2006 Quality Management Work Plan Evaluation Executive Summary

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1 H:\QM Program Eval 06 Exec Sum Master Final.doc 2006 Quality Management Work Plan Evaluation Executive Summary
Work Plan Completion/Resources

85 out of 88 (96.5%) activities were completed on time. This represents an improvement of 4.1 percentage points over 2005. Three of the delayed indicators
were related to redefining a new methodology for the Disease Management Outcome indicators, Heart Failure, Diabetes and Asthma. Therefore, it appears that
the plan is applying adequate resources to the Quality Management Program. The EQCC should continue to closely monitor QM Work Plan progress.

Clinical Indicators

Overall, there was modest improvement in the clinical indicators measured by the plan. 58% of the HEDIS measures that account towards accreditation
improved over last year. This is compared to 63% in the previous year. 3% of all measures achieved the plan’s goal of 90 th national percentile and 15% achieved the 75%ile. Comprehensive and aggressive improvement action plans have been implemented for most clinical indicators measured by the plan in an attempt to
approach benchmarks/goals. The following specific points are noted for the measures that count toward the NCQA accreditation score:

Although some improvements were noted in Timeliness of Prenatal Care, Postpartum Care, Comprehensive Diabetes Care for Eyes Exam, LDL Screening and
HbA1c Screening, Nephropathy Monitoring and Controlling High Blood Pressure, the most significant gains were made in Adolescent Immunization,
Antidepressant Medication Management, Appropriate Medication for Asthmatics, Ambulatory Follow Up after Hospitalization for Mental Illness. Refer to
Appendix C for the Improvement Action Plans (IAPs) for the various indicators.

All of the scores in the following table count toward the overall NCQA accreditation score. Shaded cells indicate improvement over previous reporting period(s)
and baseline scores to sustain the gain. Baseline rates are calculated as 3 years from the last HEDIS submission. Indicator Product Line 2004 RY 2005 RY 2006 RY % Change Last Year % Change from Baseline Benchmark 90%ile Adolescent Immunization Status – Combo 1 Commercial 39.90% 45.50% NA NA NA 84.1% Adolescent Immunization Status – Combo 2 CM Commercial 29.20% 31.39% 43.55% 38.7% 7.94% 72.3% Antidepressant Medication Management - 3 F/U Visits in 84
Days Commercial 15.36% 12.59% 11.93% -5.2% -22.33% 31.8% Antidepressant Medication Management - 3 F/U Visits in 84
Days Medicare 3.23% 11.50% 8.99% -21.8% 178.33% 20.4% Antidepressant Medication Management – 84 Days on Rx Commercial 69.29% 58.74% 65.14% 10.9% -5.99% 69.3% Antidepressant Medication Management - 84 Days on Rx Medicare 49.46% 49.56% 53.93% 8.8% 9.04% 72.9% Antidepressant Medication Management – 180 Days on Rx Commercial 52.86% 45.80% 52.29% 14.2% -1.08% 53.6% Antidepressant Medication Management - 180 Days on Rx Medicare 37.63% 32.74% 41.57% 26.9% 10.49% 59.6% Appropriate Medications for People with Asthma Commercial 73.86% 79.39% 91.48% 15.2% 23.86% 79.2% 2 H:\QM Program Eval 06 Exec Sum Master Final.doc Indicator Product Line 2004 RY 2005 RY 2006 RY % Change Last Year % Change from Baseline Benchmark 90%ile Bet-Blocker Treatment After a Heart Attack Commercial 93.10% 95.12% NE NA NA 100% Bet-Blocker Treatment After a Heart Attack Medicare 92.59% 98.68% 98.48% -0.20% 18.2% 100% Ambulatory Follow-Up After Hospitalization for Mental Illness –
7 Days Commercial 60.61% 35.77% 54.90% 53.5% -9.42% 70.2% Ambulatory Follow-Up After Hospitalization for Mental Illness –
7 Days Medicare 51.16% 17.14% 57.58% 235.9% 12.55% 63.2% Breast Cancer Screening Commercial 75.34% 77.03% 74.74% -2.9% -0.8% 81.2% Breast Cancer Screening Medicare 79.57% 84.95% 77.98% -8.2% -2.0% 83.4% Cervical Cancer Screening Commercial 84.24% 88.59% 83.15% -6.1% -1.29% 87.2% Timeliness of Prenatal Care Commercial 83.33% 87.54% 93.33% 6.6% 12.0% 96.9% Postpartum Care Commercial 75.86% 80.19% 84.44% 5.3% 11.61% 88.3% Childhood Immunization Status – Combo 2 Commercial 66.49% 75.20% 71.77% -4.6% 7.94% 81.7% Cholesterol Management After Acute CV Events (Screening) Commercial 85.51% 83.70% 79.81% -4.7% -6.67% 87.5% Cholesterol Management After Acute CV Events (Screening) Medicare 88.55% 86.40% 83.70% -3.1% -5.48% 90.5% Comprehensive Diabetes Care – Eye Exam Commercial 44.28% 48.66% 50.12% 3.0% 13.19% 66.2% Comprehensive Diabetes Care – Eye Exam Medicare 66.67% 72.26% 64.07% -11.3% -3.90% 82.7% Comprehensive Diabetes Care – LDL Screening Commercial 91.24% 92.21% 92.70% 0.5% 1.6% 94.9% Comprehensive Diabetes Care – LDL Screening Medicare 94.89% 96.84% 95.38% -1.5% 5.48% 97.3% Comprehensive Diabetes Care – HbA1c Screening Commercial 86.13% 89.05% 88.81% -0.3% 3.11% 92.5% Comprehensive Diabetes Care – HbA1c Screening Medicare 91.00% 89.54% 91.73% 2.5% 0.8% 94.5% Comprehensive Diabetes Care – Nephropathy Monitoring Commercial 45.99% 44.04% 51.09% 16.0% 11.9% 65.5% Comprehensive Diabetes Care – Nephropathy Monitoring Medicare 42.58% 44.04% 51.09% 16.0% 19.99% 74.7% Controlling High Blood Pressure Commercial 65.46% 65.69% 67.02% 2.0% 2.38% 75.4% Controlling High Blood Pressure Medicare 57.53% 61.79% 66.33% 7.4% 15.30% 74.2% Advising Smokers to Quit Commercial 68.2% 72.4% 75.9% 4.8% 11% 78.6% Advising Smokers to Quit Medicare 66% 47% 89% 89% 40% N/A Flu Shots for Older Adults Medicare 80% 79% 74% -6.7% 10.4% 82% Pneumonia Vaccination Status for Older Adults Medicare 72% 73% 71% -2.8% 14.5% 81%
NE – Not Eligible (The population was too small for the rate to be reported.)
CAHPS Indicators
3 H:\QM Program Eval 06 Exec Sum Master Final.doc Service Indicators

