MercyCare HMO Quality Program Evaluation For 2009

Transcription

1 Quality Program Evaluation For September 2010

2 Table of Contents Executive Summary Introduction 4 National Recognition 4 Quality Performance-HEDIS 4 Quality Performance-CAHPS 4.0H 7 Quality Performance-Safety 8 Overall Summary 9 HEDIS Review and Analysis Antidepressant Medication Management Measure 10 Appropriate Testing for Children with Pharyngitis 12 Appropriate Treatment for Children with Upper Respiratory Infection 14 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 15 Breast Cancer Screening 16 Cervical Cancer Screening 18 Childhood Immunization Status 19 Cholesterol Management for Patients with Cardiovascular Disease (LDL 21 Screening Performed) Colorectal Cancer Screening 23 Comprehensive Diabetes Care Screening (HbA1c Testing, Eye Exams, 24 HbA1c Poor Control, LDL-C Screening, and Medical Attention for Nephropathy) Controlling High Blood Pressure 30 Prenatal and Postpartum Care 31 Use of Appropriate Medications for People with Asthma 34 Use of Imaging Studies for Low Back Pain 36 Flu Shots for Adults (50-64) 37 Use of Spirometry Testing in the Assessment and Diagnosis of COPD 38 Follow Up for Children Prescribed ADHD Medications 39 CAHPS 4.0H Review and Analysis Claims Processing Composite 40 Customer Service Composite 42 Getting Care Quickly Composite 43 Getting Needed Care Composite 45 How Well Doctors Communicate Composite 46 Rating of All Health Care 47 Rating of Health Plan 49 Rating of Personal Doctor 50 Rating of Specialist Seen Most Often 51 Monitoring Safety Education to Members 53 Adverse Events 53 Medical Record Audit September 2010

3 Site Visits 54 Member Complaint Review 54 Pharmacy Management 54 Continuity and Coordination of Care 54 Clinical Practice Guidelines 55 Electronic Medical Records 56 Safety Committee 56 Summary 56 Approvals September 2010

4 EXECUTIVE SUMMARY AND INTRODUCTION Introduction MercyCare Insurance Company (MercyCare or MCIC) is dedicated to providing high quality healthcare and personalized service to our members by continually seeking to improve health care quality, safety, availability and transparency in addition to improving our business practices in ways that increase member satisfaction with their healthcare and understanding of their insurance benefits. This evaluation will provide a detailed review of the overall effectiveness of our QI program by examining the following: HEDIS and CAHPS scores as compared to benchmarks Progress with quality initiatives Monitoring safety Summary of overall findings National Committee for Quality Assurance (NCQA) MercyCare has been NCQA accredited since As of this year s survey we have been rated as Excellent for three surveys in a row. NCQA publishes an annual overall rating of health plans in the US News and World Report. We were just notified that we rank 96 th out of approximately 250 ranked. This represents an improvement in ranking of ten points as we were rated 106 th last year. Quality Performance HEDIS Out of the 22 HEDIS 2010 clinical measures that contribute to our NCQA score, MercyCare was scored in 19. The three measures that we do not have a score listed for and the reasons are listed below: Measure Follow-Up After Hospitalization for Mental Illness Medical Assistance for Smoking Cessation (Advising Smokers to Quit Only) Persistence of Beta-Blocker Treatment After a Heart Attack Reason Not enough members in the denominator to be able to report Considered a first year measure since: (1) The measure was changed to include smokeless tobacco, (2) the denominator was revised to include smokers and tobacco users that were not seen by a practitioner, and (3) the question response choices were revised Not enough members in the denominator to be able to report Out of the 19 measures that MercyCare participated in, we could not demonstrate comparisons on 4 of them due to the following reasons: Measure Reason Use of Appropriate Medications for People with Asthma The age band was changed in 2010 Cervical Cancer Screening Changed from a hybrid measure to an administrative measure in September 2010

5 Follow-Up for Children Prescribed ADHD Medication Use of Spirometry Testing in the Assessment and Diagnosis of COPD There were not enough members in the denominator to report in 2009 There were not enough members in the denominator to report in 2009 For the 15 measures we were able to report on and able to demonstrate comparison, we were able to establish improvement in 6 (40%). The measures below contribute to our NCQA score. Bold print indicates those showing improvement over the prior year s score. Measure 2010 HEDIS Results Antidepressant Medication Management Measure Acute Phase Continuation Phase Increase or Decrease from 2009 HEDIS Percentile th -90 th th -90 th Appropriate Testing for Children with Pharyngitis th -90 th Appropriate Treatment for Children with Upper th -90 th Respiratory Infection Avoidance of Antibiotic Treatment in Adults with Above 90 th Acute Bronchitis Use of Appropriate Medications for People with Asthma Total Can t compare age band changed Below 50 th Ages Can t compare age Below 50 th band changed Ages 5-11 Too few eligible members to report Beta-Blocker Treatment After a Heart Attack Too few eligible members to report Breast Cancer Screening-Total th -75 th Cervical Cancer Screening Can t compare Below 50 th changed from hybrid to administrative Childhood Immunization Status Combo th -90 th Combo th -90 th Chlamydia Screening in Women Total Below 50 th Ages Below 50 th Ages th -75 th Cholesterol Management for Patients with Below 50th Cardiovascular Disease (LDL-C screening performed) Colorectal Cancer Screening th -90 th Comprehensive Diabetes Care LDL-C Screening Performed HgbA1c Testing Nephropathy Monitoring th -75 th th -75 th th -90 th Eye Exams th -90 th HbA1c Poorly Controlled th -90 th September 2010

