2014 Quality Improvement and Utilization Management Evaluation Summary INTRODUCTION The Quality Improvement (QI) and Utilization Management (UM) Program Evaluation summarizes the completed and ongoing quality improvement and utilization management activities and evaluates the overall effectiveness of Kentucky Health Cooperative (KYHC) Quality Improvement Program (QIP). The Clinical Care Integration Department has established annual reporting of QI/UM initiatives, activities, results and analysis by completing the QI/UM Program Evaluation for this first reporting period, plan year 2014. At this time, it does not allow for timely reporting of Healthcare Effectiveness Data and Information Set (HEDIS ) results and other annual measurements since this is the first year baseline evaluation. Therefore, this evaluation is focused on activities completed between January 1, 2014 and December 31, 2014. It addresses the Quality Improvement (QI) Program Description, the Utilzation Management (UM) Program Description, the QI/UM Work Plan and related QI/UM projects, studies and initiatives during this defined time frame. The 2014 QI/UM Evaluation also provides an overview and summary of the results of KYHC s clinical and service initiatives which affect its membership. The 2014 program results are evaluated, tracked and trended herein for the purpose of overall program evaluation and planning for the year 2015. The 2014 QI/UM Work Plan was developed to meet the obligations outlined in the QI/UM Program Descriptions, NCQA accreditation standards and both state and federal contractual requirements; it includes quality improvement goals and objectives for the year. The KYHC Board of Directors approves the QI/UM Program Evaluation in order to fulfill its responsibility to managed care members, the community, regulatory agencies and accreditation bodies. The QI Program Description, the UM Program Description, the QI/UM Work Plan and QI/UM Program Evaluation are reviewed and approved at least annually by the Quality Improvement Committee (QIC) and the KYHC Board of Directors (BOD). MISSION STATEMENT Kentucky Health Cooperative exists to promote community health and well-being by engaging the members and practitioners it serves in the valued delivery of quality coverage of integarated health care services. The organization s mission encompasses outreach to all eligible individuals with a particular focus on population segments previously ignored by other health insurers. Commonly known as the working uninsured, Kentucky Health Cooperative will seek to help those individuals who need health insurance coverage, but are not eligible for public assistance in other forms. As Kentucky Health Cooperative will operate as a statewide organization, it will devote equal effort to promote coverage of individuals and small groups in rural as well as urban settings.
PURPOSE The purpose of the QI/UM Program Evaluation is to plan, implement and monitor ongoing efforts that demonstrate improvements in member safety, health status, outcomes, and satisfaction. The quality improvement program is evaluated to determine its effectiveness and how the program has improved care and service to members. PROGRAM OVERVIEW Clinical Care Integration (CCI) Department Structure and Resources The CCI Department resources did not always meet the needs of the QI/UM Program during 2014, resulting in the need to hire, train and maintain both UM Nurse Managers and Intake Coordinators. The following positions and staff were involved in various QI/UM Program activities: Vice President for Clinical Care Integration (VPCCI) serves as the Senior Executive for Quality Initiatives Director, Quality Improvement (RN) Director, Utilization and Case Management (RN) Appeals Coordinators (1) Case Management Coordinators (2) Disease Management Coordinators (2) Intake Coordinators (4) Pharmacy Coordinator (2) Program Coordinator (1) QI Coordinators (1) QI Project Manager (1) Utilization Management Nurses (6) Chief Medical Officer (1) (part-time) Committee Structure During 2014, the following Committees supported the QI/UM Program: Board of Directors KYHC s Board of Directors (BOD) has the ultimate authority and accountability for the QI/UM Program. The Board of Directors delegates the authority of the QI/UM Program to KYHC s CEO who delegates the daily operations of the QI/UM Program to the Vice President of Clinical Care Integration (VPCCI). The BOD met eleven times during 2014. At each meeting, QI/UM activities were reviewed, evaluated, and approved and/or recommendations were made related to the activities.