The Service Quality Committee (SQC) met and reviewed 46 key service indicators 11 times in 2006. Efforts the previous two years to enhance the
meaningfulness of the indicators and to make sure they were reported timely bore fruit in 2006, although further improvement is still desirable in both of these
areas. The service indicator review process allowed the SQC to identify and prioritize a number of significant improvement actions. A summary of the Service
Indicators and the Service Quality Improvement Action Plan was reviewed with the EQCC on 3 occasions. In general, the process for reviewing the indicators,
identifying and prioritizing improvement opportunities was enhanced so as to better align Service Quality Program initiatives with the over-all strategic priorities
of the company.

A few particulars to note: Provider Support Services telephone abandonment rate improved significantly in 2006, meeting the goal in every month. Appeal
timeliness continued to be a strength, as was Claims timeliness and accuracy. “Timeliness of Contact Service Form Resolution” fell significantly in 2006, after a
major effort to improve it in 2005. Other opportunities for improvement include Member Telephone Service Level and some of the Eligibility measures
associated with new group processing.

NCQA Accreditation Status

The plan began the year with its NCQA status in good standing as follows: Commercial – Excellent and Medicare – Excellent. Improved HEDIS scores that
were submitted in June, the NCQA re-evaluated the health plan’s accreditation status. The total score for the Commercial and Medicare product lines improved.
SummaCare has been ranked "One of America's Best Health Plans" by US News and World Report/NCQA. Our Medicare plan is ranked 8th in the country!
We are the highest ranked health plan in Ohio.
An overall score of 90% or more is needed for Excellent status and the current scores stand as follows:
Commercial Medicare Standards Compliance 70.0000 70.0000 HEDIS Scores 28.1018 28.0186 Total Score 98.1018 98.0186
The plan is scheduled to undergo its third NCQA survey under a set of updated standards in January 2007. Steps to prepare for this important activity have been
ongoing.

Government/Regulatory Compliance

The Centers for Medicare and Medicaid Services (CMS) uses The Quality Improvement System for Managed Care standards and guidelines as key tools in
implementing quality assurance through the Quality Assessment and Performance Improvement (QAPI) program. SummaCare is required to conduct
performance improvement projects that achieve through ongoing measurement and intervention, demonstrable and sustained improvement in significant aspects
of clinical and non-clinical focus areas. The following table illustrates the required QAPI National projects in order of initiation year.

