National Quality Management and Measurement

Transcription

1 Policy - QM 07 National Quality Management and Measurement Subject Member Access to Practitioners and Member Services Approval Date: Effective Date: 04/26/2011 Originating Dept. National Quality Management and Measurement Signed original on file in National Quality Management and Measurement Signed: Date: Signature Authority: Andrew Baskin, MD National Medical Director, Quality and Provider Performance Measurement Applies to: HMO products PPO products Medicare Advantage HMO Type: New Revision Replacement Medicare Advantage PPO Aetna Golden Medicare Dual Advantage Plan (SNP) Medicare Advantage Private Fee For Service Related Communications: Participation Criteria: Primary Care Physician Participation Criteria Schedule Specialty Physician Participation Criteria Schedule Office Assessment Policy QM 55 Purpose: To define the standards for practitioner appointment accessibility. To define the standards for member access to the Aetna Member Service Department. To define standards for member access to the centralized triage department of Aetna Behavioral Health. To define standards for behavioral health practitioner appointment accessibility. To establish a mechanism for monitoring, evaluating, and managing member access to practitioners and member services. 1 1 More stringent state requirements supersede these requirements. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 1 of 20

2 Policy QM 07 Background: A member s ability to obtain a healthcare appointment with a participating practitioner within a reasonable time period is an important driver of member satisfaction with the health plan. Appropriate wait time varies according to the type of care situation (i.e., urgent, emergent or routine care). Access to care is contingent on access to participating practitioners both during and outside of normal business hours. Members may access a behavioral health care contractor/practitioner in four ways: through a referral from the primary care physician, through a referral from employee assistance (EAP), through a student assistance provider (SAP), or through direct access by the member. No referral from the PCP is needed. Definitions: Members have access to assistance with their plan benefits and services by calling the toll-free Member Services telephone number listed on the member s health plan identification card. Accessibility: The extent to which a patient can obtain available services when they are needed. Services refers to both telephone access and ease of scheduling an appointment if applicable. (Source: NCQA 2011 Standards and Guidelines for the Accreditation of Health Plans, Glossary) Aetna: Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) means: "Aetna" is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companies that offer, underwrite or administer benefit coverage include Aetna Health Inc., Aetna Health of California Inc, Aetna Life Insurance Company, Aetna Health Insurance Company of New York, and Aetna Health Insurance Company. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. Average Speed of Answer (ASA): the total number of seconds to answer every call. (the time between when a call is accepted into the service representative s queue and when it is answered by a service representative divided by the total number of calls.) Behavioral Health Practitioner: An independent practitioner who is duly licensed or certified and recognized under state law, and who is contracted to provide mental health or chemical dependency services to Aetna members. Examples of such practitioners include but are not limited to: psychiatrists, psychologists, social workers, and certified addiction counselors. Call Abandonment Rate (AR): The number of Member Service calls not answered (abandoned or hung up) divided by the total number of calls that reach the queue. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 2 of 20

3 Policy QM 07 Non-Life-Threatening Behavioral Health Emergency: A non-life-threatening emergency exists when the Member has a condition that requires rapid intervention to prevent acute deterioration of the member's clinical condition. Preventive Care: Well child examinations, routine wellness examinations or health screenings. Participation Criteria: Business and professional competence and conduct criteria schedules that are part of the Physician Agreements. Regular or Routine Care: Preventive (i.e., well-child or adult examinations or health screening) and primary care for non-urgent conditions. Routine Behavioral Health Care: A routine situation exists when the member's condition is considered to be sufficiently stable. Symptomatic Care/Non-urgent Complaint: Primary care for non-urgent conditions that, if not treated, may pose minimal risk of harm. Total Service Factor (TSF): Percent of all calls answered within an established goal, e.g. 30 seconds. Urgent Behavioral Health Care: Urgent is a situation that is less clinically compelling than a non-life threatening emergency situation. A referral for urgent level of care services is made when the clinical situation would likely deteriorate if the member was not seen in a timely fashion. Urgent Care: Primary care for symptomatic conditions that if not treated, may pose serious risk of harm. Access to Primary Care Physician Services When and how is access measured? All standards for access to Primary Care are defined in the Primary Care Physician Participation Criteria, e.g. preventive care and symptomatic care. The accessibility standards and goals/goal methodology as outlined in Attachment A are monitored for compliance. These standards are measured using valid methodology and analyzed on an annual basis and presented to the NQOC for review and approval. Methods of monitoring may include one or more of the following mechanisms: - CAHPS survey - Other member satisfaction surveys - Telephonic Provider Access surveys - Other access surveys - Analysis of member complaints related to access Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 3 of 20

