Making the Grade! A Closer Look at Health Plan Performance

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1 Primary Care Update August 2011 Making the Grade! A Closer Look at Health Plan Performance HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized measures designed to track performance on 71 measures related to preventive care, early diagnosis and appropriate care of specific medical conditions. HEDIS is a required component of health plan accreditation and is submitted to the National Committee for Quality Assurance (NCQA). HEDIS is sponsored, supported and maintained by the National Committee for Quality Assurance (NCQA). Superior s 2011 HEDIS ratings: Superior (Superior) uses HEDIS data to identify areas for improvement and monitor ongoing initiatives. Most data are sourced from claims, ImmTrac and medical record reviews. All data is audited by an NCQA certified auditor prior to submission. Below are selected measures that demonstrate Good Performance and areas that are In Need of Improvement, based on Superior s 2011 HEDIS ratings: Measure Good Performance 2010 Superior 2011 Superior NCQA HEDIS 2010 Medicaid 75 th Percentile Childhood Immunization Status (Combo 3 - DTaP, OPV, MMR, HiB, Hep B, VZV, Pneumococcal) 81.5% 80.1% 76.5% Adolescent Well Care 58.4% 60.6% 55.8% Well Child Visits in the 3 rd, 4 th, 5 th & 6 th Years of Life 74.8% 78.7% 77.3% Timeliness of Prenatal Care 91.7% 93.6% 89.9% Use of Appropriate Medications for People with Asthma 93.9% 94.5% 90.8% Cholesterol Management for Members with Cardiovascular Disease 81.5% 86.7% 84.9% Measure In Need of Improvement 2010 Superior 2011 Superior NCQA HEDIS 2010 Medicaid 75 th Percentile Breast Cancer Screening 46.8% 47.9% 59.5% Cervical Cancer Screening 53.5% 54.7% 72.9% Comprehensive Diabetes Care - Annual HbA1c Testing 77.9% 80.3% 86.4% Comprehensive Diabetes Care - Annual LDL-C Screening 77.6% 80.0% 84.9% Comprehensive Diabetes Care - Annual Eye Exam 48.9% 50.0% 63.7% Inappropriate Antibiotic Treatment for Adults with Acute Bronchitis 32.9% 26.6% 27.0%

2 Children with Pharyngitis 51.0% 53.5% 73.5% Quality Improvement Program, Progress & Goals Wondering How You Can HELP? What are the next steps? HEDIS helps us pinpoint areas in our healthcare delivery process where we succeed, as well as where we need improvement. Over the next several weeks, Superior will be analyzing the results, identifying opportunities for improvement, and taking action to improve scores. We look forward to collaborating with our Primary Care Providers as we focus upon quality patient care, and improved outcomes, enhancing the overall patient experience, and thank you for your cooperation in accommodating HEDIS medical record reviews. Who should I contact at Superior for Assistance? If you have any questions, comments, or concerns related to the annual HEDIS project or the medical record reviews, please contact the Superior Quality Improvement Department at

3 Quality Improvement Program Description 2012 How We Ensure Quality Quality Assessment and Improvement Program Structure Superior is committed to the provision of a well-designed and well-implemented Quality Assessment and Performance Improvement Program (QAPI Program). Superior s culture, systems and processes are structured around its mission to improve the health of all enrolled Members. The purpose of the QAPI Program is to plan, implement, and monitor ongoing efforts that demonstrate improvements in Member safety, overall health, and satisfaction. Goals and Objectives Safety - Where care doesn t harm Members: Superior monitors patient safety issues as part of routine operations, and intervenes on an urgent basis in situations that pose an immediate threat to the health and safety of its Members to ensure that a high level of health status and quality of life is achieved and maintained; Satisfaction -Where Members feel valued: Superior uses a structured, valid and reliable survey instrument and process, to assess Member and network Provider satisfaction, evaluate opinions of services provided by Superior, and to identify any potential issues, along with conducting the activities below: Feedback from Member & Practitioner/Provider Satisfaction Surveys. Continuous assessment of complaints from Members and Practitioners/Providers to identify any potential quality concerns in either clinical care or service delivery. An analysis of complaint trends is presented quarterly to the Quality Improvement Committee (QIC) and to the Boards of Directors (BOD). Efficiency - Where resources are used to maximize quality and minimize waste: Superior strives to ensure efficient structures and processes are in place across the Plan s daily operations and functions and to institute interventions that achieve demonstrable improvement and promote Continuous Quality Improvement. Below are just a few of such processes and functions: UM Decision Timeliness: Ongoing assessment of time frames for decision-making by Utilization Management (UM) staff, in order to prevent clinical service interruptions for Members served and to ensure compliance with applicable regulations for UM decision timeliness. Claims: Ongoing monitoring of accurate and prompt payment of claims for Practitioners/Providers. Credentialing: Ongoing monitoring of the activities of the credentialing and recredentialing processes to ensure that Practitioners/Providers and facilities applying for Superior s network membership are reviewed in a timely way, and ensuring that Practitioners/Providers have the appropriate qualifications to deliver appropriate care to Superior s Membership. Provider Practice Overviews (formerly Profiles): Production and distribution of quality practice overviews for Primary Care Providers and select high volume Practitioners. Superior s profiling tool is used to identify those Providers with potential best practices and those Providers needing assistance in establishing or managing their site based performance improvement programs and processes. Eliminating Disparities - Where quality care is reliably received regardless of geography, income, language, or diagnosis: Superior incorporates objectives for serving a culturally and linguistically diverse Membership by adopting standardized quality measures (i.e., NCQA, HEDIS) to provide information about care that is accurate, reliable, and relevant in a patient-centered way, and to help ensure Superior s established performance goals and performance quality indicators are being met by conducting the following:

