QUALITY MANAGEMENT PROGRAM 2015 EVALUATION

Transcription

1 QUALITY MANAGEMENT PROGRAM 2015 EVALUATION Tim Gutshall, MD Vice President & Chief Medical Officer Wellmark Blue Cross and Blue Shield

2 Table of Contents Purpose... 2 Scope of Work... 2 Objectives... 2 Lessons Learned and Opportunites... 2 Patient Safety: Quality of Care and Service Quality Investigation Timeliness... 3 HEDIS Measures... 4 Antibiotic Stewardship... 4 Comprehensive Diabetes Care... 5 Management of Respiratory Conditions... 7 Prescribing for Behavioral Health... 9 Cardiovascular Care Transitions of Care and Utilization of Services Preventive Screening Pediatric Care Health and Care Management Quality Projects CAHPS Measures Satisfaction Surveys Continuity and Coordination of Care Consumer transparency Quality Management Program Activities Acronyms Legend Wellmark Blue Cross and Blue Shield 1

3 PURPOSE The Quality Management Program (QMP) is designed to promote an objective and systematic approach to monitoring and evaluating the quality and safety of select services that Wellmark, Inc., on its own behalf or on behalf of its subsidiaries Wellmark of South Dakota, Inc. and Wellmark Health Plan of Iowa, Inc. provide to specific customer groups. This document is an evaluation of the quality management program and the measures as described within the QMP work plan. SCOPE OF WORK The scope of this quality management program is as follows: Iowa Department of Human Services (DHS) Healthy and Well Kids in Iowa (hawk-i) contract requirements; Medical and behavioral case management functions performed on behalf of the Federal Employee Plan (FEP) Director s Office of the Blue Cross and Blue Shield Association; Utilization review functions performed on behalf of all members and customer groups; and Services, in addition to those stated above, to support Wellmark Health Plan of Iowa (WHPI), Inc. s continued health plan accreditation under the Wellmark Health Plan of Iowa, Inc. and Wellmark, Inc. Management Agreement. OBJECTIVES The objectives for the quality management program are to: Systematically monitor and evaluate key indicators and measures of the services referenced in the stated Scope of Work section; Identify, prioritize and develop interventions to improve the above named services; Measure and report the results of quality improvement activities to staff, and corporate management; and Monitor ongoing compliance with applicable accreditation and regulatory standards. LESSONS LEARNED AND OPPORTUNITES The lessons learned and opportunities of the Quality management Program are evaluated in a variety of ways. Recommendations received from our accreditation consultant, results from accreditation readiness reviews, suggestions from QM process owners and quality improvement consultants are carefully reviewed. The feedback from these sources is summarized below. Lessons Learned Customers have increased expectations regarding cost and quality transparency Providers reflect they are over burdened with quality metrics and desire consistency across payers Accountable Care Organizations (ACOs) require not only data regarding quality metrics (Value Index Score) but also desire utilization rates for specific services to engage the conversation with their clinicians Wellmark s interventions, both internal process and provider collaboration, have positively impacted: Wellmark Blue Cross and Blue Shield 2

4 o CAHPS (Consumer Assessment of Healthcare Providers and Systems) survey scores, and o NCQA (National Committee for Quality Assurance) standard scores Federal Employee Program (FEP) is increasing the emphasis of clinical quality Healthcare Effectiveness Data and Information Set and CAHPS metrics for service payment Effort will be needed to align resources for Iowa and South Dakota PPO accreditation due to the FEP mandate Our decision to be involved in the exchange for 01/01/2017 will require resources and incentives to improve the Quality Rating System (QRS) metrics to improve star status of our products on the exchange Opportunities Enhance Wellmark s tools and communication strategy to promote cost and quality transparency Continue to align the Quality Management Program with the work of the payment innovation strategy Expand payment innovation to providers beyond Accountable Care Organization participants QRS will need to be prioritized with the network through transparency and incentives Understanding both the member and provider experience will be integral in our work in order for Wellmark to maintain its status as the preferred health plan in Iowa and South Dakota PATIENT SAFETY: QUALITY OF CARE AND SERVICE QUALITY INVESTIGATION TIMELINESS Customer Service collects Wellmark members inquiries and complaints regarding provider quality of care and service quality. Wellmark Quality Management staff monitors and acts on member complaints received through the Customer Service complaint and appeal process. Provider Quality of Care and Service Quality complaints and inquiries are also collected through the Health and Care Management SharePoint site where all Wellmark employees can document member provider issues. Cases are categorized as Class 1 through 4. The higher the class number indicates a more complex the complaint. Cycle times reflect the number of days required to address the complaint from the time it was received by the Quality Management staff until the time it is closed. The resolution cycle times for each class are: Class 1 and 2 are 30 days, Class 3 is 75 days, and Class 4 is 160 days. All Quality of Care complaints and any questionable Service Quality complaints are reviewed with a Wellmark Medical Director. Service quality issues are forwarded to the appropriate Wellmark business partner for additional investigation and intervention for complaint resolution. Quality of Care and Service Quality issues (including adverse events) are forwarded to Network Administration for ongoing monitoring of physician performance. All quality of care and service quality complaints met class timeliness expectations. Enhancements were made to the Peer Review Process which included inclusion of the BlueCard team for out of network medical record request. Requesting medical records out-of-state is less timely than requesting medical records in-state. Enhancements to the Peer Review Process continues as opportunities arise. Additional barriers overcame in 2015 include: Wellmark Blue Cross and Blue Shield 3

