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Quality Improvement Committee Meeting
Thursday, December 14, 2017 7:30 – 9:00 AM
50 Beale Street, 13th
Floor
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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. 2)
7:35 Consent Calendar (5 min) Update / Vote Dr. Glauber
Review of Minutes – October 12, 2017 (p. 3)
Health Services Update – November 2017 (p. 12)
Pharmacy & Therapeutics Committee Minutes – July 2017 (p. 16)
o P&T Committee Interim Vote for New Hepatitis C drugs (p. 24)
Q2 2017 Emergency Room Visit/Prescription Access Report (p. 28)
Q3 2017 Grievance and Appeals Report (p. 31)
Q3 2017 Potential Quality Issue Report (p. 44)
UM Clinical Criteria o Interqual (p. 46) o Hayes (p. 51) o SFHP Criteria for Genital Gender o Confirmation Services (p. 52)
Vote
7:40 Quality Improvement (80 minutes)
Policy and Procedures QI-06 & QI-15 Summary of Updates (p. 59)
o QI-06 Member Grievances and Appeals – 5 min. (p. 60)
o QI-15 Quality Improvement Program – 5 min. (p. 62)
2017 QI Program Evaluation – 20 min. (p. 66)
2018 QI Plan – 20 min. (p. 103)
2017 Beacon Quality Program Evaluation – 10 min. (p. 149)
2016 Beacon Member Satisfaction Survey Results – 10 min. (p. 175)
Vote Vote Vote Vote Update
J. Soos A. Sharma L. Grossmann/ M. Sijapati
9:00 PAC
NEXT MEETING THURSDAY, FEBRUARY 8, 2018
QIC Meeting Date Follow Up Item Owner Complete By Comments
February 2017Update the Pharmacy Authorizations graph to reflect the correct number of authorizations in Q3 K. McDonald 4/6/17 Completed
The number of authorizations in Q3 are correct. Kirk will reformat the graph so that it is clearer.
February 2017Present an annual review for medical and pharmacy appeals in the next QIC meeting K. McDonald 4/6/17 Completed
Kirk will present the Medical and Pharmacy Appeals Annual Review in the next QIC meeting on April 6, 2017.
February 2017 Provide the committee with the number of completed FSRs in 2016 J. Hagg 4/6/17 CompletedThere was a total of 23 Facility Site Reviews and 23 Medical Record Reviews in 2016.
February 2017 Provide an update on the status of open CAPS in the next QIC meeting O. Leon 4/6/17 CompletedOdalis will provide an update on the status of open Corrective Action Plans in the next QIC meeting on April 6, 2017.
February 2017Include grievance rate across California Medi-Cal health plans in future Grievance Reports. A. Sharma 6/8/17 Completed
The grievance rate across California Medi-Cal health plans are included in the Grievance Report.
April 2017 Include an agenda item on non-specialty mental health in the June QIC meeting. G. Dadios 6/8/17 CompletedGrace included an agenda item on non-specialty mental health and incorporated the documents in the QIC packet.
April 2017 Present year to date Facility Site Review data in the June QIC meeting. J. Hagg 6/8/17 Completed Jackie to present year to date Facility Site Review data in the next QIC meeting on June 8, 2017.
August 2017Follow up on why there is a discrepancy between actual and projected membership in the Membership Report.
J. Glauber 10/12/17 CompletedThe Finance Department elected to use December 2016 membership as the projection for fiscal year 2017/2018 to be conservative.
August 2017Confirm if members must exhaust SFHP's appeal process prior to requesting an Independent Medical Review (IMR).
J. Soos 10/12/17 CompletedMembers must exhaust the grievance process with SFHP prior to requesting an IMR from DMHC, unless the IMR request is expedited or related to experimental/investigational treatment.
August 2017 Provide QIC with the Disease Management Program phone script. F. Donald/E. Ratliff 10/12/17 Completed Fiona and Eloyscia sent the Disease Management phone scripts to the committee on 10/4/17.
August 2017Explore if there are data to show Disease Management Program participation across medical groups.
F. Donald/E. Ratliff 12/14/17 CompletedItems related to the Disease Management Program are put on hold as the program is currently undergoing major changes.
August 2017Post Health Education materials used in the Disease Management intervention in the Provider Portal
F. Donald/E. Ratliff 12/14/17 Completed
The Disease Management health incentive materials are posted on the SFHP provider-facing website. Elo will work with Marketing to also have the revised health education booklets posted. Update 11/13/17: The Disease Management Program is currently undergoing major changes which will impact the materials and their distribution. As a result, the revised health education booklets were not posted in the Provider Portal.
October 2017Explore if sister plans give monetary incentives to members for completing the Health Risk Assessment tool.
F. Donald 2/8/18 In Progress
Quality Improvement Committee Follow Up List
Quality Improvement Committee Minutes
1 | P a g e
Date: October 12, 2017 Meeting Place: San Francisco Health Plan, 50 Beale Street 13th floor, San Francisco, CA 94105 Meeting Time: 7:30AM - 9:00AM Members Present: Jeanette Cavano, PharmD; Daniel Chan, MD; Ellen Chen, MD; Irene Conway; Jeffrey Critchfield, MD; Lukejohn Day,
MD; Edward Evans; Todd May, MD; Joseph Woo, MD; Albert Yu, MD; James Glauber, MD, MPH Staff Present: Tammie Chau, PharmD; Dayana Chaves, LCSW; Grace Dadios; Fiona Donald, MD; Sean Dongre; Lisa Ghotbi, PharmD;
Adam Sharma; Jim Soos
Topic Discussion
[including Identification of Quality Issue]
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 public comments or questions.
• No follow up needed. • n/a
Follow Up Items
Follow-Up Items from August 2017 • Eloyscia Ratliff, Disease Management Program Manager,
e-mailed the Disease Management scripts for asthma and diabetes to the committee.
• Regarding the discrepancy between actual and projected membership in the Membership Report, SFHP’s Finance Department used December 2016 membership as the projection for fiscal year 2017/2018 since SFHP does not expect dramatic changes in membership given that membership has been flat over the past few years.
Jim Glauber, Chief Medical Officer, provided the following updates.
• SFHP completed the final upload for the National Commission for Quality Assurance (NCQA) First Survey on October 10.
• No follow up needed. • n/a
o NCQA will conduct an on-site audit in early December that will entail a file review of SFHP’s credentialing, authorization, and UM files to ensure they are following NCQA standards.
• SFHP’s Provider Recognition Dinner was held on September 26. The following QIC members were recipients of Provider Recognition Awards:
o Dr. LukeJohn Day and the Clinical Practice Group won an award for their work in improving specialty care access.
o Northeast Medical Services won an award for the development of a specialty pharmacy within their clinic-based pharmacy. This allows their patients who are on specialty medications to receive more integrated care rather than having their medications shipped from specialty pharmacies out of state.
• In October SFHP was awarded the Outstanding Plan Performance Award from the Department of Health Care Services (DHCS) for measurement year 2016. This award is based on aggregated External Accountability Set (EAS) HEDIS scores.
o Since 2008, SFHP has been awarded this honor every year but one.
Consent Calendar
• Review of Minutes – August 10, 2017 • Membership Report – September 2017 • Health Services Update – September 2017 • Reappointment of Pharmacy and Therapeutics Committee
Current Membership o Maria Lopez, Pharm. D. Curriculum Vitae
Maria Lopez, Pharm. D is appointed to SFHP’s Pharmacy and Therapeutic Committee. She is the president and founder of Mission Wellness Pharmacy and a Provider Recognition Dinner
Approved: • Review of Minutes –
August 10, 2017 • Membership Report –
September 2017 • Health Services Update –
September 2017 • Reappointment of
Pharmacy and Therapeutics Committee Current Membership
recipient for providing integrated specialty pharmacy services to patients in several safety net clinics.
• UM Committee – July & August 2017 • Q2 2017 Grievance and Appeals Report
o SFHP is seeing a 40% decline in grievance rates over the past few years.
• Q2 2017 Potential Quality Issues Report
• Maria Lopez, Pharm. D. Curriculum Vitae
• UM Committee – July & August 2017
• Q2 2017 Grievance and Appeals Report
• Q2 2017 Potential Quality Issues Report
Quality Improvement
Department of Healthcare Services Final Audit Report • DHCS issued SFHP’s Final Audit Report from the March 2017
Medical Audit and we received three findings. o One finding was not having a systematic process of
ensuring that clinicians in the Health Services department have current licenses. This finding has already been corrected.
o Another finding was a discrepancy between SFHP’s access monitoring policy of how we monitor daytime and after-hours access to telephone advice and what is actually being done. This item is specifically related to monitoring the minutes elapsed for clinician call back. SFHP will be revising its policy to align with practice.
o The last finding is regarding the use of Licensed Vocational Nurses (LVNs) in the prior authorization process. LVNs conduct the initial review of requests and if criteria are met, will approve the request. If not, they will submit the request to the Medical Directors for decision. If they receive insufficient information, they will ask the provider to submit additional information. DHCS concluded that LVNs are practicing out of their scope of license. SFHP Corrective Action Plan CAP will integrate direct RN oversight of LVN handling of specific UM cases.
Q2 2017 Quality Improvement Workplan Scorecard Adam Sharma, Director of Health Outcomes Improvement, highlighted selected measures from the Q2 2017 Quality Improvement Workplan Scorecard. • SFHP improved in all three CAHPS indicators (Getting Care
Quickly, Getting Needed Care, and Rating of Health Plan). • Cervical Cancer Screening improved to 68.7% with a target of
71.5%. • The Non-Specialty Mental Health (NSMH) Penetration Rate is
currently 3.2% with a goal of 4%. This rate has plateaued for the past 6 months.
• The Pharmacy Point-of-Service Claim Rejection Rate has decreased 5.6% from the 2016 baseline of 21%. The target is a 10% decrease.
• The Community Health Network (CHN) Out of Medical Group (OMG) All Cause Readmissions rate is 24.1% with a target of 14.4%.
• The influenza immunization rate is 15.6% with a target of 20.5%. The data is collected from pharmacy data, medical claims data, and the California Immunization Registry (CAIR).
o It has been difficult to determine a valid rate because there are points of vaccine administration that are not documented.
o In contrast to the above rate reported through claims/encounters/CAIRS, the self-reported immunization rate (via CAHPS) is 54%, which is in the 90th percentile.
HRA Tool Dayana Chaves, Care Management Clinical Supervisor, presented the Health Risk Assessment (HRA) Tool. • All Plan Letter (APL) 17-013: Requirements for Health Risk
Assessment of Medi-Cal Seniors and Persons with Disabilities (SPDs) requires Managed Care Plans to include verbatim specific Long-Term Services and Supports (LTSS) referral questions in
the HRA. • The committee suggested to include:
American Sign Language in the list of preferred languages.
If a member needs his/her existing durable medical equipment (DME) repaired.
If a member has access to nutritious food. If a member has sleep apnea or other sleep
disorders. • The committee discussed methods in which this information is
disseminated to providers. o One method is through Care Management’s intake
coordination process which includes mailings that inform providers of SPD members. Care Management staff share more member information should providers contact them.
• The committee discussed if sister plans give monetary incentives to members for completing the survey. Fiona Donald, Medical Director, will investigate this.
• Dayana will present the survey at the November Member Advisory Committee (MAC) meeting to obtain member feedback.
Provider Satisfaction Survey Results Sean Dongre, Provider Relations Manager, presented the 2017 Provider Satisfaction Survey Results. • SPH Analytics conducted the survey on behalf of SFHP. • The survey was e-mailed and mailed to providers. A phone
follow-up was also conducted. o Of 750 providers, 100 providers out of 750 completed the
survey, a 20% decrease in response rate relative to 2016. • Sean highlighted a few results:
o SFHP performed significantly better than the other 58 Medicaid plans in SPH Analytics’ Medicaid Book of Business in almost every category.
o Compared to 2016, there is improvement in several sub-areas: Finance, Utilization Management, Customer
• Fiona Donald, Medical
Director, will explore if monetary incentives are given to members for completing the survey.
Service, and Provider Relations. Pharmacy had the largest improvement.
o Satisfaction with patients’ access to services improved. Questions on satisfaction with patients’ access to
non-specialty and specialty mental health were added this year. 61.5% and 51.6% of providers responded “very satisfied” and “satisfied” respectively
o Providers’ support for SFHP’s Member Incentive Program decreased relative to previous years but generally remain positive. Providers may not know about the program as the
incentive cards are often completed by other healthcare staff.
o The Health Outcomes Improvement team conducted an analysis a few years ago comparing the HEDIS rates of members who received an incentive versus members who did not. Members who received an incentive had higher
HEDIS rates than members who did not. The magnitude of difference varied depending on the incentive/HEDIS measure.
Augmenting Care Management with Medication Reconciliation (MTM) Lisa Ghotbi, Director of Pharmacy, and Tammie Chau, Care Coordination Pharmacist presented the work of the Care Management and Pharmacy Teams to augment Care Management with Medication Reconciliation. • Three years ago SFHP launched a Medication Therapy
Management Program using an outside contracted vendor. o The program had low uptake and limited coordination
with prescribing physicians and staff and therefore was terminated.
• The current program was developed to meet Centers for Medicare
and Medicaid Services (CMS), NCQA, and Health Homes requirements.
o CMS requires MTM programs to be designed to ensure the medications prescribed are appropriately used to optimize therapeutic outcomes and designed to reduce the risk of adverse events.
o NCQA requires Complex Case Management programs to conduct a full medical history including medications.
o Health Homes requires an in-person visit within five days of discharge and completion of medication reconciliation.
• SFHP has an interdisciplinary care management team that includes community coordinators, nurses, a clinical pharmacist, a mental health clinician, social workers, and a Medical Director.
• Essette, SFHP’s Care Management system, now has a Pharmacy system embedded within the web-based application.
o The clinical pharmacists use MedsTracker, an electronic medication reconciliation solution embedded in SFHP’s Care Management system (Essette), to perform medication reconciliation.
o Meducation provides personal medication education resources that are written at a fifth to eighth grade reading level and available in 21 languages in multiple font sizes.
• An intervention is selected based on the pharmacist’s medication assessment.
o Member interventions include educational resources, helping the member with medication adherence, and connecting to the clinic pharmacist if available as they can directly promote safe and effective medication use with members as they are picking up refills or new medications.
o Provider interventions include sharing member adherence interventions and recommendations for optimizing their patient’s medication regimen.
• To date 20 medication reconciliations have been completed for members meeting NCQA criteria for complex care management (diagnosis of both diabetes with complications and hypertension
and without a PCP visit in the past 12 months). o The next step is to build an algorithm to identify other
members who would benefit the most from the program. 2017 HP-CAHPS Access Results Adam Sharma, presented the 2017 HP-CAHPS Results broken down by Medical Group • The provider groups surveyed are:
o Brown and Toland Physicians (BTP) o Chinese Community Health Care Association (CCHCA) o Hill Physicians o Kaiser Permanente o North East Medical Services o San Francisco Consortium of Community Clinics o San Francisco Health Network o University of California, San Francisco
• SFHP oversampled by 60% in order to achieve valid results by provider group. The final sample size was 2,160. SFHP provides an oversample every other year to yield provider group level results.
o CCHCA members had the highest response rate of 38.2%.
• Almost all provider groups improved in the Getting Needed Care composite.
o Relative to 2015 all provider groups improved in the question “In the last 6 months, how often was it easy to get the care, tests, or treatment you needed?” whereas half of the provider groups worsened in the question “In the last 6 months, how often did you get an appointment to see a specialist as soon as you needed?”
• NEMS, SFHN, and SFCCC improved by more than two percent whereas UCSF decreased by more than two percent in the Getting Care Quickly composite.
• The committee discussed the member satisfaction differences among CCHCA and NEMS, who treat predominantly Asian
QI Committee Chair's Signature & Date: ___________________ _11/1/17______ Minutes are considered final only with approval by the QIC at its next meeting.
Americans, and the other provider groups. o It is difficult to determine whether the differences are due
to operational differences between Chinese-speaking providers, cultural differences in how satisfaction is translated in numerical ratings, or responding to a Chinese translated survey.
P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800 1(415) 547-7821 FAX www.sfhp.org
Date: October 24, 2017
To Quality Improvement Committee
From James Glauber, MD, MPH Chief Medical Officer
Regarding Health Services Report
HEALTH SERVICES UPDATE The following Health Services update provides key updates from Health Outcomes Improvement, Clinical Operations, Care Management and Pharmacy Services. Chief Medical Officer Update On October 10, 2017, Jim Glauber, MD, MPH, gave a presentation “Member Incentives as a Performance Improvement Strategy” at the annual California Association of Health Plans conference in conjunction with the Chief Medical Officers of Anthem Blue Cross, Barsam Kasravi, MD, MPH, MBA, and Partnership Health Plan, Robert Moore, MD, MPH, MBA. Health Outcomes Improvement Health Care Effectiveness Data & Information Set (HEDIS) SFHP was awarded the Outstanding Quality Award from the Department of Health Care Services acknowledging this year’s top HEDIS results. Since 2008, SFHP has been awarded this top honor every year but one. To drive further improvement, SFHP is proposing a member incentive pilot and expanded pay-for-performance (PIP) funding as part of the next Strategic Use of Reserves program.
Practice Improvement Program (PIP) As part of the current Strategic Use of Reserves (SUR) project, the second enhanced PIP payments were distributed totaling $1,751,303, based on Q2 PIP performance. This represents 70% of funds available for Q2. Any funds not earned will roll over into the participant’s next quarter’s eligible amount, as is the case for standard PIP funding. Population Health Grants 2017-2020 SFHP received 10 proposals to support high-impact interventions in diabetes, asthma, and Hepatitis C using unearned PIP funds, as approved by the Governing Board earlier in 2017. Seven proposals have been approved. SFHP is working with the remaining three to finalize objectives. We estimate that nearly $2 million will be distributed during the three-year grant program. Strategic Use of Reserves The objective of the FY 15-16 SUR initiative is to achieve significant improvement in member perception of access to services, as well as improve real-time data sharing with hospitals. During August –October 2017, SFHP met with SUR participants to discuss milestones, monitor progress and provide payout for the grants. Year to date, SFHP has disbursed $9,908,596 to the participating groups for initial funding and completion of milestones. An additional SUR opportunity was offered to contracted hospitals in May 2017 and all four of the SFHP network hospitals have received funding for their projects related to transitions of care, clinical quality and patient safety, operational efficiency and patient experience. Year to date, SFHP has disbursed $14,296,230 to the hospitals for initial funding for this program. Access Monitoring During the past several months, SFHP distributed corrective action plans to provider groups to address access deficiencies identified through access surveys conducted in 2016. SFHP is conducting the Provider Appointment Availability Survey (PAAS) from August until December 2017; the survey measures provider adherence to statewide timely access requirements. This is the first time that SFHP staff are conducting the PAAS survey. SFHP will summarize the results of all access surveys and share them with provider groups in April 2018.
Clinical Operations QNXT Improvements The FY17-18 QNXT (claims payment system) improvements effort includes enhancements of QNXT’s configuration to align with best practices and address known configuration issues. The objective of this project is to reduce manual efforts by reducing the volume of mismatches when claims and authorizations adjudicate. This reduction will impact the UM Coordinators, UM Nurses, and Claims Examiners by reducing manual activities by 75 to 120 hours per month. Care Management Clinical Pod Rounds Over the last several months Care Management hired four new Care Management Community Coordinators, two new Care Management Nurses and an intern from the UC Berkeley, School of Social Welfare master’s program. With the new staff, we will be able to serve 100 more members, as well as expanded our intervention to include nursing assessments and health coaching for chronic conditions. To support our growing interdisciplinary team, the Clinical Supervisors, along with Fiona Donald, Medical Director, created and implemented monthly Clinical Pod Rounds. These meetings are a unique opportunity for staff from across the department including Pharmacy and the co-located Beacon Mental Health consultant to provide input on the complex members being managed by our Community Coordinators. Additionally, the clinical team participated in a two-day health coaching training from UCSF Center of Excellence in Primary Care and a three-day motivational interviewing training led by Gregory Merrill, LCSW, and Field Director in the UC Berkeley School of Social Welfare. CHAMP Grant Analysis Final Update On September 28, 2017, Care Management leadership presented a final update of our CHAMP grant analysis to the California Health Facilities Finance Authority (CHFFA) Board in Sacramento. The presentation included a review of grant deliverables, an overview of challenges faced in our evaluation, and a summary of our findings. The Board asked many questions and provided favorable feedback on project outcomes. SFHP staff, along with our Principle Investigator Maria Raven, MD, MPH, will be working to wrap up some additional analysis over the next few months and complete a manuscript for publication. Health Homes In September, SFHP relaunched the Health Homes implementation project to ensure we meet the benefit start date of July 1, 2018.
Pharmacy Services Hepatitis C Update The new Hepatitis C (Hep C) medication, Mavyret™ (pronounced mav-er-et), was added to the SFHP Formulary effective September 1, 2017. Mavyret™ is pan-genotypic (works for all types of Hep C), and is the treatment choice for 85% of new Hep C treatment starts in the month of September. DHCS confirmed that Mavyret™ will be eligible for supplemental Kick funding and released new supplemental kick payment numbers in October. The new kick payment rates will require Mavyret™ use over 80% to cover the Hep C cost of therapy. SFHP Pharmacy services will continue to monitor and maintain this preferred choice when possible. Optimizing Medication Use Beginning in August 2017, SFHP pharmacists began conducting individual medication regimen assessments for our members as part of our integrated approach to case management completing over 20 assessments so far. Working in the same case management system as our social workers, nurses and other members of the care team, pharmacists are identifying medication improvement opportunities as part of the comprehensive care plan. This new integrated medication management software application was developed as a beta solution with First Data Bank and Essette. SFHP presented to the Essette National User Conference in September to highlight this new module to other health plans which is now being offered to all clients. After discussions with other sister plans in the state, this program appears to be a “best-in-class” example that others are interested in modeling for their membership. Drug Utilization Review (DUR) A new DHCS mandate will focus the work of pharmacy services on conducting a broader range of data analyses monitoring for the appropriate use of medications across our Medi-Cal membership. Medication compliance reports for chronic conditions including hypertension, diabetes, cholesterol, and asthma will prompt education and intervention activities. Overuse of unsafe medications will also be a focus. SFHP will participate in the DHCS Statewide DUR Committee and bring insights back to SFHP.
Pharmacy Services San Francisco Health Plan Pharmacy & Therapeutics Committee Wednesday, July 19, 2017 7:30AM – 9:30AM 50 Beale St., 13th Floor, San Francisco, CA 94119
Meeting called by: James Glauber, MD Minutes: Sheila Zeno, CPhT (SFHP Pharmacy Analyst) Andrew Costiniano, CPhT (SFHP Pharmacy Specialist)
Meeting Objective: Vote on proposed formulary andprior authorization(PA) criteria changes Type of meeting: Quarterly
Attendees: Voting Members: James Glauber, MD (SFHP Chief Medical Officer) Lisa Ghotbi, Pharm. D (SFHP Director of Pharmacy) Nicolas Jew, MD Ronald Ruggiero, Pharm. D Robert (Brad) Williams, MD Shawn Houghtaling, Pharm. D. Linda Truong, Pharm. D. Ted Li, MD
Others in Attendance: Kaitlin Hawkins, Pharm. D (SFHP Pharmacist) Ralph Crowder, R.Ph. (SFHP Pharmacist) Tammie Chau, Pharm. D (SFHP Pharmacist) Ryan Cotten, Pharm. D (SFHP Resident Pharmacist) Jessica Shost, Pharm. D (SFHP Resident Pharmacist) Jenna Heath, Pharm. D (PerformRx Pharmacist) Jessica Huang, Pharm. D (Perform Rx Pharmacist) Jennifer Denning (BMS) Mike Barkett (Pfizer) Marc Rueckert (Pfizer) Nene Hardin (Neurocrine Biosciences) Alyssa Grasso (Otonomy) Troy Larsen (Otonomy)
Members Absent: Joseph Pace, MD Jamie Ruiz, MD Roger Tiao, Pharm. D Steven Wozniak, MD
Meeting Materials:
Summary of all approved changes are posted under “Materials” section at http://www.sfhp.org/providers/formulary/pharmacy-therapeutics-committee/ SFHP formulary is located at http://www.sfhp.org/providers/formulary/sfhp-formulary/ SFHP prior authorization criteria are located at http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf
Topic Brought By Time/
Duration Discussion Action
1. Call to Order James Glauber The meeting was called to order at 7:30 am. 2. Agenda overview and other
topics
James Glauber 2 min Introduction agenda topics. Conflicts of Interest checked and instructions given.
Topic Brought By Time/ Duration
Discussion Action
3. Informational Updates James Glauber Lisa Ghotbi
10 min • In the news the Centers for Disease Control and Prevention (CDC) released the national diabetes statistics underscoring why diabetes medications are #2 in our pharmaceutical spending. The report referred to the number of people with type 2 diabetes and those unaware of their diagnosis: 84 million American adults with pre-diabetes which is (1 out of 3) in the U.S. Transitioning to better news, effective 7/18 Department of Health Care Services (DHCS) will be covering Diabetes Prevention Program(DPP) for Medi-Cal members. There are no details as yet to which type of DPP programs will be covered.
• Staffing updates: SFHP has 4 new pharmacists: Kaitlin Hawkins our new formulary management pharmacist, Two (2) one-year pharmacy managed care residents Ryan Cotten from University of Minnesota and Jessica Shost from University of California San Francisco , and Tammie Chau, clinical pharmacist (Temp) focusing our Medication Therapy Management (MTM) program.
4. Review and Approval of April 19, 2017 P&T Minutes
James Glauber 2 min The committee requested no corrections to the minutes.
VOTE: Review and Approval of April 19, 2017 P&T Minutes Motion: Nicolas Jew; 2nd Brad Williams Vote: Unanimous approval (8/8)
****Adjourn to Closed Session**** Closed Session pursuant to Welfare and Institutions Code Section 14087.36 (w)
5 Discussion and Recommendation for Change to SFHP Formulary and Prior Authorization Criteria for Select Drug Classes
Gastrointestinal: o Gattex Monograph (FDA-
approved in 2012) o Xermelo Monograph
(FDA-approved 2/28/17) o Irritable Bowel Syndrome
Class Review o Ulcerative Colitis/Crohn’s
Jenna Heath Kaitlin Hawkins
30 min The plan presented therapeutic review and recommendations for Gastrointestinal medications. Major recommendations included the following: Formulary Recommendations: (Medi-Cal, Healthy Kids and Healthy San Francisco) • Remove prior authorization from Linzess® to
align with American Gastroenterological Association (AGA) guidelines due to preferred pricing
• Remove Cesamet® (Nabilone) 1 mg capsule and Tigan® (Trimethobenzamide) 100 mg/mL vial from formulary and remove prior
VOTE: Gastrointestinal: Approve recommendations with noted changes:
• The required panel test results will be removed from Ocalva criteria for medication consideration.
Motion: Shawn Houghtaling; 2nd Lisa Ghotbi Vote: Unanimous approval (9/9)
Topic Brought By Time/ Duration
Discussion Action
Disease Class Review o Anti-spasmodics Class
Review o Anorexia/Weight Gain
Class Review o Bile Salts Class Review o Ammonia Inhibitors Class
Review o Pancreatic Enzyme Class
Review o Antiemetic Class Review o Miscellaneous GI
Medications (abbreviated review)
(20-155 July of 2017 P&T Packet)
authorization due to zero utilization • Add Transderm-Scopolamine to formulary
with PA to align with current PA criteria guidelines.
(Medi-Cal, Healthy Kids and Healthy Workers) • Add Cortifoam® to formulary. • Remove quantity limits from all formulary 5-
acetylsalicylic acid (ASA) oral and rectal preparations.
• Remove branded Apriso®, Delzicol® and Uceris® from formulary and prior authorization due to limited utilization.
(Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco) • Remove atropine 0.05 mg/mL syringe from
formulary due to zero utilization • Remove chlordiazepoxide/clidinium from
formulary with grandfathering due to very low utilization and the availability of formulary alternative glycopyrrolate, which is more utilized and more cost-effective
• Add Creon® (lipase/protease/amylase) 36-114k DR capsule to formulary due to preferred pricing.
• Remove quantity limits from Creon® and Zenpep® due to preferred pricing.
• Refer to Product Table detailed list of recommended changes
(Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco (excluding where OTC exclusion applies)) • Add lansoprazole capsule (Rx) and Nexium®
capsule (OTC) to formulary due to significant utilization and cost-effectiveness.
• Remove the following due to availability of lower cost formulary alternatives and grandfather current users: o Ranitidine capsule (Rx), 150mg and 300mg o Protonix® granule packet
• Add age limit requirement to the following due to availability of lower cost formulary alternatives: o Famotidine oral suspension o Ranitidine oral syrup
Topic Brought By Time/ Duration
Discussion Action
• Add quantity limit requirement to the following due to excessive quantity fills o Imodium® (loperamide) 2mg capsule, 30 capsules per 30 days
• Evaluate chronic use of Proton-pump inhibitors (PPIs) for possible educational campaign.
PA Criteria Recommendations: (Medi-Cal, Healthy Kids and Healthy San Francisco) • Update criteria to reflect formulary status of
Linzess®. • New criteria is proposed for alosetron based
on indication and AGA guidelines • New criteria proposed for oxandrolone
requiring appropriate diagnosis. • Add diagnosis and coverage criteria for
postoperative nausea and vomiting (PONV)to Antiemetic/Antivertigo Agents criteria (for aprepitant and netupitant/palonosetron)
(Medi-Cal, Healthy Kids and Healthy Workers) • Remove prior authorization(PA) criteria
for Budesonide and Uceris® • Add ursodiol 500 mg tablet to formulary. • Add Cholbam and Ocaliva to formulary
and require prior authorization. (Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco)
• Remove chlordiazepoxide/clidinium from PA criteria
• Update criteria for PPI to reflect formulary changes
Committee Discussion: The committee inquired about why 2 PAs for Linzess® were denied. No specific denial information was available but it was speculated that at least 2 formulary laxatives were not tried. The proposal of updated criteria would address this. Discussion whether panel test results should be required for Ocalva® consideration. The committee decided to remove this requirement. Discussion of following up with a full in-depth clinical review of probiotics at a future P&T
Topic Brought By Time/ Duration
Discussion Action
meeting.
Ophthalmics o Glaucoma Class Review o Mydriatics Class Review o Cystaran Monograph
(FDA-approved in 2012) (P156-177 of July 2017 P&T Packet)
15 min The plan presented therapeutic review and recommendations for Ophthalmic medications. Major recommendations included the following: Formulary Recommendations: (Medi-Cal, Healthy Kids and Healthy San Francisco) • Add a second prostaglandin analog, generic
bimatoprost 0.3% drops to formulary • Add the alpha agonist, Alphagan P®
(brimonidine) 0.1% drops, to formulary • Add the beta blocker/alpha agonist
combination agent, Combigan® (brimonidine/timolol), to formulary.
• Remove Lopidine® (apraclonidine from formulary due to no utilization and limited place in therapy.
• Remove carteolol, metipranolol from formulary due to being obsolete.
(Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco) • Remove Paremyd®
(hydroxyamphetamine/tropicamide) from formulary due to zero utilization
• Remove tropicamide 0.5% from formulary due to zero utilization
PA Criteria Recommendations: (Medi-Cal, Healthy Kids and Healthy San Francisco) • Remove travoprost (with benzalkonium)
0.004% eye drops from criteria due to product being obsolete
Committee Discussion: The committee had no comments or questions.
VOTE: Ophthalimcs Approve recommendations as presented. Motion: Nicholas Jew; 2nd Ron Ruggiero Vote: Unanimous approval (9/9)
Dermatology o Topical
Immunomodulators Class Review
o Miscellaneous Dermatology Medications (abbreviated review)
o Eucrisa Monograph (FDA-approved 12/14/16)
(P178-209 of July 2017 P&T
15 min The plan presented therapeutic review and recommendations for Dermatology. Major recommendations included the following: Formulary Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco (excluding where OTC exclusion applies): • Add calcipotriene 0.005% topical solution to formulary due to cost-effectiveness comparable to alternative formulations
VOTE: Dermatology Approve recommendations as presented. Motion: Brad Williams; 2nd Lisa Ghotbi Vote: Unanimous approval (9/9)
Topic Brought By Time/ Duration
Discussion Action
Packet)
• Remove Condylox® (podofilox) gel from formulary due to availability of lower cost formulary alternatives PA Criteria Recommendations: (Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco (excluding where OTC exclusion applies): • Update criteria for Vitamin D Analogs to reflect the addition of Dovonex® (calcipotriene) 0.005% solution on the formulary. Committee Discussion: The committee had no comments or questions.
Otic o Otic Antibiotic-Steroid
Preparations Class Review
(P210-218 of July 2017 P&T Packet)
10 min
The plan presented therapeutic review and recommendations for tic medications. Major recommendations are listed below. Formulary Recommendations: • No recommendations for change. PA Criteria Recommendations: • No recommendations for change. Committee Discussion: The committee discussed removal of step therapy(ST) on Ciprodex® 0.3%-0.1% ear drops, suspension
VOTE: Otic Approve recommendations as presented except step therapy (ST) edit on Ciprodex® 0.3%-0.1% ear drops, suspension. Motion: Lisa Ghotbi; 2nd Ted Li Vote: Unanimous approval (9/9)
c. Provider Request for Formulary Modification (P219-224 of July 2017 P&T Packet)
Ralph Crowder 10 Mins The plan discussed requests by providers for formulary inclusion: Anoro Ellipta® (umeclidinium bromide/vilanterol) 62.5-25 mcg inhaler): Recommendation: Option #1: Add the following product to formulary with prior authorization required:
• Anoro Ellipta® (umeclidinium 62.5 mcg/vilanterol 25 mcg) • See attached prior authorization criteria
Option #2: ST if following criteria are met: • Past claims for inhaled corticosteroid steroid (ICS)/ long-acting beta-2 agonist (LABA) combination product OR • Past claims for long-acting anti-muscarinic agents (LAMA) OR • Past claims for LABA
Committee Discussion: The committee discussed both options presented and selected Option#2
VOTE: Provider Request for Formulary Modification Reviewed recommendations as presented and approved Option #2 Motion: Lisa Ghotbi; 2nd Ted Li Vote: Unanimous approval (9/9)
6. ****RECONVENE IN OPEN SESSION**** 7. Summary of Closed Session James Glauber 2 min Reconvened Open session around 9:15am Non-voting
Topic Brought By Time/ Duration
Discussion Action
9. Pharmacy Policy &
Procedure Updates and Monitoring (P220-244 July 2017 P&T Packet)
Lisa Ghotbi 7 min The plan presented changes to the Pharmacy Policy and Procedures (P&P): Pharm 01- Pharmacy and Therapeutics Committee Pharm 02- Prior Authorization Pharm 14- Pharmacy Drug Utilization Review(DUR) Program For detail of changes, please see pages 220-243 P&T packet. Committee Discussion: The committee discussed briefly the addition to prospective & retrospective DUR and educational program review to be done by the committee per APL 17-008.
VOTE: Pharmacy Policy and Procedure Updates Approve recommendations as presented. Motion: Ted Li; 2nd Brad Williams Vote: Unanimous approval (9/9)
10. Review and Approval of Interim Formulary Changes and Formulary Placement for New Drugs to Market (P245-248 of July 2017 P&T Packet)
Kaitlin Hawkins
5 min The plan presented interim formulary changes and formulary status for new drugs to market. Committee Discussion: The committee had no comments or questions
VOTE: Review and Approval of Interim Formulary Changes and Formulary Placement for New Drugs to Market Approve recommendations as presented. Motion: Lisa Ghotbi; 2nd Ted Li Vote: Unanimous approval (9/9)
11. Informational Update on New Developments in the Pharmacy Market (P249-264 of July 2017 P&T Packet)
Jenna Heath 5 min The plan provided information on new developments in the pharmacy market. Noted: Food and drug Administration (FDA) approved generic Air Duo for patients 12 yrs. & older for asthma.
