The graphs used to illustrate the various measures arescaled from either 0% to 20%, or 0% to 30%, to reflect the historical range of uninsuredpercentage scores.


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Uninsured Percentage


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Statewide - Longitudinal

The Hawaii statewiderate of the total

population withouthealthcare insurancehas varied in a narrowrange between 9% and10% from 2000 to2005, with the highestrate of 10.1% occurringin 2003 and the lowestrate of 9.1% occurringin 2005. Over time, therate has risen from9.4% in 2000 to thehigh in 2003, then decreased to the low in 2005.


Uninsured as a Percent of Total Population


0%

5%

10%

15%

20%

95% CI Up 10.8% 11.0% 11.4% 11.5% 10.7% 10.4%

Rate 9.4% 9.6% 10.0% 10.1% 9.4% 9.1%

95% CI Low 8.0% 8.3% 8.7% 8.8% 8.0% 7.7%

2000 2001 2002 2003 2004 2005

2005 National Average = 15.9%

2006 Hawaii Target = 8.8%

At the 95% confidence level, the uninsured rate for any given year is not significantlydifferent from the other years reported.

At the 95% confidence level, the Hawaii statewide uninsured rate for each year issignificantly lower than the 2005 national average rate of 15.9%. Also, the Hawaii Targetrate of 8.8% is not significantly different from the Hawaii statewide uninsured rate for eachyear.

By State - in 2005

When compared to otherstates uninsured rates,Hawaii does quite well.Hawaiis 2005 rate of9.1% was the lowest ofthe comparison states Maryland,Massachusetts, andRhode Island. The

closest state wasMassachusetts with a2005 rate of 9.8%.Rhode Island andMaryland trailed farther behind. All comparisonstates reported rateslower than the 2005



By State - in 2005

0%

5%

10%

15%

20%

95% CI Up 16.0% 10.4% 15.7% 10.9% 13.6%

Rate 15.9% 9.1% 14.1% 9.8% 11.9%

95% CI Low 15.7% 7.7% 12.6% 8.6% 10.1%

United States Hawaii Maryland Massachusetts Rhode Island



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national average rate of 15.9%.

At the 95% confidence level, the Hawaii uninsured rate was not significantly different fromMassachusetts or Rhode Island. Hawaiis rate was significantly lower than Maryland, aswell as lower than the national average rate.

At the 95% confidence level, the Hawaii uninsured rate is not significantly different from theHawaii Target rate of 8.8%. Of the comparison states, only the Massachusetts rate is notsignificantly from the Hawaii Target rate.

By State - from 2000 to2005

While the predominanttrend in other states andnationwide has been forthe uninsured rate to

increase from 2000 to2005, Hawaii rate hasbeen virtually flat tomarginally decreasing.As the other three statesin this comparison havehad rate increases thatrange from 1.1% to4.5%, Hawaiis rateactually dropped by0.3%. The national rate

moved up by 1.7% over the same period.



By State - from 2000 to 2005

0%

5%

10%

15%

20%

United States 14.2% 14.6% 15.2% 15.6% 15.6% 15.9%

Hawaii 9.4% 9.6% 10.0% 10.1% 9.4% 9.1%

Maryland 10.4% 12.3% 13.4% 13.9% 14.3% 14.1%

Massachusetts 8.7% 8.2% 10.0% 10.7% 11.7% 9.8%

Rhode Island 7.4% 7.7% 9.8% 10.3% 10.9% 11.9%

2000 2001 2002 2003 2004 2005


The period from 2000 to 2005 saw Hawaii go from the third lowest uninsured rate to theoverall lowest rate. Conversely, in the same period Rhode Island went from having theoverall lowest rate to having the third lowest rate. Maryland remainded as the state with thehighest rate for all years. The national rate remained higher than all of the comparison statesfor each year from 2000 to 2005.

The Hawaii target rate of 8.8% is lower than any of the reported rates from between 2002 and2005. Only Massachusetts and Rhode Island in 2000 and 2001 reported rates lower than theHawaii target rate.

Discussion of Results

Hawaiis decrease in its uninsured percentage is partially attributable to the increase in thenumber of Medicaid eligible populations due to the various Medicaid expansion programsHawaii has implemented since 2000. More programs mean more opportunities for healthcarecoverage for Hawaiis uninsured. Also, Hawaiis seasonally adjusted rate of unemployment hasdecreased over the 2000 2005 period, going from 4.4% in January 2000 to 2.6% in December


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2005. Lower unemployment can lead to greater access to employee sponsored healthcarecoverage.

Uninsured Children (Age 0-18) Percentage



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The Hawaii statewiderate of children in thetotal population withouthealthcare insurance hasvaried widely from 13%to 21% in the periodfrom 2002 to 2005. Therate in 2002 was the

highest at 21.1% whilethe lowest rate of 12.8%occurred in 2004.

At the 95% confidencelevel, the Hawaii rate ofuninsured children from2002 to 2005 was not significantly different from each other. Also, the rates in all but oneyear, 2004, were not significantly different from the 2005 national average rate of 19.4%.The rate in 2004 was significantly lower than the 2005 national average.


Uninsured Children (Age 0-18) as a Percent of Total Uninsured


0%

10%

20%

30%

95% CI Up 25.7% 23.4% 16.8% 21.7%

Rate 21.1% 18.9% 12.8% 17.2%

95% CI Low 16.5% 14.4% 8.9% 12.8%

2002 2003 2004 2005



At the 95% confidence level, the Hawaii target rate of 15.5% is not significantly differentfrom the Hawaii rate of uninsured children from 2003 through 2005. The Hawaii rate in

2002 is significantlyhigher than the Hawaiitarget rate.



