Quality Management Utilization Management

Transcription

1 Aetna Better Health Aetna Better Health Kids Quality Management Utilization Management 2015 Program Evaluation

2 EXECUTIVE SUMMARY Aetna Better Health, a Medicaid Physical Health-Managed Care Organization in the state of Pennsylvania since 2010 provides managed care services 189,330 Medicaid recipients which is representative of 1,997,332 member months. The increase from 160,424 members in 2014 is largely attributed to the successful implementation of the Healthy PA - Private Care Option (PCO) plan with subsequent transition of PCO members to the HealthChoices program. The evaluation of the 2015 QAPI is an annual comprehensive summary of quality activities that occur across the organization and are performed under the scope of the Quality Management and Utilization Management (QM/UM) Workplan. Aetna Better Health s 2015 high level view of its accomplishments and challenges will be outlined in the summary and the remainder of the evaluations will provide a more in-depth overview of the QAPI. The 2015 QM/UM evaluation provides the identification of opportunities for existing and planned program activities in The overall evaluation of the scope of activities demonstrated how quality, performance and process improvement exists throughout Aetna Better Health and addresses members, practitioners and providers for the Medicaid and CHIP lines of business. This analysis of our 2015 performance provides the backdrop for the identification of opportunities for improvement as the plan continuously seeks to evaluate and improve its Quality Management and Utilization Management programs throughout the organization. QAPI STRUCTURE AND OPERATIONS The Aetna Better Health QAPI Program primary focus is on the member and thereby monitors processes, assesses the effectiveness of its activities, and ensures that providers and members have input in the development of plan policies, procedures, activities, programs and improvement actions. The Aetna Better Health Board of Directors has ultimate accountability for the QAPI and all related processes, activities and systems. The chief executive officer on behalf of the Quality Management Oversight Committee submits the QAPI program description and any subsequent revisions to the board of directors for approval. Directing the development and implementation of the QAPI within the plan is the accountability of the chief medical officer under whose direction the Quality Management Department coordinates the QAPI, provides support to plan committees and addresses quality-related requests from members, practitioners, providers, regulatory authorities and other referral sources. PROGRAM GOALS AND OBJECTIVES Aetna Better Health s QAPI program s primary goal is to continually improve the quality of care for our members and the quality of the services provided to both members and our practitioner and provider network. The plan s overall objective is to achieve the best outcomes possible for our Medicaid and CHIP members through continued collaborative efforts with members, practitioners and providers. Additional goals and objectives include: Improve member and provider satisfaction with the health plan Promote safety through processes that address the quality of care, provider preventable conditions, provider credentialing and pharmacy needs of members Monitor and evaluate the continuity, availability and accessibility of care and/or services provided to members

3 Continually improve HEDIS rates with the goal of reaching and exceeding the NCQA 90 th percentile Continue to improve PA Performance Measure rates Maintain NCQA Health Plan accreditation and improve standards and HEDIS/CAHPS rates with the goal of achieving an accreditation rating of Commendable Partnership with Head Start programs in each county we serve to drive improvement of preventive health and dental services for children Continue effective working partnership with the Department of Human Services and it s EQRO to comply with all requirements Continue to manage and grow robust Value Based Services including Provider P4Q and incentive programs with targeted practices Establish and maintain performance improvement projects that effectively improve outcomes for members Ensure that the plan s practitioner and provider networks are robust and able to accommodate the diverse needs of the Medicaid and CHIP memberships Monitor outpatient and inpatient services to identify and address deviations from care and services standards ACCOMPLISHMENTS Accomplishments of 2015 include: Implemented the Healthy PA PCO Program Transitioned Healthy PA PCO Program to HealthChoices Grew membership by 30K+ members Met all Member Services required service levels Established Whole Person approach across all functional areas, including approach to improvement in member outcomes demonstrated by improved HEDIS rates Year over year reduction in inpatient utilization trends Improved our Dental HEDIS Rates by more than six (6) percentage points Successfully implemented ICD10, including providing training to the staff and providers Increased UM care coordination with Case Management: Welcome Home and Readmission Reduction Program Successful implementation of Neonatal Abstinence Syndrome program Successful implementation of Avoidable Admission initiative Active participation in workgroup activities to improve overall HEDIS scores Successful integration of Disease Management (chronic condition management) into the Integrated Care Management Program. Implementation of Hepatitis C treatment adherence care management program. Implementation of face to face visits to members by case managers

