SummaCare Quality Management Program

SummaCare provides a comprehensive, community-focused health plan that maximizes service and choice to our providers, members and employers.  We are committed to a thorough and effective Quality Management Program that follows the principles of Continuous Quality Improvement to improve the care and services members receive.

Major goals and objectives of the quality program include:

  • Promoting and building quality into the structure and processes of our organization
  • Monitoring and working to improve outcomes
  • Enhancing the customer experience and promoting preventive health and wellness through targeted interventions
  • Promptly identifying opportunities for improvement with actions for resolution

Quality indicators for both clinical studies and operational metrics are objective, measureable, based on existing knowledge and clinical experience, and reviewed on an ongoing basis to assure the need for program changes are identified promptly.

Member Mailings

To assist members in obtaining preventive screenings and optimal care for chronic conditions such as diabetes and cardiovascular diseases, SummaCare continues to send annual preventive health letters that identify recommended services for our members.

Various care opportunity letters are sent throughout the year to members if we have not received claims by mid-year for recommended screenings and other health related conditions.  These letters are intended to remind and encourage our members to contact their physicians to obtain the care they need.

We continue to evaluate and improve our outreach to members and providers to determine additional effective ways to help members get the care they need. 

Performance Measures

The healthcare industry's Healthcare Effectiveness and Data Information Set (HEDIS) provides standardized performance measures and comparisons against national benchmarks.  Using HEDIS results, SummaCare monitors its quality improvement program performance and initiates efforts to improve performance when indicated. 

HEDIS results measured in 2015 for 2016 performance identified SummaCare’s strengths and opportunities for improvement as follows:

For Medicare, measures that were at the 90th percentile were:

  • Medical Assistance with Smoking Cessation 
  • Pneumonia Vaccination Status for Older Adults 
  • Use of High-Risk Medications in the Elderly Rate 
  • How Well Doctors Communicate 
  • Rating of Personal Doctor

For Commercial PPO, Measures that were in the 90th percentile were:

  • How Well Doctors Communicate 
  • Rating of Personal Doctor

Our greatest opportunities for improvement are improving rates for routine screenings such as breast cancer, colorectal cancer and cervical cancer screenings. SummaCare has many initiatives in place for 2016, such as process improvement teams, provider strategies, member outreach, and clinical campaigns. Many improvements have been put in place and are being planned for enhancing the member experience and satisfaction with the health plan.

For more information on our Quality Management Program or if you would like a summary of the annual program evaluation, call 330-996-8857.