Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company Commercial Lines of Business

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1 Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Coventry Health and Life Insurance Company Commercial Lines of Business Quality Management Program 2012 Overview Quality Improvement Strategy Coventry s Board of Directors delegates responsibility of the respective health s plan quality improvement process to the Regional Quality Improvement Committee (RQIC), which oversees the regional quality program. The Health Plan Senior Medical Directors within the region have ultimate accountability and oversight of the program, including participation as active members of the RQIC. Committee members are comprised of regional and health plan management which includes; CEO or designee, Regional VP of Quality Improvement, Regional Director of Quality Improvement, Regional lead of HEDIS or Health Care Consultant, Pharmacy lead, the lead from Health Services, Network Operations, Provider Relations, Finance and Marketing as appropriate, Compliance, Customer Service and the Regional Quality Improvement staff as appropriate. The RQIC meets at a minimum, quarterly, or more frequently, as needed or required to meet the Quality Improvement Program goals. Performance measures are reported to the RQIC. The RQIC monitors and ensures appropriate follow-up of all regional committee activities including, but not limited to, the following committees: Regional Physician Advisory Committee and Peer Review Regional Credentialing/Re-credentialing Regional Delegated Vendor Oversight Committee National Commercial and Medicare Pharmacy & Therapeutics Committee All of us at Coventry are working hard to improve the quality and safety of health care. One way we do this is by measuring how well we and others are doing. We also work with groups of doctors and other health professions. Our clinical activities and programs are based on guidelines. These come form the best, proven medical practices we can find. We also give our members and their health care providers the information and tools they need to make confident decisions. Again, our goal is to make health care even better.

2 Program Goals We aim to: Meet the health needs of all of our members, whatever their health care needs. Measure, monitor and improve the clinical care our members receive. We look at both quality and safety. Address racial and ethnic differences in health care. Come up with way to do our jobs even better. Make sure we obey all the rules, whether those rules come from plan employers, federal and state regulators, or accrediting groups. Help our clinical staff learn new skills. Make sure providers in our networks meet all of our standards. Program Scope We work to make our members care better by: Providing our members with clear information so they can make good decisions. Reviewing the health care services we cover and how care is coordinated. Encouraging providers to communicate with one another. Developing, carrying out and monitoring patient safety plans. Monitoring the effectiveness of our programs. Monitoring compliance with regulatory and accrediting body requirements including privacy laws. Reviewing key quality improvement activities, such as accessibility of our network providers, high volume diagnoses, and continuity and coordination of care. Annual compliance review of medical record documentation and access standards. Monitoring the overuse and underuse of services. Performing credentialing and re-credentialing activities. Assessing member and provider satisfaction. Providing direction on quality improvement initiatives. Ensuring practitioner participation in the QI program through planning, design, implementation or review. Reviewing the results of quality improvement activities to ensure performance meets standards, make recommendations for improvements to be carried out by sub-committees and suggest needed actions. Ensuring quality health care delivery at the most appropriate level of care in a timely, safe, effective and efficient manner for members. Monitoring and evaluating all HEDIS data, including the evaluation of HEDIS action plans, goals and benchmarks.

3 HEDIS What is HEDIS? HEDIS stands for Healthcare Effectiveness Data and Information Set. HEDIS was developed and is maintained by the National Committee for Quality Assurance (NCQA) whose vision is to transform health care quality through measurement, transparency, and accountability. HEDIS is the most widely-used set of performance measures in the managed care industry. It measures performance on the quality and effectiveness of health care and services to members. HEDIS 2013 is published across a number of volumes and includes 80 measures across five domains of care. This standardization allows for comparison between plans and regions. Part of NCQA accreditation scoring is determined by the results of the yearly HEDIS data collection. HEDIS results also assist in focusing on areas needing improvement so that health plan providers can continuously improve their clinical and customer services. Improvements were noted in the following measures: Measure CHCFL CHPFL Colorectal Cancer Screening Cervical Cancer Screening Chlamydia Screening Breast Cancer Screening Cholesterol Management after a Cardiac Event Adult Body Mass Index Assessment Controlling Blood Pressure Blood Pressure Control Diabetics LDL-C Control Diabetics LDL-C Screening - Diabetics HbA1c Testing Diabetics HbA1c Control Diabetics Monitoring Nephropathy Diabetics Eye Exams Diabetics Immunizations for Adolescents Childhood Immunization Status Persistence of Beta-Blocker Treatment after a Heart Attack Antidepressant Medication Management Follow Up Care for Children Prescribed ADHD Medication Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Pharmacy Management for COPD Exacerbation (Systemic Corticosteroid) Use of Spirometry Testing in Assessment & Diagnosis of COPD Medication Management for People with Asthma Follow Up after Hospitalization for Mental Illness Prenatal and Postpartum Care Appropriate Testing for Children with Pharyngitis Appropriate Treatment of Children with Upper Respiratory Infection Children and Adolescents Access to Primary Care Practitioners Well Child Visits in the First 15 months of Life

