Glossary of Terms GENERAL TERMS Rank: Based on score. Commercial, Medicare, and Medicaid health plans are ranked separately. Score: The highest possible score is 100, including up to 15 points (based on compliance with accreditation standards) if plan is accredited by the National Committee for Quality Assurance (NCQA). The score summarizes clinical and service performance in four major categories: access to care, overall member satisfaction, prevention, and treatment. Numerous measures define performance in each category: 42 measures in all for commercial plans, 33 for Medicare plans, and 39 for Medicaid plans. Not all measures are shown. State: Where the plan operates. Type: In a health-maintenance organization (HMO), a primary-care physician provides basic care, with other care delivered by a strictly defined network of specialists. Members pay out of pocket for care received outside the network. In a point-of-service (POS) plan, the plan pays some of the cost of out-of-network care. NCQA accreditation: The National Committee for Quality Assurance (NCQA) is managed care's major accrediting body. Worth up to 15 points in plan's score, depending on conformance with accreditation standards. Unaccredited plans receive 0 points. COMMERCIAL PLAN TERMS Access to care (6 measures): Getting needed care, getting care quickly, well-child visits in the first 15 months, well-child visits in the 3rd through 6th years, primary care from ages 7 to 11, adolescent well-care visits. Overall member satisfaction (7 measures): Doctors' communication skills, high rating of personal doctor or nurse, rating of specialist, high rating of healthcare received, claims processing, customer service, high rating of plan services. Prevention (10 measures) Early childhood immunizations, adolescent immunizations, chlamydia screening in young women, timeliness of prenatal and postpartum care, regular mammograms and Pap tests, colorectal screening, strep test for children diagnosed with sore throat; appropriate use of antibiotics for children with common cold. Treatment (19 measures): Appropriate asthma medication; effective diabetes care (checking eyes, testing and controlling blood sugar, checking and controlling LDL cholesterol, monitoring kidney disease); administering and continuing beta blocker after heart attack; controlling high blood pressure; advising smokers to quit and offering strategies and medications; effective care for depression (providing suitable specialist in acute depression, medicating depression appropriately over short and long term); following up after hospitalization for mental illness; initiating and continuing treatment for alcoholism and substance abuse. Individual Measures—Commercial Plans Getting care: Getting needed care; getting care quickly. Getting needed care: Percentage of members most recently surveyed who said getting needed care from their personal doctor or a specialist was not a problem. Getting care quickly: Percentage of members most recently surveyed who said delays in getting care were not a problem. Children and adolescents: Percentage of children who had at least six well-child visits from birth to 15 months old; percentage of children age 3, 4, 5, or 6 who had a well-child visit during the year reported; percentage of children ages 7 to 11 who had a well-child visit during the current or previous year; percentage of members age 12 to 21 who had at least one comprehensive well-care visit. High rating of personal doctor or nurse: Percentage of members most recently surveyed who answered 8, 9, or 10 when asked to rate their personal doctor or nurse from 0 (worst possible) to 10 (best possible). High rating of healthcare received: Percentage of members most recently surveyed who gave plan an 8, 9, or 10 when asked to rate the quality of care from 0 (worst possible) to 10 (best possible). Satisfaction with plan services: Claims processing; customer service; high rating of plan services. High rating of plan services: Percentage of members most recently surveyed who gave plan an 8, 9, or 10 when asked to rate the quality of all services from 0 (worst possible) to 10 (best possible). Child and adolescent immunizations: Percentage of children who got all recommended immunizations by their second birthday; percentage of adolescents who got all recommended follow-up immunizations by their 13th birthday. Women's reproductive health: Chlamydia screening in young women; timeliness of prenatal and postnatal care. Cancer screening: Regular mammograms; regular screening for cervical cancer; regular screening for colorectal cancer. Regular mammograms: Estimated percentage of women ages 50 to 69 who had at least one mammogram in the previous two years.. Colorectal cancer screening: Percentage of adults ages 50 to 80 who have been tested for colorectal cancer. Antibiotic overuse in children: Percentage of children ages 3 months to 18 years diagnosed with a common cold who were not prescribed an antibiotic for three days; percentage of children ages 2 to 18 diagnosed with sore throat who were prescribed an antibiotic and