Assessment of Harvard Pilgrim Health Care, Inc.

Transcription

ASSESSMENT OF HARVARD PILGRIM
HEALTH CARE, INC.:
PROVISION OF CARE
FROM 2000 THROUGH 2003
Submitted to:
The Massachusetts Office of the Attorney General
PREPARED BY:
DMA Health Strategies
HARVARD PILGRIM HEALTH CARE
REPORT
TABLE OF CONTENTS
Executive Summary ………………..Executive Summary Page
1
I.
Introduction…………………………………………………
1
II.
Methodology………………………………………………..
2
III.
HPHC Background and External Factors………………..
4
A.
B.
C.
D.
IV.
Background……………………………………………. 4
External Factors……………………………………….. 5
HMO Trends in Massachusetts……………………… 7
Conclusion…………………………………………….. 11
V.
A.
B.
C.
D.
VI.
Introduction ………………………………………… 12
Large and Small Group Plans ……………………… 12
Non-Group Plans …………………………………… 16
Medicare Risk ……………………………………… 18
Medicare Cost ……………………………………..… 18
Enrollment …………………………………………… 20
Provider Network for Commercial Plans ………… 26
Clinical/Authorization Policies …………………… 35
Provider Survey……………………………………… 38
Grievances and Appeals ……………………………. 39
Utilization of Medical Ambulatory Services……….. 42
HEDIS Access and Satisfaction Measures ………… 50
Conclusion …………………………………………… 53
Dougherty Management Associates, Inc.
VII.
……………………………… 57
Behavioral Health ……………………………………
Prescription Coverage ………………………………
Rehabilitation Services ………………………………
Conclusion…………………………………………….
57
77
88
92
Special Populations ……………………………………….. 95
A.
B.
C.
Access to Services………………………………………….. 12
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
Access to Specific Service
Limited English Speakers…………………………… 95
People with Chronic Illness ………………………… 105
Conclusion ………………………………………… 132
Community Benefits………………………………………. 137
A.
B.
C.
D.
Department of Ambulatory Care and Prevention 137
Community Service Center ………………………… 138
Charitable Care
…………………………… 139
Summary of Community Benefits ………………… 139
VIII. Conclusion
………………………………………………. 141
Page i
EXECUTIVE SUMMARY
A.
The Office of the Attorney General identified several specific
topics to be the focus of the assessment. These include:
INTRODUCTION
Late in 1999, Harvard Pilgrim Healthcare Inc. (HPHC)
identified accounting errors that showed it to be in a
significantly worse financial situation than previously
recognized. It immediately reported this situation to the
state, which responded by putting HPHC into receivership
at the beginning of 2000. After a four-month investigation,
the Massachusetts Division of Insurance and Office of the
Attorney General determined that HPHC’s continuation as
an independent company and implementation of its
proposed rehabilitation plan would best serve the interests
of HPHC’s 800,000 members. The court approved the two
agencies’ petition to end the receivership and required that
they continue to monitor the implementation of the
approved rehabilitation plan. To address public concerns
that measures to control costs might lead to withholding
care or seeking to disenroll members with more intensive
treatment needs, HPHC was required to finance a 4 year
assessment of its provision of access and services. The Office
of the Attorney General with the consultation of HPHC and
Health Care for All, a health care advocacy group, selected
Dougherty Management Associates, Inc. – now doing
business as DMA Health Strategies (DMA) - as the
independent assessor in a competitive process. This report
summarizes the results of our assessment.
This report describes HPHC’s performance in Massachusetts
during the entire 4-year period from 2000 through 2003,
using 2000 as the baseline.
It focuses on HPHC’s
Massachusetts operations.
HPHC’s former affiliate,
Neighborhood Health Plan, was not included in the
receivership is therefore not included in this report.
•
•
•
•
Access to HMO coverage
Coverage and Benefits
Access to Critical Services
Behavioral Health
Prescription Drugs
Rehabilitation
Access of Vulnerable Groups
Non-English speakers
Members with Chronic Illness
Provision of Community Benefits
The organization of the report corresponds to those target
areas focusing on the indicators for which we have 4 years of
data.
B.
METHODOLOGY
DMA consultants sought data from a wide variety of sources
to assess HPHC’s provision of care. We used data from
reports submitted by HPHC and other Health Maintenance
Organizations (HMOs) about their operations and services
to the following Massachusetts State Agencies: the Division
of Insurance (DOI), the Department of Public Health’s Office
of Patient Protection (OPP), and the Office of the Attorney
General.
In addition, we drew upon the National
Committee on Quality Assurance’s (NCQA) Health Plan
Employer Data and Information Set (HEDIS), a national
performance benchmarking initiative addressing a number
of aspects of health plan operations and provision of service,
and the annual Drug Trend Report produced by Express
Scripts company from a national sample of its clients’ claims.
Executive Summary Page 1
To familiarize itself with HPHC’s operations, DMA
consultants conducted key informant interviews. DMA also
analyzed utilization and enrollment reports, reports on
administrative operations, and surveys of HPHC members
and HPHC providers, and reviewed key policy documents.
Finally, DMA interviewed or surveyed trade associations
who could represent the experience of their members who
contract with HPCH and advocacy and service organizations
who serve and/or represent the vulnerable populations that
are a specific focus of this assessment in order to understand
the impact of changes caused by the receivership and
rehabilitation plan on these parties.
It also surveyed a
sample of HPHC employers with large numbers of limited
English speaking members.
Since HPHC’s provision of services was affected both by
changes in the external environment and the rehabilitation
plan, DMA selected other large Massachusetts HMOs to
serve as a comparison group when analyzing trends in
utilization, benefits and rates. These include: Aetna, Cigna,
Fallon, Health New England, HMO Blue, and Tufts. For
HEDIS data, the Massachusetts and national averages for
HMOs and point of service (POS) plans were used for
comparison.
C.
HPHC’s financial recovery strategy began before and
continued after this brief period of receivership. It included
changes in company structure and in the operations of most
if not all departments. Some key aspects of financial
recovery included:
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•
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BACKGROUND
HPHC’s receivership began on January 4, 2000 and lasted
through April of the same year. During the receivership
some employers whose contracts with HPHC came up for
renewal were concerned about HPHC’s stability, and chose
not to renew their HPHC coverage. These concerns may
have also influenced HPHC members to transfer to other
HMOs during open enrollment periods. In any case, HPHC
began to experience a significant decline in its enrollment.
•
•
HPHC terminated its contracts with Rhode Island;
It subcontracted with Perot systems to perform claims
processing and with ValueOptions to manage mental
health and substance abuse benefits;
Staffing was downsized to correspond to the decline in
membership and therefore in the volume of certain
member related tasks;
HPHC invested in interactivity and web-based
functionality;
Differences
between
historically
Harvard and
historically Pilgrim accounts and providers were
eliminated;
HPHC introduced a tiered formulary and a new
pharmacy benefits manager;
It negotiated longer term contracts (4 years) with some
large practice groups to provide both them and HPHC
with predictability during a time of uncertainty;
As of 2001, HPHC ended its participation in Medicare
Risk in three counties in southeastern Massachusetts,
Barnstable, Bristol, and Plymouth, and in Worcester
County because of low federal reimbursement (which
varies by County) and reduced provider participation.
In 2001, it subcontracted for case management of
members whose conditions were not being optimally
treated.
In 2002, HPHC introduced Medicare’s Resource Based
Relative Value Scale (RBRVS) for payment of physicians.
HPHC progressively showed improvement in its financial
performance, moving from a $17 million loss in 2000 to a $25
million gain in 2001, with gains of about $30 million
following in 2002 and again in 2003.
HPHC accomplished this during a period of continuing
medical cost inflation, driven by increasing utilization and
costs of pharmacy, increased market power of hospitals, and
increased staff and liability costs. In response, HMO
premiums rose at double-digit rates throughout the period.
Employers shared some of that increase with their
employees by choosing plans with higher co-pays and tiered
pharmacy. A few moved towards a new type of product
with high deductibles. Other Massachusetts plans, most
notably Tufts, also experienced financial difficulties, though
by the end of the period, all major Massachusetts HMOs
were showing profits.
D.
ACCESS TO SERVICES
1. Overall Indicators of Access and Utilization
HEDIS utilization indicators which include HPHC’s group,
Medicare Cost and Individual members, showed HPHC to
have experienced growth in all types of utilization,
outpatient, emergency, and inpatient. However, its rates of
growth tended to be somewhat lower than that of the state
and national averages for HMOs. This left it at the end of
the period with outpatient utilization slightly lower than the
state average and inpatient medical and surgical utilization
lower than the state and national averages. Lower rates of
inpatient utilization, especially when paired with relatively
high rates of outpatient utilization may indicate a desirable
pattern of preventive care. Other indicators of service
provision and a more detailed look at utilization in HPHC’s
different plan types also contribute to an assessment of
access.
Other HEDIS measures confirm that HPHC has been doing a
good job of proving preventive care. HPHC led in access to
primary care in all age categories and showed increasing
rates of access to primary care except in young children,
where its rates were so high (97%) that further improvement
might not be possible. While HPHC began the period with
moderate member scores on providing care quickly and
providing needed care, it increased its scores on both
measures to lead the state and national averages at the end
of the period. Finally, HPHC has showed increasing levels
of satisfaction over the four-year period, far outpacing other
Massachusetts HMOs and the national average.
The rate of grievances is another indicator of how often
members request changes in service authorization decisions.
HPHC’s own data on appeals showed an increasing rate. In
contrast, the data submitted to the Massachusetts Office of
Patient Protection indicated that HPHC’s rate of internal
grievances remained stable, while that of other HMOs
increased over the period. Since internal appeal data did not
increase faster than utilization rates and comparative data
show no increase, it does not appear that authorization
decisions are a significant problem area overall.
2. Access for Commercial Members
Though HPHC’s benefit plans for its three largest
commercial accounts were similar to those of other large
Massachusetts HMOs, its rates were considerably higher at
the beginning of the period. Relatively high rates, combined
with the uncertainty about HPHC’s financial condition likely
had a role in the 25% decrease in group enrollment
experienced between 2000 and 2001 that was much steeper
than the 2% decrease experienced by the other
Massachusetts plans. HPHC enrollment grew slowly after
2001. We had limited data available to analyze what groups
were most likely to leave HPHC, but we did find that
HPHC’s age and gender mix showed a considerable increase
in older individuals over the four year period, an indication
that HPHC enrollees had become higher in need and
providing one indication that more vulnerable members
were not losing coverage. We did find that HPHC lost
enrollment differentially across the state, with residents of
the Northeast, Boston and MetroWest affected less than
those in the Southeast and Western and Central
Massachusetts.
In the first year of the assessment period, HPHC’s PCP
network had decreased somewhat, and its specialist network
decreased even more. However, the magnitude of the
decrease in specialists was similar to the magnitude of the
decrease in enrollment, changing the ratio of specialists to
members minimally, and by 2003, both the PCP network and
the specialist network had grown substantially, more than
outpacing the growth in members and likely increasing
access.
Members’ ratings of their HPHC providers were
relatively high in 2000 and they increased over the period,
putting HPHC above both state and national averages.
Another indication that the provider network was adequate
was that HPHC members increased their outpatient and
inpatient utilization over the period. In comparison to other
HMOs, HPHC’s rates of utilization were either the same or
higher, suggesting that HPHC provided access to services
that met or exceeded that of other HMOs throughout the
analysis period.
3. Access for Non-group Members
HPHC and other Massachusetts HMOs were required to
comply with new state regulations governing benefits and
rates for non-group coverage in 2001. HPHC’s non-group
rates went from lower than most other Massachusetts HMOs
to only slightly lower or - for some members – a bit higher.
HPHC was also required to end its existing low-cost nonDougherty Management Associates, Inc.
group plan and introduced another plan that attracted only
about one third the number that had been enrolled in the
plan that ended. This change accounted for most of the 50%
decrease in HPHC’s non-group enrollment over the fouryear period.
Utilization of non-group members differed from other
HMOs. Both outpatient and inpatient utilization began at
rates that exceeded that of other HMOs, in the case of
outpatient, considerably. Both experienced a dramatic drop
in the second year of the period – a time when enrollment
also changed and HPHC’s legacy plan was replaced by its
low option plan. In the succeeding years, both outpatient
and inpatient utilization rates increased, ending the period
the same or higher than other plans. This pattern suggests
that the enrollment changes did affect higher need
individuals, who may have disproportionately left the plan.
The dramatically lower rates of utilization – in the absence of
different clinical utilization policies for non-group members
– may well be due to the absence of higher need individuals.
While high-need, individually insured members appear to
have lost HPHC coverage, the loss of coverage is more likely
due to changes in benefit plan and plan rates that were
determined by state regulations, not by elements of HPHC’s
recovery plan.
4. Access for Medicare Risk Members
In general Medicare HMOs regarded federally determined
capitation rates as inadequate during this period. They
responded by dropping coverage in certain counties and
raising rates. Medicare providers also perceived rates as
inadequate and a number of hospitals and physicians
discontinued their Medicare practices, reducing the
networks available to Medicare HMOs. HPHC’s Medicare
Risk plan, First Seniority, shared in this industry trend.
While it offered largely the same basic benefits throughout
the period, it dropped coverage for Worcester, Barnstable,
Bristol, and Plymouth counties, and implemented a
premium which almost doubled in each of the next two
years, while pharmacy and visit co-pays also increased. Its
enrollment dropped by almost thirty percent in 2001 due
mostly to eliminating the coverage area. However, the
remaining counties also experienced a 13% decrease.
Results of the Medicare CAHPS survey at the beginning of
the period indicated that HPHC members were leaving at
higher rates than from other Massachusetts or national
HMOs, and that they were doing so primarily because of
concerns about health care or services rather than because of
costs and benefits. This suggests that HPHC’s loss of
hospitals and some physicians in its network may have been
more important than premium and co-pay increases.
However, by the end of the period, HPHC’s termination
rates were lower than the state and national averages, and
the reasons for leaving were equally due to concerns about
services and costs.
Despite dramatic changes in enrollment, HPHC’s Medicare
Risk members’ utilization was relatively stable. HPHC
moved from somewhat lower outpatient utilization than
other HMOs to somewhat higher over the four years, while
its inpatient utilization was variable, but not as variable as
the average of other HMOs. HPHC’s inpatient utilization
was generally higher or about the same as that of other
HMOs. These patterns suggest that HPHC’s Medicare risk
members had equivalent or better access to services as those
enrolled in other large Massachusetts HMOs.
5. Access for Medicare Cost Members
We have limited information about Medicare Cost enrollees.
HPHC enrollment data shows that their enrollment
increased from 1,436 average members in 2000 and to a point
in time enrollment of 4,473 in 2003, approximately doubling
despite considerable increases in premiums. HPHC’s rate of
increase in enrollment exceeded that of other HMOs, whose
level of enrollment increased by only 20%.
E.
ACCESS TO SPECIFIC SERVICES
1. Provision of Mental Health and Substance Abuse Care
Access to needed behavioral health services is one of the
most critical issues identified by stakeholders. HPHC
subcontracted with ValueOptions to manage its behavioral
health services during the period of this contract.
The
number of hospitals available to HPHC members in need of
psychiatric inpatient care increased considerably over the
period, and a decrease in the number of individual mental
health specialists was offset to some degree by an increase in
mental health clinics entering the network. Member and
provider surveys, as well as other feedback, indicated that
administrative functions were a continuing and sometimes
an escalating problem for HPHC’s provision of mental
health and substance abuse services. They may have
contributed to fewer individual practitioners contracting to
be in ValueOption’s network.
ValueOptions focused resources on and demonstrated
improvements in access to services. Division of Insurance
data for 2003 and HEDIS data suggest that HPHC members
have better than average access to outpatient mental health
services, equivalent access to day/night care, and higher
access to inpatient care than other Massachusetts HMOs.
However, HPHC’s high rates of inpatient care and longer
lengths of stay could be indications of a higher need
population or less effective preventive care. Both sources of
data suggest that substance abuse treatment is an area in
which HPHC members may not have as much access as
other Massachusetts HMOs, as indicated by both lower
outpatient and inpatient utilization.
Utilization of
psychotropic drugs grew considerably. Though we do not
have a benchmark for comparing the rate of increase to
others, it does show increasing utilization by HPHC
members.
HPHC has excelled on some measures of quality of mental
health care according to HEDIS, where it has exceeded state
and national averages and showed consistent improvement,
particularly for follow-up after inpatient discharge.
However, it has shown steeply increasing rates of
readmission for both mental health and substance abuse
inpatient services, suggesting that longer than average
lengths of stay and high rates of community follow-up are
not having the desired effect of establishing patients stably
in the community. Member surveys showed high and
increasing rates of satisfaction with their therapist and with
their outcomes of treatment.
2. Provision of Medications
In HEDIS comparisons, HPHC showed both higher cost per
capita of medications and a higher rate of growth in
utilization than the Massachusetts and national averages,
suggesting that HPHC members have a relatively high
access to medications overall. Despite utilization growth,
HPHC’s three tier formulary appears to constrain growth in
HPHC’s cost for medications, both by sharing cost with
members who are responsible for a co-pay, and by
decreasing utilization of many Tier 3 drugs, for which less
expensive alternatives are available. While the introduction
of the tiered pharmacy benefit coincided with a high rate of
pharmacy related appeals, the pharmacy appeals rate
dropped considerably in succeeding years, suggesting that
members had accepted it. Our comparison of HPHC
utilization of specific drug classes to that of a mixed
commercial population drawn from throughout the country
shows HPHC to use four classes of drugs more frequently,
hypertensives, antidepressants, allergy drugs, and antivirals; and two classes less frequently, drugs for
management of lipid levels, and gastrointestinal drugs.
However, HPHC’s rates of growth are either higher than in
the national average or close to the same for these two
classes, and HPHC exceeded the state and national average
HEDIS scores for managing lipid levels after heart attacks,
providing one indication that HPHC’s prescription patterns
are appropriate for its clientele.
We also reviewed the
medications that HPHC had made harder to get through
moving them to higher tiers or requiring prior approval, and
found that HPHC used these mechanisms for relatively few
medications, and there was strong justification for giving
them additional scrutiny.
3. Provision of Rehabilitation Services
We were limited in the degree of detail available to analyze
HPHC’s provision of rehabilitation services. In addition, the
network of rehabilitation facilities tended to stay the same or
increase, suggesting a similar level of continuing access to
these providers. The outpatient rehabilitation providers we
contacted were generally positive about the quality of
HPHC’s authorization procedures, though they expressed
concern about timeliness and billing issues that can affect
HPHC’s continued ability to provide rehabilitation care.
However, the data we did have showed increasing rates of
utilization for inpatient services, outpatient therapies, as
well as for other outpatient services plus equipment between
2000 and 2003. Despite increasing authorization rates,
rehabilitation authorization decisions were appealed more
often than most other types of service, especially in 2000 and
2001, and physical therapy remained one of the most
frequent reasons for appeal in 2002 and 2003, suggesting that
some members are not satisfied with the amount of physical
therapy they are receiving.
F.
SPECIAL POPULATIONS
1. Provision of Services for Limited English Speakers
HPHC has demonstrated a strong and continued
commitment toward providing quality care for limited
English speaking individuals and other members of nondominant cultural groups, through the development and
dissemination of training programs in different aspects of
cross-cultural health care. The program has grown through
the four years of analysis, both adding new courses and
increasing the number of health care professionals receiving
training, both inside and outside HPHC’s network. HPHC
also ensures that its clinical and administrative staff include
some individuals who speak other languages, particularly
Spanish, and that they have access to telephone
interpretation for languages that staff do not speak. Use of
HPHC’s telephonic interpretation has grown over the
period. The limited data on satisfaction of limited English
speaking members showed that their levels of satisfaction on
access to services was the same or higher than English
speaking members. Employers with significant numbers of
limited English speaking HPHC members also indicated that
their employees did not have problems with aspects of
HPHC’s provision of service for limited English speakers.
However, both surveys indicated that limited English
speakers were sensitive to the cost of health coverage.
Despite these conclusions, our ability to analyze provision of
care for limited English speakers was highly compromised
by lack of relevant data on the number and health status of
limited English speaking members and on the bilingual
capacity of HPHC’s provider network. However, we could
determine that:
•
HPHC appears to have an extensive provider network
that can serve Spanish, Portuguese, Russian, Italian and
•
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French speaking members, though community
respondents pointed out that the HPHC network in
Cambridge does not include the clinics with the greatest
Portuguese speaking capacity.
It also has a high concentration of providers that speak
Chinese languages, though we can’t determine whether
both Mandarin and Cantonese speakers are equally well
served.
Other language groups, like Armenian, Vietnamese, and
Korean, appear to have a sufficient ratio of bilingual
providers in the network, but the number of providers is
small enough that members in some locations may not
have a bilingual provider that is easily accessible.
Similarly, the network of bilingual specialists may not
include the types of specialties a particular individual
needs.
A few significant language groups, Haitian Creole, and
Khmer, are very limited and fall below the physicians
per thousand ratio of the overall network, while no
bilingual Cape Verde Kriolu speakers providers are
listed.
The limitations of relevant data from HPHC are likely
shared by other health plans and reflect that the customary
reporting and analysis expected of them do not account for
language or ethnic group, and thus prevent them from
seriously assessing the health care needs of limited English
speakers.
2. Provision of Services for People with Chronic Illness
We also looked at a wide variety of data related to care for
people with chronic illness, a population not easy to identify.
Since HPHC’s First Seniority members have a greater
likelihood of chronic illness than its younger commercial
population, we looked at additional aspects of care for these
Medicare cost members. The network of PCPs for First
Seniority members was relatively larger than that for its
commercial population in most regions, but in the Northeast
and Metrowest the First Seniority network dropped to or
below commercial levels, which may signify problems in
access. These levels, plus a smaller and changing network of
hospitals, may have contributed to the decline in
membership described above.
Appeals of service
authorization decisions by First Seniority members were
significantly elevated in 2001 and 2002, particularly for
outpatient services, with lesser increases for emergency care,
visual services and inpatient care, though they had
approached 2000 levels by the end of the period. It is
possible that these are related to members losing providers
who had left the network and experiencing disruptions in
their usual patterns of care. Rising appeals for durable
medical equipment are a special concern for members with
chronic illnesses. However, HPHC’s performance on the
percentage of members over 65 with an ambulatory or
preventive visit in the last three years exceeded the national
and state averages, suggesting high access to primary care.
First Seniority also performed similarly to other
Massachusetts and national HMOs on several aspects of
access and satisfaction with health plan services. However,
HPHC’s and other HMOs’ ratings fell over time, suggesting
some across the board decline in reaching the highest levels
of access and quality.
First Seniority members’ access to prescription medications
is affected by their benefit type. The rate of prescription
claims paid by HPHC for members with quarterly caps was
significantly lower that for members who continued to be
fully covered, but we cannot determine whether this reflects
lower utilization or simply lack of data on claims paid solely
by members. However, both groups’ showed increased
HPHC claims per thousand even as members’ co-pays and
premiums increased and benefit caps decreased, indicating
that members are continuing to benefit from
pharmaceuticals.
However, members are clearly
experiencing increases in their expenditures for these drugs,
despite moving from the more expensive Tier 2 and 3
options.
Utilization of three drug classes of special
importance for people with chronic illness: hypotensives;
drugs to treat hypertension; and drugs to treat seizure
disorder also had a pattern of increasing utilization,
suggesting that members are increasingly accessing
medications to treat these three conditions. Decreases in use
of Tier 3 drugs affect relatively few individuals and were
more than offset by increases in the other tiers. While
utilization has increased, it is hard to imagine that increased
costs are not affecting access for lower income First Seniority
members. However, other HMOs implemented similar
pharmacy benefits and likely experienced similar trends as
HPHC.
HPHC increased its resources for coordinating care for
people with chronic and complex illnesses over the four
years. It maintained its case management staffing in
proportion to enrollment, while markedly increasing the
number of people served.
HPHC introduced
HealthAdvance, a service that identifies individuals with
serious, and often multiple, conditions who are not getting
optimal services and conducts outreach to establish a more
appropriate treatment plan and to arrange for necessary
supports, dramatically lowering subsequent hospital
admissions.
HPHC’s quality improvement process
supported 16 Quality Improvement projects per year
proposed by its providers, most frequently focused on
improving care of members with diabetes, cardiac disease or
asthma.
The effectiveness of these and prior efforts are reflected in
HPHC’s excellent and improving scores on HEDIS measures
for the effective treatment of diabetes for both its commercial
and Medicare members, and for asthma in children.
HPHC’s scores on cardiac treatment show more reliance on
less invasive procedures than more invasive procedures, a
desirable pattern. However, its performance on some other
HEDIS measures for which optimal performance cannot be
as clearly identified is inconclusive. HPHC had mixed
performance on HEDIS measures related to surgical
procedures for men and women over 65. However, it began
the period low on most measures in 2000 relative to
Massachusetts and national averages and ended closer to the
state and national averages. While we cannot easily
determine whether this is an improvement, it brings HPHC
practice patterns closer to those of other HMOs.
CAHPS results of respondents who classified their health as
fair or poor rated some aspects of HPHC care better than
individuals in good health; getting care quickly when they
had an illness or an injury and getting a specialist referral,
and their ratings improved over the period. However, they
were not as satisfied as those in good health in being seen by
their PCP or specialist for an urgent problem or
understanding written materials from the health plan. While
most members rated cost of health insurance as reasonable,
it was more of a problem for those in fair or poor health.
G.
dramatically decreased HPHC’s contributions toward
research and teaching, though these programs leveraged
sufficient grant funding to more than make up for the loss in
HPHC’s share. HPHC’s Quality Improvement program also
suffered significant cuts.
HPHC’s grants to other
community organizations, however, expanded by 60%,
targeted particularly to improve access to care for
underserved populations.
H.
CONCLUSION
HPHC has lost membership overall, and those members
who disenrolled from its individual plans appear to have
higher levels of need and use for medical care than those
who remained. However, in its larger commercial plans it
has generally enrolled an older and therefore higher need
group and fostered increased utilization of services among
them. Its utilization remains similar to or above that of both
state and national HMOs. Of the areas we analyzed, the
following have shown stable or increasing access, quality
and/or utilization.
•
COMMUNITY BENEFITS
HPHC’s overall charitable giving increased by 14% between
2000 and 2003, but this has been a period of considerable
transition in the uses of charitable resources. In 2001, an
obligation to pay an assessment to the Commonwealth’s
uncompensated care pool equal to over 40% of HPHC’s total
gifts necessitated a considerable redistribution in its other
types of charitable activity. Coincidentally, HPHC’s small
existing program to subsidize the premiums of incomeeligible individuals and its $15 million pledge to community
health centers were decreasing as they approached their
planned ending dates. Paying the free care pool assessment
•
•
Most indicators show that HPHC has maintained and
increased access to care for its group and Medicare Risk
plan members. Quality scores have improved to very
high levels, often exceeding other HMOs. Satisfaction
scores for commercial members have also grown, while
those for First Seniority members remain high, they have
eroded somewhat, similar to other Medicare HMOs.
HPHC has expanded Medicare Cost coverage to a
greater degree than other MA HMOs. Partial data on
utilization shows provision of levels of care that equal or
exceed those of other HMOs.
Overall HPHC has maintained and improved access to
behavioral health services. HPHC members had high
satisfaction with their services, and HPHC has excelled
on some measures of quality of mental health care
according to HEDIS.
Both commercial and Medicare members show
increasing utilization of medications, through cost
sharing provisions similar to those enacted by other
HMOs undoubtedly affect lower income seniors and
likely prevent them from using all the medications that
might benefit them.
Overall access to rehabilitation services has increased.
HPHC shares the same limitations experienced by the
industry as a whole in its ability to reliably identify and
understand the health care needs of its limited Englishspeaking members. However, it has made a substantial
and continuing commitment to developing crosscultural training materials and offering training to
medical practitioners in its network and to the larger
healthcare community.
HPHC’s community benefit expenditures have grown
modestly, even in this period of financial discipline.
However, meeting its new obligations to fulfill its
assessment to the free care pool has been accommodated
by reducing its contributions toward education and
research. During this period it completed its $15 million
commitment to Health Centers.
•
In a few limited areas, HPHC has reduced its provision of
care from prior levels or there are indications of some
dissatisfaction or performance problem.
•
•
•
•
•
•
Individual members experienced both enrollment
decreases and dramatic drops in utilization between
2000 and 2001 that suggest that higher need members
may have dropped coverage. The rate and coverage
changes influencing disenrollment were largely
determined by state regulation and rate setting decisions
which HPHC attempted to moderate within allowable
parameters.
•
•
•
•
High rates of inpatient psychiatric utilization and
readmission rates suggest room for additional
improvements in assisting members to stabilize after
discharge. We do not have data that allows us to
compare these rates to those of other HMOs.
A high level of appeals suggest that HPHC members
desired more rehabilitation therapy services than they
get, with physical therapy standing out as a continued
issue at the end of the period.
needs.
listed.
HPHC is providing less access for substance abuse
treatment than other HMOs as indicated by lower
utilization rates.
HPHC may be providing less access for substance abuse
utilization rates. However, questions about the accuracy
of categorizing claims with both mental health and
substance abuse diagnoses make this a tentative
conclusion.
Overall available indicators show that HPHC has achieved
financial stability while maintaining and / or increasing the
level of services provided, and initial loss of enrollment has
been followed by slow growth as its premiums have become
more similar to those of other Massachusetts HMOs. Many
of the areas in which indicators show continued enrollment
decrease or service limitations have been determined by
external agents or are similar to the policies or performance
of other HMOs.
I.
INTRODUCTION
Late in 1999, Harvard Pilgrim Healthcare Inc. (HPHC) identified
accounting errors that showed it to be in a significantly worse
financial situation than previously recognized. It immediately
reported this situation to the state, which responded by putting
HPHC into receivership at the beginning of 2000. After a fourmonth investigation, the Massachusetts Division of Insurance and
Office of the Attorney General determined that HPHC’s continuation
as an independent company and implementation of its proposed
rehabilitation plan would best serve the interests of HPHC’s 800,000
members. The court approved the two agencies’ petition to end the
receivership and required that they continue to monitor the
implementation of the approved rehabilitation plan.
To address public concerns that measures to control costs might lead
to withholding care or seeking to disenroll members with more
intensive treatment needs, HPHC was required to finance a fouryear assessment of its provision of access and services. The Office of
the Attorney General with the consultation of HPHC and Health
Care for All, a health care advocacy group, selected Dougherty
Management Associates, Inc. – now doing business as DMA Health
Strategies (DMA) - as the independent assessor in a competitive
process.
An interim report covering the first two years of the period was
submitted to the Office of the Attorney General. This report
summarizes the full results of our assessment. It describes HPHC’s
performance in Massachusetts during the entire 4-year period from
the beginning of 2000 through 2003, using the year 2000 as the
baseline. It focuses on HPHC’s Massachusetts operations. HPHC’s
former affiliate, Neighborhood Health Plan, was not included in the
receivership and is therefore not included in this report.
The Office of the Attorney General identified several specific topics
to be the focus of the assessment. These include:
•
•
•
•
Access to HMO coverage
Coverage and Benefits
Access to Critical Services
Behavioral Health
Prescription Drugs
Rehabilitation
Access of Vulnerable Groups
Non-English speakers
Members with Chronic Illness
Provision of Community Benefits
The organization of the report corresponds to those target
areas, focusing on the indicators for which we have 4 years
of data.
•
•
•
•
•
•
•
•
Chapter One introduces the assessment
Chapter Two describes methodology used by DMA.
Chapter Three provides background information about
HPHC and about health care trends in general.
Chapter Four analyzes indicators related to access to
HPHC coverage.
Chapter Five analyzes HPHC’s provision of targeted
services, specifically mental health care, pharmacy, and
rehabilitation services.
Chapter Six discusses HPHC’s provision of care to two
vulnerable populations: limited English speakers and
members with chronic illnesses.
Chapter Seven describes HPHC’s Community Benefits
program.
Chapter Eight presents our overall conclusions from this
assessment.
Page 1
II.
METHODOLOGY
DMA consultants sought data from a wide variety of sources to
assess HPHC’s provision of care. We used data from reports
submitted by HPHC and other Massachusetts Health Maintenance
Organizations (HMOs) about their operations and services to the
following: Massachusetts Division of Insurance (DOI), the
Department of Public Health’s Office of Patient Protection (OPP),
and the Office of the Attorney General. In addition, we drew upon
the National Committee on Quality Assurance’s (NCQA) Health
Plan Employer Data and Information Set (HEDIS), a national
performance benchmarking initiative addressing a number of
aspects of health plan operations and provision of service. Finally,
Express Scripts, a pharmacy management company, produces an
annual report entitled Drug Trend Report, which is based on analysis
of a national sample from its commercial clients’ claims. This report
provided data on national trends in pharmaceutical utilization and
price that can help in interpreting those experienced by HPHC.
DMA consultants conducted key informant interviews with HPHC
managers at the beginning of the assessment, and as needed to
understand important changes thereafter. DMA also analyzed
utilization and enrollment reports, reports on administrative
operations, and surveys of HPHC members and HPHC providers,
and reviewed key policy documents. Finally, DMA interviewed or
surveyed trade associations who could represent the experience of
their members who contract with HPHC and advocacy and service
organizations who serve and/or represent the vulnerable
populations that are a specific focus of this assessment. We sought
to understand the impact of changes caused by the receivership and
rehabilitation plan on these parties. We also surveyed a sample of
HPHC employers with large numbers of limited English speaking
members.
Since HPHC’s provision of services was affected both by changes in
the external environment and the rehabilitation plan, DMA selected
other large Massachusetts HMOs to serve as a comparison group
when analyzing trends in utilization, benefits and rates. These
include: Aetna, Cigna, Fallon, Health NE, HMO Blue, and Tufts.
For HEDIS data, the Massachusetts and national averages for HMOs
and point of service (POS) plans were used for comparison.
There have been limitations in our assessment, particularly in our
ability to delve deeper in certain areas. This was particularly true for
limited English speakers, where we had differing counts of
enrollment and no utilization data. In addition, utilization data for
rehabilitation services was summarized into two categories,
preventing analysis of the utilization of specific services.
We also caution that many trends may be affected by case mix
changes about which we have quite limited information. While we
had HPHC data indicative of its changing age/gender mix over the
period, we have no information about case mix in other
Massachusetts HMOs. Similarly, we are not aware of how case mix
changes may have affected the HMOs included in the HEDIS
Compass averages or the plans included in Express Scripts Drug
Trend report. Therefore, conclusions drawn from these comparisons
must be qualified.
Finally, we note that utilization data from the Division of Insurance
may not be reported consistently by different plans. Methodology
for these reports is not specified in as much detail as are HEDIS
measures, and we noted several discrepancies and dramatic changes
in some reporting categories that led us to exclude some
observations from our comparisons.
Because of these limitations, we have sought a variety of different
measures from different sources for each topic of analysis. To the
degree that we find similar results from a variety of related sources
of data, we can put more confidence in our conclusions. Where
Page 2
results do not agree, our conclusions must be considered less
definitive.
More detailed information about our methods is provided in the
narrative that discusses specific data or in the notes pertaining to
tables and charts.
Page 3
III.
HPHC BACKGROUND AND EXTERNAL FACTORS
A.
BACKGROUND
1. About HPHC
Harvard Pilgrim Healthcare Inc. (HPHC)’s receivership was
the most dramatic event that occurred as the organization
identified and responded to serious financial problems. A
new chief executive officer appointed 1999, 6 months before
the receivership, and his new chief operating officer
identified the extent of the financial difficulties and reported
them to the state.
They also initiated significant
organizational changes and developed new management
strategies, including:
•
•
•
•
•
Merging the administrative systems of the organization
and streamlining and standardizing policies and
operations;
Terminating HPHC’s contracts with Rhode Island;
Changing the terms of both its provider contracts and its
benefit contracts in order to make them more
standardized in both terms and price;
Subcontracting with Perot systems for claims processing;
and
Subcontracting with Value/Options to manage its
behavioral health network and benefits.
Despite these swift and decisive changes, HPHC was in
receivership at the beginning of 2000.
2. Receivership - January through April 2000
On January 4, 2000, the Massachusetts Division of Insurance
(DOI) declared HPHC to be in unsound financial condition
and instituted a receivership.
After a four-month
investigation, the Massachusetts Division of Insurance and
Office of the Attorney General determined that HPHC’s
continuation
as
an
independent
company
and
implementation of its proposed rehabilitation plan would
best serve the interests of HPHC’s 800,000 members. The
court approved the two agencies’ petition to end the
receivership and required that they continue to monitor the
implementation of HPHC’s approved rehabilitation plan.
During the receivership some employers whose contracts
with HPHC came up for renewal during this period were
concerned about HPHC’s stability, and chose not to renew
their HPHC coverage. These concerns may have also
influenced HPHC members to transfer to other HMOs
during open enrollment periods. In any case, HPHC began
to experience a significant decline in its enrollment.
3. Overall Financial Recovery Strategy
In 2000, HPHC’s financial recovery strategy involved all
departments.
•
•
•
•
Staffing was downsized to correspond to the decline in
membership and therefore in the volume of certain
member related tasks;
All departments evaluated the value added of their
activities, looking for ways to cut staff, cut costs and
improve performance;
HPHC made a tremendous investment in moving to
interactivity and web-based functionality;
Another major theme was rationalizing HPHC’s
procedures at many levels of the organization, finally
fully eliminating differences between historically
Page 4
•
•
Harvard and historically Pilgrim accounts and
providers;
In addition, HPHC’s insurance functions were clearly
delineated from its remaining direct care functions (the
Harvard Vanguard Centers), and the direct care
functions were eventually spun off;
Later in 2000, HPHC ended its participation in Medicare
Risk in three counties in southeastern Massachusetts
(Barnstable, Bristol, and Plymouth) and in Worcester
County, because of low federal reimbursement (which
varies by County) and reduced provider participation.
Over the four years of this assessment, HPHC implemented
additional changes to improve quality or contain costs.
Some of the most significant actions included:
•
•
•
•
•
In 2000, introducing a tiered formulary and a new
pharmacy benefits manager;
Also in 2000, negotiating longer term contracts (4 years)
with some large practice groups to provide both them
and HPHC with predictability during a time of
uncertainty;
In 2002, introducing Medicare’s Resource Based Relative
Value Scale (RBRVS) for payment of physicians.
Over the entire four years, providing grants to physician
practices for quality improvement activities targeted at
illnesses such as diabetes, congestive heart failure,
asthma and depression; and
Subcontracting a case management program for
members whose conditions are not receiving optimal
treatment.
1. Financial Results
HPHC progressively showed improvement in its financial
performance, showing a $17 million loss in 2000, a $30
million gain in 2001, and remaining at about that level in
2002 and 2003. They were able to maintain these gains while
some of their competitors, most notably Tufts Health Plan,
were having financial difficulties, though by the end of the
period, all the major Massachusetts HMOs were showing
profits.
B.
EXTERNAL FACTORS
The period in which HPHC experienced critical financial
difficulties was one of consistently high increases in health
care costs. A number of studies of health care spending and
industry trends show the following factors driving higher
levels of health care spending than had been seen in the
previous decade.1 PricewaterhouseCooper identified the
most significant factors driving prices during 2001 and 2002
as:
•
•
•
•
•
Drugs, medical devices and medical advances;
Rising provider expenses, including medical staff pay
rates;
Government mandates and regulation;
Increasing consumer demand; and
Litigation and risk management.2
Reflecting these increases in service cost, premium costs for
employers began rising more rapidly. However, with the
tight labor market in the late nineties, employers bore most
of the increase, passing relatively little of it onto their
1 Strunk, Bradley C.; Ginsburg, Paul B.; and Gabel, Jon R, “Tracking Health Care
Costs” Health Affairs, Web Exclusive, 2001.
Levit, Katharine; Smith, Cynthia; Cowan, Cathy; Lazenby, Helen; and Martin, Anne,
“Inflation Spurs Health Spending in 2000”, Health Affairs, 21:1.
2 McDonough, John E. and Hager, Christie L., “Health Care at the Crossroads: A
Guide for the Perplexed”, Chapter 6 in Governing Greater Boston: Meeting the Needs of
the Region’s People, 2003 Edition.
Page 5
employees. The first exception to this was the introduction
of a three-tiered co-pay system for prescription drugs, which
has moderated the rate of growth in pharmacy spending,
though pharmaceuticals continue to be a significant cost
driver in health care. Between 2000 and 2004, employers
continued to experience double digit increases in premium
costs and increasingly moved to health plans with higher
deductibles.3 As employers increasingly shopped for better
deals in health care, HPHC and other health plans began to
introduce high deductible managed care plans, though they
had not gained a large share of the market by the end of this
analysis.
optimal service provision. These improvements also have
desirable effects in containing expenditures for high cost
cases.
Hospitals, squeezed by the Medicare payment provisions of
the Balanced Budget Act, and having experienced loss of
excess bed capacity in their communities, found themselves
in a stronger negotiating position with insurers, and won
significant price increases over the last few years that
improved their ability to carry increasing costs of personnel
and liability insurance.5 The balanced budget act has also
affected Medicare + Choice HMOs. Nationally, and in some
Massachusetts counties, insurers deemed 2001 rates to be too
low, and withdrew from offering such plans.6 Continued
low rates decreased the pool of providers willing to accept
Medicare payments and the combination of lower rates and
smaller networks led some HMOs to reduce their Medicare
+ Choice offerings further. Increasing demands, higher
costs, and stagnant reimbursement have eroded the practice
environment for physicians, particularly in Massachusetts,
where physician surveys showing continued declines from
1992. However, in 2002 and 2003 several Massachusetts
insurers increased physician pay to better compensate for
increases in malpractice insurance costs.
There had also been changes in the health insurance
marketplace, with declining enrollment into HMOs, the
most restrictive insurance entities, and increasing enrollment
into Preferred Provider Organizations (PPOs), which allow
member to use out-of-network providers at a somewhat
higher rate than charged for network providers4.
In
addition, through legislation and consumer preference – as
reflected through employers – managed care controls were
relaxed. For example, most plans have made it easier for
members to see specialists and have dropped
preauthorization requirements for certain procedures. Plans
began to introduce incentive payments for certain hospitals
and physician practices as a way to influence desirable
practice patterns.
They also implemented disease
management programs that focus on improving health
outcomes for members by using nurses to work with
members to encourage lifestyle changes and coordinate
3 Cross, Margaretann, “Some HMOs See Dividends in Charging Deductibles”,
Managed Care, October 2003.
4 Gabel, Jon, Clzxton, Gary, Gil, Isadore, Pickreign, Jeremy, Whitmore, Heidi, Holve,
Erin, Finder, Benjamin, Hawkins, Samantha, Rowland, Diane, “Health Benefits in
2004: Four Years of Double Digit Premium Increases Take Their Toll on Coverage”,
Health Affairs, 23:5.
In addition to the challenges posed by increasing utilization
and costs, the health care industry has also experienced an
increasing emphasis on quality of care. The Institute of
op. cit. .McDonough and Hager.
Kowalczyk, Liz, “2 More Firms to End Coverage in Bay State”, Boston Globe,
7/25/2000.
5
6
Page 6
Medicine identified a ‘quality chasm’ in healthcare and encouraged the adoption of continuous quality improvement methodologies in
health care settings to address a variety of challenges, including: reduction of error rates in hospitals; faster and more comprehensive
adoption of evidence-based practices; development of timely and responsive care processes; and greater responsiveness to health care
consumers. HMOs participated in this movement by measuring their providers on certain dimensions of quality – often those measured
by HEDIS - sponsoring Quality Improvement processes to help their providers address identified opportunities for improvement, and
introducing financial incentives (pay for performance) related to achieving specified quality of care goals.
C.
HMO TRENDS IN MASSACHUSETTS
This section presents an analysis of several information sources about the enrollment, and service provision of the major commercial
HMOs operating in Massachusetts. Data relevant to HMO clients on Medicaid was excluded because HPHC does not offer Medicaid
plans.
Over the analysis period, enrollment in Massachusetts’ major commercial HMOs decreased consistently for the two largest categories of
coverage, Groups and Medicare Risk, with Medicare Risk losing more than 30% of covered lives. Overall enrollment in HMOs fell by
14%. Much smaller enrollment groups, Medicare Cost and Individual policies, increased.
