Care Management Reports

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New York State Department of Health Office of Quality and Patient Safety

2016
Health Plan
Care Management Report

Last revised October 2018

Table of Contents

Plan-led care management, also referred to as case management, is an intervention-based program intended to improve the health plan members’ health outcomes. In this context, care management includes: a comprehensive assessment of a member’s needs, an individualized care plan, and interventions. The care plan is developed from the assessment, and the interventions are designed to achieve the care plan goals. The aim is to provide coordinated, efficient, quality care, and optimize health outcomes for people with complex health issues. Medicaid managed care (MMC) health plans are required to provide case management and disease management services for their members with chronic health conditions, or complex health issues or situations. MMC is a Medicaid health insurance plan that coordinates the provision, quality, and cost of care for its membership. With this kind of information, over the past 10 years there have been gains in building a foundation to: 1) explore the effectiveness of care management on health service use and outcomes, 2) determine which populations or members benefit the most, and 3) understand if any program models are associated with more effective results.

In New York State, plans have been required to provide case management and disease management services since the 1997 Partnership Program implementation. In 2008, the Medicaid managed care contract requirement for case management and disease management services (section 10.19 and 10.20 of the Medicaid contract) was amended to include specific data requirements for the evaluation of care management by the New York State Department of Health (NYSDOH). Since 2011 (measurement year 2010), NYSDOH has collected and evaluated case management and disease management services and outcomes through standardized measures. Plans are required to submit specific information for all Medicaid members involved in plan-administered care management programs during each calendar year. The collection of this standardized data provides NYSDOH with information that is used to evaluate care management programs, including the number of individuals receiving these services, the types of conditions individuals have, and the impact of care management services on outcomes.

The Department is committed to sharing information about care management services with the public, plans, and stakeholders. Therefore, this report provides a summary of each plan’s most recent care management data submission. This submission included data about member and program characteristics for all members who received care management services administered by health plans during measurement year 2016.

The goal of this annual report is 1) to provide information about plan care management programs, the members identified for care management, and the efficiency of their programs, 2) to describe utilization patterns for emergency department visits, inpatient stays, and outpatient services for members in care management, and 3) to describe quality results for members in care management.

This report is principally based on two data sources, the Health Plan Care Management Assessment Reporting Tool (CMART) and the New York State Medicaid Data. These data provide information regarding which members received care management services; the scope and nature of those services; and claims, encounters, and demographic details. To understand outcomes of members receiving plan-led care management, two additional data sources were used: The Vital Statistics Birth file for High-Risk Obstetrics (HROB) was used to calculate birth outcomes of pregnancies receiving HROB care management and the Clinical DataMart was used for quality measures.

The Health Plan CMART is submitted annually to the Department of Health. This data documents the process of plan-led care management services which include:

  • Members triggered to receive care management
  • Date members are triggered to receive management
  • For those who enroll in plan-led care management, CMART includes:
    • Start and end date of care management
    • Type of care management service received
    • Number of interventions
    • Type of interventions: letter, phone, in-person intervention

The Medicaid Data contains all claims and encounters data as well as demographics, diagnoses, etc. regarding health plan members. The Clinical Risk Groups (CRGs) (developed by 3M®) used for stratifications are also from this data source.

The Vital Statistics Birth file consists of all live births that occur in NYS during each calendar year. This data provides the following information about the infants and mothers, which is not recorded in CMART:

  • Mother characteristics
    • Demographics (nationality, race/ethnicity, Medicaid aid category, education level, age at time of delivery, region of NYS child was delivered)
    • Gestational weeks at delivery
    • Number of prenatal visits
    • Maternal risk factors
      • Diabetes
      • Gestational diabetes
      • Hypertension
      • Gestational hypertension
    • Referral to High-Risk OB provider
    • Number of times hospitalized during the pregnancy
    • Number of previous live births
  • Infant characteristics
    • Neonatal Intensive Care Unit (NICU) use
    • Sex
    • Birthweight

The DOH Clinical DataMart is utilized to calculate quality measures consistent with Healthcare Effectiveness Data and Information Set (HEDIS®) quality measures from the National Committee for Quality Assurance, and Prevention Quality Indicators (PQIs) from the Agency for Healthcare Research and Quality. PQIs can be used to identify potential problem areas in health care quality. These quality measures and quality indicators are used to better understand the quality of care provided by health plan care management.

The tables provided in this report are for comparison to the statewide rates/numbers only. These comparisons tell us many characteristics about the care managed recipients, however, the data does not tell us the reason(s) why the recipients are enrolled in the care management program. Program variation between plans/programs limits the ability to compare one plan to another. Plans differ in their methods to identify members as eligible for care management services and plans differ in how care management services are carried out. Trends over time for a single plan may be useful, but because plans can change their internal policies, discontinuities in the data may or may not reflect changes in practice. The variation in plan-led care management programs may create differences in results that would not be apparent.

Variation and/or extreme values in results are difficult to interpret where numbers are small. Therefore, results with fewer than 30 eligible individuals are reported in the tables as SS (small sample).

This report represents the health plan population during 2016 and contains the following four sections:

  • Outreach: Descriptive statistics and process measures for members contacted for acute/active care management services.
  • Enrollment: Descriptive statistics and process measures for members enrolled in acute/active care management services.
  • Quality Measures: quality measures for members enrolled in care management services at any point in the calendar year.
  • HROB: Pregnancy/birth outcomes for live-birth infants and mothers who triggered for the HROB Care Management programs.

The Outreach, Enrollment, and Quality Measures sections do not include members who are in the HROB care management program; these members are in the HROB section only.