got a strep test. Diabetes: Estimated percentage of members with diabetes who got blood glucose and LDL cholesterol tests and eye exams, whose blood glucose and LDL cholesterol was controlled, and whose kidney disease was monitored. Glucose testing: Estimated percentage of members ages 18 to 75 with type 1 and type 2 diabetes who got blood glucose testing. Eye exams: Estimated percentage of members ages 18 to 75 with type 1 and type 2 diabetes who had a retinal eye exam. Heart disease: Administering and continuing beta blocker after heart attack; controlling high blood pressure; advising smokers to quit and offering both strategies and medications for doing so. Mental and behavioral health: Percentage of members seeing suitable specialist to manage, appropriately medicate, and appropriately follow up acute depression; follow up appropriately after hospitalization for mental illness; initiate and continue treatment for alcoholism and substance abuse. Medicate depression appropriately: Percentage of members newly diagnosed with depression who received antidepressant medication for 12 weeks after the initial diagnosis. MEDICARE PLAN TERMS Access to care (2 measures): Getting needed care, getting care quickly. Overall member satisfaction (6 measures): Doctors' communication skills, high rating of personal doctor or nurse, rating of specialist, high rating of healthcare received, customer service, high rating of plan services. Prevention (7 measures): Pneumonia vaccination; regular mammograms, colorectal screening, physical health status; mental health status, flu shots, glaucoma screening. Treatment (18 measures): Screening women for osteoporosis after a fracture; managing urinary incontinence; effective diabetes care (checking eyes, testing and controlling blood sugar, checking and controlling LDL cholesterol, monitoring kidney disease); administering and continuing beta blocker after heart attack; controlling high blood pressure; advising smokers to quit; providing effective care for depression (providing suitable specialist in acute depression, medicating depression appropriately over short and long term); following up after hospitalization for mental illness; initiating and continuing treatment for alcoholism and substance abuse. Individual Measures—Medicare Plans Getting care: Getting needed care; getting care quickly. Getting needed care: Percentage of members most recently surveyed who said getting needed care from their personal doctor or a specialist was not a problem. Getting care quickly: Percentage of members most recently surveyed who said delays in getting care were not a problem. Satisfaction with plan physicians: Doctors’ communication skills; high rating of personal doctor or nurse; rating of specialist; high rating of healthcare received. High rating of personal doctor or nurse: Percentage of members most recently surveyed who rated their personal doctor or nurse a 9 or 10, with 0 meaning worst possible and 10 meaning best possible. High rating of healthcare received: Percentage of members most recently surveyed who rated plan a 9 or 10, with 0 meaning worst possible and 10 meaning best possible. Satisfaction with plan services: Customer service; high rating of plan services. High rating of plan services: Percentage of members most recently surveyed who rated plan services a 9 or 10, with 0 meaning worst possible and 10 meaning best possible. Regular mammograms: Estimated percentage of women up to age 69 who had at least one mammogram in the previous two years. Colorectal cancer screening: Percentage of adults up to age 80 who have been tested for colorectal cancer. Diabetes: Estimated percentage of members with diabetes who got blood glucose and LDL cholesterol tests and eye exams, whose blood glucose and LDL cholesterol was controlled, and whose kidney disease was monitored. Glucose testing: Estimated percentage of members up to age 75 with type 1 and type 2 diabetes who got blood glucose testing. Eye exams: Estimated percentage of members up to age 75 with type 1 and type 2 diabetes who had a retinal eye exam. Heart disease: Administering and continuing beta blocker after heart attack; controlling high blood pressure; advising smokers to quit. Manage high blood pressure: Estimated percentage of members up to age 85 diagnosed with hypertension whose blood pressure was controlled (not above 140/90 in latest year). Mental and behavioral health: Percentage of members seeing suitable specialist to manage, appropriately medicate, and appropriately follow up acute depression; following up appropriately after hospitalization for mental illness; initiating and continuing treatment for alcoholism and substance abuse. Medicate depression appropriately: Percentage of members newly diagnosed with depression who received antidepressant medication for 12 weeks after the initial diagnosis. MEDICAID PLAN TERMS Access to care (6 measures): Getting needed care, getting care quickly, well-child visits in the first 15 months, well-child visits in the 3rd through 6th years, primary care from ages 7 to 11, adolescent