QualityPath Frequently Asked Questions (FAQs)

 

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Download the FAQs as a .pdf or browse the list below.

General Questions


 What is QualityPath?

QualityPath is a new way to find and pay for high-quality health care.

QualityPath identifies high-quality care; uses new ways to pay for care; and rewards patients who choose that care with lower out-of-pocket costs.

QualityPath‘s innovative approaches include:

  • Identifying doctors, hospitals and other facilities that meet or exceed national measures for delivering quality care for selected surgeries and tests. For surgeries, measures are based on the performance of a specific doctor working at a specific hospital.
  • Asking designated doctors and facilities to adopt processes that are shown to improve care.
  • Requiring providers to adopt decision-support tools system-wide to benefit all patients.
  • Focusing on non-emergency surgeries and tests that allow patients to “shop” for care.
  • Assisting employers in creating health benefit plans that encourage employees and family members to choose high-quality care.
  • Exploring new ways to pay for care, such as bundled payments and warranties.

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Why did The Alliance create QualityPath?

The Alliance’s experience shows that measuring the quality of care is an important step toward improving the quality of care. By helping more people select high-quality health care providers, QualityPath can improve health care for everyone.

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How was QualityPath developed?

The Alliance gathered information from multiple sources in an inclusive process. Input from clinicians; medical specialty societies; and other purchasers provided valuable insights. Members of The Alliance pledged their support for QualityPath, which helped show hospitals and doctors that employers are committed to changing the way they purchase ‘shoppable’ surgeries and tests to impact quality and cost.

The Business Health Care Group, which serves employers in the Milwaukee area, supported the development of QualityPath.

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How do hospitals and doctors gain QualityPath designation?

Doctors, hospitals and other facilities can apply to participate each year using a request for proposal (RFP) process. Once they are part of QualityPath, they must complete a “maintenance of designation” application process to continue to participate. Their performance on national quality measures is examined annually as part of this process. Learn more about the process.

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How are applications reviewed?

Identifying information is removed from responses to the request for proposal (RFP).

These “de-identified” responses are reviewed separately by the manager of value measurement and a team of medical reviewers from Metastar, a quality improvement organization. Each reviewer scores the responses against a template, determining whether each criterion was met or not. Any scoring differences are discussed and resolved.

A summary of the initial review and the de-identified responses are then presented to the full review team for review and discussion. This review team includes:

  • The Alliance Manager of Value Measurement
  • The Alliance President and CEO
  • A physician who serves as The Alliance Health Care Transformation Consultant
  • Other physicians or experts as needed

Once decisions are made and evaluations are finalized, the identifying information is restored. The review team holds conference calls with each applicant to discuss evaluation results. Each applicant also receives written feedback, including any gaps that must be closed to fully meet the criteria.

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What happens when QualityPath doctors, hospitals or clinics change their status?

Doctors, hospitals or clinics may leave the program if they relocate, choose not to seek maintenance of designation, fail to meet quality standards or are unwilling to negotiate a lower, bundled price. When that occurs, The Alliance works with employers to notify patients of the switch and guide them to another designated provider. You can verify current QualityPath doctors, hospitals and clinics here. Patients can contact the Patient Experience Manager at 800.223.4139 to learn more.

QualityPath designation for surgeries is based on a specific doctor working together with a specific hospital. Together, they must meet national measures of quality and implement processes that have been shown to improve care for patients. Some hospitals that are designated to provide surgeries through QualityPath have only one designated doctor. If that doctor leaves the hospital, then the hospital no longer is designated as a QualityPath provider. To regain its QualityPath designation, the hospital must apply again based on its performance when working with one or more doctors.

When a doctor works with a hospital that is already part of QualityPath, the doctor can gain designation when he or she meets the quality criteria.

Please note that QualityPath designation does not affect a doctor or hospital’s status as an in-network provider through The Alliance.

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Is QualityPath information shared publicly?

