partnership healthplan of california … · page 1 of 2 regular meeting of partnership healthplan...

PARTNERSHIP HEALTHPLAN OF CALIFORNIA PHYSICIAN ADVISORY COMMITTEE ~ MEETING NOTICE

Members: Khuram Arif, M.D. Jeffrey Bosworth, M.D. Shandi Fuller, M.D. *alternates Jeffrey Gaborko, M.D. (Chair) Michael Ginsberg, M.D. Steve Gwiazdowski, M.D.

Michele Herman, M.D. Willard Hunter, M.D. Melissa Marshall, M.D. -excused Antoinette Martinez, M.D. Mills Matheson, M.D.

Danielle Oryn, D.O. Thomas Paukert, M.D. Mitesh Popat, M.D. Michael Stacey, M.D. *alternates Colleen Townsend, M.D. Lisa Ward, M.D.

PHC Staff: Liz Gibboney, Chief Executive Officer Robert Moore, MD, MPH, Chief Medical Officer Wendi West, Northern Executive Director Peggy Hoover, RN, Senior Director, Health Services Patti McFarland, Chief Financial Officer Mary Kerlin, Senior Dir., Provider Relations (PR) Dept. Marshall Kubota, MD, Regional Medical Director Mark Netherda, MD, Regional Medical Director Michael Vovakes, MD, Northern Regional Med. Dir. Jeffrey Ribordy, MD, Regional Medical Director James Cotter, MD, Regional Medical Director Jessica Thacher, Director, Quality & Performance Improvement Debra McAllister, RN, Director of Utilization Mgmt. Stan Leung, Pharm.D., Director, Pharmacy Services Kevin Spencer, Director of Member Services Ad Hoc PHC Sonja Bjork, Chief Operating Officer Paula Frederickson, Senior Claims Director Members: Kirt Kemp, Chief Information Officer Bettina Spiller, MD, Associate Medical Director Lynn Scuri, Regional Director Mark Glickstein, MD, Associate Medical Director Kelley Sewell, N. Region Mbr Services & PR Director David Katz, MD, Associate Medical Director Carolyn Stewart, Senior Director of Financial Analysis Diane Wong, Pharm.D., Senior Clinical Pharmacist Jennifer Chancellor, Northern Regional Manager Nancy Steffen, Assoc. Dir. of Quality Improvement (N) Karen Stephen, Ph.D., Mental Health Clinical Director Ledra Guillory, Senior Prov. Relations Rep. Manager Carly Fronefield, RN, N. Region, Health Services Dir. Margarita Garcia-Hernandez, Manager, Health Analytics Rebecca Boyd Anderson, RN, Director, Care Coord. Margaret Kisliuk, Behavioral Health Administrator Robin Krohn, N. Region Manager, Care Coordination Rachael French, Sr. Mgr. of Quality Compliance & Accreditation cc: PHC Commission Chair Harris Levin, MD Gabriel Samuel Chua, MD Gregory Baldwin, MD Kali Stanger, MD Voltaire Velarde, MD Richard Fogg Jerry Douglas, MD Amy Brom, Psy.D.

FROM: Linda Largent DATE: April 5, 2018 SUBJECT: PHYSICIAN ADVISORY COMMITTEE MEETING The Physician Advisory Committee will meet as follows and will continue to meet the second Wednesday of every month (exception / July and December.) Please review the Meeting Agenda and attached packet, as discussion time is limited.

DATE: Wednesday, April 11, 2018 TIME: 7:30 a.m. – 9:00 a.m.

LOCATIONS:

________Via Video Conference________ ____________________________Access Via Teleconference____________________________

Partnership HealthPlan of CA 4665 Business Center Drive (Please Park in Front of Bldg.) Fairfield, CA

PHC – Sonoma Office 495 Tesconi Circle Santa Rosa

Baechtel Creek Medical 1245 S. Main Street Willits

Marin Community Clinic9 Commercial Blvd., Suite100, Novato

United Indian Health 1600 Weeot Way Arcata

Shasta Community Health Centers 1035 Placer Street Redding

PHC - Eureka Office 1036 5th Street, Suite E Eureka

PHC – Redding Office 2525 Airpark Drive Redding

Redwood Community Health Coalition 1310 Redwood Way, #135 Petaluma

Ole Health 1141 Pear Tree Lane Napa

CommuniCare Health 2051 John Jones Road Davis

Please contact me at (707) 863-4228, or e-mail [email protected] if you are unable to attend.

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REGULAR MEETING OF PARTNERSHIP HEALTHPLAN OF CALIFORNIA’S PHYSICIAN ADVISORY COMMITTEE - MEETING AGENDA

Date: April 11, 2018 Time: 7:30 – 9:00 a.m. Location: PHC

PUBLIC COMMENTS Speaker 2 minutes

Speaker 2 minutes

Welcome / Introductions I. Approval of Minutes – Chair 5 - 15 7:30 II. Standing Agenda Items Lead Pg # Time

A. Status Update Administration Medical / Health Services Report Regional Medical Director Reports

- Napa County - Southeast Counties - Southwest Counties - Northwest Counties - Northeast Counties

Ms. Gibboney

Dr. Moore

Dr. Cotter - out Dr. Netherda Dr. Kubota Dr. Ribordy Dr. Vovakes

7:40 7:50

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7:55 7:58 8:01 8:04

A1. Update from County Public Health Departments Available Representative(s)

8:07

A2. Committee Member Highlight Dr. Ginsberg 8:10

B. Quality / Utilization Advisory Committee (Q/UAC) Activities Report with attachments – Consent Review Activities & Minutes of the March 21, 2018 meeting: - Minutes – Internal Quality Improvement meeting 02/13/18 (attached)

*Policies &Procedures: March Reviewed for April PAC * See Pages 33-34

Note – only pages with significant changes are included for policies

- Quality Improvement Update - March - Waiver Programs Policy (MCUP3106) - Excerpts -PHC TAR Requirements & Medical Necessity Criteria for Pain Management Procedures (vs. review of MCUP3049) - Inter-Rater Reliability, TARs and Timeliness Data - 2016/2017 Primary Care Provider (PCP) Quality Improvement Program (QIP) Evaluation Pages 54 - 70

Dr. Moore

16 - 70 8:15

C. Pharmacy &Therapeutics (P&T) Committee / Consent Review No meeting in March

Dr. Leung / Dr. Moore

-- --

D. Provider Advisory Group (PAG) Report – Consent Review No Meeting in March

Ms. Kerlin / Ms. Sewell

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E. Credentialing Committee Meeting Summary – Committee approved Summary of the February 14, 2018 meeting (attached)

Dr. Kubota 71 – 82

8:16

F. Recommended Committee Appointments / Resignations

Dr. Moore -- --

III. Old Business Lead Pg # Time

IV. New Business

A. Hospital Quality Improvement Program (QIP) 2018/2019 Measures – Approval Required

Ms. Lasher 83 – 90

8:16

B. Demonstration of Partnership Quality Dashboard (PQD) Mr. Yao 91 - 97 8:35

VI. Adjournment 8:55

This agenda contains a brief description of each item to be considered. Except as provided by law, no action shall be taken on any item not appearing on the agenda. Government Code §54957.5 requires that public records related to items on the open session agenda for a regular committee meeting be made available for public inspection. Records distributed less than 72 hours prior to the meeting are available for public inspection at the same time they are distributed to all members, or a majority of the members of the committee. The committee has designated the Administrative Assistant to the Chief Medical Officer as the contact for Partnership HealthPlan of California located at 4665 Business Center Drive, Fairfield, CA 94534, for the purpose of making those public records available for inspection. The Physician Advisory

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Committee Agenda and supporting documentation is available for review from 8:00 AM to 5:00 PM, Monday through Friday at all PHC regional offices (see locations under the Meeting Notice). It can also be found online at www.partnershiphp.org. In compliance with the Americans with Disabilities Act, PHC meeting rooms are accessible to people with disabilities. Individuals who need special assistance or a disability-related modification or accommodation (including auxiliary aids or services) to participate in this meeting, or who have a disability and wish to request an alternative format for the agenda, meeting notice, agenda packet or other writings that may be distributed at the meeting, should contact the Administrative Assistant to the Chief Medical Officer at least two (2) working days before the meeting at (707) 863-4228 or by email at [email protected]. Notification in advance of the meeting will enable PHC to make reasonable arrangements to ensure accessibility to this meeting and to materials related to it.

Meeting Notes – Physician Advisory Committee – 04/11/2018

Action Items Assigned To:

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PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEETING MINUTES

PAGE 1 OF 11 Committee: Physician Advisory Committee Date / Time: March 14, 2018 - 7:35 to 9:02 am

Members Present:

Jeffrey Bosworth, MD - TC Jeffrey Gaborko, MD (Chair)

Michael Ginsberg, MD Steven Gwiazdowski, MD

Willard Hunter, MD - VC Melissa Marshall, MD - TC Mills Matheson, MD - TC

Colleen Townsend, MD Lisa Ward, MD - VC

Members Excused:

Shandi Fuller, MD Michele Herman, MD

Mitesh Popat, MD

Members Absent:

Khuram Arif, MD Antoinette Martinez, MD

Danielle Oryn, DO Michael Stacey, MD

Participated via Teleconference, but not included in Quorum based on Brown Act regulations.

Thomas Paukert, MD

Visitors: Touro Rotation Student, Leah Benner Note: via Video Conf. (VC) via Teleconference (TC)

PHC Staff Present:

Liz Gibboney, Chief Executive Officer Patti McFarland, Chief Financial Officer Sonja Bjork, Chief Operating Officer - VC Kirt Kemp, Chief Information Officer Wendi West, Northern Executive Director- VC Margaret Kisliuk, Behavioral Health Admin. Lynn Scuri, Regional Director - VC Jennifer Chancellor, N. Regional Mgr.- VC

Robert Moore, MD, Chief Medical Officer Peggy Hoover, RN, Senior Director, Health Services James Cotter, MD, Regional Medical Director Stan Leung, Pharm.D., Pharmacy Director Jessica Thacher, Dir., Quality & Perf. Improvement Debra McAllister, RN, Dir. Utilization Management Mary Kerlin, Sr. Director, Provider Relations Ledra Guillory, Sr. Prov. Relations Rep. Mgr. Robin Krohn, Care Coord. Team Manager (North)-VC

Marshall Kubota, MD, Regional Medical Director - VC Michael Vovakes, MD, Northern Regional Med. Dir. -VC Jeff Ribordy, MD, NW Regional Medical Director - VC Bettina Spiller, MD, N. Associate Medical Director - VC Carly Fronefield, RN, Northern, Health Services Dir.- VC Ro Summers, Quality Improvement Prgrm, Project Mgr. Amy Lasher, Quality Project Manager Cody West, Senior Quality Improvement Analyst - North Tara Fogliasso, Quality Project Manager - North

AGENDA

ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET

DATE DATE

RESOLVED

Public Comments Quorum I. Approval of Minutes II.A. Status Update Administration

Committee Chairman, Dr. Gaborko, asked for public comments. None were presented. The Committee’s Chair presented the February 2018 meeting minutes for approval. The HealthPlan’s Chief Executive Officer (CEO) provided the following report on Partnership HealthPlan of California (PHC) activities. Recognition – There is sad news to report. Herrmann Spetzler, Chief Executive Officer (CEO) of Open Door Community Health Centers (ODCHC) in Humboldt and Del Norte counties, has passed away

N/A Committee quorum requirements met. MOTION: Dr. Gwiazdowski moved to approve Agenda Item [I.] as presented, seconded by Dr. Ginsberg. ACTION SUMMARY: [9] yes, [0] no, [0] abstentions. Motion carried. For information only, no formal action required.

N/A

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Physician Advisory Committee Minutes – 03/14/18 - Page 2 of 11

AGENDA ITEM

DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION

DATE RESOLVED

II.A. Status Update Admin., Continued

unexpectedly. Mr. Spetzler has been with Open Door for forty years. He and his wife have been instrumental in the expansion and growth of the health center. They have been visionary leaders with telehealth, provider recruitment, and adopting electronic health records. Mr. Spetzler has been a member of the HealthPlan’s Board since its expansion into the Northern Region in 2013. His passing is a tremendous loss to the community, and touches the 500 staff employed at Open Door, many of whom have worked with him for years. Open Door’s Chief Operating Officer (COO), Mrs. Cheyenne Spetzler, has been named the Interim CEO, which should ease the transition. Dr. Hunter, Chief Medical Officer (CMO) for Open Door reflected on Mr. Spetzler’s huge presence in Humboldt County, along with the state and the Partnership HealthPlan. His advocacy for health services in the rural areas extended to a national level. Open Door is now a main player in the county for primary care. He was instrumental in starting and expanding what is now ODCHC, though it had its non-supporters in the startup years. Mr. Spetzler has been a tireless advocate for the underserved populations (and staff), having mortgaged his home to meet payroll demands a couple of times in the early years. He spearheaded the initiative of increasing the minimum wage to $15 an hour for all the employees, and made sure they also had the benefit of a retirement fund. As a personal friend, Mr. Spetzler was appreciated for his inquisitive mind and wide-ranging interests. Open Door has a transition plan in place. At their meeting last evening, the Board scheduled a strategy session for replacing Mr. Spetzler’s position. As of now, a date for a Celebration of Life has not been selected. Everyone’s support has been very appreciated during this time of loss. - Federal Budget and Medicaid – There has been a lot of waiver activity with the new Centers for Medicare &

Medicaid Services (CMS) Administrator, in terms of approving waivers nationwide, particularly from more conservative states. Those waivers include the allowance of work requirements to receive Medicaid benefits, as well as a heightened interest in capping Medicaid benefits over the course of the member’s lifetime. PHC is monitoring how those waivers roll out, and if CMS will use waivers to manipulate some states.

- HealthPlan Budget – Next year’s fiscal budget (starting July 1) is in the process of being developed. Preliminary rates for the new fiscal year are expected from the State next month, which is earlier than anticipated. There are several new initiatives being worked on that will start up in the new fiscal year, which include the California Children Services (CCS) Redesign, and Drug Medi-Cal. With the Housing Initiative, the Plan is in the process of contracting with a variety of organizations that submitted applications. Some entities are further along than others. It will take a number of months for the roll-out. Some applicants are also contenders with the State’s “No Place Like Home” housing funds, which is currently tied up in a lawsuit.

- California Future Health Workforce Commission – Partnership’s CEO continues to participate, with focus on the behavioral health portion. The Commission is expected to wrap-up in October. Some of the emerging themes include:

For information only, no formal action required. For information only, no formal action required. For information only, no formal action required.

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AGENDA ITEM


DATE RESOLVED

II.A. Status Update Administration, Continued II.A. Status Update Medical

A lot of interest in regulatory easing related to peer support providers, especially in the substance use area Interest in expanding California’s recognition of psychiatric nurses’ ability to practice. Other states are

much less restrictive than California. Push to restore significant funding for training at the state level, which sunsets this year.

- National Committee for Quality Assurance (NCQA) Accreditation – The HealthPlan is approximately 54% in

compliance with standards, with a target of being 100% compliant by this June. The next level of Accreditation is already being worked on, which will come after this initial set.

- Major Initiatives with the State –

CCS Redesign – The Redesign is still scheduled to go forwrd next January 2019. Staff is talking with each of its counties regarding the model they want to pursue - Partnership taking over the Utilization Management (UM) and Care Coordination of CCS services, or the HealthPlan may subcontract back to some of the counties for a period of time. The caveat to the second option is that the county meets NCQA Accreditation standards.

Drug Medi-Cal Program – PHC is in active discussions with the Department of Health Care Services (DHCS) regarding its financial model, showing its data, and developing final rates. The State asked for innovation, and it is believed the Plan’s model meets that requirement. However, the State is unsure how to proceed with the Regional Model.

Health Homes Program (HHP) – The draft rates received from the State were determined to be insufficient, in addition to some other programmatic changes that DHCS wanted to make. The HealthPlan provided feedback regarding the rates and other changes, and recently discussed its continued concerns with DHCS. A final decision has still not been made.

Prospective Payment System (PPS) Redesign – DHCS has advised health plans that it is no longer actively working with CMS on this potential pilot. So, Partnership is looking internally for a Plan B, and potentially partner with one interested Federally Qualified Health Center (FQHC) to redesign how payments are structured. The HealthPlan is committed to this redesign, as it will go a long way toward delivering better outcomes and continuity for all of its members, but the lift is heavy.

The HealthPlan’s Chief Medical Officer (CMO presented an overview of some Health Services activities. - Spring Quality Conference – This Plan-sponsored event is scheduled for next Monday, and there is still room

for some reservations. The conference will be available at all four PHC locations via video (Eureka held at the Sequoia Conference Center). Details were included in the Clinical Newsletter distributed a few days ago.

- Regional Medical Director Meetings – The round of regional meetings have been completed, and all were well attended. There was even representation from the Plan’s most remote site in Cedarville.

- Confidential Screening/Billing Report (PM 160) Form Followup – In followup to the discrepancy of information received this past year, the State has confirmed that the Child Health and Disability Prevention (CHDP) services form (PM 160) will no longer be required. Providers will not be required to submit these forms to PHC, since it will no longer submit to the State. However, there is information included on

For information only, no formal action required. For information only, no formal action required. For information only, no formal action required.

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DATE RESOLVED

II.A. Status Update Medical, Continued

the form relevant to CHDP providers, that is of benefit to their county. Information on children under the Gateway or State Medi-Cal programs requiring a referral needs to be directed to the county. Providers are encouraged to contact their county to see what is required for these cases. Each county may require something different.

- Cologuard for Colon Cancer Screening – This test is good for up to three years, and is recognized by the NCQA. DHCS has approved Cologuard as a Medi-Cal benefit, and the Partnership has an active contract with the company for the test. Though DHCS’ benefit indicates yearly, the HealthPlan has limited the screening to every two years, which is well under the three year interval recommended by the US Preventive Services Task Force (USPSTF).

- 340B Program – The State released suggested “Trailer Bill Language”, though the Legislature has not yet accepted the language. In essence, the language attempts to dismantle the 340B Program as much as possible. There is a lot of ongoing advocacy to stop this effort. The Plan is not a viable advocate, as that is better represented by benefit recipients.

- Drug Medi-Cal – There are a number of activities around this program. The Plan’s Behavioral Health Administrator advised that there are two major areas identified for clinical policies, which are: 1) detoxification (detox) withdrawal management services, and developing more guidelines on Medication Assisted Treatment (MAT), and 2) residential care, and how utilization is monitored.

PHC’s Regional Medical Director for Napa County presented a brief overview. - Ole Health – Management has been in the process of recruiting a new CMO. David Gorchoff, MD, has accepted

that position. - Medical Reserve Corps (MRC) – There has been ongoing work with Napa County for the MRC. MRC is where

physicians sign up to be volunteers for cases of emergency. Signups are done through the State, and counties have a list of those physicians. Napa has had three major disasters in the past ten years, and it is expected that another will befall the area. As it turns out, MRC’s list includes deceased and retired physicians, along with some unknown in the area. Napa Medical Society is working with the County toward creating a robust list. Other counties are encouraged to do something similar.

- Palliative Care Benefit – There have been over 250 members (nearing their end of life) to participate in the in-home care program. The Plan’s current focus is to ensure that primary care providers (PCPs) and communities are aware of this benefit. A presentation was made to the Plan’s Consumer Advisory Committee (CAC) last week. The program has been well received, though not everyone is aware of the benefit.

- Introduction and Community Health Initiative – Leah Benner, student with Touro University’s Masters in Public Health and Physician Assistant program, was introduced to the Committee. Ms. Benner is on her last rotation and will be graduating in a couple of weeks. She has been working with the Regional Medical Director on the Children’s Health Initiative (now the Community Health Initiative) in Napa. The Initiative has improved the number of children who are medically insured (now at 98%), those who have a PCP (up to 98%), and those who have had a well-child visit within the first ten months of joining (85%). The outreach is extending their focus to adults and seniors. Napa’s County Health Officer participates on the Initiative’s Evaluation Committee, along with the County’s Administrator in charge of Medi-Cal applications.

For information only, no formal action required.

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DATE RESOLVED

II.A. Status Update Medical, Continued

The application process from the County, to the State, and ultimately to PHC can take three months or longer. The Initiative’s Evaluation Committee is striving to speed up the process at the county level, since there are individuals not receiving the care they need during the gaps of time. Ms. Benner is assisting the Regional Medical Director with the program evaluation process, which is out of date.

PHC’s Regional Medical Director for the Southeastern (SE) counties was not available for an overview. PHC’s Regional Medical Director for the Southwestern (SW) counties presented a brief overview. - Health Officers – There have been several changes with Health Officers in the SW counties. In

Mendocino, Dr. Gary Pace has assumed that role. Dr. Pace has been in the area for 30 years. Lake County also has a new Health Officer, Dr. Sara Goldgraben. Sonoma County continues to recruit to fill the void left by Dr. Karen Milman’s resignation.

- New Health Center – Dr. Ward advised that the Santa Rosa Community Health Centers (SRCHC) opened a 24 exam room facility with 14 full-time equivalent (FTE) providers. The location also houses a Complimentary and Alternative Medicine (CAM) suite, as well as the Intellectual and Developmental Disabilities Program for community dwelling adults needing primary and some specialty services care, who formerly lived at the Sonoma Developmental Center. It is expected that this facility will eventually take care of 8,000 patients. The expansion also includes a dental wing, allowing for sedation dental services and teledentistry in the home, so it can accommodate some of the complexity of dental care required by individuals with developmental disabilities. As a whole, it is a complex program housed in a stunning clinic, which has been planned for years. Of note, teledentistry is handled by staff in the home (or institutional home), avoiding the need of general anesthesia or physical restraints. The object is to give patients with complex mental illness or neurodevelopmental disorders the most care, with the least amount of intervention. Services include screenings, some diagnostic treatments, portable x-rays, etc. This past Monday, a second clinic was opened called the Airway Campus. That site is a temporary, year-long clinic located in the Sutter Ambulatory Care building. It includes another 24 exam rooms, and is housing SRCHC’s 36 Family Medicine Residents and 10 faculty members. The site is used for SRCHC’s internal specialty care referral network, residency training, and specialty care services. In a two week timeframe, SRCHC expanded by 50 exam rooms.

- Sonoma West – This surgical site is targeted to open next week, which is good news for the area. The

facility’s surgical unit has been closed for sterilization cleanup, due to findings of mold by inspectors. PHC’s Regional Medical Director for the Northwestern (NW) counties presented a brief overview. - Regional Medical Directors’ Meeting – As previously noted, the forum was well attended. And, as with

other regions, providers are attending for the purpose of Plan updates, versus using it as an opportunity to express complaints and concerns. Unfortunately, some providers were not able to attend, due to poor weather conditions.

N/A For information only, no formal action required. For information only, no formal action required.

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DATE RESOLVED

II.A. Status Update Medical, Continued II.A1. Update - County Public Health II.A.2. Committee Member Highlight

- Access – There has not been a lot of movement with providers in the area. There is one pediatrician at Open Door who will be leaving, since her husband is being transferred. St. Joseph’s (St. Joe’s) Hospital has hired a new Ear, Nose and Throat (ENT) specialist, which is a big help for the area. And, it is understood that they have been having difficulty retaining emergency room (ER) and hospitalist physicians. Team Health is currently handling both placements. St. Joe’s has changed contracts several times over the past five years, which lends to the inconsistency. The latest rumor is that St. Joe’s will go in-house to create their own hospitalist and ER section.

