2016 Quality Management Annual Evaluation Executive Summary

Transcription

1 2016 Quality Management Annual Evaluation Executive Summary July 2017

2 Mission and Vision The purpose of the 2016 Annual Evaluation is to assess IEHP s Quality Program. This assessment reviews the quality and effectiveness of all studies performed and implemented by various IEHP departments in The Quality Management Department leads IEHP s Annual Evaluation assessment in a collective and collaborative process utilizing data and reports from committees, departments, content experts, data analysts, and work plans to analyze and evaluate the effectiveness of the Quality Programs. Overall effectiveness of the programs is assessed by analyzing the goals and actions of the study, reviewing qualitative and quantitative results, defining barriers and next steps. IEHP s mission is to improve the delivery of quality, accessible and wellness based healthcare services. The organization prides itself in the following five (5) core values: o Health and Quality before Costs: Place Member s health care needs above all else. o Team Culture: Dedicated and cohesive team focused on Member care and supporting our Providers. o Think and Work LEAN: Strive to continuously improve daily operations and delivery of health care services. o Partner with Providers: Ensure a strong working relationship with our Providers based on mutual respect and collaboration. o Stewardship of Public Funds: Strive for transparency to the public and prudent fiscal management. Quality Management Program Description IEHP supports an active, ongoing and comprehensive Quality Management (QM) Program with the primary goal of monitoring and improving the quality of care, access to care, patient safety, and quality of services delivered to Members. The Quality Management Program provides a formal process to systematically monitor, objectively evaluate and track the health plan s quality, efficiency, and effectiveness. The QM Program is designed to improve all aspects of care delivered to IEHP Members. The following are key areas included in the QM Program scope: o Defining the Program structure o Assessing and monitoring the delivery and safety of care o Assessing and monitoring behavioral health services and disease management programs provided to Members o Supporting Practitioners and Providers to improve the safety of their practices o Involvement of designated physician and behavioral healthcare Practitioner in the QM program o Identifying, implementing, and tracking opportunities for quality improvement initiatives o Measuring the effectiveness of interventions and using the results for future quality improvement planning o Establishing specific role, structure and function of the QM Committee and other committees, including meeting frequency o Reviewing resources devoted to the QM program o Assessing and monitoring processes to ensure the Member s cultural and linguistic needs are being met 2016 QM Annual Evaluation Executive Summary Page 1

3 The QM Program includes tiered levels of authority and responsibility related to quality of care and services provided to Members. The line of authority originates from the Governing Board and extends to Practitioners through a number of different subcommittees. IEHP Governing Board: IEHP was created as a public entity as a result of a Joint Powers Agency (JPA) agreement between Riverside and San Bernardino Counties. Two (2) Members from each County Board of Supervisors sit on the Governing Board as well as three (3) public Members from each county. The Governing Board provides direction for the QM Program, evaluates QM Program effectiveness, and evaluates and approves the annual QM Program Description. Quality Management Committee: The QM Committee reports to the Governing Board and retains oversight of the QM Program with direction from the Chief Medical Officer. The QM Committee promulgates the quality improvement process to participating groups, Physicians, Subcommittees, and internal IEHP departments. The following are functions of the QM Committee: meet at least quarterly to report findings, report actions and recommendations to the IEHP Governing Board, seek methods to increase the quality of health care for Members, recommends policy decisions, evaluate QI activity results, and provide oversight for Subcommittees. The following Subcommittees, chaired by the IEHP Chief Medical Officer or designee, report findings and recommendations to the QM Committee: o Quality Improvement Subcommittee reviews all Quality studies and Quality projects in accordance with the Subcommittee work plan. Provides oversight of all quality activities related to NCQA, DMHC, DHCS, and CMS are on track and up to date. o Peer Review Subcommittee reviews all Provider, Member, or Practitioner grievances and/or appeals, Practitioner related quality issues, and other peer review matters. o Credentialing Subcommittee reviews individual Practitioners who directly contract with IEHP to deny or approve their participation in the IEHP network. o Pharmacy and Therapeutics reviews IEHP s medication formulary, monitors medication prescribing practices by IEHP Practitioners, under- and over-utilization of medications, provides updates to pharmacy related programs, and reviews patient safety reports related to medication. o Utilization Management reviews all Care Management (CM), Disease Management (DM), and Behavioral Health (BH) Activities. Reviews inpatient statistics, Utilization, Member Appeals, referral turn-around time and policies and procedures. o Behavioral Health Advisory Committee reviews all aspects of BH services administered to Members. Its focus is to improve access to mental health services, increase the number of In Network Behavioral Health (BH) Providers, and monitor the BH call center performance QM Annual Evaluation Executive Summary Page 2

