ALAMEDA ALLIANCE FOR HEALTH BOARD OF GOVERNORS REGULAR MEETING September 9, 2016 12:00 pm 2:00 pm 1240 South Loop Road, Alameda, CA SUMMARY OF PROCEEDINGS Board Members Present: Jane Garcia (Chair),Marty Lynch (Vice-Chair), Dr. Bertram Lubin, Scott Coffin, Dr. Evan Seevak, Dr. Rollington Ferguson, Delvecchio Finley, Will Scott, Dr. Michael Marchiano, Travis Stein, Feda Almaliti, Aarondeep Basrai, Nicholas Peraino Excused: Wilma Chan, Ray Davis Jr. Alliance Staff Present: Scott Coffin, Matt Levin, Matt Woodruff, Tim Reilly, Dr. Michael Griffis, Tiffany Cheang, Elia Gallardo, Craig Kellar, Aman Bhasin AGENDA 1. CALL TO ORDER J. Garcia The regular board meeting was called to order by J. Garcia at 12:05 pm. A board quorum was established by a simple majority for the meeting. 2. INTRODUCTIONS J. Garcia Introductions were made for those present. 3. AGENDA APPROVAL OR MODIFICATIONS J. Garcia J. Garcia inquired if there were any modifications to the agenda. There were no changes to the agenda. 4. PUBLIC COMMENTS (NON-AGENDA S) J. Garcia J. Garcia requested comments from the public in regards to non-agenized items. There were no comments. 5. CEO UPDATE S. Coffin S. Coffin provided the following updates: Performance highlights:
Fiscal 2016 reported net income of $49M; revenue $800M; TNE $100M or 490%. Compliance continues to be a top priority across all departments New system in place; still working though issues in HealthSuite; implemented tracking mechanisms for payment accuracy Repaid $5M county bridge loan three (3) years in advance Initiated provider incentive program 3-Year Strategy Plan: Quality Improvement, Operations Excellence and Financial Stewardship Emphasis on community partnerships to improve health outcomes Transformation into Whole Person Care and Health Homes model Targeting October to approve the 3-Year Strategic Plan; E. Seevak shared current plans: o Develop Committee Charter; roles and bylaws o Good BOG and Alliance staff participation and engagement Fiscal 2017 Priorities and Objectives: Stabilization of claims system is a top priority Data sharing with community partners Increasing care coordination for the highest utilizing members Improvement of HEDIS scores; goal of 5% improvement per year; 15% in 3 years; yield a higher default rate of our members. M. Lynch inquired as to how much of the HEDIS overall rating is based on the data problems or just not meeting the HEDIS measures? M. Griffis responded and T. Cheang concurred that gap reporting with our providers can identity those not meeting a HEDIS standard which will be distributed to our providers. M. Griffis added that the Alliance is currently meeting with clinical staff at Highland clinic to identify and treat members according to the standards. R. Reilly provided an explanation of HEDIS as process measures but not a direct measure of the quality of care provided to the member. Improvements can be seen though efficient data collection process. E. Seevak noted that a significant portion of the HEDIS results is related to access and administrative documentation. Once issues are identified, providers can be encouraged to complete the required AAH BOG 9/9/2016 2 of 9
processes. B. Lubin inquired if the Alliance needs the Board to put more support and resources to make HEDIS a major priority? S. Coffin responded affirmatively and alluded to the approval of the fiscal 2017 budget which will include the resources need to continue the movement with HEDIS improvement. J. Garcia inquired as to what contributes to the difference in HEDIS scores of the Alliance and Blue Cross? S. Coffin responded that assuming the provider networks are equivalent; one example of the difference of the results is in the process of collection the encounter data. M. Griffis added that in addition to the data the chase and specific practice processes are contributors to the difference. Readiness for the Whole Person Care Pilot Readiness for self-funded Health Home project CFO Recruitment The Alliance is recruiting and interviewing qualitied candidates Plans to extend an offer within the next 30-45 days, prior to the exit of the remote monitoring period Medi-Cal 50 th Anniversary Celebration October 26, 2016 Alliance is coordinating three different locations in the East Bay celebration First 5 The Alameda County Board of Supervisors appointed S. Coffin to serve a 5-year term as a commissioner on the First 5 Board. 6. CONSENT CALENDAR J. Garcia J. Garcia requested a motion to approve the Consent Calendar. a. Approval of Minutes Motion: W. Scott Second: T. Stein Approved unanimously 7. BOARD BUSINESS AAH BOG 9/9/2016 3 of 9