Project Name Initiation Date Outcome 4 H:\QM Program Eval 06 Exec Sum Master Final.doc Pneumonia Project Flu vaccine rate 2000 Project completed Retinal Eye Exams 2000 Project completed Heart Failure Extra Payment 2001 Project completed Depression 2001 Project completed Heart Failure QAPI Project 2001 Indicator #1. Appropriate evaluation of Left Ventricular Function Assessment improved from 1 st remeasurement rate of 94% (2002 dates of service) to 97% (2003 dates of service) Indicator #2. Appropriate use of Angiotensin Enzyme Inhibitors (ACEI) or documentation of why ACEI was not used increased from 1 st remeasurement rate of 78.5% (2002 dates of service) to 82% (2003 dates of service) Project completed Breast Cancer Screening 2002 Rate improved from baseline rate of 79.21% (for 2001 dates of service) to 84.95% (2004 dates of service) Project completed Culturally and Linguistically Appropriate Services (CLAS) 2003 Foreign language identification added to the Provider Directories Project completed QAPI 2006 Comprehensive Diabetes Care- Nephropathy Monitoring, Eye Exams and Controlling High Blood Pressure
Member and Practitioner Satisfaction

In 2006, Member Satisfaction with SummaCare was the highest it has ever been, both compared to previous years and external benchmarks. This was true of
both the Commercial and Medicare product line. The rating of “Claims Payment” and the “Quality of the Healthcare Provided” by our core network were
particular areas of strength. SummaCare’s strong performance on the Consumer Assessment of Healthcare Provider & Systems (CAHPS) survey was a major
factor in receiving the U.S. News & World Report “Best Health Plans” ranking. Commercial HMO and PPO members also ranked SummaCare in the top 20 th percentile nationally on the J.D. Power & Associates survey, earning SummaCare the “Distinguished Health Plan” award for the second year in a row.
Practitioner Satisfaction 2006 2005 2004 2003 2002 2001 1999 % of Practitioners Somewhat or Very Satisfied* 74.5 60.0 62.2 61.5 70.4 62.8 63.8 Member Satisfaction (CAHPS) 2006 2005 2004 2003 2002 2001 2000 Overall Rating of Health Plan – Commercial 73.2 71.8 68.8 65.6 68.0 67.5 64.4 Overall Rating of Health Plan – Medicare 84 65 63 86 88 86 89 *not performed in 2000
5 H:\QM Program Eval 06 Exec Sum Master Final.doc Awards/Recognition

The Centers for Medicare and Medicaid Services (CMS) began to offer deeming status to Medicare-serving health plans early in 2002. However, for various
good reasons SummaCare has not elected to pursue this avenue. Besides the U.S. News and World Report national rankings, the plan received the following
additional quality-related awards in 2006.

For the 5th year in a row, the plan was recognized by the Ohio Association of Health Plans (OAHP). This year, SummaCare received recognition from the OAHP
for 3 projects. The first was a Meritorious Award for the process improvement project between the recovery and accounting units Accessing the Power of
Collaboration, which streamlined the process while meeting the diverse requirements of both. The 2nd Meritorious Award was received for the Optimizing
Excellence in Service Program which reduced the amount of service forms and significantly streamlined processes and processing time. The 3 rd award was the Pinnacle Award for Improving the Rate of Lipid Screening in Diabetes of which SummaCare ranks in the top 10%ile of the country for Commercial and
Medicare.

SummaCare has also been recognized for providing "An Outstanding Member Experience" by J.D. Power and Associates for our Commercial PPO members.


