Care Management Reports

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

2017
Health Plan
Care Management Report

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 2017.

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).

It is important to note that data in this report includes only plan-administered care management. Members of health plans may receive care management services from other providers such as Health Homes, and that information would not be included in this report.

This report represents the health plan population during 2017 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, 2017, and the total number of triggered care management episodes for the entire year of 2017.

  Enrollment Total Episodes
Affinity Health Plan 222,415 1,479
CDPHP 81,460 2,279
Empire BlueCross BlueShield Health Plus 330,628 10,519
Excellus BlueCross BlueShield 166,552 8,693
Fidelis Care New York, Inc. 1,207,268 15,248
HealthFirst PHSP 956,600 20,035
HealthNow New York Inc. 28,650 4,407
HIP (EmblemHealth) 140,028 4,933
Independent Health´s MediSource 58,575 1,883
MetroPlus Health Plan 391,457 6,441
Molina Healthcare 29,722 922
MVP Health Care 210,902 7,894
UnitedHealthCare Community Plan 471,856 31,961
WellCare of New York 106,000 5,862
YourCare Health Plan 40,900 1,384
Statewide 4,444,587 123,940

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 care management eligibility and the trigger 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 66 4 59 4 215 15 882 60 257 17
CDPHP 108 5 94 4 399 18 1,432 63 246 11
Empire BlueCross BlueShield Health Plus 257 2 236 2 2,327 22 6,498 62 1,201 11
Excellus BlueCross BlueShield 238 3 219 3 1,521 17 5,632 65 1,083 12
Fidelis Care New York, Inc. 728 5 459 3 1,817 12 8,900 58 3,344 22
HealthFirst PHSP 1,984 10 811 4 5,299 26 9,698 48 2,243 11
HealthNow New York Inc. 283 6 228 5 1,210 27 2,470 56 216 5
HIP (EmblemHealth) 311 6 124 3 852 17 2,997 61 649 13
Independent Health´s MediSource 215 11 66 4 247 13 1,058 56 297 16
MetroPlus Health Plan 513 8 236 4 1,197 19 3,335 52 1,160 18
Molina Healthcare 36 4 23 2 213 23 527 57 123 13
MVP Health Care 355 4 376 5 1,447 18 4,929 62 787 10
UnitedHealthCare Community Plan 6,894 22 3,630 11 5,872 18 13,147 41 2,418 8
WellCare of New York 1,492 25 587 10 1,454 25 1,867 32 462 8
YourCare Health Plan 53 4 50 4 209 15 860 62 212 15
Statewide 13,533 11 7,198 6 24,279 20 64,232 52 14,698 12

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 over 50 percent of triggered Statewide.

Members in the Healthy CRG may have acute events or have onset of new conditions that have not yet been fully represented in the 12 months of data used for the CRG.

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 1,479 609 41 218 36 352 58 39 6
CDPHP 2,279 1,998 88 1,619 81 347 17 32 2
Empire BlueCross BlueShield Health Plus 10,519 3,993 38 2,009 50 1,688 42 296 7
Excellus BlueCross BlueShield 8,693 6,726 77 3,633 54 2,260 34 833 12
Fidelis Care New York, Inc. 15,248 11,272 74 3,379 30 3,531 31 4,362 39
HealthFirst PHSP 20,035 6,927 35 711 10 3,481 50 2,735 39
HealthNow New York Inc. 4,407 575 13 228 40 278 48 69 12
HIP (EmblemHealth) 4,933 3,389 69 1,620 48 1,350 40 419 12
Independent Health´s MediSource 1,883 1,084 58 917 85 108 10 59 5
MetroPlus Health Plan 6,441 3,727 58 1,591 43 1,413 38 723 19
Molina Healthcare 922 619 67 93 15 406 66 120 19
MVP Health Care 7,894 3,849 49 2,558 66 1,207 31 84 2
UnitedHealthCare Community Plan 31,961 4,334 14 780 18 2,001 46 1,553 36
WellCare of New York 5,862 5,140 88 4,288 83 670 13 182 4
YourCare Health Plan 1,384 920 66 402 44 428 47 90 10
Statewide 123,940 55,162 45 24,046 44 19,520 35 11,596 21

Note: This table excludes 11 enrollments for which contact timeframe could not be calculated.

