San Francisco Health Plan

50 Beale St., 12 th Floor San Francisco, CA 94119 www.sfhp.org San Francisco Health Plan 2018 Quality Improvement Program Evaluation Page 1 of 28

Table of Contents 1. Introduction... 3 1.1 Executive Summary... 3 1.2 Highlights from the 2018 QI Program Measures... 4 2. Quality of Service and Access to Care... 6 2.1 Compliance with Cultural Linguistic Services Requirements (Plan Year 2017)... 6 2.2 Member Grievances and Appeals... 7 2.3 Getting Care Quickly/Getting Needed Care... 9 2.4 Potential Quality Issues (PQI)... 11 3. Clinical Quality and Patient Safety... 12 3.1 Influenza Vaccine Utilization (Plan Year 2017)... 12 3.2 Medication Therapy Management (MTM) (Plan Year 2017)... 13 3.3 Chlamydia Screening... 14 3.4 Pharmacotherapy Management of COPD... 15 3.5 Cervical Cancer Screening... 15 4. Care Coordination and Services... 18 4.1 Complex Medical Case Management (CMCM) Client Satisfaction (Plan Year 2017)... 18 4.2 Screening for Clinical Depression and Follow Up (Plan Year 2017)... 18 4.3 Community Health Network (CHN) Out of Medical Group All Cause Readmissions (Plan Year 2017)... 19 5. Utilization Management... 21 5.1 Pharmacy POS Claim Rejection (Plan Year 2017)... 21 5.2 Non-Specialty Mental Health Penetration Rate... 22 5.3 Members with Primary Care Visit... 23 6. Delegation Oversight... 24 6.1 Delegation Oversight (Plan Year 2017)... 24 6.2 UM Delegation Improvements (Plan Year 2017)... 25 7. Quality Oversight Activities... 27 Page 2 of 28

1. Introduction The goal of the San Francisco Health Plan (SFHP) Quality Improvement (QI) Program is to ensure high quality care and services for its members by proactively seeking opportunities to improve the performance of its internal operations and health care delivery system. SFHP s QI Program is detailed in the SFHP QI Program Description. The QI Program Description contains an annual Work Plan, outlined in Appendix I, representing the current year improvement activities and measure targets. The QI Work Plan is evaluated on a quarterly basis and consolidated annually. The QI Evaluation provides a detailed review of progress towards the measures and goals set forth in the QI Work Plan. In this evaluation, the results are presented for five activity domains: Quality of Service & Access to Care Clinical Quality and Patient Safety Care Coordination and Services Utilization Management Quality Oversight At the time of this evaluation, some data for the 2018 measures have not been finalized. As such, only measures with finalized data are included. SFHP will include the remaining measures in the 2019 QI Evaluation. 1.1 Executive Summary Oversight Under the leadership of SFHP s Governing Board, the Quality Improvement Committee (QIC) oversees the development and implementation of the QI Program and annual QI Work Plan. The QIC is supported by multiple committees including Access to Care, Grievance Review, Utilization Management, Physician Advisory and Peer Review, Pharmacy and Therapeutics, and Provider Network Oversight. SFHP s Quality Committees, under the leadership of the Chief Medical Officer, ensure ongoing and systematic involvement of SFHP s staff, members, medical groups, practitioners, and other key stakeholders where appropriate. Participation in the QI Program: Leadership, Practitioners, and Staff Senior leadership, including the Chief Executive Officer (CEO) and Chief Medical Officer (CMO), provided key leadership for the QI program. The CEO championed SFHP s journey to NCQA accreditation as well as an organization-wide effort to improve member s ability to access services in a timely manner within the provider network and improve member s experience of access as reflected in CAHPS scores. This effort included instituting NCQA Accreditation and Access to Care as organizational strategic priorities. In addition, the CEO ensured that Board members received regular reports on the QI program components. Page 3 of 28

The CMO provided ongoing support for all quality improvement studies and activities and was responsible for leading the Quality Improvement Committee; Physician Advisory, Peer Review, and Credentialing Committee; Pharmacy and Therapeutics Committee; and Grievance Committee. The CMO led key clinical improvement efforts, particularly prioritizing and designing interventions for clinical quality performance measures as represented in the QI Work Plan. Beyond SFHP senior leadership, SFHP achieved stakeholder participation in the QI program through provider and member involvement in several key committees. Stakeholders participated in the Quality Improvement Committee, the Practice Improvement Program Advisory Committee that advises on the pay-for-performance program (i.e. PIP), and the annual HEDIS/PIP review meetings during which health plan leadership meets with senior leadership in the network to review outcomes and solicit input on measures in the Clinical Quality and Patient Safety domain of the QI Program. Additionally, SFHP s Member Advisory Committee supported key QI activities by reviewing and providing feedback on existing programs and new initiatives including a new member incentive, member perception regarding access to care, and service recovery mechanisms. Overall, leadership and practitioner participation in the QI program in 2018 was sufficient to support the execution of the QI Plan. The staff accountable for implementing the annual QI Work Plan represents the cross-functional nature of quality improvement activities at SFHP. Staff monitor quality indicators and programs and implement and evaluate SFHP s QI work plan. For a detailed summary of all staff supporting the QI Program, please refer to the Quality Improvement Program Description. 1.2 Highlights from the 2018 QI Program Measures The San Francisco Health Plan had many positive outcomes during the 2018 QI Program Evaluation period. SFHP sets stretch goals each year; many performance measures demonstrated strong improvement despite not meeting the stretch goal. Of the 22 measures included in the 2018 QI Evaluation, 10 met the target. Of the 12 measures that did not meet the target, five improved from baseline. SFHP is currently finalizing the measurement of seven remaining measures; these will be included in the 2019 QI Program Evaluation. SFHP will utilize lessons learned from 2018 to inform the 2019 QI Program and to drive continuous improvement in operations and outcomes. In summary, SFHP identified the following areas from the QI Work Plan as either demonstrating effectiveness or as opportunities for improvement. Quality of Service and Access to Care: SFHP met two of the five measure targets in this domain, while two of the remaining three measures improved over baseline. Some notable improvements include: Exceeded target in the HP-CAHPS composite Getting Care Quickly. Improved compliance with Cultural and Linguistic standards. Page 4 of 28

