AGENDA - sfhp.orgFiona Donald presented the SFHP Opioid Safety and Pain Management update. • Evolution of the Approach to Pain Management o The United States declared a Public Health

Quality Improvement Committee Meeting Thursday, August 8th, 2019

7:30 – 9:00 AM 50 Beale Street, 13th Floor

Join Skype MeetingTrouble Joining? Try Skype Web App

Conference Call Number: +1 (628) 220-4855, access code: 8039349

AGENDA

Quality Improvement Committee: Open Session Time Topic Objective Assigned

7:30 Follow Up Items (5 min) Update Dr. Glauber

QIC: quorum: 5 QIC members, 3 physicians, including committee chair

• Public Comments/Questions• Follow Up Items (p. 3)

7:35 Consent Calendar (10 min) Update/Vote Dr. Glauber

• Review of Minuteso April 4, 2019 (p.4)

• UM Committee Minuteso January 2019 (p. 12)o March 2019 (p. 19)o April 2019 (p. 26)o May 2019 (p. 31)o June 2019 (p. 38)

• Q4 2018 Emergency Room Visit/Prescription Access Report (p. 45)

• Q1 2019 Emergency Room Visit/Prescription Access Report (p. 48)

• QI 2019 Grievances Report (p. 51)• QI 2019 UM Medical and Pharmacy Appeals Report (p. 61)• Q1 2019 Potential Quality Issue Report (p. 64)• Q1 2019 QI Work Plan Scorecard Summary (p. 67)• Policies & Procedures Summary of Changes

(p. 69)o HE-02: Health Outcomes Improvement (HOI) (p. 72)o Care-04: Medi-Cal (p. 79)o Care-07: Medi-Cal, Healthy Kids HMO (p. 93)

7:45 Quality Improvement (75 minutes)

• SFHP Provider Satisfaction Results - 10 min. (p. 99)

• DHCS Advancements in Quality Monitoring - 15 min.(p. 115)

• NCQA Accreditation and External Accountability Set Quality Measures – 15 min. (p. 142)

• Updates on Online Formulary - 10 min. (p. 153)

• Medication Therapy Management (MTM) Program: 2018

Update

Update

Update

Update

Update

Sean Dongre

Adam Sharma /Jim Glauber

Elizabeth Sekera/Annie Humphreys

Kaitie Hawkins

Tammie Chau 1

https://skypemeet.sfhp.org/gdadios/8Y4R188L

https://skypemeet.sfhp.org/gdadios/8Y4R188L?sl=1

Program Summary and Results - 10 min. (p. 160)

• CAHPS Results – 15 min. (p. 168) Update Yves Gibbons

9:00 PAC

NEXT MEETING THURSDAY, OCTOBER 10TH, 2019

2

QIC Meeting Date Follow Up Item Owner Complete By Comments

April 2018Add a section in the Provider Newsletter listing the pharmacies that offer bubble packs.

Ralph Crowder Oct. 2019 Open Information received on the survey completed in June 2019.

Quality Improvement Committee Follow Up List

3

Quality Improvement Committee Minutes

1 | P a g e

Date: April 4, 2019 Meeting Place: San Francisco Health Plan, 50 Beale Street, San Francisco, CA 94105 Meeting Time: 7:30AM - 9:00AM Members Present: Daniel Chan, MD; Ellen Chen, MD; Irene Conway; Lukejohn Day, MD; Edward Evans, Jaime Ruiz, MD; Kenneth Tai, MD;

Ana Valdes, MD; Joseph Woo, MD; Annelie Briones; James Glauber, MD, MPH (Chief Medical Officer, SFHP) Staff Present: Julie Wong, Health Services Specialist; Adam Sharma, Director, Health Outcomes Improvement; Yves Gibbons, Program

Manager, Access and Care Experience; Fiona Donald, MD; Shimi Sharief, MD; Joel Nellis, NCQA Project Manager; Tammie Chau, Care Coordination Pharmacist

Topic Follow-up

[if Quality Issue identified, Include Corrective Action]

Resolution, or Closed Date [for Quality Issue, add plan for

Tracking after Resolution]

Call to Order • Meeting was called to order at 7:30AM with a quorum.

• No follow up needed. • n/a

Follow Up Items

Dr. Glauber gave the following updates: • The landscape is changing for SFHP and other Medi-

Cal plans due to the new Governor Gavin Newsom, who had campaigned on healthcare and California being a single-payer. He also cares about underserved populations and pediatric healthcare.

• Governor Newsom issued an executive order saying that the pharmacy benefit is going to be carved out of Medicaid plans to allow:

o The state to do bulk purchasing of medications o Have a standard statewide formulary o To maximize rebate revenue

• Although there are a lot of discussion and lobbying, our work is focused on mitigating the negative impacts to members, maintaining timely pharmacy data availability and hopefully some ability to customize the formulary based on local practice patterns.

• n/a

4

• There is a heightened emphasis of pediatric healthcare due to the critical California State audit report of EPSDT-(Early, Periodic, Screening, Diagnostic, and Treatment) enrolled children,

• Prop. 56 (Tobacco Tax) dollars will be available to Primary Care Physicians to treat children for both developmental screening of children and for adverse childhood prevents both adults and ongoing basis for children.

• There are pharmacies in our network that can bubble wrap medications. Bubble pack means that rather than getting separate pill bottles 4-5 tablets it will be in a screen bubble pack so easier to take it in the morning. SFHP is surveying our pharmacies and we got responses from the large retail pharmacies some of independent pharmacies. We got responses from about 40 pharmacies so we are in the process of doing call backs to try to determine their status once we have better results and will it be published in the provider newsletter.

Dr. Shimi Sharief is the new SFHP Associate Medical Director. Consent Calendar

• Review of Minutes – February 14, 2019 • Health Services Update • Utilization Management (UM) Committee Minutes

o December 2018 • Q4 2018 Quality Improvement (QI) Scorecard • 2018 Annual Review Medical & Pharmacy Appeals

Approved: o Review of Minutes – February

14, 2019 o UM Committee Minutes

o December 2018 Approved:

o Q4 2018 QI Scorecard o 2018 Annual Review

Medical & Pharmacy Appeals

Quality Improvement

2018 Access Update Yves Gibbons presented the Accessibility Monitoring Annual update. • Access Monitoring Overview:

o Survey Administration o Highlights o Medical Groups achieving 80% o Opportunities for Improvement

Approved: o 2018 Access

Update o Opiate Workshop

5

o Next Steps • SFHP access compliance policy QI-05 Monitoring of

Accessibility of Provider Services consists of perception of access, wait times in provider offices, appointment, telephone and triage access.

• Wait Time & Triage Elements: o Telephone Time to Answer o Telephone Time to Return o Office Wait Time o Daytime Triage o After Hours Triage

• Wait Time & Triage Compliance Parameters: o Each Element: 80% rate is required for compliance. o Survey Response Rate: non-response that does not

contribute to compliance rate calculation. o Clinic or Site Level: compliance reflects individual

sites. • Wait Time & Triage Highlights:

o Wait Time for providers to return phone calls by the end of the following business day is a new standard set by SFHP. In 2018, SFHP surveyed this standard for the first time. The results of the survey are as follows: Overall compliance rate: 86%. SFHP reached 80% compliance for time to answer and office wait time.

o Triage among primary care providers demonstrated an increase in overall SFHP after-hours compliance. 49% in 2017 and 78% in 2018.

• Medical Groups Achieving 80% for Each Element: o Telephone Time to Answer – 11/11 compliant o Telephone Time to Return* – 9/12 compliant o Office Wait Time – 10/10 compliant o Daytime Triage – 4/11 compliant o After Hours Triage – 6/11 compliant

*Groups will not receive requests for corrective action for this element for Measurement Year (MY) 2018. • Opportunities for Improvement:

o Improve compliance rate and consistency with triage.

6

• Wait Time & Triage Next Steps: o Complete corrective action process. o Offer Technical Assistance and plan for 2019

fielding. • Appointment Availability Access Elements:

o Primary care consists of routine, urgent and prenatal appointments.

o Specialty consists of routine and urgent appointments.

o Behavioral Health consists of routine and urgent appointments.

o Ancillary consists of routine appointments. • Specialty:

o Includes: Cardiology, Oncology, Gynecology, Gastroenterology and Endocrinology.

• Appointment Availability Compliance Parameters: o Each element requires 80% rate for compliance. o Response Requirements:

Seven days to respond to survey. Non-response does not contribute to

compliance rate. o Site vs. Provider:

Primary Care Physician (PCP): compliance for appointments reflects appointment availability for the entire provider site, not individual providers.

All others: Compliance reflects individual provider.

• Appointment Availability Highlights: o Primary care - All provider groups reached 80% for

urgent and routine appointments. o Specialty – SFHP reached 80% compliance for

routine gastroenterology and oncology appointments.

o Behavioral Health – SFHP reached 80% compliance for routine appointments.

o Ancillary – SFHP reached 100% compliance for Magnetic Resonance Imaging (MRI).

• Medical Groups by Each Element: o Provider type consists of primary care.

7

o Compliance elements consists of routine, urgent and prenatal.

o There are 30 applicable Medical Groups. • Medical Groups Achieving 80% for Each Element:

o Primary Care: 29/30 compliant o Specialty Care: 25/58 compliant o Behavioral Health: 10/15 compliant o Ancillary Care: 8/10 compliant

• Opportunities for Improvement: o Improve compliance rate. o Historic response rate:

MY 2016: 60% MY 2017: 53% MY 2018: 50%

• Medical Groups Achieving 50% Response Rate by Provider Type:

o Primary Care: 10/10 compliant o Specialty Care: 7/14 compliant o Behavioral Health: 2/9 compliant o Ancillary Care: 6/7 compliant

• Provider Appointment Availability Survey (PAAS) next steps:

o Request corrective action for <80% compliance with access standard and/or <50% response rate.

o Close clinic & group corrective action plans: end of 6/2019.

o Plan for 2019 PAAS fielding & offer TA. Opiate Workgroup Fiona Donald presented the SFHP Opioid Safety and Pain Management update.

• Evolution of the Approach to Pain Management o The United States declared a Public Health

Emergency in 2017 to address the National Opioid Crisis.

o According to the 2017 Annual Surveillance Report of Drug-Related Risks and Outcomes.

63% of drug overdose deaths in 2015 involved prescription or illicit opioids.

In 2014, opioids accounted for

8

approximately 22% of emergency department visits for nonfatal, unintentional drug poisonings.

• Trends in Opiate Use at SFHP o SFHP continues to see a decline in percentage

of members who received an opiate prescription in the past year, from 12% in 2014 to 7%in the most recent year.

• Although percentages of SFHP members receiving opioid Rx has decreased, SFHP is aware of ongoing need to monitor potentially other sources of opioid risk.

• Dr. Donald reviewed San Francisco county data for ED visits for opioid related causes.

• ED visits for overdoses related to opiates continues to be a concern.

• SFHP monitors various aspects of opioid safety to determine whether or not additional steps can be taken to address ongoing concerns and risk of overdose.

• Components of SFHP Pain/Opioid Safety Program o Medication safety

Decrease number of SFHP members with Rx for opioids and other central nervous system depressants.

• We have developed an Opioid Drug Utilization Review and Monitoring of Monthly Dashboard.

Decrease number of SFHP members initiating opioid treatment who receive >7 day supply of short-acting opioids.

• Implemented 7-day edit policy for new opiate Rx.

Decrease number of SFHP members on high dose opioids.

• Quantity Limits on opioids (#120 tabs per 30 days).

• Performance Improvement Projects (PIP) measure incentivizing review of members on high doses.

9

o Benefits for Members Integrating Behavioral Health and

chronic pain treatment. • Beacon to complete survey of

providers with expertise treating clients with chronic pain.

• Beacon to take steps to link members struggling chronic pain and/or opiate use disorder to providers with aforementioned expertise.

Increase number of members accessing non-opioid treatment.

• Monitor/improve use of non-pharmaceutical treatment (Acupuncture and Chiropractic).

o Provider Support Increase number of Buprenorphine

prescribers. • PIP measure to increase # of

providers with X licenses. • Access CHCF Database of X

licenses. • Access pharmacy adequacy of

Buprenorphine. Increase number of members initiating

buprenorphine in inpatient settings. • SUR Grants to Contracted

Hospitals to Support Inpatient Addiction Treatment services and linkages to drug treatment.

10

QI Committee Chair's Signature & Date ____________________________6/7/19___ Minutes are considered final only with approval by the QIC at its next meeting.

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San Francisco Health Plan Utilization Management Committee 24 January 2019 (Thursday) 1:00PM – 2:00PM Conference Room Bayview

Meeting called by: Matija Cale

Type of meeting: Monthly Meeting Recorder: Kerr, Morgan

Attendees: Baldzikowski, Monica; Cale, Matija; Cornejo, Rebecca; Custodio, Ralph; Tai, Tony; Crowder, Ralph; Donald, Fiona; Nellis, Joel; Ghotbi, Lisa; Golubski, Nina; Staniford, Tamsen; Clark, Betty DeLos Reyes; Kerr, Morgan; Harris, SeDessie; McDonald, Kirk

Not Present: Glauber, Jim; Suwannarat, Sona; Maruyama, Nina; Liang, Betty; Garcia, Crystal; Hawkins, Kaitlin; Torres, Gabby;

Documents Presented

Draft_Minutes_UMC_Dec_2018_v12.18.18 Overview_24-ABPMCriteria_v1.18.19 Overview_BrightLightTherapyCriteria_v1.18.19 Overview_CGMCriteria_v1.18.19 Overview_HumanMilk_v1.18.19 UMC January 2019 Appeals_v1.22.19

1.24.19 Minutes

AGENDA Brought By Time Documents Reviewed Notes

1 Action Items Review and

Approve Matija

1:00PM –

1:02PM Draft_Minutes_UMC_Dec_2018_v12.18.18 • See Action Step tables below

• Voted to approve the December minutes.

2 Appeals

IMR/State Fair Hearing

Matija

Ralph Crowder

Betty

1:02PM -

1:10PM UMC January 2019 Appeals_v1.22.19

• Two overturned UM appeals: o SFHP denied the prior authorization request for laser hair

reduction treatment to the forearm, chest, stomach, and breast using SFHP’s UM Non-Genital Gender Confirmation Criteria and Medi-Cal standards. The request was deemed cosmetic and denied as a non-covered benefit. This denial was overturned based on several indicators: 1) Laser hair removal should improve member’s state of living by reducing gender dysphoria, 2) SFHP UM Criteria for Non-Genital Gender Confirmation Services does not provide criteria guidance about non-facial hair removal, 3) The CA Reconstructive Surgery statute confirms

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Page 2 of 7

bodily hair on forearm, chest, stomach, and breast is not normal in a female.

o SFHP denied the prior authorization request for laser hair reduction treatment to the chest using SFHP’s UM Non-Genital Gender Confirmation Criteria and Medi-Cal standards. The request was deemed cosmetic and denied as a non-covered benefit. This denial was overturned based on several indicators: 1) Laser hair removal should improve member’s state of living by reducing gender dysphoria, 2) SFHP UM Criteria for Non-Genital Gender Confirmation Services does not provide criteria guidance about non-facial hair removal, 3) The CA Reconstructive Surgery statute confirms bodily hair on forearm, chest, stomach, and breast is not normal in a female.

• Two overturned Pharmacy appeals: o SFHP denied prior authorization for Epclusa 400 MG-100MG

tablet using SFHP’s "Hepatitis C" prior authorization criteria. This criterion requires a member to try Mavyret before Epclusa can be approved. This denial was overturned based on literature published by ZSFGH’s Liver Clinic which indicated Quetiapine, currently prescribed for the member, may cause a drug interaction with Mavyret.

o SFHP denied prior authorization for Boost Plus 0.06G-1.5 using SFHP "Enteral Nutrition Products" prior authorization criteria. This denial was overturned based continuity of care as new information provided demonstrated the member had been receiving Boost Plus 0.06G-1.5 since 2014.

Discussion evolved from the Enteral Nutrition appeal.

o Enteral Nutrition is not a standard pharmacy benefit, but SFHP offers it through both Pharmacy and Outpatient UM.

Pharmacy team requests this benefit needs to be evaluated to identify if enteral nutrition should only be an Outpatient UM benefit.

Next Steps: 1. Pull utilization data (both OP UM and Pharmacy) 2. Confirm with Sister Plans whether the benefit is

only offer by UM or by both UM and Pharmacy 3. Bring to Health Services Leadership Team

(HSLT) for discussion.

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• No new IMR or State Fair Hearings

3

Vote on confirming no

PA requirement for human breast milk

Tamsen 1:10PM

– 1:20PM

• Mother’s Milk Bank in San Jose (SFHP’s only vendor) receives requests directly from providers. Mother’s Milk Bank is currently reviewing all requests against the defined Medi-Cal criteria. SFHP is essentially doing a duplicative review.

• QNXT configured to not require PA, likely during last year’s QNXT overhaul.2 members have ever received the service. Both between May and Nov 2018.

o Avg claim for $609, weekly service; $15,756 total paid.

Given the above, UMC voted to remove the auth requirement for Human Breast Milk.

4

Long-acting reversible

contraceptives (LARC)

Jim Glauber X Carried over to March UMC meeting

5

EPSDT requirements

relative to PT/OT/ST

Jim Glauber X Carried over to March UMC meeting

6

Discuss criteria needs

for Ben-ex benefits

Tamsen 1:20PM

– 1:50PM

• BLT o Discussed creating homegrown criteria versus limiting claim

payments to only pay for SAD diagnosis UMC voted against a prior auth requirement. Instead investigate whether QNXT claim system can be

configured to pay BLT claims containing SAD diagnosis. If QNXT is able to be configured, UM will monitor the

utilization and report to UMC in six (6) months.

• CGM o InterQual criteria for medical benefit are stricter than the current

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pharmacy benefit; however, the pharmacy benefit criteria is only for 1 product and InterQual includes all CGM products.

Discussed using InterQual criteria for medical benefit versus creating homegrown criteria to match Pharm’s

Pharmacy CGM (Freestyle Libre) criterion has recently changed. The changes include: 1) exclusion for members with gestational diabetes, 2) added insulin specific requirements

UMC has requested UM and Pharmacy collaboratively review InterQual and pharmacy benefit criteria. Criteria recommendation to be brought to next UMC for vote.

• 24hr ambulatory BP monitoring o No InterQual criteria. Discussed building homegrown criteria

versus using guardrails of 1) no PA requirement, or 2) limit claim payment to certain diagnosis codes.

Cost is roughly $2000 for the service each time it’s done. This cost includes device and professional readings.

UCSF is the only provider that has ever submitted claims.

o UMC has requested additional information. 1) What does Medicare reimburse? 2) Are capitated facilities requesting this service also?

7 Wrap Up / Review of

Action Items Morgan

1:50PM –

1:55PM

1.24.19 – Action Steps, Status, & Final Decisions Responsible

Member Action Item Status and Final Decisions

1. Kirk Long-acting reversible contraceptives (LARC): Add to UMC March agenda for Jim Completed

2. Kirk EPSDT requirements relative to PT/OT/ST: Add to UMC March agenda for Jim Completed 3. Lisa/Tamsen Pull enteral nutrition utilization data for pharmacy and OP UM

4. Monica/Tamsen/Kirk Investigate SFHP’s UM Non-Genital Gender Confirmation Services which does not provide criteria guidance about non-facial hair removal

In progress. • Updated the genital/non-genital confirmation

criteria • Next steps

o Work with Fiona to craft the language o Submit to UMC for review o Engage outside expertise for their

review and input

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5. Tamsen If QNXT can be configured, monitor BTL utilization and report data to UMC in six (6) months

6. Ralph Crowder Provide updated Pharmacy CGM (Freestyle Libre) criterion to Tamsen

7. Tamsen Provide UMC with additional information regarding 24hr BP monitor. 1) What does Medicare reimburse? 2) Are capitated facilities requesting this service also?

12/18.18 – Action Steps, Status, & Final Decisions Responsible


8 Morgan Work with HOI to update QI-01 policy to reflect new UM criteria approval process (UMC prior to QIC) Complete

9 Matija Confirm if InterQual has a policy or process to screen conflict of interests of the sources they use when developing criteria (passive v. proactive process)

Complete

1 Monica/Tamsen Compare InterQual’s newly published gender confirmation criteria against SFHP’s homegrown gender confirmation criteria (e.g., Is facial feminization included or missing?)

In progress

1 Kirk Submit updated longitudinal benchmark charts with 2019 approved new benchmarks

In progress 3.21.19

• Updated the HEDIS benchmarks and created draft tables for UMC to review.

• Requested codes from Erica Sanchez (via Clarizen) o Next step will be the BI team once codes received. o This is for the following services:

Back Surgery Bariatric Cholecystectomy

• laparoscopic • Open

Hysterectomy • Abdominal • Vaginal

Lumpectomy Mastectomy Tonsillectomy Cervical Cancer Screening

1 Kirk Request utilization data for benchmark expansion determination

1 Kirk Work with BI to correct the data source of Readmission Rate (DHCS, not HEDIS)

11.29.18 – Action Steps, Status, & Final Decisions Responsible Action Item Status and Final Decisions

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Member 14. Lisa/Ralph Provide finalized peer-to-peer request workflow requirements to PBM Complete 9.25.18 – Action Steps, Status, & Final Decisions

Responsible Member Action Item Status and Final Decisions

15. Ralph Custodio

Discuss how DMGs will inform SFHP about potential PQIs identified by their UM staff with Sandy / PNO. In progress

Parking Lot

1. 2.20.18 Monica • Will obtain metrics on Retrospective

Utilization Reviews to guide Compliance on the effect of a 90 or a 180 day guideline.

• On hold until DHCS Audit is complete. • The current strategy is there will be no

changes to UM-22 retrospective policy.

2. 5.15.18 Ralph Crowder • What reports/information does the UMC need

to review from the Pharmacy and Therapeutics Committee (P&T) moving forward?

07.25.2018: Discussion that any pharmacy under/over utilization will be discussed in UMC as well as Pharmacy and Therapeutics Committee (P&T). If an under/over utilization if identified, UMC will lead process to improve/change any outliers.

• Pharmacy reports need to be evaluated too see what should be included in UMC.

Recommendations: • 1. Drug Utilization Report (DUR)

Analysis. DUR is currently under P&T Committee and State Oversight

• 2. Pharmacy benefit change affect analysis

3. 9.28.18 Tamsen/Monica Develop Milliman Criteria and InterQual Criteria comparison presentation.

• Presentation on hold. • Confirmed that the current InterQual

contact is valid through June 2020. HSBR team is currently researching InterQual’s newly developed modules (i.e. Care Transition Module)

4. 9.28.18 Ralph Crowder/ Tamsen

Benefit Overlap with Pharmacy & UM. Bring examples for discussion Example: Contraception devices (IUD, implants, etc.)