The Alliance publicly shares:

  • Doctors, hospitals and clinics that are designated to provide care through the QualityPath program for a specific time period.
  • Doctors, hospitals and clinics that applied for the program and met the quality criteria, but did not agree to the lower bundled rate with warranty.
  • Information about the criteria used for QualityPath

Information about costs for QualityPath surgeries and tests is only available to employers who are members of The Alliance.

The Alliance does not release any information about doctors, hospitals or clinics that applied but did not meet QualityPath criteria.

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What does “bundling” mean? What is included in a QualityPath bundle?

A bundle is a flat rate that covers multiple elements of a medical test or surgery.

  • For surgeries, the QualityPath bundle covers medical procedure costs, which includes the surgery itself, in-hospital care and doctor visits after surgery. Rehabilitation costs may be included, depending on whether the patient chooses to have follow-up services, such as physical therapy, at the QualityPath facility where the surgery was performed. The bundle also applies to care for most complications covered under the warranty offered by the provider for the service or surgery.
  • For CTs and MRIs, the QualityPath bundle covers the cost of the test as well as the fees for radiologists who interpret the results.

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Do doctors and hospitals who have left the QualityPath program still meet national quality measures?

We annually review the performance of QualityPath doctors and hospitals against national quality measures. Once they leave the program we no longer conduct this review.

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Employers


What is the role of employers in QualityPath?

Participating employers are required to:

  • Use QualityPath plan designs that encourage employees to use QualityPath designated doctors, hospitals and facilities.
  • Send a letter and brochure to employees’ homes to notify them about QualityPath once a year, with The Alliance paying to print and mail materials in an employer’s first year of participation.
  • Educate employees about The Alliance supports this effort with videos, presentations and materials.

The Alliance’s Find a Doctor website also guides employees and family members to QualityPath doctors, hospitals and facilities.

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If my organization participates in QualityPath, what are the plan design requirements?

These requirements differ for surgeries and tests.

These requirements apply to QualityPath surgeries:

  • Under The Alliance standard network plan, QualityPath surgeries must be covered at 100 percent so there is no out-of-pocket cost to the employee for pre-operative visits and tests, the surgical procedure and the follow-up care, including physical therapy.
  • In addition, employers with benefit plans that have low out-of-pocket costs to the employee are strongly encouraged to offer financial incentives to motivate employees to select QualityPath providers.
  • For plans with Health Savings Accounts (HSAs), 100 percent coverage is required after the deductible is paid. In addition, the employer must provide the patient with a minimum of a $1,000 cash incentive to be either funded in the HSA account or paid directly to the patient. At this time, this requirement applies only to the QualityPath surgeries of total hip replacement, knee replacement and heart bypass surgery.

These requirements apply to QualityPath tests:

  • Under The Alliance standard network plan, QualityPath CTs and MRIs must be covered at 100 percent so there is no out-of-pocket cost to the employee for the test and the radiologist’s fee for reading it. The deductible is waived for QualityPath; however, the employee still pays the deductible when using other health services.
  • In addition, employers with benefit plans that have low out-of-pocket costs to the employee are strongly encouraged to offer financial incentives to motivate employees to select QualityPath providers.
  • For plans with Health Savings Accounts (HSAs), 100 percent coverage is required after the deductible is paid. In addition, the employer must provide the patient with a minimum of a $100 cash incentive to be either funded in the HSA account or paid directly to the patient.

For more information about plan design requirements, contact Mike Roche, member services manager, at 800.223.4139, x6645, or mroche@the-alliance.org.

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Can my organization choose to enhance its QualityPath plan design to make it more appealing to employees and family members? If so, what are my options?

Yes, employers are encouraged to enhance the QualityPath plan design to adjust for benefit plans that already provide high coverage. Employers may choose to:

  1. Offer cash incentives/bonuses. This is important for plans with low out-of-pocket obligations for employees and family members, as well as high-deductible health plans with HSAs.
  2. Offer reimbursement for travel expenses such as mileage, parking or tolls; hotels; or a per diem daily allowance for travel.