4 Well Child Visits in the Third, Fourth, Fifth and Sixth Years Adolescents Well Care Visits Rheumatoid Arthritis Management Weight Assessment & Counseling for Nutrition Use of Imaging Studies in Low Back Pain Adult Access to Preventive/Ambulatory Health Services Initiation and Engagement of Alcohol & Other Drug Dependence Treatment Satisfaction We asked members how satisfied they are with Coventry. Consumer Assessment of Health Plans Study (CAHPS) is a measure for member satisfaction that examines the percentage of members satisfied with the health plan. It empowers prospective members to benefit from the experience of others. This domain included a member health care survey, as well as other measures of members satisfaction. Overall levels of satisfaction provide a general indication of whether a health plan is meeting enrollee expectations. Coventry has implemented the NCQA HEDIS CAHPS 4.0H Membership Satisfaction Survey for reporting this measure on an annual basis. A random sample of all eligible members were selected and mailed the survey. Opportunities for improvement have been identified and we are developing initiatives to improve our satisfaction results in the future. The CHCFL survey revealed favorable satisfaction trends in the following Composite Scores: Personal Doctor Overall Rating Specialist Overall Rating How Well Doctors Communicate Shared Decision Making CHCFL Rating/Composite QC Average Health Plan Overall Rating 61.6% 56.1% 52.5% % Health Care Overall Rating 68.4% 75.0% 73.2% % Personal Doctor Overall Rating 79.8% 77.4% 79.5% % Specialist Overall Rating 76.8% 79.6% 83.6% 82.3% Getting Needed Care 84.8% 84.7% 84.7%+ 86.2% Getting Care Quickly 85.8% 83.0% 82.1%+ 86.5% How Well Doctors Communicate 90.0% 88.7% 94.9% 93.9% Health Plan Customer Service 81.9% 80.2% 79.5% % indicates a significant difference between the 2012 plan result and the 2011 plan result + Indicates a significant difference between the 2012 result and the 2011 QC average The CHPFL survey revealed favorable satisfaction trends in the following Composite Scores:

5 Personal Doctor Overall Rating Specialist Overall Rating Customer Service Operations CHPFL Rating/Composite QC Average Health Plan Overall Rating 52.9% 50.2% 46.3% % Health Care Overall Rating 60.8% 71.1% 64.3% % Personal Doctor Overall Rating 74.2% 74.0% 74.3% % Specialist Overall Rating 75.2% 74.6% 79.8% 82.3% Getting Needed Care 79.3% 81.2% 79.3% % Getting Care Quickly 77.3% 82.2% 77.7% % How Well Doctors Communicate 83.2% 78.7% 81.6% 83.9% Health Plan Customer Service 83.2% 78.7% 81.6% 83.9% indicates a significant difference between the 2012 plan result and the 2011 plan result + Indicates a significant difference between the 2012 result and the 2011 QC average The Florida plans also have a program to assess physician satisfaction with the service they receive. The overall satisfaction with the Health Plan increased. For the Primary Care survey, the plan s overall satisfaction rate increased by 4% o There was an increase in 36 of the 49 questions from the previous year o Claims Service gained a 10% improvement All the measures in the specialist survey resulted in an increase in the satisfaction rate, with some as high as an additional 10% or more: o Access to a Medical Director increased by 13% o Access to Appeals and Grievances Staff increased by 11% o Claims payment timeliness increased by 11%. Disease Management Coventry Disease Management Programs take a proactive approach in the identification and care of chronic illnesses through Disease Management (DM) programs. Contact is made with all members who have a condition/chronic disease: asthma, coronary artery disease (CAD), heart failure (HF), chronic obstructive pulmonary disease (COPD) and diabetes. Coventry connects with members through educational mailings or phone calls from health education associates. Members are identified for a disease management program through claims, self-referral, practitioner referral, pharmacy, and other sources. The ultimate goal of the program is to improve quality of life for our members. Some 2012 achievements include: Introduced Enhanced Case Management Program, to provide consistency in CM throughout Coventry and provide quality service to members and meet industry and accreditation standards. The Plan continues to offer Vital Decisions to all members to provide counseling on end of life issues.