4 Analyze existence of significant health care disparities in clinical areas through ongoing monitoring of activities to ensure that our Practitioners/ Providers deliver culturally competent services by monitoring the cultural needs of our Members and performing, but not limited to the following activities: Data collection of race/ethnicity and language; Providing language services such as translation of written documents and oral interpretation; Monitoring Practitioner/Provider network cultural responsiveness by conducting chart reviews and interviews to understand the difference in care provided and outcomes achieved; Conduct Member-focused interventions with culturally competent outreach materials that focus on race/ethnicity/language specific risks; Conduct focus groups or key informant interviews with cultural or linguistic minority Members to determine how to better meet their needs; Accountability and quality improvement, including using data to improve Culturally and Linguistically Appropriate Services (CLAS); and Identify and reduce specific health care disparities. Scope of Program The scope of the QAPI Program is comprehensive and addresses both the quality and safety of clinical care and quality of services provided to the Superior s Membership including medical, behavioral health, dental and vision care. Superior incorporates all demographic groups, lines of business, benefit packages, care settings, and services in its Quality Improvement (QI) activities, including preventive care, emergency care, primary care, specialty care, acute care, short-term care, long-term care (depending upon the Plan s products), and ancillary services. Program Structure Oversight Ultimate authority is held by the BOD. The QIC is the senior management lead committee reporting to the BOD. The QIC is supported by the following committees: Credentialing Committee Utilization Management Committee Peer Review Committee Performance Improvement Team Special Provider Advisory Groups, such as the OB Subcommittee and Young Physicians Council Member and Community Advisory Committees Quality Improvement Program Activities QI initiatives (clinical and non-clinical performance improvement projects, focused studies, etc.) are selected: based on having the greatest potential for improving health outcomes or the quality of service delivered to Plan s Members and network Providers; to test an innovative strategy; and to reflect distinctive regional emphasis on populations and cultures. Performance improvement projects, focused studies and other QI initiatives are designed and implemented in accordance with principles of sound research design and appropriate statistical analysis. Results of these studies are used to evaluate the appropriateness and quality of care and services delivered against established standards and guidelines for the provision of that care or service. Each QI initiative is also designed to allow Superior to monitor improvement over time. The following aspects of care and service delivery are included in Superior s Quality Improvement Program: Quality of Care/Services Quality of care/ services is a key focus of the Plan s QAPI program. Monitoring and promoting quality of care, services provided to Superior s Membership is integrated throughout many activities across the plan including but not limited to: identification and investigation of potential and/or actual quality of care events; tracking and monitoring potential quality of care issues received in the QI department for trends in occurrence, regardless of their outcome or severity level;

