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About the Data California Regional Health Care Cost & Quality Atlas

Thank you for using the California Regional Health Care Cost & Quality Atlas (Atlas). We encourage you to become more familiar with the Atlas’s underlying data and have provided this overview to help guide you. Because of differences in measurement methodologies, not all results in the tool are directly comparable. For more detail, please see the Methodological Measurement Details section at the end of this document. The intention of the Atlas is not to compare performance across payer types but rather to assess variation in performance across regions, measures, and product types within a payer type.

Insurance Types and Enrollment Covered There are seven main insurance types included in the Atlas: three payer types (commercial, Medicare and Medi-Cal) each with two product types (HMO and PPO/FFS), plus commercial EPO. In total, the Atlas covers about 29 million Californians, broken down by insurance type as follows.

Payer Type Product Type Enrollment in Atlas % of CA Enrollment 2013 2015 2017 2018 2019

Commercial HMO 10.1 M 9.3 M 9.0 M 9.9 M 9.8 M 95+% PPO 4.3 M 4.3 M 4.7 M 5.7 M 4.2 M 55+% EPO -- -- 0.2 M 0.09 M 0.09 M 80%

Medicare

Advantage (HMO)

1.6 M 1.8 M 1.8 M 1.9 M 2.0 M 80+%

FFS No member level data

2.9 M 3.2 M TBD TBD TBD

Medi-Cal (full-scope)

Managed Care (HMO)

5.7 M 9.3 M 9.8 M TBD TBD TBD

FFS 1.2 M 1.6 M -- TBD TBD TBD TOTAL 22.9 M 29.2 M 28.7 M TBD TBD TBD

The table below lays out the framework for tracking performance by region and payer/product type, as well as the data sources used.

Payer Types Product Types Clinical Quality Costs Hospital Utilization

Commercial

HMO Health Plans/Data Aggregator

Health Plans/Data Aggregator

Health Plans/Data Aggregator

PPO Health Plans/Data Aggregator

Health Plans/Data Aggregator

Health Plans/Data Aggregator

EPO Health Plans/Data Aggregator

Health Plans/Data Aggregator

Health Plans/Data Aggregator

Medicare Advantage Health Plans/Data

Aggregator Health Plans/Data

Aggregator Health Plans/Data

Aggregator

FFS CMS1/Data Aggregator (not 2013)

CMS1/Data Aggregator (not 2013) CMS1/Data Aggregator

Medi-Cal Managed Care DHCS2 DHCS2 (2013 only) DHCS2

FFS DHCS2 DHCS2 (2013 only) DHCS2

1 Centers for Medicare & Medicaid Services 2 Department of Health Care Services

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Atlas Data Sources Twelve health plans participate in the Atlas, contributing data for 2013, 2015, 2017, 2018, and/or 2019 for commercial HMO, commercial PPO, commercial EPO and/or Medicare Advantage. The plans submitted their data to the Data Aggregator (Onpoint Health Data starting in 2017 and IBM Watson Health prior to 2017), which aggregated the health plan claims/encounter, eligibility, and cost data, and then generated the measures. For Medicare Fee-for-Service (FFS), member-level data were obtained from the Centers for Medicare & Medicaid Services (CMS). All Medi-Cal results were calculated by the California Department of Health Care Services (DHCS).

Health Plan Data Contributors Aetna Kaiser Permanente Anthem Blue Cross SCAN Health Plan (Medicare Only) Blue Shield of California Sharp Health Plan Cigna Sutter Health Plus Health Net L.A. Care (starting 2017)

United Healthcare Western Health Advantage

Atlas Geographic Regions and Populations The Atlas maps data according to the 19 regions used by Covered California, the state’s health insurance exchange. Members are mapped to a region based on their zip code and county of residence. The regions are defined as follows:

Super Region Region Counties Region Population

Northern California

1. Northern Counties Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, Yuba

1,328,056

2. North Bay Counties Marin, Napa, Solano, Sonoma 1,280,190 3. Greater Sacramento El Dorado, Placer, Sacramento, Yolo 2,142,566 4. San Francisco County San Francisco 807,758 5. Contra Costa County Contra Costa 1,047,659 6. Alameda County Alameda 1,514,494 7. Santa Clara County Santa Clara 1,791,109 8. San Mateo County San Mateo 715,718

Central California

9. Central Coast–North Monterey, San Benito, Santa Cruz 732,537 10. Central Valley–North Mariposa, Merced, San Joaquin, Stanislaus, Tulare 1,907,913 11. Greater Fresno Area Fresno, Kings, Madera 1,223,984 12. Central Coast–South San Luis Obispo, Santa Barbara, Ventura 1,514,204 13. Eastern Region Imperial, Inyo, Mono 206,508 14. Kern County Kern 836,691

Southern California

15. Los Angeles–East Los Angeles (partial) 4,056,806 16. Los Angeles–West Los Angeles (partial) 5,774,325 17. Inland Empire Riverside, San Bernardino 4,201,182 18. Orange County Orange 3,018,544 19. San Diego County San Diego 3,082,661

Statewide 37,182,903 Sources: Counties mapped to regions based on Covered California regional boundaries: http://www.coveredca.com/. Region population gathered from 2010 U.S. Census data at the zip code level and then rolled up to region: https://data.census.gov/cedsci/.