5 Changing the staff ownership of the Peer Review Process from the Network Administration team to the Accreditation and Compliance team. Additional Health and Care Management staff and Customer Service training increased the number of complaints documented against services provided by Providers. HEDIS MEASURES HEDIS is one of the most widely used sets of health care performance measures in the United States. The term HEDIS originated in the late 1980s as the product of a group of forward-thinking employers and quality experts, and was entrusted to NCQA in the early 1990s. The NCQA measurement development process has expanded the size and scope of HEDIS to include measures for physicians, PPOs and other organizations. This data is collected via the HEDIS Data Submission System. HEDIS is designed to provide purchasers and consumers with the information they need to reliably compare the performance of health care plans. HEDIS results are included in Quality Compass (QC), an interactive, web-based comparison tool that allows users to view plan results and benchmark information. QC users benefit from the largest database or comparative health plan performance information to conduct competitor analysis, examine quality improvement and benchmark plan performance. Antibiotic Stewardship Three HEDIS measures encompass the Antibiotic Stewardship grouping which includes: Appropriate Testing for Children with Pharyngitis (CWP): Percentage of children 2 18 years of age diagnosed with pharyngitis and dispensed antibiotic, and who also received a group A Strep test for the episode (measurement period is 07/01/ /30/2014) Appropriate Treatment for Children with Upper Respiratory Infection (URI): Percentage of children 3 months 18 years of age who were given a diagnosis of URI and were not dispensed an antibiotic prescription (measurement period is 07/01/ /30/2014) Avoidance of Antibiotic treatment in Adults with Acute Bronchitis (AAB): Percentage of adults years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription on or 3 days after episode (measurement period 01/01/ /24/2014) All Antibiotic Stewardship measures are at or below the 10 th percentile NCQA QC for all product lines. WHPI rates for both HEDIS measures, CWP and URI, have an increased compliance rate of 3% over the past four years. The AAB measure had a decreasing rate of 4.24%. SD FEP and SD PPO rates are steadily greater than the WHPI and IA PPO product rates. The hawk-i population, a WHPI population segmentation, had a 5% lower rate than the WHPI population as a whole. QC rates for both CWP and URI followed a slow upward five year trend and AAB 90 th percentile NCQA QC had a 10% upward trend over the past five years. Only WHPI and hawk-i rates are displayed below. Similar barriers continue year-over-year for both the members and providers prescribing the antibiotics. These include: Member s health literacy about the long term effects of inappropriate antibiotic use Wellmark Blue Cross and Blue Shield 4

6 The cultural / social stressors expectations for providers to prescribe antibiotics for acute URI. 90% Appropriate Treatment - Children with URI 40% Inapprop AB Treatment - Adults with Acute Bronchitis 80% 70% 75.24% 71.66% 74.98% 30% 20% 18.29% 11.94% 13.56% 60% 10% WHPI hawk-i 10th 25th 90th WHPI 10th 25th 90th Appropriate Testing - Children with Pharyngitis 95% 75% 65% 63.48% 67.26% 69.43% 69.44% 70.43% 55% WHPI hawk-i 10th 25th 90th Comprehensive Diabetes Care Five subcategories of HEDIS measures encompass the Comprehensive Diabetes Care (CDC) measure. Percentage of adults years of age with diabetes (type 1 and type 2) who had each of the following: o HbA1c testing, o HbA1c control, o Medical attention for nephropathy, o Blood pressure control, and o Retinal eye exam during measurement year or negative retinal exam in year prior. Wellmark Blue Cross and Blue Shield 5

7 The Comprehensive Diabetes Care measure is a hybrid measure for the WHPI population. Hybrid data collection is a combination of claims data and medical record review. Reportable elements of the medical record are abstracted to demonstrate providers in the network are performing the identified tasks. Evidence of HbA1c testing is primarily claims based information. HbA1c control and blood pressure control is primarily medical record reviewed information. Providers are able to submit CPT II codes to provide health plans the member s documented rate, but less than 1% of the provider population submit this information with their claims. Acquiring the diabetic retinopathy eye exam information is a mix between claims and medical record reviewed information for the WHPI population. Both SD and IA FEP products have achieved the 90 th percentile QC for the retinal eye exam testing. The hawk-i population is assessed on their HbA1c testing for pediatric patients indicated as being diabetic. The population scored 100%. The 90 th percentile QC remained the same, increasing by less than one percentage point in five years for all Comprehensive Diabetes Care measures, except for the HbA1c Control which increased by 2.67 points. The HbA1c testing rate range between the 90 th and 50 th percentile QC is 4.61 percentage points. Part of the Value Index Score (VIS) metrics for the Wellmark Accountable Care Organizations (ACOs) includes the maintaining or improvement of attributed member s Clinical Risk Group (CRG) scores. It is unknown if ACO providers are ordering the appropriate health maintenance diabetic monitoring interventions for diabetic members in an effort to improve or maintain a member s CRG score. FEP members diagnosed with diabetes receive diagnosis based educational mailings and are enrolled in Disease Management services. The WHPI rates met the QC benchmarks. Barriers for all other products not meeting goal include: Providers not submitting CPT II codes VIS metrics are not directly related to the treatment of a diabetic patient Frequency of follow-up appointment scheduling when desired rates are not obtained Member compliance with disease management activities (medication and diet compliance) 95% 90% HbA1c Test IA PPO SD PPO SD FEP IA FEP 50th 75th 90th Eye Exam 80% 70% 60% 50% 40% 30% IA PPO SD PPO SD FEP IA FEP 10th 25th 90th Wellmark Blue Cross and Blue Shield 6

