At Health Alliance Medical Plans, Inc. we share your concerns about health care safety. As a health insurance company we include patient safety in our quality programs because we want the hospitals and physicians in our health plans to make safety an important part of how they care for our members. In the table below you will see some of the things Health Alliance does to improve the safety of the care our members receive.
| Safety Activity |
Explanation |
Do we see improvement? |
Data Analysis |
| Maintain accreditation by the National Committee for Quality Assurance (NCQA) |
Every three years Health Alliance participates in an accreditation process by the NCQA. Participation includes a site visit from the NCQA survey team as well as submission of detailed information to the Washington DC headquarters. Auditors review how we do our daily processes as a health plan and how we improve the care our members receive. We have been reviewed by the NCQA every three years since 1995. |
Health Alliance is an excellent rated health plan reaching the highest level set by the NCQA. We have achieved the excellent rating since 1995. To find out more about NCQA, visit www.ncqa.org |
Every three years during the Health Alliance Medical Plan NCQA onsite review of the standards, a report is submitted prior to the onsite that answers questions from the NCQA about:
- Access and Service- can our members get the care they need
- Qualified providers- how do we assess doctor's qualifications
- Staying Healthy- how well do we help members prevent illness and stay healthy
- Getting Better- how well do provide care for our members who get sick
- Living with Illness-how well do we help our members with chronic illness
The final decision about our NCQA rating is made by the NCQA Review Oversight Committee. The committee is made up of physicians outside our network of physicians. These physicians are often medical directors or chief medical officers for other health insurance plans. |
| Submit data about the health care our members receive annually for the Health Employer Data Information Set (HEDIS) |
Part of the NCQA accreditation is participation in HEDIS. HEDIS measures health plan performance in areas such as heart disease, preventive health and diabetes. |
Our HEDIS scores are part of our NCQA rating as an excellent health plan. Our methods for gathering HEDIS data are audited by an outside auditor approved by the NCQA. In many areas our HEDIS scores meet or exceed national goals. |
The Quality and Medical Management department uses HEDIS specifications issued each year by the NCQA. Health Alliance annually uses a certified product to collect HEDIS data. Results are audited by a certified auditor prior to submission to NCQA. |
| Reduce medication errors at the pharmacies our members use |
Contract with pharmacies that use electronic warning systems to alert the pharmacist about drugs with potential harmful interactions. |
The standard of care in the pharmacy industry is to operate and maintain electronic warning systems at the point of service. |
The Pharmacy Director ensures that pharmacies operate at standards accepted in the drug industry. |
| Reduce the risk of side effects and harmful drug interactions |
An electronic system is in place through the company that manages our pharmacy benefits and our contracted pharmacies. The system alerts a pharmacist when there is a potential for drug-drug interaction. |
Primary Care Providers receive a quarterly report of members prescribed a high number of maintenance medications. A Clinical Pharmacist reviews the reports and consults with prescribers regarding appropriate recommendations. |
A quarterly utilization report from the pharmacy benefit management company monitors poly pharmacy. Health Alliance pharmacists review the reports and generates appropriate alerts regarding recommended actions. |
| Investigate member complaints about quality of care | Review each complaint through a confidential peer review process |
Each year we review all complaints to see if there are any trends. If a trend is found, we take the information to the Peer Review Committee for advice and direction. Checking the credentials of physicians who are contracted with us includes checking for medical quality of care complaints. |
The medical management and credentialing databases are used to monitor and track complaints and credentials. |
| Client Provider Services staff perform site visits upon initial contract with Health Alliance and periodically to make sure the physical environment is safe |
Following the visit, send the provider a report and list any improvements that need to be made. Ask for a plan, which includes a completion date. |
Site visits are triggered for a number of reasons including member complaints, If a member registers a complaint about the physical environment of a provider office, staff performs a site visit. If the visit score does not reach the acceptable threshold another site visit is conducted. |
Results of provider site visits are monitored and stored in the provider’s credentialing file. |
| Review medical records at provider offices to make sure that documentation follows recommendations by the public health department of the state and external regulatory agencies. |
Registered nurses and other trained health care staff review medical records using a special survey tool. Based on the results of the survey, the provider may be required to submit an action plan for improvement(s). |
Providers are asked to make the changes by a certain date, usually six months from the date of the review.
