National Quality Management and Measurement

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1 Policy - QM 07 National Quality Management and Measurement Subject Member Access to Practitioners and Member Services Issue Date: Effective Date: 05/28/2010 Originating Dept. National Quality Management and Measurement Approved Applies to 1 : HMO products PPO products Date: Signed original on file in National Quality Management and Measurement Signature Authority: Andrew Baskins, MD National Medical Director, Quality and Provider Performance M t Medicare Advantage HMO Type: New Revision Replacement Medicare Advantage PPO Aetna Golden Medicare Dual Advantage Plan (SNP) Medicare Advantage Private Fee For Service Related Communications Participation Criteria: Primary Care Physician Participation Criteria Schedule Specialty Physician Participation Criteria Schedule Office Assessment Policy QM 55 Aetna Behavioral Health Contractor Standards Manual HMO Aetna Behavioral Health Contractor Standards Manual - PPO Purpose: To define the standards for practitioner appointment accessibility. To define the standards for member access to the Aetna Member Service Department. To define standards for member access to the centralized triage department of Aetna Behavioral Health. To define standards for behavioral health practitioner appointment accessibility. To establish a mechanism for monitoring, evaluating, and managing member access to practitioners and member services. 1 More stringent state requirements supersede these requirements. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 1 of 17

2 Policy QM 07 Background: A member s ability to obtain a healthcare appointment with a participating practitioner within a reasonable time period is an important driver of member satisfaction with the health plan. Appropriate wait time varies according to the type of care situation (i.e., urgent, emergent or routine care). Access to care is contingent on access to participating practitioners both during and outside of normal business hours. Members may access a behavioral health care contractor/practitioner in four ways: through a referral from the primary care physician, through a referral from employee assistance (EAP), through a student assistance provider (SAP), or through direct access by the member. No referral from the PCP is needed. Definitions: Members have access to assistance with their plan benefits and services by calling the toll-free Member Services telephone number listed on the member s health plan identification card. Accessibility: The extent to which a patient can obtain available services when they are needed. Services refers to both telephone access and ease of scheduling an appointment if applicable. (Source: NCQA 2010 Standards and Guidelines for the Accreditation of Health Plans, Glossary) Average Speed of Answer (ASA): the total number of seconds to answer every call. (the time between when a call is accepted into the service representative s queue and when it is answered by a service representative divided by the total number of calls.) Behavioral Health Practitioner: An independent practitioner who is duly licensed or certified and recognized under state law, and who is contracted to provide mental health or chemical dependency services to Aetna members. Examples of such practitioners include but are not limited to: psychiatrists, psychologists, social workers, and certified addiction counselors. Call Abandonment Rate (AR): The number of Member Service calls not answered (abandoned or hung up) divided by the total number of calls that reach the queue. Non-Life-Threatening Behavioral Health Emergency: A non-life-threatening emergency exists when the Member has a condition that requires rapid intervention to prevent acute deterioration of the member's clinical condition. Preventive Care: Well child examinations, routine wellness examinations or health screenings. Participation Criteria: Business and professional competence and conduct criteria schedules that are part of the Physician Agreements. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 2 of 17

3 Policy QM 07 Regular or Routine Care: Preventive (i.e., well-child or adult examinations or health screening) and primary care for non-urgent conditions. Routine Behavioral Health Care: A routine situation exists when the member's condition is considered to be sufficiently stable. Symptomatic Care/Non-urgent Complaint: Primary care for non-urgent conditions that, if not treated, may pose minimal risk of harm. Total Service Factor (TSF): Percent of all calls answered within an established goal, e.g. 30 seconds. Urgent Behavioral Health Care: Urgent is a situation that is less clinically compelling than a non-life threatening emergency situation. A referral for urgent level of care services is made when the clinical situation would likely deteriorate if the member was not seen in a timely fashion. Urgent Care: Primary care for symptomatic conditions that if not treated, may pose serious risk of harm. Access to Primary Care Physician Services When and how is access measured? All standards for access to Primary Care are defined in the Primary Care Physician Participation Criteria, e.g. preventive care and symptomatic care. The Quality Oversight Committee (QOC) shall approve one or more of the Regular and Routine Care standards for monitoring Compliance with the Aetna Access Standards for appointment accessibility is measured using valid methodology and analyzed on an annual basis and may include one or more of the following mechanisms: - Availability of appointments (The availability of appointments is assessed when a site visit is required for member complaints to evaluate the physical accessibility, physical appearance, and the adequacy of waiting and exam room space.) - CAHPS survey - Other member satisfaction surveys - Telephonic Provider Access surveys - Other access surveys - Analysis of member complaints related to access Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 3 of 17