8 Monitor Nephropathy 100% 95% 90% 89.57% 87.66% 89.80% IA PPO SD PPO SD FEP IA FEP 75th 90th Management of Respiratory Conditions Four HEDIS measures encompass the Management of Respiratory Conditions subgroup. They include: Pharmacotherapy for COPD (Chronic Obstructive Pulmonary Disease) Exacerbation (PCE): Percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or Emergency Department (ED) visit on or between January 1 st November 30 th of the measurement year and who were dispensed appropriate medications. o Dispensed a systemic corticosteroid within 14 days of the event o Dispensed a bronchodilator within 30 days of the event Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR): Percentage of adults 40 years and older with a new diagnosis or newly active COPD who received spirometry testing to confirm the diagnosis (measurement period 07/01/ /30/2014). Chronic lung disease diagnosis includes emphysema, chronic bronchitis, and COPD. Use of Appropriate Medications for People with Asthma (ASM): Percentage of members 5 64 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year. Advising Smokers to Quit (MSC): Percentage of adults 18 years of age and older who are current smokers / tobacco users and received cessation advice from a physician during the measurement year; Rolling two year average All product lines show an upward five year trend for both PCE measures. Rate increases outpaced the QC increased rate trending. The WHPI PEC corticosteroid measure rate did not meet the 75 th percentile, but the PEC bronchodilator rate was at the 75 th percentile. IA PPO and SD PPO rate continues to lag behind the WHPI rates. The IA FEP PEC corticosteroid rate is 7 points higher than the WHPI rate and the bronchodilator rate is 4 points higher. SD FEP s PEC corticosteroid rate is similar to SD PPO s rate, but PEC bronchodilator rates are dramatically different, SD FEP 92.86% and SD PPO 78.69%. Wellmark Blue Cross and Blue Shield 7

9 The SPR measure has limited five year rate increases for the WHPI, IA PPO and SD PPO products. SD FEP increased by 6.73 percentage points with a rate spike in 2013, while IA FEP increased by 4.71 percentage points. All rates fall within the 25 th or 50 th percentile QC, not meeting goal. The ASM measure has tight compliance practice patterns. Seven percentage points separate the 90 th and the 10 th percentile NCQA QC. For five years, rates have remained constant for all measured products. SD FEP has the highest rate at 93.20%, 75 th percentile. MSC is a WHPI only HEDIS measure. It is measured through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Because of the low number of member s who smoke, NCQA rated the health plan fully compliant for this measure. The member population did respond with an 85.9% satisfaction. The HEDIS measures did not meet benchmarks except for the PEC: Bronchodilator measure. Barriers include: Small scoring span for practice pattern variations Calculating COPD exacerbations: the diagnosing, treating and educating appropriately Lack of patient education about need for spirometry testing Quality metrics are not diagnosis specific Patient Compliance with treatment plan and understanding of disease states COPD Exacerbation: Bronchodilator 95% 85.87% 82.55% 86.86% 75% 77.08% 65% WHPI IA PPO SD PPO SD FEP IA FEP 50th 75th 90th Wellmark Blue Cross and Blue Shield 8

10 95% COPD Exacerbation: Systemic Corticosteroid 75% 77.17% 77.18% 78.83% 72.92% 65% WHPI IA PPO SD PPO SD FEP IA FEP 25th 75th 90th 55% Spirometry Testing in Assessment and Dx of COPD 45% 35% 40.47% 40.69% 38.67% 44.82% 25% WHPI IA PPO SD PPO SD FEP IA FEP 25th 50th 90th Prescribing for Behavioral Health There are two HEDIS measures discussed under the prescribing for behavioral health HEDIS measure grouping. Each measure has two subcategories. They include: Follow-up Care for Children prescribed ADHD Medications (ADD): o Initiation phase percentage of children between 6 12 years of age diagnosed with ADHD and had one follow-up visit with a prescribing practitioner within 30 days of 1 st prescription of ADHD medication o Continuation and Maintenance phase percentage of children between 6 12 years of age with a prescription for ADHD medication who remained on med for at least 210 days AND had at least 2 follow-up visits with practitioner in the nine months subsequent to the initiation phase; 12 month window starting 03/01/ /28/2015 Wellmark Blue Cross and Blue Shield 9

11 Antidepressant Medication Management (AMM): Percentage of members 18 years of age and older diagnosed with new episode of major depression and treated with antidepressant medication and remained on medication; 12 month window is 05/01/ /30/2014 o Effective Acute Phase percentage of members who remained on antidepressant for at least 84 days o Effective Continuation Phase percentage who remained on antidepressant for at least 180 days The IA PPO product had a decreased rate for the ADD measure for both the initiation and maintenance phases. SD PPO saw similar rate trending. WHPI and the hawk-i population had rate increases in the initiation phase measurement. WHPI had an increased maintenance phase rate, but hawk-i rates have remained the same. SD FEP and IA FEP have an increasing three year trend in both the initiation and maintenance phases, but IA FEP decreased when comparing 2014 to Similar five year AMM HEDIS measure trending rates for the WHPI, IA PPO and SD PPO populations. SD FEP had a notable increase in the effective acute phase. IA FEP had a notable decrease in both the acute and continuation phases, but in 2011 FEP started as the highest ranking group for both segmentations. All product lines had a 2013 percentage spike. QC for both segmentations remained constant except the 75 th and 90 th percentiles which have had a notable percentage increase. Barriers continuing for this group include: Increasing number of members with a depression diagnosis and ADHD diagnosis Patient medication compliance Patient / family health literacy Parent prioritization Geographic distance between patient and practitioner in rural IA and rural SD No quality metric directly tied to diagnosis 80% Antidepressant Mgmt: Acute Med Trial Effective 65% Antidepressant Mgmt: Effective Drug Therapy Continuation 70% 55% 60% SD FEP 2013 IA FEP th th 90th 45% SD FEP IA FEP 50th 75th 90th Wellmark Blue Cross and Blue Shield 10

