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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 NCQA national rating and accreditation status

Priority Health plans 2016 NCQA rating Accreditation status

Commercial group HMO/POS

4 out of 5  Commendable

Commercial group PPO

3.5 out of 5 Accredited
QHP/Marketplace MyPriority® HMO No rating program Accredited
QHP/Marketplace MyPriority® POS
No rating program Accredited
Medicaid  4 out of 5 Excellent
Medicare Advantage HMO/POS 4 out of 5 Commendable
Medicare Advantage PPO  3.5 out of 5 Commendable

Summary of our quality performance for 2016

Accessible and timely services

Getting care where and when it's needed

  • Statewide we maintained 95% availability of physicians (PCPs within 30 miles of each member in rural areas, 15 miles in urban settings).
  • We demonstrated 85% of timely access to urgent and after-hours care in all products.
  • We continue to inform members that they can access care through virtual (phone and computer) visits.
  • 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 16,000 Medicare members and more than 22,000 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 4% (2010-2016).
  • 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 and asthma care.
  • Our lower-performing preventive care measures include management of COPD, behavioral health (3 measures), and advising smokers to quit.
  • We keep improving 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.
  • Our home-based primary care initiative, which brings primary care and social services to high-risk elderly members at their homes, continues to reduce acute care events.
  • Our online Cost Estimator tool shows comparative costs to members for hundreds of procedures and services such as X-rays, MRIs, lab tests and surgeries.

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
       
  • We've evaluated multiple member satisfaction surveys to identify and prioritize opportunities for improvement.

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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