Data presented in this report are often stratified by Clinical Risk Group (CRG). CRGs are a categorical clinical model (developed by 3M®) which assigns each member of a population to a single mutually exclusive risk category. The CRGs provide a way to consider illness and resource utilization of a full range of patient types, including low income, elderly, commercial beneficiaries, and those with disabilities. CRGs use standard claims data, and when available, additional data such as pharmaceutical data and functional health status which is collected longitudinally. Each CRG is clinically meaningful and correlates with health care utilization and cost. The Standard Model set of CRGs was used, which removes the effects of pregnancy/delivery during the calendar year.

We have combined the Standard Model CRGs as shown below. Each CRG group is defined and includes examples of conditions which could qualify a member for that CRG group.

  • Healthy: Non-User and CRG number 1 (Healthy)
    • Non-User: No medical care encounters
      CRG #1: Uncomplicated upper respiratory infection
  • Stable: CRG numbers 2 (Significant acute disease) and 3 (Single minor chronic disease)
    • CRG #2: Pneumonia
      CRG #3: Migraine Headache
  • Simple Chronic: CRG numbers 4 (Minor chronic disease in multiple organ systems) and 5 (Single dominant or moderate chronic disease)
    • CRG #4: Migraine Headache and Hyperlipidemia
      CRG #5: Diabetes
  • Complex Chronic: CRG numbers 6 (Pairs – significant chronic disease in multiple organ systems) and 7 (Triples – dominant chronic disease in three or more organ systems)
    • CRG #6: Diabetes and Congestive Heart Failure (CHF)
      CRG #7: Diabetes and CHF and Chronic Obstructive Pulmonary Disorder
  • Critical/HIV: CRG numbers 8 (Malignancies – dominant, metastatic, and complicated) and 9 (Catastrophic conditions/HIV)
    • CRG #8: Metastatic Colon Malignancy, under active treatment
      CRG #9: History of Major Organ Transplant

Table 1 shows the enrollment in mainstream health plans as of December 31, 2016, and the total number of triggered care management episodes for the entire year of 2016.

  Enrollment Total Episodes
Affinity Health Plan 240,114 1,783
CDPHP 85,000 3,002
Empire BlueCross BlueShield Health Plus 358,256 12,204
Excellus BlueCross BlueShield 165,073 4,638
Fidelis Care New York, Inc. 1,255,924 12,401
HealthFirst PHSP 914,100 28,149
HealthNow New York Inc. 22,997 1,036
HIP (EmblemHealth) 172,508 8,693
Independent Health´s MediSource 61,914 1,684
MetroPlus Health Plan 461,262 5,856
Molina Healthcare 35,029 896
MVP Health Care 165,659 5,992
UnitedHealthCare Community Plan 457,440 31,163
WellCare of New York 145,000 1,239
YourCare Health Plan 46,610 1,165
Statewide 4,586,886 119,901

Plans identify members in need of care management services throughout the year; the State does not identify members for plan-led care management. The first step in the plan-led care management process is outreach, which starts with the trigger. Criteria for eligibility, the trigger, for care management varies by plan and may include utilization patterns, diagnoses, or other healthcare metrics. Members who trigger and do not enroll are referred to as “triggered only.” In general, the process is as follows:

  • Outreach is a process that occurs between the trigger date and when the plan contacts the member. Not all triggered members are contacted by the plans.
  • The plan identifies and triggers the eligible member, which initiates the plan’s care management protocol. A member may trigger more than one time during a measurement year. If a Medicaid member changes plans during the calendar year, one or more plans may trigger that member for plan-led care management services.
  • Plans may have additional information which can further refine members they attempt to outreach.

Table 2 shows the number of care management triggered episodes, stratified by CRG.

  Healthy Stable Simple Chronic Complex Chronic Critical/HIV
N % N % N % N % N %
Affinity Health Plan 188 11 105 6 278 16 820 46 392 22
CDPHP 244 8 156 5 562 19 1,818 61 222 7
Empire BlueCross BlueShield Health Plus 430 4 344 3 1,796 15 8,792 72 842 7
Excellus BlueCross BlueShield 376 8 214 5 767 17 2,758 59 523 11
Fidelis Care New York, Inc. 939 8 598 5 1,435 12 6,407 52 3,022 24
HealthFirst PHSP 3,801 14 1,595 6 6,344 23 11,553 41 4,856 17
HealthNow New York Inc. 42 4 45 4 192 19 693 67 64 6
HIP (EmblemHealth) 1,805 21 920 11 2,131 25 3,144 36 693 8
Independent Health´s MediSource 80 5 52 3 200 12 1,039 62 313 19
MetroPlus Health Plan MetroPlus Health Plan 954 16 280 5 891 15 2,495 43 1,236 21
Molina Healthcare 72 8 26 3 217 24 541 60 40 4
MVP Health Care 413 7 366 6 1,042 17 3,599 60 572 10
UnitedHealthCare Community Plan 6,874 22 3,730 12 5,534 18 12,935 42 2,090 7
WellCare of New York 90 7 69 6 165 13 721 58 194 16
YourCare Health Plan 57 5 37 3 160 14 760 65 151 13
Statewide 16,365 14 8,537 7 21,714 18 58,075 48 15,210 13

Note: CRG % by plan may not sum to 100 % because of missing data

Members in the Complex Chronic CRG, significant chronic disease in multiple organ systems and dominant chronic disease in three or more organ systems, account for just under 50 percent of triggered Statewide.

Once the member is triggered, the plan’s care management program will attempt to contact the member and offer care management services. This is the outreach phase. Outreach is usually conducted by phone, but occasionally is conducted in-person.