J. Garcia J. Garcia reported that the board interviewed Rebecca Gebhart who is currently the Interim Director of the Health Care Services Agency. The Board is recommending she be appointed to the Board. J. Garcia made a motion that Rebecca Gebhart, Interim Director of the Health Care Services Agency be appointed as an At-Large board director for the Board of Governors. Motion: J. Garcia Second: M. Lynch Approved unanimously This is the position that was vacated by Alex Briscoe and is the last open space on the Board. The resolution will be submitted to the Board of Supervisors. This At-Large position is an open position that is not directly tied to a specific position on the Board. 8. a. BOARD BUSINESS STAFF PRESENTATION MEDICAL MANAGEMENT M. Griffis Dr. Griffis provided the following updates and activities to Medical Management: Structure, Key Functions & Headcount: The Alliance provides utilization management for 104,000 members The Quality requirements are provided by the Alliance for 230,000 members. Quality function is delegated only to Kaiser Medical Services: Inpatient UM and Transition of Care, Outpatient UM, Case and Disease Management, Clinical Grievances and Appeals, Provider Dispute Resolution, Health Education Pharmacy: Clinical Pharmacy; ER follow up Quality: HEDIS, CAHPS, NCQA Accreditation Facility Site Review, Potential Quality Issues Credentialing: Ensuring board certification of our provider network; Peer Review and Credentialing Committee As of February 2016 there were 43 staff; Quality 2; Pharmacy 4, Medical Service 37, 3 vacant positions Current Challenges: HEDIS ranking was very low; T. Reilly provided an explanation of how the plans score based on being a closed system, number of plans in the county and geographic coverage. W. Scott requested some documentation of T. Reilly s explanation. E. Seevak commented that 4-5 years ago, the Alliance was in a significantly better position to the left on the HEDIS chart. T. Reilly to collect applicable documentation to consider for distribution to the Board. AAH BOG 9/9/2016 4 of 9
M. Griffis added that although the rates represent process, they also demonstrate good clinical care. A. Bhasin added that with regard to the data, focusing on collecting encounter data appropriately and accurate reporting is important. M. Marchiano added that collaboration is key and obtaining good documentation from the providers. Also, ongoing patient contingencies prevent the correct collection of information. Readmission Rates: The Alliance is currently at a rate of 20.03% for 30-day Readmissions. This is one of the 30 quality measures. The Alliance s rate in 2012 was 14.6% R. Ferguson shared an example of readmission rates being caused by medications that are not covered upon discharge from the hospital. Based on the plan data is there information on why the patients are being readmitted? M. Griffis responded he does not have the data; however he has reviewed the Alliance s processes and procedures; currently short staffed, has not focused on discharge planning or transition of care to identify reasons for readmissions. A. Basrai inquired how pharmacy will be involved with transition of care. M. Griffis responded he is identifying current pharmacy staff and resources; adding additional pharmacist to staff; identifying hospitals and more efficient hospital concurrent review process. It has been difficult to recruit nursing staff for this purpose. CY 2016 Accomplishments: HEDIS 2015 collected and reviewed 8,500 charts within a month. 25 staff persons were trained to go out to provider offices. Currently working with Alameda Health systems to develop opportunities for better documentation and access to care. Quality department expanded from two (2) to ten (10) staff persons. Two (2) people are specifically focused on HEDIS. Reviewed and provided decisions for over 200 appeals; performed over 130 Provider Dispute Resolution reviews; hired additional clinical nursing staff for reviews. AAH BOG 9/9/2016 5 of 9
Transition of Care: Historically very short staffed and inadequate nursing resources to provide reviews. In addition there was no manager for this area for over a year. Processes set up during the conservatorship detracted from solid discharge planning; first day medical necessary reviews were not being performed; these processes will be corrected to anticipate the needs for discharge and to ensure prior authorization overrides are in place. Improving staffing, training of nurses and develop efficient workflows and guidelines for impatient care. Identify opportunities and areas of focus to create case management programs Development of ER follow up program Improvements in True Care and provider portal 2016-2019 Strategic Framework Goals: Improve quality of care; Whole Person Care and Health Home pilots. Manage growth; current staff of 56 was previously 43. Budgeted for 83 staff by end of fiscal year. Improve operational efficiencies; building out the Quality department; meeting state requirements. 