Medical Management

We focus on keeping our members healthy. That’s why we closely watch and evaluate our programs and the medical care you receive. We measure their quality and safety to find out what works best. This process of figuring out how to improve your care is called the Quality Improvement Program. It helps us find areas where we can be better. Plus, it helps us improve your health.

Maryland Physicians Care has a Quality Management (QM) Program. The QM Program monitors and assesses the health care services delivered to our members. The goal is to deliver high-quality care and services to all members.

Every year Maryland Physicians Care measures our progress against goals. We measure all parts of the QM Program. That includes clinical and service activities like:

  • Promoting health care safety with member and provider education.
  • Establishing preventive health guidelines and clinical practice guidelines. These help members understand what kind of services they need and how often they’re needed.
  • Making sure members have access to qualified health care professionals.
  • Evaluating the quality of care members receive. We look at data known as the Healthcare Effectiveness Data and Information Set® (HEDIS). That info helps us see if members are receiving appropriate preventive care. Examples of preventive care:
    • Annual flu shots
    • Child immunizations (shots)
    • Eye tests
    • Cholesterol tests
    • Prenatal care for pregnant women
    • Evaluating member quality of care concerns and take action if needed
    • Conducting surveys to see if members are satisfied. Example: The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey: 
      • The survey is mailed to members every year to complete and send back.
      • The survey helps us see how happy or unhappy members are with their care and doctors.
      • The survey helps us find areas to improve.

For more information about our Quality Management Program, please contact Member Services at 1-800-953-8854.

 

Listed below are some of our 2014 accomplishments:

  • Achieved a score of 100 percent during the 2014 External Quality Review Organization (EQRO) Audit
  • Improved outcomes in the following HEDIS measures:
    • Immunizations for Adolescents - Combo 1
    • Well Child Visits First 15 Months of Life
    • Well Child Visits for 3-6 Year Olds
    • Adolescent Well Care
    • Child Access 25 mo – 6 yrs.
    • Adult Access 45-64
    • Breast Cancer Screening
    • Cervical Cancer Screening
    • Postpartum Care
    • Frequency of Prenatal Care
    • CDC – HbA1c Testing
    • CDC – HbA1c Adequate Control < 8
    • CDC – Eye Exam
    • CDC – LDL Testing
    • CDC – LDL Control < 100
    • CDC – Nephropathy
    • CDC – Blood Pressure < 140/90
  • Improved member satisfaction in the following CAHPS survey areas:
    • General Child and Chronic Condition Child
      • Shared Decision Making
      • Care Coordination
      • Doctor Communication
      • Getting Needed Care
    • Adults
      • Doctor Communication
      • Getting Care Quickly
      • Customer Service

Listed below are some of our areas of focus and goals for 2015:

  • Continue to look for way to improve access to care for our members
  • Continue to work with doctor offices to coordinate care and help schedule an appointment
  • Continue to reduce hospital readmissions
  • Enhance staff training

Listed below are some of our 2015 accomplishments:

  • Achieved a preliminary score of 100 percent for the 2015 External Quality Review Organization (EQRO) audit. Final results are due in September.  It is expected this will be the 5th year in a row Maryland Physicians Care receives a perfect score.
  • Achieved a National Committee for Quality Assurance (NCQA) accreditation status of Commendable for service and clinical quality, meeting and exceeding NCQA’s rigorous requirements for consumer protection and quality improvement.
  • Improved outcomes in the following HEDIS measures:
    • Adult BMI assessment
    • Weight assessment and counseling for children
    • Childhood immunizations - Combo 4 through Combo 10
    • Immunizations for Adolescents – Combo 1
    • Breast Cancer Screening
    • Chlamydia Screening in Women – total (16-24) years
    • Medication management of COPD worsening – Bronchodilator Rate
    • Use of Appropriate Medications for people with Asthma – total ages 5-64
    • Medication management for people with Asthma
    • Appropriate testing for children with a sore throat
    • Controlling High Blood Pressure
    • Appropriate treatment with medicine after a heart attack
    • Comprehensive Diabetes Care: HbA1c testing
    • Comprehensive Diabetes Care: HbA1c control (<8%)
    • Comprehensive Diabetes Care: medical attention for kidney disease
    • Comprehensive Diabetes Care: controlling blood pressure
    • Child and Adolescents’ Access to a Primary Care Provider
    • Well Child visits the first 15 months of life
  • Improved member satisfaction in the following Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey areas:
    • Adults
      • How Well Doctors Communicate
      • Getting Needed Care
      • Getting Care Quickly
      • Health Promotion and Education
      • Coordination of Care
    • Child
      • Health Promotion and Education
    • Child with Chronic Conditions
      • Doctor Communication
      • Getting Care Quickly
      • Customer Service
      • Health Promotion and Education
  • Improved satisfaction rates in all six of the Provider Satisfaction Survey composite measures:
    • Overall satisfaction
    • No-Show Appointments
    • Finance Issues
    • Customer Service/Provider Relations
    • Coordination of Care/Case Management
    • Utilization Management
  • MPC achieved success in the 2 state mandated Performance Improvement Projects (PIPs)
    • Adolescent Well Care -- MPC was able to sustain a rate above the national benchmark for a second year in a row.
    • Controlling High Blood Pressure -- MPC exceeded our goal and saw an improvement of 14.6 percentage points above last year.
  • MPC performed well in the annual Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program evaluation. MPC met or exceeded the rate required for all 5 components of the review. 