Opportunities for Improvement
SummaCare has opportunities to improve to reach the 90%ile ranking in all of the HEDIS measures, these additional indicators will be a focus for 2007:
• Timeliness of Contact Service Form Resolution • Satisfaction with Customer Service • Increased Collaboration with Disease Management Efforts • Practitioner Satisfaction • Finalization and Measurement of the ADHD Clinical Practice Guideline • Enhanced Employer Group Reporting • Enhanced Physician Communication These opportunities for improvement will be addressed in the 2007 Quality Management Program Work Plan. 6 H:\QM Program Eval 06 Exec Sum Master Final.doc Confidential SUMMACARE, INC. 2006 Quality Management Program Evaluation Activity Outcome Limitations Recommendations Quality Improvement 1. Complete 2005 QMP
annual evaluation • Completed on time • None • None 2. Address progress
toward influencing safe
clinical practices in the
2005 QMP annual
evaluation • 11 adverse outcomes were reported in 2006
related to the evaluation of the 2005 data
resulting in the identification of two (2)
quality issues (see #10) • Published or posted four articles in member
newsletters designed to promote safety (see
#8) • Continued Prescription for Safety as a
standing section of the provider newsletter
(see #9) • Published Collecting & Providing
Information on Hospital Provider Safety and
Quality on the provider website. • Published Continuity & Coordination of
Care Between SNFs and PCPs on the
provider website. • Implemented the plan for collecting and
providing information on provider and
practitioner safety and quality that promotes
the JCAHO National Patient Safety Goals
(see #12) • Adverse events reporting decreased significantly in 2005 supporting the
belief that adverse events continue
to be underreported • As a MCO, the plan’s ability to monitor and influence safe clinical
practices is inherently limited • Continue to coach the Health
Services Management staff
regarding the reporting of adverse
events • Explore new and innovative ways
to address the influence of safe
clinical practices • Continue to publish/post articles
designed to promote safety on the
corporate web site, in the
provider newsletter, and in the
member newsletters 3. Approval/review of
2006 QMP annual
evaluation by EQCC,
CQRMC, & BOD • Completed on time • None • None 4. Update the QMP
Description for 2006 • Completed on time • None • None 5. Approval/review of
2006 QMP Description • Completed on time • None • None 7 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations by EQCC, CQRMC, &
BOD
6. Complete 2006 QMP
Work Plan • Completed on time • None • None 7. Approval/review of
2006 QMP Work Plan
by EQCC, CQRMC, &
BOD • Completed on time • None • None 8. Maintain at least two
articles per year on the
SummaCare web site
that address the
improvement of clinical
care safety • Completed on time • 5 Steps to Safer Health Care was published
in the Medicare newsletter • Medicines…Use Them Safely! Ran in the
Medicare newsletter • 20 Tips to Help Prevent Medical Errors in
Children was published in the Health
Update column in the Web site • Important Information About Your
Medication ran in the Medicare newsletter
and in the Health Update column of the
Web site • None • Continue to publish and post 9. Maintain a patient
safety section of the
provider newsletter and
publish related
information in each
edition • Completed on time • The Institute For Safe Medication
Practices newsletter is lengthy and
tends to focus on inpatient issues • The QM Director should continue to screen the ISMP newsletter and
make suggestions to the CMO.
Other sources of material should
continue to be considered 10. 2006 annual adverse
event monitoring report
analysis by CPRC • Completed on time • Of the 11 reported adverse events, two (2)
quality issues were identified and addressed • Provided reporting forms and “one on one”
coaching of nursing staff on reporting of
adverse events • The report was reviewed and
approved by the CPRC on 2/10/06. • Adverse events reporting decreased
significantly in 2005 (reported in
2006) supporting the belief that
adverse events continue to be
underreported • Continue to monitor adverse
events as per the Adverse Event
Reporting policy • Continue to coach the Health
Services Management staff
regarding the reporting of adverse
events 11. Report on QMP
progress to the BOD
each quarter • Completed on time • None • None 12. Develop and • Implemented the plan to collect and share • The JCAHO developed reporting of • Continue to collect and share 8 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations implement a plan for
collecting and providing
information on provider
and practitioner safety
and quality information on provider and practitioner
safety and quality by reviewing and posting
compliance with contracted hospitals with
the National Patient Safety Goals (NPSFs)
on the SummaCare Web site. The plan was
reviewed and approved at the 6/18/06 CPRC
meeting. the NPSFs and include them in
their accreditation program. Two
(2) network hospitals are
osteopathic facilities and are not
accredited by the JACHO. Those
facilities provided self-reported
information regarding the standards
and their level of compliance. information on NPSGs for
providers who are accredited by
the JACHO. Continue to collect
and share self-reported compliance
with the NPSGs from osteopathic
facilities not accredited by
JACHO. • Continue to publish the
information regarding NPSGs on
the SummaCare website. 13. Measure
performance against
practitioner availability
standards • analyze findings • develop IAP • implement
interventions
Commercial – Carroll County 36% of the
members have a cardiovascular disease
physician within 15 miles and 69% of the
members have an ophthalmologist within 15
miles. However, there are only 39 commercial
members residing in Carroll County. Typically
these members travel to Stark County
(approximately 27 miles) for care because not
many providers are located in the more rural
Carroll County.
Medicare – Carroll County we have
zero cardiovascular disease physicians
and zero ophthalmologists. According
to the State of Ohio Medical License
web-site, there are no physicians with
these specialties in Carroll County.
There is only 1 Medicare member in
Carroll County and typically members
travel to Stark County (approximately
27 miles) for care. There is no hospital
located in Carroll County. There are no opportunities for
improvement that require follow-up
action and no barriers to future
ability to meet availability standards.
Therefore, it is recommended that
SummaCare continue monitoring
using the methodologies identified. 14. Measure performance against
accessibility of services
