Quality Initiatives

CIGNA HealthCare is committed to achieving and maintaining quality in our business with respect to:

• Accreditation Recognition
• National Committee for Quality Assurance (NCQA)
• URAC (formerly the Utilization Review Accreditation Committee)
• Joint Commission on Accreditation of Health Care Organizations (JCAHO)
• Health Management Resources
• Preventive Care
• Chronic Care
• Member Effectiveness of Care and Satisfaction Outcomes
• Measurements of Success
• Pharmacy
• Clinical management programs
• Patient Safety
• The Leapfrog Group
• Provider Recognition
• Physician quality and cost efficiency profile
• CIGNA Care Network
• Provider Credentialing and Recredentialing
• Medical Record Reviews
• Other important information
• Continuity and Coordination of Care
• Medical Technology
• Medical Ethics
• Advantages of Being a CIGNA HealthCare Participating Provider

Accreditation Recognition

National Committee for Quality Assurance (NCQA)
In April 2007, NCQA awarded 100% of all accredited CIGNA HMO health plans "Excellent status" when evaluated against NCQA's Managed Care Organization (MCO) accreditation standards. In addition, 100% of accredited CIGNA health plans received "Distinguished status" when evaluated against NCQA's Quality Plus Member Connections and Physician Hospital and Quality standards. In December 2007, NCQA awarded CIGNA HealthCare PPO Full Accreditation, the highest level of accreditation for PPO plans. CIGNA was one of the first national PPO plans to receive this accreditation.

URAC (formerly the Utilization Review Accreditation Committee)
Our 24-Hour Health Information Line, utilization management and case management programs have been awarded full accreditation status by URAC. Our utilization management, case management and call center policies criteria are based on standards set by URAC.

Joint Commission on Accreditation of Health Care Organizations (JCAHO)
Participating hospitals are accredited by JCAHO, or must undergo onsite reviews by the state, Medicare or CIGNA HealthCare, based on NCQA standards.

Health Management Resources Our member health and wellness programs can help people get healthy and stay healthy. We offer a 24-hour health information, support for healthy moms and babies, transplant care management, pharmacy outcome improvement and chronic condition management.Through these programs, a variety of reminders are sent to members and/or their physicians to encourage important health screenings, exams and immunizations.

Preventive care
Prevention and Screening are key components of helping members stay healthy and lead to quality, cost effective care. Reminding members and/or physicians when services are due or missed, using claim data, is critical to our success. Examples of programs that support this goal are:

• Well Informed Program - Reminders are sent to members and/or their physicians when a gap has been identified in receiving important evidence-based medicine services, to encourage them to receive important health screenings, exams and immunizations. For exemple, women age 40 - 69 who have missed a mammogram in the last 24 months are reminded about the need for this service and their physicians are notified of the missed service.
• CIGNA HealthCare Colorectal Cancer Screening Program - Members age 50 - 65 who are in need of colorectal cancer (CRC) screening are engaged by offering to send them a fecal immunochemical test kit in the mail if they return a business reply card. The American Cancer Society has endorsed this test for colorectal screening.
• Immunization Reminder Program - Reminder mailing to the parents of children turning 18 months old regarding the shots that need to be given by two years old.
• Preventive Care Benefit Guidelines - Our Preventive Care Benefit Guidelines were assembled based on U.S. Preventive Health Services Task Force guidelines and other nationally recognized organizations. The guidelines have been reviewed and approved by the CIGNA Quality Council.

Chronic care
CIGNA Well Aware for Better Health^® can provide individualized care, education and support for members with the following chronic conditions:

• Asthma
• Diabetes
• Heart disease
• Low back pain
• Depression
• Weight complications
• Chronic obstructive pulmonary disease
• Targeted conditions*

• Well Aware Care Guides based on national clinical practice guidelines
• quarterly condition-specific newsletters
• patient-specific medication reports
• patient-specific compliance report twice a year
• patient-specific notification of positive depression screening (with the patient's permission)
• information on recognizing depression in patients with chronic conditions
• other patient-specific information, as appropriate

Member Effectiveness of Care and Satisfaction Outcomes
As a provider in the CIGNA HealthCare network, your commitment to quality care greatly contributes to our members care and satisfaction outcomes.

Measurements of Success
CIGNA HealthCare uses HEDIS® clinical metrics to measure the results of many of our clinical interventions. Beginning in 2006, we've measured and reported the clinical effectiveness results for all products (HMO/POS and OAP/PPO) and submitted these results to NCQA to be included in developing benchmark data .

The CIGNA HealthCare 2008 HMO/POS national results for the HEDIS®* Effectiveness of Care (EOC) measures increased this year by 4.23 percent over 2007. Once again, our strong results demonstrate our success in supporting quality care for our members.