TABLE 1
TOTAL MASSACHUSETTS ENROLLMENT IN
MASSACHUSETTS LICENSED MANAGED CARE COMPANIES 2000 THROUGH 2003
Plan Type
Groups
Members as
of 12/31/00
Members as
of 12/31/01
Members as
of 12/31/02
Members as
of 12/31/03
% Change
2000 to 2003
2,233,499
2,189,404
2,087,525
1,950,661
-13%
Medicare Risk
235,697
216,003
203,251
163,044
-31%
Medicare Cost
10,505
10,859
11,864
12,620
20%
Individual
34,318
32,530
35,879
40,520
18%
Other
688
495
356
273
-60%
Total
2,514,707
2,449,291
2,338,875
2,167,118
-14%
Definitions and Explanatory Notes
Group coverage is offered through
employer groups. Medicare Risk coverage
allows Medicare eligible individuals to put
their Medicare premiums toward coverage
in an HMO, which may also charge a
supplementary premium. Another form of
Medicare coverage entitled Medicare Cost
does not put the HMO at risk for providing
care.
Massachusetts HMOs are also
required to offer individual coverage for
citizens who are not affiliated with a group
and wish to purchase coverage for
themselves and their families.
Source: NAIC 2000 - 2003 Quarterly Report for Quarter 4, filed by MA HMOs to MA Division of Insurance
Page 7
In Massachusetts, HPHC, HMO Blue and Tufts, have statewide coverage. Two smaller HMOs have significant roles in the Central and
Western regions of the state. Only HMO Blue increased its enrollment from 2000 to 2003. HPHC has the greatest share of the Boston
market. Tufts, HMO Blue and HPHC share Metrowest fairly equally. HMO Blue has the most enrollees in the North East. These three
HMOs all experienced considerable growth in the Southeast region, with HMO Blue having the largest share. Fallon dominates in the
Central region, though the other three large HMOs also have a share. HMO Blue and Health New England (Health NE) are dominant in
the Western region.
CHART 2
ENROLLMENT IN MAJOR MASSACHUSETTS
HMOS BY COMPANY AND REGION AS OF 12/31/2003
CHART 1
ENROLLMENT IN MAJOR MASSACHUSETTS
HMOS BY COMPANY AND REGION AS OF 12/31/2000
800,000
800,000
Boston
Boston
MW
400,000
MW
SE
MW
NE
SE
Central
Western
Central
Central
Western
Western
HPHC, Inc.
HMO Blue
72,954
157,104
55,290
212,720
41,831
6,435
48,528
191,186
103,409
250,871
76,286
402,329
Central
Western
Tufts
Fallon
34,471
159,877
68,961
147,759
60,933
34,290
812
16,840
5,202
4,816
148,477
2,398
Source: DOI Report of Massachusetts Managed Care
Central
3
9
1
5
323
62,713
NE
Central
SE
HPHC, Inc.
74,990
184,288
52,902
137,566
51,959
11,308
NE
Western
HMO Blue
55,396
192,354
111,393
153,049
78,198
117,721
Tufts
56,912
176,715
85,450
109,620
66,269
43,968
Boston
SE
Central
Western
Western
0
Boston
Metro West
Northeast
Southeast
Central
Western
SE
MW
SE
Health NE, Inc.
MW
NE
200,000
W
NE
MW
NE
SE
SE
Boston
Boston
200,000
Boston
MetroWest
Northeast
Southeast
Central
Western
MW
Boston
NE
NE
0
600,000
Western (W)
Boston
Boston
Metro West (MW)
Northeast (NE)
Southeast (SE)
Central
Western (W)
Boston
Southeast (SE)
Central
MW
600,000
400,000
Metro West (MW)
Northeast (NE)
Central
Fallon
1,715
22,578
8,634
5,168
151,881
2,089
W
Health NE, Inc.
67,388
0
0
0
350
68,575
Source: DOI Report of Massachusetts Managed Care
Page 8
Outpatient, emergency and inpatient utilization all grew during the study period, both in Massachusetts HMOs and nationally.
Massachusetts HMOs use more outpatient and emergency services, and less inpatient services than the national average. Though not
definitive, this pattern suggests that Massachusetts’ greater use of outpatient and emergency care may prevent some use of inpatient care.
Inpatient surgery was the fastest growing category of utilization.
TABLE 2
UTILIZATION PER THOUSAND MEMBERS
(Ambulatory Visits, Inpatient Medicine Discharges, Inpatient Surgery Discharges, ER Visits)
% Change
2000 & 2003
National Avg.
(HMO/POS)
MA average
(HMOs/ POS)
National Avg.
(HMO/POS)
MA average
(HMOs/ POS)
National Avg.
(HMO/POS)
MA average
(HMOs/ POS)
National Avg.
(HMO/POS)
2003
MA Average
(HMOs/ POS)
Emergency Room visits per
thousand
Inpatient Acute Care – Medicine
discharge per thousand
Inpatient Acute Care – Surgery
discharges per thousand
2002
National Avg.
(HMO/POS)
Ambulatory visits per thousand
2001
MA average
(HMOs/ POS)
2000
3825.23
3191.75
3831.16
3383.41
3974.69
3520.16
4052.48
3540.88
6%
11%
170.81
164.25
184.17
176.88
194.1
182.56
203.42
181.25
19%
10%
20.87
22.97
21.47
24.31
21.82
23.65
22.15
24.32
6%
6%
13.37
16.22
15.08
17.16
15.55
18.88
17.42
19.08
30%
18%
Source: Quality Compass 2001, V2; Quality Compass 2002, 2003 and 2004
Definitions and Explanatory Notes
NCQA established the Health Plan Employer and Data Information Set (HEDIS) to measure key aspects of the performance of health
plans and it collects these measures from a large set of health plans that agree to make their results public. They are published in
NCQA’s Quality Compass.
Page 9
The following table shows the percentage of respondents to a national standardized survey that rated their experience with their health
plan positively. Massachusetts HMOs had higher rates of satisfaction than national HMOs in all years. Rates of satisfaction peaked in
2001 for both Massachusetts and national HMOs. However, national HMOs held steady at that level, while satisfaction with
Massachusetts HMOs fell somewhat.
TABLE 3
CAHPS HEALTH PLAN RATINGS FOR
PARTICIPATING MASSACHUSETTS AND NATIONAL HMO’S
% Change
2000 & 2003
National Avg.
(HMO/POS)
MA average
(HMOs/ POS)
National Avg.
(HMO/POS)
MA average
(HMOs/ POS)
National Avg.
(HMO/POS)
MA average
(HMOs/ POS)
National Avg.
(HMO/POS)
2003
MA average
(HMOs/ POS)
2002
National Avg.
(HMO/POS)
Percentage Rating Health Plan
8, 9, or 10
2001
MA average
(HMOs/ POS)
2000
67%
59%
68%
62%
65.57%
61.3%
64%
61.8%
-4%
5%
Source: Quality Compass 2001, V2; Quality Compass 2002
Table 3 - Definitions and Explanatory Notes
HEDIS includes data from CAHPS, the Consumer Assessment of Health Plans, a consumer survey for health plan members. Members
rate their health plans positively on a scale of 0 to 10, with 10 being the best plan possible.
Page 10
“An Act Relative to Mental Health Benefits”, commonly
known as the Mental Health Parity Law provided that,
beginning in 2001, health plans must apply the same annual
or lifetime limits as they use for physical conditions to the
diagnosis and treatment of biologically-based mental
illnesses, and establishes a minimum benefit for other
mental and substance use disorders.
2. Regulatory Changes
During the analysis period, significant regulatory changes in
Massachusetts enhanced the benefits of health plan members
and their rights to recourse if their benefits are not provided,
and the rights of providers to timely payment. Together,
they reduced the differences between health plans and
constrained the types of choices health plans can make in
designing benefits and managing them.
The Health Insurance Portability and Accountability Act of
1996 (HIPAA) met several key implementation dates during
the analysis period of this assessment. In 2002, billing and
payment systems of providers and payers had to conform to
the electronic transaction and code set developed to move
toward industry standardization. In 2003, health care
providers had to comply with new privacy and
confidentiality regulations, some of which required them to
develop new processes for maintaining and sharing health
care information.
“An Act Relative to Managed Care Practices in the
Insurance Industry”, which became effective on January 1,
2001. This law:
•
•
•
•
•
•
•
Established a more liberal definition of emergency care;
Required that claims be paid or denied within 45 days
and for interest to be paid on any period exceeding 45
days (this provision became effective in mid-2000);
Limited the types of risks that physicians can accept in
their contracts with a managed care plan;
Established several processes for reconsideration,
grievance and appeal of denials of service;
Established the Office of Patient Protection, which
provides external review and binding decisions;
Required that health plans allow standing referrals for
people with chronic illnesses; and
Required plans to provide interpretation or translation
services for administrative procedures.
“An Act Providing that Certain Health Care Plans and
Policies Shall Cover Payment for Costs Arising from Speech,
Hearing and Language Disorders” required Massachusetts
managed care plans to cover all medically necessary services
to treat these disorders as of April 2001.
D.
CONCLUSION
Nationally, this four-year period was one of continued
health care cost increases resulting in premium increases,
which were increasingly shared by members. An increasing
emphasis on measuring health care quality accompanied
these inflationary pressures. During this period,
Massachusetts HMOs saw enrollment decline and overall
utilization of HMO members increase, with relatively
greater use of outpatient and emergency services. Members
experienced favorable but slightly declining rates of
satisfaction while regulatory changes gave them and their
providers more rights with respect to their care. Overall,
plans ended the period with less ability to vary their benefits
in ways that would differentiate them.
Page 11
IV.
ACCESS TO SERVICES
A.
INTRODUCTION
A number of aspects of managed care operations determine access to
care. First, is the ability to enroll in a health plan. This can be
affected by a number of dimensions of the health plan’s perceived
value, including the price of the plan relative to its benefits, network
of providers affiliated with the plan (most importantly, whether
current providers are included), and the reputation of the plan for
authorizing services. Once enrolled in a health plan, access will
depend on the location and availability of a primary care physician
and other needed specialty care. Finally, if needed providers are
available, certain services must be authorized by the health plan as
medically necessary.
This Chapter will analyze how these
dimensions of managed care operations have affected HPHC
enrollment overall. In addition, we will discuss HPHC’s provider
network, its overall utilization management processes, and present
data on utilization rates for outpatient and inpatient care.
HPHC offers several types of plans for its members. The major types
of plans that HPHC offers include large group plans for groups with
at least 50 members enrolled; small group plans for less than 50
members; Non-Group plans for individuals who are not affiliated
with any group and wish to purchase health plan coverage; and
Medicare Risk plans and Medicare cost plans for Medicare eligible
individuals who wish to participate in a managed care plan for their
Medicare benefits. Methods for setting prices, premiums, eligibility,
and benefits all differ between these types of plans. We will discuss
each in turn.
B.
LARGE AND SMALL GROUP PLANS
1. Benefits
HMO benefits can be summarized, in general, by the scope
of services and the size of any co-pay fee for which the
member is responsible. The most commonly offered plans
during the analysis period had either $5 or $10 dollar copays for office visits. During the four-year period, the entire
industry went to three-tier pharmacy plans and increased
the top co-pay, while adjusting their mental health benefits
in similar ways to comply with the provisions of the new
parity law. Many plans also increased their emergency copays. Few plans changed their inpatient and outpatient
surgery co-pays. Three of five plans experienced decreased
enrollment in their largest $5 co-pay plans, while three
experienced increases in their $10 co-pay plans, suggesting a
possible move toward higher co-pays with lower premium
costs. In 2000, only two companies, Tufts and Blue Cross,
had significant enrollment in a plan with a $15 co-pay for
office visits. Both plans have co-pays for inpatient care and
ambulatory surgery. However, in 2003, both HPHC and
Health NE had $15 co-pay plans with at least 5% of their
total enrollment. Tufts also had a plan with a $25 co-pay, no
pharmacy coverage and $600 co-pays for inpatient and
ambulatory surgery.
The relatively small differences between HPHC’s plans and
the other large HMOs had diminished by 2003 as plans
responded to the parity law and implemented 3 tier
pharmacy. In 2000, HPHC’s $5 co-pay plans were similar to
other $5 co-pay plans, though with slightly higher co-pays
than some.
Page 12
Its $10 co-pay plans were somewhat more generous than other $10 co-pay plans, particularly with regard to co-payments for emergency
and mental health visits. In 2004, by keeping its pharmacy co-pays the same, HPHC’s third tier pharmacy co-pays were lower than other
$5 co-pay plans, but its emergency co-pays were higher than 3 of the other $5 co-pay plans. HPHC’s $10 co-pay plans were very much the
same on most dimensions as the other $10 co-pay plans. In 2003, HPHC’s enrollment in its top $5 co-pay plans dropped considerably and
its enrollment in its $10 co-pay options increased somewhat, as it did for several of the other plans.
TABLE 4
BENEFIT PLANS FOR MASSACHUSETTS HMOS IN 2000 AND 2003
Emergency
Co.
2000
2003
Office Visit Co–Pay $5
HPHC
$30
$50
Prescription
2000
2003
$5 / $10
$25
$5 / $10
Fallon
$25
No change
Cigna
$35
No change
Health
NE
BCBS
$30
$50
$25
No change
$7 / $15
$25
$5 / $10
$25
$5 / $10
Some $30,
Most $50
$5/ $10
$25
Office Visit Co-Pay $10
HPHC
$30
Fallon
Tufts
Cigna
Health
NE
Source:
No
change
$5 / $15
$35
$5 / $15
$35
$10/$20
$35
$10/$20
$35
Outpatient MH
2000
2003
Inpatient
2000
$5 visits 1-8
$25 visits 9-20
$10
$5 for 25
visits
$5
None
$5 visits 1-8
50% visits 9-20
$10/$20
No change
None
$5 for 20
visits
$5 to 24
visits
None
$10 to 25
visits
None or $50 per
day to max of
$250
N/A
$5 visits 1-10
$15 visits 11-20
$5-10
$10 visits 1-8
$10-20
$25 visits 9-20
$25-35
N/A
$50
N/A
$5 / $15
N/A
$25
$50
No change
$5 / $10
$5 / $10
$10 visits 1-8
$25
$25-30
50% visits 9-20
$35 or
$35
$7 / $15
$5-7
$10 visits 1-8
$50
$25
$15-20
50% visits 9-20
$30-35
$10/$20
$7-10
$30 or
$50
$5 $7
$15-20
$50
$10 $15
$30-35
$25 $30
Rate Filings, Division of Insurance, Quarters 1-4, 2000 and Quarters 1 and 4, 2003
$10
$10 to 24
visits
No change
$10 to 20
visits
None
None
None
None or $500
None or $250
Outpt. Surgery
2000
2003
% Total Avg. Members.
2000
2003
No
change
No
change
No
change
No
change
No
change
None
No
change
No
change
No
change
No
change
No
change
Sm: 10%
Lg: 36%
Sm: 2%
Lg: 4%
Sm: 1%
Lg: 5%
Sm: 18%
Lg: 48%
Sm: 13%
Lg: 44%
Sm: 5%
Lg: 5%
Sm: 0.4%
Lg: 1%
Sm: 9%
Lg. 31%
Sm: 6%
Lg: none
Sm: 11%
Lg: 63%
None
None
No
change
Sm: 5%
Lg: 16%
Sm: 6%
Lg: 24%
None
N/A
None
N/A
No
change
None or
$250
None
No
change
No
change
Sm: 19%
Lg: 62%
Sm: 1%
Lg: 3%
Sm: 1%
Lg: none
Sm: 10%
Lg: 43%
Sm: 31%
Lg: 45%
None,
$250 or
$500
Sm: 12%
Lg: 21%
Sm: 9%
Lg: 26%
2003
None,
$250 or
$500
None
None
None
None
None or
$250
None or
$250
All Massachusetts HMOs are required to file a summary of the benefits and rates of their three largest small group and large group plans with the Division of Insurance on
a quarterly basis. In 2000, plans with $5 co-pays for office visits constituted about two thirds of the enrollment in the three largest small groups and the three largest large
groups.
Page 13
2. Rate Setting
In 2000, HPHC initiated changes in its rate setting
procedures to make the pricing of historically Harvard and
Pilgrim accounts consistent, to more adequately account for
actual costs, to use a county-based rating system consistent
with industry practice, and to reflect broker commissions.
Some groups experienced decreased rates, but more,
especially smaller, companies experienced steep increases.
3. Analysis of Rates for Three Most Populated Plans
We analyzed the rates of the most populated plans included
in the prior Table 4. The prices analyzed are fairly
representative for HPHC and Health NE, applying to 40% of
their members in 2003. They are more representative for
Blue Cross/Blue Shield, Tufts and Cigna, in which the
analyzed prices apply to 53% or more of their average
annual members. They are not necessarily representative for
Fallon, for which the analyzed prices apply to only about 4%
of their average annual enrollment.
exceeded the highest average rate of the other plans’ by at
least 8% and the lowest average rates by as much as 70%, a
peak difference reached in 2002. HPHC’s average $10 copay plan for small groups showed the same pattern, but
differences ranged from a low of 7% to a high of 27%,
reached in 2001. However, in 2003, HPHC’s small group
plans no longer had the highest average rates and other
plans averages were much closer. HPHC’s large plan
averages also exceeded all other plans’ averages in 2000 and
2001, but by smaller margins - at least 5% and as much as
31%. In 2002, HPHC’s $5 co-pay large plans fell within the
range of other plans and in 2003; its $10 co-pay plan did so
as well.
The differential between HPHC and other plans which
existed through much of the period may have influenced the
decrease observed in enrollment in the three largest small
group plans and the increase in large group plans within
HPHC, as well as HPHC’s overall drop in enrollment.
As shown in the charts that follow, in 2000, though its
benefit plan was similar, the average premium rates for
HPHC’s three most populated plans exceeded those of other
plans. HPHC’s average small plan rates for the $5 co-pay
Page 14
CHART 3
CHART 4
Average Rates for Most Populated Large
Group Plans with $10 Co-pay and Pharmacy
Average Rates for Most Populated Small
2000
$350
$318
$312
$300
$250
2002
2001
2003
$303
$301
2000
$260
$254
$251
$238
$214
$216
$212
$196
$198
$200
$250
$226
$208
$196
$200
$285
2003
$284
$255
$213
$205
$150
$150
$100
$100
$50
$50
$258
$246
$249
$242
$228
$218
$211
$193
$201
$203
$185
$179
$177
$0
2002
$304
$300
$279
$249
2001
$350
$0
HPHC
Tufts
Cigna
Health NE
Fallon
HPHC
Aetna
Tufts
Cigna*
Health NE
Fallon
Aetna
Source: Rate Filings, Division of Insurance, Quarters 1-4, 2000, 2001, 2002 and 2003
CHART 5
CHART 6
Average Rates for Most Populated Large
Average Rates for Most Populated Small
2000
$350
$318
$312
$300
$250
2002
2001
2003
$303
$301
2000
$214
$260
$216
$212
$198
$200
$254
$251
$238
$196
$196
$208
2002
2003
$304
$300
$285
$284
$279
$249
2001
$350
$250
$226
$200
$255
$228
$205
$213
$193
$177
$150
$150
$100
$100
$50
$50
$249
$242
$211
$179
$258
$246
$218
$201
$203
$185
$0
$0
HPHC
Tufts
Cigna
Health NE
Fallon
Aetna
HPHC
Tufts
Cigna*
Health NE
Fallon
Aetna
Source: Rate Filings, Division of Insurance, Quarters 1-4, 2000, 2001, 2002 and 2003
Page 15
C.
NON-GROUP PLANS
1. Benefits
Non-Group, or individual insurance plans offer an
important option for individuals who are not affiliated with
a group through which they can purchase health insurance.
In the late 1990’s reform of Massachusetts’ Non-Group
insurance laws mandated that HMOs offer a guaranteed
issue plan for individuals who wish to purchase health
coverage that is available to any individual who is willing to
pay the premium. The state specifies a standard set of
benefits and established a rate setting methodology. The
reform also eliminated certain existing individual insurance
plans, which did not conform to the new standards.
The following table shows the mandated benefits for the
standard option and the low option plan that HPHC
initiated in 2001 to replace the individual plans that it was
no longer able to offer. The low option was designed by
HPHC to meet state regulations and keep the premium as
low as possible so that the members of the phased out plans
could continue to afford HPHC coverage. In contrast to the
plans it replaced, the new low option plan had higher copays at all levels and did not cover prescription drugs. As
the chart shows, the only change in the major plan benefits
during the analysis period was to lift limitations on mental
health services for certain conditions in order to comply with
Massachusetts’ parity law.
TABLE 5
HPHC NON-GROUP BENEFIT PLANS
Option
Office Visit
Emergency
Prescription
$15
$50
$20/$25
Annual max
of 50
$25
$100
None
Outpatient MH
Inpatient
Outpatient Surgery
Comments
$300
Added some services, such
as diabetes care, in 2001
Standard Option
2000-2001
2002-2003
$15 visits 1-10
$25 visits 11-20
$500
$15 visits 1-24
$15 visits after 24*
*For parity-related
diagnosis
Low Option
2001
2002 - 2003
$25 visits 1-24
$25 visits 1-24
$25 visits after 24*
$1,000
$1,000
*For parity-related
diagnosis
Source: Schedule of Benefits, The Harvard Pilgrim HMO, KO and 8M, 2000 and 2003.
Both options have a 6-month waiting period for new members in which only emergency services will be covered. The waiting period can be waived if the
applicant has had similar coverage from another health plan and did not experience a break in coverage of 63 days or more.
Page 16
2. Non-Group Rates
HPHC’s individual plan rates were increasingly prescribed by the regulatory requirements of Non-Group reform and HPHC had to raise
rates on its existing plans. Likely as a result of these rate increases, HPHC’s Non-Group plans lost enrollment. Serving smaller groups
further increased HPHC costs.
At the beginning of the period, HPHC rates were considerably lower than other plans particularly for non-elderly members and for
Boston. Rates rose considerably over the 4-year period 30% to 40% for HMOs other than HPHC, and 64% to 75% for HPHC. These
increases brought HPHC close to those of the other HMOs, though non-elderly rates in Boston remained lower than for other HMOs and
elderly rates in Springfield had become considerably higher.
TABLE 6
SAMPLE OF STANDARD NON-GROUP OPTION MONTHLY RATES
HPHC COMPARED TO OTHER MASSACHUSETTS HMOS
Average of
all others
HPHC as %
of average
Average of
all others
HPHC, Inc.
HPHC, Inc.
% Change
2000- 2003
2003
HPHC as %
of average
Average of
all others
HPHC, Inc.
2002
HPHC as %
of average
Average of
all others
HPHC, Inc.
2001
HPHC as %
of average
Average of
all others
HPHC, Inc.
2000
Boston
Single 25
$185
$255
73%
$250
$275
91%
$298
$306
97%
$304
$352
86%
64%
38%
Family
$556
$770
72%
$749
$819
91%
$894
$965
93%
$912
$1,092
81%
64%
42%
63 w/spouse
$742
$906
82%
$999
$973
103%
$1,191
$1,104
108%
$1,216
$1,217
100%
64%
34%
Single 25
$185
$224
83%
$265
$236
112%
$316
$281
113%
$323
$311
104%
75%
39%
Family
$556
$664
84%
$794
$679
117%
$949
$900
105%
$968
$970
96%
74%
46%
63 w/spouse
$742
$788
94%
$1,059
$806
131%
$1,264
$984
128%
$1,290
$1,045
123%
74%
33%
Springfield
Source: Division of Insurance: Massachusetts Nongroup Health Insurance Guaranteed Issue Plan Rates for the period between December 1 and November 30,1999- 2000, 2000-2001, 20012002, 2002-2003 from www.mass.gov/doi/consumer/css-healthplans05-12.html.
Page 17
D.
MEDICARE RISK
1. Benefits and Rates
HPHC offers one Medicare + Choice Plan, called First Seniority available to individuals 65 and over or disabled who receive all Medicare
A and Medicare B benefits and live in those counties where HPHC offers this program. It is available on a Non-Group (individual) basis
and through HPHC groups. In addition to all Medicare A and B covered benefits, it covers preventative, hearing, vision and prescription
services. A limited prescription benefit is available to Non-Group enrollees, and an unlimited prescription benefit is available to group
plans. Rates paid to HPHC for Medicare A and B services are set by the Center for Medicare and Medicaid Services (CMS) by county.
HPHC may also establish an additional premium to cover the benefits that exceed Medicare A and B coverage. HPHC therefore decides
on a county-by-county basis which rates are favorable and in which it will offer a plan.
Most of the major First Seniority benefits stayed the same over the analysis period. However, the physician visit co-pay jumped from $5
to $15 in 2003, premiums grew substantially, pharmacy co-pays grew, the maximum pharmacy benefit dropped, and the plan was offered
in fewer counties.
E.
MEDICARE COST
1. Benefits
HPHC has offered several other
small plans to certain groups with
members that carried Medicare A
and B. One was an indemnity
plan available with or without
drug coverage.
We did not
analyze data from indemnity
plans, which operate under a
separate license, for this report.
In 2000, the others were HMO
plans offered only in certain parts
of Southeastern Massachusetts
and included drug coverage.
These plans, Enhanced 65 and
Preferred 65, utilize the overall
HPHC network to provide
TABLE 7
HPHC FIRST SENIORITY BENEFIT PLAN
Benefits remaining constant between 2000 and 2003
Emergency
Outpatient MH
Inpatient
$50
$5 visits 1- 8
None for acute.
$25 visits 9 -20
Up to 90 days for
50% of any more visits
rehab or long-term.
Benefit/price changes
Year
Office Visit
Prescription
2000
$5
$5/$10/$25 or by mail $8/$15/$75
Max annual benefit $800
2001
$5
2002
$5
2003
$15
$5/$10/$25 or by mail $8/$15/$75
Max annual benefit $600
$8/$10 or by mail $8/$15
Max quarterly benefit $130
$10/$20/$35 or by mail $20/$40/$105
Max quarterly benefit $150
Skilled Nursing
Max of 100 days
per benefit
period
Outpatient Surgery
None
Monthly Premium
$0 - Essex, Middlesex, Suffolk, Norfolk
$30 - Plymouth, Worcester
$50 - Bristol, Barnstable
$35
Essex, Middlesex, Suffolk, Norfolk
$60
$120
Source: HPHC First Seniority Summary of Benefits, January 1, 2000- December 31, 2000, 2001, 2002 and 2003.
Page 18
services. They are not restricted to the First Seniority
Medicare Network. Data on the members in these plans are
included in the commercial category for this report.
Utilization data and enrollment were reported with HPHC’s
commercial population, rather than with its Medicare Risk
population. The corporate home of these plans changed
several times during the assessment period, and Enhanced
65 was moved to HPHC’s indemnity license. In 2003, they
were both phased out and a new plan, Medicare Enhanced,
was offered in their place under the indemnity license.
The benefits of these plans “wraparound” the benefits of
Medicare Part A and Part B, administered directly by
Medicare. HPHC’s policy pays most Medicare deductibles
and offers additional coverage after the Medicare maximum
has been reached, for example, for hospital stays. They do
have $5 or $10 co-pays for outpatient visits and for certain
other services. Enhanced and Preferred 65 benefits changed
little between 2000 and 2002.
outpatient mental health and substance abuse care, cardiac
rehabilitation and diabetes treatment, and reduced the
annual mental health inpatient benefit limit from 120 to 60
days and the annual substance abuse benefit from 60 to 30
days for conditions other than those considered biologically
based or rape related. Another somewhat more restricted
version of Medicare Enhanced had a higher emergency room
co-pay and excluded services in rehabilitation hospitals and
dental surgery.
2. Rates
As shown in the table below, HPHC’s Medicare Cost plans
experienced considerable rate increases during the first three
years of the assessment period, but the new Medicare
Enhanced plan was priced at a level which appeared to
contain the rate increase, even though its benefits had not
been dramatically reduced from those of the plans it
replaced.
They were increased somewhat in 2001 to comply with new
mental health parity and speech therapy regulatory
requirements. However, certain Enhanced 65 benefits were
slightly reduced by decreasing maximum reimbursements
for specified services.
In comparison to Enhanced and Preferred 65 plans, which
preceded it, the benefits of Medicare Enhanced were
substantially similar, though somewhat less generous. Its
benefits were most similar to those of Medicare Preferred 65.
Like that plan, Medicare Enhanced had $5 co-pays for office
visits and offered the same coverage of hospital and nursing
home care. It was more generous in removing limits on
provision of private duty nursing in hospitals and on
physical and occupational therapy, dropping the co-pay for
dialysis visits, and covering deductibles and coinsurance for
blood transfusions. However, it added co-payments for
TABLE 8
HPHC MEDICARE COST PLAN PREMIUMS
2000
2001
2002
Quarter 4
2003
Average Quarterly Rate
Enhanced
Preferred
65
65
$ 238.05
$ 216.16
$ 315.50
$ 278.37
$ 347.31
$ 338.66
Medicare Enhanced
$ 355.00
% Annual Increase
from Prior Year
Enhanced
Preferred
65
65
33%
10%
29%
22%
2%
5%
Source: Correspondence from HPHC by Fax 12/19/02 and by email 3/15/06.
Page 19
F.
ENROLLMENT
1. HPHC Enrollment by Plan Type
During the baseline year, HPHC lost considerable
enrollment; during the receivership period it could not sell
new business, and the uncertainty caused some groups to
look elsewhere for HMO coverage. HPHC indicates that it
lost healthier groups among the small group market (where
it cannot set lower rates for those relatively healthy groups
with lower levels of service utilization as it can for larger
groups). Among the large groups, it lost those with higher
rate increases. In addition, HPHC made a series of changes
in its small Medicare Cost program which moved part, and
then all, of its enrollment from its HMO license to its
indemnity license. Since most of the enrollment tables in
this section are drawn from reports required only for HMO
plans, our enrollment counts for this group are not truly
comparable across years.
As seen in Table 9, HPHC’s enrollment fell sharply between
2000 and 2001 in all plan types and continued to fall between
2001 and 2002. During 2003, the reversal of this pattern was
seen, with growth in group and individual plans that offset
continued declines in Medicare enrollment. At the end of
the period enrollment remained 26% below 2000 levels, with
the sharpest drop in individual, which dropped by almost
half. HPHC’s individual enrollment trends contrast with the
overall state, whose individual enrollment increased by
about 20%. While about half of HPHC’s overall decline was
comparable to state-wide declines in managed care
enrollment, it is clear that HPHC’s Massachusetts enrollment
decreased disproportionately.
The apparent decrease in HPHC’s Medicare Cost enrollment
was an artifact of reporting changes that moved HPHC’s
Enhanced 65 Medicare Cost enrollment to its indemnity
license, which was not included in its reports to the Division
of Insurance.
HPHC’s replacement plan, Medicare
Enhanced, was also under HPHC’s indemnity license. Thus,
the following table’s 2002 and 2003 counts include only its
Preferred 65 Plan, which was phased out in 2003. In 2002, at
year end, Preferred and Enhanced 65 had a combined
enrollment of 5,018. At the end of the following year, the
replacement plan had an enrollment of 4,473, approximately
10% lower. Even with the 10% drop, HPHC ended the
period with more than double the Medicare cost enrollment
it had in 2000, exceeding the state average growth of 20%.
Page 20
TABLE 9
HPHC
TOTAL MASSACHUSETTS AND MAINE ENROLLMENT BY PLAN TYPE AND COMPANY
Plan Type
Average Members in 2000
HPHC
Groups
Pilgrim
Average Members in 2001
Total
HPHC
Pilgrim
Total
Avg. Members
in 2002
HPHC
Avg. Members
in 2003
HPHC
% Change
between
2000-2003
711,174
56
711,230
536,639
16
536,655
482,062
537,258
-24%
Medicare Risk
55,523
0
55,523
39,261
0
39,261
39,352
35,542
-36%
Medicare Cost
0
1,436
1,436
0
1,249
1,249
1,083
446**
-69%
16,231
0
16,231
11,467
0
11,467
8,336
8,597
-47%
Other
0
294
294
0
101
101
21
8
-97%
Total
782,928
1,786
784,714
587,367
1,365
588,732
530,854*
581,850*
-26%
Individual
Source: MA Division of Insurance, NAIC Quarterly Report for Quarter 4, for HPHC, Inc.: 2000, 2001, 2002; for Pilgrim Healthcare: 2000,2001; for HPHC, New England: 2002.
MA Division of Insurance HMO Supplemental Report for HPHC, Inc. and HPHC New England: 2003 Year End.
* Excludes Enhanced 65 and Medicare Enhanced Enrollees.
In 2000, HPHC, Inc. enrolled Massachusetts and a small number of Maine residents into two of its licensed HMOs, Harvard Pilgrim Health Care,
Inc. ("HPHC") and Pilgrim Health Care, Inc. For the purposes of this report, we are disregarding Massachusetts residents who may be enrolled in
an HPHC plan in a neighboring state. However, enrollment quoted for Massachusetts HPHC plans may include non-Massachusetts residents
enrolled in a Massachusetts- based plan. Some HPHC reports primarily for Massachusetts also include a small number of Maine enrollees, which
could not be readily separated. HPHC wrote the bulk of the group coverage, all of the Medicare Risk coverage and all of the Non-Group coverage.
Pilgrim Healthcare is much smaller, and wrote primarily Medicare cost coverage, with a small percentage of group and all of the other coverage. In
2000, Maine enrollees accounted for about 10% of Group enrollment, 18% of Medicare Cost enrollment, 2% of Non-Group enrollment, and less than
1% of Medicare Risk enrollment. In 2001, Maine’s share of group enrollment fell to 7%. As of January 1, 2002, Pilgrim Health Care was eliminated
and its members were rolled into a new organization, HPHC of New England except for Medicare Cost enrollees, in the Enhanced 65 Plan, who
were moved to HPHC’s indemnity license and no longer included on the managed care reports to the Division of Insurance. As of June 2003,
HPHC New England wrote only New Hampshire Groups and all Medicare Cost enrollees were moved to a new plan, Medicare Enhanced under
HPHC’s indemnity license, which is not included in these reports. In 2002 and 2003, HPHC continued to have about 7% of its enrollment out-ofstate.
Page 21
Table 10 shows how HPHC’s enrollment changes compared to those of other Massachusetts HMOs. In this period, all Massachusetts
HMOs consisted predominantly of group plans, with HPHC having slightly higher group enrollment than all HMOs. Total HMOs held a
steady share of Medicare Risk enrollees at about 8.5% until 2003, when the percentage dropped by half to 4.4%, while HPHC maintained a
6% to 7% share. HPHC had a lower than average share of Medicare cost members, and dropped even lower in 2003, while other HMOs
had a steady 0.4% share. However, these figures exclude HPHC Medicare Cost members counted under its indemnity license. Its overall
enrollment more than doubled making it similar to other large HMOs. HPHC served a higher percentage of Non-Group enrollees than
the other HMOs, but its percentage dropped more steeply than other HMOs, diminishing the difference between them.
TABLE 10
AVERAGE ENROLLMENT BY TYPE OF PLAN IN LARGE MA HMOS
HPHC
2000
Groups
2001
Large MA HMOs
2002
2003
2000
2001
2002
2003
90.6%
91.2%
91.3%
92.3%
89.8%
89.8%
89.5%
94.1%
Medicare Risk
7.1%
6.7%
7.0%
6.1%
8.5%
8.5%
8.7%
4.4%
Medicare Cost
0.2%
0.2%
0.2%*
0.1%*
0.4%
0.4%
0.5%
0.4%
Non-Group
2.1%
1.9%
1.4%
1.5%
1.3%
1.2%
1.3%
1.1%
* Excludes Enhanced 65 and Medicare Enhanced members.
Source: NAIC 2000, 2001, 2002 Quarterly Reports and 2003 Supplemental Utilization Report filed by MA HMOs to MA Division of
Insurance. Includes out of state and IPP members.
Page 22
2. HPHC Enrollment by Region
In 2000, HPHC’s enrollment was centered in and around Boston and the Southeast, with about 8% enrollment in the Northeast and
another 8% in Central Mass and 2% enrollment in Western Mass. All regions lost membership between 2000 and 2003, but more members
were lost in the Western and Central parts of the state than in HPHC’s core areas. Boston, the Northeast, the Southeast, and Central
regions reversed the declining trend in 2003, experiencing small rebounds.
CHART 7
HPHC TOTAL AVERAGE ENROLLMENT BY REGION
2000
2001
2002
2003
275,000
250,000
225,000
200,000
175,000
150,000
125,000
100,000
75,000
50,000
25,000
0
Boston
Metro West
Northeast
Southeast
Central
Western
Note: Excludes IPP enrollment, except in FY2003, when Medicare Cost enrollees were reported in this category.
Includes only Medicare Cost enrollees of HPHC NE in FY 2002 and 2003.
Source: DOI Quarterly Reports for 2000,2001, 2002 Membership and Supplemental Utilization Report, 2003.
Page 23
3. Changes in Medicare Risk Enrollment
Some data is available about the reasons members left HPHC’s Medicare Risk plans. As shown in Table 11, during the first two years of
the period HPHC’s Medicare Risk plans experienced a higher rate of voluntary disenrollment than either Massachusetts or the nation, and
the reasons given were related to health care and services to a greater degree than in other Massachusetts or national Medicare plans.
HPHC’s rate of leaving decreased considerably in the last two years of the period, while that for Massachusetts increased and the national
rate remained fairly stable. In the last two years, HPHC’s leave rate fell close to and then below the national and below Massachusetts’
rates. All rates fell in the final year of the period. In the first three years, HPHC leavers were responding to health care or service
concerns more than to costs and benefits. In the final year, leavers were equally motivated by service and cost concerns.
TABLE 11
MOST IMPORTANT REASONS WHY MEMBERS CHOSE TO LEAVE MEDICARE MANAGED CARE PLANS
HPHC COMPARED TO STATE AND NATIONAL AVERAGES
HPHC
MA
Average
National
Average
HPHC
MA
Average
National
Average
HPHC
MA
Average
National
Average
2003
National
Average
2002
MA
Average
2001
HPHC
2000
Total percentage
15%
9%
11%
14%
n/a
11%
11%
18%
10%
4%
6%
8%
Left because of costs and benefits
2%
3%
6%
4%
n/a
6%
2%
6%
5%
2%
3%
4%
Left because of health care or services
13%
6%
5%
10%
n/a
5%
9%
12%
5%
2%
3%
4%
Source: Medicare Quality Compare, medicare.gov
The Center for Medicare and Medicaid services collects information on the reasons why Medicare eligibles chose to leave a specific
Medicare+ Choice plan.
Page 24
4. Changes in Non-Group Enrollment
Table 12 shows how HPHC’s NonTABLE 12
Group plans changed.
HPHC’s
HPHC TOTAL NON-GROUP ENROLLMENT
standard option plan dropped by
Total Members
% Change
almost half, almost as much as the
overall
drop
in
Non-Group
Dec. 2000
Dec. 2001
Dec. 2002
Dec. 2003
2000-2003
Plan Type
Dec. 1999
enrollment. When the legacy plan
HPHC Legacy
8,717
6,589
n/a
n/a
n/a
n/a
was eliminated, the alternative low
Standard Plan
9,367
7,478
7,241
5,401
5,372
-43%
option plan enrolled only about a
third of the number disenrolled.
Low Option Plan
n/a
n/a
2,333
2,727
3,621
n/a
These changes suggest that NonTotal
18,084
14,067
9,574
8,128
8,993
-50%
Group enrollees were sensitive to
the rate increases these changes
Source: Harvard Pilgrim Health Care, Inc "Guaranteed Issue Non-Group Membership Report” and DOI Non-Group Membership
entailed. Enrollment in the low
Report as of 12/31/2003.
option plan grew over time, but not
sufficiently to offset standard plan enrollment declines. In Massachusetts as a whole, Non-Group enrollment increased 18% from 2000
levels, indicating that HPHC has not maintained its share of Non-Group enrollment over this period, despite having lower than average
rates for many categories during 2003.
5. Case Mix in Commercial Plans
The changes experienced in HPHC’s enrollment between 2000 and 2003 resulted in a change in HPHC’s case mix as indicated by the
age/sex factors they used for planning and budgeting purposes. This method categorizes all enrollees into 14 age ranges and the two
genders. While there was little overall change in commercial enrollment in the first two years, by the fourth year, there was a considerable
change in broad age categories. The share of enrollees over 45 increased by almost 5% for males and almost 4% for females. The age
categories showing highest growth were over 65, which grew by over 20%, and 55 to 64, which grew by over 10%. No other 5-year age
groups showed more than a 4% increase, and many showed decreases. Given the greater health care needs of older people, this change
signifies the likelihood of a higher need case mix and would likely be reflected in somewhat higher rates. While the dynamics that created
this change in age mix may have also affected case mix in ways not accounted for by the age/gender classifications available for this
analysis, all other things being equal, these changes suggest that HPHC did not set its rates, market its plans, or make other public
changes in such a way as to discourage enrollment of potential members with high levels of medical need more than those with moderate
or low levels of need.
Page 25
G.
PROVIDER NETWORK FOR COMMERCIAL PLANS
This section analyzes the extent and adequacy of HPHC’s provider network, as well as a number of aspects of HPHC’s relationship with
its providers that can affect its ability to attract and retain providers. There were some changes in the ways that HPHC shared risk with
and paid providers that may have affected their willingness to participate in HPHC’s network. Beginning in 2000, HPHC reduced the risk
carried by some of its physician groups and hospitals and negotiated longer-term agreements with some provider groups. In 2002, HPHC
introduced Medicare Risk Value Based Rates (RVBS) in physician payment.
TABLE 13
HPHC PRIMARY CARE PHYSICIANS PER 1,000 MEMBERS BY REGION
1. HPHC Network
HPHC had a total of 84 hospitals in its network
in 2000, of which five were psychiatric only
and seven were rehabilitation hospitals. The
network included many of the most
recognizable hospital names in the state and
also the two hospitals most known for serving
underserved and uninsured populations, the
Boston Medical Center and Cambridge
Hospital. The network changed little in the
four years. By the end of the period, three
small hospitals were no longer in HPHC’s
network.
2000
2001
2003
PCP
Offices
Offices Per
thousand
PCP
Offices
Offices Per
thousand
PCP
Offices
Offices Per
thousand
Boston
1,110
15
1,102
18
1,162
21
Metro West
1,011
6
950
7
1,053
8
North East
561
11
543
13
591
14
South East
1,457
6
1,408
7
1,408
7
Central
491
9
489
12
531
15
West
452
31
444
55
548
79
Region
Grand Total
5,082
7
4,936
7
5,293
12
Table 13 shows that HPHC’s primary care
network increased from 2000 to 2003 by 4%,
Source: HPHC Physician Directory, Volume 2 2000, Volume 2, 2001, Fall 2003.
but because of a lower level of enrollment, this
resulted in a more than 50% increase in PCP
offices per thousand members. In 2001, the
numbers of PCP offices had dropped, but had
HPHC directories list the number of physician’s offices. Since some physicians maintain more
remained in proportion to enrollment. The
than one office, the number of physicians is somewhat smaller. The ratio between physicians
and members is not an absolute indicator of access, since it does not account for the available
smallest changes were seen in the Northeast
unused capacity in the doctor’s practice. In addition, when a member leaves an HMO, she does
and Southeast, where the PCP offices per
not necessarily leave her PCP’s practice if she is able to see him in the network of another
thousand increased only slightly. MetroWest’s
insurer.
proximity to Boston likely allows some
members to take advantage of the increase in Boston offices. The West showed a considerable increase in its already high rates per
thousand.
Page 26
Table 14 shows that HPHC experienced a 20% increase in the offices in its specialty network, almost doubling the number of specialist
offices per thousand members, between 2000 and 2003. Though the number of specialist offices dropped in 2001, the rate of specialist
offices per thousand members did not drop in most regions. As for primary care, the Southeast region has the smallest specialty network
per enrollee, while Boston and the West have the highest rates.
TABLE 14
HPHC SPECIALISTS PER 1,000 MEMBERS BY REGION
2000
2001
2003
PCP
Offices
Offices Per
thousand
PCP
Offices
Offices Per
thousand
PCP
Offices
Offices Per
thousand
Boston
3,319
45
2,780
45
3,924
72
Metro West
1,646
9
1,276
9
1,974
16
North East
916
17
692
16
1,045
25
South East
1,980
8
1,884
9
2,484
13
Region
Central
816
15
706
18
1,020
28
West
788
54
642
80
878
126
9,465
13
7,980
11
11,333
25
Grand Total
Source: HPHC Physician Directory, Volume 2 2000, Volume 2, 2001, Fall 2003.