Table 3 shows the percentage of triggered members who were contacted. The percentage contacted is the number of members successfully contacted by the plan divided by the number triggered during the calendar year. The percentage contacted same day, contacted 1-30 days, and contacted 31+ days is the number of members successfully contacted by the plan in each time frame divided by the total number contacted. The percentage of members contacted varies across plans because of differences in eligibility criteria, outreach strategies, and other factors.

  Triggered Contacted Total Contacted Same Day Contacted 1-30 Days Contacted 31+ Days
N N % N % N % N %
Affinity Health Plan 1,783 1,095 61 492 45 407 37 196 18
CDPHP 3,002 2,104 70 1,351 64 709 34 44 2
Empire BlueCross BlueShield Health Plus 12,204 3,692 30 1,686 46 1,528 41 478 13
Excellus BlueCross BlueShield 4,638 2,865 62 1,159 40 1,314 46 392 14
Fidelis Care New York, Inc. 12,401 8,596 69 3,707 43 1,319 15 3,570 42
HealthFirst PHSP 28,149 6,773 24 425 6 3,603 53 2,745 41
HealthNow New York Inc. 1,036 386 37 86 22 282 73 18 5
HIP (EmblemHealth) 8,693 3,678 42 2,151 58 1,307 36 220 6
Independent Health´s MediSource 1,684 1,075 64 544 51 426 40 105 10
MetroPlus Health Plan 5,856 3,251 56 1,379 42 1,226 38 646 20
Molina Healthcare 896 510 57 70 14 374 73 66 13
MVP Health Care 5,992 3,433 57 1,485 43 1,816 53 132 4
UnitedHealthCare Community Plan 31,163 14,810 48 2,317 16 10,190 69 2,303 16
WellCare of New York 1,239 1,239 100 939 76 245 20 55 4
YourCare Health Plan 1,165 846 73 304 36 401 47 141 17
Statewide 119,901 54,353 45 18,095 33 25,147 46 11,111 20

Statewide, a little less than half of outreach efforts end in a successful contact. Most successful contacts occur within the first month after the member is triggered.

Once the plan contacts the member, the member may choose to engage in care management or decline the offer.

Table 4 shows the percentage of contacted members who enroll in plan-led care management services. The percentage enrolled is the number of members enrolled by the plan divided by the number successfully contacted during the calendar year. The percentage enrolled same day enrolled 1-30 days, and enrolled 31+ days is the number of members enrolled by the plan in each time frame divided by the total number successfully contacted.

  Contacted Enrolled Total Enrolled Same Day Enrolled 1-30 Days Enrolled 31+ Days
N N % N % N % N %
Affinity Health Plan 1,095 483 44 154 32 209 43 120 25
CDPHP 2,104 2,042 97 1,346 66 657 32 39 2
Empire BlueCross BlueShield Health Plus 3,692 1,550 42 358 23 858 55 334 22
Excellus BlueCross BlueShield 2,865 2,063 72 733 36 865 42 465 23
Fidelis Care New York, Inc. 8,596 5,917 69 5,809 98 102 2 6 0
HealthFirst PHSP 6,773 6,278 93 381 6 3,281 52 2,616 42
HealthNow New York Inc. 386 362 94 96 27 256 71 10 3
HIP (EmblemHealth) 3,678 2,255 61 1,548 69 604 27 103 5
Independent Health´s MediSource 1,075 959 89 473 49 385 40 101 11
MetroPlus Health Plan 3,251 2,785 86 1,118 40 977 35 690 25
Molina Healthcare 510 371 73 72 19 240 65 59 16
MVP Health Care 3,433 2,390 70 1,239 52 1,103 46 48 2
UnitedHealthCare Community Plan 14,810 2,367 16 738 31 915 39 714 30
WellCare of New York 1,239 1,160 94 826 71 267 23 67 6
YourCare Health Plan 846 484 57 199 41 191 39 94 19
Statewide 54,353 31,466 58 15,090 48 10,910 35 5,466 17

Note: This table excludes 38 enrollments for which enrollment timeframe could not be calculated.

Statewide, almost 60% of contacted members enroll in health plan care management, with slightly less than half enrolling on the day of contact.

Members who are enrolled in plan-led care management services receive interventions. Services and referrals made to the enrolled member are based on an individualized plan of care.

Table 5 shows the number of care management enrolled episodes, stratified by CRG. An episode is a distinct unit of care management with a begin date and an end date. A member may trigger for and enroll in a care management episode more than one time during the measurement year, and therefore have more than one episode during the measurement year. The percentage enrolled in each CRG group is the number of members enrolled in each CRG group divided by the total number enrolled in care management episodes by plan.

  Healthy Stable Simple Chronic Complex Chronic Critical/HIV
N % N % N % N % N %
Affinity Health Plan 41 8 35 7 61 13 246 51 104 21
CDPHP 167 8 101 5 358 18 1,288 63 128 6
Empire BlueCross BlueShield Health Plus 54 3 56 4 192 12 1,011 65 238 15
Excellus BlueCross BlueShield 61 3 45 2 196 10 1,480 72 281 14
Fidelis Care New York, Inc. 138 2 102 2 538 9 4,120 70 1,019 17
HealthFirst PHSP 313 5 160 3 1,017 16 3,652 58 1,136 18
HealthNow New York Inc. 9 2 13 4 50 14 261 72 29 8
HIP (EmblemHealth) 196 9 148 7 438 19 1,178 52 295 13
Independent Health´s MediSource 32 3 22 2 82 9 605 63 218 23
MetroPlus Health Plan 339 12 111 4 362 13 1,174 42 827 29
Molina Healthcare 22 6 9 2 69 19 251 68 20 5
MVP Health Care 185 8 125 5 307 13 1,449 61 324 14
UnitedHealthCare Community Plan 212 9 160 7 212 9 1,384 58 399 17
WellCare of New York 84 7 66 6 159 14 669 57 187 16
YourCare Health Plan 14 3 11 2 42 9 362 75 55 11
Statewide 1,867 6 1,164 4 4,083 13 19,130 61 5,260 17

As in Table 2 Triggered by CRG, the Complex Chronic CRG is the largest group.

