QUALITY IMPROVEMENT PROGRAM

Medicare Stars

CMS evaluates Medicare health plans based on a 5-star rating system. Star Ratings are calculated each year and may change year to year. To support our Star ratings improvement processes, we have an internal business analytics team to capture, track and trend Star Rating performance measures. These ratings will be compared to the yearly targets. Any deficiencies will be addressed, and interventions will be put into action as needed to meet our annual goals.

For our current Star Ratings, visit 2025 Plan Ratings (English)(Espanol)

The GlobalHealth Quality Improvement Program (QIP) summarizes the defined goals and organized activities we use to monitor, assess and improve the quality of healthcare services.

Our QIP is guided by a cross functional team that includes network providers, operational and clinical staff. Our continuous QI process allows us to:

• Assess current clinical, service, safety and behavioral health practices
• Identify opportunities for improvement
• Choose the most effective interventions
• Gauge, analyze and measure the success of implemented interventions, refining as appropriate.

QI Program Activities

Program Description and Work Plan

Annually, the Quality Improvement Committee reviews the previous year’s Quality Improvement Program (QIP) and assesses the successes and opportunities of program activities. The evaluation, along with other identified goals, are used to refine the QIP and develop the annual Quality Improvement Work Plan. The Work Plan is proactively monitored throughout the year as part of the ongoing oversight. The Quality Improvement Committee works collaboratively with various departments to develop and possibly implement initiatives targeted at improving clinical care, service, safety and outcomes. Our information sources include, but are not limited to, encounter, lab and pharmacy data, internal reports, appeals and grievances, member satisfaction survey, HEDIS®, medical record reviews and CAHPS®.

HEDIS®

The Healthcare Effectiveness Data and Information Set (HEDIS) measures the quality of care and important health issues. It provides consumers with an “apples to apples” comparison of the plan performance. It includes more than 90 measures across 6 domains.

• Effectiveness of Care
• Access/Availability of Care
• Experience of Care
• Utilization and Risk Adjusted Utilization
• Health Plan Descriptive Information
• Measures Collected Using Electronic Clinical Data Systems

We conduct year-round HEDIS medical record abstraction, supported with monthly data runs. We provide HEDIS information regarding care gaps to providers and partner with provider groups to assist them with gaps closure drives, resource development and staff training.

HEDIS results are used as part of the calculation of Medicare Star Ratings..

For 2025, our HEDIS measures and targets are:

Medicare:

For more information, visit HEDIS.

CAHPS®

The CAHPS Health Plan Survey is a tool for collecting standardized information on members’ experiences with health plans and their services. This survey has become the national standard for measuring and reporting on the experiences of members with their health plans. A version of this survey is conducted in almost every State in the U.S.

CAHPS measures healthcare members' satisfaction with the quality of care and customer service provided by their health plan. GlobalHealth utilizes the mixed mail/telephone protocol. This protocol includes mailing a questionnaire with a cover letter, followed by a thank you/reminder postcard. For those selected members who did not respond to the first questionnaire, a second questionnaire with a cover letter encouraging participation is sent which is also followed by a reminder postcard. If a selected member still does not respond to the questionnaire, at least four telephone calls are made to complete the survey using trained telephone interviewers.

CAHPS results are used as part of the calculation of Medicare Star Ratings.

For 2025, we have selected Coordination of Care as our CAHPS improvement target. We encourage active communication and care between healthcare providers, including medical care providers and behavioral health clinicians.

Care Coordination improves health outcomes, reduces healthcare costs, minimizes potential medication interactions or misuse and provides confirmation of follow through on care recommendations and referrals.

For more information, visit CAHPS.

Utilization Management Program

GlobalHealth expects our network providers to operate according to guidelines established by CMS and NCQA. We support our providers in the provision of care based on evidence-based, best practice, clinical guidelines. We utilize CMS National and Local Coverage Determinations, MCG™ Care Guidelines, Hayes, Inc. Ratings and Plan Medical Policies to support our clinical decision making. We review and approve our criteria annually and update our Clinical Guidelines at least every two years.

Our current QIP approved Clinical Practice Guidelines are available here. Vaccine Information Statements (VISs) are available here. The CDC Epidemiology and Prevention of Vaccine- Preventable Diseases (“Pink Book”- 13th ed.) can be found here.

Proactive and Discharge Outreach teams

The UM Discharge Outreach team identifies and conducts telephonic outreach for members recently discharged from inpatient care to facilitate transition between levels of care and reduce readmissions.

The Proactive Outreach Program is designed to provide members with support to promote continuity and coordination of care and member involvement in managing their healthcare. Members participating in the program are given a comprehensive clinical assessment to determine how the Proactive Team may best assist the member.

We also embed case managers in hospitals and practices and collaborate with providers who deliver case management for behavioral health.

Quality Medical Record Review

We monitor the quality of care throughout the utilization management process. When areas of concern are identified, the case is referred to the Quality Medical Review team for records review. Cases are referred by utilization management (UM), claims, or by members and practitioners. Following the initial review by Quality clinical staff, the cases are discussed in the Medical Quality Review workgroup which consists of our Medical Director, UM, case management, pharmacy, nursing and behavioral health clinicians and claims staff. The Medical Director may refer for a board certified third party external review at any time due to specialty, severity or trends.

Additional information:

CMS Hospital-Acquired Conditions (HAC)

CMS ICD-10 HAC List

CMS Hospital Readmissions Reduction Program (HRRP)

Serious Reportable Events (“Never Events”) - National Quality Forum

Never Events - Agency for Healthcare Research and Quality

Provider Partnerships

We meet regularly with hospital and large medical group leadership to review member outcomes and collaborate on improvement activities to achieve shared goals.

Quality Shared Savings

For more information, contract Provider Relations:

GlobalHealth Provider Relations
210 Park Ave., Suite 2900
Oklahoma City, OK 73102-5621
(866) 277-5300 (toll free)
For medical network inquiries: [email protected]

Electronic Medical Records

To facilitate the secure exchange of information to support utilization management, proactive outreach and HEDIS activities, GlobalHealth has arranged access to EMR systems for our larger provider groups. Our next goal is establishing shared access with the mid-sized provider groups.

For More Information

We will share our Quality Improvement Program with members and providers upon request. If you would like more information about the GlobalHealth Quality Improvement Program or if you have suggestions, please contact:

Quality Improvement

Local: 405-580-5658
Toll Free: 1-844-280-5562
Monday-Friday 9:00AM - 5:00PM Central
E-mail: [email protected]