Learn what quality is, and how Harvard Pilgrim can improve the quality of your care.
Quality health care means doing the right thing, at the right time, in the right way, for the right person and having the best possible results.
There are important differences in the quality of care delivered in different parts of the United States, and even among physicians, hospitals and health plans here in New England.
Most consumers look for:
- The basics: Cost, coverage and access to services
- Staying healthy: Help with preventing illness and complications of disease
- Getting better: Testing and treatment for short-term, acute illness
- Living with illness: Reducing and managing the effects of chronic illnesses
- Coping with change: Understanding and adapting to life transitions (i.e. early childhood development, adolescence, menopause, etc.)
Congress mandated that the federal government produce an annual National Healthcare Quality Report (NCQA) and National Health Care Disparities Report to assess how well health care in the United States measures up in each of the following areas:
- Safe: Avoiding injuries to patients from the care that is intended to help them
- Effective: Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit
- Patient-Centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
- Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care
- Efficient: Avoiding waste, including waste of equipment, supplies, ideas and energy
- Equitable: Providing care that does not vary in quality because of personal characteristics
Here’s what you can do to make sure you’re getting the top quality health care.
Choose quality doctors
Most Harvard Pilgrim members have a primary care provider (PCP), such as a family physician, internist, pediatrician or general practitioner, as their personal doctor, while a few may see a specialist for all or most of their care. While members in our HMO and Point of Service (POS) plans are required to have a PCP, it's a good idea for all members to have a PCP. The PCP can work with you to keep you healthy as well as coordinate your care when you are sick. This is especially important if you have more than one health problem and see different specialist doctors for different conditions.
Choosing a PCP can be a difficult task because doctors have different qualifications, training and areas of expertise—and the quality of care they provide can vary greatly.
Why is choosing a PCP important?
Since you will be partnering with your PCP to ensure your good health, you need to be comfortable talking with him/her about your health care concerns and be confident that he/she will meet your needs and provide you with quality health care.
What is Harvard Pilgrim doing to help members choose a PCP and other providers?
To find out which PCPs and other providers participate in Harvard Pilgrim’s network, go to our Provider Directory where you‘ll be able to search for doctors who fit your criteria for location, specialty, gender and group or hospital affiliation. Once you have a list of providers that meet your criteria, look for those with a Harvard Pilgrim Quality Honors award designation.
A red ribbon symbol, is given to PCPs who practice in physician groups or health care systems (with multiple medical practices) that achieved a "Quality Honor Roll" award—the top performance level on a series of clinical quality measures.
- For more information, see the Harvard Physician Group Honor Roll
- You can also contact Member Services to have a Provider Directory mailed to you
- If you have difficulty finding a doctor, contact Member Services, and a representative will be glad to assist you
What you can do to choose a PCP
The U.S. Agency for Healthcare Research and Quality (AHRQ) offers the following suggestions for selecting a personal doctor:
- Write down the things that are important to you about a doctor (e.g., training/experience, credentials, personal manner, accessibility, hospital affiliation, languages spoken, etc.).
- Get referrals from friends, family, other doctors, local medical society, health plans or hospitals and make a list of the doctors you want to know more about.
- Check the doctor's qualifications through trusted sources, such as those listed below.
- Call the doctor's office and ask basic questions, such as whether he/she is accepting new patients, office hours, other physicians in the practice, appointment availability, coverage for emergencies, etc.
- Once you have identified your top choice, make an appointment to meet the doctor to discuss your concerns and determine if you will be comfortable having him/her as your personal doctor.
What to look for when choosing a doctor:
- Choosing a doctor, by the Agency for Healthcare Research and Quality (AHRQ)
- Physician Compare at Medicare.gov
- Administrators in Medicine DocFinder
Boards of Registration in Medicine:
Learn about the performance of physicians or physician groups:
- Massachusetts Health Quality Partners
- Maine Health Management Coalition
- NCQA's Physician Recognition Programs (for best results, view in Mozilla Firefox or Google Chrome)
Harvard Pilgrim's network includes 182 of the area's most respected community, teaching and specialty hospitals. Many of these hospitals are recognized around the world for their excellence and high quality.
What is Harvard Pilgrim doing to identify high-quality hospitals?
- Through their secure account, Harvard Pilgrim members can access information to help them prepare for procedures and compare hospitals based on location, procedure or condition, and important indicators of patient safety and clinical quality of care.
- To see if your doctor has admitting privileges at a particular hospital, use the Provider Directory and perform a "Quick search" for your doctor. Your doctor's listing will show his/her hospital affiliations.
- You can also contact Member Services to have a Provider Directory mailed to you. The directory includes lists of affiliated hospitals.
What you can do to choose a high-quality hospital
The U.S. Agency for Healthcare Research and Quality (AHRQ) suggests you ask the following questions when selecting a hospital:
- Does my health plan cover care at the hospital?
