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According to the Agency for Healthcare Research and Quality (AHRQ), medical errors are responsible for injury in as many as one out of every 25 hospital patients; an estimated 48,000 - 98,000 patients die from medical errors each year. Errors in health care have been estimated to cost more than $5 million per year in a large teaching hospital, and preventable health care-related costs to the economy range from $17 to $29 billion each year. SummaCare is committed to working with its practitioners and providers toward the goal of reducing medical errors. The health plan is currently engaged in a variety of activities designed to improve patient safety and reduce the risk of medical errors for its members. These activities are coordinated by the Director of Quality Management.

Credentialing and Recredentialing

At the time of initial practitioner credentialing and again every three years at the time of recredentialing, each practitioner and the National Practitioner Data Bank (NPDB) are queried to determine if any judgements, settlements, or adverse actions have occurred involving medical errors. These findings are scrutinized by the plan's Credentialing and Peer Review Committee to identify possible trends and patterns of unsafe treatment. If identified, such trends and patterns may be addressed by the Credentialing and Peer Review Committee in the form of an educational requirement or removal/non-inclusion from the SummaCare network.

Adverse Event Monitoring

SummaCare identifies, reports, and possibly investigates adverse events involving patient safety issues. Such patient safety issues may include:

• Medication errors
• Delayed follow-up of abnormal test results
• Unexpected deaths
• Patient falls resulting in injury
• Surgical errors
• Any event that causes untoward harm to the patient

Adverse events are reviewed and investigated as indicated by the plan's Quality Management staff. Concerns that the appropriateness of medical care may have contributed to the injury or potential injury of a member are reviewed by the Credentialing and Peer Review Committee. This committee may recommend action to the Board of Directors. An annual aggregate report of adverse events is also reviewed by the committee to identify trends and patterns by facilities, practitioners, and adverse event types.

Member Education

Every other year, the health plan publishes a member newsletter article entitled, "Five Steps to Safer Health Care." This article expands on the following recommendations:

1. Speak up if you have questions or concerns
2. Keep a list of all the medicines you take
3. Make sure you get the results of any test or procedure
4. Talk with your doctor and health care team about your options if you need hospital care

Every other year, we also publish a member newsletter article entitled, "12 Tips to Prevent Medical Errors." In addition, throughout the course of the year, the newsletter includes several articles related to seasonal safety around the home and workplace.

Practitioner Efforts

Each quarterly issue of the physician newsletter contains a section dedicated to patient safety issues called, "Prescription for Safety." Hazard alerts and tips to prevent medical errors are published here from the Institute for Safe Medication Practices. In addition, an incentive program rewards those physicians that demonstrate high quality in the delivery of care. Clinical practice guidelines are also developed and approved for preventive health services as well as medical and behavioral health conditions that are high volume and/or high risk and/or high cost. In addition to child and adult preventive health guidelines, the health plan currently has practice guidelines in place for diabetes mellitus, beta blocker use after a myocardial infarction, asthma, chronic obstructive pulmonary disease, congestive heart failure, hypertension, and major depressive disorder.

Disease Management

SummaCare's Disease Management Programs provide specialized services to members who have been diagnosed with a chronic condition or who are at risk for certain illnesses and complications. These programs offer education and collaboration between member, physician and the health plan with the goal of increased member understanding of their illness. SummaCare has the following Disease Management Programs: Diabetes, Asthma, Heart Failure, High Risk Pregnancy, and Cardiovascular Disease. Participants in these programs can expect risk assessment, educational materials, appointment reminders by mail, and access to the services of an RN care coordinator for questions and guidance.

Prescription Drug Services

Under the SummaCare prescription drug benefit plan, all prescription claims are processed on-line in a real time format. Any prescription claim request submitted by a network pharmacy is evaluated against an enrollee's prescription history for potential drug interactions, therapeutic duplicates, and contraindicated medications. If, based on previous history, there appears to be a documented potential for an interaction or duplicative therapy, a warning is communicated to the dispensing pharmacist prior to the prescription being filled. In addition, all prescription claims are checked against a national medication database to help to prevent the dispensing of a medication dose higher than expected based on the age of the enrollee. If the potential for a high dose is found, the dispensing pharmacists will receive an alert and must confirm the medication dosage before the prescription can be processed.

SummaCare does has an Individualized Drug Use Evaluation program utilizing an automated process that helps identify enrollees that may be at high risk for potential adverse medication events based on a factors such as high number of prescriptions from one therapeutic class, the high number of different dispensing pharmacies, and overall higher than expected prescription drug use. The prescription profiles of these enrollees are reviewed by a physician or pharmacist, and if it is deemed appropriate, the profile is provided to the enrollee's primary care physician with a letter describing the potential issues. Letters are reviewed by a Medical Director prior to mailing.