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Atlas Measures The Atlas now includes five years of performance measurement: 2013, 2015, 2017, 2018, and 2019. Measures include clinical quality, cost of care and hospital utilization. The full member population that meets the measurement criteria is included in the measurement; there is no sampling. The types of measures are described below. See Appendix A for a table of individual measures and descriptions, showing applicable payer types and years.

1. Clinical Quality Measures: Most are from the Healthcare Effectiveness Data and Information Set(HEDIS®)—spanning preventive cancer screenings, acute care for bronchitis and low back pain, andchronic care for diabetes and asthma—and are included in the Atlas for the appropriate payer types.Starting in 2017, Atlas added two opioid measures. Clinical quality measures are not risk adjusted.

All clinical quality measures applicable to a payer type for each measurement year are alsocombined into a composite measure based on Z-scores (see 4. Composite Measures below).

2. Cost of Care Measures: These measures cover the average costs of providing care per member peryear, including payments by insurance and by members for all covered professional, pharmacy,hospital and ancillary care. Measures include total cost of care and costs broken out by capitation,professional services, pharmacy, outpatient facility and inpatient facility, as well as member costsharing and plan paid amount. Payments for mental health/chemical dependency, chiropractic,acupuncture, vision, and dental are excluded.

Total cost of care is available as observed cost, risk-adjusted cost, and geography and risk-adjustedcost. Risk adjustment accounts for differences in age, gender, and health status across populations.Geography adjustment accounts for geographic differences in input costs.

3. Hospital Utilization Measures: Several hospital utilization measures from HEDIS® are reportedacross payer types in the Atlas, including emergency department (ED) visits; all-cause readmissions(observed and risk-adjusted); frequency of selected commonly overused procedures; and inpatientbed days, discharges, and average length of stay (each broken out by medical, surgical, maternityrelated stays). Starting in 2017, Atlas added High Inpatient Utilization and two new risk-adjustedHEDIS® measures for commercial and Medicare: Emergency Department Utilization and AcuteHospital Utilization.

All hospital utilization measures applicable to a payer type for each measurement year arecombined into a composite measure based on Z-scores (see 4. Composite Measures below).

4. Composite Measures: All measures within clinical quality and within hospital utilization for eachmeasurement year and payer type are combined into a composite measure based on Z-scores.

Z-scores are calculated for each measure using the average performance and the distribution ofperformance for that measure across a defined population. A Z-score of 0 is assigned to thepopulation average, therefore, negative scores are worse than the population average, and positivescores are better than the population average. The magnitude of the number indicates how muchbetter or worse the performance is from the population average. Z-scores range from +3 to -3.

For the Atlas, Z-scores are assigned separately for each payer type (i.e., commercial, Medicare, and Medi-Cal), and the population average is the statewide average for that payer type.

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Clinical Quality Composites and Hospital Utilization Composites based on Z-scores can only be used to compare performance within a payer type and are not comparable across payer types. For each payer type, the average performance for a measure is set to a Z-score of 0, so the performance rate associated with a Z-score of 0 could be different for each payer type for the same measure.

Clinical Quality Averages are another type of composite and are calculated using an unweighted average of the rate for each of the measures included in the composite. The clinical quality average is used instead of the Z-scores in some of the Atlas materials.

5. National All Payer Benchmarks: These benchmarks are calculated from the HEDIS® Quality Compass payer-specific All LOBs benchmarks for the applicable measure, weighted by the California population for each applicable payer type. Some benchmarks include all three payer types and some benchmarks only include two payer types, depending on which payer types the measure is applicable. The table in Appendix A indicates which payer types are applicable for each measure. Please note the National All Payer Benchmarks are not available for 2019.

6. Demographics and Utilization Factors: Additional information on the demographics of a population—size of enrollment, average age and percentage female—are included and can be displayed. Factors that would be expected to affect utilization, such as average risk scores and percentage of the population that are seniors or persons with disabilities, are also available for display. Educational attainment, median income, and ethnicity data is based on the 2010 U.S. Census and is not specific to payer or product types.

Methodological Measurement Details The intention of the Atlas is not to compare performance across payer types but rather to assess variation in performance across regions, measures, and product types within a payer type. All Payer Types 1. Members with zip codes outside of California are not included.

2. All results are based on administrative data (medical and pharmacy claims and encounters), with some supplemental lab results data. Clinical data is incomplete when using administrative data, which may result in rates that are lower than actual performance due to data limitations.

3. Minimum denominator sizes are required for reporting. Clinical quality measures require a denominator of 30 or more; hospital utilization and cost measures require a denominator of 200 or more.

4. Clinical Quality Composites and Hospital Utilization Composites can only be used within a payer type to compare performance and are not comparable across payer types. For each payer type, the average performance for a measure is set to a Z-score of 0. Therefore, the performance rate associated with a Z-score of 0 could be different for each payer type.

5. Some hospital utilization measures are not risk adjusted. However, sicker members (i.e., those with higher risk scores) are expected to use more hospital resources. Average risk scores vary across regions and may explain some of the variation in hospital utilization. The average risk score across members in a region is included as a utilization factor that can be displayed alongside measure results.

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6. For 2013 and 2015, total cost of care results only include members that have both medical and pharmacy benefits with the health plan contributing data; starting in 2017, all members with medical benefit are included, regardless of pharmacy benefit.