The CIGNA HealthCare 2008 PPO national results for the HEDIS Effectiveness of Care (EOC) measures also increased this year by 5.0 percent over 2007. Over the last three years (2006-2008), our EOC rates for PPO have increased 8.26 percent.

Over the last seven years (2002-2008), our overall EOC rates for HMO/POS have increased 25.49 percent. Here is a sampling of our 2008 national averages for the HMO/POS plans:

Member Satisfaction Results
CIGNA HealthCare is committed to quality of service. To help monitor the quality of services delivered to members, we participate in the National Committee for Quality Assurance (NCQA) Member Satisfaction Surveys. This annual survey measures performance in key areas of care and service and is based on the Health Plan Employer Data and Information Set (HEDIS^®) Effectiveness of Care results and the Consumer Assessment of Health care providers and systems (CAHPS^®) results submitted to NCQA.

Each year CIGNA HealthCare shows ongoing improvements as measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results. Between 2005 and 2008, Rating of Doctor (+3.9), Rating of Specialist (+3.7), Claim Processing (+3.6), Customer Service (+2.5), and Rating of Health Plan (+1.1) all improved for HMO/POS plans.

We present an overview of the findings of the 2008 HEDIS CAHPS Member Satisfaction Survey fielded among the 23 CIGNA HealthCare Accredited HMO/POS Plans and our national PPO plan. CIGNA HealthCare national results report on the 9 NCQA key measures among others derived from the HEDIS CAHPS Survey.

The survey is conducted with HMO and HMO POS members (including HMO Open Access and HMO POS Open Access)and PPO/OAP members enrolled in CIGNA HealthCare for the full 2007 calendar year.

Data were collected between February and May of 2008, with initial results released in June. Over 24,000 members in these plans responded to the NCQA CAHPS survey. The national sample is very large, so even very small differences in member perceptions are meaningful.

Pharmacy
Providing you with information about your patient's pharmaceutical treatment patterns and options can help you improve outcomes and avoid unintended drug consequences. Our pharmacy outreach programs support you and your patients who have both CIGNA HealthCare medical and pharmacy benefits.

If you have patients who are CIGNA HealthCare members and who meet the criteria for a pharmacy outreach program, we may receive a notification letter with the patient's clinical history. A pharmacist from CIGNA Pharmacy Management may call you to discuss the patient's information.

Clinical management programs
Following are some examples of our pharmacy clinical management programs.

• Refill Too Soon - CIGNA Pharmacy Management maintains refill logic based on days supply for retail and mail order scripts. The program is designed to help monitor use and promote safe medication management.
• DACON - DACON is when a member is taking two or more tablets or capsules per day of a medication when it may be clinically appropriate to receive the same dose in a single, higher strength tablet or capsule. The benefits of this program can include reduction in the number of doses per day, potentially improved compliance and a reduction in the cost of the prescription. We communicate this opportunity to our network pharmacist, the prescribing physician and our participants.
• Save with Generics - Member & Physician Outreach - When clinically therapeutic alternatives are available, we may reach out to prescribers of single source brands. We also may notify members in situations where there could be potential savings.

• Cholesterol Treatment
• Asthma Management
• Depression Management

Patient Safety
We promote the health and safety of our members through quality tools and measures.

The Leapfrog Group
As an employer member of The Leapfrog Group, we support patient safety initiatives in a number of ways, including

• Our Senior Medical Executives are actively involved in Leapfrog as members of The Leapfrog Healthplan Lilipad Group and the Incentives and Rewards Workgroup.
• We provide continuous education to our members and providers on patient safety.
• We recognize participating hospitals that meet or exceed Leapfrog standards through our online Provider Excellence Recognition Directory hospital selection tool.
• We base many of our activities on meeting patient safety goals developed by the Institute of Medicine (IOM). For example, to help meet the goal of medication safety, we use a pharmacy edit system that helps identify potential medical problems when a prescription is filled and can notify the pharmacist online. The system has identified problems with up to 5% of prescriptions, including issues of drug interactions, prescriptions that exceeded maximum dose guidelines, and potential duplications of therapies that could result in drug toxicity.

Provider Recognition
We encourage quality through a variety of recognition programs designed to reward excellence, help change practice patterns, help improve care, and help members make more informed decisions.

Our Provider Excellence Recognition Directory includes participating physicians who have achieved quality-related recognition from the National Committee for Quality Assurance (NCQA) for diabetes, heart/stroke care, or Physician Practice Connections. It also includes participating hospitals that meet one or more of The Leapfrog Group patient safety standards.

Many physicians applying for NCQA recognition reported their practice patterns improved and/or changed to ensure care was delivered consistently with established treatment guidelines.

