Final Evaluation Of 2015 Quality Improvement Programs for Commercial HMO, EPO Products Marketplace HMO, EPO Products MercyHealth Employee Health Benefit Plan
October 2016 MercyCare HMO 2015 Quality Improvement Program Evaluation
TABLE OF CONTENTS
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EXECUTIVE SUMMARY
Introduction
MercyCare Insurance Company (MercyCare) is dedicated to providing high quality healthcare and personalized service to our members by continually seeking to improve health care quality, safety, availability and transparency in addition to improving our business practices in ways that increase member satisfaction with their healthcare and understanding of their insurance benefits.
This evaluation will provide a detailed review of the overall effectiveness of our Quality Improvement Program by examining the following:
HEDIS® scores as compared to benchmarks CAHPS® scores as compared to benchmarks Progress with quality initiatives Monitoring safety Summary of overall findings and future plans.
National Recognition by NCQA
MercyCare HMO products, which include our EPO and the MHS Employee Health Benefit Plan have been accredited by the National Committee for Quality Assurance at least at a Commendable status since 2001. NCQA rating of health plans changed last year and they will no longer give national HMOs an absolute ranking but are using a “five star” ranking system. MercyCare HMO is given a ranking of “four stars” currently.
Our Marketplace HMO and EPO products were reviewed in 2016 for the first time along with our HMO NCQA certification renewal survey. A set of HEDIS metrics are also run on these Marketplace Qualified health plans but in most instances we had too few members in the measure to have them reported. Where they are we have so indicated in each measure.
Because our PPOs are issued by MCIC not MCHI, our Marketplace PPO had to be separately reviewed this year and passed. Because of the low number of members and no HEDIS data because of that we can only achieve and did achieve an “accredited” rating.
Quality Performance: HEDIS
NCQA evaluates the organization’s performance on the required HEDIS® measures against applicable benchmarks and thresholds by product line in addition to comparison to our largest regional competitor, Dean Health Plan. NCQA assigns points for certain HEDIS clinical measures based on whether the regional and national results fall in the following ranges:
0 – 24th percentile 25th – 49th percentile 50th – 74th percentile
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75th – 89th percentile 90th percentile and above
Thirty five measures are defined in HEDIS® 2015 for measurement year 2015 and are included in the NCQA score. However, MercyCare was scored on only thirty measures, as there were an inadequate number of members who fell into the following measures:
1. Persistence of Beta-Blocker Treatment after a Heart Attack 2. Follow-up for Children Prescribed ADHD Medication (Both Rates) 3. Management of COPD Exacerbation (Both Rates) 4. Medical Assistance With Smoking and Tobacco Use Cessation
During the 2015 measurement year the Use of Spirometry Testing in the Assessment and Diagnosis of COPD was removed as a HEDIS Measure, and replaced by Pharmacotherapy Management of COPD Exacerbation. Other changes to HEDIS include the additions of the Asthma Medication Ratio measure and the Plan All-Cause Readmissions measure.
Table 1 contains measures that performed above the 90th percentile benchmark. Eleven measures or 37% of measures fall into this category.
Table 1: 2016 HEDIS® Measures above the 90th Percentile
MercyCar 2015- e HMO 90th 75th 50th 2014 Measure Score Percentile Percentile Percentile Adult BMI Assessment 94.48 -1.32 91.04 84.27 74.00 Antidepressant Medication Management Effective Acute Phase Treatment 77.40 1.30 74.30 70.96 66.57 Antidepressant Medication Management Effective Continuation Phase Treatment 65.54 14.44 58.76 55.30 50.49 Medication Management for People with Asthma: Medication Compliance 75% 61.79 8.89 57.05 51.79 47.11 Comprehensive Diabetes Care: Medical Attention for Nephropathy 93.50 4.50 93.08 91.16 89.05 Comprehensive Diabetes Care: Blood Pressure Control [<140/90] 77.57 8.97 75.27 68.75 59.12 Comprehensive Diabetes Care: HbA1c Control [<8.0%] 65.83 5.83 65.67 60.95 55.47 Controlling High Blood Pressure 75.17 11.17 74.07 66.38 56.38
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Flu Vaccinations for Adults Ages 18-64 59.71 -3.99 58.04 53.22 47.59 Prenatal and Postpartum Care - Postpartum Rate 91.79 6.29 86.76 81.41 72.21 Use Of Imaging Studies for Low Back Pain 84.65 0.02 82.83 79.49 75.26
Table 2 contains measures that performed between the 75th and 90th percentile benchmarks. Eight measures or 27% of all measures fell into this band this year.
Table 2: 2016 HEDIS® Measures between the 75th and 90th Percentiles
MercyCare HMO 2015-2014 90th 75th 50th Measure Score Percentile Percentile Percentile Asthma Medication Ratio 81.48 0.37 83.71 81.22 78.42 Breast Cancer Screening 76.75 4.85 80.18 75.38 71.02 Cervical Cancer Screening 79.73 1.63 81.15 77.43 73.71 Colorectal Cancer Screening 67.70 2.40 71.64 66.31 59.51 Comprehensive Diabetes Care: Eye Exams 67.30 -2.70 68.98 58.39 48.91 Comprehensive Diabetes Care: HbA1c Control Poor [>9.0%] 25.37 -0.63 21.90 27.37 34.03 Follow Up After Hospitalization for Mental Illness (7-Day Rate) 59.38 N/A 65.79 58.65 49.82 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents - BMI Percentile 78.15 -3.05 82.22 71.17 57.29
Table 3 contains measures that performed between the 50th and 75th percentile benchmarks. Four measures fell into this performance band, which equates to 13% of the total measures scored.
Table 3: 2016 HEDIS® Measures between the 50th and 75th Percentiles
MercyCare 2015- 75th HMO 2014 90th Percentil 50th Measure Score Percentile e Percentile Appropriate Treatment for Children With Upper Respiratory Infection 90.96 -5.24 95.05 92.25 89.15
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Immunizations for Adolescents (Combo 1) 76.73 1.23 87.22 78.69 70.59 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents - Counseling For Nutrition 62.25 2.65 79.23 67.89 57.57 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents - Counseling For Physical Activity 58.72 3.92 73.97 63.10 52.38
Table 4 contains measures that performed below the 50th percentile benchmarks. Seven measures fell into this category this year or 23% of the total measures scored.
Table 4: 2016 HEDIS® Measures below the 50th Percentile
MercyCare 75th 2015- HMO 90th Percentil 50th 25th 2014 Measure Score Percentile e Percentile Percentile Appropriate Testing for Children With Pharyngitis 73.12 -3.98 92.29 88.33 83.67 76.99 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 22.09 -1.41 38.71 29.00 24.51 20.59 Childhood Immunization Status (Combo 10) 42.86 -1.84 62.89 56.59 49.24 39.21 Chlamydia Screening in Women 41.20 0.60 60.22 50.91 43.38 38.02 Human Papillomavirus Vaccine for Female Adolescents 12.36 -11.94 23.60 18.73 14.77 11.76 Initiation & Engagement of Alcohol & Other Drug Dependence Treatment (Engagement Total) 11.54 -21.26 18.76 15.57 12.34 9.28 Plan All-Cause Readmissions : Observed- to-Expected Ratio 0.8521 -0.3579 0.6385 0.7394 0.8060 0.8803
Measurement year 2015 was a year of mixed results but overall our points awarded for HEDIS measures were up by one tenth of a point. All of the measurements which scored above the 75th percentile showed further improvement from the prior year’s scores. Breast cancer screening and blood pressure control showed continued improvement with fifteen and ten percent improvements in the last three years respectively. Wherever we can, there are quality
Presented October 2016 - 6 - MercyCare HMO 2015 Quality Improvement Program Evaluation initiatives for continuous improvement. WCHQ has recently added additional measures including adolescent immunizations and chlamydia testing which will result in additional initiatives at MercyHealth that will synergistically help the health plan achieve improved results..