- Residency Program (Program) – Dr. Hunter advised that the Program had a site review by the Accreditation Council for Graduate Medical Education (ACGME), and the reviewer was very pleased and impressed by the medical staff and the administrative portion. Somehow, the Program was added to the ACGME’s docket for their April meeting. Staff should know sometime in April on the status of the Program’s Accreditation. If that is the case, they will be able to start recruiting candidates for the first cohort of residents for the summer of 2019. There is great hope that the Residency Program will help stabilize the area’s access to medical care.

The HealthPlan’s Northern Regional Medical Director presented a brief overview on activities for the Northeastern (NE) counties. - Regional Medical Directors’ Meeting – Last week’s forum in Redding had around 30 attendees, and

included representation from all the NE counties. - Access – There has not been any major shifts in providers for the area. Of good news, Canby Clinic

has been without a physician for quite a long time. Dr. Matthew Edmonds, previously with the clinic, has moved back to the area and has rejoined the staff. Coming this spring is a mobile mammography pilot for Modoc and Trinity counties. The details of this program are still being worked out. It is hoped that this will begin in April, as both counties do not have these services currently.

Dr. Stacey was not available to present a brief epidemiology update to the Committee. Continuing with the ongoing effort to be more familiar with members of the Committee, Dr. Townsend shared some highlights about herself. Raised in Minnesota, she grew up around the Twin Cities area and attended a small Liberal Arts college in Central Wisconsin. During college, she took some time off to live abroad in England, completing the non-science portions of pre-medical requirements. Since London was so enjoyable, she stayed another couple years and worked as a nanny for a couple with one child. She has maintained that friendship over the years. The University of Minnesota was selected for her medical school, which really emphasizes primary care in their curriculum, and consistently has one of the largest graduating primary care classes. The college

For information only, no formal action required. N/A For information only, no formal action required.

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AGENDA ITEM

DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION DATE RESOLVED

II.A.2. Committee Member Highlight, Continued II.B. Quality/ Utiliz. Advisory, II.D. Provider Adv., & II.E. Credentialing committees II.F. Committee Membership

placed a lot of emphasis on primary care for rural communities when she attended, since the state is largely rural. At that time, Dr. Townsend did not want to live in a rural community, though she wanted to pursue primary care. Through research, she found that some challenges for primary care were specific to urban areas. Along with other interested medical students, they developed a rotation that focused on serving underserved communities in the urban areas (currently known as social determinants of health). The group started a program in which medical students could spend 2 to 3 months working in community health centers for their primary care rotation. This was a progression for Dr. Townsend’s love of primary care, having interfaced with the National Health Service in England. That allowed her to see community medicine and the single payer system. Residency in Family Practice was done at the University of California, San Francisco (San Francisco General at that time). That program was chosen because of its focus on community medicine and addressing systems for better care within underserved communities in urban areas. Dr. Robert Moore recruited her to join Ole Health’s physician team in 2001. Her intent was to fulfill a three-year commitment for the National Health Service, but she found something in Ole Health that has kept her there. Over the past sixteen years, she has been able to grow clinically, and serve the community and organization by participating in leadership and management, and help build programs that serve the communities. Though Dr. Townsend has had many roles at Ole Health, her current position is Senior Director of Community and Specialty Partnerships, allowing her to help cultivate and maintain the relationships with organizations and specialists to better serve Ole Health’s patients. On a personal note, she is married with two children, who are active in athletics. She had learned to love baseball through Little League, but the interest has shifted to La Cross, requiring her avid attention to follow the fast pace of the sport. Other interests include hiking and traveling, and spending time with friends in the area. There were no items pulled for additional review by the Committee. The Plan’s CMO advised that Dr. Rod Manalo, a member of the Quality / Utilization Advisory Committee (Q/UAC) from its inception in 1994, who retired from Kaiser several years ago, has decided to move out of the area. He is no longer able to participate on the committee. Dr. Manalo has been a quality champion. With reluctance, his resignation is recommended.

MOTION: Dr. Townsend moved to approve Agenda Items [II.B., II.D., & II.E.] as presented, seconded by Dr. Gwiazdowski. ACTION SUMMARY: [9] yes, [0] no, [0] abstentions. Motion carried. MOTION: Dr. Townsend moved to approve Agenda Item II.F., as presented, seconded by Dr. Ginsberg. ACTION SUMMARY: [9] yes, [0] no, [0] abstentions. Motion carried.

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AGENDA ITEM

DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION DATE RESOLVED

IV.A. Lactation Clinical Practice Guideline (CPG) (MPXG5008) IV.B. CPG: Pain Mgmt., Chronic Pain Mgmt., & Safe Opioid Prescribing (MPXG5009) IV.C. eReports System (& the new Partnership Quality Dashboard System – Deferred)

PHC’s CMO noted that the Lactation CPG was pulled from consent, as these are reviewed by the Committee. There were a couple of minor changes, mainly with the language around the Plan’s current program, in which, staff calls members regarding their postpartum visits, and to inquire if there are any issues. The Plan’s CMO advised that language was updated in the CPG to include the importance of the patient’s primary care provider’s (PCP’s) role in the pain management, prior to being referred to a pain management specialist. Non-opioid options to treating pain were also added to the guideline. Partnership’s CMO reported that the Plan is pleased to share electronic tools relating to its pay for performance program (Quality Improvement Program [QIP]). Today’s agenda reflects both the eReports System and the Partnership Quality Dashboard (PQD), but the latter is being deferred to next month for presentation to the Committee. The Plan’s Quality Director shared that the eReports system supports the clinical measures of PHC’s PCP QIP. The non-clinical measurements are not encompassed under eReports. The system allows providers to see their denominator list, and the numerator status, as well as understand how many members they are away from meeting their target. Aside from creating some transparency regarding the population that the provider’s payment will be based upon, it allows providers to upload data to the HealthPlan, when that information is not available. Of note, the PQD, which will be demonstrated next month, has similar information as eReports, but it is more of an analytics tool. The Plan’s Senior Quality Improvement (QI) Analyst (QI Analyst) and Quality Project Manager (Project Manager) from the Northern Region were introduced to the group. PHC’s Project Manager highlighted the QIP eReports system for those not familiar with it. The on-line system tracks all of the QIP clinical measures, and was developed in-house by the Plan’s Web Applications team. The QIP team is available to provide assistance to PCPs for utilization of the tool. The database gives providers the ability to track their clinical performance in real time and download patient reports for all clinical measures tracked, along with the ability to upload any supplemental data not being received by the HealthPlan through other administrative sources. Feedback from providers is taken into account when exploring the feasibility of enhancing the system.

MOTION: Dr. Gwiazdowski moved to approve Agenda Item IV.A. as presented, seconded by Dr. Townsend. ACTION SUMMARY: [9] yes, [0] no, [0] abstentions. Motion carried. MOTION: Dr. Ginsberg moved to approve Agenda Item IV.B. as presented, seconded by Dr. Gwiazdowski. ACTION SUMMARY: [9] yes, [0] no, [0] abstentions. Motion carried.

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AGENDA ITEM

DISCUSSION / CONCLUSIONS

IV.C. eReports System, Continued (Partnership Quality Dashboard System – Deferred)

The first major enhancement made is Single Sign-On. It allows the provider to log onto the system with one user name and password. Some practice sites had multiple user names and passwords. All previous user names and passwords to the QIP eReports system have been deactivated. Providers are required to complete a brief survey to designate an eReports administrative user, and access their Secret Key. The administrative user will also be the internal owner of the Secret Key, and the one who designates the appropriate permissions within their organization. One primary point of contact is required for the entity, and more than one is fine. The second major enhancement is the provider’s ability to Drill Down to Site Level Data. The initial log-in gets the user to the site’s parent organization level. The user can then drilldown to the various sites (if applicable). The dropdown feature is available under the Threshold Report. The Plan’s QI Analyst reviewed the new clinical measures added to QIP eReports for 2018. All measures are shown by their practice type (Family, Internal, and Pediatric), so that each site will list the measures assigned to them. Data for eReports is acquired through claims (i.e. immunizations from care, lab results, pharmacy data), as well as the supplemental data providers upload. This information is used for calculations of denominators and numerators. In the past, eReports was refreshing nightly. This year, those refreshes will occur once per end of week (Friday eve), to allow for capture of data from the noted sources. Measurements added for 2018 are included in the system for the appropriate practice type. Breast cancer screening reviews the number of continuously enrolled Medi-Cal women ages 50 to 74 years, who have had a mammogram. This measurement takes into account the full Healthcare Effectiveness Data and Information Set (HEDIS) specification, and staff is looking at enrollment criteria prior to the measurement year (enrolled in the HealthPlan) for fairness to providers. The childhood immunization Combination 3 measure reviews children two years of age, who need to satisfy a series of seven vaccinations (providers should review the QIP Specifications [Specs] Manual for details). This measure is undergoing further development in eReports, due to its complexity. Staff continues to work on a way to meaningfully display gaps in care and what vaccinations may be missing. The timeline of this additional information is sometime between June and December. The addition of supplemental data is not yet available for this measure, pending the ability to display gaps in care. The asthma medication ratio reviews members 5 to 18 years of age, who have been identified as having persistent asthma and have a ratio of controller medications to total asthma medications of 0.5 or greater, during the measurement year. This is only being added to measurements for pediatric practices. Immunizations for adolescents is not a new measure, but it is a new combination. The Human Papillomaviruses (HPV) vaccine has been added for patients between the ages of 9 and 13. eReports enhancements include the ability for providers to capture numerators through administrative services for diabetic retinal eye exams. Again, providers should refer to the QIP Specs for details. Partnership’s Project Manager demonstrated the system live for the benefit of the Committee. The QIP eReports can be accessed under the Plan’s website, then drilling down by hovering over “Providers” then clicking the link to the PCP QIP under Quality. This leads the user to the QIP website, and ultimately to the measurements by practice type. eReports can be accessed under the “Tools” option. Once there, providers are encouraged to bookmark the location, for ease in future access. Providers will always be reminded of the “Terms and Conditions”, and required to accept, due to the Protected Health Information (PHI) included under the site. Using the cervical cancer screening as a sample, the Plan’s Project Manager demonstrated how the provider can review their targets, the additional number of patients required to meet that target, the denominator (number of eligible members), and the numerator (number of women who have completed the screening), resulting in the provider’s current rate. The system further breaks this information down, showing the targets for the 75th and 90th percentile levels. New measurements for the current year will reflect the 50th percentile level.

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AGENDA ITEM

DISCUSSION / CONCLUSIONS

IV.C. eReports System, Continued (Partnership Quality Dashboard System – Deferred)

This gives the provider the opportunity to prepare for the next measurement year. The data can also be exported to an Excel table. Organizations with multiple sites (or practice types) can drilldown to show specific data by site or practice type. Users wanting a list of members within each measure can do so through a hyperlink under the Denominator or the Numerator caption. Specific examples were highlighted with the group, showing compliance by member. Additionally, the system will reflect all the data sources used to bring the member into the practice site’s measure, along with the applicable procedure code. The patient list for a measure can also be downloaded into Excel. There are multiple ways to access the patient list. One of the newer enhancements was derived from provider feedback. Whereas, providers wanted the ability of downloading their entire member denominator list for all measurements. This is now available through a single click, call the QIP Member Report, and can be filtered as the provider prefers. Member Search was another enhancement added. Sites have requested a way to determine if a member is included under more than one measurement. This is achieved by entering the member’s Client Identification Number (CIN), or any of the search criteria listed under the site page, then hit search. A detailed link will populate, allowing the provider to view this information. If the member has been excluded from a measurement (i.e. not under cervical cancer screening if received a hysterectomy), that has also been identified. Uploading QIP data into the system was demonstrated. Elements for numerator compliance, which the HealthPlan requires for a measurement, is also listed for the provider’s reference. Areas addressed by the Committee included: - Dr. Gwiazdowski complimented the program, which is a powerful tool for providers. He asked if there was a way to project the nominator (patients still

requiring the screening). – The Plan’s Quality Director advised that, for the purpose of the QIP, members are included under the numerator portion when they become compliant. The denominator reflects those not compliant. Secondly, how is the data set populated into the database? – PHC’s QI Analyst shared that the value sets are derived from the HEDIS information and the sources previously highlighted.

- Dr. Ward asked about the timeframe from service to claims, as many of the metrics are driven by claims data. What is the general time before claims data is part of the weekly upload? - PHC’s QI Analyst advised that staff has also been challenged to answer this, in terms of how much time should be allowed before the provider should upload supplemental data. Ultimately, this is dependent on each organization’s timeframe of billing. Data uploaded and refreshed can occur within one to two weeks, and is based on received (not paid) claims. Consequently, providers are encouraged to go to the “details” section of eReports to determine if the system has captured the information. There is also a grace period allowed at the end of the year for providers to add data not captured. In terms of physicians who split their time between sites, Dr. Ward wondered if there was a mechanism to reflect a PCP at more than one site simultaneously. If not, how are affiliations communicated so that the information is most reflective of where PCPs are practicing? – The Plan’s Quality Director advised that the eReports system is by site, and not drilled down to the clinician level (based on member assignment).

- Dr. Gwiazdowski questioned how duplication of data uploads are handled, and how the data’s integrity is preserved, when there is self-reporting involved.

– PHC’s QI Analyst advised that the system is set up to capture all the data, but will filter so that it is counted only once. The duplication will simply be shown as additional information. Data integrity is determined through the end-of-year audit process, and reconciled by Plan staff.

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AGENDA ITEM


DATE RESOLVED

IV.C. eReports System, Continued IV.D. 2016/2017 Hospital QIP Evaluation Adjournment

Provider feedback on the eReports system has been very favorable, and reported to be on the cutting edge when comparing programs similar health plans have available. The Plan’s QIP Project Coordinator (Project Coordinator) reported that the Hospital QIP was started in 2012. There are currently 37 eligible hospitals in PHC’s 14 counties, with 26 hospitals participating. The purpose of the program is to improve health outcomes of Plan members, and to assist hospitals in assessing the quality of care they are providing. There were nine measures included in the 2016/2017 measurement set, and large hospitals (at least 50 general acute beds) reported on all nine measures. Small hospitals (less than 50 acute beds) reported on two of those measures. The Hospital QIP Evaluation is to assess the performance of the measures, and to identify areas needing improvement. As the information is reviewed, there are some considerations to note. In 2012, there were six hospitals participating. In 2017, the program started with 26 participants. Performance statistics revealed stable or increased improvements overall, with the exception of the exclusive breast milk feeding (EBMF) rates. The Plan’s rate for EBMF was 75%, and shows a slight decrease from the previous year, but the statewide average is at 65%. Quality staff is working with hospitals to determine the discrepancy for the vaginal birth after cesarean (VBAC) rate. But, overall, there was improvement. The last measure to point out is elective delivery (before 39 weeks gestation). Due to a correction submitted by a hospital a few days ago, that percentage should now reflect 2.98%, not 3.98%. Though there is one outlier hospital, the balance of hospitals have a low elective delivery rate overall. In summary, at least 70% of the Plan’s hospitals earned whole points for 8 out of 9 measurements. These measures use targets that are based on national trends and thresholds. Going forward, staff will focus on retrieving maternal data from the California Maternal Quality Care Collaborative (CMQCC), which should help reduce errors. Provider engagements will be continued, along with the Quality Symposium sponsored by the HealthPlan, and monthly newsletter updates. The Plan’s CMO reminded the Committee that the Evaluation was based on the measurement set at that time, which was changed for this year. Next month, proposed changes for the coming year will be brought to the Committee for review and approval. The Committee adjourned at 9:02 AM Respectfully submitted: Linda Largent

For information only, no formal action required. For information only, no formal action required.

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The foregoing minutes were APPROVED AS PRESENTED on: ___________________________ ____________________________________ Date Jeffrey Gaborko, M.D., Committee Chairman The foregoing minutes were APPROVED WITH MODIFICATION on: ___________________________ ____________________________________ Date Jeffrey Gaborko, M.D., Committee Chairman

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Committee: Quality and Utilization Advisory Committee (Q/UAC) Meeting

Date/Time: Wednesday, March, 21, 2018 / 7:30 AM – 9:00 AM Napa/Solano Room, 1st Floor Members Present: Choudhry, Sara, M.D. Gwiazdowski, Steven, M.D., FAAP Montenegro, Brian, M.D. Murphy, John, M.D.

Namihas, Steven, M.D. Quon, Robert, M.D. Swales, Chris, M.D. Thomas, Randolph, M.D. Wilson, Jennifer, M.D.

Members Absent: Borde, Madhusudan, M.D. Paukert, Thomas, M.D.

Strain, Michael, PHC Consumer Member Threlfall, Alexander, M.D.

PHC Members Present: French, Rachael, Senior Manager, Quality Compliance and Accreditation Glickstein, Mark, Associate Medical Director Guillory, Ledra, Senior Provider Relations Representative Manager Hoover, Peggy, RN, Health Services Senior Director Kubota, Marshall, MD, Regional Medical Director McAllister, Debra, RN, Utilization Management Director Moore, Robert, MD, MPH, MBA Chief Medical Officer – Chairman

Netherda, Mark, MD, Regional Medical Director Ribordy, Jeff, Northern Region Medical Director Stevenson, Lauri, Northern Region Manager of Clinical Quality and Patient Safety Thacher, Jessica, MPH, Director Quality, Performance Improvement Vovakes, Michael, MD, Northern Region Medical Director

PHC Members Absent: Boyd Anderson, Rebecca, Care Coordination Director Chancellor, Jennifer, Regional Manager Cotter, James, MD, Associate Medical Director Cuellar, Dina, Director of Regulatory Affairs Fronefield, Carly, Northern Region Health Services Director Garcia-Hernandez, Margarita, Manager Health Analytics Jenkins, Shauncey, Member Services Supervisor Kerlin, Mary, Provider Relations Senior Director Kisliuk, Margaret, MPP, JD, Behavioral Health Administrator

Leung, Stan, Pharmacy Services Director Santos, Rosemenia, Manager of Quality Assurance/Patient Safety Scuri, Lynn, Administration Regional Director Sewell, Kelley, Northern Region Director of Member Services & Provider Relations Sibilsky, Susanna, Northern Region Health Educator Spiller, Bettina, M.D. Northern Region Associate Medical Director Steffen, Nancy, Northern Region Associate Director Quality, Analytics and Project Management Stephen, Karen, PhD, Health Services Mental Health Director West, Wendi, Northern Region Executive Director

Guests: Beavers, Mitchell, Relypsa Pharma. Inc. Garnick, Karen, Member Services Administrative Assistant Hoffman-Spector, Sharon, UM Team Manager

Lasher, Amy, Project Coordinator Nopwaskey, Sara, Performance Improvement Clinical Specialist Thomas, Andrea, Quality Improvement Communications Coordinator Yao, Qi, QI Analyst

AGENDA ITEM DISCUSSION RECOMMENDATIONS / ACTION DATE RESOLVED

I. Call to Order Approval of Minutes

Dr. Robert Moore called the meeting to order at 7:30 a.m. Internal Quality Improvement Minutes from 2.13.18 and Quality and Utilization Advisory Committee Minutes from 2.21.18

Motion for IQI Minute acceptance: Dr. Quon Second for Minute acceptance: Dr. Gwiazdowski Accepted with no changes

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A request for public comment was made by Dr. Moore.

Motion for QUAC Minute acceptance: Dr. Gwiazdowski Second for Minute acceptance: Dr. Quon Approved with no changes

II. Standing Agenda Items 1. Status of Open

Action Items None

2. QI Department Update

Jess Thacher gave the Quality Improvement update found on page 25. We have a number of Quality Improvement Programs (QIP) on the annual calendar so there

is still activity around wrapping up last year’s program, which includes finalizing scores and calculating payments so we can send checks out. We then will kick off the current year and will host webinars to get the providers up to speed on the measurement set and any changes to the program for this year.

Hospital QIP is not on the annual year, it’s on the fiscal year from July-June. We are finalizing the measurement set and the goal is to bring it to PAC in April for approval.

Today’s meeting will include presentations on two of the QIPs; the 16-17 PCP QIP evaluation and the 16-17 Hospital QIP evaluation. This will be the last year we are evaluating the PCP QIP on the fiscal year, since we are now transitioning to the calendar year.

The Partnership Quality Dashboard has gone live and we will be hosting a webinar to officially launch the first module for the Provider Network. We have been working on this for a couple of years and this is the first piece that is being released externally for the provider network. Module 1 shows the non-clinical measures for the QIP. Historically the data has been shared via PDF reports that are emailed every other month. This will be a huge improvement for providers to access data real-time, in a web-based platform. It will also allow them to drill down to patient level detail that wasn’t readily available on the non-clinical measures before.

The HEDIS 2018 On-Site Audit was completed in February. The HEDIS medical record retrieval project is underway; we are currently about 40%

complete with procurement and chart reviews.. We have received and gone through a little over 5,500 medical charts as of March 16. We are on track to complete the project by NCQA’s completion date of May 9th.

Our ADVANCE program is wrapping up this month. Our final 2-day in-person learning session will focus on how to develop a sustainability and spread plan.

PHC hosted the Better Health through Better Partnerships: How Health Centers Integrate Their Knowledge of the Community with the Delivery System symposium earlier this week.

In regards to HEDIS score improvement, QI is helping with the cervical cancer screening media campaign in Lake and Mendocino Counties.

We have four new Advance Care Planning (ACP) coalitions that PHC has awarded grant funding to and have arranged for technical assistance to be provided by the Coalition for Compassionate Care of California. The new ACP coalitions are in Humboldt, Lake, Siskiyou and Yolo counties.

There has been a lot of work on the annual monitoring for patients on persistent medications (MPM) measure. We have done a few different PDSAs that have really demonstrated the efficacy of live calls to our members on this measure so we are talking about how we can spread that a little more to do health plan based live calls to encourage members to go in for their screenings.

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The Northern Region did a birthday club pilot at Shasta Community Health Center to improve the rate of Well Child visits. The data is promising in regards to direct member outreach and an incentive for children to get their well-check visits.

We are about 54% compliant with our interim NCQA survey requirements. Our goal is to be at 100% by the end of the fiscal year. Big focus items include delegation oversight and NCQA analytic requirements. There are also new NCQA standards on population health management strategy that we are working on.

Statistics on the Patient Safety volume in terms of Potential Quality Issue (PQI) and site review are included in the written report.

3. HealthPlan Update

Dr. Moore gave the HealthPlan update. From our board meeting in February, after the Affordable Care Act (ACA) there was a

confluence of factors plus the geographic expansion that led to a time of revenue exceeding expenses by quite a bit which is why we had our Strategic Use of Reserves (SUR) for several years. Currently, PHC is in the part of the cycle where you go below the breakeven line and we will be spending some of the reserves for regular operations this year. Our goal is to incorporate some of the increased expenses into our rates which will hopefully make us whole in approximately two years from now. The big dependency is how the state actuaries and what the assumptions will be in their calculations, as just a 1 or 2 % change in their assumptions could have a large impact on a big budget. We hope to get our rates in April and that will tell us if it’s a tolerable use of reserves or more worrisome rapid use. PHC does have enough reserves built up to last for a couple of years but we’d rather not use them all. PHC will continue with projects we are currently working on and will not be doing any major new spends or initiatives at this time.

