Protect yourself from mail delivery delays. Review this Consumer Advisory from The Maryland Insurance Administration.

Quality Improvement Program

Expand All | Collapse All

The goal of the Quality Improvement (QI) program is to continuously improve the quality and safety of clinical care, including behavioral health care, and the quality of services provided to plan members within and across health care organizations, settings and levels of care. CareFirst strives to provide access to health care that meets the Institute of Medicine’s aim of being safe, timely, effective, efficient, equitable and patient-centered.

The QI supports ongoing efforts to improve clinical care and services through activities such as:

  • Assessment and improvement of clinical care
  • Safe clinical practices
  • Measuring quality of service and satisfaction
  • Efficient use of resources

Specific QI Program goals and objectives are:

  1. Support and promote all aspects of the CareFirst Patient Centered Medical Home (PCMH) and Care Support programs to improve quality of care, safety, access, efficiency, coordination, and service
  2. Develop and maintain highest quality of health care; ensure positive health outcomes; keep costs at a minimum; and, enable member access to the full spectrum of needed healthcare services
  3. Maintain overall Medical Trend or below 5.0 percent
  4. Implement methods, tracking, monitoring, and oversight processes for all Care Support Programs to measure their value and impact for patients with complex healthcare needs
  5. Heighten enterprise-wide awareness and understanding of quality through an ongoing communication strategy directed toward all levels of the organization
  6. Establish collaborative partnerships to proactively engage clinicians, providers, and community hospitals and organizations
  7. Develop partnerships that address identified (medical and behavioral) health and service needs of Members with an emphasis on those services most likely to improve health outcomes
  8. Offer quality and cost data and support to clinicians to promote evidence-based clinical practice and informed referral choices
  9. Encourage Members to use their benefits to their fullest
  10. Maintain a systematic process to continuously identify, measure, assess, monitor, and improve the quality, safety, and efficiency of clinical care (medical and behavioral health), and quality of service
  11. Assess the race, ethnicity, language, interpreters, cultural competency, gender identity, and sexual orientation needs of CareFirst populations. Consider their diverse nature in the analysis of data and implementation of interventions to reduce health care disparities and improve network adequacy. Improve cultural competency through services, materials and communications
  12. Monitor and oversee the performance of delegated functions especially for high priority partners (CVS, Sharecare, and AIM)
  13. Develop and maintain a high-quality network of health care practitioners and providers meeting the needs and preferences of Members; maintain a systematic monitoring and evaluation process
  14. Operate a QI Program that is compliant with and responsive to federal, state, and local public health goals, and requirements of plan sponsors, regulators and accrediting bodies
  15. Provide insight based on Searchlight data, a repository in iCentric, with data categorized by Panel, PCP, and/or Practice, to increase the knowledge base of Medical Panels in the evaluation of outcome measures
  16. Address health needs of patients along the care continuum, including those with complex needs (advanced developmental, chronic physical and/or behavioral illness, or complicated clinical situation)
  17. Support quality improvement principles throughout the organization; acting as a resource in process improvement activities
  18. Create an awareness for social determinants of health; including, what they are and how they affect our members’ ability to fulfill their health goals.
  19. Support Dental initiatives in order to create a path to integrate oral health with overall health care

The QI team, with input from appropriate CareFirst staff, writes a detailed description of all the completed and ongoing QI activities on the QI Work Plan for the year. The Quality Improvement Council and the Service & Quality Oversight Committee review the QI Program Evaluation at least once a year.

QI Program

2019 QI Program GoalsEvaluation
Address health needs of all patients along the health care continuum, including those with complex health needs (advanced developmental, chronic physical and/or behavioral illness, or complicated clinical situation); Patient Activation Measure (PAM) correlates with future Emergency Room (ER) visits, hospital admissions and readmissions, medication adherence and more. Patient activation is regularly assessed among Members receiving care coordination.. The Patient Centered Medical Homes (PCMH) team assessed an average of 99% of Core Target 1 and Core Target 3 identified Members during 2019. These assessments included a discussion between the Local Care Coordinator (LCC) and the Primary Care Physician (PCP).
Support and promote all aspects of the CareFirst Patient Centered Medical Home (PCMH) program and the Clinical programs to improve quality of care, safety, access, efficiency, coordination, and service; High adoption of the Core Target by providers. Each month 99% of the 40,000 high risk Core Target Members were successfully assessed and connected to supporting services as clinically appropriate. Improvement in PCMH panel engagement and cost savings continued, with 68% of panels earning outcome incentive awards for performance year 2019. Since its inception in 2011, the PCMH program has resulted in a net cost savings of $1.3B.
Maintain overall Medical Trend, including pharmacy, at or below 5.0 percent; In-area medical trend (adjusted for rebates, excluding Affordable Care Act) was 3.6% in 2019 – below the target goal of 5%.
Implement methods, tracking, monitoring, and oversight processes for all Clinical Programs to measure their value and impact for appropriate patients with complex healthcare needs; A program management and accountability structure was in place for each Clinical program. An in-depth program evaluation was completed in the fall and determined positive results (clinical or financial) for these programs.