By State - in 2005

0%

10%

20%

30%

95% CI Up 19.9% 21.7% 19.8% 17.1% 20.9%

Rate 19.4% 17.2% 16.6% 12.8% 16.8%

95% CI Low 18.9% 12.8% 13.5% 8.4% 12.7%



By State - in 2005

Hawaiis 2005 rateof uninsured

children, at 17.2%,is in the highestwhen compared toother comparisonstates.Massachusettscomes in with thelowest rate at


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12.8%, with Maryland (16.6%) and Rhode Island (16.8%) having rates closer to Hawaiisrate. The 2005 national average rate of 19.4% was higher that all of the states rates.

At the 95% confidence level, Hawaii, rate of uninsured children is not significantlydifferent than the rates for Rhode Island, Maryland, and the national average rate. OnlyMassachusetts has a rate that is significantly lower than the national average rate, buttheir rate is not significantly different than Hawaiis rate. The small sample sizes used tocalculate the state rates necessitate large confidence intervals.

At the 95% confidence level, the Hawaii target rate of 15.5% is not significantly differentfrom any of the reported states rate of uninsured children. The national average rate issignificantly higher than the Hawaii target rate.



By State -- from 2002 to 2005

0%

10%

20%

30%

United States 21.3% 20.3% 19.2% 19.4%

Hawaii 21.1% 18.9% 12.8% 17.2%

Maryland 20.5% 16.5% 18.0% 16.6%

Massachusetts 14.9% 19.9% 13.0% 12.8%

Rhode Island 12.5% 14.8% 16.5% 16.8%

2002 2003 2004 2005


By State - from 2002 to2005

Most of the reportedstates showed decreasesin the rate of uninsuredchildren from 2002 to2005. Hawaiis ratedropped 3.9% from 2002to 2005, although therate in 2005 is higherthan the 2004 rate. OnlyRhode Island had ahigher rate in 2005

(16.8%) than in 2002(12.5%).

Of the reported states, Hawaii had the highest rate of uninsured children in 2002. Afterbriefly having the lowest rate of all the states in 2004 (12.8%), Hawaii also reported thehighest rate in 2005.

The Hawaii target rate of uninsured children of 15.5% is lower than three of the four reportedyears for Hawaiis rate. Only Massachusetts rate in 2005 (12.5%) is below the target rate; allother states rates and the national average rate is above the target.


The reasons for the decreasing trend in the overall uninsured percentage apply to thedecreasing trend in the uninsured children percentage as well. Additionally, with the State ofHawaii funded programs for immigrant children and implementation of passive renewals,more children are becoming eligible and fewer cases are being closed due to incompleteeligibility reviews. The many steps taken to streamlining and simplifying the eligibilityprocess for QUEST recipients were discussed in the Executive Summary, and these steps are


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a large reason for the overall downtrend in the uninsured children rate over the four reportedyears.

Percent of Children (Age 0-18) Between 200% and 300% FPL who are Uninsured


The Hawaii statewide rate of children in households with income between 200% and 300%of the Federal PovertyLevel (FPL) who areuninsured variedbetween 5% and 10%from 2002 to 2005.The lowest rate of4.8% occurred in 2004,and the highest rate of

10.0% occurred in2005. While the ratesdipped in the middleyears, Hawaii startedand ended up withnearly the same rate.

At the 95% confidencelevel, the Hawaii ratesof uninsured children

between 200% and 300% FPL from between 2002 to 2005 were not significantly different

from each other. The rates in 2002 and 2005 were not significantly different from the 2005national average of 19.4%. Showing some improvement, the rates in 2003 and 2004 weresignificantly lower than the 2005 national average.


Percentage of Children (Age 0-18) Between 200% FPL and 300% FPL who are Uninsured


0%

5%

10%

15%

20%

95% CI Up 14.2% 10.7% 8.3% 14.2%

Rate 9.7% 6.9% 4.8% 10.0%

95% CI Low 5.1% 3.2% 1.2% 5.8%

2002 2003 2004 2005



At the 95% confidence level, the Hawaii rates of uninsured children between 200% and300% FPL from between 2002 to 2005 were not significantly different from the Hawaiitarget rate of 5.9%. A major factor causing this is the very wide confidence intervals.

By State - in 2005

Hawaiis 2005 rate of uninsured children between 200% and 300% FPL of 10.0% was only

bested by the Rhode Island rate of 7.1%. Masschusetts (10.2%) and Maryland (14.1%)recorded higher rates. The 2005 national average rate was 12.0%.

At the 95% confidence level, Hawaii, rate of uninsured children between 200% and 300%FPL is not significantly different than the rates for all three of the comparison states or thenational average rate. Only Rhode Island has a rate that is significantly lower than thenational average rate. Again, small sample sizes used to calculate the state rates necessitatelarge confidence intervals.


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At the 95% confidencelevel, the Hawaii targetrate of 5.9% was notsignificantly differentthan the Hawaii,Massachusetts &Rhode Island rate ofuninsured childrenbetween 200% and300% FPL. Again,very wide confidenceintervals are a factor inthe target not beingdifferent than thesestates rates. Marylandhad a rate that washigher than the Hawaiitarget rate.




By State - in 2005

0%

5%

10%

15%

20%

95% CI Up 12.6% 14.2% 18.4% 14.9% 10.9%

Rate 12.0% 10.0% 14.1% 10.2% 7.1%

95% CI Low 11.5% 5.8% 9.7% 5.4% 3.4%



The recent trend in the rate of uninsured children between 200% and 300% FPL from 2002 to2005 is clearly higher, as every single state recorded increased rates. Hawaiis rate increaseof 0.3% was the lowest increase of the group. The increases in the comparison states rates

ranged from 2.5%(Maryland) to 5.1%(Rhode Island). Each ofthe states showed muchvariation in their year-over-year scores.




