Quality Improvement Committee: Open Session. Time Topic Objective Assigned 7:30 Follow Up Items (5 min) Update Dr. Glauber

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1 Quality Improvement Committee Meeting Thursday, April 5, :30 9:00 AM 50 Beale Street, 13 th Floor Join Skype Meeting Trouble Joining? Try Skype Web App Conference Call Number +1 (628) Access Code: 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 February 8, 2018 (p. 3) Health Services Update (p. 10) 2017 Annual Review of Appe (p. 16) 7:40 Quality Improvement (45 minutes) 2017 Annual Grievance and Appe Report 15 min. (p. 27) Vote N. Ylagan 2017 Access Monitoring Results 20 min. o 2017 Appointment Availability Report (p. 30) o 2017 Results for Access to Triage Services (p. 45) o 2017 Results: Telephone and Provider Office Wait Time (p. 50) Vote Y. Gibbons SFHP Pain/Opiate Workgroup 10 min. (p. 53) Update F. Donald/E. Ratliff 9:00 PAC NEXT MEETING THURSDAY, JUNE 14, 2018

2 Quality Improvement Committee Follow Up List QIC Meeting Date Follow Up Item Owner Complete By Comments December 2017 Present the Pain and Opiate Safety Coalition to QIC in Spring F. Donald 4/5/18 Complete February 2018 February 2018 Explore changing the nomenclature in the Appe Report to clarify the meaning of an overturned appeal. Edit the CHF criteria language as it is not clear if a member must be in the hospital at the time they are approved. K. McDonald 4/5/18 In Progress J. Soos 4/5/18 Complete February 2018 Present the comparative data on failure rates across Medi-Cal plans to QIC J. Hagg 6/14/18 In Progress The SFHP Pain/Opiate Workgroup Meeting will be presented in April QIC. SFHP cannot change the language in the Appe Report as it is standard "health plan" operational language. SFHP will include a glossary in the report or a link to the definitions to help clarify the terms. In reviewing the policy and the APL, the requirement states that the member is hospitalized due to CHF as the primary diagnosis with no further invasive interventions planned or meets the criteria for the New York Heart Association s heart failure classification III or higher, thus current hospitalization is not a requirement, but meeting one of the two criteria is.

3 Quality Improvement Committee Minutes Date: February 8, 2018 Meeting Place: San Francisco Health Plan, 50 Beale Street 13 th floor, San Francisco, CA Meeting Time: 7:30AM - 9:00AM Members Present: Staff Present: Edwin Batonbacal; LCSW; Jeanette Cavano, PharmD; Irene Conway; Jeffrey Critchfield, MD; Lukejohn Day, MD; Edward Evans; Todd May, MD; Kenneth Tai, MD; Joseph Woo, MD; Albert Yu, MD; James Glauber, MD, MPH (Chief Medical Officer, SFHP) Matija Cale, Interim Director, Clinical Operations; Grace Dadios, Health Services Department Specialist; Fiona Donald, MD, Medical Director; Lisa Ghotbi, PharmD, Director, ; Jackie Hagg, Nurse Specialist, Provider Quality and Outreach; Odalis Leon, Manager, Delegation Oversight and Credentialing; Adam Sharma, Director, Health Outcomes Improvement; Jim Soos, Medical Policy Administrator Topic Call to Order Meeting was called to order at 7:30AM with a quorum. public comments or questions. Follow Up Follow-Up Items from December 2017 Items Fiona Donald asked the Medical Directors in the Local Initiative Health Plans and County Organized Health Systems (LI/COHS) distribution group if they give monetary incentives to members for completing the Health Risk Assessment Tool and did not receive a response. QIC requested the details for the Pharmacotherapy Management of chronic obstructive pulmonary disease (COPD) measure. Adam Sharma created a slide detailing what is being measured. The baseline for self-reported health is 78% and is based on San Francisco Health Plan s (SFHP) previous CareSupport Program population. SFHP sets conservative target of 60% for year 1 due Follow-up [if Quality Issue identified, Include Corrective Action] follow up needed. n/a follow up needed. n/a Resolution, or Closed Date [for Quality Issue, add plan for Tracking after Resolution] 1 P a g e

4 to changes in SFHP s Care Management population. Jim Glauber provided the following updates. SFHP is officially a National Commission for Quality Assurance (NCQA) Accredited Health Plan for Medicaid. SFHP received out of 50 points. o SFHP will undergo reaccreditation in October 2020 and will be based on 100 points. 50 points are based on the reaccreditation standards and the remaining 50 are based on SFHP s Health Care Effectiveness Data and Information Set (HEDIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores. Adam Sharma noted that SFHP will be required to publicly report its HEDIS and CAHPS scores at this time. In addition, SFHP will be reporting on additional 25 HEDIS measures. A preliminary report on these measures will be presented in future QIC meetings. The annual Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC) medical audits are scheduled for March and August 2018, respectively. The DMHC audit occurs every three years. Consent Calendar Review of Minutes December 14, 2017 UM Committee December 2017 & Therapeutics Committee Minutes October 2017 Q Grievance Report SFHP will explore changing the nomenclature in the Appe Report to clarify the meaning of an overturned appeal. Q Appe Report Q Potential Quality Issue Report Q QI Scorecard SFHP will explore changing the nomenclature in the Appe Report to clarify the meaning of an overturned appeal. Approved: Review of Minutes December 14, 2017 UM Committee December 2017 & Therapeutics Committee Minutes October 2017 Q Grievance Report Q Appe Report

5 Quality Improvement Q Emergency Room Visit/Prescription Access Report Q Potential Quality Issue Report Q QI Scorecard Q Emergency Room Visit/Prescription Access Report Policy and Procedure HE-06: Alcohol Misuse Screening and Approved: Policy and Counseling (AMSC) Procedure HE-06: Alcohol Misuse Screening and Jim Soos presented Policy and Procedure HE-06: Alcohol Misuse Counseling (AMSC) Screening and Counseling (AMSC). Providers in primary care settings must offer and document AMSC services for any member 18 years of age and older who answers yes to the alcohol question in the Staying Healthy Assessment (SHA) or at any time the primary care provider (PCP) identifies a potential alcohol misuse problem. In 2017, SFHP received 81 total claims for AMSC from the provider network. Utilization may be higher but providers may be coding this benefit incorrectly. Palliative Care Benefit Matija Cale and Jim Soos presented on the Palliative Care Benefit and UM-58, respectively. Medi-Cal Managed Care plans are required to provide palliative care services per SB o DHCS released the Palliative Care and Medi-Cal Managed Care All Plan Letter in October 2017 and defined requirements including: Member eligibility Member is likely to or has begun using hospit or emergency departments as a means of managing his/her advanced disease. Disease-specific eligibility Member must meet the disease specific Approved: UM-58: Palliative Care

6 criteria for at least one of the following conditions: o Congestive heart failure (CHF) o Chronic Obstructive Pulmonary Disease (COPD) o Advanced cancer o End Stage Liver disease SFHP assures that the following seven services are provided at minimum when medically necessary: Advanced care planning Palliative care assessment Plan of care Palliative care team Care coordination Pain and symptom management Mental health and medical social services SFHP contracted with Hospice by the Bay to provide palliative care services. Hospice by the Bay is a nonprofit organization and the first hospice in California and the second in the United States. SFHP identified 1,265 potentially eligible members based on diagnosis codes, emergency room (ER) and inpatient utilization patterns and the four qualifying diseases. Of the 1,265 members: o 28.2% were identified with COPD o 19.6% were identified CHF o 9.6% were identified with liver cancer o 5.4% had advanced cancer 27% of members have more than one qualifying condition. o 30.43% and 23.4% of eligible members are Black and Hispanic, respectively. o 54% of hospitalizations and 72% of ER rates were for CHF. o 54% of members are potentially Health Homes eligible.

7 QIC discussed the issue of members not understanding the concept of palliative care and how it is different from hospice care. o Members may consider hospice to be a negative term and will not consider these types of services. Hospice by the Bay and the San Francisco Health Network call their palliative care clinics By the Bay Health and the Plus Clinic, respectively. Information on the palliative care benefit was included in the provider newsletter and Your Health Matters (SFHP s member newsletter). Jim Soos will edit the CHF criteria language as it is not clear if a member must be in the hospital at the time they are approved Facility Site Review Results Jackie Hagg presented the 2017 Facility Site Review (FSR) Results. DHCS requires Medi-Cal Managed Care Plans to conduct Full Scope FSR for every PCP as part of the initial credentialing process and at least every 36 months thereafter. o The Site Review Survey (SRS) evaluates 139 criteria. o The Medical Record Review (MRR) evaluates 32 criteria. SFHP conducted 49 site review surveys, 47 MRRs, and 77 Interim Monitoring /Focused (IM) reviews. o All but one medical group/health plan scored % in the SRS. o Seven providers scored 80 89% while three providers scored less than 80% in the MRR. DHCS standards do not pass a provider/clinic with scores below 80%. The Corrective Action Plans (CAP) were closed for two of the providers (CCHCA and HPMG) who received less than 80%. Jackie provided considerable support to the third provider (SFHP affiliated with HPMG). o The committee discussed if comparative data on failure Jim Soos to edit the CHF criteria language as it is not clear if a member must be in the hospital at the time they are approved. Approved: 2017 Facility Site Review Results