Ensure all elements of the CareFirst Clinical Program will be operating at targeted levels in 2019 (maintaining at least 4 out of 5 quality score) by actively managing core target list identifying Members with complex health needs:

Outcomes:

  • Percent Admissions Triaged by Hospital Transition of Care (HTC)= 99%;
  • Specialty Pharmacy Coordination – 375 engaged members
  • CMR Tier I – 1,650 completed CMRs
  • CMR Tier II Pharmacy Advisor Counseling – 198,000 engaged members
  • CMR Tier II Pharmacy Advisor Adherence Support – 40,000 messages to members and providers
  • CMR Tier II Pharmacy Advisor Closing Gaps – 23,000 interventions to providers (no member engagement)
  • CMR Tier II Safety and Monitoring – 3,800 prescriber letters (no member engagement)
  • CMR Tier II Drug Savings Review – 160,000 prescriber letters
  • Medical and Behavioral Health Care Coordination Care Plans = 37,500;
  • Home Based Services Cases = 10,000;
  • Community Based Program Cases = 2,050
  • Enhanced Monitoring Program Cases = 2,500
  • Expert Consult Cases = 400
  • Video Visit = 8,000

CareFirst Clinical Program - 2019 Evaluation Criteria Results

CareFirst Clinical Program - 2019 Evaluation Criteria Results

In some but not all cases, target goals were met. For those not meeting target goals, detailed evaluations were completed. Those findings are informing a clinical programs roadmap and a redesign of our care management programs planned to begin in 2020.

Establish collaborative partnerships to proactively engage clinicians, providers, and community hospitals and organizations to implement interventions that address the identified (medical and behavioral) health and service needs of our membership throughout the entire continuum of care and those that are likely to improve desired health outcomes. Clinical compacts were established between primary care and specialty providers. In 2019, 844 providers were in established compacts.
  • Utilized committees to assure oversight for our key partners.
  • We worked collaboratively with Sharecare, Medtronic, and CVS to align their programs with our clinical programs.
  • iCentric was enhanced to support bi-directional data exchange.
  • Community providers, hospitals, and specialists were engaged in the development of these enhancements.
  • CareFirst partnered with national specialty organizations in the development of clinical programs.
Promote the provision of quality and cost data and support to clinicians to promote evidence-based clinical practice and informed referral choices and Members to use their benefits to their fullest; iCentric, our online health record system, offers 24/7 access to population and Member specific claims and care coordination data for Members engaged in a care plan. This system is used to document Member health history, current health status, and progress toward meeting goals. SearchLight reports are available to practitioners, practices, and at the panel levels to evaluate aggregate performance and utilize data to identify attributed Members needing support. Practice Consultants assist PCMH panels in data analysis and identify potential opportunities for increased cost savings and improved quality. LCCs reinforced the availability and functionality of portal tools for PCPs to assist with population management. CareFirst offered PCP cost data for specialists to help them make informed referrals.
Maintain a systematic process to continuously identify, measure, assess, monitor, and improve the quality, safety, and efficiency of clinical care (medical and behavioral health), and quality of services;

CareFirst utilized industry standard reporting measures such as Healthcare Effectiveness Data and Information Set (HEDIS®), Consumer Assessment of Healthcare Providers and Systems (CAHPS®), Clinical Quality, Customer Service, and Resource Use Measures (QCR), and Quality Rating System (QRS) to compare plan performance to national standards and benchmarks for 13 reporting populations.

Clinical Quality Scorecards were used for ongoing monitoring of PCMH outcomes by tracking and assessing clinical care, efficiency, and service.

Quality, safety, and efficiency of clinical care and quality of service was assessed and measured through the annual Quality Improvement Program and by monitoring delegate performance. Input from providers, practitioners, Members, and partners was incorporated to assess quality and access to care through frequent QI committee meetings and in the evaluation of reports, satisfaction surveys, etc.