Our Centers of Excellence(PDF 243k) Hospital Value Profile program supports the growing consumer demand for information on hospital outcomes and efficiency for specific diagnoses and procedures. Through this program, participating hospitals have both a patient outcomes and cost efficiency score for several procedures/conditions.

Physician quality and cost efficiency profile
Members have online access to quality and cost efficiency profiles for some physician specialties. Employers are asking us to help their employees - our members - make more informed health care choices. To support the industry's movement toward consumerism, we have created programs that align with the Executive Order signed by President Bush directing Federal agencies to provide health care quality and price information for consumers.

Profiles for participating physicians in 21 specialties are available in most service areas in the form of star (*) designations. Separate star designations appear for quality and cost efficiency. These designations are viewable only by members via the online provider directory on our secure member website.

Quality stars are determined based on:

• National Committee for Quality Assurance (NCQA) recognition for diabetes care, cardiac and stroke care, or physician practice connections.
• Performance on select evidence-based quality measures derived from measures endorsed by the Ambulatory Care Quality Alliance (AQA), National Quality Forum (NQF) and Health Plan Employer Data and Information Set (HEDIS).
• Satisfaction of our board certification criteria.
• For bariatric surgeons performing at a Certified Hospital for Bariatric Surgery, satisfaction of our bariatric surgery criteria.

CIGNA Care Network^®
CIGNA Care Network^® is a benefit plan option available for CIGNA HealthCare plans in 58 service areas across the country as of January 1, 2007. Developed in response to our customers' requests for more information about physician quality and cost efficiency, the CIGNA Care Network^® designation helps distinguish physicians within our provider network based on their performance under specific quality and cost efficiency measures in 21 areas of specialty care.

Under the CIGNA Care Network^® benefit plan, a subset of participating physicians in 21 specialties receive the CIGNA Care Network^® designation providers based on specific selection criteria. These specialties include allergy and immunology, gastroenterology, gynecology, orthopedics and surgery and dermatology. CIGNA HealthCare participating providers are considered in-network whether or not they receive the CIGNA Care Network^® designation. However, a lower member copayment or coinsurance level applies if the member chooses a CIGNA Care Network^® designated physician. Learn more about CIGNA Care Network.

Provider Credentialing and Recredentialing
You must meet our standard credentialing criteria to become a provider in a CIGNA HealthCare network. Our credentialing process evaluates practitioner qualifications including certification, training, licensure and criteria related to professional conduct. Recredentialing occurs every three years or sooner if required by law.

Our credentialing criteria include, but are not limited to the following:

• Signed application and agreement (see information about CAQH below)
• Verification of unrestricted state medical license with appropriate licensing agency
• Verification of valid, unrestricted DEA certificate
• Verification of full, unrestricted admitting privileges in good standing on the medical staff at a CIGNA HealthCare participating hospital
• Satisfaction of our board certification criteria
• Satisfactory malpractice claims history
• Verification of education and training
• Review of work history
• Verification of adequate malpractice insurance
• Onsite visit to PCPs, OB/GYNs and high-volume behavioral health specialists
• Acceptable history relative to all types of disciplinary action by any hospital and health care institution and any licensing, regulatory, or other professional organization with jurisdiction over the applicant
• Proof of appropriate professional licensing (only for practitioners whose professions do not require medical licensure)

Medical Record Reviews
Providers use medical records to plan patient care and provide continuity in information about the patient's medical treatment. As a permanent record, the patient's medical record informs other health care providers about medical history.
As part of our quality improvement program, CIGNA HealthCare conducts an Ambulatory Medical Record Review (AMRR) for physicians in our direct contracted networks. The AMRR evaluates medical records, but does not define standards of care or replace your clinical judgment.

• The selection process - We select a random sample of medical records from network primary care-type physicians who have more than 30 members as patients. This sample includes internal medicine, family practice and pediatric practitioners. The review may be conducted at your office or by fax. A quality management representative will work with you and your office staff to facilitate access to the record samples designated for review.
• Medical record documentation - Medical records should be current, detailed and organized to help ensure our members receive effective, safe and confidential care. Medical records should include:
  • Updated, completed problem list or summary of health maintenance exams
  • Current prescription medication list or medication notes
  • Allergies and adverse reactions to medication
  • Medical history
  • Exam coinciding with chief complaint
  • Documentation of treatment plan
  • Review of lab and diagnostic studies
  • Notation of each follow-up visit
  • Consultation report, if requested
  • Review of consultant report, if present
  • Problem addressed at each visit and an ongoing problem list

