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HEDIS® 2002

QUALITY PERFORMANCE

Coventry Health Care, Inc. · 6705 Rockledge Drive, Suite 900 · Bethesda, MD 20817-1850

REGIONS SERVED BY THE HMOS OF COVENTRY HEALTH CARE, INC. (COMMERCIAL GROUP BUSINESS) ADMINISTERING PLANS

Carelink Health Plans, Inc. Coventry Health Care of Delaware, Inc. Coventry Health Care of Georgia, Inc. Coventry Health Care of Iowa, Inc. Coventry Health Care of Kansas, Inc. Coventry Health Care of Louisiana , Inc. Coventry Health Care of Nebraska, Inc. Group Health Plan, Inc. (GHP) Health America Pennsylvania, Inc. Southern Health Services, Inc. WellPath Select, Inc.

REGIONS SERVED

West Virginia Delaware, Maryland Georgia Iowa Kansas, Western Missouri Louisiana Nebraska Eastern and Central Missouri, and Southern Illinois Central and Western Pennsylvania, Eastern Ohio Virginia North Carolina, South Carolina

www.CoventryHealth.com

Copyright © 2002 Coventry Health Care, Inc.

COVENTRY HEALTH CARE MISSION

Coventry Health Care's mission is to provide high quality care and services to our members and to be profitable in the process. We are also committed to maintaining excellence, respect, and integrity in all aspects of our operations and our professional and business conduct. We strive to reflect the highest ethical standards in our relationships with members, providers, and shareholders.

Introduction

The Coventry Health Care, Inc. Quality Performance Report was developed to present HEDIS® 2002 quality performance measures and to describe the improvement initiatives the Coventry Health Care Plans have undertaken to improve the quality of care and service delivered to our members. Our members think of Coventry as a health improvement company. Through initiatives such as post card reminders for various health screenings and assistance in managing complex cases and diseases, we make it easier for members to receive the necessary services for their health. The HEDIS measures reflect how well we are assisting members in improving their health. Developing HEDIS measures and conducting clinical and service improvement studies are part of our ongoing efforts to systematically monitor, evaluate and improve the quality, adequacy and appropriateness of health services provided within the Coventry Health Care Plans. Continuously improving core performance measures, as measured by HEDIS, is also an integral part of Coventry Gold Standards.

COVENTRY'S GOLD STANDARDS

Coventry Health Care has established a set of quality standards that all Coventry Health Plans are committed to implementing and meeting. These standards are based on the process of continuous quality improvement and apply to both the quality of service and health care delivered to our members. They include: · · · · · · · · · · Program Standards Practitioner and Provider Network Customer Satisfaction Utilization Management Information Management and Analysis Clinical Quality Improvement Service Quality Improvement Internal Process Improvement Outcome-based Performance Delegation

Questions

Any questions? Please call Pamela Mittelstadt, RN, MPH, Corporate Quality Management Director, Coventry Health Care, 301-581-5395.

In addition to adhering to Coventry's Gold Standards, Coventry Health Care Plans seek external accreditation to meet State, Federal or local market area requirements.

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

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What is HEDIS 2002?

The Health Plan Employer Data and Information Set (HEDIS) is a standardized set of performance measures developed by the National Committee for Quality Assurance (NCQA). HEDIS allows health plans to develop meaningful information about the quality of their services and permits employers to understand the value of health care that they are purchasing. It also provides the Health Plans with measures upon which to continuously improve their clinical and customer services. This report presents the results of HEDIS 2002 for Coventry Health Care for care and services delivered in 1997, 1998, 1999 and 2000 and 2001. HEDIS 2002 specifications were followed to obtain data to develop these measures.

HEDIS 2002

The measures presented on the following pages look at Coventry Health Care Plans' performance across a broad spectrum of health care services that fall into these general areas: Effectiveness of Care · · · · · · · · Childhood Immunizations Adolescent Immunizations Breast Cancer Screening Cervical Cancer Screening Comprehensive Diabetes Care Beta-Blocker Treatment after Heart Attack Controlling High Blood Pressure Follow-Up After Hospitalization for Mental Illness

"The performance measures permit employers to understand the value of the health care that they are purchasing."