Met the target for turnaround times in PQI resolution. Recommendations for continued improvement include: Provide technical assistance and grant funding for access improvement through Strategic Use of Reserves. Incentivize clinics and provider groups to implement projects to improve access under SFHP s Pay for Performance program. Collaborate and train provider groups on requirements for cultural and linguistic services. Develop protocols to support expedited decision making, thus supporting Medical Directors in grievance determination. Conduct member focus groups to better understand member perception regarding Getting Needed Care, Tests, and Treatment. Clinical Quality and Patient Safety: SFHP met two of the six measure targets in this domain. Two measures that did not meet target improved over baseline. Three other measures are not yet finalized and will be included in the 2019 QI Evaluation. Some notable improvements include: Improved 10.6% in the influenza vaccination rate. Provided Medication Therapy Management to 90% of members engaged in Care Management programs. Continued improvement in the Cervical Cancer Screening rate. Recommendations for continued improvement include: Leverage SFHP s pay-for-performance program to improve Chlamydia screening rate. Conduct thorough root cause analysis for SFHP s low and declined performance in Chlamydia screening. Expand target population for SFHP s Adult Wellness Visit member incentive to further improve Cervical Cancer screening. Care Coordination: SFHP met one of the three measures in this domain in 2018. Four other measures are not yet finalized and will be included in the 2019 QI Evaluation. Some notable improvements include: Attained high member satisfaction with care management services provided by SFHP. Developed capacity to capture and report follow up for members who screen positive for depression. Recommendations for continued improvement include: Page 5 of 28

Continue to offer in-person post-discharge planning services at discharging hospital. Maximize use of Health Homes and Palliative Care benefits to better support members discharged from the hospital. Utilization Management: SFHP met two of the three measure targets in this domain, while the remaining measures improved over baseline. Some notable improvements include: Met the target for adult non-specialty mental health penetration rate. Increased the percentage of members with a primary care visit in the past year. Improved pharmacy point of service rejection rate. Recommendations for continued improvement include: Focus on improving mental health continuity of care amongst members initiating a therapeutic relationship with a BH clinician. Outreach and provide education to members who may benefit from telehealth services. Incentivize providers to outreach to members enrolled but not yet seen in primary care. Expand adult wellness visit member incentive. Delegation Oversight: SFHP met three of the five measure targets in this domain. SFHP is eliminating this domain from its QI program and incorporating monitoring and evaluation activities in a Quality Oversight domain. 2. Quality of Service and Access to Care Quality of Service and Access to Care are measures that improve service to members. They may include service metrics (wait times), accessibility (ease of access), or member perception of care (Consumer Assessment of Healthcare Providers and Systems). 2.1 Compliance with Cultural Linguistic Services Requirements (Plan Year 2017) Measure: Compliance with Cultural Linguistic Services Requirements Numerator 177 Baseline 55% Final Performance 77% Denominator 230 Target 80% Evaluation Year 2018 The Cultural Linguistic Services measure is in the Quality of Service and Access to Care domain. This rate is calculated based on the number of providers who pass the linguistic services portion of the Provider Time to Answer Survey (i.e. providers who respond with having in-person interpreter services, and language line or equivalent telephonic interpretation on site) out of the total number of providers Page 6 of 28