We continue to face some physicians who disagree with HEDIS standards or believe compliance with them would result in lower patient satisfaction:
o Residency program teaches residents that a strep test is not necessary to diagnosis strep throat in classic cases. There is literature to support this but there is also much literature that refutes it. This has kept the children with pharyngitis measure below the 75th percentile for five years. o We have held a number of in-service sessions with OBGYN physicians regarding the HEDIS Chlamydia measure. This measure tracks the CDC recommendation that EVERY woman under the age of 26 who is sexually active should be screened annually for chlamydia. They have repeated expressed concerns that women would feel labeled as promiscuous if the provider brings up the testing.
Quality Performance: CAHPS®
The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program develops and supports the use of a family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care. CAHPS surveys include ratings of personal doctors and other health care staff, as well as an overall rating of the health plan, and asks patients and consumers to report on their experiences with health care services.
Members chosen must have been with the plan for the entire previous plan year and must be a minimum of 18 years old. Members first receive a written survey and can either fill it out and return it or complete it online. Members who do not respond will receive reminder notices and finally a telephone call from the survey vendor.
MercyCare is scored on 7 items for CAHPS®. They are: Rating of the Health Plan, Customer Service, Getting Needed Care Composite, Rating of All Health Care, Rating of Personal Doctor, Rating of Specialist, and Getting Care Quickly Composite, Two measures were removed during the 2015 measurement year, Claims Processing Composite and How Well Doctors Communicate.
Table 5 contains the CAHPS® Measures that fell above the 90th Percentile. Two measures or 29% of all measures scored were above the 90th Percentile.
Table 5: 2015 CAHPS® Measures above the 90th Percentile MercyCare 75th 50th 2015- HMO 90th Percentil Percen 2014 Measure Score Percentile e tile Rating of Personal Doctor (8+9+10) 89.90 -1.10 88.68 86.64 84.75 Rating of All Health Care (8+9+10) 83.39 1.79 82.72 79.87 77.02
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No CAHPS® measures which were scored fell between the 75th & 90th Percentile during the 2015 measurement year. Table 6 shows the CAHPS® Measures between the 50th and 75th Percentile. One measure or 14% of all measures scored fell between the 50th and 75th Percentile.
Table 6: 2015 CAHPS® Measures between the 50th and 75th Percentile
MercyCare 2015- 75th 50th HMO 2014 90th Percentil Percen Measure Score Percentile e tile Rating of Health Plan (8+9+10) 62.36 5.46 74.92 68.03 56.10
Table 7 shows the CAHPS® Measures below the 50th Percentile. Four measures or 57% of the scored measures were below the 50th Percentile.
Table 7: 2015 CAHPS® Measures below the 50th Percentile
MercyCare 2015- HMO 2014 90th 75th Measure Score Percentile Percentile 50th Percentile Getting Care Quickly 82.78 -3.42 89.83 87.80 85.86 Getting Care Needed 86.62 -4.38 91.05 89.39 87.81 Customer Service 84.01 -5.39 92.50 90.47 88.06 Rating of Specialist Seen Most Often (8+9+10) 82.35 -3.25 88.65 86.14 83.64
Our goal is to perform at or above the 75th percentile benchmark, and ultimately, have as many measures possible over the 90th percentile benchmark. Individual Report Cards and Departmental and System-wide Dashboards are used to reach these goals. Action plans are required on an annual basis for any measures that are on a report card or dashboard and do not meet the targeted goal.
Quality Performance: Safety
The safety of our members is of the utmost importance. Our commitment to ensuring safety is addressed in the following ways: member education, monitoring adverse events, medical record audits, site visits, member complaint resolution process, pharmacy management, continuity and coordination of care projects, and clinical practice guidelines. See page 64 of this evaluation for additional information regarding these important safety items.
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HEDIS® REVIEW & ANALYSIS
The following sections contain:
A Description of the Measures 2015 Quality Improvement Activities and Initiatives Identified Barriers Quantitative Analysis Qualitative Analysis 2016 Action Plans
For detailed work plans see document 2017 Commercial & Medicaid Work Plans
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Antidepressant Medication Management
The percentage of members 18 years of age and older with a diagnosis of major depression and were newly treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported.
Effective Acute Phase Treatment: The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 84 days (12 weeks).
Effective Continuation Phase Treatment: The percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 180 days (6 months).
Quality Improvement Activities & Interventions
None in 2015 due to identified barrier
Identified Barriers
With ICD9 coding and the complexities of combining pharmacy data with visit data, we have been unable to create a usable report to effectively target the population in real time for a timely intervention that would affect both measures. The department’s only Access Programmer was not able to complete an ICD10 strategy prior to his departure.
Quantitative Analysis for AMM – Acute Treatment
2016 HEDIS® performance is above the 90th percentile for the fifth year in a row. Performance not significantly different than the primary regional competitor Trend is flat 2015 MARKETPLACE QRS is 82.61%
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Qualitative Analysis
The very high score in HEDIS 2012 and the marked improvement in 2011 were due to an RN disease management program we had in place at the time. However, this program enrolled so few people while being so time intensive that it was deemed as a poor use of resources. Over the last decade there has been consistent improvement in underlying clinical practice in our network.
Quantitative Analysis for AMM – Continuation of Treatment
2016 HEDIS® performance is above the 90th percentile Performance is above the primary regional competitor 2015 MARKETPLACE QRS is 60.87%
Qualitative Analysis
The performance level of this measure had been steadily improving since 2005 but results have been inconsistent for three years. The graph suggested there might have been some data irregularities in the HEDIS 2014 submission. Renewed attention to this measure is prudent. It is noted that the drop off in compliance is three months into treatment and this would be easier to manage an intervention at the health plan.
Action plan
The new Access Programmer is working on a strategy for identifying members who are not filling their scripts real time to allow timely reminder calls in 2017
Presented October 2016 - 11 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Appropriate Testing for Children with Pharyngitis
The percentage of children 2–18 years of age, who were diagnosed with pharyngitis, dispensed an antibiotic and received a group A Streptococcus (strep) test for the episode. A higher rate represents better performance (i.e., appropriate testing).
Quality Improvement Activities & Interventions
Emphasized at all primary, emergency and urgent care physician and nurse practitioner orientations throughout 2015 and 2016.
No staff interventions in 2015 due to other priorities and open positions.
Identified Barriers
Some years ago, Secondary diagnoses are not being coded and patients treated for exposure miscoded as having a diagnosis of strep pharyngitis.
Some providers persist in the belief that strep throat can be clinically diagnosed including some attending physicians at the residency program. This continues to have a major effect on our results.
Quantitative Analysis
2016 HEDIS® performance is below the 50th percentile Slightly below regional competitor Stable trend or slight deterioration over the last seven years 2015 MARKETPLACE QRS is 100.00%
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Qualitative Analysis
Practitioners have continued to prescribe antibiotics without performing a strep screening ~ 20% of the time.
Action plan
Retrospective review for billing errors and omissions in fall 2017.
Emphasize at all primary, emergency and urgent care physician and nurse practitioner orientations throughout 2016 and 2017.
Appropriate Treatment for Children with Upper Respiratory Infection
The percentage of children 3 months–18 years of age who were given a diagnosis of upper respiratory infection (URI) and were not dispensed an antibiotic prescription.