12 Follow-up Care for Children ADHD: Initiation Follow-up Care for Children ADHD: Maintenance 45% 55% 35% 45% 35% 25% 25% IA PPO SD PPO 10th IA PPO SD PPO 10th 25th 90th 25th 90th Cardiovascular Care The Cardiovascular Care HEDIS measure population includes: Controlling High Blood Pressure (CBP): Percentage of adults years of age with diagnosis of hypertension and whose blood pressure was adequately controlled. Adequately control is defined as less than 140/90 for members years of age or years of age with diagnosis of diabetes and less than 150/90 for members years of age without a diagnosis of diabetes. Persistence of Beta-Blocker after Heart Attack (PBH): Percentage of adults 18 years of age and older during measurement year who were hospitalized with diagnosis of Acute Myocardial Infarct and discharged from 07/01/2013 to 06/30/2014, and received persistent beta blocker treatment for six months after discharge. CBP HEDIS measure is a hybrid only measure. No codes are accepted to represent compliance according to NCQA technical specifications. WHPI is the only product with a reportable rate. The population saw a positive trend comparing 2013 to The HEDIS 2014 rate did not reached the 2011 measure rating high. Remarkable positive five year trending occurred for WHPI, IA PPO, SD PPO and IA FEP in relation to prescribing of beta blocker treatment after an Acute Myocardial Infarct. SD FEP s trend line had a remarkable rating spike in 2014, but small denominators played a part in the rate spike. Product rate increases outpaced the QC rate increases. Goals were met for both of these measures, but barriers still exist for members. They include: Medication complaint and monthly refills Wellmark Blue Cross and Blue Shield 11

13 Hospital discharge communication process; continuity and coordination of medical care Controlling HBP - Total 79.08% 76.16% 75% 72.75% 65% WHPI 75th 90th 100% Persistence of Beta Blocker Treatment 90% 80% 70% 60% 88.00% 91.06% 89.26% 80.31% 68.94% WHPI IA PPO SD PPO SD FEP IA FEP 75th 90th Transitions of Care and Utilization of Services Continuity and coordination of care is important for every member s health care. Four HEDIS measures display the results of four different transitional moments in health care. Follow-up After Hospitalization for Mental Illness (FUH): Percentage of discharges for members 6 years of age and older, hospitalized for treatment of selected mental health disorders and had an outpatient visit, intensive outpatient visit or partial hospitalization with mental health practitioners within seven days of discharge (measurement period is 01/01/ /31/2014) Use of Imaging Studies for Low Back Pain (LBP): Percentage of adults 18 50, with primary diagnosis of low back pain, who did not have an imaging study (plain x-ray, MRI or CT scan) within 28 days of diagnosis (measurement period is 01/01/ /31/2014) Timeliness of Prenatal and Postpartum Care (PPC): Wellmark Blue Cross and Blue Shield 12

14 o Percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment in health plan o Percentage of deliveries that had a postpartum visit on or between days after delivery. Measurement is based on deliveries from 11/06/ /15/2014 Ambulatory Care (AMB) Emergency department Visits: Measure summarizes utilization of ambulatory care. It excludes mental health or chemical dependency services. The measure is displayed as Visits per 1,000 Member Months. Plan All-Cause Readmission (PAC): For members 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. The FUH measure had an increasing three year trend for the WHPI (25 th percentile), hawk-i (50 th percentile), IA PPO (10 th percentile) and SD PPO (10 th percentile) populations. SD FEP (10 th percentile) and IA FEP (50 th percentile) rates have both remarkably decreased. The LBP had a remarkable improvement for the FEP populations, achieving above the 90 th percentile. The SD PPO population is also above the 90 th percentile QC. IA PPO and WHPI lag behind in the 75 th percentile. Medical record review is needed for the PPC measures. Comparing WHPI to IA PPO, approximately a 63 percentage point increase was seen for the prenatal measure with medical record review. Reviewing the five year trend, rates have been steady with a slight spike for both measures in Emergency department utilization is at a four year low for the WHPI and hawk-i products. This measure is tied to the hawk-i Performance Improvement Project: Child and Adolescent Access to Care. Calculations were not available for the IA and SD PPO and IA and SD FEP populations. Emergency department utilization is tied to the ACO VIS metrics. PAC measures have also decreased for the WHPI and SD PPO products. IA PPO and hawk-i product rates increased. Plan All-Cause Readmissions are indirectly tied to ACO VIS scoring metrics. This is the first year QC was released for the HEDIS measure. The majority of the products are in the 25 th percentile, SD PPO is in the 50 th, and hawk-i is in the 10 th percentile. Barriers to meeting the goal include: Perceived behavioral health (BH) access issue Timely notification of BH admissions and/or discharges impact member discharge outreach Member s lack of engagement with Wellmark s call outreach program Discharge planning and member compliance Health literacy about follow-up care (emergent versus urgent) Wellmark Blue Cross and Blue Shield 13

15 80% Follow-Up After Hosp for Mental Illness (7 days) 70% 60% 51.91% 50% 48.89% 46.57% 46.26% 49.63% 40% WHPI hawk-i 25th 50th 90th 95% Use of Imaging Studies for Low Back Pain 80.46% 79.30% 78.23% 78.25% 79.69% 75% WHPI IA PPO SD PPO SD FEP IA FEP 75th 90th Wellmark Blue Cross and Blue Shield 14

