Commercial 2016 QI Program Evaluation

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1 Commercial QI Program Evaluation Color Code: Red does not meet target. Blue meets or exceeds target. ( ) Summary of #1 Priority Measures Immunizations for Adolescents (combo 1) 70.6% 72.5% 77.4% 86% 50th ly significant improvement from - (z = 93.9% 1.961; p = 0.05) Grand Valley : CHP staff practices following up to schedule patients needing vaccines. Immunization Clinic for members with staff PCPs held June. Report developed and posted to Connect and EMR dashboard in July for physician intervention. On hold message played in March and July, Network News article 6/ and 5/. In, Health Promotions (HP) began providing manual lists to affiliate practices for intervention. Controlling High Blood Pressure (<140/90) 69.8% 74.5% 75.2% 75% 90th 91.19% - Mid- improvement from - (z = 2.960; p = 0.003) Member level reports available on EHR and CHP Connect. & : CHP staff nurses are rechecking BPs when results are out of control. Network News article February. Discussion at QIC July. TPCA taking BPs at the end of the visit for some practices. Controlling BP is addressed in the annual Disease Management letters that are mailed to the Diabetic and Vascular Disease population. Topic of discussion with the Health Information Line (HIL) and Beta blocker follow-up calls. BP Control <140/ % 73.0% 78.8% 76% 90th 85.9% improvement from - Mid- - (z = 2.014; p = 0.044) Same interventions as above. HPV Immunization 23.6% 20.9% 21.2% 22% 75th 43.8% - Mid- : CHP staff practices following up to schedule patients needing vaccines. Immunization Clinics for members with staff PCPs held June. Report developed and posted to Connect and EMR dashboard in July for physician intervention. Measure changed January to include boys in the denominator. Measure incorporated into Immunizations for Adolescents measure for Rating of Specialist Seen Most Often (CAHPS: 9-10) 67.0% 67.9% 68.3% 72% 50th 82.2% UPMC * s are set based on prior year 90th national percentile. 1

2 Commercial QI Program Evaluation ( ) Summary of Getting Needed Care usually/always 92.0% 90.3% 90.4% 92.0% 75th 95.1% Results stable in ; not meeting the 90th national percentile. This measure is identified as a priority for improvement in 2017 for both the CMS star ratings and NCQA ratings. Current information about "Centers of Excellence" is integrated into UM decisions to provide high quality options for members. Claims Processing usually/always) 94.7% 91.4% 94.2% 93.0% 95th 97.5% : New reporting created to analyze member calls, complaints & issues. Increased throughput on existing EDI claims via enhanced system logic. Decreased claims that drop to paper from non-par providers. Asthma Medication Compliance; 75%; combined score 30.0% 31.5% 34.5% 55% 5th 78.8% In, HP staff provided lists to affiliate PCPs utilizing internal reports. and - letters to PCP asking for a 90 day supply of Singular if the member is filling a 30 day supply. Gap report developed; posted to Connect and EMR dashboard. QL for inhalers implemented. Physician education through Network News. QI and HP staff communicated with high performing ACHP plan in October, Plan has network pharmacists adjusting individual prescriptions to resolve the inhaler size issue. Plan is using vendor to provide quarterly member visits with a pharmacist to monitor adherence. AOD Dependence - Initiation Treatment (Combined) 41.9% 31.6% 34.0% 43% 25th 54.6% (CA) decrease from - (z = -2.96; p = 0.00) Flu Vaccinations for Adults (CAHPS; age 18-64) 47.0% 47.3% 49.9% 59% 50th 85.2% Denver : CHP staff practices are following up to schedule patients needing vaccines. Immunization Clinics held for members with staff Pediatric PCPs held in June. Flu Clinics held 5 Saturdays from September - November for members with CHP staff PCPs. Financial incentive for nursing staff of CHP Family Practice & Internal Medicine PCPs. * s are set based on prior year 90th national percentile. 2