8 rates across Medi-Cal plans were available. Health Plans in Southern California o use Healthy Data Systems to conduct FSRs so SFHP is able to make this comparison. All four of SFHP s certified nurse reviewers passed the rthern California DHCS Inter-Rater Reliability chart review process recertification. Jackie is assisting Lyon Martin Health Services (part of HealthRight 360), who works with a large transgender population, with an Alternative Individual Health Education Behavior Assessment (IHEBA) Request form so the clinic can tailor their behavioral assessments to this unique population. Jackie to present the comparative data on failure rates across Medi-Cal plans to QIC. Approved: Delegated Groups 2017 Audit Results Delegated Groups 2017 Audit Results Odalis Leon presented the Delegated Groups 2017 Audit Results. The delegated groups that were audited include: Brown and Toland Physicians (BTP) o BTP passed in Utilization Management; however, SFHP identified two deficiencies in their tice of Action (NOA) letters: The letters did not include a reference and the non-english NOAs did not include a statement indicating that the member can obtain a copy of the actual benefit provision. o BTP s Language Accessibility Survey results were not favorable and were asked to submit a CAP. The response submitted was insufficient and the CAP remains open. CCHCA o Although CCHCA received a 99% score in the UM audit, few severe irregularities have been identified with the group s application of UM criteria. o CCHCA did not pass the Quality Improvement (QI), Credentialing, Claims and Provider Dispute

9 HPMG o o Resolution (PDRs), Health Education Cultural and Linguistic Services, (HECLS) and Care Management areas and have open CAPs. HPMG passed the Claims audit, but failed the PDR audit. The CAP remains open. HPMG s Language Accessibility Survey results were not favorable and thus are required to submit a CAP.. The CAP remains open until evidence of implementation is provided. rtheast Medical Services (NEMS) o NEMS passed all of its audits. Beacon Health Options o Kaiser o o o Beacon passed all areas reviewed except Provider Training. The CAP will remain open until the training attestations are received. In 2017 San Francisco Bay Area health plans (Partner Plans) participated in the Kaiser Shared- Audit. SFHP conducted the UM and HECLS audits. Kaiser received a passing score for Compliance,, and Mental Health; however the Partner Plans discovered a few deficiencies in these areas. Kaiser did not receive a passing score in Credentialing because they did not provide a complete set of credentialing policies and procedures. University of California, San Francisco (UCSF) o UCSF passed all areas reviewed. San Francisco Health Network (SFHN) o SFHN passed all areas reviewed. QI Committee Chair's Signature & Date 2/28/18 Minutes are considered final only with approval by the QIC at its next meeting.

10 P.O. Box San Francisco, CA (415) (415) FAX Date: March 21, 2018 To From Regarding Quality Improvement Committee James Glauber, MD, MPH Chief Medical Officer Health Services Report HEALTH SERVICES UPDATE The following Health Services update provides key updates from Health Outcomes Improvement, Clinical Operations, Care Management and Services. Health Outcomes Improvement Strategic Use of Reserves Update Status of FY15-16 Program (Total=$15,000,000) $15,000,000 in funding, $10,976,096 disbursed to date o 60% disbursed upon approval o 30% disbursed for deliverables to be completed by July 2018 o 10% withheld for outcome measure to be evaluated and paid by September active hospital and professional group projects o Formal quarterly check-ins and ad-hoc advising o 104 Total Deliverables 63 Complete 39 on-track for completion 2 off track, active corrective actions in place Status of 16/17 Program (Total=$30,000,000) $15,000,000 in professional funding, $10,955,000 disbursed to date

11 o 50% paid on selection of a measure in PIP o 50% paid based on performance of PIP measure, paid each quarter o Final disbursement by April 2018 $15,000,000 in hospital funding, $13,500,000 disbursed to date o 5 active hospital projects that focus on Patient Experience, Transitions of Care, Clinical Quality and Patient Safety, Operational Efficiency & Service Expansion 90% paid upon project approval 10% withheld for outcome measure to be evaluated by September 2019 Status of FY17-18 Program (Total=$13,600,000) Statements of intent have been received Applications will be sent to interested parties by March 22, 2018 Applications will be due by April 26, 2018 Health Care Effectiveness Data & Information Set (HEDIS) SFHP has begun its Reporting Year 2018 HEDIS season. A team of six temporary staff have been hired to complete medical record reviews, and will be onsite at SFHP from 1/16/18-5/8/18. Due to data quality improvements conducted in 2017, SFHP is starting the season with higher administrative rates and thus fewer medical record positives needed to attain 90th percentile go. Practice Improvement Program (PIP) SFHP has launched 2018 PIP with two new primary care measures supporting increased primary care utilization and palliative care. Population Health Grants SFHP has distributed seven first-year payments to support high-impact interventions in diabetes, asthma, and hepatitis C using unearned PIP funds, as approved by the Governing Board in SFHP is working with the remaining two grantees to finalize project plans so that payments can be released. Close to $600,000 has been remitted so far and it is estimated that nearly $2 million will be distributed during the three-year grant program. Access Monitoring SFHP has completed the Provider Appointment Availability Study (PAAS) and summarized findings. A total of 1,677 providers were surveyed. SFHP will be delivering findings and requests for corrective action to provider groups. Overall, SFHP saw improvements in access to primary care and some specialties (e.g. cardiology, oncology). Access challenges identified from the 2017 study include access to

12 psychiatry, endocrinology, and gastroenterology. In addition, accuracy of provider rosters contributed to lower results across SFHP s network as 25% of providers had incorrect information documented. Clinical Operations QNXT Improvements We are currently in user acceptance testing (UAT) for phase 2A and system integration testing (SIT) phase 2B, which increases authorization and claims matching by adding service groups furthering enhancing payment accuracies due to decrease claims edits. These improvements helps decrease administrative burden for both providers and SFHP. Palliative Care Benefit We are excited to announce that SFHP implemented the new palliative care benefit on January 1, 2018 following APL guidelines. We were able to offer this benefit for all medical groups except Kaiser utilizing our Strategic Use of Reserves (SUR) funding. Palliative care is patient and family centered care that aims to optimize quality of life. This community based palliative care program offers a comprehensive list of services through a team of providers to address physical, medical, psychosocial, emotional and spiritual needs of members and their families. This benefit targets four specific disease categories: Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Advanced Cancer and Liver Disease. We have contracted with Hospice By the Bay to provide this benefit, as they have been providing hospice services for over 40 years and have an alliance with UCSF in order to better serve our community in the area of palliative care and hospice services. Based on our analysis of diagnosis and utilization data we anticipate approximately 1,100 potentially eligible members across all medical groups. We are currently in the process of sharing our data with providers in order for them to clinically review these members and refer to this wonderful benefit if appropriate. Staffing Changes After four years with SFHP s Director, Clinical Operations, Collin Elane, RN, left the organization in October of 2017 and moved to Hawaii for personal reasons. Matija Cale, RN, has been promoted to the Interim Director, Clinical Operations. Matija has been with SFHP for six years, most recently in the role of Senior Manager, Concurrent Review. She has over 17 years of health care experience, including ER nursing, discharge planning and UM at the hospital. During her time at SFHP she has built a tight and compliant UM program, launched a 24/7 staffing model, a successful repatriation process with SFHN and a discharge planning program. Most recently she led our inpatient file review for NCQA audit, which we received 100% of available points.

13 Care Management After many months of program development and preparation, Care Management leadership participated in our first NCQA chart audit in December Care Management received very positive feedback from the NCQA auditor on the scope and approach of our Complex Case Management program. Currently we are working to incorporate some of the feedback and further refine the role of our nurse care managers. We are looking forward to partnering with the rest of Health Services on implementation of the new Population Health Management standards which include many of the old QI-5 Complex Case Management elements. Care Management s Children and Family Program Manager has been focused on the development of a suite of new programs targeting children, adolescents and transition aged youth aging out of CCS services. In preparation for these new programs the Care Management team has engaged in multiple trainings, including: Mandated Reporter, Compliance/Information Sharing for Minors, and a Healthy Kids overview. These new program are set to launch in March 2018 and will help us target and more holistically serve our children, adolescents and transition aged youth. Finally, Care Management leadership is working with leadership from across SFHP and within our provider network on implementation of the new DHCS Health Homes benefit. DHCS has confirmed that CMS has approved the State Plan Amendment (SPA) for the Health Homes program and secured the 10% funding from the California Endowment. More information on the new benefit will be provided in the upcoming months prior to the benefit start date of July 1, Services Benefit Manager Request for Proposal (PBM RFP) On February 13, 2018, SFHP released an request for proposal (RFP) intent-to-bid packet to a select group of Benefit Managers (PBMs). This release will launch a PBM black-out period, which will continue until the Governing Board approves a contract recommendation scheduled for the June meeting. 340B Program Support is supporting the launch of a project to work with a 340B Administration vendor to work with our 340B entities for accurate identification of claims and encounters. This effort should ensure accurate reporting to DHCS and additional revenue opportunity for our network 340B entities. DHCS Carve-Out claim data is now available A carve-out benefit is a Medi-Cal service that is available to SFHP members, but is paid for by FFS Medi-Cal, not SFHP. Examples of Carve-Out services include Specialty Mental Health Care including medications, Dental Care, and Substance Abuse Treatment, HIV medications, among others. SFHP now receives this claim data

