2015 Blue Cross Blue Shield of Michigan

Transcription

1 2015 Blue Cross Blue Shield of Michigan Quality Improvement Program Description June 2015

2 Introduction Headquartered in Detroit, Blue Cross Blue Shield of Michigan is the state s largest Preferred Provider Organization (PPO) health plan, serving approximately 2.2 million members in the state of Michigan. Through exemplary service and cost-effective, innovative products using a skilled workforce and strong relationships with providers, Blue Cross offers members what they need high-quality, comprehensive and cost-effective medical care when they need it. Some quality improvement achievements we are proud of include: Successfully maintained accreditation with a Commendable rating from the National Committee for Quality Assurance Improved member satisfaction with providers. Members personal doctor and specialists both scored in the 90 th percentile, based on 2014 Consumer Assessment of Healthcare Providers and Systems member satisfaction surveys. Exceeded annual goals for volumes of identified, reached and engaged members for both case management and chronic condition management Implemented pharmacy program for 24-hour turnaround timeframes to make coverage decisions for non-formulary drugs in urgent circumstances Sixty-four Michigan hospitals representing over 80 percent of the total Blue Cross hospital payout have signed a value-based contract. Ninety-two percent of designated patient-centered medical homes achieved redesignation in Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association Blue Cross Blue Shield of Michigan Page 2

3 Blue Cross Blue Shield of Michigan is transforming health care through a series of initiatives that are promoting personal and population health, improving quality and lowering costs. As shown below in our Total Health Engagement Model, our goal is to combine innovative plan designs, dedicated health support and enhanced care delivery to provide members with the highest quality health care experience. Blue Cross Total Health Engagement model Blue Cross created the Quality Improvement Program to continuously and comprehensively assess, monitor, measure, evaluate and implement strategies to improve the quality of care delivered to our members. Through this program, we identify opportunities to improve their health, care and satisfaction. We annually collect information about: Access to care Clinical quality Continuity and coordination of care Member satisfaction Patient safety Provider performance Utilization and medical management programs Page 3

4 Case Management Delegation oversight The Quality Improvement Committee has direct oversight of the QI Program activities and meets quarterly to review progress toward goals. This evaluation is also supported through the health outcomes of: The Healthcare Effectiveness Data and Information Set (known as HEDIS ) HEDIS is a tool Blue Cross uses to measure performance as it relates to important dimensions of care and service. Blue Cross uses HEDIS results to analyze where improvement efforts should be focused. Blue Cross complies with all the HEDIS reporting requirements established by National Committee for Quality Assurance (NCQA), the Office of Financial and Insurance Regulations, Centers for Medicare and Medicaid Services and Michigan Department of Community Health. HEDIS activities and results are audited by an NCQA-certified auditor and submitted for public reporting annually. After scores are reported, a series of HEDIS quality improvement activities are implemented in order to address those areas in which opportunities are identified. Consumer Assessment of Healthcare Providers and Systems member satisfaction surveys (known as CAHPS ) Blue Cross gathers feedback from its members using the CAHPS survey conducted annually by a vendor certified by the NCQA. We evaluate survey results, combining them with other member feedback surveys to determine areas in which Blue Cross can improve service to members. The CAHPS survey results are reported to NCQA and other governmental and regulatory agencies as required. And we ensure compliance with local, state and federal regulatory requirements. Below, you ll learn more about key initiatives that support our Quality Improvement Program. Member satisfaction The Blue Cross Customer Experience department creates member improvement strategies, aligns resources and monitors member satisfaction results. We leverage the CAHPS survey and other member feedback including complaints and appeals to identify opportunities and align resources to drive improvements in selected areas. The Customer Experience department also develops ongoing programs to educate employees on the member pain points identified through research and analysis. As part of this effort, tools are created to help employees improve the member experience. Page 4

