Scope of the program

1. Aspects of care and service will be reviewed at least annually to assure relevance to the QI plan that include, but are not limited to:
1. High volume, high cost, and high risk member healthcare activity
2. Demographic or disease trends
3. Utilization trends
4. Performance against national or regional benchmarks
5. Expectations of regulators or purchasers
6. Evidence-based medical literature findings
7. Problematic trends
2. Priority Health's Quality Improvement Program is comprehensive in nature to include measurement indicators and improvement activities for:
1. Clinical and service activities
2. Members and practitioner/providers
3. A variety of product lines (Commercial, Medicaid, Medicare)
4. All age ranges
5. Acute and chronic conditions
6. Healthcare services provided across the health care continuum including primary care, specialty care, behavioral health care, hospital facilities, and ancillary services.
3. Priority Health's Quality Improvement Program indicators and measures include, but are not limited to:
1. Availability of healthcare services
1. Primary care and specialty care practitioners, including behavioral health
2. Accessibility to healthcare services
1. Appointment scheduling and after-hours care
2. Telephone responsiveness
3. Member satisfaction with accessibility
3. Complaints, grievances, and appeals
1. Member, practitioner, provider, and employer complaints, and subsequent grievances and appeals.
4. Customer satisfaction
1. Member (including CAHPS) and practitioner satisfaction.
5. Disease management program effectiveness
6. Compliance to clinical practice guidelines
7. Continuity and coordination of care between practitioners and/or providers including medical and behavioral health
8. Clinical topics (including HEDIS®)
1. Preventive services including immunizations, cancer screenings, sexually transmitted disease, smoking cessation, and well child and adolescent exams
2. Obstetrical care, including prenatal care in the first trimester and check-ups after delivery
3. Cardiovascular risk reduction and treatment including beta-blocker treatment after a heart attack, hyperlipidemia and hypertension management, cholesterol management, and congestive heart failure
4. Comprehensive diabetes and asthma care
5. Behavioral health care including follow-up after hospitalization for mental illness, depression management and alcohol and substance abuse disorders
9. Patient safety
1. Leapfrog initiatives including computerized physician order entry of pharmacy prescriptions, ICU Intensivists, and evidence-based procedure referrals
2. National Quality Forum (NQF) indicators
3. Institute for Safe Medication Practices (ISMP) indicators
4. Practitioner office compliance to OSHA requirements
5. Pharmacy initiatives including management of poly-pharmacy, potential drug-to-drug interactions and notification of FDA required or voluntary drug withdrawals
10. Individual occurrences of inpatient and ambulatory quality events including member deaths
11. Practitioner office site visit and medical record keeping inspections
12. Pharmacy measurement and monitoring activities
13. Operational performance including claims processing, telephone responsiveness and other customer service indicators
4. Priority Health takes affirmative efforts to overcome discrimination and disparity in healthcare by the collection and analysis of race and ethnicity data, and implementation of activities to improve the quality of healthcare delivered.
5. Compliance with National Committee for Quality Assurance (NCQA) Standards.
6. Compliance with Michigan Department of Community Health (MDCH), Michigan Office of Financial & Insurance Regulation (OFIR), and Centers for Medicare and Medicaid Services (CMS) regulations and reporting requirements.
7. Compliance with federal confidentiality regulations and requirements (HIPAA).