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 609 529 87 99 19 348 66 82 16
CDPHP 1,998 1,981 99 1,619 82 333 17 29 1
Empire BlueCross BlueShield Health Plus 3,993 1,026 26 313 31 670 65 43 4
Excellus BlueCross BlueShield 6,726 5,233 78 2,598 50 1,415 27 1,220 23
Fidelis Care New York, Inc. 11,272 9,507 84 9,424 99 75 1 8 0
HealthFirst PHSP 6,927 6,346 92 660 10 3,093 49 2,593 41
HealthNow New York Inc. 575 303 53 101 33 159 52 43 14
HIP (EmblemHealth) 3,389 849 25 232 27 399 47 218 26
Independent Health´s MediSource 1,084 1,058 98 911 86 103 10 44 4
MetroPlus Health Plan 3,727 2,845 76 638 22 1,420 50 787 28
Molina Healthcare 619 491 79 82 17 323 66 86 18
MVP Health Care 3,849 2,589 67 2,535 98 38 1 16 1
UnitedHealthCare Community Plan 4,334 3,893 90 1,679 43 876 23 1,338 34
WellCare of New York 5,140 941 18 353 38 464 49 124 13
YourCare Health Plan 920 568 62 307 54 199 35 62 11
Statewide 55,162 38,159 69 21,551 56 9,915 26 6,693 18

Note: This table excludes 72 enrollments for which enrollment timeframe could not be calculated.

Statewide, almost 70% of contacted members enroll in health plan care management, with a little more 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 30 6 17 3 51 10 309 58 125 23
CDPHP 99 5 92 5 362 18 1,287 65 141 7
Empire BlueCross BlueShield Health Plus 19 2 43 4 110 11 615 60 239 23
Excellus BlueCross BlueShield 105 2 87 2 719 14 3,510 67 812 16
Fidelis Care New York, Inc. 146 2 121 1 774 8 6,307 66 2,159 23
HealthFirst PHSP 72 1 64 1 1,049 17 4,047 64 1,114 18
HealthNow New York Inc. 0 - 2 1 42 14 232 77 27 9
HIP (EmblemHealth) 7 1 8 1 95 11 507 60 232 27
Independent Health´s MediSource 27 3 19 2 104 10 667 63 241 23
MetroPlus Health Plan 218 8 113 4 384 13 1,314 46 847 29
Molina Healthcare 17 3 17 3 87 18 295 60 75 15
MVP Health Care 118 5 128 5 359 14 1,588 61 396 15
UnitedHealthCare Community Plan 197 5 262 7 456 12 2,335 59 680 17
WellCare of New York 116 12 74 8 200 21 430 46 122 13
YourCare Health Plan 10 2 16 3 55 10 392 69 95 17
Statewide 1,181 3 1,063 3 4,847 13 23,835 62 7,305 19

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 38,231 enrolled episodes in 2017, 17,742 episodes remained while 330 enrolled and closed the same day and 20,159 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 105 23.0 3.6 264 53.0 6.0
CDPHP 196 25.0 3.3 1,188 72.0 6.3
Empire BlueCross BlueShield Health Plus 68 22.5 5.8 646 94.0 8.5
Excellus BlueCross BlueShield 334 16.0 2.9 2,513 155.0 8.8
Fidelis Care New York, Inc. 560 19.0 2.6 2,252 201.0 3.9
HealthFirst PHSP 1,130 19.0 11.8 2,363 63.0 18.5
HealthNow New York Inc. 101 19.0 2.2 140 54.0 3.0
HIP (EmblemHealth) 68 16.0 3.2 383 96.0 6.0
Independent Health´s MediSource 249 15.0 2.4 353 73.0 4.0
MetroPlus Health Plan 476 14.0 3.0 1,528 101.0 4.8
Molina Healthcare 34 16.0 4.2 296 82.0 7.8
MVP Health Care 1,438 14.0 4.0 876 51.0 9.5
UnitedHealthCare Community Plan 276 27.0 2.4 1,204 69.0 4.9
WellCare of New York 428 16.0 8.8 412 48.0 11.5
YourCare Health Plan 24 22.0 4.8 254 112.0 9.0
Statewide 5,487 17.0 5.5 14,672 91.0 8.5

