2011 ANNUAL REPORT. SHAREHOLDERS MEETING April 24, Arnold Blustein, MD Board President. Steven Yedlin, MD Chief Medical Officer

Transcription

1 2011 ANNUAL REPORT SHAREHOLDERS MEETING April 24, 2012 CHILDREN FIRST MEDICAL GROUP Arnold Blustein, MD Board President Steven Yedlin, MD Chief Medical Officer Lenda Townsend-Williams, MBA Chief Operating Officer

2 Lenda Townsend-Williams, MBA Chief Operating Officer Steve Yedlin, MD Chief Medical Officer To Our Shareholders Children First Medical Group continues to provide high quality care and to improve the health and wellness of pediatric members. Our physician shareholders continue to serve as a choice for pediatric well care and specialty care services in the local community, and surrounding counties and states. As your Individual Practice Association (IPA), we remain committed to operate a well-managed organization in an organized and efficient manner while containing costs. Thank you for your continued participation and ongoing support of our mission. Overall membership increased by 10% Highlights Membership in Alameda Alliance for Health increased by 10%. Membership in Anthem Blue Cross State Sponsored Program increased by 9%. The Claims Department processed 244,389 paper and EDI claims. The Claims Error Ratio was <1% compared to the industry standard of 5%. The Medical Management Department processed 8,493 authorizations compared to 8,754 authorizations in Primary Care Physicians and Specialty Care Physicians expressed satisfaction with the services provided by CFMG with a rating of 100% and 75% respectively. Member Satisfaction was also excellent with Primary Care Practices receiving a rating of 97% and Specialty Care Practices 96%. Thirty-six (36) new physicians joined our network. The Provider Relations Department received 2,904 calls on the customer service line compared to 2,456 calls in We hosted four (4) Provider Education & Training Workshops. We published two (2) Quarterly Provider Newsletters.

3 Successfully met NCQA and Department of Health Care Services requirements for all delegated activities. We maintained credentialing delegation authority with 23 payors. We enhanced our provider network in Alameda and Contra Costa County by adding Webster Orthopedics. They have offices in Oakland, Berkeley, Livermore, Pleasanton, San Ramon, and Walnut Creek. We received 100% on the following audits: 1) Claims 2) Credentialing 3) Quality Management 4) Utilization Management Steve Yedlin, MD Chief Medical Officer Lenda Townsend-Williams, MBA Chief Operating Officer

4 Financial Review Children First Medical Group (CFMG) total revenue increased by 22% with an increase in member-months of 11%. Operational expenses decreased by 6%. The total operating costs decreased $200,000 and from 15% to 11% of total revenue. These comparisons are influenced by changes in the business. Revenue increases include changes in the Alameda Alliance for Health (Alliance) contract. Currently, we are paid capitation for preventative services. Previously, we were paid Fee-For-Service as a pass-through from Alliance. Operating revenue currently includes nurse advice line services for which we collect payment to be passed on to the service provider. Results are better reflected in the year end surplus. CFMG reserve funds available for distribution as surplus for 2011 were $3.4 million, $1.7 million more than This is the result of a decrease in administrative expenses, well as an improved Alliance contract. The adoption of a new single fee schedule for both health plans helped control costs. Prior to shareholder distribution and consistent with prior years, funds were allocated from reserve dollars to pay for a variety of CFMG sponsored activities. These funds included a $26,500 donation to the Children s Specialty Care Coalition. This is a statewide association of pediatric California Children Services (CCS) providers that leads the effort to protect the CCS program and the level of CCS reimbursement. It is currently working with the State to find ways to maintain service while decreasing cost for both patient care and program administration. The remaining surplus was distributed to CFMG pediatric specialists and primary care providers who were active participants in the Medi-Cal Managed Care program in appreciation for their continuing support both for participation and in proportion to services rendered. This includes a return of the entire 0.25 PMPM withhold on PCP capitation payments. Under direction from our board of both primary care and specialty physicians, the overall payment to the two groups including surplus has been balanced to the same multiple of the Medi-Cal Fee Schedule. This has formalized a policy in place for several years. It moves us away from the original capitation formula based on services provided to Medi-Cal members in the early 90s, before the advent of managed care for Medi-Cal. Despite continued financial problems at the State level, our contracts with the health plans have remained intact. We anticipate stable results this year. We continue to successfully meet and exceed financial solvency requirements for the Department of Managed Health Care.