Services offered to members within care management programs will differ by plan and by member needs. These differences impact the duration of enrollment and the number of interventions provided to enrolled members. Of the 31,504 enrolled episodes in 2016, 13,104 episodes remained while 1,541 enrolled and closed the same day and 16,859 closed one or more days after enrollment. Table 6 shows the median number of days enrolled in care management and mean number of interventions, stratified by the number of days to closure per each episode.
  1-30 Days 31+ Days
# Enrolled Episodes Median days Mean Interventions # Enrolled Episodes Median days Mean Interventions
Affinity Health Plan 67 20.0 5.7 271 73.0 10.0
CDPHP 222 23.0 3.2 1,159 71.0 6.7
Empire BlueCross BlueShield Health Plus 115 19.0 4.4 994 96.5 8.0
Excellus BlueCross BlueShield 88 20.0 3.0 910 126.0 5.9
Fidelis Care New York, Inc. 88 20.5 3.1 1,467 232.0 5.9
HealthFirst PHSP 927 16.0 10.6 2,314 68.5 13.3
HealthNow New York Inc. 69 18.0 6.8 164 68.0 13.5
HIP (EmblemHealth) 117 20.0 3.1 1,879 517.0 11.0
Independent Health´s MediSource 247 17.0 3.0 297 77.0 6.4
MetroPlus Health Plan 290 12.0 2.8 1,007 96.0 5.4
Molina Healthcare 14 27.0 4.8 236 91.0 7.9
MVP Health Care 1,068 16.0 7.7 880 62.0 15.0
UnitedHealthCare Community Plan 433 25.0 4.1 1,158 82.5 4.8
WellCare of New York 45 20.0 13.9 52 59.5 17.0
YourCare Health Plan 17 22.0 3.5 264 121.0 9.5
Statewide 3,807 18.0 6.6 13,052 98.0 9.0

Note: Only episodes that closed in the calendar year are included; episodes with the same enrolled and closed date are excluded from this table

The plans vary in both the median number of days enrolled in care management and the mean number of interventions. The variation is largely driven by differences in member’s needs to successfully meet the goals of their care plan. One method used to determine the success of care management is to look at the reason the episode closed.

Table 7 shows the number of closed episodes by reason for closure, the median number of days enrolled in care management, and the mean number of interventions for each reason for closure.

  N % Median # days Mean Interventions
Met program goals 8,219 49 70.0 9.3
Lost to follow up 5,146 31 62.0 9.0
Disenrolled from plan 2,237 13 108.0 6.8
Refused to continue 774 5 99.5 6.0
Missing 319 2 61.0 6.2

Note: Only episodes that closed in the calendar year are included; episodes with the same enrolled and closed date are excluded from this table

An episode that met program goals is considered a success. Table 8 shows the percentage of episodes that closed with goals met. The total percentage of closure is the number of episodes that met program goals divided by the total number of episodes that closed. The percentage closed by CRG is the number of episodes closed in each CRG divided by the total number of episodes closed for each health plan.

  Total %
of
Closure		 Healthy Stable Simple Chronic Complex Chronic Critical/HIV
N % N % N % N % N %
Affinity Health Plan 40 14 10 21 15 20 15 64 47 17 13
CDPHP 47 54 8 29 4 120 18 401 62 46 7
Empire BlueCross BlueShield Health Plus 37 12 3 33 8 53 13 237 58 77 19
Excellus BlueCross BlueShield 30 6 2 11 4 32 11 221 73 34 11
Fidelis Care New York, Inc. 17 3 1 9 3 28 11 142 55 78 30
HealthFirst PHSP 25 35 4 37 5 124 15 474 59 133 17
HealthNow New York Inc. 40 3 3 3 3 4 4 71 76 13 14
HIP (EmblemHealth) 82 164 10 118 7 346 21 892 54 126 8
Independent Health´s MediSource 28 8 5 7 5 15 10 109 71 15 10
MetroPlus Health Plan 57 32 4 18 2 92 12 488 66 110 15
Molina Healthcare 43 5 5 2 2 14 13 79 74 7 7
MVP Health Care 83 97 6 76 5 195 12 1,025 64 215 13
UnitedHealthCare Community Plan 70 129 12 114 10 93 8 624 56 152 14
WellCare of New York 74 8 11 4 6 8 11 38 53 14 19
YourCare Health Plan 43 1 1 3 2 9 7 100 83 8 7
Statewide 49 571 7 485 6 1,153 14 4,965 60 1,045 13

Note: Only episodes that closed in the calendar year are included; episodes with the same enrolled and closed date are excluded from this table

Statewide, most of the members that ended care management because they met episode program goals were in the complex chronic CRG group (60%). Please note, this does not include episodes that are not closed within the measurement year. There may be episodes which successfully meet goals and close in the subsequent year.

