QUALITY IMPROVEMENT PROGRAM EmblemHealth s mission is to create healthier futures for our customers and communities. We will do this by providing members with a broad range of benefits and conscientious service; striving to enhance the experience for health care professionals; offering high value to those who purchase our health plans; working with government agencies to increase access to coverage; and partnering with the communities in which we live and work to improve their overall health. EmblemHealth continues to have a comprehensive quality improvement program that encompasses all operational areas and establishes a framework and processes that continuously work to improve the health care and services our members receive. We routinely monitor and review the following areas to ensure that our members have access to the highest quality medical and behavioral care and services: Quality of care Quality of service Patient safety Care management Member and physician satisfaction Accessibility Availability Delegation Member complaints and appeals Health management tools Cultural diversity We use various data sources and software to measure quality improvement processes and outcomes, and determine barriers to improvement, including but not limited to Healthcare Effectiveness Data and Information Set (HEDIS ) and Consumer Assessment of Healthcare Providers and Systems (CAHPS ) data. The data helps determine appropriate ways to improve quality and overcome barriers. Highlights of the Quality Improvement Program include, but are not limited to the following: QUALITY OF CARE Clinical and health promotion activities are systematically selected and prioritized. Interventions are based upon recognized evidence-based clinical guidelines and member-specific needs. Activities focused on optimizing the health and well-being of EmblemHealth s members include but are not limited to: Members personalized health communications. These are designed to make members aware of any gaps in preventive or chronic maintenance care and empower them to make educated choices that affect their health and well-being. Targeted incentive mailing to Medicaid members who are missing certain tests, well-visits, or dental visits. Mailing of preventive health guidelines, member newsletters, and health and wellness information in an effort to help members maintain their health. Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies. EMB_PR_OTH-WEB_40617_2017QualityImprovementProg 12/17
Calls to members to confirm certain diagnoses, such as rheumatoid arthritis or osteoporosis, and encourage them to use appropriate medications and go for appropriate tests. Medication adherence activities, including contacting those providers with members who did not refill needed medications. A new Provider Incentive Award Program for high volume health care professional groups was launched in 2016. Collaborative relationships with the groups quality teams and leadership were built as a result of the program. Monthly gaps in care reports, report cards, and Healthcare Effectiveness Data and Information Set (HEDIS ) measure dashboards were distributed to groups highlighting performance and opportunities for improvement. Calls to members recently discharged from the hospital to ensure the member gets appropriate follow-up care with a health professional. A gap in care program with several health homes. Training materials, outcome reports, and monthly gaps in care reports are shared with the health homes. Continued collaboration with Disease Management, Case Management, and Pharmacy departments to promote HEDIS, New York State Quality Assurance Reporting Requirements (QARR ) and Centers for Medicare and Medicaid Services (CMS) Medicare Star Ratings Program measures. Partnerships with vendors who conduct in-home tests, such as bone mineral density and diabetic testing. EmblemHealth offers members with certain health conditions access to education and support through its Care Management PATH (Positive Actions Toward Health) programs. These programs complement the care members receive from their doctors and assist the member by helping them better understand and manage their condition. Eligible members are offered Care Management PATH programs for the following conditions: Asthma Chronic Obstructive Pulmonary Disease (COPD) Diabetes Coronary Artery Disease (CAD) Heart Failure Chronic Kidney Disease and End-Stage Renal Disease Healthy Beginnings PATH Pregnancy Management Program Tobacco-Free PATH Smoking Cessation Program Serious and Persistent Mental Illness Disease Management Services These programs provide interventions based on members assessments. Services include but are not limited to: One-on-one telephonic health coaching and monitoring based on care plans created by a registered nurse and/or other health care staff. The plan addresses each member s physical, behavioral, and emotional health and accounts for the members lifestyle and cultural needs. Educational materials about symptom management, health and safety