3 Non-recommended Cervical Cancer Screening in Adol. Females (low score is better) Commercial QI Program Evaluation 9.1% 4.3% 2.5% 1.5% 25th ( ) 100% improvement from Aetna (MO) - (z = Humana (IL) 5.095; p = 0.00) Summary of Pharmacotherapy Mgmt of COPD Exacerbation - Systemic Corticosteroid (actual score: 83%) 72.1% 68.6% 82.0% 10th 94.3% Aetna Health (KY) Outreach to members after discharge from the hospital if no Rx. If Commercial members need copay assistance, HP staff works with Prime for override. If diagnosis of COPD is not the primary diagnosis after chart review HP staff works with TMH staff to restack the diagnosis on the claims. Use of Imaging Studies for Low Back Pain 79.4% 75.8% 74.1% 83% 25th 94.2% (Hawaii) decrease - (z = ; p = 0.00) : Implemented pre-authorization requirements for lumbar MRI procedures. Care Coordination department is evaluating the use of external reviewers with expertise in imaging reviews to address overutilization of procedures. Asthma Medication Ratio 78.3% 80.6% 82.8% 83% 75th 98.1% Christus HP staff review medication refill data for the population, contact PCPs and/or members when necessary. QL for inhalers implemented. Pharmacotherapy Mgmt of COPD Exacerbation - Bronchodilator (actual score: 83%) 81.4% 80.0% 88% 50th 95.3% (Hawaii) HP staff provide outreach to members after discharge from the hospital if no Rx. If Commercial members need copay assistance, staff works with Prime for override. If diagnosis of COPD is not the primary diagnosis after chart review HP staff works with TMH staff to restack the diagnosis on the claims. Appropriate Treatment for Children w/ URI 89.6% 90.6% 90.7% 95% 50th 98.8% Grand Valley HP staff monitor this population of members. Use of First-Line Psychological Care for Children/Adol (89%) (78.57%) 80.98% BCBS (MA) * s are set based on prior year 90th national percentile. 3

4 Metabolic Monitoring for Children/Adol Commercial QI Program Evaluation 60.4% 63.8% 100th ( ) 66.7% (Hawaii) Summary of Letters are sent to prescribers and PCPs advising that members need to have labs completed. Staff pediatricians assist with contacting PCP if there are questions/issues. Use of Multiple Antipsychotics in Children/Adol (low score better) 6.4% 2.5% 19% BCBS (MA) HP staff monitor the population. Statin Adherence (80%) for Patients with Cardiac Disease 68.9% Member education provided through the Vascular disease management program. Article in Network News February and May encouraged 90 day refills. Report posted 7/16 on Connect and EMR dashboard for physician intervention. Adherence addressed in annual letter for Disease Management (DM) population and in the phone call to DM patients who have had an MI. Statin Adherence (80%) for Patients with Diabetes 58.5% Member education provided through the Vascular disease management program. Article in Network News February and May encouraged 90 day refills.report posted 7/16 on Connect and EMR dashboard for physician intervention. Adherence addressed in annual letter for Disease Management (DM) population and in the phone call to DM patients who have had an MI. Persistence of Beta Blocker Treatment 87.2% 91.1% 80.0% 92% 25th Eye Exams 77.1% 67.9% 58.4% 70% 50th #2 Priority Measures 98.7% - Colorado decrease - (z = % 2.97; p=0.003); and - Mid- - (z= ; p = 0.00) HP staff follow the population and contact members to make sure they are taking their beta blockers. Prenatal Care Visits 95.9% 93.2% 91.7% 95% 75th 100% Tufts HMO (PPO) * s are set based on prior year 90th national percentile. 4

