Our Health Care Services Department vision and mission are aligned with the corporate mission to enhance the lives of our enrollees.
We promote quality, effective, and affordable health care that supports every stage of life. Our enrollee and provider-centric programs focus on appropriate evidence based clinical care, education, and information access resulting in enrollee empowerment, improved health outcomes, and overall well-being.
National Committee for Quality Assurance Accreditation (NCQA)
The National Committee for Quality Assurance (NCQA) provides an evidence-based framework for systematically improving health care and services. HealthNow promotes quality health care delivery for our members. Improving the quality of health care enriches the lives of our members, decreases overall morbidity and mortality and ultimately results in savings of health care dollars. HealthNow undergoes a rigorous NCQA re- accreditation survey process every three years in order to demonstrate and maintain the highest levels of quality and service. In January 2013, HealthNow underwent a full NCQA re- accreditation survey to demonstrate continued commitment and attainment of the highest quality standards. Our Commercial HMO/POS/ PPO, Medicare HMO/PPO, and Medicaid lines of business were brought forth for review. In 2013, HealthNow maintained “Excellent” status for our Commercial and Medicare business by surpassing the minimum threshold of 90% for the excellent category, the highest level awarded by NCQA. Commendable status was achieved for the Medicaid business.
Health care Effectiveness Data and Information Set (HEDIS®) Surveys
This survey is developed to measure a health plan’s performance on the quality of health care and services enrollees receive. The majority of managed care plans in the United States participate in collecting this data using more than 81 different specifically designed measures. This standardization allows comparison between plans and regions creating a “report card” for health insurance companies that is available to the public. The annual HEDIS survey includes preventive health care such as well child visits and adult cancer screening, along with disease specific care including diabetes and cardiac conditions. The results of this survey assist us in identifying health care areas needing improvement. HEDIS results are used to develop and evaluate many of the quality programs and are listed with the various programs found in this report. In 2013 our NCQA HEDIS score was 40.5 points out of a possible 50 points. This score is one piece of the scoring which contributed to the maintenance of our excellent accreditation rating.
Quality Assurance Reporting Review (QARR)
Quality Assurance Reporting Review or QARR measures a health plan’s performance in managed care for New York State. The measures can be identical to the HEDIS measures or specially designed by the state such as the Adolescent Preventive Care measures. All results are reported to New York State Department of Health. Results are publically reported by the state to assist an enrollee in choosing a health plan. As with HEDIS, the results are used to identify opportunities for improvement of services and evaluating existing quality programs.
Hospital Quality Incentive Program Overview
Utilization Management/Health Care Quality Improvement teams continue to partner in a variety of ways with hospitals and other health care facilities to identify opportunities to build health care systems and processes that promote improvement in the quality of care delivered to our members and the larger communities we serve.
The Hospital Quality Incentive Program works in collaboration with hospitals and other healthcare facilities by working together to achieve the following:
Utilization Management/Health Care Quality Improvement teams work closely with participating facilities that qualify and seek to achieve specialty Blues Center for Distinction Designations.
Blue Distinction Centers for Specialty Care®
Blue Distinction® is a national designation program that recognizes those facilities that demonstrate expertise in delivering quality specialty care — safely, efficiently and cost effectively. True to its original commitment as a quality-based program, Blue Distinction has evolved to include a value-based designation awarded to facilities that meet nationally established, objective quality measures focused on patient safety and outcomes, developed with thoughtful input from the medical community, as well as cost of care criteria. Its goal is to help consumers find both quality and value for their specialty care needs, on a consistent basis, while encouraging healthcare professionals to improve the overall quality and delivery of care nationwide.
Guiding principles for the selection process were developed through a balanced set of quality, cost and access considerations, to provide consumers with meaningful differentiation in value for those specialty care facilities that are designated as Blue Distinction Centers (BDCs), including:
We met our 2012/2013 goals in continuing to leverage P4P Performance to support Patient Centered Medical Home initiatives. The Pharmacy and Service Component have been eliminated and the attribution methodology was revised to “PCP or Record or Imputed PCP” with the implementation of our new analytical tool McKesson Risk Manager (MRM).
MRM has been deployed to our provider web sites. We are tentative to have our 2012 settlement completed by the end of the 1st quarter 2014. Specifications for determining ROI and the potential of integrating outcome metrics for these programs are ongoing.