4 Policy QM 07 Access to Member Services Policy on Member Access to Health Plan Services Telephone access will be monitored via the indicators defined in Attachment A. When and how is Member Service telephone access monitored? Member Services management staff monitors automated call distribution (ACD) telephone reports on a daily basis. Member Services telephone access measures are reported to the NQOC on an annual basis. Analysis of complaints and appeals in regard to access issues are reported to the NQOC at least annually. Member Satisfaction is reported to NQOC. Access to Behavioral Health Care Behavioral Health Practitioners are obligated to access standards as defined in Attachment A. When and how is behavioral health access measured? Aetna Behavioral Health measures Aetna Behavioral Health access standards. Telephone indicators are reported to the Aetna Behavioral Health QOC quarterly. Analyses of member satisfaction surveys and member complaints are reported to the Aetna Behavioral Health QOC and NQOC annually. Behavioral Health Contractors centralized telephone indicators and compliance with access standards are measured by the Contractor and reported to the Aetna NQOC annually. Practitioners are informed about Aetna access standards Primary Care and Specialty Care practitioners may be informed about access standards in the Physician Participation Criteria Schedules, Physician Toolkit, in newsletters and in the Aetna Behavioral Health Provider Manual. Exception Process: Exceptions to this policy requires approval from the Chief Medical Officer. Policy History: Revised: QM 07, issued 02/02/2011 Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 4 of 20

5 Policy QM 07 Revised: QM 07, issued 03/01/2010 Revised: QM 07, issued 04/24/2009 Revised: QM 07, issued 05/28/2008 Revised: QM 07, issued 04/25/2007 Revised: QM 07, issued 04/25/2006 Revised: QM 07, issued 01/31/2005 Revised: QM 07, issued 01/16/2004 Replacement: QM , issued 12/13/02 Replacement: QM , issued 10/08/02 Replacement: QM , issued 08/02/02 Replacement: QM , issued 07/11/02 Original policy: QM 97-23, issued 6/29/99 FOR FURTHER INFORMATION: Contact: Janona Davis Dept/Unit: National Quality Management and Measurement National Quality Oversight Committee Review/Adoption Date: 04/26/ /26/2011 Leonard J. Harvey, M.D. Date National Quality Oversight Committee Chairperson Aetna Behavioral Health Quality Oversight Committee Review/Adoption Date: 04/25/ /25/2011 Avivah S. Goldman, MSN, MA Date Aetna Behavioral Health Quality Oversight Committee Chairperson Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 5 of 20

6 Policy QM 07 Approval to Implement Review/Approval Date: 04/26/2011 Grant Tarbox, D.O. Oklahoma Medical Director 04/26/2011 Date Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 6 of 20

7 Policy QM 07 Approval to Implement Review/Approval Date: 04/26/2011 Grant Tarbox, D.O. Texas Medical Director 04/26/2011 Date Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 7 of 20