In the 2000 directory, physical therapists, as well as some other non-physician services, like
optometry, were included but practitioners such as these were only rarely listed in the 2001.
This indicates that the directory is not strictly limited to specialty physicians, and that the
criteria for inclusion in the listing may have been changed between 2000 and 2001.
One HPHC member living in Berkshire County who was solicited as part of a survey of members with special health care needs reported
great difficulty in finding providers that would accept HPHC because of problems getting paid. Many of her providers had left the
HPHC network. It is possible that HPHC’s smaller enrollment limits its market leverage in the Western part of the state, leaving it with a
smaller provider network that is not necessarily able to meet all the needs of HPHC members who have more complicated health care
needs.
Page 27
Despite this degree of change between years in the directory listings, HPHC turnover rates for primary care practitioners reported to
HEDIS showed relatively low rates. HPHC’s primary care turnover between December 31, 1999 and the same date in 2000 was 4.46%,
the second lowest rate in the state, and well below the Massachusetts average of 6.49% and the national average of 10.01%. It was even
lower at 2.65% on 2003, the lowest in the state and well below the state average of 4.8% and the national average of 6.5%.
In contrast, HPHC’s physician termination rates reported to DPH’s Office of Patient Protection was on the high side in 2001. HPHC’s rate
at which physicians terminated contracts was the second highest rate following Blue Cross, as seen in Table 15. Thereafter, HPHC’s rates
fell, while some HMOs experienced increased rates. In 2003, HPHC had a much lower rate than in 2001 and was second lowest among
those analyzed. The most frequent reasons for termination were similar for all the companies, including relocation, retirement, and
leaving a participating provider group. Another common reason was non-compliance with recredentialing. However, plans differed as
to whether they reported this as a voluntary or involuntary termination, possibly explaining some of the variation in involuntary
termination rates.
TABLE 15
PHYSICIAN CONTRACT TERMINATION RATES FROM MASSACHUSETTS HMOS
Insurance Providers
AETNA Life Insurance Company – Medical
Blue Cross & Blue Shield of Massachusetts
CIGNA Health Care of Massachusetts
Fallon Community Health Plan
2001
% of Physicians
Voluntarily Terminating
0.07%
HMO Blue: 6.2%
2.64%
N/A in 2001
Harvard Pilgrim Health Care, Inc.
5.7%
Health New England
4.0%
Tufts Associated Health Maintenance Organization
5.3%
2002
% of Physicians
Terminating Contracts
Voluntary – 1.7%
Involuntary – 7.3%
Voluntary – 5.4%
Voluntary – 2%
Involuntary – 0%
Voluntary – 7.8%
Voluntary – 4.7%
Voluntary – 6%
Involuntary – 0%
Voluntary – 5.9%
2003
% of Physicians
Terminating Contracts
Voluntary - 1.7%
Involuntary - 14.5%
Voluntary - 6.5%
Not available as percentage
N/A
Voluntary - 5.4%
Voluntary - 2.62%
Involuntary - <1%
Voluntary - 4%
Involuntary - 1%
Voluntary - 5.1%
Source: Years 2001, 2002 and 2003 Annual Reporting Requirements for Massachusetts Health Plans (https://www.mass.gov/dph/opp/data.htm#annual).
Page 28
2. HEDIS Network Measures
This table presents data about the
composition of the HPHC provider
network that is not entirely consistent
with the counts we made from
HPHC’s physician directory in the first
two years of the period. The HEDIS
counts of PCP’s significantly exceed
our counts of PCP offices, and the
HEDIS counts of specialists are fairly
close to our count of offices in 2000,
but exceed them considerably in 2001.
Both counts show relatively stable
numbers of PCPs, but the directory
count shows a much more significant
decrease in specialists between years
than does the HEDIS count.
HEDIS data showed that HPHC’s
network consists of 77% PCPs, 9%
pediatricians, and 14% OB/GYNs, and
changed little in 2001. All but one to
three percent had completed their
residencies in both 2000 and 2001.
However, Compass did not include
these data in 2002 and 2003.
HPHC’s rates of board certification
were sometimes similar to the
Massachusetts average for PCPs and
geriatricians, but were closer to the
lower national average for some
provider groups such as OB/GYNs
and specialists other than geriatricians.
HPHC’s rates of board certification
among pediatricians were the lowest
TABLE 16
HPHC PROVIDER NETWORK COMPOSITION AND QUALIFICATIONS
Number
Percent
of
Subtotal
5,533
77%
98.26%
86.08%
645
9%
97.36%
72.87%
99.00%
HPHC Residency
completion rate
HPHC
Board Certification Rate
MA Avg.
National Avg.
(HMOs/POS)
(HMOs/POS)
As of December 31, 2000
PCPs
Pediatric Practitioners
OB/GYNs
1,002
14%
Subtotal PCPs
7,180
100%
Geriatricians
86.89%
81.08%
81.34%
85.03%
80.31%
197
2%
94.42%
88.32%
89.27%
80.50%
Other Specialists
9,540
98%
97.09%
81.23%
84.07%
81.65%
Subtotal Specialists
9,737
100%
5,787
78%
99.02%
87.30%
87.95%
81.68%
586
8%
97.95%
73.21%
99.42%
80.95%
84.07%
79.79%
PCPs
OB/GYNs
1,029
14%
Subtotal PCPs
7,402
100%
Geriatricians
194
2%
96.39%
88.66%
87.6%
78.49%
Other Specialists
8,981
98%
97.84%
81.26%
83.91%
81.5%
9,175
100%
PCPs
-
88.27%
89.38%
82.61%
-
72.94%
76.62%
78.65%
OB/GYNs
-
82.45%
86.09%
80.17%
Subtotal PCPs
-
Geriatricians
-
88.02%
88.71%
78%
Other Specialists
-
81.95%
85.19%
80.98%
83.48%
PCPs
88.41%
90.1%
74.06%
79.87%
79.0%
OB/GYNs
83.45%
86.6%
80.41%
Geriatricians
86.82%
89.27%
76.63%
Other Specialists
81.97%
84.99%
81.45%
Subtotal PCPs
Source: Quality Compass 2001, V2; Quality Compass 2002, 2003, and 2004
Page 29
of all physician types, and actually fell below the national average in 2002 and 2003. Overall, HPHC’s network is less likely to include
board certified physicians than the state average, and is especially low for pediatricians. This is a possible indication of lower quality in
physician services.
In contrast to these figures, HEDIS consumer satisfaction surveys show that HPHC’s provider network excels in satisfying their patients.
Most consumers in all health plans are satisfied with the physicians. HPHC started the period with scores on client satisfaction with their
doctors that were lower than the Massachusetts average and, except for ratings of specialists, also fell below the even lower national
average, which was somewhat lower than the Massachusetts average. However, its satisfaction scores rose rapidly, exceeding both the
Massachusetts and national averages by 2002 and remaining higher in 2003. These results suggest that HPHC physicians are meeting
their patients’ expectations at a very high level.
TABLE 17
CAHPS RATINGS OF HEALTH CARE PROVIDERS
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
2003
National Avg.
(HMO/POS)
2002
MA average
(HMO/ POS)
2001
HPHC
(HMO/POS
combined)
2000
How well doctors communicate
89.28%
91.89%
89.92%
90.21%
92.34%
90.72%
93.63%
92.25%
90.99%
94.72%
92.86%
91.52%
Rating of personal doctor
72.94%
77.06%
74.28%
77.59%
77.40%
74.71%
78.89%
75.75%
75.04
77.58%
76.54%
76.2%
Rating of specialist seen most often
77.15%
78.76%
76.32%
85.48%
80.8%
76.33%
83.7%
78.87%
76.04%
85.77%
78.07%
77.06%
Source: Quality Compass 2001, V2; Quality Compass 2002, 2003, and 2004
“How well doctors communicate” represents the percentage of respondents who answered always or usually to the questions:
In the last 12 months, how often did doctors or other health providers listen carefully to you?
In the last 12 months, how often did doctors or other health providers explain things in a way you could understand?
In the last 12 months, how often did doctors or other health providers show respect for what you had to say?
In the last 12 months, how often did doctors or other health providers spend enough time with you?
Provider ratings indicate the percentage of respondents who rated their provider with an 8, 9 or 10 on a scale where 10 is the best possible.
Page 30
Other aspects of the adequacy of the
provider
network
concern
geographical
accessibility
and
appointment availability. HPHC does
set standards for access and
appointment availability (see Table
18) which are checked as part of its
site visit protocol. HPHC conducts
site visits for all PCPs, OB/GYNs and
high volume behavioral health
practitioners as part of its initial
credentialing process.
However,
ratings on performance against these
standards are not summarized.
TABLE 18
HPHC STANDARDS FOR ACCESS AND APPOINTMENT AVAILABILITY
PCP
Incoming phone calls answered
Specialist
Within 5 rings
Max time on hold before contact with office staff or a voice system
3 minutes
Symptomatic office visit
Within 7 days
Within 14 days
Urgent visit
Within 24 hours
Within 7 days
Emergency coverage
24 hours
N/A
Source: HPHC Policy CC 1.10: Site Visit to Affiliated Practice Sites, p.6
3. Provider Payment
Timeliness and accuracy of payment
may affect providers’ willingness to
join or continue with a particular
managed care plan.
This section
analyzes HPHC’s ability to pay
provider claims in a timely and
accurate manner.
TABLE 19
HPHC CLAIMS AGING BY QUARTER
2000
2001
2002
2003
20 days
30 days
20 days
30 days
20 days
30 days
20 days
30 days
Quarter 1
77.3%
84.0%
91.8%
94.8%
96.0%
97.2%
96.2%
97.5%
Quarter 2
81.5%
88.7%
94.9%
97.3%
97.5%
98.7%
97.1%
97.9%
Given its financial difficulties, HPHC
Quarter 3
86.0%
93.3%
95.8%
97.4%
97.8%
98.7%
96.6%
97.9%
was
experiencing
considerable
Quarter 4
87.4%
93.0%
97.6%
98.5%
97.5%
98.6%
96.6%
98.1%
difficulties in paying its claims on a
timely basis at the time of the
Source: HPHC Claims Aging Report 2000-2003
receivership and – working with its
new claims processor, Perot Systems, focused considerable effort on working with providers and their associations to resolve problems.
Since providers could not terminate their contracts with HPHC during the receivership, HPHC had a window of opportunity to make
improvements. Representatives of provider trade associations commented favorably on the improvements in HPHC’s payment
procedures, noting a dramatic improvement in timely payment. They also commented favorably on its moves toward standardization
and automation, but were less pleased with the rates at which their outstanding claims were settled. Rates remained a significant concern
Page 31
of providers throughout the period, and in 2003, they also expressed concern about what they described as HPHC’s increasing tendency
to unilaterally dictate the terms of provider contracts.
Table 19 confirms the improvement in claims payment over the analysis period from a low of 60% in preceding years. The table shows
consistently increases in the percentage of claims paid within 20 days of receipt and within 30 days of receipt. The final two years of the
period showed Perot consistently paying 96% or more of its bills in 20 days and 97% in 30 days.
4. Provider Satisfaction
Provider satisfaction surveys also show that HPHC succeeded in improving providers’ satisfaction in a number of these administrative
areas. Chart 8 shows that overall provider satisfaction with HPHC’s ability to pay claims has increased substantially with each survey,
achieving a 20% improvement in providers who were very and somewhat satisfied and a drop of almost 15% in levels of dissatisfaction.
The final survey showed that HPHC had largely maintained the gains achieved.
CHART 8
PROVIDER OFFICE SURVEY:
OVERALL, HOW SATISFIED ARE YOU WITH HPHC’S ABILITY TO PAY CLAIMS?
100%
Satisfied (very & somewhat)
90%
70%
82%
78%
80%
Dissatisfied (very & somewhat)
85%
83%
65%
60%
50%
40%
36%
30%
22%
20%
18%
15%
10%
0%
January, 2000
October, 2000
May, 2001
February, 2002
4th Qtr 2003*
* Results through 2002 exclude ‘don’t know’ responses from the denominator of percentage calculations, but the method of
calculation for 2003 is unknown, possibly making it not directly comparable.
Source: Perot Health Services Harvard Pilgrim Health Care: Survey of Provider Satisfaction with Claims Services, May 2001,
Opinion Dynamics Corporation, #5408 and HPHC 2003 Survey of Primary Care, Specialty, Hospital and Ancillary Practice.
Page 32
Providers were also asked to rate HPHC on their claims payment timeliness and accuracy in comparison to other managed care plans (see
Charts 9 and 10). HPHC showed improvement from 2000 to 2001, being rated increasingly as the same or better than other plans. A 2002
survey comparing HPHC specifically to Blue Cross/Blue Shield and Tufts and asking separately about claims timeliness and accuracy
showed HPHC more likely to be rated as least as well as its major competitors and less likely to be rated worse, except for claims
timeliness, where Blue Cross met or exceeded HPHC most of the time.
CHART 9
PROVIDER OFFICE SATISFACTION SURVEY:
COMPARED WITH OTHER MANAGED CARE PLANS YOU SERVE, HOW
CLAIMS SERVICES RATE IN TERMS OF CLAIMS PAYMENT?
DOES HPHC
CHART 10
FEBRUARY 2002 PROVIDER OFFICE SATISFACTION SURVEY:
COMPARED WITH BLUE CROSS/BLUE SHIELD AND TUFTS, HOW DOES
HPHC CLAIMS SERVICES RATE IN TERMS OF CLAIMS PAYMENT
TIMELINESS & ACCURACY?
Better (somewhat + significantly)
About the same
Worse (somewhat + significantly)
70%
48%
41%
40%
72%
57%
60%
50%
70%
70%
60%
30%
About the same
80%
44%
35%
32%
24%
21%
26%
50%
30%
20%
47% 45%
40%
30%
10%
10%
0%
23%
20%
20%
19%
18%
11%
8%
9%
0%
January, 2000
October, 2000
May, 2001
BCBS
Tufts
BCBS
Timeliness
Tufts
Accuracy
Source: Perot Health Services Harvard Pilgrim Health Care: Survey of Provider Satisfaction with Claims Services, May 2001, Opinion Dynamics Corporation, #5408
Page 33
Chart 11 shows that the percentage of claims paid on the first submission by May of 2001. Data on this question were not available for
2002 and 2003. However, in 2002, 74% of provider offices rated HPHC’s claims processing accuracy as good, very good or excellent.
In the first two years of the period, when there were problems with claims, HPHC frequently required a number of contacts to resolve
them. As shown in Chart 12, less than half of claims problems or questions were resolved by talking to just one person in 2000 and 2001.
These data were not available in 2002 and 2003. However, in 2002, 75% of responding provider offices rated HPHC’s same call resolution
as good, very good or excellent. This appeared to be considerably higher than the 40% that spoke to 1 person to resolve a claims issue in
2001.
CHART 11
PROVIDER OFFICE SATISFACTION SURVEY: EXCLUDING THOSE CLAIMS
THAT ARE RETURNED TO YOU FOR ADDITIONAL INFORMATION,
APPROXIMATELY WHAT % OF YOUR HPHC CLAIMS ARE RESUBMITTED
OR APPEALED BEFORE THEY ARE PAID OR DENIED?
CHART 12
PROVIDER OFFICE SATISFACTION SURVEY: HOW
MANY DIFFERENT PEOPLE DO YOU TYPICALLY SPEAK
WITH TO RESOLVE A CLAIM PROBLEM OR QUESTION?
50%
50%
Less than 5%
5 to 25%
26 to 50%
41%
40%
38%
40%
37%
44%
More than 50%
42%
40%
32%
30%
30%
20%
1 person 2 people 3-4 people 5 or more people
40%
36%
31%
28%
23%
19%
25%
23%
24%
20%
15%
14%
10%
8%
10%
5%
0%
10%
10%
9%
6%
0%
January, 2000
October, 2000
May, 2001
January, 2000
October, 2000
May, 2001
Source: Perot Health Services Harvard Pilgrim Health Care: Survey of Provider Satisfaction with Claims Services, May 2001, Opinion Dynamics Corporation, #5408
Page 34
The Table 20 lists typical claims problems or questions that survey respondents encountered in 2000 and 2001, listed in the order of
frequency at the start of the period. Dramatic improvements were seen in reducing incorrect information and numbers problems.
Improvements were also seen in slow payments and unpaid claims, lost claims, slow processing or response, problems with
authorization, and other types of problems. A few types of problems increased in frequency, including problems related to denials and
general authorization problems. Two new types of problems arose in the final survey, problems with electronic claims and incorrect
reimbursement. However, the number of respondents citing no problems increased over the period. These data were not available in
2002 and 2003.
These responses generally suggest a pattern of improvement in claims payment and resolution functions. However, these data also
suggest that there continue to be problems in resolving claims, and perhaps some minor bugs must be worked out in electronic claims
processing. These new results for electronic claims and reimbursement amounts point to the value of using these surveys for quality
improvement. While overall
TABLE 20
satisfaction
with
claims
HPHC TYPICAL CLAIMS PROBLEMS / QUESTIONS*
payment has remained high, in
2002 as seen in Chart 10, ratings
Oct 2000
May 2001
Jan-00
for
timeliness
of
claims
Unweighted
Weighted
Weighted
payment were relatively low
Incorrect information / Number problems
23%
23%
19%
11%
and may continue to be a
relative weakness in this area.
Slow payment / Unpaid claims
19%
14%
12%
13%
H.
Denial of Claim/Denial without explanation
12%
16%
14%
16%
CLINICAL/AUTHORIZATION
POLICIES
Lost claims
11%
5%
3%
5%
Slow processing / Response
9%
10%
9%
5%
An
HMO’s
policies
for
determining how a member
receives
services
are
a
significant
determinant
of
members’ access to care.
Policies include whether a
member’s
physician
can
authorize services or whether
the service request must be
reviewed by HMO clinicians
for approval, the criteria used
to
make
a
review
determination, and the types of
Referral problems (general)
8%
16%
15%
13%
Problems with authorization
6%
4%
4%
2%
Problems with electronic claims
0%
0%
0%
4%
Incorrect reimbursement
0%
0%
0%
3%
Other
8%
5%
6%
3%
None/no others
2%
1%
1%
4%
Don’t Know
0%
0%
10%
10%
* Excludes problems experienced by 2% or fewer of respondents.
Source: Perot Health Services Harvard Pilgrim Health Care: Survey of Provider Satisfaction with Claims Services, May 2001, Opinion
Dynamics Corporation, #5408
Page 35
procedures used for reviews. This area of HPHC operations
has not changed substantially over the review period.
Outpatient medical services are managed primarily by PCPs,
who recommend needed services and decide how to
respond to their clients’ requests for services by providing
care themselves, making referrals to specialists, and
prescribing medications. Procedures for authorization of
mental health and rehabilitation services will be described in
related sections of this report.
HPHC does not routinely review hospital admissions unless
they are for procedures that require precertification. Instead,
hospitals notify HPHC of the admission of their members,
eligibility is checked, and the case is referred to the case
management department which determines if the case meets
their criteria for case management attention. In addition,
several HPHC reviewers are sited in high volume hospitals.
HPHC describes a process that focuses on meeting the
member’s treatment needs and results in few disagreements
between hospital and HPHC clinical staff on required
treatment. In 2001, HPHC reduced the number of hospitals
that had on-site reviewers from 45 (60% of hospitals) to 22
and used active or passive telephonic review instead. In
2002 and 2003, a few more on-site reviewers were added
back, but more than two-thirds of hospitals continued to be
reviewed by telephone.
HPHC has identified certain surgical procedures that require
prior authorization (focused review) by HPHC’s utilization
reviewers. Its goal is to reduce the number of procedures
reviewed, potentially to just cosmetic procedures, by
educating providers about the criteria for appropriateness
for other procedures. Between 2000 and 2001, several new
procedures were added to the review list, one of which was
speech therapy, which previously was subject to benefit
limits. Other procedures were dropped from the list, as
shown in the table below. Several procedures were added to
the list in 2002, including Formulas/Enteral Nutrition,
Growth Hormone, case-by-case review of new technologies,
and Pulmonary Rehabilitation (Outpatient), but only one,
OP Pulmonary Rehabilitation remained on the list in 2003.
Certain cosmetic procedures were added in 2003, while
several others were removed. Overall, the list was only two
procedures longer in 2003 than in 2000.
Page 36
TABLE 21
HPHC LIST OF PROCEDURES REQUIRING FOCUSED REVIEW
(PRE-CERTIFICATION)
Procedure
Advanced Reproductive Technology
Services
Autologous Chondrocyte Implantation
(Knee)
2000
2001
2002
2003
Y
Y
Y
Y
Y
Breast Implant Removal
Y
Breast Augmentation Mammoplasty
Y
Breast Reduction Mammoplasty
Y
Y
Y
Y
Y
Y
Y
Ptosis Repair
Y
Y
Y
Port Wine Stain Removal
Pulmonary Rehabilitation
(Outpatient)
Rhinoplasty
Y
Breast Gynecomastia Removal
Cosmetic/Potentially Cosmetic Proced.
(e.g., Scar Revision, Blepharoplasty)
Formulas/Enteral Nutrition
Y
Septoplasty
Y
Gastric Stapling/Gastric By-pass
Y
Y
Y
Y
Y
Y
Growth Hormone
Y
Y
Laminectomy/Fusions/Discectomy
Y
Lung Volume Reduction Surgery
Y
Mandibular/Maxillary Osteotomy (TMJ)
Y
Y
Y
Y
Y
Y
Y
2001
2002
2003
Y
Panniculectomy (replaces
“Abdominoplasty”)
Pelvic Laparoscopy
Y
BMT/Stem Cell Transplant
2000
Odontectomy
Bariatric Surgeries
Blepharoplasty
Procedure
New Technologies
(Case by case)
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Speech Therapy
Spinal Fusion
Transplants other than Kidney
and Cornea
Uvulopalatopharyngoplasty
(UPPP)
Varicose Vein Excision &
Ligation
Y
Total
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
18
17
19
20
Y
Source: HPHC Approved/revised focused review list Sept 1999- Dec 2000, HPHC Focused Review List (Effective 1/1/01) and HPHC Attorney General RFI Responses.
Page 37
I.
PROVIDER SURVEY
In 2001, HPHC commissioned a survey company, Fact Finders, to survey a sample of primary care physicians about HPHC’s performance
of utilization management and care coordination. A high percentage of those responding to the question, 94%, agreed that HPHC’s staff
worked to ensure that members receive the care they need, and 35% were very satisfied with HPHC’s utilization management program.
Only 8% were not satisfied. Less detailed questions from HPHC’s 2003 provider survey found these functions to have high overall
ratings. Ninety percent of providers rated the clinical utilization review process as good, very good or excellent, while 92% rated support
for care managers as good or better.
However, while most rated HPHC’s referral
process as easy, 20%, rated it difficult, and the
same percentage rated HPHC’s authorization
process as difficult. There was some level of
disagreement with HPHC’s authorization
decisions. 81% agreed with HPHC’s decisions
most of the time, but 19% agreed only some of
the time. Most felt that HPHC’s decisions
were timely.
Eighty-eight percent rate
timeliness as good to excellent. In 2002 and
2003, provider offices rated HPHC’s referral
representatives and its process much more
positively, other than the time required to
reach a representative. In 2003, the overall
rating was still high, but had fallen from 2002,
as shown in Chart 13.
CHART 13
SATISFACTION WITH REFERRAL AUTHORIZATIONS
Excellent, very good, good
100%
98%
92%
90%
Very & somewhat satisfied
95%
90%
80%
74%
60%
40%
20%
0%
Time to Reach RA
Rep
RA Rep
Professionalism
Rep's Clear
Answers
Same Call
Resolution
February 2002
Overall
Satisfaction
Overall
Satisfaction
4th Qtr 2003
Source: Fact Finders 2002 and 2003 Survey of HPHC Provider Offices
Page 38
J.
GRIEVANCES AND APPEALS
HPHC’s internal review process has a number of stages that incorporate important safeguards for members:
•
•
•
•
•
Initial review by a nurse, who
can approve
Review of any potential
denials by a physician advisor
Notifying
the
requesting
physician of a denial and
allowing at least two days for
response and discussion
Issuance of a denial letter to
all involved parties, including
the member.
Members can request an
expedited appeal to be
completed within 72 hours
with a different physician
than the one who denied the
care.
TABLE 22
HPHC COMMERCIAL MEMBER APPEALS BY MAJOR SERVICE TYPE PER 1,000
Out-Patient Care/ Ambulatory Care
2000
2001
2002
2003
% Change between
2000 and 2003
0.40
0.45
0.28
0.41
2%
Pharmacy
0.50
0.43
0.38
0.27
-46%
Rehabilitative Services
0.39
0.72
0.60
0.68
77%
Mental Health Services/ Behavioral Health*
0.30
0.35
0.53
0.73
143%
Durable Medical Equipment
0.25
0.19
0.20
0.30
21%
Dental
0.19
0.18
0.19
0.18
-3%
Excluded Services
0.16
0.07
0.11
0.12
-29%
Emergency Care
0.12
0.15
0.03
n/a
In Patient Care
0.09
0.05
0.11
0.10
8%
Visual Services
0.07
0.08
0.07
0.05
-27%
Cosmetic/ Reconstructive Surgery
0.11
0.11
0.06
0.06
-45%
Diagnostic Services
0.08
0.06
0.02
n/a
If a procedure is denied as not
medically necessary, HPHC uses
Fee For Services
0.05
0.00
0.00
0.00
-100%
an independent physician to
Infertility Care/ART Services
0.06
0.07
0.07
0.12
96%
review the case. HPHC’s Member
Home Health Care
0.00
0.03
Appeals Committee (which has
Total
2.76
2.92
2.65
3.04
10%
some consumer members) hears
* Excludes ValueOptions
appeals of any expedited appeal
Source: HPHC Appeals by Major Service Type by First and Second Appeals, 2000 through 2003
denials and the Member may
present their case to the Committee. For the few appeals that reach this stage, members have a final option to request an external review
from the Massachusetts Department of Public Health, Office of Patient Protection.
Appeals are an indicator of the degree to which members feel that their health plan is providing them the services they need. Appeals
per thousand by commercial members stayed relatively stable over the first 3 years, increasing by just 6%, and then jumped by 13% in
Page 39
2003 for an overall increase throughout the period of 10%.
Increased appeals of rehabilitative and mental health
services increased from 90% to 160%, accounting for most of
the increase. Appeals of infertility services experienced a
similar increase, but on a smaller base that contributed less
to the overall rate.
Durable medical equipment and
outpatient care also experienced increases of 31% and 10%
respectively.
Pharmacy and cosmetic surgery appeals
decreased by about 40%, which somewhat offset the
dramatic increases in rehab and mental health services.
In contrast to HPHC’s data on appeals, its reports to the
Office of Patient Protection (see Table 23) showed a low and
falling rate of internal grievances across the 3-year period,
differing from most other HMOs, which showed grater
variability and a rising trend of grievances and appeals. In
the second and third year, HPHC had the lowest rate of
external appeals of all the large HMOs. Its rate of approval
of internal grievances began at 46% and increased to 57% in
2002, increasing to 60% in 2003. This rate of approval fell in
the middle of other HMOs, which ranged from 45% to 69%.
Approximately 4% to 5% of HPHC’s grievances were
appealed externally – in the middle of the range. However,
because of their low rate of grievances, they also had a low
rate of external grievances per thousand, falling at the
bottom of the range. Overall, these data suggest that
relatively few HPHC members have problems getting
requested services authorized.
When we looked at the reasons that external review requests
were made, we found that in 2001, HPHC had a different
profile of requests from other HMOs, with more review
requests related to behavioral health, rehabilitation,
outpatient and inpatient services, and fewer for
experimental treatments, cosmetic/reconstructive surgery,
pharmacy and durable medical equipment. In 2003, HPHC’s
profile looked very similar to the total distribution.
Behavioral health accounted for over half of external review
requests for HPHC and all HMOs. HPHC was somewhat
higher in review requests for rehab services, inpatient
services, and excluded services, and somewhat lower for
cosmetic reconstructive surgery and outpatient services. All
other services experienced a rate of review request not
markedly different from the overall profile. This suggests
that HPHC’s authorization decisions are quite comparable to
those of other HMOs. Behavioral health is a notable area for
disagreement in all plans, and HPHC experiences a
somewhat heightened rate of external review requests for
rehabilitation services.
Page 40
TABLE 23
INTERNAL GRIEVANCES AND EXTERNAL APPEALS
External Appeals
per thousand
External Appeals
as a % of Denied
Grievances
Filed Grievances
per thousand
Percent Internally
approved
External Appeals
per thousand
External Appeals
as a % of Denied
Grievances
Filed Grievances
per thousand
Percent Internally
approved
External Appeals
per thousand
External Appeals
as a % of Denied
Grievances
2003
Percent Internally
approved
2002
Filed Grievances
per thousand
2001
6.6
50%
0
0%
10.1
49%
0.04
1%
23.0
61%
0.00
0%
2.6
55%
0.02
1%
3.4
62%
0.14
11%
3.3
63%
0.16
24%
8.2
59%
0.09
3%
8.3
50%
0.14
3%
3.9
54%
0.04
2%
Fallon Community Health Plan
10.4
29%
0.05
4%
7.5
69%
0.05
2%
11.9
22%
0.06
4%
Harvard Pilgrim Health
Care, Inc.
2.5
46%
0.02
2%
2.4
57%
0.04
5%
2.5
60%
0.04
4%
Health New England
3.4
63%
0.12
9%
5.5
45%
0.11
4%
8.5
51%
0.07
2%
2
22%
0.13
9%
4.2
58%
0.12
8%
3.0
21%
0.14
6%
Insurance Provider
AETNA Life Insurance
Company – Medical
Blue Cross & Blue Shield of
Massachusetts
CIGNA Health Care of
Massachusetts
Tufts Associated Health
Maintenance Organization
Source: Department of Public Health, Office of Patient Protection, Health Plan Grievance, and Number of Requests Received by Health Plan; Division of Insurance, Data
Collection Report 2001-2003.
Beginning in 2001, if a health plan denies an internal appeal, the member can file an external appeal to the Department of Public Health, Office of Patient
Protection (OPP). Also beginning in 2001, all Massachusetts managed care plans were required to file data on their internal grievance processes with OPP, and
OPP posts these data and a summary of their own reviews on its website.
Page 41
K.
UTILIZATION OF MEDICAL AMBULATORY SERVICES
Actual utilization of services by HPHC members provides
information about how the members, the provider network
and clinical management policies interacted in the provision
of services. We reviewed utilization data from HEDIS and
from the Massachusetts Division of Insurance to see how
utilization by HPHC members changed between 2000 and
2003, and how it compared to the experience of other HMOs
in the state and nationwide.
HEDIS’ measurement
methodology has been defined in significant detail over the
years, making measurement probably more consistent
between different reporting entities than the Division of
Insurance data. However, neither method accounts for case
mix differences that may occur between different HMOs
even within the same coverage type. Changes in case mix
may therefore account for certain differences between years
or between two HMOs. Though the large enrollment of
most HMOs make dramatic case mix changes less likely, our
conclusions must be tempered by our limited ability to
account for such changes.
1. HEDIS Utilization Measures
Table 23 shows HEDIS measures of utilization. Nationally,
HMOs showed increasing ambulatory, emergency room and
acute care surgery utilization across the period, growing at
high rates between 2000 and 2002, and moderating
somewhat in 2003. Inpatient medicine discharge rates
jumped from 2000 to 2001, dropped slightly in 2002 and then
rebounded in 2003. Massachusetts HMOs showed similar
increasing trends with outpatient and emergency utilization
rates higher than the national average and inpatient medical
and surgical discharge rates lower than the national average
throughout the period. HPHC’s outpatient and emergency
room utilization rates were initially higher than the
Massachusetts average, but fell below in 2002 and 2003.
HPHC slightly reduced its rates of medical and surgical
discharges until 2003, when they jumped to a new 4-year
high. HPHC began the period with a similar rate of
inpatient medical discharges as the state average, but
increased at a slower rate, ending somewhat below the state
average. In contrast, HPHC’s rate of surgical discharges
exceeded both the state and national averages at the
beginning of the period, but HPHC actually decreased
utilization in 2001 and moderated its rate of increase so that
in 2003, it was less than the national average and only
slightly above the state average. In general, high rates of
outpatient care and low or average rates of inpatient care
suggest that members get treatment at earlier stages of
illness and can avoid or postpone more invasive surgical
procedures and inpatient stays. Thus these patterns of
somewhat reduced inpatient care likely reflect good
preventive care and do not raise concerns about HPHC
member access to care.
Page 42
TABLE 24
HPHC UTILIZATION PER THOUSAND
(Ambulatory Visits, Inpatient Medicine Discharges, Inpatient Surgery Discharges, ER Visits)
National Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/POS)
National Avg.
(HMO/POS)
2003
MA average
(HMO/ POS)
Ambulatory visits per
thousand
Emergency Room visits
per thousand
Inpatient Acute Care –
Medicine discharges per
thousand
Inpatient Acute Care –
Surgery discharges per
thousand
2002
2001
HPHC
(HMO/POS
combined)
2000
3852.72
3825.23
3191.75
3896.53
3831.16
3383.41
3907.65
3974.69
3520.16
4006.18
4052.48
3540.88
180.09
170.81
164.25
186.64
184.17
176.88
187.82
194.1
182.56
196.1
203.42
181.25
20.29
20.87
22.97
20.26
21.47
24.31
19.96
21.82
23.65
21.38
22.15
24.32
17.47
13.37
16.22
16.82
15.08
17.16
17.38
15.55
18.88
18.25
17.42
19.08
Source: NCQA Quality Compass 2001, Health Plan Employer Data and Information Set 2002, 2003 and 2004.
2. Division of Insurance Outpatient Utilization Measures
Reports submitted by Massachusetts HMOs to the Division of Insurance provide additional detail about HPHC’s utilization, by plan type.
Plans showed considerable changes between 2000 and 2001, with Groups and Medicare Risk showing peaks in utilization, with gradual
drops thereafter. At the end of the period, Group utilization remained above the beginning rate, while Medicare Risk rates had decreased
to somewhat below the starting rate. In contrast, Individual members experienced a dramatic 54% drop in utilization between 2000 and
2001. After this drop, individual utilization rebounded to close to its starting level. In 2002, only Medicare Cost utilization looked
dramatically different, about half of its 2000 level. However, this change may have been due to the exclusion of Enhanced 65 members,
for which utilization data was unavailable. Over the four years there was a shift towards increasing provision of outpatient services by
physicians.
Page 43
TABLE 25
HPHC MASSACHUSETTS AND MAINE
TOTAL AMBULATORY ENCOUNTERS BY PLAN TYPE
Plan Type
2000
Groups
Medicare Risk
Medicare Cost
Individual
Grand Total
% of Total
2001
Groups
Medicare Risk
Medicare Cost
Individual
Grand Total
% of Total
2002
Groups
Medicare Risk
Medicare Cost **
Individual
Grand Total
% of Total
2003*
Groups
Medicare Risk
Medicare Cost
Individual
Grand Total
% of Total
Physician
Non Physician
Total
Total Ambulatory Encounters %
of Grand Total
Ambulatory Encounters per
Thousand
3,000,164
440,985
18,995
78,336
3,538,480
83%
556,627
164,008
5,244
16,467
742,346
17%
3,556,791
604,993
24,239
94,803
4,280,826
83%
14%
1%
2%
100%
5,196
10,896
16,875
5,841
5,647
2,389,668
343,353
7,101
25,135
2,765,257
81%
481,229
152,649
1,939
5,647
641,464
19%
2,870,897
496,002
9,040
30,782
3,406,721
84.3%
14.6%
0.3%
0.9%
100%
5,561
12,633
7,241
2,684
5,994
2,283,377
376,682
4,698
41,316
2,706,073
87%
360,092
49,002
2,973
6,600
418,667
13%
2,643,469
425,684
7,671
47,916
3,124,740
85%
14%
0.2%
2%
100%
5,484
10,817
7,080
5,748
5,886
2,364,566
312,444
289,625
45,393
5,364
10,125
42,006
2,719,015
89%
4,411
339,429
11%
2,654,190
87%
357,837
12%
No data available
46,417
2%
3,058,444
100%
5,433
5,677
* In 2003, DOI began collecting and reporting utilization data only for MA HMO members. Prior years included both in and out of state enrollees in
MA HMOs.
**Excludes utilization of Enhanced 65 members.
Source: “Data – Outpatient” from Harvard Pilgrim Health Care, Inc. Quarterly Report, (2000, 2001, 2002)
Pilgrim Health Care, Inc. Quarterly Report (2000, 2001), Harvard Pilgrim NE, Inc. Quarterly Report (2002), and Harvard Pilgrim Healthcare, Inc.
“HMO Supplemental Utilization”, 2003.
Page 44
Overall, HPHC went from providing somewhat lower utilization of outpatient services than the other major Massachusetts HMOs to
somewhat higher utilization. Group member utilization steadily increased from about the same as for other HMOs at the beginning of the
period to more than 20% higher at the end. Medicare Risk members had lower utilization than for other HMOs at the beginning of the
period, but equaled and then somewhat exceeded it by the end. HPHC Medicare Cost utilization was considerably higher at the
beginning of the period – almost threefold that of other HMOs. It dropped considerably to be only 30% higher than average in 2000 and
dropped again in 2002, but remained above the average. However, its 2002 figures excluded utilization of its Enhanced 65 members.
There was considerable variation in outpatient utilization among HPHC’s individual members. They began with a much higher than
average rate, dropped to below average, increased again in 2003 and dropped a little in the final year. In that year, utilization by the
individual members of other HMOs increased considerably, making their rates equivalent to HPHC’s. These extreme variations – as those
of Medicare Cost members – may be due to the effect of the potential disproportionate effect of members with outlier utilization in a
TABLE 26
MASSACHUSETTS AND MAINE MEDICAL* AMBULATORY ENCOUNTERS BY PLAN TYPE:
HPHC COMPARED TO OTHER** MA HMOS
5,484
12,054
90%
12,633
12,327
102%
10,817
5,883
287%
7,241
5,576
130%
7,080+
5,841
3,588
163%
2,684
3,917
69%
5,647
6,054
93%
5,994
6,054
99%
HPHC
16,875
Individual
Grand Total
HPHC as a
percent of
Other HMOs
HPHC
104%
10,896
Weighted Avg.
Other MA
HMOs*
HPHC as a
percent of
Other HMOs
5,328
Medicare Cost
HPHC
Weighted Avg.
Other MA
HMOs*
5,561
Medicare Risk
HPHC as a
percent of
Other HMOs
HPHC
101%
5,196
2003 Ambulatory
encounters per thousand*
Weighted Avg.
Other MA
HMOs
HPHC as a
percent of
Other HMOs
2002 Ambulatory
encounters per thousand
5,166
Plan Type
Groups
2001 Ambulatory
Weighted Avg.
Other MA
HMOs**
2000 Ambulatory
4,678
117%
5,364
4,392
122%
9,950
109%
10,125
9,205
110%
6,133
115%
n/a
7,111
n/a
5,748
3,773
152%
5,433
5,462
99%
5,886+
5,396
109%
5,677
4,998
114%
* Excludes Outpatient Mental Health visits
**Excludes HMO Blue. Discrepancy in 2001 encounter data. Excludes Aetna, whose enrollment fell below 2% threshold in FY2002.
+ Excludes Enhanced 65 members.
Source: "Outpatient Days Report” from Harvard Pilgrim Health Care, Inc. Quarterly Report, (2000, 2001, 2002), Pilgrim Health Care, Inc.
Quarterly Report (2000, 2001), Harvard Pilgrim NE, Inc. Quarterly Report (2002), and Harvard Pilgrim Healthcare, Inc. “HMO Supplemental
Utilization”, 2003.
Page 45
relatively small caseload. In addition, we know that membership has changed considerably for these two plan types over the period, and
thus, different groups are being measured in the different years. Overall, this analysis shows that the dramatic changes HPHC
experienced between 2000 and 2001 brought it closer to the rates of other Massachusetts HMOs and that by the final two years of the
period, HPHC provided equal or greater access to outpatient services as the other HMOs.
Table 27 below shows that most outpatient visits are office visits, with small percentages for ambulatory surgery, observation stays, or the
emergency room. Office visits peaked in 2001 and dropped thereafter, dropping slightly as a share of total outpatient visits from 94% to
91%. Over the four-year period, ambulatory surgery visits tripled their share from 2% to 6%, while observation days dropped from .3% to
.1% and the rate of emergency visits decreased somewhat.
TABLE 27
HPHC MASSACHUSETTS AND MAINE
AMBULATORY ENCOUNTERS BY TYPE
2000
Encounters
Office
Visits***
Ambulatory
Surgery
Observation
Days
Emergency
Room
Total
Total
Encounters
2001
2002
%
Total
Encounters
4,031,568
94.2%
5,318
3,198,750
93.9%
5,628
2,893,629
92.6%
5,451
90,903
2.1%
120
81,906
2.4%
144
143,184
4.6%
270
11,823
0.3%
16
9,584
0.3%
17
4,076
0.1%
146,532
3.4%
193
116,481
3.4%
205
84,134
2.7%
4,280,826
100.0%
5,647
3,406,721
100.0%
5,994
3,125,023
100.0%
*
%
Encounters
per 1,000
Total
Encounters
2003
Encounters
per 1,000
*
%
Encounters
per 1,000
**Total
Encounters
%
Encounters
per 1,000
2,782,031
91.0%
5,164
182,801
6.0%
339
8
3,958
0.1%
7
158
89,668
2.9%
166
3,058,458
100.0%
5,677
5,887
Excludes Enhanced 65 utilization.
Excludes all Medicare Cost utilization.
***Excludes mental health office visits.
Source: "Outpatient Days Report” from Harvard Pilgrim Health Care, Inc. Quarterly Report,(2000, 2001, 2002), Pilgrim Health Care, Inc. Quarterly Report (2000, 2001), Harvard Pilgrim NE, Inc.
Quarterly Report (2002), and Harvard Pilgrim Healthcare, Inc. “HMO Supplemental Utilization”, 2003.
*
**
Page 46
3. Division of Insurance Inpatient Utilization Measures
Table 28 shows the total number of inpatient days by plan type. Inpatient utilization differs by plan type even more dramatically than
ambulatory utilization. While Group enrollees continue to utilize the majority of beds, they have the lowest rate of days per thousand.
Their utilization rate slightly dropped, but by 2003, showed an increase over 2000 rates. Medicare Risk enrollees used inpatient services at
almost 10 times the rate of Group members. Their rate fluctuated between 2,500 and over 2,600 in the first three years, and then increased
by 2003 to considerably exceed 2000 rates. Medicare Cost enrollees initially showed a rate more than twice that of Medicare Risk
enrollees, but this rate dropped 80% to be half that of Medicare Risk in 2001 and increased to become closer to Medicare Cost in 2002.
However, these figures are affected in unknown ways by the exclusion of Enhanced 65 members no longer reported in this data set. NonGroup enrollees’ inpatient utilization dropped dramatically, by more than half, in 2001, but rebounded to slightly exceed initial rates in
2003. All plan types other than Medicare cost showed increased utilization at the end of the period. While Medicare Cost remained well
below its initial exceptionally high 2000 rate in 2002, the last year in which data were available, these results are inconclusive since 2002
figures exclude data on Enhanced 65 members included in the two prior years.
TABLE 28
HPHC MASSACHUSETTS AND MAINE* INCURRED INPATIENT DAYS BY PLAN TYPE
Total
Hospital
Patient Days
Days per
Thousand
% of Grand
Total
Total
Hospital
Patient Days
Days per
Thousand
% of Grand
Total
Total
Hospital
Patient Days
Days per
Thousand
% of Grand
Total
2003*
% of
Grand Total
2002
Days per
Thousand
2001
Total
Hospital
Patient Days
2000
Groups
189,755
277
55.0%
141,580
274
57.1%
131,620
273
56%
136,511
294
58%
Medicare Risk
141,361
2,546
41.0%
103,065
2,625
41.6%
98,550
2,504
42%
97,041
2,746
41%
Medicare Cost
7,377
5,136
2.1%
1,258
1,008
0.5%
2,027**
1,871**
1%
Individual
6,234
384
1.8%
1,938
169
0.8%
2,886
346
1%
3,343
391
1%
344,727
455
100.0%
247,841
436
100.0%
235,083**
443**
100%
236,895
474
100%
Plan Type
Grand Total
not available
* In 2003, DOI began collecting and reporting utilization data only for MA HMO members. Prior years included both in and out of state enrollees in MA HMOs.
