Finding Progress on Timely Access Issues

Transcription

1 Finding Progress on Timely Access Issues Bill Barcellona SVP for Government Affairs, CAPG L. Gordon Moore, MD Senior Medical Director, 3M Health Data Science Group Dan Southard Deputy Director, Office of Plan Monitoring

2 Presentation Outline What is Timely Access? How is Timely Access Assessed by the DMHC? Statutes and Regulations Policies, Procedures and Health Plan Reporting Compliance? MY 2015 and MY 2016 Results What s Ahead? Questions? HealthHelp.ca.gov 2

3 Timely Access Standards Appointment Type Urgent Care (prior authorization not required by health plan) Urgent Care (prior authorization required by health plan) Non-Urgent Doctor Appointment (primary care physician) Non-Urgent Doctor Appointment (specialty physician) Non-Urgent Mental Health Appointment (non-physician) 1 Non-Urgent Appointment (ancillary provider) 2 Timeframe 48 hours from request 96 hours from request 10 business days 15 business days 10 business days 15 business days 1 Examples of non-physician mental health providers include counseling and substance abuse professionals. 2 Examples of a non-urgent appointment for ancillary services include lab work or diagnostic testing, such as a mammogram or MRI or treatment of an illness or injury such as physical therapy. HealthHelp.ca.gov 3

4 How is Timely Access Assessed by the Department? Analyze health plan timely access Provider Appointment and Availability data submitted by health plans on an annual basis (A-F data) Analyze annual network data submitted by health plans on an annual basis (G data) HealthHelp.ca.gov 4

5 Statute Background Health & Safety Code sections and requires the Department to develop and adopt regulations including standardized methodologies by January 1, 2020, to ensure health plan enrollees have access to necessary health care services in a timely manner requires the Department to work with the Office of Patient Advocate (OPA) to include timely access compliance information in the annual OPA Report Card. HealthHelp.ca.gov 5

6 Statute Background requires the Department to consider the following when developing regulations: Waiting times for appointments with physicians; Timeliness of care in an episode of illness, including timeliness of referrals; Wait time to speak to a physician/nurse who is trained to screen or triage enrollee medical issues; and Clinical appropriateness, nature of specialty, urgency of care and other legal requirements. HealthHelp.ca.gov 6

7 Statute Background requires health plans to report: Provider location; Area of specialty; Hospitals where providers have admitting privileges; Providers with open practices; Number of enrollees assigned to a primary care provider/capacity of PCPs; and Timely access and network adequacy grievances. Gave the Department the authority to develop the reporting format. HealthHelp.ca.gov 7

8 Regulation Background CA Code Of Regulations section Became effective January, 2010 Health Plans required to adopt fully implemented policies, procedures and systems necessary to comply with regulation by January 2011 Regulation has two components: (1) Compliance and (2) Annual Report HealthHelp.ca.gov 8

9 Additional Regulatory Requirements Health plans must arrange for 24/7 telephone triage or screening services, including a call back within 30 minutes The wait time during normal business hours to speak to customer service representative is not greater than 10 minutes Monitor network compliance and investigate and correct deficiencies Provide interpreter services HealthHelp.ca.gov 9

10 Policies and Procedures Initial submission for full service and mental health plans occurred in 2010 These initial submissions were initially reviewed by the Office of Plan Licensing and Managed Healthcare Unlimited (MHU) As health plans change their policies, they are required to file an Amendment in E-filing (J-13) HealthHelp.ca.gov 10

11 Health Plan Reporting Filings due by March 31 st, annually Filed by full-service and mental health plans Includes results of the Provider Appointment Availability Survey (PAAS) Health plan policies & procedures Rate of compliance with the time elapsed standards HealthHelp.ca.gov 11

12 Health Plan Reporting Incidents of non-compliance that resulted in substantial harm or patterns of non-compliance List of providers utilizing advanced access appointment scheduling Description of triage; telemedicine, health information technology Results of enrollee/provider satisfaction surveys Provider network snapshot as of December 31st HealthHelp.ca.gov 12

13 Compliance? What is considered compliance? How does the Department determine compliance? HealthHelp.ca.gov 13

14 Measurement Year 2015 Majority of health plans submitted poor data Department was unable to produce a report comparing health plans DMHC Director call with the health plan CEOs All Plan Letter (February, 2017) Health plans could no longer use the Industry Collaborative Effort (ICE) or the survey vendor, Call Logic Required a Vendor Validator for MY 2016/2017 HealthHelp.ca.gov 14