surveyed. Assessing and improving the availability of linguistic services across SFHP s provider network is important to ensure members have access to health care providers and services in the language of their choice. The target of 80% was set because this is SFHP s audit passing threshold. All activities conducted to support this measure were completed, including: Issuing and approving Corrective Action Plans (CAPs) to 5 medical groups that did not pass the linguistic services portion of the January 2017 survey. Educate providers and members about linguistic service requirements: o Presentation of SFHP s 2016 Education and Linguistic Group Needs Assessment (GNA) results to all contracted medical groups. o Articles published in the Summer and Fall 2017 member newsletters notifying members of the availability of linguistic services. o Articles published in the March, October and December 2017 provider newsletters to inform providers of state-required linguistic services and improve their readiness to respond to the survey. While all activities were completed, the timing of when they were completed was a barrier to achieving the target. The member and provider newsletter articles appeared during or after the Time to Answer survey was fielded, thus had little impact on the results. Effectiveness of the CAPs is dependent on when groups complete their corrective actions. Completion of these activities occurred during and after the survey field period. As such, the impact of these activities may have positive impacts for the 2018 survey results. Although the final result of 77% did not meet the target of 80%, the measure improved by 22 percentage points when compared to baseline. SFHP recommends retaining this measure to continue monitoring and improving member access to Cultural Linguistic Services. The target will remain at 80%. Activities to support this measure will include: o o o Articles to be published in the member and provider newsletters, but timed to appear prior to the Provider Time to Answer survey. Continue to issue and approve Corrective Action Plans (CAP) to medical groups who do not pass the pass the linguistic services portion of the 2018 Provider Time to Answer survey; based on the timing last year s activities, it is possible that more medical groups will be in compliance. Provide training materials and resources on standards of linguistic services to medical groups that are not in compliance. 2.2 Member Grievances and Appeals Measure: Member Grievances and Appeals Page 7 of 28

Numerator 266 Baseline 99.2% Final Performance 99.6% Denominator 267 Target 100.0% Evaluation Year 2018 The Member Grievances measure is in the Quality of Service and Access to Care domain. It measures the rate of member grievances resolved within regulated time frames (standard clinical and non-clinical grievances within 30 calendar days or with an approved extension). Timely grievance resolution is important to member satisfaction and provides opportunities for improving individual members health care quality concerns. SFHP chose the target of 100% because timely resolution of grievances is a regulatory requirement of the Department of Health Care Services (DHCS) and the Department of Managed Health Care (DMHC). From July 1, 2017 to June 30, 2018, 99.6% of all grievances were resolved within the acceptable timeframes. One grievance did not meet the turnaround time due to staff oversight. Barriers to meeting this target include receiving late responses from providers, grievance staff receiving grievance mail late, and gaps in internal SFHP grievance processes resulting in grievances not being identified in a timely manner. To improve performance, SFHP completed the following activities: Grievance Review Committee reviewed trends for both clinical and non-clinical grievances each month and discussed approaches to improve provider response times. Discussed grievance trends and turnaround times with provider groups during joint operations meetings. Established interdepartmental meetings to ensure continued collaboration of improved grievance processes. Created an organization-wide shared metric goal for grievance turnaround time to promote accountability among all staff involved in the grievance process. Grievance staff improved the grievance management system, including a queue for the Chief Medical Officer and documentation of letter correspondence. SFHP will keep this measure for 2019 but augment the measure to remove the extensions past 30 days in order to be compliant with DMHC requirements. The target will be 90% from a new baseline of 78% based on the change in the new definition of the measure. Activities will include: Review trends in provider response times and discusses approaches to address non-responsive providers. Discuss grievance trends and turnaround times with provider groups during joint operations meetings. Continue with shared organization-wide metric goal for grievance turnaround time compliance to promote accountability among all staff involved in the grievance process. Improve efficiency of resolving grievances in a timely manner by creating nurse protocols to ensure timely clinical review. Page 8 of 28

Utilize grievance management system for Grievance Review Committee to improve committee member review and timely grievance resolution. Develop a report that calculates provider response turnaround times. 2.3 Getting Care Quickly/Getting Needed Care Measure: Getting Care Quickly Baseline 68.1% Final Performance 73.0% Target 71.1% Evaluation Year 2018 Measure: Getting Needed Care Baseline 68.5% Final Performance 68.4% Target 71.5% Evaluation Year 2018 The Getting Care Quickly and Getting Needed Care composites from the Health Plan Consumer Assessment of Healthcare Providers and Systems (HP-CAHPS) survey assess member experience of care and are in the Quality of Service and Access to Care domain. HP-CAHPS performance is important to SFHP for three reasons: HP-CAHPS is the primary means by which members provide feedback about their satisfaction with SFHP and their overall health care. SFHP strives for high member satisfaction, in addition to high quality and affordability. Improvement in the Getting Care Quickly and Getting Needed Care composites are the biggest contributors to SFHP members overall satisfaction with the health plan, and therefore remains an organizational priority. Full NCQA Accreditation is partly dependent on strong performance in HP-CAHPS. The Getting Care Quickly composite is composed of two questions: 1) Got urgent care as soon as needed In the last 6 months, when you needed care right away, how often did you get care as soon as you needed? and 2) Got routine care as soon as needed In the last 6 months, how often did you get an appointment for a check-up or routine care at a doctor's office or clinic as soon as you needed? The Getting Needed Care composite is comprised of two questions: 1) Easy to get needed care How often was it easy to get the care, tests, or treatment you needed? and 2) Easy to see specialists How often did you get an appointment to see a specialist as soon as you needed? The results for these composites represent the percentage of members responding Usually and Always to each of the questions, then averaged to create the composite score. SFHP determined the target of 3% improvement by consulting with SFHP s survey vendor. The target is based on industry knowledge of achievable improvement from year to year. SFHP met the target and improved by over 3% in the Getting Care Quickly composite. This success is largely due to the increase in usually and always responses to the question of members getting urgent care as soon as needed. Within Getting Needed Care, the question of ease in accessing specialty care increased from 62.4% in 2017 to 69.0% in 2018. However, the Getting Needed Care composite did not meet its target due to the Page 9 of 28

