Freedom Health is an organization committed to improving the health status of enrollees and promoting healthy lifestyles. Through implementation of this Quality Management Program, Freedom Health Care establishes the goals and structure to support this commitment.
Description:
The Quality Management Program, established at the direction of the Board of Directors of Freedom Health, the governing body, is designed to promote quality care and service excellence for Freedom Health enrollees. The Program is based on the quality principle that performance improvement results from ongoing and systematic measurement, intervention, and follow-up of key clinical and non-clinical aspects of care. Primary responsibility for administration of the Program is vested in the Medical Director and quality committees; however, all employees share in the responsibility to define and implement improvements in processes that enhance clinical efficiency, provide effective utilization and focus on improved outcome management achieving the highest level of success.
Goals:
The overall goal of the Quality Management Program is to achieve quality care and services for Freedom Health enrollees thorough the design, implementation and ongoing improvement of organizational systems.
The Program includes the use of performance data available through standardized measures, including State and national information; including performance measures, benchmarks and root cause analyses that relate measuring outcomes and identifying opportunities for improvement. Analytical resources are available through Quality Management staffing and on basis through the employment of project-specific consultants. Staff have access to end-user data-systems for claims/encounter data, enrollment and UM data; grievance and administrative services to provide information for performance measures and quality improvement activities.
Performance Indicators
A major focus of the Quality Management Program is the establishment of clinical improvement initiatives involving quality improvement projects, focus studies, and interventions designed to improve selected HEDIS and other performance measures. Freedom Health will be undergoing measurement of our baseline HEDIS report; for care rendered in 2006. Once available, audited information relevant to Freedom Health’s baseline HEDIS project will be published through the following sources; newsletters, website, Choosing A Quality Health Plan: Florida HMO Report; published annually by the Agency For Healthcare Administration and the www.medicare.gov website.
Guidelines & Standards
Medical care management activities are an important component of the Program, and key elements include practice guidelines and standards, over and under utilization monitoring, use of review criteria, and clinical peer review of medical appropriateness.
Availability:
The QM Program is available, upon request, to Freedom Health providers and members.
HEDIS link
What is HEDIS?
Health Plan Employer Data & Information Set (HEDIS) is the most extensively used set of standardized performance measures in the managed care industry. HEDIS is used by over ninety percent of the country’s managed care organizations, including Freedom Health, Inc. The National Committee Quality Assurance (NCQA) created HEDIS to assist employers’ and consumers needs as purchasers of health care. HEDIS is designed to accommodate comparative reporting; it allows reliable comparison of managed health care plans based on the documented care given by providers.
Scope:
Areas of care addressed by HEDIS are related to significant public health issues such as cancer, depression, breast cancer, heart disease, glaucoma, hypertension and diabetes. HEDIS contains over 60 measures in 8 domains of care. Each Health plan in Florida must undergo an audit of their HEDIS process, by an NCQA-certified audit firm, in order to report and publish their rates both nationally and in the State of Florida. Annually, both state and regulatory entities publish summary and plan-specific data pertinent to HEDIS reporting.
HEDIS is required by:
- NCQA (The National Committee for Quality Assurance) for Accreditation.
- CMS (The Centers for Medicare and Medicaid Services,) to monitor health care quality and services provided by Medicare managed care plans.
- AHCA (The Agency for Healthcare Administration)
In-Office HEDIS Chart Reviews:
Freedom Health, Inc will collect HEDIS 2009 data for Medicare populations and the care they received in 2008. Beginning in early 2009, Freedom Health will be contacting provider offices to review medical records. This component is pivotal in the HEDIS process; and this data is used to augment the claims data maintained in our transaction system. Certain data is unavailable or not contained in the claims information submitted, e.g. blood pressure readings and the chart information from our network providers is an integral part of the success of HEDIS. HEDIS rates assist Freedom Health in assessing and improving the health care of all enrolled members. According to NCQA, improvements in data collection proficiency are as important as clinical improvements.
Effectiveness of provider medical care, evaluated for HEDIS, ranges from mammograms to micro-albuminuria testing, including cholesterol screening and hypertension management, to name a few. The calculated results are presented in terms of a rate for each measure by line of business; namely Medicare for Freedom Health. The data collected during the in-office chart review supplements claims data to determine accurate and comprehensive HEDIS rates.
Performance Indicators:
Freedom Health will be undergoing measurement of our baseline HEDIS report; for care rendered in 2006. Once available, audited information relevant to Freedom Health’s baseline HEDIS project will be published through the following sources, including but not limited to; Freedom Health newsletters, the Freedom Health website, state reports; Choosing A Quality Health Plan: Florida HMO Report; published annually by the Agency For Healthcare Administration and the www.medicare.gov website.
Link to Member Rights and Responsibilities
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