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Accreditation

The National Committee for Quality Assurance (NCQA) is a private, non-profit organization dedicated to improving health care quality. Each year, NCQA rates health benefit organizations that voluntarily provide health care quality information using their Healthcare Effectiveness and Data Information Sets (HEDIS®*) and Consumer Assessment Healthcare Providers and System (CAHPS**) surveys.

Priority Health earned high ratings in 2015 and 2016

  • We earned 4.5 out of 5 stars by the National Committee for Quality Assurance (NCQA) for our Commercial HMO/POS plan.
  • We earned 4.5 out of 5 stars by the Centers for Medicare and Medicaid Services (CMS) for our Medicare Advantage HMO plan and 4 out of 5 stars for our Medicare Advantage PPO plan.
  • We earned 4.5 out of 5 stars for our Medicaid plan in Michigan and received the highest ranking in all five categories of the 2016 Medicaid Health Plan Consumer Guide by the Michigan Department of Health and Human Services. 
  • We earned 4 out of 5 stars by the Centers for Medicare and Medicaid Services (CMS) for our Marketplace HMO and PPO plans.
Our plans National ranking

Priority Health HMO/POS

Priority Health Medicaid

Priority Health Medicare HMO

4.5 out of 5 stars

Priority Health Medicare Advantage HMO

Priority Health Marketplace HMO

Priority Health Marketplace PPO

4 out of 5 stars
Priority Health PPO Marketplace POS 3 out of 5 stars

Changes in performance from 2014 to 2015

Accessible and timely services

Getting care where and when its needed

  • Statewide we maintained 90% availability of physicians (PCPs within 16 miles of each member in rural areas, 8 miles in urban settings).
  • We demonstrated 85% of timely access to routine and urgent care in all products.
  • We contracted with additional Community Mental Health organizations and initiated tele-psychiatry services to increase behavioral health services in low access geographical regions.

Safe care

Making health care safer for patients
  • Through our Medication Therapy Management Program, more than 22,000 Medicare members and 10,000 Commercial members received comprehensive medication reviews with retail pharmacists, reducing the risk of adverse effects from medications.
  • Through physician education, we've continued to reduce the use of high-risk medications in the elderly from 22% to 3% (2010-2015), earning a five star rating in this measure from CMS.
  • Our hospital incentive program continues to focus on reducing surgical site infections and other hospital acquired infections.
  • We have increased the number of members seeing a mental health provider within 7 days of a psychiatric inpatient discharge in order to reduce readmissions.
  • We continue to focus significant efforts on reducing avoidable hospital readmissions by providing care transition services.

Effective care

Help with avoiding, and managing, illnesses
  • We score at or near national 90th percentile in preventive care such as childhood and adolescent immunizations, cancer screenings, and measuring body mass index (BMI).
  • We score at or near national 90th percentile in diabetes care.
  • Our lower-performing preventive care measures include management of COPD, behavioral health (3 measures), and advising smokers to quit.
  • We improved chronic condition care through expansion of care management in physician practices.

Patient-centered care

Encouraging coordination and collaboration
  • We support and reimburse physician practices in developing care management programs that provide care transition/coordination support.
  • We participated in the Michigan Patient Experience of Care initiative and supported the increase in the number of practices conducting patient experience surveys.
  • Our home-based primary care initiative, which brings primary care and social services to high-risk elderly members at their homes, is showing a 64% reduction in acute care events.
  • Our new online Cost Estimator tool is now showing comparative costs to members for more than 300 X-rays, MRIs, surgeries and other services.

Efficient care

Keeping high-quality affordable
We continue to distribute comparative reports to accountable care networks and physician organizations on:
  • Total cost of care
  • Cost and utilization of services
  • Variation in practices in efficiency for specialties such as orthopedic, cardiovascular and gastroenterology services
  • Variation in preference-sensitive procedures between physician groups

Service quality

Responding to our customers
       
  • Our Medicare HMO product earned 5 out of 5 stars by CMS in customer service.

Wellness & health promotion

Helping employers improve health and lower costs
  • We support wellness through employer-based programs that engage employees various wellness programs, health coaching, biometric screening and managing chronic conditions. We strive to improve the overall health and quality of life of our members.

Strategic quality focus for 2016

  • Improve care outcomes in diabetes, cardiovascular and behavioral health through innovation in care delivery and engagement of members.
  • Engage with accountable care networks and physician organizations to add or strengthen care management at the point of care, and expand Advance Medical Homes that offer pharmacy, behavioral health and primary care at the same point-of-service.
  • Expand services that engage members through web and mobile applications.
  • Expand services delivered through e-visits, virtual visits and telephone visits for both medical and behavioral health care.

*HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

**CAHPS is a registered trademark of the Agency for Healthcare Research and Quality.

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