Quality Improvement Activities & Interventions
Emphasized at all primary, emergency and urgent care physician and nurse practitioner orientations throughout 2015 and 2016.
No staff interventions in 2015 due to other priorities and open positions.
Identified Barriers
Secondary diagnoses that exclude children from the measure sometimes not coded.
Quantitative Analysis
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2016 HEDIS® performance is above the 75th percentile Performance comparable to regional competitor Flat trend over the last five years 2015 MARKETPLACE QRS is 100.00%
Qualitative Analysis
Emphasize at all primary, emergency and urgent care physician and nurse practitioner orientations throughout 2016 and 2017.
Chart review for potential exclusions in fall 2017.
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
The percentage of adults 18–64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription.
Quality Improvement Activities & Interventions
Emphasized at all primary, emergency and urgent care physician and nurse practitioner orientations throughout 2015 and 2016.
No staff interventions in 2015 due to other priorities and open positions.
Identified Barriers
Not all diagnosis codes are added.
Practitioners give an antibiotic prescription to be filled in the next couple of days if the patient is not feeling better.
Practitioners prescribing antibiotics for viral infections.
Co-morbid conditions that may have excluded the member from the measure are documented under past medical history but are not up to date; therefore, the diagnosis code cannot be added.
Because of pertussis outbreaks in recent years in Wisconsin, physicians are more apt to treat coughs with azithromycin.
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Quantitative Analysis
2016 HEDIS® performance is below the 50th percentile Unfavorable comparison to regional competitor Markedly variable performance 2015 MARKETPLACE QRS is 16.67%
Qualitative Analysis
Reported rate has been erratic but we and our auditors have not identified any methodological errors. Chart review of the potential non-hits is beneficial. Chart review indicates physicians are continuing to prescribe antibiotics for bronchitis.
Action plan
Emphasize at all primary, emergency and urgent care physician and nurse practitioner orientations throughout 2016 and 2017.
Retrospective review for billing errors and omissions in fall 2017.
Breast Cancer Screening
The percentage of women 50–74 years of age who had a mammogram to screen for breast cancer within 24 months of the last one.
Quality Improvement Activities & Interventions
Identified and sent letters and educational inserts to members appropriate for the measure that had not received a mammogram screening and encouraged them to do so.
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Various Mercy Legacy initiatives to identify and engage women needing mammography.
Barriers Identified
Difficulty is observed by women who:
Do not schedule mammograms. Do not routinely visit their gynecologist or primary care physician. Do not obtain Well-Woman Exams. Have tests ordered by their PCP but then never schedule with radiology. Survey conducted in 2013 with over a hundred respondents showed to our surprise that women who don’t get mammograms were not aware that this has been available at no copay or patient liability for over a decade in Wisconsin
Quantitative Analysis
2016 HEDIS® performance is above the 75th percentile Improved performance from the prior year with favorable trend over the last three years 2015 MARKETPLACE QRS is 69.57%
Qualitative Analysis
Interventions and attention at the MHS and MercyCare have resulted in an uptrend in the past three years.
Action plan
Mercycare and MercyHealth will continue to send out a variety of reminders.
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Childhood Immunizations Status Combo 10
The percentage of children who had all of the following BEFORE their second birthday:
Four diphtheria, tetanus and acellular pertussis (DTaP) Three polio (IPV) One measles, mumps and rubella (MMR) Three H influenza type B (HiB) Three hepatitis B (HepB) One chicken pox (VZV) Pneumococcal conjugate (PCV) Hepatitis A (HepA) Rotavirus (RV) Influenza
Quality Improvement Activities & Interventions
Completely revised the approach to managing the measure: Completely redesigned the audit and outreach strategy in order to proactively manage population. Revised the data pull strategy in order to identify members appropriate for the measure, which allows for earlier data review and more time for MercyCare and clinic interventions. A targeted reminder is sent to parents of children due for immunizations. Physician to Physician intervention with list of children due for vaccines. Work with clinic staff and clinic administration in scheduling and resolving some of the identified barriers for members. MercyCare participates in the Wisconsin Immunization Registry (WIR). Assure newly recommended vaccines are covered in the benefit plan by reviewing at the Benefits Interpretation Committee (BIC).
Identified Barriers
Children are missing their 15 and/or 18-month Well-Child Visits. Parental refusals in line with negative national media publicity. Clinic staff fails to identify children who are behind on immunizations when they come to the clinic for other visits. Children scheduled for their catch up immunizations after their second birthday. Sometimes clinics only chose to send a letter to parents rather then call to get the child in for immunizations in a timely manner.
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Quantitative Analysis
2016 HEDIS® performance is below the 50th percentile. Unfavorable comparison to regional competitor
Qualitative Analysis
Inadequate performance despite intensive interventions by the health plan. Review of physician specific data has shown some pediatricians not emphasizing Hep A and flu vaccines for young infants. Marked decrease for Dtap and PCV vaccines given timely. RVR has two options of Immunizations which can be confusing when giving. If RVR three dose is started, child must get three doses.
Action plan
This topic has been brought up at the MercyHealth Clinic Quality committee and a workgroup has been assigned to determine an action plan.
Chlamydia Screening in Women – Total
The percentage of women 16–24 years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year.
Quality Improvement Activities & Interventions
Medical Director discusses when attending OBGYN department meeting.
Communication on adolescent health to all pediatricians, family physicians, and OB/Gyn physicians included discussion of this measure in early 2015.
Presented October 2016 - 18 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Emphasized at all nurse practitioner and physician orientations
Identified Barriers
The measure counts women who are using birth control pills as sexually active; women who are taking birth control pills for acne or dysmenorrhea cannot be excluded from the measure.
Some providers do not test married women or women who have not had a new partner in the last year for this STD.
Discussions with the OB/GYNS in 2014 at a department meeting were met with resistance to the CDC guideline despite articles in the local newspaper regarding a rising epidemic of Chlamydia in Rock County
Quantitative Analysis
2016 HEDIS® performance is below the 50th percentile 2015 MARKETPLACE QRS is 64.29% (9/14 events only) Equivalent performance to regional competitor Stable trend over the last six years
Qualitative Analysis
MercyCare’s performance has remained flat while national performance has increased dramatically over the last decade.
Action plan
New specimen collection kits test for multiple pathogens and concurrent PAP smear and may have an impact on the results
Presented October 2016 - 19 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Colorectal Cancer Screening
The percentage of members 50–75 years of age who had appropriate screening for colorectal cancer.
Quality Improvement Activities & Interventions
Members who are over 50 years of age who have not had appropriate screening for colorectal cancer are offered an at-home fecal occult blood test (FOBT).
Send FOBT kits to members who request them.
FOBT results are sent from the lab to the physicians through EPIC.
A second letter was sent later in the year to remind members of the FOBT and make another offer to do the home screening.
Identified Barriers
Members do not schedule screening. Members do not return FOBT request form. Preventative counseling by “roomers” at the MHS emphasizes colonoscopy without mentioning any alternatives such as annual fecal occult blood testing. MercyCare has initiated discussion with MHS and rooming script will be revised.
Quantitative Analysis
2016 HEDIS® performance improved from prior year Equivalent performance to regional competitor 2015 MARKETPLACE QRS is 76.19%
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Qualitative Analysis
Trend is on the upswing after reinstituting two mailings, an initial and a reminder, to members per year, as compared to one market piece and one mailing in 2014.