7. Risk adjustment is determined by the age, gender, and health status of the member, based on the diagnoses from claims and encounters (medical claims for commercial and Medicare, pharmacy claims for Medi-Cal). Each of these factors is assigned a weighting, and the weighting for all factors for a member is summed to get the member’s risk score. The statewide average risk score is set to 1.0 for a particular payer type (i.e., for commercial, for Medicare, or for Medi-Cal). Risk scores below 1.0 indicate a healthier, lower-risk population that is expected to need less health care; risk scores above 1.0 indicate a sicker, higher-risk population that is expected to need more health care.

8. Different risk-adjustment methods are used for different payer types and different years. For 2013 and 2015, Verisk 3.1 Model 18 is used for commercial, Verisk CMS mode is used for Medicare, and pharmacy-based Chronic Illness and Disability Payment System MedicaidRX is used for Medi-Cal (2013 only). Starting in 2017, Johns Hopkins ACG System is used for commercial and Medicare, using an under 65 reference population for commercial and a 65+ reference population for Medicare. Therefore, risk-adjusted total cost of care is not comparable across payer types; it is only comparable across product types within a payer type. Similarly, risk-adjusted total cost of care is not comparable between 2015 and 2017 due to the change in risk adjustment methodology.

Commercial 9. HMO calculations use encounter data, while PPO calculations use claims data. Encounter data may

not be as complete as claims data because payment does not directly depend on encounter data submission. The resulting impact is that the risk in HMO populations may be under-captured, which may make the risk-adjusted total cost of care for HMOs higher than it should be. Incomplete encounter data for HMOs may also result in lower than actual resource use and clinical quality rates.

10. In 2017, one large plan did not include complete service category information for commercial HMO, resulting in artificially low utilization rates.

11. Not all participating plans provide full cost category information.

12. The average risk score is determined across the whole commercial population included in the Atlas, including HMO, PPO, and EPO. Consequently, HMO, PPO and EPO total cost of care can be directly compared. However, commercial results are not directly comparable to Medicare or Medi-Cal results (see number 8 under All Payer Types).

13. Displayed cost results are calculated from data from at least three plans. To protect the confidentiality of plan payment arrangements, regional costs are rounded. The minimum rounding increment for a measure is based on 5% of the 90th percentile value of the measure, and amounts are rounded.

14. Kaiser Permanente is excluded from the following Explorations because including them would mask the differences among non-Kaiser Permanente populations, or because Kaiser Permanente did not provide the necessary information.

● Commercial Members in Accountable Care Organizations (ACO) vs. not in ACO ● Risk Sharing Arrangements Among Providers – level of capitation, FFS ● Commercial Market Segments - Large Employer, Small Employer, Individual Coverage

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Medicare 15. For 2018 and 2019, the Atlas currently includes only Medicare Advantage (HMO) results. Medicare

FFS results are not yet available due to data lag.

16. Dual-eligibles (also referred to as Medi-Medi) are included in the Medicare results and not in the Medi-Cal results. The percentage of the Medicare population that also qualifies for Medi-Cal varies across regions and may impact the measure results, especially for hospital utilization and total cost of care.

17. Medicare Advantage includes both Medicare Advantage HMO and Medicare Advantage PPO. However, less than 1% of Medicare Advantage is PPO. Medicare FFS is “traditional Medicare.”

18. Medicare HMO calculations use encounter data, while FFS calculations use claims data. Encounter data may not be as complete as claims data because payment does not directly depend on encounter data submission. The resulting impact is that the risk in HMO populations may be under-captured, which may make the risk-adjusted total cost of care for HMOs higher than it actually should be. Incomplete encounter data for HMOs may also result in lower than actual resource use and clinical quality rates.

19. Medicare FFS results for 2013 hospital utilization were obtained from CMS public use files. County-level information was aggregated up to the 19 geographic regions. Detailed specifications of the CMS methodology were not available. While the measure concepts are the same, the underlying methodology may be slightly different for Medicare Advantage. Please use caution when comparing hospital utilization results for Medicare FFS and Medicare Advantage for 2013 or comparing Medicare FFS hospital utilization results from 2013 to subsequent years. For 2013, there are no clinical quality results for Medicare FFS since IHA did not have access to member level data.

20. In 2017, one large plan did not include complete service category information for Medicare Advantage (HMO), resulting in artificially low utilization rates.

21. Not all participating plans provide full cost category information.

22. The average risk score is determined across the whole Medicare population included in the Atlas, including Medicare Advantage and FFS. Consequently, Medicare Advantage and FFS total cost of care can be directly compared. However, Medicare results are not directly comparable to commercial or Medi-Cal results (see number 8 under All Payer Types).

23. Displayed cost results are calculated from data from at least three plans. To protect the confidentiality of plan payment arrangements, regional total costs for Medicare are rounded. The minimum rounding increment for a measure is based on 5% of the 90th percentile value of the measure, and amounts are rounded up.

24. Kaiser Permanente is excluded from the following Exploration since including them would mask the differences among non-Kaiser Permanente populations:

● Risk Sharing Arrangements Among Providers – level of capitation, FFS

Medi-Cal 25. For 2017, the Atlas includes only Managed Care (HMO) results for Medi-Cal. Department of Health

Care Services did not provide results for Medi-Cal FFS for 2017. Results for 2018 and 2019 are not yet available due to data lag.