Non-voting item
12. Adjournment
James Glauber 2 min The meeting adjourned at 9:30 am. 2017-18 P&T Committee Meeting dates are:
• Wednesday, October 18, 2017 • Wednesday, January 17, 2018 • Wednesday, April 18, 2018 • Wednesday, July 18, 2018
The meeting was adjourned at 9:30 AM
Respectfully submitted by:
September 18, 2017 ------------------------------------------------------- ---------------------------------
James Glauber, MD, MPH Date Chief Medical Officer
Topic Brought By Discussion Action
Pharmacy Services San Francisco Health Plan Pharmacy & Therapeutics Committee Interim Vote by email Completion: Tuesday, August 29, 2017 50 Beale St., 13th Floor, San Francisco, CA 94119
Meeting called by: James Glauber, MD Minutes: Sheila Zeno, CPhT (SFHP Pharmacy Analyst)
Meeting Objective: Vote on proposed formulary and prior authorization(PA) criteria changes Type of meeting: Ad-Hoc (Email)
Attendees: Voting Members: James Glauber, MD (SFHP Chief Medical Officer) Lisa Ghotbi, Pharm. D (SFHP Director of Pharmacy) Nicolas Jew, MD Ronald Ruggiero, Pharm. D Robert (Brad) Williams, MD Shawn Houghtaling, Pharm. D. Linda Truong, Pharm. D. Ted Li, MD Jamie Ruiz, MD Steven Wozniak, MD
Others Participants: Kaitlin Hawkins, Pharm. D (SFHP Pharmacist) Ralph Crowder, R.Ph. (SFHP Pharmacist) Tammie Chau, Pharm. D (SFHP Pharmacist) Ryan Cotten, Pharm. D (SFHP Resident Pharmacist) Jessica Shost, Pharm. D (SFHP Resident Pharmacist)
Members Absent: Joseph Pace, MD
Meeting Materials:
Summary of all approved changes are posted under “Materials” section at http://www.sfhp.org/providers/formulary/pharmacy-therapeutics-committee/ SFHP formulary is located at http://www.sfhp.org/providers/formulary/sfhp-formulary/ SFHP prior authorization criteria are located at http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf
Topic Brought By Discussion Action 1. Interim Vote Summary Kaitlin Hawkins SFHP Pharmacy & Therapeutics Committee
reviewed the interim vote packet pertaining to the newest Hepatitis C drugs, Mavyret and Vosevi. The packet contains a monograph for each of the two new drugs, and an appendix containing our “forecast” of changes to the American Association for the Study of Liver Diseases (AASLD)/ Infectious Diseases Society of America (IDSA) guidelines. The guidelines have not yet been updated to include these drugs, as they were recently approved by the Food and Drug Administration (FDA); the Mavyret™ (FDA-approved 08/03/17) and Vosevi™ (FDA-approved 07/18/17); and added to market in August 2017. However, these drugs will significantly impact treatment of Hepatitis C virus (HCV) for our members and providers; therefore we asked for an interim vote on the formulary and Prior Authorization criteria changes from SFHP Pharmacy & Therapeutics Committee.
Hepatitis C interim vote packet was emailed to the SFHP Pharmacy & Therapeutics Committee on Tuesday, August 22, 2017 for review and vote.
2. Discussion and Recommendation for Change to SFHP Formulary and Prior Authorization Criteria for Select Drug Classes
Hepatitis C: o Mavyret™ Monograph
(FDA-approved 08/03/17) o Vosevi™ Monograph
(FDA-approved 07/18/17) (P 3-36 Interim vote of 2017 P&T Packet)
Kaitlin Hawkins Ryan Cotten
The plan presented therapeutic review and recommendations for Hepatitis C medications. Major recommendations included the following: Formulary Recommendations: (Medi-Cal, Healthy Kids and Healthy Workers) • Add Mavyret™ to formulary with PA
required, as preferred agent for treatment naïve patients with HCV genotypes 1-6, and for select treatment-experienced patients per table below (also add Vosevi™ per separate Monograph)
• Add Vosevi™ to formulary with PA required, as preferred agent for select treatment-experienced patients per table below (also add Mavyret™ per separate Monograph)
• Keep Epclusa®, Harvoni®, and Zepatier® on formulary with PA; available for patients unable to use preferred agents due to failure/intolerance/contraindication
• Remove the following from formulary: Viekira Pak®, Technivie®, Sovaldi®, Daklinza®
PA Criteria Recommendations: (Medi-Cal, Healthy Kids and Healthy Workers) • Update Hepatitis C prior authorization criteria
to include Mavyret™ for non-direct acting
VOTE: Hepatitis C: Motion & Vote: See Voting section below
Topic Brought By Discussion Action
antivirals (DAA) failure patients Committee Discussion: A committee member asked, “Do you keep track of how many patients that receive the treatment have their Hepatitis C status resolved and how many patients continue with Hepatitis C despite treatment? Unrelated to treatment but you might want to know that people are compliant and there is resolution with the diagnosis.” Plan responded, “Right now we don’t actively track HCV resolution for our treated patients. We do actively track compliance via Rx filling. We agree that this would be worth looking into and will follow up with our team. Thanks for the input!”
3. Committee Voting
Committee Member Vote: Y/N
James Glauber, MD Yes Lisa Ghotbi, Pharm D Yes
Joseph Pace, MD No Response by deadline
R. Brad Williams, MD Yes Nicholas Jew, MD Yes Ron Ruggiero, Pharm D Yes Steven Wozniak, MD Yes Jaime Ruiz, MD Yes Shawn Houghtaling, Pharm D Yes Ted Li, MD Yes Linda Truong, Pharm D Yes
The interim P&T Committee vote completed on COB Tuesday, August 29th, 2017 resulted in the approval on the recommendation presented that became effective on September 12, 2017. Vote: Approval (10/11) *Please note: Dr. Pace failed to respond with vote by posted deadline.
4. Adjournment
2017-18 P&T Committee Meeting dates are: • Wednesday, October 18, 2017 • Wednesday, January 17, 2018 • Wednesday, April 18, 2018 • Wednesday, July 18, 2018
The interim vote was adjourned COB Tuesday, August 29th, 2017
Respectfully submitted by:
September 19, 2017 ------------------------------------------------------- ---------------------------------
James Glauber, MD, MPH Date Chief Medical Officer
Prepared: 11/15/17 SFHP Pharmacy Services
Emergency Room Visit / Prescription Access Report 2nd Quarter 2017
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 SFHP, 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 2Q2017, 9,717 members had 15,497 ER visits, averaging 1.59 ER visits per member. This reflects an ER visit by 7.25% of our Medi-Cal membership within the quarter. The distribution of ER visits by ER facility is reported in Table 1A. The number of ER visits by member is reported in Table 1B.
Table 1A: Visits by ER Facility Table 1B: Member ER Visits ER Facility ER Visits # ER Visits Members ZSFG - ACUTE CARE 5877 1 7,071 UC SAN FRANCISCO MEDICAL CENTER 2470 2 1,634 ST FRANCIS MEMORIAL HOSPITAL 2019 3 462 CPMC ST LUKES CAMPUS 1786 4 202 CPMC PACIFIC CAMPUS 1242 5 114 ST MARYS MEDICAL CENTER 701 6 67 CPMC DAVIES CAMPUS 494 7 32 CHINESE HOSPITAL 259 8 24 KAISER FOUNDATION HOSPITAL SAN FRANCISCO 181
9 21
CHINESE COMMUNITY HEALTH CARE ASSOCIATION 139
10 12
Other 329 11 - 29 78 TOTAL 15497 TOTAL 9,717
Prepared: 11/15/17 SFHP Pharmacy Services
Section 2 - Top Diagnoses
Of the 15,497 ER visits in 2Q2017, 10434 visits (67.3%) resulted in a medication (from ER or pharmacy) within 72 hours of the ER Visit and 5063 (32.7%) did not. Not all ER visits warranted medication treatment (ie. chest pain, abdominal pain or altered mental status). From Q12017 to Q22017, the diagnoses related to chest infections dropped overall – this is consistent with what would be expected for the season. The top diagnoses for ER Visits are reported in Table 2.
Table 2: Percent ER Visits by Diagnoses Top Diagnoses Categories ICD10 ER Visits % of Visits Abdominal Pain R10.xx 1022 6.59% Chest pain R07.xx 775 5.00% Alcohol abuse/dependence F10.xx 559 3.61% Fever R50.xx 355 2.29% Nausea w/wo Vomiting R11.xx 297 1.92% Headache R51 224 1.45% Asthma J45.xx 220 1.42% Altered Mental Status R41.82 205 1.32% Acute Upper Respiratory Infection Unspecified J06.9 197 1.27% Shortness of Breath R06.02 183 1.18% Cough R05 182 1.17% Acute Pharyngitis Unspecified J02.9 165 1.06% Low Back Pain M54.5 161 1.04% Dizziness and giddiness R42 154 0.99% UTI unspecified N39.0 135 0.87% All Other Diagnoses 10663 68.81% TOTAL 15497 100%
Section 3 - Key Diagnoses Category
Selected key diagnoses category with a high likelihood for ER discharge prescription is reported in Table 3. For 2Q2017, at least 95% of ER visits for Asthma, UTI, and Pneumonia received medication treatment within 72 hours of the visit. The number of medications filled for bronchitis decreased from 96% to 75% since 1Q2017. This is consistent with current guidance; given that bronchitis often has a viral origin, this diagnosis is targeted as an indicator of over-prescription of antibiotics. No ad hoc analysis will be performed for this reason. For the selected key diagnoses with no prescriptions, members may already have asthma medications or antibiotics from previous pharmacy fills. In some cases, antibiotic treatment or dexamethasone one-time dose for asthma in the emergency room is sufficient to treat the presenting symptoms and no discharge prescription is required.
Table 3: ER Visit – Key Diagnoses Category Diagnoses Category
ICD10 RX filled ER treated
No RX Total %RX
Prepared: 11/15/17 SFHP Pharmacy Services
Asthma J45.901,J45.909 92 55 7 154 95% UTI N39.0 86 31 4 121 97% Pneumonia J18.9 66 15 4 85 95% Bronchitis J20.8, J20.9,
J21.9, J40 20 20 13
53 75%
Section 4 - Pharmacy Location
For the members that did fill a prescription from a Pharmacy within 72 hours of their ER visit date, a further analysis evaluated the location of the pharmacy in relation 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 50% of our pharmacies are open until 9pm. 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 6,727 member visits to a pharmacy after an ER discharge, the most utilized pharmacies are reported in Table 4. Since 1Q2017, Walgreens at 1979 Mission St and at 2494 San Bruno have increased their number of member visits, surpassing Walgreens at 790 Van Ness Ave.
Table 4. Pharmacies where Members obtained Rx within 72 hours of ER Visit Pharmacy Hours of Operation Mbr Visits % of Visits
Walgreens 3711(1189 Potrero Ave) 8AM – 10PM 590 8.77% SF General (1001 Potrero Ave) 9AM – 8PM M-F, 9AM-1PM Sat 489 7.27% Walgreens 1327 (498 Castro St) 24 Hours 349 5.19% Walgreens 5487 (5300 3rd St) 9AM – 9PM 302 4.49% Walgreens 4609 (1301 Market St) 8AM – 8PM 247 3.67% Walgreens 1126 (1979 Mission St) 9AM – 9PM 187 2.78% Walgreens 1626 (2494 San Bruno) 9AM – 9PM 183 2.72% Walgreens 7150 (965 Geneva Ave) 9AM – 9PM 182 2.71% All Others 4198 62.41% TOTAL 6727 Summary: ER utilization was insignificantly higher in 2Q17 compared to 1Q17 (15,497 visits vs 15,148) and (9717 members versus 9700). In 2Q17, each member utilizing the ER, had 1.58 visits compared to 1.56 in 1Q17, also not a significant change. In 2Q2017, the number of medications filled for bronchitis changed from 96% to 75%. This drop below 90% is reasonable based on clinical guidelines, and also has not occurred for two consecutive quarters. No other selected key diagnoses had less than 90% for two consecutive quarters that warranted an ad hoc analysis. No barrier to pharmacy access during after-hours was identified in this quarter. Monitoring of member access to medication treatment after an ER visit will continue.
P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800 1(415) 547-7821 FAX www.sfhp.org
6279X 0515
Date: August 1, 2017 To Quality Improvement Committee
From Nicole A. Ylagan – Grievance Analyst Kirk McDonald – UM Program Manager
Regarding Q3 2017 Grievance & Appeals Report A total of 93 grievances were reported in the third quarter of 2017 (from July 1 – September 30). The overall volume did not change from the previous quarter (Q2 2017) when the total number of grievances filed was 93. A total of 9 grievances deliverables were not closed within the required timeframes in the third quarter of 2017. Three out of 95 acknowledgement letters were not sent out within five calendar days. An SFHP internal department did not notify the grievance team and therefore delayed the acknowledgement of the grievance. Six out of 93 grievances were not 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). However, all six grievances had an approved 14 calendar day extension and were closed within the timelines stated in the letter sent to the member.
Grievances filed by members who are Seniors and Persons with Disabilities (SPD): SFHP continues to monitor grievances filed by members who are part of the SPD population. In Q3 2017, 39 grievances were filed by SPD members. This quarter, the number of grievances filed by SPDs increased by 18.2% compared to the prior quarter (Q2 2017). The types of grievances received vary quarter by quarter. However, a consistent pattern of issues related to quality of service, quality of care and denials are filed by both SPD and non-SPD members. Grievance Rate by Medical Group:
Source of the grievances: The graph below shows who was involved in the grievance i.e. the member’s PCP, the clinic staff, specialist etc. In Q3 2017, there were no trending grievances identified associated with a member’s PCP, the clinic staff, specialist etc.
Access to Care Grievances: SFHP’s Member Experience Dashboard shows all grievances (exempt, decline to file, clinical and non-clinical) associated with access from Q3 2016 – Q1 2017. There were no trends identified regarding access in Q2 2017.
Beacon: Beacon Health Options is SFHP's non-specialty mental health provider. Grievances are semi-delegated. In Q3 2017, a trend was identified regarding delays Applied Behavioral Analysis services. SFHP is actively engaged with Beacon to increase transparency and reporting for referrals and access to appointments.
Kaiser: Kaiser is fully delegated to investigate and resolve grievances. In Q3 2017, there were no trends identified with Kaiser grievances.
08.1 Final_Q3-17_Appeals_MedPharm_v11.29.17.docx
Prepared by: K. M. McDonald (11.27.17) Page 1 of 5
Q3-2017 UM Medical and Pharmacy Appeals Activity UM Medical and Pharmacy Appeals Activity – Overview During 3Q-17, there were a total of 18 appeals filed (medical 12, pharmacy 6)i. In Q3-17, there were a total of 4,474 authorizations (medical 2,981, 1,493 pharmacy). On a per 1,000 authorization basis, this is 4.0 appeals per 1,000 authorizations; or 2.7/1,000 appeals for medical authorizations and 1.3/1,000 appeals for pharmacy authorizations.
08.1 Final_Q3-17_Appeals_MedPharm_v11.29.17.docx
Prepared by: K. M. McDonald (11.27.17) Page 2 of 5
Comparing appeal activity in Q3-17 to Q2-17:
• 28 appeals in Q2-17 vs. 18 appeals in Q3-17. • 4.3 appeals/1000 in Q2-17 vs. 4.0 appeals/1000 in Q3-17.
Of the 18 appeals in Q3-17, 12 appeals were overturned (medical 8, pharmacy 4), which is a 67% overturn rate. This compares to a 39% overturn rate in Q2-17 (11 overturned out of 28 appeals).
08.1 Final_Q3-17_Appeals_MedPharm_v11.29.17.docx
Prepared by: K. M. McDonald (11.27.17) Page 3 of 5
UM Medical Out-of-Medical-Group (OOMG) / Out of-Network Appeals (OON) Activityii There were a total of 8 OOMG / OON medical appeals. The adjudication of the appeals resulted in 2 appealed denials upheld. Q3-17 compared to Q3-15/16:
08.1 Final_Q3-17_Appeals_MedPharm_v11.29.17.docx
Prepared by: K. M. McDonald (11.27.17) Page 4 of 5
UM Medical and Pharmacy Appeal Activity by Medical Groups The medical and pharmacy appeals by medical group appear representative of the distribution of membership.
08.1 Final_Q3-17_Appeals_MedPharm_v11.29.17.docx
Prepared by: K. M. McDonald (11.27.17) Page 5 of 5
Analysis • The average quarterly membership increased by 1.5% from Q2-17 (146,563) to Q3-17
(148,813)iii. • Total authorization denials remained relatively flat year-over-year (392/3Q-16 vs. 395/3Q-17),
which represents 0.62 denials/1000 authorizations (392 denials/627 authorizations) in 3Q-16 versus 0.88 denials/1000 authorizations in 3Q-17 (395 denials/447 authorizations).
• Total appeals per 1000/authorizations also remained relatively flat year-over-year: 20 appeals/1000 authorizations in 3Q-16 versus 18 appeals/1000 authorizations in 3Q-17.
• Overturned appeal rate was 67%/3Q-17, 39%/2Q-17, and 47%/1Q-17.
Actions • The Utilization Management Committee (UMC) has standing agenda items 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: 7/1/2017 - 9/30/2017 as of 11/15/2017 2:24:42 PM. This is an aggregate number of medical and pharmacy appeals; members appealing were 17 MediCal members and 1 Healthy Workers members. ii The data for Q3 in the report 0944ES A&G UM APPEALS REPORT: Case RECEIPT DATE: 7/1/2017 - 9/30/2017 as of 11/15/2017 2:24:42 PM did not distinguish between the categories of OOMG and OON. iii Source: 0021E Executive Membership Report_v11.15.17.
P.O. Box 194247 San Francisco, CA 94119 1(415) 547-7800 1(415) 547-7821 FAX www.sfhp.org
6279X 0515
Date: November 14, 2017 To Quality Improvement Committee From Derek Malley
UM Nurse Supervisor/Quality Review Clinical Operations
Regarding Quarter 3 2017 Potential Quality Issue Report
Q3 2017 PQI Cases Reviewed
Referral Sources for PQI Grievances (Clinical/Non-Clinical) 97 UM Referrals 0 Provider Preventable Condition Reporting 0 Appeals 13 Total Cases 110
Case Breakdown for 110 Reviewed Number of cases which required additional documentation and medical peer review
6
Formal PQI investigation 1 Confirmed PQI 1 All PQI cases were reviewed within the 45 day time frame as outlined in UM56.
Confirmed Quality Issues Case 1: Initial Complaint: Member treated inappropriately with antibiotics for possible strep pharyngitis, clinical guidelines allow for empiric treatment for possible strep pharyngitis only when a Centor score of 4 is well documented. Initial findings: Inappropriate antibiotic treatment with Azithromycin for possible strep pharyngitis. Investigation: Clinical guidelines require a documented Centor score of 4 prior to antibiotic treatment of strep pharyngitis. In this case a Centor score of 1 was documented indicating empiric antibiotic treatment was not warranted. Findings: Clinical guidelines were not followed, discussion between SFHP Chief Medical Officer and provider. SFHP Medical Director confirmed Clinical Quality Issue. Case ranked: 1A Minor quality issue, no harm to member. Follow up/ recommendations: Provider group indicates continual monitoring for similar instances with appropriate corrective action and teaching. Analysis: No identified PQI trends during Q3 2017.
11/28/2017 Faster, Simpler, Smarter: InterQual 2017 Streamlines Clinical Care Decisions | McKesson
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Faster, Simpler, Smarter: InterQual2017 Streamlines Clinical Care
DecisionsApril 03, 2017
Annual release introduces new content to provide better support forMedicare population and admission decisions
NEWTON, Mass.—April 3, 2017—Change Healthcare today unveiled InterQual 2017, the latestversion of the company’s flagship clinical decision support solution. This year’s release introduces atime-saving new product, Medicare Procedures powered by InterQual , and a more efficient set ofCriteria, Initial Review, that help drive rapid care decisions. InterQual 2017 also boasts an extensivenumber of enhanced features and content, all designed to quickly inform and guide clinicians moreefficiently and effectively.
“InterQual 2017 identifies the essence of what is needed to foster faster, safer, and better clinicaldecisions,” said Jackie Mitus, MD, General Manager & SVP, Decision Management, of ChangeHealthcare. “For forty years, our focus has been on supporting appropriate care while streamliningadministrative burdens. This year we’re bringing more clinical intelligence, more automation, and moreknow-how to the forefront, all so the clinician can devote more time to direct patient care. That’s at theheart of what we do.”
Smarter, Simpler Decisions: New Medicare Procedures powered by InterQual automates more than400 Medicare National and Local Coverage Determinations for inpatient and outpatient surgical
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11/28/2017 Faster, Simpler, Smarter: InterQual 2017 Streamlines Clinical Care Decisions | McKesson
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procedures, making this CMS content easily accessible in InterQual’s streamlined workflow. BringingInterQual’s proven technology and easy Q&A structure to Medicare Procedures improves reviewconsistency and simplifies the cumbersome prior auth process, which helps reduce denials for bothpayers and providers.
Earlier, Faster Decisions: Time is always of the essence in healthcare. And for conditions coveringroughly 90% of Emergency Department (ED) admissions nationally, care managers can use the newInitial Review Criteria to determine the appropriate level of care using just the patient data typicallyavailable at the time of admission. The result: ED staff can quickly and correctly place patients in theappropriate level of care. Initial Review Criteria are part of InterQual 2017’s Acute Adult Level of Caremodule.
Safer, Evidence-Based Decisions: New and enhanced content is a hallmark of the InterQual annualrelease, and this year is no different. InterQual 2017 customers gain a wealth of new updates,enhancements, and technological advancements, including more than 125 new content areas. Inaddition, ongoing literature review led to extensive updates of InterQual content, reflecting the latestmedical evidence and standards of care which help ensure appropriate decisions. This year’s featuredadvances include:
New Level of Care Features and Criteria: A highlight of the new additions to InterQualAcute Adult is CMS’s geometric mean length of stay (GMLOS) data that provide a targetlength-of-stay for Medicare beneficiaries. In addition, new Early Responder Criteria helpsreduce LOS of those patients who respond to treatment earlier than average with guidanceto move them through the care continuum properly and safely. Lastly, InterQualSubacute/SNF gains a new Medicare Skilled Nursing Facility subset that aligns with thelatest Medicare SNF guidelines.
New Care Planning Criteria: Highlights include the addition of five oncology and eightnon-oncology specialty drugs to InterQual Specialty Rx, bringing the total to 156 drugs tohelp manage rising specialty drug costs. InterQual Molecular Diagnostics gains five newtests covering four conditions and three multi-gene panels for oncology (colorectal, ovarian,and prostate). New to InterQual Procedures is a length-of-stay assignment for inpatientprocedures using the CMS GMLOS, as well as the addition of new procedures in areas suchas early elective vaginal deliveries and gender reassignment surgeries, among others.
Updated Behavioral Health Criteria: InterQual Behavioral Procedures was revamped intoan easy-to-use Q&A format, making it consistent with the established format of InterQual’sCare Planning suite. A new level of care was also added to InterQual Substance UseDisorders, Inpatient Rehabilitation, aligning with the level of care that Medicare recognizes.
Updated InterQual Coordinated Care Content: A new Opioid Risk Assessment screeningtool was added in response to the opioid epidemic, to help identify members who mightneed further evaluation for this disorder. New content was also added to help address
11/28/2017 Faster, Simpler, Smarter: InterQual 2017 Streamlines Clinical Care Decisions | McKesson
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challenging conditions such as Sleep Apnea, Dyslipidemia, and High-Risk Neonate andCaregiver Discharge.
Technology Investments and Innovations: Enhancements that streamline administration andadvance technological capabilities were added to both the software and SaaS products. Most notably,the InterQual Review Manager workflow software underwent a significant update to the user interfaceimproving ease of use. And with the 2017 release, InterQual is now fully and exclusively a digitalclinical decision support platform, available on desktop PC, mobile devices, on-demand in the cloud,and integrated into care management systems offered by InterQual Alliance Partners. In closing thebook on the print version, InterQual 2017 opened the door to faster updates and greater innovation.
InterQual evidence-based criteria and technology solutions help improve clinical decision-making andcare management across the medical and behavioral health continuums of care. The InterQual clinicaldevelopment team synthesizes the most current, best evidence into a fully referenced decision supporttool. InterQual’s development process is founded on rigorous review of the literature, and includesextensive peer review by practicing clinical experts across the United States.
About Change Healthcare
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157 S. Broad Street, Lansdale, PA 19446 215.855.0615 www.hayesinc.comCopyright © 2012 Winifred S. Hayes, Inc.
What Does Hayes Do?We evaluate healthcare technologies to answer these ques ons:
• Is the technology effec ve for diagnosing, trea ng, or preven ng the target condi on?
• How does the technology compare with other diagnos c, therapeu c, or preven ve op ons for the condi on?
• Is the technology safe, and what are the associated complica ons?
• For which pa ents might the technology provide a true health benefit?
A er we evaluate technologies, we grade them using a proprietary ra ng system that reflects the strength and direc on of the evidence for each applica on of a technology.
Hayes Solu ons for Health PlansOur integrated suite of health technology assessment (HTA) products, educa on, and customized services is designed to:
• Address your need for clear, unbiased, evidence-based informa on.
• Complement your efforts to compare the outcomes associated with similar technologies to iden fy the most cost-effec ve approach based on a balance of cost and quality.
• Facilitate the development of consistent, cohesive, and defensible coverage policies, care management proto-cols, and best-prac ce guidelines that are based on the best available evidence.
• Provide guidance regarding the proper applica on of gene c and genomic tests for specific and complex pa ent popula ons.
• Assist you in comple ng prior authoriza ons (precer fica on) and/or appeal reviews, as well as one-
me coverage decisions, when there is no policy.
DESCRIPTION OF BUSINESS:Hayes, Inc., an interna onally recognized leader in health technology research and consul ng, is dedicated to the delivery of high-quality healthcare and improved outcomes through the integra on of evidence into decision making and policy development. The unbiased informa on and compara ve-effec veness analyses we provide enable evidence-based decisions about acquiring, managing, and paying for health technologies. Our worldwide clients include health plans, government agencies, hospitals, healthcare systems, and employers. Hayes, Inc. is a cer fied woman-owned small business (WOSB).
CONTACT INFORMATION:Silvana SchneiderGlobal Account [email protected]
Supporting Health Plans’ Efforts to Develop Defensible, Transparent Coverage Policies, Care Management Protocols, and Clinical Practice Guidelines
1
UM CRITERIA FOR NON-GENITAL GENDER CONFIRMATION SERVICES
Mammoplasty…………………………………………………………………..... 1 Mastectomy……………………………………………………………………..... 1 Facial Reconstruction…………………………………………………………… 3 Surgical Revisions………………………………………………………………. 4 Surgical Site Hair Reduction…………………………………………………... 4 Facial Hair Reduction…………………………………………………………….. 5
Note: criteria pertains to adults members of SFHP and not those under the age of 18
GENDER CONFIRMATION MAMMOPLASTY AND MASTECTOMY
1. SURGICAL CONSULTATION: Mammoplasty and Mastectomy with Male Chest reconstruction require:
• For San Francisco Community Health Network members: a. Send consultation request and supporting documents to
Transgender Health Services via eReferral
• Prior authorization from SFHP Utilization Management Department
• Documentation of Medical Evaluation
• Documentation of Behavioral Health Evaluation
• Documentation of Patient Education
Documentation of Medical Evaluation
• Comprehensive history and physical dated within 3 months of request date • Gender confirmation mammoplasty and mastectomy both require:
a. Received 12 continuous months of hormonal therapy; OR
b. Viable medical contraindication to hormonal therapy
c. Lived as preferred gender for 12 continuous months
d. Substance use well-controlled for at least 6 months prior to request date
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e. No medical contraindications to surgery
f. Completed “Medical Evaluation” form (available at sfhp.org)
• Gender Confirmation Mammoplasty additionally requires:
a. Documentation that 12 continuous months of estrogen therapy has failed to result in breast tissue growth of at least Tanner Stage 5 when hormonal therapy has no medical contraindication
Documentation of Behavioral Health Evaluation
• Referral for surgery from a qualified behavioral health professional who has assessed the member for mammoplasty/mastectomy
• Referral must include a statement that
a. Behavioral health professional is available for coordination of care
b. Welcomes phone calls to establish care-coordination
• Evaluation dated within one year of prior authorization request via EITHER:
a. Completed “Transgender Health Service Therapist Documentation” form (available at sfhp.org); OR
b. Narrative typewritten statement documenting responses to all items on the “Transgender Health Service Therapist Documentation Form”
Documentation of Patient Education
• “Transgender Health Patient Education” form (available at sfhp.org)
a. Signed by member
b. Surgery-specific Note: gender confirmation surgery can have long wait times. SFHP requires updated medical and behavioral health documentation for surgical clearance prior to surgery. 2. SURGICAL PROCEDURE: Mammoplasty and Mastectomy with Male Chest reconstruction require:
• Prior authorization from SFHP Utilization Management Department
• Completion of surgical consult
• List of requested procedure(s)
• Statement from the surgeon recommending surgery
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GENDER CONFIRMATION FACIAL RECONSTRUCTIVE PROCEDURES
SFHP will review requests of this type when the medical referral and behavioral health evaluation support medical necessity.
1. SURGICAL CONSULTATION:
Facial reconstruction requests require:
• For San Francisco Community Health Network members: a. Send consultation request and supporting documents to
Transgender Health Services via eReferral
• Prior authorization from SFHP Utilization Management Department
• Documentation of Medical Evaluation
• Documentation of Behavioral Health Evaluation
Documentation of Medical Evaluation
• Comprehensive history and physical dated within 3 months of request date
• 12 continuous months of hormonal therapy; OR
• Viable medical contraindication to hormonal therapy
• Member has lived as the preferred gender for 12 continuous months
• Substance use well-controlled for at least 6 months prior to request date
• No medical contraindications to surgery
Documentation of Behavioral Health Evaluation
• Referral for surgery from a qualified behavioral health professional who has assessed the member for facial reconstruction and includes:
a. Evaluation of facial feature(s) that cause persistent gender dysphoria
b. How the presence of stated feature(s) impair function in relation to activities of daily living
c. How the reconstruction of said features will improve quality of life and daily function
d. Must include statement that:
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1. Behavioral health provider is available for coordination of care
2. Welcomes phone calls to establish care-coordination
• Evaluation dated within one year of prior authorization request via EITHER:
a. Completed “Transgender Health Service Therapist Documentation Form” (available at sfhp.org); OR
b. Narrative typewritten statement documenting responses to all items on the “Transgender Health Service Therapist Documentation Form”
2. SURGICAL PROCEDURE:
Facial reconstruction requests require:
• Prior authorization from SFHP Utilization Management Department
• Completion of surgical consult
• List of requested procedure(s)
• Statement from the surgeon recommending surgery as part of the treatment for gender dysphoria
• Documentation of signed Patient Education
REVISIONS OF NON-GENITAL GENDER CONFIRMATION SURGERY SFHP authorizes requests for surgical revisions on a case-by-case basis consistent with Medi-Cal guidelines for medical necessity. SFHP does not cover cosmetic surgery. Clinical documentation must support medical necessity. Surgical revisions require:
• Medical and/or functional complications of prior gender confirmation procedure
• Measurements and/or photographs of deformity/asymmetry (if applicable)
• Statement from the performing surgeon recommending the procedure
HAIR REDUCTION PROCEDURES
1. SURGICAL SITE HAIR REDUCTION SFHP will cover electrolysis or laser hair reduction prior to gender confirmation surgery in order to prepare the surgical site
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Surgical hair reduction requests require:
• Prior authorization from SFHP Utilization Management Department
• Completion of surgical consult
• Surgeon indicates member as an appropriate surgical candidate
• Authorization requests must come from the office of the consulting surgeon
2. FACIAL HAIR REDUCTION
SFHP will review requests of this type when the medical referral and behavioral health evaluation support medical necessity for MtF transgender individuals on a case-by-case basis. Facial hair reduction requests require:
• Prior authorization from SFHP Utilization Management Department
• Documentation of Medical Evaluation
• Documentation of Behavioral Health Evaluation Documentation of Medical Evaluation
• 12 continuous months of hormonal therapy; OR
• Viable medical contraindication to hormonal therapy
• Member has lived as the preferred gender for 12 continuous months
Documentation of Behavioral Health Evaluation
• Referral for procedure from a qualified behavioral health professional who has independently assessed the member and includes:
a. Evaluation of gender dysphoria related to the presence of facial hair
b. How the presence of facial hair impairs function in relation to activities of daily living
c. How the reduction of facial hair will improve quality of life and daily function
d. List of alternative methods of hair reduction and their results
e. Ability to give informed consent
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DEFINITIONS MEDICAL NECESSITY
Services reasonable and necessary to protect life; prevent significant illness and/or disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness, or injury GENDER DYSPHORIA
Distress caused by conflict between a person's sex assigned at birth and the gender he/she/they currently identifies with FEMALE TO MALE (FtM)
A person assigned female sex at birth and later adopts the identity, appearance, and gender role of a male, especially after gender confirmation surgery MALE TO FEMALE (MtF)
A person assigned male at birth and later adopts the identity, appearance, and gender role of a female, especially after gender confirmation surgery QUALIFIED MEDICAL PROFESSIONAL
The medical professional must have appropriate training (MD, DO, NP, PA): • Up-to-date clinical license in the State of California • Training, continuing education, and experience working with the diagnosis and
treatment of Gender Dysphoria
QUALIFIED BEHAVIORAL HEALTH PROFESSIONAL
The behavioral health professional must have appropriate training: • Master’s degree or its equivalent in a clinical behavioral science field by an
accredited institution
• Doctor of medicine or osteopathy, specializing in psychiatry and/or PhD in clinical behavioral science field by an accredited institution
• Licensed Psychiatrist
• Up-to-date clinical license
• Training, continuing education, and experience working with the diagnosis and treatment of Gender Dysphoria
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GENDER CONFIRMATION SURGERY
Surgical procedure that changes a person's physical appearance and function from his/her existing sex characteristics, including secondary sex characteristics, to resemble that of the opposite sex in order to affirm his/her gender identity. Gender confirmation surgery can meet medical necessity as an important part of treating gender dysphoria TRANSGENDER
Diverse group of individuals who cross or transcend culturally-defined categories of gender. Gender identity of transgender people differs to varying degrees from their sex or physical gender assigned at birth WORLD PROFESSIONAL ASSOCIATION OF TRANSGENDER HEALTH (WPATH)
Organization founded in 1979 and formerly known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA). It devotes its resources to understanding the treatment of Gender Dysphoria and has developed internationally accepted Standards of Care (SOC)
REVISION HISTORY
Effective Date: April 10, 2014 Approval Date: April 10, 2014 Revision Date(s): June 2013; January 31, 2014, March 2014, May 2014, February
2015, October 2015, February 2016, April 2016
REFERENCES Criteria based on the following:
• 7th edition of the World Professional Association of Transgender Health, WPATH, Standards of Care
• Medi-Cal Provider Manual “Surgeries”
Quality Improvement Committee December 2017
Policies and Procedures (P&Ps) Updates and Monitoring
P&P Updates: Policy Summary of Updates QI-06 – Medical Director License Verification
• (Policy Change) Added: Adds section to Procedure regarding appeals of non-formulary drugs requested by Healthy Workers or Healthy Kids members: o Makes HW and HK non-formulary drug denial appeals compliant with SB
282. o Establishes timeframe (180 days) for member to appeal. o Establishes conditions that require external review of the appeal. o Establishes timeframes for SFHP to respond to appeal requests (72
hours standard, 24 hours expedited). o Includes requirements of appeal resolution letters (signatory, reviewers,
readability, further appeal rights). QI-15 – Quality Improvement Program
• New Policy: New Policy defining SFHP’s Quality Improvement Program (QIP) including requirements for: o the QI Program Description and QI Work Plan: Areas of focus Staff and committee responsibilities Delegated QI activities Measurement areas Evaluation procedure QIC and Governing Board oversight
o the QI Program Evaluation: Assessment of QI Work Plan activities Oversight of delegated organizations’ QI functions Three-year trending Effectiveness of QI program
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SFHP POLICY AND PROCEDURE
Member Grievances and Appeals Policy and Procedure number:
QI-06
Department Owner: Health Improvement Lines of Business Affected: Medi-Cal, Healthy Workers, Healthy Kids
IV. Appeals about Non-Formulary Drugs rRequested by HWW or HWK members
The following process applies when a Healthy Workers or Healthy Kids member disputes the denial of a nonformulary drug. This process does not apply to a denial disputes about formulary drugs filed by Healthy Workers or Healthy Kids. Refer to section XX for that process. This process does not apply to any grievances or appeals requested by Medi-Cal members. Refer to section XX for that process. 1. Healthy Workers and Healthy Kids members may request coverage of nonformulary
drugs (also known as an “exception request”). If the member receives an NOA denying a request for a nonformulary drug, the NOA provides the member with information about how to file an appeal (also known as a “grievance seeking an external exception request review”).