16 100% 90% 80% 70% 60% 50% 40% 30% 20% Pre/Postpartum Care: Prenatal 97.32% 95.13% 93.67% 100% 90% 80% 70% 60% 50% 40% 30% Pre/Postpartum Care: Postpartum 85.89% 87.35% 86.13% WHPI IA PPO 75th 90th WHPI IA PPO 75th 90th Emergency Department Utilization WHPI hawk-i 10th 25th 50th 90th Plan All Cause Readmission: Observed to Expected Ratio WHPI hawk-i IA PPO SD PPO SD FEP IA FEP 50th 75th 90th Preventive Screening Four HEDIS metrics encompass the Preventive Screening subgroups. Cervical Cancer Screening (CCS): Percentage of women ages years of age, who received one or more Pap tests to screen for cervical cancer in 2014 or two years prior. Pap test in conjunction with a negative Human Papillomavirus test only needs to be performed once every five years. Breast Cancer Screening (BCS): Female members ages 50 72, who have had a mammography screening every two years (2014 or year prior) Colorectal Cancer Screening (COL): Percentage of adults years of age, who had appropriate screening for colorectal cancer (FOBT / flexible sigmoidoscopy / colonoscopy) during the applicable measurement period (1 year / 5 year / 10 year) Wellmark Blue Cross and Blue Shield 15

17 Chlamydia Screening (CHL): Percentage of women ages years of age, who were identified as sexually active and who had at least one test for Chlamydia during the measurement year 2014 The measurement for CCS is primarily a medical record review measure looking for the exclusions of having a total hysterectomy. Comparing IA PPO and WHPI rates demonstrates a 12 percentage point increase in the rate with the review of medical records. The point increase can be attributed to finding the applicable exclusions. WHPI demonstrated an upward trend with medical record reviews. IA PPO, IA FEP, SD FEP, and SD PPO all demonstrated population compliance of approximately 68%. Five year trending had a similar pattern for all products and QC. The WHPI population receives reminder postcards regarding annual preventive health exams. IA and SD FEP members received mail files reminding them about their need for mammography testing. IA and SD PPO lag behind. Historically these two groups do not receive additional educational materials. An ACO VIS quality metric is directly related to this quality measurement. The COL measure is also a medical record review measure. If the member receives a colonoscopy the historical lookback can be ten years. COL increased to the 90 th percentile in An ACO VIS quality metric is directly related to this quality measurement. CHL is a physician process and physician communication measure. The product populations are at least percentage points below benchmark and are all at or below the 10 th percentile. The hawk-i population which demonstrates the youngest population had a 21.44% screening rate. Barriers to meeting the goals include: Confusion Changes in recommendations for female cancer screenings Health Literacy Barriers from Gaps in Care Calls: Cost, Time, Personal (Fear, Pain and Procrastination) and Network Availability Disbandment of Iowa Department of Health workgroup on Chlamydia 60% 50% Chlamydia Screening in Women 40% 33.99% 34.46% 33.48% 31.05% 33.76% 30% 20% WHPI hawk-i IA PPO SD PPO 10th 90th Wellmark Blue Cross and Blue Shield 16

18 75% Cervical Cancer Screening 82.00% 79.18% 78.26% 79.38% 77.37% 75% 65% 55% Colorectal Cancer Screening 64.48% 68.13% 72.75% 45% 65% 35% WHPI IA PPO 75th 90th WHPI IA PPO SD PPO 75th 90th Breast Cancer Screening 80% 77.31% 78.87% 73.23% 72.60% 73.22% 70% 60% WHPI IA PPO SD PPO SD FEP IA FEP 75th 90th Pediatric Care Eight HEDIS measures are grouped into two subgroups (Infant and Childhood / Adolescent Health Care) represents pediatric care. They are: Infant and Childhood Health Care o Childhood Immunization Status (CIS) (Combo 2): Percentage of children 2 years of age who had four DTaP, one MMR, three IPV, three Hib, three Hepatitis B and one VZV immunizations during the child s first two years of life by 2014 o Well Child Visits in 1 st 15 months of life (W15): Percentage of members who turned 15 months old during the measurement year, who received six plus visits during their 1 st 15 months of life o Well Child Visits at 3 rd, 4 th, 5 th and 6 th years of life (W36): Percentage of members 3 6 years of age, who had one or more well child visits with a PCP during the measurement year Wellmark Blue Cross and Blue Shield 17

19 o Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (WCC): BMI Total: Percentage of children, 3 17 years of age, who had an outpatient visit with a PCP or OB/Gyn and had a BMI percentile documented Adolescent Health Care o Adolescent Well Child Visits (AWC): Percentage of members age years of age, who had at least one comprehensive well-care visit with a PCP or OB/Gyn during the measurement year 2014 o Immunizations for Adolescents (IMA): Percentage of children who turned 13 years old during measurement year, who had one dose of meningococcal vaccine and one Tdap or TD by their 13 th birthday o Human Papillomavirus Vaccinations (HPV): Percentage of female adolescents who turned 13 during the measurement year that had three HPV vaccinations on different dates between their 9 th and 13 th birthdays o Child and Adolescents Access to Primary Care practitioners (CAP): Percentage of members 12 months 19 years of age, who had a visit with a PCP CIS (Combo 2) is a medical record review measure. The measure was rotated which means the HEDIS medical record reviewed rate was rolled over to current HEDIS year. Rates reached an all-time low in The pregnancy program discusses with new moms about new baby s preventive health care. Capturing the Hep B immunization given at the hospital is the primary driver for the need for medical record review. IMA rates are climbing upward comparing HEDIS 2014 to HEDIS There were legislative changes requiring DTaP immunizations prior to 8 th grade due to recent outbreaks of whooping cough. The HPV measure continues to be a difficult measure to move upward for all product lines, but the low IA and SD rates are within 50 th to 25 th percentile range. Health literacy is the primary barrier to increasing all immunization rates. Both IMA and HPV measurements are included in the hawk-i Performance Improvement Project: Adolescent Health. There was a downward trend for IA FEP W15 measure over the past three years. In contrast SD FEP stabilized over the past three years. They are both in the 25 th percentile. WHPI rates are remarkably higher in the 75 th percentile, but have not made any remarkable changes over the past four years. Both IA and SD PPO lag behind. This measure is directly related to an ACO VIS metric. PPO and WHPI populations are the only membership information provided to the ACO. W36 measurement rates have remained constant over the past five years, except the hawk-i population made a notable rate increase. AWC measurement also had a similar trend only with a lower reported rate and a lower benchmark. WCC: BMI Total measure is a medical record review measure. Only the hawk-i population had their medical records reviewed. Less than 1% of providers are reporting CPT II codes which would demonstrate compliance. WHPI rates for the CAP are in the 75 th percentile where the IA and SD PPO rates are in the 10 th or below the 10 th percentile QC. IA availability standards are met for IA PPO and WHPI. There is a tight margin Wellmark Blue Cross and Blue Shield 18