Patient Centered Medical Home (PCMH)
The Plan either manages or is a participant in multiple Patient Centered Medical Home (PCMH) Initiatives.
Corporate Commercial PCMH is an initiative to provide assistance to primary care practices (PCP), both adult and pediatric, once the practice achieves national recognition through the National Committee for Quality Assurance (NCQA). BlueCross Blue Shield of Western New York provides additional financial reimbursement in a multi-faceted approach. Primary care practices are encouraged to engage in this voluntary recognition program and embrace the PCMH model that supports quality, safe and accessible care to their patients, our members.
The number of practices that have achieved PCMH recognition has increased from 40 practices in 2010 to 195 practices by the end of 2013.
To provide ongoing support to the PCMH model the Plan offers:
New York State PCMH Pass-Through for Medicaid, Child Health Plus and Family Health Plus is a New York State Department of Health initiative to incentivize the development of Patient Centered Medical Homes to improve health outcomes through better coordination and integration of patient care for persons enrolled in New York State government programs.
Culturally and Linguistically Appropriate Services (CLAS)
This program is designed to enhance the enrollee/provider/health plan relationship from a cultural and linguistic perspective. Language Line Services is used to assist with any language barriers that may exist in order to improve understanding and compliance for all parties and to ultimately improve the health and health care of our enrollees. Educational programs are provided to promote culturally competent care, and programs are planned to decrease ethnic disparities in care. Annual training of employees is completed to expand and keep current knowledge regarding how culture and language barriers affect our enrollees and how they can help to make the enrollees health care experience a positive one promoting increased compliance and wellness. Seminars for providers are available on our provider portal.
Continuity and Coordination of Care
Continuity and Coordination of Care (CCC) between settings and transitions in care is essential to quality care across the health care system. CCC helps prevent duplication of services, improves appropriateness of care, patient safety and can lead to a reduction in medical cost.
Information sharing is essential to the effective management of a patient’s overall health. In 2013, surveys and medical record review were used to assess information exchange within the health care system. In addition other program/projects (i.e. Case and Disease Management, Radiation Safety, Medco Rationale Med, Poly-Pharmacy Alerts, Patient Centered Medical Home (PCMH), Emergency Room Utilization etc.) measure coordination and work toward improving CCC for all our members.
2013 projects included measurement of communication between urgent care centers/ER/specialists/behavioral health and primary care providers. Results identified opportunity for improvement in rate, timeliness and process for information exchange between urgent care centers, ER, specialists, behavioral health practitioners and primary care.
1. Primary Care Providers reported that specialists have been effectively communicating the initial consult but the follow up visit is less frequently shared with the PCP’s. It was also indicated that about 6 in 10 PCP’s receive communication from the emergency rooms but the urgent care facilities have significantly less communication with the PCP. It was noted that vast improvements are needed with behavioral health providers communicating annual updates, as well as change in medication, condition and treatments to the primary care physician. Almost all PCP’s in both WNY and NENY have adopted the use of EMR’s (electronic medical records) or are planning to in the future. Adoption of Health Information Exchange is slow, but trending upward over the last three years.
2. Behavioral Health Providers report that communication from the PCP’s office has shown improvement in 2013 but is still low overall. Behavioral Health specialists continue to have low usage of new technologies with the majority not planning to adopt to an Electronic Medical Record system, Health Information Exchange or E-Prescribing.
3. Based on focused Medical Record review communication of specialty care (Dermatology and Orthopedic) to the PCP occurs as follows.
Interventions were developed and implemented to improve performance. Information exchange continues to be monitored via medical record review for standards, provider surveys and other CCC related activities.
Medical Record Review for Standards
Primary Care/Patient Centered Medical Home medical records are reviewed and rated against established documentation standards in an effort to identify areas for improvement in the medical record documentation and to assess for quality of care concerns.
The areas routinely identified as needing improvement are:
1. A Health Care Proxy/Advance Directive has been discussed or signed and this documentation is present in the record.
2. For adult patients seen three or more times there are appropriate notations concerning substance use and sexual activity.
3. Personal/Demographic data will include documentation of employer, work contact and emergency contact information as applicable.