0%

5%

10%

15%

20%

United States 11.3% 10.6% 11.6% 12.0%

Hawaii 9.7% 6.9% 4.8% 10.0%

Maryland 11.6% 8.4% 8.2% 14.1%

Massachusetts 6.3% 10.3% 7.8% 10.2%

Rhode Island 2.0% 7.0% 7.5% 7.1%

2002 2003 2004 2005


Of the reported states,Rhode Island had thelowest rate of uninsuredchildren between 200%and 300% FPL in both2002 and 2005. Hawaiibriefly having the lowestrate of all the states in

2004 (4.8%), but startedand ended up mid-pack.

The Hawaii target rate of5.9% was lower than most of the 2002 through 2005 reported rates of uninsured childrenbetween 200% and 300% FPL, save the 2002 Rhode Island rate (2.0%) and the 2004 Hawaiirate (4.8%).


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HEDIS Measures

The Health Plan Employer Data & Information Set (HEDIS) measures are included in this reportto measure both the quality of healthcare delivered to, as well as the overall healthcare utilizationlevels of, the Hawaii QUEST recipients.

The HEDIS measures mostly involve ratios of a target behavior over the entire population that iseligible for that behavior. Occasionally ratios are reported on a sample of the population insteadof the entire population, but on these occasions there are intensive internal claim audits areapplied to the sample encounters. The HEDIS measures are based on self-reported HEDISreports received from the three individual plans that are contracted with Med-QUEST AlohaCare, HMSA, and Kaiser. HEDIS reports from the plans are based on a fiscal year period,a twelve-month period beginning in July 1 and ending on June 30 of the report year, and are dueto Med-QUEST on December 31 of the report year. These are sent via electronic file to Med-QUEST, and are then compiled to create composite HEDIS measures for the entire QUESTpopulation for a single year. The plans are required to report on all of the HEDIS measures ineach year. The definitions of the various HEDIS measures reported by the plans are no differentfrom the national standard HEDIS definitions. All three plans use HEDIS-approved softwareprograms to calculate their scores. Since the plans are not required to conduct acomprehensive audit of the HEDIS scores before reporting them to Med-QUEST, the

HEDIS data submitted by the plans may or may not be audited by a third party.

Annual audits on how the plans calculate and report their HEDIS scores are conducted by theExternal Quality Review Organization (EQRO) entity under contract with, and under thedirection of, Med-QUEST. Typically, these audits only involve a sample of three HEDISmeasures. The measures presented below are a small sample of the complete set of HEDISmeasures that are reported each year,

Two types of analysis are done for most of the HEDIS measures. First, a longitudinal analysis iscompleted on the statewide QUEST rates to determine if there are broad trends in the measureover a period of several years. Scores are reported for each year from 2002 to 2005. Second, acomparison of the three plans scores and the statewide QUEST score in 2005 is done to observeany differences between health plans in the management of their population. For both analyses,comparisons are made to the 2005 National Medicaid Median score and the 2005 NationalMedicaid 75th Percentile score to bring perspective to where we score on a national level. Whenavailable, the National Medicaid 75th Percentile score will be the target score for all of theHEDIS measures. Finally, a 95% confidence interval is calculated for each score to determinethe significance of any differences in scores.

For a discussion on the specifics of each HEDIS measure, please see Appendix A. Please seeAppendix B for a detailed discussion on how the statewide rates, and 95% confidence intervals,are calculated. For all of the HEDIS measures except for the Maternity Average Length of Stayand Hemoglobin A1c Poorly Controlled, higher numeric scores are considered positive andlower numeric scores are considered negative; for these measures lower numeric scores areconsidered positive and higher numeric scores are considered negative.


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Prenatal Care


The statewide QUEST rateof women receiving aprenatal care visit in thefirst trimester or within 42days of enrollment hasvaried between 70% and78% from 2002 to 2005,with the highest rate of77.7% occurring in 2004and the lowest rate of70.9% occurring in 2002.

At the 95% confidencelevel, the rate of prenatalcare visits in 2002 issignificantly lower that the

rates in both 2003 and 2004. There is no significant difference in the rate between the twomiddle years (2003 and 2004).

HEDIS Measures

Prenatal Care (PPC)


0%

25%

50%

75%

100%

95% Upper 72.7% 78.4% 80.1% 75.1%

Rate 70.9% 76.1% 77.7% 72.9%

95% Lower 69.0% 73.7% 75.4% 70.6%

2002 2003 2004 2005

2005 National Medicaid Median = 81.5%

2005 National Medicaid 75th %ile = 86.7%

At the 95% confidence level, statewide QUEST rates of prenatal care visits for all the years2002 through 2005 are all significantly lower than the 2005 national Medicaid median scoreof 81.5%. The 2005 national Medicaid 75

thpercentile score was 86.7%.

By Plan in 2005


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Of the three plans 2005rates, Kaiser had thehighest rate of prenatalcare visits at 75.3%,followed by HMSA at73.2% and AlohaCareat 68.4%. Both Kaiserand HMSA were higherthat the 2005 statewide

QUEST average of72.9%.

At the 95% confidencelevel, the rates ofprenatal care visits forthe three plans were not significantly different from each other or the statewide QUESTaverage.

HEDIS Measures

Prenatal Care (PPC)

By Plan -- in 2005

0%

25%

50%

75%

100%

95% Upper 75.1% 73.0% 77.6% 78.6%

Rate 72.9% 68.4% 73.2% 75.3%

95% Lower 70.6% 63.8% 68.8% 72.0%

Hawaii QUEST AlohaCare (Hybrid) HMSA (Admin) Kaiser (Admin)




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At the 95% confidence level, the rates of prenatal care visits for the three plans are allsignificantly lower than the 2005 national Medicaid median score of 81.5%. The 2005national Medicaid 75

thpercentile score was 86.7%.


Cultural factors impact this score with several Polynesian and Asian cultures not traditionallyreceiving prenatal care. This is the most prevalent factor causing low prenatal visits scores.Targeted member education on the benefits of prenatal care is a possible intervention to improvethese scores.