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What makes participating in QualityPath worthwhile for employers?

Employers gain:

  • Confidence that high-quality care will be provided and the patient – their employee or family member – will have a better patient experience.
  • Cost savings from a bundled price that covers most elements of the surgery or test.
  • Warranties that cover the cost of complications for surgeries or the need to repeat a test, which can quickly escalate costs.

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Why is The Alliance adding outpatient CT and MRI scans to QualityPath?

Adding CT and MRI to QualityPath will help us make a difference in these areas:

  • Total cost: Alliance employers spend a significant amount on CT and MRI each year. For example, employers typically spend more on imaging each year than the combined cost of all QualityPath surgeries. One in 11 people who get care through The Alliance network has an outpatient CT or MRI each year.
  • Cost variation: CT and MRI costs vary widely from one facility to another. Within The Alliance network, the lowest price for an MRI of a joint in the lower leg is $440 while the highest is $3,130, based on cost estimates obtained from Find a Doctor in April 2016. This variation can be difficult to predict, as no single facility is high-cost or low-cost in all types of CT or MRI imaging.
  • Quality measurement: Quality measures are available for facilities that offer CT and MRI scans, yet consumers currently lack an easy way to tap into these quality measures to choose a facility based on quality and cost.
  • Ability to steer consumers: Some employers already reward consumers for choosing lower-cost facilities for CT and MRI scans, which shows consumers are likely to be receptive to information about cost and quality.
  • Opportunity to allow more health care facilities to participate. Hospitals, clinics and free-standing imaging facilities that offer CTs and MRIs throughout The Alliance service area can now apply to be part of QualityPath.

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Will all CTs and MRIs be available through QualityPath?

No. QualityPath will cover most types of outpatient CTs and MRIs; however, some highly specialized CT and MRI scans will be excluded. Inpatient and emergency CTs and MRIs are also excluded.

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Is there a fee for Alliance members to participate in QualityPath

No.

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Do providers who are paid less for QualityPath surgeries and tests simply raise the prices of other treatments and procedures to make up for it?

QualityPath prices were negotiated with the expectation that a higher volume of patients will help make a bundled price worthwhile for hospitals, clinics and doctors. In addition, Alliance contracts are designed to protect employers from this type of price-shifting.

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Can an employer participate in only one part of QualityPath, just surgeries or just tests, for example?

No. Employers who participate in QualityPath must offer both surgeries and tests through the program.

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Is QualityPath available to my employees who live outside The Alliance service area?

Yes. Employers can make arrangements for employees and family members who live outside The Alliance service area to have access to QualityPath. To learn more, contact Mike Roche, member services manager, at 800.223.4139, x6645, or mroche@the-alliance.org.

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Which hospitals and doctors have met these standards and agreed to a bundled price to become QualityPath participants?

A current list of QualityPath doctors and hospitals is available at www.qualitypath.com and highlighted on the Find a Doctor website. Please note that designations for surgeries apply to specific doctors working at specific hospitals; neither a doctor nor a hospital qualifies on its own.

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How long does it take to add a new procedure to QualityPath?

It takes roughly 12 to 15 months to add a new procedure to QualityPath. The process focuses on collaborating with hospitals, doctors and clinics to measure the quality and then negotiate the cost of QualityPath tests and procedures.

Three to Five Months

Month 1 – 3 Compile data and then select potential procedures based on differences in cost and quality; the availability of national quality measures; the patient’s ability to shop for care; usage by patients in The Alliance network; and other factors. This step may take several months.
Form a Blue Ribbon Panel representing local health care providers, Alliance staff, national and regional quality experts for this procedure, and in some instances an employer. This panel hones in on procedure quality and whether it can be measured and improved.