Quality Improvement Committee (QIC) The Quality Improvement Committee (QIC) is a key committee at KYHC and provides delegated oversight of the QI/UM Program on behalf of the BOD and is charged with developing and implementing the QI/UM Program. The QIC reports directly to the BOD. The QIC provided direction to, and oversight of, those management and subcommittee functions responsible for the provision of clinical care and services. The QIC is responsible for approval of the annual QI and UM Program Descriptions, review of the QI/UM Work Plan and Annual QI/UM Evaluations. The QIC is also responsible for the review and approval of clinical and preventive health guidelines, UM criteria, under- and over-utilization findings, clinical and service audit findings, and administrative policies that have an impact on the member s health care. The QIC provided recommendations regarding practitioner education and interventions, health education programs, and other Plan initiatives. It is charged with accountability for the review of member complaints for quality of care and sentinel events having the potential for an adverse effect on members. The QIC reviewed the aggregate data of member complaints and surveys, as well as the results of practitioner audits. The QIC met seven times during 2014. Credentialing Committee (CC) The CC is responsible for managing the Credentialing Program to credential and re-credential providers, practitioners, facilities, and ancillary providers. The CC is a statewide committee that incorporates data identified through QI and UM process as indicated in its ongoing monitoring and re-credentialing process. The CC reports directly to the QIC; it met eight times during 2014. Utilization Management Committee (UMC) The UMC is responsible for the review and appropriate approval of medical necessity criteria, protocols, policies and procedures. The UMC monitors and analyzes relevant data to detect and correct patterns of potential or actual inappropriate under- or over-utilization, which may affect health care services, as well as the coordination of care, appropriate use of services, resources and member and practitioner satisfaction with the UM process. Annually, the UMC reviews and approves the Utilization Management Program Description, Work Plan and Program Evaluation. The UMC reports directly to the QIC; it met five times during 2014. Complaint and Appeals Committee (CAC) The CAC oversees all member complaints and appeals activities to maintain compliance with the contractual regulatory and accreditation requirements and reviews. The CAC also oversees delegated entity complaints for KYHC members. The CAC monitors all follow-up review resolutions related to member complaints and appeals and they review member complaints and appeals for trends and/or patterns and categorizes accordingly. The CAC reports directly to the QIC and meets quarterly. The CAC met once during 4 th quarter and reviewed 1 st, 2 nd and 3 rd quarter complaints and appeals.
QI/UM PROGRAM EFFECTIVENESS During 2014 the QI/UM Program continued its collaboration with all organizational departments to facilitate continuous improvement in performance by empowering all stakeholders through education, communication, and evaluation. KYHC has continued to improve the quality of care and services provided to the membership through continuous assessment of patterns and trends and identification of barriers to quality outcomes. Strengths and Accomplishments 1. All Plan Policies and Procedures were reviewed and updated as needed 2. Developed multiple QI/UM initiatives 3. Maintained ongoing audits of Denial and Appeal Files 4. Access goals for Primary Care and High Volume Specialist were exceeded 5. HIPAA Audits were conducted by Compilance on all KYHC employees 6. Completed verification of licensure on 100% of licensed employees 7. All UM Medical Necessity Appeals met Turn Around Time (TAT) less than or equal to 30 days 8. All DOI complaints resolutions were completed in a timely manner 9. KYHC Provider Manual was made available to practitioners on the provider tab of the KYHC public website 10. Placed links on the Clinical Care web page for Clinical Practice Guidelines and Preventive Care Guidelines adopted by KYHC 11. New direct contract practitioner orientation program is conducted monthly 12. Annual Compliance Training completed for all KYHC employees in 2014 13. Identified various process flows for managing prior authorizations and educated the practitioner network of the various UM requirements 14. Maintained consistency in utilization care manager application of InterQual medical necessity criteria. 15. Established ongoing delegated oversight with Behavioral Health, Pharmacy, Vision Services and Helpline Opportunities for Improvement 1. Maintain regularly scheduled committee meetings 2. Increase the number of participating practitioners in the following committees a. Quality Improvement Committee b. Credentialing Committee 3. Educate participating practitioners on KYHC appointment and after hours standards 4. Initiate the Complex Case Management Program 5. Increase resources in the CCI department 6. Obtain Baseline HEDIS Data 7. Obtain Baseline CAHPS Qualified Health Plan Member Experience Data 8. Increase the Complaints and Appeals Workgroup Meetings to four times a year 9. Meet TAT for UM Medical Necessity initial determinations