If there are safety concerns that cannot wait, the provider is contacted personally until the improvements are made.
The Health Alliance Quality Improvement Committee (QIC) oversees this process. The committee can set limits on the provider if necessary. For example, the committee can limit the number of members the provider sees. |
Ambulatory review results are scanned electronically so aggregate data can be tracked and trended as well as individual provider data. |
| Disease management programs provide members with chronic disease, i.e. diabetes, asthma, and high-risk pregnancies education and an expert resource within the health plan
who can assist with improvement of quality of life and long-term health. |
Health Alliance develops newsletters and other educational information to our members. We offer special incentives to encourage members to take the steps they need to stay healthier.
Registered nurses contact the members by phone to work with the members and their physicians to improve health.
Members with diabetes receive a mailing called everyDay three times each year. They also receive helpful information when they enroll in the program.
Through these mailings members teach how to prevent long-term complications from the disease. Nurse case managers contact some members who may not be in control of their diabetes. The nurses contact the physician to discuss ways to help the patient including proper use of medications. The nurses screen for depression as well since people with a chronic illness can become depressed.
Adults with asthma receive mailings for services received in relation asthma care. Adolescents with asthma receive Asthmazine, a newsletter focusing on asthma education. These mailings contain tips to control asthma and prevent emergencies when an asthma attack can become a life or death situation.
Women who agree to enroll in our program called Special Delivery get three phone calls from a registered nurse during the first trimester. If the nurse can, with the member's permission, talk to the physician in case any problems come up.
Members who have had an acute myocardial infarction (AMI or heart attack) receive a mailing when they get home from the hospital. In the mailing we remind them about healthy life style changes. We also include information about depression since some people become depressed after an AMI. |
Diabetes: Annually, during HEDIS we measure how many of our members with diabetes are being monitored by their primary care physicians for
- Blood glucose (Glycohemoglobin)
- Cholesterol (lipids)
- Kidney function (nephropathy)
- Retina health (dilated eye exams)
The results are shared with the physicians each year so they can see how well they are doing at caring for their members.
Asthma: Each quarter we monitor the use of medications. High use of certain medications may mean that asthma control is poor. Physicians receive an alert from us with recommendations based on expert guidelines so they can call their patients and make medication adjustments.
Women who are pregnant and turn out to be at risk for complications are referred to nurse case managers for follow up. Annually we look at reports that tell us how many mothers had complications and how many babies were born prematurely. We also receive reports from Special Delivery. Based on this information we can decide if we need to make any improvements in our program.
We measure how many of our members with AMIs are discharged home on the medications that will help them avoid another AMI and live longer, healthier lives. |
Annually the QIC reviews the HEDIS results to assess effectiveness of the interventions. Upon identification of care gaps, additional interventions are planned and implemented |
| The Director of Quality and Medical Management oversees safety initiatives |
The Director is responsible for quality management and improvement at Health Alliance. These responsibilities include oversight for initiatives that impact patient safety. |
The Director presents an annual program, plan and evaluation to the Quality Improvement Committee (QIC) and the Board of Directors for Health Alliance. These committees review the program, plan and evaluation. On a monthly basis the QIC reviews and discusses all quality improvement activities within the scope of the program. |
NCQA reviews committee minutes and written copies of the program, plan and evaluation during site visits. |
| Health Alliance provides access to evidence based clinical guidelines and preventive health guidelines. |
Health Alliance promotes the use of the Institute for Clinical Systems Improvement (ICSI) and the United States Preventive Services Task Force (USPSTF). Additional disease specific guidelines are promoted, including ADA for Diabetes, JNC-VII for Hypertension and Gold Standards for COPD. |
Guidelines are reviewed every two years by the QIC to ensure the guidelines utilized are the most up-to-date. |
HEDIS rates may reflect the practice patterns of physicians. Physicians who refer to nationally accepted guidelines could improve the care patients receive. Improvement in care leads to improved patient safety. |