5 Independent Children First Medical Group, Inc. Auditor s Report

6 Administrative Services Lenda Townsend-Williams, MBA Chief Operating Officer Michael McCarty Claims Manager Membership CFMG currently serves over 54,000 enrollees who are participants through Alameda Alliance for Health (AAH) and Anthem Blue Cross. Approximately 5,000 of these members are participating through the AAH Healthy Families Program and 240 members are participating through the Anthem Blue Cross Healthy Families Program. In addition, approximately 1,300 participate through AAH s Non-Mandatory Medi-Cal Program. Provider Network Our provider network exceeds 494 physicians, with 193 Primary Care Physicians (PCPs) and 302 Specialty Care Physicians. HMO Commercial Contracts Contract Management We maintain contracts for Specialty services with the following payors: Affinity Medical Group Bay Valley Medical Group Brown & Toland Medical Group CIGNA Healthcare Hill Physicians Medical Group John Muir Physician Network Marin-Sonoma IPA Palo Alto Medical Foundation San Jose Medical Group Sutter Gould Medical Group Sutter Medical Foundation Medi-Cal and Healthy Families Contracts We manage contracts with the following State Sponsored Plans: Alameda Alliance for Health Anthem Blue Cross Medi-Cal HMO Specialist Contracts We Manage contracts with the following State Sponsored Plans: Contra Costa Health Plan Community Health Center Network Health Plan of San Joaquin

7 PPO Contracts We currently maintain Preferred Provider Organization (PPO) contracts with the following payors: Aetna Beech Street Corporation Benefit Risk Management CIGNA Healthcare Coventry First Health Care Healthsmart (Interplan) Hometown Health Humana/ChoiceCare Network MultiPlan/Private Healthcare Systems Pacific Health Alliance Pacific Foundation for Medical Care PPO Next (Beech Street) Prime Health Services, Inc. Provider Select Sutter Medical Foundation Sutter Redwoods Medical Foundation Three Rivers Provider Network USA Managed Care Provider Contract Data Link We continue to maintain the Provider Payor Data Link on the Children s Hospital & Research Center Oakland (Children s) website, which includes current CFMG & Children s contracts. To view Children s contracts, please access website at To view CFMG contracts, please access website at Claims Management _ Processed Claims 244, ,365 Errors Ratio <1% <1% We processed over 24,000 fewer claims in 2011 than in There were less reworks and adjusted claims due to intensive provider education which attributed to the increase in clean claims submission: A Claims Tip Sheet for billing agents and providers was posted on the CFMG website. Provider and billing agents in-service trainings performed on request for new staff members. Our claims processing errors ratio maintained a standard of less than 1%. We continually remain below the industry standard of 5%. Electronic Data Interchange (EDI) We processed and adjudicated 229,413 professional claims through the EDI system. A cross-reference table used to link provider NPI numbers to internal system provider ID numbers continues to keep our electronic claims inload process efficient. Our department is compliant in meeting claims acknowledgement and processing timelines. Credentialing

8 The Credentialing Department continued to improve operations and updated all policies and procedures according to health plan requirements. The Credentialing Department received an average of 100% on all health plan annual audits. Our provider network continues to steadily increase, with the addition of thirty-six (36) new physicians. Total PCP SCP Total CFMG Physicians: Total Physicians Recredentialed: Total New Physicians: Total Physicians Terminated/Retired: We maintained delegation authority for credentialing with the following payors: Aetna Alameda Alliance for Health Anthem Blue Cross Anthem Blue Cross Prudent Bayer Beech Street Corporation Benefit Risk Management Service Brown & Toland Medical Group Humana ChoiceCare Network Coventry First Health Care CIGNA Healthcare Health Plan of San Joaquin Healthsmart Integrated Health System Interplan Health Group Marin-Sonoma IPA Multiplan/Private Health Care Systems Pacific Foundation for Medical Care Palo Alto Medical Foundation Provider Select, Inc. Prime Health Services, Inc. Sutter Redwoods Medical Foundation Three Rivers PPO Network USA Managed Care Organization Member Services We received 424 calls from Anthem Blue Cross and Alameda Alliance for Health Medi-Cal enrollees. Provider Relations/Customer Services We received 2,904 calls on the customer service line compare to 2,456 calls in 2010 and returned all calls within 2-3 hours. We continue to educate and train physician office staff and billers through its Provider Outreach Program. As new providers join CFMG, training is scheduled with the office staff to ensure they are properly trained on billing guidelines and the Messenger Model contracting process. Electronic Medical Record Update (EMR)

9 As we noted last year, the federal government is providing funds through the ARRA-HITECH Act to help Medicaid and Medicare providers purchase and maintain EMR systems. Although there are no penalties yet on the Medicaid side, Medicare providers will begin to be paid lower rates if they have not installed EMRs beginning in You should expect sooner or later the same will be true for Medicaid and perhaps commercial payors as well. After a review of available systems we recommended eclinicalworks as a vendor of choice. Lumetra, as the Regional Extension Center, has done a good job helping providers with vendor contracts as well as evaluations. They will also help providers register and apply for the federal subsidies. In March, Children s Hospital Oakland signed a contract to purchase Epic for the hospital and its clinic sites. It is expected they will be able to offer Epic to community medical staff as well. Details have yet to be worked out. We hope to have Epic live at the hospital by the end of 2013 and to start implementing community practices soon thereafter. The advantage of Epic for the community is the interconnectivity for hospital and specialists as well as the ability to connect to any Epic site anywhere. We do not know what the cost will be as yet. Please keep in mind the primary reason to implement these systems is to improve patient safety and to have clinical decision support. These issues should be foremost when you are evaluating systems for your practice.

