Activities that improve health care quality, increase the likelihood of desired health outcomes, and are grounded in evidence-based medicine are to be included in medical costs for the medical loss ratio calculation.
Quality Improvement programs are designed to achieve the following goals:
- Improve health outcomes, including an increased likelihood of desired outcomes compared to a baseline and reduced health disparities among specified populations
- Prevent hospital readmissions
- Improve patient safety and reduce medical errors, lower infection and mortality rates
- Increase wellness and promote health activities
- Enhance the use of health care data to improve quality, transparency, and outcomes
Examples of quality improvement activities include the following case and disease management and care coordination services:
- Arranging and managing transitions
- Medication and care compliance
- Programs to support shared decision-making with patients, their families, and the patient’s representatives
- Use of medical homes (as defined in the Affordable Care Act)
- Nurse-line (with some exceptions)
- Comprehensive discharge planning
- Prospective medical and drug utilization review
- Certain wellness and health promotion activities (e.g., coaching and incentives)
- Fraud and abuse programs (the lesser of expenses and recoveries)
- Certain limited health technology (HIT) expenses
Quality improvement activities must be designed to improve the quality of care received by an enrollee and be able to be objectively measured for producing verifiable results and achievements.