Customer Satisfaction · · · · · · Health Plan Getting Needed Care Personal Doctor Health Care Customer Service Claims Processing

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Member Reminder System

Continuous Quality Improvement

This report also includes the description of quality improvement initiatives taken by the Coventry Health Care Plans to improve the health and service to members. One of the tools that the Health Plans use is the Member Reminder System. This system assists the Health Plans in identifying members who are in need of preventive screening tests, immunizations or special monitoring tests because of a chronic condition, such as diabetes. Health Plans will send reminder cards or telephone members to let them know about the test or service they need to have to maintain their health and detect early or prevent disease. The system also provides the Health Plans with a list of practitioners whose patients are in need of tests or immunizations. The practitioners are sent the lists to assist them in remembering the services their patients need. Health Information on Coventry's Web Site Coventry provides our members with easy access to health information with a click of a mouse. Our web site's "Health Information" area offers links to nationally recognized web sites such as the National Heart, Lung & Blood Institute, March of Dimes, American Diabetic Association, American Lung Association and the American Heart Association. Additionally, all of our members can link directly to WebMD as a reliable source for medical information. The Coventry member page provides information and links to credible and effective sources for chronic conditions such as diabetes and heart disease. Coventry also provides helpful, age-specific information for men, women and children. NCQA Quality Compass® We used Quality Compass 2002 national averages as benchmarks. Quality Compass 2002 is NCQA's comprehensive national database of health plans' HEDIS and CAHPS® results.

The source for data contained in this publication is Quality Compass 2002 and is used with the permission of the National Committee for Quality Assurance (NCQA). Any analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such analysis, interpretation, or conclusion. Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA). CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). -2-

Measure effectiveness of care and service Identify opportunities for improvement Develop initiatives Implement interventions · · · · Chronic Care Prenatal Care Preventive Care Customer Service

Re-measure effectiveness of care and service

HEDIS® 2002

Childhood Immunizations

100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 0% 61.7% 62.5% 68.8% 70.7 % 69.3%

NCQA National Average 2002

1998

1999

2000

2001

200 2

Coventry Health Plans' Quality Performance as Compared to NCQA National Average for Childhood Immunizations

(Weighted average of all the Coventry Health Care Plans' HEDIS rates)

Childhood immunizations are the most effective means of preventing a variety of diseases affecting children and one of the most cost-effective strategies in preventive health care. This measure shows the percentage of children in the Health Plans who received their appropriate immunizations by their second birthday. These immunizations help to prevent serious illnesses such as polio, tetanus, whooping cough, hepatitis and influenza and assist in preventing the potentially harmful effects of mumps, measles and chickenpox. Coventry Health Care continues to exceed the national average for the number of children receiving their recommended immunizations. The Coventry Health Care Plans utilize a variety of initiatives to ensure children two years and under are fully immunized. These include reminder letters to parents, follow-up telephone calls, birthday card reminders to children, lists of children not immunized to members' physicians, articles in the member newsletters and distribution of preventive health guidelines to physicians and members. Coventry Health Care 1998 and 1999 rates are based on Combo 2 (Four DTP, three OPV, one MMR, three Hepatitis B, and two Hib vaccines). CHC 2000 & 2001 rates are based on Combo 1, which is the same as Combo 1 of 1998 and 1999 and the same as the NCQA benchmark. CHC 2002 rate is based on Combo 1.

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HEDIS® 2002

Adolescent Immunizations

100% 90% 80% 70% 60% 50% 40% 30% 0% 35.9% 45.2%

43.2%

NCQA National Average 2002

2000

2001

2002

Coventry Health Plans' Quality Performance as Compared to NCQA National Average for Adolescent Immunizations

(Weighted average of all the Coventry Health Care Plans' HEDIS rates)

Immunizations protect adolescents against preventable and serious illness, and are one of the best examples of prevention in medicine. These immunizations help to prevent serious illnesses, such as hepatitis and assist in preventing the potentially harmful effects of mumps, measles and chickenpox. For the past three years, Coventry Health Care has continued to increase the number of adolescents receiving their immunizations and exceeded the national average by 3.2%. The Coventry Health Care Plans utilize a variety of initiatives to ensure adolescents have received recommended immunizations by their 13th birthday. These include reminder letters to parents, birthday card reminders to adolescents, articles in the member newsletters and distribution of preventive health guidelines to physicians and members. Coventry Health Care adolescent immunization 2000, 2001 & 2002 rates are based on Combo 1 (A second dose of MMR by the 13th birthday and three Hepatitis B vaccines on or before the member's 13th birthday).

