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. HealthNow underwent a re-accreditation survey in January through March 2016, under the NCQA 2015 Standards and Guidelines for the Accreditation of Health Plans, to demonstrate continued commitment and attainment of the highest quality standards. Our Commercial HMO/POS/ PPO, Medicare HMO/PPO, Marketplace/Qualified Health Plans and Medicaid lines of business are brought forth for review.
Healthcare Effectiveness Data and Information Set (HEDIS®)
The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. HEDIS was developed and is maintained by the National Committee for Quality Assurance (NCQA). Altogether, HEDIS consisted of 83 measures across 5 domains of care in 2015.
Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis.
HEDIS results are collected and reported separately for populations covered by Commercial, Medicaid Medicare and Qualified Health Plan (Marketplace) products (collected and reported for the first time in 2015). The Commercial submission is a combination of HMO, POS, PPO, EPO and FEP lines of business. HEDIS results are used to identify areas for improvement in the healthcare provided to our members and to evaluate many of the quality programs. In 2015, HEDIS clinical measures, along with consumer satisfaction survey results, contributed to the NCQA Health Plan Accreditation status for our products.
Quality Assurance Reporting Requirements (QARR)
The Quality Assurance Reporting Requirements or QARR are reported to the New York State Department of Health and consist of measures from the National Committee for Quality Assurance’s (NCQA) HEDIS® and New York State-specific measures (HIV/AIDS Comprehensive Care and Colorectal and Lead Screening measures). In 2015, QARR was publically reported for our Commercial, Medicaid and Marketplace products. QARR performance results assist our members and enrollees in choosing a health plan. These results are also used to identify opportunities for improvement of services and for evaluating existing and potential 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:
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:
The Pay for Performance program is designed to reward physicians for delivering high quality of care to our members in their patient panel. We identify HEDIS measures annually that are in need of improvement from a plan performance perspective for inclusion in the program. Providers have on-demand, real time access to their compliance so that they can self-manage their performance while maximizing their incentive. The plan benefits by increased physician engagement in Quality and improved HEDIS scores.
Several measures were added to the 2015 program based on plan performance:
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 are 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.
According to our 2015 Culturally and Linguistically Appropriate Services evaluation:Spanish continues to be the most widely translated language using Language Line Services showing slight increase for the Commercial LOB; however, Government programs and ASO WNY/NENY continue to show a decline in utilization from previous years.
Moderately used language translations across all lines of business included Mandarin, Cantonese, Arabic, Nepali, Punjabi, and Vietnamese.
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 2015 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, Express Scripts RationalMed, Poly-Pharmacy Alerts, Emergency Room Utilization etc.) measure coordination and work toward improving CCC for all our members.
2015 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.
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:
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 including 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 76 quality issues (including Blue Squared - Out of Area issues) that were investigated in 2015, 78% (n=59) of all of the quality investigations were not substantiated. None of the quality investigations were determined to be substantiated after investigation and review by a Medical Director. All Quality Investigations are reviewed 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 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 by 100% of offices not meeting this standard.
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 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.
The 2015 performance goal to achieve a 2% decrease in average dose per member for all places of service was achieved. There was a decrease of 7% in the average radiation dose for all members for all places of service. This is a continued decrease beginning with the 1/2008-12/2009 measurement period.
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. A simple tracking tool is available through the Radiology Info.org link 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. Members were encouraged to review medications with their healthcare provider.
Falls Prevention Educational materials have been developed consisting of a Falls Risk questionnaire, Medication Reconciliation special purpose bag, a wallet card, and an informational brochure and 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 the network representatives. 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 providers to their patients (while supplies last).
Falls Prevention education and materials were provided at Community venues such as the Allegany County Senior Expo, Cattaraugus County Health Fair, and at the Provider Expo.
Senior Center programming in the community continues and includes important information regarding medication adherence and physical activity in preventing and reducing the falls.
Outreach calls to Medicare members by Health Coaches encourage and educate members regarding the importance of physical activity and its role in good health and fall prevention.
Various home care programs are in places that include a home safety/falls risk assessment for our members.
A new program is in place beginning in 2015 to reach out to members who may have been in the Emergency Room due to a fall. These members are offered services that may assist them to avoid future falls.
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.