2. The member has one hundred and eighty (180) days from the date of the NOA to file an appeal.
3. The resolution letter serves as both the written acknowledgement of receipt and resolution of the appeal.
4. Appeals may be filed by a beneficiary, a provider acting on behalf of the beneficiary, or an authorized representative either orally or in writing.
5. If an appeal is filed on behalf of a member, SFHP requires a written, signed consent from the member. If the consent form is not received from the member, SFHP will still process the appeal.
6. Upon receipt of an appeal of a nonformulary drug, SFHP forwards the appeal and all applicable documentation to anSFHP’s contracted external review organization for review. If the original request does not include sufficient clinical information to make a decision, SFHP denies the appeal request within 72 hours following receipt of the appeal, or within 24 hours following the receipt of the appeal if the original request was expedited. The grievance resolution letter informs the member and requesting provider of the need to submit additional clinical information.
7. If the original request was processed as a standard prior authorization request (“standard exception request”), SFHP provides the member or authorized
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representative of the decision no later than 72 hours following the receipt of the appeal.
8. If the original request was processed as an expedited prior authorization request (“expedited exception request”), SFHP provides the member or authorized representative of the decision no later than 24 hours following the receipt of the appeal.
9. The decision is communicated to the member by phone in a culturally and linguistically appropriate manner and a written resolution letter. The written resolution letter will be translated to a HW or HK threshold language if time allows prior to the expiration of the 72-hour or 24-hour timeframe. A copy of the resolution letter will be sent to the provider, if the provider appeals on the member’s behalf.
10. For appeals in which the original denial decision was overturned, services are authorized or provided within 72 hours of the decision to overturn.
11. The SFHP’s Medical Director reviewing physician reviews and signs all appeal resolution letters which reference the benefit provision, guidelines, protocols or other similar criterion on which the appeal decision is based.
12. The appeal resolution letters includes a list of titles and qualifications, including specialties of the individuals participating in the appeal review.
13. The appeal resolution letters is written in easy-to-understand language. The resolution letter includes a complete explanation of the grounds for the denial written in plain language that a layperson can understand and does not include abbreviations or acronyms that are not defined or health care procedure codes that are not explained.
14. Additional information for further appeal rights will be given to the member with the resolution letter, including the option to request an IMR from DMHC.
15. Members will have reasonable access to and copies of all documents relevant to the appeal, free of charge, upon request.
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SFHP POLICY AND PROCEDURE
Quality Improvement Program Policy and Procedure number:
QI-15
Department Owner: Health Outcomes Improvement Lines of Business Affected: Medi-Cal, Healthy Workers, Healthy Kids
POLICY STATEMENT The purpose of the San Francisco Health Plan (SFHP) Quality Improvement Program (QIP) is to establish comprehensive methods for systematically monitoring, evaluating, and improving the quality of the care and services provided to San Francisco Health Plan members. The QI Program is designed to ensure that members have access to quality health care services that are safe, effective, accessible, equitable, and meet their unique needs and expectations. Under the oversight of SFHP’s Governing Board, the Quality Improvement Program is developed and implemented through the Quality Improvement Committee (QIC). SFHP’s Quality Improvement Program (QIP) complies with contract requirements set forth by the Department of Managed Health Care (DMHC) and the Department of Health Care Services (DHCS), as well as standards recommended for National Committee for Quality Assurance (NCQA) accreditation. The requirements include: QI Program Description and QI Work Plan
• Assessment of plan performance and determination of measures to address needed improvement.
• Organizational chart showing key staff and committees responsible for executing QI activities.
• Qualifications of staff responsible for QI studies, including education, experience, and training.
• Evidence of involvement of a CMO, or other physician representative. • Evidence of involvement of a designated behavioral health care practitioner
(must be MD or have a clinical PhD or PsyD). • Description of role, structure, and function of QIC, as well as support committees. • Description of delegated QI activities. • Quality of care problems are identified and corrected for all provider entities. • Description or copy of health plan accreditation reports, including status, survey
results, corrective actions, and expiration date.
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• Procedures to ensure absence of discrimination in delivery of healthcare services and that all covered services are provided in a culturally and linguistically appropriate manner.
• Procedures for evaluating the QI program. • Measures that address the following areas:
o Access and availability of services o Member satisfaction surveys o Measures represented in the DHCS External Accountability Set o Availability of case management and coordination of care for members
with complex health needs (physical disabilities, developmental disabilities, chronic conditions, or severe mental illness)
o Service utilization, including over and under utilization o Measures that correspond to DHCS-required Quality Improvement
Projects o Behavioral Health Care services o Patient safety o Reduced disparities, cultural competency, network adequacy for
underserved populations, or other efforts aimed at improving services for a diverse membership
• Timeframe for completion of measures and staff members responsible for each activity.
• Approval by QIC and the Governing Board by or near the beginning of the calendar year.
QI Program Evaluation
• Assessment of QI activities listed in the QI Work Plan. • Monitoring and auditing of QI functions performed by delegated organizations
(see DO-07: Oversight of QI Functions Performed by Delegated Organizations). • Evaluation of areas of success and needed improvements. • Trend performance for at least three (3) years for clinical care and quality of
service. • Analysis of overall effectiveness of QI program, including adequacy of resources,
QI committee structure, practioner participation/leadership, and need for structural improvement to the QI program.
.
PROCEDURE The QIC structure, under the leadership of the SFHP Chief Medical Officer (CMO), assures ongoing and systematic collaboration between SFHP and its key stakeholders, including members, medical groups, and practitioners. The QI Program objectives and outcomes are detailed in the QI Work Plan. Each program objective is monitored at least quarterly and evaluated at the end of each year. Measures and targets are selected based on volume, opportunities for improvement, risk, organizational priorities, and evidence of disparities.
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SFHP evaluates the overall effectiveness of the Quality Improvement Program through an annual evaluation process that results in a written report, which is approved by the CMO, QIC, and Governing Board. The evaluation includes an executive summary and a summary of quality indicators, identifying significant trends and areas for improvement. Each measure included in the evaluation includes the following elements:
• Brief description of the QI activity/intervention and how it purports to improve the domain in which it is included.
• Target(s) of the QI activity/intervention • Measures / Metrics used to demonstrate the efficacy of the QI
activity/intervention • Results • Barriers that impeded the QI activity from demonstrating effectiveness • Recommended interventions/actions to overcome barriers in the following year
The QI Plan measures are divided into four (4) domains: Care Coordination and Services, Clinical Quality and Patient Safety, Quality of Service and Access to Care, and Utilization of Services. The SFHP Governing Board has ultimate authority and oversight of the QI program. At least one (1) time per year, SFHP presents the QI Plan and Evaluation and requests approval. As an official committee of the Governing Board, QIC serves as clinical oversight and provides accountability for the QI program. QIC approves both the QI Plan and Evaluation, prior to approval of the Governing Board. Immediately following the end of a quarter, SFHP presents the status of the QI work plan to the QIC, requesting input on how to improve activities. Following approval by QIC, the QI Program Description, QI Work Plan, and QI Evaluation are sent to DHCS.
MONITORING Procedures described in this policy are monitored by the Quality Improvement Committee (QIC) via the following reports:
1) QI Program Description (Annual) 2) QI Work Plan (Annual) 3) QI Program Evaluation (Annual) 4) QI Scorecard (Quarterly)
DEFINITIONS Quality Improvement Program Description: Document that describes the structure, resources and methodology of the QI Program. Quality Improvement Program Evaluation: Document that assesses effectiveness of QI Program activities, including measure activities and overall program. Quality Improvement Work Plan: Document that describes the QI measures, targets, and activities to improve measure performance.
Page 4 of 4
AFFECTED DEPARTMENTS/PARTIES Health Services sub-departments:
• Health Outcomes Improvement • Clinical Operations • Pharmacy • Care Management
Provider Network Operations Compliance and Regulatory Affairs
RELATED POLICIES AND PROCEDURES, DESKTOP PROCESS and PROCESS MAPS
DO-07: Oversight of QI Functions Performed by Delegated Organizations QI-01: Quality Improvement Committee QI-10: Governing Board Role in QI Program
REVISION HISTORY Effective Date: Approval Date: Revision Date(s):
REFERENCES 28 CCR §1300.70 SFHP-DHCS Contract Exhibit A, Attachment 4 NCQA Standards for Quality Management and Improvement
Page 1 of 37
50 Beale St., 12th Floor San Francisco, CA 94119 www.sfhp.org
San Francisco Health Plan
2017 Quality Improvement Program Evaluation
Page 2 of 37
Table of Contents 1. Introduction..................................................................................................................................... 4
1.1 Executive Summary........................................................................................................................ 4
1.2 Factors Influencing Implementation of QI Programs in 2017: ......................................................... 5
1.3 Highlights from the 2017 QI Program Measures ............................................................................. 6
2. Quality of Service and Access to Care................................................................................................... 8
2.1 Potential Quality Issues (PQI) ......................................................................................................... 8
2.2 Potential Quality Issues (PQI) ......................................................................................................... 9
2.3 Member Grievances....................................................................................................................... 9
2.4 Member Grievances..................................................................................................................... 10
2.5 Health Plan Consumer Assessment of Healthcare Providers and Systems (HP-CAHPS).................. 11
2.6 Provider Satisfaction .................................................................................................................... 14
2.7 Cultural and Linguistic Services (Plan Year 2016) .......................................................................... 15
3. Clinical Quality and Patient Safety...................................................................................................... 16
3.1 Initial Health Assessment (IHA) Rate ............................................................................................ 16
3.2 Cervical Cancer Screening ............................................................................................................ 17
3.3 Well Child Visits for Children Ages 3-6 .......................................................................................... 18
3.4 Postpartum Care .......................................................................................................................... 18
3.5 Medication Therapy Management (MTM) (Plan Year 2016) ......................................................... 19
3.6 Pain Management/ Opioid Safety ................................................................................................ 20
4. Care Coordination and Services ......................................................................................................... 21
(These measures will be reported in the 2018 Evaluation) ..................................................................... 21
5. Utilization Management .................................................................................................................... 21
5.1 Pharmacy Prior Authorization (PA) Turn Around Time (TAT) (Plan Year 2016) .............................. 21
5.2 UM Coordinator UM File Audits (Plan Year 2016) ......................................................................... 22
5.3 Interrater Reliability (Plan Year 2016)........................................................................................... 23
5.4 UM Timeliness of Decision and Notification (Plan Year 2016) ....................................................... 23
5.5 Non-Specialty Mental Health Penetration Rate ............................................................................ 24
5.6 Non-Specialty Mental Health Penetration Rate ............................................................................ 25
6. Delegation Oversight ......................................................................................................................... 26
6.1 Delegation Oversight (Plan Year 2016) ......................................................................................... 26
Appendix I: 2017 Quality Improvement Work Plan............................................................................... 28
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1. Introduction The goal of the San Francisco Health Plan (SFHP) Quality Improvement (QI) Program is to assure high quality care and services for its members by proactively seeking opportunities to improve the performance of our internal operations and health care delivery system.
SFHP’s QI Program is detailed in the SFHP QI Program Description. The QI Program Description contains an annual Work Plan, outlined in Appendix I, representing the current year improvement activities and measure targets. The QI Work Plan is evaluated on a quarterly basis and consolidated annually. The QI Evaluation provides a detailed review of progress towards the measures and goals set forth in the QI Work Plan. In this evaluation, the results are presented for five activity domains:
• Quality of Service & Access to Care • Clinical Quality and Patient Safety • Care Coordination and Services • Utilization Management • Delegation Oversight
At the time of this evaluation, not all data for the 2017 measures have been finalized. As such, only measures with finalized data are included. SFHP will include the remaining measures in the 2018 QI Evaluation.
1.1 Executive Summary Oversight Under the leadership of SFHP’s Governing Board, the Quality Improvement Committee (QIC) oversees the development and implementation of the QI Program and annual QI Work Plan. The QIC is supported by multiple committees including Access to Care, Grievance Oversight, Utilization Management, Physician Advisory and Peer Review, Pharmacy and Therapeutics, and Provider Network Oversight. SFHP’s Quality Committees, under the leadership of the Chief Medical Officer, ensure ongoing and systematic involvement of SFHP’s staff, members, medical groups, practitioners, and other key stakeholders where appropriate.
Impact of QI Program on Patient Safety SFHP successfully influenced network-wide safe clinical practices through a multi-pronged approach including adopting clinical guidelines, implementing the pain management program, incentivizing primary care follow-up after acute hospital discharge, and incentivizing population health best practices through a pay-for-performance program.
SFHP continues to operate a comprehensive pain management program, driving to ensure safe opiate prescribing practices. SFHP convenes a safety-net pain management workgroup that advises SFHP on pain management provider trainings, updating practice guidelines, ensuring safe opiate prescribing, and improving patient function while minimizing risk.
Page 5 of 37
In addition, SFHP monitors timely assessment and follow up on Potential Quality Issues (PQI) through its quality program. PQIs are identified from a variety of mechanisms, including grievances, utilization management activities, and case management activities.
The Pay-For-Performance program reinforced patient safety activity through rewarding performance in pain management best practices, follow-up outreach after member discharge from the hospital and HEDIS population health practices, such as various cancer screenings.
SFHP launched and operates a discharge planning program in order to ensure members’ safe transition from the hospital and prevent possible readmission.
Participation in the QI Program: Leadership, Practitioners, and Staff Senior leadership, including the Chief Executive Officer (CEO) and the Chief Medical Officer (CMO) provided key leadership for the QI program. The CEO championed SFHP’s NCQA journey and an organization-wide effort to improve member’s ability to access services in a timely manner within the provider network. This included instituting ‘NCQA Accreditation’ and ‘Access to Care’ as organizational strategic priorities. In addition, the CEO ensured that there were regular reports at Board meetings on the QI program components. The CMO provided ongoing support for all quality improvement studies and activities, and was responsible for leading the Quality Improvement Committee, Physician Advisory and Peer Review, Credentialing Committee, the Pharmacy and Therapeutics Committee, and the Grievance Committees. The Medical Director provided leadership for the Pain Management program, Case Management Program, and Disease Management Program. Beyond SFHP Medical Directors, stakeholder participation in the QI program was achieved through involvement of providers and members in the Quality Improvement Committee, the Practice Improvement Program Advisory Committee that advises on the pay-for-performance program (i.e. PIP), and the annual HEDIS/PIP review meetings during which health plan leadership meets with senior leadership in the network to review outcomes and solicit input on the health plan QI program. Additionally, SFHP administered 19 member focus groups to better inform development of QI measures, targets, and barriers. Overall, leadership and practitioner participation in the QI program in 2017 was sufficient to support the execution of quality objectives.
The staff accountable for implementing the annual QI Work Plan represents the cross-functional nature of quality improvement activities at SFHP. Staff monitor quality indicators and programs, and implement and evaluate SFHP’s QI work plan. For a detailed summary of all staff supporting the QI Program, please refer to the Quality Improvement Program Description.
1.2 Factors Influencing Implementation of QI Programs in 2017: SFHP plans the QI Work Plan for the upcoming year prior to the start of the year. Throughout the year, expected and unexpected challenges may impact implementation of planned activities. Some of the factors that may have impacted the 2017 QI Program include:
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• Infrastructure Improvement: Essette Care Management System – S FHP utilizes Essette, an
enterprise-wide application, designed to strengthen its utilization management, care coordination, grievance management, and population health efforts. Each year, SFHP implements several enhancements to improve overall care coordination for our members. In 2017, SFHP integrated MedsTracker (a First Data Bank application) to allow the SFHP pharmacy team to perform medication therapy management more effectively and fully integrate with our community based Care Management team. SFHP also enhanced its Provider Portal which allows providers and their delegates to submit authorizations directly to Essette via a web interface. Essette use has increased staff efficiencies, but also impacted staff capacity as they participated in the implementation of new functionalities.
• Implementation of Additional State Mandates and Benefits - In 2017, SFHP implemented non-emergency transportation. Work has begun on implementing palliative care and Health Homes for 2018. In addition, several major state mandates affected SFHP, including revised Health Information Form/Member Evaluation Tool, Pharmacy Drug Utilization Review, revised credentialing requirements, and the integration of member carve-out historical data. While these benefits and mandates ultimately improve the care and services that SFHP members receive, these requirements impacted SFHP staff availability for other projects.
• NCQA – SFHP committed to achieving NCQA First Survey accreditation in 2017. NCQA preparation requires significant staff resources as we initiated several new programs and improved many of our existing processes. While positively impacting health plan ongoing operations, NCQA preparation impacted staff time devoted to QI measures in the short term.
1.3 Highlights from the 2017 QI Program Measures The San Francisco Health Plan had many positive outcomes during the 2017 QI Program Evaluation period. SFHP sets stretch goals each year, ensuring that we are improving at a meaningful pace. As such, many performance measures have demonstrated strong improvement despite not meeting the stretch goal. Of the 26 measures included in the 2017 QI Evaluation, 10 met the target. Of the 16 measures not meeting the target, four improved from baseline. SFHP is currently finalizing the measurement of 13 remaining measures; these will be included in the 2018 QI Program Evaluation. SFHP will utilize lessons learned from 2017 to evolve the 2018 QI Program and to drive continuous improvement in operations and outcomes.
In summary, SFHP identified the following areas from the QI Work Plan as either demonstrating effectiveness or as opportunities for improvement:
Quality of Service and Access to Care:
SFHP met five of the nine measure targets in this domain. One other measure is not yet finalized and will be included in the 2018 QI Evaluation. Some notable improvements include:
• HP-CAHPS “Overall Rating of Health Plan”, “Getting Needed Care” and “Rating of Health Plan”.
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• Provider satisfaction with SFHP services. • Turnaround times in PQI resolution.
Recommendations for continued improvement include:
• Identification and monitoring of Provider Preventable Conditions. • Review of both clinical and non-clinical grievances at Grievance Oversight Committee to address
incomplete responses from providers. • Provider technical assistance and grant funding for access improvement through Strategic Use
of Reserves. • Incentivizing clinics and provider groups to implement projects to improve access under SFHP’s
Pay for Performance program. • Increasing CAHPS measurement frequency to help determine improvement strategies.
Clinical Quality and Patient Safety: SFHP met one of the six measure targets in this domain. Two measures not meeting target improved over baseline. Two other measures are not yet finalized and will be included in the 2018 QI Evaluation. Some notable improvements include:
• The provider network continues to provide exemplary clinical quality as demonstrated by 9 HEDIS measures meeting NCQA Medicaid 90th percentile.
• 7.2% in compliance with Cervical Cancer Screening (CCS) from 2016. • 17% relative decrease from 2016 in the percent of members receiving an opiate prescription in
the past year relative.
Recommendations for continued improvement include: • Add chiropractic benefit as part of SFHP’s Pain Management program strategy. • Utilize Strategic Use Reserves to increase availability of inpatient addiction services. • Prioritize HEDIS Measures and assign appropriate resources to increase performance.
Care Coordination:
There are three measures in this domain. They are not yet finalized and will be reported in the 2018 QI Evaluation.
Utilization Management:
SFHP met four of the six measure targets in this domain. Two measures not meeting target improved over baseline. Two other measures are not yet finalized and will be included in the 2018 QI Evaluation. Some notable improvements include:
• Increase in the adult non-specialty mental health network penetration rate. • Timeliness of UM decisions and notifications to providers and members.
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Recommendations for continued improvement include:
• Increasing adult non-specialty mental health rate by encouraging members who may not have sought behavioral health services to use this treatment modality.
• Implementation of a provider Pay for Performance depression screening measure to increase identification of members who may benefit from behavioral health treatment.
Delegation Oversight:
SFHP met zero of the five measure targets in this domain. Five other measures are not yet finalized and will be included in the 2018 QI Evaluation. Some notable improvements include:
• Improvement in Credentialing and Quality Improvement delegation scores from previous audit period.
Recommendations for continued improvement include:
• Implementation of provider communications regarding DHCS guidelines for Mega Regulations.
2. Quality of Service and Access to Care
2.1 Potential Quality Issues (PQI) (Plan Year 2016) Measure: Potential Quality Issues Numerator 4 Baseline N/A Final Performance 100% Denominator 4 Target 95% Evaluation Year 2017 *This measure is from the 2016 QI Plan. It was not finalized at the time of the 2016 QI Evaluation and is now being included here.
This measure calculates the percentage of confirmed PQIs that meet the 45 calendar day resolution divided by the total number of confirmed PQIs. Extensions to 60 calendar days are allowed if additional clinical information is needed. The target was set at 95% due to the high visibility and potential risk to SFHP members. An anticipated barrier included providers not supplying clinical information in a timely manner. This barrier was mitigated by escalating to other SFHP staff when needed.
The following activities were completed:
• Provided PQI training to Health Services staff in March 2016. • Implemented PQI and Decline-to-File Grievances process in SFHP’s Care Management
System. • Implemented quarterly reporting to Quality Improvement Committee (QIC) starting
January 2017.
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This measure will be continued in 2017. Addressing quality of care issues continues to be a priority for SFHP and is required by SFHP’s DHCS contract. The target will increase to 100%.
2.2 Potential Quality Issues (PQI) Measure: Potential Quality Issues (PQI) Numerator 6 Baseline 43% Final Performance 100% Denominator 6 Target 93% Evaluation Year 2017
The Potential Quality Issues (PQI) measure is in the Quality of Service and Access to care domain. It measures the percent of confirmed clinical PQIs resolved within 45 days. This measure increases member safety by identifying potentially systemic clinical quality issues whose resolution could prevent additional members from experiencing similar incidents. The target of 93% was assigned due to the high visibility of this measure and potential risk to our members. SFHP met the target, achieving 100%. There were no barriers to meeting the target. There were no issues completing the activities, which included:
• Providing PQI training to Health Services staff. • Streamlining processes by implementing a PQI and Decline-to-File grievance function in SFHP’s
Care Management System. • Implementing quarterly reporting of PQI Turnaround Times. • Escalating to SFHP leadership when providers had a delayed response.
For the next evaluation period, the target will be set at 100%. The activities to support this target include:
• Triage of Care Management case referrals by QI Review Nurse. • Identification and monitoring of Provider Preventable Conditions. • PQI refresher training with Utilization Management Outpatient Team. • Refine PQI workflow in Essette to maximize functionality.
2.3 Member Grievances (Plan Year 2016) Measure: Member Grievances Numerator 353 Baseline 100% Final Performance 99% Denominator 357 Target 100% Evaluation Year 2017 *This measure is from the 2016 QI Plan. It was not finalized at the time of the 2016 QI Evaluation and is now being included here.
The Member Grievances measure impacts the Quality of Service and Access to Care domain. It measures the rate of member grievances that are resolved within regulated time frames; either 30 calendar days or approved extension. Resolving grievances quickly are important to member satisfaction as well as identifies areas for improvement within the health care system. This measure is
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also a requirement from the Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC).
This measure is calculated by determining the percentage of member grievances resolved within 30 calendar days out of the total member grievances received. For 2016, 99% of all grievances were resolved within 30 calendar days. Barriers to meeting the target included four grievances that did not meet the turnaround time due to:
• Late provider responses • Additional follow up being required • Resolution letters needing translation
In 2016, the following activities were completed:
• A Frequently Asked Questions (FAQ) on grievances was created to help members understand the grievance process, including what a member can file a grievance about and information if the member is not satisfied with the resolution of their grievance.
• SFHP met with two provider groups to increase communication of the grievance process and decrease provider response times.
• SFHP provides regular reminders to providers via email or phone regarding the due date for the provider response.
• SFHP details the specific reasons contributing to grievances not resolved in a timely manner.
Member grievances provide SFHP with information about the healthcare experience; identifying areas for improvement in both SFHP operations and the broader provider network. For 2017, the target will remain at 100%. Activities will include:
• Grievance Review Committee will review grievances 2 times a week. • Grievance Oversight Committee will review trends and quarterly grievance reports each
month and address non-responsiveness of providers. • Institute periodic meetings with provider groups with a large volume of grievances.
2.4 Member Grievances Measure: Member Grievances Numerator 378 Baseline 99% Final Performance 99% Denominator 381 Target 100% Evaluation Year 2017
The Member Grievances measure impacts the Quality of Service and Access to Care domain. It measures the rate of member grievances that are resolved within regulated time frames (expedited grievances within three days and standard grievances within 30 calendar days or with an approved extension). Resolving grievances quickly is important to member satisfaction, as well as provides
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opportunities for improvement within the health care system. This measure is also a requirement from the Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC).
This measure is calculated by determining the percentage of member grievances resolved within a compliant timeframe out of the total member grievances received. In 2016, 99% of all grievances were resolved within the acceptable timeframes. Three grievances did not meet the turnaround times for the following reasons:
• Grievance staff inadvertently missed the grievance deadline due to coverage issues. • Customer service staff inadvertently did not escalate the grievance to grievance staff within the
required time.
To improve performance, the following activities were completed:
• Included all types of grievances (exempt, decline to file, and clinical) in the grievance management system to enable efficient processing of grievances.
• Escalated to the Chief Medical Officer when providers were non-responsive to grievance follow-up requests.
• Reviewed and reported turnaround times during internal grievance staff meetings and during the Grievance Oversight Committee. Missed deadlines were escalated to the Manager of Access and Care Experience. Root cause of the missed deadline and opportunities for future process improvements were identified.
For the next evaluation period, the target will be set at 99% for two reasons. First, regulated timeframe requirements became more restrictive over the past year. And, SFHP will modify the measure to include both clinical and non-clinical grievances. To maintain performance, SFHP proposes that:
• Grievance Oversight Committee review trends for both clinical and non-clinical grievances each month and discuss approaches to address non-responsive providers.
• Grievance staff discusses grievance trends and turnaround times with provider groups during joint operations meetings.
• A shared metric goal for grievance turnaround time compliance is developed across different departments to promote accountability among all staff involved in the grievance process.
2.5 Health Plan Consumer Assessment of Healthcare Providers and Systems (HP-CAHPS) Measure: Rating of Health Plan Baseline 67.82% Final Performance 72.76% Target 69.82% Evaluation Year 2017 Measure: Getting Care Quickly Baseline 65.35% Final Performance 68.10% Target 68.00% Evaluation Year 2017 Measure: Getting Needed Care
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The Getting Care Quickly, Getting Needed Care, and Rating of Health Plan measures from the Health Plan Consumer Assessment of Healthcare Providers and Systems (HP-CAHPS) survey, assesses member perception and is in the Quality of Service and Access to Care domain. HP-CAHPS performance is important to SFHP for three reasons:
• HP-CAHPS is the primary means by which members provide feedback about their satisfaction with SFHP and their overall health care. SFHP strives for high member satisfaction, in addition to high quality and affordability.
• Improvement in the Getting Care Quickly and Getting Needed Care composites are the biggest contributors to SFHP members’ overall satisfaction, and therefore remains an organizational priority.
• Full NCQA Accreditation is partly dependent on a strong performance in HP-CAHPS.
The Getting Care Quickly Rating is composed of two questions from the HP-CAHPS survey: 1) “In the last 6 months, when you needed care right away, how often did you get care as soon as you needed?” and 2) “In the last 6 months, how often did you get an appointment for a check-up or routine care at a doctor's office or clinic as soon as you needed?” The Getting Needed Care composite is comprised of two questions from the HP-CAHPS survey: 1) “How often was it easy to get the care, tests, or treatment you needed?” and 2) “How often did you get an appointment to see a specialist as soon as you needed?” The results for these composites represent the percentage of members responding “Usually” and “Always” out of the total responses to the two questions of each composite. The Rating of Health Plan performance is measured from one question in the HP-CAHPS survey: “Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your health plan?” The results for this rating represent the percentage of members responding 8, 9, or 10 out of the total responses to the above question.
The target of 2% improvement was determined by consulting with SFHP’s survey vendor, and is based on industry knowledge of achievable improvement from year to year. SFHP met the goal and improved by over 2% in the Getting Needed Care, Getting Care Quickly composites, and Rating of Health Plan in 2017.
Based on information gathered from member grievances and conversations with provider groups, SFHP found that providers sometimes lack the infrastructure to provide efficient care in the manner that members expect. Infrastructure needs include technological improvements (EHR workflows, data integration, telephone systems), ability to provide care beyond typical face-to-face visits, effective recruitment strategies for providers, and processes to inform/manage expectations with members. To address these barriers, SFHP implemented several improvement projects to improve performance in both HP-CAHPS access composites:
Baseline 66.11% Final Performance 68.52% Target 68.40% Evaluation Year 2017
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• Inclusion of the Clinician Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey results in SFHP’s Pay for Performance program. Inclusion of the CG-CAHPS access composite incentivized provider groups to achieve improvement targets in member perception of access. Of the four medical groups participating in this program, all achieved relative improvement. Of the 15 clinics in the Community Health Network participating, eight achieved relative improvement.
• Distribution of 57 Corrective Action Plans to provider groups to correct access deficiencies in triage screening and appointment availability.
• Access improvement projects implementation by provider groups, funded by SFHP through the Strategic Use of Reserves Grants.
• Expanded telephonic/video access to primary care providers via the implementation of Teladoc. • Offered Studer Group trainings to 54 SFHP provider network staff about two evidence-based
practices known to improve patient experience. • Offered Baird Group trainings to 51 SFHP provider network staff and SFHP member-facing staff
about service recovery to enhance patient experience. • Continuation of the DHCS Performance Improvement Project to pilot three-way calls between
members and provider offices.
SFHP recommends increasing the targets for each measure by 2%, which is consistent with industry knowledge of yearly achievable and meaningful improvement. Improvements in access to care represent a key driver to CAHPS improvement. Activities to continue improvement in these measures include:
• Strategic Use of Reserves Grant program to provide technical assistance and grant funding for access improvement.
• Increased monitoring of access in the network and request for corrective action when provider groups are found to be non-compliant. SFHP will allow those groups who receive a request for a Corrective Action Plan to complete a project under SFHP’s Pay for Performance program measure, which incentivizes clinics and provider groups to implement a project to improve access.
• Identify access-related issues via the Access to Care Committee, and develop plans to address found issues.
• Provide technical assistance to the network about best practices for improving access. This will happen by way of webinar and one-on-one coaching with the intention of improving appointment availability.
• Pilot and implement three-way scheduling calls between SFHP’s customer service department and provider offices.
• Increase CAHPS measurement frequency to help determine improvement strategies. • Redesigning marketing communications to mirror language from the CAHPS survey. • Conduct member focus groups to gain additional insight on member perception of access.
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2.6 Provider Satisfaction Measure: Provider Satisfaction Question 8A: Provider Relations representative's ability to answer questions and resolve problems. Numerator 47 Baseline 71.5% Final
Performance 70.1%
Denominator 67 Target Statistically-significant increase at 95% confidence interval, OR 90th national Medicaid percentile (61.5%)
Evaluation Year
2017
Question 8C: Quality of written communications, policy bulletins, and manuals. Numerator 43 Baseline 72.4% Final
Performance 62.3%
Denominator 69 Target Statistically-significant increase at 95% confidence interval, OR 90th national Medicaid percentile (39.0%)
Evaluation Year
2017
*Question 8D: Overall satisfaction with Provider Relations. Numerator 44 Baseline 72.4% Final
Performance 63.7%
Denominator 69 Target Statistically-significant increase at 95% confidence interval
Evaluation Year
2017
* There are no Medicaid percentiles/benchmarks for this question.
The Provider Satisfaction measure is in the Quality of Service and Access to Care domain. SFHP members are directly impacted by provider satisfaction as provider dissatisfaction can indicate problems such as onerous processes and other interferences with the provision of health care services. The target was defined as achieving a statistically-significant rate increase at the 95% confidence interval, or achieving the 90th national Medicaid percentile, and was set in an effort to maintain a high level of provider satisfaction throughout SFHP’s network.
The Provider Satisfaction questions ask SFHP providers to rate their experiences with SFHP's Provider Relations department’s ability to answer questions and resolve problems, the quality of the department’s written communications, policy bulletins and manuals, as well as their overall satisfaction with the department. Response options include: “Completely Satisfied”, “Somewhat Satisfied”, “Neither dissatisfied nor satisfied”, “Somewhat dissatisfied”, “Completely dissatisfied”, and “Does not apply”.
Although all three rates dropped from baseline, two of the three questions (i.e. 8A & 8C) met the 99th percentile target. Barriers to meeting the target for question 8D may have been related to the launch of a new provider portal. The original expectation for the new portal was to be a complete replacement of the previous tool, with additional functionality. However, some older functionality became temporarily unavailable and some new, planned functionality was not implemented. In addition, new regulatory
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requirements (e.g., provider rosters, cultural awareness) implemented by SFHP can be considered burdensome by providers.
The activities conducted this year included:
• An analysis of the 2016 provider satisfaction survey and addressing findings. • Modifying medical policies intended to decrease prior authorizations needed. • Ongoing publication of the Provider Update newsletter to maintain open communication with
providers. • Ongoing monitoring and process improvement of service metrics such as phone answer time,
inquiry response time, and newsletter schedule adherence. • In-person provider visits to all medium and large volume sites.
Recognizing continued high performance in provider satisfaction, SFHP recommends retiring this measure from the QI program and replacing it with an alternative measure needing improvement.
2.7 Cultural and Linguistic Services (Plan Year 2016) Measure: Cultural and Linguistic Services Numerator 1 Baseline 0% Final Performance 20% Denominator 5 Target 100% Evaluation Year 2017 *This measure is from the 2016 QI Plan. It was not finalized at the time of the 2016 QI Evaluation and is now being included here.
The Cultural and Linguistic Services measure impacts the Quality of Service and Access to Care domain. The measure indicates the percentage of medical groups meeting the cultural and linguistic standards set by regulatory agencies (DHCS and DMHC). This measure allows SFHP to evaluate member access to low-literacy, culturally and linguistically appropriate health education and self-management resources in all threshold languages. In addition, the measure evaluates the provision of appropriate interpreter services at all points of healthcare contact, including both clinical and non-clinical staff.
SFHP audits its provider groups each year. Results from these audits were used to evaluate the measure’s performance. Providers were counted as meeting the requirements if they received a score of 95% or higher on the standardized audit tool in the cultural and linguistic services domain. SFHP set the measure’s target at 100% of medical groups meeting the requirements. The target date and score were not met. Upon further review of Cultural and Linguistic requirements, SFHP significantly modified its audit tool in order to better monitor cultural and linguistic services policies and procedures. As a result, SFHP did not have a true baseline from which to base the improvement target.
In 2016, the following activities were completed:
• Developed a standardized audit tool for provider groups that included: 1) availability and confidentiality of interpreter services, 2) linguistic competency of clinical and non-clinical staff, and 3) cultural competency training requirements.
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• Five audits of delegated groups were performed, and one pre-delegated audit was performed for a network new to SFHP in 2016.
• In addition to the 5 delegated medical groups that were audited, SFHP conducted additional audits of non-delegated provider groups, including the San Francisco Health Network and the San Francisco Community Clinic Consortium.
• Incorporated provider language assessment at the time of initial provider credentialing.
SFHP recommends that this measure be discontinued for 2017 and replaced with a measure focused on availability of interpreter services, which was identified as an opportunity for improvement in grievance review and during the member needs assessment. The recommended target is 80%.