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Breast Cancer Screening

HEDIS® 2002

100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 0% 1998 1999 2000 2001 2002

73.9%

73.9%

75.0%

77.7%

78.1%

NCQA National Average 2002

Coventry Health Plans' Quality Performance as Compared to NCQA National Average for Breast Cancer Screening

(Weighted average of all the Coventry Health Care Plans' HEDIS rates)

This measure looks at how well women are screened for breast cancer. It provides the percentage of women between the ages of 52 and 69, who had at least one mammogram during the past two years. Breast cancer is the second most common type of cancer among American women. Women, who have their breast cancer detected early, have better chances of survival. Mammograms have been shown to reduce mortality by 20 to 40 percent among women aged 50 and older, and are the best method available for detecting breast cancer early, when it can be most effectively treated. For the past five years, Coventry Health Plans have continued to increase the number of women being screened for breast cancer and exceeded the national average by 6.4%. The Coventry Health Care Plans implemented several different types of interventions depending on their physician and member community. Reminder letters were sent to women over fifty whose records did not document a mammogram in the past two years. Besides the letter addressing the need for mammograms, the letter also emphasized the need to see their practitioner to receive a clinical breast exam, listed places where they could receive a mammogram without a referral and how to do self-breast exams. Reminder letters were also sent to practitioners with a list of their patients who were in need of a mammogram. Some Plans provide an opportunity for their members to request to receive email reminders to schedule an appointment for a mammogram from nationally recognized organizations web sites.

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HEDIS® 2002

Cervical Cancer Screening

100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 0% 1998 1999 2000 2001 2002 69.5% 70.4% 72.9% 78.7%

79.3%

NCQA National Average 2002

Coventry Health Plans' Quality Performance as Compared to NCQA National Average for Cervical Cancer Screening

(Weighted average of all the Coventry Health Care Plans' HEDIS rates)

This measure provides the percentage of women age 21 to 64 who had at least one Papanicolau (Pap) test during the past three years. Approximately 13,000 new cases of cervical cancer are diagnosed each year, and about 4,800 women die from the disease. If cervical cancer is detected early, the likelihood of survival is almost 100 percent with appropriate treatment and follow-up. Coventry Health Care Plans continue to improve the delivery of cervical cancer screening to women and meet the national average. The Plans sent reminders to women about their need to receive a Pap smear and reminders to practitioners with lists of their patients who needed to have a Pap smear. In some Health Plans with large employer groups, reminders were included in employer mailings. Articles about the need for regular cervical cancer screening also appeared in the member newsletters. Some Plans provide an opportunity for their member's to request to receive email reminders to schedule an appointment for a Pap test from nationally recognized organizations web sites.

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HEDIS® 2002

Comprehensive Diabetes Care

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Dilated Eye Exam HgA1c Testing Lipid Profile Kidney Disease Monitoring

NCQA National Average 2002

48.7% 50.1% 51.9% 41.6% 37.2% 47.2% 77.5% 80.2% 83.0% 81.4% 75.4% 68.6% 80.7% 81.4%

51.5% 46.3%

CHC 2000

CHC 2001

CHC 2002

(Weighted average of all the Coventry Health Care Plans' HEDIS rates)

These four measures provide a comprehensive clinical picture of how well the members with diabetes are managing their care. They identify areas about which members and their practitioners need to be reminded in order to prevent the complications of diabetes. The measures look at the percent of diabetics who had: Dilated eye exam Glycohemoglobin (HgA1c) blood test Lipid profile blood test (LDL-C screening) Test to monitor for kidney disease

Coventry Health Care Plans were able to improve the care delivered to members with diabetes as evidenced by an increase in all of the comprehensive diabetes care measures. They also exceeded the national average for glycohemoglobin testing and kidney disease monitoring. Diabetes is one of the most costly and highly prevalent chronic diseases in the U.S. Complications from the disease cost the country nearly $100 billion annually. Many of these complications can be prevented by members receiving the tests listed above on a regular basis. The Coventry Health Care Plans developed a variety of actions to improve the care to members with diabetes. Reminder letters were sent to diabetics and practitioners whose patients with diabetes had not received the necessary tests. Telephone calls were made when necessary. Complex case management was provided to diabetics at high risk. Some Plans sent general education materials, such as diabetic self- care handbooks to members with diabetes. Some Plans sponsored health fairs where members could receive education, as well as eye and foot exams, and laboratory tests.

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HEDIS® 2002

Beta-Blocker After Heart Attack

100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 0% 1998 1999 2000 2001 2002 74.5% 69.7% 79.7% 84.2% 88.0%

NCQA National Average 2002

Coventry Health Plans' Quality Performance as Compared to NCQA National Average for Beta-Blockers After Heart Attack

(Weighted average of all the Coventry Health Care Plans' HEDIS rates)

This measure looks at the number of Health Plan members who had a heart attack and then received a prescription for a beta-blocker, which can help prevent a second heart attack. Heart disease is the leading cause of death in the United States, and every year more than 500,000 Americans die from heart disease. Annually, approximately 1.5 million Americans suffer a heart attack. Beta-blockers are a remarkably effective, low cost drug that have been shown to significantly reduce morbidity and mortality associated with heart disease, as well as reduce the chance of a second heart attack. The Coventry rate continues to improve. The Health Plans were able to increase the rates of members with a previous heart attack receiving the appropriate medication by 4.5%. The Health Plan contacted physicians about the need to prescribe beta-blockers after a patient had a heart attack. Also, the Utilization Review nurses, while they were in the hospital, identified members who had suffered a heart attack. If the member was not on a beta-blocker, the Medical Director would discuss this with the member's physician, if appropriate. As a result, the Plans' rates increased significantly again.