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San Francisco Health Plan Utilization Management Committee 28 March 2019 (Thursday) 1:00PM – 2:00PM Conference Room Bayview

Meeting called by: Matija Cale


Attendees: Baldzikowski, Monica; Cale, Matija; Cornejo, Rebecca; Custodio, Ralph; Tai, Tony; Crowder, Ralph; Ghotbi, Lisa; Donald, Fiona; Glauber, Jim; Sharief, Shimi; Nellis, Joel; Golubski, Nina; Staniford, Tamsen; Clark, Betty DeLos Reyes; Kerr, Morgan; Harris, SeDessie; McDonald, Kirk

Not Present: Torres, Gabby; Garcia, Crystal; Hawkins, Kaitlin; Maruyama, Nina;

Documents Presented

Draft_Minutes_UMC_Jan_2019_v2.13.19 UM Director Dashboard_January 2019_2 22 19 Gabby_UMC Feb-Mar 2019 Appeals_v3.25.19 Betty_IMR-StateFairHearings_v3.25.19 24hr_ AMBP answers from Jan UMC questions Draft_2019-Benchmarks_v3.20.19

3.28.19 Minutes


1 Action Items Review and Approve

Matija 1:00PM – 1:05PM

Draft_Minutes_UMC_Jan_2019_v2.13.19 UM Director Dashboard_January 2019_2 22 19

• See Action Step tables below o Enteral Nutrition: Pharmacy benefit, Medical benefit, or both?

Disconnect between DHCS literature and SFHP Provider Manual. Pharmacy team outreaching to DHCS for benefit guidance.

• Voted to approve January minutes Director Dashboard

• No concerns or trends escalated for UMC discussion.

2 Appeals IMR/State Fair Hearing

Matija Ralph

1:05PM - 1:15PM

Gabby_UMC Feb-Mar 2019 Appeals_v3.25.19

Four overturned UM appeals: 1. Brown and Toland Medical Group (BTMG) denied specialist referral

request to OON ENT Surgeon, redirecting member to alternative in-

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Page 2 of 7

Crowder Betty

Betty_IMR-StateFairHearings_v3.25.19

network SFHP/BTMG ENT surgeons. Member’s Endocrinologist appealed this decision stating the suggested alternative in-network ENT surgeons are acceptable for general ENT surgery, but do not specialize in thyroid surgery. SFHP Medical Director, Fiona Donald, overturned this denial and approved specialist referral to ENT surgeon specializing in thyroid surgery and is in BTMG’s private network (not in SFHP network).

2. North East Medical Services (NEMS) denied authorization request for dentoalveolar surgery and dental anesthesia to OON provider, Bay Area Dental, redirecting member to in-network provider, UCSF Pediatric Dental Clinic. SFHP Medical Director, Fiona Donald, overturned denial because UCSF Pediatric Dental Clinic has a 4-5 month waiting period for an appointment and the member symptoms required urgent attention.

3. NEMS denied authorization request for physical therapy services to OON provider, Mission Physical Therapy, redirecting member to in-network physical therapists at CPMC. Member’s provider appealed this decision informing that in-network provider was not possible as the member is currently residing in San Luis Obispo for college and required immediate physical therapy (three weeks post injury) in order to maintain elbow functionality. SFHP Medical Director, Fiona Donald, overturned denial for medical necessity under EPSDT benefit.

4. NEMS denied authorization request for office visit with OOMG provider

at ZSFG Liver Clinic: where the member had requested a specific practitioner. NEMS redirected member to IMG provider. Evidence was provided indicating the member had been treated by the requested provider. SFHP Medical Director, Fiona Donald, overturned denial for continuity of care and approved one transitional visit. Member was informed to switch medical group enrollment for continued care with requested provider at ZSFG Liver Clinic or transition care to in-network liver specialist.

DMG authorization appeal cases were escalated to Clinical Quality and Outreach Nurse. Action item listed below. Three overturned Pharmacy appeals: 1. SFHP denied authorization request for Cimzia 200 MG/ML Starter Kit

at 400mg every 2 weeks using SFHP “Quantity Limit Exception”

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Page 3 of 7

authorization criteria. The criterion requires failed trail of Cimzia 400mg every 4 weeks, and medical study or guidelines to support 400mg every 2 weeks before this dose can be approved. This denial was overturned based on the additional clinical information indicating that a higher dose was needed to treat the member’s medical condition, because a lower dose had only partially treated the condition. Supporting medical literature was also included in the appeal submission.

• Given the overturned approval allowing for increase of dosage, given the medical literature supporting the increase, Pharmacy Team was advised to monitor utilization patterns.

2. SFHP denied authorization request for Nicotrol Cartridge Inhaler using

SFHP "Nicotine Replacement Therapy (NRT)" authorization criteria. The criterion requires failed trials of the preferred medicines: nicotine gum, lozenge or patch, bupropion, and Chantix. This denial was overturned based on the additional clinical information indicating failed trials of the formulary alternatives.

3. SFHP denied authorization request for Ampyra ER 10 MG using SFHP

“Non-FDA Approved or Off-Label Uses” authorization criteria. Ampyra ER 10 MG is not approved by the FDA for treatment of member’s medical condition, Neuromyelitis Optica (NMO). This denial was overturned based on medical literature provided showing Ampyra to be beneficial to improve walking speed and other neurological functions. SFHP approved Ampyra ER 10 MG Tab# 60 as a trial for 6 months. For continued therapy approval, SFHP must receive evidence of ongoing improvement in walking time.

State Fair Hearing 1. Member filed a SFH after receiving a denial NOA regarding their

inpatient stay at Mills Peninsula Medical Center. SFHP denied authorization because the clinical information received did not meet acute inpatient criteria. SFHP informed the member they would not be billed for the services. Compliance is drafting response to the State.

No active IMRs/Consumer Complaints requiring UMC review.

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3 Ben-Ex Tamsen 1:15PM – 1:30PM

24hr_ AMBP answers from Jan UMC questions

24-hour AMBP • Per UMC request: Reviewed Medicare pricing, CMS criteria,

UpToDate literature, and capitated provider utilization data. • Cross departmental approval is complete. Presentation to E.T. is to

be scheduled.

Given the adoption of CMS criteria for 24-hour AMBP, UMC discussed whether revising the clinical criteria hierarchy was required for CO-57 Clinical Criteria PP.

• Decision made to include CMS criteria in CO-57. CMS criteria will be used on a case-by-case basis.

CGM • No updates in Ben-Ex process since Jan UMC. Discussion moved

to April UMC. BLT

• Portable version was approved via Ben-Ex process • QNXT configuration in process to ensure claim with SAD diagnosis

are not misdirected to Beacon/CBHS.

Proposed Benchmarks Analysis

K. McDonald

1:30PM – 1:40PM

Draft_2019-Benchmarks_v3.20.19 Moved to April UMC

4

Bi-Annual Review of PA/No PA Requirements

Monica 1:40PM – 1:50PM

• Decision made to change from bi-annual to annual review • FY 2018-2019 review scheduled to occur between May 1st-June

20th. • Will include review:

o Public facing “Services Requiring Authorization” and o QNXT configuration of services requiring authorization by

service group • Recommendations will be presented at June 27th UMC

5 UMC Membership Vote

Matija 1:50PM – 1:55PM

UMC unanimously approved membership of SFHP’s Medical Director, Shimi Sharief.

6 Wrap Up / Review of Action Items

Morgan 1:55PM – 2:00PM

3.28.19 – Action Steps, Status, & Final Decisions

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Page 5 of 7


1. Kirk Long-acting reversible contraceptives (LARC): Add to UMC March agenda for Jim Add to April’s Agenda 2. Kirk EPSDT requirements relative to PT/OT/ST: Add to UMC March agenda for Jim Add to April’s Agenda

3. Morgan Add CMS criteria (case-by-case basis) into CO-57

4. Lisa Enteral Nutrition benefit (Pham v. Medical): Update UMC on DHCS’s response 5. Lisa/Ralph Pharmacy Team will monitor utilization patterns for Cimzia dosage increases 6. Tasmen Continue to provide Ben-Ex updates for BLT and CGM

7. Ralph Educate NEMS on UCSF Pediatric Dental Clinic access issue. Based on the appeal review, it was determined that NEMS should develop a clearer and concise rational when determining denial for OON requests.

Completed



1. Kirk Long-acting reversible contraceptives (LARC): Add to UMC March agenda for Jim See 3.28.19 action steps

2. Kirk EPSDT requirements relative to PT/OT/ST: Add to UMC March agenda for Jim See 3.28.19 action steps 3. Lisa/Tamsen Pull enteral nutrition utilization data for pharmacy and OP UM In progress





review and input

5. Tamsen If QNXT can be configured, monitor BTL utilization and report data to UMC in six (6) months In progress. Confirmed QNXT can be configured

6. Ralph Crowder Provide updated Pharmacy CGM (Freestyle Libre) criterion to Tamsen Complete 12/18.18 – Action Steps, Status, & Final Decisions Responsible


1. Monica/Tamsen Compare InterQual’s newly published gender confirmation criteria against SFHP’s homegrown gender confirmation criteria (e.g., Is facial feminization included or missing?)

In progress

2. Kirk Submit updated longitudinal benchmark charts with 2019 approved new benchmarks

Longitudinal charts - completed

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3. Kirk Request utilization data for benchmark expansion determination 3.6.19 • Updated the HEDIS benchmarks and created

draft tables for UMC to review. • Requested codes from Erica Sanchez (via

Clarizen) o Next step will be the BI team once

codes received. o This is for the following service:

Bariatric

4. Kirk Work with BI to correct the data source of Readmission Rate (DHCS, not HEDIS)



1. Lisa/Ralph Provide finalized peer-to-peer request workflow requirements to PBM Complete 9.25.18 – Action Steps, Status, & Final Decisions


1. Ralph Custodio


Parking Lot












24

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25

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San Francisco Health Plan Utilization Management Committee 25 April 2019 (Thursday) 1:00PM – 2:00PM Conference Room Bayview

Meeting called by: Baldzikowski, Monica


Attendees: Baldzikowski, Monica; Cornejo, Rebecca; Custodio, Ralph; Crowder, Ralph; Donald, Fiona; Nellis, Joel; Golubski, Nina; Sharief, Shimi; Staniford, Tamsen; Kerr, Morgan; Harris, SeDessie; McDonald, Kirk

Not Present: Matija Cale; Tai, Tony; Ghotbi, Lisa; Garcia, Crystal; Hawkins, Kaitlin; Glauber, Jim; Maruyama, Nina; Clark, Betty DeLos Reyes; Torres, Gabby

Documents Presented

Draft_Minutes_UMC_March_2019_v4.23.19 Gabby_UMC April 2019 Appeals_v4.24.19 DRAFT_UMCommitteeCharter_v3.28.19 Draft_2019-Benchmarks_v3.20.19 Draft_UMAdverseDecisionAuditReport_Q3-Q4-2018_v4.25.19

4.26.19 Minutes


Action Items Review and Approve


Draft_Minutes_UMC_March_2019_v4.23.19

• See Action Step tables below • Voted to approve March minutes

Director Dashboard

• March and April data to be presented and discussed at May UMC Agenda Topic Announcement:

• As the means to communicate agenda items; UMC Agenda Item_Topic Requests_2019 document is posted in the UM Committee 2019 folder on SharePoint.

2 Appeals IMR/State Fair Hearing

Monica Ralph Crowder

1:05PM - 1:15PM

Gabby_UMC April 2019 Appeals_v4.24.19 No overturned Medical appeals Two overturned Pharmacy appeals: 1. SFHP denied authorization request for Candesartan Cilexetil 16 MG

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Betty

TB using SFHP "Non-Formulary ARBS and ARB Combination Products" prior authorization criteria. The criterion requires failed trials of the preferred medicines: irbesartan, losartan, telmisartan and valsartan. The member had not failed telmisartan. This denial was overturned based on the additional clinical evidence supporting the use of candesartan for migraine prophyaxis and blood pressure regulation.

2. SFHP denied authorization request for Cimzia 200 MG/ML Kit using SFHP "Disease Modifying Biologics" prior authorization criteria. The criterion requires failed trials of the preferred medicines: Enbrel or Humira, Actemra, Orencia, and Xeljanz or Xeljanz XR. This denial was overturned based on clinical information identifying member’s history of latent tuberculosis (TB) coupled with medical research evidence indicating that Cimzia behaves similar to Enbrel, but has less risk for causing illness from TB bacteria.

No active IMRs/State Fair Hearings requiring UMC review.

3 UMC Charter Vote Kirk

1:15PM – 1:20PM

DRAFT_UMCommitteeCharter_v3.28.19 NCQA-2019_UMProgDescrip_v4.25.2019

Discuss UM Program Description Updates

• On Hold until NCQA Consultant, Diane, reviews and provides feedback.

• Bring back to UMC after NCQA Mock audit close

Proposed Benchmarks Analysis

Kirk 1:20PM – 1:35PM

Draft_2019-Benchmarks_v3.20.19

Reviewed updated longitudinal benchmark graphs for Q1 2017- Q4 2018. Confirmed commitment to previously approved benchmarks. See UMC 12.18.2018 minutes for details. Average Length of Stay (ALOS) Acute Admits

• Given payment methodology change from Per-Diem to APRDRG (in 2018), assumption would be that the ALOS may decrease.

o SFHP will monitor ALOS to identify any decreases. o SFHP will monitor ALOS per acute facility to assess if

ALOS for XX diagnosis is equivalent amongst the unique acute facilities.

Readmission Rate Inpatient Acute Days / 1000 MM ED Visits / 1000 MM

• Include 75th and 90th percentile statistics into longitudinal benchmark charts

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4 3Q/4Q Internal Audit Report

Kirk 1:35PM – 1:45PM

Draft_UMAdverseDecisionAuditReport_Q3-Q4-2018_v4.25.19

Due to DHCS on Friday 4.26.19 Executive Summary Q3/Q4-2018 Appeal Audit

• The compliance rate with the NCQA standard UM-9 was 100%. Q3/Q4-2018 Clinical Operations Medical Necessity Audit: Prior Authorization

• The compliance rate with State (DHCS /DMHC) requirements was 100%.

Q3/Q4-2018 Clinical Operations Medical Necessity Audit: Concurrent

• The compliance rate with State (DHCS /DMHC) requirements was 100%.

Q3/Q4-2018 Pharmacy Medical Necessity Audit

• The compliance rate with State (DHCS/DMHC) requirements was 100%.

5 Wrap Up / Review of Action Items




1. Fiona/Shimi Consult with CMO on benchmark monitoring suggestions for ALOS and Readmission Rate(see content above)

2. Kirk Include 75th and 90th HEDIS percentile statistics into longitudinal benchmark charts for ED Visits



3. Kirk Long-acting reversible contraceptives (LARC): Add to UMC May agenda for Jim Add to May’s Agenda 4. Kirk EPSDT requirements relative to PT/OT/ST: Add to UMC May agenda for Jim Add to May’s Agenda

5. Morgan Add CMS criteria (case-by-case basis) into CO-57 In progress

6. Lisa Enteral Nutrition benefit (Pham v. Medical): Update UMC on DHCS’s response In progress

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7. Lisa/Ralph Pharmacy Team will monitor utilization patterns for Cimzia dosage increases Ongoing 8. Tasmen Continue to provide Ben-Ex updates for BLT and CGM Ongoing 1.24.19 – Action Steps, Status, & Final Decisions Responsible


1. Kirk Long-acting reversible contraceptives (LARC): Add to UMC March agenda for Jim See 3.28.19 action steps

2. Kirk EPSDT requirements relative to PT/OT/ST: Add to UMC March agenda for Jim See 3.28.19 action steps 3. Lisa/Tamsen Pull enteral nutrition utilization data for pharmacy and OP UM In progress





review and input





In progress

2. Kirk Submit updated longitudinal benchmark charts with 2019 approved new benchmarks

Longitudinal charts - completed 3.6.19

• Updated the HEDIS benchmarks and created draft tables for UMC to review.

• Requested codes from Erica Sanchez (via Clarizen)

o Next step will be the BI team once codes received.

o This is for the following service: Bariatric

3. Kirk Request utilization data for benchmark expansion determination

4. Kirk Work with BI to correct the data source of Readmission Rate (DHCS, not HEDIS)

9.25.18 – Action Steps, Status, & Final Decisions Responsible Action Item Status and Final Decisions

29

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Member

1. Ralph Custodio


Parking Lot

















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San Francisco Health Plan Utilization Management Committee 22 May 2019 (Wednesday) 1:00PM – 2:00PM Conference Room Bayview

Meeting called by: Baldzikowski, Monica


Attendees: Baldzikowski, Monica; Cornejo, Rebecca; Custodio, Ralph; Tai, Tony; Crowder, Ralph; Garcia, Crystal; Glauber, Jim; Kerr, Morgan; Harris, SeDessie; Nellis, Joel; Golubski, Nina;

Not Present: Cale, Matija; Sharief, Shimi; Hawkins, Kaitlin; Staniford, Tamsen; Clark, Betty DeLos Reyes; Torres, Gabby;

Documents Presented

Draft_Agenda_UMC_v5.20.19 Draft_Minutes_UMC_April_2019_v5.14.19 UM Director Dashboard_February 2019_3 26 19 UM Director Dashboard_March 2019_4 15 19 UM Director Dashboard_April 2019_5 13 19 GTorres_UMC_May2019 Appeals_v5.21.19 CMS_BehavioralHealthIntegration UCSF SFHP JOM slides_Pumar_Tutman_FINAL DHCS_Study_LongActingReversibleContraception_v1.16.19 Compliance_Comments_Email_HSAG-LARC study_v1.16.19

4.26.19 Minutes




Draft_Agenda_UMC_v5.20.19 UM Director Dashboard_February 2019_3 26 19 UM Director Dashboard_March 2019_4 15 19 UM Director Dashboard_April 2019_5 13 19

• See Action Step tables below • Voted to approve April minutes

Director Dashboard

• Reviewed February, March and April data • No concerns or trends identified which required

further UMC discussion

Appeals Monica 1:05PM No overturned Medical appeals

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IMR/State Fair Hearing

Ralph Crowder Betty

- 1:15PM

GTorres_UMC_May2019 Appeals_v5.21.19 Two overturned Pharmacy appeals: 1. SFHP denied authorization request for Pediasure 1.5

Liquid as a non-covered benefit using the Healthy Kids HMO Evidence of Coverage, as well as for over the counter product availability. This denial was overturned based on additional clinical information indicating a current evaluation of member’s low appetite and poor weight gain resulting from medication prescribed for member’s ADD diagnosis (Concentra). Considering impacted growth and development, SFHP approved request for Pediasure for a limited trial of 6 months. For continued approval, SFHP requires demonstration of alternative actions taken to increase your weight without the use of nutritional supplements and an evaluation of whether other contributing factors may be causing the weight loss.

2. SFHP denied authorization request for Norditropin Flexpro 15 mg /1.5 using "Somatropin (Growth Hormone)" prior authorization criteria. The criterion requires a diagnosis of growth hormone deficient short stature; however, members documented diagnosis was idiopathic short stature (ISS), which is an excluded diagnosis. This denial was overturned by SFHP’s Associate Medical Director based on medical literature indicating growth hormone therapy can help people diagnosed with ISS and validation from an external MRIoA physician reviewer (board certified by the American Board of Pediatrics in Pediatric Endocrinology as well as the American Board of Internal Medicine in Endocrinology, Diabetes and Metabolism) recommended Norditropin as an appropriate treatment.

No active IMRs/State Fair Hearings requiring UMC review.

Update on new technology assessment

Monica / Kirk

1:15PM – 1:25PM

NCQA UM10: Evaluation of New Technology • Clinical Operations has elected to move forward

with an N/A for this standard given that the state mandates benefits and new technology

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process determinations. SFHP’s Benefit Exception process will remain the proactive approach for evaluating requested non-covered benefits.

Collaborative Care Management Codes

Jim 1:25PM – 1:40PM

CMS_BehavioralHealthIntegration UCSF SFHP JOM slides_Pumar_Tutman_FINAL

CMO Presentation UCSF has initiated a Collaborative Care Model (CoCM) focused on integrating behavioral health services into medical settings. This model enhances “usual” primary care by adding two key services: 1) care management support for patients receiving behavioral health treatment; and 2) regular psychiatric inter-specialty consultation to the primary care team. Goals of the CoCM model include focus on whole-person care, reducing stigma, increasing access, and efficiently improving outcomes. CMS published supporting CoCM data demonstrating improved access to treatment for patients with mild to moderate depression and an association with a 20% reduction in medical services cost reduction among recipients/beneficiaries. UCSF’s provision of CoCM integrated mental health care to SFHP members is dependent on a provider agreement. UMC member unanimously agreed on the value of the CoCM model and voted to initiate benefit exception process for CoCM service.

• CoCM CPT Codes include 99492, 99493, and 99494.

Long-acting reversible contraceptives (LARC)

Jim 1:40PM – 1:45PM

DHCS_Study_LongActingReversibleContraception_v1.16.19 Compliance_Comments_Email_HSAG-LARC study_v1.16.19

CMO Presentation LARC services are nationally underutilized despite the numerous advantages (e.g., cost effective, high efficacy and continuation rates, minimal maintenance and high patient satisfaction ratings) in comparison to alternative methods of contraception. To address this issue, DHCS completed a focused study on LARC management practices and utilization patterns among

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MCPs. Study results indicated: • CA Statewide LARC utilization in 2015 was 4.2%

among 15-44 year’s old women. • SFHP’s rate was 5.8%.

DHCS recommendations for MCPs included: • Conduct provider training on LARC administration • Monitor LARC activities to identify barriers and

opportunities for improving LARC usage • Share any applicable best practices relevant to

increasing LARC utilization (e.g., device recoupment fees, provider incentives for stocking and/or insertion of devices, separate payment for device and insertion/removal procedures, offer as a pharmacy benefit)

Suggested next steps for SFHP:

1. Develop report to assess utilization data by medical group.

2. Implement a provider survey to assess barriers at provider/clinic level.

3. Educate providers and medical groups through JAM 4. SUR suggestion: Implement post-partum LARC

initiative

Wrap Up / Review of Action Items


• Announcement - Head's up about Internal Audit (Kirk)



1. Kirk Initiate Benefit Exception process for CoCM services

2. Crystal Provide Tony with LARC CPT codes

3. Tony Submit new project request for 2018 utilization data of LARC services by Medical Group

34

Morgan K

Long-Acting Reversible Contraception (LARC) Methods Intrauterine copper (Paraguard) J7300 Skyla J7301 Levonorgestrel-releasing intrauterine contraceptive system (Mirena) J7302 Etonogestrel (Implanon, Nexplanon) J7307 Is there more? /

Page 5 of 7

4. Ralph Custodio Add LARC utilization and/or barriers to accessing LARC as agenda item for JAMs



5. Fiona/Shimi Consult with CMO on benchmark monitoring suggestions for ALOS and Readmission Rate In progress

6. Kirk • ALOS / Readmission rate analysis • ED Visits / 1000 MM: Update the longitudinal benchmark charts to include

75th and 90th HEDIS percentiles.

