Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Summit Health Plan of Florida

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1 Coventry Health Care of Florida, Inc. Coventry Health Plan of Florida, Inc. Summit Health Plan of Florida Medicare Quality Management Program Overview Quality Improvement (QI) Overview At Coventry, we work 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 that come from proven medical practices. Our goal is to make health care even better. We want to provide you with information about our Quality Improvement Program, results of our activities and progress in meeting our annual goals. We want to update you on QI activities related to: Program Goals and Scope HEDIS Data Reporting Results of Member Satisfaction Medicare STAR Ratings Disease and Case Management Programs Access to Care and Services Utilization Decisions and How We Ensure Accuracy Quality Improvement Projects Patient Safety Activities Provider Credentialing Program Medical Record Requirements Behavioral Health Programs Accreditation Activities We have a quality improvement program that is overseen by our Quality Improvement Committee (RQIC). Members of the RQIC include; Medical Directors, Plan Management, CEO or designee, Regional VP and Director of Quality Improvement, Regional lead of HEDIS or Health Care Consultant, Pharmacy lead, the lead from Health Services, Network Operations, and Provider Relations. We also have people from our Finance, Marketing Compliance, Customer Service and Regional Quality Improvement teams participate as appropriate. 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

2 National Commercial and Medicare Pharmacy & Therapeutics Committee QI 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 receiveby looking at quality and safety Address racial and ethnic differences in health care Come up with ways 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 QI Program Scope We work to make our members care better by: Providing 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 standards are met Recommending improvements and 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 measures performance on the quality and effectiveness of health care and services to members and allows for comparison between plans and regions. HEDIS results also assist in focusing on areas needing improvement so that health plan providers can continuously improve their clinical and customer services. From 2011 to 2012, our plans improved in the following areas: Members Obtaining Preventive Health Screenings: (Colorectal Screenings, Glaucoma Screenings, Osteoporosis Testing and Breast Cancer Screenings) Effective Management of Chronic Conditions: (Diabetes, High Blood Pressure, Cardiovascular Conditions and Mental Health and Respiratory Disorders) Member & Physician Satisfaction We asked members how satisfied they are with Coventry. Overall levels of satisfaction provide a general indication of whether a health plan is meeting enrollee expectations. Consumer Assessment of Health Plans Study (CAHPS) is a measure for member satisfaction that examines the percentage of members satisfied with the health plan. 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. We identified opportunities for improvement and are developing initiatives to improve future satisfaction. The survey revealed favorable satisfaction trends in the following Composite Scores: Health Plan Overall Rating Health Care Overall Rating Personal Doctor Overall Rating How Well Doctors Communicate Health Plan Customer Service Rating of Drug Coverage We also have a program to assess physician satisfaction with our services. The overall satisfaction with the Health Plan increased. For the Primary Care survey, the plan s overall satisfaction rate increased by 4% 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%

4 Medicare STARS Ratings The Centers for Medicare and Medicaid Services (CMS) rates Medicare Advantage (MA) plans on a scale of 1 STAR (poor performance) to 5 STARs (excellent performance). The STAR ratings are based upon HEDIS scores, CAHPS and HOS scores, Part D safety outcomes, Compliance issues, and plan management of member appeals. STAR results* for 2013 are presented below: * Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next Star ratings based on CMS reported data 8/10/12 ** 3x weighted measures CHCFL*** - H1076 STAR Rating C07-Improving / Maintaining Physical Health ** 67% 5 C08-Improving / Maintaining Mental Health 74% 2 C09-Monitoring Physical Activity 44% 2 C21- Improving Bladder Control No Data Available No Data Available C22- Reducing the Risk of Falling 60% Star ratings based on CMS reported data 8/10/12 ** 3x weighted measures ***CHCFL = Coventry Health Care of Florida CHPFL = Coventry Health Plan of Florida SHP = Summit Health Plan of Florida CHPFL*** - H1013 STAR Rating C07-Improving / Maintaining Physical Health ** 66% 4 C08-Improving / Maintaining Mental Health 77% 2 C09-Monitoring Physical Activity 53% 3 C21- Improving Bladder Control 40% 3 C22- Reducing the Risk of Falling 69% Star ratings SHP*** - H5850 STAR Rating based on CMS reported data 8/10/12 ** 3x weighted measures C07-Improving / Maintaining Physical Health ** 66% 4 C08-Improving / Maintaining Mental Health 79% 3 C09-Monitoring Physical Activity 47% 2 C21- Improving Bladder Control 38% 3 C22- Reducing the Risk of Falling 65% 4

5 Disease Management Programs Coventry Disease Management programs take a proactive approach in identifying and caring for chronic illnesses. Contact is made with all members who have the following condition/chronic diseases: 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. We identify members for disease management programs through claims, self-referrals, practitioner referrals, pharmacy, and other sources. The ultimate goal of the program is to improve quality of life for our members. Some achievements include: Introduced Enhanced Case Management (CM) Program, to provide consistency in CM throughout Coventry and provide quality service to members and meet industry and accreditation standards. Offered a Vital Decisions Program to provide counseling on end of life issues. 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. 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 Services and Satisfaction Coventry Health Care members have access to case management - a collaborative process between our plans, members, and providers. Our case management programs are designed to

6 assess and meet the member s health care needs. The program is staffed by registered nurses to advocate for the member in the case management process. Our 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 communities. Our health plan nurses embrace cultural diversity and are well suited to assist members of any background. We require our nurses to expand their expertise through professional development including certification, seminars and classes for continuing education and case management credits. SATISFACTION RATE - Overall Score CHC 84% 85% CHP 86% 86% SHP 87% 87% The satisfaction rate goal is 80%. The goal was met as all plans achieved greater than 80% satisfaction rate. 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. Some accomplishments include: Customer Service representatives and the Pharmacy Call Center for our Medicare plans met goals for call abandonment rate and answered calls with an average speed of 30 seconds. HEDIS Data measuring access to care through annual PCP visits is close to 90% for all Medicare members Practitioner accessibility and availability meets all state requirements and is measured on an annual basis. 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 tests

7 Quality Improvement Projects Our Medicare plans have Quality Improvement Projects (QIP) / Chronic Care Improvement Projects (CCIP) in process. Below are examples of how we help lower hospital readmissions and help people with their diabetes. Lowering Hospital Readmissions We call members to help schedule PCP follow-up appointments after someone has been in the hospital. This action has helped reduce hospital re-admissions. Helping Members with their Diabetes We outreach to members to provide diabetes education and encourage them to participate in our Diabetes Disease management program. Patient Safety Activities Examples of our patient safety 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 important part of providing quality care. 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. We have credentialed / re-credentialed over 3571 physicians and 256 facilities. Coventry audits provider medical records to: Medical Record Keeping Requirements 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

8 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 Program Psychcare and Coventry are engaged with coordination of care and medical integration activities. In 2012, the Behavioral Health Program demonstrated achievements in: Network Practitioner Satisfaction Survey Network Provider Patient Safety and Continuity and Coordination of Care Member inpatient psychiatric consultations ordered by attending medical physicians on medical units in acute care facilities Member psychiatric medication evaluations ordered by attending medical physicians in nursing homes and/or skilled nursing Accreditation Activities 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 we are 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. <Coventry Health Care is a Coordinated Care plan with a Medicare contract and a contract with the Florida Medicaid program. Enrollment in our plan depends on contract renewal.> CVTY_CCP_2014_0001_3146NR Feb 2014