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HEDIS® 2002

Controlling High Blood Pressure

100% 90% 80% 70% 60% 50% 40% 30% 0% 54.0% 57.1%

NCQA National Average 2002

2001

2002

Coventry Health Plans' Quality Performance as Compared to NCQA National Average for Controlling High Blood Pressure

(Weighted average of all the Coventry Health Care Plans' HEDIS rates)

This measure looks at whether blood pressure was controlled in members age 46- 85 years old who are diagnosed with hypertension. Blood pressure control is demonstrated by a blood pressure reading less than or equal to 140 mm Hg systolic and 90 mm Hg diastolic. An estimated 50 million American adults (1 in 4) have high blood pressure. Untreated hypertension may, over time, cause damage to other organs such as the heart, kidney and brain. Studies have shown that aggressively treating high blood pressure can reduce mortality from heart disease, stroke and kidney disease. NCQA introduced the Controlling High Blood Pressure measure to the HEDIS data set in 2000. Coventry Health Care has been measuring their performance since 2001with this standard and has increased the number of member's whose blood pressure is controlled by 5.7 % and exceeded the national average by 3%. Plans have included information on healthy lifestyles such as diet and activity in member newsletters. The Coventry web site includes health information for members with high blood pressure as well as links to nationally recognized web sites.

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HEDIS® 2002

Follow-Up After Hospitalization for Mental Illness

100% 90% 80% 70% 60% 50% 40% 30% 0% 2001 2002 76.8% 69.1%

100% 90%

NCQA Nat'l 80% Avg 2002

70% 60% 50% 40% 30% 0% 2001 2002 7 Day Follow-up 47.9% 51.1%

NCQA Nat'l Avg 2002

30 Day Follow-up

Coventry Health Plans' Quality Performance as Compared to NCQA National Average for Follow-up After Hospitalization for Mental Illness

(Weighted average of all the Coventry Health Care Plans' HEDIS rates)

This measure looks at the percentage of members age six and over who were hospitalized for selected mental disorders and who were seen on an outpatient basis by a mental health provider within 7 days or within 30 days after their discharge. Since 2001, the Coventry Plans have consistently collected performance data for this measure. The percentage of members receiving follow-up visits within 30 days after discharge increased 11% in 2002 and exceeded the national average by 4.9%. The percentage of members receiving follow-up visits within 7 days after discharge increased 6.6% in 2002 and meets the national average. Lapses in care following discharge from inpatient treatment are associated with decreased mental health status, health risks related to poorly managed medication use, and readmission. Ensuring timely aftercare for members discharged from inpatient treatment plays an important role in maintaining and improving members' health status. The Coventry Health Care Plans work with their Behavioral Health Care vendors to establish guidelines for scheduling ambulatory follow up visits after discharge from inpatient treatment.

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Member Experience and Satisfaction

At Coventry Health Care, we value the opinions of our members. Thus, we annually perform a member satisfaction survey, using the standardized HEDIS® survey tool (CAHPS® 2.0H). Member satisfaction is measured in two areas: quality of health care and quality of service. Health care quality is measured by overall satisfaction with health care, personal physician care, and getting needed care (figure 1). Health care service is measured through satisfaction with the health plan, customer service and claims processing (figure 2). Coventry member satisfaction with quality of care exceeds the national average in all areas. Satisfaction with service approaches or exceeds the national average. Figure 1. Member Satisfaction - Quality of Care

Getting Needed Care

76.7% 76.3% 74.3% 73.3% 76.2% 75.2% 78.4% 79.1%

Personal Doctor

73.3%

Health Care

65.00% 70.00%

71.1%

79.4% 75.5% 75.00% 80.00%

CHC 2000

CHC 2001

CHC 2002

NCQA National Average 2002

(Weighted average of all the Coventry Health Care Plans' HEDIS rates)

Figure 2. Member Satisfaction - Quality of Service

Claims Processing

67.2% 66.0% 65.2% 83.8% 82.0% 83.0% 81.7%

Customer Service

60.5% 61.9% 62.1% 58.30% 59.8%

55.00% 60.00% 65.00%

Health Plan

50.00%

70.00%

75.00%

80.00%

85.00%

CHC 2000

CHC 2001

CHC 2002

NCQA National Average 2002

(Weighted average of all the Coventry Health Care Plans' HEDIS rates)

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