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 7,536 37 47.0 7.9
Lost to follow up 6,275 31 54.0 9.3
Disenrolled from plan 3,933 20 121.0 6.6
Refused to continue 1,830 9 51.0 4.6
Missing 585 3 122.0 4.7

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 69 23 9 12 5 24 9 154 61 40 16
CDPHP 47 22 3 32 5 123 19 447 69 28 4
Empire BlueCross BlueShield Health Plus 48 6 2 13 4 36 10 218 64 70 20
Excellus BlueCross BlueShield 28 10 1 9 1 64 8 507 64 198 25
Fidelis Care New York, Inc. 8 6 3 4 2 21 9 138 59 63 27
HealthFirst PHSP 23 24 3 13 2 212 26 463 57 95 12
HealthNow New York Inc. 21 0 0 0 0 5 10 38 75 8 16
HIP (EmblemHealth) 24 0 0 1 1 14 13 70 64 25 23
Independent Health´s MediSource 40 10 4 4 2 39 16 166 69 21 9
MetroPlus Health Plan 35 53 8 40 6 125 18 405 58 75 11
Molina Healthcare 34 4 4 4 4 15 14 71 64 17 15
MVP Health Care 82 87 5 82 4 288 15 1,191 63 254 13
UnitedHealthCare Community Plan 55 125 15 181 22 112 14 295 36 96 12
WellCare of New York 51 50 12 38 9 85 20 199 46 59 14
YourCare Health Plan 39 0 0 3 3 10 9 74 68 22 20
Statewide 37 420 6 436 6 1,173 16 4,436 59 1,071 14

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 (almost 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.

In New York State, quality measures and PQIs are used to measure performance across health plans, identify problems, and ascertain opportunities for improvement. 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) 0 0 0 90 0
Breast Cancer Screening (BCS) 0 0 59 68 61
Cervical Cancer Screening (CCS) 76 84 73 64 64
Chlamydia Screening (CHL) 76 85 77 73 60
Colorectal Cancer Screening (COL) 23 34 44 59 56
Comprehensive Diabetes Care - HbA1c Test (CDC) 0 0 80 89 81
HIV/AIDS Comprehensive Care - Syphilis Screening 0 0 0 43 74
HIV/AIDS Comprehensive Care - Viral Load Monitoring 0 0 0 2 70
HIV/AIDS Comprehensive Care - Engaged in Care 0 0 0 98 94
Medication Management for People with Asthma - 50% Days covered (MMA) 0 0 54 69 79
Medication Management for People with Asthma - 75% Days covered (MMA) 0 0 25 45 52
Antidepressant Medication Management - Acute Phase (84 days) (AMM) 0 31 39 58 53
Antidepressant Medication Management - Continuation Phase (180 days) (AMM) 0 19 27 46 42
Follow Up After Hospitalization for Mental Illness - 7 days (FUH) 0 0 66 63 47
Follow Up After Hospitalization for Mental Illness - 30 days (FUH) 0 0 80 79 67
Initiation of Alcohol and Other Drug Dependence Treatment (IET) 0 0 63 57 56
Engagement of Alcohol and Other Drug Dependence Treatment (IET) 0 0 22 14 11
Follow Up After ED Visit for Alcohol Use - 7 days (FUA) 0 0 32 26 25
Follow Up After ED Visit for Alcohol Use - 30 days (FUA) 0 0 40 35 30
Follow Up After ED Visit for Mental Illness - 7 days (FUM) 0 0 67 70 61
Follow Up After ED Visit for Mental Illness - 30 days (FUM) 0 0 76 83 73