8 HMO Monitors (Medical) ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS Regular or routine care appointments Within seven days Goals are based on prior year survey results and are calculated following the NCQA minimum effect size guidelines with the applicable effect size divided in half. The regular or routine care 7 days standard is monitored with: CAHPS Q6: Percentage of members who reported that they always or usually got regular or routine care as soon as they wanted it. Annual CAHPS Member Satisfaction Survey Urgent Care Appointments Same day or within 24 hours Goals are based on prior year survey results and are calculated following the NCQA minimum effect size guidelines with the applicable effect size divided in half. CAHPS Q6a: Assess how long members waited between making an appointment and seeing a practitioner for routine care. CAHPS Q4: Percentage of members who responded always or usually if they needed care right away, they got care as soon as they thought they needed it. CAHPS Q4a: Assess how long members waited between trying to get care and seeing a practitioner when care was needed right away for an illness, injury, or condition. Annual CAHPS Member Satisfaction Survey For health plans where membership does not meet CAHPS survey requirements for a valid sample size, a telephonic survey will be performed with a goal established at 100%. 03/31/11 Page 8 of 20

9 ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS After-hours Care Access to Appointments. Each Primary Care Physician must have a reliable twentyfour (24) hours a day, seven (7) days-a-week answering service or machine with a beeper or paging system. A recorded message or answering service that refers members to emergency rooms is not acceptable. 100% CAHPS Q21a Percentage of members who reported that when they tried to call their personal doctor when the office was closed, they did reach an answering service or message telling them how to contact a physician? Not Applicable Track and Trend CATS Reporting: Quality of Care - Refused to See Member Quality of Care - Long Wait Time (Appt/Visit) Quality of Service Access to and Responsiveness of service Quality of Service Appointment Availability Quality of Service Office Hours Not Convenient Quality of Service Access to Care Quality of Services Unable to Access Provider After Hours Quality of Service - Phone Access to Par Provider Annual CAHPS Member Satisfaction Survey Complaints: At least annually For health plans where membership does not meet CAHPS survey requirements for a valid sample size, a telephonic survey will be performed with a goal established at 100%. 03/31/11 Page 9 of 20

10 Medicare HMO Monitors (Medical) ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS Regular or routine Care appointments Within seven days or by meeting the established goal for satisfaction with the CAHPS question measuring the percentage of members who reported that they "always" or "usually" got regular or routine care as soon as they wanted it. Goals are based on prior year survey results and are calculated following the NCQA minimum effect size guidelines with the applicable effect size divided in half. The regular or routine care 7 days standard is monitored with: CAHPS Q06: Percentage of members who reported that they always or usually got regular or routine care as soon as they wanted it. Annual CAHPS Member Satisfaction Survey Annual Survey Urgent Care Appointments Same day or within 24 hours or by meeting the established goal for satisfaction with the CAHPS question measuring the percentage of members who responded "always" or "usually" if needed care right away, they got care as soon as they thought they needed it. Goals are based on prior year survey results and are calculated following the NCQA minimum effect size guidelines with the applicable effect size divided in half. CAHPS Q04: Percentage of members who responded always or usually if needed care right away, they got care as soon as they thought they needed it. Annual CAHPS Member Satisfaction Survey Annual Survey After-hours Care Each Primary Care Physician must have a reliable twenty-four (24) hours a day, seven (7) days-a-week answering service or machine with a beeper or paging system. A recorded message or answering service that refers members to emergency rooms is not 100% Regional after hours and emergency directions phone availability survey. Annual Survey Page 10 of 20

11 ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS acceptable. Access to Appointments Not Applicable Track and Trend CATS Reporting: Quality of Care - Refused to See Member Quality of Care - Long Wait Time (Appt/Visit) Quality of Service Access to and Responsiveness of service Quality of Service Appointment Availability Quality of Service Office Hours Not Convenient Quality of Service Access to Care Quality of Services Unable to Access Provider After Hours Quality of Service - Phone Access to Par Provider Complaints: At least annually Page 11 of 20

12 PPO Monitors (Medical) ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS Regular or routine care appointments Within seven days Goals are based on prior year survey results and are calculated following the NCQA minimum effect size guidelines with the applicable effect size divided in half. The regular and routine care 7 days standard is monitored with: CAHPS Q6: Percentage of members who reported that they always or usually got regular or routine care as soon as they wanted it. Annual CAHPS Member Satisfaction Survey Urgent Care Appointments Same day or within 24 hours Goals are based on prior year survey results and are calculated following the NCQA minimum effect size guidelines with the applicable effect size divided in half. CAHPS Q6a: Assess how long members waited between making an appointment and seeing a practitioner for routine care. CAHPS Q4: Percentage of members who responded always or usually if they needed care right away, they got care as soon as they thought they needed it. CAHPS Q4a: Assess how long members waited between trying to get care when care was needed right away for an illness, injury, or condition. Annual CAHPS Member Satisfaction Survey Page 12 of 20