20 between the 10 th and 90 th percentiles for all age stratifications. This measure is included in the hawk-i Performance Improvement Project: Child and Adolescent Access to Care. Barriers to meeting goals include: SD rates appear lower due to inability to have access to the state immunization registry; use of Public Health rural nurses for immunizations; WHPI chart audits are reflective of Hep B in hospital not a separate claim for the baby; low percentage of hospitals use registry; global billing of birthing event encompasses Hep B vaccine where the birthing mom is indicated as having a Hep B shot Health literacy and provider education practices about adolescent immunizations BMI percentage is not noted in the medical record Physicians continue to just document height and weight and not BMI percentile Childhood Immunization Status (Combo 2) HPV for Female Adolescents 95% 20% 21.21% 83.94% 87.83% 81.02% 10% 14.12% 16.09% 75% 0% WHPI 75th 90th WHPI hawk-i IA PPO SD PPO SD FEP IA FEP 65% 55% Adolescent Well Child Visits 48.33% 47.05% 47.08% 46.90% 46.83% 45% 35% 25% 15% WHPI hawk-i IA PPO SD PPO 10th 25th 50th 75th 90th Wellmark Blue Cross and Blue Shield 19

21 75% 65% 55% 45% 35% Weight Assessment and Counseling: BMI Percentile - Total 51.58% 66.67% 66.67% WHPI hawk-i 50th 75th 90th 90% 80% 70% 60% Well Child visits first 15 months (6+) 76.83% 75.56% 87.64% 83.77% 78.28% SD FEP IA FEP 25th 50th 90th Well-Child 3rd, 4th, 5th and 6th 90% 80% 70% 74.72% 74.17% 75.16% 73.33% 74.54% 60% 50% 40% WHPI hawk-i IA PPO SD PPO 10th 25th 50th 90th Immunizations for Adolescents 80% 70% 60% 50% 40% 30% 20% 10% 0% 44.77% 46.23% 49.09% 46.90% 53.88% WHPI hawk-i IA PPO SD PPO SD FEP IA FEP 10th 25th 90th Wellmark Blue Cross and Blue Shield 20

22 HEALTH AND CARE MANAGEMENT QUALITY PROJECTS Health and Care Management establishes two Utilization Management (UM) program Quality Improvement Projects (QIPs) and two Case Management (CM) program QIPs. The UM QIPs both provide opportunities to impact the member experience and CAHPS scores. They are Improving Documentation for Utilization Management Denial Rationales o Measure: Criteria denied upon by physician Is accurately reflected in denial letter o Goal: Increase compliance to 90% Ensuring Appropriate Timeframes for Utilization Management Decision Making o Measure: UM denials are reviewed and mailed within appropriate turnaround times o Goal: Increase compliance to 90% Improving Documentation for UM Denial Rationales Ensuring Appropriate Timeframes for UM Decision Making Time Period Results Time Period Results 3 rd Qtr (Baseline) 73% 3 rd Qtr (Baseline) 80% 4 th Qtr % 4 th Qtr % 1 st Qtr % 1 st Qtr % 2 nd Qtr % 2 nd Qtr % 3 rd Qtr Pending 3 rd Qtr Pending Different teams within Utilization Management as well as the Medical Director team worked collaboratively to create solutions to this important member experience QIP. Rates continue to fluctuate throughout the quarters. Work continues to be meet goals. Interventions include: Audits to monitor compliance Report metrics to QOC Education provided to nurse s by team leader Nurses document conversations when rationales are changed upon discussion with physicians Evaluation of letter writing process to determine appropriate skill set Collaborative team discussion with NCQA consultant Process for review and education about requests that come late in the day and/or with little clinical information Daily reports produced for monitoring to ensure all denial letters are sent timely The CM QIPs focus on the patient safety with their medication management. CM nurses play a vital role in the member s health and health education. Their understanding and properly documenting the member s medication with provide the CM nurse tools to promote proper medication management. The QIPs are Medication Reconciliation for Member Safety o Measures Wellmark Blue Cross and Blue Shield 21

