Federal Employee Health Benefits

Arnett HMO Patient Safety Initiatives

Arnett Health Plans obtained a three year NCQA accreditation in 2004.

Member Safety continues to be a service and clinical initiative for Arnett Health Plans. Arnett Health Plans has established four key functions focused on Member Safety:

• Ensure qualified health care providers care for members;
• Evaluate new technology for proven results, desired outcomes, and minimal risks;
• Adjust the Preferred Drug List (formulary) based on drug efficacy, proven drug safety, and drug cost.
• Influence network-wide safety practices;

Ensure Qualified Health Care Providers

The Plan works diligently in the credentialing of individual practitioners. Each practitioner must meet and maintain the minimum standards set forth by the Plan to be included in the network at the time of initial credentialing and then when recredentialed every three years. As part of the credentialing/recredentialing activity, office site and medical record reviews are conducted.

• The office site review consists of six established criteria with elements contributing to the criterion average. The criteria include items related to external and internal office environment, internal management, medication storage, infection control, and emergency preparedness. To be compliant with the Plan's standards, offices must score 100% in each section.
• The medical record review consists of four established categories with individual criterion scores. To be compliant with the Plan's standards, the practitioner must score at least 90% for each element in areas related to record keeping practices, clinical documentation, continuity and coordination of care, and acceptable standards of care.

The Plan continues to scrutinize practitioner performance annually between the triennial recredentialing cycle. This activity consists of profiling the practitioner's Medicare/Medicaid sanctions, complaints, pending malpractice information, appointment access, and clinical initiative study results.

AHP reviews all quality of care complaints. Resolution of the complaints involves practitioner trending and individual practitioner education. Complaints are part of the practitioner's annual performance review and are profiled at the time of the Credentialing Committee review.

Evaluate New Technology

Arnett Health Plan evaluates the inclusion of new medical technologies and the new application of existing technologies for potential coverage as Plan health care benefits. The evaluation includes consideration of published research, federal government regulatory body decisions, and whether the benefit obtained from the technology or pharmaceutical has short-term or long-term benefits. Technology assessments are conducted prospectively or as a response from primary care physicians, specialists, or members who request new treatment options to meet health needs.

Adjust the Preferred Drug List

The Preferred Drug List is managed and maintained by the Pharmacy and Therapeutics (P&T) Committee of Arnett Health Plans. The P&T Committee is comprised of Plan practitioners and pharmacists. The formulary is reviewed on a quarterly basis to ensure it remains responsive to the needs of practitioners and members. Specific patient safety initiatives from the Pharmacy Benefits Program include the following:

• Therapy Adherence Program was continued for mail order participants. The goal of the program is to educate the members about their prescribed drug therapy and remind them when it is time to refill or renew a prescription. This is accomplished through mailings and refill reminders by phone that communicate the importance of therapy adherence. Four hundred nine (409) members were contacted related to compliance issues which was an increase from the previous year's 137. This increase is due in part to the increase utilization of the Express Scripts Mail Order program.
• The Therapy Initiation program continued for high-risk members requiring medication management for Diabetes, Beta blockers/Congestive Heart Failure, Hyperlipidemia, and Hypertension. The program communicates with patients' physicians about optimizing the patient's medication therapy.
• The Emerging Therapeutic Issues program notifies practitioners and members taking identified medications of FDA recalls.
• The Drug Utilization Review program continues. There are two types of patient review criteria utilized: (1) therapeutic criteria consisting of drug-drug interactions or drug-disease interactions; and (2) utilization criteria, which consist of over-utilization, under-utilization, drug-age and drug-pregnancy interactions.

Influence Network-wide Safety Practices

Quality of Care Indicators (QCI) are collected through the monitoring of inpatient stays to determine any causative effects or trends related to practitioner or provider performance. The QCI process continues to identify system, process, and individual performance issues related to the quality of care provided to members as well as the delivery of that care. Individual physician benchmarks are incorporated into their Credentialing files and is profiled along with malpractice actions, peer review findings, and complaints. There are nine (9) categories in which a QCI is placed as listed below. Each category contains subsets.

• Care Prior to Hospital Admissions by Selected Diagnosis
• Unexpected complications during hospital stay.
• Unanticipated admissions following outpatient procedures
• Unanticipated Death
• Readmissions within 30 days for related conditions
• Documentation discrepancies
• Continuity and Coordination of Care issues
• Patient Safety
• Pharmacologically induced admissions