26. Medi-Cal results include only members with full-scope benefits.

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27. Dual-eligibles (also referred to as Medi-Medi) are not included in the Medi-Cal results; they are included in the Medicare results.

28. Seniors and persons with disabilities (SPDs) who are not also eligible for Medicare are included in the Medi-Cal results and are not reported separately. This population may use more health care resources. The percentages of the Medi-Cal population that are SPDs varies across regions and may impact the measure results, especially for hospital utilization and total cost of care. The percentage SPDs in a region is included as a utilization factor that can be displayed with measure results.

29. Medi-Cal Managed Care calculations use encounter data, while FFS calculations use claims data. Encounter data may not be as complete as claims data because payment does not directly depend on encounter data submission. Incomplete encounter data may result in lower than actual resource use and clinical quality rates.

30. Medi-Cal clinical quality results only include members who were continuously enrolled in Medi-Cal for at least 11 of 12 months, are eligible for full scope benefits and the services being measured, and were in FFS or with the same managed care plan for at least six months.

31. The average risk score is determined across the whole Medi-Cal population included in the Atlas, including Managed Care and FFS. Consequently, Medi-Cal Managed Care and FFS total cost of care can be directly compared. However, Medi-Cal results are not directly comparable to commercial or Medicare results (see number 8 under All Payer Types). (Medi-Cal risk score only available for 2013.)

32. Mental health and chemical dependency costs are included for Medi-Cal total cost of care (but excluded for commercial and Medicare Advantage). Thus, Medi-Cal total cost of care is not comparable to commercial or Medicare total cost of care. (Medi-Cal costs only available for 2013.)

33. FFS costs include the amount Medi-Cal paid, the patient’s liability amount and other coverage amount for FFS members eligible for the following Medi-Cal programs: IHSS, EPSDT, State Hospital, Short Doyle, FFS Medi-Cal, and FPACT. (Medi-Cal costs only available for 2013.)

34. Managed care costs include FFS costs for the programs above, as well as capitated payments for Managed Care and COHS programs of the following types: Primary Capitation, HQAF Primary Capitation, Hyde, AIDS, Agnews, CBAS, Craig/Bonta, HQAF AIDS, HQAF Agnews, HQAF Craig/Bonta, HQAF Healthy Families, Healthy Families Capitation, Hyde Healthy Families and Maternity. (Medi-Cal costs only available for 2013.)

“All Available Payers” and “All Available Products” Filters in Atlas Webtool

35. Not all Explorations, measures, and filters are applicable to all payer types. Therefore, the Atlas webtool does not include results for every payer type for some Explorations, measures, or filters. When selecting the “All Available Payers” filter, it will only include the payer types which have results for the selected Exploration, measure, and data filters. Similarly, the “All Available Products” filter will only include the product types which have results for the selected Exploration, measure, and data filters. The dropdown for each filter will indicate which payer type(s) or product type(s) are included.

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APPENDIX A: Atlas Measures Table

Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Clinical Quality Measures Breast Cancer Screening

The percentage of women 50 to 74 years of age who had one or more screening mammograms during the measurement year or the year prior to the measurement year.

2013, 2015, 2017, 2018, 2019

20133, 2015, 2017, 20183, 20193

2013, 2015, 20174

Cervical Cancer Overscreening

Not a HEDIS measure

The percentage of women 21 to 64 years of age who received more cervical cancer screenings than recommended by evidence-based guidelines.

2015, 2018, 2019

20183

Cervical Cancer Underscreening

Cervical Cancer Screening (inverse of this measure)

The percentage of women 21 to 64 years of age who were not screened for cervical cancer when they should have been according to evidence-based guidelines.

2015, 2018, 2019

20183

Colorectal Cancer Screening

The percentage of members 50 to 75 years of age who were appropriately screened for colorectal cancer.

2013, 2015, 2017, 2018, 2019

20133, 2015, 2017, 20183, 20193

2013, 2015, 20174

Diabetes Care: Blood Sugar Screening

Comprehensive Diabetes Care - HbA1c Testing

The percentage of members 18 to 75 years of age with either type 1 or type 2 diabetes who had an HbA1c test performed during the measurement year.

2013, 2015, 2017, 2018, 2019

20133, 2015, 2017, 20183, 20193

2015, 20174

Diabetes Care: Blood Sugar Control <8.0%

Comprehensive Diabetes Care - HbA1c Control (<8%)

The percentage of members 18 to 75 years of age with either type 1 or type 2 diabetes whose most recent HbA1c test result was below 8.0%.

2015, 2017, 2018, 2019

20153, 20173; 20183, 20193

Diabetes Care: Poorly Controlled Blood Sugar

Comprehensive Diabetes Care - Poor HbA1c Control

The percentage of members 18 to 75 years of age with either type 1 or type 2 diabetes whose most recent HbA1c test result was above 9.0% or was missing for the measurement year.

2013, 2015, 2017, 2018, 2019

20133, 20153, 20173, 20183, 20193

3 Medicare Advantage only, no Medicare FFS results 4 Medi-Cal Managed Care only, no Medi-Cal FFS results

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Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Diabetes Care: Kidney Disease Monitoring

Comprehensive Diabetes Care - Medical Attention for Nephropathy

The percentage of members 18 to 75 years of age with either type 1 or type 2 diabetes who had nephropathy screening or evidence of nephropathy during the measurement year.