% members answering usually/always % members asnwering usually/always decrease in usually and always responses for the ease of getting needed care question from 74.7% in 2017 to 67.9% in 2018. 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% Getting Care Quickly Composite and Questions 74.6% 70.9% 73.0% 80.8% 67.7% 68.1% 66.0% 65.4% 65.3% 65.2% 63.0% 57.4% 2015 2016 2017 2018 Year Getting Care Quickly Composite Got urgent care as soon as needed Got routine care as soon as needed 2018 Getting Care Quickly Target 85.0% Getting Needed Care Composite and Questions 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% 65.5% 66.4% 74.7% 67.9% 68.5% 68.4% 69.0% 66.1% 65.8% 62.0% 62.4% 58.4% 2015 2016 2017 2018 Year Getting Needed Care Composite Easy to get needed care Easy to see specialists 2018 Getting Needed Care Target A barrier to meeting the Getting Needed Care target include: lack of clear and timely communication about how to get care when needed (e.g. visits with other providers, telephonic or email options). These barriers were identified through member focus groups and SFHP s monitoring of appointment availability. To address these barriers, SFHP implemented several improvement projects to improve performance in HP-CAHPS access composites: Page 10 of 28

Provided technical assistance and grant funding for access improvement through the Strategic Use of Reserves Grant program. Increased monitoring of access in the network and request for corrective action when it has been determined that provider groups have not met the access standard. Provided technical assistance to the network about best practices for improving access. This occurs by way of coaching clinics and providers with the intention of improving appointment availability. Piloted and implemented three-way scheduling calls between member, SFHP staff, and provider offices. Redesigned marketing communications to mirror language from the CAHPS survey, including the marketing of Teladoc, which provides an alternative to primary care or emergency care for when members primary care providers are not able to offer a timely or convenient appointment. Conducted member focus groups to gain additional insight on member perception of access. SFHP abandoned the three-way call scheduling pilot. It was abandoned due to finding that most members calling SFHP s customer service were not eligible for a three-way call because they already had a primary care appointment scheduled. SFHP recommends setting the targets for each measure by 2% over baseline, which is consistent with industry knowledge of yearly achievable and meaningful improvement. Improvements in access to care represent a key driver to CAHPS improvement. Activities to continue improvement in these measures include: Support providers in collecting point of service member experience feedback through SFHP s Provider Grant. Increase monitoring of network access and request Corrective Actions when needed. Identify access-related issues via the Access to Care Committee, and develop plans to address found issues. Conduct member focus groups. 2.4 Potential Quality Issues (PQI) Measure: Potential Quality Issues (PQI) Numerator 6 Baseline 100% Final Performance 100% Denominator 6 Target 100% Evaluation Year 2018 The Potential Quality Issues (PQI) measure is in the Quality of Service and Access to Care domain. This measure reflects activities to improve identification and processing of PQIs in a timely manner (45 calendar days). The measure only includes confirmed PQIs, rather than the number of PQIs referred for review. This measure benefits members by identifying and resolving systemic issues in the healthcare system, resulting in improved quality of care overall. The target for this measure was 100%. This target reflects SFHP s commitment to resolve all PQIs in a timely manner. The following activities were completed: Page 11 of 28

Triaged Care Management referrals by Quality Review Nurse. Identified and monitored Provider Preventable Conditions. Conducted PQI refresher training with Utilization Management Outpatient Team. Refined PQI workflow in SFHP s Case Management System (Essette) to maximize functionality. The final result for this measure was 100%. The target was met and all confirmed PQIs were resolved in a timely manner. This measure is discontinued for 2019 and will continue to be monitored as part of SFHP s daily operations. 3. Clinical Quality and Patient Safety These are measures that improve clinical based outcomes. Patient safety prevents adverse health outcomes, such as death or poor quality of life. 3.1 Influenza Vaccine Utilization (Plan Year 2017) Measure: Influenza Vaccine Utilization Numerator 34,007 Baseline 17.5% Final Performance 28.1% Denominator 121,151 Target 20.5% Evaluation Year 2018 The Influenza Vaccine Utilization measure is in the Clinical Quality and Patient Safety domain. This rate is calculated based on the total number of SFHP members 19 years and older who received an influenza vaccination. The vaccine provides protection against influenza that can result in hospitalization and sometimes death, especially in the very young, elderly and those with serious chronic illness. However, the influenza vaccine has been historically underutilized. The target of 20.5% was set to achieve a 3% absolute improvement from baseline prior year performance. The activities conducted to support this measure included: Production of educational materials to inform members about the benefits of influenza vaccinations. Informational materials were distributed to 80,000 members and 348 providers via the SFHP member and provider newsletters. Updated SFHP formulary to include additional available influenza vaccines including: o Quadrivalent recombinant flu vaccines Afluria, FluBlok, and FluLaval. o High dose influenza vaccine, Fluzone High Dose, for members 65 and older. Promotion of influenza vaccines by SFHP s Care Management program as part of medication therapy management interventions. The following activities were planned but not completed: Launch of an influenza vaccination member incentive. o SFHP did not launch a member incentive for influenza vaccination because it was decided a financial incentive was not the most effective improvement strategy. Instead, Page 12 of 28