6 Controlling High Blood Pressure th -75 th Follow-Up After Hospitalization for Mental Illness 7 Days Too few eligible members to report 30 Days Too few eligible members to report Follow-Up for Children Prescribed ADHD Medication Initiation Too few eligible Below 50 th members to report Continuation for 2009 Too few eligible members to report Medical Assistance with Smoking Cessation First year measure (Advising Smokers to Quit Only) Prenatal and Postpartum Care Timeliness of Prenatal Visits th -75 th Below 50 th Timeliness of Postpartum Care Use of Imaging Studies for Low Back Pain th -90 th Flu Shots for Adults (50-64) th -75 th Use of Spirometry Testing in the Assessment and Diagnosis of COPD Too few eligible members to report for 2009 Below is a breakdown of the percentile bands that each measure fell into: Below 50 th Below 50 th Percentile 50 th to 75 th Percentile 75 th to 90 th Percentile 90 th Percentile and Above Women s Health Postpartum Care Chlamydia Cervical Cancer Women s Health Prenatal Care Breast Cancer Diabetes Care Eye Exams HbA1c Poor Control Diabetic Nephropathy Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Use of Spirometry Testing in the Assessment and Diagnosis of COPD Diabetes Care LDL-C Screening HbA1c Testing Antidepressant Medication Acute Phase Continuation Phase Use of Appropriate Medications for People with Asthma Cholesterol Management for Patients with Cardiovascular Conditions- Screening Follow Up Care for Children Prescribed ADHD Medications Flu Shots for Adults Controlling High Blood Pressure Appropriate Treatment for Children with Upper Respiratory Infection Appropriate Testing for Children with Pharyngitis Colorectal Cancer Screening Childhood Immunization Status Use of Imaging Studies for Low Back Pain September 2010

7 Our goal is to have all measures at or above the 75 th percentile, and ultimately, have as many as possible over the 90 th percentile. We now have quality improvement activities relating to most of the above measures and will continue to expand the scope of our activities as much as possible with current staffing. CAHPS CAHPS scores are a result of surveys sent out in the spring to assess members satisfaction with MercyCare from the prior year. Results summarize member experiences through ratings, related to five composite scores (composite scores are made up of several questions) and four overall ratings of consumer experience: Composite Scores Claims Processing Customer Service Getting Care Quickly Getting Needed Care How Well Doctors Communicate Overall Ratings Rating of All Health Care Rating of Health Plan Rating of Personal Doctor Rating of Specialist Seen Most Often The results of these CAHPS questions are also factored into our NCQA score. MercyCare demonstrated improvement in 7 of the 9 CAHPS 4.0H survey items. Those items that did show improvement are identified as bolded in the table below. Survey Item 2010 Results Increase or Percentile Decrease from 2009 Results Claims Processing Composite Below 50 th Customer Service Composite th -75 th Getting Care Quickly Composite Below 50 th Getting Needed Care Composite Below 50 th How Well Doctors Communicate Composite Below 50 th Rating of All Health Care Below 50 th Rating of Health Plan th -75 th September 2010

8 Rating of Personal Doctor th -75 th Rating of Specialist Seen Most Often th -75 th Below is a breakdown of the percentile bands that each measure fell into: Below 50th Percentile Claims Processing Composite 50th to 75th Percentile Customer Service Composite Getting Care Quickly Composite Rating of Health Plan Getting Needed Care Composite Rating of Personal Doctor How Well Doctors Communicate Composite Rating of Specialist Seen Most Often The interventions to date have had some impact as indicated above where 7 of the 9 composites and/or experience ratings showed improvement. MercyCare s 3 year trend indicated improvement in all composites and/or patient experience questions. Moving forward, we will continue to work to improve our member s perception of our health plan by increasing direct communications with our membership to promote, the positive aspects of our plan, including MercyCare accessibility standards, our commitment to quality and our commitment to getting the care that they need. Safety The safety of our members is of the utmost importance. Our commitment to ensuring safety is addressed in the following ways: Safety Mechanism Providing education to our members Monitoring adverse events Medical record audit Site visits Member complaint review Pharmacy management Description The MercyCare website provides members with information regarding WI CheckPoint, a site sponsored by the Wisconsin Hospital Association in partnership with the State of Wisconsin. We also encourage improved patient-physician communication through the Ask Me 3 website. We educate our members regarding the importance of electronic medical records and notify of their rights and responsibilities, along with additional quality and safety resources. MercyCare identifies possible quality issues during all health plan activities such as member complaints, hospital reviews, or case management. Potential quality issues are referred to a peer review process. MercyCare audits medical records to ensure practitioners are keeping with organizational standards for documentation, confidentiality and availability of medical records. Prior to a site being credentialed, the provider site is reviewed to ensure the site is in compliance with our safety requirements. Member complaints are reviewed routinely to identify complaints related to quality of care, accessibility, and availability. MercyCare implements prior authorization processes and quantity limits on specific drugs to prevent over-utilization, ensure appropriateness of September 2010