10 – 13 Months

Month 1 Develop quality criteria.
Hold a quality criteria webinar for hospitals, clinics and doctors.
Create a draft of the quality criteria for public comment.
Month 2 Publicly share the quality criteria for comment and review by doctors, hospitals and clinics.
Month 3 Post feedback from clinics, hospitals and doctors online along with The Alliance’s response.
Month 4 Use their feedback to create the RFP document.
Month 5 Post the final document and notify doctors, hospitals and clinics that it is available. They will have roughly four weeks to indicate their “intent to respond.”
Hold an RFP webinar to allow hospitals, doctors and clinics to gain more information and ask questions. A recording of the webinar and answers to any questions are posted on The Alliance website.
“Intent to respond” is due from doctors, hospitals and clinics.
Month 7 RFPs are due from clinics, doctors and hospitals. Identifying information is omitted from RFPs so reviewers will not be swayed by the names of doctors, hospitals and clinics that apply for designation.
Completed RFP responses are sent to a third-party measurement firm to be “scored” by a panel of quality experts.
Month 8 RFP responses and their scores are reviewed. This process has several steps built in to audit results. Both Alliance staff and outside experts participate in the review.
Month 9 Hold feedback calls with the hospitals, clinics and doctors who applied. If necessary, ask for clarifying information for unclear responses.
Negotiate cost savings in QualityPath contracts with doctors, hospitals and clinics who will meet quality criteria when the program launches. Cost savings give employers an incentive to “steer” employees and family members to designated QualityPath providers.
Month 11 Announce the clinics, doctors and hospitals that meet QualityPath standards for quality and cost.
Participating employers begin working to notify employees about where to go for QualityPath surgeries and tests. They may also decide to offer additional incentives to encourage employees to use QualityPath for surgeries or tests.
Month 13 The QualityPath surgery or test is available from designated doctors, hospitals and clinics.

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TPAs

How does The Alliance work with TPAs to implement QualityPath?

The Alliance continues to consult with TPAs to effectively implement QualityPath. Any TPA that represents Alliance members and would like to learn more about QualityPath should contact Carlene Boehmer, Director of Claims and Customer Service, at 608.210.6601, cboehmer@the-alliance.org.  Employers are also welcome to contact Carlene to learn whether The Alliance has met with your TPA or to set up a TPA meeting.

Doctors & Hospitals


How do doctors and hospitals qualify for QualityPath surgeries?

Doctors and hospitals that perform elective surgeries as part of QualityPath annually complete an extensive application process that includes a review of past outcomes for these procedures as well as the implementation of important standardized clinical processes. These measures examine the performance of a specific doctor working at a specific hospital. Doctors and hospitals also agree to provide care at a bundled price that covers all elements of the procedure and to offer a warranty that covers the cost of complications. QualityPath is a voluntary program and any facility that offers these surgeries can apply.

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How do doctors and facilities qualify for QualityPath for CT and MRI scans?

Facilities that perform CT and MRI scans as part of QualityPath must annually complete an application process that verifies their accreditation; participation in the ACR National Radiology Data Registry; ability to share images electronically; participation in national safety efforts, including the Image Wisely and Image Gently programs that aim to lower the amount of radiation used in medically necessary imaging for adults and children while eliminating unnecessary tests; and demonstrate appropriate use of certain types of scans. They must also commit to processes shown to improve outcomes for patients, including decision support for ordering CTs and MRIs. QualityPath is a voluntary program and any facility that offers these tests can apply.

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What are the QualityPath standards?

Quality standards are built on evidence-based practices that contribute to better results for patients, including:

  • Appropriate Use of Imaging, which means the decision to use high-tech imaging is based on clinical evidence so patients get high-value care without unnecessary exposure to radiation.
  • A Patient-Centered Process, which means patients are fully informed and have a voice in important decisions, including whether to have the procedure and at what point.
  • Transparency, which means hospitals, doctors and clinics share the results of procedures with registries to improve quality measurement as well as offering information to patients.
  • Positive Patient Outcomes, which means that designated hospitals and doctors for QualityPath surgeries have a proven record of working together to achieve good patient outcomes for those surgeries.