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) 0 0 33 1,114 2,565
Diabetes Long-Term Complications Admission Rate (PQI #3) 0 0 16 2,008 2,342
COPD or Asthma in Older Adults Admission Rate (PQI #5) 0 0 152 6,571 9,218
Hypertension Admission Rate (PQI #7) 0 0 16 552 1,498
Heart Failure Admission Rate (PQI #8) 0 0 181 3,186 6,149
Dehydration Admission Rate (PQI #10) 0 0 82 762 1,306
Bacterial Pneumonia Admission Rate (PQI #11) 0 0 82 853 1,816
Urinary Tract Infection Admission Rate (PQI #12) 83 96 33 748 924
Uncontrolled Diabetes Admission Rate (PQI #14) 0 0 0 602 1,370
Asthma in Younger Adults Admission Rate (PQI #15) 0 0 170 1,533 497
Lower-Extremity Amputation among Patients with Diabetes Rate (PQI #16) 0 0 0 388 478

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 778 1,816 1,581 1,731 1,155
CDPHP 866 1,380 1,085 1,992 2,038
Empire BlueCross BlueShield Health Plus 971 1,353 1,401 1,626 1,439
Excellus BlueCross BlueShield 629 1,130 1,103 1,779 1,481
Fidelis Care New York, Inc. 470 578 674 1,392 1,302
HealthFirst PHSP 947 1,422 1,227 2,030 1,815
HealthNow New York Inc. 308 873 860 2,621 3,623
HIP (EmblemHealth) 264 1,895 768 1,033 891
Independent Health´s MediSource 766 1,832 1,535 1,868 1,623
MetroPlus Health Plan 812 1,658 1,486 1,641 1,100
Molina Healthcare 503 1,082 926 2,403 3,506
MVP Health Care 1,063 2,235 1,747 2,685 2,924
UnitedHealthCare Community Plan 514 825 847 1,113 956
WellCare of New York 736 1,217 1,072 1,751 1,378
YourCare Health Plan 716 1,591 918 1,828 1,781
Statewide 739 1,330 1,148 1,720 1,474
  Healthy Stable Simple Chronic Complex Chronic Critical/HIV
Affinity Health Plan 960 941 989 1,887 2,684
CDPHP 213 288 214 706 2,305
Empire BlueCross BlueShield Health Plus 783 790 802 1,448 2,521
Excellus BlueCross BlueShield 498 485 388 836 1,606
Fidelis Care New York, Inc. 252 317 193 789 1,483
HealthFirst PHSP 588 707 402 979 2,239
HealthNow New York Inc. 308 1,091 194 823 1,849
HIP (EmblemHealth) 527 711 296 876 1,999
Independent Health´s MediSource 536 644 730 1,382 1,475
MetroPlus Health Plan 303 841 652 1,123 997
Molina Healthcare 251 541 286 1,127 3,977
MVP Health Care 760 641 649 1,121 2,650
UnitedHealthCare Community Plan 546 509 516 872 1,965
WellCare of New York 376 547 439 807 1,265
YourCare Health Plan 239 265 416 837 2,491
Statewide 513 570 448 937 1,779
  Healthy Stable Simple Chronic Complex Chronic Critical/HIV
Affinity Health Plan 14,650 16,962 16,953 25,117 29,651
CDPHP 4,202 6,589 6,306 11,508 18,133
Empire BlueCross BlueShield Health Plus 9,932 13,025 11,752 17,951 23,264
Excellus BlueCross BlueShield 5,109 8,518 8,075 14,749 14,703
Fidelis Care New York, Inc. 4,711 6,654 8,294 18,407 49,493
HealthFirst PHSP 9,500 12,733 8,519 18,955 23,603
HealthNow New York Inc. 8,308 5,455 5,484 12,809 12,377
HIP (EmblemHealth) 6,989 6,237 9,126 19,297 22,287
Independent Health´s MediSource 3,161 5,777 4,957 11,302 10,316
MetroPlus Health Plan 4,861 9,930 8,536 16,823 15,127
Molina Healthcare 4,147 8,754 4,686 11,297 15,035
MVP Health Care 10,327 11,719 11,614 17,860 21,434
UnitedHealthCare Community Plan 7,826 9,586 10,124 17,888 19,187
WellCare of New York 8,403 12,835 11,374 15,652 17,878
YourCare Health Plan 3,940 8,420 8,104 14,489 15,189
Statewide 7,151 9,882 8,884 17,046 19,065