2013, 2015, 2017, 2018, 2019

20133, 2015, 2017, 20183, 20193

2015, 20174

Asthma Medication Ratio

Asthma Medication Ratio (Total)

The percentage of members 5 to 64 years of age who have persistent asthma and at least half of the asthma medications they received during the measurement year were controller maintenance medications.

2017, 2018, 2019

20183 20174

Avoidance of Antibiotic Treatment for Adults with Acute Bronchitis

Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

The percentage of members 18 to 64 years of age with a diagnosis of acute bronchitis who did not receive an antibiotic prescription.

2015, 2019

20183, 20193

2015, 20174

Appropriate Use of Imaging Studies for Low Back Pain (Retired)

Use of Imaging Studies for Low Back Pain

The percentage of members with a primary diagnosis of low back pain who did not have an imaging study within 28 days of the diagnosis.

2015, 2017, 2018

2015, 20175

4

Concurrent Use of Opioids and Benzodiazepines

The percentage of members with concurrent use of opioids and benzodiazepines.

2017, 2018, 2019

2017, 20183, 20193

20174

Use of Opioids at High Dosage

For members 18+ years, the rate per thousand member years receiving prescription opioids for ≥15 days during the measurement year at a high dosage (average morphine equivalent dose [MED] >120 mg).

2017, 2018

2017, 20183

Use of Opioids at High Dosage in Persons Without Cancer

For members 18+ years, the percentage of members receiving prescription opioids over a 90 day period or more during the measurement year at a high dosage (average milligram morphine equivalent [MME] >90 mg).

2019 20193

3 Medicare Advantage only, no Medicare FFS results 4 Medi-Cal Managed Care only, no Medi-Cal FFS results

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Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Statin Therapy for Patients with Cardiovascular Disease: Received Statin Therapy

The percentage of males 21-75 years of age and females 40-75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) who were dispensed at least one high-intensity or moderate-intensity statin medication during the measurement year.

2019 20193

Statin Therapy for Patients with Cardiovascular Disease: Statin Adherence 80%

The percentage of males 21-75 years of age and females 40-75 years of age during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) who remained on a high-intensity or moderate-intensity statin medication for at least 80% of the treatment period.

2019 20193

Immunizations for Adolescents: Combination 2 (All Antigens)

The percentage of adolescents 13 years of age who had one dose of meningococcal conjugate vaccine, one tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine, and have completed the human papillomavirus (HPV) vaccine series by their 13th birthday.

2019

Immunizations for Adolescents: Combination 1 (Meningococcal and Tdap)

The percentage of adolescents 13 years of age who had one dose of meningococcal conjugate vaccine and diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine by their 13th birthday.

2019

Immunizations for Adolescents: Human Papillomavirus Vaccine for Adolescents

The percentage of adolescents 13 years of age who completed the HPV vaccination series with different dates of service between the member's 9th and 13th birthdays.

2019

Immunizations for Adolescents: Meningococcal Vaccine for Adolescents

The percentage of adolescents 13 years of age who had one dose of meningococcal conjugate vaccine by their 13th birthday.

2019

_____________________________ 3 Medicare Advantage only, no Medicare FFS results

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Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Immunizations for Adolescents: Tdap Vaccine for Adolescents

The percentage of adolescents 13 years of age who had one dose of diphtheria toxoids and acellular pertussis vaccine (Tdap) vaccine by their 13th birthday.

2019

Clinical Quality Composite – 2015 Measures – Commercial

A composite using Z-scores (see About the Data, Atlas Measures, 4.), which combines performance on the ten clinical measures available in 2015 for the commercial population.

2015, 2017, 2018, 2019

Clinical Quality Composite – 2013 Measures – Commercial

A composite using Z-scores (see About the Data, Atlas Measures, 4.), which combines performance on the five clinical quality measures available in 2013 for the commercial population.

2013, 2015, 2017, 2018, 2019

Clinical Quality Composite – 2015 Measures – Medicare

A composite using Z-scores (see About the Data, Atlas Measures, 4.), which combines performance on the five clinical measures available for 2015 for the Medicare population.

2015, 2017, 20183,20193

Clinical Quality Composite – 2015 Measures – Medi-Cal

A composite using Z-scores (see About the Data, Atlas Measures, 4.), which combines performance on the seven clinical measures available in 2015 for the Medi-Cal population.

2015, 20174

Hospital Utilization Measures Emergency Department Visits

Ambulatory Care: Emergency Dept Visits/1000 (Total)

The number of emergency department (ED) visits that did not result in an inpatient admission, reported per thousand member years (PTMY). Not risk adjusted.

2013, 2015, 2017, 2018, 2019

2013, 2015, 2017, 20183,20193

2013, 2015, 20174

Emergency Department Utilization – Risk Adjusted –Commercial

Emergency Department Utilization (multiplied by the CA commercial statewide average to calculate a rate)

The risk-adjusted rate of ED utilization for commercial members 18+ years of age.