14 monthly from DHCS and uses it for internal care management programs. This data can o be provided to our SFHP providers on request for their members. Seven-Day Limit on Initial Opioid Prescriptions SFHP is responding to the national and local opioid crisis by instituting drug use policies aimed at safer use of opioid pain medications. As of January 2018, initial opioid prescriptions for acute pain treatment have been limited to a seven-day supply. There are automated exceptions for chronic pain, cancer, hospice and palliative care. These actions are aimed to significantly reduce the number of people newly dependent upon or addicted to opioid pain medications. According to recommendations from the Centers for Disease Control, limiting the length of opioid first prescription exposure to a seven-day supply reduces the likelihood of dependence and long-term opioid use. Over the past year, nine states (Connecticut, Delaware, Maine, Massachusetts, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont) have added limits to initial opioid prescriptions by statute or agency rule. Hepatitis C Trends We have treated 1,206 members for Hepatitis C infection since 2015 with 90% completing treatment. Reasons for members do not complete treatment include: terminating SFHP membership during treatment (4%), non-compliance (1%), medication sent to clinic, but treatment not started (3.5%), and deceased during treatment (1%). Treatment has slowed in December and January with new starts per month and total members in treatment. The new drug, Mavyret, costs around $4,200 per week, compared to previous treatments such as Harvoni at $6,700 per week. This drop in cost, along with a shorter treatment course (8 weeks versus 12 weeks), resulted in Hep C treatments representing only 18.7% of our total pharmacy expenses in December 2017, compared to May 2016 when Hep C treatments represented 49% of our total pharmacy expenses. Despite declining DHCS Hep C kick payments, we have maintained a favorable Hep C medical loss ratio for FY Charts on the next page show the trends in Hep C treatment starts per month and members receiving Hep C treatment.

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16 06.0 Final_2017Annual_Medical-_AppeRpt_v docx UM Medical and UM and Appe Activity 2017 Annual Review Prepared by: K. M. McDonald ( ) Page 1 of 11

17 06.0 Final_2017Annual_Medical-_AppeRpt_v docx The San Francisco Health Plan (SFHP) Clinical Operations (CO) and Services (PS) Utilization Management (UM) programs consistently review their processes guiding utilization management decisions supporting membership in accessing plan appropriate and evidence-based, health, and behavioral health care services. The UM program s mission is to: Support the organizational mission to provide high-quality health and behavioral health care to moderate to low-income San Franciscans; Support the goal of ensuring members equitable access to effective health and behavioral health care throughout the delivery system; Support the San Franciscan healthcare safety net by efficiently leveraging the providers resources; Transform the provider safety net into a network of patient centered medical homes (PCMH) for SFHP s members; Support the Triple Aim initiative: improve population health; improve quality of care; and lower health care costs. Supporting this mission is the UM program s commitment to the principle the UM decision-making process is transparent. UM decisions are based on medical necessity within the scope of the SFHP benefit structure. Tools to support medical necessity include: industry standard UM guidelines (InterQual, Medi-Cal); peer reviewed SFHP guidelines grounded on current, scientifically sound, medical evidence; and independent medical review as needed. UM medical necessity decisions are not unduly influenced by fiscal or administrative factors. The UM program undergoes evaluation and monitoring in order to ensure SFHP members have access to medically necessary, cost effective high quality care. The integrity of this principle is grounded on a continual evaluation of, and the evolvement of, the UM program through monitoring multiple sources of medical information and metrics. The objective is to provide SFHP s members equitable access to efficient, effective health and behavioral health care throughout the healthcare delivery system. The main forum for reviewing and ensuring the UM Programs are carrying out their mission and objectives is the Utilization Management Committee (UMC). At each UMC monthly meeting, there is a standing agenda item to review all appe, Independent Medical Reviews (IMRs), and State Fair Hearings (SFHs). During 2017, the UMC conducted full committee discussions of 56 appe: 17 medical / 39 pharmacy. The UMC is committed to providing an annual appe report to the Quality Improvement Committee (QIC) recapping UMC s review activity of member appeal hearings. Prepared by: K. M. McDonald ( ) Page 2 of 11

18 06.0 Final_2017Annual_Medical-_AppeRpt_v docx 2017 Medical and Appe Metrics Prepared by: K. M. McDonald ( ) Page 3 of 11

19 06.0 Final_2017Annual_Medical-_AppeRpt_v docx The principle guiding the 2017 Annual Review of Medical and Appe report is to ensure all members appealing a denial, in all lines of business (Medi-Cal, Healthy San Francisco, Healthy Kids), are accessing and receiving appropriate medical and pharmaceutical care and services. Medical Activity in Annual Activity Member Months All Lines-of-Business In 2017, SFHP s membership decreased by 0.6 % or 882 members. Prepared by: K. M. McDonald ( ) Page 4 of 11

20 06.0 Final_2017Annual_Medical-_AppeRpt_v docx Medical Authorizations, Deni, and Appe: 2017 Annual Activity Prepared by: K. M. McDonald ( ) Page 5 of 11

21 06.0 Final_2017Annual_Medical-_AppeRpt_v docx Authorizations, Deni, and Appe: 2017 Annual Activity Prepared by: K. M. McDonald ( ) Page 6 of 11

22 06.0 Final_2017Annual_Medical-_AppeRpt_v docx Appendix Prepared by: K. M. McDonald ( ) Page 7 of 11

23 06.0 Final_2017Annual_Medical-_AppeRpt_v docx Master Medical Appe Report 0937ES Essette Grievance Report Description- All grievances and related information for all members DataSource: Essette Report Run Date 2/14/2018 Case Receipt Date 1/1/ /31/2017 as of 2/14/2018 2:58:48 PM Department of Data Management LOB Medical Group Grievance Date Submitted HIL 01/18/2017 CHN 03/08/2017 HEALTHY WORKERS HMO Reason Decision CaseStatus Services available within Medical Group Additional evidence submitted CHN 04/18/2017 Excluded benefit BTP 04/19/2017 CHN 04/25/2017 BTP 04/25/2017 UCS 05/15/2017 CHN 06/30/2017 CHN 08/09/2017 UCS 08/23/2017 UCS 09/01/2017 UCS 09/13/2017 CHN 10/25/2017 CHI 11/20/2017 CHI 12/07/2017 Does not meet Medical Necessity Member retroactively eligible Approved authorization on file Services available within Medical Group Does not meet Medical Necessity Meets Medical Necessity Services available within Medical Group Additional evidence submitted Services available within Medical Group Meets Medical Necessity Additional evidence submitted Meets Medical Necessity Initial Decision Upheld Overturned Initial Decision Upheld Initial Decision Upheld Overturned Overturned Initial Decision Upheld Initial Decision Upheld Overturned Initial Decision Upheld Overturned Initial Decision Upheld Overturned Overturned Overturned Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Resolved Grievance Subcategory Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Denial of service/treatment Disability Component State Fair Hearing Is This out of medical group? Is this out of network? Is this grievance associated with a provider Does this involve a clinic? Case Categories Is this PQI? Yes Yes UM UM Yes UM Medical Group Yes Yes SFHP - UM Outpatient Yes BTP Medical Group Yes Yes Yes Yes Yes SFHP - UM Outpatient SFHP - UM Outpatient SFHP - UM Outpatient SFHP - UM Outpatient SFHP - UM Outpatient Yes Medical Group SFHP - UM Outpatient Yes Medical Group CCHCA Medical Group Prepared by: K. M. McDonald ( ) Page 8 of 11

24 06.0 Final_2017Annual_Medical-_AppeRpt_v docx Master Appe Report Part 1 of ES Essette Grievance Report Description- All grievances and related information for all members DataSource: Essette Report Run Date 2/14/2018 Case Receipt Date 1/1/ /31/2017 as of 2/14/2018 2:58:48 PM Department of Data Management LOB HEALTHY WORKERS HMO HEALTHY WORKERS HMO Medical Group Grievance Date Submitted NEM 01/13/2017 additional evidence submitted CHN 01/19/2017 Additional evidence submitted Reason Decision CaseStatus Disability Component Initial Decision Upheld UCS 01/23/2017 Does not Initial Decision meet Medical Upheld Necessity CHN 01/27/2017 Additional evidence submitted CHN 02/03/2017 Additional evidence submitted CHN 02/09/2017 Does not Initial Decision meet Medical Upheld Necessity CHN 02/13/2017 Additional evidence submitted CHN 02/15/2017 Meets Medical Necessity CHN 02/16/2017 additional evidence submitted CHN 02/16/2017 additional evidence submitted State Fair Hearing Is This out of medical group? Is this out of network? Is this grievance associated with a provider Does this involve a clinic? Does this involve prescription medications? Resolved grievance Resolved valium 10 MG Favor of the plan Overturned Resolved Migergot Favor of the member Resolved HUMATROPE 12mg Favor of the plan Overturned Resolved ILARIS Favor of the member Overturned Resolved Epclusa 400 MG-100 MG tablet Favor of the member Resolved Harvoni Favor of the plan Overturned Resolved Viekira Favor of the member Overturned Resolved Yes Epclusa mg tab Initial Decision Upheld Initial Decision Upheld Resolved Epclusa mg tab Resolved Epclusa mg tab Favor of the member Favor of the plan Favor of the plan Case Categories Is this PQI? Grievance Category HEALTHY WORKERS HMO CHN 03/23/2017 Additional evidence submitted UCS 03/24/2017 Additional evidence submitted CHN 03/27/2017 additional evidence submitted UCS 04/05/2017 Additional evidence submitted Overturned Resolved Diabetic Test Strips Overturned Resolved Timoptic XE 0.5% Gel Solution Initial Decision Upheld Resolved Additional 4 week treatment of Epclusa Overturned Resolved Lyrica 75 MG capsule Favor of the member Favor of the member Favor of the plan Favor of the member Prepared by: K. M. McDonald ( ) Page 9 of 11