standards
• analyze findings • develop IAP • implement
interventions • Completed on time • Approved by EQCC on 6/22/06 • None • Define “Routine Appointments”
standard for Commercial
population as “within 14 days”. • Remove standards from behavioral
health survey tool 15. Complete 2006 commercial member
satisfaction survey
• using CAHPS • analyze findings • develop IAP • implement
interventions • Completed on time • The overall satisfaction rating was the
highest ever at 73.2% • A comprehensive IAP was developed by the
SQC and approved by the EQCC.
**SEE APPENDIX D • “Experience with Plan Paperwork” and “Finding/Understanding written
information” offered the most
significant opportunity for
improvement • Satisfaction with Customer Service was a second opportunity for
improvement. • Continue actions to improve in
these two areas. 9 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations 16. Complete 2006 Medicare member
satisfaction survey • using CAHPS • analyze findings • develop IAP • implement interventions • Completed on time • The overall satisfaction rating increased
significantly from 65% in 2005 to 84% in
2006, well above the 79% national avg. • A comprehensive IAP was developed by the
SQC, and approved by the EQCC.
**SEE APPENDIX D • “Experience with Plan
Paperwork” and
“Finding/Understanding written
information” offered the most
significant opportunity for
improvement • Continue actions to improve in this area. 17. 2005 annual report on informal member
complaints to SQC &
EQCC • analyze findings • develop IAP • implement
interventions • Completed on time. • Claims Issues, in particular complaints related to COB and processing errors,
offered the primary opportunity for
improvement • Coding consistency and ill
conceived categories limits ability
to identify “root cause” of
complaints • Root cause analysis and action plan
development not done quarterly. • Conduct root cause analysis at
least quarterly in 2007 • Develop new coding categories as
part of Amisys Advance
implementation 18. 2005 annual report
on formal member
complaints to SQC &
EQCC • analyze findings • develop IAP • implement
interventions • Completed on time • Appeals/1000 increased modestly from 2.15 in 2002 to 2.24 in 2003. Total appeal
volume rose to 4913 in 2003 versus 3283
in 2002 • Overturned appeals decreased to about 50% for all LOB in 2004. • Interim report of overturned appeal data for Medicare and Commercial for the first
half of 2005 to EQCC in Oct 2005. • Did not take to SQC (the SQC Taskforce was disbanded and this
change was mistaken for the SQC).
• Take 2005 Annual Appeals and
Grievance Report to SQC. • For 2005 Appeals and Grievance
annual report: o Ensure that data is reported
by product line in members
per thousand format. o Ensure that 2005 data is
compared to 2004, 2003,
2002, and 2001 data (by
LOB) concerning
complaints per 1000,
overturn rate, and top five
reasons for complaints. • Continue to examine ways to
reduce the complaints associated
with Plan Directed Care OON. 19. 2006 annual report
on PCP quality transfer
requests to CPRC &
EQCC
• analyze findings • Completed on time • Decision made to eliminate reporting
requirement due to limitations of data. • None • None 10 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations • develop IAP • implement
interventions 20. Measure outcomes
of HF disease
management program
• analyze findings • develop IAP • implement
interventions • Completed but not on time • Used initial methodology but decision made to revised. • Finalize new methodology and report findings for 2006 to
CQRMC and EQCC 21. Measure out-comes
of diabetes disease
management program
• analyze findings • develop IAP • implement interventions • Completed but not on time • Used initial methodology but decision made to revised. • Finalize new methodology and report findings for 2006 to
CQRMC and EQCC 22. Measure out-comes
of asthma disease
management program
• analyze findings • develop IAP • implement interventions • Completed but not on time • Used initial methodology but decision made to revised. • Finalize new methodology and
report findings for 2006 to
CQRMC and EQCC 23. Continue
implementing
mechanism for
informing and educating
practitioners about using
the disease management
programs for the
members assigned to
them • Completed. Implemented recommendations
from focus groups and created Disease
Management Physician Committee. • None • None. 24. Obtain Disease
Management
Association of America
certification for disease
management outcome • Completed. • None • Consider accreditation for DM
programs. 11 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations methodologies
25. Run demographic
report on membership by
product line and
combined • Completed on time • None • None 26. Run epidemiologic
reports on membership
by product line and
combined • Completed on time. • Volume of data related to non-
cancerous eye disorders distorts high
volume conditions. • Cancer continues to be high volume
condition but no clinical program
exists to address as DM initiative. • Modify report in 2007 to exclude non-cancerous eye disorders. • Consider cancer DM Program. 27. Demographic and
epidemiologic report
approval & analysis by
EQCC & CQRMC • Completed on time • None • None 28. Review of the
COPD clinical practice
guideline by the
CQRMC • Completed on time. • None • Continue to review and update
every two years 29. Review of the beta
blocker use after MI &
HF clinical practice
guidelines by the
CQRMC • Completed on time • None • Continue to review and update
every two years 30. Review of the
hypertension clinical
practice guideline by the
CQRMC • Did not require review in 2006 • None • Continue to review and update every two years 31. Review of the major
depressive disorder
clinical practice
guideline by the BHC • Completed on time. • None • Continue to review and update every two years 32. Review of the
Asthma clinical practice
guideline by the
CQRMC • Did not require review in 2006 • None • Continue to review and update
every two years 33. Review of the CAD
clinical practice
guideline by the • Did not require review in 2006 • None • Continue to review and update
every two years 12 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations CQRMC
34. Review of the
diabetes clinical practice
guideline by the
CQRMC • Did not require review in 2006 • None • Continue to review and update
every two years 35. Review of the
ADHD clinical practice
guideline by the BHC • Completed on time. • None • Continue to review and update
every two years 36. Measure performance
against the major
depressive disorder
clinical practice
guideline • analyze findings • develop IAP • implement
interventions • Completed on time