4 o HEDIS Subcommittee reviews all HEDIS and CAHPS improvement activities, sets improvement goals, establishes interventions and monitors HEDIS and CAHPS rates. Delegation Oversight IEHP delegates certain Utilization Management, Care Management, Credentialing/Recredentialing, and compliance activities to contracted Delegates that meet IEHP delegation requirements and comply with the most current National Committee for Quality Assurance (NCQA), Department of Health Care Services (DHCS), and Centers for Medicare and Medicaid Services (CMS) standards. Joint Operations Meetings (JOM) are conducted by IEHP as a means of discussing performance measures and findings as needed. The JOM includes representation from both the delegate and the IEHP Departments. In 2016, IEHP hosted JOMs with each Medi- Cal IPA. This served as a collaborative approach to discussing IPA performance regarding responsibilities, data, Member Satisfaction results, grievance trends, and any other findings. IEHP s Delegation Oversight Committee (DOC) monitors and evaluates the operational activities of contracted Delegates to ensure adherence to contractual obligations, regulatory requirements and policy performance. Elements of delegation are monitored on monthly, quarterly and annual basis for trending and compliance. Delegates who fail to meet the requirements of delegated functions are placed on a Corrective Action Plan (CAP) to ensure that deficiencies are clearly identified, analyzed for root cause analysis and that effective remediation plans are put into place. The Annual Delegation Oversight Audit (DOA) was conducted using audit tools that are based on NCQA, DMHC, DHCS and CMS standards. Delegation Oversight Audits are performed by IEHP Medical Services departments, Quality Management, Provider Services and Compliance Staff. A review of the Quality Management, Care Management, and Utilization Management Policies and file reviews for the Medi-Cal and Medicare Lines of Business was conducted for with 21 IPAs. Any deficiencies are remediated through the CAP process. These CAPs include education and recommendations to enhance their overall performance. Overall, there was an increase in scores in Denial File Audit, CM File Audit, Credentialing Policies and Procedures. Quality Improvement Initiatives HEDIS: The Healthcare Effectiveness Data and Information Set, HEDIS, is one component of the NCQA accreditation process. HEDIS is used by more than 90 percent of health plans in the United States to measure performance on important dimensions of care and service. IEHP uses HEDIS results as a tool to help focus its quality improvement efforts and as a way of monitoring the effectiveness of services. Each year, IEHP gathers data and performs analyses on clinical and service performance measures as delineated by NCQA. The following HEDIS data was collected for calendar year Multiple measures fall in the following categories: o Prevention screening: The rates show a decrease in Advance Care Planning and an increase in Care for Older Adults pain screening for the Medicare LOB. For the Medi- Cal LOB, IEHP saw significant decrease in Cervical Cancer Screening, Breast Cancer Screening and an increase in Chlamydia Screening QM Annual Evaluation Executive Summary Page 3

