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Quality Management & Improvement Efforts

Quality improvement strategy

We are 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 doctors information and tools that may help you make decisions.

Program goals

We aim to:

  • Meet members’ health care needs
  • Measure, monitor and improve clinical care and quality of service
  • 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

We work to make your health care better by:

  • 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 disparities in health care that could negatively impact quality 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 2018:

  • 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 Aetna. To improve satisfaction, we:
    • Enhanced the aetna.com website and online tools
    • Improved the accuracy of our provider directory information 
    • Improved online self-service options for members and providers
  • We surveyed members in the Aetna Case Management program. They told us that the program helped them learn how to maintain and improve their health.***
  • We surveyed members in the Aetna Disease Management program. Satisfaction with the program remained high, as well as the likelihood of members to recommend the program to a friend or family member.
  • We also:
    • Improved our patient safety program to help our members make informed health choices
    • Continued using social media to provide information about patient safety
    • Provided patient safety resources to physicians on the secure provider website
    • Provided information on our Hospital Comparison Tool to help members make more informed decisions when selecting a hospital for their medical care

Your behavioral health needs are important to us

Even as the opioid crisis continues to claim lives and harm families and communities across the country, Aetna is seeing progress on stemming the tide of opioid misuse. We also continue to help our members with their mental health needs.

The multi-pronged strategy, which includes collaboration with key industry and other stakeholders, is working. Progress in 2018 included:

  • A decrease in the average amount of opioids prescribed per month††
  • A significant increase in the percentage of members with chronic pain treated with non-opioid approaches like physical therapy and non-steroidal anti-inflammatory drugs††
  • For members struggling with opioid use disorder, we’ve increased the use of evidence-based treatment which includes counseling and medications. This helps our members to find an effective path to end misuse. 
  • Increased awareness and distribution of naloxone, a rescue medication for opioid overdoses, allowing members to learn to live without opioids
  • Expanded the Institutes of Quality (IOQ) program for substance use disorder treatment to sixteen facilities
  • Grew our Utilization Management Transformation (UMT) to 274 programs
    • UMT referrals increased to address social determinant needs and peer support
  • Produced 54 Let’s Talk” videos on behavioral health information topics
  • Expanded Measure, Act, Prevent (MAP) program which provides peer support to members who have gone through substance use disorder rehabilitation to eight states
  • Changed practitioner reimbursement to promote care coordination across behavioral health (BH) providers and between BH and medical providers 

Additional Aetna Behavioral Health program improvements in 2018 included:

  • Improved treatment for depression by helping members stay on their antidepressant medication
  • Helped improve attendance at follow-up appointments for children with attention deficit hyperactivity disorder (ADHD)
  • Expanded televideo services to all states in January of 2018
  • Increased member telephonic access to behavioral health services after hours
  • Achieved highly favorable member satisfaction rates in our UMT programs
  • We also hosted our annual conference in June which focused on the role of the health company in suicide prevention.

Our plans for 2019:

  • Introduce online recovery services to compliment traditional care and chat therapy counseling
  • Execute new streamlined clinical care model
  • Maintain clinical improvement outcomes for members with ADHD, depression or substance use disorder diagnoses
  • Encourage broader use of televideo services
  • Continue to focus our efforts to help fight the opioid epidemic
  • Increase the use and availability of online assessment and informational tools

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.

*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 2017 Aetna Case Management Member Satisfaction Analysis.
2Based on results from the 2017 Aetna Disease Management Member Satisfaction Analysis.

Disclaimers

Aetna Medicare is a HMO, PPO plan with a Medicare contract. 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.

Aetna Medicare’s pharmacy network includes limited lower cost, preferred pharmacies in: Urban Mississippi, Urban Virginia, Rural Missouri, Rural Arkansas, Rural Oklahoma, Rural Kansas, Rural Iowa, Rural Minnesota, Rural Montana, Rural Nebraska, Rural North Dakota, Rural South Dakota, Rural Wyoming. 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 https://www.aetnamedicare.com/pharmacyhelp.

Participating physicians, 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. 


       GRP_4037_1522 (05/2018)
       Page last updated: June 19, 2019

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