Action plan
MercyCare will send its occult blood test letter offer twice a year
Comprehensive Diabetes Care
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had each of the following:
HbA1c poor control (>9.0%) HbA1c good control (<8.0%) Eye exam Medical attention for nephropathy Blood pressure controlled to <140/90
HbA1c Poor Control (>9.0%) HbA1c Good Control (<8.0%)
Quality Improvement Activities & Interventions
Process and program continually reviewed and updated in the Diabetes Health Management Task Force. Physician advisors are Tim Reid, MD and Henry Juan, MD for this Task Force.
The Diabetic Case Management Program is managed by a registered nurse case manager. The nurse case manager is responsible to monitor and review all labs and tests essential for diabetes care (HbA1C, LDL, etc.). Letters are sent annually to members educating them of their current scores and the importance of receiving appropriate care. Copies of above reports are also sent to physicians annually. Telephonic case management goal increased to calls every 2 months for all engaged members with a HbA1c≥ 8.5.
Barriers Identified
Timeliness of physicians obtaining and/or ordering lab work. Labs are ordered by physicians but some members fail to obtain lab work within the necessary timeframe. Economic factors are decreasing screening frequency. Delay in Diagnosing Diabetes. Increased complexity of care/increased co-morbidities. Increased burden of copayments and coinsurance Not enough staffing to case manage patients with HbA1c between 8.0 and 8.5
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Quantitative Analysis
This is an inverse measure; therefore, a lower rate is better 2016 HEDIS® performance is between the 50th and 75th percentile Unfavorable comparison to regional competitor this year
Qualitative Analysis
The diabetes case manager will continue to case manage this population and review data at the Diabetes Task Force.
Action Plan
We are now sending out annual reports to physicians on these measures. A new guideline for care has been adopted by the MHS and MercyCare. Telephonic case management goal increased to calls every 2 months for all engaged members with a HbA1c≥ 8.5.
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HbA1c Control (<8.0%)
2016 HEDIS® is at the 90th percentile Equivalent performance to our regional competitor 2015 MARKETPLACE QRS is 71.15%
Eye Exam
Quality Improvement Activities & Interventions
Process and program continually reviewed and updated in the Diabetes Health Management Task Force. Physician advisors are Tim Reid, MD and Henry Juan, MD for this Task Force.
The Diabetic Case Management Program is managed by a registered nurse case manager. The nurse case manager is responsible to monitor and review all labs and tests essential for diabetes care (HbA1C, LDL, etc.). Letters are sent annually to members educating them of their current scores and the importance of receiving appropriate care. Eye care communication form used for members to take to their eye care provider. Copies of the reports are also sent to the provider. Telephonic case management goal increased to calls every 2 months for all members with an HbA1c≥ 8.5.
New database reports monitor Case Manager activity to ensure volume of calls, frequency of contact and amount of time spent in member outreach on phone meets program goals.
Barriers Identified
Economic factors may be decreasing screening frequency.
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Some patients do not comprehend the importance of eye exams.
Member lack of knowledge on taking care of their diabetes.
Delay in diagnosing diabetes.
Increased complexity of care and increased co-morbidities.
Provider doesn’t emphasize the importance of the frequency of the eye exam.
The optometrist/ophthalmologist recommending the eye exams only every 2 years.
Quantitative Analysis
2016 HEDIS® performance is between the 75th and 90th percentile Equivalent performance regional competitor 2015 MARKETPLACE QRS is 55.77%
Qualitative Analysis
This measure will continue to be part of the case management program and reviewed at the Diabetes Task Force.
Action plan
We are now sending out annual reports to physicians on these measures. A new guideline for care has been adopted by the MHS and MercyCare.
Presented October 2016 - 24 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Medical Attention for Nephropathy
Quality Improvement Activities & Interventions
Process and program continually reviewed and updated in the Diabetes Health Management Task Force. Physician advisors are Tim Reid, MD and Henry Juan, MD for this Task Force.
The Diabetic Case Management Program is managed by a registered nurse case manager. Case management is performed telephonically. The nurse case manager is responsible to monitor and review all labs and tests essential for diabetes care (HbA1C, LDL, etc.). Letters are sent annually to members educating them of their current scores and the importance of receiving appropriate care. Copies of above reports are also sent to physicians annually. Letters are sent to providers identifying members on their patient panels who have an eGFR of less than 60 and not on an ACE or an ARB medication. Telephonic case management goal increased to calls every 2 months for all members with an HbA1c≥ 8.5.
Barriers Identified
Timeliness of physicians obtaining and/or ordering lab work.
Economic factors are decreasing screening frequency.
Physician resistance to ordering an ACE or ARB as prevention.
Member lack of knowledge on taking care of their diabetes.
Delay in diagnosing diabetes.
Increased complexity of care/increased co-morbidities.
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Quantitative Analysis
2016 HEDIS® performance is above the 90th percentile Favorable comparison to regional competitor Improved performance from the prior year with favorable trend over the last nine years 2015 MARKETPLACE QRS is 100.00%
Qualitative Analysis
MercyCare will continue the case management of this population and review this data at the Diabetes Task Force.
Action plan
We are now sending out annual reports to physicians on these measures. A new guideline for care has been adopted by the MHS and MercyCare.
Controlling High Blood Pressure in the Diabetic population
Quality Improvement Activities & Interventions The Diabetic Case Management Program is managed by a registered nurse case manager. Case management is performed telephonically. The nurse case manager is responsible to monitor and review all labs and tests essential for diabetes care (HbA1C, LDL, BP etc.). Letters are sent annually to members educating them of their current scores and the importance of receiving appropriate care. Copies of above reports are also sent to physicians annually. Telephonic case management goal increased to calls every 2 months for all members with an HbA1c≥ 8.5.
Presented October 2016 - 26 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Barriers Identified Member lack of knowledge on taking care of their diabetes. Increased complexity of care/increased co-morbidities. Physicians not following closely with members who have an elevated B/P Physician resistance to ordering an ACE or ARB as prevention.
Quantitative Analysis
This is a subset of the following measure regarding control of high blood pressure. Currently our HEDIS score is above the 90th percentile.
Qualitative Analysis MercyCare will continue the case management of this population and review this data at the Diabetes Task Force.
Action Plan We are now sending out annual reports to physicians on these measures. A new guideline for care has been adopted by the MHS and MercyCare. Mercy Health System has a BP Task Force which focuses on better monitoring and management of BP.
Controlling High Blood Pressure
The percentage of members 18–85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.
Presented October 2016 - 27 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Quality Improvement Activities & Interventions
MHS “rooming” personnel and nurses have been in-serviced on this measure, and the now DO retake blood pressure if initial reading is borderline high.
Barriers Identified
Physician variation on treatment, monitoring, and diagnosis.
Some patients demonstrate resistance to medication treatment.
QuantitativeControlling High Blood Analysis Pressure
80 75 70 90th percentile e r
65 o c 60 S 55 50 6 3 0 0 0 0 2 2 Y e a r 75th percentile 50th percentile MercyCare HMO Dean Health Plan 2016 HEDIS® performance is above the 90th percentile Marked increase over the prior year and highest ranking so far 2015 MARKETPLACE QRS is 88.70%
Qualitative Analysis
Interventions at the MHS have effectively improved performance
Action plan
None at the health plan.
Flu Shots for Adults (18-64)
MercyCare’s performance in this measure is dependent upon members reporting accurately through CAHPS surveys.
Presented October 2016 - 28 - MercyCare HMO 2015 Quality Improvement Program Evaluation
A rolling average represents the percentage of commercial members 18–64 years of age who received an influenza vaccination between September 1 of the measurement year and the date when the CAHPS 4.0H survey was completed.
Quality Improvement Activities & Interventions
MHTC Occupational Health provides flu vaccines for employer groups who request it.
Published articles in Healthy Living magazine (a MercyCare publication).