4 CHALLENGES Challenges of 2015 include: Improving key HEDIS rates to reach and/or exceed the 50 th percentile Improving dental preventive care services for younger members 1 5 years of age Adult and Child CAHPS surveys less than the NCQA 90 th percentile benchmark Improving access to care for members by addressing appointment availability for PCPs, OB-GYNs and Specialists including dentists Reducing emergency room for ambulatory care and services Improving accessibility and availability provider survey results Improving practitioner assessment of member cultural and linguistic needs Improving the number of children and adolescents accessing preventive care Challenges exist in identifying pregnant women enrolled on the health plan that are not identified by DHS or ONAF forms from providers. Only a small number of perinatal care providers submit the ONAF electronically, reporting it is challenging to use multiple systems across the various MCOs in PA PRIORITIES Priorities for 2016 include: Continued increase in preventive dental services to children Improvement in well care, lead screenings and immunizations for children and adolescents Reduction in readmissions Establishment of targeted medication adherence program Improve member and provider satisfaction Conduct periodic independent customer service surveys to get feedback from our members on ways to improve our service Maintain compliance as a way of business Maintain/exceed regulatory required thresholds Implement robust behavioral health programs that address the needs of the population i.e. collaboration with BH-MCOs, improving follow-up care for children with ADHD, medication adherence Enhance community partnerships Implementation of community-based outreach and care management programs Structured practitioner partnerships targeted at improving quality outcomes for members Improve the number of children who receive EPSDT care, particularly developmental screenings, lead testing, immunizations Ensure that Rapid Cycle Improvement Processes remain evident throughout the plan Actively participate in the development and implementation of health care disparities initiatives Address the need for implementation of medical homes and expanding associations with Patient Centered Medical Home practices Continue to address need for technology innovation to enhance healthcare delivery

5 Continue to enhance the welcome call and orientation program for new members Increase the number of members in the Intensive level of Care Management and face to face visits with these members. Increase provider usage of the electronic ONAF submission portal Expand and continue community based care management partnerships to improve health outcomes and reduce ED and inpatient admissions/readmissions MEMBERSHIP Medicaid Membership as of December 31, 2013: 72,194 members; 772,167 member months Membership as of December 31, 2014: 160,424 members; 1,948,642 member months Membership as of December 31, 2015: 189,330 members; 1,997,332 member months Region SE Region 61.3% 53.3% 37.4% Lehigh/Capital Region 38.7% 36.5% 21.2% Southwest 2.0% 10.5% Northwest 2.8% 9.4% Northeast 5.4% 21.5% Female 53.76% 53.41% 52.3% Male 46.24% 46.59% 47.7% Under 21 years of age 64.85% 64.73% 52.8% Ages % 26.45% 37.1% Female years of age 31.11% 31.09% 33.3% Over 50 years of age 8.03% 8.82% 10.1% Category MAGI 0-2 months 1.28% 0.67% 0.50% MAGI 2-12 months 2.22% 3.98% 2.60% MAGI 1-18 years 47.82% 40.18% MAGI 19 plus 19.84% 10.68% Medically Needy State Only GA 1.35% 0.81% Categorically Needy State Only GA 5.87% 4.32% Breast and Cervical Cancer 0.17% 0.08% 0.04% SSI and Healthy Horizons 22.49% 15.70% SSI Newly Eligible Ages 19 and % Medically Frail Ages 21 to % Medically Frail Ages 35 to % Medically Frail Ages 45 to % Medically Frail Ages 55 to %

6 CHIP Region Total Membership 15,258 9, Southeast Region 75.23% 74.20% 68.06% Central Region 24.77% 25.80% 31.94% Category Female , Male , < years years , years , years , SUMMARY Aetna Better Health remains committed to continuous improvement in its plan processes by identifying and acting on opportunities for improvement identified throughout the year. Our focus is on improving outcomes for the populations we serve as evidenced throughout the annual evaluation of activities that occurred during 2015 and planned for Throughout the organization our staff is committed to providing excellent service, adhering to the principles of Total Quality Management, collaborating with partners and demonstrating improvement in member outcomes. The basis for our QAPI is continuous quality improvement, compliance with all regulatory requirements and regulations, and addressing areas we recognize as suboptimal with rapid cycle improvement strategies when able and short and long term interventions and goals. During the past year we demonstrate improvement in some areas and clearly outline the opportunities in others. We did not wait until this annual evaluation to implement change as needed and will continue to determine how we can enhance member outcomes, improve member and provider satisfaction. Our plan policies, procedures and workflows are adjusted at least annually and more frequently as needed to assure we are fluent with the changing landscape of the membership which we are privileged to serve. Our provider network is strong, as evidenced by our geo-access reporting, and analysis continues to meet the needs of members and to provide an avenue for practitioner referral, collaboration and continuity of care. We strive to improve in rural areas as new opportunities become available, and will continue to improve our community operations into 2016 through face-to-face visits with members and on-site visits and webinars training with our providers. Our 2015 HEDIS and CAHPS results identified opportunities to improve member outcomes and to that end we have vigorously renewed our commitment to quality throughout the organization. Quality is everyone s job here at Aetna Better Health/Aetna Better Health Kids. Everyone in our organization has performance targets that are directly linked to achieving quality results. To underscore this commitment, we provide quality education to all plan staff each quarter, have mandatory HEDIS and soft skills training and include an overview of clinical quality outcomes, member and provider satisfaction, process improvements and policy changes.