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Final EvaluationOf

2015 Quality Improvement Programsfor

Commercial HMO, EPO ProductsMarketplace HMO, EPO Products

MercyHealth Employee Health Benefit Plan

October 2016

MercyCare HMO2015 Quality Improvement Program Evaluation

TABLE OF CONTENTS

EXECUTIVE SUMMARY...............................................................................................................3

Introduction................................................................................................................................3National Recognition by NCQA.................................................................................................3Quality Performance: HEDIS....................................................................................................3Quality Performance: CAHPS®................................................................................................7Quality Performance: Safety.....................................................................................................8

HEDIS® REVIEW & ANALYSIS....................................................................................................9

Antidepressant Medication Management................................................................................10Appropriate Testing for Children with Pharyngitis...................................................................12Appropriate Treatment for Children with Upper Respiratory Infection.....................................13Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis..........................................14Breast Cancer Screening........................................................................................................15Childhood Immunizations Status Combo 10...........................................................................17Chlamydia Screening in Women – Total.................................................................................18Colorectal Cancer Screening...................................................................................................20Comprehensive Diabetes Care...............................................................................................21Eye Exam................................................................................................................................23Medical Attention for Nephropathy..........................................................................................25Controlling High Blood Pressure in the Diabetic population....................................................26Controlling High Blood Pressure.............................................................................................27Flu Shots for Adults (18-64).....................................................................................................28Follow Up After Hospitalization for Mental Illness...................................................................30Persistence of Beta Blocker Treatment After Heart Attack (PBH)...........................................31Pharmacotherapy Management of COPD Exacerbation (PCE)..............................................32Follow-Up Care for Children Prescribed ADHD Medication (ADD).........................................34Medical Assistance With Smoking and Tobacco Use Cessation............................................35Post-Partum Care....................................................................................................................36Asthma Measures....................................................................................................................37Medication Management for People With Asthma (MMA).......................................................37Asthma Medication Ratio (AMR).............................................................................................38Use of Imaging Studies for Low Back Pain.............................................................................40Cervical Cancer Screening (CCS)...........................................................................................41Human Papillomavirus Vaccine for Female Adolescents (HPV).............................................42Immunizations for Adolescents (IMA)......................................................................................43Weight Assessment and Counseling for Nutrition and Physical Activity for

Children/Adolescents (WCC)..............................................................................................44Adult BMI Assessment (ABA)..................................................................................................47Plan All-Cause Readmissions.................................................................................................48Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) -

Engagement........................................................................................................................49

CAHPS REPORT & ANALYSIS..................................................................................................51

Rating of the Health Plan.........................................................................................................51Customer Service....................................................................................................................52

Presented October 2016 - 1 -


Getting Needed Care...............................................................................................................52Health Care..............................................................................................................................53Rating of All Health Care.........................................................................................................53Rating of Personal Doctor.......................................................................................................54Rating of Specialist..................................................................................................................55Getting Care Quickly...............................................................................................................55Key Drivers..............................................................................................................................56Member Satisfaction Report....................................................................................................57CAHPS®..................................................................................................................................58

Action Plan...........................................................................................................................60RESULTS............................................................................................................................61ACTIONS.............................................................................................................................63

MONITORING SAFETY..............................................................................................................63

Member Education..................................................................................................................64Adverse Events.......................................................................................................................64Accessibility of Medical Appointments.....................................................................................64Availability of Practitioners.......................................................................................................64Quality of Care.........................................................................................................................64Pharmacy Management..........................................................................................................64Continuity and Coordination of Care.......................................................................................64Clinical Practice Guidelines.....................................................................................................65Electronic Medical Records.....................................................................................................65

APPROVALS...............................................................................................................................66



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





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 Attack2. 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

Measure

MercyCare HMO Score

2015-2014 90th

Percentile75th Percentile

50th 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 89.05Comprehensive 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 55.47Controlling High Blood Pressure 75.17 11.17 74.07 66.38 56.38