The goal of the Asthma Management Program is to improve the health status for members using a multi-disciplinary, population-based approach and to manage health care costs by promoting evidence-based treatment while assisting members to achieve optimal control of their disease. Interventions are individualized and targeted to specific enrollee needs based upon the enrollee’s level of self-management.
The results of HEDIS Use of appropriate Medications for People with Asthma showed a 2.0% decrease for the Commercial HMO/POS/PPO lines of business – combined age range from last measurement year.
The results of HEDIS Use of appropriate Medications for People with Asthma showed a 2.2% decrease for the Medicaid line of business – combined age range from last measurement year. Rates are consistent with NYS and national averages.
This measure is retired in 2016. Medication Management for People with Asthma 75% compliance will be utilized moving forward.
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. In 2015, goals for in the initiation phase for children prescribed an ADHD medication for Commercial and Medicaid lines of business did not meet the NYS average. Commercial rates for the continuation phase were consistent with the NYS QARR average.
Chronic Obstructive Pulmonary Disease (COPD)
The goal of the program 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.
The results of HEDIS Use of Spirometry Testing for COPD measure increased 3.0% for the Medicare HMO lines of business from last measurement year.
The results of The Pharmacotherapy Management of COPD exacerbations measure increased 2.0% for Systemic Corticosteroid for Medicaid LOB, and for Medicare HMO lines of business increased by 1.0%.
Bronchodilator rates for the Medicare HMO LOB increased 0.3%, and for Medicare PPO lines of business increased 1.3% from last measurement year.
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, timely screening and treatment can significantly reduce the severe long-term complications of diabetes. There are seven specific HEDIS diabetes measures to monitor the care our enrollees receive. Most Commercial rates increased or remained the same in 2015 with the exception of HbA1c testing. All Commercial rates, however, remained above both national and state averages. Medicare HMO and PPO performance in 2015 improved for most diabetic measures, with the exception of HbA1c testing. Most measures were above or significantly above the national and state averages, with the exception of HbA1c testing which was below for both.
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 and blood pressure control are at or above national and state average, for all lines of business. Program focus includes messaging from the Million Hearts Campaign.
The program goal is 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 HEDIS results for Use of Imaging for people with low back pain measure for Commercial HMO/POS/PPO lines of business decreased 0.2% but still above the state and national averages.
The HEDIS results for Use of Imaging for people with low back pain measure for Medicaid increased 2.4% from last measurement year.
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 was brought in house in an effort to improve member’s compliance 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, behavior health, 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. A New focus on members with cancer and chronic kidney diseases was implemented in 2015.
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 results of HEDIS Timeliness of prenatal care measure increased 4.2% for the Commercial lines of business and 3.7% for Medicaid line of business from last measurement year.
The Frequency of Ongoing Prenatal Care HEDIS measure for ≥ 81% of expected visits for Medicaid increased 3.9% from last measurement year.
The results of HEDIS postpartum care measure increased 3.4% for the Commercial HMO/POS/PPO lines of business and 4.8% for Medicaid line of business from last measurement year. These results are all above the state and national averages.
The palliative care program 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. The health plan has increased the number of hospice partners to offer a greater range of services for members.
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 goal is to promote adequate and timely care, management of comorbid conditions, and adherence with medications/treatment plan, as well as addressing high-risk behaviors to prevent 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 includes the following: Engaged in care, viral load monitoring and Syphilis screening.
While HIV/AIDS Comprehensive Care rates have decreased from last measurement year, they are still above New York State average for engaged in care and viral load monitoring.
Obstructive Sleep Apnea
The Obstructive Sleep Apnea program focuses on assisting members newly diagnosed with Sleep Apnea and treated with a Continuous Positive Airway Pressure or CPAP machine. The goal of the program is to assist enrollees in gaining compliancy in using the CPAP machine, reducing the health risks associated with sleep apnea and improving their quality of life.
Behavioral Health Case Management assists members suffering with severe and persistent mental illness and chemical dependency issues. Diagnoses include major depressive disorder, including risk for suicide, substance abuse and bipolar disorders. This team of case managers facilitates links with behavioral health treatment providers including counselors, psychiatrists and psychologists. Close follow-up with members ensures appropriate follow-up post discharge from an acute inpatient psychiatric hospitalization, adherence to treatment plan and encourages utilization of support groups.
Preventive health is a key component to keeping our members healthy. Recommended screenings, immunizations and other assessments are outlined in the Preventive Health Guidelines posted on the provider and member websites. Members and providers are also educated on preventive health requirements through various methods such as newsletters, websites, fax, phone calls and mailings. Below are a couple examples of preventive health measures and rates.
Adult Preventive Health
The Adult Preventive Health program provides preventive health information for adult male and female members, 19 years of age and older. Education of enrollees regarding vaccinations such as flu and pneumonia, colorectal screening and other age and gender specific health screenings are the areas of focus.
Women’s Preventive Health
We educate women about the importance of getting recommended screenings for breast and cervical cancer, sexually transmitted diseases such as chlamydia, and bone mineral density testing to evaluate risk for osteoporosis.
Child/Adolescent Preventive Health
We educate parents on the importance of ensuring their children receive age appropriate well care to include recommended well child and adolescent visits, screenings and vaccinations. Target goals were met for Commercial and Exchange lines of business for Childhood and Adolescent Immunizations. Rates for Well Child visits increased in 2015 for Medicaid and remain above the NYS and national averages.
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, interactive campaigns and challenges as well as expert planning, support and advice provided by a Health Promotion Specialist.
Enrollees have access to a comprehensive list of local and national fitness facilities. Memberships are offered at a discounted rate to the member. Members also have the ability of purchase fitness equipment at a discounted rate. The services are searchable by zip code and or content area.
The InhaleLife program offers members telephonic counseling on how to quit using tobacco products. Quit Coaches work with the member to develop a customized quit plan that is tailored to their needs. Overall customer satisfaction with this program remains high at 98%. Break the Habit is a tobacco cessation program offered at the employer group level. This 4-week program is aimed at helping participants succeed at leading a tobacco free lifestyle.
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 preventive approach. In an effort to address this trend, we engaged 4th graders in the Buffalo Public Schools in a new program that teaches children about the importance of proper nutrition and physical activity, the Healthy Zone Game Show.
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 personal help and information for health needs and to assist in keeping track of health information. It also provides a multitude of interactive member wellness tools, and hosts our 24 hour ask a nurse, dietitian and personal trainer functionality with secure messaging. Members can also:
We are active in joining with other organizations to improve the health and well-being of the local community. Our health experts participated in many programs throughout the year with the goal of engaging as many members as possible. More detail on collaborative participation is available on the Annual Evaluation document.
In order to improve the accuracy of the information given to customers when they call, a Call Monitoring Program is in place. Frequent modifications to our program to improve the service we offer to our customers are made.
In 2015, we modified our Quality Telephone and Correspondence program to measure and monitor our Customer Service Behavior strategies with more accuracy. The audit includes an evaluation of eight call behavior strategies that have been taught to all of our customer service representatives. This Behavior strategy program called the Ulysses Learning Program was implemented to improve and provide excellent customer service to our members, providers and partners. The modified Quality program along with the practice of new coaching skills ensures the eight call strategies are being utilized on customer calls and inquiries.
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. We measure first call resolution and have quality programs in place improve our performance. 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 do customer satisfaction surveys where members are asked questions on how they like our service. Results from surveys and customer complaints are monitored and data is shared with a team focusing on customer satisfaction. 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 Health care 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 2015, 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 2015, HealthNow’s Pharmacy Benefits Manager (PBM), Express Scripts, formerly known as Medco, met all operations performance standards for the commercial line of business except for Prompt Pay – Clean Claims Paid and Mail Service – Average Dispensing Time Electronic Fills in the first quarter and Retail Service – Direct Claim Reimbursement within 5 business days in the second and third quarter. In the first quarters of 2015, steps were taken that resulted in the improved performance of Prompt Pay and Average Dispensing Time for Electronic Mail Service refills. The missed performance guarantees for Direct Claims Reimbursement has been addressed with Express Scripts. The ESI Direct Claims processing team will develop and action plan to approve this performance standard. For the Part D line of business, Express Scripts met all operations performance standards except for Customer Service – Average Speed of Answer in Quarter 1 of 2015. This was immediately addressed with Express Scripts and improvements were made. All missed performance guarantees result in a financial penalty as defined in the agreement.
If you would like a paper copy of this report or need additional information, contact us at 1-877-878-8785 Option 3 or on our web site. You may also write to us at the following address: Quality Improvement, PO Box 80, Buffalo, New York 14240.