MHS clinics have flu shot days
MercyCare scheduled ‘robo’ calls to remind members of the importance of getting a flu shot and where to find information about the flu shot clinic
MercyCare worked with the clinics to ensure billing for MercyCare members who receive flu shots rather than self-pay and this is advertised on the flu clinic posters.
MHS 100% vaccination policy for employees.
Targeted high risk populations in our case management programs.
Barriers Identified
Some members refuse vaccinations.
Some members are unaware of the vaccination recommendations.
Quantitative Analysis
Presented October 2016 - 29 - MercyCare HMO 2015 Quality Improvement Program Evaluation
2015 CAHPS (self-reported) is above the 90th percentile Favorable comparison to regional competitor Improved performance from the prior year
Qualitative Analysis
Great performance due to efficacy of interventions
Action plan
Continue current interventions
Follow Up After Hospitalization for Mental Illness
The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported; however, we are only scored on one. The percentage discharges for which the member received follow-up within 7 days of discharge.
Quality Improvement Activities & Interventions
None due to staffing shortages last year
Barriers Identified
Appointment is not scheduled or there is no available appointment with a behavioral health provider. The member does not show up for the scheduled appointment. Transportation or other socio-economic barriers may be a factor for the member. The non-MHS facilities do not always notify MercyCare in a timely manner to help facilitate making the appointment.
Presented October 2016 - 30 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Quantitative Analysis
2016 HEDIS® performance was just above the 75th percentile 2015 MARKETPLACE QRS is 100.00%
Qualitative Analysis
Improvement occurred without intervention
Action plan
None at this time.
Persistence of Beta Blocker Treatment After Heart Attack (PBH) ***No report last several years due to low numbers***
The percentage of member 19 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge.
Presented October 2016 - 31 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Pharmacotherapy Management of COPD Exacerbation (PCE) ***No report last several years due to low numbers***
The percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED visit on or between January 1 – November 30 of the measurement year and who were dispensed appropriate medications. Two rates are reported: 1. Dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event. 2. Dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event.
Presented October 2016 - 32 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Presented October 2016 - 33 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Follow-Up Care for Children Prescribed ADHD Medication (ADD) ***No report last several years due to low numbers***
The percentage of children newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported:
Initiation Phase. The percentage of members 6-12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who had one follow up visit with practitioner with prescribing authority during the 30-day Initiation Phase. Continuation and Maintenance (C&M) Phase. The percentage of members 6-12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
Quality Improvement Activities & Interventions:
MercyCare adopted a nationally recognized guideline, ADHD in Primary Care for School-Age Children and Adolescents, Diagnosis and Management from the Institute for Clinical Systems Improvement. Actively promoted the guidelines to practitioners in years past
New care standards are to keep children on their meds year around so there are relatively very few “new starts” to be measured in our HMO.
Quantitative Analysis
Presented October 2016 - 34 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Medical Assistance With Smoking and Tobacco Use Cessation (Advising Smokers and Tobacco Users to Quit) Not reported
MercyCare’s performance in this measure is dependent upon members reporting accurately through CAHPS surveys.
This measure is collected using survey methodology. A rolling average represents the percentage of members 18 years of age and older who are current smokers or tobacco users and who received cessation advice during the measurement year.
Quantitative Analysis
Presented October 2016 - 35 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Post-Partum Care
The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses postpartum care: The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.
Quality Improvement Activities & Interventions
Information sent to members after delivery reminding members to schedule their follow-up appointment within 21-56 days of delivery.
Main hospital’s discharge instruction sheet has a section to record their follow up appointment.
Main hospital calls members within 72 hours of delivery and verifies whether or not they have scheduled their 6-week postpartum visit.
Main practice site has a process in place to schedule the patients’ postpartum appointment during a routine prenatal appointment.
Follow-up appointments for scheduled C-sections and inductions are made at the time the clinic schedules procedures.
Barriers Identified
Some members do not schedule follow-up appointments.
Some members do not attend their follow-up appointments.
Presented October 2016 - 36 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Sometimes postpartum visits are not scheduled prior to delivery.
C-section patients perceive their 2 week post-op visit as their postpartum visit.
Appointment availability and last minute cancellations by OBGYNs.
Quantitative Analysis
2016 HEDIS® performance was above the 90th percentile Favorable comparison to regional competitor Improved performance from the prior year with favorable trend over the last eight years 2015 MARKETPLACE QRS is 100.00%
Qualitative Analysis
Performance acceptable and stable
Action plan
None other than continuing post-partum information packet to members
Asthma Measures
Medication Management for People With Asthma (MMA) The percentage of members 5 -85 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. The percentage of members who remained on an asthma controller medication for at least 75% of their treatment period.
Presented October 2016 - 37 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Asthma Medication Ratio (AMR) The percentage of members 5-85 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.
Quality Improvement Activities & Interventions
Process and program continually reviewed and updated in the MCHP Asthma Health Management Task Force Committee. Physician advisors include Ronald Ragotzy, MD.
The Asthma Case Management Program is managed by a certified nurse case manager for members who had inpatient, urgent, or emergency room care and asthma office visits. Case management is performed telephonically. Case management members who have too many or an increased use in rescue inhalers. Members are encouraged to schedule an appointment with their physician. A monthly report is run to find members with a diagnosis of asthma who are not on a controller medication. The nurse case manager then contacts these members to encourage them to call their physician to talk about starting a controller medication.
Monitor the delivery of care at urgent cares in order to correct urgent care misses.
Send reports to practitioners so that they are informed of the level of care their patients are receiving.
Barriers Identified
Member Based: Treatment adherence to medication regimen. Member not aware of their diagnosis. Lack of member understanding of the importance of a Well-Asthma visit. Members’ lack of willingness to participate in the Asthma Case Management Program. Failure to take medications as ordered. Higher member copays at the pharmacy results in missed preventative medications Lack of willingness to follow up with an allergist to define triggers.
Provider Based: Lack of standardization in the assessment of asthma control in clinics. Inconsistent use of the Asthma Action Plan during visits. Lack of appropriate referrals to specialist. Inconsistent follow up after ED, Urgent Care and inpatient visits.
Presented October 2016 - 38 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Quantitative Analysis
2016 HEDIS® performance was above 90th percentile Favorable comparison to regional competitor 2015 MARKETPLACE QRS is 0.00%
Unfavorable comparison to regional competitor 2016 HEDIS® performance was at the 75th Percentile
Presented October 2016 - 39 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Qualitative Analysis
We have successfully transitioned our Asthma Disease Management Program to addressing the new measure.
Action plan
Continue case management activities
Use of Imaging Studies for Low Back Pain
The percentage of members with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
Quality Improvement Activities & Interventions
Prior authorizations is required for MRI requests from a PCP, which have resulted in frequent educational communications between the medical director and physicians since these are reviewed personally by the Medical Director
An algorithmic guideline for back pain was adopted by the plan and approved by our QUM committee and is promoting care compatible with this measure by primary care physicians.
Barriers Identified
Some members request imaging
Some PCPs request early scanning for diagnostic reasons when evidence-based guidelines recommend conservative care before scanning.
Presented October 2016 - 40 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Quantitative Analysis
2016 HEDIS® performance is right above the 90th percentile Equivalent performance to regional competitor Favorable trend over the last five years 2015 MARKETPLACE QRS is 69.23%
Qualitative Analysis
MRI utilization has become more appropriately with time in low back pain.
Cervical Cancer Screening (CCS)
The percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria: Women age 21–64 who had cervical cytology performed every 3 years. Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.
Quality Improvement Activities and Interventions
In 4th quarter of 2015 we identified members who had a total hysterectomy in the distance past by querying pathology reports thus excluding additional members from being counted inappropriately as not being screened.