3. Clinical Quality and Patient Safety
3.1 Initial Health Assessment (IHA) Rate Measure: Initial Health Assessment (IHA) Rate Numerator 6,538 Baseline 23% Final Performance 25% Denominator 25,879 Target 25% Evaluation Year 2017
The Initial Health Assessment (IHA) measure is in the Clinical Quality and Patient Safety domain. It measures SFHP’s performance in meeting the DHCS requirement that all newly-enrolled Medi-Cal members receive a comprehensive assessment during an initial primary care visit within 120 days of enrollment. The intent of the measure is to evaluate members’ engagement with primary care by measuring the rate of members who received an IHA within the required timeframe.
The rate is calculated based on the number of newly-enrolled Medi-Cal members who received an IHA out of the total newly-enrolled Medi-Cal members. The completion of an IHA is identified through specific Evaluation & Management (E&M) codes from claims and encounter data. The target of 25% is based on a 2% improvement from the previous year’s rate of 23.2%. A barrier that affected performance in 2017 was measurement methodology. The measurement relies on providers to submit accurate claims and encounter data to identify that an IHA was completed, which seems to be inconsistently documented.
Two activities conducted included:
• SFHP sent quarterly member summary reports to providers and provider groups with demographic information of IHA-eligible members, requesting that providers outreach to them and conduct an IHA.
• With the member summaries, SFHP included the IHA completion rates from the prior two quarters to communicate any opportunity for improvement.
In addition to the activities above, SFHP planned to validate the IHA measurement methodology. SFHP did not complete this activity for two reasons: 1) significant staff resources needed for chart review, and
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2) revised IHA requirements are expected as a result of national regulations set by the Centers for Medicare and Medicaid Services.
SFHP recommends replacing this measure with a measure that better represents quality of care for members. SFHP will replace this measure with percent of members with a primary care visit in the past 12 months. SFHP will continue to monitor IHA rates in day to day operations and conduct improvement activities as needed.
3.2 Cervical Cancer Screening Measure: Cervical Cancer Screening Numerator 290 Baseline 61.56% Final Performance 68.72% Denominator 422 Target 71.56% Evaluation Year 2017
The Cervical Cancer Screening measure is in the Clinical Quality and Patient Safety domain. Cervical cancer screenings have been proven to reduce morbidity and mortality from cervical cancer; however, these screenings have historically been underutilized among SFHP members. Improving this measure benefits members by enabling early detection and treatment of cervical cancer. The target of 71.56% was set to achieve a 10% absolute improvement from baseline, in anticipation of the Medicaid 90th percentile dropping in reporting year 2017.
Barriers to meeting the target included:
• A large eligible population for the measure totaling 30,343 members. • Incentivizing screening without encouraging over-utilization. • SFHP’s interpretation of new federal regulations limiting how members can be contacted on
their cell phones.
The two activities conducted to support this measure included:
• Inclusion of cervical cancer screening as a PIP measure, with nineteen PIP participants including the cervical cancer screening as a priority measure.
• The provider outreach and Cervical Cancer Incentive Program that rewarded top performing clinics and medical groups with a staff lunch for completing cervical cancer screening outreach calls and improving screening rates. A barrier to the success of this activity was low provider participation. Only 25% (6/24) of SFHP providers participated in the incentive program. SFHP has responded to this barrier by creating a new project to address cervical cancer rates, enhancing PIP incentive dollars for PIP participants who improve their rates during calendar year 2017. Seven PIP participants are enrolled in this project.
Although the target was not met, there was a 7.16% absolute improvement from baseline, indicating a significant improvement in performance. This measure will be included in the 2018 QI program, in alignment with SFHP’s HEDIS improvement priorities.
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3.3 Well Child Visits for Children Ages 3-6 Measure: Well Child Visits for Children Ages 3-6 Numerator 355 Baseline 82.18% Final Performance 82.18% Denominator 432 Target 85.18% Evaluation Year 2017
The Well Child Visits for Children Ages 3-6 years old is a measure in the Clinical Quality and Patient Safety Domain. SFHP members benefit from well child visits because these visits allow for early detection of childhood development diagnoses (e.g., vision, speech, and language) and preventive screenings (e.g., fluoride varnish, immunizations) while also providing parents with critical health education and anticipatory guidance. The target of 85.18% was set to achieve a 3% absolute improvement from baseline and was determined based on performance from the prior year.
One of the largest barriers to meeting the target is medical record data quality. Incomplete medical records could be attributed to missing documentation on the PM-160 form that is required for well-child visits, as well as PM-160 forms that are not being sent to SFHP or entered into the online system in time to be included in measure reporting. In anticipation of changes to the PM-160 form submission at the state-level, SFHP is working closely with state partners to monitor these changes and will make process improvements when those changes are announced.
There were no barriers to completing measure activities which included:
• The Well-Child Visit Member Incentive Program that offered a $25 gift card to members who brought their children to a well-child visit during the year. The SFHP member participation rate was 29% (2244/7637).
• Inclusion of Well-Child Visits as a PIP measure, with eight participants including the well-child visit measure as a priority measure.
• Data capture improvements to SFHP chart reviews to ensure abstractors exhausted all searches to find all well-child hits.
In 2015, the Well-Child Visit rate dropped. This year, the Well-Child Visits rate was sustained and remained in the 75th Medicaid Percentile.
This measure will not be included in the 2018 QI program in order to align improvement activities with other HEDIS priorities.
3.4 Postpartum Care Measure: Postpartum Care Numerator 306 Baseline 74.23% Final Performance 70.83% Denominator 422 Target 77.23% Evaluation Year 2017
The Postpartum Care measure is in the Clinical Quality and Patient Safety domain. SFHP members benefit from postpartum care visits because these visits include opportunities to help with continuation
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of breastfeeding, screen for postpartum depression, initiate family planning, and follow-up with pregnancy diagnoses such as gestational diabetes. The target of 77.23% was set to achieve a 3% absolute improvement from baseline, and was based on SFHP’s estimate of a reasonable improvement for a measure already reaching the Medicaid 90th percentile.
Barriers to reaching the target can be attributed to:
• Initial difficulty engaging the SFHP provider network due to postpartum care considered a low-priority measure by providers until it was included in PRIME.
• SFHP’s interpretation of new federal regulations limiting how members can be contacted on their cell phones.
The activities completed to support his measure included:
• The Postpartum Care Member Incentive Program offered a $25 gift card to members who received a postpartum checkup within the required visit time frame (21 to 56 days after delivery).
• Completion of DHCS Performance Improvement Program PDSAs, resulting in a steady improvement of the postpartum visit compliance rate for members assigned to Zuckerberg San Francisco General Hospital (ZSFG) and the San Francisco Health Network. The compliance rate increased from 57% in December 2015 to 63.78% in July 2017.
• Ongoing postpartum care disparities analysis and provider education regarding SFHP member incentive program.
Final performance of 70.83% did not meet the target. This measure will not be included in the 2018 QI program in order to align improvement activities with other HEDIS priorities.
3.5 Medication Therapy Management (MTM) (Plan Year 2016) Measure: Medication Therapy Management (MTM) Numerator N/A Baseline N/A Final Performance 0% Denominator N/A Target 30% Evaluation Year 2017 *This measure is from the 2016 QI Plan. It was not finalized at the time of the 2016 QI Evaluation and is now being included here.
The Medication Therapy Management (MTM) program impacts the domain of Clinical Quality and Patient Safety. Members who have multiple medication regimens and frequent transitions of care may encounter medication discrepancies identified through pharmacy claims and medical records. These discrepancies can lead to adverse patient outcomes, such as increased hospital admissions. The MTM program promotes the safe and appropriate use of medications for SFHP members by identifying medication discrepancies. The MTM program also provides members with drug information, such as common indications, side effects, and pill identification. Lastly, the MTM program provides access to Meducation®, which provides personalized medication instructions at a 5th to 8th grade reading level in 20 languages. Meducation® helps promote clear understanding of medication regimens and prevent member medication error.
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In order to implement the MTM program, SFHP needs to identify members that could potentially benefit from MTM. Among all members that could potentially benefit, the goal of the program is to target a subset of members with complex medication regimens. The measure definition is as follows:
Number of members enrolled in an MTM intervention
Number of members identified to potentially benefit from MTM intervention
The target for this measure is 30% of members eligible for the program to be enrolled in the intervention. The eligible population is members who interacted with SFHP’s Complex Medical Case Management program. The target was not met due to delays with developing a work flow into SFHP’s care management system. In particular, developing an interface with a medication database proved to be more complicated than expected. Another barrier was California’s Health Homes program implementation was delayed, making MTM less of an organizational priority.
Despite not achieving the goal, many activities were completed which provided SFHP with initial infrastructure for the MTM program. Completed activities included program design, budget approval, and pharmacy staffing approval. Due to the barriers encountered, multiple activities were not completed such as development of reporting, system interfaces, tracking tool, and member enrollment.
SFHP recommends keeping the MTM program as a measure in 2017. SFHP recommends including additional activities such as documentation of MTM workflows and sustaining coordination of the program. While the measure parameters and target of 30% remain the same for 2017, SFHP has more assurance of measure completion and meeting target as aspects of the program are regulatory requirements for National Committee for Quality Assurance (NCQA) standard and reinstitution of the Health Homes program.
3.6 Pain Management/ Opioid Safety Measure: Pain Management-Opioid Safety Numerator 11,655 Baseline 10.01% Final Performance 8.28% Denominator 140,678 Target 7.75% Evaluation Year 2017
The Pain Management – Opioid Safety measure impacts the Clinical Quality and Patient Safety domain. It impacts SFHP members by helping to monitor patterns and trends of opiate prescriptions to determine if the steps taken to address chronic opiate use and dependence are effective. The Pain Management Program’s aim is to maintain the % of members receiving at least one opiate agonist prescription at 7.75% or less. The target was based on historical trends and 2016 baseline data. However, baseline had been incorrectly calculated at 7.71%. Actual 2016 baseline was 10.01%. Target of 7.75% was not met; however, there was a 17% relative improvement over baseline.
Barriers to meeting the target included some challenges in obtaining timely reporting via our Pharmacy Benefit Manager (PBM). As part of continued improvement, the data reporting has been brought in-house and we are able to monitor/trend more frequently.
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The following activities were completed:
• Continued outreach and provider education through PIP, SF Safety Net Pain Management Workgroup, and updated website resources.
• Promoted non-narcotic alternatives for pain management, including acupuncture, cognitive behavioral therapy for those on chronic opiates.
• Coordinated opiate prescribing practices across settings such as ED, Inpatient, and Prison.
SFHP recommends continuing this measure with updates to activities. The target will continue to be 7.75% based on the 2017 baseline of 8.28% and historical trends. Activities to support this measure include:
• Addition of chiropractic benefit for members. • Continue outreach and provider education through PIP, SF Safety Net Pain
Management Workgroup, and updated website resources. • Promote non-narcotic alternatives for pain management, including acupuncture,
cognitive behavioral therapy for those on chronic opiates.
4. Care Coordination and Services
(These measures are not yet finalized and will be reported in the 2018 QI Evaluation.)
5. Utilization Management
5.1 Pharmacy Prior Authorization (PA) Turn Around Time (TAT) (Plan Year 2016) Measure: Pharmacy Prior Authorization (PA) Turn Around Time (TAT) Numerator 7,010 Baseline N/A Final Performance 99% Denominator 7,051 Target 90% Evaluation Year 2017 *This measure is from the 2016 QI Plan. It was not finalized at the time of the 2016 QI Evaluation and is now being included here.
The pharmacy prior authorization (PA) turn-around time measure impacts the Utilization Management domain. Timeliness of pharmacy utilization management decisions ensure members have timely access to approved medications or therapeutic alternatives. This measure demonstrates SFHP’s commitment to two of SFHP’s strategic anchors: exemplary service and quality care & access.
The PA turnaround time measure includes all pharmacy PA requests received for SFHP Medi-Cal and Healthy Kids members in 2016. Of those PA requests, the target was 90% meeting the 24-hour turnaround time. The measure target is in line with regulations set by the Department of Managed
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Health Care (DMHC) and the Department of Health Care Services (DHCS). In 2016, 99% of PA requests met their turnaround time frames. SFHP experienced a barrier in increasing the rate of this measure above 99% due to the limits of the software used to track PA turnaround times. For pharmacy PAs that require additional clinical information to make a decision, SFHP sends a Request for Information to the provider. The PA software used to track turnaround times could not indicate when a PA included a Request for Information. As a result, these were reported as noncompliant.
To reach the target, SFHP conducted the planned activities of monitoring of PA turnaround time, analysis of PA turnaround time reports, and a lessons learned summary for PAs with non-compliant turnaround times. In addition, SFHP modified its formulary to require less PA overall, thus decreasing the total volume of PAs for SFHP staff.
SFHP recommends that this measure be discontinued in order to incorporate a measure that more closely relates to member quality of care. Monitoring to ensure 24-hour turnaround time will continue through daily operations of SFHP’s Pharmacy Department to maintain compliance with DHCS regulations and NCQA standards.
5.2 UM Coordinator UM File Audits (Plan Year 2016) Measure: UM Coordinator UM File Audits Numerator 846 Baseline 90% Final Performance 92% Denominator 920 Target 90% Evaluation Year 2017 *This measure is from the 2016 QI Plan. It was not finalized at the time of the 2016 QI Evaluation and is now being included here.
The UM Coordinator UM File Audits impacts the Utilization Management domain. The measure is important to SFHP because it represents the authorization coordinators’ quality of work in SFHP’s Care Management System. A high level of quality has a positive effect on the amount of time it takes a clinician or Medical Director to review cases; making response times faster for providers and members. An additional benefit of accurate authorization entry is faster claim payment, which increases provider satisfaction.
The audit methodology was implemented using a standard audit tool and selecting five random cases per month per UM Coordinator. The compliance rate was calculated by taking the average of all accurate factors divided by all potential factors. The 90% target was determined by increasing the previous year’s target by 5%. Both authorizations for in-patient concurrent review and out-patient prior authorizations were included.
The following activities were completed:
• A new audit tool was created to streamline the process by focusing on critical elements of authorization entry.
• The UM Coordinators were notified and trained on the key sections where improvement was needed.
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SFHP recommends that this measure be discontinued due to consistently meeting the target. SFHP will continue the practice of auditing the UM Coordinators as a part of normal operations and oversight.
5.3 Interrater Reliability (Plan Year 2016) Measure: Interrater Reliability Numerator 26 Baseline 95% Final Performance 100% Denominator 26 Target 95% Evaluation Year 2017 *This measure is from the 2016 QI Plan. It was not finalized at the time of the 2016 QI Evaluation and is now being included here.
The Interrater Reliability measure impacts the Utilization Management domain. This measure represents the quality, consistency, and accuracy of medical necessity reviews for requested services against nationally accepted medical criteria. A high Interrater Reliability score indicates an understanding of application of criteria and clinical knowledge. This measure ensures SFHP staff are making consistent decisions regarding medically-appropriate care, thereby ensuring consistency of service for both SFHP members and providers.
Interrater Reliability utilizes a standardized multiple choice and scenario-based assessment. Nurses and Physicians are provided with clinical information and apply medical necessity criteria to respond to the assessment correctly. The target of 95% is 5% higher than the previous year.
The following activities were completed:
• Monthly InterQual trainings were conducted by internal staff where cases were presented and discussed. Criteria-related questions were escalated to the vendor. InterQual is the system that SFHP uses to make evidence-based utilization management decisions.
• The Interrater Reliability assessment was distributed in December 2016 and all Medical Directors and nurses exceeded the target.
The recommendation is to discontinue the measure in 2017. Clinical Operations will continue the practice of performing Interrater Reliability as a part of ongoing operations to maintain compliance with DHCS regulations and NCQA standards.
5.4 UM Timeliness of Decision and Notification (Plan Year 2016) Measure: UM Timeliness of Decision and Notification Numerator 46,992 Baseline 90% Final Performance 96% Denominator 49,053 Target 90% Evaluation Year 2017 *This measure is from the 2016 QI Plan. It was not finalized at the time of the 2016 QI Evaluation and is now being included here.
The UM Timeliness of Decision and Notification measure impacts the Utilization Management domain. This measure represents the decision making timeframes made by SFHP’s nurses and physicians on medical authorization requests. NCQA, DHCS, and DMHC require that authorization requests be
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reviewed timely to ensure needed care is provided quickly. Meeting this quality measure provides both the members and providers with a quick response, ensuring that the authorization process has minimal impact on providers and members.
This measure calculates the percentage of authorizations that meet compliance turnaround-times divided by the total authorizations requested. There were no barriers to meeting the target.
The following activities were completed:
• Trained staff on new turnaround time requirements. • Updated care management system to identify authorizations at risk of non-compliance. • Developed reports to track and trend turnaround times.
SFHP recommends that this measure be discontinued. SFHP will continue the practice of monitoring turnaround times as a part of ongoing operations and compliance with DHCS and DMHC regulations, as well as NCQA standards.
5.5 Non-Specialty Mental Health Penetration Rate (Plan Year 2016) Measure: Non-Specialty Mental Health Penetration Rate Numerator 2,552 Baseline 0.55% Final Performance 2.24% Denominator 113,929 Target 3% Evaluation Year 2017 *This measure is from the 2016 QI Plan. It was not finalized at the time of the 2016 QI Evaluation and is now being included here.
The Non-Specialty Mental Health (NSMH) Penetration Rate impacts the Utilization Management domain. Increasing the rate of non-specialty mental health utilization reflects improved access for members with behavioral health conditions who do not consistently seek treatment. This measure reflects continued emphasis on enhancing member and provider awareness of the availability of behavioral health services. The NSMH Penetration Rate is the total number of SFHP members with at least one visit with a behavioral health provider out of the total number of eligible SFHP members. In 2016, the NSMH penetration rate across the Medi-Cal Plans that Beacon Health Options (SFHP’s behavioral health vendor), works with ranged from 1.2% to 6.2%. SFHP has set a target of 3%.
Data was based on claims paid by Beacon Health Options. The target was based on benchmark data from other Medi-Cal Health Plans. Performance increased dramatically from 2015 (approximately 300% relative improvement). Despite the improvement, the target of 3% was not met. Barriers included:
• Lack of consistent member and provider awareness of the benefit • Contracted providers are not consistently available • Referred members did not make appointments • Limited behavioral health clinicians who speak Chinese • High relative utilization of SF County’s specialty mental health services
The following activities were completed:
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• Added telemedicine behavioral health vendors to NSMH network. • Increased rates for psychiatrists, when needed, to enhance network participation. • Increased rate of NSMH claims submitted by Community Behavioral Health Services
(CBHS). • Revised Beacon contract to include performance incentives, including call center service
metrics and -penetration rate improvement.
For 2017, SFHP increased the target to 3.5% for adults and 1.6% for children (0-21 years of age). Activities include the expansion of tele-behavioral health, a pay-for-performance depression screening measure, and continued promotion of benefit to members.
5.6 Non-Specialty Mental Health Penetration Rate Measure: Non-Specialty Mental Health Penetration Rate Numerator 2,614 Baseline 1.28% Final Performance 3.22% Denominator 81,281 Target 3.5% Evaluation Year 2017
The Non-Specialty Mental Health (NSMH) Penetration Rate impacts the Utilization Management domain. Increasing the rate of non-specialty mental health utilization reflects improved access for members with behavioral health conditions who do not consistently seek treatment. This measure reflects continued emphasis on enhancing member and provider awareness of the availability of behavioral health services. The NSMH Penetration Rate is the total number of SFHP adult members with at least one visit with a behavioral health provider out of the total number of eligible SFHP members. SFHP has set a target of 3.5%.
Data was based on claims paid by Beacon Health Options. The target was based on benchmark data from other Medi-Cal Health Plans. Performance increased from fiscal year 2015-2016 (approximately 150% relative improvement). Despite the improvement, the target of 3.5% was not met. Barriers included:
• Lack of consistent provider awareness of the benefit. • Contracted providers are not consistently available. • High relative utilization of SF County’s specialty mental health services.
The following activities were completed:
• Added telemedicine behavioral health vendors to NSMH network. • Revised Beacon contract to include performance incentives, including penetration rate
improvement. • Added depression screening as a measure to SFHP’s pay-for-performance program. • Promoted NSMH benefit to members through the member newsletter and to providers
through the provider newsletter.
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• Created a NSMH dashboard, which includes NSMH penetration by provider group. Access to Care Committee reviews dashboard quarterly to recommend interventions and activities.
For 2018, SFHP will increase the target to 4.5% for adults. Activities will include the expansion of tele-behavioral health, continuation of the pay-for-performance depression screening measure, a new pay-for-performance measure incentivizing providers to follow-up with members, continued promotion of benefit to members, and enhanced provider education about the benefit and how to refer members.
6. Delegation Oversight
6.1 Delegation Oversight (Plan Year 2016) *This measure is from the 2016 QI Plan. It was not finalized at the time of the 2016 QI Evaluation and is now being included here.
SFHP delegates case management, credentialing, quality improvement activities, and utilization management to delegated medical groups in the network. Delegation activities are regulatory requirements of the Department of Health Care Services, the Department of Managed Health Care, and the National Committee for Quality Assurance.
To assess adherence to delegated activities, SFHP reviews policies, procedures, and case files, then aggregates the results for each delegated function by delegated medical group. The audit is conducted annually for each medical group. The annual audit provides information on trends of non-compliance and areas that require improvement within the medical group.
The target for each delegation audit is 95%. The results represent the average of across medical group audit results. Barriers to reaching this target included one medical group being audited for the first time, and another group changing its core operations, making them non-compliant for all delegated activities.
Delegation Activity 2015 Average Audit Results
2016 Target 2016 Average Audit Results
Status
Case Management 86% 95% 76% Target Not Met Credentialing 70% 95% 91% Target Not Met Quality Improvement 72% 95% 81% Target Not Met Utilization Management 94% 95% 88% Target Not Met
All planned activities were completed as expected, as well as communications to the delegated groups before the audit about the requirements for delegated activities. Planned activities included: annual audits of all delegated groups, technical assistance to groups that were low performing in 2015, and requests of corrective action plans for groups that did not meet delegation requirements.
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SFHP recommends changing the measurement methodology. Instead of reviewing an average of the final audit score, the 2017 measure will score the number of delegated groups with a passing audit score among all delegated groups.
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Appendix I: 2017 Quality Improvement Work Plan
i. Clinical Quality and Patient Safety
1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
A Continued from 2016
Pain Management
SFHP Pain Management
Program’s aim is to maintain the % of
members with at least one opiate agonist
prescription at 7.75% or less (across all lines of business, annually).
7.75% PM, Health Improveme
nt
• Provider and staff trainings • PIP measure monitoring (includes part B CURES completion) • Technical Assistance • Alternative Treatment Options
6/30/17 Completed
B. Continued from 2016
Flu Vaccine Utilization
Increase in the rate of member flu
vaccinations, measured by
cumulative rate from previous seasonal period (July - June)
20%
Care Coordinatio
n Pharmacist
• Explore providing member incentives to receiving flu vaccines and promoting flu vaccines in case management and discharge populations • Issues with claims data analysis was rectified and a process to analyze flu vaccine data should be documented • Informational materials informing members regarding the benefits of flu vaccines can help with flu vaccine stigma
Q3 2017
In progress (to be
included in 2018
Evaluation)
C. Continued from 2016
Initial Health Assessment
Rate
Improve member engagement with primary care by
increasing the IHA compliance rate
25% Grievance Analyst
• Validate the methodology by the end of 2017 • Provide IHA completion rates each quarter • Send new member
6/30/17 Completed
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1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
summary to clinics and medical groups on a quarterly basis
D. Continued from 2016
Medication Therapy
Management
Increase the number of members mapped to an MTM program
intervention
30% Director, Pharmacy
• 1st quarter - program design and budget submitted • 2nd quarter - contracting, claim system and reporting developed • 3rd quarter - implement tracking tool • 4th quarter - member enrollment
Q3 2017
In progress (to be
included in 2018
Evaluation)
E. New 2017 Measure
Cervical Cancer
Screening
Improve cervical cancer screenings for
eligible population 71.56%
PM, Population
Health
• Continue member and provider outreach and incentive program (by 12/31/16) • Continue inclusion as a PIP measure (ongoing)
6/1/2017 Completed
F. New 2017 Measure
Postpartum Care
Improve postpartum care for eligible
population 77.23%
PM, Population
Health
• Continue member outreach and incentive program (ongoing) • Completion of DHCS Performance Improvement Program PDSAs (6/30/17) • Ongoing disparities analysis and provider education (by 06/30/17)
6/1/2017 Completed
G. New 2017 Measure
Well Child Visits for Children
Improve well child visits for children ages
3-6 for eligible 85.18%
Lead HEDIS RN,
Population
• Continue member outreach and incentive program (ongoing)
6/1/2017 Completed
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1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
Ages 3-6 population Health • Continue inclusion as a PIP measure (ongoing) • Data capture improvements (ongoing) • Analysis of data to rule out confounding variables (by 06/01/17)
ii. Quality of Service and Access to Care
1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
A. Continued from 2016
Getting Care Quickly
Rating (HP-CAHPS)
Increase the rate of members who report they get care quickly
68% PM,
Member Experience
• Inclusion of CG-CAHPS Access Composite in Pay for Performance program (PIP)- January 2017 • Strategic Reserves Grants and technical assistance- June 2018 • Implementation of Teladoc- June 2017 • Interview high-performing health plans to determine strategies for improvement- July 2017
7/1/2017 Completed
B. Continued from 2016
Getting Needed Care Rating (HP-
CAHPS)
Increase the rate of members who report they get needed care
68.4% PM,
Member Experience
• Continuation of Specialist question in Clinical Practice Group’s PIP – July 2017 • Strategic Reserves Grants and technical assistance- June 2018
7/1/2017 Completed
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1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
• Implementation of Teladoc – June 2017 • Interview high-performing health plans to determine strategies for improvement- July 2017
C. Continued from 2016
Member Grievances and Appeals
Increase the rate of member grievances
and appeals resolved in a timely manner
100% Grievance Analyst
• Grievance Review Committee will review grievances 2 times a week • Grievance Oversight Committee will review trends and quarterly grievance reports each month
7/1/2018 Completed
D. Continued from 2016
Provider Satisfaction
Statistically increase the rate of provider
satisfaction based on 3 provider survey
questions
Statistically-significant increase at
95% confidence
interval, OR 90th national Medicaid percentile
Supervisor, Provider Network
Operations
• Analysis of results from the 2016 survey is underway, and Provider Relations will work with the rest of SFHP to address any findings. • The Provider Relations department will continue to monitor and improve services metrics including phone answer time, inquiry response time, and newsletter schedule adherence • In-person provider visits to all medium and large volume sites in the winter holiday season • Provider Update newsletter
6/30/2017 Completed
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1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
to maintain open communication to all known provider contacts.
E. Continued from 2016
Rating of Health Plan (HP-CAHPS)
Increase the rate of members who rate
the health plan highly 69.82%
PM, Member
Experience
• Offer trainings by the Studer Group about two evidence based practices known to improve performance in patient experience: AIDET & Rounding- to be completed by June 2017 • Offer trainings about service recovery to the network to enhance patient perception of the health care system- to be completed by June 2017 • Continuation of the DHCS Performance Improvement Project with Customer Service- to be completed by June 2017
7/1/2017 Completed
F. Continued from 2016
Cultural and Linguistic Services
Increase number of providers who pass linguistic services
portion of the Provider Time to Answer Survey
80% PM,
Population Health
• Provider and member education about linguistic services requirements via member newsletter, provider updates, SFHP’s website, and Group Needs Assessment (GNA) results presentations by December 31, 2017 • Issue a Corrective Action
Q1 2018
In progress (to be
included in 2018
Evaluation)
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1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
Plan (CAP) to any provider group that does not pass the linguistic services portion of the January 2017 survey by June 30, 2017
G. New 2017 Measure
Potential Quality
Issues (PQI)
Increase the rate of PQIs resolved in a
timely manner 93%
Quality Review Nurse, Clinical
Operations
• Provide PQI training to Health Services staff by March 2017 • Implement PQI and Decline-to-File grievances in Essette by March 2017 • Implement quarterly reporting of PQI TAT by January 2017 • Mitigate barriers by contacting providers and escalating to CMO to supply needed clinical information
7/1/2017 Completed
iii. Utilization Management
1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
A. Continued from 2016
Behavioral Health
Penetration Rate
Increase the rate of NSMH utilization as
seen through Beacon claims
3.5% Chief
Medical Officer
• Expand tele-behavioral health • P4P Depression screening measure • Promote benefit to members • Follow-up with members after referral
6/30/2017 Completed
B. New 2017 Pharmacy Decrease the rate of 10% Supervisor, • Report development to Q1 2018 In progress
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1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
Measure Point of Service Claim
Rejection Rate
Pharmacy POS claims rejected
Pharmacy Operations
identify the specific drugs and drug classes that are most responsible for POS rejections. • Determining what is causing those rejections (Quantity Limits, Step Therapy, medical necessity, etc.) • Making changes to the drug formulary through the Pharmacy & Therapeutics committee. • Reassess the first two bullet points along with the overall measure to determine whether changes made to the formulary and prior authorization criteria are affecting a change in the rejection rate.
(to be included in
2018 Evaluation)
iv. Care Coordination and Services for Members with Complex Health Needs
1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
A. Continued from 2016
Complex Medical Case Management Client Satisfaction
Increase the rate of CMCM satisfaction 80%
Manager, Complex Medical Case Management
• Identify ways to increase the total number of Client Satisfaction surveys returned • Identify ways to increase the overall return rate of the Client Satisfaction surveys
Q1 2018
In progress (to be
included in 2018
Evaluation)
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1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
B. Continued from 2016
All Cause Readmissions
Reduce the rate of all cause readmissions
for CHN OOMG admissions.
14.43% Manager, Concurrent Review
• Completion of discharge assessment • D/C Summaries sent to PCP • PCP or Specialist follow-up appointments • Follow up phone calls to members post discharge (TBD) • Onsite discharge planning (TBD)
Q1 2018
In progress (to be
included in 2018
Evaluation)
C. New 2017 Measure
Screening for Clinical Depression and Follow Up
Increase the percentage of clients
in SFHP's CM programs successfully screened for clinical
depression including a follow-up plan documented if
positive
70%
Manager, Complex Medical Case Management
• A report/process will need to be developed to capture PHQ-2 screenings and care plan goals currently part of the Care Management Interview tool. • Conduct analysis of depression screening results and corresponding care plan documentation
Q1 2018
In progress (to be
included in 2018
Evaluation)
v. Delegation Oversight
1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
A Continued from 2016
Delegation of CM
Activities
Measure compliance with delegated CM
activities 95%
Manager, Delegation Oversight
• SFHP Audit Team Training regarding audit process by May 2017 • Review of Audit Tools and Audit Process by May 2017 • Quarterly SFHP staff training regarding delegation and oversight (Mar, Jun, Sep, Dec
Q1 2018
In progress (to be
included in 2018
Evaluation)
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1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
2017) • Medical groups training regarding Medi-Cal requirements; Jun 2016 – Dec 2017
B Continued from 2016
Delegation of
Credentialing
Activities
Measure compliance with delegated Credentialing
activities
95% Manager, Delegation Oversight
• SFHP Audit Team Training regarding audit process by May 2017 • Review of Audit Tools and Audit Process by May 2017 • Quarterly SFHP staff training regarding delegation and oversight (Mar, Jun, Sep, Dec 2017) • Provide Medical groups with communication regarding DHCS guidelines regarding CMS Mega Regulations for Provider Credentialing. Timeline TBD.
Q1 2018
In progress (to be
included in 2018
Evaluation)
C Continued from 2016
Delegation of QI
Activities
Measure compliance with delegated QI
activities 95%
Manager, Delegation Oversight
• SFHP Audit Team Training regarding audit process by May 2017 • Review of Audit Tools and Audit Process by May 2017 • Quarterly SFHP staff training regarding delegation and oversight (Mar, Jun, Sep, Dec 2017) • Provide Medical groups with
Q1 2018
In progress (to be
included in 2018
Evaluation)
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1. New Measure?
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
communication regarding DHCS guidelines regarding CMS Mega Regulations for Provider Credentialing. Timeline TBD.
D Continued from 2016
Delegation of UM
Activities
Measure compliance with delegated UM
activities 95%
Manager, Delegation Oversight
• SFHP Audit Team Training regarding audit process by May 2017 • Review of Audit Tools and Audit Process by May 2017 • Quarterly SFHP staff training regarding delegation and oversight (Mar, Jun, Sep, Dec 2017) • Provide Medical groups with communication regarding DHCS guidelines regarding CMS Mega Regulations for Provider Credentialing. Timeline TBD.
Q1 2018
In progress (to be
included in 2018
Evaluation)
E New for 2017
UM Delegation Improveme
nts
Implement new NOA across all medical
groups 100%
Clinical Outreach
Nurse, Clinical
Operations
• Provide the delegated medical groups with a new, compliant Notice of Action • Feedback to medical groups via 2016 UM audit • Biannual NOA denial file review • Check-in of progress during Joint Administrative Meetings
Q1 2018
In progress (to be
included in 2018
Evaluation)
2017 SFHP QI Program Description
50 Beale St. 12
th floor
San Francisco, CA 94105 www.sfhp.org
San Francisco Health Plan
2018 Quality Improvement Program
Page 2 of 46
Contents 1. Introduction ................................................................................................................ 3
2. QI Program Purpose, Scope and Goals .................................................................. 6
3. QI Program Structure ............................................................................................... 7
A. Quality Committees...................................................................................................................................... 7
B. Committees with Internal Membership Only ............................................................................................... 9
C. Quality Improvement Communications ..................................................................................................... 11
D. Quality Improvement Staff......................................................................................................................... 11
4. Quality Improvement Method and Data Sources ................................................... 19
A. Identification of Important Aspects of Care ............................................................................................... 19
B. Data Systems and Sources.......................................................................................................................... 19
C. Policies and Procedures .............................................................................................................................. 21
5. QI Program Evaluation............................................................................................... 21
A. QI Work Plan ............................................................................................................................................. 22
6. QI Activities............................................................................................................... 22
A. Clinical Quality and Patient Safety ............................................................................................................ 22
B. Quality of Service and Access to Care ....................................................................................................... 25
C. Utilization Management ............................................................................................................................. 29
D. Care Management ...................................................................................................................................... 30
E. Delegation Oversight.................................................................................................................................. 32
Appendix A: Work Plan .................................................................................................. 36
Appendix B: Quality Improvement Committee Structure ........................................ 43
Page 3 of 46
1. Introduction
San Francisco Health Plan (SFHP) is a community health plan that provides affordable health care coverage to 148,933 low- and moderate-income individuals and families as of July 2017. Members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription medicines, behavioral health and family planning services. SFHP was designed by and for
the residents it serves and takes great pride in its ability to accommodate a diverse population that includes children, young adults, seniors, and persons with disabilities (SPD). SFHP is a unique public-private partnership as established by the San Francisco Health Authority, as a public agency distinct from the county and city governments. A nineteen-member Governing Board directs SFHP. The Governing Board includes physicians and other health care providers, members, health and government officials, and labor representatives. The Board is responsible for the overall direction of SFHP, including its Quality Improvement Program. The Governing Board meetings are open for public
participation. SFHP’s products include Medi-Cal, Healthy Kids, Healthy Workers, Healthy San Francisco and City Option programs.
Medi-Cal
Medi-Cal is California’s Medicaid program, which is a federal and state-funded public health insurance program for low-income individuals. As a managed care plan, SFHP manages the funding and delivery of health services for Medi-Cal members. As of July 2017 SFHP retained 87.04% (136,427 members) of the managed care market share in San Francisco County.
Healthy Kids
Healthy Kids is a health insurance program funded by the City and County of San Francisco and administered by SFHP to eligible children in San Francisco through eighteen years of age. The program provides medical, dental, behavioral health and vision coverage for children in San Francisco who are ineligible for other publicly funded health coverage programs and who are uninsured. As of July 2017, 1,337 members are enrolled in this program.
Healthy Workers Healthy Workers is a health insurance program offered to providers of In-Home Support Services or temporary exempt employees of the City and County of San Francisco. As of July 2017,
11,215 members are enrolled in this program.