6 Introduced Wound Care Program, to identify members, provide education, improve compliance with treatment plan, increase oversight of wound care vendors, decrease ER visit and improve overall management of wounds. Conducted Disease/Case Management Satisfaction Surveys in 2012 to assess the effectiveness of the CM/DM programs, due to a low response rate, effectiveness of the programs could not be accurately determined. Disease Management Performance measures were conducted as part of the overall HEDIS analysis of member compliance with preventive health guidelines and chronic condition management. Members continue to engage in Coventry offered Wellness On-line Programs and Employer sponsored wellness events and initiatives. Member satisfaction with the Corporate Disease Management Programs scored 90% or greater in both the Commercial and Medicare lines of business in the following programs: Asthma knowledge of health coach information given by the health coach program materials access to the program ease of understanding Coronary Artery Disease information given by the health coach program materials access to the program ease of understanding health improvement Diabetes better understanding overall satisfaction Case Management Coventry Health Care members have access to case management - a collaborative process between Coventry Health Care, the member and the provider. Our case management programs are designed to assess, plan, implement and evaluate services and resources required to meet the member s health care needs. The process aims to efficiently produce the highest quality outcomes and manage health care costs. The program is staffed by registered nurses to advocate for the member in the case management process. Coventry Health Care nurses are educated in health care management and service delivery and help our members smoothly navigate their health care by connecting them with resources and support within their respective communities. Our health plan nurses embrace cultural diversity and are well suited to assist members of any background. We require that Coventry Health Care nurses continue to expand their expertise

7 through professional development including certification, seminars and classes for continuing education and case management credits. Overall satisfaction with Coventry Health Care s case management services was at 96%. Measure CM 2011 EMC 2012 Increase/ Decrease Trend Was knowledgeable about your health care needs and condition. 82.0% 96% 14% Explained to you why you were contacted. 79.0% 96% 17% Shared information with you that was easy to understand. 82.0% 96% 14% Provided information that was helpful to your condition and health care needs. NA 96% NA NA Worked with you to set goals to better manage your health. NA 96% NA NA Assisted you in knowing when to call you r doctor. NA 96% NA NA Was easy to reach during normal business hours. NA 92% NA NA Was helpful to you overall. 82.0% 96% 14% The following questions for 2012 increased by 14% or greater in comparison to 2011: Was knowledgeable about your health care needs and condition Explained why you were contacted Shared information with you that was easy to understand Was helpful to you overall Additionally, 92% felt that the program had: Impacted their health status Helped them reach their personal goals Helped them better understand their health Access to Care and Service Coventry monitors access and availability of health care services to ensure we meet standards established by Coventry, federal and state regulators and state agency requirements, as it applies to our government business. Some accomplishments include: Customer Service representatives for the Commercial line of business met goals for call abandonment rate, average speed of answer and calls answered in 30 seconds. Exceeded plan goal for overall call accuracy, overall call quality, claims paid within 30 days and overall claims accuracy. The pharmacy call center consistently met goals for call abandonment rate and average speed of answer.

8 Office wait times showed compliance for Primary Care Physicians, OB/GYNs and Cardiologists. Utilization Decision and Consistency & Accuracy The Health Plan assures the accurate and consistent application of clinical tools by staff performing medical necessity review through Inter-rate reliability testing (IRR). This process ensures that all nurses are consistently applying the same criteria in each situation. IRR is an effective method for monitoring, tracking and validating that these tools are applied accurately and consistently when performing medical necessity reviews across all staff and clinical sites. Overall, the staff achieved the goal of 85% or higher on individual teats. Quality Improvement Projects Two Quality Improvement Activities (QIA) were in process in Access to Care Quality Improvement Activity (QIA) new The goal of this Performance Improvement Project is to improve the health of enrollees by increasing member education, promoting annual PCP visits that enhance the delivery of preventive care and recommended screenings in order to improve health outcomes. Baseline data was collected. Diabetes (QIA) ongoing Analysis of HEDIS outcomes identified several opportunities for improvement. The health plan provides comprehensive support for diabetes management by adopting and disseminating the American Diabetic Association, (ADA) guidelines, which serve as the cornerstone of the Diabetes Disease Management Program. Risk Management Program The plan has a specific Risk Management Program. Coventry has a Board appointed Licensed Healthcare Risk Manager responsible for administering the Risk Management Program. The Program identifies areas of loss, potential for loss and supports implementation of loss control techniques. Loss control techniques can include prompt reporting of member, employee and visitor incidents and trending of this data to identify areas for improvement. Annually, Coventry summarizes activities for the reporting year for each component of the Risk Management Program. The health plan had a successful audit outcome for its 2012 Risk Management Program activities. Patient Safety Coventry promotes patient safety through member education, monitoring and improving continuity and coordination of care, clinical guideline evaluation, tracking and trending adverse

