Skip to Main Content

Medica Administrative Manual > Health Management and Quality Improvement > Quality Improvement Program

Quality Improvement Program


The Medica Quality Improvement (QI) program supports our mission to be the trusted health plan of choice for customers, members, partners and our employees. The QI program's purpose is to identify and implement activities that will:

  • Improve member care, service, experience, access, equity and/or safety; and/or
  • Improve service to practitioners, providers, employers, brokers and other customers and partners; and/or
  • Improve Medica’s internal operations related to care, service, experience, access and patient safety.

Our QI program encompasses a wide range of clinical and service quality initiatives affecting our customers and partners, as well as internal stakeholders throughout Medica. Key areas of focus include:

  • Access to and availability of network providers
  • Behavioral health care and service
  • Care management: condition, advanced illness and complex case management
  • Complaint, appeal and grievance management
  • Continuity, coordination and transition of care
  • Credentialing and recredentialing
  • Delegation oversight (oversight of entities to which Medica delegates selected functions)
  • Health equity
  • Medical records review and site surveys
  • Medicare Stars program
  • Member experience
  • Member rights and responsibilities
  • Patient safety
  • Performance Improvement Projects (PIPs, QIPs, CCIPs
  • Population health management
  • Provider relations and provider network support
  • Utilization (of inpatient and outpatient medical services)

All Medica's customers want care and service to be the best they can be. Medical professionals want a quality relationship with the health plan: questions answered promptly, claims paid quickly and members' benefits readily understood. Members want easily available appointments with a broad selection of providers, resulting in efficient, effective care. Employers want to provide quality health care coverage for their employees at affordable rates. Medica's QI program is designed to address all these needs.

We know that understanding our customers' perceptions and expectations is central to successful strategic and quality planning. Medica learns about members and other important stakeholders through data sources that include:

  • Member and provider satisfaction surveys, customer feedback and market research data
  • Health outcomes from case management and utilization management programs
  • Member demographic and claims data, analyzed and categorized to identify socioeconomic risk factors
  • Progress reports on QI work plan goals

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.

Medica teams use several different QI and project management models to identify and implement QI strategies and activities, including:

  • Plan-Do-Study-Act (PDSA)
  • Four Disciplines of Execution (4dX)
  • Agile/Scrum
  • Lean Six Sigma

All models support a structured approach to project planning, priority-setting, timelines, progress tracking and outcome measurement.

Medica prepares an annual Quality Improvement Work Plan that outlines key quality improvement activities for the year. The activities support our clinical and service priorities and align with the organization’s strategic imperatives.

Work plan activities throughout Medica are designed to improve clinical and service quality for members, practitioners and other stakeholders, both external and internal. For example, the current work plan includes activities designed to: 

  • Improve adherence to prescribed blood pressure medications in select member populations.
  • Improve dental visit rates for select populations.
  • Improve HEDIS performance on preventive care and chronic condition measures.
  • Improve HEDIS performance on antidepressant medication management.
  • Improve post-hospitalization follow-up rates for members with behavioral health conditions.

Activity "owners" measure and report on their progress at least quarterly. Activities or goals may change during the year based on these assessments.


Medica evaluates the QI program annually. We review the year’s clinical and service quality activities and assess our progress toward work plan goals. We also look at our QI committee structure, QI program resources, and the key challenges and barriers encountered during the year. The program evaluation report includes:

  • Descriptions of the year’s QI activities
  • Measurements and trending to assess performance
  • Analysis of Medica’s success in demonstrating improvements
  • Evaluation of the overall effectiveness of the QI program
  • Recommendations for changes in areas that did not meet annual goals

Each year’s program evaluation forms the basis of the next year’s work plan.

Medica’s senior medical director, a licensed physician, is ultimately responsible for QI program development, implementation and oversight in collaboration with our leadership team. Departments and staff throughout Medica participate in quality improvement activities with the Quality Improvement department’s oversight and support.

The Medica Quality Improvement Subcommittee (QIS) directs and oversees QI program implementation. Reporting to the Medical Committee of the Medica Board of Directors, QIS serves as a peer review body, receiving and reviewing aggregate data on all aspects of clinical and service quality.

Practitioner feedback is vital to the success of our QI program. We welcome your contributions! If you’d like to share your comments or suggestions, would like more QI program information, or are interested in participating in quality improvement activities at Medica, please contact the Medica Provider Service Center at 1 (800) 458-5512.