** Excludes Enhanced 65 member utilization.
Source: "Inpatient Days Report - ALOS" from Harvard Pilgrim Health Care, Inc. Quarterly Report, (2000, 2001, 2002), Pilgrim Health Care, Inc. Quarterly
Report (2000, 2001), Harvard Pilgrim NE, Inc. Quarterly Report (2002), and Harvard Pilgrim Healthcare, Inc. “HMO Supplemental Utilization”, 2003.
Page 47
Table 29 shows that there is considerable variation in both HPHC and other HMOs’ inpatient utilization rates for the plan types with
smaller enrollments. As mentioned earlier, in smaller groups, outlier admissions may considerably influence the group mean. The
inpatient utilization of HPHC’s Group members has been at the Massachusetts HMO average or higher throughout the period, increasing
to 33% higher in 2003. Medicare Risk members, in contrast, were higher or average in the first two years of the period, but had lower than
average inpatient utilization in the final two years. As we saw with outpatient data, Medicare Cost and Individual inpatient utilization
are highly variable. Medicare Cost utilization fluctuated considerably, but was higher or dramatically higher than other HMOs between
2000 and 2003. Individual utilization began about 10% higher than average, dropped precipitously in 2001 and then climbed back to
exceed the average in 2003.
TABLE 29
MASSACHUSETTS AND MAINE* INCURRED INPATIENT DAYS BY PLAN TYPE
HPHC COMPARED TO OTHER MA HMOS
HPHC Days
per thousand
Other HMOs
*Days per
thousand
% Difference
HPHC Days
per thousand
Other HMOs
Days per
thousand
% Difference
115.5%
274
259
106.1%
273
275
99.1%
294
220
133.7%
Medicare Risk
2,546
2,268
112.3%
2,625
2,598
101.0%
2,504
3,159
79.3%
2746
2930
93.7%
Medicare Cost
5,136
796
644.9%
1,008
849
118.7%
1,871**
519
360.2%
n/a
1331
n/a
Individual
384
336
114.5%
169
447
37.8%
346
421
82.2%
391
317
123.5%
Grand Total
455
507
89.6%
436
575
75.8%
443
538
82.3%
474
435
109.1%
Other HMOs
Days per
thousand
240
Groups
Other HMOs
Days per
Thousand
% Difference
2003*
HPHC Days
per thousand
2002
% Difference
2001
277
Plan Type
HPHC Days
per thousand
2000
* In 2003, DOI began collecting and reporting utilization data only for MA HMO members. Prior years included both in and out of state enrollees in MA HMOs. Excludes Aetna whose
enrollment fell below 2% threshold.
** Excludes Enhanced 65 member data.
Source: "Inpatient Days Report - ALOS" from Harvard Pilgrim Health Care, Inc. Quarterly Report, (2000, 2001, 2002), Pilgrim Health Care, Inc. Quarterly Report (2000, 2001),
Harvard Pilgrim NE, Inc. Quarterly Report (2002), Harvard Pilgrim Healthcare, Inc. “HMO Supplemental Utilization”, 2003 and data submitted to DOI by other HMOs.
Page 48
Table 30 shows how inpatient episodes break
down between acute care, maternity care, and
non-acute care. Average lengths of stay for the
different types of inpatient care vary, but are
quite stable over this period. Maternity stays
are shortest, averaging three days, followed by
acute care, averaging four days. Non-acute
care has a longer average length of stay, 11
days, and consequently accounts for more than
one quarter of discharge days, a larger share of
days than it has of discharges. Acute care
discharges per thousand fluctuated over the
four-year period, showing a slight overall
increase by the end of the period. Maternity
and non-acute discharges per thousand
showed little variation.
TABLE 30
HPHC MASSACHUSETTS AND MAINE*
INPATIENT DISCHARGES AND DISCHARGE DAYS BY TYPE OF SERVICE
Total
Discharges
Discharges
per thousand
Total Discharge
Days
ALOS
Acute Care
51,700
68
212,917
4.1
Maternity Care
11,051
15
31,970
2.9
Type of Inpatient Care
2000
Non-acute Care
10,046
13
110,241
11.0
Total
72,797
96
355,128
4.9
37,338
66
156,599
4.2
2001
Acute Care
Maternity Care
7,657
13
22,720
3.0
Non-acute Care
6,785
12
76,210
11.2
51,780
91
255,529
4.9
Acute Care
36,627
74
151,818
4.1
Maternity Care
6,998
14
19,878
2.8
Total
2002
Non-acute Care
7,202
15
69,413
11.1
Total
50,827
103
241,109
4.7
Acute Care
38,183
71
155,909
4.1
Maternity Care
7,010
13
20,783
3.0
2003*
Non-acute Care
6,329
12
69,023
10.9
Total
51,521
96
245,715
4.8
* In 2003, DOI began collecting and reporting utilization data only for MA HMO members. Prior years included
both in and out of state enrollees in MA HMOs.
Source: "Inpatient Days Report - ALOS" from Harvard Pilgrim Health Care, Inc. Quarterly Report, (2000, 2001,
2002), Pilgrim Health Care, Inc. Quarterly Report (2000, 2001), Harvard Pilgrim NE, Inc. Quarterly Report
(2002), Harvard Pilgrim Healthcare, Inc. “HMO Supplemental Utilization”, 2003, and data submitted tot DOI by
other HMOs.
Page 49
L.
HEDIS ACCESS AND SATISFACTION MEASURES
Table 31 shows how HPHC compares to other Massachusetts health plans and to the national average on access to health care. The
Massachusetts average exceeds the national average in all categories, and HPHC exceeded the state average in all categories for all four
years, except for children aged 12 to 24 months, where HPHC fell slightly below the state average in 2002 and 2003. However, this was
the age category that experienced the highest rates of access; HPHC exceeded 97% in all years and Massachusetts exceeded 96% in all
years. Given these very high rates of access, it was rather remarkable that both the national and the Massachusetts averages increased in
all categories in all years. HPHC’s access rates also increased in all categories in all years except for children aged 12 to 24 months and
children aged 7 to 11 years. The net effect was that, as HPHC’s and Massachusetts’ average approached the high 90s, HPHC’s lead over
the state average lessened.
TABLE 31
HEDIS ACCESS MEASURES
HPHC COMPARED TO MASSACHUSETTS AND NATIONAL AVERAGES
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National
Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National
Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/POS)
National
Avg.
(HMO/POS)
2003
National
Avg.
(HMO/POS)
2002
MA average
(HMO/ POS)
2001
HPHC
(HMO/ POS
combined)
2000
Adults Access 20-44
95.41%
92.97%
90.12%
95.64%
94.14%
91.69%
95.88%
94.57%
92.01%
95.99%
94.91%
92.49%
Adults Access 45-64
96.3%
94.52%
92.6%
96.45%
95.38%
93.81%
96.72%
95.71%
94.16%
96.83%
96.03%
94.5%
Adults Access 65+
96.39%
94.36%
93.33%
96.49%
95.4%
94.71%
96.64%
95.89%
95.16%
96.76%
96.41%
95.73%
97.9%
96.57%
92.45%
97.6%
96.63%
95.22%
97.54%
97.65%
95.66%
97.82%
98.37%
96.28%
94.54%
92.01%
82.43%
95.1%
92.94%
85.75%
95.48%
94.38%
87.24%
95.5%
95.14%
88.49%
96.43%
93.3%
83.64%
96.93%
94.42%
85.82%
96.68%
95.61%
87.43%
96.82%
96.36%
88.5%
Children’s Access 12-24
months
Children’s Access 25
mos. to 6 years
Children’s Access 7- 11
years
Source: NCQA Quality Compass 2001, Health Plan Employer Data and Information Set 2002, 2003 an 2004.
In contrast to utilization measures, which count the total services provided on average across all members, this set of measures determines what percentage
of members received the minimum services recommended for healthy individuals. Access for adults is measured by counting the percentage of members
who have seen a health care provider for any ambulatory or preventative care in the last three years. For young children, the measure is the percentage that
has seen a provider for primary care in the past year. For children ages 7 to 11, the measure is those with such a visit in the preceding two years.
Page 50
In the first two years,
HPHC ranked slightly
lower
than
the
Massachusetts average
and above the national
average
on
getting
needed care. In 2002
81.9%
76.75% 84.23% 82.19% 76.92% 86.02% 82.14%
78.4%
National
Avg.
(HMO/POS)
82.28% 82.62% 75.36% 80.79%
MA average
(HMO/POS)
78.6%
HPHC
(HMO/POS
combined)
79.72% 79.78% 80.66% 77.64% 82.71% 81.77%
National
Avg.
(HMO/POS)
82.3%
HPHC
(HMO/POS
combined)
National
Avg.
(HMO/POS)
2003
79.86% 82.74% 78.34% 79.27%
National
Avg.
(HMO/POS)
MA average
(HMO/ POS)
2002
2001
MA average
(HMO/ POS)
Getting
care quickly
Getting
needed care
MA average
(HMO/ POS)
2000
HPHC
(HMO/POS
combined)
HPHC ranked a little
low on getting care
quickly compared to
other
Massachusetts
HMOs for the first three
years of the period. Its
score was above or the
same as the national
average and below the
state average in those
years.
However, it
jumped three percentage
points in 2003 to exceed
both the state and
national averages in
2003.
TABLE 32
CAHPS MEASURES OF ACCESS TO CARE
HPHC
(HMO/POS
combined)
Starting below the state
average on the measures
of getting care quickly
and getting needed care,
HPHC
experienced
increases in consumer
ratings
on
both
measures that put it
above the state average,
which
consistently
exceeded lower national
averages.
Source: NCQA Quality Compass 2001, 2002, 2003 and 2004 Health Plan Employer Data and Information Set
HEDIS uses a standardized tool, the Consumer Assessment of Health Plans, CAHPS, for health plans to survey their
members on various aspects of their ability to get medical services. “Getting care quickly” indicates the overall
percentage of survey respondents who answered ‘always’ or ‘usually’ to the following three questions:
•
In the last 12 months, when you called during regular office hours, how often did you get the advice or help you
needed?
•
In the last 12 months, how often did you get an appointment for regular or routine health care as soon as you
wanted?
•
In the last 12 months, when you needed care right away for an illness or an injury, how often did you get care as
soon as you wanted?
•
And responded ‘seldom’ or ‘never’ to the following question: In the last 12 months, how often did you wait in the
doctor’s office or clinic more than 15 minutes past your appointment time to see the person you went to see?
“Getting needed care” measures the percentage of respondents who answered ‘not a problem’ to the following
questions:
•
With the choices you health plan gave you, how much of a problem, if any, was it to get a personal doctor or nurse
you are happy with?
•
In the last 12 months, how much of a problem, if any, was it to get a referral to a specialist that you needed to see?
•
In the last 12 months, how much of a problem, if any, was it to get the care you or a doctor believed necessary?
•
In the last 12 months, how much of a problem, if any, were delays in health care while you waited for approval
from your health plan?
Page 51
and 2003, HPHC experienced an increase in ratings, which put it above the Massachusetts average and well above the national average.
HPHC was close to the Massachusetts average and considerably above the national average in members’ ratings of their health plan at the
beginning of the period. Its ratings grew substantially, considerably exceeding the state and national averages by 2003. In contrast,
Massachusetts rates dropped below their 2000 starting point and the national average increased only a little.
TABLE 33
CAHPS MEASURE OF MEMBER HEALTH PLAN RATINGS
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/POS)
National Avg.
(HMO/POS)
2003
National Avg.
(HMO/POS)
2002
MA average
(HMO/ POS)
Rating of Health Plan
2001
HPHC
(HMO/POS
combined)
2000
66.72%
66.78%
59.3%
78.78%
68. %
61.92%
79.51%
65.57%
61.3%
83.89%
64.0%
61.8%
Source: NCQA Quality Compass 2001, 2002, 2003 and 2004 Health Plan Employer Data and Information Set
CAHPS includes one question that asks respondents to give an overall rating of their health plan on a scale of 0 to 10, with 10 being the best plan
possible. The measure presented in this table shows the percentage of respondents rating their experience with their health plan as 8, 9, or 10 on
this scale.
Page 52
M.
CONCLUSION
1. Access for Commercial Members
Between 2000 and 2003, HPHC benefit plans for its three
largest commercial accounts were similar to those of other
large Massachusetts HMOs. However, at the beginning of
the period, HPHC’s rates for these large accounts were
considerably higher than those for the largest accounts of the
other Massachusetts HMOs. This rate differential, together
with questions about HPHC’s stability that were particularly
marked during and immediately after the receivership,
likely had a role in the 25% decrease in group enrollment
experienced between 2000 and 2001 by HPHC, that was
much steeper than the 2% decrease experienced by the other
Massachusetts plans. One concern about this disenrollment
was that it would take place differentially, and affect people
with serious conditions and greater health needs more than
those with less serious health needs. We had limited data
available to analyze this, but HPHC’s age and gender mix
showed a considerable increase in older individuals in
comparison to the whole over the four year period, an
indication that HPHC enrollees had become higher in need
and providing one indication that more vulnerable members
were not losing coverage. We did find that HPHC lost
enrollment differentially across the state, with residents of
the Northeast, Boston and MetroWest affected less than
those in the Southeast and Western and Central
Massachusetts. Other than the West, each region showed
small increases in membership after the initial drop.
Different sources of data suggested different conclusions
about HPHC’s provider network. It seems likely that HPHC
experienced little change in its PCP network, but some level
of decrease in its specialty network between 2000 and 2001.
The magnitude of the decrease in specialists listed in
HPHC’s directories was similar to the magnitude of the
decrease in enrollment, changing the ratio of specialists to
members minimally. However, the selection of specialists
was certainly affected and may have reduced access. By
2003, both the PCP network and the specialist network had
grown substantially, more than outpacing the growth in
members and likely increasing access. Members’ ratings of
HPHC providers on the CAHPs survey were relatively high
in 2000, with three quarters or more of respondents giving
their providers high ratings, though they did not excel with
respect to other Massachusetts HMOs. These ratings had
increased by 2003, putting HPHC above both state and
national averages.
Problems likely to affect provider participation in HPHC’
network generally improved with HPHC’s attention to
resolving and improving claims payment, as seen by
climbing ratings of these functions by providers and by
claims aging reports during the first two years of the period,
which were maintained in the final two years.
Both outpatient and inpatient utilization of group members
were either the same or exceeded utilization rates for other
large MA HMOs throughout the period.
Outpatient
utilization grew throughout the period, moving from about
average to above average. Inpatient utilization began higher
than average, stayed about the same while that of other
HMOs grew to reach HPHC levels, and then jumped in 2003
to substantially exceed other HMOs. These patterns of
utilization suggest that HPHC provided access to services
that met or exceeded that of other HMOs throughout the
analysis period.
2. Access for Non-Group Members
Non-Group plans are determined largely by standard state
requirements. In contrast to its group rates, HPHC’s
standard Non-Group rates were less expensive than those of
Page 53
most large Massachusetts HMOs in 2000. However, its rates
grew faster than those of other HMOs. By 2003, HPHC’s
rates remained considerably lower in Boston, but were
similar in Springfield and higher for those over age 63. Not
surprisingly, given these rate changes enrollment in this
plan dropped considerably during 2000 and again in 2002,
for an overall decrease of 43% from the start of the period.
HPHC continued to offer its pre-existing Non-Group option,
which provided fewer benefits at a lower cost, during 2000,
but was not allowed to do so in 2001. Hoping to offer an
acceptable replacement, HPHC introduced a new low option
Non-Group plan with a somewhat lower price and more
limited benefits than its standard plan. However, the only
one-third the enrollment of HPHC’s pre-existing Non-Group
plan members enrolled into its low option Non-Group plan.
This change accounted for most of the overall sharp decrease
in total Non-Group enrollment. This option has experienced
growth over time, partially offsetting the continued erosion
of the standard group enrollment.
Despite this decrease in coverage, HPHC continued to serve
a slightly larger share of Non-Group enrollees than the
average
for
other
large
Massachusetts
HMOs.
Unfortunately, we lack the data to determine how this
transition may have affected higher need individuals with
Non-Group coverage.
Non-Group members are served by the same provider
network, as are commercial members. However, their
utilization patterns differed considerably. Both outpatient
and inpatient utilization began at rates that exceeded that of
other HMOs; in the case of outpatient, considerably. Both
experienced a dramatic drop in the second year of the period
– a time when enrollment also changed and HPHC’s legacy
plan was replaced by its low option plan. In the succeeding
years, both outpatient and inpatient utilization rates
increased, ending the period the same or higher than other
plans. This pattern suggests that the enrollment changes did
affect higher need individuals, who may have
disproportionately left the plan. The dramatically lower
rates of utilization – in the absence of different clinical
utilization policies for Non-Group members – may well be
due to the absence of higher need individuals. While highneed, individually insured members appear to have lost
HPHC coverage, the loss of coverage is more likely due to
changes in benefit plan and plan rates that were determined
by state regulations, not by elements of HPHC’s recovery
plan.
3. Access for Medicare Risk Members
HPHC’s Medicare Risk plan, First Seniority, offered largely
the same basic benefits throughout the period. However, in
2001, HPHC dropped coverage for the counties of
Worcester, Barnstable, Bristol, and Plymouth and
implemented a premium in addition to the Medicare A and
B premiums. This premium almost doubled in each of the
next two years, while pharmacy co-pays were increased and
in 2003, the office visit co-pay increased from $5 to $15.
Overall enrollment dropped by almost thirty percent in 2001.
Most of the decrease came from eliminating coverage in the
central and southeastern part of the state, but the remaining
counties in the Metropolitan Boston region also experienced
a 13% decrease, perhaps in part due to the imposition of a
premium or the withdrawal of some hospitals from the First
Seniority network.
Though enrollment did not change
dramatically in 2002 or 2003, the net decrease from the
beginning to the end of the period was 36%. Results of the
Medicare CAHPS survey at the beginning of the period
indicated that HPHC members were leaving at higher rates
than from other Massachusetts or national HMOs, and that
they were doing so primarily because of concerns about
health care or services rather than because of costs and
Page 54
benefits. By the end of the period, HPHC’s termination rates
were lower than the state and national averages, and the
reasons for leaving were equally due to concerns about
services and costs.
HPHC Medicare Risk enrollees
consistently accounted for 6% to 7% of its total enrollment
while the other large Massachusetts HMOs served over 8%
from 2000 to 2003, but experienced a sharp decrease to 4% in
2003.
Despite dramatic changes in enrollment levels, HPHC’s
Medicare Risk members did not experience dramatic
changes in utilization rates. Outpatient utilization rates
began about 10% lower than for other large MA HMOs, and
grew to end at 10% higher. Inpatient utilization varied,
ranging between 2500 and 2700 days per thousand.
However, inpatient utilization of other HMOs varied even
more, ranging from 2300 to 3200 days per thousand. HPHC
was higher that the other HMOs in the first two years of the
period and below in the last two, though it was quite close to
the state average in the final year. These patterns suggest
that HPHC’s Medicare Risk members had equivalent or
better access to services as those enrolled in other large
Massachusetts HMOs.
4. Access for Medicare Cost Members
The changing location of Medicare Cost plans in HPHC’s
corporate structure reduced the information available to
analyze their access. We were able to document an increase
in their enrollment between 2000 and 2003, despite
experiencing considerable premium increases till the final
year of the period. The new plan introduced in 2003 to
replace the pre-existing plans was only slightly less generous
than those it replaced, while costing somewhat less.
HPHC’s Medicare Cost enrollees share the group provider
network, but their utilization is only partially reported
because one plan, Enhanced 65, moved to HPHC’s
indemnity company and was no longer included in reports
to the Division of Insurance. While HPHC’s utilization rates
were highly variable during the period, no doubt reflecting
the exclusion of data on Enhanced 65 enrollees, its rates of
utilization have been from 15% to 3 times higher for
outpatient utilization and 6 times higher for inpatient
utilization than for other HMOs. These partial data suggest
that HPHC has expanded access to this type of coverage,
and at least its Preferred 65 Plan provides a higher level of
service utilization than other Massachusetts HMOs.
5. Clinical Review and Authorization
Clinical management policies and procedures for the
authorization of care can have a significant effect on the
actual utilization of services. Unlike some of its other
operational functions, relatively little changed in HPHC’s
clinical management of medical services as it implemented
its recovery plan. However, a new state law ending benefit
limits for speech therapy was implemented, and HPHC
introduced a process for reviewing the medical necessity of
speech therapy services.
•
•
A sample of HPHC PCPs rated HPHC care managers
relatively highly on its clinical utilization review process
and getting members needed care throughout the
period. However, a significant minority, 20%, rated its
authorization and utilization management procedures as
difficult.
Different sources of data suggested different conclusions
about HPHC’s rate of grievances. HPHC’s own data on
appeals showed an increasing rate, while the data
submitted to the Massachusetts Office of Patient
Protection indicated that the rate of internal grievances
remained stable, while that of other HMOs increased
over the period. The data are consistent on the types of
service decisions appealed, showing that HPHC’s most
Page 55
frequent grievances concern mental health and
rehabilitation services. While mental health is the most
frequently appealed decision for all HMOs, HPHC’s
rates for appeal of rehabilitation services are somewhat
elevated in comparison to other HMOs. Since internal
appeal data did not increase faster than utilization rates
and comparative data show no increase, it does not
appear that authorization decisions are a significant
problem area. However, HPHC’s elevated appeals for
mental health and rehabilitation will be considered in
Sections V-A-5 and V-C-2.
and a dramatic drop in utilization between 2000 and 2001
that suggest that higher need members may have dropped
coverage. The rate and coverage changes likely influencing
disenrollment in Individual coverage were largely
parameters. Utilization rates recovered in the following two
years, putting HPHC somewhat above other Massachusetts
HMOs.
6. Overall Utilization of Services
Other HEDIS measures confirm that HPHC has been doing a
good job of providing preventive care. HPHC led in access
to primary care in all age categories and showed increasing
rates of access to primary care except in young children,
where its rates were so high (97%) that further improvement
might not be possible. While HPHC began the period with
moderate member scores on providing care quickly and
providing needed care, it increased its scores on both
measures to lead the state and national averages at the end
of the period. Finally, HPHC has showed increasing levels
of satisfaction over the four-year period, far outpacing other
Massachusetts HMOs and the national average.
Overall, indicators suggest that HPHC has maintained and
increased access to care for its Group and Medicare Risk
plan members. Enrollment in Medicare Cost plans also
increased, though benefits were slightly decreased.
Utilization rates reported to DOI showed a sharp drop, but
remained above that of the Massachusetts HMOs, though at
period end, only half of HMOs Medicare Cost members
were included. However, individual plans with much
smaller enrollment experienced both an enrollment decrease
Page 56
V.
ACCESS TO SPECIFIC SERVICE
This chapter reviews access to certain specific services of special
importance to vulnerable populations, behavioral health,
prescription drugs, and rehabilitation services.
A.
BEHAVIORAL HEALTH
1. Introduction
The four year period of this assessment was one of
considerable change in the administration of HPHC’s
behavioral health services. Prior to 2000, behavioral health
services were administered by some of HPHC’s core groups
(larger provider practices), who were at risk, or by HPHC
itself.
•
•
•
In 2000, ValueOptions took over - on a non-risk basis utilization management functions for behavioral health
services.
In January 2001, the Massachusetts mental health parity
law took effect and HPHC initiated an at-risk carve-out
arrangement with ValueOptions.
Under this
arrangement, ValueOptions credentialed and contracted
for a behavioral health network, managed utilization,
and paid provider claims.
To promote continuity, all HPHC providers
were offered the option to contract with
ValueOptions.
ValueOptions
implemented
inpatient
utilization management processes and
registration of new and ongoing outpatient
clients.
In 2002, management of inpatient services was loosened,
with increasing facility self-management, while
•
outpatient utilization management procedures were
tightened.
In March 2003, ValueOptions moved its administrative
operations to offices located in New York. Different
personnel performed utilization management and claims
processing and the authorization process became tighter
and a claims backlog developed.
2. Provider Network
Table 34 shows that ValueOptions’ included substantially
more hospitals and outpatient clinics in its network than
were in HPHC’s network but fewer individual practitioners.
Inclusion of outpatient clinics offsets to an unknown degree
to the decrease in individual practitioners in psychiatry,
psychology and social work.
HPHC and ValueOptions have focused attention on
improving the accessibility of its mental health provider
network. In September 2000, HPHC found that virtually all
members sampled, 99.6%, had 2 network providers
(psychiatrists or psychologists) within 10 miles. More
detailed accessibility analyses performed by ValueOptions
in 2001, 2002 and 2003 found that virtually all urban
members had a practitioner within 10 miles, suburban
members had a practitioner within 25 miles, and rural
members had a practitioner within 40 miles. All categories
reached 99.9% or 100%.
However this geographic proximity doesn’t ensure that an
individual member will find a provider within these
distances; 13% of respondents in 2001, 16% in 2003, and 19%
of Medicare members in 2003 indicated in response to a
Page 57
TABLE 34
HPHC NETWORK OF MENTAL HEALTH AND SUBSTANCE ABUSE PROVIDERS
Provider Type
Inpatient Hospitals (in Massachusetts)
Outpatient Clinics
Psychiatrists/Physicians
2000**
Number
26
2001
Per
Thousand
N/A
Number
47*
2002
Per
Thousand
Number
2003
Per
Thousand
67*
Per
Thousand
109
998
1.3
Ph.D. Psychologist
1,079
1.4
1,015
1.3
937
1.7
1,003
1.9
LICSW and Licensed Masters Level Counselor
4,265
5.4
1,618
2.1
1,337
2.4
1,534
2.8
294
0.4
185
0.2
158
0.3
174
0.3
Psychiatric Clinical Nurse Specialist
Provider type unknown
4
469
Number
50
34
*Correction – hospital counted as outpatient clinic in prior report
**Provider network contracted to HPHC. Thereafter, provider network was contracted to ValueOptions
Source: Physician Directory Volume 2, 2000, 2001, Fall 2003; HPHC 2000 and 2001 Credentialing Files.
Supplemental Utilization Report 2003 HPHC and HPHC NE.
0.6
414
2
0.8
430
0.8
2
NAIC 2000, 2001, 2002 for HPHC, Harvard Pilgrim and HPHC NE,
member survey that they traveled more than 30 minutes to their mental health provider. In addition, the 2001 survey found that
respondents had a hard time finding mental health practitioners: one-third of the small number of respondents who had called for a
mental health referral called a second time to get additional names and two-thirds of members who called for a referral did not find a
therapist who was accepting new patients. However, the survey did suggest that respondents receiving treatment were able to get
appointments at convenient times; most, 94% of respondents receiving mental health services said that their therapist offered them
convenient appointment times, and three-quarter reported being able to get a first appointment within 7 days. The 2003 survey did not
address members’ ease in finding a practitioner, but did find that virtually all - 99% of both commercial and Medicare members – were
offered convenient appointment times, and 85 to 85% were able to get a first appointment within 7 days.
Almost every interview we conducted with stakeholders in the mental health system, including providers, advocates and HPHC
members emphasized the overall shortage in psychiatry that is shared by HPHC and other HMOs. Child psychiatrists, particularly those
skilled in treating children age 8 and under, are a particular shortage, and residents outside of metropolitan Boston have limited choices
among a small number of psychiatrists covering other parts of the state. At the beginning of the period, some representatives of provider
trade associations believed that this was a bigger problem for HPHC than other HMOs. At the end of the period, HPHC was not
perceived as different than other HMOs.
Page 58
Seeking to improve access, ValueOptions and HPHC initiated a Quality Improvement Activity which identified barriers to access and
developed interventions to address them, including educating providers on access standards, streamlining credentialing processes and
speeding up claims processing. They commissioned a series of Fact Finders Open Shopper Surveys of practitioners, which found that
most providers met ValueOptions’ standards for initial, routine, urgent and emergent visits in 2002 and 2003. (See Chart 14.)
ValueOptions also focused specifically on child psychiatry, recognizing that the relative shortage of child psychiatrists would necessitate
setting a lower goal of 50% of child psychiatrists having immediate availability for initial or routine referrals. Surveys in all four quarters
of 2003 in Massachusetts and the remainder of the New England Service Area found that the standard was met and access was increasing.
In 2003, another survey of HPHC Group Insurance Commission members who were seeking behavioral health services found that
provision of emergency and urgent appointments met ValueOptions timeliness standards 100% or close to 100% in 2003, and routine
appointments were available within standards over 95% of the time. These results suggest that access was a problem during the first two
years of the period, and that progress has been made in addressing it. However, access to child psychiatry remains less than optimal,
though this is a problem shared by other insurers.
CHART 14
VALUEOPTIONS OPEN SHOPPER SURVEY: PERCENTAGE OF PROVIDERS
MEETING STANDARD FOR APPOINTMENT ACCESS
Spring 02
Fall 02
Spring 03
CHART 15
2003 VALUEOPTIONS OPEN SHOPPER SURVEY: PERCENTAGE OF CHILD
PSYCHIATRISTS WITH IMMEDIATE AVAILABILITY FOR REFERRALS
Fall 03
75%
120%
100%
80%
77%
85%
82%
84%
86%
86%
84%
98%
92% 90%
89%
100%
100%
100%
100%
74%
60%
61%
52%
57%
55%
45%
60%
30%
40%
15%
20%
0%
Initial
Standard:
Routine
within 10 days
of request
Urgent
within 48 hours
of request
Emergent
0%
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Immediate
treatment options
Source: Fact Finders ValueOptions/Harvard Pilgrim 2001 Provider Survey, 2002 Provider Survey and 2003 Provider Survey.
Chart 14 & 15 - Definitions and Explanatory Notes
In an open shopper survey, the surveyor identifies themselves as a representative of ValueOptions and asks how soon an appointment could be offered. This
survey attempted to contact a random sample of ValueOptions providers and surveyors called back up to 5 times to complete the survey to ensure that it did not
include only easy-to-reach practitioners.
Page 59
3. Provider Issues
Provider representatives we interviewed for this project all
described considerable difficulties with a number of aspects
of the transition to ValueOptions and its contract terms and
policies.
These difficulties have been exacerbated by
inconsistent access to ValueOptions managers and changes
in administrative personnel caused by relocation to New
York State. These concerns were of sufficient significance to
make providers consider whether they should participate in
the ValueOptions network and to be a consideration in
deciding to serve HPHC members. However, they did not
prevent ValueOptions from being able to expand its network
over the three-year period. The issues most salient to
providers include:
•
•
Authorization procedures that are considered overly
time consuming, including:
Inpatient and continued stay authorization
Registration of outpatients at the change of year
Requests for outpatient continuing care that are
regarded as burdensome
According to several provider representatives, rates for
mental health counseling by psychiatrists are much
lower than for other Massachusetts HMOs, and rates for
other outpatient services began and have remained on
the low side compared to other payers.
•
Claims payment difficulties, including slow payment,
claims problems taking much effort to sort out, and
variable performance in paying claims. Respondents
indicated an improvement in the timeliness of claims
payment by the end of the period, though the move to
New York created a one-time claims lag.
Fact Finders was commissioned to conduct phone interviews
with a sample of ValueOptions’ provider network in 2001,
2002 and 2003. These surveys found considerable change in
how providers and facility administrators communicated
with ValueOptions to seek certification of mental health
care. While almost half of providers and administrators
preferred to certify care by phone, with about 20% each
designating an Interactive Voice Response (IVR) phone
system or Fax in 2001, in the following year about half
preferred the IVR. Preferences of providers changed again
in 2003, with providers roughly equally divided in
preferring phone, IVR and Fax. ValueOptions‘ website was
introduced in 2002 and preferred by almost 10%, but
preferences dropped to only 3% in 2003. These patterns
suggest either that this was a period in which providers
were experimenting with various methods for transmitting
authorization requests, or ValueOptions was promoting
different methods for receiving such requests.
New
methods, however, did not necessarily retain volume,
suggesting that they may not have realized their promise.
Page 60
Despite the problems and types of changes described above, Fact Finders’ surveys found that providers and facilities were largely
satisfied with ValueOptions overall, with about 90% or more somewhat or very satisfied. (See Chart 16.) Facility administrators’ ratings
fell somewhat in 2002, when 14% were not satisfied. In comparison to other behavioral health management organizations (MBHOs),
providers increasingly rated ValueOptions the same or better, but in 2002, over 40% of facilities rate ValueOptions as worse than other
MBHOs, dramatically worse than the prior year, and an indication that the procedures implemented in that year were very unpopular.
(See Chart 17.)
CHART 16
VALUEOPTIONS PROVIDERS: PERCENT VERY OR SOMEWHAT SATISFIED
WITH VALUEOPTIONS OVERALL
Providers
100%
89.4%
90.0%
95.6%
CHART 17
PROVIDER OFFICE SURVEY: COMPARED WITH OTHER MBHOS,
HOW IS YOUR EXPERIENCE WITH VALUEOPTIONS?
Administrators
92.5%
86.3%
52.0%
50.0%
50%
80%
About the same
60%
46.0%
43.5%
42.2%
40%
38.1%
35.6%
38.0%
39.1%
31.0%
60%
30%
22.2%
19.0%
20%
40%
17.4%
15.9%
10.0%
10%
20%
0%
2001
0%
2001
2002
2003
2002
Providers
2003
2001
2002
Administrators
Chart 16 & 17 - Definitions and Explanatory Notes
This survey was returned by 45 to over 60 providers and the administrators of 15 to 23 facilities. About half of the providers served 5 to 25 HPHC members, about
a quarter serving fewer than 5, and the remainder serving more than 25. Not surprisingly, the administrators who responded were from larger organizations; 80%
or more of them served more than 25 HPHC members and none served as few as 5. The providers were largely psychologists and social workers, with some
psychiatrists and other types of mental health practitioners. Mental health facilities included hospitals, residential facilities and outpatient clinics.
In spite of rising scores on its administrative functions over the three years, issues with authorization procedures and decisions continued
to be sounded, as themes in provider and facility administrator responses to open-ended questions regarding desired changes and
improvements.
Page 61
4. Claims Payment
Our analysis confirms that claims payment was a problem in
2001.
ValueOptions paid and resolved claims
extraordinarily slowly in 2001, with almost 70% of claims
paid in more than 90 days. Table 35 shows paid and other
resolved claims as a percent of total closed claims. However,
this performance improved dramatically in 2002, and
remained at a high level in 2003, indicating that timelines of
claims processing was not likely to be a problem for most
providers.
TABLE 35
PAID AND RESOLVED CLAIMS
AS PERCENT OF TOTAL CLAIMS IN 2001
30 days
60 days
90 days
>90 days
2001
Commercial
10%
21%
30%
100%
8%
23%
32%
100%
Commercial
81%
97%
98%
100%
Medicare
78%
97%
98%
100%
Medicare
The Fact Finders surveys of ValueOptions providers
confirmed that claims payment was an area with continued
problems. The surveys found that, while most providers
rated ValueOptions claims payment as good, very good or
excellent, there was a significant percentage, as high as 40%
of larger practices in 2002, that rated claims payment as fair
or poor (see Chart 18). Accuracy of claims payment was
rated higher than timeliness, and timeliness ratings actually
decreased between the first and last year rated despite the
improvement showed by Value Option’s claims aging data.
Over the three year period, there was a consistent increase in
the number of contacts that providers had with
ValueOptions over claims, and for facility administrators, a
quite dramatic increase (see Chart 19). However, most
providers were sometimes or usually satisfied with the
resolution of their claims issues, but a significant minority,
about 10% of providers, was rarely satisfied. Administrators
experienced greater satisfaction with resolution in 2002, with
only about 6% rarely satisfied, compared to 15% in the prior
year.
2002
2003
Commercial
87%
96%
98%
100%
Medicare
86%
97%
99%
100%
Source: ValueOptions Closed Claims Aging Summary, 2001, 2002 and 2003
Page 62
CHART 18
PERCENT RATING CLAIMS PAYMENT GOOD, VERY GOOD OR EXCELLENT
CHART 19
PROVIDER OFFICE SURVEY: NUMBER OF CONTACTS WITH
VALUEOPTIONS WITH A CLAIMS QUESTION OR PROBLEM
100%
Providers
88.6%
80%
77.8%
78.9%
78.3%
77.5%
80.0%
Administrators
71.1%
72.8%
1 to 3 calls
4-10 calls
59.6%
57.9%
40%
53.8%
41.0%
40.0%
31.6%
30%
34.2%
32.8%
20%
20%
15.4%
15.4%
10%
0%
Timeliness
2003
2001
2002
Accuracy
2003
2001
2002
2003
26.7%
25.9%
23.1%
2002
More than 40 calls
50%
62.5%
40%
2001
11 to 40 calls
60%
68.3%
66.7%
60%
None
79.5%
72.2%
18.4%
19.0%
20.0%
19.0%
15.8%
15.4%
7.7%
5.1%
0%
2002
6.7% 6.7%
3.4%
0.0%
2001
23.1%
0.0%
2003
2001
2002
Overall Rating
In addition, we analyzed provider complaints to ValueOptions. Balance billing and ValueOptions policies and procedures were matters
of significant concern to providers, though quality of care complaints were even more numerous. In 2003, Quality of Service remained the
most frequent reason for complaint, with grievances, claims, and policies and procedures following.
5. Utilization Management
Fact Finders surveys found that most providers rated ValueOptions procedures for certifying care as easy, and even more rated
certification decisions as appropriate. (See Charts 20 and 21.) However, while the number of providers experiencing procedures as easy
increased, facility administrators found procedures increasingly difficult, with 40% rating them so in 2002.
Page 63
CHART 20
VALUEOPTIONS PROVIDERS : PERCENT RATING VALUEOPTIONS’
PROCEDURES TO CERTIFY CARE AS EASY (VS. DIFFICULT)
Providers
100%
Administrators
CHART 21
VALUEOPTIONS PROVIDERS : PERCENT RATING VALUEOPTIONS’
COVERAGE DECISIONS AS APPROPRIATE FOR CLINICAL CONDITIONS
(VS. NOT APPROPRIATE)
Providers
89.2%
89.2%
84.2%
80%
74.3%
78.6%
87.5%
80.0%
80%
71.4%
Administrators
100%
78.9%
63.6%
60%
60%
40%
40%
20%
20%
0%
0%
2001
2002
2003
2001
2002
2003
A 2001 Fact Finders survey addressed members’ perceptions of the appropriateness of HPHC’s decisions to authorize their outpatient and
inpatient care. While most members were satisfied with the number of approved outpatient visits, more than a quarter (27.4%) was
dissatisfied. This seems quite high for the year when outpatient visit limitations were relaxed under parity laws, and there was little
actual review of outpatient visits until the 24th visit. In subsequent years, the rate of dissatisfaction dropped considerably, falling to 13%
for commercial members and 11% for Medicare members, despite the introduction of more frequent reviews. A smaller share of the
members who used hospital care – 13.3% - were dissatisfied with the number of approved days in the hospital in 2001, but their share
grew in 2002 when a full 40% were dissatisfied. In 2003, rates of dissatisfaction dropped, but the 29% for commercial remained quite high,
while among Medicare members only 11% were dissatisfied. This suggests that making the inpatient review process less frequent did not
necessarily make it less rigorous in terms of authorization decisions. It also suggests a difference in the perceptions of providers, who
mostly rated ValueOptions clinical decisions as appropriate, and members who were not satisfied with inpatient authorization decisions.
Peer Review data from 2001, summarized in Table 36, showed that HPHC members had a high chance – 52% for commercial members
and 75% for Medicare members – of having ValueOptions’ service authorization decisions reversed by a peer reviewer not involved in the
original decision. During the period, ValueOptions’ average time to make a decision was sometimes less than a half-day and seldom
exceeded two days. We did not receive data for 2002 or 2003 on peer reviews.
Page 64
Provider survey data suggests a rising trend in first level reviews
TABLE 36
over the period. Fact Finders found that facility administrators
VALUEOPTIONS PEER REVIEWS - MAY THROUGH DECEMBER 2001
were much more likely than providers to have spoken to a peer
advisor, and both were more likely to have contact with a peer
Commercial
Medicare
advisor at the end of the period than the beginning. About 30% of
Number
Per Thousand1
Number
Per Thousand
providers, rising to almost 40% in 2002, and over half of
Total
559
0.68
75
1.27
administrators, rising to 70% in 2002, had spoken to a peer
Disposition
Number
Percent
Number
Percent
advisor. Ratings of peer advisors’ mastery of treatment issues
Approved
290
52%
56
75%
were high. At least 80% of providers rated their mastery as
Modified
9
2%
0%
adequate in all years. In 2001, all administrators rated their
Denied
149
27%
9
12%
mastery as adequate, but in 2002, almost 30% rated mastery as
Other
111
20%
10
13%
inadequate – a dramatic change suggesting changes in personnel
or review standards. In contrast, providers rated consistency
1Enrollment prorated on a seven-twelfths basis.
between peer advisors and ValueOptions care managers fairly
Source: Peer review reports
low, with 40% of providers in 2001 and more than a quarter in
2003 saying the two staff were inconsistent. Facility administrators were less critical, with almost 90% rating decisions as consistent.
Again, we see a pattern with considerable change between years, suggesting changes in ValueOptions staff or decision making.
If the peer review denies the appeal, the
member or provider may file an appeal with
ValueOptions. Table 37 shows all appeals to
ValueOptions from all Massachusetts HPHC
Health Plans for 2001 through 2003. The
number of appeals increased considerably in
2003 and the pattern of appeals and of
dispositions varied considerably over the
period. Most appeals, ranging from three
quarters to 94% were from or on behalf of
members. Appeals from providers were
between 20 and 25% except in 2002, when
they represented only 6%. (This coincides
with providers’ highest ratings of Value
Option clinical decision making.) In 2001,
most, three quarters, of appeals were upheld
– that is ValueOptions affirmed the
authorization decision of its peer review
process, perhaps because many modifications
TABLE 37
VALUEOPTIONS APPEALS
FOR ALL HPHC PLANS IN MASSACHUSETTS 2001-2003
2001
2002
2003
Member appeals
Number
269
Percentage
74%
Number
343
Percentage
94%
Number
356
Percentage
80%
Provider appeals
96
26%
21
6%
88
20%
444
External appeals
Total appeals
Disposition
Upheld
Modified
Overturned
1
365
0%
0
100%
364
100%
224
65%
All Appeals
269
74%
0
100%
Member Appeals
98
27%
4
1%
9
3%
13
4%
92
25%
110
32%
246
69%
Source: ValueOptions/Harvard Pilgrim Health Care Appeals Summary for Massachusetts, Jan. through Dec. 2001,
2002 and 2003
Page 65
get made during peer reviews. However, this dropped to
65% in 2002 and precipitously to 27% in 2003. This shows an
extraordinary change in disposition of appeals that greatly
increased members’ chances of having the original decision
reversed in their favor. This may reflect a tighter approach
to authorization from the New York staff that had to be
modified to meet the enhanced access to care required to
comply with Massachusetts’ parity law.
Members may also appeal to HPHC. Appeals to HPHC
increased more than peer reviews between 2000 and 2001.
In 2002 and 2003, the number of Level II appeals dropped
considerably, not surprising given the greatly reduced
number of appeals that were upheld in Level I.
6. Coordination of Care
Increasingly, people are receiving mental health
medications prescribed by their primary care physicians.
From 2001 to 2003, surveys of members using ValueOptions’
services found that psychiatrists prescribed medications for
at least two-thirds of those whose treatment included
medications. Personal physicians prescribed psychotropic
medications for 11% to 13%. It should be noted that this
survey group had used specialty mental health services
managed by ValueOptions. Additional HPHC members are
prescribed psychotropic medications by their PCP, but do
not get ValueOptions’ services.
When specialty providers treat mental health conditions, it is
important that this care and any medications be coordinated
with care that the person may be receiving for non-mental
health conditions. This requires that behavioral health
providers – with appropriate client consent – communicate
with primary care physicians. A variety of surveys of
members, primary care physicians and ValueOptions
providers found differing perspectives on the consistency
with which primary care physicians and specialty mental
health providers communicate about the care of shared
clients. Members and ValueOptions providers consistently
reported more communication than primary care providers,
who indicated in 2001 that that only 16% of PCPs had
contact with mental health practitioners for most or all of
their cases who were seeing mental health practitioners and
41% percent said they had contact for few cases. In response
to these results, ValueOptions initiated quality improvement
activities that stressed:
• Addressing coordination of care in mental health
provider forums, HPHC Medical Directors’ Meetings,
policy manuals and newsletters;
• Having ValueOptions care managers instruct providers
to notify PCPs when one of their patients is admitted to
a psychiatric hospital; and
• Treatment Record Review audits to assess whether
coordination of care is documented.
