Overtreated? Medical evidence, quality care
Priority Health is committed to partnering with physicians to provide accountable care that optimizes clinical outcomes and ensures the best experience while eliminating avoidable costs. This includes a series of initiatives that focus on pursuing the best practices through enhanced transparency and comparative effectiveness.
Changes based on quality benchmarks
We are benchmarking the quality of care against national use rates, with a special emphasis on our Healthcare Effectiveness Data and Information Set (HEDIS) measures as established by the National Committee for Quality Assurance.
Our findings
In comparison with national use rates, Priority Health members have disproportionately higher use rates for many significant preference-sensitive procedures. Furthermore, we have observed significant variations in treatment between various counties and regions across Michigan.
Effective July 1, 2011, we’ll be adding prior authorization requirements for the procedures listed below for members in our commercial and Medicaid plans:
- Back surgery
- C-section, elective
- Colonoscopy
- EGD
- Hysterectomy, abdominal
- Hysterectomy, vaginal
- Knee arthroscopy
- Laproscopic cholecystectomy
- Myringotomy
- Tonsillectomy
We are developing condition-specific quality criteria based on input from our network physicians, and we’ll send updated policies and guidelines to affected specialists early this summer.
We’re engaging your patients
Studies have shown that patients who fully understand their options are more likely to choose conservative treatments. With this in mind:
- We’ll encourage PCPs to help patients explore all treatment options before sending them for a surgical consult.
- We’ll be providing information and tools to educate members about these preference-sensitive treatments and help them make informed decisions.
- We’ll increase our emphasis on condition management to encourage more accountability by individual patients.
Topics: Condition management, Preventive care