Assess the race, ethnicity, language, interpreters, cultural competency, gender identity, and sexual orientation needs of our diverse populations while considering such diversity in the analysis of data and implementation of intervention to reduce health disparities, improve network adequacy and improve cultural competency in materials and communications; Spanish is the predominant non-English language within our region and CareFirst offers multiple avenues to reach a diverse Membership. The Language Line provides interpreters, at no cost to Members and providers. The Disease Management and Wellness programs offer printed educational materials in English and Spanish with multi-lingual nurses staffing call centers. The Health Risk Assessment is available in Spanish online, and in printed format. Within care plans, Members are queried as to cultural and ethnic preferences. Through CareFirst Commitment, in 2019 funds were provided to community organizations to reduce or eliminate racial disparities and improve the quality and safety of care in the regions we serve. LCCs, assigned to PCMH practices, live and work in their specific regions. These individuals are familiar with the local health care systems and support and tailor care plans to the populations they serve. CareFirst directly collects Cultural, Ethnic, Racial, and Linguistic (CERL) information from Members and infers race/ethnicity from analysis of zip code.
Monitor and oversee the performance of delegated functions especially for high priority partners (CVS, Sharecare, AIM) CareFirst oversaw delegates’ performance and assured compliance with accreditation, regulatory, and CareFirst standards. The following functions were delegated: quality improvement, utilization management, case management, pharmaceutical safety, disease management, credentialing, networks, wellness, and Member connections. Delegation discussions began with new entities, including American Imaging Management (AIM) for Utilization Management. The Delegation Oversight Committee (DOC) plays an active role in monitoring activities based on delegation agreements and compliance requirements. Audits and corrective action are taken when needed to ensure delegates serve member needs and comply with state, federal and regulatory requirements.
Develop and maintain a high-quality network of health care practitioners and providers meeting the needs and preferences of its membership by maintaining a systematic monitoring and evaluation process. In 2019, there were 4,195 practitioners added to the CareFirst network which now puts CareFirst at 51,307 practitioners (this includes HMO, PPO and Behavioral Health). In addition, overall provider data accuracy improved through greater automation with Council for Affordable Quality Healthcare (CAQH). CareFirst uses CAQH to contact providers on a quarterly basis, on CareFirst’s behalf, to validate directory information. Any updates identified and made by the provider are electronically sent to CareFirst for update in CareFirst’s directory. Also, providers are required by CAQH to attest to the accuracy of the data every 120 days. CareFirst receives an electronic transmission with updated provider information.
  • CareFirst continues to grow the Behavioral Health network, with 9,013 behavioral health providers contracted in-network.
  • CareFirst assisted 8,048 members with appointment requests for behavioral health, (85% of member’s appointment were scheduled within 10 days).

For the 7th year in a row, CareFirst continued to rank #1 for HMO professional discounts, based on the latest result from Hewitt benchmarking reports.

Through credentialing, recredentialing and the entire credentialing program, CareFirst evaluates and monitors qualifications, competency and performance of practitioners and health delivery organizations who participate in the CareFirst provider networks. The Credentialing Advisory Committee (CAC) develops and implements the credentialing/recredentialing processes to select and evaluate practitioners through recommendations for credentialing decisions using a peer review process.

In 2019, the networks team completed the quarterly termination process for providers with zero-dollar payments in the prior six months. Claims are reviewed each quarter to identify providers with no claims paid during the past 6 months. Providers with no claims are terminated and removed from the directory.

Operate a QI Program that is compliant with responsive to federal, state, and local public health goals, and requirements of plan sponsors, regulators and accrediting bodies; In 2019, CareFirst submitted its renewal application to (National Committee for Quality Assurance (NCQA) and was granted 3-year accreditation status (next submission is scheduled for July 2022).
Provide insight based on Searchlight data to increase the knowledge base of the Medical Panels in the evaluation of their outcome measures; CareFirst used the comprehensive provider reporting tool (SearchLight) to have nearly 2,400 meetings with providers in 2019. Insights from specialist data available within SearchLight promoted improved referral patterns.
Support quality improvement principles throughout the organization; acting as a resource in process improvement activities; The QI team continues to focus on quality improvement initiatives throughout the organization, using our Quality Improvement Committee (QIC) as the platform to present and discuss quality improvement projects and concerns. These improvements are documented through committee minutes to demonstrate actions taken to address specific areas of concern. Quality Improvement Specialists worked with intra- and interdivisional teams to promote quality improvement throughout the organization by collaborating with functional areas to improve and/or streamline internal processes and produce a more positive experience for all members and providers.
Create an awareness for social determinants of health; including what they are and how they affect member abilities to fulfill health goals; While improving health outcomes requires an accessible and high-quality health care delivery system, CareFirst also recognize that this includes addressing root causes of poor health outcomes, or social determinants of health, to truly drive change. CareFirst has also supported programmatic efforts such care coordination, medically tailored meals, and culturally competent language services. Examples of giving include Maternal and Child Health, Access to Care, and Behavioral Health.
Heighten enterprise-wide awareness and understanding of quality through an ongoing communication strategy directed toward all levels of the organization

Business requirements and training of the field teams were completed for the PCMH quality scorecard which aligns PCMH provider incentives with “Core 10” quality measures

Implemented a pharmacist intervention to support a HEDIS measure by improving adherence to statin medications for (Federal Employee Plan (FEP) members. In Q1 2019, the FEP pharmacist successfully counseled 360 FEP members who had cardiovascular disease and were non-adherent to their statin therapy

Heightened enterprise wide awareness and understanding of being successful in accreditation, HEDIS and CAHPS, and clinical outcome reporting through Quality Talks and Quality Fairs – an innovative 2019 project series completed through in-person presentations, Skype conducted Lunch n’ Learns, and site specific Quality Fairs.

In addition to the credentialing requirements, on or after January 1, 2020, CareFirst will be calculating practice-specific profile scores that may factor into the selection of new networks. The profile scores will use data to evaluate practices in quality and member experience, cost efficiency, and relationship health. Learn more about the measures and methodology.

CareFirst Profile Score Methodology

Expand All | Collapse All