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, 2014-2016 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 2,401 1,878 78 1,430 76
CDPHP 595 388 65 354 91
Empire BlueCross BlueShield Health Plus 2,201 1,322 60 1,059 80
Excellus BlueCross BlueShield 2,061 1,068 52 648 61
Fidelis Care New York, Inc. 1,347 1,050 78 386 37
HealthFirst PHSP 15,942 3,420 21 3,213 94
HealthNow New York Inc. 216 186 86 184 99
HIP (EmblemHealth) 2,239 1,956 87 828 42
Independent Health´s MediSource 2,462 1,503 61 1,418 94
MetroPlus Health Plan 1,434 1,328 93 1,284 97
Molina Healthcare 222 160 72 122 76
MVP Health Care 3,283 1,878 57 1,096 58
UnitedHealthCare Community Plan 2,369 1,689 71 1,586 94
WellCare of New York 140 115 82 115 100
YourCare Health Plan 441 391 89 335 86
Statewide 37,353 18,332 49 14,058 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 19,120 52 7,774 54
Other 17,414 48 6,554 46
Region of NYS
Central 949 3 447 3
Hudson Valley 2,712 8 1,428 10
Long Island 3,810 11 1,439 10
Northeast 708 2 366 3
NYC 21,651 60 7,428 53
Western 6,174 17 2,960 21
Aid Category
SSI 809 2 369 3
TANF 35,334 98 13,784 97
Education Level
Not HS Graduate 10,764 30 4,128 29
HS Graduate 11,537 32 4,513 31
College 14,021 39 5,610 39
Age
< 18 Years 834 2 300 2
18 - 19 Years 1,328 4 499 3
20 - 29 Years 18,369 50 6,930 48
> 29 Years 16,003 44 6,599 46
Race
White 10,756 29 4,245 30
Black 8,769 24 3,730 26
Hispanic 2,738 7 1,129 8
Other 14,271 39 5,224 36
CRG Group
Healthy 7,643 21 2,574 18
Stable 9,828 27 3,715 26
Simple Chronic 10,079 28 3,992 28
Complex Chronic 8,134 22 3,690 26
Critical/HIV 527 1 244 2
Risks
Diabetes 695 2 362 3
Gestational Diabetes 3,787 10 1,616 11
Hypertension 1,829 5 754 5
Gestational Hypertension 2,059 6 956 7
Characteristics
High-Risk Referral 3,488 10 1,354 9
Hospitalized during Pregnancy 1,857 5 824 6
Number Previous Pregnancies
0 295 1 89 1
1 - 2 16,052 44 6,316 44
3 - 4 7,645 21 3,192 22
5 + 4,104 11 1,676 12

* Category % may not sum to 100 % because of missing data
Note: Population is number of unique mothers per year.

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 18,259 49 7,273 49
Male 19,093 51 7,621 51
Gestational Age
< 33 weeks 1,204 3 543 4
33 - 35 weeks 1,943 5 866 6
36 - 38 weeks 11,419 31 4,827 32
39 + weeks 22,787 61 8,659 58
NICU Use 5,781 15 2,478 17
Birthweight
Very Low Birthweight 814 2 368 2
Low Birthweight 3,418 9 1,466 10
Large for Gestational Age 2,309 6 981 7
Macrosomia 2,498 7 997 7
Modified Kessner Index *
Intensive 4,346 12 1,864 13
Adequate 19,512 53 7,955 54
Intermediate 9,581 26 3,731 25
Inadequate 2,261 6 708 5
No Care 120 0 39 0
Missing 1,120 3 443 3
Statewide 37,353   14,895  

