Quality Management & Improvement Efforts

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.

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

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

Each year, we check to see how close we are to meeting our goals. Here's what we did in 2019:

• We collected data on a set of clinical measures called Healthcare Effectiveness Data and Information Set (HEDIS^®1), as applicable. We shared the results with the National Committee for Quality Assurance (NCQA) Quality Compass^®2. The NCQA makes the results public. Each year, we use the results to set new goals and improve selected measures. As a result, performance 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. Satisfaction with the program remained high. Members told us they are more actively involved in managing their health, and the program provided valuable information³.
• We surveyed members in the Aetna Disease Management program. Satisfaction with the program remained high. Members told us the information they learned had a positive effect on their lives⁴.
• 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

Our quality improvement program helps to improve the behavioral health care we provide to you. We want to help you feel better. Enhancing health and mental wellbeing leads to a better quality of life. There are many ways we evaluate our outcomes. Learn about the progress we’re making, our current goals, and how we’re tracking our efforts. 

Aetna Behavioral Health program improvements in 2019 included:

• Aetna Behavioral Health received full accreditation for our Managed Behavioral Health Care Organization from the National Committee for Quality Assurance (NCQA) in 2019. Our overall score was 99.94%.
• Our HEDIS measures Follow-up care for children prescribed ADHD medication (ADD) and Anti-depressant medication management (AMM) demonstrated improvement year over year from 2017 through 2019.
• The Opioid Overdose Screening program saw improved results in:
  • Total number of members screened for opioid dependence
  • Total number of claims for naloxone, an overdose reversal medication
• A two-year quality improvement activity regarding after-hours telephone access demonstrated increased practitioner availability during non-business hours.
• Our member satisfaction quality improvement activity on claims being paid correctly and timeliness of resolving claims issues both showed statistically significant improvement.
• There was an increase screening and referrals to behavioral health care as a result of the following programs:
  • Maternity Depression Screening Program
  • Substance Abuse Screening, Brief Intervention and Referral to Treatment
  • Depression in Primary Care
  • Opioid Overdose Risk Screening
• We have a new strategy and long-term plan to grow the business while continuing to transform the overall mental wellbeing on behalf of Aetna and the broader CVS Health. Several changes to our organization are occurring that will help us strengthen our brand as a leader in mental wellbeing by delivering exceptional, empathetic member and caregiver experiences. Our new organization puts member and provider experience at the center of our work, provides for a systematic infrastructure to advance innovation and grounds us in performance management.

Our plans for 2020:
 

• Help our members address their mental wellbeing through the COVID-19 pandemic by offering the following free benefits:
  • Telemedicine
  • Mental wellbeing resources
  • Coronavirus testing and doctor visits
  • A care package for members diagnosed with COVID-19
  • Prescription delivery on CVS pharmacy prescriptions
• Aetna provides virtual wellness checks for seniors and partners with Meals on Wheels to provide food for them in targeted areas
• Continued improvement of the Aetna 360 clinical care model
• Emphasize innovation and improvement in our member and provider experiences
• Improve our behavioral health HEDIS measure results
• Drive and support mission-critical business and clinical programs through data visualization, analysis, and performance measurement
• Encourage broader use and implementation of telemedicine
• Sustain our focus on efforts to help fight the opioid epidemic
• Evaluate our structure continuously to ensure we are best aligned to meet the needs of our members and support the goals of our organization

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.

¹ HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
² Quality Compass is a registered trademark of NCQA.
³ Based on results from the 2019 Aetna Case Management Member Satisfaction Analysis.
⁴ Based on results from the 2019 Aetna Disease Management Member Satisfaction Analysis.