risks, treatments, diet, and nutrition. Periodic evaluations of members health. Health care professionals receive updates on their patients health status. Quarterly newsletters for health care professionals highlighting the latest information on chronic illnesses. Coordination of care between members and their medical professionals, as well as support-services for caregivers. Community-based support services, including culturally and language-appropriate community-based services. Members satisfaction with the Care Management PATH program is measured annually and improvement activities are implemented when required. EmblemHealth also provides unique and specialized health outreach programs such as EmblemHealth Neighborhood Care, Care for the Family Caregiver, and the National Diabetes Prevention Program. 2
EmblemHealth collects and analyzes data in an effort to continually monitor its performance and identify areas for improvement. EmblemHealth uses Healthcare Effectiveness Data and Information Set (HEDIS ) scores to determine if members are getting needed preventive screenings and treatments. Continual monitoring of HEDIS scores allows EmblemHealth to identify areas of improvement in member s care and service. Improved scores year over year indicate that EmblemHealth is continuing to reduce gaps in the health care its members receive. EmblemHealth compares the Plan s HEDIS scores to relevant industry benchmarks, such as National Committee for Quality Assurance (NCQA) Quality Compass, CMS Medicare Star Ratings Program, and New York State averages to measure its performance compared to other health plans. HIP MEDICARE HMO Adult Access to Preventive/Ambulatory Care 95.55% 95.62% 95.74%** Annual Monitoring for Patients on Persistent Medications: Total 93.60% 94.03% 86.94%** Breast Cancer Screening 78.11% 79.22% 78.00% Colorectal Cancer Screening 74.19% 78.50% 72.00% Comprehensive Diabetes Care: HbA1c Test 94.44% 95.95% 93.81%** Comprehensive Diabetes Care: Eye Exam 76.09% 82.28% 72.00% Comprehensive Diabetes Care: Monitor Nephropathy 96.62% 97.22% 96.00% Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis 76.66% 78.97% 78.00% Osteoporosis Management in Women Who Had a Fracture 55.09% 57.02% 52.00% *Benchmark: Medicare 2018 Part C & D Star Rating Technical Notes 4-Star Benchmark. ** These are not CMS Medicare Star Ratings program measures; 2017 Quality Compass National HMO Average 75th percentile is used for Benchmark. HIP MEDICAID Breast Cancer Screening 67.51% 70.21% 71.46% Cervical Cancer Screening 70.19% 77.87% 73.49% Colorectal Cancer Screening 49.42% 55.61% 60.65% Comprehensive Diabetes Care: Eye Exam 63.68% 65.94% 62.83% Controlling High Blood Pressure 53.11% 62.20% 64.32% Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis 79.90% 83.01% 80.92% Follow-Up Care for Children Prescribed ADHD Medication: Initiation Phase (30 Days) Follow-Up Care for Children Prescribed ADHD Medication: Continuation Phase (270 Days) 39.97% 60.89% 58.00% 46.67% 70.40% 67.38% Follow-Up After Hospitalization for Mental Illness: Within 7 Days 41.32% 50.80% 65.45% Follow-Up After Hospitalization for Mental Illness: Within 30 Days 58.04% 67.87% 79.24% Timeliness of Prenatal Care: Initial Visit 76.98% 87.80% 87.66% *Benchmark: QARR Statewide Average for measurement year 2015. HIP EXCHANGE HMO (QUALIFIED HEALTH PLAN (QHP))* MEASURE HEDIS 2016 HEDIS 2017 Annual Monitoring for Patients on Persistent Medications: Total 85.82% 87.68% Appropriate Testing for Children with Pharyngitis 90.00% 93.75% Breast Cancer Screening 72.63% 69.54% Cervical Cancer Screening 73.11% 60.98% Colorectal Cancer Screening 52.55% 50.73% Controlling High Blood Pressure 46.68% 47.20% Follow-Up After Hospitalization for Mental Illness: Within 7 Days 42.86% 61.54% Timeliness of Prenatal Care: Initial Visit 76.92% 88.10% *Benchmark is unavailable for Qualified Health Plan (QHP) 3
HIP COMMERCIAL HMO Adult Access to Preventive/Ambulatory Care 93.20% 93.29% 94.59% Adolescent Well Care Visits 58.69% 61.71% 42.72% Annual Monitoring for Patients on Persistent Medications: Total 85.89% 87.89% 83.65% Breast Cancer Screening 74.13% 74.84% 74.72% Cervical Cancer Screening 79.23% 84.23% 73.76% Colorectal Cancer Screening 65.38% 68.35% 65.80% Comprehensive Diabetes Care: HbA1c Test 89.85% 91.40% 91.64% Follow-Up After Hospitalization for Mental Illness: Within 7 Days 45.80% 53.33% 58.43% Follow-Up After Hospitalization for Mental Illness: Within 30 Days 62.25% 68.94% 75.98% Timeliness of Prenatal Care: Initial Visit 80.05% 90.26% 87.98% *Benchmark: 2017 Quality Compass National HMO Average 50 th percentile GHI COMMERCIAL PPO Antidepressant Medication Management: Acute Treatment (84 days) 61.54% 68.42% 68.06% Antidepressant Medication Management: Continuation Phase (180 days) 48.49% 56.62% 52.20% Chlamydia Screening in Women: Total (16 24 years) 64.47% 65.68% 43.14% Follow-Up Care for Children Prescribed ADHD Medication: Initiation Phase (30 Days) 37.33% 55.70% 38.59% Follow-Up Care for Children Prescribed ADHD Medication: Continuation Phase (270 Days) 36.36% 75.00% 44.44% Follow-Up After Hospitalization for Mental Illness: Within 7 Days 43.71% 51.68% 50.64% Follow-Up After Hospitalization for Mental Illness: Within 30 Days 61.08% 67.11% 71.08% *Benchmark: 2017 Quality Compass National PPO and EPO Average 50 th percentile EmblemHealth also uses Consumer Assessment of Healthcare Providers and Systems (CAHPS ) to survey its members about the interpersonal aspects of their health care as well as the members relationship with their doctor and experiences with their health plan. CAHPS results are publically reported on various forums and used by consumers to guide their selection of health plans. CAHPS are required by CMS for Medicare and the Qualified Health Plan Enrollee Experience Survey for the Qualified Health Plans. They are also required by the New York State Department of Health, Federal Employee Health Benefits (FEHB), the National Committee for Quality Assurance (NCQA), and URAC. Additionally, CAHPS results impact the Medicare Stars Quality Bonus Program and the New York State Department of Health Medicaid Quality Incentive Program and the potential revenue associated with both programs. Accreditation EmblemHealth submitted its renewal for the National Committee for Quality Assurance (NCQA) Health Plan accreditation for HIP Commercial HMO/POS, HIP Medicare HMO and HIP Exchange HMO in 2016. The Plan also submitted for first-time accreditation for GHI Commercial PPO. Desktop submission included submission of policies, procedures, materials, reports (including studies and analysis followed by an on-site audit which included review of grievance and appeals files, credentialing/ re-credentialing files, case management files, and utilization management files). EmblemHealth was awarded a Commendable accreditation status for HIP Medicare HMO and received an Accredited status for HIP Commercial HMO/POS, GHI Commercial PPO, and HIP Exchange HMO. The NCQA accreditation statuses remain in effect through September 12, 2019. EmblemHealth continues to hold full accreditation from URAC for Health Utilization Management and CORE standards for HIP Commercial EPO/PPO and GHI Commercial EPO/PPO. These accreditations remain in effect through July 1, 2018. Additional highlights of EmblemHealth s combined HEDIS, CAHPS, and NCQA Accreditation standards scores can be viewed at NCQA Health Insurance Plan Ratings (2017-2018). 4
QUALITY OF SERVICE EmblemHealth continually monitors experiences with the health plan to identify ways to improve the services it provides to its members and health care professionals. Customer Service EmblemHealth monitors member and health care professional (provider) telephone service standards that include specific service levels. The results are tracked and trended. The table below details the Customer Service Call Center metrics for 2016 compared to prior years: CALL CENTER METRICS METRIC GOAL PPO HMO 2015 2016 2015 2016 Total # of Calls Received n/a 2,138,526 2,274,727 2,384,286 2,229,824 Total # of Calls Answered n/a 2,091,095 1,998,489 2,325,506 2,081,047 Average Speed of Answer (ASA) 20 Seconds 50 288 49 140 % of Member Calls Answered in 45 seconds (30 seconds in 2014 and 2015) 80% of Calls 66.84% 65.11% 75.82% 83.37% % of Health Care Professional (Provider) Calls Answered in 60 Seconds 80% of Calls n/a 39.28% n/a 54.78% Abandonment Rate 2% or less 2.22% 12.00% 2.38% 6.3% First Call Resolution 85% 86.43% 87.20% 81.99% 82.81% Call center teams focused on developing plans to improve quality within the call centers during 2016. As part of this effort, we implemented a Customer Connection Quality Program to all EmblemHealth Call Centers. The program s purpose is to provide a foundation for evaluating Customer Service Advocates while empowering them to personalize each customer experience. Coaching, reminders on key components, customer feedback via an after-call survey, and quality audits are all incorporated into the program. Program enhancements began in 2016 and continued into 2017. Claims Operations EmblemHealth monitors its claims processing standards, which includes specific target service levels. We monitor and measure the following to gauge progress in meetings goals: Mean Processing Time All Claims (Days). Percentage Paid in 30 Days. The results are continually tracked and trended and process improvements are implemented as identified. The table below contains details of the Claims Processing metrics for 2016: CLAIMS OPERATIONS SUMMARY FOR 2016 HMO METRIC MEDICAL HOSPITAL 2015 2016 2015 2016 Total Claims Processed 8,307,781 7,723,136 1,377,855 1,126,680 Mean Processing Time All Claims (Days) 4.54 5.44 5.88 10.81 % Paid in 30 Days (Goal: 99%) 99.84% 98.76% 98.72% 94.38% CLAIMS OPERATIONS SUMMARY FOR 2016 PPO METRIC MEDICAL HOSPITAL DENTAL 2015 2016 2015 2016 2015 2016 Total Claims Processed 17,926,155 18,295,742 417,038 476,745 996,851 1,004,222 Mean Processing Time All Claims (Days) 3.80 6.77 4.96 6.05 5.49 6.46 % Paid in 30 Days (Goal: 99%) 99.57% 94.75% 99.63% 98.57% 98.79% 96.77% 5