5 education of Physicians, Providers and Members about safe practice protocols and procedures; and review of Practitioner and Provider initiatives to improve Member safety Behavioral Health Superior recognizes the integral role behavioral health plays in comprehensive health care for Members. When relevant, the QIC incorporates behavioral health care Providers in committees and decision-making. Focus studies and health care initiatives include behavioral health care issues and/or strategies. Access and Availability Superior s QIC provides oversight to the Provider network in order to ensure adequate numbers and geographic distribution of PCPs, specialists, hospitals, and other Providers while taking into consideration the special and cultural needs of its Membership. Superior also monitors After-Hours Accessibility and Linguistics capability to ensure Members are able to reach their PCP or another designated Practitioner via telephone after hours; and Practitioners have a process in place to meet the linguistic needs of Members during after-hours calls (i.e. English and Spanish). Member and Provider Satisfaction Superior supports continuous ongoing measurement of clinical and non-clinical effectiveness and Member satisfaction by monitoring Member and Practitioner/Provider complaints, Member and Provider satisfaction, and Member and Provider call center performance. The Plan collects and analyzes data to measure its performance against established benchmarks or standards and identifies and prioritizes improvement opportunities. Specific interventions are developed and implemented to improve performance, and the effectiveness of each intervention is measured at specific intervals, depending upon the intervention. The Plan solicits feedback from Members, Medical Consenters, and Caregivers to assess satisfaction using a range of approaches, such as NCQA s Consumer Assessment of Healthcare Providers and Systems (CAHPS), and monitoring Member complaints and direct feedback from the Member and Community Advisory Committee. Provider satisfaction is assessed annually using valid survey methodology and a standardized survey tool. Cultural and Linguistic Competency Superior will provide services to its Members of all cultures, races, ethnic backgrounds and religions in a manner that recognizes values, affirms and respects the worth of the individual Members and protects and preserves the dignity of each. To that end, Superior has developed a Multi-Cultural Healthcare Plan and Training Program based on three frameworks: Individual State definitions of cultural competency; The Office of Minority Health; Federal Culturally and Linguistically Appropriate Services (CLAS) standard guidelines; and Georgetown University National Center for Cultural Competence model framework. Continuity and Coordination of Care The following are examples of some of the activities Superior monitors to ensure continuity and coordination of care: 1) Surveying PCPs to assess their satisfaction with feedback from referred Providers, including medical/surgical specialists, and other organizational Providers; 2) Evaluating timely access to care, discharge summaries, and continuity of care; 3) Assessing the effectiveness of discharge planning via Member survey and focused studies; 4) Reviewing claims data to determine utilization patterns for specialty care and Behavioral Health (BH) referrals; 5) Assessing the quality of the information exchanged between medical and BH Providers; and 6) Working with our delegated BH vendor to ensure coordination, follow-up and integration of care. Program Evaluation The QAPI Program evaluation includes a summary of all QI activities, the impact the program has had on Members' care, an analysis of the achievement of stated goals and objectives and the need for program revisions and modifications. The annual program evaluation identifies outcomes and includes evaluation of the following: An evaluation of the overall effectiveness of the QI Program, including progress toward influencing network-wide safe clinical practices; A description of completed and ongoing QI activities that address quality and safety of clinical care and quality of service;

6 Trending of measures collected over time to assess performance in quality of clinical care and quality of service; Interventions implemented to address the issues chosen for Performance Improvement Projects (PIP) and focused studies; Measurement of outcomes; Measurement of the effectiveness of the interventions; An analysis of whether there have been demonstrated improvements in the quality of clinical care and/or quality of services; Identification of limitations and barriers to achieving program goals; and An evaluation of the scope and content of the QI Program Description to ensure that it covers all types of services in all settings and reflects demographic and health characteristics of Superior s Member population. Utilization Management The goals of the Utilization Management (UM) Program are to optimize an enrollee's health status, sense of wellbeing, productivity, and access to quality health care, while at the same time actively managing cost trends. The UM Program aims to provide services that are a covered benefit, medically necessary, appropriate to the patient's condition, rendered in the appropriate setting and meet professionally recognized standards of care. Clinical Criteria McKesson s InterQual guidelines are utilized to determine medical necessity and appropriateness of health care. The Medical Director reviews all potential medical necessity denials for medical appropriateness and is the only one with authority to implement an adverse determination, which results in reduction, suspension, denial, or termination of services. The UM criteria are nationally recognized, evidence-based standards of care and include input from recognized medical experts, reviewed at least annually and updated as appropriate, utilized as an objective screening guide and are not intended to be a substitute for Physician judgment, and made in accordance with currently accepted medical or health care practices. Confidentiality Superior has adopted the strictest confidentiality standards to ensure that QI proceedings remain privileged and include adherence to the Health Insurance Portability and Accountability Act (HIPAA) regulations. Work Plan The QI Work Plan provides an outline of the actions necessary to promote the effectiveness of the Quality Improvement Program. The formal Work Plan is approved at least annually by the QIC and BOD.

7 Provider Tips Read and follow clinical practice guidelines found at Educate Members about the importance of preventive care and routine screenings Provide or refer Members for needed services Contact Members who cancel or don t show up for scheduled appointments Report immunizations given to the Texas immunization registry, ImmTrac Submit accurate and timely claim/encounter data for each and every service rendered Claim/encounter data is the most clean and efficient way to report HEDIS Accurate and timely submission of claim/encounter data will positively reduce the number of medical record reviews required for HEDIS rate calculation.

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