23 Increase the number of members appropriately screened for medication reconciliation Ensure appropriate interventions and follow up is documented when medication reconciliation is indicated The CM nurse documented the follow up with the member was completed at the next member contact or within 30 days after implementation of the intervention o Goal:93% for measure 1 and 100% for measures 2 and 3 Improve Documentation of Medication List o Measure: The advanced care nurse will correctly document all of the medications o Goal: Increase compliance to 97% Medication Reconciliation for Member Safety Improve Documentation of Medication List Time Period Measure Results Time Period Results rd Qtr (Baseline) 53% 71% 71% 1 st Qtr (Baseline) 73.1% 4 th Qtr % 80% 80% 3 rd Qtr % 1 st Qtr % 91% 91% 2 nd Qtr % 89% 89% 3 rd Qtr % 100% 100% The CM QIP Consent for Case Management maintained meeting established goals in the beginning of The QIP was retired. 1 or 2 files create a barrier for the Medication Reconciliation for Member Safety QIP from meeting its goal. Process and education are the primary drivers for changes in the QIPs. The Improve Documentation of Medication List QIP was approved by the QOC in July There has not been enough trending data to make a concrete assessment. Interventions for these QIPs include: Audits to monitor compliance Audit results shared with staff during team huddles Report metrics to Quality Oversight Committee Education provided to nurse s by team leader Increase quality assurance weighting related to medication reconciliation question on individual team member s performance plans CAHPS MEASURES Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys ask WHPI members to report on and evaluate their experiences with health care. These surveys cover topics that are important to consumers and focus on aspects of quality that consumers are best qualified to assess, such as communication skills of providers and ease of access of health care services. CAHPS measures on the QMP work plan include Wellmark Blue Cross and Blue Shield 22

24 Getting Needed Care Getting Care Quickly Rating of Personal Doctor Rating of Specialist Seen Most Often Claims Processing Customer Service Rating of Health Plan Rating of all Health Care Getting Needed Care and Getting Needed Care Quickly continues to fall short of the 90 th percentile, but exceeds the 25 th percentile QC. Getting appointments with specialists as soon as needed and getting check-up/ routine care appointments as soon as needed had notable decreases in satisfaction. The hawk-i population continues to exceed the 90 th percentile in satisfaction. The interventions reaching out to the ACO populations does not impact specialist care. The Rating of Personal Doctor measure continues to be the same over the past 4 years. The Rating of Specialist seen most often dipped down in 2013 and 2014 from an all-time high satisfaction rating in 2012, but made a slight increase in satisfaction just falling short of the 50 th percentile. The hawk-i population continues to meet or exceed the 90 th percentile in satisfaction for both of these measures. Claims Processing is a measure for WHPI only of how satisfied the members are related to their processing of claims. In 2014, member s satisfaction was above the 90 th percentile where in 2015 satisfaction dipped to the 50 th percentile. A large majority of member dissatisfaction was the paper claims process. Process improvement activities have been started to improve this member experience measure. Member experience interventions have shown to increase the member satisfaction for the WHPI population where the hawk-i population dropped to below the 50 th percentile. Organization focus on the member experience assisted in maintaining a 75 th percentile satisfaction level for the Rating of Health Plan. The hawk-i population continues to exceed the 90 th percentile in satisfaction. Both the WHPI and hawk-i populations exceed the 90 th percentile in satisfaction related to the Rating of All Health Care. Barriers to meeting the 90 th percentile goal includes: Business decisions which effected the member: Pharmacy formulary, Prior-authorization and referral process, and denial process Small sample size for Customer Service Increase activity/ use of mywellmark.com and the mobile app Unknown the type of classification of service issues for the member to call customer service Wellmark Blue Cross and Blue Shield 23

25 Getting Needed Care 100% Getting Care Quickly 95% 93.43% 95% % 91.11% 90% 92.17% % 89.29% 87.87% WHPI hawk-i 75th 90th WHPI hawk-i 75th 90th Wellmark Blue Cross and Blue Shield 24

26 Rating of Personal Doctor Rating of Specialist Seen Most Often 95% 90% 90% 87.06% 88.93% 87.61% 88.66% 86.55% 84.24% 83.25% 82.65% 80% % WHPI hawk-i 50th WHPI hawk-i 75th 90th 75th 90th 100% 95% 90% Claims Processing 93.24% 94.05% 91.60% 95.90% 90.29% 95% 90% Customer Service 85.20% 87.90% 88.80% 92.20% 80% WHPI 50th 75th 90th WHPI hawk-i 50th 75th 90th 95% 90% 80% 75% Rating of Health Plan 74.74% 73.49% 90% 80% Rating of All Health Care 83.86% 84.59% 82.12% % 65% 69.42% 67.18% % WHPI hawk-i 50th WHPI hawk-i 75th 90th 75th 90th Wellmark Blue Cross and Blue Shield 25

27 SATISFACTION SURVEYS Case management services are provided to the FEP population as well as WHPI, IA PPO and SD PPO. Quarterly, the FEP Director s Offices as well as Wellmark, Inc. analyzes Case Management member satisfaction survey results. Overall, the response rate for the FEP CM Satisfaction Survey was less than 5 per quarter, decreasing the validity of the survey. Staffing changes impacted the member satisfaction in 1 st Quarter 2015, but member satisfaction rebounded in the 3 rd Quarter. All areas of member satisfaction was 90% or above by the 3 rd Quarter of Member experience is a corporate initiative. The Member Loyalty Index (MLI) is measured on a rolling 12 month cycle. Corporate education and interventions have taken place to impact member satisfaction. MLI numbers met targeted rates. CONTINUITY AND COORDINATION OF CARE Continuity and coordination of medical care and continuity and coordination between medical care and behavioral health care has shown to improve the member s health care experience and health outcomes. Annually, a provider satisfaction survey is sent to primary care providers, behavioral health care providers, and specialists. The survey assesses many aspects of the provider s interactions with Wellmark, but also their satisfaction with receiving medical information and the quality of the medical information as well. Significant decreases were seen in both the receiving of feedback/reports from Behavioral Health clinicians and Specialists regarding patients in their care. The movement to electronic medical records and shared medical records between the primary care practitioners and the specialist/ behavioral health clinicians decreases the member s knowledge of when medical records have been shared. Increases in timeliness and satisfaction with feedback/ reports from specialists were also seen for the provider population. Where timeliness and satisfaction with feedback/ reports from Behavioral Health clinicians for patients in your care was seen. Member s satisfaction with the continuity and coordination of the health care remained constant during the past 3 years according the CAHPS survey. Members are not experiencing the same dissatisfaction about continuity and coordination of care as providers. Providers responded negatively in the Provider Satisfaction survey about this topic. The survey is distributed to Iowa WHPI contracted providers. CONSUMER TRANSPARENCY Customers have an increasing desire for quality consumer information. Wellmark has two consumer transparency initiatives to drive educated quality health care decisions. They included the Patient Review of Physicians (PRP) program and the Physician Quality Measurement (PQM) program. Both of these programs took a larger role as a QMP activity. The QOC approved the expansion from 2 PQM measures to 12 PQM measures. Corporate Marketing and Communication increased their involvement with the PQM program to increase the member s knowledge of the tools. Wellmark Blue Cross and Blue Shield 26

