«Helping People Live Healthier Lives Section J: Quality Management (Section 14 of RFP) J.1 Document experience in other States to positively impact ...»
Helping People Live Healthier Lives
Section J: Quality Management (Section 14 of RFP)
J.1 Document experience in other States to positively impact the healthcare status of Medicaid
and or CHIP populations. Examples of areas of interest include, but are not limited to the
following: (GSA C)
Quality Assessment Performance Improvement (QAPI)
Our philosophy supporting quality assessment and performance improvement (QAPI) is to leverage our assets, capabilities and engaged employees to provide our members, providers and state partners with cost effective, high value and high quality services. We engage all UnitedHealthcare Community Plan plans to move our Healthcare Effectiveness Data and Information Set (HEDIS) quality of care measurement rates to “the best” of all our competing plans and to state-specific goals.
DHH, in turn, will benefit from the shared experiences of our other Medicaid plans and from our flexibility to address the unique needs of the Louisiana Medicaid program. This approach to positively impact theor status of Medicaid and CHIP populations, allows our national resources and organizational support to implement identified best practices, to continually measure their effectiveness, to assess and modify outreach and interventions for all UnitedHealthcare Community Plans across the county.
Identification of best practices is conducted within every UnitedHealthcare Community Plan plan as well as outside of our organization via comprehensive research analysis and partnering with collaborative quality improvement organizations.
There are two functions for a Best in Class initiative:
(1) Identify best practice approaches and programs with our health plans.
(2) Develop and facilitate the implementation of initiatives across all health plans.
One function is consultative, while the latter function is program development and implementation. The resulting “Best in Class” programs include Medicaid, Medicare and Long-Term Care membership.
QAPI Program Overview and NCQA Accreditation To demonstrate our commitment to quality health care, we are building accreditation into our Louisiana programs—setting benchmarks and maintaining rigorous quality standards to improve care delivery and clinical practice, to enhance customer service, to seek better health outcomes and to reduce medical costs.
We currently have Utilization Review Accreditation Commission (URAC) accreditation and National Committee for Quality Assurance (NCQA) for our commercial plan in Louisiana.
We will pursue NCQA accreditation for any the Louisiana Medicaid offering and will comply with the DHH’s requirements for attainment within two to four years after the start of our contract. Today, nine of our Medicaid health plans hold NCQA accreditation with additional plans expected to attain accreditation in 2011 and 2012, as shown below.
Our centralized Quality Improvement (QI) Program for all UnitedHealthcare Community Plan plans also assures continuous compliance with NCQA accreditation standards. Our goal is to achieve and sustain successful accreditation for all our plans. Also, we are working to achieve a Corporate Quality Program Accreditation for UnitedHealthcare Community Plan, which will support the accreditation process for individual UnitedHealthcare Community Plans.
As we continue building quality measures and performance improvement into our health care programs, we anticipate 20 NCQA Health Plan Accreditation applications (including corporate, initial and new health plan accreditations, and reaccreditations) scheduled through 2013 for our Medicaid business. Our
anticipated NCQA applications include:
Governing Body UnitedHealthcare Community Plan uses an integrated structure to our quality improvement oversight that includes both local and national committees as shown in the following figure. UnitedHealthcare intends to use this same approach for our UnitedHealthcare Community Plan, Louisiana. Ultimate accountability rests with the Louisiana Board of Directors whether the resource support emanates from a local committee or a national committee. UnitedHealthcare Community Plan collaborates with various
National Quality Improvement Committees Committee Description National Quality The governing body responsible for monitoring and regulating at a national level the Management Oversight affairs of the Quality Improvement, Utilization Management and Outreach Committee (NQMOC) Programs.
National Credentialing Committee conducts initial credentialing and recredentialing of providers who may Committee provide care and services to UnitedHealthcare/State government program member as indicated in the UnitedHealthcare Credentialing Plan.
Executive Medical Policy Committee is responsible for overseeing the development, implementation and Committee (EMPC) evaluation of the medical policies across UnitedHealth Group.
National Medical Committee is responsible for the development and management of evidence-based Technology Assessment position statements on selected medical technologies. In addition the committee is Committee (MTAC) responsible for assessment of the evidence supporting new and emerging technologies as well as new indications for existing technologies.
National Pharmacy and Committee is responsible for providing the clinical oversight for the development Therapeutics Committee and maintenance of the Preferred Drug List and Clinical pharmacotherapy policies.
(P&T) National Service Committee provides coordination of all customer and provider service and Improvement Committee satisfaction monitoring activities on a national scope.
(NSIC) Delegation Oversight Committee’s primary focus is to perform oversight of all nationally delegated Committee entities.
National Healthcare Committee’s primary focus is to formulate and apply a framework to assess and Disparities Committee address significant disparities in health services and health outcomes between ethnic and racial groups. Committee is also responsible for ensuring cultural diversity education is provided for staff throughout the organization.
Further descriptions of the underlying operations and resources allocated to UnitedHealthcare Community Plan’s Quality Assessment and Performance Improvement (QAPI) are provided in the next sections.
Board of Directors Blaine Bergeson is accountable to the Board of Directors (BOD) is the governing body of UnitedHealthcare Community Plan in Louisiana. The Board of Directors functions related to the quality
assurance and performance improvement program include:
Annual review and approval of the Quality Improvement (QI) Program Description, annual QI Work Plan, Annual QI Evaluation, and other reports and information as required or requested Provision of feedback and recommendations to the Quality Management Committee (QMC) related to summary reports, documents and any issues of concern Demonstration of senior level commitment to quality and to UnitedHealthcare Community Plan’s QI Program including resource allocation.
