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Quality Management & Improvement Efforts

Quality improvement strategy

We’re working hard to improve the service, quality and safety of health care. One way we do this is by measuring how well we and others are doing.

We work with groups of doctors and other health professionals to make health care better.

Our clinical activities and programs are based on proven guidelines.

We give you and your doctor information and tools that may help you make decisions.

Program goals

We aim to:

  • Meet the members' health care needs.
  • Measure, monitor and improve the clinical care and quality of service our members get.
  • Institute company-wide initiatives to improve the safety of our members and communities.
  • Make sure we obey all the rules, whether they come from plan sponsors, federal and state regulators, or accrediting groups.

Program scope

  • Developing policies and procedures that reflect current standards of clinical practice.
  • Reviewing preventive and behavioral health services and how care is coordinated.
  • Addressing racial and ethnic differences in health care.
  • Monitoring the effectiveness of our programs.
  • Studying the accessibility and availability of our network providers.
  • Monitoring the overuse and underuse of services for our Medicare members.
  • Performing credentialing and recredentialing activities.
  • Assessing member and provider satisfaction.

Program outcomes

Each year, we check to see how close we are to meeting our goals. Here's what we did in 2015:

  • We collected data on a set of clinical measures called the Healthcare Effectiveness Data and Information Set (HEDIS®*), as applicable. We shared the results with the National Committee for Quality Assurance (NCQA) Quality Compass®.** The NCQA makes the results public. Each year, we use the results to set new goals and improve selected measures. As a result, performance has improved on many measures.
  • We asked members and providers how satisfied they are with us. We noted an improvement in how quickly they are able to get care, and coordination of their care. We met the cultural and language needs of our members.
  • We surveyed members in the Case Management program. They told us that their case managers were knowledgeable about their health care needs and conditions, and that the information shared with them was easy to understand.1
  • We surveyed members in the Disease Management program. They told us that the program helped them improve their health, better understand their health, and reach their health goals.2
  • We also:
    • Continued with our patient safety program.
    • Improved the Spanish version of our member website.
    • Made available a mobile app so that members can access health and benefit information from their smart phones.

Accreditation

We take our accreditation by the NCQA seriously. It's how we show our commitment to improving your quality of care, access to care and member satisfaction.

Get more information about our NCQA accreditation

*HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
**Quality Compass is a registered trademark of NCQA.
1Based on results from the 2015 Aetna Case Management Member Satisfaction Analysis.
2Based on results from the 2015 Aetna Disease Management Member Satisfaction Analysis.

Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal. 

See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. 

Participating doctors, hospitals and other health care providers are independent contractors. They're neither agents nor employees of Aetna. The availability of any particular provider can't be guaranteed. Provider network make-up is subject to change. 

Aetna Medicare’s pharmacy network offers limited access to pharmacies with preferred cost sharing in: Suburban NY and Rural ME, NY and UT. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including pharmacies with preferred cost sharing, members please call the number on your ID card, non-members please call 1-855-338-7027 (TTY: 711) or consult the online pharmacy directory at http://www.aetnamedicare.com/pharmacyhelp.

       Y0001_4006_8294 Approved 11/04/2016

       Page last updated: Wed Dec 07 14:08:45 EST 2016

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