Postpartum Care


The statewide QUEST rate of a postpartum care visit on or between 21 and 56 days afterdelivery has varied

between 47% and 57%from 2002 to 2005.There has been acontinuous increase inthe rate from a low of47.2% in 2002 to ahigh of 57.1% in 2005.

At the 95% confidencelevel, there is nosignificant difference in

the rates of postpartumcare visits in 2002 and2003; the same can besaid for the rates in2004 and 2005.However, the jump inthe rate from 2003 to

2004 is significant at the 95% confidence level.

HEDIS MeasuresPostpartum Care (PPC)


0%

25%

50%

75%

100%

95% Upper 49.2% 52.0% 59.5% 59.6%

Rate 47.2% 49.2% 56.7% 57.1%

95% Lower 45.2% 46.5% 53.9% 54.6%

2002 2003 2004 2005



At the 95% confidence level, statewide QUEST rates of postpartum care visits for the years2002 and 2003 are significantly lower than the 2005 national Medicaid median score of

58.4%. The QUEST rates for 2004 and 2005, however, are not significantly different fromthis same 2005 national Medicaid median score. All four years QUEST rates weresignificantly below the 2005 national Medicaid 75th percentile score of 64.5%.


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By Plan in 2005


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In 2005, Kaiser hadthe highest rate ofpostpartum care visitsat 67.2%, followed byHMSA at 54.5% andAlohaCare at 42.6%.Both HMSA andAlohaCare had ratesthat were below the2005 statewideQUEST average of57.1%

At the 95%confidence level, the

rates of postpartum care visits for the three plans were ALL significantly different from eachother. Accordingly, only the HMSA rate was not significantly different than the 2005statewide QUEST average. The Kaiser rate was significantly higher, and the AlohaCare ratesignificantly lower, than the 2005 statewide QUEST average.

HEDIS Measures

Postpartum Care (PPC)

By Plan -- in 2005

0%

25%

50%

75%

100%

95% Upper 59.6% 47.5% 59.5% 70.8%

Rate 57.1% 42.6% 54.5% 67.2%

95% Lower 54.6% 37.7% 49.6% 63.7%

Hawaii QUEST AlohaCare (Hybrid) HMSA (Admin) Kaiser (Admin)



At the 95% confidence level, the 2005 national Medicaid median score of 58.4% wassignificantly above the AlohaCare rate of postpartum care visits, and not significantlydifferent from the HMSA rate. The Kaiser rate was significantly above the 2005 nationalMedicaid median score, as well as not significantly different that the 2005 national Medicaid75th percentile score of 64.5%.

Discussion of ResultsThe low postpartum rate is also linked to the same cultural differences mentioned with respect tothe prenatal visit measure. Similar member educational interventions may be utilized to improvethis measure.

Maternity Average Length of Stay

This is an administrative measure that reports the entire population of data. Therefore, noconfidence interval is needed or reported. The graphs used to illustrate this measure are scaledfrom 0.00 to 3.00 to reflect the reduced normal range of maternity discharge rates


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The statewide QUESTmaternity averagelength of stay (ALOS)for all deliveries rangedfrom 2.3 to 2.8 between2002 and 2005. After arate of 2.34 in 2002,there was a jump to arate of 2.78 in 2004followed by a decreaseto a 2005 rate of 2.46.

Maternity ALOSreported for 2002, 2003and 2005 were all lower

than both the national Medicaid median score of 2.6 and the 2005 national 75

th

percentilescore of 2.85. The 2.78 ALOS reported in 2004 was higher than the national median butlower than the national 75

thpercentile score.

HEDIS Measures

Maternity Average Length of Stay (MAT), per 1,000 Member Months


2.34 2.43 2.46

2.78

0.00

1.00

2.00

3.00

2002 2003 2004 2005

2005 National Medicaid Median = 2.592005 National Medicaid 75th %ile = 2.85

By Plan in 2005

In 2005, Kaiser had thelowest maternity ALOSat 2.27, followed byAlohaCare at 2.49 andHMSA at 2.50. Only

Kaiser had a rate thatwas below the 2005statewide QUESTaverage of 2.46.

HEDIS Measures

Maternity Average Length of Stay (MAT), per 1,000 Member Months

By Plan in 2005

2.46 2.49 2.50

2.27

0.00

1.00

2.00

3.00

Hawaii QUEST AlohaCare (Admin) HMSA (Admin) Kaiser (Admin)

2005 National Medicaid Median = 2.592005 National Medicaid 75th %ile = 2.85

All three plans hadmaternity ALOS at orbelow both the 2005national Medicaid 75thpercentile score of 2.85and the 2005 national

Medicaid median scoreof 2.6.


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Well Child Visits


The statewide QUESTrate of children whohad six or more well-child visits with aprimary carepractitioner duringtheir first 15 monthsof life has ranged from51% to 59% between2002 and 2005. Therehas been a steadydecline from a highrate of 58.9% in 2002to a low rate of 51.7%in 2005.

At the 95%confidence level, there

is no significant difference between any adjacent years rates of well child visits. Comparingrates that are two years apart, though, results in significant differences. The QUEST rate in2002 is significantly higher than the rate in 2004, and the QUEST rate in 2003 issignificantly higher than the rate in 2005.

HEDIS Measures

Well Child Visits in the First 15 Months of Life (W15) - Six or More Visits


0%

25%

50%

75%

100%

95% CI Up 60.7% 58.2% 54.2% 53.1%

Rate 58.9% 56.1% 52.6% 51.7%

95% CI Low 57.1% 54.0% 51.0% 50.3%

2002 2003 2004 2005



Statewide QUEST rates of well child visits for all four years are significantly higher, at the95% confidence level, than the 2005 national Medicaid median score of 46.4%. Whencomparing to the 2005 national Medicaid 75th percentile score of 56.3%, the QUEST rate in2002 is significantly above, the QUEST rates in 2004 and 2005 are significantly below, andthe QUEST rate for 2003 is not significantly different.


