Quality Improvement. EMB_PR_WEB_24024_2014_QualityImprovementProg 4/15

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1 Quality Improvement Program (QIP) EmblemHealth s corporate mission is to provide access to affordable, quality health coverage. In line with this corporate mission, the goal of the QI program is to continuously improve medical and behavioral health care and services received by plan members, and better serve the needs of members, employers, employees, providers, practitioners, accounts, service partners, brokers, consultants, regulatory and accreditation bodies. The QIP objectives address monitoring, evaluating and improving the care and outcome of services and identifying and implementing what can be changed to improve care, service and satisfaction. A work plan tracks all the activities, all of which are regularly reported to the Quality Improvement Committee comprised of plan leaders who provide oversight, leadership and direction to address quality improvement. EmblemHealth improves members access to and satisfaction with quality health care coverage in ways that respect and respond to their needs. Some of these activities include addressing: Quality of Care including quality improvement and health promotion activities Quality of Service Encouraging Wellness and Prevention Continuity and Coordination of Care PATH (Positive Actions Toward Health) Programs Disease Management Case Management Appropriate Use of Drugs Behavioral Health Customer Service Member Safety Utilization Management Member and Physician Satisfaction with Care and Service Availability and Accessibility to a quality network of doctors, hospitals and other health care providers Online health management tools to help members understand and manage health and benefits Minimizing gaps in care Programs to promote healthy living Programs to enhance quality of life such as Care for the Family Caregiver Special Needs Plan (SNP) Model of Care Connecting with Communities through EmblemHealth Neighborhood Care Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. EMB_PR_WEB_24024 QualityImprovementProg 4/15

2 Table of Contents Clinical Initiatives:... 2 Adults Access to Preventive/Ambulatory Health Services... 2 Breast Cancer Screening... 2 Cervical Cancer Screening... 3 Colorectal Cancer Screening... 3 Comprehensive Diabetes Care... 4 Spirometry Testing in the Assessment and Diagnosis of COPD... 5 Annual Monitoring of Patients on Persistent Medications... 6 Antidepressant Medication Management... 6 Postpartum (After Childbirth) Depression Screening... 7 Medication Adherence... 7 PATH Health Management Programs... 8 Service Initiatives:... 9 Customer Service... 9 First Call Resolution... 9 Electronic Inquiries Response... 9 Interactive Voice Response... 9 Health Care Exchange... 9 Vendor Oversight... 9 Claims Processing... 9 ii

3 Achievements in Clinical and Service Initiatives. EmblemHealth achieved a Commendable Accreditation for the HIP Commercial HMO/POS products and Commendable Accreditation for the HIP Medicare HMO products from the National Committee for Quality Assurance (NCQA) 1. NCQA is a private, not-for-profit organization dedicated to improving health care quality. NCQA Health Plan Accreditation surveys include the rigorous on and off-site evaluations of over 60 standards and selected HEDIS 2 measures. A team of NCQA-trained physicians and health plan experts conduct accreditation surveys. A national NCQA oversight committee of physicians analyzes the team s findings and assigns an accreditation level based on the performance level of each plan being evaluated to NCQA s standards. EmblemHealth has also achieved URAC Accreditation in Health Utilization Management for the GHI and HIP Commercial PPO products. URAC is an independent, nonprofit organization that is well-known as a leader in promoting health care quality through its accreditation and certification programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system and provides a symbol of excellence for organizations to validate their commitment to quality and accountability. Awards and Recognition EmblemHealth has been named a silver award winner in the fourth annual Fit Company Awards program. The awards recognize organizations nationwide that demonstrate their commitment to improving the overall health and fitness of their employees by offering exceptional employee wellness programs and benefits. EmblemHealth s NCQA rankings for its HIP Medicare, HIP Commercial HMO/POS and GHI Medicare plans, remained favorable when compared with local competitors. JD Power and Associates, in their Member Health Plan Study, ranked EmblemHealth higher in member satisfaction than the combined average for health plans in the NY/NJ region. EmblemHealth also ranked higher than the local and national competitors. Measures The program includes many clinical and service measures. Below are short descriptions for some of the programs offered and EmblemHealth s most recent results. Results are compared to national and state wide benchmarks. Benchmarks used include, but are not limited to, NY state wide average (), Medicare national averages, Medicare Stars and NCQA benchmarks called 3. How to interpret the tables below: In order for EmblemHealth to gauge performance, EmblemHealth compares the plan s HEDIS 2 score to a relevant industry benchmark, such as the NY state wide average, the NCQA or the CMS rating using Stars whereby 3 stars is midpoint and 5 stars is the best. If the plan scores are higher than the or NCQA, then this indicates that the plan is capturing health care information and using it to encourage its members to seek services that help them regain, maintain or improve their health care better than other plans. Improving quality is hard work; EmblemHealth has a team of dedicated health care professionals who work every day toward improving health services for its members. 1 Information regarding NCQA accreditations can be found at ncqa.org. Data extracted December. 2 is a registered trademark of the National Committee for Quality Assurance (NCQA). 3 is a registered trademark of the NCQA. 1