Medicaid Quality Improvement Program

Medica has Quality Improvement (QI) activities focused on improving health outcomes for our Medicaid members.   We offer Medicaid plans across Minnesota for all ages and abilities.  They include:

  •  Plans for people age 65 and older: Minnesota Senior Health Options (MSHO) and Minnesota Senior Care Plus (MSC+)
  • Plans for people age 18-64 with disabilities: (Special Needs BasicCare (SNBC) and Special Needs BasicCare with Medicare (Integrated SNBC or ISNBC)
  • Plans for people age 0-64:  Prepaid Medical Assistance (PMAP) and MinnesotaCare (MNCare).

We understand that the needs of our Medicaid members vary.  That is why each year we identify QI activities aimed to improve the health of our members.  Current focus areas include:

  •  Reducing disparities in health outcomes. This includes special focus on diabetes care and care for pregnant members, infants and children
  •  Improving member satisfaction
  • Improving oral health outcomes and access to dental care
    Examples of QI activities in these focus areas include:
  • Medica is working with other Minnesota Health Plans on a three-year Performance Improvement Project (PIP). The project aims to improve diabetes care and decrease the disparity in blood pressure rates between Black, Indigenous, and People of Color (BIPOC) members and non- Hispanic White members.
  • The PIP runs from 1/1/21 through 12/31/23.The project is focused on members enrolled in our MSHO, MSC+ and SNBC products.
  • To measure the success of the PIP, we are using a measure that looks at the percentage of members with diabetes whose blood pressure is considered well-controlled (<140/90 mm Hg).
  •  When we measured the disparity in blood pressure control before starting the project, we found a disparity of 7.45%. BIPOC members were less likely to have well-controlled blood pressure compared to non- Hispanic White members.
  •  Our goal is to decrease that disparity to 2.60% over the course of the project.
  •  To accomplish this, Medica is working with members and providers on ways to improve diabetes health and address the social and environmental factors that impact health.
  • So far, we are making good progress toward our goal, as shown in the graph below.

Visit here for helpful resources on diabetes. 


  • Medica started a "Healthy Start" Performance Improvement Project (PIP) in 2022 together with other Minnesota health plans.
  • The goal of this PIP is to promote a "Healthy Start" for children in our PMAP and MNCare populations. We want to do this by improving outcomes and reducing disparities in prenatal, postpartum and well-child care.
  •  One of the ways we aim to do this is through our Pregnancy Program. The program offers members multiple resources with the goal of helping them get on the path to a healthy pregnancy. A foundation of the Pregnancy Program is understanding the diversity of members and tailoring resources to their individual needs and desires.
  • As data is available for Medica's new PMAP and MNCare members, Medica will set project goals and measure our success in improving care and reducing disparities.
  • Visit here to learn about Medica's Pregnancy Program.


  • Each year, Medica sends surveys to a sample of MSHO, MSC+, ISNBC and SNBC members. The survey measures member satisfaction with Medica's Care Coordination program.
  •  Medica works hard to make the survey more accessible to members. In 2022, we provided the survey in English, Russian and Spanish. In 2023, Medica plans to expand the survey to include Hmong, Somali and Vietnamese.
  • We learned from these surveys that overall, our members are very satisfied with the Medica Care Coordination Program and the services they get from their Care Coordinators.
  •  In 2022, Medica also surveyed Care Coordinators and Customer Service staff who work with our members. We learned Care Coordinators and Customer Service Staff could use more resources to help them better serve Medica members. We are working on improving tools, resources and training for Care Coordinators and Customer Service Staff.


  • We understand that oral health is an important part of overall health. Taking care of your mouth and teeth can help prevent both dental and medical problems. For this reason, Medica has made improving the oral health of our members a top priority.
  • Each year, we take steps to increase the number of members who visit the dentist. Our goal is to achieve a minimum annual dental visit rate of 55% for our PMAP and MNCare membership and 80% for our Seniors and SNBC membership.
  • In 2022, Medica started a Dental Workgroup whose purpose and mission is to increase dental visits and improve dental rates for our Medicaid members.
  • We've engaged with Community Health Centers and Critical Access Dental providers to better understand the barriers that providers and our members experience in accessing dental services.
  • We are taking steps to remove those barriers and make dental care accessible and equitable for all.
  • Some of our recent activities include:
    Removing the 30/60 mile transportation rule for dental appointments
    Increasing member incentives for completing an annual dental visit
    Meeting with care systems to share dental results and discuss opportunities for improvement
    Reaching out to members who are overdue for dental visits
    Providing dental resources at community engagement events
    Training and education for care coordinators
  • As a result of these efforts, we are seeing improvement in our annual dental visit results each year.



Rev 6 /2023

Date: 3/4/2024 5:00:29 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01