4. Documentation of Body Mass Index (BMI) for adults and BMI-percentile-for-age for Pediatrics.
5. Evidence of culturally competent care. This is addressed in the record by documentation of at least one of the following: race, ethnicity or culture of the patient, language spoken, use of an interpreter or any communication or cultural issues considered in the patient care.
6. Documentation of adult immunization detail.
The standard pertaining to assessment and documentation of adolescent anticipatory guidance components was revised. The age at which assessment of elements such as risk behavior/sexual activity, depression, tobacco, alcohol and substance use was lowered from 14 years to 12 years in accordance with recommendations of the American Academy of Pediatrics. Records were reviewed against this revised standard beginning in January 2011 and continued throughout the review in 2012 and 2013.
80 - 95% of the applicable physician records reviewed in 2013 contained compliant documentation of adolescent anticipatory guidance components which included risk behaviors/sexual activity, tobacco use and substance/alcohol use. The component least assessed and documented was that of depression with 80% of applicable records reviewed containing this information. This was, however, a significant improvement from 2012 when documentation of depression was at 70%.
Ongoing monitoring of the quality of care provided by our practitioners, facilities, and vendors is done in order to identify opportunities for improvement. Quality of care concerns that may be investigated are deviations from a standard of care, and barriers to after-hours access. Issues regarding quality of care may be referred to the Healthcare Quality Improvement team by internal departments and external vendors such as: Case and Disease Management, Use Management, Provider Relations, Special Investigations Unit, Grievance and Appeals unit, Advisement from Medical Directors and external physician consultants, and Health Integrated (Behavioral Health services). Out of the 137 quality issues that were investigated in 2013, 49% (n=67) of all of the quality investigations were not substantiated. 13% (n=18) of the quality investigations were determined to be substantiated after investigation and review by a Medical Director. All substantiated cases were addressed with the provider and if necessary a Corrective Action Plan was put in place. All action plans were accepted after review by the Medical Director and HCQI Complaint Committee.
After Hours Access to Care Audits
Our plan assures the provision and maintenance of appropriate access to Primary Care services, Behavioral Health services and Member services for HealthNow (HN) members. All providers being credentialed or those who notify HN of a new location go through an on-site review and are expected to be in 100% compliance with the plan’s access to care standards.
Health Care Quality Improvement (HCQI) works in collaboration with Credentialing and Provider Relations to audit Primary Care and Behavioral Health offices to assure 24 hour access to care. If there is a provider office who does not meet our Access to Care criteria, the case is forwarded on to HCQI for a further investigation. Corrective action is required on 100% of offices not meeting this standard. In 2013, there were no after hour phone audits sent to HCQI for further quality investigations.
Patient Safety Initiatives:
The Patient Safety Program focuses on ways to improve care and clinical safety for our enrollees. Three main areas of focus have been initiated.
The Radiation Safety Awareness program is a collaborative effort with National Imaging Associates (NIA) and promotes provider and enrollee education and awareness regarding radiation exposure levels. The program provides ordering physicians with patient specific information regarding cumulative radiation exposure and promotes coordination of care between primary care, radiology and other specialists. It provides opportunity for physician discussion, encourages the ordering practitioner to consider the value of the requested procedure, consider other possible alternatives, and promotes the reduction of unnecessary imaging radiation through raised awareness.
Continued collaborative work with NIA has resulted in the completion of a member friendly interactive radiation exposure calculator, which enables members to determine their level of exposure for common radiology tests and compares this value to others of the same age and gender. Easy to understand information pertaining to radiology is also available when using the tool. This tool has been made available to members and providers on our websites, and additionally has been branded for both the Western New York and Northeastern New York markets.
Additionally, educational efforts focusing on Emergency Department physicians were considered in 2013. Efforts are focused on reducing overall radiation exposure while utilizing the most appropriate testing needed.
Image Gently Campaign
HealthNow encourages provider participation in this national campaign which focuses on reducing radiation exposure particularly for children. Tracking radiology procedures beginning in early childhood is recommended using a simple tracking tool for parents available on our member web site.
This program focuses on monitoring of medications and management tools for enrollees and providers. Collaborative efforts with Express Scripts, our pharmacy benefits manager partner, help identify, raise awareness, and educate practitioners of potentially serious drug interactions, excessive dosing or quantity considerations. Medication safety measures include Annual Monitoring of Patients on Persistent Medications (MPM).
