Aetna Better Health Aetna Better Health Kids. Quality Management Utilization Management Program Evaluation

Transcription

1 Aetna Better Health Aetna Better Health Kids Quality Management Utilization Management 2013 Program Evaluation

2 EXECUTIVE SUMMARY Introduction Aetna Better Health implemented its Medicaid Physical Health-Managed Care Organization in the state of Pennsylvania on April 1, As of December 31, 2013 our membership the Southeast and Lehigh- Capital regions of the HealthChoices Program has grown to include more than 59,000 Medicaid recipients which is representative of 696,713 member months. The QAPI Program Evaluation is a comprehensive annual summary of quality improvement activities that occur across the organization and are performed under the scope of the Quality Management and Utilization Management Workplan. The Executive Summary is a high level view of Aetna Better Health s 2013 accomplishments and challenges. The additional content of the report provides information on the plan s analysis of its trended performance measures, barriers, structure and resources that assess the quality of clinical care and service provided as well as a review of the satisfaction of our provider network and the members we serve. Where available, performance analyses are presented in comparison to goals and objectives and include barriers that may have affected the achievement of those goals and objectives. This includes a critical evaluation of achieved successes and significant events, as well as, barriers that may have affected the achievement of goals and objectives outlined in the QM Program Description and Work Plan. The 2013 QM/UM evaluation provides the identification of opportunities for existing and planned QM and UM program activities in The scope of activities reflects how quality and process improvement exist within every area of Aetna Better Health and demonstrates a concerted effort to improve the quality of care and access of services to our members. The analysis of our performance in 2013 provides the background for the identification of opportunities for improvement as the plan enhances and continues its QAPI and Utilization Management programs. Program structure and operations The Aetna Better Health QAPI Program s focus on the member is central to all that we strive to accomplish daily. With a focus on quality we monitor processes, ensure that members and providers have input in the development of plan policies, procedures, programs, activities and improvement actions. The Aetna Better Health Board of Directors has ultimate accountability for the QAPI and related processes, activities, and systems. The chief executive officer on behalf of the Quality Management Oversight Committee submits the QAPI and any subsequent revisions to the board of directors for approval. Formal medical and service committees, subcommittees and work groups advise and guide the QAPI. The Aetna Better Health chief medical officer is accountable for directing the development and implementation of the QAPI within Aetna Better Health. Under the direction of the chief medical officer, the Quality Management Department coordinates Aetna Better Health s QAPI and provides administrative support for the health plan committees. The Quality Management Department coordinates QAPI activities and evaluation and follow-up on requests related to quality from members, practitioners, providers, state or regulatory agencies or other referral sources.

3 Program Goals, Objectives and Priorities The overall goal of the QAPI program is to continually improve the quality of care provided to our members and the quality of service provided to our members and providers. Aetna Better Health s overall objective is to collaborate with both members and providers to achieve the best outcome possible for our Medicaid and CHIP members. Additional goals and objectives include but are not limited to: Maintain compliance with contract and regulatory requirements Implement additional virtual communication with and education to members and providers using web based and telephone technologies Enhance collaboration and participation among all plan departments, staff and systems to allow for the collection and sharing of quality management data and monitoring of outcomes Assess, identify and act upon opportunities for improvement by performing quality management and performance improvement activities as requested by internal and external customers (including regulatory agencies). This assessment process will include statistically valid clinical and financial analysis of data, including encounters, member demographics, HEDIS, CAHPS, regulator performance measures and other data available to the plan Monitor the provider network s capacity to accommodate the diverse needs of the Medicaid and CHIP member populations, including special health care needs as well as specific language or cultural needs and preferences Monitor outpatient and inpatient services to identify deviations from standard of care/service and develop interventions aimed at improving member care and outcomes Monitor and evaluate the continuity, availability, and accessibility of care and/or services provided to members Maintain technical business information systems to support quality management and performance improvement activities and improve them as necessary to meet program needs Promote safety through processes that address quality of care, provider preventable conditions, provider credentialing and the pharmacy needs of members HEDIS goals are to reach the NCQA 50 th percentile for all measures, benchmarks are the NCQA75 th percentile. Rates will be assessed using goals and benchmarks Program priorities for 2014 include but are not limited to: Achieving statistical improvement in HEDIS and CAHPS rates year over year with goal of reaching and surpassing the NCQA 50 th percentile Continued monitoring of outpatient and inpatient services to identify deviations from standard of care/service including preventive and practice guidelines Taking action on identified opportunities for improving health care outcomes and service for members and monitor for continued effectiveness Maintaining integrated processes to support quality management and performance improvement activities Implementing the Quality CORE tool that identifies members in need of services in accordance with HEDIS specifications and provide stratification methodologies to determine effectiveness of interventions on identified groups Educating members on preventive health guidelines and care for chronic and acute illnesses to promote improved outcomes