* 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 37 0
8 Months 530 4
7 Months 1,706 11
6 Months 2,255 15
5 Months 2,346 16
4 Months 2,137 14
3 Months 2,219 15
2 Months 1,665 11
1 Month 1,089 7
Same Day Delivery 74 0
After Delivery 837 6
  Mean  
Mean Number of Months 3.6  

* Number of women enrolled in HROB care management program

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.
Follow Up After Emergency Department Visit for Alcohol and Other Drug Dependence - 7 days (FUA):
The percent of ED visits for members with a principal diagnosis of alcohol or other drug (AOD) dependence, who had a follow-up visit for AOD within 7 days of ED visit.
Follow Up After Emergency Department Visit for Alcohol and Other Drug Dependence - 30 days (FUA):
The percent of ED visits for members with a principal diagnosis of alcohol or other drug (AOD) dependence, who had a follow-up visit for AOD within 30 days of ED visit.
Follow Up After Emergency Department Visit for Mental Illness - 7 days (FUM):
The percent of ED visits for members with a principal diagnosis of mental illness, who had a follow-up visit for mental illness within 7 days of ED visit.
Follow Up After Emergency Department Visit for Mental Illness - 30 days (FUM):
The percent of ED visits for members with a principal diagnosis of mental illness, who had a follow-up visit for mental illness within 30 days of ED 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 Kings Nassau New York
Orange Queens Richmond Rockland
Suffolk Westchester    
CDPHP
Albany Broome Columbia Fulton
Greene Montgomery Rensselaer Saratoga
Schenectady Schoharie Tioga Washington
Empire BlueCross BlueShield Health Plus
Bronx Kings Nassau New York
Putnam Queens Richmond  
Excellus BlueCross BlueShield
Broome Herkimer Livingston Monroe
Oneida Ontario Orleans Otsego
Seneca Wayne Yates  
Fidelis Care New York, Inc.
Albany Allegany Bronx Broome
Cattaraugus Cayuga Chautauqua Chemung
Chenango Clinton Columbia Cortland
Delaware Dutchess Erie Essex
Franklin Fulton Genesee Greene
Hamilton Herkimer Jefferson Kings
Lewis Livingston Madison Monroe
Montgomery Nassau New York Niagara
Oneida Onondaga Ontario Orange
Orleans Oswego Otsego Putnam
Queens Rensselaer Richmond Rockland
Saratoga Schenectady Schoharie Schuyler
Seneca St. Lawrence Steuben Suffolk
Sullivan Tioga Tompkins Ulster
Warren Washington Wayne Westchester
Wyoming Yates    
HealthFirst PHSP
Bronx Kings Nassau New York
Queens Richmond Suffolk  
HealthNow New York, Inc.
Allegany Cattaraugus Chautauqua Erie
Orleans Wyoming    
HIP (EmblemHealth)
Bronx Kings New York Nassau
Queens Richmond Suffolk Westchester
Independent Health´s MediSource
Erie      
MetroPlus Health Plan
Bronx Kings New York 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 Broome Cayuga
Chautauqua Chemung Chenango Clinton
Columbia Dutchess Erie Essex
Franklin Fulton Genesee Greene
Herkimer Jefferson Kings Lewis
Livingston Madison Monroe Nassau
New York Niagara Oneida Onondaga
Ontario Orange Orleans Oswego
Queens Rensselaer Richmond Rockland
Schenectady Seneca St. Lawrence Suffolk
Tioga Ulster Warren Wayne
Westchester Wyoming Yates  
WellCare of New York
Albany Bronx Kings Dutchess
Erie New York Nassau Niagara
Orange Queens Rensselaer Rockland
Schenectady Schuyler Steuben Ulster
YourCare Health Plan
Allegany Cattaraugus Chautauqua Erie
Monroe Ontario Wyoming  
* Not every plan may be accepting new enrollment. Please call the plan to confirm availability.