Quality improvement strategy

All of us at Aetna are working hard to improve the quality and safety of health care. One way we do this is by measuring how well we and others are doing.

We also work with groups of doctors and other health professionals. Again, our goal is to make health care even better.

Our clinical activities and programs are based on guidelines. These come from the best, proven medical practices we can find.

We also give you and your doctor the information and tools you need to make confident decisions.

Program goals

We aim to:

• Meet the health needs of all of our members, whatever their health care needs
• Measure, monitor and improve the clinical care our members get. We look at both quality and safety.
• Address racial and ethnic differences in health care
• Come up with ways to do our jobs even better
• Make sure we obey all the rules, whether those rules come from plan employers federal and state regulators or accrediting groups
• Help our clinical staff learn new skills
• Make sure providers in our networks meet all of our standards.

Program scope

We work to make your care better by:

• Providing our members with clear information so they can make good decisions
• Reviewing the health care services we cover and how care is coordinated
• Encouraging providers to communicate with one another
• Developing, carrying out and monitoring patient safety plans
• Monitoring the effectiveness of our programs
• Making sure we comply with all the rules on regulation and accreditation
• Studying the accessibility our network providers
• Setting standards on keeping all medical records. We also look at ways to audit these records.
• Monitoring the overuse and underuse of services
• Performing credentialing and recredentialing activities
• Assessing member and provider satisfaction

Program outcomes

Medical

Each year we check to see how close we are to meeting our goals. Here's what we did in 2012:

• We collected data on clinical measures called Healthcare Effectiveness Data and Information Set (HEDIS®1). We shared the results with the National Committee for Quality Assurance (NCQA) Quality Compass®.2 The NCQA makes the results public. We use the results to set new goals and improve selected measures each year. As a result, performance has improved on many measures over time.
• We asked members and providers how satisfied they are with Aetna. To improve satisfaction, we:
  • Implemented a surgery decision-making tool called WelvieSM which helps members understand their options.
  • Promoted a secure, web-based tool called RelayHealth which makes it easier for members to communicate with their doctors.
  • Developed tools that you can use to estimate how much you pay for health care, including the Price-a-Drug tool.
  • Improved how we communicate with members.
• Members in the Aetna Case Management Program told us their health had improved.3
• Members in  the Aetna Disease Management Program told us that they learned about their health and took better care of themselves.4
• We improved our Patient Safety Program and:
  • Made our Hospital Comparison Tool more useful.
  • Identified ways patients who are in the hospital may be harmed and developed related policies.
  • Worked with The Leapfrog Group, the March of Dimes® and several health plans on a campaign to increase awareness of the health risks of scheduling a delivery before 39 completed weeks of pregnancy.
  • Used social medica for patient safety communications.
  • Provided information to physicians and members to help them make better decisions about medications.

Behavioral health

Each year we check to see how effective our behavioral health (BH) programs are. In 2012, we:

• Provided information and tools to our members, providers and BH staff to promote the use of medication according to doctors' instructions.
• Continued to encourage BH providers to use assessment tools that are based on the best evidence to improve the quality of care they provide.
• Expanded a program that allows members, on the last day of their hospital stay, to meet the provider who will help them when they leave the hospital.
• Tested a program that uses medication to help treat opioid dependence.
• Improved patient safety training for all BH staff.

Accreditation

We take our accreditation by the NCQA seriously. It's how we show our commitment to:

• Finding ways to always keep improving
• Meeting people's expectations
• Setting Aetna apart from other health plans

You can get more information about our NCQA accreditations on the NCQA website.

Aetna also holds several URAC accreditations. You'll find more information on the URAC website.