25 06.0 Final_2017Annual_Medical-_AppeRpt_v docx Master Appe Report Part 2 of ES Essette Grievance Report Description- All grievances and related information for all members DataSource: Essette Report Run Date 2/14/2018 Case Receipt Date 1/1/ /31/2017 as of 2/14/2018 2:58:48 PM Department of Data Management LOB HEALTHY WORKERS HMO Medical Group Grievance Date Submitted CHN 04/14/2017 Meets Medical Necessity BTP 04/20/2017 Additional evidence submitted CHN 04/26/2017 Additional evidence submitted UCS 06/01/2017 Does not Initial Decision meet Medical Upheld Necessity NMS 06/05/2017 Additional evidence submitted CHN 06/08/2017 Does not meet Medical Necessity Initial Decision Upheld CHI 06/08/2017 Does not Initial Decision meet Medical Upheld Necessity CHN 06/14/2017 Meets Medical Necessity CHN 06/15/2017 Does not Initial Decision meet Medical Upheld Necessity CHN 06/27/2017 Meets Medical Necessity UCS 07/11/2017 Does not meet Medical Necessity Initial Decision Upheld CHN 07/16/2017 Does not Initial Decision meet Medical Upheld Necessity UCS 09/19/2017 Additional evidence submitted Reason Decision CaseStatus Disability Component State Fair Hearing Is This out of medical group? Is this out of network? Is this grievance associated with a provider Does this involve a clinic? Does this involve prescription medications? Overturned Resolved METHADOSE 10 MG TABLET Overturned Resolved Repatha 140mg/ml Resolved grievance Favor of the member Favor of the member Overturned Resolved Epclusa Favor of the member Resolved Lyrica Favor of the plan Overturned Resolved Clobetasol 0.05% cream Resolved Venclexta 100 MG tablet Resolved Cosentyx 150MG pen Favor of the member Favor of the plan Favor of the plan Overturned Resolved Yes Eplcusa Favor of the member Resolved Soolantra 1% cream Favor of the plan Overturned Resolved Zepatier Favor of the member Resolved Alli 60mg capsule Resolved modafinil 100mg tablet Overturned Resolved Zolmitriptan 2.5mg Favor of the plan Favor of the plan Favor of the member Case Categories Is this PQI? Grievance Category Prepared by: K. M. McDonald ( ) Page 10 of 11

26 06.0 Final_2017Annual_Medical-_AppeRpt_v docx Master Appe Report Part 3 of ES Essette Grievance Report Description- All grievances and related information for all members DataSource: Essette Report Run Date 2/14/2018 Case Receipt Date 1/1/ /31/2017 as of 2/14/2018 2:58:48 PM Department of Data Management LOB Medical Group Grievance Date Submitted CHN 09/20/2017 Additional evidence submitted UCS 09/28/2017 Meets Medical Necessity CHN 09/25/2017 External review BTP 10/11/2017 Additional evidence submitted UCS 10/23/2017 Additional evidence submitted UCS 10/26/2017 Additional evidence submitted UCS 10/30/2017 Additional evidence submitted UCS 10/30/2017 Does not Initial Decision meet Medical Upheld Necessity UCS 11/09/2017 Additional evidence submitted CHN 12/13/2017 additional evidence submitted CHN 12/22/2017 Additional evidence submitted Reason Decision CaseStatus Disability Component State Fair Hearing Is This out of medical group? Is this out of network? Is this grievance associated with a provider Does this involve a clinic? Does this involve prescription medications? Overturned Resolved ORENCIA 125MG SYRINGE Overturned Resolved Maxalt MLT 10 MG tablet Resolved grievance Favor of the member Favor of the member Overturned Resolved Xifaxan Favor of the member Overturned Resolved rthera Favor of the 100MG member Overturned Resolved Chantix Favor of the member Overturned Resolved Rozerem 8mg Favor of the member Overturned Resolved Adrica Favor of the member Resolved Forteo 600mg G/2.4ML Pen Initial Decision Upheld Resolved Xelijanz 10 MG Tablet Overturned Resolved Budesonide medication Favor of the plan Favor of the member Favor of the plan Favor of the member Case Categories Overturned Resolved Hydrocodoneacetaminophe n Is this PQI? Grievance Category Prepared by: K. M. McDonald ( ) Page 11 of 11

27 Date: March 30, 2018 To From Regarding Quality Improvement Committee Nicole A. Ylagan, Grievance Analyst 2017 Annual Grievance and Appe Report The intent of the report is to monitor member grievances and appe and identify areas of improvement. San Francisco Health Plan (SFHP) processes grievances and appe for members who have Medi-Cal. Medi-Cal is a state sponsored health insurance program. A total of 302 grievances and 57 appe were reported in 2017 in comparison to 353 grievances and 65 appe in The grievance volume in 2017 decreased 14.4% from The appeal volume in 2017 decreased by 12.3% from Table 1: Grievance Volume Report Category Number of grievances received in 2015 Grievance Rate per 1,000 PMPM 2015 Number of grievances received in 2016 Grievance Rate per 1,000 PMPM 2016 Number of grievance s received 2017 Grievance Rate per 1,000 PMPM 2017 Attitude/Service Quality of Care Other Access Quality of Practitioner Office Site Billing/Financial SFHP Total/Number per 1,000 per PMPM Department of Health Care Services (DHCS) Currently not available Currently not available

28 Table 2: Appeal Volume Report Category Number of Appe received in 2015 Appeal Rate 2015 per 1,000 PMPM Number of Appe received in 2016 Appeal Rate 2016 per 1,000 PMPM Number of Appe received in 2017 Appeal Rate 2017 per 1,000 PMPM appeal* UM Outpatient appeal* Other Quality of Care Administrative services Access* Attitude/Service Billing/Financial Quality of Practitioner Office Site SFHP Total/Number per 1,000 per PMPM *In 2016, appe were captured in two categories: pharmacy and utilization management (UM). In 2017, appe were categorized as access to align with National Committee for Quality Assurance (NCQA) standards. Qualitative Analysis of Grievances and Appe in 2017: SFHP s performance threshold for each category is < 1.00 per 1,000 members. If any category exceeds a rate of 1.00 for either grievances or appe, SFHP determines appropriate improvement activities for SFHP and its broader provider network. For grievances and appe in 2017, SFHP met performance threshold for all categories. SFHP identifies providers or clinics that were involved in three grievances within the same grievance category. If any provider or clinic is identified, these are classified as trends. Any of SFHP s internal committees may recommend further actions if necessary such as a Corrective Action Plan (CAP). SFHP s internal committees of Grievance Oversight Committee, Grievance Review Committee, Access to Care Committee and Joint Operations made the following recommendations based on the review of 2017 trending grievances. DuringQ1 2017, SFHP identified that UCSF Primary Care Clinics are noncompliant with the DMHC regulatory requirements for timely access to

29 appointments (California Code of Regulations ). Members complained of the challenges to schedule appointments for primary care at UCSF clinics. In April 2017, SFHP s Access to Care Committee (ATC) included these grievances with UCSF s Corrective Action Plan (CAP). As a result of the CAP, UCSF created an Access Committee and added additional primary care providers to their network. SFHP approved these improvements in vember During Q1 2017, grievances related to patient communication were identified from Sutter Pacific Medical Foundation (SPMF) Family Health Center. SPMF s leadership was asked to evaluate these grievances and work with clinic staff to identify improvement areas. SPMF was o provided with communication tools such as the Studer Group s evidence based practice for improving provider and patient communication called AIDET. AIDET is an acronym that stands for: Acknowledge- greet the patient and make them feel welcome Introduce- introduce yourself with your name, professional certification and experience Duration- let the patient know how long your interaction with them will last Explanation- explain what to expect next Thank thank the patient and their family During Q2 and Q3 2017, three grievances were filed regarding the delay of Applied Behavior Analysis (ABA) with SFHP s non-specialty mental health provider, Beacon Health Options. The delays of ABA services were discussed at Beacon s Joint Operations meeting with SFHP in October Beacon s goal was to better understand the experience of members in order to support them in accessing ABA services. Also, Beacon agreed to improve the overall penetration rate, reporting and access for ABA services. In Q4 2017, there were nine grievances associated with the member perceptions of experiencing discrimination based on ethnicity, language and/or gender identity. The nine grievances were not associated with a specific provider, clinic or medical group. Therefore, SFHP reminded providers of SFHP s non-discrimination policy with resources assist providers in these situations.