• Deliver in June o ED visits / Completed o ALOS / Readmission / ED visits –

Phase 1 completed; need to collate Readmission w/ Diagnostic codes next



7. 8. Morgan Add CMS criteria (case-by-case basis) into CO-57 In progress 9. Lisa Enteral Nutrition benefit (Pham v. Medical): Update UMC on DHCS’s response In progress 10. Lisa/Ralph Pharmacy Team will monitor utilization patterns for Cimzia dosage increases Ongoing 11. Tasmen Continue to provide Ben-Ex updates for BLT and CGM Ongoing 1.24.19 – Action Steps, Status, & Final Decisions Responsible


1. Lisa/Tamsen Pull enteral nutrition utilization data for pharmacy and OP UM In progress





review and input


12/18.18 – Action Steps, Status, & Final Decisions Responsible Action Item Status and Final Decisions

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Member


In progress

2. Kirk Request Bariatric utilization data for benchmark expansion determination

• Priya is leading this analysis re. Bariatric Surgery • Requested bariatric codes (via Clarizen)

o Next step will be the BI team, once codes received, will perform the utilization analysis.



1. Ralph Custodio


Parking Lot














contact is valid through June 2020. HSBR team is currently researching InterQual’s newly developed

36

Morgan K

Confirm with Ralph if this is complete

Page 7 of 7

modules (i.e. Care Transition Module)



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San Francisco Health Plan Utilization Management Committee 18 June 2019 (Tuesday) 10:30AM to 11:30AM Conference Room Excelsior

Meeting called by: Cale, Matija


Attendees: Baldzikowski, Monica; Cornejo, Rebecca; Tai, Tony; Crowder, Ralph; Glauber, Jim; Kerr, Morgan; McDonald, Kirk; Harris, SeDessie; Nellis, Joel; Golubski, Nina; Cale, Matija; Sharief, Shimi; Donald, Fiona; Staniford, Tamsen; Clark, Betty DeLos Reyes; Sims, Justin

Not Present: Custodio, Ralph; Garcia, Crystal; Hawkins, Kaitlin; Torres, Gabby

Documents Presented Draft_Minutes_UMC_v6.13.19 UMC June 2019 Appeals Betty_IMR_State Fair Hearing_v6.18.19

6.18.19 Minutes



Matija 10:30 – 10:35

Draft_Minutes_UMC_v6.13.19

• See Action Step tables below • Voted to approve April minutes • May and June Director dashboard to be reviewed in July.

Appeals IMR/State Fair Hearing

Matija Ralph Crowder Betty

10:35 – 10:50

UMC June 2019 Appeals Betty_IMR_State Fair Hearing_v6.18.19

No overturned Medical appeals Two overturned Pharmacy appeals:

1. SFHP denied authorization request for Phentermine 15 MG capsule using SFHP “Anti-Obesity Medications” prior authorization criteria. The criterion requires members to have had a response to therapy as shown by at least a 5% weight loss from baseline before Phentermine can be approved. This denial was overturned based on additional clinical information indicating an 11% weight loss since member start of Phentermine, which was prior to SFHP enrollment. In addition, the members weight has been steady for the past year which meets criteria to continue Phentermine for one year based on

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the Continuation of Therapy for New Members. 2. SFHP denied authorization request for Topamax 25 MG

tablets using SFHP Medi-Cal Evidence of Coverage which states members must use the generic version of a medicine if a generic version is available. SFHP also applied SFHP “Brand Name Medication Requests” prior authorization criteria. The criterion requires members try at least two generic versions of Topamax made by different manufacturers and try at least three other medicines that can be used to treat your condition before brand Topamax can be approved. This denial was overturned based on additional clinical information. The information indicated member had failed trails of Nortriptyline, Beta Blockers, and generic Topiramate. As well as, evidence supporting the members usage of Topamax, prior to SFHP enrollment, as the most effective therapy for the member’s severe migraine headaches.

DMHC: 1 IMR; 3 Consumer Complaints

• IMR: Medi-Cal member requested an IMR for denial of Metro Gel. SFHP overturned its denial and approved brand name Metro Gel before SFHP received the member’s request for IMR. DMHC dismissed the case because SFHP overturned its previous denial.

• Consumer Complaints: UMC determined Consumer Complaints listed for review were more appropriate for Grievance Review Committee (GRC). Consumer Complaints appropriate for UMC discussion include benefit and/or authorization concerns.

State Fair Hearings: 2 • Medi-Cal member’s mother grieved about the denial of Prozac

and requested the member be admitted to a mental health facility. Member had Medi-Cal FFS when Prozac request was first denied, but has since been able to fill Prozac prescription after becoming a SFHP member. Member to be advised services at mental health facilities are carved out of Medi-Cal managed care. Member also referred to Beacon for assistance with behavioral health services. Hearing scheduled for 6/24/2019.

• Kaiser Medi-Cal member requested reimbursement for lost items during stay at Kaiser Medical Center. Case was dismissed for lack of jurisdiction because the case did not

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involve a denial of services.

UM Criteria on Pediatric Dental Anesthesia

Jim / Fiona / Monica / Shimi

10:50 – 10:50

Workgroup formed to address appointment access concerns with UCSF Pediatric Dental Clinic. Workgroup includes Medical Directors, Clinical Operations and Provider Network Operations leadership. • Workgroup is assessing alternative in-and out- of network pediatric

provider dental clinics and will attempt new contracts, as needed. • Workgroup is advocating for silver diamine fluoride (SDF)

treatment to become a covered benefit under Denti-Cal. o SDF treatment does not require the use of local

anesthesia or caries excavation, o SDF is particularly beneficial to patients for whom

traditional treatment presents challenges, whether due to age, behavioral issues or medical conditions.

• Additionally, workgroup is reviewing the current UM criteria listed in policy and will provide enhancement recommendations.

• At this time, out-of-network requests are not being redirected back in network.

DHCS Findings and Responses Matija

10:50 – 11:00

• 1.2.1 – Retrospective “issue” o Per Compliance – SFHP has formally requested a

review of the initial finding; MCQMD is still reviewing the request.

• 1.2.2 – NOA cover fax sheet – 90 vs. 60 days o This was corrected on 2.27.19 (post-audit) o The initial problem was, “the fax cover sheet for the

‘Requesting Provider’ only was using a different fax cover sheet in the ‘Deferral/Denial/Modification (MC)’ letter, which has the 90 day language in there”

• 1.2.3 o Clinical Ops will update the EPSDT policy based on

the finding. EPSDT benefit guidance to be released via DHCS APL scheduled for August or September 2019.

From a holistic standpoint, SFHP will be working towards enhancing the current state care coordination activities between SFHP, SF school district, Golden Gate Regional Center, and PCP’s.

• 5.1.2

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o Compliance’s responsibility, per Nina/Crystal, to create the requested committee reporting/org chart.

o The questions Clin Ops has: Is there an NCQA accreditation requirement

or DMHC regulation that UMC has to report to QIC?

• Group was not aware of requirement; however, UMC historically has provided quarterly and annual reports to QIC.

DMG Information Flow Monica

11:00 – 11:15

Senior Manager of Prior Authorizations presented on behalf of Clinical Quality Review and Outreach Nurse. Presentation included high level overview of SFHP/DMG scenarios and appropriate next steps for each scenario. The five scenarios highlighted include: 1. UM inquiries or issues received from internal/external 2. Annual oversight audit 3. Appeals and grievance from a DMG member 4. New All Plan Letters rel. to UM, new benefit coverage 5. UM Reports as required by R3 UMC provided feedback and requested clarification on several scenarios. Updates will be presented at a later time.

NCQA Preliminary Recommendations and General Feedback

Monica / Matija / Kirk / All

11:15 – 11:25

• NCQA Follow-ups o The Year-1 of the 2-Year lookback will end September

2019 o Discussed break down of points

27 items were reviewed by Diane • 21 (78%) were 100% passed; `Diane has

requested refinements for a number of these documents to make them stronger; will be executing these refinements.

• The following just require easy refinements or updates:

o 1 was 80% passed o 3 were 50% passed

• 1 was 20% passed – this is for UM 7 – and Diane is asking us to update the NOA

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template w/ specific language about Expedited Appeals. Set up meetings on my return; this will probably involve a DHCS review. With this improvement, we will get the full points.

• 1 was 0% passed – this is for UM 4 - we met all of the points on the document side – we need to show 3 files involving MRIoA.

o 3 outpatient cases with MRIoA involvement were submitted; however, Diane did not select these files for review. Will update Diane.

Wrap Up / Review of Action Items Morgan

11:25 – 11:30



1. Kirk ALOS Readmission Data Business Analytics (BA) team is requesting to defer Clairzen report request until Q4 2019

2. Kirk Bariatric Data Completed. Will distribute to UMC via email 3. Kirk/Ralph Integrate UMC feedback of DMG information workflow into process map Meeting set up 07/18/2019 @ 11am. Participants

include Odalis, Ralph, Monica, Kirk 4. Kirk/Morgan Enhance EPSDT Policy according to DHCS finding Pending DHCS APL

5. Dental Anesthesia Workgroup

Present recommendations and updates, as necessary


Member Action Item Status and Final Decisions 6. Kirk Initiate Benefit Exception process for CoCM services In progress

7. Crystal Provide Tony with LARC CPT codes Completed

8. Tony Submit new project request for 2018 utilization data of LARC services by Medical Group

In progress

9. Ralph Custodio Add LARC utilization and/or barriers to accessing LARC as agenda item for JAMs

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10. Fiona/Shimi Consult with CMO on benchmark monitoring suggestions for ALOS and Readmission Rate

In progress. Kirk is taking the lead on this. See above

12. Kirk • ALOS / Readmission rate analysis • ED Visits / 1000 MM: Update the longitudinal benchmark charts to

include 75th and 90th HEDIS percentiles. Completed



13. Morgan Add CMS criteria (case-by-case basis) into CO-57 In progress 14. Lisa Enteral Nutrition benefit (Pham v. Medical): Update UMC on DHCS’s response In progress 15. Lisa/Ralph Pharmacy Team will monitor utilization patterns for Cimzia dosage increases Ongoing 16. Tamsen Continue to provide Ben-Ex updates for BLT and CGM Ongoing 1.24.19 – Action Steps, Status, & Final Decisions Responsible


17. Lisa/Tamsen Pull enteral nutrition utilization data for pharmacy and OP UM In progress




o Work with Fiona to craft the language

o Submit to UMC for review o Engage outside expertise for their

review and input





In progress

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21. Kirk Request Bariatric utilization data for benchmark expansion determination Completed 9.25.18 – Action Steps, Status, & Final Decisions


22. Ralph Custodio

Discuss how DMGs will inform SFHP about potential PQIs identified by their UM staff with Sandy / PNO. Completed

Parking Lot

















44

Morgan K

UMC: Let’s review and remove as appropriate.

Prepared by SFHP Pharmacy Services – TJC 5/21/19

Emergency Room Visit / Prescription Access Report 4th Quarter 2018

San Francisco Health Plan Medi-Cal LOB Goal: Evaluate access to medications prescribed pursuant to an emergency room visit and determine whether any barriers to care exist. Methodology: All claim and encounter records for an emergency room visit (without an admission) during a calendar quarter are evaluated and consolidated into a unique record of each emergency room (ER) visit date by member. These unique ER visits are analyzed by ER facility site and member count (see Tables 1A & 1B). Top diagnoses were evaluated for reason of ER visit (see Table 2). Selected key diagnoses with a high likelihood for ER discharge prescription are analyzed (see Table 3). A review of the pharmacy locations where members filled their prescriptions within 72 hours of discharge was assessed to reflect any medication barriers (see Table 4). Findings:

Section 1 - ER Visits

In 4Q2018, 9,300 members had 14,674 ER visits, averaging 1.58 ER visits per member, which is less than the previous quarter (1.63). This reflects an ER visit by approximately 7.8% of the SFHP Medi-Cal membership within the quarter. Visits by ER facility slightly decreased but the number of Member ER visits increased compared to previous quarters (14,402 and 8,831, respectively).

Table 1A: Visits by ER Facility ER Facility ER

Visits ZSFG – ACUTE CARE 5654

UCSF MEDICAL CENTER 2447 ST FRANCIS MEMORIAL HOSPITAL 1896 CPMC MISSION BERNAL CAMPUS 1545

CPMC PACIFIC CAMPUS 830 ST MARYS MEDICAL CENTER 605

CPMC DAVIES CAMPUS 443 CHINESE HOSPITAL 261

KAISER FOUNDATION HOSPITAL SF 246 CHINESE COMMUNITY HEALTH CARE 115

Other ED Facilities 632 TOTAL 14,674

Table 1B: Member ER Visits

# ER Visits Member 1 6,692 2 1,606 3 490 4 219 5 102 6 45 7 35 8 19 9 19 10 19

11 - 46 54 TOTAL 9,300

45


Section 2 - Top Diagnoses

Of the 14,674 ER visits in 4Q2018, 7,795 visits (53%) resulted in a medication (from ER or pharmacy) within 72 hours of the ER Visit and 6,879 (47%) did not. Not all ER visits warranted medication treatment (i.e. chest pain, abdominal pain or altered mental status). Overall, the distribution of top ER visits by diagnoses category (table 2) increased with previous quarters. The following categories had a spike compared to the previous quarter: upper respiratory infection (61%), cough (54%), nausea w/wo vomiting (37%), and asthma (26%). This could have attributed to the 2018 California Wildfires that was declared a national disaster in August 4, 2018 and widespread Camp Fire in November 2018 that devastated the air quality in San Francisco Bay Area.

Table 2: Percent ER Visits by Diagnoses Top Diagnoses Categories

ICD10 ER Visits % of Visits

% Change from 3Q18

Abdominal Pain R10.xx 1017 6.9% 4% Chest pain R07.xx 671 4.6% -7%

Alcohol Abuse F10.xx 429 2.9% -13% Nausea w/wo Vomiting R11.xx 305 2.1% 37%

Upper Respiratory Infection J06.9 302 2.1% 61% Asthma J45.xx 247 1.7% 26% Cough R05 230 1.6% 54% Fever R50.xx, R68.xx 196 1.3% -30%

Headache R51 189 1.3% -9% Altered Mental Status R41.82 168 1.1% 10%

Low Back Pain M54.5 162 1.1% -18% Pharyngitis J02.xx 147 1.0% 12%

Urinary Tract Infection N39.0 133 0.9% 17% COPD J44.xx 116 0.8% -4%

All Other Diagnoses 10,362 70.6% 4% TOTAL 14,674 100%

Section 3 - Key Diagnoses Category

Selected key diagnoses category with a high likelihood for ER discharge prescription is reported in Table 3. COPD replaced Bronchitis as a key diagnosis in this report because bronchitis often has a viral origin and does not need prescription of antibiotics. In 4Q2018, greater than 95% of ER visits for key diagnoses of UTI, asthma, pneumonia and COPD received medication treatment within 72 hours of the visit.

Table 3: ER Visit – Key Diagnoses Category Diagnoses Category ICD10 RX Filled ER Treated No Rxs Total %

Treatment UTI N39.0 80 26 6 112 95%

Asthma J45.901,J45.909, J45.902 148 6 4 158 97% Pneumonia J18.9 55 7 1 63 98%

COPD J40, J44.1, J44.9 89 5 2 96 98%

46


Section 4 - Pharmacy Location For the members filling a prescription from a Pharmacy within 72 hours of their ER visit date, a further analysis evaluated the location of the pharmacy relative to where the member received emergency care and the hours of operation for these pharmacies. SFHP has one 24 hour pharmacy in our San Francisco network and 56% of our pharmacies are open until 8pm. Access to a pharmacy after an ER visit can occur throughout the day and would not be limited to only after-hours. In this analysis, member visits are defined as unique days that prescriptions are filled for a member per unique pharmacy. Of the 6,115 member visits to a pharmacy after an ER discharge, the top 12 most utilized pharmacies are reported in Table 4.

Table 4. Pharmacies where Members obtained Rx within 72 hours of an ER Visit Pharmacy Hours of

Operation Mbr

Visits % of

Visits SF General (1001 Potrero Ave) 9AM – 8PM M-F,

9AM-1PM Sat 501 8.2%

Walgreens 3711(1189 Potrero Ave) 8AM – 10PM 484 7.9% Walgreens 5487 (5300 3rd St) 8AM – 9PM 263 4.3%

Walgreens 1327 (498 Castro St) 24 Hours 259 4.2% Walgreens 4609 (1301 Market St) 8AM – 9PM 235 3.8% Walgreens 1126 (1979 Mission St) 9AM – 9PM 186 3.0%

Walgreens 2153 (790 Van Ness Ave) 8AM – 8PM 184 3.0% Walgreens 2244 (3801 3rd St) 9AM – 9PM 168 2.7%

Walgreens 13668 (1496 Market St) 8AM – 9PM 165 2.7% Walgreens 7150 (965 Geneva Ave) 9AM – 9PM 157 2.6% Chinese Hospital (845 Jackson St) 8AM – 7PM M-F,

9AM-5PM Sat-Sun 145 2.4%

Walgreens 1626 (2494 San Bruno Ave) 9AM – 9PM 139 2.3% Walgreens 15331 (500 Parnassus) 8:30AM – 8PM 114 1.9% Walgreens 1120 (4645 Mission St) 9AM – 9PM 110 1.8%

Walgreens 9886 (3400 Cesar Chavez) 9AM – 9PM 87 1.4% All Other Pharmacy Locations 2,918 47.7%

TOTAL 6,115 100% Summary: No barrier to pharmacy access during after-hours was identified in this quarter. ER utilization was higher in 4Q2018 compared to 3Q2018 (14,674 visits versus 14,402) with each member utilizing the ER at 1.58 visits. Compared to last quarter, the increased top diagnoses categories of upper respiratory infection (61%), cough (54%), nausea w/wo vomiting (37%), and asthma (26%) could have been caused by the 2018 California Wildfires. 53% of ER visits received a medication (from ER or pharmacy) within 72 hours of the ER visit. COPD replaced bronchitis as key diagnoses and appropriate prescription fills were seen in all four diagnoses category. Monitoring of member access to medication treatment after an ER visit will continue.

47

Prepared by SFHP Pharmacy Services – JN & TJC 7/26/19

Emergency Room Visit / Prescription Access Report 1st Quarter 2019

San Francisco Health Plan Medi-Cal LOB Goal: Evaluate access to medications prescribed pursuant to an emergency room visit and determine whether any barriers to care exist. Methodology: All claim and encounter records for an emergency room visit (without an admission) during a calendar quarter are evaluated and consolidated into a unique record of each emergency room (ER) visit date by member. These unique ER visits are analyzed by ER facility site and member count (see Tables 1A & 1B). Top diagnoses were evaluated for reason of ER visit (see Table 2). Selected key diagnoses with a high likelihood for ER discharge prescription are analyzed (see Table 3). A review of the pharmacy locations where members filled their prescriptions within 72 hours of discharge was assessed to reflect any medication barriers (see Table 4). Findings:

Section 1 - ER Visits

In 1Q2019, 9,742 members had 15,512 ER visits, averaging 1.59 ER visits per member, which is slightly more than the previous quarter (1.58). This reflects an ER visit by approximately 7.3% of the SFHP Medi-Cal membership within the quarter. Visits by ER facility and the number of Member ER visits increased compared to the previous quarter (14,674 and 9,300, respectively).

Table 1A: Visits by ER Facility ER Facility ER

Visits ZSFG – ACUTE CARE 6039

UCSF MEDICAL CENTER 2601 ST FRANCIS MEMORIAL HOSPITAL 1943 CPMC MISSION BERNAL CAMPUS 1556

ST MARYS MEDICAL CENTER 619 CPMC PACIFIC CAMPUS 587

KAISER FOUNDATION HOSPITAL SF 283 CHINESE HOSPITAL 279

JADE HEALTH CARE – MEDICAL 108 CHINESE COMMUNITY HEALTH CARE 91

Other ED Facilities 1,406 TOTAL 15,512

Table 1B: Member ER Visits

# ER Visits Member 1 7001 2 1717 3 483 4 209 5 97 6 70 7 37 8 22 9 18 10 21

11 - 46 67 TOTAL 9,742

48


Section 2 - Top Diagnoses

Of the 15,512 ER visits in 1Q2019, 8,119 visits (52%) resulted in a medication (from ER or pharmacy) within 72 hours of the ER Visit and 7,393 (48%) did not. Not all ER visits warranted medication treatment (i.e. chest pain, abdominal pain or altered mental status). Overall, the distribution of top ER visits by diagnoses category (Table 2). Compared to previous quarter, upper respiratory infection, nausea with or without vomiting, and cough diagnoses continue to slightly increase, most likely reflecting peak flu season.

Table 2: Percent ER Visits by Diagnoses Top Diagnoses

Categories ICD10 ER Visits % of Visits

Abdominal pain R10.xx 983 6.3% Chest pain R07.xx 763 4.9%

Alcohol abuse F10.xx 404 2.6% Nausea w/wo vomiting R11.xx 364 2.3%

Upper Respiratory Infection J06.9 363 2.3% Cough R05 342 2.2%

Shortness of breath R06.02 241 1.6% Fever R50.xx 236 1.5%

Asthma J45.xx 233 1.5% Headache R51 219 1.4%

Altered mental status R41.82 191 1.2% Low back pain M54.5 158 1.1%

Altered mental status R41.82 191 1.0% All Other Diagnoses 10.839 69.9%

TOTAL 15,512 100%

Section 3 - Key Diagnoses Category Selected key diagnoses category with a high likelihood for ER discharge prescription is reported in Table 3. COPD replaced Bronchitis as a key diagnosis in this report because bronchitis often has a viral origin and does not need prescription of antibiotics. In 1Q2019, greater than 95% of ER visits for key diagnoses of UTI, asthma, pneumonia and COPD received medication treatment within 72 hours of the visit.

Table 3: ER Visit – Key Diagnoses Category Diagnoses Category ICD10 RX Filled ER Treated No Rxs Total %

Treatment UTI N39.0 48 76 11 124 92%

Asthma J45.901,J45.909, J45.902 87 147 4 234 98% Pneumonia J18.9 50 80 9 130 94%

COPD J40, J44.1, J44.9 40 77 5 117 96%

49


Section 4 - Pharmacy Location For the members filling a prescription from a Pharmacy within 72 hours of their ER visit date, a further analysis evaluated the location of the pharmacy relative to where the member received emergency care and the hours of operation for these pharmacies. Of the 6,714 member visits to a pharmacy after an ER discharge, the top 16 most utilized pharmacies are reported in Table 4. Two 24 hour pharmacies were top utilized – one in San Francisco and another in the adjacent San Mateo County. 56% of pharmacies in San Francisco are open until 8pm. Access to a pharmacy after an ER visit can occur throughout the day and would not be limited to only after-hours. In this analysis, member visits are defined as unique days that prescriptions are filled for a member per unique pharmacy.