Sent targeted mailings to members.
Barriers
Women not scheduling visit.
Presented October 2016 - 41 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Quantitative Analysis
2016 HEDIS® performance was above the 75th percentile and improved Favorable comparison to regional competitor 2015 MARKETPLACE QRS is 57.20%
Qualitative Analysis
Providers are improving performance without intervention by the health plan on this new measure
Action plan
Pathology queries for Rockford Legacy partners with previous hysterectomy entering the health plan.
Human Papillomavirus Vaccine for Female Adolescents (HPV)
The percentage of female adolescents 13 years of age who had three doses of the human papillomavirus (HPV) vaccine by their 13th birthday.
Quality Improvement Activities and Interventions
Informative mailings to parents of 11 years old children started Feb of 2015. Reminder mailings to parents of 12 years old children started Feb 2015.
Barriers Identified
Physicians and parents uncomfortable discussing vaccine at age 11 as recommended by CDC Incomplete instructions or parent reluctance result in series not being completed.
Presented October 2016 - 42 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Quantitative Analysis
2016 HEDIS® performance is below the 50th percentile Very unfavorable comparison to regional competitor 2015 MARKETPLACE QRS is 0.00%
Qualitative Analysis
Physician reluctance has to be altered.
Action plan
Physicians have already received an educational letter from medical director last year. MHS and MercyCare have met with Merck representatives and educational initiatives with physicians are planned at the health system and health plan level. There is a MercyHealth committee specifically addressing HPV initiatives.
Immunizations for Adolescents (IMA)
The percentage of adolescents 13 years of age who had one dose of meningococcal vaccine(MCV) and one dose of tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) or one tetanus, diphtheria toxoids (Td) by their 13th birthday. The measure calculates a rate for each vaccine and one combination rate.
Quality Improvement Activities and Interventions
Informative mailings to parents of 11 years old children started Feb of 2015. Reminder mailings to parents of 12 years old children started Feb 2015.
Presented October 2016 - 43 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Barriers Identified
Parents are hesitant to vaccinate for MCV at age 11 as recommended by CDC Incomplete instructions or parent reluctance
Quantitative Analysis
2016 HEDIS® performance is below the 75th percentile Favorable comparison to regional competitor 2015 MARKETPLACE QRS is 100.00%
Qualitative Analysis
Continued improvement for five years.
Action Plan
Continue current interventions
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
The percentage of members 3–17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following during the measurement year. BMI percentile documentation*. Counseling for nutrition. Counseling for physical activity.
Quality Improvement Activities and Interventions
None
Presented October 2016 - 44 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Barriers Identified
Physicians neglect this at annual exams and sports physicals
Quantitative Analysis (BMI Percentile)
2016 HEDIS® performance was above the 75th percentile Health system EPIC template initiatives are improving performance Performance equivalent to regional competitor 2015 MARKETPLACE QRS is 65.63%
Presented October 2016 - 45 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Quantitative Analysis (Counseling for Nutrition)
2016 HEDIS® performance was above the 50th percentile Health system EPIC template initiatives are improving performance Unfavorable comparison to regional competitor 2015 MARKETPLACE QRS is 65.63%
Quantitative Analysis (Counseling for Physical Activity)
2016 HEDIS® performance was above the 75th percentile Health system EPIC template initiatives are improving performance Unfavorable comparison to regional competitor 2015 MARKETPLACE QRS is 53.13%
Presented October 2016 - 46 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Qualitative Analysis
This needs to become a piece of all physicians’ templates for annual exams. Counseling for nutrition must be added to sports physicals.
Action Plan
None at the Health Plan
Adult BMI Assessment (ABA)
The percentage of members 18–74 years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.
Quality Improvement Activities and Interventions
MHS initiative to get weight taken at every visit not limited to PCP visits.
Barriers Identified
Patient is not weighed
Quantitative Analysis
2014 HEDIS® performance is above the 90th percentile. 2016 HEDIS® performance is above the 90th percentile. Performance equivalent to regional competitor 2015 MARKETPLACE QRS is 95.94%
Presented October 2016 - 47 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Qualitative Analysis
EPIC automatically calculates if a weight is taken and entered at visit
Action Plan
None at the Health Plan
Plan All-Cause Readmissions
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. Data are reported in the following categories: 1. Count of Index Hospital Stays (IHS) (denominator) 2. Count of 30-Day Readmissions (numerator) 3. Average Adjusted Probability of Readmission
Quality Improvement Activities and Interventions
New measure. UR activities try to address risk factors for readmission and high risk patients are referred to case management but often refuse.
Barriers Identified
Patient noncompliance with behavior modifications.
Quantitative Analysis
Presented October 2016 - 48 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Performance below the 50th percentile (inverse measure) Poor comparison this year to competitor but historically better in 2011, 2012, 2013.
Qualitative Analysis
The spike in 2014 was all due to one member who had monthly or more admissions due to alcoholism and refused any interventions. Many readmissions are due to substance users who refuse to quit, both alcohol and drugs.
Action Plan
Continue UR and Case Management Activities.
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) - Engagement
The percentage of adolescent and adult members with a new episode of alcohol or other drug (AOD) dependence who received the following: Initiation of AOD Treatment. The percentage of members who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. Engagement of AOD Treatment. The percentage of members who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.
Quality Improvement Activities and Interventions
Marijuana “Users” misdiagnosed as having a substance use disorder in ER and pain clinic was discussed with ER Director.
Opiate addicts under remission and seeing Dr. Ayetay are only seen every three months, and therefore fall back into the measure as failures every visit. This was discussed with Dr Ayetay in 2015.
Barriers Identified
Marijuana “Users” misdiagnosed as having a substance use disorder in ER and pain clinic
Opiate addicts under remission and seeing Dr. Ayetay are only seen every three months, and therefore fall back into the measure as failures every visit.
Presented October 2016 - 49 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Quantitative Analysis
2016 HEDIS® performance is below the 50th percentile. Equal comparison to regional competitor 2015 MARKETPLACE QRS is 0.00% Qualitative Analysis
See barriers.
Action plan
None at the Health Plan
Presented October 2016 - 50 - MercyCare HMO 2015 Quality Improvement Program Evaluation
CAHPS REPORT & ANALYSIS
Health Plan Member satisfaction with the claims processing, customer service and getting needed care are composites that have a direct impact on how a member will rate their health plan. Our goal is to exceed the 75th percentile satisfied. The following provides a summary on how members rated MercyCare:
Rating of the Health Plan
CAHPS® Question #42
Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you rate your health plan?
Top box scores = 8, 9, & 10
Presented October 2016 - 51 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Customer Service
CAHPS® Questions #35 and 36
In the last 12 months, how often did your health plan’s customer service give you the information or help you needed?
In the last 12 months, how often did your health plan’s customer service staff treat you with courtesy and respect?
Top box scores = Always and Usually
Getting Needed Care
CAHPS® Questions #23 and 27
In the last 12 months, how often was it easy to get appointments with specialists?
In the last 12 months, how often was it easy to get the care, tests, or treatments you thought you needed through your health plan?
Top box scores = always and usually
Presented October 2016 - 52 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Health Care Member satisfaction with their personal doctor, their specialists, getting care quickly and how well doctors communicate are composites that have a direct impact on how a member will rate their overall health care. The following provides a summary on how members rated MercyCare:
Rating of All Health Care
CAHPS® Question #42
Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you rate your health care in the last 12 months?
Top box scores = 8, 9, & 10
Presented October 2016 - 53 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Rating of Personal Doctor
CAHPS® Question #21
Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you rate your personal doctor?