Healthy San Francisco and City Option SFHP is the Third Party Administrator for the Healthy San Francisco and SF City Option programs. Healthy San Francisco is a health access program for uninsured adults in San Francisco with 13,472 participants as of July 2017. The SF City Option program is an option for employers
in San Francisco to comply with the Health Care Security Ordinance (HCSO) and provides employees with access to one of three benefits based on their program eligibility: Healthy San Francisco, SF MRA (Medical Reimbursement Account) or SF Covered MRA.
Page 4 of 46
67,000
68,000
69,000
70,000
71,000
72,000
73,000
74,000
75,000
76,000
77,000
78,000
Female Male
Membership by Gender
2016 Total
2017 Total
-
20,000
40,000
60,000
80,000
100,000
120,000
0-18 19-65 66+
Membership by Age Group
2016 Total
2017 Total
Page 5 of 46
0
10,000
20,000
30,000
40,000
50,000
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Page 6 of 46
2. QI Program Purpose, Scope and Goals
SFHP is committed to continuous quality improvement for both the health plan and its health care delivery system. The purpose of the SFHP Quality Improvement (QI) Program is to establish comprehensive methods for systematically monitoring, evaluating, and improving the quality of the care and services provided to San Francisco Health Plan members. The QI Program is designed to ensure that
members have access to quality health care services that are safe, effective, accessible, equitable and meet their unique needs and expectations. Delivery of these services must be in a culturally competent manner to all beneficiaries, including those with limited English proficiency, diverse cultural and ethnic backgrounds, disabilities, and regardless of gender, sexual orientation, or gender identity. SFHP contracts with health care providers, including medical groups, clinics, independent physicians and their associated hospitals, ancillary providers, behavioral health clinicians, and pharmacies to provide medical care. SFHP maintains responsibility for communicating regulatory and contractual requirements,
and policies and procedures to participating network providers. SFHP retains full responsibility for its Quality Improvement Program, and does not delegate quality improvement oversight. In certain instances, SFHP may delegate some or all QI functions to accredited provider organizations. Under the leadership of SFHP’s Governing Board, the Quality Improvement Program is developed and implemented through the Quality Improvement Committee (QIC). The QIC structure, under the leadership of the SFHP Chief Medical Officer, assures ongoing and systematic collaboration between
SFHP and its key stakeholders: members, medical groups, and practitioners. The QI Program objectives and outcomes detailed in the QI Work Plan (Appendix A). Each program objective is monitored at least quarterly and evaluated at the end of each year. Measures and targets are selected based on volume, opportunities for improvement, risk, organizational priorities, and evidence of disparities.
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Page 7 of 46
The scope and goals of the QI Program are comprehensive and encompasses major aspects of care and services in the SFHP delivery system, and the clinical and non-clinical issues that affect its membership. These include:
Improving the health status of our members
Ensuring continuity and coordination of care
Assuring access and availability of care and services
Ensuring member knowledge of rights and responsibilities
Providing culturally and linguistically appropriate services
Assuring that health care practitioners are appropriately credentialed and re-credentialed
Ensuring timely communication of DHCS standards and requirements to participating medical
groups and organizational providers
Assuring effective and appropriate utilization management of health care services, including medical,
pharmaceutical, and behavioral health care services
Providing complex case management
Providing a disease management program
Providing health education resources
Ensuring patient safety in all healthcare settings
Ensuring excellent member experience of care
Assuring that responsibilities delegated to medical groups meet plan standards
Evaluating the overall effectiveness of the QI Program through an annual, comprehensive program
evaluation
Use of the annual evaluation to update the QI Program and develop an annual QI Work Plan
3. QI Program Structure
The following section describes the Quality Improvement Committees of SFHP. Appendix B includes details on committee membership. The Quality Committees listed below under section A report either to the Quality Improvement Committee (QIC) or the Governing Board. The Committees with Internal Membership Only listed under section B report either to the Chief Medical Officer (CMO) or the Officer of Compliance and Regulatory Affairs (CCO), which in turn provide updates to the QIC or the Governing
Board through minutes or representation as appropriate.
A. Quality Committees
Please refer to Appendix B for reporting diagram and committee membership. Policies and procedures that govern SFHP Quality Committees are included in Appendix C.
i. The Quality Improvement Committee
The SFHP Quality Improvement Committee (QIC) is comprised of network clinicians (physicians, behavioral health, pharmacists) and two members of the Member Advisory Committee. QIC is chaired by SFHP’s CMO. The QIC is a standing committee of the San Francisco Health Authority Governing Board that meets six times a year. It is the main forum for member and provider oversight, assuring the quality of the healthcare delivery system. The committee is responsible for reviewing and approving the annual QI Program and QI Evaluation, and for providing oversight of the Plan’s quality improvement
activities. SFHP brings new quality improvement programs to the QIC to ensure the committee members provide input into program planning, design, and implementation. SFHP maintains an annual calendar to ensure that key SFHP QI activities are brought to the QIC for ongoing review. This includes review and
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approval of policies and procedures related to quality improvement, utilization management, and delegation oversight. SFHP maintains minutes of each QIC meeting, submits them to the Governing Board for review and approval, and submits these to DHCS on a quarterly basis. The QIC meetings are open to the public and agendas and minutes are published on SFHP’s website.
ii. The Pharmacy and Therapeutics Committee
The Pharmacy and Therapeutics (P&T) Committee is comprised of network physicians and pharmacists along with the Pharmacy Director and chaired by SFHP’s CMO. The P&T Committee convenes at least quarterly to review, evaluate, and approve the SFHP Formulary revisions based on safety, comparable efficacy and cost and to adopt pharmaceutical management procedures including prior authorization criteria, quantity limits, and step therapy protocol for covered outpatient prescription medications. The P&T Committee is responsible for pharmaceutical and therapeutic treatment guidelines and an annual approval of the pharmacy clinical policies and procedures for formulary, prior authorization, monitoring
of utilization rates and timeliness of reviews, and drug utilization review (DUR) processes. The committee meets quarterly and on an ad hoc basis, and meetings are open to the public. The P&T Committee reports to the QIC.
iii. The Physician Advisory/Peer Review/Credentialing Committee
The Physician Advisory/Peer Review/Credentialing Committee (PAC) provides comments and recommendations to SFHP on standards of care and peer review. PAC is chaired by SFHP’s CMO and consists of providers in SFHP’s network. The PAC serves to review and provide recommendations
regarding substantive quality of care concerns, in particular those related to credentialed provider performance. The Sanctions Monitoring Report is reviewed by SFHP monthly to ensure that any identified providers with investigations or actions are brought to the PAC for review, including confirmed Potential Quality Incidents (PQIs) and Facility Site Reviews (FSRs). The PAC also reviews credentials and approves practitioners for participation in the SFHP network. as appropriate. The PAC meets every two months and reports to the QIC in closed session.
iv. The Member Advisory Committee
The Member Advisory Committee (MAC) serves as the Public Policy Committee of SFHP as defined and required by the Knox-Keene Act. The MAC advises the Plan on issues of concern to the recipients of services from SFHP. The committee is made up of health plan members and health care advocates. In this forum, members can voice concerns and give advice about what health services we offer, and how we deliver services to members. It consists of at least ten (10) to no more than thirty (30) members and is led by an SFHP member. The Committee meets monthly and reports to the Governing Board.
v. The Practice Improvement Program (PIP) Advisory Committee
The Practice Improvement Program (PIP) Advisory Committee provides guidance to SFHP on pay-for-
performance program development, implementation, and evaluation. Committee members review prior and current year PIP network performance, identify and predict barriers to success for participants, and problem-solve solutions. Membership is made up of representatives from all PIP participating organizations. Meetings are held at least four times a year.
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B. Committees with Internal Membership Only
i. The Policy and Compliance Committee
The Policy and Compliance Committee (PCC) is comprised of SFHP staff and led by SFHP’s Compliance and Regulatory Affairs Officer. The PCC reviews and approves all new policies and procedures and changes to existing policies and procedures. Policies and procedures with clinical implications must be approved by QIC before review by the PCC. The PCC also communicates
regulatory updates and compliance issues to SFHP management. The PCC meets at least 10 times per year, and is chaired by the Officer of Compliance and Regulatory Affairs, or designee. Members include representatives from Health Services, Operations, Finance, Information Technology Services, Human Resources, and Marketing. PCC members: o Compliance and Regulatory Affairs Officer (Chair) o Compliance and Regulatory Affairs Specialist o Regulatory Affairs Program Manager o Compliance Program Manager
o Manager, Delegation Oversight and Credentialing o Director of Accounting, Finance o Director of Systems Development Infrastructure o Senior Human Resource Business Partner o Medical Policy Administrator o Director of Claims and Customer Service Operations o Director of Pharmacy
o Senior Project Manager, Enterprise Project Management o Quality Management Analyst o Facilities Manager o Manager, Continuous Improvement o Senior Business Analyst
ii. The Provider Network Oversight Committee
The Provider Network Oversight Committee (PNOC) is comprised of SFHP staff and led by SFHP’s
Provider Network Operations Director. The PNOC provides a forum for evaluating providers’ compliance with DHCS, DMHC, and NCQA requirements. This committee identifies issues and addresses concerns related to provider performance of their administrative responsibilities. The committee is responsible for making penalty recommendations when providers do not meet performance standards according to federal and state requirements. The Provider Network Oversight Committee is chaired by the Manager of Delegation Oversight and Credentialing, and is composed of members from the following departments: Compliance and Regulatory Affairs, Operations, and Health Services. Occasional attendance may be required of staff members from the following units: Provider Network Operations, Claims, Customer
Service, Clinical Operations, Health Outcomes Improvement, Pharmacy, Information Technology Services, Finance, Compliance and Regulatory Affairs, and Business Intelligence. PNOC members: o Provider Network Operations Director (Chair) o Compliance and Regulatory Affairs Officer o Director, Clinical Operations o Manager, Delegation Oversight and Credentialing o Director, Health Outcomes Improvement
o Director of Pharmacy o Regulatory Affairs Program Manager
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iii. The Grievance Oversight Committee
The Grievance Oversight Committee (GOC) is an internal SFHP committee that serves as an escalation point for trends identified from member grievances. If a grievance trend is identified or there is a particularly harmful grievance, the committee will recommend a Corrective Action Plan (CAP) or a notification to the Medical Group. The CAP will be escalated to the Executive Team when the
deficiencies have not been corrected. The committee is multidisciplinary, composed of the Chief Medical Officer and representatives from Member Services, Provider Relations, Health Outcomes Improvement, Care Support, Pharmacy, Clinical Operations, and Compliance and Regulatory Affairs. The committee is scheduled on a monthly basis and reviews grievance trends and system issues, and reports to the QIC. The meeting is canceled if there are no grievance trends identified. GOC members: o Chief Medical Officer o Medical Director o Manager, Customer Service
o Supervisor, Provider Network Operations o Manager, Access and Care Experience o Director, Health Outcomes Improvement o Clinical Operations Director o Compliance and Regulatory Affairs Officer o Regulatory Affairs Program Manager o Grievance Staff
iv. The Grievance Review Committee
The Grievance Review Committee (GRC) reviews individual member grievances through a collaborative process to ensure that all the components of the grievances have been resolved. The committee is multidisciplinary, composed of the Chief Medical Officer, with representatives from Care Management, Member Services, Provider Relations, Health Outcomes Improvement, Behavioral Health, and Compliance and Regulatory Affairs. The committee meets twice weekly and reports to the Grievance Oversight Committee. GRC members:
o Chief Medical Officer o Medical Director o Customer Service Manager o Provider Network Operations, Account Manager o Manager, Access and Care Experience o Regulatory Affairs Program Manager o Grievance Staff o Program Manager, Care Experience
v. The Access to Care Committee
The Access to Care Committee enhances the monitoring and improvement activities for the accessibility and availability of health care services. The committee meets at least quarterly to monitor access data, determine meaningful measures of access, and evaluate the success of access improvement initiatives both within the plan and the network. The committee is cross functional and composed of representatives from Operations, Health Services, Compliance and Regulatory Affairs, and Business Intelligence. The committee reports to the QIC. Members include:
o Chief Medical Officer o Chief Operations Officer o Director, Health Outcomes Improvement o Senior Manager, Access and Care Experience o Supervisor, Regulatory Affairs Program
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o Supervisor, Provider Relations o Clinical Pharmacist o Manager, Delegation Oversight and Credentialing o Network Manager, Provider Relations
o Program Manager, Access and Care Experience o Business Intelligence Analyst
vi. The Clinical Oversight Committee
The Clinical Oversight Committee (COC) determines the clinical measures that SFHP prioritizes for the QI program year. The COC creates a prioritized measure set through analyzing performance rates, evaluating internal and external initiatives, and assessing potential clinical impact. The COC is chaired by the Director of Health Outcomes Improvement with representatives from Care Management, Pharmacy, and Health Outcomes Improvement. The COC meets at least four times per year and reports its
recommendations to the CMO and Health Services Leadership team (which consists of the CMO and the five department Directors).
vii. The Utilization Management Committee
The Utilization Management Committee (UMC) provides oversight to assure effective and compliant implementation of SFHP’s Utilization Management Program and to support compliance with requirements for SFHP policy, the Medi-Cal contract, NCQA, DHCS, and DMHC regulations. Discussions result in changes to medical policy and criteria, Prior Authorization rules, and/or UM Process enhancements. The UMC meets monthly and reports to the QIC. UMC members:
o Chief Medical Officer o Director, Clinical Operations o Medical Director o Senior Manager, Prior Authorization o Senior Manager, Concurrent Review o Manager, UM Authorizations o Program Manager, Utilization Management
o Director of Pharmacy
C. Quality Improvement Communications
SFHP informs both its members and providers of its QI program and ongoing QI activities. Members
receive information through the annual member mailing and the quarterly newsletter, Your Health Matters. Providers receive information electronically distributed monthly provider newsletter.
D. Quality Improvement Staff
The Health Services (HS) department has primary accountability for implementing the annual QI Program and corresponding QI Work Plan. The department is organized to provide inter-disciplinary
involvement in assuring the quality of medical care and services provided to SFHP’s membership. Health Services staff monitors quality indicators, and implements and evaluates the Plan’s quality improvement activities. Health Services’ staff develop and comply with policies and procedures describing SFHP standards, legislative and regulatory mandates, contractual obligations and, as applicable, NCQA standards. Based on the QI Work Plan activities, HS staff provides summary data, analysis, and recommendations to the QIC.
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i. Health Services Staffing Structure
The Health Services Staff that support the QI program are:
Chief Medical Officer – responsible for leading the Quality Improvement Committee, Physician
Advisory and Peer Review Committee, Credentialing Committee, and the Pharmacy and Therapeutics Committee, and for all quality improvement studies and activities. The CMO provides guidance and oversight for development of policies, programs, and projects that support all activities identified in the QI Program. The CMO carries out these responsibilities with support from direct reports, including Medical Director, and Directors of Health Outcomes Improvement, Pharmacy, Clinical Operations, and Care Management. In addition, the CMO is supported by the Officer of Compliance and Regulatory Affairs and the Director of Provider Network Operations.
o Beacon Health Options Staff – Beacon Health Options is delegated to provide non-specialty
mental health care to SFHP’s members. Beacon’s Quality Director presents annually on their QI plan and participates in QIC meetings as needed. Beacon’s on-site clinical staff participates in daily patient huddles to ensure coordination of care and escalate quality issues as needed.
Director, Health Outcomes Improvement – reports to the Chief Medical Officer, ensures the completion of annual QI Program (including work plan and evaluation), and directs the execution of QI activities identified in the QI Work Plan. The Director, Health Outcomes Improvement oversees teams focused on fostering quality for our members: Population Health, Access & Care Experience, and Health Services Business Relationships.
o Manager, Population Health – Reports to the Director, Health Outcomes Improvement, and oversees activities related to improvement and auditing of clinical HEDIS measures, health education & promotion programs, and pay-for-performance. Reporting to the Manager, Population Health, the following positions support SFHP’s QI efforts:
Program Manager, Pay-for-Performance – project manages SFHP’s pay-for-
performance program, the Practice Improvement Program. This program aims to improve clinical quality, data quality, timely access to care, systems improvement, and patient
experience through financial incentives and technical assistance. Program Manager, Population Health – designs and implements interventions to
improve HEDIS rates, ensures that members have access to low-literacy health education materials/classes, and ensures that members have access to services in their preferred language.
Lead HEDIS Nurse – leads HEDIS clinical audit and data collection process and supervises project team of temporary HEDIS abstractors and coordinators during the HEDIS annual pursuit season. During the off-HEDIS season (June-November), provides technical assistance to clinical practice sites regarding closing gaps in care and documentation opportunities.
Specialists – Provides support to the above staff to execute their responsibilities, including HEDIS chart review, developing marketing materials, pay-for-performance
data management, and coordinating with providers to report pay-for-performance data.
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o Senior Manager, Access & Care Experience – Reports to the Director, Health Outcomes Improvement, and oversees grievance management, access monitoring, and CAHPS improvement (i.e. patient experience). Reporting to the Manager of Access & Care Experience, the following positions support SFHP’s QI efforts:
Program Managers, Access & Care Experience – project manages SFHP’s access monitoring requirements, including regulatory requirements, provider surveying, access analysis, and provider reporting. Measures CAHPS performance, develops and implements interventions to improve the care experience for our members, particularly focusing on access and patient/doctor communication in safety net clinics and medical groups.
Grievance Analysts – manages member grievances, and ensures that grievances are appropriately classified and resolved, in conjunction with the Grievance Oversight Committee and the Grievance Review Committee.
Specialist– Provides support to the above staff to execute their responsibilities, including
grievance management, processing incentives, and event management.
o Manager, Health Services Business Relationships – reports to the Director, Health Outcomes Improvement and oversees internal applications supporting SFHP processes that impact member care. Reporting to the Manager of Health Services Business Relationships, the following positions support SFHP’s QI efforts:
Reporting Data Analyst – coordinates report development needed to assess QI activities and develops dashboards that assess the internal operations of the Health Services department. Oversees the development of the annual QI program, including work plan and evaluation.
Project/Program Managers/ – responsible for overseeing systems and applications
affecting multiple departments within Health Services. Examples include Essette (care management software), PIPBase (Pay-for-Performance database), Verscend (HEDIS
software), and PreManage (Hospital Information Exchange).
Specialist – Provides support to the above staff to execute their responsibilities, including system support requests and processing incentives.
Medical Director– reports to the Chief Medical Officer, and is responsible for overseeing the
Disease Management program and all programs under the Care Management department including Complex Case Management (CCM), Community Based Care Management (CBCM), Time Limited Coordination (TLC), and Health Risk Assessments (HRA). To that end, this position is also responsible for meeting DHCS, DMHC, and NCQA requirements for these programs.
Director, Care Management – reports to the Medical Director, and provides oversight over the Care
Management department including: Complex Case Management (CCM), Community Based Care Management (CBCM), Time Limited Coordination (TLC), and Health Risk Assessment (HRA). The following positions support SFHP’s Care Management programs:
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Project Manager, Disease Management - contributes to key quality and care management activities by functioning as the lead for the Disease Management program and patient safety (e.g. pain management and opioid safety programs).
Program Managers, Care Management – the Care Management department has three subject-specific Program Managers; a Housing Program Manager, a Child and Family Program Manager, and an overall Care Management Program Manager. Program Managers are responsible for assisting Care Management department leadership in planning, implementing, monitoring, and evaluating relevant Care Management programs.
Project Management Coordinator, Care Management – provide administrative
assistance to Care Management leadership and Program Managers in planning, implementing, and executing Care Management projects and programs.
Clinical Supervisors, Care Management – responsible for clinical and administrative oversight of the clinical Care Management staff including the Community Care Coordinators, Nurses, and Intake Coordinator. Essential responsibilities include monitoring and reporting on program metrics, routine auditing of cases to ensured high level of care, and providing LCSW clinical input to cases.
Care Management Nurses, Care Management – provide care coordination for medically complex members for all Care Management department programs except the HRA program. The nurse coordinates care management activities with the assigned primary Community Coordinator, ensuring all medical needs are met. Responsibilities include performing care management within the scope of licensure for members with complex and chronic care needs. Performs duties telephonically and in the community, such as conducting medical assessments and informing creation of member-centered
care plans in collaboration with Community Coordinator.
Community Coordinators, Care Management – provide care coordination, assessment and referrals for all members in Care Management department programs except the HRA program. Coordinators conduct initial telephone or in-person assessments for members eligible, assessing psychosocial issues and level of function. Coordinators develop member-centered, individualized
care plans and support members in identification of their own strengths and barriers to help them be successful with their care plans. Responsibilities include coordination of care management activities with the assigned nursing and pharmacy staff, soliciting input and consultation as needed.
Intake Coordinator, Care Management - responsible for follow-up of Health Risk Assessments for SFHP’s seniors and persons with disabilities (SPDs) and reassessing
SPDs with high risk criteria who have been enrolled in SFHP for at least one year. Creates individualized care plans for engaged members and provides oversight of the Health Risk Assessment program. Refers and triages members to appropriate Care Management programs. Responsibilities include oversight and workflow of the phone line and triage of calls from staff and providers.
Director, Pharmacy – Reports to the Chief Medical Officer, responsible for coordinating and
monitoring all aspects of the pharmacy benefit for SFHP members. Ensures oversight of the daily
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pharmacy program operations including the contracted Pharmacy Benefits Manager (PBM), the specialty pharmacy vendors, and AHSP-credentialed pharmacy residency program. Responsible for clinical integration with other Health Services departments to improve medication management for members, improve HEDIS scores, and support other medication-related initiatives.
o Managed, Pharmacy Operations – reports to the Director, Pharmacy and is responsible for
administrative oversight of the SFHP Pharmacy staff and day-to-day operational and clinical activities.
o Clinical Pharmacists/Pharmacy Residents – leads the clinical pharmacy activities for
SFHP including oversight of drug monograph preparation for the Pharmacy & Therapeutics Committee, Medication Therapy Management (MTM) programs, and the clinical drug
utilization review (DUR) program. Responsible for the criteria-based evaluation of medical necessity of prescription medication requests through the pharmacy prior authorization process, including oversight of the delegated (PBM) vendor activities.
o Analysts, Pharmacy – licensed pharmacy technicians responsible for day-to-day management and coordination of pharmacy programs, compliance requirements and projects including database maintenance, analysis, and reporting. Provides oversight to PBM vendor
functions including pharmacy network management, prior authorization standards as well as services provided by specialty pharmacy vendors.
o Specialists/Coordinators, Pharmacy – licensed pharmacy technicians responsible for
supporting PBM vendor management activities, provides administrative and reporting support for clinical programs, formulary management activities, pharmacy network management, prior authorization standards, specialty pharmacy vendors, and customer
service to members and providers. Performs outbound phone calls to pharmacy, provider or member to answer and resolve issues.
Director, Clinical Operations – Reports to the CMO, ensures the completion of utilization management (UM) activities and oversees UM activities within the provider network to comply with all regulatory UM requirements. The Director, Clinical Operations supervises four functional areas
that ensure effective utilization management practices, regulatory compliance, and network oversight. These areas include Concurrent Review and Prior Authorization, UM Delegation Oversight, Quality Review, and Program Management. The following positions support SFHP’s Utilization Management activities:
o Senior Manager, Concurrent Review - reports to Director, Clinical Operations and
manages concurrent review daily operations. Ensures that concurrent review turnaround times are compliant with regulations that assure expeditious care to SFHP members and
response to SFHP hospital partners. Provides oversight of the repatriation process to support consistent, continuity of care by facilitating transfers of hospitalized members to their “home” hospital. Oversees the discharge planning program, helping to ensure members have a safe transition to the next level of care and provides them with follow-up appointments to ensure continuity of care with their primary care provider.
Supervisor, Concurrent Review – reports to the Senior Manager, Concurrent Review.
Responsible for the daily management of concurrent review staff, discharge planning and repatriation Ensures reviews are completed within timeliness standards. Speaks with hospital peers to resolve inpatient utilization issues. Provides leadership and first-level management support to nurses
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Nurses I and II, Concurrent Review - report to the Supervisor, Concurrent Review or
the Manager of Concurrent Review. Responsible for criteria-based evaluation of medical necessity of inpatient stays and identification of potential quality issues.
o Senior Manager, Prior Authorization - reports to Director, Clinical Operations and manages
the inpatient and outpatient prior authorization team and daily operations. The scope of these services includes pre-service requests and their medical appropriateness based on member’s clinical presentation and the use of industry standards or Medi-Cal medical necessity criteria. Provides oversight of the steerage of members to the appropriate providers within their medical group to support continuous and consistent care to SFHP members. Manages the Quality Review team that supports the Potential Quality Incidents (PQIs), UM Delegation
Oversight, and Provider Dispute Resolutions (PDRs).
Supervisor, Prior Authorization – reports to the Manager, Prior Authorization. Responsible for the daily management of Prior Authorization staff and ensuring authorizations are completed within timeliness standards. Outreaches to provider staff for prior authorization issues and additional information as needed. Provides leadership and first-level management support to nurses.
Nurses I and II, Prior Authorization - reports to the Manager, Prior Authorizations or
Supervisor, Prior Authorization and are responsible for the direct engagement with providers to evaluate specific pre-service authorization requests with reference to the appropriate medical necessity criteria and whether requested out of medical group services can be provided in-medical-group. Also identifies potential quality issues and escalates to leadership as appropriate.
Nurse, Clinical Outreach - reports to the Senior Manager, Prior Authorization and is
responsible for the UM delegation oversight of the Delegated Medical Groups. In collaboration with Provider Network Operations, the Clinical Outreach nurse performs the state and NCQA required delegation oversight audits to ensure that UM functions provided by the delegated medical groups are complaint with regulatory standards. The audit results are provided to the delegated medical groups and, when indicated, corrective action plans are developed with the Clinical Outreach Nurse and the Medical Group.
Nurses, Clinical Review - reports to the Senior Manager, Prior Authorization and is
responsible for the review, documentation, and management of clinical grievances, provider dispute resolution, and Potential Quality Issues (PQI). The Clinical Review Nurse performs clinician and Medical Director medical necessity denial audits to ensure quality of review and accuracy of clinical application.
o Manager, UM Authorizations - reports to the Director, Clinical Operations and responsible
for leading the non-clinical staff that support the concurrent review and prior authorization
processes. Provides oversight of SFHP’s phone service level agreements, resolution of claims edits that hinder the reimbursement of billed services, and the productivity and quality standards of the non-clinical staff.
Supervisor, UM Authorizations – reports to the Manager, UM Authorizations.
Responsible for the daily management of UM Authorizations staff and ensuring authorizations are processed and sent to the nurses within timeliness standards. Performs
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quality audits of UM Coordinators and provides feedback to staff on opportunities for improvement. Provides leadership and first-level management support to nurses.
Coordinator, UM Support - reports to the Manager, UM Authorizations or Supervisor,
UM Coordinators and is responsible for triaging and creating authorization shells in the care management system. Performs outbound phone calls, maintain timelines of designated work flows, and provides troubleshooting assistance for the claims payment process via claim edits. Other duties include supporting the provider dispute resolution (PDR) and grievance processes, intake authorizations for payment to SFHP’s delegated medical groups, and serving as subject matter experts for system upgrade/improvement initiatives.
o Program Manager, UM - reports to the Director, Clinical Operations and has a multi-faceted role to program manage several overarching UM initiatives to include NCQA accreditation, DHCS compliance, DMHC compliance and quality improvement initiatives. Creates analysis and trend reports for compliance requirements such as over/under utilization, overturned appeals, and out of network referrals.
ii. Provider Network Operations Staffing Structure Support for the QI Program
The Provider Network Operations (PNO) Department is responsible for those aspects of the QI Program
that relate to evaluation of provider qualifications and network performance. The PNO department coordinates oversight of all delegated activities and monitors the implementation of corrective action plans. It is responsible for new provider orientation and education, facility site reviews and conducting and analyzing provider satisfaction surveys. Also, the PNO department ensures adequate size and composition of SFHP’s provider network, including provider-to-member ratios, adequate counts of high impact and high volume specialists, and executes ad hoc reimbursement agreements for services authorized and provided outside of SFHP’s provider network.
The PNO staff that supports the QI Program includes:
Manager, Delegation Oversight and Credentialing – reports directly to the Director, Provider Network Operations. Manages and coordinates delegation oversight and provider credentialing processes.
Nurse Specialist, Provider Quality and Outreach– reports to the Director, Provider Network Operations. A Registered Nurse who conducts triennial Facility Site Reviews (FSRs), using standardized DHCS guidelines and audit tools, for all Primary Care Physician (PCP) sites in SFHP’s network. The Nurse Specialist also oversees the FSRs completed by Certified Nurse Reviewers for Delegated Medical Groups.
Supervisor, Provider Relations – reports to the Director, Provider Network Operations. Coordinates the provider satisfaction survey administration. Facilitates organizational review of the provider satisfaction survey and appropriate action plan development. Reviews and reports provider-to-member ratios to the Access to Care Committee at least annually. Manages all mandated and non-mandated content of provider directory.
iii. Compliance and Regulatory Affairs Department Support for QI Program
The Officer of Compliance and Regulatory Affairs is responsible for ensuring organization-wide compliance with applicable federal and state laws and regulations, contractual requirements, and NCQA
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standards. The Compliance and Regulatory Affairs Department staff provides consultation to SFHP departments to develop and implement policies and procedures which comply with regulatory and contractual requirements. This role includes performing analyses on the impact on operations of new laws and regulations, Medi-Cal contract changes, All Plan Letters (APL) and Policy Letters (PL). APLs and
PLs are the means by which California Department of Managed Care and Department of Health Care Services convey interpretation of changes in policy or procedure at the Federal or State levels, and provide guidelines to health plans on how to implement these changes on an operational basis. The Medical Policy Administrator, who reports directly to the Officer of Compliance & Regulatory Affairs, is the primary associate that presents clinical policies at the Quality Improvement Committee.
iv. Marketing and Communications Department Support for the QI Program
The Marketing and Communications Department is responsible for all mandatory and supplementary communications to our Medi-Cal members. These include the Member ID Cards, Welcome Packets, SFHP Member Handbook, Evidence of Coverage, Provider Directories and Summary of Benefits, which
the Marketing and Communications department develops and mails annually in all threshold languages and at the recommended and appropriate reading level. The Marketing and Communications Department is also responsible for the Member Portal in compliance with NCQA requirements, the Provider Online Search Tool, the Provider Portal and our external facing website www.sfhp.org. Members may request materials in Braille, large print format, electronic delivery and non-threshold languages. Through department driven member satisfaction surveys and focus group sessions, the
department crafts messaging, creates content and design, and manages translations for all printed and online materials, digital communications, advertising, and phone outreach efforts with the goal of improving our members’ lives through better health. Essential member material include the creation of an accurate and user-friendly SFHP Provider Directory, updated monthly, and delivered to new members within the mandatory timeline and to existing members annually. The department also delivers health improvement and disease management incentives such as: child immunizations and well visits, prenatal and postpartum care, diabetes and asthma care, controlling
high blood pressure, and health education materials in a continuing effort to improve our members’ health. Finally, the Marketing and Communications department, in collaboration with the Program Manager, Population Health, develops the SFHP quarterly newsletter, Your Health Matters, which delivers information including, new benefits, pharmacy formulary updates, and healthy living hints and tips.
v. Enrollment Services Support for the QI Program
The Enrollment Services Unit at SFHP’s Service Center provides application and enrollment assistance for health coverage programs in San Francisco. Clients may be SFHP members, potential members or members of the general public seeking assistance. The Service Center offers SFHP members assistance
with navigating and understanding their eligibility, enrollment for health coverage, and submission of their Medi-Cal application. SFHP staff assists members in-person and offer printed material that explains members’ benefits, rights, and responsibilities. Members have access to health education resources at the Service Center, as well as culturally and linguistic appropriate services. Enrollment Services is the point of entry for many SFHP members and the Service Center links members to other aspects of their healthcare including Customer Service, San Francisco’s Medi-Cal office, and a members’ assigned PCP.
vi. Customer Service Support for the QI Program
The Customer Service Department is responsible for ensuring SFHP members receive exemplary service
and accurate information in a timely manner. Customer Service Representatives deliver information
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telephonically to members about their health coverage, summary of benefits, and member rights to Cultural and Linguistic Services. Additionally, Customer Service Representatives assist members in navigating their health care, such as changing their primary care providers, assisting members complete health risk assessments, reporting grievances and educating members about the grievance submission
process, and understanding information regarding SFHP’s services. Customer Service Representatives also work closely with Health Services staff to manage member incentives inquiries. All Customer Service Representatives are bilingual individuals, and the Customer Service Department expands the linguistic capacity of its services through use of a language interpretation service. Finally, the Customer Service Department participates in quality improvement by partnering with the Access and Care Experience team in order to improve performance in Customer Service, as measured by Health Plan CAHPS.
4. Quality Improvement Method and Data Sources
A. Identification of Important Aspects of Care
SFHP identifies priorities for improvement based on regulatory requirements, NCQA standards, data review, and provider and member identified opportunities in the key domains of Clinical Quality & Patient Safety, Quality of Service & Access to Care, Utilization Management, and Care Coordination & Services for Members with Complex Health Needs. Particular attention is paid to those areas that are high risk, high volume, high cost, or problem prone.
The QI Program employs a systematic method for identifying opportunities for improvement and evaluating the results of interventions. The QI Program uses the following method to improve
performance: 1. Establish targets and/or benchmarks for key indicators within each domain
2. Systematically collect data
3. Analyze and interpret data at least annually
4. Identify opportunities for improvement
5. Identify barriers to improvement
6. Prioritize opportunities
7. Establish improvement objectives in support of priorities
8. Design interventions based on best practices or previous interventions
9. Implement and track progress of interventions
10. Measure effectiveness of interventions based on progress toward standards or benchmarks
B. Data Systems and Sources
i. Health Effectiveness Data and Information Set (HEDIS)
The External Accountability Set Performance Measures, a subset of HEDIS, are calculated, audited and reported annually as required by DHCS. Depending on the measure and per DHCS mandate, measures utilize administrative data (claims, encounters), supplemental data (lab sources, state immunization registry) and data collected via chart review. HEDIS Compliance Audit services are provided by the Health Services Advisory Group (HSAG) per DHCS mandate. Final results are reported to DHCS, and submitted to NCQA via the Interactive Data Submission System (IDSS).
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ii. Consumer Assessment of Healthcare Providers and Systems (CAHPS)
SFHP evaluates member experience annually through the CAHPS survey. Primary care clinics and medical groups are rewarded for improvement in CAHPS via SFHP’s Practice Improvement Program (PIP). Health Plan CAHPS is conducted every three years by DHCS and annually by SFHP.
iii. Practice Improvement Program (PIP)
Medical groups and outpatient clinics participating in PIP may select to self-report data for some of the measures included in the measure set. 2018 measures include:
Clinical Quality Domain: Diabetes HbA1c Test, Diabetes HbA1c <8, Diabetes Eye Exam,
Routine Cervical Cancer Screening, Routine Colorectal Cancer Screening, Labs for Patients on
Persistent Medications, Smoking Cessation Intervention, Controlling High Blood Pressure,
Adolescent Immunizations, Childhood Immunizations, Well Child Visits for Children 3-6 Years
of Age, Chlamydia Screening, Prenatal and Postpartum Care, Asthma Medication Ratio, Analysis
of Disparities
Patient Experience Measures that are impacted by Clinic Operations: Third Next Available
Appointment, Show Rate, Office Visit Cycle Time, Staff Satisfaction, CG-CAHPS, Expanding
Access to Services
Systems Improvement Domain: Follow-Up Visit After Hospital Discharge, Depression Screening and Follow-Up, Opioid Safety, Palliative Care, Percent of continuously-enrolled Members with a PCP Visit in the past year
iv. Data Monitoring and Reporting
SFHP monitors quality of care by generating and reviewing the following reports:
Utilization Management – Utilization Management data are captured from the authorization process and include:
Prior Authorizations
Concurrent Review Authorizations
Appeals and Clinical Grievances
Claims
Member clinical information
Provider reported data
Encounter data
Delegated medical group authorization files
Pharmacy – Pharmacy data are captured from the Pharmacy Benefits Manager and the authorization process and include:
Pharmacy claims, both paid and rejected, data from pharmacy benefit manager
Specialty pharmacy
Pharmacy prior authorization requests
Appeals and grievances
Member pharmacy information
Provider reported data
Pharmacy carve out data (e.g. substance abuse treatment, specialty behavioral health)
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Behavioral Health
Claims and Utilization, both SFHP and carve-out outpatient specialty mental health claims
Pharmacy data, both SFHP and carve-out medication claims
Appeals and Grievances
Service Level Agreements (e.g. wait times, claims processing timeliness)
Others – In addition to the data sources listed above, SFHP utilizes the following data sources to inform its QI activities:
Medical records
Enrollment data
Lab data
Key external agencies including Golden Gate Regional Services, California Children
Services, and Early Start
California Immunization Registry (CAIR)
Emergency department, hospital admission, discharge, and transfer data via information
exchange
C. Policies and Procedures
SFHP reviews and updates all of its quality and clinical policies and procedures (Utilization Management, Care Coordination, Pharmacy, Quality Improvement, Health Education, Cultural and Linguistic Services) biennially at a minimum. Clinical policies and procedures are also updated on an as-needed basis to reflect changes in federal and State statutory and regulatory requirements and/or NCQA standards. QIC and SFHP’s internal Policy and Compliance Committee approve new and updated policies and
procedures.