13 ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS After-hours Care Access to Appointments Each Primary Care Physician must have a reliable twenty-four (24) hours a day, seven (7) days-a-week answering service or machine with a beeper or paging system. A recorded message or answering service that refers members to emergency rooms is not acceptable. 100% Regional after hours and emergency directions phone availability survey. CAHPS Q21a Percentage of members who reported that when they tried to call their personal doctor when the office was closed, they did reach an answering service or message telling them how to contact a physician? Not Applicable Track and Trend CATS Reporting: Quality of Care - Refused to See Member Quality of Care - Long Wait Time (Appt/Visit) Quality of Service Access to and Responsiveness of service Quality of Service Appointment Availability Quality of Service Office Hours Not Convenient Quality of Service Access to Care Quality of Services Unable to Access Provider After Hours Quality of Service - Phone Access to Par Provider Annual Survey Annual CAHPS Member Satisfaction Survey Complaints: At least annually Page 13 of 20

14 Medicare PPO Monitors (Medical) ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS Regular or routine Care appointments Within seven days or by meeting the established goal for satisfaction with the CAHPS question measuring the percentage of members who reported that they "always" or "usually" got regular or routine care as soon as they wanted it. Goals are based on prior year survey results and are calculated following the NCQA minimum effect size guidelines with the applicable effect size divided in half.. The regular or routine care 7 days standard is monitored with: CAHPS Q06: Percentage of members who reported that they always or usually got regular or routine care as soon as they wanted it. Annual CAHPS Member Satisfaction Survey Annual Survey Urgent Care Appointments Same day or within 24 hours or by meeting the established goal for satisfaction with the CAHPS question measuring the percentage of members who responded "always" or "usually" if needed care right away, they got care as soon as they thought they needed it. Goals are based on prior year survey results and are calculated following the NCQA minimum effect size guidelines with the applicable effect size divided in half.. CAHPS Q04: Percentage of members who responded always or usually if they needed care right away, they got care as soon as they thought they needed it. Annual CAHPS Member Satisfaction Survey Annual Survey For health plans where membership does not meet CAHPS survey requirements (and therefore an invalid sample size) a telephonic survey will be conducted with a performance goal established at 100%. Page 14 of 20

15 ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS After-hours Care Access to Appointments Each Primary Care Physician must have a reliable twentyfour (24) hours a day, seven (7) days-a-week answering service or machine with a beeper or paging system. A recorded message or answering service that refers members to emergency rooms is not acceptable. 100% Regional after hours and emergency directions phone availability survey. Not Applicable Track and Trend CATS Reporting: Quality of Care - Refused to See Member Quality of Care - Long Wait Time (Appt/Visit) Quality of Service Access to and Responsiveness of service Quality of Service Appointment Availability Quality of Service Office Hours Not Convenient Quality of Service Access to Care Quality of Services Unable to Access Provider After Hours Quality of Service - Phone Access to Par Provider Annual Survey Complaints: At least Annually Page 15 of 20

16 All Products Behavioral Health Monitors (HMO, PPO, Medicare HMO & Medicare PPO) ACCESS TO BEHAVIORAL HEALTH CARE APPOINTMENTS Non-life-threatening Emergency Needs Urgent Care Evaluation appointment and initial treatment Regular or Routine Office Visit Within six hours Within 48 hours Within ten business days >75% of respondents that responded positively to Overall Satisfaction question >75% of respondents that responded positively to Overall Satisfaction question >75% of respondents that responded positively to Overall Satisfaction question Member Satisfaction Survey Member Satisfaction Survey Member Satisfaction Survey Aetna Behavioral Health QOC reports results annually to RQOC (HMO) and National QOC (PPO) Aetna Behavioral Health QOC reports results annually to RQOC (HMO) and National QOC (PPO) Aetna Behavioral Health QOC reports results annually to RQOC (HMO) and National QOC (PPO) Page 16 of 20