In addition, HPHC’s case management program coordinates
with ValueOptions for members with a serious or complex
behavioral health condition or a co-occurring medical
condition. HPHC has also recognized that people with
chronic conditions are more likely to be depressed. HPHC
case managers therefore administer a validated threequestion depression-screening tool for their clients with
chronic illnesses. When potential depression is identified,
they notify the PCP and make a referral to ValueOptions.
They are also utilizing a risk assessment tool for new
Medicare enrollees, and are working to update the
behavioral health questions to better apply to older
individuals. HPHC follows-up if the screening survey is not
returned.
In addition, HPHC has recognized the
increasingly important role PCPs play in identifying and
treating mental health conditions and has posted guidelines
for depression detection in primary care developed jointly
by Value/Options and HPHC on HPHC’s website.
Page 66
7. DOI Behavioral Health Measures
In 2003, the Massachusetts Division of Insurance initiated new reporting requirements for provision of mental health and substance abuse
services. We found enough consistency between different health plans in their reporting of these data, to feel that they represented a
reasonably accurate snapshot of the provision of behavioral health care during 2003. However, insufficient data for Medicare cost was
reported to allow for analysis.
Table 38 suggests that
TABLE 38
HPHC is providing a
OUTPATIENT MENTAL HEALTH - ENCOUNTERS PER THOUSAND – 2003
higher level of access
to
non-physician
mental
health
HPHC
Other HMOs
HPHC
Other HMOs
outpatient care than
NonNonIntermediate
Intermediate
other
HMOs,
Plan Type
Physician physician Total
Physician
physician
Total
MH
MH
especially
for
its
Group (all ages)
127.5
712.8
840.3
162.1
581.0
743.1
11.4
12.9
Medicare
Risk
Medicare Risk
145.5
312.8
458.3
101.3
165.4
266.7
12.8
1.4
population. However,
Individual
269.4
1032.9
1302.3
311.2
811.4
1122.6
14.2
30.2
Individual and Group
members may have
Source: MA Division of Insurance 2003 Supplemental Utilization Report
less
access
to
psychiatry than other HMOs. HPHC showed differences in its relative use of community-based intermediate care, using more for
Medicare Risk members and less for Individual members than other HMOs. However, the relatively low level of use of intermediate care
by HPHC Individuals in comparison to other HMOs may well be offset by higher levels of access to outpatient care.
Table 39 shows
that
HPHC
members
utilized
more
psychiatric
inpatient days
per
thousand
members than
did
other
HMOs,
with
group members
using 60% more
TABLE 39
INPATIENT MENTAL HEALTH - ENCOUNTERS PER THOUSAND – 2003
Plan Type
HPHC
MH Days
Average
per
MH Length
Thousand
of Stay
Other HMOs
MH Days
Average
per
MH Length
Thousand
of Stay
HPHC
Intermediate Average
MH Days per
Length
Thousand
of Stay
Other HMOs
Intermediate Average
MH Days per
Length
Thousand
of Stay
Group
21
6.5
13
4.0
3.3
5.8
1.5
1.9
Medicare Risk
81
13.2
64
7.3
0.5
2.7
0.6
1.1
Individual
49
8.5
34
6.0
0.9
2.7
2.0
1.2
Page 67
days than other HMOs, Medicare Risk members 27% more and individual members almost 50% more. However, this differential was due
to HPHC’s longer lengths of stay. The number of inpatient admissions per thousand was lower for HPHC’s Medicare Risk and Individual
members than for other HMOs. HPHC’s group members used more intermediate 24-hour care than other HMOs, due to longer lengths of
stay rather than admission rates. But HPHC’s Medicare Risk and Individual members were less likely to use intermediate 24 hour than
other HMOs, despite longer average lengths of stay. There may be a number of reasons for the patterns observed. Since this is the first
year of reporting, unrecognized differences in counting services may create apparent differences in utilization patterns. HPHC may be
more attractive to individuals with mental health problems, and may have a caseload with more mental health treatment needs.
However,
it
TABLE 40
appears that HPHC
OUTPATIENT SUBSTANCE ABUSE - ENCOUNTERS PER THOUSAND – 2003
members
have
relatively
good
access to outpatient
HPHC
Other HMOs
HPHC
Other HMOs
and inpatient care.
NonNonIntermediate
Intermediate
They may profit
Plan Type
Physician
physician
Total
Physician
physician
Total
MH
MH
from greater access
Group (all ages)
1.4
20.9
22.3
3.1
32.9
36.0
7.2
7.91
to
intermediate
Medicare Risk
1.2
7.4
8.6
0.3
1.4
1.7
1.2
0.65
levels of care, and
Individual
3.0
34.8
37.8
11.2
76.8
88.1
16.4
13.49
to
outpatient
psychiatry.
HPHC group and individual members were considerably less likely to use outpatient substance abuse services than members of other
HMOs. Individual members, in particular, were less than half as likely to use outpatient substance abuse services. However, HPHC
Medicare Risk members had a much higher rate - over five times - of using substance abuse services than members of the other HMOs.
Use of intermediate community services showed a somewhat different pattern. Though Medicare Risk members had a rate of utilization
twice as high as
for other HMOs,
TABLE 41
individual
INPATIENT SUBSTANCE ABUSE - ENCOUNTERS PER THOUSAND – 2003
HPHC members
were
also
HPHC
Other HMOs
HPHC
Other HMOs
somewhat
SA Days
Average
SA Days
Average
Intermediate Average Intermediate
Average
higher,
and
per
SA Length
per
SA Length
SA Days per
Length
SA Days per
Length
group members
Thousand
of Stay
Thousand
of Stay
Thousand
of Stay
Thousand
of Stay
Plan Type
were
slightly
Group
7.4
3.6
6
3.4
0
0
1.2
2.5
lower.
Use of inpatient
substance abuse
Medicare Risk
3.5
5.2
5
5.7
0
0
0.2
1.6
Individual
15.5
3.9
7
2.9
0
0
0.7
1.6
Page 68
services showed an opposite pattern. HPHC group and individual members used more days per thousand and had longer lengths of stay
than in other HMOs, while its Medicare Risk members used quite a bit fewer inpatient days and had a slightly shorter length of stay. The
high rates of outpatient substance abuse treatment among HPHC’s Medicare Risk members may prevent them from needing the more
intensive inpatient care, while group and individual members, who get lower rates of outpatient care, may disproportionately use
hospital care. HPHC reported no use of intermediate 24-hour substance abuse care, but we do not know whether this meant that no
services were used or no data was reported. Overall, it appears that HPHC’s group and individual members are not getting as much
access to outpatient substance abuse care as other HMOs, which may contribute to their high rates of using inpatient care.
8. HEDIS Behavioral Health Measures
HEDIS measures are available for all four years and they have a consistent methodology across HMOs. However, though they exclude
Medicare Risk members, they do not stratify for other membership types and thus have relatively little ability to account for case mix
differences. Table 42 contains these measures for HPHC, comparing them to the state and national averages.
TABLE 42
HEDIS MENTAL HEALTH MEASURES - HPHC COMPARED TO STATE AND NATIONAL AVERAGES
National
Average
(HMO/ POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National
Average
(HMO/POS)
HPHC
(HMO/POS
combined)
National
Average
(HMO/ POS)
MA average
(HMO/ POS)
Ambulatory Care
9.89%
7.08%
4.55%
10.11%
7.67%
5.14%
10.27%
8.1%
5.17%
10.53%
8.26%
5.29%
Day/Night Care
.11%
.08%
.17%
.1%
.1%
.13%
.1%
0.11%
.1%
0.12%
0.11%
0.12%
MA average
(HMO/POS)
HPHC
(HMO/POS
combined)
2003
National
Average
(HMO/POS)
2002
MA average
(HMO/ POS)
2001
HPHC
(HMO/POS
combined)
2000
Mental Health
Inpatient
.25%
.23%
.23%
.21%
.26%
.26%
0.25%
0.22%
0.25%
0.27%
0.25%
0.23%
Overall
9.92%
7.12%
4.63%
10.14%
7.75%
5.21%
10.31%
8.15%
5.28%
10.57%
8.32%
5.4%
Discharges per thousand
3.57
8.01
days
3.07
6.77
days
2.63
5.98
days
3.4
7.66
days
3.43
7.25
days
2.83
6.11
days
3.93
6.87
days
3.54
5.96
days
2.81
7.17
days
4.24
6.2
days
3.45
7.53
days
2.77
5.99
days
Average length of stay
Source: NCQA Quality Compass 2001, 2002, 2003, and 2004
Page 69
Consistent trends were seen in overall use of mental health care and in utilization of ambulatory care. Utilization increased for HPHC,
Massachusetts as a whole, and nationally. HPHC had considerably higher penetration than the national average and was also higher than
the Massachusetts average for both measures, though its margin decreased over time. The rate of members using day/night care was
relatively similar in HPHC, Massachusetts and nationally over most of the period, and stayed similar over time.
Rates of use of inpatient care and the amount of inpatient care provided, however, was variable. The Massachusetts and national
averages did not show a consistent trend. HPHC had higher rates of members using inpatient care than either the Massachusetts or
national average, except in 2001, a one-year drop. HPHC’s length of stay decreased considerably, putting it well below the Massachusetts
average and making it similar to the national average, while continuing to have the highest rate of discharges. These results are
consistent with the profile of utilization shown by Division of Insurance data for 2003 and suggest that HPHC members have better than
average access to outpatient services, equivalent access to day/night care, and higher access to inpatient care. However, the high rates of
inpatient care and longer lengths of stay could be indications of either a higher need population or of less effective preventive care.
Table 43 shows that HPHC experienced consistent trends in provision of substance abuse services, beginning higher than the state and
national averages, dropping in 2001 and then increasing, but not regaining beginning levels and ending lower than the state average.
Nationally, overall utilization was remarkably stable over the four-year period, while Massachusetts experienced a trend of increasing use
TABLE 43
HEDIS SUBSTANCE ABUSE MEASURES - HPHC COMPARED TO STATE AND NATIONAL AVERAGES
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National
Average
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/POS)
National
Average
(HMO/ POS)
2003
.43%
.36%
.29%
.4%
.38%
.31%
.37%
.31%
.39%
0.38%
0.44%
0.32%
.1%
.05%
.03%
.06%
.07%
.04%
.07%
.04%
.05%
0.10%
0.07%
0.04%
Inpatient
.15%
.14%
.09%
.09%
.14%
.09%
.15%
.14%
.09%
0.14%
0.15%
0.09%
Overall
.51%
.45%
.35%
.46%
.47%
.37%
.47%
.48%
.37%
0.48%
0.53%
0.37%
HPHC
(HMO/POS
combined)
National
Average
(HMO/ POS)
2002
Day/Night Care
National
Average
(HMO/POS)
MA average
(HMO/ POS)
2001
Ambulatory Care
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
2000
Chemical Dependency
2.51
2.19
1.09
1.56
1.91
1.13
2.46
1.97
1.16
2.20
2.03
1.15
Average length of stay
4.56
days
3.71
days
4.94
days
3.93
days
4.03
days
5.12
days
2.78
days
4.05
days
5.12
days
3.11
days
4.07
days
4.78
days
Source: NCQA Quality Compass 2001, 2002, 2003 and 2004
Page 70
of substance abuse services. Overall, HPHC’s members
ended with somewhat less access to outpatient care, but
higher or similar rates of access to day/night and inpatient
care. However, its discharge rates were slightly higher and
its average length of stays somewhat lower. This can be an
indication that lengths of stay are not sufficient to fully
institute a recovery process and result in additional
admissions. These results are consistent with Division of
Insurance utilization data and together suggest that
substance abuse treatment is an area in which HPHC may
not offer as much access as do other Massachusetts HMOs.
However, in response to this report, HPHC reported that it
had experienced difficulties understanding ValueOptions’
reporting conventions during this period, including how
they categorized inpatient and outpatient services and
inconsistencies in how they reported claims for members
with both mental health and substance abuse diagnoses. If
ValueOptions reported claims with both mental health and
substance abuse diagnoses as mental health claims, it would
elevate mental health utilization and depress substance
abuse utilization, and might explain the patterns we
observed in the HEDIS and Division of Insurance data.
Because of the possibility that HPHC’s mental health and
substance abuse data are somewhat questionable, our
conclusions about HPHC’s relative provision of mental
health and substance abuse care should be considered
tentative. However, HPHC’s combined level of provision of
mental health and substance abuse care exceeds that of other
Massachusetts HMOs, suggesting its overall provision of
access to behavioral health services is high.
Table 44 shows that HPHC has excelled on HEDIS mental
health measures related to quality of care. It has ranked
highest in Massachusetts in providing follow-up care after
hospitalization within 7 and 30 days and has increased over
time. In fact, its 30-day rates have probably reached a
maximum level of performance at 93%. These measures
indicate how well HPHC is able to link its members to
continuing outpatient care after they have been hospitalized
for a psychiatric condition.
A second set of measures concerns effective antidepressant
medication management. HPHC usually exceeded both the
state and the national averages on all three measures. These
measures did not show as consistent a trend of improvement
as did the follow-up measures. However, HPHC showed
improvement on all measures at the end of the period.
Page 71
TABLE 44
HEDIS MEASURES OF APPROPRIATE MENTAL HEALTH TREATMENT
National
Average
(HMO/ POS)
HPHC
(HMO/POS
combined)
MA Average
(HMO/ POS)
National
Average
(HMO/POS)
HPHC
(HMO/POS
combined)
MA Average
(HMO/POS)
National
Average
(HMO/ POS)
7 days
68.83%
59.49%
48.23%
68.83%
59.29%
51.21%
72.58%
57.85%
52.69%
78.7%
62.47%
54.44%
30 days
86.78%
80.34%
71.18%
86.78%
80.02%
73.18%
93.18%
80.06%
73.56%
91.09%
82.55%
74.42%
21.55%
27.49%
19.79%
30.03%
30.1%
19.18%
37.62%
32.46%
20.3%
57.39%
63.19%
56.78%
66.7%
63.75%
59.8%
66.22%
63.32%
60.71%
40.00%
48.22%
40.03%
51.96%
46.33%
42.8%
50.51%
47.57%
44.12%
HPHC
(HMO/POS
combined)
MA Average
(HMO/ POS)
2003
HPHC
(HMO/POS
combined)
2002
National
Average
(HMO/POS)
2001
MA Average
(HMO/ POS)
2000
Follow-up after Hospitalization
Antidepressant Medication Management
Optimal Practitioners
28.83%
Contact
Effective Acute Phase
65.33%
Effective Continuation
49.44%
Phase
Source: NCQA Quality Compass 2001, 2002, 2003 and 2004 and HPHC communication
Page 72
9. Access to
TABLE 45
COMMERCIAL AND FIRST SENIORITY CLAIMS PER THOUSAND
OF SPECIFIC DRUG CLASSES
Psychotropic
Medications
As shown in Table 45,
antipsychotic
use
increased considerably,
more than 20%, for both
group and Medicare
members. The rate of
increase was fastest, 40%
to almost 60%, for Tier 1
drugs. Tier 2 drugs, the
most highly utilized tier,
grew at 15% to 20%.
This drug class was used
much more intensively
by
First
Seniority
members. These results
suggest that HPHC
members
have
experienced increased
utilization of these
effective psychotropic
drugs.
Class
Description/
Tier
Commercial
Measures
Outcome
Table 46 shows a
reduction in the rate at
which outpatient clients
move to a higher level
of care, with Medicare
members showing a
particularly
dramatic
reduction in the rate of
2000
2001
2002
2003
% Difference
2000-2003
Tier 1
0.9
1.3
1.4
1.6
42%
5
8
9
8
58%
Tier 2
31
37
45
50
16%
96
114
106
120
19%
Tier 3
0
1
1
0
-
2
1
1
Total
32
39
47
52
101
124
116
129
21%
23%
Source: Attorney General RFI - Three Tier Analysis of Drugs in Selected Classes, 2000-2003
Atypical antipsychotics are relatively new medications that are used to treat some of the more serious illnesses, such as
schizophrenia. They are more effective than older medications for many people, and generally have less unpleasant side
effects. However, they are among the most expensive drugs.
TABLE 46
VALUEOPTIONS PERCENT OF MEMBERS DISCHARGED FROM A LEVEL OF CARE
MIGRATING TO HIGHER LEVEL OF CARE
2001
Level of Care
2002
Medicare
2.5%
Day Treatment
2.9%
no discharges
Intensive Outpatient
2.7%
0.0%
6.3%
-
5.5%
2.9%
2.5%
8.4%
9.4%
10.0%
7.2%
11.8%
12.5%
9.6%
-
12.7%
12.5%
Partial Hospitalization
Residential
Commercial
0.5%
2003
Commercial
0.7%
Outpatient
10. Other
First Seniority
% Difference
2000
2001
2002
2003
2000-2003
Antipsychotics, Atypical, Dopamine & Serotonin Antagonists
Medicare
1.4%
Commercial
0.4%
Medicare
0.8%
-
Source: ValueOptions Monthly Migration to Higher Level of Care, 2001-2003
Good clinical treatment should refer clients to the appropriate level of care to best meet their needs. Good treatment
principles also call for treatment to be at the least restrictive level of care. That is, clients should be treated in the
community rather than a residential or hospital setting as long as treatment goals can be met and clients are safe.
ValueOptions reports on the number of clients who move to a higher level of care.
Page 73
moving to more intensive care. Other levels of care are used by many fewer members, and may consequently vary considerably from
year to year based on changes in the characteristics of the relatively small group. These other levels show an increase in the rate at which
members move to a more intensive level of care. However, this may be an indication that more individuals are being offered these
alternatives to hospitalization, and that they are not sufficient for some members.
Table 47 shows considerable increases in readmission rates for most groups by the end of the period. The only reduction came for
Medicare members discharged from mental health hospitals. Commercial members discharged from both mental health and substance
abuse treatment and Medicare members discharged from substance abuse treatment were readmitted up to twice as frequently in 2003 as
in 2001. For some groups, this was actually a decrease from 2002 levels. These data would suggest that, while HPHC members have
relatively long lengths of stay (as compared to other Massachusetts HMOs) are receiving prompt services in the community (as indicated
by HPHC’s HEDIS follow-up after hospitalization rates), these services are not successful in preventing a readmission to inpatient level of
care.
TABLE 47
VALUEOPTIONS RATES OF READMISSION TO INPATIENT CARE AFTER DISCHARGE
2001
Mental Health
Commercial
Medicare
2002
Substance Abuse
Commercial
Mental Health
Medicare
2003
Substance Abuse
Mental Health
Substance Abuse
Commercial
Medicare
Commercial
Medicare
Commercial
Medicare
Commercial
Medicare
7 days
3.5%
3.5%
1.9%
6.7%
7.1%
10.4%
2.9
2.1%
7.0%
7.3%
2.7%
12.5%
30 days
9.6%
13.2%
7.7%
10.0%
16.3%
16.3%
13.9%
10.6%
15.2%
10.5%
12.8%
20.8%
90 days
16.2%
20.1%
15.9%
13.3%
24.2%
23.6%
25.3%
10.6%
24.8%
16.7%
24.2%
25.0%
Source: ValueOptions Monthly Recidivism Rates - Psychiatric vs. Substance Abuse 2001, 2002 and 2003
The rate of readmission to hospital level care after a hospital discharge is an important measure of quality of behavioral health care. While readmission can be an
important aspect of treatment for some individuals, in most cases it is regarded as undesirable and may indicate that the initial admission did not accomplish all that
it should have and/or that follow-up care was not sufficient or effective. ValueOptions documents its rates of readmission to psychiatric and substance abuse
hospital care at 7, 30, and 90 days after discharge.
Page 74
11. Member Satisfaction
received quite highly. (See Charts 22 and 23.) Ninety-five
percent rated their therapist as excellent, very good or good,
and the percent of those completely, very, and somewhat
satisfied increased from 87% to 94% for commercial and 95%
for Medicare members. Most members, (77 to 86%),
indicated that their general condition was better as an
outcome of mental health treatment. (See Chart 24.) While
there was some decline in those rating their outcomes as
better, the small percentage (2.4%) that indicated that their
condition was worse in 2001 dropped to nothing in 2003.
More than half (57.6%) were very satisfied with their
progress in 2001, growing to over two-thirds in 2003, while
those who were not satisfied dropped from 8% to 2%. (See
Chart 25.)
We analyzed several sources of information about members’
satisfaction with their behavioral health services. These
included complaints, the Fact Finders member survey, and
interviews with advocacy organizations. The most frequent
complaints received by ValueOptions from its HPHC
members had to do with quality of care or of service,
followed closely by complaints about ValueOptions policies
and procedures. Other concerns were appointment access
and claims.
However, HPHC members surveyed by Fact Finders
increasingly rated the quality of mental health services they
CHART 22
VALUEOPTIONS SURVEY OF HPHC MEMBERS:
PERCENT RATING THERAPIST GOOD, VERY GOOD OR EXCELLENT
CHART 23
PERCENT COMPLETELY, VERY OR SOMEWHAT SATISFIED WITH MENTAL
HEALTH SERVICES
100%
100%
94.7%
94.7%
97.5%
95.0%
80%
80%
60%
60%
40%
40%
20%
20%
0%
86.8%
91.4%
93.8%
95.3%
0%
2001
2002
2003
2001
2002
2003
Source: Fact Finders 2001, 2002 and 2003 ValueOptions/Harvard Pilgrim Member Surveys.
Page 75
CHART 24
PERCENT OF MEMBERS WHOSE GENERAL CONDITION IS
BETTER, THE SAME OR WORSE
Better
About the same
CHART 25
PERCENT OF MEMBERS SATISFIED WITH THEIR PROGRESS TOWARD
TREATMENT GOALS
Worse
Very satisfied
100%
75%
85.6%
82.1%
77.4%
80%
63.3%
78.9%
60%
60%
45%
40%
30%
21.2%
16.8%
1.4%
0%
2001
2002
1.0%
2003 Commercial
32.4%
30.1%
30.5%
21.1%
15%
12.0%
2.4%
Not very satisfied
67.8%
57.6%
34.8%
20%
Somewhat satisfied
68.0%
0.0%
2003 Medicare
7.6%
4.3%
2.0%
1.7%
0%
2001
2002
2003 Commercial
2003 Medicare
Source: Fact Finders 2001, 2002 and 2003 ValueOptions/Harvard Pilgrim Member Surveys.
Members were not highly impressed with the assistance they got from ValueOptions’ 800 number. Of the 48 respondents who had used
it, one-third said that they did not get the information they needed on their first call. These percentages jumped in 2003 to 40% of
commercial members and 60% of Medicare members. Initially, little more than one-third rated the accuracy of the information they got as
excellent or very good. Almost as many (29.2%) rated it fair or poor. This improved somewhat in 2002 and stayed at that higher level for
commercial members, but a third of Medicare members rated the accuracy of the information they got as poor. These figures indicate a
significant worsening in ValueOptions’ responsiveness to member information needs in 2003, particularly for Medicare members.
However, scores on the cultural sensitivity of phone staff was rated high.
We also solicited feedback from mental health advocacy groups and sought feedback from individual HPHC members. There was
considerable response about the first two years of our assessment period which identified issues such as members feeling pressure to limit
their inpatient stays, problems with ValueOptions’ crisis provider and the added complexity of communicating with both HPHC (for
medication related concerns) and ValueOptions for treatment concerns. One HPHC family described expending considerable energy to
get the right residential and inpatient mental health services, and had difficult experiences accessing crisis care. However, one
organization commented that the ValueOptions hospital network and substance abuse services were probably an improvement over the
more limited HPHC resources for inpatient and substance abuse services that they replaced. For the final two years, there was less sense
Page 76
that HPHC was different from other HMOs, though some were aware of HPHC’s low provider payment and burdensome authorization
procedures. A number of the difficulties they noted, such as difficulties in finding psychiatric care, were noted as problems of the overall
Massachusetts health system.
B.
PRESCRIPTION COVERAGE
HPHC’s pharmacy program changed subcontractors close to the time of the receivership, as it began working with a new pharmacy
benefits manager (PBM), MedImpact, and coincidentally, introduced a tiered pharmacy program that established different co-pays for
drugs assigned to three tiers. This tiered co-pay system was introduced to members at the time their employer’s contract was renewed.
An HPHC internal committee is responsible for assigning a new drug to a tier based on literature review and clinical discussion. Tier copays have generally increased over the 4 years, but there has been no change in the PBM or its basic processes during the four-year period
of this analysis.
1. Pharmacy Network
Pharmacies
per
Thousand
Number of
Pharmacies
Pharmacies
per
Thousand
2003
Number of
Pharmacies
2002
Pharmacies
per
Thousand
2001
Number of
Pharmacies
Appeals per thousand regarding pharmacy
services were the most frequent type of appeal for
commercial members in 2000, when the tiered
2000
Pharmacies
per
Thousand
2. Pharmacy Appeals
TABLE 48
HPHC PHARMACY NETWORK BY REGION
Number of
Pharmacies
Though the number of pharmacies in HPHC’s
network decreased overall between 2000 and 2003,
due to falling membership, the relative number of
pharmacies per thousand members actually
increased somewhat. (See Table 48.) The rate of
network pharmacies per thousand members varies
by region, with MetroWest having the lowest rate
and the Western region having a very elevated
rate. However, many towns in MetroWest have
two or more pharmacies. The high rates of the
Western region are partly due to its small HPHC
membership and may not reflect greater access.
Overall, pharmacy access does not appear to be a
problem.
Boston
115
1.4
115
1.7
103
1.7
104
1.6
Metro West
236
1.1
225
1.3
209
1.4
209
1.4
North East
157
2.6
119
2.5
130
2.8
114
2.2
South East
373
1.3
390
1.8
324
1.6
354
1.8
Central
123
2.0
119
2.9
105
2.9
125
3.2
Western
212
14.1
186
22.9
155
22.2
148
23.4
1,216
1.5
1,154
2.0
1,027
2.2
1,054
2.2
Region
Grand Total
Source: HPHC Pharmacy Network List, 2000, 2001, 2002 and 2003
Page 77
pharmacy benefit was introduced. However their frequency
decreased 40% between 2000 and 2003, and they fell to the
fifth most frequent reason in 2003. Appeals regarding the
three-tier formulary decreased considerably, while those
regarding drugs not being covered or the criteria for
coverage not being met became more significant.
This
pattern suggests that much of the appeal volume was related
to the introduction of the tiered formulary and that members
learned to work with the formulary fairly quickly.
3. Pharmacy Cost and Utilization
We used data from Express Scripts, Inc., a pharmacy
management company, to provide a point of comparison to
HPHC. They analyze a sample of scripts from their
customers to report on national trends in their mixed
commercial population that was approximately one-third
managed care in 2001 and 25% managed care in 2003 with
the balance fee for service. The full retail list price of the
medication is used for cost. They found a 17.2% growth in
overall per member per year pharmacy costs for their
managed care members in 2001, 18.5% growth in their entire
(managed care plus fee for service) membership in 2002 and
15.5% in 2003. This was the lowest rate of increase
experienced since 1997. Overall, per member costs increased
60.4% between 2000 and 2003. In 2001, they attributed 56.8%
of the increase to a rise in prescription costs, 37.3% to an
increase in utilization, and 5.9% to the introduction of new
drugs. In 2003, 48% of the increase was due to a rise in costs,
4.7% was due to increases in utilization, and 4.5% was due to
the use of new drugs not available in the prior year. Thus,
over the period, utilization became a less important driver
than price of existing drugs.
HEDIS data, as shown in Table 49, also show a pattern of
growth for its wholly managed care sample similar to the
trends described above. Nationally, utilization grew 17%
over the four-year period, while average prescription costs
increased more steeply – at 47%. This suggests an overall
rate of growth in pharmacy expenditures somewhat higher
than that of the Express Scripts sample. Massachusetts
showed both higher utilization and costs than the national
average and grew faster than the national average, and its
utilization rate increased by 25%, considerably more than
the national average, while its costs increased at a similar
rate, 45%.
According to these figures, HPHC increased
most of all. While its utilization was at a similar level to the
average for Massachusetts HMOS in 2000, its 34% rate of
growth resulted in much higher utilization than the
Massachusetts average by 2003. Its average cost per
prescription was somewhat higher than the average for
Massachusetts in 2000, but grew at a somewhat higher rate,
49%, determining that it would remain above the state and
national average in 2003. This suggests that HPHC members
have a high level of access to pharmacological treatment.
Depending on cost sharing arrangements, however, they
may be paying somewhat higher prices than they would for
other insurers.
Page 78
TABLE 49
HEDIS MEASURES OF OUTPATIENT DRUG UTILIZATION
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/POS)
National Avg.
(HMO/POS)
2003
National Avg.
(HMO/POS)
Average cost of
prescriptions
2002
MA average
(HMO/ POS)
Average number of
prescriptions per
member per year
2001
HPHC
(HMO/POS
combined)
2000
8.46
8.53
8.75
10.56
9.5
9.0
10.81
10.1
10.06
11.32
10.69
10.21
$32.35
$30.17
$29.11
$37.12
$34.90
$32.45
$42.6
$39.84
$37.49
$48.25
$43.89
$42.68
We also analyzed detailed data from HPHC’s standard reports on pharmacy cost and utilization. Table 50 shows that HPHC’s average
cost of prescriptions per thousand increased 13% between 2000 and 2003, much less than the per member increase in the Express Scripts
sample cited above or the 49% growth shown in HPHC’s HEDIS data. The expenditures presented are the net cost to HPHC after the
member co-pay is deducted, and are thus not entirely consistent with the full price data used in HEDIS and the study described above.
Increased co-pays for the higher tiers would have absorbed some of the cost increases occurring in this period and shifted some utilization
from higher priced to lower priced medications. Cost changes differed considerably between different classes of medications, with some
classes actually decreasing. The overall increase in HPHC payments for medications is due to some combination of increases in the price
of medications, the addition of new medications, or in the percentage of members using medications, but our data do not allow us to
analyze their relative contributions.
The most dramatic decreases were in three drug classes used to treat pigmentation disorders, weight reduction, and pain management.
Only pain management drugs are used by many individuals. Significant increases occurred for drugs to treat other respiratory disorders,
psoriasis and eczema, and other drugs.
Page 79
TABLE 50
HPHC COMMERCIAL PLANS
AVERAGE PRESCRIPTION EXPENDITURE PER THOUSAND BY MAJOR DRUG CLASS
Class Description
Allergy
Antiemesis/Antivertigo
Asthma
Autonomic Nervous System
Disorders
Behavioral Health –
Antidepressants
Behavioral Health – Other
Cardiovascular Disease Arrhythmia
Cardiovascular Disease –
Cardiac Stimulant
Cardiovascular Disease Hypertension
Lipid Irregularity
Miscellaneous Agents
Vasodilation
Contraception/Oxytocics
Cough and Cold
Dermatology - Acne
Dermatology – Antiinfective
Dermatology –
Antiinflammatory
Dermatology – Antipruritic
Drugs
Dermatology – Miscellaneous
Dermatology – Pigmentation
Disorders
Dermatology Psoriasis/Eczema
Diabetes
2000
$525
$31
2001
$541
$32
2002
$571
$33
2003
$452
$33
%
Difference
2000-2003
-14%
6%
$414
$436
$440
$446
8%
$45
$42
$35
$33
-27%
Infectious Disease – Bacterial
$700
$790
$883
$917
31%
$392
$434
$469
$503
$9
$10
$9
$26
$25
$1,222
Class Description
Hormonal Deficiency
Immunization
Immunosuppression/
Modulation
%
Difference
2000-2003
-57%
-67%
2000
$442
$3
2001
$440
$3
2002
$350
$2
2003
$192
$1
$16
$18
$19
$20
25%
$821
$860
$849
$873
6%
Infectious Disease – Fungal
$43
$45
$49
$50
16%
28%
Infectious Disease –
Miscellaneous
$18
$21
$21
$23
28%
$9
0%
Infectious Disease – Parasitic
$42
$43
$42
$42
0%
$20
$19
-27%
Infectious Disease - Viral
$63
$68
$83
$86
37%
$1,330
$1,350
$1,393
14%
Inflammatory Disease
$398
$419
$422
$417
5%
$436
$504
$550
$582
33%
Local Anesthesia
$4
$4
$4
$4
0%
$8
$9
$11
$12
50%
$40
$41
$41
$40
0%
$36
$33
$27
$25
-31%
$30
$33
$37
$41
37%
$545
$124
$595
$125
$639
$120
$654
$118
20%
-5%
$10
$41
$11
$46
$10
$11
$12
$13
20%
-68%
$83
$89
$92
$87
5%
$8
$9
$46
$47
488%
$133
$139
$134
$125
-6%
Lower Gastrointestinal
Disorders–Bowel Inflammat
Lower Gastrointestinal
Disorders - Other
Miscellaneous Agents
Neoplastic Disease
Neurological Disease –
Miscellaneous
Oral/Pharyngeal Disorders
$17
$19
$11
$12
-29%
$124
$127
$127
$120
-3%
Other Drugs
$10
$14
$24
$24
140%
$0
$0
$0
$0
0%
Other Respiratory Disorders
$0
$0
$29
$31
310%
$20
$22
$21
$19
-5%
Pain Management - Analgesics
$452
$478
$0
$0
-100%
$1
$0
$0
$0
-100%
Parkinson’s Disease
$15
$16
$502
$518
3,353%
$8
$12
$17
$21
163%
Seizure Disorder
$206
$224
$15
$16
-92%
$270
$294
$414
$418
55%
Skeletal Muscle Disorder
$75
$81
$86
$88
17%
Page 80
TABLE 50 (CONTINUED)
HPHC COMMERCIAL PLANS
AVERAGE PRESCRIPTION EXPENDITURE PER THOUSAND BY MAJOR DRUG CLASS
Class Description
Ear – General Disorders
%
Difference
2000-2003
7%
2000
$29
2001
$31
2002
$33
2003
$31
Electrolyte Reguation
$33
$34
$30
$31
-6%
Endrocrine Disorder Fertility
$79
$93
$102
$108
37%
Endrocrine Disorder - Other
$72
$102
$126
$141
96%
$251
$274
$286
$293
17%
$99
$100
$100
$99
0%
Eye - Glaucoma
$46
$48
$44
$47
2%
Eye – Miscellaneous
Gout and Related Diseases
Hematological Disorders
$0
$40
$52
$0
$43
$60
$0
$43
$63
$0
$45
$75
0%
13%
44%
Endrocrine Disorder Thyroid
Eye – General Disorders
Class Description
Smoking Cessation
Upper Gastrointestinal
Disorders – Digestive
Disorders – Spastic Disease
Disorders – Ulcer Disease
Urinary Tract – Functional
Disorders
Vaginal Disorders
Vitamin and/or Mineral
Deficiency
Weight Reduction
Grand Total
%
Difference
2000-2003
-50%
2000
$6
2001
$5
2002
$4
2003
$3
$3
$3
$2
$2
-33%
$14
$14
$14
$13
-7%
$343
$378
$422
$451
31%
$48
$55
$60
$65
35%
$27
$29
$31
$32
19%
$135
$152
$156
$158
17%
$2
$0
$0
$0
$9,187
$9,907
$10,380
$10,382
-100%
13%
Source: HPHC Prescriptions by tier by broad pharmacy class, 2000, 2001, 2002 and 2003
We looked in more detail at the top five drug classes
for which the greatest amount was spent, analyzing
data on the number of members actually using
prescription medication, and the number of
prescriptions written. The top five changed a little
over the four years, as shown.
As presented in Table 52, these data allow us to better
understand the relative importance of price changes
and utilization changes in the drug classes accounting
for the most expense. Each class was compared to the
Express Script national sample.
The sample
represents about one-third managed care and two-
TABLE 51
HPHC TOP FIVE PHARMACY CLASSES
2000
2001
2002
Allergy (Antihistamines)
X
X
X
Behavioral Health – Antidepressants
X
X
X
X
Cardiovascular Disease – Hypertension
X
X
Cardiovascular Disease - Lipid Irregularity
X
X
X
X
Upper Gastrointestinal Disorders - Ulcer Disease
X
X
X
X
Infectious Disease - Viral
Other Behavioral Health
2003
X
Source: Attorney General RFI - Three Tier Analysis of Drugs in Selected Classes
Page 81
thirds non-managed care. In contrast to the net cost figures presented for HPHC, Express Script costs are average wholesale prices and
they account only for price changes, where HPHC costs are the net effects of price changes and changes in the mix of drugs being
prescribed.
TABLE 52
HPHC COMMERCIAL CLAIMS PER THOUSAND
TOP FIVE DRUG CLASSES COMPARED TO EXPRESS SCRIPT SAMPLE
Claims per thousand
Class Description/ Tier
2000
2001
2002
2003
Net HPHC cost per claim
% Difference
2000
2001
2002
2003
% Difference
Tier 1
634
714
Tier 2
432
461
Tier 3
72
63
Total
1,138
1,238
Express Scripts Average
710
13%
Not Included in
Top 5
770
$4.68
$5.43
7%
$26.54
$25.97
-13%
$20.03
$16.38
9%
$13.95
$13.64
9.8%
16%
Not Included in
Top 5
Express Scripts
Inflation Rate
-2%
-18%
-2%
4%
Tier 1
24
25
Tier 2
380
443
509
Tier 3
6
7
12
Total
411
475
550
490
570
650
28
23%
$15.95
$17.98
$18.94
$27.42
72%
527
39%
$69.39
$68.39
$74.38
$78.92
14%
26
335%
$40.08
$45.24
$41.80
$41.21
3%
582
42%
$65.75
$65.39
$70.79
$74.63
14%
760
55%
Express Scripts Inflation Rate
18%
29
Tier 1
153
198
282
309
102%
$5.24
$23.45
$18.30
$18.52
254%
Tier 2
523
560
588
602
15%
$77.22
$76.45
$74.25
$79.25
3%
Tier 3
12
12
14
5
-54%
$90.38
$76.43
$66.79
$68.16
-25%
Total
688
770
883
917
33%
$61.49
$62.82
$56.29
$58.69
-5%
550
620
720
800
64%
21%
Tier 1
107
113
117
183
71%
$27.40
$18.93
$9.30
$49.94
82%
Tier 2
204
239
302
266
31%
$121.16
$121.87
$125.23
$127.12
5%
Tier 3
18
10
3
1
-94%
$78.14
$87.01
$111.38
$120.66
54%
Total
329
362
422
451
37%
$88.29
$88.84
$92.90
$95.72
8%
400
420
500
560
40%
17%
Page 82
TABLE 52 (CONTINUED)
HPHC COMMERCIAL CLAIMS PER THOUSAND
TOP FIVE DRUG CLASSES COMPARED TO EXPRESS SCRIPT SAMPLE
Claims per thousand
Class Description/ Tier
2000
2001
2002
2003
Net HPHC cost per claim
% Difference
2000
2001
2002
2003
% Difference
Allergy
Tier 1
26
26
25
-2%
$4.12
$4.48
$5.77
40%
Tier 2
400
413
451
13%
$36.66
$37.98
$43.90
20%
Tier 3
94
91
94
0%
$41.55
$41.43
$50.55
22%
Total
520
531
571
10%
$35.91
$36.92
$43.31
21%
290
330
370
28%
20%
-8%
$10.91
Infectious Disease – Viral
Tier 1
Tier 2
Tier 3
Total
Not Included in
Top 5
26
$24.21
20
$53.00
7%
7
$8.88
29%
83
$86.09
4%
60
70
Not Included in
Top 5
17%
$9.24
-15%
$432.18
$396.78
-8%
$275.15
$473.63
72%
$285.47
$295.70
4%
Express Scripts
Inflation Rate
7%
HPHC response to Attorney General RFI - Three Tier Analysis of Drugs in Selected Classes, 2000-2003
Express Scripts, Inc. 2001, 2002 and 2003 Drug Trend Report, www.express-scripts.com, Tables 2 and 3.
Generic drugs are assigned to Tier 1, which has the lowest co-pay. New drugs with a generic or lower priced alternative are assigned to Tier 3
with the highest co-pay. Others fall in Tier 2, whose co-pay falls in the middle.
Cardiovascular disease/hypertension drugs were the most highly utilized drug class, both for HPHC and in the Express Script sample at
the beginning of the period. HPHC members had considerably higher utilization of these drugs than the Express Script’s sample,
suggesting a high degree of access. Overall, HPHC’s rate of growth for this class was similar to that of the Express Script sample. Express
Script attributes this growth to the increasingly aggressive treatment of high blood pressure. Hypertension drugs are not particularly
expensive, but they did experience price changes. Costs rose for the most inexpensive drugs, and fell for the more expensive drugs in
Tiers 2 and 3, for an overall reduction of 2% in HPHC’s costs. Express Scripts showed an almost 5% increase in total wholesale cost.
Page 83
Because these drugs are relatively low priced, they fell from
the top five after 2001, even though their utilization
remained high.
Drugs to control lipids experienced the highest rate of
growth in utilization in HPHC, as it did in the Express Script
sample, which moved it into the top spot for Express Scripts.
However, HPHC’s utilization rate fell well below that in the
Express Script sample, and did not increase as rapidly,
making it HPHC’s third drug class. This differential raises
the question about whether these drugs are prescribed as
much as they should be. This class of drugs is more
expensive than those used to treat hypertension. Overall
costs to HPHC for this class rose dramatically in Tier 1, but
by 14% overall, less than the price inflation rate of 18%.
Antidepressants are both quite costly and used by a
considerable number of people. This class rose to become
HPHC’s top drug class in 2003, but was rated third in the
Express Scripts sample. Both groups showed a dramatic
change in utilization between 2000 and 2003, reflecting, at
least in part, the introduction of a generic version of the drug
Prozac in 2001. This increased utilization in Tier 1 by over
100%, while raising the costs to HPHC for that tier 250%.
Utilization also increased in Tier 2, while costs were stable.
Utilization of Tier 3 drugs, much less significant than
utilization levels in Tiers 1 and 2, fell considerably and costs
dropped. HPHC showed a significantly higher rate of
utilization of anti-depressants than the Express Script
sample, but didn’t grow as fast. HPHC costs actually
dropped slightly, despite a 21% increase in prices.
Drugs to treat ulcer disease were the most expensive in the
top 5 tiers, but are not quite so widely used as some of the
other drug classes listed in this table. HPHC does not
prescribe these drugs as frequently as the Express sample,
but utilization grew at a similar rate. Some of the growth in
this group of drugs is in response to advertising direct to the
consumer. Most HPHC utilization falls into Tier 2, but most
of the growth was in Tier 1, which almost doubled its
average cost. Utilization of Tier 3 declined precipitously.
However, it appears that much of the reduction in that tier
was due to reductions in prescriptions for Pepcid, a drug
also available in over the counter versions, and in drugs also
listed in Tier 2, where their utilization rates increased.
Therefore, this utilization reduction may not have reduced
access substantially. HPHC’s cost for this class of drugs was
contained to a growth rate of 8%, considerably less than the
price inflation rate.
Allergy medications are moderately priced within the top
five tiers, and their Tier 2 options are used at quite a high
rate. Utilization in this tier increased a little, by 13%.
HPHC’s utilization was much higher than that in the
Express Script sample, but did not grow as fast. This drug
category was affected by having a major drug, Claritin,
released for over the counter distribution, which likely
reduced the use of prescription Claritin and possibly other
antihistamine drugs. These utilization patterns suggest that
HPHC makes this class of drugs widely available, and may
have met most of the need. HPHC costs for Tier 2 drugs
increased by 20%, similar to the price inflation rate.
Antiviral medications entered the top five in 2002, due to
high cost and increasing utilization, partly driven by a flu
epidemic in the fall of 2003. This category includes both
tamiflu and the Herpes and HIV anti-virals.
HPHC
members used these medications at higher rates than the
Express Script sample. The least used Tier 3 medications
experienced substantial growth in both utilization (29%) and
cost (72%), while the other tiers experienced small or
declining utilization growth and drops in average price.
HPHC’s overall costs for this class did not grow as fast as
price increases.
