SummaCare Quality Management Program

SummaCare provides a high quality, low cost comprehensive, community-focused health plan that maximizes service with our integrated health system 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 program include:

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

Member Mailings

To remind and encourage members to get their preventive screenings SummaCare assists members by continuing to mail our annual preventive health and care opportunity letters. For members with chronic conditions such as diabetes and heart disease, care opportunity letters are also sent, which provide important information about screening and care for specific conditions. These letters help identify recommended services for you and your family. The care opportunity letter is only sent to members if we have not received claims by mid-year for the recommended cancer screenings, blood pressure checks and other tests or services. The letters are followed by a reminder phone call later in the year for members with continued care opportunities. SummaCare continues 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.

If  you would like a summary of the annual program evaluation, call 330-996-8857.