30 [Type text] P.O. Box San Francisco, CA (415) (415) FAX APPOINTMENT AVAILABILITY REPORT Date: March 5, 2018 Provider Appointment Availability San Francisco Health Plan (SFHP) administers the Provider Appointment Availability Survey and the Daytime Survey to evaluate appointment availability. The Department of Managed Health Care (DMHC) and the Department of Health Care Services (DHCS) require SFHP to monitor appointment availability in order to ensure that health care services are provided to patients in a timely manner appropriate for the nature of the patient s condition and consistent with professional practice. SFHP o follows access standards set by the National Committee for Quality Assurance (NCQA), which includes identifying and monitoring high impact and high volume specialty providers. Executive Summary of Results Accomplishments: San Francisco Health Network, which serves the majority of SFHP s members, significantly improved its rate of compliance in meeting the timely access standards in routine primary care, prenatal appointment availability, and routine & urgent cardiology appointment availability (Table O, page 11). Cardiology and Primary care providers response rates and compliance with appointment availability requirements significantly improved for urgent and routine appointments (Table E, page 6; Table Q, page 13). SFHP reached 80% compliance in availably for routine primary care appointments, prenatal care appointments, and routine physical therapy appointments (Table E). Overall, the rate of SFHP medical groups that met the 80% compliance requirement for each appointment standard largely remained the same or increased from 2016 to 2017 (table D, page 5). SFHP will continue to request corrective action from each group that did not meet the requirement and/or provide technical assistance from the groups when requested. Opportunities for Improvement: primary care appointment availability decreased from 64% in MY 2016 to 52% in MY2017, despite increases in appointment availability for other provider types, including routine appointment availability (Table E). Compared to MY 2016, SFHP s overall response rate for MY 2017 decreased from 60% to 53%. Although compliance with appointment availability and responsiveness increased for many providers, lack of responsiveness contributes to non-compliance and imprecise assessment of appointment availability across SFHP (Table Q). SFHP will continue to emphasize the importance of survey responses via provider communication and corrective action plans. Specialty and behavioral health providers significantly contributed to low response rates (Table Q). Collecting responses from specialty providers within seven business days of surveying is a priority for next measurement year. 1

31 [Type text] P.O. Box San Francisco, CA (415) (415) FAX Barriers: Barriers found include provider groups, particularly safety-net health care providers, lacked the infrastructure to provide efficient care, thus negatively impacting the volume of services they could provide. Infrastructure needs include technological improvements (EHR, Telephones), ability to provide care beyond typical face-to-face visits, effective recruitment strategies for providers, and processes to inform/manage expectations with members. Overall, SFHP s strategy is to work with each medical group individually to address appointment availability, clinic capacity and scheduling techniques. Next Steps: SFHP requested Corrective Action Plans (CAP) for any group that falls below the 80% compliance rate. SFHP will provide technical assistance webinars and coaching to provide best practices for improving access to care and instructions on how to accurately submit a CAP. SFHP to provide funding to groups who are participating in the Strategic Use of Reserves (SUR) grant funding program in an effort to improve access in the network. SFHP will provide an access dashboard to medical groups and includes the PAAS survey results and accessrelated grievances. Survey Methodology: SFHP utilizes two surveys to assess appointment availability for each regulation as described in Table A: the Provider Appointment Availability Survey (PAAS) and the Daytime Survey. SFHP implemented PAAS from August to December of 2017 and reported the results in March The types of providers included in PAAS are primary care providers (including internal medicine, pediatrics, and family/general medicine), cardiologists, endocrinologists, gastroenterologists, gynecologists, oncologists, non-physician behavioral health care providers, psychiatrists, and ancillary providers. Gynecology and oncology providers were identified as the top high volume and high impact specialties; therefore these specialties were included in PAAS in order to follow NCQA network access recommendations. n-physician behavioral health care included Licensed Clinical Social Workers, Marriage and Family Therapists, and Clinical Psychologists. Ancillary providers included those delivering MRI, mammography, and physical therapy services. SFHP selected a random sample of provider type for each medical group. SFHP determined sample size from DMHC s Measurement Year 2017 PAAS methodology and included an oversample of twenty providers when available. SFHP utilized the PAAS methodology recommended by DMHC and the details of the methodology can be found on the DMHC website ( If providers did not have appointments available within the required time frame, surveyors asked if sooner appointments were available with alternative providers. Provider sites had 48 hours to respond to the survey. Refusal to respond to the survey or failure to return the phone call within the allotted time was considered non-compliant. Results of individual providers were aggregated to obtain a compliance rate for each medical group. SFHP requires 80% compliance rate for each access standard. A plan for corrective action is required when a group or clinic does not meet this requirement. SFHP conducted the daytime survey from October 2017 to vember Contracted SFHP providers and contracted clinic sites that provide routine primary care (including internal medicine, pediatrics, and family/general medicine) were surveyed. Each provider group s survey population is an audit of primary care sites and therefore contains all phone numbers for primary care providers within the medical group. 2

32 [Type text] P.O. Box San Francisco, CA (415) (415) FAX For each unique phone number surveyed, SFHP relayed to provider office staff that SFHP was conducting an access compliance survey. SFHP requested information regarding if the provider office site offered prenatal care appointments; those that provided prenatal appointments were further surveyed regarding the next available prenatal care appointment available at that provider office. Survey respondents that did not provide a compliant answer for the office wait time elements described in Table A were considered non-compliant. Results of individual primary care sites were aggregated to obtain a compliance rate for each medical group. SFHP requires 80% compliance rate for prenatal care appointment availability. A plan for corrective action is required when a group or clinic does not meet this requirement. SFHP has multiple lines of business, which includes Medi-Cal, Healthy Workers, and Healthy Kids. Each line of business participates in different medical groups and is overseen by different regulatory agencies. Table B illustrates each line of business, their corresponding regulatory agency, and which medical groups are associated with each line of business. Table A: Appointment Requirements Provider Appointment Type Primary Care Appointments Appointment Within 48 hrs. without prior authorization Within 96 hrs. with prior authorization Routine Appointment Corresponding Survey Within 10 business days Provider Appointment Availability Survey Prenatal Care Appointment n-physician Behavioral Health Appointments N/A Within 48 hrs. without prior authorization Within 96 hrs. with prior authorization Within 10 business days Within 10 business days Daytime Survey Provider Appointment Availability Survey Specialty Care Appointments Within 48 hrs. without prior authorization Within 96 hrs. with prior authorization Within 15 business days Provider Appointment Availability Survey Ancillary Appointments N/A Within 15 business days Provider Appointment Availability Survey 3

33 [Type text] P.O. Box San Francisco, CA (415) (415) FAX Table B: Medical Group Lines of Business Lines of Business Regulatory Agency Applicable Medical Groups Medi-Cal DHCS DMHC Beacon Health Options Brown and Toland Physicians Chinese Community Health Care Association Hill Physicians Independent Clinics rth East Medical Services rth East Medical Services with SFHN San Francisco Consortium of Community Clinics San Francisco Health Network (SFHN) University of California San Francisco Healthy Kids DMHC Brown and Toland Physicians Chinese Community Health Care Association Community Behavioral Health Services Hill Physicians Independent Clinics rth East Medical Services rth East Medical Services with SFHN San Francisco Consortium of Community Clinics San Francisco Health Network (SFHN) University of California San Francisco Healthy Workers DMHC Community Behavioral Health Services San Francisco Health Network (SFHN) Survey Analysis: The PAAS provider sample expanded the scope of providers in 2017 by including more provider specialties than 2016 endocrinology, gastroenterology, gynecology, and oncology. Inclusion of these providers provides a more complete picture of members access to specialty care. Overall results indicate that SFHP reached 80% compliance in availably for routine primary care, prenatal care, and physical therapy appointments. SFHP did not meet 80% compliance for all other appointment types. primary care appointments decreased in in appointment availability, despite increased responsiveness across primary care providers. For all other providers, non-responsiveness to the survey contributed to non-compliance to each appointment standard. In comparison to 2016, 2017 results indicate that primary care, nonphysician behavioral health, cardiology, mammography, and physical therapy provider types were more responsive to the survey, resulting in increased compliance rates. Psychiatry and MRI providers increased in non-responsiveness to the survey, while all other newly surveyed specialties demonstrated low responsiveness to the survey. Survey Limitations: Some medical groups sample sizes significantly varied between 2016 and One explanation may be due to the timing of the survey. Sample frames were determined in July of each measurement year, with surveying from August to December, and reporting of results in the following March. In the time lapse of 9 months, some providers may terminate with medical groups and become ineligible for reporting in medical groups samples. 4

34 [Type text] P.O. Box San Francisco, CA (415) (415) FAX Table C: Results Key Green Scores marked in green indicate improvement in 2017 from 2016 Red Scores marked in red indicate that a score lowered in 2017 from 2016 Yellow Scores highlighted in yellow indicate that the group did not reach 80% compliance for the access standard Table D: Aggregate of Medical Group Compliance (80%) Provider Type Compliance Element Medical groups achieving 80% compliance (MY 2016) Medical groups achieving 80% compliance (MY 2017) Primary Care 22% 0% Routine 33% 44% Prenatal 11% 67% Cardiology 0% 29% Routine 0% 14% Endocrinology N/A 0% Routine N/A 0% Gastroenterology N/A 14% Routine N/A 14% Gynecology N/A 0% Routine N/A 14% Oncology N/A 33% Routine N/A 50% n-physician Behavioral Health Appointments 0% 0% Routine 0% 0% Psychiatry 0% 17% Routine 0% 17% Mammography Routine 0% 17% MRI Routine 50% 0% Physical Therapy Routine 29% 71% 5