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By Plan in 2005

In 2005, Kaiser hadthe highest rate of wellchild visits at 64.4%,followed byAlohaCare at 51.5%and HMSA at 49.0%.Both AlohaCare andHMSA had rates thatwere below the 2005statewide QUESTaverage of 51.7%.

At the 95% confidencelevel, the rates of wellchild visits forAlohaCare and HMSA were not significantly different from the 2005 statewide QUESTaverage. The Kaiser rate was significantly higher than the other two plans rates and the2005 statewide QUEST average.

HEDIS Measures

Well Child Visits in the First 15 Months of Life (W15) - Six or More Visits

By Plan -- in 2006

0%

25%

50%

75%

100%

95% CI Up 53.1% 54.3% 50.9% 68.3%

Rate 51.7% 51.5% 49.0% 64.4%

95% CI Low 50.3% 48.7% 47.1% 60.5%




At the 95% confidence level, all three plans rates of well child visits were significantlyhigher than the 2005 national Medicaid median score of 46.4%. The rates for bothAlohaCare and Kaiser were significantly below the 2005 national Medicaid 75th percentilescore of 56.3%. At the 95% confidence level, the Kaiser rate was significantly higher thanthe 2005 national Medicaid 75th percentile score.


A possible reason for this measure to be lower than target and decreasing over time is that thephysicians are not happy with reimbursement so they are not actively reminding patients tocome in for visits. An EPSDT educational blitz with physicians so they know that they can bepaid higher for these visits may could be utilized to improve these scores.


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Childhood Immunization


The statewideQUEST rate ofchildren who had thecomplete set ofCombination 2immunizations on orbefore their secondbirthday ranged from67% to 76 % between2002 and 2005. Thechange in the rateover the four yearscan be described as aslow decrease after alarge fall from a rateof 75.8% in 2002 to a

rate of 69.7% in 2003.

HEDIS Measures

Childhood Immunization Status (CIS) - Combination 2


0%

25%

50%

75%

100%

95% CI Up 78.2% 72.4% 70.8% 70.3%

Rate 75.8% 69.7% 68.2% 67.6%

95% CI Low 73.3% 67.1% 65.6% 65.0%

2002 2003 2004 2005



At the 95% confidence level, there is no significant difference between the immunizationrates in 2003, 2004 & 2005. The rate for 2002 is significantly higher than the rates for 2003,2004 & 2005.

At the 95% confidence level, the statewide QUEST immunization rate in 2002 was

significantly higher than the 2005 national Medicaid 75th percentile score of 71.4%. TheQUEST rate in 2003 was not significantly different from the 75th

percentile score. QUESTrates for both 2004 and 2005 were not significantly different from the 2005 nationalMedicaid median scoreof 66.0%.


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By Plan in 2005

HEDIS Measures

Childhood Immunization Status (CIS) - Combination 2

By Plan -- in 2005

0%

25%

50%

75%

100%

In 2005, Kaiser hadthe highestimmunization rate at

90.0%, followed byHMSA at 59.2% andAlohaCare at 53.3%.Both AlohaCare andHMSA had rates thatwere below the 2005statewide QUESTaverage of 67.6%.



95% CI Up 70.3% 58.2% 64.2% 93.0%

Rate 67.6% 53.3% 59.2% 90.0%

95% CI Low 65.0% 48.3% 54.3% 87.0%

Hawaii QUEST AlohaCare (Hybrid) HMSA (Admin) Kaiser (Hybrid)


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At the 95% confidence level, the immunization rates for AlohaCare and HMSA were bothsignificantly lower than the 2005 statewide QUEST average. The Kaiser rate wassignificantly higher than the other two plans rates and the 2005 statewide QUEST average.

Both HMSA and AlohaCare had immunization rates in 2005, at the 95% confidence level,that were significantly below the 2005 national Medicaid median score of 66.0%. The 2005

rate for Kaiser was significantly above both the 2005 national Medicaid median score and the2005 national Medicaid 75th percentile score of 71.4%, at a 95% confidence level.


Cultural issues mentioned previously may also be negatively affecting this measure as well, withsimilar educational interventions as a possible ways to improve scores.

Hemoglobin A1c Tested


The statewide QUEST rate of adult diabetic members who have had at least twoglycohemoglobin level tests in the reporting year varied tightly between 79% and 81% from2002 to 2005.


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At the 95% confidencelevel, the statewideQUEST diabetictesting rates in all fouryears were not

significantly different.

At the 95% confidencelevel, the statewideQUEST diabetictesting rates in 2002,2003 & 2004 were notsignificantly differentthan the 2005 nationalMedicaid median score of 78.4%. The QUEST rate in 2005 was significantly higher than the2005 national Medicaid median score, but significantly lower than the 2005 national

Medicaid 75th percentile score of 84.1%.

HEDIS Measures

Hemoglobin A1c Tested (CDC)


0%

25%

50%

75%

100%

95% CI Up 82.5% 82.2% 81.1% 83.6%

Rate 80.1% 80.0% 79.0% 81.3%

95% CI Low 77.7% 77.7% 76.9% 79.0%

2002 2003 2004 2005



By Plan in 2005


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In 2005, Kaiser had the highest diabetic testing rate at 88.0%, followed by AlohaCare at78.8% and HMSA at78.6%. BothAlohaCare and HMSAhad rates that werebelow the 2005statewide QUESTaverage of 81.3%.

At the 95% confidencelevel, the diabetictesting rates forAlohaCare, HMSA &the statewide QUESTaverage are notsignificantly different.The rate for Kaiser issignificantly higher

than the 2005 statewide QUEST average.