Page 84
Overall, this analysis suggests that HPHC experiences
relatively high utilization in 4 of the 6 drug classes, when
compared to a primarily non-managed care commercial
population, and has experienced similar rates of growth in
three of the classes. In most of these classes, ‘Express
Scripts’ sample experienced the same or higher rates of
growth, tending to somewhat lessen the difference with
HPHC. Utilization of lipid management drugs and those to
treat ulcer disease are significantly less for HPHC, and may
be a reason for concern, especially for lipid lowering drugs
where the gap is growing. HPHC’s tiered pharmacy
program appears to be effective in sharing drug price
increases with members, in encouraging use of Tier 1 drugs
and in reducing utilization among Tier 3 drugs. In general,
HPHC’s expenses have been less than drug price increases.
We caution that his analysis is not definitive, because we
have no way to account for any differences in case mix that
might explain the variation. Later in the chapter, we review
use of lipid lowering drugs in a high-risk subpopulation to
provide one indication of the effects of HPHC’s prescription
patterns.
We asked HPHC to identify any changes in its
formulary that moved a drug from one tier to a
higher tier. Since the co-pay would be higher for a
higher tier, this kind of change could discourage
utilization, while a change in the opposite
direction would make access to the drug easier for
those for whom it was prescribed. It is very
unlikely that a drug would move from Tier 1 into
a higher tier, since the drugs in this tier are generic
and will remain so. The only tier changes made in
our analysis period were to move Cytoven and
Lariam from Tier 2 into Tier 37 (see Table 53).
Initially, utilization dropped about ten percent in the
number of members per thousand who used it. Then use of
both drugs dropped markedly, with only 34 members using
Lariam and only 3 using Cytovene, resulting in negligible
utilization. However, the number of scripts for each drug
did not vary substantially. Thus, it did not appear that the
increased cost of the drug decreased the use of it by those
who chose to continue it.
Lariam is used to prevent Malaria, and may be also used to
treat it. Alternatives for this purpose include Chloroquine,
Doxycycline, and Malarone. Chloroquine and Doxycycline
are on HPHC’s formulary and are available as both a Tier 3
brand and as a Tier 1 generic. In 2002 and 2003, Lariam was
the focus of several articles in major newspapers and
Consumer’s Reports magazine that described significant
neuropsychiatric side effects on some users.
This
information validates the logic of making this a less
preferred medication, and the negative public attention is
likely to have caused members and their physicians to select
an alternative anti-malarial agent.
TABLE 53
HPHC DRUGS MOVED TO A HIGHER TIER :
PENETRATION AND SCRIPTS PER USER
Penetration – Members Using Drug
per Thousand
Drug
2000
2001
2002
Lariam
3.530
3.160
0.094
Cytovene
0.074
0.067
0.002
2003
Scripts per Members
Using Drug
2000
2001
2002
2003
0.004
1.19
1.25
1.19
1.00
0.000
3.13
3.37
2.6
3.0
Source: HPHC Response to the Attorney General’s RFI, 2000-2003
7 Correction. In our prior report, we indicated that the tier changes were made in
2001. HPHC has informed us that they became effective on January 1, 2002.
Page 85
Cytovene is used to treat certain herpes viruses. These viruses are present in all adults, but only cause disease and possible blindness in
individuals with compromised immune systems, such as those with AIDS or recent transplants. Cytovene’s falling utilization may be
influenced by shortages due to manufacturing problems affecting one formulation of the drug announced during 2001 and 2002. It may
also be related to falling rates of new HIV/AIDS cases in the state of Massachusetts. Foscarnet is an alternative antiviral, but is not listed
on the HPHC formulary, and is much more costly. Though CMV retinitis affects a small number of people, they are highly vulnerable
individuals at risk of serious disability, making the possibility that cytovene may have been less available due to shortages, and its major
alternative not included in the formulary a concern.
HPHC also manages utilization for a small number of drugs by requiring prior authorization. Table 54 shows that, on average 4 or 5
drugs were added to the list each year. Drugs requiring prior approval fall into two classes, relatively expensive drugs used to treat
TABLE 54
MEDICATIONS REQUIRING HPHC PRIOR APPROVAL
Medication
Vioxx
Mobic
Celebrex
Lamisil
Sporanox
Zyvox
Gleevec
Quinolones: Avelox, Cipro,
Levaquin, Tequin, Zagam
Penlac
Bextra
Protopic
Elidil
EMLA
Tretinoin Topicals: Retin A; Retin A
Micro Gel; Avita; Altinac
Zelnorm
Iressa
2000
4/1/2000
4/1/2000
4/1/2000
5/15/2000
5/15/2000
7/1/2000
2001
2002
2003
*
*
*
Indications
Osteoarthritis, pain management, menstrual pain
Osteoarthritis
Osteoarthritis, rheumatoid arthritis, menstrual pain
Nail fungus infection
Certain pneumonias, resistant infections, and skin infections
Chronic myeloid Leukemia after failure of interferon-alpha
therapy
Class of antibiotics requiring careful management of
resistance
Adult rheumatoid arthritis; pain mgmt; menstrual pain
Atopic dermatitis; eczema
Atopic dermatitis; eczema
Topical anesthesia
*
Acne
5/24/2001
11/9/2001
*
12/4/2001
2/14/2002
6/11/2002
6/11/2002
6/11/2002
10/1/2002
1/2003
12/2003
Forteo
12/2003
Zetia
12/2003**
Irritable Bowl Syndrome (IBS) with constipation
Non-small cell lung cancer
Postmenopausal women w/osteoporosis who are at high risk
for fracture
High cholesterol
* Prior authorization required only when restriction/limitation is exceeded.
** Prior authorization required only when step therapy is not met.
Source: HPHC correspondence
Page 86
common, but not life threatening conditions, like osteoarthritis, nail fungus, and acne and those whose use must be carefully managed,
like a class of antibiotics with high potential for resistance or a drug with potential negative side effects used to treat osteoporosis. In
2003, HPHC freed some of its prior approval drugs to be available without prior authorization within established limits, and one drug did
not require prior approval if step therapy had been followed. Step therapy begins by prescribing lower cost and lower risk medications,
moving toward higher cost and/or higher risk medications only if the first medication has not been efficacious.
4. HEDIS Measures on Appropriate Use of Medications
Several HEDIS measures indicate the percentage of individuals with a particular condition who receive the types of medication
considered to be the standard of care.
Use of beta-blocker medication for people discharged from the hospital after a heart attack can lower the risk of a second heart attack.
People for whom use of beta-blockers is clinically contraindicated are excluded from this measure, so that the higher the percentage for
this measure, the better the treatment. Table 55 shows that HPHC was above the Massachusetts average on this measure in all four years,
and considerably above the national average, reaching an extraordinarily high level – 99%- of prescribing beta blockers after heart attacks.
TABLE 55
HEDIS MEASURES OF APPROPRIATE USE OF CARDIAC MEDICATION
HPHC (HMO/
POS combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC (HMO/
POS combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC (HMO/
POS combined)
MA average
(HMO/POS)
National Avg.
(HMO/POS)
2003
National Avg.
(HMO/POS)
2002
MA average
(HMO/ POS)
Beta Blocker after Heart
Attack
Cholesterol Mgmt. Screening
Cholesterol Mgmt. –
control
Controlling high blood
pressure
2001
HPHC (HMO/
POS combined)
2000
94%
93.33%
89.35%
99.06%
95.41%
92.47%
99.06%
97.05%
93.54%
99.6%
97.51%
94.33%
81.75%
80.64%
74.16%
81.41%
80.57%
77.07%
89.58%
83.4%
79.36%
87.83%
85.92%
80.34%
59.37%
57.31%
53.42%
63.57%
63.87%
59.25%
74.48%
68.15%
61.4%
76.89%
69.67%
65.05%
54.5%
53.41%
51.49%
58.68%
60.08%
55.41%
66.83%
65.17%
58.37%
71.16%
68.0%
62.2%
Page 87
The Cholesterol Management measures pertain to individuals hospitalized for a heart attack or certain cardiac procedures, and indicate
whether they were screened for cholesterol levels between 60 and 365 days after discharge. The control measure indicates the percentage
whose LDL cholesterol levels were controlled to less than 130 mg/dL during the same period. In many cases, medications are necessary
in addition to dietary and activity changes to achieve this level. HPHC exceeded state and national averages on these two measures, and
all parties demonstrated improvement. HPHC’s success in controlling cholesterol levels in this high risk group suggests that its relatively
low utilization rates for cholesterol lowering drugs have not negatively affected this group.
Treatment of high blood pressure is important in reducing deaths from heart disease, stroke and renal failure, and affected individuals
may need to be treated with medications in addition to dietary and lifestyle changes. HPHC was above the national averages for this
measure in all but 1 year, and all parties demonstrated improvement.
C.
REHABILITATION SERVICES
Rehabilitation services focus on helping people regain functioning that may have been impaired by accident, illness, or surgery. Some
rehabilitation begins in acute care hospitals and may continue in rehabilitation hospitals or nursing homes. Rehabilitation is also
provided on an outpatient basis, and for homebound patients, may be provided in their own home.
1. Rehabilitation Network
We looked at HPHC’s network for some of the provider types most
relevant to ensuring adequate access to rehabilitation services. (See
Table 56.) There was minimal change over the four-year period.
Other than a jump in the number of home health care providers, early
intervention and skilled nursing facilities showed small decreases
while hospices and rehabilitation hospitals had small increases.
However, where the number of providers is relatively small – as for
these provider types – the location of providers or the catchment area
that home health providers serve are also important dimensions of
access.
2. Utilization Management Practices
TABLE 56
HPHC NETWORK FOR SPECIFIED SPECIALTY SERVICES
NUMBER OF CONTRACTED PROVIDERS
2000
2001
2003
Early Intervention
40
40
38
Home Health Care
43
46
67
Hospice
30
32
38
Rehabilitation Hospital
18
17
20
Skilled Nursing Facilities
162
159
153
Service Type
Source: HPHC Physician Directory, Volume 2, 2000, Volume 2, 2001, Fall 2003
HPHC requires a PCP referral for rehabilitation services. This allows
rehabilitation providers to assess the patient and submit a request for
services to meet the identified needs. In April 2001, a new law required Massachusetts managed care plans to cover all medically
necessary services to treat speech, hearing and language disorders. This law effectively eliminated benefit limits, so HPHC reviews
Page 88
speech therapy cases to determine medical necessity. For
other rehabilitation services, HPHC’s functional therapies
department assists rehabilitation providers and their
patients to work within benefit limits.
Inpatient
rehabilitation services must be authorized by HPHC in
advance of admission and non-hospital alternatives are
utilized if they make clinical sense. Rehabilitation services
provided in the home require HPHC prior authorization by
Nurse Case Managers when the member is homebound, or
when the home is the most practical or clinically appropriate
setting for services to be provided. The plan must have
concrete goals or be medically necessary to maintain the
Patient safely at home. The plan must be regularly reviewed
by a physician.
The rate of appeals for rehabilitation services provides some
indication about the types of service where members have
most concerns. Appeals regarding rehabilitation services
were the third most frequent reason for appeals by
commercial members in 2000. (See Table 22.) The rate per
thousand of rehabilitation appeals increased considerably,
by 88%, in 2001, making it the most frequent type of appeal
in that year. This was due primarily to increases in appeals
for physical and occupational therapy and the “other“
category. The rate of appeals for speech therapy declined by
22% as the benefit limit was ended. The rate of appeal
dropped in 2002 and then increased again in 2003, but not as
high as it had been in 2001. Physical therapy appeals
accounted for most of the appeals by the end of the period.
This suggests a continued level of dissatisfaction in the
provision of physical therapy, but not with speech therapy,
early intervention or cardiac rehabilitation.
3. Provider Feedback
We distributed a brief survey on HPHC’s provision of
rehabilitation care in 2002 (covering 2000, 2001, and 2002),
and again in early 2004 (covering 2003) with the assistance of
the trade association of physical therapists. Twenty-one of
their members responded to the first survey. The survey
was also distributed by the trade association for
occupational therapists and one response was received to
each of the surveys. A speech therapist was also interviewed
on the same topics as the survey in 2002, and 5 submitted
surveys during the second administration. We note that this
method of dissemination tends to elicit responses from
individuals who want to call attention to problems and is a
better method for identifying problems than for determining
how widespread and significant they are.
Most respondents rated the adequacy of HPHC’s network of
rehabilitation providers as adequate or extensive, with some
rating it as better than the networks of other HMOs
operating in Massachusetts. Despite these high ratings,
there were comments that HPHC’s network was extremely
closed to new providers, and that there was little recognition
of high quality service provision or appropriate response to
poor performance.
Claims payment and payment rates were a source of
considerable criticism from physical, speech and
occupational therapists. They rated HPHC’s rate of payment
for rehabilitation services as inadequate, with most of them
also indicating that HPHC’s rates were worse than other
Massachusetts HMOs. One speech therapist commented
that HPHC’s rates were 25% lower than average.
Payment accuracy and timeliness was rated low. Speech
therapy providers described terrible claims payment
problems for 2000 dates of service and frustrating
interactions with HPHC’s provider services staff. This was
evidently improved in 2002, as indicated by more excellent
scores and fewer poor scores, but 2003 results showed no
excellent ratings.
Page 89
The rehabilitation providers who responded to us were happier with HPHC’s authorization procedures than with claims payments, rating
them as good or excellent during the first three years. However, those who responded to the 2003 survey were more critical, with 3 of 5
rating HPHC’s authorization procedures as poor. The criticisms expressed included: difficulties getting an authorization decision within
48 hours; restrictive and unrealistic expectations for progress in treating autism; and authorizations issued for very short periods,
requiring extra work. Another commenter regretted not having more involvement and notice about changes in the authorization process.
From this information, we can tentatively conclude that HPHC’s rates and administrative practices cause significant problems for at least
some rehabilitation providers, but the problems with authorization practices have more to do with its administration than with decisions
about how much care is authorized. This type of problem can result in providers choosing to leave the HPHC network. However, for the
same period in which they criticized aspects of HPHC’s administration, most responding providers rated the network as adequate or
extensive, and rated the overall provision of rehabilitation care as good or excellent. This suggests that the problems are more likely to
affect providers than their HPHC clients.
4. Outpatient Rehabilitation Utilization
Table 57 shows the limited data we received on
TABLE 57
utilization of rehabilitation services for HPHC’s
HPHC REHABILITATION SERVICES
commercial population. These services are grouped into
COMMERCIAL UTILIZATION PER THOUSAND FOR MASSACHUSETTS MEMBERS
two categories: physical, occupational and speech
therapies; and a more disparate group of services that
Thru Q3,
% Change
2000
2001
2002
2003
2000
to 2003
includes durable medical equipment (DME), home health
DME,
VNA
Home
Health,
services, and hi tech therapy. Both categories showed
2,383
2,919
3,298
3,424
44%
Hi-Tech Therapy
steady increases in per thousand utilization, over the
Physical, Occupational,
period, resulting in increases in utilization per thousand
548
576
681
761
39%
Speech, CR, NC Therapy
in the magnitude of 40%. However, lack of more
stratified service categories makes it impossible to
Source: HPHC Response to Attorney General, 2000, 2001, 2002 and 2003
monitor the effects of the reduction in the DME covered
benefit in 2000, and how the changes in authorization of speech therapy affected utilization. In addition, we do not know if the increases
were from more members utilizing services, or from increases in the amount of service used by those receiving rehabilitation services.
5. HEDIS Non-Acute Care Measure
HEDIS employs only one set of measures that pertain to rehabilitation services: the utilization of non-acute inpatient care. This measures
utilization of care provided in hospice, nursing homes, rehabilitation, skilled nursing facilities, transitional care and respite, excluding
stays with a diagnosis of mental health or chemical dependency. As can be seen in Table 58, HPHC utilized these services substantially
more than Massachusetts or national HMOs in terms non-acute inpatient treatment episodes per thousand at the beginning of the period
Page 90
and remained higher throughout the period, though it experienced a considerable drop in utilization followed by a slow increase.
Massachusetts and national HMOs experienced slow increases during the period. In 2000, HPHC’s lengths of stay were significantly
shorter than the Massachusetts or national averages, but they increased dramatically in 2001, exceeding both averages and remained
higher for the remainder of the analysis period.
TABLE 58
HEDIS MEASURES OF NON-ACUTE INPATIENT SERVICES
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National
Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/ POS)
National
Avg.
(HMO/POS)
HPHC
(HMO/POS
combined)
MA average
(HMO/POS)
National
Avg.
(HMO/POS)
2003
National
Avg.
(HMO/POS)
2002
MA average
(HMO/ POS)
Inpatient non-acute
average length of
stay
Discharges per
thousand
2001
HPHC
(HMO/POS
combined)
2000
11.48
days
13.01
days
14.3
days
15.31
days
11.17
days
14.77
days
15.09
days
13.54
days
14.4
days
14.61%
12.38%
13.49%
3.66
1.72
1.16
2.57
2.25
1.32
2.79
2.12
1.51
2.7
2.1
1.52
These results suggest that HPHC members have a desirable level of access to these services, both in admission for treatment and for
length of stay, as compared to the state and the nation. However, further interpretation is limited since this measure compiles data on a
wide range of services; hospice is for end of life care, rehabilitation for regaining functioning, and respite to provide safety without
significant treatment or rehabilitation goals. Differences in the composition of the non-acute provider network and in the needs of
enrolled populations may also influence these results.
Page 91
6. Division of Insurance Utilization Data
The picture shown by Division of Insurance data for non-acute inpatient care in Table 59 differs somewhat from what is shown for
HEDIS. These figures are not computed using an identical methodology, nor for the same composition of HPHC members. Like HEDIS,
the Division’s data shows HPHC providing non-acute hospital care for a greater proportion of its members than other HMOs, but does
not show as much change between years nor a clear trend. Unlike HEDIS, HPHC’s length of stay appears to be shorter than for other
HMOs, and shows length of stay to be quite stable.
Taken together, the two data sources suggest HPHC members have good access to this level of care in comparison to other HMOs, though
there is a question whether their lengths of stay may be shorter.
TABLE 59
NON-ACUTE INPATIENT DISCHARGES AND DISCHARGE DAYS
2000
HPHC
Total Discharges
Total Discharge Days
Average Length of Stay
10,046
13
110,241
11
2001
Other
HMOs
16,613
9
263,959
15.9
HPHC
6,785
12
76,210
11.2
2002
Other
HMOs
21,478
11
350,456
16.3
HPHC
7,202
15
69,413
11.1
2003
Other
HMOs
20410
11.7
331,630
16.2
HPHC
6,233
12
68,113
10.9
Other
HMOs
18796
10.8
258,920
13.8
Source: Harvard Pilgrim Health Care, Inc "Inpatient Days Report - ALOS" Quarterly Report, 2000, 2001, 2002)
Pilgrim Health Care, Inc "Inpatient Days Report - ALOS" Quarterly Report (2000, 2001), Harvard Pilgrim NE, Inc. “Inpatient Days Report – ALOS”, Quarterly
Report (2002), Harvard Pilgrim Healthcare, Inc. “HMO Supplemental Utilization”, 2003.
D.
CONCLUSION
1. Provision of Mental Health and Substance Abuse Care
Overall, it appears that HPHC’s provision of mental health care is relatively generous and increased over the period, likely influenced, at
least in part, by the implementation of mental health parity. In contrast, HPHC was less generous in providing substance abuse care. The
number of hospitals available to HPHC members in need of psychiatric inpatient care increased considerably over the period, and a
decrease in the number of individual mental health specialists was offset to some degree by an increase in mental health clinics entering
Page 92
the network. ValueOptions focused considerable attention on measuring access through geo-access mapping, open shopper surveys and
provider and member surveys, and instituted quality improvement projects that demonstrated high rates of compliance with standards
for provision of timely appointments. Special attention was focused on access to child psychiatrists, which is a shortage affecting HPHC
and all insurers.
Division of Insurance data from 2003 and HEDIS data suggest that HPHC members have better than average access to outpatient mental
health services, equivalent access to day/night care, and higher access to inpatient care than other Massachusetts HMOs. However,
HPHC’s high rates of inpatient care and longer lengths of stay could be indications of a higher need population or less effective
preventive care. Both sources of data suggest that substance abuse treatment is an area in which HPHC members may not have as much
access as other Massachusetts HMOs, with lower outpatient and inpatient utilization.
However, these conclusions are somewhat
tentative due to possible inconsistencies in categorizing mental health and substance abuse services. HPHC’s combined provision of
mental health and substance abuse care exceeds the practice patterns of other Massachusetts HMOs in ValueOptions data. Utilization of
psychotropic drugs grew considerably. Though we do not have a benchmark for comparing the rate of increase to others, it does show
increasing utilization by HPHC members.
HPHC has excelled on some measures of quality of mental health care according to HEDIS, where it has exceeded state and national
averages and showed consistent improvement, particularly for follow-up after inpatient discharge. However, it has shown steeply
increasing rates of readmission for both mental health and substance abuse inpatient services, suggesting that longer than average lengths
of stay and high rates of community follow-up are not having the desired effect of establishing stability in the community. Member
surveys showed high and increasing rates of satisfaction with their therapist and with their outcomes of treatment. However, member
and provider surveys, as well as other feedback, indicated that administrative functions were a continuing and sometimes an escalating
problem during the analysis period. The most important operational issues for members and providers were:
•
•
Low rates, slow payment, billing problems, cumbersome outpatient authorization procedures, and intensive scrutiny of inpatient
cases are significant sources of frustration and have contributed to an unwillingness to participate in the ValueOptions network.
Some had become more problematic over time, rather than being resolved.
A customer service function that did not get high ratings from the HPHC members who used it.
2. Provision of Medications
In HEDIS comparisons, HPHC showed both higher cost per capita of medications and a higher rate of growth in utilization than the
Massachusetts and national averages, suggesting that HPHC members have relatively high access to medications overall. Despite
utilization growth, HPHC’s three tier formulary appears to constrain growth in HPHC’s cost for medications, both by sharing cost with
members who are responsible for a co-pay, and by decreasing utilization of many Tier 3 drugs, for which less expensive alternatives are
available. While the introduction of the tiered pharmacy benefit coincided with a high rate of pharmacy related appeals, the pharmacy
appeals rate dropped considerably in succeeding years, suggesting that members had accepted it. Our comparison of HPHC utilization of
specific drug classes to that of a mixed commercial population drawn from throughout the country shows HPHC to use four classes of
Page 93
drugs more frequently - (hypertensives, antidepressants, allergy drugs, and anti-virals); and two classes less frequently - drugs for
management of lipid levels, and gastrointestinal drugs. However, HPHC’s rates of growth are either higher than the national average or
at least the same for these two classes, and HPHC exceeded the state and national average HEDIS scores for managing lipid levels after
heart attacks, providing one indication that HPHC’s prescription patterns are appropriate for its clientele. Two drugs were moved from a
lower tier to a higher tier, and both experienced dramatic decreases over the four year period. However, one experienced considerably
publicity about dangerous side effects, and the other experienced several shortages. Therefore, we cannot attribute their dropping
utilization to HPHC’s management. HPHC has added a prior authorization requirement for approximately 5 drugs per year. However,
in 2003, HPHC added protocols for some of them that eliminate the authorization requirement if other drugs have been found ineffective,
or if utilization falls within prescribed limits. Drugs on the list are either expensive drugs to treat conditions that are not life threatening
or are drugs with serious side effects to treat very serious conditions. In both cases, requiring review seems appropriate.
3. Provision of Rehabilitation Services
We were limited in the degree of detail available to analyze HPHC’s provision of rehabilitation services. However, the data we did have
showed increasing rates of utilization for inpatient services, outpatient therapies, and other outpatient services plus equipment between
2000 and 2003. In addition, the network of rehabilitation facilities tended to stay the same or increase, suggesting a similar level of
continuing access to these providers. The outpatient rehabilitation providers we contacted were generally positive about the quality of
HPHC’s authorization procedures, though they expressed concern about timeliness. In addition, rehabilitation authorization decisions
were appealed more often than most other types of service, and experienced a very high rate of increase between 2000 and 2001, due
primarily to increases in appeals for physical and occupational therapy and the “other“ category. While appeals moderated somewhat in
2002 and 2003, physical therapy remained one of the most frequent reasons for appeal, suggesting that some members are not satisfied
with the amount of physical therapy they are receiving. Providers also expressed some significant concerns around billing problems, low
rates, and frustration in resolving billing problems that can affect HPHC’s continued ability to maintain its rehabilitation network.
Page 94
VI.
SPECIAL POPULATIONS
This chapter assesses provision of service to limited English speakers and
people with chronic illness whose special needs that may affect their access
to health care. Both populations are hard to identify within HPHC’s
overall membership, and that has limited our ability to analyze the care
they receive. We do discuss the provision of some of the special services
each population may need and have also reported on the provision of care
for First Seniority members, an elderly group that we are able to identify
and that has a greater likelihood of suffering both acute and chronic illness.
A.
LIMITED ENGLISH SPEAKERS
1.
Limited English Speaking Enrollment
HPHC’s Director of Diversity estimates that about 9000 members
indicate that English is not their first language, and that it has
stayed pretty much the same across the years. However, HPHC
has not focused on identifying all individuals who speak a second
language. New members may identify a primary language on their
application form, but language is not a required field and many
new members do not complete it.
TABLE 60
SELF-IDENTIFIED LIMITED ENGLISH SPEAKERS
ENROLLED IN HPHC INC. AND HPHC NE AS OF 5/31/2002
Language
Spanish
Portuguese
Subtotal Chinese languages
Cantonese
Mandarin
Chinese
Armenian
Vietnamese
Russian
Haitian
French
Khmer
Cape Verde
Italian
Korean
Greek
Other Languages (47)
Total
Number of
Members
3,001
1,326
917
488
368
61
557
504
442
379
373
234
224
152
111
108
507
8,835
Percentage of Limited
English Speakers
34%
15%
10%
6%
4%
1%
6%
6%
5%
4%
4%
3%
3%
2%
1%
1%
6%
100%
Our data is limited to a 2002 point in time count of those members
who indicated a second language on their enrollment form, as
shown in Table 60. Should the enrollment of limited English
speakers have stayed constant, as suggested by the Director of
Diversity, they would represent less than 1% of average members Source: HPHC and HPHC NE Integrated Product Member Language Report (Amysis)
5/31/2002
in any year. The largest language group was Spanish speakers,
who accounted for a third of all self-identified limited English speakers followed by Portuguese speakers at 15%, with Chinese languages
accounting for 10%. All other language groups listed represented 6% or less of limited English speakers. An additional 47 languages
accounted for a total of 6%. Since this is the best information we have about enrollment of limited English speakers, we have used it to
represent enrollment in all years.
Page 95
The following table, drawn from another set of data, shows that many limited English speakers are concentrated in the largest Local Care
Units (LCUs), HPHC’s term for its physician groups. The total of limited English speakers in the dataset from which this table was drawn
is over 14,000, far exceeding the 9,000-point in time count from the prior table. Though a year’s enrollment will exceed a point in time
count, we do not think that this phenomenon would fully explain the extent of this discrepancy. Should this larger figure be an accurate
count, it suggests that HPHC’s population in need of bilingual service provision is greater than the original count would suggest.
TABLE 61
LOCAL CARE UNITS WITH MORE THAN 500 LIMITED ENGLISH SPEAKING HPHC MEMBERS
MARCH 2001- FEBRUARY 2002
Local Care Unit
Harvard Vanguard Medical
Location
Boston, Braintree, Burlington, Cambridge, Chelmsford, Medford,
Peabody, Quincy, Somerville, Watertown, Wellesley, West Roxbury
Number of Limited English
Speaking Members
4,952
Beth Israel Deaconess PHY
Boston
1,376
Primary Care, LLC
Brockton, Cape Cod, Mass Bay, Milton, Norwood, Plymouth,
Quincy, Southwest Boston
924
Mass General Hospital
Boston
799
Boston Medical Center
Boston
723
Brigham & Women's
Boston
605
Pilgrim Independent Practice Association
Mostly Boston and South Shore
571
Mt. Auburn Cambridge
Cambridge
561
Pediatric Physician's Org. at Children’s
Hospital
Boston
507
Source: HPHC Integrated Product Member Language Report (Amisys) 4/3/02
Page 96
2.
Network of Bilingual Providers
Per
Thousand*
Specialist
Offices
Per
Thousand*
PCP
Offices
Per
Thousand*
Specialist
Offices
Per
Thousand*
PCP
Offices
Per
Thousand*
Specialist
Offices
Per
Thousand*
PCP
Offices
We analyzed HPHC’s provider lists to see how many physicians spoke these most common languages among members and tracked it
over time. We see an increase in bilingual providers in 2001, and then a decrease in 2003. However, because we only have a listing of
HPHC’s members who speak
TABLE 62
another language from a
OFFICES OF BILINGUAL PHYSICIANS BY LANGUAGE
single point in time, we cannot
determine whether the need
2000
2001
2003
for bilingual practitioners has
grown, decreased or stayed
the same over this 4-year
period. In addition, the listing
itself varied considerably
Language
between years; for example in
Spanish
547
182
327
109
558
186
612
204
469
156
802
267
2003 we found that many
Portuguese
84
63
63
48
96
72
123
93
80
60
150
113
PCPs newly listed as bilingual
Chinese languages
123
134
70
76
136
148
103
112
89
97
141
154
had been part of the network
Armenian
18
32
15
27
19
34
31
56
17
31
31
56
in the prior year, but not listed
Vietnamese
18
36
7
14
17
34
11
22
15
30
15
30
as bilingual. Conversely, we
Russian
65
147
49
111
77
174
83
188
60
136
88
199
also
found
that
many
Haitian
Creole**
21
55
4
11
24
63
2
5
12
32
10
26
providers listed as bilingual in
French
351
941
294
788
353
946
524
1405
263
705
578
1550
2001 remained in the network
Khmer
2
9
0
0
2
9
2
9
2
9
5
21
in 2003, but were no longer
listed as bilingual. Where a
Cape Verde Kriolu*
0
0
0
0
0
0
0
0
0
0
0
0
provider is listed will not
Italian
104
684
65
428
96
632
110
724
64
421
117
770
affect access for current
Korean
14
126
14
126
13
117
25
225
8
72
27
243
patients who will continue to
Greek
42
389
31
287
39
361
63
583
28
259
73
676
have access to a bilingual
Total
1389
167
939
113
1430
172
1689
203
1107
133
2037
245
practitioner, but it does affect
*Per thousand is calculated using 5/31/2002 count of limited English speaking enrollees.
access for potential new
**We have counted all Creole speakers under Haitian Creole. Possibly some speak Cape Verde Kriolu.
Source: HPHC Physician Directory, Volume 2, 2000, Volume 2, 2001, and Fall 2003
patients seeking a bilingual
physician and selecting from a
shorter list. HPHC reports
that physicians determine
We were unable to consistently account for providers with more than one office, so we counted the number of
offices. This results in an over count of the number of physicians. In addition, some physicians speak more than
whether they are listed as bione language, and so are double counted in our totals. Finally, unlike our earlier network counts, the listing of
lingual
and
for
which
bilingual specialists counts both physicians with specialties and mental health providers such as licensed social
languages, and that they can
workers and psychologists.
Page 97
change their listing at any time. However, these decisions
may not, in fact, be made by the physician. HPHC reports
that administrative staff usually complete physician
information forms, and these forms are often incomplete.
Thus, there is every reason to think that HPHC’s directory
under represents the full linguistic capability of its provider
network, and changes in how linguistic capacity is listed
may not have much to do with physician preferences for the
clientele they wish to attract. However, the limitations of the
directories mean that HPHC members seeking a bilingual
provider do not generally get to choose from the full
spectrum of linguistically capable providers.
3.
We had hoped to look at HPHC’s bi-lingual network in
comparison to the available bi-lingual physicians licensed to
practice in Massachusetts. This would have allowed us to
better account for the limits in availability of bi-lingual
physicians that constrain HPHC and other insurers from
providing bi-lingual services to its limited English speaking
clientele. However, the Board of Registration in Medicine’s
physician database was not structured in a way that allowed
for such an analysis.
HPHC has few standards or policies on providing clinical or
administrative services to limited English speakers.
However, it does do a number of things to enhance the
ability of its staff and provider network to serve them
effectively.
While we cannot provide a good context for evaluating
HPHC’s network of bilingual providers, we can identify that
the following language groups are most likely to have a hard
time finding bilingual services.
• Cape Verde Kriolu had no bilingual providers
listed.
• Khmer speakers have only seven providers, who
may not be geographically accessible nor
include needed specialties.
• Haitian Creole, Korean, and Armenian had high
per thousand ratios, but had relatively few
providers, which may limit geographic
accessibility and access to certain specialty
types.
Utilization of Limited English Speakers
We explored the possibility of reporting on the utilization of
non-English speakers, but it would have required a major
programming effort, including matching different databases.
The results would have also been difficult to interpret in the
absence of information on the basic health status of this
subpopulation compared to overall enrollment. However,
this gap is a major limitation of our ability to assess the care
provided to limited English speaking members of HPHC.
4.
Accommodations for Limited English Speakers
In 2000, HPHC’s Customer Services department included
eight multi-lingual representatives, four of whom spoke
Spanish and four others spoke Portuguese, French Creole,
Polish or Swedish. The capacity was similar in 2003, with
three Spanish speakers, two French speakers, and three
other individuals speaking Portuguese, Haitian Creole, and
Hindi.
HPHC provides an introductory flyer in English and the
following ten languages:
• Spanish;
• Portuguese;
• Russian;
• Polish;
• Vietnamese;
• Mandarin;
• Cantonese;
• Khmer (Cambodian);
Page 98
•
•
Haitian; and
Italian.
This list covers most of the most frequently occurring
languages among HPHC members, but excludes Armenian,
French, and Cape Verde Kriolu, of which there are as many
or more members than those indicating that they speak
Italian.
The flyer invites new members to call a toll-free number
with a tape orientation available in the same languages.
Benefit handbooks also include statements in the same
languages on how to contact member services. The phone
orientation covers topics such as choosing a primary care
physician, seeing a specialist, receiving mental health
services, accessing emergency, weekend and evening care,
co-payments, out-of-area care prescription benefits, and how
to resolve billing questions. The flyer directs speakers of
other languages to call HPHC customer services who can
access a translation service to speak with them. HPHC has
arrangements with an outside vendor to translate its
schedule of benefits when requested by the Marketing
department or by a member.
All translation needs are managed through the services of
Pacific Interpreters, which can support the translation of
approximately 2000 languages. Table 63 shows that the
number of such interpretations decreased in 2001, and over
the next two years increased to a similar level as 2000 (this
takes into account that 2000 data were not for the full year).
Our per thousand calculations use the count of selfidentified non-English speakers presented in Table 55 as of
May 2002. This gives us an idea of the relative utilization of
this service by different non-English groups, but limits our
ability to determine how changes in the number of
interpretations correspond to the actual enrollment of nonEnglish speakers in other years. It is notable that Spanish
speakers use this service at a much higher rate than other
language groups. Of the most common languages in
HPHC’s membership, Haitian and Armenian speakers use
this service quite rarely. However, Khmer and Creole
speakers have increased their use over the four-year period
in terms of numbers of interpretations requested.
This
pattern suggests that either HPHC’s limited English
speaking members are making better us of this capacity, or
their level of enrollment has increased.
The case management staff includes several individuals who
speak non-English languages, and staff are trained in the use
of phone interpretation. Healthsource also has Spanish
speaking case managers on its HPHC team and has its letters
translated into Spanish. Half of the ten cancer patient
treatment guidelines utilized by HPHC are also available in
Spanish language versions.
All disease management
materials produced by HPHC have a Spanish language
notation providing a phone number where additional
assistance in Spanish can be requested.
Page 99
TABLE 63
TELEPHONE INTERPRETATIONS PROVIDED TO HPHC MEMBERS
Jan.-Aug.,
2000
2001
Language
No.
No.
No.
Most Common Languages Among HPHC Members
Spanish
690
719
747
Portuguese
149
91
111
Subtotal Chinese
102
68
46
languages
Russian
39
18
25
Vietnamese
18
13
23
Italian
15
11
6
French
14
15
9
Greek
6
4
5
Haitian
4
0
0
Korean
3
4
4
Armenian
2
1
5
Cambodian /
2
5
5
Khmer
Creole
1
3
6
Japanese
9
7
3
Subtotal
1,054
959
995
2002
Per thousand*
language
group
members
2003
249
84
Jan.-Aug.,
2000
2002
2003
No.
988
174
Language
No.
No.
No.
Less Common Languages Among HPHC Members
Polish
4
2
1
Arabic
3
2
1
50
62
Farsi
3
0
0
2
57
46
39
24
46
0
36
9
24
20
16
7
10
6
4
3
Czechoslovakian
German
Albanian
Bosnian
Hebrew
Hindi
Turkish
Amharic
1
1
0
0
0
0
0
0
0
2
1
1
4
1
0
0
0
1
0
0
0
0
0
0
0
8
0
1
0
1
21
9
Bulgarian
1
0
26
34
57
13
15
1,351
Gujarati
Punjabi
Tagalog
Tamil
Urdu
Subtotal Less
common languages
Grand Total
1
0
1
0
0
1
1
0
1
1
No.
2001
1
2
12
13
6
19
1,066
972
1,001
1,370
Per thousand is calculated using 5/31/2002 count of limited English speaking enrollees.
Source: HPHC Response to Attorney General, 2000-2003
HPHC has an Office of Diversity that addresses the needs of diverse cultures and linguistic groups, as well as the needs of some
individuals with disabilities. Staffing of this small office has grown somewhat as its offerings have grown. In 2001, its director began
reporting directly to the CEO. Its most significant function is to provide training related to cross-cultural provision of care. It has piloted
Page 100
5.
CAHPS
Speakers
Results
for
Spanish
TABLE 64
TRAINING IN CROSS-CULTURAL CLINICAL CARE OFFERED BY HPHC
3
52
4
3
53
2
30
3
51
2
46
3
1 pilot
15
5
7
250
6
110
1 pilot
No. of
Trainees
72
No. of
Sessions
4
2003
No. of
Trainees
No. of
Sessions
2002
No. of
Trainees
2001
No. of
Sessions
Medical Interpreter (42 hours)
(Spanish, Cape Verdean,
Haitian Creole, Portuguese,
Cantonese)
Foundations in Cross Cultural
Health Care (3 days)
Behavioral Health (CME and
CEU accredited) (2 days)
Nurse Case Management (full
day)
In-service Cross Cultural
Clinical Training (in-service at
HPHC providers)
Leadership Practice in Medical
Interpretation
2000
No. of
Trainees
Course
No. of
Sessions
and added courses, and trains both direct
care providers as well as faculty in
Dental and Medical Schools. In 2003,
federal funding from the Health
Resources and Services Administration
(HRSA) has expanded the reach of
HPHC’s cultural competency trainers,
including a national closed circuit
broadcast that reached 2000 people.
Courses are offered in-house to HPHC
staff as well as to HPHC network
providers. In some cases, HPHC waives
the fees. For example, HPHC encourages
providers who have bilingual office staff
to send them to a course in medical
interpretation. This is a very significant
effort that contributes not only to
improving the capacity of HPHC’s
network to effectively serve its members
from different linguistic and cultural
groups, but also improves the capacity of
the larger health care community.
75
7
143
10
684
46
3
38
114
6
111
26
2,947
1
25
14
Source: HPHC’s Response to Attorney General
HPHC stratified its 2001 and 2003 CAHPS survey results for respondents who identify themselves as Hispanic. (See Table 60) The
number of Hispanic respondents was quite small, at most 17, for the questions we analyzed. This is small compared to over 400 nonHispanic respondents, though it was not out of proportion to the relative proportion of self-identified Spanish speaking members among
HPHC’s membership. In general, this small group of Hispanic respondents gave HPHC quite high ratings in comparison to non-Hispanic
respondents. Both groups rated different aspects of communication as having improved from 2001 to 2003, and Hispanics tended to rate
communication factors higher than all other respondents. However, both groups experienced more access problems in 2003 than in 2001.
These problems made the ratings of Hispanic clients more similar to other respondents than they were in 2001, when Hispanics tended to
rate access higher than others. None of the between group differences reached the level of statistical significance in 2003. (This is affected,
at least in part, by the small sample size of Hispanic respondents). There was one dramatic change in ratings. While in 2001, Hispanic
respondents were more likely to rate the overall cost for health insurance coverage as reasonable than other respondents, in 2003, they
Page 101
were much less likely to rate cost of insurance as reasonable. With such a small sample size for Hispanics, results can be affected
substantially by the particular individuals surveyed. However, there is a suggestion here that cost increases have affected Hispanic
members more than others.
We must be guarded in drawing any conclusions from such a small sample. In general Hispanic populations are known to respond
somewhat more positively in their global rating of health care than on their descriptions of specific aspects of health care, suggesting a
possible upward bias.
TABLE 65
2001 & 2003 CONSUMER ASSESSMENT OF HEALTH PLANS STUDY
BY HISPANIC/NON-HISPANIC RESPONSES
2001 Hispanic
2001 All Other
2003 Hispanic
2003 All Other
17
90.9%
9.1%
0
453
76.3%
18.8%
4.9%
11
82.0%
9.0%
9.0%
310
76.0%
17.0%
8.0%
15
100.0%
0
0
304
82.2%
12.8%
4.9%
8
87.0%
13.0%
0
302
79.0%
13.0%
8.0%
15
80.0%
20.0%
0
452
83.6%
14.2%
2.2%
13
85.0%
15.0%
0
355
88.0%
10.0%
2.0%
ACCESS TO PHYSICIANS
Problem to see personal doctor or nurse
N=
Not a Problem
Small Problem
Big Problem
Problem to get referral to specialist
N=
Not a Problem
Small Problem
Big Problem
Problem to get care necessary from doctor
N=
Not a Problem
Small Problem
Big Problem
COMMUNICATION
In the last 12 months, how often did office staff at the doctor's office or clinic treat you with courtesy and respect?
N=
14
453
14
441
Always
71.1%
70.2%
93.0%
75.0%
Usually
21.1%
24.9%
7.0%
22.0%
Sometimes
7.1%
4.9%
0
3.0%
Never
0
0
0
0
Page 102
TABLE 65, CONTINUED
2001 & 2003 CONSUMER ASSESSMENT OF HEALTH PLANS STUDY
BY HISPANIC/NON-HISPANIC RESPONSES
2001 Hispanic
2001 All Other
2003 Hispanic
2003 All Other
Doctors/health providers listen carefully
N=
14
453
14
441
Always
66.7%
56.9%
50.0%
65.0%
Usually
20.0%
33.2%
43.0%
29.0%
Sometimes
13.3%
9.3%
7.0%
6.0%
Never
0
0
0
0
Doctors/health providers explain things understandably
N=
15
453
14
441
Always
73.3%
62.9%
79.0%
70.0%
Usually
6.7%*
30.5%*
7.0%
27.0%
Sometimes
13.3%
5.5%
7.0%
3.0%
Never
6.7%
1.1%
7.0%
1.0%
In last 12 months, how much of a problem, if any, was it to find or understand information in written materials?
N=
8
169
2
138
Not a Problem
87.5%
67.5%
100.0%
75.0%
Small Problem
12.5%
24.9%
0
19.0%
Big Problem
0
7.7%
0
7.0%
COST
How would you rate the overall cost to you for your health insurance coverage?
(0 = Extremely Unreasonable – 10 = Extremely Reasonable)
N=
17
524
Ratings of 8, 9, 10
69.8%
41.4%
Ratings 7 or below
30.2%
58.6%
17
24.0%
76.0%
479
54.0%
46.0%
* Statistically significant from nonHispanic
Source: HPHC NCQA/Consumer Assessment of Health Plans Study, Hispanic vs. Non-Hispanic
Page 103
6.
Community Informants
It was difficult to find community informants who worked
with privately insured limited English speakers; many
advocacy and community support organizations that work
with specific linguistic/cultural groups work primarily with
those who have Medicaid coverage or are uninsured.
However, in 2001 and 2002 we spoke with two directors of
hospital interpreters’ programs, an elderly Limited English
speaking couple with long-time membership in HPHC, and
representatives from organizations that work with some of
the larger ethnic communities.
These conversations
identified some of the important issues in HPHC’s and the
overall health care system’s provision of care to people with
limited English.
•
•
•
•
•
•
HPHC’s cultural competency training was noted as an
important contribution to quality care for limited
English speaking communities.
Some of HPHC’s clinics were noted as having
particularly well-developed bi-lingual capacity that
included both bilingual providers and considerable
interpretation capacity.