5 o Behavioral Health: IEHP saw significant improvements in both Medi-cal and Medicare Lines of business (LOB) for Antidepressant Medication Management Acute Phase Treatment and in Antidepressant Medication Management Continuation Phase Treatment and Follow-Up Care for Children Prescribed ADHD Medication Maintenance Phase, for the Medi-Cal LOB only. Significant drops were seen in the Medicare LOB Follow-Up after Hospitalization for Mental Illness Measures. o Disease Management: The rates show statistically significant increase in Nephropathy Monitoring for both the Medicare and Medi-Cal LOB. There was also a significant improvement in Appropriate Treatment for Children with URI and Medication Management for People with Asthma for the Medi-Cal LOB. The Controlling Blood Pressure measure dropped significantly for Medi-Cal and Medicare LOB. o Medication Management: The Medication Management measures indicate a significant improvement for Medication Reconciliation Post-Discharge. For Avoiding Use of High Risk Medications in the Elderly, IEHP saw a significant increase in the rate. For this measure a lower rate equates to a better performance. o Access/Availability of Care Measures: The results of the Access/Availability of Care Measures show that the Medi-Cal Adults Access to Preventive/Ambulatory Health Services did not improve in CY 2015 with <68% of Members having a record of a preventive/ambulatory health services visit. Furthermore, the Children and Adolescents Access to Primary Care Practitioners rates dropped significantly for all categories. All 4 ages cohorts (ranges from 12 months to 19 years) are likely to be below the 25th percentile. The Prenatal Care measure dropped to the 25th percentile. o Utilization: For the utilization measure, the results do not show a statistically significant change. Quality Improvement Studies: IEHP implements a number of Quality Improvement Projects (QIPs), Performance Improvement Projects (PIPs), HEDIS PDSA QIPs and Chronic Care Improvement Projects (CCIPs) that are required by regulatory agencies such as DHCS and CMS. IEHP is required to conduct a Performance Improvement Project (PIP) focusing on a topic of demonstrated need such as an area in which a performance measure was below the Department of Healthcare Services (DHCS) established minimum performance level. IEHP has chosen to conduct PIPS in the following three (3) areas. The results for the following PIPs will become available in August o Cervical Cancer Screening: The PIP s goal is to increase the percentage of the Pap testing rate among eligible IEHP female Members 21 to 64 years of age by providing the external clinic partner with a standardized protocol for the identification of eligible Members. o Diabetic Members: The PIP s goal is to increase the HbA1c testing rate among IEHP Diabetic Members in San Bernardino County. The study focuses on clinic staff educating Members on completing point-of-care testing during the appointment QM Annual Evaluation Executive Summary Page 4

6 o Health Risk Assessments (HRAs): The PIP s goal is to complete an HRA within 90 days among newly enrolled LTSS Members by partnering with internal IEHP departments and developing a protocol to increase the likelihood of reaching eligible Members. IEHP has recognized that there is a need for enhancing the current HRA process and improving the rate of completed HRA s within 90 days of enrollment. IHA monitoring: An Initial Health Assessment (IHA) is a comprehensive assessment that includes healthy history, health education needs, physical exam, tests, immunizations, and the Staying Healthy Assessment (SHA)/Initial Health Education Behavioral Assessment (IHEBA). Per DHCS, all newly enrolled Members must have an IHA completed by their PCP during the initial visit within 120 days of Plan enrollment. IEHP strives to achieve an annual IHA compliance rate of 50% for all newly enrolled Members in both age bands. The results for the calendar year IHA study revealed that IEHP reached a compliance rate of 44.02%. Pharmaceutical Safety reports: The Pharmaceutical Patient Safety Report is presented quarterly to the P&T Subcommittee. The Patient Safety Report identified trends with Emergency Department (ED) overutilization and Opioid overutilization. During this trend analysis, cases identified are tasked to Case Management for coordination of care including specialist referral and/or patient education. If drug seeking behavior is confirmed (e.g. doctor shopping, pharmacy shopping), restricted authorization (POS claim edit) is put into place for that specific Member. For calendar year 2016, a positive outcome trend was observed post intervention on ED overutilization cases. Overall, 54% reduction in ED visit was noted, and 86% of Member cases resulted in ED visit reduction. In addition, a quarterly Patient Safety Report was conducted by the Medication Therapy Management (MTM) Vendor, Perform RX. The Perform RX Activity report outlines total counts of IEHP Medicare Members enrolled, Medicare Members dis-enrolled, breakdown of the types of Provider targeted interventions (i.e. profiles reviewed, numbers of Provider targeted interventions and Member targeted interventions). Recommendations include collaboration with Perform RX MTM to increase percentage of profiles reviewed and increasing overall Comprehensive Medication Review percentage. The P&T Committee also reports the Narcotic Top 10 Prescribers Report. The report has been developed through review of medical literature and accepted medical practice standards. The Committee identifies findings on the Prescribers narcotics counts and makes recommendations, such as continue to monitor, report to Compliance, or perform focus audits on the prescriber. In 2016, two (2) Focus Audits were conducted by the QM department on two (2) Providers who demonstrated higher than average narcotic utilization. These Providers are closely monitored for any deviation from expected standards. Access to Care With the rapid growth in IEHP s membership, access to care is a major initiative for the plan to which IEHP has dedicated a significant amount of resources to measuring and improving. IEHP maintains Access Standards applicable to all Providers and facilities contracted with IEHP. All PCPs, BH Providers, and Specialists must meet the access standards in order to participate in the IEHP network. IEHP monitors practitioner access to care through access studies, review of grievances and other methods. The access studies performed for the year 2016 include the following: 2016 QM Annual Evaluation Executive Summary Page 5

