Follow-up [if Quality Issue identified, Include Corrective Action] No follow up needed n/a

Transcription

1 Quality Improvement Committee Minutes Date: April 7, 2016 Meeting Place: San Francisco Health Plan, 50 Beale Street 12 th floor, San Francisco, CA Meeting Time: 7:30-9:00 am Present: Edwin Batongbacal; Irene Conway; Edward Evans; Joseph Woo, MD; Todd May, MD; Kenneth Tai, MD; Jaime Ruiz, MD; Reena Gupta, MD; Ana Valdes, MD; Ellen Chen, MD; Jeanette Cavano Staff Present: James Glauber, MD; Jim Soos; Sari Weis; Jessica Warren; Kirk McDonald; Maika Hefflefinger; Laura Grossman; Michelle Hernandez Topic Call to Order Follow Up Items Discussion [including Identification of Quality Issue] Meeting was called to order at 7:28 am. No attendance from the public and there were no public comments. Abby contacted SFHP member, Edward Evans, regarding transportation to other programs at clinics/hospitals outside of San Francisco and was unable to connect via phone call. Irene Conway provided an update on whether the Shingles vaccine is included as a pharmacy benefit for the Healthy Workers line of business. Question from Irene: if a member at Ocean Park attends a clinic without a freezer, can that member go to a SFGH clinic that has a freezer? Follow-up [if Quality Issue identified, Include Corrective Action] No follow up needed n/a Follow-up with SFHP member, Edward Evans, regarding transportation to other programs at clinics/hospitals outside of San Francisco. Jeanette Cavano confirmed that the Shingles vaccine, Zostavax, was added to the ZSFG formulary and Healthy Workers is covered under this formulary. Resolution, or Closed Date [for Quality Issue, add plan for Track ing after Resolution] Follow-up need by Abby Wolf. The SFGH formulary covers the Shingles vaccine, Zostavax, and applies to Healthy Workers. 1 Page

2 Consent Calendar The consent calendar was reviewed and approved unanimously. o Review of Minutes February 11, 2016 (p. 3) o Health Services Update (p. 14) o Membership Report (p.17) o Update of Pharmacy & Therapeutics Committee Membership (p. 22) & Minutes (p. 23) o Policies & Procedures o Summary of Changes (p.32) o QI-09 Practice Guidelines (p. 33) o QI-13 Disease Management (p. 36) o HE-03: Preventive Health Care Guidelines (p. 43) o UM Committee Minutes o February 2016 (p. 50) and March 2016 (p. 58) SFHP s Health Services has undergone reorganization into four sub-departments instead of three Health Improvement (which included Clinical Quality, Practice Improvement Program (PIP), HEDIS, and Care Coordination), Pharmacy and Clinical Operations. SFHP s Medical Director, Fiona Donald, is now leading the subdepartment, Care Management, which includes As long as a means for freezing the vaccination exists, the vaccination will be available to Healthy Workers participants at the clinic level. No follow up needed n/a Jeanette Cavano will follow-up with Irene Conway regarding her question. 2 Page

3 Quality Monitoring both Care Coordination (previously under Health Improvement) and Complex Medical Case Management.The goal is to focus on having a member-centric, integrated approach to Care Management. SFHP s Health Improvement Director, Anna Jaffe, is no longer with SFHP, and her replacement will fill the new role, Director of Health Outcomes Improvement. SFHP now covers ancillary procedures for Transgender individuals such as facial hair removal, trachea cartilage, facial feminization procedures when the procedure is deemed medically necessary (under SFHP s gender affirmation UM criteria) due to the member s appearance causing ongoing gender dysphoria. Q Grievance Report Manager of Access & Care Experience, Sari Weis, represented the Q report. A total of 137 grievances were reported in the fourth quarter of 2015 (from October 1-December 31). In comparison to the third quarter of 2015 (159 grievances), this is a 13.8% decrease relative to Q Twenty-seven grievances out of 137 were not closed in the DHCS/DMHC mandated 30-day timeframe.the timeframes were not met because of our internal process that ensures all components of the grievance have been thoroughly investigated and resolved appropriately and have been discussed by the weekly Grievance Review Committee (GRC). The majority of the grievances in the fourth quarter were due to denials, quality of service and quality of care issues. 3 Page