Table 4. Pharmacies where Members obtained Rx within 72 hours of an ER Visit Pharmacy Hours of

Operation Mbr

Visits % of

Visits Walgreens 3711(1189 Potrero Ave) 8AM – 10PM 585 8.7%

SF General (1001 Potrero Ave) 9AM – 8PM M-F, 9AM-1PM Sat 491 7.3%

Walgreens 5487 (5300 3rd St) 8AM – 9PM 306 4.6% Walgreens 1327 (498 Castro St) 24 Hours 251 3.5%

Walgreens 4609 (1301 Market St) 8AM – 9PM 235 3.0% Walgreens 1126 (1979 Mission St) 9AM – 9PM 201 2.8%

Walgreens 2153 (790 Van Ness Ave) 8AM – 8PM 189 2.6% Walgreens 7150 (965 Geneva Ave) 9AM – 9PM 177 2.5%

Walgreens 2244 (3801 3rd St) 9AM – 9PM 170 2.5%

Chinese Hospital (845 Jackson St) 8AM – 7PM M-F, 9AM-5PM Sat-Sun 168 2.5%

Walgreens 13668 (1496 Market St) 8AM – 9PM 165 2.3% Walgreens 1626 (2494 San Bruno Ave) 9AM – 9PM 153 2.1%

Walgreens 1120 (4645 Mission St) 9AM – 9PM 143 2.1% Walgreens 324 (216 Westlake, Daly City) 24 Hours 137 2.0%

CVS Pharmacy (1101 Market St) 9AM – 8PM M-F, 10AM–5PM Sat-Sun 137 2.0%

All Other Pharmacy Locations 3335 47.8% TOTAL 6714 100%

Summary: No barrier to pharmacy access during after-hours was identified in this quarter. ER utilization was higher in 1Q2019 compared to 4Q2018 (15,512 visits versus 14,674) with each member utilizing the ER at 1.59 visits, which is not a significant increase from previous quarter (1.58). About 52% of ER visits received a medication (from ER or pharmacy) within 72 hours of the ER visit, which slightly decreased from previous quarter (53%). Appropriate prescription fills were seen in all four key diagnoses category. Monitoring of member access to medication treatment after an ER visit will continue.

50

P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800 1(415) 547-7821 FAX www.sfhp.org

6279X 0515

Date: May 23, 2019

To Quality Improvement Committee

From Gabrielle Torres – Grievance Analyst

Regarding Q1 2019 Grievance Report

A total of 90 grievances were received in the first quarter of 2019. Overall grievance volume increased by 18.4% from 76 total grievances in Q4

2018. All grievances in Q1 2019 were closed within the required timeframe of 30

calendar days, as mandated by the Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS).

One acknowledgement letter was not sent out within five calendar days, as mandated by the Department of Managed Health Care (DMHC) and Department of Health Care Services (DHCS). The grievance staff that missed the acknowledgement letter turnaround time reviewed the issues and process with the Manager of Access and Care Experience.

The percentage of grievances that met the 30 calendar day requirement in Q2-Q3 2018 was lower than Q4 2018 and Q1 2019 where the percentage was 100%. However, all of the grievances in Q2-Q3 2018 that were not resolved in 30 days had an approved 14 calendar day extension.

51

*On 9/20/18, DHCS notified SFHP that the 14 calendar day extension is no longer allowed. The DMHC laws and regulations on grievances and appeals require a 30-day resolution timeframe for standard grievances.

89%

92%

100% 100%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Q2 2018 Q3 2018 Q4 2018 Q1 2019

Q2 2018 ‐ Q1 2019 Closed in 30 Days

% meetingrequirement

Performance Target

52

Since Q3 2017, SFHP’s grievance rate decreased each quarter except in Q3 2018 the grievance rate steadily started to increase. In comparison, SFHP’s grievance rate starting from Q3 2017 has continued to be lower than the DHCS grievance rate.

*DHCS data is two quarters behind.

0.600.56 0.55

0.440.50 0.51

0.61

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

Q3 2017 Q4 2017 Q1 2018 Q2 2018 Q3 2018 Q4 2018 Q1 2019Grievance Rate per 1,000 M

ember

Months

Q3 2017 ‐ Q1 2019 SFHP Grievance Rate

0.800.80

1.00

1.201.30

0.60 0.560.55

0.440.5

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

Q3 2017 Q4 2017 Q1 2018 Q2 2018 Q3 2018

Grievance Rate p

er 1,000 M

ember Months

Q3 2017 ‐ Q3 2018 Grievance Rate SFHP & DHCS*

DHCS

SFHP

53

Grievances filed by members who are Seniors and Persons with Disabilities (SPD): SFHP monitors grievances filed by members who are part of the SPD population.

In Q1 2019, 21 grievances were filed by SPD members. The number of grievances filed by SPDs increased by 5% compared to Q4 2018 when a total of 20 grievances were filed by SPD members.

The types of grievances received vary by quarter. In Q1 2019, grievances involving quality of service, quality of care, and denials were the most common grievance category for SPD members.

In comparison, SFHP’s rate remains lower than DHCS’ SPD rate because the DHCS rate is inclusive of all Medi-Cal health plans.

*DHCS data is two quarters behind

2.9 2.9

3.2

3.6

4.3

1.55 1.461.37

0.83 0.86

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Q3 2017 Q4 2017 Q1 2018 Q2 2018 Q3 2018

Grievance Rate per 1,000 M

ember Months

Q3 017 ‐ Q3 2018 SPD Grievance Rate SFHP & DHCS*

DHCS

SFHP

54

Grievance Rate by Medical Group:

JAD UCS BTP CHI CHN NEM HIL KSR NMS

Q2 2018 3.85 1.16 0.62 0.58 0.39 0.32 0.23 0 0

Q3 2018 0 1.16 1.27 0.31 0.53 0.12 1.18 0.45 0

Q4 2018 0.69 1.09 0.86 0.11 0.66 0.12 0.72 0.22 0.2

Q1 2019 0 1.81 1.29 0.6 0.57 0.33 0.73 0.22 0.19

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Grievance Rate per 1,000 m

ember months Q2 2018 ‐ Q1 2019 Grievance Rate by Medical

Group

Q2 2018

Q3 2018

Q4 2018

Q1 2019

55

Source of the grievances: The graph below shows who was involved in the grievance e.g. member’s PCP, clinic staff, specialist. In Q1 2019, there were no trending grievances identified associated with a member’s PCP, the clinic staff, specialist etc. However, the source of most grievances received in Q1 were those involving care or services provided by the member’s clinic (i.e. grievance source is “clinic”).

0

5

10

15

20

25

30

Number of Grievan

ces

Q2 2018 ‐ Q1 2019 Grievance by Source

Q2 2018

Q3 2018

Q4 2018

Q1 2019

56

Access to Care Grievances: In Q1 2019, there were no access trends identified. The highest rate of access grievances was in Q3 2018 followed by a decrease in the rate each quarter.

0.05

0.12

0.06

0.13

0.07

0.15

0.12

0.08

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

0.16

Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Q3 2018 Q4 2018 Q1 2019

Grievance Rate per 1,000 M

ember Months

Q2 2017 ‐ Q1 2019 SFHP Grievance Access Rate

57

SFHP’s Member Experience Dashboard shows all grievances (exempt, decline to file, clinical and non-clinical) associated with access in 2018. At the time this report was created Q1 2019 data was not available. This information will be reported in next quarter’s grievance report. Access Grievances per Thousand Member Months

58

Beacon: Beacon Health Options is SFHP's non-specialty mental health provider. Beacon is partially delegated for grievances. In Q1 2019, there were no trends identified.

2

0

3

4

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Q2 2018 Q3 2018 Q4 2018 Q1 2019

Number of Grievances

Q2 2018 ‐ Q1 2019 Beacon Grievances

59

Kaiser: Kaiser is fully delegated to investigate and resolve grievances. In Q4 2018, it was noted that there was a large increase in access grievances from previous quarters. Kaiser investigated this increase and found there was misalignment of grievance categories. Kaiser’s updated report shows receiving 3 access grievances in Q4 2018, which is in line with previous quarters. In Q1 2019, there were no trends identified.

Quality ofService

BenefitsQuality of

CareAccess

Denials/Appeals

Q2 2018 17 7 3 2 0

Q3 2018 28 4 3 2 2

Q4 2018 12 0 0 3 5

Q1 2019 37 13 3 3 0

0

5

10

15

20

25

30

35

40

Number of Grievances

Q2 2018 ‐ Q1 2019 Kaiser Grievances

Q2 2018

Q3 2018

Q4 2018

Q1 2019

60

0.11 Draft_Q1-19_Appeals_MedPharm_v5.16.19

Prepared by: K. M. McDonald (1.27.19) Page 1 of 3

Q1-2019 UM Medical and Pharmacy Appeals Activity UM Medical and Pharmacy Appeals Activity – Overview During Q1-19, there were a total of 16 appeals filed (medical 7, pharmacy 9)i. In Q1-19, there were a total of 5,934authorizations (medical 4,450; pharmacy 1,484)ii. On a per 1,000 authorization basis, this is 2.7 appeals per 1,000 authorizations; or 1.6 appeals per 1,000 medical authorizations and 6.0 appeals per 1,000 pharmacy authorizations.

Comparing appeal activity in Q1-19 to Q4-18:

• 16 appeals in Q1-19 vs. 11 appeals in Q4-18. • 2.7 appeals/1000 in Q1-19 vs. 1.4 appeals/1000 in Q4-18.

Of the 16 appeals in Q1-19, 11 appeals were overturned (medical 5, pharmacy 6), which is a 69% overturn rate. This compares to a 45% overturn rate in Q4-18 (5 overturned out of 11 appeals).

61



UM Medical Out-of-Medical-Group (OOMG) / Out of-Network Appeals (OON) Activity There were a total of 0 OOMG / 3 OON medical appeals. Q1-19 compared to Q4-16/17/18:

UM Medical Appeal Activity by Medical Groups The medical appeals by medical group appear representative of the distribution of membership.

62



Analysis Medical and pharmacy denials rates, between Q1-2017 and Q1-2019, are:

Between Q1-2017 and Q1-2019, the medical denial rates remained stable from 1.17% to 0.24.

Between Q1-2017 and Q1-2019, the pharmacy denial rates remained stable from 24.2% to 20.2%. Medical and pharmacy appeals and appeal rates combined, between Q1-2017 and Q1-2019, are:

Medical and pharmacy combined, overturned appeal rates, between Q1-2017 and Q1-2019, are:

Actions The Utilization Management Committee’s (UMC) standing agenda item is to review and discuss overturned medical and pharmacy utilization management appeals. The discussion and decision highlights are reflected in the UMC minutes. i Source: 0944ES A&G UM APPEALS REPORT, Case RECEIPT DATE: 1/1/2019 - 3/31/2019 as of 5/16/2019 10:09:13 AM. This is an aggregate number of medical and pharmacy appeals; members appealing were 16 Medi-Cal members. ii UM Director Dashboard_March 2019_4 15 19.

Medical Authorizations Medical Denials Medical Denial RateQ4-2017 3,766 9 0.24%Q1-2018 4,875 50 1.03%Q2-2018 4,637 18 0.39%Q3-2018 4,303 13 0.30%Q4-2018 4,026 22 0.55%Q1-2019 4,450 52 1.17%

Pharmacy Authorizations Pharmacy Denials Pharmacy Denial RateQ4-2017 1,388 303 21.8%Q1-2018 1,580 350 22.2%Q2-2018 1,532 370 24.2%Q3-2018 1,461 295 20.2%Q4-2018 1,492 303 20.3%Q1-2019 1,484 305 20.6%

Medical Appeals Pharmacy AppealsMedical + PharmacyAppeal Rate / 1000

AuthorizationsQ4-2017 3 8 2.1Q1-2018 2 15 2.6Q2-2018 10 13 3.7Q3-2018 3 8 1.9Q4-2018 6 5 1.9Q1-2019 7 9 2.7

Medical + Pharmacy Overturn Appeal Rates Med Overturned RX Overturned Total Appeals

Q4-2017 82% 3 6 11Q1-2018 41% 1 6 17Q2-2018 35% 5 3 23Q3-2018 45% 0 5 11Q4-2018 45% 2 3 11Q1-2019 69% 5 6 16

63

P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800 1(415) 547-7821 FAX www.sfhp.org

6279X 0515

Date: May 21, 2019 To Quality Improvement Committee From Nina Golubski, RN

Quality Review Nurse Health Outcomes Improvement

Regarding Quarter 1 2019 Potential Quality Issue Report

Case Reviews

Outcomes Count

PQI cases opened 6 Formal PQI investigation (PQI letter) 6 Cases requiring external physician review or peer review 2 Confirmed Quality Issue 1 Opportunity for Improvement 0 PQI cases resulting in Corrective Action Plan (CAP) 1 Confirmed Provider Preventable Condition (PPC) 0 PQI cases closed within 45-day turnaround time 5 PQI cases closed outside 45-day turnaround time 1*

Data retrieved from Microstrategy *Turnaround times met for all PQI cases. Case involving CAP was closed within 60 days. This is consistent with UM-56 Turnaround times

Q1 2019 - Case types reviewed Count Total cases reviewed for PQI 137

Grievances (Clinical) 81 Decline to File Grievances (Clinical) 28 Internal and external referrals 6 Appeals 21 Provider Preventable Condition (PPC) 1

64

Confirmed Quality Issues

Case 1 Initial complaint/ Initial findings: Member presented to hospital with abdominal pain one week after Intrauterine Device (IUD) placement at outpatient primary care clinic. Imaging found IUD had perforated through uterus. Member underwent uncomplicated laparoscopic removal of IUD. Investigation: Medical Director reviewed clinical documentation of procedure at outpatient clinic. No clinical concerns identified but due to the complication that occurred, medical director requested outpatient clinic leadership conduct a peer review of policies, process and procedures related to the incident. Findings: Peer review response concluded that standard procedure was followed: procedure occurred in teaching clinic under supervision of attending physician. Based on this incident, clinic leadership will review competency checklist for signing off procedures performed by for resident physicians. After review of Peer Review findings and clinical documentation SFHP Medical Director confirmed a quality issue given complications which occurred. Case was ranked Level 3c (please reference scoring grid). Adverse event occurred after IUD insertion by resident physician and led to operative procedure for member. Follow up/ Recommendations: Corrective Action Plan asking for review and submission of updated policy and procedures for training and clinical oversight of resident physicians related to outpatient IUD insertion within this clinic setting.

65

Deviation from Standard of care and Level of Harm Scoring Grid

Analysis: No identified PQI trends during Q1 2019

66

Q1 2019 QI Work Plan Scorecard Summary

Measure Measure Description Denom Baseline

Current

Performance

(YTD)

Planned Activities Update on Activities in Q1 2019

Community Health Network (CHN) Out Of

Medical Group (OMG) All Cause Readmissions

Reduce the rate of all cause readmissions for Community

Health Network out of medical group readmissions within

30 days

2727 22.75% 23.21%

• Provide follow up phone calls to members post discharge

• Provide discharge planning at facilities via onsite nurse

• Care Transitions team continued follow up phone calls to members

post discharge as well as onsite nurse visits.

Follow Up On Clinical Depression Increase the percentage of clients in SFHP's Care

Management programs who screen positive for depression

and receive follow up care 36 N/A 69%

• Provide training on new metric and follow-up protocols including

referrals to both Beacon and CBHS

• Monitor rate of members with PHQ-2 that required PHQ-9

• Staff attended Beacon overview that provided updates on

workflow and benefits as part of ongoing staff training.

• Supervisors reviewed follow-up reporting with staff and developed

action plans to connect members to behavioral health services.

Care Management Client Perception Of Health Improve care management client's perception of their

health based on change in self-reported health status

53 N/A 32%

• Develop report to monitor self-reported health question of SF-12 in

intake and closing assessments

• Work with staff to ensure all members have a self-management goal

when appropriate and the staff has health coaching skills needed to

support the members

• Supervisors and Medical Director reviewed self-management goal

progress with RNs to identify and address gaps in members receiving

health education.

Screening For Clinical Depression Increase the percentage of clients in SFHP's Care

Management programs successfully screened for clinical

depression 55 N/A 67%

• Conduct analysis of depression screening results for both PHQ-2 and

PHQ-9

• Facilitate staff training on best practices for conducting screenings

• Supervisors reviewed screening report with staff and developed

action plans to provide members with depression screening.

% of Members who completed Hepatitis C

Treatment

Improve the percentage of members with any past history

of Hepatitis C who have completed the Hepatitis C

treatment regimen

N/A 21% N/A

• Conduct provider outreach incentivizing adoption of Hepatitis C

identification and treatment

• Develop provider grant opportunities for at-risk members and

inclusion of Hepatitis C incentive measure in the Practice Improvement

Program (PIP)

• Participation in San Francisco's city-wide "End Hep C" efforts

• Advocacy to expand criteria of members eligible for treatment

• A new Hep C tracking and reporting improvement project has been

added to the 2019 Practice Improvement Program (PIP).

Cervical Cancer Screening (CCS) Improve cervical cancer screening rate among SFHP

members

N/A 70% N/A

• Include pay-for-performance measure in Practice Improvement

Program (PIP) and SFHP's Strategic Use of Reserves (SUR)

• Health education messaging

• Pilot Adult Wellness Incentive program

• The 2019 Practice Improvement Program (PIP) included the CCS

measure.

Chlamydia Screening (CHL) Improve chlamydia screening rate among SFHP members

N/A 35.51% N/A

• Include pay-for-performance measure in the Practice Improvement

Program (PIP)

• Meetings with medical groups to review 2017 data and identify

improvement opportunities

• Complete a root cause analysis to identify potential data and clinical

quality issues; make recommendations for improvement; implement at

least one recommendation.

• SFHP created a report to identify potential data quality issues with

chlamydia screening data.

Medication Therapy Management (MTM) Increase the percentage of members who are engaged in

SFHP's Health Homes and NCQA Complex Medical Case

Management programs and have had an initial medication

reconciliation completed by an SFHP Pharmacist N/A N/A N/A

• Perform pharmacist review for recommendation of members for

medication reconciliation intervention and complete medication

reconciliation

• Implement improvements to Essette Care Management module to

make all medication reconciliation assessments reportable

• SFHP conducted MTM rounds and interdisciplinary rounds (pods)

to collaborate on member cases.

Opioid Safety Increase the percentage of members with Opioid Use

Disorder with a buprenorphine prescription

N/A 10.9% N/A

• Increase the percentage of individuals within SFHP's network who are

trained to provide inpatient addiction treatment services

• Increase the number of buprenorphine prescribers in SFHP's network

• SFHP's Opioid workgroup has created a subgroup to identify

provider needs for education related to buprenorphine prescribing.

67

Q1 2019 QI Work Plan Scorecard Summary

Measure Measure Description Denom Baseline

Current

Performance

(YTD)

Planned Activities Update on Activities in Q1 2019

Health Plan Consumer Assessment of

Healthcare Providers and Systems (HP-CAHPS) -

Getting Care Quickly & Getting Needed Care

Rating

Increase the rate of members who report "Always" and

"Usually" in the Getting Care Quickly and Getting Needed

Care composites of the HP-CAHPS survey

N/A

Getting

Care

Quickly:

73.0%

Getting

Needed

Care: 68.4%

N/A

• Provide technical assistance and grant funding for access improvement

via Strategic Use of Reserves Grant program

• Increase monitoring of access in the network and submit requests for

corrective action when provider groups are found to be non-compliant

• Identify access-related issues via the Access to Care Committee and

develop plans to address found issues

• Improve marketing communications to encourage members to

complete the HP-CAHPS survey

• Conduct member focus groups to gain additional insight on member

perception of access

• Include performance in Clinic and Group CAHPS Access Composite in

SFHP's Pay for Performance Program (PIP)

• SFHP's Access & Care Experience team provided technical

assistance through the Strategic Use of Reserves (SUR) program via

the Service Recovery training series, which focused on repairing the

relationship with a member who is dissatisfied as a result of

communication, access, or clinical issues. SFHP and a training vendor

delivered the third and fourth of six days of training in January and

March 2019.

• SFHP requested Corrective Action Plans (CAP) of provider groups

performing under 80%.

• SFHP's Marketing team sent survey reminder postcards to members

in an effort to increase responsiveness to CAHPS.

• SFHP's Marketing team conducted member focus groups to gain

additional insight on member perception of access.

• SFHP's Access & Care Experience team provided a CAHPS roadshow

to SFHP departments and during joint standing meetings with

provider groups to facilitate shared ownership of CAHPS.

Member Grievances Resolution TAT Increase the rate of member grievances resolved within 30

calendar days (Excludes 14 day extensions included in the

past which DHCS has clarified are not compliant).

79 78% 100%

• Discuss grievance trends and turnaround times with provider groups

during Joint Operations meetings

• Develop a shared metric goal across departments for grievance

turnaround time compliance to promote accountability among all staff

involved in the grievance process

• Review trends for both clinical and non-clinical grievances each month

and discuss approaches to address non-responsive providers with

Grievance Program Leadership Team

• SFHP reviewed trends for both clinical and non-clinical grievances

with the quarterly Grievance Program Leadership Team.

• SFHP discussed grievance trends and turnaround times with

provider groups during Joint Operations meetings including issues

with members accessing acupuncture.

• SFHP's grievance team conducted an internal audit to improve

clarity and conciseness of provider responses and descriptions of

member concerns.

• Expanded trends reviewed by the Grievance Program Leadership

Team and the Grievance Review Committee to include decline to file

grievances.

Provider Appointment Availability Survey

(PAAS) - Routine Appointment Availability In

Specialty And Primary Care

Increase the rate of PCPs and non-behavioral health

specialists compliant with routine appointments as

measured by Provider Appointment Availability Survey

(PAAS)

374 87.7% 69.8%

• Develop communication plan for survey fielding

• Request Corrective Action Plans (CAP) of provider groups performing

under 80%

• Provide technical assistance with CAP

• SFHP requested Corrective Action Plans (CAP) of provider groups

performing under 80%.

Cultural and Linguistic Services (CLS) Increase the number of providers who pass the linguistic

services portion of the SFHP Daytime Survey

187 77% 88%

• Publish articles in the SFHP provider newsletters

• Request Corrective Action Plans (CAP) of provider groups performing

under 80%

• Provide technical assistance with CAP

• SFHP has launched a Cultural and Linguistic Services Program to

leverage all of SFHP’s CLS resources and develop a coordinated

strategy to address SFHP’s CLS priorities.