However, HPHC’s network in Cambridge was noted as
not including some of the Cambridge Health Alliance
Health Centers with the greatest Portuguese speaking
capability in providers and throughout the staff.
Across the health care system, there is limited health
care information published in Asian languages,
especially Cantonese and Vietnamese.
Also affecting the entire health care system, it is difficult
to get a bilingual Spanish or Chinese speaking specialist,
and interpretation is not often scheduled when the
specialist does not have linguistic capacity.
Bilingual physicians are sometimes reluctant to serve
limited English speakers; unless their support staff also
speaks the language, the physician must do the
scheduling and nursing tasks as well as the examination.
7.
Employer Survey
To get feedback on 2003 services, we surveyed employers
who had significant enrollment of limited English speakers
in an HPHC plan. Late in 2004, we drafted a survey using
CAHPS wording wherever applicable. It was sent to a
sample of 33 employers which HPHC had identified had
significant enrollment of non-English speakers. Twelve
providers responded, for a response rate of 36%. The
respondents represented a total of at least 3270 and up to or
exceeding 6340 members. They represent a very small
percentage of HPHC’s average total group enrollment for
2003, probably about 1%. Estimates of the number of nonEnglish speaking employees of these companies ranged
from about 360 to 1600 or more, constituting between 4 and
18% of the total members who disclosed speaking languages
other than English. Given that this counts only the
employee holding the policy, and not the total family
members covered by the policy, this survey likely covered a
larger percentage. Most of the respondents were companies
that employed from 50 to 250 staff eligible for health care
benefits. Five companies were larger, ranging from 250 to
over 1000 and two were smaller, with 10 to 49 eligible
employees. Spanish was the most common language, with
10 of the 12 companies citing that a significant percentage of
their employees or their families spoke it. Six cited
Portuguese and five cited Haitian.
Other languages
indicated were Chinese (3 companies), Cape Verde and
Vietnamese (2 companies), and Armenian, French, Korean
and Greek (1 company each). The companies predominantly
offer HMO plans to their employees, but some also offer a
PPO, while one self-insures with HPHC as administrator.
Most have long-term relationships with HPHC.
Page 104
Half, 6, have contracted with HPHC since before this entire assessment period. A quarter, 3, initiated a relationship with HPHC during
2000 or 2001, and the remaining quarter contracted with HPHC beginning in 2002 or 2003. Most contract only with HPHC; only 3 also
offer plans from other HMOs. In selecting a health plan, the dominant consideration of most plans (9) was the premium. Other
considerations include the size of the provider network (4), quality of care (3), HPHC’s reputation (3), and their broker’s recommendation
(3). Only 2 mentioned the linguistic capacity of the provider network.
Over the 4-year assessment period, plans offering more than one option indicated how their HPHC enrollment changed. Four of ten
responding to this question indicated that HPHC’s enrollment had increased and 5 that it had stayed the same. Only 2 experienced
decreased enrollment in HPHC. Respondents rated the enrollment of their non-English speaking employees similarly. Only 1 provider
whose overall HPHC enrollment increased reported that non-English enrollment remained the same. In all other cases, non-English
employees were reported to have behaved the same as total employees. Of the 5 employers that gave reasons for experiencing changes in
enrollment, 4 cited cost – of premiums or co-pays and deductibles as reasons for employee decisions. None cited changes in the linguistic
capacity of the provider network.
Employers were asked to rate their non-English speaking employees’ satisfaction with a number of aspects of HPHC’s health plans and to
compare them to other HMOs. As shown in Table 66, the only area in which HPHC was rated lower than good was premiums, and it was
the only aspect at which HPHC was rated lower than other HMOs. On those dimensions specifically focused on the experiences of nonEnglish speakers, HPHC was generally rated high. Satisfaction with mental health services was notable in having 2 ratings of fair, and
access and pharmacy coverage also were rated fair by 1 provider each. However, HPHC was rated as the same or better than other HMOs
on all these dimensions, suggesting that any problems are found throughout the health care system.
B.
PEOPLE WITH CHRONIC ILLNESS
1. Identifying the Population
There is no easily defined
subgroup of people suffering
from chronic illness, though it is
possible to identify those with a
specific chronic illness like
diabetes, asthma, and HIV/AIDS.
However, community informants
and advocates indicated that they
were
less
concerned
with
performance on management of
specific diseases, than with
TABLE 66
SURVEY OF EMPLOYERS WITH SIGNFICANT NON-ENGLISH ENROLLMENT
Percent rating
HPHC good
and above
Premium
50%
Non-English speaking employee satisfaction with:
Linguistic Capacity of Provider Network
100%
Linguistic Capacity of Member Services
100%
Access
92%
Quality of Care
100%
Satisfaction with Mental Health Services
80%
Satisfaction with Pharmacy Coverage
92%
Percent rating
HPHC as better
than other plans
Percent rating
HPHC as worse
than other plans
44%
11%
20%
13%
14%
29%
0%
8%
0%
0%
0%
0%
0%
0%
Source: DMA Health Strategies Survey of Selected HPHC Employers, 12/2004.
Page 105
members’ ease in accessing and coordinating the specialized
medical care, rehabilitation treatment, medical equipment
and medications they need.
One major identifiable population is HPHC’s First Seniority
program, its Medicare Risk program serving primarily
individuals over 65. As we saw when analyzing utilization
data, this group uses many more services than those in
HPHC’s commercial population. We have also collected
information about HPHC’s processes for clinical
authorization, and its specialty case management program
which serves higher need individuals with more complex
conditions. Another source of information is consumer
satisfaction data for respondents who rate their care as fair
or poor, and those who are older. We have also analyzed
HPHC’s performance on certain measures related to the
appropriate treatment for some specific chronic conditions.
Finally, we have contacted community informants who can
help us to identify relevant issues and report on their
experience receiving care from HPHC.
2. Network of Providers Serving Individuals with Chronic
Illness
There is no discrete network of providers serving people
with chronic illness; it is likely that HPHC’s entire network
serves people with chronic illness to a greater or lesser
extent. We did however, request turnover data for certain
specialties that stakeholders had indicated were of particular
importance for people with chronic illnesses.
Table 67
shows that there was minimal turnover in geriatricians,
rheumatologists, and podiatrists, and a net addition over the
4 years, despite the reduction in HPHC membership.
Another aspect of the provider network that is important to
some individuals with a chronic illness is that they work
more closely with a specialist than with a primary care
doctor. It may therefore be most convenient and effective
for that physician to serve as a primacy care physician.
HPHC does allow this if the specialist is willing to fulfill all
the responsibilities of the PCP.
HPHC reports that
oncologists are the most common type of specialist to do
this.
First Seniority has its own dedicated network, which split
from the overall network beginning in 2001. First Seniority’s
network overlaps that of the commercial population.
Because Medicare sets the payment rates to HPHC, rather
than HPHC determining what to charge, rates and contract
terms for First Seniority providers are different from those
offered for the HMO/POS program. As indicated earlier,
HPHC withdrew as a provider of First Seniority in several
counties, and lost enrollment from those counties as well as
within those that remained. These changes were also
reflected in the network of HPHC First Seniority Providers.
Eleven of 24 First Seniority Network Hospitals affiliated in
2000 were no longer included in the network in 2001. Three
of the eleven were in counties no longer covered by HPHC
First Seniority. The other eight hospitals that left the
network were located in Gloucester, Waltham, Lawrence,
Newton, Weymouth and Norfolk. There continued to be
change in the network in the next two years. Hospitals in
TABLE 67
TURNOVER IN GERIATRICIANS, RHEUMATOLOGISTS, AND
PODIATRISTS IN THE HPHC NETWORK
2000
2001
2002
2003
Number leaving the network
5
3
1
4
Number entering the network
0
4
1
14
(5)
1
0
10
Net effect
Source: HPHC Response to Attorney General
Page 106
Winchester and Needham were dropped in 2002, and
hospitals in Norwood and Framingham were lost in 2003,
but hospitals in Medford, Melrose and Salem were added.
Though the overall capacity did not decrease dramatically
between 2001 and 2003, it can make a dramatic difference to
an individual First Seniority member when the hospital
where he or she is accustomed to receiving services is no
longer available in the network.
With a relatively small network covering a wide area, it is
important to understand the geographic access of the
provider network. While HPHC accessibility analyses in
2000 found that most provider groups meet HPHC’s
standard that 95% of members have a practitioner within 30
minutes of their residence, such analyses were not available
in subsequent years. Given the reduction in the number of
providers, it is likely that fewer members had most provider
types available within 30 minutes.
The number of First Seniority primary care providers
These two measures suggest that First Seniority had a
dropped considerably between 2000 and 2001 and continued
sufficient network of primary care providers, and an
to contract slowly as seen in Table 68. Because enrollment
accessible network of specialists, mental health professionals
also dropped, however, the rate of physicians per thousand
and hospitals in 2000. Reductions in the network of PCPs
actually increased somewhat. However, this did not affect
have stretched provider PCP coverage in certain regions, the
all regions equally. The rate of PCPs per Boston member
Northeast, particularly. We do not have relevant data to
increased throughout the period, while the rates in the
assess what happened to the specialist network, nor whether
Southeast stayed about the same and rates in Metrowest
the network met the same high accessibility standards as in
decreased somewhat and decreased considerably in the
NorthEast,
where
TABLE 68
they were lowest to
IRST
S
ENIORITY
P
RIMARY CARE PHYSICIANS
F
start. This left rates in
ER
1,000
M
EMBERS BY REGION
P
these areas as low or
2000
– 2003
lower
than
the
penetration rates for
2000
2001
2002
2003
HPHC’s
healthier,
Per
Per
Per
Per
commercial
Region
Number
Number
Number
Number
Thousand
Thousand
Thousand
Thousand
population. Given the
Boston
277
45
296
58
309
64
314
66
higher
levels
of
medical need in older
Metro West
361
16
264
13
214
11
181
10
members,
HPHC’s
North East
72
14
62
13
39
7
45
8
First
Seniority
provider
network
South East
241
15
169
19
99
11
118
17
may be somewhat
Central
103
23
stretched, especially
in the North East.
Grand Total
1,062
19
793
14
662
17
658
19
Source: First Seniority Primary Care Physician Directory, Volume 1, 2000, 2001, 2002, 2003 and DOI 2003 Supplemental Utilization Schedule
NAIC 2000, 2001, 2002 for HPHC, Harvard Pilgrim and HPHC NE, Supplemental Utilization Report 2003 HPHC and HPHC NE.
Page 107
2000. Changes in hospitals included in the network may have constituted a hardship for the members who had been using them. These
changes in the available network may have contributed relatively high disenrollment rates, which leaving members attributed mostly to
problems with services.
3. First Seniority Member Ratings of HPHC Network
The Center for Medicare and Medicaid services publishes the results of certain CAHPS survey questions for members of Medicare plus
Choice plans. Table 69 shows how HPHC’s First Seniority plan compares to other Massachusetts and national Medicare Risk HMOs on
questions related to physicians.
First Seniority members rate their physicians’
communication quite highly, with over 70%
scoring their physicians ‘always’ on
questions related to how well doctors
communicate.
This was similar to the
Massachusetts average and higher than the
national average. However, all ratings fell
over the period and HPHC ended at about
the same level as the state average. Eighty
percent or more of First Seniority members
did not have a problem seeing a specialist,
similar to the Massachusetts average and
higher than the national average, but these
rates fell as well and HPHC dropped below
the Massachusetts average. Finally, almost
all, 95% of First Seniority Members, were
seen by a provider in the past year, equaling
the Massachusetts average and exceeding the
national average. These already high rates
improved by one percentage point for all
parties, maintaining their relative positions.
This suggests that the diminished network
has had some effects in making it harder to
see a specialist, but has not diminished
primary care rates.
TABLE 69
HPHC ACCESSIBILITY ANALYSIS FOR FIRST SENIORITY MEMBERS
% of Members
Within 25 Miles of
1 Provider
Jun-00
% of Members Within
30 Minutes Drive of
1 Provider
Sep-00
Dec-00
Adult PCPs
97.5%
97.6%
OB/GYNs
97.1%
96.8%
Cardiologists
99.8%
95.4%
95.2%
General Surgeons
99.8%
95.9%
96.7%
Other Surgeons
100.0%
96.9%
96.9%
Behavioral Health Providers (MDs and PhDs)
100.0%
97.0%
97.0%
Gynecologists
92.2%
91.3%
Oncologists
96.2%
96.2%
Opthamologists or Optometrists
97.0%
97.4%
Urologists
97.2%
97.2%
Hospitals
94.5%
99.9%
Source: Col 1. Massachusetts Managed Care Accessibility Analysis, June 30, 2000. Col 2,3. HPHC Medicare
Accessibility Analysis, December 2000.
Page 108
TABLE 70
MEDICARE SATISFACTION SURVEY RESULTS 2001, 2002 AND 2003
2001
2002
National
Average
MA
HPHC
MA
National
Average
HPHC
MA
How well doctors
communicate
72% E/M
74% S/N
72%
67%
68% E/M
73% N/S
72%
66%
66% E/M
70% N/S
69%
66%
Not a problem to see a
specialist
83% E/M
80% S/N
83%
79%
81% E/M
81% N/S
81%
78%
78% E/M
81% N/S
83%
78%
95%
95%
91%
95%
91%
96%
96%
92%
Percentage of plan members
seen by a provider in the
past year
HPHC
2003
National
Average
96%
E/M signifies that measures pertain to Essex and Middlesex counties
N/S signifies that measure pertain to Norfolk and Suffolk counties
Source: Medicare Health Plan Compare Quality Measure Details, Medicare.gov, 2001-2003
“How well doctors communicate” represents the percentage of respondents who answered ‘always’ to the questions:
•
•
•
•
In the last 12 months, how often did doctors or other health providers listen carefully to you?
In the last 12 months, how often did doctors or other health providers explain things in a way you could understand?
In the last 12 months, how often did doctors or other health providers show respect for what you had to say?
In the last 12 months, how often did doctors or other health providers spend enough time with you?
4. HPHC Clinical Management Practices of Importance for People with Chronic Illness
HPHC’s practices continue to conform to the Massachusetts managed care reform law, which requires that HMOs allow physicians to
issue standing referrals to specialists. This allows a member to see a specialist multiple times without needing to get a separate referral for
each visit, an important benefit to people who need to see specialists on a frequent basis.
HPHC has a Specialty Case Management program intended “to identify … members who are likely to be at risk for needing complex,
costly, or long-term health care services … and … would benefit from specialized expertise or an additional intensity of coordination of
services”. The program is staffed by nurse case managers, with staffing levels determined by enrollment levels. As seen in Table 71, the
Page 109
clinical and direct care staff decreased by 41
FTE between 2000 and 2003, a drop of 30%.
However, the rate of clinical staffing per
thousand members stayed at or above the 17
per thousand level present in 2000, indicating
that these reductions were in proportion to
enrollment reductions.
The maintenance of access to case management
is confirmed by the counts we received from
HPHC. While the number of members receiving
specialty case management dropped from 646
to 592 between 2000 and 2002, the proportion of
members provided this service actually
increased considerably – by almost 45% - from
0.8 per thousand to 1.19 per thousand. In 2003,
the number of members receiving this service
jumped considerably, to 1066, reaching 1.98 per
thousand, almost three times the rate of 2000.
However, since staffing did not change so
remarkably, these results suggest that the
method of counting clients or the types of case
management services provided may have changed.
TABLE 71
CASE MANAGEMENT DEPARTMENT FTE
Clinical and Direct Care Positions
2000*
2001*
2002*
2003**
Director
1.00
1.00
1.00
1.00
Regional Case Manager
8.00
6.50
7.00
6.75
Nurse Case Managers
112.00
84.98
73.15
70.20
Primary
93.00
68.98
57.80
54.35
Specialty
19.00
16.00
15.35
15.85
Social Workers
5.00
5.00
4.00
4.00
Clinical Trainers
5.00
5.00
5.00
4.85
Intake Coordinators
3.00
4.85
5.00
5.90
134.00
107.33
95.15
92.70
0.17
0.18
0.19
0.17
Total FTE
Clinical & Direct Care FTE per thousand
* Excludes Disease Management and Functional Therapies
** Projected staffing prior to 2003
Source: HPHC Response to Attorney General
5. Providers’ Opinions of Care Managers
HPHC’s 2001 survey of primary care providers conducted by Fact Finders found that they had a largely positive view of HPHC care
managers. About one quarter, 26%, of respondents interacted with HPHC care managers, and 81% of them rated care managers’
decisions as consistent with current standard of practice most of the time. In 2003, a higher percentage, 92%, rated support from care
managers highly.
6. Health Advance
A new service, initiated in 2001, is called HealthAdvance, provided by a company called Status1. This vendor uses encounter data to
identify members whose care is fragmented or incomplete for their identified conditions. Company nurses then work directly with the
PCP and the member, developing an active plan of care with at least one goal set by the patient and nurse together, usually reaching goals
Page 110
within 6 to 9 months. As Table 72 shows, this program
continues to work with a small percentage of commercial
members, and a significant percentage of First Seniority
members. Clients receiving this service rate their health as Fair
to Good on average. Almost all participants have a care plan for
continued services and it has succeeded in reducing their rate of
hospitalization by two-thirds for commercial populations and
one half-for First Seniority compared to the baseline. This
service is an important improvement in the care of HPHC’s high
need individuals, many of which have multiple co-morbidities
and few natural supports.
7. 2001 Grievances and Appeals
TABLE 72
HPHC MEMBERS RECEIVING STATUS1 HEALTHADVANCE SERVICES
2001
2002
2003
Commercial
% Managed Care Members
0.50%
0.54%
0.45%
Mean of Self-rate Health Status, where
1 = Poor and 5 = Excellent
2.99
3.07
2.99
Active Care Plan Rate
97%
96%
97%
16.7%
16.7%
16.7%
6.6%
5.8%
6.3%
Baseline Hospitalization Rate
Hospitalization Rate
First Seniority
As shown in Table 73, appeals from Medicare Risk members
% Managed Care Members
7%
8%
7%
were more frequent than those for Commercial members, being
Mean Functional Status
2.86
2.97
2.79
received at almost three times the rate of those for Commercial
Active Care Plan Rate
97%
94%
97%
members in 2000. They also increased dramatically between
2000 and 2001, by over 40%, much in excess of the 6% increase
Baseline Hospitalization Rate
17%
17%
17%
experienced by HPHC’s Commercial members. The greatest
Hospitalization Rate as of 4/6/04
9%
7%
9%
increase came for outpatient care services, which more than
doubled, suggesting that members experienced significant
Source: HPHC’s Response to AG Request for Information, 2001 and 2003.
problems in access to outpatient care. By the end of the period,
the rate of complaints had dropped to near the starting level.
However, different services were being appealed. While ambulatory care remained the most type of appeal, visual services and durable
medical equipment appeals became much more frequent, while dental and mental health appeals decreased dramatically. Clearly 2001
was a year when First Seniority members experienced a higher level of difficulty getting the services they wanted. This may be related to
changes in the provider network as members transitioned to new providers with somewhat different treatment approaches or tried to
access out of network care in order to continue with the providers they knew. Without more detailed data, it is impossible to know
whether the high rate of ambulatory and visual services appeals indicates a broad-based problem or a problem for particular classes of
First Seniority members. However, complaints related to durable medical equipment are likely to be of particular significance for
individuals with certain chronic illnesses, and may indicate difficulty in getting those items that physicians recommend.
Page 111
TABLE 73
FIRST SENIORITY MEMBER
APPEALS PER THOUSAND BY MAJOR SERVICE TYPE
2000
2001
2002
2003
% Change between Years
Out-Patient Care/ Ambulatory Care
1.91
4.97
2.96
2.34
22%
Pharmacy
0.65
0.43
0.64
0.79
22%
Rehabilitative Services
0.38
0.41
0.30
0.37
-3%
Mental Health Services/Behavioral Health
0.14
0.10
0.07
0.03
-80%
Durable Medical Equipment
0.49
0.59
0.54
1.15
137%
Dental
0.36
0.20
0.15
0.03
-92%
Excluded Services
0.47
0.23
1.06
0.70
50%
Emergency Care
1.03
1.63
0.45
n/a
n/a
In-Patient Care
0.81
1.17
0.96
0.93
15%
Visual Services
0.63
0.99
1.43
1.58
150%
Cosmetic/ Reconstructive Surgery
0.04
0.05
0.10
0.03
-22%
Diagnostic Services
0.58
0.36
0.10
n/a
n/a
Fee For Services
0.32
0.03
0.00
0.00
-100%
0.07
0.06
n/a
8.97
7.99
2%
Home Health Services
Total
7.80
11.16
Source: HPHC Appeals by major service type and by first and second appeals, 2000 and 2001
Page 112
8. First Seniority Access
to Prescription
Medications
TABLE 74
AVERAGE FIRST SENIORITY MEMBERS WITH PRESCRIPTION BENEFITS
2000
2001
2002
2003
As noted earlier, the
Number
Percentage
Number
Percentage
Number
Percentage
Number
Percentage
average
number
of
Non-Group
48,569
79%
30,892
76%
30,566
75%
26,887
73%
members decreased by
Group
12,962
21%
9,537
24%
9,934
25%
9,849
26%
40% between 2000 and
2003. As shown in Table
Total
61,532
100%
40,429
100%
40,500
100%
36,735
100%
74, almost 80% of First
Seniority members in
Source: HPHC Response to Attorney General RFI Drug for Member Months
2000 were Non-Group
members, dropping to 73% in 2003. They have a limited drug benefit which was capped at $800 per year in 2000 and $600 in 2001. It went
to a quarterly benefit structure in 2002, with 4 quarterly maximums of $130, resulting in an annual maximum of $520. In 2003, the
quarterly benefit increased to $150, back to the annual maximum of $600 available in 2001. First Seniority group members had access to
an unlimited prescription benefit in 2000 for a monthly premium of $77, increasing to reach $190 in 2003. HPHC introduced a limited
benefit option for group members in 2001, which had a $1200 cap on brand name drugs and unlimited generics for a monthly premium of
$91. This benefit remained unchanged in 2002 and the price increased to $145 in 2003.
The nature of the First Seniority benefit makes it more complicated to use HPHC’s prescription data to analyze access for Medicare
members. The use of caps in the First Seniority prescription benefit means that HPHC did not see any claims that exceeded the annual
cap in 2000 and 2001, and the quarterly cap in 2002 and 2003 for Non-Group members, and the higher cap in place for branded
pharmaceuticals among some group members beginning in 2001. For members with high cost brand name prescriptions that they must
take on a continuous basis, or those with multiple medications, HPHC will see claims for only a portion of the medication that they use.
Thus, the following analysis looks only at HPHC’s share of pharmacy utilization and pharmacy costs.
Even considering the significant share of prescription costs carried by Non-Group First Seniority members, HPHC’s per thousand drug
costs for First Seniority are considerably higher than those of HPHC’s commercial members, reflecting the greater health needs of this
population. HPHC’s average prescription expenditures per
TABLE 75
thousand for First Seniority increased less than the rate for
IRST SENIORITY PLANS
F
the commercial members, 8% between 2000 and 2003, (see
PRESCRIPTION EXPENDITURES PER THOUSAND
Table 75) compared to 13% for commercial members. This
is consistent with the reduction in the First Seniority NonApril –
% Difference
Group prescription benefit and the introduction of a
Dec. 2000
2001
2002
2003
2000 - 2003
capped option for group subscribers. This relatively low
Grand Total
$21,077
$22,166
$25,588
$22,810
8%
rate of increase in HPHC’s pharmaceutical expenditures for
Source: HPHC Response to Attorney General RFI, Three Tier Analysis of Drugs in all Classes by
this high utilization group compared to the overall increase
Cost
Page 113
in prescription expenditures of 60.4%
experienced in the ExpressScripts
sample suggests that First Seniority
members have been bearing a
considerable share of the likely
increase in expenditures for the
prescriptions they need.
Those
members whose income is not
sufficient to cover these escalating
costs may not be purchasing all the
medications that might benefit them.
TABLE 76
HPHC PRESCRIPTION EXPENDITURE PER THOUSAND BY TIER FOR FIRST SENIORITY MEMBERS
April – Dec. 2000
%
2001
%
2002
%
2003
%
Non-Group
Tier 1
$ 10,723
53%
$ 11,416
53%
$12,376
56%
$13,183
60%
Tier 2
$ 8,491
42%
$ 9,241
43%
$8,838
40%
$7,982
36%
Tier 3
$ 1,103
5%
$ 940
4%
$891
4%
$833
4%
Total
$ 20,317
100%
$ 21,598
100%
$22,105
100%
$21,998
100%
Tier 1
$ 11,584
48%
$ 11,617
48%
$13,617
51%
$13,869
55%
Tier 2
$ 11,157
47%
$ 11,385
47%
$12,126
45%
$10,168
Group
41%
At the beginning of the period,
Tier 3
$ 1,185
5%
$ 1,003
4%
$1,085
4%
$991
4%
HPHC incurred 15% lower average
Total
$ 23,925
100%
$ 24,006
100%
$26,828
$25,028
100%
100%
pharmacy costs for Non-Group First
Seniority members than for group
Source: Attorney General RFI, Three Tier Analysis of Drugs in all Classes by Cost
members, as shown in the Table 76.
Over the four years, the differential was somewhat reduced to 12%. Initially, HPHC incurred a higher share of pharmacy expenses for
Tier 1, generic drugs and a lower percentage on Tier 2, brand name drugs for its Non-Group members than for its group members. Both
groups experienced an increase in Tier 1 expenditures and a decrease in Tier 2 expenditures. HPHC’s share of expenditures for the
highest tier 3 drugs is quite similar for both groups, however, and remained very stable at about 4% across all four years. HPHC’s overall
average costs for both groups increased between 2000 and 2002, and then began to fall in 2003, remaining above the starting costs.
The analysis of the five most costly pharmacy classes by Tier shows a different pattern than for HPHC’s commercial population. Three of
the classes were the same as for the commercial population and for both Non-Group and group First Seniority members, medications for
hypertension, to control lipids, and those to treat upper gastro-intestinal conditions. Antidepressants were also included in the top five
for commercial and First Seniority except for Non-Group in one year. Both group and Non-Group included hematology pharmaceuticals
for most of the first two years, but diabetes drugs replaced them in the final two years. Asthma, a top drug for commercial members, and
other endocrine drugs each appeared once in the first two years. In the last two years there were no differences in the most drugs with
largest expenditures between the two plan types, with both including diabetes drugs and antidepressants as the forth and fifth items.
Table 77 presents utilization data on the drugs for which we had at least two years of data for the same sub-group.
The differences in drug benefits between group and Non-Group make a difference in the utilization of most of the medication classes,
with group claims per thousand exceeding Non-Group claims per thousand for all medication classes with data available for both types of
medication coverage. Utilization between the two types of medication coverage was most similar for hypertension drugs and those to
treat hematological disorders. In 2003, expenditures for these classes differed overall by less than 10%, while drugs for lipid irregularity
and upper GI disease differed by 33% to 67%.
Page 114
TABLE 77
HPHC FIRST SENIORITY CLAIMS PER THOUSAND
OF TOP FIVE DRUG CLASSES
Non-Group
April –
2001
2002
2003
Dec. 2000
Tier 1
3,617
3,978
4,563
5,254
Tier 2
1,955
2,013
1,568
1,006
Tier 3
262
193
190
96
Total
5,834
6,184
6,321
6,356
Tier 1
75
77
94
104
Tier 2
1,309
1,511
1,574
1,573
Tier 3
52
29
31
54
Total
1,435
1,617
1,699
1,731
Tier 1
329
346
336
389
Tier 2
361
408
432
374
Tier 3
30
13
3
0
Total
720
767
771
764
Tier 1
342
380
Tier 2
163
184
Not included
in top five
Tier 3
10
13
Class
Description/
Tier
Total
515
577
Diabetes
Tier 1
Tier 2
Not included
in top five
Tier 3
Total
Tier 1
317
Not
Tier 2
495
included in
Tier 3
29
top five
Total
841
590
851
20
1,460
617
813
16
1,447
399
468
44
910
469
461
18
949
Group
% Difference
2000-2003
April –
Dec. 2000
2001
2002
2003
% Difference
2000-2003
31%
-94%
-172%
8%
3,913
2,299
225
6,437
3,998
2,156
146
6,299
4,923
1,705
162
6,789
5,459
988
102
6,550
40%
-57%
-55%
2%
39%
20%
4%
21%
85
1,923
42
2,050
87
2,036
33
2,156
104
2,289
27
2,420
109
2,185
48
2,342
28%
14%
14%
14%
18%
4%
-99%
6%
402
642
30
1,074
383
728
19
1,130
397
886
5
1,287
503
688
1
1,192
25%
7%
-95%
11%
Not
included in
top five
400
164
18
583
Not included
in top five
48%
-7%
-38%
13%
299
561
21
881
Data not
available
Not included
in top five
668
1.060
22
1,750
645
947
26
1,618
402
617
36
1,053
468
564
15
1,047
57%
1%
-29%
19%
Source: Attorney General RFI - Three Tier Analysis of Top Five Drug Classes
Page 115
All but one of the drug classes for which we have two years of data showed growth in the utilization covered by HPHC. Only diabetes
utilization held steady, contrasting to the 56% rate of growth experienced for commercial populations in HPHC for this class of
medication. However, this drug class is used much more intensively in First Seniority than in the commercial population, and may have
less room to grow than in other age groups. Other drug classes increased from 2% to 21%. However, this varied between the tiers, with
most third tier utilization considerably decreasing from 29% to 172% from 2001. Tier three drugs to treat lipid irregularity were the
exception, growing at 4% and 14% on a very small base.
We also analyzed HPHC’s costs for these drug classes, presented in Table 78. Not surprisingly, the differences in the benefit structure
between group and Non-Group had a more dramatic effect on HPHC cost than that seen on utilization. HPHC’s average claims costs for
Non-Group members fell considerably below those for group members. In addition, HPHC’s average claims cost for Non-Group either
declined faster or grew slower than its average claim cost for group members, except for diabetes drugs. Average costs per claim actually
decreased for half of the Non-Group and half of the group categories. Drugs for hypertension and lipid irregularities decreased for both
groups, while drugs to treat upper gastro-intestinal disorders decreased for Non-Group members and diabetes drugs showed a very small
decline for group members. In contrast, hematological drugs and antidepressant drugs average HPHC claims cost increased
considerably. These results show that HPHC’s tiered pharmacy plans have succeeded in containing HPHC costs, even in the face of
increasing utilization rates. With HPHC’s increasing limits on pharmacy benefits, this undoubtedly means that members are both paying
more for prescriptions as their share increases, and minimizing their payments by moving to lower tier alternatives, when possible.
However, HPHC’s benefit structure is very similar to those of the Massachusetts HMOs, so it is likely that all HMO members are
experiencing higher medication costs.
Page 116
TABLE 78
FIRST SENIORITY NET HPHC COST PER CLAIM
OF TOP FIVE DRUG CLASSES
Class
Description/
Tier
Non-Group
April –
Dec. 2000
2001
2002
2003
Tier 1
$3.44
$3.15
$3.92
$3.95
Tier 2
$20.03
$17.92
$19.61
$18.32
Tier 3
$10.90
$8.91
$9.76
$23.47
Total
$9.34
$8.14
$7.99
$6.52
Tier 1
$11.14
$11.04
$14.02
$17.29
Tier 2
$46.93
$40.81
$43.71
$42.78
Tier 3
$18.90
$20.83
$20.06
$19.09
Total
$44.05
$39.03
$41.64
$40.51
Tier 1
$11.26
$7.15
$4.62
$9.00
Tier 2
$52.21
$39.62
$41.40
$40.98
Tier 3
$30.85
$31.78
$22.77
$37.59
Total
$32.61
$24.82
$25.28
$24.68
Diabetes
Tier 1
$9.84
$8.61
Tier 2
$39.04
$43.53
Not included
in top five
Tier 3
$11.79
$14.08
Total
$26.87
$28.30
Tier 1
$13.14
$12.10
Tier 2
$170.69
$271.41
Not included
in top five
Tier 3
$57.21
$24.09
Total
$63.79
$95.03
$2.44
Tier 1
$31.26
Tier 2
Data not
available
$18.53
Tier 3
$19.95
Total
$3.23
$24.18
$12.11
$14.42
$12.80
$40.87
$11.68
$26.42
Group
%
Difference
April – Dec.
2000
13%
-9%
54%
-43%
$6.13
$33.86
$21.44
$16.56
$7.43
$37.56
$ 26.39
$ 18.18
$9.67
$45.98
$28.78
$19.24
$8.80
$44.74
$34.87
$14.63
30%
24%
39%
-13%
36%
-10%
-1%
-9%
$22.84
$86.25
$39.10
$82.65
$23.64
$93.61
$68.21
$90.41
$33.64
$102.02
$53.26
$98.54
$33.73
$92.64
$44.04
$88.92
32%
7%
3%
-7%
-25%
-27%
18%
-32%
$22.41
$145.35
$69.12
$97.23
$15.32
$159.40
$86.43
$109.34
$11.68
$165.90
$113.53
$118.21
$46.94
$156.48
$130.73
$110.22
52%
7%
47%
12%
$28.06
$59.70
$78.50
$47.86
$22.66
$62.01
$84.68
$46.67
-19%
4%
8%
-2%
2001
-13%
12%
19%
5%
-8%
59%
-58%
49%
Not included
in top five
425%
31%
-37%
32%
$8.28
$74.58
$56.27
$30.63
$26.65
$312.03
$96.00
$109.29
Data not
available
2002
2003
% Difference
Not included
in top five
$13.47
$84.00
$57.21
$56.21
$15.14
$80.72
$40.92
$50.81
83%
8%
-27%
66%
Source: Attorney General RFI - Three Tier Analysis of Top Five Drug Classes
Page 117
This analysis suggests that– even in an environment where
prescription costs are rising - HPHC has been effective in
controlling its average per claims costs for the five most
expensive drug classes by sharing a greater percentage of the
cost with its members. However, though the claims paid at
least in part by HPHC grew for each of the drug classes,
HPHC saw fewer claims for its Non-Group members than
for group members. This is undoubtedly due in part to the
Non-Group members paying in full for prescriptions once
their quarterly cap has been reached. The relatively small
differential between group and Non-Group utilization in
hypertension and hematological drugs suggests that higher
member shares for prescriptions do not significantly
decrease access. However, the larger differentials in use of
medications for upper Gastrointestinal diseases and lipid
irregularity suggest at least a different pattern of utilization
and a potential for diminished access.
9. Medications of Importance for People with Chronic
Illness
We requested data on two drug classes and one subclass of
special importance for people with chronic illness and
analyzed their utilization for both commercial and First
Seniority members. We looked at one broad class of drugs
to reduce high blood pressure (hypertension), and one of its
important subclasses, hypotensives. These drugs can make
it easier for the heart to pump and improve the functioning
of an ailing heart. In addition, they can slow the progression
of kidney disease from high blood pressure or diabetes.
They are needed on an ongoing basis since they only reduce
blood pressure while they are being taken. They may also
be used on a preventive basis before there has been
significant damage to the heart or blood vessels. We also
looked at the class of anticonvulsant medications used to
prevent seizures. Medication is one of the first treatments to
be tested for people with epilepsy or seizure disorders. They
must reach a certain level in the blood stream to work, and
patients must take the medication regularly to maintain that
level.
As seen in Table 79, all three drug classes were used more
intensively by First Seniority members than commercial
members.
All classes showed a pattern of growth in
utilization for both populations, though First Seniority
utilization grew slower on its higher base. Hypertension
drugs were the most intensively used drug class in this
analysis, and grew 14% for commercial members and only
7% for First Seniority members. They also experienced a net
shift from Tiers 2 and 3 to Tier 1. Hypotensives/Ace
Inhibitors also showed increasing utilization overall.
Members showed a dramatic shift from Tiers 2 and 3 to Tier
1 drugs. Utilization of drugs used to treat seizure disorders
also increased. The very low utilization of Tier 3 drugs in
this class declined for both Commercial and First Seniority
members.
This pattern of increasing utilization suggests that members
are increasingly accessing medications to treat these three
conditions. The data also suggest that the tiered co-pay
structure is effective in containing the utilization of Tier 3
medications. However, relatively few prescriptions are
written for this tier, compared to Tiers 1 and 2 where the
bulk of prescriptions are written. Thus the steep declines
probably affect relatively few individuals and may reflect
the availability of good alternatives in Tiers 1 or 2.
As mentioned previously, HEDIS measures the percentage
of people who receive Beta-blockers after a heart attack. A
very high percentage of First Seniority members, 98% and
97% in 2003, were given Beta-blockers in this circumstance.
This was slightly lower than the state average of 99% for
Page 118
Medicare managed care plan members, and higher than the 94% national average for the same population. Both averages remained the
same in both years.
TABLE 79
COMMERCIAL AND FIRST SENIORITY CLAIMS PER THOUSAND
OF SPECIFIC DRUG CLASSES
Class
Description/
Tier
April –
2001
Dec. 2000
Hypotensives, Ace Inhibitors
Tier 1
13
26
Tier 2
289
332
Tier 3
20
15
Total
322
373
Tier 1
684
770
Tier 2
458
491
Tier 3
80
69
Total
1,222
1,330
Seizure Disorder
Tier 1
86
95
Tier 2
118
128
Tier 3
2
1
Total
206
224
Commercial
2002
First Seniority
% Difference
2000-2003
2003
April –
Dec. 2000
2001
2002
2003
% Difference
2000-2003
152
222
16
391
304
75
13
393
2,240%
-74%
-33%
22%
96
1,245
67
1,408
139
1,293
35
1,467
715
809
32
1,555
1,350
148
22
1,520
1,307%
-88%
-68%
8%
880
399
70
1,350
1,049
300
43
1,393
53%
-34%
-46%
14%
3,679
2,028
254
5,961
3,983
2,047
182
6,211
4,651
1,602
183
6,436
5,309
1,002
98
6,408
44%
-51%
-62%
7%
100
144
1
245
100
151
1
252
16%
28%
-75%
22%
161
194
3
358
186
215
1
402
183
211
0
394
179
205
0
384
11%
6%
-99%
7%
Source: HPHC Response to Attorney General RFI - Three Tier Analysis of Drugs in Selected Classes
10. CAHPS Ratings
Table 80 illustrates responses from HPHC’s CAHPS survey stratified for health status. The sample size of the smallest category, people in
fair or poor health, was relatively robust, 49 in 2001 and 35 in 2003. Samples in other years were likely of similar size. These responses
show that HPHC performs very well on some dimensions of care needed by people in poor health; in some they rated their access higher
than those in better health. This was true of the rating of getting needed care for illness or an injury as soon as they wanted and their
ability to get a referral to a specialist. Getting needed care was rated high and improved over time, while those in better health had
declining ratings. Referrals to specialists stayed about the same, with an unusually low rating in 2002, while ratings of people in better
health declined. However, people in poor health rated other important aspects of care lower than those who were healthier. They were
less satisfied with the time it took to get appointments with a personal doctor or specialist for an urgent problem or health condition, and
Page 119
TABLE 80
HPHC CONSUMER ASSESSMENT OF HEALTH PLANS SURVEY BY SELF-RATED STATE OF HEALTH
State of Health
RATING OF HEALTH STATUS
Fair, Poor
Good
Excellent, Very Good
ACCESS TO PHYSICIANS
2000
2001
2002
49
148
372
2003
% Yes
% Yes
% Yes
% Yes
Customized
Customized
274
Question Question 75.0%
Not Available
Not Available
87.2%
In 2002
In 2003
94.9%
Satisfied with the amount of time you had to wait to get an
initial appointment with a specialist for an urgent problem or
health condition?
% Yes
N
Fair, Poor
Good
% Yes
% Yes
% Yes
194
66.7%
73.1%
75.9%
Customized
Question Not Available
In 2002
Customized
Question Not Available
In 2003
Problem to get referral to specialist
% Not a
Problem
N
Fair, Poor
Good
2001
2002
2003
35
138
363
Satisfied with the amount of time you had to wait to get an
appointment with your personal doctor or nurse for urgent care?
N
Fair, Poor
Good
2000
% Not a
% Not a
% Not a
Problem
Problem
Problem
328
328
343
61%
84%
81.3%
84.2%
80%
78%
85.1%
80.4%
82%
80%
85.6%
82.8%
In the last 12 months, how much of a problem, if any, was it to
get the prescription medicine you needed through your health
plan?
% Not a
% Not a
% Not a
% Not a
Problem
Problem
Problem
Problem
Customized
Customized
521
Question Question 66.7%
Not Available
Not Available
77.3%
In 2002
In 2002
83%
When needed care for illness or injury, how often did you get care
as soon as you wanted?
% Always
% Always or
% Always or
% Always or
or Usually
Usually
Usually
Usually
223
223
272
79%
100%
94.7%
90.3%
86%
87%
91.5%
85.7%
89%
89%
93%
88%
COMMUNICATION
% Always
or Usually
% Always or
% Always or
% Always or
Usually
Usually
Usually
481
481
502
90%
94%
100%
86.4%
91%
94%
97.1%
93.3%
96%
97%
95.5%
94.2%
In last 12 months, how much of a problem, if any, was it to find
or understand information in written materials?
% Not a
% Not a
% Not a
% Not a
Problem
Problem
Problem
Problem
149
149
189
50%
50%
42.9%
55.6%
57%
68%
63.8%
60.9%
69%
78%
68.2%
73.6%
How would you rate the overall cost to you for your health
insurance coverage? (0= Extremely Unreasonable - 10=
Extremely Reasonable)
Ratings of
Ratings of
Ratings of
Ratings of
8, 9 or 10
8, 9 or 10
8, 9 or 10
8, 9 or 10
515
515
526
47%
49%
31.3%
61%
42%
31.8%
59%
58%
47.3%
N
Fair, Poor
Good
*Statistically significant from
Source: HPHC NCQA/Consumer Assessment of Health Plans Study by Health Status, Hispanic vs. Non-Hispanic
Page 120
more indicated that they had problems getting the prescription medicines they needed. People in fair or poor health improved somewhat
in understanding written communications from the health plan but half of them continued to have difficulties, more than those in better
health. All members rated the understandability of doctors’ and health providers’ explanations quite high, 90% and above in most years,
and members with fair or poor health rating were similar. Finally, people with fair or poor health rated the affordability of their overall
cost for health insurance as less reasonable than those with better health. Surprisingly, given continued premium increases, more
members rate coverage as reasonable at the end of the period.
Stratifying these ratings by age did not show as much differentiation as state of health. The survey sample was fairly evenly divided
between the different age categories, though the youngest age group was less well represented in the 2003. As seen in Table 91, those in
the oldest category had similar perceptions of getting a referral to a specialist as those of other ages. They rated their satisfaction with the
amount of time to get an appointment with a personal physician or specialist higher than those of other ages, and considerably higher
than those in poor health. Similarly, they generally rated their ability to get needed care for an injury or illness higher than other ages
and similar to those who rated their health as fair or poor. However, their ratings of getting needed medication were worse. Their ratings
of their providers’ explanations were high and similar to those of other ages. However, their ratings of written communications were not
markedly different from other age categories. Those in the oldest age category had the highest ratings of the reasonableness of the overall
cost for health insurance coverage, and ratings peaked in 2002.
Page 121
TABLE 81
HPHC CONSUMER ASSESSMENT OF HEALTH PLANS SURVEY BY AGE
2000
2001
2002
2003
SAMPLE SIZE
18-34
109
44
35-44
103
78
45-54
164
109
55+
134
92
Satisfied with the amount of time you had to wait to get an appointment
Years
with your personal doctor or nurse for urgent care?
of Age
% Yes
% Yes
% Yes
% Yes
N
274
18-34
85.2%
35-44
87.8%
45-54
94.4%
55+
93.4%
Satisfied with the amount of time you had to wait to get an initial
Years
appointment with a specialist for an urgent problem or health condition?
of Age
% Yes
% Yes
% Yes
% Yes
N
194
18-34
70%
35-44
59.6%
45-54
75%
55+
86.4%
2000
2001
2002
2003
When needed care for illness or injury, how often did you get care as soon as you wanted?