Flu Vaccinations for Adults Ages 18-64 59.71 -3.99 58.04 53.22 47.59Prenatal and Postpartum Care - Postpartum Rate 91.79 6.29 86.76 81.41 72.21Use 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

Measure

MercyCare HMO Score

2015-2014 90th Percentile

75th Percentile

50th Percentile

Asthma Medication Ratio 81.48 0.37 83.71 81.22 78.42Breast Cancer Screening 76.75 4.85 80.18 75.38 71.02Cervical Cancer Screening 79.73 1.63 81.15 77.43 73.71Colorectal Cancer Screening 67.70 2.40 71.64 66.31 59.51Comprehensive Diabetes Care: Eye Exams 67.30 -2.70 68.98 58.39 48.91Comprehensive Diabetes Care: HbA1c Control Poor [>9.0%] 25.37 -0.63 21.90 27.37 34.03Follow Up After Hospitalization for Mental Illness (7-Day Rate) 59.38 N/A 65.79 58.65 49.82Weight 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

Measure

MercyCare HMO Score

2015-2014 90th


50th Percentile

Appropriate Treatment for Children With Upper Respiratory Infection 90.96 -5.24 95.05 92.25 89.15



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 57.57Weight 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

Measure

MercyCare HMO Score

2015-2014 90th


50th Percentile

25th 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 20.59Childhood Immunization Status (Combo 10) 42.86 -1.84 62.89 56.59 49.24 39.21Chlamydia Screening in Women 41.20 0.60 60.22 50.91 43.38 38.02Human 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 9.28Plan 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



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

Measure

MercyCare HMO Score

2015-2014

90th Percentile

75th Percentile

50th Percentile

Rating of Personal Doctor (8+9+10) 89.90 -1.10 88.68 86.64 84.75Rating of All Health Care (8+9+10) 83.39 1.79 82.72 79.87 77.02



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

Measure

MercyCare HMO Score

2015-2014

90th Percentile

75th Percentile

50th Percentile

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

Measure

MercyCare HMO Score

2015-2014 90th

Percentile75th Percentile 50th Percentile

Getting Care Quickly 82.78 -3.42 89.83 87.80 85.86Getting Care Needed 86.62 -4.38 91.05 89.39 87.81Customer Service 84.01 -5.39 92.50 90.47 88.06Rating 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.



HEDIS® REVIEW & ANALYSIS

The following sections contain:

A Description of the Measures2015 Quality Improvement Activities and InitiativesIdentified BarriersQuantitative AnalysisQualitative Analysis 2016 Action Plans

For detailed work plans see document 2017 Commercial & Medicaid Work Plans



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 competitorTrend is flat2015 MARKETPLACE QRS is 82.61%



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 percentilePerformance is above the primary regional competitor2015 MARKETPLACE QRS is 60.87%


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



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).


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 competitorStable trend or slight deterioration over the last seven years2015 MARKETPLACE QRS is 100.00%




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.




Identified Barriers

Secondary diagnoses that exclude children from the measure sometimes not coded.




2016 HEDIS® performance is above the 75th percentilePerformance comparable to regional competitorFlat trend over the last five years2015 MARKETPLACE QRS is 100.00%



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.




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.




2016 HEDIS® performance is below the 50th percentileUnfavorable comparison to regional competitorMarkedly variable performance2015 MARKETPLACE QRS is 16.67%


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


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.


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.



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


2016 HEDIS® performance is above the 75th percentileImproved performance from the prior year with favorable trend over the last three years2015 MARKETPLACE QRS is 69.57%


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.



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


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.




2016 HEDIS® performance is below the 50th percentile.Unfavorable comparison to regional competitor


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.


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.



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


2016 HEDIS® performance is below the 50th percentile2015 MARKETPLACE QRS is 64.29% (9/14 events only)Equivalent performance to regional competitorStable trend over the last six years


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



Colorectal Cancer Screening

The percentage of members 50–75 years of age who had appropriate screening for colorectal cancer.


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.