Question was asked, what drives the cyclical nature of that and do we share historical data with them? Dr. Moore advised that part of the SUR were expenses that are being continued to expend and those will eventually be built into the rates, but it takes two years to build it in. Once they are built in, the revenue side will match. He also confirmed that yes, we do look at trends and share with the state. The California Children’s Services (CCS) Carve In, or the Whole Child Care program, is

scheduled to go live in January. This is the program that will carve in CCS in the 11 counties that are currently carved out. Should be seamless to front line providers but to PHC will be increase in staff and training to take on the roles.

Dr. Moore completed his series of four regional director meetings. One thing that came up in the Northern Region (NR) is the status of the CHDP PM 160 form. This was included in medical director’s newsletter, and basically for non-Partnership providers there is still a requirement for some type of documentation and every county is supposed to determine what that is and communicate it to the providers.

The state drafted the rates structure and regulations for Health Homes for patients with complex needs but they are not acceptable to PHC so we have pushed back with an explanation as to why they won’t work. There was conversation with the state but because of CCS and the drug Medi-Cal program and some other priorities, we can’t do them all at the same time. The earliest we would go live with Health Homes is July 2019. We remain committed to our extensive outpatient care management program and continue to support that and encourage its growth.

There was an impasse between CMS and DHCS on some key aspects of the alternate payment methodology which was passed into legislation a few years ago that could not be

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resolved. PHC received a message stating it’s unresolvable and the state will not move forward with it. PHC and some other plans are looking at an alternate way to test out that model of care using Healthplan funds but that will have increased expense. Conversations are taking place, and it appears that the pilot will not be as large of scale that the state was thinking about.

Comment from Ledra that an important notice dated 3/13/18 just went out regarding CHDP, and providers should be getting that in the mail soon. Dr. Moore asked if it a CHDP provider notice and Ledra confirmed that yes it was.

III. Old Business There was no old business discussed. IV. New Business (Committee Members as Applicable)Consent Calendar Delegation Reports - Credentialing / Re-Credentialing

Utilization Management/Care Coordination: MCUP3017 - Health Services Review of Non-admission In-hospital Obstetrical Evaluations MCUG3023 - Infant Monitor Guidelines MCUP3052 - Medical Nutrition Services MCUG3058 - Utilization Review Guidelines ICF/DD, ICF/DD-H, ICF/DD-N Facilities MCUP3119 - Sterilization Consent Protocol MPUP3129 - Podiatry Services Discussion on policy MCUP3052: On page 36, the language about Obesity and Overweight is not easy to understand. Currently it reads: Greater than the 85th percentile weight for height OR BMI (>2 y.o.) using the appropriate growth chart for age (NCHS). This should be changed to reflect: Below age 2 use weight to height and Over age 2, greater than the 85th percentile of BMI.

The following policy was extracted from the Consent Calendar for discussion: MCUP3052. Motion to approve: Dr. Gwiazdowski Second: Dr. Quon The remaining polices were approved without changes. Motion to approve MCUP3052: Dr. Thomas Second: Dr. Murphy Approved with change to reflect: Below age 2 use weight to height and Over age 2, greater than the 85th percentile of BMI.

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1. MCUP3106

Debbie McAllister reported on MCUP3106 found on page 55. On page 55, Section VI, Item A, added four additional Home and Community Based Services

(HCBS) Waiver programs. Most of these are limited and we don’t have members in them but we needed to add them to the policy per state guidelines.

On pages 57-58, Section VI, Item C, updated the referral information for the original three programs and added information on the four added programs.

On page 59, Section VII, updated the references.

What is a waiver program? Peggy confirmed it’s where there are state allocations for specific programs for a specific population of people and waives Medicaid program requirements under HCBS Waivers. In addition, Dr. Moore stated that the Pediatric Palliative Care Waiver Program expired last year and got a one year extension. We are still not sure what they will do with it. This does not change the policy, it remains in the policy as it’s currently still in place. What is the Assisted Living Waiver? Debbie confirmed that for PHC it is only in Sonoma County where there is special funding that can go to keep a patient housed there for up to a year without paying a copay. However, there are many rigid rules and as far as we know there are two beds in Sonoma County that allow the waiver program.

Motion to approve: Dr. Wilson Second: Dr. Quon Approved without changes

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2. MCUP3131

Dr. Moore reported on MCUP3131 found on page 60. On page 60, Section IV, Attachment B has changed.

Motion to approve: Dr. Gwiazdowski Second: Dr. Quon

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On page 61, Section VI, Item C, added language about TAR overrides. On Attachment A, beginning on page 64, there are many changes due to new tests, and new

Medi-Cal rules. Dr. Moore discussed a few specific changes: o On page 65 regarding test 81162, included information about the ability to override the

once in a lifetime frequency. Specific language the state put out regarding this was added on pages 66-67.

o On page 71, a duplicate was removed for test 81211. o On page 78, 81280 and 81281 were removed and replaced with 81413 and 81414 found

on page 113. o On page 94, two items removed from test 81403. These were moved as they got their

own codes and are now on page 64. o On page 85, test 81528, the new standard is now every three years; therefore, the

frequency limit changed to state no more than once every two years. Is there any kind of requirement to prove that tests have not been done before? Dr. Moore confirmed that if the TAR is put in by the lab, and they are using the same lab it should come up. Debbie confirmed that if it requires a TAR, we do check in our system to see if it’s been done but we are limited to just the time they have been a PHC member. Post Meeting Note: Per Dr. Moore, MCUP3131 was pulled from the April PAC meeting as there were new updates per Operating Instruction Letter (OIL) and also changes in the Medi-Cal guidelines. Policy will be further updated and sent back to IQI and Q/UAC in April.

Approved without changes

3. MCUG3118

Peggy Hoover reported on MCUG3118 found on page 123. This policy started through committee in January but there were questions if the policy was referencing the most current version of the American College Obstetricians & Gynecologists (ACOG) perinatal guidelines. On page 125 all of the graphs that attempted to reproduce the guidelines were taken out and

stated for providers to follow the guidelines. Should the policy state that we are really saying we are basing it on the guidelines as of this moment? Dr. Moore advised that the policy is worded so that if the guidelines change, we don’t have to change the policy; Peggy confirmed this is the intent. Comment was made that it’s up to the providers to stay up-to-date on the guidelines.

Motion to approve: Dr. Montenegro Second: Dr. Gwiazdowski Approved without changes

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4. MCUP3049

Debbie McAllister and Dr. Moore reported on MCUP3049 found on page 132. We updated the TAR request requirements to be consistent with our current one. On page 135 we changed Attachment A to state when the cumulative cost of items exceeds

$100 in a calendar. On page 143 Attachment B there was a change for codes 64490 to 64495. Previously, it was

not clear between initial injection and repeat injection. The first section is now initial injection and the second for repeat injections.

Motion to approve: Dr. Quon Second: Dr. Gwiazdowski Approved without changes

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5. MCCD2012

Peggy Hoover reported on MCCD2012 found on page 145. Requesting approval to archive the Chronic Kidney Disease Program policy as we have

added it the Complex Case Management Program policy MCCP2007. Approval today is to archive MCCD2012. Policy MCCP2007 was provided as a reference to show that CKD was added there.

Motion to approve to archive: Dr. Quon Second: Dr. Swales Approved without changes

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V. Presentations 1. Inter Rater-

Reliability/TAR Timeliness

Debbie McAllister presented the Inter Rater-Reliability, TARs and Timeliness Data found on page 161. Page 161 is the physician review data and we have a 90% target range of passing and we had

one case that dropped to the 80th percentile that was reviewed by Dr. Moore. Page 162 is the inpatient data. July, August and September were deferred due to the

implementation of Essette. Ratings are all above the 90th percentile across the board. Page 163 is the outpatient data. Also deferred July, August and September due to Essette. We

were within our threshold of >90%, ranging from 96%-100%. Page 164 is the referral (RAF) volume, manual vs. electronic. We received over 100,000

referrals between July and December, the majority of them electronic. Page 165 is denied TARs by region. In the Northern Region, there was a total of 3,416 denied

with 1,174 being denied for medical reason, 1,162 being outpatient. Due to the high number we drilled down and looked at reports and found that about 77% were from one provider sending in for scans, CTs and MRIs that did not meet criteria. Will refer this to over/under utilization so that we can drill down more. In the Southern Region is was pretty benign. For both North and South we have TARS denied needing CCS authorization. Come January we may not see this as we will be CCS authorization and denying it doesn’t mean it didn’t get paid.

Page 166 is all TARs completed, we had a total of 99,275 combined inpatient and outpatient. Dr. Thomas asked if there is any kind of follow up to see what happened to those patients with the TARS denied due to scans, etc. Debbie confirmed she is working with Carly in the north to research this and are trying to determine if they could be repeat requests.

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2. 2016-17 Hospital Quality Incentive Program Evaluation

Amy Lasher provided a presentation on the 2016-17 Hospital QIP Evaluation found on page 183. The goal of the Hospital QIP is to assess the performance of our hospitals and also to identify

areas of improvement. There are 26 hospitals participating, out of 37 in our network and this is our 5th year of the

Hospital QIP. The purpose is to improve the health outcomes of our members and to help participating

hospitals assess the quality of care provided to their patients. There were nine measures in the program. Large hospitals are measured on all nine measures,

small hospitals on just two. Considerations to keep in mind is that our participants have changed and grown over the

years, starting with six participants in 2012-12 and 26 participants in 2017-18. Any changes in performance that are in this evaluation could be due to the additional hospitals alone rather than a change in performance year to year.

Performance graphs are on pages 190 and 191 and data shows that performance has either improved or remained stable over the years. Once exception is Exclusive Breast Milk Feeding (EBMF), we saw a slight dip due to new participants added; however, we are still above the California average. There also appears to be a spike in Elective Delivery, but this is attributed to incorrect data being submitted. After drilling down on the data, we reached out to two hospitals that had most of the elective deliveries and one hospital submitted a correction, which lowered our aggregate. There still was a slight increase, but this increase is attributed to the increase in the number of hospitals participating.

At least 70% of the hospitals met full point targets for 8 out of 9 of the measures.

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On page 194 we did some performance by hospital characteristics. There is some disparity between small and large hospitals. Small hospitals are performing a little less that large hospitals and we are trying to mitigate that by creating separate measurement sets and adjusting our measures based on the differences we have seen.

We will focus on improving the quality of data collected, will work with our partners to get data directly from them to improve our data.

We will work to increase engagement and guide hospitals in the QI efforts. Dr. Quon asked why our hospital QIP is so maternal/child health heavy. Dr. Moore confirmed that about 40% of our members are children and our number one admission is childbirth. The other factor is just finding good adult measures and many times with the adult measures they have tiny denominators and it’s hard for us to make those measures especially in the smaller hospitals. He also advised that when we introduce our measurement set recommendations a few outpatient measures have been added to help provide balance, and next year there are some additional non-clinical measures. Jessica Thacher, Director of QI/PI added that we are working on measure development and we are always thinking about next year’s measures and asked if anyone has ideas about measures that they feel would be appropriate to please let us know. Dr. Quon advised that they have looked at the standardized infection ratio. Amy advised we did look at sepsis rates and although it’s publicly reported we had a challenge in establishing a baseline as the publicly available data had a two year lag, and we didn’t think it was appropriate to hold hospitals to a baseline established with two year old data. Dr. Katz commented about the classification of the hospitals, and that the physical size of the hospital makes sense but from Partnership’s point of view as a payer, should we classify hospitals by how much service they provide to our members as this may help focus incentive directives. Dr. Moore confirmed that they have to be a hospital in our region to be considered for the QIP. Dr. Murphy commented that potentially a measure could come off if it doesn’t continue to be a meaningful measure, such as advance care planning that has a 99.3% rating. Dr Moore confirmed that it did come off for the current year and clarified that the numbers in this presentation were for the prior year. Dr. Gwiazdowski commented that there are measures that fold into star ratings that hospitals are actually measuring. Is it worth considering some of these? Amy captured the suggestions and confirmed that both Dr. Quon and Dr. Gwiazdowski are available to have offline conversations regarding their suggestions.

3. 2016-17 Primary Care Provider Quality Incentive Program Evaluation

Qi Yao provided a presentation on the 2016-17 PCP QIP Evaluation found on page 199. The PCP QIP offers financial incentives, data resources and technical assistance to PCPs who

serve our members so that we can we can make significant improvements. For the review period, July 1, 2016 to June 30, 2017 we had 222 providers participating, with

30 measures and paid $36 million, and average points of 65.5. There showed a stability in the percent of providers meeting the 90th percentile target. There

was a modest increase in the percent of providers meeting the 75th percentile target. Large practice size and family practice correlate with better program performance/higher Per

Member Per Month (PMPM).

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The average point earnings is consistent year over year. Northern Region showed improvement over 15-16 and performed slightly better than the Southern Region.

Based on our findings we do believe that the PCP QIP does improve care. Many measures show improvement over time.

We also look at provider experience and 95% of the participants agreed that QIP does improve patient care, and 100% are satisfied with the program.

Significant program changes were made effective 1/1/18 which are supported by 16-17 program year results, and no measures are ready for retirement based on high performance.

We will consider slow changes to the patient experience which includes the CAHPS survey findings and also the readmissions and admissions targets in the future.

Dr. Moore discussed the slide on page 211 about the measure for Controlling High Blood (CBP) Pressure. The addition of CBP to the family practice measurement set correlated with improved HEDIS rate. The CBP performance in QIP increased in 2016-17. Dr. Moore commented that the state had noticed the increase in our 2017 HEDIS Reporting Year, we believe this is attributed to the CBP measure added to the family practice measurement set. Do we know what contributed to the drop in the northwest rating? Dr. Moore advised it could

be due to fact that this was a sampling of charts and the majority was from one provider. Rachael confirmed we are watching this measurement closely this year.

Is there some effort to gather the best practices that successful practices use and look at those that did not get high percentiles? Rachael confirmed they were and that we were surprised to see those rates considering the active engagement and the work the NR was involved with. Dr. Moore advised that there multiple ways that we do share/highlight high performers including regional directors meetings and newsletters. Rachael confirm that we did review the charts and it wasn’t that the members weren’t being seen, it was just that the most recent blood pressure taken was out of control as HEDIS looks at only the most recent taken and not the historical data in the chart.

Does this take into account home blood pressure readings? Dr. Moore confirmed that NCQA standard does not allow home blood pressure readings.

Are we able to make phone calls to members to remind them to take or pick up their medications? Dr. Moore confirmed that we do have something set up in our pharmacy system for it a patient is not picking up their medication on time it will generate an automated phone call to remind them. This is not a live nurse call; the live nurse calls were for people who specifically needed lab tests.

Dr. Quon suggested that the charts on page 202, which represent the providers that meet either the 90th or 75th percentile, would be better represented as a bar graph. This may be visually easier and could combine the slides into one. Dr. Swales asked how does PHC measures the nutrition and physical activity counseling listed on page 209? Rachael confirmed PHC uses documentation in the chart, such as handouts about physical activity or safety, and also that this is just for well-child; it does not apply to adults.

VI. Additional Business The discussion topic was deferred to the April meeting due to time constraints.

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Committee: Internal Quality Improvement (IQI) Meeting

Date/Time: Tuesday, February 13, 2018| 1:30 PM - 3:30 PM Board Room, 3rd Floor

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION

TARGET DATE

DATE RESOLVED

I. Call to Order Approval of Minutes

Dr. Robert Moore called the meeting to order at 1:30 p.m. Minutes from the 01/09/2018 IQI meeting were reviewed.

Motion: Mary Kerlin Second: Peggy Hoover Approved without changes.

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II. Standing Agenda Items

1. Status of Open Action Items

Rachael French responded to the timeline concerning the interim Group Needs Assessment (GNA). DHCS requires PHC to conduct a GNA every five years. Per NCQA, we have identified the need for an interim GNA. The Network Adequacy Team goal and the Cultural and Linguistics Workgroup are actively working on this. Once a timeline is established, it will be

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Members Present: Becerra, Eric, Grievance and Appeals Resolution Manager Bjork, Sonja, JD, Chief Operating Officer Boyd-Anderson, Rebecca, Director of Care Coordination Cabrera, Maria, Member Services Lead Representative Chancellor, Jennifer, Northern Region Administration, Regional Manager Endsley, Scott, MD, Associate Medical Director French, Rachael, Senior Manager Quality Compliance and Accreditation Hoover, Peggy, RN, Senior Director, Health Services Kerlin, Mary, Senior Director of Provider Relations

Kubota, Marshall, MD, Regional Medical Director Leung, Stan, Pharmacy Services Director McAllister, Debra, RN, Director of Utilization Management Moore, Robert, MD, Chief Medical Officer Russell, Joan, Senior Manager of Provider Education Santos, Rose, Manager, Quality and Patient Safety Scuri, Lynn, Regional Director Siblisky, Susanna, Northern Region Health Educator Steffen, Nancy, Northern Region Associate Director of QI, Analytics, PMO Thacher, Jessica, MPH, Director, QI/PI Turnipseed, Amy, Senior Director of External and Regulatory Affairs

Guests: Enos, Mary, Associate Director of Enrollment Garnick, Karen, Administrative Assistant Hoerber, Ely, Program Manager Hoffman-Spector, Sharon, Team Manager, UM Kaufer, Jennifer, Manager of Performance Improvement

Leslie, Liz, Program Manager Robinson, Gary, Compliance Oversight Manager Stevenson, Lauri, Manager of QI Performance Improvement Thomas, Andrea, Communications Coordinator Wurden, Meredith, Associate Director of Finance Policy

Members Absent: Cotter, James, MD, Associate Medical Director Cuellar, Dina, Director Regulatory Affairs Frederickson, Paula, Senior Claims Director Fronefield, Carly, Northern Region Health Services Director Garcia-Hernandez, Margarita, Manager of Health Analytics Gibboney, Elizabeth, MA, Chief Executive Officer Glickstein, Mark, MD, Associate Medical Director

Guillory, Ledra, Senior Director Provider Relations Gutierrez, Araceli, Member Services Supervisor Netherda, Mark, MD, Regional Medical Director Ribordy, Jeff, MD, Regional Medical Director Rosel, Melissa, Team Manager, Utilization Management Sewell, Kelley, Director, Member Services, Provider Relations

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communicated to the Committee. This is a first survey requirement so there is time to establish due dates.

2. QI Department Update

Jess Thacher gave the Quality Improvement update found on page 14. There were many recent changes to the Primary Care Provider Quality Improvement

Program (QIP). One major highlight includes systems build to support QIP. Our Northern Region QI team leads the production of our eReport system in partnership with IT. There is a concentrated effort in this area to get this program up and running with the 2018 Measurement Specifications. It is scheduled to launch 3/1/18.

The Partnership Quality Dashboard (PQD) is starting Module 4, which is the integration of the eReports data (the QIP clinical measures into the dashboard). Essentially, by integrating this data into the dashboard, it will allow us to do analytics on our eReports data.

The HEDIS audit is scheduled for 2/15/18 and the HEDIS medical record retrieval project is underway.

We are wrapping up our second cohort of our internal Performance Improvement Training called QI-Ex. Presentations will be given on 2/14/18 from the teams working on HEDIS related measures. This program was expanded to included Northern Region QI staff as well as Pharmacy personnel.

In terms of external opportunities, Better Health through Better Partnerships: How Health Centers Integrate Their Knowledge of the Community with the Delivery System will be hosted on 3/19. This symposium will showcase health centers who have shaped their medical practice and organizational structure around their community and community needs. On 3/7, the ABCs of Quality Improvement training will be held in Santa Rosa.

There is a lot of work centered around NCQA Accreditation. In the spring, an assessment of point earnings for interim accreditation will be conducted. In April, we will make a recommendation to the NCQA Steering Committee as to whether PHC would like to apply for interim accreditation.

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III. Old Business

There was no old business discussed.

IV. New Business (Committee Members as Applicable)

Consent Calendar Delegation Reports Credentialing/ Re-Credentialing

MCUP3013 (previously UP100313) - DME Authorization MCUP3104 - Major Organ Transplants MPUG3112 - Breast Magnetic Resonance Imaging (MRI) Guidelines MCUP3111 (previously MPUP3111) - Pulmonary Rehabilitation MPUP3018 (previously UP100318) - Health Services Review of Observation Code Billing MCUP3103 - Coordination of Care for Members in Foster Care MCCP2020 (previously MCUP3009; MPUG3009; UG100309) - Lactation Policy and Guidelines (formerly Breastfeeding Guidelines) MCCP2021 (previously MCUP3100) - Women, Infants and Children (WIC) Supplemental Food Program MC340 - Continuation of Insurance Premium (CIP) MPCR6A - Initial Credentialing Requirements for Non-Physician (Allied Health) Practitioners MPCR13 - Credentialing of Pain Management Specialist MPCR16 - Lactation Consultant Credentialing Policy MPPRPLCR401A - Initial Credentialing Document Collection, Review, and Verification for

Policy MCQP1021 was extracted from the Consent Calendar for further discussion by Lauri Stevenson. IQI Consent Calendar Motion to approve: Peggy Hoover Second: Debbie McAllister The remaining policies were approved without changes. In policy MCQP1021, an additional attachment needs to be added under Section IV. Attachments, Item C, to

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Behavioral Health Practitioners MCQP1021 (previously QP100121) - Initial Health Assessment and Behavioral Risk Assessment MCQP1052 - Physical Accessibility Review Survey - SR Part C MPQP1055 (previously CMP36) - Provider Preventable Condition (PPC) Reporting CGA024 (previously CGA-003; Health Services [HS] MCQP1034; Member Services [MS] policy #300) - Medi-Cal Member Grievance System

represent the threshold language of Tagalog. Motion to approve: Debbie McAllister Second: Peggy Hoover Approved with change.

1. MPXG5009 Rebecca Boyd Anderson presented on policy MPXG5009 found on page 178. The changes in the policy clarify timelines.

Motion to approve: Debbie McAllister Second: Peggy Hoover Approved without changes.

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2. ADM38 Dr. Moore presented on policy ADM38 found on page 189. This is an administrative policy on the development structure of policy and procedures. All

Administrative Assistants and those involved in policy writing should review. Attachment B features a template for policies outlining detailed instructions when creating a

policy. It also outlines a numbering system for policies and procedures by department and spacing guidelines.

Attachment C outlines how policies flow through Committees. Attachment D indicates the DHCS approval process. Attachment E outlines the retention duration of policies. Attachment F is the Synopsis of Changes form for Discussion Policies. Rachael French added the following points: Desktop procedures should not be part of attachments when sending an external policy

through for review. In the reference section, the Practioner’s Manual has now been changed to Provider Manual. If there are links within a policy, it is important to validate the links and then update the

accessibility date accordingly.