5 Enhancing the customer experience is a corporate goal for all employees. It focuses employees and resources on key improvement initiatives designed to address significant issues impacting the customer experience. Blue Cross will focus on the following member satisfaction goals in 2015: Assessing member satisfaction with Blue Cross care and services through CAHPS and other member surveys along with other sources of member feedback Supporting continuous improvement of services and satisfaction for members and providers Developing and promoting opportunities for employees to learn about member pain points and what can be done to address them Promoting activities that increase communication between Blue Cross departments to ensure excellent service and satisfaction to members, practitioners, providers and associates with the knowledge that, ultimately, better-informed providers result in better care for members Continuing to provide a system for members, providers and practitioners to express concerns to Blue Cross regarding care and service Evaluating member complaints and appeals as a source of data on member satisfaction, ensuring member issues are addressed in compliance with federal and state regulations and implementing process improvements Increasing member understanding of corporate strategies and health plan benefits that support the enhancement of the customer experience and assists members in coverage decision-making Providing timely and accurate claims information to members and the ability to access and track claims through the website and by telephone Voice of the Customer The Blues Voice of the Customer program is designed to gather and track member feedback from multiple channels and touch points. We are assessing data on a daily basis in order to monitor changes in customer satisfaction, better identify issues when they occur, track progress of overall member experience improvement initiatives and share insights with key leadership and stakeholders companywide. Access and availability Access and availability of practitioners is measured routinely by PPO Network Management and the Blue Cross quality improvement team. Member feedback from CAHPS, member complaints and survey results are analyzed. Areas of focus include, but are not limited to, the following: Access to services 24 hours a day, seven days a week Appointment availability Quality of care Page 5

6 Urgent care appointments Wait times Collaboration with providers Value Partnerships Program Value Partnerships is a collection of clinically-oriented initiatives and Blue Cross-sponsored partnerships that are significantly improving the quality of patient care throughout the state of Michigan. Through these initiatives, Blue Cross partners with physicians, physician organizations and hospitals to create an innovative and quality-based approach to reward the transformation of health care. These initiatives focus on: Enhancing clinical quality Decreasing complications Managing costs Eliminating errors Improving efficiency Improving health outcomes You can learn more at valuepartnerships.com. Physician Group Incentive Program Within Value Partnerships, the Physician Group Incentive Program includes 28 initiatives aimed at capability building, improving quality of care delivery and appropriate utilization of services. Patient-Centered Medical Home Program In PGIP, we recognize physician practices that have implemented a significant number of Patient-Centered Medical Home Program capabilities and delivered high quality and costeffective care. Some elements of the PCMH model that specifically address patient safety include: Telling patients how to reach their provider 24 hours a day, seven days a week and how to access urgent care Giving providers a comprehensive view of the care patients have received and ensuring treatment is appropriate and safe Patient education and support Access to patient medical records and information 24 hours a day, seven days a week Page 6

7 Tracking system with safeguards in place to ensure patients receive needed tests, timely and accurate results and follow-up care Electronic prescription systems that ensure accurate information is transmitted to the pharmacy and alerts providers to any prescribing errors, patient allergies and potential adverse outcomes or drug interactions Timely response to urgent patient needs and proper patient guidance about emergency situations and seeking care Care coordination and care transition protocols that ensure patient care is efficiently coordinated across all settings and that patients receive timely, appropriate care Specialist referral processes that provide the specialist with detailed information regarding the patient s needs and past medical history to avoid exposing patients to duplicative or unnecessary testing or treatment as well as include a feedback loop to the primary care provider Evidence-Based Care Tracking At Blue Cross, PGIP administers the Evidence-Based Care Tracking initiative, an incentivebased program incorporating HEDIS measures. This initiative strives to promote best-practice behaviors among PGIP physicians by increasing provider awareness and subsequent implementation of evidence-based medicine guidelines in their daily practice. The EBCT initiative rewards physician organizations and providers for higher quality of care to their population through adoption of evidence-based guidelines. To achieve success in EBCT, physician organizations are required to: Identify opportunities for improvement by analyzing Blue Cross data Encourage rapid, feasible improvements on all EBCT metrics Promote best practices among PGIP physicians that results in safe and effective care Support innovation and constructive change in processes for the delivery of care Promote better outcomes and coordination of care across provider settings Develop and implement strategies for population health management Organized systems of care Organized systems of care (OSC) describes a community of caregivers with a shared commitment to quality and cost-effective health care delivery through primary care. By joining together primary care physicians, specialists and hospitals into coordinated care delivery systems, OSCs are designed to address the problems inherent in the delivery of fragmented and costly health care services that fail to meet the needs of the patient population. OSC program goals are aligned with the Institute for Healthcare Improvement s Triple Aim goals, which include better care individuals, better health for populations and slow cost growth. Page 7

