Quality Improvement

Purpose

Your care means a lot to us. The purpose of the CareSource Medicare Advantage Quality Improvement program is to ensure that CareSource has the necessary infrastructure to:

  • Coordinate care
  • Promote quality
  • Ensure performance and efficiency on an ongoing basis
  • Improve the quality and safety of clinical care and services provided to Medicare Advantage members

There are two guiding tenants for the program: 

  • Our mission, which is our heartbeat, is to make a lasting difference in our members’ lives by improving their health and well-being. Our vision is to transform lives through innovative health and life services.
  • The Institutes for Healthcare Improvement’s Triple Aim:  Simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and the per capita cost of care for the benefit of communities.

The Medicare Advantage Quality Improvement program includes both clinical and non-clinical services and is revised as needed to remain responsive to member needs, provider feedback, standards of care and business needs. 

Goals and Objectives

CareSource Medicare Advantage strives to be a top performing health plan nationally. Performance goals are determined and aligned with national benchmarks where available.

The goals and objectives of the program are:

  • National Committee for Quality Assurance (NCQA)Excellent Accreditation
    • Compliance with NCQA accreditation standards
    • High level of Healthcare Effectiveness Data and Information Set (HEDIS®) performance
    • High level of Medicare Consumer Assessment of Healthcare Providers and Systems (Medicare CAHPS®) performance
    • Comprehensive population health management program
    • Comprehensive provider engagement program
  • 5-Star NCQA Health Plan Rating
    • High level of HEDIS performance
    • High level of Medicare CAHPS performance
    • Comprehensive population health management program
    • Comprehensive provider engagement program
  • Medicare Advantage 5-Star Health Plan
    • High level of HEDIS performance
    • High level of Medicare CAHPS performance
    • Comprehensive population health management program
    • Comprehensive provider engagement program

Scope

The Medicare Advantage Quality Improvement program governs the quality assessment and improvement activities for the CareSource Medicare Advantage plans. The scope includes:

  • Meeting the quality requirements of the Centers for Medicare and Medicaid Services (CMS) as outlined in the CMS’s Medicare Managed Care Manual, Chapter 5, Quality Assessment; and 42 CFR§422.152
  • Establishing safe clinical practices throughout the network of providers
  • Providing quality oversight of all clinical services
  • Compliance with NCQA accreditation standards
  • HEDIS compliance audit and performance measurement
  • Monitoring and evaluation of member and provider satisfaction
  • Managing all quality of care and quality of service complaints
  • Developing organizational competency of the Plan Do Study Act (PDSA) improvement methodology
  • Ensuring that CareSource Medicare Advantage is effectively serving culturally and linguistically diverse members
  • Ensuring that CareSource Medicare Advantage is effectively serving members with complex health needs
  • Assessing the characteristics and needs of the member population
  • Assessing the geographic availability and accessibility of primary and specialty care providers

The quality program is overseen by the Chief Clinical Officer in conjunction with the Enterprise and Ohio Medical Directors, and implementation is facilitated by the Senior Vice President, Quality and Population Outcomes. On an annual basis, CareSource makes information available about its Quality program to providers on the web. CareSource gathers and uses provider performance data to improve quality of services.

Quality Metrics

CareSource monitors member quality of care, health outcomes and satisfaction through the collection, analysis and annual review of HEDIS, the Health Outcomes Survey (HOS) and Medicare CAHPS. The Medicare HEDIS, HOS, and Medicare CAHPS survey results form the basis for the CMS Star Ratings used to evaluate the quality of care provided to CareSource Medicare Advantage members.

CMS uses a five-star quality rating system to measure Medicare beneficiaries’ experience with their health plan and the health care system. Star Ratings are based on measures of the health plan’s rating across five categories:

  • Staying healthy (screenings, tests and vaccines): Includes whether members got various screening tests, vaccines and other checkups that help them stay healthy.
  • Managing chronic (long-term) conditions: Includes how often members with different conditions got certain tests and treatments that help them manage their condition.
  • Member experience with the health plan: Includes ratings of member satisfaction with the plan.
  • Member complaints and changes in the health plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Health plan customer service: Includes how well the plan handles member appeals.

For health plans covering drug services, the overall score for quality of those services covers many different topics that fall into four categories:

Drug plan customer service: Includes how well the plan handles member appeals.

  • Member complaints and changes in the drug plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Member experience with plan’s drug services: Includes ratings of member satisfaction with the plan.
  • Drug safety and accuracy of drug pricing: Includes how accurate the plan’s pricing information is and how often members with certain medical conditions are prescribed drugs in a way that is safer and clinically recommended for their condition.

Providers can use tools available via the CareSource Provider Portal to look up services and tests needed and historical medical and pharmacy data.

Clinical and Preventive Guidelines

CareSource approves and adopts nationally accepted standards and guidelines and promotes them to practitioners and members to help inform and guide clinical care provided to CareSource Medicare Advantage members. Guidelines are reviewed at least every two years or more often as appropriate, and updated as necessary. The use of these guidelines allows CareSource to measure the impact of the guidelines on outcomes of care. Review and acceptance of the guidelines are completed by the CareSource Clinical Advisory Committee (CAC) every two years or more often as appropriate. The guidelines are then presented to the CareSource Quality Enterprise Committee for approval. Topics for guidelines are identified through analysis of Medicare Advantage members. Guidelines may include, but are not limited to:

  • Behavioral health (e.g., depression)
  • Adult health (e.g., hypertension, diabetes, cardiovascular disease, cerebrovascular disease and chronic obstructive pulmonary disease)
  • Population health (e.g., obesity, tobacco cessation)

Information about clinical practice guidelines and health information are made available to CareSource Medicare Advantage members via member newsletters, the CareSource member website, or upon request.  Clinical & Preventive Guidelines and Health Links are available to members and providers on the website or on paper.

If you would like more information on CareSource Quality Improvement, please call Member Services at 1-844-607-2827 (TTY: 1-800-750-0750 or 711). Our hours are 8 a.m. to 8 p.m. EST, seven days a week from October 1 to March 31, and Monday through Friday the rest of the year.

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 (AHRQ)

CareSource is an HMO with a Medicare contract. Enrollment in CareSource Advantage® Zero Premium (HMO), CareSource Advantage® (HMO) and CareSource Advantage Plus® (HMO) depends on contract renewal.



Y0119_OHMA-M-0251 Accepted

Updated 07/03/2019