15 Measurement Year 2016 Biweekly workgroups with health plan staff Weekly updated FAQ s posted on DMHC website All Plan Letter and work groups resulted in improved data submitted by health plans Department will be, for the first time, able to report some comparison of data across the health plans HealthHelp.ca.gov 15

16 What s Ahead? Improve/finalize reporting methodology (multi-modal) Align with SB 137 (Provider Directories) Adopt an overall monitoring process approach HealthHelp.ca.gov 16

17 Timely access to care Lessons from practice improvement December 2017

18 Health care outcomes improve with effective primary care 1. Access 2. Person-focused relationship over time 3. Comprehensive services 4. Coordination Starfield, Barbara, Leiyu Shi, and James Macinko. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly 83, no. 3 (September 2005): doi: /j x. 4 December 3M All Rights Reserved. 3M Confidential. 18

19 Appointment delays can hurt people* After hospitalization, CRG** (illness burden) defines appropriate window of follow-up visit. Missing the window increases the probability of readmission to the hospital. *Jackson, Carlos, Mohammad Shahsahebi, Tiffany Wedlake, and C. Annette DuBard. Timeliness of Outpatient Follow-up: An Evidence-Based Approach for Planning After Hospital Discharge. The Annals of Family Medicine 13, no. 2 (March 1, 2015): doi: /afm **3M Clinical Risk Group 4 December 3M All Rights Reserved. 3M Confidential. 19

20 Examples from the Institute for Healthcare Improvement* and Re-Weaving the Safety Net Project from Rochester NY** Queueing theory guides supply/demand matching: Demand can be known Visits per day = Average visits/year/work days/year Average visits/year = age x sex x illness burden x culture x other Supply can be known Visits per day = work days/yr x hours of supply/day x visits/hour *IHI.org work on Open Access, original work from Mark Murray & Catherine Tantau **Astor, Will. Hospital Center Wins National Award Rochester Business Journal. Accessed July 11, December 3M All Rights Reserved. 3M Confidential. 20

21 Job aid spreadsheet to manage supply and demand 4 December 3M All Rights Reserved. 3M Confidential. 21

22 Oct-03 Jan-04 Apr-04 Jul-04 Oct-04 Jan-05 Apr-05 Jul-05 Oct-05 Jan-06 Apr-06 Jul-06 Oct-06 Jan-07 Example: Clinton Family Health Center Rochester NY 25 CFHC: Number of days until third available long office visit Begin backlog reduction December 3M All Rights Reserved. 3M Confidential. 22

23 Sep-03 Jan-04 May-04 Sep-04 Jan-05 May-05 Sep-05 Jan-06 May-06 Sep-06 Jan-07 Impact of reducing appointment delays on No-show rate Begin Open Access Clinton Family Health Center Show Rate Open Access has changed Clinton Family Health Center's show rate from 50% to 95% December 3M All Rights Reserved. 3M Confidential. 23

24 A1C Average A1C of All Diabetics at CFHC (In practice at least 6 months) Sep-03 Nov-03 Jan-04 Mar-04 May-04 Jul-04 Sep-04 Nov-04 Jan-05 Mar-05 May-05 Jul-05 Time Sep-05 Nov-05 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07

25 Scheduling CRM ADT EMR EMR Claims When are calls received? What care opportunities are available? What type of appointment is needed? What appointment are available? What appointment was made? When did appointment take place? Does timely access improve outcomes? 4 December 3M All Rights Reserved. 3M Confidential. 25

26 Timely Access Reporting - High Level Solution

27 Advanced Access Programs Alternatives to Time-Elapse Metrics Copyright 2017, CAPG The Voice of Accountable Physician Groups

28 Compliance by Advanced Access We have previously outlined the DMHC time-elapse standards in Slide No. 5 The provision of Advanced Access appointments allows Plans to demonstrate Alternative Access compliance more easily under the DMHC regulation, It s important to understand the Alternative Access provision, because it s not being used as effectively as it can be to demonstrate compliance with access to care standards

29 Alternative Standard From the DMHC Reg. (5) (I): A plan may demonstrate compliance with the primary care time-elapse standards established by this subsection through implementation of standards, processes and systems providing advanced access to primary care appointments, as defined at subsection (b)(1). Note only the services subject to the time-elapse standard for primary care are required to be provided in an advanced access system what is the standard?