4 Improving the satisfaction of members, practitioners and providers with health care delivery Meeting NCQA requirements for the 2014 standards and successful completion of the accreditation review in October for both Medicaid and CHIP Continuing to promote involvement of members (their family/representative and/or caregiver) and practitioners in the quality management program and related activities by encouraging feedback (e.g., through member/provider satisfaction surveys, telephonic outreach, participation on committees, as applicable) Continuing to make special needs/complex care services available to all enrolled members or populations who are identified by key attributes such as, but not limited to: HIV/AIDS, Hospice, Children in Substitute Care, Mental Retardation/Developmental Disabilities as well as those members that may require care beyond what is typically required and other variables identified as high risk services required by members identified as having Special or Complex Health Needs Assessing plan operations to determine opportunities for improvement that exist in areas outside of traditional medical management and quality that may impact services, care and outcomes for members and providers/practitioners Accomplishments Accomplishments of 2013 include: Improvement in seven Medicaid Pay-for-Performance measures and benchmark achievement in two of the twelve measures Development and implementation of electronic version of the Obstetrical Needs Assessment Form allowing providers to submit member data via the form electronically for retrieval by the plan Stabilization of plan leadership allowing for continued oversight by leaders well-versed in management of the PA Medicaid and CHIP populations Successful completion of audited HEDIS and CAHPS measures Improvement in CAHPS results Improvement in Provider Satisfaction Survey results Increased EPSDT visits by from 47.7% in 2012 to 52% in 2013 Improved claims/encounters management and resolution processes leading to consistent claims internal audits of over 98% Maintained compliance with National Committee for Quality Assurance (NCQA) standards and regulatory requirements Implemented new Complaints and Grievance tracking database allowing for enhanced ability to determine opportunities for improvement and develop actions as needed Provider use of plan web portal increases in all categories by an average of 15% leading to a decrease in telephone inquiries by providers Provider outreach and education site visits enhanced by partnering Provider Relations and Quality and Medical Management staff Successful migration to CVS/Caremark as pharmacy benefits manager

5 Membership Aetna Better Health membership numbers are as follows: Membership as of December 31, 2011: 58,465 (members); 574,906 (member months) Membership as of December 31, 2012: 59,707 (members); 696,713 (member months) Membership as of December 31, 2013: 72,194 (members); 772,167 (member months) Below are tables that provide an overview of the 2013 Aetna Better Health member population compared to 2011 and Membership % Change Membership % SE Region 65.2% 62.0% 61.3% (1.12%) Lehigh/Capital Region 34.8% 38.0% 38.7% 1.78% Gender/Age Female 51.9% 52.1% 53.76% Male 48.1% 47.9% 46.24% Under 21 years of age 57.9% 55.3% 64.85% Ages % 33.4% 27.12% Female years of age 32.1% 32.2% 31.11% Over 50 years of age 9.4% 11.3% 8.03% Enrollment Category Category TANF Age % 50.19% 37.61% Healthy Beginnings Age % 28.78% 19.36% Healthy Beginnings Age 0-2 months 0.70% 0.58% 0.00% Healthy Beginnings 2-12 months 4.10% 3.61% 2.28% MAGI Age % MAGI 0-2 months 1.28% MAGI 2-12 months 2.22% TANF 0-2 months 0.76% 0.64% 0.17% TANF 2-12 months 3.79% 3.29% 2.21% Medically Needy State Only GA 2.98% 2.22% 1.35% Categorically Needy State Only GA 10.83% 8.06% 5.87% Breast and Cervical Cancer 0.17%

6 Federal GA 4.14% 2.62% SSI SSI and Healthy Horizons 97.24% 98.34% 98.76% Federal GA 2.76% 1.66% 1.24% There was a 20.9% increase in membership between 2012 and Membership decreased in the Southeast region by close to 1.12% and increased slightly in the Lehigh/Capital area, 1.12%. The female membership is 7% higher than males and the greatest percentage of membership is TANF 1+ followed by MAGI 1+ years of age. As noted in 2012, the plan continues to realize an increase in the number of members who are selecting to enroll compared to the number of auto-assignees. Leading reasons for members who dis-enroll continue to include: prefers another HMO s benefits and prefers non par doctor/specialist. Children s Health Insurance Program Below is a table that outlines the 2013 Aetna Better Health Kids (Children s Health Insurance Program) 2013 membership Total Membership Southeast Region Central Region Female Male <1 1-2 years 3-6 years 7-11 years years , % 24.77% In 2013, the plan assumed management of the CHIP program and subsequently aligned membership locations to areas where the provider network was established. This realignment resulted in a reduction in membership yet provided a stable network for members to receive care. Challenges Aetna Better Health continues to consider challenges an opportunity to seek different and innovative ways to improve its processes, services and care to members. During 2013, the plan has implemented changes that have led to improvements in processes and member outcomes and developed a cohesive data-driven, goal-oriented team. As noted in the 2012 evaluation, challenges continue with having inaccurate member demographics that hamper member contacts and the plan continues to address this as best it can when needed. Accurate member demographics remain critical to improving member outcomes as we outreach to encourage services and provide education on preventive health and plan benefits to our Medicaid and CHIP members.

7 Opportunities for 2014 include: Continued improvement of EPSDT and well care rates Improving dental screening rates Improving well care for adolescents Decreasing non-urgent emergency department utilization Improving immunization rates Improving appointment availability and access rates for all PCPs, OB/GYN and specialists Maintaining staffing levels throughout the plan to address the care and service needs of members and providers Summary During 2013, the medical, quality and operational areas of the Aetna Better Health Medicaid and CHIP plans revised, updated, enhanced and implemented many processes and interventions aimed at improving care for members and services and satisfaction and for members and providers. Evident throughout the organization is the commitment to ensuring that the plan addresses opportunities for improvement and continue to improve process that impact members and providers. Compliance and transparency remain at the forefront of our daily activities and provide the groundwork upon which we base decisions and actions. Reduction in active counties for participation in the CHIP program has allowed the plan s provider network to remain strong and able to provide care to members and will continue to be the focus of activities aimed at improving member outcomes. We believe that the member s medical and dental home is a vital partner in ensuring that members have the best possible outcome when services are needed for preventive, acute and/or chronic care. The plan s 2013 HEDIS (CY 2012) rates improved yet we are not satisfied with progress and additional improvement activities have been implemented aimed at positively impacting future rates. Medical and quality management activities conducted throughout the year yielded positive results in some areas and opportunities in others as discussed throughout this document. Aetna Better Health remains committed to providing the best care, at the right time, in the most appropriate setting for the Medicaid and CHIP populations we serve.