Our mission is to improve the health and well-being of our members and the communities in which they live. We align our efforts around the Institute for Healthcare Improvement’s (IHI’s) Triple Aim framework of improving overall population health, improving the member experience of care, and reducing overall healthcare costs. Improving health and healthcare is a continuous process, and is a goal shared among all involved in the healthcare industry. The fundamentals of our quality improvement program include coordinated efforts, regular measurement of processes and outcomes, specific performance targets, feedback, sharing of best practices, and continuous improvement.
Overall, 2020 was a successful year despite the challenges brought about by the COVID-19 public health emergency. Significant cross-departmental collaboration and our continued focus on our mission and corporate strategy and goals along with IHI’s Triple Aim enabled our success.
The goals of our Quality Improvement Program are:
- Improvement in member health and experience of care while providing the best value for the entire population served.
- Measurement of quality and outcomes through trending and analysis of quality improvement activities compared to performance goals and recognized benchmarks.
- Improvement in the member experience, implementation of effective interventions to address areas of dissatisfaction through processes including, but not limited to, conducting and analyzing member surveys and analyzing and trending member complaint and appeal data.
- Focus on population health management that addresses all members’ health needs across the continuum of care.
- Successful National Committee for Quality Assurance (NCQA) accreditation.
- Coordination of member programs and services across all levels of care.
- Facilitation of appropriate accessibility and availability of care and services, including the cultural, racial, ethnic, and linguistic needs and preferences of our membership; assessment of the availability of high-volume and high-impact providers and web access to health plan services.
- Reduction in unwarranted readmissions through improving continuity and coordination and transition of care and addressing members’ complex health needs.
- Identification of improvement opportunities using the Plan, Do, Study, Act (PDSA) cycle.
- Achievement and maintenance of compliance with all Federal and State regulatory requirements as well as appropriate accrediting bodies; i.e., NCQA, Affordable Care Act (ACA), Centers for Medicare and Medicaid Services (CMS), Pennsylvania Department of Health (DOH), Pennsylvania Insurance Department (PID), Federal Employee Program (FEP), and Employee Retirement Income Security Act of 1974 (ERISA).
- Monitoring of vendors and delegated activities for compliance with State and Federal regulations, NCQA, and Capital Blue Cross standards.
- Integration of quality strategy and communication feedback loops into appropriate functional areas, including, but not limited to, population health management, behavioral health, utilization management, member services, and network management.
- An organization-wide focus on population health management that addresses member’s health services and needs across various levels of care.
- Integration of all functional areas into decisions that affect the safety and quality of care and services provided to our members.
- Development of policies and procedures to facilitate appropriate utilization of healthcare services.
- Facilitation of a safe and effective network of providers while ensuring accessibility and availability of care and services.
- Assessment of member and provider satisfaction and implementation of effective interventions to address identified needs.
- Providing special considerations for cultural competency needs related to language, ethnicity, gender, age, complexity of health needs, and economic status to assist members in effectively accessing and using covered benefits.
Monitoring of goals and achievements in 2020
The progress, achievements, and overall effectiveness of our 2020 Quality Improvement Program included:
Continued growth of our value-based provider partnerships
- Data demonstrated that members managed through our value-based provider programs have higher rates of compliance with preventive screenings and the management of chronic conditions.
- Our member-focused interventions and communications continue to drive compliance trends in a positive direction.
- Celebrated our fifth anniversary adopting the Leapfrog Value-Based Purchasing Program as a standard measurement of our network facility’s quality and safety performance. The program continues to be well received in our market with positive year-over-year trends.
Focused on ensuring safe care for our members
- Continued to settle into our new pharmaceutical vendor relationship with Prime Therapeutics.
- Point of sale review edits, closing gaps in medication therapy, and maintenance of the formulary system through our pharmaceutical management program.
- Re-launch of the Substance Use Task Force, formerly the Opioid Task Force, with a scope of focus that includes opioid medications along with other substances of use and misuse.
Continued evolution of the population health management (PHM) strategy.
- Created a new team dedicated to leading cross-departmental in efforts to further the PHM strategy.
- Performed population analysis to gain insight into the care needs of our members.
- Data-driven actions and interventions deployed to address care needs across the health care continuum.
Continuation of our behavioral health strategy.
- Finalized the selection and began the implementation process of our new behavioral health vendor.
- Tracked the expanded use of virtual care for behavioral health services.
- Contracted and credentials our behavioral health network for all lines of business.
Enhanced assessment and understanding of member and provider experience.
- Administered focus group studies to receive member feedback for health plan improvement.
- Administered surveys with focused review and analysis of results with the majority of members reporting satisfaction with their health plan.
- Evaluated the overall provider experience with us and the adequacy and accessibility of our provider network.
Achievement of NCQA-accredited status was awarded by the National Committee of Quality Assurance for all commercial lines of business.