To identify improvement opportunities, Medica focuses on high-risk, high-volume, and problem-prone areas that may expose members to potentially adverse clinical or service outcomes. We evaluate the full spectrum of clinical care: inpatient, outpatient, ancillary, pharmacy, emergency services, home health, and skilled nursing care.
Medica analyzes information from numerous sources, ranging from claims, utilization and pharmacy data, to member complaints and appeals, to member and practitioner satisfaction surveys. Annual HEDIS® (Health Plan Effectiveness Data and Information Set) rates, health risk assessments and clinical studies provide valuable data, as do internal performance measures and audit results.
When a potential improvement opportunity emerges, Medica considers these factors:
- How is the improvement relevant to our member population?
- What is our ability to make an impact?
- What’s the potential for integration with other programs?
- What are the applicable laws and regulations?
- What are the potential program costs and resource needs?
- Are regional or national benchmarks available for goal-setting?
Once an opportunity is selected, Medica sets measurable goals against current baseline measures, and re-measures periodically to assess the improvement’s effectiveness.