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Quality Improvement Program Summary

Highmark Northeastern New York is committed to delivering to members of all age’s high quality, cost-effective medical care, and services by qualified professionals.  To achieve that goal, we provide comprehensive health, wellness, and care management programs to create quality experiences that inspire a healthier life; improve health outcomes and reduce disparities in care.

Goal Statement:

The focus of the Quality Improvement (QI) Program is to continuously assess and improve the care delivered by our participating practitioners/providers and the service delivered by Highmark Northeastern New York staff to our members. We have the responsibility of designing, measuring, assessing, and continually improving our performance. The result is the enhanced health and well-being of the populations we serve.


The scope of the QI Program is comprehensive. It includes all Highmark Northeastern New York members for all operating areas, as well as practitioners and providers who participate in the network. The QI Program includes organizational wide activities, a focus on trend analysis, and development of interventions that improve the quality of care and service provided to our members. The activities include clinical, service, and patient experience.

The QI Program monitors and evaluates a wide variety of clinical and service topics for members that include, but are not limited to, those listed below:

Clinical Topics

  • Health Promotion
  • Preventive Care
  • Disease Management
  • Case Management
  • Population Health Management
  • Utilization Management (including appropriate utilization of services)
  • Patient Safety
  • Behavioral Health Management
  • Culturally and Linguistically Appropriate Services 
  • Complaint management for access to care or quality of care issues
  • Medical policy
  • Pharmacy Management
  • Continuity and Coordination of Care

Service Topics

  • Accurate and timely phone responses
  • Access to practitioners and providers
  • Satisfaction/dissatisfaction issues identified through satisfaction surveys, complaints, appeals, and grievances
  • Information regarding processes, such as competence of staff, attitude of representatives, times of operation, efficiency of program (Customer Service Representative Coaching and Monitoring Program)
  • The Health Care Quality Improvement Program includes integration of Public Health goals whenever possible
  • Member Touch Point Measures for enrollment, claims processing, and customer service

Participation in National Proven Quality Programs

National Committee for Quality Assurance Accreditation (NCQA)

NCQA is a private, non-profit organization dedicated to improving health care quality.

The Plan is accredited for our Commercial and Exchange products. Accreditation focuses on Quality Improvement in key impact areas: care coordination, access, and member connections—availability of health resources such as wellness services and self-management tools for chronic disease management. Results are based on clinical performance and consumer experience (HEDIS® and CAHPS®).


Healthcare Effectiveness Data and Information Set (HEDIS®)

HEDIS® is the measurement tool used by the nation’s health plans to evaluate their performance in terms of clinical quality and customer service. HEDIS® includes more than 96 measures across 6 domains of care:

  • Effectiveness of care
  • Access and availability of care
  • Experience of care
  • Utilization and risk adjusted utilization
  • Health plan descriptive information
  • Measures collected using electronic clinical data systems

HEDIS® results are collected and reported separately for populations covered by Commercial, Medicaid, Medicare, Exchange/Marketplace, and Essential Plan lines of business. HEDIS® results are used to identify opportunities for improvement in the healthcare provided to our members and to evaluate many of the quality programs.

Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Survey 

CAHPS® provides a measurement of how well the plan and practitioners met members’ expectations. Results are used to compare our results with other local plans and regional and national averages, to revise goals and best practices, and to target areas of improvement for plan members, including Commercial HMO/POS and PPO, QHP (Qualified Health Plans) Medicare, Medicaid, and Essential Plan.

Quality Rating System (QRS) and Qualified Health Plan (QHP) Enrollee Experience Survey

QRS is comprised of clinical quality measures, including NCQA, HEDIS® and Pharmacy Quality Alliance (PQA). It also includes survey measures based on questions from the Qualified Health Plan Enrollee Experience Survey (QHP Enrollee Survey) that capture enrollee experience and plan efficiency, affordability, and management. This data is submitted to the Centers for Medicare & Medicaid Services (CMS) for QHPs that offers coverage through the Marketplace.  CMS collects this data and calculates quality ratings for each QHP issuer’s product type such as HMO, POS, PPO, EPO.  Performance quality ratings are produced based on a 5-star rating scale.

Quality Assurance Reporting Requirements (QARR)

QARR consist of performance measures reported annually to the New York State Department of Health for Commercial, Medicaid and Exchange/Marketplace products. QARR data includes HEDIS® measures as well as NYS-specific measures related to many preventive health conditions and services. QARR performance results assist our members and prospective members in choosing a health plan and identify service-improvement opportunities for evaluating existing and potential quality programs.


Medicare Star

The Centers for Medicare and Medicaid Services (CMS) created the star rating system to measure how well Medicare Advantage and Prescription Drug Plans (PDPs) perform. Star ratings range from one to five stars, with five being the highest score and one being the lowest. 


This five-star rating system provides Medicare beneficiaries and their families a way to compare plan performance and quality. Star ratings are calculated each year and published in the fall.


Star ratings are consistent with CMS’ quality strategy of optimizing health outcomes by improving quality and transforming the health care system. The CMS quality strategy goals reflect the eight priorities set out in the National Quality Strategy. These priorities include:

  •  Embed quality into the care journey
  • Advance health equity
  • Promote safety
  • Foster engagement among providers, individuals, and their families
  • Strengthen resiliency
  • Embrace the digital age
  • Incentivize innovation and technology to drive care improvements
  • Increase alignment to promote transparency, reduce burden and facilitate impactful and consistent advances in health equity across all programs and communities we serve