A member focused medication safety initiative to promote medication reconciliation and reduce adverse events was continued. A special purpose bag designed to be used by members to take all medications in their original container to a provider office visit is available through provider network representatives or by calling 1-877-878-8785 and selecting option #3. Members were encouraged to review medications with their healthcare provider.
The Falls Prevention program was developed in 2011. Educational materials have been developed consisting of a Falls Risk questionnaire, Medication Reconciliation special purpose bag, a wallet card, and an informational brochure are available to members. These materials have been designed to assist members in identifying their risks as well as promoting discussion and review with their primary care provider. Provider Best Practice Guidelines were adopted based on those of the American Geriatric Society.
Additionally, a Provider Tool Kit has been developed and is available to providers via both the network representatives and the provider website. The Provider Took Kit includes a Get Up and Go fall assessment test, a laminated high risk medication list and both a self assessment of fall risk and the Medication Reconciliation special purpose bag for distribution by provider to their patients.
Management of chronic health conditions is supported by the Health Management Programs. The health plan promotes improved quality of life for all enrollees by helping them to better understand their conditions and develop self-management skills. This is accomplished by providing education for enrollees and support to providers to care for these conditions. Self- care is encouraged early in the disease process to prevent life changing complications. Health coaching calls remain well received by the enrollees and the volume of calls has increased substantially due to a dedicated interdisciplinary team which includes nurses, dietician, social workers, pharmacist and outreach staff.
Interventions are individualized and targeted to specific enrollee needs based upon the enrollee’s level of self- management. The Medicaid rate for Use of Appropriate Medications for People with Asthma exceeded national averages. Additional interventions were implemented to address the needs of the population, including use of respiratory therapist for outreach education.
Attention Deficit Hyperactivity Disorder (ADHD)
The ADHD management program advocates for proper screening, diagnosis, treatment and management of ADHD in children. We work closely with our Behavioral Health vendor to develop interventions and educational material that encourage adherence to the health care practitioner directed plan of treatment whether it be medication, behavioral therapy or a combination of the two. Enrollees are identified through prescription data for inclusion in the practitioner and member outreach intervention. For our HMO/PPO/POS line of business we met goals for the initiation and continuation phases for children prescribed an ADHD medication.
Chronic Obstructive Pulmonary Disease (COPD)
The COPD program was introduced in late 2008. Our goal is for members to control their symptoms and maintain an active lifestyle. An individual’s quality of life can be seriously impacted if COPD is poorly managed and we provide tools to assist in controlling symptoms and stay healthier longer. Spirometry testing and medication management rates are measured to determine program success. Commercial use of Spirometry Testing rate was above state average and almost 10% above the national average. The Medicaid rate was 9.15% below state average, but 6.62% above national average. Most Medicare HMO and PPO rates were above state and national averages except for the HMO rate, which was .67% below the state average. Systemic Corticosteroid Use for the Commercial, Medicaid, HMO and PPO lines of business were above the state and national averages, except for the Medicaid rate which was only .56% below the state average. Bronchodilator Use was below the state average for all lines of business. The Medicaid and PPO rates were above the national average; however, our Commercial and HMO rates were below by 1.18% and 2.93%, respectively.
The Diabetes Management Program was designed to promote compliance with diabetic care standards and raise awareness of the life threatening effects of poorly controlled diabetes. Appropriate and timely screening and treatment can significantly reduce the severe long-term complications of diabetes. There are ten specific HEDIS diabetes measures to monitor the care our enrollees receive. Available laboratory results have enabled targeted member intervention to improve HgbA1C and LDL levels. Commercial and Medicaid HbA1c rates remained the same due to HEDIS rotation; however, both are above state and national averages except for the Medicaid state rate which is 1.22% below average. Although Medicare HMO and PPO had slight decreases because of the HEDIS issues, both still remained above state and national average. Commercial and Medicaid LDL <100 mg/dL rates also remained the same due to HEDIS rotation; however, both are above state and national averages. Medicare HMO was significantly above the state and national averages; however, Medicare PPO was slightly below both the state and national averages by .41% and .68%, respectively.