• None • Continue to measure annually 37. Measure
performance against the
asthma clinical practice
guideline (flu vaccine,
f/u visits, & appropriate
meds elements) • analyze findings • develop IAP • implement
interventions • Completed on time. Significantly expanded flu vaccine access.




• None • Continue to measure annually 38. Measure
performance against the
diabetes clinical practice
guideline
• analyze findings • develop IAP • implement
interventions • Did not require review in 2006 • None • Continue to review and update
every two years 39. Measure
performance against the
ADHD clinical practice • Completed on time. Measures revised to reflect the new NCQA standards. • None • Continue to measure annually 13 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations guideline
• analyze findings • develop IAP • implement
interventions


40. Conduct the survey
of SNF satisfaction with
hospital continuity and
coordination of care and
report to CQRMC
• analyze findings • develop IAP • implement
interventions
• Completed on time Post Acute Skilled Referral Form complete (including therapy) = 93% • Post Acute Skilled Transfer Form complete= 89%
• Medication list complete = 96% • Lack of staff and time to complete
the entire hospital transfer form. • Multiple staff at SHS hospitals add
documentation to the transfer form,
but no one department takes
responsibility for its completion. • Encourage continued use of the
form by SHS and other contracted
hospitals.

41. Conduct the audit of
SNF communication to
PCPs and report to
CQRMC
• analyze findings • develop IAP • implement
interventions • Completed on time • Rate increased from 50% in 2005 to 69.5%
in 2006. • PCPs seeing their patients keep
records at the SNF and not at the
office. • There may be lack of staff time to
fax discharge summaries. • It is possible that PCPs are not
filing discharge summaries
they receive. • Continue to educate the SNFs of the need for communication
between practice sites at the
monthly SummaCare and SNF
meetings. • Continue the use of a
standardized fax cover sheet for
the SNFs to transmit information to PCPs. 42. Conduct secondary
prevention screenings
for depression in
members that have
undergone coronary
artery bypass graft • Completed on time. • Data collection complete. • Complete formal analysis for program effectiveness and make
recommendations for continued
study or identification of new
study. 43. Conduct behavioral
health medical record
audit • Completed on time • None • None 44. Conduct annual
HEDIS data collection • submit to NCQA • Completed on time • Excellent NCQA accreditation status was
maintained for both product lines • Methods for communicating
clinical initiatives to members
and providers not cohesive and • Continue to implement
comprehensive HEDIS
improvement action plan 14 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations • analyze findings • develop IAP • implement
interventions • 84% of the accreditation measures
maintained or improved over last year • High HEDIS scores helped SummaCare
achieve national rankings in top 50 by U.S.
News & World Report: 8 th for Medicare and 49 th for Commercial. reflective of HealthLifestyle
theme. • Work with marketing to develop
theme for clinical programs and
communication strategy to
engage members and providers. 45. Monitor all service
quality indicators and
take action when goals
are consistently not met • A total of 46 key indicators were monitored
monthly • Timeliness of reporting improved in 2006 • Appropriate actions were taken to address
indicators that did not meet goal • Contact Service Form Timeliness
regressed in 2006 • Certain Indicators related to
Customer Service and Eligibility
consistently were below goal in
2006 • Identify and implement actions to
improve performance in these
areas in 2007 46. Continue the study
of antibiotic
inappropriateness (6th
re-measurement)-
analyze findings
• develop IAP • implement
interventions • Completed on time • Adult combined rate worsened from 24.5%
to 29.0% • Child rate improved from 17.9% to 12.9%