Quality measures and PQIs, used to measure performance across health plans in New York State, can also be used to identify problems, opportunities for improvement, and obtain a baseline assessment of current practices. They are used as a first step to establishing performance benchmarks for the care management group. Table 9 shows the quality measure performance among enrolled care management members by CRG. These measures are expressed as the percentage of members meeting the criteria definition for the quality measures.

  Healthy Stable Simple Chronic Complex Chronic Critical/HIV
Adult BMI Assessment (ABA) SS SS SS 95 SS
Breast Cancer Screening (BCS) 15 SS 63 68 65
Cervical Cancer Screening (CCS) 72 80 75 66 66
Chlamydia Screening (CHL) 80 80 76 72 51
Colorectal Cancer Screening (COL) 27 40 39 56 56
Comprehensive Diabetes Care - HbA1c Test (CDC) 70 72 87 87 83
HIV/AIDS Comprehensive Care - Syphilis Screening SS SS SS 45 72
HIV/AIDS Comprehensive Care - Viral Load Monitoring SS SS SS SS 67
HIV/AIDS Comprehensive Care - Engaged in Care SS SS SS 94 91
Medication Management for People with Asthma - 50% Days covered (MMA) SS SS 55 68 75
Medication Management for People with Asthma - 75% Days covered (MMA) SS SS 26 43 51
Antidepressant Medication Management - Acute Phase (84 days) (AMM) SS 39 50 58 52
Antidepressant Medication Management - Continuation Phase (180 days) (AMM) SS 19 36 45 41
Follow Up After Hospitalization for Mental Illness - 7 days (FUH) 62 74 68 58 51
Follow Up After Hospitalization for Mental Illness - 30 days (FUH) 78 86 82 75 68
Initiation of Alcohol and Other Drug Dependence Treatment (IET) 60 43 59 56 50
Engagement of Alcohol and Other Drug Dependence Treatment (IET) 20 12 21 13 8

SS: Small Sample Size

The measures in Table 10 are rates of potentially preventable hospitalizations for specific chronic conditions. These chronic conditions are prevalent for many of the members enrolled in care management. The measures are expressed as the rate of events per 100,000 members.

  Healthy Stable Simple Chronic Complex Chronic Critical/HIV
Diabetes Short-Term Complications Admission Rate (PQI #1) 29 41 434 2,297 1,460
Diabetes Long-Term Complications Admission Rate (PQI #3) 117 SS 170 2,264 1,675
COPD or Asthma in Older Adults Admission Rate (PQI #5) 1,770 337 1,931 8,608 6,629
Hypertension Admission Rate (PQI #7) 29 SS 38 543 86
Heart Failure Admission Rate (PQI #8) 350 41 226 4,123 4,854
Dehydration Admission Rate (PQI #10) 146 82 151 1,047 1,267
Bacterial Pneumonia Admission Rate (PQI #11) 58 SS 226 1,371 1,740
Urinary Tract Infection Admission Rate (PQI #12) 29 41 208 691 795
Uncontrolled Diabetes Admission Rate (PQI #14) SS SS 151 817 816
Asthma in Younger Adults Admission Rate (PQI #15) 139 62 418 2,127 2,899
Lower-Extremity Amputation among Patients with Diabetes Rate (PQI #16) SS SS 19 389 279

SS: Small Sample Size

Utilization of medical services is a major component of the total cost of health care. One of the goals of care management is to lower utilization cost by decreasing emergency department (ED) and inpatient use, while simultaneously increasing outpatient use. The shift from ED and inpatient treatment of acute episodes to outpatient long-term management and prevention is also expected to improve outcomes. Tables 11 through 13 show the utilization rates of emergency department, inpatient care, and outpatient care for anytime during the calendar year that the care management episode occurred.

Emergency department utilization is defined as visits to the ED that do not transfer to an inpatient stay. Inpatient utilization is defined as hospitalizations. Outpatient utilization is defined as ambulatory visits to providers.