4 Clinical Initiatives EmblemHealth sends personalized, preventive health communications to make members aware of any gaps in preventive or chronic maintenance care. Members are provided with preventive health guidelines, member newsletters and personalized communications throughout the year in an effort to help them maintain their health. Some of the services members are encouraged to receive are as follows. Adults Access to Preventive/Ambulatory Health Services Providing access to general health services, including preventive and ambulatory care, is one of the most important aspects of a health insurance plan. EmblemHealth sends educational mailings and reminders to members encouraging them to attend an annual well visit and receive needed shots, tests, screenings and counseling. Doctors are sent mailings identifying their patients who are overdue for a preventive care visit. The purpose of these mailings is to educate members about the importance of regular preventive care. The table below captures the percent of adults who attended a preventive or ambulatory care visit. Percentage of Adults Who Had a Preventive/Ambulatory Health Service HIP Commercial HMO Ages % 94.07% 93.06% 93.64% Ages % 95.56% 94.22% 95.49% HIP Commercial PPO Ages % 93.52% 92.09% 93.46% Ages % 94.89% 94.40% 95.10% GHI Commercial PPO Ages % 93.52% 92.96% 93.46% Ages % 94.89% 94.17% 95.10% NCQA 50 th Percentile HIP Medicare HMO Ages % 89.82% 91.62% 92.48% Ages % 94.76% 95.24% 96.25% Ages % 95.32% 95.51% 95.94% GHI Medicare PPO Ages % 93.23% 92.28% 94.52% Ages % 96.49% 96.32% 97.01% Ages % 95.84% 95.39% 96.42% NCQA 50 th Percentile Breast Cancer Screening EmblemHealth sends educational mailings and reminders to women who are due for their mammograms. Doctors are sent an annual mailing with a list of their patients who are due for screening, encouraging them to reach out to their patients to address the importance of mammography. The purpose of these mailings is to educate members about the importance of screening and early detection. The table below captures the percent of women screened for breast cancer. 2

5 Percentage of Women Appropriately Screened for Breast Cancer HIP Commercial HMO 74.22% 70.00% 76.40% 73.73% HIP Commercial PPO 67.20% 67.00% 69.62% 65.28% GHI Commercial PPO 62.98% 67.00% 64.14% 65.28% NCQA HIP Medicare HMO 78.60% 73.00% 78.21% 71.41% GHI Medicare PPO 65.03% 68.30% 65.43% 70.12% NCQA Cervical Cancer Screening Each year, women are sent a reminder that they should have a Pap test. We also send a report to doctors to encourage member counseling for screening. The purpose of these mailings is to educate members about the importance of regular screening and early detection. The table below captures EmblemHealth screening rates for cervical cancer. Percentage of Women Appropriately Screened for Cervical Cancer HIP Commercial HMO 79.78% 78.00% 85.35% * HIP Commercial PPO 72.90% 77.00% 78.89% * GHI Commercial PPO 72.16% 77.00% 78.14% * *Due to measure changes in (HEDIS ) there are no available. Colorectal Cancer Screening Each year, EmblemHealth sends reminders to members who have not had a colorectal cancer screening. Their doctors receive reports to encourage discussion and referral for this important screening. Adult men and women are also reminded of the need for screening throughout the year through newsletter articles and personalized mailings. The purpose of these mailings is to educate EmblemHealth s members and increase the percentage of adult members being screened for colorectal cancer. The table below captures EmblemHealth s ability to encourage colorectal cancer screenings. Percentage of Members Appropriately Screened for Colorectal Cancer HIP Commercial HMO 66.43% % 66.07% 63.76% HIP Commercial PPO 54.76% % 57.11% 63.89% GHI Commercial PPO 49.88% % 55.45% 63.89% 4 Rate is from prior year because the information was not required to be collected for this reporting year. 3