No voting required. 2/13/18

3. MPUP3026 Debbie McAllister reported on policy MPUP3026 found on page 231. This policy was revised to meet NCQA standards. On page 231, language was revised to reflect the percentages and numbers of how many

inter-rater reliabilities are conducted and how often they occur. UM Nurse Coordinator was changed to Nurse Coordinator.

On page 232, Section VI, Item B-3b, language was revised to reflect each selected TAR will be audited by a clinical staff member who is a licensed employee in a non-supervisory role.

Motion to approve: Peggy Hoover Second: Rebecca Boyd Anderson Approved without changes.

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4. MPHP8001 Susanna Sibilsky reported on MPHP8001 found on page 239. On page 240, Section VI, Item B-6, language was added to include national origin, disability and sex as components of the demographics description. On page 240, Section VI, Item B-8, language was added to reflect health education materials are available in other languages upon the request of the member. On page 241, Section VI, Item B-9, language was added to reflect the finding from the GNA as well as other internal and external data sources are utilized to guide the development and implementation of health education interventions. On page 242, Section VI, Item B-20, reflects the change of MMCD to the Managed Care Quality and Monitoring Division (MCQMD) of DHCS. On page 242, Section VII, Item A, Policy Letter 10-012 was updated to Policy Letter 17-002. This will need to be modified again from Policy Letter 17-002 to All Plan Letter.

Motion to approve: Peggy Hoover Second: Dr. Kubota Approved with change.

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5. MPHD8002 Susanna Sibilsky reported on MPHD8002 found on page 304. On page 305, the first paragraph now includes PHC’s member portal as a component of

health education program. On page 306 and 307, in the Goals section, references were added to reflect the Interim PHC

GNA that is conducted in between the state mandated GNA occurring every five years. On page 307, language was added to the Referral to Health Education Program section so it

includes the Member Portal and includes a link to the Health Education page on PHC’s website.

On page 310, under the Program Review and Evaluation section, the change was made from DHCS MMCD to the Managed Care Quality and Monitoring Division (MCQMD) of DHCS and the due date of the C&LHE work plan was changed from May 30 to December 31.

Dr. Moore suggested the following changes: On page 309, under Oversight, Provider Advisory Committee should be changed to

Physician Advisory Committee (PAC). On page 306, under Goals, an internal comment needs to be deleted. Rachael French commented on the following: On page 310, under Oversight, should Program Evaluation be added as part of the review

process? The Committee agreed the Program Evaluation should be reviewed semi-annually at CLHEC, IQI, and Q/UAC.

Jennifer Kaufer commented on the following: It appears the committee is being referenced differently throughout the policy, CLHEC and

C&LHE. A global search will be conducted to align terms.

Motion to approve: Joan Russell Second: Mary Enos Approved with changes.

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6. MPXG5008 Dr. Moore reported on policy MPXG5008 found on page 311. On page 312, language was modified to recognize the services and responsibilities of

Primary Care Providers (PCP), pain management specialists, and other specialists caring for members with chronic pain. The PCP is ultimately responsible for coordinating the services.

On page 313, the Opioid Prescribing Guidelines for Physicians were revised to offer non-opioid medications.

Motion to approve: Dr. Scott Endsley Second: Peggy Hoover Approved with no changes.

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7. CGA022 Eric Becerra reported on policy CGA022 found on page 347. On page 347, Section III, language was added describing the Adverse Benefit

Determination. Some of these definitions were updated to align with the Member Grievance policy for consistency. The Grievance Supervisor definition was added and the Lead Grievance Coordinator definition was updated.

On page 348, Section V, Item A, the word “language” was added with regard to discrimination.

On page 349, Section VI, Item B, language was added to identify the Grievance Supervisor as the designee.

On page 349, Section VI, Item D, language was changed from grievances must be submitted within 60 days to grievances can be submitted at any time.

On page 349, Section VI, Item E, language was modified to state grievances can now be made by calling Member Services in addition to written submissions.

On page 349, Section VI, Item K, 180 days was inadvertently deleted. It will be placed back in the policy.

Motion to approve: Debbie McAllister Second: Peggy Hoover Approved with change.

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8. MPQP1023

Jess Thacher reported on policy MPQP1023 found on page 353. The changes to this policy relate to NCQA standards and the DHCS APL on network certification. On page 353, Section III, Item A, the High-Impact Specialist definition now includes

oncology/hematology as a high-impact specialty type every year. On page 353, Section III, Item B, High-Volume Behavioral HealthCare Practitioner now

outlines how we identify our High-Volume Practitioner type. On pages 353 and 354, Section III, Items D, E and F, we now include DHCS’ definition for

rural, suburban or small, and urban or medium counties and outline the counties we serve within each definition.

On page 354, Section VI, Item A-1, language was added to indicate we will maintain an overall ratio of one physician to every 1,200 members.

On page 355, regarding the table entitled Geographic Distribution of Practitioners, Primary Care, the addition of Obstetrics/Gynecology was added as required by the APL.

On page 356, Item C, language was added stating PHC monitors geographic availability for additional specialty types defined by DHCS as Core Specialists.

On page 357, Item E, the featured table identifies the geographic distribution for specialty care. All of the specialty types are listed and the geographic distribution standard. It is also noted to indicate if the provider is high-volume specialty type or high-impact specialty type.

On page 359, standards for pharmacy and hospital access were added as required by the APL.

On page 360, performance goals were added around appointment wait times as NCQA requires analyses indicating performance level relative to goal.

On page 360, Item C, language was added to specify office hours and telephone access standards for primary care practitioners.

One page 361, Item D, language was added to include requests for utilization of out-of-network services.

Mary Enos commented on the following: On page 355, the second column of the table entitled Geographic Distribution of

Practitioners, Primary Care, lists “1 within 10 miles or 30 minutes from the member’s residence” for PCP’s and “1 within 30 miles or 60 minutes from the members’ residence” for Family Medicine/General Practitioner. It seems conflicting.

Jess Thacher responded DHCS has the overall Primary Care standard, which is reflective of the 1 within 10 miles or 30 minutes from the member’s residence. NCQA requires us to set standards for sub-specialty (family medicine, pediatrics, and internists). As an example, a member could be within 10 miles of a family practice provider but the member is within 30 miles of a pediatrician. We look at how close a member is to a primary care overall and then we look at how close a member is to a sub-specialist of primary care.

It was decided this table should include a disclaimer explaining the difference between the DHCS standard and that of NCQA.

Rachael French commented: On page 362, Section VII, Item B, “PHC Provider” should be removed. Item C,

“Practitioner Manuals” should be changed to “Provider Manuals”. On page 353, Section I, Item B, the Delegation Oversight Policy is referenced. This is still

being drafted so should not be listed.

Motion to approve: Mary Enos Second: Peggy Hoover Approved with changes.

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Stan Leung commented: On page 360, 5. Access to Pharmacy, language should be changed from, “the greater of 24

hours or one business day response,” to “within 24 hours.” 9. MPQP1006 Dr. Moore reported on policy MPQP1006 found on page 373.

The only change to this policy was the removal of the reference to NCQA requirements as NCQA removed the clinical practice guidelines criteria in 2018.

Motion to approve: Dr. Kubota Second: Mary Enos Approved with no changes.

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10. Facility Site Review

Lauri Stevenson presented the Facility Site Review found on page 377. Facility Site Reviews (FSR) are conducted as part of credentialing and re-credentialing

purposes. It is a state mandate sites are able to show they meet safety and access standards. There are two components: FSR and Medical Record Reviews (MRR). The FSR portion

looks at areas ranging from Access and Safety to Infection Control with an overall passing score of 80%. For the MRR, a random sample of members’ records are selected. The sample can range from 10 to 30 records depending on the number of PCPs at the site. An 80% overall score is required to pass. If any of the domains fall below 80%, a Corrective Action Plan (CAP) is required for the entire review.

Results from the period 7/1/17 - 12/31/17 for FSRs were as follows: SE - Slight decrease in infection control domain. SW - No significant changes were noted across all domains. NE - Some improvement was noted in personnel domain. NW - No significant changes were noted across all domains.

Results from the period 7/1/17 - 12/31/17 for MRRs were as follows: SE - No significant change noted in MRR. SW - No significant change noted in MRR. NE - Noted increase in pediatric preventive screening, as well as adult preventive

screening. NW - Significant increase in documentation domain.

Nurses conducting reviews agree there is a need to continue to educate on the IHA and the SHA. Adult immunizations are often lacking, as well as pap smears. Advanced Healthcare Directives continue to be low scoring, especially in young adults. Preventive health is one of the most discussed subjects on reviews and cause the majority of CAPs.

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11. Physical Accessibility Review Survey (PARS)

Lauri Stevenson presented the Physical Accessibility Review Survey (PARS) found on page 381. The purpose of the PARS is to assess the physical accessibility of provider sites using a set

of standards approved by DHCS. There were a total of 104 Part C surveys conducted during the time period 1/1/17 to

12/31/17. There are two levels upon which a provider’s site will be identified as, which include basic and limited access, in addition to medical equipment access. Of the 104 surveys, the following scores were derived: Basic Access: 35; Limited Access: 69; Medical Equipment: 18. The accessible weight scale was the main item that caused most providers to be assessed at the Limited Access Level. Other common findings included adjustable exam table and restroom fixtures in older buildings.

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12. 2016 Beacon Audit Report

Gary Robinson presented the 2016 Beacon Audit Report found on page 383. The delegation oversight audit for Beacon Health Systems was conducted in accordance

with the NCQA 2017 standards as well as DHCS contractual standards and covered the period of 1/1/16 through 12/31/16.

Motion: Debbie McAllister Second: Peggy Hoover Approved with changes.

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The audit was an evaluation of eight primary elements of performance: (1) Grievances and Appeals; (2) Member Services; (3) Care Coordination; (4) Utilization Management; (5) Quality Improvement; (6) Credentialing; (7) Health Education and Linguistic Services; and (8) Claims. A CAP was recommended for each element with a rating that fell below 95%.

Element 1 - Grievance and Appeals. This element received a rating of 100%. Element 2 - Member Services. This element resulted in a rating of 38%. A CAP was issued

but upon further documentation provided by Beacon, it was resolved and removed. Element 3 - Care Coordination. Element 3 received a rating of 88%. A CAP was issued but

upon further documentation provided by Beacon, it was resolved and removed. Element 4 - Utilization Management. This element covered 13 subcategories and two

deficiencies were found: Timeliness of Utilization Decisions. However, the overall performance rating for this element was 94% and a CAP was not recommended. This area will continue to be monitored and will be reviewed again during the next audit period.

Element 5 - Quality Improvement. This element received a rating of 100%. Element 6 - Credentialing. This element received a rating of 100%. Element 7 - Health Education and Linguistic Services. This element received a rating of

100%. Element 8 - Claims. This element received a rating of 50%. A CAP was issued but upon

further documentation provided by Beacon, it was resolved and removed. Mary Kerlin commented: Access and availability needs to be added to this audit. Rachael French commented: On page 386, in the first sentence under Scope, “and DHCS” needs to be added after NCQA

standards. VII. Additional Business

Respectfully submitted by Andrea Thomas, Quality Improvement Communications Coordinator Signature of Approval: ____________________________________ Date: ______________________________ Robert Moore, MD, MPH, MBA Chairman

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QI Department Update

March 2018 Prepared by Jess Thacher, Director of Quality and Performance Improvement

Quality Improvement Programs (QIPs) • The 2018 PCP QIP Measurement Set webinar was held on 2/6. There were 38 attendees. • 2018 eReports launched on 3/1 and will offer a demo webinar on 3/14. All eReports usernames and

secret keys are being re-set in order to eliminate separate log-in credentials for provider organizations with multiple sites.

• Partnership Quality Dashboard Module 1 (non-clinical QIP measures) is in the process of loading 2017 Transition Period data to the dashboard. The development team is evaluating data against the Business Requirement Document for Module 4 (eReports/QIP clinical data). A PQD Module 1 Kick-Off webinar is scheduled for 3/22. Following this webinar, providers will be able to access their non-clinical QIP data through PQD.

• The 2018 Palliative Care QIP webinar was held on 2/21. Seven of eight palliative care provider sites attended the webinar.

• Based on 2016-17 evaluation findings, the Hospital QIP team is exploring an opportunity to streamline maternal quality data collection by working directly with the California Maternal Quality Care Collaborative to retrieve data.

• The 2018 LTC QIP Kick-Off webinar was held on 2/14 with about 30 participants. Four additional long-term care facilities have agreed to participate in the 2018 LTC QIP, bringing the total to 68 sites out of 74 contracted with PHC.

• Comprehensive Perinatal Service Providers (CPSP) have until 3/31 to sign up to participate in the Perinatal QIP. The Kick-Off webinar was held on 2/28. PHC will host an in-person meet-and-greet sessions on 3/20 in Fairfield and 3/21 in Redding for sites to learn more about the program.

Healthcare Effectiveness Data Information Set (HEDIS) • The HEDIS 2018 On-Site Audit was completed on 2/15. The On-site Audit is a required HEDIS activity

conducted by our HSAG auditor to validate the accuracy and completeness of our data. Overall, the auditor was pleased at the progress made over the last year.

• The medical record retrieval project is underway. Approximately 1,865 of 14,058 records have been retrieved and reviewed. We are on track to complete the Medical Record project by the NCQA audit deadline of 5/9.

Quality Improvement Trainings • ADVANCE teams will meet in March for the final in-person session to learn about what it means to

be an improvement advisor and how to develop a sustainability and spread plan. • An ABCs of Quality Improvement training will be held on 3/7 in Santa Rosa and on 5/3 in Redding. • In February, QI-EX teams, comprised of PHC QI and Pharmacy staff, presented their test projects

focusing on specific HEDIS measures. Pilot projects included: o Plan-led member outreach to improve MPM rates o Member incentives to improve childhood and adolescent immunization rates o Supplying data and education to select provider sites to improve AMR rates The PI team is in the process of evaluating the program and developing recommendations for next steps. Early learnings included – high efficacy of live calls to improve MPM rates; low member knowledge of importance of lab monitoring tests when taking ACE/ARBs or diuretics, significant impact from updating PHC member contact information with more accurate records from local pharmacy.

• PHC will host a conference on 3/19, Better Health through Better Partnerships: How Health Centers Integrate Their Knowledge of the Community with the Delivery System. This symposium will showcase health centers who have shaped their medical practice and organizational structure around their community and community needs.

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HEDIS Score Improvement – Highlights • The PI team is assisting with two HEDIS improvement projects in the Southwest region focused on

member outreach, including a cervical cancer screening (CCS) media campaign in Lake and Mendocino Counties and a breast cancer screening (BCS) outreach pilot in Marin County. The CCS media campaign is anticipated to launch in April and run through June 2018. The BCS member outreach effort is under development with our clinic partner.

• Four new, local Advance Care Planning (ACP) coalitions were selected to receive grant funding from PHC. Coalition for Compassionate Care of California was engaged as a contractor to provide training and technical assistance to the new coalitions. The selected ACP grantees will receive 18 months of financial, leadership, educational, mentorship, and logistical support to enhance and expand advance care planning in their communities. The new coalitions include: o Humboldt County Advance Care Planning Coalition (HumACP) o My Life. My Way, Lake County Coalition for Advance Care Planning o Siskiyou ACP Coalition “Let’s Talk” o Yolo Coalition to Honor Choices (YCHC)

• Monitoring Patients on Persistent Medications (MPM) PDSA Cycle II for Santa Rosa Community Health Center was submitted to DHCS on 2/16. This highlighted two PDSAs testing patient outreach from 10/1/17-2/16/18. The outreach efforts included live phone calls and mailers, and the interventions were very successful. For the final PDSA cycle (February - June 2018), the clinic will continue to test outreach with an expanded sample size.

• PHC coordinated a Humboldt County Immunization focus group meeting on 3/2. The goal of the meeting was to gather perspective, barriers, and experiences to further improve activities in the Northwest region.

• The Birthday Club pilot at Shasta Community Health Center (SCHC) to improve the rate of Well Child Visits for 3-6 year olds recently concluded. The total number of children targeted was 222. Of the 222 children targeted, 130 were successfully reached. From October through December 2017, a total of 80 members (36.04%) completed exams and received gift cards. Based on these results, Shasta Community was just 1.04% short of hitting the SMART objective goal of a 15% improvement. PHC and SCHC met in February to adopt and expand this pilot across all SCHC sites for April through June 2018. At the same time, PHC and SCHC initiated brainstorming and planning meetings to apply lessons learned for a new intervention targeting the Childhood Immunization (CIS-3) measure. This measure is below MPL in the Northeast.

• With PHC strategic use of reserves funding, Shasta Family YMCA is providing a yearlong Diabetes Prevention Program to decrease the percentage of new Type 2 Diabetes diagnoses. This program will run September 2018 through August 2019. This effort serves as a precursor to the anticipated Diabetes Prevention Program Medi-Cal benefit in 2019.

Quality Compliance and Accreditation • As of 2/22, PHC is 54% compliant with Interim NCQA Survey Requirements. • The Program Management Team will share a plan-wide readiness assessment in April. The purpose

of this is to evaluate where PHC stands relative to Interim Survey Compliance and obtain Executive approval to move forward with our application process.

• Grand Analysis discussion will be presented at the upcoming PRB in March to obtain priority within the organization and assign resources to it.

Patient Safety (1/25 – 2/26) • 30 Potential Quality Issue (PQI) referrals received; 13 PQI cases processed and closed; and 53 open

PQI cases. • 5 Facility Site Reviews (FSR) conducted and 6 Medical Record Reviews (MRR) conducted. • 1 FSR Corrective Action Plan (CAP) issued and 2 MRR CAPs issued.

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Policy/Procedures/Guidelines Old Number

New Assigned Number

Comments Provider Manual

Reminder - Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting date.

Health Services – Care Coordination

Chronic Kidney Disease (CKD) Program Description

Archived

MCCD2012 Archived – Information included in MCCP2007

X

Health Services – Utilization Management

Health Services Review of Non-admission In-hospital Obstetrical Evaluations (Solano County)

MCUP3017 Regular review; no changes to policy content

X

Infant Monitor Guidelines MCUG3023 Regular review; no changes to guideline content

X

Medical Nutrition Services

Attachments: no changes

A. Referral Guidelines for Children/ Adolescents

B. Referral Guidelines for Adults C. Adult Body Mass Index


X

Utilization Review Guidelines ICF/DD, ICF/DD-H, ICF/DD-N Facilities

Attachment: unchanged

A. Bed hold/TAR Process

MCUG3058 Regular review; language corrections added for clarity (specification of calendar or business days)

X

Sterilization Consent Protocol

Attachment: no to policy

A. DHCS Form PM 330 – Consent Form

MCUP3119 Regular review; language corrections added for clarity (specification of calendar or business days)

X

Podiatry Services MPUP3129 Regular review; no changes to policy content

X

Waiver Programs MCUP3106 Regular review: Extensive updates vs. DHCS contractual obligations – addition of 4 descriptions - HCBS Waiver Programs, referral information updated; Federal citation removed (not the HealthPlan’s obligation); References updated

X

Prenatal & Perinatal Care MCUG3118 Regular review; language clarifications added; references regarding provider referrals of pregnant women to PHC’s Growing Together Perinatal Program updated to PHC’s Care Coordination Dept. for ongoing support; section qualifying Requirements removed – Amer. College of Obstetricians & Gynecologists (ACOG) and Comprehensive Perinatal Services Program (CPSP) Program Guidelines should be followed

X

PHCSystem Updates

April 2018

33 of 97

Policy/Procedures/Guidelines Old Number

New Assigned Number

Comments Provider Manual

Pain Management Specialty Services

Attachments: updated

A. PHC Treatment Auth. Request Requirements

B. PHC Medical Necessity Criteria for Pain Management Procedures


Attachments A & B updated

X

34 of 97

PARTNERSHIP HEALTHPLAN OF CALIFORNIA

POLICY / PROCEDURE

Page 1 of 5

Policy/Procedure Number: MCUP3106 Lead Department: Health Services

Policy/Procedure Title: Waiver Programs ☒External Policy

☐ Internal Policy

Original Date: 04/21/2010 Next Review Date: 11/16/201704/11/2019

Last Review Date: 11/16/201604/11/2018

Applies to: ☒ Medi-Cal ☐ Healthy Kids ☐ Employees

Reviewing

Entities:

☒ IQI ☐ P & T ☒ QUAC

☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving

Entities:

☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC

☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER

Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 11/16/201604/11/2018

I. RELATED POLICIES:

A. County specific Regional Center MOUsMemoranda of Understanding (MOUs) for specific geographical

areas

II. IMPACTED DEPTS:

A. Health Services

B. Claims

C. Member Services

III. DEFINITIONS:

A. HCBS: Home and Community Based Services

B. DHCS: Department of Health Care Services

C. IHO: In-Home Operations Waiver

A.D. DDS: Department of Developmental Services N/A

IV. ATTACHMENTS:

A. N/A

V. PURPOSE: State and Federal Waiver Programs ensure members who may benefit from Medi-Cal Home and Community

Based Services (HCBS) Waiver Programs are identified and referred for medical care coordination and care

management.

VI. POLICY / PROCEDURE:

A. The Department of Health Care Services (DHCS) administers a number of HCBS Waiver Programs.

These waiver programs include:

1. In-Home Operations Waiver (IHO)

2. Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) Home and

Community Based Services Medi-Cal Waiver Program

3. Home and Community Based Services Waiver for the Developmentally Disabled

4. Assisted Living Waiver (ALW)

5. Home and Community-Based Alternatives (HCB Alternatives) Waiver (previously titled Nursing Facility/Acute Hospital Waiver

6. Multipurpose Senior Services Program (MSSP) Waiver

3.7. Partners for Children (PFC) Pediatric Palliative Care (PPC) Waiver Program

Partnership HealthPlan of California (PHC)’s providers and/or its Utilization Management (UM)/Care

35 of 97


Policy/Procedure Title: Waiver Programs ☒ External Policy

☐ Internal Policy


Last Review Date: 11/16/201604/11/2018


Page 2 of 5

Coordination staff identify and refer members who are eligible for Waiver Programs. Members are not

disenrolled from PHC when enrolled in a waiver program.

B. Criteria Used For Identification

1. The Primary Care Provider (PCP), Specialist, and/or PHC Care Coordination/ Utilization

Management Departments refer members to Waiver Programs.

2. Persons with developmental disabilities are identified through coordination with the regional centers

and in the course of utilization and case management services. Members with developmental

disabilities who may meet the requirements for participation in this waiver are referred to the HCBS

administered by the State Department of Developmental Services (DDS).

C. Referrals

1. The PCP requests prior authorization for services from the appropriate State Waiver Program and

provides all appropriate medical information. The PCP may request assistance from the Care

Coordination department for the following:

a. Facilitating authorization from appropriate Waiver Program(s)

b. Completion of the Waiver Program application

c. Follow up on status of acceptance to appropriate Waiver Program(s)

d. Medical care coordination of member while awaiting acceptance and/or placement into a

Waiver Program

Note: No member may be enrolled in more than one HCBS Waiver Program at a time.

PHC maintains the responsibility to provide comprehensive care management and authorize all

medically necessary covered services for members including those accepted into the Waiver

Programs. The PCP will continue to treat and coordinate treatment for the member.