30 From the DMHC regulation, (b)(1): What is Advanced Access Advanced access means the provision, by an individual provider, or by the medical group or independent practice association to which an enrollee is assigned, of appointments with a primary care physician, or other qualified primary care provider such as a nurse practitioner or physician s assistant, within the same or next business day from the time an appointment is requested, and advance scheduling of appointments at a later date if the enrollee prefers not to accept the appointment offered within the same or next business day.

31 (5)(C) Non-urgent appointments for primary care: within ten business days of the request for appointment, except as provided in (G) and (H) SUBSECTION (G) STATES THAT PROVIDERS MAY EXERCISE THE CLINICAL JUDGMENT EXCEPTION WHEN LONGER WAIT TIMES ARE ACCEPTABLE SUBSECTION (H) EXCEPTS ALL PREVENTIVE CARE SERVICES Primary Care Standard

32 Subsection 5(H) Exceptions 5)(H) Preventive care services, as defined at subsection (b)(3), and periodic follow up care, including but not limited to, standing referrals to specialists for chronic conditions, periodic office visits to monitor and treat pregnancy, cardiac or mental health conditions, and laboratory and radiological monitoring for recurrence of disease, may be scheduled in advance consistent with professionally recognized standards of practice as determined by the treating licensed health care provider acting within the scope of his or her practice (these services are not subject to a time elapse standard)

33 These services cited in (5)(H) are excepted from the standard Preventive Care Services (b)(3): Preventive Care means health care provided for prevention and early detection of disease, illness, injury or other health condition and, in the case of a full service plan includes but is not limited to all of the basic health care services required by subsection (b)(5) of Section 1345 of the Act, and Section (f) of Title 28 (and those would be?)

34 Title 28, Rule (f) Preventive health services (including services for the detection of asymptomatic diseases), which shall include, under a physician's supervision, (1) reasonable health appraisal examinations on a periodic basis; (2) a variety of voluntary family planning services; (3) prenatal care; (4) vision and hearing testing for persons through age 16; (5) immunizations for children in accordance with the recommendations of the American Academy of Pediatrics and immunizations for adults as recommended by the U.S. Public Health Service; (6) venereal disease tests; (7) cytology examinations on a reasonable periodic basis; (8) effective health education services, including information regarding personal health behavior and health care, and recommendations regarding the optimal use of health care services provided by the plan or health care organizations affiliated with the plan.

35 Creating Advanced Access Commit to how the practice is going to gain capacity Reduce the backlog of appointments Use fewer appointment types Develop contingency plans Reduce demand for unnecessary visits

36 Kaiser Permanente, Roseville, Calif. It took seven years for Dr. Mark Murray to refine the process at the clinic. Increased patient matching with personal physician from 47% to over 80% The wait time of 55 days for routine appointments was reduced to 1 day in a year Decreased patient visits by 10% under base

37 Going Beyond Appointments Its not just primary care same day access, but: Urgent care clinics open after hours/weekends E.R. Departments that triage non-emergent cases to urgent care to reduce backlog Retail clinic access for improved convenience Online patient portals that enhance communication but decrease in-office visits A culture of preventive care

38 Start with a an online patient portal: Patient Empowerment Request, reschedule, or cancel an appointment with your PCP Send a message to your doctor about your appointment View your lab results and research metrics View your prescribed medications Request a prescription refill View statements and pay online View and update your personal information View and update your insurance information Share a compliment or voice a concern Access information on a variety of healthcare topics

39 Electronic Patient Portals

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42 What Physician Groups are Experiencing Physicians are currently being inundated with calls from each and every contracted health plan, or their vendors, to verify appointment availability Would you answer a call from your exchange service at 9:00 pm identified as a survey inquiry after a 12-hour work day? Most provider groups have between 6-12 contracted health plans and insurers each verifying compliance independently of the other

43 CAPG Proposal We began looking for a technology partner some time ago to help devise a pilot project for automated compliance monitoring This follows our theme of administrative simplification devising single electronic portals for provider reporting and compliance like the Sanator provider directory registry CAPG-3M-Sharp Healthcare are working on a proposal for an automated pilot with the DMHC

44 Thank You!