Executive Summary – Spending
- THCE is the Total Medical Expense (TME) incurred by Delaware residents for all health care benefits and services by all payers reporting to DHSS, plus insurers’ Net Cost of Private Health Insurance (NCPHI). THCE per capita is the THCE, as previously defined, divided by estimated members based on each payer’s cost growth data. For definitions of TME and NCPHI, please see the Glossary below.
- TME is defined in the Glossary. The per capita amount is based on estimated members from each payer’s cost growth data.
Executive Summary – Quality
| Market | Measure | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 |
|---|---|---|---|---|---|---|---|
| Commercial | Breast Cancer Screening | Met | Met | Met | |||
| Cervical Cancer Screening | Not met | Not met | Not met | ||||
| Colorectal Cancer Screening | Met | Not met | Not met | ||||
| Emergency Department Utilization | Not met | Met | Not met | Not met | Not met | ||
| Persistence of Beta-Blocker Treatment After a Heart Attack | Met | Met | Met | Not met | Not met | Not met | |
| Statin Therapy for Patients With Cardiovascular Disease | Met | Met | Met | Not met | Not met | Not met | |
| Medicaid | Breast Cancer Screening | Not met | Not met | Not met | |||
| Cervical Cancer Screening | Not met | Not met | Not met | ||||
| Colorectal Cancer Screening | Met | Met | |||||
| Persistence of Beta-Blocker Treatment After a Heart Attack | Not met | Not met | Not met | Not met | Not met | Not met | |
| Statin Therapy for Patients With Cardiovascular Disease | Met | Met | Met | Not met | Not met | Not met | |
| State – All Markets | Adult Obesity | Not met | Not met | Not met | Not met | Not met | Not met |
| Opioid-Related Overdose Deaths | Not met | Not met | Not met | Not met | Not met | Not met | |
| Use of Opioids at High Dosage | Met | Met | Met | Met | Not met |
Glossary
Allowed Amount: The amount the payer paid plus any member cost sharing for a claim. Allowed amount is the basis for measuring the claims component of medical expenses for purposes of the benchmark spending data.
Centers for Medicare & Medicaid Services (CMS): Federal government entity responsible for Medicare, Medicaid and CHIP program oversight, administration and monitoring.
Claims Data: Medical expense spending that payers reported that are associated with incurred claims. Examples include hospital inpatient, hospital outpatient, professional: primary care, long term care and other.
Department of Health and Social Services (DHSS): The State agency responsible for overseeing and administration of the benchmark data collection and reporting processes. The DHSS is also responsible for selecting and/or updating the benchmark quality measures.
Division of Medicaid and Medical Assistance (DMMA): The State agency responsible for oversight, administration and monitoring of Delaware’s Medicaid/CHIP program.
Health Risk Adjustment: A process that measures a member’s illness burden and predicted resource use based on differences in patient characteristics or other risk factors.
Insurer: A private health insurance company that offers one or more of the following: commercial insurance, Medicare managed care products and/or Medicaid/CHIP managed care organization products.
Market: The highest level of categorization of the health insurance market. For example, Medicare fee-for-service (FFS) and Medicare managed care are collectively referred to as the “Medicare market.” Medicaid/CHIP FFS and Medicaid/CHIP MCO managed care are collectively referred to as the “Medicaid market.” Individual, self-insured, small and large group markets and student health insurance are collectively referred to as the “Commercial market.”
Net Cost of Private Health Insurance (NCPHI): Measures the costs to Delaware residents associated with the administration of private health insurance (including Medicare Advantage and Medicaid Managed Care). It is defined as the difference between health [text continues below the screenshot]
Non-Claims: Medical expense spending data reported by payers that was not associated with a specific incurred claim. Examples include provider capitation payments, provider incentives, recoveries or risk settlements.
Payer: A term used to refer collectively to all entities submitting data to DHSS.
Pharmacy Rebates: Any rebates provided by pharmaceutical manufacturers to payers for prescription drugs, excluding manufacturer provided fair market value bona fide service fees.
Pharmacy Rebates were not collected on a detailed basis, rather in one single Pharmacy Rebates category. As an improvement to next year’s trend report, the DHSS plans to collect Pharmacy Rebates in alignment with the new Pharmacy service categories. For purposes of this Report, Pharmacy Rebates are allocated for each market as such:
- Commercial Market: Allocate 90% of Rebates to the Prescription Drug Benefit, 10% to the Pharmacy Medical Benefit.
- Medicaid Market: Allocate 70% of Rebates to the Prescription Drug Benefit, 30% to the Pharmacy Medical Benefit.
- Medicare Market: Allocate 90% of Rebates to the Prescription Drug Benefit, 10% to the Pharmacy Medical Benefit.
Quality Benchmark: The annual target results for the selected quality measures.
Spending Benchmark: The annual target change in the per capita THCE measured at the State level.
Total Health Care Expenditures (THCE): The total medical expense (TME) incurred by Delaware residents for all health care benefits/services by all payers reporting to the DHSS plus insurers’ NCPHI. Total Health Care Expenditures Per Capita: Total health care expenditures (as defined above) divided by Delaware’s total state population.
Total Medical Expense (TME): The total claims and non-claims medical expense incurred by Delaware residents for all health care benefits/services as reported by payers submitting data to the DHSS.
Veterans Health Administration (VHA): The federal agency responsible for provision of health care benefits to veterans.