9 Continuity and coordination of care Clinical Practice Guidelines Electronic Medical Records Safety Improvement Committee medications, identify poly-pharmacy issues, identify abuse of narcotics, and reduce the exposure of members to new medications with uncertain sideeffects. MercyCare reviews psychiatric admission to make certain the psychiatric discharge summary is sent to the members primary care physician. MercyCare intervenes when possible to ensure the summary is sent. MercyCare has clinical practice guidelines in place to ensure the care members are receiving is in keeping with the latest standards and to assist members with making decisions related to their health. These guidelines are available to all physicians and members. MercyCare encourages the use of electronic medical records. Mercy Health System has a timeline in place to implement electronic medical records (EMR) at all sites. Implementation of the EMR will allow practitioners to share information more efficiently and reduce handwritten medical errors. This committee is responsible for reviewing and comparing results of our network hospitals as published by WI CheckPoint. We will interact with our hospitals to encourage appropriate quality improvement efforts when needed. The ability to access comparative results via WI CheckPoint is on our website. Overall Summary and Planning MercyCare continues to exhibit progress in quality measures and customer service as evidenced by the improvement in our overall national ranking. We will continue to maintain our current quality task forces to serve as improvement forums to identify barriers and implement specific interventions. We have analyzed several HEDIS measures and have determined that implementation of administrative databases to identify every optional exclusion allowed by NCQA is worth the effort and should have a positive impact on our measures going forward. In regards to CAHPS, one of our challenges continues to be to change the perception that our members have of the health plan and services. We will work to do this through our website, member newsletters, and annual mailings to members September 2010

10 Report and Analysis The following report and analysis reviews HEDIS 2010 data that contribute to our NCQA score including interventions completed in 2009 to September The report does not include data for the measures beta-blocker treatment after a heart attack and follow up after hospitalization for mental illness since there was not enough data to report. Medical Assistance for Smoking Cessation (Advising Smokers to Quit Only) also is not included since it is considered a first year measure. Measure Antidepressant Medication Management The percentage of members 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported. Effective Acute Phase Treatment. The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 84 days (12 weeks). Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 180 days (6 months). Quality Improvement Activities and Interventions for Acute Phase and Continuation Phase Treatment October 2009-September 2010 The Depression Case Management Program is reviewed at the Depression Task Force The depression case management program is designed and managed by a registered nurse The depression case manager provides telephonic case management to those members with a diagnosis of depression and/or newly started on an antidepressant, who opt in The depression case manager works with members and their providers to coordinate care and educate on antidepressant use and length of treatment Reworked the data pull that identifies members for the case management program to more closely match those in the HEDIS measure The depression case manager provides educational materials to members and physicians regarding depression treatment and reinforces the physician treatment plan Reviewed and analyzed the measure at the Depression Task Force and the Behavioral Health Advisory Committee Physicians need to ask the right questions when starting a patient on an antidepressant to improve compliance Members need more education on antidepressant use (side effects; length of time to be effective) Patients discontinue medication without consulting their provider More intensive case management is needed to promote medication compliance More direct communication with the primary care physician Perceived stigma regarding taking antidepressants September 2010

11 Quantitative Analysis Antidepressant Medication Management Measure-Acute Phase Treatment Dean Health Plan Goal-90 th percentile 70.08% Remained between the 75 th and 90 th percentile from 2009 to 2010 Below the State HMO average (66.50) 3.79 points above primary regional competitor 3-year trend demonstrates a 5.46 point gain The three-year trend continues to indicate significant improvement, placing MercyCare closer to the 90 th percentile. The data above shows that MercyCare has continued to establish improvement in this sub-measure since It is evident that the depression case management program does have an impact on keeping members on their antidepressants for recommended treatment lengths. MercyCare will continue to work with members on antidepressants to provide education on their medications and encourage treatment plan compliance September 2010

12 Quantitative Analysis Antidepressant Medication Management Measure-Continuation Phase Dean Health Plan Goal-90 th percentile 54.55% Declined from above the 90 th percentile in 2009 to between the 75 th and 90 th percentile in 2010 Above State HMO average (48.36) 2.97 points above primary regional competitor 3-year trend demonstrates a.64 point gain This most recent HEDIS data evidences a 3.97% decline dropping us below the 90 th percentile. It is difficult to assess the most recent decline when there has been continual improvement since Economic factors could have played a role in this most recent decrease preventing members from filling their prescriptions. Measure Appropriate Testing for Children With Pharyngitis (CWP) The percentage of children 2 18 years of age who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing). Quality Improvement Activities and Interventions for October 2009-September 2010 Reviewed HEDIS 2010 potential misses to determine reasons why it was a non-hit Identified which clinics are not billing for attained strep tests or not providing correct coding September 2010

