EmblemHealth uses a variety of data sources and software to measure quality improvement processes and outcomes, determine and overcome barriers to improvement, and identify ways to improve quality. Data sources include, but are not limited to:
- Applicable case management and disease management
- Behavioral health
- Epidemiological, demographic, and census about EmblemHealth’s membership
- Grievance and appeals
- HEDIS®/QARR (Quality Assurance Reporting Requirements)
- Medical records
- Member and provider surveys, including but not limited to CAHPS®1 Access and Availability surveys, and Health Outcomes Survey
- National and regional benchmarks from sources such as Quality Compass® and NCQA accreditation
- Population-based member information
- Quality improvement projects/studies
- Telephone response
- Utilization review
EmblemHealth uses standard measures of clinical quality and customer experience to allow individuals to compare health plans and make informed choices when choosing a health plan for themselves and their family members. EmblemHealth uses the following key measure sets:
- Healthcare Effectiveness Data and Information Set (HEDIS®)
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
- Health Outcomes Survey (HOS)
HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS®)
We use HEDIS® to measure clinical quality and customer service performance. HEDIS® is coordinated and administered by the NCQA and used by CMS for monitoring the performance of managed care organizations.
Each year between January and May, all NCQA-accredited managed care organizations like EmblemHealth perform HEDIS® reviews. It is a retrospective review of services and performance of care for the year prior. Data is collected either through claims (administrative), medical record collection and claims (hybrid), or surveys.
As an EmblemHealth provider-practitioner, you play a critical role in HEDIS® by promoting the health of our members and providing the appropriate care within the appropriate time frames. You can contribute to EmblemHealth’s goal of improving the health outcomes of EmblemHealth members by:
- Ensuring members receive their routine preventive services and screenings.
- Helping members manage chronic conditions such as arthritis, high blood pressure, and diabetes.
- Prescribing safe medications and only when necessary.
- Ensuring patients are continually taking their medications, especially those with chronic diseases.
- Coordinating patient care.
- Providing accurate coding on a claim, which is essential for EmblemHealth to continuously work on improving members’ care and services and may also reduce the number of records requested by EmblemHealth during the medical record collection phase of HEDIS®.
CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (CAHPS®) AND ENROLLEE SATISFACTION SURVEY (ESS)
EmblemHealth uses the CAHPS® and Enrollee Satisfaction Survey (ESS) to learn about our members’ experiences with their health care, i.e., health plan, providers, and specialists. CAHPS® and ESS also focus on factors such as getting care easily and quickly, the quality of care provided to them by their primary care doctor or specialist, and overall service quality including customer service and claims.
EmblemHealth encourages providers to help improve member satisfaction. You should:
- Schedule member appointments within the time frames listed in our Appointment Availability Standards During Office Hours & After Office Hours Access Standards.
- Speak with members during each visit about their preventive health care needs and disease management goals.
- Allow time during the appointment to be sure members understand their health conditions and the services required for maintaining a healthy lifestyle.
- Answer any questions members have regarding newly prescribed medications.
- Ensure members know to bring all medications and medical histories to their specialists and understand the purpose of a specialist referral.
HEALTH OUTCOMES SURVEY (HOS)
EmblemHealth uses the Medicare HOS for signs of how well EmblemHealth manages the physical and mental health of its Medicare members. Members who receive the HOS are asked to respond to questions that reflect their physical and mental health perception. The same members are re-surveyed two years later. HOS results are used by CMS to judge EmblemHealth’s ability to maintain or improve the physical and mental health of our members.
1 CAHPS is a program of the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.