HEDIS Measures

Hemoglobin A1c Tested (CDC)

By Plan -- in 2005

0%

25%

50%

75%

100%

95% CI Up 83.6% 82.9% 82.7% 91.7%

Rate 81.3% 78.8% 78.6% 88.0%

95% CI Low 79.0% 74.8% 74.5% 84.3%

Hawaii QUEST AlohaCare (Hybrid) HMSA (Hybrid) Kaiser (Hybrid)



At the 95% confidence level, the diabetic testing rates for AlohaCare and HMSA are notsignificantly different than the 2005 national Medicaid median score of 78.4%. The rate forKaiser is significantly higher than the 2005 national Medicaid 75th percentile score of 84.1%at the 95% confidence level.


This is a relatively new measure and new way of thinking for physicians. As more physiciansare educated that this is the best practice for diabetes, the measure should improve. The most

recent scores in 2005 showed promising improvement.

Hemoglobin A1c Poorly Controlled

This measure is the only one of two measures in this study where lower scores are consideredpositive and higher scores are considered negative.


As 2005 is the first year as a HEDIS required measure, a longitudinal graph was not done.

By Plan in 2005

The statewide QUEST rate of adult diabetic members whos most recent glycohemoglobinlevel score was considered poorly controlled (score of > 9.0%, or score was missing, or hadno test in the past year) was 59.9% in 2005. Of the plans whose rate was lower than thestatewide QUEST average, Kaiser had the lowest poorly controlled diabetic rate at 47.5%followed by HMSA at 55.0%. AlohaCare had a rate of 74.5%


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At the 95% confidencelevel, the poorlycontrolled diabetic ratesfor HMSA & Kaiserwere not significantlydifferent. The rate forKaiser was significantlylower than the 2005statewide QUESTaverage, andAlohaCares rate was assignificantly higherthan the same average.

At the 95% confidencelevel, the poorly

controlled diabetic rates for AlohaCare, HMSA & the statewide QUEST average weresignificantly higher than the 2005 national Medicaid median score of 47.5%. The rate forKaiser was not significantly different from the 2005 national Medicaid median score, butsignificantly higher the 2005 national Medicaid 25th percentile score of 37.8%.

HEDIS Measures

Hemoglobin A1c Poorly Controlled (CDC)

By Plan -- in 2005

0%

25%

50%

75%

100%

95% CI Up 62.8% 79.4% 59.9% 52.9%

Rate 59.9% 74.5% 55.0% 47.5%

95% CI Low 56.9% 69.5% 50.0% 42.2%





Hawaii has a high rate of diabetes due to Polynesian populations (similar to Native Americans).This is also a cultural issue on medication and disease management. Again, a possible solutionto the low scores with this measure is physician education on best practices.

Retinal Examination


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The statewide QUESTrate of diabeticmembers 31 years andolder who have had aretinal examination inthe reporting yearvaried from 40% to53% from 2002 to2005. After an initial

drop in the rate from47.0% in 2002 to40.7% in 2003, the rateincreased over two years to reach 53.1% in 2005.

HEDIS Measures

Retinal Examination (CDC)


0%

25%

50%

75%

100%

95% CI Up 49.4% 43.4% 51.5% 56.1%

Rate 47.0% 40.7% 48.6% 53.1%

95% CI Low 44.6% 37.9% 45.7% 50.2%

2002 2003 2004 2005



At the 95% confidence level, the statewide QUEST retinal exam rates in 2002 and 2004 werenot significantly different. The rate in 2003 was significantly lower than the other threeyears.


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At the 95% confidence level, the statewide QUEST retinal exam rate in 2003 was the onlyyear that was significantly lower than the 2005 national Medicaid median score of 46.9%.The statewide rates in 2002 and 2004 were both not significantly different from the nationalmedian. The 2005 national Medicaid 75th percentile score of 54.9% was not significantlydifferent from the statewide score in 2005.

By Plan in 2005

In 2005, Kaiser had thehighest retinal exam rateat 64.8%, followed byAlohaCare at 49.9% andHMSA at 47.2%. Onlythe Kaiser rate washigher than the 2005statewide QUEST rate of53.1%.

At the 95% confidencelevel, the retinal examrates for AlohaCare,HMSA & the statewideQUEST average are notsignificantly different.The rate for Kaiser is

significantly higher than the 2005 statewide QUEST average as well as higher than theHMSAs rate.

HEDIS Measures

Retinal Examination (CDC)

By Plan -- in 2005

0%

25%

50%

75%

100%

95% CI Up 56.1% 54.8% 52.2% 70.2%

Rate 53.1% 49.9% 47.2% 64.8%

95% CI Low 50.2% 44.9% 42.3% 55.8%




At the 95% confidence level, the retinal exam rates for AlohaCare and HMSA are notsignificantly different than the 2005 national Medicaid median score of 46.9%. The rate forKaiser is significantly higher than the 2005 national Medicaid 75th percentile score of54.9%.


As with the Hemoglobin tests, this is a relatively new measure and new way of thinking forphysicians. As more physicians are educated that this is the best practice for diabetes, themeasure should improve. Again, the most recent scores in 2005 showed promisingimprovement.


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Follow-Up After Hospitalization for Mental Illness

Statewide -Longitudinal

The statewideQUEST rate ofmembers 6 years ofage and older as ofthe date of a mentalhealth discharge whowere seen on anambulatory basis orwere in intermediatetreatment with amental healthprovider within 30days of hospitaldischarge ranged from 62% to 78 % between 2002 and 2005. After a rate of 61.9% in 2002,there was a jump to a rate of 77.9% in 2003 followed by a slow decrease to a 2005 rate of72.2%.

HEDIS Measures

Follow-Up After Hospitalization for Mental Illness (FUH) - Within 30 Days


0%

25%

50%

75%

100%

95% CI Up 66.0% 81.2% 77.7% 77.3%

Rate 61.9% 77.9% 74.3% 72.2%

95% CI Low 57.7% 74.7% 70.8% 67.1%

2002 2003 2004 2005



At the 95% confidence level, the follow-up rates in 2003, 2004 & 2005 were not significantlydifferent. The rate in 2002 was significantly lower that the three years that followed.

