Quality improvement strategy
We're committed to improving healthcare quality, safety, and access for our members. We have a Quality Improvement Program (QIP) that evaluates the care our members receive, so we can continuously work to improve it.
Our QIP's goals are to:
- Make sure our members get the healthcare they need and deserve
- Evaluate and work to improve healthcare quality, safety, and access for our members
- Provide exceptional customer service to our members and providers
- Always follow all applicable laws and guidance from regulators and our accrediting body
We work toward these goals by:
- Monitoring and measuring the quality, safety, and accessibility of the healthcare our members receive
- Working with providers and other healthcare professionals to improve the quality of healthcare
- Offering evidence-based case and disease management programs and services
- Supporting our members and their doctors with the information they need to make the best possible decisions
- Continuously updating our policies and procedures to meet the latest clinical practice standards
Quality improvement activities
We use different strategies to improve the quality, safety, and accessibility of healthcare for our members. They're designed to look at different types of healthcare experiences.
We monitor and evaluate:
- The quality of clinical services our members receive
- The types of services our members get, to make sure they get the right services for their specific conditions
- How satisfied members are with their healthcare, so we can find ways to better serve them
- How well our network providers coordinate our members’ healthcare
- Overuse and underuse of certain services
- Use of preventive care services, to make sure member get the right kinds of care
- Assess the availability and accessibility of the providers in our networks
- Credential and re-credential all providers in our networks
- Search for and work to eliminate racial and ethnic disparities in healthcare quality and access
- Meet with our providers to evaluate our performance and understand how we can better serve them
Meeting our quality improvement goals
We review many areas to meet our quality improvement goals.
We collect Healthcare Effectiveness Data and Information Set (HEDIS®) details. HEDIS includes clinical data that helps us understand the quality of care our members get for common diseases like diabetes, hypertension, rheumatoid arthritis, and high cholesterol.
We look at HEDIS data to find areas where we think our members could be getting better care. And we share this data with the Centers for Medicare and Medicaid Services (CMS). We also use this data to set goals for the future.
We use our world-class data science abilities to analyze clinical and claims data. This helps us find new insights into what drives healthcare quality and outcomes. Once we understand these factors, we create ways to help improve quality and access to healthcare for our members.
Case and disease management
We support our members and our providers with case and disease management programs, like:
- Helping hospitalized members transition back into the community without needing to go back to the hospital
- Working with members to help them manage common chronic diseases like high blood pressure and diabetes. In 2023, we're focusing on growing programs for our members with chronic diseases, like congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD)
- Connecting members with community resources to help them manage the social aspects of health that may effect how they care for themselves and access healthcare services
Quality improvement programs for medications
We have quality improvement programs that help members use the right medication, like:
- Medication safety and monitoring programs that target high-risk non-opioid drugs, preventing polypharmacy and the misuse of opioids and other controlled substances
- Monitoring opioid use, so we can work to reduce opioid misuse and abuse
- Monitoring and improving the use of effective medications, like oral diabetes medications, cholesterol-lowering medications, and blood pressure-lowering medications
- Reconciling members’ medications after they go home from a hospital or post-acute care facility to help to prevent errors and problems
Member and provider satisfaction
We want to deliver excellent service to both our members and providers.
To better serve our members, we:
- Quickly and accurately process enrollment applications
- Monitor how fast we answer member calls
- Fix problems as quickly as possible
- Ask members to give us feedback throughout the year
- Provide benefits and services that support health and wellness
- Make sure we have the staff and resources to communicate with members in their preferred language
To support our network providers, we:
- Quickly process applications to join and remain in our network
- Pay claims correctly and on time
- Provide tools to help providers give our members excellent care
- Regularly speak with network providers about performance and experience