7 o Availability of Providers by Language: IEHP monitors network availability based on threshold languages. In order to ensure adequate access to PCPs, IEHP has established quantifiable standards for geographic distribution of PCPs for its threshold languages, which are English and Spanish. These two (2) languages cover over 98 % of IEHP s membership. This annual study assessed the availability of Spanish speaking staff at the Providers office. The results were grouped into PCPs, OB/Gyn Providers, and Vision Providers. All Provider offices met the compliance goal of at least 85%. The 2016 results are as follows: PCPs are 94.6% compliant, OB/Gyn offices are 95.6% compliant and Vision offices are 97.3% compliant. o Availability of Practitioners: IEHP assess the network availability for Provider to Member ratio and Time/distance standards for PCP, Specialists and Behavioral Health Practitioners. The results are compared against established ratio standards and time/distance standards (geographic distribution). When assessing Provider distribution by Time/Distance, all PCPs, High Impact/High Volume Specialists and Mental Health Providers are within the geographic distribution, except for the Internal Medicine Providers. When assessing Provider to Member ration, all PCPs, High Impact/High Volume Specialists and Mental Health Providers met the minimum Provider to Member ratio except the Psychiatrists and the Marriage and Family Therapists (MFT). o Appointment Access: IEHP monitors appointment access for PCPs, Specialists (high volume and high impact specialists), and Behavioral Health Providers and assesses them against timely access standards depending on the type of visit (e.g. Routine Visit or Urgent Visit). Annually, IEHP collects appointment access data from Practitioner offices using a timely access to care survey. Provider responses are then compared to acceptable appointment time frames to determine compliance. In addition to timely appointment availability, IEHP also evaluates grievance and appeals data to identify potential issues related to access. A combination of both of these activities helps to identify issues and implement opportunities for improvement. For the 2016 Appointment Access study, the goal is for all Providers to reach a 90% compliance rate for an available Urgent Visit and an available Routine Visit. The results reveal that PCPs were 78.6% compliant when surveyed for Urgent visit availability and 90.3% compliant with Routine Visit availability. For Specialists, 77.4% of Specialists were compliant with an Urgent visit not requiring an authorization, 78.6% were compliant with an Urgent visit requiring an authorization, and 92.0% were compliant for Routine Visit availability. The BH Providers, (LCSW, MFT, Psychologists and Psychiatrists) failed to meet the compliance for both Urgent and Routine appointment types. o After-hours access to Care: IEHP monitors after-hours access to Providers to ensure that Members have appropriate access to their Provider outside of regular business hours. The criteria for appropriate after-hours care is that the physician or designated on-call physician be available to respond to the Member s medical needs beyond normal hours. PCP offices can use a professional exchange service or automated answering system that allows the Member to connect to a live party or the physician by phone. It is also required that any after-hours system or service that a physician uses provide emergency instructions in the event that the Member is experiencing a life-threatening emergency. Annually, IEHP collects Provider after-hours access data from Provider offices using a 2016 QM Annual Evaluation Executive Summary Page 6