4 Policy QM 07 Access to Member Services Policy on Member Access to Health Plan Services When and how is Member Service telephone access monitored? Telephone access will be monitored via the indicators defined in Attachment A. Member Services management staff monitors automated call distribution (ACD) telephone reports on a daily basis. Member Services telephone access measures are reported to the Regional QOC and the National PPO Quality Council on an annual basis. Analysis of complaints and appeals in regard to access issues are reported to the Regional QOC and National PPO Quality Council at least annually. is reported to Regional QOC and National PPO Quality Council annually. Access to Behavioral Health Care Behavioral Health Practitioners are obligated to access standards as defined in Attachment A. When and how is behavioral health access measured? Aetna Behavioral Health measures Aetna Behavioral Health access standards. Telephone indicators are reported to the Aetna Behavioral Health QOC quarterly. Analyses of member satisfaction surveys and member complaints are reported to the Aetna Behavioral Health QOC, National Quality Council and each Regional QOC annually. Behavioral Health Contractors centralized telephone indicators and compliance with access standards are measured by the Contractor and reported to the Aetna Regional QOC or appropriate regional oversight committee annually. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 4 of 17

5 Policy QM 07 Practitioners are informed about Aetna access standards Primary Care and Specialty Care practitioners may be informed about access standards in the Physician Participation Criteria Schedules, Physician Toolkit, in newsletters and in the Aetna Behavioral Health Provider Manual. Exception Process: Exceptions to this policy requires approval from the Chief Medical Officer. Policy History: Revised: QM 07, issued 04/24/2009 Revised: QM 07, issued 05/28/2008 Revised: QM 07, issued 04/25/2007 Revised: QM 07, issued 04/25/2006 Revised: QM 07, issued 01/31/2005 Revised: QM 07, issued 01/16/2004 Replacement: QM , issued 12/13/02 Replacement: QM , issued 10/08/02 Replacement: QM , issued 08/02/02 Replacement: QM , issued 07/11/02 Original policy: QM 97-23, issued 6/29/99 QOC Review/Approval Date: 03/31/2010 Signature Michael A. Mesoras, M.D. Regional QOC Committee Chairperson FOR FURTHER INFORMATION: Contact: Janona Davis Dept/Unit: National Quality Management and Measurement Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies. (Aetna) Page 5 of 17

6 HMO Monitors ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS Element Standard Goal Monitoring Method Monitoring Frequency Regular or routine care appointments Within seven days Goals established utilizing the NCQA minimum effect size methodology annually by the regional QOC for each health plan. The regular or routine care 7 days standard is monitored with: CAHPS Q6: Percentage of members who reported that they always or usually got regular or routine care as soon as they wanted it. Urgent Care Appointments Same day or within 24 hours Goals established utilizing the NCQA minimum effect size methodology annually by the regional QOC for each health plan. CAHPS Q6a: Assess how long members waited between making an appointment and seeing a practitioner for routine care. CAHPS Q4: Percentage of members who responded always or usually if they needed care right away, they got care as soon as they thought they needed it. After-hours Care Each Primary Care Physician must have a reliable twenty-four (24) hours a day, seven (7) daysa-week answering service or machine with a beeper or paging system. A recorded message or answering service that refers members to emergency rooms is CAHPS Q4a: Assess how long members waited between trying to get care and seeing a practitioner when care was needed right away for an illness, injury, or condition. 100% CAPHS Q21a Percentage of members who reported that when they tried to call their personal doctor when the office was closed, they did reach an answering service or message telling them how to contact a physician? Page 6 of 17

7 not acceptable. Access to Appointments Not Applicable Track and Trend CATS Reporting: Complaints: At least Quality of Care - Refused to See Member annually Quality of Care - Long Wait Time (Appt/Visit) Quality of Service Access to and Responsiveness of service Quality of Service Appointment Availability Quality of Service Office Hours Not Convenient Quality of Service Access to Care Quality of Services Unable to Access Provider After Hours Quality of Service - Phone Access to Par Provider Medicare HMO Monitors ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS Element Standard Goal Monitoring Method Monitoring Frequency Regular or routine Care appointments Within seven days Goals established utilizing the NCQA minimum effect size methodology annually by the regional QOC for each health plan. The regular or routine care 7 days standard is monitored with: CAHPS Q06: Percentage of members who reported that they always or usually got regular or routine care as soon as they wanted it. Urgent Care Appointments Same day or within 24 hours Goals established utilizing the NCQA minimum effect size methodology annually by the regional QOC for each health For health plans where Medicare membership does not meet survey requirements, therefore an invalid sample size, a telephonic survey is required. CAHPS Q04: Percentage of members who responded always or usually if needed care right away, they got care as soon as they thought they needed it. Annual Page 7 of 17