13 Worked with clinics to correct billing Implemented an epic report that identifies members each month that were diagnosed with pharyngitis. That visit is then reviewed to identify whether or not the member received appropriate treatment. For those physicians who gave a sole diagnosis of pharyngitis, prescribed an antibiotic, but did not obtain a strep test, a letter is sent to them from the medical director indicating inappropriate treatment Will continue to review potential misses on a regular basis Performed provider rate comparison of misses Began working with clinics to provide orientation to nurse practitioners and physician assistants on quality measures Sent letters to practitioners who had 5 or more misses notifying them of their results and of current practice guidelines Providers and members will be notified of MercyCare s 2010 HEDIS results in their annual notices Met with clinic manager of the urgent care site that accounted for the largest portion of the misses Labs are not billed by provider sites for strep tests Visits are not being coded correctly Practitioners making the diagnosis based on clinical exam only Quantitative Analysis Appropriate Testing for Children with Pharyngitis Dean Health Plan Goal-90 th percentile 88.7% Declined from above the 90 th percentile in 2009 to the 75 th percentile in September 2010

14 Above State HMO average (82.15) 7.28 points above primary regional competitor 3-year trend demonstrates a point gain MercyCare s 2010 data indicated a 3.28% decline from the prior year s results. Analysis of the data looking at provider trends, revealed that a significant portion of the misses came from one of our urgent care sites. Our Quality Improvement Specialists met with the manager of that clinic to review results and the details of this measure. Appropriate Treatment for Children With Upper Respiratory Infection (URI) Measure The percentage of children 3 months 18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription. Quality Improvement Activities and Interventions for October 2009-September 2010 Potential non-hits were reviewed to identify a cause or trend This measure was presented at the Quality Utilization Management Committee for review and analysis, that includes Dr. Mark Goelzer and Dr. Keith Konkol Worked with coders to correct errors Not all diagnoses are coded Practitioners give the parent an antibiotic script to be filled if the patient is not feeling better in the next couple of days Practitioners prescribing antibiotics for viral infections Member s parent calls the practitioner s office a few days after the visit indicating symptoms are worse so a prescription is called in over the phone September 2010

15 Quantitative Analysis Appropriate Treatment for Children with Upper Respiratory Infection Dean Health Plan Goal-90 th percentile Declined from above the 90 th percentile in 2009 to just below the 90 th percentile in 2010 Above State HMO average (89.52) 1.51 points above primary regional competitor 3-year trend demonstrates a 3.43 point gain Although there was a decrease of 2.54% from 2009 to 2010, chart review of the potential nonhits is beneficial. MercyCare will continue to review non-hits and work with coding to correct errors when possible. Measure Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis The percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. Quality Improvement Activities and Interventions for October 2009-September 2010 Chart review of potential non-hits. This measure was presented at the Quality Utilization Management Committee for review and analysis, which includes Dr. Mark Goelzer and Dr. Keith Konkol. Not all diagnoses codes are added September 2010

16 Practitioners prescribing antibiotics for bronchitis Co-morbid conditions that may have excluded the member from the measure, are documented under past medical history but not up to date so the diagnosis code cannot be added. Quantitative Analysis Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis Dean Health Goal-90 th percentile Remained above the 90 th percentile from 2009 to 2010 Above State HMO average (33.96) points above primary regional competitor 3 year trend demonstrates a 7.26 point gain Even though national percentile rankings have shown a decline over the past year of data, MercyCare was able to stay pretty consistent with last year s results. Review of potential nonhits to determine coding errors continues to be beneficial. Chart review also indicated physicians are not routinely prescribing antibiotics for bronchitis. MercyCare will continue to review charts and work with coders when needed. Measure Breast Cancer Screening (BCS) The percentage of women years of age who had a mammogram to screen for breast cancer during the measurement year or the year prior, excluding those members who have had a bilateral mastectomy September 2010

17 Quality Improvement Activities and Interventions for October 2009-September 2010 Sent letters to member s in the above age range who had not had a screening mammogram in the past 2 years (women who had had a bilateral mastectomy were excluded) along with educational information and a listing of mammography sites. Women not scheduling mammograms Women not routinely seeing gynecology or primary care Women not obtaining well woman exams No database to include optional exclusions Quantitative Analysis Breast Cancer Screening Dean Health Goal-90 th percentile Remained from between the 50 th to 75 th percentile from 2009 to 2010 Below the State HMO average (77.89) 4.35 points below primary regional competitor 3 year trend indicates a 2.59 point decrease This measure continued to remain constant from 2009 to MercyCare is in the process of implementing an administrative database that should allow us to see improvement in our numbers. The database will contain members that have had a bilateral mastectomy and will be able to be submitted as exclusions September 2010