SFHP focused on distributing educational material to inform members about influenza vaccines. Promoting influenza vaccination among Health Homes discharge populations. o Delays in the launch of the Health Homes project prevented completion of this activity. SFHP will begin assessments of discharge populations with the launch of Health Homes in July 2018. The final result of 28.1% met and surpassed the target, demonstrating overall improvement in influenza vaccination utilization among SFHP members when compared to the baseline of 17.5%. SFHP performance is higher than other Medicaid health plans, as the plan is above the 75 th HEDIS percentile. Thus, SFHP is retiring the measure. 3.2 Medication Therapy Management (MTM) (Plan Year 2017) Measure: Medication Therapy Management (MTM) Numerator 38 Baseline N/A Final Performance 90% Denominator 42 Target 30% Evaluation Year 2018 The Medication Therapy Management (MTM) measure is in the Clinical Quality and Patient Safety domain. The numerator is the number of members for whom SFHP pharmacists completed Medication Reconciliation. The denominator is the total number of members engaged in SFHP s Care Management Program with a pharmacist recommendation for Medication Reconciliation. Medication Reconciliation is a personalized member intervention that creates an accurate list of all the medications a member is taking and identifies potential harmful medication interactions. This intervention improves medication safety among members with complex diseases. The target of 30% was set as an initial benchmark for the first year of measurement. All activities conducted to support this measure were completed, including: Creation of an interdisciplinary committee to review members engaged in Care Management and make recommendations to improve medication management. This resulted in enrollment of 42 members into the intervention. Development of Medication Reconciliation workflows. Eight SFHP staff members were trained on the workflows. Adoption of Medication Reconciliation tools, including Meducation a tool that provides members with medication calendar and drug information in simple terms that is available in 21 languages. Enhancements to Care Management data systems to improve system usability (i.e., quality of user experience) and stability (i.e., reduced system errors). An early barrier to completing activities included difficulties with data reporting during the early implementation phase. To address these barriers, the Care Management system, Essette, was reconfigured to ensure Medication Reconciliation assessments were reportable. A barrier to achieving Page 13 of 28

results included incomplete interventions due to members lost to follow-up. To address this barrier, staff conducted outreach activities in an effort to reengage members. The final result of 90% surpassed the 30% target. Because of the benefits of Medication Reconciliation to member medication safety SFHP recommends retaining the measure and expanding the denominator population to include members in SFHP s Health Homes program. The recommended target is 90%. Recommended activities: o Pharmacist review and recommendation of members for Medication Reconciliation intervention. o Development of tailored intervention plans, focused on the member s preferences, to prevent loss to follow-up. o Continued improvements to Essette Care Management module to make all Medication Reconciliation assessments reportable. 3.3 Chlamydia Screening Measure: Chlamydia Screening Numerator 940 Baseline 37.0% Final Performance 35.5% Denominator 2647 Target 42.0% Evaluation Year 2018 The Chlamydia Screening measure is in the Clinical Quality and Patient Safety domain. This rate is calculated based on the total number of SFHP members, with a female gender marker 16 24 years of age, who are identified as sexually active and have had at least one test for chlamydia during the measurement year. Chlamydial infections in patients can cause cervicitis and Pelvic Inflammatory Disease, which can result in fallopian tube damage, scarring, and blockage. It can also result in longterm adverse outcomes of infertility, ectopic pregnancy, and chronic pelvic pain. Improvement in the chlamydia screening rate benefits members by enabling early detection and treatment of chlamydia infections, and preventing complications from the infection. The target of 42.0% was set to achieve a 5% absolute improvement over baseline. All activities to support this measure were completed, including: Incentivized improvement of chlamydia screenings through a pay-for-performance incentive measure included in SFHP s Practice Improvement Program (PIP) Meetings with eight provider groups to review and discuss 2016 baseline data, identify specific improvement opportunities, and gain a better understanding of the group s data infrastructure and improvement activities. These meetings inform SFHP s improvement activities for the next measurement year. Outreach to three provider groups to learn how groups access chlamydia lab data. SFHP confirmed it receives data from all of the same lab sources. Analysis of lab data feeds from LabCorp and Quest. SFHP completed validation of these data sources and confirmed the health plan is receiving appropriate data. The primary objective for completing these activities was to determine if there were potential data quality concerns impacting SFHP s chlamydia screening rate. Early findings indicate SFHP receives Page 14 of 28