At the 95% confidence level, the statewide QUEST follow-up rate in 2002 was notsignificantly different than the 2005 national Medicaid median score of 58.4%. The QUEST

rates in both 2003 and 2004 were significantly higher than the 2005 national Medicaid 75thpercentile score of 70.6%. The 2005 QUEST rate was not significantly different from the2005 national Medicaid 75th percentile score but significantly higher than the 2005 nationalMedicaid median score.


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By Plan in 2005

In 2005, Kaiser had thehighest follow-up rate at76.1%, followed byAlohaCare at 71.2% and

HMSA at 70.5%. BothAlohaCare and HMSAhad rates that werebelow the 2005statewide QUESTaverage of 72.2%.

HEDIS Measures

Follow-Up After Hospitalization for Mental Illness (FUH) - Within 30 Days

By Plan -- in 2005

0%

25%

50%

75%

100%



95% CI Up 77.3% 77.7% 85.1% 87.1%

Rate 72.2% 71.2% 70.5% 76.1%

95% CI Low 67.1% 64.8% 55.8% 65.2%



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At the 95% confidence level, there are no significant differences in the follow-up rates for allthree plans in 2005. Also, the three plans rates are not significantly different from the 2005statewide QUEST average.

The follow-up rates for all three plans, at the 95% confidence level, are not significantlydifferent from the 2005 national Medicaid 75th percentile score of 70.6%. The rates for

Kaiser and AlohaCare are also significantly higher than the 2005 national Medicaid medianscore of 58.4%.


Med-QUEST has a mental health carveout (SMI and SEBD) for parts of the statewide Medicaidmental health population. About half of the population in the carve-out is in QUEST. HMSAand APS/Magellan, who administer the mental health carve-out, have been honored for theperformance of the carve-out and how well it serves its members. This may be a large factor inthe strong performance of this measure.

Mental Health Utilization

This is an administrative measure that reports the entire population of data. Therefore, noconfidence interval is needed or reported. The graphs used to illustrate this measure are scaledfrom 0% to 12% to reflect the reduced normal range of mental health utilization scores.


The statewide QUESTpercentage of membersreceiving any mental

health services(inpatient, day/nightcare, and ambulatory)ranged from 8% to 10% between 2002 and2005. After a rate of8.6% in 2002, therewas a jump to a rate of9.6% in 2003 followedby a slow decrease to a2005 rate of 9.0%.

Mental health servicerates reported from2002 to 2005 were all above the national Medicaid median score of 6.4%, and were all belowthe 2005 national Medicaid 75th percentile score of 9.7%.

HEDIS Measures

Mental Health Utilization (MPT) - Any Mental Health Services


8.6%

9.4%9.0%

9.6%

0%

6%

12%

2002 2003 2004 2005



By Plan in 2005


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In 2005, HMSA hadthe highest mentalhealth service rate at10.9%, followed byAlohaCare at 7.0% andKaiser at 6.3%. BothAlohaCare and Kaiserhad rates that werebelow the 2005statewide QUESTaverage of 9.0%.

The Kaiser rate waslower than the 2005national Medicaidmedian score of 6.4%.AlohaCares rate was

above the national Median but below the 2005 national Medicaid 75th percentile score of9.7%. The HMSA rate was above the national 75th percentile score.

HEDIS Measures

Mental Health Utilization (MPT) - Any Mental Health Services

By Plan in 2005

9.0%

10.9%

6.3%

7.0%

0%

6%

12%





The results of this measure are also probably related to the carve-out that HMSA andAPS/Magellan administers so well.

Emergency Department Visits

This is an administrative measure that reports the rate of occurrence of a measure within theentire population of data. Therefore, no confidence interval is needed or reported. The graphs

used to illustrate this measure are scaled from 0 to 60 to reflect the reduced normal range ofemergency department (ED) visit scores.

Statewide - Longitudinal HEDIS MeasuresEmergency Department Visits (AMB), per 1,000 Member Months


34.936.4

37.7 36.7

0

25

50

75

2002 2003 2004 2005

2005 National Medicaid 75th %ile = 62.6

2005 National Medicaid Median = 56.9

The statewide QUESTrate of ED visits per1,000 member monthsranged from 34 to 38between 2002 and2005. After a rate of

34.9 in 2002, there wasa jump to a rate of 36.4in 2003 and to 37.7 in2004, followed by adecrease to a 2005 rateof 36.7.

The statewide QUEST


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rates of ED visits reported from 2002 to 2005 were all below the national Medicaid medianscore of 51.4. The 2005 national Medicaid 75th percentile score was 57.5.

By Plan in 2005


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In 2005, AlohaCare had

the highest rate of EDvisits at 43.7, followedby HMSA at 37.5 andKaiser at 18.3. BothAlohaCare and HMSAhad rates that wereabove the 2005statewide QUESTaverage of 36.7.

The all three plans rate

of ED visits was lowerthan the 2005 nationalMedicaid median score of 51.4. The 2005 national Medicaid 75th percentile score was 57.5.

HEDIS Measures

Emergency Department Visits (AMB), per 1,000 Member Months

By Plan in 2005

36.7

43.7

37.5

18.3

0

25

50

75


2005 National Medicaid 75th %ile = 62.6

2005 National Medicaid Median = 56.9


All QUEST plans have put in place programs to educate their members on appropriate use of theemergency room. Plans also have been looking at offering more after hours urgent care,especially on the neighbor islands. These factors may explain the low rates of emergencydepartment visits when compared to national benchmarks.

Percentage of Well Newborns to Total Newborns

This percentage is based on the standard HEDIS score of Births and Average Lengths of Stay,Newborns (NEW). Although this percentage is not actually reported in the standard HEDISform, the numerator and denominator for this measure come straight off the standard NEWHEDIS measure. Also, there is no national median or 75 percentile score for this percentage.