2017, 2018, 2019

_____________________________ 3 Medicare Advantage only, no Medicare FFS results 4 Medi-Cal Managed Care only, no Medi-Cal FFS results

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Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Emergency Department Visits

Ambulatory Care: Emergency Dept Visits/1000 (Total)

The number of emergency department (ED) visits that did not result in an inpatient admission, reported per thousand member years (PTMY). Not risk adjusted.

2013, 2015, 2017, 2018, 2019

2013, 2015, 2017, 20183,

20193

2013, 2015, 20174

Emergency Department Utilization – Risk Adjusted – Commercial

Emergency Department Utilization (multiplied by the CA commercial statewide average to calculate a rate)

The risk-adjusted rate of ED utilization for commercial members 18+ years of age.

2017, 2018, 2019

Emergency Department Utilization – Risk Adjusted – Medicare

Emergency Department Utilization (multiplied by the CA Medicare statewide average to calculate a rate)

The risk-adjusted rate of ED utilization for Medicare members 18+ years of age.

2017, 20183,

20193

All-Cause Readmissions (trending break between 2018 and 2019)

Plan All-Cause Readmission (without risk adjustment)

The percentage of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days, for commercial members 18 to 64 years of age, for Medi-Cal members 18+ years of age, and for Medicare members 65+ years of age. Not risk adjusted.

2013, 2015, 2017, 2018, 2019

2013, 2015, 2017, 20183,

20193

2013, 2015, 20174

All-Cause Readmissions – Risk Adjusted - Commercial

Plan All-Cause Readmission (multiplied by the CA commercial statewide average to calculate a rate)

For commercial members 18 to 64 years of age, the percentage of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days, risk adjusted.

2015, 2017, 2018, 2019

All-Cause Readmissions – Risk Adjusted - Medicare

Plan All-Cause Readmission (multiplied by the CA statewide Medicare average to calculate a rate)

For Medicare members 65+ years of age, the percentage of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days, risk adjusted.

2015, 20183,

20193

_____________________________ 3 Medicare Advantage only, no Medicare FFS results 4 Medi-Cal Managed Care only, no Medi-Cal FFS results

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Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Cesarean Section Rate for Low Risk Births

Cesarean Section Rate for Low Risk Births

The percentage of women who deliver by a C-section when they are giving birth for the first time, full term, to a single baby who is in the correct vertex position.

2013, 2015, 20175, 20186, 20196

2013, 2015, 20175, 20186, 20196

Inpatient Bed Days – Total

Inpatient Utilization - GH/Acute Care - Total Inpatient Days/1000 (Total)

The total number of days members were hospitalized for acute inpatient care, reported per thousand member years (PTMY). Not risk adjusted.

2013, 2015, 2017, 2018, 2019

2013, 2015, 2017, 20183,

20193

2013, 2015, 20174

Inpatient Bed Days – Medical

Inpatient Utilization - GH/Acute Care - Medicine Days/1000 (Total)

The number of days members were hospitalized for medical acute inpatient care, reported per thousand member years (PTMY). Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

2015, 20174

Inpatient Bed Days – Surgical

Inpatient Utilization - GH/Acute Care - Surgery Days/1000 (Total)

The number of days members were hospitalized for surgical acute inpatient care, reported per thousand member years (PTMY). Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

2015, 20174

Inpatient Bed Days – Maternity

Inpatient Utilization - GH/Acute Care - Maternity Days/1000 (Total)

The number of days members were hospitalized for maternity acute inpatient care, reported per thousand member years (PTMY). Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

2015, 20174

Inpatient Discharges – Total

Inpatient Utilization - GH/Acute Care - Total Inpatient Discharges/1000 (Total)

The total number of acute inpatient discharges, reported per thousand member years (PTMY). Not risk adjusted.

2013, 2015, 2017, 2018, 2019

2013, 2015, 2017, 20183,

20193

2013, 2015, 20174

Inpatient Discharges – Medical

Inpatient Utilization - GH/Acute Care - Medicine Discharges/1000 (Total)

The number of medical acute inpatient discharges, reported per thousand member years (PTMY). Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

2015, 20174

_____________________________ 3 Medicare Advantage only, no Medicare FFS results 4 Medi-Cal Managed Care only, no Medi-Cal FFS results 5All Payer only, includes combined results for commercial, Medicare, and Medi-Cal 6All Payer only, includes combine results for commercial and Medicare Advantage

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Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Inpatient Discharges – Surgical

Inpatient Utilization - GH/Acute Care - Surgery Discharges/1000 (Total)

The number of surgical acute inpatient discharges, reported per thousand member years (PTMY). Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

2015, 20174

Inpatient Discharges – Maternity

Inpatient Utilization - GH/Acute Care - Maternity Discharges/1000 (Total)

The number of maternity acute inpatient discharges, reported per thousand member years (PTMY). Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

2015, 20174

Acute Hospital Utilization – Risk Adjusted – Commercial

Acute Hospital Utilization (multiplied by the CA commercial statewide average to calculate a rate)

The risk-adjusted rate of acute inpatient and observation discharges for commercial members 18+ years of age.

2017, 2018, 2019

Acute Hospital Utilization – Risk Adjusted – Medicare

Acute Hospital Utilization (multiplied by the CA Medicare statewide average to calculate a rate)

The risk-adjusted rate of acute inpatient and observation discharges for Medicare members 18+ years of age.