chlamydia lab data from the appropriate sources; however SFHP identified it receives a very low volume of this data. This is a potential barrier to determining SFHP s true chlamydia screening rate. In addition, the activities implemented to support this measure may not have achieved the target because they did not address the root causes of the data quality concerns. SFHP is conducting a follow-up data investigation to identify root-causes and will make recommendations for improvement. The final result of 35.5% did not meet the target of 42.0% and was a decrease of 1.5% from baseline. SFHP recommends retaining this measure which is in alignment with SFHP s clinical improvement priorities. The recommended target is a 5% absolute improvement to 40.5%. Activities that will be conducted to support this measure include: Include chlamydia screening as a pay-for-performance measure in the Practice Improvement Program. Complete root cause analysis to identify data and/or clinical quality issues potentially contributing to the screening rate and make recommendations for improvement. Meet with provider groups to review and discuss 2017 data, identifying specific improvement opportunities and gaining a better understanding of the group s data infrastructure and improvement activities. 3.4 Pharmacotherapy Management of COPD Measure: Pharmacotherapy Management of COPD Exacerbation (PCE) Rate 1 - Systemic corticosteroid Numerator 391 Baseline 58.8% Final Performance 63.1% Denominator 620 Target 63.8% Evaluation Year 2018 Rate 2 Bronchodilator Numerator 513 Baseline 85.0% Final Performance 82.7% Denominator 620 Target 90.0% Evaluation Year 2018 The Pharmacotherapy Management of COPD Exacerbation (PCE) is in the Clinical Quality and Patient Safety domain. This measure is the percentage of inpatient or ED discharges for Chronic Obstructive Pulmonary Disease (COPD) exacerbation for members 40 years of age and older on or between January 1 and November 30 of the measurement year who were dispensed appropriate medications. This measure is reported based on the following rates: Dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event. Dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event. Complications of COPD can result in an exacerbation or flare up where a patient suddenly experiences difficulty breathing and seeks medical care. Improving the PCE rate will benefit members by increasing the rate of appropriate medication dispensed following an exacerbation. This will allow members to Page 15 of 28

have the medications that can help control their COPD symptoms. The targets for rate 1 (63.8%) and rate 2 (90.0%) were set to achieve a 5% absolute improvement over baseline. All activities to support this measure were completed, including: Meetings with eight provider groups to review and discuss 2016 data, identify specific improvement opportunities, and gain a better understanding of the group s data infrastructure and improvement activities. These meetings inform SFHP s improvement activities for the next measurement year. Identification of SFHP s dispensing pharmacies and potential gaps in pharmacy data. SFHP validated pharmacy data sources and confirmed the health plan is receiving data from all appropriate sources. There were no gaps identified. The primary objective for completing these activities was to determine if there were potential data quality concerns impacting this measure. SFHP did not identify data quality concerns and is confident SFHP s data reflects the true rates. The final result of 63.1% for Systemic corticosteroid did not meet the target but increased by 4.3% from baseline. The final result of 82.7% for Bronchodilator did not meet the target and decreased by 2.3% from baseline. SFHP recommends discontinuing this measure in order to focus improvement activities on other SFHP clinical improvement priorities. 3.5 Cervical Cancer Screening Measure: Cervical Cancer Screening Numerator 253 Baseline 68.7% Final Performance 70.3% Denominator 360 Target 70.8% Evaluation Year 2018 The Cervical Cancer Screening measure is in the Clinical Quality and Patient Safety domain. The rate is based on the total number of SFHP members, 21-64 years of age with a female gender marker, who are screened for cervical cancer using one of the following: Cervical cytology performed every 3 years for ages 21-64. Cytology/human papillomavirus co-testing every 5 years for ages 30-64. Cervical cancer screenings have been proven to reduce morbidity and mortality from cervical cancer; however, these screenings have historically been underutilized by SFHP members. Improvement in the cervical cancer screening rate benefits members by enabling early detection and treatment of cervical cancer. The target of 70.8% was set to achieve the National Committee on Quality Assurance s (NCQA) National 90 th percentile for Medicaid for cervical cancer screenings for reporting year 2018. All activities conducted to support this measure were completed, including: Page 16 of 28

Incentivized improvement of cervical cancer screenings through a pay-for-performance incentive measure included in SFHP s Practice Improvement Program (PIP) and Strategic Use of Reserves (SUR) funding. o Seventeen PIP participants included cervical cancer screening as a Clinical Quality priority measure in 2017. Twelve of these participants met the participants met the PIP improvement targets for program year 2017. o Seven PIP participants focused on improving cervical cancer screening as part of their SUR improvement activities. Six of these participants met the NCQA National 90 th percentile for Medicaid for reporting year 2017, resulting in an extra distribution of SUR funding. Published health education messaging for cervical cancer screenings and screening frequency in SFHP s spring member newsletter. A barrier to conducting health education activities is SFHP s interpretation of new federal regulations limiting how members can be contacted via cell phones. SFHP is investigating other methods for member outreach and health education messaging. In addition, a potential challenge to achieving the target is due to a disconnect between NCQA numerator qualifications and updated US Preventative Services Task Force (USPSTF) guidelines for cervical cancer screening, that may result in decline in CCS rates. The final result of 70.3% was an improvement of 1.6% over baseline; however, it did not meet the target of 70.8%. 100.0% Cervical Cancer Screening: Trending Rates 90.0% 80.0% 74.5% 74.0% CCS rate 70.0% 68.7% 70.3% 2018 Target 60.0% 61.6% 50.0% 2014 2015 2016 2017 2018 SFHP recommends retaining this measure until SFHP s cervical cancer screening rate meets the NCQA National 90 th percentile for Medicaid, which is 70.68% for reporting year 2019. Page 17 of 28