5. QI Program Evaluation
San Francisco Health Plan evaluates the overall effectiveness of the Quality Improvement Program through an annual evaluation process that results in a written report which is approved by the CMO, QIC, Governing Board and submitted to DHCS. Measures completed within the evaluation timeline are included in the evaluation for that calendar year. Measure completion is determined by the staff responsible for the measure and is indicated by either completion of planned activities, obtainment of the stated target, or receipt of the required data for evaluation. Measures timelines are determined by the activities and the data frequency, and can be longer than a single calendar year. Each measure’s timeline
is indicated in the Work Plan found in Appendix A. The evaluation includes an executive summary and a summary of quality indicators, identifying significant trends and areas for improvement. Each measure included in the evaluation includes the following elements:
Brief description of the QI activity/intervention and how it purports to improve the domain in
which it is included.
Measure Target of the QI activity/intervention
Measure definition
Measure Results, trended over at least three years when available
Barriers that affected the effectiveness
Recommended interventions/actions to overcome barriers in the following year
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A. QI Work Plan
Results of the annual evaluation described above, in combination with information and priorities determined by the HS leadership and staff, are reviewed and analyzed in order to develop an annual QI Work Plan (Appendix I). This comprehensive set of measures and indicators is divided into six domains:
1. Clinical Quality and Patient Safety
2. Quality of Service and Access to Care
3. Utilization Management
4. Care Coordination and Services for Members with Complex Health Needs
5. Quality Improvement Committee Activities
The QI Work Plan is communicated to QIC via a scorecard each quarter.
6. QI Activities
The following QI activities are completed annually or are planned for the coming program year. The activities are arranged by Work Plan domain and further describe the activities referred to under each measure/indicator within the Work Plan (Appendix A). Refer to the annual Work Plan for current targets
specific to these measurements.
A. Clinical Quality and Patient Safety
i. Preventive Care
SFHP monitors and reports on a variety of HEDIS measures focused on preventive services. These include:
Cervical Cancer Screenings
Breast Cancer Screenings
Chlamydia Screenings
To encourage members to receive high priority services, SFHP offers incentives for completing the following preventative care services: $50 gift card for childhood immunizations; $25 gift card for a prenatal screening, postpartum visit, and well-child visit.
ii. DHCS Performance Improvement Projects (PIP)
SFHP implement DHCS PIPs at any given time. PIP measures aim to understand key drivers of poor
performance and conduct improvement activities based on the key drivers. For 2018, SFHP’s PIP will target the large disparities in postpartum care rates seen among the SFHP member population by race/ethnicity. SFHP aims to improve the rate of African American members who received postpartum care within the HEDIS timeframe.
iii. Initial Health Assessment and Staying Healthy Assessment
All newly-enrolled Medi-Cal members are expected to receive an Initial Health Assessment (IHA) within 120 days of enrollment as mandated by DHCS. SFHP sends monthly reports to providers with demographic information about these new members, asking providers to outreach to these members to
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conduct an Initial Health Assessment. New members receive a mailing in their primary language (Medi-Cal threshold) encouraging them to make an appointment to receive this service. SFHP monitors performance against this requirement by analyzing claims and encounter data to calculate the percentage of new members who receive an IHA visit within the DHCS-required periods. These results are then
analyzed by medical group and clinics. Providers are also required to administer the age-appropriate Staying Healthy Assessments, with state-approved questions designed to identify behavioral and other significant risk factors to be addressed by the PCP. SFHP ensures compliance with this requirement through facility site reviews and medical record reviews in compliance with Medi-Cal guidelines. SFHP provides training to providers about these assessments and facilitates deeming of equivalent tools upon provider request.
In addition to the assessment above, all members over eighteen are required to have an annual screening for alcoholism, based on recommendations from the U.S. Preventive Services Task Force, with follow-up detailed assessment questions and brief interventions, when appropriate.
iv. Initiatives to Improve Data Quality
HEDIS performance cannot be evaluated without accurate information. This requires aggressive data capture and improvement efforts. Some data capture and data quality improvement strategies are year-round pursuits, while some occur during the HEDIS audit season. Annually, the team investigates
discrepancies of 5% or more to identify if there is a data problem or a care delivery problem. This analysis informs our action plan, so we can target the solution to the appropriate problem, either focused on a particular medical group, or a SFHP department. SFHP also analyzes claims and encounter volume trended month to month by provider group, to identify any specific data issues well in advance of HEDIS season. When problems are identified, our Information Technology Services (ITS) Department contacts data submitters to facilitate improved data quality and
timeliness. Additionally, ITS monitors encounter data quality in compliance with DHCS’s quality measure for encounter data (QMED) on a quarterly basis and implements interventions as needed. Every year, SFHP adds new strategies to ensure that we can account for all reportable clinical care that is provided, as data quality issues lead to incomplete administrative data. Examples of strategies include:
Integrate data quality measures in SFHP’s Practice Improvement Program
Pursue acquisition of more complete supplemental data sources (e.g. lab tests and lab results)
Collaborate with SFHP’s Information Technology Systems and Business Intelligence
departments to improve data flow in SFHP’s Enterprise Data Warehouse (EDW)
Offer network trainings to improve encounter data quality.
v. Chronic Condition Management
SFHP monitors and reports on a variety of HEDIS measures focused on recommended interventions for members with chronic conditions. These include:
Asthma Medication Ratio
Comprehensive Diabetes Care – Eye Exam, HbA1c Testing and Control, Nephropathy
Monitoring, BP Control
Controlling High Blood Pressure
To encourage members to manage their chronic conditions, SFHP offers the following incentives: for members with diabetes, a $25 gift card for completing screenings (A1C, nephropathy, and blood pressure screenings), and a $25 gift card for completing retinopathy screening. For members with asthma, a $25
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gift card for completing the Asthma Control Test and reviewing it with a provider; and for members with hypertension, a $25 gift card for completing a blood pressure check and heart healthy action plan. SFHP’s Disease Management (DM) program, builds on past health education and incentive efforts and
focuses on members with asthma and diabetes. The program is designed to address self-management, patient adherence to the treatment plans, medical and behavioral health co-morbidities and health behaviors. The program encourages members to communicate with their practitioners and caregivers about their health conditions and treatment. SFHP facilitates access to community resources to assist members with comorbidities and psychosocial issues. The DM program systematically identifies members who qualify for each program on a monthly basis through SFHP’s claims and encounter data. SFHP informs eligible members about the DM program
through its member newsletters, outreach letters, website, and other member contacts. This information includes how to use the services, how members become eligible to participate, and how to opt out. The DM program provides interventions to members based on risk stratification and is aligned with nationally recognized evidence-based clinical practice guidelines.
vi. Health Education
SFHP ensures that members have access to low-literacy health education and self-management resources in all threshold languages mandated by DMHC and DHCS. These resources are available on the SFHP
website, and through SFHP providers. Select materials are also mailed to members as part of SFHP’s population health campaigns. Health topics covered by these tools and fact sheets include smoking and tobacco use cessation, encouraging physical activity, healthy eating, managing stress, asthma and diabetes control, parenting, and perinatal care, among others. SFHP’s member newsletter, Your Health Matters, features emerging health education topics prioritized by SFHP’s clinical leadership. In addition, the SFHP website includes
a sortable listing of free group wellness classes offered by SFHP’s provider network on a variety of topics. SFHP’s member portal prompts members to complete the Health Trio Health Appraisal tool to identify risk factors and health concerns. Based on the Health Appraisal results, members are provided with a risk and wellness profile, along with prevention strategies. In addition, the Health Trio online platform provides members with access to dynamic and evidence-based self-management tools based on their individual areas of risk or interest. These include topics such as healthy weight, healthy eating, promotion
of physical activity, managing stress, tobacco use cessation, avoiding at-risk drinking, and identifying symptoms of depression.
vii. Behavioral Health Services
Specialty mental health services and community substance abuse services are provided by county Community Behavioral Health Services (CBHS). Non-specialty mental health services are provided to Medi-Cal beneficiaries by SFHP (excluding members assigned to Kaiser). To facilitate these services, SFHP contracts with Beacon Health Options to deliver both the non-specialty mental health benefit, and
the behavioral health benefit for children diagnosed with Autism Spectrum disorders for Medi-Cal members. To ensure adequate provision of behavioral health care, SFHP integrates Behavioral Health Services with its QI program in the following manner:
Beacon Health Options provides SFHP with their QI Plan annual updates on member and
provider satisfaction. This information is presented to SFHP’s QIC.
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Beacon assists with the processing and investigation of NSMH-related grievances in compliance with SFHP standards.
Beacon co-locates two staff within SFHP’s Health Services department. Clinical Care Manager
(Licensed Marriage and Family Therapist) and Care Coordinator provide referral tracking, case management of members transitioning between county-level and plan-level services, consult with SFHP Care Management on members with complex medical and behavioral diagnoses, and ensure that issues, when appropriate, are escalated to Beacon leadership.
SFHP includes increasing non-specialty behavioral health utilization in its annual QI Plan and is
one of SFHP’s access-related Organizational Goals.
SFHP monitors service availability through its regular access monitoring work, in accordance with DHCS, DMHC, and NCQA requirements.
viii. Patient Safety
SFHP is committed to the safety of its members. Current patient safety initiatives include the following:
Medication Therapy Management (MTM) Program – SFHP Clinical Pharmacists review medication needs for members identified by the Complex Care Management (CCM) program. The goal is to optimize medication regimen by promoting safe and effective use of medications. Achieving the goal and completing interventions is a multidisciplinary effort from Pharmacy services,
Care Management team, Medical Director, and primary care providers. Educational medication resources for targeted members will also increase adherence and knowledge of their drug regimen.
SFHP Pain Management Program – SFHP conducts trainings for providers and clinic staff on multiple aspects of pain management, including safe opiate prescribing. . SFHP is working with external and internal experts to provide clinical and non-clinical pain management resources to the
community. SFHP’s pay-for-performance program (PIP) also supports best practices in opiate prescribing and pain management. SFHP co-leads the San Francisco Safety Net Pain Management Workgroup and has pain management as a standing topic on the SFHP Pharmacy & Therapeutics Committee.
Potential Quality Incidents (PQIs) – SFHP Clinical Operations, Care Management, and Pharmacy staff are trained to identify Potential Quality Incidents (PQIs) and refer them to the Quality Review Nurse. PQIs are incidents outside the standard of care that put members at risk of harm, or when medical errors caused harm. SFHP has a process that ensures that PQIs are evaluated first by the Quality Review Nurse for initial review and investigation and then reviewed with an SFHP Medical Director. Confirmed PQIs involving individual physician departures from care standards are brought
to the PAC for peer review and next step recommendations.
Drug Utilization Review (DUR): The DUR program consists of a Prospective DUR Program, a Retrospective DUR Program, and an Educational Program promoting optimal medication use to prescribers, pharmacists, and members. The SFHP DUR Program coordinates with the Medi-Cal DUR Board on retrospective DUR and educational activities for the Med-Cal line of business. The
Pharmacy DUR Program activities may focus on identifying medication use patterns to reduce fraud, abuse, waste, inappropriate, unsafe or unnecessary care and develop education programs to optimize medication use.
B. Quality of Service and Access to Care
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i. Monitoring Member Access
SFHP monitors members’ access to care, following regulations delineated by DMHC and DHCS as well as accreditation standards set by NCQA. DMHC monitoring requirements are met by the Timely Access Regulations submission in March each year. DHCS monitoring requirements are met via the annual contract oversight audit performed by DHCS. These access monitoring measures, among others, are
reviewed quarterly during SFHP’s Access to Care Committee. The Access to Care Committee reviews the Access to Care dashboard to monitor access throughout the network. Based on dashboard measures and survey results, the committee identifies access issues and requests a response when performance thresholds are not met. These data are comprehensive, addressing core areas such as member and provider satisfaction with access, availability of various appointments, after hours care, wait times, as well as indicators of network adequacy to meet members’ needs.
ii. Customized Access Improvement Strategies
Member access to the right care at the right time is a crucial component of SFHP’s core purpose to
improve health outcomes. Access is a challenge within San Francisco due to primary care provider recruitment challenges, infrastructure challenges within specific safety net clinics, and large growth in the Medi-Cal population. In addition to improving SFHP’s internal processes to identify and improve found access issues, SFHP is partnered with provider groups to improve their capacity to provide timely access to services for members. Recognizing access as a key organizational priority, SFHP’s Governing Board approved the use of $15 million in reserves to be awarded as grants to SFHP’s contracted hospitals and providers for fiscal years 2015-16 and 2016-17. The intent of this initiative is to achieve significant
improvement in HP-CAHPS Access Composites for primary and specialty care, and to improve real-time data sharing for hospitals. SFHP provided technical assistance to the network in the development and execution of the work plans created as a result of these grants. To incentivize improvement in HP-CAHPS performance, SFHP is withholding 10% of funding tied to achieving significant CAHPS improvement in 2018.
iii. Financial Incentives to Support Improvement
The Practice Improvement Program (PIP) is SFHP’s pay-for-performance program. PIP is equivalent to
approximately 18.5% of provider payments. Supporting the goals of the triple aim, PIP has four domains: Clinical Quality, Patient Experience, Systems Improvement, and Data Quality. Participants have opportunities to gain incentive funds both from meeting benchmarks and from relative improvement. Unearned funds are reserved to support improvement of performance measures via technical assistance and provider-level grants.
In addition to the pay-for-performance program, SFHP’s governing board caps financial reserves equal to two months of member capitation. Reserves in excess of this amounts are allocated to the Strategic Use
of Reserves (SUR). SFHP then reviews quality indicators (HEDIS, CAHPS, utilization, etc.) and recommends projects to improve quality for SFHP members, using funds from SUR. Projects often take the form of grants to providers and hospitals, though also include expanded benefits and member incentives.
iv. Customer Service Trainings
SFHP collaborates with the Studer Group & the Baird Group, patient experience consulting firms, to offer
trainings to all clinic staff on improving customer service to patients. Trainings either occur at the clinic site or in a centralized location. Topics for this year’s trainings include the following evidence-based practices for improving customer service for SFHP members:
AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank you)
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Patient Rounding
Service Recovery
v. Provider Satisfaction
On an annual basis, SFHP conducts a Provider Satisfaction Survey to gather information about network-wide provider issues and concerns with SFHP’s services. The survey is administered by an
outside vendor, and targets primary care and high-volume specialty care providers and office staff. It measures their satisfaction with the following SFHP functions:
Finance Processes
Utilization Management and Care Support
Network/Coordination of Care
Timely Access to Non-Emergency Health Care Services
Pharmacy
Health Plan Customer Service Staff
Provider Relations
Ancillary Provider Network
Member Incentives
Results are distributed to the impacted SFHP departments and the QIC for the identification and implementation of improvement activities. Applicable improvements are integrated into the QI Program
activities.
vi. Timely Communication to Providers
SFHP provides timely communication of standards and requirements to participating medical groups and organizational providers via the following activities:
Informing providers of new and revised policies and procedures, and legislative and regulatory
requirements as they occur through the SFHP Provider Newsletter and the Network Operations
Manual (NOM).
Sharing preventive care and other clinical practice guidelines.
Distributing results of quality monitoring activities, audits and studies, including grievances that
identify potential system issues and member experience and provider satisfaction survey results.
Providing training of new providers on SFHP’s NOM.
vii. Provider Credentialing
SFHP ensures that health care practitioners are appropriately credentialed and re-credentialed, and all network providers meet credentialing requirements. This process includes:
Bi-annual review of credentialing policies and procedures for compliance with, legislative and
regulatory mandates, contractual obligations and, NCQA standards.
Peer review of credentialing and re-credentialing recommendations, potential quality of care
issues and disciplinary actions through the Physician Advisory Committee (PAC).
Providing a mechanism for due process for practitioners who are subject to adverse actions.
Reviewing licensing and accreditation documentation of organizational providers, or reviewing for
compliance with industry standards.
Conducting provider monitoring through Medical Board of California, List of Excluded
Individuals/Entities (LEIE) database, and Medi-Cal no pay list.
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viii. Member Grievances and Appeals
SFHP ensures that members’ grievances are managed in accordance with Medi-Cal guidelines. SFHP manages and tracks complaints and grievances, and provides a quarterly analysis to the Quality Improvement Committee, identifying trends and addressing patterns when evident. To identify patterns
and trends in grievances, grievance reports are generated to report rates by line of business, medical group, and grievance category. When a grievance pattern has been identified, SFHP will work with clinics or medical groups to develop strategies for improvement or request corrective actions plans as appropriate. To formalize the above processes, both a weekly and a monthly Committee have been developed in order to improve the member experience and improve SFHP’s internal grievance process. The committees are multidisciplinary, composed of the Chief Medical Officer and representatives from Member Services,
Provider Relations, Health Outcomes Improvement, Care Support, Pharmacy, Clinical Operations, and Compliance and Regulatory Affairs. Any grievance that poses a Potential Quality Incident (PQI) is reviewed and investigated by the Quality Review Nurse and presented to the SFHP Medical Director. PQIs are incidents outside the standard of care that put members at risk of harm, or when medical errors caused harm. Confirmed PQIs involving individual physician departures from care standards are brought to the PAC for peer review and next step
recommendations.
ix. Member Rights and Responsibilities
SFHP works to ensure that members are aware of their rights and responsibilities. This includes the annual review, revision, and distribution of SFHP’s statement of member rights and responsibilities to all members and providers for compliance with SFHP standards and legislative mandates. SFHP also implements specific policies that address the member’s right to confidentiality and minor’s rights. SFHP conducts a review on at least a semi-annual basis of the grievance and appeal policies and procedures to
ensure compliance with SFHP standards, legislative mandates, DHCS contractual obligations, and National Committee for Quality Assurance (NCQA) standards. In addition, member grievances and appeals that specifically concern member rights and responsibilities issues are analyzed for trends and reviewed by the Grievance Oversight Committee. Corrective action plans are implemented as necessary in order to address specific or systemic.
x. Cultural and Linguistically-Appropriate Services
SFHP’s Cultural and Linguistic Services program is informed by regular assessment of the cultural and linguistic needs of its members via the Medi-Cal General Needs Assessment (GNA). All SFHP member
materials are available in Medi-Cal threshold languages. All SFHP health education materials are written at a sixth-grade reading level. Alternative formats for member materials, such as large text and braille, are available to members upon request. All non-English monolingual and Limited English Proficient (LEP) SFHP members have access to confidential, no-cost linguistic services at all SFHP and medical points of contact. SFHP informs members about the availability of linguistic services through its Member Handbook, Evidence of
Coverage, member newsletters and through other member contacts. The SFHP identification card also indicates the right to interpreter services. Linguistic services may be provided by bilingual providers and staff, or via interpreter services. Interpreter services are provided by a face-to-face interpreter, telephone language line, or Video Monitoring Interpretation (VMI). Interpreter services include sign language interpreters and/or TTY/TDD.
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Most SFHP members have the option to select a primary care provider or clinic that speaks their preferred language. The SFHP Provider Directory indicates languages spoken by providers and at clinic sites. SFHP conducts Member and provider language concordance studies each year.
SFHP contracts the responsibility for providing interpreter services at all medical points of contact to its medical groups. All medical groups must have language access policies and procedures that are consistent with SFHP's policy and meet all legal and regulatory requirements. The SFHP Program Manager, Population Health conducts an audit of linguistic services as part of the annual Medical Group Compliance Audit. The Program Manager, Population Health also assists in addressing grievances related to cultural and linguistic issues at both medical and non-medical points of contact, systemically investigating and intervening as needed.
C. Utilization Management
i. Utilization Management Activities
SFHP’s utilization management (UM) program ensures UM activities are regulatory complaint, align with accreditation requirements, and are based on current medical evidence.
Key utilization management activities include review and monitoring of utilization management regulatory and accreditation requirements; the Utilization Management Committee; oversight of UM delegated medical group services; identification of potential quality issues (PQIs); and medical necessity review of authorizations. On a daily basis, SFHP manages prior authorizations, concurrent review, denials, and modifications of care. On a regular frequency, UM tracks open prior authorization specialty referrals for completion of services and provider and member satisfaction with UM activities. SFHP monitors California Children Services (CCS) and Golden Gate Regional Services (GGRC) coordination
of care and the timeliness of utilization decisions and expedited appeals. SFHP provides UM and coordination of care monitoring and oversight of delegated medical groups. This includes a yearly audit of policies and procedures, case files, reports, and letters. Deficiencies in delegated UM programs are addressed with the medical group and may result in implementation of corrective actions. Ongoing process improvements and program developments are assessed via annual review and approval of the utilization management program, and supporting policies and procedures, to confirm compliance with SFHP’s clinical standards, State of California legislative and regulatory mandates, and applicable
NCQA requirements.
Over and Under Utilization of Services - SFHP monitors service utilization, including inpatient, outpatient, Emergency Department, non-specialty mental health, and ancillary services, to identify patterns of under or overutilization of services and create actionable steps to promote medically appropriate utilization of services. Inpatient and Emergency Department Utilization data are compared to HEDIS and NCQA benchmarks as appropriate. Overutilization is identified
through monthly inpatient and emergency room trend reporting. Underutilization is reported through post discharge follow-up visit reports. Outpatient and ancillary service utilization is trended over time and compared to internal network performance. In addition, utilization patterns are shared with senior leadership in the network. Adverse patterns are discussed for root-cause identification and corrective action as needed.
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ii. Pharmacy Services
Drug Utilization Review (DUR): The DUR program consists of a Prospective DUR Program, a Retrospective DUR Program, and an Educational Program promoting optimal medication use to prescribers, pharmacists, and members. The SFHP DUR Program coordinates with the Medi-Cal DUR Board on retrospective DUR and educational activities for the Med-Cal line of business. The Pharmacy
DUR Program activities may focus on identifying medication use patterns to reduce fraud, abuse, waste, inappropriate, unsafe or unnecessary care and develop education programs to optimize medication use.
Prospective DUR Program consists of claim system screens, audits, edits, and messaging conducting before each prescription is filled or delivered to the member at the point-of-sale (POS) or point of distribution. Prospective DUR includes screening and audits for drug-disease
contraindications, drug-drug interactions, appropriate dosing and duration of treatment, therapeutic duplication and other safety and formulary management requirements used to determine formulary and prior authorization criteria and treatment algorithms
Retrospective DUR Program consists of reporting and analysis for prescription claims data and other records to identify patterns of fraud, abuse, gross overuse, inappropriate or medically unnecessary care and other formulary management requirements. regularly reviews drug
utilization reports for trends in prescription over and under use and potential outlier cases. Utilization reports include member compliance reports, controlled substance overutilization reports, doctor-drug reports, asthma drug utilization reports, pharmacy outlier reports, etc.
Educational Program consists of verbal and written communication outreach activities developed by the Medi-Cal DUR team and by SFHP to educate prescribers, pharmacists and members on common drug therapy problems with the aim of improving prescribing and
dispensing practices.
iii. Discharge Planning
San Francisco Health Plan (SFHP) manages members from in the Community Health Network who are admitted at an out of medical group hospital setting and assists in creating a plan of action to create a medically safe and effective transition to an alternate level of care for. The SFHP UM Nurses and Coordinators collaborate internally and with the acute care and SNF facilities to ensure that safe
transitions are met. These include medically necessary services, and supportive services in the community for the member upon discharge. In collaboration with the Community Health Network (CHN) SFHP also coordinates timely post discharge follow-up appointments.
D. Care Management
SFHP’s department of Care Management administers four programs for members which provide a range of service from basic telephonic care coordination to intensive, in-person case management. Each program has its own criteria which allow members to be served by the program that best meets their needs. The four programs are Community Based Care Management (CBCM), Complex Case
Management (CCM), Time Limited Coordination (TLC), and Health Risk Assessment (HRA) follow-up. Care Management leadership, in conjunction with SFHP’s department of Business Intelligence, conducts an annual population assessment including an analysis of member satisfaction surveys to evaluate the programs and adjusts the programs accordingly.
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Community Based Care Management (CBCM) targets members who receive services within the
non-delegated medical groups (CHN and UCSF) and who are frequent users of acute inpatient
and emergency department services. Members receiving care within delegated Medical Groups in
the network receive case management from their Medical Group. Members enrolled with SFHP’s
CBCM receive wrap-around care coordination and case management services with an emphasis
in involving both PCP and community providers. This program will transition into a Health
Homes compliant Community Based Care Management Entity (CB-CME) provider in July 2018.
Complex Case Management (CCM) targets members across medical groups (except Kaiser) who
have complex medical conditions, are at high risk, and who are experiencing at least mild
psychosocial stability (including income, food and housing stability) and are engaged in
behavioral health care (both mental health and substance use services) as needed or are actively
seeking support in connecting to these resources. The CCM program is aligned with NCQA
standards and Medi-Cal contractual requirements.
Time-Limited Coordination (TLC) is available for member’s seeking coordination with a carved-out or contracted agency (such as GGRC, CCS and CBHS) and for members who need short-term (less than 6 months) coordination of care. To ensure continuity of care Care Management leadership in conjunction with the Family and Children Program Manager are in process of formalizing a system with California Children Services (CCS) for members who are transitioning
out of the CCS coverage program into the TLC program.
Health Risk Assessment (HRA) follow-up is for members who receive services within the non-
delegated medical groups (CHN and UCSF). Members receiving care within delegated medical
groups in the network receive follow-up from their medical group. HRAs are completed for all
new SPDs (seniors and persons with disabilities) and members are reassessed annually. Members
are stratified as either high or low risk based on their responses to the HRA or the reassessment
report data. Members who are high risk receive outreach both by phone and mail, while our low
risk members receive outreach by mail.
The goal of all Care Management programs is to improve member health, improve connection with and utilization of primary care, and reduce inpatient admissions and ED visits and in addition increase psychosocial stability (housing/food/clothing/ home health) when needed. All programs include
comprehensive assessments and member driven care plans. Through a collaborative process with the PCP, behavioral health providers, community agencies, and the member, Care Management staff ensures improved coordination of services, identify and address barriers to care, and enhance self-care knowledge and skills of engaged members. Staff collaborates, when appropriate, on the development of care plans for participants in their respective programs. The following provides a description of Care Management programs that are currently in development:
Children and Family Program - This care coordination program will be designed to serve SFHP members aged 0-18 and their families/caregivers. Evidence-based assessment tools, consent documents, and care plan goals/interventions will be created to fit the needs of this population. This program will have a specific workflow outlining program eligibility, policies, procedures, and outcome metrics. Care Management staff will be trained on workflow, as well as California consent laws and policies pertaining to children and family case management.
Health Homes Program (July 2018) - the Health Homes Program (HHP) implementation planning at SFHP was placed on hold but has been reestablished as of August 1, 2017. HHP targets members with a
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combination of conditions and utilization. The HHP intervention is community based, with a focus on coordination of care between systems (medical, mental health and social).
i. Care Coordination with External Agencies
SFHP’s Care Management and Utilization Management teams ensure coordination of care for members per Medi-Cal contractual requirements. These coordination activities include executed MOUs with key agencies such as California Children Services (CCS), Golden Gate Regional Services (GGRC), Early Start (ES) and Community-Behavioral Health Services (CBHS) that outline coordination activities. These coordination activities are designed to ensure members are aware of non-plan benefits and programs available to them and confirm coordination of care across agencies and services.
In preparation for Health Homes implementation, SFHP is also addressing the needs of members living in supportive housing and those experiencing homelessness. Through collaboration with the Department of Homelessness and Supportive Housing, supportive housing providers, and various community partners, SFHP will enhance the scope of care coordination to create a more unified and effective service system.
E. Delegation Oversight
i. Standards for Delegated Medical Groups
SFHP oversees functions and responsibilities delegated to subcontracted medical groups and behavioral health organizations. The delegated entity must comply with laws and regulations as stated in 42 CFR 438.230(B) (3), (4) and Title 22 CCR § 53867 and the Department of Health Care Services contract. SFHP ensures that delegated functions are in compliance with these laws and regulations through an annual audit process and monthly and quarterly monitoring activities.
For each delegated function, the audits consistent of an overall audit score, category score, and scores for identified critical elements. Within each delegated function, SFHP creates categories of similar audit elements; results for each element contribute to the category score. Each category may contain one or more critical element, identified by the appropriate subject matter expert. The category scores contribute to the overall audit score. A plan for corrective action is requested if:
a CRITICAL ELEMENT is missed
the OVERALL AUDIT SCORE is lower than 95%
within the UM record review, any incorrect or inappropriate UM denials
within the Claim record review, any wrongfully denied or incorrectly paid Claims
ii. Delegated Functions
Credentialing – All activities related to credentialing verification of individual practitioners are fully delegated to the medical group with which the practitioners have a contract.
o Brown and Toland, Chinese Community Health Care Association, Hill Physicians
Medical Group, Kaiser Foundation Health Plan, North East Medical Services, San Francisco Health Network, UCSF, Teladoc, and Beacon Health Options.
o SFHP conducts Credentialing verification of all practitioners providing services at clinics affiliated with SFCCC and other independent clinics.
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Utilization Management – The following groups are delegated to conduct UM activities on behalf of the Plan:
o Beacon Health Options, Brown and Toland, Chinese Community Health Care
Association, Hill Physicians Medical Group, Kaiser Foundation Health Plan, and North East Medical Services.
Pharmacy Services – Kaiser Health Plan Foundation and Perform Rx are delegated to manage pharmaceutical services on SFHP’s behalf.
Complex Case Management –The following groups are delegated to conduct CCM activities as defined by DHCS:
o Brown and Toland, Chinese Community Health Care Association, Hill Physicians Medical Group, and North East Medical Services.
The following group is delegated to conduct CCM activities as defined by NCQA: o Kaiser Foundation Health Plan.
Non-Specialty Mental Health – Kaiser Foundation Health Plan is delegated to provide behavioral health services to all of its SFHP Medi-Cal members. Beacon Health Options provides non-specialty mental health services to all other SFHP Medi-Cal members. Community Behavioral Health Services (CBHS) provides all non-specialty and specialty behavioral services to SFHP Healthy Kids and Healthy Workers members.
Quality Management – Kaiser Foundation Health Plan and Beacon Health Options are delegated for QI.
iii. Delegation Process
As a prerequisite to enter into a delegation agreement, SFHP conducts a pre-delegation evaluation of the prospect delegated functions. Dependent upon the scope of the delegated functions, SFHP requires specific documents and performs a pre-delegation audit. SFHP may waive the pre-delegation audit in lieu
of appropriately documented evidence of NCQA Accreditation or Certification. Once the pre-delegation audit is complete, a Delegation Agreement and Responsibilities and Reporting Requirements (R3) Grid is executed. The R3 Grid describes the specific responsibilities that are being delegated, and provides the basis for oversight. The R3 Grid indicates which activities are to be evaluated through annual audits, and which activities are to be evaluated through more frequent monitoring.
Six to twelve months post execution of the Delegation Agreement, SFHP conducts an audit of all delegated functions. The audit scope and review period are determined by the Provider Network Oversight Committee. The Provider Network Operations Department coordinates the audit process. The audit team is comprised of subject matter experts from the delegated functional areas. SFHP uses audit tools developed based on NCQA standards, DMHC and DHCS regulations. Audit results are communicated to the Delegate within 30 days from the completion of the audit. If deficiencies are identified, a corrective action plan (CAP) is requested. When a CAP is submitted by the
delegate, the SFHP audit team will evaluate the response and issue either an approval or a request for additional information. Annually, the Provider Network Oversight Committee (PNOC), the UM Committee (UMC), and the Quality Improvement Committee (QIC) review a summary of delegated groups audit results, provide feedback or request additional information or corrections from the delegate as needed.
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iv. Additional SFHP Responsibilities
Upon execution of the Delegation Agreement, SFHP retains the authority to:
Conduct a full-scope review at any time.
Annually review key program or policy documents.
Accept or reject the qualifications of all network providers, approve new practitioners and sites,
terminate or sanction practitioners, and report serious quality deficiencies or access issues to
appropriate authorities.
Conduct all member appeals and respond to any complaint or grievance the member elects to
address directly to the Plan.
SFHP may participate in joint audits with other Health Plans. In lieu of conducting an oversight audit, SFHP may accept a Delegate’s NCQA Accreditation or Certification if it is in good standing. SFHP does not waive the right to conduct monitoring activities.
v. De-Delegation
SFHP may partially or fully de-delegate a function. Before de-delegating, SFHP will conduct a full scope audit of the delegate against all relevant standards for the delegated function. In the event of de-delegation, SFHP and the delegate will use best efforts to facilitate SFHP resumption of the delegated function.
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Reviewed & Approved by:
Chief Medical Officer: James Glauber, MD, MPH Date:11/18/2016
Quality Improvement Committee Review Date: 12/8/2016
Board of Directors Review Date: 1/4/2017
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Appendix A: Work Plan
i. Clinical Quality and Patient Safety
1. Measure 2. Measure Summary 3. Target 4. Responsible Staff
5. Activities 6. Final Due Date
7. Status
A Pain Management-
Opioid Safety
SFHP’s Pain Management Program’s aim is to maintain the % of members with at least one opiate agonist prescription at 7.75% or less (across all lines of business, annually).
7.75% Medical Director
• Outreach and provider education through PIP, SF Safety Net Pain Management Workgroup, and updated website resources. • Promote non-narcotic alternatives for pain management, including acupuncture and, cognitive behavioral therapy. • Pharmacy benefit changes, such as initial opiate 7 day supply limit • Addition of chiropractic benefit for members. • GGrant support to expand access to inpatient addiction treatment.
12/31/2018 In progress
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1. Measure 2. Measure Summary 3. Target 4. Responsible Staff
5. Activities 6. Final Due Date
7. Status
B. % of Members
Completing Hepatitis C Treatment
Indicator for % of members cured of Hepatitis C.
35% Director, Pharmacy
• PIP measure/provider outreach incentivizing adoption of Hep C identification and treatment. • Provider grants for at-risk members. • Participation in city-wide End Hep C efforts. • Advocacy to expand criteria of members eligible for treatment.
8/1/2018 In progress
C. Chlamydia Screening
(CHL) Improve chlamydia screening rate.
42.03%
Project Manager, Health Services
Business Relationships
• Medical group meetings to improve HEDIS results. • Outreach to labs to determine if CHL data is being sent. • Outreach to other Medi-Cal Plans to learn best practices for gathering data.
9/30/2018 In progress
D.
Pharmacotherapy Management of
COPD Exacerbation (PCE)
Improve pharmacotherapy management of COPD exacerbation rate.
Rate 1: 58.84%
Rate 2: 84.98%
Project Manager, Health Services
Business Relationships
• Medical group meetings to improve HEDIS results. • Researching pharmacy data from new sources (e.g. inpatient discharge, 340b program).