**SEE APPENDIX E • The methodology has changed
twice now • The methodology has some minor,
unavoidable flaws that anger some
physicians • Continue to re-measure annually 47. Conduct the general
HOS study • Completed on time • Cohort 6: Report to EQCC January 2007
**SEE APPENDIX F • SummaCare has not used this data. • Evaluate the usefulness and data
and survey and make
recommendations for use. 48. Determine and
measure a new clinical
indicator for QAPI as
directed by CMS
• analyze findings • develop IAP implement interventions • There were no new QAPI projects initiated
in 2006 by CMS. • None • Await a new CMS initiative for the
QAPI process. 49. Conduct annual
medical record audits of
PCPs • Completed on time • 95% of SummaCare offices reviewed
passed with 90% the average score • Lack of practitioner time to
document all standards. • Practitioners may be more inclined
to document key elements if a
standard “check box” format was
available • Continue to supply offices with
chart “stickers” for Immunizations,
Health Education and Advance
Directives. • Continue to supply offices with
copies of Advance Directives upon
request. 15 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations • Present the findings at a Provider
Update Seminar and provide
supporting materials to office
staffs. • Publish findings on the provider
website. 50. Annual report on
2006 medical record
audit findings to CPRC
& EQCC • Approved by EQCC 6/26/06 • None • None 51. Conduct annual
behavioral health clinical
record audits of
practitioners • Completed on time • None • None 52. Update the
SummaCare website
with information about
the QMP • Completed on time • None • None 53. Approval of 2006
QMed Quality
Improvement Program
by CQRMC • Completed on time • None • Move to second quarter for 2006 Utilization Management 54. Complete 2005
Utilization Management
Program Evaluation • At or near utilization targets for Medicare
and commercial self funded and fully
insured products. Established new 3 year
target to reduce Medicare admissions by
24% • Implemented HCC recovery project to
maximize Medicare revenues. • Implemented predictive modeling
software. • Implemented hypertension and cholesterol
management programs. • Developed outcome reporting for disease
management programs and achieved 3 year
accreditation for savings methodology for • Evaluation of PT network
pending. • Evaluation of prior authorization
changes pending. • Evaluation of DME and AMR
network manager pending. • Underutilized data from Medicare
Health Outcome Survey • Complete ROI analysis for all
DM programs • Develop and implement
physician house call program. • Develop and implement
transitional care program. • Expand ACE model in all
contracted SNFs. • Complete financial analysis of
DME and AMR network
manager. • Complete analysis of prior
authorization changes. • Complete analysis of outpatient 16 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations asthma, diabetes, and heart failure • Developed disease management and health
and wellness presentation for sales staff to
increase sales of medical management
services. • Implemented smoking cessation program physical therapy management
and make recommendations. • Evaluate Home Care utilization
2005 vs 2006 in March 2007. • Evaluate feasibility of SNP
product for 2008 • Add high cost imaging to prior
authorization list for all
products. • Complete readmission analysis
for hospitals, SNFs and ED
encounters. • Evaluate Medicare Health
Outcome Survey and make
recommendations for use. • Evaluate outcomes of smoking
cessation program. 55. Approval of 2006
Utilization Management
Program Evaluation by
CQRMC, EQCC, &
BOD • Completed on time • Reviewed and approved by CQRMC on
1/16/06 • Approved by BOD on 2/21/06 • None • Continue to review and approve
annually 56. Update the
Utilization Management
Program Description for
2006 • Completed on time • None • Continue to review and update annually 57. Approval of 2006
Utilization Management
Program Description by
CQRMC, EQCC, &
BOD • Completed on time • Reviewed and approved by CQRMC on
1/16/05 • Approved by BOD on 2/21/06 • None • Continue to review and approve
annually 58. Conduct annual
review of medical
necessity criteria with
approval by CQRMC • Completed on time • Reviewed and approved by CQRMC on
1/16/06 • None • Continue on annual basis. 59. Evaluate the
consistency with which • Completed on time • No deficiencies were identified • None • Continue on annual basis. 17 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations health care professionals
involved in UM apply
criteria in decision
making
• analyze findings • develop IAP • implement
interventions • All performance goals were met 60. Conduct an audit of
non-behavioral health
UM files to evaluate
compliance with
decision making and
notification timeliness
standards, denial
notification contents
standards, and to verify
that relevant clinical
information is
consistently gathered • Completed on time • No deficiencies were identified • None • Continue on annual basis 61. Conduct an audit of
behavioral health UM
files to evaluate
compliance with
decision making, and
notification timeliness
standards, denial
notification contents
standards, and to verify
that relevant clinical
information is
consistently gathered • Completed on time. • Performance increased to 100%