Recommended activities include: Continue cervical cancer screening pay-for-performance measure in PIP and SUR. Include health education messaging in SFHP's member newsletter. Pilot health education messaging on SFHP s main Customer Service phone line. Pilot the Adult Wellness Visit member incentive program. 4. Care Coordination and Services These are measures that improve care and hand-offs across multiple providers/facilities. They may also be defined as serving a specific population with complex medical needs. 4.1 Complex Medical Case Management (CMCM) Client Satisfaction (Plan Year 2017) Measure: Complex Medical Case Management (CMCM) Client Satisfaction Numerator 36 Baseline N/A Final Performance 92% Denominator 39 Target 80% Evaluation Year 2018 The Complex Medical Case Management (CMCM) Client Satisfaction measure is in the Care Coordination and Services domain. CMCM services are provided to SFHP members based on medical complexity, care coordination needs, and hospital utilization. This measure reflects the satisfaction of CMCM members with their case manager by monitoring the percentage of members who rate their case manager as helpful via a semi-annual member survey. The target for this measure was 80%, which was chosen based on satisfaction survey results from other care management programs within SFHP. The following activities were completed: Collaborated with Marketing to print satisfaction surveys. Remediated member case lists to reflect only active cases. Conducted in person surveys in March and August 2017 (Response rate was 100%). The final result for this measure was 92%. The target was met. SFHP will keep this measure for 2018 but expand it to include other Care Management programs. The target will remain at 80% due to a change in the eligible population being surveyed. Activities to support this measure include: Identify themes from member survey comments regarding their satisfaction with the staff. Developing an action plan to increase client satisfaction, as needed. 4.2 Screening for Clinical Depression and Follow Up (Plan Year 2017) Measure: Screening for Clinical Depression and Follow Up Numerator 9 Baseline N/A Final Performance 36% Denominator 25 Target 70% Evaluation Year 2018 Page 18 of 28

The Screening for Clinical Depression and Follow Up measure is in the Care Coordination and Services domain. This measure reflects activities to increase the percentage of clients in SFHP's Case Management (CM) programs successfully screened for clinical depression using the PHQ-2 tool, including a documented follow-up plan if screening is positive. The PHQ-2 is a two question screening tool that inquires about the frequency of depressed mood over the past 2 weeks. SFHP staff reaches out to members with a positive screening to help connect them to behavioral health services and receive appropriate access to care. The target for this measure was 70%; the target was chosen based on results from past clinical measures. This target represents SFHP s commitment to help connect these members to appropriate services. The following activities were completed: Developed a report and process to capture PHQ-2 screenings and care plan goals currently part of the Care Management Interview tool. Conducted analysis of positive depression screening results and corresponding care plan documentation. Trained staff to self-audit for adding care management goal for positive depression screening. The final result for this measure was 36%. The target was not met. The primary barrier to meeting the target was due to an inability to capture the data for the entire reporting year. SFHP systems were not configured correctly to calculate the measure. System configurations were resolved in Q3 2017. Therefore, data presented here is incomplete. SFHP kept this measure for 2018; however it will be divided into two measures that will monitor the screening and follow-up rates separately. Follow up includes completion of related care plan goals to address depression and connection to behavioral health services. SFHP will also begin tracking cases where follow up was offered but declined by the member. The target rate for both screening and follow up will be 70%. Activities to support these new measures will include: Providing training on new metrics and follow-up protocols, including referrals to Beacon and County Behavioral Health Services (CBHS). Monitoring and analysis of screening and follow-up rates. 4.3 Community Health Network (CHN) Out of Medical Group All Cause Readmissions (Plan Year 2017) Measure: Community Health Network (CHN) Out of Medical Group All Cause Readmissions Numerator 525 Baseline 22.00% Final Performance 22.75% Denominator 2,308 Target 14.43% Evaluation Year 2018 The CHN Out of Medical Group All Cause Readmissions measure is in the Care Coordination and Services domain. This measure reflects activities to reduce readmissions of members within 30 days of discharge of an acute admission. Meeting this measure indicates SFHP s discharge planning program and case management activities are keeping members out of the hospital, preventing unnecessary admissions by Page 19 of 28

reconnecting them to their primary care or needed specialty care. All Cause Readmissions are measured quarterly using HEDIS methodology. This methodology measures the number of members who were readmitted for any diagnosis within 30 days of a hospital discharge. The target for this measure was 14.43%. The target, although considerably lower than the baseline of 22%, was chosen to align with the Medi-Cal state average of 14.43% and represents SFHP s commitment to decrease the number of members readmitted. The following activities were completed: Development of a discharge planning assessment to capture member discharge information Discharge planning assessments were created for 90% of all admissions including: o 2,480 discharge summaries sent to providers for follow up. o 1,689 PCP or Specialist follow-up appointments scheduled to help coordinate care. o 2,420 admission notifications made. The following activities were not completed: Follow up phone calls to members post discharge. Onsite discharge planning. Although the activities above were not completed in 2017, a Care Transitions Nurse was hired in March 2018 to go to the hospitals to meet with members and coordinate their post-discharge needs, including coordinating follow up phone calls. SFHP will work on developing a Care Transitions Program in 2018, coordinating continuity of care for hospitalized members pre and post discharge. The final result for this measure was 22.75%. The target was not met. A barrier to meeting the target is that only pediatric members are being repatriated since June 2017. Since most of SFHP s CHN membership is adults, most members remain out of medical group and may lack the transition of care they would receive in medical group. With onsite discharge planning and follow up calls to members beginning in May 2018 and with SFHP shifting operationally to a focus on care transitions, SFHP expects a decrease in the readmission rate in 2018. SFHP will keep this measure for 2018. The new target will be adjusted to be more achievable, reflecting a 3% improvement to 19.75%. The activities to support the measure will include: Follow up phone calls and discharge assessments for members post discharge. On-site and off-site hospital discharge planning. Implementation of Health Homes Program which will coordinate services for high utilizing members. Implementation of Palliative Care benefits which will provide additional support post discharge. Page 20 of 28