2016 HEDIS® performance improved from prior yearEquivalent performance to regional competitor2015 MARKETPLACE QRS is 76.19%




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 nephropathyBlood pressure controlled to <140/90

HbA1c Poor Control (>9.0%)HbA1c Good Control (<8.0%)


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 coinsuranceNot enough staffing to case manage patients with HbA1c between 8.0 and 8.5




This is an inverse measure; therefore, a lower rate is better 2016 HEDIS® performance is between the 50th and 75th percentileUnfavorable comparison to regional competitor this year


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.



HbA1c Control (<8.0%)

2016 HEDIS® is at the 90th percentileEquivalent performance to our regional competitor2015 MARKETPLACE QRS is 71.15%

Eye Exam



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.



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.


2016 HEDIS® performance is between the 75th and 90th percentileEquivalent performance regional competitor2015 MARKETPLACE QRS is 55.77%


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.



Medical Attention for Nephropathy



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.




2016 HEDIS® performance is above the 90th percentile Favorable comparison to regional competitorImproved performance from the prior year with favorable trend over the last nine years2015 MARKETPLACE QRS is 100.00%


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 & InterventionsThe 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.



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/PPhysician resistance to ordering an ACE or ARB as prevention.


This is a subset of the following measure regarding control of high blood pressure.Currently our HEDIS score is above the 90th percentile.

Qualitative AnalysisMercyCare will continue the case management of this population and review this data at the Diabetes Task Force.

Action PlanWe 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.




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.


2016 HEDIS® performance is above the 90th percentile Marked increase over the prior year and highest ranking so far2015 MARKETPLACE QRS is 88.70%


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.


Controlling High Blood Pressure

50

55

60

65

70

75

80

2003

2006

Y

e

a

r

Scor

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90th percentile

75th percentile

50th percentile

MercyCare HMO

Dean Health Plan


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.


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.




2015 CAHPS (self-reported) is above the 90th percentileFavorable comparison to regional competitorImproved performance from the prior year


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.


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.




2016 HEDIS® performance was just above the 75th percentile2015 MARKETPLACE QRS is 100.00%


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.



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.



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.




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.




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.


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.



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.


2016 HEDIS® performance was above the 90th percentileFavorable comparison to regional competitorImproved performance from the prior year with favorable trend over the last eight years2015 MARKETPLACE QRS is 100.00%


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.



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.


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 medicationsLack 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.




2016 HEDIS® performance was above 90th percentileFavorable comparison to regional competitor2015 MARKETPLACE QRS is 0.00%

Unfavorable comparison to regional competitor2016 HEDIS® performance was at the 75th Percentile




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.


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.




2016 HEDIS® performance is right above the 90th percentile Equivalent performance to regional competitorFavorable trend over the last five years2015 MARKETPLACE QRS is 69.23%


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.




2016 HEDIS® performance was above the 75th percentile and improvedFavorable comparison to regional competitor2015 MARKETPLACE QRS is 57.20%


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.


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 CDCIncomplete instructions or parent reluctance result in series not being completed.




2016 HEDIS® performance is below the 50th percentileVery unfavorable comparison to regional competitor2015 MARKETPLACE QRS is 0.00%


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.


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

Parents are hesitant to vaccinate for MCV at age 11 as recommended by CDCIncomplete instructions or parent reluctance


2016 HEDIS® performance is below the 75th percentileFavorable comparison to regional competitor2015 MARKETPLACE QRS is 100.00%


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.


None



Barriers Identified

Physicians neglect this at annual exams and sports physicals

Quantitative Analysis (BMI Percentile)

2016 HEDIS® performance was above the 75th percentileHealth system EPIC template initiatives are improving performancePerformance equivalent to regional competitor2015 MARKETPLACE QRS is 65.63%



Quantitative Analysis (Counseling for Nutrition)

2016 HEDIS® performance was above the 50th percentileHealth system EPIC template initiatives are improving performanceUnfavorable comparison to regional competitor2015 MARKETPLACE QRS is 65.63%

Quantitative Analysis (Counseling for Physical Activity)

2016 HEDIS® performance was above the 75th percentileHealth system EPIC template initiatives are improving performanceUnfavorable comparison to regional competitor2015 MARKETPLACE QRS is 53.13%




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.