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Statewide - LongitudinalHEDIS MeasuresPercentage of Well Newborn Discharges to Total Newborn Discharges


0%

25%

50%

75%

100%

95% CI Up 94.0% 93.0% 93.7% 93.3%

Rate 93.2% 92.2% 93.0% 92.6%

95% CI Low 92.4% 91.4% 92.3% 91.9%

2002 2003 2004 2005

The statewide QUESTpercentage of wellnewborns to totalnewborns varied from92% to 93% in the years2002 to 2005. Thepercentage in 2002 of93.2% was the highest,and the 92.2% reportedin 2003 was the lowest,over the four reportedyears. Percentages foryears 2004 and 2005 fellin between these scores.

At the 95% confidence level, and even with very narrow confidence intervals, the statewideQUEST percentage of well newborns in 2002 through 2005 were not significantly different.

By Plan in 2005

In 2005, HMSA had thehighest percentage ofwell newborns at92.9%, followed byKaiser at 92.8% and atAlohaCare 92.2%.

Only the AlohaCarepercentage was lowerthan the 2005 statewideQUEST rate of 92.6%.

HEDIS Measures

Percentage of Well Newborn Discharges to Total Newborn Discharges

By Plan -- in 2005

0%

25%

50%

75%

100%

95% CI Up 93.3% 93.4% 93.8% 94.6%

Rate 92.6% 92.2% 92.9% 92.8%

95% CI Low 91.9% 90.9% 91.9% 90.9%


At the 95% confidencelevel, the percentage ofwell newborns forAlohaCare, HMSA,Kaiser & the statewideQUEST average are not

significantly different.


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EPSDT Measures

The EPSDT measures are included in this report to measure the degree of comprehensive andpreventive child healthcare for individuals under the age of 21.

The EPSDT measures are based on self-reported EPSDT reports received from the threeindividual plans that are contracted with Med-QUEST AlohaCare, HMSA, and Kaiser. Allthree plans create custom queries to calculate their scores, and all of the EPSDT measures arereported in each year. The format of the various EPSDT measures reported by the plans is nodifferent from the national standard EPSDT format, but there are differences in the periodicity ofvisits by state. Audits on how the plans calculate and report their EPSDT scores are notcurrently conducted; future plan audits on the EPSDT calculation and reporting are beingconsidered. EPSDT reports from the plans are based on a fiscal year period, a twelve monthperiod beginning in October 1 and ending on September 30 of the report year, and are due toMed-QUEST on the last day of February in the year following the report year. The measurespresented below are a small sample of the complete set of EPSDT measures that are reportedeach year.

Two types of analysis are done for each EPSDT measure. First, a longitudinal analysis iscompleted on the statewide QUEST rates to determine if there are broad trends in the measureover a period of several years. Scores are reported for each year from 2002 to 2005. Second, acomparison of the three plans scores and the statewide QUEST score in 2005 is done to observeany differences between health plans in the management of their population. For both analyses,comparisons are made to the CMS National Goal score of 80% to bring perspective to where wescore on a national level. Finally, a 95% confidence interval is calculated for each score todetermine the significance of any differences in scores.

For a discussion on the specifics of each EPSDT measure, please see Appendix A. Please seeAppendix B for a detailed discussion on how the statewide rates, and 95% confidence intervals,are calculated.

For all of the EPSDT measures, higher numeric scores are considered positive and lowernumeric scores are considered negative.


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Screening RatioEPSDT Measures

Screening Ratio


0%

25%

50%

75%

100%

95% CI Up 96.8% 93.9% 94.7% 92.1%

Rate 96.6% 93.8% 94.5% 91.9%

95% CI Low 96.5% 93.6% 94.3% 91.7%

2002 2003 2004 2005

CMS National Goal = 80%


The statewide QUESTEPSDT ratio of actualscreenings receivedover expectedscreenings ranged from92% to 97 % between2002 and 2005. Overfour years, the ratiosshow a declining trend.The highest ratio wasrecorded in 2002 at96.6%, and the lowestratio of 91.9% wasrecorded in 2005.

At the 95% confidence level, and largely because of razor-thin confidence intervals, thescreening ratios for each of the reported years are significantly different from each other.

At the 95% confidence level, the screening ratios for each of the reported years aresignificantly higher than CMS National Goal of 80.0%.

By Plan in 2005

In 2005, Kaiser had thehighest screening ratioat 100.0%, followed byHMSA at 93.0% andAlohaCare at 87.7%.AlohaCare had a ratiothat was below the 2005statewide QUESTaverage of 91.9%.

At the 95% confidence

level, there aresignificant differencesin the screening ratiosfor all three plans in2005. Also, the threeplans ratios are allsignificantly different

from the 2005 statewide QUEST average.

EPSDT MeasuresScreening Ratio

By Plan -- in 2005

0%

25%

50%

75%

100%

95% CI Up 92.1% 88.1% 93.2% 100.0%

Rate 91.9% 87.7% 93.0% 100.0%

95% CI Low 91.7% 87.3% 92.8% 100.0%

Hawaii QUEST AlohaCare HMSA Kaiser

CMS National Goal = 80%


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At the 95% confidence level, the screening ratios for all three plans in 2005 are significantlyhigher than CMS National Goal of 80.0%.


A possible reason for the low AlohaCare score could be because they quit using an EPSDT formand went to administrative reporting. Moving away from an EPSDT form may increase the

difficulty in following the guidelines, which in turn may lower their score.

Participant Ratio EPSDT MeasuresParticipant Ratio


0%

25%

50%

75%

100%

95% CI Up 70.7% 68.6% 71.0% 68.8%

Rate 70.4% 68.3% 70.5% 68.5%

95% CI Low 70.0% 68.0% 70.1%

hawaii quest 1115 annual report 2006

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