Listed below are some of our areas of focus and goals for 2016:

  • Continue to look for and find ways to improve access to care for our members.
  • Continue to help coordinate care and assist members with scheduling doctor appointments, especially for preventative care.
  • Reduce the number of members who are readmitted to the hospital.
  • Increase the number of children who complete the appropriate testing for lead poisoning.
  • Increase the number of practitioners who are certified in the Maryland Healthy Kids Program which establishes preventative care standards for children and young adults 0-21 years old.
  • Continue to work to improve the quality scores for the healthcare standardized measures.

Listed below are some of our 2016 accomplishments:

  • The External Quality Review Organizations’ (EQRO) annual review has been changed to every 3 years however MPC received official word of the 100% score for the 5th year in a row for the CY 2015 review in the summer of 2016. The interim review for CY 2016 was positive and a full report is due later this year.
  • Maintained a National Committee for Quality Assurance (NCQA) accreditation status of Commendable for service and clinical quality, continuing to meet and exceed NCQA’s rigorous requirements for consumer protection and quality improvement.
  • Improved outcomes in the following HEDIS measures:
    • Childhood immunizations
    • Immunizations for Adolescents – Combo 1
    • Human Papillomavirus Vaccine (HPV) for female Adolescents
    • Lead Screening in Children
    • Medication management of COPD worsening
    • Use of Appropriate Medications for people with Asthma – total ages 5-64
    • Medication management for people with Asthma
    • Appropriate testing for children with a sore throat
    • Adult access to preventative / ambulatory Health Services
    • Child and Adolescents’ Access to a Primary Care Provider
    • Pregnancy Care and Care of Women After giving birth
    • Well Child visits the first 15 months of life
    • Well Child visits in the 3rd, 4th, 5th and 6th years of life
    • Adolescent Well Care visits
  • Improved member satisfaction in the following Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey areas:
    • Adults
      • Customer Service
      • Shared Decision Making
      • Health Promotion and Education
      • Coordination of Care
    • Child
      • Customer Service
      • Getting Needed Care
    • Child with Chronic Conditions
      • Customer Service
      • Getting Needed Care
      • Coordination of Care
      • Health Promotion and Education
  • Improved satisfaction rates for the “Overall Satisfaction” score in the Provider Satisfaction Survey.
  • Successfully added technology for improved member communication through text messaging and our enhanced Facebook page.
  • MPC remains successful with the 2 state mandated Performance Improvement Projects (PIPs)
    • Adolescent Well Care -- MPC was able to sustain the success of being above the national benchmark for three years in a row this PIP is now retired.
    • Controlling High Blood Pressure -- MPC continues to work to help improve the care of our members with Hypertension.
  • MPC performed well in the annual Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program evaluation. MPC met or exceeded the rate required for 4 of 5 components of the review.

Listed below are some of our areas of focus and goals for 2017:

  • Continue to look for and find ways to improve access to care for our members.
  • Continue to help coordinate care and assist members with scheduling doctor appointments, especially for preventative care.
  • Maintain the low number of members who are readmitted to the hospital.
  • Increase the number of children who complete the appropriate testing for lead poisoning within the recommended time frame.
  • Increase the number of practitioners who complete and include in the medical record the lab testing and screenings that are recommended by the Maryland Healthy Kids Program. This program establishes preventative care standards for children and young adults 0-21 years old.
  • Help improve members understanding of Asthma including its causes, things that can trigger an attack and the medications that can help treat it.
  • Continue to work to improve the quality scores for the healthcare standardized measures.