35 [Type text] P.O. Box San Francisco, CA (415) (415) FAX Table E: Aggregate of SFHP Providers MY 2016 MY 2017 SFHP Sample nresponsivcompliant size responsive compliant n- Sample n- n- Compliant Compliant Overall size 12% 64% 35% 52% % % Primary Care Routine 5% 71% 3% 84% Prenatal % 15% 58% 44 N/A 18% 82% Cardiology 16% 17% 12% 44% 84 67% 78 44% Routine 6% 27% 6% 50% Endocrinology Routine 12% 18% 16% 14% t surveyed in % Gastroenterology Routine 8% 20% 12% 16% t surveyed in % Gynecology 16% 24% t surveyed in % Routine 11% 29% Oncology 21% 21% t surveyed in % Routine 2% 40% n-md 13% 13% 5% 31% % % Behavioral Routine 2% 24% 2% 34% Psychiatry 11% 14% 3% 8% 73 75% % Routine 2% 23% 2% 9% Mammography Routine 5 60% 0% 40% 24 42% 4% 54% MRI Routine 19 11% 0% 89% 51 27% 2% 71% Physical Therapy Routine 19 26% 16% 58% 37 14% 5% 81% Tables F-P: Individual Medical Group Compliance Beacon Health Options n-md Behavioral Psychiatry MY 2016 MY 2016 Sample nresponsivcompliant n- Compliant Sample n- n- Compliant size size responsive compliant 16% 17% 7% 28% 30 67% 46 65% Routine 3% 30% 2% 33% 11% 24% 33% 22% 17 65% 9 45% Routine 6% 29% 44% 11% 6

36 [Type text] P.O. Box San Francisco, CA (415) (415) FAX MY 2016 MY 2017 Brown and Toland Sample nresponsivcompliant size responsive compliant n- Sample n- n- Physicians Compliant Compliant size 29% 52% 34% 56% 42 19% 41 10% Primary Care Routine 19% 62% 14% 76% Prenatal 12 25% 25% 50% 6 N/A 0% 100% Cardiology 27% 23% 54% 31% 22 50% 13 15% Routine 14% 36% 31% 54% Endocrinology Routine 50% 25% 75% 0% t surveyed in % Gastroenterology Routine 15% 20% 20% 15% t surveyed in % Gynecology 10% 60% t surveyed in % Routine 0% 70% Oncology 33% 33% t surveyed in % Routine 0% 67% Mammography Routine 2 50% 0% 50% 5 40% 0% 60% MRI Routine 7 0% 0% 100% 12 25% 0% 75% Physical Therapy Routine 11 9% 9% 82% 21 14% 0% 86% 7

37 [Type text] P.O. Box San Francisco, CA (415) (415) FAX Chinese Community Health Care Association MY 2016 MY 2017 Sample size Compliant Sample size Compliant Community Behavioral Health Services n-md Behavioral Psychiatry nresponsive ncompliant nresponsive ncompliant 14% 60% 8% 77% 65 26% 39 15% Primary Care Routine 5% 69% 3% 82% Prenatal 19 21% 11% 68% 6 N/A 0% 100% Cardiology 27% 9% 0% 50% 11 64% 6 50% Routine 9% 27% 0% 50% Endocrinology Routine 0% 67% 0% 67% t surveyed in % Gastroenterology Routine 0% 0% 0% 0% t surveyed in % Gynecology 0% 40% t surveyed in % Routine 0% 40% Oncology 0% 100% t surveyed in % Routine 0% 100% Mammography Routine t surveyed in % 0% 100% MRI Routine 2 0% 0% 100% 4 50% 0% 50% Physical Therapy Routine 2 50% 0% 50% 5 20% 0% 80% MY 2016 MY 2017 Sample nresponsivcompliant n- Compliant Sample size size nresponsive ncompliant Compliant 12% 11% 3% 33% 74 77% 66 64% Routine 1% 22% 1% 35% 10% 11% 4% 16% 56 79% 88 80% Routine 0% 21% 1% 19% 8

38 [Type text] P.O. Box San Francisco, CA (415) (415) FAX Independent Clinics Primary Care MY 2016 MY 2017 Hill Physicians Sample nresponsivcompliant size responsive compliant n- Sample n- n- Compliant Compliant size 18% 54% 28% 50% 50 28% 46 22% Primary Care Routine 12% 60% 8% 70% Prenatal 15 40% 7% 53% 9 N/A 22% 78% Cardiology 33% 50% 0% 100% % 4 0% Routine 16.5% 67% 0% 100% Endocrinology Routine 0% 25% 0% 25% t surveyed in % Gastroenterology Routine 0% 100% t surveyed in % 0% 100% Gynecology 29% 57% t surveyed in % Routine 0% 86% Oncology 0% 100% t surveyed in % Routine 0% 100% Mammography Routine 1 100% 0% 0% 4 50% 0% 50% MRI Routine 3 33% 0% 67% 9 22% 0% 78% Physical Therapy Routine 1 100% 0% 0% 2 0% 0% 100% MY 2016 MY 2017 Sample nresponsivcompliant size responsive compliant n- Sample n- n- Compliant Compliant size 0% 40% 50% 0% 5 60% 4 50% Routine 0% 40% 0% 50% Prenatal 1 100% 0% 0% 1 N/A 0% 100% 9

39 [Type text] P.O. Box San Francisco, CA (415) (415) FAX rth East Medical Services with SFHN Primary Care Cardiology ncompliant Endocrinology Gastroenterology Gynecology Psychiatry Physical Therapy MY 2016 MY 2017 Sample size Compliant Sample size MY 2016 MY 2017 rth East Sample nresponsivcompliant size responsive compliant n- Sample n- n- Medical Services Compliant Compliant size 5% 84% 27% 63% 63 11% 60 10% Primary Care Routine 5% 84% 0% 90% Prenatal 20 5% 5% 90% 6 N/A 50% 50% Cardiology 0% 33% 0% 88% 3 67% 8 12% Routine 0% 33% 13% 75% Endocrinology Routine 0% 50% 0% 50% t surveyed in % Gastroenterology Routine 0% 0% 0% 0% t surveyed in % Gynecology 0% 50% t surveyed in % Routine 0% 50% Oncology 50% 50% t surveyed in % Routine 0% 100% Psychiatry 0% 100% t surveyed in % Routine 0% 100% Mammography Routine 2 50% 0% 50% 5 40% 0% 60% MRI Routine 2 50% 0% 50% 10 30% 0% 70% Physical Therapy Routine 1 0% 0% 100% 5 20% 20% 60% nresponsive ncompliant nresponsive 3% 85% 20% 78% 33 12% 40 2% Routine 3% 85% 0% 98% Prenatal 6 17% 33% 50% 5 N/A 40% 60% 0% 0% 0% 50% 8 100% 4 50% Routine 0% 0% 0% 50% 0% 11% t surveyed in % Routine 0% 11% 0% 0% t surveyed in % Routine 0% 0% 0% 8% t surveyed in % Routine 0% 8% 0% 2% t surveyed in % Routine 0% 2% Compliant Routine 1 0% 100% 0% 1 0% 0% 100% 10

40 [Type text] P.O. Box San Francisco, CA (415) (415) FAX San Francisco Consortium of Community Clinics Primary Care MY 2016 MY 2017 Sample size Compliant Sample size nresponsive ncompliant nresponsive ncompliant Compliant 15% 37% 61% 13% 27 48% 23 26% Routine 0% 52% 0% 74% Prenatal 12 42% 25% 33% 3 N/A 0% 100% MY 2016 MY 2017 San Francisco Sample nresponsivcompliant size responsive compliant n- Sample n- n- Health Network Compliant Compliant size 1% 80% 43% 50% 85 19% 130 7% Primary Care Routine 0% 81% 0% 93% Prenatal 22 23% 27% 50% 7 N/A 14% 86% Cardiology 0% 20% 0% 50% 10 80% 2 50% Routine 0% 20% 0% 50% Endocrinology Routine 0% 0% 0% 0% t surveyed in % Gastroenterology Routine 0% 44% 11% 33% t surveyed in % Gynecology 0% 0% t surveyed in % Routine 0% 0% Oncology 33% 0% t surveyed in % Routine 0% 33% Psychiatry 1% 3% t surveyed in % Routine 3% 1% Mammography Routine t surveyed in % 0% 33% MRI Routine t surveyed in % 0% 67% Physical Therapy Routine 1 0% 100% 0% 1 0% 0% 100% 11

41 [Type text] P.O. Box San Francisco, CA (415) (415) FAX University of California San Francisco MY 2016 MY 2017 Sample size Compliant Sample size Compliant nresponsive ncompliant nresponsive ncompliant 22% 45% 54% 25% 60 33% 56 21% Primary Care Routine 5% 62% 2% 77% Prenatal 23 39% 9% 52% 1 N/A 0% 100% Cardiology 13% 8% 7% 32% 24 79% 41 61% Routine 0% 21% 0% 39% Endocrinology Routine 14% 14% 14% 14% t surveyed in % Gastroenterology Routine 7% 7% 7% 7% t surveyed in % Gynecology 43% 9% t surveyed in % Routine 43% 9% Oncology 12% 8% t surveyed in % Routine 4% 16% Psychiatry 2% 4% t surveyed in % Routine 0% 6% Mammography Routine t surveyed in % 17% 50% MRI Routine t surveyed in % 10% 70% Physical Therapy Routine 2 100% 0% 0% 2 0% 50% 50% 12