The Cardiac Management Program was developed in 2005 to address the growing concerns regarding cardiac disease. Prevention of cardiac disease starts early and in many cases before there is a diagnosis of heart disease. Efforts are focused on enrollees with diabetes, hypertension and elevated cholesterol. HEDIS results for cholesterol management, both testing and LDL levels remained the same, based on HEDIS rotation of measures. The results are above national and state average. Medicare HMO and PPO HEDIS scores for both LDL testing, and results exceeded state averages. Program focus includes messaging from the Million Hearts Campaign.
Musculoskeletal Health Management
The program, developed in 2010, was designed to raise awareness and improve outcomes related to the cause, treatment, and management of back related conditions with both our physicians and members. We utilize the HEDIS measure for Use of Imaging Studies for low back pain (LBP) to monitor the care our enrollees receive. The program has expanded to include more spinal conditions.
The primary focus of the Depression Management Program is to improve the quality of life for our enrollees with depression by advocating for the proper screening, diagnosis, treatment and management in the primary care setting. Assuring our enrollees receive appropriate office follow-up after an antidepressant medication has been prescribed and following hospitalization are major objectives of this program. The follow up after hospitalization post discharge intervention continues in an effort to assist members to comply with provider orders.
The case management program assumes responsibility for the coordination of all aspects of care for enrollees identified with chronic or high-risk conditions. This includes high risk maternity care, palliative care and enrollees awaiting a transplant. The case manager follows the enrollee through the health care continuum. The role of the case manager is to promote quality care and meet the enrollee’s needs while maximizing benefits and assuring proper use of services in the most appropriate setting. A stable workforce of clinical staff with flexible work schedules result in improved efforts for early identification and engagement of appropriate members to best meet member needs.
Right Start Prenatal and Newborn
The Prenatal Case management program (Right Start) continued as a priority focus. The emphasis of the program is to promote full term births among program participants.
The Right Start program assumes responsibility for the coordination of all aspects of care for pregnant enrollees identified as high-risk. The case manager follows the enrollee throughout the pregnancy. The role of the case manager is to promote quality care and meet the enrollee’s needs while maximizing benefits and assuring proper use of services in the most appropriate setting. The program utilizes the NYS Department of Health Medicaid Prenatal guidelines in an effort to standardize and improve prenatal care.
The palliative care program is designed for those enrollees with end stage illness who are not ready to enter hospice. This program is a collaborative with community palliative care partners to provide supportive care to enrollees and their families. The program has a dedicated case manager to interact with enrollees, their families and their health care providers to assist members in achieving goals during a difficult time.
Using an interdisciplinary approach, the staff from both case management and utilization management creates a team to work collaboratively to improve care for transplant candidates. Targeting providers from Centers of Excellence for increased interaction of potential candidates has resulted in increased member satisfaction and increased cost savings, with quality care.
Our HIV/AIDS Case Management program was developed in 2010. Adequate and timely care, management of comorbid conditions, and adherence with medications/treatment plan, as well as addressing high-risk behaviors are key to preventing the spread of infection. Linkage with proper care, support services and home care promote improved outcomes. Analysis of annual QARR measures for Medicaid comprehensive care include: Engaged in care, viral load monitoring and Syphilis screening.
Routine preventive health screenings are very important for our members to stay healthy. There are many cancer screenings, immunizations and other health issues addressed through Preventive Health Guidelines posted on the provider and member websites. Communication to members and providers regarding various issues are communicated to them through various methods such as newsletters, web sites, fax, phone calls and mailings. Below are a couple examples of preventive health measures and rates.
|MEASURE||2011 Rate||2012 Rate||2013 Rate|
|Adolescent Immuniazation (Medicaid)||56%||61%||62%|
|Chlamydia Screening in Women||53%||56%||58%|
Adult Preventive Health
The Adult Preventive Health program targets its preventive health message on the adult enrollee, male and female, 19 years of age and older. Education of enrollees regarding flu and pneumonia vaccine, colorectal screening and health screenings is the main focus.
Women’s Preventive Health
We educate women about the importance of getting checkups for breast and cervical cancer, Chlamydia (sexually transmitted disease - STD) and osteoporosis (weak bones). Outreach calls to non-compliant women are made regarding breast and cervical cancer screenings.
Child/Adolescent Preventive Health
We educate parents on the importance of making sure their children receive age appropriate well care (recommended health screenings, vaccines).
