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Quality and Cost Programs

Quality Improvement Program

Program Purpose | Program Scope | Customer-Driven Quality Strategy |
Identifying Opportunities for Improvement | QI Model | Annual Work Plan | 
Program Evaluation | Program Staff and Governance | For More Information

Program Purpose

The Medica Quality Improvement (QI) program supports our mission to meet our customers’ needs for health plan products and services. The QI program’s purpose is to identify and implement activities that will:

  • Improve member care, service, access and/or safety;
  • Improve service to providers, employers, brokers and other customers and partners; and/or
  • Improve Medica's internal operations.

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Program Scope

Our QI program encompasses a wide range of clinical and service quality initiatives affecting our members, providers, employer and brokers, as well as internal stakeholders throughout Medica. Key areas of focus include:

  • Access to and availability of network providers
  • Behavioral health care and service
  • Complaint, appeal and grievance management
  • Continuity, coordination and transition of care
  • Credentialing and recredentialing
  • Delegation oversight (oversight of entities to which Medica delegates selected functions)
  • Health and wellness coaching
  • Medical records review and site surveys
  • Member rights and responsibilities
  • Member satisfaction
  • Patient safety
  • Utilization (of inpatient and outpatient medical services)

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Customer-Driven Quality Strategy

All Medica's customers want care and service to be the best they can be. Medical professionals want a quality relationship with the health plan: questions answered promptly, claims paid quickly and members' benefits readily understood. Members want easily available appointments with a broad selection of providers, resulting in efficient, effective care. Employers want to provide quality health care coverage for their employees at affordable rates. Medica’s QI program is designed to address all these needs.

We know that understanding our customers’ perceptions and expectations is central to successful strategic and quality planning. Medica learns about members and other important stakeholders through data sources that include:

  • Member and provider satisfaction surveys
  • Member Advisory Council feedback
  • Health outcomes
  • Utilization management data
  • Complaint and appeal data
  • Progress reports on QI work plan goals

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Identifying Opportunities for Improvement

To identify improvement opportunities, Medica focuses on high-risk, high-volume, and problem-prone areas that may expose members to potentially adverse clinical or service outcomes. We evaluate the full spectrum of clinical care: inpatient, outpatient, ancillary, pharmacy, emergency services, home health, and skilled nursing care.

Medica analyzes information from numerous sources, ranging from claims, utilization and pharmacy data, to member complaints and appeals, to member and practitioner satisfaction surveys. Annual HEDIS® (Health Plan Effectiveness Data and Information Set) rates, health risk assessments and clinical studies provide valuable data, as do internal performance measures and audit results.

When a potential improvement opportunity emerges, Medica considers these factors:

  • How is the improvement relevant to our member population?
  • What is our ability to make an impact?
  • What's the potential for integration with other programs?
  • What are the applicable laws and regulations?
  • What are the potential program costs and resource needs?
  • Are regional or national benchmarks available for goal-setting?

Once an opportunity is selected, Medica sets measurable goals against current baseline measures, and re-measures periodically to assess the improvement's effectiveness.

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QI Model

Medica uses the Plan-Do-Study-Act (PDSA) model to identify and implement QI strategies and activities:

  • Plan: Evaluate data, identify improvement opportunities, and determine appropriate intervention strategies based on best practices and known barriers.
  • Do: Implement program(s) to address identified needs and barriers.
  • Study: Measure the effects of the improvement and assess its effectiveness.
  • Act: Continue intervention if effective. Adjust as necessary to achieve goal targets. Repeat cycle if intervention doesn't achieve desired result.

The PDSA process continues until we meet our goals, or until results show we need to focus resources in another way.

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Annual Work Plan

Medica prepares an annual Quality Improvement Work Plan that outlines key quality improvement activities for the year. The activities support our clinical and service priorities and align with the organization’s strategic imperatives.

 Work plan activities throughout Medica are designed to improve clinical and service quality for members, practitioners and other stakeholders, both external and internal. For example, the 2016 work plan includes activities designed to: 

  • Improve depression management and antidepressant medication adherence.
  • Improve well-child visit rates for select populations.
  • Implement interventions to address opioid overprescribing.
  • Implement process improvements to improve the member experience.

 Activity “owners” measure and report on their progress at least quarterly. Activities or goals may change during the year based on these assessments.

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Program Evaluation

Medica evaluates the QI program annually. We review the year's clinical and service quality activities and assess our progress toward work plan goals. We also look at our QI committee structure, QI program resources, and the key challenges and barriers encountered during the year. The program evaluation report includes:

  • Descriptions of the year’s QI activities
  • Measurements and trending to assess performance
  • Analysis of Medica’s success in demonstrating improvements
  • Evaluation of the overall effectiveness of the QI program
  • Recommendations for changes in areas that did not meet annual goals

Each year's program evaluation forms the basis of the next year's work plan.

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Program Staff and Governance

Medica’s senior medical director, a licensed physician, is ultimately responsible for QI program development, implementation and oversight in collaboration with our leadership team. Departments and staff throughout Medica participate in quality improvement activities with the Quality Improvement department's oversight and support.

The Medica Quality Improvement Subcommittee (QIS) directs and oversees QI program implementation. Reporting to the Medical Committee of the Medica Board of Directors, QIS serves as a peer review body, receiving and reviewing aggregate data on all aspects of clinical and service quality.

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For More Information

Practitioner feedback is vital to the success of our QI program. We welcome your contributions! If you'd like to share your comments or suggestions, would like more QI program information, or are interested in participating in quality improvement activities at Medica, please contact the Medica Provider Service Center at 1-800-458-5512.

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Date: 4/25/2019 5:09:16 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CMSWEB01