The Aetna Medicare plan serving Maine and Security Health Plan's Medicaid product in Wisconsin, both highly ranked by the National Committee for Quality Assurance, offer examples of using quality measures to improve care coordination, case management, payment for value, and member satisfaction.
The NCQA's annual State of Health Care Quality Report 2013 showed that, despite some marked problems, "care is better in many ways than it was 10 years ago, or even five years ago," said Margaret O'Kane, NCQA president in a recent briefing about the findings.
Currently, 43 percent of the U.S. population is covered in health plans that report quality metrics.
Among the more serious of problems found in the analysis is that the overuse of antibiotics continues to be resistant to change, leading to more health problems and higher healthcare costs. And childhood immunizations rates, although increasing, are far below where they should be.
On the improvements side, the report found progress in calculating the body mass index of children at medical check-ups in order to track childhood obesity for the second consecutive year.
Patients also reported better experiences of care in their Medicaid plans, much of that attributed to federal and state officials' increased focus on quality, Kane said.
Security Health Plan, an HMO based in Marshfield, Wis., and owned by Marshfield Clinic, is the 10th ranked Medicaid plan in the nation according to NCQA, which analyzed data from the 2012 Healthcare Effectiveness Data and Information Set, or HEDIS, a widely used performance tool for health plans. "We don't outsource customer service. Our customer service representatives, case managers and all staff are located locally in central Wisconsin," said Mark LePage, MD, Security Health Plan CEO.
In Security's Medicaid program, 90 percent of children at every age range receive the recommended well-child care using a variety of strategies, including providing appointment request reminder postcards to plan providers so they have an easy-to-use tool to engage their Medicaid members, he said. Security also contacts members directly by sending birthday cards when children turn 1- and 2-years old, reminds parents and guardians to schedule well-child exams, and follows up with reminder cards when appointments have been scheduled but missed.
Among all Security providers, about 89 percent of children in the Medicaid program are screened for obesity using the body mass index (BMI), but Marshfield Clinic has achieved a 92 percent rate in BMI screening, along with a similar pattern for the nutrition and physical activity counseling measures.
"While some of the credit should go to Marshfield Clinic's electronic health record, Security Health Plan has also had an impact through support of the clinic's patient-centered medical home model of care coordination," LePage said.
Security also has an annual pay-for-performance program to foster higher quality care for Medicaid members. Last year, the plan aligned its incentives with clinical performance targets identified for Medicaid health plans by the Wisconsin Department of Health Services.
In Maine, Aetna Medicare has developed provider collaborations throughout the state on shared quality goals, building on foundations of care management with dedicated or embedded nurse case managers working with providers; timely sharing of clinical information and analytics at population and member levels; and financial incentives that encourage improvement in clinical process and outcome measures beyond fee-for-service reimbursement.
The plan also focuses on strategic relationships at the physician leadership level to accomplish the quality goals, said Joseph Agostini, MD, chief medical officer for Medicare collaboration at Aetna.
"We have found in Maine that members affiliated with a provider collaboration practice achieve on average higher quality scores compared to other Medicare members not in the relationship," he said.
Nurse case managers are key. They can improve the consumer experience by working with the Medicare member by telephone or in person, helping them with multiple chronic conditions, encourage timely follow-up and scheduling appointments, Agostini said. Case managers also play a critical role in transitions of care, when Medicare members are discharged from hospital to home or skilled nursing facilities to home, helping to prevent readmission.