8 standardized survey. Provider responses are then compared to acceptable protocols to determine compliance. Provider survey results were reported by Provider Types. PCPs were surveyed as well as the following Specialists types: Cardiology, OB/Gyn, Orthopedic, Oncology/Hematology, and Ophthalmology. BH Providers (Psychologists, Psychiatrists, MFTs, and LCSW) were also surveyed. The goal is to reach a 90% compliance rate for both call types; Ability to connect to an on-call physician and appropriate protocol for a life threatening emergency call. The 2016 results revealed the following compliance rates for an On-call Provider: PCP 53.3%, BH 48.0 %, and Specialist 42.5%. For a life threatening emergency call, the results are as follows: PCP 89.3%, BH 79.0%, and Specialist 50.1%. No Provider type met the 90% compliance goal. o Addressing cultural and linguistic needs of Members: The purpose of the study is to identify the linguistic and ethnic diversity of IEHP s PCP and Member populations. More specifically, the study assesses the cultural, ethnic, racial and linguistics needs of Members. In the 2016 Cultural and Linguistic study, the results show that IEHP met the language distribution for English and Spanish PCPs to Member ratio, exceeding the goal of 1.0 PCPs per 2,000 Members for both English and Spanish languages. For Race/Ethnicity, IEHP continues to fall below the goal of 1.0 PCPs per 2,000 Members. Race and Ethnicity is an optional field on the Bi-annual Provider Directory Verification form and on the IEHP Provider Contracting application. Many Providers do not report their Ethnicity; therefore this may not provide an accurate depiction of PCP to Member Ratios. o Member Services Call Tracking and Interpreter services: The Member Services and Language Line Report serves as an example of data review, analysis of barriers, and implementation of interventions. Since IEHP s membership grew significantly to over one million Members, the Member Services Department had difficulty meeting their service levels due to the call volume increase. Through this report, the QM Committee is able to monitor data as well as the Member Services Department Corrective Action Plan s various interventions that aim to improve service level and call volume. The QM Committee provides necessary feedback to help the Member Services Department meet their goals. By year end, the goals were achieved and will continue to be monitored quarterly. Member and Provider Satisfaction Consumer Assessment of Healthcare Providers and Systems (CAHPS ) 5.0H Survey: IEHP conducts a comprehensive CAHPS survey and analysis annually to assess Member satisfaction with healthcare services. This standardized survey focuses on key areas like receiving needed care; receiving appointments to PCPs and Specialists (SPCs); satisfaction with IEHP and its Practitioners; and other key areas of the Plan operations As a part of the annual evaluation, IEHP reviews the CAHPS results to identify relative strengths and weaknesses in performance, determine where improvement is needed, and to track progress with interventions over time. Results are reported by Adult population and by Child population. The 2015 results were compared to the 2016 results for each composite performance area listed above. The differences between Getting Needed Care and How Well Doctors Communicate were found to be statistically significantly higher from 2015 to When results were compared to the 2016 QM Annual Evaluation Executive Summary Page 7

9 NCQA National Medicaid Scoring thresholds- Adult population National Benchmarks, IEHP scored below the 25th percentile for three measures ( Getting Needed Care, Rating of Personal doctor, Rating of Health Plan ). Three (3) measures scored at the 25 th percentile ( Rating of Health Care, How well doctors communicate, and Getting care quickly ). One (1) measure scored at the 50th percentile ( Rating of specialist ). HOS: The objective of the Health Outcome Survey (HOS) study is to comply with standards established in 2013 by the Affordable Care Act. This study is designed to guide each Quality Improvement Organization (QIO) and Medicare Advantage Organization (MAO) in identifying the overall health of their Medicare population and in maintaining or improving health status. Currently, IEHP presents one HOS study each year which includes baseline and follow-up data of a random sample of IEHP s Member population. The HOS study will be presented to IEHP s Quality Improvement Subcommittee in September Provider Satisfaction: IEHP monitors performance areas affecting Provider satisfaction. The annual Provider satisfaction study assesses the satisfaction experienced by IEHP s network of PCPs, Specialists, and Behavioral Health Providers. Information obtained from this survey allows IEHP to measure how well they are meeting their Providers expectations and needs. The study examines Provider experience in the following areas: Overall Satisfaction, Finance Issues, Utilization and Quality Management Network, Coordination of Care, Pharmacy, Health Plan Call Center Service Staff, and Provider Relations. The results for 2016 show that IEHP scored above the 95 th percentile in all composite areas when compared to the SPH Analytics Medicaid Book of Business. (The Book of Business consists of data from 46 plans representing 13,436 respondents in Primary Care, Specialty, and Behavioral Health areas.) This is significantly higher when compared to other health plans. Grievance and Appeals: IEHP monitors performance areas affecting Member experience. IEHP has established categories and quantifiable standards to evaluate grievances (i.e. complaints) received by Members. All grievances are categorized into the following categories including but not limited to: Access to Care, Quality of Care, Quality of Service, Enrollment/Disenrollment, Benefits/Coverage, and Compliance. Additionally, grievance resolutions are assigned levels to determine the severity. The levels range from Level Zero (no issues found) to Level 4 (issue was found and resulted in significant harm to the Member). The Grievance and Appeals Department regularly analyzes all grievance and appeal data internally. The purpose of the analysis is to identify trends and develop interventions. In 2016, there were over 7,000 Level 0 Grievances reported. There were no reported Level 4 Grievances. The majority of Grievances filed were in the Quality of Service category followed by Quality of Care. The least number of grievances filed were in the Enrollment/Disenrollment category. Patient Safety Potential Quality Incident: IEHP conducts a review of its Potential Quality Incidents (PQI) which include documentation and resolution of PQIs identified by Members and internal sources. The process includes a review of case documents (e.g. medical records) to determine severity and classify into one of the following levels: Level 1 is no issue found, Level 2 is opportunity for improvement, and Level 3 is Unacceptable care or service which requires a Corrective action plan. In 2016, IEHP received 153 Level 1 cases, 248 Level 2 cases, and 3 Level 3 cases. The cases received were further analyzed to determine the case type. The top five (5) case types for 2016 were as follows: Provider 2016 QM Annual Evaluation Executive Summary Page 8