2017, 20183,

20193

High Inpatient Utilizers Acute Hospital Utilization

The percentage of the eligible population with three or more acute inpatient discharges in the measurement year

2017, 2018, 2019

2017, 20183,

20193

Average Length of Stay – Total

Inpatient Utilization - GH/Acute Care - Total Inpatient ALOS (Total)

The mean length of stay for acute inpatient stays. Not risk adjusted.

2013, 2015, 2017, 2018, 2019

2013,2015, 2017, 20183,

20193

2013, 2015, 20174

Average Length of Stay – Medical

Inpatient Utilization - GH/Acute Care - Medicine ALOS (Total)

The mean length of stay for medical acute inpatient stays. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

2015, 20174

_____________________________ 3 Medicare Advantage only, no Medicare FFS results 4 Medi-Cal Managed Care only, no Medi-Cal FFS results

Page 15 of 20

Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Average Length of Stay – Surgical

Inpatient Utilization - GH/Acute Care -Surgery ALOS (Total)

The mean length of stay for surgical acute inpatient stays. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,20193

2015, 20174

Average Length of Stay – Maternity

Inpatient Utilization - GH/Acute Care -Maternity ALOS(Total)

The mean length of stay for maternity acute inpatient stays. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,20193

2015, 20174

Frequency of All Selected Procedures

Summation of all FSP measures

The frequency of all fourteen selected procedures performed per 1,000 member years (PTMY). Procedures include back surgery, hip replacement, knee replacement, bariatric weight loss surgery, angioplasty (PCI), coronary artery bypass graft, cardiac catheterization, carotid endarterectomy, cholecystectomy, hysterectomy, lumpectomy, mastectomy, prostatectomy, and tonsillectomy. Note: Each rate also available separately.

2015, 2017, 2018, 2019

2015, 2017, 20183,20193

2015, 20174

Hospital Utilization Composite – 2015 – Commercial

A composite using Z-scores (see About the Data, Atlas Measures, 4.), which combines performance on four hospital utilization measures available in 2015 for the commercial population: risk-adjusted readmissions, total inpatient bed days, ED visits, and frequency of all selected procedures.

2015, 2017, 2018, 2019

Hospital Utilization Composite – 2013 – Commercial

A composite using Z-scores (see About the Data, Atlas Measures, 4.), which combines performance on the three hospital utilization measures available in 2013 for the commercial population: readmissions, total inpatient bed days, ED visits.

2013, 2015, 2017, 2018, 2019

_____________________________ 3 Medicare Advantage only, no Medicare FFS results 4 Medi-Cal Managed Care only, no Medi-Cal FFS results

Page 16 of 20

Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Hospital Utilization Composite – 2015 – Medicare

A composite using Z-scores (see About the Data, Atlas Measures, 4.), which combines performance on four hospital utilization measures available in 2015 for the Medicare population: risk-adjusted readmissions, total inpatient bed days, ED visits, and frequency of all selected procedures.

2015, 20177, 20183,20193

Hospital Utilization Composite – 2013 – Medicare

A composite using Z-scores (see About the Data, Atlas Measures, 4.), which combines performance on the three hospital utilization measures available in 2013 for the Medicare population: readmissions, total inpatient bed days, ED visits.

2013, 2015, 2017, 20183,20193

Hospital Utilization Composite – 2015 – Medi-Cal

A composite using Z-scores (see About the Data, Atlas Measures, 4.), which combines performance on four hospital utilization measures available in 2015 for the Medi-Cal population: readmissions, total inpatient bed days, ED visits, and frequency of all selected procedures.

2015, 20174

Hospital Utilization Composite – 2013 – Medi-Cal

A composite using Z-scores (see About the Data, Atlas Measures, 4.), which combines performance on the three hospital utilization measures available in 2013 for the Medi-Cal population: readmissions, total inpatient bed days, ED visits.

2013, 2015, 20174

Cost Measures Total Cost of Care - Observed

The average total amount paid by insurance and by members to providers to care for a member for a year. Not risk adjusted.

2013, 2015, 2017, 2018, 2019

20133, 2015, 2017, 20183,20193

2013

Total Cost of Care – DxCG Risk Adjusted – Commercial

The average risk-adjusted total amount paid by insurance and by members to providers to care for a Commercial member for a year.

2013,2015

_____________________________ 3 Medicare Advantage only, no Medicare FFS results 4 Medi-Cal Managed Care only, no Medi-Cal FFS results 7 All-Cause Readmissions – Risk Adjusted – Medicare excluded from composite, results unavailable for 2017

Page 17 of 20

Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Total Cost of Care – ACG Risk Adjusted – Commercial

The average risk-adjusted total payments by insurance and by members to providers to care for a Commercial member 1 to 64 years of age for a year.

2017, 2018, 2019

Total Cost of Care – Geography and ACG Risk Adjusted – Commercial

The average geography and risk-adjusted total payments by insurance and by members to providers to care for a Commercial member 1 to 64 years of age for a year.

2017, 2018, 2019

Total Cost of Care – DxCG Risk Adjusted – Medicare

The average risk-adjusted total amount paid by insurance and by members to providers to care for a Medicare member for a year.

20133, 2015

Total Cost of Care – ACG Risk Adjusted – Medicare

The average risk-adjusted total payments by insurance and by members to providers to care for a Medicare member 1+ years of age for a year.

