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Quality Management & Improvement Efforts

Quality Improvement Strategy

We are working hard to improve the service, quality and safety of health care. One way we do this is by measuring how well we and others are doing.

We work with groups of doctors and other health professionals to make health care better.

Our clinical activities and programs are based on proven guidelines.

We give you and your doctors information and tools that may help you make decisions.

Program Goals

We aim to:

  • Meet the members’ health care needs
  • Measure, monitor and improve clinical care and quality of service
  • Institute company-wide initiatives to improve the safety of our members and communities
  • Make sure we obey all the rules, whether they come from plan sponsors, federal and state regulators, or accrediting groups

Program Scope

We work to make your health care better by:

  • Developing policies and procedures that reflect current standards of clinical practice
  • Reviewing preventive and behavioral health services, and how care is coordinated
  • Addressing racial and ethnic disparities in health care
  • Monitoring the effectiveness of our programs
  • Studying the accessibility and availability of our network providers
  • Monitoring the overuse and underuse of services for our Medicare members
  • Performing credentialing and recredentialing activities
  • Assessing member and provider satisfaction

Program outcomes

Each year, we check to see how close we are to meeting our goals. Here's what we did in 2016:

  • We collected data on a set of clinical measures called the Healthcare Effectiveness Data and Information Set (HEDIS®*), as applicable. We shared the results with the National Committee for Quality Assurance (NCQA) Quality Compass®.** The NCQA makes the results public. Each year, we use the results to set new goals and improve selected measures. As a result, performance has improved on many measures.
  • We asked members and providers how satisfied they are with Aetna. To improve satisfaction, we:
    • Enhanced the Aetna.com website and online tools
    • Improved the accuracy of our provider directory information 
    • Improved online self-service options for providers
  • We surveyed members in the Aetna Case Management program. They told us that the program has helped them meet their health care needs.1
  • We surveyed members in the Aetna Disease Management program. They told us that the program provided valuable information they would not otherwise have known, and helped them understand the importance of getting the recommended exams and/or blood tests for their specific conditions.2
  • We also:
    • Improved our patient safety program to help our members make informed health choices
    • Continued using social media for patient safety communications to our members
    • Provided information to physicians on patient safety in the ambulatory setting
    • Provided information on our Hospital Comparison Tool to help members make more informed decisions when selecting a hospital

Your behavioral health needs are important to us

Last year we took several steps to address the dramatic rise in opioid addiction - to pain killers and to illegal drugs such as heroin.  To help avoid addiction, we increased communications to our providers to encourage alternatives to opioids for treating pain. We also asked providers to follow prescription practices that help to avoid opioid dependence.  If dependence has already developed and is identified during a case review, our clinicians perform a risk assessment. Members and providers are urged to consider naloxone as a rescue medication in the event of an opioid overdose. 

Additional program improvements in 2016 include:

  • An improvement in the way we identify members with extensive behavioral health needs to increase the effectiveness of our program
  • Activities to help members with autism spectrum disorder
  • Follow-up care for children prescribed ADHD medications
  • Introducing three new videos in our ‘It Only Takes a Minute’ series on YouTube. The videos raised awareness and reduced stigma related to addiction, suicide and self-esteem

Accreditation

We take our accreditation by the NCQA seriously. It's how we show our commitment to improving your quality of care, access to care and member satisfaction.

*HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
**Quality Compass is a registered trademark of NCQA.
1Based on results from the 2016 Aetna Case Management Member Satisfaction Analysis.
2Based on results from the 2016 Aetna Disease Management Member Satisfaction Analysis.

Disclaimers

Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. 

Participating physicians, hospitals and other health care providers are independent contractors. They're neither agents nor employees of Coventry. The availability of any particular provider can't be guaranteed. Provider network make-up is subject to change. 

Aetna Medicare’s pharmacy network offers limited access to pharmacies with preferred cost sharing in: Suburban NY; and Rural AR, NY, and UT. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use.

For up-to-date information about our network pharmacies, including pharmacies with preferred cost sharing, members please call the number on your ID card, non-members please call 1-855-338-7027 (TTY: 711) or consult the online pharmacy directory at http://www.aetnamedicare.com/pharmacyhelp.


       Y0001_4006_10830 Pending
       Page last updated: Sun Oct 01 01:52:26 EDT 2017

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