10 Preventable Condition, Safety Issues, Postoperative complications, Infections related, and Diagnosis/Treatment Issue. Provider Preventable conditions (PPC) Pilot Study: The purpose of the PPC study is to assess the compliance of hospital facilities in their submission of PPCs as outlined in All Plan Letter (APL) , Reporting Requirements Related to Provider Preventable Conditions. IEHP conducted a pilot study to determine compliance of PPC submission by reviewing encounter data submitted by network Providers and hospitals for evidence of PPCs. Based on the a selected sample size, the results show there were 0% of confirmed PPCs based on IEHP s medical review. Additionally, for the second pilot study there were 8% of reported PPCs that were confirmed based on IEHP s review of the medical records. Promoting Safety Practices for Members: IEHP offers various safety programs to Members. The Bicycle Safety Program for children between 5 to 14 years old assesses children s and parent s knowledge on bicycle safety and offers a free helmet to program participants. Another safety program offered by IEHP is the Child Car Seat Safety Program. This program provides Members with information on car seat laws and choosing the right car seat. Also available to Members are educational materials on health topics such as immunizations, flu and cold facts, avoiding allergens, and medication reconciliation. All safety initiatives are developed in collaboration with the Health Education and Medical Services departments as safety needs are identified. Conclusion Overall, IEHP s QM Program was effective in reviewing data, assessing trends, identifying issues and developing improvement activities within the Health Plan related to access to care, satisfaction and quality of care. IEHP will focus on meeting the 2017 Program goals and completing all initiatives as outlined in the 2017 QM Work Plan. IEHP s Leadership Team has recognized that the Health Plan s average quality performance scores were not at the desired level, placing IEHP at a 3- star rating Health Plan. IEHP s goal is to become a 5-Star quality healthcare delivery system. IEHP has identified five key Strategic Priorities as a framework for become a 5-Star Health Plan: o Access to Care and Services: Focuses on all aspects of our Members ability to receive the care they need, when they need it and at the right level/place. o Practice Transformation: Focuses on working with key high volume PCPs and some Specialists to help them change their practices. o Quality of Care and Services: Focuses on activities, programs and interventions designed to improve the quality of care and Member satisfaction with our delivery system. o Technology and Data Analytics: Focuses on data strategies and technology. o Human Development: Focuses on IEHP Team Members. IEHP Program Managers will work with the Strategic Priority Steering Group to appropriately prioritize projects based on their impact to IEHP s 5-Star Rating. IEHP Projects will be developed to align with the key strategic priorities and ensure resources are devoted appropriately. Additionally, IEHP s QM Committee has enhanced the 2017 QM Work Plan template to include QM Committee deliverables by regulatory agency, added quality improvement fields throughout the Work Plan, and a Corrective Action Plan (CAP) section. The QM Department will be responsible for managing all work plan updates and ensure all deliverables are reported timely and in accordance with all regulatory agencies QM Annual Evaluation Executive Summary Page 9