42 [Type text] P.O. Box San Francisco, CA (415) (415) FAX Table Q: 2016 and 2017 PAAS Response Rates Medical Group Provider type Response Rate (MY 2016) SFHP Overall Response Rate (MY 2017) All PAAS provider types 60% 53% -7% Primary Care 76% 87% 11% Cardiology 33% 56% 23% Endocrinology N/A 31% N/A Gastroenterology N/A 28% N/A Gynecology N/A 40% N/A Oncology N/A 42% N/A n-md Behavioral 26% 36% 11% Psychiatry 25% 11% -14% Mammography 40% 58% 18% MRI 89% 73% -16% Physical Therapy 74% 86% 12% Response Rate Change (MY 2016 MY 2017) Beacon Health Options Brown and Toland Physicians Chinese Community Health Care Association n-md Behavioral 33% 35% 2% Psychiatry 35% 56% 21% Primary Care 81% 90% 9% Cardiology 50% 85% 35% Endocrinology N/A 75% N/A Gastroenterology N/A 35% N/A Gynecology N/A 70% N/A Oncology N/A 67% N/A Mammography 50% 60% 10% MRI 100% 75% -25% Physical Therapy 91% 86% -5% Primary Care 74% 85% 11% Cardiology 36% 50% 14% Endocrinology N/A 67% N/A Gastroenterology N/A 0% N/A Gynecology N/A 40% N/A Oncology N/A 50% N/A Mammography N/A 100% N/A MRI 100% 50% -50% Physical Therapy 50% 80% 30% 13

43 [Type text] P.O. Box San Francisco, CA (415) (415) FAX Medical Group Provider type Response Rate (MY 2016) Community Behavioral Health Services Response Rate (MY 2017) n-md Behavioral 23% 36% 13% Psychiatry 21% 20% -1% Response Rate Change (MY 2016 MY 2017) Hill Physicians Primary Care 72% 78% 6% Cardiology 83% 100% 17% Endocrinology N/A 25% N/A Independent Clinics rth East Medical Services rth East Medical Services with SFHN San Francisco Consortium of Community Clinics Gastroenterology N/A 100% N/A Gynecology N/A 86% N/A Oncology N/A 100% N/A Mammography 0% 50% 50% MRI 67% 78% 11% Physical Therapy 0% 100% 100% Primary Care 40% 50% 10% Primary Care 89% 90% 1% Cardiology 33% 88% 55% Endocrinology N/A 50% N/A Gastroenterology N/A 0% N/A Gynecology N/A 50% N/A Oncology N/A 100% N/A Psychiatry N/A 100% N/A Mammography 50% 60% 10% MRI 50% 70% 20% Physical Therapy 100% 80% -20% Primary Care 88% 98% 10% Cardiology 0% 50% 50% Endocrinology N/A 11% N/A Gastroenterology N/A 0% N/A Gynecology N/A 8% N/A Psychiatry N/A 2% N/A Physical Therapy 100% 100% 0% Primary Care 52% 74% 22% 14

44 [Type text] P.O. Box San Francisco, CA (415) (415) FAX Medical Group Provider type Response Rate (MY 2016) San Francisco Health Network University of California San Francisco Response Rate (MY 2017) Primary Care 81% 93% 12% Cardiology 20% 50% 30% Endocrinology N/A 0% N/A Gastroenterology N/A 44% N/A Gynecology N/A 0% N/A Oncology N/A 33% N/A Psychiatry N/A 5% N/A Mammography N/A 33% N/A MRI N/A 67% N/A Physical Therapy 100% 100% 0% Primary Care 67% 79% 12% Cardiology 21% 39% 18% Endocrinology N/A 29% N/A Gastroenterology N/A 13% N/A Gynecology N/A 52% N/A Oncology N/A 20% N/A Psychiatry N/A 6% N/A Mammography N/A 67% N/A MRI N/A 80% N/A Physical Therapy 0% 100% 100% Response Rate Change (MY 2016 MY 2017) NOTE: Kaiser Permanente is a fully delegated medical group and was not included in the survey. Kaiser will submit their Timely Access report directly to DMHC. 15

45 [Type text] P.O. Box San Francisco, CA (415) RESULTS FOR ACCESS TO TRIAGE SERVICES Date: February 15, 2018 Access Monitoring Requirements The Department of Managed Health Care (DMHC) and the Department of Health Care Services (DHCS) require SFHP to monitor accessibility requirements for telephonic triage. DMHC and DHCS require that primary care and behavioral health providers offer 24-hour coverage with the ability to access a clinician within 30 minutes of the member s request. In addition, DMHC and DHCS require that providers inform members on how to access emergency care when calling a provider. Executive Summary of Results Accomplishments: SFHP s network reached 80% compliance in providing accurate emergency instructions (Table E, page 5). Overall the rate of compliance for providing triage during business hours increased from 42% in 2016 to 65% in 2017 (Table E) Opportunities/Barriers: The number of groups reaching 80% compliance with each element either decreased in the case of after-hours triage or did not increase in the cases of emergency instructions and triage during business hours (Table D, page 4). Compared to 2016, SFHP decreased in compliance for providing triage after hours from 74% to 49% in 2017 (Table E). Overall the daytime survey had a 12% non-response rate. When clinic staff was not available during the daytime, SFHP left messages for sites requesting a call back to complete the survey. Sites that did not complete the survey from refusal or from non-response to the survey were included in results as non-compliance. n-responsiveness contributed to overall noncompliance rate for this survey. Next Steps: SFHP will request Corrective Action Plans (CAP) for any group that falls below the 80% compliance rate (Table D). SFHP will provide technical assistance to provide best practices for improving access to care and instructions to accurately submit a CAP. Survey Methodology SFHP conducted the daytime and after-hours triage surveys from October 2017 to December 2017 during and after business hours, between 9 AM to 5PM, and 8 PM to 11 PM. Contracted SFHP providers and contracted clinic sites that provide routine primary care (including internal medicine, pediatrics, and 1

46 [Type text] P.O. Box San Francisco, CA (415) family/general medicine) were surveyed. Additionally, SFHP surveyed SFHP s contracted behavioral health care call centers. Each medical group s survey population is an audit of primary care sites and therefore contains all phone numbers for primary care providers within the medical group. SFHP has multiple lines of business, which include Medi-Cal, Healthy Workers, and Healthy Kids. Each line of business participates in different medical groups and is overseen by different regulatory agencies. Table A lists each line of business, their corresponding regulatory agency, and which medical groups are associated with each line of business. For each unique phone number surveyed, SFHP relayed that SFHP was conducting an access compliance survey. SFHP requested information regarding the amount of time to hear back from a provider in the event of a member expressing an urgent need to speak with a clinician. Survey respondents that did not provide a compliant answer for the survey elements described in Table B were considered noncompliant. Results of individual primary care sites and behavioral sites were aggregated to obtain a compliance rate for each medical group. SFHP requires 80% compliance rate for each access standard. A plan for corrective action is required when a group or clinic does not meet this requirement. Table A: Medical Group Lines of Business Lines of Business Regulatory Agency Applicable Medical Groups Medi-Cal DHCS DMHC Beacon Health Options Brown and Toland Physicians Chinese Community Health Care Association Hill Physicians Independent Clinics rth East Medical Services rth East Medical Services with SFHN San Francisco Consortium of Community Clinics San Francisco Health Network (SFHN) University of California San Francisco Healthy Kids DMHC Brown and Toland Physicians Chinese Community Health Care Association Community Behavioral Health Services Hill Physicians Independent Clinics rth East Medical Services rth East Medical Services with SFHN San Francisco Consortium of Community Clinics San Francisco Health Network (SFHN) University of California San Francisco Healthy Workers DMHC Community Behavioral Health Services San Francisco Health Network (SFHN) 2

47 [Type text] P.O. Box San Francisco, CA (415) Table B: Triage Requirements Survey Element Definition Emergency Instructions Daytime Triage After-Hours Triage Correct emergency instructions to go to nearest hospital or call 911 if members experience an emergency. Triage call from a licensed clinician within 30 minutes of request during operating hours when members have an urgent (not emergency) medical need. Triage return call from a licensed clinician within 30 minutes of request after operating hours when members have an urgent (not emergency) medical need. Survey Results SFHP reached 80% compliance overall in correct emergency instructions. SFHP did not meet 80% compliance for daytime or after-hours triage within 30 minutes. n-responsiveness to the daytime survey contributed to non-compliance to each standard. In comparison to 2016, 2017 results indicate that more provider sites offer triage within 30 minutes during business hours. However, less provider sites offer triage within 30 minutes after hours. The survey methodology and analysis were reviewed and validated by SFHP staff: Adam Sharma, MPA, Director of Health Outcomes Improvement. Table C: Results & Provider Group Key Green Scores marked in green indicate that the group scored higher in 2017 than in 2016 Red Scores marked in red indicate that the group scored lower in 2017 than in 2016 Yellow Scores highlighted in yellow indicate that the group did not reach 80% compliance for the access standard BHO Beacon Health Options BTP CBHS CCHCA CHNO HILL NEMS NMS SFCCC SFHN UCSF SFHP Brown and Toland Medical Group Community Behavioral Health Services Chinese Community Health Care Association Independent Clinics & Unaffiliated Providers Hill Physicians Medical Group rth East Medical Services rth East Medical Services with SFHN San Francisco Community Clinic Consortium San Francisco Health Network University of California San Francisco Medical Group San Francisco Health Plan Overall 3