2017, 20183,

20193

Total Cost of Care – Geography and ACG Risk Adjusted – Medicare

The average geography and risk-adjusted total payments by insurance and by members to providers to care for a Medicare member 1+ years of age for a year.

2017, 20183,

20193

Total Cost of Care – Risk Adjusted – Medi-Cal

The average risk-adjusted total amount paid by insurance and by members to providers to care for a Medi-Cal member for a year.

2013

Member Cost Sharing The average amount a member paid out of pocket per year. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

Plan Paid Amount The average amount the health plan paid per member per year. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

Pharmacy Costs The average pharmaceutical costs per member per year. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

_____________________________ 3 Medicare Advantage only, no Medicare FFS results

Page 18 of 20

Atlas Name NCQA HEDIS® Name (when different)

Description Payer

Com

mer

cial

Med

icar

e

Med

i-Cal

Global Capitation Amount

The average amount of capitation paid per member per year when an organization is capitated for the full spectrum of care, including both professional and facility services. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

Total Professional Costs The average total professional costs per member per year. This includes professional capitation and fee-for-service amounts, but does not include any portion of global capitation. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

Professional Capitation Amount

The average amount of capitation paid for professional services per member per year. Does not include any portion of global capitation. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

Professional FFS Costs The average fee-for-service costs for professional services per member per year. Does not include capitation. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

Total Facility Costs The average total facility costs per member per year. This includes inpatient and outpatient facility capitation and fee-for-service amounts, but does not include any portion of global capitation. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

Facility Capitation Amount

The average amount of capitation paid per member per year for inpatient and outpatient facility services. Does not include any portion of global capitation. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

Inpatient Facility FFS Costs

The average fee-for-service costs for inpatient facility services per member per year. Does not include capitation. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

Outpatient Facility FFS Costs

The average fee-for-service costs for outpatient facility services per member per year. Does not include capitation. Not risk adjusted.

2015, 2017, 2018, 2019

2015, 2017, 20183,

20193

_____________________________ 3 Medicare Advantage only, no Medicare FFS results

Page 19 of 20

NCQA HEDIS® Copyright and Disclaimer

COPYRIGHT NOTICE AND DISCLAIMER

Content reproduced with permission from HEDIS 2019, Volume 2: Technical Specifications for Health Plans by the National Committee for Quality Assurance (NCQA). HEDIS® is a registered trademark of NCQA. HEDIS measures and specifications are not clinical guidelines and do not establish a standard of medical care. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. Anyone desiring to use or reproduce the materials without modification for an internal non-commercial purpose may do so without obtaining any approval from NCQA. Use of the Rules for Allowable Adjustments of HEDIS to make permitted alterations of the materials does not constitute a modification. All other uses, including a commercial use and/or external reproduction, distribution or publication must be approved by NCQA and are subject to a license at the discretion of NCQA. Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. NCQA disclaims all liability for use or accuracy of any coding contained in the specifications. To purchase copies of this publication, including the full measures and specifications, contact NCQA Customer Support at 888-275-7585 or visit www.ncqa.org/publications. Note: The Cervical Cancer Overscreening measure is an Align. Measure. Perform. (AMP) Program measure that is co-owned by IHA and NCQA. MEASURE CERTIFICATION DISCLAIMERS

The Cost & Quality Atlas contains California regional average performance rates which were calculated by IHA by aggregating measure rates stemming from NCQA HEDIS measure specifications. NCQA has granted IHA permission to create and display the aggregated rates. The creation, display, analysis, interpretation, or conclusion based on the of the California regional average performance rates is solely that of the IHA, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. None of the logic used to produce measure results for the Cost & Quality Atlas has been certified by NCQA. NCQA specifications provided in the Cost & Quality Atlas are for reference only and are not an indication of measure validity. Calculated measure results, based on unadjusted HEDIS specifications, may not be termed “Health Plan HEDIS rates” until they are audited and designated reportable by an NCQA-Certified Auditor. Such results should be referred to as “Unaudited Health Plan HEDIS Rates.” The underlying HEDIS measure rates used to produce the aggregated California regional average performance rates constitute “Uncertified, Unaudited Health Plan HEDIS rates.” NCQA BENCHMARK ASSOCIATION DISCLAIMER

The NCQA benchmarks displayed in the California Regional Health Care Cost & Quality Atlas are displayed alongside IHA-produced aggregated HEDIS measure specification rates that constitute California regional average rates with the permission of NCQA. The creation, display, analysis, interpretation, or conclusion based on comparison of the NCQA benchmarks to the aggregate rates is

Page 20 of 20

solely that of the IHA, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. ALL PAYER BENCHMARK DISCLAIMER

The All Payer Benchmarks displayed in the California Regional Health Care Cost & Quality Atlas are derived from National Committee for Quality Assurance (“NCQA”) HEDIS® benchmarks contained in Quality Compass® 2019. HEDIS benchmarks stem from HEDIS rates have been audited and approved by an NCQA-certified HEDIS Compliance Auditor. NCQA hold copyright in Quality Compass, a registered trademark of NCQA. NCQA has granted IHA permission to create and display the All Payer Benchmarks. The creation, display, analysis, interpretation, or conclusion based on the All Payer Benchmarks is solely that of the IHA, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion.