Ambetter from Peach State Health Plan ( Ambetter) has adopted the Institute for Healthcare Improvement’s (IHI) Triple Aim goals as follows:

1. Improve the health of our members
2. Improve the member and provider experience with care
3. Lower per capita costs of health care

Ambetter achieves these goals by creating programs to assist members in managing chronic conditions such as educational programs, as well as case managers who are here to assist you.  In addition, we monitor certain clinical measures annually to ensure you are receiving the care you deserve. We work to improve the member experience by asking you to complete a satisfaction survey each year as well as monitoring complaints you may have, to identify ways we can improve. Finally, we have processes in place to ensure you get the right services and the right time in the right location to assist us in keeping your health care costs down. 

The remaining information in this document discusses the outcomes for Ambetter from Peach State goals from 2015. Should you wish to receive additional information about the Quality Program you may contact our member services team at 1-877-687-1180. They will transfer you to the Quality Improvement Team who will be able to give you more details about the Quality Improvement Program as well as outcomes and interventions. If you would like a copy of the Program Description and/or Annual Evaluation, it can be mailed to you by calling Member Services. 

Improve the Health of our Members

One way Ambetter measures progress towards meeting our goals each year, and determines areas in need of improvement, is by using the Healthcare Effectiveness Data and Information Set, or HEDIS®. HEDIS is a measurement tool used by health plans across the nation to evaluate performance in clinical quality and services provided by the health plan. Annual HEDIS scores are an indicator for Ambetter to evaluate progress towards Quality Improvement Program goals, and where opportunities exist to improve overall services and health care for our members. Ambetter continuously looks for ways to increase the effectiveness of interventions and identify new initiatives for improvement. Below is a sample of results for measurement year 2015: 

Measures – Goal Met

• Diabetes – HbA1c Testing
• Annual Monitoring Rx for Diuretics
• Antidepressant Medication Management – Acute

Measure – Goal Not Met

• Diabetes – Eye Exams

Ambetter from Peach State supports initiatives to drive quality improvement. In 2017, Ambetter will continue to monitor performance through HEDIS and initiatives to promote adult preventive screenings, importance of medication adherence, and activities that are apart of disease management programs.

Every year, we use a survey to ask our members how we’re doing. Your input shows us where we are doing well. It also shows where we need to improve. If you filled out the survey in 2016, thank you! Ambetter improved from 2015 to 2016 in the Access to Care and Plan Administration areas on the Qualified Health Plan Enrollee Experience Survey. We are still working towards improving satisfaction in the Care Coordination area.

In summary, Ambetter’s primary quality improvement goal is to improve members’ health status through a variety of meaningful quality improvement initiatives implemented across all care settings and aimed at improving quality of care and services delivered. The objectives to support this goal are:

• To improve member health outcomes through continuous quality improvement efforts
• To seek input from and work with members, providers and community resources to ensure quality of care
• To share periodic quality improvement information to participating providers in order to support their efforts to provide high quality health care
• To ensure adequate resources with the expertise required to support and effectively carry out all functions of the QI Program are employed
• Improve HEDIS® and CAHPS® (member experience survey) rates
• To facilitate provider adoption of evidence based Preventive Health and Clinical Practice Guidelines

The Quality Improvement Program and annual evaluation are presented to the Quality Improvement Committee and Ambetter from Peach State’s Board of Directors for review and approval. If you have questions or would like more information about Ambetter’s QI Program, Contact Member Services at 1-877-687-1180 and ask for the Quality Department.                             

Ambetter from Peach State Health Plan Quality Improvement Program

Ambetter strives to improve the health of all enrolled members by focusing on helping them get healthy and stay healthy. Ambetter has created a Quality Improvement (QI) Program to support this goal. The goal of the program is to ensure our members receive high quality care and services that are effective, safe and responsive to their health care needs, while understanding their cultural and linguistic needs and preferences. The program extends to all internal departments and measures numerous aspects of the care and services offered through Ambetter.

Ambetter’s Board of Directors provides the Quality Improvement Committee the authority to oversee the QI Program. The Quality Improvement Committee is led by our Medical Director, who provides direction and has lead responsibility for health plan‐wide QI Program activities. The QI Program utilizes a systematic approach to quality using reliable and valid methods of monitoring, analyzing, evaluating and improving the delivery of health care to all members.

This systematic approach provides a continuous cycle for assessing the quality of care and service among initiatives, including preventive health, acute and chronic care, behavioral health, over‐ and under‐utilization, continuity and coordination of care, and patient safety.

Quality Assessment and Performance Improvement (QAPI) Program Goals

Ambetter from Peach State Health Plan adopted the three aims listed below (known as the Triple Aim), which were developed by the Institute for Healthcare Improvement, as the QAPI Program’s global aims.

• Population Health: Improve overall quality of care by making health care more patient-centered, reliable, accessible, and safe.
• Member Experience: Improve overall satisfaction with care and services through safe and effective patient-centered delivery.
• Per Capita Cost: Reduce the cost of quality health care for individuals, families, employers, and government.

The QAPI Program goals and measureable objectives below reflect Ambetter’s commitment to achieving the Triple Aim. Ambetter’s primary quality improvement goal is to improve members’ health status through a variety of meaningful quality improvement activities implemented across all care settings and aimed at improving quality of care and services delivered.

Quality Assessment and Performance Improvement Program Scope

The scope of the QAPI Program is comprehensive and addresses both the quality and safety of clinical care and the quality of service provided to Ambetter’s members. Ambetter  incorporates all demographic groups, lines of business, benefit packages, care settings and services in its QI activities including preventive care, emergency care, primary care, specialty care, acute care, short term care and ancillary services. Ambetter’s QAPI Program monitors the following:

• Acute and chronic care management
• Compliance with member confidentiality laws and regulation
• Compliance with preventive health and clinical practice guidelines
• Continuity and coordination of care
• Delegated entity oversight
• Department performance and service
• Employee and provider cultural competency
• Marketing practices
• Member enrollment and disenrollment
• Member grievance system
• Member satisfaction
• Patient safety
• Pharmacy
• Provider and Ambetter’s after-hours telephone accessibility
• Provider appointment availability and accessibility
• Provider network adequacy and capacity
• Provider satisfaction
• Selection and retention of providers (credentialing/recredentialing)
• Utilization Management, including under and over utilization

Interaction with Functional Areas

The QI Department maintains strong working relationships with key functional areas within the health plan such as Provider Network Services, Member Services and Connections, Utilization Management, Regulatory Compliance and the Grievance and Appeals Coordinator(s). Quality is integrated throughout the Plan and represents the strong commitment to quality of care and services for members.

• Provider Network Services such as Provider Relations and Contracting and the QI Department work together to verify that clinical materials distributed to providers are understandable and useful, and that providers understand the members’ rights and responsibilities and treat enrolled members accordingly. These departments also coordinate efforts for appropriate access and availability through ongoing monitoring.
• Member Services, MemberConnections and the QI staff collaborate in relation to Member Satisfaction survey activities, to include Performance Improvement Projects (PIP). The QI and Member Services/Connections departments work collaboratively to maintain performance data related to EPSDT outreach activities and any other QI activities related to member services functions, including call center functions, are tracked, trended and used as a tool to identify opportunities for performance improvement, as appropriate.
• Utilization Management provides utilization management, case management and disease-focused services to enrolled members. Utilization Management staff identifies and refers quality concerns to the QI Department for investigation, and recommends benefit enhancements and participates in QI activities and projects.
• Regulatory Compliance and the QI Department work together to ensure that Ambetter initiatives comply with CMS requirements and accreditation requirements for NCQA.
• Grievance and Appeals Coordinator(s) and the Provider Relations Department work closely with the QI Department to ensure that: any grievance related to a quality of care issue is promptly investigated; grievances and second-level reviews of grievances and administrative reviews are handled timely; data collection and reporting is in compliance with relevant contractual and regulatory requirements; and reporting to appropriate quality committees occurs.

Performance Improvement Process

Ambetter’s QI Committee (QIC) reviews and adopts an annual QAPI Program Description and QI Work Plan based on managed care Medicaid appropriate industry standards. The QIC adopts traditional quality/risk/utilization management approaches to problem identification with the objective of identifying improvement opportunities. As part of this approach, the health plan President or designee, and the Medical Director, in conjunction with the QI Department, determine the scope and frequency of QI initiatives (clinical and non-clinical performance improvement projects, focus studies, etc.). Most often, initiatives are selected based on data that indicates the need for improvement in a particular clinical or non-clinical area, and includes targeted interventions that have the greatest potential for improving health outcomes or the service. Other initiatives are selected to test an innovative strategy. Each initiative topic will reflect distinctive regional emphasis on populations and cultures. Once a QI topic is selected, the QI Department, in conjunction with specific functional areas as appropriate, presents the proposed QI initiative to the QIC for approval. The QIC selects those initiatives that have the greatest potential for improving health outcomes or the quality of service delivered to members and network providers.

Performance improvement projects, focused studies, and other QI initiatives are designed and implemented in accordance with principles of sound research design and appropriate statistical analysis. Results of these studies are used to evaluate the appropriateness and quality of care and services delivered against established standards and guidelines for the provision of that care or service. Each QI initiative is also designed to allow Ambetter to monitor improvement over time.

The development and selection of clinical performance improvement projects is the responsibility of QIC due to its clinical representation. The QIC continues to monitor progress of clinical performance improvement projects. The Ambetter QAPI Program allows for continuous performance of quality improvement activities through analysis, evaluation and improvement in the delivery of healthcare provided to all members, and has established mechanisms to track issues over time.

Annually, Ambetter develops a QI Work Plan for the upcoming year. The QI Work Plan serves as a working document to guide quality improvement efforts on a continuous basis. The Work Plan integrates QI activities, reporting and studies from all areas of the organization (clinical and service) and includes timelines for completion and reporting to the QI Committee as well as requirements for external reporting. Studies and other performance measurement activities and issues to be tracked over time are scheduled in the QI Work Plan. The QI Work Plan is used by the QI Department to manage projects and used by the QI committees, QI sub-committees and Ambetter Board of Directors to monitor progress. The Work Plan is modified and enhanced throughout the year.

At any time, Ambetter members and providers may request information on Ambetter’s quality program including a description of the QAPI Program and a report on the Plan’s progress in meeting the QAPI Program goals by contacting Ambetter’s QI Department.

Feedback on Physician Specific Performance

As part of the quality improvement process, performance data on each provider is reviewed and evaluated and may be used for quality improvement activities. The Credentialing Committee and/or other committees involved in quality improvement may do this. This review of provider specific performance data may include, but is not limited to:

• Site evaluation results including medical record audit, appointment availability, after-hours access, cultural proficiency and in-office waiting time
• Preventive care, including well-child exams, immunizations, lead screening, cervical cancer screening, breast cancer screening and screening for detection of chronic diseases such as diabetes and kidney disease
• Prenatal care
• Member complaint and grievance data
• Utilization management data including referrals/1000 and bed days/1000 reports
• Sentinel events and/or adverse outcomes
• Compliance with clinical practice guidelines

Healthcare Effectiveness Data and Information Set (HEDIS)

HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA), which allows comparison across health plans. HEDIS gives purchasers and consumers the ability to distinguish between health plans based on comparative quality instead of simply cost differences. HEDIS reporting is a required of all Marketplace health plans.