4 Q Appeals Report UM Program Manager, Kirk McDonald, represented the Q report. A total of 27 medical and pharmacy appeals were reported out of 9,056 authorization requests. This represents a 37% decrease relative to Q appeals and a 47% decrease when expressed as appeals per 1000 members. with 43 medical and pharmacy appeals out of 7,623, this encompassed a 37% decrease in Q In terms of per 1,000, this was a 47% decrease. Compared to the third quarter, there was a 33% decrease in appeals for out-of-network and out-ofmedical groups with a total of 2 appeals, one overturned and one upheld for the fourth quarter. Comment [JG1]: Please double check the math here. It doesn t seem to equate to a 47% decrease. Comment [S2]: 27 or 27%; when I did the math with a the common denominator of 9056, I got For 2015 in total, there were 142 pharmacy appeals with 80 upheld and 62 overturned. For Utilization Management (UM), there were a total of 60 medical appeals with 31 upheld and 29 overturned. Comparing Q to Q4 2015, the ratio of appeals upheld to appeals overturned decreased from 2.19 to SFHP s Utilization Management Committee (UMC) has analyzed the UM appeal activity over the course of 2015 and has improved the priorauthorization process by eliminating medical necessity review for several service categories. In 2016, SFHP plans on revising the appeals report to reflect a separation in the pharmacy and UM medical metrics. 4 Page

5 Dr. Glauber highlighted that there is a 64% decline in appeals per 1,000 authorizations from Q1 to Q The overall decrease in denial rate has mediated this downward trend. The reduction in denial rates reflects the changes that SFHP s UM program has undergone to align with the organizational mission to increase access to care. For both UM and Pharmacy, less services are being subjected to medical necessity review. For example, there have been changes and additions to SFHP s formulary, resulting in fewer denials. Recent improvements include the addition of new oral anticoagulants and second-line diabetes medications offered as step-therapy to the SFHP formulary. In terms of medical prior-authorizations review over the course of the year, SFHP s denial rate has decreased from 3.5% to 0.6%. Question: Please give examples of when review restrictions may have been lessened with procedures and diagnostics? Advanced imaging no longer requires medical necessity review. Additionally, medical necessity review has been reduced for certain ambulatory procedures to requests for the procedure out of medical group. One of SFHP s projects this year is to reconfigure the claims system to reflect services that no longer 5 Page

6 require medical necessity review. Currently, a service that does not need medical necessity review may still need authorization for the claims to be paid. Once our claims systems becomes simplified and aligned, providers will be able to directly bill for a service if it no longer requires medical necessity review (unless if being requested out-of-medical-group). Question: Formulary restrictions tend to be used to ensure appropriate use of medications. As restrictions are being loosened and/or made broader to improve access, is there a way to check if the medications are being used appropriately? Dr. Glauber mentions there will be a MTM program. Members with complex cases and multiple regimens will be integrated into SFHP s new program, Health Homes. Other strategies will also be employed. Currently, the spending on hepatitis medications has dramatically increased. Over 40% of SFHP s pharmacy spending is allocated to Hep C s class of medications and much of the focus is on tracking patients once approved to ensure they are maintaining medication adherence. SFHP is seeing higher nonadherence rates thant have been reported in clinical trials. Building a process of feedback with treating physicians as early as possible when non-adherence is observed is extremely important. Comment [JG3]: This is not an answer to the question. Are you sure this was my response. Also MTM needs to be spelled out, not abbreviated. Dr. Ana Valdes from Health Right 360 comments: A lot of case management is needed to follow-up with 6 Page