- Does my doctor have privileges at the hospital (is permitted to admit patients)?
- Does the hospital meet national quality standards?
- How does the hospital compare with others in my area?
- Does the hospital have experience with my condition?
- Has the hospital had success with my condition?
- How well does the hospital check and improve on its own quality of care?
- Choosing a Hospital, by the Agency for Healthcare Research and Quality (AHRQ).
- The Leapfrog Group has information comparing hospitals on how well they are complying with recommended standards for protecting patient safety.
- The Joint Commission on Accreditation of Healthcare : "Quality Check" provides information on how a hospital measures up on clinical quality and compliance with patient safety standards.
- Hospital Compare is a tool for comparing hospitals on clinical quality that was developed by the Centers for Medicare and Medicaid Services. It uses some of the same measures used in the Joint Commission's "Quality Check."
- New Hampshire Hospital Association provides information on patient quality, safety and price transparency.
- Maine Hospital Association features quality statistics and other information for Maine hospitals.
- Commonwealth of Massachusetts offers resources for consumers to find health care quality and cost information for Massachusetts hospitals.
- Rhode Island Department of Health provides reference information for major RI hospitals.
- Healthfinder Hospital Links include Quality Guidelines and other resources to help people stay healthy.
Providers and their office staff are the first and most important link in delivering the highest quality medical care. Harvard Pilgrim has created programs to encourage and reward best practices among physicians and physician groups.
Building the foundation for excellence
Harvard Pilgrim has created financial incentives for physician groups to invest in clinical information technologies, such as patient registries and electronic medical records, that have proven value in increasing physician compliance with the best clinical practices and preventing medical errors.
As part of Harvard Pilgrim's strategy to promote and recognize high quality care, we publish an annual list of physician groups whose commitment to high-quality care has earned them the distinction of membership on the Harvard Pilgrim Physician Group Honor Roll.
The Honor Roll for adult and pediatric practices is based on performance against national clinical quality benchmarks. Primary care physicians who are affiliated with a physician group that has achieved Honor Roll or Honorable Mention status are noted with award ribbons in Harvard Pilgrim's print and online physician directories.
Harvard Pilgrim has built financial incentives into our contracts with physician groups to promote and reward their achievement of high levels of clinical and service quality on performance measures that have been targeted for improvement.
Quality grants program
Grants awarded to physician groups are meant to help achieve two important quality improvement goals:
- Provide support for physician practices to explore innovative strategies and programs to improve care in important clinical topic areas.
- Provide support for quality improvement interventions in local physician practices that may face particular challenges to achieving our high-performance targets. These grants help practices to address challenges such as:
- Geographic access to needed services
- Language or cultural barriers
- Outreach and other services to disadvantaged populations
These practices, in turn, support Harvard Pilgrim Health Care's mission to improve the health of its members and the community at large.
Other practice support for providers
- Clinical guidelines and performance feedback
- Patient handouts and support tools
- Patient registry data and information for disease management
Harvard Pilgrim is dedicated to maintaining a robust quality improvement program. Quality initiatives include both clinical and service improvement projects. Each year, Harvard Pilgrim sets a quality improvement agenda, monitors its progress and evaluates its effectiveness.
2019 Quality Program Description (pdf)
Contains description of Harvard Pilgrim’s Quality Program, including goals and objectives, scope, quality structure, activities and annual evaluation.
2019 Quality Improvement Workplan Summary (pdf)
Contains a complete list of all current clinical and service quality initiatives along with each project's key objectives.
Evaluation of Harvard Pilgrim’s 2018 Quality Program (pdf)
Contains a high-level assessment of the effectiveness of the clinical and service quality projects on Harvard Pilgrim's Quality Improvement Work Plan. It includes an overview of the scope of the prior year's Quality Program and highlights program accomplishments.
HEDIS* HMO/POS Results
for Harvard Pilgrim Health Care and
HEDIS* HMO/POS Results
for Harvard Pilgrim Health Care of New England
Contains the most recent publicly-reported HMO/POS results for the HEDIS effectiveness-of-care measures. Results are reported for Harvard Pilgrim Health Care, Inc. (MA and ME members) and for Harvard Pilgrim Health Care of New England (NH members). The national HMO/POS averages are included for comparison.
HEDIS PPO HPIC Results (pdf)
Contains the most recent publicly-reported PPO Commercial results for the HEDIS effectiveness-of-care measures for HPIC (MA & CT PPO members only). The national PPO averages are included for comparison.
*HEDIS (Healthcare Effectiveness Data and Information Set)
Guide to HEDIS* Measures (pdf)
Contains a description of the effectiveness-of-care measures detailed in the HEDIS report, including inclusion criteria for age, gender, time frame and clinical parameters.
* HEDIS (Healthcare Effectiveness Data and Information Set