9 events and member complaints. Coventry met this objective through its continual focus on patient safety activities. These activities include: Distribution of patient safety information to members via the member website Improvement of continuity and coordination of behavioral and medical health care to avoid miscommunication leading to poor outcomes Monitoring and investigation of adverse event reports to identify system issues that contribute to poor safety Analysis of complaint and member satisfaction data that relate to clinical safety and appropriate follow-up Credentialing Program Credentialing and re-credentialing activities are an integral part of assuring the quality of care provided by the network. Through this process CHCFL assures each practitioner meets minimum quality standards to participate in the network. Once the practitioner is credentialed, their quality is continually evaluated through clinical quality studies and a review of their practice patterns. Through this process, 3571 physicians and 256 facilities were credentialed / re-credentialed. Medical Record Keeping Coventry conducts audits of provider s medical records audits to: ensure that our providers maintain medical records in a manner that is current, detailed and organized in a confidential manner that supports safe and effective quality patient care identify medical record keeping practices of network provider offices enhance patient safety ensure medical record confidentiality provide education and offer identified best practices provide quality monitoring of providers for re-credentialing Coventry conducted a specific medical record audit in 2012 for Continuity and Coordination of Care PCP/Specialists to assess whether continuity and coordination of care standards between the PCP, hospitalists, and specialists were met. Continuity of Care (COC) is met when the outcomes of any member admissions, or specialist referrals, are noted in the patient s record. Improvement was noted in the number of summaries present in the medical records. Behavioral Health Care The plan s behavioral health vendors, MHNet for CHCFL and CHPFL and Psychcare for CHCLIC,

10 are engaged with coordination of care and medical integration activities. The behavioral health vendors continue to focus on continuity between themselves and the Health Plans. In 2012, the Behavioral Health Programs demonstrated achievements in: Treatment records containing evidence of appropriate documentation of diagnosis and evidence of appropriate documentation of treatment plans. (MHNet) Major Depression - number of members who attend an outpatient appointment within 90 days of intervention. (MHNet) Network Practitioner Satisfaction Survey. (Psychcare) Network Provider Patient Safety and Continuity and Coordination of Care. (Psychcare) Member inpatient psychiatric consultations ordered by attending medical physicians on medical units in acute care facilities. (Psychcare) Member psychiatric medication evaluations ordered by attending medical physicians in nursing homes and/or skilled nursing. (Psychcare) Additional Strengths and Accomplishments (MHNet) Improvement in access to care/telephone statistics with implementation of a new phone system that allows for enhanced quality and reporting Significant improvement of results in encouraging members to obtain conjoint therapy when being prescribed antipsychotic medications from their primary care physician Practitioner Treatment Record audits demonstrated superior quality with 97% compliance of MHNet s standards MHNet continue to provide a high volume of Value Added Services to improve the quality of care by facilitating open lines of communication with Physicians, Employer Groups, Health Plans and members. Significant improvement in OTR processing turn around time Increased resources dedicated to the Quality Improvement Department Accreditation Coventry promotes the importance of quality health care and takes pride in the steps needed to achieve accreditation. It is how we show our commitment to: Findings ways to always keep improving and ensuring quality health care Meeting expectations of healthcare in a timely, safe, effective and efficient manner for members Setting Coventry apart from other health plans The Florida Coventry plans are proud to have received accreditation by the Utilization Review Accreditation Commission (URAC) and is moving to pursue accreditation by the National Committee for Quality Assurance (NCQA) in You can obtain more information on accreditation at the respective websites, NCQA and URAC.

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