2. Referrals for the In-Home Waiver Program are made via telephone or mail:

In-Home Operations SectionBranch

1501 Capitol Avenue

MS 4502

P.O. Box 942732, 97437Mail Stop 4502

Sacramento, CA 95899-74374234-7320

(916) 552-9105 in Sacramento

(213) 897-6774 in Los Angeles

Fax: (916) 552-91459149

3. Referrals toFor the HIV/AIDS Home and Community Based ServicesMedi-Cal Waiver Program

(MCWP)m, patients should be referred to a MCWP Provider in their county (or if their county does

not have an MCWP are made by requesting a HIV/AIDS Waiver Program Application

from:provider, they may be referred to a nearby county that participates in the MCWP). A list of

MCWP Providers can be found here: https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/MCWPProviderList.pdf

Information for the AIDS Medi-Cal Waiver Program is posted on this website:

https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_care_mcwp.aspx

Through this waiver program, local agencies provide home and community based services as an alternative to nursing

facility care or hospitalization. The agencies are under contract with the

California Department of Health ServicesCalifornia Department of Public Health

Office of AIDS

Community-Based Care Section

MS 7700

P.O. Box 997426

Sacramento, CA 95899-7426

(916) 449-5900

36 of 97

https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/MCWPProviderList.pdf

https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_care_mcwp.aspx



☐ Internal Policy


Last Review Date: 11/16/201604/11/2018


Page 3 of 5

4. Referrals Members who may qualify for services through to the Persons withthe Home and

Community Based Services Waiver for the Developmentally Disabledilities who may qualify for

services are referred to the Regional Center responsible for their geographic area as followsor to:

a. Alta California Regional Center (provides services in Yolo county)

2241 Harvard Street, Suite 100

Sacramento, CA 95815

(916) 978-6400

b. Far Northern Regional Center (provides services in Lassen, Modoc, Shasta, Siskiyou and

Trinity counties)

1900 Churn Creek Road

Redding, CA 96002

(530) 222-4791

c. Golden Gate Regional Center (provides services in Marin county)

4000 Civic Center Drive, Suite 310

San Rafael, CA 94903

(415) 446-3000

d. North Bay Regional Center (provides services in Solano, Napa, and Sonoma counties)

Solano/ Napa Sonoma

610 Airpark Road 2351 Mendocino Avenue

Napa, CA 94558 Santa Rosa, CA 95403

(707) 256-1100 (707) 569-2000

e. Redwood Coast Regional Center (provides services in Del Norte, Humboldt, Lake, and

Mendocino counties)

Del Norte Humboldt

1301-A Northcrest Drive 525 2nd Street, Suite 300

Crescent City, CA 95531 Eureka, CA 95501

(707) 464-7488 (707) 445-0893

Lake Mendocino

180 3rd Street 270 Chestnut Street, Suite A

Lakeport, CA 95453 Fort Bragg, CA 95437

(707) 262-0470 (707) 964-6387

Contact information for the State agency is as follows:

California Department of Developmental Services (DDS)

1600 9th Street

Sacramento, CA 95814

Mailing Address:

P. O. Box 944202


Info: (916) 654-1690

TTY: (916) 654-2054

5. The Assisted Living Waiver (ALW) program is only offered in certain counties. Sonoma County is

currently the only county which PHC serves that provides ALW services. A list of all participating

facilities can be found at this webpage:

http://www.dhcs.ca.gov/services/ltc/Documents/ListofRCFEfacilities.pdf

Additional downloadable forms related to the ALW program can be found at this website:

http://www.dhcs.ca.gov/services/ltc/Pages/Assisted-Living-Waiver-Provider-Resources.aspx

How to enroll: Medi-Cal members do not submit applications. Medi-Cal members are enrolled

through Care Coordination Agencies, which are providers within the ALW program. Full scope

37 of 97

http://www.dhcs.ca.gov/services/ltc/Documents/ListofRCFEfacilities.pdf

http://www.dhcs.ca.gov/services/ltc/Pages/Assisted-Living-Waiver-Provider-Resources.aspx



☐ Internal Policy


Last Review Date: 11/16/201604/11/2018


Page 4 of 5

Medi-Cal members must contact a Care Coordination Agency, which determines each individual's

care needs. Assessments are done by registered nurses employed by a Care Coordination Agency

(CCA). A list of these agencies by county can be found on this webpage:

http://www.dhcs.ca.gov/services/ltc/Documents/CareCoordinationAgencies2017.pdf

NorCal Care Coordinator Agency (Alameda, Contra Costa, Sacramento, San Francisco, San

Joaquin, San Mateo, Santa Clara and Sonoma Counties):

6060 Sunrise Drive, Suite 3350 Citrus Heights, CA 95610-7099

Debbie Brooke (916) 385-2784

Yolanda Nixon (925) 519-6100 FAX (916) 512-3473

Debbie Brooke and Yolanda Nixon, Owners [email protected] [email protected]

Assisted Living Waiver Program

Department of Health Care Services

Long-Term Care Division

1501 Capitol Avenue, MS 4503

PO Box 997437


ALW Hotline (916) 552-9322

6. The Home and Community-Based Alternatives (HCB Alternatives) Waiver (previously titled

Nursing Facility/Acute Hospital Waiver) provides care management services at home to Medi-Cal

beneficiaries with high level needs who would otherwise receive care in a facility. Some of the

services that may be provided to support Waiver participants in the community include, but are not

limited to: in-home nursing services, waiver personal care services, family/caregiver training, home

or facility respite, habilitation services, community transition services, environmental accessibility

adaptation, medical equipment operating expenses, personal Emergency Response System (PERS)

installation, testing, and operation. The application for the program can be found here:

http://www.dhcs.ca.gov/services/ltc/Documents/HCBA_Application.pdf

When complete, mail this application to the following address:

Integrated Systems of Care Division

HCBS Programs Eligibility/Intake Unit

311 South Spring Street, Ste. 800

Los Angeles, CA 90013

Or submit the application by FAX: (213) 620-4448

7. Referrals for the Multipurpose Senior Services Program (MSSP) Waiver program are made by

sending the Medi-Cal Member (who is 65 years or older) to a local MSSP site in the county

where the Member resides. MSSP site staff will make a certification determination based upon

Medi-Cal criteria. A list of MSSP sites can be found here:

https://www.aging.ca.gov/ProgramsProviders/MSSP/Contacts/

8. The Partners for Children (PFC) Pediatric Palliative Care (PPC) Waiver Program is offered in

participating counties as noted on this webpage:

http://www.dhcs.ca.gov/services/ppc/Pages/CCSProgram.aspx

Marin and Sonoma County are currently the only counties which PHC serves that participate. The

program offers supportive services for eligible children with life-limiting or life-threatening illnesses

and their families. These services are provided by local participating hospice and home health agencies. General information about PPC Waiver Program can be found on this web page:

http://www.dhcs.ca.gov/services/ppc/Pages/default.aspx

Members whose family may benefit from this program should talk to their PCP. The child’s doctor

will provide information about the child’s medical condition to the County CCS office. The CCS

38 of 97

http://www.dhcs.ca.gov/services/ltc/Documents/CareCoordinationAgencies2017.pdf

mailto:[email protected]

http://www.dhcs.ca.gov/services/ltc/Documents/HCBA_Application.pdf

https://www.aging.ca.gov/ProgramsProviders/MSSP/Contacts/

http://www.dhcs.ca.gov/services/ppc/Pages/CCSProgram.aspx

http://www.dhcs.ca.gov/services/ppc/Pages/default.aspx



☐ Internal Policy


Last Review Date: 11/16/201604/11/2018


Page 5 of 5

office will determine if the child is eligible and contact the family with more details and to set up a

meeting to talk about enrollment.

VII. REFERENCES: Regulatory: Title 22 California Code of Regulations (CCR) Section 1915 (c)

DHCS Contract: Exhibit A, Attachment 11, Provisions 11.C. and 15.A. and B. aAttachment 18, Provision

11.U and Exhibit A, Attachment 18, Provisions 11.M, S, and X.Attachment 11, Provision 9.C

VIII. DISTRIBUTION:

A. PHC Department Directors

B. PHC Provider Manual

IX. POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services

X. REVISION DATES: 11/28/12; 01/20/16; 11/16/16; *04/11/18

*Through 2017, Approval Date reflective of the Quality/Utilization Advisory Committee meeting

date. Effective January 2018, Approval Date reflects that of the Physician Advisory Committee’s meeting

date.

PREVIOUSLY APPLIED TO: N/A

*********************************

In accordance with the California Health and Safety Code, Section 1363.5, this policy was developed with

involvement from actively practicing health care providers and meets these provisions:

Consistent with sound clinical principles and processes

Evaluated and updated at least annually

If used as the basis of a decision to modify, delay or deny services in a specific case, the criteria will be

disclosed to the provider and/or enrollee upon request

The materials provided are guidelines used by PHC to authorize, modify or deny services for persons with similar

illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits

covered under PHC.

PHC’s authorization requirements comply with the requirements for parity in mental health and substance use

disorder benefits in 42 CFR 438.910.

39 of 97


POLICY / PROCEDURE

Page 1 of 5


Policy/Procedure Title: Waiver Programs ☒External Policy ☐ Internal Policy

Original Date: 04/21/2010 Next Review Date: 04/11/2019 Last Review Date: 04/11/2018

Applies to: ☒ Medi-Cal ☐ Employees

Reviewing Entities:

☒ IQI ☐ P & T ☒ QUAC

☐ OPERATIONS ☐ EXECUTIVE ☐ COMPLIANCE ☐ DEPARTMENT

Approving Entities:

☐ BOARD ☐ COMPLIANCE ☐ FINANCE ☒ PAC

☐ CEO ☐ COO ☐ CREDENTIALING ☐ DEPT. DIRECTOR/OFFICER

Approval Signature: Robert Moore, MD, MPH, MBA Approval Date: 04/11/2018

I. RELATED POLICIES:

Regional Center Memoranda of Understanding (MOUs) for specific geographical areas

II. IMPACTED DEPTS: A. Health Services B. Claims C. Member Services

III. DEFINITIONS:

A. HCBS: Home and Community Based Services B. DHCS: Department of Health Care Services C. IHO: In-Home Operations Waiver D. DDS: Department of Developmental Services

IV. ATTACHMENTS: A. N/A

V. PURPOSE: State and Federal Waiver Programs ensure members who may benefit from Medi-Cal Home and Community Based Services (HCBS) Waiver Programs are identified and referred for medical care coordination and care management.

VI. POLICY / PROCEDURE:

A. The Department of Health Care Services (DHCS) administers a number of HCBS Waiver Programs. These waiver programs include: 1. In-Home Operations Waiver (IHO) 2. Acquired Immune Deficiency Syndrome (AIDS) Medi-Cal Waiver Program 3. Home and Community Based Services Waiver for the Developmentally Disabled 4. Assisted Living Waiver (ALW) 5. Home and Community-Based Alternatives (HCB Alternatives) Waiver (previously titled Nursing

Facility/Acute Hospital Waiver 6. Multipurpose Senior Services Program (MSSP) Waiver 7. Partners for Children (PFC) Pediatric Palliative Care (PPC) Waiver Program Partnership HealthPlan of California (PHC)’s providers and/or its Utilization Management (UM)/Care Coordination staff identify and refer members who are eligible for Waiver Programs. Members are not disenrolled from PHC when enrolled in a waiver program.

40 of 97


Policy/Procedure Title: Waiver Programs ☒ External Policy ☐ Internal Policy



Page 2 of 5

B. Criteria Used For Identification 1. The Primary Care Provider (PCP), Specialist, and/or PHC Care Coordination/ Utilization

Management Departments refer members to Waiver Programs. 2. Persons with developmental disabilities are identified through coordination with the regional centers

and in the course of utilization and case management services. Members with developmental disabilities who may meet the requirements for participation in this waiver are referred to the HCBS administered by the State Department of Developmental Services (DDS).

C. Referrals 1. The PCP requests prior authorization for services from the appropriate State Waiver Program and

provides all appropriate medical information. The PCP may request assistance from the Care Coordination department for the following: a. Facilitating authorization from appropriate Waiver Program(s) b. Completion of the Waiver Program application c. Follow up on status of acceptance to appropriate Waiver Program(s) d. Medical care coordination of member while awaiting acceptance and/or placement into a

Waiver Program Note: No member may be enrolled in more than one HCBS Waiver Program at a time. PHC maintains the responsibility to provide comprehensive care management and authorize all medically necessary covered services for members including those accepted into the Waiver Programs. The PCP will continue to treat and coordinate treatment for the member.

2. Referrals for the In-Home Waiver Program are made via telephone or mail: In-Home Operations Branch 1501 Capitol Avenue MS 4502 P.O. Box 997437 Sacramento, CA 95899-7437 (916) 552-9105 in Sacramento (213) 897-6774 in Los Angeles Fax: (916) 552-9149

3. For the AIDS Medi-Cal Waiver Program (MCWP), patients should be referred to a MCWP Provider in their county (or if their county does not have an MCWP provider, they may be referred to a nearby county that participates in the MCWP). A list of MCWP Providers can be found here: https://www.cdph.ca.gov/Programs/CID/DOA/CDPH%20Document%20Library/MCWPProviderList.pdf Information for the AIDS Medi-Cal Waiver Program is posted on this website: https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_care_mcwp.aspx Through this waiver program, local agencies provide home and community based services as an alternative to nursing facility care or hospitalization. The agencies are under contract with the

California Department of Public Health Office of AIDS

(916) 449-5900 4. Members who may qualify for services through the Home and Community Based Services Waiver

for the Developmentally Disabled are referred to the Regional Center responsible for their geographic area as follows: a. Alta California Regional Center (provides services in Yolo county)

2241 Harvard Street, Suite 100 Sacramento, CA 95815 (916) 978-6400

41 of 97





Page 3 of 5

b. Far Northern Regional Center (provides services in Lassen, Modoc, Shasta, Siskiyou and Trinity counties)

1900 Churn Creek Road Redding, CA 96002 (530) 222-4791

c. Golden Gate Regional Center (provides services in Marin county) 4000 Civic Center Drive, Suite 310 San Rafael, CA 94903 (415) 446-3000

d. North Bay Regional Center (provides services in Solano, Napa, and Sonoma counties) Solano/ Napa Sonoma 610 Airpark Road 2351 Mendocino Avenue Napa, CA 94558 Santa Rosa, CA 95403 (707) 256-1100 (707) 569-2000

e. Redwood Coast Regional Center (provides services in Del Norte, Humboldt, Lake, and Mendocino counties) Del Norte Humboldt 1301-A Northcrest Drive 525 2nd Street, Suite 300 Crescent City, CA 95531 Eureka, CA 95501 (707) 464-7488 (707) 445-0893

Lake Mendocino 180 3rd Street 270 Chestnut Street, Suite A Lakeport, CA 95453 Fort Bragg, CA 95437 (707) 262-0470 (707) 964-6387

Contact information for the State agency is as follows: California Department of Developmental Services (DDS) 1600 9th Street Sacramento, CA 95814 Mailing Address: P. O. Box 944202 Sacramento, CA 94244-2020 Info: (916) 654-1690 TTY: (916) 654-2054

5. The Assisted Living Waiver (ALW) program is only offered in certain counties. Sonoma County is currently the only county which PHC serves that provides ALW services. A list of all participating facilities can be found at this webpage: http://www.dhcs.ca.gov/services/ltc/Documents/ListofRCFEfacilities.pdf Additional downloadable forms related to the ALW program can be found at this website: http://www.dhcs.ca.gov/services/ltc/Pages/Assisted-Living-Waiver-Provider-Resources.aspx How to enroll: Medi-Cal members do not submit applications. Medi-Cal members are enrolled through Care Coordination Agencies, which are providers within the ALW program. Full scope Medi-Cal members must contact a Care Coordination Agency, which determines each individual's care needs. Assessments are done by registered nurses employed by a Care Coordination Agency (CCA). A list of these agencies by county can be found on this webpage: http://www.dhcs.ca.gov/services/ltc/Documents/CareCoordinationAgencies2017.pdf

NorCal Care Coordinator Agency (Alameda, Contra Costa, Sacramento, San Francisco, San Joaquin, San Mateo, Santa Clara and Sonoma Counties): 6060 Sunrise Drive, Suite 3350 Citrus Heights, CA 95610-7099

42 of 97





Page 4 of 5

Debbie Brooke (916) 385-2784 Yolanda Nixon (925) 519-6100 FAX (916) 512-3473 Debbie Brooke and Yolanda Nixon, Owners [email protected] [email protected]

Assisted Living Waiver Program Department of Health Care Services Long-Term Care Division 1501 Capitol Avenue, MS 4503 PO Box 997437 Sacramento, CA 95899-7413 ALW Hotline (916) 552-9322

6. The Home and Community-Based Alternatives (HCB Alternatives) Waiver (previously titled Nursing Facility/Acute Hospital Waiver) provides care management services at home to Medi-Cal beneficiaries with high level needs who would otherwise receive care in a facility. Some of the services that may be provided to support Waiver participants in the community include, but are not limited to: in-home nursing services, waiver personal care services, family/caregiver training, home or facility respite, habilitation services, community transition services, environmental accessibility adaptation, medical equipment operating expenses, personal Emergency Response System (PERS) installation, testing, and operation. The application for the program can be found here: http://www.dhcs.ca.gov/services/ltc/Documents/HCBA_Application.pdf When complete, mail this application to the following address: Integrated Systems of Care Division HCBS Programs Eligibility/Intake Unit 311 South Spring Street, Ste. 800 Los Angeles, CA 90013 Or submit the application by FAX: (213) 620-4448

7. Referrals for the Multipurpose Senior Services Program (MSSP) Waiver program are made by sending the Medi-Cal Member (who is 65 years or older) to a local MSSP site in the county where the Member resides. MSSP site staff will make a certification determination based upon Medi-Cal criteria. A list of MSSP sites can be found here: https://www.aging.ca.gov/ProgramsProviders/MSSP/Contacts/

8. The Partners for Children (PFC) Pediatric Palliative Care (PPC) Waiver Program is offered in participating counties as noted on this webpage: http://www.dhcs.ca.gov/services/ppc/Pages/CCSProgram.aspx Marin and Sonoma County are currently the only counties which PHC serves that participate. The program offers supportive services for eligible children with life-limiting or life-threatening illnesses and their families. These services are provided by local participating hospice and home health agencies. General information about PPC Waiver Program can be found on this web page: http://www.dhcs.ca.gov/services/ppc/Pages/default.aspx Members whose family may benefit from this program should talk to their PCP. The child’s doctor will provide information about the child’s medical condition to the County CCS office. The CCS office will determine if the child is eligible and contact the family with more details and to set up a meeting to talk about enrollment.

VII. REFERENCES:

DHCS Contract: Exhibit A, Attachment 11, Provisions 11.C. and 15.A. and B. and Exhibit A, Attachment 18, Provisions 11.M, S, and X.

43 of 97

Attachment A - MCUP3041 Attachment A - MCUP3049 Attachment B - MCUG3007

(TAR to be submitted by the provider performing the service) Revised 08/16/201704/11/2018

Page 1 of 8

PHC TAR REQUIREMENTS

A. Hospitalization 1. The hospital must notify PHC of any admission within 24 hours of the admission. 2. Authorization for elective admission must be requested by the admitting physician prior to the admission.

B. Long Term Care

The LTC facilities must notify PHC of any admissions, transfer, bed hold/ leave of absence, or change in payor status within one working day. (Examples include Medicare non-coverage or exhaustion of benefits / hospice election.)

C. Outpatient Surgical Procedures – see CPTs Requiring TAR list

D. Pain Management – see CPTs Requiring TAR list

E. Outpatient Hemo / Peritoneal Dialysis

(Note: initial authorization will be limited to 90 days and a lifetime TAR will be granted only after submission of Medicare determination.)

F. Drugs and Pharmaceuticals – A TAR is required for all prescription drugs, over-the-counter drugs and injectable drugs (including drugs compounded for IV infusion therapy) not on the PHC formulary.

PLEASE REFER TO PHC FORMULARY

G. Diagnostic Studies

♦ CT Scans (Except 76497) ♦ MRI (Except 76494, 76380, 76506) ♦ Cardiac MRI - 75561 only (effective 08/01/2017) ♦ MRA ♦ PET scan ♦ Transcranial Doppler ♦ Sleep Studies / Polysomnography

H. Ancillary / Support Services

RAF authorizes one visit only. Requests for additional visits require the ancillary service provider to submit copies of initial evaluation and treatment plan attached to TAR. TAR must include total visits requested including initial visit.

♦ Acupuncturist Speech Therapy ♦ Chiropractor Occupational Therapy ♦ Faith Healer Home Infusion Therapy (Nursing Component Only) ♦ Physical Therapy Home Health Care

I. Hospice Care (Inpatient Only)

44 of 97

lblacks

Text Box

Excerpt - Pages 4 - 8 removed from Attachment (no changes)



Page 2 of 8


J. Pulmonary Rehabilitation K. Hyperbaric Oxygen Pressurization

L. Non-Emergency Medical Transportation

M. EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Supplemental Services

N. Phototherapy for dermatological condition

O. Dental Anesthesia

P. CCS/GHPP - Authorization for services related to eligible condition(s) must be requested from

CCS or GHPP office(s). Q. Supplies / Equipment

♦ Orthotics – Cumulative costs for repair/maintenance or purchase exceeds $250 / item ♦ Prosthetics – Cumulative costs for repair / maintenance or purchase exceeds $500 / item

And any unlisted / miscellaneous code including: - L0999 Addition to spinal orthosis, not otherwise specified - L1499 Spinal orthosis, not otherwise specified - L2999 Lower extremity orthosis, not otherwise specified - L3649 Orthotic shoe, modification, addition or transfer, not otherwise specified - L3999 Upper limb orthosis, not otherwise specified - L5999 Lower extremity prosthesis, not otherwise specified - L7499 Upper extremity prosthesis, not otherwise specified - L8039 Breast prosthesis, not otherwise specified - L8499 Unlisted procedure for miscellaneous prosthetic services - L8699 Prosthetic implant, not otherwise specified ANY CUSTOM MADE ITEM THAT DOES NOT HAVE A MEDI-CAL RATE (BY-REPORT OR BY-INVOICE)

♦ Ostomy Supplies – If monthly cumulative cost for all related supplies exceeds $150 ♦ Hearing Aid – All purchases, rentals or repairs exceeding $50 / item

(Batteries are non-covered except some CCS / EPSDT cases, in which case TAR is required)

♦ Oxygen and related supplies ♦ Diabetic Supplies are to be provided by Pharmacies ONLY ♦ Nebulizers – When the billed price including tax is $100 or more ♦ Medical Supplies – (If dispensed by PHARMACY, please refer to formulary) ♦ DME – (If dispensed by PHARMACY, please refer to formulary)

- Repairs or maintenance over $250.00 / item (Out of guarantee repairs are to be guaranteed for at LEAST three (3) months from the date of repair. Reimbursement will NOT be allowed for parts or labor during a guarantee period if due to a defect in material or workmanship)

- Purchase items when the cumulative cost of items within a group exceeds over $100.00 within the calendar month. / item Providers may refer to the Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates section in the Medi-Cal manual to determine if items are related within a group. Items grouped together under specific headings, such as “Hospital Beds” or “Bathroom Equipment,” are considered within the same group. (Vendor to guarantee for a MINIMUM of six (6) months from the date of purchase)

- Rental items when the cumulative cost of rental for items within the group exceeds over

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Page 3 of 8


$50.00 / month / itemwithin a 15-month period. This includes any daily amount that an individual item, or a combination of a similar group of DME items, exceeds the $50 threshold. The 15-month period begins on the date the first item is rented. (Rental rate includes equipment related supplies.)