10. Initiate Perinatal Depression Screening Awareness Program 11. Initiate Medical and Behavioral Health Continuity and Coordination Meetings between KYHC and MHNet 12. Develop health and wellness programs utilizing self-management tools 13. Develop tools to assist members in obtaining information regarding claims processing, ordering an ID card and managing pharmacy benefits online Conclusion The above evaluation focuses not only on KYHC strengths and accomplishments, but identifies several opportunities for improvements in our processes, our training methods, and ways in which KYHC procures and shares information. The evaluation highlights the need for continuous quality improvement with regard to stabilize KYHCs operational components affecting responsiveness to members, with regard to member services call center operations, UM staffing and administrative processes. Attracting almost double the anticipated enrollment into the KYHC plan offerings significantly challenged the ability of the plan to have administrative processes and procedures in place to meet the needs of members, particularly given the unusual mix of consumers without previous health plan experience and the adverse selection that occurred with the enrolled patient mix. According to the Exchange, KYHC received approximately 90% of the State s High Risk Pool population that enrolled with a Qualified Health Plan in 2014. Based upon the existing patient demographics and utilization patterns, KYHCs patient mix maintains a higher level of acuity than most traditional commercial populations. KYHC has taken actions to avoid significant net new enrollments, and has adjusted staffing, or engaged external resources to better meet the needs of its members going forward. Conversely, KYHC was able to offer health benefit plans that appealed to more consumers than it had anticipated. This allowed the plan to enroll a sufficient membership base to begin baseline assessments of population-based underlying health status, evaluation of chronic health care needs, and identification of disease specific conditions, as well as early identification of opportunities for improvement. These opportunities align closely with the KYHCs mission of providing quality health insurance benefits access to consumers in both urban and rural areas of the state. The first year of operations resulted in providing an exciting new choice in Kentucky for consumers. KYHC is committed to continuous quality improvement in its operational functions to better focus on its mission: identifying member needs, designing programs/interventions that lower costs while continuing to maintain quality, and helping improve health outcomes for KYHC members. KYHC has the ability, with its relatively small size, to be nimble and responsive to marketplace demands, to engage with members and practitioners in communities, and to be
innovative with regard to utilization strategies that lead to health outcomes improvement. Being one of only two statewide issuers on the Kentucky Exchange provides KYHC with the unique opportunity to work in small rural communities, considering the social determinants such as lack of education, transportation, income, cultural, or other common social barriers which may negatively affect patient compliance, use of preventive measures, and achievement of personal health outcomes. The opportunity to positively affect change in these areas is further strengthened by KYHC s proximity to its membership. In addition, the baseline data gathered reflects opportunities for KYHC to provide focused education to its members, practitioners, and others in regard to the benefits of maintaining health insurance, the importance of health improvement and health maintenance, and the prevention of health complications. This not only impacts the members themselves, but extends to other stakeholders, such as their families, their communities, and employers. Many of our members report anecdotally that they have never had consistent insurance coverage prior to enrolling this year. This may explain the unique profile that is the average KYHC member. Our members are still learning how to appropriately access and engage the healthcare system. Many are for the first time in a long-time establishing care with a provider. Even more are just beginning to learn how to be their own healthcare advocates. They are learning how their health insurance works and how to receive benefits. There is a learning curve to this process which may explain the utilization rates we are experiencing. While the goals described are ambitious, given the strides made this past year as a brand new start-up insurer, KYHC is confident we will continue to develop multiple strategies for improving our product, our member s access to health care and the quality of care provided to our members. The CO-OP concept, (i.e. nonprofit, member-governed health plans), has proven a very attractive option to both rural and urban constituents. Cooperatives engender a greater level of trust from members and practitioners than typical commercial insurers tend to experience. Member trust in a health plan is a foundational building block for a positive working relationship. Offering a reliable benefits plan, with quality coverage, at a fair price, with a broad network of providers, affords us the trust of our members to educate them, advocate for them and expand their options for care, and in the process, positively change members lives. It also provides a platform which extends beyond the Member, and integrates working with their practitioners s and healthcare facilities, to achieve improved overall health outcomes for the Member, their families, their employers and the greater community, and ultimately, for a healthier Kentucky