Community Wellness Program
A community network of health educators offer wellness programming to eligible members free of charge. These educational programs provide members with the information and skills necessary to assist them in making positive lifestyle changes. Topics include nutrition, fitness, weight management, stress reduction and diabetes education.
Worksite Wellness Program
The Worksite Wellness Program is a comprehensive wellness program centered on the needs of an employer. This program includes access to a customized wellness web site, access to on-site wellness workshops and lectures, and expert planning, support and advice provided by a health promotion specialist.
Enrollees have access to a comprehensive list of local and national discounts for fitness memberships, and access to health and wellness related services at a discounted rate. The services are searchable by zip code/content area.
This program offers counseling on how to quit using tobacco products. Service is available by phone, on the internet or face to face. Overall customer satisfaction with this program remains high at 98%.
Childhood Health and Wellness
Overweight children and adolescence are an important public health issue because of its rapidly increasing prevalence and the associated adverse medical and social consequences. The dramatic increase, co-morbidities, and associated financial burden warrant a strong preventative approach. In an effort to address this trend, we will engage the healthcare provider, family and school.
To educate, motivate and support people with health risks, and guide them to achieve health improvement. Coaching services can be delivered face-to-face, by telephone or electronically by online communication. A Health Coach’s role can range from working with a participant to set goals, to establish a treatment plan, and to follow-up on compliance as needed.
Wellness Web Site
My Health is an interactive web-site that promotes enrollee self-management of health. This web site is secure and private. The Health Assessment is available to give you personal help and information for your health needs and to assist you in keeping track of your health information. It also provides a multitude of interactive member wellness tools, and hosts our 24 hour ask a nurse functionality with secure messaging.
We’re active in joining with other community groups to work together to improve the health of the community. We participate in twenty programs that address special needs and activities for our region. We also participate in two statewide and two national collaborative groups. More detail on collaborative participation is available on our website. Refer to “Summary of Collaborative and Coalition activities 2013”. Paper copies are available upon request.
To ensure accuracy and quality of information provided to our customers, The Corporate Quality Department monitors the performance of all customer service representatives, claims processors and enrollment specialists.
The review concentrates on the accuracy and quality of telephone calls, correspondence, chats, e-mail, claims, enrollment and billing transactions. It significantly focuses on the CSR’s professionalism including demeanor, language and tone, providing correct information, processing claims accurately and ensuring that enrollment and billing information is entered appropriately. The accuracy of these transactions has a direct impact to HealthNow’s customers overall customer experience.
Customer Satisfaction Monitoring
We have a program that monitors the quality of our customer service department. This includes making sure that information shared by our staff is accurate and that customers do not have to wait long for a response to their question. Many times our customers contact us with quality of care complaints. This allows us to investigate and track issues in order to identify areas for improvement.
We also perform customer satisfaction surveys. Results from surveys and customer complaints are monitored and data is shared with the customer satisfaction team. Although we routinely receive concerns from our customers, our data shows that our customer quality of care complaints are within normal ranges.
One of the surveys done is called the Consumer Assessment of Healthcare Providers and Systems (CAHPS)®. The same questions are asked to customers across the nation to measure satisfaction with their health plan and doctor. This survey allows us to compare ourselves with other health plans and to focus on specific areas of improvement.
In 2013, the majority of our lines of business were rated above the national average on the overall satisfaction rating of the health plan. Members’ satisfaction with customer service also scored positively, with all lines of business scoring at or above the national average.
Pharmacy Benefits Satisfaction
In 2013, HealthNow’s Pharmacy Benefits Manager (PBM), Express Scripts, formerly known as Medco, met all operations performance standards for the commercial line of business. For Part D line of business, Express Scripts met all operations performance standards with the exception of the Retail Service – Telepaid Claims Accuracy. A number of steps were implemented that resulted in improved performance throughout the contract year.
Corporate Pharmacy Services saw significant savings attributed to the use of RationalMed again this year. RationalMed alerts for Medicare and Medicaid lines of business were turned on in April 2012 and saw a significant increase in pharmacy savings from 2012 to 2013.
If you would like a paper copy of this report or need additional information, contact us at 1-800-677-3086 Option 5 or on our web site via ‘Click and Comment.’ You may also write to us at the following address: Quality Improvement, PO Box 80, Buffalo, New York 14240.