8 Hospital pay-for-performance Blue Cross hospital pay-for-performance programs recognize acute care hospitals for their achievements in improving health care quality and cost efficiency. In 2014, Blue Cross updated the hospital pay-for-performance program to align more closely with key elements of the Physician Group Incentive Program. Population health management was a major focus in 2014 and will continue in Collaborative Quality Initiatives Collaborative Quality Initiatives support our efforts to work collaboratively with physicians, hospital partners and community leaders to develop programs and initiatives that save lives and reduce health care costs. CQIs are developed and administered by Michigan physician and hospital partners with funding and support from Blue Cross and Blue Care Network. CQIs seek to address some of the most common, complex and costly areas of surgical and medical care. Blue Cross is providing funding and active leadership for 14 hospital CQIs and five professional CQIs addressing one or more of the following clinical conditions: Angioplasty Angioplasty Anticoagulation Anticoagulation Bariatric surgery Bariatric Breast cancer surgery Breast Cardiac cancer surgery General surgery Cardiac surgery Hospital efficiency General Lean transformation surgery Hospital Oncologyefficiency Lean Pathways transformation Oncology Pathways Radiation Radiation oncology oncology Spine Spine surgery surgery Surgery-related Surgery-related processes processes Urology Urology Total knee and hip replacement Trauma Total knee and hip replacement Transitions Traumaof care Vascular Transitions interventions of care Hospitalists Vascular prevention interventions of adverse events Hospitalists prevention of adverse events Page 8

9 PPO network management and health services contracting Through its quality and legal oversight process, Blue Cross ensures that providers are credentialed before they are contracted and re-credentialed every three years. All credentialing and re-credentialing functions are carried out by BCN on behalf of Blue Cross and provider contracts are compliant with accreditation and regulatory requirements. The oversight groups ensure that contracted Michigan providers adhere to contract requirements and provider manual guideline and policies, which include compliance with quality improvement activities, access to medical records and protection of member information confidentiality. Contracts with practitioners include affirmative statements indicating that practitioners may freely communicate with patients about their treatment, regardless of benefit coverage limitations. In 2015, Blue Cross will focus on the following goals with respect to qualified providers: Develop and promote educational opportunities for in-network health care providers using Blue Cross-sponsored collaborative initiatives outlined in this document. Oversee process for credentialing and re-credentialing providers including follow up on provider complaints or quality issues brought to the attention of Blue Cross through the clinical complaint process. These are then referred to BCN for further investigation. Review physician practices to identify and assist providers with aberrant utilization. Monitor provider utilization to ensure requirements for utilization management programs are met. Page 9

