Quality Improvement Interview: Fallon Community Health Plan

Fallon Community Health Plan has established itself at the top of the charts for the past three years on the Centers for Medicare and Medicaid Services’ Medicare Advantage Star Ratings.  This year, the plan once again received 4.5 stars, an indicator of its commitment to – and success at – providing high quality health care to its members.

We spoke with Beth Foley, senior director of Quality Services at Fallon, about the health plan’s performance, including its strengths, areas of improvement and measures on which it is focusing.

Because of the plan’s history as an integrated staff model, in which preventive medicine is integral to patient care, Fallon has traditionally done very well on preventive and screening measures. A substantial portion of the health plan’s Medicare membership is seen by a provider network with which Fallon has a close working relationship.

It is due in part to this connection, along with a robust electronic medical record, that screening and preventive measures have remained a particular strength of Fallon’s. As Foley says, it is second nature to make sure members are getting their screenings. “That’s what we’re all about.”

Fallon also performed highly on the Care for Older Adults measure of the Star Ratings, pertaining to Medicare Advantage Special Needs Plan (SNP) enrollees (vulnerable populations who include dual-eligibles and those with chronic conditions). Foley attributes the plan’s significant improvement to supplemental data sources, more vigorous outreach to physicians and better documentation of medications and functional status assessments.

Fallon’s quality in this area is particularly significant to their members, as most of its members are in their 80s and 90s.

One of the most valuable aspects to the Star Ratings is the ability to benchmark data and set goals for improvement. There are always areas in which plans can improve, and the quality data facilitates these efforts. Currently, Fallon is focusing on the readmissions measure, which needs to be at 5 percent to receive top marks.

The plan is looking to bring the “navigator model,” used for its SNP NaviCare, into their general Medicare Advantage plan.

NaviCare, as Foley explains, is a highly successful care model that employs a comprehensive care team to look after patients. She expects that this will help to coordinate care, resulting in better medication adherence, better health outcomes and fewer readmissions.

Because of the ability to see how current performance stacks up against prior performance – as well as the ratings of other organizations – Fallon is able to set informed, attainable goals and focus on achieving them.

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New Report: NCQA State of Health Care Quality 2012

Earlier this week, the National Committee for Quality Assurance released its annual State of Health Care Quality Report for 2012.

The report synthesizes quality data collected by the Healthcare Effectiveness Data Set (HEDIS®), one of the industry’s most widely-used performance improvement tools, according to NCQA’s press release.

The report finds that clinicians are placing increased emphasis on health and wellness promotion, and particularly on fighting obesity. The Adult Body Mass Index Assessment – a HEDIS® measure released in 2009 – was the most improved measure in 2012 of more than 40 quality measures.

The greatest gains were seen among Medicare plans, with an increase of 18 percentage points for HMOs and almost 26 percentage points for PPOs.

Medicare Advantage plans also had larger overall improvements than commercial or Medicaid plans, the report found.

View the entire report for a summary of significant changes in HEDIS® and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures, as well as an overall assessment of health plan performance on each HEDIS® measure.

Prevention Strategies: The Latest on Obesity

The Organisation for Economic Co-operation and Development (OECD) released a report in February analyzing the latest trends in obesity internationally, with grim (albeit unsurprising) results: the United States is officially the fattest country of all OECD member countries. U.S. childhood obesity rates are higher than any other country in the OECD – 40 percent of American children are overweight. That’s over one in three kids. And for adults, the prognosis is far, far worse: the OECD projects that based on current rates, by 2020, 75 percent of U.S. adults will be overweight or obese.  That is a staggering three out of four adults.

Let’s take a moment to consider that statistic and its significance. Independent research demonstrates that ailments associated with obesity are a prime factor in skyrocketing health care costs. Health expenditures for people whose weight falls into the “obese” category are, on average, 25% higher than for others. With this knowledge, it’s not hard to see how some predictions estimate that by 2018, the price of health care for all obesity-related ailments in the U.S. will be $344 billion.

While the statistics and research confirm that obesity is indeed a public health crisis, there are a heartening number of initiatives, campaigns, and programs aimed at addressing the challenges of reducing obesity. Ideally, we should aim at preventing obesity-related health problems in the first place, by addressing the problem early on – that is, by tackling childhood obesity.  Effectively reducing pediatric obesity requires a multi-faceted approach: one that incorporates comprehensive strategies involving communities, health care providers, and individuals.

ACHP organizations, as community-based nonprofit providers, are acutely aware of the necessity of building and maintaining healthy lifestyles from an early age, in order to prevent pediatric obesity. Over the past several years, ACHP plans have developed dozens of innovative, local programs that support healthy and active lifestyles. These initiatives integrate a variety of resources and approaches, including research-driven pilot projects, community engagement events, and clinical programs developed collaboratively with providers.

UCare in Minnesota, along with Group Health Cooperative Seattle, Group Health Cooperative of South Central Wisconsin, CareOregon, and many other health plans have developed programs designed to increase the accessibility of healthy food to children and educate them on nutrition and portion size. HEALTHY Armstrong (Healthy Eating Active Lifestyles Together Helping Youth),  a partnership between the  University of Pittsburgh Medical Center Health Plan and community organizations, focuses on educating children and their families  through these community partnerships. This highly collaborative model utilizes principles of a program developed by the National Institutes of Health, and was recognized in the Health Communities Act of 2009 as a model for community organizations to emulate.

Other ACHP member plans have initiatives focused on engaging parents and families, such as Kaiser Permanente Georgia’s Operation Zero (OZ), a family-based program that involves dieticians and fitness specialists. OZ incorporates rubrics of progress in order to help set goals and keep track of improvements. Minnesota’s HealthPartners FiiT Kids Program is a collaboration with providers, initiated through pediatrician referrals, and encourages the entire family to participate in healthy behaviors. 5210 Screening, a program developed by Martin’s Point Healthcare in Portland, Maine, screens members in a clinical setting, in order to help pediatricians and parents make more informed decisions regarding a child’s health.

While the issue of pediatric obesity increasingly garners national recognition as a critical problem demanding immediate attention, it is up to all of us – communities, providers, and families – to look for effective solutions and preventive measures. ACHP member plans take this responsibility to heart; they are, after all, an integral part of their communities. Their comprehensive approaches offer inspiration on how health plans can play a prominent role in public health. In order to foster systemic change and to slow (and perhaps even reverse) the alarming trends in obesity, we all need to be invested in the health of our communities. And with so many local and engaged health plans focused on exactly that, the outlook may not be quite so grim.