17 ACCESS TO BEHAVIORAL HEALTH CARE APPOINTMENTS Access to Appointments Not Applicable Track and Trend CATS Reporting: Quality of Service Emergency: No appointment available within 6 hours Quality of Service Urgent: Appointment not available within 48 hours Quality of Service Routine Appointment: Not available within 10 business days Complaints: At least Annually Page 17 of 20

18 All Products Customer Service Monitors (HMO, PPO, Medicare HMO & Medicare PPO) CUSTOMER SERVICES TELEPHONE ACCESS NATIONAL ACCOUNTS Call Abandonment Rate HMO 1.1% 100% QM Indicator Report Quarterly Traditional < 1% Total < 1% Average Speed of Answer 25 seconds 100% QM Indicator Report Quarterly Total Service Factor (TSF) 80% answered within 30 seconds or less 100% QM Indicator Report Quarterly Access to Customer Service by Telephone Not Applicable Track and Trend Complaints CATS Reporting: Customer Service - Member Services - Phone Access Customer Service - Member Services IVR Unable to Access CSP Quarterly CUSTOMER SERVICES TELEPHONE ACCESS SMALL & MIDDLE MARKETS Call Abandonment Rate 2% 100% QM Indicator Report Quarterly Average Speed of Answer 30 seconds 100% QM Indicator Report Quarterly Total Service Factor (TSF) Access to Customer Service by Telephone 75% answered within 30 seconds or less 100% QM Indicator Report Quarterly Not Applicable Track and Trend Complaints CATS Reporting: Quarterly Customer Service - Member Services - Phone Access Customer Service - Member Services IVR Unable to Access CSP Page 18 of 20

19 CUSTOMER SERVICES TELEPHONE ACCESS RETIREE MARKETS (MAPD & NON-MAPD) Call Abandonment Rate 2% 100% QM Indicator Report Quarterly Average Speed of Answer 30 seconds 100% QM Indicator Report Quarterly Total Service Factor (TSF) 80% answered within 30 seconds or less 100% QM Indicator Report Quarterly Access to Customer Service by Telephone Not Applicable Track and Trend Complaints CATS Reporting: Customer Service - Member Services - Phone Access Customer Service - Member Services IVR Unable to Access CSP Quarterly CUSTOMER SERVICES TELEPHONE ACCESS INDIVIDUAL & AARP Call Abandonment Rate 3% 100% QM Indicator Report Quarterly Average Speed of Answer 30 seconds 100% QM Indicator Report Quarterly Total Service Factor (TSF) 70% answered within 30 seconds or less 100% QM Indicator Report Quarterly Access to Customer Service by Telephone Not Applicable Track and Trend Complaints CATS Reporting: Customer Service - Member Services - Phone Access Customer Service - Member Services IVR Unable to Access CSP Quarterly Page 19 of 20

20 All Products TELEPHONE ACCESS TO BEHAVIORAL HEALTH CARE Telephone access to screening and triage *Callers reach a nonrecorded voice w/in 30 seconds. If using an automated system, member must reach a non-recorded voice w/in 30 seconds. *Abandonment rates do not exceed three percent at any given time. < 30 seconds nonclaims calls <30 seconds claims calls <3%-Abandonment Rate non-claims calls <3% Abandonment Rate claims calls >80% non-claims calls >80% claims calls 100% Call Management System Report Reported to Aetna within the ABHNR report Call Management System Report Reported to Aetna within the ABHNR report Aetna Behavioral Health QOC reports results semi-annually to RQOC (HMO) and National QOC (PPO). Aetna Behavioral Health QOC reports results semi-annually to RQOC (HMO) and National QOC (PPO). Page 20 of 20