18 Measure Cervical Cancer Screening (CCS) The percentage of women years of age who received one or more Pap tests to screen for cervical cancer within the measurement year or two years prior. Quality Improvement Activities and Interventions for October 2009-September 2010 Letters sent to members who had not had a pap test within the measurement year or two years prior to encourage them to schedule one. Educational inserts on cervical cancer sent to members who had not had a pap test. Women are not scheduling well woman exams Practitioners not including the cervical cancer screen in their well woman exams No database to include optional exclusions Quantitative Analysis Cervical Cancer Screening Dean Health Plan Goal-90 th percentile 81.58% Cannot compare to 2009 since the measure was changed from a hybrid measure to an administrative measure Below State HMO average (80.36) 6.45 points below primary regional competitor Unable to perform 3 year trend since the measure changed from a hybrid measure to an administrative measure in September 2010

19 Most recent data places MercyCare below the 50 th percentile. This result is probably largely due to the fact that the measure changed from a hybrid measure to an administrative measure. Quality Improvement is currently reviewing potential 2011 HEDIS misses to identify whether or not the member has had a total or vaginal hysterectomy. Data for those that have had a total or vaginal hysterectomy will then be placed in an administrative database that is currently under development. Current review has identified several hysterectomies thus far that can be used as exclusions. Implementations of this database will place MercyCare much closer to our goal of the 90 th percentile. Childhood Immunizations Status Combo Measure The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one measles, mumps and rubella (MMR); two H influenza type B (HiB); three hepatitis B (HepB), one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates. Quality Improvement Activities and Interventions for October 2009-September 2010 One on one telephonic and/or written communication with provider and member Participates in the Wisconsin Immunization Registry (WIR) Assure newly recommended vaccines are covered in the benefit plan by reviewing at the Benefits Interpretation Committee (BIC) Reviews members that are identified as not current with their immunizations and works to correct Quality Improvement department working with clinic managers Began receiving data earlier and implemented a 3 rd data pull Reviewing data earlier to allow more time for MercyCare and clinic interventions Children are missing their 15 and/or 18-month well child visit Parental refusals Staffing shortages at MercyCare and Mercy Clinic East Children scheduled for their immunizations after their second birthday Quantitative Analysis September 2010

20 Childhood Immunization Status-Combo Dean Health Plan Goal-90 th percentile 84.26% Improved from between the 50 th and 75 th percentile in 2009 to between the 75 th and 90 th percentile in 2010 Above the State HMO average (81.73) 2.79 points above primary regional competitor 3-year trend demonstrates a 8.86 point loss September 2010

21 Childhood Immunization Status-Combo Dean Health Goal-90 th percentile 81.48% Improved from between the 50 th and 75 th percentile in 2009 to between the 75 th and 90 th percentile in 2010 Above State HMO average (79.30) 3.6 points above primary regional competitor 3 year trend indicates 9.01 point loss The three-year trend for the combo 2 and 3 continues to indicate a sizeable drop even though a slight improvement did occur between 2009 and MercyCare currently is represented at Clinic Management meetings where this measure and barriers have been reviewed and discussed. This representation along with earlier review should allow for greater improvement. MercyCare will continue to work with clinics to be more proactive in scheduling immunizations timely. Measure Cholesterol Management for Patients with Cardiovascular Disease (LDL-C Screening Performed) The percentage of members years of age who were discharged alive for AMI, coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) from January 1 November 1 of the year prior to the measurement year, or who had a diagnosis of September 2010

22 ischemic vascular disease (IVD) during the measurement year and the year prior to measurement year, who had each of the following during the measurement year. LDL-C screening Quality Improvement Activities and Interventions for October 2009-September 2010 Healthy heart case management program for cardiovascular health addressing cardiovascular risk factors, identifiable causes, co-morbidities, medication compliance, therapeutic lifestyle changes, and overall improvement of the member s health. Selected members who meet criteria are in telephonic case management Helps members determine what changes they are ready to make Member does not understand risk factors Member does not follow up with their physician Need for physician reminders to patients for screenings Quantitative Analysis Cholesterol Management for Patients with Cardiovascular Conditions-Screening Dean Health Goal-90 th percentile Declined from between the 50 th and 75 th percentile in 2009 to below the 50 th percentile in 2010 Below State HMO average (90.21) 2.02 points below national regional competitor 3 year trend indicates a 3.26 point gain September 2010

23 While our three year trend indicates improvement, MercyCare experienced a 3.25% decline from 2009 to The current case manager splits time between this and the asthma case management program. More time may need to be devoted to the healthy heart program. Measure Colorectal Cancer Screening The percentage of members years of age who had appropriate screening for colorectal cancer. Quality Improvement Activities and Interventions for October 2009-September 2010 Send letters to members over 50 who have not had appropriate screening for colorectal cancer offering an at home fecal occult blood test (FOBT) Send FOBT kits to members who request them FOBT results are sent from the lab to the physician through electronic medical records Member does not schedule screening Member does not return ifobt request form Member not educated on what screenings are needed and the timeframes No database to include optional exclusions Quantitative Analysis Colorectal Cancer Screening Dean Health September 2010