10 Medical care Continuity and coordination of care Coordinated care is a critical element in improving the quality of care for our members. Coordination involves communication among multiple providers who provide their expertise, knowledge and skills toward the goal of reducing inefficiencies and responding to patients unique care needs. We are focused on the following goals: Collecting and analyzing data to identify opportunities for improvement in coordination of medical care Improving coordination between behavioral and medical care Measuring effectiveness of the interventions implemented Patient safety management Blue Cross monitors and improves patient safety through activities focused on identifying and reporting of safety concerns, reduction of medical errors and collaboration with delivery systems, hospitals and physicians and clinicians to develop innovative plans to improve patient safety and clinical outcomes. Patient safety efforts are designed to work in collaboration with other Michigan managed care plans, hospitals, purchasers and practitioners to identify safety concerns, develop action plans with measureable outcomes and implement plans with the goal of improved patient safety and fewer medical errors. Patient safety standards are developed and communicated in key areas that have been documented as potential patient safety concerns, such as reduction of medical errors and improving patient outcomes, computer physician order entry system, intensive care unit physician staffing and an evidence-based hospital referral standard. Three examples of patient safety management initiatives at Blue Cross are the Blue Distinction Centers for Specialty Care, Michigan Health & Hospital Association Keystone Center for Patient Safety and Quality and the Michigan Health Information Network. Utilization management Blue Cross has a comprehensive plan that includes medical care and behavioral health utilization activities across the health care continuum. The UM program includes the following: Behavioral Health Pharmacy Case Management Precertification Human Organ Transplant Provider Relations Medical Affairs and Consulting Utilization Review (audit) Page 10

11 Each area addresses the evaluation of the appropriateness, medical need and efficiency of health care services, procedures and facilities according to established criteria or guidelines and under Blue Cross provisions. UM decision-making is based only on appropriateness of care, service, setting and existence of coverage. Utilization management is a process which includes: precertification, concurrent review, clinical case appeals and peer reviews, which include appeals introduced by the provider, payer or patient. The appropriate practitioners are involved in adopting and reviewing criteria. The criteria used for the evaluation and monitoring of health care services are annually reviewed and approved. New criteria and updates to existing criteria are distributed to all network facilities. Local rules are developed with input from practitioners to supplement approved criteria. Our UM program adheres to the following standards: Oversight by a senior medical director involved in the development, implementation and evaluation of the program annually to ensure utilization management decisions affecting members are fair, impartial and consistent Involvement of behavioral health practitioners in UM decision-making with respect to development of criteria and clarifications to vendor medical necessity guidelines Application of objective and evidenced-based criteria taking into account the individual circumstances and the local delivery system when determining the medical appropriateness of health care services Access to staff for members and practitioners regarding the UM process and authorization of care Assurance that qualified licensed health care practitioners assess clinical information to support UM decisions Timely UM decisions made, ensuring compliance with state and federal regulatory requirements and minimize any disruption in the provision of care Decisions based on medical necessity, relevant clinical information and peer-to-peer review with treating practitioner Annual review of and updates to the UM program, as necessary Non-approval decisions with rationale that are clearly communicated to members and providers, providing sufficient information to understand and make a decision whether to appeal Written policy and procedures in place to ensure a full and fair process for resolving member and provider disputes and responding to reconsiderations and appeals within state and federal regulatory requirements Assessment and evaluation of customer (member and provider) satisfaction with the UM process and to identify areas of improvement Facilitation of all necessary emergency services We are focused on annually evaluating all UM quality improvement components. Page 11

12 Behavioral health In 2015, Blue Cross will enter into a contract with New Directions, a specialty health care manager, for general care management services. These services include preauthorization and case management for members who receive behavioral health services through Blue Cross. Like Blue Cross, New Directions is accredited by NCQA. New Directions has more than 20 years of experience in utilization and case management services, in addition to extensive experience working with Blue plans nationwide. The behavioral health program is administered according to all applicable accreditation, regulatory and legal requirements, including the federal Mental Health Parity law behavioral health goals include: Streamline authorizations by implementing an online application called WebPass Continue work with PGIP and the Behavioral Health Interest workgroup to promote dialog between physician organizations, their primary care physicians and the behavioral health specialists who provide services to their attributed members Work to include behavioral health conditions as part of the required contents of patient registries for PCMH with a proposed measure being the proportion of medical charts with contact from behavioral health specialists Chronic condition management The Blue Cross Chronic Condition Management program is an integrated, member-centered program with comprehensive care management interventions designed to help members manage their conditions and diseases. This program offers support and assistance to relatively healthy, chronically ill and acutely ill members to maintain, restore or improve health. The program also does reach and engage activities for members to ensure interventions are delivered at the most effective point in time, optimizing member health. Chronic condition management is available nationwide to all Blue Cross members who are eligible for BlueHealthConnection. Member participation is voluntary, and members may opt out of the program at any time. The program is tailored to meet the member s individual needs based on his or her diagnosis and risk factors. Members and their caregivers will receive personalized educational and self-care materials and assistance in the management of their chronic conditions based on current evidence-based practice and standards of care. Chronic condition management addresses a broad segment of the Blue Cross member population with targeted chronic conditions. The program identifies members for whom health education and self-care management interventions can have a positive impact on the quality, clinical outcomes and cost effectiveness of care. This is achieved through the proactive identification of our member population with select chronic conditions and the provision of interventions that address demonstrated needs. These interventions are available to members who are generally healthy, but have specific chronic conditions. They may also have gaps in the management of their chronic conditions which require more intensive support in order to achieve compliance with evidence-based clinical practice guidelines for their diseases. Page 12