  Healthy Stable Simple Chronic Complex Chronic Critical/HIV
Affinity Health Plan 957 1,612 1,553 2,032 1,248
CDPHP 1,037 1,544 1,566 2,470 2,986
Empire BlueCross BlueShield Health Plus 1,133 1,778 1,173 1,550 1,906
Excellus BlueCross BlueShield 681 996 1,098 1,873 1,932
Fidelis Care New York, Inc. 696 1,271 952 1,386 1,461
HealthFirst PHSP 1,240 1,714 1,488 2,250 2,019
HealthNow New York Inc. 1,392 2,784 1,136 2,457 1,067
HIP (EmblemHealth) 743 920 676 1,060 1,029
Independent Health's MediSource 1,394 1,870 1,487 2,311 1,462
MetroPlus Health Plan 646 1,568 997 1,611 1,154
Molina Healthcare 1,412 1,707 1,816 3,109 3,056
MVP Health Care 981 1,652 1,578 2,838 2,393
UnitedHealthCare Community Plan 783 768 1,091 2,055 1,546
WellCare of New York 599 1,044 992 1,591 1,707
YourCare Health Plan 1,815 2,531 1,773 2,112 2,768
Statewide 926 1,408 1,245 1,913 1,659
  Healthy Stable Simple Chronic Complex Chronic Critical/HIV
Affinity Health Plan 1,074 1,020 1,165 1,890 1,883
CDPHP 513 524 506 1,156 3,210
Empire BlueCross BlueShield Health Plus 848 752 602 1,229 2,521
Excellus BlueCross BlueShield 540 563 466 895 1,672
Fidelis Care New York, Inc. 635 687 401 816 1,681
HealthFirst PHSP 682 820 483 1,315 2,615
HealthNow New York Inc. 1,094 667 746 1,673 2,286
HIP (EmblemHealth) 433 716 489 904 1,899
Independent Health's MediSource 918 659 754 1,353 1,244
MetroPlus Health Plan 338 803 520 1,187 833
Molina Healthcare 318 659 484 1,180 2,111
MVP Health Care 930 951 802 1,388 2,961
UnitedHealthCare Community Plan 973 844 1,144 1,564 2,558
WellCare of New York 574 787 602 1,277 1,618
YourCare Health Plan 630 1,359 674 1,155 2,582
Statewide 717 793 601 1,161 1,942
  Healthy Stable Simple Chronic Complex Chronic Critical/HIV
Affinity Health Plan 15,667 15,507 16,860 20,664 19,286
CDPHP 5,923 6,975 8,145 13,337 19,810
Empire BlueCross BlueShield Health Plus 11,472 13,802 11,741 18,033 24,247
Excellus BlueCross BlueShield 5,880 7,693 8,801 15,350 15,080
Fidelis Care New York, Inc. 9,617 10,863 10,543 18,429 21,087
HealthFirst PHSP 10,093 12,556 8,864 17,749 22,343
HealthNow New York Inc. 5,436 7,804 4,780 10,616 10,210
HIP (EmblemHealth) 5,567 9,072 7,566 16,167 22,592
Independent Health's MediSource 4,822 6,323 5,339 12,639 10,667
MetroPlus Health Plan 4,562 9,155 7,173 14,856 13,195
Molina Healthcare 6,424 10,220 7,047 11,868 16,278
MVP Health Care 13,455 12,575 11,188 19,281 25,316
UnitedHealthCare Community Plan 9,169 10,397 12,117 19,750 21,249
WellCare of New York 6,780 9,526 8,555 16,113 18,117
YourCare Health Plan 5,074 8,344 7,356 14,588 15,181
Statewide 9,036 10,814 9,470 17,009 19,321

The Health Plan CMART has a total of ten program type choices. Not all plans have all ten programs; however, all plans offer the HROB program. This section describes the HROB population served by the plans and the population’s health outcomes. The HROB care management program is different from the other program types, because there is a definitive closure day to each person’s time in the program (either the birth of the child or two weeks after the birth). In this section, measures are based on women who were referred to an HROB care management group and numbers and percentages are based on a rolling three years. For this report, 2013-2015 data is included.

The HROB care management program is not included in the counts, percentages, or rates in any other section of this Report.

Table 14 shows the distribution of HROB pregnancies across the plans by enrollment. The percentage contacted is the number of pregnancies for which the mothers were successfully contacted divided by the total number of pregnancies triggered during the calendar year. The percentage enrolled is the number of pregnancies for which the mothers enrolled in care management services divided by the total number successfully contacted.

  Triggered Pregnancies Contacted Enrolled *
N % N %
Affinity Health Plan 2,381 1,334 56 818 61
CDPHP 631 418 66 372 89
Empire BlueCross BlueShield Health Plus 2,979 1,859 62 1,211 65
Excellus BlueCross BlueShield 1,812 1,134 63 602 53
Fidelis Care New York, Inc. 1,605 1,021 64 220 22
HealthFirst PHSP 19,666 5,414 28 5,343 99
HealthNow New York Inc. 362 350 97 349 100
HIP (EmblemHealth) 2,993 2,487 83 918 37
Independent Health's MediSource 2,632 1,919 73 1,909 99
MetroPlus Health Plan 1,486 1,378 93 1,341 97
Molina Healthcare 124 84 68 63 75
MVP Health Care 2,319 1,248 54 800 64
UnitedHealthCare Community Plan 2,716 1,567 58 1,567 100
WellCare of New York 219 197 90 196 99
YourCare Health Plan 529 444 84 402 91
Statewide 42,454 20,854 49 16,111 77

* Enrolled N does not include 837 women who enrolled in HROB care management services after infant birth

Although CMART provides basic demographic information about the mothers, it does not provide any demographic data about the infants. The CMART data is matched to the Vital Statistics Birth file to provide additional information on the mother and infant.

Table 15 shows the maternal demographics and other characteristics for members who triggered compared to those who enrolled in HROB care management services during the measurement year.

Demographic Triggered Enrolled Only
N % * N % *
Place of Birth
USA 21,772 51 9,115 54
Other 20,682 49 7,912 46
Region of NYS
Central 965 2 433 2
Hudson Valley 1,743 4 760 6
Long Island 4,426 11 1,917 9
Northeast 661 2 268 2
NYC 27,556 66 14,663 59
Western 6,371 15 3,440 21
Aid Category
FHP 1,418 3 583 3
SSI 982 2 456 3
TANF 40,008 94 15,970 94
Education Level
Not HS Graduate 12,781 30 4,998 29
HS Graduate 13,350 31 5,361 31
College 16,100 38 6,583 39
Age
< 18 Years 852 2 305 2
18 - 19 Years 1,749 4 650 4
20 - 29 Years 22,354 53 8,730 51
> 29 Years 17,499 41 7,342 43
Race
White 13,738 32 5,597 33
Black 10,249 24 4,442 26
Hispanic 3,790 9 1,576 9
Other 14,677 35 5,412 32
CRG Group
Healthy 9,721 23 3,389 20
Stable 11,136 26 4,317 25
Simple Chronic 12,086 28 4,925 29
Complex Chronic 9,026 21 4,155 24
Critical/HIV 483 1 241 1
Risks
Diabetes 686 2 376 2
Gestational Diabetes 3,711 9 1,669 10
Hypertension 1,141 3 530 3
Gestational Hypertension 2,212 5 985 6
Characteristics
High-Risk Referral 3,274 8 1,503 8
Hospitalized during Pregnancy 2,045 5 1,179 5
Number Previous Pregnancies
0 10,881 26 4,075 24
1 - 2 18,561 44 7,469 44
3 - 4 8,394 20 3,552 21
5 + 4,618 11 1,931 11

* Category % may not sum to 100 % because of missing data

Table 16 reports demographic data for infants born to the women triggering and enrolling in HROB care management.