24 Goal-90 th percentile Remained between the 75 th to 90 th from 2009 to 2010 Above State HMO average (66.64) 4.02 points above primary regional competitor 3-year trend demonstrates a 4.86 point gain Although national percentiles increased from 2009 to 2010, MercyCare and our primary regional competitor remained stagnate, broadening our gap between the 2010 results and our goal of the 90 th percentile. MercyCare will continue to communicate screening opportunities to members and work with members and Mercy lab on test results that were inaccurate. Measure Comprehensive Diabetes Care The percentage of members years of age with diabetes (type 1 and type 2) who had each of the following. Hemoglobin A1c (HbA1c) testing HbA1c poor control (>9.0%) HbA1c control (<8.0%) HbA1c control (<7.0%) * Eye exam (retinal) performed LDL-C screening LDL-C control (<100 mg/dl) Medical attention for nephropathy BP control (<130/80 mm Hg) BP control (<140/90 mm Hg) The sub measures analyzed below are those that are part of our NCQA score. Hemoglobin A1c (HbA1c) Testing Quality Improvement Activities and Interventions for October 2009-September 2010 Process and program continually reviewed and updated in the Diabetes Health Management Task Force, Tim Reid, MD, physician advisor and Steven Bartz, MD, physician advisor. Telephonic diabetic case management program managed by a certified case manager, RN, and certified diabetic educator Annual physician performance comparative profiles using HEDIS data Quarterly query for members who have not had an A1c, eye exam, or LDL test in the last 9 months Letters sent to those identified in the above query and to physician Letters sent include LDL and nephropathy verbiage Member timeliness of obtaining lab work Economic factors may decrease screening frequency September 2010

25 Physicians are not ordering the lab work Timeliness of ordering lab work Quantitative Analysis Comprehensive Diabetes Care-HbA1c Testing Dean Health Plan Goal-90 th percentile Remained between the 50 th to 75 th percentile from 2009 to 2010 Below State HMO average (92.16).34 points below primary regional competitor 3-year trend demonstrates a.17 point loss The 3-year trend indicates that this measure has remained somewhat stagnate. Chart review continues to indicate that physicians are not ordering lab work on a timely basis. MercyCare will continue to case manage this population and inform physicians when their members are missing their lab work. Eye Examination Quality Improvement Activities and Interventions for October 2009-September 2010 Process and program continually reviewed and updated in the Diabetes Health Management Task Force, Tim Reid, MD, physician advisor and Steven Bartz, MD, physician advisor Quarterly notification to members of missing eye exams Quarterly letters sent to PCPs notifying them of the tests their patients are missing (A1c, LDL, REE) Eye care communication form used for members to take to their eye care provider September 2010

26 General Motors vision benefit is a separate benefit utilizing non-plan providers therefore, MercyCare does not get a claim Patient understanding of the importance of eye exams Member lack of knowledge Quantitative Analysis Comprehensive Diabetes Care-Eye Exams Dean Health Plan Goal-90 th percentile Remained between the 75 th to 90 th percentile from 2009 to 2010 Below State HMO average (70.98).31 points below primary regional competitor 3-year trend demonstrates a 1.00 point gain MercyCare did show slight improvement over last years results as did national percentiles. Members continue to fail to schedule needed tests. Financial constraints and economic factors may contribute missed exams. This measure will continue to be part of the case management program and reviewed at the Diabetes Task Force. HbA1c Poor Control (>9.0%) Quality Improvement Activities and Interventions for October 2009-September 2010 Process and program continually reviewed and updated in the Diabetes Health Management Task Force, Tim Reid, MD, physician advisor, and Steven Bartz, MD, physician advisor September 2010

27 Telephonic case management program managed by a certified case manager, RN, and certified diabetic educator Annual physician performance comparative profiles using HEDIS data Physician and member notification mailings for those members who have not had an A1c in the last 9 months Telephonic case management goal increased to calls every 2 months for all members with a HbA1c 8.5 Targeted educational member mailings for those members that were unreachable by phone Cost of tests Not filling medications due to financial constraints Physicians are not ordering the lab work Timeliness of ordering lab work Quantitative Analysis-(Reverse Measure) Comprehensive Diabtes Care-HbA1c-Poor Control Dean Health Plan Goal-90 th percentile Remained between the 75 th and 90 th percentile from 2009 to 2010 Below the State HMO average (21.31) 1.78 points below primary regional competitor 3-year trend demonstrates a 6.2 point decrease MercyCare continues to see a significant increase in the number of members that have been identified as having poor control. Again financial and economic factors may be contributing to September 2010