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Which hospitals and doctors have met these standards and agreed to a bundled price to become QualityPath participants?

A current list of QualityPath doctors and hospitals is available at www.qualitypath.com and highlighted on the Find a Doctor website. Please note that designations for surgeries apply to specific doctors working at specific hospitals; neither a doctor nor a hospital qualifies on its own.

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Why are there differences between QualityPath and other quality assessments?

There are four factors that lead to differences.

  1. The science of quality measurement is young. We hope that common measures and methodologies will emerge over time, but that appears unlikely in the near future.
  2. Proprietary methodologies. Some measurement instruments use proprietary methodologies that make it very difficult to understand differences. QualityPath uses an open methodology that we hope will lead to buy-in and improvement over time.
  3. How the results will be used impacts how quality is measured. Some transparency tools, for example, give an overall hospital quality rating. There is a place for that, since it can give providers and payers a general sense for the quality of care provided. Our data shows that the quality of care within a provider system can vary based on the service provided and the doctor providing it. It’s possible that a hospital could receive a low quality score overall yet perform quite well when the measurement hones in on a specific area of care.
  4. Different groups seek to measure different things. For example, the Leapfrog Group’s Hospital Safety Score examines patient safety for an entire hospital. In contrast, QualityPath measures for surgeries looked at specific outcome and complication measures for specific surgeries at specific hospitals performed by specific doctors.

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Will you release the names of hospitals or doctors that applied for QualityPath designation but did not meet the standards, or did not complete the process?

No. Hospitals and doctors may have many reasons for choosing not to pursue QualityPath designation or for being unable to completely meet the standards at this time, including pursuing other goals or priorities related to quality and patient care. The Alliance set a high bar for QualityPath quality criteria and we recognize that it takes a significant commitment to meet the standards.

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Are there hospitals and doctors that meet the quality standards but are not designated QualityPath providers?

Possibly. For example, a provider may apply and meet the quality standards, but then be unwilling to commit to the pricing portion of the program. We only review the performance of doctors, hospitals and other facilities who are part of The Alliance network and who are willing to share their data with us so it is possible that some hospitals and doctors that choose not to apply could meet quality standards. Check www.qualitypath.com for current QualityPath doctors, hospitals and clinics.

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For surgeries, why are hospitals and doctors rated only in combination and only for the performance of specific procedures?

We know that quality varies from hospital to hospital. There is evidence that quality also varies from doctor to doctor, even within the same hospital. So identifying high-quality care for high-stakes surgeries means we need to know the outcomes for the combination of a specific facility and a specific doctor for a specific procedure.

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How do the doctors, hospitals and clinics in QualityPath handle the added volume of QualityPath tests and surgeries?

All the tests and surgeries included in QualityPath are non-emergent, elective and “shoppable.” That means employees have time to make choices about when, where and whether to have surgery, which gives them some flexibility in scheduling.

It’s worth noting that quality must always remain the highest priority even when caregivers are in high demand. We believe seeking high-quality care is worthwhile even in situations when patients must wait for surgery or travel a little farther for care.

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Why do doctors, hospitals and clinics have to apply to participate in QualityPath? Why didn’t you simply rate every hospital, clinic or doctor in your network that participates in these surgeries and tests?

The Alliance is not attempting to force this approach on all doctors, hospitals and clinics; instead, we want to work with doctors, hospitals and clinics that are willing to share data on their ability to deliver high-quality care. Our goal is to change the marketplace by continually inviting hospitals, doctors and clinics to participate in QualityPath, sharing information about national measures of care, encouraging doctors and hospitals to participate in regional and national organizations that set standards for care, and searching for opportunities to help patients actively voice their needs and preferences. As part of this process, we ask doctors, hospitals and clinics to share information that is typically unavailable to the general public; in other words, the doctors, hospitals and clinics must choose to provide this information to The Alliance.

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Surgeries & Tests

What surgeries and tests are offered through QualityPath?