The Board of Directors meets at least annually and has ultimate responsibility for the QI Program and related processes and activities. The Board of Directors delegates oversight of committee QI functions to the National Quality Management Oversight Committee (NQMOC) and the Quality Management Committee (QMC). The composition and responsibilities of these two bodies are described below.
Committees for Development, Implementation and Overseeing the QAPI Program The National Quality Management Oversight Committee (NQMOC) and the Quality Management Committee (QMC) share responsibility for ensuring the quality improvement processes outlined in the QI Plan are implemented and monitored. Provided below is a summary of the membership and respective functions of each of these committees within UnitedHealthcare Community Plan’s QAPI program.
National Quality Management Oversight Committee (NQMOC) The National Quality Management Oversight Committee (NQMOC) is UnitedHealthcare Community Plan national body responsible for the oversight and regulation of local quality improvement, utilization management, and outreach programs.
Quality Management Committee (QMC) The Quality Management Committee (QMC) is the decision-making body that is ultimately responsible for the implementation, coordination and integration of all quality improvement activities for the health plan. The QMC meets at least quarterly and reports to our Board of Directors at least annually and to the National Quality Management Oversight Committee (NQMOC) at least twice per year.
This committee membership includes: Chief Executive Officer (CEO), Blaine Bergeson (Committee Chair), Chief Medical Officer (CMO), Mark Mahler, MD, Director of Operations, Director of Health Services, Director of Quality Management, Network Management Representative, Compliance Officer, Financial Officer, Dental Services Representative, Behavioral Health Services Representative and other representation as identified by the Executive Director.
The responsibilities of the QMC include:
Provide program direction and continuous oversight of quality improvement (QI) activities as related to the unique needs of the member and providers in the areas of clinical care, service, patient safety, administrative processes, compliance and network credentialing and recredentialing Formally evaluate, at least annually, the impact and effectiveness of Medicaid specific Performance Improvement Projects (PIPs) and recommend changes as necessary Review, prioritize and align the Annual QI Work Plan with strategic objectives of the organization Review and approve benchmarks, performance goals and standards for quality activities Analyze and evaluate the QI program annually and assess the overall effectiveness of the program.
Recommend policy decisions based on this evaluation Submit the QI Program Description, Annual QI Work Plan and Annual Evaluation of the QI Program to the Board of Directors for review and approval Report annually or more frequently as needed, on quality activities to the Board of Directors Monitor annual HEDIS / CAHPS® results and other state clinical metrics and action plans to improve results Monitor Member complaints, appeals and grievances and results of Member satisfaction surveys Monitor action plans to address identified opportunities and improve performance Monitor network access and availability and review performance against standards at least annually Monitor, evaluate and implement improvement plans for access and availability of network providers Monitor and evaluate the cultural and linguistic needs of our enrollment Review and accept decisions of the National Quality Management Oversight Committee that have been delegated by UnitedHealthcare Community Plan’s Board of Directors, offering feedback as appropriate Louisiana Department of Health and Hospitals Medicaid Prepaid Coordinated Care Network RFP Solicitation # 305PUR-DHHRFP-CCN-P-MVA June 30, 2011 Helping People Live Healthier Lives Review reports and recommendations from other national and local committees, act upon recommendations as appropriate and provide feedback, follow-up, direction to the committees Recommend, monitor, and assure barrier analysis and follow up of quality activities Incorporate findings from the QI activities into strategic program and resource planning. Adjust programs to address identified needs Ensure provider participation in clinical aspects of the QI program, including advising on clinical and provider issues (Note peer review is performed by the Provider Advisory Committee, which is describe in a following section.) Ensure compliance with regulatory requirements and accrediting organizations Provide oversight to applicable UnitedHealthcare Community Plan Business Partners Provide local delegation oversight as specified by State regulatory requirements. Review and make final recommendation of approval or denial of delegation pre-assessment and annual audit results for delegates scoring 80 percent on audits or with Improvement Action Plans (IAP) to determine acceptance or denial of delegates to a given network Review and accept the National Credentialing Plan, with addendum for line of business regulatory requirements as applicable Review and accept PAC peer review decisions concerning clinical quality of care and service Recommend appropriate resources in support of prioritized activities.
QAPI Program Resources, Staffing and Qualifications including Data and Analytical Resources UnitedHealthcare Community Plan bases its QAPI program upon the principles of “Continuous Quality Improvement and Total Quality Management.” We utilize ongoing data analysis to appropriately measure the current quality of Member services and to prioritize opportunities for improvement. The following
data sources are used to support our QAPI activities:
Claims database Population and demographic reports State agencies National, State and internal databases UnitedHealthcare Community Plan’s clinical management information system Member and provider satisfaction surveys GeoAccess analysis reports of provider availability Member grievance and appeal data Member treatment records Credentialing data Information collected through office site visit.
With guidance from internal data analysts and statisticians, we have developed, designed, implemented and validated various methodologies to access and use data to support our QAPI activities. In addition to the data above, several other sources of analytical resources are available. These resources include UnitedHealthcare Community Plan’s SMART data warehouse, Impact Pro, MedMeasures by ViPS, and our Universal Tracking Database (UTD). These tools and resources are described in the in the Section 030.090.40 Management Information System above.