Cigna-HealthSpring Quality Improvement program helps to improve the medical care we provide our customers. It's our aim to help customers feel better, which leads to a better quality of life. There are many ways we evaluate our Quality Improvement program. Throughout the year, we ask you to submit customer surveys and complete preventive health screenings to show us how you're doing. By comparing those results to the Quality Improvement goals, we are able to see how our program helps our customer's health. We've put together a quick summary of some of the focus areas of our Quality Improvement program.
In 2017, Cigna-HealthSpring aimed to have 84% of women complete a breast mammogram. Six markets either declined or remained the same in mammogram completion compared to 2016, and two markets reached the 84% goal.
Colorectal cancer screenings are very important because it is usually difficult to know if you have symptoms for colorectal cancer. It was our goal for 80% of our customers to have a colorectal cancer screening in 2017. While nine markets reached our goal, eleven markets improved in these screenings from 2016. One market decreased from the previous year.
Customers with diabetes should have a retinal eye exam every year. If you had a diabetic eye exam this year and you do not have any problems with retinal eye changes, you can wait two years to have your next exam. Our goal was for 81% of our customers with diabetes to complete this eye exam. Eleven markets saw improvements with increased diabetic eye examinations. Seven markets reached the 81% goal. Cigna-HealthSpring is aware of how important it is for customers to get preventive screenings and will be working towards improving these rates in the coming year.
Cigna-HealthSpring recognizes the importance of customers understanding and managing their own health care. Our Quality Improvement program attempts to help track this in many different methods. In this report, we will focus on high blood pressure.
Blood pressure control scores showed improvement in most markets in 2017. Thirteen markets had improvement over 2016, with two reaching our goal of 86%. This is measured by evaluating the health of each customer with high blood pressure, including but not limited to healthy diet, exercising, and taking prescribed blood pressure medications from their doctor.
If you have any questions, or to find results specific to your region, please call Customer Service.
Cigna-HealthSpring must provide in a timely manner a written organization determination to enrollees who request this information. A written organization determination is a determination by the plan prior to a provider furnishing a service confirming whether that service is both medically necessary and a plan-covered service and in consequence will be paid for by the MA plan.
*We will give you an answer sooner if your health requires us to do so.
If you disagree with a coverage decision we have made, you can appeal our decision. For more information about organization determinations, coverage determinations, and appeals, see your Evidence of Coverage.
Cigna-HealthSpring Utilization Management associates base utilization decisions on the clinical needs of the members, benefit availability, and appropriateness of care. Objective, scientifically-based clinical criteria and treatment guidelines such as InterQual criteria and Medicare National Coverage Guidelines, in the context of provider or member-supplied clinical information, guide the decision-making process. Cigna-HealthSpring in no way rewards or incentivizes, either financially or otherwise, practitioners, utilization reviewers, case managers, physician advisers, or other individuals involved in conducting utilization review, for issuing denials of coverage or service, or inappropriately restricting care.
The Pharmacy & Therapeutics Committee and Clinical Guidelines Committee carefully review new medications, medical and behavioral procedures, and devices as potential benefit additions for our customers. The Cigna-HealthSpring Pharmacy & Therapeutics Committee is made up of practicing physicians and pharmacists from various clinical specialties, including experts regarding care of the elderly or disabled individuals. Together, these professionals review new medications, as well as evaluate new Food and Drug Administration approved uses of medications. The Pharmacy & Therapeutics Committee considers whether a particular drug is better than, the same as, or worse than the medical benefit and safety of other available drugs within the same drug class. The Pharmacy & Therapeutics Committee looks at scientific studies and standards of care, including clinical guidelines and current medical and drug studies. Based on this review, the Pharmacy & Therapeutics Committee votes on whether medications work better than, as well as, or worse than other treatments in terms of medical benefit and safety. This decision is used to help determine what drugs are listed on the formulary.
TennCare is not responsible for payment for these benefits, except for appropriate cost sharing amounts. TennCare is not responsible for guaranteeing the availability or quality of these benefits.