Members With A Primary Care Visit In Last 12

Months

Increase percentage of continuously enrolled members

with at least one primary care visit in the past 12 months

107407 67.9% 68.6%

• Conduct direct outreach to members to encourage use of the

telehealth benefit

• Provide member incentives to visit their PCP

• Communicate availability of Teladoc and providers

• Incentivize providers to increase primary care visits by including

measure in 2018 Pay for Performance (PIP) program

• The 2019 Practice Improvement Program (PIP) included the percent

of members with primary care visits measure.

Percentage Of Members Utilizing The Non

Specialty Mental Health (NSMH) Benefit With

More Than Two NSMH Visits

Increase the rate of members with more than two NSMH

visits in the past 12 months of members utilizing the NSMH

benefit

4905 54.3% 43%

• Share the rate with Beacon and medical groups to encourage

providers promoting the benefit and engaged mental health care

utilization

• Beacon to outreach to members who have been given referrals to

mental health providers but have not initiated service

• Refer members with identified service barriers to SFHP’s Care

Management staff for intervention

• Shared the NSMH rate with Beacon.

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Policy & Compliance Committee June 2019

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Policies and Procedures (P&Ps) Updates and Monitoring

P&P Updates: Policy Summary of New Policy and Updates CARE-04: Complex Care Management

Policy Update (Biennial Review): • POLICY STATEMENT

o Added language about Population Health Management Strategy to reflect updates to the NCQA standards

o Added language about the delegated medical groups to clarify the populations and requirements for NCQA and DHCS CCM programs

• PROCEDURE o Added language about the Population Health Management

population analysis and strategy to reflect updates to the procedures based on changes to the NCQA standards

o Updated referral sources o Clarified language on data sources for member identification o Added Jade to list of medical groups o Added language about vetting for duplication of services prior

to outreaching to member o Updated wording for readability o Added language about condition-specific assessments o Updated assessment completion timeframe from 30 days to

60 days to reflect updates in NCQA requirements o Updated participants in multi-disciplinary clinical pod

meetings to reflect current processes o Added references to social determinants of health to reflect

language used by NCQA o Updated description of nurse oversight to reflect current

processes o Moved audit and oversight to “Monitoring” section o Removed “recidivism” and replaced with “members with high

levels of hospital utilization and/or low outpatient utilization” on p2.

o MARA was abbreviated, but now spelled out to general description of the software on p2.

o From NCQA feedback, in CCM Initial Assessment, added “natural disaster” and “member is deceased” to the list of reasons why assessment may be delayed on p6.

• MONITORING o Moved audit and oversight to “Monitoring” section, updated

audit schedule, and added the role of Quality Program Manager

o Added language about the Population Health Management Strategy to reflect updates to NCQA standards

• AFFECTED DEPARTMENTS o Added Health Outcomes Improvement, Pharmacy, and

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Business Analytics to reflect new procedures based on changes to NCQA standards

o Removed “Disease Management” to reflect organizational restructure

• RELATED DOCUMENTS o Removed QI-13 Disease Management as program is no longer

active o Updated titles of revised P&Ps o Added DO-10 Oversight of Delegated CM Functions

• REFERENCES Updated NCQA Standard title and year

CARE-07: Golden Gate Regional Center

Policy Update (Biennial Review): • POLICY STATEMENT

o Added/clarified that GGRC managed two different programs (Early Start and “Ongoing/Lanterman Act Services)

• PROCEDURE o Changed “practitioners” to contracted provider o Added more language on education activities to more

accurately reflect the full scope of services GGRC provides o Divided eligibility criteria into 2 sections for the two different

programs; clarified language around eligibility o Added section to outline referral process for both GGRC

programs; updated GGRC intake contact info where referrals get submitted; Clarified information that needs to accompany a referral

o Updated SFHP responsibilities: expanded aim of quarterly meetings with GGRC; updated EOC and NOM with new document names

o Clarified process for managing/sharing and utilizing GGRC Common Member list to reflect current process for collaboration

o Section II.B. (p3), deleted reference “we educate members about GGRC on the website” statement in the policy since we currently educate members about GGRC through the Member Guidebook and Handbook only.

• MONITORING o Added GGRC quarterly meetings to monitoring section

• AFFECTED DEPARTMENTS o No changes

• RELATED DOCUMENTS o Replaced UM-09 with Care-01 (current coordination of care

policy) o Updated name if UM-33 policy

• REFERENCES o No changes

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HE-02 IHA and IHEBA

Policy Update (Re-update from Feb PCC approval): • POLICY STATEMENT

o Removed IHEBA to only specify SHA • MONITORING

o Moved FSR Annual Reports under QIC monitoring • AFFECTED DEPARTMENTS

o Added Network Providers, Delegated Groups, and Marketing and Communications

• RELATED DOCUMENTS o Added P&P DO-06 Oversight of Delegated Credentialing o Added MC-02 and MC-03

• REFERENCES o Add PR-03

• DEFINITIONS o Updated the definitions for Facility Site Review, Medical

Record Review and Staying Healthy Assessment to include PL-14-004 reference.

o Added definition for Site Review Survey

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https://teams.sfhp.org/square1/Shared%20Documents/PP_CO_(HE-02)_IHA%20and%20IHEBA_2019.05.23.pdf

SFHP POLICY AND PROCEDURE Initial Health Assessment (IHA) and Initial Health Education Behavioral Assessment (IHEBA) Policy and Procedure number: HE-02 Department Owner: Health Outcomes Improvement (HOI) Lines of Business Affected: Medi-Cal

POLICY STATEMENT SFHP ensures providers complete an Initial Health Assessment (IHA) for each member within specific timeframes following enrollment (see Appendix A). An IHA consists of a history and physical exam and an Individual Health Education Behavioral Assessment (IHEBA). An IHEBA may be conducted using the Staying Health Assessment (SHA), or other DHCS-approved assessment tool. includes a DHCS approved tool such as an age appropriate Staying Healthy Assessment (SHA) formAn IHA includes an Individual Health Education Behavioral Assessment (IHEBA) and completion of the age-appropriate Staying Healthy Assessment (SHA) form, DHCS’s approved Individual Health Education Behavioral Assessment (IHEBA).. The IHA supports providers to assess and manage the acute, chronic and preventive health needs of members. SFHP ensures that IHA services are provided in a culturally appropriate manner, in the member’s preferred language, including with a qualified interpreter if needed, and in a way that is fully accessible to patients with disabilities.

PROCEDURE 1. Provider Notification

HOI notifies its medical groups quarterly of their assigned members due for an IHA. Medical groups receive a New Member Report and Rate Report via secure email. Independent provider offices not affiliated with a medical group receive a report for all members assigned to that provider’s office.

The report includes member:

a. Name b. Address c. Phone number d. SFHP ID number e. Date of birth f. Gender g. Spoken language h. Assigned medical group i. Date effective with SFHP j. Date effective with PCP

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2. Provider Types Responsible for Completing IHA

The member’s PCP of record, a perinatal care provider, other primary care provider, or a non-physician mid-level practitioner can facilitate completion of and review the IHA with the member.

3. Provider Training

SFHP’s Provider Network Operations (PNO) is responsible for ensuring that all SFHP providers receive the Summary of Key Information (SOKI), which includes education on the purpose of and instructions for how to facilitate the IHA. Providers sign an attestation following receipt and review of the SOKI. Provider resources are also posted on SFHP’s provider web pages. For more detail on Provider Training, refer to PR-03: New Provider Training.

4. Member Eligibility

HOI develops eligible member lists using the following criteria: a. New members enrolled in the Plan for at least 30 days b. Current members who have not completed an updated IHA

5. Member Notification

a. SFHP sends a New Member Packet to all new members within seven (7) days of joining the Plan. The welcome letter, printed in threshold languages, encourages the member to make an appointment for the IHA and importance of the IHA.

b. The member handbook and Medi-Cal provider directory also include messages that encourage members to arrange a first preventive visit with their primary care provider (PCP).

6. Required Components of the IHA:

a. A complete IHA consists of the following components: 1. Medical, behavioral and social history and development of a

Problem List, if appropriate 2. Review of systems 3. Review of current medications and development of a Medication

List, if appropriate 4. Review of preventive services 5. Physical exam 6. Diagnostic tests as needed 7. Assessment of high-risk behaviors of individual members 8. Prioritized individual health education needs 9. Plan of care including interventions, referrals, health education and

high-risk behavior counseling, and follow-up care b. SFHP Policy HE-03 Preventive Health Care and Clinical Practice Guidelines

describe the clinical guidelines and recommendations followed for preventive care.

7. IHA Completion Timeframe

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a. San Francisco Health Plan (SFHP) notifies providers to complete the IHA within 120 days after the effective date of enrollment.

b. Exceptions to the 120 days from enrollment requirement are: 1. All IHA elements completed within 12 months prior to member’s effective

date of enrollment (e.g. by a previous provider) and PCP reviewed and updated, if relevant, accordingly;

2. Member was not continuously enrolled in the plan for the required number of days

3. Member was dis-enrolled from the plan before an IHA could be performed; 4. Member, including emancipated minors or a member’s parent or guardian,

refused an IHA; or 5. Member missed a scheduled appointment with the PCP and at least two

additional documented attempts to reschedule have been unsuccessful.

c. Providers will use a note or structured data in the member’s medical record to document any of the above exceptions.

8. Initial Health Education Behavioral Assessment (IHEBA) Tool Selection

a. An IHEBA tool that is not the SHA is an alternative IHEBA. b. SFHP’s Facility Site Review includes evaluation of IHEBA tool during routine site

reviews. c. If a provider proposed use of an alternative tool or the Facility Site Review

identifies an alternative tool is in use, SFHP’s Facility Site Review team and HOI’s Access and Care Experience (ACE) Program Manager review the alternative tool to ensure it meets the following requirements:

i. Covers the same content and specific risk factors as the most current version SHA.

ii. Has a comparable administration schedule as the SHA. iii. Is supported by an operational process similar to the SHA. iv. Has been translated into SFHP’s threshold languages.

d. SFHP’s ACE Program Manager submits to DHCS documentation of any tool selected as an alternative to the SHA.

e. SFHP’s Facility Site Review Nurse or ACE Program Manager notify DHCS one month in advance before implementation if providers wish to use: i) An electronic or other version of the SHA.

(1) This is an acceptable alternative when all SHA questions are included verbatim.

(2) SFHP’s notification to DHCS shall include a copy of the SHA in the electronic or other format, such as screen shots.

ii) American Academy of Pediatrics Bright Futures assessment. (1) This is an acceptable alternative to the SHA when it is the most current

version, administered according to Bright Futures guidelines, and translated into threshold languages.

(2) SFHP’s notification to DHCS shall include the provider/medical groups who will be using the Bright Futures assessment, for which age groups,

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and their method/process to be used to document and verify the administration and follow-up.

f. If approved, SFHP’s ACE Program Manager will re-submit to DHCS every three years alternative IHEBAs for continued approval.

MONITORING

1. IHA Rate Report:

a. On a quarterly basis, SFHP’s Access and Care Experience team generates a report to monitor IHA completion compliance.

b. If any clinic/provider falls below 80% completion of the IHA, SFHP’s Access and Care Experience Program Manager sends a letter to the site with their rates and a request to respond with an improvement plan.

c. HOI reviews and validates IHA rate report code sets every two years.

2. Benchmark Report HOI benchmarks performance against other Medi-Cal plans’ IHA completion rates every two (2) years.

3. Facility Site Reviews (see PR-10 for more information): A sample of 10 – 30 PCP charts per PCP site medical group are selected for Medical Record Review (MRR). The MRR occurs every three years and includes evaluation of compliance with the IHA.

a. FSR Annual Reports show results of initial and periodic review of IHA compliance.

4. Quality Improvement Committee (QIC):

a. Annually, QIC reviews the IHA rate report. a.b. FSR Annual Reports show results of initial and periodic review of

IHA compliance.

DEFINITIONS Bright Futures Assessment: The American Academy of Pediatrics’ compendium of visit forms for developmental, behavioral, and psychosocial screening and assessment. Effective Date of Enrollment: 1) The first of the month following notification from DHCS that the member is eligible to receive services from SFHP, that capitation is paid, and that the member is not on “hold” status; 2) For infants born to SFHP members, the effective date of enrollment is the date of birth; and 3) In the case of retroactive enrollment, the effective date of enrollment, for purposes of determining the time-frame for performing the IHA, is the date SFHP receives notification of the member’s enrollment. Evidence of Coverage (EOC): Document describing benefits and services covered by SFHP.

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Facility Site Review (FSR): A Facility Site Review (FSR), consisting of the MMCD FSR and MRR Survey Tools, assesses and ensures that primary care provider (PCP) sites are compliant with all applicable local, state, and federal standards (PL-14-004). Survey and scoring to audit facility sites and medical records. Initial Health Assessment (IHA): A complete physical and mental health exam and a comprehensive medical history including a complete social history. An IHA includes a n DHCS approved tool such as an age appropriate Staying Healthy Assessment (SHA) formIndividual Health Education Behavioral Assessment (IHEBA) and completion of the age-appropriate Staying Healthy Assessment (SHA) form, DHCS’s approved Individual Health Education Behavioral Assessment (IHEBA). Initial Health Education Behavioral Assessment (IHEBA): Generic term for an assessment tool, while SHA is a specific assessment tool. IHEBA can mean SHA, Bright Futures, or any other DHCS-approved alternative assessment tool. IHEBA and SHA are not interchangeable terms. IHEBA is used to identify & document patients’ health education needs related to lifestyle, behavior, environment and cultural and linguistic background and follow up Medical Records Review (MRR): Assessment of a primary care provider’s quality of preventive care delivery through an audit of medical records for format; legal protocols; documented evidence of the provision of pediatric, adult, and/or obstetric preventive and coordination and continuity of care services (PL 14-004). Documented evidence of preventative care and coordination and continuity of care services. The medical records provide legal proof that the patient received care. Site Review Survey: Assessment of primary care provider sites as part of the initial review process and every three years thereafter to ensure that sites have sufficient capacity to: provide appropriate primary health care services; carry out processes that support continuity and coordination of care; maintain patient safety standards and practices; and operate in compliance with all applicable local, state, and federal laws and regulations (PL 14-004). Staying Healthy Assessment (SHA) - A specific behavioral assessment tool that complements the physical assessment.

AFFECTED DEPARTMENTS/PARTIES Health Outcomes Improvement Provider Network Operations Compliance and Regulatory Affairs Network Providers

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Delegated Medical Groups Marketing and Communications

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS QI-05: Monitoring Accessibility of Provider Services (QI-05) PR-10: Facility Site and Medical Record Review (PR-10) HE-03: Preventive Health Care and Clinical Practice Guidelines (HE-03) HE-06: Alcohol Misuse Screening and Counseling (AMSC) (HE-06) DO-06: Oversight of Delegated Credentialing (DO-06) PR-03: New Provider Training MC-02: New Member Materials MC-03: Translation of Member Materials

REVISION HISTORY Effective Date: May 5, 2004 Approval Date: July 15, 2008, June 23, 2009, June 22, 2011, April 10,

2014, August 22, 2014, June 11, 2015, November 19, 2015, July 21, 2016, November 16, 2016, February 21, 2019

Revision Date(s): May 5, 2004, May 16, 2006, July 15, 2008, June 12, 2009, April 15, 2011, June 1, 2011, May 31, 2013, April 10, 2014, July 9, 2014, June 1, 2015, November 9, 2015, June 27, 2016, November 2, 2016, December 8, 2017, February 13, 2019, May 13, 2019

REFERENCES 1. DHCS/SFHP Medi-Cal Contract Exhibit A, Attachment 10, Provision 3 2. 22 CCR §53851 3. 17 CCR §§6847 and 6846 4. MMCD Policy Letter 08-003: Initial Comprehensive Health Assessment 5. MMCD Policy Letter 13-001: Staying Healthy Assessment/Individual Health

Education Behavioral Assessment. 6. MMCD Policy Letter 14-004: Site Reviews: Facility Site Review and Medical Record

Review 7. MMCD All Plan Letter 14-008: Standards for Determining Threshold Languages

(revised, supersedes APL 02-003) 8. MMCD All Plan Letter 14-017: Coverage of Early and Periodic Screening,

Diagnostic, and Treatment (EPSDT) Services 9. MMCD All Plan Letter 16-014: Tobacco Prevention and Cessation Service 10. MMCD All Plan Letter 17-016: Alcohol Misuse Screening and Behavioral Counseling

Interventions in Primary Care

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APPENDIX A: Table of Requirements

Member/Enrollee Age

Assessment Type Administration timeframes Policy/APL

18 months and older

Initial Health Assessment (IHA)

• Within 120 days of enrollment

• IHAs conducted within 12 months of enrollment date count if reviewed, included in the medical record, and updated accordingly

POLICY LETTER 08-003 - Initial Comprehensive Health Assessment

0-17 • Age group

breakdowns are: 0-6 mos, 7-12 mos, 1-2 yrs, 3-4 yrs, 5-8 yrs, 9-11 yrs, 12-17 yrs

Initial Health Education Behavioral Assessment (IHEBA) • SHA Pediatric

Questionnaires by age group

• Within 120 days of enrollment along with IHA for new members

• At subsequent well care visits depending on age

OR • By first scheduled

preventive care office visit upon reaching a new age group

POLICY LETTER 13-001 - Requirements for the Staying Healthy Assessment/Individual Health Education Behavioral Assessment

18-55 years 55 and older

Initial Health Education Behavioral Assessment (IHEBA) • Adult

Questionnaire • Senior

Questionnaire

• Within 120 days of enrollment

AND • Reviewed annually • Re-administered every

3-5 years

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SAN FRANCISCO HEALTH PLAN

CARE-04: Complex Care Management

APPROVAL/REVIEW /REVISION HISTORY Signature Title Date Action

CEO Biennial Review

CMO

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SFHP POLICY AND PROCEDURE Complex Care Management Policy and Procedure number: CARE-04 Department Owner: Care Management Lines of Business Affected: Medi-Cal

POLICY STATEMENT San Francisco Health Plan’s (SFHP) Complex Care Management (CCM) program provides care management to members identified as high risk due to complex or chronic medical conditions. SFHP conducts an annual population assessment to identify and target members who require medical management and intervention as part of the overall Population Health Management Strategy. Members are identified through referral or data review and are then vetted to confirm they meet CCM eligibility criteria. Members who meet eligibility are contacted and enrolled in CCM on a voluntary basis. Once a member is identified by the CCM program, a comprehensive psychosocial and medical assessment is completed and a person-centered care plan is created. Primary goals of a care plan include; referrals and support for condition and disease self-management, health system and benefit navigation, addressing barriers to housing and transportation and other social determinants of health, and referrals to appropriate health plan and community services. All CCM members have access to a multidisciplinary care team that consists of the Community Coordinator, licensed clinical social worker (LCSW) Clinical Supervisor, nurse, and SFHP Medical director. The Care Team works in conjunction with the member’s primary care provider and SFHP network and community partners to achieve person-centered care plan goals. SFHP CCM is an opt-out program; all eligible members have the right to participate or to decline participation. SFHP CCM meets the requirements as outlined in National Association for Quality Assurance (NCQA) accreditation as well as the California Department of Health Care Services (DHCS) contractual requirements for a Complex Case Management (CCM) program. SFHP’s delegated medical groups provide DHCS CCM services based on their membership needs that fulfill the DHCS contract. As SFHP’s CCM program fulfills both DHCS and the additional requirements required by NCQA, members from all medical groups except for Kaiser (independently NCQA-accredited) are eligible for SFHP’s CCM program. Communication between SFHP and its delegated medical groups ensure no duplication of services. This approach of multiple programs allows a

SAN FRANCISCO /1.,0Q HEALTH PLAN" ~J)J ))

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greater number of members to be served by the most appropriate program to meet their needs. This policy outlines the SFHP CCM program and does not include the CCM programs at each of the delegated medical groups. Details on oversight of the delegated medical groups CCM programs can be found in DO-10: Oversight of Delegated CM Functions.

PROCEDURE

I. Population Assessment

As part of the overall Population Health Management population analysis and strategy development, SFHP Care Management leadership, in coordination with Business Intelligence and other Health Services department leadership, conducts an annual population assessment and analysis to ensure the CCM program remains relevant to member needs. Findings from the population assessment are used to target appropriate subpopulations, adjust delivery methods, and member service offerings accordingly. Data used in this analysis includes, but is not limited to:

a. Medical claims and utilization data b. Pharmacy data c. Data from predictive modeling (such as risk scores, when the software is

available) d. CCM member satisfaction survey results e. Available data on CCM program grievances f. Member demographics; including but not limited to the following

demographics: i. Medi-Cal Seniors and Persons with Disabilities (SPDs) ii. Members with multiple chronic conditions iii. Members with high levels of hospital utilization and/or low outpatient

utilization iv. Members of at risk, ethnic, language, racial groups v. Children and adolescents (ages 2-19)1 including those with potential

eligible CCS conditions A formal annual evaluation of program resources, including staffing ratios, health education materials, annual staff training curriculum and program communication, is conducted to provide a comprehensive overall assessment. The population analysis and evaluation of resources are used for program improvement. The final analysis is reviewed and approved by the Medical Director. Any performance improvement activities are implemented in the subsequent year.

1 The 2019 NCQA Population Health Management Standard defines children and adolescents as 2-19.

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II. Program Description The CCM program aligns with the standards of the Case Management Society of America (CMSA) and promotes a person-centric approach to achieve health goals. The program employs member self-care and behavioral change principles to assist the member to navigate and access health care benefits and community resources. An individualized care plan is developed with input from the member, the member’s family/caregiver when appropriate, and the member’s health care team to establish and monitor short and long-term goals and identifies resources to assist in meeting the goals. Refer to Complex Care Management Program Description for details.

III. Identifying Members for Complex Care Management CCM eligible members are identified through referrals as well as data review. Referrals sources for CCM include:

a) Member or caregiver referral b) Referrals from internal SFHP departments:

i. SFHP Clinical Operations (formerly Utilization Management) ii. SFHP Medical Director iii. SFHP Customer Service iv. SFHP Pharmacy v. SFHP Appeals and Grievances vi. SFHP Provider Relations vii. SFHP Compliance viii. Transfers from Health Risk Assessment (HRA) and Health Risk

Reassessment CM programs

c) External referrals i. Primary Care Provider and/or Specialist or clinic staff ii. Hospital Discharge Planner referral iii. Behavioral health providers (specialty and non-specialty) iv. Other community-based providers v. Members and caregivers

SFHP staff use the referral form in SFHP’s care management system to refer members for the CCM program. SFHP uses the following data sources to identify members for CCM:

i. Claims or encounter data. ii. Hospital admission and discharge data. iii. Pharmacy data. iv. Data collected through the authorization process.

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v. Data supplied by the California Department of Health Care Services (DHCS), including demographic, Health Information Forms (HIF) data, and carve-out data

vi. Data supplied by members or caregivers, including Health Risk Assessment (HRA).