5 Well-Child Visits First 15 Months (6+ visits) Commercial QI Program Evaluation 83.7% 86.5% 84.3% 88% 50th ( ) 97.0% (CA) Summary of Member level reports posted on CHP Connect. Practices encouraged to submit claims for well child visits. Well-Child Visits (Age 3-6) 83.7% 84.8% 85.8% 87% 75th 93.6% BCBS (MA) improvement - (z=2.56; p=0.0108) Adolescent Well- Care Visits 58.5% 58.9% 57.4% 62% 75th 78.4% BCBS (MA) Medical Attention to Nephropathy 90.8% 88.6% 95.9% 90% 95th improvement % (z=3.81; Grand Valley p=0.000);and - (z=2.91; (MI) p=0.004) HbA1c Control (<8) 71.5% 68.6% 67.9% 67.5% 95th 74.0% Network Getting Care Quickly usually/always Health Promotion and Education usually/always) 91.0% 90.2% 90.9% 89.9% 95th 77.0% 80.4% 80.4% 80% 90th 95.4% 85.14% Tokio Marine Pacific Insurance * s are set based on prior year 90th national percentile. 5

6 Commercial QI Program Evaluation ( ) Summary of Coordination of Care 9-10) 82.4% 84.8% 84.6% 88% 75th Member education provided through Healthline newsletter in spring of. Survey Questions: - PCP informed and up to date on care from specialists - PCP has medical records and other information about members care - PCP communicates test results to members in a timely manner - PCP office manages care between different providers #3 Priority Measures Postpartum Care 91.7% 89.3% 89.3% 88% 95th 95.6% (CA) Appropriate Testing for Children w/ Pharyngitis on antibiotics 90.1% 92.8% 91.7% 92% 75th 98.1% Fallon Community decrease - (z=- 2.24; p =0.025) Avoidance of Antibiotics Adults w/ Bronchitis (higher % is better) 48.2% 46.4% 31.7% 38% 75th 79.9% - Northwest decrease - (z=- 3.54; p =0.00) Rating of Personal Doctor (CAHPS: 9-10) 71.3% 74.0% 73.6% 72% 90th 83.9% Humana s (PR) Children & Adolescent BMI Assessment (combined) 83.9% 88.6% 89.1% 83% 95th 99.1% - Southern California improvement - PCPs are encouraged to submit applicable ICD-CM codes on (z=2.10; claims. p=0.037) Childhood Immunization (combo 10) 64.2% 68.6% 63.3% 60% 90th 77.4% BCBS (RI) Rating of Health Plan (CAHPS: 9-10) 67.6% 69.7% 70.8% 51% 95th 87.9% * s are set based on prior year 90th national percentile. 6

7 Commercial QI Program Evaluation ( ) Summary of Rating of Health Care (CAHPS: 9-10) 61.0% 65.2% 63.1% 58% 95th 75.1% ADHD - Initiation Phase 59.4% 70.0% 75.8% 47.0% 100th 75.8% Capital improvement - (z=2.86; p=0.004). Letters are mailed to the PCP and/or Prescriber for a 30-day follow-up appointment for member. HP staff follow up as needed with PCP and/or Prescriber. Follow-Up After Hospitalization for Mental Illness - 7 Day 85.6% 88.6% 64.4% 67% 75th 88.2% Tufts Associated HMO decrease - (z=- 5.78; p = 0.00). CRMC BH facility opened in, and TMBC follow-up interventions discontinued in. Denominator increased to 281 (167 in ). TMH began partnering with Apalachee in, and implemented new post discharge visits. CHP and TMBC staff met July 18, to discuss interventions for this measure. Chlamydia Screening in Women (Combined) 68.6% 67.6% 63.9% 60% 90th 78.5% (GA) Sta. sig decrease - (z=- 3.81; p= 0.00) and - (z= p = 0.00) Breast Cancer Screening 85.4% 83.0% 81.4% 81% 90th decrease 88.2% - (z= - - Mid- 9.15; p= 0.00) Significant community promotion for breast cancer awareness. Adult BMI Assessment 94.9% 95.6% 96.1% 91% 95th 99% - Mid- Colorectal Cancer Screening 83.7% 80.5% 79.8% 72% 95th 87.8% Denver Colon Screening Program tracks members & provides screening procedures. Antidepressant Med Mgmt - Acute Phase Treatment 67.7% 80.7% 85.1% 75% 100th 85.1% Capital improvement - (z= 5.47; p=0.00) Diagnosis code 311 has been eliminated from CHP and TPCA's EMRs since. * s are set based on prior year 90th national percentile. 7