Demographic Triggered Enrolled Only
N % N %
Sex
Female 21,540 49 8,759 49
Male 22,270 51 9,085 51
Gestational Age
< 33 weeks 1,408 3 639 4
33 - 35 weeks 2,260 5 1,024 6
36 - 38 weeks 13,083 30 5,645 32
39 + weeks 27,060 62 10,537 59
NICU Use 6,436 15 2,767 16
Birthweight Very Low Birthweight 968 2 440 2
Low Birthweight 3,990 9 1,736 10
Large for Gestational Age 2,630 6 1,127 6
Macrosomia 2,887 7 1,185 7
Modified Kessner Index *
Intensive 4,996 11 2,211 12
Adequate 23,174 53 9,614 54
Intermediate 11,317 26 4,506 25
Inadequate 2,930 7 931 5
No Care 150 0 47 0
Missing 1,067 2 471 3
Statewide 43,811   17,845  

* Adequacy of prenatal care is defined in terms of timing and quantity of prenatal visits, adjusted for gestation length.
Note: Demographic groups may not total the Statewide total due to missing data.

The amount of time the women are in the HROB program is an important piece of the high-risk pregnancy care management program. The shorter the time the woman is enrolled in the HROB care management program, the less time there is to provide interventions that could increase positive outcomes.

Table 17 shows the number and percentage of time women are enrolled in the HROB program prior to delivery. The percentage of mothers who were triggered and enrolled after the infant was born were most likely members of a mom and infant oriented care management program that occurs during the first two weeks of the infants’ lives.