5. Utilization Management These are measures that address appropriate utilization, i.e., decrease over-utilization or increase under-utilization. 5.1 Pharmacy POS Claim Rejection (Plan Year 2017) Measure: Pharmacy Point-of-Service (POS) Claim Rejection Rate Numerator 93,825 Baseline 21% Final Performance 19.2% Denominator 489,235 Target 18.9% Evaluation Year 2018 The Pharmacy Point-of-Service (POS) Claim Rejection Rate measure is in the Utilization Management domain. This rate is calculated based on the number of pharmacy POS claims that are rejected out of the total number of pharmacy POS claims received during the 2017 measurement period. The POS claim rejection rate is an indicator of member access to SFHP s pharmacy services, such as over-the-counter and prescription filling. By improving this rate, members will have better access to prescribed medications with the potential to improve medication adherence and health outcomes. Improvement of this rate can also result in higher member satisfaction with SFHP s pharmacy services. The measure target of 18.9% was set based on historical data to achieve at least a 10% relative decrease from the baseline rejection rate. The activities conducted to support this measure included: Developed Pharmacy POS Claim Rejection report. This report identifies the POS rejection rate by medical group, to help SFHP identify causes of POS rejections and opportunities for improvement. Data from this report, qualitative feedback from prescribers and pharmacies, and Prior Authorization submissions were used to determine common causes of POS rejections. Approved changes to SFHP s drug formulary to address commonly known causes of POS rejections. An example includes changing quantity limits on commonly used medications. The changes were made on medications that were rejected for exceeding a set quantity limit, but the quantity limit was not based on safety concerns. This change allowed more claims to process without rejection. The following activities were not completed: Develop a detailed report that can be filtered by drugs, drug classes, pharmacy, and provider. A report with this detail would allow for a more focused response to rejections and would allow SFHP to quickly make changes to improve access when appropriate. The primary barrier for developing this enhanced reporting was difficulty working with the current database and lack of analytic resources to build a report of this magnitude. The final result of a 19.2% rejection rate represents an 8.57% percent relative decrease from the 2016 baseline of 21%. However, this measure did not meet the measure target of 18.9%. Page 21 of 28

SFHP recommends discontinuing this measure due to the barriers that prevent development of a report that captures precise, actionable data. 5.2 Non-Specialty Mental Health Penetration Rate Measure: Non-Specialty Mental Health Penetration Rate Numerator 2,734 Baseline 3.2% Final Performance 4.5% Denominator 60,970 Target 4.5% Evaluation Year 2018 The Non-Specialty Mental Health (NSMH) Penetration Rate is in the Utilization Management domain. Increasing the non-specialty mental health utilization reflects improved access for members with behavioral health conditions who do not consistently seek treatment. This measure reflects continued emphasis on enhancing member and provider awareness of the availability of the non-specialty mental health benefit. The NSMH Penetration Rate is the percentage of adult Medi-Cal SFHP members with at least one visit with a behavioral health provider from April 1 st, 2017 to March 31 st, 2018. SFHP set a target of 4.5%. Data is based on NSMH claims paid by Beacon Health Options and claims and encounters submitted by mental health providers directly to SFHP. The target was based on benchmark data from other Medi-Cal Health Plans and previous SFHP performance. Performance increased from the previous measurement year (April 1 st, 2016 to March 31 st, 2017) and SFHP met the target. Barriers to meeting this target include: High relative utilization of SF County s specialty mental health services. Lack of consistent provider awareness of the benefit. Low rate of primary care provider screening of members for depression. Behavioral health claims with a primary and secondary medical diagnosis have not been counted due to claims payment rules requiring a primary behavioral diagnosis To improve performance, SFHP completed the following activities: Expanded tele-behavioral health to include two tele-behavioral health services accessible to members. SFHP promoted this benefit to members. Included depression screening measure in SFHP s pay-for-performance program. Added family therapy as a covered NSMH benefit. Promoted NSMH benefit to members through the member newsletter. Communicated NSMH benefit to providers through direct outreach and presentations. Targeted communication of the NSMH benefit to provider groups whose members have relative low NSMH utilization. Additionally in-services were provided to thirteen community based organizations that serve SFHP s membership in connecting members to resources. Revised Beacon contract to include performance incentives, including penetration rate improvement. Page 22 of 28