7 complex patients, and when clinics funding is limited to the visit only, it s difficult to have appropriate case management and follow-up to check on medication adherence. Timely Access Regulations & Access to Care Committee Update Practice Improvement Project Manager, Jessica Warren, presented on SFHP s 2015 strategies for access monitoring and next steps. The three strategies that were implemented in 2015 were: 1) Creating a cross-functional, internal Access to Care Committee, with the primary purpose to create sustainable processes around monitoring and improving access. 2) Creating an Access to Care Dashboard that contains key internal and external measures that is used to monitor access and to establish performance thresholds for each of these measures. The Access to Care Dashboard is reviewed by the Access to Care Committee quarterly. 3) Establishing policy QI-05 that establishes network monitoring processes and standards. This policy was approved by QIC is <month/year> Comment [JG4]: Name the policy Over the course of 2015, Access to Care Committee has undergone this process of: 7 Page

8 1) Understanding over 40 access regulations. 2) Determining measures for monitoring each of the regulations. 3) Identifying gaps such as requirements that we didn t have data to monitor or process changes needed to meet regulations. 4) After establishing the measures and thresholds for each regulation, SFHP is currently in the process of monitoring and targeting interventions. 5) At the end of the year, SFHP will assess the effectiveness of the interventions so that improvements can be made where needed. The Access to Care Dashboard has 36 measures, however only a few measures did not meet their target over the last two quarters of review, Q3 and Q These measures were discussed to solicit improvement recommendations from QIC. These included: 1) Mental Health Triage, which comprises of answering the phone within 30 seconds, was not being met by Beacon so SFHP implemented penalties in line with the Beacon contract in Q4 of This is an access measure for SFHP because members need to call Beacon to get screened for specialty or non-specialty criteria in order to access the NSMH benefit. 2) CAHPS Access Composites is probably the most robust intervention. A strategic goal was created for FY 15/16 for a 3% CAHPS improvement as well an associated work plan to achieve that goal. SFHP has also partnered Comment [JG5]: Are there really 40 regulation or is 40 a compilation of regulations and DHCS contract requirements? Comment [JG6]: This statement is vague. Please clarify with Jessica. Comment [JG7]: This sentence is non-sensical. CAHPS Access Composites are scores for several questions, so how can this be a most robust intervention. 8 Page

9 with the 2 largest medical groups in terms of membership to implement specific improvement efforts. 3) In compliance with the policy QI-05, 24/7 Telephone Triage, if a group/clinic is not meeting an 80% threshold, corrective action plans (CAPs) are requested. SFHP is working with these groups to create an improvement plan. This requirement involves having a clinician available within 30 minutes of the initial phone call as well as having correct emergency instructions on voic s telling members to call 911 or go to the nearest emergency room if they have an emergency. 4) SFHP is in ongoing communication with providers and members to ensure that Initial Health Assessments occur within the required timeframe. SFHP is making strides to cover adult Evaluation and Management (E/M) codes related to IHA s that would incentivize providers to submit qualifying encounters with those codes. Comment [JG8]: Name the policy. G B members and the public will not know what QI-05 means. QI-05 is SFHP s policy that speaks to how the network is monitored around access. There are four monitoring activities presented: 1) Perception of access which includes CAHPS and provider satisfaction 2) Timely appointment access 3) Wait times in providers offices 4) Telephone and triage access The focus of the discussion is on the latter three areas Comment [JG9]: This policy should already be identified and defined earlier in the minutes, should you should not need to define it again here. 9 Page