IV. CCM Member Eligibility Criteria

Participation in the CCM Program is voluntary. Members are identified as eligible by meeting ALL of the following criteria:

i. A member of SFHP’s Medi-Cal line of business; ii. A member of one (1) of the following medical groups: Community Health

Network, University of California, San Francisco Medical Center (UCSF), Hill Physicians, Brown & Toland Physicians, North East Medical Services, Jade Health Care, or Chinese Community Health Care Association; and

iii. A member who does not have Medicare.

AND members must have one (1) or more of the following risks and would likely benefit from clinical intervention by Care Management staff:

i. Acute health care needs, post-emergency department (ED), or acute

hospitalization. ii. Chronic medical issues and/or multiple co-morbidities. iii. Children with Special Health Care Needs (CSHCN). iv. Poorly controlled disease states. v. High ED (more than four (4) ED visits) or inpatient utilization (more than two

(2) inpatient admissions) within a 6-month period.

AND members must have one (1) or more of the following needs:

i. Challenges with adherence to treatment (medications, not showing for office visits, etc.).

ii. Need assistance in coordinating care (e.g., facilitate communication between providers, appointments, transportation, specialty visits).

iii. No recent Primary Care Provider (PCP) visits. iv. Need for patient education and coaching about their significant chronic

conditions. v. In need of assistance with identifying, referring, and accessing supportive

community care services.

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V. Care Management Process

A. CCM Review of Program Candidates Members who are identified for CCM through referral and claims and encounter data undergo additional vetting prior to the case being opened in CCM. Additional member information including authorizations and responses from the Health Information Form (HIF) are pulled when available to provide additional information on the member’s pattern of care and overall health status. The final round of vetting is completed within six (6) business days by Care Management staff and includes the following process:

i. The Community Coordinator completes a psychosocial history based on review of available data, including checking for potential duplication of services from a delegated medical group’s CCM program or other case management program;

ii. The Care Management Nurse completes a medical diagnosis and treatment review; and

iii. The Care Coordination Pharmacist provides a medication compliance report.

B. CCM Program Outreach Members who meet the CCM program criteria are contacted by a Community Coordinator who explains the model and the nature of the care management program. For members who verbally consent to participate, the Community Coordinator documents this consent in SFHP’s care management system. If consent is not received within thirty (30) days or if the member declines, the referral is closed. Program intake includes outreach to the primary care provider (PCP) and/or treating provider in order to discuss the referral and gather additional clinical information. If a member has no documented relationship with a PCP, then the care plan will include the goal of establishment of a patient/PCP relationship.

C. CCM Initial Assessment The initial assessment includes both a psychosocial and medical assessment as well as one or more condition-specific assessments that cover additional detail based on the member’s medical conditions. The Community Coordinator completes the psychosocial assessment and the Care Management Nurse completes the medical and condition-specific assessments. These assessments can be completed in person, at a member’s home, SFHP Service Center, or other agreed upon community setting, or over the phone. The assigned Community Coordinator and nurse coordinate completion of these assessments in a manner that works best for the member. The assessments cover many domains including:

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i. Linguistic Needs and Consent ii. Initial Assessment of Member Health Status, Including Condition-Specific

Issues iii. Memory and Understanding and Cognitive Functions iv. Behavioral Health v. Psychosocial Overview vi. Cultural Needs and End of Life Planning vii. Caregiver Resources and Involvement viii. Evaluation of Available Benefits ix. Evaluation of Available Community Resources x. Goal Prioritization xi. Activities of Daily Living (ADLs)/Instrumental Activities of Daily Living (IADLs) xii. Visual and Hearing Needs, Preferences or Limitations

The initial CCM assessment is begun within 30 calendar days of identifying member eligibility for CCM and completed within 60 calendar days. Unavoidable delays in the completion of the initial assessment include member hospitalization, inability to contact member, natural disaster, or member is deceased. In these instances the Community Coordinator documents the reasons for the delay and actions taken to complete the assessment.

D. CCM Care Planning Individualized care plans are developed in collaboration with the member, member’s caregiver when appropriate, and member's health care team based on the answers provided in the initial assessment. The assigned Community Coordinator and SFHP Care Management team work with the member and caregivers (as appropriate) to prioritize the identified goals. Priorities are identified as low, medium, or high and reflect the member’s and caregivers’ goals, preferences, and desired level of involvement. E. Ongoing Care Management Activities Following completion of the initial assessment and care plan, the care management team works with the member to connect them to providers, community agencies and complete care plan goals. Care management interventions supporting progress toward goal completion may include:

i. Development and communication of member self-management plans ii. Member education on chronic conditions iii. Follow-up after referral to a resource or other program

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Member/Provider Follow-up and Communication Plan

Member Acuity Status Communication High-Risk (3) High-risk members may require prompt attention to address crisis and/or to ensure health and safety. These members present with a combination of the following factors: • Recent or ongoing ED/IP utilization within the last month • Multiple unmanaged chronic conditions • Any specialty mental health and/or substance abuse

diagnosis • Low self-efficacy (poor appointment compliance, limited

mobility, very limited participation in own care) • Low Health Literacy • Lack of social support/isolation • Challenges meeting basic needs, such as housing, food,

in-home support and transportation • Moderate to severe cognitive impairment

The minimum recommended contact is four (4) in-person, phone or email contacts per month.

Moderate (2) Moderate-risk members have chronic and ongoing needs—both medical and social. Member is motivated to change and has capacity to manage needs with moderate direction and assistance. Member is receptive to and welcomes health education coaching in regard to self-efficacy and self-advocacy. Member can maintain regular PCP appointments and requires moderate assistance with specialty/new providers. Most basic needs are met.

The minimum recommended contact is two (2) in-person, phone or email contacts per month.

Low (Maintenance) (1) Member is high functioning (utilizes medical system appropriately and has a system in place to manage medication), adequate social and medical support, informed of many community services, connected to appropriate services, and most basic needs are met. Client has fewer and more concrete goals and is moving toward “well managed” and maintenance.

The minimum recommended contact is one (1) in-person, phone or email contacts per month.

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F. CCM Continuation/Closure Criteria Criteria for Program Continuation Ongoing CCM program enrollment is based on member’s participation in the progress toward goals or development of any new goals. At any point, the assigned Community Coordinator in accord with their supervisor conduct a reassessment to determine if the case should remain open. Criteria for Case Closure The Community Coordinator submits cases to their supervisor for closure that meet one (1) or more of the closure criteria below. The Community Coordinator will document and route cases for closure using SFHP’s care management system. Closure criteria include:

i. Member completed care management goals. ii. Member is lost to care or does not engage in service.

i. Lost to follow-up is identified when: i. If an engaged member has not returned three (3) voicemails

and/or presented to the last two (2) scheduled visits or home visit attempts the member is considered lost to follow-up.

ii. Community Coordinator is to document member is now lost to follow-up and will try outreaching for four (4) weeks prior to closing the case as “lost to follow-up”.

iii. Outreach During the four (4) weeks of outreach, the Community Coordinator needs to:

a) Make two (2) phone call attempts to member. b) Make one (1) call or email to PCP. c) Mail “Lost to Follow Up Letter” (in care management

system correspondence). d) Make one (1) visit attempt or one (1) additional phone

call as indicated based on prior work with member. iii. Member declines case management or chooses to terminate service. iv. Member no longer eligible based on eligibility criteria. v. Member is referred to or enrolls in a program that provides comparable case

management services. vi. Member is transferred to another setting, such as hospice and no longer

requires case management. vii. Member death. viii. Member is not compliant with plan of care. ix. Member has attained maximum improvement. x. Interventions are not successful/all resources exhausted. xi. Member is dis-enrolled from health plan.

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VI. Complex Care Management Staffing SFHP’s Care Management department utilizes a clinical pod staffing structure that includes Licensed Clinical Social Work (LCSW) Supervisors who each oversee teams of up to five (5) Community Coordinators and one (1) Care Management Nurse. Each Community Coordinator acts as the primary care manager for each member engaged in the program. The nurse conducts the nursing assessments and other medical case management including managing health education and self-management of chronic condition goals. Additionally, the Care Coordination Pharmacist completes the medication history for each member and performs medication reconciliation as indicated. Each clinical pod meets regularly with the Medical Director for medical oversight and input. The clinical pod including Care Coordination Pharmacist and Medical Director are referred to as the member’s care team. Other SFHP staff, such as representatives from Clinical Operations, or co-located staff from the non-specialty mental health vendor may participate in the clinical pod meetings depending on the members’ needs. The Community Coordinator and nurse collaborate with members, families, and/or caregivers, PCPs, specialty providers and community-based agencies to ensure the provision of timely and appropriate healthcare services for both acute and chronic conditions. A person-centered approach is used to develop and implement individualized care plans to optimize the member’s health status and function, and to enhance self-management knowledge and skills. After completion of the initial assessment, the Community Coordinator, with input from the nurse and Clinical Supervisor, works to ensure that the care plan is person-centered and addresses the member’s and their caregiver’s health care needs, priorities, goals, abilities and preferences, including desired level of participation. The Community Coordinator coordinates services, including carved-out and linked services to ensure the timely delivery of services, and reduces, eliminates, or addresses any barriers adversely affecting progress toward goals. The Community Coordinator makes referrals to appropriate community resources and other agencies. Additionally, the Community Coordinator monitors and documents progress toward goals, and update care plans regularly to ensure interventions are responsive to the member’s health care needs. As needed, the Community Coordinator accompanies the member to provider office appointments to ensure coordination of care plans. The Community Coordinator, with support from the nurse, Pharmacy Team, and Clinical Supervisor, communicates with and coordinates across multiple disciplines and settings, including primary care providers, specialists, acute and sub-acute providers/case managers, home health, wound care, pharmacy, behavioral health providers, benefit community agencies that address social determinants such as food access and transportation,

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Community Coordinators present members’ cases at clinical meetings when members have made limited progress toward goals, and/or when care coordination across internal SFHP departments (Clinical Operations, Pharmacy, Appeals and Grievances) is needed. The Community Coordinator ensures the member and member’s designees have the opportunity to participate fully in any discussion or decisions regarding treatments and services. Member and family education materials are provided as indicated. A. Documentation All clinical Care Management staff document care management activities in SFHP’s care management system, which provides data integration for member care management. This system supports:

i. Evidence-based clinical guidelines or algorithms to conduct assessment and management.

ii. Automatic documentation of the staff member’s ID and date, and time of action on the case or when interaction with the member occurred.

iii. Automated prompts for follow-up, as required by the case management plan.

iv. Contact logs, including contact information and role of support persons and collaborating community providers.

v. Assessments. vi. Date/Time-stamped case progress notes, including details of referrals,

need for coordination with other service providers and actual coordination of services that take place.

vii. Releases signed by participants to facilitate communication with support persons and collaborating providers.

MONITORING

The responsibility for the oversight and monitoring of the CCM program is the responsibility of the Quality Program Manager, the Director, Care Management and the Medical Director under the supervision of the Chief Medical Office. SFHP annually measures the effectiveness of its CCM program using three (3) measures, in addition to client engagement in CCM. These measures vary year to year based on the population identified by the population analysis and other Population Health Management Strategy priorities. For each measure, SFHP:

a) Identifies a relevant process or outcome. b) Uses valid methods that provide quantitative results. c) Sets a performance goal. d) Clearly identifies measure specifications.

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e) Collects data and analyzes results. f) Identifies any opportunities for improvement.

Community Coordinator and Nurse Oversight

Community Coordinators and nurses meet weekly with their Clinical Supervisor to review cases. The nurses meet with the LCSW Clinical Supervisors and Medical Director bimonthly for group supervision. The clinical pod meets monthly and care teams meet more frequently as needed. Community Coordinators and Care Management Nurses consult with the SFHP Medical Director during bimonthly group supervision and on an as-needed basis during the assessment and care management process, in order to obtain guidance regarding:

i. Members with co-morbid behavioral health and medical issues. ii. Comprehensive diagnostic workups. iii. Members with medication or polypharmacy issues. iv. Engagement of members, including those opposed to seeking needed

health care. v. Identification of potential quality issues and follow-up next steps.

All Care Management charts undergo regular auditing by the LCSW Clinical Supervisor to evaluate short- and long-term goals and progress toward goals. Each Community Coordinator is audited quarterly by their supervisor on no less than five (5) random charts, and feedback is provided in writing for areas of improvement. In addition, Community Coordinators complete a self-audit on all assigned cases every other month. The Quality Program Manager conducts quarterly chart audits using 8/30 methodology to ensure compliance with program policies and procedures.

DEFINITIONS

Activities of Daily Living (ADLs): Routine activities that people tend to do every day without needing assistance, including eating, bathing, dressing, toileting, transferring, and continence. An individual’s ability to perform ADLs independently is important for determining what type of long-term care an individual needs. Complex Care Management (CCM): Is a program run by SFHP’s Care Management department that maximizes skills of both a Community Coordinator and Care Management Nurse to assess and care plan with member’s who have multiple chronic conditions but a level of psychosocial stability that allows them to focus on self-management of chronic conditions. Members receive intense coordination with providers and community partners; and engagement of members (family/caregivers) in the planning and implementation of their care plan. Members enrolled in CCM receive coaching and guidance for their medical conditions and referrals to resources that will allow them to regain or maintain optimum health and/or functionality. Care plans reflect

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care coordination, condition-specific education, advocacy, and system navigation to meet the member’s comprehensive health needs, based on available resources. CCM Program assessments are based on clinical best practices. Person-Centered Planning: As defined by the California Department of Health Care Services (DHCS), is a highly individualized and ongoing process to develop individualized care plans that focus on a person’s abilities and preferences. Children with Special Health Care Needs (CSHCN): As defined by the Federal Maternal-Child Health Bureau, are children who have or are at increased risk for chronic physical, behavioral, developmental, or emotional conditions and who also require health or related services of a type or amount beyond that required by children generally.

AFFECTED DEPARTMENTS/PARTIES Business Analytics Clinical Operations Health Outcomes Improvement Customer Service Delegated Group Network Provider Pharmacy

RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS 1. CARE-01 Community-Based Care Management Care Management Programs:

Health Homes, and Time-Limited Care Coordination, and Child, Adolescent and Transition Age Youth Programs

2. CARE-02 Risk Stratification, Health Information Forms (HIFs), and Health Risk Assessments (HRAs)

3. CARE-03 Client and Staff Safety 4. CO-20 California Children’s Services (CCS) 5. Complex Case Management Program Description 6. DO-10 Oversight of Delegated CM Functions 7. QI-13 Disease Management 8. UMCO-33 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and

EPSDT Supplemental Services

REVISION HISTORY

Effective Date: February 12, 2015 Approval Date: February 12, 2015, February 22, 2016, June 15, 2017, June 20,

2019 Revision Date(s): January 15, 2016, May 24, 2017, June 7, 2019

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REFERENCES 1. DHCS/SFHP Contract, Exhibit A, Attachment 11, Provision 1; Exhibit A, Attachment

18, Provision 11 2. NCQA Standard PHM 5 Complex Case Management (2019)

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SAN FRANCISCO HEALTH PLAN

CARE-07: Golden Gate Regional Center

APPROVAL/REVIEW /REVISION HISTORY Si nature Title Date Action

CEO Biennial Review

CMO

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SFHP POLICY AND PROCEDURE Golden Gate Regional Center Policy and Procedure number: CARE-07 Department Owner: Care Management Lines of Business Affected: Medi-Cal, Healthy Kids HMO

POLICY STATEMENT

San Francisco Health Plan (SFHP) members with specific conditions are eligible to receive support and services through the two programs managed by Golden Gate Regional Center (GGRC): Early Start (ES) and Ongoing/Lanterman Act services. . SFHP provides members identified with or suspected of having developmental disabilities/delays with all medically necessary and appropriate developmental screenings, primary preventive services, and diagnostic and treatment services. For members at risk of giving birth to a child with a developmental disability/delay, SFHP provides genetic counseling and other Medi-Cal-covered prenatal genetic services when medically indicated. . SFHP coordinates services with the GGRC in order to achieve optimum outcomes for members with developmental disability/delay.

PROCEDURE

I. Eligibility for and referral to Golden Gate Regional Center (GGRC) Programs: A. SFHP, its medical groups, and Network Provider identify SFHP members with

potential GGRC-eligible diagnoses and refer them to GGRC. B. SFHP educates its provider network and members about GGRC programs and

services through the Provider Manuel, new provider trainings, Provider Resource Guide, Member Handbook, and Member Guidebook. This education includes: 1. Description of the services offered by GGRC programs: GGRC provides

services and support for developmentally disabled/delayed persons and their families. Services can include:: a. Training in skills for daily living b. Advocacy and legal assistanceFamily support, training and counseling c. Adult Day Programs d. Respite care e. Community Living placement, (Residential care or assisted living) and

supportive living services f. Supportive employment and vocational programs g. Assistive technology h. PT/OT/Speech Therapy i. Transportation

2. Eligibility Criteria:

SAN FRANCISCO AOO HEALTH PLAN" l@AJ .))

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a. Early Start: To be eligible for Early Start (ES), members, must be children from birth through 36 months of age who need early intervention services as a result of developmental delays/conditions (cognitive, physical, motor, communication, emotional-social, adaptive) or who have an established condition with a high probability of developmental delay such as chromosomal disorders, inborn errors of metabolism, neurological disorders and visual, speech or hearing impairment and those whose early health histories place them at risk for delay. Early Start refers any child who is eligible for continuing services in the school system to the Local Education Agency on or before the child is 36 months of age.

b. Ongoing Services/Lanterman Act: To be eligible for Ongoing/Lanterman

Act services, members must be age three (3) years or older suspected of having an intellectual disability due to genetic conditions, cerebral palsy, epilepsy, or autism that originated before the age of 18. The condition must be expected to continue indefinitely, and constitute a substantial handicap. GGRC refers eligible members to the Genetically Handicapped Persons Program and/or the Home and Community Based Services Waiver Program for the Developmentally Disabled for additional support and services.

c. If members under age 21 are not accepted for Targeted Case Management (TCM) services as specified in 22 CCR §51351, SFHP ensures that the member’s access to services is comparable to Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) TCM services.

3. Referral information:

a. Referrals to both ES and Ongoing/Lanterman Act Services are made the same way; SFHP staff, medical groups, primary or speciality care providers,, community case managers, parents, or members can refer to the GGRC by contacting GGRC’s intake unit via phone, email or fax:

• Phone: 1-888-339-3305 • Email: [email protected] • Fax: 1-888-339-3306.

b. ES referrals made by email or fax should also accompany a completed

referral form; Ongoing/Lanterman Act referrals made by fax or email should accompany a client contact form. All appropriate forms can be found on the GGRC website: http://www.ggrc.org/services/applying-for-services

c. Referrals from providers and professionals should be made within two (2) business days of determing the need for developmental services. All referrals should accompany documentation that includes: complete medical history and physical examination; any results of developmental screening and assessment/psychological evaluation; and other diagnostic tests as

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mailto:[email protected]

http://www.ggrc.org/services/applying-for-services

3

indicated. (GGRC Medical Consultants are available for consultations and further assessment as needed.)

II. SFHP Responsibilities

A. SFHP executes and maintains a Memorandum of Understanding (MOU) with GGRC for coordination of all GGRC programsSFHP meets or communicates with the Regional Center staff at least quarterly. The meetings are used to address/monitor access issues or barriers for shared SFHP and GGRC members, resolve issues and exchange program and policy updates. Once a year the MOU is reviewed and revised, as needed.

B. SFHP educates members on GGRC services and programs through the Member Handbook and Member Guidebook.

C. SFHP educates the medical group staff and providers through the distribution of the SFHP Provider Resource Guide, the SFHPProvider Manual , and provider updates regarding any GGRC programmatic changes.

D. SFHP receives a monthly list from Department of Developmental Services (DDS)/Department of Health Care Services (DHCS), known as the GGRC Common Member list. This list, including GGRC eligibility diagnosis, is then combined with information from SFHP’s data warehouse to add current member contact information, as well as the PCP/Clinic contact information (name, address, phone, etc.). This report is run monthly for each medical group and forwarded via secure email to the designated case management staff at each medical group. SFHP Care Management and Health Services staff also generate this report on an ongoing basis to verify GGRC enrollment for qualifying members in order to provide necessary care coordination. An updated contact list of staff at GGRC is shared internally among Health Services staff and is also sent to each medical group to assist with coordination of care.

E. SFHP Care Management department and medical group staff communicate and collaborate with GGRC staff in order toensure member’s needs are being met and available resources/benefits are being maximized. This coordination also aims to , prevent duplication of assessments and services, coordinate medical and non-medical needs of members, and discuss members who are not getting timely care or making progress.

III. PCP Responsibilities

A. Providers should refer members to GGRC for assessment of eligibility, as stated in the Provider Manual , when the need for developmental services and supports is determined.

B. After enrollment, the assigned PCP continues to act as Basic Case Manager providing primary care and referral to any other covered medical services.

C. PCPs must provide Basic Case Management services, including coordination of and referral to linked services, including GGRC.

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MONITORING Through Facility Site Reviews, SFHP monitors referrals and coordination of care between the PCP and linked services, including GGRC and ES. The auditor looks for evidence of coordination between GGRC providers treating the SFHP member and for indications that the PCP is providing primary and preventive care and coordinating care with GGRC. Quarterly meetings with GGRC and SFHP leadership are utilized to monitor and address access barriers and care coordination needs of SFHP members enrolled in GGRC programs.

DEFINITIONS Basic Case Management: A collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s health needs. Services are provided by the Primary Care Physician (PCP), or by a PCP-supervised Physician Assistant (PA), Nurse Practitioner (NP), or Certified Nurse Midwife, as the Medical Home. Coordination of carved out and linked services are considered basic case management. Developmental Disability: A disability that originates before an individual attains 18 years of age; continues, or can be expected to continue, indefinitely; and constitutes a substantial disability for that individual. As defined by the Director of Developmental Services, in consultation with the Superintendent of Public Instruction, this term shall include intellectual disability, cerebral palsy, epilepsy, and autism. This term shall also include disabling conditions found to be closely related to intellectual disability or to require treatment similar to that required for individuals with an intellectual disability, but shall not include other handicapping conditions that are solely physical in nature. (W&I Code §4512) Regional Center – The single-point-of-entry into the developmental services system. Regional Centers provide diagnosis, counseling, case management, client and family supports and access to interventions and rehabilitation programs from birth throughout the lifetime of individuals having substantial disabling conditions. By California statute (W&I Code §4659), Regional Centers are “payers of last resort,” and as such, must utilize all generic, federal funds, and private insurance programs prior to expending center funder – state general fund – to obtain services for clients.