QualityPath offers:

  • Total hip replacement.
  • Knee replacement.
  • Coronary artery bypass graft (CABG) surgery, also known as heart bypass surgery.
  • Most types of outpatient CT and MRI scans.

How does The Alliance select QualityPath tests and surgeries?

QualityPath focuses on high impact tests and surgeries where there is significant potential both to improve patient outcomes because of variation across doctors and facilities, and to reduce costs for patients and employers alike. In addition, two criteria are followed:

  • Proven quality standards must be available to measure performance.
  • Surgeries and tests must be elective and “shoppable,” which means that patients have time and opportunity to thoughtfully select their caregivers.

QualityCounts®

Did The Alliance discontinue its QualityCounts® Outpatient and Inpatient reports?

Yes. Information about the cost and quality of health care offered in The Alliance network is instead built into the Find a Doctor website. QualityCounts is now used to highlight our efforts to improve quality, cost and transparency for employers and consumers.

Employees & Family


Why does The Alliance help employees and family members learn about quality and cost?

It can be hard to find credible, easy-to-understand information about quality and price for specific surgeries and tests. Without that information, patients can’t determine which doctors, hospitals and clinics provide good value and outcomes. Employees and family members can use QualityPath information to select doctors, hospitals and other facilities that have proven their ability to meet quality standards and have agreed to provide care at a bundled price that covers 100 percent of the cost of the QualityPath medical procedure or test for the employee (special provisions apply for high-deductible health plans with a health savings account). The Patient Experience Manager guides employees through the process and answers questions along the way.

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Are you asking me to change my primary care doctor?

No. Primary care doctors refer patients to other caregivers for QualityPath tests and surgeries. When patients have the option of using QualityPath caregivers for lower out-of-pocket costs, we ask primary care patients to assist in making those referrals. The Patient Experience Manager works with patients to help make the connection to QualityPath caregivers. When the procedure is done, the Patient Experience Manager will help return the patient to the primary care doctor for care.

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Why should a patient use a QualityPath doctor, hospital or clinic?

There are at least three reasons why a patient who is eligible for QualityPath should choose a designated doctor, hospital or facility:

  1. Quality of Care: All QualityPath caregivers must meet or exceed quality standards that are based on national measures and recommended practices for care. For surgeries, quality of care is based on a specific doctor when working with a specific hospital.
  2. A Better Patient Experience: Support for patients is built into QualityPath. For surgeries, QualityPath offers personalized assistance from the Patient Experience Manager to help make appointments, arm the patient with information and coordinate care.
  3. Cost: When patients use QualityPath, their claims are covered at 100 percent (special provisions apply to patients who are enrolled in a high-deductible health plan with an HSA). Patients also benefit from a warranty. Contact your human resources representative to learn whether your employer participates and what costs and rewards are offered.

alertPatients who are considering a QualityPath surgery are required to call the Patient Experience Manager at 800.223.4139 prior to having the surgery. Please call as early as possible in the process.

QualityPath CT or MRI patients are asked to tell us when they schedule an appointment at www.qualitypath.com/TellUs. This call is not required, but it will help patients get the full benefits of QualityPath. Use www.qualitypath.com or the Find a Doctor website to find hospitals and clinics that offer QualityPath CTs and MRIs.

The Alliance also offers a flyer to help educate consumers about their options for choosing doctors or health systems.

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What does the QualityPath warranty cover?

For surgeries, QualityPath hospitals and doctors offer a warranty that covers any care related to complications that arise during the surgical procedure or in the 90 days that follow it. The warranty assures the patient that if there are complications related to the QualityPath procedure or care, the QualityPath provider will take care of you without any additional charges. The patient returns to the QualityPath facility to receive this care unless it is urgent or emergent care and the patient has traveled a distance for the procedure. Following recommendations for follow-up care such as physical therapy or cardiac rehabilitation keeps the warranty in effect.

For CTs and MRIs, the 30-day warranty covers scans that must be redone because of poor image quality.