6 NCQA 50 th Percentile HIP Medicare HMO 72.22% 59.00% 71.88% 65.45% GHI Medicare PPO 58.54% 58.78% 56.64% 62.18% HIP SNP % 62.84% 68.10% 65.45% HIP SNP % 62.84% 87.21% 65.45% GHI SNP % 58.78% 58.31% 62.18% NCQA 50 th Percentile Comprehensive Diabetes Care Diabetes is one of the leading causes of death and disability in the United States. Approximately 24 million Americans, or close to 8 percent of the population, have the disease. Much of the burden of illness and cost of diabetes is related to potentially preventable long-term complications that include heart disease, blindness, kidney disease and stroke. Timely screening and careful treatment can significantly reduce and delay the onset of complications of diabetes. In addition to educational materials provided through the Diabetes Care PATH program, EmblemHealth monitors screenings for diabetics for early identification of medical complications. In order to decrease long-term complications, there are several ways plans can monitor members living with diabetes. One way is to monitor diabetic care outcomes through HbA1c screenings, LDL screenings, receiving retinal eye exams and monitoring for nephropathy. Diabetic Care Outcomes HIP Commercial HMO HbA1c Screening 90.35% % 92.17% 90.33% LDL Screening 89.74% % 88.02% 87.17% LDL Control 47.93% % 38.10% 44.79% Monitoring for Nephropathy 80.55% % 81.41% 81.78% Retinal Eye Exam 63.86% % 58.68% 56.38% Diabetic Care Outcomes HIP Commercial PPO HbA1c Screening 88.38% % 89.50% 87.89% LDL Screening 85.52% % 86.91% 85.99% LDL Control 38.38% % 36.68% 43.71% Monitoring for Nephropathy 80.81% % 82.80% 77.41% Retinal Eye Exam 53.03% % 53.27% 52.88% Diabetic Care Outcomes GHI Commercial PPO HbA1c Screening 87.22% % 86.14% 87.89% LDL Screening 85.96% % 84.58% 85.99% LDL Control 38.17% % 35.98% 43.71% Monitoring for Nephropathy 76.66% % 78.97% 77.41% Retinal Eye Exam 48.42% % 46.11% 52.88% 4 Rate is from prior year because the information was not required to be collected for this reporting year. 4

7 Diabetic Care Outcomes HIP Medicare HMO NCQA Quality Compass HbA1c Screening 95.09% 91.00% 93.36% 92.94% LDL Screening 92.23% 88.00% 93.58% 89.99% LDL Control 56.85% 52.67% 54.87% 54.99% Monitoring for Nephropathy 94.27% 89.00% 90.27% 91.31% Retinal Eye Exam 82.41% 65.00% 77.43% 69.84% NCQA Quality Compass Diabetic Care Outcomes GHI Medicare PPO NCQA Quality Compass HbA1c Screening 89.56% 91.24% 89.85% 91.97% LDL Screening 90.22% 86.86% 91.17% 88.41% LDL Control 42.67% 50.58% 47.46% 54.17% Monitoring for Nephropathy 90.22% 88.32% 85.65% 89.89% Retinal Eye Exam 69.11% 64.72% 64.68% 64.70% NCQA Quality Compass Use of Spirometry Testing in the Assessment and Diagnosis of COPD Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death in the United States. Spirometry is a test that measures lung capacity and the ability to exchange air on inhalation and exhalation. The test is helpful in diagnosing COPD and in classifying the severity of the disease into one of its stratified stages. In addition to sending educational mailings and reminders to members, EmblemHealth notifies doctors of their patients recently discharged following treatment for COPD to encourage them to follow up with their patient. The purpose of these mailings is to encourage members and providers to have spirometry testing to confirm a COPD diagnosis. The table below reflects EmblemHealth s ability to encourage members to have spirometry testing. Use of Spirometry Testing in the Assessment and Diagnosis of COPD HIP Commercial HMO 53.01% 47.87% 57.16% 46.09% HIP Commercial PPO 57.14% 47.06% 61.48% 46.11% GHI Commercial PPO 58.89% 47.06% 57.17% 46.11% NCQA HIP Medicare HMO 53.16% 35.00% 54.03% 35.00% GHI Medicare PPO 56.59% 35.00% 59.79% 35.00% NCQA 5