8 Commercial QI Program Evaluation Cervical Cancer Screening 87.1% 86.4% 80.8% 82% 75th ( ) 98.3% Denver decrease - (z= ; p = 0.019) Summary of Customer Service usually/always) 94.9% 91.2% 89.4% 92% 50th 97.7% Point (Northeast) Member Services calls are monitored; individual follow-up and training for staff members. Smoking Cessation: advising smokers to quit usually/always 83.8% 77.3% 78.2% 83% 50th 91.8% Point (Northeast) TPCA practices identify smokers, and provide smoking cessation information. Smoking Cessation: strategies for quitting usually/always 54.1% 49.6% 49.2% 56% 50th 65.4% Point (Northeast) Same interventions as above. Smoking Cessation: meds for quitting usually/always) 51.8% 54.1% 53.3% 58% 75th 74.1% Point (Northeast) Same interventions as above. Use of Aspirin (CAHPS) 40.9% 44.5% 42.4% 51% 50th 61.4% (Northwest) AOD Dependence - Engagement of Tx (combined) 10.7% 7.1% 5.3% 19% <5th Measures not Included in NCQA Ratings 30.2% Cigna Healthcare (CT) decrease - (z=- 4.27; p=0.00) Anti-Rheumatic Drug Therapy 88.1% 88.2% 88.6% 93% 50th 98.2% Aetna Health Letters are sent to diagnosing physicians asking them to evaluate the patient for correct diagnosis and to start patients on appropriate medications. * s are set based on prior year 90th national percentile. 8

9 Commercial QI Program Evaluation ( ) Summary of How well Doctors Communicate usually/always) Annual Monitoring of Patients on Long Term Meds (combined) HbA1c Testing HbA1c Control ( 9) Antidepressant Med Mgt: Cont.Phase Tx 96.8% 95.9% 95.9% 97% 50th 84.1% 84.7% 84.2% 86% 50th 94.6% 95.4% 93.2% 94% 75th 81.5% 78.6% 76.9% 79% 75th 52.6% 64.2% 63.1% 61% 95th 99.4% Aetna (IL) PPO 97.1% UnitedHealth Midwest 97.3% Aetna Health (ME) 85.4% Network 75.9% Rocky Mountains improvement - (z=2.90; p=0.00) ADHD - Cont and Maint Phase Spirometry Testing for Diagnosis of COPD (actual score: 67%) 78.3% 80.0% 56% 100th 70.5% 64.0% 46.5% 52% 75th 81.8% - Hawaii 72.9% - Southern California decrease - (z= ; p=0.00) and - (z= p=0.00) Plan All-Cause Readmission 8.0% 8.4% 8.6% 25th TPCA practices monitor hospital discharges, and schedule PCP visits within 7 days. Children & Adolescents Access to PCP (age 7-11) 93.3% 93.9% 93.9% 97% 50th 99.2% Fallon Community * s are set based on prior year 90th national percentile. 9

10 Children & Adolescent Nutrition Counseling (combined) Children & Adolescent Counseling for Physical Activity (combined) Commercial QI Program Evaluation 65.0% 66.2% 71.8% 78% 75th 63.8% 68.1% 70.3% 73% 75th ( ) 99.1% (Hawaii) 99.1% (Hawaii) Summary of improvement - (z=2.16; Practices are encouraged to submit applicable ICD-CM codes on p=0.031) claims. Practices are encouraged to submit applicable ICD-CM codes on claims. Report Date: 10/28/ QIC Review: 11/8/ Health Delivery Committee Review: 11/16/ * s are set based on prior year 90th national percentile. 10

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