well-care visits. Overall member satisfaction (6 measures): Doctors’ communication skills, high rating of personal doctor or nurse, rating of specialist, high rating of healthcare received, customer service, high rating of plan services. Prevention (9 measures): Early childhood immunizations, adolescent immunizations, chlamydia screening in young women, timeliness of prenatal and postpartum care, regular mammograms, colorectal screening, strep test for children diagnosed with sore throat; appropriate use of antibiotics for children with common cold. Treatment (18 measures): Appropriate asthma medication for each of several age groups; effective diabetes care (checking eyes, testing and controlling blood sugar, checking and controlling LDL cholesterol, monitoring kidney disease); administering beta blocker after heart attack; controlling high blood pressure; advising smokers to quit and offering strategies and medications; effective care for depression (providing suitable specialist in acute depression, medicating depression appropriately over short and long term); following up after hospitalization for mental illness; initiating and continuing treatment for alcoholism and substance abuse. Individual Measures—Medicaid Plans Getting care: Getting needed care; getting care quickly. Overall member satisfaction (6 measures): Doctors' communication skills, high rating of personal doctor or nurse, rating of specialist, high rating of healthcare received, customer service, high rating of plan services. Children and adolescents: Percentage of children who had at least six well-child visits from birth to 15 months old; percentage of children age 3, 4, 5, or 6 who had a well-child visit during the year reported; percentage of children ages 7 to 11 who had a well-child visit during the current or previous year; percentage of members age 12 to 21 who had at least one comprehensive well-care visit with a primary-care practitioner or OB/GYN physician during the year. Satisfaction with plan physicians: Doctors' communication skills; high rating of personal doctor or nurse; rating of specialist; high rating of healthcare received. High rating of personal doctor or nurse: Percentage of members most recently surveyed who answered 8, 9, or 10 when asked to rate their personal doctor or nurse from 0 (worst possible) to 10 (best possible). High rating of healthcare received: Percentage of members most recently surveyed who gave plan an 8, 9, or 10 when asked to rate the quality of care from 0 (worst possible) to 10 (best possible). Satisfaction with plan services: Customer service; high rating of plan services. High rating of plan services: Percentage of members most recently surveyed who gave plan an 8, 9, or 10 when asked to rate the quality of all services from 0 (worst possible) to 10 (best possible). Child and adolescent immunizations: Percentage of children who got all recommended immunizations by their second birthday; percentage of adolescents who got all recommended follow-up immunizations by their 13th birthday. Women’s reproductive health: Chlamydia screening in young women; regular mammograms; regular cervical cancer screening; timeliness of prenatal and postnatal care. Regular mammograms: Estimated percentage of women ages 50 to 69 who had at least one mammogram in the previous two years. Antibiotic overuse in children: Percentage of children ages 3 months to 18 years diagnosed with a common cold who were not prescribed an antibiotic for three days; percentage of children ages 2 to 18 diagnosed with sore throat who were prescribed an antibiotic and got a strep test. Asthma: Percentage of members in each group from age 5 to 9, age 10 to 17, and age 18 to 56 who were identified as having persistent asthma and were prescribed appropriate medication. Diabetes: Estimated percentage of members with diabetes who got blood glucose and LDL cholesterol tests and eye exams, whose blood glucose and LDL cholesterol was controlled, and whose kidney disease was monitored. Glucose testing: Estimated percentage of members ages 18 to 75 with type 1 and type 2 diabetes who got blood glucose testing. Eye exams: Estimated percentage of members ages 18 to 75 with type 1 and type 2 diabetes who had a retinal eye exam. Heart disease: Administering and continuing beta blocker after heart attack; controlling high blood pressure; advising smokers to quit and offering both strategies and medications for doing so. Manage high blood pressure: Estimated percentage of members ages 46 to 85 diagnosed with hypertension whose blood pressure was adequately controlled (not above 140/90 in the most recent year). Mental and behavioral health: Percentage of members seeing suitable specialist to manage, appropriately medicate, and appropriately follow up acute depression; follow up appropriately after hospitalization for mental illness; initiate and continue treatment for alcoholism and substance abuse. Medicate depression appropriately: Percentage of members newly diagnosed with depression who received antidepressant medication for 12 weeks after the initial diagnosis.