28 poor scores. The diabetes case manager will continue to case manage this population and review data at the Diabetes Task Force. LDL-C Screening Performed Quality Improvement Activities and Interventions for October 2009-September 2010 Process and program continually reviewed and updated in the Diabetes Health Management Task Force, Tim Reid, MD, physician advisor, and Steven Bartz, MD, physician advisor Telephonic case management program managed by a certified case manager, RN, and certified diabetic educator Annual physician performance comparative profiles using HEDIS data Quarterly member notification mailings of members who have not had their screening in the last 9 months Quarterly letters sent to PCPs notifying them of the tests their patients are missing (A1c, LDL, REE) Timeliness of physicians ordering lab work Economic factors may be decreasing screening frequency Quantitative Analysis Comprehensive Diabetes Care LDL-C Screening Dean Health Plan Goal-90 th percentile Remained between the 50 th and 75 th percentile from 2009 to 2010 Below State HMO average (86.91).73 points below primary regional competitor September 2010

29 3 year trend indicates a.84 point gain MercyCare did see slight improvement in this measure similar to those seen in the national percentiles. Chart review continues to indicate physicians are not ordering lab work. The diabetes case manager will continue to case manage this population and notify physicians of missing lab work. Medical Attention for Nephropathy Quality Improvement Activities and Interventions for October 2009-September 2010 Process and program continually reviewed and updated in the Diabetes Health Management Task Force, Tim Reid, MD, physician advisor, and Steven Bartz, MD, physician advisor Telephonic case management program managed by a certified case manager, RN, certified diabetic educator Annual physician performance comparative profiles using HEDIS data Sent letters to physicians if member s egfr is less than 60 and not on an ACE or an ARB Timeliness of physicians ordering lab work Physician resistance to ordering an ACE or ARB as prevention Members seeing physician, but the physician is not obtaining the lab work Quantitative Analysis Comprehensive Diabetes Care-Monitoring Diabetic Nephropathy Dean Health Plan Goal-90 th percentile Improved from between the 50 th and 75 th in 2009 to between 75 th and 90 th percentile in 2010 Below State HMO average (88.19) September 2010

30 1.70 points below primary regional competitor 3 year trend indicates a 3.1 point gain MercyCare s 3-year trend does show improvement of this measure. MercyCare will continue to case management this population and review this data at the Diabetes Task Force. Measure Controlling High Blood Pressure (CBP) The percentage of members years of age who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90) during the measurement year. Quality Improvement Activities and Interventions for October 2009-September 2010 Heart healthy case management program for patients that meet specific criteria Telephonic case management to those that are in the heart healthy case management program Work place screenings for larger employee groups Implemented an epic report that identifies members that have seen their physician and have a systolic rating over 140 or a diastolic rating over 90. Physicians who saw that member receive a letter reminding them of the HEDIS standard. Physician variation on treatment, monitoring, and diagnosis Resource availability for chart review activities to determine control Access to employee demographic information for case management follow up activities Identified incorrectly into measure Patient resistance to medication treatment Quantitative Analysis Controlling High Blood Pressure Dean Health Plan September 2010

31 Goal-90 th percentile 72.68% Improved from below the 50 th percentile in 2009 to between the 50 th and 75 th percentile in 2010 Above the State HMO average (67.61).96 points above primary regional competitor 3 year trend indicates a 5.5 point gain MercyCare has shown positive improvement since 2007 with a more distinct increase between 2009 and MercyCare will continue to impact this measure through case management and the use of epic reports. Measure Prenatal and Postpartum Care (PPC) The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the following facets of prenatal and postpartum care. Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization. Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. Quality Improvement Activities (Prenatal Care) and Interventions for October September 2010 Main provider continues to manage their scheduling system to allow more time slots for prenatal appointments Main provider transfers from reception to the physicians nurse if an appointment is not available Appointment accessibility Patient waits to make an appointment Patient does not obtain prenatal care September 2010

32 Quantitative Analysis Timeliness of Prenatal Care Dean Health Plan Goal-90 th percentile 97.58% Remained between the 50 th and 75 th percentile from 2009 to 2010 Below State HMO average (94.47) 4.42 points above primary regional competitor 3-year trend demonstrates a 1.26 decrease MercyCare continues to remain just below the 75 th percentile and 3.14 points below our goal of the 90 th percentile. MercyCare will continue to report this measure and make our results available to our members and providers. Quality Improvement Activities (Postpartum Care) and Interventions for October September 2010 Letters sent to members after delivery reminding members to schedule their follow up appointment within days of delivery Main hospital s discharge instruction sheet has a section to record their follow up appointment Main hospital calls members within 72 hours of delivery and verifies whether or not they have scheduled their 6-week postpartum visit Main practice site has a process in place to schedule the patient s postpartum appointment during a routine prenatal appointment Follow up appointments for scheduled c-sections and inductions are made at the time the clinic is scheduling their procedure Reviewed HEDIS misses to identify practitioner trends September 2010