10 since perception of access, HP-CAHPS and provider satisfaction, are brought to QIC on a regular basis. Meeting materials include results per medical group for Telephone and Triage access surveys. The afterhours survey assesses primary care providers on after-hours telephone triage. Nine groups were surveyed, and of those four were compliant. Corrective Action Plans (CAP) were requested of all five non-compliant groups.. Evidence that SFHP requires to close the CAP includes a re-survey by the group or SFHP. SFHP expects to be in compliance with the after hours and triage requirements by July. Additionally, a script has beenprovided to the answering service or clinics to ensure that their voic correctly states emergency instructions and indicates that a clinician will return a member s call within 30 minutes. Appointment Access and Wait Times are assessed by one survey, the Provider Appointment Availability Survey, which monitors primary, specialty, ancillary, behavioral health, urgent and initial pre-natal care. The focus for specialty was on cardiology, allergy, and dermatology as dictated by DMHC. Likewise MRI s, mammograms, and physical therapy were monitored for ancillary care. The survey is administered by the Industry Collaborative Effort (ICE) consisting of over 20 Health Plans in CA. ICE then contracts with an outside vendor to complete the calls and track results. There are regulations for follow-up specialty referrals 10 Page

11 which should be met within 15 days. Those specialty providers that lie outside the 15-day range are noncompliant. Comment [JG10]: Pl ease clarify t his sentence with Jessica. My understanding is that the PAAS surveys initial specialty appointment waiting time, not follow-up specialty referrals. Referrals doesn t seem to be the correct term here. DHCS has not established a performance standard for Wait Times. The standard Wait Time in the waiting room established by SFHP is 30 minutes. SFHP s created performance standard is that at least 80% of surveyed clinics meet the 30 minute standard. Question: In looking at the urgent appointments data, what does non-responsive mean? Answer: DMHC states that if a provider does not respond within 48 hours to a call-back/follow-up request, this provider is marked as noncompliant in the survey results. Question: How do survey auditors present themselves on the telephone when speaking to a clinic? Answer: Auditors have call scripts and state that they are calling on behalf of California health plans and surveying for a Californian requirement. Survey results were presented to primary care leadership for each medical group. There was a 40% noncompliance rate across SFHP s network. Scripts used were the same across medical groups, and where noncompliance was high for a specific medical group this indicated evidence of other issues going on. Comment [JG11]: Work with Jessica to better define non-compliance rate. I believe what was communicated was non-responsiveness to the survey. In other words differentiate nonresponsiveness from non-compliance. 11 Page

12 SFHP isevaluating ways providers and receptionists can be given notification prior to the survey to reduce the unresponsiveness. Next steps: In the next month, SFHP will be requesting CAPs from medical groups in areas that are noncompliant. SFHP s standard is 80%; performance below 80% will require a CAP. Additionally, SFHP will work with the specific medical groups with high rates of non-responsiveness to the PAAS. We hope to learn best practices from groups that showed were compliant. SFHP wants to work collaboratively with the network to improve access, not just request CAPs. DHCS and DMHC has been seeking robust action on the plan s part to improve access, including requesting CAPs. Dr. Glauber mentioned that to improve urgent care and after-hours access, we will be recommending approval at the May Governing Board meeting offering our members a24/7 Telemedicine primary service through Teladoc. Irene s Question: For survey methodology, is there a way to add dwell time (total wait time including wait time in the reception area as well as in the exam room) to the survey? 12 Page

13 Jessica Warren reiterates that capturing dwell time data is currently one of the drawbacks to the survey. Part of the problem is that the receptionists responding to the survey questions may not have access to this data. However, Dr. Glauber mentions that SFHP s Practice Improvement Program (PIP) monitors and provides rewards for a measure that improves cycle time. Time stamp data is also available for some Medical Groups to measure time for eligibility/registration, time with the medical assistant, and time ready for and with the provider which captures the entire wait time of the patient. Drs. Ellen Chen and Todd May from SFHN wants to make sure that SFHP is aware that patients are transferred to a centralized call center to make an urgent appointment at the medical home and not through a receptionist at a clinic. Thus, SFHN may be meeting the urgent appointment needs up to 60-70% and at ZSFG up to 95%. SFHP s aim is to copy the member experience when seeking an appointment. If members are transferred to a central call center, PAAS should be monitoring that processs too. Comment [JG12]: Please clarify the distinction between SFHN (60-70%) and ZSFG (95%) Beacon Evaluation 2015 Amendment Michelle Hernandez presented the SFHP s 2015 Beacon Program Evaluation. The Program Evaluation is produced annually and shares the results from clinical and service quality improvement activities. For San Francisco Health Plan (SFHP) the report covers the Medi-Cal 13 Page