8 plan. After-hours Care Each Primary Care Physician must have a reliable twenty-four (24) hours a day, seven (7) days-a-week answering service or machine with a beeper or paging system. A recorded message or answering service that refers members to emergency rooms is not acceptable. For health plans where Medicare membership does not meet survey requirements, therefore an invalid sample size, a telephonic survey is required. 100% Regional after hours and emergency directions phone availability survey. Access to Appointments Not Applicable Track and Trend CATS Reporting: Quality of Care - Refused to See Member Quality of Care - Long Wait Time (Appt/Visit) Quality of Service Access to and Responsiveness of service Quality of Service Appointment Availability Quality of Service Office Hours Not Convenient Quality of Service Access to Care Quality of Services Unable to Access Provider After Hours Quality of Service - Phone Access to Par Provider Annual Annual Complaints: At least annually Page 8 of 17

9 PPO Monitors ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS Element Standard Goal Monitoring Method Monitoring Frequency Regular or routine care appointments Within seven days Goals established utilizing the NCQA minimum effect size methodology annually by the regional QOC for each health plan. The regular and routine care 7 days standard is monitored with: CAHPS Q6: Percentage of members who reported that they always or usually got regular or routine care as soon as they wanted it. Urgent Care Appointments After-hours Care Same day or within 24 hours Each Primary Care Physician must have a reliable twenty-four (24) hours a day, seven (7) days-a-week answering service or machine with a beeper or paging system. A recorded message or answering service that refers members to emergency rooms is not Goals established utilizing the NCQA minimum effect size methodology annually by the regional QOC for each health plan. CAHPS Q6a: Assess how long members waited between making an appointment and seeing a practitioner for routine care. CAHPS Q4: Percentage of members who responded always or usually if they needed care right away, they got care as soon as they thought they needed it. CAHPS Q4a: Assess how long members waited between trying to get care when care was needed right away for an illness, injury, or condition. 100% Regional after hours and emergency directions phone availability survey. CAPHS Q21a Percentage of members who reported that when they tried to call their personal doctor when the office was closed, they did reach an answering service or message telling them how to contact a Annual Page 9 of 17

10 acceptable. physician? Access to Appointments Not Applicable Track and Trend CATS Reporting: Complaints: At least Quality of Care - Refused to See Member annually Quality of Care - Long Wait Time (Appt/Visit) Quality of Service Access to and Responsiveness of service Quality of Service Appointment Availability Quality of Service Office Hours Not Convenient Quality of Service Access to Care Quality of Services Unable to Access Provider After Hours Quality of Service - Phone Access to Par Provider Page 10 of 17

11 Medicare PPO Monitors ACCESS TO APPOINTMENTS FOR PRIMARY CARE PHYSICIANS Element Standard Goal Monitoring Method Monitoring Frequency Regular or routine Care appointments Within seven days Goals established utilizing the NCQA minimum effect size methodology annually by the regional QOC for each health plan. The regular or routine care 7 days standard is monitored with: CAHPS Q06: Percentage of members who reported that they always or usually got regular or routine care as soon as they wanted it. Urgent Care Appointments Same day or within 24 hours Goals established utilizing the NCQA minimum effect size methodology annually by the regional QOC for each health plan. For health plans where Medicare membership does not meet survey requirements, therefore an invalid sample size, a telephonic survey is required. CAHPS Q04: Percentage of members who responded always or usually if they needed care right away, they got care as soon as they thought they needed it. Annual After-hours Care Each Primary Care Physician must have a reliable twenty-four (24) hours a day, seven (7) daysa-week answering service or machine with a beeper or paging system. A recorded message or answering service that refers members to emergency rooms is not acceptable. For health plans where Medicare membership does not meet survey requirements, therefore and invalid sample size, a telephonic survey is required. 100% Regional after hours and emergency directions phone availability survey. Annual Annual Page 11 of 17

12 Access to Appointments Not Applicable Track and Trend CATS Reporting: Complaints: At least Quality of Care - Refused to See Member Annually Quality of Care - Long Wait Time (Appt/Visit) Quality of Service Access to and Responsiveness of service Quality of Service Appointment Availability Quality of Service Office Hours Not Convenient Quality of Service Access to Care Quality of Services Unable to Access Provider After Hours Quality of Service - Phone Access to Par Provider Page 12 of 17