% Always or Usually % Always or Usually % Always or Usually % Always or Usually
272
218
93.9%
87.5%
79%
93%
89.4%
85.2%
82%
82%
95.2%
84.3%
88%
92%
92.9%
96.4%
94%
91%
COMMUNICATION
% Always or Usually % Always or Usually % Always or Usually % Always or Usually
502
473
95.1%
91.3%
93%
96%
98.6%
92.8%
94%
96%
95.3%
91.7%
91%
95%
95.8%
95.7%
97%
98%
In last 12 months, how much of a problem, if any, was it to find or understand
Years Problem to get referral to specialist
information in written materials?
of Age
% Not a Problem % Not a Problem % Not a Problem % Not a Problem % Always or Usually % Always or Usually % Always or Usually % Always or Usually
N
189
146
343
323
18-34
70.4%
71.4%
55%
65%
84%
82.7%
77%
77%
35-44
64.1%
67.2%
71%
83%
84.2%
79.5%
79%
74%
45-54
60%
72.7%
61%
71%
85.7%
93.5%
82%
78%
55+
67.4%
63.2%
68%
72%
85.5%
83.7%
80%
87%
In the last 12 months, how much of a problem, if any, was it to get the
COST - How would you rate the overall cost to you for your health insurance coverage?
Years
prescription medicine you needed through your health plan?
(0= Extremely Unreasonable - 10= Extremely Reasonable)
of Age
Ratings 8, 9 or 10
Ratings 8, 9 or 10
Ratings 8, 9 or 10
Ratings 8, 9 or 10
% Not a Problem % Not a Problem % Not a Problem % Not a Problem
N
521
526
18-34
82.6%
42.9%
57%
48%
35-44
83.9%
38.9%
54%
52%
45-54
76.8%
40%
60%
50%
55+
76.7%
46.9%
64%
61%
* Statistically significant from other age groups - Source: HPHC NCQA/Consumer Assessment of Health Plans Study, 2000, 2001, 2002 and 2003
Page 122
We also analyzed several similar measures for HPHC’s First Seniority programs. As seen in Table 82, in 2001, quite a high percentage,
59% to 63%, of First Seniority members responding to the survey met the high standard of always getting the care they needed, similar to
the Massachusetts and national averages. Ratings fell somewhat over the next two years, and HPHC fell somewhat with respect to the
state
and
TABLE 82
national
MEDICARE CONSUMER ASSESSMENT OF HEALTH PLAN SURVEY
average.
A
higher
percentage of
respondents,
87% to 88%,
had
no
problems
getting needed
care in the past
six
months.
Again, this was
similar
to
Massachusetts
and above the
national
average. These
rates also fell
somewhat over
the three years,
but
HPHC
remained
similar to the
MA
average
and somewhat
higher than the
national
average.
HPHC
was
rated
quite
highly as being
2001
MA
Average
National
Average
HPHC
59% E/M*
63% N/S**
63%
59%
87% E/M
88% N/S
86%
82%
46%
40%
53%
46%
HPHC
Always got
care
No problems
getting
needed care
Best Possible
Health Plan
Best Possible
Care
47% E/M
45% N/S
53% E/M
52% N/S
2002
MA
Average
National
Average
HPHC
53% E/M*
60% N/S**
61%
54%
84% E/M
84% N/S
83%
79%
44%
38%
51%
44%
44% E/M
47% N/S
49% E/M
49% N/S
2003
MA
Average
National
Average
52% E/M*
57% N/S**
59%
55%
83% E/M
82% N/S
84%
80%
33%
32%
47%
43%
33% E/M
35% N/S
44% E/M
47% N/S
* E/M signifies that measures pertain to Essex and Middlesex counties
** N/S signifies that measure pertain to Norfolk and Suffolk counties
Source: Medicare Health Plan Compare Quality Measure Details, Medicare.gov, 2001, 2002 and 2003
Answers to the following questions were combined to determine how many members always got the care they needed:
•
•
•
•
Got the advice or help they needed when they called the doctor’s office during regular office hours;
Got treatment as soon as they wanted when they needed to be seen right away for an illness or an injury;
Got an appointment as soon as they wanted for regular or routine care; and
Waited only 15 minutes or less past their appointment time to see the person they went to see.
Answers to the following questions were combined to determine how many members said that they did not have problems in the
past 6 months:
•
•
•
•
Finding a personal doctor or a nurse;
Getting a referral to a specialist that they wanted to see;
Getting the care they and their doctor believed necessary; or
Getting care approved by the health plan without delays.
The final two measures asked respondents to rate their health plan and their own health care on a 10 point scale where 10 was the
best possible.
Page 123
the best possible health plan and providing the best possible care, with almost half rating their health plan and slightly more than half
rating their own health care as the best possible, similar to the Massachusetts average and above the national average. Again these ratings
fell by about 10 percentage points over the three years, but the relative relationships remained the same.
Taken together, these results suggest that HPHC’ network is highly responsive to its sickest and oldest members. Though responsiveness
has declined somewhat, this is shared by other HMOs, and HPHC has maintained a rating similar to other Massachusetts HMOs. Access
to medications is one area in which people in poor health and those who are older rate their experience as worse than those who are
healthier or younger. This could well be related to increasing co-pays for individuals needed more medications. However, premiums
were not generally rated as problematic.
Written
TABLE 83
communication is also an area with room for improvement.
HPHC QUALITY AWARD PROGRAM GRANTS
11. Quality Improvement
HPHC’s Quality Improvement program focuses the
attention of its clinical managers and provider network on
effective management of certain chronic diseases. This
section describes HPHC’s processes for improving the
quality of care provided to its members.
One important method HPHC uses to communicate with its
physician network is quarterly meetings with the Medical
Directors of its Local Care Units. They are used to address
system changes and discuss topics related to treatment
quality. Their meetings continued throughout the period.
Topic in 2003 included e-health and radiology.
HPHC implemented a Quality Award Program in 2000. It is
a grant-based incentive program that provides financial and
consulting support to selected quality improvement
initiatives conducted by network providers or physician
groups. In earlier years, bonus programs for physician
groups were based on performance on key quality indicators
without consideration of the group’s focus on improvement.
Table 83 shows the funds awarded for this program, and
how they were distributed by topic, size of provider group,
and region. Focus appeared to shift from cardiac disease
and asthmas toward behavioral health. Projects included
# Submissions
# Grants Awarded
FY00
FY01
FY02
FY03
29
34
30
Unknown
16
16
15
18
$1.4M
$1.4M
$1.3M
$1.5M
Diabetes
6
7
2
6
Asthma
1
5
1
0
Cardiac Disease
7
0
1
0
Funding $
Funded Topics
Behavioral Health
1
1
3
4
Other
8
7
9
6
Projects by size of Local Care Unit
XL
5
2
4
L
4
6
4
Unknown
Unknown
M
4
4
2
Unknown
S
3
3
3
Unknown
XS
0
1
2
Unknown
Mass – Ctrl
3
4
2
2
Mass – East
6
5
5
9
Mass – SE
7
3
3
4
By Region
Maine
Not eligible
2
3
2
NH
Not eligible
2
2
1
Source: QAP Mini-Summary 2000 and 2001, Update on Grant Recommendations 2002, 2003.
Page 124
practices from all regions and sizes. Funding averaged $1.4
per year with minimal changes.
Late in 2003, HPHC initiated the first payments under a
“Rewards for Excellence” program for larger practices that
met target levels of performance for mammography, PAP
and Chlamydia testing, well child care, and diabetes and
depression management. Target levels are set to reward
practices that reach the higher percentiles of performance.
Rewards are 25¢ or 50¢ per member per month.
Some of the following HEDIS measures capture HPHC’s
effectiveness in improving quality of care for some of these
targeted conditions.
12. HEDIS Measures Related to Chronic Illness
Several HEDIS measures presented earlier are relevant to
adults over 65. As reported in Chapter 4, Table 31, HPHC
exceeds the state and national average in the percentage of
adults over 65 with an ambulatory or preventative visit
within the last 3 years, but it does not excel in this area for
elder adults as much as it does for younger populations,
where it is ranked as high as first or second in the state.
HPHC is similar to the state average in the percentage of its
geriatric specialists who are board certified. (See Chapter 4,
Table 16.)
Another area of special significance to older adults is cardiac
treatment. Table 84 shows several measures related to
appropriate treatment for cardiac problems. In 2000, HPHC
fell on the low side for males over 65 on these measures,
below the Massachusetts average, which is below the
national average on all measures. In comparison to the
national distribution, HPHC was in the low middle for
angioplasty, somewhat lower than that for cardiac
catheterization, and near the lower band boundary for
coronary bypass surgery. It ended close to or exceeding the
MA average. All parties increased their use of less invasive
angioplasty. HPHC’s increase was so great that it exceeded
both averages in 2002, and fell between the two in 2003.
State and national bypass averages ended lower than they
started but HPHC’s increased, making it comparable to
Massachusetts average. These results suggest that HPHC is
becoming more similar to state practice patterns and is
increasingly emphasizing less invasive treatments over more
invasive treatments, a desirable treatment practice.
The female rates on all these procedures fall below those for
males. HPHC’s rates for females on most measures fell
between the Massachusetts average and the national
average, placing HPHC near the middle of the national
distribution, suggesting that access for females is similar to
that in many other health plans. However, in 2003, HPHC’s
female rates fell well below the state and national averages
for angioplasty and cardiac catheterization, though it fell
between the state and national averages for bypass. These
changes made HPHC’s rates for angioplasty of women quite
a bit lower than the averages for both Massachusetts and
national HMOs and raise a potential concern about access.
However, the fact that its 2002 rates were in the high range
indicates that HPHC is willing to use this procedure more
frequently, and fluctuations in rate may be due to
differences in need in a relatively small population.
Page 125
TABLE 84
HEDIS MEASURES OF CARDIAC CARE
National Avg.
(HMO/POS)
HPHC (HMO/
POS combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC (HMO/
POS combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC (HMO/
POS combined)
MA average
(HMO/POS)
National Avg.
(HMO/POS)
2003
MA average
(HMO/ POS)
Angioplasty per thousand
males over 65
Cardiac Catheterization per
thousand males over 65
Coronary bypass per
thousand males over 65
Angioplasty per thousand
females over 65
Cardiac Catheterization per
thousand females over 65
Coronary bypass per
thousand females over 65
2002
2001
HPHC (HMO/
POS combined)
2000
9.72
10.43
13.92
10.62
11.52
14.93
17.34
12.97
16.34
14.01
13.6
17.18
19.45
24.28
28.64
20.67
23.14
30.36
20.43
20.73
30.79
22.88
22.63
28.53
6.92
8.60
12.26
5.69
7.21
10.85
4.62
6.4
10.65
7.63
7.44
9.63
3.94
3.65
5.50
3.24
4.81
5.76
5.93
4.88
6.61
2.78
4.76
6.59
12.69
9.39
16.86
11.57
11.27
18.09
10.67
11.62
18.77
8.33
11.05
17.8
2.74
1.92
4.32
1.62
1.59
3.68
2.13
1.74
3.52
2.14
2.08
2.7
Angioplasty is a procedure used to treat patients whose coronary artery disease cannot be properly managed with medication. Very low rates may indicate
insufficient use of this treatment option. Very high rates, especially if rates of bypass procedures are also high may indicate overuse of invasive treatments.
Cardiac catheterization is a procedure used to diagnose the location, severity and extent of coronary artery disease. It is needed particularly if coronary artery
surgery is contemplated. Unusually high rates may indicate that some patients are receiving an unnecessarily invasive diagnostic procedure. Low rates may
indicate problems with access to this service. Coronary artery bypass graft surgery represents the standard surgical treatment for patient with coronary artery
disease who fail to respond to medical treatment and for whom angioplasty is either not possible or has not been effective. HEDIS suggests that the rates be
judged together.
Page 126
HEDIS includes measures of other procedures stratified for
older adults, prostate surgery for males over 65,
hysterectomies for females over 65, and cholecystectomy
(surgical removal of the gall bladder).
In 2000, HPHC’s
provision of prostatectomies, surgical removal of a man’s
prostate to treat cancer or enlargement, was similar to the
Massachusetts average, and well below the national average,
putting it in the mid-range of practice patterns. (See Table
85.)
However, in 2001, HPHC’s rate had increased
considerably, exceeding both the MA and national averages
but then fell, putting it somewhat below both averages in
2003. The range in rates was considerably smaller at the end
of the period.
In 2000, HPHC’s rates of abdominal hysterectomy for
women over 65 were relatively low in comparison to the
Massachusetts and national averages, which were similar.
At the end of the period, HPHC had increased and the state
and national averages had dropped, making practice
patterns more similar. This pattern suggests that HPHC
remains successful in minimizing the rates of hysterectomy,
a procedure that tends to be overused. HPHC was more in
the mid-range of health plans in its provision of vaginal
hysterectomies, a less invasive procedure, in 2001, falling
between the higher national average and the lower
Massachusetts average. While it was at or above the other
averages for most of the period, it dropped considerably in
2003, putting it well below the other averages, which had
also dropped from 2000 levels. There was considerable
fluctuation in rates over the period, but overall rates of
closed procedures increased and of open procedures fell. In
addition, variation between the different parties was
reduced with a smaller range in 2003 than in 2000.
HPHC’s rates for males for gallbladder removal and its rate
for the open procedure females fell between the
Massachusetts and national averages at the beginning of the
period. At the end, HPHC fell below the average for males
and for closed procedure females, while it was above for
open procedure females. However, its scores were very
similar to the averages for all except closed procedure
females.
Page 127
TABLE 85
HEDIS MEASURES FOR OLDER ADULTS
National Avg.
(HMO/POS)
HPHC (HMO/
POS combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC (HMO/
POS combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC (HMO/
POS combined)
MA average
(HMO/POS)
National Avg.
(HMO/POS)
2003
MA average
(HMO/ POS)
Prostate surgery per thousand
over 65
Abdominal Hysterectomy per
thousand over 65
Vaginal Hysterectomy per
thousand over 65
Gallbladder removal per
thousand males over 65 – closed
thousand males over 65 – open
thousand females over 65 –
closed
thousand females over 65 –
open
2002
2001
HPHC (HMO/
POS combined)
2000
8.55
8.37
10.41
11.57
8.44
9.66
9.83
9.59
9.63
7.27
8.37
8.92
1.20
2.07
2.10
2.08
1.97
2.64
2.61
3.02
2.58
1.5
1.99
1.98
1.89
2.11
1.68
2.31
1.61
1.79
1.66
1.93
1.67
0.43
1.51
1.25
2.65
2.29
2.98
3.22
2.96
4.03
2.31
2.72
4.17
3.72
3.76
3.82
1.03
1.02
1.33
1.52
1.23
1.16
1.16
1.45
1.2
0.89
1.0
0.98
3.43
4.03
5.70
4.86
4.1
7.15
5.22
4.25
6.76
4.06
4.91
6.07
.86
.60
.95
1.62
0.92
0.99
0.47
0.68
0.93
0.64
0.61
0.62
These procedures can be overused, while very low rates may indicate access problems. Removal of gallbladders can be done by
conventional surgery (open), or with a laparascope, requiring only a small incision (closed). However the closed procedure is more
challenging and may cause complications and require additional surgery.
Page 128
HEDIS has a set of measures, which together assess the provision of comprehensive care for people with diabetes. HPHC began and
remained above both the Massachusetts and national averages as all parties improved performance on screening for diabetic
complications, the first four measures. (See Table 86.) The final two measures are indicators of the control of diabetes, and on these
measures HPHC began between or worse than the Massachusetts and national averages and ended better than most, as all parties realized
dramatic increases.
TABLE 86
HEDIS MEASURES OF COMPREHENSIVE DIABETES CARE
HPHC (HMO/
POS combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC (HMO/
POS combined)
MA average
(HMO/ POS)
National Avg.
(HMO/POS)
HPHC (HMO/
POS combined)
MA average
(HMO/POS)
National Avg.
(HMO/POS)
2003
National Avg.
(HMO/POS)
2002
MA average
(HMO/ POS)
2001
HPHC (HMO/
POS combined)
2000
Eye Exams
60.79%
55.74%
48.07%
66.67%
62.68%
51.99%
67.64%
60.84%
51.71%
72.26%
61.76%
48.77%
HbA1c Testing
83.37%
81.34%
78.42%
87.59%
84.05%
81.39%
92.21%
86.97%
82.58%
92.7%
89.05%
84.55%
Lipid Profile
80.40%
76.73%
76.52%
84.91%
82.05%
81.39%
93.67%
90.83%
88.41%
42.18%
40.52%
41.35%
59.85%
49.51%
46.30%
68.37%
59.63%
51.82%
66.18%
57.95%
48.24%
44.17%
42.27%
42.52%
31.87%
38.2%
36.86%
27.49%
30.18%
33.92%
27.49%
29.29%
31.95%
40.69%
39.95%
44.27%
49.15%
47.3%
49.77%
63.26%
61.25%
60.44%
Monitoring
diabetic
neuropathy
Poor HbA1c
control
Lipid Control
Not Available
Not Available
The measures are based on a sample of members with diabetes and measure the percentage of the sample that received needed services. For all
measures except for poor HbA1c control, higher percentages indicate better provision of diabetes care.
Page 129
Table 87 shows some of
TABLE 87
the diabetic screening
MEDICARE HEDIS MEASURES 2001 AND 2002
measures for HPHC’s
First Seniority members.
Level of performance on
2001
2002
2003
these measures was
MA
National
MA
National
MA
National
higher for Medicare
HPHC
HPHC
HPHC
Average Average
Average Average
Average Average
members
than
for
Eye Exams
87%
79%
69%
87%
82%
72%
84%
79%
68%
overall
commercial
HbA1c Testing
93%
92%
86%
95%
93%
87%
94%
94%
89%
members in all cases.
Lipid
Profile
87%
84%
87%
94%
92%
91%
97%
95%
93%
Eye exam scores rose
and then fell below
Source: Medicare Health Plan Compare Quality Measure Details, Medicare.gov, 2001, 2002 and 2003
starting levels, while
HbA1c Testing exceed the national average and Lipid Profile rates rose each year. HPHC continued to meet or exceed MA average and to
exceed the national average.
Asthma is a high incidence chronic condition of importance for children, sometimes requiring restricted activity and potentially causing
death if not appropriately treated. In 2000, HPHC ranked third in the state and exceeded both state and national averages in prescribing
appropriate medications to manage children’s asthma. (See Table 88.) All parties increased their performance on these measures between
2000 and 2003. HPHC continued to exceed the state and national averages.
TABLE 88
PEDIATRIC ASTHMA
HPHC
(HMO/ POS
combined)
MA
Average
(HMO/
POS)
National
Average
(HMO/POS)
HPHC
(HMO/ POS
combined)
MA
Average
(HMO/POS)
National
Average
(HMO/POS)
66.18%
61.35%
78.6%
71.26%
63.17%
78.82%
70.42%
69.51%
83.46%
78.81%
72.4%
67.33%
63.62%
59.50%
72.82%
66.52%
61.62%
73.89%
66.93%
65.24%
74.21%
72.69%
68.18%
MA
Average
(HMO/
POS)
National A
Average
(HMO
/POS)
National
Average
(HMO/POS)
2003
MA
Average
(HMO/
POS)
2002
71.06%
HPHC
(HMO/ POS
combined)
Appropriate asthma
med. Ages 5-9
Appropriate asthma
med. Ages 10-17
2001
HPHC
(HMO/ POS
combined)
2000
Page 130
This analysis shows HPHC excelling and improving in
treating conditions for which there is a clear direction for
desirable performance. These results may point to the
effectiveness of HPHC’s quality improvement program,
which targets diabetes and asthma, among others. This
analysis is unable to address whether emphasizing care for
specific conditions generalizes to improve care processes for
all patients with chronic diseases, or whether it might divert
practice attention from non-targeted conditions and actually
decrease quality of care.
Where optimal provision of surgical care is not well
established, HEDIS measures of HPHC’s performance are
difficult to assess. For most surgeries, HPHC moved closer
to state and national averages, suggesting that its members
had similar levels of access to needed surgeries and
protection from unneeded surgeries.
However, its
performance in 2003 differed from state and national
averages for vaginal hysterectomies and closed gallbladder
removal surgery for females in being lower than state and
national averages. This raises the possibility that access is
reduced, or alternatively that HPHC is excelling in
preventing unnecessary surgeries.
However, there is
sufficient variation in these rates to suggest that HPHC’s rate
may be more affected by variation in need from year to year
than by over- or under- utilizing practice styles.
HPHC services, and all but one of our email survey
respondents rated HPHC 8, 9, or 10 where 10 is the best
health plan possible. Most had been quite long-term HPHC
members and were members in 2000 and/or 2001. Most
were insured through their employers, though one young
adult had Medicare coverage. They had a wide variety of
special health care needs in their family, which included
gastro-intestinal problems, seizures, mental retardation,
congenital heart defect, and autism. Many individuals had
more than one condition, and a number of families had more
than one member with a serious medical condition.
However, most were in good or excellent health over the
three-year period. The same organizations agreed to solicit
their members, requesting their response to an email survey
about their HPHC experiences in 2003, but no responses
were received.
Overall, responses were quite positive.
•
•
13. Consumer Feedback
We used a number of different approaches to gather input
from HPHC members with special healthcare needs and
from advocacy organizations about the first three years of
the analysis period. We conducted three phone interviews
with members of the Federation for Children with Special
Needs, and two organizations distributed email surveys to
their members, of which we received seven responses.
These respondents were generally quite satisfied with their
•
•
•
Respondents use a variety of providers, including their
PCP, specialists, and Children’s Hospital. They were
generally happy with their primary care physicians, and
have often been with them for quite awhile. One
changed PCPs to get one willing to treat her son’s
seizure disorder.
Most respondents found it quite easy to get the referrals
they need for specialists, but sometimes found it difficult
to get a timely appointment.
Experiences with provider transitions varied; some
easily obtained approval to see a physician who had left
the network when they had a pre-existing relationship,
while others transitioned to an in-network replacement.
People who use HPHC case managers were quite
positive about the value of their assistance.
Some individuals use rehabilitation services provided by
HPHC, while others receive similar services in schools.
Respondents whose children use speech therapy said
Page 131
•
•
•
One respondent had a much more negative view of HPHC;
she rated it as 5 on the scale where ten is the best health plan
possible, and was the only respondent to attribute recent
changes to the receivership. While she has been satisfied
with the care she receives and with the assistance of an
individual HPHC customer services staff person, she
describes difficulties in accessing services in Berkshire
County because physicians are reluctant to accept new
HPHC patients because of payment problems.
We also spoke to several advocates from groups that assist
people with cerebral palsy, diabetes, multiple sclerosis, and
seniors at the time of the first survey. They had a range of
comments:
•
•
•
that provision had improved when the state mandate
was passed.
While medication is significant for these families, they
felt that HPHC had clearly communicated the tiered
pharmacy program, and none indicated that it was any
problem to get the medications they needed.
Individuals who had contacted HPHC’s customer
services department did not experience problems getting
the service they needed.
Cost was a problem for a disabled young adult having
difficulty paying the Medicare premium out of a
stipend, and a family with 3 members who have health
care needs, and most of whose medications are in higher
tiers.
HPHC was flexible in approving all current clients of a
specialty clinic to continue with their specialist out-ofnetwork on an ongoing basis.
Overdue HPHC bills were “sky high” at the time of the
receivership.
A number of HPHC members newly diagnosed with
diabetes call the diabetes organization for information
that they should be getting from a health plan
nutritionist.
For the first three years of the analysis period, these
responses suggest that HPHC is often quite flexible in
authorizing out of network care, and its case management
staff offer valued assistance to families with more complex
health needs. However, at least in the Western part of the
state, where HPHC does not have the leverage of large
market share, its payment problems have affected the
adequacy of the provider network. Lack of response about
2003 limits our ability to describe whether HPHC’s desirable
practices continued. In our experience with qualitative data
collection methods, this may be an indication that there are
no salient issues that people wish to address.
C.
CONCLUSION
1. Provision of Services for Limited English Speakers
HPHC has demonstrated a strong and continued
commitment toward providing quality care for limited
English speaking individuals and other members of nondominant cultural groups, through the development and
dissemination of training programs in different aspects of
cross-cultural health care. The program has grown through
the four years of analysis, both adding new courses and
increasing the number of health care professionals receiving
training. HPHC has emphasized dissemination within its
provider network, has waived fees for community health
centers, and opened enrollment outside of its network.
HPHC’s network includes its former health centers, many of
which have a significant enrollment of limited English
speakers and rich interpreter resources. HPHC also ensures
that its clinical and administrative staff include some
Page 132
individuals who speak other languages, particularly
Spanish, and that they have access to telephone
interpretation for languages that staff do not speak. Use of
HPHC’s telephonic interpretation has grown over the
period. Written information is readily available for Spanish
speakers, and members who speak other languages can
request translations. The limited data on satisfaction of
Spanish speaking members showed that their levels of
satisfaction on access to services was the same or higher than
English speaking members. Employers with significant
numbers of limited English speaking HPHC members also
indicated that their employees did not have problems with
aspects of HPHC’s provision of service for limited English
speakers. However, both surveys indicated that limited
English speakers were sensitive to the cost of health
coverage.
Despite these conclusions, our ability to analyze provision of
care for limited English speakers was highly compromised
by lack of relevant data. Members self-identify as speaking a
non-English primary language on their application form.
Any additional information on their language needs would
only be included in their individual medical charts. Even
the counts of self-identified individuals were ambiguous.
Two different reports resulted in very different counts, and
we could not follow either report for a subsequent year to
track change. Similarly, we found that HPHC’s Provider
Directory differed between years in whether it identified the
linguistic capacity of certain bi-lingual providers, making
our counts questionable and compromising new members’
ability to identify the full range of practitioners who speak
their language. The state licensing board is also limited in its
information. While practitioners list their linguistic ability
as part of their licensing information, it was not possible to
produce a database that would allow us to analyze the size
of the pool of bi-lingual physicians that HPHC could
potentially recruit into its network. Because member selfDMA Health Strategies
reported language status was in a different database than
utilization data, it was beyond the scope of this project to
produce utilization information about limited English
speaking members and any such information would have
been difficult to interpret in the absence of data on the
group’s health status.
The available data allowed us to draw broad comparisons
between the incidence of the most common language groups
in HPHC’s enrollment and compare them to the language
capacity in HPHC’s provider network, clinical and
administrative staffing and written information. HPHC’s
network capability of serving limited English speakers
varies considerably depending on the language needed.
•
•
•
•
HPHC appears to have an extensive provider network
that can serve Spanish, Portuguese, Russian, Italian and
French speaking members, though community
respondents pointed out that the HPHC network in
Cambridge does not include the clinics with the greatest
Portuguese speaking capacity.
It also has a high concentration of providers that speak
Chinese languages, but since many don’t specify
whether they speak Mandarin or Cantonese, it is
difficult to determine whether both major Chinese
languages are equally well served.
needs.
Page 133
bilingual Cape Verde Kriolu speaking providers are
listed.
The limitations of relevant data from HPHC are likely
shared by other health plans and reflect that the customary
reporting and analysis expected of them do not account for
language or ethnic group. This attempt to analyze services
for limited English speakers makes it clear that the health
care industry as a whole is far from even beginning to be
able to seriously address the health care needs of limited
English speakers. While HPHC’s provision of training in
cross-cultural health care exceeds what other Massachusetts
health plans have committed to this area, lack of data
prevents it from assessing the real outcomes of the resources
it has committed.
2. Provision of Services for People with Chronic Illness
We also looked at a wide variety of data related to care for
people with chronic illness, a population not easy to define.
One of our major sources of information was to look at care
received by HPHC’s First Seniority members, a group with a
greater likelihood of chronic illness than its younger
commercial population. First Seniority members had a
higher proportion of PCPs per thousand in its dedicated
network than did its commercial population in most regions,
but the Northeast and Metrowest dropped to or below
commercial levels, and may signify problems in access.
These levels, plus a smaller and changing network of
hospitals, may have contributed to some members leaving
because of problems with health care or services. As
determined in Chapter III, First Seniority members had
increasing ambulatory utilization, putting it higher than
other Massachusetts HMOs and inpatient utilization that
varied but remained higher than or equivalent to that
provided by other Massachusetts HMOs. Its performance
on the percentage of members over 65 with an ambulatory
or preventive visit in the last three years exceeded the
national and state averages. These indicators suggest that
HPHC’s First Seniority Members experienced some
difficulties with HPHC’s reduced physician and hospital
networks, which may have contributed to elevated appeals
levels for several years and to some disenrollment due to
problems with services. However, continuing members
showed high and expanding rates of utilization that was
better than or equivalent to other Massachusetts HMOs.
We also looked at First Seniority prescription access, which
varies according with the capped Non-Group benefit and
the more generous group benefit for the five highest cost
drug classes. The effects of higher level of cost sharing in
HPHC’s First Seniority Plans compared to its commercial
plans was dramatic. Within First Seniority, the difference
between Non-Group members with quarterly caps, and
group members, some of whom continued to be fully
covered, was also significant. However, it is difficult to
determine whether differences in claims per member are due
to utilization among Non-Group members, or to the less
complete claims records for these members, since HPHC
does not see the claims for prescriptions over the quarterly
cap. Increases in utilization occurring even as members’ copays and premiums are increasing and benefit caps are
decreasing indicates that members are continuing to benefit
from pharmaceuticals.
However, members are clearly
experiencing increases in their expenditures for these drugs,
despite moving from the more expensive Tier 2 and 3
options. It is hard to imagine that increased costs are not
affecting access for lower income First Seniority members.
However, we have no reason to think that HPHC benefit
structure is worse than for other Medicare HMOs.
We also analyzed data on utilization of three drug classes of
special importance for people with chronic illness:
hypotensives, drugs to treat hypertension, and drugs to treat
Page 134
seizure disorder. All had a pattern of increasing utilization,
suggesting that members are increasingly accessing
medications to treat these three conditions. Decreases in use
of Tier 3 drugs affect relatively few individuals and were
more than offset by increases in the other tiers.
First Seniority also performed similarly to other
Massachusetts and national HMOs on several aspects of
access and satisfaction with health plan services.
This
suggests that though selection of hospitals may be more
restricted than previously and the cost of care has risen, First
Seniority members get an increasing level of service and
prescriptions, and are pleased with their care. However,
HPHC’s ratings fell over time and with respect to other
HMOs in getting care and ratings of the health plan.
Members were somewhat less likely to say that they always
got the care they needed, somewhat more likely to have
problems getting care and less likely to rate their health plan
and the care they received as the best possible.
Another avenue for considering care provided to people
with chronic illness is to examine HPHC’s processes for
authorizing and coordinating care, since these processes are
more frequently used for individuals with chronic and
complex illnesses. Our analysis shows that HPHC actually
increased its case management staffing and the number of
people served between 2000 and 2001, suggesting an
enhanced ability to assist in coordinating care. HPHC also
introduced a new service called HealthAdvance in 2001.
This service identifies individuals with serious conditions
who are not getting optimal services and conducts outreach
to establish a more appropriate treatment plan and to
arrange for necessary supports. It represents a proactive
effort to reach people whose health status is not optimal.
However, there were some indications that HPHC’s First
Seniority service authorization process experienced
problems. Though they had returned to 2000 levels by the
end of the period, appeals of authorization decisions were
significantly elevated in 2001 and 2002, particularly for
outpatient services, with lesser increases for emergency care,
visual services and inpatient care. It is possible that these
are related to members losing providers who had left the
network and experiencing disruptions in their usual patterns
of care. It would be interesting to know how many appeals
may have involved requests for out of network services.
We also note that HPHC has a quality improvement process
that involves quarterly meetings with the medical directors
of its Local Care Units, and a grants program that supports
16 Quality Improvement projects per year proposed by its
providers. These projects generally set goals to improve
care of a specific disease. They have most frequently
targeted diabetes, cardiac disease and asthma.
The
effectiveness of these and prior efforts are reflected in
HPHC’s excellent and increasing scores on HEDIS measures
for the effective treatment of diabetes for both its commercial
and Medicare members, and for asthma in children.
However, while its scores on cardiac treatment show more
reliance on less invasive procedures than more invasive
procedures - a desirable pattern - its use of less invasive
angioplasty for women tends to be low compared to
Massachusetts and national averages, and may indicate less
than optimal access. A counter indication is that HPHC
provided the procedure at quite a high rate in 2002. HPHC
had mixed performance on HEDIS measures related to
surgical procedures for men and women over 65. While it
was low on most measures in 2000 relative to Massachusetts
and national averages, it ended the period closer to the state
and national averages, indicating that its practice patterns
were similar to those of other HMOs.
Our final method for considering care of people with chronic
illness was to analyze the CAHP results of respondents who
classified their health as fair or poor. They rated some
aspects of HPHC care better than individuals in good health
Page 135
- getting care quickly when they had an illness or an injury
and getting a specialist referral - and their ratings improved
over the period. However, they were not as satisfied as
those in good health in being seen by their PCP or specialist
for an urgent problem or understanding written materials
from the health plan. Their ratings of the understandability
of their doctors varied, but were quite high. While most
members rated cost of health insurance as reasonable, it was
more of a problem for those in fair or poor health.
Page 136
VII. COMMUNITY BENEFITS
Harvard Pilgrim Healthcare’s community benefit program is primarily administered by the Harvard Pilgrim Health Care Foundation, which also
tracks community benefit activities conducted by other HPHC departments. A separate not-for-profit, tax-exempt corporation, the Foundation
operates on an annual allocation from HPHC and is overseen by a board whose membership overlaps with HPHC’s board. The Foundation has
been affected by HPHC’s financial difficulties and by the imposition of a new assessment on HMOs to support payments to hospitals and health
centers that provide services for low-income patients who are uninsured. However, despite these challenges, HPHC’s community benefit
expenditures increased from the baseline year of this assessment, ending the period 14% higher than it began.
Nonetheless, HPHC’s allocations between types of community benefit have changed considerably. Most dramatically, free care pool assessments
represented 40% of total expenditures in 2001, when they were introduced, and then virtually doubled in the next year. They fell considerably in
2003, but constituted almost two-thirds of total expenditures. In order to fulfill this requirement, HPHC reduced other community benefit
expenditures considerably. The research/teaching program was impacted most dramatically, with a 70% decrease in dollars contributed from
HPHC. However, these funds have always been leveraged by grant and other funds from additional sources. These leveraged grant funds
increased from $15 million in 2001 to $22 million in 2003, more than making up for the loss in HPHC support. Administrative expenses increased
considerably, by 97% between 2000 and 2003, primarily due to accounting changes. The year 2000 included only DACP administrative expenses,
while subsequent years included staffing costs for the other community service functions.
A.
TABLE 89
HPHC COMMUNITY BENEFIT EXPENDITURE BY MAJOR CATEGORIES
DEPARTMENT
OF
AMBULATORY CARE AND
PREVENTION
DACP
is
a
joint
undertaking of HPHC
and
the
Harvard
Medical School and, as
shown in the table, is
one major avenue for
HPHC
charitable
endeavors. Its function
is to enhance the clinical
competencies
of
clinicians as needed to
adapt to the rapid
changes of the current
Foundation Areas
2000
2001
2002
2003
Percentage
Change
Department of Ambulatory Care and Prevention (DACP)
Provider Teaching Program*
$2,737,203
$1,834,829
Research*
$7,500,000
$1,747,700
Community Service Center
$6,585,250
Free Care Pool Assessment
Subtotal Program Areas
Administrative
Grand Total
$2,626,967
$3,065,289
-70%
$6,061,532
$4,169,428
$3,725,320
-43%
n/a
$8,077,834
$16,569,393
$12,292,039
52%
$16,822,453
$17,721,895
$23,365,788
$19,082,648
13%
$204,325
$360,727
$488,891
$403,131
97%
$17,026,778
$18,082,622
$23,854,679
$19,485,779
14 %
*Occupancy and IT expenses were allocated between these two programs in proportion to their direct allocations.
Source: HPHC 2000 Community Benefits Report, HPHC Community Benefits Annual Report 2001, 2002 and 2003
Page 137
Healthy People 2010 Leading Health Indicators”8 using the
healthy communities model. This resulted in a shift from
the categorical issues bulleted above to a broader approach.
However, initiatives for the above goals continue to be
supported as well.
medical system.
Training focuses on primary care,
prevention, population based care, clinician/patient
relationships, and responsiveness to social concerns.
Programs are geared both to students and to practicing
professionals. In addition to course work, HPHC affiliated
clinicians act as preceptors to clinicians participating in
structured clinical clerkships.
HPHC also participates in the MA Health Funders Network,
a group that includes other HMO foundations and several
regional and other charitable foundations that focus on
health. This group allows individual foundations to select
complementary and non-duplicative funding goals and can
facilitate meeting emergency financial needs of community
health agencies by more easily identifying a compatible
source of available funds.
The Department also has a research component that funds
projects related to improving the quality of care. In 2001,
HPHC’s funding contributed to research projects that were
supported by an additional $15.1 million from other sources,
and in 2003 by an additional $22 million. These projects
address many different healthcare areas such as pediatric
asthma care, breast cancer screening in the elderly, and
public health preparedness and response to bioterrorism.
B.
1. Community Service Expenditures by Program
The table that follows shows community service
expenditures by program. During the assessment period,
the Community Health Centers Enhancement Fund
completed HPHC’s $15 million commitment to community
health centers. It issued grants to help them improve their
ability to compete with other health care providers by
implementing projects to address such issues as decreasing
administrative costs and improving information and clinical
management systems. HPHC’s goals for addressing health
disparities were integrated into this grant program.
COMMUNITY SERVICE CENTER
HPHC’s second major avenue for charitable giving is the
Community Service Center of the Foundation. The mission
of the center emphasizes prevention. In the year 2000, the
Center continued its existing priorities, which were:
•
•
•
•
•
•
AIDS/HIV prevention.
Violence prevention.
Substance Abuse prevention.
Elder health promotion.
Teen pregnancy prevention.
Support for Healthy Communities Initiatives.
HPHC’s Quality Award Program was described previously
as a component of HPHC’s Quality Improvement program.
Community benefits fund the awards made to practices that
implement practice-based improvement initiatives such as
Simultaneously, as the result of wide ranging conversations
with community stakeholders the Foundation increased its
focus on “reducing health disparities among populations
disproportionately affected by conditions related to the
8
Harvard Pilgrim Health Care 2001 Community Benefits Report, June7, 2002. Page 4.
Page 138
smoking cessation and asthma
management.
This program
has declined from the $2 million
spent in 2000 to $1.3 million
spent in 2003.
TABLE 90
COMMUNITY SERVICE CENTER EXPENDITURES BY PROGRAM
Foundation Areas
Foundation
Expenditures
in 2000
Foundation
Expenditures
in 2001
Foundation
Expenditures
in 2002
Foundation
Expenditures
in 2003
Percentage
Change
Community Health Centers
The Supplementation Program
$3,048,773
$3,612,682
$1,689,789
$414,580
-86%
Enhancement Fund
consisted of two premium
Quality Award Program
$2,084,726
$1,400,000
$1,031,200
$1,281,025
-39%
subsidy programs for certain
groups of HPHC members.
Supplementation Program
$185,309
$1,409
n/a
n/a
One
program
provided
Community Grants
$1,266,442
$1,047,441
$1,448,439
$2,029,715
60%
assistance
to
purchase
insurance coverage for those
Total
$6,585,250
$6,061,532
$4,169,428
$3,725,320
-43%
individuals residing in the
Source: HPHC 2000 Community Benefits Report, HPHC Community Benefits Annual Report 2001, 2002 and 2003
Mission Hill and Parker Hill
neighborhoods of Boston who
had access to insurance coverage but could not afford the employee portion of the coverage. The second program subsidized members of
HPHC who elected coverage under the Federal Consolidated Omnibus and Reconciliation Act (COBRA) for individuals who qualified
based on income. The first program ended on May 31, 2000 due to HPHC’s financial losses and the second program, established in 1996
as a four-year program, ended as originally scheduled on March 31, 2000.
The Foundation’s support for community-based health and human service organizations working in the Foundation’s priority areas has
grown from around one million to over two million dollars in 2003.
C.
CHARITABLE CARE
In 2001, a third major avenue of charitable giving was established as the Commonwealth levied a fee on all HMOs operating in
Massachusetts to strengthen funding for the Massachusetts Uncompensated Care Pool. The Massachusetts Office of the Attorney General
considers this to be a form of charitable giving, though it is not voluntary. Clearly, HPHC’s payment of this assessed fee displaced funds
that previously had supported other forms of giving.
D.
SUMMARY OF COMMUNITY BENEFITS
HPHC’s overall charitable giving increased by 14% between 2000 and 2003. This has been a period of considerable transition. The
necessity in 2001 to pay an assessment to the Commonwealth’s uncompensated care pool equal to over 40% of HPHC’s total gifts
necessitated a considerable redistribution in its other types of charitable activity. Coincidentally, HPHC’s small existing program to
subsidize the premiums of income-eligible individuals and its $15 million pledge to community health centers were decreasing as they
Page 139
approached their planned ending dates. Fulfilling the free care pool assessment had the most dramatic impact in HPHC’s contributions
toward research and teaching, though these programs leveraged sufficient grant funding to more than make up for the loss in HPHC’s
share. HPHC’s Quality Improvement program also experienced a cut. HPHC’s grants to other community organizations, however,
expanded by 60%, targeted particularly to improve access to care for underserved populations.
Page 140
VIII. CONCLUSION
HPHC has lost membership overall, and those members
who disenrolled from its individual plans appear to have
higher levels of need and use for medical care than those
who remained. However, in its larger commercial plans it
has generally enrolled an older and therefore higher need
group and fostered increased utilization of services among
them. Its utilization remains similar to or above that of both
state and national HMOs. Of the areas we analyzed, the
following have shown stable or increasing access, quality
and/or utilization.
•
•
•
•
•
•
Most indicators show that HPHC has maintained and
increased access to care for its group and Medicare Risk
plan members. Quality scores have improved to very
high levels, often exceeding other HMOs. Satisfaction
scores for commercial members have also grown, while
those for First Seniority members remain high, they have
eroded somewhat, similar to other Medicare HMOs.
HPHC has expanded Medicare Cost coverage to a
greater degree than other MA HMOs. Partial data on
utilization shows provision of levels of care that equal or
exceed those of other HMOs.
•
Overall HPHC has maintained and improved access to
behavioral health services. HPHC members had high
satisfaction with their services, and HPHC has excelled
on some measures of quality of mental health care
according to HEDIS.
Both commercial and Medicare members show
increasing utilization of medications, through cost
sharing provisions similar to those enacted by other
HMOs undoubtedly affect lower income seniors and
•
likely prevent them from using all the medications that
might benefit them.
Overall access to rehabilitation services has increased.
HPHC shares the same limitations experienced by the
industry as a whole in its ability to reliably identify and
understand the health care needs of its limited Englishspeaking members. However, it has made a substantial
and continuing commitment to developing crosscultural training materials and offering training to
medical practitioners in its network and to the larger
healthcare community.
HPHC’s community benefit expenditures have grown
modestly, even in this period of financial discipline.
However, meeting its new obligations to fulfill its
assessment to the free care pool has been accommodated
by reducing its contributions toward education and
research. During this period it completed its $15 million
commitment to Health Centers.
In a few limited areas, HPHC has reduced its provision of
care from prior levels or there are indications of some
dissatisfaction or performance problem.
•
Individual members experienced both enrollment
decreases and dramatic drops in utilization between
2000 and 2001 that suggest that higher need members
may have dropped coverage. The rate and coverage
changes influencing disenrollment were largely
parameters.
High rates of inpatient psychiatric utilization and
readmission rates suggest room for additional
Page 141
•
•
•
•
•
improvements in assisting members to stabilize after
discharge. We do not have data that allows us to
compare these rates to those of other HMOs.
A high level of appeals suggest that HPHC members
desired more rehabilitation therapy services than they
get, with physical therapy standing out as a continued
issue at the end of the period.
needs.
listed.
HPHC is providing less access for substance abuse
utilization rates.
HPHC may be providing less access for substance abuse
utilization rates. However, questions about the accuracy
of categorizing claims with both mental health and
substance abuse diagnoses make this a tentative
conclusion.
external agents or are similar to the policies or performance
of other HMOs.
Overall available indicators show that HPHC has achieved
financial stability while maintaining and / or increasing the
level of services provided, and initial loss of enrollment has
been followed by slow growth as its premiums have become
more similar to those of other Massachusetts HMOs. Many
of the areas in which indicators show continued enrollment
decrease or service limitations have been determined by
Page 142

Assessment of Harvard Pilgrim Health Care, Inc.

Transcription

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