AFFECTED DEPARTMENTS/PARTIES Care Management Delegated Groups GGRC MOU Network Providers Provider Network Operations

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RELATED POLICIES AND PROCEDURES AND OTHER RELATED DOCUMENTS 1. CARE-05 Coordination of CareCO-33: EPSDT and EPSDT Supplemental Services 2. DO-01: Oversight of Delegated Functions

REVISION HISTORY Effective Date: March 22, 2006 Approval Date: March 22, 2006; February 9, 2009; January 22, 2015; July 20,

2017; June 20, 2019 Revision Date(s): February 9, 2009; December 29, 2011; December 2, 2014; April 1,

2017; June 1, 2019

REFERENCES 1. 17 CCR §§54000, et seq. 2. 22 CCR §51351 1. 34 CFR § 303.321 2. California Early Intervention Services Act – Gov Code §95000, et seq. 3. DHCS/SFHP Contract - Exhibit A, Attachment 11, Provision 10 3. DHCS/SFHP Contract - Exhibit A, Attachment 11, Provision 11 4. Lanterman Developmental Disabilities Services Act – W&I Code §§4400, et seq. 5. MMCD Policy Letter 11-006 4. MMCD Policy Letter 97-02 6. MMCD Policy Letter 97-03

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SFHP Provider Satisfaction Survey

Sean Dongre Provider Relations Manager

Provider Satisfaction Survey Results and Discussion

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Motives and Objectives of the survey • Survey conducted by SPH Analytics

• SPH performs comparison/benchmarking against its other clients – 77 Medicaid plans, 102 total plans

• Supports NCQA Accreditation • Supports DMHC access standards • Allows us to assess and improve

providers’ experience with many aspects of SFHP.

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Details

• Survey was administered from February to March 2019 • 3 rounds: email, mail, and phone followup

• From a sample of 750 providers, 148 surveys were returned (19.7% net return) • Last year was 13.7%; compare with 5-20% in

other plans • First 100 respondents rewarded with coffee

gift cards

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Summary

• Specialist physicians and practices are 51% of respondents. This proportion is trending up for four years.

• Approval in most areas are down (Finance, UM, Customer Service, Provider Relations, etc), not stat. significantly different compared with last year

• SFHP is significantly better than 77-plan Medicaid group in almost every category except overall satisfaction, finance/claims, and CS

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Segmentation Analysis

• Primary Care vs. Specialty (Report Page 3E) • SFHP earns better satisfaction from Primary

care than Medicaid plans, consistently (shaded in green)

• Specialists rate almost everything lower than PC.

• SFHP specialists rate SFHP lower on overall satisfaction than the Medicaid average as well, but not by much.

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Segmentation Analysis

• SFHN, Consortium, UCSF vs. Delegated Group (Report page 6H) • There are big differences in satisfaction

between these sides. See Range in last column.

• Largest range in Network/Coordination of Care, Pharmacy, UM. Large difference in overall satisfaction as well.

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Custom SFHP questions (no benchmarks) • Satisfaction with dialysis providers down

from 76.3% to 53.8% • Satisfaction with DME 67.7% to 50.0% • Satisfaction with wheelchair specialists

60.8% to 41.7% • 35-55% of survey takers responded to

these questions and they didn’t address these factors in their comments. • Any insights from QIC?

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Provider Satisfaction with Access (CA only)

Satisfaction with: 2017 2018 2019 Referral/PA Process 85.7 85.1 77.9% Patients’ access to urgent care 91.5 94.3 89.1% Patients’ access to primary care 89.2 95.6 89.2% Patients’ access to urgent care 83.1 83.1 80.5% Patients’ access to ancillary care 88.3 85.9 86.6% Patients’ access to nonspec. MH (Beacon) 61.5 73.5 59.1% Patients’ access to specialty MH (CBHS) 51.6 67.7 61.6% Interpreter appointments 88.7 79.3% Interpreter language range 91.9 87.8% Interpreter training & competency 94.5 87.2%

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Provider Satisfaction with Incentives (SFHP only)

Does this help your patients’ health care behaviors?:

2017 2018 2019

Childhood Immunization incentive 74.1 85.4 80.4% Well Child incentive 70.9 76.2 81.4% Diabetes incentive 75.0 69.5 79.2% Perinatal incentive 60.0 67.9 85.0% Hypertension incentive 75.9 70.9 81.7% Asthma Control incentive 64.9 62.5 77.3% Adult Wellness incentive 73.7%

2017 2018 2019 Are you familiar with SFHP incentives? 66.3 44.0

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Segmentation

• We can divide responses by the segment of our network in which they participate

• Providers in CHN and UCSF usually interact with SFHP more directly than IPA providers. IPA providers work with their IPA for most UM and finance issues.

• Caveat: Segmentation reduces sample size considerably, so statistical power is reduced

• Large disparities between segments in satisfaction with: • SFHP overall • Number, quality, and communication of specialists in the

network • Timeliness of claims processing • Provider Relations ability to answer questions and resolve

problems 108

Next steps

• Next steps • Dive into segmentation analyses, comments, etc.

for more insights • Address weakness such as ease of reaching staff

& obtaining information, and satisfaction with specialty quality in delegated groups

• Maintain high performance in our strengths, especially the issues that correlate highly with overall satisfaction (Provider Relations, Pharmacy, UM)

• Work with vendor to improve contact information, fielding strategy, and therefore response rate, for greater statistical power and breadth of response

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Profile of Survey Respondents San Francisco Health PlanSurvey Demographics Provider Satisfaction Survey

148 Total Respondents

Note: The sum of responses for Area of Medicine may be greater than 100% as respondents are able to choose multiple response options.

62.3%

50.7%

0% 20% 40% 60% 80%

Primary Care

Specialty

Area of Medicine (A)

Solo43.5%

2 - 5 physicians

23.1%

More than 5 physicians

33.3%

Physicians in Practice (B)

Less than 5 years25.9%

5 - 15 years46.8%

16 years or more27.3%

Years in Practice (C)

Physician40.5%

Office Staff37.2%

Nurse/Clinical Staff7.4%

Other14.9%

Survey Respondent (E)

CHNUCS44.6%

DMG55.4%

Delegation (Database)

0 - 10%27.5%

11 - 20%14.1%

21 - 100%58.5%

Portion of Managed Care Volume Represented by Health Plan (D)

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Summary of Benchmark Comparisons San Francisco Health PlanComposites and Attributes - Summary Rate Scores Provider Satisfaction Survey


Valid nSummary

Rate*Valid n

Summary Rate*

Valid n Summary

Rate*Medicaid Aggregate

Overall Satisfaction 126 73.8% 101 73.3% 79 74.7% 66.6% 68.2%

129 85.3% 101 86.1% 80 91.3% 83.2% 84.0%

126 73.8% 101 73.3% 79 74.7% 66.6% 68.2%

All Other Plans (Comparative Rating) 139 48.9% 117 55.6% 96 49.0% 32.9% 33.6%

139 48.9% 117 55.6% 96 49.0% 32.9% 33.6%

Finance Issues 93 33.6% 82 39.3% 67 43.2% 28.6% 28.9%

93 26.9% 82 40.2% 67 43.3% 26.8% 27.1%

93 36.6% 79 38.0% 65 47.7% 30.4% 31.0%

91 37.4% 78 37.2% 65 40.0% 31.1% 31.2%

83 33.7% 72 41.7% 62 41.9% 26.0% 26.5%

Utilization Management and Care Support 127 45.0% 102 49.8% 83 47.6% 30.9% 31.5%

111 44.1% 90 43.3% 68 42.6% 29.0% 29.6%

127 41.7% 102 52.0% 80 48.8% 29.6% 30.2%

121 42.1% 101 51.5% 79 46.8% 29.9% 30.4%

126 44.4% 100 46.0% 79 46.8% 30.6% 31.1%

118 52.5% 101 56.4% 83 53.0% 35.4% 36.3%

Network/Coordination of Care 126 37.5% 97 43.9% 84 47.6% 27.9% 29.2%

124 31.5% 97 40.2% 83 42.2% 25.8% 27.4%

126 43.7% 95 45.3% 84 54.8% 31.5% 33.0%

120 37.5% 91 46.2% 83 45.8% 26.5% 27.4%

Pharmacy 116 28.6% 92 31.7% 78 32.2% 21.3% 21.7%

115 34.8% 92 37.0% 78 33.3% 22.6% 23.0%

111 29.7% 90 35.6% 77 33.8% 20.0% 20.5%

116 31.0% 87 28.7% 78 32.1% 21.8% 22.4%

112 18.8% 86 25.6% 71 29.6% 20.8% 21.1%

Health Plan Customer Service Staff 102 40.1% 85 53.4% 72 47.1% 36.2% 36.6%

93 34.4% 77 58.4% 67 46.3% 32.9% 33.5%

96 43.8% 80 51.3% 67 47.8% 38.2% 38.7%

102 42.2% 85 50.6% 72 47.2% 37.3% 37.5%

Provider Relations 112 56.9% 74 67.3% 69 63.8% 34.6% 35.1%

91 61.5% 71 67.6% 67 70.1% 43.2% 44.6%

73 52.1% 64 64.1% 56 58.9% 30.7% 30.8%

112 57.1% 74 70.3% 69 62.3% 30.0% 30.0%

* Summary Rates represent the most favorable response percentage(s).

Note 3: The Overall Satisfaction Summary Rate includes only 12B. It does not include 12A.

Note 1: Significance Testing - Cells highlighted in red denote current year plan percentage is significantly lower when compared to trend or benchmark data; Cells highlighted in green denote current year plan percentage is significantly higher when compared to trend or benchmark data; No shading denotes that there was no significant difference between the percentages, there is no benchmark,

** SPH Analytics's 2018 Medicaid Book of Business consists of data from 77 projects representing 18710 respondents, while the Aggregate Book of Business consists of data from 102 projects representing 26280 respondents in Primary Care, Specialty, and Behavioral Health areas of medicine. See Technical Notes for more information.

Composites and Key Questions

20192018 SPH Book of

Business Benchmarks**

7B. Variety of drugs on the formulary.

7A. Extent to which formulary reflects current standards of care.

5C. The timeliness of feedback/reports from specialists in this health plan's provider network.

12A. Would you recommend SFHP to other physicians' practices?

12B. Please rate your overall satisfaction with San Fransisco Health Plan.

5B. The quality of specialists in this health plan's provider network.

5A. The number of specialists in this health plan's provider network.

3E. Degree to which the plan covers and encourages preventive care and wellness.

3D. The health plan's facilitation/support of appropriate clinical care for patients.

3C. Timeliness of obtaining pre-certification/referral/authorization information.

3B. Procedures for obtaining pre-certification/referral/authorization information.

3A. Access to knowledgeable UM staff.

2D. Resolution of claims payment problems or disputes.

8A. Ease of reaching health plan call center staff over the phone.

7D. Availability of alternative drugs to substitute those not included in the formulary.

7C. Ease of prescribing your preferred medications within formulary guidelines.

9C. Quality of written communications, policy bulletins, and manuals.

9B. Quality of provider orientation process.

9A. Provider Relations representative's ability to answer questions and resolve problems.

8C. Overall satisfaction with Customer Services.

2018 2017

Current

Note 2: Question wording for 7B, 7D, and 8C on the SFHP 2019 survey tool is different from the 2018 SPH Analytics Book of Business. Caution is advised when making comparisons. See Question Summaries for further detail.

Note 4: Caution is advised when comparing the Provider Relations composite and attributes to the 2018 SPH Analytics Book of Business. Attributes in the Book of Business were gated by the following question: "Do you have a Provider Relations representative from this health plan assigned to your practice?" The 2019 survey tool does not include this gate question. Additionally, the response option scale differs from the 2018 SPH Analytics Book of Business. See Question Summaries for further detail.

2C. Timeliness of claims processing.

2B. Accuracy of claims processing.

2A. Consistency of reimbursement fees with your contract rates.

1A. How would you rate SFHP compared to all other health plans you contract with?

8B. Process of obtaining member information (eligibility, benefit coverage, co-pay amounts).

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Benchmark Comparisons San Francisco Health Plan2018 SPH Analytics Medicaid Book of Business Percentiles Provider Satisfaction Survey


25th 50th 75th 90th

Overall Satisfaction 73.8% 65th 66.6% 60.0% 67.6% 74.4% 79.0%

85.3% 55th 83.2% 76.4% 85.5% 88.5% 92.1%

73.8% 65th 66.6% 60.0% 67.6% 74.4% 79.0%

All Other Plans (Comparative Rating) 48.9% 86th 32.9% 23.1% 30.0% 39.7% 49.3%

48.9% 86th 32.9% 23.1% 30.0% 39.7% 49.3%

Finance Issues 33.6% 67th 28.6% 24.1% 29.7% 36.0% 46.8%

26.9% 47th 26.8% 19.2% 26.3% 32.7% 39.9%

36.6% 71st 30.4% 23.3% 30.0% 35.4% 46.4%

37.4% 68th 31.1% 23.4% 31.3% 38.0% 44.8%

33.7% 76th 26.0% 18.1% 23.8% 30.7% 41.4%

Utilization Management and Care Support 45.0% 90th 30.9% 26.5% 31.2% 36.9% 44.6%

44.1% 91st 29.0% 23.1% 27.3% 33.9% 44.4%

41.7% 84th 29.6% 21.0% 26.8% 35.8% 46.7%

42.1% 87th 29.9% 22.6% 27.7% 36.1% 47.9%

44.4% 88th 30.6% 23.0% 28.5% 37.3% 46.0%

52.5% 89th 35.4% 26.3% 34.0% 43.2% 50.7%

Network/Coordination of Care 37.5% 83rd 27.9% 21.9% 26.3% 34.5% 40.8%

31.5% 73rd 25.8% 19.0% 23.6% 30.7% 37.3%

43.7% 86th 31.5% 25.0% 28.5% 35.8% 42.8%

37.5% 85th 26.5% 20.4% 25.1% 32.5% 39.5%

Pharmacy 28.6% 75th 21.3% 17.4% 20.9% 28.3% 35.6%

34.8% 84th 22.6% 14.8% 22.2% 27.8% 36.4%

29.7% 78th 20.0% 12.1% 19.7% 26.0% 32.6%

31.0% 81st 21.8% 13.7% 22.1% 27.3% 34.6%

18.8% 42nd 20.8% 12.5% 20.0% 26.5% 34.4%

Health Plan Customer Service Staff 40.1% 68th 36.2% 31.6% 34.6% 43.9% 54.0%

34.4% 55th 32.9% 26.3% 32.1% 37.7% 49.7%

43.8% 68th 38.2% 29.9% 37.4% 45.0% 52.0%

42.2% 68th 37.3% 27.7% 34.4% 44.3% 56.2%

Provider Relations 56.9% 91st 34.6% 28.0% 34.6% 43.0% 54.7%

61.5% 83rd 43.2% 32.5% 43.1% 55.8% 62.5%

52.1% 92nd 30.7% 20.6% 30.0% 39.3% 46.5%

57.1% 95th 30.0% 21.5% 28.4% 37.5% 47.5%

At or above the 75th percentile.

At or above the 50th percentile, but below the 75th percentile.

At or above the 25th percentile, but below the 50th percentile; or no benchmark.

Below the 25th percentile.

* Summary Rate Scores represent the most favorable response percentage(s).




** SPH Analytics's 2018 Medicaid Book of Business consists of data from 77 projects representing 18710 respondents in Primary Care, Specialty, and Behavioral Health areas of medicine. See Technical Notes for more information.

Composite/Attribute2019 SFHP Summary

Rate Score*

2018 SPH Medicaid B.o.B. Percentiles

2018 SPH B.o.B.

Summary Rate**






Percentile Ranking





















3CSPH Analytics112

Benchmark Comparisons San Francisco Health Plan2018 SPH Analytics Medicaid Respondent-Level Benchmark Provider Satisfaction SurveyArea of Medicine (A)

91 Total Primary Care Respondents

74 Total Specialty Respondents

Valid n SRS* Valid n SRS*

Overall Satisfaction 80 81.3% 71.3% 60 65.0% 67.5%

80 88.8% 86.0% 62 80.6% 84.1%

80 81.3% 71.3% 60 65.0% 67.5%

All Other Plans (Comparative Rating)

83 61.4% 34.1% 71 35.2% 32.6%

Finance Issues 50 35.9% 30.2% 57 32.5% 27.8%

49 32.7% 28.1% 57 22.8% 25.6%

50 38.0% 31.7% 57 36.8% 29.7%

49 38.8% 33.1% 54 38.9% 30.4%

44 34.1% 27.9% 51 31.4% 25.6%

Utilization Management and Care Support 82 49.6% 32.8% 64 37.6% 30.9%

66 50.0% 30.5% 58 37.9% 29.3%

77 45.5% 30.0% 64 34.4% 30.8%

72 45.8% 30.5% 64 35.9% 30.7%

79 49.4% 31.9% 61 37.7% 30.7%

82 57.3% 41.1% 50 42.0% 33.1%

Network/Coordination of Care 84 41.3% 28.3% 59 30.0% 29.5%

80 32.5% 26.5% 59 27.1% 27.0%

84 47.6% 31.3% 57 33.3% 32.8%

80 43.8% 27.1% 54 29.6% 28.6%

Pharmacy 78 33.3% 23.6% 51 18.2% 21.3%

78 43.6% 24.6% 49 18.4% 21.9%

75 37.3% 22.5% 48 12.5% 19.7%

77 32.5% 24.6% 51 27.5% 22.7%

76 19.7% 22.6% 48 14.6% 20.8%

Health Plan Customer Service Staff 59 41.8% 36.8% 54 37.2% 37.1%

56 35.7% 33.6% 43 34.9% 35.0%

53 49.1% 40.2% 53 37.7% 39.2%

59 40.7% 36.4% 54 38.9% 37.3%

Provider Relations 72 61.8% 39.0% 49 52.0% 36.0%

54 68.5% 48.0% 45 57.8% 47.5%

45 60.0% 34.9% 34 41.2% 30.0%

72 56.9% 34.2% 49 57.1% 30.5%



** The 2018 SPH Analytics Medicaid Book of Business Benchmark consists of Primary Care Physicians, Specialists, and Behavioral Health Clinicians. These benchmark comparisons are based on respondent-level results. Please see the Technical Notes for further detail.


* Summary Rate Scores (SRS) represent the most favorable response option(s).

Note 1: Significance Testing - Cells highlighted in red denote current year plan percentage is significantly lower when compared to benchmark data; Cells highlighted in green denote current year plan percentage is significantly higher when compared to benchmark data; No shading denotes that there was no significant difference between the percentages, there is no benchmark, or that there was insufficient sample size to conduct the statistical test. All significance testing is performed at the 95% significance level.












Composite/Attribute

2019 SFHP Primary Care

Only

2018 SPH Medicaid Respondent-Level

Benchmark** (Primary Care Only)

SRS*

2019 SFHP Specialty Only

2018 SPH Medicaid Respondent-Level

Benchmark** (Specialty Only)

SRS*















3ESPH Analytics113

Segmentation Analysis San Francisco Health PlanPlan Summary Rates by Delegation (Database) Provider Satisfaction Survey


Valid n**

%Valid n**

%

Overall Satisfaction 87.9% 61.8% 26.2%

57 89.5% 72 81.9% 7.5%

58 87.9% 68 61.8% 26.2%

All Other Plans (Comparative Rating) 0.0%

62 72.6% 77 29.9% 42.7%

Finance Issues 44.4% 29.3% 15.2%

27 40.7% 66 21.2% 19.5%

25 52.0% 68 30.9% 21.1%

28 46.4% 63 33.3% 13.1%

26 38.5% 57 31.6% 6.9%

Utilization Management and Care Support 57.3% 34.9% 22.4%

48 62.5% 63 30.2% 32.3%

58 53.4% 69 31.9% 21.6%

53 56.6% 68 30.9% 25.7%

60 53.3% 66 36.4% 17.0%

56 60.7% 62 45.2% 15.6%

Network/Coordination of Care 55.9% 21.7% 34.2%

55 47.3% 69 18.8% 28.4%

59 67.8% 67 22.4% 45.4%

57 52.6% 63 23.8% 28.8%

Pharmacy 40.8% 17.3% 23.5%

56 51.8% 59 18.6% 33.1%

52 46.2% 59 15.3% 30.9%

55 41.8% 61 21.3% 20.5%

55 23.6% 57 14.0% 9.6%

Health Plan Customer Service Staff 51.0% 33.9% 17.1%

39 43.6% 54 27.8% 15.8%

31 58.1% 65 36.9% 21.1%

37 51.4% 65 36.9% 14.4%

Provider Relations 51.6% 60.2% 8.6%

33 63.6% 58 60.3% 3.3%

27 37.0% 46 60.9% 23.8%

48 54.2% 64 59.4% 5.2%

** Valid n refers to the total number of respondents answering the item within the subgroup under the column heading.


* Range is the difference between Summary Rates shown. The larger the number, the greater the difference in Summary Rates between segment groups for any given question/composite.

























Composite/AttributeCHNUCS DMG

Range*


SPH Analytics 6H114

DHCS ADVANCES IN QUALITY MONITORING

ADAM SHARMA JIM GLAUBER

115

M A N A G E M E N T T E A M M E E T I N G

California State Auditor Report: Millions of Children in Medi-Cal Are Not Receiving Preventive Services

Audit Highlights Our audit regarding DHCS’ oversight of the delivery of preventative services to children in Medi-Cal revealed the following: An annual average of 2.4 million children enrolled in Medi-Cal do

not receive all required preventative services. Many of the State’s children do not have adequate access to

Medi-Cal providers who can deliver the required pediatric preventative services.

Limited provider access is due, in part, to low Medi-Cal reimbursement rates.

States with higher utilization rates offer financial incentive programs that California could implement, but it would likely require additional funding.

2 116


California State Auditor Report: Millions of Children in Medi-Cal Are Not Receiving Preventive Services

Audit Highlights DHCS delegates responsibilities to ensure access and use

of children’s preventative services to managed care plans, but it does not provide effective guidance and oversight.

• It does not provide adequate information to plans, providers, and beneficiaries about the services it expects children to receive.

• It does not ensure that plans regularly identify and address

underutilization of children’s preventative services. • It has not followed up on plans’ efforts to mitigate cultural

disparities in the usage of preventative services.