28 QUALITY MANAGEMENT PROGRAM ACTIVITIES Activities Start End Resources Needed Share aggregate HEDIS results with providers via web / Blue Ink New software capabilities (Verisk) to include reporting for monitoring New software capabilities (Verisk) to include reporting for monitoring 01/15 12/15 Health and Care Management (HCM), Corporate Communications (CC) 01/15 12/15 HCM, Information Technology (IT), Verisk 01/15 12/15 HCM, IT Disease Management Activities 01/15 12/15 HCM, IT, WebMD Member education (web, portal, Blue) 01/15 12/15 HCM, CC Explore options with Disease Monitor tool 01/15 12/15 HCM ACO Value Index Scoring dashboard documents Annual reminder card to all female WHPI members, fully insured Alliance & Blue Select and purchased Self-Funded 01/15 12/15 Network Engagement (NE) 01/15 12/15 HCM Design provider educational pieces 01/15 12/15 HCM, CC CareNet call campaign to member to educate about value of spirometry testing Depression care guide and screening tool available to providers on Wellmark.com 01/15 12/15 HCM, Business Intelligence and Reporting, CareNet 01/15 12/15 HCM, Behavioral Health Consultant (BHC), CC, Website Behavioral Health Forum 01/15 12/15 NE, CC, BHC ADHD clinical guideline for providers available on Wellmark.com update every 2 years (March 2014) and with new recommendations 01/15 12/15 NE, CC, BHC, Web Online self-management tools WebMD 01/15 12/15 WebMD Inclusion of discharge planning questions in the Provider Satisfaction Survey CareNet discharge call program: Members follow up arrangements and offer to assist in making appointments if needed 01/15 12/15 HCM 01/15 12/15 HCM Wellmark Blue Cross and Blue Shield 27

29 Activities Start End Resources Needed Utilization Management and Advanced Care Management Programs 01/15 12/15 HCM Wellmark Pregnancy Program activities 01/15 12/15 HCM Member portal reminder process targeted preventive messaging (includes identified members delinquent with screenings) Annual immunization reminder cards mailed to parents of newborns, 12 & 18 month old infants and 10, 11 & 12 year old children Blue Ink article directed at hawk-i members focusing on importance of preventive care; drafting in 6 th grade reading level Verisk HEDIS tool to determine class of physicians who are causing greatest impact to the measure of low back pain American Imaging Management (AIM) provides pre-authorization for defined set of diagnostic imaging 01/15 12/15 MyWellmark 01/15 12/15 HCM, IT, JT Direct, CC 01/15 12/15 CC 01/15 12/15 HCM 01/15 12/15 HCM ACRONYMS AAB ACO ADD AMB AMM ASM AWC BCS BHC CAHPS CAP CBP CC CCS CDC CHL CIS Avoidance of Antibiotic treatment in Adults with Acute Bronchitis Accountable Care Organizations Follow-up Care for Children prescribed ADHD Medications Ambulatory Care Antidepressant Medication Management Use of Appropriate Medications for People with Asthma Adolescent Well Child Visits Breast Cancer Screening BH Consultant Consumer Assessment of Healthcare Providers and Systems Child and Adolescents Access to Primary Care practitioners Controlling High Blood Pressure Corporate Communications Cervical Cancer Screening Comprehensive Diabetes Care Chlamydia Screening Childhood Immunization Status Wellmark Blue Cross and Blue Shield 28

30 COL COPD CWP DHS FEP FUH hawk-i HCM HEDIS HPV IMA IT LBP MSC NE PAC PBH PCE PPC QC QMP SPR URI VIS W15 W36 WCC WHPI Colorectal Cancer Screening Chronic Obstructive Pulmonary Disease Appropriate Testing for Children with Pharyngitis Iowa Department of Human Services Federal Employee Plan Follow-up After Hospitalization for Mental Illness Healthy and Well Kids in Iowa Health and Care Management Healthcare Effectiveness Data and Information Set Human Papillomavirus Vaccinations Immunizations for Adolescents Information Technology Use of Imaging Studies for Low Back Pain Advising Smokers to Quit Network Engagement Plan All-Cause Readmission Persistence of Beta-Blocker after Heart Attack Pharmacotherapy for Chronic Obstructive Pulmonary Disease(COPD) Exacerbation Timeliness of Prenatal and Postpartum Care Quality Compass Quality Management Program Use of Spirometry Testing in the Assessment and Diagnosis of COPD Appropriate Treatment for Children with Upper Respiratory Infection Value Index Score Well Child Visits in 1 st 15 months of Life Well Child Visits at 3 rd, 4 th, 5 th and 6 th years of life Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents Wellmark Health Plan of Iowa LEGEND Graph Line Meaning Wellmark Health Plan of Iowa (WHPI) Healthy and Well Kids in Iowa (hawk-i) Iowa PPO (IA PPO) South Dakota PPO (SD PPO) Iowa Federal Employee Program (IA FEP) Wellmark Blue Cross and Blue Shield 29