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Monitoring Quality Management

QM Program

Our goal at Optimum Healthcare is to help our members improve their health by providing the best care and service options. In order to do this, we rely on our Quality Management (QM) program. The QM program monitors the quality of care given by Plan providers. The QM Program also looks for areas of service that need to be improved.

Measuring Success

Every year, we measure to see the progress we have made toward meeting our goals for healthy members. One of the tools we use to do this is called HEDIS®, which stands for Healthcare Effectiveness Data and Information Set. HEDIS® is a very common tool used by health care plans to see how well they are serving their members. We use these HEDIS® results to see where we need to focus our improvement efforts.

HEDIS® Results

Our 2020 HEDIS® (DOS 2019) results show that Optimum Healthcare improved its performance and met quality goals in many HEDIS®measures. These areas include:

  • Adult Access to Preventive Services
  • Adult BMI Assessment
  • Antidepressant Med Management: Acute and Continuation Phase Rx
  • Breast Cancer Screening
  • Controlling High Blood Pressure
  • Colorectal Cancer Screenings
  • Comprehensive Diabetes Care: Poor HbA1c Control >9 (inverted), HbA1c Control <8 and HbA1c Testing
  • Comprehensive Diabetes Care: Blood Pressure Controlled <140/90 mm Hg
  • Comprehensive Diabetes Care: Eye Exams
  • Comprehensive Diabetes Care: Monitoring Diabetic Nephropathy
  • Medication Reconciliation Post- Discharge
  • Osteoporosis Management in Women
  • Persistence of Beta Blocker Heart Attack
  • Rx in Rheumatoid Arthritis
  • Pharmacotherapy Management of COPD: Systemic Corticosteroid

Areas where we would like to improve our performance include:

  • Follow-up Hospital Mental Illness
  • Pharmacotherapy Management of COPD: Bronchodilator
  • Spirometry Testing for COPD
  • Use of High-Risk Medications in the Elderly

You can view our full quality Health Plan Report Card at:

For more information on HEDIS® and Quality Measurement, go to:

You can also call Member Services at 1-866-245-5360.

Last updated 10/01/2020