3 117


Utilization Rates for Children In Medi-Cal Have Remained Below 50 Percent

4 118


California’s Utilization Rate for Children’s Preventive Services Ranked 40th in the Country Federal Fiscal Year 2017

5 119


DHCS Approved More Alternative Access Standards for Plans with Lower Utilization Rates for Children’s Preventive Services

6 120


Utilization Rates Were Low for Some of the Youngest Children in Medi-Cal Fiscal Years 2013-14 Through 2017-18

7 121

M A N A G E M E N T T E A M M E E T I N G DHCS’s Performance Measures Capture Only a Few of the Bright Futures Services

8 122


Current External Accountability Set • MCPs report yearly

on a set of quality measures

• Most measures are from HEDIS®

Future Managed Care Accountability Set • MCPs and DHCS will

report yearly on a set of quality measures

• Measures will be from CMS Child and Adult Core Sets as feasible

9

DHCS External Accountability Measure Set

123


Recognition

SFHP

124


• 2019 CMS Adult Core Set: https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2019-adult-core-set.pdf

• 2019 CMS Child Core Set: https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2019-child-core-set.pdf

7/30/2019 11

Core Set Resources

125

https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2019-adult-core-set.pdf



https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2019-child-core-set.pdf




Current Minimum Performance Level • DHCS contracts require the

MCPs to perform at least as well as the lowest 25% of Medicaid plans in the US

Future Minimum Performance Level • DHCS will require MCPs to

perform at least as well as 50% of Medicaid plans in the US where that information is available and services measured are delivered by MCPs

• DHCS may establish alternative benchmarks for measures where that information is not available and for which the services measured are delivered by MCPs

12

Benchmarks

126


• Children’s Health • Developmental Screening • CAP • Audiological Diagnosis • AMB-ED

• Behavioral Health • Depression Screening • DM Screening SMI • DM Care SMI H9 • Opioids high dose • Opioids and benzos

• Women’s Health • Elective Delivery • Cesarean Section • Contraceptive Care All

Women • Contraceptive Care

Postpartum • Acute Chronic Disease

Mgmt • PQI Diabetes • PQI COPD • PQI CHF • PQI Asthma • HIV Viral Load Suppression • MPM

7/30/2019 13

Additional Measures

Admin measures DHCS may report on; no benchmarks currently 127


HEDIS Measures

DHCS California-Only Perspective

NCQA Nationwide Perspective

Both

• Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis

• All Cause Readmissions • Ambulatory Care • Children and Adolescents

Access to Primary Care • Depression Screening and

Follow-Up for Adolescents and Adults

• Annual Monitoring for Patients on Persistent Medications

• Adult BMI Assessment • Follow-up Care for Children Prescribed

ADHD Medication • Annual Dental Visits • Antidepressant Medication

Management • Chlamydia Screening in Women • Appropriate Testing for Children with

Pharyngitis • Follow-up After Hospitalization for

Mental Illness • Initiation and Engagement of Alcohol

and Other Drug Abuse • Medical Assistance with Smoking and

Tobacco Use Cessation • Pharmacotherapy Management of COPD

Exacerbation • Antipsychotics Adherence for

Schizophrenia • Statin Therapy for Patients with

Cardiovascular Disease • Statin Therapy for Patients with

Diabetes • Appropriate Treatment for Children with

Upper Respiratory Infection • Diabetes Screening for People with

Schizophrenia or Bipolar Disorder who are using Antipsychotic Medication

• Asthma Medication Ratio • Comprehensive Diabetes

Care • Childhood IZ Status • Adolescent IZ Status • Cervical Cancer Screening • Breast Cancer Screening • Use of Imaging Studies for

Low Back Pain • Prenatal and Postpartum

Care • Weight Assessment and

Counseling for Nutrition and Physical Activity for Children and Adolescents

128

15

Managed Care Accountability Set (RY 2020)

Measure Held to MPL

1 Plan All‐Cause Readmissions Yes 2 Adolescent Well-Care Visits Yes 3 Adult Body Mass Index Assessment Yes 4 Antidepressant Medication Management – Acute Phase

Treatment Yes

5 Antidepressant Medication Management – Continuation Phase Treatment

Yes

6 Asthma Medication Ratio** Yes^ 7 Breast Cancer Screening Yes 8 Cervical Cancer Screening Yes 9 Childhood Immunization Status – Combo 10 Yes 10 Chlamydia Screening in Women Ages 16 – 24** Yes^

11 Comprehensive Diabetes Care HbA1c Testing Yes 12 HbA1c Poor Control (>9.0%) Yes 13 Controlling High Blood Pressure <140/90 mm Hg Yes 14 Immunizations for Adolescents – Combo 2 (meningococcal,

Tdap, HPV) Yes

15 Prenatal & Postpartum Care – Timeliness of Prenatal Care Yes

16 Prenatal & Postpartum Care – Postpartum Care Yes 129

16

17 Weight Assessment & Counseling for Nutrition & Physical Activity for Children & Adolescents: Body Mass Index Assessment for Children/Adolescents

Yes

18 Well-Child Visits in the First 15 months of Life – Six or More Well Child Visits Yes

19 Well‐Child Visits in the 3rd 4th 5th & 6th Years of Life Yes 20 Ambulatory Care: Emergency Department (ED) Visits No

21 Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medications – Initiation Phase

No

22 Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medications – Continuation and Maintenance Phase

No

23 Children & Adolescents’ Access to Primary Care Practitioners: 12‐24 Months No

24 Children & Adolescents’ Access to Primary Care Practitioners: 25 Months – 6 Years No

25 Children & Adolescents’ Access to Primary Care Practitioners: 7‐11 Years No

26 Children & Adolescents’ Access to Primary Care Practitioners: 12‐19 Years No

27 28

Contraceptive Care: All Women Ages 15-44**: • Most or moderately effective contraception • Long Acting Reversible Contraception (LARC)

No

29 30 31 32

Contraceptive Care: Postpartum Women Ages 15-44**: • Most or moderately effective contraception – 3 days • Most or moderately effective contraception – 60 days • LARC – 3 days • LARC – 60 days

No

130

17

* Stratified by Seniors and Persons with Disabilities ** Measure is part of both the CMS Adult and Child Core Sets. Though MCPs

will report the “Total” rate, data will be collected stratified by the child and adult age groups.

^ MCPs held to the MPL on the total rate only.

33 Developmental Screening No 34 HIV Viral Load Suppression No 35 Annual Monitoring for Patients on Persistent Medications: ACE

inhibitors or ARBs No

36 Annual Monitoring for Patients on Persistent Medications: Diuretics No

37 Concurrent Use of Opioids and Benzodiazepines No

38 Use of Opioids at High Dosage in Persons Without Cancer No

39 Screening for Depression and Follow-Up Plan: Age 12 and Older** No

131


• Current • Required QI work if

MCPs below MPL on measures

• 3 Quality Corrective Action Plan (CAP) triggers for MCPs with sustained poor performance

• Multi-year CAPs with milestones

• Sanctions if CAP milestones are not met

• Future • Any MCP not meeting

the MPL on any of the required measures will do required QI work with immediate sanctions

• Three Quality Oversight Tiers, including two levels of CAPs

• CAPs are re-evaluated annually

• Possibility of progressive sanctions for sustained poor performance

7/30/2019 18

Quality Monitoring Process

132


RY2019 National Benchmarks 50th and 75th Comparison

19

MeasureName AverageRate 5thPercentile 25thPercentile 50thPercentile 75thPercentile 90thPercentile

Adherence to Antipsychotic Medications for Individuals With Schizophrenia 58.96 38.05 53.91 60.19 65.92 71.74

Adult BMI Assessment 84.53 44.98 83.09 88.56 92.46 95

Annual Monitoring for Patients on Persistent Medications - Total 88.22 82.66 86 88.2 90.67 92.76

Appropriate Treatment for Children With Upper Respiratory Infection 89.08 73.85 86.63 90.42 93.77 95.94

Asthma Medication Ratio (Total) 61.35 42.86 56.85 62.28 67.03 71.93

Childhood Immunization Status - Combo 3 69.41 54.01 65.45 70.8 74.7 79.56

Comprehensive Diabetes Care - HbA1c Control (<8%) 49.34 32.14 44.44 51.34 55.47 59.49

Prenatal and Postpartum Care - Postpartum Care 64.35 49.06 59.61 65.21 69.34 73.97

Prenatal and Postpartum Care - Timeliness of Prenatal Care 81.13 64.59 76.89 83.21 87.06 90.75

Well-Child Visits in the first 15 Months of Life (3 visits) 4.87 1.95 3.65 4.52 5.84 7.06



Well-Child Visits in the first 15 Months of Life (6 or more visits) 64.14 46.02 58.54 66.23 71.29 75.43

133


• Any MCP not meeting all the required benchmarks will be sanctioned and required to do QI work

• MCPs’ required QI work and DHCS’ level of oversight will fall into three tiers • Identification of which quality oversight tier the MCP falls under will be

completed annually. • Each year the MCPs may move up or down the tiers. • At the 2nd and 3rd level Tiers MCPs are considered to be under Quality

CAP • Identification of which tier will depend on reporting unit level performance;

however, the oversight will be at the MCP level • DHCS reserves the right to elevate a MCP’s tier if the MCP has

disproportionally poor performance in one domain (see example in ‘Notes’)

7/30/2019 20

Tiered Quality Oversight Process

134


• Required QI work and sanctions, no CAP • MCPs will do QI project (PDSA or PIP) on

any measure below the MPL in any reporting unit, up to a maximum of 6 QI projects (e.g., 2 PIPs and 4 PDSAs).

• PIPs will continue to be conducted through the EQRO process

• PDSAs will continue to be conducted through the DHCS NC3 process

• Technical assistance calls will be held as needed, as guided by NC3 or the MCP QI staff 7/30/2019 21

Tier One

135


• Lower CAP Tier, including QI work and sanctions • MCPs will do QI project (PDSA and PIP) on any measures

below the MPL in any reporting unit, up to a maximum of 8 QI projects (e.g., 2 PIPs and 6 PDSAs)

• MCP will submit a quarterly summary to its DHCS NC3 to include information pertaining to QI projects and other efforts for measures not identified for a specific QI project requirement.

• MCPs must include progress report towards benchmarks on all measures

• Technical assistance calls will be held quarterly with the NC3

• MCP will have one in person meeting with DHCS Executive Staff after the Tier 2 CAP is established.

7/30/2019 22

Tier Two CAP

136


• Higher CAP Tier, including QI work and sanctions • MCPs will do QI project (PDSA and PIP) on any measures

below the MPL in any reporting unit, up to a maximum of 10 QI projects (e.g., 2 PIPs and 8 PDSAs)

• MCP will submit a quarterly summary to its DHCS NC3 to include information pertaining to QI projects and efforts for other measures not identified for a specific QI project requirement.

• MCPs must include progress report towards benchmarks on all measures

• Technical assistance telephonic meetings will be held quarterly with the DHCS Quality Improvement Specialists Team and MCP QI, HEC and data staff

• In person executive leadership meetings will be held between the MCP and DHCS biannually.

7/30/2019 23

Tier Three CAP

137


• For those MCPs who remain under a Tier Three CAP for multiple years, DHCS reserves the right to impose progressive sanctions, including but not limited to: • Additional financial sanctions • Placement of a MCP monitor or consultant • Contract termination

7/30/2019 24

Tier Three CAP

138

M A N A G E M E N T T E A M M E E T I N G Follow-up Care for Children Prescribed Attention Deficit/Hyperactivity Disorder Medication: Continuation and Maintenance Phase

25

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

35.1% 57.1% 69.1%

SFHP RateNCQA 50%NCQA 90%

139


Adolescent Well Visits

26

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

49.3% 54.6% 66.8%


140


Well-Child Visits in the First 15 Months of Life (W15-CH) – 6 or More Visits

27

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

12.7% 66.2% 75.4%


141

NCQA Accreditation and External Accountability Set Quality Measures

2019

Elizabeth Sekera and Annie Humphreys

142

Why is it important?

Represents the care our members receive

Auto-Assignment

NCQA Accreditation Benchmarking

143

SFHP Reporting Accountabilities Measurement Year 2018/Reporting Year 2019

California External

Accountability Set

NCQA Accreditation Measure Set

HEDIS Measures

144

Changes Coming to Reporting Accountability • California is moving to the Managed Care

Accountability Set (MCAS) • This now includes measures from the Center for

Medicare & Medicaid Services (CMS) Core Measure Set

• MCAS includes measures by stewards other than NCQA

• MCAS also expands the number of HEDIS measures that the state requires SFHP to report

• Minimum Performance Level increasing from 25th Percentile to 50th Percentile

4 145

How do we do?

• Achieved 85.42% of available HEDIS points for NCQA accreditation.

• Opportunities for improvement include: • Breast Cancer Screening • Chlamydia Screening • Follow-up Care for Children Prescribed ADHD Medication • Pharmacotherapy Management for COPD Exacerbation • Medication Management for People with Asthma – 75%

Compliance • Timeliness of Prenatal Care • Statin Therapy for Patients with Cardiovascular Disease

5

146

Measures Prioritized for Improvement in 2019-2020

• Breast Cancer Screening • Chlamydia Screening • Well-Child Visits for Children aged 0-15

months

6 147

Breast Cancer Screening

7

2016 – 62.6% 2017 – 61.1% 2018 –64.3%

Performance Improvement Activities • Measure in Practice Improvement Program • Investigate additional data sources • Execute a root cause analysis to identify potential data and clinical

quality issues • Will analyze data to find answers to research questions that may

be impacting rate • Will be conducting provider surveys to find gaps in BCS

activities and referral processes 148

Chlamydia Screening in Women

8

2016 – 37% 2017 – 35.5% 2018 – 38.25%

Performance Improvement Activities • Measure in Practice Improvement Program • Completed a root cause analysis to identify potential data and

clinical quality issues • Identified opportunities for lab data quality improvement. • Will re-evaluate clinical quality once lab data is addressed.

149

Well-Child Visits for Children Aged 0-15 months (6 visits)

9

2018 Administrative Rate– 12.81%

Performance Improvement Activities • Identify baseline rate in RY2020 • Identify provider partner to create a pilot improvement project • Collaboration with UCSF, SFDPH, Anthem, California First Five,

Stupski Foundation and California Children’s Trust

150

FY 2019-20 Organization Goal

Goal 2017 Score Goal

Obtain 85% of NCQA HEDIS points earned for 2019. Measurement based on NCQA-defined points earned methodology.*

85.42% Stretch: 87% Meets: 85% Min: 80%

SFHP Performance

Other Health Plans’

Performance

Medi-Cal Covered Benefits

Medicaid Special

Scoring Rules

What influences NCQA HEDIS points earned? *pending approval

151

Questions?

11 152

Online Pharmacy Formulary

Updates to Improve Provider Access: Formulary and Prior Authorization

Criteria

153

D E PAR T M E N T T I T L E


• SFHP pharmacy formulary is available online for providers: • https://www.sfhp.org/providers/pharmacy-

services/sfhp-formulary/

154

https://www.sfhp.org/providers/pharmacy-services/sfhp-formulary/

https://www.sfhp.org/providers/pharmacy-services/sfhp-formulary/



• Some drugs require prior authorization • Pharmacy & Therapeutics Committee

• Approves drug status • Approves criteria for use

155



• Effective April 2019, criteria pertinent to a drug are now linked directly to that drug listing • Both non-formulary and formulary PA-required drugs

156



157



• Effective April 2019, criteria pertinent to a drug are now linked directly to that drug listing • General (“blanket”) criteria for non-formulary drugs or

other restrictions (e.g., age or quantity limits) are also linked

158



159

Medication Therapy Management (MTM) Program

2018 Program Summary and Results

160

MTM Program Goals

• Individualize an optimal medication regimen for members engaged in Care Management.

• Support member self-management with medication knowledge and compliance aids.

• Meet DHCS program expectations and NCQA accreditation requirements for MTM.

161

Multidisciplinary Care Management

• Using the same Care Management system, Pharmacists are tasked to complete a medication reconciliation

Clinical Pharmacist

Behavioral Health

Clinical Supervisor

LCSW

CM Nurse

Medical Director

Care Management

Client

Care Coordinator

162

MTM Program Results

• From July 1, 2017 to December 31, 2018, 456 completed pharmacy tasks in Essette

Initial Follow-Up Post-Discharge

Closing Total

68 17 48 4 137

Rx Compliance Report, 242,

53%

Rx Consultation,

77, 17%

Medication Reconciliation,

137, 30%

Completed Pharmacy Tasks (n=456)

Number of Completed Medication Reconciliation Tasks (n=137)

163

MTM Program Results

• Pharmacists discovered 263 total interventions. • 204 interventions (78%) were completed for 78 engaged

clients

Underuse 32%

Suboptimal drug therapy

26%

Unsafe drug therapy

12%

Unnecessary drug therapy

6%

Needs Immunization

19%

Blood Pressure Monitor

5%

Completed Interventions by Medication Therapy Problem (n=204)

NCQA Chronic

Condition Mgmt 51%

Time Limited Coordination

13%

Health Homes

Program 36%

Completed Interventions by Care Management Program Type (n=78)

164

MTM Member Successes

• Duplication of therapy: losartan and Entresto in pharmacy paid claims. • Notified PCP and Cardiologist, and called Walgreens to

discontinue losartan prescription • Discrepancies of medication lists found between

facilities, discharge summaries, and pharmacy paid claims. • Notified PCP and provided reconciled med list to provider and

client • Medication administration: Nurse with client called

pharmacist to ask if medications are safe to crush and mix with food • Reviewed medications and provided information

165

Current MTM Dashboard

• Upward trend of pharmacy tasks • Expanded pharmacy support across all 5 programs in Essette CM module • Updated workflow and training • Increase in number of Care Coordinators

• Increased Average Time Spent for Pharmacist to complete Med Recs due to complex client cases in Health Homes Program

166

Future of MTM

• Add reconciled medication lists to PreManage/EDIE Collective Notification for continuity of care during ER and inpatient admission

• Collaborate with pharmacists in clinics and hospitals • Continue medication support to clients across all 5

programs in Care Management • NCQA, TLC, Health Homes, CATY, Care Transitions

167

MEMBER EXPERIENCE SURVEY - CAHPS

CAHPS RESULTS

Yves Gibbons Program Manager, Access and

Experience

168

Member Experience Survey – CAHPS SFHP annually conducts the Health Plan Consumer Assessment of Healthcare Providers and Systems (HP-CAHPS), a standardized survey measuring member experience with their health plan and covered health care services. SFHP underperforms on the Adult Medi-Cal HP-CAHPS compared to other Medicaid plans. Survey results provide SFHP and its provider network actionable member experience information. SFHP’s performance in CAHPS contributes to National Committee for Quality Assurance (NCQA) accreditation. SFHP sets a 2% improvement target over previous years’ performance for each Rating and Composite shown below.

National percentile

Ratings and Composites 2015 2016 2017 2018 2019 2019 Target comparison

Rating of Health Plan 64.2% 67.8% 72.8% 74.8% 76.3% 76.8% 25th

Rating of Personal Doctor 75.5% 75.7% 80.7% 75.5% 83.9% 77.5% 90th

Rating of Specialist Seen Most Often 73.4% 76.5% 83.9% 81.6% 80.8% 83.6% 50th

Rating of All Health Care 64.8% 68.3% 73.9% 74.0% 76.7% 76.0% 25th

Getting Needed Care 62.0% 66.1% 68.5% 68.4% 73.8% 70.4% Below 25th

Getting Care Quickly 66.0% 65.3% 68.1% 73.0% 72.9% 75.0% Below 25th

Coordination of Care 77.5% 83.3% 77.8% 73.6% 87.6% 75.6% 25th

Customer Service 74.4% 80.7% 81.2% 84.2% 83.4% 86.2% Below 25th

How Well Doctors Communicate 86.6% 88.7% 91.6% 87.0% 92.4% 89.0% 50th

Shared Decision Making 74.3% 81.3% 80.4% 75.9% 76.7% 77.9% Below 25th

Health Promotion and Education 69.1% 69.0% 75.5% 72.5% 72.5% 74.5% 25th

Results Key Methodology & Response Rate Fielding: February 16th to May 15th, 2019 Sample: 1350 Medi-Cal members Response rate: 32% (n=435) Administration mode: Mail and telephone

Reaction Key Mets 2019 target AND percentile increased from 2018

Mets 2019 target OR percentile increased from 2018

Did not meet 2019 target OR no percentile increase from 2018

Green Scores meet 2019 target

Orange Scores do not meet 2019 target

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Member Experience Survey – CAHPS

SFHP Prioritizes Improvement in CAHPS While SFHP did not reach the 2% improvement target for all Ratings and Composites, we prioritize questions that are key drivers of members’ Rating of Health Plan. HP-CAHPS key drivers most relevant for improvement include questions related to access to care, customer service, provider communication, care coordination, the plan’s written and online materials, and ratings of providers.

Priorities for Current Key Driver Performance Room for Improvement on Key Driver Overall Improvement Opportunity

2019 SFHP Rates Percentage Point Difference Between Current Key Driver Score and Best Practice Score

Expected Percentage Point Improvement in Rating of Health Plan score if we reach Best Practice Level

Ease of getting needed care, tests, or treatment 78.97% +12.29%

75.23% +17.16% Customer service provided needed information or help Made appointments for routine care at a

69.40% +9.17% doctor's office or clinic Plan's written materials/Internet provided needed information 68.75% +13.34%

91.26%

92.39%

78.57%

82.09%

+5.34% +1.96%

+1.66%

+1.64%

Summary of 2018 Improvement Efforts Opportunity: Access to Care, Tests, Treatment, and Appointments • Strategic Use of Reserves technical investments include:

1)Health Homes – six medical groups, clinics, and SFHP coordinate care for high-need members. 2) Service Recovery program - nine medical groups and clinics use grant funds to implement provider level surveys and complete training series focused on repairing relationships with members dissatisfied with care or service. 3) Hospital capacity building (e.g. pharmacy upgrades, medically assisted therapy, palliative care).

• Increased Teladoc registrations - 23% more members have access to telehealth care 24 hours a day, 7 days a week.

• Incentivized access performance in Clinic and Group CAHPS in our Pay for Performance program.

• Two medical groups representing the majority of SFHP membership extended call center and nurse advice line hours.

• Two medical groups provided patient-care team communication training AIDET (Ask, Introduce, Duration, Explanation, Thank You) to their network providers and staff.

• One medical group expanded team based care to meet member appointment demand by creating provider teams based on panel size capacity and provider availability.

Barriers

Planned Actions

• Specialty access barriers - poor experience with referrals and appointment availability. • Experience race, ethnicity, or primary language negatively affecting ability to access care.

• Continue network access monitoring; request corrective actions when medical groups or clinics do not meet access requirements. Identify trending access issues via Access Compliance Committee; develop action plans.

• Conduct ongoing conduct member focus groups to gain insight on member perception of access and how race, ethnicity, and primary language impact the perception of access and quality of care received.

• Continue to promote SFHP’s telehealth services to increase perception of access to care. Opportunity: Customer Service Provided Needed Information or Help Barrier

Planned Actions

• Difficult to access information from Medi-Cal, SFHP, and provider offices regarding how to access care, covered services, administrative information, and processes to make changes to medical care.

• Develop and make available member-facing information tools specific to each of SFHP’s medical groups, including administrative information and how to access care.

• Create member communication tools regarding dental and vision services, and SFHP’s role in supporting member access to these programs

Opportunity: Plan's Written Materials and Internet Provides Needed information Barrier

Planned Actions

• Members are unclear of actions to take in response to SFHP correspondence. • Improve readability of member correspondence for UM approvals, denials, and appeals. • Conduct ongoing member focus groups to collect more information on readability and clarity of information

provided by SFHP. 170