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Medicaid plan focuses on HEDIS measures
Quality is a year-round focus by every employee
At Health Plan of Michigan, every employee is trained on the importance of HEDIS measures, and the health plan offers incentives to employees, physicians, and patients based on performance on the quality improvement measures.
The emphasis on HEDIS has paid off. Health Plan of Michigan has been ranked in the top 10 Medicaid health plans in the country by U.S. News/National Committee for Quality Assurance (NCQA) America's Best Health Plans and has received an NCQA "excellent" accreditation as a managed care plan.
The health plan consistently has improved its scores on HEDIS measures.
For instance, in diabetes care, hemoglobin A1c testing increased from 51.5% in 2000 to 89.2% in 2008. During the same period of time, the percentage of eligible women receiving breast cancer screening increased from 1.6% to 67.1% and the percentage of children receiving well child visits from birth to 15 months increased from 6.8% to 72%.
"Ensuring that our members receive the highest-quality care possible is a year-round, every day program for us. We engage all of our employees and the provider community in our quality program and work hard at engaging our membership," says Vicki Boyle, director of quality management for the Detroit-based health plan.
With more than 186,000 members, Health Plan of Michigan is the second largest Medicaid health plan in Michigan.
Recognizing the challenges in ensuring that the Medicaid population it serves receives the recommended care, the health plan has developed a program that integrates membership outreach, case management, disease management, and provider relations in the quest to improve HEDIS compliance.
The health plan collaborates with physicians and pharmacists to ensure that its members understand their treatment plan and receive the recommended care.
Internally, the health plan includes quality measures on the agenda at every department staff meeting.
"We focus on one HEDIS measure and our results each month, and the directors take it out and spread the message to the staff. We have infused quality throughout the entire company," Boyle says.
New staff, regardless of what department they work in, undergo training on HEDIS and CAHPS (Consumer Assessment of Healthcare Providers and Systems).
Boyle and her team explain HEDIS and CAHPS to the staff in layperson's terms, describing why it's important, why it is measured, how it impacts the health plan, and what areas it affects.
"Every employee has training on HEDIS measures. We even include our information technology staff in the training. They don't get member calls but they may get a provider call," she says.
"We discuss all of our efforts to ensure that patients get the recommended care including what we are doing internally, what we are doing for the provider, and what we are doing for our members," she says.
Whenever anyone at the health plan calls up a member's file on the computer system, a HEDIS alert, in the form of a red "H," is prominently displayed on the screen if a member has not received a recommended screening, immunization, or test.
"The entire staff are trained to recognize a HEDIS alert and to educate the member on the importance of receiving the recommended service by following an online script," Boyle says.
For instance, if members call in about a bill, the customer service staff educate them about the missing procedure and insert a note in the system.
The health plan runs outreach campaigns on specific HEDIS measures throughout the year, using an automated calling system, which automatically displays the member's information on the screen when someone answers.
When someone at Health Plan of Michigan talks to a member about a HEDIS concern, he or she enters a code into the computer system. If data analysis shows that the member hasn't addressed the issue within 60 days, he or she is automatically placed back in the system to be contacted again.
Members receive follow-up post cards after each outreach call and receive incentives, such as gift cards, phone calls, and gas cards when they complete certain services.
If the outreach staff are unable to reach members by telephone, the health plan sends them educational flyers about their condition and the need to take care of the recommended preventive measures and tests.
Employees at Health Plan of Michigan receive bonuses when the health plan meets targets for 13 different HEDIS measures. They can view the progress on the HEDIS measures through graphs built into the computer system that monitors performance on a daily basis.
The health plan has installed flat-screen monitors throughout the building to display the status of each HEDIS measure as compared to the same time in the previous year.
The health plan teams with providers to ensure that members receive the care specified in the HEDIS measures.
Through a system provided by the health plan, providers may check for compliance with HEDIS measures while the member is in the office. Health Plan of Michigan mails reminder cards with information about recommended procedures to members on behalf of their physicians.
The health plan's provider representatives work in the communities where the members typically live and work with the primary care physicians to ensure that the members receive the recommended services.
Provider representatives have a health care background and are active in the communities they are serving. "They know the area, the providers, and the people in the community," Boyle says.
The provider representatives attend local health fairs, serve on advisory boards within their community, and get to know the members and the providers.
"The provider representatives interact with the provider network on a regular basis. They help us grow the network by engaging new providers and keep the providers educated on the HEDIS measures, best practices, and assist with billing issues," she says.
When members are missing one of the recommended HEDIS services, the provider representative talks to the physicians and enlists their help in ensuring that the member receives the recommended care.
The health plan works closely with the physician practices to ensure that the members get the assistance they need to overcome obstacles to complying with their treatment plan.
"We try to overcome all the barriers that prevent our population from receiving the recommended care. They may be in a homeless shelter or move from family member to family member, or their only telephone number may be a pre-paid cell phone. We collaborate with physicians and pharmacists to reach the members," she says.
Providers can call on Health Plan of Michigan's case managers if members are having transportation issues or other community needs.
If the member needs more clinical assistance, the case manager sets up a telephone call appointment while the member is at the doctor's office.
"During the call, they can reinforce the patient's treatment plan and find out about any transportation needs for the next appointment. Members leave the appointment knowing that their follow-up visit is scheduled and they have transportation to it," she says.
As part of its pay-for-performance initiatives, the health plan offers quarterly bonuses for providers if a certain percentage of their patients receive specific HEDIS measures. Providers receive between $15 and $100 per HEDIS service. The health plan sends the providers monthly reports showing the HEDIS services their members need and the amount of the potential bonus if all services are completed.
The health plan has tried innovative ways to ensure that members receive recommended care, such as sponsoring a raffle for a Nintendo Wii to encourage well-child visits to the doctor. Parents were entered into the raffle if they took their children, ages 3 to 6, for a well-child visit between April 1 and May 31, 2008.
As a result, the percentage of children receiving well-child visits increased from 12.6% in April to 30.3% in July 2008. The program was expanded to include adolescents for back-to-school and sports visits.