- Any unlisted or miscellaneous code - Purchase of any wheelchairs for Medi-Medi members

♦ Incontinence Supplies

- Incontinence supplies if monthly cumulative cost for all related supplies exceeds $125.00 - Washes and creams for members with incontinence will only be authorized if the physician

justifies medical necessity ♦ Nutritional Supplements (Submit TAR to Pharmacy) ♦ AND any unlisted or miscellaneous code

R. Genetic Testing – A TAR is required for certain genetic testing as outlined in Attachment A of the Genetic Testing policy MCUP3131.

S. Gender Dysphoria– A TAR is required for all procedures related to gender dysphoria. T. Fecal Microbiota Transplant (FMT)

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Medical Necessity Criteria for Pain Management Procedures MCUG3007 Authorization of Ambulatory Procedures and Services - Attachment C MCUP3049 Pain Management Specialty Services – Attachment B 03/15/201704/11/2018

Page 2 of 3

63650 thru 63688 Insertion, revision, or removal of spinal neurostimulator

Covered for the following conditions after a temporary stimulator in the epidural space demonstrates at least 50% relief of pain documented by a pain log for a minimum 48 hour trial: 1. Failed back syndrome with low back pain and significant

radicular pain; 2. Complex regional pain syndrome 3. Last resort treatment for severe chronic neuropathic pain

resulting from actual damage to peripheral nerves, lumbosacral arachnoiditis and radiculopathies, phantom limb/stump pain, peripheral neuropathy, or incomplete spinal cord injury that is refractory to 12 or more months of standard therapy.

64479 to 64484 Transforaminal epidural injection

Same as InterQual except: remove requirement for documentation of trial of NSAIDS; 1. Progress note must document a history of radicular symptoms

and imaging must document nerve root impingement. If MRI shows spinal stenosis with no significant impingement, epidural injection is not medically indicated.

2. A minimum of 30 days conservative treatment before eligible for epidural steroid injection.

3. For repeat injections, a minimum of 50% improvement in pain symptoms lasting 8 weeks from the prior epidural injection is required.

4. Maximum of 2 levels of transforaminal epidural injections of the spine per 3 months. This may be 2 levels on the same side or 1 level bilaterally.

5. The interval between injections must be no more frequently than every 2 months, and the maximum number of injections per site is 3 per year.

64490 to 64495 Paravertebral facet injections and medial branch blocks

Initial injection: Same as InterQual criteria, except documentation of physical therapy for 6 weeks and NSAIDs are not needed. 1. Patient must have a minimum of 12 weeks of symptoms

consistent with facet joint pain. 2. The progress note should document a physical examination of

the back, including pain elicited with movement. 3. No more than 3 levels will be approved, either 3 levels

unilaterally or 3 levels bilaterally. 4. Maximum of 2 MBB per level per year.

For Repeat Injections:, Aa pain log must be submitted showing that the pain relief from the previous injection was consistent with the anesthetic agent used, with documentation of at least 50% reduction in pain. For example, for a pure bupivacaine block, this is about 2‐3 hours; bupivacaine plus minimal dose steroid block could be up to 3‐4 days for medial branch blocks versus a month to several months for facet joint block.

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lblacks

Text Box

Excerpt - no changes to pages 1 or 3 of 3

UTILIZATION MANAGEMENT - PHYSICIAN REVIEW

#Inter-Rater Physician

Review 07/2017 -

12/2017Total

TARs

Process

Errors

No

Process

Errors

%Could not

determine

Inter-Rater

Physician

Review

07/2017 -

12/2017Total

TARs

Criteria

Did not

Agree

Criteria

Agreed

%Could not

determine

1 5 0 5 100.0% 0 1 5 0 5 100.0% 0

2 5 0 5 100.0% 0 2 5 0 5 100.0% 0

3 5 0 5 100.0% 0 3 5 0 5 100.0% 0

4 5 0 5 100.0% 0 4 5 1 4 80.0% 0

5 5 0 5 100.0% 0 5 5 0 5 100.0% 0

6 5 0 5 100.0% 0 6 5 0 5 100.0% 0

7 5 0 5 100.0% 0 7 5 0 5 100.0% 0

8 5 1 4 80.0% 0 8 5 0 5 100.0% 0

Process Compliance 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 80.0%

Criteria Compliance 100.0% 100.0% 100.0% 80.0% 100.0% 100.0% 100.0% 100.0%

Target Compliance Rate 90% 90% 90% 90% 90% 90% 90% 90%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

1 2 3 4 5 6 7

PROCESS/CRITERIA/TARGET COMPLIANCE RATE

Process Compliance Criteria Compliance Target Compliance Rate

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UTILIZATION MANAGEMENT - INPATIENT INTER - RATER RELIABILITY -JULY THRU DECEMBER 2017

Month Total TARs Eligibility TimelinessCouldn't

Determine

Free from

Error% Total TARs

Criteria

Did not

Agree

Criteria

Agreed %

Couldn't

Determine

* Jul #DIV/0! #DIV/0!

* Aug #DIV/0! #DIV/0!

* Sep #DIV/0! #DIV/0!

Oct 50 1 0 0 49 98.0% 50 3 47 94.0% 0

Nov 50 0 2 0 48 96.0% 50 4 46 92.0% 0

Dec 60 2 0 0 58 96.7% 60 5 55 91.7% 0

Month Jul Aug Sep Oct Nov Dec

Process

Compliance #DIV/0! #DIV/0! #DIV/0! 98.0% 96.0% 96.7%

Criteria

Compliance#DIV/0! #DIV/0! #DIV/0! 94.0% 92.0% 91.7%

Target

Compliance

Rate

90% 90% 90% 90% 90% 90%

**DUE TO IMPLEMENTATION OF ESSETTE MANAGEMENT DEFERRED THE IRRS UNTIL OCTOBER 2017

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Jul Aug Sep Oct Nov Dec

Process Compliance/Criteria Compliance/Target Compliance


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UTILIZATION MANAGEMENT - OUTPATIENT INTER - RATER RELIABILITY -JULY THRU DECEMBER 2017

Month Total TARs Eligibility TimelinessCouldn't

Determine

Free from

Error% Total TARs

Criteria

Did not

Agree

Criteria

Agreed %

Couldn't

Determine

* Jul #DIV/0! #DIV/0!

* Aug #DIV/0! #DIV/0!

* Sep #DIV/0! #DIV/0!

Oct 30 0 1 0 29 96.7% 30 1 29 96.7% 0

Nov 30 0 1 0 29 96.7% 30 0 30 100.0% 0

Dec 30 0 1 0 29 96.7% 30 1 29 96.7% 0

Month Jul Aug Sep Oct Nov Dec

Process

Compliance #DIV/0! #DIV/0! #DIV/0! 96.7% 96.7% 96.7%

Criteria

Compliance#DIV/0! #DIV/0! #DIV/0! 96.7% 100.0% 96.7%

Target

Compliance

Rate

90% 90% 90% 90% 90% 90%

**DUE TO IMPLEMENTATION OF ESSETTE MANAGEMENT DEFERRED THE IRRS UNTIL OCTOBER 2017

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Jul Aug Sep Oct Nov Dec

Process Compliance/Criteria Compliance/Target Compliance


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Report Title: RAF Volume - Manual vs Electronic (Summary)

Region Input Source Count Auths Percentage

Northern Region Electronic 30,142 98.52%

Manual (Amisys) 453 1.48%

Northern Region Region Total: 30,595 30.31%

Region Input Source Count Auths Percentage

Southern Region Electronic 69,810 99.24%

Manual (Amisys) 532 0.76%

Southern Region Region Total: 70,342 69.69%

Grand Total: 100,937 100.00%

Entered Between: 7/1/17 - 12/30/17

Report Name/Date: Manual vs Electronic - RAF Volume - 2/7/18

Outpatient RAF Statistics:

Total Outpatient RAF Volume: 100,937

Total Manual (Amisys) RAFs: 985

Total Electronic RAFs: 99,952

Percent of Manual (Amisys) RAFs: 0.98%

Percent of Electronic RAFs: 99.02%

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kryan

Highlight

kryan

Highlight

UTILIZATION MANAGEMENT - DENIED TARS BY REGION 07-01-17_12-31-17

NORTHSTATUS DESCRIPTION INPATIENT OUTPATIENT

DENIED - PER MEDICAL REVIEW 12 1162 1174

Needs CCS authorization 249 112 361

Adminstrative Denials (No TAR Required, Not a Benefit, Not Accepted, Not Timely, Other Ins., Req. Info Not Recvd.)397 1484 1881

TOTAL TARS 658 2758 3416

SOUTHSTATUS DESCRIPTION INPATIENT OUTPATIENT

DENIED - PER MEDICAL REVIEW 44 527 571

Needs CCS authorization 349 261 610

Adminstrative Denials (No TAR Required, Not a Benefit, Not Accepted, Not Timely, Other Ins., Req. Info Not Recvd.)1073 4526 5599

TOTAL TARS 1466 5314 6780

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CLASS Jul Aug Sep Oct Nov Dec Total:

MediCal: INPATIENT 4167 4498 4089 4816 4221 3975 25766

OUTPATIENT 12015 13604 12013 12256 12051 11570 73509

Subtotal: 16182 18102 16102 17072 16272 15545 99275

UTILIZATION MANAGEMENT - ALL COMPLETED TARS 7/1/2017 thru 12/31/2017

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PCP QIP 2016-2017 Program Evaluation Summary

The Primary Care Provider Quality Improvement Program (PCP QIP) offers substantial financial incentives, data resources, and technical assistance to PCPs who serve our capitated members so that significant improvements can be made across a variety of care domains.

Significant program changes were made, effective 1/1/2018. This evaluation is an analysis of the July 1, 2016 – June 30, 2017 program year, and therefore does not analyze the impact of our most recent changes.

Program Performance

Overall performance was consistent with prior year

Stability in % of providers meeting 90th percentile

target; modest increase in % of providers meeting

75th percentile target

Large practice size and Family Practice correlated

with better program performance/higher PMPM

Consistent year-over-year average point earnings;

NR improvement compared to last year

Provider Experience

100% satisfaction with the program

More providers actively participated in the program

based on Unit of Service measure submission and

eReports utilization

Opportunity to improve ease and usefulness of eReports

and the non-clinical reports

Does the PCP QIP Improve Care?

Tentatively yes, but difficult to conclude definitively without more robust research methods

Modest improvement over time seen in population-level rates

95% of surveyed participants agreed that the QIP improves patient care

QIP performance tracks with HEDIS performance; impacting the former should impact the latter

Want to accelerate improvement/program impact 2018 program changes

30%40%50%60%70%80%90%

Population Level Rates for Clinical Measures Plan Wide

2014-2015 2015-2016 2016-2017 HEDIS 2017 (MY2016)

222 providers 30 measures $36 million

Average points 65.5

Program Improvements

We made significant program changes effective

1/1/18; those changes are supported by 16-17

program year results

No measures ready for retirement based on high

performance

Consider slow changes to CAHPS, Readmissions

and Admissions targets in future years

63

64

65

66

67

68

2013-2014 2014-2015 2015-2016 2016-2017

Average Points Earnings By Region, Trended

South North All

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2016‐2017 PCP QIP Evaluation

March 2, 2018By Qi Yao

ContentsContents

‐ Overview‐ Summary of 16‐17 QIP program performance‐ Provider engagement with the QIP‐ Does QIP improve care?‐ Re‐assessing 2018 program changes‐ For consideration: Future improvements to QIP program

‐ Conclusion

PHC Internal Use Only

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OverviewOverview

‐ 222 providers participated in the 2016‐2017 PCP QIP

‐ In 2016‐2017, the base rate committed on a per member per month basis was $5.00.

‐ The total pay‐out was $36 million (15‐16: $34 million)

‐ Fixed Pool*: ‐ 14 Clinical measures (Child BMI retired)‐ 8 Non‐Clinical Measures

‐ Unit of Service:‐ 8 Measures (Health Information Exchange added)

*Not all practice types report on all measures


Summary of 16‐17 QIP Program PerformanceSummary of 16‐17 QIP Program Performance

‐ Providers meeting full/partial target – Clinical Domain

‐ Providers meeting full target – Non‐Clinical Domain

‐ Points earnings breakdown

‐ Points earnings by practice type and size

‐ Absolute change in adjusted points earned

‐ PMPM distribution by practice size

‐ PMPM distribution by practice type

‐ Patient experience


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Providers Meeting Full Targets – Clinical DomainProviders Meeting Full Targets – Clinical Domain


*Demonstrates statistically significant improvement (p<.05) using the fisher’s exact test.

Proportion of sites meeting the 90th percentile target

• Low: 12.08% (DTap); Median: 27.49% (MPM, Hba1c); High: 66.67% (Asthma Care)• Overall limited change over time in % of providers meeting 90th percentile target. • The percentage meeting target rose for five measures (1 statistically significant), and

declined for six (0 statistically significant).

Measure 2011‐2012 2012‐2013 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Asthma Care ‐ ‐ ‐ ‐ ‐ 66.67%

Nephropathy Screenings ‐ ‐ 62.90% 62.36% 58.29% 41.45%

Nutrition Counseling ‐ ‐ ‐ 26.32% 33.33% 36.84%

Controlling High Blood Pressure ‐ ‐ ‐ 16.67% 16.13% 33.69%

Childhood Immunization MMR ‐ ‐ ‐ ‐ ‐ 33.33%

Physical Activity Counseling ‐ ‐ ‐ 36.84% 27.78% 31.58%

HbA1C Good Control 24.70% 41.10% 56.20% 19.66% 34.76% 28.50%

MPM ‐ ‐ ‐ 34.48% 40.00% 26.47%

Adolescent Immunization 40.00% 31.30% 25.00% 47.37% 38.89% 26.32%

Retinal Eye Exams ‐ ‐ 11.20% 19.10% 11.76% 17.10%

Well‐Child Visits 17.60% 44.40% 30.10% 20.13% 20.63% 16.88%

Colorectal Cancer Screening ‐ ‐ ‐ ‐ ‐ 15.15%

Cervical Cancer Screening 1.00% 15.20% 23.20% 5.29% 6.09% 12.50%*

DTaP ‐ ‐ ‐ 21.05% 13.91% 12.08%

Providers Meeting Partial Targets – Clinical DomainProviders Meeting Partial Targets – Clinical Domain


*Demonstrates statistically significant improvement (p<.05) using the fisher’s exact test.

Proportion of sites meeting the 75th percentile target

• Low: 16.11% (DTap); Median: 42.45% (CBP, IMA); High: 66.67% (Asthma Care)• Overall positive change• The percentage in all but three measures (HbA1C Good Control, MPM and DTaP) rose

with Cervical Cancer Screening being significant.

Measure 2011‐2012 2012‐2013 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Asthma Care ‐ ‐ ‐ ‐ ‐ 66.67%

Nephropathy Screenings ‐ ‐ 71.90% 64.60% 58.29% 63.21%

Nutrition Counseling ‐ ‐ ‐ 46.70% 44.44% 52.63%

Physical Activity Counseling ‐ ‐ ‐ 33.30% 27.78% 47.37%

Childhood Immunization MMR ‐ ‐ ‐ ‐ ‐ 44.44%

HbA1C Good Control 36.40% 55.60% 67.40% 20.80% 44.39% 43.52%

Controlling High Blood Pressure ‐ ‐ ‐ 21.70% 19.35% 42.78%

Adolescent Immunization 46.70% 43.80% 31.30% 53.30% 38.89% 42.11%

Colorectal Cancer Screening ‐ ‐ ‐ ‐ ‐ 33.84%

MPM ‐ ‐ ‐ 36.40% 43.33% 32.35%

Well‐Child Visits 29.40% 61.10% 38.60% 37.80% 25.00% 29.38%

Retinal Eye Exams ‐ ‐ 16.90% 30.20% 16.58% 21.76%

Cervical Cancer Screening 5.80% 22.20% 35.40% 16.50% 10.66% 19.00%*

DTaP ‐ ‐ ‐ 40.00% 55.56% 16.11%

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Providers Meeting Full Targets – Non‐clinical DomainProviders Meeting Full Targets – Non‐clinical Domain


0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Pharmacy Readmissions Admissions/1000 Opioid Safety

% of Sites Meeting Targets for Appropriate Use of Resource Measures

2011‐2012 2012‐2013 2013‐2014 2014‐2015 2015‐2016 2016‐2017

• Consistently high percentage of sites meeting targets for Appropriate Use of Resource measures, and steadily increasing in Avoidable ED measure.

• Pharmacy and Opioid Safety measures retired.

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Avoidable ED PCP Office Visits Open Practice

% of Sites Meeting Targets for AccessMeasures Plan Wide

2011‐2012 2012‐2013 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Patient ExperiencePatient Experience


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2016 CAHPS (n=68) 2015‐2016 Survey/Training(n=151)

2015‐2016 PatientExperience (n=219)

2017 CAHPS (n=94) 2016‐2017 Survey/Training(n=128)

2016‐2017 PatientExperience (n=222)

Patient Experience Provider Point Distribution

Full Points Partial Points No Points

• While the proportion of sites earning points from the Survey/Training option has remained steady, many more sites earned points from the CAHPS survey.

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Points Earnings BreakdownPoints Earnings Breakdown


Region Southern Northern Plan‐wide

Year2013‐

2014

2014‐

2015

2015‐

2016

2016‐

2017

2013‐

2014

2014‐

2015

2015‐

2016

2016‐

2017

2013‐

2014

2014‐

2015

2015‐

2016

2016‐

2017

Average 66.7 66.5 65.8 65.3 65.8 67.6 63.2 65.8 66.3 65.9 64.7 65.5

Median 66.1 65.8 68.4 64.4 70.3 64 63.6 66.1 66.8 65.0 65.0 65.5

Lowest 20.0 30.0 25.0 25.0 20.0 28.0 26.8 37.9 20.0 28.0 25.0 25.0

Highest 100.0 95.0 100.0 100.0 100.0 95.0 100.0 100.0 100.0 95.0 100.0 100.0

• The plan‐wide increase from 2015‐2016 to 2016‐2017 is mainly driven by Northern Region providers with their improvement on DTaP and Colorectal Cancer Screening.

Average Point Earnings by Practice Type and SizeAverage Point Earnings by Practice Type and Size


Size Adult Family Pediatric Total

1‐49 48.28 (n=16) 59.62 (n=14) N/A (n=0) 53.57 (n=30)

50‐199 46.91 (n=8) 56.32 (n=16) 51.41 (n=5) 52.88 (n=29)

200‐749 65.89 (n=10) 65.88 (n=40) 66.16 (n=7) 65.91 (n=57)

750‐1649 85.83 (n=3) 67.14 (n=34) 82.19 (n=4) 69.67 (n=41)

1650+ N/A (n=0) 73.51 (n=61) 71.25 (n=3) 73.41 (n=64)

Total 55.72 (n=35) 67.54 (n=165) 65.70 (n=22)

• On the whole, larger practices/Family earned more points on the PCP QIP.

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Absolute Change in Adjusted Points EarnedAbsolute Change in Adjusted Points Earned


Points Change Number of Sites Percent to Total (n=211*)

<‐20 13 6.16%

>=‐20, <‐10 28 13.27%

>=‐10, <0 57 27.01%

>=0, <10 53 25.12%

>=10, <20 37 17.54%

>=20 23 10.90%

• The number of sites that experienced a positive change in points exceeded the number of sites that had a negative change which indicates overall improvement this year.

• Only the same 211 sites participated in both 2015‐2016 and 2016‐2017 measurement years.

PMPM Distribution by Practice SizePMPM Distribution by Practice Size


0

2

4

6

8

10

12

>5000 1000‐5000 <1000

PMPM Distribution by Practice Size

• The large sites had a higher average and narrower range of PMPM amount.

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PMPM Distribution by Practice TypePMPM Distribution by Practice Type


• Family Practice had a higher average of PMPM amount.• Pediatric had a narrower range of PMPM amount.

0

2

4

6

8

10

12

Family Adult Pediatric

PMPM by Practice Type

Provider Engagement with the QIPProvider Engagement with the QIP

‐ Provider engagement survey

‐ Webinar attendance

‐ eReports utilization

‐ Pay‐for‐Reporting measures performance


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Provider Engagement SurveyProvider Engagement Survey


• Overall, 95% of the respondents believed that the QIP led to improved patient care at their respective provider sites.

• Ongoing concern with ease and usefulness of eReports and the non‐clinical reports.

• 0% strongly agreed that the annual QIP results are a good reflection of the care provided.

Survey Questions Strongly

Agree

Agree Disagree Strongly

Disagree

I am satisfied with the program. 25% 75% 0% 0%

The annual QIP results are a good reflection of the care provided. 0% 71% 14% 14%

Staff and providers in my organization are aware of the QIP. 50% 40% 5% 5%

My opinions are heard in various QIP processes, including measure

development.

21% 53% 16% 10%

I understand what the requirements are in order to perform well in

the QIP.

50% 45% 5% 0%

In monitoring clinical measures, eReports is useful and easy to use. 32% 37% 15.5% 15.5%

In monitoring non‐clinical measures, the quarterly non‐clinical reports

are useful and easy to use.

11% 52% 21% 16%

I am aware of the pre‐payment validation processes, including the

eReports grace period and Preliminary Reports.

35% 50% 0% 15%

The QIP measures are actionable. 15% 80% 0% 5%

The QIP leads to improved patient care at my provider site. 30% 65% 0% 5%

The QIP drives our quality improvement agenda. 40% 55% 0% 5%

The QIP team responds to my questions and concerns in a timely

manner.

53% 37% 5% 5%

The QIP team’s response to my questions and concerns is helpful. 63% 32% 0% 5%

Important program updates to the QIP are communicated effectively. 50% 45% 0 5%

Webinar AttendanceWebinar Attendance


Webinar Date No. of Participants % rating of good and/or

excellent

Kick‐Off Webinar (Advanced) July 26, 2016 24 100.0% (13/13)

Kick‐Off Webinar (Beginner) July 27, 2016 6 100.0% (2/2)

MPM Webinar October 3, 2016 56 93.8% (30/32)

eReports Demo Webinar October 5, 2016 48 86.7% (26/30)

Measurement Year Transition & 2018 Measure

Development

January 30, 2017 48 96.8% (30/31)

2016‐2017 QIP Wrap‐Up and 2015‐2016 Evaluation June 13, 2017 43 100.0% (26/26)

• An overall 86.7%‐100% approval rating where the respondents rated the webinar they attended as good or excellent, improved dramatically from last year’s Kick Off Advanced ratings (15‐16 Advanced:29.4% 5/17 mainly due to technical difficulties).