13 Case management Blue Cross case management is a member-focused program. It s available to all members and provides support and coordination of health care services. The goal of the case management program is to develop cost-effective and efficient ways of coordinating health care services that improve the member s quality of life. This is achieved through collaboration with the member, family and the treating physician as well as members of the health care team to: Arrange appropriate services and care settings Assist in the evaluation of services Encourage communication among health care providers Provide education for complicated health care needs This collaborative process includes assessment, planning, implementation, monitoring and evaluation of options and services to promote quality outcomes. The following objectives have been established to support our case management goals: Help members manage and maintain good health by providing best-in-class health assessment and digital coaching programs that provide a path to a healthier lifestyle based on each member s unique needs, motivation, confidence, barriers and readiness for change Provide a comprehensive suite of programs though BlueHealthConnection to support all members at any level of wellness, with the goal of keeping healthy people well and minimizing risk factors Offer a case management program to assist in the delivery of effective and efficient coordination of healthcare services that improve member quality of life and help manage transition of care, medically complex chronic conditions, catastrophic events and high-cost claims Ensure the necessary health care services are rendered at the appropriate level of care Identify lower cost care alternatives for services of equal or higher quality Improve member health status (both functional and psychological) Coordinate care and support treatment plans for members with complex, catastrophic conditions Educate members about their condition and treatment options available to them Encourage members to self-advocate, assist in setting goals and make informed decisions Assist providers in ensuring members receive high quality services in a timely and costeffective manner Build and strengthen family and community support as well as enhancing member safety Page 13

14 Case management targets members with high-cost chronic and acute conditions, as well as those who are at high risk for incurring high costs in the future. These members represent one to three percent of the member population and almost 45 percent of the annual health care expenditures. This population represents the greatest opportunity to positively impact member utilization, health status, quality of care and benefit cost. Our current goals include: Implementing outreach tailored to individual members with specific reminders for needed care based on condition or risk factor as well as missed services Addressing issues and concerns that impact all users on the care advance platform Cultural and linguistic diversity Our goal is to improve the health of Michigan s diverse communities and assess specific preventive and chronic care management gaps that may exist within our insured population. We are working to improve member engagement with targeted and customized preventive services, care and case management. Identifying membership race, ethnicity and chronic diseases We identify areas where service disparities exist within our population and focus on the following: Outreach to members who have increased risk of specific conditions or reduced preventive services and who may need more customized approaches to engage them in their health care Provider education on health care disparities (partner with same providers to address disparities in their communities) Launching pilot program in 2015 In 2015, Blue Cross will collaborate with one physician organization to conduct a pilot program. The program centers around three culturally competent components: (1) physician education; (2) new patient-centered medical home guidelines; and (3) a quality improvement plan to identify and reduce disparities in the chosen population. Blue Cross will evaluate the results of this pilot and use the results to determine whether the program could serve as a model for future expansion. Quality Improvement Program evaluation Blue Cross completes an evaluation of the Quality Improvement Program annually. The written evaluation is an assessment of the effectiveness of the individual components as well as overall effectiveness of the program s activities. Page 14