33 Met with new OB team lead and director to review this measure Members not attending their follow up appointments Members do not schedule follow up appointments Postpartum visit is not scheduled prior to delivery C-section patients perceive their 2 week post-op visit as their postpartum visit Appointment accessibility Quantitative Analysis Timeliness of Postpartum Care Dean Health Plan Goal-90 th percentile Remained below the 50 th percentile from 2009 to 2010 Below the State HMO average (87.31) 5.51 points below primary regional competitor 3-year trend demonstrates an point gain MercyCare s 3 year trend indicates significant improvement of over 11 points suggesting that interventions with our main provider site have had a positive impact. MercyCare will continue to collaborate with practitioners when needed, and make information regarding this measure available to members and providers September 2010

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35 Quantitative Analysis Use of Appropriate Medication for People with Asthma-Total Dean Health Plan Goal-90 th percentile Cannot compare to prior years data since the age bands changed in 2010 Below State HMO average (93.60) 1.06 points below primary regional competitor Unable to perform 3 year trend since the age bands changed in Data from 2010 places MercyCare below the 50 th percentile and below the state average. Moving forward MercyCare is working with the ED/urgent care providers to prescribe an asthma controller medication when a rescue inhaler is prescribed. MercyCare has also expanded its ED/urgent care/ inpatient report to include not only Mercy Health System providers, but also all MercyCare providers. The case manager is currently working on a one page asthma guideline for all primary care physicians to encourage appropriate utilization of ICS inhalers. This measure will continue to be a large part of the asthma case management program and be reviewed at the Asthma Task Force September 2010

36 Use of Imaging Studies for Low Back Pain Measure The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. Quality Improvement Activities and Interventions for October 2009-September 2010 Prior authorizations for MRI requests. Prior authorization requirement resulting in frequent educational communications between the medical director and physicians. Patient requests scan PCPs request early scanning for diagnostic reasons when evidence based guidelines recommend conservative care before scanning Quantitative Analysis Use of Imaging Studies for Low Back Pain Dean Health Goal-90 th percentile 80.90% Declined from above the 90 th percentile in 2009 to the 75 th percentile in 2010 Below State HMO average (78.12) 2.7 points below primary regional competitor 3-year trend demonstrates a.49 point decrease September 2010

37 MercyCare data indicated a sharp decline of 6.23% from 2009 to This decrease could be attributed to removing the prior authorization process for specialists. Flu Shots for Adults (50-64) Measure A rolling average represents the percentage of members years of age who received an influenza vaccination between September 1 of the measurement year and the date on which the CAHPS 4.0H adult survey was completed. Quality Improvement Activities and Interventions for October 2009-September 2010 None Members do not want a vaccination Members are unaware vaccination recommendations Quantitative Analysis Flu Shots for Adults Ages Dean Health Goal-90 th percentile 60% Remained below the 50 th percentile from 2009 to 2010 Below State HMO average (56.16) September 2010

38 2 points below primary regional competitor 3-year trend demonstrates a 6.58 point increase Although the 3-year trend indicates a substantial increase, MercyCare still remains below our goal and below that of the state average. Moving forward we will remind physicians of the CDC recommendations that everyone over 6 months receive the flu shot. Member education also needs to be made available. Use of Spirometry Testing in the Assessment and Diagnosis of COPD Measure The percentage of members 40 years of age and older with a new diagnosis or newly active COPD who received appropriate spirometry testing to confirm the diagnosis. Quality Improvement Activities and Interventions for October 2009-September 2010 None Physicians do not review this as a high priority standard. Quantitative Analysis Use of Spirometry Testing in the Assessment and Diagnosis of COPD Dean Health Goal-90 th percentile 48.12% September 2010

39 Cannot compare to prior years data since we did not have a large enough denominator to report in 2009 Below State HMO average (42.62) 3.25 points above primary regional competitor Cannot perform 3 year trend since we were unable to report in 2009 MercyCare has not always had enough members to report data for this measure, so interventions were not implemented. Moving forward, MercyCare will educate physicians on this measure. Follow-Up for Children Prescribed ADHD Medication Measure The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who have at least three follow-up care visits within a 10-month period, one of which is within 30 days of when the first ADHD medication was dispensed. Two rates are reported. 1. Initiation Phase. The percentage of members 6 12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase. 2. Continuation and Maintenance (C&M) Phase. The percentage of members 6 12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. Quality Improvement Activities and Interventions for October 2009-September 2010 Education sent to providers indicating the methodology behind the measure and referencing the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry guidelines which support recommendations for routine follow up visits. Weekly report run that identifies members age 6-12 newly started on an ADHD medication. Those members are then reviewed to identify whether or not they have an appointment scheduled within 30 days. If an appointment is not scheduled a letter is sent to the prescribing practitioner requesting that they schedule an appointment. Members do not schedule appointments Pediatricians do not agree with follow up recommendations Psychiatric appointment accessibility Quantitative Analysis There is no data to report for the continuation phase since there were not enough members in the denominator September 2010