• Opportunity to improve participation

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eReports UtilizationeReports Utilization


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Uploaded Data Logged In

Percent of Provider Sites Utilizing eReports

2014‐15 2015‐16 2016‐2017

• Fewer sites (73%) logged in during 2016‐2017 compared to 79% during 2015‐2016, more sites uploaded data (61%) compared to 60% during 2015‐2016.

Pay‐for‐Reporting Measures PerformancePay‐for‐Reporting Measures Performance


0%

5%

10%

15%

20%

25%

30%

PCMH Recognition Peer‐Led Self ManagementSupport Group

Advance Care Planning SBIRT Buprenorphine

Proportion of Plan‐Wide Providers Participating in Manual Submission Measures

2013‐2014 2014‐2015 2015‐2016 2016‐2017

• More providers participated in four measures except a small decline in PCMH Recognition because it was designed to be a one‐time payment.

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Does QIP Improve Care?Does QIP Improve Care?

‐ Population‐level performance – Clinical Domain

‐ Population‐level performance – Non‐Clinical Domain

‐ Controlling High Blood Pressure measure impact on HEDIS


Population‐level Performance – Clinical DomainPopulation‐level Performance – Clinical Domain


Historical QIP Performance 16‐17 QIP Performance HEDIS 2017 Performance

(for comparison)

Measure 2014‐2015 2015‐2016 2016‐2017 HEDIS 2016

Percentile

HEDIS 2017

Rate

HEDIS 2017

Percentile

Cervical Cancer Screening 51.95% 52.48% 55.72%* 25th – 50th 56.73% 50th – 75th

Well‐Child Visits 70.00% 71.75% 72.95%* 50th – 75th 72.13% 50th – 75th

Adolescent Immunization ‐ 81.26% 83.08% 75th – 90th 69.46% 25th – 50th

HbA1C Good Control ‐ 62.43% 64.93%* 50th – 75th 62.18% 50th – 75th

Retinal Eye Exams ‐ 48.57% 54.03%* 25th – 50th 53.59% 50th – 75th

Nephropathy Screenings ‐ 86.20% 86.22% 75th – 90th 88.19% <25th

Controlling High Blood Pressure ‐ 58.53% 63.09%* 50th – 75th 59.70% 50th – 75th

MPM ‐ 81.37% 85.67%* 25th – 50th 85.39% <25th

Nutrition Counseling ‐ 65.01% 73.99%* 75th – 90th 69.16% 50th – 75th

Physical Activity Counseling ‐ 48.75% 58.78%* 50th – 75th 64.06% 75th – 90th

DTaP ‐ 71.77% 70.60% <25th 72.23% <25th

Colorectal Cancer Screening ‐ 33.00% 36.20%* 50th – 75th ‐ ‐

Asthma Care ‐ 62.14% 66.38% >90th 51.22% 25th – 50th

MMR ‐ 88.73% 81.90%# <25th 85.69% <25th

* Demonstrates statistically significant improvement (p<.05) from previous measurement year using the Chi‐Square Test.# Demonstrates statistically significant decline (p<.05) from previous measurement year using the Chi‐Square Test.

• Nine of the 14 measures showed statistically significant improvement.• DTaP and MMR were below MPL for both QIP and HEDIS 2017.

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Population‐level Performance – Clinical DomainPopulation‐level Performance – Clinical Domain



• The QIP and HEDIS rates aligned well for the most part, changes that impact QIP performance will impact HEDIS.

30%

40%

50%

60%

70%

80%

90%

Population Level Rates for Clinical Measures Plan Wide

2014‐2015 2015‐2016 2016‐2017 HEDIS 2017 (MY2016)

Population‐level Performance – Non‐clinical DomainPopulation‐level Performance – Non‐clinical Domain



Measure 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Admissions/1000 ‐ ‐ 47.11 48.23#

Readmission Rate ‐ 14.22% 12.02% 13.54#

Generic Prescription Rate 92.22% 89.02% 89.01% 88.74%#

Formulary Prescription Rate 94.72% 98.33% 98.54% 98.27%#

Avoidable ED Visits 39.53 36.82 21.70 18.14*

PCP Office Visits ‐ 2.50 2.36 2.35#

Opioid Safety ‐ ‐ 61.70% 69.55%*

• Pharmacy‐related measures continue to have high performance (retired).• The two measures that saw significantly improvement were Avoidable ED

Visits and Opioid Safety.• Increase in Admissions/Readmissions

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12

Controlling High Blood Pressure Measure Impact on HEDISControlling High Blood Pressure Measure Impact on HEDIS

• CBP was to Internal Med in 2013‐14 and added to Family Practice in 2014‐15.• Addition of CBP to the measurement set correlated with improved HEDIS rate, though

not a perfectly linear relationship• The CBP population‐level performance in QIP increased from 58.53% in 2015‐16 to

63.09% in 2016‐17 which should be reflected in HEDIS 2018 (MY2017), indicating the improvement in the long term.

48.42%

54.74%

64.30%

47.45%

60.34%

48.10%

54.01%

65.53% 64.89%

56.72%58.52%

65.59%

61.70%

69.55% 69.79% 70.32% 70.55%

40.00%

45.00%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

HEDIS 2014 (MY2013) HEDIS 2015 (MY2014) HEDIS 2016 (MY 2015) HEDIS 2017 (MY 2016)

CBP

NE NW SW SE HEDIS 90%ile

Internal med measure Family practice

measure

Re‐assessing 2018 Program ChangesRe‐assessing 2018 Program Changes

‐ Relative improvement change

‐ Continuous enrollment change

‐ Pharmacy measure removal

‐ CAHPS RI removal, consider target changes in future years


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13

Relative Improvement Change‐Point Earnings Distribution for Clinical Measures Plan‐Wide

Relative Improvement Change‐Point Earnings Distribution for Clinical Measures Plan‐Wide


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Point Earnings Distribution for Clinical Measures Plan‐Wide

Full Points (Target) Full Points (Improvement) Partial Points (Target) Partial Points (Improvement) No Points

• While relatively few providers meet the target for many measures, a significantly higher proportion earned points as a result of improvement. It supports our finding in 2015‐16 evaluation and beginning in 2018, only significant improvement – defined as 15% relative improvement (and meeting MPL) – will be rewarded.

CE Change‐QIP Denominators Compared to HEDISCE Change‐QIP Denominators Compared to HEDIS

HEDIS denominators after exclusions applied

** Not reported for HEDIS 2017. Used internal HEDIS 2017 flowchart to extract data.


QIP Measure QIP Denominator HEDIS 2017

Population*

Percentage

Annual Monitoring of Patients on Persistent Medications 14,305 27,319 52.36%

Cervical Cancer Screenings 66,883 97,010 68.94%

Childhood Immunization ‐ DTaP 6,922 10,286 67.30%

Childhood Immunization – MMR 746 10,286 7.25%

DM – Retinal Eye Exams 11,593 15,975 72.57%

DM ‐ HbA1C Good Control 11,593 15,975 72.57%

DM ‐ Nephropathy Screenings 11,593 15,975 72.57%

Controlling High Blood Pressure 15,318 19,204 79.76%

Immunizations for Adolescents 721 9,668 7.46%

Medication Management for Asthma** (Asthma Care) 116 2,368 4.90%

Physical Activity Counseling 8,773 111,061 7.90%

Nutrition Counseling 8,773 111,061 7.90%

Well Child Visits 28,123 42,057 66.87%

Colorectal Cancer Screenings Not reported for HEDIS

• In 2016‐17, the population measured by the QIP is about 38% of the size of the HEDIS population. Beginning in 2018, the definition of continuous enrollment will change to meaning assigned to the same PCP parent organization for nine out of 12 months of the measurement period. This will allow the QIP to represent a better sample of the entire eligible population and to extend care to our members.

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14

Pharmacy Measure RemovalPharmacy Measure Removal


Measure 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Generic Prescription Rate 92.22% 89.02% 89.01% 88.74%

Formulary Prescription Rate 94.72% 98.33% 98.54% 98.27%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

Pharmacy

Percent of Sites Meeting Targets for Pharmacy Measure Plan Wide

2011‐2012 2012‐2013 2013‐2014 2014‐2015 2015‐2016 2016‐2017

Population‐Level Performance

• Performance on the Pharmacy measure continues to be high, supporting the measure removal starting in 2018.

CAHPS RI RemovalCAHPS RI Removal


• Points earned were based on hitting the targets instead of achieving improvement.• Final score is based on the higher of the two composite types.• Overall more sites earned full points this year.• RI calculation adds administrative burden.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Adult Access Adult Comm Child Access Child Comm

CAHPS Points Earned Distrubution 2016‐2017

Full Points (Target) Full Points (RI) Partial Points (Target) Partial Points (RI) No Points

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15

For Consideration: Future Improvements to QIP ProgramFor Consideration: Future Improvements to QIP Program

‐ No measures ready for retirement based on 2016‐2017 performance; however, need to consider size of measurement set.

‐ The current CAHPS targets are 25th (partial) and 50th (full), consider potentially increase targets as almost all sites were earning points.

‐ High percentage of providers are meeting targets for Readmissions and Admissions measure; consider slow changes to these targets.


ConclusionsConclusions

‐ Modest positive change in population‐level rates and % of providers meeting targets and earning points.

‐ Significant improvement in Northern Region average points earned

‐ On the whole, larger sites/Family practices earned more points/received higher PMPM on the PCP QIP.

‐ High provider satisfaction with program administration‐ More providers actively participated in the program (UOS)‐ The QIP and HEDIS rates aligned well for the most part,

changes that impact QIP performance will impact HEDIS.‐ Based on QIP data, improvement priorities align with those

identified based on HEDIS results (IZ, CCS, MPM).‐ 2016‐17 data supports 2018 program changes.‐ No measure is ready for retirement, but consider increasing

CAHPS targets.PHC Internal Use Only

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3/5/2018

16

Thank YouThank You


Questions?

70 of 97

PHC (PARTNERSHIP HEALTHPLAN OF CALIFORNIA)

PAC SUMMARY

Pg. 1 of 12 * =by phone conference Committee: Credentialing Committee Date/Time: February 14, 2018 7:00 a.m. – 7:30 a.m. Members Present: M. Tracy Johnson, MD; Bradley Sandler, MD; Jeff Gaborko, MD; Steven Gwiazdowski, MD; Michael Stacey, MD*; Candy Stockton, MD* PHC Staff: Robert Moore, MD MPH MBA, PHC Chief Medical Officer; Marshall Kubota, MD*, PHC Regional Medical Director; Michael Vovakes, MD*,

PHC Northern Region Medical Director; Scott Endsley, MD, PHC Associate Medical Director of Quality; Mark Netherda, MD, PHC Regional Director, Bettina Spiller, MD*, PHC Northern Region Medical Director; Mary Kerlin, Senior Director of Provider Relations; Heidi Lee, Provider Systems Manager; Rose Rad, Credentialing Supervisor, Jasmine Jones, Credentialing Specialist II; Skyler Bellmore, Credentialing Specialist II; Carol Kriek, Credentialing Specialist II; Cathy Beltran, Credentialing Specialist

AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET DATE

DATE RESOLVED

I. Meeting called to order

I. PHC Regional Medical Director Marshall Kubota, MD called the meeting to order.

2-14-2018

II. Review/Approval of previous minutes

II.A. The Credentialing Committee meeting minutes for January 10, 2018

II. Motion: Dr. Jeff Gaborko, MD. Second: Dr. Bradley Sandler, MD. Meeting minutes approved without changes.

2-14-2018

III. Old Business A. Siskiyou County B. Communication Process: Information Only IV. New Business A. Shasta County B. Review of Practitioner File

III. A. The Credentials Committee requested staff to provide a history of the providers credentialing at this meeting. III. B. Communication Process: Information Only: PHC will now include a list of providers that are monitored monthly and when Credentials Chair or CMO recommend a provider be monitored monthly it will be reported to Committee. IV: A. Dr. Moore gave the option of Summary Suspension or Administrative Actions. IV. B. Please see approved list of Routine Providers on Pages 4-12 The Committee reviewed and discussed the list of twenty five (25) Physicians, two (2) Non-Physician Medical Practitioners, fourteen (14) Behavioral Health Analysts, , and two (2) Chiropractors for Initial Credentialing, twenty five (25) Physicians, nine (9) Non-Physician Medical Practitioners, two (2) Podiatrists, and one (1) Chiropractor for Re-Credentialing.

III. A. Motion: Dr. Jeffrey Gaborko, MD. Second: Dr. Bradley Sandler, MD to continue to monthly monitor of sanctions. III. B. No discussion from Committee. IV.A. It was suggested that the Plan looked at a pathway of some form of suspension based on accusation and determine if these types of suspensions IV. B. Motion: Dr. Jeffrey Gaborko, MD. Second: Dr. Bradley Sandler, MD. Approved the list without changes of twenty five (25) Physicians, two (2) Non-Physician Medical Practitioners, fourteen (14) Behavioral Health Analysts, , and two (2) Chiropractors for Initial Credentialing, twenty five (25) Physicians, nine (9) Non-Physician Medical Practitioners, two (2) Podiatrists, and one (1) Chiropractor for Re-Credentialing.

2-14-2018

2-14-2018

2-14-2018

2-14-2018

71 of 97

PHC Credentialing PAC Summary 2-14-18 Page 2 of 12 AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET

DATE DATE

RESOLVED C. Lassen County

V. Update of Ongoing Monitoring of Sanctions. Information Only

VI. Consent Calendar Items. A. Report of Long Term Care Facility, Hospital, and Ancillary Prov. List. B. Review of Suboxone/ Buprenorphine credentialed primary care providers. C. 3rd Quarter: Mercy Medical Group: Credentialing/ Re- Credentialing Activities. D. 3rd Quarter: Sutter Pacific Medical Foundation- Physician Foundation Medical Associates and Marin Headlands: Credentialing/ Re- Credentialing Activities. E. MP CR 6A (No Changes): Initial Credentialing Requirements for Non-Physician (Allied Health)

IV. C. Chart review conducted for this physician because he did not meet the criteria of PHC Policy MP CR #17-Standards for Contracted Primary Care Providers. V. Information Only: A Medical Board of California License alert dated 1/17/2018 stated that this provider’s license was issued a Cease Practice Order effective 1/16/2018. This provider was termed from all PHC systems. VI. A. Report of Long Term Care Facility, Hospital, and Ancillary provider list.

IV. C. Motion: Candy Stockton, MD. Second: Dr. Jeffrey Gaborko, MD and Approved to place provider on 6 months’ probation, pending review of the results of a PACE assessment. V. No discussion from Committee.

VI. Motion: Dr. Jeff Gaborko, MD. Second: Dr. Candy Stockton, MD. Approved Consent Calendar Items without changes.

2-14-2018

2-14-2018

2-14-2018

72 of 97

PHC Credentialing PAC Summary 2-14-18 Page 3 of 12 AGENDA ITEM DISCUSSION / CONCLUSIONS RECOMMENDATIONS / ACTION TARGET

DATE DATE

RESOLVED VI. Consent Calendar Items F. MP CR 13 (No Changes): Credentialing of Pain Management Specialist. G. MP PR 16 (No Changes): Lactation Consultant Credentialing Policy. H. MP PR PL CR 401A (No Changes): Initial Credentialing Document Collection, Review, and Verification for Behavioral Health Practitioners. VII. Meeting Adjourned

F. MP CR 13 (No Changes): Credentialing of Pain Management Specialist. G. MP PR 16 (No Changes): Lactation Consultant Credentialing Policy. H. MP PR PL CR 401A (No Changes): Initial Credentialing Document Collection, Review, and Verification for Behavioral Health Practitioners. With No further items for discussion, the meeting was adjourned Next Meeting Scheduled for March 14, 2018

2-14-2018

PAC Summary Meeting Minutes for February 14, 2018 respectfully prepared and submitted by Jasmine Jones - Credentialing Specialist II Chairman Signature of Approval __________________________________________ Date______________________________ Marshall Kubota M.D., PHC Credentialing Chairman

73 of 97

February 2018

AppType

Practitoner Name

Provider Type Practice Name County Name

Specialty Description Board Name

Board Certified Hospital Name

Staff Category

Settlement Date

RAdkins, Amanda C.,MD PCP

NBHG: Center for Primary Care-Fairfield, A NorthBay Affiliate Solano Internal Medicine

ABMS of Internal Medicine Yes

Hospitalist Coverage

No Privileges

I

Ahmad, Amenaghawon BCBA BHP

Maxim Healthcare Services Inc. Sacramento Behavioral Health

Behavior Analyst Certification Board Yes

R Anand, Arun MD SPEC

An Anesthesia and Pain Management Medical Corp Solano Anesthesiology ABMS of Anesthesiology Yes

Sutter Solano Medical Center Active


An Anesthesia and Pain Management Medical Corp Solano

Pain Management & Rehabilitation None No



An Anesthesia and Pain Management Medical Corp Solano Pediatrics ABMS of Pediatrics No


R

Anderson, Jacqueline E.,FNP PCP

Healdsburg Physician Group-PCP Sonoma

Family Nurse Practitioner

American Academy of Nurse Practitioners Certification Board Yes

IAndrews, Laura FNP SPEC

NBHG: Heart and Vascular Center - Surgical. A NB Affiliate Solano



RAphailee, Victoria L.,CNM SPEC

Communicare Health Centers - Davis Community Clinic Yolo

Certified Nurse Midwife

American Midwifery Certification Board Yes


Communicare Health Centers - Salud Clinic Yolo




Communicare Health Centers-Hansen Family Medical Center Yolo



RAtray, Naveen K.,MD SPEC

Capital Nephrology Medical Group Yolo Internal Medicine

ABMS of Internal Medicine No

Sutter Medical Center Sacramento Active 02/03/2015

RAtray, Naveen K.,MD SPEC

Capital Nephrology Medical Group Yolo Nephrology


Sutter Medical Center Sacramento Active

IAyanzen, Ron H.,MD SPEC

Health Diagnostics of California Marin

Diagnostic Radiology ABMS of Radiology Yes

No Direct Patient Contact

No Privileges

RBallenger, John R.,MD SPEC



Mercy General Hospital of Sacramento Active





74 of 97

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date


Capital Nephrology Medical Group - Woodland Yolo Internal Medicine




Capital Nephrology Medical Group - Woodland Yolo Nephrology



RBarth, Gary P.,MD SPEC

Eye Care Institute, A Medical Corporation Sonoma Ophthalmology ABMS of Ophthalmology Yes

Sutter Santa Rosa Regional Hospital Courtesy

RBarylski, Chad R.,FNP BOTH Annadel Medical Group Sonoma Chiropractic None No

RBarylski, Chad R.,FNP BOTH Annadel Medical Group Sonoma



RBarylski, Chad R.,FNP BOTH

Annadel Medical Group (Family Practice) Sonoma Chiropractic None No


Annadel Medical Group (Family Practice) Sonoma




Annadel Medical Group: Orthopedic Surgery Sonoma Chiropractic None No


Annadel Medical Group: Orthopedic Surgery Sonoma



I Basu, Anjuli MD PCPPRIMA Medical Foundation Marin Internal Medicine


Marin General Hospital Active

I Basu, Anjuli MD PCPPRIMA Medical Foundation Marin Pediatrics ABMS of Pediatrics Yes


RBirnbaum, Neal S.,MD SPEC

Adventist Health- Ukiah Valley Rural Health Mendocino Internal Medicine


Ukiah Valley Medical Center Consulting

RBirnbaum, Neal S.,MD SPEC

Adventist Health- Ukiah Valley Rural Health Mendocino Rheumatology


Ukiah Valley Medical Center Consulting

IBourne, Margaret E.,MD SPEC Hospice by the Bay Marin Family Medicine ABMS of Family Medicine Yes


No Privileges

IBourne, Margaret E.,MD SPEC Hospice by the Bay Marin

Hospice and Palliative Medicine ABMS of Family Medicine Yes


No Privileges

IBuechner, John P.,DC SPEC

Active Care Chiropractic, Fogg Professional Corporation Humboldt Chiropractic None No

IBurk, David R.,MD SPEC

Sutter Coast Community Clinic Del Norte

Orthopaedic Surgery None No


No Privileges

75 of 97

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

IByrnes, Rebecca R.,BCBA BHP

Gateway Learning Group Marin Behavioral Health


RChase, Karen G.,FNP SPEC

Sutter Coast Community Walk-In Clinic Del Norte



I Chen, Judy J.,MD SPEC

West Coast Retina Medical Group-Corte Madera Marin Ophthalmology None No Group Coverage

No Privileges

I Chen, Judy J.,MD SPEC

West Coast Retina Medical Group-San Francisco Marin Ophthalmology None No Group Coverage

No Privileges

IClark, Richard A.,MD SPEC

Sacramento Heart & Vascular Medical Associates Yolo

Cardiovascular Disease

ABMS of Internal Medicine Yes Group Coverage

No Privileges

IClark, Richard A.,MD SPEC

Sacramento Heart & Vascular Medical Associates Yolo Internal Medicine

ABMS of Internal Medicine Yes Group Coverage

No Privileges

ICrain, Sidney M.,MD SPEC

Dignity Health dba Mercy Regional Cancer Center Shasta Internal Medicine


Mercy Medical Center of Redding Courtesy

ICrain, Sidney M.,MD SPEC

Dignity Health dba Mercy Regional Cancer Center Shasta Oncology


Mercy Medical Center of Redding Courtesy

RDavid, Frederick C.,MD SPEC Annadel Medical Group Sonoma

Radiation Oncology ABMS of Radiology No

Santa Rosa Memorial Hospital Active

RDavid, Frederick C.,MD SPEC Annadel Medical Group Sonoma

Therapeutic Radiology ABMS of Radiology Yes

Santa Rosa Memorial Hospital Active

RDeck, Tatyana L.,PA-C PCP Elica Health Center Yolo

Physician Assistant Certified

National Commission on Certification of Physician Assistants Yes

RDeRose, David J.,MD PCP

Adventist Health Clear Lake Lake Internal Medicine



No Privileges

RDeRose, David J.,MD PCP

Adventist Health Clear Lake Lake

Public Health & General Preventive Medicine

ABMS of Preventive Medicine Yes


No Privileges

IDiPerna, Danielle A.,MD SPEC

Obstetrix Medical Group of Sacramento, PC Yolo

Maternal and Fetal Medicine None No Group Coverage

No Privileges 02/05/2015

IDiPerna, Danielle A.,MD SPEC

Obstetrix Medical Group of Sacramento, PC Yolo

Obstetrics and Gynecology

ABMS of Obstetrics and Gynecology Yes Group Coverage

No Privileges

76 of 97

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

IEckel, Gregory M.,MD SPEC

Harbor-UCLA Medical Foundation Trinity



No Privileges

REichner Blanusa, Lora K.,MD PCP Harvest Pediatrics Napa Pediatrics ABMS of Pediatrics Yes Group Coverage

No Privileges

IFamularo, Michael A.,MD SPEC

Adventist Health Feather River Shasta




No Privileges


Adventist Health Feather River Shasta Internal Medicine



No Privileges


Adventist Health Feather River Shasta

Interventional Cardiology



No Privileges

IFulton, William R.,DO SPEC

NBHG: Center for Specialty Care, A NorthBay Affiliate Solano General Surgery AOB of Surgery Yes