Our Case Management Department is here to help you understand and control complex health conditions. Case managers and care coordinators can help Monday through Friday during normal business hours. A case manager may be assigned to help you plan for and receive health care services. The case manager also keeps track of what services are needed and what has been provided.

HealthChoice members with special needs may also qualify for case management:

  • Children with special health care needs
  • People with physical and/or developmental disabilities
  • Pregnant and postpartum women (The Mother's Guide to Pregnancy and The Mother's Guide to Life After Delivery)
  • Learn about our Start Smart for Your Baby program
  • People who are homeless
  • People with HIV/AIDS
  • People who need substance abuse treatment
  • Children in State-supervised care

For more information about case management or to request services, call 1-800-953-8854.

HealthChoice members with other special needs may also qualify for case management:

  • Children with special health care needs
  • People with physical and/or developmental disabilities
  • Pregnant and postpartum women – learn about our Small Miracles program
  • People who are homeless
  • People with HIV/AIDS
  • People who need substance abuse treatment

For more information about case management, call toll-free 1-800-953-8854.

Special needs populations
The state has named certain groups as needing special support from the MCO. These groups are called “special needs populations” and include:

  • Children with special health care needs
  • Adults or children with a physical disability
  • Adults or children with a developmental disability
  • Pregnant women and women who have just given birth
  • Adults and children who are homeless
  • Adults and children with HIV/AIDS
  • Adults and children with a need for substance abuse treatment
  • Children in State‑Supervised care

We have a process to let you know if you are in a special needs population. If you have a question about your special needs, contact our Member Services department at 1‑800‑953‑8854.

Managed Care Organizations no longer cover recipients for Substance Use Disorder Services.  These services will be provided directly through the Maryland Medical Assistance Program.

To request Substance Use Disorder Services please contact the Behavioral Health Systems, etc. by calling 1-800-888-1965.

Please note, this change does not affect your MCO assignment and Maryland Physicians Care (MPC) will continue to cover you for all other HealthChoice services.  If you have any questions or concerns about your coverage under MPC, please call Member Services at 1-800-953-8854.

Concurrent review is a way to evaluate admissions while a member is hospitalized. Admissions are reviewed for medical necessity, and continuing services are reviewed for the appropriate use of inpatient medical resources. Our inpatient concurrent review process has multiple steps to reach a decision. The initial process can be done over the phone, by fax for in hospital admissions

Additionally, Maryland Physicians Care would like to remind you of our affirmation statement regarding incentives:

  • Utilization Management decision-making is based only on the appropriateness of care and the service being provided
  • Maryland Physicians Care does not reward health care providers or other individuals for issuing denials of coverage or service
  • There are no financial incentives for UM decision makers to encourage underutilization

For more information about Utilization Management, please call 1‑800‑953‑8854, then follow the prompts.  Staff is available at least eight (8) hours a day during normal business hours for inbound collect or toll-free calls regarding utilization management issues.  Staff can receive inbound communication regarding UM issues after normal business hours by fax to 1-877-535-0591 or phone 1-800-953-8854 and following prompts to the UM department and leaving a voice message. Maryland Physicians Care TDD/TTY (Telecommunications Device for the Deaf/TeleTypewriter) services are provided for members who need this service at 1-800-735-2258.  Language assistance is also available for members to discuss utilization management issues. MPC requires utilization management staff to identify themselves by name, title and organization when initiating or returning calls regarding UM issues.

We offer disease management programs that can help you better manage your health. These programs educate you on your disease and give you tips on how to stay healthy. If you are an adult over the age of 18 and have asthma or diabetes, we can help you.

Through the disease management program, you can get information to read and the names and phone numbers of resources who can help you manage your illness. We'll work with your doctor to come up with a care plan that is just right for you. The care plan will help you meet your goals and manage your illness.

It's your choice to participate in a disease management program.

You can join by calling our Special Needs Coordinator at 1-800-953-8854 or by email  at MBU-MDMedicaidSpecialNeeds@marylandphysicianscare.com

Your PCP, specialist, or other health care providers may also suggest that you join the program. Because it's an opt-in program, you can choose to join or leave the program at any time without any impact to your benefits.