48 [Type text] P.O. Box San Francisco, CA (415) Table D: Aggregate of Medical Group Compliance (80%) Compliance Element Medical groups achieving 80% compliance (MY 2016) Medical groups achieving 80% compliance (MY 2017) Emergency Instructions 100% 100% Daytime Triage 36% 36% After-Hours Triage 45% 9% Table E: MY Telephone Triage Compliance Rates Medical Group BHO BTP CBHS Survey Element MY 2016 Survey n MY 2016 Compliance Rate MY 2017 Survey n MY 2017 Compliance Rate Emergency Instructions 100% 100% Daytime Triage 1 100% 1 100% After-Hours Triage 100% 100% Emergency Instructions 92% 100% Daytime Triage 24 25% 37 62% After-Hours Triage 75% 49% Emergency Instructions 100% 100% Daytime Triage 1 100% 1 100% After-Hours Triage 0% 0% CCHCA Emergency Instructions 95% 95% Daytime Triage 54 41% 60 62% CHNO HILL NEMS NMS SFCCC After-Hours Triage 85% 75% Emergency Instructions 83% 67% Daytime Triage 6 83% 3 33% After-Hours Triage 33% 33% Emergency Instructions 100% 98% Daytime Triage 36 39% 50 58% After-Hours Triage 67% 56% Emergency Instructions 92% 96% Daytime Triage 12 70% 23 83% After-Hours Triage 67% 26% Emergency Instructions 100% 100% Daytime Triage 1 100% % After-Hours Triage 100% 0% Emergency Instructions 100% 73% Daytime Triage 10% 80% After-Hours Triage 80% 13% 4

49 [Type text] P.O. Box San Francisco, CA (415) Medical Group SFHN UCSF SFHP Survey Element MY 2016 Survey n Emergency Instructions 18 MY 2016 Compliance Rate 100% MY 2017 Survey n MY 2017 Compliance Rate 69% Daytime Triage 67% 16 75% After-Hours Triage 72% 75% Emergency Instructions 100% 92% Daytime Triage 10 20% 13 31% After-Hours Triage 80% 0% Emergency Instructions 95% 93% Daytime Triage % % After-Hours Triage 74% 49% NOTE: Kaiser Permanente is a fully delegated medical group and was not included in the survey. Kaiser submits their access reports directly to DHCS and DMHC. 5

50 [Type text] P.O. Box San Francisco, CA (415) (415) FAX RESULTS: TELEPHONE AND PROVIDER OFFICE WAIT TIME Date: February 21, 2017 Access Monitoring Requirements The Department of Health Care Services (DHCS) contractually requires SFHP to implement and maintain a procedure for monitoring wait time in provider offices and wait time for provider offices to answer the telephone. SFHP surveys provider offices time to answer telephone calls and average wait time in offices on an annual basis. The performance expectation for offices time to answer is 80% of provider offices surveyed to answer the telephone within 10 minutes. This standard was developed by SFHP in order to match SFHP Customer Service maximum wait time of 10 minutes, set by the Department of Managed Health Care. The survey performance expectation for offices wait time is 80% of provider offices surveyed must have an average office wait time of 30 minutes or less. Executive Summary of Results Accomplishments: SFHP s network scored 99% in provider telephone wait time within 10 minutes, and 85% in provider office wait time within 30 minutes (Table C, page 3). Opportunities/Barriers: Overall the daytime survey had a 12% non-response rate. When clinic staff was not available during the daytime, SFHP left messages for sites requesting a call back to complete the survey. Sites that did not complete the survey from refusal or from non-response to the survey were included in results as non-compliance. n-responsiveness contributed to overall noncompliance rate for wait time in provider offices. Next Steps: SFHP will communicate survey results for wait time elements to provider groups. Survey Methodology SFHP conducted the daytime survey from October 2017 to vember 2017 during business hours, between 9 AM to 5 PM. Contracted SFHP providers and contracted clinic sites that provide routine primary care (including internal medicine, pediatrics, and family/general medicine) were surveyed. Additionally, SFHP surveyed SFHP s contracted behavioral health care call centers. Each medical group s survey population is an audit of primary care sites and therefore contains all phone numbers for primary care providers within the medical group. For each unique phone number surveyed, SFHP recorded the wait time for office staff to answer the phone from the time of dialing to the time of reaching a live person. When a live person was not available, SFHP recorded the telephone wait time from dialing to reaching the ability to leave a voic . Survey sites that had a telephone wait time of 10 minutes or longer were considered noncompliant. Once provider office staff was reached, SFHP relayed that SFHP was conducting an access compliance survey. SFHP requested information regarding the average wait time in the waiting room at the provider office. Survey respondents that did not provide a compliant answer for the office wait time elements described in Table A were considered non-compliant. Results of individual primary care sites 1

51 [Type text] P.O. Box San Francisco, CA (415) (415) FAX and behavioral sites were aggregated to obtain a compliance rate for each medical group. SFHP requires 80% compliance rate for each access standard. A plan for corrective action is required when a group or clinic does not meet this requirement. Table A: Wait Time Requirements Survey Element Definition Telephone Time to Answer Wait time on telephone to schedule appointment does within 10 minutes. Provider Office Wait Time Wait time at provider offices before appointments does not exceed 30 minutes. Survey Results Overall results indicate that SFHP reached 80% compliance in wait times for both telephone and provider offices. All medical groups reached 80% compliance in both wait time survey elements. nresponsiveness to the daytime survey contributed to non-compliance to provider office wait time. In comparison to 2016, 2017 results indicate that more provider sites have offices have wait times 30 minutes or less. The survey methodology and analysis were reviewed and validated by SFHP staff: Adam Sharma, MPA, Director of Health Outcomes Improvement. Table B: Results & Provider Group Key Green Scores marked in green indicate that the group scored higher in 2017 than in 2016 Red Scores marked in red indicate that the group scored lower in 2017 than in 2016 BHO Beacon Health Options BTP CCHCA CHNO HILL NEMS NMS SFCCC SFHN UCSF SFHP Brown and Toland Medical Group Chinese Community Health Care Association Independent Clinics & Unaffiliated Providers Hill Physicians Medical Group rth East Medical Services rth East Medical Services with SFHN San Francisco Community Clinic Consortium San Francisco Health Network University of California San Francisco Medical Group San Francisco Health Plan Overall 2

52 [Type text] P.O. Box San Francisco, CA (415) (415) FAX Table C: 2017 Wait Time Compliance Rates Medical Group Survey Element MY 2016 Survey n MY 2016 Compliance Rate MY 2017 Survey n BHO Telephone Time to Answer 1 100% 1 100% BTP Telephone Time to Answer % % Provider Office Wait Time 75% 81% CCHCA CHNO HILL NEMS NMS SFCCC SFHN UCSF SFHP Telephone Time to Answer 100% % 54 Provider Office Wait Time 72% 83% Telephone Time to Answer 100% 3 100% 6 Provider Office Wait Time 100% 100% Telephone Time to Answer 100% 50 98% 36 Provider Office Wait Time 67% 82% Telephone Time to Answer 100% % 12 Provider Office Wait Time 58% 91% Telephone Time to Answer 100% % 1 Provider Office Wait Time 100% 100% Telephone Time to Answer 100% % 10 Provider Office Wait Time 100% 80% Telephone Time to Answer 100% % 18 Provider Office Wait Time 100% 94% Telephone Time to Answer 90% 13 92% 10 Provider Office Wait Time 80% 85% Telephone Time to Answer 99% % 174 Provider Office Wait Time 76% 85% MY 2017 Compliance Rate NOTE: Kaiser Permanente is a fully delegated medical group and was not included in the survey. Kaiser submits their access reports directly to DHCS. 3

53 P.O. Box San Francisco, CA (415) (415) FAX Date: March 23, 2017 To From Regarding SFHP Quality Improvement Committee Fiona Donald, Medical Director, and Eloycsia Ratliff, Disease Management Project Manager 2018 SFHP Pain/Opiate Stewardship Workgroup Background In 2017, the United States declared a Public Health Emergency to address the National Opioid Crisis. According to the Center for Disease Control and Prevention (CDC), opioids killed more than 42,000 people in 2016 (including nearly 2,000 in California), which is more than any year on record. 40% of all opioid overdose deaths involve a prescription opioid. At the plan level, San Francisco Health Plan (SFHP) has taken critical steps towards intervening at both the provider and patient level to reduce use of opioids including the following: population assessments, targeted interventions, educational trainings, improving data & reporting, and implementing strict policies for prescribing opioids. San Francisco Health Plan (SFHP) Pain/Opiate Stewardship: The SFHP Pain Management program is a larger program that addresses pain/opiate related activities on multiple levels at the health plan. The program is governed by the SFHP Pain/Opiate Stewardship, a cross functional workgroup comprised of various health services programs that work on pain/opiate related activities. The shared SFHP goal is to create a shared responsibility and shared knowledge across groups to facilitate a regular forum on pain/opiate activities and provide updates in an effort to strengthen cohesion in managing chronic pain and opiate use. This is a priority area for SFHP s Health Services department, as it aligns and supports a larger Population Health NCQA initiative for Patient Safety. Priorities/Go The larger program has established the following go/ priorities for managing chronic pain and opiate use: Reduce opioids poisonings within the network by implementing activities to focus on improvement on safe management.

54 P.O. Box San Francisco, CA (415) (415) FAX Enhance internal data and reporting methods by building one shared data report for retrieving data as it relates to programs. Create a comprehensive health team for members with chronic pain that are knowledgeable about helpful resources such as covered alternative care, specialized referral processes, and effective communication strategies between patients and providers. SFHP Pain/Opiate Stewardship Representation: Health Outcome and Improvement -ACE -Population Health -PIP Care Management Business Intelligence (BI) Beacon Health Strategies