Northbay Medical Center

Active/Admitting

IGoodwin, Gregory T.,PA PCP

Karuk Health Center, Orleans Humboldt

Physician Assistant None No


Karuk Tribal Health Clinic, Happy Camp Siskiyou



Karuk Tribal Health Clinic, Yreka Siskiyou


RHanahan, Ralph B.,MD SPEC Annadel Medical Group Sonoma

Radiation Oncology None No

Santa Rosa Memorial Hospital Courtesy

RHanahan, Ralph B.,MD SPEC Annadel Medical Group Sonoma Radiology ABMS of Radiology Yes


RHanahan, Ralph B.,MD SPEC Annadel Medical Group Sonoma



IHolder, Pinella A.,DO SPEC

Humboldt Medical Specialists- Physical Medicine & Rehabilitation Humboldt

Physical Medicine & Rehabilitation

ABMS of Physical Medicine & Rehabilitation Yes Group Coverage

No Privileges

IHolder, Pinella A.,DO SPEC

Humboldt Medical Specialists- Physical Medicine & Rehabilitation Humboldt Sports Medicine

ABMS of Physical Medicine & Rehabilitation Yes Group Coverage

No Privileges

IJohnson, Troy R.,BCBA BHP

Learning Solutions Kids, Inc. Yolo Behavioral Health


RJoseph, Jay S.,MD SPEC Annadel Medical Group Mendocino

Radiation Oncology ABMS of Radiology Yes

Ukiah Valley Medical Center Active

RKashyap, Rohit MD SPEC



Sutter General Hospitals Active

RKashyap, Rohit MD SPEC



Sutter General Hospitals Active 02/03/2015

77 of 97

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

IKatana, John M.,MD PCP

Dignity Health - Mercy Mt. Shasta Comm Clinic Siskiyou Family Medicine ABMS of Family Medicine Yes

Mercy Medical Center Mt. Shasta Active

RKazak, Marat DPM SPEC

Sacramento Foot and Ankle Center, Inc. Yolo Podiatry None No

Mercy San Juan Hospital Active

I Khan, Akbar DO SPECNBHG: NorthBay Center For Pain Solano

Pain Management & Rehabilitation

ABMS of Physical Medicine & Rehabilitation Yes


No Privileges

R Khosla, Anil MD SPECSolano Diagnostic Imaging Solano



Non-Applicable

R Khosla, Anil MD SPECSolano Diagnostic Imaging Solano Neuroradiology ABMS of Radiology Yes


Non-Applicable

R Lee, Marge PA-C PCP

Communicare Health Centers-Hansen Family Medical Center Yolo

Physician Assistant Certified

National Commission on Certification of Physician Assistants Yes

ILeon, Federico G.,MD PCP Alliance Medical Center Sonoma Family Medicine ABMS of Family Medicine Yes


No Privileges

ILongchamp, Carla P.,MD PCP

SR Comm Hlth Centers: Southwest Comm Health Center Sonoma Family Medicine ABMS of Family Medicine Yes


No Privileges

IMantik, David W.,MD SPEC

Dignity Health- Redding Radiation Oncologists, PC: Mercy Regional Cancer Center Siskiyou


IMantik, David W.,MD SPEC

Redding Radiation Oncologists, PC: Redding Cancer Treatment Center Shasta


RManubens, Sergio M.,MD SPEC

QVMA: Queen of the Valley Medical Associates - Cardiology Napa



Queen of the Valley Active


QVMA: Queen of the Valley Medical Associates - Cardiology Napa Internal Medicine




QVMA: Queen of the Valley Medical Associates - Cardiology Napa

Interventional Cardiology



R

McGovern, Catherine A.,CNM SPEC

Communicare Health Centers - Davis Community Clinic Yolo



78 of 97

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

R

McGovern, Catherine A.,CNM SPEC

Communicare Health Centers - Salud Clinic Yolo



IMeek, Emily BCBA BHP Learning ARTS Yolo Behavioral Health


IMey, Samantha BCBA BHP Learning ARTS Yolo Behavioral Health


RMiller, Terina M.,MD SPEC

East Bay Nephrology Medical Group Solano Internal Medicine

ABMS of Internal Medicine No

Alta Bates Summit Medical Center Active

RMiller, Terina M.,MD SPEC

East Bay Nephrology Medical Group Solano Nephrology



IMontano, Danette R.,BCBA BHP Starfish Hero Inc Humboldt Behavioral Health


INeedens, Brandon BCBA BHP Learning ARTS Yolo Behavioral Health


INejad, Michael L.,MD SPEC Hospice by the Bay Marin

Hospice and Palliative Medicine



No Privileges

INejad, Michael L.,MD SPEC Hospice by the Bay Marin Internal Medicine



No Privileges

RO'Brien, Michael W.,MD SPEC

Dignity Health: Foundation - North State - Airpark Dr Shasta Neurology

ABMS of Psychiatry & Neurology Yes

Mercy Medical Center of Redding Active

RO'Brien, Michael W.,MD SPEC

Dignity Health: Foundation - North State - Airpark Dr Shasta

Vascular Neurology


Mercy Medical Center of Redding Active

RO'Keefe, Galina BCBA BHP

Trumpet Behavioral Health-Dublin Solano Behavioral Health


ROdabaei, Golaun MD SPEC

East Bay Nephrology Medical Group Solano Internal Medicine



ROdabaei, Golaun MD SPEC

East Bay Nephrology Medical Group Solano Nephrology



IOrquiz, Chelsea D.,BCBA BHP

Center for Autism and Related Disorders, LLC Solano Behavioral Health


IPena, Shady A.,BCBA BHP Learning ARTS Yolo Behavioral Health


IPike, Deanna BCBA BHP

Autism Spectrum Therapies-Sacramento Yolo Behavioral Health


79 of 97

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

RPurrinson, Beth N.,NM SPEC Capital OB/GYN, Inc. Yolo


American Midwifery Certification Board No

RRagsdale, Richard A.,MD SPEC Greenville Rancheria Shasta Internal Medicine

ABMS of Internal Medicine Yes Group Coverage None

RRagsdale, Richard A.,MD SPEC Greenville Rancheria Shasta

Pulmonary Diseases

ABMS of Internal Medicine Yes Group Coverage None

I

Rezai, Mohammed T.,DO BOTH

Redding Rancheria: Churn Creek Healthcare- Shasta Family Medicine

Meets MPCR#17, verified residency by Residency Letter No


No Privileges

I


Redding Rancheria: Churn Creek Healthcare Shasta Urgent Care None No


No Privileges

I


SCHC: Shasta Community Health Center- Shasta Family Medicine

Meets MPCR#17, verified residency by Residency Letter No


No Privileges

I


SCHC: Shasta Community Health Center Shasta Urgent Care None No


No Privileges

RRobinson, Mark W.,NP PCP

Fairchild Medical Clinic (PCP Clinic) Siskiyou Nurse Practitioner None No

RRobinson, Mark W.,NP PCP Harold Budhram, MD Shasta Nurse Practitioner None No

ISafra, Jessica A.,MD SPEC Hospice by the Bay Marin

Hospice and Palliative Medicine



No Privileges

ISafra, Jessica A.,MD SPEC Hospice by the Bay Marin Internal Medicine



No Privileges

ISchaedler, Alisa E.,BCBA BHP



IScripko, Patricia D.,MD SPEC TeleMed2U Yolo Neurology



No Privileges

RSingh, Kabir J.,MD SPEC

Marin Healthcare Dist: Cardiovascular Assoc of Marin and SF Marin





Marin Healthcare Dist: Cardiovascular Assoc of Marin and SF Marin Internal Medicine




Marin HealthCare District: SF and Sirona Vascular Center Marin





Marin HealthCare District: SF and Sirona Vascular Center Marin Internal Medicine



RSnyder, Robert E.,MD PCP

Lassen Indian Health Center Lassen Family Practice None No


No Privileges

80 of 97

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date

RStanton, Thomas S.,II, MD SPEC Annadel Medical Group Sonoma Hematology


Petaluma Valley Hospital Active

RStanton, Thomas S.,II, MD SPEC Annadel Medical Group Sonoma Internal Medicine



RStanton, Thomas S.,II, MD SPEC Annadel Medical Group Sonoma Medical Oncology



RStrange, Nicholas G.,DO BOTH Annadel Medical Group Sonoma Family Practice AOB of Family Physicians Yes


No Privileges

RStrange, Nicholas G.,DO BOTH Annadel Medical Group Sonoma

Osteopathic Manipulative Therapy AOB of Family Physicians Yes


No Privileges

RStrange, Nicholas G.,DO BOTH

Annadel Medical Group: Afters Hours Care Sonoma Family Practice AOB of Family Physicians Yes


No Privileges

RStrange, Nicholas G.,DO BOTH

Annadel Medical Group: Afters Hours Care Sonoma

Osteopathic Manipulative Therapy AOB of Family Physicians Yes


No Privileges

ISundberg, Kelsey BCBA BHP



RTan, Jessica C.,MD SPEC

Health Diagnostics of California Marin



No Privileges


Health Diagnostics of California Marin Neuroradiology ABMS of Radiology Yes


No Privileges


Marin Community Clinic: San Rafael Clinic Marin



No Privileges


Marin Community Clinic: San Rafael Clinic Marin Neuroradiology ABMS of Radiology Yes


No Privileges

RTovmassian, Gregory DPM SPEC

Sacramento Foot and Ankle Center, Inc. Yolo Podiatry None No

Mercy San Juan Hospital Active

IUkatu, Chidi J.,MD SPEC

Sutter Coast Community Clinic Del Norte General Surgery

Meets MPCR #17, Verified Residency on AMA No


No Privileges

RVeletto, Tony D.,MD PCP

Healdsburg Physician Group-PCP Sonoma Internal Medicine


Healdsburg District Hospital

Provisional Active

IWada, Hitomi BCBA BHP

Center for Autism and Related Disorders, LLC Solano Behavioral Health


IWallace, Sandra L.,MD SPEC

Marin Community Clinic: Campus Clinic Marin Infectious Disease


Transfer Agreement

No Privileges

IWallace, Sandra L.,MD SPEC

Marin Community Clinic: Campus Clinic Marin Internal Medicine


Transfer Agreement

No Privileges

RWeldon, Barbara J.,DC SPEC

Marin Community Clinic: Campus Clinic Marin Chiropractic None No

81 of 97

February 2018

AppType

Practitoner Name




Staff Category

Settlement Date


Marin Community Clinic: Larkspur Clinic Marin Chiropractic None No


Marin Community Clinic: Novato Clinic Marin Chiropractic None No


Marin Community Clinic: San Rafael Clinic Marin Chiropractic None No


Marin Community Clinic: South Novato Clinic Marin Chiropractic None No

IWilke, Allan J.,MD PCP

Humboldt Medical Specialists Humboldt Family Medicine ABMS of Family Medicine Yes Group Coverage

No Privileges

IWilke, Allan J.,MD PCP

Humboldt Medical Specialists Humboldt Geriatric Medicine ABMS of Family Medicine Yes Group Coverage

No Privileges

RWong, Kalane J.,MD SPEC

Eye Care Institute, A Medical Corporation Sonoma Ophthalmology ABMS of Ophthalmology Yes


IWright, Richard S.,DC SPEC

Active Care Chiropractic, Fogg Professional Corporation Humboldt Chiropractic None No

I Zeim, Sam MD SPECHarbor-UCLA Medical Foundation Trinity



No Privileges

Medical Director/Physician Approval of Routine List____________________________________________________

Marshall Kubota M.D., PHC Credentialing Chairman

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2018‐19 Hospital QIP (HQIP) Proposed Measurement Set: Large Hospitals

2017‐18 Large Hospital Measures Proposed 2018‐19 Large Hospital Measures Considerations Requirements

Health Information Exchange (HIE) Requirement New participants: Hospitals must complete

Admission, Discharge, and Transfer (ADT) interface with a community HIE by the end of the measurement year.

Existing participants: Hospitals complete Premanage/ED interface, and also maintain their existing ADT interface with their established HIE partner, by the end of the measurement year.

If not met, entire incentive amount will be withheld.

All hospitals: By the end of the measurement year, both of the following:

1. Live with EDIE including a mechanism for the EDIE data to be pushed to ED physicians for patients who are seen.

2. ADT interface with a community HIE. If not met, entire incentive amount will be withheld.

Setting uniform standards given status of HIE in the state.

Delegation Requirement Hospitals must :

Submit to Partnership HealthPlan of California (PHC) a written Utilization Program Description

Submit timely reports. Exact timeliness is TBD, and will be based on the Reporting Schedule in each hospital’s delegation agreement.

Proposed impact of not meeting the entire requirement (TBD) is a 5% or 10% payment reduction

As PHC seeks National Committee for Quality Assurance (NCQA) Accreditation, it is important that NCQA UM requirements are met by all capitated hospitals in PHC’s network.

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Measures 1. All‐Cause Adult Readmission Rate Back‐up measure: Follow‐up visit within 4

calendar days of discharge Pay for Performance

1. All‐Cause Adult Readmission Rate Back‐up measure: Follow‐up visit within 4 calendar days of discharge Pay for Performance

May help concentrate the focus on readmissions. Furthermore, no hospital has ever used the Follow‐up option to meet this measure.

2. Palliative Care Capacity. Two options: ‐ Option 1: Dedicated inpatient palliative care

team (all hospitals): o One Physician Champion o One trained Licensed Clinical Social Worker o One trained Licensed RN, NP, or PA (Registered Nurse, Nurse Practitioner, or Physician Assistant)

o Availability of video or in‐person consult with a Palliative Care Physician

‐ Option 2: Inpatient palliative care capacity (small hospitals only):

o Two licensed staff: RN, NP, or PA o Availability of either video or in‐person consult with a Palliative Care Physician

Hospitals with fewer than 20 beds excluded. Pay for Process


team (all hospitals): o One Physician Champion o One trained Licensed Clinical Social Worker OR Licensed RN, NP, or PA





Changing option 1 to include one Physician and one RN/NP/PA would make the measure more achievable for hospitals, while still meeting our goal of having a dedicated PC team. Propose to remove the <20 bed exclusion after a hospital with fewer than 20 beds informed us that this is an achievable measure for them.

3. Elective Delivery before 39 weeks Pay for Performance

3. Elective Delivery before 39 weeks Hospitals will submit data to California Maternal Quality Care Collaborative (CMQCC), and PHC will work directly with CMQCC for reports. Pay for Performance

Change will decrease chance of data errors. Currently, hospitals submit numerator and denominator statement to PHC. Staff submitting data often aren’t close to this area, and errors sometimes occur in data transit. ‐ Will require chart abstraction

4. Exclusive Breast Milk Feeding

4. Exclusive Breast Milk Feeding Hospitals will submit data to CMQCC, and PHC will work directly with CMQCC for reports.

Change will decrease chance of data errors. Currently, hospitals submit numerator and denominator statement to PHC. Staff

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Pay for Performance Pay for Performance submitting data often aren’t close to this area, and errors sometimes occur in data transit. ‐ Will require chart abstraction

5. Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate

Pay for Performance

5. NTSV Cesarean Birth Rate Hospitals will submit data to CMQCC, and PHC will work directly with CMQCC for reports. Pay for Performance

Change will decrease chance of data errors. Currently, hospitals submit numerator and denominator statement to PHC. Staff submitting data often aren’t close to this area, and errors sometimes occur in data transit. ‐ No chart extraction required

6. Timely Participation in California Perinatal Quality Care Collaborative (CPQCC) Data Reporting

Pay for Reporting

6. Timely Participation in California Perinatal Quality Care Collaborative Data Reporting

Reporting based on CPQCC deliverable deadlines Attend one CPQCC collaborative by end of measurement year. Pay for Reporting

Change will ensure hospitals have a meaningful interaction with CPQCC.

7. Timely Participation in California Maternal Quality Care Collaborative Data Reporting

Pay for Reporting

Timely Participation in California Maternal Quality Care Collaborative Data Reporting Pay for Reporting

Removing because retrieving data from CMQCC for three maternal measures will ensure participation.

8. Venous thromboembolism (VTE)‐6 – Hospital‐Acquired Potentially‐Preventable VTE

Pay for Performance

7. No Change.

N/A

9. California Hospital Patient Safety Organization (CHPSO) Patient Safety Organization Participation

Pay for Reporting

8. No Change.

N/A

10. Quality Improvement (QI) Capacity Pay for Reporting

9. No Change.

N/A

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10. OP‐18b: Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients

Pay for Performance

PHC leadership requested outpatient measure. 12 out of 13 large hospitals and 1 out of 13 small hospitals are currently reporting HQIP average: 150 minutes CA average: 169.6 minutes HQIP Min: 96 minutes HQIP Max: 208 minutes

11. California Immunization Registry (CAIR) utilization measure

Pay for Reporting First Year

PHC is required by Department of Health Care Services (DHCS) to have all contracted entities report to CAIR. No cost to use CAIR. 12 out of 13 large and 8 out of 13 small hospitals are registered with a CAIR ID. Of these, 8 large and 5 small hospitals have submitted data within the last 4 months Average monthly entries Dec 2017 – Feb 2018 for 5 small HQIP hospitals: 35 Min: 15 Max: 87 Average monthly entries Dec 2017 – Feb 2018 for 8 large hospitals: 164 Min: 69 Max: 744

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2018‐19 Hospital QIP Proposed Measurement Set: Small Hospitals

2016‐17 Small Hospital Measures 2017‐18 Small Hospitals Proposed Measures Change Rationale 1. All‐Cause Adult Readmission Rate Back‐up measure: Follow‐up visit within 4

calendar days of discharge Pay for Performance

3. All‐Cause Adult Readmission Rate Back‐up measure: Follow‐up visit within 4 calendar days of discharge Pay for Performance

May help concentrate the focus on readmissions. Furthermore, no hospital has ever used the Follow‐up option to meet this measure.

4. Palliative Care Capacity. Two options: ‐ Option 1: Dedicated inpatient palliative care team

(all hospitals): o One Physician Champion o One trained Licensed Clinical Social Worker o One trained Licensed RN, NP, or PA o Availability of video or in‐person consult with a Palliative Care Physician





team (all hospitals): o One Physician Champion o One trained Licensed Clinical Social Worker OR Licensed RN, NP, or PA





Changing option 1 to include one Physician and one RN/NP/PA would make the measure more achievable for hospitals, while still meeting our goal of having a dedicated PC team. Propose to remove the <20 bed exclusion after a hospital with fewer than 20 beds informed us that this is an achievable measure for them.

1. CHPSO Patient Safety Organization Participation Pay for Reporting

3. No Change. Pay for Reporting

N/A

4. QI Capacity Pay for Reporting

4. No Change. Pay for Reporting

N/A

5. Elective Delivery before 39 weeks Hospitals will submit data to CMQCC, and PHC will work directly with CMQCC for reports. Pay for Performance

7 out of 13 small hospitals offer maternity services ‐ Will require chart abstraction

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6. Exclusive Breast Milk Feeding Hospitals will submit data to CMQCC, and PHC will work directly with CMQCC for reports. Pay for Performance

7 out of 13 small hospitals offer maternity services ‐ Will require chart abstraction

7. NTSV Cesarean Birth Rate Hospitals will submit data to CMQCC, and PHC will work directly with CMQCC for reports. Pay for Performance

7 out of 13 small hospitals offer maternity services ‐ No chart extraction required

8. CAIR utilization measure Pay for Reporting First Year

PHC is required by DHCS to have all contracted entities report to CAIR. No cost to use CAIR. 12 out of 13 large and 8 out of 13 small hospitals are registered with a CAIR ID. Of these, 8 large and 5 small hospitals have submitted data within the last 4 month Average monthly entries Dec 2017 – Feb 2018 for 5 small HQIP hospitals: 35 Min: 15 Max: 87 Average monthly entries Dec 2017 – Feb 2018 for 8 large hospitals: 164 Min: 69 Max: 744

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Proposed new measures OP‐18b: Median Time from ED Arrival to ED Departure for Discharged ED Patients (large hospitals only) Recommendation: Add as pay for performance measure to large hospital measurement set only. Description Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department. Rationale Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Specifications Pay for performance, baseline determined by 2016‐17 data. Report to PHC time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. Use Hospital OQR Specifications Manual v11.0a Considerations 12 out of 13 large hospitals and 1 out of 13 small hospitals are currently reporting

Hospital staff comment: We’ve been looking at comparative data on the CMS website for OP‐18b and find that other hospitals in the Bay area with similar EDs to ours (trauma centers, etc.) are having the same times and more often worse than ours using the National median, not the CA median or top decile. As long as patient flow remains a problem nationally and patients use EDs for primary care, I think the throughput measures will continue to be challenging. We’re actively working on this. Prefer OP‐22.”

HQIP average: 150 minutes CA average: 169.6 minutes HQIP Min: 96 minutes HQIP Max: 208 minutes Size Hospital Name County Measure Score Sample Large MAD RIVER COMMUNITY HOSPITAL HUMBOLDT OP_18b 145 278

Large MARIN GENERAL HOSPITAL MARIN OP_18b 149 381

Large MERCY MEDICAL CENTER MT SHASTA SISKIYOU OP_18b 136 355

Large MERCY MEDICAL CENTER REDDING SHASTA OP_18b 156 371

Large NORTHBAY MEDICAL CENTER SOLANO OP_18b 173 1439

Large PETALUMA VALLEY HOSPITAL SONOMA OP_18b 156 342

Large QUEEN OF THE VALLEY MEDICAL CENTER NAPA OP_18b 148 386

Large SANTA ROSA MEMORIAL HOSPITAL SONOMA OP_18b 192 343

Small SONOMA VALLEY HOSPITAL SONOMA OP_18b 136 358

Large ST HELENA HOSPITAL NAPA OP_18b 96 354

Large ST JOSEPH HOSPITAL HUMBOLDT OP_18b 208 400

Large UKIAH VALLEY MEDICAL CENTER MENDOCINO OP_18b 120 359

Large WOODLAND MEMORIAL HOSPITAL YOLO OP_18b 130 37489 of 97

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CAIR utilization measure (small and large hospitals) Recommendation: Add as pay for reporting measure for both small and large hospitals. Description Monitor the CAIR utilization of our contracted hospitals.

Rationale PHC is required by DHCS to have all contracted entities report to CAIR. Considerations 12 out of 13 large and 8 out of 13 small hospitals are registered with a CAIR ID. Of these, 9 large and 6 small hospitals have submitted data between December 2017 – Feb 2018: Small Hospital QIP Hospitals Large Hospital QIP Hospitals Monthly average 35 Entries 164 Entries Min 15 Entries 69 Entries Max 87 Entries 744 Entries Specifications Pay for reporting: Submit Policy/procedure and CAIR report by end of MY.

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Partnership Quality Dashboard (PQD) Demo

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Non‐Clinical Measures Provider DashboardNon‐Clinical Measures Provider Dashboard

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Non‐Clinical Measures Drill DownNon‐Clinical Measures Drill Down

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Non‐Clinical Measures Performance DashboardNon‐Clinical Measures Performance Dashboard

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Non‐Clinical Measures Points DashboardNon‐Clinical Measures Points Dashboard

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HEDIS Monthly TrendHEDIS Monthly Trend

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HEDIS Annual TrendHEDIS Annual Trend

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