It’s important to note that the warranty is offered by the facility and doctor – not by The Alliance.

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When a patient who had a QualityPath surgery is still within the 90-day warranty period, what happens if the patient seeks care from a doctor or hospital that is not part of The Alliance network?

It is important to stay within The Alliance network whenever possible. The 90-day warranty offered by the QualityPath provider pays for post-surgical care and related complications when it is provided by QualityPath doctors and hospitals. If you use a doctor or hospital that is not part of The Alliance network, the warranty does not apply and any services will be paid according to your standard benefit. Emergency care may be covered at the in-network rate; check your benefit plan to learn more about the level of payment for in-network and out-of-network care. If you feel that an exception should be made due to special circumstances, you can follow your health plan’s guidelines for appealing a claim.

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How do patients qualify to participate in QualityPath?

Patients must:

  1. Work for (or an eligible dependent of someone who works for) an employer that participates in QualityPath.
  2. Be covered by a health plan that uses The Alliance network and is eligible for QualityPath.
  3. If having a QualityPath surgery, call the Patient Experience Manager at 800.223.4139 before having the surgery. Make this call as early as possible to gain the greatest benefit from QualityPath. The Patient Experience Manager works closely with the patient throughout the QualityPath process.
  4. If having a QualityPath test, patients should ask the doctor ordering their scan to use a QualityPath hospital or clinic. Next, patients should notify The Alliance of their appointment at www.qualitypath.com/TellUs.
  5. Use a QualityPath doctor, hospital or clinic. For surgeries, this means using a QualityPath doctor and hospital team. Patients should call 800.223.4139 to verify that they are using a QualityPath doctor, hospital or clinic.

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How can patients learn more about QualityPath?

  • Ask your employer whether your company participates in QualityPath. If so, your employer will have educational materials they can share.
  • Visit the QualityPath website at qualitypath.com.
  • If you work for a participating employer and are deciding whether to have a QualityPath surgery, contact The Alliance at 800.223.4139 and ask to speak to the Patient Experience Manager.
  • Check The Alliance’s Find a Doctor tool to find QualityPath designated doctors, hospitals and clinics.

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What if a patient chooses not to have a QualityPath surgery as a result of the shared decision-making approach required by QualityPath?

Pre-operative doctor visits and related tests will be covered at 100 percent even if the patient decides that surgery is not the right care at this time. The Third Party Administrator (TPA) that pays claims on the employer’s behalf will determine whether the pre-operative work was medically appropriate as part of the QualityPath process.

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I know someone who had a poor result from a surgery performed at a QualityPath facility. Why are they on the list of designated providers?

First, programs change and improve. Every single applicant who entered this process made positive changes to their program. So the program they have now is likely to be significantly different than the program they had in the past. That’s the kind of change QualityPath aims to encourage.

Second, we know that outcomes for surgeries can vary from doctor to doctor. QualityPath rates a specific facility working with a specific doctor to try to account for that difference.

Third, no hospital, doctor or facility is perfect. For a variety of reasons, they can sometimes have imperfect results.

Finally, QualityPath cannot guarantee a good outcome for every patient. We want to increase the likelihood of a good outcome by directing patients to doctors, hospitals and clinics that have proven outcomes and that have processes and procedures in place to maintain a high level of quality.

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Could patients be asked to travel to hospitals or facilities outside their local area to benefit from QualityPath?

It is likely that there are QualityPath hospitals and doctors near you for some surgeries and tests – 75 percent of people who rely on The Alliance network to access care are within 30 miles of designated hospitals and doctors for orthopedic surgeries such as hip or knee replacement. Ninety-one percent are within a 50-mile range. For MRIs, 72 percent of patients are within a 30-mile range of a designated provider, while 93 percent are within a 50-mile range. For CTs, 25 percent are in a 30-mile range while 39 percent are in a 50-mile range.