**SEE APPENDIX G • None • Continue on annual basis 62. Conduct an audit of
Appeals files to evaluate
compliance with
standards for the
appropriate handling of
appeals • Completed on time. • Many changes occurred due to implementation of Medicare Part D
and regulatory requirements related
to appeal processing. • Conduct audits to determine
compliance with new Medicare
Part D regulations. 63. Maintain a log of all • Completed on time • None • None 18 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations requests for coverage of
new medical
technologies and new
uses of existing
technologies
64. Report the 2005
Practitioner Satisfaction
Survey to the SQC &
EQCC analyze findings
develop IAP
implement interventions Overall satisfaction for physicians decreased
from 62.2% to 60.0% Overall satisfaction for Office Managers
was 95.6% Focus groups (1 for physicians and 1 for
office managers were also conducted)









**SEE APPENDIX H Physician response rate only 16.6%
(office manager was 45%) The disconnect between physician
overall satisfaction and scores
associated with specific
performance mesasures. Significant differences in the
scores between physicians and
office managers. Secondary areas of opportunity
include provider relations and
utilization management Leverage office staff satisfaction;
increase communication with
physicians (use different modes of
communication) Monitor reengineered PSS service
delivery model; implement add’l
service quality indicators Maintain auth unit abandonment
rate; conduct in-dept survey re:
UM in high-volume offices Create disease management
committee; reinforce case/disease
management in all written
communication to providers;
evaluate/create models that include
incentives for physicians to
participate in CM/DM 65. Conduct the 2006
Practitioner Satisfaction
Survey
• analyze findings • develop IAP • implement
interventions • In process – final report due late
January/early February 2007



• • 66. Conduct annual
assessment of member
satisfaction with UM
processes and address
any areas of
dissatisfaction • Completed on time • Significant improvement with results related
to getting needed care. • None • Continue efforts to improve members satisfaction with UM
including analysis of interim
satisfaction surveys with
members. 67. Conduct annual
assessment of
practitioner satisfaction
with UM processes and • Completed on time • Findings and recommendations were
approved by the Clinical Quality &
Resource Management Committee on • None • None 19 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations address any areas of
dissatisfaction 6/1/06 • Physician satisfaction improved
significantly with timeliness of pre-cert
process (28%); eliminating the hassle factor
(12.8%); and Administration of PCP
referrals (13.7%) 68. Complete annual
review & update of the
pharmaceutical
management procedures
with approval by P&TC • In process – final report due late
January/early February 2007 • • 69. Distribute updated
policies and procedures
for pharmaceutical
management to
practitioners • Communicated in the Fall 2006 issue of
Provider press • Policies and procedures are no longer included in the Provider
Manual as a routine component. It
was decided that communication
via the newsletter with reference to
our website provided the
information. The 2006 formulary
(on the SummaCare website) also
identifies drugs subject to prior
auth, utilization management and
contact information. • The Catalyst/SummaCare
pharmacy website also has link for
physician information. 70. Conduct systematic
monitoring of Medicare
over & underutilization
and report findings to
CQRMC • analyze findings • develop IAP • implement
interventions • Completed on time • All measures fell within acceptable
thresholds. • Committee recommended adding
SummaCare’s results relative to
percentile performance. • Continue on annual basis Credentialing 20 H:\QM Program Eval 06 Exec Sum Master Final.doc Activity Outcome Limitations Recommendations 71. Conduct an audit of
credentialing files to
evaluate compliance
with standards for initial
credentialing
verification, application
& attestation, initial
sanction information,
and initial credentialing
site visits • A quality audit has been conducted on all
credentialing files prior to each SC CPR
Committee. • Very minor deficiencies were noted and
resolved prior to the SC CPR Committee
meetings. • All deficiencies were resolved
prior to submission to each SC
CPR Committee meeting. • Continued to conduct quality audits of all credentialing files
prior to each SC CPR Committee
meeting. 72. Annual report of
credentialing site visits
to CPRC & EQCC

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