2017 Quality Management overview
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1 Quality Management overview Amerigroup Community Care wants to make sure our members get and stay healthy at a low cost. We do this by: Offering quality programs Working with doctors and/or facilities Educating our community Quality Management looks at services members receive, finds ways to make programs better and creates new programs. National and state quality programs National Committee for Quality Assurance (NCQA) Amerigroup maintains national accreditation through the NCQA. NCQA uses surveys and HEDIS scores to look at our: Policy and procedures Quality programs Customer satisfaction Quality and access to care Healthcare Effectiveness Data and Information Sets (HEDIS ) HEDIS is a set of measures collected by all accredited health plans using the same specifications. The results are publically reported every year and allow a fair comparison of each health plan. We use the results to make our programs better and create new ones. HEDIS looks at seven areas: Effectiveness of care Access/availability of care Experience of care Utilization and risk adjusted utilization Relative resource use Health plan descriptive information Measures collected using electronic clinical data systems Our HEDIS scores improved in 30 measures in Preventive services like assessing BMI, nutritional counseling and physical activity counseling increased an average of 10 percentage points from WEBMMD
2 Measure BMI Nutritional counseling Physical activity counseling Our quality programs Medical records review for documentation standards Complete and accurate medical records improve quality and help us coordinate care. Our Quality Management team reviews medical records from primary care providers (PCPs). We give providers the results and use them to improve medical record documentation. Continuity and coordination of care PCPs, specialists, hospitals and urgent care centers need to communicate to improve quality of care. Surveys and medical record reviews look at communication between PCPs, specialists and/or facilities. We give providers and facilities the results along with ways they can improve. Patient safety Amerigroup helps providers make sure members receive the right medication in the right dosage and avoid negative drug interactions. Some of our pharmacy-related programs that help do this are: Polypharmacy: We tell providers about members with multiple medications and prescribers. Age appropriateness: We tell providers when a medication is not recommended because of a person s age. Health promotion Amerigroup health promotion includes health risk assessments, member outreach and community events. We do targeted outreach with members to: Learn about problems they have getting care. Educate them about the importance of a healthy lifestyle. We use claims history to choose members and make sure they received recommended preventive and routine health care.
3 Our health program representative participates in community events and tells people about: Women s health Prenatal care Children s wellness visits Case Management programs Case Management programs help members with health concerns take control of their care by: Coordinating quality health care services. Making sure members know how to manage their condition. Case managers work with members, their families and caregivers. They develop individual care plans and provide education and health care resources. This helps improve members health outcomes. Members may be referred to a case management program by providers, other internal programs and self-referral. Disease Management program Disease Management helps members meet health care goals. We encourage member education and self-care by working with members and/or family members and caregivers. Disease managers may: Coordinate health care services. Support relationships between members and providers. Provide interventions to help members be as healthy as they can be. Refer members to Beacon Health Options to help with behavioral health conditions. The Disease Management program includes seven NCQA accredited programs: Asthma Coronary health disease (CAD) Congestive heart failure (CHF) Diabetes Disease Management also offers programs for: Bipolar disorder Hypertension Substance use disorder HIV/AIDS Major depressive disorder Schizophrenia We use claims data to identify members for the Disease Management program.
4 Customer satisfaction Amerigroup is committed to keeping our members happy. Our plan uses member surveys, member complaint and appeals data, and provider feedback to improve member experience and satisfaction. The annual Customer Assessment of Healthcare Providers and Systems (CAHPS ) survey lets our members give feedback on: The health plan Providers Their experience getting the care they need Their experience getting the care their child needs The results tell us how we can better serve our members. Here are some of our 2016 and 2017 CAHPS results for adult members. Our goal is to be at the 50th percentile or above. CAHPS Adult Survey Question 2016 score* 2017 score* 2017 percentile We want to know your rating of the specialist you saw most often in the last 6 months. Using any number from 0-10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you rate that specialist? personal doctor listen carefully to you? personal doctor show respect for what you had to say? Treated with courtesy and respect by the health plan s Customer Services? 81.07% 82.63% 67th 93.15% 94.54% 90th 94.18% 94.18% 75th 73.1% 78.4% 66th * Percentage of members that selected the highest rating
5 Overall, members said they were happy with these key areas: How well doctors talk to them (92.3% Summary Rate Always/Usually) Customer service (88.4% Summary Rate Always/Usually) Coordination of care (82.6% Summary Rate Always/Usually) Customer satisfaction - Child We also asked parents or guardians of child members 17 years of age and younger to share how happy they were with Amerigroup and getting health care for their child. Here are some of our 2016 and 2017 CAHPS results for child members. CAHPS Child Survey Question 2016 score* 2017 score* 2017 percentile child s doctor explain things about your child s health in a way that was easy to understand? child s doctor listen carefully to you? child s doctor show respect for what you had to say? In the last 6 months, how often did customer service at your child s health plan give you the information or help you needed? 78.0% 78.6% 28th 64.1% 82.0% 39th 86.4% 86.9% 22nd 52.4% 56.6% 26th * Percentage of parents that answered Always Overall, members with children said they were happy with these areas: How well doctors talk to them (92.5% Summary Rate Always/Usually) Customer service (86.0% Summary Rate Always/Usually) Getting care quickly (85.7% Summary Rate Always/Usually)
6 Provider satisfaction We also talk to your primary care physicians (PCPs) to see what we can do to improve your care and services. In 2017, we asked your PCPs to rate us on case management, finance issues, customer service for PCPs, timing of approvals for patient services and more. Here are some of the results: 60.00% Provider satisfaction survey results 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Coordination of Care/ Case Management Timing of Claims Processing Timing for Approval of Inpatient Care Fair/Poor Good Excellent/Very Good Eight out of 10 PCPs said they would recommend Amerigroup to their patients (81.6%) and/or to other doctors (80.1%). Based on the PCP feedback, we re working to improve in these areas: Coordination of care and Case Management programs Customer service and provider relations Answering questions and/or fixing problems quickly
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