As both the State and Federal government move toward a healthcare industry that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. State purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a health insurance company’s ability to demonstrate an improvement in preventive health outreach to its members. Physician specific scores are being used as evidence of preventive care from primary care office practices. The rates then serve as a basis for physician incentive programs such as ‘pay for performance’ and ‘quality bonus funds.’ These programs pay providers an increased premium based on scoring of such quality indicators used in HEDIS.

How are HEDIS rates calculated?

HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim or encounter data submitted to the health plan. Measures typically calculated using administrative data include: annual mammogram, annual Chlamydia screening, annual Pap test, treatment of pharyngitis, treatment of URI, appropriate treatment of asthma, cholesterol management, antidepressant medication management, access to PCP services and utilization of acute and mental health services.

Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data reduces the necessity of medical record review. Measures typically requiring medical record review include: comprehensive diabetes care, control of high-blood pressure, immunizations, prenatal care and well-child care.

Qualified Health Plan Enrollee Experience Survey

Section 1311(c) (4) of the Affordable Care Act (ACA) requires the development of a system to rate Qualified Health Plans (QHPs) offered through a Marketplace based on quality and price. One significant part of this mandate requires the development and implementation of a survey to assess the consumer experience. The goal of the Quality Rating System is to provide information for consumers   to use when they select a health plan in the Marketplace and to facilitate regulatory oversight by states, CMS, and accreditation authorities. Results will be displayed using a 5-star rating scale. The QHP Enrollee Experience Survey supplies data to the QRS regarding patient experiences with their health care.

The current QRS measure set consists of 43 measures, some of which are survey measures that are collected as part of the QHP Enrollee Experience Survey. For 2016, all 43 measures will be required for submission, however CMS will use only the 28 measures for scoring. The remaining 14 measures require at least three years of coverage data in order to report and CMS intends to require these measures as part of the 2017 QRS measure set. The following measures are from the QHP Enrollee Experience Survey: 

2016 Survey Measures:

1. Access to Care
2. Access to Information
3. Care Coordination
4. Cultural Competence
5. Flu Vaccinations for Adults Ages 18-64
6. Plan Administration
7. Rating of All Health Care
8. Rating of Health Plan
9. Rating of Personal Doctor
10. Rating of Specialist
11. Aspirin Use and Discussion
12. Medical Assistance with Smoking and Tobacco Use Cessation

Provider Satisfaction Survey

Ambetter conducts an annual provider satisfaction survey, which includes questions to evaluate provider satisfaction with our services such as claims, communications, utilization management and provider services. An external vendor conducts the survey. The vendor randomly selects participants, meeting specific requirements outlined by Ambetter, and the participants are kept anonymous. We encourage providers to respond timely to the survey as the results of the survey are analyzed and used as a basis for forming provider related quality improvement initiatives. Other surveys may be used for provider feedback as well.

Feedback of Aggregate Results

Aggregate results of studies and guideline compliance audits are presented to the QIC. Participating physician members of the QIC provide input into action plans and serve as a liaison with physicians in the community. Aggregate results are also published in the provider newsletter or a special provider mailing may be distributed.

At least quarterly, a Provider Relations Specialist meets with PCPs and bi-annually with high volume specialists to review policies, guidelines, indicators, medical record standards and provide feedback of audit/study results. These sessions are also an opportunity for providers to suggest revisions to existing materials and recommend priorities for further initiatives. When a guideline, indicator or standard is developed in response to a documented quality of care deficiency, Ambetter disseminates the materials through an in-service training program to upgrade providers' knowledge and skills. The Ambetter Medical Director and Pharmacist conduct special training and meetings to assist physicians and other providers with quality and service improvement efforts.

The QI Program and annual evaluation are presented to the QIC and Ambetter from Peach State’s Board of Directors for review and approval. If you have questions, would like more information about, and/or would like a copy of the entire QI Program and evaluation, Contact Member Services at 1-877-687-1180 and ask for the Quality Department.