8. b. BOARD BUSINESS STAFF PRESENTATION - FINANCE T. Reilly T. Reilly provided the following Finance updates: FY 2015-2016 period Reporting on the financial performance for two periods (June 2016 and July 2016) because there was no board meeting in August. These two periods have not been closed based on the audit plan with Moss Adams to allow a greater claims period to collect paid claims to maximize the accuracy of the IBNP calculations. The Alliance projects to close the year with a $49M net income on revenue of $822M with over 3 million member months (MM). Tangible Net Equity (TNE) increased to $133M which represents 490% of DMHC s required minimum TNE of $27M. Administrative Expense YTD is 6.5% AAH BOG 9/9/2016 6 of 9
Net Income YTD is 5.9%; due to MCE July 2016 period Net income $5.6M Tangible Net Equity (TNE) $139M or 493% of requirement Administrative expense is 6% J. Garcia clarified that since the fiscal year financials have not been closed; this is not an item for approval. E. Seevak inquired about the decrease in membership of children. E. Gallardo explained this is due to redeterminations and ineligibility. She also explained that the Alliance has not received as many undocumented children as was initially expected. Fiscal Year 2017 Budget: MCE margin and increased membership results in updated total projected income of $8.5M Medi-Cal MCE, Child and Adult aid categories contribute positive gross margin; SPDs and duals have a negative gross margin Group Care contributes positive gross margin Medical Loss Ratio (MLR) projected to be 92%; previously 88-89%; due to adult MCE population Administrative expense projected to be 7.1% Tangible Net Equity (TNE) 468% of required TNE; the minimum requirement will grow every year. F. Almaliti shared her recollection of when the MCE was passed and how it would be funded. T. Reilly confirmed that currently MCE is 100% funded by the federal government and the state does not contribute. As of January 2017, Alameda County will be making a 5% contribution. M. Marchiano inquired as to the impact of the HEDIS measures to the budget. T. Reilly responded currently HEDIS scores do not affect the rates; however, the state is considering incorporating HEDIS measures into the rate process. Net income revised from $36M to $8.5M is primarily due to membership projection revisions resulting in $22M decrease in AAH BOG 9/9/2016 7 of 9
revenue; expansion of staff increases administrative expense Overall plan to strive for operational efficiencies and maximize resources M. Lynch and E. Seevak inquired if the projection is overly conservative. T. Reilly pointed out recent deficits is averaging out to $8.5M and he does not feel this is an overly conservative projection. The Alliance needs to be conservative and build back up in to a positive position. W. Scott inquired what can be done now to effect change regarding the SPD and duals rates. T. Reilly responded there have been ongoing discussions and communications and it depends on the state s budget. S. Coffin added that the complex case management functions will address some of the SPDs. J. Garcia requested a motion to extend the meeting time from 2:00 2:30 pm. The motion was proposed, seconded and passed with one (1) abstention. Motion: M. Lynch Seconded: W. Scott Motion passed with one (1) abstention R. Ferguson reported that the Finance Committee is still recruiting new members. The finance report also includes information regarding staffing updates, capital expenditures, membership volatility, claims operations, medical management and provider contracting R. Ferguson moved to accept the projected budget for fiscal year 2016-2017. 9. BOARD MEMBER REPORTS J. Garcia D. Finley shared that Alameda Health System received a generous grant from Kaiser Permanete to fund a new MRI machine as part of their capital campaign. Motion: R. Ferguson Seconded: M. Marchiano Motion passed unanimously F. Amaliti reported that AB796, which lifts the Autism Insurance Mandate is expected to be approved. AAH BOG 9/9/2016 8 of 9
10. STAFF ADVISORIES ON BOARD BUSINESS FOR FUTURE MEETINGS J. Garcia There were no staff advisories. 11. ADJOURNMENT TO CLOSED SESSION J. Garcia J. Garcia adjourned the meeting to closed session at 2:08 pm Motion: E. Seevak Seconded: M. Lynch Motion passed unanimously Respectfully Submitted By: Lynda Fong, Compliance Coordinator AAH BOG 9/9/2016 9 of 9