Top box scores = 8, 9, & 10
Presented October 2016 - 54 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Rating of Specialist
CAHPS® Question #25
Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you rate your personal doctor?
Top box scores = 8, 9, & 10
Getting Care Quickly
CAHPS® Questions #4 and 6
In the last 12 months, when you needed care right away, how often did you get care as soon as you thought you needed?
In the last 12 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor’s office or clinic as soon as you thought you needed?
Top box scores = always and usually
Presented October 2016 - 55 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Key Drivers Based on detailed analysis, DSS (our CAHPS vendor) assigned the Retain, Power, Wait and Opportunity categories as described below:
Retain
Items in this category are somewhat less important to members but our performance was above average. Simply maintain performance on these items.
Doctor listened carefully Personal doctor overall Doctor explained things Ease of filling out forms Doctor spent enough time Doctor showed respect Customer Service provided information/help Ease of getting care, tests or treatment Doctors informed about care from other doctors
Power
Items in this category are very important to members and our performance levels on these items are high. Promote and leverage strengths in this category.
Got specialist appointment Specialist overall Customer Service treated you with courtesy and respect Got routine care
Presented October 2016 - 56 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Wait
Though still important to members, these items are somewhat less important than those that fall in the Power and Opportunity categories. Relatively speaking, our performance was low on these items. Dealing with these items can wait until more important items have been dealt with.
Written material/Internet provided needed info
Opportunities
Items in this category are very important to our members but our performance is below average. Focus resources on improving processes that underlie these items and look for significant improvements in satisfaction scores.
Healthcare overall Got urgent care Found service/equipment cost information Claims handled correctly Found prescription cost information Claims handled quickly
The items that fall into the Opportunity category have been listed in order of importance. Again, focusing resources on these items should result in significant improvements in member satisfaction.
Member Satisfaction Report DESCRIPTION: In order to assess and improve member satisfaction with MercyCare Health Plans, member complaints, appeals and CAHPS scores are reviewed and analyzed at least annually. This analysis involves the Customer Service and Claims Departments, all MercyCare Directors, and MercyCare’s Vice President. Review of the complaints is inclusive of all member complaints and appeals for all members of every product line. CAHPS scores and analysis is only of our HMO product.
MEASURES: MercyCare reviews all complaints entered in GITS (General Information Tracking System) and Grievance (Appeals) related to: Quality of Care Access Attitude/Service Billing/Financial Quality of practitioner office site
The results of MercyCare’s CAHPS scores are also reviewed annually and presented separately to the Quality Initiatives and Utilization Management Committee.
Presented October 2016 - 57 - MercyCare HMO 2015 Quality Improvement Program Evaluation
GOAL: Our goal is to obtain scores of the 75th percentile for all CAHPS scores. We believe that by putting interventions in place as a result of our review and analysis of member complaints and grievances will have the greatest impact on member satisfaction/CAHPS.
METHODOLOGY: CAHPS® The CAHPS Health Plan Survey is a tool for collecting standardized information on enrollees’ experiences with health plans and their services.
Complaints
All member calls are routed through Customer Service. The Customer Service Representative records all entries into GITS and categorizes them by provider or member. The entries are then further delineated in inquiry, complaint, or grievance, and then by the code that best describes the reason for the call. A report is then run routinely that identifies complaints by the main categories listed above under Measures and analyzed for trends, deficiencies, or process improvements.
Grievances
All grievances are categorized and tracked to be compliant with state regulations. They are broken down by general types of complaints as listed above under Measures. The outcome of each grievance is then tracked by those that were approved, denied, compromised, and withdrawn by the category. It is further delineated to determine who or which committee made the determination. The person(s) or committees that make these determinations are: Complaint Coordinator, Medical Director, Pharmacy Director, Compliance Officer, Internal Appeals Committee, Administrative, or Grievance Committee.
CAHPS®
Qualitative Analysis Reviewing the quantitative analysis and focusing on areas in which we did not meet system goals of a percentile ranking of 75% or greater resulted in the following observations: Getting Care Quickly Composite (Questions 4 and 6) o Gap analysis indicated the area to focus on is “Routine Care” . In the last 12 months, when you needed care right away, how often did you get care as soon as you needed? 175 responses in which 27 responded negatively Getting Care Needed Composite (Questions 14 and 25) o Gap analysis indicated the area to focus on is “Got Appointment with Specialist” . In the last 12 months, how often did you get an appointment to see a specialist a soon as you needed? 210 responses in which 34 were responded negatively Customer Service Composite (Questions 35 and 36) o Gap analysis indicated the area to focus on is “Info from Customer Service” . In the past 23 months, how often did your health plan’s customer service give you the information or help you needed?
Presented October 2016 - 58 - MercyCare HMO 2015 Quality Improvement Program Evaluation
116 responses in which 26 responded negatively Rating of Specialist Seen Most Often (Question 27) o This was only one question, so it was not included in the Gap analysis. However there is a direct correlation to the “Getting Care Needed” composite . We want to know your rating of the specialist you saw most often in the last 12 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist. 204 responses in which 36 responded negatively
Analyzing nationwide “Voice of the Member” feedback, the following observations were made: Question 4. Got urgent care as soon as needed (specialist visit) o PRIMARY CARE DOCTOR VISIT: How long do patients expect to wait for an URGENT CARE appointment to see a specialist? . Most members expect to wait one to three weeks for a routine care appointment with a primary care doctor. Millennials (those under the age of 35) are willing to wait up to 2- 1/2 weeks, on average. Those older than 35 are willing to wait a little longer than three weeks. o SPECIALIST VISIT: How long do patients expect to wait for an URGENT CARE appointment to see a specialist? . Most expect to wait nearly two weeks and are willing to wait up to four weeks, on average, for a routine appointment with a specialist o Improvement Actions Suggested . Keep wait times shorter than 30 minutes or offer an explanation . Give the patient an explanation if there is a long wait time . Assist with alternative arrangements when necessary Question 6: Got a check-up or routine appointment as soon as needed o Improvement Actions Suggested . Keep wait times shorter than 30 minutes . Apologize for delays . Communicate reasons for delays . Offer to reschedule appointments . Be respectful of the patient’s time Question 14: Ease of getting care, tests or treatment o Improvement Actions Suggested . Provide multiple services during one visit . Minimize lag time between steps . Provide accurate diagnosis . Encourage long-term doctor-patient relationships Question 25: Got an appointment with a specialists as soon as needed o Improvement Actions Suggested . Ensure that the network includes enough specialists . When rescheduling, ensure that appointment can be honored Question 35: Customer Service provided needed information or help o Improvement Actions Suggested . Minimize transfers
Presented October 2016 - 59 - MercyCare HMO 2015 Quality Improvement Program Evaluation
. Ensure that call center representatives have the needed information and training . Equip representatives to resolve issues quickly
Question 36: Customer Service treated member with courtesy and respect o Improvement Actions Suggested . Be patient, kind and friendly . Limit the use of automated systems . Call back when requested or promised . Staff the call center with native English speakers Question 27: Rating of Specialist o Improvement Actions Suggested . Personalize the patient experience . Foster relationships with patients
Action Plan MercyCare chose the following action plans to improve member satisfaction pertaining to customer service: First call resolution – setting goals based on industry standards to assure we are properly addressing customer’s needs the first time they call, thereby eliminating the need for the customer to follow up with a second call. Claim reconsideration – reviewing calls pertaining to specific types of complaints that resulted in a claim requiring reconsideration due to an error made by MercyCare. Nineteen specific categories are being addressed in this action plan. Mercy Health System has implemented goals and action plans directly correlated to member satisfaction by using HCAHPS, CAHPS and other internal and external sources.