13 All Products Behavioral Health Monitors (HMO, PPO, Medicare HMO & Medicare PPO) ACCESS TO BEHAVIORAL HEALTH CARE APPOINTMENTS Element Standard Goal Monitoring Method Monitoring Frequency Non-life-threatening Emergency Needs Urgent Care Evaluation appointment and initial treatment Regular or Routine Office Visit Within six hours Within 48 hours Within ten business days >75% of respondents that responded positively to Overall Satisfaction question >75% of respondents that responded positively to Overall Satisfaction question >75% of respondents that responded positively to Overall Satisfaction question Access to Appointments Not Applicable Track and Trend CATS Reporting: Quality of Service Emergency: No appointment available within 6 hours Quality of Service Urgent: Appointment not available within 48 hours Quality of Service Routine Appointment: Not available within 10 Aetna Behavioral Health QOC reports results annually to RQOC (HMO) and National QOC (PPO) Aetna Behavioral Health QOC reports results annually to RQOC (HMO) and National QOC (PPO) Aetna Behavioral Health QOC reports results annually to RQOC (HMO) and National QOC (PPO) Complaints: At least Annually Page 13 of 17

14 business days Page 14 of 17

15 All Products Customer Service Monitors (HMO, PPO, Medicare HMO & Medicare PPO) CUSTOMER SERVICES TELEPHONE ACCESS NATIONAL ACCOUNTS Element Standard Goal Monitoring Method Monitoring Frequency Call Abandonment Rate 2% 100% QM Indicator Report Quarterly Average Speed of Answer 25 seconds 100% QM Indicator Report Quarterly Total Service Factor (TSF) 80% answered within 30 seconds or less 100% QM Indicator Report Quarterly Access to Customer Service by Telephone Not Applicable Track and Trend Complaints CATS Reporting: Customer Service - Member Services - Phone Access Customer Service - Member Services IVR Unable to Access CSP Quarterly CUSTOMER SERVICES TELEPHONE ACCESS REGIONAL BUSINESS CUSTOMER OPERATIONS (INDIVIDUAL, SMALL, AND MIDDLE MARKET) Element Standard Goal Monitoring Method Monitoring Frequency Call Abandonment Rate 2% 100% QM Indicator Report Quarterly Average Speed of Answer 30 seconds 100% QM Indicator Report Quarterly Total Service Factor (TSF) 75% answered within 30 seconds or less 100% QM Indicator Report Quarterly Access to Customer Service by Telephone Not Applicable Track and Trend Complaints CATS Reporting: Customer Service - Member Services - Phone Access Customer Service - Member Services IVR Unable to Access CSP Quarterly CUSTOMER SERVICES TELEPHONE ACCESS RETIREE MARKETS Element Standard Goal Monitoring Method Monitoring Frequency Page 15 of 17

16 Call Abandonment Rate 2% 100% QM Indicator Report Quarterly Average Speed of Answer 30 seconds 100% QM Indicator Report Quarterly Total Service Factor (TSF) 80% answered within 30 seconds or less 100% QM Indicator Report Quarterly Access to Customer Service by Telephone Not Applicable Track and Trend Complaints CATS Reporting: Customer Service - Member Services - Phone Access Customer Service - Member Services IVR Unable to Access CSP Quarterly CUSTOMER SERVICES TELEPHONE ACCESS AARP Element Element Element Element Element Call Abandonment Rate 3% 100% QM Indicator Report Quarterly Average Speed of Answer 30 seconds 100% QM Indicator Report Quarterly Total Service Factor (TSF) 85% answered within 30 seconds or less 100% QM Indicator Report Quarterly Access to Customer Service by Telephone All Products Not Applicable Track and Trend Complaints CATS Reporting: Customer Service - Member Services - Phone Access Customer Service - Member Services IVR Unable to Access CSP Quarterly TELEPHONE ACCESS TO BEHAVIORAL HEALTH CARE Element Standard Goal Monitoring Method Monitoring Frequency Telephone access to screening and triage *Callers reach a non-recorded < 30 seconds non- >80% non-claims calls Call Management System Report Aetna Behavioral Page 16 of 17

17 voice w/in 30 seconds. claims calls >80% claims calls Reported to Aetna within the ABHNR Health QOC reports If using an automated <30 seconds claims report results semi-annually to system, member must reach a calls RQOC (HMO) and non-recorded voice w/in 30 National QOC (PPO). seconds. *Abandonment rates do not exceed three percent at any given time. <3%-Abandonment Rate non-claims calls <3% Abandonment Rate claims calls 100% Call Management System Report Reported to Aetna within the ABHNR report Aetna Behavioral Health QOC reports results semi-annually to RQOC (HMO) and National QOC (PPO). Page 17 of 17

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