9/30/2018 In progress
E. Cervical Cancer Screening (CCS)
Improve cervical cancer screening rate.
70.80% Program Manager,
Population Health
• PIP Measure, including enhance funding to incentivize improvement. • Health Education messaging.
6/30/2019 In progress
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F. Medication Therapy Management (MTM)
Increase the number of members mapped to an MTM program intervention.
30% Care Coordination
Pharmacist
• Member enrollment • Promote MTM intervention in Care Support, CMCM, and Health Homes. • Work on Phase 2 enhancements, plan workflow for Health Homes. • Plan for Phase 3 if needed, prepare MTM for Health Homes starting July 2018.
6/30/2018 In progress
ii. Quality of Service and Access to Care
1. Measure 2. Measure Summary 3. Target 4. Responsible Staff
5. Activities 6. Final Due Date 7. Status
A. Member Grievances
Increase the rate of member grievances resolved in a timely manner.
100% Grievance
Analyst
• Review trends for both clinical and non-clinical grievances. • Develop strategies to improve timeliness of provider response. • Shared metric/incentive across departments to promote accountability among all staff involved in grievances.
6/30/2018 In progress
B.
Getting Care Quickly & Getting Needed Care Rating (HP-
CAHPS)
Increase the rate of members who report getting care quickly and getting needed care.
Getting Care Quickly: 71.1%
Getting Needed Care: 71.5%
Program Manager, Access
& Care Experience
• Provider Grant program to support point of service feedback and technical assistance. • Increase monitoring of network access and request
6/30/2018 In progress
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1. Measure 2. Measure Summary 3. Target 4. Responsible Staff
5. Activities 6. Final Due Date 7. Status
Corrective Actions when needed. • Identify access-related issues via the Access to Care Committee, and develop plans to address found issues. • Pilot three-way scheduling calls between SFHP and provider offices. • Redesign marketing communications to mirror CAHPS language. • Conduct member focus groups.
C. Potential Quality
Issues (PQI)
Increase the rate of PQIs resolved in a timely manner.
100%
Quality Review Nurse, Clinical
Operations
• Triage of Care Management case referrals by QI Review Nurse. • Identification and monitoring of Provider Preventable Conditions. • Refine PQI workflow to maximize functionality.
6/30/2018 In progress
iii. Utilization Management
1. Measure 2. Measure Summary 3. Target 4. Responsible Staff
5. Activities 6. Final Due Date
7. Status
A. Non-specialty mental Increase the rate of 4.5% Adults Chief Medical • Expand tele-behavioral health 6/30/2018 In progress
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1. Measure 2. Measure Summary 3. Target 4. Responsible Staff
5. Activities 6. Final Due Date
7. Status
health (NSMH) Penetration Rate
members utilizing NSMH Services.
Officer • PIP Depression screening measure
• Promote benefit to members
• Follow-up with members after referral
B.
Members with primary care visit in last 12
months
Increase percentage of members with at least 1 PCP visit in the past 12 Months.
67%
Program Manager, Access
& Care Experience
• Promote use of primary care telehealth. • Develop member incentive to target members without a PCP visit. • PIP measure to incentivize providers.
6/30/2018 In progress
iv. Care Coordination and Services
2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
A. Screening for Clinical Depression
Increase the percentage of clients in SFHP's Care Management programs successfully screened for clinical depression.
70% Director, Care Management
• Conduct analysis of depression screening results for both PHQ-2 and PHQ-9. • Design workflows to ensure members in care management are screened.
12/31/2018 In progress
B. Follow up on Clinical Depression
Increase the percentage of clients in SFHP's Care Management programs with follow up to address clinical depression.
70% Director, Care Management
• 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.
12/31/2018 In progress
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2. Measure 3. Measure Summary 4. Target 5. Responsible Staff
6. Activities 7. Final Due Date
8. Status
C.
Care Management Client Satisfaction with Staff
Improve member's experience with the staff.
80% Director, Care Management
• Review themes in dissatisfaction. • Work with staff to improve satisfaction.
12/31/2018 In progress
D.
Care Management Client Perception of Health
Increase the percentage of SFHP’s Care Management client who improve their perception of their health after closing assessment.
60%
Care Management Project Management Coordinator
• Report on Question 1 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.
12/31/2018 In progress
v. Quality Oversight Activities
Oversight Summary Resp. Staff Activities Due Date
A Quality Improvement Committee
Ensure Quality Improvement Committee (QIC) oversight of QI activities outlined in the QI Plan
CMO Six meetings to be held in 2017 12/30/2018
B Pharmacy and Therapeutics Committee
Ensure oversight and management of the SFHP formulary and DUR initiatives
CMO Quarterly and ad hoc P&T
Committee meetings 12/30/2018
C
Provider Advisory, Peer Review, and Credentialing Committee
Ensure oversight of credentialing and peer review by the Provider Advisory Committee
CMO Six meetings to be held in 2017 12/30/2018
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Oversight Summary Resp. Staff Activities Due Date
D Annual Evaluation of the QI Program
Review Quality Improvement plan and determine efficacy of implemented plan based on outcomes
Director, Health Outcomes
Improvement
Evaluate each measure in the QI work plan
QIC review of QI evaluation
Governing Board review of QI Evaluation
3/1/2018
E QI Plan Approval for Calendar Year
Review and approve proposed Quality Improvement work plan
Director, Health Outcomes
Improvement
QIC review of QI work plan
Governing Board review of QI Work Plan
3/1/2018
F Delegation Oversight for QI Ensure oversight of QI for all delegated entities
Director, Health Outcomes
Improvement
Follow delegation oversight procedures
QIC review of Delegated Oversight Audits for QI
12/30/2018
G DHCS Performance Improvement Projects
Ensure oversight and follow through on required DHCS Performance Improvement Projects (PIPs)
Director, Health Outcomes
Improvement
Attend DHCS-led PIP calls.
Adhere to process delineated by DHCS.
12/30/2018
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Appendix B: Quality Improvement Committee Structure
Quality Committees Reporting to Governing Board
SFHP Governing
Board (GB)
Quality Improvement
Committee (QIC)
Physician Advisory/Peer Review/Credentialing
Committee (PAC)
Pharmacy & Therapeutics
Committee (P&T)
Member Advisory Committee (MAC)
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Operational Quality Committees Reporting to Chief Medical Officer
Chief Medical Officer –
James Glauber, MD, MPH
Clinical Oversight
Committee (COC)
Access to Care
Committee (ATC)
Practice Improvement
Program (PIP) Advisory
Committee
Grievance Oversight
Committee (GOC)
Grievance Review
Committee (GRC)
Utilization
Management
Committee (UMC)
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Quality Committee Reporting to Compliance and Regulatory Affairs Officer
Compliance and
Regulatory Affairs
Officer –
Nina Maruyama
Policy & Compliance
Committee (PCC)
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Quality Committee Reporting to Chief Operations Officer
Chief Operations Officer
– Deena Louie
Provider Network Oversight
Committee (PNOC)
1
SAN FRANCISCO HEALTH PLAN
2017
QUALITY PROGRAM EVALUATION
PROPRIETARY AND CONFIDENTIAL
2
TABLE OF CONTENTS
INTRODUCTION ....................................................................................................................... 3
EVALUATION OF CLINICAL QUALITY IMPROVEMENT INITIATIVES ..................................... 4
Depression ............................................................................................................................. 4
Attention Deficit Hyperactivity Disorder (ADHD) ..................................................................... 6
CONTINUITY AND COORDINATION OF CARE MONITORING ACTIVITIES ........................... 9
Continuity and Coordination of Care ....................................................................................... 9
SERVICE IMPROVEMENT ACTIVITIES ...................................................................................11
Appointment Accessibility and Availability .............................................................................11
Telephone Access .................................................................................................................13
Cultural and Linguistic Program .............................................................................................14
PATIENT SAFETY ....................................................................................................................17
Timeliness of Handling Member Complaints ..........................................................................17
Timeliness of Incident Reporting ............................................................................................18
EVALUATION OF THE EFFECTIVENESS OF THE QUALITY PROGRAM ..............................19
ATTACHMENT 1 ......................................................................................................................21
ATTACHMENT 2 ......................................................................................................................25
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INTRODUCTION The scope of the Beacon Cypress Service Center (CSC) Quality program encompasses the ongoing assessment, monitoring and improvement of all aspects of care and service delivered to members, including member safety. The population served is diverse, representing multiple cultural and linguistic groups and includes pediatric, adult and geriatric individuals in the state of California. The lines of business managed out of CSC include Commercial, Exchange (marketplace), Medicare and Medicaid (Medi-Cal). The membership for the Cypress Service Center for 2017 was approximately 4,648,842. The CSC has maintained the NCQA MBHO accreditation for Commercial, Exchange (marketplace), Medicare and Medicaid lines of business under Beacon Health Strategies, LLC. with reaccreditation submission scheduled for September, 2018. The Quality Program evaluation serves to assess the overall effectiveness of the Quality Program, including the effectiveness of the committee structure, the adequacy of the resources, practitioner and leadership involvement, the strengths and accomplishments of the program, and the Service Center’s performance in quality of clinical care and quality of service initiatives. The Annual Evaluation of Beacon’s Quality Programs for San Francisco Health Plan (SFHP) is presented in this report. The information presented includes results from clinical and service quality improvement activities for the Medi-Cal line of business. Please note that claims based measures presented in this report reflect data run through October 31, 2017, and will be updated in March, 2018 to reflect claims run out for Service Year 2017. Additionally, claims data reported in this report include BH claims only and do not include medical or pharmacy claims.
4
EVALUATION OF CLINICAL QUALITY IMPROVEMENT INITIATIVES Beacon’s clinical and service quality improvement initiatives are discussed below. Under each performance measure, the following elements are presented:
Goal
Interventions implemented
Results
Results analysis
Barrier analysis, and
Next Steps
Depression Goal: Improve the percentage of members 18 years of age and older with a diagnosis of major depression who are newly treated with antidepressant medication, and who remain on antidepressant medication treatment (HEDIS Antidepressant Medication Management (AMM) measures and American Psychiatric Association CPG measures). Interventions implemented
Continued to review, approve and disseminate guidelines on depression as part of the guideline review process through Quality Packets, PCP Toolkit and Provider Bulletin.
Continued to educate providers (BH and PCPs) on Beacon’s Quality Program through distribution of “Quality Packets” as well as through PCP Toolkit on Beacon website.
Continue to educate Beacon providers and PCPs about information and updates to all Depression Management tools that are available on the website via postcard and Provider Bulletin. Annual Provider Postcard distributed to 1,367 providers in September, 2017.
Through Provider Bulletin, educated providers regarding the treatment record documentation standards as it facilitates communication, and promotes effective and efficient treatment (January 2017).
In lieu of pharmacy and medical claims, identified providers treating members 18 years or older diagnosed with depressive disorder and outreached those providers with education materials around HEDIS AMM. Number of SFHP providers outreached in 2017 include:
o 52 in May and June, 2017 o 23 in September, 2017
Updated chart review request letter in order to improve chart review scores by adding depression specifics below (June, 2017):
o Medication list and any known allergies o Clinical intake materials assessments or intake progress notes that includes risk and
depression screening
Conducted PCP Webinar to promote the PCP Toolkit which now links interactively with Achieve Solutions, Beacon’s health and wellness information library (17 providers attended October, 2017).
Commenced HEDIS and Depression Screening Workgroups focused on improving performance on Depression measures including HEDIS Depression Screening and Follow-up for Adolescents and Adults (DSF) and HEDIS AMM (July, 2017).
Enhanced Beacon website to include link to Achieve Solutions health library, which includes articles, quizzes, resources, and interactive self-assessment tools related to depression on member pages.
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Results
Measures Goal 2015 2016 2017
1. Clinical Practice Guideline Measure:
The percentage of members (18+)
newly diagnosed with depressive
disorder who received two (2) or more
Behavioral Health (BH) visits within 84
days of diagnosis. (Claims)
50.0% 53.6% (52/97)
44.2% (91/206)
54.8%* (102/186)
2.
a. The percentage of members (18+) newly diagnosed with depressive disorder who received one (1) or more medication visits within 90 days of diagnosis. (Claims)
20% 2.0% (2/100)
12.1%* (25/206)
16.7% (31/186)
b. The percentage of members (18+) newly diagnosed with depressive disorder who received one (1) or more medication visits within 90 days of the first medication visit. (Claims)
95% 100% (2/2)
92.0% (23/25)
87.1% (27/31)
*Statistically significant change from the previous reporting period using z-test for proportions at p<0.05
Result Analysis The percent of members ages 18 years and older with depressive diagnosis who received two or more visits within 12 weeks of initial diagnostic visit met the established goal at 54.8% in 2017, resulting in significant improvement from 2016 to 2017. Although the target for measure 2a fell short of the goal, there was an improvement to the percent of members ages 18 years and older with depressive diagnosis who received one or more medication visits within 90 days of diagnosis. Of members receiving one or more medication visit, 87.1% had another follow up appointment within 90 days of their first medication visit indicating strong medication adherence. Barrier Analysis As Beacon has access to BH claims only, Beacon is unable to capture members that may have received BH services from their PCP; consequently, measurement estimates may be artificially low. Below are additional barriers believed to affect members’ depression treatment:
Claims data used for this report was ran on October 31, 2017, which does not provide complete representation for services provided throughout 2017.
Members may be reluctant to seek treatment due to social stigma or cultural barriers.
Members may not adhere to instructions for treating depression and the provider may have a poor follow up plan.
Members may stop attending therapy sessions if they do not feel better immediately.
Members with depression may have chronic co-morbid medical conditions that could make accessing outpatient care for depression more difficult.
Members may not be aware that it takes time for the medication to take effect, and may discontinue if they do not see changes immediately, and if they experience side effects.
Members may discontinue medication when they start feeling better.
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Next Steps
Research and review current guidelines on Depression. Disseminate guidelines to provider network once approved by Beacon Scientific Review Committee (SRC) and Corporate Medical Management Committee (CMMC).
Continue the efforts to collaborate with health plan to identify and outreach to newly prescribed members that qualify for HEDIS AMM measure with educational materials around common side effects and the importance of follow-up appointments. Similarly, outreach and educate prescribers, both BH and PCP around HEDIS AMM measure and best practice.
Continue to educate Beacon providers and PCPs about information and updates to all depression management tools that are available on the website via Provider Postcard and Provider Bulletin (Annual).
Promote use of online resources to members and providers through plan newsletters Beacon Provider Bulletins, site visits and Provider Advisory Councils.
Continue the efforts to collaborate with the health plan around exchange of Medical and Pharmacy data for production of HEDIS AMM and accurate production of CPG measures. Additionally, access to real time data will ensure real time and effective interventions.
Explore opportunities to promote best practices for treatment of members with chronic medical and BH conditions, such as complex care management models and initiatives for members with dual eligibility (Ongoing).
Conduct a comprehensive HEDIS training for all clinical staff to educate them on all HEDIS measures including AMM and best practices to their day-to-day activities, especially when working with members and providers.
Ensure depression materials and screening tools on website are up-to-date and easily available (Ongoing).
Attention Deficit Hyperactivity Disorder (ADHD) Goal: Improve the rate with which children are screened and treated for attention-deficit/hyperactivity disorder (ADHD) (American Academy of Child and Adolescent Psychiatry (AACAP) CPG measures). Improve the rate with which children newly prescribed ADHD medication have at least three follow-up care visits within a 10-month period, one of which is within 30 days of when the first ADHD medication was dispensed (HEDIS Follow-Up Care for Children Prescribed ADHD Medication (ADD) measures). Interventions completed
Collaborated with SFHP to review pharmacy data looking for children with ADHD diagnosis that had medications prescribed. Results showed low diagnosis rates and very low medication prescribing rates (Q1, 2017).
Data from pharmacy review used to develop presentation to group of pediatricians to educate about ADHD and medication algorithm (October, 2017).
Collaborated with SFHP on Provider Newsletter article and Member Newsletter article.
Initiated ADHD QIA focused on designing and implementing improvements in areas that Beacon identifies as key thus improving quality of care and services for our members, providers and health plans (June, 2017).
Continued to promote the use of online resources to members and providers through Beacon Provider Bulletins, site visits and Provider Advisory Councils.
Continued to educate providers (BH and PCPs) on Beacon’s Quality Program through distribution of “Quality Packets” as well as through PCP Toolkit on Beacon website.
Collaborated with local MPPs around educational materials for providers.
Through Provider Bulletin, educated providers regarding the treatment record documentation standards as it facilitates communication, and promotes effective and efficient treatment (January, 2017).
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Through Provider Bulletin, educated providers regarding HEDIS ADD measure in order to improve the quality and effectiveness of the care provided (September, 2017).
In lieu of pharmacy and medical claims, identified providers treating members with ADHD between the ages of 6-12 years and outreached those providers with education materials around HEDIS ADHD as well as Beacon's medication treatment algorithm. Number of SFHP providers outreached:
o 5 in May and June, 2017 o 2 in September, 2017
Conducted PCP Webinar to promote the PCP Toolkit and the use of online resources by members and providers, including the PCP Toolkit that includes new screening tools and ADHD rating scales (17 providers attended October).
Updated chart review request letter in order to improve chart review scores by adding ADHD specifics below (June, 2017):
o Medication list and any known allergies o Clinical intake materials assessments or intake progress notes that includes ADHD
screening for members age 12 and under
Enhanced Beacon website to include link to Achieve Solutions health library, which includes articles, quizzes, resources, and interactive self-assessment tools related to ADHD on member pages.
Results
Measures Goal 2015
2016 2017
1. The percentage of members ages 6-12
years old with a diagnosis of ADHD,
who had an OP psychopharmacology
visit within 30-90 days following the
initial diagnostic visit. (Claims)
20% 0.0% (0/4)
0.0% (0/4)
0.0% (0/9)
2. The percentage of members ages 6-12
years old with a diagnosis of ADHD,
who had an OP psychopharmacology
visit within 30-90 days following the
initial diagnostic visit and had an
additional follow up visit within 30-90
days following the qualifying
psychopharmacology visit. (Claims)
70% NA (0/0)
NA (0/0)
NA (0/0)
3. The percentage of members ages 6-12
years’ old who are assessed for ADHD.
(Chart Review)
95% 0.0% (0/1)
0.0% (0/4)
0.0% (0/4)
4. The percentage of members ages 6-12
years’ old who screened positive for
ADHD and have family involvement in
the treatment. (Chart Review)
95% NA (0/0)
NA (0/0)
NA (0/0)
5. The percentage of members ages 6-12
years’ old who screened positive for
ADHD and showed evidence that he or
she was referred to or participated in a
medication evaluation. (Chart Review)
90% NA (0/0)
NA (0/0)
NA (0/0)
Result Analysis
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Based on the claims data, only nine members between the ages of 6-12 were diagnosed with ADHD in 2017. Of the nine members identified as having an initial diagnosis of ADHD, none demonstrated evidence of having an OP psychopharmacology visit within 30-90 days of initial diagnostic visit. In addition to claims based measures, data was also monitored using chart audits. Twenty charts were reviewed in 2017 for SFHP. Of the twenty charts, four charts were of members between the ages of 6 and 12. And of the four reviewed in service year 2017 for members between the ages of 6-12 years old, none were assessed for ADHD. Barrier Analysis Beacon’s treatment record review process for high volume SFHP providers is an annual process. For each health plan, Beacon aims to review 36 charts annually, 18 for children and adolescents, and 18 for adults. As ADHD measures are for children between the ages of 6-12, there may not be enough high volume providers that treat children specifically from whom sample can be drawn. Additionally, members are selected based on the number of claims (>3 claims) received from the provider in the lookback period to ensure comprehensive treatment record and progress notes, hence reducing the sample size further. For claims based data, as Beacon only has access to BH claims. As a result, SFHP looked at 3 years of pharmacy claims data to determine rates of children diagnosed with ADHD, and prescribed medication. This information was shared with Beacon, but is not captured through Beacon claims and affects the medication management rates. Below are additional barriers we believe affect members’ ADHD treatment.
Parents of newly diagnosed members lack an understanding of the recommended treatment protocol for ADHD, including the importance of seeing a BH practitioner for follow-up.
Parents may be reluctant to have their children on medication for ADHD due to concerns regarding side effects.
Members or their parents may not adhere to instructions around taking medication.
Parents may change dosage or stop medication for their children to correct the negative side effects experienced by their children without consulting the prescribing psychiatrist.
Providers may not be scheduling follow up appointments but leaving the responsibility up to the member and/or parent.
Providers may not be regularly educating their members to not discontinue medication if they experience negative side effects, but to schedule a follow up appointment with the prescriber.
In situations where member follows up with their PCP rather than their prescribing psychiatrist, lack of coordination between medical and BH providers regarding issues experienced by the member such as side effects and actions taken such as change in medication dosage, may further delay prescribers from outreaching to members for follow up appointments.
Next Steps
Ensure the availability of charts on regular basis to obtain valid data.
Continue to educate providers through trainings on specific topics, Provider Advisory Council, Provider Bulletins and articles.
Collaborate with health plans to identify and outreach to newly prescribed members that qualify for HEDIS ADD or ADD like measures with educational materials around common side effects and the importance of follow-up appointments. Similarly, outreach and educate the prescribers (BH and PCP) around best practice and HEDIS ADD measure.
Based on chart review results, continue to provide feedback on provider’s performance and documentation. Send letters to providers with tips for improving performance.
Encourage the use of appropriate screening tools and CPGs through the distribution of the annual provider postcard.
Continue to educate providers on Beacon’s Quality Program through the distribution of Inpatient, Outpatient, and PCP “Quality Packets” (Ongoing).
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CONTINUITY AND COORDINATION OF CARE MONITORING ACTIVITIES
Continuity and Coordination of Care (COC) Goal: Improve the continuity and coordination between behavioral health providers, both acute and ambulatory, and primary medical care providers. Interventions completed
Developed COC QIA focused on designing and implementing improvements in areas that Beacon identifies as key, thus improving quality of care and services for our members, providers and health plans (Q3, 2017).
Shared article with providers regarding the importance of coordination of care, including getting patients to complete an authorization for release of information to the PCP (March, 2017).
Through Provider Bulletin, educated providers regarding the treatment record documentation standards as it facilitates communication, coordination and continuity of care (January, 2017).
Continued to emphasize during the New Provider Orientation Beacon’s expectation that providers work collaboratively with PCPs, other BH providers, and community based organizations (5 trainings sessions held in 2017).
Continued to educate high volume providers on the importance of communicating and coordinating with PCPs through the PCP Toolkit and web based tools and the Provider Bulletin.
Collaborated with the health plan to educate PCPs on collaborating with the member’s BH providers as well as availability of PCP Toolkit and other tools on Beacon website.
Monitored provider performance using chart review process and sent providers the results of their 2017 audits with suggestions to improve their scores on measures regarding communication with other BH provider and with PCPs.
Updated chart review request letter in order to improve chart review scores by adding COC specifics below (June, 2017): o Release of information for member's PCP or any other treating BH provider o Documentation of any treatment collaboration
Continued to make the PCP/BH Communication Form available to all providers. Results
Measures Goal 2015
2016 2017
1. The percentage of members for whom
their OP behavioral health (BH)
practitioners have obtained at least one
Release of Information, Authorization, or
Consent to speak with at least one other
OP mental health or OP substance
abuse treatment provider. (Chart Review)
80% 60.0% (6/10)
66.7% (6/9)
80.0% (4/5)
2. The percentage of members for whom their OP BH practitioner contacted, collaborated, received clinical information from or communicated in any way with another OP provider regarding member’s clinical care. (Chart Review)
80% 33.3% (2/6)
66.7% (6/9)
50.0% (2/4)
3. The percentage of members for whom
their OP BH practitioners have obtained
a release of information to communicate
with their PCP. (Chart Review)
80% 100% (13/13)
100% (29/29)
50.0% (2/4)
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4. The percentage of members for whom their OP BH practitioners have contacted, collaborated, received clinical information from or communicated in any way with the PCP. (Chart Review)
80% 84.6% (11/13)
100% (29/29)
0.0% (0/3)
5. The percentage of members whom their OP BH practitioners use the Beacon or other standardized PCP/BH communication. (Chart Review)
TBD
100% (9/9)
100% (29/29)
0.0% (0/2)
Result Analysis Outpatient BH-BH Communication: Of the twenty charts reviewed, only five (5) members had prior or current other BH provider. The percent of records with evidence that release of information, authorization or consent was obtained from the member to speak to another BH provider was at 80.0%. The percent of records that had evidence of communication between the treating BH provider and member’s other BH provider (if any) was 50.0% for 2017. Outpatient BH-PCP Communication: Of the twenty charts reviewed, four had identifiable PCPs. Of those, 50% had evidence a release of information was obtained from the provider to speak to the member’s PCP in 2017. Lastly, none of records indicated any evidence of communication between treating BH provider and member’s PCP or the use of a standardized communication form. Barrier Analysis
Members may be hesitant to share their BH conditions with their PCPs and may not provide consent for communication.
Members may report that they do not have an assigned PCP or do not know their assigned PCP.
Providers may attempt to obtain releases, but fail to document the attempt in the member’s chart. Next Steps
Continue to monitor provider performance using chart review process and send providers the results of their 2017 audits with suggestions to improve their scores on measures regarding communication with other BH provider and with PCPs.
Continue mandatory annual Beacon training for all Beacon Clinicians regarding documentation standards.
Collaborate with the health plan to educate PCPs on collaborating with the member’s BH providers as well as availability of PCP Toolkit and other tools on Beacon’s website.
Share results of survey with providers along with tools targeted towards barriers identified through survey.
Ensure all coordination of care materials on website are up-to-date, easily available, and consistent across all plans (Ongoing).
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SERVICE IMPROVEMENT ACTIVITIES
Appointment Accessibility and Availability Goal: To improve member accessibility to medically necessary behavioral health ambulatory care that meets timeliness standards for the individual’s perceived urgency of the situation and physical access standards as well. Interventions completed
Developed Access and Availability (A&A) QIA focused on designing and implementing improvements in areas that Beacon identifies as key thus improving quality of care and services for our members, providers and health plans (June 19, 2017).
Continued quarterly provider survey to capture providers’ availability to see members within 6 hours, 48 hours and 10 business days as well as provider and staff language/cultural capability and specialty (March and July, 2017).
Through deployment of new email software, conducted targeted follow up with providers who are non-responsive to quarterly provider access survey (Q1, 2017).
Created internal ticketing system for staff to report provider demographic and access issues. System will allow for tracking and reporting of issues. Interventions will be developed based off of findings (April, 2017).
Worked in conjunction with the Beacon Provider Partnerships and Provider Relations Departments to identify providers who are out of compliance with access standards to create Performance Improvement Plans.
Continued educating staff (clinicians and member services staff) on the availability and location of triage and referral manual that outlines procedures for Emergent, Urgent and Routine calls.
Developed trigger through Clinical when members request a prescriber in areas where Beacon does not have face-to-face prescribers (Q3, 2017).
Through monthly Provider Bulletin, continued to educate provider network on appointment access standards (January, 2017).
Through monthly Provider Bulletin, provided workflow for no-show appointments to assist providers with patients who schedule an appointment and do not show up (January & February, 2017).
Continued expanding Telehealth program, both site based as well as home based, in areas with identified need.
Results
a. Appointment Assistance Data:
Measure Goal 2015 2016 2017
1. The percent of members accessing non-life-threating emergent behavioral healthcare within 6 hours of request.
100% NA (0/0)
NA (0/0)
NA (0/0)
2. The percent of members accessing urgent behavioral healthcare within 48 hours of request.
100% NA (0/0)
NA (0/0)
NA (0/0)
3. The percent of members accessing routine behavioral healthcare within 10 business days of request.
85% Overall: 80.0% (4/5) Non-Prescriber: 100% (3/3)
Overall: 75.0% (3/4) Non-Prescriber: 75.0% (3/4)
Overall: 80.0% (8/10) Non-Prescriber: 88.9% (8/9)
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b. Member Satisfaction Data:
c. Member Complaints:
d. Provider Availability through GeoAccess analysis:
See Attachment 2 Result Analysis Appointment Assistance data: In 2017, there were no non-life-threating Emergent (6 hour) or Urgent (48 hours) requests received. Eight requests for prescriber Routine (10 business days) appointment assistance were received and 80.0% were met within the timeframe. Member Satisfaction Survey: Based on the member satisfaction data, the measure related to non-life-threating Emergent (6 hours) and Urgent appointments (48 hours) and Routine (10 business days) did not meet the goal of 85% in 2016. It is important to note that this is self-reported data and member’s interpretation of Emergent and Urgent appointments may be different from providers’ criteria resulting in lower satisfaction by members around access to providers for Emergent and Urgent appointments. The 2017 Member Satisfaction Survey results will be available summer of 2018. Member Complaints: In 2017, there were three grievance received by Beacon regarding Access to Care which meets the target of less than 1 grievance per 1,000 members. GeoAccess data: Detailed provider availability data based on GeoAccess data is available in Attachment 2. Based on this data, the standard regarding distance (1 provider within 10 miles or 30 minutes) was met for all OP services (PhD, LCSW, LMFT) and prescribers (MD, DO, NP). The numeric standard (Practitioners/ Providers: Members) was not met for any provider or service type. Barrier Analysis
Providers’ availability in providing appointments within 10-business day timeframe.
Prescriber: 50.0% (1/2)
Prescriber: NA (0/0)
Prescriber: 0.0% (0/1)
Measure Goal 2015 2016 2017
1. Was Beacon able to refer you to the care you needed within 6 hours?
85% 58.3% (7/12)
65.1% (28/43)
TBD
2. Was Beacon able to refer you to the care you needed within 48 hours?
85% 50.0% (5/10)
71.4% (30/42)
TBD
3. Were you offered your first appointment within 10 business days of your call?
85% 78.9% (30/38)
78.0% (110/141)
TBD
Measure Goal 2015 2016 2017
Number of complaints regarding access to care per 1,000 members
<1/1,000 1 (0.008/1,000 members)
1 (0.008/1,000 members)
3 (0.020/1,000 members)
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Provider not returning voicemails on timely basis.
Providers’ availability to accept new members due to members cancelling appointments or “no show”.
Member’s definition of Urgent appointments may not commiserate with the definition used to determine urgency by providers.
Next Steps
Continue quarterly provider access and availability survey to ensure providers are available to take members within the 6-hour, 48-hour, and 10 business day time frames and Beacon directory is updated with real time data.
Continue to conduct targeted follow up with providers who are non-responsive to quarterly provider access surveys through email software.
Continue to explore various means of capturing appointment accessibility data such as through complaints, claims, appointment request and survey.
Continue publishing articles in the Provider Bulletin around Beacon’s access standards.
Telephone Access Goal: Maintain the rate at which member and provider calls are answered in a timely manner, and reduce the rate that calls are abandoned. Interventions completed
Educated and trained staff on the new Customer Service Call Audit Tool as part of Customer Service Initiative which will include the utilization of courtesy (January, 2017).
Updated Customer Service Call Audit Tool to include courtesy statements to enhance customer service experience (February, 2017)
Continued to hire more Member Services Representatives (MSR) with previous customer service experience to ensure better quality of service to members.
Continued to educate staff on the documentation of call types to improve tracking and monitoring.
Continued to improve upon workforce management and develop increased oversight of call center operations as it relates to break and lunch schedules, paid time off requests, and personal time.
Initiated MSR audit process to ensure call accuracy and documentation accuracy in FlexCare.
Continued to provide quarterly workflow refresher trainings to member services (Q3 training on September 27 & 28).
Educated and trained staff on the new Customer Service Call Audit Tool as part of Customer Service Initiative which will include the utilization of courtesy (May, 2017).
Initiated building of a new Member Services Claims Resolution team. This team will solely focus on addressing claims related calls such that issues are resolved timely and member and provider satisfaction continues to improve (March, 2017).
Results
Measures Goal 2015 2016 2017
1. Call Abandonment Rate < 5% 6.3% (167/2,652)
2.8% (65/2,345)
0.08%* (2/2,458)
2. % Answered Within 30 Seconds
> 80% 56.3% (1,493/2,652)
82.5% (1,934/2,345)
96.1%* (2,363/2,458)
3. Average Seconds To Answer
< 30 Seconds 79.7 34.6 4.1
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4. Call Volume NA 2,652 2,345 2,458
*Statistically significant change from the previous reporting period using z-test for proportions at p<0.05
Result Analysis
Interventions implemented throughout the year continue to demonstrate improvement in performance metrics. Targets for call abandonment rate, percent of calls answered within 30 seconds and average seconds to answer exceeded established goals in 2017. It is important to note that percent of calls answered within 30 seconds increased to 96.1% in 2017, a significant increase of thirteen percentage points from 2016. Similarly, average seconds to answer decreased significantly to 4.1 seconds in 2017 compared to 34.6 seconds in 2016. Barrier Analysis
No barriers identified. Next Steps
Continue recruiting efforts to fill open positions timely.
Hire additional staff to work part time during peak times such as Mondays, after holidays, and during lunch hours to ensure all queues are adequately monitored during all times.
Continue to train MSRs on all lines of business to act as back-up to health plan specific teams.
Continue to provide quarterly workflow refresher trainings to member services (Ongoing).
Continue MSR auditing process to ensure call accuracy and documentation accuracy in operating systems.
Cultural and Linguistic Program Goal: To assess and improve healthcare quality and equity by reducing health care disparity, and to deliver culturally and linguistically appropriate health care services to its member population. Interventions completed
Developed and conducted Transgender training for staff.
Continued annual training for Beacon staff on Cultural and Linguistic program (Companywide training completed in May, 2017).
Continued mandatory annual training for providers on Cultural and Linguistic program (Training completed in May, 2017).
Updated and distributed Cultural and Linguistic Staff Toolkit to Beacon staff members (January and September, 2017).
Continued to evaluate linguistic capability and proficiency of Beacon bilingual staff through the ICE Employee Language Skills Assessment Tool.
Continued to utilize the Cultural and Linguistic Workgroup to improve systems, and monitor member access to culturally and linguistically appropriate services. Distributed Cultural and Linguistic Provider Toolkit to providers (Q1, 2017).
Through Provider Bulletin, educate and remind providers regarding 24-hours availability of interpreter services through a Beacon contracted vendor (September, 2017).
Continued supporting providers and practitioners through monthly trainings.
Surveyed provider network quarterly for up-to-date information related to their and their staff cultural and linguistic capabilities.
Published Updated Cultural and Linguistic Toolkit in the Provider Bulletin (November, 2017).
Through Provider Bulletin, distribute a copy of Beacon’s Cultural and Language Member Rights and remind providers to post requirements (April, 2017)
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Results
Measures Goal 2015 2016 2017
Utilization
1. Number and percentage of calls (SFHP) to Beacon that used language interpreter services
NA 8.5% (226/2,652)
26.4%* (620/2,345)
31.0% (763/2,458)
2. The rate of members who requested written translation services
NA NA (0)
NA (0)
NA (0)
3. The percentage of Beacon staff that are bilingual
NA 18.9% (66/350)
19.4% (73/376)
18.2% (77/422)
Turnaround Time
1. The percentage of time that the TTY/TTD services and foreign language interpretation were available when needed by members who called the Beacon’s customer service phone line (CMS measure)
95% 100% 100% 100%
2. The percentage of time the member materials were made available to members in the language they requested within 21 calendar days of request.
95% NA (0/0)
NA (0/0)
NA (0/0)
Member Satisfaction Survey
1. The percentage of members that responded “Yes or No” to member satisfaction question: Do you feel your counselor has met your cultural, religious, or language needs?
85% 87.9% (29/33)
90.7% (137/151)
TBD
2. The percentage of members that responded “Yes or No” to member satisfaction question: In getting mental health services, did you need interpreter or translation services?
NA 14.6% (6/41)
12.7% (21/166)
TBD
2.a. The percentage of members that responded “Yes or No” to member satisfaction survey question: Did Beacon have these services immediately available for you?