MHS initiative to get weight taken at every visit not limited to PCP visits.

Barriers Identified

Patient is not weighed


2014 HEDIS® performance is above the 90th percentile.2016 HEDIS® performance is above the 90th percentile.Performance equivalent to regional competitor2015 MARKETPLACE QRS is 95.94%




EPIC automatically calculates if a weight is taken and entered at visit

Action 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


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.




Performance below the 50th percentile (inverse measure)Poor comparison this year to competitor but historically better in 2011, 2012, 2013.


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.


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.




2016 HEDIS® performance is below the 50th percentile.Equal comparison to regional competitor2015 MARKETPLACE QRS is 0.00%Qualitative Analysis

See barriers.

Action plan




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



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


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



Health CareMember 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


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?




Rating of Personal Doctor


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?




Rating of Specialist


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?


Getting Care Quickly


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



Key DriversBased 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 carefullyPersonal doctor overallDoctor explained thingsEase of filling out formsDoctor spent enough timeDoctor showed respectCustomer Service provided information/helpEase of getting care, tests or treatmentDoctors 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 appointmentSpecialist overallCustomer Service treated you with courtesy and respectGot routine care



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 overallGot urgent careFound service/equipment cost informationClaims handled correctlyFound prescription cost informationClaims 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 CareAccessAttitude/ServiceBilling/FinancialQuality 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.



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 AnalysisReviewing 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?



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 specialisto 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 neededo 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 treatmento 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 neededo 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 helpo Improvement Actions Suggested

Minimize transfers



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 respecto 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 Specialisto Improvement Actions Suggested

Personalize the patient experience Foster relationships with patients

Action PlanMercyCare 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



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 AnalysisTable 1: Complaint volume report

Category

Previous Year Complaints,

Total

Previous Year Complaints per 1,000 Members

Current Measurement

Year Complaints,

Total

Current Measurement

Year Complaints per 1,000 Members

Quality of Care 1 .03 0 0Access 9 .24 14 .36Attitude/Service 1 .03 0 0Billing/Financial 470 12.72 676 17.42Quality of Practitioner Office Site

0 0 0 0

Total/Number per 1,000 481 13.02 690 17.78

Table 1a: Complaint by category by year

2014 2015 ChangeTotal Calls 43171 54573 26%Member Rcvd 23169 27483 19%Member Ansd 21441 23211 8%

Total Complaints 483 693 43%

Complaint types 2014 2015 Increase/DecreaseACCP 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%NCMB 7 19 171%



PB 0 17 #DIV/0!New category for 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%


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


Table 2: Grievance volume report

CategoryPrevious Year Appeals, Total

Previous Year Appeals per

1,000 Members

Current Measurement Year Appeals,

Total

Current Measurement Year Appeals

per 1,000 Members

Quality of Care 0 0 0 0Access 28 .49 18 .46Attitude/Service 0 0 0 0Billing/Financial 76 1.73 64 1.65Quality of Practitioner Office Site

0 0 0 0

Total Average 104 2.22 82 2.11



Table 2a: Grievance change by year report

2014 2015 Increase/DecreaseQuality of Care 0 0 N/A

Access 28 18 -36%(request to out of network provider)

Attitude/Service 0 0 N/ABilling/Financial 76 64 -16%Quality of Site 0 0 N/ATotal 104 82 -21%


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 eventsMember Complaint Resolution ProcessPharmacy ManagementContinuity and Coordination of Care Projects



Clinical Practice GuidelinesElectronic 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 0Availability of Practitioners 0Quality of Medical Care 3Accessibility 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

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.



APPROVALS

_____________________________________ _______________________Philip Bedrossian, MD DateMedical Director

_____________________________________ _______________________E. Patrick Cranley DateVice President/Chief Operating Officer

____________________________________ _______________________Rowland McClellan Date of Board ApprovalBoard of Directors, Chairman


mercycare health plans · web viewpractitioners prescribing antibiotics for viral infections. ......

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