14 Expansion (MCE) line of business. It is important to note that Beacon and SFHP began their relationship in June 2015, so only partial year data is presented. The data reported has been updated to reflect the claims lag for Q3 but Q4 does not account for the claims lag. Claims data reported includes behavioral health claims only and does not include medical or pharmacy claims. The evaluation covers clinical improvement activities (for depression, alcohol and drugs, and ADHD), monitoring of continuity and coordination of care, service improvement activities (telephone access, appointment accessibility and availability, and cultural and linguistic program), and patient safety (timeliness of handling member complaints and adverse incident reporting). The data collected was from June-December For depression, the data came from claims and the target was 50%. SFHP exceeded the target with 59.3% for the measure - two or more visits within 12 weeks of initial diagnostic visit. No data was collected for the measure - one or more medication visits within 12 weeks (84 days) of diagnosis. This can be due to no claims submissions or treatment of the member by the PCP not resulting in claims submission to Beacon. For the alcohol and drug category (AOD), the target is 90% for both measures and SFHP scored in the 80 th percentile: 14 Page

15 1) There is documentation that the member was screened for alcohol or other substance abuse or dependence. 2) Members that screened positive for AOD was recorded in the diagnosis, treatment plan, or being addressed on an on-going basis as part of treatment. After assessing continuity and coordination of care between the Outpatient (OP) treatment provider, the primary care physician (PCP), and other community resources, SFHP received 100% on three of six metrics with a target of 80%. Areas for improvement included: 1) Percent of records with documentation of the release of information and evidence that the OP treatment provider received information, contacted, collaborated, or in any way, communicated with the PCP. 2) Percent of records with documentation to indicate that release of information, Authorization, Consent was obtained to speak with at least one other Outpatient [OP] mental health or OP substance abuse treatment provider. 3) Percent of records with documentation that the release was obtained and that the OP treatment provider received information, contacted, collaborated, or in any way, communicated with other BH providers regarding member s clinical care. 15 Page

16 Access and availability is assessed quarterly through a self-reported provider survey with two metrics that had targets of 100% and 90% respectively: 1) Can your practice schedule appointments for patients in ongoing treatment with an urgent need within 48 hours? 2) Can your practice schedule an appointment within 10 business days for routine/nonurgent appointments? On average, SFHP scored 83.3% and 94.4% respectively for the above metrics. For Q3 and Q4, Beacon Health was below target for metrics - call abandonment rate (target: < 5%, SFHP: 6.35%), percent of calls answered within 30 seconds (target: > 90%, SFHP: 57%), and average speed to answer (target: < 30 seconds, SFHP: 83.2 seconds). This was due to unforeseen staffing fluctuations over the summer with staff transfers, resignations, and unexpected leaves of absences. SFHP went live in June 2015 which increased the overall call volume handled by the Member Services team. With the decreased staffing and increased calls, the staffing pattern was not sufficient. Currently, the Director of Member Services is diligently working to hire staff as well as restructuring the department to best serve members. Additionally, Beacon Health is incorporating assessment of cultural and linguistic metrics. Q3 and Q4 data captured some metric results: 1) 10.7% of SFHP members who called Beacon 16 Page

17 used one or more language interpreter services. 2) 18.9% of Beacon staff are bilingual QI Committee Chair's Signature & Date: 5/10/16 Minutes are considered final only with approval by the QIC at its next meeting. 17 Page