For heart surgeries, the shift from a Madison location to Gundersen Health System in LaCrosse means that more patients will face a drive of roughly two to four hours.

Some employers make arrangements for employees and family members who live outside The Alliance service area to have access to QualityPath. These employers help cover the cost of travel to help employees and family members use QualityPath for care.

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If travel is required, who pays for it?

Employers decide whether to cover travel costs as part of their health plan or through other arrangements. Check with your human resources representative for details.

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If a patient who has a QualityPath surgery chooses to have follow-up care (such as physical therapy) from a local provider, rather than a QualityPath provider, does that mean the patient has to pay for it out-of-pocket?

That depends on your employer’s health plan. Follow-up care at the QualityPath provider who performed the procedure (not just any QualityPath provider) is covered at 100 percent. In addition, some employers also cover follow-up care at facilities within your community at 100 percent. Check with your human resources representative to learn more.

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What items are not covered at 100 percent for patients who have a QualityPath surgery?

For surgeries, items that are not included in the 100 percent benefit level include:

  • Medications purchased at a pharmacy.
  • Care provided at a nursing home following surgery. This care is only covered for a patient who has a bilateral knee replacement.
  • Post-discharge durable medical equipment.
  • Any other services received from a QualityPath provider that are not related to the QualityPath procedure.
  • Non-emergency follow-up care and care for complications if not performed by the QualityPath provider.
  • Care related to the procedure that occurs outside the 90-day warranty period.

Consult your health plan to learn how these services will be covered.

For tests, some MRIs of a joint require an injection of contrast material into the joint. This injection is a separate, additional service that is not eligible for 100 percent coverage in QualityPath. Instead, it will be covered by at your standard benefit level. Only about 2 percent of all MRIs require this type of injection.

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Does the warranty for QualityPath surgeries and tests cover anything that occurs?

No.

For QualityPath surgeries, the patient must comply with recommendations for follow-up care, such as physical therapy or cardiac rehabilitation, to qualify for the warranty. In addition, the need for additional care must be directly related to the surgical procedure.

For QualityPath tests, the warranty covers the need to perform the test again. To be covered by the warranty, this test must be performed by the QualityPath hospital or clinic that did the first test.

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What is an “eligible health plan” for participation in QualityPath?

First, the patient must gain access to health benefits through an employer or insurance trust that participates in QualityPath.

Second, the patient must select a health plan that accesses care through The Alliance network.

Third, the employee cannot be enrolled in an exclusive provider organization (EPO).

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I have primary insurance through another plan, but gain access to The Alliance network through secondary insurance. Can I still get 100 percent coverage through QualityPath?

No. Anyone is welcome to use QualityPath doctors and hospitals, but only people who have primary insurance that uses The Alliance network qualify for QualityPath benefits and services.

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I’m on a high-deductible health plan with a health savings account. How does that change QualityPath’s coverage of surgery costs?

If you are in a high-deductible health plan with a health savings account, you must pay your deductible before 100 percent coverage of your surgeries or tests will begin.

  • Employers who participate in QualityPath help reduce your out-of-pocket costs for a QualityPath surgery by giving you a special payment of at least $1,000, which may be paid directly to you or deposited to your health savings account. Check with your human resources representative to learn the details of your employer’s health plan.
  • For CT or MRI tests, employers who participate in QualityPath help reduce your out-of-pocket costs by giving you a special payment of at least $100, which may be paid directly to you or deposited to your health savings account.

All other benefits of the QualityPath program remain in place.

Check with your human resources representative to learn the details of your employer’s health plan.

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I’ve already had a joint replacement and need to have the same hip or knee replaced again. Does QualityPath cover this surgery?

No. QualityPath covers first-time joint replacements only. A “revision” is a more complex surgery.

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What if I have other services done at the same visit as my QualityPath test?

Other services done during the same visit as the test are covered at your standard benefit level, not the QualityPath level. Examples of services that are typically not part of the QualityPath benefit include an office visit, an X-ray or certain types of injections for MRI tests.

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