8 Annual Monitoring of Patients on Persistent Medications Patients on long-term medications may be at increased risk for adverse drug events. Persistent use of some drugs calls for monitoring and follow-up by the prescribing physician. Members on drugs that require lab monitoring are sent a reminder to speak to their physician. In addition, physicians receive a report of their patients who are overdue for monitoring. The purpose of these mailings is to educate our members and providers and increase the monitoring of members who take long-term medications. The table below captures EmblemHealth s ability to work with its physicians to monitor members who take certain medications. Annual Monitoring of Patients on Persistent Medications Total HIP Commercial HMO 86.20% 83.00% 87.34% 83.19% HIP Commercial PPO 85.24% 81.00% 84.83% 83.80% GHI Commercial PPO 86.31% 81.00% 85.68% 83.80% NCQA HIP Medicare HMO 93.19% 92.28% 93.87% 92.36% GHI Medicare PPO 93.00% 91.54% 93.40% 91.91% HIP SNP % 92.28% 94.14% 92.36% HIP SNP % 92.28% 96.60% 92.36% GHI SNP % 91.54% 92.42% 91.91% NCQA Antidepressant Medication Management Members who are prescribed an antidepressant for the first time are sent educational information about the importance of staying on their medications. Members are also encouraged to consult the doctor before discontinuing use of their medications. Prescribing doctors are informed if their patients have prematurely discontinued their medications. The purpose of these mailings is to educate EmblemHealth s members and providers and improve the monitoring and adherence to medication dosage for members who are prescribed antidepressants. The table below captures EmblemHealth s member s adherence and management of their antidepressant medications. Antidepressant Medication Management HIP Commercial HMO Acute Phase Treatment 72.27% 68.00% 75.87% 64.32% Continuation Phase Treatment 60.64% 55.00% 64.39% 48.64% HIP Commercial PPO Acute Phase Treatment 69.64% 70.00% 80.51% 67.08% Continuation Phase Treatment 60.71% 56.00% 70.34% 53.32% GHI Commercial PPO Acute Phase Treatment 73.64% 70.00% 80.17% 67.08% Continuation Phase Treatment 60.03% 56.00% 72.42% 53.32% 6

9 NCQA NCQA HIP Medicare HMO Acute Phase Treatment 75.81% 71.00% 85.77% 67.32% Continuation Phase Treatment 68.76% 60.00% 78.04% 52.83% GHI Medicare PPO Acute Phase Treatment 85.45% 73.65% 86.86% 70.73% Continuation Phase Treatment 78.18% 61.65% 78.47% 57.02% HIP SNP 029 Acute Phase Treatment 71.56% 69.37% 80.72% 67.32% Continuation Phase Treatment 64.22% 57.33% 68.07% 52.83% GHI SNP 018 Acute Phase Treatment NA* 73.65% 83.33% 70.73% Continuation Phase Treatment NA 61.65% 71.43% 57.02% *NA: Sample size less than 30, measure not reportable. Postpartum (After Childbirth) Depression Screening Approximately 10 to 25 percent of new mothers suffer from perinatal mood disorders including postpartum depression. All new mothers receive a series of mailings that discuss postpartum depression. Mailings include a flyer describing baby blues and postpartum depression and a postpartum depression survey. The survey is re-sent as part of the Welcome Home Kit. New moms are encouraged to complete the survey and to contact their OB/GYN, call directly for mental health services or call EmblemHealth for assistance if there is a positive score. EmblemHealth Healthy Beginnings PATH case managers are nurses who are dedicated to helping members have healthy babies and follow-up care after delivery and are available to members throughout pregnancy and the postpartum period. Medication Adherence Members with conditions such as diabetes, high blood pressure and high cholesterol must make a commitment to continued use of medications to achieve, control and prevent long-term complications and health issues. Members with a 90-day prescription receive a postcard after 60 days reminding them that they have a 30-day supply left and encouraging them to refill their prescription. Members who may be stretching their medication and members who have not refilled their prescription receive an Interactive Voice reminder call. The purpose of these reminders is to educate our members about the importance of medication adherence. Members with chronic conditions such as diabetes, hypertension and high cholesterol often need to be on medication for the rest of their lives and do not realize the dangers associated with stopping or changing their doctors medication instructions. The table below captures medication adherence rates for chronic conditions. Part D Medication Adherence for Diabetes Medications Rate CY CMS 3 Star Benchmark 2015 Rate CY 2015 CMS 3 Star Benchmark HIP Medicare HMO 77.00% 71.00% 76.00% 73.00% GHI Medicare PPO 74.00% 71.00% 76.00% 73.00% GHI Medicare PDP 81.00% 76.00% 80.00% 76.00% 7