Other important information

• Confidentiality of medical records - Providers should maintain confidentiality of all medical records and treatment information in accordance with state and federal law.
• Performance goals - Performance goals are established by our Quality Management Committee to serve as a benchmark for the quality of medical records documentation.
• Medical record best practices - CIGNA provides a consultative approach to conducting medical record reviews and offers suggestions and tools to physician practices to assist them with increasing the overall performance of medical record documentation. The following best practices can have a positive impact on physicians' medical record documentation.
• The use of an electronic medical record documentation system, that addresses all important aspects of care (i.e., allergies, adverse reactions and instructions for 'return visit follow up care'), improves legibility (with fewer errors and omissions), patient safety and continuity of care.
• The consistent use of a stamp or sticker to the front of the chart specifying patient allergies and reactions can improve documentation of allergies and patient safety.
• The consistent use of a pre-printed chronic care management tool for tracking assessment, planning and follow-up needs, serves as a quick guide for overall disease management & treatment goals. Examples of such tracking tools are as follows:
  
  Cardiac:http://www.ama-assn.org/ama1/pub/upload/mm/370/cadflowsheet.pdf
  Diabetes:http://www.takingondiabetes.org/PDFs/toolkit_sect2_6-6.PDF
• The use of a Problem List/Health Maintenance tool updated regularly with medications, patient and family history improves patient care management & safety.

Continuity and Coordination of Care

Continuity of care is a process for ensuring the seamless delivery of medical care throughout the course of care. Through communication and coordination of care, disruptions and delays in treatment may be prevented and poor health outcomes averted.

CIGNA annually analyzes data to assess the extent to which providers caring for members in conjunction with one or more specialists, communicate and coordinate care. According to recent data, approximately one-half of medical records reviewed indicate providers are effectively communicating information and coordinating care.

The most commonly identified barriers to coordination of care include:

• Lack of recognition for the need to communicate;
• No means for communicating information; and
• Unaware other providers were involved in the care.

To help facilitate communication between providers, CIGNA has developed communication tools available to download. These tools may serve as a model for exchanging clinical information throughout the coordination of care:

• Diabetic Retinal Exams: Fact Sheet (PDF)
• Diabetes Flowsheet (PDF)
• Cardiology Continuity of Care Report (PDF)
• Ophthalmology/Optometry Continuity and Coordination Report (PDF)

Back to top

Medical Technology
Our Medical Technology Assessment Committee reviews new medical products and procedures in an effort to help make sure we provide coverage only for products and processes proven safe and effective for our members.

The committee, consisting of physicians and other clinicians, analyzes literature, policies and technology assessments and evidence summaries from external experts in the field to determine if new technologies will be approved for coverage.

After a new technology receives final approval from the appropriate government regulatory agency, the committee evaluates answers to the following questions:

• Is the technology safe and effective?
• Are the trials well conducted with sound study methodology?
• Are health outcomes positive and do these positive outcomes outweigh any harmful effects?
• Is the technology available outside of the investigational setting?

Medical Ethics
As an industry leader, CIGNA HealthCare recognizes the importance of ethics in health care today. We were one of the first managed care companies to examine ethical issues and develop a set of formal ethical principles to frame clinical decision-making in general. We were also one of the first to develop an ethics-based care management decision tool to support our physicians as they make complex medical decisions.

Advantages of Being a CIGNA HealthCare Participating Provider
We share your commitment to providing quality health care to our members.

• We're committed to quality and patient safety. All of our health plans have gone through accreditation by the National Committee for Quality Assurance (NCQA).
• We can help you manage your practice. We provide practice management tools to help streamline your administrative practices.
• We can provide clinical resources. You'll have access to the latest clinical care guidelines to help you screen for and treat various conditions.
• We support physician-patient communication. We encourage our participating providers to discuss treatments and procedures freely and openly, even if they're not covered by a member's benefit plan.
• We recognize quality providers. We have a special directory of participating providers who have achieved quality-related recognition from the National Committee for Quality Assurance (NCQA) for diabetes or heart/stroke care. It also includes participating hospitals that meet The Leapfrog Group patient safety standards.
• We focus on wellness. We want our members to get healthy and stay healthy. That's why we offer member health and wellness programs that provide 24-hour health information, support for healthy moms and babies, transplant care management, pharmacy outcome improvement and chronic condition management.
• We communicate with you. We want to be aware of your concerns, and we want you to be aware of what's happening at CIGNA HealthCare. Our Network News newsletters provide important updates on policies and procedures, health-related news and tips, and more. In addition, we post important updates on this site.
• Participating providers can have a peer-to-peer discussion about any utilization management decision which was not approved or certified. Providers can initiate peer-to-peer discussions by contacting the CIGNA HealthCare Health Services Department at 1.800.88CIGNA (882.4462).