85% 80.0% (4/5)
77.8% (14/18)
TBD
Complaints and Grievances
1. Number of grievances per 1,000 members that are around cultural and linguistic issues
<1/1,000 members
NA (0)
NA (0)
NA (0)
*Statistically significant change from the previous reporting period using z-test for proportions at p<0.05
Result Analysis Utilization: The rate that SFHP members utilized language interpreter services in 2017 was 31.0% of all SFHP callers, an increase of five percentage points from 2016. This increase can be attributed to education of
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members, providers and Beacon staff around the availability to provide interpreter services. To meet cultural and linguistic needs of non-English speaking members, 18.2% of Beacon staff who work directly with member were bi-lingual. Turnaround Time: There were no requests for materials to be translated into another language in 2017 by SFHP members. Member Satisfaction: Based on member satisfaction data for 2016, the percentage of members that felt their counselor met their cultural, religious, or language needs exceed the goal by six percentage points. Fourteen out of eighteen members that reported needing interpreter or translation services felt that Beacon had these services immediately available to them. The 2017 Member Satisfaction Survey results will be available summer of 2018.
Grievances/Complaints: There were no grievances related to Cultural and Linguistic issues in 2017. Barrier Analysis
Members may not be aware that they can have materials translated by Beacon. Next Steps
Continue to review and distribute the Cultural and Linguistic Toolkit for providers and staff.
Continue annual training for Beacon staff on Cultural and Linguistic Program.
Continue conducting monthly training for network providers on Beacon’s requirement around program.
Field Member Satisfaction Survey quarterly.
Continue to recruit new providers for the network who can provide cultural and linguistically appropriate services.
Continue to provide monthly Cultural and Linguistic trainings for providers.
Continue to track and trend grievances and complaints for cultural and linguistic concerns.
Continue to share articles with providers regarding the importance of providing culturally and linguistically appropriate services.
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PATIENT SAFETY
Timeliness of Handling Member Complaints Goal: To ensure member needs are met and grievances are resolved in a timely manner. Interventions completed
Presented each grievance received to the SFHP Grievance Review Committee (GRC).
Continue to provide training to Member Services staff, Clinical, and co-located teams regarding grievance process. Training held on March and September, 2017.
Developed grievance process training on an online platform called Relias (Q3, 2017).
Finalized Telehealth workflow and train member services and other responsible staff regarding new workflow and services. Training held in January 2017 and went live on February 6, 2017.
In collaboration with the Provider Relations team, participated in biweekly training for new providers.
Educated providers on Beacon’s expectation around Adverse Incident reporting and the grievance process.
Monitor provider performance. If a provider exceeds the threshold of three (3) complaints in twelve (12) months, provider will be reported to the credentialing committee for review.
Continued network expansion including working with out of network providers to encourage them to join the network.
Continued expanding Telehealth program, both site based as well as home based. Results
Measures Goal 2015
2016
2017
1. Number of complaints by
category:
a. Quality of Care
b. Access to Care
c. Beacon Internal Process
d. Billing and Financial Issues
e. Attitude and Service
f. Quality of Office Site
1/1,000
(1.00)
1. 1 (0.008) a. 0 b. 1 (0.008) c. 0 d. 0 e. 0 f. 0
1. 6 (0.047) a. 0 b. 1 (0.008) c. 4 (0.031) d. 0 e. 1 (0.008) f. 0
1. 6 (0.039) a. 0 b. 3 (0.020) c. 2 (0.013) d. 0 e. 1 (0.007) f. 0
2. Percent of complaints resolved within timeframe (30 CD for routine; 72 hours for urgent)
95% 100% (1/1)
100% (6/6)
100% (6/6)
Results Analysis There were six (6) member complaints that Beacon received directly in 2017. All were resolved within timeframe. Barrier Analysis
No barriers identified at this time as the volume is low and timeframes are being met. Next Steps
Continue to provide quarterly education to Beacon’s member services team as well as clinical staff to offer grievances to members.
Continue presenting grievances to the SFHP GRC as they are received.
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Continue to monitor provider performance related to complaints and report to credentialing committee for review as needed.
Timeliness of Incident Reporting
Goal: To enhance member safety and quality of clinical care by tracking and reporting on Adverse Incidents (AIs) and Quality of Care (QOC) issues. Interventions completed
Continued to review, investigate, track, and trend all AI and act on identified patterns of patient safety violations.
Continued to produce analysis of AIs if occurred in a facility not contracted by Beacon, collaborated with the health plan to complete investigation.
Shared article with providers regarding patient safety and AI reporting requirements and how to report an AI (February, 2017).
Reviewed potential trends related to reportable events and identified actions as needed through the Peer Review Committee/Quality of Care Committee.
Continued to educate and train Member Services, Clinical, and co-located staff regarding AI reporting and QOC Concerns including the need for timely notification to external agencies and Quality Department (Training held in March, 2017 for Q1, 2017 and September, 2017 for Q3, 2017).
Educated new providers on timely notification of AI’s and QOC’s through the new provider orientation training (75 trainings held in Q1, Q2, and Q3, 2017).
Continued educating providers on Beacon’s expectation around AI reporting through the weekly new provider orientation training.
Results
Measures Goal 2015
2016 2017
Percentage of reportable events that are reported and reviewed within specified time frames (reported to plan within 24 hours)
95% NA (0/0)
100% (1/1)
NA (0/0)
Percentage of Quality of Care concerns that are resolved within 30 days
95% NA (0/0)
NA (0/0)
NA (0/0)
Results Analysis There were no reportable events or QOC concerns reported for SFHP members in 2017. Barrier Analysis
NA. Next Steps
Continue current activities and monitoring.
Continue to produce analysis of AI and QOC trends.
Continue to provide ongoing training and support to Beacon staff regarding the reporting and investigation of AIs and other reportable incidents (Quarterly).
Educate providers regarding patient safety and reporting timeframe standards for AIs and other reportable incidents.
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Continue to educate new providers on timely notification of AI’s and QOC’s through the new provider orientation training.
EVALUATION OF THE EFFECTIVENESS OF THE QUALITY PROGRAM
Summary of Strengths include: Beacon implemented several targeted interventions in 2017. As a result, Beacon demonstrated improvements in some areas and identified areas for improvement in others. Clinical Quality Improvement Initiatives Depression: For 2017, the rate at which members ages 18 years and older received two or more outpatient therapy visits within 84 days of their diagnoses was above the goal of 50%. The medication visit scores however were not met. These scores were unmet due to claims lag and unavailability of data from remainder of the year. In addition, the data would not capture those members who are receiving antidepressant medication from their PCPs. Beacon does not manage these benefits and therefore is unable to track whether or not these members had a visit within the measure timeframe. Service Improvement Initiatives Telephone Access: During 2017, call metrics including Abandonment Rate, Average Speed to Answer and Percent of Calls Answered within 30 Seconds met and exceeded established goals. Beacon attributes the improvement to the interventions implemented by Member Services throughout the year including investments in technology, health plan specific teams, and four team leads added to improve efficiency and increase knowledge of membership specific needs. Appointment Accessibility and Availability: Appointment accessibility is measured through five areas: Appointment Assistance, claims based Follow-up Routine Care, Member Satisfaction Survey, Member Complaints, and GeoAccess. According to appointment accessibility data, 88.9% of members requesting Routine appointments (within 10 business days) were able to see a non-prescribing provider exceeding the 85% target. Complaints data regarding access and availability was also below the threshold. Cultural and Linguistic Program: The effectiveness of the Cultural and Linguistic Program is measured through utilization of interpreter services, turnaround time of translated document requests, Member Satisfaction survey results, and Grievance and Complaints related to cultural and linguistic services. To meet the cultural and linguistic needs of non-English speaking members, Beacon increased the number of bi-lingual staff to 77 in Cypress office that work directly with members in 2017. It is noteworthy to mention that an increased percent of members calling Beacon used language assistance interpreter services during 2017 compared to 2016. Patient Safety Member Complaints: There were a total of six (6) grievances handled by Beacon in 2017 for SFHP. All grievances were processed within the required state of California timeframes. The Beacon Quality team continues to provide quarterly training regarding grievances to all member facing staff, including Member Services and Clinical teams.
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Priorities for the 2018 Quality Program include: Depression: Beacon will continue collaborating with health plans on sharing of HEDIS rate including member level details. Efforts toward making providers aware of the AMM measures and encouraging the use of the PHQ-9 assessment tool will be continued in 2018. Additionally, Beacon will also focus on depression screening and monitoring for adolescents and post-partum members. Attention Deficit Hyperactivity Disorder (ADHD): Beacon will select high volume providers who specifically treat children ages 6-12 to gather sufficient chart review based ADHD metrics. This data will be used to identify poor performers and provide feedback and education as needed. Beacon will also collaborate with the health plan on HEDIS ADD rate and possible real time interventions. Beacon will also identify newly diagnosed or prescribed members through behavioral health claims, then track and remind them of the follow-up appointments, as well as send educational material to treating providers. Continuity and Coordination of Care: Beacon will continue to focus on collaborating and expanding the local Continuity and Coordination of Care QIA with other Beacon Regional Offices to share best practices and develop new member centered interventions between BH providers and medical professionals as BH to BH and community based services. Telephone Access: Beacon intends to maintain meeting call metrics by continuing to provide training and hands on monitoring of Member Service Representatives though monthly trainings as well as monthly audits to ensure call and documentation accuracy. Appointment Accessibility: Efforts in 2018 will be focused on educating providers regarding standards for non-life threatening Emergent, Urgent, and Routine appointments. Beacon will continue to capture provider availability through quarterly provider surveys and update the provider directory with current availability, language and specialty in real time. Beacon will continue to utilize the company wide and local QIA around Access Availability to address California specific access issues. In addition, efforts will be made to continue adherence to access standards via the appointment assistance provided by Beacon staff. Beacon will continue to work towards expanding the Telehealth program. Complaints and Adverse Incidents: Beacon continuously educates providers on adverse incidents and the importance of timely reporting. Beacon will also continue to monitor any identified trends by providers and implement interventions or outreach where appropriate. Additionally, quarterly trainings will continue to be provided to all member-facing staff. Beacon will also continue presenting grievances to the SFHP GRC.
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ATTACHMENT 1
Treatment Record Review
Measure Goal 2015 2016 2017
A. Documentation
1. Documentation that the member received a copy of his or her rights
80% 53.8% (7/13)
55.2% (16/29)
95.0% (19/20)
2. Are medication allergies and adverse reactions prominently noted in the record? If the member has no known allergies or adverse reactions, are these noted?
NA
38.5% (5/13)
69.0% (20/29)
60.0% (12/20)
3. Is past medical history easily identified? If not significant medical history, is this noted?
NA 76.9% (10/13)
79.3% (23/29)
65.0% (13/20)
B. Continuity and Coordination – Outpatient to Outpatient
1. Is there evidence in the chart that at least one Release of Information, Authorization, or Consent was obtained to speak with at least one other OP mental health or OP substance abuse treatment provider?
80%
60.0% (6/10)
66.7% (6/9)
80.0% (4/5)
2. Is there evidence that the OP treatment provider received clinical information, contacted, collaborated, or in any way, communicated with another OP provider regarding member’s clinical care?
80%
33.3% (2/6)
66.7% (6/9)
50.0% (2/4)
C. Continuity and Coordination – Outpatient to PCP
1. Is there evidence in the chart that a Release of Information was obtained to communicate with the PCP?
80%
100% (13/13)
100% (29/29)
50.0% (2/4)
2. Is there evidence that the OP treatment provider received information, contacted, collaborated, or in any way, communicated with the PCP?
80%
84.6% (11/13)
100% (29/29)
0.0% (0/3)
3. Is there evidence that the Beacon standardized PCP/BH communication form was used?
NA 100% (9/9)
100% (29/29)
0.0% (0/2)
D. Comprehensiveness of Record (Age at Intake)
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Measure Goal 2015 2016 2017
1. Is there documentation that the member was screened for alcohol or other drug abuse or dependence? (13+)
90%
83.3% (10/12)
52.0%* (13/25)
68.8% (11/16)
2. If the member screened positive, was treatment for AOD included in the treatment plan?
90% 80.0% (4/5)
83.3% (5/6)
25.0% (1/4)
3. If the member screened positive for alcohol or other substance abuse/dependence, was there family involvement in the treatment?
NA
50.0% (1/2)
20.0% (1/5)
25.0% (1/4)
4. If the member is 13-18, was the member screened for depression?
90% 100% (1/1)
100% (1/1)
50.0% (1/2)
5. If the member is 13-18 and screened positive for depression, was suicide risk assessment completed?
90%
100% (1/1)
100% (1/1)
NA (0/0)
6. If the member is 13-18 and screened positive for depression, was there family involvement in the treatment?
NA
0.0% (0/1)
0.0% (0/1)
NA (0/0)
7. If the member is 13-18 and screened positive for depression, was there evidence that s/he was referred to or participated in a medication evaluation for an antidepressant?
NA
0.0% (0/1)
0.0/% (0/1)
NA (0/0)
8. If the member is 13-18, screened positive for depression, and was prescribed a medication for treatment, is there evidence that the OP provider is monitoring for compliance with the medication?
NA
0.0% (0/1)
NA (0/0)
NA (0/0)
9. If the member is 6-12, was the member assessed for ADHD?
95% 0.0% (0/1)
0.0% (0/4)
0.0% (0/4)
10. If the member is 6-12 and screened positive for ADHD, was there family involvement in treatment?
95%
NA (0/0)
NA (0/0)
NA (0/0)
11. If the member is 6-12 and diagnosed with ADHD, is there evidence that s/he was referred to or participated in a medication evaluation?
90%
NA (0/0)
NA (0/0)
NA (0/0)
E. Targeted Clinical Review
23
Measure Goal 2015 2016 2017
1. The DSM-IV Diagnosis is documented that is consistent with the presenting problems, history, mental stats examination and/or other assessment data.
95%
76.9% (10/13)
79.3% (23/29)
70.0% (14/20)
2. Treatment plans demonstrate objective and measurable goals?
80% 84.6% (11/13)
41.4%* (12/29)
70.0% (14/20)
3. Treatment plan includes short term time frames for goal attainment or problem resolution?
80%
84.6% (11/13)
37.9%* (11/29)
70.0% (14/20)
4. Frequency of treatment contact matches the severity of the member’s symptoms?
80% 100%
(13/13) 93.1% (27/29)
100.0% (20/20)
5. Progress notes are goal directed and focused on treatment objectives?
80% 84.6% (11/13)
72.4% (21/29)
70.0% (14/20)
6. Is there any indication that the provider is misrepresenting any services provided, i.e. patterns of duplicate billing?
NA
0.0% (0/13)
0.0% (29/29)
100.0% (20/20)
7. Are there treatment notes to match the claims submitted?
NA 100% (13/13)
100% (15/15)
100.0% (20/20)
8. Is there evidence that an outcome tool was utilized in determining the member’s treatment plan?
NA
63.6% (7/11)
100%* (29/29)
20.0% (4/20)
9. Appropriate informed treatment consent form(s); parent or guardian consent for treatment of minor; include office policies regarding scheduling and financial responsibility
NA
61.5% (8/13)
55.2% (16/29)
95.0% (19/20)
10. Mental Status Exam includes affect, speech, mood, thought content, judgment, insight, attention/concentration, memory and impulse control
NA
76.9% (10/13)
79.3% (23/29)
50.0% (10/20)
11. All risk factors (SI, H/I, CD, History of non-compliance) noted with appropriate intervention and care plan
NA
84.6% (11/13)
72.4% (21/29)
55.0% (11/20)
12. Record indicates what psychotropic medications have been prescribed, including dosage; date prescribed and reflects informed consent noted by MD.
NA
55.6% (5/9)
65.2% (15/23)
75.0% (12/16)
24
Measure Goal 2015 2016 2017
13. For members age 18 or older diagnosed with depression or dysthymia: Was the PHQ-9 tool used to monitor progress of treatment?
NA
33.3% (3/9)
33.3% (5/15)
0.0% (0/3)
14. If question 1 was YES, was the tool used once every four months to monitor progress?
NA 0.0% (0/1)
60.0% (3/5)
NA (0/0)
*Statistically significant change from the previous reporting period using z-test for proportions at p<0.05
25
ATTACHMENT 2 Geographic and Numeric Availability Assessment Report
Practitioner, Provider or
Service Type
Geographic Distribution Numeric Distribution
Standard Performance
Goal Result
Standard (Practitioners/ Providers:
Members) Result
I. Outpatient (OP) Services
Any OP Service (All PhD/
LCSW/MFT)
1 OP practitioner available within 10
miles of a member’s home or
30 minutes from member/enrollee’s ZIP
Code of residence.
95%
Miles Minutes
1:500
1:622
100% 100%
A. Availability of Mental Health and Substance Abuse OP Services
Mental Health (MH) OP Services
1 OP practitioner available within 10
miles of a member’s home or
30 minutes from member/enrollee’s ZIP
Code of residence. 95%
Miles Minutes
1:500 for MH
1:622 100% 100%
Substance Abuse (SA) OP
Services
1 OP practitioner available within 10
miles of a member’s home or
30 minutes from member/enrollee’s ZIP
Code of residence.
NA NA NA
NA
26
B. Availability of Prescription Writing Services
MD/DO/NP
1 MD, DO, NP available within 10 miles of a member’s home or
30 minutes from member/enrollee’s ZIP
Code of residence.
95%
Miles Minutes
1:1,500
1:2,248 100% 100%
C. Availability of Psychological Testing Services
PhD Services
1 PhD available within 10 miles or
30 minutes from member/enrollee’s ZIP
Code of residence.
95%
Miles Minutes
1:2,000
1:2,136
100% 100%
Beacon Health Options 2016 Member Satisfaction Survey Results
San Francisco Health Plan
1 2016 SFHP Member Satisfaction Results
Purpose Beacon Health Options (Beacon) uses the annual Member Satisfaction Survey to ascertain information about member experiences with Beacon covered treatment. Beacon organizes the results of the annual Member Satisfaction Survey to guide activities to improve the quality of care and services members receive and to provide assessments of member satisfaction to health plan partners. Background Beacon continually strives to provide quality service to all members. One of the ways Beacon measures quality is through setting and achieving high standards within Member Satisfaction Survey results. Beacon’s Member Satisfaction Survey is a standardized survey designed to collect members’ ratings of behavioral health treatment and satisfaction with services. The survey tool is comprised of items assessing member experience with specialty behavioral health care including mental health. The services are delivered by specialty behavioral health providers, which include psychiatrists, psychologists, social workers, psychiatric nurses, marriage and family therapists, and other behavioral health specialists. Survey results are based on a randomly selected sample of members from Beacon’s outpatient population. This report summarizes results derived from the Member Satisfaction Survey as applied to a random sample of San Francisco Health Plan (SFHP) Medicaid (Medi-Cal) members. In general, member satisfaction is presented by Summary Rate Scores, which represent the percent of respondents who chose the most positive responses. 2016 Survey Methodology Beacon contracted with Fact Finders Inc. (“Fact Finders”), an independent research company established in 1980 and headquartered in Albany, New York, to administer the 2016 survey. Surveys were administered in the second quarter of 2016 to a sample of SFHP members that received services in 2016. Beacon provided Fact Finders with the database of eligible members for the plan. Fact Finders selected a random sample of SFHP members from the database of eligible members received from Beacon. By selecting a simple, random sample of SFHP members, each eligible SFHP member had an equal probability of being selected for Fact Finders’ sample, thereby helping to mitigate potential biases as a result of sampling methodology. Additionally, Fact Finders also monitored the SFHP samples to match key demographic and product population parameters, as determined by the database of eligible members received (Please see Appendix 2 for demographic comparison between database supplied and respondents.) Fact Finders utilized mail and phone methodology to survey the members. For the phone data collection modality, Fact Finders utilizes computer-assisted telephone interviewing (CATI). All interviews are conducted by Fact Finders' skilled staff interviewers from their data collection facility in Albany, New York. Data collection extended from 9 AM to 9 PM EST Monday through Friday and 11 AM to 3 PM EST on Saturday and Sunday. Members are contacted at varying times and dates to lower the probability of a sample of convenience. Fact Finders also utilized Language Line translators, contracted through Beacon, to assist with members who prefer to be interviewed in languages other than English. For the mail data collection modality, Fact Finders sent out English and Spanish versions of the questionnaires with a translation card that
Beacon Health Options 2016 Member Satisfaction Survey Results
San Francisco Health Plan
2 2016 SFHP Member Satisfaction Results
instructed members on how to receive assistance in understanding the questionnaire. For members that have a preferred language that is a threshold language, the questionnaire was sent to them in their preferred language. The standardized questionnaire used to survey members has been developed by Beacon and Fact Finders in an effort to effectively measure key indicators of quality care and services. The performance goal set by Beacon is a Summary Rate Score of 85% for each question in all domains except overall satisfaction with Beacon (Acceptability), where the standard is 90%. The ability to assess how well Beacon meets these performance goals is important for determining what effect policies or procedures may have on members’ satisfaction with various services. It is through this activity that Beacon has the ability to track changes in results and to measure success, ultimately enabling it to meet the members’ needs and expectations more effectively in the future. For this report, the response rate was calculated as the proportion of completed surveys divided by the total sample minus the ineligible surveys. The calculations are detailed below:
71 (Phone) + 99 (Mail) ______________________________________= 13.2% (Response Rate)
1,704 (Total Sample) – 420 (Ineligible Sample)
Interventions Implemented in 2016 Below are some of the interventions implemented in 2016 that impacted member satisfaction with the services received from Beacon and Beacon’s network of providers. For extensive list of interventions by clinical and service areas, please refer to 2016 Quality Program Evaluation. Customer focused interventions included:
o Continued Access and Availability Quality Improvement Activity (QIA) team meetings, with focuses on improving members’ access to prescribers and non-prescribers.
o Conducted monthly meetings to go over any changes in processes and workflows (Ongoing).
o Continued quarterly provider survey to capture providers’ availability to see members within 6 hours, 48 hours and 10 business days as well as provider and staff language/cultural capability and specialty.
o Continued assisting members in securing an appointment when needed. Rather than just providing a list of providers in member’s geographical area, staff reach out to providers to secure an appointment when requested.
o Continued monitoring Member Services Representative (MSR) on quality of calls to ensure appropriate customer service and proper call technique.
o Enhanced Achieve Solutions on Beacon’s website to include Google Translator which allows members to easily translate materials in their preferred language (December, 2016).
o Distributed a newly updated Member Services employee manual, which includes department specific workflows and training aides.
Beacon Health Options 2016 Member Satisfaction Survey Results
San Francisco Health Plan
3 2016 SFHP Member Satisfaction Results
Staff focused activities included: o Trained all staff on “diversity and cultural and linguistic (C&L) competency”. This
training informed staff of member, provider and staff diversity, language services provided by Beacon (both interpreter and translation), and tips when working with limited English proficiency (LEP) members, seniors, and persons with disability. This should improve Beacon’s customer service and improve member satisfaction. Three hundred and seventy-seven (377) staff completed the training in April, 2016.
o Continued educating staff (clinicians and member services staff) on the availability and location of the triage and referral manual outlining procedures for Emergent, Urgent and Routine calls (April, 2016).
o Trained clinical staff on risk assessment and access standards (November, 2016). o Continued annual training of Beacon staff on cultural diversity (Q2, 2016). o Updated and distributed C&L Staff Toolkit to Beacon staff members (Q2 & Q4, 2016). o Conducted a comprehensive HEDIS® training for all Beacon clinical staff to educate
them on all HEDIS® measures including AMM and best practices that can be applied to their day-to-day activities, especially when working with members and providers (September, 2016).
Provider focused interventions included: o Network department trained new providers joining Beacon network through webinars
and through on-site visits and educated them on areas such as Beacon’s functions, different benefits managed, review of clinical processes, best ways to contact with Beacon as well as Beacon’s expectation of the providers.
o Educated PCPs regarding the PCP toolkit on the Beacon website. In 2016, 14 trainings to PCPs were conducted.
o Shared article with providers regarding treatment record documentation including the need for coordinating care with other BH providers as well as PCPs (May, 2016).
o Through Beacon’s Provider Bulletin, distributed article regarding the importance of coordination of care (June, 2016).
o Continued to educate high volume providers on the importance of communicating and coordinating with PCPs through the PCP Toolkit and other tools available on website as well as provider bulletin.
o Educated provider network on access standards and contractual requirements through monthly provider bulletin (Q1 & Q3, 2016).
o Through the provider bulletin, shared the importance of providing C&L appropriate services (Q4, 2016).
o Continued supporting providers and practitioners through monthly cultural diversity trainings.
o (MPPs continued to work closely with providers on building highly collaborative relationships with providers, driving provider performance improvement through education and data, and identifying top-performing providers for innovative programs/pilots.
Results and Analysis Table of results with 2016 data can be found in Appendix 1.
Beacon Health Options 2016 Member Satisfaction Survey Results
San Francisco Health Plan
4 2016 SFHP Member Satisfaction Results
For the service year 2016, there were 170 respondents. Of those members, majority of the respondents were between the ages of 50-64 (30.4%), 30-39 (25.2%), 40-49 (20.7%), 18-29 (16.3%), and 65 and over at 3.0%. In terms of Race and Ethnicity, majority of the respondents were Caucasian/White at 33.1% followed by Asian at 32.0%. In response to the question, “Which language do you prefer to speak in your home”, 65.5% of the members mentioned English, followed by “other” at 29.2%. Please see Appendix 2 for additional demographic distribution. Overall, in 2016, 91.0% of the respondents were satisfied with Beacon and 92.1% were satisfied with their provider. Lastly, net promoter was calculated to fathom how likely members were willing to recommend Beacon to their friends or family. Net promoter (calculate below) for SFHP was 21 indicating growth and positive member satisfaction with Bacon and its services. SFHP Overall Net Promoter Score = 21 Percentage of Promoters (42.6%) – Percentage of Detractors (21.9%) = 20.7% The questions are categorized into four main domains: Appointment Access and Availability, Acceptability, Scope of Services, and Experience of Care. Provided below is the sub-analysis based on these four categories. Please note that this is the first year of the survey for SFHP therefore the data presented in this report is the baseline. Sub Analysis of Results: Appointment Access and Availability Five questions from the 2016 survey fall under this category. Three of these are related to accessing services within 6 hours for non-life threatening Emergent, 48 hours for Urgent and 10 business days for Routine. Based on these measures, 65.1% of the respondents felt they were referred to the care they needed within 6 hours when in crisis, an increase of seven percentage points since 2015. Similarly, 71.4% of the respondents felt they were referred to the care they needed within 48 hours when needing an Urgent appointment, an increase of 21 percentage points since 2015. For the question around access to providers for Routine appointment within 10 business days, 78.0% of respondents felt they were referred timely in 2016. The fourth measure around access was related to whether the members could reach their provider’s office within 30 minutes. Around 68.9% of respondents responded positively to this question. Lastly, member satisfaction with Beacon’s interpretation and translation services was screened as well. After screening only 21 of the 166 members who responded to the screening question required those services in 2016 and 77.8% of them indicated that these services were available to them when needed. Acceptability Five questions from the 2016 survey fall under this category and all but two exceeded the goal of 85%. The question, “Overall, how satisfied are you with the services you received from your counselor,” 92.1% of the members responded very satisfied or somewhat satisfied. The question around whether the member felt their counselor included them in planning their treatment goals did not meet the goal at 87.2%. The question around whether the member felt their counselor met their cultural, religious or language needs exceeded the goal at 90.7%. Question regarding members’ overall satisfaction with mental health services of Beacon was at 91.0% (exceeding the established goal of 90%) and question regarding whether it was easy of difficult to get the care they needed was at 81.6% (easy).
Beacon Health Options 2016 Member Satisfaction Survey Results
San Francisco Health Plan
5 2016 SFHP Member Satisfaction Results
Scope of Services The Scope of Services category contains five questions. In 2016, three of the five measures exceeded the goal of 85%. The questions around whether the provider protected confidential information, provided all information needed to manage the member’s condition and sent information to PCP was at 95.7%, 84.2% and 57.0%, respectively. Regarding the scope of services provided by Beacon, 93.3% of members felt that Beacon staff were helpful and 94.4% felt that staff explained things in a way they could understand. Experience of Care For all three questions under this category, around 84.9%, 82.0% and 83.1% of the members felt that as a result of the services provided by their provider, they are better able to handle problems, get along with others and manage daily life respectively. Two out of three questions showed improvement since 2015 but fell just short of the established goal (85%). Opportunities for Improvement Urgent, Emergent and Routine care appointment access Increased collaboration between BH and PCPs
Barrier Analysis Providers’ availability to accept new members may change, but there may be delay in
notifying Beacon to update their status. Member’s perception of Emergent and Urgent needs may be different from the clinical
judgments of providers and Beacon staff. Lack of accurate and timely information regarding provider’s availability. Lack of providers in certain service areas that meet specific prescribing and non-prescribing
needs. Certain prescribers in FQHCs may not be willing to see the members unless members
switch their PCP to FQHC also, this may result in member dissatisfaction and delay of services.
Member lack of awareness that Beacon staff can assist with procuring appointments. Members may be confusing their county access experience (especially around Emergent)
with Beacon. Members may not be aware of interpretative service offered by Beacon. Members may not be aware that they can have materials translated by Beacon. Provider need for understanding that communication between BH providers and PCPs is a
contractual obligation. Next Steps
Listed below are interventions focused around those areas and questions that have not met the goal set by Beacon. For other initiatives, please refer to 2016 Quality Program Evaluation.
Beacon Health Options 2016 Member Satisfaction Survey Results
San Francisco Health Plan
6 2016 SFHP Member Satisfaction Results
Access and Availability Continue to monitor access to Emergent, Urgent, and Routine appointments when members
call for services. Continue to connect members with case management and other services that can assist
members in obtaining Emergent appointments within specified timeframes as needed. Continue with quarterly provider surveys and update provider directory with current referral,
access, and language and specialty information. Continue working with Beacon’s MPPs to educate high volume providers around network
issues and to remind them of Beacon’s expectations around appointment availability. Provider Partnerships to use site visits as an opportunity to discuss network issues with the
providers and remind them of Beacon’s expectation of them in terms of communicating with PCPs and appointment availability.
Continue outreaching to providers to keep specialty information up-to-date. Continue publishing articles in the provider bulletin around Beacon’s access standards. In addition to Beacon wide QIA for Access and Availability, continue local workgroup to
discuss and address California specific access issues. Analyze GeoAccess data on a quarterly basis. Continue aftercare coordination initiatives to assist members both in securing appointments
immediately as well as informing members of Beacon’s availability in assisting with securing future appointments.
Utilize multiple modes of communication to remind providers of Beacon’s expectations in terms of communicating with PCPs and appointment availability.
Implement Telehealth to improve access and availability of services for members.
Acceptability Continue to recruit prescribers and other providers based on specialty, C&L, and geographic
needs. Continue using out-of-network data to bring providers into network. Continue to provide on-going training and consultation to providers through:
o Site Visits o Telephone contacts o Online materials o Beacon provider manual o High prescriber mailings o PCP information packets including information on BH and PCP communication and
other best practice methods o Newsletter articles o Annual postcard mailing o Ad hoc email blasts
Continue annual C&L training for all Beacon staff and providers. Continue to recruit new providers for the network who can provide C&L appropriate
services. Commence C&L workgroup to serve as an avenue to develop creative and innovative
interventions with the intentions of improving member access to C&L services.
Scope of Services and Experience of Care
Beacon Health Options 2016 Member Satisfaction Survey Results
San Francisco Health Plan
7 2016 SFHP Member Satisfaction Results
Continue quarterly PAC meetings to receive feedback and suggestions regarding the Quality Improvement efforts (including practitioner based interventions), outcome measures, satisfaction surveys, performance standards and clinical practice guideline.
Establish a QIA around Member Empowerment to encourage members to take an active role in their treatment planning and decision making.
Continue sending out provider communication tools (PCP form and ROI form) to all newly contracted providers in provider welcome packets.
Survey BH providers on how frequently they communicate with PCPs. Analyze member satisfaction annually and implement interventions as appropriate. Educate providers on tools available to facilitate communication. Share Coordination of Care survey results with providers including additional questions
focused on what the provider considers best practices for achieving coordination of care. Promote and train on enhanced PCP Toolkit on the Beacon website. Member Services Department to ensure that all new Member Services Representatives
pass an evaluation prior to taking calls independently. Train all Member Services Representatives on the use of the Beacon website and offer
updated trainings with each enhancement to the website.
Appendix 1
8 2016 SFHP Member Satisfaction Results
Question Number
Survey Item
Goal 2016 Valid n
2016 Summary
Rate*
2015 Valid n
2015 Summary
Rate* Q1 Overall, how satisfied are
you with the services you received from your counselor?
>85% 164 92.1% 40 90.0%
Q2 Do you feel your counselor has included you in planning your treatment goals?
>85% 156 87.2% 39 76.9%
Q3 Do you feel your counselor has met your cultural, religious, or language needs?
>85% 151 90.7% 33 87.9%
Q4 Do you feel your counselor has protected confidential information?
>85% 161 95.7% 40 92.5%
Q5 Do you feel your counselor has provided all the information or resources you needed to manage your condition?
>85% 146 84.2% 35 77.1%
Q6 Do you feel your counselor has sent information or discussed your care with your primary care doctor?
>85% 121 57.0% 24 45.8%
Q7 Can you get to your counselor’s office in less than 30 minutes?
>85% 161 68.9% 40 67.5%
Q8 Were you offered your first appointment within 10 business days of your call?
>85% 141 78.0% 38 78.9%
Q9 As a result of the services provided by your counselor, are you better able to handle problems?
>85% 146 84.9% 35 85.7%
Q10 As a result of the services provided by your counselor, are you better able to get along with others?
>85% 133 82.0% 35 77.1%
Q11 As a result of the services provided by your counselor, are you better able to manage daily life?
>85% 142 83.1% 35 80.0%
Appendix 1
9 2016 SFHP Member Satisfaction Results
Question Number
Survey Item
Goal 2016 Valid n
2016 Summary
Rate*
2015 Valid n
2015 Summary
Rate* Q12 In the last year, did you
have a mental health crisis that needed care right away?
NA 156 35.9% 41 39.0%
Q13 Was Beacon able to refer you to the care you needed within 6 hours?
>85% 43 65.1% 12 58.3%
Q14 In the last year, did you need mental health services quickly, but could wait up to 48 hours for care?
NA 148 36.5% 36 41.7%
Q15 Was Beacon able to refer you to the care you needed within 48 hours?
>85% 42 71.4% 10 50.0%
Q16 In the last year, did you call Beacon about your behavioral health services?
NA 154 49.4% 38 42.1%
Q17 How helpful were the staff?
>85% 75 93.3% 16 81.3%
Q18 Did Beacon staff explain things in a way you could understand?
>85% 72 94.4% 15 86.7%
Q19 Was it easy or difficult to get the care you thought you needed?
>85% 141 81.6% 35 71.4%
Q20 Overall, how satisfied are you with the behavioral health services of Beacon?
>90% 166 91.0% 41 87.8%
Q21 How likely is it that you would recommend Beacon to a friend or family member?
>85% 161 44.7% 41 48.8%
Q22 In getting behavioral health services, did you need interpreter or translation services?
NA 166 12.7% 41 14.6%
Q23 Did Beacon have these services immediately available for you?
>85% 18 77.8% 5 80.0%
* Summary Rate Scores (SRS) generally represent the sum of the most favorable response percentages and are defined to facilitate comparisons.
Appendix 2
10 2016 SFHP Member Satisfaction Results
Profile of Survey Respondents
1. Representativeness of Sample SFHP Sample
Parameters Age Categories 11 and Under 1.5%
12 to 17 3.0% 18 to 29 16.3% 30 to 39 25.2% 40 to 49 20.7% 50 to 64 30.4% 65+ 3.0%
Product Medi-Cal 100%
2. Race and Ethnicity
33.1%14.0%
9.5%32.0%
1.2%2.4%
9.5%1.8%
0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0%
Race/Ethnicity
No Opinion Other
American Indian/Alaska Native Native Hawaiian/Pacific Islander
Asian African American/Black
Latino/Hispanic Caucasian/White
Appendix 2
11 2016 SFHP Member Satisfaction Results
3. Primary Language:
65.5%5.4%
29.2%
1.2%
Primary Language
English Spanish Other No Opinion