Complaint and Grievance types Quality of Care . A member complained that his doctor misdiagnosed his condition or the radiologist misread his chest x-ray. Access . Complaint that an out-of-network referral was not allowed. The member believed in- network practitioners did not have the expertise necessary to deal with an issue. The member appealed the decision. . Member complained that there is a shortage of practitioners who speak Spanish and wished to go out of network. It was not allowed and the member appealed the decision. . Participating practitioners lacked available appointments. . The primary care practitioner will not refer the member to a specialist. The member appealed to the organization to allow the referral. Attitude and Service . Member complained that her physician was rude and used abusive language. . Member complained that she had to wait 30 minutes to check-out after her appointment. Billing/Financial . Out-of-network services where members are balance billed. . Disputes of deductibles and copayments. Quality of Practitioner Office Site
Presented October 2016 - 60 - MercyCare HMO 2015 Quality Improvement Program Evaluation
. The member sought out-of-network care because the participating practitioner’s offices lacked wheelchair accessibility. The organization identified other practitioners with wheelchair access but the member was not satisfied with the practitioner and appealed to go out of network.
RESULTS
Quantitative Analysis Table 1: Complaint volume report Current Previous Current Measureme Previous Year Measureme nt Year Year Complaints nt Year Complaints Complaints, per 1,000 Complaints, per 1,000 Category Total Members Total Members Quality of Care 1 .03 0 0 Access 9 .24 14 .36 Attitude/Service 1 .03 0 0 Billing/Financial 470 12.72 676 17.42 Quality of Practitioner 0 0 0 0 Office Site Total/Number per 1,000 481 13.02 690 17.78
Table 1a: Complaint by category by year 2014 2015 Change Total Calls 43171 54573 26% Member Rcvd 23169 27483 19% Member Ansd 21441 23211 8%
Total Complaints 483 693 43%
Complaint types 2014 2015 Increase/Decrease ACCP 9 14 56% ADIN 29 39 34% AUNR 32 24 -25% AUT 40 28 -30% AUTM 18 14 -22% CLEC 32 34 6% CLEE 18 42 133% CLOS 16 15 -6% COBC 22 24 9% CPAY 15 10 -33% EE 15 87 480% INAU 34 38 12%
Presented October 2016 - 61 - MercyCare HMO 2015 Quality Improvement Program Evaluation
NCMB 7 19 171% New category for PB 0 17 #DIV/0! 2015 PPOT 29 24 -17% PPWO 17 17 0% PRFE 51 80 57% SPAO 36 51 42% SRNC 13 10 -23% Total of list 434 586 35% Total Complaints 483 693 43% 0.898551 0.845599 -6%
Quantitative Analysis
Billing/Financial complaints have continued to be the largest cause of member telephone calls to customer service. Reviewing data from 2014 vs 2015 showed a significant increase in volume of complaints. Although phone call volume increased, was not the overwhelming cause of the increase. The largest volumes fall into the following categories:
Enrollment entry errors
Members not understanding their EOB’s
Providers billing members for services they had not billed the insurance company
Provider filing errors
System set up issues
Qualitative Analysis
Table 2: Grievance volume report Current Previous Current Measureme Previous Year Measureme nt Year Year Appeals per nt Year Appeals per Appeals, 1,000 Appeals, 1,000 Category Total Members Total Members Quality of Care 0 0 0 0 Access 28 .49 18 .46 Attitude/Service 0 0 0 0 Billing/Financial 76 1.73 64 1.65 Quality of Practitioner 0 0 0 0 Office Site
Presented October 2016 - 62 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Total Average 104 2.22 82 2.11
Table 2a: Grievance change by year report 2014 2015 Increase/Decrease Quality of Care 0 0 N/A (request to out of network Access 28 18 -36% provider) Attitude/Servic e 0 0 N/A Billing/Financial 76 64 -16% Quality of Site 0 0 N/A Total 104 82 -21%
Quantitative Analysis
Review of the grievances did not show any specific specialty that was requested due to the service not being available in network for either year. Most requests were for the following reasons: Mew members who were requesting to continue their treatment with their previous provider Members requesting accessing services outside of the service area due to the location near their home
ACTIONS MercyHealth approved and purchased Tapestry claims processing software in 2016 for implementation midyear 2017. This software has many tools available to assure a continuous process improvement can be followed. MercyCare developed audits that were implemented and made part of the MercyCare departmental dashboard not only to monitor quality and service prior to the implementation, but to create a baseline to use at the time and after implementation o Areas being monitored: . Member ID card sent timely . Customer Service first call resolution . Medical and pharmacy referrals turned around timely . Claims reconsiderations due to internal errors Additional staff approved during budgeting process to help to obtain and meet goals
MONITORING SAFETY
The safety of our members is of the utmost importance. MercyCare is committed to ensuring safety is addressed for our members by focusing on safety in the following ways:
Member Education Adverse events Member Complaint Resolution Process Pharmacy Management
Presented October 2016 - 63 - MercyCare HMO 2015 Quality Improvement Program Evaluation
Continuity and Coordination of Care Projects Clinical Practice Guidelines Electronic Medical Records
Member Education
MercyCare provides links to a variety of cost and safety information to members on the member quality and safety tab on our website.
Adverse Events
MCHP monitors adverse events by identifying quality-related issues during health plan activities, i.e., customer service complaints, inpatient reviews, case management. Identified issues are confirmed to be under review by the facility or health system peer review process or if not are referred to the health plan’s peer review committee.
Table 9 outlines the number of member complaints in 2014.
Table 9: Member Complaints Summary
Type of Complaint Count of Complaints Accessibility of Medical Appointments 0 Availability of Practitioners 0 Quality of Medical Care 3 Accessibility of a Routine Behavioral Health Appointments 0
Accessibility of Medical Appointments: No complaints filed
Availability of Practitioners: No complaints filed
Quality of Care: Each of the cases were based on a member’s perception. No patterns found.
Pharmacy Management
MercyCare manages medication safety through the implementation of prior authorizations and quantity limits in order to:
Prevent Over-Utilization
Ensure Appropriate Use of Medications
Identify Abuse or Diversion in the Case of Narcotics
Reduce Exposure of Members to New Medications with Uncertain Side-Effects
Continuity and Coordination of Care
Presented October 2016 - 64 - MercyCare HMO 2015 Quality Improvement Program Evaluation
MercyCare strongly supports continuity and coordination of care between behavioral health and primary care physicians. MercyCare reviews inpatient psychiatric admissions to network providers to verify whether or not the psychiatric discharge summary has been sent to the primary care physician. The psychiatric discharge summary is a key piece of correspondence since it includes the member’s diagnosis, discharge medications, and follow-up recommendations.
Clinical Practice Guidelines
MercyCare guidelines are posted online as a resource to providers.
Case managers incorporate these guidelines into their disease and case management programs to make certain the care members are receiving is in keeping with the latest standards.
Electronic Medical Records
Electronic medical records (EMR) are available throughout the system, inpatient and outpatient. In time, this will allow practitioners higher efficiencies in sharing patient medical information and reduce the number of medical errors caused by handwritten abbreviations. It also serves as an additional safety mechanism for those patients who receive care in multiple medical settings.
All of our provider organizations now have EMRs.
Presented October 2016 - 65 - MercyCare HMO 2015 Quality Improvement Program Evaluation
APPROVALS
______Philip Bedrossian, MD Date Medical Director
______E. Patrick Cranley Date Vice President/Chief Operating Officer
______Rowland McClellan Date of Board Approval Board of Directors, Chairman
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