10 Part D Medication Adherence for Hypertension (RAS Antagonist) Rate CY CMS 3 Star Benchmark 2015 Rate CY 2015 CMS 3 Star Benchmark HIP Medicare HMO 78.00% 72.00% 78.00% 76.00% GHI Medicare PPO 78.00% 72.00% 78.00% 76.00% GHI Medicare PDP 83.00% 76.00% 83.00% 76.00% Part D Medication Adherence for Cholesterol (Statins) Rate CY CMS 3 Star Benchmark 2015 Rate CY 2015 CMS 3 Star Benchmark HIP Medicare HMO 73.00% 68.00% 72.00% 68.00% GHI Medicare PPO 71.00% 68.00% 71.00% 68.00% GHI Medicare PDP 78.00% 72.00% 78.00% 69.00% Note: CMS rates plans on a 5 Star scale. PATH Health Management Programs Managing a health condition can be overwhelming. EmblemHealth offers eligible members access to education and support through our PATH health management programs. These programs complement the care members receive from their doctors and assist the member by helping them better understand and manage their condition. Members are offered the following PATH health management programs: Better Breathing PATH for asthma Better Breathing PATH for chronic obstructive pulmonary disease (COPD) Condition Care PATH for rare, chronic conditions Diabetes Care PATH Healthy Beginnings PATH for pregnancy management Healthy Living PATH Heart Care PATH for coronary artery disease (CAD) Heart Care PATH for heart failure Kidney Care PATH for chronic kidney disease and end-stage renal disease Steps-4-Safety PATH for fall prevention Tobacco-Free PATH for smoking cessation 8

11 Service Initiatives At every point of contact, EmblemHealth strives to improve the customer experience. quality improvement program (QIP) This includes, but is not limited to: Answering phone inquiries promptly, courteously and effectively. Responding to members electronic inquiries. Currently, EmblemHealth responds to s only. In the near future, this will be expanded to include other forms of electronic inquiries. Fast and accurate claims processing. Customer Service EmblemHealth knows that a good experience with customer service is very important to members. As part of continually improving this experience, the following was accomplished: First Call Resolution EmblemHealth continues to monitor and improve Customer Relationship Management systems that provide customer service advocates (CSAs) with additional tools to help them quickly resolve issues during the first call. Respond to members electronic inquiries ( s). In the future, this will be expanded to other forms of electronic inquiries. Interactive Voice Response (IVR) Enhanced functionality and increased performance testing of the IVR helps to improve the customer experience and quickly respond to needs. HealthCare Exchange Customer Service representatives received comprehensive training on EmblemHealth s products offered on the New York State of Health Marketplace. Vendor Oversight Customer Service continues to monitor the quality, accuracy and overall performance of contracted vendors. Claims Processing To improve the experience with claims processing, EmblemHealth monitors and measures the following to gauge progress in meeting goals: Mean Process Time All Claims Financial Accuracy Percent Processed within 30 Days Claims Processing Medical HIP GHI PPO Metric Mean Processing Time All Claims (days) Financial Accuracy % 98.68% 97.99% 98.73% % Processed within 30 Days 99.81% 99.78% 99.98% 99.87% 5 Financial Accuracy from Performance Metric Audit results ( = Last Twelve Months (LTM) through 4Q13 audit; = LTM through 3Q14 audit) 9

12 Claims Processing Hospital Metric HIP GHI PPO Mean Processing Time All Claims (days) Financial Accuracy % 99.51% 99.59% 99.07% % Processed within 30 Days 99.53% 99.39% 99.86% 99.67% The source for some data contained in this publication is and and is used with the permission of the National Committee for Quality Assurance (NCQA). and include certain CAHPS data. Any data display, analysis, interpretation or conclusion based on this data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation or conclusion. is a registered trademark of the NCQA. CAHPS is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 5 Financial Accuracy from Performance Metric Audit results ( = Last Twelve Months (LTM) through 4Q13 audit; = LTM through 3Q14 audit) 10