  Enrolled Only
N * %
Length of Time Before Delivery
More than 8 Months 46 0
8 Months 664 4
7 Months 2,047 11
6 Months 2,538 14
5 Months 2,770 16
4 Months 2,650 15
3 Months 2,695 15
2 Months 2,005 11
1 Month 1,318 7
Same Day Delivery 82 0
After Delivery 1,030 6
  Mean  
Mean Number of Months 3.6  
Adult BMI Assessment (ABA):
Percent of members, with an outpatient visit, who had their BMI documented during the measurement year or the year prior to the measurement year.
Breast Cancer Screening (BCS):
Percent of women who had one or more mammograms to screen for breast cancer at any time two years prior up through the measurement year.
Cervical Cancer Screening (CCS):
Percent of women, who had cervical cytology performed every 3 years or who had cervical cytology/human papillomavirus co-testing performed every 5 years.
Chlamydia Screening (CHL):
Percent of sexually active young women who had at least one test for Chlamydia during the measurement year.
Colorectal Cancer Screening (COL):
Percent of adults who had appropriate screening for colorectal cancer during the measurement year.
Comprehensive Diabetes Care - HbA1c Test (CDC):
The percent of members with diabetes who received at least one Hemoglobin A1c (HbA1c) test within the year.
HIV/AIDS Comprehensive Care - Syphilis Screening:
The percent of members with HIV/AIDS who were screened for syphilis in the past year.
HIV/AIDS Comprehensive Care - Viral Load Monitoring:
The percent of members with HIV/AIDS who had two viral load tests performed with at least one test during each half of the past year.
HIV/AIDS Comprehensive Care - Engaged in Care:
The percent of members with HIV/AIDS who had two visits for primary care or HIV-related care with at least one visit during each half of the past year.
Medication Management for People with Asthma - 50 % Days covered (MMA):
The percent of members with persistent asthma who filled prescriptions for asthma controller medications during at least 50 % of their treatment period.
Medication Management for People with Asthma - 75 % Days covered (MMA):
The percent of members with persistent asthma who filled prescriptions for asthma controller medications during at least 75 % of their treatment period.
Antidepressant Medication Management - Acute Phase (84 days) (AMM):
The percent of members who remained on antidepressant medication during the entire 12-week acute treatment phase.
Antidepressant Medication Management - Continuation Phase (180 days) (AMM):
The percent of members who remained on antidepressant medication for at least six months.
Follow Up After Hospitalization for Mental Illness - 7 days (FUH):
The percent of members who were seen on an ambulatory basis or who were in intermediate treatment with a mental health provider within 7 days of discharge.
Follow Up After Hospitalization for Mental Illness - 30 days (FUH):
The percent of members who were seen on an ambulatory basis or who were in intermediate treatment with a mental health provider within 30 days of discharge.
Initiation of Alcohol and Other Drug Dependence Treatment (IET):
The percent of members who, after the first new episode of alcohol or drug dependence, initiated treatment within 14 days of the diagnosis.
Engagement of Alcohol and Other Drug Dependence Treatment (IET):
The percent of members who, after the first new episode of alcohol or drug dependence, initiated treatment and had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.
Diabetes Short-Term Complications Admission Rate (PQI #1):
Admissions for a principal diagnosis of diabetes with short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 population; excludes obstetric admissions.
Diabetes Long-Term Complications Admission Rate (PQI #3):
Admissions for a principal diagnosis of diabetes with long-term complications (renal, eye, neurological, circulatory, or complications not otherwise specified) per 100,000 population; excludes obstetric admissions.
COPD or Asthma in Older Adults Admission Rate (PQI #5):
Admissions with a principal diagnosis of COPD or asthma per 100,000 population, ages 40 and older; excludes obstetric admissions.
Hypertension Admission Rate (PQI #7):
Admissions with a principal diagnosis of hypertension per 100,000 population; excludes kidney disease combined with dialysis access procedure admissions, cardiac procedure admissions, and obstetric admissions).
Heart Failure Admission Rate (PQI #8):
Admissions with a principal diagnosis of heart failure per 100,000 population; excludes cardiac procedure admissions and obstetric admissions.
Dehydration Admission Rate (PQI #10):
Admissions with a principal diagnosis of dehydration per 100,000 population; excludes obstetric admissions.
Bacterial Pneumonia Admission Rate (PQI #11):
Admissions with a principal diagnosis of bacterial pneumonia per 100,000 population; excludes sickle cell or hemogobin-5 admissions, other indications of immunocompromised state admissions, and obstetric admissions.
Urinary Tract Infection Admission Rate (PQI #12):
Admissions with a principal diagnosis of urinary tract infection per 100,000 population; excludes kidney or urinary tract disorder admissions, other indications of immunocompromised state admissions, and obstetric admissions.
Uncontrolled Diabetes Admission Rate (PQI #14):
Admissions for a principal diagnosis of diabetes without mention of short-term (ketoacidosis, hyperosmolarity, or coma) or long-term (renal, eye, neurological, circulatory, or other unspecified) complications per 100,000 population; excludes obstetric admissions.
Asthma in Younger Adults Admission Rate (PQI #15):
Admissions for a principal diagnosis of asthma per 100,000 population, ages 18 to 39 years; excludes admissions with an indication of cystic fibrosis or anomalies of the respiratory system and obstetric admissions.
Lower-Extremity Amputation among Patients with Diabetes Rate (PQI #16):
Admissions for any-listed diagnosis of diabetes and any-listed procedure of lower-extremity amputation per 100,000 population; excludes any-listed diagnosis of traumatic lower-extremity amputation admissions, toe amputation admissions, and obstetric admissions.
Ambulatory Care - Emergency Department (AMB-ED):
Utilization of ambulatory care ED visits per 1,000 member years. Does not include mental health- or chemical dependency-related services.
Ambulatory Care - Outpatient (AMB-OP):
Utilization of ambulatory care OP visits per 1,000 member years. Does not include mental health- or chemical dependency- related services.
Inpatient Utilization (IPU):
Utilization of total acute inpatient stays per 1,000 member years. Does not include mental health- or chemical dependency-related inpatient stays.
Counties * in NYS each Mainstream plan cover
Affinity Health Plan
Bronx Brooklyn Manhattan Nassau
Orange Queens Rockland Staten Island
Suffolk Westchester    
CDPHP
Albany Broome Columbia Fulton
Greene Montgomery Rensselaer Saratoga
Schenectady Schoharie Tioga Washington
Empire BlueCross BlueShield Health Plus
Bronx Brooklyn Manhattan Nassau
Putnam Queens Staten Island  
Excellus BlueCross BlueShield
Broome Herkimer Livingston Monroe
Oneida Ontario Orleans Otsego
Seneca Wayne    
Fidelis Care New York, Inc.
Albany Allegany Bronx Brooklyn
Broome Cattaraugus Cayuga Chatauqua
Chemung Chenango Clinton Columbia
Cortland Delaware Dutchess Erie
Essex Franklin Fulton Genesee
Greene Hamilton Herkimer Jefferson
Lewis Livingston Madison Manhattan
Monroe Montgomery Nassau Niagara
Oneida Onondaga Ontario Orange
Orleans Oswego Otsego Putnam
Queens Rensselaer Rockland Saratoga
Schenectady Schoharie Schuyler Seneca
St. Lawrence Staten Island Steuben Suffolk
Sullivan Tioga Tompkins Ulster
Warren Washington Wayne Westchester
Wyoming Yates    
HealthFirst PHSP
Bronx Brooklyn Manhattan Nassau
Queens Staten Island Suffolk  
HealthNow New York, Inc.
Allegany Cattaraugus Chautauqua Orleans
Wyoming      
HIP (EmblemHealth)
Bronx Brooklyn Manhattan Nassau
Queens Staten Island Suffolk Westchester
Independent Health's MediSource
Erie      
MetroPlus Health Plan
Bronx Brooklyn Manhattan Queens
Staten Island      
Molina Healthcare
Cortland Onondaga Tompkins  
MVP Health Care
Albany Columbia Dutchess Genesee
Greene Jefferson Lewis Livingston
Monroe Oneida Ontario Orange
Putnam Rensselaer Rockland Saratoga
Schenectady Sullivan Ulster Warren
Washington Westchester    
UnitedHealthCare Community Plan
Albany Bronx Brooklyn Broome
Cayuga Chautauqua Chemung Chenango
Clinton Columbia Dutchess Erie
Essex Franklin Fulton Genesee
Greene Herkimer Jefferson Lewis
Livingston Madison Manhattan Monroe
Nassau Niagara Oneida Onondaga
Ontario Orange Orleans Oswego
Queens Rensselaer Rockland Schenectady
Seneca St. Lawrence Staten Island Suffolk
Tioga Ulster Warren Wayne
Westchester Wyoming Yates  
WellCare of New York
Albany Bronx Brooklyn Dutchess
Erie Manhattan Nassau Niagara
Orange Queens Rensselaer Rockland
Schenectady Schuyler Steuben Ulster
YourCare Health Plan
Allegany Cattaraugus Chautauqua Erie
Monroe Ontario Wyoming