10 Steve Yedlin, MD Chief Medical Officer Medical Management Sylvia Herrick, RN, MS Director, Utilization/Quality Management The Medical Management Department continued to improve operations and updated all policies and procedures according to health plan requirements. The Department processed 8,493 authorizations, compared to 8,754 authorizations in We underwent annual health plan audits by Alameda Alliance for Health and Anthem Blue Cross State Sponsored Program. The Department successfully met NCQA and Department of Health Care Services (DHS) requirements for all delegated activities: Utilization Management - 100% Quality Management -100% Medi-Cal Specific Activities -100% Credentialing -100% Claims-100% Hospital Utilization Overall, hospital utilization for the Medi-Cal and Healthy Families programs was lower than Admits/ 1000 = % lower than 2010 ALOS = 2.44 days 5% higher than 2010 Days/ 1000 = % lower than 2010 Hospital utilization for the AAH Non-Mandatory Managed Medi-Cal Members. Since this is a high-risk population, CFMG continues to closely monitor their hospital and ED utilization. Admissions and Days/K were lower compared to Admits/ 1000 = % lower than 2010 ALOS = 3.05 days 5% higher than 2010 Days/ 1000 = % lower than 2010 Children s Hospital & Research Center Oakland ER Utilization Overall, ED utilization for Medi-Cal and Healthy Families programs was higher compared to ED Visits/1000 = % higher than 2010 Overall, ED Utilization for AAH Non-Mandatory Managed Medi-Cal Members was lower compared to ED Visits/ 1000 = % lower than 2010

11 The UM / QM Committees met quarterly to review utilization data, member grievances, satisfaction surveys, quality improvement reports, and to approve policies and procedures. Quality Improvement Studies CFMG conducted the following quality improvement studies in 2011: Access to Care Telephone Answer Survey o The median telephone response time for the Primary Care offices was 5 seconds, and 18 seconds for the Specialty offices. Average Wait for new Specialty Appointments o The average wait for a non-urgent, new patient appointment ranged from 1-4 weeks. Appropriate Utilization of Emergency Services o CFMG notified the PCP's of members with 3 or more ED visits per quarter. Pediatric Advice Line Utilization and Quality Report Member Mortality Report Claims Input Error Report o The claims error ratio was <1%, which is well below the industry standard of 5%. The QM Department provides support to Alameda Alliance in resolving member grievances. Only two member grievances were received during the year. Provider Satisfaction Survey CFMG conducted its annual Provider Satisfaction Survey in the fall of this year. Providers expressed continued satisfaction with services provided by CFMG. The overall satisfaction ratings for 2011 were: Primary Care Physicians 100% Specialists 75%

12 Member Satisfaction Survey Once again, members reported a high level of satisfaction with the care provided by CFMG. Surveys were distributed in Chinese, English, Spanish, and Vietnamese. Our physicians received the highest satisfaction rating from their members, since the beginning of the survey process in 2002, which shows their commitment to delivering high quality care. The overall satisfaction ratings for 2011 were: Primary Care Physicians 97% Specialists 96%

13 Board of Directors & Committees Board of Directors Arnold J. Blustein, MD, President Robert Watts, MD, Secretary Theodore Chaconas, MD Jonathan Clarke, MD Stephen Daane, MD Art D Harlingue, MD Kenneth Ducker, MD Bruce Gach, MD Carol Glann, MD Robert Haining, MD Caroline Hastings, MD Mika Hiramatsu, MD Lawrence Ng, MD Howard Rosenfeld, MD Stephen Santucci, MD Budd Shenkin, MD Lloyd Takao, MD Michael Usem, MD Robin Winokur, MD Steven Yedlin, MD Credentialing Committee Steve Yedlin, MD, Chair Fadi Haddad, MD David Kittams, MD Kathleen Newkumet, MD Robert Nicholson, MD Miriam Rhew, MD Elizabeth Salsburg, MD Compensation Committee Steve Yedlin, MD, Chair Jonathan Clarke, MD Caroline Hastings, MD Budd Shenkin, MD Robert Watts, MD Robin Winokur, MD Contracting Committee Steve Yedlin, MD, Chair Jonathan Clarke, MD Howard Rosenfeld, MD Budd Shenkin, MD Robin Winokur, MD Nominating Committee Howard Rosenfeld, MD, Chair Jonathan Clarke, MD Bruce Gach, MD Mika Hiramatsu, MD Larry Ng, MD Utilization Management Committee Robert Nicholson, MD, Chair Mindy Benson, PNP Theodore Chaconas, MD Art D Harlingue, MD Carol Glann, MD Jose Enz, MD David Kittams, MD Gena Lewis, MD Steve Yedlin, MD

14